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Background and objectives: The COVID-19 pandemic has forced universities to move the completion of university studies online. Spain's National Conference of Medical School Deans coordinates an objective, structured clinical competency assessment called the Objective Structured Clinical Examination (OSCE), which consists of 20 face-to-face test sections for students in their sixth year of study. As a result of the pandemic, a computer-based case simulation OSCE (CCS-OSCE) has been designed. The objective of this article is to describe the creation, administration, and development of the test. Materials and methods: This work is a descriptive study of the CCS-OSCE from its planning stages in April 2020 to its administration in June 2020. Results: The CCS-OSCE evaluated the competences of anamnesis, exploration, clinical judgment, ethical aspects, interprofessional relations, prevention, and health promotion. No technical or communication skills were evaluated. The CCS-OSCE consisted of ten test sections, each of which had a 12-minutes time limit and ranged from six to 21 questions (mean: 1.1 minutes/question). The CCS-OSCE used the virtual campus platform of each of the 16 participating medical schools, which had a total of 2,829 students in their sixth year of study. It was jointly held on two dates in June 2020. Conclusions: The CCS-OSCE made it possible to bring together the various medical schools and carry out interdisciplinary work. The CCS-OSCE conducted may be similar to Step 3 of the United States Medical Licensing Examination.

Objectives To describe the therapeutic management of rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) in patients initiating treatment with biological agents. Materials and methods Observational, retrospective, longitudinal study in 33 Spanish hospitals. Patients with RA, PsA and AS starting treatment with biological agents between September 2009 and August 2010 and a follow-up longer than 3 years were included. Clinical-demographic characteristics, drugs, biological therapy survival, and reasons for discontinuation or switching were analysed. Results Four hundred and sixty-three patients were included (183 RA, 119 PsA and 161 AS), with a mean follow-up of 3.8 years. At the end of follow-up, a high proportion continued with the first biological prescribed (41.0% of RA, 59.7% of PsA and 51.6% of AS), 31.1%, 47.9% and 42.9% of RA, PsA and AS patients requiring dosage adjustments, respectively. There was temporary discontinuation in 8.2%, 8.4% and 15.5% of patients, and a switch of biologic agent was required in 37.7%, 26.1% and 24.2%. Definitive discontinuation occurred in 13.1%, 5.9% and 8.7% of RA, PsA and AS patients, respectively. Mean time to discontinuation or switching was 30.1 months for RA and 35.7 months for PsA and AS. Conclusions Our results suggest that, in practice, half of patients with RA and two thirds with PsA or AS maintained the first biological, but with frequent dose adjustments.

Introduction Rheumatoid arthritis (RA) is the most frequent chronic polyarthritis. The current goal of RA treatment is to achieve clinical remission. Objective The goal of this study was to determine the prevalence of remission in a cohort of patients from clinical practice, and to identify potentially modifiable factors associated with remission. Methods A retrospective study was performed on a cohort of RA patients seen at the first consultation at the HUGC Rheumatology Service Dr. Negrin (HUGCDN) between first of January 2000 and thirtieth of April 2014. Sustained remission was defined as DAS28 less than 2.6 in the last two available visits in the medical history. Results A total of 463 patients were consecutively included, most (75%) women, with a mean age at the onset of RA of 50 years and a mean duration of the disease at follow-up of 8 years. 46% of the patients achieved sustained remission. Multiple logistic regression analyses found male sex (P = .031, OR 1.7, 95% CI 1.05–2.82), diagnosis in the first year of symptoms (P = .023, OR 1.7, 95% CI 1.07–2.69) and the initial DAS28 (P = .035) to be independent predictors for sustained remission. Conclusions The 46% of the patients with RA followed in the HUGC Dr. Negrin are in persistent remission, being the early diagnosis a modifiable factor predictor of remission. Thus, an objective of the Rheumatology Service should be to improve the diagnostic delay of RA in the health area.

Background Long-term adherence to antiosteoporosis medication (AOM) in the setting of a fracture liaison service (FLS) are not well known. Methods Patients ≥50 with hip fracture seen in an FLS and recommended for treatment to prevent new fractures were analyzed. Baseline data included demographics, identification mode, previous treatment and FRAX® items. Patient records were reviewed 3-8 years later, and these data were collected: 1) survival; 2) major refracture; 3) initiation of treatment, proportion of days covered (PDC) and persistence with AOM. Results 372 patients (mean age, 79 years; 76% women) were included. Mean follow-up was 47 months, 52 patients (14%) had a refracture (22 hip) and 129 (34.5%) died. AOM was started in 283 patients (76.0%). Factors associated with initiation of AOM were previous use of bisphosphonate (OR9.94;95%CI:1.29-76.32) and a lower T-score lumbar (OR 0.80;95%CI:0.65-0.99). Persistence decreased to 72.6%, 60% and 47% at 12, 36 and 60 months. A PDC>80% was confirmed in 208 patients (55.7%) and associated with previous use of bisphosphonate (OR3.38;95%CI:1.34-8.53), treatment with denosumab (OR2.69;95%CI:1.37-5.27), and inpatient identification (OR2.26; 95%CI:1.18-4.34). Conclusions Long-term persistence with AOM was optimal in patients with hip fracture seen at an FLS. A PDC>80% was associated with inpatient identification and prescription of denosumab.

Objective To update the recommendations on osteoporosis (OP) of the Spanish Society of Rheumatology (SER) based on the best possible evidence. Methods A panel of nine expert rheumatologists in OP was created, previously selected by the SER through an open call. The phases of the work were: identification of the key areas for updating the previous consensus, analysis and synthesis of the scientific evidence (using the SIGN levels of evidence) and formulation of recommendations based on this evidence and consensus techniques. Results This revision of the recommendations implies an update in the diagnostic evaluation and treatment of OP. It proposes some criteria to consider the high risk of fracture and some indications to start treatment. The recommendations also address issues related to the safety of treatments and the management of special situations such as inflammatory diseases and treatment with glucocorticoids. Conclusions We present an update of SER recommendations on OP.

The objective of the study was to assess the ESSDAI index characteristics in the SJOGRENSER cohort (Spanish Rheumatology Association’s registry of patients with Primary Sjogren Syndrome [PSS]). SJOGRENSER is a prospective multicentric study on a cohort of Spanish patients with PSS who meet the 2002 American–European consensus from rheumatology units. 298 variables were studied in patients for the inclusion of the study from an anonymous list from each department. The ESSDAI (EULAR Sjogren’s syndrome disease activity index) includes 12 domains and measures systematic activity in PSS patients. Each domain is divided into 3–4 levels, (0: no activity; 1: low activity; 2: moderate activity; 3: high activity) and is attributed a weight. Each domain score is obtained by multiplying the activity level by the weight assigned. According to ESSDAI: low activity

[Abstract] Objective. To determine and analyse the organisational approach adopted by Spanish rheumatologists to osteoporosis (OP) to define strategic priorities. Material and method. A group of experts designed a questionnaire on OP in the rheumatologist practice. The survey was sent to the Spanish Society of Rheumatology (SER) members. Through the Delphi round, strategic priorities were agreed upon in OP. Results. The priorities are: 1) The SER should promote the inclusion of OP in 100% of the services and expand the training offer; 2) Rheumatology services should promote the role of the nurse in OP, promote quality indicators and referral protocols agreed with primary care in addition to promoting their training in this area; 3) The SER and Rheumatology services should promote electronic consultation, OP monographic clinics and participation in Fracture Liaison Service units. Conclusions. Strategic priorities in OP help identify areas of improvement at organisational, structural and quality standards level in this pathology. [Resumen] Introducción. Los estudios de opinión sobre la percepción del reumatólogo de la práctica asistencial en osteoporosis (OP) pueden ayudar a identificar áreas de mejora en la gestión de esta patología. Objetivo. Conocer y analizar el enfoque organizativo que adoptan los reumatólogos españoles ante la OP para definir prioridades estratégicas y establecer unos estándares de calidad. Material y método. Un grupo de expertos diseñó una encuesta sobre creencias y conductas en OP en la práctica del reumatólogo. La encuesta se remitió a los socios de la Sociedad Española de Reumatología (SER). Mediante ronda Delphi se consensuaron las prioridades estratégicas en OP. Resultados. El grupo de expertos consensuó como prioridades estratégicas en OP: 1) La SER debería impulsar la inclusión de la OP en el conjunto de prestaciones de todos los servicios de reumatología, así como ampliar la oferta formativa específica para médicos y enfermeras; 2) Los servicios de reumatología debieran fomentar el papel de la enfermera en OP, impulsar la implantación y el seguimiento de indicadores de calidad e implantar protocolos de derivación consensuados con atención primaria además de impulsar su formación en este área; 3) La SER y los servicios de reumatología deberían impulsar la implantación de la consulta electrónica y la consulta monográfica o dedicada a OP así como la participación del reumatólogo en unidades de fractura Fracture Liaison Service (FLS). Conclusiones. Las prioridades estratégicas en OP derivadas de la encuesta a los reumatólogos españoles ayudan a identificar las áreas de mejora a nivel organizativo, estructural y de estándares de calidad en esta patología.

