Cómo medir la actividad de la enfermedad en artritis reumatoide precoz: un nuevo reto

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Medicina. Fecha de lectura: 06-06-2014The objective of our research was to evaluate the use of composite indices to measure disease activity in rheumatoid arthritis (RA), with a special focus in early disease. It has been well established that early initiation of treatment improves patient outcomes. However, treatments used in patients with RA are not exempt of side effect; therefore, it is vital to adjust the treatment to each patient’s disease activity. This thesis is divided into a number of parts and chapters. The first part provides a general introduction about the options available for measuring disease activity in patients with RA, points to consider when addressing patients with an early disease, as well as the framework on how to improve or develop new instruments for measurement. In this opening section the aim and outline of the research and individual studies is also included, as well as the methodology followed to address the questions posed. The second part contains the results of the different studies that support this thesis. A first chapter highlights some limitations of the available instruments; concretely, we address the study of such limitations in an early arthritis register, in which we propose new cut-­‐offs for a version of the most widely used composite index, the DAS28 with CRP, given its limitations. The following chapter focuses on the choice of an appropriate instrument in patients with early disease, including the search for available instruments and recommendations on how to investigate and follow-­‐up undifferentiated peripheral inflammatory arthritis. A final chapter covers the development of a new composite index appropriate for patients with early disease. The third part of the thesis is a discussion of all the presented results pondered by the strength and limitations of the study approaches. Finally, the conclusions illustrate the significance of improving measures in RA and future perspectives on this topicEl objetivo de nuestra investigación fue evaluar el uso de índices compuestos para medir la actividad de la enfermedad en la artritis reumatoide (AR), con un enfoque especial en la enfermedad precoz. Ha sido claramente establecido cómo el tratamiento precoz mejora las medidas de desenlace del paciente. Sin embargo, los tratamientos que se utilizan en la AR no están exentos de efectos adversos por lo que es importante ajustar los tratamientos a la actividad de la enfermedad de cada paciente. Esta tesis está dividida en distintas partes y capítulos. La primera parte consiste en una introducción general sobre la opciones disponibles para medir la actividad de la enfermedad en pacientes con AR, qué aspectos hay que considerar cuando se evalúan pacientes con enfermedad precoz, y una estrategia para mejorar o desarrollar nuevos instrumentos de medida. En esta parte inicial también se incluyen los objetivos, una descripción de la metodología de investigación y los estudios individuales así como la metodología seguida en cada pregunta de investigación. La segunda parte incluye los resultados de los diferentes estudios que apoyan esta tesis. En el primer capítulo se destacan algunas de las limitaciones de los instrumentos disponibles. En concreto presentamos un estudio de la limitación de estos índices en un registro de artritis precoz, en el cual proponemos nuevos puntos de corte para el índice compuesto más empleado, el DAS28 calculado con PCR. El siguiente capítulo se centra en la elección del instrumento apropiado en pacientes con enfermedad precoz, e incluye una búsqueda de los instrumentos disponibles y recomendaciones sobre cómo investigar y hacer el seguimiento de los pacientes con artritis inflamatoria periférica indiferenciada. El capítulo final se centra en el desarrollo de un nuevo índice compuesto que sea apropiado para pacientes con enfermedad precoz. La tercera parte de la tesis es una discusión de todos los resultados presentados haciendo hincapié en las fortalezas y limitaciones de los citados estudios. Finalmente, las conclusiones ilustran el significado de mejorar las medidas en la AR y cuáles son las perspectivas futuras en este tem

Relación del clima organizacional y desempeño laboral de los trabajadores en una clínica de Lima Metropolitana, 2019

