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The Portuguese Rheumatology Society (SPR) embraced quality as a major goal and launched, in early 2015, a program to aim for excellence in global clinical care: Rheuma SPACE - Standard Practice Aiming Clinical Excellence. Evaluating daily reality is the first step in a quality development timeline, ultimately contributing for health gains. Herein we describe the results of the evaluation of the quality indicators defined for this project and the improvement strategies identified. The Rheuma SPACE project included three phases: 1) establishing a set of quality indicators and an excellence quality model; 2) assessment of the current care at Rheumatology departments concerning the defined quality indicators in the scope of the excellence model; and 3) elaboration of global and customized reports for each participating Rheumatology department, resulting in the identification of improvement opportunities. Ten Rheumatology departments, countrywide, including larger and smaller institutions, were asked to participate in Rheuma SPACE. This resulted in an in-dividual report for each department along with global benchmarking practices analysis. Furthermore, a list of improvement initiatives was developed. We concluded that departments lack physicians and need exclusively dedicated nurses. Time dedicated to research and audit activities should be specifically allocated. Internal contracting is well established, and professionals are committed to targets. Processes are still suboptimal, needing standardization of triage criteria, more frequent follow-up, as well as better medical records and multidisciplinary coverage. Regarding outcomes, patients are satisfied with the provided care and professionals with the working environment. However, department facilities for the former, and career related aspects, for the latter should improve. With this innovative study conducted in Portugal we expect to have enlightened tailored opportunities for improvement, ensure patient-focused practices and be able to define the indispensable quality requirements for excellence. [ABSTRACT FROM AUTHOR]

We report the case of a 40-year old woman followed at our Rheumatology department for a 14-year history of a relatively well controlled Sjögren's Syndrome who developed, for the first time in life, lesions suggestive of subacute cutaneous lupus erythematosus, nine weeks after taking oral terbinafine prescribed for onychomycosis. She denied additional symptoms, namely systemic manifestations, and no other clinical finding besides cutaneous lesions were detected. No laboratory findings were in favour of a flare of her connective tissue disease. Here we explore the possibility of terbinafine-induced subacute cutaneous lupus erythematosus in the context of previous autoimmunity. This clinical case highlights the importance of avoiding the prescription of terbinafine in this kind of patients. [ABSTRACT FROM AUTHOR]

Background: Quality of care is a key component of the right to health, and the route to equity and dignity. The aim of the project Rheuma SPACE - Standard Practice Aiming Clinical Excellence was to develop a set of quality indicators focused in rheumatoid arthritis care and apply them to rheumatology departments of the Portuguese National Health Service in order to benchmark the care for these patients. This article details the methodology that was applied. Methodology: This was a single country, three-phase project, each phase comprising multiple steps. The first step defined quality indicators and the excellence quality model to be used. It involved a literature search for international benchmarking of quality of care initiatives and indicators, followed by a pre-selection of an initial set of indicators. The set of indicators was latter on narrowed after an online Delphi round with all Portuguese rheumatologists and two consensus meetings involving the study task force. A set of 26 quality indicators was defined, within the three classic Donabe dian dimensions of healthcare quality: Structure (9), Pro cesses (11), and Outcomes (6). These indicators cover eleven domains of quality of care: personnel and organizational structure, training and research, facilities, equipment and information technology, budgeting and financial resources, access to care, clinical records, patient communication, multidisciplinary management, clinical outcomes, and patient and personnel satisfaction. Decision on quality and excellence thresholds for each of the 26 quality indicators was agreed upon a consensus meeting gathering principal investigators of the eight Rheumatology Departments that decided to participate, task force core set members and invited representatives of all Portuguese Departments/Units. Rheumatoid arthritis was the chosen disease model of the project based on the reliability of the outcomes to be measured in the context of this condition. The se - cond step was the assessment of the participating Rheumatology Departments. During eighteen months, research teams applied the 26 quality indicators to their own Departments. The third step comprised data ana - lysis and the elaboration of individual Rheumatology Department reports and of a global public report. Results: Eight Departments, comprising 80 specialists, 20 residents and 30 nurses, covering 5.904.080 inhabitants, underwent quality evaluation. More than one thousand patients (1.325) and 113 health professionals' surveys were analysed, as well as data from 570 clinical records and 3.927 medical appointments on rheumatoid arthritis patients. Discussion: 26 quality indicators were used for the first evaluation of Portuguese Rheumatology Departments, turning Rheuma SPACE into a pioneer project. Data analysis and benchmarking will be the subject of a further publication. [ABSTRACT FROM AUTHOR]

