Distribution and characteristics of the certification of rheumatologists in Mexico.

OBJECTIVE: Describe the distribution of adult and pediatric rheumatologists with current certification in Mexico and the factors associated with this distribution. METHODS: The databases of the Mexican Council of Rheumatology and the Mexican College of Rheumatology for 2020 were reviewed. The rate of rheumatologists per 100,000 inhabitants by state of the Mexican Republic was calculated. To find out the number of inhabitants by state, the results of the 2020 population census of the National Institute of Statistics and Geography were consulted. The number of rheumatologists with current certification by state, age, and sex was analyzed. RESULTS: In Mexico, there are 1002 registered adult rheumatologists with a mean age of 48.12 ±â€¯13 years. The male gender prevailed with a ratio of 1.18:1. Ninety-four pediatric rheumatologists were identified with a mean age of 42.25 ±â€¯10.4 years, with a predominance of the female gender with a ratio of 2.2:1. In Mexico City and Jalisco, more than one rheumatologist/100,000 inhabitants were reported in the specialty of adults and only in Mexico City in pediatrics. The current certification is 65%-70% on average and the factors associated with a higher prevalence were younger age, female gender and geographic location. CONCLUSIONS: There is a shortage of rheumatologists in Mexico and in the pediatric area there are underserved regions. It is important that health policies apply measures that allow a more balanced and efficient regionalization of this specialty. Although most rheumatologists have current certification, it is necessary to establish strategies to increase this proportion.

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.

A randomized, double-blind, placebo-controlled 12-week trial of infliximab in patients with juvenile-onset spondyloarthritis.

OBJECTIVE: To assess the efficacy and safety of infliximab versus placebo in the treatment of patients with juvenile-onset spondyloarthritis (JoSpA). METHODS: Phase III, randomized, double-blind, placebo-controlled trial of 12 weeks that included patients ≤ 18 years old with JoSpA not responding to nonsteroidal anti-inflammatory drugs, sulfasalazine, or methotrexate. Patients were randomly assigned 1:1 to the infusion of infliximab 5mg/kg or placebo; completers entered then an open-label extension (OLE) period of 42 weeks. The primary endpoint was the number of active joints. Secondary outcomes included the assessment of disease activity, tender entheses, spinal mobility, serum C-reactive protein (CRP), the Bath Ankylosing Spondylitis Disease Activity and Functional Index, and the Childhood Health Assessment Questionnaire (CHAQ). RESULTS: We randomized 12 patients to infliximab and 14 to placebo. No significant differences were found between groups at baseline. At week 12, the mean number of active joints was 1.4 (SD 2.4) in the infliximab group and 4.1 (SD 3.0) in the placebo group (p = 0.0002). A repeated-measures mixed model analysis that included all endpoints in the study demonstrated sustained favourable outcomes of infliximab for active joints, tender joints, swollen joints, and tender enthesis counts, as well as for CHAQ and CRP (p < 0.01). Adverse events were more frequent in the infliximab group, including infections and infusion reactions, but none of them was serious. CONCLUSION: Infliximab is efficacious for patients with JoSpA with an inadequate response to conventional treatment. No serious adverse events with the use of infliximab were observed.

Perception of risk and impact of the COVID-19 pandemic on patients with rheumatic diseases: a case-control study.

