Association of class II HLA alleles with susceptibility to develop immune-mediated diseases in Paraguayan patients.

Genetic and nongenetic factors are involved in the pathogenesis of immune-mediated inflammatory diseases (IMIDs). The best-known genetic factor for susceptibility to IMIDs is the human leukocyte antigen (HLA). The aim of the present study was to evaluate the association of HLA class II genes with the risk of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and systemic sclerosis (SSc) in the Paraguayan population. We included 254 patients with IMIDs (101 SLE, 103 RA, and 50 SSc) and 50 healthy controls. The haplotypes of five genes corresponding to HLA class II genes and their relationship to the IMIDs studied were determined. Note that 84.6% were women, with a mean age of 43.4 ± 14 years. Among the associated HLA alleles, we found the previously identified risk factors in other populations like HLA-DRB1*03:01 and HLA-DRB1*14:02 for RA, as well as new ones not previously identified, such as DPA1*02:01 for SLE and, DB1*02:01 for RA and SSc. In the genetic association analysis, already known associations have been replicated, and unpublished associations have been identified in Paraguayan patients with IMIDs. This is the first genetic association study in Paraguayan patients with IMIDs.

Association between vitamin D deficiency and disease activity in Paraguayan patients with systemic lupus erythematosus / Asociación entre la deficiencia de vitamina D y la actividad de la enfermedad en pacientes paraguayos con lupus eritematoso sistémico

ABSTRACT Objective: To identify the association between vitamin D (VD) concentrations and the activity of systemic lupus erythematosus (SLE) and determine a supplementation dose that allows patients to maintain adequate levels of VD. Methods: Longitudinal, observational study. Serum levels of 25-hydroxy-VD were measured in 100 Paraguayan SLE patients from the Hospital de Clínicas between 2016 and 2018. To analyze the response to different doses of VD supplementation, 50 patients received 1000IU/day and the other 50 patients received 2000IU. SLE disease activity measured by SELENA-SLEDAIwas scored before and after supplementation. Results: The mean age was 27.5 ±9.8 years, 88.9% of patients presented mild disease activ ity and 11.1% presented moderate to severe activity. The mean VD concentration was 30.8 ± 11.8 ng/mL. A total of 34% of patients presented VD insufficiency and 13% VD defi ciency. There was an inverse relationship between VD concentrations and SLE disease activity (p = 0.03). Increasing levels of serum VD are associated with supplementation of 2000 IU/day (p = 0.0224). Conclusion: SLE activity was associated with low levels of VD. In our cohort, SLE patients required a supplementation dose equal to or greater than 2000 IU/day to increase their serum VD.

R E S U M E N Objetivo: Identificar la asociación entre las concentraciones de vitamina D (VD) y la actividad del lupus eritematoso sistémico (LES), además de encontrar una dosis de suplementación que les permita a los pacientes mantener niveles adecuados de VD. Métodos: Estudio observacional longitudinal. Se midieron los niveles séricos de 25-hidroxi-VD en 100 pacientes paraguayos con LES, del Hospital de Clínicas, entre los años 2016 y 2018. Para analizar la respuesta a diferentes dosis de suplementación con VD, 50 pacientes recibieron 1.000 UI/día y los otros 50 pacientes recibieron 2.000 UI/día. La actividad de la enfermedad del LES medida por SELENA-SLEDAI se puntuó antes y después de la suplementación. Resultados: La media de edad fue de 27,5 ± 9,8 años, el 88,9% de los pacientes presentó actividad leve de la enfermedad y el 11,1% presentó actividad moderada a severa. La concentración media de VD fue de 30,8 ± 11,8 ng/ml. El 34% de los pacientes presentó insuficiencia de VD y el 13%, deficiencia de VD. Hubo una relación inversa entre las concentraciones de VD y la actividad de la enfermedad del LES (p = 0,03). Los niveles crecientes de VD en suero se asocian con una suplementación de 2.000 UI/día (p = 0,0224). Conclusión: La actividad del LES se asoció con niveles bajos de VD. En nuestra cohorte, los pacientes con LES requirieron una dosis de suplementación igual o superior a 2.000 UI/día para aumentar su VD sérica.

