A Hybrid Online Off-Policy Reinforcement Learning Agent Framework Supported by Transformers.

Reinforcement learning (RL) is a powerful technique that allows agents to learn optimal decision-making policies through interactions with an environment. However, traditional RL algorithms suffer from several limitations such as the need for large amounts of data and long-term credit assignment, i.e. the problem of determining which actions actually produce a certain reward. Recently, Transformers have shown their capacity to address these constraints in this area of learning in an offline setting. This paper proposes a framework that uses Transformers to enhance the training of online off-policy RL agents and address the challenges described above through self-attention. The proposal introduces a hybrid agent with a mixed policy that combines an online off-policy agent with an offline Transformer agent using the Decision Transformer architecture. By sequentially exchanging the experience replay buffer between the agents, the agent's learning training efficiency is improved in the first iterations and so is the training of Transformer-based RL agents in situations with limited data availability or unknown environments.

Modeling Dynamical Positional Physical Data on Field Zones Occupied by Playing Positions in Elite-Level Futsal: A Comparison Between Running Velocities, Accelerations, and Decelerations.

ABSTRACT: Serrano, C, Felipe, JL, García-Unanue, J, Vicente Gimenez, J, Jiménez-Linares, L, Ibáñez, E, Hernando, E, Gallardo, L, and Sánchez-Sánchez, J. Modeling dynamical positional physical data on field zones occupied by playing positions in elite-level futsal: a comparison between running velocities, acceleration, and deceleration. J Strength Cond Res 37(1): 200-206, 2023-The aim of this study was to analyze the influence of playing positions on the physical demands and the specific court zones occupied during official futsal games. The total number of observations were 188, corresponding to 8 matches from the first division of the Spanish Futsal League during the 2019-2020 season. All dynamic motion representations were recorded using an 18 Hz device with ultra-wideband technology and local positioning system installed on the futsal pitch for each position. Python Data Analysis Library, Matplotlib, and Python programming language were applied as computational tools to generate visual analysis of figures to represent every physical demand analyzed. An analysis of variance test showed differences between playing positions, specifically, for winger position (p < 0.05). Based on eta-square coefficients, all variables showed large effects, except acceleration distance zone 1 (1-2 m·s-2). Accordingly, the visual representation of positional dynamic motion data showed differences in the physical demands and the court zone occupied by the different playing positions. This innovative visual analysis allows fitness coaches to associate the physical demands with court zones occupied by different playing positions, and it aids in the design of training drills associated with futsal competition requirements.

Vaginal Electrical Impedance Detects the Fertile Window in Healthy Women: a Pilot Study / La Impedancia Eléctrica Vaginal Detecta la Ventana Fértil en Mujeres Sanas: un Estudio Piloto

ABSTRACT This work analyzes the electrical impedance (EI) measurement of cervical mucus (CM) using a device to determine the fertile window. In this prospective and longitudinal study, fourteen healthy women aged 18 to 44 were enrolled to evaluate three menstrual cycles. EI was measured through a medical device inserted into the vagina for two minutes daily. Patients were monitored by urine luteinizing hormone (LH) strip, blood collection, and vaginal ultrasound to visualize the dominant follicle. Finally, the predictive EI capacity was validated by the receiver operating characteristic (ROC) of anovulatory vs. ovulatory impedances. The peak of LH was 35.7 (±4.5) mUI/ml and the dominant follicle size was 15.45 mm (±0.559). There were statistical differences in EI measurements between the follicular and luteal phases vs. the ovulation phase (p<0.0361 and p<0.0160). After data normalization, an area under the ROC curve (AUC) of 0.713 (P value= 0.0253), a Youden J index of 0.4545Ω, a sensitivity of 63.6%, and a specificity of 81.8% were found. Low EI in the ovulatory period belongs to the LH ovulatory peak and follicular release. EI can be used for ovulation monitoring, birth control, or promoting pregnancy as a safe and innocuous method.