Objectives: To assess the discontinuation of first-line biological treatment and to evaluate the reasons and predictors thereof in patients with rheumatoid arthritis (RA) from daily clinical practice. Methods: RA patients registered in the Rheumatic Di - seases Portuguese Register (Reuma.pt) starting treatment with biologic DMARDs (bDMARDs) were inclu - ded in this prospective observational study. The main outcome was the time to discontinuation (in years) due to any cause. Discontinuation was defined as a 90-day discontinuation of treatment or the occurrence of any switch to another bDMARD during follow-up. Baseline and time-varying sociodemographic and clinical cha - racteristics were tested as possible predictors of discontinuation using multivariable Cox models. Results: Of the 1,851 RA patients included in the study, 871 (47%) discontinued their first bDMARD. The median overall persistence of the first bDMARD was 5.5 years and the leading cause of discontinuation was inefficacy [N=476 (55%)], followed by adverse events [N=262 (30%)], other causes [N=69, (8%)] and unknown causes [N=64 (7%)]. Patients with a higher HAQ score (more disability) at baseline were more likely to discontinue their first bDMARD [hazard ratio (HR):1.39 (95% CI: 1.17-1.64)], as were patients with a higher number of comorbidities [HR: 1.17 (1.05--1.29)] and patients starting treatment from 2007 onwards [HR:1.89 (1.5-2.38)]. On the contrary, recei ving TNFi bDMARD [HR:0.74 (0.57-0.94)] as opposed to non-TNFi was associated with less discontinuation. Expectedly, the higher the DAS28 during follow-up the higher the likelihood to discontinue bDMARD [HR:1.08 (1.06-1.1)]. No other time-varying predictor was found. Conclusion: In the Portuguese RA population, mainte - nance of first-line bDMARD was shown to be relati ve - ly high. Inefficacy was the leading cause of discontinua - tion. Features found to predict drug discontinuation (e.g. baseline disability) may contribute to inform cli - nician's decisions in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Psoriatic arthritis (PsA) is a chronic inflammatory disease commonly managed by rheumatologists. Switching between biologic therapies is a re - commended strategy for PsA patients that show insufficient response or adverse events with a biologic agent. Although the choice of the subsequent biologic may be dependent on many factors (accessibility, clinical aspects, patient's preference), assessing the quality of the switch decision is of utmost relevance. Objectives: To develop and validate two outcomes measurement tools to evaluate the quality of biologic therapies switch in PsA patients with axial and peri - pheral phenotypes in clinical practice. Methods: A Task Force and an Expert Panel were specifically assembled for this purpose. The tool development comprised a modified-Delphi method in a four-step procedure: 1) literature search and experts' opinion collection about quality indicators for PsA management; 2) Delphi design to address the deve - lopment of the measurement tool; 3) three Delphi questionnaire rounds; 4) consensus meeting to discuss the results and reach a decision regarding outcomes measurement tools' components. This phase resulted in the definition of two measurement tools to evaluate the quality of biologic switch in peripheral and axial PsA. For the validation of these tools, 12 experienced rheumatologists were asked to evaluate and classify the biologic switch of 80 patient profiles (40 with peri - pheral PsA and 40 with axial PsA phenotypes). Clinical judgement was defined as the "gold standard" against which, tools' output was compared. Each patient profile was evaluated by 3 experts and only those with consensual clinical judgment (agreement between at least 2 of 3 rheumatologists) were included in the validation analysis. The results were used to assess the validity (by sensitivity/specificity analysis) and the reliability, more specifically inter-rater reliability, (by Cohen's kappa) of both tools. Results: The developed tools consisted of 6 domains (disease activity, dactylitis, enthesitis, skin and nail manifestations, physical function and quality of life), their respective instruments and thresholds. The classification of the biologic switch was divided into three quality levels: "Good", based on treat-to-target thresholds; "Moderate", based on improvement from baseline thresholds; and the remaining as "Insufficient". In the validation phase, an agreement (i.e. clinical judgement versus tools' output) of 75% was obtained for peripheral PsA and 63% for axial PsA. The peripheral PsA tool was found to be more sensitive (92%) with the "Good" quality level and more specific (97%) with the "Insufficient" quality level. Regarding the axial PsA tool, higher sensitivity and specificity was obtained for all quality levels, as well as a higher Cohen's kappa than Peripheral PsA tool (0.94 vs 0.71). Conclusion: The two developed outcomes measurement tools address the quality of treatment decisions regarding biologics' switch in PsA clinical practice. The data in the validation part support the tools' reliability for both peripheral and axial PsA and could complement clinical judgment too. Therefore, these fully developed and validated tools are expected to support rheumatologists in making better and more informed therapeutic decisions. Disclosure of Interest: This publication was deve - loped under the project "Switch to Quality: Psoriatic Arthritis biologic switching consensus" that was sponsored by Novartis and executed with the collaboration of IQVIA. Acknowledgments: To all rheumatologists who collaborated in the clinical judgement. [ABSTRACT FROM AUTHOR]

The Portuguese Rheumatology Society (SPR) embraced quality as a major goal and launched, in early 2015, a program to aim for excellence in global clinical care: Rheuma SPACE - Standard Practice Aiming Clinical Excellence. Evaluating daily reality is the first step in a quality development timeline, ultimately contributing for health gains. Herein we describe the results of the evaluation of the quality indicators defined for this project and the improvement strategies identified. The Rheuma SPACE project included three phases: 1) establishing a set of quality indicators and an excellence quality model; 2) assessment of the current care at Rheumatology departments concerning the defined quality indicators in the scope of the excellence model; and 3) elaboration of global and customized reports for each participating Rheumatology department, resulting in the identification of improvement opportunities. Ten Rheumatology departments, countrywide, including larger and smaller institutions, were asked to participate in Rheuma SPACE. This resulted in an individual report for each department along with global benchmarking practices analysis. Furthermore, a list of improvement initiatives was developed. We concluded that departments lack physicians and need exclusively dedicated nurses. Time dedicated to research and audit activities should be specifically allocated. Internal contracting is well established, and professionals are committed to targets. Processes are still suboptimal, needing standardization of triage criteria, more frequent follow-up, as well as better medical records and multidisciplinary coverage. Regarding outcomes, patients are satisfied with the provided care and professionals with the working environment. However, department facilities for the former, and career related aspects, for the latter should improve. With this innovative study conducted in Portugal we expect to have enlightened tailored opportunities for improvement, ensure patient-focused practices and be able to define the indispensable quality requirements for excellence.

Objective: As part of European League against Rheumatism (EULAR)/European Musculoskeletal Conditions Surveillance and Information Network, 20 user-focused standards of care (SoCs) for rheumatoid arthritis (RA) addressing 16 domains of care were developed. This study aimed to explore gaps in implementation of these SoCs across Europe., Methods: Two cross-sectional surveys on the importance, level of and barriers (patients only) to implementation of each SoC (0-10, 10 highest) were designed to be conducted among patients and rheumatologists in 50 European countries. Care gaps were calculated as the difference between the actual and maximum possible score for implementation (ie, 10) multiplied by the care importance score, resulting in care gaps (0-100, maximal gap). Factors associated with the problematic care gaps (ie, gap≥30 and importance≥6 and implementation<6) and strong barriers (≥6) were further analysed in multilevel logistic regression models., Results: Overall, 26 and 31 countries provided data from 1873 patients and 1131 rheumatologists, respectively. 19 out of 20 SoCs were problematic from the perspectives of more than 20% of patients, while this was true for only 10 SoCs for rheumatologists. Rheumatologists in countries with lower gross domestic product and non-European Union countries were more likely to report problematic gaps in 15 of 20 SoCs, while virtually no differences were observed among patients. Lack of relevance of some SoCs (71%) and limited time of professionals (66%) were the most frequent implementation barriers identified by patients., Conclusions: Many problematic gaps were reported across several essential aspects of RA care. More efforts need to be devoted to implementation of EULAR SoCs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

We report the case of a 40-year old woman followed at our Rheumatology department for a 14-year history of a relatively well controlled Sjögren's syndrome who developed, for the first time in life, lesions suggestive of subacute cutaneous lupus erythematosus, nine weeks after taking oral terbinafine prescribed for onychomycosis. She denied additional symptoms, namely systemics, and no other clinical finding besides cutaneous lesions were detected. No laboratory findings were in favour of a flare of her connective tissue disease. Here we explore the possibility of terbinafine-induced subacute cutaneous lupus erythematosus in the context of previous autoimmunity. This clinical case highlights the importance of avoiding the prescription of terbinafine in this kind of patients.

