Time trends in the incidence, prevalence, and severity of rheumatoid arthritis: A systematic literature review

Incidence and Complication Rates for Total Hip Arthroplasty in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis Across Four Decades

INTRODUCTION

Over the past several decades, management of rheumatoid arthritis (RA) has evolved significantly, but few studies have examined the real-world impact of these changes on orthopaedic surgery in patients with RA. This systematic review assessed total hip arthroplasty (THA) incidence and postoperative complication rates across the past four decades.

METHODS

This is a systematic literature review sourcing data on THA in patients with RA from the electronic databases MEDLINE, EMBASE, Scopus, and Cochrane between January 1, 1980 and December 31, 2019.

RESULTS

The search retrieved 1715 articles of which 44 were included for quantitative synthesis. The rate for THA decreased by almost 40% from 11/1000 patient years (PY) in the 2000s to 7/1000 PY in the 2010s, while the overall complication rate decreased from 9.9% in the 1990s to 5.3% in the 2010s. Throughout the duration of the study, THA incidence and overall complication rate decreased. However, not all individual complication rates decreased. For example, revision and periprosthetic fracture decreased, infection and aseptic loosening remained constant, and dislocation increased.

CONCLUSION

Medical management of patients with RA has reduced the need for THA, while postoperative medical and surgical management has improved some postoperative outcomes. Nevertheless, there remains room for further improvement to postoperative outcomes through RA-specific management.

Comparison of the analytical and clinical performances of four anti-cyclic citrullinated peptide antibody assays for diagnosing rheumatoid arthritis

INTRODUCTION/OBJECTIVES

Anti-cyclic citrullinated peptide antibody (anti-CCP) is one of the most important serologic markers for diagnosing rheumatoid arthritis (RA). This study aimed to compare the analytical and clinical performances of the second- and third-generation anti-CCP assays.

METHODS

Four automated anti-CCP assays were evaluated: Chorus anti-CCP (Diesse Diagnostica), Elecsys anti-CCP (Roche Diagnostics), Atellica® IM anti-CCP IgG (Siemens Healthineers), and Quanta Flash® CCP3 (Inova Diagnostics Inc.). Analytical performance included the precision, linearity, correlation, and concordance rate. For evaluating the clinical performance, 240 patient samples (120 positive and 120 negative samples, determined by the Chorus anti-CCP assay) were used, including those with a diagnosis of RA (n = 132) and non-RA (n = 108). Using receiver operating characteristic (ROC) curve analysis, the sensitivity and specificity were evaluated.

RESULTS

All four assays that were evaluated showed good precision and linearity, and their correlation and concordance rates were in acceptable ranges. The area under the curve (AUC) values ranged from 0.888 to 0.914, showing a good diagnostic performance. The sensitivity and specificity of all assays were similar (88.0-97.2%).

CONCLUSIONS

All four anti-CCP assays showed good analytical and diagnostic performances for diagnosing RA. After adjusting the cutoff values, these assays are expected to show enhanced sensitivity and specificity. Key Points • Previous studies have described the diagnostic performance of a few immunologic markers in RA diagnosis, but nothing has been proven to be sufficiently good in clinical practice. • All four automated anti-CCP assays showed good analytical and diagnostic performances for diagnosing RA in clinical practice. • After adjusting the cutoff values, these assays are expected to show enhanced sensitivity and specificity. • The present study provides reassuring evidence that any of the studied commercially available anti-CCP tests for detecting rheumatoid arthritis provide similar diagnostic information to institutions that adopt these specific testing systems.

A mobile app using therapeutic exercise and education for self-management in patients with hand rheumatoid arthritis: a randomized controlled trial protocol

Background

Therapeutic exercise is a safe and cost-effective approach to alleviate hand rheumatoid arthritis (RA)-related symptoms. This study aims to investigate the differences in self-management between a smartphone app (CareHand), using hand exercises and educational advices, compared with a standard approach, on hand overall function, pain intensity, stiffness, and grip and pinch strength in patients with hand RA.

Methods

The project is a prospective, longitudinal, superiority, randomized controlled trial. Fifty-eight participants with hand RA will be randomly assigned into an experimental group (CareHand app) or a control group (conventional treatment). Control intervention involves a paper sheet with exercises and recommendations, and the experimental group includes the use of a smartphone app, which provides individualized exercise programs, self-management, and educational strategies to promote adherence to treatment. Both intervention protocols will last for 3 months. The principal investigator will conduct an educational session at baseline for all participants. Primary outcome comprises the overall hand function, assessed with the Michigan Hand Outcome Questionnaire (MHQ). Secondary outcomes include self-reported functional ability with the Quick DASH questionnaire, self-reported pain intensity and morning stiffness using a Visual Analogue Scale (VAS), and hand grip and pinch strength (dynamometer). Outcome measures will be collected at baseline, and at 1 month and 3-month follow-up.

Discussion

This study will evaluate the effectiveness of a tele-rehabilitation tool, which uses exercise and self-management strategies, compared to a conventional approach, in patients with hand RA. The smartphone app will allow to monitor the patient’s status and to enhance patient-therapist communication. Some limitations may be related to the short follow-up duration and the lack of evaluation of psychosocial factors. Overall, this new way of promoting long-term effects in patients with a chronic rheumatic disease could be feasible and easy to implement in daily life clinical practice and current musculoskeletal care.

Trial registration

ClinicalTrials.gov NCT04263974. Registered on 7 March 2020. Date of last update 15 April 2020. Ethics committee code: PI_RH_2018.

[Prevalence of Rheumatoid Arthritis in Germany: Analysis of Longitudinal Data of Statutory Health Insurance]

BACKGROUND

Rheumatoid arthritis (RA) is a progressive chronic inflammatory systemic autoimmune disease with destructive joint changes. Data on prevalence in adult patients are only available to a limited extent in Germany.

METHODOLOGY

Anonymised diagnosis and prescription data for 2008-2013 were evaluated at patient level for approximately 2.3 million insured adults (total data set; status 2013) and approx. 1.2 million insured adults (smaller data set with additional information such as treatment by a specialist; status 2013) from 7 different statutory health insurance companies. RA was diagnosed if the code M05 (seropositive chronic polyarthritis) or M06 (other chronic polyarthritis) was present (diagnosis group M0[5,6]) and if the patient was either an outpatient at least twice (in 2 different quarters) or at least once an inpatient within a calendar year (according to the BVA criteria, inpatient diagnoses were thus classified as more reliable). The data were extrapolated to the SHI-insured and total population in Germany for 2013.

RESULTS

The prevalence of RA in the total data set was 1.26% on average over all years (2008-2013). More than 90% of the diagnosis was based on the diagnosis code M06. In 88% of the cases, the classification was based exclusively on outpatient diagnoses. Taking into account a diagnosis by a specialist based on a smaller data set containing this additional information to determine a "reliable" RA diagnosis, the average RA rate for 2011-2013 was about 0.99%. Related to the diagnosis group M0[5,6] in the total data set, the prevalence of RA in 2013 was about 1.8% of women and about 0.8% of men. Only about 40% of diagnosed patients were treated with DMARDs.

