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To develop a joint proposal for screening criteria of interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA) and vice versa, which serves as a guidelines in patient referral between the Rheumatology and Pneumology departments to early detection of these patients.A systematic literature review was carried out on the risk factors for the development of ILD in RA patients, and for the referral criteria to Rheumatology for suspected early RA. Based on the available evidence, screening criteria were agreed using the Delphi method by a panel of pneumologists and rheumatologists with expertise in these pathologies.Screening criteria for ILD in patients with RA and for the early detection of RA in cases with ILD of unknown etiology have been developed. In both cases, a detection strategy was based on clinical risk factors. Recommendations also included the complementary tests to be carried out in the different clinical scenarios and on the periodicity that screening should be repeated.A selective screening strategy is recommended for the first time in the early diagnosis of patients with ILD-RA. This multidisciplinary proposal aims to solve some common clinical questions and help decision-making, although its usefulness to identify these patients with good sensitivity must be confirmed in a validation study.

Resumen Objetivos Analizar el riesgo de fractura calculado por FRAX® y la frecuencia de alto riesgo de fractura en la poblacion general en Espana. Metodos EPISER2016 es un estudio transversal multicentrico de base poblacional de la prevalencia de las enfermedades reumaticas en poblacion adulta en Espana. Un total de 3.154 sujetos de edad igual o superior a 40 anos (1.184 hombres y 1.970 mujeres) se seleccionaron mediante muestreo aleatorio estratificado. Las preguntas relacionadas con los factores de riesgo de fractura se realizaron mediante encuesta telefonica. El riesgo de fractura principal (RFP) y de cadera (RFC) se calcularon con la version espanola de la herramienta FRAX®, sin la inclusion de la densidad mineral osea. Para definir alto riesgo de fractura, se utilizaron los umbrales RFP ≥ 20%, RFP ≥ 10%, RFP ≥ 7,5% y RFC ≥ 3%. Resultados La mediana (rango intercuartilico) del RFP fue 2,61% (1,55-6,34%) en mujeres y 1,67% (1,15-2,87%) en hombres; la del RFC fue 0,39% (0,14-1,86%) y 0,18% (0,07-0,77%). El 3,83% de las mujeres y ningun hombre tenian un RFP ≥ 20%; el 15,71% y el 1,14% tenian un RFP ≥ 10%; el 20,62% y el 2,21%, un RFP ≥ 7,5%; y el 19,27% y el 8,05%, un RFC ≥ 3%. En las mujeres de 65 anos o mas, el RFC fue alto en el 58,09%. Conclusiones EPISER2016 nos ha permitido conocer el riesgo de fractura calculado por FRAX® y la prevalencia de alto riesgo de fractura en la poblacion general segun los diversos umbrales utilizados en Espana.

Objectives To develop recommendations for the prevention of infection in adult patients with systemic autoimmune rheumatic diseases (SARD). Methods Clinical research questions relevant to the objective of the document were identified by a panel of experts selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network criteria. Specific recommendations were made. Results Five questions were selected, referring to prevention of infection by Pneumocystis jirovecii with trimethoprim/sulfamethoxazole, primary and secondary prophylactic measures against hepatitis B virus, vaccination against human papillomavirus, vaccination against Streptococcus pneumoniae and vaccination against influenza virus, making a total of 18 recommendations, structured by question, based on the evidence found for the different SARD and/or expert consensus. Conclusions There is enough evidence on the safety and efficacy of vaccinations and other prophylactic measures against the microorganisms reviewed in this document to specifically recommend them for patients with SARD.

