Ultrasound Changes in the Enthesis and Peri-enthesis Area of the Patellar and Achilles Tendons in Response to Physical Exercise: Comparison Between Healthy Subjects and Patients with Spondyloarthritis in Clinical Remission.

RATIONALE AND OBJECTIVES: The goal of achieving clinical remission in patients with spondyloarthritis does not necessarily include the resolution of entheseal inflammation from a histological perspective. However, enthesis not clinically inflamed, under mechanical stress, may behave differently from healthy subjects considering the physiopathology of SpA. Our goal was to determine whether ultrasound changes in entheses differ between SpA patients in clinical remission and healthy subjects. METHODS: SpA patients in clinical remission and matched healthy controls were recruited. At baseline, the following variables were measured on the dominant side by ultrasound: thickness of the distal patellar enthesis (hDP), the deep infrapatellar bursa (hDIB), the Achilles enthesis (hA), the preachilleal bursa (hPAB), effusion in the preachileal bursa (hePAB), and the presence of power Doppler signal in both enthesis. All measurements except hDP and hA were collected again after exercise (post-stress ultrasound). RESULTS: 30 patients and 30 controls were enrolled. In all subjects, hDIB, hPAB, and the preachileal bursa occupancy index increased significantly after the exercise. The increase was significantly greater in patients for all variables. At baseline, in patients, hyperemia was detected in one patellar tendon (3.3%) and in two Achilles tendons (6.7%). After exercise, the number of tendons with hyperemia increased to 11/30 (36.7%) and 12/30 (40%), respectively. Among controls, there was no detectable basal hyperemia, but after exercise, it was detected in 1/30 patellar tendons (3.3%) and 2/30 Achilles tendons (6.7%). CONCLUSION: Exercise triggers a greater effusive and hyperemic synovial response in patients in remission than in healthy controls. These findings suggest that the definition of remission should also include an assessment of the synovial response to mechanical stress.

Ultrasound changes following controlled mechanical stress in synovial tissue in the hands of healthy individuals.

OBJECTIVE: The physiological response of the synovium to acute mechanical stress has not been extensively studied. This response is interesting in terms of the morphological changes it can cause as any such changes should be taken into account during ultrasound examinations. The purpose of this study was to assess the extent of changes in ultrasound images of the synovial joint in the hands of healthy individuals after controlled mechanical stress. METHOD: We included 110 healthy volunteers on whom we carried out two ultrasound examinations of the non-dominant hand: one at baseline and the other after controlled handgrip exercise at 70% of the maximum voluntary contraction. RESULTS: The synovitis scores at baseline and after exercise were 0.472±0.798 and 0.772±1.162 t(109)=-3.791, respectively; p < 0.001. We observed no tenosynovitis in 88.2% of the participants at baseline, while after exercise the percentage fell to 70.9%; x2 (1, N=110) =10.0851, p = 0.0014. CONCLUSION: We conclude that synovitis and tenosynovitis are inducible by physical exercise and are detectable on ultrasound. This should be taken into account during ultrasound examinations for suspicion or follow-up of inflammatory rheumatism.

Determinants of therapeutic success of corticoids injections in trigger finger syndrome.

BACKGROUND AND OBJECTIVE: Trigger finger is a frequent complaint in which corticosteroid infiltrations play a relevant therapeutic role in intermediate degrees of severity when conservative treatment has not worked. However, there are no criteria to select which patients will benefit most from this procedure. The present study aimed to identify the factors leading to the therapeutic success of corticosteroid infiltration in these patients. MATERIALS AND METHODS: We designed a prospective longitudinal study based on routine clinical practice with adult patients with a clinical diagnosis of trigger finger grade II or III on the Quinnell scale, who underwent an infiltration of 20 mg of triamcinolone acetate. The outcome variables were to achieve a Quinnell grade I or reduce the severity of the symptoms by at least one category two months after the procedure. To identify the determinants of complete or partial therapeutic success, binary logistic regression predictive modelling was performed using those variables that had a satisfactory univariate correlation. RESULTS: 74 patients were included over three years, 42 of whom (61.8%) were classified as Quinnell grade III. After infiltration, 22 (32.4%) achieved complete resolution and 50 (73.5%) partial resolution. The variables tendon thickening (HR 10.72; 95%CI 2.88-39.93; P < .001) and progression time (HR 1.23; 95%CI 1.02-1.49; P = .027) proved to be predictors of therapeutic success in complete resolution. For the modelling for partial resolution, the same variables proved to be determining predictors (HR 5.57; 95%CI 1.38-22.41; P = .016 and HR 1.18; 95%CI .99-1.41; P = .051, respectively). Pulley thickening did not demonstrate predictive ability in either model. DISCUSSION AND CONCLUSIONS: Our results indicate that the demonstration of finger flexor apparatus thickening is the main determining factor for the success of corticosteroid infiltrations in this pathology. This is in agreement with the histological findings of specimens obtained from both tenosynovial and pulley tissue. In the former, in addition to an infiltrate of inflammatory characteristics, the presence of chondrocytoid cells producing hyaluronic acid is demonstrated. Although the therapeutic success of infiltrations in previous studies reaches 70%, the recurrence rate is similar after 12 months. The selection of patients with tendon thickening ensures therapeutic success in the short term, could reduce recurrence in the long term, and avoid delay in release surgery.

