Reincorporación al trabajo tras un episodio de incapacidad temporal por trastornos músculo-esqueléticos: revisión sistemática de guías de buenas prácticas / Return to work after musculoskeletal disorders; A systematic review of good practices guidelines

Objetivo: Identificar las guías disponibles en la literatura sobre retorno al trabajo después de un episodio de incapacidad temporal (IT) por trastornos músculo-esqueléticos (TME) y evaluar la calidad metodológica de las mismas. Métodos: Se realizó una búsqueda sistemática de guías específicas de retorno al trabajo en inglés, castellano y catalán cuyo contenido tenía en forma total o parcial información sobre TME. Las guías identificadas fueron evaluadas cualitativa y cuantitativamente por siete expertos utilizando el método validado AGREE II. Para cada dominio se calcularon tanto las puntuaciones estandarizadas como las medianas de las puntuaciones con las que los evaluadores habían calificado cada ítem. Además, cada evaluador hizo un juicio cualitativo de la calidad metodológica de la guía. Resultados: Se identificaron 32 guías, de estas seis fueron seleccionadas para evaluar su calidad metodológica (tres específicas para TME). Sólo dos guías, la Official Disability Guidelines (ODG) y la Work-related Musculoskeletal Disorders Guide &Tools (WRGT), podrían utilizarse en la práctica profesional sin necesidad de modificaciones en su metodología. En general, todas las guías definen bien sus objetivos y a quién van dirigidas; y las opciones de retorno al trabajo se presentan en forma precisa. Sin embargo, todas excepto una (ODG) tienen limitaciones en los criterios para seleccionar la evidencia científica y no se mencionan los potenciales conflictos de interés. Conclusiones: Sólo fueron identificadas dos guías con alta calidad metodológica. Sin embargo, sería recomendable una evaluación basada en la evidencia de la calidad de sus recomendaciones

Objective: To identify existing return-to-work (RTW) guidelines following a sickness absence (SA) due to musculoskeletal disorders (MSD) and evaluate their methodological quality. Methods: We performed a systematic search for RTW guideliness written in English, Spanish and Catalan, that included total or partial information on MSD. The identified guidelines were evaluated qualitatively and quantitatively by seven experts using the validated AGREE method. Standardized scores for each domain were calculated for each of the guidelines, as well as the median of the experts scores for each of the items. In addition, each expert made a subjective judgment on the quality of the selected guidelines. Results: Thirty-two guidelines were identified. From these, 6 (3 of which were MSD-specific) were selected for an evaluation of their methodological quality. Only two, the Official Disability Guidelines (ODG) and the Work-related Musculoskeletal Disorders Guide & Tools (WRGT) were felt to be suitable for use without further methodological modifications. In general, all of the guidelines properly define their objectives and target audience, and the RTW options are presented in a clear and precise way. However, all guides but one (ODG) have limitations in the criteria for selection of scientific evidence, and the potential conflicts of interest are not stated. Conclusions: Only two guides of high methodological quality were identified. However, an evidence-based evaluation of the quality of their recommendations is recommended prior to their use in professional practice

[Return to work after musculoskeletal disorders: a systematic review of good practices guidelines]. / Reincorporación al trabajo tras un episodio de incapacidad temporal por trastornos músculo-esqueléticos: revisión sistemática de guías de buenas prácticas.

OBJECTIVE: To identify existing return-to-work (RTW) guidelines following a sickness absence (SA) due to musculoskeletal disorders (MSD) and evaluate their methodological quality. METHODS: We performed a systematic search for RTW guideliness written in English, Spanish and Catalan, that included total or partial information on MSD. The identified guidelines were evaluated qualitatively and quantitatively by seven experts using the validated AGREE method. Standardized scores for each domain were calculated for each of the guidelines, as well as the median of the experts scores for each of the items. In addition, each expert made a subjective judgment on the quality of the selected guidelines. RESULTS: Thirty-two guidelines were identified. From these, 6 (3 of which were MSD-specific) were selected for an evaluation of their methodological quality. Only two, the Official Disability Guidelines (ODG) and the Work-related Musculoskeletal Disorders Guide & Tools (WRGT) were felt to be suitable for use without further methodological modifications. In general, all of the guidelines properly define their objectives and target audience, and the RTW options are presented in a clear and precise way. However, all guides but one (ODG) have limitations in the criteria for selection of scientific evidence, and the potential conflicts of interest are not stated. CONCLUSIONS: Only two guides of high methodological quality were identified. However, an evidence-based evaluation of the quality of their recommendations is recommended prior to their use in professional practice.

