Serum vitamin D levels and mortality in Mexicans: results from the Mexican Health and Aging Study.

Introduction: Background: the population in Latin America is aging and elders face several obstacles for good health, including an elevated frequency of vitamin D deficiency. Thus, identification of patients at high risk to develop its negative consequences should be a priority. Objective: the objective of this analysis was to determine if levels of vitamin D lower than 15 ng/ml are associated with high mortality in Mexican elderly population, from the database of the Mexican Health and Aging Study (MHAS). Methods: prospective, population study in Mexico, that included Subjects of 50 years and older who were evaluated for Serum vitamin D levels during the year 2012 (third wave of the study). Serum 25(OH)D levels were categorized into four groups, based on cutoff points used in previous studies on vitamin D and frailty: < 15, 15-< 20, 20-< 30 and ≥ 30 ng/ml. Mortality was evaluated during 2015 (fourth wave of the study). Hazard ratio was calculated (for mortality) through Cox Regression Model, adjusted for covariates. Results: we included 1626 participants, and those with lower levels of vitamin D were older, more often women, required more aid for activities of daily living, reported higher number of chronic diseases, and lower scores on cognition. The relative risk of death was 5.421 (95 % CI 2.465-11.92, p < 0.001) for the participants with vitamin D levels < 15, which after adjusting for covariates, remained statistically significant. Conclusions: levels of vitamin D lower of 15, are associated with an increase in the rate of mortality in community-dwelling senior Mexicans.

Introducción: Introducción: la población en América Latina está envejeciendo y los adultos mayores enfrentan varios obstáculos para gozar de buena salud, incluida una frecuencia elevada de deficiencia de vitamina D. Por lo tanto, la identificación de pacientes con alto riesgo de desarrollar sus consecuencias negativas debe ser una prioridad. Objetivo: el objetivo de este análisis fue determinar si los niveles de vitamina D inferiores a 15 ng/ml están asociados con una alta mortalidad en la población adulta mayor mexicana, a partir de la base de datos del Estudio de Salud y Envejecimiento en México. Métodos: estudio poblacional prospectivo en México, que incluyó Sujetos de 50 años y mayores que fueron evaluados para los niveles de vitamina D en suero durante el año 2012 (tercera ola del estudio). Los niveles séricos de 25(OH)D se clasificaron en cuatro grupos, según los puntos de corte utilizados en estudios previos sobre vitamina D y fragilidad: < 15, 15-< 20, 20-< 30 y ≥ 30 ng/ml. La mortalidad se evaluó durante 2015 (cuarta ola del estudio). Se calculó la razón de riesgo (para la mortalidad) a través del modelo de regresión de Cox, ajustado por covariables. Resultados: incluimos 1626 participantes, y aquellos con niveles más bajos de vitamina D eran mayores, más a menudo mujeres, requerían más ayuda para las actividades de la vida diaria, informaron un mayor número de enfermedades crónicas y puntuaciones más bajas en cognición. El riesgo relativo de muerte fue de 5,421 (IC 95 % 2,465-11,92, p < 0,001) para los participantes con niveles de vitamina D < 15, que después de ajustar por covariables, se mantuvo estadísticamente significativo. Conclusiones: niveles de vitamina D inferiores a 15, se asocian con un aumento en la tasa de mortalidad en adultos mayores mexicanos residentes en la comunidad.

Joint position statement on management of patient with osteoporosis during COVID-19 contingency from the AMMOM, CONAMEGER, FELAEN, FEMECOG, FEMECOT, and ICAAFYD.

