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Kenney HM, Chen KL, Schnur L, Fox JI, Wood RW, Xing L, Ritchlin CT, Rahimi H, Schwarz EM, Awad HA. High-throughput micro-CT analysis identifies sex-dependent biomarkers of erosive arthritis in TNF-Tg mice and differential response to anti-TNF therapy. PLoS One 2024; 19:e0305623. [PMID: 38968295 PMCID: PMC11226038 DOI: 10.1371/journal.pone.0305623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/03/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Development of reliable disease activity biomarkers is critical for diagnostics, prognostics, and novel drug development. Although computed tomography (CT) is the gold-standard for quantification of bone erosions, there are no consensus approaches or rationales for utilization of specific outcome measures of erosive arthritis in complex joints. In the case of preclinical models, such as sexually dimorphic tumor necrosis factor transgenic (TNF-Tg) mice, disease severity is routinely quantified in the ankle through manual segmentation of the talus or small regions of adjacent bones primarily due to the ease in measurement. Herein, we sought to determine the particular hindpaw bones that represent reliable biomarkers of sex-dependent disease progression to guide future investigation and analysis. METHODS Hindpaw micro-CT was performed on wild-type (n = 4 male, n = 4 female) and TNF-Tg (n = 4 male, n = 7 female) mice at monthly intervals from 2-5 (females) and 2-8-months (males) of age, since female TNF-Tg mice exhibit early mortality from cardiopulmonary disease at approximately 5-6-months. Further, 8-month-old WT (n = 4) and TNF-Tg males treated with anti-TNF monoclonal antibodies (n = 5) or IgG placebo isotype controls (n = 6) for 6-weeks were imaged with micro-CT every 3-weeks. For image analysis, we utilized our recently developed high-throughput and semi-automated segmentation strategy in Amira software. Synovial and osteoclast histology of ankle joints was quantified using Visiopharm. RESULTS First, we demonstrated that the accuracy of automated segmentation, determined through analysis of ~9000 individual bones by a single user, was comparable in wild-type and TNF-Tg hindpaws before correction (79.2±8.9% vs 80.1±5.1%, p = 0.52). Compared to other bone compartments, the tarsal region demonstrated a sudden, specific, and significant bone volume reduction in female TNF-Tg mice, but not in males, by 5-months (4-months 4.3± 0.22 vs 5-months 3.4± 0.62 mm3, p<0.05). Specifically, the cuboid showed significantly reduced bone volumes at early timepoints compared to other tarsals (i.e., 4-months: Cuboid -24.1±7.2% vs Talus -9.0±5.9% of 2-month baseline). Additional bones localized to the anterolateral region of the ankle also exhibited dramatic erosions in the tarsal region of females, coinciding with increased synovitis and osteoclasts. In TNF-Tg male mice with severe arthritis, the talus and calcaneus exhibited the most sensitive response to anti-TNF therapy measured by effect size of bone volume change over treatment period. CONCLUSIONS We demonstrated that sexually dimorphic changes in arthritic hindpaws of TNF-Tg mice are bone-specific, where the cuboid serves as a reliable early biomarker of erosive arthritis in female mice. Adoption of automated segmentation approaches in pre-clinical or clinical models has potential to translate quantitative biomarkers to monitor bone erosions in disease and evaluate therapeutic efficacy.
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Affiliation(s)
- H. Mark Kenney
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Pathology & Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Kiana L. Chen
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Pathology & Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Lindsay Schnur
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Jeffrey I. Fox
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Ronald W. Wood
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Neuroscience, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Urology, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Lianping Xing
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Pathology & Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Christopher T. Ritchlin
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Medicine, Division of Allergy, Immunology, Rheumatology, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Homaira Rahimi
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Pediatrics, Pediatric Rheumatology, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Edward M. Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Pathology & Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Urology, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Medicine, Division of Allergy, Immunology, Rheumatology, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Hani A. Awad
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, United States of America
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Wang Y, Jones G, Keen HI, Hill CL, Wluka AE, Kasza J, Teichtahl AJ, Antony B, O'Sullivan R, Cicuttini FM. Methotrexate to treat hand osteoarthritis with synovitis (METHODS): an Australian, multisite, parallel-group, double-blind, randomised, placebo-controlled trial. Lancet 2023; 402:1764-1772. [PMID: 37839420 DOI: 10.1016/s0140-6736(23)01572-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/20/2023] [Accepted: 07/26/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Hand osteoarthritis is a disabling condition with few effective therapies. Hand osteoarthritis with synovitis is a common inflammatory phenotype associated with pain. We aimed to examine the efficacy and safety of methotrexate at 6 months in participants with hand osteoarthritis and synovitis. METHODS In this multisite, parallel-group, double-blind, randomised, placebo-controlled trial, participants (aged 40-75 years) with hand osteoarthritis (Kellgren and Lawrence grade ≥2 in at least one joint) and MRI-detected synovitis of grade 1 or more were recruited from the community in Melbourne, Hobart, Adelaide, and Perth, Australia. Participants were randomly assigned (1:1) using block randomisation, stratified by study site and self-reported sex, to receive methotrexate 20 mg or identical placebo orally once weekly for 6 months. The primary outcome was pain reduction (measured with a 100 mm visual analogue scale; VAS) in the study hand at 6 months assessed in the intention-to-treat population. Safety outcomes were assessed in all randomly assigned participants. This trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000877381). FINDINGS Between Nov 22, 2017, and Nov 8, 2021, of 202 participants who were assessed for eligibility, 97 (48%) were randomly assigned to receive methotrexate (n=50) or placebo (n=47). 68 (70%) of 97 participants were female and 29 (30%) were male. 42 (84%) of 50 participants in the methotrexate group and 40 (85%) of 47 in the placebo group provided primary outcome data. The mean change in VAS pain at 6 months was -15·2 mm (SD 24·0) in the methotrexate group and -7·7 mm (25·3) in the placebo group, with a mean between-group difference of -9·9 (95% CI -19·3 to -0·6; p=0·037) and an effect size (standardised mean difference) of 0·45 (0·03 to 0·87). Adverse events occurred in 31 (62%) of 50 participants in the methotrexate group and 28 (60%) of 47 participants in the placebo group. INTERPRETATION Treatment of hand osteoarthritis and synovitis with 20 mg methotrexate for 6 months had a moderate but potentially clinically meaningful effect on reducing pain, providing proof of concept that methotrexate might have a role in the management of hand osteoarthritis with an inflammatory phenotype. FUNDING National Health and Medical Research Council of Australia.
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Affiliation(s)
- Yuanyuan Wang
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Graeme Jones
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Helen I Keen
- Rheumatology Group, School of Medicine, University of Western Australia, Perth, WA, Australia; Department of Rheumatology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Catherine L Hill
- The Queen Elizabeth Hospital and Department of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Anita E Wluka
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Alfred Hospital, Melbourne, VIC, Australia
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | | - Benny Antony
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Richard O'Sullivan
- Lumus Imaging, Richmond, VIC, Australia; Department of Medicine, Central Clinical School, Monash University, Prahran, VIC, Australia
| | - Flavia M Cicuttini
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Alfred Hospital, Melbourne, VIC, Australia.
