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Background Primary Sjogren’s syndrome (pSS) is a systemyc autoimmune disease that produces a limpho-plasmocitary infiltrate of the exocrine glands. Considering the primary role attributed to B-lymphocytes in pSS pathophysiology, it has been suggested that Rituximab (RTX) may have certain role in controlling the disease. Objectives To evaluate RTX efficacy in the treatment of xerostomia, xerophthalmia and systemic manifestations (including fatigue) in patients with pSS. Methods In the framework of the preparation of a recommendations document of the Spanish Society of Rheumatology on the use of biologics in pSS, a systematic search of the literature was carried out (until May 2017). Were included adults older than 18 years who met the 2002 American European Consensus Criteria, treated with RTX, with desired comparison to groups treated with other drugs or with placebo and a follow-up time of 6 months. The quality of the studies was assessed through the levels of evidence (LOE) of SIGN scale. Results The search resulted in a total of 749 articles and only 9 of them were selected (figure 1). The best available evidence for each variable studied is summarised in chart 1 (”+” significant improvement; ”-” no significant improvement). The most relevant results obtained in the studies with LOE 1+, showed significant differences comparing RTX with lacebo (p Conclusions The studies of high methodological quality that evaluate the efficacy of RTX in pSS do not find significant improvement in the primary outcome variables, such as ESSDAI, glandular involvement and other objective parameters of dryness. However, open and retrospective studies find significant improvement in activity parameters, systemic manifestations, glandular involvement and improvement of certain objective tests of dryness. Disclosure of Interest None declared

Background Ultrasonography (US) is the rheumatologists’ best tool that must be taught and learnt correctly. The ultrasound school of the Spanish Society of Rheumatology has trained many rheumatologists for more than twenty years. Approximately 75% of the rheumatology departments in Spain use US. However, we lack current views of features related with competency, teaching rheumatology residents, US usage and implementation. Methods A cross sectional survey was performed using an online standardised questionnaire sent to all members of the SSR in January 2017. The questionnaire was developed by the four authors, corrected for size, style, syntaxes and was piloted on four different aged rheumatologists. Six aspects were studied; general data, US training, rheumatology residents training in US and main uses and applications of US. The questionnaire used either closed or Likert scale answers and took about 20 min to answer. Herein we describe the main results on usage and applications of US. Results 113 responses: 60% women, 45±12 years old, 73% working in public university hospital with one or more US machines. US is usually used at the time of clinical consultation or at appointment for US. 43% have a specific agenda for US diagnosis and monitoring inflammatory arthritis patients. The 3 principals for using US are: as a problem solving tool in the clinical context; as a diagnostic tool in inflammatory arthritis and; as a tool to guide injections. The table shows the percentage of the responses always and almost always for 10 clinical contexts. As diagnostic tool in rheumatoid arthritis (RA), 66% use US to confirm arthritis when clinical exam is unclear and 33% in patients with inflammatory arthralgia plus high ESR, CRP, RF or anti-CCP. 36% monitor disease activity using a reduced joint assessment; one target joint plus 2,3 MCP and 2,3, 5 MTP joints and 32% use a validated joint count. 66% use US to assess remission in RA all patients (22%), only in those treated with biologic drugs (28%) and in RA patients with poor prognostic factors (18%). Most use US to confirm clinical enthesitis when a spondyloarthropathy (SpA) is suspected and half consider that a positive entheseal Dopppler signal supports more aggressive management. 76% perform real-time guided injections for the following disorders/sites: Baker’s cyst, subacromial-subdeltoid bursa, tibionavicular joint, anterior coxofemoral joint, retrocalanceal bursa and extensor wrist tenosinovitis. Conclusions Rheumatologist- ultrasonographers in Spain use ultrasonography in a wide spectrum of diseases and clinical contexts mainly to facilitate diagnosis and improve treatment of rheumatic patients. Disclosure of Interest None declared

Objectives To investigate the primary respiratory manifestations (PRM) in SLE. Methods All patients in the RELESSER cohort were retrospectively investigated for the presence of PRM Results At least one PRM was present in 11.3% (365/3215) of cases. The most common was pleurisy, occurring in 21.1% of patients, followed by ALP in 3.6%, PE in 2.9%, PPH 4%, DILD in 2%, DAH in 0.8%, and SLS in 0.8%. The variables associated with the presence of PPM are shown in the following table 1: Conclusions PPM independently contributed to a decreased survival in SLE Disclosure of Interest None declared

Background Primary Sjogren syndrome (pSS) is a systemic autoimmune disease whose main characteristic is the involvement of the exocrine glandular system. Thus, its most common clinical manifestation is eye and mouth dryness. No therapy has been demonstrated to significantly modify disease course and, currently, evidence-based therapy for pSS is mainly limited to symptomatic drugs for drynes. Objectives To describe the dryness treatment in a cohort of primary Sjogren Syndrome patients. Methods SJOGRENSER registry is a multicentre descriptive cross-sectional study of pSS patients, fulfilling European/American criteria, from 33 Spanish rheumatology departments. Data were collected by reviewing clinical records and interviewing the patients. Informed consent was obtained and local ethics committees approved the study. Variables were analysed by descriptive statistics using means, medians and ranges. Chi square test was used to compare categorical variables. A p Results Four hundred and thirty seven patients were included (female 95%; median age 58 years). Ninety four per cent of the patients complained of daily, persistent, troublesome dry eyes for more than 3 months, 92% had sensation of sand in the eyes, 16% developed corneal ulcer. Ninety four per cent of the patients complained of dry mouth for more than 3 months and 27% had dental loss. The most frequent ocular dryness treatments were tear substitutes (96%), followed by lubricating ophthalmological ointments (46%), autologous sera solutions (14%), topical corticosteroids (13%), topical cyclosporine (6%). Comparing patients with and without ocular dryness, only pilocarpine and lubricating eye ointment were used significantly with more frequency in symptomatic patients (p Conclusions Despite the high number of symptomatic patients, the use of dryness treatments is limited in pSS patients. Chewing gums or candies without sugar, xylitol and fluoride remain underutilised in this cohort. Despite the dryness VAS score, patients do not seem to use all the symptomatic therapeutic options available. Disclosure of Interest None declared