We analyzed the long-term persistence of treatment in a FLS. During follow-up, 15.2% of patients had a refracture and 23.8% died. At the 5-year checkup, 74% had started treatment (associated with female sex, previous use of bisphosphonate, and referral to an osteoporosis clinic). Persistence at 1 and 5 years was 70.6% and 46.5%, respectively. To analyze the long-term persistence of treatment in a fracture liaison service (FLS). Patients ≥ 50 years with a fragility fracture attended between 2012 and 2016 who were recommended for treatment to prevent new fractures were included. Baseline data included demographics, type of fracture, previous treatment, and FRAX® items. Five years later, patient records were reviewed and the following data were collected: [1] survival; [2] refracture; [3] initiation of treatment, persistence, and medication possession ratio (MPR) > 80%. We included 888 patients, mean age 75 years, 83% women, and mean follow-up 56 months. During follow-up, 135 patients (15.2%) had a refracture (109 major fractures, 50 hip refractures) and 212 patients died (23.8%); at the 5-year checkup, 657 patients (74%) had started some type of treatment. Factors associated with the start of treatment were female sex (OR 2.10; 95% CI: 1.42–3.11), previous use of bisphosphonate (OR 3.91; 95% CI: 2.23–6.86), and referral to an osteoporosis clinic (OR 1.46; 95% CI: 1.02–2.07). Persistence decreased from 70.6% at 12 months to 46.5% at 60 months. An MPR > 80% was confirmed in 449 patients, 68.3% of whom were under treatment. A total of 521 and 447 patients received treatment for at least 24 and 36 months, respectively (79.3% and 68.0% of those who started treatment). Patients with fragility fractures attended at an FLS showed optimal long-term persistence of treatment. These data can help healthcare managers better calculate the cost-effectiveness of implementing the FLS model.

Resumen Antecedentes y objetivos La pandemia de la COVID-19 ha obligado a completar los estudios universitarios online. La Conferencia Nacional de Decanos de Facultades de Medicina coordina una prueba de evaluacion de competencias clinicas objetiva y estructurada (ECOE) de 20 estaciones presenciales a los estudiantes de sexto del grado. Como consecuencia de la pandemia se ha disenado una ECOE sustitutoria con casos-clinicos computarizados simulados (ECOE-CCS). El objetivo del articulo es describir la elaboracion, la ejecucion y el desarrollo de la prueba. Materiales y metodos Estudio descriptivo de la ECOE-CCS conjunta desde su gestacion en abril 2020 hasta su ejecucion en junio 2020. Resultados La ECOE-CCS evaluo las competencias de anamnesis, exploracion, juicio clinico, aspectos eticos, relaciones interprofesionales, prevencion y promocion de la salud. No se evaluaron habilidades tecnicas ni de comunicacion. La ECOE-CCS consistio en 10 estaciones de 12 minutos de duracion, con un numero de preguntas de seis a 21 (media: 1,1 minutos/pregunta). En la ECOE-CCS se utilizo la plataforma virtual del campus de cada una de las 16 facultades de Medicina que participaron, con un total de 2.829 estudiantes de sexto curso. Se realizo de una forma conjunta en dos fechas de junio del 2020. Conclusiones La experiencia de la ECOE-CCS permitio llevar a cabo una integracion y el trabajo interdisciplinar de las diferentes facultades de Medicina. La ECOE-CCS realizada podria asemejarse al Step 3 CCS de la United States Medical Licensing Examination.

Prevalence and risk factors of vertebral fractures in postmenopausal RA women were assessed in 323 patients and compared with 660 age-matched women. Of patients, 24.15% had at least one vertebral fracture vs.16.06% of controls. Age, glucocorticoids and falls were the main fracture risks. Vertebral fractures were associated with disease severity. Introduction There is little quality data on the updated prevalence of fractures in rheumatoid arthritis (RA) that may have changed due to advances in the therapeutic strategy in recent years. This study was aimed at analysing the prevalence and risk factors of vertebral fractures in postmenopausal women with RA and comparing it with that of the general population. Methods We included 323 postmenopausal women diagnosed with RA from 19 Spanish Rheumatology Departments, randomly selected and recruited in 2018. Lateral radiographs of the thoracic and lumbar spine were obtained to evaluate morphometric vertebral fractures and the spinal deformity index. We analysed subject characteristics, factors related to RA, and fracture risk factors. The control group consisted of 660 age-matched Spanish postmenopausal women from the population-based Camargo cohort. Results Seventy-eight (24.15%) RA patients had at least one vertebral fracture. RA patients had increased fracture risk compared with controls (106 of 660, 16.06%) (p = 0.02). Logistic regression analysis showed that age (OR 2.17; 95% CI 1.27-4.00), glucocorticoids (OR 3.83; 95% CI 1.32-14.09) and falls (OR 3.57; 95% CI 1.91-6.86) were the independent predictors of vertebral fractures in RA patients. The subgroup with vertebral fractures had higher disease activity (DAS28: 3.15 vs. 2.78, p = 0.038) and disability (HAQ: 0.96 vs. 0.63, p = 0.049), as compared with those without vertebral fractures. Conclusion The risk of vertebral fracture in RA is still high in recent years, when compared with the general population. The key determinants of fracture risk are age, glucocorticoids and falls. Patients with vertebral fractures have a more severe RA.

We present the achievements and difficulties of our pioneering FLS within the Spanish public health system over an 8-year period. Despite implementing consolidating measures at the unit, the addition of a support nurse, the establishment of a solid alliance with primary care, the involvement of primary care nurses, and starting initial prescriptions at the hospital are pending. To assess the consolidation of an FLS after its implementation as well as the problems that have arisen over time. The program for secondary fracture prevention was implemented in 2012. Initially manned by the same staff assigned to the rheumatology department, a part-time support nurse was added in 2016. Patients were identified from the emergency registry and, more recently, from among those admitted for hip fracture and treated in a monographic osteoporosis clinic. The baseline visit consisted of a consultation with the nurse, as well as DXA and bone metabolism analytics. Patients were referred to their primary care physician to start treatment. Of the 2416 attended patients, 30% presented forearm fractures, 27% hip, 20% humerus, 10% spine, and 11% other fractures. In comparison with 2012, in 2019, the monthly average of patients had doubled, with an increased in the number of hip and spine fractures and an increase in the percentage of captured patients. The performance of DXA fell from 100 to 52%, and fewer patients were referred to the osteoporosis clinic. One in four patients was referred to a fall prevention school. Despite implementing consolidating measures at the unit (the addition of a support nurse and the establishment of a solid alliance with primary care), the involvement of primary care nurses and starting initial prescriptions at the hospital are pending. We present herein the achievements made by our FLS and the difficulties within the Spanish public health system over an 8-year period.

La fragmentación del conocimiento distancia a las organizaciones educativas de la realidad y pone en entredicho la legitimidad de la academia ante la sociedad. Esta investigación busca contribuir en la resolución de problemas asociados a la gestión del conocimiento y el trabajo interdisciplinar en una Facultad de Artes. El estudio fue de tipo exploratorio y descriptivo, analizó el conocimiento implícito y explícito de los docentes mediante la aplicación de una encuesta estructurada y entrevistas realizadas a los docentes. La muestra estuvo conformada por 22 docentes de una universidad colombiana. Se encontró que existe un potencial de interacción entre los integrantes del equipo que puede ser explorado en el desarrollo de proyectos, para lo cual es necesario enfocar la visión y generar espacios para la construcción colectiva de proyectos desde una perspectiva sistémica

Objective: To describe the incidence of bacteremia in a large multicentric cohort of patients with systemic lupus erythematosus (SLE) and their clinical characteristics and to identify risk factors. Methods: All bacteremic episodes from the Spanish RELESSER registry were included. Clinical and laboratory characteristics concerning bacteremia and SLE status, as well as comorbidities at the time of infection, were retrospectively collected. A comparison with sex- and age-matched SLE controls without bacteremia was made. A logistic regression was conducted. Results: The study included 114 episodes of bacteremia in 83 patients. The incidence rate was 2.7/1000 patient-years. At the time of bacteremia, the median age was 40.5 (range: 8-90) years, and 88.6% of patients were female. The Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index was 4 [interquartile range (IQR) 8]; 41% had an SLE flare (66% severe); Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index was 3 (IQR 4). A comorbidity was recorded in 64% of cases. At the time of bacteremia, 88.6% received corticosteroids (68.6% > 10 mg/day) and 57% immunosuppressors. Gram-negative bacilli, most frequently Escherichia coli (29.8%), caused 52.6% of the episodes. The bacteremia-related mortality was 14% and bacteremia was recurrent in 27.2% of cases. A dose-response relationship was found between corticosteroids and bacteremia risk. In the multivariate analysis, these factors were associated with bacteremia: elevated creatinine (OR 1.31, 95% CI 1.01-1.70; p = 0.045), diabetes (OR 6.01, 95% CI 2.26-15.95; p < 0.001), cancer (OR 5.32, 95% CI 2.23-12.70; p < 0.001), immunosuppressors (OR 6.35, 95% CI 3.42-11.77; p < 0.001), and damage (OR 1.65, 95% CI 1.31-2.09; p < 0.001). Conclusion: Bacteremia occurred mostly in patients with active SLE and was frequently associated with severe flares and corticosteroid use. Recurrence and mortality were high. Immunosuppressors, comorbidities, and disease-related damage were associated with bacteremia. This work was supported by the Spanish Foundation of Rheumatology. JMPR is supported by grant 316265 (BIOCAPS) from the European Union 7th Framework Programme (FP7/ REGPOT-2012-2013.1) and FIS/ISCIII-Fondo Europeo de Desarrollo regional (FEDER) (Grant number PI11/02857).