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Ciurea A, Distler O, Kwok K, Jo H, Wang L, Killeen T, Ospelt C, Frank Bertoncelj M. Joint-level responses to tofacitinib and methotrexate: a post hoc analysis of data from ORAL Start. Arthritis Res Ther 2023; 25:185. [PMID: 37773189 PMCID: PMC10540368 DOI: 10.1186/s13075-023-03144-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 08/23/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) has a variable impact on different synovial joints, with inflammation being more commonly observed in some joints than others. Emerging evidence suggests that the anatomical variation in pathophysiology could result in differential responses to treatments across the joints, both within and between modes of action. This analysis aimed to characterize joint-specific responses to tofacitinib and methotrexate monotherapy in patients with RA. METHODS This was a post hoc analysis of data from the phase III trial ORAL Start (NCT01039688), in methotrexate-naïve patients with RA. A paired joint pathology score (PJPS), derived from bilateral tender/swollen joint counts, was calculated. The percentage change from baseline in PJPS (%∆PJPS) and treatment-specific responses (tofacitinib 5 and 10 mg twice daily [BID] vs methotrexate; tofacitinib 5 vs 10 mg BID) for each patient joint pair, except for those with baseline/post-baseline PJPS = 0, were calculated at month 3, month 6, and month 12. Radiographic progression was similarly assessed using the Modified Total Sharp Score at month 6 and month 12. RESULTS In methotrexate-naïve patients, differences in %∆PJPS demonstrated greater responses with tofacitinib vs methotrexate in most joint locations. Lesser responses with tofacitinib vs methotrexate were observed in most joints of the feet, particularly at month 12. Despite this, radiographic progression at month 12 was significantly worse in the foot (and metacarpophalangeal) joints of patients receiving methotrexate vs tofacitinib. CONCLUSION We observed variation in joint-specific responses with tofacitinib and methotrexate monotherapy. Despite a proximal-distal efficacy gradient, with better clinical responses in the feet, patients receiving methotrexate monotherapy demonstrated more radiographic progression in the foot joints compared with those receiving tofacitinib. These findings suggest that body site- and therapy-specific characteristics may interact to produce differential treatment responses. TRIAL REGISTRATION ClinicalTrials.gov, NCT01039688.
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Affiliation(s)
- Adrian Ciurea
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Oliver Distler
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Kenneth Kwok
- Inflammation & Immunology, Pfizer Inc., New York, NY, USA
| | - Hyejin Jo
- Inflammation & Immunology, Pfizer Inc., New York, NY, USA
| | - Lisy Wang
- Inflammation & Immunology, Pfizer Inc., Groton, CT, USA
| | - Tim Killeen
- Inflammation & Immunology, Pfizer AG, Schärenmoosstrasse 99, 8052, Zürich, Switzerland.
| | - Caroline Ospelt
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Mojca Frank Bertoncelj
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
- BioMed X Institute, Heidelberg, Germany
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Askanase AD, Aranow C, Kim MY, Kamen DL, Arriens C, Khalili L, Tang W, Barasch J, Dall'Era M, Mackay M. Protocol for virtual physical examination in an observational, longitudinal study evaluating virtual outcome measures in SLE. Lupus Sci Med 2023; 10:e000952. [PMID: 37429672 DOI: 10.1136/lupus-2023-000952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 05/26/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE There is a lack of data on the use of telemedicine (TM) in SLE. SLE outcome measures remain complex, and clinicians and clinical trialists have raised concerns about the accuracy of virtual disease activity measures. This study evaluates the level of agreement between virtual SLE outcome measures and face-to-face (F2F) encounter. Here, we describe the study design, virtual physical examination protocol and demographics for the first 50 patients evaluated. METHODS AND ANALYSIS This is an observational, longitudinal study of 200 patients with SLE with varying levels of disease activity from 4 academic lupus centres serving diverse populations. Each study participant will be evaluated at a baseline and a follow-up visit. At each visit, participants are evaluated by the same physician first via a videoconference-based TM and then a F2F encounter. For this protocol, virtual physical examination guidelines relying on physician-directed patient self-examination were established. SLE disease activity measures will be completed immediately after the TM encounter and repeated after the F2F encounter for each visit. The degree of agreement between TM and F2F disease activity measures will be analysed using the Bland-Altman method. An interim analysis is planned after the enrolment of the first 50 participants. ETHICS AND DISSEMINATION This study has been reviewed by the Columbia University Medical Center Institutional Review Board (IRB Protocol #: AAAT6574). The full results of this study will be published after the final data analysis of 200 patients. The abrupt shift to TM visits due to the COVID-19 pandemic disrupted clinical practice and clinical trials. Establishing a high level of agreement between SLE disease activity measures obtained with videoconference TM and F2F at the same time point, will allow for improved assessment of disease activity when F2F data cannot be acquired. This information may guide both medical decision-making and provide reliable outcome measures for clinical research.
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Affiliation(s)
- Anca D Askanase
- Division of Rheumatology, Columbia University Irving Medical Center, New York City, New York, USA
| | - Cynthia Aranow
- The Center for Autoimmune & Musculoskeletal Disease, The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Mimi Y Kim
- Department of Epidemiology & Population Health Division of Biostatistics, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Diane L Kamen
- Division of Rheumatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Cristina Arriens
- Arthritis and Clinical Immunology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Leila Khalili
- Division of Rheumatology, Columbia University Irving Medical Center, New York City, New York, USA
| | - Wei Tang
- Division of Rheumatology, Columbia University Irving Medical Center, New York City, New York, USA
| | - Julia Barasch
- Division of Rheumatology, Columbia University Irving Medical Center, New York City, New York, USA
| | - Maria Dall'Era
- Division of Rheumatology, UCSF, San Francisco, California, USA
| | - Meggan Mackay
- The Center for Autoimmune & Musculoskeletal Disease, The Feinstein Institute for Medical Research, Manhasset, New York, USA
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Koppikar S, Diaz P, Kaeley GS, Eder L. Seeing is believing: Smart use of musculoskeletal ultrasound in rheumatology practice. Best Pract Res Clin Rheumatol 2023; 37:101850. [PMID: 37481369 DOI: 10.1016/j.berh.2023.101850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/19/2023] [Indexed: 07/24/2023]
Abstract
Musculoskeletal ultrasonography has become an increasingly valuable tool as a complement to the physical exam in rheumatology practice. Its point-of-care access, low cost, safety, portability, and reliability in trained hands, make this technique especially useful in patients with inflammatory arthritis. Growing evidence has demonstrated the value of musculoskeletal ultrasound in the detection of inflammatory and structural changes in patients with joint pain without obvious joint swelling, in differentiating various inflammatory diagnoses, in the monitoring of inflammatory arthritis, and interventional procedures. The potential role of ultrasound guiding treat-to-target strategies or tapering treatment in inflammatory arthritis requires further research. However, musculoskeletal ultrasound can also have pitfalls and limitations that a clinician should be aware of.
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Affiliation(s)
- Sahil Koppikar
- Division of Rheumatology, Women's College Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Pamela Diaz
- Departamento de Inmunologia Clinica y Reumatologia, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Gurjit S Kaeley
- Division of Rheumatology and Clinical Immunology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Lihi Eder
- Division of Rheumatology, Women's College Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada.
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van Dijkhuizen EHP, Ridella F, Naddei R, Trincianti C, Avrusin I, Mazzoni M, Sutera D, Ayaz NA, Penades IC, Constantin T, Herlin T, Oliveira SK, Rygg M, Sanner H, Susic G, Sztajnbok F, Varbanova B, Ruperto N, Ravelli A, Consolaro A. Validity and Reliability of Four Parent/Patient-Reported Outcome Measures for Juvenile Idiopathic Arthritis Remote Monitoring. Arthritis Care Res (Hoboken) 2023; 75:391-400. [PMID: 35015379 PMCID: PMC10087383 DOI: 10.1002/acr.24855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/30/2021] [Accepted: 12/30/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this work was to provide evidence of validity and reliability for 4 parent/child-reported outcome measures included in the Outcome Measures in Rheumatology juvenile idiopathic arthritis core domain set: the evaluation of the child's pain and level of disease activity, the assessment of morning stiffness duration, and an active joint count for proxy/self-assessment. METHODS Patients were included in the multinational study Epidemiology Treatment and Outcome of Childhood Arthritis. Criterion validity was assessed by examining the correlation of the 4 tested measures with physician measures and the clinical Juvenile Arthritis Disease Activity Score in 10 joints (cJADAS10) in the whole sample and after grouping patients by International League of Associations for Rheumatology (ILAR) category, geographic area, and education level. Reliability was assessed comparing 2 visits 7-14 days apart with intraclass correlation coefficients (ICCs). RESULTS A total of 8,643 parents and 6,060 patients had all the evaluations available. Correlations of tested measures were moderate (0.4-0.7) with physician-reported measures. The level of correlation with the cJADAS10 remained stable after grouping patients by ILAR category, geographic areas, and level of education of the parent filling the questionnaire. In 442 parents and 344 children, ICCs ranged between 0.79 and 0.87 for parents and 0.81 and 0.88 for children. CONCLUSION The 4 tested parent/child-reported outcomes showed good criterion validity and excellent reliability. These tools can be considered for remote patient assessment, when in-person evaluation might not be possible.
