EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis: 2023 update.

INTRODUCTION: Hip and knee osteoarthritis (OA) are increasingly common with a significant impact on individuals and society. Non-pharmacological treatments are considered essential to reduce pain and improve function and quality of life. EULAR recommendations for the non-pharmacological core management of hip and knee OA were published in 2013. Given the large number of subsequent studies, an update is needed. METHODS: The Standardised Operating Procedures for EULAR recommendations were followed. A multidisciplinary Task Force with 25 members representing 14 European countries was established. The Task Force agreed on an updated search strategy of 11 research questions. The systematic literature review encompassed dates from 1 January 2012 to 27 May 2022. Retrieved evidence was discussed, updated recommendations were formulated, and research and educational agendas were developed. RESULTS: The revised recommendations include two overarching principles and eight evidence-based recommendations including (1) an individualised, multicomponent management plan; (2) information, education and self-management; (3) exercise with adequate tailoring of dosage and progression; (4) mode of exercise delivery; (5) maintenance of healthy weight and weight loss; (6) footwear, walking aids and assistive devices; (7) work-related advice and (8) behaviour change techniques to improve lifestyle. The mean level of agreement on the recommendations ranged between 9.2 and 9.8 (0-10 scale, 10=total agreement). The research agenda highlighted areas related to these interventions including adherence, uptake and impact on work. CONCLUSIONS: The 2023 updated recommendations were formulated based on research evidence and expert opinion to guide the optimal management of hip and knee OA.

Key steps and barriers in the journey of patients with epilepsy through the National Healthcare System in Spain: The EPIPASS qualitative study.

OBJECTIVE: Epilepsy requires continuous medical attention from multiple healthcare specialists, specialized facilities, and community-based care. In Spain, there is no standardized approach to epilepsy care. The aim of this study was to identify the factors impacting on the delivery of high-quality care by exploring key steps and barriers along the patient journey through the Spanish National Healthcare System (NHS). METHODS: A qualitative study was conducted using opinions and experiences of neurologists, nurses, patients, and caregivers shared in discussion meetings. Using thematic content analyses, relevant aim-focused statements were coded according to prespecified issues in a discussion map (i.e., key steps and barriers), and sub-coded according to emerging issues. Thematic saturation and co-occurrence of key steps/barriers were evaluated to identify the most relevant factors impacting on the delivery of high-quality care. RESULTS: Sixty-five stakeholders took part in discussion meetings (36 neurologists, 10 nurses, 10 patients, and nine caregivers). Six key steps on the patient journey were identified: emergency care, diagnosis, drug therapy, follow-up, referral, and interventional treatment. Of these, follow-up was the most relevant step impacting on the delivery of high-quality patient care, followed by drug therapy and diagnosis. Emergency care was considered a hot-spot step with impact throughout the patient journey. Communication (among HCPs and between HCPs and patients) was a barrier to the delivery of high-quality care at several stages of the patient journey, including drug therapy, follow-up, referral, and interventional treatment. Resource availability was a barrier for diagnosis (especially for confirmation), drug therapy (drug availability), and referral (lack of professionals and specialized centers, and long waiting lists). SIGNIFICANCE: This is the first study capturing perspectives of four key stakeholders involved in epilepsy care in Spain. We provide an overview of the patient journey through the Spanish NHS and highlight opportunities to improve the delivery of patient-centered care with a chronicity perspective. PLAIN LANGUAGE SUMMARY: Patients with epilepsy may require prolonged medical care. In Spain, care is provided by a range of specialist and non-specialist centers. In this study, a team of Spanish neurologists, nurses, patients and caregivers identified barriers that affect the delivery of high-quality care for patients with epilepsy at each stage of their journey through the Spanish NHS. Specific epilepsy training for healthcare providers, appropriate resources for diagnosing and treating patients, and good communication between healthcare workers and patients were identified as important factors in providing high-quality care for patients with epilepsy.

