Enhanced Recombinant Protein Expression in Insect Cells by Natural and Recombinant Components of Lepidoptera Hemolymph.

Prior research has established the anti-apoptotic effects in insect cell cultures of Bombyx mori (B. mori) hemolymph, as well as the heightened production yields of recombinant proteins facilitated by baculovirus vectors in insect cells cultivated in media supplemented with this hemolymph. In this study, we investigated the hemolymph of another Lepidoptera species, Trichoplusia ni (T. ni), and observed similar beneficial effects in insect cells cultivated in media supplemented with this natural substance. We observed enhancements in both production yield (approximately 1.5 times higher) and late-stage cell viabilities post-infection (30-40% higher). Storage-protein 2 from B. mori (SP2Bm) has previously been identified as one of the abundant hemolymph proteins potentially responsible for the beneficial effects observed after the use of B. mori hemolymph-supplemented cell culture media. By employing a dual baculovirus vector that co-expresses the SP2Bm protein alongside the GFP protein, we achieved a threefold increase in reporter protein production compared to a baculovirus vector expressing GFP alone. This study underscores the potential of hemolymph proteins sourced from various Lepidoptera species as biotechnological tools to augment baculovirus vector productivities, whether utilized as natural supplements in cell culture media or as hemolymph-derived recombinant proteins co-expressed by baculovirus vectors.

Vibration motor stimulation device in smart leggings that promotes motor performance in older people.

Globally, accelerated aging is taking place alongside increased life expectancy of the population. This poses a challenge to maintaining autonomy and independence as people age but preventing falls and disabilities. Currently, there are few specific technologies on the market that are focused on the rehabilitation and promotion of autonomy in older adults. This study presents the development of a prototype (Myoviber®) of a low-cost, wearable everyday garment, designed to stimulate the lower limbs by the application of focal muscle vibration and incorporating technical textile qualities. The presented approach is proactive and preventive, maintaining functionality for the elderly while integrating electronic technology into an everyday garment. For this, a comprehensive study was carried out that included the design of the leggings through anthropometric analyses, the development of vibration devices at a stable frequency located in the knee extensor muscle and a smart belt with wireless connection, and the optimization of the battery autonomy. The development of the prototype was carried out through the construction of a vibratory device, which was validated with biomechanical evaluations. The results show an increase in the functional capacity of the lower limbs, in relation to motor tasks such as postural balance and gait in older people.

Quality criteria in MOOC: Comparative and proposed indicators.

The MOOC (Massive Open Online Course) offer revolution requires processes that can define their quality, especially due to the number of courses offered, as well as the high number of students enrolled in them. The objective of this study is to identify the main requirements and indicators of the MOOC following the ENQA (The European Association for Quality Assurance in Higher Education) considerations. To establish this system, the study has been carried out through the Delphi method with successive rounds of application from the systematic use of expert judgment. This method has been applied to achieve consensus on a set of requirements and indicators of 20 experts from eight different institutions in the field of application and development of MOOCs that assessed the indicators according to the quality criteria according to three aspects: relevance, feasibility, and comparability. Therefore, the outcome of this study is a system as a mechanism for the university to approve or disapprove a MOOC (checklist) and assess its quality.

The genomic basis of host and vector specificity in non-pathogenic trypanosomatids.

Trypanosoma theileri, a non-pathogenic parasite of bovines, has a predicted surface protein architecture that likely aids survival in its mammalian host. Their surface proteins are encoded by genes which account for ∼10% of their genome. A non-pathogenic parasite of sheep, Trypanosoma melophagium, is transmitted by the sheep ked and is closely related to T. theileri. To explore host and vector specificity between these species, we sequenced the T. melophagium genome and transcriptome and an annotated draft genome was assembled. T. melophagium was compared to 43 kinetoplastid genomes, including T. theileri. T. melophagium and T. theileri have an AT biased genome, the greatest bias of publicly available trypanosomatids. This trend may result from selection acting to decrease the genomic nucleotide cost. The T. melophagium genome is 6.3Mb smaller than T. theileri and large families of proteins, characteristic of the predicted surface of T. theileri, were found to be absent or greatly reduced in T. melophagium. Instead, T. melophagium has modestly expanded protein families associated with the avoidance of complement-mediated lysis. We propose that the contrasting genomic features of these species is linked to their mode of transmission from their insect vector to their mammalian host. This article has an associated First Person interview with the first author of the paper.

