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MASEI is the main validated ultrasound score for the evaluation of enthesis. The lack of studies facing the agreement to achieve for the interpretation of the MAdrid Sonographic Enthesis Index (MASEI) among researchers from different centers in multicenter studies is of concern. The aim of this multicenter was to evaluate the interobserver reliability of MASEI. An experienced ultrasonographer-rheumatologist performed ultrasound scans of the areas included in MASEI index in three patients with Ankylosing Spondylitis and Psoriatic Arthritis. Videos were captured. The videos were then evaluated by 24 rheumatologists of the ultrasound working group of the Catalan Society of Rheumatology (EcoCAT). A face-to-face training meeting was held. Ten days after the workshop, the study participants evaluated the videos. A reliability assessment was performed. The ICC for the MASEI scores after the workshop was of 0.97 (95% CI 89-99). Reliability did not vary statistically with examiner experience. Globally, no problems of reliability by structures were seen, and all the ICCs were above 0.90 and improved slightly after the educational program. However, the correlation observed between examiners at plantar aponeursis and triceps tendon was weak. The small variability observed in the results of the index validation in our study, suggests that the MASEI index is reproducible by different observers when those are well trained and show awesome results of the enthesis when examined by ultrasound.

Resumen Objetivo 1) Analizar la implementacion de los modelos de atencion multidisciplinar en pacientes con artritis psoriasica (APs), y 2) definir estandares de calidad de minimos y de excelencia. Metodos Se envio una encuesta a profesionales que ya realizan atencion multidisciplinar o estan en vias preguntando por: 1) tipo de modelo de abordaje multidisciplinar, y 2) grado, prioridad y facilidad de la implementacion de los estandares de calidad de estructura, proceso y resultado. En 6 reuniones regionales se presentaron y discutieron los resultados de la encuesta, tanto a nivel nacional como regional, y se definio la prioridad definitiva de los estandares de calidad. En una reunion de grupo nominal, 11 expertos (reumatologos y dermatologos) analizaron los resultados de la encuesta y las reuniones regionales. Con ello definieron que estandares de calidad son actualmente de minimos y cuales de excelencia. Resultados Los modelos de atencion multidisciplinar conjunto y paralelo son los mas implementados, y los de los estandares de calidad es muy variable: en los de estructura varia del 22 al 74%, en los de proceso del 17 al 54% y en los de resultado del 2 al 28%. De los 25 estandares de calidad originales, 9 se consideran solo de minimos, 4 de excelencia y 12 tienen definidos unos criterios para ser de minimos y otros para la excelencia. Conclusiones La definicion de estandares de calidad de minimos y de excelencia ayudara en la consecucion del objetivo de la atencion multidisciplinar para pacientes con APs, que es la mejor asistencia sanitaria posible.

Resumen Objetivo Describir la estructura y procesos de distintos modelos de atencion multidisciplinar de pacientes con artritis psoriasica (APs) en Espana, asi como las barreras y facilitadores en su implantacion. Metodos Se realizo un estudio cualitativo mediante entrevistas estructuradas a 24 profesionales (12 reumatologos y 12 dermatologos que realizan atencion multidisciplinar en pacientes con APs). Se recogieron datos relacionados con el centro, servicio, poblacion atendida y sobre el modelo de atencion multidisciplinar (tipo, recursos materiales y humanos, requerimientos de los profesionales, objetivos, criterios de entrada y salida, agendas, protocolos de actuacion, responsabilidades, toma de decisiones, actividad investigadora y docente, sesiones clinicas conjuntas, creacion/inicio, planificacion, ventajas/desventajas del modelo y barreras/facilitadores en la implantacion del modelo. Se describen sus caracteristicas. Resultados Analizamos 12 modelos de atencion multidisciplinar en APs, implantados desde hace al menos 1-2 anos, que globalmente pueden resumirse en 3 subtipos diferentes: presencial conjunto, presencial paralelo y circuito preferencial. La implantacion de uno u otro modelo es consecuencia de la adaptacion a las circunstancias del centro y profesionales. Una correcta planificacion de la implantacion es fundamental. La implicacion y buena sintonia entre profesionales asi como un acceso y criterios de derivacion bien definidos son facilitadores muy importantes en la implantacion de un modelo. La gestion de las agendas y la recogida de datos para medir resultados de salud de estos modelos son las principales barreras. Conclusiones Existen distintos modelos de atencion multidisciplinar implantados que tienen como objetivo intentar mejorar la atencion del paciente con APs, la eficiencia del sistema y la colaboracion entre especialistas.

