Established rheumatoid arthritis: rationale for best practice: physicians' perspective of how to realise tight control in clinical practice

Discrepancy between clinical and ultrasound remissions in rheumatoid arthritis: a multicentre ultrasound cohort study in Japan

Objectives: Using multicentre ultrasound (US) cohort data among patients with rheumatoid arthritis (RA), we aimed to identify baseline factors that permit differentiation between two patient cohorts achieving US remission and clinical remission, and to determine the factors contributing to the discrepancy.Method: We reviewed 248 Japanese patients diagnosed with RA who underwent treatment with biological disease-modifying anti-rheumatic drugs at 13 centres. We performed US assessments of the synovia of 22 joints. We assessed the percentages of patients with clinical remission and US remission, defined as total power Doppler scores of 0 at 12 months.Results: The 87 patients who achieved US remission were divided into a group that achieved both clinical and US remission (n = 53) and a group that achieved US remission only (n = 34). Baseline factors that were significantly and independently associated with clinical remission at 12 months among patients who also achieved US remission included short disease duration, the presence of concomitant methotrexate use, and low patient global assessment score (p < 0.05, p < 0.05, and p < 0.005, respectively).Conclusions: RA patients with baseline high patient global assessment scores and long disease duration at baseline were unlikely to achieve clinical remission even after achieving US remission. Objective joint assessments using US provide additional information of potential importance for the management of RA.

Time to update the ICF by including socioemotional qualities of participation? The development of a "patient ladder of participation" based on interview data of people with early rheumatoid arthritis (the Swedish TIRA study)

Purpose: The aim of was to identify and illustrate in what situations and with what qualities people with early RA experience participation in every day's life.Methods: Fifty-nine patients (age 18-63 years) were interviewed; 25 men and 34 women. Content analysis was used to identify meaning units that were sorted based on the type of situations described and later on, categories based on quality aspects of participation were developed.Results: Participation was described as: 1. being part of a group, where a sense of belonging arose. 2. In doing activities with others for example at work or in leisure. 3. When sharing everyday chores and responsibilities for example in domestic duties. 4. When experiencing influence on actions such as when being asked for opinions on how to conduct a specific task. 5. When having the possibility to give direction of goals in rehabilitation, or elsewhere. 6. When sharing decision making and experiencing a high degree of influence in the situation.Conclusions: Participation from an individual's perspective is about belonging and having influence that mediates a positive feeling of being included and that you matter as a person. The results are important when using participation as a goal in clinical care. It is important to expand participation beyond the definitions in ICF and guidelines to include the patients' socio-emotional participation in order to promote health.Implications for rehabilitationFacilitation of participation in daily activities is an important part of rehabilitation.Participation is expressed as determined by a person's unique life circumstances often in engagement with others.It is important to expand participation beyond the definitions in ICF and guidelines to include the patients' socio-emotional participation in order to promote health.Collected information about socioemotional participation can serve as a starting point for interventions aimed at the patient's social environment and also provide support for health professions how to involve significant others in the rehabilitation.

Improving access in rheumatology: Evaluating the validity of a paper triage process involving an advanced practice physiotherapist through a retrospective chart review

Objectives: This study evaluated a standardized paper triage process conducted by an advanced practice physiotherapist (APP) at a rheumatology center. The aims were to (1) determine the concordance between paper triage priority assignment and the rheumatologist's diagnosis; (2) determine the sensitivity and specificity of the paper triage process; and (3) assess reasons for incorrect priority ranking. Methods: Referrals were triaged by a formally trained APP into one of the three priorities, guided by a priority referral tool. A retrospective review of 192 charts was performed. Raw proportion of agreement between paper triage and rheumatologist's diagnosis was supplemented by a prevalence-adjusted bias-adjusted kappa (PABAK). Priority categories were collapsed to calculate sensitivity and specificity. For discordant cases, additional information was collected from the referral and chart to identify potential features leading to discrepancy. Results: Overall agreement was 76%. The PABAK was 0.80 [95% confidence interval 0.70-0.90]. Sensitivity ranged 0.64-0.92 and specificity ranged 0.81-0.94, depending on the priority category. Forty-six cases were discordant, with the APP choosing a higher priority in 37 cases. An incorrect diagnosis from the family physician with no supporting information for the paper triage led to discordance in 16 cases. Conclusion: A standardized paper triage process conducted by an APP showed substantial concordance, sensitivity, and specificity.

Identification of Three Rheumatoid Arthritis Disease Subtypes by Machine Learning Integration of Synovial Histologic Features and RNA Sequencing Data

OBJECTIVE

In this study, we sought to refine histologic scoring of rheumatoid arthritis (RA) synovial tissue by training with gene expression data and machine learning.

METHODS

Twenty histologic features were assessed in 129 synovial tissue samples (n = 123 RA patients and n = 6 osteoarthritis [OA] patients). Consensus clustering was performed on gene expression data from a subset of 45 synovial samples. Support vector machine learning was used to predict gene expression subtypes, using histologic data as the input. Corresponding clinical data were compared across subtypes.