Relationship between serum lipopolysaccharide binding protein levels, disease activity, and clinical characteristics in Paraguayan patients with systemic lupus erythematosus.

INTRODUCTION: Systemic exposure to bacterial components like lipopolysaccharide (LPS) is among the non-genetic factors that could be involved in the onset or progression of systemic lupus erythematosus (SLE). Lipopolysaccharide-binding protein (LBP) participates in the recognition of LPS and in the inflammatory response. Here, we investigated LBP in SLE patients and its relationship with disease activity and SLE phenotypes. METHODS: Eighty-one adult patients with SLE from IMID-PY biobank (Paraguay) were included in the study. The clinical and laboratory variables were used to determine SLE activity. LBP levels were determined by ELISA in SLE patients and age- and sex-matched population-based controls. RESULTS: Patients with SLE have lower levels of circulating LBP compared to healthy controls (p = 0.0007). No significant correlation was found between serum LBP levels and disease activity. A significant difference was observed in LBP levels with regard to the presence of arthritis (p = 0.026). No other relation was found with clinical parameters. CONCLUSIONS: We found low levels of LBP in SLE patients compared to the control group. No correlation was detected between LBP levels and disease activity. It would be interesting for future studies to evaluate the impact of low levels of LBP on lupus immunopathogenesis.

A longitudinal multiethnic study of biomarkers in systemic lupus erythematosus: Launching the GLADEL 2.0 Study Group.

Introduction: After more than 20 years of sustained work, the Latin American Group for the Study of Lupus (GLADEL) has made a significant number of contributions to the field of lupus, not only in the differential role that race/ethnicity plays in its course and outcome but also in several other studies including the beneficial effects of using antimalarials in lupus patients and the development of consensus guidelines for the treatment of lupus in our region. Methods: A new generation of "Lupus Investigators" in more than 40 centers throughout Latin America has been constituted in order to continue the legacy of the investigators of the original cohort and to launch a novel study of serum and urinary biomarkers in patients with systemic lupus erythematosus. Results: So far, we have recruited 807 patients and 631 controls from 42 Latin-American centers including 339 patients with SLE without renal involvement, 202 patients with SLE with prevalent but inactive renal disease, 176 patients with prevalent and active renal disease and 90 patients with incident lupus nephritis. Conclusions: The different methodological aspects of the GLADEL 2.0 cohort are discussed in this manuscript, including the challenges and difficulties of conducting such an ambitious project.

Prevalencia de valores inadecuados de vitamina D y factores de riesgo asociados en jóvenes universitarios de Asunción / Prevalence of inadequate vitamin D values and associated risk factors in university students of the city of Asunción

La vitamina D es una hormona cumple una función en la regulación de numerosos genes que participan en la proliferación y maduración celular. El objetivo de este trabajo fue determinar la prevalencia de valores inadecuados de esta vitamina en jóvenes sanos de Asunción e identificar los posibles factores de riesgo asociados. Estudio observacional descriptivo basado en datos clínico-epidemiológicos y en la determinación de la 25-hidroxivitamina D (25-OH vitamina D) por el método de quimioluminiscencia (CMIA). Se consideró valor adecuado ≥30 ng/dl, inadecuado por debajo de este rango y deficiente ≤20 ng/dl. El análisis estadístico se realizó con el programa R-proyect. Para establecer factores de riesgo para tener deficiencia de vitamina D se utilizó regresión logística bi y multivariante. Se incluyeron 817 jóvenes universitarios de edad promedio 21 años. La concentración de vitamina D tuvo una media de 25 ± 8 ng/dl, oscilando entre 64,3 y 2,4 ng/dl. El 75,5% de los participantes tenían valores inadecuados de vitamina D. La deficiencia de vitamina D fue significativamente (p = 0,006) más frecuente en mujeres, personas con sobrepeso (p = 0,03), con falta de exposición al sol (p = 0,001) y con sedentarismo (p = 0,0001). Este estudio confirma la elevada prevalencia de valores inadecuados de vitamina D en nuestro país y permite definir un perfil de muy alto riesgo para las jóvenes sedentarias y con sobrepeso, lo que justifica una atención especial de parte de los médicos y las instituciones responsables de la salud pública en nuestro país(AU)