OBJECTIVES: Risk perception of the COVID-19 pandemic may affect chronic disease outcomes among patients with rheumatic diseases (RD). To describe and compare the perception of risk and effects of the COVID-19 pandemic on patients with RD from two health care centers compared with a control group. METHODS: A retrospective case-control study was conducted. Patient respondents completed an online survey to measure risk perception and effects of the COVID-19 pandemic. The case group consisted of patients with a confirmed diagnosis of RD, coming from two third-level health care centers. The control group was a population group without RD from a public university. RESULTS: A total of 3944 participants were included: 986 patients with an RD (cases) from the two hospital centers and 2958 controls without RD. A greater perception of risk severity and perception of contagion was observed in the group of patients with RD, OR: 1.70, 95% CI 1.44‒2.01 and OR: 2.0, 95% CI 1.79‒2.23, respectively; more significant deterioration in family life OR: 1.14, 95% CI 1.01‒1.29; greater economic impact, OR 3.94, 95% CI 3.48‒4.46; as well as negative emotions and feelings (alarmed, anxiety, depression, confusion, fear, isolation, and discrimination). This impact was maintained when the model was adjusted for comorbidities. CONCLUSION: In the face of an unexpected and catastrophic event such as the COVID-19 pandemic, patients with RD report apparently greater impact on their mental state and economic situation than the control population, as well as increased perception of discrimination. Key Points • The multidisciplinary analyses of risk perception are required to promote actions that can enhance the preparedness and responses of public efforts for possible future pandemics in a way that considers the specific needs of vulnerable people like patients with rheumatic diseases. • Identifying risk perceptions of possible effects of the pandemic, sources of communication, and opinions is essential to ensure self-care in rheumatic disease. • The impact of COVID-19 has been much greater for people with rheumatic disease, especially in terms of the perceived severity of the pandemic, impacts on family and economy, preventive behaviors, and uncertainty.

A Novel Technique for the Evaluation and Interpretation of Elastography in Salivary Gland Involvement in Primary Sjögren Syndrome.

Ultrasound (US) of major salivary glands (MSG) evaluates echogenicity, border features and vascularization, with elastography, it can detect tissue elasticity and glandular fibrosis, related to inflammation in Primary Sjögren's syndrome (pSS). This study aimed to develop a novel technique by pixel analysis for evaluation and interpretation of elastography in MSG in pSS. A cross-sectional and observational multicenter study was conducted. The US of MSG performed in orthogonal planes in grayscale, Doppler, and shear-wave elastography. For elastography images of each gland were analyzed with the open-source program ImageJ to perform a pixel analysis. Statistical analysis was performed with the IBM-SPSS v25 program. Fifty-nine women with a mean age of 57.69 (23-83) years were recruited; pSS mean duration of 87 (5-275) months, and 12 healthy women without sicca symptoms as a control group with a mean age of 50.67 (42-60) years. Intragroup analysis showed p-values >0.05 between sicca symptoms, ocular/dryness tests, biopsy, US, and pixel analysis; correlation between Hocevar and pixel analysis was not found (rho < 0.1, p >0.5). MSG anatomical size was 41.7 ± 28.2 mm vs. 67.6 ± 8.8 mm (p ≤ 0.0001); unstimulated whole saliva flow rate was 0.80 ± 0.80 ml/5 min vs. 1.85 ± 1.27 ml/5 min (p = 0.016). The elastography values (absolute number of pixels) were 572.38 ± 99.21 vs. 539.69 ± 93.12 (p = 0.290). A cut-off point risk for pSS identified with less than 54% of red pixels in the global MSG mass [OR of 3.8 95% CI (1.01-15.00)]. Pixel analysis is a new tool that could lead to a better understanding of the MSG chronic inflammatory process in pSS.

Factors associated to COVID-19 vaccine acceptance in Mexican patients with rheumatic diseases: A cross-sectional and multicenter study.

COVID-19 vaccination is recommended in patients with rheumatic diseases (RDs) to prevent hospitalized COVID-19 and worse outcomes. However, patients' willingness to receive a SARS-CoV-2 vaccine and the associated factors vary across populations, vaccines, and time. The objective was to identify factors associated with COVID-19 vaccine acceptance (VA) in Mexican outpatients with RDs. This multicenter study was performed between March 1 and September 30, 2021, and four national centers contributed with patients. Participants filled out a questionnaire, which included 32 items related to patients' perception of the patient-doctor relationship, the COVID-19 vaccine component, the pandemic severity, the RD-related disability, comorbid conditions control, immunosuppressive treatment impact on the immune system, and moral/civil position of COVID-19 vaccine. Sociodemographic, disease-related, and treatment-related variables and previous influenza record vaccination were also obtained. Multiple logistic regression analyses identified factors associated with VA, which was defined based on a questionnaire validated in our population. There were 1439 patients whose data were analyzed, and the most frequent diagnoses were Rheumatoid Arthritis in 577 patients (40.1%) and Systemic Lupus Erythematosus in 427 (29.7%). Patients were primarily middle-aged women (1235 [85.8%]), with (mean±SD) 12.1 (±4.4) years of formal education. Years of education, corticosteroid use, patient perceptions about the vaccine and the pandemic severity, patient civil/moral position regarding COVID-19 vaccine, and previous influenza vaccination were associated with VA. In Mexican patients with RDs, COVID-19 VA is associated with individual social-demographic and disease-related factors, patient´s perceptions, and previous record vaccination. This information is crucial for tailoring effective vaccine messaging in Mexican patients with RDs.