En esta investigación se realizó con el objetivo de determinar la relación del clima organizacional y el desempeño laboral de los trabajadores de una clínica de Lima Metropolitana, 2019, se planteó la hipótesis a contrastar, en la que el clima organizacional se relaciona directamente en el desempeño laboral de los trabajadores, para ello nuestro estudio fue una investigación descriptiva – explicativa y correlacional. La población estuvo constituida por los 95 trabajadores de una clínica de Lima Metropolitana, distribuidos en diferentes áreas administrativas. Para determinar la muestra se utilizó el tipo de muestreo aleatorio probabilístico, en la cual solo se consideró 40 trabajadores, al realizar la aplicación del instrumento, Se empleó la estadística descriptiva para la presentación de los resultados en cuadros de distribución de frecuencias diversas con sus correspondientes gráficos y análisis, de igual forma la estadística inferencial, para la prueba de contrastación de la hipótesis, consistente en el coeficiente de correlación de Pearson, luego realizando el análisis estadístico correspondiente, se pudo observar que el 60% de los trabajadores presente un nivel alto de clima organizacional, un 32.5% presentan un nivel medio, y el 7.5% del resto de trabajadores un nivel bajo. Realizando la inferencia, También se aprecia un nivel de significancia (p = 0.000) menor que 0.05, De los resultados obtenidos podemos concluir que existe relación del clima organizacional y el desempeño laboral de los trabajadores de una clínica de Lima Metropolitana, 2019.This research was carried out with the objective of determining the relationship of the organizational climate and the work performance of the Lima Metropolitan clinic workers, 2019, the hypothesis to be tested was raised, in the organizational climate it is directly related to the work performance of the workers For this, our study was a descriptive research - explanatory and correlational. The population was constituted by the 95 workers of the Lima Metropolitan clinic, distributed in different administrative areas. To determine the sample, se Hill se the type of random probabilistic sampling, in which ola 40 workers will be considered, when applying the instrument, descriptive statistics were used to present the results in various frequency distribution tables with their corresponding ones. graphs and analysis, in the same way inferential statistics for the test of hypothesis testing, consisting of the Pearson correlation coefficient, then carrying out the corresponding statistical analysis, it was observed that 60% of the workers present a high level of organizational climate, 32.5% have a médium level, and 7.5% of other workers a low level. Making the inference, a level of significance is also appreciated (p = 0.000) less than 0.05. From the results obtained we can conclude that there is a relationship between the organizational climate and the work performance of the Lima Metropolitan clinic workers, 2019

Predictors of remission in RA Personal non-commercial use only

ABSTRACT. Objective. To identify baseline variables that predict remission according to different criteria in rheumatoid arthritis (RA) in a comprehensive French ESPOIR early arthritis database

Factors associated with discontinuation of biologics in patients with inflammatory arthritis in remission: data from the BIOBADASER registry

Background: The objectives of this study were to assess the discontinuation of biologic therapy in patients who achieve remission and identify predictors of discontinuation of biologics in patients with inflammatory arthritis in remission. Methods: An observational retrospective study from the BIOBADASER registry comprising adult patients diagnosed with rheumatoid arthritis (RA), ankylosing spondylitis (AS), or psoriatic arthritis (PsA) and receiving 1 or 2 biological disease-modifying drugs (bDMARDs) between October 1999 and April 2021. Patients were followed yearly after initiation of therapy or until discontinuation of treatment. Reasons for discontinuation were collected. Patients who discontinued bDMARDs because of remission as defined by the attending clinician were studied. Predictors of discontinuation were explored using multivariable regression models. Results: The study population comprised 3,366 patients taking 1 or 2 bDMARDs. Biologics were discontinued owing to remission by 80 patients (2.4%): 30 with RA (1.7%), 18 with AS (2.4%), and 32 with PsA (3.9%). The factors associated with a higher probability of discontinuation on remission were shorter disease duration (OR: 0.95; 95% CI: 0.91-0.99), no concomitant use of classic DMARDs (OR: 0.56; 95% CI: 0.34-0.92), and shorter usage of the previous bDMARD (before the decision to discontinue biological therapy) (OR: 1.01; 95% CI: 1.01-1.02); in contrast, smoking status (OR: 2.48; 95% CI: 1.21-5.08) was associated with a lower probability. In patients with RA, positive ACPA was associated with a lower probability of discontinuation (OR: 0.11; 95% CI: 0.02-0.53). Conclusions: Discontinuation of bDMARDs in patients who achieve remission is uncommon in routine clinical care. Smoking and positive ACPA in RA patients were associated with a lower probability of treatment discontinuation because of clinical remission.This research is supported by the Research Unit of the Spanish Society of Rheumatology. BIOBADASER is supported by the Spanish Agency of Medicines and Medical Devices (AEMPS), Biogen, Bristol-Myers and Squibb (BMS), Celltrion, Janssen, Lilly, Merck Sharp and Dohme (MSD), Novartis, Pfizer, Regeneron, and Samsung Bioepis.S