CONCLUSIONS

The prevalence estimates for RA derived from the larger data set correspond to those of previous surveys with partially different methodological approaches. Based on the analysis of the health insurance data presented, the prevalence of diagnosed RA in adults in Germany is 1.26%, which is within the range of 0.81-1.62% that can be found in the literature. This represents about 721,000 adult SHI-insured persons. The low rate of DMARD prescriptions may indicate inadequate care of these patients.

Association of telomere length with risk of rheumatoid arthritis: a meta-analysis and Mendelian randomization

OBJECTIVE

To evaluate the telomere length (TL) in patients with RA relative to that in controls and to test whether TL is causally associated with risk of RA.

METHODS

Systematic review and meta-analysis of relevant literature was conducted to evaluate the association between TL and RA. Standardized mean differences with 95% CIs of TL in RA patients relative to controls were pooled using fixed or random-effects models. TL-related single-nucleotide polymorphisms were selected from a genome-wide association study of 37 684 individuals, and summary statistics of RA were obtained from a genome-wide association study meta-analysis including 14 361 RA patients and 43 923 controls. Mendelian randomization was performed using the inverse-variance weighted, weighted-median and likelihood-based methods. Sensitivity analyses were performed to test the robustness of the association.

RESULTS

In the meta-analysis of 911 RA patients and 2498 controls, we found that patients with RA had a significantly shorter TL compared with controls (standardized mean differences = -0.50; 95% CI -0.88, -0.11; P = 0.012). In the Mendelian randomization analysis, we found that genetically predicted longer TL was associated with a reduced risk of RA [odds ratio = 0.68; 95% CI 0.54, 0.86; P = 0.002 using the inverse-variance weighted method]. Sensitivity analyses using alternative Mendelian randomization approaches yielded similar findings, suggesting the robustness of the causal association.

CONCLUSION

Our study provides evidence for a negative causal association of TL with risk of RA. Further studies are warranted to elucidate the underlying mechanism for the role of telomeres in the development of RA.

Anti-modified citrullinated vimentin antibody: a novel biomarker associated with cardiac systolic dysfunction in patients with rheumatoid arthritis

Background

Studies have demonstrated that seropositive patients with rheumatoid arthritis (RA) are susceptible to cardiovascular diseases (CVDs). In this study, we aimed to determine the association of autoantibodies with the echocardiographic parameters of systolic and diastolic dysfunction in such patients.

Methods

In this cross-sectional study, we evaluated patients with RA who were referred to our clinic from October 2017 to August 2018. After the exclusion of patients with concomitant CVD, all patients underwent transthoracic echocardiography and measurement of plasma autoantibodies. Moreover, possible confounders—including medications, CVD risk factors, Framingham risk score, disease activity score-28, duration of disease, simple disease activity index, and functional status—were assessed.

Results

We studied 135 patients with RA (mean age = 52.3 years; 111 (82.2%) females). We had missing data rates of up to 8.9% for some characteristics. E velocity was inversely correlated with rheumatoid factor (P = 0.009). Furthermore, the plasma levels of anti-citrullinated protein and anti-modified citrullinated vimentin (anti-MCV) antibodies were negatively correlated with left ventricular ejection fraction (LVEF) (P = 0.019 and P<0.001, respectively). After an adjustment for possible confounders, the linear regression model demonstrated that the anti-MCV level and the patient’s age are significant predictors of LVEF. The receiver operating characteristic curve showed that anti-MCV antibody titer≥547.5 (IU/mL) signifies reduced LVEF (<50%) with a sensitivity of 85.7% and specificity of 93% (C-statistic = 0.843).

Conclusions

Our findings showed a significant inverse correlation between anti-MCV antibody titer and LVEF. These results indicate that the application of anti-MCV is promising for the screening and early detection of cardiac systolic dysfunction. Future prospective studies will determine its role.

Multiple-dose tranexamic acid for perioperative blood loss in total knee arthroplasty in patients with rheumatoid arthritis：a single-blinded, randomised, parallel-controlled study protocol in China

INTRODUCTION

This clinical trial is designed to evaluate the effect of multiple-dose tranexamic acid (TXA) on perioperative blood loss in patients with rheumatoid arthritis (RA).

METHODS AND ANALYSIS

A randomised, single-blinded, parallel-controlled study will be designed. Patients with RA (age 50-75 years) undergoing unilateral primary end-stage total knee arthroplasty will be randomly divided into group A or group B. Group A will be treated with one dose of TXA (1 g; intravenous injection 3 hours postsurgery) and group B with three doses (1 g; intravenous injection at 3, 6 and 12 hours postsurgery) after surgery. The primary outcomes will be evaluated with blood loss, maximum haemoglobin drop and transfusion rate. The secondary outcomes will be evaluated with knee function and complications.

ETHICS AND DISSEMINATION

The Shanghai Guanghua Hospital of Integrated Traditional Chinese Medicine and Western Medicine Ethics Committee approved in this study in July 2019. Informed consent will be obtained from all participants. Results of the trial will be published in the Dryad and repository in a peer-reviewed journal. Additionally, deidentified data collected and analysed for this study will be available for review from the corresponding author on reasonable request.

TRIAL REGISTRATION NUMBER

ChiCTR1900025013.

Comprehensive analysis of multiple cytokines and blood parameters for the diagnosis of bacterial infections in rheumatoid arthritis

Patients with rheumatoid arthritis (RA) are more susceptible to infections, which elevate the levels of relative cytokines. However, the ability of the cytokines levels to predicate bacterial infections in RA patients remains unclear. Here, we assessed the ability of the combination of serum cytokine levels and blood parameters to diagnose bacterial infections in RA patients. We measured the levels of a panel of serum cytokine and blood parameters in 168 RA patients and 81 healthy individuals. RA patients were divided into the bacterial infection (INFE) group (n = 76) and RA flare without INFE group (n = 92). Bacterial infection was confirmed by microbial culture, imaging, antibiotic response, and typical clinical symptoms. The discriminative ability of the combination of the cytokine levels and inflammatory parameters was assessed using the receiver-operating characteristic (ROC) curves analysis and a novel bioscore system. The levels of interleukin (IL)-6 (p = 0.006), IL-10 (p = 0.019), interferon (IFN)-γ (p = 0.033), CRP (p < 0.001), and ESR (p < 0.001) were higher in patients of the INFE group than in patients with RA flare, and the absolute numbers of CD19⁺ B cells (p < 0.001) and CD4⁺ T cells (p = 0.009) were lower. For discriminating bacterial infection, the combination of IL-6, IL-10, IFN-γ, ESR, CRP, CD19⁺ B cells, and CD4⁺ T cells, provided an area under the curve (AUC) of 0.827 [(95% confidence interval (CI): 0.760-0.881)], which was profoundly larger than that of IL-6, IL-10, IFN-γ, ESR, CRP, CD19⁺ B cells, or CD4⁺ T cells alone. In addition, we also developed a bioscore system based on the combination of these seven biomarkers. Seventeen (100%) patients with a bioscore of 0 were non-infected, while seven (100%) patients with a score of 7 had bacterial infections. The bioscore based on the combination of ESR, CRP, IL-6, IL-10, IFN-γ, CD19⁺ B cells and CD4⁺ T cells may be a promising and robust tool to diagnose bacterial infections in RA patients.

