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To analyze the effects of a fast-velocity concentric resistance training (FVCRT) program on maximum strength of upper and lower limb, gait speed, walking endurance, fatigue, physical self-perception, and catastrophizing pain in people with multiple sclerosis (MS).Participants were randomized to either an experimental [EG] (n = 18) or a control [CG] (n = 12) group. The EG carried out 10-weeks of lower limb FVCRT. The CG did not perform any intervention. The maximum isometric voluntary contraction (MVIC) during knee extension, hand-grip strength, gait speed, walking endurance, fatigue, physical self-perception, and catastrophizing pain were measured.Inter-group differences after intervention were found on the right and left sides in MVIC (p = .032; ES = -0.7 and p = .009; ES = -0.9), and hand grip strength (p = .003; ES = -1.0 and p = .029; ES = -0.7). After FVCRT, there was in increase in MVIC (p .001; ES = -1.7 and p .001; ES = -1.3) and hand grip strength (p .001; ES = -1.3 and p .001; ES = -1.3) on both right and left sides, respectively. In addition, gait speed (p = .023; ES = 1.3), walking endurance (p .001; ES = -1.0), symptomatic fatigue (p = .004; ES = 0.6), and catastrophizing pain (p .001; ES = 1.0) improved in EG.Lower limb FVCRT improved the upper and lower limb strength, walking, symptomatic fatigue, and catastrophizing pain in MS participants.

To analyse the efficacy, adherence, patient satisfaction, safety, pharmacodynamics and cost-effectiveness of parenteral methotrexate (MTX) in patients with rheumatic diseases.A systematic review of literature was carried out in Medline, Embase and Cochrane Central from the beginning until June 2019. Studies including adult patients with rheumatic diseases being treated with parenteral MTX were identified and data on efficacy, adherence, satisfaction, safety, pharmacokinetics, and cost-effectiveness analysed. As for the designs, systematic reviews, clinical trials, or observational studies were permitted, including cross-sectional and small-sample studies if they were pharmacokinetic studies.Out of 4160 identified articles, 80 articles were finally included. The efficacy profile of parenteral MTX seems useful in general and in those patients with insufficient response to oral MTX. The parenteral route does not seem to increase the rate or severity of adverse events due to the use of MTX. The use of parenteral MTX is an appropriate way to reduce costs in patients with inadequate response to oral MTX. Adherence and satisfaction are favoured by training programmes in the use of the parenteral route. The results in rheumatic diseases other than rheumatoid arthritis (RA) are very scarce and do not enable obtaining conclusive data.Parenteral MTX can be an alternative to the use of oral MTX, due to its profile of efficacy, safety, adherence and pharmacoeconomic results, especially in those patients with RA.

Background. People with multiple sclerosis (MS) suffer from symptoms related to neural control, such as reduced central activation, lower muscle activity, and accentuated spasticity. A forced 9-week home confinement related to COVID-19 in Spain may have worsened these symptoms. However, no study has demonstrated the impact of home confinement on neuromuscular mechanisms in the MS population. This study was aimed at analyzing the effects of a 9-week home confinement on central activation, muscle activity, contractile function, and spasticity in MS patients. Methods. Eighteen participants were enrolled in the study. Left and right knee extensor maximum voluntary isometric contraction (MVIC), maximal neural drive via peak surface electromyography (EMG) of the vastus lateralis, central activation ratio (CAR), and muscle contractile function via electrical stimulation of the knee extensor muscles, as well as spasticity using the pendulum test, were measured immediately before and after home confinement. Results. Seventeen participants completed the study. CAR significantly decreased after lockdown ( ES = 1.271 , p < 0.001 ). Regarding spasticity, there was a trend to decrease in the number of oscillations ( ES = 0.511 , p = 0.059 ) and a significant decrease in the duration of oscillations ( ES = 0.568 , p = 0.038 ). Furthermore, in the left leg, there was a significant decrease in the first swing excursion ( ES = 0.612 , p = 0.027 ) and in the relaxation index ( ES = 0.992 , p = 0.001 ). Muscle contractile properties, MVIC, and EMG variables were not modified after confinement. Conclusions. The results suggest that a home confinement period of 9 weeks may lead to an increase in lower limb spasticity and a greater deficit in voluntary activation of the knee extensors.

Benign rheumatoid nodules are subcutaneous nodules, identical in morphology and histology to the nodules that develop over the course of rheumatoid arthritis (RA); they present in individuals with no symptoms of arthritis and with negative rheumatoid factor (RF). This article introduces the case of a 46-year-old caucasian male who consulted for a tumour in his right leg. He tested negative for rheumatoid factor, anticitrullinated protein antibodies, antinuclear antibodies, and antineutrophil cytoplasmic antibodies, as well as for acute phase reactants. A musculoskeletal ultrasound showed a solid tumour of 3.5 × 1.5 cm with well-defined margins in the soleus muscle, and with a heterogeneous hypoechoic structure with intra- and peri-lesional vascularisation. The MRI showed a fibrous tumour with no signs suggestive of aggressive growth. An ultrasound-guided biopsy showed the characteristic histology of a rheumatoid nodule. The clinical presentation, diagnosis, differential diagnosis, and treatment of benign rheumatoid nodules are discussed.

Objective To evaluate the efficacy and safety of belimumab in patients with Primary Sjogren's syndrome (pSS). Methods The search included manuscripts assessing the efficacy or safety of belimumab in patients with pSS (American-European Consensus Criteria 2002) published between 2004 and 2017 in MEDLINE, EMBASE or Cochrane databases. Two reviewers independently selected the articles, extracted data and evaluated the quality of the evidence following Scottish Intercollegiate Guidelines Network (SIGN) recommendation grades. Results Out of 135 citations, only 3 articles were included. All of them publishing results from the same study at different time points including 28 patients. At week 28 improvement was reported for visual analogue scale (VAS) dryness score and glandular manifestations in 37% and 77% of patients, respectively, which persisted at week 52 (W52). Belimumab was well tolerated and safely administered. Conclusion Published evidence to determine the efficacy of belimumab in pSS is limited. Belimumab seems to be effective to reduce systemic activity, parotid enlargement, lymphadenopathies, articular manifestation and B cell biomarkers.