Infection by SARS-Cov-2 (COVID-19) has affected practically all the world. This joint position statement of Latin American Medical Societies provides an updated guide for the prevention, diagnosis, and treatment of osteoporotic patients in the face of possible clinical scenarios posed by the COVID-19 health crisis. BACKGROUND: Infection by SARS-Cov-2 (COVID-19) has affected practically all the world. Characterized by high contagiousness, significative morbidity, and mortality in a segment of those infected, it has overwhelmed health services and forced to redirect resources to the emergency while impacting the attention of acute non-COVID-19 and many chronic conditions. OBJECTIVE: The objective of this study is to provide an updated guide for the prevention, diagnosis, and treatment of osteoporotic patients in the face of possible clinical scenarios posed by the COVID-19 health crisis. METHODS: A task force, of bone specialists with a wide range of disciplines in the field of osteoporosis and fragility fracture, was convened with the representation of several professional associations, namely, the Mexican Association of Bone and Mineral Metabolism (AMMOM), the National College of Geriatric Medicine (CONAMEGER), the Latin American Federation of Endocrinology (FELAEN), the Mexican Federation of Colleges of Obstetrics and Gynecology (FEMECOG), the Mexican Federation of Colleges of Orthopedics and Traumatology (FEMECOT), and the Institute of Applied Sciences for Physical Activity and Sports of the University of Guadalajara (ICAAFYD). Clinical evidence was collated, and an evidence report was rapidly generated and disseminated. After finding the gaps in the available evidence, a consensus opinion of experts was made. The resulting draft was reviewed and modified accordingly, in 4 rounds, by the participants. RESULTS: The task force approved the initial guidance statements, with moderate and high consensus. These were combined, resulting in the final guidance statements on the (1) evaluation of fracture risk; (2) stratification of risk priorities; (3) indications of bone density scans and lab tests; (4) initiation and continuation of pharmacologic therapy; (5) interruptions of therapy; (6) treatment of patients with incident fracture; (7) physical therapy and fall prevention; and (8) nutritional interventions. CONCLUSION: These guidance statements are provided to promote optimal care to patients at risk for osteoporosis and fracture, during the current COVID-19 pandemic. However, given the low level of available evidence and the rapidly evolving literature, this guidance is presented as a "living document" and future updates are anticipated.

Burden of rheumatoid arthritis on patients' work productivity and quality of life.

BACKGROUND: To determine the burden of Rheumatoid Arthritis (RA) on patients' work productivity and health related quality of life (HRQoL), and examine the influence of several exposure variables; to analyze the progression of RA over 1 year and its impact on work productivity and HRQoL. METHODS: International multicenter prospective survey including patients in 18 centers in Argentina, Brazil, Colombia and Mexico with diagnosis of RA and aged between 21-55 years. The following standard questionnaires were completed at baseline and throughout a 1-year follow-up: WPAI:RA, WALS, WLQ-25, EQ-5D-3 L and SF-36. Clinical and demographic variables were also collected through interview. RESULTS: The study enrolled 290 patients on baseline visit. Overall mean scores at baseline visit were: WPAI:RA (presenteeism) = 29.5% (SD = 28.8%); WPAI:RA (absenteeism) = 9.0% (SD = 23.2%); WPAI:RA (absenteeism and presenteeism) = 8.6% (SD = 22.6%); WALS = 9.0 (SD = 6.1); WLQ-25 = 7.0% (SD = 5.1%); SF-36 Physical Scale = 39.1 (SD = 10.3) and Mental Scale = 45.4 (SD = 11.3); EQ-5D-3 L VAS = 69.8 (SD = 20.4) and EQ-5D-3 L index = 0.67 (SD = 0.23). Higher educational levels were associated with better results in WLQ-25, while previous orthopedic surgeries reduced absenteeism results of WPAI:RA and work limitations in WLQ-25. Higher disease duration was associated with decreased HRQoL. Intensification of disease activity was associated with decreased work productivity and HRQoL, except in WLQ-25. In the longitudinal analysis, worsening in disease activity was associated with a decrease in both work productivity and HRQoL. CONCLUSIONS: RA patients are dealing with workplace disabilities and limitations and loss in HRQoL, and multiple factors seems to be associated with this. Worsening of disease activity further decreased work productivity and HRQoL, stressing the importance of disease tight control.

Burden of rheumatoid arthritis on patients' work productivity and quality of life

