Pedro Santos-Moreno

REAL-PANLAR Project for the Implementation and Accreditation of Centers of Excellence in Rheumatoid Arthritis Throughout Latin America: A Consensus Position Paper From REAL-PANLAR Group on Improvement of Rheumatoid Arthritis Care in Latin America Establishing Centers of Excellence.

ObjectiveA consensus meeting of representatives of 16 Latin American and Caribbean countries and the REAL-PANLAR group met in the city of Bogota to provide recommendations for improving quality of care of patients with rheumatoid arthritis (RA) in Latin America, defining a minimum standards of care and the concept of center of excellence in RA. MethodsTwenty-two rheumatologists from 16 Latin American countries with a special interest in quality of care in RA participated in the consensus meeting. Two RA Colombian patients and 2 health care excellence advisors were also invited to the meeting. A RAND-modified Delphi procedure of 5 steps was applied to define categories of centers of excellence. During a 1-day meeting, working groups were created in order to discuss and validate the minimum quality-of-care standards for the 3 proposed types of centers of excellence in RA. Positive votes from at least 60% of the attending leaders were required for the approval of each standard. ResultsTwenty-two opinion leaders from the PANLAR countries and the REAL-PANLAR group participated in the discussion and definition of the standards. One hundred percent of the participants agreed with setting up centers of excellence in RA throughout Latin America. Three types of centers of excellence and its criteria were defined, according to indicators of structure, processes, and outcomes: standard, optimal, and model. The standard level should have basic structure and process indicators, the intermediate or optimal level should accomplish more structure and process indicators, and model level should also fulfill outcome indicators and patient experience. ConclusionsThis is the first Latin American effort to standardize and harmonize the treatment provided to RA patients and to establish centers of excellence that would offer to RA patients acceptable clinical results and high levels of safety.

Treatment of rheumatoid arthritis with methotrexate alone and in combination with other conventional DMARDs using the T2T strategy. A cohort study

The aim of this study was to evaluate the effect of treatment with methotrexate (MTX), by itself or combined with other non-biological disease-modifying antirheumatic drugs (DMARDs) (methotrexate, MTX with prednisolone, MTX with leflunomide, MTX with chloroquine, and MTX with sulfasalazine) on clinimetric outcomes in a retrospective cohort with a 6-month follow-up and under a Treat to Target (T2T) approach. Patients in treatment with conventional DMARDs and classified as moderate disease activity (MDA) and high disease activity (HDA) were included. Changes in disease activity score (DAS28), health assessment questionnaire (HAQ), tender joint count (TJC), and swollen joint count (SJC) are compared using the Wilcoxon nonparametric test for paired data. Hypothesis contrasts were raised in order to look for differences between the different exposure groups and the outcomes defined by means of the Kruskal–Wallis (KW) nonparametric test. Follow-up was documented in 307 patients, including 250 (81.4xa0%) women. At the onset, 243 subjects (79.2xa0%) were classified as MDA and 64 (20.9xa0%) in HDA. A total of 247 subjects (80.4xa0%) presented some degree of improvement, with 156 subjects (51xa0%) entering remission, which is a significant number (p valueu2009=u20090.047). There were no differences in the level of severity between the treatment groups (pu2009=u20090.98). This study, developed in a cohort of patients with RA with moderate or severe disease activity who were treated with MTX by itself or combined with other non-biological DMARDs under T2T strategy, showed a decrease in the severity of disease activity in 80xa0% of patients. The difference between monotherapy (MTX) and the combinations with other non-biological DMARDs could not be established.

Epidemiology of Spondyloarthritis in Colombia

There are no formal statistics about the incidence, prevalence or demographics of patients with spondyloarthropathies (SpAs) in Colombia. However, information from a few studies provides a preliminary snapshot of SpAs in the country. In this article, the authors review what has been published; document what their group is doing and outline what they still need to do in the future. The analysis suggests that although information on SpA in Colombia is limited, it is known that the diagnostic entities of SpA are different than those reported at other latitudes. Thus, it is important to improve and expand the current database of SpA, particularly undifferentiated SpA, not only in Colombia but in all of Latin America.

Direct Comparative Effectiveness Among 3 Anti–Tumor Necrosis Factor Biologics in a Real-Life Cohort of Patients With Rheumatoid Arthritis