In 2015 the Spanish Society of Rheumatology (Sociedad Espanola de Reumatologia [SER]) published its position paper on biosimilar drugs. In this update, the SER, continues to manifest its unequivocal commitment to the sustainability of the health system of our country and is aligned with the measures that, without reducing quality of care, are aimed at ensuring its continuity. Since the publication of the previous position paper, the European Commission has authorized new biosimilar drugs, which provides an excellent opportunity to advance the efficiency of health care. In this new scenario of increased therapeutic offer of biologics, the SER considers it crucial to preserve the freedom of prescription of physicians who prescribe drugs based exclusively on the characteristics and individual circumstances of each patient, without forgetting the economic aspects there of.

Objective The aim of this study is to describe the findings of a protocolised odontological evaluation of patients with primary Sjogren’s syndrome (pSS) treated in rheumatology units in the Community of Madrid. Methods Multicentric descriptive study in which pSS patients classified according to the American-European consensus of 2002 criteria were included. We collected the demographic, clinical and serological data of each patient. A complete oral examination was performed and salivary flow and the CAOD caries index were collected. The patients completed the visual analogue scale for xerostomia, the Oral Health Impact Profile-14 questionnaire and an oral health questionnaire. Results Sixty-one patients were recruited. Ninety-eight percent were women and the mean age of the patients was 57 years. Pathological oral signs (unstimulated salivary flow/salivary glands sialography/scintigraphy) were present in 52.5% of the patients, anti-Ro/anti-La were positive in 90.2%. Ninety-two percent of the patients reported xerostomia and 61% of the patients suffered from hyposialia. Thirty-five patients presented oral mucosa lesions. CAOD index was 16.97 ± 7.93 and visual analogue scale for xerostomia was 46.69 ± 14.43. The results of the OHIP-14 questionnaire were 23.13 ± 14.16. Patients with pathological oral signs obtained a significantly higher Oral Health Impact Profile-14 score (P = .03). We also found that patients with peripheral nervous system involvement obtained a significantly higher Oral Health Impact Profile-14 score (P = .001). Conclusions The presence of xerostomia in this cohort of pSS patients was high and hyposialia was present in 61% of the patients. Oral lesions appeared in more than half of the subjects. Oral health had a negative impact on the quality of life of patients with pSS, being higher in those with pathological objective oral signs and in those with peripheral nervous system involvement.

La esclerosis múltiple (EM) es una enfermedad neurológica progresiva, que conduce a un declive de la función física, siendo la espasticidad uno de los síntomas más recurrentes en esta población. En los últimos años, el entrenamiento vibratorio de cuerpo completo (WBVT) ha mostrado beneficios en la capacidad funcional, la función neuromuscular o la calidad de vida en personas con EM. Sin embargo, los efectos agudos de una sesión de WBVT sobre variables como la espasticidad son todavía desconocidos. Por ello, los objetivos principales de este estudio fueron analizar los efectos agudos del WBVT sobre la espasticidad de la rodilla, así como conocer las diferencias en esta variable entre la pierna más y menos afectada tras la sesión en personas con EM.13 sujetos formaron parte de este estudio. La sesión de WBVT consistió en 12 series de 1 minuto de vibración con 1 minuto de descanso entre series en posición de sentadilla estática. La frecuencia y la amplitud fue fijada en 35 Hz y 4 mm respectivamente. Para medir la espasticidad de la articulación de la rodilla, el Test del Péndulo fue utilizado antes y después de la sesión. No se encontraron diferencias pre-post en ninguna de las variables. Sin embargo, el tiempo de oscilación mejoró significativamente en el post-sesión en la pierna menos afectada en comparación con la más afectada. Basándonos en nuestros resultados, se evidencia que la respuesta ante una sesión de WBVT es diferente dependiendo tanto del grado de discapacidad como de la pierna analizada de un mismo paciente. Estos resultados muestran que la individualización del WBVT es una cuestión de vital importancia en población con EM., Multiple sclerosis (MS) is a progressive neurological disease, which leads to a decline in physical function, being spasticity one of the most recurrent symptoms in this population. In recent years, whole body vibration training (WBVT) has shown benefits in functional capacity, neuromuscular function or quality of life in people with MS. However, the acute effects of a WBVT session on variables such as spasticity are still unknown. Therefore, the main objectives of this study were to analyzethe acute effects of WBVT on knee spasticity, as well as to know the differences in this variable between the most and least affected leg after the session in people with MS. 13 subjects were part of this study. The WBVT session consisted of 12 series of 1-minute vibration with 1 minute rest between series in a static squat position. The frequency and amplitude were set at 35 Hz and 4 mm respectively. To measure the spasticity of the knee joint, the Pendulum Test was used before and after the session. No pre-post differences were found in any of the variables. However, the time of oscillation was significantly improved in the post-session in the less affected leg compared to the more affected one. Based on our results, it is evident that the response to a WBVT session is different both depending on the degree of disability and between the legs of the same patient. These results show that the individualization of WBVT is a matter of vital importance in the population with MS.

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. (C) 2019 Elsevier Espana, S.L.U. and Sociedad Espanola de Reumatologia y Colegio Mexicano de Reumatologia. All rights reserved.

