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Background and objective Axial spondyloarthritis is an immune-mediated disease with a high cost, diagnostic delay and associated complications that makes it a particularly important condition. This work aims to establish a certification standard (SpACE Project) for monographic consultations in its diagnosis and treatment. Materials and methods Qualitative study of consensus, through the technique of the nominal group. First, a pragmatic review of the literature was carried out. Second, professionals involved throughout the care process (rheumatology, ophthalmology, gastroenterology, traumatology, family medicine, physical therapy, and nursing) were included. Results Thirty-seven possible standards were extracted from the pragmatic review of the literature. During the consensus phase only those standards with high feasibility and importance in the care process were prioritized. Finally, the group of 26 experts agreed on the inclusion of 14 standards. Discussion and conclusions SpACE is a consensus-based certification standard that seeks to improve health outcomes and more integrated care.

Resumen Antecedentes y objetivo La espondiloartritis axial es una enfermedad inmunomediada con un elevado coste, retraso diagnostico y complicaciones asociadas, lo que la convierte en una enfermedad con especial importancia. Este trabajo busca por consenso establecer un modelo de certificacion (Proyecto SpACE) para consultas monograficas en su diagnostico y tratamiento. Materiales y metodos Estudio cualitativo de consenso, a traves de la tecnica del grupo nominal. Primero, fue realizada una revision pragmatica de la literatura. Segundo, fueron incluidos profesionales involucrados a lo largo del proceso asistencial (reumatologia, oftalmologia, gastroenterologia, traumatologia, medicina de familia, fisioterapia y enfermeria). Resultados Producto de la revision pragmatica de la literatura fueron extraidos 37 posibles estandares. Durante la fase de consenso solo aquellos estandares con una elevada factibilidad e importancia en el proceso asistencial fueron priorizados. Finalmente, el grupo de 26 expertos acordo la inclusion de 14 estandares. Discusion y conclusiones SpaCE es una norma de certificacion, fruto del consenso, que busca mejorar los resultados en salud y una atencion mas integrada.

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

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.

Objective To date, between 17% and 35% of patients with rheumatoid arthritis (RA) do not respond as expected to the initial biological therapy. The objective of this project is to recognize and weigh the attributes of biologic DMARD (bDMARD) to identify the most appropriate for each case, in the first lines of treatment of RA (after inadequate response to at least one synthetic DMARD or previous bDMARD). Methods To recognize the possible attributes that could define the bDMARD, we performed a systematic search of the literature that recognized the possible attributes involving general aspects, pharmacology, efficacy, safety, management, and cost. Then a Delphi process was conducted with two rounds among a group of selected expert rheumatologists in the management of RA indicating the degree of agreement with the attributes identified in the literature. The project was completed between February and September 2015, indicating the degree of importance that was ascribed to each attribute. Two criteria were applied to determine the consistency of results: (1) based on the median and interquartile range; and (2) on the simultaneous compliance with mean, median, standard deviation, interquartile range and coefficient of variation. The agreement and final ratification of the expert panel were also determined. Results Eighty-three Spanish rheumatologists participated and completed both rounds of the Delphi process. In no case was the importance of the 77 attributes identified considered to be low; 75 of 77 (97.4%) were considered highly important and 76 of 77 (98.7%) were ratified. Fifteen attributes had the support of 100% of the working group. Conclusions There was a high degree of agreement concerning the selected attributes. Fifteen of them had the support of 100% of the working group and could be considered the definition of the ideal bDMARD in the first lines of RA treatment.