RESUMEN Este trabajo analiza la medición de la impedancia eléctrica (IE) del moco cervical (MC) mediante un dispositivo para determinar la ventana fértil. En este estudio prospectivo y longitudinal, se incluyeron 14 mujeres sanas de 18 a 44 años para evaluar tres ciclos menstruales. La IE se midió a través de un dispositivo médico colocado en la vagina durante dos minutos diarios. Las pacientes fueron monitoreadas con una tira de hormona luteinizante (LH) en orina, recolección de sangre y ultrasonido vaginal para visualizar el folículo dominante. Finalmente, la capacidad predictiva de IE fue validada por la curva ROC (receiver operating characteristic) de impedancias anovulatorias vs. ovulatorias. El pico de LH fue de 35.7(±4.5) mUI/ml; el folículo de tamaño dominante fue de 15.45 mm (±0.559). Se encontraron diferencias estadísticas para la medición de la IE de las fases folicular y lútea versus la fase de ovulación (p<0.0361 y p<0.0160). Después de la normalización de los datos, se encontró un área bajo la curva ROC (AUC) de 0.713 (valor de P = 0.0253), un índice de Youden J de 0.4545 Ω, sensibilidad del 63.6 % y especificidad del 81.8 %. La IE baja en el período ovulatorio que pertenece al pico ovulatorio de LH y liberación folicular. La IE se puede utilizar para el control de la ovulación, el control de la natalidad o la promoción del embarazo como método seguro e inocuo.

Real-World Effectiveness and Treatment Retention of Secukinumab in Patients with Psoriatic Arthritis and Axial Spondyloarthritis: A Descriptive Observational Analysis of the Spanish BIOBADASER Registry.

Rheumatic diseases are extensively managed with biological disease-modifying antirheumatic drugs (bDMARDs), but a notable proportion of patients withdraw in the long term because of lack of effectiveness, adverse events, or the patient's decision. The present real-world analysis showed the effectiveness, retention, and safety data collected in the Spanish BIOBADASER registry for patients with psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA, including ankylosing spondylitis (AS) and non-radiographic axSpA) treated with secukinumab, a human antibody against interleukin-17A (IL-17A), for more than 12 months. Six hundred and thirty-nine patients were analysed (350, 262, and 27 PsA, AS, and nr-axSpA patients, respectively). The results showed an improvement in the disease activity after 1 year of treatment, in terms of decreases of the mean Disease Activity Score 28 using C-reactive protein (DAS28-CRP), the mean Disease Activity Psoriatic Arthritis (DAPSA) score, swollen joint counts (SJC), and tender joint counts (TJC) in PsA patients and decreases in the mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the mean Ankylosing Spondylitis Disease Activity Score (ASDAS) in axSpA patients. This improvement was maintained or increased after 2 and 3 years of treatment, indicating that secukinumab is effective in both naïve and non-responder patients. Retention rates were higher when secukinumab was used as the first-line biological treatment, although they were also adequate in the second and third lines of treatment. Collected safety data were consistent with previous reports.

Evaluación de la profilaxis quirúrgica en hernioplastia electiva ambulatoria no complicada

Las guías de profilaxis antibiótica alrededor del mundo señalan que la selección del antibiótico debe basarse en los microorganismos según el tipo y sitio de operación. Objetivo: Determinar la aplicación de las recomendaciones de las guías nacionales de profilaxis antibiótica perioperatoria y comparar con el protocolo de uso en cirugías electivas tipo hernias en el Departamento de Cirugía General en el "Hospital Militar Universitario Dr. Carlos Arvelo" en el período marzo 2019 - marzo 2020. Metodología: Tipo de investigación no experimental longitudinal bajo el modelo de estudio documental con enfoque descriptivo y cuantitativo. Resultados: Muestra de 73 pacientes, de los cuales un 64,98 % no tuvo una selección del antibiótico recomendado, el tiempo de colocación del antibiótico no estuvo adherido en 69,89 %, el intervalo de dosis no fue adherido con un 84,93 % y la vía de administración fue la correcta con 100 %. Se evidenciaron infección de sitio quirúrgico en 11 pacientes en su mayoría no adheridos a la guía de la SVI. Conclusión: La evaluación del consenso de la SVI fue baja. La profilaxis antibiótica se ha convertido en una herramienta esencial para la disminución de infecciones del sitio quirúrgico, el conocimiento de consenso y uso correcto de la norma es de suma importancia.

Antibiotic prophylaxis guidelines around the world indicate that antibiotic selection should be based on microorganisms according to the type and site of operation. Objective: To determine the application of the recommendations of the national guidelines for perioperative antibiotic prophylaxis and to compare with the protocol for use in elective hernia-type surgeries in the Department of General Surgery at the "Hospital Military Universitario Dr. Carlos Arvelo" in the period March 2019 - March 2020. Methodology: Type of longitudinal non-experimental research under the documentary study model with a descriptive and quantitative approach. Results: Sample of 73 patients, of which 64.98 % did not have a recommended antibiotic selection, the antibiotic placement time was not adhered in 69.89 %, the dose interval was not adhered with 84.93 % and the route of administration was correct with 100 %. Surgical site infection was evidenced in 11 patients, most of who did not adhere to the IVS guideline. Conclusion: The consensus assessment of the SVI was low. Antibiotic prophylaxis has become an essential tool for reducing surgical site infections, knowledge of consensus and correct use of the standard is of utmost importance

Characterisation of Goal Scoring Patterns during Open Play Related to Zone Pitch Division and Number of Players Involved in the 2018 FIFA World Cup.

