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Abstract Objectives A subset of patients with rheumatoid arthritis (RA) who remains symptomatic after failing to multiple drugs are deemed to have “difficult-to-treat RA” (D2T RA). Fatigue is a burdensome symptom for RA patients, hindering their improvement. Our purpose was to evaluate the role of fatigue in D2T RA. Methods This cross-sectional study included rheumatoid arthritis (RA) patients between 2018 and 2022, treated with biological agents or targeted synthetic disease-modifying antirheumatic drugs. D2T RA was defined attending EULAR criteria. Independent variable was fatigue (dimensions and impact) assessed by the Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire and Numerical Rating Scales. Covariables: sociodemographic, clinical and treatment. To identify factors independently associated to D2T RA, multivariable logistic regression was run. Results The study included 145 patients and 38 (26.21%) developed D2T RA. D2T RA group were older, with more comorbidity and disability. D2T RA patients scored higher for global fatigue (p = 0.003), and almost for all their dimensions except for cognitive fatigue (p = 0.06) and fatigue coping (p = 0.07). Females with D2T RA showed more fatigue than those with non-D2T RA. In the adjusted models, all fatigue dimensions were associated with D2T RA: global fatigue RA (OR: 1.03; p = 0.007), physical (OR: 1.09; p = 0.008), living (OR: 1.09; p = 0.016), cognitive (OR: 1.1; p = 0.046) and emotional (OR: 1.18; p = 0.012). Conclusions Despite the absence of an explicit mention of fatigue in the definition of D2T RA, it appears to be associated to this outcome. Fatigue should be evaluated in a multidimensional perspective, and gender-specific differences should be considered.

Background: Switching between therapies is a recommended strategy for psoriatic arthritis (PsA) patients who experience treatment failure; however, studies including real-life data are scarce. Objectives: To assess the incidence rate (IR) of switching between biologics and targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs) due to inefficacy in PsA, and to compare the risk of switching due to inefficacy across different b/tsDMARDs groups. Design: A longitudinal retrospective study, spanning from 2007 to 2022, was conducted on patients with PsA treated with b/tsDMARDs at an outpatient rheumatology clinic. Methods: The primary outcome was switching between b/tsDMARDs due to inefficacy. The independent variable was the exposure to b/tsDMARDs during follow-up. As covariates, clinical, treatment-related, and sociodemographic variables were considered. Survival techniques were run to estimate the IR of switching due to inefficacy per 100 patients*year and confidence interval at 95% (95% CI). Cox multivariate regression analyses were run to assess the risk of b/tsDMARDs switching due to inefficacy, expressed as hazard ratio (HR) and 95% CI. Results: In all, 141 patients were included, with 893.09 patients*year follow-ups. 52.48% of them were females in their fifties. In total, 262 courses of treatment were recorded. During the study period, 56 patients presented 121 switches and 103 related to inefficacy (IR: 11.53 (9.51–13.98)). Tumor necrosis factor-alpha inhibitors (TNFi) showed the lowest IR. In the bivariate analysis, all b/tsDMARDs had more risk of switching compared to TNFi (HR: anti-lL-17 vs TNFi: 2.26 (1.17–4.36); others vs TNFi: 3.21 (1.59–6.45)); however, this statistical significance was no longer present in the multivariate analysis once adjustments were made for the covariates. Still, the final model achieved statistical significance in the following variables: gender, clinical symptoms, prescription year, therapy courses, glucocorticoids, and sulfasalazine. Conclusion: In this study, we did not find differences in the rate of switching due to inefficacy among different groups of b/tsDMARDs. Other concomitant treatments, sociodemographic, and clinical variables were identified as risk factors for switching due to inefficacy.