Financial fraud and health: the case of Spain / Fraudes financieros y salud: el caso de España

Objective: To examine whether financial fraud is associated with poor health sleeping problems and poor quality of life. Methods: Pilot study (n=188) conducted in 2015-2016 in Madrid and León (Spain) by recruiting subjects affected by two types of fraud (preferred shares and foreign currency mortgages) using venue-based sampling. Information on the monetary value of each case of fraud; the dates when subjects became aware of being swindled, lodged legal claim and received financial compensation were collected. Inter-group comparisons of the prevalence of poor physical and mental health, sleep and quality of life were carried according to type of fraud and the 2011-2012 National Health Survey. Results: In this conventional sample, victims of financial fraud had poorer health, more mental health and sleeping problems, and poorer quality of life than comparable populations of a similar age. Those who had received financial compensation for preferred share losses had better health and quality of life than those who had not been compensated and those who had taken out foreign currency mortgages. Conclusion: The results suggest that financial fraud is detrimental to health. Further research should examine the mechanisms through which financial fraud impacts health. If our results are confirmed psychological and medical care should be provided, in addition to financial compensation (AU)

Objetivo: Explorar si los fraudes financieros se asocian a la mala salud, problemas de sueño y mala calidad de vida. Métodos: Estudio piloto (n=188) realizado en 2015-2016 en Madrid y León reclutando personas afectadas por dos tipos de fraudes (preferentes e hipotecas multidivisas), por el método venue-sampling. Se recogió información sobre el valor monetario del fraude, las fechas en que la persona conocía que había sido estafada, había iniciado una demanda y había recibido una compensación económica. Se compararon las prevalencias de mala salud física y mental, sueño y calidad de vida entre grupos según tipo de fraude y con la Encuesta Nacional de Salud de 2011-2012. Resultados: En esta muestra convencional, las víctimas de fraude financiero presentaron peor salud, más problemas de salud mental y de sueño, y peor calidad de vida que las poblaciones comparables de la misma edad. Aquellos que habían recibido una compensación económica por las pérdidas en preferentes tuvieron mejor salud y calidad de vida que los que no habían recibido compensación y que aquellos que habían contratado hipotecas multidivisas. Conclusión: Los resultados sugieren que los fraudes financieros causan daños a la salud. Deberían investigarse los mecanismos por los que los fraudes financieros causan daños de salud. Si los resultados se confirman, debe proveerse asistencia psicológica y médica, además de las compensaciones económicas (AU)

Recomendaciones para una prescripción segura de antiinflamatorios no esteroideos: documento de consenso elaborado por expertos nominados por 3 sociedades científicas (SER-SEC-AEG) / Safe prescription recommendations for non steroidal anti-inflammatory drugs: Consensus document ellaborated by nominated experts of three scientific associations (SER-SEC-AEG)

Este artículo señala las recomendaciones claves para una adecuada prescripción de antiinflamatorios no esteroideos a pacientes que presentan indicación de tratamiento con esta medicación, en base a la evidencia científica actual y teniendo en consideración aspectos de seguridad gastrointestinal y cardiovascular. Las recomendaciones se han consensuado por expertos designados por 3 sociedades científicas (Sociedad Española de Reumatología, Asociación Española de Gastroenterología y Sociedad Española de Cardiología), siguiendo una metodología Delphi a 2 rondas. Las áreas que se han tenido en cuenta engloban: eficacia, riesgo cardiovascular, riesgo gastrointestinal, riesgo hepático, riesgo renal, enfermedad inflamatoria intestinal, anemia, dolor postoperatorio y estrategias de prevención. Se propone un algoritmo de manejo de pacientes que recoge los aspectos fundamentales de las recomendaciones (AU)

This article outlines key recommendations for the appropriate prescription of non steroidal anti-inflammatory drugs to patients with different musculoskeletal problems. These recommendations are based on current scientific evidence, and takes into consideration gastrointestinal and cardiovascular safety issues. The recommendations have been agreed on by experts from three scientific societies (Spanish Society of Rheumatology [SER], Spanish Association of Gastroenterology [AEG] and Spanish Society of Cardiology [SEC]), following a two-round Delphi methodology. Areas that have been taken into account encompass: efficiency, cardiovascular risk, gastrointestinal risk, liver risk, renal risk, inflammatory bowel disease, anemia, post-operative pain, and prevention strategies. We propose a patient management algorithm that summarizes the main aspects of the recommendations (AU)