Study of Factors Influencing Dry Eye in Rheumatoid Arthritis

Purpose

The present study investigated the relationship between dry eye and the disease activity in patients with rheumatoid arthritis (RA).

Methods

Patients with RA were divided by the Ocular Surface Disease Index (OSDI) into the symptomatic group (score ≥ 12) and the asymptomatic group (score < 12). By using the Disease Activity Score (DAS-28) questionnaire, they were divided into the active group (score > 2.6) and the stable group (score ≤ 2.6). In the control group, 20 healthy adults with matched sex and age were selected. RA patients and healthy adults were inspected for the tear film break time (TBUT), tear meniscus height (TMH), corneal fluorescein staining (CFS), meibomian scan (MS), meibomian gland secretion score (MSS), and eyelid margin assessment (EMS).

Results

The TBUT of the RA group was significantly less than that of the control group, while the CFS, MS, EMS, and MSS were higher. The TBUT of the symptomatic RA group was significantly less than that of the asymptomatic group, and the CFS was higher. In the active RA group, only the CFS was higher than that of the stable group, and there was no significant difference between the two groups for other parameters. Furthermore, there was no significant correlation between the course of RA and the dry eye (P > 0.05).

Conclusion

The rheumatoid activity does not necessarily lead to an aggravation of dry eye. Regardless of the duration, RA was not found to exhibit relation with the severity of dry eye. Translational Relevance. RA patients with disease active period cannot be ignored for the existence of dry eye, since patients with dry eye often lack the signs and symptoms.

Comparative efficacy, safety and cost of oral Chinese patent medicines for rheumatoid arthritis: a Bayesian network meta-analysis

BACKGROUND

Rheumatoid arthritis (RA) is a common inflammatory disease with a substantial burden for society and economic worldwide. Chinese patent medicines (CPMs) have gained attention as alternative remedies due to they can exert the satisfactory therapeutic effects via holistic regulation. Currently, several oral Chinese patent medicines are routinely recommended for managing and treating RA. Therefore, a network meta-analysis (NMA), which tries to synthesize evidences for a decision making by evaluating the comparative effectiveness of multiple interventions against the same disease, was undertaken to identify the optimal intervention according to their efficacy in clinical treatment and symptom remission, safety profile and daily cost.

METHODS

Randomized controlled trials (RCTs) regarding CPMs to treat RA were comprehensive retrieved from 3 foreign databases and 4 Chinese databases, and the retrieved results were last updated on January 10, 2019. The bias of the selected trials was assessed by two individuals independently through RoB2. A random-effects model was adopted during the meta-analytic procedures, and outcomes concerning efficacy and safety were evaluated as odds ratios (OR), mean differences (MD) and 95% credible intervals (CI) utilizing Stata 14.1 and WinBUGS 1.4.3 software. Furthermore, the cluster analysis and comprehensive investigation were preformed concerning the comparative efficacy, safety and cost of oral CPMs.

RESULTS

One hundred sixteen RCTs involving 10,213 individuals met the inclusion criteria and were enrolled into current NMA. The results from existing evidence indicated that Biqi capsule and Yuxuebi capsule probably had a favorable balance in consideration of benefits, tolerability and daily cost. Furthermore, as the least expensive choice, glucosides of Tripterygium Wilfordii tablet was associated with displaying a trend of relieving joint tenderness, joint swelling, and morning stiffness for patients with RA.

CONCLUSION

Biqi capsule, Yuxuebi capsule and glucosides of Tripterygium Wilfordii tablet were recommended for treating RA based on the favorable benefits in both clinical efficacy and symptoms, and they, meanwhile, might be associated with the more tolerable and acceptable therapeutic alternative in terms of safety profile and daily cost. Nevertheless, the additional results from high-quality, multi-center and head-to-head trials would be pivotal for supporting our findings.

A sliding scale to predict postoperative complications undergoing posterior spine surgery

BACKGROUND

There is a lack of consensus of operative time (OT) and estimated blood loss (EBL) for elderly patients based on the predicted risk of complications after posterior spine surgery. The purpose of this study was to evaluate the effect of age, OT, and EBL on the postoperative complication risk and to develop a simple sliding scale.

METHODS

We explored prospectively collected data of consecutive patients who underwent posterior spine surgery in seven tertiary referral hospitals from November 2013 to May 2016. Age (<70, 70-74, 75-79, 80-84, ≥85 years), OT (<2, 2-<3, 3-<4, 4-<5, ≥5 h), and EBL (<500, 500-<1000, 1000-<1500, 1500-<2000, ≥2000 ml) were categorized ranging from 1 (lowest) to 5 (highest). The association between the crude cumulative categories' number and the incidence of complications was analyzed. We further evaluated the association by re-categorizing the cumulative number into three groups (3-4, 5-10, ≥11).

RESULTS

Total of 2416 patients (median age: 70 years old) were enrolled and major complications were observed in 75 (3.1%) patients. Age, OT, and EBL showed similar odds ratio (1.18-1.19) as each category increased. The cumulative categories' number fitted the estimate complication risk (Hosmer-Lemeshow P = 0.87), and statistically significant trend was observed between predicted and actual complication rates (Cochran-Armitage test, P < 0.001). When cumulative categories' numbers were stratified into three groups, significant increasing trend of risk were observed (Mantel-Haenszel P < 0.001). Based on the categorical numbers, we proposed a simple sliding scale.

CONCLUSION

Our data indicated that the risk of postoperative complication was associated with cumulative score based on increased age, OT, and EBL. A simple sliding scale was developed based on these factors, which may be useful to predict complication risk after posterior spine surgery.

Rheumatoid arthritis risk in periodontitis patients: A systematic review and meta-analysis

OBJECTIVE

Many clinical studies have been carried out to investigate the relationship between periodontitis and rheumatoid arthritis (RA). Owing to limited evidence and inconsistent findings among these studies, it is unclear whether periodontitis would increase the risk for RA. This meta-analysis was performed to evaluate whether periodontitis represents a risk factor for RA.

METHODS

PubMed, Cochrane Library, Embase, Web of Science, and Wanfang were searched for eligible studies that compared periodontitis patients with controls. A pooled odds ratio (OR) and 95% confidence interval (CI) were calculated to assess the association between periodontitis and RA.

