Valve Abnormalities, Risk Factors for Heart Valve Disease and Valve Replacement Surgery in Spondyloarthritis. A Systematic Review of the Literature.

Objective: Evaluate the evidence on the abnormalities of the aortic root and heart valves, risk and prognostic factors for heart valve disease and valve replacement surgery in spondyloarthritis. Methods: A systematic literature review was performed using Medline, EMBASE and Cochrane databases until July 2021. Prevalence, incidence, risk and prognostic factors for heart valve disease; dimension, morphology, and pathological abnormalities of the valves were analyzed. Patient characteristics (younger age, history of cardiac disease or longer disease duration) and period of realization were considered for the analysis. The SIGN Approach was used for rating the quality of the evidence of the studies. Results: In total, 37 out of 555 studies were included. Overall, the level of evidence was low. The incidence of aortic insufficiency was 2.5-3.9‰. Hazard Ratio for aortic insufficiency was 1.8-2.0. Relative risk for aortic valve replacement surgery in ankylosing spondylitis patients was 1.22-1.46. Odds ratio for aortic insufficiency was 1.07 for age and 1.05 for disease duration. Mitral valve abnormalities described were mitral valve prolapse, calcification, and thickening. Aortic valve abnormalities described were calcification, thickening and an echocardiographic "subaortic bump." Abnormalities of the aorta described were thickening of the wall and aortic root dilatation. The most common microscopic findings were scarring of the adventitia, lymphocytic infiltration, and intimal proliferation. Conclusions: A higher prevalence and risk of aortic valve disease is observed in patients with ankylosing spondylitis. Studies were heterogeneous and analysis was not adjusted by potential confounders. Most studies did not define accurate outcomes and may have detected small effects as being statistically significant.

Nomenclátor jerarquizado en reumatología / Hierarchical nomenclature in rheumatology

INTRODUCCIÓN: Una misión de la Sociedad Española de Reumatología es aportar las herramientas necesarias para alcanzar la excelencia asistencial. En la actualidad no existe una referencia que cuantifique la complejidad de los actos médicos de esta especialidad. MATERIAL Y MÉTODO: Se elaboró una relación de los actos propios del reumatólogo y se estableció un sistema de clasificación jerárquica a partir de la construcción de un índice de complejidad, calculado mediante el tiempo de realización y el grado de dificultad de cada acto. RESULTADOS: Los resultados del método Delphi tendieron a una opinión grupal consensuada (media σ2 - σ1=0,75-1,43=-0,68, media IQR2 - IQR1=0,8-1,9=-1,1). El rango de valores del índice de complejidad osciló de 48 a 465 puntos. Entre las consultas, las que alcanzaron mayor gradación fueron la primera visita al paciente hospitalizado (366) y la visita a domicilio (369). Entre las técnicas diagnósticas, destacaron las biopsias. Las que puntuaron más alto fueron: biopsia ósea (465), de nervio sural (416) y sinovial (380). La ecografía tuvo una puntuación de 204, la capilaroscopia de 113 y la densitometría de 112. Entre las técnicas terapéuticas, la máxima dificultad (388), la alcanzó la infiltración/artrocentesis/ inyección articular infantil. La puntuación de la inyección articular con control ecográfico fue de 163. El informe clínico de minusvalía, 323 y el informe pericial, 370. CONCLUSIONES: Este trabajo ha permitido elaborar un nomenclátor de 54 actos en reumatología donde se identifican como actos más complejos la realización de biopsias (ósea, nervio sural, sinovial), la visita a paciente hospitalizado, la visita a domicilio, la infiltración infantil bajo sedación y la elaboración de un informe pericial. La ecografía osteomuscular es considerada el doble de compleja de una visita sucesiva, la capilaroscopia o la densitometría ósea

INTRODUCTION: One of the missions of the Spanish Society of Rheumatology is to provide the necessary tools for excellence in health care. Currently, there is no reference point to quantify medical actions in this specialty, and this is imperative. MATERIAL AND METHOD: A list of actions was drawn up and a hierarchical classification system was established by developing a complexity index, calculated based on the completion time and difficulty level of each action. RESULTS: The results of the Delphi method tended to the consensus opinion within a group (mean σ2 - σ1=0.75-1.43=-0.68, mean IQR2 - IQR1=0.8-1.9=-1.1). The values of the complexity index ranged between 48 and 465 points. Among consultation actions, those reaching the highest scores were the first inpatient visit (366) and visits to the patient's home (369). Among diagnostic techniques, biopsies were prominent, those with the highest score were: bone biopsy (465), sural nerve biopsy (416) and synovial biopsy (380). Ultrasound scan scored 204, capillaroscopy 113 and densitometry 112. Among therapeutic techniques, infiltration/ arthrocentesis/articular injection in children reached the highest difficulty (388). The score for ultrasound-guided articular injection was 163. The score for clinical report on disability was 323 and expert report 370. CONCLUSIONS: A nomenclature of 54 actions in Rheumatology was compiled. Biopsies (bone, sural nerve, synovial), inpatient visits, visits to the patient's home, infiltrations in children, and the preparation of the expert report were identified as the most complex actions. Musculoskeletal ultrasound is twice as complex as subsequent visits, capillaroscopy or bone densitometry

Association of apolipoprotein B/apolipoprotein A1 ratio and cardiovascular events in rheumatoid arthritis: results of the CARMA study.