Background: Switching between biologic therapies is a recommended strategy for Psoriatic Arthritis (PsA) patients that show an insufficient response or adverse events. Although the choice of the subsequent biologic may be dependent on many factors, assessing the quality of the switch decision is of utmost relevance., Objectives: To develop and validate two outcomes measurement tools (for patients with peripheral and axial PsA phenotypes) that address the quality of treatment decisions in PsA regarding the switch of biologic therapies in clinical practice., Methods: A Task Force and an Expert Panel were specifically assembled for this purpose. The Psoriatic Arthritis Switch Quality Assessment tool (PASQAL) development comprised a modified-Delphi method in a four-step procedure: 1) literature search and experts' opinion collection about quality indicators for PsA management; 2) Delphi design to address the development of the measurement tool; 3) three Delphi questionnaire rounds; 4) final consensus meeting. This phase resulted in the definition of two measurement tools, one to evaluate the quality of biologic switch in peripheral (pPASQAL) and another one in axial PsA (axPASQAL). For the validation of PASQAL, 12 experienced rheumatologists were asked to evaluate and classify the biologic switch of 80 clinical cases (40 with predominant peripheral and 40 with predominant axial PsA). Clinical judgement was defined to be the "gold standard" against which the performance of PASQAL was assessed. The results were used to assess tools' performance (sensitivity/specificity analysis) and the agreement between the tools and the gold standard (Cohen's kappa)., Results: PASQAL consists of 6 domains (joint disease activity, dactylitis, enthesis, physical function, quality of life, and skin and nail manifestations), respective instruments and thresholds. The classification of the biologic switch was divided into three quality levels: "Good", based on treat-to-target thresholds; "Moderate", based on improvement from baseline; and the remaining as "Insufficient". pPASQAL was found to be highly sensitive (92%) with the "Good" quality level and specific (97%) with the "Insufficient" quality level. Whilst axPASQAL showed overall higher sensitivity and specificity for all quality levels, as well as a higher level of agreement between the tool and the gold standard than pPASQAL (k=0.87 vs k=0.71)., Conclusion: PASQAL was developed and showed good criterion validity for the evaluation of the quality of switch in both peripheral and axial PsA phenotypes. These tools may be used in research as well as in clinical practice, to support rheumatologists in making more informed therapeutic decisions.

Pain is a common feature of most rheumatic diseases and it is often the main reason for the patient to seek for a clinical appointment. Chronic pain has a major impact on patient's quality of life, being frequently associated with functional incapacity, sleep and mood disorders. This leads to absenteeism and heavy consumption of health resources, both representing huge burdens on national economy. Managing musculoskeletal pain is pivotal but can be challenging. The use of the available pharmaceutical armamentarium should be parsimonious. Opioids are strong analgesic drugs that mostly act through their agonist action on µ-receptors in the central nervous system. Opioid-related side effects are not negligible and are mediated through both central and peripheral opioid receptors. The use of opioids is well established in the treatment of oncologic pain but their role in the management of musculoskeletal pain is still controversial. Inflammatory rheumatic diseases, osteoarthritis, osteoporotic fractures, chronic low back pain and fibromyalgia represent diverse major rheumatic conditions that frequently lead to chronic pain. In order to standardize and optimize management of musculoskeletal chronic pain in these prevalent diseases, the Portuguese Rheumatology Society elaborated this position paper. The objectives were: a) to define the importance of pain assessment and classification; b) to guide patient selection, appropriate choice of opioids, their management, and raise awareness of their adverse effects; c) to review the existent data on possible indications of opioid therapy on rheumatic diseases.

Objectives: To describe and explore differences in formal regulations around sick leave and work disability (WD) for patients with rheumatoid arthritis (RA), as well as perceptions by rheumatologists and patients on the system's performance, across European countries., Methods: We conducted three cross-sectional surveys in 50 European countries: one on work (re-)integration and social security (SS) system arrangements in case of sick leave and long-term WD due to RA (one rheumatologist per country), and two among approximately 15 rheumatologists and 15 patients per country on perceptions regarding SS arrangements on work participation. Differences in regulations and perceptions were compared across categories defined by gross domestic product (GDP), type of social welfare regime, European Union (EU) membership and country RA WD rates., Results: Forty-four (88%) countries provided data on regulations, 33 (75%) on perceptions of rheumatologists (n=539) and 34 (77%) on perceptions of patients (n=719). While large variation was observed across all regulations across countries, no relationship was found between most of regulations or income compensation and GDP, type of SS system or rates of WD. Regarding perceptions, rheumatologists in high GDP and EU-member countries felt less confident in their role in the decision process towards WD (β=-0.5 (95% CI -0.9 to -0.2) and β=-0.5 (95% CI -1.0 to -0.1), respectively). The Scandinavian and Bismarckian system scored best on patients' and rheumatologists' perceptions of regulations and system performance., Conclusions: There is large heterogeneity in rules and regulations of SS systems across Europe in relation to WD of patients with RA, and it cannot be explained by existing welfare regimes, EU membership or country's wealth., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Quality of care is a key component of the right to health, and the route to equity and dignity. The aim of the project Rheuma SPACE - Standard Practice Aiming Clinical Excellence was to develop a set of quality indicators focused in rheumatoid arthritis care and apply them to rheumatology departments of the Portuguese National Health Service in order to benchmark the care for these patients. This article details the methodology that was applied., Methodology: This was a single country, three-phase project, each phase comprising multiple steps. The first step defined quality indicators and the excellence quality model to be used. It involved a literature search for international benchmarking of quality of care initiatives and indicators, followed by a pre-selection of an initial set of indicators. The set of indicators was latter on narrowed after an online Delphi round with all Portuguese rheumatologists and two consensus meetings involving the study task force. A set of 26 quality indicators was defined, within the three classic Donabedian dimensions of healthcare quality: Structure (9), Processes (11), and Outcomes (6). These indicators cover eleven domains of quality of care: personnel and organizational structure, training and research, facilities, equipment and information technology, budgeting and financial resources, access to care, clinical records, patient communication, multidisciplinary management, clinical outcomes, and patient and personnel satisfaction. Decision on quality and excellence thresholds for each of the 26 quality indicators was agreed upon a consensus meeting gathering principal investigators of the eight Rheumatology Departments that decided to participate, task force core set members and invited representatives of all Portuguese Departments/Units. Rheumatoid arthritis was the chosen disease model of the project based on the reliability of the outcomes to be measured in the context of this condition. The second step was the assessment of the participating Rheumatology Departments. During eighteen months, research teams applied the 26 quality indicators to their own Departments. The third step comprised data analysis and the elaboration of individual Rheumatology Department reports and of a global public report., Results: Eight Departments, comprising 80 specialists, 20 residents and 30 nurses, covering 5.904.080 inhabitants, underwent quality evaluation. More than one thousand patients (1,325) and 113 health professionals' surveys were analysed, as well as data from 570 clinical records and 3,927 medical appointments on rheumatoid arthritis patients., Discussion: 26 quality indicators were used for the first evaluation of Portuguese Rheumatology Departments, turning Rheuma SPACE into a pioneer project. Data analysis and benchmarking will be the subject of a further publication.

