Evaluation of medical ethics competencies in rheumatology: local experience during national accreditation process.

INTRODUCTION: Rheumatologists are the primary healthcare professionals responsible for patients with rheumatic diseases and should acquire medical ethical competencies, such as the informed consent process (ICP). The objective clinical structured examination is a valuable tool for assessing clinical competencies. We report the performance of 90 rheumatologist trainees participating in a station designed to evaluate the ICP during the 2018 and 2019 national accreditations. METHODS: The station was validated and represented a medical encounter in which the rheumatologist informed a patient with systemic lupus erythematosus with clinically active nephritis about renal biopsy. A trained patient-actor and an evaluator were instructed to assess ICP skills (with a focus on kidney biopsy benefits, how the biopsy is done and potential complications) in obtaining formal informed consent, delivering bad news and overall communication with patients. The evaluator used a tailored checklist and form. RESULTS: Candidate performance varied with ICP content and was superior for potential benefit information (achieved by 98.9% of the candidates) but significantly reduced for potential complications (37.8%) and biopsy description (42.2%). Only 17.8% of the candidates mentioned the legal perspective of ICP. Death (as a potential complication) was omitted by the majority of the candidates (93.3%); after the patient-actor challenged candidates, only 57.1% of them gave a clear and positive answer. Evaluators frequently rated candidate communications skills as superior (≥80%), but ≥1 negative aspect was identified in 69% of the candidates. CONCLUSIONS: Ethical competencies are mandatory for professional rheumatologists. It seems necessary to include an ethics competency framework in the curriculum throughout the rheumatology residency.

Vaccination against influenza and pneumococus in patients with rheumatoid arthritis.

BACKGROUND: Vaccination against pathogens such as influenza or pneumococcus is widely recommended for patients with rheumatoid arthritis; the prevalence of adherence to these vaccination programmes in Mexico is not known. METHODS: A cross-sectional descriptive study was carried out, through the application of a survey to adult patients with a diagnosis of rheumatoid arthritis treated in a tertiary hospital in Mexico City. RESULTS: 227 patients were included, vaccination against influenza was found in 31.3% and against pneumococcus in 17.6% of patients, the main reasons for non-compliance with the vaccination schedule were related to ignorance and the recommendation by doctors not to do so. CONCLUSIONS: Compliance with the recommended vaccination schedules in the studied population is lower than those reported in other populations. The most important interventions to improve coverage should be aimed at educating both patients and medical personnel.

Distribution and characteristics of the certification of rheumatologists in Mexico.

OBJECTIVE: Describe the distribution of adult and pediatric rheumatologists with current certification in Mexico and the factors associated with this distribution. METHODS: The databases of the Mexican Council of Rheumatology and the Mexican College of Rheumatology for 2020 were reviewed. The rate of rheumatologists per 100,000 inhabitants by state of the Mexican Republic was calculated. To find out the number of inhabitants by state, the results of the 2020 population census of the National Institute of Statistics and Geography were consulted. The number of rheumatologists with current certification by state, age, and sex was analyzed. RESULTS: In Mexico, there are 1002 registered adult rheumatologists with a mean age of 48.12 ±â€¯13 years. The male gender prevailed with a ratio of 1.18:1. Ninety-four pediatric rheumatologists were identified with a mean age of 42.25 ±â€¯10.4 years, with a predominance of the female gender with a ratio of 2.2:1. In Mexico City and Jalisco, more than one rheumatologist/100,000 inhabitants were reported in the specialty of adults and only in Mexico City in pediatrics. The current certification is 65%-70% on average and the factors associated with a higher prevalence were younger age, female gender and geographic location. CONCLUSIONS: There is a shortage of rheumatologists in Mexico and in the pediatric area there are underserved regions. It is important that health policies apply measures that allow a more balanced and efficient regionalization of this specialty. Although most rheumatologists have current certification, it is necessary to establish strategies to increase this proportion.

Epidemiological Profile and Social Welfare Index as Factors Associated with COVID-19 Hospitalization and Severity in Mexico City: A Retrospective Analysis.

