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

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

Lung Ultrasound Performed by Primary Care Physicians for Clinically Suspected Community-Acquired Pneumonia: A Multicenter Prospective Study.

PURPOSE: We investigated whether lung ultrasound (US) performed in primary care is useful and feasible for diagnosing community-acquired pneumonia (CAP) compared with chest radiography, as most previous research has been conducted in hospital settings. METHODS: We undertook a prospective observational cohort study of lung US performed in 12 primary care centers. Patients aged 5 years and older with symptoms suggesting CAP were examined with lung US (by 21 family physicians and 7 primary care pediatricians) and chest radiograph on the same day. We compared lung US findings with the radiologist's chest radiograph report as the reference standard, given that the latter is the most common imaging test performed for suspected CAP in primary care. The physicians had varied previous US experience, but all received a 5-hour lung US training program. RESULTS: The study included 82 patients. Compared with chest radiography, positive lung US findings (consolidation measuring >1 cm or a focal/asymmetrical B-lines pattern) showed a sensitivity of 87.8%, a specificity of 58.5%, a positive likelihood-ratio of 2.12, and a negative likelihood-ratio of 0.21. Findings were similar regardless of the physicians' previous US training or experience. We propose a practical algorithm whereby patients having consolidation measuring greater than 1 cm or normal findings on lung US could skip chest radiography, whereas patients with a B-lines pattern without consolidation (given its low specificity) would need chest radiography to ensure appropriate management. Lung US was generally performed in 10 minutes or less. CONCLUSION: Point-of-care lung US in primary care could be useful for investigating suspected CAP (avoiding chest radiography in most cases) and is likely feasible in daily practice, as short training programs appear sufficient and little time is needed to perform the scan.

Claves del acompañamiento educativo integral a estudiantes de Medicina: una revisión de la bibliografía biomédica / Keys of comprehensive educational mentoring for medical students: a review of biomedical literature

Introducción: Existen razones de orden teórico y empírico que justifican el interés del acompañamiento educativo integral (AEI). El presente trabajo se propone identificar las claves recogidas en la bibliografía médica del AEI en estudiantes de Medicina. Materiales y métodos: Se ha realizado una búsqueda con las palabras ‘Mentor’ y ‘Medical students’ en Medline, EMBASE, Cochrane Database of Systematic Reviews, ScienceDirect, Scopus© y SCIELO Journals, sin fecha inicial hasta mayo de 2019. Resultados: Se revisaron 1.816 títulos, de los que se seleccionaron 169 resúmenes y, de ellos, 51 artículos a texto completo. En la bibliografía médica se destaca que el objetivo fundamental del AEI es lograr un desarrollo integral personal y profesional del estudiante, contar con criterios de selección y formación de mentores excelentes, lo que es clave para lograr una adecuada relación en el AEI, diseñar un plan curricular flexible, que la institución apoye y reconozca el trabajo de AEI, que se tengan en cuenta obstáculos posibles para evitarlos y que se evalúen el proceso, los contenidos y los resultados del plan. Conclusión.: El presente estudio ha identificado claves del AEI en el ámbito médico. Se constata la necesidad de avanzar en la definición de un marco conceptual teórico bien definido y en la obtención de pruebas sobre los resultados formativos.(AU)

Introduction: There are theoretical and empirical reasons that justify the interest of comprehensive educational mentoring (CEM). The present work aims to identify the keys collected in the medical literature of the CEM in medical students. Materials and methods: A search has been carried out, with the words ‘Mentor’ and ‘Medical Students’ in Medline, EMBASE, Cochrane Database of Systematic Reviews, ScienceDirect, Scopus© and SCIELO Journals, with no initial date until May 2019. Results: 1816 titles were reviewed, from which 169 abstracts were selected and, of them, 51 full-text articles were used to obtain keys about CEM. In the medical bibliography it is highlighted that the fundamental objective of CEM is to achieve a comprehensive personal and professional development of the student, that is important designing mentors’ selection criteria and training, achieving an adequate relationship, designing a flexible curricular plan, the institution support and work awarding, taking into account of possible obstacles to avoid them and that the process, contents and results of the plan have to be evaluated. Conclusion: The present study has identified CEM keys in the medical field. It is needed an advance in the definition of a well-focus theoretical conceptual framework and gaining evidence on the training outcomes.(AU)

