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espanolLos avances terapeuticos en la artritis reumatoide obligan a revision periodica de las guias de tratamiento. Objetivo Actualizar las guias del Colegio Mexicano de Reumatologia del tratamiento farmacologico de la artritis reumatoide. Metodo Participaron reumatologos certificados de diferentes instituciones de salud y regiones del pais. Se conformaron equipos de trabajo que revisaron las guias previas, elaboraron nuevas preguntas, revisaron la literatura y calificaron la evidencia, que fue presentada y discutida en sesion plenaria. Las conclusiones se comentaron con infectologos, ginecobstetras y pacientes. Se emiten recomendaciones basadas en niveles de evidencia de acuerdo con la metodologia GRADE. Resultados Se presentan recomendaciones actualizadas para el empleo de los medicamentos disponibles en Mexico hasta 2017 para el tratamiento de la artritis reumatoide. Se enfatiza la importancia del control adecuado y sostenido de la enfermedad y se describen aspectos relevantes de seguridad. Se incluyen conflictos bioeticos y se invita a la accion gubernamental para fortalecer el tratamiento adecuado de la enfermedad. Conclusiones La actualizacion de las recomendaciones del Colegio Mexicano de Reumatologia del tratamiento farmacologico de la artritis reumatoide integra la mejor informacion disponible para ser utilizada en el sistema de salud de Mexico. EnglishTherapeutic advances in rheumatoid arthritis require periodic review of treatment guidelines. Objective To update the Mexican College of Rheumatology guidelines on the pharmacological treatment of rheumatoid arthritis. Method Board certified rheumatologists from different health institutions and regions of the country participated. Work teams were formed that reviewed the previous guidelines, elaborated new questions, reviewed the literature, and scored the evidence that was presented and discussed in plenary session. The conclusions were presented to infectologists, gynaecologists and patients. Recommendations were based on levels of evidence according to GRADE methodology. Results Updated recommendations on the use of available medications for rheumatoid arthritis treatment in Mexico up to 2017 are presented. The importance of adequate and sustained control of the disease is emphasized and relevant safety aspects are described. Bioethical conflicts are included, and government action is invited to strengthen correct treatment of the disease. Conclusions The updated recommendations of the Mexican College of Rheumatology on the pharmacological treatment of rheumatoid arthritis incorporate the best available information to be used in the Mexican health care system.

Epidemiological data indicate that Mexico holds the 19th place in cumulative cases (5506.53 per 100,000 inhabitants) of COVID-19 and the 5th place in cumulative deaths (256.14 per 100,000 inhabitants) globally and holds the 4th and 3rd place in cumulative cases and deaths in the Americas region, respectively, with Mexico City being the most affected area. Several modifiable and non-modifiable risk factors have been linked to a poor clinical outcome in COVID-19 infection; however, whether socioeconomic and welfare factors are associated with clinical outcome has been scanty addressed. This study tried to investigate the association of Social Welfare Index (SWI) with hospitalization and severity due to COVID-19. A retrospective analysis was conducted at the Centro Médico Nacional “20 de Noviembre”—ISSSTE, based in Mexico City, Mexico. A total of 3963 patients with confirmed or suspected COVID-19, registered from March to July 2020, were included, retrieved information from the Virology Analysis and Reference Unit Database. Demographic, symptoms and clinical data were analyzed, as well as the SWI, a multidimensional parameter based on living and household conditions. An adjusted binary logistic regression model was performed in order to compare the outcomes of hospitalization, mechanical ventilation requirement (MVR) and mortality between SWI categories: Very high (VHi), high (Hi), medium (M) and low (L). The main findings show that lower SWI were independently associated with higher probability for hospital entry: VHi vs. Hi vs. M vs. L-SWI (0 vs. +0.24 [OR = 1.24, CI95% 1.01–1.53] vs. +0.90 [OR = 1.90, CI95% 1.56–2.32] vs. 0.73 [OR = 1.73, CI95% 1.36–2.19], respectively); Mechanical Ventilation Requirement: VHi vs. M vs. L-SWI (0 vs. +0.45 [OR = 1.45, CI95% 1.11–1.87] vs. +0.35 [OR = 1.35, CI95% 1.00–1.82]) and mortality: VHi vs. Hi vs. M (0 vs. +0.54 [OR = 1.54, CI95% 1.22–1.94] vs. +0.41 [OR = 1.41, CI95% 1.13–1.76]). We concluded that SWI was independently associated with the poor clinical outcomes in COVID-19, beyond demographic, epidemiological and clinical characteristics.

