Analysis of the implementation of an innovative IT solution to improve waiting times, communication with primary care and efficiency in Rheumatology.

OBJECTIVE: To describe in detail an innovative program based on telemedicine for semi-automated prioritization of referrals from Primary Care (PC) to Rheumatology, for reproducibility purposes, and to present the results of the implementation study. METHODS: The context and situation were carefully analyzed, paying attention to all processes in place, referral numbers, waiting times, and number of complementary tests prior to discharge from Rheumatology. The composition of the team, aims, users, scope, and implementation phases were defined. Eight process indicators were established and measured before and 32 months after the program implementation. RESULTS: The program, which includes IT circuits, algorithms based on response to specific guideline-based checklists, e-consultation, and appointments based on priority, was fully implemented in our health area after a pilot study in two PC centers. After implementation, 6185 rheumatology referrals showed an e-consultation response delay of 8.95 days, and to first face-to-face visit (after e-consultation) of 12.6 (previous delay before program implementation was 83.1 days). Resolution by e-consultation reached 20% (1195 patients did not need seeing the rheumatologist to have the problem solved), and 1369 patients (32%) were discharged after the first visit. The overall resolution rate was 44.0% (2564 discharges/5830 e-consultations). From a random sample of 100 visits, only 10% of patients needed additional complementary tests to make a diagnosis and decision by Rheumatology (20.9% decrease from previous period). CONCLUSION: A careful analysis of the situation and processes, with implementation of simple IT circuits, allows for the improvement of the efficiency and resolution of problems in Rheumatology.

The activity of psoriatic arthritis with axial involvement correlates with the PsAID12.

OBJECTIVE: To determine the impact of the disease in patients with PsA in daily clinical practice and to evaluate its relationship with its axial activity. METHODS: A cross-sectional study was conducted in consecutive patients attended from January 2021 to December 2021 who met the CASPAR criteria, with clinical of inflammatory back pain and positive axial imaging, with or without peripheral involvement. Demographic, clinical, analytical data, HAQ index, PsAID12 and activity index (BASDAI and ASDAS-PCR) were also collected. Patients were divided into two groups, those with high impact and those with low impact according to PsAID results. Continuous variables are shown as median (Q1-Q3) and categorical variables as percentages and frequencies. RESULTS: Of the 269 patients evaluated with PsA, 72 patients with axial involvement were included, 40 men (55.6%), with a median age of 54.1 years and disease duration of 7 years. 28.3% of the patients were obese and serum CRP level was 0.45 mg/dl (0.08-1.10). BASDAI was 4.2 (2.0-6.2) and ASDAS-PCR was 2.4 (1.5-3.2), which translates into 39.6% of patients in low activity or remission. The median PsAID total score was 3.9 (1.6-5.4), evaluated in 61 patients. The patients who achieved a PsAID12 ≤ 4 were 63%, mostly men and with lower CRP levels than PsAID ≥ 4 patients. In addition, low impact measured by the PsAID12 was associated with low results in BASDAI and ASDAS-PCR. CONCLUSIONS: Axial involvement reflected lower impact of the disease measured by PsAID12 and it is correlated with low activity measured by BASDAI and ASDAS-PCR.

Semaphorin3B promotes an anti-inflammatory and pro-resolving phenotype in macrophages from rheumatoid arthritis patients in a MerTK-dependent manner.