Comparative Sensitivity and Specificity of the 7SL sRNA Diagnostic Test for Animal Trypanosomiasis.

Animal trypanosomiasis (AT) is a significant livestock disease, affecting millions of animals across Sub-Saharan Africa, Central and South America, and Asia, and is caused by the protozoan parasites Trypanosoma brucei, Trypanosoma vivax, and Trypanosoma congolense, with the largest economic impact in cattle. There is over-reliance on presumptive chemotherapy due to inadequate existing diagnostic tests, highlighting the need for improved AT diagnostics. A small RNA species, the 7SL sRNA, is excreted/secreted by trypanosomes in infected animals, and has been previously shown to reliably diagnose active infection. We sought to explore key properties of 7SL sRNA RT-qPCR assays; namely, assessing the potential for cross-reaction with the widespread and benign Trypanosoma theileri, directly comparing assay performance against currently available diagnostic methods, quantitatively assessing specificity and sensitivity, and assessing the rate of decay of 7SL sRNA post-treatment. Results showed that the 7SL sRNA RT-qPCR assays specific for T. brucei, T. vivax, and T. congolense performed better than microscopy and DNA PCR in detecting infection. The 7SL sRNA signal was undetectable or significantly reduced by 96-h post treatment; at 1 × curative dose there was no detectable signal in 5/5 cattle infected with T. congolense, and in 3/5 cattle infected with T. vivax, with the signal being reduced 14,630-fold in the remaining two T. vivax cattle. Additionally, the assays did not cross-react with T. theileri. Finally, by using a large panel of validated infected and uninfected samples, the species-specific assays are shown to be highly sensitive and specific by receiver operating characteristic (ROC) analysis, with 100% sensitivity (95% CI, 96.44-100%) and 100% specificity (95% CI, 96.53-100%), 96.73% (95% CI, 95.54-99.96%) and 99.19% specificity (95% CI, 92.58-99.60%), and 93.42% (95% CI, 85.51-97.16% %) and 82.43% specificity (95% CI, 72.23-89.44% %) for the T brucei, T. congolense and T. vivax assays, respectively, under the conditions used. These findings indicate that the 7SL sRNA has many attributes that would be required for a potential diagnostic marker of AT: no cross-reaction with T. theileri, high specificity and sensitivity, early infection detection, continued signal even in the absence of detectable parasitaemia in blood, and clear discrimination between infected and treated animals.

Profiling Children Sexual Abuse in a Sample of University Students: A Study on Characteristic of Victims, Abusers, and Abuse Episodes.

Because of its prevalence and its potential negative consequences, child sexual abuse (CSA) is a public health problem in every country in the world. Knowledge of the characteristics of abuse episodes (victim, abuser, relationship between them, type of sexual contact, duration, threat and/or use of force) is essential to specify the contents of intervention programs for the detection and reduction of the negative consequences of CSA. Starting with an initial sample of 1605 university students of both sexes (70.9% women, 29.1% men), aged between 18 and 26 years (M = 21.1, SD = 2.2), 90 participants who had suffered an episode of CSA up to age 16 were selected (84.4% women, 15.6% men; Mage = 21.1, SD = 2.2). It was found that: (1) there was a higher prevalence of CSA among women and that the victims' average age when they suffered abuse was around 11 years; (2) the abusers were mostly male, close to the victims, and with an average of slightly less than 30 years; and (3) there was a significant proportion (25.6%) of CSA cases with penetration and in which force was used or threatened. These results are relevant, as they show that there is still a noteworthy prevalence of CSA cases on university campuses that needs to be addressed. Knowing the characteristics of these episodes is critical to implementing more effective interventions.