Background Primary Sjogren’s Syndrome (pSS) is a systemic autoimmune disorder characterised by lymphocytic infiltration of the exocrine glands resulting in dry syndrome. Approximately one-third of patients have extraglandular systemic findings, such as respiratory symptoms (43%–75%), that are also considered to be a cause of morbidity and conditioning quality of life. The aim of the study is to estimate the prevalence of pulmonary manifestations in pSS, and to identify factors associated with its development. Methods SJOGREN-SER (Spanish Rheumatology Society Registry of pSS) is a multicenter cross-sectional study of pSS patients under active follow-up at 33 rheumatology departments through Spain. Patients fullfilled the European-American consensus criteria of 2002. Airway disease (dry cough, xerotrachea, bronchial, hyperresponsiveness and airway obstruction) and pulmonary involvement (ILD, pulmonary amyloidosis, pulmonary arterial hypertension, vasculitis and pleural involvement) were considered according to the definition contained in EULAR Sjogren’s Disease Activity Index (ESSDAI), as well as Sjogren’s Syndrome Disease Damage Index. Bivariate logistic regression models and multivariate analysis were used to establish the independent effect of patient characteristics associated with pulmonary manifestations. The results were considered significant when the P value was less than 0.05. Results The SJOGREN-SER registry included 437 patients (95% women, median age at inclusion 59 years [50–68 years] and mean of ESSDAI 2 (IQR 0–4)). One hundred and seventeen patients (26.8%) had pulmonary manifestations (19.2% airway disease and 9.8% pulmonary involvement). Ten patients presented both. Sociodemographic characteristics were: mean age 59.5 years (SD: 11.46), 94.9% women and 19.6% smokers or former smokers. Patients with pulmonary manifestations had higher ESSDAI score (6 (SD 6) vs 4 (SD 5)), prolonged disease duration (10.05 years (SD: 7.15) vs 7.7 (SD 6.3)) and were ANA positive more frequently (94.9% vs 62.2%). Airway involvement preceded or occurred at the time of diagnosis in 46.4% of patients. Pulmonary involvement occurred 5 years after the diagnosis of pSS in 37.2% of them. [RS1] Twenty-nine patients (6.6%) were diagnosed with ILD. The most frequent radiological patterns were: Non-Specific Interstitial Pneumonia n=14, Usual Interstitial Pneumonia n=5, Lymphocytic Interstitial Pneumonia n=5 and Cryptogenic Organised Pneumonia n=2. Stepwise multivariate analysis was performed including the following variables: sex, age, laboratory findings, disease duration, smoking and ESSDAI. Disease duration (OR of 1.05 (95% CI, 1.006–1.083)), ESSDAI score (OR of 1.044 (95% CI, 1.006–1.083)) and positivity for ANA (OR of 3.725 (95% CI, 1.141–12.159)) were found to be associated factors with pulmonary involvement in pSS. Conclusions Prevalence of pulmonary manifestations in this cohort of pSS patients is substantial due to both airway disease and pulmonary involvement. Disease duration, activity of pSS according to ESSDAI score and ANA positivity were factors associated with the development of pulmonary manifestation. Disclosure of Interest None declared

Background: Systemic lupus erythematosus (SLE) is a common systemic autoimmune disease with a complex genetic inheritance. Genome-wide association studies (GWAS) have significantly increased the number of significant loci associated with SLE risk. To date, however, established loci account for less than 30% of the disease heritability and additional risk variants have yet to be identified. Here we performed a GWAS followed by a meta-analysis to identify new genome-wide significant loci for SLE. Methods: We genotyped a cohort of 907 patients with SLE (cases) and 1524 healthy controls from Spain and performed imputation using the 1000 Genomes reference data. We tested for association using logistic regression with correction for the principal components of variation. Meta-analysis of the association results was subsequently performed on 7,110,321 variants using genetic data from a large cohort of 4036 patients with SLE and 6959 controls of Northern European ancestry. Genetic association was also tested at the pathway level after removing the effect of known risk loci using PASCAL software. Results: We identified five new loci associated with SLE at the genome-wide level of significance (p < 5 × 10? 8): GRB2, SMYD3, ST8SIA4, LAT2 and ARHGAP27. Pathway analysis revealed several biological processes significantly associated with SLE risk: B cell receptor signaling (p = 5.28 × 10? 6), CTLA4 co-stimulation during T cell activation (p = 3.06 × 10? 5), interleukin-4 signaling (p = 3.97 × 10? 5) and cell surface interactions at the vascular wall (p = 4.63 × 10? 5). Conclusions: Our results identify five novel loci for SLE susceptibility, and biologic pathways associated via multiple low-effect-size loci. This study was funded by the Spanish Ministry of Economy and Competitiveness (grant numbers: PSE-010000-2006-6 and IPT-010000-2010-36). This work has been also sponsored by the grant SEV-2011-00067 of Severo Ochoa Program, awarded by the Spanish Government. This work was supported by an EFSD/Lilly research fellowship. Josep M. Mercader was supported by Sara Borrell Fellowship from the Instituto Carlos III. Sílvia Bonàs was awarded an FI-DGR Fellowship from FI-DGR 2013 from Agència de Gestió d’Ajuts Universitaris i de Recerca (AGAUR, Generalitat de Catalunya). The study sponsors had no role in the design of the study, collection, analysis or interpretation of the data.