RESULTS

Thirteen studies including a total of 706611 periodontitis patients and 349983 control subjects were included. The pooled OR of RA risk between periodontitis and controls was (OR: 1.69; 95% CI: 1.31-2.17; P<0.0001), indicating that the patients in periodontitis group had a 69% greater risk for RA than people in control group. When stratified by disease type, the pooled results showed periodontitis represents a risk factor for incident RA (OR=1.70, 95%CI: 0.75-3.85, P<0.001) and mixed RA (OR=1.61, 95%CI: 1.26-2.06; P<0.001). When stratified by disease duration, the pooled results showed periodontitis represents a risk factor for RA disease duration>5 years (OR=2.88, 95%CI: 0.66-12.62, P=0.018), disease duration<5 years (OR=2.59, 95%CI: 0.83-8.11, P<0.001), mixed disease duration (OR=1.53; 95%CI: 1.05-2.22, P<0.001).

CONCLUSION

Our meta-analysis revealed an increased risk of RA in patients with periodontitis compared to healthy controls. Moreover, when stratified by disease type, there was a higher risk between incident RA and periodontitis. When stratified by disease duration, the patients with periodontitis might be more closely associated with the RA patients with disease duration >5 years.

Anti-inflammatory Diet In Rheumatoid Arthritis (ADIRA)-a randomized, controlled crossover trial indicating effects on disease activity

BACKGROUND

Many patients with rheumatoid arthritis (RA) report symptom relief from certain foods. Earlier research indicates positive effects of food and food components on clinical outcomes in RA, but insufficient evidence exists to provide specific dietary advice. Food components may interact but studies evaluating combined effects are lacking.

OBJECTIVES

We aimed to investigate if an anti-inflammatory diet reduces disease activity in patients with RA.

METHODS

In this single-blinded crossover trial, 50 patients with RA were randomly assigned to an intervention diet containing a portfolio of suggested anti-inflammatory foods, or a control diet similar to the general dietary intake in Sweden, for 10 wk. After a 4-mo washout period the participants switched diet. Food equivalent to ∼50% of energy requirements was delivered weekly to their homes. For the remaining meals, they were encouraged to consume the same type of foods as the ones provided during each diet. Primary outcome was change in Disease Activity Score in 28 joints-Erythrocyte Sedimentation Rate (DAS28-ESR). Secondary outcomes were changes in the components of DAS28-ESR (tender and swollen joints, ESR, and visual analog scale for general health) and DAS28-C-reactive protein.

RESULTS

In the main analysis, a linear mixed ANCOVA model including the 47 participants completing ≥1 diet period, there was no significant difference in DAS28-ESR between the intervention and control periods (P = 0.116). However, in unadjusted analyses, DAS28-ESR significantly decreased during the intervention period and was significantly lower after the intervention than after the control period in the participants who completed both periods (n = 44; median: 3.05; IQR: 2.41, 3.79 compared with median: 3.27; IQR: 2.69, 4.28; P = 0.04, Wilcoxon's Signed Rank test). No significant differences in the components were observed.

CONCLUSIONS

This trial indicates positive effects of a proposed anti-inflammatory diet on disease activity in patients with RA. Additional studies are required to determine if this diet can cause clinically relevant improvements.This trial was registered at clinicaltrials.gov as NCT02941055.

Radioscapholunate arthrodesis versus radiolunate arthrodesis in rheumatoid wrist surgery: Clinical and radiographic outcomes

Radiolunate arthrodesis is a validated surgical technique in rheumatoid wrist surgery. When the radioscaphoid joint is involved or when there is radiolunate instability, a radioscapholunate arthrodesis must be preferred. The objective was to compare clinical and radiographic outcomes for both types of arthrodesis. Patients were evaluated retrospectively at a minimal follow-up of 12 months after radiolunate arthrodesis (RL-A group) or radioscapholunate arthrodesis (RSL-A group). Mean follow-up was 10.7 years (1-25 years). One hundred and one patients were included in RL-A group and 26 in RSL-A group. At follow-up, pain level was significantly reduced by 3.7 points and by 2.9 points in RL-A and RSL-A groups, respectively. Mobility in flexion/extension was significantly reduced by 25° in both groups. DASH and PRWE scores were 42.9 and 41.4 in RL-A group, 41.8 and 20.6 in RSL-A group, respectively. Larsen stage for the midcarpal joint increased significantly in both groups (+0.8 in RL-A group; +0.9 in RSL-A group), carpal height index decreased (-0.03 in RL-A group (significant); -0.02 in RSL-A group (non-significant)), carpal ulnar translation index increased (+0.038 in RL-A group; +0.037 in RSL-A group), without significant difference between both groups. Nonunion rate was significantly higher in RSL-A group (62%) than in RL-A group (30%). A pain free and functional wrist can be obtained after radiolunate and radioscapholunate arthrodesis. However, arthritis lesions and carpal deformities increased with follow-up similarly with both surgical techniques. Our results have shown that radiolunate arthrodesis remains a reliable surgical procedure for advanced rheumatoid wrist.

Predictors, demographics and frequency of sustained remission and low disease activity in anti-tumour necrosis factor-treated rheumatoid arthritis patients

Objectives

To investigate the frequency and predictors of sustained 28-joint DAS (DAS28) remission and low disease activity (LDA) in patients receiving anti-TNF therapy and changes in responses over a 12 year period.

Methods

Data from the British Society for Rheumatology Biologics Registry for Rheumatoid Arthritis were used. Sustained remission and LDA were defined according to DAS28-ESR thresholds sustained for 6 months. The dataset was dichotomized into sequential chronological subgroups (2001–2010 and 2010–2013). Predictive variables were identified from a previous systematic review and modelled using multivariable logistic regression.

Results

Overall, 2144 (14.9%) and 3802 (26.3%) patients achieved sustained remission or LDA, respectively. Positive predictors of sustained remission/LDA included adalimumab (vs etanercept), greater patient global assessment, never- and ex-smoker status (vs current smoking), greater swollen joint count, more recent commencement of anti-TNF and MTX co-prescription (except in the 2010–2013 subgroup). Negative predictors of sustained remission and LDA included poor baseline functional status (HAQ), female gender, older age at starting anti-TNF, infliximab use (vs etanercept), increasing BMI and greater baseline ESR. Increasing tender joint count was negatively associated with sustained LDA only. The overall proportion of patients achieving sustained remission and LDA has increased significantly over time.

Conclusion

Sustained remission/LDA on anti-TNF treatment remains uncommon. Adalimumab use, greater patient global assessment, never- and ex-smoker status, greater swollen joint count, more recent commencement of anti-TNF and MTX co-prescription are associated with achievement of sustained remission/LDA. However, co-prescription of MTX was not associated with an increased likelihood of achieving sustained remission or LDA in the analysis of more recent anti-TNF responses.

