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Resumen Objetivo Estudiar la utilidad a largo plazo de un reumatologo consultor in situ (RCI) en un centro de salud (CS). Material y metodos Estudio observacional retrospectivo sobre la cohorte completa de pacientes atendidos entre 2013 y 2019. Se analizaron lsa variables clinicas y de curso asistencial, intentando perfilar que diagnosticos de los pacientes reumaticos tenian mas probabilidades de continuar su atencion en el CS con el medico de Atencion Primaria (MAP). Resultados Se atendieron 876 consultas; 205 de varones (23,4%) y 671 de mujeres (76,6%), con una edad media de 64,1 anos (DE = 16,6). La mayoria de las consultas (280; 33,2%) fueron diagnosticas. En 167 ocasiones (19,8%) se abordaron temas terapeuticos; en 47 (5,6%) se realizaron infiltraciones. La peticion de pruebas no disponibles para el MAP se verifico en 154 situaciones (18,3%). El perfil de paciente con mas opciones de continuar su seguimiento con el MAP en el CS es el que tenia artrosis (OR = 0,13; IC 95%: 0,02-0,67), reumatismo de partes blandas (OR = 0,06; IC 95%: 0,01-0,45) o hernia discal cervical (OR = 0,13; IC 95%: 0,02-0,66). Los pacientes con menos probabilidades de seguimiento por MAP tras su paso por RCI son los que tenian artritis reumatoide (OR = 0,03; IC 95%: 0,00-0,24), otras artropatias inflamatorias (OR = 0,36; IC 95%: 0,16-0,80) o polimialgia reumatica (OR = 0,19; IC 95%: 0,06-0,64); tambien los que necesitan control de enfermo cronico (OR = 0,16; IC 95%: 0,07-0,34). Conclusiones El RCI facilita el seguimiento por el MAP de la artrosis, reumatismos de partes blandas y de la discopatia cervical, pues le permite disponer de determinadas pruebas complementarias para el diagnostico.

We aimed to develop recommendations for the management of methotrexate (MTX) when considering the combination with biological (b) or targeted synthetic (ts) disease modifying drugs (DMARDs) in rheumatoid arthritis (RA). Methods: Eleven experts on RA were selected. Two coordinators formulated 13 questions about the combination therapy of MTX with bDMARDs or tsDMARDs. A systematic review was conducted to answer the questions. Inclusion and exclusion criteria were established as well as the search strategies (Medline, Embase and the Cochrane Library were searched up to January 2019). Two reviewers selected the articles and collected data. Simultaneously, EULAR and ACR meeting abstracts were evaluated. Based on this evidence, the coordinators proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation was established using the Oxford Center for Evidence Based Medicine and the level of agreement with a Delphi. Agreement was established if at least 80% of the experts voted ‘yes’ (yes/no). Results: The systematic review retrieved 513 citations of which 61 were finally included. A total of 10 recommendations were generated, voted and accepted. The level of agreement was very high in all of them and it was achieved in the first Delphi round. Final recommendations cover aspects such as the optimal MTX dosage, tapering strategy or patients’ risk management. Conclusions: This document is intended to help clinicians solve usual clinical questions and facilitate decision making when treating RA patients with MTX in combination with bDMARDs or tsDMARDs, Desarrollar recomendaciones sobre el uso de metotrexato (MTX) en combinación con medicamentos modificadores de la enfermedad (DMARD) biológicos (b) o sintéticos específicos (ts) en la artritis reumatoide (AR). Se seleccionaron 11 expertos en AR. Dos coordinadores formularon 13 preguntas sobre la terapia combinada de MTX con bDMARD o tsDMARD. Se realizó una revisión sistemática para responder las preguntas. Se establecieron criterios de inclusión y exclusión, así como las estrategias de búsqueda (se realizaron búsquedas en Medline, Embase y la Biblioteca Cochrane hasta enero de 2019). Dos revisores seleccionaron los artículos y recopilaron datos. Simultáneamente, se evaluaron los resúmenes de las reuniones EULAR y ACR. Con base en esta evidencia, los coordinadores propusieron recomendaciones preliminares que los expertos discutieron y votaron en una reunión de grupo nominal. El nivel de evidencia y el grado de recomendación se establecieron utilizando el Centro de Oxford para Medicina Basada en Evidencia y el nivel de acuerdo con un Delphi. El acuerdo se estableció si al menos el 80% de los expertos votaron «sí» (sí/no). La revisión sistemática recuperó 513 citas, de las cuales finalmente se incluyeron 61. Se generaron, votaron y aceptaron un total de 10 recomendaciones. El nivel de acuerdo fue muy alto en todas ellas y se logró en la primera ronda de Delphi. Las recomendaciones finales cubren aspectos como la dosis óptima de MTX, la estrategia de reducción o la gestión del riesgo de los pacientes. Este documento está destinado a ayudar a los médicos a resolver preguntas clínicas habituales y facilitar la toma de decisiones al tratar a pacientes con AR con MTX, en combinación con bDMARD o tsDMARD

BACKGROUND/OBJECTIVES Immune-mediated inflammatory diseases (IMIDs) are prevalent diseases. There is, however, a lack of understanding of the link between diet and IMIDs, how much dietary patterns vary between them and if there are food groups associated with a worsening of the disease. SUBJECTS/METHODS To answer these questions we analyzed a nation-wide cohort of n = 11,308 patients from six prevalent IMIDs and 2050 healthy controls. We compared their weekly intake of the major food categories, and used a Mendelian randomization approach to determine which dietary changes are caused by disease. Within each IMID, we analyzed the association between food frequency and disease severity. RESULTS After quality control, n = 11,230 recruited individuals were used in this study. We found that diet is profoundly altered in all IMIDs: at least three food categories are significantly altered in each disease (P