Objectives: To assess the discontinuation of first-line biological treatment and to evaluate the reasons and predictors thereof in patients with rheumatoid arthritis (RA) from daily clinical practice., Methods: RA patients registered in the Rheumatic Diseases Portuguese Register (Reuma.pt) starting treatment with biologic DMARDs (bDMARDs) were included in this prospective observational study. The main outcome was the time to discontinuation (in years) due to any cause. Discontinuation was defined as a 90-day discontinuation of treatment or the occurrence of any switch to another bDMARD during follow-up. Baseline and time-varying sociodemographic and clinical characteristics were tested as possible predictors of discontinuation using multivariable Cox models., Results: Of the 1,851 RA patients included in the study, 871 (47%) discontinued their first bDMARD. The median overall persistence of the first bDMARD was 5.5 years and the leading cause of discontinuation was inefficacy [N=476 (55%)], followed by adverse events [N=262 (30%)], other causes [N=69, (8%)] and unknown causes [N=64 (7%)]. Patients with a higher HAQ score (more disability) at baseline were more likely to discontinue their first bDMARD [hazard ratio (HR):1.39 (95% CI: 1.17-1.64)], as were patients with a higher number of comorbidities [HR: 1.17 (1.05-1.29)] and patients starting treatment from 2007 onwards [HR:1.89 (1.5-2.38)]. On the contrary, receiving TNFi bDMARD [HR:0.74 (0.57-0.94)] as opposed to non-TNFi was associated with less discontinuation. Expectedly, the higher the DAS28 during follow-up the higher the likelihood to discontinue bDMARD [HR:1.08 (1.06-1.1)]. No other time-varying predictor was found., Conclusion: In the Portuguese RA population, maintenance of first-line bDMARD was shown to be relatively high. Inefficacy was the leading cause of discontinuation. Features found to predict drug discontinuation (e.g. baseline disability) may contribute to inform clinician's decisions in clinical practice.

Background: Advances in osteoporosis (OP)case definition, treatment options, optimal therapy duration and pharmacoeconomic evidence in the national context motivated the Portuguese Society of Rheumatology (SPR) to update the Portuguese recommendations for the diagnosis and management of osteoporosis published in 2007., Methods: SPR bone diseases' working group organized meetings involving 55 participants (rheumatologists, rheumatology fellows and one OP specialist nurse) to debate and develop the document. First, the working group selected 11 pertinent clinical questions for the diagnosis and management of osteoporosis in standard clinical practice. Then, each question was investigated through literature review and draft recommendations were built through consensus. When insufficient evidence was available, recommendations were based on experts' opinion and on good clinical practice. At two national meetings, the recommendations were discussed and updated. A draft of the recommendations full text was submitted to critical review among the working group and suggestions were incorporated. A final version was circulated among all Portuguese rheumatologists before publication and the level of agreement was anonymously assessed using an online survey., Results: The 2018 SPR recommendations provide comprehensive guidance on osteoporosis prevention, diagnosis, fracture risk assessment, pharmacological treatment initiation, therapy options and duration of treatment, based on the best available evidence. They attained desirable agreement among Portuguese rheumatologists. As more evidence becomes available, periodic revisions will be performed. Target audience and patient population: The target audience for these guidelines includes all clinicians. The target patient population includes adult Portuguese people. Intended use: These recommendations provide general guidance for typical cases. They may not be appropriate in all situations - clinicians are encouraged to consider this information together with updated evidence and their best clinical judgment in individual cases.

Objective: To update the recommendations for the treatment of axial spondyloarthritis (axSpA) with biological therapies, endorsed by the Portuguese Society of Rheumatology., Methods: These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. At a national meeting, the 7 recommendations included in this document were discussed and updated. A draft of the full text of the recommendations was then circulated and suggestions were incorporated. A final version was again circulated before publication and the level of agreement among Portuguese Rheumatologists was anonymously assessed using an online survey., Results: A consensus was achieved regarding the initiation, assessment of response and switching of biological therapies in patients with axSpA. In total, seven recommendations were produced. The first recommendation is a general statement indicating that biological therapy is not a first-line drug treatment option and should only be used after conventional treatment has failed. The second recommendation is also a general statement about the broad concept of axSpA adopted by these recommendations that includes both non-radiographic and radiographic axSpA. Recommendations 3 to 7 deal with the definition of active disease (including the recommended threshold of 2.1 for the Ankylosing Spondylitis Disease Activity Score [ASDAS] or the threshold of 4 [0-10 scale] for the Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]), conventional treatment failure (nonsteroidal anti-inflammatory drugs being the first-line drug treatment), assessment of response to treatment (based on an ASDAS improvement  of at least 1.1 units or a BASDAI improvement of at least 2 units [0-10 scale] or at least 50%), and strategy in the presence of an inadequate response (where switching is recommended) or in the presence of long-term remission (where a process of biological therapy optimization can be considered, either a gradual increase in the interval between doses or a decrease of each dose of the biological therapy)., Conclusion: These recommendations may be used for guidance in deciding which patients with axSpA should be treated with biological therapies. They cover a rapidly evolving area of therapeutic intervention. As more evidence becomes available and more biological therapies are licensed, these recommendations will have to be updated.

