Update of the guidelines for the pharmacological treatment of rheumatoid arthritis by the Mexican College of Rheumatology 2023.

OBJECTIVE: To develop updated guidelines for the pharmacological management of rheumatoid arthritis (RA). METHODS: A group of experts representative of different geographical regions and various medical services catering to the Mexican population with RA was formed. Questions based on Population, Intervention, Comparison, and Outcome (PICO) were developed, deemed clinically relevant. These questions were answered based on the results of a recent systematic literature review (SLR), and the evidence's validity was assessed using the GRADE system, considered a standard for these purposes. Subsequently, the expert group reached consensus on the direction and strength of recommendations through a multi-stage voting process. RESULTS: The updated guidelines for RA treatment stratify various therapeutic options, including different classes of DMARDs (conventional, biologicals, and JAK inhibitors), as well as NSAIDs, glucocorticoids, and analgesics. By consensus, it establishes the use of these in different subpopulations of interest among RA patients and addresses aspects related to vaccination, COVID-19, surgery, pregnancy and lactation, and others. CONCLUSIONS: This update of the Mexican guidelines for the pharmacological treatment of RA provides reference points for evidence-based decision-making, recommending patient participation in joint decision-making to achieve the greatest benefit for our patients. It also establishes recommendations for managing a variety of relevant conditions affecting our patients.

Gender representation in rheumatology journals: an assessment of editors, editorial boards, and authors.

Diversity is widely recognized as a driver of excellence and innovation. In recent years, women have become an increasingly significant part of the rheumatology workforce. We aimed to assess the gender representation of the leading rheumatology journals' editors and to explore whether editors' gender correlates with the gender of the first and last authors of published articles. We conducted a cross-sectional study and extracted editorial members of rheumatology journals in quartiles 1 to 3 (Clarivate Analytics) from each journal's website. We categorized editorial positions according to the level of influence in manuscript acceptance decision-making (levels I to III). The gender of editors and of the first and last authors in all 2019 original articles published in a sample of 15 rheumatology journals was assigned using a combination of digital gallery and manual searches. There were 2242 editors' names retrieved from 43 journals, 24 (26%) of the 94 editors at level I, 139 (36%) of 385 editors at level II, and 469 (27%) of 1763 at level III were female. The imbalance between journals was heterogeneous. Females were the first authors in 1342 (48%) and the last authors in 969 (35%) of the 2797 published articles. However, we found no significant correlation between editors' and authors' gender. Our data showed uneven gender representation on the editorial boards of most rheumatology journals, but we did not find any apparent vertical segregation or influence on publishing by gender. Our findings suggest that a generational transition may be occurring among authors.

The Use of Reporting Guidelines in Rheumatology: A Cross-Sectional Study of Over 850 Manuscripts Published in 5 Major Rheumatology Journals.

OBJECTIVE: To assess whether 16 of the Enhancing the Quality and Transparency of Health Research (EQUATOR) Network-related reporting guidelines were used in rheumatology publications. METHODS: This was a cross-sectional study of research articles published in 5 high-performance rheumatology-focused journals in 2019. All articles were (1) manually reviewed to assess whether the use of a reporting guideline could be advisable, and (2) searched for the names and acronyms (eg, CONSORT [Consolidated Standards of Reporting Trials], STROBE [Strengthening the Reporting of Observational Studies in Epidemiology]) of 16 reporting guidelines. To calculate the "advisable use rate," the number of articles for which a guideline was used was divided by the number of articles for which the guideline was advised. Descriptive statistics were used. RESULTS: We reviewed 895 manuscripts across the 5 journals. The use of a guideline was deemed advisable for 693 (77%) articles. Reporting guidelines were used in 50 articles, representing 5.6% of total articles and 7.2% (95% CI 5-9) of articles for which guidelines were advised. The advisable use rate boundaries within which a guideline was applied by the journals were 0.03 to 0.10 for any guideline, 0 to 0.26 for CONSORT, 0.01 to 0.07 for STROBE, 0 to 0.8 for Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), and 0 to 0.14 for Animal Research: Reporting of In Vivo Experiments (ARRIVE). No identifiable trends in the variables studied were observed across the 5 journals. CONCLUSION: The limited use of reporting guidelines appears counterintuitive, considering that guidelines are promoted by journals and are intended to help authors report relevant information. Whether this finding is attributable to issues with the diffusion, awareness, acceptance, or perceived usefulness of the guidelines remains to be clarified.

