Ingris Peláez-Ballestas

Epidemiology of the Rheumatic Diseases in Mexico. A Study of 5 Regions Based on the COPCORD Methodology

Objective. To estimate the prevalence of musculoskeletal (MSK) disorders and to describe predicting variables associated with rheumatic diseases in 5 regions of México. Methods. This was a cross-sectional, community-based study performed in 5 regions in México. The methodology followed the guidelines proposed by the Community Oriented Program for the Control of the Rheumatic Diseases (COPCORD). A standardized methodology was used at all sites, with trained personnel following a common protocol of interviewing adult subjects in their household. A “positive case” was defined as an individual with nontraumatic MSK pain of > 1 on a visual analog pain scale (0 to 10) during the last 7 days. All positive cases were referred to internists or rheumatologists for further clinical evaluation, diagnosis, and proper treatment. Results. The study included 19,213 individuals; 11,602 (68.8%) were female, and their mean age was 42.8 (SD 17.9) years. The prevalence of MSK pain was 25.5%, but significant variations (7.1% to 43.5%) across geographical regions occurred. The prevalence of osteoarthritis was 10.5%, back pain 5.8%, rheumatic regional pain syndromes 3.8%, rheumatoid arthritis 1.6%, fibromyalgia 0.7%, and gout 0.3%. The prevalence of MSK manifestations was associated with older age and female gender. Conclusion. The prevalence of MSK pain in our study was 25.5%. Geographic variations in the prevalence of MSK pain and specific diagnoses suggested a role for geographic factors in the prevalence of rheumatic diseases.

Validation of the Health Assessment Questionnaire disability index in patients with gout.

OBJECTIVE To assess the psychometric properties of the Health Assessment Questionnaire (HAQ) disability index (DI) in patients with gout. METHODS This study was conducted in a multicenter cohort of patients with gout whose data were collected at baseline (time 0) and 6 months later (time 6). Reliability was assessed by test-retest reliability (intraclass correlation coefficient [ICC]) and internal consistency (Cronbachs alpha coefficient). Construct validity was assessed with convergent validity (HAQ DI correlation with Short Form 36 [SF-36]) and discriminative validity (HAQ DI correlation with clinical features). Sensitivity to change was determined by comparing HAQ DI time 0 versus HAQ DI time 6 (percentage of change, effect size, smallest real difference [SRD], and Guyatts responsiveness index [GRI]). RESULTS We included 206 patients (96.6% men, mean +/- SD age and disease duration 56.3 +/- 12.4 years and 9.3 +/- 8.5 years, respectively). Of these, 52.4% had joint pain, 22.8% swelling, 32.5% reduced joint mobility, and 36.9% tophi. The mean HAQ DI score was 0.59 +/- 0.77 (95% confidence interval [95% CI] 0.49-0.70). ICC (n = 36, evaluations at baseline and 5 days later) was 0.76. Cronbachs alphas were 0.91 (95% CI 0.88-0.92, P = 0.000) for the 20 HAQ DI items and 0.93 (95% CI 0.92-0.94, P = 0.000) for the 8 HAQ DI categories. The HAQ DI correlated in predictable ways with SF-36 subscales and clinical variables, and discriminated between subgroups with and without any joint pain, swelling, and tophi. Concerning sensitivity to change (n = 167), the difference between HAQ DI time 0 and HAQ DI time 6 was 0.31 +/- 0.58 (effect size 0.62, SRD 0.59, and GRI 1.91). DeltaHAQ DI correlated with Deltapain (r = 0.349, P = 0.000). CONCLUSION The HAQ DI is a valid and reliable measure of functioning in patients with gout.

Prevalence of Musculoskeletal Pain and Rheumatic Diseases in the Southeastern Region of Mexico. A COPCORD-Based Community Survey

Objective. To assess the prevalence of musculoskeletal (MSK) pain and rheumatic diseases in the southeastern Mexican state of Yucatán. Methods. Using the Community Oriented Program in the Rheumatic Diseases (COPCORD) methodology, we performed a door-to-door, cross-sectional study generated through a multistage, stratified, randomized method on 3915 adult residents (age 42.7 ± 17.1 yrs; women 61.8%; urban setting 45.7%) of the Mexican state of Yucatán. We used universally accepted criteria for the diagnosis or classification of rheumatoid arthritis (RA), osteoarthritis (OA; knee and hand), fibromyalgia, systemic lupus erythematosus (SLE), gout, ankylosing spondylitis, regional rheumatic pain syndromes, and inflammatory back pain. Results. Nontraumatic MSK pain in the last 7 days was present in 766 (19.6%; 95% CI 18.3–20.8) individuals. MSK pain was more prevalent in women (26.6%) versus men (12.2%; p < 0.01). Self-reported MSK disability occurred in 1.7%. Most MSK pain-related variables were consistently more prevalent in the urban setting. The prevalence of rheumatic disease was: OA 6.8% (95% CI 6.0–7.6); back pain 3.8% (95% CI 3.2–4.4); RA 2.8% (95% CI 2.2–3.3); rheumatic regional pain syndromes 2.3% (95% CI 1.9–2.8); inflammatory back pain 0.7% (95% CI 0.5–1.0); fibromyalgia 0.2% (95% CI 0.1–0.4); gout 0.1% (95% CI 0.07–0.3); and SLE 0.07% (95% CI 0.01–0.2). Conclusion. The prevalence of MSK pain was 19.6%. MSK pain was more prevalent in women and in the urban setting. A remarkably high prevalence of RA was found in this population, which suggests a role for geographic factors.