Recomendaciones para una prescripción segura de antiinflamatorios no esteroideos: documento de consenso elaborado por expertos nominados por 3 sociedades científicas (SER-SEC-AEG) / Safe prescription recommendations for non steroidal anti-inflammatory drugs: Consensus document ellaborated by nominated experts of three scientific associations (SER-SEC-AEG)

Este artículo señala las recomendaciones claves para una adecuada prescripción de antiinflamatorios no esteroideos a pacientes que presentan indicación de tratamiento con esta medicación, en base a la evidencia científica actual y teniendo en consideración aspectos de seguridad gastrointestinal y cardiovascular. Las recomendaciones se han consensuado por expertos designados por 3 sociedades científicas (Sociedad Española de Reumatología, Asociación Española de Gastroenterología y Sociedad Española de Cardiología), siguiendo una metodología Delphi a 2 rondas. Las áreas que se han tenido en cuenta engloban: eficacia, riesgo cardiovascular, riesgo gastrointestinal, riesgo hepático, riesgo renal, enfermedad inflamatoria intestinal, anemia, dolor postoperatorio y estrategias de prevención. Se propone un algoritmo de manejo de pacientes que recoge los aspectos fundamentales de las recomendaciones

This article outlines key recommendations for the appropriate prescription of nonsteroidal anti-inflammatory drugs to patients with different musculoskeletal problems. These recommendations are based on current scientific evidence, and takes into consideration gastrointestinal and cardiovascular safety issues. The recommendations have been agreed on by experts from three scientific societies (Spanish Society of Rheumatology [SER], Spanish Association of Gastroenterology [AEG] and Spanish Society of Cardiology [SEC]), following a two-round Delphi methodology. Areas that have been taken into account encompass: efficiency, cardiovascular risk, gastrointestinal risk, liver risk, renal risk, inflammatory bowel disease, anemia, post-operative pain, and prevention strategies. We propose a patient management algorithm that summarizes the main aspects of the recommendations

Impacto psicosocial y su manejo en enfermedad inflamatoria intestinal. El punto de vista de los pacientes / The psychosocial impact of inflammatory bowel disease and its management. From the patients' perspective

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Factores motivadores y barreras para implantar una vía clínica de atención precoz de espondiloartritis: estudio cualitativo con médicos de atención primaria / Motivations and objections to implement a spondyloarthritis integrated care pathway. A qualitative study with primary care physicians

Fundamento y objetivo. Previo al desarrollo de una vía clínica (VC) para espondiloartritis (EspA) precoz, se realizó un estudio cualitativo para conocer la actitud de los médicos de atención primaria (MAP) respecto de su implantación, para aumentar sus posibilidades de éxito. Métodos. Se realizaron 5 grupos de discusión (2 en Madrid, 2 en Barcelona y 1 en Sevilla) y 3 entrevistas en Bilbao. Se incluyeron MAP con perfiles que garantizaran la diversidad de puntos de vista. Tanto grupos como entrevistas fueron realizados por expertos en metodología cualitativa. Resultados. En general, los MAP no conocen las VC. Se consideraron motivaciones para su implantación: mejorar la atención de los pacientes, disponibilidad de un consultor especialista, posibilidad de formación e investigación, remuneración y reconocimiento profesional. Se consideraron dificultades para su implantación: trabajo adicional, burocratización excesiva, falta de respuesta del especialista, desconocimiento informático y la no remuneración. El conocimiento de las EspA por los MAP fue deficiente: se asociaba simultáneamente «espondilitis» con artrosis, lumbalgia, espondilitis anquilosante y artritis psoriásica. Solo derivaban al especialista para confirmar el diagnóstico, lo demandaba el paciente o el tratamiento era ineficaz. Conclusiones. Para implantar una VC de EspA, con colaboración óptima de primaria es necesario: a) formalizar los procesos a través de un programa sencillo, práctico y aprobado por gerencia, que facilite la interacción con el especialista sin aumentar la carga de trabajo; b) permitir una retroalimentación de seguimiento del paciente a lo largo de todo el proceso, además de un consultor permanente, y c) proporcionar formación en EspA a los MAP (AU)