The role of patient adherence in improving the efficacy of any treatment is widely accepted, as well as its impact in optimizing the use of healthcare resources and associated costs. Adherence is particularly affected in chronic conditions, such as rheumatoid arthritis (RA), requiring long-term therapies and a commitment of the patient to manage his/her disease. Methotrexate (MTX) is one of the mainstays of treatment for several immune-mediated inflammatory joint and skin diseases, especially RA. The use of parenteral MTX, particularly when administered as a subcutaneous (SC) injection, has recently raised a great interest to overcome the limitations of oral MTX. For addressing this issue, new optimized self-injection systems have been developed to improve the ease of use of SC MTX. Increasing evidence shows how patients tend to opt for autoinjectors over prefilled syringes or conventional syringes in terms of easiness of use, preference and satisfaction, regardless of whether the treatment is a biologic or MTX. Additionally, positive views and beliefs of patients about treatment may contribute to increasing expectations of effectiveness and treatment adherence. Similarly, the implementation of prefilled pens in clinical practice might be a way to facilitate and simplify the self-injection of SC MTX delivery, optimizing adherence and treatment outcomes as a consequence. This article aimed to review the available literature data on the use of MTX autoinjectors and their impact on treatment adherence and patients’ perceptions.

espanolObjetivos Emitir recomendaciones sobre aspectos practicos de la monitorizacion de los niveles de farmacos biologicos que puedan ser de utilidad para reumatologos. Metodos Se realizo una revision sistematica de la literatura de estudios en los que se determinaron niveles de farmaco y de anticuerpos antifarmaco en pacientes con artritis reumatoide o espondiloartritis para estudiar si podian predecir diferentes desenlaces. Con los resultados de la revision un grupo de expertos discutio bajo que circunstancias podria ser util la solicitud de niveles de farmacos biologicos y sus anticuerpos, lo que se concreto en una serie de preguntas clinicas que fueron respondidas con la evidencia cientifica disponible y creandose algoritmos para facilitar la toma de decisiones. Resultados Se establece que la determinacion de los niveles de farmaco puede ser especialmente util en 2 situaciones clinicas, cuando hay fallo al tratamiento (primario o secundario) y en remision mantenida. Se revisa tambien que tecnica de laboratorio y momento para tomar la muestra son los mas adecuados para la medicion, y se establecen recomendaciones sobre la interpretacion de los niveles de farmaco y sobre factores a tener en cuenta (por ejemplo, indice de masa corporal y farmacos modificadores de la enfermedad). Conclusiones Se han elaborado algoritmos y establecido posibles pautas y directrices para solicitar niveles de farmaco y de anticuerpos antifarmaco en pacientes con artritis reumatoide y espondiloartritis, basados en la evidencia, que pueden ayudar a la toma de decisiones clinicas. EnglishObjectives Issue recommendations on practical aspects of the monitoring of levels of biological drugs that may be useful for rheumatologists. Methods We conducted a systematic review of studies in which drug and anti-drug antibody levels were determined in patients with rheumatoid arthritis (RA) or spondyloarthritis (SpA) to study whether they could predict different outcomes. In light of the results of the review, a group of experts discussed under what circumstances testing biological drug levels and their antibodies could be useful. The discussion resulted in a series of clinical questions that were answered with the scientific evidence collected, and in algorithms that facilitate decision making. Results It was established that the determination of drug levels can be especially useful in two clinical situations, on treatment failure (primary or secondary) and on sustained remission. It is also reviewed which laboratory technique and timing for sample drawing are the most suitable for the measurement. Recommendations are issued on the interpretation of drug levels and on factors to be taken into account (for example, body mass index and disease modifying drugs). Conclusions Evidence-based algorithms and guidelines have been established to test drug levels and anti-drug antibodies in patients with RA and SpA, which can help clinical decision making.

Resumen Objetivo Generar recomendaciones sobre el bloqueo de la interleucina 6 (IL-6) en pacientes con artritis reumatoide (AR), basadas en la mejor evidencia y experiencia. Metodos Se selecciono a 10 expertos reumatologos en el manejo de los inhibidores de la IL-6. Los 2 coordinadores generaron 23 preguntas sobre el bloqueo de la IL-6 en la AR (perfiles de indicacion, eficacia, seguridad, etc.) para ser contestadas mediante una revision sistematica de la literatura. Con base en las preguntas se definieron los criterios de inclusion y exclusion, y las estrategias de busqueda (para interrogar Medline, Embase y la Cochrane Library). Dos revisores seleccionaron los articulos resultantes de la busqueda. Se generaron tablas de evidencia. Paralelamente, se evaluaron abstracts de congresos de EULAR y ACR. Con toda esta evidencia los coordinadores propusieron 8 recomendaciones preliminares que se evaluaron, discutieron y votaron en una reunion de grupo nominal con el resto de los expertos. Para cada recomendacion se establecio el nivel de evidencia y grado de recomendacion, y el grado de acuerdo mediante un Delphi. Se definio acuerdo si al menos el 80% de los participantes contestaban si a la recomendacion (si o no). Resultados Las 8 recomendaciones preliminares se aceptaron tras el Delphi. Abarcan aspectos como su uso en monoterapia, en combinacion, en pacientes refractarios o intolerantes, la evaluacion de su respuesta, la optimizacion o la gestion del riesgo. Conclusiones Este documento pretende resolver algunos interrogantes clinicos habituales y facilitar la toma de decisiones con el bloqueo de la IL-6 en el manejo de la AR.

