The patient journey of fibromyalgia in Latin America.

OBJECTIVES: To explore the patient journey of people with fibromyalgia (FM) in Latin American countries in order to identify problems in health care and other areas that may be resolvable. METHODS: Qualitative study with phenomenological and content analysis approach through focus groups and patient journey (Ux; User Experience) methodology. Nine virtual focus groups were conducted with FM patients and healthcare professionals in Argentina, Mexico and Colombia recruited from key informants and social networks. RESULTS: Forty-three people participated (33 were clinicians and 10 were patients). The agents interacting with the patient in their disease journey are found in three spheres: healthcare (multiple medical specialists and other professionals), support and work life (including patient associations) and socioeconomic context. The line of the journey presents two large sections, two loops and a thin dashed line. The two major sections represent the time from first symptoms to medical visit (characterized by self-medication and denial) and the time from diagnosis to follow-up (characterized by high expectations and multiple contacts to make life changes that are not realized). The two loop phases include (1) succession of misdiagnoses and mistreatments and referrals to specialists and (2) new symptoms every so often, visits to specialists, diagnostic doubts, and impatience. Very few patients manage to reach the final phase of autonomy. CONCLUSION: The journey of a person with FM in Latin America is full of obstacles and loops. The desired goal is for all the agents involved to understand that self- management by the patient with FM is an essential part of success, and this can only be achieved with early access to resources and guidance from professionals.

El viaje del paciente con fibromialgia en Latinoamérica / The patient journey of fibromyalgia in Latin America

Objetivos: Explorar la experiencia de las personas con fibromialgia (FM) en países latinoamericanos con objeto de identificar problemas en la atención sanitaria y otros ámbitos potencialmente solucionables. Métodos: Estudio cualitativo con enfoque fenomenológico y de análisis de contenido a través de grupos focales y metodología de viaje del paciente (Ux del inglés User Experience). Se llevaron a cabo 9 grupos focales virtuales con pacientes con FM y profesionales sanitarios en Argentina, México y Colombia reclutados a partir de informantes clave y redes sociales. Resultados: Participaron 43 personas (33 clínicos y 10 pacientes). Los agentes que interaccionan con el paciente en la enfermedad se encuentran en 3 esferas: la de la atención sanitaria, la del apoyo y vida laboral y la del contexto socioeconómico. La línea del viaje presenta 2 grandes tramos, 2 bucles y una línea discontinua delgada. Los 2 grandes tramos representan los tiempos que van desde los primeros síntomas hasta la visita médica y desde el diagnóstico hasta el seguimiento. Los bucles incluyen: 1.°) sucesión de diagnósticos, tratamientos erróneos y derivaciones a especialistas y 2.°) nuevos síntomas cada cierto tiempo, visitas a especialistas y dudas diagnósticas. Pocos pacientes logran la fase final de autonomía. Conclusión: El viaje de una persona con FM en Latinoamérica está lleno de obstáculos. La meta deseada es que todos los agentes entiendan que el automanejo por parte del paciente con FM es una parte indispensable del éxito, y solo se puede lograr accediendo a recursos de forma precoz y guiado por profesionales.(AU)

Objectives: To explore the patient journey of people with fibromyalgia (FM) in Latin American countries in order to identify problems in health care and other areas that may be resolvable. Methods: Qualitative study with phenomenological and content analysis approach through focus groups and patient journey (Ux; User Experience) methodology. Nine virtual focus groups were conducted with FM patients and healthcare professionals in Argentina, Mexico and Colombia recruited from key informants and social networks. Results: Forty-three people participated (33 were clinicians and 10 were patients). The agents interacting with the patient in their disease journey are found in three spheres: healthcare (multiple medical specialists and other professionals), support and work life (including patient associations) and socioeconomic context. The line of the journey presents two large sections, two loops and a thin dashed line. The two major sections represent the time from first symptoms to medical visit (characterized by self-medication and denial) and the time from diagnosis to follow-up (characterized by high expectations and multiple contacts to make life changes that are not realized). The two loop phases include (1) succession of misdiagnoses and mistreatments and referrals to specialists and (2) new symptoms every so often, visits to specialists, diagnostic doubts, and impatience. Very few patients manage to reach the final phase of autonomy. Conclusion: The journey of a person with FM in Latin America is full of obstacles and loops. The desired goal is for all the agents involved to understand that self-management by the patient with FM is an essential part of success, and this can only be achieved with early access to resources and guidance from professionals.(AU)