Background: The JAK inhibitors, a new group of targeted synthetic DMARDs were marketed in Spain in 2018. These oral drugs are a good therapeutic alternative for patients with MTX failure. These are not biologic DMARDs and its place in clinical practice is not clear. Objectives: To identify the clinical characteristics of the patients treated with JAK inhibitors in a Rheumatology service in the South of Spain. To know the efficacy and safety of these drugs used in usual clinical practice. Methods: Setting: Rheumatology department in a 3rd level University Hospital. Design: an observational and analytical case series. From September 2018 to January 15, 2019 clinical data were collected of all patients with RA (ACR/EULAR 2010) treated with JAK inhibitors. The variables collected were demographics, clinical, related to RA, comorbidities, activity (DAS28ESR) and EULAR response. Safety variables included severe adverse events, and adverse events that caused the interruption of the treatment. The protocol was approved and conducted according to the local ethic committee regulations. The statistical analysis was done with descriptive and inferential non parametric tests. Data are shown as median (percentile 25 – percentile 75). Results: In the study period, 33 patients were treated with JAK inhibitors. Two patients were excluded of this review due to lack of an evaluation of follow-up. Data of 31 RA patients are presented. They were female (74%) with RF+, ACPA+ and erosive disease en more of 90% of cases; 61% had at least one comorbidity. The Charlson comorbidity index was 3 (2-6). The median age at the time of the start of the JAK inhibitor was 63.3 (56.8 – 70.7) years. The disease duration at the time of the start of the JAK inhibitor was 14.7 (8.6 – 27.5) years. All the patients had received synthetic conventional DMARDs, the number of previous scDMARDs was 2 (2 – 6); 26% had been treated with biologic DMARDs. The number of previous bDMARDS was 2 (1 – 5); 26 (84%) patients were treated with baricitinib and 5 with tofacitinib, oh these 25 (77%) were treated with corticosteroids, the median daily dose of prednisone was 7.5 (5 – 15) mg/day, and 16 (52%) were treated with MTX, the mean weekly dose was 15 (10 – 25) mg/week. The baseline DAS28ESR was 4.9 (4.1 – 5.7) and the end DAS28ESR was of 2.6 (2.07 – 3.5), p Conclusion: The JAK inhibitors are tsDMARD with good profile of efficacy and safety in clinical practice. The patients treated with these drugs had a long and severe disease with failure to several drugs and poor prognostic variables, and a high comorbidity index, however these drugs show good response rates. Disclosure of Interests: None declared

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

Background: As part of the IOF recommendations and the “Capture the fracture” program a Multidisciplinary and focussed on Primary Medicine Fracture Liaison Prevention Unit (FLS) was created in May of 2018 in the Hospital Universitario Virgen Macarena, in Seville, Spain. In previous reprts, the rate of osteoporosis treatment prescription after the fragility fracture was as low as 20%, with a poor communication between the medical specialties involved in the attention of this patients. Objectives: To improve the medical attention and treatment of patients with a FF. To create a multidisciplinary FLS with the collaboration of Primary Care Medicine, Internal Medicine, traumatology, Emergency Room, Rheumatology, Rehabilitation Service and the Medicine Department of the Seville University. Design: A prospective, observational study in the setting of usual clinical practice and with approval of the local ethics committee. The Multidisciplinary FLS started to work at may, 2018 connecting primary care with medical specialties. The FLS has 3 weekly consultations (11 first visits, 4 second visits and email consultation, each day) attended by 2 internal medicine physicians, one Rheumatologist and one nurse. All the medical specialties involved in the attention of patients with FF can refer patients and the inclusion criteria is the history of a FF in the past 18 months. In a single medical visit, the doctor and the nurse make a clinical history, assesses the risk of FF according to FRAX, the risk of falls (J.H. Downton scale), they evaluate malnutrition (Mini Nutritional Assessment Elderly) and sarcopenia (hands dynamometry and Short Physical Performance Battery). Complete blood count and blood and urine biochemistry in order to evaluate secondary causes of osteoporosis and vertebrae radiographs are done. A treatment plan agreed and discussed with the patient is started. The plan advice on diet and exercises, drugs, and a written report and medical prescription. And a phone follow-up is programmed. The data are entered and stored in a database (OpenClinica) in real time. Results: From May to October of 2018, 170 patients have been included; 135 (89%) women. The mean (standard deviation) age was 73 ± 11.8 years old; 25% of them with ages between 83 to 94 years. The patients were referred from Perioperative Internal Medicine (46%), Traumatology and orthopedic surgery (37%), Rheumatology (6%), Primary Medicine (5%) and others medical areas (6%). The anatomical sites of the FF were hip (58%), vertebrae (22%), distal radius (13%), humerus (4%) and other sites (7%). The prescribed treatment was alendronate (66%), denosumab (18%), teriparatide (10%), risedronate acid (4%) and calcium and/or vitamin D supplementation in 98% of the patients. The compliance was measured by phone call in 42 patients that completed six months after the first evaluation, and it was good in 100%. Conclusion: The multidisciplinary FLS activity increased the rate of evaluation of risk and prescription of treatment at 100% with rates of compliance at six months of 100%. The FLS allows the creation of fluid reference circuits and improves the patient care. References [1] Walters S, et al. Clinical Interventions in Aging2017:12117–127 Disclosure of Interests: None declared