OBJECTIVES: To assess the plasma apolipoprotein B/apolipoprotein A1 ratio and its potential association with cardiovascular events (CVE) in patients with rheumatoid arthritis (RA). METHODS: A baseline analysis was made of the CARdiovascular in rheuMAtology Project (CARMA), a 10-year prospective study evaluating the presence of at least one CVE in 775 Spanish patients with RA. Of them, 29 had already experienced CVE prior to the inclusion in the study. We assessed the association between the elevation of the apoB/apoA1 ratio with the presence of CVE according to a logistic regression model for possible confounding factors. We also analysed the main parameters of activity of RA and parameters related to lipid metabolism. RA patients were classified according to treatment: patients treated with disease-modifying anti-rheumatic drugs without biologics and those undergoing biologic therapy (anti-TNF-α, anti-IL-6 receptor, and other biologic agents). RESULTS: The apoB/apoA1 ratio of patients who had experienced CVE was higher than that of patients without previous CVE (0.65 vs. 0.60). However, the difference between both subgroups did not reach statistical significance (p=0.197). It was also the case after the multivariate analysis [OR: 1.48 (95% CI: 0.15-14.4); p=0.735]. RA patients from the group with CVE were more commonly receiving lipid-lowering treatment with statins than those without CVE history (41.4% vs. 20%, p=0.005). High HAQ and high atherogenic index were significantly associated with the presence of CVE. There was no statistical association between the type of biologic therapy used in RA and the presence of CVE. CONCLUSIONS: No association between ApoB/apoA1 ratio and CVE was found at the baseline visit of patients with RA from the CARMA study.

Hierarchical nomenclature in rheumatology. / Nomenclátor jerarquizado en reumatología.

INTRODUCTION: One of the missions of the Spanish Society of Rheumatology is to provide the necessary tools for excellence in health care. Currently, there is no reference point to quantify medical actions in this specialty, and this is imperative. MATERIAL AND METHOD: A list of actions was drawn up and a hierarchical classification system was established by developing a complexity index, calculated based on the completion time and difficulty level of each action. RESULTS: The results of the Delphi method tended to the consensus opinion within a group (mean σ2 - σ1=0.75-1.43=-0.68, mean IQR2 - IQR1=0.8-1.9=-1.1). The values of the complexity index ranged between 48 and 465 points. Among consultation actions, those reaching the highest scores were the first inpatient visit (366) and visits to the patient's home (369). Among diagnostic techniques, biopsies were prominent, those with the highest score were: bone biopsy (465), sural nerve biopsy (416) and synovial biopsy (380). Ultrasound scan scored 204, capillaroscopy 113 and densitometry 112. Among therapeutic techniques, infiltration/ arthrocentesis/articular injection in children reached the highest difficulty (388). The score for ultrasound-guided articular injection was 163. The score for clinical report on disability was 323 and expert report 370. CONCLUSIONS: A nomenclature of 54 actions in Rheumatology was compiled. Biopsies (bone, sural nerve, synovial), inpatient visits, visits to the patient's home, infiltrations in children, and the preparation of the expert report were identified as the most complex actions. Musculoskeletal ultrasound is twice as complex as subsequent visits, capillaroscopy or bone densitometry.

Metotrexato en pacientes con artritis reumatoide en España: subanálisis del proyecto AR Excellence / Methotrexate in patients with rheumatoid arthritis in Spain: subanalysis of the AR Excellence project

OBJETIVO: El proyecto AR Excellence evalúa la atención clínica a los pacientes con artritis reumatoide (AR) en España. El objetivo del presente estudio es analizar la utilización de metotrexato (MTX) en AR Excellence y compararla con las recomendaciones vigentes. PACIENTES Y MÉTODOS: Se revisó a pacientes con AR que habían iniciado tratamiento con MTX, recogiendo datos demográficos, dosificación, vías de administración, combinaciones con otros fármacos antirreumáticos modificadores de enfermedad (FAME), tiempo hasta combinación con otro FAME (convencional o biológico) y efectos adversos. RESULTADOS: Se incluyó a 625 pacientes con AR (edad media de 55,1 años; 70,6% mujeres), con una duración media de la AR de 21,3 meses. El 90% inició tratamiento con MTX. La dosis media de inicio fue de 11mg semanales; en el 58% de los casos se incrementó la dosis. El tiempo medio hasta alcanzar la dosis plena de MTX (20mg semanales) fue de 6,67 meses. El tiempo hasta la combinación de MTX con otro FAME sintético o biológico fue de 3 meses. El 67,4% de los pacientes recibieron el MTX por vía oral y el 18,6%, subcutáneo. En el 12% de los casos se cambió la vía de administración, transcurrida una media de tiempo de 6 meses. En 544 pacientes se asociaron suplementos de folato. El 17,3% de los sujetos presentaron acontecimientos adversos por MTX. CONCLUSIÓN: El MTX es el fármaco sobre el que pivota el tratamiento de la AR. El subanálisis del proyecto AR Excellence nos informa de que la escalada a sus dosis plenas no se realiza con la rapidez adecuada. La vía subcutánea se utiliza en pocos pacientes