Genomic insights into the origin and diversification of late maritime hunter-gatherers from the Chilean Patagonia.

Patagonia was the last region of the Americas reached by humans who entered the continent from Siberia ∼15,000-20,000 y ago. Despite recent genomic approaches to reconstruct the continental evolutionary history, regional characterization of ancient and modern genomes remains understudied. Exploring the genomic diversity within Patagonia is not just a valuable strategy to gain a better understanding of the history and diversification of human populations in the southernmost tip of the Americas, but it would also improve the representation of Native American diversity in global databases of human variation. Here, we present genome data from four modern populations from Central Southern Chile and Patagonia (n = 61) and four ancient maritime individuals from Patagonia (∼1,000 y old). Both the modern and ancient individuals studied in this work have a greater genetic affinity with other modern Native Americans than to any non-American population, showing within South America a clear structure between major geographical regions. Native Patagonian Kawéskar and Yámana showed the highest genetic affinity with the ancient individuals, indicating genetic continuity in the region during the past 1,000 y before present, together with an important agreement between the ethnic affiliation and historical distribution of both groups. Lastly, the ancient maritime individuals were genetically equidistant to a ∼200-y-old terrestrial hunter-gatherer from Tierra del Fuego, which supports a model with an initial separation of a common ancestral group to both maritime populations from a terrestrial population, with a later diversification of the maritime groups.

Investigating cranial morphological variation of early human skeletal remains from Chile: A 3D geometric morphometric approach.

OBJECTIVES: Archaeological and genetic research has demonstrated that the Pacific Coast was a key route in the early colonization of South America. Research examining South American skeletons >8000 cal BP has revealed differences in cranial morphology between early and late Holocene populations, which may reflect distinct migration events and/or populations. However, genetic, cultural, and some skeletal data contradict this model. Given these discrepancies, this study examines ∼9000 years of prehistory to test the hypothesis that Early skeletons have a distinct cranial morphology from later skeletons. MATERIALS AND METHODS: Using 3D digital models, craniofacial landmarks, and geometric morphometric analyses, we compared Early Holocene crania (n = 4) to later Chilean samples (n = 90) frequently absent in continental assessments of craniofacial variation. PCA, Mahalanobis distances, posterior and typicality probabilities were used to examine variation. RESULTS: Two of the earliest skeletons from northern Chile show clear affinities to individuals from later sites in the same region. However, the hypothesis cannot be rejected as one Early individual from northern Chile and one individual from inland Patagonia did not always show clear affinities to coastal populations. DISCUSSION: Biological affinities among northern populations and other regions of Chile align with genetic and archaeological data, supporting cultural and biological continuity along the Pacific Coast. In Patagonia, archaeological data are in accordance with skeletal differences between the Early inland steppe individual and coastal populations. This study incorporates 3D methods and skeletal datasets not widely used in assessments of biological affinity, thus contributing to a critical body of research examining the ancient population history of western South America.

[Osteoarthrosis: implementation of current diagnostic and therapeutic algorithms]. / Osteoartrosis: implementación de los algoritmos de diagnóstico y terapéutico vigentes.

