Evaluating sarcopenia prevalence and SARC-F effectiveness in elderly Spanish women with RA: a comparative study of EWGSOP criteria.

Introduction: The European Working Group on Sarcopenia in Older People (EWGSOP) has put forward two key proposals for diagnosing sarcopenia: the EWGSOP1 in 2010 and the EWGSOP2 in 2019. These proposals are currently the most widely used guidelines for diagnosing sarcopenia. However, data on the prevalence of sarcopenia in patients with rheumatoid arthritis (RA) based on EWGSOP criteria are limited. This study aimed to: (a) establish the prevalence of sarcopenia in an elderly Spanish cohort of women with RA using both EWGSOP1 and EWGSOP2 criteria; and (b) evaluate the effectiveness of the SARC-F questionnaire in detecting sarcopenia. Methods: In this observational, cross-sectional study, 67 women aged over 65 years who met the ACR 2010 criteria for RA were consecutively recruited from a tertiary university hospital. Assessments included: (a) demographic and anthropometric data; (b) RA-related variables (disease history, analytical evaluation, activity, disability, quality of life); and (c) sarcopenia-related variables (muscle strength, gait speed, skeletal muscle mass, and SARC-F questionnaire). The prevalence of sarcopenia was determined using both EWGSOP1 and EWGSOP2 criteria. Furthermore, the effectiveness of the SARC-F questionnaire for detecting sarcopenia were calculated. Results: The prevalence of sarcopenia was 43% according to the EWGSOP1 criteria and 16% according to the EWGSOP2 criteria. Patients diagnosed with sarcopenia based on the latter criteria also met the EWGSOP1's criteria for sarcopenia. Agreement between the two sets of EWGSOP criteria was poor. The SARC-F questionnaire demonstrated an inherently high sensitivity (100%) as well as good specificity (75%) and diagnostic accuracy (79%) in detecting sarcopenia according to EWGSOP2 criteria. Conclusions: The prevalence rate of sarcopenia among elderly Spanish women with RA varies significantly depending on whether EWGSOP1 or EWGSOP2 criteria are applied. The SARC-F questionnaire is effective for predicting sarcopenia when used in conjunction with the EWGSOP2 criteria, which is currently the most accepted standard in clinical practice.

SLESIS-R: an improved score for prediction of serious infection in patients with systemic lupus erythematosus based on the RELESSER prospective cohort.

OBJECTIVE: To develop an improved score for prediction of severe infection in patients with systemic lupus erythematosus (SLE), namely, the SLE Severe Infection Score-Revised (SLESIS-R) and to validate it in a large multicentre lupus cohort. METHODS: We used data from the prospective phase of RELESSER (RELESSER-PROS), the SLE register of the Spanish Society of Rheumatology. A multivariable logistic model was constructed taking into account the variables already forming the SLESIS score, plus all other potential predictors identified in a literature review. Performance was analysed using the C-statistic and the area under the receiver operating characteristic curve (AUROC). Internal validation was carried out using a 100-sample bootstrapping procedure. ORs were transformed into score items, and the AUROC was used to determine performance. RESULTS: A total of 1459 patients who had completed 1 year of follow-up were included in the development cohort (mean age, 49±13 years; 90% women). Twenty-five (1.7%) had experienced ≥1 severe infection. According to the adjusted multivariate model, severe infection could be predicted from four variables: age (years) ≥60, previous SLE-related hospitalisation, previous serious infection and glucocorticoid dose. A score was built from the best model, taking values from 0 to 17. The AUROC was 0.861 (0.777-0.946). The cut-off chosen was ≥6, which exhibited an accuracy of 85.9% and a positive likelihood ratio of 5.48. CONCLUSIONS: SLESIS-R is an accurate and feasible instrument for predicting infections in patients with SLE. SLESIS-R could help to make informed decisions on the use of immunosuppressants and the implementation of preventive measures.

Radiculopathy with motor deficit: a cross-sectional study of the impact of the surgeon's experience on the indication and timing of surgical treatment.