Singapore Chapter of Rheumatologists updated consensus statement on the eligibility for government subsidization of biologic and targeted-synthetic therapy for the treatment of rheumatoid arthritis

INTRODUCTION

Approximately 30% of patients with rheumatoid arthritis (RA) respond inadequately to conventional-synthetic disease-modifying anti-rheumatic drugs (csDMARDs). However, widespread use of biologic DMARDs (bDMARDs) and targeted-synthetic (tsDMARDs) is limited by cost. We formulated updated recommendations for eligibility criteria for government-assisted funding of bDMARDs/tsDMARDs for RA patients in Singapore.

MATERIALS AND METHODS

Published guidelines regarding use of bDMARD and tsDMARDs were reviewed. We excluded those without a systematic literature review, formal consensus process or evidence grading. Separately, unpublished national reimbursement guidelines were included.

RESULTS

Eleven recommendations regarding choice of disease activity measure, initiation, order of selection and continuation of bDMARD/tsDMARDs were formulated. A bDMARD/tsDMARD is indicated if a patient has: (a) at least moderately active RA with a Disease Activity Score in 28 joints/erythrocyte sedimentation rate (DAS28-ESR) score of ≥3.2; (b) failed ≥2 csDMARD strategies, 1 of which must be a combination; (c) received an adequate dose regimen of ≥3 months for each strategy. For the first-line bDMARD/tsDMARD, either tumor necrosis factor inhibitors (TNFi), non-TNFi (abatacept, tocilizumab, rituximab), or tsDMARDs, may be considered. If a first-line TNFi fails, options include another TNFi, non-TNFi biologic or tsDMARDs. If a first-line non-TNFi biologic or tsDMARD fails, options include TNFi or another non-TNF biologic or tsDMARD. For continued bDMARD/tsDMARD subsidization, a patient must have a documented DAS28-ESR every 3 months and at least a moderate European League Against Rheumatism response by 6 months.

CONCLUSION

These recommendations are useful for guiding funding decisions, making bDMARD/tsDMARDs usage accessible and equitable in RA patients who fail csDMARDs.

Pain appraisal and quality of life in 108 outpatients with rheumatoid arthritis

Individual differences in emotional functioning, pain appraisal processing, and perceived social support may play a relevant role in the subjective experience of pain. Due to the paucity of data regarding individuals with Rheumatoid Arthritis (RA), the present study aimed to examine pain intensity, emotional functioning (psychological distress and alexithymia), pain appraisal (pain beliefs, pain catastrophizing, and pain-related coping strategies) and social support, and their relationships with the health-related quality of life (HRQoL) in patients with RA. Data were collected from 108 female patients diagnosed with RA. Clinically relevant levels of depressive and anxiety symptoms assessed by the HADS subscales were present in 34% and 41% of the patients, respectively, and about 24% of them exhibited the presence of alexithymia. The results of hierarchical multiple regression analyses showed that pain intensity, alexithymia, the maladaptive beliefs regarding the stability of pain and the coping strategy of guarding explained 54% of the variance in the physical component of HRQoL (p < 0.001). Depression subscale of the HADS, alexithymia, the coping strategy of resting, and the rumination factor of pain catastrophizing significantly explained 40% of the variance in the mental component of HRQoL (p < 0.001). The present findings provide evidence regarding the importance of emotional functioning and pain appraisal in the negative impact of RA on patients' quality of life. These findings provide additional evidence for the biopsychosocial model of chronic pain, further supporting the complex interaction between emotional, cognitive, and behavioral processes in patients with chronic pain.

Management of rheumatoid arthritis: 2019 updated consensus recommendations from the Hong Kong Society of Rheumatology

The expanding range of treatment options for rheumatoid arthritis (RA), from conventional synthetic disease-modifying antirheumatic drugs (DMARDs) to biological DMARDs (bDMARDs), biosimilar bDMARDs, and targeted synthetic DMARDs, has improved patient outcomes but increased the complexity of treatment decisions. These updated consensus recommendations from the Hong Kong Society of Rheumatology provide guidance on the management of RA, with a focus on how to integrate newly available DMARDs into clinical practice. The recommendations were developed based on evidence from the literature along with local expert opinion. Early diagnosis of RA and prompt initiation of effective therapy remain crucial and we suggest a treat-to-target approach to guide optimal sequencing of DMARDs in RA patients to achieve tight disease control. Newly available DMARDs are incorporated in the treatment algorithm, resulting in a greater range of second-line treatment options. In the event of treatment failure or intolerance, switching to another DMARD with a similar or different mode of action may be considered. Given the variety of available treatments and the heterogeneity of patients with RA, treatment decisions should be tailored to the individual patient taking into consideration prognostic factors, medical comorbidities, drug safety, cost of treatment, and patient preference.

Does Abatacept Increase Postoperative Adverse Events in Rheumatoid Arthritis Compared with Conventional Synthetic Disease-modifying Drugs?

Objective.

To investigate whether abatacept (ABA) causes more adverse events (AE) than conventional synthetic disease-modifying antirheumatic drugs (csDMARD) after orthopedic surgery in patients with rheumatoid arthritis (RA).

Methods.

A retrospective multicenter nested case–control study was performed in 18 institutions. Patients receiving ABA (ABA group) were matched individually with patients receiving csDMARD and/or steroids (control group). Postoperative AE included surgical site infection, delayed wound healing, deep vein thrombosis or pulmonary embolism, flare, and death. The incidence rates of the AE in both groups were compared with the Mantel-Haenszel test. Risk factors for AE were analyzed by logistic regression model.

Results.

A total of 3358 cases were collected. After inclusion and exclusion, 2651 patients were selected for matching, and 194 patients in 97 pairs were chosen for subsequent comparative analyses between the ABA and control groups. No between-group differences were detected in the incidence rates of each AE or in the incidence rates of total AE (control vs ABA: 15.5% vs 20.7% in total, 5.2% vs 3.1% in death).

Conclusion.

Compared with csDMARD and/or steroids without ABA, adding ABA to the treatment does not appear to increase the incidence rates of postoperative AE in patients with RA undergoing orthopedic surgery. Large cohort studies should be performed to add evidence for the perioperative safety profile of ABA.

Predictors for progression of two different types of cervical lesions in rheumatoid arthritis treated with biologic agents

BACKGROUND

Biologic agents (BAs) enabled not only a reduction of disease activity but also a slowing down of structural damage to the joints in patients with rheumatoid arthritis (RA). However, the incidence of cervical lesions in patients with RA is still high.

PURPOSE

To elucidate the predictors for the progression of two different cervical lesions in patients with RA under BA treatment.

METHODS

Of 151 subjects who received more than two years of continuous BA treatment, 101 subjects who had cervical X-ray images taken at baseline and final visit were enrolled. The mean disease duration and mean radiography interval were 10.6 years and 4.4 years, respectively. The existence and progression of cervical lesions (atlanto-axial subluxation [AAS], vertical subluxation [VS], and subaxial subluxation [SS]) were investigated. And predictors for the AAS or VS progression were analyzed by multivariate logistic regression analysis.