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Affiliation(s)
- E H Pieter van Dijkhuizen
- IRCCS Istituto Giannina Gaslini, Genoa, Italy, and Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | | | - Roberta Naddei
- IRCCS Istituto Giannina Gaslini, Genoa, and University of Naples Federico II, Napoli, Italy
| | | | - Ilia Avrusin
- IRCCS Istituto Giannina Gaslini, Genoa, Italy, and Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | | | - Diana Sutera
- IRCCS Istituto Giannina Gaslini, Genoa, and Gaetano Martino University Hospital, University of Messina, Messina, Italy
| | - Nuray Aktay Ayaz
- Kanuni Sultan Süleyman Education and Research Hospital, Istanbul, Turkey
| | | | | | | | | | - Marite Rygg
- Norwegian University of Science and Technology and St. Olavs University Hospital of Trondheim, Trondheim, Norway
| | | | - Gordana Susic
- Institute of Rheumatology of Belgrade, Belgrade, Serbia
| | | | | | | | - Angelo Ravelli
- IRCCS Istituto Giannina Gaslini, Genoa, Italy, and Sechenov First Moscow State Medical University, Moscow, Russia
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de Jongh J, Hemke R, Zwezerijnen GJC, Yaqub M, van der Horst-Bruinsma IE, van de Sande MGH, van Kuijk AWR, Voskuyl AE, van der Laken CJ. 18F-sodium fluoride PET-CT visualizes both axial and peripheral new bone formation in psoriatic arthritis patients. Eur J Nucl Med Mol Imaging 2023; 50:756-764. [PMID: 36370181 PMCID: PMC9852163 DOI: 10.1007/s00259-022-06035-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/02/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE As bone formation is associated with psoriatic arthritis (PsA), positron emission tomography (PET) using a 18F-Fluoride tracer may enable sensitive detection of disease activity. Our primary aim was to determine the feasibility of whole-body 18F-sodium fluoride PET-CT in clinically active PsA patients to depict new bone formation (as a reflection of disease activity) at peripheral joints and entheses. Our secondary aim was to describe 18F-sodium fluoride findings in the axial skeleton. METHODS Sixteen patients (female 10/16, age 50.6 ± 8.9 years) with PsA fulfilling CASPAR criteria or with a clinical diagnosis of PsA according to the treating rheumatologist and with ≥ 1 clinically active enthesitis site were included. Of each patient, a whole-body 18F-sodium fluoride PET-CT scan was performed. All scans were scored for PET-positive lesions at peripheral joints, enthesis sites and the spine. Clinical disease activity was assessed by swollen/tender joint count 44, enthesitis according to MASES and SPARCC scores. RESULTS Out of 1088 evaluated joints, 109 joints showed PET enhancement, mainly in the interphalangeal and metatarsal joints of the feet (14/109, 12.9%) and the distal interphalangeal joints of the hands (14/109, 12.9%). PET positivity was found at 44/464 enthesis sites, mainly at the patella tendon insertion (11/44, 25%) and quadriceps tendon insertion (10/44, 22.7%). Of the PET-positive joints and enthesis sites, respectively 18.2% and 29.5% were clinically positive; 81.8% and 70.5% of the PET-positive joints and entheses respectively were clinically asymptomatic. In 11 patients, ≥ 1 axial PET-positive lesion was observed, mainly in the cervical spine. CONCLUSIONS New molecular bone formation was observed on 18F-sodium fluoride PET-CT scans, in all domains in which PsA disease activity can be observed, with a substantial part showing no clinical symptoms. CLINICAL TRIAL REGISTRATION EudraCT: 2017-004,850-40, registered on 13 December 2017.
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Affiliation(s)
- Jerney de Jongh
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Location VUmc, P.O. Box 7057, Amsterdam, the Netherlands.
| | - Robert Hemke
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, Location AMC, 1007 MB, Amsterdam, The Netherlands
| | - Gerben J C Zwezerijnen
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Maqsood Yaqub
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | | | - Marleen G H van de Sande
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | | | - Alexandre E Voskuyl
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Location VUmc, P.O. Box 7057, Amsterdam, the Netherlands
| | - Conny J van der Laken
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Location VUmc, P.O. Box 7057, Amsterdam, the Netherlands
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Benavent D, Fernández-Luque L, Núñez-Benjumea FJ, Navarro-Compán V, Sanz-Jardón M, Novella-Navarro M, González-Sanz PL, Calvo-Aranda E, Lojo L, Balsa A, Plasencia-Rodríguez C. Monitoring chronic inflammatory musculoskeletal diseases mixing virtual and face-to-face assessments-Results of the digireuma study. PLOS DIGITAL HEALTH 2022; 1:e0000157. [PMID: 36812651 PMCID: PMC9931291 DOI: 10.1371/journal.pdig.0000157] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/09/2022] [Indexed: 06/18/2023]
Abstract
Mobile health technology holds great promise for the clinical management of patients with chronic disease. However, evidence on the implementation of projects involving digital health solutions in rheumatology is scarce. We aimed to study the feasibility of a hybrid (virtual and face-to-face) monitoring strategy for personalized care in rheumatoid arthritis (RA) and spondyloarthritis (SpA). This project included the development of a remote monitoring model and its assessment. After a focus group with patients and rheumatologists, relevant concerns regarding the management of RA and SpA were raised, leading to the development of the Mixed Attention Model (MAM), which combined hybrid (virtual and face-to-face) monitoring. Then, a prospective study using the mobile solution Adhera for Rheumatology was conducted. Over a 3-month follow-up period, patients were given the opportunity to complete disease-specific electronic patient reported outcomes (ePROs) for RA and SpA with a pre-established frequency, as well as flares and changes in medication at any time. Number of interactions and alerts were assessed. The usability of the mobile solution was measured by the Net-Promoter Score (NPS) and through a 5-star Likert scale. Following the MAM development, forty-six patients were recruited to utilize the mobile solution, of whom 22 had RA and 24 SpA. There were 4,019 total interactions in the RA group, and 3,160 in the SpA group. Fifteen patients generated a total of 26 alerts, of which 24 were flares and 2 were medication-related problems; most (69%) were managed remotely. Regarding patient satisfaction, 65% of the respondents were considered to have endorsed Adhera for Rheumatology, yielding a NPS of 57 and an overall rating was 4.3 out of 5 stars. We concluded that the use of the digital health solution is feasible in clinical practice to monitor ePROs for RA and SpA. Next steps involve the implementation of this telemonitoring method in a multicentric setting.
