Recommendations by the Spanish Society of Rheumatology on risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis.

OBJECTIVE: To present recommendations based on the available evidence and the consensus of experts, for risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis. METHODS: Clinical research questions relevant to the purpose of the document were identified. These questions were reformulated in PICO format (patient, intervention, comparison, outcome or outcome) by a panel of experts, selected based on their experience in the area. A systematic review of the evidence was carried out, grading according to the GRADE criteria (Grading of Recommendations Assessment, Development, and Evaluation). Specific recommendations were then formulated. RESULTS: 6 PICO questions were proposed by the panel of experts based on their clinical relevance and the existence of recent information regarding the risk of occurrence of serious infections, the risk of reactivation of the hepatitis B virus, the risk of reactivation of the virus varicella-zoster, the risk of appearance of skin (melanoma and non-melanoma) or haematological cancer, the risk of appearance of thromboembolic disease and the risk of progression of the human papilloma virus. A total of 28 recommendations were formulated, structured by question, based on the evidence found and the consensus of the experts. CONCLUSIONS: The SER recommendations on risk management of treatment with biologic therapies and JAK inhibitors in rheumatoid arthritis are presented.

Hierarchical Cluster Analysis Based on Clinical and Neuropsychological Symptoms Reveals Distinct Subgroups in Fibromyalgia: A Population-Based Cohort Study.

Fibromyalgia (FM) is a condition characterized by musculoskeletal pain and multiple comorbidities. Our study aimed to identify four clusters of FM patients according to their core clinical symptoms and neuropsychological comorbidities to identify possible therapeutic targets in the condition. We performed a population-based cohort study on 251 adult FM patients referred to primary care according to the 2010 ACR case criteria. Patients were aggregated in clusters by a K-medians hierarchical cluster analysis based on physical and emotional symptoms and neuropsychological variables. Four different clusters were identified in the FM population. Global cluster analysis reported a four-cluster profile (cluster 1: pain, fatigue, poorer sleep quality, stiffness, anxiety/depression and disability at work; cluster 2: injustice, catastrophizing, positive affect and negative affect; cluster 3: mindfulness and acceptance; and cluster 4: surrender). The second analysis on clinical symptoms revealed three distinct subgroups (cluster 1: fatigue, poorer sleep quality, stiffness and difficulties at work; cluster 2: pain; and cluster 3: anxiety and depression). The third analysis of neuropsychological variables provided two opposed subgroups (cluster 1: those with high scores in surrender, injustice, catastrophizing and negative affect, and cluster 2: those with high scores in acceptance, positive affect and mindfulness). These empirical results support models that assume an interaction between neurobiological, psychological and social factors beyond the classical biomedical model. A detailed assessment of such risk and protective factors is critical to differentiate FM subtypes, allowing for further identification of their specific needs and designing tailored personalized therapeutic interventions.

Efficiency traps beyond the climate crisis: exploration-exploitation trade-offs and rebound effects.

Higher levels of economic activity are often accompanied by higher energy use and consumption of natural resources. As fossil fuels still account for 80% of the global energy mix, energy consumption remains closely linked to greenhouse gas (GHG) emissions and thus to climate change. Under the assumption of sufficiently elastic demand, this reality of global economic development based on permanent growth of economic activity, brings into play the Jevons Paradox, which hypothesises that increases in the efficiency of resource use leads to increases in resource consumption. Previous research on the rebound effects has limitations, including a lack of studies on the connection between reinforcement learning and environmental consequences. This paper develops a mathematical model and computer simulator to study the effects of micro-level exploration-exploitation strategies on efficiency, consumption and sustainability, considering different levels of direct and indirect rebound effects. Our model shows how optimal exploration-exploitation strategies for increasing efficiency can lead to unsustainable development patterns if they are not accompanied by demand reduction measures, which are essential for mitigating climate change. Moreover, our paper speaks to the broader issue of efficiency traps by highlighting how indirect rebound effects not only affect primary energy (PE) consumption and GHG emissions, but also resource consumption in other domains. By linking these issues together, our study sheds light on the complexities and interdependencies involved in achieving sustainable development goals. This article is part of the theme issue 'Climate change adaptation needs a science of culture'.