Vitamin D is a hormone that plays a role in the regulation of numerous genes involved in cell proliferation and maturation. The objective of this work was to determine the prevalence of inadequate values of this vitamin in healthy young people of the city of Asunción and to identify the possible risk factors associated with it. Descriptive observational study based on clinical-epidemiological data and in the determination of 25-hydroxyvitamin D (25-OH vitamin D) by the chemiluminescence method (CMIA). It was considered appropriate values ≥30 ng/dl, inappropriate below this range and deficient <20 ng/dl. Statistical analyzes were carried out with the R-project program. To establish the association, bivariate and multivariate logistic regression was used. We included 817 university students with an average age of 21 years. The average value of the vitamin D concentration was 25 ± 8 ng/dl, ranging from 64.3 to 2.4 ng/dl. Inadequate vitamin D values were found in 75.5% of the participants. Vitamin D deficiency was significantly (p <0.006) more frequent in women, overweight people (p <0.03), lack of sun exposure (p = 0.001) and sedentary lifestyle (p = 0.0001). This study confirms the high prevalence of inadequate vitamin D values in our country and allows us to define a very high risk profile for sedentary and overweight young women, which justifies special attention from physicians and institutions responsible for public health in our country(AU)

First Latin American clinical practice guidelines for the treatment of systemic lupus erythematosus: Latin American Group for the Study of Lupus (GLADEL, Grupo Latino Americano de Estudio del Lupus)-Pan-American League of Associations of Rheumatology (PANLAR).

Systemic lupus erythematosus (SLE), a complex and heterogeneous autoimmune disease, represents a significant challenge for both diagnosis and treatment. Patients with SLE in Latin America face special problems that should be considered when therapeutic guidelines are developed. The objective of the study is to develop clinical practice guidelines for Latin American patients with lupus. Two independent teams (rheumatologists with experience in lupus management and methodologists) had an initial meeting in Panama City, Panama, in April 2016. They selected a list of questions for the clinical problems most commonly seen in Latin American patients with SLE. These were addressed with the best available evidence and summarised in a standardised format following the Grading of Recommendations Assessment, Development and Evaluation approach. All preliminary findings were discussed in a second face-to-face meeting in Washington, DC, in November 2016. As a result, nine organ/system sections are presented with the main findings; an 'overarching' treatment approach was added. Special emphasis was made on regional implementation issues. Best pharmacologic options were examined for musculoskeletal, mucocutaneous, kidney, cardiac, pulmonary, neuropsychiatric, haematological manifestations and the antiphospholipid syndrome. The roles of main therapeutic options (ie, glucocorticoids, antimalarials, immunosuppressant agents, therapeutic plasma exchange, belimumab, rituximab, abatacept, low-dose aspirin and anticoagulants) were summarised in each section. In all cases, benefits and harms, certainty of the evidence, values and preferences, feasibility, acceptability and equity issues were considered to produce a recommendation with special focus on ethnic and socioeconomic aspects. Guidelines for Latin American patients with lupus have been developed and could be used in similar settings.

Educational website incorporating rheumatoid arthritis patient needs for Latin American and Caribbean countries.

Health education is fundamental in the management of RA patients. This study explored patient needs for educational material appropriate for RA patients in our region through a website. This study includes seven focus groups and semi-structured interviews across 4 countries (Argentina, Chile, Colombia, and Mexico) with 71 RA patients. Transcripts were analyzed by anthropologists using qualitative analysis (QA), resulting in themes and subthemes to be developed. Five themes and over 50 subthemes of interest were identified by patients. Grouped into categories as follows: (1) knowing the disease, (2) living with arthritis, (3) treatment and therapies for RA, (4) psychosocial support, and (5) information for families. A response was written by the team in plain Spanish on patient subthemes of interest including additional areas that the team considered relevant. Three videos for YouTube were produced: on patient-doctor relationships, patients at work, and home and at the clinic. Illustrations in a comic book format on RA diagnosis were created. The educational site on RA of PANLAR can be found at htpp://artritisreumatoide.cl. This project accomplished a comprehensive list of RA patient interests, revealing the complex relationship between the information on the disease, the experience of a chronic disease, and the way in which patients approach, conceive, and manage their disease. We expect to gather information on how the website will be used in the future for patients and their families and maintain and improve the website as well as adapt its content to different socioeconomic realities.