Prevalence of vitamin D deficiency and association with parathyroid hormone.

Objectives: We evaluated the prevalence of 25-hydroxyvitamin D (25-(OH)D) deficiency in our setting according to season, sex, and age. We also studied the association with parathyroid hormone (PTH) levels. Methods: The study population comprised all patients with requests for assessment of 25-(OH)D between January 1 and December 31, 2018, as registered in the database of the laboratory information system. Major exclusion criteria were pediatric samples (<18 years) and factors affecting 25-(OH)D and/or PTH levels (i.e., kidney injury, liver disease, PTH disorders). Results: Among 33,601 patients (24,028 women, 9,573 men), the prevalence of 25-(OH)D deficiency was 48%. Prevalence was greater in males than in females (53% vs. 46%). By age group, deficiency was more prevalent in quartile 1 (Q1, 74-87 years) and less prevalent in quartile 2 (Q2, 60-73 years). By season, deficiency was greater in spring (nonsignificant differences with respect to winter) and lower in summer. The association between 25-(OH)D and PTH was assessed in 9,368 persons. Linear regression analysis showed a weak association (coefficient - 0.303). Multiple logistic regression analysis revealed a significant association between 25-(OH)D deficiency and increased PTH (Odds ratio (OR), 1.63). Other risk factors for increased PTH include female sex (OR, 1.27), season (winter, OR 1.63, spring OR 1.16), and age (quartile 1, OR, 3). Conclusions: The prevalence of 25-(OH)D deficiency differed according to sex, age, and season of the year. Furthermore, elevation of PTH is mainly influenced by low 25-(OH)D, female sex, season, and age.

Delay and diagnostic pathway of patients with psoriatic arthritis in Spain.

INTRODUCTION AND OBJECTIVES: Delayed diagnosis results in a worse prognosis in patients with psoriatic arthritis. Our objective is to determine the diagnostic delay, the specialties consulted and the referral points of patients with psoriatic arthritis in our environment. PATIENTS AND METHODS: We distributed a survey to members of the Spanish association Acción Psoriasis inquiring about the objectives of the study. RESULTS: A total of 503 surveys were analysed. The diagnostic delay was 4.01 ±â€¯1.42 years. The proportion of patients who had consulted, before diagnosis, primary care was 79.9%, traumatology 33.8% and the emergency department was 30.2%. The proportion of referrals that eventually led to diagnosis came from primary care in 29.3% of cases, traumatology 15.8% and the emergency department 3.5%. DISCUSSION AND CONCLUSIONS: The delay in diagnosis far outweighs other European results. Emergency departments are an important transit point for these patients, but the proportion of referrals is very low. We believe that focusing on the importance of early diagnosis in this particular medical sector could resolve a large part of diagnostic delay.

[COVID-19: modification of the risk of infection and disease development associated with the performance of blended work.] / COVID-19: Modificación del riesgo de infección y desarrollo de enfermedad asociado a la realización del trabajo semipresencial.

