Desarrollo de una aplicación para teléfonos móviles (app) basada en la colaboración Sociedad Española de Reumatología/Sociedad Española de Medicina de Familia y Comunitaria para derivación de enfermedades autoinmunes sistémicas / Development of an application for mobile phones (App) based on the collaboration between the Spanish Society of Rheumatology and Spanish Society of Family Medicine for the referral of systemic autoimmune diseases from primary care to rheumatology

El diagnóstico y tratamiento de las enfermedades autoinmunes sistémicas (EAS) constituye un reto. Aunque infrecuentes, afectan a cientos de miles de pacientes en España. El médico de familia (MF) se enfrenta a síntomas o signos inespecíficos que hacen sospechar EAS al inicio del proceso, y tiene que decidir a quiénes debería derivar. Para facilitar su reconocimiento y mejorar su derivación, expertos de la Sociedad Española de Medicina de Familia y Comunitaria y de la Sociedad Española de Reumatología seleccionaron 26 síntomas/signos-guía y alteraciones analíticas. Se escogieron parejas de MF y reumatólogo para elaborar algoritmos diagnósticos y de derivación. Posteriormente se revisaron y adaptaron al formato de aplicación para móviles (app) descargable. El resultado es el presente documento de derivación de EAS para MF en formato de papel y app. Contiene algoritmos de fácil manejo utilizando datos de la anamnesis, exploración física y pruebas analíticas accesibles en atención primaria para orientar el diagnóstico y facilitar la derivación a reumatología o a otras especialidades

Management of systemic autoimmune diseases is challenging for physicians in their clinical practice. Although not common, they affect thousands of patients in Spain. The family doctor faces patients with symptoms and non-specific cutaneous, mucous, joint, vascular signs or abnormal laboratory findings at the start of the disease process and has to determine when to refer patients to the specialist. To aid in disease detection and better referral, the Spanish Society of Rheumatology and the Spanish Society of Family Medicine has created a group of experts who selected 26 symptoms, key signs and abnormal laboratory findings which were organized by organ and apparatus. Family doctors and rheumatologists with an interest in autoimmune systemic diseases were selected and formed mixed groups of two that then elaborated algorithms for diagnostic guidelines and referral. The algorithms were then reviewed, homogenized and adapted to the algorithm format and application for cell phone (apps) download. The result is the current Referral document of systemic autoimmune diseases for the family doctor in paper format and app (download). It contains easy-to-use algorithms using data from anamnesis, physical examination and laboratory results usually available to primary care, that help diagnose and refer patients to rheumatology or other specialties if needed

Lesiones cutáneas y eosinofilia como forma de presentación de síndrome de Wells / Wells' syndrome presented as skin lesions and eosinophilia

El síndrome de Wells o celulitis eosinofílica es una rara entidad cutánea, caracterizada por el polimorfismo de sus lesiones y por la presencia aumentada de eosinófilos tanto en las lesiones como en sangre periférica. Su etiología permanece desconocida, y la falta de especificidad de sus lesiones hace que en ocasiones su diagnóstico resulte difícil, representando la biopsia cutánea una prueba clave (figuras en llama). Su tratamiento inicial son los corticoides, aunque puede autolimitarse sin nuevos brotes. Presentamos el caso de una paciente con lesiones cutáneas asociado a eosinofilia en el contexto de un síndrome de Wells

Wells' syndrome or eosinophilic cellulitis is a rare skin disease characterized by the polymorphism of the lesions and by the increased presence of eosinophils both in the lesions and in peripheral blood. Its etiology remains unknown, and the lack of specificity of its lesions often makes diagnosis difficult. Skin biopsy is a key test (flame figures). The initial treatment is corticosteroids, though the disease can be self-limited, with no further outbreaks. We present the case of a woman with skin lesions associated with eosinophilia in the context of a Wells' syndrome

Development of an application for mobile phones (App) based on the collaboration between the Spanish Society of Rheumatology and Spanish Society of Family Medicine for the referral of systemic autoimmune diseases from primary care to rheumatology. / Desarrollo de una aplicación para teléfonos móviles (app) basada en la colaboración Sociedad Española de Reumatología/Sociedad Española de Medicina de Familia y Comunitaria para derivación de enfermedades autoinmunes sistémicas.

