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Studies conducted by various scientific societies have shown that the demand for specialized rheumatology care is greater than the projected growth of the workforce. Our research aims to assess the current status of the rheumatology workforce in Latin America.This is a descriptive, cross-sectional study. A survey was created on the RedCap platform. Data were analyzed with STATA 15® Software. We present descriptive analyses. The rate of inhabitants per rheumatologist was calculated using the number of rheumatologists practicing in each country and the inhabitants for year 2020.Our sample was composed by 19 PANLAR member countries in Latin America. Latin America has one rheumatologist per 106,838 inhabitants. The highest rate of rheumatologist per inhabitants was found in Uruguay (1 per 27,426 inhabitants), and the lowest was found in Nicaragua (1 per 640,648 inhabitants). Mean age was 51.59 (SD12.70), ranging between 28 and 96 years of age. Mean monthly compensation was USD $2382.6 (SD$1462.5). The country with lowest salary was Venezuela ($197), whereas the highest was Costa Rica ($4500).There is a high variability in rheumatologists' workforce characteristics in Latin America. These results could lead to policies aiming to increase the availability and income of rheumatologists, in order to increase opportunity and quality of care of patients living with rheumatic diseases. Key Points • The rheumatologists' workforce varies significantly among Latin American countries. • The supply of rheumatologists is insufficient for meeting the increasing need for specialists in this field.

Rheumatic diseases are a reason for frequent consultation with primary care doctors. Unfortunately, there is a high percentage of misdiagnosis.To design an algorithm to be used by primary care physicians to improve the diagnostic approach of the patient with joint pain, and thus improve the diagnostic capacity in four rheumatic diseases.Based on the information obtained from a literature review, we identified the main symptoms, signs, and paraclinical tests related to the diagnosis of rheumatoid arthritis, spondyloarthritis with peripheral involvement, systemic lupus erythematosus with joint involvement, and osteoarthritis. We conducted 3 consultations with a group of expert rheumatologists, using the Delphi technique, to design a diagnostic algorithm that has as a starting point "joint pain" as a common symptom for the four diseases.Thirty-nine rheumatologists from 18 countries of Ibero-America participated in the Delphi exercise. In the first consultation, we presented 94 items to the experts (35 symptoms, 31 signs, and 28 paraclinical tests) candidates to be part of the algorithm; 74 items (25 symptoms, 27 signs, and 22 paraclinical tests) were chosen. In the second consultation, the decision nodes of the algorithm were chosen, and in the third, its final structure was defined. The Delphi exercise lasted 8 months; 100% of the experts participated in the three consultations.We present an algorithm designed through an international consensus of experts, in which Delphi methodology was used, to support primary care physicians in the clinical approach to patients with joint pain. Key Points • We developed an algorithm with the participation of rheumatologists from 18 countries of Ibero-America, which gives a global vision of the clinical context of the patient with joint pain. • We integrated four rheumatic diseases into one tool with one common symptom: joint pain. It is a novel tool, as it is the first algorithm that will support the primary care physician in the consideration of four different rheumatic diseases. • It will improve the correct diagnosis and reduce the number of paraclinical tests requested by primary care physicians, in the management of patients with joint pain. This point was verified in a recently published study in the journal Rheumatology International (reference number 31).