Ranking the importance of their own diseases: A positioning analysis in rheumatic patients and their proxies.

INTRODUCTION/OBJECTIVE: To assess the positioning that patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), ankylosing spondylitis (AS) and their proxies give to their diseases. METHODS: Subjects completed a self-administered questionnaire to rank 11 diseases from "worst" to "least bad". Then they defined the "worst" disease and ranked 10 diseases from highest to lowest importance from a list including "my rheumatic disease/my relative's disease". The lists of the included diseases represented the mindshare from a sample of healthy adults. RESULTS: There were 570 respondents (104 SLE, 99 RA, 82 AS, and 285 proxies). Rheumatoid arthritis was considered the third-worst disease (recoded ranking first by 41% of patients and 43% proxies, second by 49% and 44%, and third by 10% and 13%). A disease that kills was the preferred definition for the worst disease. "My disease/my relative's disease" was ranked fourth in importance (first by 41% of patients, second by 38%, and third by 21%). Rankings were not associated with age, schooling, disease duration, or setting. DISCUSSION AND CONCLUSIONS: Most respondents ranked their own disease considerably lower than other non-rheumatic conditions.

Ranking the importance of their own diseases: A positioning analysis in rheumatic patients and their proxies / La importancia que dan los pacientes reumáticos a sus propias enfermedades: un análisis de posicionamiento

Introduction/objective: To assess the positioning that patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), ankylosing spondylitis (AS) and their proxies give to their diseases. Methods: Subjects completed a self-administered questionnaire to rank 11 diseases from “worst” to “least bad”. Then they defined the “worst” disease and ranked 10 diseases from highest to lowest importance from a list including “my rheumatic disease/my relative's disease”. The lists of the included diseases represented the mindshare from a sample of healthy adults. Results: There were 570 respondents (104 SLE, 99 RA, 82 AS, and 285 proxies). Rheumatoid arthritis was considered the third-worst disease (recoded ranking first by 41% of patients and 43% proxies, second by 49% and 44%, and third by 10% and 13%). A disease that kills was the preferred definition for the worst disease. “My disease/my relative's disease” was ranked fourth in importance (first by 41% of patients, second by 38%, and third by 21%). Rankings were not associated with age, schooling, disease duration, or setting. Discussion and conclusions: Most respondents ranked their own disease considerably lower than other non-rheumatic conditions.(AU)

Introducción/objetivo: Evaluar el posicionamiento que pacientes con lupus eritematoso sistémico (LES), artritis reumatoide (AR), espondilitis anquilosante (EA) y sus acompañantes dan a sus enfermedades. Métodos: Los participantes completaron un cuestionario para clasificar 11 enfermedades de «peor» a «menos mala». Luego definieron la «peor» enfermedad y el ranking de 10 enfermedades de una lista que incluía «mi enfermedad reumática/de mi familiar». Las listas de enfermedades incluidas representaron la «conciencia de marca» de un grupo de adultos sanos. Resultados: Hubo 570 encuestados (104 LES, 99 AR, 82 EA y 285 acompañantes). La AR se posicionó como la tercera peor enfermedad (en primer lugar, por el 41% de pacientes, segundo por el 49% y tercero por el 10%). La definición preferida para «peor» enfermedad fue aquella que mata. «Mi enfermedad reumática/de mi familiar» fue la cuarta más importante (primer lugar por el 41% de pacientes, segundo por el 38% y tercero por el 21%). El posicionamiento no estuvo asociado con edad, escolaridad, duración de la enfermedad ni centro de atención. Discusión y conclusiones: La mayoría de los encuestados calificaron su enfermedad reumática más abajo que otros padecimientos no reumáticos.(AU)

Evaluation of the quality and subsequent performance of manuscripts rejected by Clinical Rheumatology: a research report.

