Pressure ulcers related to prone positioning: a pandemic amidst a pandemic.

OBJECTIVE: To explore the epidemiology and risk factors associated with the development of pressure ulcers (PUs) in patients receiving prone positioning (PP) ventilatory therapy; to compare the inflammatory status of patients who develop PUs with those who do not; and to describe the experience and useful findings that have allowed us to improve the management of these patients to reduce the incidence of PUs. METHOD: An observational, descriptive and longitudinal study was conducted, where sociodemographic and laboratory data were collected from patients who were hospitalised and required PP ventilatory therapy in critical care areas (CCA) during the months of May-October 2020. RESULTS: From the total number of patients who required PP during their CCA stay (n=240), 202 (84.2%) developed a PU. The four most frequent areas where a PU appeared were: the head and neck (n=115); the pinna (n=21); the torso (n=21); and the lower limbs (n=21). Patients who developed PU were more frequently males with higher initial levels of creatinine phosphokinase and ferritin. The incidence for each month of follow-up decreased from 8.3% to 5.8%. CONCLUSION: Regardless of the intervention, a multidisciplinary approach is required to optimise the prevention and treatment of these wounds. While PUs are often the result of other medical conditions or poor health status in general, the vast majority of PUs are avoidable.

Patients Journey Before Early Rheumatoid Arthritis Diagnosis Contributes to disease's Activity Level: A Real-Life Study.

INTRODUCTION: The help-seeking process in rheumatoid arthritis (RA) patients is challenging, and its study is limited in Latin America. The study describes the real-life journey before patients' incorporation into an early arthritis clinic (EAC) and its impact on baseline and 1-year cumulative disease activity levels. PATIENTS AND METHODS: The patient's journey was assessed through a questionnaire that captured the patient's path from the first disease-related symptom to the initial assessment in the EAC. A disease activity (28 joints evaluated)-erythrocyte sedimentation rate (DAS28-ESR) score >5.1 defined a high-disease activity level. The mean of individual consecutive DAS28-ESR scores summarized cumulative DAS28-ESR. Multiple logistic regression analysis identified factors associated with a DAS28-ESR score >5.1 at the first assessment. Linear regression analysis assessed the impact of general practitioner (GP)-first consultant and time on disease-modifying antirheumatic drugs (DMARDs) on baseline and cumulative DAS28-ESR scores. RESULTS: Through January 2023, the EAC had 241 RA patients, among whom 209 (86.7%) completed the patients' journey questionnaire (PJQ) and 176 (84.2%) at least 1 year of follow-up. A GP was the first consultant in 76.6% of the patients, and only 12.4% were prescribed DMARDs. Patients had additional evaluations with either rheumatologists (38.6%) or other specialists (31.6%), and half of them were initiated DMARDs. GP-first consultant (adjusted odds ratio: 2.314, 95% confidence interval: 1.190-4.500, p = 0.013) and time on DMARDs (adjusted odds ratio: 0.738, 95% confidence interval: 0.585-0.929, p = 0.010) were associated with baseline DAS28-ESR score >5.1. The B coefficient magnitudes for GP-first consultant and time on DMARDs to predict cumulative DAS28 progressively decreased during the first year of follow-up. CONCLUSIONS: Patients' journey before recent-onset RA diagnosis predicts first-year disease activity levels.

Factors Associated With Distress Related to Perceived Dignity in Patients With Rheumatic Diseases.