Desarrollo de una aplicación para teléfonos móviles (app) basada en la colaboración Sociedad Española de Reumatología/Sociedad Española de Medicina de Familia y Comunitaria para derivación de enfermedades autoinmunes sistémicas / Development of an application for mobile phones (App) based on the collaboration between the Spanish Society of Rheumatology and Spanish Society of Family Medicine for the referral of systemic autoimmune diseases from primary care to rheumatology

El diagnóstico y tratamiento de las enfermedades autoinmunes sistémicas (EAS) constituye un reto. Aunque infrecuentes, afectan a cientos de miles de pacientes en España. El médico de familia (MF) se enfrenta a síntomas o signos inespecíficos que hacen sospechar EAS al inicio del proceso, y tiene que decidir a quiénes debería derivar. Para facilitar su reconocimiento y mejorar su derivación, expertos de la Sociedad Española de Medicina de Familia y Comunitaria y de la Sociedad Española de Reumatología seleccionaron 26 síntomas/signos-guía y alteraciones analíticas. Se escogieron parejas de MF y reumatólogo para elaborar algoritmos diagnósticos y de derivación. Posteriormente se revisaron y adaptaron al formato de aplicación para móviles (app) descargable. El resultado es el presente documento de derivación de EAS para MF en formato de papel y app. Contiene algoritmos de fácil manejo utilizando datos de la anamnesis, exploración física y pruebas analíticas accesibles en atención primaria para orientar el diagnóstico y facilitar la derivación a reumatología o a otras especialidades

Management of systemic autoimmune diseases is challenging for physicians in their clinical practice. Although not common, they affect thousands of patients in Spain. The family doctor faces patients with symptoms and non-specific cutaneous, mucous, joint, vascular signs or abnormal laboratory findings at the start of the disease process and has to determine when to refer patients to the specialist. To aid in disease detection and better referral, the Spanish Society of Rheumatology and the Spanish Society of Family Medicine has created a group of experts who selected 26 symptoms, key signs and abnormal laboratory findings which were organized by organ and apparatus. Family doctors and rheumatologists with an interest in autoimmune systemic diseases were selected and formed mixed groups of two that then elaborated algorithms for diagnostic guidelines and referral. The algorithms were then reviewed, homogenized and adapted to the algorithm format and application for cell phone (apps) download. The result is the current Referral document of systemic autoimmune diseases for the family doctor in paper format and app (download). It contains easy-to-use algorithms using data from anamnesis, physical examination and laboratory results usually available to primary care, that help diagnose and refer patients to rheumatology or other specialties if needed

Development of an application for mobile phones (App) based on the collaboration between the Spanish Society of Rheumatology and Spanish Society of Family Medicine for the referral of systemic autoimmune diseases from primary care to rheumatology. / Desarrollo de una aplicación para teléfonos móviles (app) basada en la colaboración Sociedad Española de Reumatología/Sociedad Española de Medicina de Familia y Comunitaria para derivación de enfermedades autoinmunes sistémicas.

Management of systemic autoimmune diseases is challenging for physicians in their clinical practice. Although not common, they affect thousands of patients in Spain. The family doctor faces patients with symptoms and non-specific cutaneous, mucous, joint, vascular signs or abnormal laboratory findings at the start of the disease process and has to determine when to refer patients to the specialist. To aid in disease detection and better referral, the Spanish Society of Rheumatology and the Spanish Society of Family Medicine has created a group of experts who selected 26 symptoms, key signs and abnormal laboratory findings which were organized by organ and apparatus. Family doctors and rheumatologists with an interest in autoimmune systemic diseases were selected and formed mixed groups of two that then elaborated algorithms for diagnostic guidelines and referral. The algorithms were then reviewed, homogenized and adapted to the algorithm format and application for cell phone (apps) download. The result is the current Referral document of systemic autoimmune diseases for the family doctor in paper format and app (download). It contains easy-to-use algorithms using data from anamnesis, physical examination and laboratory results usually available to primary care, that help diagnose and refer patients to rheumatology or other specialties if needed.