Abstract Background The objective of the present study is to describe the characteristics of interstitial pneumonia with autoimmune features (IPAF) patients, to assess the incidence rate of functional respiratory impairment over time and to evaluate the influence of therapeutic alternatives on the prognosis of these patients. Methods A longitudinal observational multicenter study was performed (NEREA registry). It was carried out by a multidisciplinary team in seven Hospitals of Madrid. Patients were included from IPAF diagnosis. Main outcome: poor prognosis as functional respiratory impairment (relative decline in FVC % defined as ≥ 5% every 6 months). Covariates: therapy, sociodemographic, clinical, radiological patterns, laboratory and functional tests. Statistics: Survival techniques were used to estimate IR per 100 patients-semester with their 95% confidence interval [CI]. The influence of covariates in prognosis were analyzed through cox multivariate regression models (hazard ratio (HR) and [CI]). Results 79 IPAF were included, with a mean and a maximum follow-up of 3.17 and 12 years respectively. Along the study, 77.2% received treatment (52 glucocorticoids, 25 mycophenolate, 21 azathioprine, 15 rituximab and 11 antifibrotics). IR was 23.9 [19.9–28.8], and 50% of IPAF developed functional respiratory impairment after 16 months from its diagnosis. Multivariate analysis: usual interstitial pneumonia (UIP) had poorer prognosis compared to non-specific interstitial pneumonia (NSIP) (p = 0.001). In NSIP, positive ANA, increased the risk of poor prognosis. In UIP, glucocorticoids (HR: 0.53 [0.34–0.83]), age (HR: 1.04 [1.01–1.07]), and Ro-antibodies (HR: 0.36 [0.19–0.65]) influenced the prognosis. Conclusions IPAF have functional impairment during the first years of disease. Factors predicting deterioration differ between radiographic patterns. Our real-life study suggests the potential benefit of particular therapies in IPAF.

Objectives Most studies on difficult-to-treat rheumatoid arthritis (D2T RA) have focused on established RA. Here, we analyse whether disease activity in the early stages of RA could influence progression to a D2T RA under real-life conditions. Other clinical and treatment-related factors were also analysed.Methods A longitudinal multicentre study of patients with RA was conducted from 2009 to 2018. Patients were followed up until January 2021. D2T RA was defined based on EULAR criteria (treatment failure, signs suggestive of currently active/progressive disease and management being perceived as problematic by the rheumatologist and/or patient). The main variable was disease activity in the early stages. The covariates were sociodemographic, clinical and treatment-related factors. We ran a multivariable logistic regression analysis to investigate risk factors associated with progression to D2T RA.Results The study population comprised 631 patients and 35 (5.87%) developed D2T RA. At the time of diagnosis, the D2T RA group were younger, with a higher disability, 28-joint Disease Activity Score (DAS28) score, tender joint count and pain scores. In our final model, DAS28 was not statistically significantly associated with D2T RA. No differences were found between groups for therapy. Disability was independently associated with D2T RA (OR: 1.89; p=0.01).Conclusions In this cohort of patients newly diagnosed with RA, our results do not allow us to prove the influence of active disease according to DAS28. However, we did find that younger patients and those with elevated initial disability scores are more likely to develop D2T RA regardless of other factors.