Epidemiological data indicate that Mexico holds the 19th place in cumulative cases (5506.53 per 100,000 inhabitants) of COVID-19 and the 5th place in cumulative deaths (256.14 per 100,000 inhabitants) globally and holds the 4th and 3rd place in cumulative cases and deaths in the Americas region, respectively, with Mexico City being the most affected area. Several modifiable and non-modifiable risk factors have been linked to a poor clinical outcome in COVID-19 infection; however, whether socioeconomic and welfare factors are associated with clinical outcome has been scanty addressed. This study tried to investigate the association of Social Welfare Index (SWI) with hospitalization and severity due to COVID-19. A retrospective analysis was conducted at the Centro Médico Nacional "20 de Noviembre"-ISSSTE, based in Mexico City, Mexico. A total of 3963 patients with confirmed or suspected COVID-19, registered from March to July 2020, were included, retrieved information from the Virology Analysis and Reference Unit Database. Demographic, symptoms and clinical data were analyzed, as well as the SWI, a multidimensional parameter based on living and household conditions. An adjusted binary logistic regression model was performed in order to compare the outcomes of hospitalization, mechanical ventilation requirement (MVR) and mortality between SWI categories: Very high (VHi), high (Hi), medium (M) and low (L). The main findings show that lower SWI were independently associated with higher probability for hospital entry: VHi vs. Hi vs. M vs. L-SWI (0 vs. +0.24 [OR = 1.24, CI95% 1.01-1.53] vs. +0.90 [OR = 1.90, CI95% 1.56-2.32] vs. 0.73 [OR = 1.73, CI95% 1.36-2.19], respectively); Mechanical Ventilation Requirement: VHi vs. M vs. L-SWI (0 vs. +0.45 [OR = 1.45, CI95% 1.11-1.87] vs. +0.35 [OR = 1.35, CI95% 1.00-1.82]) and mortality: VHi vs. Hi vs. M (0 vs. +0.54 [OR = 1.54, CI95% 1.22-1.94] vs. +0.41 [OR = 1.41, CI95% 1.13-1.76]). We concluded that SWI was independently associated with the poor clinical outcomes in COVID-19, beyond demographic, epidemiological and clinical characteristics.

Mortality and evolution between community and hospital-acquired COVID-AKI.

BACKGROUND: Acute kidney injury (AKI) is associated with poor outcomes in COVID patients. Differences between hospital-acquired (HA-AKI) and community-acquired AKI (CA-AKI) are not well established. METHODS: Prospective, observational cohort study. We included 877 patients hospitalized with COVID diagnosis at two third-level hospitals in Mexico. Primary outcome was all-cause mortality at 28 days compared between COVID patients with CA-AKI and HA-AKI. Secondary outcomes included the need for KRT, and risk factors associated with the development of CA-AKI and HA-AKI. RESULTS: A total of 377 patients (33.7%) developed AKI. CA-AKI occurred in 202 patients (59.9%) and HA-AKI occurred in 135 (40.1%). Patients with CA-AKI had more significant comorbidities, including diabetes (52.4% vs 38.5%), hypertension (58.4% vs 39.2%), CKD (30.1% vs 14.8%), and COPD (5.9% vs 1.4%), than those with HA-AKI. Patients' survival without AKI was 87.1%, with CA-AKI it was 75.4%, and with HA-AKI it was 69.6%, log-rank test p < 0.001. Only age > 60 years (OR 1.12, 95% CI 1.06-1.18, p <0.001), COVID severity (OR 1.09, 95% CI 1.03-1.16, p = 0.002), the need in mechanical lung ventilation (OR 1.67, 95% CI 1.56-1.78, p <0.001), and HA-AKI stage 3 (OR 1.16, 95% CI 1.05-1.29, p = 0.003) had a significant increase in mortality. The presence of CKD (OR 1.48, 95% CI 1.391.56, p < 0.001), serum lymphocytes < 1000 µL (OR 1.03, 95% CI 1.00-1.07, p = 0.03), the need in mechanical lung ventilation (OR 1.06, 95% CI 1.02-1.11, p = 0.003), and CA-AKI stage 3 (OR 1.37, 95% CI 1.29-1.46, p < 0.001) were the only variables associated with a KRT start. CONCLUSIONS: We found that COVID patients who are complicated by CA-AKI have more comorbidities and worse biochemical parameters at the time of hospitalization than HA-AKI patients, but despite these differences, their probability of dying is similar.

Neurological Manifestations and Outcomes in a Retrospective Cohort of Mexican Inpatients with SARS-CoV-2 Pneumonia: Design of a Risk Profile.