(SpA), a qualitative study was performed to know the attitude of primary care physicians (PCP) with respect to CP implementation. Methods: 5 discussion groups (2 in Madrid, 2 in Barcelona and 1 in Sevilla) and 3 interviews in Bilbao, were performed. PCP with different profiles were included. Groups and interviews were carried out by experts on qualitative methodology.Results: PCP know little about CP. Motivations of professionals to work on a SpA CP were: to improve patients care, availability of a specialist consultant, possibility of learning and doing research, remuneration, and professional recognition. Objections to CP implementation were: extra work, excessive bureaucracy, absence of a specialist consultant, computer difficulties, and no remuneration. SpA knowledge by PCP was defective. PCP associated the term “spondylitis” with osteoarthritis, low-back pain, ankylosing spondylitis and psoriatic arthritis. They only referred patients to the rheumatologist to confirm the diagnosis, when patients complained and when treatment was ineffective. Conclusions: For an optimal CP implementation, the following is deemed necessary: 1) a practical, simple program that eases the interaction with the rheumatologist without an increase on the PCP work load; 2) to provide continuous feedback by the specialist and 3) to provide knowledge on SpA to PCP (AU)

¿Se derivan adecuadamente las espondiloartropatías desde primaria a especializada? / Are spondyloarthropathies adequately referred from primary care to specialized care?

Objetivo. Evaluar el grado de acuerdo entre los médicos de atención primaria (MAP) y los reumatólogos en la valoración de los criterios de derivación en pacientes con sospecha de espondiloartritis (EspA) precoz. Material y métodos. Se derivaron los pacientes con sospecha de EspA precoz, a través de la plataforma electrónica, por MAP siguiendo unos criterios de derivación predeterminados a Unidades de EspA precoz, donde fueron de nuevo evaluados por reumatólogos y confirmados los diagnósticos. Se ha analizado la concordancia de los criterios de derivación predeterminados entre MAP y reumatólogos mediante el índice kappa (k) en aquellos pacientes con diagnóstico de EspA precoz. Resultados. Analizamos 802 pacientes, de los que el 8,31% fueron mal derivados. El grado de acuerdo en relación con criterios de derivación predeterminados fue pobre para la lumbalgia inflamatoria (k=0,16; intervalo de confianza del 95% [IC 95%] 0,09-0,23), sacroilitis radiológica (k=0,31; IC 95% 0,211-0,428), raquialgia o artralgia (k=0,21; IC 95% 0,14-0,29); moderado para el criterio de artritis asimétrica (k=0,51; IC 95% 0,43-0,59), HLA B27 positivo (k=0,59; IC 95% 0,52-0,67) e historia familiar (k=0,50; IC 95% 0,415-0,604). Los grados de acuerdo fueron buenos o muy buenos para la presencia de uveítis anterior (k=0,81; IC 95% 0,68-0,93), enfermedad inflamatoria intestinal (k=0,87; IC 95% 0,79-0,96) y psoriasis (k=0,73; IC 95% 0,65-0,81). Conclusiones. El grado de acuerdo entre MAP y reumatólogos respecto a la valoración de los criterios preestablecidos para derivación de EspA precoz es variable. La concordancia es baja para criterios de derivación clave para el diagnóstico de pacientes con EspA. Facilitar programas de formación y entrenamiento para MAP resulta fundamental para identificar a pacientes con EspA precoz (AU)