Objective: To update the recommendations for the treatment of Rheumatoid Arthritis (RA) with biological therapies, endorsed by the Portuguese Society of Rheumatology (SPR)., Methods: These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. At a national meeting the 10 recommendations were discussed and updated. The document resulting from this meeting circulated to all Portuguese rheumatologists, who anonymously voted online on the level of agreement with the recommendations., Results: These recommendations cover general aspects as shared decision, prospective registry in Reuma.pt, assessment of activity and RA impact and treatment objective. Consensus was also achieved regarding specific aspects as initiation of biologic therapy, assessment of response, switching and definition of persistent remission., Conclusion: These recommendations may be used for guidance of treatment with biological therapies in patients with RA. As more evidence becomes available and more therapies are licensed, these recommendations will be updated.

Background: Methotrexate (MTX) is the first-line drug in the treatment of rheumatoid arthritis (RA) and the most commonly prescribed disease modifying anti-rheumatic drug. Moreover, it is also used as an adjuvant drug in patients under biologic therapies, enhancing the efficacy of biologic agents., Objectives: To review the literature and update the Portuguese recommendations for the use of MTX in rheumatic diseases first published in 2009., Methods: The first Portuguese guidelines for the use of MTX in rheumatic diseases were published in 2009 and were integrated in the multinational 3E Initiative (Evidence Expertise Exchange) project. The Portuguese rheumatologists based on literature evidence and consensus opinion formulated 13 recommendations. At a national meeting, the recommendations included in this document were further discussed and updated. The document resulting from this meeting circulated to all Portuguese rheumatologists, who anonymously voted online on the level of agreement with the updated recommendations., Results: Results presented in this article are mainly in accordance with previous guidelines, with some new information regarding hepatitis B infection during MTX treatment, pulmonary toxicity monitoring, hepatotoxicity management, association with hematologic neoplasms, combination therapy and tuberculosis screening during treatment., Conclusion: The present recommendations combine scientific evidence with expert opinion and attained desirable agreement among Portuguese rheumatologists. The regular update of these recommendations is essential in order to keep them a valid and useful tool in daily practice.

Psoriatic arthritis (PsA) is a chronic inflammatory rheumatic disease with a broad clinical spectrum. PsA can affect the axial skeleton, peripheral joints, entheses, synovial sheaths of tendons, skin, nails and extra-articular organs. Tumour necrosis factor alpha blockers (TNF blockers) were a breakthrough development in the treatment of PsA. Identifying predictors of response to biological therapies in patients with PsA is of utmost importance, especially in view of the costs and potential side effects of these agents. The aims of the present study were to determine baseline predictive factors of response to biological therapies, at 3 and 6 months, in PsA patients with polyarticular involvement (with or without axial involvement). Data were collected from the Rheumatic Diseases Portuguese Register (Reuma.pt). Eligible patients had to be anti-TNF-naive at baseline and to have at least 3 months of follow-up after the beginning of TNF blocker therapy. Only patients with information on at least one of the response measures (at 3 or 6 months of follow-up) were included in the analysis. Univariable logistic regression analysis of potential baseline predictors of European League Against Rheumatism (EULAR) good clinical response, EULAR good/moderate response, 28-joint Disease Activity Score with three variables including the erythrocyte sedimentation rate (DAS28-3V-ESR) remission and Health Assessment Questionnaire (HAQ) response were performed. Multivariable logistic regression using a forward selection procedure was used until the best-fit model was obtained, taking confounding effects into account. A total of 180 patients were eligible for the study (mean age 52 years, 54% women). In multivariable analysis at 3 months, females were less likely to attain a good EULAR response [OR=0.082 (95% CI=0.024, 0.278)], a DAS28-3V-ESR remission [OR=0.083 (95% CI=0.017, 0.416)], a moderate or good EULAR response [OR=0.091 (95% CI=0.011, 0.091)] and a HAQ response [OR=0.074 (95% CI=0.009, 0.608)]. At 6 months, female gender was also less likely to achieve a good EULAR response [OR=0.060 (95% CI=0.011, 0.325)], DAS28-3V-ESR remission [OR=0.060 (95% CI=0.012, 0.297)], and a HAQ response [OR=0.138 (95% CI= 0.029, 0.654)]. In this study we found that gender was the most consistent predictor of response to TNF blocker therapy in patients with polyarticular PsA, with females having a lower probability of response compared to males. These findings suggest that gender-related biochemical, hormonal and psychological factors could play an important role in the response to TNF blocker therapy in PsA.

The aim of this paper was to assess the validity and reliability of the touch-screen standard Portuguese version of the following patient-reported outcomes (PROs), compared with paper format, in patients with rheumatoid arthritis (RA) and spondyloarthritis: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Ankylosing Spondylitis Quality of Life scale (ASQoL), Short-Form 36 (SF-36), Health Assessment Questionnaire (HAQ) and visual analogue scales (VAS) measuring pain and burden of disease. Adult patients with RA and spondyloarthritis attending the Portuguese Institute of Rheumatology were recruited from March 2013 to January 2014. Patients filled the paper and touch-screen formats of the standard Portuguese versions of the PROs. Two groups of VAS were used, RA and psoriatic arthritis (Global VAS) and another specific for spondyloarthrites (Spa-VAS). Paper questionnaires were filled 15 min before touch-screen formats. Agreement between formats (validity) was assessed by intraclass correlation coefficient (ICC), while internal consistency of scales (reliability) was assessed by Cronbach's alpha. Overall, 134 patients were included with a mean age of 51 years, 74.6 % female and 57.5 % presenting RA. BASDAI, BASFI, HAQ and ASQoL showed high ICC between paper and touch-screen formats (0.977, 0.958, 0.974 and 0.940, respectively). ICC for Global VAS ranged from 0.906 to 0.921, while Spa-VAS ranged from 0.867 to 0.943. The mean ICC for all SF-36 domains was 0.889 (ICC for each domain ranged from 0.781 to 0.944). Touch-screen standard Portuguese formats of these PROs may be valid and reliable tools for PRO measurement in rheumatology.