Aims Interstitial lung disease (ILD) is frequent in patients with rheumatoid arthritis (RA) and is associated with significant morbidity and mortality. The aim of this review was to identify the different screening methods for ILD in patients with RA. Methods We ran a systematic search in Pubmed, Embase and Cochrane Library up to April 2020 and did a hand search of the references of the retrieved articles. The search was limited to humans and articles published in English, Spanish or French. We selected studies with any design where: (a) the population included adult patients with RA; (b) the intervention was any screening method for ILD; and (c) validity or reliability of the screening method were evaluated, or a screening method was described. Two reviewers independently screened the articles by title and abstract and subsequently extracted the information using a specific data extraction form. Results 25 studies were included with a total of 2593 patients. The most frequently used tool for ILD screening was high resolution computed tomography (HRCT) of the lung. Electronic auscultation, biochemical markers, bronchoalveolar lavage (BAL), pulmonary function tests (PFTs) and lung ultrasonography were also evaluated. Across the different studies, electronic auscultation and lung ultrasonography achieved higher accuracy than PFTs, BAL and biochemical markers. Conclusions HRCT resulted as the most sensitive tool for ILD screening in patients with RA. Given its harmlessness and high sensitivity, lung ultrasonography may become the first-choice tool in the future.

Objective To describe the progress of the attractiveness of rheumatology at successive MIR calls, from 1983 to 2014. Methods Candidates in the Spanish training system for medical doctors choose their specialties sequentially, ordered by their ranking in the qualifying exam (MIR). The highest, median and lowest rank of candidates choosing rheumatology training positions in every MIR call from 1983 to 2014 was requested from the Department of Management of Specialized Medical Training (General Department of Professional Regulation; Spanish Ministry of Health). To compare, the same data was requested for other specialties. In order to define and analyze the attractiveness of each specialty we introduce an ‘index of attractiveness’, based on the normalized difference of the actual median rank reported for each year and the average median obtained in 1000 simulations in which candidates choose specialties at random. Results Regarding the median of the election of rheumatology, the range went from 244th in 1983 to 3394th in 2008, showing a progressive increase over the years in absolute figures. A mathematical simulation allowed quantifying the difference between the observed median and what would have happened if specialties had been chosen by pure chance. Results show a tendency to recover the attractiveness of rheumatology in recent years. Conclusions After a sharp decline in the attractiveness of rheumatology during the last years of the 20th century, there seems to be a recovery.

Aim: To describe the methodology of the EPISER 2016 (study of the prevalence of rheumatic diseases in adult population in Spain), as well its strengths and limitations. The aim of this study is to estimate the prevalence of rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE), Sjogren's syndrome (SS), osteoarthritis (knee, hip, hands, and cervical and lumbar spine), fibromyalgia, gout and clinical osteoporotic fracture. Material and method: Population-based, multicenter, cross-sectional study, with the participation of 45 municipalities in the 17 Spanish autonomous communities. The reference population will consist of adults aged 20 years and over residing in Spain. A computer-assisted telephone interview (CATI) system will be used for data collection. Diagnostic suspicions and diagnoses received by the participants will be studied by rheumatologists in the referral hospitals in the selected municipalities. Statistical analysis: the prevalence of the rheumatic diseases will be calculated using estimators and their 95% confidence intervals. Weights will be calculated in each of the sampling stages in accordance with the probability of selection. The distribution of the population in Spain will be obtained from the Spanish Statistics Institute. Conclusions: Sociodemographic and lifestyle changes over the last 16 years justify EPISER 2016. This study will provide current data about the prevalences of RA, AS, PsA, SLE, SS, osteoarthritis, fibromyalgia, gout and clinical osteoporotic fracture. The results will allow comparisons with studies from other countries and EPISER 2000. (C) 2017 Elsevier Espana, S.L.U. and Sociedad Espanola de Reumatologia y Colegio Mexicano de Reumatologia. All rights reserved.