Objective: To evaluate the degree of agreement between primary care physicians and rheumatologists when evaluating the referral criteria in patients with suspected early spondyloarthropathy (Spa). Material and methods: Patients with suspected early Spa (according to predefined clinical referral criteria) were sent by primary care physicians to early Spa units (where a rheumatologist evaluated the same criteria and confirmed the diagnosis) through an on-line platform. We assessed the agreement between primary care physicians and rheumatologists regarding the predefined clinical refererral criteria among patients with definitive Spa using the kappa index (k). Results: Eight hundred and two patients were analysed, 8.31% of whom were incorrectly referred to the rheumatologist. The degree of agreement regarding the predefined clinical referral criteria was poor for inflammatory back pain (k = 0.16; 95% confidence interval [95% CI] 0.09-0.23), radiographic sacroiliitis (k = 0.31; 95% CI 0.211-0.428), back or joint pain (k = 0.21; 95% CI 0.14-0.29); mild for asymmetric arthritis (k = 0.51; 95% CI 0.43-0.59), positive HLA B27 (k = 0.59; 95% CI 0.52-0.67) and family history (k = 0.50; 95% CI 0.415-0.604); and it was good or very good for anterior uveitis (k = 0.81; 95% CI 0.68-0.93), inflammatory bowel disease (k = 0.87; 95% CI 0.79-0.96) and psoriasis (k = 0.73; 95% CI 0.65-0.81),. Conclusions: The degree of agreement between primary care physicians and rheumatologists regarding the predefined clinical referral criteria was variable. Agreement was very poor for variables like inflammatory back pain, which are crucial for the diagnosis of Spa. Training programs for primary care physicians are important in order for them to correctly identify early Spa patients (AU)

Fibromyalgia Health Assessment Questionnaire, evaluación de la sensibilidad al cambio

Objetivo. Analizar la sensibilidad al cambio del cuestionario Fibromyalgia Health Assessment Questionnaire (FHAQ) en un grupo de pacientes con fibromialgia (FM). Métodos. Estudio observacional, prospectivo longitudinal, incluido en el Proyecto ICAF (Índice combinado de afectación en pacientes con fibromialgia), realizado en 15 centros españoles. Se estudió de forma consecutiva a 232 pacientes con FM con una edad media de 47 años, el 98,3% mujeres, que se evaluaron en una visita basal y 3 meses después de que se les instaurara un tratamiento según práctica médica habitual. El análisis estadístico incluyó: comparación de medias, respuesta media estandarizada (RME), medida basal estándar (DE), coeficiente de correlación intraclase (R), error estándar de medida (EEM), diferencia mínima detectable (DMD) y proporción de cambio real. Resultados. La diferencia de puntuación media del FHAQ en la visita basal y a los 3 meses fue de 0,098 (IC del 95%, 0,034-0,16) con una p<0,003. Sin embargo, la RME fue de 0,21 (cambio pequeño); DE=0,57, R=0,81, EEM=0,25, DMD=0,69. La proporción de cambio real fue del 17% (39 pacientes). No obstante, el sentido del cambio fue positivo en 28 casos (menor puntuación a los 3 meses) y negativo en los otros 11 (mayor puntuación a los 3 meses). Conclusiones. La puntuación a los 3 meses fue significativamente mejor que la basal, pero con los resultados de este estudio no se puede considerar que el FHAQ sea suficientemente sensible al cambio como para recomendar su uso en estudios longitudinales. El hecho, conocido, de que muchos pacientes pueden empeorar con el tratamiento empleado ha ido en detrimento de la valoración psicométrica del FHAQ (AU)

Objective. To analyze the sensitivity to change of the Fibromyalgia Health Assessment Questionnaire (FHAQ) in a group of patients with fibromyalgia (FM). Methods. Observational, prospective and longitudinal study related to the project ICAF was taken part in 15 Spanish centers. 232 patients were included and diagnosed of FM: 98.3% were women, the mean age was 47years old, they were analyzed at a basal visit and 3months visit, afterwards an appropriated treatment was prescribed. The statistical analysis was performed including: mean comparison, mean standardized response (RME), basal standard media (DE), intraclass correlation coefficient (R), standard error of the mean (EEM), minimal detectable difference (DMD) and percentage change in real. Results. The difference in mean comparison of the FHAQ in the baseline visit and the 3monts visit was of 0,098 (IC 95%: 0,034-0,16), with a P<.003. Nevertheless the RME was 0.21, a slightly change, the DE=0.57, R=0.81, EEM=0.25, and the DMD=0.69. The percentage change in real was 17% (39 patients). But the sense of the change was positive in 28cases (less punctuation in the 3monts visit) and negative in other 11cases (higher punctuation in the 3monts visit). Conclusions. The punctuation in the 3months visit was significant better than the basal, but the results of this study do not let it to consider that the FHAQ have enough change susceptibility to recommend it in longitudinal studies. The well knowing fact, some patients can become worse with the treatment prescribed would be to the detriment of the FHAQ psychometric value (AU)