Fracture Liaison Service (FLS) model for secondary prevention of fractures has demonstrated its cost-effectiveness using decision models. We analyze the impact of a FLS on pharmaceutical expenditures for osteoporosis (OP) in real-world circumstances.Expenditures on OP medications from January 2011 to January 2017 were compiled. Pharmaceutical expenditures in the southern area of Gran Canaria were used as a control group to measure the impact of implementing an FLS in the northern area. We estimated generalized least squares regressions with interrupted time-series analysis where two interventions were considered: March 2012 (implementation of the FLS) and March 2016 (incorporation of nursing staff for inpatients with hip fracture).The northern area incurred greater expenditures for group I and II drugs. The difference in bisphosphonates expenditures between areas varied from 10.5% higher in the northern area pre-FLS to 11.2% post-FLS and 18.3% since March 2016. However, interrupted time series models do not find a significant impact of implementation of FLS on the pharmaceutical expenditures for either drug group.The implantation of an FLS did not lead to an increase in pharmaceutical expenditures for OP over the 5-year period compared to the standard care provided for secondary fracture preventions.

Objectives To develop recommendations for the management of methotrexate (MTX) in psoriatic arthritis (PsA), based on best evidence and experience. Methods A group of 12 experts on MTX use was selected. The coordinators formulated 14 questions about the use of MTX in PsA patients (indications, efficacy, safety and cost-effectiveness). A systematic review was conducted to answer the questions. Using this information, inclusion and exclusion criteria were established, as were the search strategies (Medline, EMBASE and the Cochrane Library were searched). Two different reviewers selected the articles. Evidence tables were created. At the same time, European League Against Rheumatism and American College of Rheumatology abstracts were evaluated. Based on this evidence, the coordinators proposed 12 preliminary recommendations that the experts discussed and voted on in a nominal group meeting. The level of evidence and grade of recommendation were established using the Oxford Center for Evidence Based Medicine and the level of agreement with the Delphi technique (two rounds). Agreement was established if at least 80% of the experts voted yes (yes/no). Results A total of 12 preliminary recommendations on the use of MTX were proposed, 9 of which were accepted. One was included in a different recommendation and other two were not voted on and were thereafter clarified in the main text. Conclusions These recommendations aim to answer frequent questions and help in decision making strategies when treating PsA patients with MTX.

To describe variability in the prescription of biologics (B-DMARDs) for patients with rheumatoid arthritis (RA) in hospitals in Spain, and to explore which characteristics of the patient, the doctor and the hospital are associated with this variability. Cross-sectional multicentric study in 46 rheumatology services of the National Health System. Medical records of 1188 randomly selected patients were reviewed. The association of each variable with B-DMARD prescription was analyzed using simple logistic regressions. Multilevel logistic regression models were created to analyze variability among centers. 36.8% of patients had received B-DMARD. The proportion of patients being treated with B-DMARDs varied between 3.6 and 71.4% depending on the center. Association of prescription of B-DMARD with patient age (OR = 0.958, 95% CI = 0.947-0.968, p

Resumen Introduccion y objetivos La calidad de la colonoscopia es clave para asegurar la prevencion del adenocarcinoma colorrectal (ACCR), aunque el riesgo de ACCR existe. Los objetivos del estudio fueron investigar la incidencia, las caracteristicas y los factores predictores de ACCR poscolonoscopia (ACCRPC). Material y metodo Estudio observacional retrospectivo y prospectivo sobre una poblacion sometida a colonoscopia entre 1-01-1997 y 31-12-2014. Se analizaron variables demograficas, caracteristicas de la colonoscopia diagnostica de ACCR, de las previas y de las lesiones encontradas en ellas. Se aplicaron test de contraste de hipotesis para comparar el grupo de ACCRPC con el de ACCR sin colonoscopia previa y regresion logistica multiple para identificar factores independientes de ACCRPC (SPSS ® 15), considerando significacion estadistica una p Resultados Se registraron 56.984 colonoscopias, 1.977 ACCR y 132 pacientes (edad media de 70,8 anos y 56,8% varones) con al menos una colonoscopia en los 10 anos previos (ACCRPC). El 70,5% de las colonoscopias previas fueron completas y el 63,7% tenian una preparacion adecuada. Los factores de riesgo independientes relacionados con la aparicion de ACCRPC fueron los antecedentes personales de polipos colonicos (OR 35,01; IC 95% 11,1-110,8; p Conclusiones La tasa de ACCRPC a 10 anos fue del 6,7%. Realizar un adecuado seguimiento y una colonoscopia de calidad puede evitar la aparicion del ACCRPC, especialmente en los pacientes con factores de riesgo.

A high quality colonoscopy is key in preventing colorectal cancer, but the risk of colorectal cancer (CRC) exists. The aims of the study were to investigate the incidence, characteristics and predictive factors of post-colonoscopy colorectal cancer (PCCRC).A retrospective and prospective observational study was designed. A population undergoing colonoscopy between 1-01-1997 and 31-12-2014 was included. We analysed demographic variables, characteristics of the diagnostic colonoscopy of CRC, of the previous ones and the lesions found in them. To compare the PCCRC group versus the CRC group without previous colonoscopy, the Student's t-test and multiple logistic regression were used to determine predictive factors of PCCRC (SPSSA total of 56,984 colonoscopies, 1,977 CRC and 132 patients (mean 70.8 years old, 56.8% male) with at least one colonoscopy in 10 years before were registered (PCCRC). Seventy and a half percent of the previous colonoscopies were completed and 63.7% had an adequate bowel preparation. Predictive factors of PCCRC were personal history of polyps (OR 35.01; 95% CI 11.1-110.8; P.001), previous CRC (OR 176.64; 95% CI 51.5-606.1); P.001), family history of CRC (OR 3.14; 95% CI 1.5-6.4); P=.002) and proximal CRC (OR 3.15; 95% CI 2.1-4.9; P.001).PCCRC rate in 10 years was 6.7%. An adequate follow-up and a high-quality colonoscopy could prevent PCCRC, especially in patients with risk factors.

Resumen Objetivos Determinar el porcentaje de perdida de masa osea y el riesgo de fractura inducido por la terapia de deprivacion androgenica en pacientes con cancer de prostata. Material y metodos Estudio prospectivo en 2 fases. En la primera se recogieron variables demograficas, FRAX ® , densidad mineral osea y fracturas clinicas antes de iniciar la terapia y hasta un ano despues de finalizada. En la segunda se realizo una entrevista telefonica una media de 8,5 anos despues del inicio del estudio para evaluar nuevas fracturas. Resultados Se incluyeron 150 pacientes con una edad media de 67 anos y duracion media de la terapia de 24 meses. Antes del inicio del tratamiento 62 pacientes (41%) presentaban osteoporosis o baja masa osea en la densitometria. Despues del primer ano de tratamiento la densidad mineral osea descendio una media de 3,7% y 2,1% en la columna lumbar y el cuello femoral, respectivamente. Al final del segundo y tercer ano el porcentaje de perdida fue menor. Durante la primera fase del estudio 4 pacientes (2,7%) sufrieron una fractura. En la entrevista telefonica a 80 pacientes (53%) solo uno habia sufrido una fractura. Conclusiones En los pacientes con cancer de prostata y terapia de deprivacion androgenica la mayor perdida osea se produce durante el primer ano. Cuando el tratamiento no supera los 2 anos el riesgo absoluto de fractura es bajo, y la fractura clinica infrecuente a corto y a largo plazo.