PURPOSE: The optimal management of patients with compressive radiculopathy with motor deficit (CRMD) is controversial. Our goal was to provide evidence on the impact of the spine surgeons' experience on surgical planning and timing. METHODS: Spine surgeons were invited to participate in a 5-item online survey. A literature review was carried out. RESULTS: Of the 94 spine surgeons who responded to the survey, 70% would operate early on a patient with acute CRMD, but only 48% would do so if the radicular pain had resolved. Surgeons with more than 15 years of experience chose more conservative options. Twenty published studies were selected in the literature review. CONCLUSION: The optimal management of patients with compressive radiculopathy associated with a non-progressive motor loss remains unknown. The results of our survey show that surgeons with extensive surgical experience take a more conservative and cautious approach.

Executive summary: Guidelines for the diagnosis and treatment of septic arthritis in adults and children, developed by the GEIO (SEIMC), SEIP and SECOT.

Infection of a native joint, commonly referred to as septic arthritis, is a medical emergency because of the risk of joint destruction and subsequent sequelae. Its diagnosis requires a high level of suspicion. These guidelines for the diagnosis and treatment of septic arthritis in children and adults are intended for use by any physician caring for patients with suspected or confirmed septic arthritis. They have been developed by a multidisciplinary panel with representatives from the Bone and Joint Infections Study Group (GEIO) belonging to the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Paediatric Infections (SEIP) and the Spanish Society of Orthopaedic Surgery and Traumatology (SECOT), and two rheumatologists. The recommendations are based on evidence derived from a systematic literature review and, failing that, on the opinion of the experts who prepared these guidelines. A detailed description of the background, methods, summary of evidence, the rationale supporting each recommendation, and gaps in knowledge can be found online in the complete document.

Feasibility of a multidisciplinary group videoconferencing approach for chronic low back pain: a randomized, open-label, controlled, pilot clinical trial (EN-FORMA).

BACKGROUND: Low back pain is a common condition that becomes even more prevalent with aging. A non-pharmacological multidisciplinary approach for chronic non-specific low back pain (CNSLBP) has been recommended, but integrating different healthcare professionals is challenging. A multidisciplinary group videoconferencing approach (MGVA) can be helpful. Our aim was to provide evidence on MGVA's feasibility in managing CNSLBP and its impact on clinical practice. METHODS: We conducted an open-label, randomized, controlled, parallel-group pilot clinical trial with CNSLBP patients irresponsive to conservative treatment. Patients between 18 and 67 years of age were randomly assigned (1:1) to either Standard-of-Care + MGVA (experimental group) or Standard-of-Care alone (control group). MGVA consisted of integrated sessions for physical rehabilitation/physiotherapy, psychology, and social work treatments. The control group received standard clinical practice treatment. The feasibility was assessed by the number of study procedures completed to at least 80% as planned. The impact on clinical practice was evaluated by the number of patients who changed their status from "candidate" to "non-candidate" to low back surgery as the treatment of choice for CNSLBP. The SF-36, Oswestry Disability Index, and TMMS-24 questionnaires were used. We performed a whole population-based descriptive analysis. RESULTS: We included 20 patients, but only 18 were randomized (2 withdrew consent before randomization). The mean (SD) age was 53.1 (5.9) years, and mostly women (13/18); 7 were actively employed. In the experimental group, 6/9 (67%, 95%CI:35-88%) patients attended at least 80% of the scheduled procedures, while in the control group, 8/9 (89%, 95%CI:57-98%) did. Additionally, 1 out of 4 (25%) patients in the experimental group changed their status from "candidate" for low back surgery to "non-candidate". None of the 2 patients in the control group did so. We found differences between groups in the SF-36 mental health component (p-value:0.061), Oswestry Disability Index (p-value:0.032), and TMMS-24 Repair component (p-value:0.014) at the end of the trial favoring MGVA. CONCLUSIONS: The multidisciplinary group videoconferencing approach to managing chronic non-specific low back pain was feasible, suggesting overall beneficial effects on patients' health and could play a role in changing a patient's status from "candidate" to "non-candidate" for surgery. TRIAL REGISTRATION: NCT05093543 (ClinicalTrials.gov), first registered in 26/10/2021.

Anti-TNF vs tocilizumab in refractory uveitic cystoid macular edema due to Behcet's disease. Multicenter study of 49 patients.