Resumen Introduccion En los ultimos anos, el peso especifico de las consultas externas ha aumentado considerablemente. En la actualidad, la mayor parte de la atencion reumatologica se lleva a cabo en esta area del hospital. Sin embargo, apenas existe documentacion respecto a estandares de calidad asistencial. Objetivo Desarrollar, mediante consenso, estandares de calidad asistencial especificos para las consultas externas de reumatologia. Metodo El proyecto se llevo a cabo mediante metodologia Delphi a 2 rondas. Se conto con la participacion de un comite cientifico (13 reumatologos), 5 grupos nominales (45 reumatologos y 12 enfermeras especializadas) y un grupo de discusion formado por 9 pacientes. Se generaron de forma sucesiva diversos borradores hasta obtener un documento final que incluyo los estandares que recibieron una puntuacion igual o superior a 7 en al menos el 70% de los participantes. Resultados El documento consta de 148 estandares distribuidos en 9 areas tematicas: a) estructura (22); b) actividad clinica y relacion con los pacientes (34); c) planificacion (7); d) niveles de prioridad (5); e) relacion con atencion primaria, con el servicio de urgencias y con otros servicios del hospital (20); f) proceso (26); g) enfermeria (13); h) docencia e investigacion (13), e i) computo de actividad (8). Conclusion Se han consensuado unos estandares de calidad asistencial que pueden ser utiles para organizar la actividad en las consultas externas de los servicios de reumatologia y servir como marco de referencia a la hora de elevar propuestas de mejora a la gerencia del hospital o a otros estamentos de la administracion.

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.

Transverse myelitis is a rare focal inflammation of the spinal cord. Multiple etiologies have been identified including autoimmune diseases, mainly systemic lupus erythematosus and Sjögren' syndrome. It can occur in an acute or subacute clinical onset, with the acute presentation having a worse prognosis. An early diagnosis and intensive treatment are important features recommended in these patients. We present three cases with transverse myelitis associated with autoimmune diseases. We discuss different clinical manifestations, association with autoantobodies, radiologic findings, and therapeutic and prognostic issues.

Resumen La mielitis transversa es una inflamacion focal poco frecuente de la medula espinal. Su etiologia es multiple y entre ellas se encuentran las enfermedades autoinmunes, incluyendo principalmente el lupus eritematoso sistemico y el sindrome de Sjogren. Su presentacion clinica puede ser de forma aguda o subaguda, con peor pronostico en la mielitis transversa aguda. Un diagnostico precoz y tratamiento intensivo desde el inicio es de gran importancia en la evolucion de este tipo de pacientes. Presentamos 3 casos con mielitis transversa asociados a enfermedades autoinmunes y discutimos sus distintas manifestaciones clinicas, la asociacion a autoanticuerpos, las imagenes radiologicas, el tratamiento y el pronostico.

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.

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)

Existen pacientes con artritis reumatoide (AR) que no responden de la forma deseada a la terapia biológica. Nuestro objetivo fue reconocer los atributos del FAME biológico (FAMEb) que podrían identificar al más adecuado en las primeras líneas de tratamiento de la AR. Métodos Para reconocer los atributos que podrían definir el FAMEb, se realizó una búsqueda sistemática de la literatura acerca de aspectos generales, farmacología, eficacia, seguridad, administración y coste. A continuación, se realizó un proceso Delphi a 2 rondas entre un grupo de reumatólogos expertos en el manejo de la AR para determinar el grado de acuerdo con los atributos identificados, indicando el grado de importancia que se le daba a cada atributo. Se aplicaron 2 criterios para determinar la consistencia de los resultados: 1) sobre la base de la mediana y el rango intercuartílico, y 2) el cumplimiento simultáneo de media, mediana, desviación estándar, rango intercuartílico y coeficiente de variación. Se determinaron también la concordancia y la ratificación final del panel de expertos. Resultados Ochenta y tres reumatólogos españoles completaron las 2 circulaciones del proceso Delphi. Ninguno de los 77 atributos identificados se consideró de baja importancia, 75 de los 77 (97,4%) se consideraron de alta importancia y 76 de los 77 (98,7%) fueron ratificados. Quince tuvieron el apoyo del 100% del grupo de trabajo. Conclusiones Quince atributos tuvieron el apoyo del 100% del grupo de trabajo y podrían considerarse los que definirían el FAMEb ideal en las primeras líneas de tratamiento de la AR. To date, between 17% and 35% of patients with rheumatoid arthritis (RA) do not respond as expected to the initial biological therapy. The objective of this project is to recognize and weigh the attributes of biologic DMARD (bDMARD) to identify the most appropriate for each case, in the first lines of treatment of RA (after inadequate response to at least one synthetic DMARD or previous bDMARD). Methods To recognize the possible attributes that could define the bDMARD, we performed a systematic search of the literature that recognized the possible attributes involving general aspects, pharmacology, efficacy, safety, management, and cost. Then a Delphi process was conducted with two rounds among a group of selected expert rheumatologists in the management of RA indicating the degree of agreement with the attributes identified in the literature. The project was completed between February and September 2015, indicating the degree of importance that was ascribed to each attribute. Two criteria were applied to determine the consistency of results: 1) based on the median and interquartile range; and 2) on the simultaneous compliance with mean, median, standard deviation, interquartile range and coefficient of variation. The agreement and final ratification of the expert panel were also determined. Results Eighty-three Spanish rheumatologists participated and completed both rounds of the Delphi process. In no case was the importance of the 77 attributes identified considered to be low; 75 of 77 (97.4%) were considered highly important and 76 of 77 (98.7%) were ratified. Fifteen attributes had the support of 100% of the working group. Conclusions There was a high degree of agreement concerning the selected attributes. Fifteen of them had the support of 100% of the working group and could be considered the definition of the ideal bDMARD in the first lines of RA treatment. Sin financiación No data JCR 2018 0.363 SJR (2018) Q3, 38/66 Rheumatology No data IDR 2018 UEM