To analyze the influence of tobacco smoking on systemic lupus erythematosus (SLE) clinical features and damage. Cross-sectional and retrospective, case-control study comparing SLE patients with and without tobacco exposure. Cumulative clinical data and comorbidities were collected, and severity (Katz index) and damage (SLICC/ACR damage index) (SDI) indices were calculated. Pack-years (PY) was used to estimate lifetime tobacco exposure. A logistic regression was carried out to explore the impact of tobacco use on retinal damage. 216 patients were included. The mean age was 49 years (± 12.7), 93% were females, and median disease duration was 17 years [interquartile range (IQR):9-25]. Fifty-three percent of patients were smokers at some point. The median PY was 13 (IQR: 6-20.5). Only 54.8% of active smokers recalled having been informed of the negative effects of smoking, versus 83.3% of never smokers ( 0.001). In a bivariant analysis, an association between tobacco use at any time and discoid lupus [OR: 3.5(95%CI 1.5-8.9); p = 0.002] photosensitivity [OR: 2.06(95%CI 1.16-3.7); p = 0.01] and peripheral arteriopathy (p = 0.007) was found. Considering SDI item by item, a significant association with retinal damage, adjusted for age [OR: 1.03(95%CI 1-1.07); p = 0.04], was found. Using PYs, an association was found with discoid lupus (p = 0.01), photosensitivity (p = 0.03) and peripheral arteriopathy (p = 0.01), global SDI 0 (p = 0.002) and retinal damage (p = 0.02). In a multivariate analysis exploring factors associated with retinal damage, any previous smoking history and SDI remained associated with retinal damage. Tobacco smoking is associated with cutaneous manifestations and damage and is an independent predictor of retinal damage in SLE patients.

Background Secondary prevention of osteoporotic fracture is more efficient with the Fracture Liaison Service (FLS) model. Objectives To describe the characteristics of male patients attended in a FLS Methods Prospective observational study. The program consists of: 1) recruitment from the emergency records, hip fracture admitted or referral to outpatient rheumatology; 3) baseline visit: questionnaire including demographCI variables, FRAX and previous treatments; 4) DXA; 5) patient education; 6) report of results to the patient and the PC doctor, with specifCI management recommendations; complex patients are referred to rheumatology; and 7) follow-up through telephone survey plus prescription check in electronCI records. The characteristCIs of male patients are described and compared with women. Results 2,135 patients have been included, 382 male (18%). The recruitment was in 300 cases (78%) from the emergency list, in 55 cases (14%) admission for hip fracture and in 25 cases (6%) from outpatient clinCI. The characteristCIs of the patients are shown in the table. The average age was similar in men and women. Hip fracture was more frequent in men (34% vs. 25%, OR 1.63 CI 95% 1.50-1.75) as opposed to forearm fracture (18% vs. 33%, OR 0.46 CI 95% 0.32-0.60). Male had previous DXA (6% vs 25%, OR 0.22 CI 95% 0.00-0.43) and previous treatment with bisphosphonate (4% vs 19%, OR 0.17 CI 95% 0, 0-0.44) less frequently. Of the variables included in the FRAX, in men was less frequent the previous fracture (13% vs 24%, OR 0.48 CI 95% 0.32-0.64), the hip fracture of the parents (9% vs. 13%; OR 0.66 CI 95% 0.47-0.85) and the use of corticoids (6% vs 10%, OR 0.61 CI 95% 0.39-0.84). However, active smoking was more frequent in men (21% vs 14%, OR 1.67 CI 95% 1.53-1.81) as well as consumption >2 daily units of alcohol (18% vs 5%; OR 3.96 CI 95% 3.78-4.13). The percentage of osteoporosis was lower in men compared to women (30% vs 46%, OR 0.49 CI 95% 0.30-0.68) as well as the percentage of patients with >1 fall in the last year (29% vs 45%, OR 0.51 CI 95% 0.30-0.71). In addition, after the visit to the FLS, a bisphosphonate was indicated less frequently to men than to women (68% vs. 77%, OR 0.64 CI 95% 0.51-0.76) and were referred less frequently to PC (64% vs. 76%; OR 0.55 95% CI 0.41-0.70). Finally, persistence at 12 months was lower in men than in women (53% vs. 68%, OR 0.53 CI 95% 0.30-0.76). Conclusion Compared with women, men seen in an FLS present hip fracture more frequently and a forearm fracture less frequently. Men also have a lower frequency of personal and family history of fracture and a greater frequency of smoking and alcohol intake. The percentage of patients who are candidates for treatment and persistence is lower than in women. These data should be taken into account in the identification and treatment of fragility fracture in men. Acknowledgement Fabiola Santana and Carmen Alonso Disclosure of Interests Antonio Naranjo Grant/research support from: Amgen, Consultant for: UCB, Speakers bureau: Amgen, UCB, Soledad Ojeda Grant/research support from: AMGEN, Speakers bureau: AMGEN, Aida Saavedra: None declared, Cristina Sepulveda: None declared, Francisco Rubino: None declared, Amparo Molina Speakers bureau: AMGEN, Olga Suarez: None declared, Casimira Dominguez: None declared, Jose A. Lorenzo: None declared, Nieves Martin: None declared, Carlos Rodriguez-Lozano: None declared

Background: Streptococcus pneumoniae (SPN) is an encapsulated gram-positive bacterium that can be found in the nasopharynx as part of the normal flora. However, is the most common cause of community-acquired pneumonia in adults and can also cause invasive diseases such as bacteremia, meningitis, and otitis media. Pneumococcal cellulitis and fasciitis are uncommon. Several factors are associated with a predisposition to infections in patients with Systemic Lupus Erythematosus (SLE). Objectives: To describe and analyze all documented cases of cellulitis or fasciitis caused by SPN in SLE patients. Methods: In the framework of the study of a 24-years-old woman that during the SLE onset presented left tight cellulitis and fasciitis caused by SPN, a systematic review was conducted (until September 2018). The search included terms to identify any SPN infection in SLE patients and all those articles that reported cellulitis or fasciitis were selected (Table 1). Results: A total of 313 articles were obtained. Eight of them (1-8) and 1 article identified in a manual search (9) described a total of 15 cases presenting SLE and cellulitis or necrotizing fasciitis caused by SPN; our case is the 16th described. Documented infections (n=16): – Cellulitis (n=8): neck, face or chest (n=5, 62.5%); extremities (foot or hand) (n=2, 25%); breast (n=1, 12.5%). – Fasciitis (n=8): neck, face ot chest (n=5, 62.5%); tights (n=3, 37.5%). Description of the documented cases: – Demographic characteristics (n=13): female sex (n=11, 85%); – Time of SLE evolution at the moment of the infection (n=9): ≤ 1 month (n=3, 33.3%); ≤ 3 years (n=3, 33.3%); ≤ 8 years (n=3, 33.3%). – Associated conditions (n=12): previous high doses of prednisone (n=5, 45%); recent respiratory sympthoms (n=4, 33.3%); renal insufficiency (n=2, 16.6%); previous SPN infections (n=1, 8.3%); recent surgery in the affected area (n=1, 8.3%). – Microbiological diagnosis (n=12): blood cultures (n=11, 91.6%); other cultures (n=5, 41.6%). – Treatment (n=12): beta–lactams (n=12, 100%); intensive care support (n=6, 50%); surgical debridment (n=5, 41%). – Outcome (n=15): death (n=3, 20%); reccurrent SPN infections (n=2, 13.3%). Conclusion: – Pneumococcal cellulitis and fasciitis in SLE were predominantly presented in young women and in a high rate of cases during the disease onset. – Almost half of the cases were previously treated with high doses of steroids. Nevertheless, no other potential predictors of pneumococcal cellulitis or fasciitis were identified; in addition, only one patient presented a previous surgery in the affected anatomical area, previous trauma were not described in any case, and a low number of cases reported associated respiratory symptoms. This supports the importance of the intrinsic immune dysregulation in SLE patients. – Pneumococcal cellulitis and fasciitis in SLE patients present poor prognosis, requiring intensive care support and surgical debridement in a high rate of cases, and presenting a fatal outcome in a fifth of them. References [1] DiNubile; 1991. [2] Hill; 1997. [3] Isik; 2007. [4] McDonald; 1993. [5] Page; 2003. [6] Patel; 1994. [7] Sabio; 2006. [8] Sanchez; 2016. [9] Kamran; 2008. Disclosure of Interests: Martin Greco: None declared, Inigo Rua-Figueroa: None declared, Antonio Naranjo Grant/research support from: Amgen, Consultant for: UCB, Speakers bureau: Amgen, UCB, Sabrina Ghiglione: None declared, Maria Celia Erausquin: None declared, Juan Carlos Quevedo-Abeledo: None declared, Carlos Rodriguez-Lozano: None declared, Cristina Almeida: None declared, Paola Leon: None declared, Estibaliz Loza Grant/research support from: Roche, MSD, Pfizer, Abbvie, BMS, UCB, Actelion, Celgene, Grunenthal and Sanofi