OBJECTIVE: The health crisis caused by COVID-19 has had an economic impact at all levels and the labor market has been shaken by the pandemic. Companies have had to adapt to new work models and have had to decide between face-to-face, teleworking, or mixed models without conclusive scientific evidence on the impact on transmission. To determine the change in the risk of SARS-CoV-2 infection and the development of disease associated with the performance of blended work with respect to remote work and the general population in a non-healthcare company while respecting the measures of social distancing, use of masks and hand hygiene. METHODS: Observational ecological study followed by a retrospective cohort study. Data were collected on the total daily cases and incidence of COVID-19 between September 1, 2020 and April 30, 2021 from the population of a non-healthcare company and the reference population of the Community of Madrid. Analysis was also performed in two 30-day periods on the same population differentiated by the existence of fully remote or blended work. The statistical analysis was performed by determining the Chi2 distribution (χ2) and calculating the Odds Ratio (OR). RESULTS: The average number of employees during the study period was 642 (30.55% women). The reference population was 6,745,591 people (52.16% women). The number of people aged between 20 and 69 years was 4,520,116 (51.67% women). The incidence in the period (Ip) in the study population was 9.5%. The Ip in the Community of Madrid was 7.81%. No statistical differences were found OR 1.23 (95% CI 0.95-1.61) χ2=2.55 p-value 0.11. Ip in the population of the Community between 20 and 69 years was 8.84% OR 1.08 (95% CI 0.83-1.41) χ2=0.35 p-value 0.556. In the comparison performed in the study population, no statistically significant differences were found between both periods OR 0.59 (IC95% 0.26-1.37) χ2=1.53 p-value 0.216. CONCLUSIONS: Based on the data analyzed, we found no statistically significant evidence to show that performing semi-distance work with security measures in a non-healthcare company increases the risk of SARS-CoV-2 infection and the development of disease.

OBJETIVO: La crisis sanitaria provocada por el COVID-19 ha tenido un impacto económico en todos los niveles y el mercado laboral se ha visto agitado por la pandemia. Las empresas han precisado adaptarse a nuevos modelos de trabajo debiendo decidir entre modelos presenciales, teletrabajo o mixtos sin que existan evidencias científicas concluyentes sobre el impacto en la trasmisión. El objetivo de este trabajo fue determinar la modificación del riesgo de infección por el SARS-CoV-2 y desarrollo de enfermedad asociado a la realización del trabajo semipresencial con respecto al trabajo en remoto y la población general en una empresa no sociosanitaria respetando las medidas de distanciamiento social, el uso de mascarilla y la higiene de manos. METODOS: Estudio observacional ecológico seguido de un estudio de cohortes retrospectivo. Se recogieron datos del total de los casos diarios y de la incidencia de COVID-19 entre el 1 de septiembre de 2020 y el 30 de abril de 2021 de la población de una empresa no sociosanitaria y la población de referencia de la Comunidad de Madrid. Se realizó también análisis en dos periodos de 30 días sobre la misma población diferenciados por la existencia de trabajo íntegramente en remoto o semipresencial. El análisis estadístico se realizó mediante la determinación de la distribución de Chi2 (χ²2) el cálculo de la Odds Ratio (OR). RESULTADOS: La media de empleados durante el periodo de estudio se calculó en 642 (30,55% mujeres). La población de referencia fue de 6.745.591 personas (52,16% mujeres). El número de personas de entre 20 y 69 años fue de 4.520.116 (51,67% mujeres). La incidencia en el periodo (Ip) en la población de estudio fue 9,5%. La Ip en la Comunidad de Madrid fue 7,81%. No se encontraron diferencias estadísticamente significativas OR 1,23 (IC 95% 0,95-1,61) χ2=2,55 p-valor 0,11. La Ip en la población de la Comunidad de Madrid entre los 20 y los 69 años fue de 8,84% OR 1,08 (IC95% 0,83-1,41) χ2=0,35 p-valor 0,556. En la comparación realizada en la población de estudio no se encontraron diferencias estadísticamente significativas entre ambos periodos OR 0,59 (IC95% 0,26-1,37) χ2=1,53 p-valor 0,216. CONCLUSIONES: Con los datos analizados no encontramos evidencias estadísticamente significativas que demuestre que la realización de trabajo semipresencial con medidas de seguridad en una empresa no sociosanitaria aumente el riesgo de infección por el SARS-CoV-2 y el desarrollo de enfermedad.

Relationship between anthropometric variables and the cross-sectional area of the median nerve by ultrasound assessment in healthy subjects.

OBJECTIVE: Ultrasound study of the wrist in patients with suspected entrapment syndrome has severe limitations due to the variability of what is considered normal for the cross-sectional area of the median nerve and where to proceed to measure it. We aim to determine the extent to which different anthropometric variables influence the median nerve area in subjects without carpal tunnel syndrome. METHODS: We conducted an observational study based on a multivariate linear regression analysis using as a dependent variable the area of the median nerve cut at two specific points in the wrist of healthy subjects. The independent variables were sex, age, height, weight, body mass index, finger flexor strength, and carpal circumference. MAJOR RESULTS: The measurements of the median nerve cross-sectional area were normalized using a quadratic fixing procedure. Of all the variables included in the linear regression analysis, only carpal circumference and sex (0: female, 1: male) contributed significantly in the final model using the wrist crease as the measurement point (Constant B=-209.45, carpal circumference coefficient=21.07, sex coefficient 10.87). At four centimeters distal to the carpal fold, the model included the same variables (Constant B=-221.84, carpal circumference coefficient=24.01, and sex coefficient=11.41). CONCLUSION: Both the wrist circumference and the sex are variables that should be considered to determine cut-off points of normality in future validation studies about the cross-sectional area of the median nerve.