Eventos cardiovasculares en pacientes con lupus eritematoso sistémico y su asociación con factores de riesgo cardiovascular / Cardiovascular events in patients with systemic lupus erythematosus and their association with cardiovascular risk factors

Los pacientes con lupus eritematoso sistémico (LES) presentan un elevado riesgo cardiovascular, cuya etiología aún no se conoce con exactitud. Se ha postulado que podrían estar implicados tanto los factores de riesgo cardiovascular tradicionales como determinados factores relacionados a la propia enfermedad. En el presente estudio, se ha analizado a un grupo de pacientes con LES y se ha determinado la presencia de eventos cardiovasculares (EC), así como también a los factores de riesgo cardiovascular (FRCV) tradicionales y los relacionados a la enfermedad. Además, se ha estudiado la asociación de estos últimos con el desarrollo de un EC (i.e. infarto de miocardio agudo, hipertensión arterial, accidente cerebrovascular). En el total de 83 pacientes analizados, el EC más frecuente fue la hipertensión arterial (HTA) en un 41%. En relación a los FRCV tradicionales, el sedentarismo fue el hallado con más frecuencia, seguido por la obesidad. Al analizar cada EC y su asociación con los FRCV, se observó una asociación significativa entre la HTA y la dislipidemia (p = 0,001). En relación a los accidentes cerebrovasculares, se observó una asociación con la edad avanzada (p = 0,037) y la presencia de síndrome antifosfolípido (p = 0,001). La elevada frecuencia de EC en los pacientes con diagnóstico de LES pone de manifiesto la necesidad de una evaluación inicial detallada para estratificar tanto FRCV tradicionales como los no tradicionales de los pacientes con LES para permitir una mejor supervisión y así mejorar el pronóstico cardiovascular de estos pacientes

Patients with systemic lupus erythematosus (SLE) have a high cardiovascular risk, whose etiology is not yet known accurately. It has been postulated that both traditional cardiovascular risk factors and certain factors related to the disease itself could be involved. In this study, we analyzed a group of patients with SLE and determined the presence of cardiovascular events (CE), and cardiovascular risk factors (CVRF), both traditional ones and those inherent to the disease. Besides, the association of the risk factors with the development of a CE (i.e. acute myocardial infarction, arterial hypertension (AHT), cerebrovascular accident) was studied. In a total of 83 patients, the most frequent CE was AHT in 41% of the patients. In relation to traditional CVRF, sedentary lifestyle was the most frequent (72%) followed by obesity. When we analyzed each CE and their association with the CVRF, we found a significant association between AHT and dyslipidemia (p = 0.001). In relation to cerebrovascular accidents, we observed an association with advanced age (p = 0.037) and presence of antiphospholipid syndrome (p = 0.001). The high frequency of CE in patients with diagnosis of SLE showed the need of a detailed initial assessment to stratify both traditional and non-traditional CVRF of a patient with SLE to allow a better monitoring and thus improve cardiovascular prognosis of these patients.

PANLAR Consensus Recommendations for the Management in Osteoarthritis of Hand, Hip, and Knee.