The aim of this work is to study the prevalence of mycobacterial infection (M.I.), the associated factors and their clinical significance in patients included in a large SLE cohort. Methods Retrospective descriptive study of RELESSER patients with a history of M.I. and analysis of the factors associated with the infection of this aetiology. Results In RELESSER 3,658 SLE patients were included. 90% women, mean age of 32.9 years. 93% Caucasians. The mean follow-up time (±S.D.) was 120.2 (±87.6) months. 705 (19.3%) patients had at least a serious infection, 1227 serious infections occurred. M.I. were diagnosed in 42 patients (1.2% of all RELESSER patients, 3.4% of all serious infections), 85.7% women. The incidence rate of mycobacterial infection was 1 per 1000 patients/year (95% CI: 0.7 to 1.4). M.I. presentation was pulmonary in 18 (42.9%) patients and extrapulmonary in 24 (57.1%)patients:joints in 8 (19.0%) patients, soft tissue in 6 (14.3%) and other sites in 10 (23.8%). The extrapulmonary form was associated with the use of immunosuppressants: 84.6% of the 13 patients treated with immunosuppressive drugs versus 44.4% of the 27 patients without (p=0.01). We did not observe this association with the use of corticosteroids. To study the factors associated with mycobacterial infection, we performed a bivariate analysis including the variables associated with severe infection identified in RELESSER (age, sex, ethnicity, use of corticosteroids, immunosuppressants, antimalarials, previous admission by SLE activity, use of rituximab, use of anti-TNF, Katz severity index, SDI damage index, SLEDAI activity index and Charlson comorbidity index). There is a statistically significant association with previous admission by SLE activity (RR: 2.9,95–95% CI: 1.3 to 6.2, p=0.007), renal impairment (RR:2.0, 95% CI: 1,1 to 3,7, p=0,04), the Katz score (RR: 2.1, 95% CI:1.1–4.0,p=0.04) and the Charlson index (RR: 2.5; 95% CI: 1.3 to 4.8, p=0.009). The accumulated damage (SDI>0) was closely associated with significance: RR: 2.0; 95% CI: 1.0 to 4.0, p=0.07. The use of immunosuppressants was associated with a significant increase in the risk of mycobacterial infection: RR: 4.3; 95% CI: 2.2 to 8.3, p=0.31. Two patients (4.8%) died (1respiratory and 1extrapulmonary). The mean survival after diagnosis in these cases was 21 days. Conclusion M.I. in RELESSER affects 1.15% of patients. Its incidence rate is 1 per 1000 patients/year (95% CI: 0.7 to 1.4). Extrapulmonary localization affects more than half of the patients and is associated with the use of immunosuppressants. Previous admission by SLE activity, renal involvement, severity of SLE, and increased number of associated comorbidities are factors associated with the existence of mycobacterial infection.

A biosimilar (BS) is a biological drug that contains a version of the active substance of an already authorized original biological product. The BSs are marketed after patent period of the original drug has ended and once it has been demonstrated that the differences regarding the innovative medicine have no relevant effect on its safety or clinical efficacy. The Spanish Society of Rheumatology, in line with the European Medicines Agency, considers that because of its nature and complexity of production, a BS cannot be considered to be the same as a generic drug. The Spanish Society of Rheumatology expresses an unequivocal commitment to the sustainability of the health system in our country and our steadfast alignment with all measures designed to ensure continuity, without reducing the quality of care. Therefore, we believe that the advent of BSs will likely facilitate access of patients with rheumatic diseases to the biological drugs. This article reviews the European Medicines Agency requirements for authorization, the Spanish legal framework and controversies on BS and presents the position paper of the Spanish Society of Rheumatology on these drugs.

Objetivo Establecer recomendaciones para el manejo de pacientes con artritis reumatoide (AR) centrado en el papel de los farmacos antirreumaticos modificadores de enfermedad (FAME) sinteticos y biologicos disponibles, que sirvan de referencia para todos los profesionales implicados en la atencion de estos pacientes. Metodos Las recomendaciones se consensuaron a traves de un panel de 14 expertos previamente seleccionados por la Sociedad Espanola de Reumatologia (SER). Se recogio la evidencia disponible mediante la actualizacion de las 3 revisiones sistematicas (RS) que se utilizaron para las recomendaciones EULAR 2013, a las que se anadio una nueva RS para dar respuesta a una pregunta adicional. Todas fueron realizadas por miembros del grupo de revisores de la SER. La clasificacion del nivel de la evidencia y del grado de la recomendacion se realizo utilizando el sistema del Centre for Evidence-Based Medicine de Oxford. Se utilizo la metodologia Delphi para evaluar el grado de acuerdo entre los panelistas para cada recomendacion. Resultados Se emiten un total de 13 recomendaciones sobre el manejo terapeutico de pacientes con AR del adulto. El objetivo terapeutico debe ser tratar al paciente en fases precoces de la enfermedad, con el objetivo de la remision clinica, teniendo un papel central el metotrexato como FAME sintetico de referencia. Se actualizan las indicaciones de los FAME biologicos disponibles, se enfatiza la importancia de los factores pronosticos y se incide en el concepto de optimizacion de biologicos. Conclusiones Se presenta la quinta actualizacion de las recomendaciones SER para el manejo de la AR con FAME sinteticos y biologicos.

Resumen Los pacientes con lupus eritematoso sistemico presentan una prevalencia elevada de deficiencia e insuficiencia de vitamina D. Esto se debe probablemente a las medidas de fotoproteccion y a factores intrinsecos de la enfermedad. Los niveles bajos de vitamina D aumentan el riesgo de presentar una densidad mineral osea reducida y de fractura. El deficit de vitamina D podria tambien tener efectos no deseados sobre la respuesta inmune de los pacientes, potenciando mecanismos de perdida de tolerancia y autoinmunidad. Los niveles de vitamina D deberian ser monitorizados periodicamente y los pacientes deberian ser tratados con el objetivo de alcanzar unos niveles de vitamina D superiores a 30-40 ng/ml.

Los agentes anti-TNFa han representado un notable avance en el control sintomatico de los pacientes con espondilitis anquilosante y respuesta inadecuada a AINE. Los antagonistas del TNFa son eficaces y seguros a largo plazo pero es necesario su uso continuado para un adecuado control sintomatico. Tras el fracaso a uno de ellos, el uso de un segundo agente anti-TNFa parece ser eficaz y seguro. Aun no se ha demostrado un efecto beneficioso del tratamiento con antagonistas del TNFa sobre la evolucion radiologica en la espondilitis anquilosante, a pesar de la desaparicion rapida y mantenida de la inflamacion osea, evidenciada mediante RM. Parece necesario explorar nuevas dianas moleculares implicadas en el proceso de osificacion

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.