Uso apropiado de los antiinflamatorios no esteroideos en reumatología: documento de consenso de la Sociedad Española de Reumatología y el Colegio Mexicano de Reumatología / Appropriate use of non-steroidal anti-inflammatory drugs in rheumatology: guidelines from the Spanish Society of Rheumatology and the Mexican College of Rheumatology

Objetivos: Elaborar recomendaciones para el uso apropiado de AINE en reumatología. Métodos: Se utilizó una metodología modificada de RAND/UCLA. Se seleccionaron dos grupos de panelistas, uno por el CMR y otro por la SER. A partir de grupos nominales, se obtuvieron propuestas de recomendaciones, que fueron sometidas a la prueba de acuerdo entre los reumatólogos de ambas sociedades mediante encuesta Delphi a dos rondas. Del análisis de la segunda ronda Delphi, se extrajeron las recomendaciones finales y posteriormente se revisó el nivel de evidencia y el grado de acuerdo de la recomendación según el Centro de Medicina Basada en la Evidencia de Oxford. Finalmente, se efectuó revisión sistemática de cinco recomendaciones sin acuerdo. Resultados: Se presentan recomendaciones sobre el uso seguro de los AINE en las enfermedades reumáticas, con base en la mejor evidencia disponible, la opinión de expertos, el acuerdo entre reumatólogos y la revisión de la literatura. La tendencia es disminuir la frecuencia, la duración y la dosis de AINE en favor de medidas no farmacológicas, analgésicos o fármacos modificadores de los síntomas o del curso de la enfermedad. Además, es obligado identificar perfiles de mayor riesgo de toxicidad, en especial gastrointestinal y cardiovascular. Se recomiendan pautas de actuación y monitorización en los diferentes grupos de riesgo y en pacientes con empleo de antiagregantes plaquetarios, anticoagulación o con terapias concomitantes. El porcentaje de acuerdo es elevado en la mayoría de los casos. Conclusiones: Los AINE son medicamentos seguros y eficaces en el tratamiento de las afecciones reumáticas. No obstante, dado su perfil de riesgo, es necesario individualizar su uso (AU)

Objective: To develop guidelines for the appropriate use of NSAIDs in rheumatology. Methods: We used a methodology modified from the one developed by RAND/UCLA. Two groups of panellists were selected, one by the CMR and another by the SER. Recommendations were proposed from nominal groups and the agreement to them was tested among rheumatologists from both societies by a tworound Delphi survey. The analysis of the second Delphi round supported the generation of the final set of recommendations and the assignment of a level of agreement to each of them. Systematic reviews of five recommendations in which the agreement was low or was divided were also carried out. Results: Here we present recommendations for the safe use of NSAIDs in rheumatic diseases, based on the best available evidence, expert opinion, the agreement among rheumatologists, and literature review. The trend is to reduce the frequency, duration and dose of NSAIDs in favour of non-pharmacological measures, analgesic drugs or disease modifying drugs. In addition, the recommendations help to identify profiles for increased toxicity, with an emphasis on gastrointestinal and cardiovascular risks. The recommendations deal with the course of action and monitoring in different risk groups and in patients using antiplatelet or anticoagulant drugs. The overall level of agreement is high. Conclusions: The NSAIDs are safe and effective drugs for the treatment of rheumatic diseases. However, it is necessary to individualize its use according to their risk profile (AU)