OBJECTIVE: To compare the efficacy of TNF inhibitors (adalimumab (ADA) and infliximab (IFX)) vs tocilizumab (TCZ) in patients with refractory cystoid macular edema (CME) due to Behçet's disease (BD). METHODS: Multicenter study of patients with BD-associated CME refractory to conventional and/or biological immunosuppressive drugs. From a cohort of 177 patients treated with anti-TNF and 14 patients treated with TCZ, we selected those with CME at baseline. We analyzed the evolution of macular thickness (main outcome), best-corrected visual acuity (BCVA) and intraocular inflammation (Tyndall and vitritis) from baseline up to 4 years in the 3 groups mentioned. RESULTS: 49 patients and 72 eyes with CME were included. ADA was used in 25 patients (40 eyes), IFX in 15 (21 eyes) and TCZ in 9 (11 eyes). No statistically significant baseline differences were observed between the 3 groups except for a lower basal BCVA in TCZ group and a higher basal degree of intraocular inflammation in ADA group. Most patients from all groups had received several conventional immunosuppressive drugs. In addition, most patients in the group of TCZ had also received anti-TNF agents. Biological therapy was used in monotherapy (n=8) or combined with conventional immunosuppressive drugs (n=41). Macular thickness progressively decreased in the 3 groups, with no signs of CME after 1 year of treatment. Similarly, BCVA improvement and inflammatory intraocular remission was achieved in all groups. CONCLUSION: Refractory CME associated with BD uveitis can be effectively treated either with ADA, IFX or TCZ. Furthermore, TCZ is effective in patients resistant to anti-TNF therapy.

A Thermographic Disease Activity Index for remote assessment of rheumatoid arthritis.

OBJECTIVES: Remote assessment of patients with rheumatoid arthritis (RA) has increased during recent years. However, telematic consultations preclude the possibility of carrying out a physical examination and obtaining objective inflammation. In this study, we developed and validated two novel composite disease activity indexes (Thermographic Disease Activity Index (ThermoDAI) and ThermoDAI-CRP) based on thermography of hands and machine learning, in order to assess disease activity easily, rapidly and without formal joint counts. METHODS: ThermoDAI was developed as the sum of Thermographic Joint Inflammation Score (ThermoJIS), a novel joint inflammation score based on the analysis of thermal images of the hands by machine learning, the Patient Global Assessment (PGA) and, for ThermoDAI-CRP, the C reactive protein (CRP). Construct validity was tested in 146 patients with RA by using Spearman's correlation with ultrasound-determined grey-scale synovial hypertrophy (GS) and power Doppler (PD) scores, CDAI, SDAI and DAS28-CRP. RESULTS: Correlations of ultrasound scores with ThermoDAI (GS=0.52; PD=0.56) and ThermoDAI-CRP (GS=0.58; PD=0.61) were moderate to strong, while the correlations of ultrasound scores with PGA (GS=0.35; PD=0.39) and PGA+CRP (GS=0.44; PD=0.46) were weak to moderate. ThermoDAI and ThermoDAI-CRP also showed strong correlations with Clinical Disease Activity Index (ρ>0.83), Simplified Disease Activity Index (ρ>0.85) and Disease Activity Score with 28-Joint Counts-CRP (ρ>0.81) and high sensitivity for detecting active synovitis using remission criteria. CONCLUSIONS: ThermoDAI and ThermoDAI-CRP showed stronger correlations with ultrasound-determined synovitis than PGA and PGA + CRP, thus presenting an opportunity to improve remote consultations with patients with RA.

Assessment of inflammation in patients with rheumatoid arthritis using thermography and machine learning: a fast and automated technique.

OBJECTIVES: Sensitive detection of joint inflammation in rheumatoid arthritis (RA) is crucial to the success of the treat-to-target strategy. In this study, we characterise a novel machine learning-based computational method to automatically assess joint inflammation in RA using thermography of the hands, a fast and non-invasive imaging technique. METHODS: We recruited 595 patients with arthritis and osteoarthritis, as well as healthy subjects at two hospitals over 4 years. Machine learning was used to assess joint inflammation from the thermal images of the hands using ultrasound as the reference standard, obtaining a Thermographic Joint Inflammation Score (ThermoJIS). The machine learning model was trained and tuned using data from 449 participants with different types of arthritis, osteoarthritis or without rheumatic disease (development set). The performance of the method was evaluated based on 146 patients with RA (validation set) using Spearman's rank correlation coefficient, area under the receiver-operating curve (AUROC), average precision, sensitivity, specificity, positive and negative predictive value and F1-score. RESULTS: ThermoJIS correlated moderately with ultrasound scores (grey-scale synovial hypertrophy=0.49, p<0.001; and power Doppler=0.51, p<0.001). The AUROC for ThermoJIS for detecting active synovitis was 0.78 (95% CI, 0.71 to 0.86; p<0.001). In patients with RA in clinical remission, ThermoJIS values were significantly higher when active synovitis was detected by ultrasound. CONCLUSIONS: ThermoJIS was able to detect joint inflammation in patients with RA, even in those in clinical remission. These results open an opportunity to develop new tools for routine detection of joint inflammation.