Objective: Portuguese data concerning general population knowledge and prevalence about neuropathic pain (NeP) are sparse and many patients remain frequently undiagnosed as this disease is still under recognized among population. This study aimed to evaluate Portuguese perception about NeP and to characterize their knowledge and information sources. Additionally, the study had the exploratory objective of determining NeP prevalence., Materials and Methods: Epidemiological, cross-sectional study of a representative sample of the Portuguese population aged 18 years old or more, by direct application of a structured questionnaire. Demographic data and data on knowledge and perception about NeP were collected. It was also collected data about NeP diagnosis. Descriptive analysis and a logistic regression assuming a significance level of 0.05 were performed., Results: 1072 subjects were included, 47.9% male, mean±SD age 46.4±18.6 years old. 71.3% referred never having heard about NeP. The percentage of individuals who declared to know about NeP characteristics decreased as the specificity of the theme increased: 24.8% referred knowing the disease's symptoms, 23.0% knew how it is treated and 15.6% knew which situations/ pathologies can cause NeP. The three most referred symptoms of the disease were itching (42.6%), numbness (33.6%) and joint pain (31.2%). An older age and a higher educational level were associated with a higher knowledge about this pathology. A 3.2% auto-referred prevalence of NeP was observed., Conclusions: The data highlight the lack of information about NeP in Portugal. Defining multidimensional strategies to improve people's awareness about NeP might improve early diagnosis and treatment of this very debilitating condition.

Objective: To update recommendations for the treatment of psoriatic arthritis with biological therapies, endorsed by the Portuguese Society of Rheumatology (SPR)., Methods: These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. At a national meeting the 16 recommendations included in this document were discussed and updated. The level of agreement among Portuguese Rheumatologists was assessed using an online survey. A draft of the full text of the recommendations was then circulated and suggestions were incorporated. A final version was again circulated before publication., Results: A consensus was achieved regarding the initiation, assessment of response and switching biological therapies in patients with psoriatic arthritis (PsA). Specific recommendations were developed for several disease domains: peripheral arthritis, axial disease, enthesitis and dactylitis., Conclusion: These recommendations may be used for guidance in deciding which patients with PsA should be treated with biological therapies. They cover a rapidly evolving area of therapeutic intervention. As more evidence becomes available and more biological therapies are licensed, these recommendations will have to be updated.

Objectives: This study aimed to describe patterns of occupational biomechanical demands in the beginning of professional life and to quantify their association with the presence and intensity of regional musculoskeletal pain., Methods: Cross-sectional data from 21-year-old participants were collected during the third wave of the EPITeen cohort study (N=1733, 37.5% were workers). Ten different work-related biomechanical tasks were characterized. Latent class analysis was conducted to identify empirical patterns of occupational biomechanical demands. The presence and intensity of regional musculoskeletal pain in the previous year were also evaluated., Results: Four patterns of occupational biomechanical demands were found: "low demands", "sitting demands", "repetitive and asymmetric demands", and "high and vibrational demands". When compared to workers with low demands, those with repetitive and asymmetric demands or high and vibrational demands presented 80% higher adjusted odds ratio (OR adj) of reporting neck/shoulder pain. High and vibrational demands occupations were significantly associated with upper-/lower-back pain in comparison to low demands [OR adj1.80, 95% confidence interval (95% CI%) 1.09-2.96]. In addition, workers with sitting demands were more likely to report any or severe upper-/lower-back pain [OR adj1.56 (95% CI 0.99-2.45) and 1.66 (95% CI 1.03-2.66), respectively] when compared to those with low demands., Conclusions: Patterns of high work-related physical demands were associated with the presence of neck/shoulder pain and severity of upper-/lower-back pain. This emphasizes that even short-term biomechanical exposures at the workplace may be involved in the etiology of musculoskeletal complaints.