Background: Multiple sclerosis (MS) is a neurological disease that affects balance. Among the non-pharmacological strategies to improve this variable, physical exercise is one of the most widely used. However, the benefits of some types of training, such as resistance training, on static balance in this population are still unclear. This study aims to analyze the effects of a resistance training (RT) intervention on balance in people with MS. Methods: Thirty people with MS were randomized to either an experimental (n = 18) or a control (n = 12) group. The RT group performed 10 weeks of lower limb resistance training with a concentric phase at maximum velocity. Static balance was measured before and after intervention. Results: No significant group × time interaction effects were found (ANOVA test) in any of the variables at the end of the intervention. No intragroup differences were found before or after the intervention in the balance variables. Conclusions: Resistance training with a concentric phase at maximum velocity showed no impact on balance in our sample. Future studies should examine programs of longer duration or combined with other types of training, such as balance training, with the aim of obtaining improvements in this variable in people with MS.

Introduction The current paradigm of the management of rheumatoid arthritis (RA) recommends achieving a state of remission or low disease activity through the treat-to-target strategy. Our study assesses adherence to this strategy. Method Patients with RA (ACR-EULAR 2010 criteria) were included. From each centre, 19 patients were randomly selected. Clinical histories (CH) were assessed by independent auditors, checking compliance with predefined quality criteria. The study was approved by ethics committees. Results We included 856 patients (mean age 54 years; 71% women). The use of a combined index (CI) was recorded in 61% of cases. Visits were recorded every 4 weeks using a CI in 4% of CH while attempts were made to achieve remission. Monitoring of disease activity every 6–8 months after reaching the target was recorded in 73% of cases. Conclusions The implementation of the treat-to-target strategy is barely recorded in patients with RA in routine clinical practice.

Introduction One of the missions of the Spanish Society of Rheumatology is to provide the necessary tools for excellence in health care. Currently, there is no reference point to quantify medical actions in this specialty, and this is imperative. Material and method A list of actions was drawn up and a hierarchical classification system was established by developing a complexity index, calculated based on the completion time and difficulty level of each action. Results The results of the Delphi method tended to the consensus opinion within a group (mean σ2 − σ1 = 0 .75–1.43 = −0.68, mean IQR2–IQR1 = 0.8–1.9 = −1.1). The values of the complexity index ranged between 48 and 465 points. Among consultation actions, those reaching the highest scores were the first inpatient visit (366) and visits to the patient's home (369). Among diagnostic techniques, biopsies were prominent, those with the highest score were: bone biopsy (465), sural nerve biopsy (416) and synovial biopsy (380). Ultrasound scan scored 204, capillaroscopy 113 and densitometry 112. Among therapeutic techniques, infiltration/arthrocentesis/articular injection in children reached the highest difficulty (388). The score for ultrasound-guided articular injection was 163. The score for clinical report on disability was 323 and expert report 370. Conclusions A nomenclature of 54 actions in Rheumatology was compiled. Biopsies (bone, sural nerve, synovial), inpatient visits, visits to the patient's home, infiltrations in children, and the preparation of the expert report were identified as the most complex actions. Musculoskeletal ultrasound is twice as complex as subsequent visits, capillaroscopy or bone densitometry.

Introduction Nerve conduction studies (NCS) have been considered as the gold standard in carpal tunnel syndrome (CTS) diagnosis, despite correlation between clinical symptomatology and NCS severity has shown to be poor. In fact, clinical symptoms precede NCS changes in months or years. Few papers have been published about the clinical response to treatment of clinically typical CTS, but with normal NCS (NNCS). Objective To compare the clinical response to local corticosteroid injections (LCI) in clinically typical CTS, with NNCS and abnormal NCS (ANCS). Method We included patients older than 18, with typical CTS symptoms (ongoing daily nocturnal pain/paresthesias in hand, at least during 3 months). Follow-up was done at 3, 6 and 12 months. Primary outcome was the visual analog scale for pain (p-VAS), comparing NNCS CTS wrists with ANCS CTS wrists. Statistic signification was established by the Student's t test, Mann–Whitney's “U”, χ2 test and Yates’ correction. Results We included 44 wrists in the NNCS group, and 83 in the ANCS group. There was no statistical significance between data in both groups, except in the 12-month follow-up, where the NNCS group achieved better results than the ANCS group in the 20% response (p = 0.006). There was a trend toward a better 50% response in the 12-month follow-up. Conclusions Our data suggest that LCI are similarly effective in both CTS with NNCS and ANCS. Nonetheless, there is a mild better effect in NNCS than in ANCS at 12-month follow-up.

Objectives: This study aims to analyse the validity (agreement between two methods) of the movement propulsive velocity (MPV) as an indicator of relative load in leg press (LP) and bench press (BP) exercises in persons with multiple sclerosis (MS). Methods: 18 persons with MS (sex = 55% male, age (mean SD) = 44.88 10.62 years, body mass = 67.19 10.63 kg, height = 1.66 0.07 m, Expanded Disability Status Scale (EDSS) = 3.12 1.73) performed an incremental loading test in BP and LP exercises in two separate sessions. Individual determination of the one-repetition maximum (1RM) and full load-velocity profile were obtained for each participant. Results: a significant linear relationship was observed between the %1RM load and the MPV in LP (%1RM = &minus, 133.58 &times, MPV + 117.44, r2 = 0.84, standard error of the estimate (SEE) = 9.38%1RM) and BP (%1RM = &minus, 95.66 &times, MPV + 115.26, r2 = 0.86, SEE = 9.82%1RM). In addition, no significant differences were found between the %1RM achieved directly and the %1RM obtained by the equation calculated from the linear regression (LP, p = 0,996, BP, p = 0,749). Conclusions: these results indicate that movement velocity can estimate the relative load in bench press and leg press exercises in persons MS.