Objective To provide a reference to rheumatologists and other physicians involved in the treatment of systemic lupus erythematosus (SLE) who are using, or about to use biologic therapies. Methods Recommendations were developed following a nominal group methodology and based on systematic reviews. The level of evidence and degree of recommendation were classified according to a model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through a Delphi technique. Results We have produced recommendations on the use of belimumab, the only biological agent with approved indications for SLE, and other biological agents without an indication for SLE. The objective of treatment is to achieve a complete clinical response, taken as the absence of perceived or evident disease activity. Nuances regarding the use of biologic therapies in SLE were reviewed as well, such as the evaluation that should be performed prior to administration and the follow up of patients undergoing these therapies. Conclusions We present the SER recommendations for the use of biological therapies in patients with SLE.

Corticosteroids are a mainstay in the therapy of rheumatoid arthritis (RA). In recent years, a number of high-quality controlled clinical trials have shown their effect as a disease-modifying anti-rheumatic drug (DMARD) and a favorable safety profile in recent-onset RA. Despite this, they are more frequently used as bridge therapy while other DMARDs initiate their action than as true disease-modifying agents. Low-dose corticosteroid use during the first two years of disease slows radiologic damage and reduces the need of biologic therapy aimed at reaching a state of clinical remission in recent-onset RA. Thus, their systematic use in this clinical scenario should be considered.

a b s t r a c t Purpose: To determine the efficacy and safety of denosumab in osteoporosis. Methods: A systematic search was performed in MEDLINE, EMBASE, and The Cochrane Central Register of Controlled Trials (1950 to July 2010), meeting abstracts (2009-2010), trial registries, and reference lists. The selection criteria were as follows: (population) osteoporosis patients of any age; (intervention) treatment with denosumab; (outcome) efficacy and safety; (study design) randomized clinical trials (RCTs); no language restrictions. Two reviewers independently screened titles and abstracts and subse- quently extracted data from the selected studies including quality items, and on outcomes of interest. A meta-analysis was performed for safety issues. Results: A total of 25 studies were included. Denosumab reduces the risk of new radiographic vertebral fracture in a 68% compared with placebo (p < 0.001) and increases bone mineral density (BMD) at lumbar spine, total hip, and one-third radius more than alendronate and placebo. A single subcutaneous dose of denosumab resulted in a dose-dependent, rapid, profound, and sustained decrease bone turnover markers (BTMs). Denosumab was in general well tolerated. A meta-analysis has shown an increase in the incidence of urinary infections (p = 0.012) and eczema (p < 0.001) in the patients treated with denosumab. Meta-analysis of efficacy was complicated due to the study features. Conclusions: Denosumab given subcutaneously twice yearly is associated with a reduction in the risk of vertebral, nonvertebral, and hip fractures in women with osteoporosis. Denosumab is associated with greater and sustained increases in BMD and reductions in BTMs compared with placebo and/or alendronate and with a risk of urinary infections and eczema.

Objective. To critically appraise the validity of activity indices used in the followup of patients with undifferentiated peripheral inflammatory arthritis (UPIA). Methods. A systematic review was performed in Medline, Embase, the Cochrane Library, and abstracts presented at the 2007 and 2008 meetings of the American College of Rheumatology and European League Against Rheumatism. Selection criteria were: patients with UPIA, the assessment of instruments to evaluate disease activity, and assessment of validity of the instruments. Two reviewers screened titles and abstracts independently and collected data using ad hoc standard forms. Results. The search yielded 179 articles and 834 abstracts, of which 4 articles and 1 abstract were included. We found no study that validated Disease Activity Score (DAS), Clinical Disease Activity Index (CDAI), or Simplified Disease Activity Index (SDAI). Included studies addressed validation of 4 questionnaires: WHO Disability Assessment Schedule (WHODAS), London Handicap Scale (LHS), Disease Repercussion Profile (DRP), and the Health Assessment Questionnaire (HAQ); and 3 indexes: RA Disease Activity Index (RADAI), McGill Range of Motion Index (McROMI), and NOAR Damaged Joint Count (NOAR-DJC). Questionnaires were self-administered and feasible; RADAI was the most feasible index. Internal consistency was studied in the questionnaires (Cronbach’s α > 0.83). Responsiveness was tested in the DRP, LHS, and HAQ, but the approach to study sensitivity to change was poorly explained, with no clear intervention. Construct validity, examined by means of convergence with other instruments, was generally moderate, and slightly higher for the RADAI. Conclusion. No instrument of disease activity has been fully validated for use in UPIA. We found no direct evidence of what is the most useful index to follow up patients with UPIA.