Although low back pain (LBP) is a high-impact health condition, its burden has not been examined from the syndemic perspective. To compare and assess clinical, socioeconomic, and geographic factors associated with LBP prevalence in low-income and upper-middle-income countries using syndemic and syndemogenesis frameworks based on network and cluster analyses. Analyses were performed by adopting network and cluster design, whereby interrelations among the individual and social variables and their combinations were established. The required data was sourced from the databases pertaining to the six Latin-American countries. Database searches yielded a sample of 55,724 individuals (mean age 43.38 years, SD = 17.93), 24.12% of whom were indigenous, and 60.61% were women. The diagnosed with LBP comprised 6.59% of the total population. Network analysis showed higher relationship individuals’ variables such as comorbidities, unhealthy habits, low educational level, living in rural areas, and indigenous status were found to be significantly associated with LBP. Cluster analysis showed significant association between LBP prevalence and social variables (e.g. Gender inequality Index, Human Development Index, Income Inequality). LBP is a highly prevalent condition in Latin-American populations with a high impact on the quality of life of young adults. It is particularly debilitating for women, indigenous individuals, and those with low educational level, and is further exacerbated by the presence of comorbidities, especially those in the mental health domain. Thus, the study findings demonstrate that syndemic and syndemogenesis have the potential to widen the health inequities stemming from LBP in vulnerable populations.

Health education is fundamental in the management of RA patients. This study explored patient needs for educational material appropriate for RA patients in our region through a website. This study includes seven focus groups and semi-structured interviews across 4 countries (Argentina, Chile, Colombia, and Mexico) with 71 RA patients. Transcripts were analyzed by anthropologists using qualitative analysis (QA), resulting in themes and subthemes to be developed. Five themes and over 50 subthemes of interest were identified by patients. Grouped into categories as follows: (1) knowing the disease, (2) living with arthritis, (3) treatment and therapies for RA, (4) psychosocial support, and (5) information for families. A response was written by the team in plain Spanish on patient subthemes of interest including additional areas that the team considered relevant. Three videos for YouTube were produced: on patient-doctor relationships, patients at work, and home and at the clinic. Illustrations in a comic book format on RA diagnosis were created. The educational site on RA of PANLAR can be found at htpp://artritisreumatoide.cl. This project accomplished a comprehensive list of RA patient interests, revealing the complex relationship between the information on the disease, the experience of a chronic disease, and the way in which patients approach, conceive, and manage their disease. We expect to gather information on how the website will be used in the future for patients and their families and maintain and improve the website as well as adapt its content to different socioeconomic realities.

The implementation of excellence centers in specific diseases has been gaining recognition in the field of health; specifically in rheumatoid arthritis, where the prognosis of the disease is related to an early diagnosis and a timely intervention, it is necessary that the provision of health services is developed in an environment of quality, opportunity, and safety with the highest standards of care. A methodology that allows this implementation in such a way that is achievable by the most of the care centers is a priority to achieve a better attention to populations with this disease. In this paper, we propose a systematic and progressive methodology that will help all the institutions to develop successful models without faltering in the process. The expected impact on public health is defined by a better effective coverage of high-quality treatments, obtaining better health outcomes with safety and accessibility that reduces the budgetary impact for the health systems of our countries.

To identify baseline predictors of remission and low disease activity (LDA) in early rheumatoid arthritis (RA) from the GLADAR (Grupo Latino Americano De estudio de la Artritis Reumatoide) cohort.Patients with 1- and 2-year follow-up visits were included. Remission and LDA were defined by DAS28-ESR ( 2.6 and ≤ 3.2, respectively). Baseline predictors examined were gender, ethnicity, age at diagnosis, socioeconomic status, symptoms' duration, DMARDs, RF, thrombocytosis, anemia, morning stiffness, DAS28-ESR (and its components), HAQ-DI, DMARDs and corticosteroid use, and Sharp-VDH score. Multivariable binary logistic regression models (excluding DAS28-ESR components to avoid over adjustment) were derived using a backward selection method (α-level set at 0.05).Four hundred ninety-eight patients were included. Remission and LDA/remission were met by 19.3% and 32.5% at the 1-year visit, respectively. For the 280 patients followed for 2 years, these outcomes were met by 24.3% and 38.9%, respectively. Predictors of remission at 1 year were a lower DAS28-ESR (OR 1.17; CI 1.07-1.27; p = 0.001) and HAQ-DI (OR 1.48; CI 1.04-2.10; p = 0.028). At 2 years, only DAS28-ESR (OR 1.40; CI 1.17-1.6; p 0.001) was a predictor. Predictors of LDA/remission at 1 year were DAS28-ESR (OR 1.42; CI 1.26-1.61; p 0.001), non-use of corticosteroid (OR 1.74; CI 1.11-2.44; p = 0.008), and male gender (OR 1.77; CI 1.2-2.63; p = 0.036). A lower baseline DAS28-ESR (OR 1.45; CI 1.23-1.70; p 0.001) was the only predictor of LDA/remission at 2 years.A lower disease activity consistently predicted remission and LDA/remission at 1 and 2 years of follow-up in early RA patients from the GLADAR cohort. Key Points • In patients with early RA, a lower disease activity at first visit is a strong clinical predictor of achieving remission and LDA subsequently. • Other clinical predictors of remission and LDA to keep in mind in these patients are male gender, non-use of corticosteroids and low disability at baseline. • Not using corticosteroids at first visit is associated with a lower disease activity and predicts LDA/remission at 1 year in these patients.