RESULTS

The incidence of cervical lesions at baseline were no pre-existing cervical lesion (none) in 50 cases (50%), AAS only in 32 (32%), both AAS and VS in 12 (12%), and VS only in 7 cases (7%). In the none group, only 4 cases of AAS progression (8%) was observed during the follow-up. In contrast, in the groups with pre-existing cervical lesions, a high incidence of VS progression was observed (63% in the AAS only group, 58% in the AAS + VS group, and 71% in the VS only group). Multivariate regression analysis demonstrated that the DAS-CRP value at baseline (odds ratio [OR] = 9.23) and matrix metaloprotease-3 level at baseline (OR = 1.01) were significant predictors for the progression of AAS, and pre-existing AAS (OR = 18.38) was a sole significant predictor for the progression of VS.

CONCLUSIONS

Cervical lesions progressed irrespective of disease activity after AAS development. Strict disease control before the development of AAS is crucial for preventing further progression and development of cervical lesions.

Normal mortality of the COBRA early rheumatoid arthritis trial cohort after 23 years of follow-up

OBJECTIVES

Mortality in patients with rheumatoid arthritis (RA) is higher than in the general population. We investigated mortality in the COBRA-trial cohort after 23 years follow-up, compared with a reference sample of the Dutch population.

METHODS

The COBRA-trial randomised patients with early RA to sulfasalazine monotherapy (SSZ, n=79) or a combination of SSZ, low-dose methotrexate and initially high, step-down prednisolone (COBRA, n=76). We compared the mortality in the COBRA-trial up to 2017 to a reference sample of the general population in the Netherlands (standardised mortality ratio, SMR), and its relation to early prognostic factors through stepwise Cox regression.

RESULTS

Duration of follow-up in patients alive was mean 23 (range 22-24) years. In total, 44 patients died (28%, SMR=0.80 [95% CI 0.59 to 1.06]); 20 of 75 COBRA patients (27%, SMR 0.75 [0.47 to 1.14]) and 24 of 79 SSZ patients (30%, SMR 0.85 [0.56 to 1.25]); p=0.61). In the reference sample of the general population, 55 people (36%) died. 5 factors were significantly associated with increased mortality hazard: damage progression at 28 weeks; high Health Assessment Questionnaire (HAQ) score and absence of HLA-DR 2 or 3; disease duration from start of complaints was also significant, but showed an uninterpretable pattern.

CONCLUSIONS

This prospective trial cohort study of early RA is one of the first to show similar mortality compared with the general population after 23 years of follow-up. It confirms that early, intensive treatment of RA has long-term benefits and suggests that treating to target is especially important for patients with poor prognosis.

Secular trends in the incidence and prevalence of rheumatoid arthritis within members of an integrated health care delivery system

The study objective was to estimate secular trends in the overall incidence rate (IR) and prevalence rate (PR) of rheumatoid arthritis (RA); and subgroup-specific IR and PR by race, ethnicity, and sex in a multi-ethnic population of a large integrated health care delivery system. An ecological study was conducted within the adult population of Kaiser Permanente Southern California health plan. From January 1995 up to and including December 2014, annual IR and PR were calculated separately by race, ethnicity, sex and pooled overall. Depending on the stationarity of each ecological series, annual percentage change in IR and PR was evaluated using auto-regressive integrated moving average models. Average overall IR was 53 [95% confidence interval (CI) 46, 61] per 100,000 person-years. The overall as well as subgroup-specific annual IR of RA were unchanged from 1995 to 2014. In 1995, the overall PR of RA was 59 (44, 74) per 100,000 person-years which increased by 14% (7%, 21%) annually thereafter. The increase in PR in Caucasians was lower as compared to African American, Asian and other race (13% vs 15%, 15%, and 18%, respectively). Compared to non-Hispanic ethnicity, the increase in PR among Hispanic was higher (17% vs 14%). Over the past 2 decades, while the incidence of RA was unchanged, the prevalence had increased significantly overall as well as within every subgroup of race, ethnicity, and sex.

The severity of psychiatric disorders

The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM-5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom-defined disorders depends on factors extrinsic to those disorders, such as self-efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.

Analysis of Socioeconomic Status in the Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory disease with different etiologies in different areas. Our study focused on the prevalence of RA in Taiwan from 2001 to 2011. This study contained longitudinal enrollment files, claims data, catastrophic illness files, and treatment registries from Taiwan Longitudinal Health Insurance Research Database. We identified RA patients by ICD-9-CM code 714.0. The demographical variables including age, sex, income and area of registration were evaluated. The multivariate Poisson regression was applied to calculate relative risk for developing RA. In Taiwan, the ratio of female to male was about 5:1. From 2001 to 2011, significant increasing prevalence of RA, from 0.07% to 0.14%, was found in women. The prevalence of RA was increasing 6% per year in both sex groups. The annual incidence rate (per 10,000 person years) ranged from 1.62 to 2.02 (female: 2.30–3.14; male: 0.71–1.17) from 2003 to 2011. City area had lowest incidence rate of RA compared with suburban or rural area. Higher incidence of RA was observed among lower socioeconomic status. The prevalence of RA was rising from 0.07% in 2001 to 0.14% in 2011. Incidence was about 2/10,000 person-years and female to male ratio was 5:1. Lower socioeconomic status and living rural region might be a risk factor for developing RA.

Is Anti-Citrullinated Protein Antibody-Positive Rheumatoid Arthritis Still a More Severe Disease Than Anti-Citrullinated Protein Antibody-Negative Rheumatoid Arthritis? A Longitudinal Cohort Study in Rheumatoid Arthritis Patients Diagnosed From 2000 Onward

Objective

Because of its association with joint destruction, anti–citrullinated protein antibody (ACPA)–positive rheumatoid arthritis (RA) is considered to be more severe than ACPA‐negative RA. Clinically relevant joint destruction is now infrequent thanks to adequate disease suppression. According to patients, important outcomes are pain, fatigue, and independence. We evaluated whether ACPA‐positive RA patients diagnosed during or after 2000 have more severe self‐reported limitations and impairments, including restrictions at work, than ACPA‐negative RA patients.

Methods

A total of 492 ACPA‐positive and 450 ACPA‐negative RA patients who fulfilled the 2010 criteria and were included in the Leiden Early Arthritis Clinic cohort during or after 2000 were compared for self‐reported pain, fatigue, disease activity, general well‐being (measured by numerical rating scales), physical function (measured by the Health Assessment Questionnaire), and work restrictions, including absenteeism at baseline and during the 4‐year followup. Linear mixed models were used.

Results

At disease presentation, ACPA‐negative patients had more severe pain, fatigue, self‐reported disease activity scores, and functional disability (P < 0.05), although absolute differences were small. During followup, ACPA‐negative patients remained somewhat more fatigued (P = 0.002), whereas other patient‐reported impairments and limitations were similar. Thirty‐eight percent of ACPA‐negative and 48% of ACPA‐positive patients reported absenteeism (P = 0.30), with median 4 days missed in both groups in the last 3 months. Also, restrictions at work among employed patients and restrictions with household work were not statistically different at baseline and during followup.