OBJECTIVE: The objective of this consensus is to update the recommendations for the treatment of hand, hip, and knee osteoarthritis (OA) by agreeing on key propositions relating to the management of hand, hip, and knee OA, by identifying and critically appraising research evidence for the effectiveness of the treatments and by generating recommendations based on a combination of the available evidence and expert opinion of 18 countries of America. METHODS: Recommendations were developed by a group of 48 specialists of rheumatologists, members of other medical disciplines (orthopedics and physiatrists), and three patients, one for each location of OA. A systematic review of existing articles, meta-analyses, and guidelines for the management of hand, hip, and knee OA published between 2008 and January 2014 was undertaken. The scores for Level of Evidence and Grade of Recommendation were proposed and fully consented within the committee based on The American Heart Association Evidence-Based Scoring System. The level of agreement was established through a variation of Delphi technique. RESULTS: Both "strong" and "conditional" recommendations are given for management of hand, hip, and knee OA and nonpharmacological, pharmacological, and surgical modalities of treatment are presented according to the different levels of agreement. CONCLUSIONS: These recommendations are based on the consensus of clinical experts from a wide range of disciplines taking available evidence into account while balancing the benefits and risks of nonpharmacological, pharmacological, and surgical treatment modalities, and incorporating their preferences and values. Different backgrounds in terms of patient education or drug availability in different countries were not evaluated but will be important.

Manifestaciones clínicas y laboratoriales en el lupus eritematoso sistémico - LES / Clinical and laboratory manifstations in systemic Lupus erythematosus

El Lupus eritematoso sistémico (LES) es una enfermedad autoinmune compleja que se caracteriza por su capacidad de afectar a diversos órganos, lo que determina las diferentes manifestaciones clínicas objetivadas durante la evolución de la enfermedad. De forma asociada se ha descrito que estas manifestaciones presentan una variación geográfica o étnica, siendo por lo general menos grave en pacientes con ascendencia europea que en aquellos que presentan ascendencia africana, asiática o hispana. Alteraciones, tanto del sistema inmune adaptativo (células T y B) como del innato (Toll like receptorx-TLR), contribuyen al desarrollo del LES. Las células B tienen su papel en la producción de los autoanticuerpos (i.e. anticuerpos anti-ADN y anticuerpos anti-nucleosoma) y de determiandas citocinas. Las pruebas de laboratorio son de gran valor cuando se evalúa a un paciente con sospecha de enfermedad autoinmune. Los resultados pueden confirmar el diagnóstico, estimar la severidad de la enfermedad, evaluar el pronóstico y son de suma utilidad para el seguimiento de la actividad del LES.

Systemic Lupus Erythematosus (SLE) is a complex autoimmnune disease characterizedby its ability to affect different organs, which determines different clinical manifestationsobserved during the course of the disease. It has been described that thesemanifestations have geographic or ethnic varations being generally less serious in patientsof European descent than in those with African, Asian or Hispanic descents. Alterations ofboth the adaptative (T and B cells) and innate (Toll like receptorx-TLR) immnune systemscontribute to the development of SLE. B cells have a role in the production of autoantibodies(i.e. anti-DNA and anti-nucleosome antibodies) and some cytokines. Laboratorytests are invaluable when evaluating a patient with suspected autoimmune disease. Theresults can confirm the diagnosis, estimate the severity of the disease, assess prognosisand are extremely useful for monitoring the activity of SLE.

Osteoarthritis in Latin America: Study of Demographic and Clinical Characteristics in 3040 Patients.

BACKGROUND: Latin America is a heterogeneous region made up of different populations, cultures, latitudes, altitudes, and immigrants from different areas and ethnic groups. OBJECTIVE: The purpose of this study is to describe the clinical and demographic profile of patients with osteoarthritis (OA) evaluated by a selected group of rheumatologists in 13 Latin American countries. METHODS: A descriptive, observational, cross-sectional study was conducted in 13 Latin American countries of patients with symptomatic OA. Data were collected over a 3-month period using an ad hoc questionnaire to evaluate the clinical and demographic features of OA seen by rheumatologists. RESULTS: Among the 3040 patients, their average age was 62.5 years, and female-to-male ratio was 4.8:1. Patients with body mass index of greater than 30 kg/m or obesity was found in 38.2%. Approximately 88% had primary OA. Joints with OA were as follows: knee 31.2%, hand 9.5%, hand and knee 22.9%, proximal and distal interphalangeal joints (erosive OA) 6.5%, axial 6.6%, and hip 1.3%. Approximately 88.5% had radiographic severity of grade 2 or 3 on Kellgren-Lawrence scale (0-4). Nonsteroidal anti-inflammatory drugs were the predominant OA treatment included in combinations with glucosamine sulfate/chondroitin and viscosupplementation. Associated comorbidities included hypertension (39%), obesity (36.3%), diabetes mellitus (12%), and without comorbidity (12.7%). CONCLUSIONS: This is 1 of the largest population studies that evaluated the characteristics of OA in 3040 patients evaluated by rheumatologists in 13 Latin American countries. This study provides important data for each Latin American country to develop new health care planning in management of OA.