OBJECTIVE: The AR Excellence project evaluates clinical monitoring in patients with rheumatoid arthritis (RA) in Spain. The aim of the study was to analyze the use of methotrexate (MTX) in the AR Excellence cohort and to compare it with current recommendations. PATIENTS AND METHODS: We collected data from RA patients who initiated treatment with MTX. They included demographics, dose and routes of administration, switching among them, highest dose in each route, combinations with other disease-modifying antirheumatic drugs (DMARDs), time to combination with another DMARD (either conventional or biological) and adverse events. RESULTS: Six hundred twenty-five patients with RA (mean age 55 years; 70.6% women) were included, with an average disease duration of 21 months. Ninety percent of the patients initiated treatment with MTX. Therapy was begun with a mean dose of 11mg per week; this initial dose was increased in 58% of the individuals. The average time to reach the full dose of MTX (20mg a week) was 6,67 months. Time to combination of MTX with another DMARD, either synthetic or biological, was 3 months. In all, 67.4% of the patients received oral MTX and the route was subcutaneous in 18.6%. In 12% of the cases, there was a change in the route of administration after a period of 6 months. In 544 patients, folate supplements were added to MTX; MTX-related adverse events were detected in 17.3% of the patients. CONCLUSION: MTX is currently the pivotal treatment in RA. The subanalysis of the AR Excellence project demonstrates that MTX escalation to its full doses is not done with adequate speed. The subcutaneous route is used in a small proportion of patients

Indicador compuesto para evaluar la calidad asistencial en el manejo de los pacientes con artritis reumatoide en las consultas externas de Reumatología / A composite indicator to assess the quality of care in the management of patients with rheumatoid arthritis in outpatient rheumatology clinics

Objetivo: El paradigma actual en el tratamiento de la artritis reumatoide (AR) contempla el diagnóstico temprano y el uso precoz de fármacos modificadores de enfermedad (FAME) para alcanzar la remisión o baja actividad inflamatoria, lo cual, se conoce como «treat to target» (T2T). El objetivo del trabajo es desarrollar un indicador compuesto (IC) para evaluar la calidad asistencial en el manejo de los pacientes con AR atendiendo a la estrategia T2T y a otras recomendaciones generales para la atención de estos pacientes. Material y método: La construcción del IC siguió las fases: 1) selección de los criterios de calidad mediante un juicio de expertos; 2) priorización de los criterios, a partir de un Delphi con 20 expertos; 3) diseño de los indicadores de calidad, y 4) cálculo del IC ponderado. La fuente de información para el cálculo del IC son las historias clínicas de los pacientes con AR. Resultados: De los 37 criterios seleccionados, 12 necesitaron una segunda ronda Delphi. Se priorizaron 31 criterios, los cuales presentaron una mediana en relevancia y factibilidad, en las rondas Delphi, mayor o igual a 7,5, con un rango intercuartílico inferior a 3,5, y un grado de acuerdo (puntuación mayor o igual a 8) igual o superior al 80%. Conclusiones: El IC construido, consensuado y ponderado, permite evaluar la calidad asistencial de los pacientes con AR, en las Unidades de Reumatología de hospitales españoles, ofreciendo una medida resumen válida y fácilmente interpretable

Objective: The current guidelines in the treatment of rheumatoid arthritis (RA) include the early diagnosis and early use of disease modifying drugs to achieve remission or low disease activity level, known as "Treat to Target" (T2T). The objective of this study is to develop a composite indicator (CI) to evaluate the quality of care in the management of patients with RA, according to the T2T strategy and other general recommendations concerning the management of these patients. Material and method: The phases of the construction of the CI were: 1) selection of quality criteria through expert judgment; 2) prioritization of the criteria, according to relevance and feasibility, applying the Delphi methodology (two rounds) involving 20 experts; 3) design of quality indicators; and 4) calculation of the weighted CI, using the mean value in relevance and feasibility granted by the experts. The source of information for the calculation of the CI are the medical records of patients with RA. Results: Twelve criteria out of 37 required a second Delphi round. Thirty-one criteria were prioritized. These criteria presented a median in relevance and feasibility greater than or equal to 7.5, with an interquartile range of less than 3.5, and a level of agreement (score greater than or equal to 8) greater than or equal to 80%. Conclusions: The constructed CI allows us to evaluate the quality of care of patients with RA following the T2T strategy in the rheumatology units of Spanish hospitals, offering a valid and easily interpretable summary measure

Methotrexate in patients with rheumatoid arthritis in Spain: Subanalysis of the AR Excellence project. / Metotrexato en pacientes con artritis reumatoide en España: subanálisis del proyecto AR Excellence.

OBJECTIVE: The AR Excellence project evaluates clinical monitoring in patients with rheumatoid arthritis (RA) in Spain. The aim of the study was to analyze the use of methotrexate (MTX) in the AR Excellence cohort and to compare it with current recommendations. PATIENTS AND METHODS: We collected data from RA patients who initiated treatment with MTX. They included demographics, dose and routes of administration, switching among them, highest dose in each route, combinations with other disease-modifying antirheumatic drugs (DMARDs), time to combination with another DMARD (either conventional or biological) and adverse events. RESULTS: Six hundred twenty-five patients with RA (mean age 55 years; 70.6% women) were included, with an average disease duration of 21 months. Ninety percent of the patients initiated treatment with MTX. Therapy was begun with a mean dose of 11mg per week; this initial dose was increased in 58% of the individuals. The average time to reach the full dose of MTX (20mg a week) was 6,67 months. Time to combination of MTX with another DMARD, either synthetic or biological, was 3 months. In all, 67.4% of the patients received oral MTX and the route was subcutaneous in 18.6%. In 12% of the cases, there was a change in the route of administration after a period of 6 months. In 544 patients, folate supplements were added to MTX; MTX-related adverse events were detected in 17.3% of the patients. CONCLUSION: MTX is currently the pivotal treatment in RA. The subanalysis of the AR Excellence project demonstrates that MTX escalation to its full doses is not done with adequate speed. The subcutaneous route is used in a small proportion of patients.