Previous works from our group show that Semaphorin3B (Sema3B) is reduced in RA and plays a protective role in a mouse arthritis model. In turn, MerTK plays a protective function in murine arthritis models, is expressed by synovial tissue macrophages and is linked to remission in patients with RA. In this study, we examined the role of Sema3B in the phenotypic characteristics of RA macrophages and the implication of MerTK. Peripheral blood monocytes from RA patients were differentiated into IFN-γ (RA MØIFN-γ) or M-CSF (RA MØM-CSF) macrophages and stimulated with LPS, Sema3B or their combination. Alternatively, RA fibroblast like synoviocytes (FLS) were stimulated with RA MØIFN-γ and RA MØM-CSF supernatants. Gene expression was determined by qPCR and protein expression and activation by flow cytometry, ELISA and western blot. Sema3B down-regulated the expression of pro-inflammatory mediators, in both RA MØIFN-γ and RA MØM-CSF. We observed a similar reduction in RA FLS stimulated with the supernatant of Sema3B-treated RA MØIFN-γ and RA MØM-CSF. Sema3B also modulated cell surface markers in macrophages towards an anti-inflammatory phenotype. Besides, MerTK expression and activation was up-regulated by Sema3B, just as GAS6 expression, Resolvin D1 secretion and the phagocytic activity of macrophages. Importantly, the inhibition of MerTK and neuropilins 1 and 2 abrogated the anti-inflammatory effect of Sema3B. Our data demonstrate that Sema3B modulates the macrophage characteristics in RA, inducing a skewing towards an anti-inflammatory/pro-resolving phenotype in a MerTK-dependant manner. Therefore, here we identify a new mechanism supporting the protective role of Sema3B in RA pathogenesis.

Medication persistence on biological therapies prescribed for the treatment of chronic inflammatory arthropathies: a real-world data study.

OBJECTIVES: Medication persistence, defined as the duration of time from its initiation to its discontinuation, is a surrogate for treatment effectiveness. The aim of the study was to evaluate persistence and causes of biological therapy (BT) suspension in patients with chronic inflammatory arthropathies: rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. METHODS: Single institution, descriptive, retrospective cohort study. Adult patients with chronic inflammatory arthropathies on BT between January 2009 and December 2016 were included. Persistence to BT was compared considering the type of pathology and treatment. The Kaplan-Meier test was used to analyse medication persistanence and factors associated with it. An analysis of reasons for therapy discontinuation was performed. RESULTS: Three hundred and sixty-two patients were included in the study, which comprised 478 BT lines. For all patients, the 12-month persistence rate was 71.3% (341 out of 478). At the end of the study, 45.2% of the patients continued on their initial BT. Median treatment persistence was 1489 days (CI 95% 1195 to 1783). Longer BT persistence was associated with naïve BT patients: 1945 days (95% CI 1523 to 2367; P<0.001) and ankylosing spondylitis diagnosis: 2402 days (95% CI 1604 to 3200; P=0.014). The most frequent causes of treatment discontinuation were therapeutic failure (47.6%) and adverse drug events (28.2%). CONCLUSIONS: We found good long-term persistence in patients with chronic inflammatory arthropathies treated with BT. Patients with rheumatoid arthritis had significantly shorter persistence compared with those with ankylosing spondylitis and psoriatic arthritis. Naïve BT was associated with longer persistence. Therapeutic failure was the main cause of BT withdrawal.

Secukinumab as Biological Treatment for Psoriatic Arthritis in Real Clinical Practice. / Secukinumab como tratamiento biológico en la artritis psoriásica en práctica clínica real.

INTRODUCTION: Clinical trials of secukinumab have demonstrated their efficacy and safety in psoriatic arthritis as biological first choice or after inadequate response to other biological treatments. OBJECTIVE: To analyze the efficacy and safety of secukinumab in peripheral psoriatic arthritis over 12 months in real clinical practice. MATERIAL AND METHODS: Patients with active peripheral psoriatic arthritis who started treatment with secukinumab according to the technical specifications were included. Efficacy and safety were evaluated from baseline to 12 months comparing naive and non-naive to biological therapy patients. RESULTS: A total of 76 patients were included (22 naive and 54 non-naive to biological) with an age of 51.9 years (10.3) and duration of the disease of 9.5 years (7.1). Of them, 31.6% with dactylitis, 51.3% with enthesitis and the baseline DAPSA was 19.0 (9.8). The retention rate was high, 90.9% in naive and 81.5% in non-naïve patients, and the percentage of patients with a DAPSA less than or equal to 14 was higher in the naive patients even after adjusting for age, sex and FAMEsc (P=.016). The safety data were similar to those described in the clinical trials. CONCLUSIONS: Secukinumab is effective and safe in 12-month treatment in peripheral active psoriatic arthritis in real clinical practice, after inadequate response to TNF or as first biological treatment.