Prevalence of rheumatic diseases in Baix Empordà.

BACKGROUND: In Spain, the prevalence of different rheumatic diseases is known mainly through the EPISER studies coordinated by the Spanish Society of Rheumatology and based on surveys in a population sample. The aim of our study is to describe the prevalence in 2016 of different rheumatic diseases in the population residing in Baix Empordà according to healthcare coding records. MATERIALS AND METHODS: Observational, descriptive and cross-sectional study carried out on the population attended from 2016 to 2017 in SIBBE (Serveis de Salut Integrats del Baix Empordà), an organizational service that includes all the healthcare facilities in the Baix Empordà area with a unique information system. Patients ≥ 20 years of age were selected and the ICD9-CM coding of all their healthcare contacts was analysed according to 11 entities and 28 diseases. The entities were: polyarthritis, spondyloarthritis, microcrystalline arthritis, osteoarthritis, soft tissue rheumatism, fibromyalgia, chronic spinal pain, osteoporosis, connective tissue diseases, vasculitis and others. The studied population was assigned to the categories: "with rheumatic disease", "possible rheumatic disease" and "without rheumatic disease". RESULTS: In total, 71,785 patients were distributed as: 36.2% "with rheumatic disease (n = 25,990); 6.1% with "possible rheumatic disease" (n = 4406) and 57.7% "without rheumatic disease" (n = 41,389). The group "with rheumatic disease" showed a predominance of women (59.7% vs. 44.9%) and older age (59.1 ±â€¯17.7 vs. 45.1 ±â€¯16.2; p < .001) compared to the group "without rheumatic disease". The presence of rheumatic disease increased progressively with age, being maximum in the group between 55-75 years. CONCLUSIONS: 36.2% of our population has some type of rheumatic disease. The estimated prevalence of some rheumatic diseases in the Baix Empordà population is partially consistent with that estimated by the EPISER 2016 study. Rheumatic disease affects women in a greater proportion and is more frequent in patients over 45 years of age.

Rheumatology manpower in the public system in Catalonia (Spain).

OBJECTIVE: To determine the current state of Rheumatology in Catalonia and to update the information regarding previous studies. MATERIAL AND METHODS DESIGN: Observational, descriptive and cross-sectional study. Data collection from January to June 2017. SAMPLE: Rheumatologists practising public healthcare activity in Catalonia. An online questionnaire was sent to gather individual data and data from rheumatology services/sections. RESULTS: Information was obtained on 109 rheumatologists: 39 men and 70 women; mean age: 47±9 years. The number of rheumatologists has increased by 8% over the past 5 years. One hundred and one (92.7%) doctors qualified as rheumatologists through the MIR. Rheumatology practice was mostly in a hospital setting: 68 (62.4%) physicians. Ninety-six (88.1%) rheumatologists were full-time practitioners. Fifty-four (50%) rheumatologists also practiced in the private sector. Clinical practice was predominant: 76% of daily time was devoted to this area. Of note, it was found that most of the rheumatology services, 24 (705), were dependent hierarchically on other services, namely internal medicine and orthopaedic surgery. There are still 6 hospitals in Catalonia without a rheumatologist. CONCLUSIONS: The number of rheumatologists in the public health sector of Catalonia has increased over the past 5 years. The mean age of rheumatologists is advanced and there is a clear predominance of female practitioners in the specialty. Many rheumatology services depend on other services. Rheumatology activity is primarily focussed in the city of Barcelona.

Sarcopenia, immune-mediated rheumatic diseases, and nutritional interventions.