Background Rheumatoid arthritis (RA) is a risk factor for the development of fragility fractures, but there is little quality data on its prevalence. Conversely, osteoporosis is one of the most frequent comorbidities of RA. Objectives To determine the prevalence of vertebral fractures in postmenopausal women with RA and to analyse their characteristics and associated risk factors. Methods We included 346 postmenopausal women diagnosed with RA according to the ACR/EULAR 2010 criteria in 19 Spanish Rheumatology Departments, randomly selected from the registry of RA patients in each center, recruited during 2018. Lateral radiographs of the dorsal and lumbar spine were obtained from all patients, to evaluate morphometric vertebral fractures. Expert rheumatologists identified vertebral fractures and classified them into mild (grade 1: reduction of height of 20-25%), moderate (grade 2: reduction of 26-40%) and severe (grade 3: reduction > 40%), according to the Genant grading scale. The spinal deformity index (SDI) was calculated by assigning numbers 1, 2 and 3 to each fractured vertebra and adding the total score of each patient. The study variables were: a) age, body mass index (BMI), b) factors related to RA: time of evolution, FR, ACPA, and c) fracture risk factors: prior fragility fracture, parental hip fracture, glucocorticoids, smoking, alcohol intake ≥3 units daily, secondary osteoporosis and time since menopause. Results The mean age was 66.8 (SD: 10.1) years and the median evolution of the disease, 8.00 [RIQ: 3.00-15.5] years. 77.2% (n: 267) and 75.7% (n: 252) had FR and ACPA +, respectively. The mean duration of the postmenopausal period was 15.0 (SD: 9.6) years. 23.4% (n: 79) of patients had at least one vertebral fracture; 10.7% (n: 36) had a single fracture and 12.7% (n: 43), multiple fractures. The most fractured vertebrae were D12, L1 and L2 (fractured in > 5% of patients). The median SDI was 3 [RIQ: 2-5]. The vertebrae with the highest mean IDE were D8, D10, D11 and L1 (all mean IDE ≥ 2).An association was found between the presence of vertebral fractures and age, height, postmenopausal period, time of disease progression, glucocorticoid treatment and parental hip. No linear association was found between SDI and age, time of evolution of the disease, BMI and time since menopause. Conclusion One out of every 4 postmenopausal women with RA has at least one vertebral fracture. Vertebrae of the dorso-lumbar hinge are the most frequently involved and the magnitude of the spinal deformity is relevant. Vertebral fractures are related to the time of evolution of RA and to the risk factors for fracture. Disclosure of Interests Carmen Gomez Vaquero: None declared, Dacia Cerda: None declared, Cristina Hidalgo: None declared, JA Martinez Lopez: None declared, Luis Marcelino Arboleya Rodriguez: None declared, Javier Aguilar del Rey: None declared, Silvia Martinez Pardo: None declared, Inmaculada Ros: None declared, Xavier Suris Speakers bureau: Lilly, Pfizer, MSD, Dolors Grados: None declared, Chesus Beltran: None declared, Evelyn Suero-Rosario: None declared, Inmaculada Gomez Gracia: None declared, Asuncion Salmoral: None declared, Irene Martin-Esteve: None declared, Helena Florez: None declared, Antonio Naranjo: None declared, Santos Castaneda Consultant for: Amgen, BMS, Pfizer, Lilly, MSD, Roche, Sanofi, UCB, Soledad Ojeda Grant/research support from: AMGEN, Speakers bureau: AMGEN, S Garcia Carazo: None declared, Alberto Garcia-Vadillo: None declared, Laura Lopez Vives: None declared, A Martinez-Ferrer: None declared, Helena Borrell: None declared, Pilar Aguado: None declared, Raul Castellanos-Moreira Speakers bureau: MSD, Lilly, Nuria Guanabens Consultant for: Advisory Boards from Amgen, Alexion and UCB, Speakers bureau: Fees and lectures from Eli Lilly

Smoking is associated with a higher prevalence of many diseases. When a health professional is well informed of the risks of smoking in rheumatic diseases, the advice given to the patient about quitting smoking could be more effective. It is known that smokers in the general population have an increased frequency of elevated rheumatoid factor (RF). Since 1987, we have known that cigarette smoking is a risk factor for rheumatoid arthritis (RA), especially in men with RF-positive who are heavy smokers. Later, it could be verified that cigarette smoking is implicated in the pathogenesis of RA particularly when associated with antibodies, cyclic citrullinated peptides (ACPA) and the shared epitope. Smoking increases the risk of both subsets of RA with a more pronounced influence on the risk of ACPA positive RA. The polyclonal immune response against modified antigens in patients with RA is not exclusively citrulline-specific, carbamylation of antigens like vimentin could be involved in the pathogenesis of the disease. Thus, smoking is a risk factor for breaking tolerance to multiple autoantigens in RA. In RA patients, cigarette smoking correlated with an increased risk of joint erosions, extra-articular manifestations and cardiovascular disease, in addition to the established effects of longstanding disease activity on the risk of myocardial infarction and stroke. Systemic lupus erythematosus (SLE) is also associated with smoking. A strong and specific connection of current smoking and >10 pack-years of smoking with dsDNA+ SLE has been observed. In patients with SLE, smoking exposure has deleterious effects on lupus morbidity and is related to cumulative chronic damage. In mucocutaneous SLE, smoking have a negative impact on the efficacy of belimumab and a 2-fold decrease in the proportion of patients achieving cutaneous improvement with antimalarials. Published data indicate that smoking has a dose-dependent impact on structural damage progression in Ankylosing Spondylitis. In a large UK cohort, smoking was positively associated with the risk of psoriatic arthritis in the general population, but negatively associated among patients with psoriasis. In addition, smokers with psoriatic arthritis had a poorer response to TNFi”s compared to non-smokers. Regarding osteoporosis, smoking has been identified as a predictor of ten-year fracture risk in men and women, largely independent of the densitometric results. This finding has eventually lead to incorporation of this risk factor into FRAX®. The impact of smoking on bone status is mainly associated with the number of smoking years. In a few reports, it has been observed an association between smoking and carpal tunnel syndrome and inflammatory bowel disease. Finally, current smoking in patients with fibromyalgia is associated with greater pain, possibly as a function of depression. Disclosure of Interests: Antonio Naranjo Grant/research support from: Amgen, Consultant for: UCB, Speakers bureau: Amgen, UCB

Background The enigma of fragility fracture with normal bone mass; Experience of a Liaison Service Fracture Unit Objectives To describe the characteristics of patients with fragility fracture and normal DXA treated in an FLS unit. Methods Prospective 6-year observational study of a FLS fracture unit. Demographic variables, FRAX items, DXA and TBS were collected. The characteristics of patients with normal and abnormal DXA are described. The statistical analysis was performed by means of a descriptive, comparing the normal DXA/osteopenia/osteoporosis groups by means of contingency tables, Fisher’s exact test, Student’s t test or ANOVA, as appropriate, as well as regression analysis. Results 1,631 patients were included, 205 with normal DXA (12.5%), 747 with osteopenia (45.8%) and 680 with osteoporosis (41.6%). Patients with normal DXA were characterized by a higher percentage of males, a younger age and a higher BMI. Hip fracture was less frequent in patients with normal DXA, while the frequency of other fractures was higher. The frequency of previous fracture, history of hip fracture of the parents and secondary osteoporosis was lower in patients with normal DXA. The TBS and FRAX values were higher in the cases of normal DXA compared to osteopenia and osteoporosis. In the multiple regression analysis, excluding TBS, remained significant associated with abnormal DXA age (OR 1.04; 1.03-1.06), sex (OR 2.48; 1.71-3.58), BMI (OR 0.91; 0.89-0.94),) and parent hip fracture (OR 1.99; 1.11-3.58). Including TBS Conclusion Patients with fragility fracture and normal DXA are younger, with more frequent males and with BMI and higher TBS values. Acknowledgement Fabiola Santana y Carmen Alonso Disclosure of Interests Antonio Naranjo Grant/research support from: Amgen, Consultant for: UCB, Speakers bureau: Amgen, UCB, Soledad Ojeda Grant/research support from: AMGEN, Speakers bureau: AMGEN, Aida Saavedra: None declared, Cristina Sepulveda: None declared, Amparo Molina Speakers bureau: AMGEN, Tatiana Marrero: None declared, Maria Pino Afonso: None declared, Margarita Ramirez: None declared, Nieves Martin: None declared, Alicia Olivares: None declared, Carlos Rodriguez-Lozano: None declared