Variabilidad espacial de la captura ribereña de camarón en el Sistema Lagunar Mar Muerto, Oaxaca-Chiapas, México

The Mar Muerto Lagoon System was divided into three sectors (A, B, and C). Spatial variability of artisanal shrimp catch (Ct) can be mostly explained with a spatial layout of sediments (SLS). Mud was dominant on sand in the A and B sectors, and sand was dominant on mud in the C sector. Higher Ct was recorded in the B sector, while in the border area between the B and C sectors, the Ct was low. The Ct was lower in the rest of the C sector and in the A sector. According to available literature, the A sector is the innermost sector with extreme variations in water surface temperature (WST) and salinity (S). The C sector constantly receives the marine influence of the Gulf of Tehuantepec, with low variations in WST and S. The B sector is reported to have an intense river discharge with higher seasonal variations in WST and S. The SLS was not the only variable that influenced spatial variation of the Ct. In the B sector, higher Ct could be explained with dominance and persistence of mud, and magnitude changes were related to seasonal variations in WST and S. Although mud was dominant in the A sector, the Ct was lower, due to extreme variations in WST and S. In the rest of the C sector the Ct was lower, due to dominance and persistence of sand.El Sistema lagunar Mar Muerto se dividió en tres zonas (A, B y C). La variación espacial de la captura ribereña de camarón (Ct), se explicó con la disposición espacial de los sedimentos (DES). En las zonas A y B, los lodos fueron dominantes sobre de las arenas y en la zona C, las arenas dominaron sobre los lodos. La Ct fue mayor en la zona B y menor en la sección limítrofe entre las zonas B y C. La Ct fue baja en el resto de la zona C y también en la zona A. De acuerdo con los antecedentes, la zona A es la más interna, con variaciones extremas en la temperatura superficial del agua (TSA) y la salinidad (S). La zona C recibe constantemente la influencia marina del Golfo de Tehuantepec y tiene una menor variación en la TSA y la S. En la zona B incide una mayor descarga fluvial, con variaciones estacional en la TSA y la S. La DES no fue la única variable que incidió sobre la variación espacial de la Ct. En la zona B, la mayor Ct se explicó con la presencia dominante de los lodos; pero sus cambios de magnitud resultaron estar en relación con las variaciones estacionales de la TSA y la S. Aunque en la zona A los lodos fueron dominantes, la Ct fue muy baja, debido a las variaciones extremas en la TSA y la S. En el resto de la zona C la Ct también fue baja, debido a la dominancia y persistencia de las arenas

Real-world persistence of initial targeted therapy strategy in monotherapy versus combination therapy in patients with chronic inflammatory arthritis