A composite indicator to assess the quality of care in the management of patients with rheumatoid arthritis in outpatient rheumatology clinics. / Indicador compuesto para evaluar la calidad asistencial en el manejo de los pacientes con artritis reumatoide en las consultas externas de Reumatología.

OBJECTIVE: The current guidelines in the treatment of rheumatoid arthritis (RA) include the early diagnosis and early use of disease modifying drugs to achieve remission or low disease activity level, known as "Treat to Target" (T2T). The objective of this study is to develop a composite indicator (CI) to evaluate the quality of care in the management of patients with RA, according to the T2T strategy and other general recommendations concerning the management of these patients. MATERIAL AND METHOD: The phases of the construction of the CI were: 1) selection of quality criteria through expert judgment; 2) prioritization of the criteria, according to relevance and feasibility, applying the Delphi methodology (two rounds) involving 20 experts; 3) design of quality indicators; and 4) calculation of the weighted CI, using the mean value in relevance and feasibility granted by the experts. The source of information for the calculation of the CI are the medical records of patients with RA. RESULTS: Twelve criteria out of 37 required a second Delphi round. Thirty-one criteria were prioritized. These criteria presented a median in relevance and feasibility greater than or equal to 7.5, with an interquartile range of less than 3.5, and a level of agreement (score greater than or equal to 8) greater than or equal to 80%. CONCLUSIONS: The constructed CI allows us to evaluate the quality of care of patients with RA following the T2T strategy in the rheumatology units of Spanish hospitals, offering a valid and easily interpretable summary measure.

Barreras y facilitadores en la implantación de estándares de calidad en las unidades de hospital de día reumatológicas. Análisis cualitativo del proyecto VALORA / Barriers to and facilitators of implementing quality standards in Hospital Day Care Units in Rheumatology: Qualitative approach to the VALORA study

Objetivo: Identificar las barreras y los facilitadores en la implantación de estándares de calidad en las unidades de hospital de día (UHdD) reumatológicas. Material y métodos: Se analizaron las valoraciones sobre UHdD clasificadas en torno a estándares de estructura, procesos y resultados. La aproximación cualitativa se llevó a cabo mediante 13 grupos de discusión (GD) formados por profesionales de Reumatología (7), de Enfermería (4) y pacientes (2) de UHdD. La captación de informantes se realizó mediante muestreo intencionado atendiendo a variables que configuran las percepciones de las UHdD. El análisis de los datos se realizó siguiendo una perspectiva descriptiva-interpretativa. Resultados: La especialización de las UHdD monovalentes y la formación específica en Reumatología para Enfermería se perciben como los principales facilitadores para la implantación de estándares. Por el contrario, la demora en la disponibilidad de los fármacos en las UHdD se identifica como una barrera que prolonga la estancia de pacientes y desaprovecha recursos. Las diferencias en regulaciones locales se perciben como una posible barrera para el acceso equitativo a fármacos. El elemento mejor valorado por los pacientes fue la atención recibida, por encima de las variables estructurales o de proceso. Conclusiones: Los hallazgos de este estudio sugieren que las mejoras para la implantación de estándares de calidad en las UHdD pueden incluir 3 niveles de actuación: la propia UHdD, el centro hospitalario, y un tercero relacionado con regulaciones locales de acceso a fármacos

Objective: To identify barriers and facilitators in the implementation of quality standards in hospital day care units (HDCU) in rheumatology. Material and methods: We analyzed appraisals of HDCU in terms of standards for structure, processes and results. The qualitative approach was conducted through 13 discussion groups created by rheumatology health professionals (7), nursing professionals (4) and HDCU patients (2). The recruitment of informants was done through purposive sampling, attending to variables that form the perceptions of the HDCU. Data analysis was performed using a descriptive-interpretive method. Results: The specialization of the HDCU and specific training in rheumatology for nursing are perceived as the main facilitator for the implementation of standards. Conversely, the delay in the availability of medicines at the HDCU is identified as a barrier that prolongs patient stay and wastes resources. Differences in local regulations are perceived as a potential barrier to equitable access to medicines. The patients gave higher ratings to the care received than to structural variables or those related to process. Conclusions: The findings of this study suggest that improvements in the implementation of quality standards in HDCU may include three levels of action: the HDCU, the hospital and a third related to local regulations to access to medicines

Barriers to and facilitators of implementing quality standards in Hospital Day Care Units in Rheumatology: Qualitative approach to the VALORA study. / Barreras y facilitadores en la implantación de estándares de calidad en las unidades de hospital de día reumatológicas. Análisis cualitativo del proyecto VALORA.

OBJECTIVE: To identify barriers and facilitators in the implementation of quality standards in hospital day care units (HDCU) in rheumatology. MATERIAL AND METHODS: We analyzed appraisals of HDCU in terms of standards for structure, processes and results. The qualitative approach was conducted through 13 discussion groups created by rheumatology health professionals (7), nursing professionals (4) and HDCU patients (2). The recruitment of informants was done through purposive sampling, attending to variables that form the perceptions of the HDCU. Data analysis was performed using a descriptive-interpretive method. RESULTS: The specialization of the HDCU and specific training in rheumatology for nursing are perceived as the main facilitator for the implementation of standards. Conversely, the delay in the availability of medicines at the HDCU is identified as a barrier that prolongs patient stay and wastes resources. Differences in local regulations are perceived as a potential barrier to equitable access to medicines. The patients gave higher ratings to the care received than to structural variables or those related to process. CONCLUSIONS: The findings of this study suggest that improvements in the implementation of quality standards in HDCU may include three levels of action: the HDCU, the hospital and a third related to local regulations to access to medicines.

