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Systemic lupus erythematosus (SLE) is characterized by great clinical heterogeneity. The objectives of its management are to make a timely diagnosis and to initiate treatment as promptly as possible so organ damage can be avoided while at the same time exposure to potentially toxic drugs is minimized so that its overall course and outcome improve. In reviewing the current literature, it became quite clear that there are specific topics in which controversies do exist. These include how to treat patients with incomplete lupus erythematosus, the real possibility of abandoning altogether the use of oral glucocorticoids, and the pros and cons of the use of cyclophosphamide and mycophenolate mofetil for the induction treatment of lupus nephritis. Herein we discuss different points of view regarding these still unresolved issues; these comments represent a debate that took place during the PANLAR Virtual Congress (Pan American League of Associations for Rheumatology) and that was organized by the PANLAR Lupus study group, GLADEL (Grupo Latino Americano De Estudio del Lupus) on September 19, 2020.

Background/objective Demand for rheumatology care has steadily increased in recent years. The number of specialists in this field, however, seems insufficient. No recent studies have diagnosed the attributes of rheumatology training in Latin America. Methods This is a descriptive cross-sectional study. We obtained data on each country through local rheumatologists of the Pan-American League Against Rheumatism, who acted as principal investigators for participating countries. Our sample was analyzed and described through means and standard deviations or through frequencies and percentages, depending on the variable. Results Countries with the most rheumatology-training programs were Brazil (n = 50), Argentina (n = 18), and Mexico (n = 15). Ecuador, Honduras, and Nicaragua do not have rheumatology-training programs. The countries with the most available slots for rheumatology residents were Brazil (n = 126) and Argentina (n = 36). To be admitted into rheumatology training, candidates were required to have completed graduate studies in internal medicine in 42.1% of the programs. In 8 countries (42.1%), residents are not required to pay tuition; the median cost of tuition in the remaining countries is US $528 (interquartile range, US $2153). Conclusions Conditions associated with rheumatology training in Latin America vary. Significant differences exist in income and tuition fees for residents, for example, and 4 countries in Latin America do not currently offer programs. Information collected in this study will be useful when comparing the status of rheumatology services offered in Latin America with those in other countries. Most countries require a wider offering of rheumatology-training programs, as well as more available slots.

Background/objective Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). Interstitial lung disease (ILD) is an extra-articular manifestation of RA. We investigated incidence rates of ILD in patients with RA, receiving tofacitinib 5 or 10 mg twice daily, and identified potential risk factors for ILD. Methods This post hoc analysis comprised a pooled analysis of patients receiving tofacitinib 5 or 10 mg twice daily or placebo from 2 phase (P)1, 10 P2, 6 P3, 1 P3b/4, and 2 long-term extension studies. Interstitial lung disease events were adjudicated as "probable" (supportive clinical evidence) or "possible" (no supportive clinical evidence) compatible adverse events. Incidence rates (patients with events per 100 patient-years) were calculated for ILD events. Results Of 7061 patients (patient-years of exposure = 23,393.7), 42 (0.6%) had an ILD event; median time to ILD event was 1144 days. Incidence rates for ILD with both tofacitinib doses were 0.18 per 100 patient-years. Incidence rates generally remained stable over time. There were 17 of 42 serious adverse events (40.5%) of ILD; for all ILD events (serious and nonserious), 35 of 42 events (83.3%) were mild to moderate in severity. A multivariable Cox regression analysis identified age 65 years or older (hazard ratio 2.43 [95% confidence interval, 1.13-5.21]), current smokers (2.89 [1.33-6.26]), and Disease Activity Score in 28 joints-erythrocyte sedimentation rate score (1.30 [1.04-1.61]) as significant risk factors for ILD events. Conclusions Across P1/2/3/4/long-term extension studies, incidence rates for ILD events were 0.18 following tofacitinib treatment, and ILD events were associated with known risk factors for ILD in RA.