Objetive To describe (structure, processes) of the multidisciplinary care models in psoriatic arthritis (PsA) in Spain, as well as barriers and facilitators of their implementation. Methods A qualitative study was performed following structured interviews with 24 professionals (12 rheumatologists, 12 dermatologists who provide multidisciplinary care for patients with PsA). We collected data related to the hospital, department, population and multidisciplinary care model (type, physical and human resources, professional requirements, objectives, referral criteria, agendas, protocols, responsibilities, decision-making, research and education, clinical sessions, development and planning of the model, advantages and disadvantages of the model, barriers and facilitators in the implementation of the model). The models characteristics are described. Results We analyzed 12 multidisciplinary care models in PsA, with at least 1–2 years of experience, and 3 subtypes of models, face-to-face, parallel, and preferential circuit. All are adapted to the hospital and professionals characteristics. A proper implementation planning is essential. The involvement and empathy between professionals and an access and well-defined referral criteria are important facilitators in the implementation of a model. The management of agendas and data collection to measure the multidisciplinary care models health outcomes are the main barriers. Conclusions There are different multidisciplinary care models in PsA that can improve patient outcomes, system efficiency and collaboration between specialists.

Background: At present, there are not specific targets to treat or prevent Systemic Sclerosis (SSc), but there are some to reduce the impact of its associated complications. Although mycophenolate (MP) is not recommended in latest EULAR SSc guidelines to treat cutaneous and pulmonary manifestations, its efficacy is known, based on observational studies and the Sclerodermalungstudy II. Objectives: To describe our center’s experience in treating SSc patients with MP. Methods: Descriptive series of SSc patients treated with MP from November 2017 to December 2018. Demographic, clinical, analytical, spirometric, radiological (HR-CT) and modified Rodnan skin score (mRSS) data were collected. Results: Case 1: woman diagnosed at 42 years old with diffuse SSc, having positive anti-toposiomerase-I antibody (ATA), telangiectasias, pitting scars, scleroderma and Non-specific interstitial Pneumonia (NSIP) without significant alterations in spirometry. One year after diagnosis, as a result of skin worsening (mRSS 21), we started MP in association with prednisone (mean dose 5 mg. A day). After treatment for 14 months, she showed significant improvement (mRSS 9) without spirometric changes. Case 2: woman diagnosed at 30 years old with diffuse SSc, having positive aTA, pitting scars, gastroesophageal reflux disease (GERD) and scleroderma. This same year, we started MP due to skin involvement (mRSS 14), improving significantly (mRSS 9) after 14 months of treatment. Case 3: woman diagnosed at 35 years old with diffuse SSc, having positive anti-RNA polymerase-III (ARA), pitting scars, telangiectasias, calcinosis, myopathy and scleroderma. 40 months after diagnosis, MP and prednisone (mean dose 5mg. A day) were started to treat skin (mRSS 19) and muscle (confirmed by biopsy) involvement. Both showed significant improvement after 8 months of treatment, with mRSS 13, myopathy symptoms resolution and creatine kinase (CK) normalization. Case 4: a woman diagnosed at 35 years of age with limited SSc, having positive anti-Ro52, telangiectasias, skin involvement (mRSS 14) and NSIP with non-assessable spirometry. Clinical respiratory improvement was shown after just 1 month of treatment, without mRSS changes. Case 5: woman diagnosed at 54 years old with diffuse SSc, having positive aTA, hands edema, scleroderma (mRss 11), GERD and NSIP (FVC 56%, FEV1 64%, non-assessable DLCO). After 25 months of disease progression and skin involvement, we started MP with prednisone (mean dose 8mg. A day), observing no significant changes after treating for 8 months on skin or lung disease, only improving the hands edema. Case 6: woman diagnosed at 47 years old with diffuse SSc, having telangiectasias, scleroderma, positive aTA and NSIP. At 100 months from diagnosis, after 6 cyclophosphamide cycles followed by azathioprine (both ineffective) due to lung function (FVC 76%, FEV 83%, DLCO 26%) and skin (mRSS 30) worsening, MP and prednisone (mean dose 15mg. A day) were started. Currently, we are still waiting to assess clinical response. Conclusion: Despite it is not included in EULAR current recommendations for SSc complications, our patients have remarkably improved with MP, especially skin involvement, with a good safety profile. These data reaffirm those obtained in previous studies and encourages us to continue considering its use. Disclosure of interests: None declared