BACKGROUND: The loss of perceived dignity is an existential source of human suffering, described in patients with cancer and chronic diseases and hospitalized patients but rarely explored among patients with rheumatic diseases (RMDs). We recently observed that distress related to perceived dignity (DPD) was present in 26.9% of Mexican patients with different RMDs. The study aimed to investigate the factors associated with DPD. METHODS: This cross-sectional study was performed between February and September 2022. Consecutive patients with RMDs completed patient-reported outcomes (to assess mental health, disease activity/severity, disability, fatigue, quality of life [QoL], satisfaction with medical care, and family function) and had a rheumatic evaluation to assess disease activity status and comorbidity. Sociodemographic variables and disease-related and treatment-related variables were retrieved with standardized formats. DPD was defined based on the Patient Dignity Inventory score. Multivariate regression analysis was used. RESULTS: Four hundred patients were included and were representative of outpatients with RMDs, while 7.5% each were inpatients and patients from the emergency care unit. There were 107 patients (26.8%) with DPD. Past mental health-related comorbidity (Odds Ratio [OR]: 4.680 [95% Confidence Interval [CI]: 1.906-11.491]), the number of immunosuppressive drugs/patient (OR: 1.683 [95% CI: 1.015-2.791]), the physical health dimension score of the World Health Organization Quality of Life-Brief questionnaire (WHOQOL-BREF) (OR: 0.937 [95% CI: 0.907-0.967]), and the emotional health dimension score of the WHOQOL-BREF (OR: 0.895 [95% CI: 0.863-0.928]) were associated with DPD. CONCLUSIONS: DPD was present in a substantial proportion of patients with RMDs and was associated with mental health-related comorbidity, disease activity/severity-related variables, and the patient QoL.

Sleep quality and predictors of optimal sleep in patients with rheumatoid arthritis: data from a recent-onset cohort.

OBJECTIVES: Sleep disorders are part of the symptomatology of rheumatoid arthritis (RA) patients and are related to disease characteristics and comorbidities. The study describes sleep quality among RA patients and identifies predictors of optimal sleep. METHODS: Patients whose data were analysed were identified from the recent-onset RA cohort initiated in 2004. In 2010, the Medical Outcome Study Sleep Scale (MOS-SS) was incorporated into the patients' assessments. Up to December 2019, the cohort comprised 187 patients with at least one MOS-SS application (in 78 patients at cohort entry) and six months of outcomes behaviour (cumulative) previous to the MOS-SS application: DAS28-ESR, pain-VAS, fatigue, HAQ-DI, SF-36, treatment (corticosteroids, DMARDs/patient and adherence), Charlson score, and major depressive episodes. A trained data abstractor retrospectively reviewed their charts. Multiple logistic regression analysis estimated odds ratios (95% confidence interval) to define baseline and cumulative variables predictive of optimal sleep (dichotomised variable derived from the quantity of sleep dimension of the MOS-SS). RESULTS: At the first MOS-SS application, patients were primarily middle-aged women with short disease duration and low disease activity. They scored higher on the "snoring" and "sleep non-adequacy" MOS-SS dimensions. There were 96 patients (51.3%) with optimal sleep. Lower baseline BMI, better baseline fatigue score, longer follow-up at the clinic, and better SF-36 physical summary score were predictors of optimal sleep (mental summary score also remained in the model when switched to the physical summary score). CONCLUSIONS: Optimal sleep is achieved by half of the RA patients and predicted by BMI, patient-reported outcomes, and follow-up.

The COVID-19 epidemic curve and vaccine acceptance among patients with rheumatic diseases: an ecological study.

The attitudes toward emerging COVID-19 vaccines have been of great interest worldwide, especially among vulnerable populations such as patients with rheumatic and musculoskeletal diseases (RMDs). The aim of this study was to analyze the relationship between the nationwide number of COVID-19 cases and deaths, and vaccine acceptance or hesitancy of patients with RMDs from four patient care centers in Mexico. Furthermore, we explored differences in acceptance according to specific diagnoses: rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). This ecological study was a secondary analysis of a cross-sectional study using a validated questionnaire to measure vaccine acceptance. We generated a global Likert scale to evaluate overall attitudes toward the COVID-19 vaccine. We analyzed data from 1336 patients from March to September 2021: 85.13% (1169) were women, with a mean age of 47.87 (SD 14.14) years. The most frequent diagnoses were RA (42.85%, 559) and SLE (27.08%, 393). 635(47.52%) patients were unvaccinated, 253(18.93%) had one dose and 478(35.77%) had two doses. Of all participating patients, 94% were accepting toward the COVID-19 vaccine. Vaccine acceptance remained consistently high throughout the study. However, differences in vaccine acceptance are identified when comparing diagnoses. The peak of the national epidemic curve coincided with an increase in hesitancy among patients with RA. Contrastingly, patients with SLE became more accepting as the epidemic curve peaked. Mexican patients show high acceptance of the COVID-19 vaccine, influenced in part by a patient's specific diagnosis. Furthermore, vaccine acceptance increased mirroring the curve of COVID-19 cases and deaths in the country. This should be taken into consideration when updating recommendations for clinical practice.