SummaryBackground Information on the safety of tumour necrosis factor (TNF) antagonists frequently arises from their use in rheumatic diseases, their first approved indications, and is later applied to psoriasis. Whether the risk of biological therapy is similar in psoriasis and rheumatoid arthritis has been considered a priority research question. Objectives To compare the safety profile of anti-TNF drugs in patients with rheumatoid arthritis and psoriasis. Methods We compared two prospective safety cohorts of patients with rheumatoid arthritis and psoriasis that share methods (BIOBADASER and BIOBADADERM). Results There were 1248 serious or mortal adverse events in 16 230 person-years of follow-up in the rheumatoid arthritis cohort (3171 patients), and 124 in the 2760 person-years of follow-up of the psoriasis cohort (946 patients). Serious and mortal adverse events were less common in patients with psoriasis than in rheumatoid arthritis (incidence rate ratio of serious adverse events in psoriasis/rheumatoid arthritis: 0·6, 95% confidence interval 0·5–0·7). This risk remained after adjustment for sex, age, treatment, disease, hypertension, diabetes, hypercholesterolaemia and simultaneous therapy with methotrexate (hazard ratio 0·54, 95% confidence interval 0·47–0·61), and after excluding patients receiving corticosteroids. Patients with rheumatoid arthritis showed a higher rate of infections, cardiac disorders, respiratory disorders and infusion-related reactions, whereas patients with psoriasis had more skin and subcutaneous tissue disorders and hepatobiliary disorders. Conclusions Patients with rheumatoid arthritis clinical practice have almost double the risk of serious adverse events compared with patients with psoriasis, with a different pattern of adverse events. Safety data from rheumatoid arthritis should not be fully extrapolated to psoriasis. These differences are likely to apply to other immune-mediated inflammatory diseases.

The aim of this study was to explore the variability in hospital admissions of patients with spondyloarthritis (SpA) in Spain, and the centre factors that may influence that variability. Descriptive cross-sectional study, part of the emAR II study, performed in Spain (2009-2010). Health records of patients with a diagnosis of SpA and at least one visit to the rheumatology units within the previous 2 years were reviewed. Variables related to hospital admissions, to the SpA, and to the patient and centre were collected. A multilevel logistic regression analysis of random intercept with non-random slopes was performed to assess variability between centres. From 45 centres, 1168 patients' health records were reviewed. Main SpA forms were ankylosing spondylitis (55.2 %) and psoriatic arthritis (22.2 %). A total of 248 admissions were registered for 196 patients (19.2 %, n = 1020). An adjusted variability of 17.6 % in hospitalizations between centres was noted. The following hospital-related factors showed a significant association with admissions: the total number of admissions of the centre, the existence of electronic admission, and the availability of ultrasound in rheumatology. However, these factors only explained 42.9 % of the inter-centre variability. The risk of a patient with SpA of being admitted could double (median OR 2.09), depending on the hospital where the patient was being managed. Hospital admissions of patients with SpA varied between hospitals due to centre characteristics. Further studies are needed to ascertain which specific factors may be causing the variation, as studied variables explained less than half of the variability.

Background:Incidence of clinical fractures in rheumatoid arthritis (RA) is not as well-known as hip or vertebral fracture incidence.Objectives:1. To estimate the incidence of clinical fragility fractures in a population of postmenopausal women diagnosed with RA and compare it with that of the general population; 2. To analyze the risk factors for fracture.Methods:330 postmenopausal women with RA from 19 Spanish Rheumatology Departments, randomly selected from the registry of RA patients in each center. The control group consisted of 660 Spanish postmenopausal women from the Camargo Cohort. Clinical fractures during the previous 5 years were recorded. Assessed risk factors for fracture were: sociodemographic characteristics, BMD and variables related to RA.Results:Median age of RA patients was 64 yrs. vs. 63 yrs. in controls (ns). Evolution of the disease was 8 yrs. 78% and 76% had RF and ACPA+, respectively. 69% of patients were in remission or low activity. 85% had received glucocorticoids and methotrexate and 40% at least one biological DMARD. We identified 105 fractures (87 fragility and 18 traumatic) in 75 patients. Fifty-four patients and 47 controls had at least one major fracture (MF) (p< 0.001). Incidence of MF was 3.55 per 100 patient-year in patients and 0.72 in controls. Risk factors for MF in RA patients were age, previous fracture, parental hip fracture, postmenopausal period, hip BMD and cumulative dose of glucocorticoids. In controls, risk factors were age, age at menopause and lumbar BMD.Among RA-associated factors, MFs were associated with erosions, disease activity and disability. Previous fracture in RA patients was a strong risk for MF (HR: 10.37 [95% CI: 2.95-36.41]).Conclusion:Between 3 and 4 of every 100 postmenopausal women with RA have a major fracture per year, four times more than the general population. Disease activity and disability associated with RA, the cumulative dose of glucocorticoids and mainly previous fracture are associated with the development of fragility fractures.References:NoneAcknowledgments:Funded in part by ISCIII (PI18/00762) that included FEDER funds from the EU.Disclosure of Interests:Carmen Gómez Vaquero: None declared, Jose Manuel Olmos: None declared, J. Luis Hernández: None declared, Dacia Cerda: None declared, Cristina Hidalgo: None declared, JA Martínez López: None declared, Luis Marcelino Arboleya Rodríguez: None declared, Javier Aguilar del Rey: None declared, Silvia Martinez Pardo: None declared, Inmaculada Ros: None declared, Xavier Surís: None declared, Dolors Grados Canovas: None declared, Chesús Beltrán Audera: None declared, Evelyn Suero-Rosario: None declared, Inmaculada Gómez Gracia: None declared, Asunción Salmoral: None declared, Irene Martín-Esteve: None declared, Helena Florez: None declared, Antonio Naranjo Grant/research support from: amgen, Consultant of: UCB, Speakers bureau: AMGEN, Santos Castañeda: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO, S García Carazo: None declared, Alberto García-Vadillo: None declared, Laura López Vives: None declared, À Martínez-Ferrer: None declared, Helena Borrell Paños: None declared, Pilar Aguado: None declared, Raul Castellanos-Moreira: None declared, Cristian Tebé: None declared, Núria Guañabens: None declared

OBJECTIVE: To identify biomarkers of articular and ocular disease activity in patients with Blau syndrome (BS). METHODS: Multiplex plasma protein arrays were performed in five BS patients and eight normal healthy volunteers (NHVs). Plasma S100A12 and S100A8/9 were subsequently measured by ELISA at baseline and 1-year follow-up in all patients from a prospective multicentre cohort study. CRP was measured using Meso Scale Discovery immunoassay. Active joint counts, standardization uveitis nomenclature for anterior uveitis cells and vitreous haze by Nussenblatt scale were the clinical parameters. RESULTS: Multiplex Luminex arrays identified S100A12 as the most significantly elevated protein in five selected BS vs eight NHVs and this was confirmed by ELISA on additional samples from the same five BS patients. In the patient cohort, S100A12 (n = 39) and S100A8/9 (n = 33) were significantly higher compared with NHVs (n = 44 for S100A12, n = 40 for S100A8/9) (P = 0.0000004 and P = 0.0003, respectively). Positive correlations between active joint counts and S100 levels were significant for S100A12 (P = 0.0008) and S100A8/9 (P = 0.015). CRP levels did not correlate with active joint count. Subgroup analysis showed significant association of S100 proteins with active arthritis (S100A12 P = 0.01, S100A8/9 P = 0.008). Active uveitis was not associated with increased S100 levels. CONCLUSION: S100 proteins are biomarkers of articular disease activity in BS and potential outcome measures in future clinical trials. As secreted neutrophil and macrophage products, S100 proteins may reflect the burden of granulomatous tissue in BS.

Resumen En los ultimos anos, la ensenanza universitaria ha experimentado un profundo cambio como consecuencia de la creacion del Espacio Europeo de Educacion Superior. Se ha pasado de un modelo centrado en el profesor, basado en la transmision de conocimientos a traves de las clases magistrales, a otro centrado en el alumno, basado en la adquisicion de competencias y que otorga gran importancia al aprendizaje autonomo. Esta transformacion comporta la necesidad de reorganizar la actividad academica y de emplear nuevas herramientas docentes, como las metodologias activas de aprendizaje, mas acordes con las exigencias actuales. En este articulo se exponen los ejes vertebradores del Espacio Europeo de Educacion Superior y se describen diversas experiencias de innovacion docente en el marco de Reumacademia y de 3 universidades espanolas.

In recent years, university education has undergone profound changes as a result of the creation of the European Space for Higher Education. It has gone from a teacher-centred model, based on the transmission of knowledge through lectures, to being student-centred, based on the acquisition of skills and attaching great importance to independent learning. This transformation involves the need to reorganise academic activity and employ new teaching tools, such as active learning methodologies, more in line with current requirements. In this article, the backbones of the European Space for Higher Education are presented, and diverse experiences of teaching innovation described under Reumacademia and from three Spanish universities.