The original version of this article, unfortunately, contained an error. The first and family name of Loreto Massardo was interchanged and is now presented correctly in this article.

Rheumatoid arthritis (RA) is one of the most important rheumatic diseases. Its prevalence varies among ethnic groups. Genetic and environmental factors influence its incidence and prevalence. This chronic disease will increase its frequency in the future due to population aging. The personal impact of this disease on many relevant areas of an individual requires special efforts to prevent and treat it properly. Adequate advice on several recently described risk factors such as tobacco and alcohol exposure, infections, obesity, and physical exercise should be part of every medical consultation. This knowledge should be incorporated to improve health care prevention programs. Patients and clinicians must work together through better communication skills to finally improve outcomes. Including RA in priority health care lists will need special effort from rheumatology societies and better communication with policy makers.

Measuring quality of life (QOL) is important, but to date, questionnaires to measure QOL in Mexican patients with osteoporosis (OP) have not been validated. A study was carried out to culturally adapt and validate the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) in a Mexican population. Interviews were performed with 160 women, 80 patients with at least one vertebral fracture, and 80 patients with OP as determined by the World Health Organization criteria. Several cultural modifications were made to the Spanish version of the QUALEFFO. Content validity was assessed by a group of experts, and a pilot study was undertaken. At the same time, the Spanish version of the Short Form 36 (Medical Outcomes Study) was applied. The mean age of patients was 71.9 ± 11.1. The QOL questionnaire showed a test–retest reproducibility (R i = 0.94) and internal consistency (α = 0.92), while social function scored low (α = 0.46). Concurrent validity was significant (r = −0.837, p < 0.001). Significant differences were found between the two groups for pain (p < 0.05), physical function (p < 0.01), social function (p < 0.01), mental function (p < 0.05), and number of fractures (p < 0.001). Discriminatory characteristics between the groups were significant for physical (p < 0.001), social (p < 0.001), and mental (p < 0.02) function. The cultural adaptation of the QUALEFFO was consistent, homogenous, and discriminative. It also showed deterioration in the QOL group of Mexicans with vertebral fractures. The QUALEFFO can be used in a Mexican population to measure the QOL in patients with vertebral fractures after some cultural modifications to take into account local sensibilities.

Multilevel studies have gained importance for highlighting social inequalities in health. These associations have been reported previously in diseases such as arthritis and chronic pain. We conducted a cross-sectional study using multilevel analysis to identify individual and contextual factors associated with the variation of prevalence of osteoarthritis (OA) in the Mexican population. The sample included 17,566 individuals of which 10,666 (60.7 %) were women. The relationship between individual and contextual factors and OA were analyzed with a multilevel strategy. From the total population, 1,681 individuals had OA. Multilevel analysis showed that individual variables such as female gender (odds ratio (OR) = 1.3, 95 % confidence interval (CI) 1.1, 1.4), age range 55–65 years (OR = 1.6, 95 % CI 1.3, 2.0), musculoskeletal pain in the last 7 days (OR = 2.6, 95 % CI 2.3, 3.0), and use of pain treatments (OR = 1.4, 95 % CI 1.2, 1.7) were associated with OA. At the regional level, the Social Gap Index (SGIx) was associated with the diagnosis of OA (coefficient 0.5, 95 % CI 0.2–1.1). The SGIx contextual variable was positively associated with the regional prevalence of OA and the variation in prevalence of OA in different regions. The larger the social gap, the greater the variation in OA prevalence. These factors were independently associated with the prevalence of OA: female gender, pain intensity, physical limitation, and the use of pain treatments were individual variables associated with OA. The association between OA prevalence and regional variations with SGIx reflects inequities in health provisions that should be considered in health programs.