Prescripción de ácidos alendrónico y risedrónico en varones: uso fuera de la ficha técnica en un área de salud / Prescription of alendronate and risedronate in men: off-label use in a health area

Fundamento y objetivo. El ácido alendrónico y ácido risedrónico son eficaces y seguros para la osteoporosis del varón, pero solo el ácido risedrónico recoge esta indicación en su ficha técnica. Compararemos su uso en ambos sexos. Pacientes y métodos. Estudio descriptivo retrospectivo de prescripciones de ácido risedrónico y alendrónico en 2012 en atención primaria en el área noroeste de la Comunidad de Madrid. Comparamos la proporción de pacientes y dosis diarias definidas (DDD) dispensadas según género. Resultados. Catorce mil ochocientos cincuenta y siete pacientes utilizaron 1.847.370 de DDD de alendronato y risedronato, 1.145 (7,7%) varones. En mujeres, alendronato fue un 10% más prescrito que risedronato (55% vs. 45%). En varones, el risedronato fue el preferido, 47,6% vs. 52,4%, con una diferencia estadísticamente significativa (p < 0,001). Conclusiones. El ácido risedrónico es preferido al alendrónico en varones, que se utiliza a menudo fuera de ficha técnica a pesar de existir alternativas (AU)

Background and objective: Alendronate and risedronate are both effective and safe treatments for osteoporosis in men, but only risedronate has this indication in its data-sheet. We compared their use by gender. Patient and methods: Retrospective descriptive study of prescriptions of risedronate and alendronate in 2012 in primary care in the northwest area of the Community of Madrid. We compared patients and defined daily doses (DDD) dispensed by gender. Results: 14.857 patients used 1.847.370 DDD of alendronate or risedronate, 1.145 (7.7%) patients were men. In women alendronate was most prescribed (55% vs. 45%) than risedronate. Risedronate was preferred in men, 47.6% vs. 52.4%, resulting in a statistically significant difference (P<.001). Conclusions: Risedronate is preferred to alendronate in men, which is often used off-label, despite the existence of alternatives (AU)

Recomendaciones para la detección, investigación y derivación del dolor lumbar inflamatorio en Atención Primaria / Reccomendations for the detection, study and referral of inflammatory low-back pain in Primary Care

Objetivo. Diseñar una estrategia de detección y derivación precoz de pacientes con posible espondiloartritis mediante el desarrollo de recomendaciones consensuadas dirigidas a los médicos de Atención Primaria (AP). Métodos. Se utilizó una metodología modificada de RAND/UCLA y revisión sistemática de la literatura. Se seleccionó un grupo de discusión formado por reumatólogos y médicos de AP. Se estudió el mapa del proceso y se propusieron recomendaciones y algoritmos que fueron sometidos a 2 rondas Delphi para evaluar el grado de aceptación y preferencia de criterios en un grupo amplio de reumatólogos y médicos de AP. Del análisis de la segunda ronda Delphi se extrajeron las recomendaciones finales. Resultados. Se presentan recomendaciones, junto con su grado medio de acuerdo, para la derivación rápida de pacientes con sospecha de espondiloartritis. En concreto, se recomienda investigar el dolor lumbar crónico en menores de 45 años en 4 fases: 1) clínica: preguntas clave; 2) clínica: preguntas extra; 3) exploración física, y 4) pruebas complementarias. Se debe derivar a Reumatología si existen: 1) dolor lumbar inflamatorio; 2) signos indicativos de espondiloartritis, o 3) HLA B27 positivo, elevación de proteína C reactiva o signos radiológicos de sacroilitis. Se incluyen recomendaciones sobre el proceso de derivación y otras adicionales. Conclusiones. El grado de acuerdo con estas sencillas recomendaciones es amplio. Es necesario diseñar estrategias de formación y sensibilización desde los servicios de Reumatología para mantener una óptima colaboración de AP en la identificación de los casos y facilitar que los servicios de Reumatología estén preparados para asumir las derivaciones (AU)

Objective. To design a strategy for the early detection and referral of patients with possible spondyloarthritis based on recommendations developed, agreed upon, and directed to primary care physicians. Methods. We used a modified RAND/UCLA methodology plus a systematic literature review. The information was presented to a discussion group formed by rheumatologists and primary care physicians. The group studied the process map and proposed recommendations and algorithms that were subsequently submitted in two Delphi rounds to a larger group of rheumatologists and primary care physicians. The final set of recommendations was derived from the analysis of the second Delphi round. Results. We present the recommendations, along with their mean level of agreement, on the early referral of patients with possible spondyloarthritis. The panel recommends that the study of chronic low back pain in patients under 45 years be performed in four phases 1) clinical: key questions, 2) clinical: extra questions, 3) physical examination, and 4) additional tests. Conclusions. The level of agreement with these simple recommendations is high. It is necessary to design strategies for the education and sensitization from rheumatology services to maintain an optimal collaboration with primary care and to facilitate referral to rheumatology departments (AU)

Prescription of alendronate and risedronate in men: off-label use in a health area.