OBJETIVO: Identificar las guías disponibles en la literatura sobre retorno al trabajo después de un episodio de incapacidad temporal (IT) por trastornos músculo-esqueléticos (TME) y evaluar la calidad metodológica de las mismas. MÉTODOS: Se realizó una búsqueda sistemática de guías específicas de retorno al trabajo en inglés, castellano y catalán cuyo contenido tenía en forma total o parcial información sobre TME. Las guías identificadas fueron evaluadas cualitativa y cuantitativamente por siete expertos utilizando el método validado AGREE II. Para cada dominio se calcularon tanto las puntuaciones estandarizadas como las medianas de las puntuaciones con las que los evaluadores habían calificado cada ítem. Además, cada evaluador hizo un juicio cualitativo de la calidad metodológica de la guía. RESULTADOS: Se identificaron 32 guías, de estas seis fueron seleccionadas para evaluar su calidad metodológica (tres específicas para TME). Sólo dos guías, la Official Disability Guidelines (ODG) y la Work-related Musculoskeletal Disorders Guide & Tools (WRGT), podrían utilizarse en la práctica profesional sin necesidad de modificaciones en su metodología. En general, todas las guías definen bien sus objetivos y a quién van dirigidas; y las opciones de retorno al trabajo se presentan en forma precisa. Sin embargo, todas excepto una (ODG) tienen limitaciones en los criterios para seleccionar la evidencia científica y no se mencionan los potenciales conflictos de interés. CONCLUSIONES: Sólo fueron identificadas dos guías con alta calidad metodológica. Sin embargo, sería recomendable una evaluación basada en la evidencia de la calidad de sus recomendaciones.

Salud laboral en España: balance de una década / No disponible

No disponible

Risk, predictors, and clinical characteristics of lymphoma development in primary Sjögren's syndrome.

OBJECTIVE: To assess the risk and predictors of lymphoma development in a large cohort of patients with primary Sjögren's syndrome (pSS). METHODS: Cox-regression analyses were used to study the predictive value of clinical and laboratory findings at pSS diagnosis, and Kaplan-Meier survival curves to compare survival probability between patients who developed lymphoma and the total cohort. Expected risk for lymphoma was calculated by comparison with the background population. RESULTS: Eleven (4.5%) from 244 patients developed a non-Hodgkin lymphoma (NHL). Diffuse large B-cell and mucosa-associated lymphoid tissue lymphomas occurred at a similar frequency. Three (27.3%) patients died: 2 due to transformation from mucosa-associated lymphoid tissue to diffuse large B-cell. Purpura (HR 8.04, 95% confidence interval [CI] 2.33-27.67), parotidomegaly (HR 6.75, 95%CI 1.89-23.99), anemia (HR 3.43, 95%CI 1.04-11.35), leukopenia (HR 8.70, 95%CI 2.38-31.82), lymphocytopenia (HR 16.47, 95%CI 3.45-78.67), hypergammaglobulinemia (HR 4.06, 95%CI 1.06-15.58), low C3 (HR 36.65, 95%CI 10.65-126.18), and low C4 (HR 39.70, 95%CI 8.85-126.18) levels at pSS diagnosis were significant predictors of NHL development, but only hypocomplementemia and lymphocytopenia were independent risk factors. Hypocomplementemia was related to earlier development of NHL and higher mortality. The cumulative risk of developing lymphoma ranged from 3.4% in the first 5 years to 9.8% at 15 years. Standardized incidence ratio (95%CI) for NHL development was 15.6 (95%CI 8.7-28.2). CONCLUSIONS: Patients with pSS have a 16-fold increased risk of developing lymphoma. This risk increases with time. Hypocomplementemia and lymphocytopenia at pSS diagnosis are the strongest predictors. Survival is clearly reduced in patients with hypocomplementemia. Indolent lymphomas tend to evolve over time toward a more aggressive histologic type.