We analyzed the neurological manifestations in Mexican patients hospitalized with pneumonia due to COVID-19 and investigated the association between demographic, clinical, and biochemical variables and outcomes, including death. A retrospective, analytical study was conducted using the electronic records of patients hospitalized between 1 April 2020 and 30 September 2020. Records of 1040 patients were analyzed: 31.25% died and 79.42% had neurological symptoms, including headache (80.62%), anosmia (32.20%), ageusia (31.96%), myopathy (28.08%), disorientation (14.89%), encephalopathy (12.22%), neuropathy (5.4%), stroke (1.3%), seizures (1.3%), cerebral hemorrhage (1.08%), encephalitis (0.84%), central venous thrombosis (0.36%), and subarachnoid hemorrhage (0.24%). Patients also had comorbidities, such as hypertension (42.30%), diabetes mellitus (38.74%), obesity (61.34%), chronic obstructive pulmonary disease (3.17%), and asthma (2.01%). Factors associated with neurological symptoms were dyspnea, chronic obstructive pulmonary disease, advanced respiratory support, prolonged hospitalization, and worsening fibrinogen levels. Factors associated with death were older age, advanced respiratory support, amine management, chronic obstructive pulmonary disease, intensive care unit management, dyspnea, disorientation, encephalopathy, hypertension, neuropathy, diabetes, male sex, three or more neurological symptoms, and obesity grade 3. In this study we designed a profile to help predict patients at higher risk of developing neurological complications and death following COVID-19 infection.

Update of the Mexican College of Rheumatology Guidelines for the Pharmacological Treatment of Rheumatoid Arthritis, 2018. / Actualización de las guías del tratamiento farmacológico de la artritis reumatoide del Colegio Mexicano de Reumatología 2018.

Therapeutic advances in rheumatoid arthritis require periodic review of treatment guidelines. OBJECTIVE: To update the Mexican College of Rheumatology guidelines on the pharmacological treatment of rheumatoid arthritis. METHOD: Board certified rheumatologists from different health institutions and regions of the country participated. Work teams were formed that reviewed the previous guidelines, elaborated new questions, reviewed the literature, and scored the evidence that was presented and discussed in plenary session. The conclusions were presented to infectologists, gynaecologists and patients. Recommendations were based on levels of evidence according to GRADE methodology. RESULTS: Updated recommendations on the use of available medications for rheumatoid arthritis treatment in Mexico up to 2017 are presented. The importance of adequate and sustained control of the disease is emphasized and relevant safety aspects are described. Bioethical conflicts are included, and government action is invited to strengthen correct treatment of the disease. CONCLUSIONS: The updated recommendations of the Mexican College of Rheumatology on the pharmacological treatment of rheumatoid arthritis incorporate the best available information to be used in the Mexican health care system.

[Hepatic fasciolasis diagnosed in state phase]. / Fasciolosis hepática diagnosticada en fase de estado.

INTRODUCTION: Hepatic fasciolosis is a zoonosis that accidentally can invade the human. REPORT OF A CASE: 62 years old male, farmer, lives in a rural community in Tehuacan, Puebla, Mexico. His living space is not provided with running water nor drainage. He has contact with sheep and bovines. Started presenting symptoms two years before. Suffered from myalgia, joint pain, fever of 38 degrees C and epigastric pain that radiated the hypocondrium and the right shoulder. He had diarrhea five times in 24 hours as well as lack of appetite that lead to a weight loss of 20 kilograms in two years. He was hospitalized and the physical examination revealed diminished muscular mass, right hypocondrium pain and hepatomegaly of 3 cm below costal margin. He said he ate watercress (Nasturium officinalis) two or three times a week. Blood test revealed erythrocytes of 3.6 x 105 mm3; hemoglobin of 11.9 g/dL; hematocrit of 30%; leukocytes 8950 mm3; neutrophils 65%; lymphocytes of 30%; eosinophils of 3%; monocytes of 1% and basophiles of 1%. Globular sedimentation was 83 mm and hemoglobin concentration was 33. Liver test results were normal and mycobacterium in fecal samples was negative, but stool detection tests revealed eggs of Fasciola hepatica. The diagnosis was hepatic fasciolosis in its biliar stage. Dehidrohemetine (1.5 mg/kg) was administered during 10 days. Symptoms disappeared within 48 hours. CONCLUSION: The lack of knowledge about fasciolosis makes it hard to diagnose it. The publication of case reports must help to facilitate its diagnosis.

Efficacy and tolerability of rituximab in patients with rhupus.