Background: Ustekinumab (UST) is an anti- interleukin (IL) 12/23 monoclonal antibody that has been shown to be effective and safe in psoriatic arthritis (PsA) in two phases III clinical trials. However, we have very few UST data in a real- life setting. Objectives: To assess the effectiveness, safety and survival of UST among patients with PsA treated under routine clinical care. Methods: Retrospective and multicentric study. Epidemiological and clinical data were collected through the electronic medical record of all patients with PsA who started UST due to rheumatological indication in 14 hospitals of Catalonia and the Balearic Islands (Spain). Results: 152 patients were included, 116 (76.3%) with 45mg and 36 (23.8%) with 90mg. 55.9% were women, mean age 54.79 (12.5) years, and mean disease duration 209 months. 132 patients (87%) had oligo (30.3%) or polyarticular involvement (56.6%). 26.8% had enthesitis and 36.2% dactylitis. 48p(35.6%) had erosions. 94p (61.8%) had previously received another biological therapy, and 39 of them (38.8%) had received 2 or more. 54.6% of the patients were taking DMARDs and 39.5% glucocorticoids. The baseline DAS 28 was 3.97 (1.45), C reactive protein (CRP) was 2 mg/dl (2), SJC was 4.0 (5.4), and PASI was 6.5 (8.4). There were no significant differences in clinical and epidemiological data between patients at 45 or 90 mg except in obese patients (58.4% in 90mg vs 40% in 45mg, p = 0.038). Overall, there was a significant decrease in DAS28, SJC, TJC and PASI in the first month of treatment, with more pronounced improvement in skin (PASI and BSA) than in joints outcomes, where the curves reached a plateau at 6 months. There were no significant differences between joint and/or skin outcomes between 45 and 90 mg doses. Patients naive to biological therapy had an earlier skin improvement than patients with previous biological failure. Likewise, the improvement in joint outcomes was also faster in naive vs biological experienced patients (DAS28 and SJC 4m, p = 0.01 and 0.01, respectively). After an average of 19m of follow-up, 94 out of 152p (61.8%) continued with UST, 54.4% started at 45mg and 72.2% at 90mg (p = 0.04). 42p (28.2%) stopped UST due to joint inefficacy, 8p (5.4%) for skin inefficacy and 4 (2.7%) for adverse effect. Although survival was better in patients with fewer previous biological agents, no significant differences were achieved (p = 0.233 for naive and p = 0.072 for patients with 1 biological failure). Conclusion: This analysis demonstrates that UST, administered to PsA patients in a routine clinical care setting, is safe and effective in improving skin and joint outcomes. 61.2% of the patients continued with the treatment after an average of 19m of follow-up. Joint and skin outcomes reached significant differences from the first month. The efficacy seems faster in those patients with fewer lines of previous biological therapies. One third of the patients interrupted the therapy due to joint inefficacy. Acknowledgement: JANSSEN Disclosure of interests: Ana Belen azuaga-Pinango: None declared, Beatriz Frade-Sosa: None declared, ana Laiz Consultant for: Lilly, Novartis, abbVvie, MSD, UCB and Janssen, Speakers bureau: Lilly, Novartis, abvvie, MSD, UCB and Janssen, Paula Estrada: None declared, Luciano Polino: None declared, Emma Beltran: None declared, Agueda Prior-Espanol: None declared, Lourdes Mateo Soria: None declared, Carme Moragues Pastor : None declared, agusti Sellas-Fernandez: None declared, aNA URRUTICOECHEA-ARANA: None declared, Mireia Moreno : None declared, Javier Garcia Miguel: None declared, Jose L Tandaipan: None declared, Manel Pujol: None declared, Vicenc Torrente Segarra : None declared, inmaculada Ros Vilamajo : None declared, Sergi Ordonez : None declared, Delia Reina-Sanz: None declared, andrea Cuervo: None declared, Juan D. Canete: None declared, Julio Ramirez: None declared