Documento de Recomendaciones de la Sociedad Española de Reumatología para el manejo clínico del paciente con artritis reumatoide que no puede utilizar metotrexato / Recommendations by the Spanish Society of Rheumatology for the management of patients diagnosed with rheumatoid arthritis who cannot be treated with methotrexate

El objetivo es establecer recomendaciones para el manejo del paciente con artritis reumatoide (AR) que no puede utilizar metotrexato (MTX) por contraindicación, toxicidad o falta de adherencia farmacológica, y establecer las estrategias terapéuticas más eficaces y seguras. Se realizó un análisis cualitativo de la evidencia científica disponible hasta junio de 2015. Se utilizó un Delphi con un panel de 17reumatólogos para consolidar la opinión de expertos en aquellas recomendaciones con ausencia o baja calidad científica. Se elaboraron 18recomendaciones, y 14 de ellas abordan aspectos de seguridad. Se han actualizado las recomendaciones sobre la contraindicación del MTX y su toxicidad, y se recomienda como una opción terapéutica preferente la utilización de monoterapia biológica en pacientes con contraindicación, intolerancia o circunstancias que desaconsejan el uso de MTX. Existe evidencia científica de buena calidad que contraindica y extrema la utilización de MTX en pacientes con AR con determinados perfiles clínicos (AU)

To establish a set of recommendations for the management of patients diagnosed with rheumatoid arthritis (RA) who cannot be treated with methotrexate (MTX) due to contraindications, drug toxicity or lack of adherence, and to establish therapeutic strategies more effective and safer in these RA patients. A qualitative analysis of the scientific evidence available to June 2015. The 2-round Delphi technique of consensus was used to collect and establish expert opinion based on the participants’ clinical experience when only low quality evidence was available. A total of eighteen recommendations were developed for the management of this patient profile. Fourteen of these recommendations were related to drug safety aspects. Recommendations on contraindication and toxicity of MTX have been updated. The experts recommend the use of biological monotherapy, a preferred treatment option, in patients whose profiles reveal a contraindication, intolerance or circumstances that prevent us against the use of MTX. There is some high-quality scientific evidence that supports contraindication and establishes certain conditions of MTX use in RA patients with specific clinical profiles (AU)

Asociación entre títulos de anticuerpos antinucleares y conectivopatías sistémicas en una Unidad de Reumatología / Association between antinuclear antibody titers and connective tissue diseases in a Rheumatology Department

Objetivo. Determinar los niveles en los títulos de anticuerpos antinucleares (ANA) observados por inmunofluorescencia indirecta en sustrato de célula HEp-2, y su asociación con el diagnóstico de enfermedad del tejido conectivo sistémica en las pruebas solicitadas por una Unidad de Reumatología. Método. Se seleccionaron muestras de pacientes que acudían por primera vez a consulta de reumatología, sin prueba de ANA previa, durante el periodo comprendido entre enero de 2010 y diciembre de 2012. Se registró el título de dilución, patrón y especificidad antigénica. En enero de 2015 se valoraron los diagnósticos de los pacientes y se clasificaron en conectivopatías sistémicas (lupus eritematoso sistémico, síndrome de Sjögren, esclerosis sistémica, conectivopatía indiferenciada, síndrome antifosfolípido, enfermedad mixta del tejido conectivo y miopatía inflamatoria) o no conectivopatía sistémica. Resultado. De un total de 1.282 pruebas solicitadas por la Unidad de Reumatología en sujetos sin estudio previo 293 resultaron positivas, predominando las mujeres (81,9%). Con conectivopatía sistémica se registraron 105 pacientes y 188 sin conectivopatía. En diluciones 1/640 el valor predictivo positivo en las conectivopatías fue de 73,3% frente al 26,6% de las no conectivopatías, y para valores ≥1/1.280, 85% frente al 15% respectivamente. Al realizar el análisis multivariante se observó una asociación positiva entre las diluciones 1/320 OR 3,069 (IC 95%: 1,237-7,614; p=0,016), 1/640 OR 12,570 (IC 95%: 3,659-43,187; p=0,000) y ≥1/1.280 OR 42,136 (IC 95%: 8,604-206,345; p=0,000). Conclusión. Estos resultados muestran asociación de títulos de dilución ≥1/320 para la primera prueba de ANA realizada en una Unidad de Reumatología con pacientes con conectivopatía sistémica. El VPP en estos pacientes resultó superior a estudios previos desarrollados por otras especialidades médicas. Esto puede indicar la importancia de una solicitud de la prueba de forma dirigida (AU)