INTRODUCTION: Sarcopenia is defined by a loss of muscle mass and function associated with mortality, decreased physical performance, falls, and disability. Since chronic inflammation and decreased physical activity are risk factors for developing sarcopenia, it is critical to assess the role of sarcopenia in immune-mediated rheumatic diseases (IMRDs). Moreover, nutritional interventions are emerging as key modifiable and affordable options to improve physical performance in sarcopenia. OBJECTIVE: The aim of this review is to critically summarize current information on the evidence linking nutritional interventions and sarcopenia in IMRDs. METHODS: The search and selection of articles was performed in Medline, Dimensions.ai, Google Scholar, Cochrane Library, Epistemonikos, and Trip Database. The results were clustered into three areas: sarcopenia and IMRDs, sarcopenia and biological disease-modifying antirheumatic drugs (bDMARDs), and nutritional interventions for sarcopenia. FINDINGS: Several cross-sectional studies have shown a higher prevalence of sarcopenia in IMRDs, such as rheumatoid arthritis. Although not fully established, evidence linking sarcopenia and other IMRDs (ankylosing spondylitis and systemic sclerosis) has been also described. For secondary sarcopenia prevention and treatment, bDMARDs' administration proved efficacy in patients with rheumatoid arthritis. Furthermore, there is growing evidence linking nutrition to the prevention and treatment of sarcopenia. Evidence linking unfavourable results in nutritional risk assessment, insufficient intake of protein, vitamin D, antioxidant nutrients, and long-chain polyunsaturated fatty acids and sarcopenia have been reported. CONCLUSION: Given that sarcopenia and IMRDs have strong links, further research is needed to improve patient care.

Increased Prevalence of Moderate to Severe Mitral and Aortic Valve Dysfunction in Systemic Sclerosis: A Case-control Study.

OBJECTIVE: To investigate the prevalence, severity, and associated clinical factors of mitral and aortic valvular involvement in patients with systemic sclerosis (SSc). METHODS: Our case-control study included 172 patients with SSc and 172 non-SSc adults without known cardiac disease matched by age, sex, and prevalence of cardiovascular (CV) risk factors. The screening of mitral and aortic valvular involvement was performed by transthoracic Doppler echocardiogram. The prevalence of aortic stenosis (AS) was also compared with that reported in a population-based study performed in our community during the same period. RESULTS: Patients with SSc showed an almost 5-fold increased prevalence of moderate to severe mitroaortic valve dysfunction compared to non-SSc controls (OR 4.60, 95% CI 1.51-13.98; P = 0.003). The most common lesion was mitral regurgitation (MR), which was observed in 5.2% of patients, followed by AS in 3.5%, and aortic regurgitation (AR) in 1.7%. Analyzing the different types of valvular lesion separately, we observed a significantly higher frequency of MR compared to controls (OR 4.69, 95% CI 1.12-22.04; P = 0.032), as well as a higher frequency of AS in the 65-75 (OR 7.51, 95% CI 1.22-46.23, P = 0.01) and 76-85 age groups (OR 3.53, 95% CI 1.03-12.22, P = 0.043) when compared to the general population in our community. CONCLUSION: We found an increased prevalence of moderate to severe MR and AS in SSc compared to age-matched non-SSc controls with similar CV comorbidities. While results from this study do not allow for establishing a direct causal relationship, they strongly support the contribution of SSc-specific factors in the development of these complications.

Rituximab as a rescue treatment added on mycophenolate mofetil background therapy in progressive systemic sclerosis associated interstitial lung disease unresponsive to conventional immunosuppression.