ObjectiveThis study aimed to compare the clinical response at 36 months and evaluate the adverse events in a cohort of patients with rheumatoid arthritis treated with etanercept, infliximab, or adalimumab. MethodsAn observational retrospective cohort study was performed. Patients older than 18 years with active rheumatoid arthritis, for which the physician had initiated a treatment scheme with etanercept, infliximab, or adalimumab, were included in the study. The follow-up was conducted through at least trimestral evaluations during the course of 36 months. Outcomes evaluated included Disease Activity Score 28, level of disease activity, Health Assessment Questionnaire, and degree of disability. ResultsThree hundred seven subjects were included in the cohort (108 adalimumab, 107 infliximab, and 92 etanercept). The median Disease Activity Score 28 at the onset was 4.1 and 2.39 at month 36. There were no differences among the 3 medications (P = 0.51). The remission rate was of 7.4 per 100 people per month (95% confidence interval [CI], 6.6–8.3) without differences between groups. The initial Health Assessment Questionnaire median was 1.75 and 0.25 at 36 months. No differences per medicine were found (P = 0.54). The most common adverse effect was dermatitis. Eighteen cases of serious adverse effects occurred, including 11 cases of serious infectious events. The adverse events rates were as follows: infliximab, 24 per 100 people per year (95% CI, 19–29); adalimumab, 22 per 100 people per year (95% CI, 18–27); and etanercept, 12 per 100 people per year (95% CI, 8–16). ConclusionsEtanercept, infliximab, and adalimumab are 3 effective therapeutic anti–tumor necrosis factor alternatives to reduce the level of severity and the degree of disability generated by rheumatoid arthritis. Etanercept presented a rate of adverse events lower than those for infliximab and adalimumab.

From the model of integral attention to the creation of centers of excellence in rheumatoid arthritis

For the Pan American Health Organization (PAHO), the care of patients with chronic diseases currently experiences fragmentation in attention, generating poor performance of health services. Thus, comprehensive health care strategies arise to mitigate these problems; one of them are Centers of Excellence (CoEs), which aim to obtain high quality results in health from the adequate and minimum use of resources. The objective of this study was to describe the history and current context of the CoE in comprehensive care in patients with rheumatoid arthritis (RA). A systematic search of the literature terms (MeSH) was performed. The bases used were PubMed, Ebsco Host, Lilacs, Science Direct, Ovid, and Google (gray literature). The source of the information was evaluated to determine its quality. International standards focus the CoEs starting from comprehensive management of patients with RA and patient volume, continuous improvement, and quality of health care, constituting an interdisciplinary team. The REAL-PANLAR group suggested that the inclusion of the strategy “Treat to Target”, and patient education improves patient conditions and understanding of the disease. RA is a prevalent and costly disease. The creation of comprehensive care centers of the CoE type is an initiative that improves the prognosis of RA. This document aims to encourage rheumatologists and scientific societies to structure CoE in an interdisciplinary endeavor.

Is the Treatment with Biological or Non-biological DMARDS a Modifier of Periodontal Condition in Patients with Rheumatoid Arthritis?

BACKGROUND AND OBJECTIVEnExperimental models suggest the use of different therapy protocols in rheumatoid arthritis (RA) as modulators on periodontal condition. This study evaluated the effects of conventional drug treatment and anti-TNF therapy in patients with RA on microbiological and periodontal condition, establishing the association of markers of periodontal infection with indexes of rheumatic activity.nnnMATERIALS AND METHODSnOne hundred seventy nine individuals with RA were evaluated (62 with anti-TNF-. and 115 with only DMARDs). The periodontal evaluation included plaque and gingival indexes, bleeding on probing (BOP), clinical attachment loss (CAL), pocket depth (PD) and subgingival plaque samples for microbiological analysis. Rheumatologic evaluations included a clinical examination, rheumatoid factor (RF), antibodies against cyclic-citrullinated peptides (ACPAs), and activity markers (DAS28-ERS), high sensitive C-reactive protein (hs-CRP), erythrocyte sedimentation rate (ESR).nnnRESULTSnAnti-TNF-alpha therapy influenced periodontal microbiota with a higher frequency of T. denticola (p=0.01). Methotrexate combined with leflunomide exhibited a higher extension of CAL (p=0.005), and anti-TNF-alpha therapy with methotrexate was associated with a lower extension of CAL (p=0.05). The use of corticosteroids exerted a protective effect on the number of teeth (p=0.027). The type of DMARD affected P. gingivalis, T. forsythia and E. nodatum presence. Elevated ACPAs titers were associated with the presence of red complex periodontal pathogens (p=0.025). Bleeding on probing was associated with elevated CPR levels (p=0.05), and ESR was associated with a greater PD (p=0.044) and presence of red complex (p=0.030).nnnCONCLUSIONnDifferent pharmacological treatments for RA affect the clinical condition and subgingival microbiota.

Report on the First PANLAR Rheumatology Review Course Rheumatoid Arthritis: Challenges and Solutions in Latin America.

AbstractThe First PANLAR Rheumatology Review Course was held in Barranquilla, Colombia, in April 2015. Researchers, rheumatologists, epidemiologists, and a variety of allied professionals and patients attended the meeting. The scientific program included plenary sessions and symposia delivered by renowned experts in the field, followed by an interactive forum of discussion during 2 days.A broad spectrum of topics was discussed, reflecting the current challenges and opportunities for diagnosis and treatment of rheumatoid arthritis (RA) in Latin America. The scientific program included not only traditional disease aspects, but also social implications, research projects, and educational characteristics, patient perspectives, and novel care models, emphasizing the need for training human resources and proposing unique approaches to RA health care in Latin America, therefore helping us to increase and improve the knowledge and understanding of the characteristics of this health condition in the region, thus promoting and encouraging equity, quality, and efficiency of RA health care.