AIM Tumor necrosis factor inhibitors (TNFi) are effective in controlling disease activity in spondyloarthritis (SpA). However, in a proportion of patients these treatments are ineffective or lead to adverse events. Recently, alternative therapies, such as interleukin (IL)-17 or IL-23 inhibitors, have emerged in the treatment of these pathologies. This study aimed to determine clinical and genetic predictors of non-response to TNFi treatment in 118 spondyloarthritis patients diagnosed according to Assessment in SpondyloArthritis International Society (ASAS) criteria. METHOD From the literature, 41 single nucleotide polymorphisms (SNPs) were selected that had previously been associated with TNFi treatment response in spondyloarthropathies, rheumatoid arthritis and psoriasis. A clinical non-response was defined as a decrease of

Objective To analyze the performance of the 1980 ACR and new 2013 ACR/EULAR criteria for systemic sclerosis (SSc) in cutaneous SSc (lcSSc) patients, especially those affected by lcSSc and pulmonary arterial hypertension (PAH). Methods All patients with a clinical lcSSc diagnosis from a prospective observational SSc cohort were included. Sociodemographic and disease-related variables were collected, and PAH confirmed by right heart catheterization (RHC). Performance of the 2013 and 1980 SSc criteria was analyzed in terms of clinical diagnosis. Descriptive and between-group analyses were performed as to the fulfillment of criterion sets, including comparison of survival. Results Overall, 321 patients were included, 63% of whom fulfilled the 1980 ACR and 93% the 2013 ACR/EULAR criteria. Agreement between both criteria sets proved poor ( κ = 0.23). LcSSC patients fulfilling both criterion sets were significantly younger at diagnosis, whilst presenting organ involvement, calcinosis, fingertip digital ulcers, and pitting scars more frequently than those who met the 2013 criteria only. Patients who fulfilled the 2013 but not the 1980 criteria presented a higher degree of ACA positivity and PAH. Nearly 12% of patients developed PAH. Patients who did not meet the 1980 criteria were affected by a milder disease from but demonstrated higher pulmonary vascular resistance and lower cardiac index than those fulfilling both criterion sets. Whereas patients with PAH met the 2013 criteria, only 47% fulfilled the 1980 criteria. Regardless of criterion set fulfillment, high mortality was observed in PAH patients, with no significant between-patient difference based on criterion set. Conclusion The new 2013 ARC/EULAR criteria prove more accurate than the former 1980 ACR criteria in identifying and differentiating patients with lcSSc, especially those with associated PAH. Since PAH exhibits a better prognosis if treated early, all SSc patients should undergo PAH screening.

Background: Systemic lupus erythematosus (SLE) is a genetically complex rheumatic disease characterized by heterogeneous clinical manifestations of unknown etiology. Recent studies have suggested the existence of a genetic basis for SLE heterogeneity. The objective of the present study was to identify new genetic variation associated with the clinically relevant phenotypes in SLE. Methods: A two-stage pathway-based approach was used to identify the genetic variation associated with the main clinical phenotypes in SLE. In the discovery stage, 482 SLE patients were genotyped using Illumina Human Quad610 microarrays. Association between 798 reference genetic pathways from the Molecular Signatures Database and 11 SLE phenotypes was tested using the set-based method implemented in PLINK software. Pathways significantly associated after multiple test correction were subsequently tested for replication in an independent cohort of 425 SLE patients. Using an in silico approach, we analyzed the functional effects of common SLE therapies on the replicated genetic pathways. The association of known SLE risk variants with the development of the clinical phenotypes was also analyzed. Results: In the discovery stage, we found a significant association between the vascular endothelial growth factor (VEGF) pathway and oral ulceration (P value for false discovery rate (P FDR ) < 0.05), and between the negative regulation signaling pathway of retinoic acid inducible gene-I/melanoma differentiation associated gene 5 and the production of antinuclear antibodies (P FDR < 0.05). In the replication stage, we validated the association between the VEGF pathway and oral ulceration. Therapies commonly used to treat mucocutaneous phenotypes in SLE were found to strongly influence VEGF pathway gene expression (P = 4.60e-4 to 5.38e-14). Analysis of known SLE risk loci identified a strong association between PTPN22 and the risk of hematologic disorder and with the development of antinuclear antibodies. Conclusions: The present study has identified VEGF genetic pathway association with the risk of oral ulceration in SLE. New therapies targeting the VEGF pathway could be more effective in reducing the severity of this phenotype. These findings represent a first step towards the understanding of the genetic basis of phenotype heterogeneity in SLE, This study was funded by the Spanish Ministry of Economy and Competitiveness (grant numbers: PSE-010000-2006-6 and IPT-010000-2010-36 and by the “Agència de Gestió d’Ajuts Universitaris i de Recerca” (AGAUR, Generalitat de Catalunya, FI-DGR 2016, grant number: 00587)

Background One of the missions of the Spanish Society of Rheumatology (SER) is to provide professionals involved with the necessary tools to ensure a better care for patients suffering from a rheumatic disease. Up to now, there is no benchmark that quantifies the complexity of medical acts in this specialty. Therefore, there is a need to adopt a physician activity scale that would allow assessment of their professional activity and skills regarding patient care. Objectives To compile a nomeclature of medical, diagnostic, and therapeutic procedures in the field of rheumatology; and to establish a hierarchical classification system according to a complexity index. Methods A list of care, diagnostic, and therapeutic acts was compiled based on the nomenclature created by Drs Fernandez and Olive. The hierarchical classification system was based on the construction of a complexity index which was calculated by two factors: time of completion and degree of complexity of each act. Time of completion was stated according to the document “Standards of Process Time and Patient Care Quality” by Dr Alonso. The degree of complexity of each rheumatologic act was agreed thanks to a panel of experts using a Delphi technique in two rounds. Subsequently, it was validated against a questionnaire which was sent to the 1144 partners of SER via its web. Results The total of included acts was 54. The results obtained with the Delphi method tended to show a consensus of opinion (media σ2 - σ1=0.75–1.43=-0.68, media IQR2 – IQR1=0.8–1.9=-1.1). Furthermore, a validation of these results was carried out through a massive survey among the partners of SER. The survey results showed a high degree of agreement (at least 70.0 per cent of the partners agreed or strongly agreed with the complexity of each act). The degree of complexity in successive visits was 100. In the query section for consultations, the highest scores were obtained by first visit to hospitalized patient (366) and home visit (369). Regarding diagnostic techniques, the highest scores were obtained with biopsies: bone (465), sural nerve (416), and synovial (380). Also worth mentionioning the scores obtained by ultrasound scan (204), capillarioscopy (113) and densitometry (112). Regarding therapeutic techniques, intra-articular injection under sedation in children obtained a score of 388; while intra-articular injection with ultrasound control obtained a score of 163. The clinical report of disability was agreed to have a score of 323, and the expert report obtained a score of 370. Conclusions This work has made it possible to create a nomenclature of 54 acts in Rheumatology where biopsies (bone, sural nerve, synovial), visits to hospitalized patients, home visits, infiltration under sedation in children, and expert reports are identified as the most complex acts. Musculoskeletal ultrasound is considered twice as complex as a successive visit, capillaroscopy, or bone densitometry. These results will make it possible to improve patient care and establish a solid and agreed foundation to negotiate the provision of public and private services. Disclosure of Interest None declared