Variation in perceived health across gender, working status, educational level, and regional health care expenditure in Spain (2014-2017).

A gender perspective was used to analyze whether and how education, unemployment, and per capita public health expenditure were associated with perceived health among the Spanish population between the years 2014 and 2017. Using multilevel methodologies (looking at year, individual, and region) and linear and logistic specifications, we analyzed longitudinal microdata files from the Survey on Living Conditions. The results suggest that women with lower educational levels tend to report worse health than their more educated counterparts. On the other hand, women's bad health was not associated with unemployment, unlike men's. Regional per capita public health expenditure was not associated with perceived health in either men or women.

Assessment of RANK/RANK-L prevalence and clinical significance in NSCLC European Thoracic Oncology Platform Lungscape cohort and SPLENDOUR randomized clinical trial.

BACKGROUND: The primary objective of this study is to evaluate the clinical significance of RANK/L expression, in both a retrospective cohort of surgically resected stage I-III NSCLC (Lungscape) and a randomized clinical trial-cohort (SPLENDOUR) of advanced NSCLC treated with chemotherapy alone or in combination with denosumab. METHODS: RANK-L expression was assessed on tissue microarrays (TMAs) in Lungscape and whole sections in SPLENDOUR, using immunohistochemistry, with H-scores values > 0 indicating positivity. Prevalence of RANK positivity and its association with clinicopathological characteristics, and patient outcome was explored in a subset of the ETOP Lungscape cohort and in SPLENDOUR. Also investigated were the prevalence of RANK overexpression (proportion of positive cancer cells ≥ 50%) in the Lungscape cohort, and RANK-L in the SPLENDOUR trial. RESULTS: In the Lungscape cohort, RANK expression was assessed at a median follow-up of 46 months (N = 488 patients; 4 centers); 35% were female, 44/49/6% adenocarcinomas (AC)/squamous cell carcinomas (SCC)/other, 48/27/25% with stage I/II/III. Median RFS/TTR/OS were 58/Not reached/74 months. Prevalence of RANK expression was 31% (95%CI:27%-35%); significantly higher in AC: 50% (95%CI:43%-57%) vs SCC: 12% (95%CI:8%-16%) (p < 0.001); more frequent in females (42% vs 25%, p < 0.001) and tumors ≤ 4 cm (35.3% vs 23.3%, p = 0.0065). No association with outcome was found. In the SPLENDOUR trial (463 patients), the prevalence of membranous and cytoplasmic RANK positivity was 34% (95%CI:30%-38%) and 9% (95%CI:7%-12%), respectively, while prevalence for RANK-L was 5% (95%CI:3%-7%) and 36% (95%CI:31%-40%), respectively. Cytoplasmic RANK-L positivity was more common among females (47% vs 31%, p = 0.001) and in non-SCC histology (45% vs 10%, p < 0.0001). At the pre-specified 1% significance level, no prognostic or predictive effect was found. CONCLUSIONS: Both cohorts indicate that RANK expression is more common in adenocarcinoma/non-squamous NSCLC and in female patients. No prognostic effect is found, and in the clinical trial involving addition of denosumab to chemotherapy no predictive effect is detected.

Comparative life cycle assessment of conventional and novel microalgae production systems and environmental impact mitigation in urban-industrial symbiosis.