Ultrasound of sacroiliac joints in spondyloarthritis: a systematic review

Ultrasound (US) is an accessible imaging technique with a possible role to diagnose active sacroiliitis, so this technique is projected as a promising diagnostic tool for the diagnosis of SpA. We analyse the available evidence about the use of US as a diagnostic tool in sacroiliitis in patients with SpA, by a systemic review of the literature fulfilling OMERACT criteria. A systematic literature search for original articles was carried out using four databases (Medline, Embase, Scopus and Web of Science). Data from studies were included only if participants had SpA and a US examination of sacroiliac joint (SIJ) was performed. The methodological quality of the studies was assessed using QUADAS-2 tool. Thirteen studies were included. All studies were observational, prospective and cross-sectional. In most articles (76.9%), the main US finding compatible with sacroiliitis evaluated was the presence of vascularisation (Doppler signals) with measurements of the resistive index (RI). The sensitivity and specificity analysis were performed in seven studies (58.8%) and were good, with a median of 90 and 89.2%, respectively. The studies showed a positive to moderate a strong correlation between the US and the gold standard but this was optimal only in four studies. In general, the agreement was good in all studies (≥u20090.80). The methods of evaluation of sacroiliitis vary between the studies included. To date, there is not enough evidence to support the use of ultrasound as a diagnostic method for sacroiliitis but it has potential to identify structural lesions at SIJ’s level.

A comprehensive care program achieves high remission rates in rheumatoid arthritis in a middle-income setting. Experience of a Center of Excellence in Colombia

Management of rheumatoid arthritis (RA) in many Latin-American countries is impaired by fragmentation and scarce healthcare provision, resulting in obstacles to access, diagnosis, and treatment, and consequently in poor health outcomes. The aim of this study is to propose a comprehensive care program as a model to provide healthcare to RA patients receiving synthetic DMARDs in a Colombian setting by describing the model and its results. Health outcomes were prospectively collected in all patients entering the program. By protocol, patients are followed up during 24xa0months using a treat-to-target strategy with a patient-centered care (PCC) model, meaning that a patient should be seen by rheumatologist, physical and occupational therapist, physiatrist, nutritionist and psychologist, at least three times a year according to disease activity by DAS28. Otherwise, patients receive standard therapy. The incidence of remission and low disease activity (LDA) was calculated by periods of follow-up. A total of 968 patients entered the program from January 2015 to December 2016; 80.2% were women. At baseline, 41% of patients were in remission, 17% in LDA and 42% in MDS/SDA. At 24xa0months of follow-up, 66% were in remission, 18% in LDA and only 16% in MDS/SDA. Regarding DAS28, the mean at the beginning of the time analysis was 3.1 (SD 1.0) and after 24xa0months it was 2.4 (SD 0.7), showing a statistically significant improvement (pu2009<u20090.001). In all patients, the reduction of disease activity was 65% (95% CI, 58–71). Patients entering the PCC program benefited from a global improvement in disease activity in terms of DAS28.

Dickkopf 1 protein circulating levels as a possible biomarker of functional disability and chronic damage in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is an inflammatory disease characterized by joint destruction, deformity, lower functionality, and decrease in life expectancy. Wingless signaling pathway (Wnt) has been recently involved in bone homeostasis. Studies suggest that overexpression of the pathway inhibitors, like the Dickkopf 1 protein (DKK1), has been implicated in bone destruction. The objective of this study is to compare circulating levels of DKK1 in different groups of patients with disease activity (remission, low, moderate, high activity,) and functionality status. Three hundred seventy-nine patients with RA were evaluated between March 2015 and November 2016. Disease activity was evaluated by disease activity score 28 with C-reactive protein (DAS28CPR), simplified and clinical disease activity scores (SDAI, CDAI), routine assessment of patient index data 3 (RAPID3), functional status using Multidimensional Health Assessment Questionnaire (MD-HAQ), and the Steinbrocker functional classification. DKK1 levels were measured by ELISA. The mean age was 60.7xa0±u200913.9xa0years. Disease duration was 13.2xa0±u200910.9xa0years. Higher levels of DKK1 were not associated with disease activity by CDAI (pu2009=u20090.70), SDAI (pu2009=u20090.84), DAS28CRP (pu2009=u20090.80), or RAPID3 (pu2009=u20090.70). Interestingly higher levels of DKK1 were significantly associated to lower functional status evaluating by the Steinbrocker classification (pu2009=u20090,013), severe disability by MD-HAQ (pu2009=u20090,004), and variables associated with joint destruction like osteoporosis, higher titles of rheumatoid factor, smoking, and increased hospital admissions related to RA. Higher levels of DKK1 were found in patients with lower functional status. This association was not found in patients with greater disease activity by CDAI, SDAI, DAS28, and RAPID3. This could be explained by more structural damage; DKK1 could be used as a biomarker of joint destruction in RA.