Specific Competencies of Prehospital Emergency Nursing: The Views of Spanish University Professors.

BACKGROUND: The guarantee of nursing competence in prehospital urgent care requires the identification and delimitation of the specific competencies. This work describes the importance attributed by professors of Spanish universities to the competencies of prehospital nursing positions and indicates the most appropriate training level required to achieve them. METHOD: The current work consisted of a survey with an online questionnaire. Sixty competencies over 10 domains were studied. RESULTS: The most valued domains were those of general and personal competencies. The competencies considered most important were "Recognizes the vital risk and knows how to perform basic and advanced life support maneuvers" and "Provides quality health care." The nursing degree is considered appropriate to train students to the required level in only eight competencies. CONCLUSION: The proposed competencies can be considered as specific competencies necessary in prehospital emergency nursing. Effective performance requires training to a higher level than a nursing degree. [J Contin Educ Nurs. 2020;51(12):556-567.].

A Narrative Review of the Description of Training Profiles Used for Emergency Nursing Care Worldwide.

BACKGROUND: This study describes the training profiles of emergency care nurses worldwide, which can serve as a guide for training these professionals. METHOD: A narrative review was developed. RESULTS: Five training profiles were identified, according to the requirements of undergraduate, postgraduate, complementary training, and previous work experience within the training itineraries of emergency nursing worldwide. CONCLUSION: The most appropriate level of training for emergency nursing is the 1-year postgraduate level (academic or specialty). The description of these profiles can guide the regulatory organizations and professionals regarding the most appropriate training requirements for effective, safe, and adjusted care assistance. [J Contin Educ Nurs. 2019;50(12):543-550.].

Feature engineering for sentiment analysis in e-health forums.

INTRODUCTION: Exploiting information in health-related social media services is of great interest for patients, researchers and medical companies. The challenge is, however, to provide easy, quick and relevant access to the vast amount of information that is available. One step towards facilitating information access to online health data is opinion mining. Even though the classification of patient opinions into positive and negative has been previously tackled, most works make use of machine learning methods and bags of words. Our first contribution is an extensive evaluation of different features, including lexical, syntactic, semantic, network-based, sentiment-based and word embeddings features to represent patient-authored texts for polarity classification. The second contribution of this work is the study of polar facts (i.e. objective information with polar connotations). Traditionally, the presence of polar facts has been neglected and research in polarity classification has been bounded to opinionated texts. We demonstrate the existence and importance of polar facts for the polarity classification of health information. MATERIAL AND METHODS: We annotate a set of more than 3500 posts to online health forums of breast cancer, crohn and different allergies, respectively. Each sentence in a post is manually labeled as "experience", "fact" or "opinion", and as "positive", "negative" and "neutral". Using this data, we train different machine learning algorithms and compare traditional bags of words representations with word embeddings in combination with lexical, syntactic, semantic, network-based and emotional properties of texts to automatically classify patient-authored contents into positive, negative and neutral. Beside, we experiment with a combination of textual and semantic representations by generating concept embeddings using the UMLS Metathesaurus. RESULTS: We reach two main results: first, we find that it is possible to predict polarity of patient-authored contents with a very high accuracy (≈ 70 percent) using word embeddings, and that this considerably outperforms more traditional representations like bags of words; and second, when dealing with medical information, negative and positive facts (i.e. objective information) are nearly as frequent as negative and positive opinions and experiences (i.e. subjective information), and their importance for polarity classification is crucial.

Recommendations for the use of parenteral methotrexate in rheumatic diseases. / Recomendaciones sobre el uso de metrotexato parenteral en enfermedades reumáticas.