Effectiveness of occupational injury prevention policies in Spain.

OBJECTIVE: We examined the effectiveness of preventive interventions against occupational injuries (preferential action plans [PAPs]) developed by Spanish regional governments starting in 2000. METHODS: We included 3,252,028 occupational injuries with sick leave due to mechanical causes occurring between 1994 and 2004 in manufacturing and private service companies. Time trends for occupational injury rates were estimated before and after implementation of PAPs in each region, with a control group defined for those regions in which no PAPs were implemented (e.g., Galicia, Madrid, and Cataluña). We determined annual change percentages and their 95% confidence intervals (CIs) through a negative binomial regression model. Regions were grouped into three categories according to formal quality of their PAPs. RESULTS: The regions with the best PAPs (Andalucia, Aragon, Valencia, and Murcia) showed annually increasing occupational injury rates (2.3%, 95% CI -2.5, 7.4) before implementation of PAPs. After PAPs were implemented, occupational injury rates decreased significantly to -7.4% (95% CI -10.2, -4.5). Similar results were also found for regions with PAPs of lower quality and even for regions that didn't implement a PAP (control group). These results did not vary substantially in stratified analysis by gender, age, type of contract, or length of sick leave. CONCLUSION: PAPs are not related to a general decline in occupational injury rates in Spain starting in 2000. Reinforcement of Spanish health and safety regulations and labor inspection activities since 2000, resulting from a social agreement between central government and social agents, remains an alternative hypothesis requiring additional research.

Stroke and multi-infarct dementia as presenting symptoms of giant cell arteritis: report of 7 cases and review of the literature.

Cerebrovascular accidents (CVAs) and multi-infarct dementia have rarely been reported as presenting symptoms of giant cell arteritis (GCA), although 3%-4% of patients with GCA may present with CVAs during the course of the disease. We describe 7 patients with biopsy-proven GCA who presented with stroke or multi-infarct dementia. Most of them had other symptoms of GCA when the disease began that were misdiagnosed or not noticed. The internal carotid arteries were involved in 4 patients and the vertebrobasilar arteries in 3, with bilateral vertebral artery occlusion in 1. Small cerebral infarction foci on cranial computed tomography (CT) scan and magnetic resonance imaging (MRI) were found in 5 cases, and cerebellar infarction, in 2. MR angiography showed intracranial arteritis in 4 cases. Treatment with glucocorticoids and adjunctive antiplatelet or anticoagulant therapy was given in all cases, with neurologic improvement in 5. Two patients died. Necropsy demonstrated generalized GCA involving the medium and small cerebral vessels in 1 case. Central nervous system involvement is a rare complication in GCA but is important to recognize, as it can be reversible if diagnosed and treated promptly. Suspicion should arise in elderly patients suffering from strokes with a quickly progressing stepwise course and associated headache, fever, or inflammatory syndrome. In these cases, temporal artery biopsy should be performed without delay. Early diagnosis of GCA and immediate initiation of corticosteroid treatment may prevent progressive deterioration and death. Additional antiplatelet or anticoagulant therapy should be evaluated according to the individual risk and benefit to the patient under care.

Fármacos antifactor de necrosis tumoral en las vasculitis sistémicas / Anti-TNF alpha agents in vasculitis

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Paraneoplastic vasculitis in patients with solid tumors: report of 15 cases.

