SLESIS-R: an improved score for prediction of serious infection in patients with systemic lupus erythematosus based on the RELESSER prospective cohort.

OBJECTIVE: To develop an improved score for prediction of severe infection in patients with systemic lupus erythematosus (SLE), namely, the SLE Severe Infection Score-Revised (SLESIS-R) and to validate it in a large multicentre lupus cohort. METHODS: We used data from the prospective phase of RELESSER (RELESSER-PROS), the SLE register of the Spanish Society of Rheumatology. A multivariable logistic model was constructed taking into account the variables already forming the SLESIS score, plus all other potential predictors identified in a literature review. Performance was analysed using the C-statistic and the area under the receiver operating characteristic curve (AUROC). Internal validation was carried out using a 100-sample bootstrapping procedure. ORs were transformed into score items, and the AUROC was used to determine performance. RESULTS: A total of 1459 patients who had completed 1 year of follow-up were included in the development cohort (mean age, 49±13 years; 90% women). Twenty-five (1.7%) had experienced ≥1 severe infection. According to the adjusted multivariate model, severe infection could be predicted from four variables: age (years) ≥60, previous SLE-related hospitalisation, previous serious infection and glucocorticoid dose. A score was built from the best model, taking values from 0 to 17. The AUROC was 0.861 (0.777-0.946). The cut-off chosen was ≥6, which exhibited an accuracy of 85.9% and a positive likelihood ratio of 5.48. CONCLUSIONS: SLESIS-R is an accurate and feasible instrument for predicting infections in patients with SLE. SLESIS-R could help to make informed decisions on the use of immunosuppressants and the implementation of preventive measures.

Ajuste en la práctica clínica de las directrices treat-to-target para la artritis reumatoide: resultados del estudio ToARCan / Adjustment in the clinical practice of treat-to-target guidelines for rheumatoid arthritis: results of the ToARCan study

Objetivo. Analizar el cumplimiento de las directrices t2t en la práctica clínica. Métodos. Estudio observacional transversal en pacientes consecutivos con artritis reumatoide (AR) de 5 hospitales canarios. Los pacientes cumplimentaron escalas de actividad, el HAQ y respondieron si el médico les había explicado el objetivo del tratamiento. El médico recogió además: visitas en el último año, empleo de índices y HAQ, DAS28 de la visita actual y fecha de la siguiente consulta. Se analizó el porcentaje de cumplimiento de las recomendaciones t2t (R) 1, 3, 5-7 y 10. Resultados. Se reclutó a 343 pacientes, 77% mujeres, con edad promedio de 57 años y duración de la AR de 10 años. La mediana de visitas en el último año fue de 3 y el promedio de meses entre la visita anterior y la actual de 5,6. El 93% estaba en tratamiento con FAME y el 44% en remisión por DAS (R1). Se había realizado recuento articular en la visita previa al 85%, HAQ al 19%, EVA actividad del paciente al 41% y DAS28 al 35% (R6). La siguiente visita se programó en un promedio entre uno y 3 meses (R5) al 64% de los pacientes con DAS28>3,2. El 96% de los pacientes dijo haber sido informado del objetivo del tratamiento (R10). La variabilidad entre centros era moderada, pero existía. El único factor que determinaba la realización de un DAS28 en la última consulta era el centro de procedencia del paciente. Conclusiones. Los centros canarios estudiados logran altas cotas de remisión y baja actividad en sus pacientes; la realización de índices compuestos y la frecuencia de seguimiento recomendado por el t2t se cumplen, aunque hay oportunidad de mejora (AU)