Background Primary Sjogren9s syndrome (pSS) is a chronic systemic autoimmune disease often accompanied by analytical abnormalities. Altered levels in serum protein concentration, blood cell count and autoantibodies contribute to the broad spectrum of biological manifestations that characterize pSS. Objectives The objective of this study is to evaluate the presence of laboratory abnormalities in patients with pSS from the SjogrenSER registry. Methods We conducted a multicentre transversal study of a cohort of pSS patients fulfilling 2002 European/American criteria, from 33 Spanish rheumatology departments. Every patient was interviewed for data collection and signed an informed consent. Data were also collected by reviewing medical records. Local ethics committees approved the study. Variables were analysed by descriptive statistical methods, using means, medians and rates. Chi-square was used to establish the statistical associations. A p Results Four hundred and thirty-seven patients were included. Ninety-five percent of them were women. The median age of the cohort was 58 years. AntiRo antibodies were present in 93.6% of patients and AntiLa antibodies in 67.3% of patients. All patients were ANA+. Rheumatoid factor (RF) was positive in 64.8% of patients. Low levels of C3 and C4 were observed in 14.87% and 14.19% of patients, respectively. Polyclonal hypergammaglobulinemia (HGG) was present in 53% of patients. Thirteen patients had cryoglobulins (2.97%). An increase in β2microglobulin was observed in 22.2% of patients. Fifty-six percent of the patients had hematological involvement: 29% of the patients had anemia, 38% had leukopenia (38% lymphopenia, 10.5% had neutropenia), and 9% had thrombocytopenia. The median ESR was 25 mm. Age at diagnosis and age at onset of symptoms were significantly lower in patients presenting RF+ vs RF- (48.71 vs 53.73, p Conclusions in SjogrenSER registry all patients were serologically positive. More than half of the patients presented abnormalities in serum proteins and 14% had hipocomplementemia. More than half of the patients had abnormalities, mostly leucopenia and lymphopenia. Patients with analytical alterations were younger at the time of diagnosis and had more often elevated ESR and higher ESSDAI score. Disclosure of Interest None declared

Background Recent genome-wide association studies (GWAS) have identified more than 50 loci associated with systemic lupus erythematosus but they explain less than 30% of the heritability of the disease. Meta-analysis including new populations can contribute to identify additional genetic risk factors. Objectives The aim of the presents study was to identify additional genetic risk loci for SLE. Methods We performed a meta-analysis using data from a recent large scale GWAS from 4,036 cases and 6,959 controls from Caucasian European ancestry [1] and a newly genotyped cohort of 907 SLE patients and 1,524healthy controls from Spain. Genetic association was tested at the single-marker level using linear regression and at the pathway-level using Fisher9s modified method. Results Combining the two cohorts we identified genome-wide significant association (P Conclusions In conclusion, we have identified five new risk loci for SLE through a meta-analysis including a new GWAS. References Bentham J, Morris DL et al. Nature Genetics 2015. Acknowledgements We would like to thank the clinical researchers and patients participating in the IMID Consortium for their collaboration. We would also like to thank the international SLE consortium for access to the data. Disclosure of Interest None declared

Background One of the main features of primary Sjogren9s syndrome (pSS) is the polyclonal activation of B cells, leading to the synthesis of a large variety of autoantibodies. Objectives The aim of this study is to describe the prevalence of atypical autoantibodies in patients with pSS from the SjogrenSER registry. Methods SjogrenSER registry is a multicenter transversal study of pSS patients fulfilling European/American consensus criteria 2002. Patients were included by randomization from thirty-three Rheumatology Spanish departments. Data were collected by reviewing clinical records and interviewing the patients. Informed consent was obtained and local ethics committees approved the study. Variables were analysed by descriptive statistical methods, using means, medians, and rates. Chi-square was used to establish the statistical associations, being considered a p Results Four hundred and thirty-seven patients were included. Ninety-five percent of them were women. The median age of the cohort was 58 years. Twenty-three patients had AntiDNA (5.26%), 10 patients AntiSm (2.29%), 23 patients AntiRNP (5.26%) and 26 patients antiphospholipid antibodies (5.95%). Regarding AntiDNA+ patients, there were minimal non-significant differences in age at diagnosis and age at onset of symptoms compared to AntiDNA- patients (47 vs 50.5 years and 43.5 vs 46.5 years, respectively). The association with some systemic manifestation was only observed with joint involvement, which was significantly more frequent in AntiDNA+ patients (56.5% vs 34.2%, p=0.031). Regarding AntiSm+ patients, a significant negative association with AntiDNA antibodies was observed, being 70% of patients AntiDNA-; we also found a significant positive association with AntiRo and AntiLa, being 100% and 68% of patients AntiRo+ and AntiLa+ respectively. A significant negative association with lymphopenia was observed (no AntiSm+ patient had lymphopenia). AntiRNP+ patients showed a significant negative association with AntiDNA antibodies, being 80% of patients AntiDNA-, and a significant positive association with AntiRo, being 96% patients AntiRo+. A significant positive association was also observed with decreased C4 compared to AntiRNP- patients (28% vs 13.38%, p=0.025). Regarding patients with antiphospholipid antibodies, a significant negative association was observed with antiDNA antibodies, being 93% of patients AntiDNA-. A significant positive association with some systemic manifestation was only observed with the presence of anemia (44% vs 17.7%). A significant positive association with decreased C3 and C4 was also observed, compared with the AntiRNP- patients (C3 20% vs 13.67% and C4 33% vs 12.67%). Conclusions More than 5% of pSS patients had antibodies characteristic of other autoimmune diseases. These atypical autoantibodies were significantly related to some pSS characteristic: antiSm, antiRNP and antiphospholipid antibodies were significantly related to the presence of antiRo, antiDNA antibodies were significantly related to joint involvement, antiphospholipid antibodies were significantly related to anemia, and antiRNP and antiphospholipid antibodies were significantly related to hypocomplementemia. Disclosure of Interest None declared