Background: Although the survival rate has considerably improved, many patients with systemic lupus erythematosus (SLE) develop irreversible organ damage., Objectives: The objectives of this paper are to characterize cumulative damage in SLE patients and identify variables associated with its presence and severity., Methods: A cross-sectional analysis of SLE patients from the Portuguese Lupus register Reuma.pt/SLE in whom damage assessment using the SLICC/ACR-Disability Index (SDI) was available was performed. Predictor factors for damage, defined as SDI ≥ 1, were determined by logistic regression analyses. A sub-analysis of patients with severe damage (SDI ≥ 3) was also performed., Results: In total, 976 patients were included. SDI was ≥1 in 365 patients, of whom 89 had severe damage. Musculoskeletal (24.4%), neuropsychiatric (24.1%) and ocular (17.2%) domains were the most commonly affected. Older age, longer disease duration, renal involvement, presence of antiphospholipid antibodies and current therapy with steroids were independently associated with SDI ≥ 1. The subpopulation with severe damage had, in addition, a greater interval between the first manifestation attributable to SLE and the clinical diagnosis as well as and more frequently early retirement due to SLE., Conclusions: This large lupus cohort confirmed that demographic and clinical characteristics as well as medication are independently associated with damage. Additionally, premature retirement occurs more often in patients with SDI ≥ 3. Diagnosis delay might contribute to damage accrual., (© The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Objectives: . The 28-joint DAS (DAS28), clinical disease activity index (CDAI) and simplified disease activity index (SDAI) are indices frequently used to assess disease activity in RA patients. Cut-off values were defined to classify the states of RA disease activity: remission, low, moderate and high. The aim of this work was to assess disease activity states classified by DAS28, CDAI and SDAI and to analyse their agreement in the Rheumatic Diseases Portuguese Register Reuma.pt., Methods: . A total of 2795 patients and 14 440 visits were selected from Reuma.pt for analysis. Pearson's correlation coefficients (PCCs) were calculated for the three indices. McNemar's chi-squared tests, PCCs and kappa statistics were performed to analyse and compare the distribution of visits among all disease activity states and indices., Results: A strong correlation was found between the three indices throughout the 14 440 visits: r = 0.874 for DAS28/CDAI, r = 0.877 for DAS28/SDAI and r = 0.984 for CDAI/SDAI (all PCCs with P < 0.0001). However, when categorization in the different disease activity states was analysed, McNemar's chi-squared tests and PCCs revealed significant disagreement between the cut-offs of the three indices., Conclusion: DAS28, CDAI and SDAI cut-offs do not translate into the same clinical information in Reuma.pt. Although this might be expected for the original DAS28 cut-offs, when compared with CDAI and SDAI significant disagreement was also found for the DAS28 modified cut-offs. For visits where patients are in CDAI or SDAI remission, we also find disagreement between these two indices, which may contradict previous conclusions that acute phase reactants add little to composite disease activity indices for RA., (© The Author 2014. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Introduction: Osteoarthritis (OA) is one of the ten most disabling diseases in developed countries and one of the leading causes of pain and disability over the world. Early diagnosis increases the likelihood of preventing disease progression., Objectives: To estimate the prevalence of self-reported osteoarthritis and quality of life in Portuguese adults with 45 or more years old., Methods: Observational, cross-sectional study, implemented in households by face-to-face interview., Results: 1,039 subjects with mean age of 62 years and 54.2% female were included. The prevalence of self-reported osteoarthritis was 9.9%. Knees and hands were the most frequent site of disease. The prevalence of OA was higher in women and in participants without professional activity. Presence of OA was higher in participants with comorbidities. Most subjects have done some treatment at some point in time for this disease: 94.5% had drug therapy, 49.5% physiotherapy, and 19.8% physical activity. Pain was associated with height, with some disease locations specifically neck, lower spine and shoulders, SF12 scores of quality of life, and measurements of impact in daily living, severity of disease and disability. The impact of OA in daily living was greater in subjects that had been on sick leave or stopped working due to OA, had worse physical and mental health, and with more severe of disease., Conclusion: This study confirmed that osteoarthritis is a very relevant disease with a high potential impact on quality of life, function and work ability and because of its prevalence with a very high growing social impact., (Copyright © 2014 Elsevier Editora Ltda. All rights reserved.)

Background: Despite the widespread availability of biologics across Europe, rheumatoid arthritis (RA) patients' access to these drugs differs significantly among countries., Objectives: To compare the proportion of RA patients treated with biologics across Europe and investigate the factors that most influence it, with focus on the Portuguese case, reportedly with low access rates to biologics., Methods: The biologics' market was characterized for 15 selected European countries. Variables potentially influencing patients' access to biologics (PAB) in RA were also collected, including demographic, disease, economic, funding and biologics' market-related data. A multivariable regression model identified the factors that best explain PAB. Based on these determinants, a cluster analysis was performed to group the countries with most similar behaviour regarding PAB allowing the evaluation of Portugal's relative position among these countries., Results: The regression model (R(2) = 0.953) indicated that PAB in selected countries is explained mostly by its gross domestic product (GDP) per capita, the usage of methotrexate (MTX) and the biologics' distribution channel. Current MTX usage in Portugal shows similarity with practice from UK, France, Germany or Spain 5 years before, explaining why PAB in Portugal stood at 7% in 2010, 12 percentage points below the average of selected countries., Conclusions: Variations in RA PAB were found across selected countries with Portugal showing the lowest proportion. GDP per capita, biologics distribution channel and consumption of MTX appear to be the best explanatory factors for these fluctuations in European countries.

Objective: To develop recommendations for the treatment of axial spondyloarthritis with biological therapies, endorsed by the Portuguese Society of Rheumatology., Methods: These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. A draft of the recommendations and supporting evidence was first circulated to all Portuguese rheumatologists and their suggestions were incorporated in the draft. Secondly, at a national meeting the recommendations were presented, discussed and revised. Finally, the document resulting from this meeting was again circulated to all Portuguese rheumatologists, who anonymously voted online on the level of agreement with the recommendations., Results: A consensus was achieved regarding the initiation, assessment of response and switching biological therapies in patients with axial spondyloarthritis., Conclusion: These recommendations may be used for guidance in deciding which patients with axial spondyloarthritis should be treated with biological therapies. They cover a rapidly evolving area of therapeutic intervention. As more evidence becomes available and more biological therapies are licensed, these recommendations will have to be updated.

Objective: To develop recommendations for the treatment of psoriatic arthritis (PsA) with biological therapies, endorsed by the Portuguese Society of Rheumatology., Methods: These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. A draft of the recommendations was first circulated to all Portuguese rheumatologists and their suggestions were incorporated in the draft. At a national meeting the recommendations were discussed and all attending rheumatologists voted on the level of agreement for each recommendation. A second draft was again circulated before publication., Results: A consensus was achieved regarding the initiation, assessment of response and switching biological therapies in patients with PsA. Specific recommendations were developed for several disease domains: peripheral arthritis, axial disease, enthesitis and dactylitis., Conclusion: These recommendations may be used for guidance in deciding which patients with PsA should be treated with biological therapies. They cover a rapidly evolving area of therapeutic intervention. As more evidence becomes available and more biological therapies are licensed, these recommendations will have to be updated.