OBJECTIVE: To review all cases of concurrent vasculitis and solid tumors diagnosed at our Department over a 15-year period and explore evidence that would support the notion of vasculitis being a true paraneoplastic syndrome. METHODS: We reviewed the records of all patients diagnosed with vasculitis and solid tumors within 12 months of each other and prospectively followed until death or our report. We analyzed the main features and outcome of vasculitis in this setting. We also reviewed all cases published in the French-English literature. RESULTS: Fifteen patients (9 men and 6 women) in whom both vasculitis and solid tumor occurred within the same 12 months were identified. Mean age was 72.5 years (range 58-84). In 7 cases the diagnosis of vasculitis antedated that of cancer, in 6 both processes were synchronously diagnosed, and in 2 vasculitis appeared after cancer diagnosis. The most common vasculitis was cutaneous leukocytoclastic vasculitis (n = 9). Other vasculitides included Henoch-Shönlein purpura (n = 2), polyarteritis nodosa (n = 1), and giant cell arteritis (n = 3). The commonest malignancies were carcinomas of urinary organs (40%), lung (26.7%), and gastrointestinal tract (26.7%). The median followup was 28.4 months (range 1-96). Thirteen of the 15 patients demonstrated concordance of disease activity and treatment response for both cancer and vasculitis. Vasculitis flared heralding tumor recurrence or progression in 7 (46.6%) cases. CONCLUSION: In our patients, resolution of vasculitis following effective treatment of the putatively linked malignancy, and recurrence of vasculitis heralding tumor recurrence or progression, provide strong evidence for vasculitis being a true paraneoplastic syndrome. Chronic or persistent vasculitis with poor response to usually effective therapy, especially in elderly patients, should raise questions about underlying malignancy.

Evaluación de la efectividad de las actividades preventivas (planes de actuación preferente) sobre la incidencia de las lesiones traumáticas no mortales con incapacidad laboral por accidentes de trabajo en jornada en España (1994-2004) / Evaluation of the effectiveness of preventive activities (strategic action plans) on the incidence of non-fatal traumatic occupational injuries leading to disabilities in Spain (1994-2004)

Fundamento. Los planes de actuación preferente (PAP) han sido lasprincipales actividades preventivas desarrolladas por las comunidadesautónomas (CCAA) frente a las lesiones por accidentes de trabajo (LAT)en España desde 1999. El objetivo de este trabajo es evaluar la efectividadde los planes.Métodos. Fueron seleccionados 4.714.080 casos incidentes de LATno mortales con incapacidad laboral, ocurridos entre 1994 y 2004 durantela jornada laboral producidos por causas mecánicas y por sobreesfuerzoen empresas manufactureras y de servicios no públicos. A partir de lasincidencias anuales se estimó en cada CCAA el porcentaje de cambioanual y su intervalo de confianza al 95% (IC95%) para el periodo anteriory posterior del inicio del PAP mediante una regresión binomial negativa.Resultados. El patrón observado siguió una tendencia ascendente en losperiodos previos al inicio del PAP y descendente a continuación de la puestaen marcha de estos planes. Por ejemplo, en Aragón, donde el PAP se inicióen 1999, observamos un incremento de +5,3% entre 1994-1999 frente a undescenso de -4,9% entre 2000-2004. En Baleares, que inició su PAP en 2002,la tendencia correspondiente fue de +5,4% entre 1994-2001 frente a -14%entre 2002-2004. Sin embargo, se observaron tendencias similares en Madrid(-3,9% entre 2000 y 2004) o en Galicia (-4,8% entre 2000 y 2004), donde noconsta que se pusieran en marcha un PAP específico en el periodo de estudio.Conclusiones. Estos resultados no permiten atribuir a los PAP el descensogeneralizado en la incidencia de las LAT no mortales a partir del 2000en España. Posiblemente, otras acciones de carácter general, que habríanafectado a todas las CCAA por igual (incluyendo a aquéllas que no han desarrolladosus propios PAP), explicarían este descenso en la incidencia de laslesiones por accidente de trabajo seleccionadas en el presente análisis(AU)

Backgound: The strategic action plans have been the mainpreventive activities carried out by the Autonomous CommunityGovernments in relation to occupational injuries in Spain since 1999.This study is aimed at evaluating the effectiveness of these plans.Methods.A total of 4,714,080 cases of non-fatal traumatic occupationalinjuries leading to disability having occurred within the 1994-2004 perioddue to mechanical causes and over-exertion at non-publicly owned serviceand manufacturing companies were included. Based on the annual incidencerates, the percentage of annual change and the 95% confidence interval (95%CI) were estimated for the periods prior to and following the start-up of theStrategic Action Plans by means of negative binomial regression.Results. The pattern found followed an upward trend during theperiods prior to the start-up of the Strategic Actions Plans, followed by adownward trend as of the start-up of these plans. For example, in Aragon,where the Strategic Action Plan was started up in 999, a +5.3% rise wasfound within the 1994-1999 period, as compared to a –4.9% decreaseduring the 2000-2004 period. On the Balearic Islands, which started uptheir Strategic Action Plan in 2002, the corresponding trend was +5.4%for 1994-2001, as compared to –14% for 2002-2004. However, similartrends were found in Madrid (-3.9% for 2000-2004) or in Galicia (-4.8%for 2000-2004), where there is no record of any specific Strategic ActionPlan having been gotten under way during the period under study...(AU)