BACKGROUND. Five percent of cases of COVID-19 will develop acute respiratory distress syndrome and cytokine storm syndrome, which are leading causes of death in patients with SARS-CoV-2 infection. Plasma exchange therapy (PLEX) effectively removes pro-inflammatory factors, modulating and restoring innate and adaptive immune responses. This clinical trial aimed to evaluate the impact of PLEX on the survival of patients with severe SARS-CoV-2 and the effect on the cytokine release syndrome. METHODS. Hospitalized patients diagnosed with SARS-CoV-2 infection and cytokine storm syndrome were selected to receive 2 sessions of PLEX or standard therapy. Primary outcome was all-cause 60-days mortality; secondary outcome was requirement of mechanical ventilation, SOFA, NEWs-2 scores modification, reduction of pro-inflammatory biomarkers and hospitalization time. RESULTS. Twenty patients received PLEX were compared against 40 patients receiving standard therapy. PLEX reduced 60-days mortality (50% vs 20%; OR 0.25, 95%CI 0.071 - 0.880; p = 0.029), and this effect was independent from demographic variables and drug therapies used. PLEX significantly decreased SOFA, NEWs-2, pro-inflammatory mediators and increased lymphocyte count, accompanied with a trend to reduce affected lung volume, without effect on SatO2/FiO2 indicator or mechanical ventilation requirement. CONCLUSIONS. PLEX therapy provided significant benefits of pro-inflammatory clearance and reduction of 60-days mortality in selected patients with COVID-19, without significant adverse events.

We analyzed the neurological manifestations in Mexican patients hospitalized with pneumonia due to COVID-19 and investigated the association between demographic, clinical, and biochemical variables and outcomes, including death. A retrospective, analytical study was conducted using the electronic records of patients hospitalized between 1 April 2020 and 30 September 2020. Records of 1040 patients were analyzed: 31.25% died and 79.42% had neurological symptoms, including headache (80.62%), anosmia (32.20%), ageusia (31.96%), myopathy (28.08%), disorientation (14.89%), encephalopathy (12.22%), neuropathy (5.4%), stroke (1.3%), seizures (1.3%), cerebral hemorrhage (1.08%), encephalitis (0.84%), central venous thrombosis (0.36%), and subarachnoid hemorrhage (0.24%). Patients also had comorbidities, such as hypertension (42.30%), diabetes mellitus (38.74%), obesity (61.34%), chronic obstructive pulmonary disease (3.17%), and asthma (2.01%). Factors associated with neurological symptoms were dyspnea, chronic obstructive pulmonary disease, advanced respiratory support, prolonged hospitalization, and worsening fibrinogen levels. Factors associated with death were older age, advanced respiratory support, amine management, chronic obstructive pulmonary disease, intensive care unit management, dyspnea, disorientation, encephalopathy, hypertension, neuropathy, diabetes, male sex, three or more neurological symptoms, and obesity grade 3. In this study we designed a profile to help predict patients at higher risk of developing neurological complications and death following COVID-19 infection.