The aim of this study was to characterise all the goal scoring patterns during open play (elaborate attacks versus counterattacks) related to zone pitch division and the number of players involved in the 2018 FIFA World Cup in Russia. An Iterative Dichotomiser 3 (ID3) decision tree algorithm was used to classify all the goal scoring patterns (94 goals in 64 matches). The results did not show statistical differences between the type of scoring goal during the 2018 FIFA World Cup (p > 0.05; ES = Moderate). According to the result of the patterns of how the goals were achieved, an ID3 algorithm decision tree with seven classification decision nodes was calculated. Consequently, this study may aid national team coaches for the next World Cup to establish notational analyses and spatial-temporal relations to understand how scoring patterns during open play are related to zone pitch division and the number of players involved.

Magnetic resonance imaging assessment in patients with axial spondyloarthritis: development of checklists for use in clinical practice.

The objective of our study was to standardize magnetic resonance imaging (MRI) assessment of spine and sacroiliac joints in patients with axial spondyloarthritis (axSpA) and/or inflammatory spinal pain, by creating checklists and templates based on the opinions of rheumatologists and radiologists. A scientific committee developed a series of questionnaires with multiple items regarding MRI in patients with axial inflammatory pain and/or axSpA. Then an expert panel of rheumatologists and radiologists rated all items in a 9-point Likert scale. Finally, the scientific committee and the expert panel met to create the definitive documents. Several definitive checklists and templates were generated for rheumatologist-requested MRI and for radiologist-requested MRI reports of sacroiliac joint and spinal examinations. A technical requirement protocol was also agreed on. Our results could be useful in increasing understanding between rheumatologists and radiologists regarding MRI in axSpA diagnosis and follow-up.

Use of the ptxD gene as a portable selectable marker for chloroplast transformation in Chlamydomonas reinhardtii.

Synthetic biology and genetic engineering in algae offer an unprecedented opportunity to develop species with traits that can help solve the problems associated with food and energy supply in the 21st century. In the green alga Chlamydomonas reinhardtii, foreign genes can be expressed from the chloroplast genome for molecular farming and metabolic engineering to obtain commodities and high-value molecules. To introduce these genes, selectable markers, which rely mostly on the use of antibiotics, are needed. This has risen social concern associated with the potential risk of horizontal gene transfer across life kingdoms, which has led to a quest for antibiotic-free selectable markers. Phosphorus (P) is a scarce nutrient element that most organisms can only assimilate in its most oxidized form as phosphate (Pi); however, some organisms are able to oxidize phosphite (Phi) to Pi prior to incorporation into the central metabolism of P. As an alternative to the use of the two positive selectable makers already available for chloroplast transformation in C. reinhardtii, the aadA and the aphA-6 genes, that require the use of antibiotics, we investigated if a phosphite-based selection method could be used for the direct recovery of chloroplast transformed lines in this alga. Here we show that following bombardment with a vector carrying the ptxD gene from Pseudomonas stutzeri WM88, only cells that integrate and express the gene proliferate and form colonies using Phi as the sole P source. Our results demonstrate that a selectable marker based on the assimilation of Phi can be used for chloroplasts transformation in a biotechnologically relevant organism. The portable selectable marker we have developed is, in more than 18 years, the latest addition to the markers available for selection of chloroplast transformed cells in C. reinhardtii. The ptxD gene will contribute to the repertoire of tools available for synthetic biology and genetic engineering in the chloroplast of C. reinhardtii.

Anti-IL6-Receptor Tocilizumab in Refractory and Noninfectious Uveitic Cystoid Macular Edema: Multicenter Study of 25 Patients.