Delay and Diagnostic Pathway of Patients with Psoriatic Arthritis in Spain. / Retraso y recorrido diagnóstico de pacientes con artritis psoriásica en España.

INTRODUCTION AND OBJECTIVES: Delayed diagnosis results in a worse prognosis in patients with psoriatic arthritis. Our objective is to determine the diagnostic delay, the specialties consulted and the referral points of patients with psoriatic arthritis in our environment. PATIENTS AND METHODS: We distributed a survey to members of the Spanish association Acción Psoriasis inquiring about the objectives of the study. RESULTS: A total of 503 surveys were analysed. The diagnostic delay was 4.01±1.42 years. The proportion of patients who had consulted, before diagnosis, primary care was 79.9%, traumatology 33.8% and the emergency department was 30.2%. The proportion of referrals that eventually led to diagnosis came from primary care in 29.3% of cases, traumatology 15.8% and the emergency department 3.5%. DISCUSSION AND CONCLUSIONS: The delay in diagnosis far outweighs other European results. Emergency departments are an important transit point for these patients, but the proportion of referrals is very low. We believe that focusing on the importance of early diagnosis in this particular medical sector could resolve a large part of diagnostic delay.

Specialized rheumatology clinic in an emergency department: A year of the rheumatology and musculoskeletal emergencies clinic (RMSEC) experience. / La consulta especializada de reumatología en un servicio de urgencias: un año de experiencia con la unidad de urgencias reumatológicas y musculoesqueléticas (URMES).

BACKGROUND: In October 2013, the emergency department of our hospital started up a rheumatology and musculoskeletal emergencies clinic (RMSEC) with the participation of three specialists in Rheumatology. The purpose of this study was to describe the experience gained in the first year since the beginning of our activity. METHOD: A descriptive study of healthcare activity of the RMSEC throughout its first year of operation was performed. RESULTS: 1788 assessments on 1663 patients were performed. The range of age was 7 to 67 years. 1530 (85.57%) assessments were performed in patients of the healthcare area of our hospital. Of all the assessments made, 633 (35.4%) were related to inflammatory processes and the remaining 1155 (64.6%) to mechanical or degenerative joint or soft tissue processes. According to the topography of the complaint, 435 (24.3%) patients consulted for a process related to the knee, 362 (20.3%) with axial lumbar region and 336 (18.8%) with the shoulder. CONCLUSION: Our results denote an intense clinical activity that could have a positive impact on the management of rheumatic and musculoskeletal general emergency.

[Assessment of resident physicians' performance in a university hospital's emergency department]. / Experiencia en la evaluación de la actividad asistencial de los médicos residentes en un servicio de urgencias de un hospital universitario.

OBJECTIVES: To describe an experience with the evaluation of resident physicians doing rotations in a tertiary-care hospital emergency department and to analyze the correlation between results on the various assessment tools and the resident's rank on Spain's standardized selection examination for admission to residency programs. MATERIAL AND METHODS: The residents took 2 written examinations in 2013 and 2014, and rotation supervisors wrote subjective evaluations of the residents' clinical performance in the workplace. The residents also provided self-assessments of theoretical and practical knowledge and their aptitude for emergency department work. The results on these assessment tools were tabulated independently, and it was investigated if there were correlations between them. RESULTS: We observed an inverse correlation between the residents' rank on the standardized selection examination and their scores on the written examinations of knowledge and the supervisors' workplace assessments. The written examination scores after the rotation correlated positively with workplace assessments. Self-assessments were distributed normally, suggesting they were of scarce value, and they did not correlate with the results of the other assessment tools. CONCLUSION: Written examinations are acceptably correlated with subjective workplace assessments of practical competencies, whereas ranking on the residency program admissions examination is not acceptably correlated with emergency department workplace performance. We believe that efforts to prepare ways to evaluate residents' emergency department performance will be of interest in the future, once a specialization in emergency medicine is approved.