COVID-19 vaccine hesitancy among Mexican outpatients with rheumatic diseases.

Vaccine hesitancy (VH) has emerged as a recognized threaten to contain the COVID-19 pandemic. Historically, low vaccine acceptance rates had been described among patients with rheumatic diseases (RMDs). The study objective was to determine COVID-19 VH among Mexican outpatients with RMDs and validate the COVID-19 VH questionnaire. This cross-sectional study was developed in three steps. Step 1 consisted of translation/cultural adaptation of the Oxford-COVID-19-VH questionnaire. Step 2 consisted of pilot testing and questionnaire feasibility, content, construct and criterion validity, reliability (internal consistency and temporal stability) and questionnaire sensitivity to change. Step 3 consisted of VH phenomenon quantification in patients from two metropolitan tertiary-care-level centers. Step 1 followed ISPOR-task-force recommendations. Patients who participated in step 2 (n = 50 for pilot testing/feasibility and n = 208 for questionnaire validation [91 in test-retest and 70 in questionnaire-sensitivity to change]) and step 3 (n = 600) were representative outpatients with RMDs. The seven-item COVID-19 VH questionnaire was found feasible, valid (experts' agreement ≥80%; a 1-factor structure accounted for 60.73% of the total variance; rho = 0.156, p = .025 between COVID-19 VH questionnaire and score from the Spanish version of the Vaccine Hesitancy Scale; and lower questionnaire scores in patients who reported 5 years-previous influenza vaccination), reliable (Cronbach's ɑ = 0.889, intra-class correlation coefficient = 0.933 and 95% confidence interval = 0.898-0.956) and sensitive to change (effect size = 1.17 and 0.86, respectively, in patients who decreased [n = 34] and increased [n = 31] questionnaire-score after intervention). VH phenomenon was 35.5%. VH phenomenon was present in a substantial number of Mexican patients with RMDs. The COVID-19 VH questionnaire showed good psychometric properties to assess COVID-19 VH in our population.

Comorbidity burden in terms of disability in patients with osteoarthritis in Mexico. The IMPACTAR registry.

OBJECTIVE: To determine the comorbidities associated with disability in patients with OA in Mexico (2013-2015). MATERIAL AND METHODS: A cross-sectional, retrospective and multicentre IMPACTAR study (n=7703) in Mexican patients (2013-2015). Comorbidities associated with disability were identified in 4971 patients diagnosed with OA from the IMPACTAR registry (n=7073). An adjusted logistic regression analysis was carried out by demographic, economic, clinical and medical variables. RESULTS: Mean age was 63 years; and 75% of the patients were women. Subjects with OA and presence of comorbidities are 42% more likely to develop disabilities than patients without associated comorbidity, considering age, sex, family income, OA diagnosis duration, and education level. The highest rate of people with disability (28.9%) was concentrated in Region 7, which corresponds to Mexico City. There are also significant differences between median family incomes, when the income of persons with disability is under $13 000 (IQR: 9000-16 000) Mexican pesos, compared to patients without disability. Almost half of the subjects (49.6%) reported having at least one comorbidity. Arterial hypertension was the risk factor with a statistically significant difference (32.8%) among those with disability (34.7%). CONCLUSIONS: Programs and interventions for OA patients should take into consideration comorbidity factors, being female, family income, and the region of residence as variables that may increase the possibility of developing an OA-associated disability.

Prevalence of complementary and alternative medicine despite limited perceived efficacy in patients with rheumatic diseases in Mexico: Cross-sectional study.