Rheumatoid arthritis (RA) is a chronic, autoimmune disease characterized by joint destruction. Tofacitinib is an oral Janus kinase inhibitor for the treatment of RA. This post hoc analysis assessed the safety of tofacitinib in Latin American (LA) patients with RA versus the Rest of World (RoW) population.Data were pooled from 14 clinical studies of tofacitinib: six Phase 2, six Phase 3 and two long-term extension studies. Incidence rates (IRs; patients with events/100 patient-years of treatment exposure) were calculated for safety events of special interest combined across tofacitinib doses. 95% confidence intervals (CI) for IRs were calculated using the maximum likelihood method. Descriptive comparisons were made between LA and RoW (excluding LA) populations.This analysis included data from 984 LA patients and 4687 RoW patients. IRs for safety events of special interest were generally similar between LA and RoW populations, with overlapping 95% CIs. IRs for discontinuation due to adverse events, serious infections, tuberculosis, all herpes zoster (HZ), serious HZ, malignancies (excluding non-melanoma skin cancer) and major adverse cardiovascular events were numerically lower for LA versus RoW patients; IR for mortality was numerically higher. No lymphoma was reported in the LA population versus eight cases in the RoW population. Exposure (extent and length) was lower in the LA population (2148.33 patient-years [mean = 2.18 years]) versus RoW (10515.68 patient-years [mean = 2.24 years]).This analysis of pooled data from clinical studies of tofacitinib in patients with RA demonstrates that tofacitinib has a consistent safety profile across LA and RoW patient populations.

The First PANLAR Rheumatology Review Course was held in Barranquilla, Colombia, in April 2015. Researchers, rheumatologists, epidemiologists, and a variety of allied professionals and patients attended the meeting. The scientific program included plenary sessions and symposia delivered by renowned experts in the field, followed by an interactive forum of discussion during 2 days.A broad spectrum of topics was discussed, reflecting the current challenges and opportunities for diagnosis and treatment of rheumatoid arthritis (RA) in Latin America. The scientific program included not only traditional disease aspects, but also social implications, research projects, and educational characteristics, patient perspectives, and novel care models, emphasizing the need for training human resources and proposing unique approaches to RA health care in Latin America, therefore helping us to increase and improve the knowledge and understanding of the characteristics of this health condition in the region, thus promoting and encouraging equity, quality, and efficiency of RA health care.