In the modern world, among the different clinical presentations of osteoarthritis, gonarthrosis and coxarthrosis exhibit the highest prevalence. In this paper, the characteristics of osteoarthritis and the different scales of assessment and classification of this pathology are exposed, to provide an exhibition of current evidence generated around diagnostic algorithms and treatment of osteoarthritis, with emphasis set out in the knee and hip, as these are the most frequent; a rational procedure for monitoring patients with osteoarthritis based on characteristic symptoms and the severity of the condition is also set. Finally, reference is made to the therapeutic benefits of the recent introduction of viscosupplementation with Hylan GF-20.

En el mundo moderno, de entre las distintas presentaciones clínicas de la osteoartrosis, la gonartrosis y la coxartrosis son las que exhiben las mayores prevalencias. En el presente artículo se enuncian los rasgos característicos de la osteoartrosis y las diferentes escalas de evaluación y clasificación de esta patología, para a continuación ofrecer una exposición de la evidencia actual generada en torno a los algoritmos de diagnóstico y terapéuticos de la osteoartrosis, con énfasis en la de rodilla y la de cadera por ser estas las de mayor frecuencia; también se establece un procedimiento racional para el seguimiento del paciente con osteoartrosis en función de la sintomatología característica y el grado de severidad del padecimiento. Finalmente, se alude a los beneficios terapéuticos de la reciente introducción de la viscosuplementación mediante Hilano GF-20.

Falta de asociación entre inflamación subclínica evaluada por ultrasonido y niveles de citocinas en artritis reumatoide / Lack of association between ultrasound-defined subclinica inflammation and cytokines levels in rheumatoid arthritis

Antecedentes: La artritis reumatoide (AR) es una enfermedad autoinmune crónica que se caracteriza por proliferación sinovial, ruptura de cartílago y destrucción ósea. Los biomarcadores en AR no se utilizan en forma rutinaria para evaluar la inflamación y tampoco la remisión. El ultrasonido musculoesquelético (US) visualiza los cambios en las articulaciones y el daño morfoestructural, mejorando la evaluación de la sinovitis.Objetivo: Identificar y describir la inflamación subclínica en pacientes con AR en re-misión, utilizando US.Métodos: Se incluyeron pacientes con AR en remisión. Se realizó una evaluación clí-nica con DAS28; se tomó muestra de sangre para analizar citocinas. Un ecografista reumatólogo sin acceso a datos clínicos realizó un conteo ecográfico utilizando el sco-re-7. Se utilizaron parámetros de tendencia central, análisis de correlación bivariada y X cuadrado. Se estableció un nivel de confianza del 95% y, por tanto, cualquier valor p ≤0.05 se consideró significativo.Resultados: Se incluyeron 38 pacientes con AR. La edad media fue de 45,26±12,24 años. Los niveles de citocinas asociadas al tiempo de la AR desde la remisión, no fue-ron estadísticamente significativas. El ultrasonido en los pacientes evidenció al menos una de las lesiones elementales; en escala de grises, la sinovitis ocurrió en un 94,7%; sinovitis con señal Doppler de poder (DP) 52,6%; en cuanto a erosiones, se registra-ron, respectivamente, un 55,3% en escala de grises y un 15,8% con DP. DAS28 >2,04 fue positivo al asociarse con el recuento de articulaciones dolorosas y significativo (p=0,009). Conclusión: La asociación entre la sinovitis clínica y en ecografía no tiene correlación con los criterios de AR en remisión, independientemente de cuán estricta sea su aplicación.