OBJECTIVE: To develop recommendations for the use of parenteral methotrexate (MTX) in rheumatic diseases, mainly rheumatoid arthritis, based on best evidence and experience. METHODS: A group of 21 experts on parenteral MTX use was selected. The coordinator formulated 13 questions about parenteral MTX (indications, efficacy, safety and cost-effectiveness). A systematic review was conducted to answer the questions. Using this information, inclusion and exclusion criteria were established, as were the search strategies (involving Medline, EMBASE and the Cochrane Library). Three different reviewers selected the articles. Evidence tables were created. Abstracts from the European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) were evaluated. Based on this evidence, the coordinator proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation were established using the Oxford Center for Evidence-Based Medicine and the level of agreement with the Delphi technique (2 rounds). Agreement was established if at least 80% of the experts voted yes (yes/no). RESULTS: Most of the evidence involved rheumatoid arthritis. A total of 13 preliminary recommendations on the use of parenteral MTX were proposed; 11 of them were accepted. Two of the 13 were not voted and are commented on in the main text. CONCLUSIONS: The manuscript aims to solve frequent questions and help in decision-making strategies when treating patients with parenteral MTX.

Cross-sectional evaluation of patient functioning and health-related quality of life in patients with neuropathic pain under standard care conditions.

AIM: The purpose of this cross-sectional evaluation was to determine the impact of neuropathic pain (NeP) on patient functioning and Health-Related Quality of Life (HRQoL) under standard care conditions. METHODS: Patients with NeP or neuropathic and nociceptive pain [Mixed Pain (MP)] enrolled in the DONEGA study, a naturalistic, prospective and multi-centre study of the effectiveness of gabapentin under usual care conditions, were included in this cross-sectional evaluation before starting study treatments. Participants completed the Short Form-McGill Pain Questionnaire, MOS Short Form-12 (SF-12), and Sheehan Disability Scale (ShDS). Multivariate analysis and regression models were used to analyze patient data. RESULTS: A total of 1519 patients [mean+/-SD; 56.0+/-13.7 yrs old (58.8% female)] with NeP or MP were enrolled in the study. The mean pain history was 1.1+/-2.8 yrs, current pain intensity on a 5-point visual analogue scale was 2.8+/-1.0 and mean pain in previous week was 71.3+/-19.0mm. Pain substantially interfered (i.e., score > or = 5 on 0-10 scale) with normal work (5.9+/-3.0), social life (5.7+/-3.0), and family life (5.3+/-3.0), producing substantial disability (total ShDS score of 16.9+/-8.3 pts). Country-standardised physical (PCS) and mental health (MCS) component summary scores of SF-12 indicated significant impairment in both domains compared with the general Spanish population: PCS; -1.13+/-1.0 SDS (standard deviation score), and MCS; -1.21+/-0.7 SDS, equivalent to the 15th and 25th percentiles of normative populations, respectively. CONCLUSIONS: Under standard care conditions, neuropathic and mixed pain are associated with impaired physical and mental QoL, producing a substantial level of disability in these patients.

Versión actualizada de la definición de dolor de la IASP: un paso adelante o un paso atrás / Updated version of the IASP definition of pain: one step forward or one step back

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Improved Production Efficiency of Virus-Like Particles by the Baculovirus Expression Vector System.

Vaccines based on virus-like particles (VLPs) have proven effective in humans and animals. In this regard, the baculovirus expression vector system (BEVS) is one of the technologies of choice to generate such highly immunogenic vaccines. The extended use of these vaccines for human and animal populations is constrained because of high production costs, therefore a significant improvement in productivity is crucial to ensure their commercial viability. Here we describe the use of the previously described baculovirus expression cassette, called TB, to model the production of two VLP-forming vaccine antigens in insect cells. Capsid proteins from porcine circovirus type 2 (PCV2 Cap) and from the calicivirus that causes rabbit hemorrhagic disease (RHDV VP60) were expressed in insect cells using baculoviruses genetically engineered with the TB expression cassette. Productivity was compared to that obtained using standard counterpart vectors expressing the same proteins under the control of the polyhedrin promoter. Our results demonstrate that the use of the TB expression cassette increased the production yields of these vaccine antigens by around 300% with respect to the standard vectors. The recombinant proteins produced by TB-modified vectors were fully functional, forming VLPs identical in size and shape to those generated by the standard baculoviruses, as determined by electron microscopy analysis. The use of the TB expression cassette implies a simple modification of the baculovirus vectors that significantly improves the cost efficiency of VLP-based vaccine production, thereby facilitating the commercial viability and broad application of these vaccines for human and animal health.