Objectives: The aim of this study was to assess the cause-specific mortality rate related to COVID-19 (CMR) in patients with rheumatic and musculoskeletal diseases (RMDs) and COVID-19 and to analyze the role of the different RMDs in their mortality risk. Methods: An observational longitudinal study was conducted during the first pandemic wave in our center. Patients with the diagnosis of RMDs and COVID-19 were included. Main outcome is the death related to COVID-19. Independent variable – type of RMDs: autoimmune rheumatic diseases (ARD), such as chronic inflammatory arthritis (CIA) and connective tissue diseases (CTD) and non-autoimmune Rheumatic Diseases (non-ARD). Survival techniques were used to estimate the CMR per 1000 patients-month with a 95% confidence interval (CI), and Cox multivariate regression analysis was run to examine the effect of ARD compared to non-ARD on mortality risk adjusted by confounders. Results were expressed by Hazard Ratio (HR) and CI. Results: Overall, 405 patients were included (642.5 patients-month). During the study period, 44 (10.86%) deaths were recorded. CMR was 68.48 (50.96–92.01). After adjusting for confounders, HR of mortality in ARD compared to non-ARD did not achieve statistical significance [HR: 1.15 (0.64–2.07)], neither CTD versus CIA nor CTD versus non-ARD. Age and certain comorbidities which are being diagnosed in March compared to April or May [HR: 2.43 (1.1–5.55)] increased the mortality risk. Glucocorticoids and disease-modifying antirheumatic drugs (DMARDs) dropped from the final model. Conclusion: In patients with RMDs and COVID-19, CMR was 6.8% patients-month. This study shows that mortality risk is higher in males, older patients, and similar between CTD, CIA, and non-ARD. COVID-19 management improved after the first month of pandemic. Plain Language Summaries Mortality related to the outbreak of COVID-19 in patients with rheumatic and musculoskeletal diseases Why was this study done? - To report the COVID-19-specific mortality rate in patients with a variety of RMDs during the first pandemic peak in a tertiary hospital in Madrid and to analyze the role of specific types of ARD and other possible factors in the risk of death related to COVID-19. What did the researchers do? - We performed a retrospective observational study during the first wave of the COVID-19 pandemic in Madrid, Spain. What did the researchers find? - In this study, neither the different diagnoses of RMDs, including CIA, CTD, or non-ARD disease or its treatment were not implicated as a potential risk of death related to COVID-19 - In consonance with other studies, RMDs patients and COVID-19, older age, male sex, and certain comorbidities implied more mortality risk - Our data reflect COVID-19 severity in a particular context, time, and population. In times of the absence of COVID-19 vaccine, healthcare, social, and political measures taken to contain the coronavirus outbreak have worked properly. What do the findings mean? - The presence of comorbidities in RMDs patients represents a greater risk than the different types of RMDs themselves, in the development of COVID-19 fatal outcome. It is important to integrate the control of comorbidities in the daily management.