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Affiliation(s)
- Diego Benavent
- Hospital Universitario La Paz, IdiPaz, Department of Rheumatology, Madrid, Spain
| | | | | | | | - María Sanz-Jardón
- Hospital Universitario La Paz, IdiPaz, Department of Rheumatology, Madrid, Spain
| | | | | | - Enrique Calvo-Aranda
- Hospital Universitario Infanta Leonor, Department of Rheumatology, Madrid, Spain
| | - Leticia Lojo
- Hospital Universitario Infanta Leonor, Department of Rheumatology, Madrid, Spain
| | - Alejandro Balsa
- Hospital Universitario La Paz, IdiPaz, Department of Rheumatology, Madrid, Spain
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Cagnotto G, Jacobsson LTH, Rydell E, Eberhard A, Compagno M, Turesson C. Male Sex Predicts a Favorable Outcome in Early ACPA-Negative Rheumatoid Arthritis: Data From an Observational Study. J Rheumatol 2022; 49:990-997. [PMID: 35501149 DOI: 10.3899/jrheum.211199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The aim of the present study was to investigate whether the relationship between sex and clinical outcomes in early rheumatoid arthritis (RA) varies by autoantibody status. METHODS Two inception cohorts of consecutive patients with early RA (ie, symptom duration ≤ 12 months) in the southern region of Sweden were investigated. Patients were stratified by anticitrullinated peptide antibody (ACPA) status. The primary outcome was remission (Disease Activity Score in 28 joints [DAS28] < 2.6) at 12 months. Secondary outcomes were remission at 6 months and European Alliance of Associations for Rheumatology good response at 6 and 12 months compared to baseline. In logistic regression models, which were adjusted for age, DAS28 values, and Health Assessment Questionnaire values at baseline, the relationship between sex and clinical outcomes, stratified by ACPA status, was investigated. RESULTS In total, 426 patients with early RA were included: 160 patients were ACPA negative and 266 patients were ACPA positive. At 12 months, 27.1% (38/140) of females and 24.1% (13/54) of males with ACPA-positive RA achieved DAS28 remission. In ACPA-negative RA, 16.0% (13/81) of females and 48.6% (18/37) of males achieved DAS28 remission at 12 months. Males had higher odds of reaching remission at 12 months in the ACPA-negative patient group (pooled adjusted odds ratio [OR] 4.79, 95% CI 1.97-11.6), but not in the ACPA-positive group (pooled adjusted OR 1.06, 95% CI 0.49-2.30). CONCLUSION Male sex was associated with better clinical outcomes in ACPA-negative early RA, but not in ACPA-positive early RA. The poor outcomes in females with early seronegative RA suggest that this represents a difficult-to-treat patient group.
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Affiliation(s)
- Giovanni Cagnotto
- G. Cagnotto, MD, Senior Consultant Rheumatologist, A. Eberhard, MD, M. Compagno, MD, PhD, Senior Consultant Rheumatologist, C. Turesson, MD, PhD, Professor, Rheumatology, Department of Clinical Sciences, Lund University, and Department of Rheumatology, Skåne University Hospital, Malmö;
| | - Lennart T H Jacobsson
- L.T.H. Jacobsson, MD, PhD, Professor, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, Gothenburg University, Gothenburg
| | - Emil Rydell
- E. Rydell, MD, Rheumatology, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Anna Eberhard
- G. Cagnotto, MD, Senior Consultant Rheumatologist, A. Eberhard, MD, M. Compagno, MD, PhD, Senior Consultant Rheumatologist, C. Turesson, MD, PhD, Professor, Rheumatology, Department of Clinical Sciences, Lund University, and Department of Rheumatology, Skåne University Hospital, Malmö
| | - Michele Compagno
- G. Cagnotto, MD, Senior Consultant Rheumatologist, A. Eberhard, MD, M. Compagno, MD, PhD, Senior Consultant Rheumatologist, C. Turesson, MD, PhD, Professor, Rheumatology, Department of Clinical Sciences, Lund University, and Department of Rheumatology, Skåne University Hospital, Malmö
| | - Carl Turesson
- G. Cagnotto, MD, Senior Consultant Rheumatologist, A. Eberhard, MD, M. Compagno, MD, PhD, Senior Consultant Rheumatologist, C. Turesson, MD, PhD, Professor, Rheumatology, Department of Clinical Sciences, Lund University, and Department of Rheumatology, Skåne University Hospital, Malmö
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Durez P, Westhovens R, Baeke F, Elbez Y, Robert S, Ahmad HA. Identification of poor prognostic joint locations in an early rheumatoid arthritis cohort at risk of rapidly progressing disease: a post-hoc analysis of the Phase III AGREE study. BMC Rheumatol 2022; 6:24. [PMID: 35418172 PMCID: PMC9009012 DOI: 10.1186/s41927-022-00252-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 02/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Rheumatoid arthritis (RA) is a heterogeneous disease with established poor prognostic factors such as seropositivity, joint damage, and high disease activity at an early, treatment-naïve stage of disease. However, few studies have examined if specific joint locations are correlated with these factors in such a population. This analysis explored the potential correlation of individual swollen and erosive joints with other disease characteristics at baseline and with remission rates in a post-hoc analysis of the Phase III randomized AGREE study. Methods Methotrexate (MTX)-naïve, erosive, RF- and/or ACPA-positive early RA patients (N = 509) were retrospectively evaluated. Baseline joint swelling was analyzed for large and small joints. Baseline erosions were analyzed for wrist, MCP1–5, IP1, PIP2–5 and MTP1–5. Remission rates were assessed after 6 months of treatment with abatacept (ABA) + MTX (N = 256) or MTX (N = 253). The following statistical tests were used: Chi-Square or Fisher’s exact test (categorical variables); Student’s t-test or Wilcoxon rank-sum test (continuous variables); continuity-corrected Chi-square test (efficacy remission endpoints). Results Baseline swelling was most frequent in wrist (91.9%) and MCP2 joint (89.1%), while baseline erosion was most frequent in MTP5 joint (43.5%). Swollen shoulder was significantly correlated (p < 0.0001) with swelling of almost all other large or medium joints. Baseline swelling in the knee, temporomandibular joint (TMJ), wrist and elbow was highly correlated (p < 0.001) with higher tender and swollen joint counts, higher DAS28(CRP) and higher SDAI and CDAI. Baseline swelling was not correlated with erosion per joint, except for MCP2. The largest difference in mean Boolean remission rates at 6 months was in patients with baseline swollen wrist favoring ABA + MTX (14.0% vs 4.4%; p < 0.001). Conclusions Swelling in the large and medium joints (knee, TMJ, elbow and wrist) was highly correlated with severe disease activity while MCP2 swelling seemed to be correlated with joint damage. The correlation of joint locations at an early, treatment-naïve stage with poor prognostic factors, higher disease activity and joint damage, could establish a rapidly progressing anatomical pattern in early RA. Trial registration: ClinicalTrials.gov NCT00122382, registered July 2005. Supplementary Information The online version contains supplementary material available at 10.1186/s41927-022-00252-4.
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Affiliation(s)
- Patrick Durez
- Institut de Recherche Expérimentale Et Clinique (IREC), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Service de rhumatologie, 1200, Bruxelles, Belgium.
| | - Rene Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium
| | - Femke Baeke
- Bristol-Myers Squibb, Braine L'Alleud, Belgium
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11
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Barber CE, Levy DM, Ahluwalia V, Mendel A, Taylor-Gjevre R, Gerschman T, Koppikar S, Jilkine K, Stringer E, Barnabe C, Aydin SZ, Luca N, Berard R, Tam K, Burt J, Murdoch JC, Zinck G, Lane T, Heeley J, Mannerow M, Mills R, Wilhelm L, Spencer N, Ohata B. Best Practices for Virtual Care, a Consensus Statement from the Canadian Rheumatology Association. J Rheumatol 2022; 49:408-418. [DOI: 10.3899/jrheum.211017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 11/22/2022]
Abstract
Objective To develop best practice statements for the provision of virtual care in adult and pediatric rheumatology for the Canadian Rheumatology Association's (CRA) Telehealth Working Group (TWG). Methods Four members of the TWG representing adult, pediatric, university-based and community rheumatology practices defined the scope of the project. A rapid literature review was conducted between April-May 2021 of existing systematic reviews, policy documents and published literature and abstracts on the topic. The review informed a candidate set of 7 statements and a supporting document. The statements were submitted to a 3-round (R) modified Delphi process with 22 panelists recruited through the CRA and patient advocacy organizations. Panelists rated the importance and feasibility of the statements on a Likert scale of 1-9. Statements with final median ratings between 7-9 with no disagreement were retained in the final set. Results 21 (95%) panelists participated in R1, 15 (71%) in R2 and 18 (82%) in R3. All but one statement met inclusion criteria during R1. Revisions were made to 5/7 statements following R2 and an additional statement was added. All statements met inclusion criteria following R3. The statements addressed the following themes in the provision of virtual care: adherence to existing standards and regulations, appropriateness, consent, physical examination, patient-reported outcomes, use in addition to in-person visits, and complex co-management of disease. Conclusion The best practice statements represent a starting point for advancing virtual care in rheumatology. Future educational efforts to help implement these best practices and research to address identified knowledge gaps are planned.