The versatility of microalgae biomass as candidates for various products and bioremediation needs motivates interests towards design and implementation of novel microalgae bioreactors. Conventional open-reactors are reliant on large quantities of sunlight and space while yields are constrained by outdoor environment conditions. Conversely, closed-reactor systems like bubble columns reduces these constrains on microalgae growth while occupying far less space at the expense of high energy demands, notably from lighting systems. A novel patented closed reactor design has recently been proposed that improves the bubble column concept with an efficient and effective lighting system. The present study uses Life Cycle Assessment approach to compare the environmental performance of conventional reactors and the proposed internally luminated novel closed reactor design, expressing impacts per kg biostimulant for the Scenedesmus almeriensis harvest from such units. All performance data was collected from a pilot facility in Almeria, Spain. Urban-industrial symbiosis scenarios are also portrayed in the study using wastewater and incinerator flue gas. Results show that under synthetic nutrient and carbon inputs in Spanish pilot operations, the cumulative energy demand for the novel photobioreactors is similar to conventional vertically-stacked horizon bioreactors but are substantially more demanding than conventional open reactors. However, when leveraging renewable energy sources and the photosynthesis process to consume wastestreams in urban-industrial symbiosis scenarios, the novel photobioreactor was able to achieve up to 80 % improvements in several impact categories e.g. eutrophication and climate change. Impact mitigation credits per kg dwt biomass across all energy scenarios in symbiosis amount to ≈1.8 kg CO2eq and ≈0.09 kg PO4 eq. This highlights that such closed and internally illuminated photobioreactors can be competitive with conventional reactors, and have potential to harness photosynthesis to reduce environmental burdens in an urban-industrial symbiosis setting. Possible economies of scale and the associated potential gains in efficiencies are further discussed.

Proposal for updating the Health Assessment Questionnaire.

OBJECTIVE: To propose a consensus modification of the HAQ according to the predominant values, language, and culture of the society. METHODS: First, a scoping review of the literature and a survey of HAQ users were conducted to identify the problems of this questionnaire. In a second phase, a meeting was held with expert professionals to discuss the results and design proposals for modification. RESULTS: The scoping review allowed us to describe the main versions of the HAQ, as well as their psychometric properties. The HAQ users survey assessed the degree of comprehension, usefulness, timeliness, and universality of each of the items, and suggestions and opinions on its main limitations were accepted. During the discussion meeting, modifications to the items were proposed based on the results of the scoping review and the users survey. In addition, the difficulty of understanding the items, their difficulty in assessing intended movements, redundancy, obsolescence, and possible gender bias were taken into account. CONCLUSIONS: An update of the Spanish version of the HAQ is proposed based on the literature review and expert opinion that highlights the paradigm shift in cultural values and aims to increase the content validity and discrimination capacity of this questionnaire.

Re-envisioning, Retooling, and Rebuilding Prevention Science Methods to Address Structural and Systemic Racism and Promote Health Equity.

The historic momentum from national conversations on the roots and current impacts of racism in the USA presents an incredible window of opportunity for prevention scientists to revisit how common theories, measurement tools, methodologies, and interventions can be radically re-envisioned, retooled, and rebuilt to dismantle racism and promote equitable health for minoritized communities. Recognizing this opportunity, the NIH-funded Prevention Science and Methodology Group (PSMG) launched a series of presentations focused on the role of Prevention Science to address racism and discrimination guided by a commitment to social justice and health equity. The current manuscript aims to advance the field of Prevention Science by summarizing key issues raised during the series' presentations and proposing concrete research priorities and steps that hold promise for promoting health equity by addressing systemic racism. Being anti-racist is an active practice for all of us, whether we identify as methodologists, interventionists, practitioners, funders, community members, or an intersection of these identities. We implore prevention scientists and methodologists to take on these conversations with us to promote science and practice that offers every life the right to live in a just and equitable world.

FLT3-ITD Expression as a Potential Biomarker for the Assessment of Treatment Response in Patients with Acute Myeloid Leukemia.

FLT3-internal tandem duplication (ITD) analysis is not typically performed in cDNA samples and is not considered an appropriate marker for monitoring measurable residual disease (MRD). The aims of this study were to compare FLT3-ITD mutation analysis in DNA and cDNA samples at diagnosis and to demonstrate the usefulness of its expression measurement as an MRD marker after allogeneic stem cell transplantation (allo-HSCT) or FLT3 inhibitor (FLT3i) administration. A total of 46 DNA and cDNA diagnosis samples, 102 DNA and cDNA post-allo-HSCT samples from 34 patients and 37 cDNA samples from 7 patients with refractory/relapse AML treated with FLT3i were assessed for the FLT3-ITD mutation through fragment analysis. In terms of sensitivity, the analysis of cDNA was superior to that of DNA, quantifying higher allelic ratio values in most cases at diagnosis, and thus optimizing the detection of minor clones and prognostic classification. Regarding the last sample before post-HSCT relapse, cDNA analysis anticipated relapse in most cases, unlike DNA analyses. With regard to the post-FLT3i follow-up, FLT3-ITD expression was reduced after the first FLT3i cycle when the treatment was effective, whereas it was not reduced in refractory patients. FLT3-ITD expression could be a useful additional biomarker at diagnosis and for the assessment of MRD after allo-HSCT and FLT3i in AML.