BACKGROUND AND OBJECTIVE: Alendronate and risedronate are both effective and safe treatments for osteoporosis in men, but only risedronate has this indication in its data-sheet. We compared their use by gender. PATIENT AND METHODS: Retrospective descriptive study of prescriptions of risedronate and alendronate in 2012 in primary care in the northwest area of the Community of Madrid. We compared patients and defined daily doses (DDD) dispensed by gender. RESULTS: 14.857 patients used 1.847.370 DDD of alendronate or risedronate, 1.145 (7.7%) patients were men. In women alendronate was most prescribed (55% vs. 45%) than risedronate. Risedronate was preferred in men, 47.6% vs. 52.4%, resulting in a statistically significant difference (P<.001). CONCLUSIONS: Risedronate is preferred to alendronate in men, which is often used off-label, despite the existence of alternatives.

Reccomendations for the detection, study and referral of inflammatory low-back pain in primary care.

OBJECTIVE: To design a strategy for the early detection and referral of patients with possible spondyloarthritis based on recommendations developed, agreed upon, and directed to primary care physicians. METHODS: We used a modified RAND/UCLA methodology plus a systematic literature review. The information was presented to a discussion group formed by rheumatologists and primary care physicians. The group studied the process map and proposed recommendations and algorithms that were subsequently submitted in two Delphi rounds to a larger group of rheumatologists and primary care physicians. The final set of recommendations was derived from the analysis of the second Delphi round. RESULTS: We present the recommendations, along with their mean level of agreement, on the early referral of patients with possible spondyloarthritis. The panel recommends that the study of chronic low back pain in patients under 45 years be performed in four phases 1) clinical: key questions, 2) clinical: extra questions, 3) physical examination, and 4) additional tests. CONCLUSIONS: The level of agreement with these simple recommendations is high. It is necessary to design strategies for the education and sensitization from rheumatology services to maintain an optimal collaboration with primary care and to facilitate referral to rheumatology departments.

Uso de recursos sanitarios y pérdida de productividad en pacientes con trastornos depresivos atendidos en atención primaria: Estudio InterDep / Use of health care resources and loss of productivity in patients with depressive disorders seen in Primary Care: INTERDEP Study

Introducción. El estudio InterDep analiza las caracteresticas de los pacientes con trastorno depresivo que en losúltimos años han recibido atención sanitaria en las consultas de atención primaria de un área sanitaria. Además, evalúa el uso de recursos sanitarios imputables al trastorno depresivo en este ámbito (costes directos) y la pérdida de productividad (costes indirectos). Se analiza además, la derivación a atención especializada. Métodos. Estudio observacional multicéntrico, retrospectivo realizado a partir de los registros informatizados de las historias clínicas recogidas en una base de datos anonimizada de 22.795 pacientes atendidos, entre 2005 y 2009, por un nuevo episodio de trastorno depresivo en los centros de salud de la antigua Área 6 de Atención Primaria del Servicio Madrileño de Salud de la Comunidad de Madrid. Resultados. El 74,5% de los pacientes con trastornos depresivos analizados son mujeres, con una edad media de 54 años (DE 17,7). Según la clasificación CIAP, la depresión fue el diagnóstico más frecuente en la población analizada (48,4%), seguida de ansiedad (35,4%) y trastorno adaptativo mixto (16,2%). El 88,5% estaba tratado con inhibidores selectivos de la recaptación de serotonina ISRS (N06AB). El coste total anual promedio (costes directos y costes indirectos) fue de 725,2 euros. La pérdida de productividad laboral representó el principal coste en pacientes con depresión atendidos en atención primaria (501,0 euros), principalmente en aquellos pacientes que causaron baja laboral. El 29,7% de los pacientes fue derivado a atención especializada. Conclusiones. La prevalencia e impacto socio-sanitario de los trastornos depresivos en atención primaria requiere del médico de familia una competencia clínica apropiada para garantizar un correcto manejo de la patología, minimizando así el importante coste directo (recursos asistenciales) e indirecto (bajas laborales)