Management of systemic autoimmune diseases is challenging for physicians in their clinical practice. Although not common, they affect thousands of patients in Spain. The family doctor faces patients with symptoms and non-specific cutaneous, mucous, joint, vascular signs or abnormal laboratory findings at the start of the disease process and has to determine when to refer patients to the specialist. To aid in disease detection and better referral, the Spanish Society of Rheumatology and the Spanish Society of Family Medicine has created a group of experts who selected 26 symptoms, key signs and abnormal laboratory findings which were organized by organ and apparatus. Family doctors and rheumatologists with an interest in autoimmune systemic diseases were selected and formed mixed groups of two that then elaborated algorithms for diagnostic guidelines and referral. The algorithms were then reviewed, homogenized and adapted to the algorithm format and application for cell phone (apps) download. The result is the current Referral document of systemic autoimmune diseases for the family doctor in paper format and app (download). It contains easy-to-use algorithms using data from anamnesis, physical examination and laboratory results usually available to primary care, that help diagnose and refer patients to rheumatology or other specialties if needed.

[Symptoms. Localizations: knee, hip, hands, spine, other localizations]. / Clínica. Localizaciones: rodilla, cadera, manos, columna, otras localizaciones.

The symptoms of osteoarthritis vary widely from patient to patient, depending especially on the localization on the disease. There is a poor correlation between radiological involvement and pain. In general, symptom onset is gradual and symptoms increase slowly but progressively. The most commonly affected joints are the knees, hips, hands, and spine. The main signs and symptoms are pain, stiffness, joint deformity, and crepitus. Pain is mechanical and its causes are multifactorial; in the initial phases, pain usually manifests in self-limiting episodes but may subsequently be almost constant. The criteria of the American college of Rheumatology for the classification of osteoarthritis of the knee, hip and hands are an aid to classification and standardization but are not useful for diagnosis. Hip osteoarthritis usually produces inguinal pain in the internal and anterior sections of the muscle extending to the knee and, with progression, tends to limit mobility. Knee osteoarthritis is more frequent in women and is usually associated with hand osteoarthritis and obesity. In hand osteoarthritis, the most commonly affected joints are the distal interphalangeal joints, followed by the proximal interphalangeal joints and the trapeziometacarpal joints; the development of Heberden and Bouchard nodes is common; involvement of the trapeziometacarpal joint is called rhizarthrosis and is one of the forms of osteoarthritis that produces the greatest limitation on hand function. Osteoarthritis of the spine affects the facet joints and the vertebral bodies. Other, less frequent, localizations are the foot, elbow and shoulder, which are generally secondary forms of osteoarthritis.

[Diagnosis. History and physical examination]. / Diagnóstico. Historia y examen físico.

Family physicians play a key role in the diagnosis and management of patients with osteoarthritis. Diagnosis is mainly clinical and radiological. A complete history should be taken with meticulous physical examination of the joints. The history-taking should aim to detect risk factors and compatible clinical symptoms. Pain characteristics should be identified, distinguishing between mechanical and inflammatory pain, and an exhaustive examination of the joints should be performed, with evaluation of the presence of pain, deformity, mobility restrictions (both active and passive), crepitus, joint effusion, and inflammation. A differential diagnosis should be made with all diseases that affect the joints and/or produce joint stiffness.

Clínica. Localizaciones: rodilla, cadera, manos, columna, otras localizaciones / Symptoms. Localizations: knee, hip, hands, spine, other localizations

La clínica que presentan estos pacientes difiere mucho de unos a otros, dependiendo especialmente de la localización de la artrosis, y no hay buena correlación entre la afectación radiológica y el dolor. Generalmente, la clínica es de inicio gradual y evolución lenta, aunque progresiva, y las articulaciones más afectadas son las rodillas, las caderas, las manos y la columna vertebral. Los principales síntomas y signos son el dolor, la rigidez, la deformidad articular y la crepitación. El dolor es de características mecánicas y de causa multifactorial; en fases iniciales suele cursar en brotes autolimitados y posteriormente puede permanecer casi constante. Los criterios del American College of Rheumatology para clasificar las artrosis de rodilla, cadera y manos son una ayuda para la clasificación y estandarización, pero no sirven para el diagnóstico de la enfermedad. La artrosis de cadera suele presentar dolor inguinal, en la parte interna y anterior del muslo hasta la rodilla y con la evolución tiende a producir limitación de la movilidad. La artrosis de rodilla es más frecuente en mujeres y suele asociarse con la de mano y la obesidad. En la artrosis de manos, las articulaciones más afectadas son las interfalángicas distales, seguidas de las interfalángicas proximales y la trapeciometacarpiana; es frecuente la aparición de nódulos de Heberden y Bouchard; la afectación de la articulación trapeciometacarpiana se denomina rizartrosis, siendo una de las artrosis que más limita la funcionabilidad de la mano. La artrosis de columna afecta a las articulaciones interapofisarias y a los cuerpos vertebrales. Otras artrosis menos frecuentes son las del pie, codo y hombro, que generalmente son secundarias