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12
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Reappraisal of bone scintigraphy as a new tool for the evaluation of disease activity in patients with rheumatoid arthritis. Sci Rep 2021; 11:21809. [PMID: 34750402 PMCID: PMC8575878 DOI: 10.1038/s41598-021-01104-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 10/19/2021] [Indexed: 11/08/2022] Open
Abstract
We aimed to compare the reliability of bone scintigraphy (BS) and fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)-derived parameters in the detection of active arthritis in 28-joint areas and evaluate the reliability of joint counts between BS and clinical assessment in patients with rheumatoid arthritis (RA). We enrolled 106 patients (67 in the development group and 39 in the validation groups) with active RA who underwent BS, 18F-FDG PET/computed tomography (CT), and clinical evaluation of disease activity. We compared the results of BS-derived joint assessment with those of PET-derived and clinical joint assessments. Subsequently we developed a disease activity score (DAS) using BS-positive joints and validated it in an independent group. The number of BS-positive joints in 28-joint areas significantly correlated with the swollen /tender joint counts (SJC/TJC) and PET-derived joint counts. A BS uptake score of 2 (strong positive) was significantly more sensitive compared with a BS uptake score of 1 (weak positive) in detecting a PET-positive joint among the 28-joints. After conducting multivariate analyses including erythrocyte sediment rate (ESR) and patient global assessment (PGA) in addition to BS-derived parameters, BS/DAS was obtained as follows: 0.056 × number of BS-positive joints in 28 joints + 0.012 × ESR + 0.030 × PGA. A significant correlation between BS/DAS and DAS28-ESR was confirmed in the validation group. Strong positive uptake of BS is sensitive and reproducible for the detection of active joints, and can complement the clinical assessment of disease activity in RA.
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13
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Jones A, Rapisardo S, Zhang L, Mellors T, Withers JB, Gatalica Z, Akmaev VR. Analytical and clinical validation of an RNA sequencing-based assay for quantitative, accurate evaluation of a molecular signature response classifier in rheumatoid arthritis. Expert Rev Mol Diagn 2021; 21:1235-1243. [PMID: 34727834 DOI: 10.1080/14737159.2021.2000394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES This study reports analytical and clinical validation of a molecular signature response classifier (MSRC) that identifies rheumatoid arthritis (RA) patients who are non-responders to tumor necrosis factor-ɑ inhibitors (TNFi). METHODS The MSRC integrates patient-specific data from 19 gene expression features, anti-cyclic citrullinated protein serostatus, sex, body mass index, and patient global assessment into a single score. RESULTS The MSRC results stratified samples (N = 174) according to non-response prediction with a positive predictive value of 87.7% (95% CI: 78-94%), sensitivity of 60.2% (95% CI: 50-69%), and specificity of 77.3% (95% CI: 65-87%). The 25-point scale was subdivided into three thresholds: signal not detected (<10.6), high (≥10.6), and very high (≥18.5). The MSRC relies on sequencing of RNA extracted from blood; this assay displays high gene expression concordance between inter- and intra-assay sample (R2 > 0.977) and minimal variation in cumulative gene assignment diversity, read mapping location, or gene-body coverage. The MSRC accuracy was 95.8% (46/48) for threshold concordance (no signal, high, very high). Intra- and inter-assay precision studies demonstrated high repeatability (92.6%, 25/27) and reproducibility (100%, 35/35). CONCLUSION The MSRC is a robust assay that accurately and reproducibly detects an RA patient's molecular signature of non-response to TNFi therapies.
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Affiliation(s)
- Alex Jones
- Data Science, Scipher Medicine Corporation, Waltham, MA, USA
| | - Sarah Rapisardo
- Laboratory Operations, Scipher Medicine Corporation, Waltham, MA, USA
| | - Lixia Zhang
- Data Science, Scipher Medicine Corporation, Waltham, MA, USA
| | | | | | - Zoran Gatalica
- Laboratory Operations, Scipher Medicine Corporation, Waltham, MA, USA
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14
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De Cock D, Buckinx E, Pazmino S, Bertrand D, Stouten V, Westhovens R, Verschueren P. Belgian rheumatologists' preferences regarding measures of disease activity in patients with rheumatoid arthritis: results from a mixed-methods study. Rheumatol Int 2021; 42:815-823. [PMID: 34687348 DOI: 10.1007/s00296-021-05020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/02/2021] [Indexed: 12/01/2022]
Abstract
The reliability and clinical usefulness of the different composite disease activity scores and their individual components in Rheumatoid Arthritis (RA) are still debated. This study investigated which measures of disease activity were preferred by rheumatologists. A mixed-method study was performed. First, ten Belgian rheumatologists were invited for individual interviews on their current practice and preferences for measurement of RA disease activity. Results of this qualitative study and evidence from literature served as input for developing a survey. This survey asked rheumatologists to rate preferred standard disease activity score(s), their individual components, ultrasound and related patient-reported outcomes (PROs), by maximum difference scaling. The relative importance score (RIS) for each indicator was calculated using hierarchical Bayes modeling. The qualitative study included 6/10 invited rheumatologists. Composite scores and components were perceived as useful, while PROs were found subjective. Interestingly, ultrasound was used to mediate discrepancies between physician and patient. The survey based on this was sent to 244 Belgian rheumatologists, 83/244 (34%) responded, including 66/83 (80%) complete and 17/83 (20%) incomplete surveys (two missing essential information). Most rheumatologists (75/81, 93%) used a disease activity score and 68/81 (84%) preferred the DAS28-CRP. Swollen joint count obtained the highest mean ± SD RIS (22.54 ± 2.64), followed by DAS28 ESR/CRP (20.61 ± 4.06), ultrasound (16.47 ± 7.97), CRP (13.34 ± 6.11) and physician's global assessment (12.59 ± 7.83). PROs including fatigue, pain, and patient's global assessment, and Health Assessment Questionnaire, obtained the lowest mean RIS (0.34-2.54). Rheumatologists place more faith in self-assessed disease activity components or in laboratory tests. Trust in PROs to evaluate disease activity is low in clinical practice.
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Affiliation(s)
- D De Cock
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium.
| | - E Buckinx
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - S Pazmino
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - D Bertrand
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - V Stouten
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - R Westhovens
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium.,Department of Rheumatology, University Hospitals of Leuven, 3000, Leuven, Belgium
| | - P Verschueren
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium.,Department of Rheumatology, University Hospitals of Leuven, 3000, Leuven, Belgium
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15
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Tam K, Hazlewood GS, Barber CEH. Effect of Training on Patient Self-Assessment of Joint Counts in Rheumatoid Arthritis: A Systematic Review. ACR Open Rheumatol 2021; 3:860-869. [PMID: 34535968 PMCID: PMC8672172 DOI: 10.1002/acr2.11344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/16/2021] [Indexed: 11/11/2022] Open
Abstract
Objective Patient self‐assessed joint counts, if accurate and reliable, could potentially serve as a useful clinical assessment tool in rheumatoid arthritis (RA). This systematic review examines the effect of patient training on the inter‐rater reliability of joint counts between patients and clinicians. Methods The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. A search was performed in PubMed, Embase, Cochrane Library, and CINAHL for articles that incorporated patient training and measured the reliability of patient self‐assessed joint counts in RA. Articles were included if they reported on the inter‐rater reliability between patient and clinician joint counts in both trained and untrained patients with RA. Data were extracted on characteristics of patients, structure and components of the training interventions, joint count reliability of patients with and without training, and patient feedback on training interventions. The relevant data were summarized and described. Results Multiple training methods have been studied (n = 5), including in‐person sessions run by rheumatologists and instructional videos on the joint examination. Overall, training improved the reliability of patient self–joint counts, with more marked improvement in reliability of swollen joint counts than tender joint counts. Patients had positive feedback when surveyed on their experiences with training. Conclusion Various training modalities (in‐person and video‐based) may be effective at improving reliability of patient self–joint counts. More research is needed on this topic, with potential areas for future research including 1) comparison between the efficacy of different modalities of training, and 2) impact of patient factors (education level and disease severity) on the efficacy of training.