With the aim to develop and validate a clinical + ultrasound (US) inflammation score in rheumatoid arthritis (RA) for use in clinical practice, a mixed-method study was conducted. The theoretical development of the index was achieved with qualitative methodology (discussion group and Delphi survey). Subsequently, a cross-sectional study was carried out to analyse issues related to scoring and validation of the new index. RA patients underwent clinical [28 swollen and tender joints count, patient and physician global assessment (PhGA), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)], and US assessments [synovitis or tenosynovitis by grey-scale (GS) and power Doppler (PD) of 42 structures]. An index was created based on statistical models and expert interaction. Construct validity was tested by correlation with DAS28, SDAI, CDAI, and PhGA. Reliability was evaluated in a subgroup of patients with the intraclass correlation coefficient (ICC). US assessment, CRP, and swollen joints were the items that passed the prioritization phase (Delphi study). For the cross-sectional study, 281 patients were randomly divided into design (n = 141) and validation samples (n = 140). The combination of US sites chosen (7 bilaterally) detected the maximum proportion of synovitis and PD present. Three scoring methods were tested: semiquantitative (0-3 GS + 0-3 PD), dichotomous (0/1 GS + 0/1 PD), and qualitative (0/1 based on algorithm). All showed strong correlation with activity measures (? = 0.60), and reliability (ICC 0.89-0.93). The index with best parameters of validity, feasibility, and reliability was the qualitative. The final index chosen was the sum of swollen joint count, US qualitative score, and CRP. The UltraSound Activity score is a valid and reliable measure of inflammation in RA equal to the sum of 28 SJC, a simplified (0/1) US assessment of 11 structures and CRP. It is necessary further investigation to demonstrate additional value over existing indices.

Objective (1) To analyse the implementation of multidisciplinary care models in psoriatic arthritis (PsA) patients, (2) To define minimum and excellent standards of care. Methods A survey was sent to clinicians who already performed multidisciplinary care or were in the process of undertaking it, asking: (1) Type of multidisciplinary care model implemented; (2) Degree, priority and feasibility of the implementation of quality standards in the structure, process and result for care. In 6 regional meetings the results of the survey were presented and discussed, and the ultimate priority of quality standards for care was defined. At a nominal meeting group, 11 experts (rheumatologists and dermatologists) analysed the results of the survey and the regional meetings. With this information, they defined which standards of care are currently considered as minimum and which are excellent. Results The simultaneous and parallel models of multidisciplinary care are those most widely implemented, but the implementation of quality standards is highly variable. In terms of structure it ranges from 22% to 74%, in those related to process from 17% to 54% and in the results from 2% to 28%. Of the 25 original quality standards for care, 9 were considered only minimum, 4 were excellent and 12 defined criteria for minimum level and others for excellence. Conclusions The definition of minimum and excellent quality standards for care will help achieve the goal of multidisciplinary care for patients with PAs, which is the best healthcare possible.