Factors Associated With Household Work Limitations in Mexican Patients With Rheumatoid Arthritis: The Impact of the Disease on Women's Life.

BACKGROUND: Little attention has been given to the impact of rheumatoid arthritis (RA) on domestic work, which remains the domain of women, particularly in the Latin American region. The study identified factors associated with RA-related household work limitations (HOWL) in Mexican for women with long-standing disease. METHODS: This cross-sectional study was performed between September 2020 and April 2022, in patients from the recent-onset RA cohort (initiated in 2004). At study entry, patients had standard rheumatic assessments and were administered the HOWL questionnaire, a survey to assess family responsibilities, household work characteristics, and the patient's economic dependency, and the family APGAR index to assess family function. Multiple logistic regression analysis identified variables associated with RA-related HOWL. RESULTS: Data from 114 female RA patients were analyzed. Overall, at cohort entry, patients were middle-aged (median, 37.5 years), with 12 years of education, and the minority (n = 42 [39.3%]) were married or living together. Patients were representative of typical patients with recent-onset disease and had significant disease activity. At study entry, the patients had 12 (7-16) years of disease duration, and their disease was under control. The median (interquartile range) HOLW-Q score was 0.67 (0-3.33), and 33 patients (28.9%) had RA-related HOWL. Receiving financial support for family living expenses, requiring assistance for activities of daily living, and DAS28 (Disease Activity Score, 28 joints evaluated) were associated with RA-related HOWL; meanwhile, a better Short-Form 36 score at disease onset was protective. CONCLUSIONS: Domestic work in Mexican RA women might be impacted by social determinants, health-related quality of life at disease onset, and current disease activity status.

A comprehensive approach to complementary and alternative medicine usage among patients from a vascular department.

INTRODUCTION: Use of complementary and alternative medicine (CAM) therapies had been described in patients with disabling, chronic and painful conditions; these characteristics define the majority of vascular surgery (VS) entities. A lack of disclosure about CAM use from patients has been universally cited and may impact effective patient-doctor communication. Our primary objective was to describe CAM use, modalities, perceived benefits, safety, and associated factors among adult patients attending a VS outpatient clinic; we additionally explored patient's attitudes about CAM disclosure with their primary vascular surgeon. METHODS: This cross-sectional study invited 223 consecutive outpatients to an interview where the ICAM-Q (International Complementary and Alternative Medicine Questionnaire) and the PDRQ-9 (Patient-Doctor Relationship Questionnaire-9 items) were applied. In addition, sociodemographics, vascular disease and treatment-related information, comorbidity, and disease severity characteristics were obtained. Appropriated statistics was used; multiple logistic regression analysis identified factors associated to CAM use. All statistical tests were two-sided, and a p value ≤ 0.05 was considered significant. IRB approval was obtained. RESULTS: Patients recruited were primary females (69%) and had a median age of 65 years (54-75). Most frequent vascular diagnoses were chronic venous insufficiency (36.2%) and peripheral artery disease (26%). There were 104 (46.6%) patients who referred CAM use, primarily self-helped practices (96%), and use of herbal, vitamins, or homeopathic medicines (23.7%). Overall, the majority of the patients perceived CAM modalities helpful and 94.6% denied any adverse event. Female sex (OR: 1.768, 95% CI: 0.997-3.135, p = 0.051) and hospitalization during the previous year (OR: 3.173, 95% CI: 1.492-6.748, p = 0.003) were associated to CAM use. The majority of the patients (77%) agreed about CAM disclosure with their primary vascular surgeon; meanwhile, among CAM users, up to 54.9% did not disclose it, and their main reasons were "Doctor didn't ask" (32%) and "I consider it unnecessary" (16%). The patient-doctor relationship was rated by the patients with high scores. CONCLUSIONS: CAM use is frequent and perceived as safe and beneficial among VS outpatients; nonetheless, patients do not disclose CAM use with their primary vascular surgeons, and a wide range of reasons are given by the patients that prevent effective and open communication.

Comparison of Teleconsultations and In-Person Consultations from Outpatients with Rheumatoid Arthritis, During the COVID-19 Pandemic: An Internal Audit of Medical Notes.