Morbimortalidad cardiopulmonar en pacientes con lupus eritematoso sistémico / Cardiopulmonary morbidity and mortality in patientswith systemic lupus erythematosus

Los pacientes con diagnóstico de lupus eritematoso sistémico (LES) presentan unaelevada morbi-mortalidad asociada a las manifestaciones cardiopulmonares que sedesarrollan durante la evolución de la enfermedad. En este sentido, se han descrito dospicos de incidencia de mortalidad de esta enfermedad inmunológica. El primer pico estárelacionado a la actividad de la enfermedad y se observa durante los tres primeros añosposteriores al diagnóstico. El segundo pico está relacionado principalmente a lascomplicaciones cardiopulmonares y se presenta entre los 4 y 20 años posteriores aldiagnóstico. Si bien la mortalidad temprana ha disminuido gracias a un mayorconocimiento de la fisiopatología de la enfermedad y al uso de terapiasinmunosupresoras, la mortalidad tardía presenta un aumento progresivo de sufrecuencia a pesar del avance en el manejo terapéutico. El estudio de estascomplicaciones se ha convertido en un tema de gran interés debido a su efecto negativoen el pronóstico de los pacientes que las presentan. Algunos estudios epidemiológicossugieren que los pacientes con LES tienen un mayor riesgo cardiovascular al sercomparados con la población sana. En este sentido, se ha descrito que estos presentanun mayor riesgo de desarrollar eventos cardiovasculares (infarto agudo del miocardio,accidente cerebro vascular y enfermedad arterial periférica) en comparación con lapoblación general. De forma asociada, se ha objetivado que la presencia demanifestaciones pleuro-pulmonares (pleuritis lúpica, neumonitis, hemorragia pulmonar,embolismo pulmonar e hipertensión pulmonar) aumenta la morbimortalidad de lospacientes con LES. El conocimiento adecuado de las complicaciones cardiopulmonaresen los pacientes con diagnóstico de lupus eritematoso sistémico permitirá realizar unmanejo individualizado y por lo tanto más eficaz, permitiendo disminuir la morbilidadasociada a las citadas complicaciones...

Patients with the diagnosis of systemic lupus erythematosus (SLE) have an elevatedmorbidity and mortality from cardiopulmonary complications that develop during theevolution of the disease. Considering the incidence of the mortality in this immunologic disease, two peaks have been described. The first one is related to the immune activityitself and it is observed in the first three years the diagnosis. The second peak is relatedto the cardiopulmonary complications and it is observed after 4 to 20 years afterdiagnosis. Although, early mortality has diminished due to better knowledge of thephysiopathology of the disease and to the use of immunosuppressive drugs, latemortality has a progressive increment despite advances in the therapeutic management.There is a great interest in the study of these complications due to the negative impacton the prognosis of the SLE patients. Some epidemiologic studies suggest that patientswith SLE have a higher cardiovascular risk than the healthy population. Indeed, theyhave greater risk of developing cardiovascular events (acute myocardial infarction,cerebrovascular accidents, and peripheral artery disease) in comparison to the generalpopulation. The presence of pulmonary complications (pleuritic effusion, pneumonitis,pulmonary hemorrhage, pulmonary embolism, pulmonary hypertension) increases themortality in SLE patients. The proper knowledge of the cardiopulmonary complicationsin SLE patients will provide an individual and more effective management allowing adecrease in morbidity and mortality...