Background: Rheumatoid arthritis (RA) is a chronic autoimmune disease, character-ized by synovial proliferation, cartilage breakdown and bone destruction. Biomarkers are not routinely used to evaluate inflammation neither remission. Musculoskeletal ultrasound visualizes joint changes and morpho-structural damage improving the as-sessment of synovitis.Objective: To identify and describe subclinical inflammation in patients with RA in remission using US.Methods: RA patients in remission were included. A clinical evaluation and DAS28 score performed; a blood sample took to analyze cytokines. A rheumatologist ultraso-nographer blinded to clinical data performed a US 7-score joint count. Central tenden-cy parameters, bivariate correlation analysis, and X Square were used. A confidence level of 95% was set and, therefore, any p-value ≤0.05 was considered as significant.Results: 38 RA patients were included. Mean age was 45.26±12.24 years. Cytokines associated with the time since remission was not statistically significant. Patients dis-played at least one of US elementary lesions; gray-scale synovitis occurred in 94.7%; synovitis with PD signal 52.6%; gray-scale erosions 55.3% and erosions with PD 15.8% respectively. DAS28 >2.04 positive for tender joint count was significant (p=0.009).Conclusion: The association between the clinical and US synovitis does not correlate with RA remission criteria no matter how strict is its application.

Antiquity and geographic distribution of cranial modification among the prehistoric groups of Fuego-Patagonia, Chile.

OBJECTIVES: Nineteenth and twentieth century documents testify that four ethnic groups, generally classified as terrestrial hunters or canoe nomads, inhabited Fuego-Patagonia. Archaeologically, however, their presence and temporal depth remains unknown. This study analyzes the antiquity and geographic distribution of cranial modification, a highly visible symbol of social identity, in Fuego-Patagonia, Chile, to assess whether it expressed ethnic affiliation. MATERIALS AND METHODS: A total of 60 adult skulls from Southern Patagonia (n = 32; 53.3%) and Tierra del Fuego (n = 28; 46.7%) were examined for age-at-death, sex and cranial modification with standard methods. Individuals were further categorized as terrestrial (n = 26; 43.3%), marine (n = 21; 35%) or indetermined hunter-gatherers (n = 13; 21.7%) based on the archaeological site's characteristics, geographic location, and isotopic information. RESULTS: Thirty percent (n = 18) of the skulls in this study were modified, and most of the modified skulls (n = 15) presented a tabular-erect shape. No statistically significant differences were identified between Fuegians and Patagonians, males or females, or between the different types of adaptation and geographic locations. DISCUSSION: Thus, this Late Holocene, widely distributed practice, was not a reflection of ethnicity, but a material expression of information circulation and the complex social relations that these small-size groups had with one another. These results suggest that the emergence of modern ethnic identities in the region is a historic process that resulted from the interaction of local groups with European and Criollos.

Terapia biológica, sobrevida y seguridad en padecimientos reumáticos. Resultados del Registro Nacional Biobadamex 1.0 / Patient survival and safety with biologic therapy. Results of the Mexican National Registry Biobadamex 1.0

Mediante registro multicéntrico ambispectivo de 2.047 pacientes con diversas afecciones reumáticas bajo terapia biológica (TxB), incluyendo un grupo control de pacientes con artritis reumatoide (AR) sin TxB, se reporta la supervivencia en la terapia y eventos adversos asociados a su uso. Los diagnósticos más frecuentes son: AR 79,09%; espondilitis anquilosante (EA) 7,96%; artritis psoriásica (APso) 4,40%; lupus eritematoso sistémico (LES) 3,37% y artritis idiopática juvenil (AIJ) 1,17 por ciento. Un análisis de 1.514 casos de la muestra total reportó que la tasa de incidencia para cualquier evento adverso es de 178/1.000 pacientes-año en TxB vs. 109/1.000 pacientes-año en controles con un riesgo relativo (RR) de 1,6 (IC del 95%, 1,4-1,9); para eventos adversos graves un RR de 15,4 (IC del 95%, 3,7-63,0 p < 0,0001). La supervivencia global de TxB es del 80% a 12 meses, el 61% a 24 meses, el 52% a 36 meses y el 45% a 48 meses. La tasa de mortalidad estandarizada (TME) es de 0,23 (IC del 95%, 0,0-49,0) para TxB vs. 0,00 (IC del 95%, 0,0-0,2) para controles. Se concluye que la TxB se asocia a un mayor riesgo de presentar eventos adversos, especialmente infecciosos, en comparación con pacientes sin TxB. La mortalidad de los pacientes expuestos a TxB no es mayor que la esperada para la población general ajustada a edad y sexo (AU)