Rhupus in an infrequent disease in which an overlap between lupus eritematosus and rheumatoid arthritis exists. Joint manifestations are prominent and treatment with non biological DMARDs is not always satisfactory, so immunosupressors and biological agents have been tried. A prospective, open clinical study was done to evaluate efficacy and tolerability of rituximab in patients with Rhupus. The main objective was a change in DAS28 at 6 months and secondary objectives were a change in MEX-SLEDAI at 6 months, change in DAS28 and MEX-SLEDAI during follow up, steroid requirements and detection of adverse events. We included 9 women with a mean age of 43 years and disease duration of 10 years. A significant reduction in DAS28 was observed (from 5.73 at baseline to 3.02 at 6 months, P<.001). Improvement in DAS28 was maintained during follow up. At 6 months, 3 patients were in remission and 3 had low disease activity. MEX-SLEDAI diminished from 5 points at baseline to 1.22 at 6 months (P<.001). There was a negative correlation between clinical improvement and anti-CCP levels (r=-0,794, P=.011). Mean prednisone dose was reduced from 11.66mg/day at baseline to 0,55 and 1.11mg/day at 12 and 24 months. Treatment was well tolerated. In this study rituximab was effective not only for joint affection but also for other manifestations of the disease. We consider that this biological agent can be a good therapeutic option for patients with rhupus.

Strategic evaluation of silent myocardial ischemia in a group of patients with rheumatoid arthritis and traditional cardiovascular risk factors / Evaluación estratégica de la isquemia miocárdica silenciosa en un grupo de pacientes con artritis reumatoide y factores de riesgo cardiovascular tradicionales

Abstract: Introduction: IHD has become an important long-term end point for RA patients independent of traditional CVRF. Therefore, cardiovascular injury and mortality might be due to the presence of a chronic systematic inflammatory response. Nonetheless, there is a gap in its diagnosis since symptoms remain silent until major events occur. Objective: We aimed to evaluate by gated single-photon emission computed tomography (g-SPECT). Myocardial perfusion in asymptomatic Mexican patients with RA and at least one traditional CVRF, and without history of angina. Patients and methods: A prospective study with a total number of 91 patients was conducted. We evaluated CVRF and RA characteristics. We non-invasively assessed them with g-SPECT to reveal ischemia, territories and severity. We calculated relative risks and 95% CI of ischemia given the associated variables. Results: 22 (24.2%) patients presented ischemia, half of them in the LAD territory. Regarding CVRF and disease's characteristics; only smokers and patients under a steroid treatment were at more risk to present ischemia (0.49 [0.24 to 0.98] and 2.04 [1.01 to 4.14], respectively) with a p = 0.046. Conclusion: We have contributed with additional evidence to strategically diagnose IHD in patients with RA even if they have no symptoms and independently of the existence of cardiovascular risk factors to prevent and reduce cardiovascular mortality.

Resumen: Introducción: La IC se ha convertido en un importante punto de partida a largo plazo para los pacientes con AR independientemente de los FRCV tradicionales. Por lo tanto, las lesiones cardiovasculares y la mortalidad podrían deberse a la presencia de una respuesta inflamatoria sistemática crónica. Sin embargo, hay una brecha en su diagnóstico ya que los síntomas permanecen en silencio hasta que ocurren eventos importantes. Objetivo: Evaluar mediante tomografía computarizada de emisión de un solo fotón (g-SPECT). Perfusión miocárdica en pacientes mexicanos asintomáticos con AR y al menos un FRCV tradicional, sin antecedentes de angina. Pacientes y métodos: Se realizó un estudio prospectivo con un número total de 91 pacientes. Se evaluaron las características FRCV y AR. Los evaluamos de forma no invasiva con g-SPECT para revelar isquemia, territorios y severidad. Se calcularon los riesgos relativos la isquemia de 95% dadas las variables asociadas. Resultados: Veintidós (24.2%) pacientes presentaron isquemia, la mitad de ellos en territorio LAD. Respecto a los FRCV y características de la enfermedad; sólo los fumadores y los pacientes sometidos a un tratamiento con esteroides presentaron mayor riesgo de presentar isquemia (0.49 [0.24 a 0.98] y 2.04 [1.01 a 4.14], respectivamente) con p = 0.046. Conclusión: Hemos aportado pruebas adicionales para diagnosticar la isquemia estratégicamente en los pacientes con AR, incluso si no tienen síntomas y con independencia de la existencia de factores de riesgo cardiovascular para prevenir y reducir la mortalidad cardiovascular.