OBJECTIVE: To test whether the use of rituximab (RTX) is effective and safe as a rescue therapy add-on treatment to mycophenolate (MMF) in patients with progressive systemic sclerosis-associated interstitial lung disease (SSc-ILD) in whom conventional immunosuppressants (IS) have failed. METHODS: Longitudinal retrospective observational study of a cohort of patients with SSc-ILD that started treatment with RTX due to ongoing lung function impairment despite treatment with glucocorticoids and IS (cyclophosphamide and/or MMF). All patients were treated with 2 or more cycles of RTX and evaluated for at least 12 months. RESULTS: Twenty-four patients were included. Before initiation of RTX the mean decline in%pFVC and %pDLCO during the previous 2 years (delta) was -12.9% and -12.5%, respectively. After 1 year of treatment with RTX, a significant improvement in %pFVC (∆+8.8% compared to baseline, 95% CI: -13.7 to -3.9; p = 0.001) and%pDLCO (∆+4.6%, 95% CI: -8.2 to -0.8; p = 0.018) was observed. In addition, there was a significant reduction in the median dose of prednisone and it could be suspended in 25% of patients. At 2 years of treatment, RTX had been discontinued in 9 patients (due to adverse events in 3 cases and inefficacy in 6). In the 15 patients (62.5%) that completed 24 months of therapy, the statistically significant amelioration in pulmonary function test parameters was maintained: ∆%pFVC: +11.1% (95% CI: -17.6 to -4.5; p = 0.003) and ∆%pDLCO: +8.7% (95% CI: -13.9 to -8.3; p = 0.003). CONCLUSION: Based on our results, RTX's use as an add-on treatment to MMF appears to be effective as a rescue therapy in patients with a more aggressive SSc-ILD phenotype.

Real-world clinical effectiveness of rituximab rescue therapy in patients with progressive rheumatoid arthritis-related interstitial lung disease.

OBJECTIVE: To assess the real-world, long-term effectiveness of rituximab (RTX) as a rescue therapy in patients with progressive rheumatoid arthritis-related interstitial lung disease (RA-ILD) in whom more conventional therapy has failed. METHODS: Longitudinal retrospective observational study of a cohort of patients with RA-ILD that started treatment with RTX due to ongoing progressive ILD despite treatment with glucocorticoids and csDMARDs or immunosuppressants (IS). All patients were treated with two or more cycles of RTX and evaluated for at least 12 months. Ongoing therapy with csDMARDs or IS remained unchanged. RESULTS: Thirty-one patients were analyzed. Before initiation of RTX the mean decline (delta) in %pFVC and %pDLCO from the ILD diagnosis (median 21 months) was -16.5% and -19.7%, respectively. After 1 year of treatment, RTX was able to reverse the decline of pulmonary function test (PFTs) parameters: ∆%pFVC +8.06% compared to baseline (95% CI: -10.9 to -5.2; p<0.001) and ∆%pDLCO +12.7% (95% CI: -16.3 to -9.1; p<0.001). In addition, there was a significant reduction in the median dose of prednisone, and it could be suspended in 26% of cases. Dividing the population into UIP and non-UIP patterns, we observed a significant increase in PFTs parameters in both groups. In the 25 patients (80.6%) that completed 2 years of treatment, the statistically significant amelioration in PFTs parameters observed at one year was maintained: ∆%pFVC +11.2% (95% CI: -15.6 to -6.8; p<0.001) and ∆%pDLCO +14.8% (95% CI: -19.3 to -10.3; p<0.001). At the end of the follow-up period (median 32 months; IQR 25th-75th 26-64), only 23 of the 31 patients (74.2%) were still undergoing treatment with RTX: in 3 cases (10%) it was stopped due to adverse events, in another 3 (10%) treatment failed ultimately requiring a lung transplant, and 2 patients (6%) died due to progression of the ILD and infectious complications. The frequency of adverse events reached 32% of cases. CONCLUSION: Based on our results, RTX appears to be effective as rescue therapy in a considerable proportion of patients with progressive RA-ILD unresponsive to conventional treatment.

Rheumatology Manpower in the Public System in Catalonia (Spain). / Estado actual de la reumatología en el sector sanitario público de Cataluña.

OBJECTIVE: To determine the current state of Rheumatology in Catalonia and to update the information regarding previous studies. MATERIAL AND METHODS DESIGN: Observational, descriptive and cross-sectional study. Data collection from January to June 2017. SAMPLE: Rheumatologists practising public healthcare activity in Catalonia. An online questionnaire was sent to gather individual data and data from rheumatology services/sections. RESULTS: Information was obtained on 109 rheumatologists: 39 men and 70 women; mean age: 47±9 years. The number of rheumatologists has increased by 8% over the past 5 years. One hundred and one (92.7%) doctors qualified as rheumatologists through the MIR. Rheumatology practice was mostly in a hospital setting: 68 (62.4%) physicians. Ninety-six (88.1%) rheumatologists were full-time practitioners. Fifty-four (50%) rheumatologists also practiced in the private sector. Clinical practice was predominant: 76% of daily time was devoted to this area. Of note, it was found that most of the rheumatology services, 24 (705), were dependent hierarchically on other services, namely internal medicine and orthopaedic surgery. There are still 6 hospitals in Catalonia without a rheumatologist. CONCLUSIONS: The number of rheumatologists in the public health sector of Catalonia has increased over the past 5 years. The mean age of rheumatologists is advanced and there is a clear predominance of female practitioners in the specialty. Many rheumatology services depend on other services. Rheumatology activity is primarily focussed in the city of Barcelona.