Objective To describe the progress of the attractiveness of rheumatology at successive MIR calls, from 1983 to 2014. Methods Candidates in the Spanish training system for medical doctors choose their specialties sequentially, ordered by their ranking in the qualifying exam (MIR). The highest, median and lowest rank of candidates choosing rheumatology training positions in every MIR call from 1983 to 2014 was requested from the Department of Management of Specialized Medical Training (General Department of Professional Regulation; Spanish Ministry of Health). To compare, the same data was requested for other specialties. In order to define and analyze the attractiveness of each specialty we introduce an ‘index of attractiveness’, based on the normalized difference of the actual median rank reported for each year and the average median obtained in 1000 simulations in which candidates choose specialties at random. Results Regarding the median of the election of rheumatology, the range went from 244th in 1983 to 3394th in 2008, showing a progressive increase over the years in absolute figures. A mathematical simulation allowed quantifying the difference between the observed median and what would have happened if specialties had been chosen by pure chance. Results show a tendency to recover the attractiveness of rheumatology in recent years. Conclusions After a sharp decline in the attractiveness of rheumatology during the last years of the 20th century, there seems to be a recovery.

Objective To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging in patients with spondyloarthritis, including psoriatic arthritis, and juvenile idiopathic arthritis. Methods Recommendations were generated following a nominal group technique. A panel of experts (15 rheumatologists and 3 radiologists) was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of participants voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence Based Medicine levels of evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist. Results A total of 12 recommendations were proposed for each disease. They include, along with explanations of the validity of US and magnetic resonance imaging regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies. Conclusions These recommendations will help clinicians use US and magnetic resonance imaging in patients with spondyloarthritis and juvenile idiopathic arthritis.

Background The COVID-19 pandemic caused a global confinement of more than 2 months in Spain. As a result, the general population has significantly decreased their physical activity levels. The consequences of this abrupt, sedentary lifestyle in Spanish people with Multiple Sclerosis (pwMS) were unknown. Our aim was to examine the impact of COVID-19 home confinement on neuromuscular performance, functional capacity, physical self-perception, and anxiety in pwMS. Methods Eighteen pwMS (8:10 men/women, age: 43.41±10.88 years, Expanded Disability Status Scale: 2.85±1.34) participated in the study. Rate of force development (RFD) and maximal voluntary isometric contraction during knee extension in both legs, Timed-Up and Go test (TUG), sit-to-stand test, 6 min walk test, 10 m walk test, Physical-Self Perception Questionnaire (PSPQ) and State-Train Anxiety Inventory (STAI) were performed just before and after home confinement. Results A non-significant moderate effect (p = 0.07; ES = -0.48) was observed in the time in the sit-to-stand test compared to pre-home confinement. There was a significant increase in the time in TUG (p = 0.02; ES = -0.67). The PSQP score decreased (p = 0.01; ES = 0.79) and STAI-state increased (p = 0.01; ES = -0.65) following home confinement. Conclusion Home confinement had an impact on functional capacity, physical self-perception and state anxiety. However, neuromuscular performance was not altered after home confinement.

Ramos-Campo, DJ, Martínez-Guardado, I, Rubio-Arias, JA, Freitas, TT, Othalawa, S, Andreu, L, Timón, R, and Alcaraz, PE. Muscle architecture and neuromuscular changes after high-resistance circuit training in hypoxia. J Strength Cond Res 35(11): 3035-3040, 2021-This study aimed to analyze the effect of 8 weeks of high-resistance circuit (HRC) training in hypoxia on muscle architecture, strength, and neuromuscular variables. Twenty-eight resistance-trained subjects were assigned to a hypoxia (FiO2 = 15%; HG: n = 15; age: 24.6 ± 6.8 years; height: 177.4 ± 5.9 cm; and mass: 74.9 ± 11.5 kg) or normoxia group (FiO2 = 20.9%; NG: n = 13; age: 23.2 ± 5.2 years; height: 173.4 ± 6.2 cm; and mass: 69.4 ± 7.4 kg). Each training session consisted of 2 blocks of 3 exercises (block 1: bench press, leg extension, and front lat pulldown; block 2: deadlift, elbow flexion, and ankle extension). Each exercise was performed with a 6 repetition maximum load. Subjects exercised twice weekly and, before and after the training program, vastus lateralis muscle thickness and pennation angle, knee extensors electromyographic activity, maximum voluntary contraction (MVC), and rate of force development (RFD) and H-Reflex (Hmax), M-wave of the soleus muscle were assessed. Both training groups showed similar improvements in muscle thickness (effect size [ES] = HG: 0.23; NG: 0.41), pennation angle (ES = HG: 0.86; NG: 0.15), MVC (ES HG: 0.63; NG: 0.61), Hmax (ES = HG: 0.96; NG: 0.40), RFD at 200 milliseconds (ES = HG: 0.31; NG: 0.61) and peak RFD (ES = HG: 0.21; NG: 0.66). No significant between-group differences were found. In conclusion, similar morphological and neuromuscular adaptations can be achieved after 8 weeks of HRC training under hypoxic or normoxic conditions.

Objective To describe the objectives and methods of the Spanish Society of Rheumatology primary Sjogren syndrome (pSS) registry (SJOGREN-SER). Methods This is a multicenter descriptive transversal study of a cohort of pSS patients fulfilling European/American consensus criteria collected from Rheumatology clinics all over Spain. Patients were included by randomisation from an anonymised list provided by every department. Data were collected by reviewing clinical records and an interviewing the patients. Two hundred and ninety eight variables were investigated: epidemiological, clinical, serological characteristics, treatments and complications. Informed consent was obtained and local ethics committees approved the study. Variables were analyzed by descriptive statistical methods, using means, medians, and rates, with their deviations and interquartile ranges (p25–p75). Results A total of 3 rheumatology departments participated in the registry. A total of 437 patients were included. And 95% of them were women, with a median age of 58. Median age at pSS's diagnosis was 50 years. Dryness symptoms (95%) were the most frequent complaint and anti-Ro/SS-A were present in 94% of the cases. Only 27% of the patients fulfilled the new 2012 SICCA-ACR classification criteria. Conclusions SJOGREN-SER has been designed in order to characterize a representative pSS Spanish cohort, in clinical daily practice, to analyze the magnitude and distribution of its manifestations, activity, accumulated damage and therapeutic management of the disease. This will allow broadening the knowledge of this disease and plan strategies of action in pSS.