Introduction: The objectives of this study were to compare the quality-of-care and compliance with medical record regulations between in-person consultations (QIP and CIP) and telephone consultations (QTP and CTP), from rheumatoid arthritis (RA) outpatients, during the COVID-19 pandemic, and to explore the impact of the consultation modality on the treatment. Methods: Data from 324 medical notes corresponding to rheumatic consultations between July and December 2020 were abstracted. Notes were selected considering a stratified (in-person and telephone consultations) random sampling strategy. QIP, CIP, QTP, and CTP were scored based on prespecified criteria as percentages, where higher numbers translated into better standards. Logistic regression analysis investigated the association between the consultation modality and the treatment recommendation (dependent variable). Results: There were 208 (64.2%) medical notes related to in-person consultations and 114 (35.2%) to telephone consultations. Overall, medical notes corresponded to middle-aged women with long-standing disease. QIP was superior to QTP (median, interquartile range): 60% (60-75%) versus 50% (25-60%), p ≤ 0.001, and differences were related to disease activity and prognosis documentation (81.3% vs. 34.5% and 55.8% vs. 33.6%, respectively, p ≤ 0.001) and the prolonged prescription of glucocorticoids with a documented management plan (58.5% vs. 30.4%, p = 0.045). Meanwhile, CIP and CTP were similar. Telephone consultation was a significant risk factor for no changes in the treatment recommendation (odds ratio: 2.113, 95% confidence interval: 1.284-3.479, p = 0.003), and results were consistent in the 142 medical notes with documented absence of disease activity. Conclusions: In the clinical context of RA, the quality-of-care provided by telephone consultations is below the standard of care and impacts the treatment.

Factors Associated With the Quality of the Patient-Doctor Relationship: A Cross-Sectional Study of Ambulatory Mexican Patients With Rheumatic Diseases.

BACKGROUND: The patient-doctor relationship (PDR) is a complex phenomenon with strong cultural determinants, which impacts health-related outcomes and, accordingly, does have ethical implications. The study objective was to describe the PDR from medical encounters between 600 Mexican outpatients with rheumatic diseases and their attending rheumatologists, and to identify factors associated with a good PDR. METHODS: A cross-sectional study was performed. Patients completed the PDRQ-9 (Patient-Doctor Relationship Questionnaire, 9 items), the HAQ-DI (Health Assessment Questionnaire Disability Index), the Short-Form 36 items (SF-36), a pain-visual analog scale, and the Ideal Patient Autonomy Scale. Relevant sociodemographic, disease-related, and treatment-related variables were obtained. Patients assigned a PDRQ-9 score to each patient-doctor encounter. Regression analysis was used to identify factors associated with a good PDR, which was defined based on a cutoff point established using the borderline performance method. RESULTS: Patients were primarily middle-aged female subjects (86%), with substantial disease duration (median, 11.1 years), without disability (HAQ-DI within reference range, 55.3%), and with deteriorated quality of life (SF-36 out of reference range, 73.7%-78.6%). Among them, 36.5% had systemic lupus erythematosus and 31.8% had rheumatoid arthritis. There were 422 patients (70.3%) with a good PDR and 523 medical encounters (87.2%) involved certified rheumatologists.Patient paternalistic ideal of autonomy (odds ratio [OR], 3.029; 95% confidence interval [CI], 1.793-5.113), SF-36 score (OR, 1.014; 95% CI, 1.003-1.025), female sex (OR, 0.460; 95% CI, 0.233-0.010), and being certified rheumatologist (OR, 1.526; 95% CI, 1.059-2.200) were associated with a good PDR. CONCLUSIONS: Patient-related factors and the degree of experience of the attending physician impact the quality of the PDR, in Mexican outpatients with rheumatic diseases.

How Do Mexican Patients With Rheumatoid Arthritis Define Sexual and Reproductive Health? A Content Analysis Study.