Objective: The persistence of biologic (b) and targeted synthetic (ts) disease-modifying antirheumatic drugs(DMARDs) in monotherapy versus in combination with conventional synthetic (cs) DMARDs is still a controversial topic in rheumatic diseases. To clarify this issue, the retention of the initial treatment strategy of b/tsDMARD in combination with csDMARD versus monotherapy in rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) patients under real-life conditions was evaluated. Factors associated with maintenance of the initial strategy were analysed. Methods: Nested cohort study within the Spanish BIOBADASER III registry. Bivariate comparisons and multivariate Cox proportional hazards models were used for the analyses. Results: A total of 2521 patients were included in the study. In the multivariate model, the initial strategy of combination therapy was associated with shorter persistence in patients with RA (hazard ratio [HR] 1.58;95% confidence interval [CI] 1.00-2.50; p = .049), PsA (HR 2.48; 95% CI 1.65-3.72) and AS (HR 16.77; 95% CI 7.37-38.16; p < .001), regardless of sex, time of disease progression, baseline disease activity, glucocorticoid use or type of b/tsDMARD. Overall, the combination strategy was associated with an increased incidence of adverse events (incidence rate ratio [IRR] 1.13; 95% CI 1.05-1.21). Conclusions: In this real-life study, the strategy of combining a b/tsDMARD with a csDMARD is associated with lower persistence and worse safety profile compared to monotherapy in RA and especially in PsA and AS, suggesting that combination therapy should be rethought as first choice in RA patients, but especially in PsA and AS patients.This research is supported by the Research Unit of the Spanish Society of Rheumatology. BIOBADASER is supported by the Spanish Agency of Drugs and Medical Devices (AEMPS), Biogen, Bristol-Myers and Squibb (BMS), Celltrion, Janssen, Lilly, Merck Sharp and Dohme (MSD), Novartis, Pfizer, Regeneron, and Samsung Bioepis.S

Prevalence of hospital PCR-confirmed COVID-19 cases in patients with chronic inflammatory and autoimmune rheumatic diseases

[Abstract] Background: The susceptibility of patients with rheumatic diseases and the risks or benefits of immunosuppressive therapies for COVID-19 are unknown. Methods: We performed a retrospective study with patients under follow-up in rheumatology departments from seven hospitals in Spain. We matched updated databases of rheumatology patients with severe acute respiratory syndrome coronavirus 2-positive PCR tests performed in the hospital to the same reference populations. Rates of PCR+ confirmed COVID-19 were compared among groups. Results: Patients with chronic inflammatory diseases had 1.32-fold higher prevalence of hospital PCR+ COVID-19 than the reference population (0.76% vs 0.58%). Patients with systemic autoimmune or immune-mediated disease (AI/IMID) showed a significant increase, whereas patients with inflammatory arthritis (IA) or systemic lupus erythematosus did not. COVID-19 cases in some but not all diagnostic groups had older ages than cases in the reference population. Patients with IA on targeted-synthetic or biological disease-modifying antirheumatic drugs (DMARDs), but not those on conventional-synthetic DMARDs, had a greater prevalence despite a similar age distribution. Conclusion: Patients with AI/IMID show a variable risk of hospital-diagnosed COVID-19. Interplay of ageing, therapies and disease-specific factors seem to contribute. These data provide a basis to improve preventive recommendations to rheumatic patients and to analyse the specific factors involved in COVID-19 susceptibility.Instituto de Salud Carlos III; RD16/0012 RETICS Progra

Differences and similarities between the EULAR/ASAS-EULAR and national recommendations for treatment of patients with psoriatic arthritis and axial spondyloarthritis across Europe

This is the first report comparing EULAR and national treatment recommendations for PsA patients across Europe, and the first this decade to compare ASAS-EULAR and national treatment recommendations in axSpA patients. An electronic survey was completed from October 2021-April 2022 by rheumatologists in 15 European countries. One and four countries followed all EULAR and ASAS-EULAR recommendations, respectively. Five countries had no national treatment recommendations for PsA and/or axSpA, but followed other regulations. In several countries, national treatment recommendations predated the most recent EULAR/ASAS-EULAR recommendations. Entry criteria for starting biologic/targeted synthetic disease-modifying anti-rheumatic drugs varied considerably. In several countries, for PsA patients with significant skin involvement, interleukin-17 inhibitors were not given preference. The positioning of Janus Kinase inhibitors differed and Phosphodiesterase-4 inhibitors were not in use/reimbursed in most countries. This study may motivate European countries to update their national treatment recommendations, to align them better with the latest international recommendations