Objective: The aim of this study was to analyse differences in clinical presentation in patients with early (< 3 years’ duration) systemic sclerosis (SSc), comparing three age groups according to disease subsets. Method: Cross-sectional analysis of the prospective EULAR Scleroderma Trials and Research database (EUSTAR) was performed. Patients fulfilling preliminary American College of Rheumatology 1980 classification criteria for SSc, with < 3 years from the first non-Raynaud’s SSc symptom at first entry, were selected. Patients with < 3 years from the first SSc symptom, including Raynaud’s phenomenon, were also analysed. SSc-related variables, including antibodies, SSc subsets, and organ involvement, were examined. Age was categorized into ≤ 30, 31–59, and ≥ 60 years. We performed descriptive and bivariate analyses. Results: The study included 1027 patients: 90% Caucasian, 80% women, and 40% with diffuse disease. In early stages of SSc, younger patients had significantly more anti-Scl-70 antibodies and diffuse disease. With increasing age, we observed more elevation of estimated pulmonary systolic pressure on echocardiography (5%, 13%, and 30%, respectively, in the three age groups), cardiac conduction blocks (6%, 6%, and 15%), and left ventricular diastolic dysfunction (4%, 12%, and 27%). The results were similar for 650 patients with < 3 years from first SSc symptom, including Raynaud’s. Conclusion: In early stages of SSc, older patients showed data indicating more severe disease with greater cardiac involvement. The diffuse subset was more frequent in the younger subgroup. The identification of such differences may help in selecting appropriate management for individual patients in clinical practice. (Less)

Objective The AR Excellence project evaluates clinical monitoring in patients with rheumatoid arthritis (RA) in Spain. The aim of the study was to analyse the use of methotrexate (MTX) in the AR Excellence cohort and to compare it with current recommendations. Patients and methods We collected data from RA patients who initiated treatment with MTX. They included demographics, dose and routes of administration, switching among them, highest dose in each route, combinations with other disease-modifying antirheumatic drugs (DMARDs), time to combination with another DMARD (either conventional or biological) and adverse events. Results Six hundred twenty-five patients with RA (mean age 55 years; 70.6% women) were included, with an average disease duration of 21 months. Ninety percent of the patients initiated treatment with MTX. Therapy was begun with a mean dose of 11 mg per week; this initial dose was increased in 58% of the individuals. The average time to reach the full dose of MTX (20 mg a week) was 6.67 months. Time to combination of MTX with another DMARD, either synthetic or biological, was 3 months. In all, 67.4% of the patients received oral MTX and the route was subcutaneous in 18.6%. In 12% of the cases, there was a change in the route of administration after a period of 6 months. In 544 patients, folate supplements were added to MTX; MTX-related adverse events were detected in 17.3% of the patients. Conclusion MTX is currently the pivotal treatment in RA. The subanalysis of the AR Excellence project demonstrates that MTX escalation to its full doses is not done with adequate speed. The subcutaneous route is used in a small proportion of patients.

Whole-body vibration training (WBVT) has been used in people with relapsing-remitting multiple sclerosis (pwMS), showing improvements in different neuromuscular and mobility variables. However, the acute effects of this training are still unknown. The acute effects of WBVT on neuromuscular performance, mobility and rating of perceived exertion (RPE) were evaluated in 10 pwMS.Maximal voluntary isometric contraction (MVIC), central activation ratio (CAR), electromyography (EMG) of the vastus lateralis during isometric knee extension, Timed Up and Go Test (TUG), walking speed and RPE were assessed before and immediately after a session of WBVT (twelve 60-s bout of vibration; frequency 35 Hz; amplitude 4 mm; 1-min rest intervals) in both hypoxic and normoxic conditions.EMG 0-100, 0-200 ms and peak EMG resulted in significant differences (p 0.05) between normoxic and hypoxic sessions. The EMG activity tended to decrease in all phases after the hypoxic session, indicating possible influence of hypoxia on neuromuscular performance. No changes were found in CAR, MVIC, TUG and walking speed in both conditions.Based on our results, as well as those obtained by other studies that have used WBVT with other populations, more studies with a higher sample and lower dose of vibration exposure should be conducted in pwMS.

Sarcopenia is an age-related condition. However, the prevalence of sarcopenia may increase due to a range of other factors, such as sleep quality/duration. Therefore, the aim of the study is to conduct a systematic review with meta-analysis to determine the prevalence of sarcopenia in older adults based on their self-reported sleep duration. Methods: Three electronic databases were used—PubMed-Medline, Web of Science, and Cochrane Library. We included studies that measured the prevalence of sarcopenia, divided according to sleep quality and excluded studies (a) involving populations with neuromuscular pathologies, (b) not showing prevalence values (cases/control) on sarcopenia, and (c) not including classificatory models to determine sleep quality. Results: high prevalence values in older adults with both long and short sleep duration were shown. However, prevalence values were higher in those with inadequate sleep (

The association of dermatomyositis with myasthenia gravis (MG) is uncommon, having been reported so far in only 26 cases. We report the case of a 69 year-old man diagnosed with MG two years ago and currently treated with piridostigmyne. The patient developed acute proximal weakness, shoulder pain and elevated creatine-kinase (CK). He also developed generalized facial erythema and Gottron's papules. Laboratory tests showed positive antinuclear and anti-Mi2 antibodies. Further analysis confirmed CK levels above 1000 U/l. The clinical management of the patient and the therapeutic implications derived from the coexistence of both entities are discusssed.