Objectives (1) To systematically and critically review the evidence on the characteristics, efficacy and safety of glucocorticoids (CS) in rheumatoid arthritis (RA); (2) to generate practical recommendations. Methods A systematic literature review was performed through a sensitive bibliographic search strategy in Medline, Embase and the Cochrane Library. We selected randomized clinical trials that analyzed the efficacy and/or safety of CS in patients with RA. Two reviewers performed the first selection by title and abstract. Then 10 reviewers selected the studies after a detailed review of the articles and data collection. The quality of the studies was evaluated with the Jadad scale. In a nominal group meeting, based on the results of the systematic literature review, related recommendations were reached by consensus. Results A total of 47 articles were finally included. CS in combination with disease-modifying antirheumatic drugs help control disease activity and inhibit radiographic progression, especially in the short-to-medium term and in early RA. CS can also improve function and relieve pain. Different types and routes of administration are effective, but there is no standardized scheme (initial dose, tapering and duration of treatment) that is superior to others. Adverse events when using CS are very frequent and are dose-dependent and variable severity, although most are mild. Seven recommendations were generated on the use and risk management of CS. Conclusions These recommendations aim to resolve some common clinical questions and aid in decision-making for CS use in RA.

Resumen Objetivos 1) Revisar sistematica y criticamente la evidencia sobre las caracteristicas de uso, eficacia y seguridad de los glucocorticoides (GC) en la artritis reumatoide (AR); 2) emitir recomendaciones practicas sobre su utilizacion. Metodos Se realizo una revision sistematica de la literatura con una estrategia de busqueda bibliografica sensible en Medline, Embase y Cochrane Library. Se seleccionaron ensayos clinicos aleatorizados que analizasen la eficacia y/o la seguridad de los GC en pacientes con AR. Dos revisores realizaron la primera seleccion por titulo y abstract y 10, la seleccion tras lectura en detalle y la recogida de datos. La calidad se evaluo con la escala de Jadad. En una reunion de grupo nominal con base en sus resultados se consensuaron una serie de recomendaciones. Resultados Se incluyeron 47 articulos. Los GC, en combinacion con los farmacos antirreumaticos modificadores de la enfermedad, ayudan a controlar la actividad de la enfermedad y a inhibir la progresion radiografica, especialmente en el corto-medio plazo y en las AR de inicio. Los GC pueden mejorar la funcion y el dolor. Distintos tipos y vias de administracion son eficaces, sin que exista un esquema de tratamiento estandarizado (dosis de inicio, desescalada y duracion del tratamiento con los GC) superior a otro. Los acontecimientos adversos de los GC son muy frecuentes, dependientes de la dosis, de gravedad variable, muchos de ellos leves. Se generaron 7 recomendaciones sobre el uso y la gestion del riesgo de los GC. Conclusiones Estas recomendaciones pretenden resolver algunos interrogantes clinicos habituales y facilitar la toma de decisiones con respecto al uso de GC en la AR.

Legged robotic technologies have moved out of the lab to operate in real environments, characterized by a wide variety of unpredictable irregularities and disturbances, all this in close proximity with humans. Demonstrating the ability of current robots to move robustly and reliably in these conditions is becoming essential to prove their safe operation. Here, we report an in-depth literature review aimed at verifying the existence of common or agreed protocols and metrics to test the performance of legged system in realistic environments. We primarily focused on three types of robotic technologies, i.e., hexapods, quadrupeds and bipeds. We also included a comprehensive overview on human locomotion studies, being it often considered the gold standard for performance, and one of the most important sources of bioinspiration for legged machines. We discovered that very few papers have rigorously studied robotic locomotion under irregular terrain conditions. On the contrary, numerous studies have addressed this problem on human gait, being nonetheless of highly heterogeneous nature in terms of experimental design. This lack of agreed methodology makes it challenging for the community to properly assess, compare and predict the performance of existing legged systems in real environments. On the one hand, this work provides a library of methods, metrics and experimental protocols, with a critical analysis on the limitations of the current approaches and future promising directions. On the other hand, it demonstrates the existence of an important lack of benchmarks in the literature, and the possibility of bridging different disciplines, e.g., the human and robotic, towards the definition of standardized procedures that will boost not only the scientific development of better bioinspired solutions, but also their market uptake.