The mission of PANLAR (Pan American League of Associations for Rheumatology) is 2-fold: (1) to stimulate and promote the study and research of rheumatic diseases for the prevention, treatment, and rehabilitation of patients with rheumatic conditions in the American continent and (2) to stimulate the continuing development of the specialty of rheumatology. PANLAR is committed to encourage and facilitate patient access to care as it affects the ability of rheumatic disease patients to obtain affordable, high-quality, and specialized health care. The national health care systems within the Latin America (LA) and Caribbean area are heterogeneous in their organizational structure and complex in their operational configuration and the principles guiding the public and private sector roles in the provision of health care services. Latin American and Caribbean countries exhibit wide variations regarding their main health care systems objectives and operation. Chronic illnesses, which greatly impact health and quality of life, are actually 1 of their priorities despite requiring efforts to manage the burden of infectious diseases, providing care for the reproductive-age female population, childhood pathology, and violence-related injuries, among others.1 Patients with rheumatoid arthritis (RA) have substantial unmet medical needs. The World Health Organization recommends at least 1 rheumatologist per 100,000 people, that is, an estimated need of 6000 specialists in LA. Currently excluding the United States and Canada, the 19 LA and Caribbean Rheumatology National Societies have a workforce of around 3900 specialists to serve 588 million inhabitants. Not all rheumatologists are active, nor are they accredited according to country requirements.2 Although this number could be higher because some active practicing rheumatologists are not affiliated to their local societies, therefore, the actual number of specialists cannot be determined accurately. In addition to the shortage of rheumatologists in Latin American and Caribbean countries, the regional distribution on supply of specialists is mainly in metropolitan areas, whereas other areas have a low density of specialists, such as in rural areas and small towns, resulting in several underserved areas. These factors not only constitute barriers to patient access to specialized health care, but also contribute to a suboptimal quality of care provided, poor diagnosis, and treatment of RA in a large proportion of affected individuals.3,4 However this is not the only problem that RA patients face. Most patients in the region have limited access to medicines, rehabilitation programs, and orthopedic interventions, all of which are highly recommended for optimal disease management. Moreover, they do not have substantial education programs, which are necessary to empower them and their families in their daily management and adjustment to their illnesses, because drug therapy alone does not substantially improve quality of life.3,4 The data also reveal the importance of considering early diagnosis and adequate treatment of RA as a public health priority in Latin American and Caribbean countries, because early treatment of RA has shown to effectively reduce disability in the long run.3,4 Accurate measures known as quality indicators (QIs) are needed to assess quality of care. Quality indicators are usually more specific as compared with treatment recommendation guidelines, because they precisely describe who must do what, to whom, and exactly when.5 In 2007, the American College of Rheumatology (ACR) submitted a set of minimum QIs for RA patient care; patient adherence to these standards seems possible. Introduction of these QIs presents clinicians with an enormous opportunity to clearly understand the minimum standards expected in the profession.6 An essential goal of QIs is establishing minimum standards of care that should be delivered to patients as a means to evaluate care across patients and provider groups and stimulate quality improvement efforts that ultimately lead to better patient care and outcomes.6 The involvement of national scientific specialty organizations is an important way of delivering the message that implementing these measures is necessary for patients with RA. Eventually, it may be feasible to move beyond the specification of minimal care and reach a consensus regarding good and excellent care for our patients. There is a great potential to reduce the large and growing burden of RA across the PANLAR member societies through evidence-based interventions and harmonization of the standards of care. The REAL (Red de Excelencia en Artritis para la America Latina) project evolved as a strategic need to implement Centers of Excellence (CoEs) in RA throughout the LA and Caribbean region to help ensure affordable, high-quality, and specialized health care for these patients, improving their quality of life and managing their health care costs. Taking into account the difficulties posed by diverse health system organizations across countries and lack of resources, the REAL main goals are as follows: To promote assessment of standards of care for RA in alignment with PANLAR clinical guidelines and the Treat to Target (T2T) strategy7 To accomplish the need to measure and document disease activity, disability, comorbidities, quality of life, and adherence to treatment by RA patients To establish harmonized minimum standards of care for RA patients To inform doctors and other allied health professionals about all aspects of RA To educate patients and their family members about the facts of RA in order to help them to cope with the disease and collaborate, improving adherence to treatment and rehabilitation programs To improve patient accessibility to arthritis centers and implement continuous health care quality programs To establish and foster Latin American and Caribbean regional registries and databases To form a strategic alliance with Latin American and Caribbean governments and nongovernmental organizations in order to implement the T2T strategy and CoEs in RA throughout the LA and Caribbean region To raise awareness about the need for CoEs in RA among policy makers, private and public health payers, and insurers in the region

Antinuclear antibodies (ANA) are frequently found in healthy populations. To define the prevalence, pattern, and titer of ANA in different groups of the healthy Mexican population, we studied 304 individuals, classified into 3 groups: 104 blood donors, 100 hospital personnel working at The State General Hospital, which included doctors, laboratory technicians, and nurses; and 100 relatives of patient diagnosed either with systemic lupus erythematosus or rheumatoid arthritis, all of them apparently healthy at the time of study. We determined ANA using immunofluorescence microscopy performed on HEp-2 cells. Fluorescence was detected in 165 serum samples (54.3%). The most frequent pattern was the speckled (50.3%). The most frequent dilution was 1:40 (35.4%), followed by 1:80 (13.4%), 1:160 (3.2%), and 1:320 (1.3%).Regarding the results by study group, we found a trend toward higher ANA levels in group 2 (hospital personnel), compared with group 1 (blood donors) and group 3 (relatives of patients), a trend also reflected by the increasing frequency of serum titers of 1:80 and higher (P = 0.074). According to occupation, medical doctors showed a higher incidence of speckled pattern when compared with other occupations (P = 0.022). Medical doctors (n = 75) showed also higher titers of this particular pattern (P = 0.03). In group 3, relatives of patients with systemic lupus erythematosus showed the speckled pattern more frequently than relatives of patients with rheumatoid arthritis, in low titers (P = 0.017). We suggest that ANA tests showing speckled pattern should be at a 1:160 titer or higher to be considered positive; other patterns such as homogeneous, peripheral, or centromeric might be considered positive even at low titers (