Introduction. The InterDep Study analyzes the characteristics of patients with a depressive disorder who, in the last years, have received health services at Primary Care in an specific health care area. The InterDep Study evaluates the use of heath care resources attributable to depression (direct costs) and loss of productivity (indirect costs). It also analyzes these patients’ referral to the specialist. Methods. A retrospective, multicenter observational study was conducted using computerized medical records collected in an anonymized database of 22,795 patients who received health care services between 2005 and 2009 for a new episode of depressive disorder in a specific Primary Care Area of the Madrid Health Service (Community of Madrid) (former Area 6). Results. A 74.5% of the patients with depressive disorders were women, mean age 54 years (SD 17.7). According to the ICPC classification, depression was the most frequently diagnosed disorder (48.4%), followed by anxiety (35.4%) and adjustment disorder (16.2%). A 88.5% were treated with selective serotonin reuptake inhibitors (SSRIs) (N06AB). The average total annual cost (both direct and indirect costs) was 725.2 Euros. Loss of productivity was the major cost in depressed patients treated in primary care (501.0 Euros), especially among those patients on disability. A 29.7% of the patients were referred to specialized care.Conclusions. The prevalence and the socio-sanitary impact of depressive disorders in primary care require adequate clinical competence from the physician to guarantee proper disease management thus, minimizing the significant direct (health care resources) and indirect (loss of productivity) cost

Use of health care resources and loss of productivity in patients with depressive disorders seen in Primary Care: INTERDEP Study.

INTRODUCTION: The InterDep Study analyzes the characteristics of patients with a depressive disorder who, in the last years, have received health services at Primary Care in an specific health care area. The InterDep Study evaluates the use of heath care resources attributable to depression (direct costs) and loss of productivity (indirect costs). It also analyzes these patients' referral to the specialist. METHODS: A retrospective, multicenter observational study was conducted using computerized medical records collected in an anonymized database of 22,795 patients who received health care services between 2005 and 2009 for a new episode of depressive disorder in a specific Primary Care Area of the Madrid Health Service (Community of Madrid) (former Area 6). RESULTS: A 74.5% of the patients with depressive disorders were women, mean age 54 years (SD 17.7). According to the ICPC classification, depression was the most frequently diagnosed disorder (48.4%), followed by anxiety (35.4%) and adjustment disorder (16.2%). A 88.5% were treated with selective serotonin reuptake inhibitors (SSRIs) (N06AB). The average total annual cost (both direct and indirect costs) was 725.2 Euros. Loss of productivity was the major cost in depressed patients treated in primary care (501.0 Euros), especially among those patients on disability. A 29.7% of the patients were referred to specialized care. CONCLUSIONS: The prevalence and the socio-sanitary impact of depressive disorders in primary care require adequate clinical competence from the physician to guarantee proper disease management thus, minimizing the significant direct (health care resources) and indirect (loss of productivity) cost.

Estudio ARTRO-PRO: percepción del beneficio clínico y calidad de vida en pacientes con artrosis de cadera y rodilla / Can an intervention on clinical inertia have an impact on the perception of pain, functionality and quality of life in patients with hip and/or knee osteoarthritis? Results from a cluster randomised trial