Epidemiological Characteristics and Adverse Events of Patients with Psoriatic Arthritis Undergoing Treatment with Biological Therapies in Galicia. / Características epidemiológicas y eventos adversos de los pacientes con artritis psoriásica en tratamiento con terapias biológicas en Galicia.

Patients with severe forms of psoriatic arthritis (PsA) usually require treatment with biological agents. A greater knowledge of this subgroup of patients and their treatment enables better decision making in real clinical practice. METHODS: Longitudinal, multicentric observational study. We included all patients older than 16 years diagnosed with PsA in treatment with biological therapies from January 1, 2011 to December 31, 2015 treated in 6 Galician hospitals. RESULTS: Six hundred and fourpatients with PsA received biological therapies. Etanercept was the most used biological treatment. The average time of follow-up was 2.5 years and 67.9% were being treated with the first biological treatment. They were mostly patients with the peripheral subtype and met the criteria for clinical remission. Thirty-two percent had positive HLA-B27 and it was associated with axial PA subtypes. The prevalence of tuberculosis treated previously was 5.9%, and 23% of patients received chemoprophylaxis for latent tuberculosis. Twenty-four patients had undergone a prosthetic replacement. Hip prosthesis was the most frequent. Ninety-nine cases were treated for affective disorders. A diagnosis of fibromyalgia was established in 11 cases mostly women. Of the cases, 6.6% had episodes of serious infections, with respiratory infections being the most frequent. Sixteen tumours were detected (2.9%). Prostate cancer and gynaecological tumours were the most frequent. As with infections, the greater the age the greater the risk of presenting a tumour. CONCLUSIONS: We describe the epidemiological and safety characteristics in real life of a Galician multicentre cohort of patients with psoriatic arthritis under biological treatment.

Biological therapy safety in chronic inflammatory arthropathy patients.

OBJECTIVE: The marketing of biological therapies transformed the treatment of rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. But there is still concern about patient safety and management in daily clinical practice. The aim of this study was to estimate risk factors of the adverse effects in a cohort of Spanish patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. METHODS: A single institution, descriptive, retrospective, cohort study was developed from January 2009 to December 2016. Patients diagnosed with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis on biological therapies were included. Undesirable events affecting patients during biological therapy, their clinical implications and the use of health resources related to adverse effects were collected. RESULTS: Three hundred and sixty-two patients corresponding to 478 biological therapy lines were analysed. It implied 1192 years of monitoring. There were 57 adverse effects per 100 biological patient- years and 4.8 serious adverse effects per 100 biological patient-years. The only significant factor for a likely serious adverse effect was having a Charlson Index ≥10, OR of 6.2 (CI 95%: 3.4-11.1, p<0.001). Around 15 % of patients with adverse effects were admitted to hospital and 25% received attention at the Emergency Department. CONCLUSION: Over half of the patients with arthropathies on biological therapy can suffer adverse effect during treatment but only 8.5% of these effects are serious. Special vigilance must be paid to patients with a higher number of comorbidities because they are more likely to experience serious adverse effects.

Biological therapy safety in chronic inflammatory arthropathy patients.

OBJECTIVE: The marketing of biological therapies transformed the treatment of rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. But there is still concern about patient safety and management in daily clinical practice. The aim of this study was to estimate risk factors of the adverse effects in a cohort of Spanish patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. METHODS: A single institution, descriptive, retrospective, cohort study was developed from January 2009 to December 2016. Patients diagnosed with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis on biological therapies were included. Undesirable events affecting patients during biological therapy, their clinical implications and the use of health resources related to adverse effects were collected. RESULTS: Three hundred and sixty-two patients corresponding to 478 biological therapy lines were analysed. It implied 1192 years of monitoring. There were 57 adverse effects per 100 biological patient-years and 4.8 serious adverse effects per 100 biological patient-years. The only significant factor for a likely serious adverse effect was having a Charlson Index ≥10, OR of 6.2 (CI 95%: 3.4-11.1, p<0.001). Around 15 % of patients with adverse effects were admitted to hospital and 25% received attention at the Emergency Department. CONCLUSION: Over half of the patients with arthropathies on biological therapy can suffer adverse effect during treatment but only 8.5% of these effects are serious. Special vigilance must be paid to patients with a higher number of comorbidities because they are more likely to experience serious adverse effects.