PURPOSE: Cystoid macular edema (CME) is a leading cause of blindness. This study assessed the efficacy and safety of tocilizumab (TCZ) in refractory CME. DESIGN: Retrospective case series. METHODS: Patients with CME secondary to noninfectious uveitis who had inadequate response to corticosteroids and at least 1 conventional immunosuppressive drug, and in most cases to other biological agents, were studied. CME was defined as central retinal thickness greater than 300 µm. The primary outcome measure was macular thickness. Intraocular inflammation, best-corrected visual acuity (BCVA), and corticosteroid-sparing effect were also analyzed. RESULTS: A total of 25 patients (mean ± standard deviation age 33.6 ± 18.9 years; 17 women) with CME were assessed. Underlying diseases associated with uveitis-related CME are juvenile idiopathic arthritis (n = 9), Behçet disease (n = 7), birdshot retinochoroidopathy (n = 4), idiopathic (n = 4), and sarcoidosis (n = 1). The ocular patterns were panuveitis (n = 9), anterior uveitis (n = 7), posterior uveitis (n = 5), and intermediate uveitis (n = 4). Most patients had CME in both eyes (n = 24). TCZ was used in monotherapy (n = 11) or combined with conventional immunosuppressive drugs. Regardless of the underlying disease, compared to baseline, a statistically significant improvement in macular thickness (415.7 ± 177.2 vs 259.1 ± 499.5 µm; P = .00009) and BCVA (0.39 ± 0.31 vs 0.54 ± 0.33; P = .0002) was obtained, allowing us to reduce the daily dose of prednisone (15.9 ± 13.6 mg/day vs 3.1 ± 2.3 mg/day; P = .002) after 12 months of therapy. Remission was achieved in 14 patients. Only minor side effects were observed after a mean follow-up of 12.7 ± 8.34 months. CONCLUSION: Macular thickness is reduced following administration of TCZ in refractory uveitis-related CME.

Biomass and lipid production from Chlorella vulgaris UTEX 26 cultivated in 2 m3 raceway ponds under semicontinuous mode during the spring season.

A Chlorella vulgaris UTEX 26 semicontinuous culture was implemented in 2000 L raceways with M medium during spring season at greenhouse conditions. Areal biomass productivities between 20 and 26 g m-2 d-1 were reached on the third day. The maximal areal lipid productivity obtained was 6.1 g m-2 d-1 and an increment in the saturated fatty acids (SFA) proportion (C14-C18) was favored in comparison with the fatty acids obtained with M medium in photobioreactors of 1 L and photoperiod light:darkness 12:12 h. After the eighth day of the culture or biomass concentrations above 0.25 g L-1, the microalgal cultures were prone to contamination by ciliates and amoebae, due to the sugars excreted by C. vulgaris UTEX 26. The periodical addition of NH4HCO3 to the microalgal culture maintained the ammonium concentration between 25 and 50 mg L-1, which contributed to diminish the contamination risks by protozoa.

Desarrollo de un cuadro de actuación para la evaluación de pacientes con espondiloartritis axial y artritis psoriásica en la práctica diaria: proyecto ONLY TOOLS / Development of a checklist for patients with axial spondyloarthritis and psoriatic arthritis in daily practice: ONLY TOOLS project

Objetivo. Estandarizar la evaluación clínica de pacientes con espondiloartritis (EspA) axial y artritis psoriásica (APs). Métodos. Estudio cualitativo que incluyó: 1) grupo nominal (18 expertos); 2) revisión de la literatura sobre variables empleadas en la evaluación de los pacientes con EspA axial o APs, y 3) grupo focal con reumatólogos y otro con pacientes con EspA axial o APs para analizar la evaluación de las EspA en las consultas de reumatología. Los expertos seleccionaron las variables a incluir en el cuadro de actuación con base en su relevancia, factibilidad en consulta y método/s de medición. Resultados. El cuadro de actuación incluye las variables para valorar antecedentes personales, exploración física, actividad y función, pruebas complementarias y tratamientos. Detalla factores de riesgo de progresión radiográfica, factores predictores de respuesta a terapia biológica, e incluye variables de excelencia. Conclusiones. Este cuadro de actuación para pacientes con EspA axial y APs podrá ayudar a homogeneizar la práctica clínica diaria y a mejorar el manejo y el pronóstico de estos pacientes

Objective. To standardize clinical evaluation of patients with axial spondyloarthritis (SpA) and psoriatic arthritis (PsA) using a checklist. Methods. Qualitative study that included: 1) nominal group (18 experts); 2) literature reviews of measures used in the assessment of patients with axial SpA or PsA; and 3) focus groups, one with rheumatologists and another with patients, organized to become familiar with their opinion on medical assistance. Taking this into account, the experts selected the measures to be included in the checklist based on their relevance, feasibility, and the outcome type. Results. The checklist includes measures for the evaluation of personal history, physical examination, activity and function, laboratory tests, imaging studies and treatments. It also defines risk factors of radiographic progression, predictors of the response to biological therapies, and comprises measures of excellence. Conclusions. This checklist for patients with axial SpA and PsA could help standardize daily clinical practice and improve clinical management and patient prognosis

The EJES-3D tool for personalized prescription of exercise in axial spondyloarthritis through multimedia animations: pilot study.