INTRODUCTION: Complementary and alternative medicine (CAM) is frequently used by patients with rheumatic diseases (RD) to improve their symptoms; however, its diversity and availability have increased notably while scientific support for its effectiveness and adverse effects is still scarce. OBJECTIVE: To describe the prevalence and diversity of CAM in patients with RD in Chihuahua, Mexico. METHODS: A cross-sectional study was conducted in 500 patients with RD who were interviewed about the use of CAM to treat their disease. The interview included sociodemographic aspects, characteristics of the disease, as well as a description of CAM use, including type, frequency of use, perception of the benefit, communication with the rheumatologist, among others. RESULTS: The prevalence of CAM use was reported by 59.2% of patients, which informed a total of 155 different therapies. The herbal CAM group was the most used (31.4%) and included more than 50 different therapies. The use of menthol-based and arnica ointments was highly prevalent (35%). Most patients (62.3%) reported very little or no improvement in their symptoms. Only a fourth of the patients informed the rheumatologist of the use of CAM. The use of CAM was influenced by female sex, university degree, diagnosis delay, lack adherence to the rheumatologist's treatment, family history of RD, and orthopedic devices. CONCLUSION: The use of CAM in our population is highly prevalent and similar to reports in different populations suggesting a widespread use in many different societies. We found high use of herbal remedies; however, there were many different types suggesting a lack of significant effect. Patients continue using CAM despite a perception of no-effectiveness. Recurrent use of CAM is explained by factors other than its efficacy.

Comorbidity burden in terms of disability in patients with osteoarthritis in Mexico. The IMPACTAR registry.

OBJECTIVE: To determine the comorbidities associated with disability in patients with OA in Mexico (2013-2015). MATERIAL AND METHODS: A cross-sectional, retrospective and multicentre IMPACTAR study (n=7703) in Mexican patients (2013-2015). Comorbidities associated with disability were identified in 4971 patients diagnosed with OA from the IMPACTAR registry (n=7073). An adjusted logistic regression analysis was carried out by demographic, economic, clinical and medical variables. RESULTS: Mean age was 63 years; and 75% of the patients were women. Subjects with OA and presence of comorbidities are 42% more likely to develop disabilities than patients without associated comorbidity, considering age, sex, family income, OA diagnosis duration, and education level. The highest rate of people with disability (28.9%) was concentrated in Region 7, which corresponds to Mexico City. There are also significant differences between median family incomes, when the income of persons with disability is under $13 000 (IQR: 9000-16 000) Mexican pesos, compared to patients without disability. Almost half of the subjects (49.6%) reported having at least one comorbidity. Arterial hypertension was the risk factor with a statistically significant difference (32.8%) among those with disability (34.7%). CONCLUSIONS: Programs and interventions for OA patients should take into consideration comorbidity factors, being female, family income, and the region of residence as variables that may increase the possibility of developing an OA-associated disability.

Syndemic and syndemogenesis of low back pain in Latin-American population: a network and cluster analysis.

INTRODUCTION: Although low back pain (LBP) is a high-impact health condition, its burden has not been examined from the syndemic perspective. OBJECTIVE: To compare and assess clinical, socioeconomic, and geographic factors associated with LBP prevalence in low-income and upper-middle-income countries using syndemic and syndemogenesis frameworks based on network and cluster analyses. METHODS: Analyses were performed by adopting network and cluster design, whereby interrelations among the individual and social variables and their combinations were established. The required data was sourced from the databases pertaining to the six Latin-American countries. RESULTS: Database searches yielded a sample of 55,724 individuals (mean age 43.38 years, SD = 17.93), 24.12% of whom were indigenous, and 60.61% were women. The diagnosed with LBP comprised 6.59% of the total population. Network analysis showed higher relationship individuals' variables such as comorbidities, unhealthy habits, low educational level, living in rural areas, and indigenous status were found to be significantly associated with LBP. Cluster analysis showed significant association between LBP prevalence and social variables (e.g. Gender inequality Index, Human Development Index, Income Inequality). CONCLUSIONS: LBP is a highly prevalent condition in Latin-American populations with a high impact on the quality of life of young adults. It is particularly debilitating for women, indigenous individuals, and those with low educational level, and is further exacerbated by the presence of comorbidities, especially those in the mental health domain. Thus, the study findings demonstrate that syndemic and syndemogenesis have the potential to widen the health inequities stemming from LBP in vulnerable populations. Key points • Syndemic and syndemogenesis evidence health disparities in Latin-American populations, documenting the complexity of suffering from a disease such as low back pain that is associated with comorbidities, unhealthy habits, and the social and regional context where they live. • The use of network and cluster analyses are useful tools for documenting the complexity and the multifaceted impact in health in large populations as well as the differences between countries. • The variability and impact of socioeconomic indicators (e.g., Gini index) related to low back pain and comorbidities could be felt through the use of cluster analysis, which generates evidence of regional inequality in Latin America. • Populations can be studied from different models (network and cluster analysis) and grouping, presenting new interpretations beyond geographical groupings, such as syndemic and inequity in health.