A fracture liaison service in Spain is able to maintain 73 % of the patients on antiresorptive 2 years after the fracture. The purpose of this study was to evaluate the 2-year effectiveness of a program for the secondary prevention of fractures. Fragility fractures in patients over 50 attending the emergency room in our centre are captured by the recruitment system of a secondary prevention program. The unit is attended by a nurse, coordinated by two rheumatologists and with the collaboration of primary care consisted of a training program and annual meetings. The outcome of the program was analysed 2 years after implementation, including: (1) percentage of attendees/eligible; (2) percentage of attendees who start treatment with antiresorptive; (3) percentage of patients who retain treatment after 6, 12, 18 and 24 months; and (4) factors associated to adherence. After 2 years of implementation, the program detected 1674 patients with fracture, of whom 759 finally entered the program (57 % of eligible). After 3 months, 82 % of patients prescribed an antiresorptive started treatment. After a year, 52 % of the patients in the program, 72 % of those of a prescribed treatment, were taking antiresorptives. Adherence at 24 months among those who had prescribed anti-fracture drugs was 73 %. Factors associated with adherence at 12 months were female sex (76 vs 45 %; p = 0.01) and previous treatment with antiresorptive (86 vs 68 %; p = 0.02). In Spain, a program designed to prevent secondary fragility fractures based on the collaboration between primary care and rheumatology seems effective in terms of recruitment of patients and adherence to treatment in the mid/long-term.

Objective: To describe the variability in the prescription of non-biologic disease-modifying antirheumatic drugs (nbDMARDs) for the treatment of spondyloarthritis (SpA) in Spain and to explore which factors relating to the disease, patient, physician, and/or center contribute to these variations. Methods: A retrospective medical record review was performed using a probabilistic sample of 1168 patients with SpA from 45 centers distributed in 15/19 regions in Spain. The sociodemographic and clinical features and the use of drugs were recorded following a standardized protocol. Logistic regression, with nbDMARDs prescriptions as the dependent variable, was used for bivariable analysis. A multilevel logistic regression model was used to study variability. Results: The probability of receiving an nbDMARD was higher in female patients [OR ¼ 1.548; 95% confidence interval (CI): 1.208–1.984], in those with elevated C-reactive protein (OR ¼ 1.039; 95% CI: 1.012–1.066) and erythrocyte sedimentation rate (OR ¼ 1.012; 95% CI: 1.003–1.021), in those with a higher number of affected peripheral joints (OR ¼ 12.921; 95% CI: 2.911–57.347), and in patients with extra-articular manifestations like dactylitis (OR ¼ 2.997; 95% CI: 1.868–4.809), psoriasis (OR ¼ 2.601; 95% CI: 1.870–3.617), and enthesitis (OR ¼ 1.717; 95% CI: 1.224–2.410). There was a marked variability in the prescription of nbDMARDs for SpA patients, depending on the center (14.3%; variance 0.549; standard error 0.161; median odds ratio 2.366; p o 0.001). After adjusting for patient and center variables, this variability fell to 3.8%. Conclusion: A number of factors affecting variability in clinical practice, and which are independent of disease characteristics, are associated with the probability of SpA patients receiving nbDMARDs in Spain.

espanolObjetivos: El objetivo del estudio fue analizar el empleo de bisfosfonatos en mujeres con artritis reumatoide (AR) de las Islas Canarias. Material y metodos: Estudio observacional multicentrico en el que se incluyeron mujeres con una edad igual o superior a 50 anos. En una unica visita se recogieron variables demograficas y de la AR, antecedente de fractura por fragilidad, uso de corticoides, realizacion de densitometria osea (DXA) y tratamiento actual con bisfosfonatos. Se empleo una herramienta FRAX® simplificada y se aplico la recomendacion de profilaxis de osteoporosis por corticoides del American College of Rheumatology (ACR). Resultados: Se incluyeron 192 mujeres con edad promedio de 62 anos. Un total de 91 (48%) pacientes recibian corticoides; 17 de ellas (9%) habian sufrido fractura; a 123 se les habia realizado DXA (66%); y 52 (28%) tomaban bisfosfonatos (el 70% de las pacientes con osteoporosis o fractura y el 45% de aque- llas con criterios de profilaxis de osteoporosis por corticoides). Los factores asociados de manera significativa con el empleo de bisfosfonatos fueron la edad, la duracion de la enfermedad, el cuestionario de capacidad funcional HAQ, el riesgo de fractura determinado por FRAX®, el tratamiento con corticoides, el antecedente de fractura y la realizacion previa de DXA. En el estudio multivariante solo se asociaron de manera significativa la DXA (p=0,03) y el antecedente de fractura (p=0,02). Conclusiones: En las mujeres postmenopausicas con AR de las Islas Canarias la prescripcion de bisfosfonatos podria adecuarse mejor a las guias, especialmente en pacientes que reciben tratamiento con corticoides. EnglishObjective: The objective of this study was to analyse the use of bisphosphonates in women with rheumatoid arthritis (RA) in the Canary Islands. Material and methods: This multicentre observational study included women aged 50 years or over. At a single visit, demographic variables and those relating to the RA, history of fragility fractures, use of corticoids, performance of bone densitometry (DXA) and current treatment with bisphosphonates were recorded. The simplified FRAX ® tool was used and the recommendations of the American College of Rheumatology (ACR) for the prophylaxis of osteoporosis with corticoids were applied. Results: 192 women were included, with an average age of 62 years. A total of 91 (48%) patients were receiving corticoids; 17 of these (9%) had suffered a fracture; 123 (66%) had had a DXA; and 52 (28%) were taking bisphosphonates (70% of the patients with osteoporosis or fracture and 45% of those with criteria for prophylactic use of corticoids for osteoporosis). Those factors having a significant association with the use of bisphosphonates were age, duration of the disease, the HAQ functional capacity questionnaire, the risk of fracture determined by FRAX®, treatment with corticoids, history of fracture and the previous performance of DXA. In the multivariate study only the DXA (p=0.03) and history of fracture (p=0.02) were significantly associated. Conclusions: In postmenopausal women from the Canary Islands with RA the prescription of bisphosphonates could conform better to the guidelines, especially in patients receiving treatment with corticoids.

An observational study was carried out in two hospitals in patients > 65 years admitted for hip fracture. At 6 months, 15% of patients in the hospital with orthogeriatric standard care and 75% in the hospital with fracture liaison service were receiving bisphosphonates. Many patients with fractures are discharged without preventive therapy against further fractures. We sought to compare the effectiveness of an orthogeriatric fracture liaison service (FLS), outpatient FLS, and the standard care after hip fractures in prevention of future fractures. An observational study was carried out in two hospitals in patients > 65 years of age, admitted between March and July 2016 for fractures. The Candelaria hospital (HUNSC) has no specific protocol for secondary prevention, while at the Negrin Hospital (HUGCDN), an FLS nurse visits the inpatients, gathers metabolic history, instructs regarding the diet, exercises, and fall prevention, and completes a discharge report regarding osteoporosis treatment. The prescription rate of osteoporosis treatment was analyzed at admission, discharge, and 6 months after discharge. We also analyzed the data of patients with hip fractures who attended the outpatient FLS before March 2016. We included a total of 185 inpatients with a mean age of 82 years and 73% were women. At admission, 8% of the patients in HUNSC and 10% in HUGCDN were receiving bisphosphonates. At discharge, the percentages were 8 and 96%, while at 6 months they were 15 and 75%, respectively (p

Resumen Objetivo Evaluar la influencia de la implantacion de un programa para la prevencion secundaria de fracturas osteoporoticas sobre la prescripcion de bisfosfonatos y la persistencia del tratamiento a corto plazo. Pacientes y metodos Se incluyeron pacientes con fractura por fragilidad > 50 anos atendidos en el servicio de urgencias durante un ano. El programa consistio en: 1) plan de formacion en osteoporosis de los medicos de primaria; 2) densitometria osea; 3) cuestionario relativo a osteoporosis y educacion del paciente por la enfermera; 4) derivacion al medico de primaria o, en caso de multiples fracturas o precisar terapia parenteral, a consulta hospitalaria; y 5) seguimiento y comprobacion de inicio del tratamiento prescrito a traves de los registros electronicos y encuesta telefonica. La variable principal de desenlace fue el porcentaje de pacientes que, habiendose prescrito un bisfosfonato, cumple el tratamiento a los 3 meses. Resultados De 532 pacientes con criterios de inclusion, 202 (38%) no aceptaron participar. Comparados con los pacientes que participaron, los que rechazaron tenian una edad promedio mayor (p Conclusiones El programa de prevencion secundaria de fracturas coordinado por reumatologia consigue que el numero de pacientes que inicia bisfosfonato se multiplique por 4 en comparacion con la visita basal.