Expert Consensus on a Set of Outcomes to Assess the Effectiveness of Biologic Treatment in Psoriatic Arthritis: The MERECES Study.

OBJECTIVE: To reach a consensus on the instruments to be used in clinical practice to evaluate the effectiveness of biological disease-modifying antirheumatic drug (bDMARD) treatment in patients with psoriatic arthritis (PsA) in the short to medium term (3-6 mos), and to establish the minimum health outcomes for treatment continuation. METHODS: A 2-round Delphi questionnaire was developed based on both the information gathered in the literature review and 4 discussion groups. The suitability and feasibility of the proposed sets of instruments were assessed on a 7-point Likert scale. Consensus was established when at least 75% of healthcare professionals (HCP) reached agreement. To define a minimum health outcome to continue treatment, a combination of 4 disease activity states and 3 health-related quality of life states were defined for 3 hypothetical patient profiles. HCP were given a dichotomous choice (yes/no) to respond to whether they would continue treatment in each case. RESULTS: The second round was completed by 106 HCP. Consensus was reached on the use of (1) Disease Activity in Psoriatic Arthritis + Psoriatic Arthritis Impact of Disease (PsAID12) or minimal disease activity + PsAID12 + C-reactive protein, in peripheral PsA; and (2) Ankylosing Spondylitis Disease Activity Score + PsAID12, in axial PsA. Health outcomes considered sufficient to continue treatment were stricter for bDMARD-naive patients than for patients who failed several bDMARD. CONCLUSION: To the best of our knowledge, this is the first multidisciplinary consensus on a set of outcomes for the evaluation of bDMARD effectiveness in PsA, in routine clinical practice.

Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring in clinical practice: the spanish cohort of the COMORA study.

OBJECTIVES: To describe the prevalence of comorbidities in patients with RA in Spain and discuss their management and implications using data from the Spanish cohort of the multinational study on COMOrbidities in Rheumatoid Arthritis (COMORA). METHODS: This is a national sub-analysis of the COMORA study. We studied the demographics and disease characteristics of 200 adults patients diagnosed with RA (1987 ACR), and routine practices for screening and preventing the following selected comorbidities: cardiovascular, infections, cancer, gastrointestinal, pulmonary, osteoporosis and depression. RESULTS: Patients had a mean age of 58 years and a mean RA duration of 10 years. Mean DAS28 score was 3.3 and approximately 25% of patients were in remission (DAS28 <2.6). Forty-four (22%) patients had ≥1 comorbidity, the most frequent being depression (27%) and obesity (26%). A history of myocardial infarction or stroke was observed in 5% and 1% of patients, respectively, and any solid tumor in 6%. Having a Framingham Risk Score >20% (51%), hypercholesterolemia (46%) or hypertension (41%) and smoking (25%) were the most common CV risk factors. For prostate, colon and skin cancers, only 9%, 10% and 18% of patients, respectively, were optimally monitored. Infections were also inadequately managed, with 7% and 17% of patients vaccinated against influenza and pneumococcal, respectively, as was osteoporosis, with 47% of patients supplemented with vitamin D and 56% with a bone densitometry performed. CONCLUSIONS: In Spain, the prevalence of comorbidities and CV risk factors in RA patients with established and advanced disease is relatively high, and their management in clinical daily practice remains suboptimal.

Pulmonary arterial hypertension in adult-onset Still's disease: A case series and systematic review of the literature.