Are Target Urate and Remission Possible in Severe Gout? A Five-year Cohort Study.

OBJECTIVE: Determine the proportion of patients achieving target serum urate (SU), defined as < 6 mg/dl for patients with non-severe gout and < 5 mg/dl for patients with severe gout, as well as the proportion of patients achieving remission after 5 years of followup. METHODS: Patients from the Gout Study Group (GRESGO) cohort were evaluated at 6-month intervals. Demographic and clinical data were obtained at baseline. Visits included assessments of serum urate, flares, tophus burden, health-related quality of life using the EQ-5D, activity limitations using the Health Assessment Questionnaire adapted for gout, and pain level and patient's global assessment using visual analog scales. Treatment for gout and associated diseases was prescribed according to guidelines and available drugs. RESULTS: Of 500 patients studied, 221 had severe gout (44%) and 279 had non-severe gout (56%) at baseline. No significant differences were observed across the study in percentages of severe gout versus non-severe gout patients achieving SU 6 mg/dl or 5 mg/dl. The highest proportion of patients achieving target SU (50-70%) and remission (39%) were found after 3-4 years of followup. In the fifth year, these proportions decreased and 28% of the patients were in remission, but only 40 patients remained in the study. None of the patients with severe gout achieved remission. CONCLUSION: In patients with severe gout, target SU was hard to achieve and remission was not possible. The main obstacles for target SU and gout remission include poor medication adherence, persistent tophi, and loss to followup.

Peripheral neuropathies in rheumatic diseases: More diverse and frequent than expected. A cross-sectional study.

BACKGROUND/OBJECTIVE: Peripheral neuropathies (PN) are heterogeneous nerve disorders; frequently rheumatic patients have neuropathic symptoms. In some rheumatic diseases (RD) PN are secondary to nerve compression while others are related to metabolic abnormalities, inflammation or vasculitis. Our aim was to explore the frequency of neuropathic symptoms with three neuropathy questionnaires (NQ) and nerve conduction studies (NCS) in RD. METHODS: This is a cross-sectional study in patients with any RD attending for the first time to a rheumatology outpatient clinic. We included all patients who accepted to participate and who answered three NQ and received a physical evaluation. Twenty patients were randomly selected to perform NCS and 10 healthy subjects were included as controls. The topographic diagnoses were: mononeuropathy, multiplex mononeuropathy, and/or polyneuropathy. STATISTICAL ANALYSIS: descriptive statistics (mean, median, standard deviation, interquartile range and frequency, odds ratios and Pearson correlation test). RESULTS: One hundred patients and 10 healthy subjects were included. Sixty-nine were female, mean age 40.6 ± 15.7 years. Rheumatic diagnoses were: systemic lupus erythematosus (26%), rheumatoid arthritis (16%), gout (14%), and osteoarthritis (11%). Fifty-two patients had neuropathic signs during physical examination and 67% had positive questionnaires with variable scores among several RD. Abnormal NCS was reported in 14 patients (70%): 6 (42.8%) median nerve mononeuropathies, 4 (28.5%) multiplex mononeuropathies and 4 (28.5%) polyneuropathies. None of the healthy subjects had neuropathy (NQ, physical evaluation, or NCS). Risk of being NCS positive is higher when the patients were NQ positive. CONCLUSION: PN has variable distribution and high frequency in patients with RD; NQ+ increases the risk of presenting NCS+ for PN.