Significant productivity improvement of the baculovirus expression vector system by engineering a novel expression cassette.

Here we describe the development of a baculovirus vector expression cassette containing rearranged baculovirus-derived genetic regulatory elements. This newly designed expression cassette conferred significant production improvements to the baculovirus expression vector system (BEVS), including prolonged cell integrity after infection, improved protein integrity, and around 4-fold increase in recombinant protein production yields in insect cells with respect to a standard baculovirus vector. The expression cassette consisted of a cDNA encoding for the baculovirus transactivation factors IE1 and IE0, expressed under the control of the polyhedrin promoter, and a homologous repeated transcription enhancer sequence operatively cis-linked to the p10 promoter or to chimeric promoters containing p10. The prolonged cell integrity observed in cells infected by baculoviruses harbouring the novel expression cassette reduced the characteristic proteolysis and aberrant forms frequently found in baculovirus-derived recombinant proteins. The new expression cassette developed here has the potential to significantly improve the productivity of the BEVS.

Genome-wide analysis of single nucleotide polymorphisms and copy number variants in fibromyalgia suggest a role for the central nervous system.

Fibromyalgia (FM) is a highly disabling syndrome defined by a low pain threshold and a permanent state of pain. The mechanisms explaining this complex disorder remain unclear, and its genetic factors have not yet been identified. With the aim of elucidating FM genetic susceptibility factors, we selected 313 FM cases having low comorbidities, and we genotyped them on the Illumina 1 million duo array. Genotypic data from 220 control women (Illumina 610k array) was obtained for genome-wide association scan (GWAS) analysis. Copy number variants in FM susceptibility were analyzed by array comparative genomic hybridization (aCGH) experiments on pooled samples using the Agilent 2×400K platform. No single nucleotide polymorphism (SNP) reached GWAS association threshold, but 21 of the most associated SNPs were chosen for replication in 952 cases and 644 controls. Four of the SNPs selected for replication showed a nominal association in the joint analysis, and rs11127292 (MYT1L) was found to be associated to FM with low comorbidities (P=4.28×10(-5), odds ratio [95% confidence interval]=0.58 [0.44-0.75]). aCGH detected 5 differentially hybridized regions. They were followed up, and an intronic deletion in NRXN3 was demonstrated to be associated to female cases of FM with low levels of comorbidities (P=.021, odds ratio [95% confidence interval]=1.46 [1.05-2.04]). Both GWAS and aCGH results point to a role for the central nervous system in FM genetic susceptibility. If the proposed FM candidate genes were further validated in replication studies, this would highlight a neurocognitive involvement in agreement with latest reports.

Production of functional active human growth factors in insects used as living biofactories.

Growth factors (GFs) are naturally signalling proteins, which bind to specific receptors on the cell surface. Numerous families of GFs have already been identified and remarkable progresses have been made in understanding the pathways that these proteins use to activate/regulate the complex signalling network involved in cell proliferation or wound healing processes. The bottleneck for a wider clinical and commercial application of these factors relay on their scalable cost-efficient production as bioactive molecules. The present work describes the capacity of Trichoplusia ni insect larvae used as living bioreactors in combination with the baculovirus vector expression system to produce three fully functional human GFs, the human epidermal growth factor (huEGF), the human fibroblast growth factor 2 (huFGF2) and the human keratinocyte growth factor 1 (huKGF1). The expression levels obtained per g of insect biomass were of 9.1, 2.6 and 3mg for huEGF, huFGF2 and huKGF1, respectively. Attempts to increase the productivity of the insect/baculovirus system we have used different modifications to optimize their production. Additionally, recombinant proteins were expressed fused to different tags to facilitate their purification. Interestingly, the expression of huKGF1 was significantly improved when expressed fused to the fragment crystallizable region (Fc) of the human antibody IgG. The insect-derived recombinant GFs were finally characterized in terms of biological activity in keratinocytes and fibroblasts. The present work opens the possibility of a cost-efficient and scalable production of these highly valuable molecules in a system that favours its wide use in therapeutic or cosmetic applications.