To develop and evaluate a web application based on multimedia animations, combined with a training program, to improve the prescription of exercises in spondyloarthritis (SpA). After a review of exercises included in the main clinical trials and recommendations of international societies, a multidisciplinary team-rehabilitators, rheumatologists, physiotherapists, computer scientists and graphic designers-developed a web application for the prescription of exercises (EJES-3D). Once completed, this was presented to 12 pairs of rehabilitators-rheumatologists from the same hospital in a workshop. Knowledge about exercise was tested in rheumatologists before and 6 months after the workshop, when they also evaluated the application. The EJES-3D application includes 38 multimedia videos and allows prescribing predesigned programs or customizing them. A patient can consult the prescribed exercises at any time from a device with internet connection (mobile, tablet, or computer). The vast majority of the evaluators (89%) were satisfied or very satisfied and considered that their expectations regarding the usefulness of the web application had been met. They highlighted the ability to tailor exercises adapted to the different stages of the disease and the quality and variety of the videos. They also indicated some limitations of the application and operational problems. The EJES-3D tool was positively evaluated by experts in SpA, potentially the most demanding group of users with the most critical capacity. This allows a preliminary validation of the contents, usefulness, and ease of use. Analyzing and correcting the errors and limitations detected is allowing us to improve the EJES-3D tool.

Should over-treatment of axial spondyloarthritis with biologics remain a concern after the issue of the new ASAS criteria? Data from REGISPONSERBIO (Spanish Register of Biological Therapy in Spondyloarthritides).

OBJECTIVES: To study whether disease status at treatment initiation has changed after the issue of the ASAS classification criteria. METHODS: REGISPONSERBIO registers patients with axial spondyloarthritis (axSpA) on biological treatment since 2013. It includes patients starting biological treatment (incident) or already on biological therapies (prevalent). Patients in both groups were compared in terms of: age at disease onset and at treatment start, disease duration, gender, HLA-B27, body mass index (BMI), BASDAI, BASFI, C-reactive protein, ESR, metrological data, ASQoL, WAPAI, extra-articular manifestations, comorbidities, radiological study, type of biological treatment and concomitant treatments. RESULTS: 256 patients were included, of whom 174 (65%) were already on biologic therapy. Compared to incident patients, prevalent patients started treatment with longer disease duration (15 vs. 8.6 years; p<0.001), a higher proportion of them were men (83% vs. 67%; p=0.01), a smaller proportion of them showed non-radiographic axial spondylarthritis (nr-axSpA)(17% vs. 32%; p<0.01), and a higher proportion had HLAB27 (85% vs. 73%; p=0.02). There were no statistically significant differences in terms of disease activity, degree of disability, quality of life, or prevalence of extra-articular manifestations. CONCLUSIONS: Data suggest that, after the issue of the new classification criteria for SpA, biological therapy is being administered earlier than previously in SpA patients and in a higher proportion of patients with nr-axSpA. However, this change in prescribing profile, apparently, has not caused an over-treatment, as patients do not seem to have a lower disease burden than prior to the issue of the criteria.

Prevalence and characteristics associated with dactylitis in patients with early spondyloarthritis: results from the ESPeranza cohort.

OBJECTIVES: Dactylitis is a typical feature of psoriatic arthritis. However, dactylitis was included as a spondyloarthritis (SpA) feature for both (axial and peripheral) of the ASAS classification criteria, but data about its prevalence are scarce, especially in patients with a recent onset of the disease. Our objective was to determine the prevalence and characteristics associated with dactylitis in patients with early SpA. METHODS: A baseline dataset from the ESPeranza cohort was used. This programme included patients who were suspected of having SpA (age <45 years, symptoms duration of 3-24 months and with inflammatory back pain, or asymmetrical arthritis, or spinal/joint pain plus ≥1 of the SpA features). For this study, 609 patients who were diagnosed with SpA by their physician were included. Descriptive, univariable and multivariable logistic regression analyses were employed to investigate the association between the presence of dactylitis and the characteristics associated with SpA. RESULTS: Fifty-eight (9.5%) patients currently or previously had dactylitis. In the multivariable analysis, dactylitis was independently associated with peripheral arthritis (OR= 4.83; p<0.001), enthesitis (OR= 2.49; p=0.01), psoriasis (OR= 3.62; p<0.01) and the physician's visual analogue scale (OR= 0.82; p=0.01). However, 67% of the patients who had dactylitis did not have peripheral arthritis or psoriasis and 15% had predominantly axial disease. CONCLUSIONS: Dactylitis is a frequent manifestation in patients with SpA, even during the early stages of the disease. Its presence is mainly associated with peripheral manifestations and psoriasis. Nevertheless, dactylitis is not exclusive of patients with PsA or peripheral manifestations.