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Affiliation(s)
- Keith Tam
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Glen S Hazlewood
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada, and Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Claire E H Barber
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada, and Arthritis Research Canada, Vancouver, British Columbia, Canada
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16
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van Weely SFE. The Reproducibility of Patient Self-reported Joint Counts in Rheumatoid Arthritis: A Closer Look at the Results of a Review. J Rheumatol 2021; 48:1767-1770. [PMID: 34470794 DOI: 10.3899/jrheum.210822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In the management of rheumatoid arthritis (RA), the systematic evaluation of disease activity is of paramount importance. It is the cornerstone of the "treat-to-target" approach, aiming at disease remission and optimization of quality of life.1 In times of increasing delivery of remote care, accelerated due to the coronavirus disease 2019 (COVID-19) pandemic, the role of patients in the monitoring of disease activity becomes more topical.
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Affiliation(s)
- Salima Francis Elisabeth van Weely
- S.F.E. van Weely, PT, PhD, Senior Researcher, Department of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, the Netherlands. The author declares no conflicts of interest relevant to this article. Address correspondence to Dr. Salima FE van Weely, LUMC (Leiden University Medical Center), Department of Orthopaedics, Rehabilitation and Physical Therapy, J11, P.O. Box 9600, 2300 RC Leiden, the Netherlands.
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A Molecular Signature Response Classifier to Predict Inadequate Response to Tumor Necrosis Factor-α Inhibitors: The NETWORK-004 Prospective Observational Study. Rheumatol Ther 2021; 8:1159-1176. [PMID: 34148193 PMCID: PMC8214458 DOI: 10.1007/s40744-021-00330-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Timely matching of patients to beneficial targeted therapy is an unmet need in rheumatoid arthritis (RA). A molecular signature response classifier (MSRC) that predicts which patients with RA are unlikely to respond to tumor necrosis factor-α inhibitor (TNFi) therapy would have wide clinical utility. Methods The protein–protein interaction map specific to the rheumatoid arthritis pathophysiology and gene expression data in blood patient samples was used to discover a molecular signature of non-response to TNFi therapy. Inadequate response predictions were validated in blood samples from the CERTAIN cohort and a multicenter blinded prospective observational clinical study (NETWORK-004) among 391 targeted therapy-naïve and 113 TNFi-exposed patient samples. The primary endpoint evaluated the ability of the MSRC to identify patients who inadequately responded to TNFi therapy at 6 months according to ACR50. Additional endpoints evaluated the prediction of inadequate response at 3 and 6 months by ACR70, DAS28-CRP, and CDAI. Results The 23-feature molecular signature considers pathways upstream and downstream of TNFα involvement in RA pathophysiology. Predictive performance was consistent between the CERTAIN cohort and NETWORK-004 study. The NETWORK-004 study met primary and secondary endpoints. A molecular signature of non-response was detected in 45% of targeted therapy-naïve patients. The MSRC had an area under the curve (AUC) of 0.64 and patients were unlikely to adequately respond to TNFi therapy according to ACR50 at 6 months with an odds ratio of 4.1 (95% confidence interval 2.0–8.3, p value 0.0001). Odds ratios (3.4–8.8) were significant (p value < 0.01) for additional endpoints at 3 and 6 months, with AUC values up to 0.74. Among TNFi-exposed patients, the MSRC had an AUC of up to 0.83 and was associated with significant odds ratios of 3.3–26.6 by ACR, DAS28-CRP, and CDAI metrics. Conclusion The MSRC stratifies patients according to likelihood of inadequate response to TNFi therapy and provides patient-specific data to guide therapy choice in RA for targeted therapy-naïve and TNFi-exposed patients. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00330-y. A blood-based molecular signature response classifier (MSRC) integrating next-generation RNA sequencing data with clinical features predicts the likelihood that a patient with rheumatoid arthritis will have an inadequate response to TNFi therapy. Treatment selection guided by test results, with likely inadequate responders appropriately redirected to a different therapy, could improve response rates to TNFi therapies, generate healthcare cost savings, and increase rheumatologists’ confidence in prescribing decisions and altered treatment choices. The MSRC described in this study predicts the likelihood of inadequate response to TNFi therapies among targeted therapy-naïve and TNFi-exposed patients in a multicenter, 24-week blinded prospective clinical study: NETWORK-004. Patients with a molecular signature of non-response are less likely to have an adequate response to TNFi therapies than those patients lacking the signature according to ACR50, ACR70, CDAI, and DAS28-CRP with significant odds ratios of 3.4–8.8 for targeted therapy-naïve patients and 3.3–26.6 for TNFi-exposed patients. This MSRC provides a solution to the long-standing need for precision medicine tools to predict drug response in rheumatoid arthritis—a heterogeneous and progressive disease with an abundance of therapeutic options. These data validate the performance of the MSRC in a blinded prospective clinical study of targeted therapy-naïve and TNFi therapy-exposed patients.
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18
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Bugatti S, De Stefano L, Manzo A, Sakellariou G, Xoxi B, Montecucco C. Limiting factors to Boolean remission differ between autoantibody-positive and -negative patients in early rheumatoid arthritis. Ther Adv Musculoskelet Dis 2021; 13:1759720X211011826. [PMID: 34093745 PMCID: PMC8141996 DOI: 10.1177/1759720x211011826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/31/2021] [Indexed: 12/14/2022] Open
Abstract
Background: The patient global assessment of disease activity (PGA) is the major limiting factor to Boolean remission in patients with established rheumatoid arthritis (RA). Here, we investigated the limiting variables to disease remission in patients with early RA treated with conventional synthetic disease modifying anti-rheumatic drugs, also in relation to autoantibody status. Methods: Data were retrieved from 535 early RA patients (<12 months of symptoms) with an observation period of 6–12 months upon initiation of therapy with methotrexate aimed at the achievement of low disease activity based on the 28-joints disease activity score. Near-remission was defined as any of the four core items of Boolean remission >1 with the remaining three all ⩽1. Reasons for missing Boolean remission and predictors of near-remission subcategories were analyzed in relation to baseline disease variables. Results: After 6 and 12 months, near-remission was two-times more frequent than Boolean remission (25.6% and 26.9% at the two time-points). A 28-swollen joint count (SJC28) >1 was responsible for the majority of near-remission (56.2% and 57.6% at 6 and 12 months, respectively), and PGA > 1 accounted for approximatively 35% of the cases. Autoantibody-positivity independently predicted the risk of missing remission because of SJC28 > 1 [adjusted odds ratio (OR) 95% confidence interval (CI) 2.81 (1.59–4.9) at 6 months and 1.73 (1.01–3.01) at 12 months], whilst autoantibody-negativity was an independent predictor of PGA near-remission [adjusted OR (95% CI) 2.45 (1.25–4.80) at 6 months and 5.71 (2.47–13.2) at 12 months]. Conclusion: In early RA, Boolean remission is more frequently missed because of persistent swollen joints. However, barriers to full-remission vary in relation to the autoantibody status. Autoantibody-positive patients more commonly experience residual swollen joints, whilst PGA more frequently impairs remission in autoantibody-negative patients. Efforts to target full-remission in early RA may thus require different strategies according to autoantibody profile.