[Evaluation of the effectiveness of preventive activities (Strategic Action Plans) on the incidence of non-fatal traumatic occupational injuries leading to disabilities in Spain (1994-2004)]. / Evaluación de la efectividad de las actividades preventivas (Planes de Actuación Preferente) sobre la incidencia de las lesiones traumáticas no mortales con incapacidad laboral por accidentes de trabajo en jornada en España (1994-2004).

BACKGROUND: [corrected] The strategic action plans have been the main preventive activities carried out by the Autonomous Community Governments in relation to occupational injuries in Spain since 1999. This study is aimed at evaluating the effectiveness of these plans. METHODS: A total of 4,714,080 cases of non-fatal traumatic occupational injuries leading to disability having occured within the 1994-2004 period due to mechanical causes and over-exertion at non-publicly owned service and manufacturing companies were included. Based on the annual incidence rates, the percentage of annual change and the 95% confidence interval (95% CI) were estimated for the periods prior to and following the start-up of the Strategic Action Plans by means of negative binomial regression. RESULTS: The pattern found followed an upward trend during the periods prior to the start-up of the Strategic Actions Plans, followed by a downward trend as of the start-up of these plans. For example, in Aragon, where the Strategic Action Plan was started up in 999, a +5.3% rise was found within the 1994-1999 period, as compared to a -4.9% decrease during the 2000-2004 period. On the Balearic Islands, which started up their Strategic Action Plan in 2002, the corresponding trend was +5.4% for 1994-2001, as compared to -14% for 2002-2004. However, similar trends were found in Madrid (-3.9% for 2000-2004) or in Galicia (-4.8% for 2000-2004), where there is no record of any specific Strategic Action Plan having been gotten under way during the period under study. CONCLUSIONS: These results do not make it possible to attribute the widespread drop in the non-fatal traumatic occupational injury incidence as of 2000 in Spain to the Strategic Action Plans. Possibly other actions of a general nature which may have had a bearing on all of the Autonomous Communities in the same manner (including those which have not developed their own Strategic Action Plans) might explain this drop in the incidence of the occupational injuries selected in this analysis.

Arteritis de células gigantes / Giant-cell arteritis

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Metalloproteinase-2 and -9 in giant cell arteritis: involvement in vascular remodeling.

BACKGROUND: Both matrix metalloproteinase-2 (MMP-2) and -9 (MMP-9) have been postulated to play roles in the pathophysiology of giant cell arteritis (GCA) because of their ability to degrade elastin. Understanding the specific mediators of arterial damage in GCA could lead to new therapeutic targets in this disease. METHODS AND RESULTS: Temporal artery biopsy specimens were obtained from 147 consecutive patients suspected of GCA. Clinical and histopathological data were collected according to protocol. Using immunohistochemistry, we compared the expression of MMP-2 and MMP-9 in the temporal artery biopsies of both GCA cases (n=50) and controls (n=97). MMP-9 was found more frequently in positive than in negative temporal artery biopsies (adjusted odds ratio [OR], 3.20; P=0.01). In contrast, the frequency of MMP-2 was not significantly different between positive and negative biopsies (adjusted OR, 2.18; P=0.22). Both MMP-2 and MMP-9 were found in macrophages and giant cells near the internal elastic lamina and in smooth muscle cells and myofibroblasts of the media and intima. MMP-9 was also found in the vasa vasorum. MMP-9 but not MMP-2 was associated with internal elastic lamina degeneration, intimal hyperplasia, and luminal narrowing, even after adjustment for possible confounding variables. CONCLUSIONS: MMP-9 appears more likely than MMP-2 to be involved in the pathophysiology of GCA. MMP-9 not only participates in the degradation of elastic tissue but also is associated with intimal hyperplasia, subsequent luminal narrowing, and neoangiogenesis. The expression of MMP by smooth muscle cells implicates these cells as potential secretory cells in GCA.