Introdução O Ministério da Saúde, MS, vem adquirindo inovações promissoras e controvertidas e as testando mediante estudos controlados em polos de referência da Rede SUS. Apresenta-se o exemplo da aquisição de um robô cirúrgico visando avaliar segurança, efetividade e sua relação de custo-efetividade em um UNACON. Métodos Estudo controlado randomizado por blocos conforme os tipos de cirurgia de câncer contratualizados pelo MS nas especialidades de gastroenterologia, ginecologia, cirurgias de cabeça e pescoço, urologia e pneumologia. Casuística: portadores de neoplasias com indicação cirúrgica e elegíveis para as três técnicas cirúrgicas em estudo, i.e., cirurgia aberta, videolaparoscopia e videolaparoscopia robótica, informados e concordaram com o protocolo assinando o TCLE, foram randomizados. O protocolo delineado (NCT02292914/ ClinicalTrials.gov) foi executado segundo as Diretrizes Metodológicas/Avaliação Econômica do MS, com micro-custeio operacional. Os custos de treinamento, de aquisição de capital, de manutenção etc. e custos indiretos, foram excluídos. Instrumentos validados foram usados para comparar benefícios funcionais e qualidade de vida por 36 a 60 meses. Resultados Oito cirurgias de câncer foram avaliadas em 783 pacientes randomizados, (4 de gastroenterologia, 1 ginecologia, 1 de cabeça e pescoço, 1 urologia, e 1 pneumologia) nos 3 Grupos: Robô (n = 421), Videolaparoscopia (n = 173) e Convencional-Aberta (n = 189), Idade Média±DP de 62±9 anos e IMC 27,6±5,4 kg/m2, no ICESP/HCFMUSP entre 2014 e 2021, com impacto da pandemia COVID no seguimento. A distribuição absoluta dos custos dos controles (laparoscópicos, exceto prostatectomias vs. cirurgia aberta) e das diferenças médias incrementais pela robótica e desvios de dias de internação no período pós-operatório e de custos totais foi de Esofagectomias (R*n=21) -3,6 dias de internação e incremento de R$ 15.691,08± R$ 4.252,56 comparado aos 22/lap internados por 20,3±7,4 dias e custo de R$ 50.998,44± R$ 14.601,45; Gastrectomias (*n=20) -0,2 dias e incremento de R$ 14.644,03± R$ 1.758,44 vs. 24/ lap com 11,5±4,1 dias e custaram R$ 22.303,28± R$ 5.526,34; Reto (*n=24) -1,1 dias e mais R$ 7.642,08± R$ 1.959,34 vs. 24/lap com 10,0±2,5 e custo R$ 24.997,87± R$ 5.296,93; Pancreatectomias (*n=29) com 7,8±1,2 dias de internação e custaram R$ 23.901,79± R$ 3.785,65 sem controles; Histerectomias (R*n=43) com +0,1 dia adicionou R$ 9.141,37± R$ 744,27 vs. 42/lap com 3,3±1,3 dias e custo de R$ 22.025,58± R$ 10.054,45; Cabeça & Pescoço (*n=36) -2,5 e incrementou R$ 1.631,66± R$ 1.530,95 vs. 55/videolap com 7,3±5,4 dias e custo R$ 18.463,00± R$ 8.872,60; Prostatectomias (*n=169) -0,7 dias e mais R$ 9.660,99± R$ 3.305,69 que as 167/abertas com 3,7±0,9 dias e custo de R$ 8.989,73± R$ 1.909,38; e, Lobectomias pulmonares (R*n=43) -0,3 dia economizaram -R$ 420,60± R$ 2.602,66 vs. 40/lap que permaneceram 6,0±3,1 dias e custaram R$ 34.103,60± R$ 2.112,03, respectivamente. Não houve complicações maiores ou mortalidade relacionadas às cirurgias nos braços estudados. A qualidade de vida e escores funcionais tenderam a ser melhores até 12 meses e foram similares no seguimento extendido. Discussão e conclusões Embora com ganhos estruturais, trabalhistas, ensino e pesquisa, este estudo corroborou a controvérsia internacional sobre os modestos benefícios da robótica no local para os pacientes. Atualmente, o custo de materiais descartáveis e monopólio da empresa o tornam pouco sustentáveis no SUS.

ABSTRACT Objective: The purpose of this study was to assess performance in the Brazilian Lung Cancer Registry Database by using the parsimonious EuroLung risk models for morbidity and mortality. Methods: The EuroLung1 and EuroLung2 models were tested and evaluated through calibration (calibration plot, Brier score, and the Hosmer-Lemeshow test) and discrimination (ROC AUCs), in a national multicenter registry of 1,031 patients undergoing anatomic lung resection. Results: The evaluation of performance in Brazilian health care facilities utilizing risk-adjustment models, specifically EuroLung1 and EuroLung2, revealed substantial miscalibration, as evidenced by calibration plots and Hosmer-Lemeshow tests in both models. In terms of calibration, EuroLung1 exhibited a calibration plot with overlapping points, characterized by a slope of 1.11 and a Brier score of 0.15; the Hosmer-Lemeshow test yielded a statistically significant p-value of 0.015; and the corresponding ROC AUC was 0.678 (95% CI: 0.636-0.721). The EuroLung2 model displayed better calibration, featuring fewer overlapping points in the calibration plot, with a slope of 1.22, with acceptable discrimination, as indicated by a ROC AUC of 0.756 (95% CI: 0.670-0.842). Both models failed to accurately predict morbidity and mortality outcomes in this specific health care context. Conclusions: Discrepancies between the EuroLung model predictions and outcomes in Brazil underscore the need for model refinement and for a probe into inefficiencies in the Brazilian health care system.