Surgical Error Compensation Claims as a Patient Safety Indicator: Causes and Economic Consequences in the Murcia Health System, 2002 to 2018.

OBJECTIVES: Compensation claims are a useful source of information on patient safety research. The purpose of this study was to determine the main causes of surgical compensation claims and their financial impact on the health system. METHODS: A descriptive observational study with analytical components was carried out on compensation claims brought against the surgical area of the Murcia Health System between 2002 and 2018. We analyzed the frequency, causes, consequences, locations and surgical settings of these claims, the time of judicial procedure, and compensation adjusted to the Consumer Price Index. RESULTS: There were 1172 compensation claims. "orthopedic surgery and traumatology" (27.4%), "gynecology and obstetrics" (25.7%), and "general surgery" (17.2%) were the main surgical settings involved. The most frequent causes were surgical error (42.4%) and treatment error (30.9%). The main sequelae were musculoskeletal (20.0%), neurological (17.7%), and obstetric (17.7%). The average time from incident to resolution of claims was 6.3 years. A total of 20.1% of these claims were successful, particularly those involving retained surgical foreign bodies (71.4% successful claims; P < 0.001). The total compensation paid was €56,338,247 (an average of €17,207 per claim). Compensation was higher in cases with respiratory sequelae (median, 131,600; P = 0.033), death (75,916; P < 0.001), and neurological (60,000; P = 0.024). CONCLUSIONS: Compensation claims associated with surgical procedures are made on a variety of grounds. They are drawn-out proceedings, and patients are only successful in 20% of cases.

An analysis of the competitiveness of the tourism industry in a context of economic recovery following the COVID19 pandemic.

Business activities within the tourism industry are especially suffering from the consequences of the COVID19 pandemic. Those countries whose economy depends largely on tourism will experience a troublesome situation for years to come. Their return to a normal situation will be conditioned by the competitiveness of their tourism sector. The study begins by pinpointing the countries that have been more hardly stricken by the pandemic and in which tourism accounts for a greater share of the GDP. A comparative analysis of the competitiveness of these countries with that of world-leading countries will be carried out so as to conclude which will face the recovery period in a more vulnerable situation. The measurement of tourism competitiveness will be supported by the creation of a synthetic indicator based on the P2 distance method. A group of 13 countries has been identified as the most vulnerable, and it is advisable to act urgently in the following areas: the promotion of cultural elements and the historical and artistic heritage, the protection of natural areas, the availability of information and communication technologies, the international openness of the destination, and the availability of transportation infrastructures and tourist services.

Foraging decisions of rock lizards may be dependent both on current rival assessment and dear enemy recognition.

Foraging strategies aim to maximize the amount of food obtained while minimizing searching costs. To reduce these costs, animals use different strategies based on the use of personal or social information to exploit food patches. At the same time, the social attraction for food resources could increase competition intensity for them. Prior experiences of animals regarding social risk and the foreknowledge of the competitors might drive the foraging strategies. In this paper, we examined experimentally whether rock lizards used behavioural strategies to reduce the risks of foraging in presence of potential competitors. We measured the foraging behaviour of a lizard resident to a territory (i.e. terrarium), in the presence of both familiar and unfamiliar conspecifics (potential competitors). We considered whether foraging choices between two food sources of different value (i.e. quantity) are influenced by familiarity with the intruder and the evaluation of its competitive ability based on body size differences between lizards. We found differences in the number of attacks performed to the best food source, with more attacks when the intruder was unfamiliar. The results suggest evidence of both dear enemy recognition and current rival assessment modulate the foraging choices depending on the identity and the social relationship with the intruder.

Human Rights in the Least Developed Countries of Asia: An Index for Quantifying Sustainable Development Goal 3 (Good Health and Wellbeing).