Diagnosis of Chronic Gout: Evaluating the American College of Rheumatology Proposal, European League Against Rheumatism Recommendations, and Clinical Judgment

Objective. Observation of monosodium urate (MSU) crystal is the gold standard for diagnosis of gout, but is rarely performed in daily clinical practice, and diagnosis is based on clinical judgment. Our aim was to identify clinical and paraclinical data included in the European League Against Rheumatism recommendations (EULARr) and American College of Rheumatology proposed criteria (ACRp) for diagnosis of gout in patients with chronic gout according to their attending rheumatologists. Methods. This cross-sectional and multicenter study included consecutive patients from outpatient clinics with a diagnosis of gout by their attending rheumatologists according to their expertise. The frequency of each item from the ACRp and EULARr was determined. Possible combinations of the items that were frequent, clinically relevant, and simple to evaluate in daily practice were determined. Results. We studied 549 patients (96% men), mean age 50 ± 14 years. Analysis of MSU crystals was performed in 15%. We selected 7 clinical criteria and 1 laboratory measure because of their frequency, importance, and simplicity to obtain: current or past history of: > 1 attack of acute arthritis (93%); mono or oligoarthritis attacks (74%); rapid progression of pain and swelling (< 24 hours; 74%); podagra (70%); erythema (56%); unilateral tarsitis (33%); tophi (52%); and hyperuricemia (93%). The chronic gout diagnosis (CGD) proposal comprised ≥ 4/8 of these; 88% of patients had the criteria of the CGD proposal while 75% had 6/11 ACRp criteria (p = 0.001). When analysis of MSU crystals was added, 90.1% (CGD) and 83.9% (ACRp) met the criteria (p = 0.004). Conclusion. Current or past history of ≥ 4/8 CGD parameters is highly suggestive of chronic gout.

Catastrophic health expenses and impoverishment of households of patients with rheumatoid arthritis

BACKGROUND The cost of certain diseases may lead to catastrophic expenses and impoverishment of households without full financial support by the state and other organizations. OBJECTIVE To determine the socioeconomic impact of the rheumatoid arthritis (RA) cost in the context of catastrophic expenses and impoverishment. PATIENTS AND METHODS This is a cohort-nested cross-sectional multicenter study on the cost of RA in Mexican households with partial, full, or private health care coverage. Catastrophic expenses referred to health expenses totaling >30% of the total household income. Impoverishment defined those households that could not afford the Mexican basic food basket (BFB). RESULTS We included 262 patients with a mean monthly household income (US dollars) of

Epidemiology of Rheumatic Diseases. A Community-Based Study in Urban and Rural Populations in the State of Nuevo Leon, Mexico

376 (0–18,890.63). In all, 50.8%, 35.5%, and 13.7% of the patients had partial, full, or private health care coverage, respectively. RA annual cost was

Prevalence of Rheumatic Regional Pain Syndromes in Adults from Mexico: A Community Survey Using COPCORD for Screening and Syndrome-specific Diagnostic Criteria

5534.8 per patient (65% direct cost, 35% indirect). RA cost caused catastrophic expenses in 46.9% of households, which in the logistic regression analysis were significantly associated with the type of health care coverage (OR 2.7, 95%CI 1.6–4.7) and disease duration (OR 1.024, 95%CI 1.002–1.046). Impoverishment occurred in 66.8% of households and was associated with catastrophic expenses (OR 3.6, 95%CI 1.04–14.1), high health assessment questionnaire scores (OR 4.84 95%CI 1.01–23.3), and low socioeconomic level (OR 4.66, 95%CI 1.37–15.87). CONCLUSION The cost of RA in Mexican households, particularly those lacking full health coverage leads to catastrophic expenses and impoverishment. These findings could be the same in countries with fragmented health care systems.