La ultrasonografía en cadera dolorosa / Ultrasonography of the painful hip

En la consulta reumatológica el dolor de cadera es un síntoma frecuente, y la ultrasonografía (US) se impone cada vez más en la práctica clínica como un método auxiliar no invasivo, inocuo, sencillo y económico para su estudio. La US nos permite la evaluación de diversas condiciones reumatológicas de la articulación coxofemoral, como presencia y magnitud de sinovitis que acompañan a padecimientos inflamatorios y degenerativos, evalúa el contorno de la cabeza femoral, por lo que permite detectar fracturas insospechadas, osteofitos y erosiones, también las alteraciones cartilaginosas en las artropatías degenerativas y por microcristales, así como el rodete acetabular permite detectar fragmentos osteocartilaginosos intraarticulares que se ubican en las porciones declives de la articulación; además, existen bursas que en condiciones patológicas pueden ser identificadas. Por otro lado, el estudio dinámico nos ayuda en la coxa saltans o el chasquido de cadera y sus patologías subyacentes. Se ha empleado para realizar procedimientos guiados, como artrocentesis, infiltraciones o biopsias para diagnóstico y tratamiento. Asimismo, la US permite la evaluación adecuada de estructuras en esta zona en caso de cadera protésica o con material metálico en las que se producen artefactos cuando se usa tomografía computarizada (TAC) o resonancia magnética nuclear (RMN). En la presente revisión se describen patologías que producen síndrome de cadera dolorosa y que se pueden evaluar adecuadamente por US.

Painful hip is a common symptom in rheumatological practice. In recent years, ultrasonography (US) of the hip has gained wider acceptance as a convenient, accurate, unexpensive and non-invasive technique for the clinical evaluation of the painful hip. US is an appropriate method for the evaluation of a number of rheumatological conditions of the coxo-femoral joint, causing painful hip. It lets the trained rheumatologist evaluate the existence and extent of synovitis associated to inflammatory and degenerative conditions; it assesses the contour of the femoral head, detecting unsuspected fractures, osteofites and erosions. It also shows cartilage changes seen in degenerative and cristal-induced arthropathies; as well as evaluates the acetabular labrum. It detects intra-articular osteocartilaginous fragments found in lower portions of the joint. Additionally some bursae that are not normally identified, can be seen when inflammed. The exam also includes a dynamic part that is useful in the diagnosis of coxa saltans or snapping hip and associated pathologies. It is also helpful for guided procedures such as arthrocenthesis, infiltration or diagnostic biopsies. US avoids some of the technical limitations of CT or MRI in the evaluation of the prosthetic hip or with the presence of metallic material in a person. This review presents a revision of the most frequent etiologies causing painful hip and their study with US.

Pan-American League of Associations for Rheumatology (PANLAR) recommendations and guidelines for musculoskeletal ultrasound training in the Americas for rheumatologists.

OBJECTIVE: To develop guidelines for Musculoskeletal Ultrasound (MSKUS) training for rheumatologists in the Americas. METHODS: A total of 25 Rheumatologists from 19 countries of the American Continent participated in a consensus-based interactive process (Delphi method) using 2 consecutive electronic questionnaires. The first questionnaire included the following: the relevance of organizing courses to teach MSKUS to Rheumatologists, the determination of the most effective educational course models, the trainee levels, the educational objectives, the requirements for passing the course(s), the course venues, the number of course participants per instructor, and the percentage of time spent in hands-on sessions. The second questionnaire consisted of questions that did not achieve consensus (>65%) in the first questionnaire, topics, and pathologies to be covered at each course MSKUS level. RESULTS: General consensus was obtained for MSKUS courses to be divided into 3 educational levels: basic, intermediate, and advanced. These courses should be taught using a theoretical-didactic and hands-on model. In addition, the group established the minimum requirements for attending and passing each MSKUS course level, the ideal number of course participants per instructor (4 participants/instructor), and the specific topics and musculoskeletal pathologies to be covered. In the same manner, the group concluded that 60% to 70% of course time should be focused on hands-on sessions. CONCLUSION: A multinational group of MSKUS sonographers using a consensus-based questionnaire (Delphi method) established the first recommendations and guidelines for MSKUS course training in the Americas. Pan-American League of Associations for Rheumatology urges that these guidelines and recommendations be adopted in the future by both national and regional institutions in the American continent involved in the training of Rheumatologists for the performance of MSKUS.