Objective. To analyze compliance with t2t clinical practice guidelines. Methods. Cross-sectional observational study in consecutive patients with rheumatoid arthritis (RA) in 5 hospitals in the Canary Islands. Patients filled out activity scales, HAQ and answered the question of whether the doctor had explained the treatment target. The rheumatologist also collected: visits in the past year, use of activity indices and HAQ, DAS28 of current visit and date of the next visit. The percentage of compliance to indicators based on the t2t recommendations (R) 1, 3, 5-7 and 10 was analyzed. Results. A total of 343 patients were recruited, 77% female, mean age 57, RA duration of 10 years. Median visits in the last year were 3 and mean time between last and current visit was 5.6 months. A total of 93% of the patients were treated with DMARDs and 44% were in remission by DAS (R1). In the previous visit, documented joint count was present in 85%, a HAQ in 19%, patient VAS in 41%, and a DAS28 in 35% of the patients (R6). The next visit was scheduled at an average of 4.3 months (R5). In 64% of patients with DAS28> 3.2 a visit between one and 3 months was scheduled (R5). A total of 96% of patients said they had been informed of the treatment target (R10). Variability between centers existed but was moderate. The only factor determining the performance of a DAS28 in the last visit was the patient's center of origin. Conclusions. The Canary Island centers studied achieved high levels of remission and low activity in their patients. The performance of composite indices and follow-up frequency recommended by the t2t are met, although there is room for improvement (AU)

Adjustment in the clinical practice of treat-to-target guidelines for rheumatoid arthritis: Results of the ToARCan study.

OBJECTIVE: To analyze compliance with t2t clinical practice guidelines. METHODS: Cross-sectional observational study in consecutive patients with rheumatoid arthritis (RA) in 5 hospitals in the Canary Islands. Patients filled out activity scales, HAQ and answered the question of whether the doctor had explained the treatment target. The rheumatologist also collected: visits in the past year, use of activity indices and HAQ, DAS28 of current visit and date of the next visit. The percentage of compliance to indicators based on the t2t recommendations (R) 1, 3, 5-7 and 10 was analyzed. RESULTS: A total of 343 patients were recruited, 77% female, mean age 57, RA duration of 10 years. Median visits in the last year were 3 and mean time between last and current visit was 5.6 months. A total of 93% of the patients were treated with DMARDs and 44% were in remission by DAS (R1). In the previous visit, documented joint count was present in 85%, a HAQ in 19%, patient VAS in 41%, and a DAS28 in 35% of the patients (R6). The next visit was scheduled at an average of 4.3 months (R5). In 64% of patients with DAS28> 3.2 a visit between one and 3 months was scheduled (R5). A total of 96% of patients said they had been informed of the treatment target (R10). Variability between centers existed but was moderate. The only factor determining the performance of a DAS28 in the last visit was the patient's center of origin. CONCLUSIONS: The Canary Island centers studied achieved high levels of remission and low activity in their patients. The performance of composite indices and follow-up frequency recommended by the t2t are met, although there is room for improvement.

Factors associated with the intensification of treatment in rheumatoid arthritis in clinical practice.

The aim of the present study was to analyse the patterns of treatment adjustment in rheumatoid arthritis (RA) patients with active disease in routine clinical care. This was a cross-sectional study of consecutive patients with RA conducted in five hospitals. Activity scales (DAS28-ESR) and function (HAQ) were measured, as well as whether ultrasound was performed as part of the assessment. Treatment decision (no changes/reduction/intensification) and time to the next scheduled visit were the outcomes variables. Associated factors were analysed by multilevel regression models. A total of 343 patients were included (77 % women, mean age 57 years, mean RA duration 10 years), of whom 44 % were in remission by DAS28. Treatment was continued in 202 (59 %) patients, reduced in 57 (16 %), and intensified in 83 (24 %). In the 117 patients with active RA (DAS28 ≥ 3.2), treatment was intensified in 61 (52 %). Factors associated with treatment intensification were physician and patient VAS, and DAS28, but not the centre. In the multilevel regression analysis with intensification of treatment as dependent variable, the following factors were significantly associated: DAS28 [OR 3.67 (95 % CI 2.43-5.52)], patient VAS [OR 1.04 (95 % CI 1.01-1.08)], and have performed an ultrasound [OR 3.36 (95 % CI 1.47-7.68)]. Factors associated with time to the next scheduled visit (an average of 4.3 months) were patient and physician VAS, DAS28, and centre. In clinical practice, half of the patients with active RA maintain or reduce the treatment. The decision to intensify treatment in active RA as recommended by a treat-to-target strategy is complex in practice.