Background: In neurorehabilitation, we are witnessing a growing awareness of the importance of standardized quantitative assessment of limb functions. Detailed assessments of the sensorimotor deficits following neurological disorders are crucial. So far, this assessment has relied mainly on clinical scales, which showed several drawbacks. Different technologies could provide more objective and repeatable measurements. However, the current literature lacks practical guidelines for this purpose. Nowadays, the integration of available metrics, protocols, and algorithms into one harmonized benchmarking ecosystem for clinical and research practice is necessary. Methods: This work presents a benchmarking framework for upper limb capacity. The scheme resulted from a multidisciplinary and iterative discussion among several partners with previous experience in benchmarking methodology, robotics, and clinical neurorehabilitation. We merged previous knowledge in benchmarking methodologies for human locomotion and direct clinical and engineering experience in upper limb rehabilitation. The scheme was designed to enable an instrumented evaluation of arm capacity and to assess the effectiveness of rehabilitative interventions with high reproducibility and resolution. It includes four elements: (1) a taxonomy for motor skills and abilities, (2) a list of performance indicators, (3) a list of required sensor modalities, and (4) a set of reproducible experimental protocols. Results: We proposed six motor primitives as building blocks of most upper-limb daily-life activities and combined them into a set of functional motor skills. We identified the main aspects to be considered during clinical evaluation, and grouped them into ten motor abilities categories. For each ability, we proposed a set of performance indicators to quantify the proposed ability on a quantitative and high-resolution scale. Finally, we defined the procedures to be followed to perform the benchmarking assessment in a reproducible and reliable way, including the definition of the kinematic models and the target muscles. Conclusions: This work represents the first unified scheme for the benchmarking of upper limb capacity. To reach a consensus, this scheme should be validated with real experiments across clinical conditions and motor skills. This validation phase is expected to create a shared database of human performance, necessary to have realistic comparisons of treatments and drive the development of new personalized technologies., The authors thank Eleonora Guanziroli and Luciana Magoni from the Villa Beretta Neurorehabilitation Center and Clara Sanz Morère and Natacha León from Hospital Los Madroños for the valuable contribution in the definition of this work.

Resumen Objetivo El proyecto AR Excellence evalua la atencion clinica a los pacientes con artritis reumatoide (AR) en Espana. El objetivo del presente estudio es analizar la utilizacion de metotrexato (MTX) en AR Excellence y compararla con las recomendaciones vigentes. Pacientes y metodos Se reviso a pacientes con AR que habian iniciado tratamiento con MTX, recogiendo datos demograficos, dosificacion, vias de administracion, combinaciones con otros farmacos antirreumaticos modificadores de enfermedad (FAME), tiempo hasta combinacion con otro FAME (convencional o biologico) y efectos adversos. Resultados Se incluyo a 625 pacientes con AR (edad media de 55,1 anos; 70,6% mujeres), con una duracion media de la AR de 21,3 meses. El 90% inicio tratamiento con MTX. La dosis media de inicio fue de 11 mg semanales; en el 58% de los casos se incremento la dosis. El tiempo medio hasta alcanzar la dosis plena de MTX (20 mg semanales) fue de 6,67 meses. El tiempo hasta la combinacion de MTX con otro FAME sintetico o biologico fue de 3 meses. El 67,4% de los pacientes recibieron el MTX por via oral y el 18,6%, subcutaneo. En el 12% de los casos se cambio la via de administracion, transcurrida una media de tiempo de 6 meses. En 544 pacientes se asociaron suplementos de folato. El 17,3% de los sujetos presentaron acontecimientos adversos por MTX. Conclusion El MTX es el farmaco sobre el que pivota el tratamiento de la AR. El subanalisis del proyecto AR Excellence nos informa de que la escalada a sus dosis plenas no se realiza con la rapidez adecuada. La via subcutanea se utiliza en pocos pacientes.

To evaluate the effectiveness and safety of tocilizumab (TCZ) monotherapy in biologic-naïve patients with rheumatoid arthritis (RA) versus patients with previous biologic exposure in a real-world setting.Non-controlled clinical-trial, 32-week prospective multicenter study including RA patients with moderate-severe disease activity starting TCZ in monotherapy who had a prior inadequate response or were intolerant to methotrexate (MTX). Effectiveness according to EULAR response evaluated at 24-week and safety at 32-weekwere assessed.Of the 93 were enrolled of whom 84 (90%) were eligible for the effectiveness analysis. Biologic-naïve patients (n=46, 54.8%) were younger (51.5 versus 57.9) with shorter disease duration (6.4 versus 13.3) but presented similar comorbidities in comparison with non-naïve patients. DAS28 remission was achieved in a higher percentage in the group of patients with prior biological treatment. 89 adverse events (AE) were recorded in 50 patients, most of them non-serious AE (non-SAE) (86.3%).In a real world setting, TCZ exhibit similar effectiveness and safety in monotherapy in patients with RA regardless previous exposure to other biologic therapies. This study provides additional and valuable real-world findings on the use of TCZ in patients with RA.

To the scarce information on dietary habits in fibromyalgia (FM), it is added that there are no comparative studies with other rheumatic diseases. The objective of this study was to characterise the dietary habits of patients with FM by comparing, for the first time, with healthy controls (HC) and rheumatoid arthritis (RA).This cross-sectional, observational study was based on data obtained from the Dietfibrom project for FM and from the IMID Consortium for RA and HC. All participants completed a food frequency questionnaire evaluating their weekly dietary intake of main food groups. The three cohorts were compared using a multiple logistic regression model adjusted for age, sex, and body mass index.After quality control, n=287 FM, n=1,983 HC and n=1,942 RA patients were analysed. We found that FM had a profound impact in the diet compared to HC, reducing the consumption of dairy (OR=0.32, p0.0001), bread and/or whole grain cereals (OR=0.59, p=0.0006), fresh fruit (OR=0.66, P=0.008), and fish (OR=0.64, p=0.002). These same four food groups were also significantly reduced in FM patients in comparison to RA patients (p0.0005 in all cases). Additionally, a lower consumption of pasta, rice and/or potatoes was also observed in FM compared to RA (OR=0.72, p=0.028).The present cross-sectional study shows that FM is associated to a significant change in the normal dietary patterns. These results underscore the importance of diet in this prevalent disease and are a warning of the potential long-range effects of a deficient nutritional status.