Abstract Background: To determine the burden of Rheumatoid Arthritis (RA) on patients' work productivity and health related quality of life (HRQoL), and examine the influence of several exposure variables; to analyze the progression of RA over 1 year and its impact on work productivity and HRQoL. Methods: International multicenter prospective survey including patients in 18 centers in Argentina, Brazil, Colombia and Mexico with diagnosis of RA and aged between 21-55 years. The following standard questionnaires were completed at baseline and throughout a 1-year follow-up: WPAI:RA, WALS, WLQ-25, EQ-5D-3 L and SF-36. Clinical and demographic variables were also collected through interview. Results: The study enrolled 290 patients on baseline visit. Overall mean scores at baseline visit were: WPAI:RA (presenteeism) = 29.5% (SD = 28.8%); WPAI:RA (absenteeism) = 9.0% (SD = 23.2%); WPAI:RA (absenteeism and presenteeism) = 8.6% (SD = 22.6%); WALS = 9.0 (SD = 6.1); WLQ-25 = 7.0% (SD = 5.1%); SF-36 Physical Scale = 39.1 (SD = 10.3) and Mental Scale = 45.4 (SD = 11.3); EQ-5D-3 L VAS = 69.8 (SD = 20.4) and EQ-5D-3 L index = 0.67 (SD = 0.23). Higher educational levels were associated with better results in WLQ-25, while previous orthopedic surgeries reduced absenteeism results of WPAI:RA and work limitations in WLQ-25. Higher disease duration was associated with decreased HRQoL. Intensification of disease activity was associated with decreased work productivity and HRQoL, except in WLQ-25. In the longitudinal analysis, worsening in disease activity was associated with a decrease in both work productivity and HRQoL. Conclusions: RA patients are dealing with workplace disabilities and limitations and loss in HRQoL, and multiple factors seems to be associated with this. Worsening of disease activity further decreased work productivity and HRQoL, stressing the importance of disease tight control.

Impact of osteoporosis-associated vertebral fractures on health-related quality of life in the Mexican population.

OBJECTIVE: To measure the impact on the health-related quality of life (HRQoL) of a sample of Mexicans with vertebral fractures. MATERIAL AND METHODS: One hundred fifteen subjects with vertebral fractures were interviewed and compared with 135 subjects similar in age without the fracture. Subjects were men and women > 50 years of age with osteoporosis confirmed by bone mineral densitometry and with at least 1 vertebral fracture verified by vertebral morphometry and Xrays. The sample was recruited from two sources: The Clínica de Osteoporosis at the Instituto Nacional de Rehabilitación and a random sample from the Latin American Osteoporosis Study. The Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) validated in Spanish for the Mexican population was applied. Descriptive statistics were used for demographic and clinical aspects of the sample, as well as χ2 for categorical variables and Student t test for independent samples for continuous variables. A multiple linear regression (LR) was conducted to characterize predictive variables related to quality of life. RESULTS: Two hundred fifty subjects were interviewed; 64% of them were women. The average age of those interviewed was 73.4 ± 11.4 years; 46% of the sample had vertebral fractures; of them 43% of were lumbar and 57% thoracic; the most frequent site was L1-T12. Significant changes were found in the group with fractures in pain, physical function, social function, and mental function (p < 0.05); in women, pain and social function were different between groups (p < 0.05); and those over 70 years also presented differences in physical, social, and mental function (p < 0.05); differences were found associated with the place of recruitment being worse in their quality of life those coming from the Clínica de Osteoporosis. Two or more fractures, age, being female and widowed were significant predictors for greater deterioration of HRQoL with the LR. CONCLUSION: This is the first study looking at the HRQoL in osteoporosis related fractures in Mexicans were quality of life deterioration on physical, social, and emotional functioning was demonstrated in subjects with two vertebral fractures. Age is a determining factor for greater deterioration in all studied domains. Differences between the samples obtained at the Clínica de Osteoporosis at the Instituto Nacional de Rehabilitación and the random population exemplifying that asymptomatic fractures are common and not diagnosed. It is important to scrutinize vertebral fractures at the first level because their timely detection allows for their evaluation and treatment and diminishes the probability of a second fracture. Our results can be generalized to men and women over 50 who live in the central megalopolis and in other states of the Valley of México.

Sustained clinical remission and rate of relapse after tocilizumab withdrawal in patients with rheumatoid arthritis.

OBJECTIVE: Data on when to stop use of biological agents in rheumatoid arthritis (RA) are scant. We assessed the length of remission and the rate of clinical relapse in patients with RA who had to discontinue treatment with tocilizumab (TCZ) because of the ending of longterm (5 yrs) open-label clinical trials. METHODS: All patients at 2 participating centers in Mexico were in remission, defined as Disease Activity Score 28 ≤ 2.6, with no swollen joints at the time of the last TCZ infusion. Patients were followed thereafter every 8 weeks for 12 months or until relapse. Relapse was defined as the presence of ≥ 1 swollen joint. Doses of methotrexate and antiinflammatory drugs were not changed during the followup period. RESULTS: Forty-five patients were analyzed, 87% were women (mean age 52 yrs, mean disease duration 14 yrs). During the 12 months of followup, 44% of patients maintained remission. Relapses occurred in 56% of patients: 14 during the first 3 months after the last TCZ administration. Retreatment using other agents achieved low disease activity or remission. CONCLUSION: Longterm clinical remission is possible in a number of patients with RA after suspension of TCZ. This effect has also been reported with other biologic agents. Additional data are required to support recommendations for discontinuing a biological agent after achieving remission.