Objective. To determine the dilution titles at antinuclear antibodies (ANA) by indirect immunofluorescence observed in cell substrate HEp-2 and its association with the diagnosis of systemic connective tissue disease in ANA test requested by a Rheumatology Unit. Method. Samples of patients attended for the first time in the rheumatology unit, without prior ANA test, between January 2010 and December 2012 were selected. The dilution titers, immunofluorescence patterns and antigen specificity were recorded. In January 2015 the diagnosis of the patients were evaluated and classified in systemic disease connective tissue (systemic lupus erythematosus, Sjögren's syndrome, systemic sclerosis, undifferentiated connective, antiphospholipid syndrome, mixed connective tissue and inflammatory myophaty) or not systemic disease connective tissue. Result. A total of 1282 ANA tests requested by the Rheumatology Unit in subjects without previous study, 293 were positive, predominance of women (81.9%). Patients with systemic connective tissue disease were recorded 105, and 188 without systemic connective tissue disease. For 1/640 dilutions the positive predictive value in the connective was 73.3% compared to 26.6% of non-connective, and for values ≥1/1,280 85% versus 15% respectively. When performing the multivariate analysis we observed a positive association between 1/320 dilution OR 3.069 (95% CI: 1.237-7.614; P=.016), 1/640 OR 12.570 (95% CI: 3.659-43.187; P=.000) and ≥1/1,280 OR 42.136 (95% CI: 8.604-206.345; P=.000). Conclusion. These results show association titles dilution ≥1/320 in ANA's first test requested by a Rheumatology Unit with patients with systemic connective tissue disease. The VPP in these patients was higher than previous studies requested by other medical specialties. This may indicate the importance of application of the test in a targeted way (AU)

Variabilidad en los hospitales de día de Reumatología en España: proyecto VALORA / Variability in Rheumatology day care hospitals in Spain: VALORA study

Objetivos. Describir la variabilidad de las unidades de hospitalización de día (UHdD) de Reumatología en España, en términos de recursos estructurales y procesos de funcionamiento. Material y métodos. Estudio descriptivo, multicéntrico, con evaluación de las UHdD mediante cuestionario autocumplimentado a partir de estándares de calidad de la Sociedad Española de Reumatología. Se analizaron recursos estructurales y procesos de las UHdD estratificados por complejidad del hospital (comarcal, general, mayor y complejo), y se determinó la variabilidad mediante el coeficiente de variación (CV) de la variable con relevancia clínica que presentara diferencias estadísticamente significativas al comparar por centros. Resultados. Un total de 89 centros (16 comunidades autónomas y Melilla) se incluyeron en el análisis. El 11,2% de los hospitales son comarcales; el 22,5%, generales; el 27%, mayores, y el 39,3%, complejos. El 92% de las UHdD son polivalentes. El número de tratamientos aplicados, la coordinación entre las UHdD y farmacia hospitalaria y la presencia de formación posgrado fueron las variables de proceso que presentaron diferencias estadísticamente significativas en función del nivel de complejidad del hospital. La tasa de tratamientos más alta se halló en hospitales complejos (2,97 por 1.000 habitantes), y la más baja, en hospitales generales (2,01 por 1.000 habitantes). El CV fue de 0,88 en hospitales mayores, de 0,86 en comarcales, de 0,76 en generales y de 0,72 en los complejos. Conclusiones. Existe una mayor variabilidad en el número de tratamientos de UHdD en los hospitales mayores, seguido de los comarcales. Sin embargo, la variabilidad en estructura y funcionamiento no parece deberse a diferencias de complejidad de los centros (AU)

Objective. To describe the variability of the day care hospital units (DCHUs) of Rheumatology in Spain, in terms of structural resources and operating processes. Material and methods. Multicenter descriptive study with data from a self-completed questionnaire of DCHUs self-assessment based on DCHUs quality standards of the Spanish Society of Rheumatology. Structural resources and operating processes were analyzed and stratified by hospital complexity (regional, general, major and complex). Variability was determined using the coefficient of variation (CV) of the variable with clinical relevance that presented statistically significant differences when was compared by centers. Results. A total of 89 hospitals (16 autonomous regions and Melilla) were included in the analysis. 11.2% of hospitals are regional, 22,5% general, 27%, major and 39,3% complex. A total of 92% of DCHUs were polyvalent. The number of treatments applied, the coordination between DCHUs and hospital pharmacy and the post graduate training process were the variables that showed statistically significant differences depending on the complexity of hospital. The highest rate of rheumatologic treatments was found in complex hospitals (2.97 per 1,000 population), and the lowest in general hospitals (2.01 per 1,000 population). The CV was 0.88 in major hospitals; 0.86 in regional; 0.76 in general, and 0.72 in the complex. Conclusions. there was variability in the number of treatments delivered in DCHUs, being greater in major hospitals and then in regional centers. Nonetheless, the variability in terms of structure and function does not seem due to differences in center complexity (AU)

Association between antinuclear antibody titers and connective tissue diseases in a Rheumatology Department. / Asociación entre títulos de anticuerpos antinucleares y conectivopatías sistémicas en una Unidad de Reumatología.

OBJECTIVE: To determine the dilution titles at antinuclear antibodies (ANA) by indirect immunofluorescence observed in cell substrate HEp-2 and its association with the diagnosis of systemic connective tissue disease in ANA test requested by a Rheumatology Unit. METHOD: Samples of patients attended for the first time in the rheumatology unit, without prior ANA test, between January 2010 and December 2012 were selected. The dilution titers, immunofluorescence patterns and antigen specificity were recorded. In January 2015 the diagnosis of the patients were evaluated and classified in systemic disease connective tissue (systemic lupus erythematosus, Sjögren's syndrome, systemic sclerosis, undifferentiated connective, antiphospholipid syndrome, mixed connective tissue and inflammatory myophaty) or not systemic disease connective tissue. RESULT: A total of 1282 ANA tests requested by the Rheumatology Unit in subjects without previous study, 293 were positive, predominance of women (81.9%). Patients with systemic connective tissue disease were recorded 105, and 188 without systemic connective tissue disease. For 1/640 dilutions the positive predictive value in the connective was 73.3% compared to 26.6% of non-connective, and for values ≥1/1,280 85% versus 15% respectively. When performing the multivariate analysis we observed a positive association between 1/320 dilution OR 3.069 (95% CI: 1.237-7.614; P=.016), 1/640 OR 12.570 (95% CI: 3.659-43.187; P=.000) and ≥1/1,280 OR 42.136 (95% CI: 8.604-206.345; P=.000). CONCLUSION: These results show association titles dilution ≥1/320 in ANA's first test requested by a Rheumatology Unit with patients with systemic connective tissue disease. The VPP in these patients was higher than previous studies requested by other medical specialties. This may indicate the importance of application of the test in a targeted way.