Objective To report the long-term experience of a rheumatologist consultant “in situ” (RCI) in a primary care centre (PCC). Material and methods Observational retrospective study analysing the complete cohort of the patients seen by the RCI between 2013 and 2019. Rheumatology patients’ clinical characteristics and course of care were collected to estimate the diagnoses that were most likely to be monitored by a primary care physician (PCP). Results A total of 876 consultations were attended; 205 were men (23.4%) and 671 women (76.6%).Most of the consultations (280, 33.2%) were diagnostic. On 167 occasions (19.8%) therapeutic issues were analysed; in 47 (5.6%) therapeutic infiltrations were performed. Chronic patient control was applied in 163 subjects (19.3%). A request for tests not available to the PCP was the reason for the consultation in 154 situations (18.3%). The profile most likely to continue being monitored in the PCC is the patient with osteoarthritis (OR = .13, CI 95%: .02–.67), soft tissue rheumatism (OR = .006, 95% CI: .01–.45) or cervical disc herniation (OR = .13, 95% CI: .02–.66). Less likely to be monitored by PCP after being seen by the RCI were subjects with rheumatoid arthritis (OR = .03, 95% CI: .00–.24), other inflammatory arthropathies (OR = .36, 95% CI: .16–.80) or with polymyalgia rheumatica (OR = .19, 95% CI: .06-.64 ), and those in need of chronic disease monitoring (OR = .16, 95% CI: .07–.34). Conclusions The RCI makes it easier for the PCP to monitor patients with osteoarthritis, soft tissue rheumatism and cervical disc pathology.

Rheumatoid arthritis (RA) is an immune-mediated inflammatory disease characterized by a defective adaptive immune receptor repertoire (AIRR) that fails to distinguish self from non-self antigens. The AIRR is vast, encompassing four T cell receptor (TCR) and three B cell receptor (BCR) chains, each of which displays an extraordinary amino acid sequence variability in the antigen-binding site. How the concerted action of T and B cell clones is associated with the development and clinical evolution of immune-mediated diseases is still not known. Using a new immunosequencing technology that allows the unbiased amplification of the seven receptor chains, we conducted an in-depth quantitative analysis of the seven-receptor chain variability in RA. Compared to healthy controls, the AIRR in RA was found to be characterized by a lower BCR diversity, the depletion of highly similar BCR clones, an isotype-specific signature as well as a skewed IGL chain and gene segment usage. A predictor based on quantitative multi-chain AIRR information was able to accurately predict disease, including the elusive seronegative subset of RA patients. AIRR features of the seven immune receptor chains were also different between patients with distinct clinically relevant phenotypes. Incorporating HLA variation data, we were able to identify the TCR clones that are specifically associated with the main disease risk variants. The longitudinal analysis of the AIRR revealed that treatment with Tumor Necrosis Factor (TNF) inhibitors selectively restores the diversity of B cell clones in RA patients by reducing the frequency of clones with a similar biochemical profile. The biochemical properties of the TNFi-modulated clones were also found to differ between responders and non-responders, supporting a different antigenic reactivity in the B cell compartment of these two groups of RA patients. Our comprehensive analysis of the TCR and BCR repertoire reveals a complex T and B cell architecture in RA, and provides the basis for precision medicine strategies based on the highly informative features of the adaptive immune response.

Resumen Introduccion Durante la pandemia por COVID-19 las necesidades de prevencion de transmision de la infeccion viral nos obligaron a potenciar las consultas virtuales. Objetivo El objetivo de estudio es describir los resultados obtenidos con la anterior estrategia y definir el perfil de paciente mas idoneo para aplicarla. Material y metodos Durante el periodo comprendido entre el 16 de marzo y y el 10 de mayo del 2020 todas las consultas sucesivas de nuestro servicio fueron realizadas en formato de teleconsulta reumatologica (TCR). Se recogieron las caracteristicas sociodemograficas, geofuncionales y clinicas de los pacientes; se evaluo mediante escala numerica verbal (0-10, donde 0 = muy insatisfecho hasta 10 = completamente satisfecho) el grado de satisfaccion del paciente/medico con la TC. Resultados La mayoria de los pacientes atendidos en las 469 TCR realizadas fueron mujeres, con una edad media de 60,83 anos. Solo el 16% habia realizado estudios universitarios. La distancia media recorrida para acudir a una consulta presencial era de 33 km, con una inversion de tiempo total promedio de 2 h. La mayoria de los sujetos estaban diagnosticados de artrosis/reumatismos de partes blandas u osteoporosis; el 21% eran presentaban artritis reumatoide. La duracion media de la TCR fue de 9,64 min. Encontramos una mayor satisfaccion con la TCR por parte del paciente, cuando el nivel de estudios era mas alto (OR = 4,33) y por parte del medico cuando el individuo manejaba mejor Internet (OR = 3,22). Conclusion Es posible transferir actividad asistencial reumatologica hacia la TCR con un grado importante de satisfaccion para el paciente y el medico.