The status of fostamatinib in the treatment of rheumatoid arthritis.

Fostamatinib (R788) is a prodrug rapidly converted to its active metabolite on oral administration. This (known as R406) is a potent inhibitor of spleen tyrosine kinase, required for the expression of a number of proinflammatory cytokines. Fostamatinib has shown significantly superior efficacy (when compared with placebo) in the control of patients with rheumatoid arthritis not responding to methotrexate in Phase II clinical trials. Treatment emergent adverse events with a higher frequency than in those on placebo included diarrhea, hypertension, urinary tract infections, neutropenia and elevated transaminases. The studied doses have shown a linear pharmacokinetic pattern and the administration of methotrexate does not affect it. Fostamatinib may have a role in the therapy of patients with rheumatoid arthritis with poor response to conventional therapy. If these results are confirmed once Phase III studies are completed, it may find a place in the evolving treatment algorithm for rheumatoid arthritis.

Strategies for the prevention and control of osteoporosis in developing countries.

The frequency of osteoporosis and fragility fractures has been studied to a very limited extent in few developing countries. The aim of this paper is to review briefly the burden of osteoporosis and fragility fractures in these countries and to propose some strategies for the prevention and control of those conditions, considering barriers and facilitators for their implementation. The evolution of the demographic composition in most regions with developing countries shows a considerable increase in life expectancy and therefore, a significant growth in elderly population can be expected. Reports on the incidence of fragility fractures show figures in many of those countries that are comparable to those found in developed nations. Health resources (for acute treatment of fractures, their rehabilitation and chronic management, for diagnostic centers and drug therapy for osteoporosis) are limited in most of those regions and are allocated to other health priorities. Internationally accepted guidelines can be adapted to the realities of developing nations and may be promoted by organizations of health professionals and patients, but require endorsement and support by health authorities. The steps should include: (a) campaigns to increase awareness, both among the population at risk and relevant health workers; (b) the promotion of a preventive lifestyle in the general population; (c) the development of national or regional, evidence-based guidelines for the diagnosis and treatment of osteoporosis; (d) development and implementation of guidelines for the treatment of fragility fractures, their rehabilitation and prevention of falls; (e) collection of economic data on fractures and osteoporosis; and (f) development of country-specific fracture databases. These steps may help in reducing the increasing burden of osteoporotic fractures. Their implementation will require solid scientific basis and commitment from policy makers, health professionals, patient organizations, and ultimately the general population.

The burden of osteoporosis in Latin America.

Osteoporosis causes considerable morbidity, mortality and resource utilization in industrialized nations. Its burden is relatively well known in United States and Canada, but poorly studied in the rest of America. This study aimed to discover the burden of osteoporosis in Latin America through a review of literature and publicly available information. In this transversal and descriptive study, information from 20 countries in Latin American region was collected from diverse published and electronic sources. Rheumatologists and bone specialists were asked for additional information through a questionnaire created by consensus. In the year 2000, the population of the Latin America and Caribbean region was 524 million from diverse ethnic origins. On average, 5.5% of the population is 65 years and older. However, with life expectancy higher than 70 years in most countries, a significant growth in the elderly population is anticipated. Studies using World Health Organization's criteria for osteoporosis report 12-18% of women 50 years and older with vertebral osteoporosis and 8-22% with proximal femur osteoporosis. Community based studies in Argentina reported between 263 and 331 hip fractures per 100,000 people 50 years and older. Hospital based studies in Colombia, Chile, Brazil, Mexico, Panama, Peru and Venezuela reported between 40 and 362 hip fractures per 100,000 persons aged 50 and more. Between 17 and 37% of hip fracture sufferers die in the year following fracture. Prevalence of vertebral fractures in community-dwelling women aged 50 and more in Mexico is 19.35%. Data on other fractures are rare. Direct costs of a hip fracture ranged from $4500 to $6000. National gross income per capita in the region ranges from $410 to $7550. The burden of osteoporosis varies across countries with differences in populations and health resources. Considerable support for research is required, since numerous gaps in knowledge need to be filled to face the anticipated explosive growth in osteoporotic fractures.