OBJECTIVES: To assess the quality and performance of manuscripts previously rejected by a rheumatology-focused journal. METHODS: This was a cross-sectional, audit-type, exploratory study of manuscripts submitted to Clinical Rheumatology (CLRH) and rejected by one associate editor in 2019. We used a 36-item quality assessment instrument (5-point ordinal scale, 1 being worst). Performance variables included whether a rejected manuscript was published in another PubMed-listed journal, impact factor of the publishing journal (Scimago), number of citations (Web of Science), and social media attention (Altmetrics). Exploratory variables included authors' past publications, use of reporting guidelines, and text structure. Exploratory variables were assessed using non-parametric tests. RESULTS: In total, 165 manuscripts were rejected. Reporting guidelines were used in only five (4%) manuscripts. The mean overall quality rating was 2.48 ± 0.73, with 54% of manuscripts rated 2; 40-80% were rated < 3 on crucial items. Over a 26-month follow-up, 79 (48%) rejected manuscripts were published in other journals, mostly with lower impact factors; 70% of these had at least one citation, compared with 90.5% for manuscripts published in CLRH. Altmetrics was significantly lower for manuscripts published elsewhere than for those published in CLRH. As for text structure, the methods and results sections were shorter and the discussion longer than suggested. The corresponding authors' past experience and text structure were not associated with quality or acceptance. CONCLUSIONS: Research report quality is an area for improvement, mainly for items critical to explaining the research and findings. The use of reporting guidelines should be encouraged by journals. Key Points • The quality of research reports (in rejected manuscripts) is insufficient. • Guidelines for reporting are seldom used in rejected manuscripts. • A manuscript rejected by Clinical Rheumatology may subsequently be published in another journal with a lower impact factor and have fewer citations and less social media attention than accepted manuscripts.

Non-Coding RNAs in Rheumatoid Arthritis: Implications for Biomarker Discovery.

Recent advances in gene expression analysis techniques and increased access to technologies such as microarrays, qPCR arrays, and next-generation sequencing, in the last decade, have led to increased awareness of the complexity of the inflammatory responses that lead to pathology. This finding is also the case for rheumatic diseases, importantly and specifically, rheumatoid arthritis (RA). The coincidence in major genetic and epigenetic regulatory events leading to RA's inflammatory state is now well-recognized. Research groups have characterized the gene expression profile of early RA patients and identified a group of miRNAs that is particularly abundant in the early stages of the disease and miRNAs associated with treatment responses. In this perspective, we summarize the current state of RNA-based biomarker discovery and the context of technology adoption/implementation due to the COVID-19 pandemic. These advances have great potential for clinical application and could provide preclinical disease detection, follow-up, treatment targets, and biomarkers for treatment response monitoring.

Overexpression of TLR7 and TLR9 Occurs Before Onset Symptoms In First-Degree Relatives of Rheumatoid Arthritis Patients.

BACKGROUND: Autoantibodies have a central role in the physiopathology of Rheumatoid Arthritis (RA). However, the responsible factors that trigger and perpetuate the autoantibodies production are unknown. Toll-like receptors (TLRs) have been considered as promotors of autoantibodies production to break down the immunotolerance in RA. AIM OF THE STUDY: Evaluate the expression levels of TLR7 and TLR9 as well as their correlation with autoantibodies in first-degree relatives (FDR) of RA patients (seropositive and seronegative to ACPA), respect to early RA (eRA) and chronic RA (cRA) patients. METHODS: We selected 32 RA patients (16 as eRA and 16 as cRA) and 32 FDR of RA patients (16 seropositive and 16 seronegative to ACPA). Expression levels of TLR7 and TLR9 in whole blood samples from each group were measured by real-time PCR using total RNA extracted from each subject. Also, correlation analysis between TLRs expression and autoantibodies was performed. RESULTS: The expression of TLR7 and TLR9 was diminished in RA patients (p <0.01) but elevated in ACPA- FDR (p <0.0001) and ACPA+ FDR (p <0.05) with a positive correlation between them (r = 0.749, p <0.000). Moreover, the expression levels of TLR7 correlate positively with ACPA levels in both seropositive ACPA+ FDR subjects (r = 0.582, p = 0.018) and eRA patients (r = 0.593, p = 0.020). CONCLUSIONS: Our results showed overexpression of TLR7 and TLR9 may occur in preclinical RA subjects. TLR7 overexpression correlated with ACPA levels' production, suggesting TLR7 may play a role in ACPA development.

