Introducción: En los últimos años se ha reconocido la importancia del diagnóstico precoz de la artritis reumatoidea y las espondiloartritis. Aún existen barreras que impiden la derivación precoz de estos pacientes.Objetivo: Evaluar si existe un aumento significativo en el número de derivaciones al Servicio de Reumatología luego de implementar una estrategia de concientización a otros especialistas.Material y métodos: Estudio observacional, retrospectivo.Resultados: Durante el primer período, el servicio realizó un total de 1027 consultas, de las cuales 130 fueron derivaciones. Las consultas efectuadas luego de la implementación del plan de derivación fueron 1199 con 202 derivaciones (17% IC 95 14,7-19); la diferencia entre ambos períodos fue estadísticamente significativa (p 0,003).Conclusión: La implementación de estrategias de derivación fue valiosa, puesto que encontramos un incremento en el número de derivaciones realizadas. Consideramos que estas intervenciones deben perdurar en el tiempo para mejorar el diagnóstico precoz.
BackgroundIt has been seen that patients who achieve remission measured by DAS28 persist with subclinical synovitis on hands and toes evaluated by ultrasound. In recent times stricter criteria as the CDAI, SDAI and ACR EULAR Boolean have been proposed.ObjectivesTo evaluate the stricter criteria as diagnostic test with ultrasound considered as reference test or gold standard in patients in remission for DAS28.MethodsWe evaluated consecutive patients in remission by DAS28 less than 2,6. Strict criteria were applied. A rheumatologist specializing in musculoskeletal ultrasound, who was unaware of the clinical status and laboratory activities, performed ultrasonography on hands and and toes. Systematic evaluation was performed on grayscale and Doppler technique with multifrequency linear transducer (10 -18 MHz) in longitudinal and transverse sections of radiocarpal joint, second and third metacarpophalangeal, second and third proximal interphalangeal in both hands, second to fifth metatarsophalangeal joint, bilateral. It was considered as cases, synovitis absence grade II-III and/or Power Doppler II-III using OMERACT's definitions. We defined controls as the ones with at least one of these signs of activity. We consider positive diagnosis test to remission status for different stricter criteria. Sensitivity, specificity, positive likelihood ratio, positive predictive value (PPV) and negative predictive value (NPV).Results100 scans were performed in 100 patients, 80% were women (n=80) and the mean age 52.7 SD 12. There were no differences in age, sex, duration of disease, treatment, or RF and anti CCP positivity between cases and controls. Of the ultrasound screening 58 didn't have signs of activity and 42 had synovitis and/or PD grade II-III. Table 1 shows the status of activity and Table 2 shows the results.Table 1Ultrasound without activity on hands and toesn (%)Remission by Boolean ACR/EULAR criteria (n=45)16 (36)No Remission by Boolean ACR/EULAR criteria (n=55)26 (47)Remission by SDAI (n=70)29 (41)No remission by SDAI (n=30)13 (43)Remission by CDAI (n=62)26 (41)No remission by CDAI (n=38)16 (42) Table 2SensitivitySpecificityPPVNPVPositive LR% (95 CI)% (95 CI)% (95 CI)% (95 CI)Boolean ACR/EULAR38 (29–48)50 (40–60)36 (26–45)53 (43–63)0,8 (0,5–1,2)CDAI62 (53–71)38 (28–47)42 (32–52)58 (48–68)1 (0,8–1,3)SDAI69 (60–78)29 (20–38)41 (32–51)57 (47–66)1 (0,8–1,3) ConclusionsWe found that in this population, which is in remission for DAS28, none of the three criteria is of great value to detect absence of activity using ultrasound as gold standard.ReferencesFelson DT, Smolen JS, Wells G, Zhang B, van Tuyl LH, Funovits J, et al. American College of Rheumatology; European League Against Rheumatism. American College of Rheumatology/European League Against Rheumatism provisional definition of remission in rheumatoid arthritis for clinical trials. Arthritis Rheum. 2011; 63:573-86.Disclosure of InterestNone declared
BackgroundThe purpose of the T2T approach in RA is to achieve remission or LDA according to results from objective activity measurements. This strategy has proven clinical benefits, however objective adherence T2T measurement tools are lacked in daily practice.ObjectivesTo evaluate the setting, usage of a T2T adherence measure: T2T70 and T2T100, and its association with sustained low disease activity (LDAS) as a measure of outcome.MethodsProspective study, consecutive patients with RA diagnosis (ACR/EULAR 2010) and follow-up between 1 and 24 months were included. Data from electronic medical record (EHR) were collected. Demographic variables, characteristics of the disease and treatment were recorded. The following T2T characteristics were defined and collected from each patient: number of visits, visits where treatment was adjusted, CDAI measurements, use of ultrasound to measure disease activity and achievement of LDA. Sustained LDA (LDAS) was defined when the patient had 2 or more records of that