Consumo de calcio en mujeres de nivel socioeconómico bajo en León, Guanajuato / Content of calcium in the diet in women of low social and economic status in the city of Leon in Mexico

En México, la frecuencia de las fracturas de cadera va en aumento y la mayoría de las mujeres de más de 60 años tiene osteopenia u osteoporosis (OP). El consumo de calcio es uno de los determinantes de la formación y la conservación de la masa ósea y se sabe poco de él en nuestro medio. Objetivo. Conocer la cantiad de calcio ingerido diariamente por mujeres sanas de nivel socioeconómico bajo en León, Gto. Métodos. Se aplicó una escuesta a mujeres seleccionadas aleatoriamente entre las acompañantes de las salas de espera del Hospital General Regional, que se referían sanas, conteniendo información demográfica, somatométrica y de factores de riesgo para OP, así como un recordatorio del consumo de alimentos en las últimas 24 horas para definir el consumo de calcio en mg. Los hallazgos se portan utilizando estadística simple. Resultados. Se encuestaron 768 mujeres con edad media de 40.1 (ñ14.6) años, 39.5 por ciento de ellas eran post-menopáusicas y 81.2 por ciento tenían algún otro factor de riesgo para OP. Estos hallazgos podrían tener importancia para planear estrategias educacionales e intervenciones preventivas específicas

Fracturas de cadera en egresos de hospitales de León, Guanajuato (México). Un indicador econométrico de osteoporosis

Aunque se desconoce la epidemiología de la osteoporosis (OP) en México, la frecuencia de las fracturas de cadera parece aumentar en los hospitales de Ortopedia. Con el propósito de conocer la frecuencia de las fracturas de cadera por trauma mínimo como un indicador de la importancia de la OP en hospitales públicos de nuestro medio, analizamos los registros de egresos de 4 hospitales generales del Sector Salud, en la ciudad de León, Guanajuato (México). Se revisaron los expedientes de todos los mayores de 50 años que sufrieron fractura de cadera. De un total de 113,410 pacientes egresados, 429 tuvieron una fractura de cadera por trauma mínimo. Estas se consideran de origen probablemente osteoporótico y se presentaron con una tasa de 3.78 por 1000 egresos por año. El 66 por ciento de estas fracturas ocurrieron en mujeres, con una edad media de 76.1 años. El 62 por ciento fueron transtrocantéricas y 19 por ciento transcervicales. Requirieron 12.2 días de hospitalización media y manejo quirúrgico en el 86 por ciento. El 12.5 por ciento de los pacientes sufrieron alguna complicación hospitalaria y 1.86 por ciento fallecieron en este lapso. El costo promedio de la estancia hospitalaria fue de US$1,266.01 (dolares americanos), más gastos quirúrgicos en la mayoría. La proyección al total de egresos hospitalarios del Sector Salud de México en 1995 revela un elevado costo directo. La fractura de cadera como una consecuencia común de la OP, representa una pesada carga económica. La única opción costo-efectiva está en la prevención tanto de la OP como de las caídas en la población general

Métodos diagnósticos en osteoporosis / Diagnostic methods in osteoporosis

Se describen aquí los principales métodos de diagnóstico de osteoporosis. Los rayos X (RX) simples no permiten medir la masa ósea, sólo pueden detectar osteopenia y tienen un alto grado de error para pacientes con osteoporosis. La radiogrametría metacarpiana es un procedimiento sencillo y barato, útil en el escrutinio de osteoporosis. La radioabsorciometría emplea una placa simple de mano tomada junto a una cuña de aluminio, tiene buena precisión y exactitud. La Absorciometría Dual de RX (DXA) es actualmente el método estándar para la medición de la masa ósea, permite realizar mediciones del esqueleto entero y de segementos como columna lumbar anteroposterior y lateral, antebrazo, cuello femoral y mano. La absorciometría dual de RX Morfométrica (MXA) tiene además la ventaja de analizar la morfometría de los cuerpos vertebrales así como una mejor calidad en las imágenes gracias a su tecnología de RX en abanico. La Tomografía Cuantitativa Computarizada (QCT) es el único método que proporciona medidas del contenido mineral en 3 dimensiones y puede determinar la densidad del hueso cortical y trabecular en forma separada. El Ultrasonido Cuantitativo (QUS) es un procedimiento sencillo no invasivo útil en el escrutinio de pacientes con osteoporosis y permite además evaluar la calidad del hueso