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Affiliation(s)
- Serena Bugatti
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation University Hospital, Viale Golgi 19, Pavia, 27100, Italy
| | - Ludovico De Stefano
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Antonio Manzo
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | - Blerina Xoxi
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
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Rampes S, Patel V, Bosworth A, Jacklin C, Nagra D, Yates M, Norton S, Galloway J. Systematic Review and Metaanalysis of the Reproducibility of Patient Self-reported Joint Counts in Rheumatoid Arthritis. J Rheumatol 2021; 48:1784-1792. [PMID: 33993117 DOI: 10.3899/jrheum.201439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the reproducibility of patient-reported tender (TJCs) and swollen joint counts (SJCs) of patients with rheumatoid arthritis (RA) compared to trained clinicians. METHODS We conducted a systematic literature review and metaanalysis of studies comparing patient-reported TJCs and/or SJCs to clinician counts in patients with RA. We calculated pooled summary estimates for correlation. Agreement was compared using a Bland-Altman approach. RESULTS Fourteen studies were included in the metaanalysis. There were strong correlations between clinician and patient TJCs (0.78, 95% CI 0.76-0.80), and clinician and patient SJCs (0.59, 95% CI 0.54-0.63). TJCs had good reliability, ranging from 0.51 to 0.85. SJCs had moderate reliability, ranging from 0.28 to 0.77. Agreement for TJCs reduced for higher TJC values, suggesting a positive bias for self-reported TJCs, which was not observed for SJCs. CONCLUSION Our metaanalysis has identified a strong correlation between patient- and clinician-reported TJCs, and a moderate correlation for SJCs. Patient-reported joint counts may be suitable for use in annual review for patients in remission and in monitoring treatment response for patients with RA. However, they are likely not appropriate for decisions on commencement of biologics. Further research is needed to identify patient groups in which patient-reported joint counts are unsuitable.
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Affiliation(s)
- Sanketh Rampes
- MY is funded by Versus Arthritis. S. Rampes, MA, V. Patel, MSc, Faculty of Life Sciences & Medicine, King's College London, London; A. Bosworth, C. Jacklin, National Rheumatoid Arthritis Society, Berkshire; D. Nagra, MD, M. Yates, PhD, S. Norton, PhD, J.B. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK. S. Rampes and V. Patel contributed equally to this work. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. J.B. Galloway, Centre for Rheumatic Diseases, Room 3.46, Third Floor, Weston Education Centre, King's College London, London SE5 9RJ, UK. . Accepted for publication May 5, 2021
| | - Vishit Patel
- MY is funded by Versus Arthritis. S. Rampes, MA, V. Patel, MSc, Faculty of Life Sciences & Medicine, King's College London, London; A. Bosworth, C. Jacklin, National Rheumatoid Arthritis Society, Berkshire; D. Nagra, MD, M. Yates, PhD, S. Norton, PhD, J.B. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK. S. Rampes and V. Patel contributed equally to this work. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. J.B. Galloway, Centre for Rheumatic Diseases, Room 3.46, Third Floor, Weston Education Centre, King's College London, London SE5 9RJ, UK. . Accepted for publication May 5, 2021
| | - Ailsa Bosworth
- MY is funded by Versus Arthritis. S. Rampes, MA, V. Patel, MSc, Faculty of Life Sciences & Medicine, King's College London, London; A. Bosworth, C. Jacklin, National Rheumatoid Arthritis Society, Berkshire; D. Nagra, MD, M. Yates, PhD, S. Norton, PhD, J.B. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK. S. Rampes and V. Patel contributed equally to this work. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. J.B. Galloway, Centre for Rheumatic Diseases, Room 3.46, Third Floor, Weston Education Centre, King's College London, London SE5 9RJ, UK. . Accepted for publication May 5, 2021
| | - Clare Jacklin
- MY is funded by Versus Arthritis. S. Rampes, MA, V. Patel, MSc, Faculty of Life Sciences & Medicine, King's College London, London; A. Bosworth, C. Jacklin, National Rheumatoid Arthritis Society, Berkshire; D. Nagra, MD, M. Yates, PhD, S. Norton, PhD, J.B. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK. S. Rampes and V. Patel contributed equally to this work. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. J.B. Galloway, Centre for Rheumatic Diseases, Room 3.46, Third Floor, Weston Education Centre, King's College London, London SE5 9RJ, UK. . Accepted for publication May 5, 2021
| | - Deepak Nagra
- MY is funded by Versus Arthritis. S. Rampes, MA, V. Patel, MSc, Faculty of Life Sciences & Medicine, King's College London, London; A. Bosworth, C. Jacklin, National Rheumatoid Arthritis Society, Berkshire; D. Nagra, MD, M. Yates, PhD, S. Norton, PhD, J.B. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK. S. Rampes and V. Patel contributed equally to this work. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. J.B. Galloway, Centre for Rheumatic Diseases, Room 3.46, Third Floor, Weston Education Centre, King's College London, London SE5 9RJ, UK. . Accepted for publication May 5, 2021
| | - Mark Yates
- MY is funded by Versus Arthritis. S. Rampes, MA, V. Patel, MSc, Faculty of Life Sciences & Medicine, King's College London, London; A. Bosworth, C. Jacklin, National Rheumatoid Arthritis Society, Berkshire; D. Nagra, MD, M. Yates, PhD, S. Norton, PhD, J.B. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK. S. Rampes and V. Patel contributed equally to this work. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. J.B. Galloway, Centre for Rheumatic Diseases, Room 3.46, Third Floor, Weston Education Centre, King's College London, London SE5 9RJ, UK. . Accepted for publication May 5, 2021
| | - Sam Norton
- MY is funded by Versus Arthritis. S. Rampes, MA, V. Patel, MSc, Faculty of Life Sciences & Medicine, King's College London, London; A. Bosworth, C. Jacklin, National Rheumatoid Arthritis Society, Berkshire; D. Nagra, MD, M. Yates, PhD, S. Norton, PhD, J.B. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK. S. Rampes and V. Patel contributed equally to this work. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. J.B. Galloway, Centre for Rheumatic Diseases, Room 3.46, Third Floor, Weston Education Centre, King's College London, London SE5 9RJ, UK. . Accepted for publication May 5, 2021
| | - James Galloway
- MY is funded by Versus Arthritis. S. Rampes, MA, V. Patel, MSc, Faculty of Life Sciences & Medicine, King's College London, London; A. Bosworth, C. Jacklin, National Rheumatoid Arthritis Society, Berkshire; D. Nagra, MD, M. Yates, PhD, S. Norton, PhD, J.B. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK. S. Rampes and V. Patel contributed equally to this work. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. J.B. Galloway, Centre for Rheumatic Diseases, Room 3.46, Third Floor, Weston Education Centre, King's College London, London SE5 9RJ, UK. . Accepted for publication May 5, 2021
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20
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Abstract
There have been considerable advances in the classification and assessment of psoriatic arthritis (PsA). In this report, we give an overview of historic and current classification criteria and discuss its role and limitations in research and clinical practice. We discuss the most commonly used assessment instruments for arthritis, psoriasis, onychodystrophy, enthesitis, dactylitis and axial PsA with a focus on clinical practice. We pay particular attention to the current evidence for the use of composite outcome measures, and their use in randomised controlled trials and routine care.