Objective To know rheumatologists’ opinion on the usefulness of ultrasound in diagnostic and therapeutic decision making as applied to rheumatic diseases. Materials and methods A National survey was sent to all rheumatology units in hospitals with at least 200 beds. The questionnaire included: (a) general data, (b) purpose and most common areas of ultrasound exploration and (c) assessment of the usefulness of ultrasound in routine clinical practice in general and in some rheumatologic diseases. Results One-hundred and sixty-nine out of 234 rheumatology units contacted answered the questionnaire. The utility in routine clinical practice was scored at 7.8 (scale 0–10) and ultrasound was integrated in making diagnostic and therapeutic decisions. Half of the indications (50.9%) were ultrasound related to the process of diagnosis of diseases or treatment decision making (monitoring synovitis 14.6%, guided puncture 11.4%, early detection of joint erosion or synovitis 10.3%, early detection of enthesopathy 5.9%, carpal tunnel syndrome or other peripheral neuropathies 3.4%, detection of uric acid or pyrophosphate deposits 3%, vasculitis 1% and others 1.1%. On a 1–5 Likert, scale most of the answers support the use of ultrasound in clinical practice, especially in diagnostic and therapeutic decision making for detection of subclinical synovitis, erosions and treatment decisions in rheumatoid arthritis, enthesitis diagnosis, crystal diseases, polymyalgia rheumatica and giant cell arteritis. Conclusions Ultrasound is becoming a useful tool integrated into clinical practice and is linked to the decision-making processes in the areas of diagnosis, activity and treatment.

Corticosteroids are a mainstay in the therapy of rheumatoid arthritis (RA). In recent years, a number of high-quality controlled clinical trials have shown their effect as a disease-modifying anti-rheumatic drug (DMARD) and a favorable safety profile in recent-onset RA. Despite this, they are more frequently used as bridge therapy while other DMARDs initiate their action than as true disease-modifying agents. Low-dose corticosteroid use during the first two years of disease slows radiologic damage and reduces the need of biologic therapy aimed at reaching a state of clinical remission in recent-onset RA. Thus, their systematic use in this clinical scenario should be considered.

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

Objective To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA). Methods Recommendations were generated following a nominal group technique. A panel of experts, consisting of 15 rheumatologists and 3 radiologists, was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of experts voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist. Results A total of 20 recommendations were proposed. They include the validity of US and MRI regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies. Conclusions These recommendations will help clinicians use US and MRI in RA patients.

Objective To know the situation of ultrasound in Spanish rheumatology. Methods A national survey addressed to all rheumatology units in hospitals with at least 200 beds. The questionnaire studied: (a) the availability and the model of the ultrasound equipment, (b) the degree of training, (c) the purpose and areas of ultrasound examination, (d) the usefulness, and (e) the relevance of ultrasound in the training of residents. Results 169 units of the 234 surveyed physicians answered the questionnaire. The availability of ultrasound equipment was high (90%), 38.7% of rheumatologists use ultrasound, although half of the units had a rheumatologist especially dedicated to performing them. Training plans have enabled the incorporation of ultrasound, but there are areas that could be improved. The utility in routine clinical practice was scored at 7.8 (0–10), and ultrasound was integrated in the diagnostic and therapeutic decisions. There is a broad consensus on the need to include ultrasound in the training of residents. Administration is adding ultrasound to the portfolio of specialty services. Conclusions In just 15 years, ultrasound has become available in 90% of rheumatology units from being previously inexistent. Its use is extensive, integrated into clinical practice and linked to the decision making processes. Training plans have been effective, but areas for improvement were identified, and there is a broad consensus on the need to integrate ultrasound in residents’ training.

The National Commission of Rheumatology has developed a satisfaction survey for residents concerning their training period. 37% of the 176 invited to participate answered the survey. 71% said they were satisfied or very satisfied with the influence of the assistance activities during their training. 38% were dissatisfied or very dissatisfied with supervision by staff. 39% were dissatisfied or very dissatisfied with their training in polarized light microscopy. 52% said no regular meetings were structured to monitor their training. 66% said that there had been no effective evaluation of their training. 39% were dissatisfied or very dissatisfied on the tools they were given to publish at their teaching unit. Overall satisfaction on classroom training for residents of Rheumatology is high. There are opportunities for improvement relating to training in certain techniques, monitoring and evaluation of the training period and training in research skills.

Lupus nephritis is a relevant source of morbidity and mortality in patients with systemic lupus erythematosus. The standard therapy of remission induction in severe lupus nephritis is based on the use of monthly intravenous cyclophosphamide. Recent data have established that the maintenance of remission in lupus nephritis can be achieved with azathioprine or mycophenolate mofetil, with less adverse effects than quarterly intravenous cyclophosphamide. In recent years, a number of controlled randomized clinical trials have been published, opening new therapeutic options in the induction of remission in lupus nephritis, such as less aggressive regimens of intravenous cyclophosphamide or mycophenolate mofetil. Further studies are needed for establishing the optimal therapy of lupus nephritis patients.

Background: Immune-mediated inflammatory diseases (IMIDs) are a group of complex and prevalent diseases where disease diagnostic and activity monitoring is highly challenging. The determination of the metabolite profiles of biological samples is becoming a powerful approach to identify new biomarkers of clinical utility. In order to identify new metabolite biomarkers of diagnosis and disease activity, we have performed the first large-scale profiling of the urine metabolome of the six most prevalent IMIDs: rheumatoid arthritis, psoriatic arthritis, psoriasis, systemic lupus erythematosus, Crohn's disease, and ulcerative colitis. Methods: Using nuclear magnetic resonance, we analyzed the urine metabolome in a discovery cohort of 1210 patients and 100 controls. Within each IMID, two patient subgroups were recruited representing extreme disease activity (very high vs. very low). Metabolite association analysis with disease diagnosis and disease activity was performed using multivariate linear regression in order to control for the effects of clinical, epidemiological, or technical variability. After multiple test correction, the most significant metabolite biomarkers were validated in an independent cohort of 1200 patients and 200 controls. Results: In the discovery cohort, we identified 28 significant associations between urine metabolite levels and disease diagnosis and three significant metabolite associations with disease activity (P-FDR < 0.05). Using the validation cohort, we validated 26 of the diagnostic associations and all three metabolite associations with disease activity (PFDR < 0.05). Combining all diagnostic biomarkers using multivariate classifiers we obtained a good disease prediction accuracy in all IMIDs and particularly high in inflammatory bowel diseases. Several of the associated metabolites were found to be commonly altered in multiple IMIDs, some of which can be considered as hub biomarkers. The analysis of the metabolic reactions connecting the IMID-associated metabolites showed an overrepresentation of citric acid cycle, phenylalanine, and glycine-serine metabolism pathways. Conclusions: This study shows that urine is a source of biomarkers of clinical utility in IMIDs. We have found that IMIDs show similar metabolic changes, particularly between clinically similar diseases and we have found, for the first time, the presence of hub metabolites. These findings represent an important step in the development of more efficient and less invasive diagnostic and disease monitoring methods in IMIDs.