Resumen Objetivos Desarrollar recomendaciones sobre el uso de metotrexato (MTX) en pacientes con artritis psoriasica (APs) basadas en la mejor evidencia y experiencia. Metodos Se selecciono un grupo de 12 expertos reumatologos en el manejo de MTX. Los coordinadores generaron 14 preguntas sobre el uso de MTX en pacientes con APs (perfiles de indicacion, eficacia y seguridad) para ser contestadas mediante una revision sistematica de la literatura. En funcion de las preguntas se definieron los criterios de inclusion y exclusion y las estrategias de busqueda (para interrogar Medline, Embase y la Cochrane Library). Dos revisores seleccionaron los articulos resultantes de la busqueda. Se generaron tablas de evidencia. Paralelamente se evaluaron abstracts de congresos de EULAR y ACR. Con toda esta evidencia los coordinadores generaron 12 recomendaciones preliminares que se evaluaron, discutieron y votaron en una reunion de grupo nominal con el resto de expertos. Para cada recomendacion se establecio el nivel de evidencia, grado de recomendacion, y grado de acuerdo mediante un Delphi. Se definio acuerdo si al menos el 80% de los participantes contestan si a la recomendacion (si o no). Resultados De las 12 recomendaciones preliminares se aceptaron 9 recomendaciones sobre el uso de MTX en la APs. Una se englobo en otra y otras 2 no se llegaron a votar porque se decidio no incluirlas, pero se comentan en el texto final. Conclusiones Estas recomendaciones pretenden resolver algunos interrogantes clinicos habituales y facilitar la toma de decisiones con el uso de MTX en la APs.

Objectives To develop recommendations for the management of methotrexate (MTX) in psoriatic arthritis (PsA), based on best evidence and experience. Methods A group of 12 experts on MTX use was selected. The coordinators formulated 14 questions about the use of MTX in PsA patients (indications, efficacy, safety and cost-effectiveness). A systematic review was conducted to answer the questions. Using this information, inclusion and exclusion criteria were established, as were the search strategies (Medline, EMBASE and the Cochrane Library were searched). Two different reviewers selected the articles. Evidence tables were created. At the same time, European League Against Rheumatism and American College of Rheumatology abstracts were evaluated. Based on this evidence, the coordinators proposed 12 preliminary recommendations that the experts discussed and voted on in a nominal group meeting. The level of evidence and grade of recommendation were established using the Oxford Center for Evidence Based Medicine and the level of agreement with the Delphi technique (two rounds). Agreement was established if at least 80% of the experts voted yes (yes/no). Results A total of 12 preliminary recommendations on the use of MTX were proposed, 9 of which were accepted. One was included in a different recommendation and other two were not voted on and were thereafter clarified in the main text. Conclusions These recommendations aim to answer frequent questions and help in decision making strategies when treating PsA patients with MTX.

Resumen Objetivos Desarrollar recomendaciones sobre el uso de metrotexato (MTX) parenteral en pacientes con enfermedades reumaticas, fundamentalmente en la artritis reumatoide, basadas en la mejor evidencia y experiencia. Metodos Se selecciono un grupo de 21 expertos reumatologos en el manejo de MTX. El coordinador genero 13 preguntas sobre el uso de MTX parenteral (perfiles de indicacion, eficacia, seguridad, costo-eficacia y biodisponibilidad) para ser contestadas mediante una revision sistematica de la literatura. Con base en las preguntas se definieron los criterios de inclusion y exclusion, y las estrategias de busqueda (en Medline, EMBASE y la Cochrane Library). Tres revisores seleccionaron los articulos resultantes de la busqueda. Se generaron tablas de evidencia. Paralelamente se evaluaron abstracts de congresos de la European League Against Rheumatism (EULAR) y del American College of Rheumatology (ACR). Con toda esta evidencia el coordinador genero 13 recomendaciones preliminares que se evaluaron, discutieron y votaron en una reunion del grupo nominal con los expertos. Para cada recomendacion se establecio el nivel de evidencia y grado de recomendacion, y el grado de acuerdo mediante un Delphi. Se definio acuerdo si al menos el 80% de los participantes contestaron si a la recomendacion (si o no). Resultados La mayoria de la evidencia proviene de la artritis reumatoide. De las 13 recomendaciones preliminares se aceptaron 11 recomendaciones sobre el uso de MTX parenteral en reumatologia. Dos no se llegaron a votar y se decidio no incluirlas, pero se comentan en el texto final. Conclusiones Este documento pretende resolver algunos interrogantes clinicos habituales y facilitar la toma de decisiones con el uso de MTX parenteral.

To establish a set of recommendations for the management of patients diagnosed with rheumatoid arthritis (RA) who cannot be treated with methotrexate (MTX) due to contraindications, drug toxicity or lack of adherence, and to establish therapeutic strategies more effective and safer in these RA patients. A qualitative analysis of the scientific evidence available to June 2015. The 2-round Delphi technique of consensus was used to collect and establish expert opinion based on the participants’ clinical experience when only low quality evidence was available. A total of 18 recommendations were developed for the management of this patient profile. Fourteen of these recommendations were related to drug safety aspects. Recommendations on contraindication and toxicity of MTX have been updated. The experts recommend the use of biological monotherapy, a preferred treatment option, in patients whose profiles reveal a contraindication, intolerance or circumstances that prevent us against the use of MTX. There is some high-quality scientific evidence that supports contraindication and establishes certain conditions of MTX use in RA patients with specific clinical profiles.

To establish a set of recommendations for the management of patients diagnosed with rheumatoid arthritis (RA) who cannot be treated with methotrexate (MTX) due to contraindications, drug toxicity or lack of adherence, and to establish therapeutic strategies more effective and safer in these RA patients. A qualitative analysis of the scientific evidence available to June 2015. The 2-round Delphi technique of consensus was used to collect and establish expert opinion based on the participants' clinical experience when only low quality evidence was available. A total of eighteen recommendations were developed for the management of this patient profile. Fourteen of these recommendations were related to drug safety aspects. Recommendations on contraindication and toxicity of MTX have been updated. The experts recommend the use of biological monotherapy, a preferred treatment option, in patients whose profiles reveal a contraindication, intolerance or circumstances that prevent us against the use of MTX. There is some high-quality scientific evidence that supports contraindication and establishes certain conditions of MTX use in RA patients with specific clinical profiles.