ResumenLa artritis reumatoide (AR) es una enfermedad sistémica crónica inflamatoria caracterizada por una respuesta inmune patogénica que ocasiona daño articular el cual puede ser incapacitante e incluso condicionar una muerte prematura. Entre las articulaciones afectadas puede encontrarse la articulación temporomandibular (ATM) ocasionando dolor, crepitación, inflamación y limitación de los movimientos mandibulares. La disfunción de la ATM es una entidad muy común, por lo que el objetivo de este estudio fue determinar en qué medida los pacientes con AR tienen afección de la ATM comparado con pacientes sanos e identificar las principales diferencias en la presentación clínica, para lo cual se realizó un estudio de casos y controles. Se incluyeron 37 pacientes en cada grupo. En el grupo de pacientes con AR se encontró una afección de la ATM en el 75% de los pacientes (28 casos), mientras que en el grupo control solo el 13,5% (5 casos). Los hallazgos identificados en el grupo de pacientes con AR y disfunción de ATM fueron principalmente desviación mandibular, ruidos articulares, pérdida dental, dolor articular y limitación de la apertura. En este estudio se pudo identificar que existe un riesgo 82% (OR 19,9, IC=0,71-0,89) veces mayor de desarrollar disfunción de ATM en pacientes con AR comparado con pacientes sanos, por lo que resulta de suma importancia realizar revisiones periódicas de la ATM con el fin de identificar signos y síntomas tempranos para así evitar la progresión de la disfunción, lo cual se verá reflejado en una mejor nutrición y calidad de vida del paciente.AbstractRheumatoid arthritis (RA) is a chronic systemic inflammatory disease characterised by a pathogenic immune response that causes joint damage that can be disabling and even cause premature death. The temporomandibular joint (TMJ) can also be affected, causing pain, crepitus, swelling, and limitation of mandibular movements. TMJ dysfunction is a very common condition, thus the aim of this study was to determine to what extent patients with RA have TMJ dysfunction compared with healthy patients and to identify the main differences in the clinical presentation. A case-control study was performed with the objective of identifying the main differences in the clinical presentation. A total of 37 patients were included in each group. In the group of patients with RA it was found that 75% of patients (28 cases) had TMJ dysfunction, while in the control group there were only 13.5% (5 cases). The findings identified in the group of patients with RA and TMJ dysfunction were mainly: mandibular deviation, joint sounds, tooth loss, joint pain, and limitation of the opening. This study was able to identify that there is an increased risk of 82% (OR 19.9, 95% CI=0.71-0.89) in developing TMJ dysfunction in patients with RA compared with healthy patients. It is concluded that it is important to perform periodic TMJ exploration to be able to identify early signs and symptoms of dysfunction to avoid progression. This would be reflected in better nutrition and quality of life of the patient.

IntroductionRheumatologists are the primary healthcare professionals responsible for patients with rheumatic diseases and should acquire medical ethical competencies, such as the informed consent process (ICP). The objective clinical structured examination is a valuable tool for assessing clinical competencies. We report the performance of 90 rheumatologist trainees participating in a station designed to evaluate the ICP during the 2018 and 2019 national accreditations.MethodsThe station was validated and represented a medical encounter in which the rheumatologist informed a patient with systemic lupus erythematosus with clinically active nephritis about renal biopsy. A trained patient–actor and an evaluator were instructed to assess ICP skills (with a focus on kidney biopsy benefits, how the biopsy is done and potential complications) in obtaining formal informed consent, delivering bad news and overall communication with patients. The evaluator used a tailored checklist and form.ResultsCandidate performance varied with ICP content and was superior for potential benefit information (achieved by 98.9% of the candidates) but significantly reduced for potential complications (37.8%) and biopsy description (42.2%). Only 17.8% of the candidates mentioned the legal perspective of ICP. Death (as a potential complication) was omitted by the majority of the candidates (93.3%); after the patient–actor challenged candidates, only 57.1% of them gave a clear and positive answer. Evaluators frequently rated candidate communications skills as superior (≥80%), but ≥1 negative aspect was identified in 69% of the candidates.ConclusionsEthical competencies are mandatory for professional rheumatologists. It seems necessary to include an ethics competency framework in the curriculum throughout the rheumatology residency.