BACKGROUND: A patient-centered approach is essential for promoting sexual health (SH) and reproductive health (RH) in rheumatoid arthritis patients. The study aimed to describe and interpret Mexican rheumatoid arthritis outpatients' testimonies of their SH and RH definitions. METHODS: Qualitative and quantitative content analysis was conducted on free-text comments from 219 and 223 descriptions of patients' SH and RH definitions, respectively. A comprehensive system of major themes, categories, and subcategories was structured for each definition. The representational foundations of these categories and the context of their production were analyzed. Integration of quantitative and qualitative content analysis was used to comprehend patients' definitions of SH and RH. Internal review board approved the study. RESULTS: Ten major themes emerged for each definition, and their assigned frequencies differed between SH and RH definitions, and between groups of patients integrated according to age, education level, and sex. Both definitions had similar contents, expressed in the shared major themes and categories, and in managing at the same time SH- and RH-related contents within each definition. The "overall prevention-patient oriented care" major theme defined a common core for both definitions' contents. Meanwhile, a diversity of meanings was also evident particularly at the subcategory level. CONCLUSIONS: In our population, SH content was distinguished by related diseases and their consequences, individual actions directed to prevention, and couple mentions. Meanwhile, RH was distinguished by a primarily biological perspective of the reproductive function, which was required at a particular life stage to concrete a family project.

Telomeres Length Variations in a Rheumatoid Arthritis Patients Cohort at Early Disease Onset and after Follow-Up.

Background: Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic synovial joint inflammation, progressive disability, premature immune aging, and telomere length (TL) shortening. Objectives: The objective of the study was to study TL changes in patients at early disease onset and after follow-up. Methods: Relative leukocyte TL (rLTL) was measured by quantitative polymerase chain reaction (qPCR) in 88 at-admission patients (AAP) with < 1 year of symptoms onset, self-compared after follow-up, and a reference group of sex- and age-matched healthy individuals. Correlations between rLTL percentage change after variable disease exposure time (DET) and clinical laboratory disease activity markers and treatments were assessed. Non-parametrical statistics were applied, considering < 0.05 p-value significant. Results: The median (p25, p75) rLTL was lower in patients after DET (0.61, 0.49-0.70) than in AAP (0.64, 0.50-0.77), p = 0.017. Furthermore, telomeres at early stages of RA were shorter than in the reference group (0.77, 0.59-0.92; p = 0.003). HLA-DRB1*04 allele carrier status did not significantly affect rLTL at an early stage and after follow-up. The patients' rLTL shortening was mainly associated with longer at-admission telomeres (OR 16.2, 95%CI: 3.5-74.4; p < 0.0001). Conclusions: At follow-up, RA patients showed significantly shorter rLTL than AAP, particularly in those AAP with longer telomeres, disregarding disease activity and treatments, denoting an rLTL shortening effect influenced by age, DET, and native rLTL.

Toenail abnormalities in rheumatoid arthritis patients are associated with radiographic damage and impact disability: a cross sectional study nested within a cohort.

OBJECTIVES: Cutaneous involvement is an extra-articular manifestation of rheumatoid arthritis (RA). This includes nail abnormalities, which are often overlooked. We described nail findings in RA patients currently attending an early arthritis cohort (n=145), and associated them with disease activity and/or damage, as well as patient-reported outcomes. METHODS: A standardised nail examination was performed in 122 patients (84.1% of the cohort), concomitant to the rheumatic assessment. Disability, quality of life and perceived nail-related health were also assessed. Nail findings and their location were recorded and classified according to standardised definitions. Logistic and linear regression models were used to investigate predictors of nail findings and to identify the impact of toenail findings on disability, which was evaluated with the HAQ. Patients consented to participate. RESULTS: Patients were primarily middle-aged females, with median follow-up of 9 years, and had disease under control. Most patients (62.3%) had at least one nail finding and these patients scored lower their nail-related health. The median (IQR) of findings/abnormalities per patient was 3 (2-5) and the number of nails affected per patient was 10 (2-12). Age (OR: 1.04, 95%CI: 1.007-1.074) and erosive disease (OR: 2.26, 95%CI: 1.1-5.1) were associated with nail findings. Toenail involvement was consistently associated with HAQ score out of normal range (OR=3.4, 95%CI=1.24-9.35, p=0.02). There was a linear association between the number of toenails affected and the HAQ score. CONCLUSIONS: Nail abnormalities are common and heterogeneous findings in RA patients; they are associated with erosive damage and impact disability.