OBJETIVO: Describir la experiencia obtenida en un servicio de urgencias (SU) de un hospital universitario de tercer nivel en términos de evaluación de residentes así como la correlación de los resultados obtenidos por las herramientas utilizadas entre si mismas y con el número de acceso a la plaza de médico interno residente (MIR). METODO: Estudio retrospectivo observacional. Se realizaron dos pruebas escritas a lo largo del periodo lectivo 2013- 2014, y evaluaciones subjetivas por los supervisores durante las jornadas de atención continuada y se solicitó una autoevaluación de conocimientos teóricos, prácticos y de disposición al trabajo en urgencias. Los resultados de estas herramientas se exponen independientemente y se investiga si existe correlación entre ellos. RESULTADOS: El número MIR se correlacionó inversamente con los resultados de las pruebas escritas de conocimientos y con los resultados de las evaluaciones durante las jornadas de atención continuada. Los resultados de las evaluaciones escritas mostraron una correlación directa con las evaluaciones durante las jornadas de atención continuada. En términos generales, la autoevaluación presentó una distribución normal reflejando una escasa utilidad y ninguna correlación con las formas de evaluación por terceros. CONCLUSIONES: Las pruebas escritas consiguen una correlación aceptable con la evaluación subjetiva de competencias prácticas de los MIR en el SU y viceversa. Los esfuerzos orientados a preparar estrategias de evaluación de residentes en la actividad en urgencias serán de interés en el futuro, cuando exista la especialidad la Medicina de Urgencias.

[Application of a cooperative learning approach for training residents in the emergency department and comparison with a traditional approach]. / Aplicación del método de aprendizaje cooperativo comparado con la técnica tradicional de enseñanza en la formación de residentes en urgencias.

OBJECTIVES: To analyze the benefits of using a cooperative learning (CL) model to teach hospital residents doing rotations in the emergency department and to compare the CL approach to traditional training. MATERIAL AND METHODS: Two training sessions on the same content were given by 2 expert instructors. A traditional method of instruction was used in one of the sessions and the CL model was used in the other. Immediately after the sessions and 3 months later, the residents took a multiple-choice test that was developed by a third expert. A control group of residents who had not attended either session also took the test. RESULTS: Twenty-one residents were in the CL group and 17 were in the traditional-training group. The mean (SD) scores on the examinations immediately after training were 8.81 (1.40) and 7.88 (1.26), in the CL and traditional groups, respectively (P=.0414). Three months later, the mean scores of these same residents retaking the examination and 32 control residents were as follows: CL group, 8.19 (1.12); traditional group, 7.00 (1.22); and control group, 6.37 (1.37) (P<.05, CL vs traditional; P>.05, traditional vs control). CONCLUSION: The CL approach proved superior to traditional training in terms of short- and medium-term retention of information. Although this is the first analysis of CL in this type of specialized medical training, extending its use in preparing medical residents working in emergency departments would seem to be justified.

OBJETIVO: Determinar el beneficio del uso de la técnica de aprendizaje cooperativo (AC) en la docencia de médicos internos residentes (MIR) que realizan actividades de atención continuada en urgencias, comparado con la enseñanza tradicional (ET). METODO: Estudio prospectivo secuencial de casos de controles. Se programaron dos sesiones formativas separadas realizadas por expertos en el mismo tema y dirigidas a residentes de primer año. Una sesión se basó en la ET y la otra en el modelo AC. Los MIR realizaron un test con respuesta múltiple diseñado por un tercer experto al término de cada sesión y tres meses después, que incluyó un grupo control de MIR que no habían asistido a ninguna sesión. RESULTADOS: El AC se aplicó sobre 21 alumnos y la ET sobre 17. Las puntuaciones medias y desviaciones estándar de los exámenes escritos realizados inmediatamente después de las sesiones formativas fueron 8,81 (1,40) y 7,88 (1,26) respectivamente (p = 0,0414). Tres meses después de las sesiones formativas, los mismos alumnos y 32 residentes controles fueron sometidos a un nuevo examen escrito con respuesta múltiple. La puntuaciones medias ± desviaciones estándar de este examen fueron 8,19 (1,12), 7,00 (1,22) y 6,37 (1,37) para el grupo AC, ET y control, respectivamente (p < 0,05 entre ACy ET, p > 0,05 entre ET y control). CONCLUSIONES: El método AC demuestra superioridad frente a la ET en términos de retención de información a corto y medio plazo. Si bien esta es la primera experiencia documentada en formación médica especializada, su utilidad en la formación transversal en MIR en urgencias podría justificar la extensión de su uso.