Ranking the Importance of Their Own Diseases: A Positioning Analysis in Rheumatic Patients and Their Proxies.

INTRODUCTION/OBJECTIVE: To assess the positioning that patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), ankylosing spondylitis (AS) and their proxies give to their diseases. METHODS: Subjects completed a self-administered questionnaire to rank 11 diseases from "worst" to "least bad". Then they defined the "worst" disease and ranked 10 diseases from highest to lowest importance from a list including "my rheumatic disease/my relative's disease". The lists of the included diseases represented the mindshare from a sample of healthy adults. RESULTS: There were 570 respondents (104 SLE, 99 RA, 82 AS, and 285 proxies). Rheumatoid arthritis was considered the third-worst disease (recoded ranking first by 41% of patients and 43% proxies, second by 49% and 44%, and third by 10% and 13%). A disease that kills was the preferred definition for the worst disease. "My disease/my relative's disease" was ranked fourth in importance (first by 41% of patients, second by 38%, and third by 21%). Rankings were not associated with age, schooling, disease duration, or setting. DISCUSSION AND CONCLUSIONS: Most respondents ranked their own disease considerably lower than other non-rheumatic conditions.

Recommendations of the Mexican College of Rheumatology for the Management of Spondyloarthritis. / Recomendaciones del Colegio Mexicano de Reumatología para el manejo de las espondiloartritis.

OBJECTIVES: To update the recommendations for the management of patients with Spondyloarthritis (SpA) in the Mexican population, and identify which variables could influence patient management. MATERIAL AND METHODS: A group of 15 experts in SpA translated, analyzed and modified the recommendations of the Mexican College of Rheumatology (CMR) and the International Society for the Assessment of Spondyloarthritis (ASAS)/European League Against Rheumatism (EULAR) 2016 group through a systematic review of the literature by two external reviewers during the period from 2015 to 2018 using the grade of recommendation, Oxford levels of evidence, percentage of concordance (Delphi). RESULTS: Compared to previous recommendations, there were no significant changes from the year 2015. However, we modified the five fundamental principles and reduced the number of recommendations to ten by incorporating the first item in the text and combining five recommendations into two and adding a further recommendation. We confirmed the tendency to use glucocorticoids for patients with inflammatory activity and scarce access to biologicals. We identified the sociodemographic and clinical characteristics of patients with SpA and their influence on the application of the recommendations. CONCLUSIONS: The ten recommendations of the CMR and the analysis of the characteristics of the Mexican patients with SpA focussed on step therapy, including pharmacological and non-pharmacological therapies, in a spectrum from easily accessible to high-tech substances available to a small percentage of the population.

Consenso ASAS en nomenclatura en español para las espondiloartritis / Assessment of SpondyloArthritis International Society (ASAS) consensus on Spanish nomenclature for spondyloarthritis