OBJECTIVE: To investigate the prevalence, clinical characteristics and prognosis of pulmonary arterial hypertension (PAH) in adult onset Still's disease (AOSD). METHODS: We retrospectively reviewed all patients with AOSD diagnosed during a 33-year period in 2 referral tertiary care hospitals, selecting for analysis those who presented PAH confirmed as by right heart catheterization. A systematic review of the literature (PubMed 1990 to July 2018) was also performed, in order to determine the prognosis and the most appropriate treatment strategy for this complication. RESULTS: The overall prevalence of PAH in our AOSD population was 4.8% (2/41). Including our 2 cases, 20 well-documented patients have been reported. PAH may complicate AOSD at any time during its course, and usually occurs in patients who have persistent and severe disease, with a considerable frequency (35%) of previous or concomitant severe clinical complications. In all cases, the etiology of pulmonary hypertension was a group 1 PAH based on the 2015 ESC/ERS guidelines. Most patients in this series had advanced WHO functional classes III-IV at the time of PAH diagnosis, reflecting an important diagnostic delay. Thirty-three percent of patients had a poor outcome despite the therapy, with a mortality rate that reached 22%. The therapeutic strategy that achieved the best results was the use of glucocorticoids, immunosuppression and PAH-specific vasodilator therapy. CONCLUSION: HAP is an under-recognized complication of AOSD that should be kept in mind in the differential diagnosis of those patients who experience dyspnea on exertion or a decrease in exercise tolerance.

Limited Joint Mobility Progression in Type 1 Diabetes: A 15-Year Follow-Up Study.

OBJECTIVE: To assess the evolution of joint mobility over a period of 15 years in type 1 diabetic patients and healthy controls and to determine whether microalbuminuria is associated with a different evolution of joint mobility. METHODS: Joint mobility of hand and wrist was determined in 63 patients with type 1 diabetes and 63 healthy subjects. Fifteen years later, 37 (58.7%) diabetic patients and 16 (25.4%) healthy subjects were studied again. Joint mobility was assessed with the Prayer sign and by measuring the angle of maximal flexion of the fifth and third metacarpophalangeal (MCP) joints and wrist. Patients with diabetes were visited 2-4 times every year with regular assessment of glycated hemoglobin (HbA1c), urinary albumin excretion (UAE), and ophthalmoscopy. RESULTS: Fifteen years after the initial exam, diabetic patients showed reduced flexion of the fifth MCP joint (82.6 ± 5.8 versus 76.0 ± 6.4 degrees, p < 0.001) and wrist (75.9 ± 8.1 versus 73.2 ± 7.4 degrees, p = 0.015) compared to baseline examination. Joint mobility did not change significantly in healthy subjects. Patients with microalbuminuria showed greater reduction in hand joint mobility than diabetic patients with normal UAE or than healthy subjects (p < 0.001). CONCLUSIONS: In type 1 diabetic patients, the severity of LJM progresses with time, and the progression is enhanced in patients with microalbuminuria.

Genome-wide association study meta-analysis identifies five new loci for systemic lupus erythematosus.

BACKGROUND: Systemic lupus erythematosus (SLE) is a common systemic autoimmune disease with a complex genetic inheritance. Genome-wide association studies (GWAS) have significantly increased the number of significant loci associated with SLE risk. To date, however, established loci account for less than 30% of the disease heritability and additional risk variants have yet to be identified. Here we performed a GWAS followed by a meta-analysis to identify new genome-wide significant loci for SLE. METHODS: We genotyped a cohort of 907 patients with SLE (cases) and 1524 healthy controls from Spain and performed imputation using the 1000 Genomes reference data. We tested for association using logistic regression with correction for the principal components of variation. Meta-analysis of the association results was subsequently performed on 7,110,321 variants using genetic data from a large cohort of 4036 patients with SLE and 6959 controls of Northern European ancestry. Genetic association was also tested at the pathway level after removing the effect of known risk loci using PASCAL software. RESULTS: We identified five new loci associated with SLE at the genome-wide level of significance (p < 5 × 10- 8): GRB2, SMYD3, ST8SIA4, LAT2 and ARHGAP27. Pathway analysis revealed several biological processes significantly associated with SLE risk: B cell receptor signaling (p = 5.28 × 10- 6), CTLA4 co-stimulation during T cell activation (p = 3.06 × 10- 5), interleukin-4 signaling (p = 3.97 × 10- 5) and cell surface interactions at the vascular wall (p = 4.63 × 10- 5). CONCLUSIONS: Our results identify five novel loci for SLE susceptibility, and biologic pathways associated via multiple low-effect-size loci.