RESULTS

Consensus clustering of gene expression data revealed 3 distinct synovial subtypes, including a high inflammatory subtype characterized by extensive infiltration of leukocytes, a low inflammatory subtype characterized by enrichment in pathways including transforming growth factor β, glycoproteins, and neuronal genes, and a mixed subtype. Machine learning applied to histologic features, with gene expression subtypes serving as labels, generated an algorithm for the scoring of histologic features. Patients with the high inflammatory synovial subtype exhibited higher levels of markers of systemic inflammation and autoantibodies. C-reactive protein (CRP) levels were significantly correlated with the severity of pain in the high inflammatory subgroup but not in the others.

CONCLUSION

Gene expression analysis of RA and OA synovial tissue revealed 3 distinct synovial subtypes. These labels were used to generate a histologic scoring algorithm in which the histologic scores were found to be associated with parameters of systemic inflammation, including the erythrocyte sedimentation rate, CRP level, and autoantibody levels. Comparison of gene expression patterns to clinical features revealed a potentially clinically important distinction: mechanisms of pain may differ in patients with different synovial subtypes.

Effectiveness of a telemonitoring intensive strategy in early rheumatoid arthritis: comparison with the conventional management approach

BACKGROUND

The advent of Internet and World Wide Web has created new perspectives toward interaction between patients and healthcare professionals. Telemonitoring patients with rheumatoid arthritis (RA) is an emerging concept to guide the collaborative management treatment and improve outcomes in patients. The objective of this study was to investigate whether an intensive treatment strategy, according to a telemonitoring protocol, is more effective than conventional management strategy in reaching remission and comprehensive disease control (CDC) after 1 year in early rheumatoid arthritis (ERA) patients.

METHODS

Forty-four ERA patients were randomly allocated into two groups: the telemonitoring intensive strategy (TIS) group (group 1) or the conventional strategy (CS) group (group 2). Three patients refused to participate. In group 1 (n = 21), a remote monitoring system of disease activity, in combination with protocolised treatment adjustments aiming for remission was applied. In group 2 (n = 20), patients were treated according to daily clinical practice, with regular evaluation of disease activity, but without protocolised treatment adjustments. A telemedical care called "REmote TElemonitoring for MAnaging Rheumatologic Condition and HEaltcare programmes" (RETE-MARCHE), was developed to perform the remote monitoring.

RESULTS

A higher percentage of patients in the TIS group achieved CDAI remission vs patients in the CS group (38.1 % vs 25 % at year 1, p <0.01). Time to achieve remission was significantly shorter in the group 1 than in the group 2, with a median of 20 weeks vs a median over 36-weeks (p <0.001). Concordantly, the patients in group 1 showed a greater improvement (p <0.001), compared with group 2 in terms of functional impairment (71.4 % vs 35 %) and radiological damage progression (23.8 % vs 10 %), resulting in a greater rate of CDC (19.4 % vs 5 %).

CONCLUSIONS

According to our results, an intensive treatment strategy by telemonitoring leads to more effective disease remission and more rapid CDC than treatment according to conventional management strategy in ERA.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

ISRCTN13142685 Date of registration: March, 17(th) 2016.

A nurse-led rheumatology clinic versus rheumatologist-led clinic in monitoring of patients with chronic inflammatory arthritis undergoing biological therapy: a cost comparison study in a randomised controlled trial

BACKGROUND

Recommendations for rheumatology nursing management of chronic inflammatory arthritis (CIA) from European League Against Rheumatism (EULAR) states that nurses should take part in the monitoring patients' disease and therapy in order to achieve cost savings. The aim of the study was to compare the costs of rheumatology care between a nurse-led rheumatology clinic (NLC), based on person-centred care (PCC), versus a rheumatologist-led clinic (RLC), in monitoring of patients with CIA undergoing biological therapy.

METHODS

Patients with CIA undergoing biological therapy (n = 107) and a Disease Activity Score of 28 ≤ 3.2 were randomised to follow-up by either NLC or RLC. All patients met the rheumatologist at inclusion and after 12 months. In the intervention one of two annual monitoring visits in an RLC was replaced by a visit to an NLC. The primary outcome was total annual cost of rheumatology care.

RESULTS

A total of 97 patients completed the RCT at the 12 month follow-up. Replacing one of the two annual rheumatologist monitoring visits by a nurse-led monitoring visit, resulted in no additional contacts to the rheumatology clinic, but rather a decrease in the use of resources and a reduction of costs. The total annual rheumatology care costs including fixed monitoring, variable monitoring, rehabilitation, specialist consultations, radiography, and pharmacological therapy, generated € 14107.7 per patient in the NLC compared with € 16274.9 in the RCL (p = 0.004), giving a € 2167.2 (13 %) lower annual cost for the NLC.

CONCLUSIONS

Patients with CIA and low disease activity or in remission undergoing biological therapy can be monitored with a reduced resource use and at a lower annual cost by an NLC, based on PCC with no difference in clinical outcomes. This could free resources for more intensive monitoring of patients early in the disease or patients with high disease activity.