This paper aims to measure disparities among the variables associated with Sustainable Development Goal (SDG) 3 defined by the United Nations (UN) in the least developed countries (LDCs) of Asia. In the terms of the UN Conference on Trade and Development, LDCs are countries with profound economic and social inequalities. The indicator was constructed using a set of variables associated with SDG3: Good Health and Wellbeing. Applying Pena's DP2 distance method to the most recent data available (2018) enables regional ordering of Asia's LDCs based on the values of these variables. The index integrates socioeconomic variables that permit examination of the impact of each individual indicator to determine territorial disparities in terms of the partial indicators of SDG3. "Maternal education," "Proportion of women who make their own informed decisions regarding sexual relations, contraceptive use, and reproductive health care," and "Gender parity index in primary education" are the most important variables in explaining spatial disparities in good health and wellbeing in the LDCs of Asia.

[The efficiency of «Cross-speciality Geriatrics¼ in the co-management of patients older than 80 years admitted to the General Surgery Service. Economic results]. / Eficiencia del apoyo de Geriatría Transversal en el manejo de pacientes mayores de 80 años ingresados en el Servicio de Cirugía General. Resultados en la liberación de estancias y el coste asociado.

OBJECTIVE: To determine the efficiency of «Cross-speciality Geriatrics¼ program in patients older than 80 years admitted to the Colorectal Pathology Unit of a General Surgery Department. MATERIAL AND METHODS: A «before-after¼ study was conducted. The initial period (usual treatment for General Surgery) included patients admitted from 1st January to 31st August 2018, and the subsequent period (with support from geriatrics) from 1st January to 31st December 2019. Two types of patients were studied: Type 1, who were admitted to the Emergency Department, and Type 2, programmed admissions for colorectal cancer intervention. The Geriatrics intervention consisted of daily monitoring in the ward, collaboration in clinical management, and discharge planning. Furthermore, in Type 2 patients, a previous visit was made in the clinic, which included the detection and approach of frailty and pre-habilitation for surgery. RESULTS: A total of 175 patients were included, of whom 53 were treated by General Surgery and 122 with the co-management of geriatrics. The mean age was 84.9 years (SD 4.8). In the period with the Cross-speciality Geriatrics program, the mean stay was reduced by 10.6 days (39%), and 8.5 days (44%) in types 1 and 2, respectively (P < .01). This led to a decrease in bed occupancy (3.3 beds/day) and a cost reduction (1,215,970 € / year). CONCLUSIONS: The support of Cross-speciality Geriatrics in patients older than 80 years admitted to General Surgery is an efficient care model. These data support its implementation in hospitals where this care line has not yet been developed.

Human rights in the Horn of Africa: an index of child and maternal health.

OBJECTIVE: To construct a territorial measure and classification of child and maternal health in the countries of the Horn of Africa based on the 2030 Agenda for Sustainable Development adopted by all United Nations Member States in 2015. METHOD: The design of our index includes the variables child and maternal health defined in the Sustainable Development Goals (SDGs) to enable territorial ranking of the countries. For this purpose, we used Pena's distance method for 2017. RESULTS: The results indicate a relatively high territorial disparity in maternal health between the countries of the Horn of Africa according to the differing values of the SDGs variables of child and maternal health. CONCLUSIONS: We propose a territorial classification in the countries of the Horn of Africa. We believe that the most striking differences between countries relate to basic variables of maternal health such as being attended by skilled health personnel.

Ecological risk assessment of mercury and chromium in greenhouse soils.

Very little information is available about Hg and Cr evolution in greenhouse soils. This paper presents the results of determining Hg and Cr in greenhouse soils in a semi-arid region in the southern Iberian Peninsula (Almería, Spain), and assessing the enrichment level and the Potential Ecological Risk Index (PERI) according to crop age. Hakanson's approach was used to evaluate the PERI. To investigate the behaviour of Hg and Cr in greenhouse soils over time, samples were grouped into values in soils for blocks according to crop age: 0 years, 5-10 years, 10-20 years, more than 20 years. The results showed that 74% of GS exceeded the obtained background level (37.1 µg kg-1) for Hg, with 43% (48.9 mg kg-1) for Cr. Temporal patterns indicated that these elements are accumulating in greenhouse soils and this trend was very significant for Hg. After more than 20 intensive crop-farming years, concentrations and the PERI had clearly increased. Although the ecological risk was moderate, our observations suggest that the farming practices performed in the last 35 years have allowed these metals to accumulate. In fact, the 15% of the studied soils presented a considerable potential risk and were the soils that had been used longer.