consecutive state of activity. Measures of adherence to T2T were defined as follows: T2T-70, when therapeutic decisions were accompanied by the measurement of activity by 70% and the interval between visits did not exceed 6 months; And T2T-100, when 100% of the decisions were accompanied with the activity measurement and the interval between each visit did not exceed 6 months. Statistical analysis: a descriptive analysis of the variables was performed and Chi2 test (categorical) and Student or MannWhitney test (continuous) were applied. For multivariate logistic regression analysis we considered as dependent variable LDAs.Results96 patients were included, with a mean follow-up of 15 months (DS 7.8), equivalent to 120.6 patients/year. Eighty percent of the patients were women, mean age 53.7 years (SD 13), disease duration 36 months (RIC, 12–52), 64% had early diagnosis, 85% and 75% positive For FR and ACPA, respectively. According to T2T characteristics, 526 visits were recorded, 270 were treatment adjustment and 208 (78%) of them were performed according to the CDAI value. The frequency of LDAS was 20% (IC95: 12–30). The frequency of T2T-70 compliance was 62.5% (IC95: 52–72) and T2T-100 was 42% (IC95: 32–52). Compliance with T2T-70 and T2T-100 presented a statistically significant association to the achievement of LDAS in the uni and multivariate analysis (p: 0.000). Compliance with T2T-70 and T2T-100 was associated with a shorter time course of disease; And T2T-70 also showed association with early diagnosis.ConclusionsT2T-70 and T2T-100 adherence were 62% and 42%, respectively, patients who met these criteria reached more LDAS. The early diagnosis and shorter time to disease evolution at baseline were variables that were variables that were associated with more compliance of these tools.AcknowledgementsDra Josefina Marcos.Disclosure of InterestNone declared
BackgroundCurrently, one of the main goals of rheumatoid arthritis treatment is to attain remission. Stricter criteria, namely CDAI, SDAI ACR/EULAR Boolean have been proposed. Moreover, DAS28 is criticized for the exclusion of foot joints assessment. However the degree of agreement that they have with the ultrasound findings in patienrs in remission is not well known.ObjectivesThe aim of our study is to evaluate the degree of agreement between the state of remission as measured by different stricter criteria and the absence of activity assessed by ultrasound of hands and toes.MethodsWe included consecutive patients diagnosed with RA according to ACR EULAR 2010 criteria being in remission defined as DAS28 <2.6. We evaluated whether stricter criteria were met (CDAI, SDAI, Boolean, Boolean without EVA). A rheumatologist specialized in musculoskeletal ultrasound, who was unaware of the state of activity, performed ultrasonography on hands and toes. Systematic evaluation was performed on grayscale and power Doppler technique with multifrequency linear transducer (10-18MHz) in longitudinal and transverse sections of the radiocarpal joint, second and third metacarpophalangeal, second and third proximal interphalangeal in both hands and second to fifth articulation metatarsophalangeal (all of them bilateral). Lack of activity was defined when the patient had no exudative synovitis grade II and III, and power Doppler grade II and III in any of the evaluated joints.Results100 ultrasounds were performed in 100 patients, 80% were women (n=80) and the mean age was 52.7 DS 12. There were no differences in age, sex, duration of disease, treatment, or RF and antiCCO positivity between patients with and without ultrasound activity. Table 1 shows the state of remission of the evaluated patients. Table 2 shows the degree of agreement among different criteria, and the absence of activity assessed by ultrasound in hands and feet.Table 1Ultrasound with activity on handsUltrasound with activity on footUltrasound without activity on hands)Ultrasound without activity on footn (%)n (%)n (%)n (%)Remission by Boolean (n=45)26 (58)8 (18)19 (42)37 (82)Remission by Boolean without VAS (n=71)30 (42)18 (25)41 (58)53 (75)Remission by SDAI (n=70)34 (48)19 (27)36 (52)51 (73)Remission by CDAI (n=62)51 (82)17 (27)11 (18)45 (72) Table 2Remission criteriaAgreementCI 95Boolean ACR/EULARk −0,1−0,3–0,09Boolean without EVAk 0,40,22–0,53SDAIk 0,270,11–0,42CDAIk −0,07−0,21–0,07 ConclusionsThere was no agreement between the state of remission measured by the various strict criteria and the absence of activity assessed by ultrasound feet in this study population. Only acceptable agreement was found with the Boolean criterion that excludes EVA on hands was found.ReferencesFelson DT, Smolen JS, Wells G, Zhang B, van Tuyl LH, Funovits J, et al. American College of Rheumatology; European League Against Rheumatism. American College of Rheumatology/European League Against Rheumatism provisional definition of remission in rheumatoid arthritis for clinical trials. Arth...
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