Objetivo: Determinar la prevalencia de parásitos intestinales en personas y su relación con algunos factores de riesgo en dos comunidades de Guerrero, México. Material y métodos: Se realizó el diagnóstico por la técnica de Faust y por copro-ELISA, así como la aplicación de una encuesta, para conocer aspectos que favorecen la parasitosis. Resultados: Se evaluaron 305 personas. De ellas, 181 (59.3%) fueron positivas mediante Faust. El parásito más frecuente fue Ascaris sp., con 118 positivos (38.7%); se observaron variaciones significativas entre ambas comunidades, porque en Yoloxóchitl, se identificaron 101/184 (54.9%), mientras que en Zentixtlahuaca solo se encontraron 17/121 (14.05%). Respecto a la identificación de riesgo por la tenencia de letrina y cerdos, éstos últimos resultaron ser un factor de riesgo para la teniosis (p =0.013), mientras que su tenencia mostró protección contra otras parasitosis en la población (p = 0.03), no se encontró significancia entre tener o no letrinas. Conclusiones: Los resultados del examen coproparasitoscópico sugieren que, si bien la convivencia con cerdos podría ser un factor de protección o riesgo según el problema, seguramente también dependen de otras condiciones como el fecalismo ambiental y el consumo de carne con metacestodos, por lo que debe trabajarse de manera integral para su solución.

El estudio se realiza con el objetivo de analizar la gestión de riesgo y vulnerabilidad como contenido para alcanzar la resiliencia en la población vulnerable a fenómenos naturales residentes en la comunidad de Punta Gorda en el territorio de Cienfuegos, se concreta en varias etapas de ejecución, que conforman actividades metodológicas diseñadas por docentes universitarios a partir de un diagnostico a un grupo de esta población. Las actividades metodológicas aportan elementos generales sobre la gestión de riesgo y vulnerabilidad de desastres que a partir de lo cognitivo y actitudinal conducirá al cambio, fundamentados en las características, y los recursos usados en las personas desde su propia mirada. Se emplea la metodología cualitativa de tipo explicativo. Los resultados evidenciaron una relación significativa entre la generación, preservación y difusión del conocimiento y el cambio como acto de modificación de la actuación humana.

Abstract The emergence of large language models (LLM) with remarkable performance such as ChatGPT and GPT-4, has led to an unprecedented uptake in the population. One of their most promising and studied applications concerns education due to their ability to understand and generate human-like text, creating a multitude of opportunities for enhancing educational practices and outcomes. The objective of this study is twofold: to assess the accuracy of ChatGPT/GPT-4 in answering rheumatology questions from the access exam to specialized medical training in Spain (MIR), and to evaluate the medical reasoning followed by these LLM to answer those questions. A dataset, RheumaMIR, of 145 rheumatology-related questions, extracted from the exams held between 2010 and 2023, was created for that purpose, used as a prompt for the LLM, and was publicly distributed. Six rheumatologists with clinical and teaching experience evaluated the clinical reasoning of the chatbots using a 5-point Likert scale and their degree of agreement was analyzed. The association between variables that could influence the models’ accuracy (i.e., year of the exam question, disease addressed, type of question and genre) was studied. ChatGPT demonstrated a high level of performance in both accuracy, 66.43%, and clinical reasoning, median (Q1–Q3), 4.5 (2.33–4.67). However, GPT-4 showed better performance with an accuracy score of 93.71% and a median clinical reasoning value of 4.67 (4.5–4.83). These findings suggest that LLM may serve as valuable tools in rheumatology education, aiding in exam preparation and supplementing traditional teaching methods.