Since the introduction of biologic agents for the treatment of patients with rheumatoid arthritis (RA), there have been enormous advances in clinical and therapeutic aspects of the disease. Likewise, there is now much more information on the role of genetics and environmental factors in the pathogenesis of the disease. Throughout the years, the main therapeutic target is the control of disease activity as soon as possible to prevent structural damage and functional consequences. RA is a diagnosis that is not easily recognized at early phases. Lay people associate rheumatic diseases with old age, minor physical trauma, weather, dietetic conditions, or emotional issues. It is not a surprise that many patients seek medical care at late stages, when irreversible damage has already occurred. Sustained remission or low-disease activity levels without joint space loss and erosions have become the main objective of current therapies. Health-related quality of life (HRQoL) improves and long-term socioeconomic consequences decreases. Primary care physicians are usually the first medical contact. These clinicians should have special tools for early diagnosis, proper referral, and initial treatment in all patients with a clinical suspicion of RA. This is not the case in many countries where rheumatology training in undergraduate programs is not fully implemented. Rheumatology societies in Latin America should have a more active participation in medical education in undergraduate programs including practical activities. This will be probably an important investment to diminish the burden of illness that RA causes to the society [1]. Another challenge that many countries face is having an insufficient number of rheumatologists. As expected, rheumatologists usually have busy clinical activities. The time devoted to individual care is not enough to establish an adequate relationship, consultations are not usually as frequent as they should be, medical resources are not always what medical guidelines suggest, and patients tend to receive a suboptimal medical care. This should motivate rheumatology organizations to identify intelligent and practical alternatives to improve medical care despite a shortage of rheumatologists. Education, innovation, and coordination seem to be the key activities to be done. Once a clinical diagnosis has been made, clinicians should be aware that low educational level in RA patients in Latin America has been associated with higher disease activity, more radiologic progression, and poor clinical outcomes. This is probably related to late diagnosis and some practical and therapeutic variables [2]. All patients and particularly those with a low educational level require special health education programs. Patient education in rheumatoid arthritis is an urgent need to discuss what is expected of medical and nonmedical treatments and the importance of patient and family participation and improve patient-doctor communication skills. Adherence to medical treatment in chronic diseases remains a very important problem in the world. It is recognized that poor adherence is associated with worse clinical and radiological outcomes [3]. Costs of medication impose an important economic burden to patients and their families [4]. Comorbidity in rheumatoid arthritis increases complexity to medical care. In many cases, rheumatologists are the team coordinators and should be prepared to offer proper management. There is a need to implement therapeutic strategies that include a more comprehensive medical care. It is now 20 years since the first report on the efficacy of a monoclonal antibody—infliximab—to tumor necrosis factor alpha (TNF-α) in patients with RA [5]. Compared to placebo, the effect of the TNF-α blocker was impressive and authors concluded that such “results provide the first good evidence that specific cytokine blockade can be effective in human inflammatory disease and define a new direction for the treatment of rheumatoid arthritis.” That new direction has benefited thousands of patients all over the world through the implementation of programs for early recognition of the disease, redefinition of classification criteria, improved designs of protocols for the study of the efficacy and safety of biologics and DMARDs, continuous increase in the number of agents—many directed to new targets, the instauration of biologic registries, and post-marketing surveillance. It is clear that the implementation and maintenance of such programs require a considerable budget to cover the cost of the infrastructure needed to accomplish their goals and the cost of biologics itself. While most European countries relay in the percentage of their gross domestic product (GDP) devoted to health care to comply with those programs, in other parts of the world, including Latin America, the cost is partially covered by a variety of