This work reports patient treatment survival and adverse events related to Biologic Therapy (BT), identified by a multicenter ambispective registry of 2047 rheumatic patients undergoing BT and including a control group of Rheumatoid Arthritis (RA) patients not using BT. The most common diagnoses were: RA 79.09%, Ankylosing Spondilytis 7.96%, Psoriatic Arthritis 4.40%, Systemic Lupus Erythematosus 3.37%, Juvenile Idiopathic Arthritis 1.17%. A secondary analysis included 1514 cases from the total sample and was performed calculating an incidence rate of any adverse events of 178 × 1000/ BT patients per year vs. 1009 x 1000/control group patients per year with a 1.6 RR (IC95% 1.4-1.9). For serious adverse events the RR was: 15.4 (95% CI 3.7-63.0, P<.0001). Global BT survival was 80% at 12 months, 61% at 24 months, 52% at 36 months and 45% at 48 months. SMR: 0.23 (95%CI 0.0-49.0) for BT vs. 0.00 (95%CI 0.0-0.2) for the control group. In conclusion, BT was associated to a higher infection risk and adverse events, compared to other patients. Mortality using BT was not higher than expected for general population with same gender and age (AU)

Patient survival and safety with biologic therapy. Results of the Mexican National Registry Biobadamex 1.0.

This work reports patient treatment survival and adverse events related to Biologic Therapy (BT), identified by a multicenter ambispective registry of 2047 rheumatic patients undergoing BT and including a control group of Rheumatoid Arthritis (RA) patients not using BT. The most common diagnoses were: RA 79.09%, Ankylosing Spondilytis 7.96%, Psoriatic Arthritis 4.40%, Systemic Lupus Erythematosus 3.37%, Juvenile Idiopathic Arthritis 1.17%. A secondary analysis included 1514 cases from the total sample and was performed calculating an incidence rate of any adverse events of 178 × 1000/BT patients per year vs 1009 × 1000/control group patients per year with a 1.6 RR (95% CI 1.4-1.9). For serious adverse events the RR was: 15.4 (95% CI 3.7-63.0, P<.0001). Global BT survival was 80% at 12 months, 61% at 24 months, 52% at 36 months and 45% at 48 months and SMR: 0.23 (95% CI 0.0-49.0) for BT vs 0.00 (95% CI 0.0-0.2) for the control group. In conclusion, BT was associated to a higher infection risk and adverse events, compared to other patients. Mortality using BT was not higher than expected for general population with same gender and age.

[Guidelines in RA treatment: concepts on safety and recommendations using anti-TNF-alpha inhibitors. Grupo de Estudio de Nuevas Terapias de Enfermedades reumáticas (GENTE)]. / Recomendaciones para el tratamiento médico de la artritis reumatoide: actualización sobre la seguridad de los antagonistas del factor de necrosis tumoral alfa. Grupo de Estudio de Nuevas Terapias de Enfermedades reumáticas (GENTE).

Recommendations for the use of Disease-Modifying Antirheumatic Drugs (DMARD) with both conventional and biological agents in Rheumatoid Arthritis (RA) must be based on their safety profile, adverse effects, risks, and advantages. With the purpose of presenting the most updated information about the safety of tumor necrosis factor alpha (TNFalpha) antagonists, in this article we summarize the literature published during the last three years about this sort of biological agents in specific clinical situations, such as risk of developing infections, cancer, cardiovascular diseases, and autoimmunity; as well as their administration to patients who will undergo surgical procedures, pregnant and/or breast-feeding women, and patients who need immunizations. Likewise, in this analysis we offer specific recommendations, based on evidence, for the best anti-TNF-alfa management.

[Treatment guidelines for ankylosing spondylitis and its effect on Mexican rheumatology]. / Fundamentos para el tratamiento de la espondilitis anquilosante y su efecto en la reumatología mexicana.