Background Plasma concentrations of lipoprotein (a) (Lp(a)), a lipoprotein with atherogenic and thrombogenic properties, have a strong genetic basis, although high concentrations of Lp(a) have also been reported in the context of inflammation, as in rheumatoid arthritis (RA). Few studies evaluate the impact of biologic therapies (BT) on Lp(a) in RA, taking into account that with these new therapies a better control of inflammation is achieved. Objective The aim of the study was to evaluate the plasma concentrations of Lp(a) in Spanish RA patients on BT attending rheumatology outpatient clinics. Methods Baseline analysis of the CARdiovascular in rheuMAtology project, a 10-year prospective study, evaluating the risk of cardiovascular events in RA and other forms of inflammatory arthritis. RA patients were classified according to treatment: no biologic, anti-tumor necrosis factor, anti-interleukin-6 receptor tocilizumab (TCZ), and other biologic (rituximab or abatacept). A model of linear multivariate regression was built in which the dependent variable was Lp(a) concentration and the explanatory variable was BT. The model was adjusted for confounding factors. Results Seven hundred and seventy-five RA patients were analyzed. Plasma concentrations of total cholesterol and triglyceride were significantly higher in TCZ-treated patients. Nevertheless, no significant difference in the atherogenic index between TCZ-treated patients and patients without BT was found. After adjusting for confounding factors, patients with BT had lower concentrations of Lp(a) than those without BT; however, only TCZ-treated patients achieved statistically significant differences (?: ?0.303, 95% confidence interval: ?0.558 to ?0.047; P = .02). Conclusions RA patients treated with TCZ show lower plasma concentrations of Lp(a) compared with patients without BT. This project has been supported by an unrestricted grant from Abbvie, Spain. The design, analysis, interpretation of results, and preparation of the article have been done independently of Abbvie. Dr González-Gay's studies have been supported by grants from “Fondo de Investigaciones Sanitarias” PI06/0024, PS09/00748, and PI12/00060 and RD12/0009/0013 (RIER) from “Instituto de Salud Carlos III” (ISCIII) (Spain).

Introduccion y objetivos Determinar la frecuencia relativa y las caracteristicas clinicas de la fibrilacion auricular paroxistica idiopatica, en comparacion con las de la fibrilacion auricular secundaria. Pacientes y metodo Se llevo a cabo un registro multicentrico prospectivo (registro FAP) con la participacion de 11 hospitales comarcales de Cataluna, en el que se incluyeron 300 pacientes atendidos en los servicios de urgencia a causa de una crisis de fibrilacion auricular. Resultados La fibrilacion paroxistica idiopatica se presento en el 22,3% de los casos (67 pacientes), frente al 33,7% atribuible a la hipertension arterial; el 12% a las lesiones valvulares y el 9,7% a la cardiopatia isquemica. Los pacientes con fibrilaciones primarias eran mas jovenes que el resto (edad promedio de 55 frente a 65 anos; p = 0,0001); estas tenian mayor tendencia a aparecer durante el sueno y la disnea era menos frecuente (p = 0,007). El tamano de la auricula izquierda era inferior (p Conclusiones La fibrilacion auricular paroxistica idiopatica se revela como una de las formas clinicas mas frecuente en los pacientes asistidos en los hospitales comarcales de nuestro medio, solo superada por la secundaria a la hipertension arterial. Las caracteristicas clinicas son muy similares a las de la fibrilacion secundaria.

The objective of this work is to analyze the survival of infliximab, etanercept and adalimumab in patients who have switched among tumor necrosis factor (TNF) antagonists for the treatment of chronic arthritis. BIOBADASER is a national registry of patients with different forms of chronic arthritis who are treated with biologics. Using this registry, we have analyzed patient switching of TNF antagonists. The cumulative discontinuation rate was calculated using the actuarial method. The log-rank test was used to compare survival curves, and Cox regression models were used to assess independent factors associated with discontinuing medication. Between February 2000 and September 2004, 4,706 patients were registered in BIOBADASER, of whom 68% had rheumatoid arthritis, 11% ankylosing spondylitis, 10% psoriatic arthritis, and 11% other forms of chronic arthritis. One- and two-year drug survival rates of the TNF antagonist were 0.83 and 0.75, respectively. There were 488 patients treated with more than one TNF antagonist. In this situation, survival of the second TNF antagonist decreased to 0.68 and 0.60 at 1 and 2 years, respectively. Survival was better in patients replacing the first TNF antagonist because of adverse events (hazard ratio (HR) for discontinuation 0.55 (95% confidence interval (CI), 0.34-0.84)), and worse in patients older than 60 years (HR 1.10 (95% CI 0.97-2.49)) or who were treated with infliximab (HR 3.22 (95% CI 2.13-4.87)). In summary, in patients who require continuous therapy and have failed to respond to a TNF antagonist, replacement with a different TNF antagonist may be of use under certain situations. This issue will deserve continuous reassessment with the arrival of new medications. © 2006 Gomez-Reino and Loreto Carmona; licensee BioMed Central Ltd.