entities, including patients’ and households’ own pocket money. Similar or even worst situations occur in Africa and Asia resulting in a tremendous gap between developed and underdeveloped countries regarding the identification of RA and its current treatment. In this sense, the implementation of programs for early detection and treatment of RA might be less successful than in developed countries. Health care in Latin America is typically fragmentary [6]. In some countries, the state provides health care for the whole population while in others, individuals pay for their medical expenses. Reimbursement is very limited and is only available in some countries. Access programs are available in some countries where the government usually provides the drug. In this sense, it is not convenient to make any generalization of the characteristics of health care in Latin America. Barriers to implement early recognition of RA and treat them early on the course of the disease related to the healthcare system in Latin America include several aspects. The nation’s GDP budget for health care had a sustainable increase in several Latin American nations. The mean percentage of Argentina, Brazil, Chile, Colombia, Mexico, and Venezuela increased from 7.9 % in 2009 to an estimated 8.1 % in 2017 [7]. The way each country handles their annual budget is unknown. In general, most of the budget goes to pediatric diseases, chronic degenerative conditions, and metabolic diseases reducing the individual life expectancy. The situation here is that the percentage of such budget devoted to rheumatic diseases is probably very small and insufficient to run any health program at the national level. As a group, rheumatic diseases are not considered of clinical, socioeconomic, and cost relevance for the state. It is therefore neither as a group nor individually deserve the attention of health authorities whom apparently consider that rheumatic diseases are not a health problem. The role of the state—represented by healthcare system—in implementing early arthritis clinics is limited. The cost of such a program includes some infrastructure, human resources, and effective treatment. The prevalence of RA in Latin America ranges between 0.4 and 1.6 % [8–10]. At least in the Mexican population, there are variations in the prevalence of RA related to geographic regions that might be explained by the low educational and socioeconomic level represented by people who only speak a native language. In contrast to what health authorities consider, epidemiological data supports the idea that RA is not a rare disease and that late diagnosis is associated to bad prognosis. It is possible that at the institutional level, the facilities to carry on an additional clinic, specifically an early arthritis clinic and human resources, would be impossible. Most clinics, physicians, and nurses are overwhelmed by daily consultations. Despite the fact that needs would depend on the success of the program, some challenging situations must be solved. The infrastructure requires the space needed to take care of patients with early disease. Space limitations may account for inadequate care and communication between the patient and the physician. There should be access to laboratory examinations, imaging studies, infusion rooms, and refrigeration systems. Human resources include physicians—from general practitioners to rheumatologists, nurses, joint counters, and some administrative people. They should be paid for their services and should be continuously trained. The design of protocols according to the procedures to be performed should be clear and well justified. Similarly, the clinic should have the capacity to provide the patient with the medication he needs. Despite its popularity, recommendations for treating patients with RA according to international standards, including the American College of Rheumatology/European League Against Rheumatism recommendations [11] and the Treat to Target initiative [12], its implementation in clinical practice might be difficult in the presence of some of the barriers mentioned before. Early recognition and proper assessment of the clinical status of the patient does not mean that medications would be available for everyone. In summary, recognition and therapeutic advances in RA have evolved very rapidly in the last 20 years. Unfortunately, alongside with these advances, a gap between fragmented and socialized healthcare services is becoming wide. And that seems to be the case for some Latin American countries. We have identified the most important challenges that patients, doctors, and medical systems face to improve the medical care of one of the most important rheumatic diseases. RA will remain a health problem despite medical advances if we do not effectively act on these challenges to modify the outcome in most RA patients in Latin America.