Takayasu's Arteritis from the Patients' Perspectives: Measuring the Pulse to the Patient-Reported Outcomes.

BACKGROUND: Patients with Takayasu's arteritis (TA) experience important changes in lifestyle, quality of life, and functional status due to ischemic symptoms or treatment toxicity. PURPOSE: To describe the clinical characteristics and the patient-reported outcomes (PROs), such as quality of life, disability, fatigue, and perception/impact of the disease in Mexican patients with TA. METHODS: Cross-sectional study including patients with established diagnosis of TA recruited at a tertiary care center. Demographics, comorbidities, clinical characteristics, laboratory, imaging, and treatment were retrieved. Disease activity (the Indian Takayasu Clinical Activity Score (ITAS) 2010), damage (Vasculitis Damage Index (VDI)), quality of life (Short Form 36 (SF-36)), disability (Health Assessment Questionnaire Disability Index (HAQ-DI)), fatigue (Multidimensional Fatigue Inventory-20), and patient's disease perceptions were assessed. RESULTS: Fifteen women were included, with a median age of 41 years (interquartile range (IQR) 30-45) and disease duration of 108 months (IQR 55-197). Median ITAS 2010 and VDI scores were 0 (IQR 0-2) and 3 points (IQR 2-6), respectively. Mean SF-36 score was 71.38 ± 13.39, with mean physical and mental component summaries of 66.52 ± 13.37 and 76.24 ± 14.89, respectively. HAQ-DI mean score was 0.48 ± 0.62, being grip the most affected domain. Among fatigue subscales, the higher scores were present in the physical fatigue (16.3 ± 5.8). Correlations between the HAQ-DI and the VDI score (r = 0.64, P = 0.03); between the general fatigue, score, and disease duration (r = -0.71, P = 0.01); and between the SF-36 total score and the HAQ-DI (r = -0.87, P = 0.0004) were found. CONCLUSIONS: It is important to identify disease-specific outcomes of interest to the patients to develop tools that assess them with a holistic approach.

Systemic lupus erythematosus diagnosis impacts clinical outcomes of arteriovenous fistulas in comparison to other end-stage renal disease etiologies.

OBJECTIVES: Arteriovenous fistulas primary patency at one-year occurs in 43-85% of the patients with end-stage renal disease. The diagnosis attributable to end-stage renal disease has been suggested to impact arteriovenous fistulas outcomes. The objective was to compare primary patency at one week, 1, 3, 6, and 12 months of follow-ups, among systemic lupus erythematosus patients and two control groups; additionally, we evaluated the impact of systemic lupus erythematosus to predict early patency loss. METHODS: A retrospective review of charts from arteriovenous fistulas created between 2008 and 2017 was performed. One-hundred thirty-four patients were identified and classified according to end-stage renal disease attributable diagnosis as: systemic lupus erythematosus cases (N = 14), control-group-1 (91 patients with primarily diabetes and hypertension), and control-group-2 (29 patients with idiopathic end-stage renal disease). A case-control matched design (1:2:1) was proposed. Logistic regression analysis and Kaplan-Meier curves were used. Institutional Review Board approval was obtained. RESULTS: More systemic lupus erythematosus patients lost primary patency at 3 (28.6%) and 12 months (71.4%) than patients from control-groups-1 (vs. 3.6% and 35.7%, respectively) and -2 (vs. 0% and 14.3%, respectively), (p ≤ 0.011 for both). Days of primary patency survival were shorter in systemic lupus erythematosus patients (p = 0.003). Systemic lupus erythematosus diagnosis was the only factor associated with early patency loss, HR: 3.141, 95%CI: 1.161-8.493 (systemic lupus erythematosus diagnosis vs. control-group-1) and HR: 12.582, 95%CI: 1.582-100.035 (systemic lupus erythematosus diagnosis vs. control-group-2). CONCLUSIONS: Diagnosis attributable to end-stage renal disease has a major impact on arteriovenous fistula outcomes in patients. Systemic lupus erythematosus patients have an increased risk of arteriovenous fistulas patency loss within the first six months of follow-up. Patients with idiopathic end-stage renal disease had an excellent one year arteriovenous fistula patency survival.

Smoking cessation is associated with lower disease activity and predicts cardiovascular risk reduction in rheumatoid arthritis patients.