Efficacy and Safety of Combined Therapy With Synthetic Disease-modifying Antirheumatic Drugs in Rheumatoid Arthritis: Systematic Literature Review. / Eficacia y seguridad de la terapia combinada con fármacos modificadores de la enfermedad sintéticos en la artritis reumatoide: revisión sistemática de la literatura.

OBJECTIVE: 1) To systematically and critically review the evidence of combined therapy with synthetic disease-modifying antirheumatic drugs (DMARD) in rheumatoid arthritis (RA); 2) To design practical recommendations on their use. METHODS: A systematic literature review (SLR) was performed with a sensitive bibliographic search strategy in Medline, EMBASE and Cochrane Library. We selected randomized clinical trials that analyzed the efficacy and/or safety of 1) combined therapy of synthetic compared with sequential therapy of synthetic DMARD in early RA; and 2) combination of methotrexate+leflunomide or triple therapy with synthetic DMARD in established RA refractory to synthetic DMARD. Two reviewers made the first selection by title and abstract and 11 performed the selection after detailed review of the articles and data collection. The quality of the studies was evaluated with the Jadad scale. Based on the results, related recommendations were agreed upon in a nominal group meeting. RESULTS: Ultimately, no articles were included in the SLR. The analysis of the reviewed articles demonstrated the effectiveness of the treatment with synthetic DMARD following a "treat to target" strategy in early RA patients, and of combination therapy of synthetic DMARD in established RA refractory to synthetic DMARD. This resulted in 6 recommendations concerning combination therapy with synthetic DMARD. CONCLUSIONS: These recommendations aim to facilitate decision-making with the use of combined therapy with DMARD in RA.

Adherence to biological therapies in patients with chronic inflammatory arthropathies.

INTRODUCTION: The aims of the study were to quantify adherence, determine the factors that can  predict adherence and identify the consequences of poorer adherence in patients with chronic  inflammatory arthropathies treated with biological therapies in daily clinical practice. METHOD: A descriptive, observational and retrospective study was carried out. Patients with  rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis who started a biologic therapy  between 1 January 2009 and 31 December 2016 were included. Variables related to socioeconomic  status, the disease, the biological therapy and hospital resources were included. Adherence was  calculated by using the medication possession ratio. RESULTS: Three hundred and sixty-two patients and 423 lines of biological therapy were included.  Mean age ± standard deviation was 50.3 ± 13.9 years, and 228 (53.9%) were women. The  percentage of adherent patients was 187 out of 216 (87%) in rheumatoid arthritis, 91 out of 107  (85%) in ankylosing spondylitis and 84 out of 100 (84%) in psoriatic arthritis. Greater adherence was  associated with more frequent visits to the pharmacy service (odds ratio 1.2, 95% confidence  interval: 1.1-1.3 [p = 0.001]) and poorer adherence with a failure to attend scheduled appointments  at the rheumatology clinic (odds ratio 0.2, 95% confidence interval: 0.1-0.9 [p = 0.030]). There were  no differences between  adherent and non-adherent patients in terms of the number of hospital resources used. CONCLUSIONS: There are no differences in adherence to biological therapies among patients with  chronic inflammatory arthropathies. Adherence correlates with attendance at outpatient  appointments, but this does not imply an increase in the use of hospital resources.