We describe the guidelines for the current treatment of ankylosing spondylitis with an emphasis on the role and outlook of the Mexican rheumatologic community. The topics we analyze include: epidemiological as well as professional, financial, health status, and quality of life aspects. We propose to acknowledge that axial spondyloarthritis is the earliest form of ankylosing spondylitis. Finally we carry out a review of the literature supporting current therapeutic recommendations. Regarding the latter, we approached the ASAS/EULAR recommendations for the treatment of ankylosing spondylitis and their level of agreement with Mexican and other countries' rheumatologists. Finally, we analyzed the recommendations to start tumor necrosis alpha blockers among patients with ankylosing spondylitis.

Fundamentos para el tratamiento de la espondilitis anquilosante y su efecto en la reumatología mexicana / Treatment guidelines for ankylosing spondylitis and its effect on Mexican rheumatology

Esta revisión trata de los fundamentos sobre los que descansa el tratamiento actual de la espondilitis anquilosante, enfatizando la participación y la opinión de la comunidad reumatológica nacional. En la temática se incluye la repercusión de la enfermedad —aspectos epidemiológicos, laborales, económicos, estado de salud y calidad de vida—, propuestas para la identificación de la espondiloartritis axial como la forma más precoz de la espondilitis anquilosante y el análisis de la literatura que dio origen a las recomendaciones terapéuticas actuales. Con relación al último punto, se abordan las recomendaciones ASAS/EULAR para el tratamiento de la espondilitis anquilosante y el nivel de concordancia con la opinión del reumatólogo mexicano y de otros países. Finalmente, se analizan las recomendaciones para iniciar bloqueadores del factor de necrosis tumoral en pacientes con espondilitis anquilosante.

We describe the guidelines for the current treatment of ankylosing spondylitis with an emphasis on the role and outlook of the Mexican rheumatologic community. The topics we analyze include: epidemiological as well as professional, financial, health status, and quality of life aspects. We propose to acknowledge that axial spondyloarthritis is the earliest form of ankylosing spondylitis. Finally we carry out a review of the literature supporting current therapeutic recommendations. Regarding the latter, we approached the ASAS/EULAR recommendations for the treatment of ankylosing spondylitis and their level of agreement with Mexican and other countries' rheumatologists. Finally, we analyzed the recommendations to start tumor necrosis alpha blockers among patients with ankylosing spondylitis.

Rheumatoid arthritis treatment with weekly leflunomide: an open-label study.

OBJECTIVE: To assess the safety and effectiveness of leflunomide (LNF) using 100 mg/week in patients with rheumatoid arthritis (RA). METHODS: Patients who were clinically active using the American College of Rheumatology criteria for RA were enrolled. They received a loading dose of 100 mg of LFN for 3 days, followed by 100 mg of LFN weekly. Efficacy and adverse events (AE) were recorded. RESULTS: Fifty patients were enrolled; 46 (93.6%) were women with a mean age of 45.6 years (range: 24 to 83). Disease duration was 3.7 years (range: 0.5 to 12). Twenty patients (40.8%) had previously taken disease modifying antirheumatic drugs. Outcomes achieved after 24 weeks of treatment were as follows: ACR20 (74%), ACR50 (64%), and ACR70 (28%). Five patients were withdrawn due to AE: 2 due to urticaria, 2 patients had elevated liver enzymes, and one had thrombocytopenia. Six patients (12%) were lost to followup. No severe AE were seen. CONCLUSION: The results in our preliminary report indicate that using a 100 mg/week dose achieves a similar benefit to the LFN 20 mg/day treatment, and there were no severe AE. In addition, a single LFN weekly dose has better treatment compliance. A secondary important benefit is the reduction of the monthly cost of medication. Comparative and blind trials are necessary in order to confirm longterm improvement and benefits on this regimen.