Conclusion

In current rheumatology practice, ACPA‐positive RA is not more severe than ACPA‐negative RA in terms of patients’ relevant outcomes, including physical functioning and restrictions at work. This implies that efforts to further improve the disease course should be proportional to both disease subsets.

2017 recommendations of the Brazilian Society of Rheumatology for the pharmacological treatment of rheumatoid arthritis

The objective of this document is to provide a comprehensive update of the recommendations of Brazilian Society of Rheumatology on drug treatment of rheumatoid arthritis (RA), based on a systematic literature review and on the opinion of a panel of rheumatologists. Four general principles and eleven recommendations were approved. General principles: RA treatment should (1) preferably consist of a multidisciplinary approach coordinated by a rheumatologist, (2) include counseling on lifestyle habits, strict control of comorbidities, and updates of the vaccination record, (3) be based on decisions shared by the patient and the physician after clarification about the disease and the available therapeutic options; (4) the goal is sustained clinical remission or, when this is not feasible, low disease activity. Recommendations: (1) the first line of treatment should be a csDMARD, started as soon as the diagnosis of RA is established; (2) methotrexate (MTX) is the first-choice csDMARD; (3) the combination of two or more csDMARDs, including MTX, may be used as the first line of treatment; (4) after failure of first-line therapy with MTX, the therapeutic strategies include combining MTX with another csDMARD (leflunomide), with two csDMARDs (hydroxychloroquine and sulfasalazine), or switching MTX for another csDMARD (leflunomide or sulfasalazine) alone; (5) after failure of two schemes with csDMARDs, a bDMARD may be preferably used or, alternatively a tsDMARD, preferably combined, in both cases, with a csDMARD; (6) the different bDMARDs in combination with MTX have similar efficacy, and therefore, the therapeutic choice should take into account the peculiarities of each drug in terms of safety and cost; (7) the combination of a bDMARD and MTX is preferred over the use of a bDMARD alone; (8) in case of failure of an initial treatment scheme with a bDMARD, a scheme with another bDMARD can be used; in cases of failure with a TNFi, a second bDMARD of the same class or with another mechanism of action is effective and safe; (9) tofacitinib can be used to treat RA after failure of bDMARD; (10) corticosteroids, preferably at low doses for the shortest possible time, should be considered during periods of disease activity, and the risk-benefit ratio should also be considered; (11) reducing or spacing out bDMARD doses is possible in patients in sustained remission.

[Getting older with rheumatoid arthritis-is there a burnout of the disease?]

Rheumatoid arthritis (RA) is a chronic inflammatory disease. Synovitis is the main pathology and can lead to a progressive destruction of the joints. It is often said that RA "burns out", implying that the inflammation decreases spontaneously in the long term, mostly severe course of RA and reaches a stage with a stable absence of joint inflammation, even without treatment. To test this concept we analyzed the published evidence. Data of historic long-term inception cohorts of patients who have never been treated with antirheumatic drugs and patients who received conventional disease-modifying antirheumatic drugs (DMARD), show that the disease stays active with sustained radiological progression in the majority of patients. At best, the disease can show a milder course with time or a stage of absence of joint inflammation can be reached if patients responded very well to initial drug treatment. Terminating DMARD treatment in this situation bears the risk of a latent progressive joint destruction, the appearance of extra-articular manifestations and an increase in the cardiovascular risk. Hence there is no evidence for the existence of a "burnt out" RA with stable inactive disease without drug treatment in the long-term course. In a modern treatment strategy of RA following the treat-to-target principle and aiming at remission, the term "burnt out" RA should no longer be used.

Current status of ultrasound and dual-energy computed tomography in the evaluation of gout

Gout is the most common inflammatory arthritis and is increasing in relevance due to its rising prevalence and incidence. Dual-energy CT (DECT) and ultrasound (US) are the most frequently used imaging modalities for the diagnosis of gout and for the follow-up of patients receiving therapy. Although DECT has the highest diagnostic accuracy for gout and shows consistently excellent reader agreement in the assessment of urate deposition change after therapy, US also performs well and remains just as important an imaging tool in these realms due to its practical advantages in cost, availability, and safety. This article reports the current status of these two modalities in regard to diagnosis and therapy follow-up.

Air pollution as a determinant of rheumatoid arthritis

Pollution has long been incriminated in many cardiovascular and respiratory diseases. More recently, studies evaluated the potential role for particulate pollutants in autoimmune diseases, including rheumatoid arthritis (RA). The incidence of RA was found to be higher in urban areas. Living near air pollution emitters was associated with higher risks of developing RA and of producing RA-specific autoantibodies. Nevertheless, no strong epidemiological evidence exists to link one or more specific air pollution particles to RA. The presence in the bronchi of lymphoid satellite islands (inducible bronchus-associated lymphoid tissue, iBALT) is strongly associated with both inflammatory lung disease and RA-associated lung disease. Diesel exhaust particles can stimulate iBALT formation. The induction by air pollution of an inflammatory environment with high citrullination levels in the lung may induce iBALT formation, thereby causing a transition toward a more specific immune response via the production of anti-citrullinated peptide antibodies. Air pollution not only triggers innate immune responses at the molecular level, increasing the levels of proinflammatory cytokines and reactive oxygen species, but is also involved in adaptive immune responses. Thus, via the aryl hydrocarbon receptor (AHR), diesel exhaust particles can trigger a T-cell switch to the Th17 profile. Finally, in the murine collagen-induced arthritis model, animals whose lymphocytes lack the AHR develop milder arthritis.

Rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, inflammatory, autoimmune disease that primarily affects the joints and is associated with autoantibodies that target various molecules including modified self-epitopes. The identification of novel autoantibodies has improved diagnostic accuracy, and newly developed classification criteria facilitate the recognition and study of the disease early in its course. New clinical assessment tools are able to better characterize disease activity states, which are correlated with progression of damage and disability, and permit improved follow-up. In addition, better understanding of the pathogenesis of RA through recognition of key cells and cytokines has led to the development of targeted disease-modifying antirheumatic drugs. Altogether, the improved understanding of the pathogenetic processes involved, rational use of established drugs and development of new drugs and reliable assessment tools have drastically altered the lives of individuals with RA over the past 2 decades. Current strategies strive for early referral, early diagnosis and early start of effective therapy aimed at remission or, at the least, low disease activity, with rapid adaptation of treatment if this target is not reached. This treat-to-target approach prevents progression of joint damage and optimizes physical functioning, work and social participation. In this Primer, we discuss the epidemiology, pathophysiology, diagnosis and management of RA.