Objetivo: Los objetivos del estudio fueron cuantificar la adherencia, determinar los factores  predictivos y conocer las consecuencias de una menor adherencia, en la práctica clínica diaria, en  pacientes con artropatías inflamatorias crónicas tratados con terapias biológicas. Método: Estudio descriptivo, observacional y retrospectivo. Se incluyeron pacientes con artritis  reumatoide, espondilitis anquilosante y artritis psoriásica que iniciaron una terapia biológica entre el 1  de enero de 2009 y el 31 de diciembre de 2016. Se recogieron variables sociodemográficas, relacionadas con la enfermedad, sobre las terapias biológicas y los recursos  hospitalarios. La adherencia se calculó mediante la ratio media de posesión.Resultados: Se incluyeron 362 pacientes y 423 líneas de terapia biológica. La media de edad ±  desviación estándar fue de 50,3 ± 13,9 años; 228 (53,9%) fueron mujeres. El porcentaje de  adherentes fue de 187 de 216 (87%) en artritis reumatoide, 91 de 107 (85%) en espondilitis  anquilosante y 84 de 100 (84%) en artritis psoriásica. La adherencia se relacionó con acudir con más  frecuencia a la consulta del servicio de farmacia(odds ratio de 1,2; intervalo de confianza 95%: 1,1- 1,3 [p = 0,001]) e inversamente con no acudir a las consultas de reumatología en la fecha prevista (odds ratio de 0,2; intervalo de confianza 95%: 0,1-0,9 [p = 0,030]). No hubo diferencias en  el número de recursos hospitalarios utilizados por pacientes adherentes y no adherentes.Conclusiones: La adherencia a las terapias biológicas entre las artropatías inflamatorias crónicas es  similar. Dicha adherencia se correlaciona con la frecuentación a consultas externas, pero no implica  un aumento del consumo de recursos.

[Pyomyositis: report of seventeen cases]. / Piomiositis: presentación de 17 casos en niños y adultos.

BACKGROUND: Pyomyositis is a bacterial infection of skeletal muscle. Although more commonly seen in the tropics, it is increasingly recognized in temperate regions. The age distribution for patients with so called "tropical" or "temperate" pyomyositis differs. Most cases of tropical pyomyositis are seen in otherwise healthy patients and mainly in children, while the majority of cases of temperate pyomyositis occur in inmunocompromised adults. AIM: To report a series of patients with pyomyositis. MATERIAL AND METHODS: Retrospective review of clinical records of patients admitted to our hospital with pyomyositis during the period 1996-2001. RESULTS: Seventeen patients were identified, aged from 5 to 86 years old, nine (53%) males. Staphylococcus aureus (13 cases, 76%) was the most common infecting organism. Eleven patients (65%) had a history of previous trauma. All patients were immunocompetent. Six patients underwent surgical drainage. Six patients (35%) presented complications and of those, one died. CONCLUSIONS: All patients of this series were immunocompetent. Pyomyositis is a serious and life threatening disease but curable. An early treatment is the key to a better prognosis.

Piomiositis: presentación de 17 casos en niños y adultos / Pyomyositis: Report of seventeen cases

Background: Pyomyositis is a bacterial infection of skeletal muscle. Although more commonly seen in the tropics, it is increasingly recognized in temperate regions. The age distribution for patients with so called "tropical" or "temperate" pyomyositis differs. Most cases of tropical pyomyositis are seen in otherwise healthy patients and mainly in children, while the majority of cases of temperate pyomyositis occur in inmunocompromised adults. Aim: To report a series of patients with pyomyositis. Material and Methods: Retrospective review of clinical records of patients admitted to our hospital with pyomyositis during the period 1996-2001. Results: Seventeen patients were identified, aged from 5 to 86 years old, nine (53%) males. Staphylococcus aureus (13 cases, 76%) was the most common infecting organism. Eleven patients (65%) had a history of previous trauma. All patients were immunocompetent. Six patients underwent surgical drainage. Six patients (35%) presented complications and of those, one died. Conclusions: All patients of this series were immunocompetent. Pyomyositis is a serious and life threatening disease but curable. An early treatment is the key to a better prognosis.