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.

Pan-American League of Associations for Rheumatology (PANLAR) capillaroscopy study group consensus for the format and content of the report in capillaroscopy in rheumatology.

OBJECTIVE: The aim of this work was to produce a consensus-based report for capillaroscopy in rheumatology to be used in daily clinical practice. METHODS: A written Delphi questionnaire regarding capillaroscopy report was developed from a literature review and expert consensus. The Delphi questionnaire was sent to an international panel including 25 rheumatologists experts in capillaroscopy, asking them to rate their level of agreement or disagreement with each statement. The exercise consisted of three online rounds and a face-to-face (live meeting) that took place in the PANLAR 2018 congress held in Buenos Aires, Argentina. RESULTS: The participants to the first, second, third, and face-to-face round were 22, 21, 21, and 16 rheumatologists, respectively. Fifty-five items were discussed in the first round, 58 in the second, 22 in the third, and 9 in the face-to-face meeting. At the end of the exercise, 46 recommendations for the capillaroscopy report in rheumatology reached a consensus. CONCLUSION: This is the first consensus-based report in capillaroscopy. It will be useful in daily clinical practice and to address the effort of the standardization in the technique. KEY POINTS: • The current lack of consensus for the capillaroscopy report makes difficult the interpretation of findings as well as follow-up of rheumatic diseases. • This study produced the first international consensus for the format and content of the naifold capillaroscopy report in rheumatology. • The report is an integral part of the capillaroscopy examination and its use in a homogeneous form can help in the correct interpretation of findings in daily practice.

Clinical practice guidelines for the treatment of systemic lupus erythematosus by the Mexican College of Rheumatology. / Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología.

There are national and international clinical practice guidelines for systemic lupus erythematosus treatment. Nonetheless, most of them are not designed for the Mexican population or are devoted only to the treatment of certain disease manifestations, like lupus nephritis, or are designed for some physiological state like pregnancy. The Mexican College of Rheumatology aimed to create clinical practice guidelines that included the majority of the manifestations of systemic lupus erythematosus, and also incorporated guidelines in controversial situations like vaccination and the perioperative period. The present document introduces the «Clinical Practice Guidelines for the Treatment of Systemic Lupus Erythematosus¼ proposed by the Mexican College of Rheumatology, which could be useful mostly for non-rheumatologist physicians who need to treat patients with systemic lupus erythematosus without having the appropriate training in the field of rheumatology. In these guidelines, the reader will find recommendations on the management of general, articular, kidney, cardiovascular, pulmonary, neurological, hematologic and gastrointestinal manifestations, and recommendations on vaccination and treatment management during the perioperative period.

Improvement in OMERACT domains and renal function with regular treatment for gout: a 12-month follow-up cohort study.

OMERACT proposed a set of mandatory and discretionary domains to evaluate the effect of treatment in patients with gout. To determine the percentage of improvement and the effect size 6 and 12 months after starting a proper treatment in patients with gout from our cohort (GRESGO) based on the OMERACT proposal for chronic gout. GRESGO is a cohort of consecutive, new patients with gout attending either of two dedicated clinics. This report includes 141 patients evaluated at baseline and 6 months plus 101 of them completing a 12-month follow-up in 2012. Clinical data including the OMERACT domains for chronic gout were collected at baseline and every 6 months. Treatment was prescribed by their attending physician with the purpose of getting < 6 mg/dL of seric uric acid (sUA). Most patients were males (96%) with inappropriate treatment (95%); 66% had tophi, 30% metabolic syndrome, and 32% low renal function. Mean dose of allopurinol at baseline and throughout the study went from 344 ± 168 mg/day to 453 ± 198 at 12 months. Most OMERACT domains and renal function improved significantly; 73% improved > 20% from 6 to 12 months. Greater improvement was observed in the domains: flares, index tophus size, pain, general health assessment, and HAQ score, all of them associated to lower sUA values. Chronic gout patients improve significantly in most OMERACT domains when conventional and regular treatment is indicated. sUA < 6 mg/dL is associated with greater improvement.