Validity of the COPCORD Core Questionnaire as a Classification Tool for Rheumatic Diseases

Objective. To estimate the prevalence of rheumatic diseases in rural and urban populations using the WHO-ILAR COPCORD questionnaire. Methods. We conducted a cross-sectional home survey in subjects > 18 years of age in the Mexican state of Nuevo Leon. Results were validated locally against physical examination in positive cases according to an operational definition by 2 rheumatologists. We used a random, balanced, and stratified sample by region of representative subjects. Results. We surveyed 4713 individuals with a mean age of 43.6 years (SD 17.3); 55.9% were women and 87.1% were from urban areas. Excluding trauma, 1278 individuals (27.1%, 95% CI 25.8%–28.4%) reported musculoskeletal pain in the last 7 days; the prevalence of this variable was almost twice as frequent in women (33% vs 17% in men); 529 (11.2%) had pain associated with trauma. The global prevalence of pain was 38.3%. Mean pain score was 2.4 (SD 3.4) on a pain scale of 0–10. Most subjects classified as positive according to case definition (99%) were evaluated by a rheumatologist. Main diagnoses were osteoarthritis in 17.3% (95% CI 16.2–18.4), back pain in 9.8% (95% CI 9.0–10.7), undifferentiated arthritis in 2.4% (95% CI 2.0–2.9), rheumatoid arthritis in 0.4% (95% CI 0.2–0.6), fibromyalgia in 0.8% (95% CI 0.6–1.1), and gout in 0.3% (95% CI 0.1–0.5). Conclusion. This is the first regional COPCORD study in Mexico performed with a systematic sampling, showing a high prevalence of pain. COPCORD is a useful tool for the early detection of rheumatic diseases as well as for accurately referring patients to different medical care centers and to reduce underreporting of rheumatic diseases.

Development and validation of a questionnaire to assess delay in treatment for breast cancer

Objective. To assess the prevalence of rheumatic regional pain syndromes (RRPS) in 3 geographical areas of México using the Community Oriented Program in the Rheumatic Diseases (COPCORD) screening methodology and validate by expert consensus on case-based definitions. Methods. By means of an address-based sample generated through a multistage, stratified, randomized method, a cross-sectional survey was performed on adult residents (n = 12,686; age 43.6 ± 17.3 yrs; women 61.9%) of the states of Nuevo León, Yucatán, and México City. Diagnostic criteria for specific upper (Southampton group criteria) and lower limb (ad hoc expert consensus) RRPS were applied to all subjects with limb pain as detected by COPCORD questionnaire. Results. The overall prevalence of RRPS was 5.0% (95% CI 4.7–5.4). The most frequent syndrome was rotator cuff tendinopathy (2.36%); followed by inferior heel pain (0.64%); lateral epicondylalgia (0.63%); medial epicondylalgia (0.52%); trigger finger (0.42%); carpal tunnel syndrome (0.36%); anserine bursitis (0.34%); de Quervain’s tendinopathy (0.30%); shoulder bicipital tendinopathy (0.27%); trochanteric syndrome (0.11%); and Achilles tendinopathy (0.10%). There were anatomic regional variations in the prevalence of limb pain: Yucatán 3.1% (95% CI 2.5–3.6); Nuevo León 7.0% (95% CI 6.3–7.7); and México City 10.8% (95% CI 9.8–11.8). Similarly, the prevalence of RRPS showed marked geographical variation: Yucatán 2.3% (95% CI 1.8–2.8); Nuevo León 5.6% (95% CI 5.0–6.3); and México City 6.9% (95% CI 6.2–7.7). Conclusion. The overall prevalence of RRPS in México was 5.0%. Geographical variations raise the possibility that the prevalence of RRPS is influenced by socioeconomic, ethnic, or demographic factors.

Prevalence of Back Pain in the Community. A COPCORD-Based Study in the Mexican Population

Objective. Rheumatic diseases are vastly underdiagnosed and undertreated, particularly among minorities and those of low socioeconomic status. The WHO-ILAR Community Oriented Program in the Rheumatic Diseases (COPCORD) advocates screening of musculoskeletal complaints in the community. The objective of this study was to evaluate the performance of the COPCORD Core Questionnaire (CCQ) as a diagnostic tool for rheumatic diseases. Methods. We conducted a cross-sectional study designed in parallel with a large COPCORD survey in Mexico. A subsample of 17,566 questionnaires, selected from 4 of the 5 states included in a national COPCORD survey were included in the analysis as a diagnostic test to evaluate sensitivity, specificity, receiver operating characteristics curve (ROC), and positive likelihood ratio (LR+) of the CCQ as a case-detection tool for rheumatic diagnosis and for the most frequent diagnoses identified in the survey, osteoarthritis, regional rheumatic pain syndromes, and rheumatoid arthritis (RA). Logistic regression with the questions with LR+ ≥ 1 was performed to identify the strength of association (OR) for each question. Results. Pain in the last 7 days, high pain score (> 4), and previous diagnosis were the questions with highest LR+ for diagnosis, and for diagnosis of RA treatment with NSAID. The variables that contributed most to the model were pain in the last 7 days (OR 2.0, 95% CI 1.8–2.3), NSAID treatment (OR 3.3, 95% CI 3.0–3.7), a high pain score (OR 1.15, 95% CI 1.13–1.17), and having a previous diagnosis (OR 1.4, 95% CI 1.3–1.6). These 4 questions had R2 = 0.24, p < 0.01, for detection of any rheumatic diagnosis. The single variable that explains 16% (OR 1.33, 95% CI 1.31–134) of variance was a high pain score in the last 7 days. Conclusion. Some variables were identified in the CCQ that could be combined in a brief version for case detection of rheumatic diseases in community surveys. The validity of this proposal has to be tested against the original version.