Objective To establish recommendations for the management of patients with rheumatoid arthritis (RA) to serve as a reference for all health professionals involved in the care of these patients, and focusing on the role of available synthetic and biologic disease-modifying antirheumatic drugs (DMARDs). Methods Consensual recommendations were agreed on by a panel of 14 experts selected by the Spanish Society of Rheumatology (SER). The available scientific evidence was collected by updating three systematic reviews (SR) used for the EULAR 2013 recommendations. A new SR was added to answer an additional question. The literature review of the scientific evidence was made by the SER reviewer's group. The level of evidence and the degree of recommendation was classified according to the Oxford Centre for Evidence-Based Medicine system. A Delphi panel was used to evaluate the level of agreement between panellists (strength of recommendation). Results Thirteen recommendations for the management of adult RA were emitted. The therapeutic objective should be to treat patients in the early phases of the disease with the aim of achieving clinical remission, with methotrexate playing a central role in the therapeutic strategy of RA as the reference synthetic DMARD. Indications for biologic DMARDs were updated and the concept of the optimisation of biologicals was introduced. Conclusions We present the fifth update of the SER recommendations for the management of RA with synthetic and biologic DMARDs.

Hypohidrosis is a classic feature of Fabry disease; in contrast, hyperhidrosis has only been rarely described. The aim of the study is to characterise the baseline descriptive data on hyperhidrosis (frequency, age at onset, sex ratio and outcome with and without enzyme replacement therapy) in hemizygous male and heterozygous female patients with Fabry disease. We describe case histories of five patients with Fabry disease and hyperhidrosis seen at three different centres. We have also analysed a cohort of 21 paediatric patients in the UK and a large European cohort of patients enrolled in the Fabry Outcome Survey (FOS). Five patients (three female, two male) with hyperhidrosis were originally identified, although each had additional symptoms related to Fabry disease. The age at onset of hyperhidrosis was less than 18 years in four cases. In the cohort of 21 paediatric patients (12 female, nine male), one female had hyperhidrosis; the age at onset of this symptom was 11 years. In the FOS cohort, 66 of 714 patients with Fabry disease had hyperhidrosis (44 of 369 females, 11.9%; 22 of 345 males, 6.4%). The female predominance was observed in seven of nine countries from which data were analysed. Hyperhidrosis is an increasingly recognised feature of the Fabry disease phenotype. It is more prevalent in females than in males and often appears in childhood or adolescence. The efficacy of enzyme replacement therapy on this recently recognised symptom should be assessed.

The prevalence of vitamin D deficiency and insufficiency among patients with systemic lupus erythematosus is high. This is likely due to photoprotection measures in addition to intrinsic factors of the disease. Low levels of vitamin D increase the risk of low bone mineral density and fracture. Vitamin D deficiency could also have undesirable effects on patients' immune response, enhancing mechanisms of loss of tolerance and autoimmunity. Vitamin D levels should be periodically monitored and patients should be treated with the objective of reaching vitamin D levels higher than 30-40 ng/ml.

Anti-tumor necrosis factor-a (TNF) therapy has been associated with reactivation of hepatitis B virus infection. Case reports have suggested the concomitant need of lamivudine treatment in patients with HBV infection treated with antiTNFa agents. We describe a case of ankylosing spondylitis with positive HBV surface antigen (HBsAg) treated with infliximab and lamivudine. Clinical response was excellent but when lamivudine therapy was stopped, reactivation of replication viral occurred. After the reintroduction of lamivudine, viral replication was controlled and liver function tests were normalized. Preventive long-term lamivudine therapy is mandatory when anti-TNFa therapy is maintained in patients with chronic HBV infection.

The patient is a 39-year-old woman who presented nocturnal paresthesia lasting for 6 months on both hands, but predominantly right (dominant hand). She presented mechanical pain of both wrists, with a visual analog score (VAS) of 90/100. Upon examination, there was a solid tumor on the posterior side of both wrists (Fig. 1), painful limitation of extension of the wrist and supination, mainly on the left side. The hemogram and blood chemistry were normal, as well as the neurophysiological study of the median and ulnar nerves. A karyotype demonstrated mosaicism (86% XX, 5% XXX, 9% X). The posteroanterior wrist X-rays (Fig. 2) showed typical Madelung deformity changes on the right wrist1: shortening of the radius compared to the ulna, dorsally and radially curved radius, dorsal and radial convexity, an angle similar to the distal radial joint surface, a mismatch of the distal radioulnar joint and carpal dislocation. The lateral projection (Fig. 3) demonstrated anterior arching of the radius and dorsal dislocation on the ulnar head; the carpus was also dislocated on the ulnar side and anteriorly in the distal radioulnar joint, in a way that made the wrist bones appear to follow the arch of the radius.2 The patient was diagnosed with a carpal tunnel syndrome due to Madelung’s deformity and was programmed for an evaluation by the orthopedics department but, due to a delay, medical treatment with local steroid infiltrations was carried out. 1 ml of triamcinolone was injected into the right wrist using a standard technique.3 The pain improved in the next 2 days (VAS: 50/100), disappearing completely after one week (VAS: 0/100).