Objective.To determine the incidence of pneumonia and associated factors in a single-center systemic lupus erythematosus (SLE) cohort.Methods.We included all our SLE patients [1997 American College of Rheumatology (ACR) criteria] with ≥ 1 pneumonia event, and 196 age and sex-matched SLE controls with no pneumonia events. Cumulative clinical data, weighted Systemic Lupus International Collaborating Clinics/ACR damage index (wSLICC/ACR-DI), comorbidities, and risk factors for pneumonia were retrospectively collected. The standardized incidence ratio (SIR) of pneumonia was estimated. Polymorphisms at genes coding for mannose binding lectin (MBL), MBL-associated serine protease 2, Fc-gamma receptors, and surfactant proteins A1, A2, and D were determined, and their potential association with pneumonia was analyzed. Patients with and without pneumonia were compared using a multivariate logistic regression model for adjustment of pneumonia-associated factors.Results.Thirty-six of 232 patients with SLE had experienced ≥ 1 pneumonia event. SIR for pneumonia was 5.1 (95% CI 3.5–7.4; p < 0.0001). Excluding patients receiving immunosuppressive therapy at the time of pneumonia (13%), associations were found for Katz Severity Index (KSI) (p = 0.016), wSLICC/ACR-DI (p = 0.044), number of SLE criteria (p = 0.005), hospital admissions (p < 0.001), FCGR2A HH genotype (p = 0.03), previous use of immunosuppressive therapy (p = 0.049), cutaneous ulcers (p < 0.001), and vasculitis (p = 0.008) in bivariate analyses. In the multivariate analysis adjusted to previous immunosuppressive treatment, only KSI and FCGR2A HH genotype remained statistically significant (p = 0.05 and p = 0.03, respectively).Conclusion.The incidence of pneumonia in patients with SLE is higher than that in the general population, and particularly high in severe SLE, regardless of immunosuppressive therapy. The HH genetic variant of FCGR2A appears to predispose patients with SLE to pneumonia.

The aim of this study was to analyze the longitudinal practice patterns of prophylaxis of glucocorticoid-induced osteoporosis in patients with polymyalgia rheumatica (PMR). Patients diagnosed with PMR were collected retrospectively in two rheumatology departments. In addition to demographic and diagnostic criteria, the chart review included the following information at baseline and at follow-up: doses of prednisone, prescription of calcium, vitamin D and bisphosphonates, bone mass measurement (BMD) and fragility fractures. We analyzed the percentage of patients undergoing BMD and were prescribed a bisphosphonate over the years. We evaluated 158 patients: 117 of them were women, mean age was 73 years, and they had an average follow-up of 4.8 years. 104 patients (66 %) received osteoporosis medication during the first visit, 44 of them were given bisphosphonate. During follow-up, another 30 treatments with bisphosphonate were added (46 % overall) while 37 cases (23 %) received no treatment with calcium or bisphosphonate. BMD was performed in 111 patients (69 %; 53 % of males and 76 % of females). Factors associated with the use of bisphosphonates were female sex (OR 4.4, 95 % CI 4.02-4.86), BMD (OR 2.4, 95 % CI 2.05-2.78) and commencement of treatment after the year 2005 (54 vs 37 %, OR 1.93, 95 % CI 1.60-2.26). No significant differences were found with age, initial doses of prednisone or the hospital. According to recent prevention guidelines, treatment with biphosphonate should have been administered in more than 90 % of patients. Although prophylaxis of glucocorticoid-induced osteoporosis in patients with PMR has increased in the recent years, many patients do not receive prophylaxis with bisphosphonate during the first visit.

Resumen Introduccion En los pacientes que han recibido resecciones gastricas parciales, las dificultades para realizar la colangiopancreatografia retrograda endoscopica (CPRE) se ven aumentadas debido a la alteracion anatomica regional. Objetivo Revisar la experiencia de la CPRE en pacientes con gastrectomia parcial y gastroenteroanastomosis (GE) tipo Billroth II o con otras GE (Billroth I e indeterminadas) en nuestro centro. Material y metodos Se incluyeron todos los pacientes con gastrectomia parcial y GE que recibieron CPRE en un periodo de 19 anos. Resultados Se incluyeron 233 pacientes (91% varones y 9% mujeres) desde 1993 a 2012. El 88,4% los pacientes presentaban gastrectomia con GE Billroth II y el 11,6% otras GE, siendo la tasa de exito de la CPRE del 51,9 y 55,6%, respectivamente. Las causas mas frecuentes de fracaso fueron en primer lugar la imposibilidad de canulacion (44%) y la no identificacion de la papila (39,6%). El 31,8% de los pacientes presento coledocolitiasis como diagnostico final. El numero medio de sesiones fue de 1,09. El porcentaje de complicaciones fue del 2,6%. Conclusiones El grado de dificultad tecnica influye en el exito de la CPRE, por este motivo, en nuestro centro, tuvo una tasa de exito algo superior al 50%, pero con un escaso numero de complicaciones.

Resumen Introduccion La dilatacion neumatica y la miotomia quirurgica son actualmente los tratamientos de eleccion de la acalasia sintomatica. La seleccion de una u otra como primera opcion depende de la experiencia de cada centro y de las preferencias del paciente. Objetivo Revisar la experiencia en nuestro centro de la dilatacion neumatica en pacientes con acalasia. Material y metodos Se incluyeron todos los pacientes con diagnostico clinico, endoscopico y manometrico compatible con acalasia a los que se les practico una dilatacion neumatica en un periodo de 19 anos. Todas las dilataciones se realizaron de forma sistematica con un balon Rigiflex ® , en la mayoria de los casos con presiones de 250, 250 y 300 mmHg en 3 tiempos de un minuto separados por un minuto de duracion. Se evaluo el exito de la dilatacion en funcion de la sintomatologia del paciente, numero de sesiones requeridas y necesidad de cirugia, asi como la presencia de complicaciones. Resultados Se incluyeron 171 pacientes, 53,2% varones y 46,8% mujeres, con una edad media de 51,53 ± 17,78 anos (16-87), desde junio de 1993 hasta octubre de 2012. En 157 pacientes se utilizo un balon de 35 mm, en 9 pacientes un balon de 30 mm y en 7 pacientes, uno de 40 mm. Del total de pacientes: 108 requirieron una sola sesion de dilatacion, 56 dos sesiones con un tiempo medio entre la primera y la segunda sesion de 25,23 ± 43,25 meses (1-215) y 7 pacientes, 3 sesiones con un tiempo medio entre la segunda y la tercera sesion de 6,86 ± 5,33 meses (1-15). El 82% de los pacientes presentaron una buena evolucion tras la dilatacion, considerandose esta exitosa. De los 140 pacientes que presentaron respuesta, 121 tuvieron respuesta completa (desaparicion total de los sintomas sin reaparicion de los mismos) y 19 respuesta parcial (desaparicion inicial de los sintomas con posterior reaparicion). Un 15,8% de los pacientes requirieron cirugia (miotomia de Heller). En 4 de los 171 pacientes hubo complicacion de la tecnica, siendo todas ellas perforaciones que se resolvieron satisfactoriamente, 2 de ellas con tratamiento conservador y otras 2 de forma quirurgica. No hubo ningun evento de mortalidad en relacion con la tecnica ni con las complicaciones de la misma. Conclusiones En nuestra serie, la dilatacion neumatica presento una alta tasa de exito, en la mayoria de los casos con una unica sesion, y un escaso porcentaje de complicaciones, por lo que demuestra ser una tecnica eficaz y segura para estos pacientes, evitando un gran numero de intervenciones quirurgicas.

Objective.To analyze sociodemographic and clinic-related factors associated with the use of orthopedic surgical procedures in rheumatoid arthritis (RA), focusing on the potential role of new biologic therapies.Methods.A retrospective medical record review was performed in a probability sample of 1272 patients with RA from 47 units distributed in 19 Spanish regions. Sociodemographic and clinical features, use of drugs, and arthritis-related joint surgeries were recorded following a standardized protocol.Results.A total of 94 patients (7.4%) underwent any orthopedic surgery during their disease course, with a total of 114 surgeries; 47 (41.2%) of these surgeries were total joint replacement (TJR). The median time to first orthopedic procedure was 7.9 years from the onset of RA symptoms, and the rate of orthopedic surgery (excluding TJR) was 4.5 procedures per 100 person-years from the beginning of RA, while the rate of TJR was 2.25 interventions per 100 person-years. A higher risk of undergoing an orthopedic surgical procedure was associated with taking nonsteroidal antiinflammatory drugs (NSAID) in the previous 2 years, female sex, longterm disease, and the presence of extraarticular complications. The risk factors for undergoing a TJR were being old, having a longterm disease, and taking biologic therapies.Conclusion.In the era of biologics, our national audit found a low percentage of patients who underwent orthopedic surgery, probably reflecting a thorough management of the RA. Sociodemographic factors, longterm RA, extraarticular complications, and NSAID were associated with orthopedic surgery.