Background: The utility of electrodiagnostic studies (EDX) continues to be a point of debate in the diagnosis of carpal tunnel syndrome (CTS). If surgeons can predict the results of EDX with high accuracy, it may suggest that ordering the test is unnecessary from a diagnostic standpoint. Methods: Two surgeons with subspecialty training in hand surgery were asked to classify hands into “definitely having or not having CTS” or into an “unclear category” when presented with patients having a chief complaint of hand paresthesias. Clinical diagnosis was compared against EDX, ordered after the initial patient visit, as the reference standard. Results: Of the 175 hands, 111 hands were predicted to have CTS, 37 hands were predicted not to have CTS, and 27 hands had an unclear diagnosis. Overall surgeon accuracy was 86% (124/148). Accuracy was improved when subdivided by a positive prediction of CTS (88%) compared with a negative prediction of CTS (70%) (P = .03). Sensitivity was 90% and specificity was 67%. The senior surgeon had a higher accuracy at 90% than the more junior surgeon at 74% (P = .02). Conclusions: Surgeons with sub-specialty training in hand surgery are able to accurately diagnose CTS without EDX. Surgeon experience is important and resulted in a higher accuracy in predicting EDX results.

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.

The objective of the study was to develop evidence-based and practical recommendations for the detection and management of comorbidity in patients with rheumatoid arthritis (RA) in daily practice. We used a modified RAND/UCLA methodology and systematic review (SR). The process map and specific recommendations, based on the SR, were established in discussion groups. A two round Delphi survey permitted (1) to prioritize the recommendations, (2) to refine them, and (3) to evaluate their agreement by a large group of users. The recommendations cover: (1) which comorbidities should be investigated in clinical practice at the first and following visits (including treatments, risk factors and patient's features that might interfere with RA management); (2) how and when should comorbidities and risk factors be investigated; (3) how to manage specific comorbidities, related or non-related to RA, including major adverse events of RA treatment, and to promote health (general and musculoskeletal health); and (4) specific recommendations to assure an integral care approach for RA patients with any comorbidity, such as health care models for chronic inflammatory patients, early arthritis units, relationships with primary care, specialized nursing care, and self-management. These recommendations are intended to guide rheumatologists, patients, and other stakeholders, on the early diagnosis and management of comorbidity in RA, in order to improve disease outcomes.

To identify risk and predictors of lymphoma or lymphoproliferative disease in patients with primary Sjögren syndrome. Articles were identified through a comprehensive search strategy in Medline, Embase and Cochrane CENTRAL. Studies had to investigate primary Sjögren syndrome patients, 18 years of age or older, with the goal of examining potential clinical, immunological and hematological risk factors for lymphoma or lymphoproliferative disease. The quality of the studies was graded using the Oxford Levels of Evidence Scale. Whenever possible, the authors created evidence tables and performed meta-analysis. Of 900 studies identified, 18 were selected for inclusion. These studies provided data from over 15,000 patients (90 % female) for analysis. Lymphadenopathy, parotid enlargement, palpable purpura, low C4 serum levels and cryoglobulins were the most consistent non-Hodgkin´s lymphoma/lymphoproliferative disease predictors. Additionally, some of the studies identified splenomegaly, low C3 serum levels, lymphopenia and neutropenia as significant prognostic factors. The detection of germinal center-like lesions in primary Sjögren Syndrome diagnostic salivary biopsies was also proposed as highly predictive of non-Hodgkin´s lymphoma. In contrast, anemia, anti-Ro, anti-La, antinuclear antibodies, rheumatoid factor, male gender and hypergammaglobulinemia were not associated with lymphoma or lymphoproliferative disease. Patients with primary Sjögren syndrome have an increased risk of lymphoma or lymphoproliferative disease compared to the general population. Ascertaining relevant and reliable predictors in this patient population would greatly facilitate the identification of patients at elevated risk for closer monitoring in the context of limited resources.

Resumen Introduccion Nos planteamos el problema: ?cual es el numero adecuado de facultativos en un servicio de anatomia patologica (SAP) para responder sin demora al numero de solicitudes de estudio que se reciben? Material y metodos Aplicamos conceptos basicos de teoria de colas y motivamos al lector a introducirse en ellos. Resultados y discusion Un SAP funciona como un sistema de colas y se ajusta a los modelos de cola infinita con uno (M/M/1) y, todavia mejor, con multiples recursos (M/M/m). El numero de facultativos (m) ha de cumplir: m >> velocidad de llegada de biopsias al SAP/velocidad de cierre de biopsias por facultativo. Conclusiones Como sistema de colas, un SAP solo es viable si su capacidad de respuesta es mayor que las necesidades planteadas por la demanda. El modelo de multiples recursos (facultativos) amortigua mejor los aumentos sostenidos de la demanda.

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.

Resumen La asociacion de dermatomiositis y miastenia gravis (MG) es infrecuente, habiendose comunicado hasta la actualidad unicamente 26 casos. Se presenta el caso de un varon de 69 anos diagnosticado de MG 2 anos atras, en tratamiento con piridostigmina, que inicia cuadro agudo de debilidad muscular proximal, artralgias en hombros y elevacion de creatincinasa (CK); asi como aparicion de eritema facial generalizado y papulas de Gottron. En el estudio de laboratorio se evidencio positividad de anticuerpos antinucleares y anti-Mi2. Ulteriores determinaciones de CK mostraron niveles por encima de 1.000 U/l. Se discute el manejo clinico de este paciente y las implicaciones terapeuticas que plantea la coexistencia de ambas entidades.

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.