Brain networks offers a new insight about connections between function and anatomical regions of human brain. We present results from brain networks built from functional magnetic resonance images during finger tapping paradigm. Pearson voxel-voxel correlation in time and frequency domains were performed for all subjects. Besides this standard framework we have implemented a new approach consisting in filtering the data with respect to the fMRI paradigm (finger tapping) in order to obtain a better understanding of the network involved in the execution of the task. The main topological graph measures have been compared in both cases: Voxel-voxel correlation and voxel-paradigm filtering plus voxel-voxel correlation. With the standard voxel-voxel correlation a clearly free-scale network was obtained. On the other hand, when we prefiltered the paradigm we obtained two different kind of networks: 1) free-scale; 2) random-like. To our best knowledge, this behaviour is reported here for first time for brain networks. We suggest that paradigm signal prefiltering can provide more infomation about the brain networks., CA is supported by MINECO/FEDER, under grant PGC2018-095895-B-I00. Ministerio de Asuntos Económicos y Transformación Digital. https:\\www.mineco.gob.es. SJ is partially supported by MINECO under grant MTM2015- 67396-P. Ministerio de Asuntos Económicos y Transformación Digital. https:\\www.mineco.gob.

Background Immune-Mediated Inflammatory Diseases (IMIDs) are a group of conditions/diseases characterized by common pathways leading to inflammation, which may result from a dysregulation of the normal immune response. The activity of these diseases is usually measured by the assessment of clinical symptoms. Objectives To apply a three-stage proteomic strategy to find plasma biomarkers useful to monitor disease activity in patients three different IMIDs: rheumatoid arthritis (RA), psoriatic arthritis (PsA) and systemic lupus erythematosus (SLE). Methods A three-stage proteomic strategy was conducted: 1) Discovery stage: a random selection of 80 plasma samples from patients with different RA activities according to the DAS28, which were classified as low activity (LA, n=40) and high activity (HA, n=40). The analysis was conducted by shotgun mass spectrometry (MS) applying an iTRAQ 8-plex strategy, by nanoLC-MS/MS using three different MS instruments. 2) Verification stage: a targeted proteomics strategy was used to verify the candidate biomarkers from the screening, using the same 80 samples of this first stage. This analysis was performed by Multiple Reaction Monitoring (MRM) with the aid of synthetic heavy-labelled peptides, by nanoLC-MS/MS in an ESI-QTRAP 5500. 3) Validation stage: ELISA experiments were performed to confirm the previous results on an independent set of plasma samples from patients with RA (n=170), PsA (n=80) and SLE (n=80). Results 1) Discovery stage: The MS analysis led to the identification of 186 proteins. A panel of 9 proteins was identified as candidate biomarkers for disease activity monitoring in RA. Most of these proteins are related with the pathogenic process and the effects caused by this type of disease (inflammation and immune disorder in joints). 2) Verification stage: four from the 9 proteins (SAA1, AACT, HPT, A1AG1) were found to be quantitatively altered between patients with extreme disease activities (p Conclusion Using a three-stage proteomic strategy, we have identified HPT, SAA1 and AACT as protein biomarker candidates for monitoring PsA activity. Disclosure of Interests Lucia Gonzalez Rodriguez: None declared, Valentina Calamia: None declared, Rocio Paz Gonzalez: None declared, Patricia Fernandez Puente: None declared, Cristina Ruiz-Romero: None declared, Juan D. Canete: None declared, Antonio Julia: None declared, Antonio Fernandez Nebro: None declared, Jesus Tornero: None declared, Sara Marsal: None declared, Francisco J. Blanco Consultant for: AbbVie, Bioiberica, BMS, GSK, Grunenthal, Janssen, Lilly, Pfizer, Regeneron, Roche, Sanofi, TRB Chemedica, and UCB