OBJETIVO: Desarrollar un documento de consenso para estandarizar los términos, abreviaturas y acrónimos en español empleados en el campo de las espondiloartritis (EspA). MÉTODOS: Se creó un grupo de trabajo internacional compuesto por todos los miembros de Assessment of SpondyloArthritis International Society (ASAS) nativos de habla española, miembros del comité ejecutivo del Grupo para el estudio de la Espondiloartritis de la Sociedad Española de Reumatología (GRESSER), 2 metodólogos, 2 lingüistas de la Real Academia Nacional de Medicina de España (RANM) y 2 pacientes de la Coordinadora Española de Asociaciones de Espondilitis (CEADE). Se realizó una revisión de la literatura de los últimos 15 años (publicaciones, el CIE y CIF, guías, consensos y recomendaciones) para identificar los términos, abreviaturas y acrónimos discrepantes. Mediante un Delphi de 3 rondas y una reunión presencial, se discutieron, seleccionaron y acordaron los términos, abreviaturas y acrónimos a utilizar. Durante todo este proceso se siguieron las recomendaciones de la RANM basadas en el Diccionario panhispánico de términos médicos. RESULTADOS: Se consensuaron 46 términos, abreviaturas y acrónimos. Se aceptó la traducción al español para 6 términos y 6 abreviaturas empleados para nombrar o clasificar la enfermedad y para 6 términos y 4 abreviaturas relacionados con las EspA. Se acordó no traducir 15 acrónimos por estar ya establecidos, pero al mencionarlos, se recomendó seguir esta estructura: tipo de acrónimo en español y acrónimo y forma extensa en inglés. Con respecto a 7 términos o abreviaturas asociados a acrónimos, se acordó traducir solo la forma extensa y se consensuó una traducción. CONCLUSIONES: Con esta estandarización del lenguaje de las EspA se pretende establecer un uso común de la nomenclatura en español para las EspA. Su implementación será muy beneficiosa, evitando malentendidos y consumo de recursos

OBJECTIVE: To develop a consensus to standardize the use of Spanish terms, abbreviations and acronyms in the field of spondyloarthritis (SpA). METHODS: An international task force comprising all native Spanish-speaking Assessment of SpondyloArthritis International Society (ASAS) members, the executive committee of Grupo para el estudio de la Espondiloartritis de la Sociedad Española de Reumatología (GRESSER), two methodologists, two linguists from the Real Academia Nacional de Medicina de España (RANM) and two patients from the Spanish Coordinator of Spondylitis Associations (CEADE) was established. A literature review was performed to identify the conflicting terms/abbreviations/acronyms in SpA. This review examined written sources in Spanish including manuscripts, ICF and ICD, guidelines, recommendations and consensuses. This was followed by a nominal group meeting and a three-round Delphi. The recommendations from the RANM based on the Panhispanic dictionary were followed throughout the process. RESULTS: Consensus was reached for 46 terms, abbreviations or acronyms related to the field of SpA. A Spanish translation was accepted for 6 terms and 6 abbreviations to name or classify the disease, and for 6 terms and 4 abbreviations related to SpA. It was agreed not to translate 15 acronyms into Spanish. However, when mentioning them, it was recommended to follow this structure: type of acronym in Spanish and acronym and expanded form in English. With regard to 7 terms or abbreviations attached to acronyms, it was agreed to translate only the expanded form and a translation was also selected for each of them. CONCLUSIONS: Through this standardization, it is expected to establish a common use of the Spanish nomenclature for SpA. The implementation of this consensus across the community will be of substantial benefit, avoiding misunderstandings and time-consuming processes

Subclinical inflammation in the preclinical phase of rheumatoid arthritis might contribute to articular joint damage.

The first degree relatives of rheumatoid arthritis (RA) patients have a higher risk of developing RA, which is related to the expression of autoantibodies against citrullinated proteins (ACPA). Remarkably, prior to the onset of RA, cartilage damage is already initiated, whereas ACPA autoantibodies are already expressed. Here we show that both TNF-α and IL-6 are also increased prior to the onset of RA. Furthermore, when the levels of DKK1 and Sclerostin were evaluated in first degree relatives of RA patients, we found that the serum levels of TNF- α correlate with the expression levels of both DKK1 and Sclerostin. Interestingly, when the disease is already established, the correlation of TNF- α with DKK1 is lost in RA patients, whereas the correlation of Sclerostin with both TNF- α and IL-6 is further increased. Our data suggest a subclinical inflammation in patients at high risk of developing RA, which might lead to an increase in the levels of both DKK1 and Sclerostin, contributing to joint damage in the preclinical phase of the disease linked to the expression of ACPA autoantibodies.