Screening for the presence of FMR1 premutation alleles in women with fibromyalgia.

Fibromyalgia is a chronic condition characterized by widespread pain, fatigue, non-restorative sleep and cognitive difficulties that affects 2-4% of the general population. Recently a possible relationship between the FMR1 premutation and fibromyalgia has been pointed out. In attempt to gather more data we screened for the FMR1 CGG expansion 700 DNA samples from unrelated fibromyalgia patients. This data might be useful for evaluating the incorporation of this test in rheumatologic procedures for women with fibromyalgia. The observed frequency of FMR1 premutation carriers (3 of 700, 0.4%) is not significantly different from the estimated rate in the general female population (1/250-1/400) (P=0.539, P=0.716). Clinical examination of the FMR1 premutation carriers identified revealed that all of them had important neurological symptoms with regard to muscular symptoms, neurocognitive alterations and neurovegetative impairments. With regard to other clinical aspects of the disease the cases apparently did not differ from the average fibromyalgia patients. On the basis of our results an FMR1 screening among fibromyalgia female patients would not be recommended. However it would be worthwhile to further evaluate the different clinical presentations that fibromyalgia patients might present based on their FMR1 premutation carrier status.

Cluster analysis of clinical data identifies fibromyalgia subgroups.

INTRODUCTION: Fibromyalgia (FM) is mainly characterized by widespread pain and multiple accompanying symptoms, which hinder FM assessment and management. In order to reduce FM heterogeneity we classified clinical data into simplified dimensions that were used to define FM subgroups. MATERIAL AND METHODS: 48 variables were evaluated in 1,446 Spanish FM cases fulfilling 1990 ACR FM criteria. A partitioning analysis was performed to find groups of variables similar to each other. Similarities between variables were identified and the variables were grouped into dimensions. This was performed in a subset of 559 patients, and cross-validated in the remaining 887 patients. For each sample and dimension, a composite index was obtained based on the weights of the variables included in the dimension. Finally, a clustering procedure was applied to the indexes, resulting in FM subgroups. RESULTS: VARIABLES CLUSTERED INTO THREE INDEPENDENT DIMENSIONS: "symptomatology", "comorbidities" and "clinical scales". Only the two first dimensions were considered for the construction of FM subgroups. Resulting scores classified FM samples into three subgroups: low symptomatology and comorbidities (Cluster 1), high symptomatology and comorbidities (Cluster 2), and high symptomatology but low comorbidities (Cluster 3), showing differences in measures of disease severity. CONCLUSIONS: We have identified three subgroups of FM samples in a large cohort of FM by clustering clinical data. Our analysis stresses the importance of family and personal history of FM comorbidities. Also, the resulting patient clusters could indicate different forms of the disease, relevant to future research, and might have an impact on clinical assessment.

Characterization of a Trichoplusia ni hexamerin-derived promoter in the AcMNPV baculovirus vector.