Therapeutic advances in rheumatoid arthritis require periodic review of treatment guidelines. Objective To update the Mexican College of Rheumatology guidelines on the pharmacological treatment of rheumatoid arthritis. Method Board certified rheumatologists from different health institutions and regions of the country participated. Work teams were formed that reviewed the previous guidelines, elaborated new questions, reviewed the literature, and scored the evidence that was presented and discussed in plenary session. The conclusions were presented to infectologists, gynaecologists and patients. Recommendations were based on levels of evidence according to GRADE methodology. Results Updated recommendations on the use of available medications for rheumatoid arthritis treatment in Mexico up to 2017 are presented. The importance of adequate and sustained control of the disease is emphasised and relevant safety aspects are described. Bioethical conflicts are included, and government action is invited to strengthen correct treatment of the disease. Conclusions The updated recommendations of the Mexican College of Rheumatology on the pharmacological treatment of rheumatoid arthritis incorporate the best available information to be used in the Mexican health care system.

Resumen El rhupus es una entidad poco comun en la que se superponen datos de lupus eritematoso generalizado y artritis reumatoide, predominando con frecuencia las manifestaciones articulares. En muchos casos el tratamiento con farmacos modificadores de la enfermedad no biologicos es insatisfactorio, por lo que se ha intentado el uso de inmunosupresores y farmacos biologicos. Se realizo un estudio prospectivo y abierto para evaluar la eficacia y la tolerabilidad de rituximab en pacientes con rhupus. El objetivo principal fue el cambio en el DAS28 a los 6 meses; fueron objetivos secundarios el cambio en MEX-SLEDAI a los 6 meses, el cambio en DAS28 y MEX-SLEDAI durante el seguimiento, el requerimiento de esteroides y el registro de eventos adversos. Se incluyo a 9 pacientes, todas mujeres, con edad promedio de 43 anos y tiempo de evolucion de 10 anos. Se observo un descenso en la puntuacion basal de DAS28 de 5,73 a 3,02 a los 6 meses (p En los pacientes de nuestro estudio, el tratamiento con rituximab mostro ser eficaz tanto en las manifestaciones articulares, con reduccion significativa del DAS28, como en otras manifestaciones de lupus, con mejoria del MEX-SLEDAI. Consideramos que esta puede ser una buena opcion terapeutica para pacientes con rhupus.

Rhupus in an infrequent disease in which an overlap between lupus eritematosus and rheumatoid arthritis exists. Joint manifestations are prominent and treatment with non biological DMARDs is not always satisfactory, so immunosupressors and biological agents have been tried. A prospective, open clinical study was done to evaluate efficacy and tolerability of rituximab in patients with Rhupus. The main objective was a change in DAS28 at 6 months and secondary objectives were a change in MEX-SLEDAI at 6 months, change in DAS28 and MEX-SLEDAI during follow up, steroid requirements and detection of adverse events. We included 9 women with a mean age of 43 years and disease duration of 10 years. A significant reduction in DAS28 was observed (from 5.73 at baseline to 3.02 at 6 months, P

Hepatic fasciolosis is a zoonosis that accidentally can invade the human.62 years old male, farmer, lives in a rural community in Tehuacan, Puebla, Mexico. His living space is not provided with running water nor drainage. He has contact with sheep and bovines. Started presenting symptoms two years before. Suffered from myalgia, joint pain, fever of 38 degrees C and epigastric pain that radiated the hypocondrium and the right shoulder. He had diarrhea five times in 24 hours as well as lack of appetite that lead to a weight loss of 20 kilograms in two years. He was hospitalized and the physical examination revealed diminished muscular mass, right hypocondrium pain and hepatomegaly of 3 cm below costal margin. He said he ate watercress (Nasturium officinalis) two or three times a week. Blood test revealed erythrocytes of 3.6 x 105 mm3; hemoglobin of 11.9 g/dL; hematocrit of 30%; leukocytes 8950 mm3; neutrophils 65%; lymphocytes of 30%; eosinophils of 3%; monocytes of 1% and basophiles of 1%. Globular sedimentation was 83 mm and hemoglobin concentration was 33. Liver test results were normal and mycobacterium in fecal samples was negative, but stool detection tests revealed eggs of Fasciola hepatica. The diagnosis was hepatic fasciolosis in its biliar stage. Dehidrohemetine (1.5 mg/kg) was administered during 10 days. Symptoms disappeared within 48 hours.The lack of knowledge about fasciolosis makes it hard to diagnose it. The publication of case reports must help to facilitate its diagnosis.