Variability in Rheumatology day care hospitals in Spain: VALORA study. / Variabilidad en los hospitales de día de Reumatología en España: proyecto VALORA.

OBJECTIVE: To describe the variability of the day care hospital units (DCHUs) of Rheumatology in Spain, in terms of structural resources and operating processes. MATERIAL AND METHODS: Multicenter descriptive study with data from a self-completed questionnaire of DCHUs self-assessment based on DCHUs quality standards of the Spanish Society of Rheumatology. Structural resources and operating processes were analyzed and stratified by hospital complexity (regional, general, major and complex). Variability was determined using the coefficient of variation (CV) of the variable with clinical relevance that presented statistically significant differences when was compared by centers. RESULTS: A total of 89 hospitals (16 autonomous regions and Melilla) were included in the analysis. 11.2% of hospitals are regional, 22,5% general, 27%, major and 39,3% complex. A total of 92% of DCHUs were polyvalent. The number of treatments applied, the coordination between DCHUs and hospital pharmacy and the post graduate training process were the variables that showed statistically significant differences depending on the complexity of hospital. The highest rate of rheumatologic treatments was found in complex hospitals (2.97 per 1,000 population), and the lowest in general hospitals (2.01 per 1,000 population). The CV was 0.88 in major hospitals; 0.86 in regional; 0.76 in general, and 0.72 in the complex. CONCLUSIONS: there was variability in the number of treatments delivered in DCHUs, being greater in major hospitals and then in regional centers. Nonetheless, the variability in terms of structure and function does not seem due to differences in center complexity.

Recommendations by the Spanish Society of Rheumatology for the management of patients diagnosed with rheumatoid arthritis who cannot be treated with methotrexate. / Documento de Recomendaciones de la Sociedad Española de Reumatología para el manejo clínico del paciente con artritis reumatoide que no puede utilizar metotrexato.

To establish a set of recommendations for the management of patients diagnosed with rheumatoid arthritis (RA) who cannot be treated with methotrexate (MTX) due to contraindications, drug toxicity or lack of adherence, and to establish therapeutic strategies more effective and safer in these RA patients. A qualitative analysis of the scientific evidence available to June 2015. The 2-round Delphi technique of consensus was used to collect and establish expert opinion based on the participants' clinical experience when only low quality evidence was available. A total of eighteen recommendations were developed for the management of this patient profile. Fourteen of these recommendations were related to drug safety aspects. Recommendations on contraindication and toxicity of MTX have been updated. The experts recommend the use of biological monotherapy, a preferred treatment option, in patients whose profiles reveal a contraindication, intolerance or circumstances that prevent us against the use of MTX. There is some high-quality scientific evidence that supports contraindication and establishes certain conditions of MTX use in RA patients with specific clinical profiles.

Supervivencia de pacientes con insuficiencia cardiaca en atención primaria / Survival of patients with heart failure in primary care

OBJETIVO: Describir la supervivencia de los pacientes con insuficiencia cardiaca (IC) con seguimiento en atención primaria (AP) y analizar el efecto del sexo, edad, factores clínicos, de utilización de servicios y nivel de renta, en la supervivencia. DISEÑO: Estudio observacional longitudinal de una cohorte retrospectiva de pacientes a partir de la historia clínica electrónica. Emplazamiento: Área 7 de AP de la Comunidad de Madrid. PARTICIPANTES: Pacientes mayores de 24 años con una consulta en AP en el año 2006. MEDICIONES PRINCIPALES: Casos incidentes de IC desde 2006 a 2010 o hasta su fallecimiento. Análisis de supervivencia de Kaplan-Meier y de regresión multivariante de riesgos proporcionales de Cox. RESULTADOS: Se identificaron 3.061 pacientes en una cohorte de 227.984. Su supervivencia fue del 65% a los 5 años. Fallecieron 519 pacientes con una supervivencia media de 49 meses. Los factores asociados a mayor riesgo de mortalidad fueron la edad (HR = 1,04; 1,03-1,05) y tener diagnóstico de cardiopatía isquémica (HR = 1,45; 1,15-1,78) o de diabetes (HR = 1,52; 1,17-1,95). Los factores con un efecto protector fueron ser mujer (HR = 0,72; 0,59-0,86), no pensionista (HR = 0,43; 0,23-0,84), haber recibido la vacunación de la gripe anualmente (HR = 0,01; 0,00-0,06), tener prescritos hipolipidemiantes (HR = 0,78; 0,61-0,99) o IECA (HR = 0,73; 0,60-0,88), así como que se le hubieran solicitado analíticas (HR = 0,98; 0,95-1), radiografías (HR = 0,81; 0,74-0,88) y electrocardiogramas (HR = 0,90; 0,81-0,99) en AP. CONCLUSIONES: Los datos de los pacientes con IC seguidos en AP indican que su supervivencia es mejor que la obtenida en otros países, apoyando el argumento de la mejor evolución de la IC en los países mediterráneos