No detection of parvovirus B19 or herpesvirus DNA in giant cell arteritis.

BACKGROUND: Compelling arguments exist for a role of infectious agent in giant cell arteritis (GCA). Parvovirus B19 and several herpesviruses have focussed the attention in recent years, but the few studies to date have yielded inconsistent results. OBJECTIVES: To study the relationship between the presence of parvovirus B19 DNA or major known herpesviruses and the histopathological features of GCA. STUDY DESIGN: Between January 1997 and March 2002, 147 consecutive temporal artery biopsies were performed in our center because of a clinical suspicion of GCA. Using polymerase chain reaction (PCR) procedures validated by the World Health Organization and employed routinely by our laboratory, we examined the paraffin-embedded specimens for DNA from parvovirus B19, herpes simplex viruses (HSV) 1 and 2, Epstein-Barr virus (EBV), varicella-zoster virus (VZV), human cytomegalovirus (HCMV), and human herpesvirus 6 (HHV-6). We investigated positive results further with immunohistochemistry studies. RESULTS: Fifty of the 147 temporal artery biopsies (34%) showed histological features of GCA. Three biopsies (2.5%) were initially PCR positive for parvovirus B19. None of the herpesvirus PCR assays were positive. Upon repeat testing by both PCR and immunohistochemistry, none of the three initially positive parvovirus B19 assays were confirmed. The results of both positive and negative control assays in these studies validated these findings. We confirmed the presence of amplifiable DNA in the temporal artery biopsy specimens using PCR primers for beta-globin and indoleamine 2,3-dioxygenase (IDO). CONCLUSIONS: The results of our study do not support a role in the etiopathogenesis of GCA for either parvovirus B19 or any of these six herpesviruses.

Síndrome hipereosinofílico / Hypereosinophilic syndrome

No disponible

Síndrome de Sjögren primario: características clínicas e inmunológicas de 114 pacientes / Primary Sjögren's syndrome: clinical and immunological characteristics of 114 patients

FUNDAMENTO: Analizar las características clínicas, evolutivas e inmunológicas de una serie de 114 pacientes diagnosticados de síndrome de Sjögren primario. Evaluar las diferencias clínicas en función de los criterios diagnósticos utilizados y la asociación del síndrome de Sjögren primario con procesos linfoproliferativos. PACIENTES Y MÉTODO: Se incluyeron 114 pacientes (108 mujeres y 6 varones) diagnosticados de síndrome de Sjögren primario. Todos cumplían los criterios diagnósticos propuestos por el Grupo de Estudio de la Comunidad Europea, y 76 cumplían los criterios de San Diego. RESULTADOS: La edad media de los pacientes fue de 51 años, con un tiempo medio de seguimiento clínico de 7,3 años. El síntoma más frecuente de inicio de la enfermedad (70 por ciento) fue la xerostomía/xeroftalmía (síndrome seco). Entre las manifestaciones extraglandulares, se observó afección articular en un 42 por ciento de los pacientes, neurológica en un 35 por ciento, pulmonar en el 21 por ciento y hepática en el 13 por ciento. Once pacientes (9 por ciento) presentaron fenómenos vasculíticos y 3 (2 por ciento), un proceso linfoproliferativo. No se apreciaron diferencias estadísticamente significativas en los síntomas de inicio de la enfermedad, en la frecuencia de afección glandular y extraglandular, ni en la gravedad de la enfermedad entre los pacientes diagnosticados según los criterios europeos frente a los de San Diego. La presencia del virus de la hepatitis C (VHC) se asoció de forma significativa con la vasculitis (p < 0,001; odds ratio [OR]: 20,6; intervalo de confianza [IC] del 95 por ciento, 3,2-129) y con procesos linfoproliferativos (p < 0,001). CONCLUSIONES: El curso clínico del síndrome de Sjögren no varía en función de los criterios diagnósticos. Existe asociación entre la vasculitis y los procesos linfoproliferativos con el VHC, lo que confiere unas características diferenciales a este subgrupo de pacientes (AU)