Introduction: Rheumatoid arthritis is a chronic systemic inflammatory rheumatic disease whose characteristics have a clear impact on the life of the patient and his/ her family. Doctor-patient relationship is increasingly based on communication and information transfer. In the case of chronic diseases and especially in RA, that information is fundamental for a better compliance, but also for the prevention of problems and the patient's better management of the disease on a daily basis., Objectives: To determine in a population of RA patients which are the principal sources of information about the disease, what unmet needs exist and the level of patient involvement in therapeutic decision., Methods: We applied a questionnaire in person and by telephone to a population of patients with rheumatoid arthritis fulfilling the criteria of the ACR, which were followed at several departments of rheumatology in mainland Portugal, about their expectations, the degree and type of information they expected, and their unmet needs., Results: A total of 223 RA patients filled in the questionnaire, 82.5% of which were female, mean age 55.13 +/- 14.49 years and whose mean duration of disease was above 5 years in 69.5% of the individuals. Of these, 17.5% found that RA had an impact on quality of life, 15.7% felt that RA affected their ability to enjoy life and 14.3% had difficulties in performing activities of daily living. Some activities were found to be more difficult for a patient with RA (on a scale of 0 to 10), such as gardening (6.36) and practicing sports (5.79). Other basic tasks were also considered difficult, as are the case of household chores (5.76) sleeping (5.08) walking (4.99) and working (4.86). Regarding the clinical impact of RA, as expected pain is almost a universal factor (87.9%), although the majority of patients also refer arthritis (78%), pain when moving (65.5%), fatigue (60.1%) and joint deformities (58.3%) as very common symptoms. Diminishing pain (81.2%), a general improvement of symptoms (73.1%) in a lasting way (57.4%) and reducing arthritis (59.2%) appeared as the main concerns of patients with RA. Regarding quality of information, 68.2% of patients consider they are well informed about the disease, but these numbers decrease if we consider information about treatment options (46.2%), the concept of remission (20.6%) or the recognition of the DAS 28 scale (17%). As preferred sources of information about the disease, 67.7% of individuals indicate their rheumatologist, 31.4% their general practitioner, 17% the Internet and 9% the attending nurse. The same order is obtained when asked about treatment information. As to the need for additional information, the patients refer «more information about therapies/treatments» (26.9%), «new scientific developments and social support» (17.5% each), «how to improve symptoms and live better in everyday life» (16.6%). «What is the disease» (6.7%) is referred last, being that only 8.1% of patients consider they are well informed. In what concerns discussion and participation in the process of clinical decision about medication, 56.1% of patients say that they share it with their doctors during their consultation., Conclusion: These results, which somewhat differ from the existing literature, demonstrate that there are important issues that should be considered in clinical practice, both relating to clinical issues and the unmet needs of our patients. We are unaware of the results coming from a treatment strategy designed to increase the RA patient's perception of their general state of health or of their perception of function. We should, however, keep in mind that pain, wellbeing and disease activity (as well as remission) should be important goals in therapeutic strategies that are to be increasingly shared with our patients.

Introduction: Work related musculoskeletal diseases (WRMSDs) have a huge social and economic impact being a public health problem., Objectives: To determine the prevalence of WRMSDs in Portuguese active workers., Methods: A questionnaire was sent by regular mail to the occupational physician of 822 large dimension companies in Portugal (over 250 employees). This questionnaire was addressed to the physician and contemplated data on file from the occupational medical doctor of clinically relevant WRMSDs (rather than addressing workers complaints). A reply form and a telephone reminder were used to assure a higher number of respondents., Results: Of the selected 822 companies, 515 responded (response rate of 62.3%) involving a total population of 410,496 workers. The prevalence of clinically relevant WRMSD was of 5.9% (24,269 cases). The more prevalent WRMSD were back pain with a prevalence of low back pain of 2.27% (n=9310 , 38.4% of total WRMSD). Dorsal pain 0.82% (n= 3379, 13.9% of total WRMSDs) and cervical pain 1.13% (n=4651, 19.2% of total WRMSD). Back pain accounts for 4.22% (n= 17340) and a total of 74.9% of all WRMSDs. Regarding the upper limb we found a prevalence of 1.61% (n= 6493). From this total, shoulder tendonitis was 0.59%(n= 2398, 9.9% of total WRMSDs), carpal tunnel syndrome 0.29% (n=1170, 4.8% of total WRMSDs), elbow tendonitis 0.29% (n=1202, 5% of total WRMSDs) and hand tendonitis 0.44% (n=1823, 7.5% of total WRMSDS). A lower prevalence was observed in the lower limbs with lower limb tendonitis of 0.08% (n=336, 0.01% of total WRMSDs)., Discussion/conclusion: Our work was representative of 11% of the working Portuguese population. We have found a prevalence of clinically relevant WRMSD of 5,9%. If we extrapolate for the total of the working population we would have 220 467 workers with WRMSDs. Our data are in conflict with national social security services regarding these diseases with much lower reported diseases that proves the inefficacy of the national reporting system. There are clear differences in our data when compared with the literature. We found a higher number of back pain, and in proportion of cervical pain, and lower numbers of upper and lower limb WRMSDs. In the upper limb we found a higher level of hand tendonitis and a decrease of elbow tendonitis and carpal tunnel syndrome. This work was a first effort to characterize WRMSDs in Portugal. Due to the study design we believe that further studies aimed for higher risk populations should be performed.

Rheumatic diseases have a substantial impact on the patient but also on the work status and on a social-economical context. In Europe 25% of the cost of disease is related with rheumatic diseases. We are focusing more on disease activity as a clinical challenge but we have to consider that patient occupational activity is a main issue as a strategic gold for patient management. Rheumatologists have to prove on a daily basis their positive impact on the socio-economical impact of these diseases. The search for practical solutions to empower patients in their work status must be based not only on disease activity management but also in facilitating the work station adaptation to the unique characteristics and ability of each patient.

Introduction: Rheumatology has 60 years in Portugal 31 of them as an autonomous specially. However since the beginning, all of what has been achieved was by a small number of specialists., Objectives: To evaluate the human resources in rheumatologists with a link to the Portuguese national health service (SNS) in 2009 and to predict the evaluation until 2019., Methods: Data regarding sex, age, link to SNS was obtained by consulting the Portuguese medical association and the Portuguese society of rheumatology data base., Results: In 2009 there are 99 specialists linked to SNS that corresponds to 0,93 for 100,000 people with a higher number of female specialists. There is a consistent increase in the number since 2002., Discussion: There is a national plan since 2002 and although an increase of number is observed there is still a need for 77 to 119 until 2019., Conclusion: Considering 50% of needed appointments as our target, Portugal has still one of the lowest ratings in number of rheumatologists per capita in Europe. If nothing is changed the predicted values existing and needed will only be achieve in 2032.