Lupus nephritis is a relevant source of morbidity and mortality in patients with systemic lupus erythematosus. The standard therapy of remission induction in severe lupus nephritis is based on the use of monthly intravenous cyclophosphamide. Recent data have established that the maintenance of remission in lupus nephritis can be achieved with azathioprine or mycophenolate mofetil, with less adverse effects than quarterly intravenous cyclophosphamide. In recent years, a number of controlled randomized clinical trials have been published, opening new therapeutic options in the induction of remission in lupus nephritis, such as less aggressive regimens of intravenous cyclophosphamide or mycophenolate mofetil. Further studies are needed for establishing the optimal therapy of lupus nephritis patients.

Anti-tumor necrosis factor-a (TNF) therapy has been associated with reactivation of hepatitis B virus infection. Case reports have suggested the concomitant need of lamivudine treatment in patients with HBV infection treated with antiTNFa agents. We describe a case of ankylosing spondylitis with positive HBV surface antigen (HBsAg) treated with infliximab and lamivudine. Clinical response was excellent but when lamivudine therapy was stopped, reactivation of replication viral occurred. After the reintroduction of lamivudine, viral replication was controlled and liver function tests were normalized. Preventive long-term lamivudine therapy is mandatory when anti-TNFa therapy is maintained in patients with chronic HBV infection.

Objective. To evaluate the diagnostic and prognostic utility of genetic testing in undifferentiated peripheral inflammatory arthritis (UPIA). Methods. A systematic literature search was performed in Medline, Embase, the Cochrane Library, and abstracts presented at the 2007 and 2008 meetings of the American College of Rheumatology and the European League Against Rheumatism. The target studies were those evaluating diagnostic or prognostic value of genetic markers specifically in UPIA. Two reviewers independently screened titles and abstracts and reviewed included articles in detail. All data were collected using ad hoc standard forms, permitting the calculation of positive and negative likelihood ratios of each genetic marker for diagnoses of different rheumatic diseases and for the development of relevant outcomes. Results. Of the 3109 articles retrieved, 26 original studies fulfilled criteria of the systematic review. The most frequent diagnosis tested was rheumatoid arthritis, followed by inflammatory polyarthritis, and spondyloarthropathies. The main prognostic outcome evaluated was development of erosions, followed by median Larsen score, remission, Health Assessment Questionnaire (HAQ) score, and persistent synovitis. In total, 122 genetic markers were tested. No genetic marker had a high likelihood ratio for the diagnosis of a specific rheumatic disease. The shared epitope was associated with poor prognosis (erosions, HAQ > 1, mortality, and persistent synovitis). Other genes did not predict outcome in undifferentiated arthritis. Other outcomes for persistent disease or disability were not studied in depth. Conclusion. In isolation, no studied genetic marker is very informative of a future diagnosis in patients with UPIA. The shared epitope has a slight association with poor prognosis of UPIA.

Glucocorticoids (GC) are a mainstay of the therapy in rheumatoid arthritis (RA). Currently, and despite their extensive use, the discussion about the benefits and adverse effects of low dose GC in the management of RA persists. In recent years, a number of clinical trials have attempted to establish the benefits of long-term GC use as a disease-modifying antirheumatic drug in RA, and to define their side effects. Results of these clinical trials provide solid evidence that low-dose GC can inhibit radiographic damage in early RA, and that side effects of GC, when used in that clinical framework, are limited to hyperglycaemia, cataracts, and transient weight gain.