[Assessment of the impact of pulmonary rehabilitation on sexual activity in patients with chronic obstructive pulmonary disease]. / Evaluación del impacto sobre la actividad sexual de un programa de rehabilitación pulmonar para pacientes con enfermedad pulmonar obstructiva crónica.

BACKGROUND AND OBJECTIVE: Chronic obstructive pulmonary disease (COPD) affects life quality, and also sexual activity. Pulmonary rehabilitation (PR) is a helpful treatment in COPD patients. The aim of this study is to assess sexual activity on COPD patients, and the effect of PR over it. PATIENTS AND METHODS: Single cohort prospective study over male COPD candidates to PR. Clinical, respiratory and biochemical assessment (FSH, LH, T, and progesterone) was performed. Patients were asked to fill baseline International Index of Erectile Function (IIEF) questionnaire, and 6 months after PR. A descriptive initial analysis compared respiratory values between patients with and without sexual activity. Changes in IIEF results were assessed after PR, and satisfaction with treatment using Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS). RESULTS: Between 2014 and 2016, 62 male COPD patients enlisted. Mean age: 66.5 years (SD 7.2). 52 Ex-smokers. 10 declared being sexually active (16.1%). No hormonal levels alterations. No significant differences on respiratory parameters between sexually active and non-active patients (FEV1, 6-minutes walking test, number of exacerbations, CAT score). Baseline mean IIEF values: Erectile function 8, orgasmic function 4, sexual desire 5.6, intercourse satisfaction 5.3, and overall satisfaction 4.5. After PR, significant increase in mean IIEF value: 6.1 (CI95% 1.9-10.3). Improvement was found in all domains, with statistical significance on intercourse satisfaction 0.9 (CI95% 0.2-1.6). Moderate satisfaction with treatment was achieved according to EDITS. CONCLUSIONS: Only a low percentage of COPD males included in PR is sexually active. No pulmonary differences were found between sexually active and non-active patients. PR improves sexual function, particularly intercourse satisfaction domain.

Risk of suicide in households threatened with eviction: the role of banks and social support.

BACKGROUND: One of the greatest effects of the financial crisis in Spain has been the enormous increase in the number of evictions. Several studies have shown the association of evictions with different aspects of the physical and mental health. Furthermore, evictions have been associated with an increased risk of suicide. Our objective was to evaluate the risk of suicide among victims of eviction and investigate whether it is associated with specific characteristics of households and interviewees, the eviction process and social support, and health needs. METHODS: A total of 205 participants from households threatened with eviction in Granada, Spain, and 673 being the total number of members of these households, were interviewed in one-on-one sessions between April 2013 and May 2014. Through a questionnaire, information was obtained on physical and mental health, characteristics of their eviction process and support networks, and the use of health services. RESULTS: Almost half of the sample (46.7%) were at low (11.8%), moderate (16.9%), or high suicide risk (17.9%). Household and interviewee features had a limited association with suicide risk. On the contrary, the risk of suicide is greater with a longer exposure to the eviction process. In addition, threatening phone calls from banks increased significantly the risk of suicide, especially among men. Suicide risk was also associated with low social support, especially among women. Interviewees at risk of suicide received more help from nongovernmental organizations than those who were not at risk. In interviewees at risk, the main unmet needs were emotional and psychological help, especially in men. A high percentage of those at risk of suicide declare having large unmeet health needs. Finally, there was a tendency among the evicted at risk of suicide to visit emergency room and primary care more often than those not at risk, especially among women. CONCLUSIONS: To our knowledge, this is the first study showing that when banks adopt a threatening attitude, suicide risk increases among the evicted. As hypothesized, when the evicted felt socially supported, suicide risk decreased. Emotional help was the main mediator of suicide risk and the main unmet need, especially among men.