The symptoms of osteoarthritis vary widely from patient to patient, depending especially on the localization on the disease. There is a poor correlation between radiological involvement and pain. In general, symptom onset is gradual and symptoms increase slowly but progressively. The most commonly affected joints are the knees, hips, hands, and spine. The main signs and symptoms are pain, stiffness, joint deformity, and crepitus. Pain is mechanical and its causes are multifactorial; in the initial phases, pain usually manifests in self-limiting episodes but may subsequently be almost constant. The criteria of the American college of Rheumatology for the classification of osteoarthritis of the knee, hip and hands are an aid to classification and standardization but are not useful for diagnosis. Hip osteoarthritis usually produces inguinal pain in the internal and anterior sections of the muscle extending to the knee and, with progression, tends to limit mobility. Knee osteoarthritis is more frequent in women and is usually associated with hand osteoarthritis and obesity. In hand osteoarthritis, the most commonly affected joints are the distal interphalangeal joints, followed by the proximal interphalangeal joints and the trapeziometacarpal joints; the development of Heberden and Bouchard nodes is common; involvement of the trapeziometacarpal joint is called rhizarthrosis and is one of the forms of osteoarthritis that produces the greatest limitation on hand function. Osteoarthritis of the spine affects the facet joints and the vertebral bodies. Other, less frequent, localizations are the foot, elbow and shoulder, which are generally secondary forms of osteoarthritis

Diagnóstico. Historia y examen físico / Diagnosis. History and physical examination

El médico de familia tiene un papel clave en el diagnóstico y manejo del paciente artrósico. El diagnóstico es fundamentalmente clínico y radiológico, y se debe realizar una anamnesis completa junto con una exploración articular meticulosa. La anamnesis debe dirigirse a detectar la existencia de factores de riesgo y sintomatología clínica compatible. Debemos averiguar las características del dolor distinguiendo si es mecánico o inflamatorio y realizar una exploración exhaustiva articular valorando la existencia de dolor, deformidad, limitación de la movilidad, tanto activa como pasiva, crepitación, presencia de derrame articular e inflamación. El diagnóstico diferencial debe realizarse con todas las enfermedades que afecten a las articulaciones y/o produzcan rigidez en ellas

Family physicians play a key role in the diagnosis and management of patients with osteoarthritis. Diagnosis is mainly clinical and radiological. A complete history should be taken with meticulous physical examination of the joints. The history-taking should aim to detect risk factors and compatible clinical symptoms. Pain characteristics should be identified, distinguishing between mechanical and inflammatory pain, and an exhaustive examination of the joints should be performed, with evaluation of the presence of pain, deformity, mobility restrictions (both active and passive), crepitus, joint effusion, and inflammation. A differential diagnosis should be made with all diseases that affect the joints and/or produce joint stiffness

Estudio ARTRO-PRO: percepción del beneficio clínico y calidad de vida en pacientes con artrosis de cadera y rodilla / Can an intervention on clinical inertia have an impact on the perception of pain, functionality and quality of life in patients with hip and/or knee osteoarthritis? Results from a cluster randomised trial