Development of a checklist for patients with axial spondyloarthritis and psoriatic arthritis in daily practice: ONLY TOOLS project. / Desarrollo de un cuadro de actuación para la evaluación de pacientes con espondiloartritis axial y artritis psoriásica en la práctica diaria: proyecto ONLY TOOLS.

OBJECTIVE: To standardize clinical evaluation of patients with axial spondyloarthritis (SpA) and psoriatic arthritis (PsA) using a checklist. METHODS: Qualitative study that included: 1) nominal group (18 experts); 2) literature reviews of measures used in the assessment of patients with axial SpA or PsA; and 3) focus groups, one with rheumatologists and another with patients, organized to become familiar with their opinion on medical assistance. Taking this into account, the experts selected the measures to be included in the checklist based on their relevance, feasibility, and the outcome type. RESULTS: The checklist includes measures for the evaluation of personal history, physical examination, activity and function, laboratory tests, imaging studies and treatments. It also defines risk factors of radiographic progression, predictors of the response to biological therapies, and comprises measures of excellence. CONCLUSIONS: This checklist for patients with axial SpA and PsA could help standardize daily clinical practice and improve clinical management and patient prognosis.

Impacto de las enfermedades autoinmunitarias en el tratamiento y el pronóstico del síndrome coronario agudo / Impact of autoimmune disease on the management and prognosis of acute coronary syndrome

No disponible

Assessment of Chlorella vulgaris and indigenous microalgae biomass with treated wastewater as growth culture medium.

The aim of the present work was to evaluate the feasibility of microalgae cultivation using secondary treated domestic wastewater. Two Chlorella vulgaris strains (CICESE and UTEX) and an indigenous consortium, were cultivated on treated wastewater enriched with and without the fertilizer Bayfolan®. Biomass production for C. vulgaris UTEX, CICESE and the indigenous consortium grown in treated wastewater was 1.167±0.057, 1.575±0.434 and 1.125±0.250g/L, with a total lipid content of 25.70±1.24, 23.35±3.01and 20.54±1.23% dw, respectively. The fatty acids profiles were mainly composed of C16 and C18. Regardless of the media used, in all three strains unsaturated fatty acids were the main FAME (fatty acids methyl esters) accumulated in a range of 45-62%. An enrichment of treated wastewater with Bayfolan® significantly increased the production of biomass along with an increase in pigments and proteins of ten and threefold, respectively.

Identification and management of comorbidity in psoriatic arthritis: evidence- and expert-based recommendations from a multidisciplinary panel from Spain.

The objective is to establish recommendations, based on evidence and expert opinion, for the identification and management of comorbidities in patients with psoriatic arthritis (PsA). The following techniques were applied: discussion group, systematic review, and Delphi survey for agreement. A panel of professionals from four specialties defined the users, the sections of the document, possible recommendations, and what systematic reviews should be performed. A second discussion was held with the results of the systematic reviews. Recommendations were formulated in the second meeting and voted online from 1 (total disagreement) to 10 (total agreement). Agreement was considered if at least 70% voted ≥7. The level of evidence and grade of recommendation were assigned using the Oxford Centre for Evidence-Based Medicine guidance. The full document was critically appraised by the experts, and the project was supervised at all times by a methodologist. In a final step, the document was reviewed and commented by a patient and a health management specialist. Fourteen recommendations were produced, together with a checklist to facilitate the implementation. The items with the largest support from evidence were those related to cardiovascular disease and risk factors. The panel recommends paying special attention to obesity, smoking, and alcohol consumption, as they are all modifiable factors with an impact on treatment response or complications of PsA. Psychological and organizational aspects were also deemed important. We herein suggest practical recommendations for the management of comorbidities in PsA based on evidence and expert opinion.