Resumen Objetivo Conocer la opinion de los reumatologos sobre la utilidad de la ecografia en la toma de decisiones diagnosticas y terapeuticas en reumatologia. Material y metodos Encuesta nacional, dirigida a todas las unidades de reumatologia de hospitales con mas de 200 camas. El cuestionario incluia: a) datos generales; b) finalidad y areas de exploracion ecografica mas comunes, y c) evaluacion de la utilidad de la ecografia en la practica clinica habitual en general y en algunas enfermedades reumatologicas en particular. Resultados Respondieron al cuestionario 169 unidades de reumatologia de las 234 consultadas. La utilidad se valoro en 7,8 (escala 0-10). La mitad de las indicaciones (50,9%) se relacionaban con el diagnostico de enfermedades o toma de decisiones terapeuticas (monitorizacion de sinovitis: 14,6%; puncion guiada: 11,4%; deteccion temprana de erosion articular o sinovitis: 10,3%; deteccion temprana de la entesopatia: 5,9%; sindrome del tunel carpiano u otras neuropatias perifericas: 3,4%; deteccion de depositos de acido urico o pirofosfatos: 3%; vasculitis: 1%, y otros: 1,1%). En una escala de Likert de 1-5, la mayoria de las respuestas respalda el uso de la ecografia en la practica clinica, especialmente en la toma de decisiones diagnosticas y terapeuticas para la deteccion de sinovitis subclinica, erosiones y decisiones de tratamiento en casos de artritis reumatoide, diagnostico de entesitis, enfermedades de deposito articular, polimialgia reumatica y arteritis de celulas gigantes. Conclusiones La ecografia se esta convirtiendo en una herramienta util integrada en la practica clinica y vinculada a la toma de decisiones en procesos diagnosticos y terapeuticos.

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.

Los glucocorticoides son un componente fundamental en el tratamiento de la artritis reumatoide (AR). En los ultimos anos, numerosos ensayos clinicos controlados de alta calidad metodologica han demostrado su accion como farmaco antirreumatico modificador de enfermedad (FAME) y un favorable perfil de seguridad en la AR de reciente comienzo. No obstante, es frecuente que se utilicen mas como terapia puente hasta que otros FAME comienzan a actuar que como autenticos agentes modificadores de enfermedad. Los glucocorticoides a dosis bajas durante los 2 primeros anos de la enfermedad frenan el deterioro radiologico y reducen la necesidad de usar agentes biologicos para conseguir la remision clinica en la AR de inicio por lo que se deberia valorar su utilizacion sistematica en este contexto clinico

Primary Sjogren syndrome (PSS) is an autoimmune disease characterized by lymphocytic infiltration in exocrine glands, mainly the salivary and lachrymal glands, resulting in xerophthalmia and xerostomia. Occasionally, PSS has extra-glandular manifestations, including central (CNS) and peripheral nervous system (PNS) involvement. The reported prevalence varies in the literature, mainly because of heterogeneity in the diagnostic and classification criteria. Involvement of the PNS is more frequent than that of the CNS, presenting as axonal, sensory, autonomic or small fiber neuropathies and mononeuritis multiplex. CNS manifestations may be focal or diffuse and are associated with increased extra-glandular involvement and the presence of autoantibodies. Treatment is based on corticosteroids. In severe, refractory- or corticosteroid-dependant cases, immunosuppressant agents such as azathioprine or cyclophosphamide may be useful. Observational studies have suggested that rituximab is useful in some PSS extra-glandular manifestations. Currently, clinical trials with new biological agents such as belimumab and epratuzumab are being conducted in PSS.

We aimed to describe juvenile-onset systemic lupus erythematosus (jSLE) features and to establish its differences compared to adult-onset SLE (aSLE) from a large national database.Data from patients (≥4 ACR criteria) included in Spanish Society of Rheumatology Lupus Registry (RELESSER) were analysed. Sociodemographic, clinical, serological, activity, treatment, cumulative damage, comorbidities and severity data were collected. Patients with disease onset18 years were described and compared to those with disease onset ≥18 years.We reviewed 3,428 aSLE patients (89.6% women) and 484 jSLE patients (89.8% girls), 93% Caucasian (both groups). Mean age at diagnosis was 38.1±14 and 16.6±6.3 years (p0.001) and mean age at the end of follow-up was 48.8±14.3 and 31.5±30 years (p0.001), respectively. jSLE showed significantly more clinical (including lymphadenopathy, fever, malar rash, mucosal ulcers, pericarditis, pleuritis, Raynaud's phenomenon, lupus nephritis, recurrent nephritis, histologic nephritis changes, thrombocytopenia, haemolytic anaemia, thrombotic thrombocytopenic purpura, seizures, lupus headache and organic brain syndrome) and immunological (a-dsDNA and a-Sm antibodies, hypocomplementaemia) involvement than did aSLE, except for secondary Sjögren's syndrome, a-Ro antibodies, fibromyalgia and osteoporosis. jSLE also showed more SLE family history, longer diagnosis delay, higher SLEDAI and Katz scores, but lower Charlson scores than aSLE. Several specific domains were more frequently involved in SLICC/ACR DI in jSLE. jSLE patients more frequently underwent all SLE-related treatment and procedures, as well as dialysis and kidney transplantations.jSLE shares many clinical and serological features with aSLE. However, jSLE patients typically manifested more activity, severity, cumulative damage in certain areas, than their aSLE counterparts.

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.

To assess fibromyalgia (FM) prevalence in a large cohort of primary Sjögren's syndrome patients (pSS) from a National Database.Data included in the national retrospective register of pSS patients of the Spanish Society of Rheumatology (SJOGRENSER) were analysed.437 pSS patients were included and a 14.6% of FM prevalence was found. FM-pSS patients significantly showed more constitutional, fatigue and arthralgia symptoms, splenomegaly, genital, skin and ear involvement and dyslipidaemia (p0.05), as well as higher ESSPRI and SSDAI scores (p0.01). Several symptomatic treatments were more frequently used in FM-pSS patients. No differences were observed in laboratory markers, imaging techniques or histologic inflammatory findings. Patients with FM showed statistically more fatigue than pSS without FM. In the multivariate logistic regression analysis several features were associated to pSS-FM patients.We show data on a reliable prevalence of FM in pSS patients and its multiple associated factors along with the presence of higher disease activity scores than patients who did not show FM. The presence of fatigue, arthralgia, constitutional symptoms and dyslipidaemia were more likely to coexist in pSS-FM patients.