Objetivos: Evaluar si una intervención aplicada a médicos de familia para evitar la inercia clínica tuvo un impacto en el dolor, funcionalidad y calidad de vida relacionada con la salud (CVRS) de los pacientes con artritis de cadera y/o rodilla. Diseño: Estudio de grupos paralelos de cluster, multicéntrico, prospectivo, aleatorizado. Los médicos fueron asignados a 2 grupos, el grupo 1 recibió una sesión de entrenamiento, el grupo 2, no. Emplazamiento: Centros de salud representativos del territorio español. Participantes: Médicos de familia de 329 centros de salud. Intervenciones: Consistieron en una sesión motivadora para proponer una atención proactiva, basada en recomendaciones actualizadas. Mediciones principales: Escala analógica visual (EVA); funcionalidad (escala WOMAC) y percepción global de salud mediante SF-12 en 2 visitas separadas por 6 meses. Resultados: Participaron 1.361 médicos y 4.076 pacientes. No se observaron diferencias significativas en el beneficio clínico obtenido entre los pacientes asignados al grupo 1 y grupo 2. Sin embargo, se observó una mejora significativa en la población total (grupos 1 + 2) en la EVA (p<0,001), WOMAC (p<0,0001) y el SF-12V2 (p<0,001) en la visita 2 en comparación con la visita 1. Conclusiones: Esta intervención sobre médicos de familia no proporcionó un beneficio clínico adicional a los pacientes. Se observó en ambos grupos una mayor conciencia de la enfermedad del paciente por el uso novedoso de índices de funcionalidad y CVRS, que parece mejorar el dolor percibido, la funcionalidad y la calidad de vida relacionada con la salud(AU)

Objectives: Evaluate whether an intervention applied to general practitioners to prevent clinical inertia had an impact on pain, functionality, and health-related quality of life (HRQoL) of patients with hip and/or knee osteoarthritis. Design: This was a cluster-based, multicentre, prospective, randomized, parallel-group study. Clusters of physicians working were assigned to one of two study groups. Physicians in Group 1 received a training session while those in Group 2 did not. Setting: Primary Care Health centers representative of the entire Spanish territory. Participants: 329 general practitioners of primary healthcare centre. Interventions: The intervention consists of a motivational session to propose a proactive care, based on current recommendations. Measurements: Visual analogue scale (VAS); functionality (WOMAC scale) and global perception of health by SF-12. Effects were measured in two visits six months apart. Results: A total of 1361 physicians, and 4076 patients participated in the study. No significant differences were observed in the clinical benefit obtained between patients assigned to Group 1 and Group 2. Nevertheless, a significant improvement was observed in the combined population (Groups 1 + 2) in the VAS (p<0.001), WOMAC (p<0.0001) and SF-12v2 (p<0.001) questionnaires in Visit 2 compared to Visit 1. Conclusions: The results indicate that, although this specific intervention carried out on physicians did not provide an additional clinical benefit to patients with knee and/or hip osteoarthritis, an increased awareness of the patient's disease through the use of functionality indexes, as well as the mere fact of being observed, seem to improve patient-reported pain, functionality and HRQoL(AU)

Can an intervention on clinical inertia have an impact on the perception of pain, functionality and quality of life in patients with hip and/or knee osteoarthritis? Results from a cluster randomised trial.

OBJECTIVES: Evaluate whether an intervention applied to general practitioners to prevent clinical inertia had an impact on pain, functionality, and health-related quality of life (HRQoL) of patients with hip and/or knee osteoarthritis. DESIGN: This was a cluster-based, multicentre, prospective, randomized, parallel-group study. Clusters of physicians working were assigned to one of two study groups. Physicians in Group 1 received a training session while those in Group 2 did not. SETTING: Primary Care Health centers representative of the entire Spanish territory. PARTICIPANTS: 329 general practitioners of primary healthcare centre. INTERVENTIONS: The intervention consists of a motivational session to propose a proactive care, based on current recommendations. MEASUREMENTS: Visual analogue scale (VAS); functionality (WOMAC scale) and global perception of health by SF-12. Effects were measured in two visits six months apart. RESULTS: A total of 1361 physicians, and 4076 patients participated in the study. No significant differences were observed in the clinical benefit obtained between patients assigned to Group 1 and Group 2. Nevertheless, a significant improvement was observed in the combined population (Groups 1 + 2) in the VAS (p<0.001), WOMAC (p<0.0001) and SF-12v2 (p<0.001) questionnaires in Visit 2 compared to Visit 1. CONCLUSIONS: The results indicate that, although this specific intervention carried out on physicians did not provide an additional clinical benefit to patients with knee and/or hip osteoarthritis, an increased awareness of the patient's disease through the use of functionality indexes, as well as the mere fact of being observed, seem to improve patient-reported pain, functionality and HRQoL.

Chronic fatigue syndrome: aetiology, diagnosis and treatment.