Introduction In recent years, outpatient clinics have undergone extensive development. At present, patients with rheumatic diseases are mainly assisted in this area. However, the quality standards of care are poorly documented. Objective To develop specific quality criteria and standards for an outpatient rheumatology clinic. Method The project was based on the two-round Delphi method. The following groups of participants took part: scientific committee (13 rheumatologists), five nominal groups (45 rheumatologists and 12 nurses) and a group of discussion formed by 9 patients. Different drafts were consecutively generated until a final document was obtained that included the standards that received a punctuation equal or over 7 in at least 70% of the participants. Results 148 standards were developed, grouped into the following 9 dimensions: (a) structure (22), (b) clinical activity and relationship with the patients (34), (c) planning (7), (d) levels of priority (5), (e) relations with primary care physicians, with Emergency Department and with other clinical departments, (f) process (26), (g) nursing (13), (h) teaching and research (13) and (i) activity measures (8). Conclusion This study established specific quality standards for rheumatology outpatient clinic. It can be a useful tool for organizing this area in the Rheumatology Department and as a reference when proposing improvement measures to health administrators.

La artritis reumatoide (AR) es una enfermedad inflamatoria sistemica cronica de etiologia desconocida. Presenta un curso fluctuante y un pronostico impredecible, si bien su evolucion habitual es hacia la destruccion de las estructuras articulares, lo que origina una perdida de la funcion fisica y una disminucion en la calidad de vida de los pacientes que la presentan1. Los objetivos del tratamiento de la AR serian reducir el dolor y la inflamacion articular, mejorar la capacidad fisica y funcional y evitar o atenuar el dano estructural articular. Se trataria de inducir una remision clinica de la enfermedad, con el consiguiente aumento de la supervivencia de los pacientes2. Los antiinflamatorios no esteroideos (AINE) son farmacos que se han utilizado tradicionalmente en el tratamiento del dolor y la inflamacion articular en los pacientes con AR. En los textos clasicos de reumatologia se los consideraba un escalon terapeutico inicial, situado en la base de la “piramide” ya en desuso, que permitia un alivio sintomatico del dolor y la inflamacion y conservar cierta calidad de vida. En los ultimos anos, el diagnostico precoz de la enfermedad, la introduccion rapida de los farmacos modificadores de enfermedad (FAME) y un correcto manejo de la dosis de estos ultimos, fundamentalmente metotrexato, asi como el empleo de terapias biologicas, han motivado ciertas dudas sobre la necesidad del uso de AINE en el tratamiento de la AR. En esta breve revision trataremos de hacer una justificacion etiopatogenica del uso de AINE, analizaremos su eficacia en el control clinico y radiologico de la enfermedad y, por ultimo, describiremos las recomendaciones de diferentes guias de practica clinica sobre su empleo. Razones a favor del uso de antiinflamatorios no esteroideos durante la induccion de remision de la artritis reumatoide

Among the extraintestinal manifestations of inflammatory bowel disease (IBD), pyoderma gangrenosum (PG) often poses a therapeutic challenge. We describe two cases of PG associated with inflammatory bowel disease, who responded to treatment with Infliximab.

Dentro de las manifestaciones extraintestinales de la enfermedad inflamatoria intestinal (EII), el pioderma gangrenoso (PG) plantea con frecuencia dificultades terapeuticas. Describimos 2 casos de PG asociados a enfermedad inflamatoria intestinal, con buena respuesta al tratamiento con infliximab

years of age, while in the United Kingdom it is of the order of 4.5%. It is characterized by excessive and abnormal bone remodeling in localized areas of the skeleton. It can be observed as a casual finding on x-rays. Its clinical presentation varies according to the localization and distribution of the lesions1,2. Among the complications related to this disease, malignant degeneration appears in less than 1% of patients