A consensus meeting of representatives of 18 Latin-American and Caribbean countries gathered in Reñaca, Chile, for 2 days to identify problems and provide recommendations for the care of patients with rheumatoid arthritis (RA) in Latin America, a region where poverty and other health priorities make the efforts to provide effective and high quality care difficult. This report includes recommendations for health professionals, patients, and health authorities in Latin America, with an emphasis on education and therapeutic issues.Fifty-one rheumatologists (list available only online on the JCR website) from 18 Latin-American and Caribbean countries with a special interest in RA participated in the consensus meeting. Participants were experts identified and appointed by the National Societies of Rheumatology affiliated with the Pan-American League of Associations for Rheumatology (PANLAR) and by the Grupo Latino Americano De Estudio de Artritis Reumatoide (GLADAR)-an independent group of Latin American rheumatologist researchers were also invited to the meeting. Eight topics were identified as priorities: patient, community and allied health professional education, health policy and decision making, programs for early detection and appropriate treatment of RA, role of classic disease modifying antirheumatic drugs (DMARDs), role of biologic therapy, and drug safety surveillance. To reach consensus, a survey with questions relevant to the topic of interest was sent to all participants before the meeting. During a 2 day meeting, the answers of the survey were reviewed and discussed by each group, with final recommendations on action items.The specific topic of the survey was answered by 86% of the participants and 68% of them answered the entire survey. It was agreed that RA and rheumatic diseases which are currently not but should be public health priorities in Latin America, because of their prevalence and impact on quality of life.Strategic areas identified as priorities for our region included: early diagnosis and access to care by multidisciplinary teams, creation of databases to identify infections with the use of biologic agents in RA which are relevant to Latin America, and overall efforts to improve the care of RA patients in accordance with international standards. Implementation of educational programs aimed to improve self-management for patients with RA was also considered crucial.

Objective To estimate the prevalence, burden of illness, and help-seeking behavior of patients with musculoskeletal complaints and provide point prevalence estimates of osteoarthritis, low back pain, fibromyalgia, rheumatoid arthritis, gout, and bone fractures not related to trauma among the adult population in a urban community in Havana City. Methods Home survey of adults validated against physical examination. Forty-eight trained family doctors and 3 rheumatologists supervised the interviews and confirmed diagnoses. Family doctors applied a validated Community Oriented Program for the Control of Rheumatic Diseases core questionnaire. A diagnosis using American College of Rheumatology criteria was established. Analysis was based on descriptive statistics and point prevalence estimates with 95% confidence intervals (CIs) of most common diseases and associated disability rate. Results One thousand two hundred thirty-eight men and 1917 women were included. Prevalence of musculoskeletal pain was estimated in 43.9% (95% CI: 42.2-45.7). The knees were the most affected area (11.7%; 95% CI: 10.6-12) followed by low back pain (11.6%; 95% CI: 10.5-12.8). Point prevalence and 95% CI were as follows: osteoarthritis, 20.4% (95% CI: 19-21.8); gout, 0.38% (95% CI: 0.2-0.6); fibromyalgia, 0.22% (95% CI: 0.09-0.4); systemic lupus erythematosus, 0.06% (95% CI: 0.01-0.25); spondyloarthropathies, 0.19% (95% CI: 0.07-0.4); and rheumatoid arthritis,1.24% (95% CI: 0.8-1.7). Bone fractures not related to trauma were found in 1.14%, hip fracture being the most common (30.5%). Most patients were seen by the general practitioner (65.4%) and 6.2% described some disability. Conclusions Musculoskeletal pain is highly prevalent in Cuba. Prevalence estimates are similar to those described in other surveys except for rheumatoid arthritis that seems more prevalent in Cuba and fibromyalgia less prevalent.

Clinical and laboratory features were analyzed in 107 Latin American male patients with systemic lupus erythematosus (SLE) who were compared with a group of 1,209 Latin American female patients with SLE to determine the presence of gender-associated differences. Males had an increased prevalence of renal disease, vascular thrombosis, and the presence of anti-dsDNA antibodies, as well as the use of moderate to high doses of corticosteroids, compared with female SLE patients. Although there was no difference in mortality from all causes, SLE-related mortality was higher in the male group. All these findings are consistent with a more severe disease in Latin American males than in female patients from the same region.