Objective This study aimed to estimate the incidence of giant cell arteritis (GCA) in Spain and to analyse its clinical manifestations, and distribution by age group, sex, geographical area and season.Methods We included all patients diagnosed with GCA between 1 June 2013 and 29 March 2019 at 26 hospitals of the National Health System. They had to be aged ≥50 years and have at least one positive results in an objective diagnostic test (biopsy or imaging techniques), meet 3/5 of the 1990 American College of Rheumatology classification criteria or have a clinical diagnosis based on the expert opinion of the physician in charge. We calculated incidence rate using Poisson regression and assessed the influence of age, sex, geographical area and season.Results We identified 1675 cases of GCA with a mean age at diagnosis of 76.9±8.3 years. The annual incidence was estimated at 7.42 (95% CI 6.57 to 8.27) cases of GCA per 100 000 people ≥50 years with a peak for patients aged 80–84 years (23.06 (95% CI 20.89 to 25.4)). The incidence was greater in women (10.06 (95% CI 8.7 to 11.5)) than in men (4.83 (95% CI 3.8 to 5.9)). No significant differences were found between geographical distribution and incidence throughout the year (p=0.125). The phenotypes at diagnosis were cranial in 1091 patients, extracranial in 337 patients and mixed in 170 patients.Conclusions This is the first study to estimate the incidence of GCA in Spain at a national level. We found a predominance among women and during the ninth decade of life with no clear variability according to geographical area or seasons of the year.

Fundamento: la superación docente sobre gestión de riesgo de desastres naturales en ciencias médicas de Cienfuegos se ha caracterizado por el insuficiente tratamiento de su contenido en la actividad profesional, a pesar de ser una temática de marcada importancia, concedida tanto a nivel nacional como internacional.Objetivo: diseñar un curso de superacion en gestión de riesgo frente a desastres naturales dirigido a los docentes de ciencias médicas.Métodos: investigación pedagógica realizada en la Facultad de Ciencias Médicas de Cienfuegos en el curso 2020-2021. Se realizó el diagnóstico de las necesidades de aprendizaje, se diseñó el curso y fue sometido a validación por expertos. Se impartió a un grupo de docentes que presentaron tesinas al finalizar el curso. Se utilizaron métodos del nivel teórico como el analítico-sintético, inductivo-deductivo, histórico-lógico, y del nivel empírico la modelación y la encuesta.Resultados: el curso fue estructurado en cinco temas que incluyeron los problemas relacionados con la identificación, el análisis y evaluación de riesgo, como parte de los pasos necesarios para comprender la gestión del riesgo y el aprendizaje de sus tres etapas: proactiva correctiva y reactiva. Los expertos lo consideraron factible, pertinente y de elevada calidad. Los cursistas presentaron tesinas con gran rigor científico metodológico que sirvieron de plataforma en proyectos investigativos y trabajos de ciencia, tecnología y sociedad.Conclusiones: el curso contribuyó al incremento de los conocimientos de los docentes de la Facultad de Ciencias Médicas de Cienfuegos en cuanto a la gestion de riesgo de desastres.

ABSTRACT Objective: To compare 90-day morbidity in patients undergoing lung lobectomy performed by either robotic-assisted thoracic surgery (RATS) or video-assisted thoracic surgery (VATS). Intraoperative complications, drainage time, length of hospital stay, postoperative pain, postoperative quality of life, and readmissions within 90 days were also compared. Methods: This was a two-arm randomized clinical trial including patients with lung lesions (primary lung cancer or lung metastasis) who were candidates for lung lobectomy. Patients with comorbidities that precluded surgical treatment were excluded. All patients followed the same postoperative protocol. Results: The overall sample comprised 76 patients (39 in the VATS group and 37 in the RATS group). The two groups were similar regarding gender, age, BMI, FEV1 in % of predicted, and comorbidities. Postoperative complications within 90 days tended to be more common in the VATS group than in the RATS group, but the difference was not significant (p = 0.12). However, when only major complications were analyzed, this tendency disappeared (p = 0.58). Regarding postoperative outcomes, the VATS group had a significantly higher number of readmissions within 90 days than did the RATS group (p = 0.029). No significant differences were found regarding intraoperative complications, drainage time, length of hospital stay, postoperative pain, and postoperative quality of life. Conclusions: RATS and VATS lobectomy had similar 90-day outcomes. However, RATS lobectomy was associated with a significant reduction in the 90-day hospital readmission rate. Larger studies are necessary to confirm such a finding. (ClinicalTrials.gov identifier: NCT02292914 [http://www.clinicaltrials.gov/])