Autonomía en movimiento: reflexión desde las prácticas políticas alternativas de jóvenes en Colombia / Autonomy in action: reflection from the Colombian youths’ alternative political practices / Autonomia em movimento: reflexões desde as práticas políticas alternativas dos jovens colombianos

En este artículo presentamos una reflexión sobre los ejercicios de autonomía en las prácticas políticas de jóvenes en Colombia que, desde los principios de desobediencia y noviolencia activa, resisten a la lógica patriarcal y militarista que impera en la organización social y en la cultura dominante. En esta vía, ubicamos a la autonomía como una trama de la subjetividad política que trasciende la mirada de ilustración del pensamiento y la capacidad de pensar por sí mismo, al entenderla también como acción transformadora que se dinamiza a partir de las ideas de: un nosotros, la acción política y la esperanza de un mundo -presente y futuro- distinto.

Neste artigo apresentamos uma reflexão sobre os exercícios de autonomia nas práticas políticas dos jovens Colombianos os quais, desde os princípios de desobediência e não-violência ativa , resistem à lógica patriarcal e militarista que impera na organização social e na cultura dominante. Desta maneira, localizamos a autonomia como uma trama da subjetividade política que transcende a perspectiva da ilustração do pensamento e a capacidade de pensar per se mesmo, quando a compreendemos como uma ação transformadora que se dinamiza a partir da ideia de um “nós”: a ação política e a esperança de um mundo – presente e futuro – diferente.

This article aims at presenting a reflection about the autonomy exercises in the Colombian youths’ political practices who, from the principles of disobedience and active non-violence, resist to the patriarchal and militaristic logics that prevail in the social organization and in the predominant culture. This way, autonomy is viewed as a plot of political subjectivity that goes beyond the limits of the perspective of thinking illustration and the capacity to think by oneself when understanding it as a transforming action which is dynamized from the idea of “us”: the political action and hope of a distinct - present and future – world.

Miasis de nasofaringe, completando ciclo biológico in vitro / Myasis of nasopharynx, biologic cycle completed in vitro

Introducción. Miasis es la destrucción de tejidos de animales, incluido el hombre, por larvas de moscas. Caso clínico. Paciente femenino de 13 años de edad con antecedente de convivencia con aves de corral, que presentó, 5 días previos a su ingreso, temperatura de 38° C, dolor y prurito nasofaríngeo. En el servicio de urgencias se diagnosticó como rinofaringitis bacteriana, prescribiéndole penicilina procaínica y clorfeniramina. A los 3 días refirió salida de gusanos por boca y nariz en número de 10. A la exploración física se apreció faringe con hiperemia, saliendo por nariz y boca gusanos activamente móviles de color blancoamarillento, de 10 mm de longitud y 3 mm de ancho, en número de 20. Enviados a la Facultad de Medicina de Puebla, donde completaron ciclo biológico. La mosca obtenida fue Dermatobia hominis, familia Enterebridae. En el hospital se le practicó extracción de 85 larvas utilizando anestesia general e irrigación continua. Fue dada de alta 10 días después, asintomática. Conclusiones. La miasis es poco frecuente y puede ocasionar grandes destrucciones de tejido.

Introduction. Myasis is the parasitism of organs and tissues of warm-blooded vertebrates by the larvae of flies of different species. Case report. Thirteen year old female. Her house is provided with running water and sewer she had contact with farm house poultry. She began presenting symptoms 5 days prior to admission she presented with nasal discharge and pharyngitis. Her temperature was 38° C. At emergency services the patient was diagnosed with bacterial pharyngytis. Penicillin and clorfeniramine were administered. Three days later, larvae started coming out of her nose and mouth. In total 10 larvae were documented. In emergency services at a hospital, physical examination revealed pharyngeal erythema and rinorrhea. The larvae were described as yellowish, 10 mm long and 3 mm wide. The worms were sent to the Department of Parasitology of the School of Medicine of Puebla, Mexico, where they completed the in vitro cycle and were identified as Dermatobia hominis (fly), belonging to the Enterebridae family. In the hospital, 85 larvae were extracted from the patient. She discharged after 10 days of asymptomatic hospitalization. Conclusion. Myasis is not frequent and it can cause great tissue destruction. Antibiotic administration is generally not warranted unless there is evidence of concomitant superinfection.