TRIAL REGISTRATION

The trial is registered as a clinical trial at the ClinicalTrials.gov (NCT01071447). Registration date: October 8, 2009.

Are We Able to Suppress Disease Activity Adequately in Patients With Established Rheumatoid Arthritis? An Observational and Cross-Sectional Study

Objectives

This study aims to explore current disease activity status and simultaneous pharmacological therapies in patients with established rheumatoid arthritis (RA) to determine the extent to which treatment targets are achieved.

Patients and methods

One hundred patients (7 males, 93 females; median age 57 years; range 31 to 76 years) with established RA receiving any conventional synthetic disease modifying anti-rheumatic drug (DMARD) and/or biological DMARD for at least three months were enrolled. Disease activity was determined by using the Simplified Disease Activity Index. First, patients were categorized into four groups as remission, low disease activity, moderate disease activity, and high disease activity. Then, they were divided into two subgroups, namely a remission/low disease activity subgroup and moderate disease activity/high disease activity subgroup.

Results

Fifty-one percent of the patients had remission or low disease activity. The most frequently used conventional synthetic DMARDs were methotrexate (50%) and leflunomide (34%). Forty-five percent of patients were receiving glucocorticoid therapy. In patients receiving only conventional synthetic DMARDs, the proportion of remission and low disease activity was 54% (42/78). Forty-two percent (8/19) of the patients receiving biological DMARDs were in remission or had low disease activity. A comparison of subgroups revealed that median age and sulfasalazine use were significantly higher in the moderate disease activity/high disease activity subgroup.

Conclusion

The results of this study demonstrated that half of patients with established RA had moderate or high disease activity in our local outpatient clinic. Some barriers might be responsible for the difficulties in controlling disease activity. Determining such barriers might result in a better clinical response during the management of patients with established RA in real-life practice.

Imaging as an Outcome Measure in Gout Studies: Report from the OMERACT Gout Working Group

OBJECTIVE

The gout working group at the Outcome Measures in Rheumatology (OMERACT) 12 meeting in 2014 aimed to determine which imaging modalities show the most promise for use as measurement instruments for outcomes in studies of people with chronic gout and to identify the key foci for future research about the performance of these imaging techniques with respect to the OMERACT filter 2.0.

METHODS

During the gout session, a systematic literature review of the data addressing imaging modalities including plain radiography (XR), conventional computed tomography (CT), dual-energy computed tomography (DECT), magnetic resonance imaging (MRI), and ultrasound (US) and the fulfillment of the OMERACT filter 2.0 was presented.

RESULTS

The working group identified 3 relevant domains for imaging in gout studies: urate deposition (tophus burden), joint inflammation, and structural joint damage.

CONCLUSION

The working group prioritized gaps in the data and identified a research agenda.

Rheumatoid arthritis pathophysiology: update on emerging cytokine and cytokine-associated cell targets

Biologic therapies that target pathogenic cytokines such as TNF, IL-1β or IL-6 have greatly improved the treatment of RA. Unfortunately, not all RA patients respond to current biologic therapies and responses are not always maintained, suggesting that there are alternative drivers of RA pathogenesis that might serve as promising therapeutic targets. Discovery of the new Th17 subset of Th cells, and their role in autoimmune disease development, has implicated the proinflammatory IL-12 and IL-17 families of cytokines in RA disease pathogenesis. Members of these cytokine families are elevated in the blood and joints of RA patients and have been shown to remain elevated in patients who do not respond to current biologics. In addition, these cytokines have been shown to play roles in joint destruction and erosion. A new subclass of biologics that target the IL-12 and/or IL-17 signalling pathways are under development. Here we review evidence for a role of Th17 cells as well as IL-12 and IL-17 cytokines in RA pathogenesis as the rationale for a subsequent discussion of the ongoing and completed clinical trials of newly emerging biologic therapies directed at IL-12 or IL-17 pathway inhibition.

Recent paradigm shifts in the diagnosis and treatment of rheumatoid arthritis

Rheumatoid arthritis (RA) is a progressive inflammatory disease with severe symptoms of pain and stiffness. Chronic persistent inflammation of RA often leads to joint destruction, deformity and limitation of function, which ultimately results in significant deterioration of quality of life (QoL). RA is characterized pathogenetically by immunologically driven, chronic synovitis, and production of autoantibodies, such as rheumatoid factor and anti-cyclic citrullinated peptide antibodies. Although the cause of RA is yet unknown, advances in the molecular biology led to in-depth understanding of its pathogenesis, and have fostered the recent development of novel treatments. The last decade has seen the dramatic change in the landscape of RA treatment with more aggressive therapy early in the disease course and with treatment guided by a structured assessment of disease activity, with the ultimate goal of reaching remission. In addition, prevention and control of joint damage and improvement in QoL are important goals. To achieve these goals, a multidisciplinary approach to reduce disease activity with disease modifying antirheumatic drugs and biological therapy is needed. We also need to find ways to identify those patients who are at risk for more rapid disease progression who would benefit from intensive therapy early in the course of disease.