OBJECTIVES: Smoking is a major risk factor for the development of both cardiovascular disease (CVD) and RA and may cause attenuated responses to anti-rheumatic treatments. Our aim was to compare disease activity, CVD risk factors and CVD event rates across smoking status in RA patients. METHODS: Disease characteristics, CVD risk factors and relevant medications were recorded in RA patients without prior CVD from 10 countries (Norway, UK, Netherlands, USA, Sweden, Greece, South Africa, Spain, Canada and Mexico). Information on CVD events was collected. Adjusted analysis of variance, logistic regression and Cox models were applied to compare RA disease activity (DAS28), CVD risk factors and event rates across categories of smoking status. RESULTS: Of the 3311 RA patients (1012 former, 887 current and 1412 never smokers), 235 experienced CVD events during a median follow-up of 3.5 years (interquartile range 2.5-6.1). At enrolment, current smokers were more likely to have moderate or high disease activity compared with former and never smokers (P < 0.001 for both). There was a gradient of worsening CVD risk factor profiles (lipoproteins and blood pressure) from never to former to current smokers. Furthermore, former and never smokers had significantly lower CVD event rates compared with current smokers [hazard ratio 0.70 (95% CI 0.51, 0.95), P = 0.02 and 0.48 (0.34, 0.69), P < 0.001, respectively]. The CVD event rates for former and never smokers were comparable. CONCLUSION: Smoking cessation in patients with RA was associated with lower disease activity and improved lipid profiles and was a predictor of reduced rates of CVD events.

Musculoskeletal ultrasound to complement clinical evaluation and drive treatment of rheumatoid arthritis patients in remission does not prevent worsening of patient-reported outcomes: the ULTRAPRO randomised controlled study.

OBJECTIVES: The primary objective was to determine the impact of sharing musculoskeletal ultrasound (MUS) results with rheumatologists on worsening patient-reported outcomes (PROs) at 6 months of follow-up in rheumatoid arthritis (RA) patients with clinical remission. Secondary objectives were to describe MUS findings and to compare the proportion of patients with flares, according to the DAS28-ESR, following the intervention. METHODS: Ninety-four consecutive outpatients with clinical remission had PROs and a treatment proposal recorded at study entry. MUS was then performed by trained specialists who were blinded to clinical assessments. Forty-seven patients were randomised (1:1) to either the intervention group (MUS data shared with the primary rheumatologist) or the control group (data not shared); changes in the treatment proposal were recorded. PROs worsening and the proportion of patients with ares were compared between both groups at 6±2 months of follow-up. The study received IRB approval. Appropriate statistics were used. RESULTS: At baseline, patients from the intervention and control groups had similar characteristics; 43 and 41 patients, respectively, completed the 6-month follow-up period. PROs worsening at 6 months of follow-up were similar between groups, as were the DAS28-ESR and the proportion of patients who flared. In general, MUS findings were in accordance with the clinical remission status, although power Doppler synovitis was detected in up to 37% of the patients. RA-related treatment was increased in all the patients from the intervention group with discordant findings between clinical and MUS assessments. CONCLUSIONS: The addition of MUS to clinical evaluation of RA outpatients in remission did not prevent worsening PROs at 6 months.

Cardiovascular risk factors' behavior during the early stages of the disease, in Hispanic rheumatoid arthritis patients: a cohort study.

Rheumatoid arthritis (RA) patients from Latin America present distinctive characteristics relevant when assessing their cardiovascular (CV) risk. The objective was to monitor CV risk factor behavior in the early stages of the disease and to identify predictors of major CV outcomes (MACE). A recent-onset RA cohort was initiated in 2004; data from 185 patients with ≥ 1 year of follow-up were analyzed. Patients underwent prospective assessments of CV risk factors. Incident MACE were confirmed according to standardized definitions. Appropriated statics was used based on the distribution of the variables. At baseline, patients were primarily middle-aged females (87.6%), with active disease (69.7%). Most prevalent CV risk factors were C-reactive-protein > 1 mg/L (90.3%), Castelli ratio > 3 (83.8%), and low-high-density lipoprotein levels (73.5%). The number of patients with an incident CV risk factor after 1 year was higher for a Castelli ratio > 3 (23%), low-high-density lipoprotein serum cholesterol (16.3%), high total serum cholesterol (10.6%), and BMI ≥ 30 kg/m2 (10%). A minority of patients met the age-range criteria for the application of ACC/AHA 2013 criteria and Reynolds Risk Score (45.8% and 34.1%, respectively). Fifteen patients were classified with high-CV risk during the first year of follow-up, according to ACC/AHA 2013 criteria. Until June 2018, the cohort underwent 1358 patient/years follow-up; six patients developed incidental MACE; high-CV risk at baseline failed to predict MACE. Recent-onset RA Hispanic patients present a distinctive pattern and first-year behavior of CV risk factors. During follow-up, few patients developed incidental MACE.