Chronic fatigue syndrome is characterised by intense fatigue, with duration of over six months and associated to other related symptoms. The latter include asthenia and easily induced tiredness that is not recovered after a night's sleep. The fatigue becomes so severe that it forces a 50% reduction in daily activities. Given its unknown aetiology, different hypotheses have been considered to explain the origin of the condition (from immunological disorders to the presence of post-traumatic oxidative stress), although there are no conclusive diagnostic tests. Diagnosis is established through the exclusion of other diseases causing fatigue. This syndrome is rare in childhood and adolescence, although the fatigue symptom per se is quite common in paediatric patients. Currently, no curative treatment exists for patients with chronic fatigue syndrome. The therapeutic approach to this syndrome requires a combination of different therapeutic modalities. The specific characteristics of the symptomatology of patients with chronic fatigue require a rapid adaptation of the educational, healthcare and social systems to prevent the problems derived from current systems. Such patients require multidisciplinary management due to the multiple and different issues affecting them. This document was realized by one of the Interdisciplinary Work Groups from the Institute for Rare Diseases, and its aim is to point out the main social and care needs for people affected with Chronic Fatigue Syndrome. For this, it includes not only the view of representatives for different scientific societies, but also the patient associations view, because they know the true history of their social and sanitary needs. In an interdisciplinary approach, this work also reviews the principal scientific, medical, socio-sanitary and psychological aspects of Chronic Fatigue Syndrome.

Concordancia en el diagnóstico de Dolor Torácico entre urgencias de Atención Primaria y Especializada / The agreement in the diagnosis of the thoracic pain in a service of urgencies in Primary Care and the Hospital

Objetivo. Analizar la concordancia en el diagnóstico y actuación clínica en los casos de dolor torácicoatendidos en un servicio de urgencias extrahospitalarias, derivados al Hospital de referencia.Metodología. Estudio descriptivo de los pacientes atendidos por dolor torácico en la unidad de urgenciasextrahospitalarias de Campoo y derivados al Hospital Sierrallana durante el año 2002, comparandola asistencia clínica y el diagnóstico realizados en cada nivel. Análisis estadístico: para variablescuantitativas se utilizó la media y porcentajes para las cualitativas, chi-cuadrado para comparar variablescualitativas y t-Student para comparar medias; el índice Kappa para analizar la concordanciaentre los diagnósticos.Resultados. Se atendieron 52 casos, con una edad media de 67,3 años y ligero predominio masculino.El índice Kappa en el diagnostico de dolor torácico entre los dos niveles (urgencias-hospital) fuede 0,231 para el angor y de 0,866 para el IAM. Al 91.4% de los pacientes derivados se les realizó anivel hospitalario alguna prueba o interconsulta no accesible a nivel de atención primaria. Ingresó el38.5 % de los pacientes derivados.Conclusiones. Existe una baja concordancia entre niveles en el diagnostico de angor y muy buenoen el de IAM. La derivación puede considerarse correcta en la mayoría de los casos. No se realizael ECG a la totalidad de los pacientes. Las diferencias de concordancia se debieron en su mayoríaa dolores torácicos atípicos. A nivel hospitalario se cumplimentan mejor los volantes de derivación yse administra más medicación. A nivel de Atención Primaria hay mayor registro de tensión arterial ypulso arterial

Objective. To analyze the agreement in the diagnosis and clinical performance of the cases of thoracicpain in a service of extrahospitable urgencies and derivates to the reference Hospital.Methodology. Cross-sectional study of the patients with thoracic pain attended in the extrahospitableurgencies service of Campoo and derivatives to Sierrallana Hospital during the year 2002, it comparingthe clinical attendance and diagnosis made in each level. Statistical analysis: quantitative variableshave been used the mean and percentage for the qualitative ones, chi-square has been used tocompare qualitative variables and t-student has been used to compare averages; Kappa index havebeen used to analyze the agreement between the diagnoses.Results. 52 cases were attended, with an average age of 67.3 years and mainly masculine sex. TheKappa index of agreement of diagnoses between both levels (urgency-hospital) was 0.231 for angorand 0,866 for cardiac infarction. In the 91.4% of the patients in the hospital was done any non accessibletest at level of primary care. The 38.5% of the derived patients was ingresed.Conclusions. It exists a low agreement between levels in the diagnosis of angor and very good in cardiacinfarction, probably it is motivated by the doubt of the physician. The derivation can be consideredcorrect. It is important the non accomplishment of the ECG in the totality of the patients. The differencein the agreement is mainly by atypical thoracic pains. The medical inform is better complimented in thehospital but the arterial tension and arterial pulse is better at the level of Primary Care