The method used to set the pass mark in an objective structured clinical examination defines the performance of candidates for certification as rheumatologists. / El método para establecer el punto de corte en el examen clínico objetivo estructurado define el desempeño de los candidatos a la certificación como reumatólogo.

BACKGROUND: The Mexican Accreditation Council for Rheumatology certifies trainees (TR) on an annual basis using both a multiple-choice question (MCQ) test and an objective structured clinical examination (OSCE). For 2013 and 2014, the OSCE pass mark (PM) was set by criterion referencing as ≥6 (CPM), whereas overall rating of borderline performance method (BPM) was added for 2015 and 2016 accreditations. We compared OSCE TR performance according to CPM and BPM, and examined whether correlations between MCQ and OSCE were affected by PM. METHODS: Forty-three (2015) and 37 (2016) candidates underwent both tests. Altogether, OSCE were integrated by 15 validated stations; one evaluator per station scored TR performance according to a station-tailored check-list and a Likert scale (fail, borderline, above range) of overall performance. A composite OSCE score was derived for each candidate. Appropriate statistics were used. RESULTS: Mean (±standard derivation [SD]) MCQ test scores were 6.6±0.6 (2015) and 6.4±0.6 (2016) with 5 candidates receiving a failing score each year. Mean (±SD) OSCE scores were 7.4±0.6 (2015) and 7.3±0.6 (2016); no candidate received a failing CPM score in either 2015 or 2016 OSCE, although 21 (49%) and 19 (51%) TR, respectively, received a failing BPM score (calculated as 7.3 and 7.4, respectively). Stations for BPM ranged from 4.5 to 9.5; overall, candidates showed better performance in CPM. In all, MCQ correlated with composite OSCE, r=0.67 (2015) and r=0.53 (2016); P≤.001. Trainees with a passing BPM score in OSCE had higher MCQ scores than those with a failing score. CONCLUSIONS: Overall, OSCE-PM selection impacted candidates' performance but had a limited affect on correlation between clinical and practical examinations.

Severe tophaceous gout and disability: changes in the past 15 years.

Epidemiologic data from recent decades show a significant increase in the prevalence and incidence of gout worldwide, in addition to changes in its clinical expression. Our objective was to compare the frequency of the severity of gout and disability in two patient groups at our clinic during different periods. We included and compared data of two groups: group A (1995-2000), patients from previous report, and group B (2010-2014), the baseline data of current patients participating in a cohort (GRESGO). This evaluation included data of socioeconomic and educational levels, demographics, associated diseases, previous treatment, clinical and biochemical data, and disability evaluated using the Health Assessment Questionnaire (HAQ). We included data of 564 gout patients. Participants were 35.7 ± 12.7 years old at onset and had 12.0 ± 9.2-years disease duration at their first evaluation in our department. Group B patients were younger, had higher educational and socioeconomic levels, and had more severe disease. However, this group had less frequency of some associated diseases and significantly higher HAQ scores. With increased HAQ score, a higher number of acute flares and tender, limited-to-motion, and swollen joints were seen. The spectrum of gout has changed over the past decade. A higher percentage of our patients had a severe form of disease, were younger, had earlier disease onset, and had more disability reflected in higher HAQ scores. In our current patient group, the variable most associated with disability was limited-to-motion joints; however, the number of acute flares and tender and swollen joints was also higher in patients with greater disability.

Doctor-Patient Relationship Between Individuals With Fibromyalgia and Rheumatologists in Public and Private Health Care in Mexico.

The aim of this article was to describe and analyze the doctor-patient relationship between fibromyalgia patients and rheumatologists in public and private health care contexts within the Mexican health care system. This medical anthropological study drew on hospital ethnography and patients' illness narratives, as well as the experiences of rheumatologists from both types of health care services. The findings show how each type of medical care subsystem shape different relationships between patients and doctors. Patient stigmatization, overt rejection, and denial of the disease's existence were identified. In this doctor-patient-with-fibromyalgia relationship, there are difficult encounters, rather than difficult patients. These encounters are more fluid in private consultations compared with public hospitals. The doctor-centered health care model is prevalent in public institutions. In the private sector, we find the characteristics of the patient-centered model coexisting with the traditional physician-centered approach.