Fractura por estrés en artritis reumatoide / Stress fracture in rheumatoid artritis

Objetivo. Describir las características clínicas y radiográficas de siete pacientes con artritis reumatoide (AR) que presentaron ocho fracturas por estrés (FE). Método. En un lapso de 10 años se reunieron retrospectivamente siete casos de pacientes con AR, que estaban bajo tratamiento y control médico. La información se obtuvo de los expedientes clínicos y estudios radiográficos. Resultados. Todas las pacientes fueron mujeres con edad promedio de 51.2 años, duración promedio de la enfermedad, 13.2 años y factor reumatoide seropositivo. Como parte de su esquema de tratamineto, todas recibían antiinflamatorio no esteroideo e inductores de remisión. Las siete pacientes estaban recibiendo dosis bajas de corticoesteroides por vía oral. Previo a la FE se enocntraban en clase funcional I-II y sin causa aparente cursaron con datos de inflamación peri o paraarticular. La radiografía inicial no fue concluyente en todos los casos, pero 3 y 4 semanas después se hizo evidente el trazo de fractura. Todas las fracturas ocurrieron en extremidad pélvica (4 en metatarsianos, 2 en el peroné y una doble en iliopubis e isquiopubis). En todos los casos se hizo un manejo conservador, con respuesta satisfactoria. Conclusiones. El dolor, la inflamación y la limitación de la función, con topografía peri o paraarticular cuando ocurre en pacientes con AR deben orientar a la posibilidad de fracturas por estrés. El seguimiento radiológico permite confirmar o descartar dicha posibilidad

Enfermedades reumáticas de inicio juvenil y su diagnóstico de envío / Rheumatic juvenile disease and sending diagnosis

Objetivos: Determinar la frecuencia de las diferentes enfermedades reumáticas de inicio juvenil, enviadas a un Servicio de Reumatología general y detectar la proporción de diagnósticos de envío correctos. Metodología: Se estudiaron 226 pacientes, con inicio de las manifestaciones clínicas antes de los 16 años de edad, durante el período comprendido entre junio de 1981 a mayo de 1991. Se analizaron de manera retrospectiva la información de los datos demográficos y clínicos. Se compararon los diversos diagnósticos de referencia y definitivo. Resultados: La frecuencia de población pediátrica atendida en la consulta reumatológica general fue de 5.5 por ciento. En 188 pacientes (83 por ciento), se estableció el diagnóstico de alguna forma crónica de artritis juvenil, específicamente: Artritis Reumatoide Juvenil (ARJ) en 102 casos (54 por ciento), Espondilitis Anquilosante Juvenil (EAJ) en 31 niños (16 por ciento), Enfermedades del Tejido Conectivo (ETC) en 23 pacientes (12 por ciento) y Fiebre Reumática (FR) en 12 casos (6 por ciento); el diagnóstico de otras enfermedades reumáticas se estableció en 20 niños (11 por ciento). Un total de 38 envíos (17 por ciento) no eran portadores de enfermedad reumática. El índice global del diagnóstico de envío correcto fue del 57 por ciento; la ARJ estuvo correctamente diagnosticada en 66 de 102 envíos (65 por ciento), las ETC en 14 de 23 casos (61 por ciento), la EAJ en 16 de 31 niños (52 por ciento), la FR en 4 de 12 pacientes (33 por ciento) y en 20 casos, con otras enfermedades reumáticas, el diagnóstico correcto se había establecido sólo en 7 niños (35 por ciento). Conclusiones: La proporción de enfermedades reumáticas de inicio juvenil sólo representaron el 5.5 por ciento de la población, en el contexto de un Servicio de Reumatología general. El índice global de certeza diagnóstica, de los envíos por parte de los diferentes servicios de referencia, tales como Pediatría, Medicina Familiar y de otras especialidades fue del 57 por ciento. Es indispensable mayor difusión de las enfermedades reumáticas en Pediatría