Background: In the last years multiple genetic variants have been associated with autoimmune disease (AD) risk. However, much less is known on the association with important environmental factors like diet. Objectives: The objective of the present study is to characterize the dietary patterns of six prevalent ADs, including rheumatoid arthritis (RA), psoriatic arthritis (PsA) and systemic lupus erythematosus (SLE). Methods: A cross-sectional cohort of 11,621 individuals from Spain encompassing 1,949 RA, 2,186 psoriasis (PS), 1,437 PsA, 699 SLE, 1,415 ulcerative colitis (UC), 1,952 Crohn’s disease (CD) and 1,983 healthy controls, was recruited by the IMID-Consortium. The weekly consumption frequency of main food categories was recorded, together with drinking habits and smoking status. Multivariate linear models were used to test for association while adjusting for confounders. Results: Patients with AD targeting the digestive system showed the largest differences in comparison to controls. In the rheumatic ADs several food categories were also found to be consumed differently compared to controls. SLE had a high consumption of sweets and pastries, and RA ate more fruit and bread/wholegrain foods and less meat and cold cuts compared to controls. In PsA the dietary pattern differences with controls where milder, and non-overlapping with psoriasis. Disease activity was significantly associated with specific food categories in CD, UC and PS, mildly in RA and SLE, and PsA showed no association. High smoking cessation rates were observed in UC, CD and SLE, but not in Ps, RA and PsA. Tea/coffee and alcohol consumption was low in all ADs compared to controls. Conclusion: Our results show previously unreported associations with dietary habits in rheumatic ADs. Disclosure of Interests: Antonio Julia: None declared, Sergio Hilario Martinez: None declared, Jesus Tornero: None declared, Juan D. Canete: None declared, Antonio Fernandez-Nebro: None declared, Francisco Blanco: None declared, Jesus Rodriguez: None declared, Francisco J Lopez-Longo: None declared, Benjamin Fernandez-Gutierrez: None declared, Jordi Gratacos: None declared, Jose Javier Perez Venegas: None declared, Carolina Perez: None declared, Ruben Queiro Silva: None declared, Alejandro Olive: None declared, Mercedes Alperi-Lopez: None declared, Carlos A. Montilla-Morales: None declared, Jose Luis Andreu: None declared, Juan Carlos Torre-Alonso: None declared, M Angeles Aguirre-Zamorano: None declared, Hector Corominas: None declared, Paloma Vela Casasempere: None declared, Victor Martinez Taboada : None declared, Sara Manrique Arija Speakers bureau: ABBvie, MSD, Janssen, Lillly, Roche, Pfyzer, Novartis., Joan Miquel Nolla: None declared, Isidoro Gonzalez-Alvaro: None declared, Santiago Munoz-Fernandez: None declared, Jose Luis Marenco Speakers bureau: abbie, pfizer, novartis, janmsen, Carlos M. Gonzalez: None declared, Antonio Zea: None declared, Maria Lopez Lasanta: None declared, Daniel Roig: None declared, Jose M Pego-Reigosa: None declared, Mireia Lopez Corbeto: None declared, Pedro Zarco-Montejo: None declared, Mercedes Freire Gonzalez: None declared, Alba Erra: None declared, Elvira Diez Alvarez: None declared, Santos Castaneda Consultant for: Amgen, BMS, Pfizer, Lilly, MSD, Roche, Sanofi, UCB, Esther Rodriguez Almaraz: None declared, Alicia Garcia: None declared, Patricia Carreira: None declared, GEORGINA SALVADOR ALARCON: None declared, Cesar Diaz Torne Consultant for: Grunenthal, Speakers bureau: Grunenthal, Ricardo Blanco: None declared, Alfredo Willisch Dominguez: None declared, Jose Antonio Mosquera Martinez: None declared, Simon Sanchez Fernandez: None declared, Julio Ramirez: None declared, Sara Marsal: None declared

Objective Rheumatoid factor (RF) is a well-established diagnostic and prognostic biomarker in rheumatoid arthritis (RA). However, ∼20% of RA patients are negative for this anti-IgG antibody. To date, only variation at the HLA-DRB1 gene has been associated with the presence of RF. This study was undertaken to identify additional genetic variants associated with RF positivity. Methods A genome-wide association study (GWAS) for RF positivity was performed using an Illumina Quad610 genotyping platform. A total of 937 RF-positive and 323 RF-negative RA patients were genotyped for >550,000 single-nucleotide polymorphisms (SNPs). Association testing was performed using an allelic chi-square test implemented in Plink software. An independent cohort of 472 RF-positive and 190 RF-negative RA patients was used to validate the most significant findings. Results In the discovery stage, a SNP in the IRX1 locus on chromosome 5p15.3 (SNP rs1502644) showed a genome-wide significant association with RF positivity (P = 4.13 × 10(-8) , odds ratio [OR] 0.37 [95% confidence interval (95% CI) 0.26-0.53]). In the validation stage, the association of IRX1 with RF was replicated in an independent group of RA patients (P = 0.034, OR 0.58 [95% CI 0.35-0.97] and combined P = 1.14 × 10(-8) , OR 0.43 [95% CI 0.32-0.58]). Conclusion To our knowledge, this is the first GWAS of RF positivity in RA. Variation at the IRX1 locus on chromosome 5p15.3 is associated with the presence of RF. Our findings indicate that IRX1 and HLA-DRB1 are the strongest genetic factors for RF production in RA.

OBJECTIVE RA patients with serum ACPA have a strong and specific genetic background. The objective of the study was to identify new susceptibility genes for ACPA-positive RA using a genome-wide association approach. METHODS A total of 924 ACPA-positive RA patients with joint damage in hands and/or feet, and 1524 healthy controls were genotyped in 582 591 single-nucleotide polymorphisms (SNPs) in the discovery phase. In the validation phase, the most significant SNPs in the genome-wide association study representing new candidate loci for RA were tested in an independent cohort of 863 ACPA-positive patients with joint damage and 1152 healthy controls. All individuals from the discovery and validation cohorts were Caucasian and of Southern European ancestry. RESULTS In the discovery phase, 60 loci not previously associated with RA risk showed evidence for association at P < 5×10(-4) and were tested for replication in the validation cohort. A total of 12 loci were replicated at the nominal level (P < 0.05, same direction of effect as in the discovery phase). When combining the discovery and validation cohorts, an intronic SNP in the Solute Carrier family 8 gene (SLC8A3) was found to be associated with ACPA-positive RA at a genome-wide level of significance RA [odds ratio (95% CI): 1.42 (1.25, 1.6), Pcombined = 3.19×10(-8)]. CONCLUSIONS SLC8A3 was identified as a new risk locus for ACPA-positive RA. This study demonstrates the advantage of analysing relevant subsets of RA patients to identify new genetic risk variants.