Objetivos: Evaluar si una intervención aplicada a médicos de familia para evitar la inercia clínica tuvo un impacto en el dolor, funcionalidad y calidad de vida relacionada con la salud (CVRS) de los pacientes con artritis de cadera y/o rodilla. Diseño: Estudio de grupos paralelos de cluster, multicéntrico, prospectivo, aleatorizado. Los médicos fueron asignados a 2 grupos, el grupo 1 recibió una sesión de entrenamiento, el grupo 2, no. Emplazamiento: Centros de salud representativos del territorio español. Participantes: Médicos de familia de 329 centros de salud. Intervenciones: Consistieron en una sesión motivadora para proponer una atención proactiva, basada en recomendaciones actualizadas. Mediciones principales: Escala analógica visual (EVA); funcionalidad (escala WOMAC) y percepción global de salud mediante SF-12 en 2 visitas separadas por 6 meses. Resultados: Participaron 1.361 médicos y 4.076 pacientes. No se observaron diferencias significativas en el beneficio clínico obtenido entre los pacientes asignados al grupo 1 y grupo 2. Sin embargo, se observó una mejora significativa en la población total (grupos 1 + 2) en la EVA (p<0,001), WOMAC (p<0,0001) y el SF-12V2 (p<0,001) en la visita 2 en comparación con la visita 1. Conclusiones: Esta intervención sobre médicos de familia no proporcionó un beneficio clínico adicional a los pacientes. Se observó en ambos grupos una mayor conciencia de la enfermedad del paciente por el uso novedoso de índices de funcionalidad y CVRS, que parece mejorar el dolor percibido, la funcionalidad y la calidad de vida relacionada con la salud(AU)

Objectives: Evaluate whether an intervention applied to general practitioners to prevent clinical inertia had an impact on pain, functionality, and health-related quality of life (HRQoL) of patients with hip and/or knee osteoarthritis. Design: This was a cluster-based, multicentre, prospective, randomized, parallel-group study. Clusters of physicians working were assigned to one of two study groups. Physicians in Group 1 received a training session while those in Group 2 did not. Setting: Primary Care Health centers representative of the entire Spanish territory. Participants: 329 general practitioners of primary healthcare centre. Interventions: The intervention consists of a motivational session to propose a proactive care, based on current recommendations. Measurements: Visual analogue scale (VAS); functionality (WOMAC scale) and global perception of health by SF-12. Effects were measured in two visits six months apart. Results: A total of 1361 physicians, and 4076 patients participated in the study. No significant differences were observed in the clinical benefit obtained between patients assigned to Group 1 and Group 2. Nevertheless, a significant improvement was observed in the combined population (Groups 1 + 2) in the VAS (p<0.001), WOMAC (p<0.0001) and SF-12v2 (p<0.001) questionnaires in Visit 2 compared to Visit 1. Conclusions: The results indicate that, although this specific intervention carried out on physicians did not provide an additional clinical benefit to patients with knee and/or hip osteoarthritis, an increased awareness of the patient's disease through the use of functionality indexes, as well as the mere fact of being observed, seem to improve patient-reported pain, functionality and HRQoL(AU)

Can an intervention on clinical inertia have an impact on the perception of pain, functionality and quality of life in patients with hip and/or knee osteoarthritis? Results from a cluster randomised trial.

OBJECTIVES: Evaluate whether an intervention applied to general practitioners to prevent clinical inertia had an impact on pain, functionality, and health-related quality of life (HRQoL) of patients with hip and/or knee osteoarthritis. DESIGN: This was a cluster-based, multicentre, prospective, randomized, parallel-group study. Clusters of physicians working were assigned to one of two study groups. Physicians in Group 1 received a training session while those in Group 2 did not. SETTING: Primary Care Health centers representative of the entire Spanish territory. PARTICIPANTS: 329 general practitioners of primary healthcare centre. INTERVENTIONS: The intervention consists of a motivational session to propose a proactive care, based on current recommendations. MEASUREMENTS: Visual analogue scale (VAS); functionality (WOMAC scale) and global perception of health by SF-12. Effects were measured in two visits six months apart. RESULTS: A total of 1361 physicians, and 4076 patients participated in the study. No significant differences were observed in the clinical benefit obtained between patients assigned to Group 1 and Group 2. Nevertheless, a significant improvement was observed in the combined population (Groups 1 + 2) in the VAS (p<0.001), WOMAC (p<0.0001) and SF-12v2 (p<0.001) questionnaires in Visit 2 compared to Visit 1. CONCLUSIONS: The results indicate that, although this specific intervention carried out on physicians did not provide an additional clinical benefit to patients with knee and/or hip osteoarthritis, an increased awareness of the patient's disease through the use of functionality indexes, as well as the mere fact of being observed, seem to improve patient-reported pain, functionality and HRQoL.

Responsabilidad legal del residente y «pena de banquillo» / Legal liability of residents and stigma of frivolous accusations

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Repercusión de las ausencias no suplidas en el tamaño de los cupos y el salario de los médicos de familia / Repercussion of absences that are not covered on the size of lists and the salaries of family doctors

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No disponible