OBJECTIVE: To describe survival of patients with chronic heart failure (HF) followed up in primary care (PC) and analyse the effect of sex, age, clinical and health services factors, and income levels on survival. DESIGN: Longitudinal observational study of a retrospective cohort of patients with information extracted from electronic medical records. SETTING: PC Area 7 of the Community of Madrid. PARTICIPANTS: Patients 24 year and older with at least one visit to PC in 2006. Principal measurement: Incident cases of HF followed up from 2006 to 2010 or until death. Survival analysis with Kaplan-Meier and Cox proportional hazard multivariate regression. RESULTS: A total of 3,061 cases were identified in a cohort of 227,984 PATIENTS: The survival rate was 65% at 5 years, with 519 patients dying with a median survival of 49 months. Factors associated with increased risk of mortality were, age (HR = 1.04, 1.03-1.05), and having a diagnosis of ischemic heart disease (HR = 1.45, 1.15- 1.78), or diabetes (HR = 1.52, 1.17-1.95). Factors with a significant protective effect were: female sex (HR = 0.72, 0.59-0.86), non-pensioner (HR = 0.43, 0.23-0.84), having received the influenza vaccine annually (HR = 0.01, 0.00-0.06), prescribed lipid-lowering drugs (HR = 0.78, 0.61-0.99) or ACE inhibitors (HR = 0.73, 0.60-0.88), and blood tests having been requested (HR = 0.97, 0.95-1.00), X-rays (HR = 0.81, 0.74-0.88), or electrocardiograms (HR = 0.90, 0.81-0.99) in PC. CONCLUSIONS: Data from patients with HF followed up in PC indicate that their survival is better than that obtained in other countries, supporting the argument of a better evolution of HF in Mediterranean countries

Variability in the prescription of non-biologic disease-modifying antirheumatic drugs for the treatment of spondyloarthritis in Spain.

OBJECTIVE: To describe the variability in the prescription of non-biologic disease-modifying antirheumatic drugs (nbDMARDs) for the treatment of spondyloarthritis (SpA) in Spain and to explore which factors relating to the disease, patient, physician, and/or center contribute to these variations. METHODS: A retrospective medical record review was performed using a probabilistic sample of 1168 patients with SpA from 45 centers distributed in 15/19 regions in Spain. The sociodemographic and clinical features and the use of drugs were recorded following a standardized protocol. Logistic regression, with nbDMARDs prescriptions as the dependent variable, was used for bivariable analysis. A multilevel logistic regression model was used to study variability. RESULTS: The probability of receiving an nbDMARD was higher in female patients [OR = 1.548; 95% confidence interval (CI): 1.208-1.984], in those with elevated C-reactive protein (OR = 1.039; 95% CI: 1.012-1.066) and erythrocyte sedimentation rate (OR = 1.012; 95% CI: 1.003-1.021), in those with a higher number of affected peripheral joints (OR = 12.921; 95% CI: 2.911-57.347), and in patients with extra-articular manifestations like dactylitis (OR = 2.997; 95% CI: 1.868-4.809), psoriasis (OR = 2.601; 95% CI: 1.870-3.617), and enthesitis (OR = 1.717; 95% CI: 1.224-2.410). There was a marked variability in the prescription of nbDMARDs for SpA patients, depending on the center (14.3%; variance 0.549; standard error 0.161; median odds ratio 2.366; p < 0.001). After adjusting for patient and center variables, this variability fell to 3.8%. CONCLUSION: A number of factors affecting variability in clinical practice, and which are independent of disease characteristics, are associated with the probability of SpA patients receiving nbDMARDs in Spain.

[Survival of patients with heart failure in primary care]. / Supervivencia de pacientes con insuficiencia cardiaca en atención primaria.

OBJECTIVE: To describe survival of patients with chronic heart failure (HF) followed up in primary care (PC) and analyse the effect of sex, age, clinical and health services factors, and income levels on survival. DESIGN: Longitudinal observational study of a retrospective cohort of patients with information extracted from electronic medical records. SETTING: PC Area 7 of the Community of Madrid. PARTICIPANTS: Patients 24 year and older with at least one visit to PC in 2006. PRINCIPAL MEASUREMENT: Incident cases of HF followed up from 2006 to 2010 or until death. Survival analysis with Kaplan-Meier and Cox proportional hazard multivariate regression. RESULTS: A total of 3,061 cases were identified in a cohort of 227,984 patients. The survival rate was 65% at 5 years, with 519 patients dying with a median survival of 49 months. Factors associated with increased risk of mortality were, age (HR=1.04, 1.03-1.05), and having a diagnosis of ischemic heart disease (HR=1.45, 1.15- 1.78), or diabetes (HR=1.52, 1.17-1.95). Factors with a significant protective effect were: female sex (HR=0.72, 0.59-0.86), non-pensioner (HR=0.43, 0.23-0.84), having received the influenza vaccine annually (HR=0.01, 0.00-0.06), prescribed lipid-lowering drugs (HR=0.78, 0.61-0.99) or ACE inhibitors (HR=0.73, 0.60-0.88), and blood tests having been requested (HR=0.97, 0.95-1.00), X-rays (HR=0.81, 0.74-0.88), or electrocardiograms (HR=0.90, 0.81-0.99) in PC. CONCLUSIONS: Data from patients with HF followed up in PC indicate that their survival is better than that obtained in other countries, supporting the argument of a better evolution of HF in Mediterranean countries.