EULAR recommendations for the management of rheumatoid arthritis: what is new in 2017 and its applicability in our local setting

Rheumatoid arthritis (RA) is the most common rheumatic disease being managed by the rheumatologists. With the emergence of the biologic and targeted synthetic disease modifying anti-rheumatic drugs (b/tsDMARDs), the prognosis of RA has improved substantially. However, these novel agents are associated with high cost and untoward effects. International consensus statements for the drug management of RA have been published to guide the practice of rheumatologists. In this article, updates from the 2016 EULAR management recommendations for RA are reviewed and discussed within the context of our local situation in Hong Kong.

Tumor Necrosis Factor-Alpha Targeting Can Protect against Arthritis with Low Sensitization to Infection

Tumor necrosis factor-alpha (TNF-α) blockade is an effective treatment for rheumatoid arthritis (RA) and other inflammatory diseases, but in patients, it is associated with reduced resistance to the infectious agents Mycobacterium tuberculosis and Listeria monocytogenes, among others. Our goal was to model infection and arthritis in mice and to compare etanercept, a currently used anti-TNF-α inhibitor, to an anti-TNF-α vaccine. We developed a murine surrogate of the TNF-α kinoid and produced an anti-murine TNF-α vaccine (TNFKi) composed of keyhole limpet hemocyanin conjugated to TNF-α, which resulted in anti-TNF-α antibody production in mice. We also used etanercept (a soluble receptor of TNF commonly used to treat RA) as a control of TNF neutralization. In a mouse model of collagen-induced arthritis, TNFKi protected against inflammation similar to etanercept. In a mouse model of acute L. monocytogenes infection, all TNFKi-treated mice showed cleared bacterial infection and survived, whereas etanercept-treated mice showed large liver granulomas and quickly died. Moreover, TNFKi mice infected with the virulent H37Rv M. tuberculosis showed resistance to infection, in contrast with etanercept-treated mice or controls. Depending on the TNF-α blockade strategy, treating arthritis with a TNF-α inhibitor could result in a different profile of infection suceptibility. Our TNFKi vaccine allowed for a better remaining host defense than did etanercept.

Calidad de vida, nivel de salud percibido y factores sociodemográficos en personas con artritis reumatoide

Objetivo: determinar la relación entre la calidad de vida, el nivel de salud y los factores sociodemográficos en personas con artritis reumatoide (AR). Materiales y método: estudio correlacional explicativo. Se realizó una entrevista directa en el momento de la consulta de enfermería antes del control médico de reumatología. A través de un muestreo intencional no probabilístico de sujetos tipo se contó con la participación de 635 personas. Resultados: se encontró una frecuencia de presentación de AR mayor en mujeres (87%). También se evidenció una correlación positiva (0,596; P<0,001) entre calidad de vida y nivel de salud. Sociodemográficamente, las mujeres con educación básica y bajo estrato socioeconómico presentan una menor percepción de calidad de vida y nivel de salud. Estas variables se sometieron a un proceso de prueba con el uso de un modelo Path de análisis de covarianza. Conclusiones: las condiciones sociales que viven las personas con AR son factores que determinan la puesta en marcha de acciones de intervención dirigidas a solucionar la problemática de la calidad de vida en esta población.

Systemic glucocorticoid use in Denmark: a population-based prevalence study

OBJECTIVES

Glucocorticoid (GC) use is widespread and associated with many adverse effects. Thus, it is important to ascertain GC utilisation patterns. In this study, we examined the annual prevalence of prescription users and amount of use of systemic GCs.

DESIGN

Population-wide prevalence study.

SETTING

The primary healthcare and hospital sectors in Denmark from 1999 to 2015.

RESULTS

Approximately 3% of the Danish population redeemed at least one prescription for a systemic GC annually between 1999 and 2015, with annual prevalence remaining constant over the period. However, after adjusting for age and sex, we observed a decrease in annual prevalence from 1999 to 2015, with a prevalence ratio of 0.92 (95% CI 0.91 to 0.92). Annual prevalence was highest among the elderly (7.0%-8.2% among persons 65-79 years of age and 8.4%-10% among persons 80+ years of age). Prednisolone was the most frequently redeemed systemic GC, with annual prevalence increasing from 1.4% to 2.1% during the 1999-2015 period. The amount of systemic GCs provided to the hospital sector increased from 2.3 defined daily doses (DDD)/1000 inhabitants/day in 1999 to 3.5 DDD/1000 inhabitants/day in 2015, while the amount provided to the primary healthcare sector remained constant in the range of 10-11 DDD/1000 inhabitants/day.

CONCLUSION

We found a high prevalence of systemic GC use of 3% with a remarkably high prevalence in elderly of up to 10%, wherefore continued awareness of its effects is mandated.

Polymorphisms of RAD51B are associated with rheumatoid arthritis and erosion in rheumatoid arthritis patients

Rheumatoid arthritis (RA) is a common, chronic autoimmune disease affecting 0.5–1.0% of adults worldwide, including approximately 4.5–5.0 million patients in China. The genetic etiology and pathogenesis of RA have not yet been fully elucidated. Recently, one new RA susceptibility gene (RAD51B) has been identified in Korean and European populations. In this study, we designed a two-stage case-control study to further assess the relationship of common variants in the RAD51B gene with increased risk of RA in a total of 965 RA patients and 2,511 unrelated healthy controls of Han Chinese ancestry. We successfully identified a common variant, rs911263, as being significantly associated with the disease status of RA (P = 4.8 × 10⁻⁵, OR = 0.64). In addition, this SNP was shown to be related to erosion, a clinical assessment of disease severity in RA (P = 2.89 × 10⁻⁵, OR = 0.52). These findings shed light on the role of RAD51B in the onset and severity of RA. More research in the future is needed to clarify the underlying functional link between rs911263 and the disease.

Chlorinated Phospholipids and Fatty Acids: (Patho)physiological Relevance, Potential Toxicity, and Analysis of Lipid Chlorohydrins

Chlorinated phospholipids are formed by the reaction of hypochlorous acid (HOCl), generated by the enzyme myeloperoxidase under inflammatory conditions, and the unsaturated fatty acyl residues or the head group. In the first case the generated chlorohydrins are both proinflammatory and cytotoxic, thus having a significant impact on the structures of biomembranes. The latter case leads to chloramines, the properties of which are by far less well understood. Since HOCl is also widely used as a disinfecting and antibacterial agent in medicinal, industrial, and domestic applications, it may represent an additional source of danger in the case of abuse or mishandling. This review discusses the reaction behavior of in vivo generated HOCl and biomolecules like DNA, proteins, and carbohydrates but will focus on phospholipids. Not only the beneficial and pathological (toxic) effects of chlorinated lipids but also the importance of these chlorinated species is discussed. Some selected cleavage products of (chlorinated) phospholipids and plasmalogens such as lysophospholipids, (chlorinated) free fatty acids and α-chloro fatty aldehydes, which are all well known to massively contribute to inflammatory diseases associated with oxidative stress, will be also discussed. Finally, common analytical methods to study these compounds will be reviewed with focus on mass spectrometric techniques.