Methotrexate (MTX) is the first-choice drug for the treatment of rheumatoid arthritis (RA) patients. However, 30% of RA patients discontinue therapy within 1 year, usually because of adverse effects. Previous studies have reported conflicting results on the association of polymorphisms in the MTHFR gene with the toxicity of MTX in RA. The aim of this study was to assess the involvement of the C677T and A1298C polymorphisms in the MTHFR gene in the toxicity of MTX in a Spanish RA population.The study included retrospectively 468 Spanish RA patients treated with MTX. Single nucleotide polymorphism (SNP) genotyping was performed using the oligonucleotide microarray technique. Allele and genotype association analyses with regard to MTX toxicity and a haplotype association test were also performed.Eighty-four out of the 468 patients (18%) had to discontinue therapy due to adverse effects or MTX toxicity. The C677T polymorphism (rs1801133) was associated with increased MTX toxicity [odds ratio (OR) 1.42, 95% confidence interval (CI) 1.01-1.98, p = 0.0428], and the strongest association was shown in the recessive model (OR 1.95, 95% CI 1.08-3.53, p = 0.0246). The A1298C polymorphism (rs1801131) was not associated with increased MTX toxicity (OR 0.94, 95% CI 0.65-1.38, p = 0.761). A borderline significant risk haplotype was found: 677T-1298A (OR 1.40, 95% CI 1.00-1.96, p = 0.0518).These results demonstrate that the C677T polymorphism in the MTHFR gene is associated with MTX toxicity in a Spanish RA population.

Objective Due to the increasing use of biologic therapy in rheumatic diseases and the importance of its risk management, the Spanish Society of Rheumatology (SER) has promoted the development of recommendations based on the best evidence available. These recommendations should be a reference to rheumatologists and those involved in the treatment of patients who are using, or about to use biologic therapy irrespectively of the rheumatic disease. Methods Recommendations were developed following a nominal group methodology and based on systematic reviews. The level of evidence and degree of recommendation were classified according to the model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through a Delphi technique. Evidence from previous consensus and clinical guidelines was used. Results We have produced recommendations on risk management of biologic therapy in rheumatic patients. These recommendations include indication risk management, risk management before the use of biologic therapy, risk management during follow-up, attitude to adverse events, and attitude to special situations. Conclusions We present the SER recommendations related to biologic therapy risk management.

The National Rheumatology Board is responsible for postgraduate formation in rheumatology. Herein we present the new criteria for accreditation of teaching units. These criterion contemplate four domains, namely: structure, clinical work, teaching and research. Each domain is divided in subdomains and items. Some of them are of an obligatory nature. This document serves as reference for future applications. The document may be reviewed in the future.

Objective To provide a reference to rheumatologists and to those involved in the treatment of RA who are using, or about to use biologic therapy. Methods Recommendations were developed following a nominal group methodology and based on systematic reviews. The level of evidence and grade of recommendation were classified according to the model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through Delphi technique. Results We have produced recommendations on the use of the seven biologic agents available for RA in our country. The objective of treatment is to achieve the remission of the disease as quickly as possible. Indications and nuances regarding the use of biologic therapy were reviewed as well as the evaluation that should be performed prior to administration and the follow up of patients undergoing this therapy. Conclusions We present an update on the SER recommendations for the use of biologic therapy in patients with RA.

Anti-TNFα agents represent an outstanding advance in the symptomatic control of patients with ankylosing spondylitis presenting an inadequate response to non-steroidal anti-inflammatory drugs. Anti-TNFα antagonists have demonstrated efficacy and safety in the long-term but continuous therapy is needed for an adequate control of symptoms. After the failure to a first anti-TNFα agent, the use of a second TNFα antagonist seems to be effective and safe. Despite the fast and continuous suppression of bone inflammation, demonstrated by magnetic resonance imaging, the beneficial effect of treatment with TNFα antagonists on the radiological evolution has not been demonstrated to date in ankylosing spondylitis. It seems that insights into new therapeutic molecular targets implicated in the process of ossification are needed.

Glucocorticoids (GC) are a mainstay of the therapy in rheumatoid arthritis (RA). Currently, and despite their extensive use, the discussion about the benefits and adverse effects of low dose GC in the management of RA persists. In recent years, a number of clinical trials have attempted to establish the benefits of long-term GC use as a disease-modifying antirheumatic drug in RA, and to define their side effects. Results of these clinical trials provide solid evidence that low-dose GC can inhibit radiographic damage in early RA, and that side effects of GC, when used in that clinical framework, are limited to hyperglycaemia, cataracts, and transient weight gain.

Pulmonary tuberculosis (TB) is a common worldwide lung infection. The radiological features show considerable variation, but in most cases they are characteristic enough to suggest the diagnosis. Classically, tuberculosis is divided into primary, common in childhood, and postprimary, usually presenting in adults. The most characteristic radiological feature in primary tuberculosis is lymphadenopathy. On enhanced CT, hilar and mediastinal nodes with a central hypodense area suggest the diagnosis. Cavitation is the hallmark of postprimary tuberculosis and appears in around half of patients. Patchy, poorly defined consolidation in the apical and posterior segments of the upper lobes, and in the superior segment of the lower lobe is also commonly observed. Several complications are associated with tuberculous infection, such as hematogenous dissemination (miliary tuberculosis) or extension to the pleura, resulting in pleural effusion. Late complications of tuberculosis comprise a heterogeneous group of processes including tuberculoma, bronchial stenosis bronchiectasis, broncholithiasis, aspergilloma, bronchoesophageal fistula and fibrosing mediastinitis. Radiology provides essential information for the management and follow up of these patients and is extremely valuable for monitoring complications.