Assessment of SpondyloArthritis International Society (ASAS) Consensus on Spanish Nomenclature for Spondyloarthritis. / Consenso ASAS en nomenclatura en español para las espondiloartritis.

OBJECTIVE: To develop a consensus to standardize the use of Spanish terms, abbreviations and acronyms in the field of spondyloarthritis (SpA). METHODS: An international task force comprising all native Spanish-speaking Assessment of SpondyloArthritis International Society (ASAS) members, the executive committee of Grupo para el estudio de la Espondiloartritis de la Sociedad Española de Reumatología (GRESSER), two methodologists, two linguists from the Real Academia Nacional de Medicina de España (RANM) and two patients from the Spanish Coordinator of Spondylitis Associations (CEADE) was established. A literature review was performed to identify the conflicting terms/abbreviations/acronyms in SpA. This review examined written sources in Spanish including manuscripts, ICF and ICD, guidelines, recommendations and consensuses. This was followed by a nominal group meeting and a three-round Delphi. The recommendations from the RANM based on the Panhispanic dictionary were followed throughout the process. RESULTS: Consensus was reached for 46 terms, abbreviations or acronyms related to the field of SpA. A Spanish translation was accepted for 6 terms and 6 abbreviations to name or classify the disease, and for 6 terms and 4 abbreviations related to SpA. It was agreed not to translate 15 acronyms into Spanish. However, when mentioning them, it was recommended to follow this structure: type of acronym in Spanish and acronym and expanded form in English. With regard to 7 terms or abbreviations attached to acronyms, it was agreed to translate only the expanded form and a translation was also selected for each of them. CONCLUSIONS: Through this standardization, it is expected to establish a common use of the Spanish nomenclature for SpA. The implementation of this consensus across the community will be of substantial benefit, avoiding misunderstandings and time-consuming processes.

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

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

Desempeño de las escuelas de medicina en México: resultados del Examen Nacional para Aspirantes a Residencias Médicas / Performance of medical schools in Mexico: Results from the Examen Nacional para Aspirantes a Residencias Médicas

Resumen: Objetivo: Evaluar el desempeño de las facultades y escuelas de medicina (FEM) utilizando como subrogado los resultados del Examen Nacional para Aspirantes a Residencias Médicas (ENARM). Material y métodos: Se analizaron las bases de datos oficiales del ENARM 2016 y 2017, empleando cinco criterios de desempeño (CD) por cada FEM: dos oficiales y tres creados exprofeso. Resultados. En 2016 y 2017 se registraron sustentantes de 112 y 115 FEM, respectivamente. Dependiendo del CD, la FEM que quedó clasificada en el primer lugar obtuvo entre 5 y 20 puntos más que la del segundo lugar, y entre 23 y 98 puntos más que la FEM ubicada en el último lugar. Aproximadamente 25% de los sustentantes fueron calificados como "deficientes en conocimientos" y aproximadamente 80% de éstos provenían de menos de un tercio de las FEM. Conclusiones: El ENARM arroja información sobre el desempeño de las FEM. Aproximadamente uno de cada cuatro sustentantes obtuvo puntajes menores al aprobatorio en cualquier especialidad.

Abstract: Objective: To assess the performance of medical schools (FEM) by analyzing the results of their applicants in the Examen Nacional para Aspirantes a Residencias Médicas (ENARM). Materials and methods: Five performance criteria, two official and three created on purpose, were calculated from the ENARM-2016 and -2017 official databases to assess FEM performance. Results: In 2016 and 2017, applicants registered from 112 and 115 FEM, respectively. Depending on the performance criteria, the FEM in the first place obtained 5 to 20 points more than the one placed second, and 23 to 98 points more than the FEM in the last place. Approximately 25% applicants were classified as "knowledge-deficient," and about 80% of these originated from less than one third of the FEM. Conclusion: The ENARM results provide information on the performance of the FEM. Approximately one of every four applicants obtained scores lower than the approval threshold of any specialty.