The promoter sequences of the encoding genes for the three most abundant hexamerins of the Lepidoptera Trichoplusia ni were isolated and cloned into the Autographa californica multiple nucleopolyhedrovirus (AcMNPV)-derived baculovirus expression vector. From the sequences analyzed, the DNA region driving the expression of the Basic juvenile hormone-suppressible protein 2 (BJHSP-2), denominated pB2, presented the highest promoter strength in the context of the baculovirus vector in Sf21 insect cells. This promoter activity occurred earlier in baculovirus-infected cells than that achieved by a conventional polyhedrin promoter (polh), but surprisingly stopped at 48h post-infection. A mapping of pB2 essential promoter elements determined that a region of about 400bp, denominated pB29, retained and even increased the transcriptional activity with respect to the parental full-length sequence. Finally, several chimeric combinations of the insect-derived pB2 with the virus-derived conventional polh or p10 promoters were constructed and incorporated into an AcMNPV baculovirus vector. The pB2-p10 combination showed increased recombinant protein expression at early times post-infection and similar expression levels at very late times post-infection in Sf21 cells with respect to conventional late promoters. To the best of our knowledge, pB2 is the first promoter isolated from the Lepidoptera T. ni, the natural host of AcMNPV, to be assayed in a baculovirus expression vector.

Recomendaciones sobre el uso de metrotexato parenteral en enfermedades reumáticas / Recommendations for the use of parenteral methotrexate in rheumatic diseases

Objetivos. Desarrollar recomendaciones sobre el uso de metrotexato (MTX) parenteral en pacientes con enfermedades reumáticas, fundamentalmente en la artritis reumatoide, basadas en la mejor evidencia y experiencia. Métodos. Se seleccionó un grupo de 21 expertos reumatólogos en el manejo de MTX. El coordinador generó 13 preguntas sobre el uso de MTX parenteral (perfiles de indicación, eficacia, seguridad, costo-eficacia y biodisponibilidad) para ser contestadas mediante una revisión sistemática de la literatura. Con base en las preguntas se definieron los criterios de inclusión y exclusión, y las estrategias de búsqueda (en Medline, EMBASE y la Cochrane Library). Tres revisores seleccionaron los artículos resultantes de la búsqueda. Se generaron tablas de evidencia. Paralelamente se evaluaron abstracts de congresos de la European League Against Rheumatism (EULAR) y del American College of Rheumatology (ACR). Con toda esta evidencia el coordinador generó 13 recomendaciones preliminares que se evaluaron, discutieron y votaron en una reunión del grupo nominal con los expertos. Para cada recomendación se estableció el nivel de evidencia y grado de recomendación, y el grado de acuerdo mediante un Delphi. Se definió acuerdo si al menos el 80% de los participantes contestaron sí a la recomendación (sí o no). Resultados. La mayoría de la evidencia proviene de la artritis reumatoide. De las 13 recomendaciones preliminares se aceptaron 11 recomendaciones sobre el uso de MTX parenteral en reumatología. Dos no se llegaron a votar y se decidió no incluirlas, pero se comentan en el texto final. Conclusiones. Este documento pretende resolver algunos interrogantes clínicos habituales y facilitar la toma de decisiones con el uso de MTX parenteral

Objective. To develop recommendations for the use of parenteral methotrexate (MTX) in rheumatic diseases, mainly rheumatoid arthritis, based on best evidence and experience. Methods. A group of 21 experts on parenteral MTX use was selected. The coordinator formulated 13 questions about parenteral MTX (indications, efficacy, safety and cost-effectiveness). A systematic review was conducted to answer the questions. Using this information, inclusion and exclusion criteria were established, as were the search strategies (involving Medline, EMBASE and the Cochrane Library). Three different reviewers selected the articles. Evidence tables were created. Abstracts from the European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) were evaluated. Based on this evidence, the coordinator proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation were established using the Oxford Center for Evidence-Based Medicine and the level of agreement with the Delphi technique (2 rounds). Agreement was established if at least 80% of the experts voted yes (yes/no). Results. Most of the evidence involved rheumatoid arthritis. A total of 13 preliminary recommendations on the use of parenteral MTX were proposed; 11 of them were accepted. Two of the 13 were not voted and are commented on in the main text. Conclusions. The manuscript aims to solve frequent questions and help in decision-making strategies when treating patients with parenteral MTX