Reduced quality of life impacts knowledge and type of informed consent in rheumatoid arthritis patients.

OBJECTIVES: Informed consent (IC) is an ethical process required in human subject research. Primary objective was to determine factors associated to poor knowledge of IC content (PK) in patients from an early rheumatoid arthritis cohort. METHODS: The cohort initiated in 2004, had assistant and research purposes (NCT03389711). At inclusion, each patient selected 1 of 4 options of the IC form; options ranged from broad consent (patient's data could be used for research) to patient denied to have his/her data used. Once enrolled, patients had regular assessments. Up to May 2017, the cohort had 146 patients with (median, range) follow-up of 8.8 years, (4.3-11.9) and 143 agreed to participate in a cross-sectional study; patients had scheduled rheumatic evaluations; additionally, a social worker applied a questionnaire that addressed objective described. PK was established by the borderline performance method. Multiple regression models were applied to investigate factors associated to PK. RESULTS: At cohort inclusion, patients were primarily middle-aged (38.3±13.1 years) females (88.9%), with high disease activity (DAS28: 5.8 [4.6-6.8)] and poor quality of life (SF-36: 42 [29-59]). All the patients gave broad IC. At study entry, 35-41.3% of them had PK; longer follow-up and lower SF-36 scores at cohort inclusion, were associated to PK. In addition, 79.7% of the patients had DAS28-remission and 67.1% had SF-36 scores within normal range; interestingly, only 49% of the patients considered broad re-consent and these patients had poorer SF-36 emotional subscore than their counterpart (79±23 vs. 87±1, p=0.02). CONCLUSIONS: Poor quality of life impacts the autonomy of RA patients.

Attitudes about principle of autonomy in Hispanic patients from a dynamic early rheumatoid arthritis cohort.

OBJECTIVES: In 2004, we began assembling an incidental cohort of patients with recent-onset rheumatoid arthritis (RA). In February 2018, we performed a cross-sectional study with the objective to investigate patients' attitudes/knowledge regarding the autonomy principle. METHODS: Patients currently attending the cohort (n=146) were invited to participate. A 4-dimensional questionnaire was administered, and a rheumatologic evaluation performed in the 143 patients who agreed to participate. Dimension-4 (D-4) included 7 multiple-choice (strongly agree-strongly disagree) sentences, 3 of which were related to patients' rights/obligations about health-related decisions (group-1), and 4 additional sentences challenged physician's recommendations (group-2). The D-4 score was considered a surrogate of knowledge autonomy (KA). Additionally, the surveyor scored KA with a Likert scale (poor, borderline and superior), and a cut-off point for poor KA was set using Borderline methodology. Mann-Whitney U-tests and logistic regression analysis were used. The study received IRB approval. RESULTS: At the time the questionnaire was administered, mean (±SD) patient age was 46.9 (±13.6) years, and median (interquartile range) cohort follow-up time was 8.8 (4.3-11.9) years. Fifty-one patients (35.6%) had poor KA; increased age (OR: 0.97, 95% CI: 1.004-1.063, p=0.023) was associated with better KA. Patients more frequently agreed-strongly agreed with group-1 sentences than they did with group-2 sentences (86.7% vs. 58%, p≤0.001). The results were reproduced in the subpopulations with sufficient KA (98.9% vs. 88%, p=0.007) and poor KA for patients in whom the gap was extreme (64.9% vs. 3.9%, p≤0.001). CONCLUSIONS: Hispanic RA patients' sense of autonomy suggests paternalism in the physician-patient relationship.

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

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