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.

Resumen Objetivo Conocer la situacion de la ecografia en la reumatologia espanola. Material y metodos Encuesta nacional, dirigida a todas las unidades de reumatologia de hospitales con mas de 200 camas. Se investigaba: a) disponibilidad de ecografos y tipo; b) grado de formacion; c) finalidad y areas de exploracion ecografica; d) utilidad asistencial, y e) importancia de la ecografia en la formacion de residentes. Resultados Respondieron 169 unidades de las 234 consultadas. La disponibilidad de equipos de ecografia era alta (90%). El 38,7% de los reumatologos utilizan el ecografo, aunque en la mitad de las unidades existia un reumatologo especialmente dedicado a realizarlas. Los planes de formacion han posibilitado la incorporacion de la ecografia, pero se detectan importantes aspectos de mejora. La utilidad en la practica clinica habitual se valoro en 7,8 (escala 0-10) y la ecografia se integraba en la toma de decisiones diagnosticas y terapeuticas. Es de destacar el amplio consenso sobre la necesidad de incluir la ecografia en la formacion de residentes. La Administracion esta incorporando la ecografia a la cartera de servicios de la especialidad. Conclusiones En tan solo 15 anos la ecografia ha pasado de la inexistencia, a estar disponible en el 90% de las unidades reumatologicas. Su uso es amplio, integrado en la practica clinica y vinculado a la toma de decisiones en multiples procesos. Los planes de formacion han sido eficaces, pero se detectan areas de mejora, y hay un amplio consenso sobre la necesidad de integrarla en la formacion MIR.

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.

Resumen Objetivo Presentar un metodo de analisis grafico de costes ocasionados por los falsos positivos (FP) y falsos negativos (FN) de una prueba diagnostica. Material y metodos Construimos una funcion de costes ligada a la sensibilidad (S) y a la especificidad (E) de la prueba diagnostica. A partir de esta funcion obtenemos lineas de isocoste, cuya pendiente es la relacion coste FP/coste FN. Representamos cada prueba diagnostica en el espacio ROC como el punto (1-E, S). Resultados Las lineas de isocoste permiten visualizar si el gasto asociado a FP y FN de una nueva prueba diagnostica es menor o igual que el de la antigua. Conclusiones El analisis grafico de la funcion de costes de una prueba diagnostica ayuda a decidir su introduccion o su rechazo.

Objective. To compare the efficacy of surgical decompression vs local steroid injection in the treatment of idiopathic CTS. Methods. This is an open, prospective, randomized clinical trial. We studied the effects of surgical decompression vs local steroid injection in 163 wrists with a clinical diagnosis and neurophysiological confirmation of CTS, with an extended follow-up of 2 years. The primary end point was the percentage of wrists that reached a 520% improvement in the visual analogue scale score for nocturnal paraesthesias. Statistical analysis was done by Student’s t-test for continuous variables and by chi-square test for categorical variables. Analyses were performed on an intent-to-treat basis. P < 0.05 were considered statistically significant. Results. Both treatment groups had comparable severity of CTS at baseline. Eighty wrists were randomly assigned to surgical decompression and 83 wrists to local steroid injection. Fifty-five wrists in the surgery group and 48 wrists in the injection group completed the 2-year follow-up. In the intent-to-treat analysis, at 2-year follow-up, 60% of the wrists in the injection group vs 69% in the surgery group reached a 20% response for nocturnal paraesthesias (P < 0.001). Conclusion. Our findings suggest that both local steroid injection and surgical decompression are effective treatments in alleviating symptoms in primary CTS at 2-year follow-up. Surgery has an additional benefit in the 2-year follow-up, although clinical relevance of those differences remains to be defined. Trial Registration: Current Controlled Trials, www.controlled-trials.com, ISRCTN26264638.

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.

Resumen La Comision Nacional de Reumatologia ha elaborado una encuesta sobre la satisfaccion de los residentes respecto a su periodo formativo. Contestaron un 37% de los 176 invitados a participar. Un 71% manifesto que estaba satisfecho o muy satisfecho de la influencia de la actividad asistencial en su formacion. El 38% estaba insatisfecho o muy insatisfecho de la supervision por parte de la plantilla. El 39% estaba insatisfecho o muy insatisfecho del adiestramiento en microscopia de luz polarizada. El 52% contesto que no existian reuniones periodicas estructuradas de monitorizacion de su formacion. El 66% declaro que no habia existido ningun tipo de evaluacion efectiva de su formacion. El 39% se mostro insatisfecho o muy insatisfecho respecto a las facilidades para publicar que le brindo su unidad docente. La satisfaccion global sobre la formacion asistencial de los residentes de reumatologia es elevada. Existen oportunidades de mejora referentes al entrenamiento en determinadas tecnicas, la monitorizacion y evaluacion del periodo formativo y la formacion en habilidades de investigacion.

Resumen Objetivo Dado el creciente uso de las terapias biologicas en distintas enfermedades reumatologicas, y la importancia de la gestion de riesgo de las mismas, desde la Sociedad Espanola de Reumatologia (SER) se ha impulsado el desarrollo de recomendaciones basadas en la mejor evidencia posible. Estas deben de servir de referencia para reumatologos e implicados en el tratamiento de pacientes en tratamiento o en los que se quiere indicar la terapia biologica independientemente de su enfermedad de base. Metodos Las recomendaciones se emitieron siguiendo la metodologia de grupos nominales. El nivel de evidencia y el grado de recomendacion se clasificaron segun el modelo del Center for Evidence Based Medicine de Oxford y el grado de acuerdo se extrajo por tecnica Delphi. Se utilizo toda la informacion de consensos y guias de practica clinica previas. Resultados Se realizan recomendaciones sobre la gestion del riesgo del uso de las terapias biologicas en pacientes con enfermedades reumatica. Incluyen la gestion del riesgo de la indicacion, gestion del riesgo antes de iniciar el tratamiento, gestion del riesgo durante el seguimiento, actitud ante acontecimientos adversos, y actitud en situaciones especiales. Conclusiones Se presentan las recomendaciones SER sobre la gestion del riesgo del tratamiento con terapias biologicas.