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21
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Han L, Hazlewood GS, Barnabe C, Barber CEH. Systematic Review of Outcomes and Patient Experience with Virtual Care in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2021; 74:1484-1492. [PMID: 33650316 DOI: 10.1002/acr.24586] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/06/2021] [Accepted: 02/25/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To conduct a systematic review on patient outcomes of virtual care compared to conventional care in rheumatoid arthritis (RA) including disease activity and patient experience. METHODS A systematic search of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials was performed from database inception to 03/19/2020. Observational and randomized controlled trials (RCTs) describing the use of RA virtual care supplanting conventional visits and reporting on disease activity and/or patient experience were included. A narrative synthesis of results was conducted as a meta-analysis was not possible due to heterogeneity of study designs and outcome reporting. RESULTS 352 studies were identified, and 6 were selected for final inclusion: 3 were RCTs and 3 were observational studies. Disease activity and patient experience were comparable between virtual and conventional care models. In addition, one RCT found no difference in observed outcomes between virtual care delivered by a rheumatologist and by a rheumatology nurse. Virtual care was found to have additional benefits for improved treatment adherence, maintenance of functional status, and quality of life. The overall risk of bias was low in 2/3 RCTs, but high in the observational studies. Study quality was limited by incomplete data reporting, lack of sample size justification and sufficient timeframe to assess objectives. CONCLUSIONS There is limited evidence that virtual RA care is an acceptable alternative to conventional care, maintaining comparable patient outcomes and experience of care. Additional research into effective implementation strategies and long-term health system and patient outcomes of virtual care are needed. SIGNIFICANCE AND INNOVATIONS There is a paucity of research in the use of virtual care for rheumatology, especially describing the ability of virtual care modalities to supplant in person visits. Virtual care for rheumatoid arthritis (RA) management appears in the short term to provide equivalent control of disease activity and good patient experience compared to conventional follow-up strategies. Future studies should evaluate the long-term impacts of virtual care on RA outcomes and health service utilization.
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Affiliation(s)
- Lily Han
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Glen S Hazlewood
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Arthritis Research, Canada
| | - Chery Barnabe
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Arthritis Research, Canada
| | - Claire E H Barber
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Arthritis Research, Canada
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22
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Henderson J, Condell J, Connolly J, Kelly D, Curran K. Review of Wearable Sensor-Based Health Monitoring Glove Devices for Rheumatoid Arthritis. SENSORS 2021; 21:s21051576. [PMID: 33668234 PMCID: PMC7956752 DOI: 10.3390/s21051576] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/31/2021] [Accepted: 02/18/2021] [Indexed: 02/07/2023]
Abstract
Early detection of Rheumatoid Arthritis (RA) and other neurological conditions is vital for effective treatment. Existing methods of detecting RA rely on observation, questionnaires, and physical measurement, each with their own weaknesses. Pharmaceutical medications and procedures aim to reduce the debilitating effect, preventing the progression of the illness and bringing the condition into remission. There is still a great deal of ambiguity around patient diagnosis, as the difficulty of measurement has reduced the importance that joint stiffness plays as an RA identifier. The research areas of medical rehabilitation and clinical assessment indicate high impact applications for wearable sensing devices. As a result, the overall aim of this research is to review current sensor technologies that could be used to measure an individual's RA severity. Other research teams within RA have previously developed objective measuring devices to assess the physical symptoms of hand steadiness through to joint stiffness. Unfamiliar physical effects of these sensory devices restricted their introduction into clinical practice. This paper provides an updated review among the sensor and glove types proposed in the literature to assist with the diagnosis and rehabilitation activities of RA. Consequently, the main goal of this paper is to review contact systems and to outline their potentialities and limitations. Considerable attention has been paid to gloved based devices as they have been extensively researched for medical practice in recent years. Such technologies are reviewed to determine whether they are suitable measuring tools.
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Affiliation(s)
- Jeffrey Henderson
- School of Computing, Engineering and Intelligent System, Ulster University Magee Campus, Northland Rd, BT48 7JL Londonderry, Ireland; (J.C.); (D.K.); (K.C.)
- Correspondence: ; Tel.: +44-79-3309-4221
| | - Joan Condell
- School of Computing, Engineering and Intelligent System, Ulster University Magee Campus, Northland Rd, BT48 7JL Londonderry, Ireland; (J.C.); (D.K.); (K.C.)
| | - James Connolly
- School of Science, Letterkenny Institute of Technology, Port Rd, Gortlee, F92 FC93 Letterkenny, Ireland;
| | - Daniel Kelly
- School of Computing, Engineering and Intelligent System, Ulster University Magee Campus, Northland Rd, BT48 7JL Londonderry, Ireland; (J.C.); (D.K.); (K.C.)
| | - Kevin Curran
- School of Computing, Engineering and Intelligent System, Ulster University Magee Campus, Northland Rd, BT48 7JL Londonderry, Ireland; (J.C.); (D.K.); (K.C.)
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23
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Gessl I, Popescu M, Schimpl V, Supp G, Deimel T, Durechova M, Hucke M, Loiskandl M, Studenic P, Zauner M, Smolen JS, Aletaha D, Mandl P. Role of joint damage, malalignment and inflammation in articular tenderness in rheumatoid arthritis, psoriatic arthritis and osteoarthritis. Ann Rheum Dis 2021; 80:884-890. [PMID: 33436384 DOI: 10.1136/annrheumdis-2020-218744] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/21/2020] [Accepted: 12/29/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To determine whether clinical tenderness can be considered a sign of inflammatory joint activity in patients with rheumatoid arthritis (RA), osteoarthritis (OA) or psoriatic arthritis (PsA) and to assess other possible factors associated with tenderness. METHODS Patients diagnosed with RA, PsA and OA underwent clinical and ultrasound examination of wrists and finger joints. Radiographs of the hands were scored for erosions, joint space narrowing (JSN), osteophytes and malalignment. A binary damage score (positive if ≥1 erosion, JSN and/or presence of malalignment) was calculated. Differences in grey scale signs of synovitis and power Doppler (PD) between tender non-swollen (TNS) versus non-tender non-swollen (NTNS) joints were calculated. Disease duration was assessed,<2 years was regarded as early and >5 years as long-standing arthritis. RESULTS In total, 34 patients (9 early and 14 long-standing) from patients with RA, 31 patients (7 early and 15 long-standing) with PsA and 30 with OA were included. We found equal frequencies of PD signal between TNS and NTNS joints in RA (p=0.18), PsA (p=0.59) or OA (p=0.96). However, PD had a significant association with tenderness in early arthritis both in RA (p=0.02) and in PsA (p=0.02). The radiographic damage score showed significant association with tenderness in RA (p<0.01), PsA (p<0.01) and OA (p=0.04). CONCLUSION Tenderness might not always be a sign of active inflammation in RA, PsA and OA. While tenderness in early arthritis may be more related to inflammation, established disease is better explained by joint damage and malalignment.
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Affiliation(s)
- Irina Gessl
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Mihaela Popescu
- Department of Rheumatology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Victoria Schimpl
- Department of Pediatric and Adolescent Medicine, Klinik Donaustadt, Vienna, Austria
| | - Gabriela Supp
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Thomas Deimel
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Martina Durechova
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Miriam Hucke
- Department of Internal Medicine and Gastroenterology, Hepatology, Endocrinology, Rheumatology and Nephrology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Kärnten, Austria
| | - Michaela Loiskandl
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Paul Studenic
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Michael Zauner
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Josef S Smolen
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Peter Mandl
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
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24
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Grainger R, Townsley HR, Stebbings S, Harrison AA, Taylor WJ, Stamp LK. Codevelopment of Patient Self-Examination Methods and Joint Count Reporting for Rheumatoid Arthritis. ACR Open Rheumatol 2020; 2:705-709. [PMID: 33200883 PMCID: PMC7738803 DOI: 10.1002/acr2.11197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/09/2020] [Indexed: 12/15/2022] Open
Abstract
Objective To determine whether training increases accuracy of self‐reported joint counts in people with rheumatoid arthritis (RA) and describe the knowledge and techniques for self‐examination of joints for reporting of RA disease activity. Methods This mixed‐methods study included 10 patients with RA and four rheumatologists. A rheumatologist presented about joint inflammation and disease monitoring in RA. Patients then self‐examined and reported 28‐tender joint count (28‐TJC) and 28‐swollen joint count (28‐SJC). Next, two paired rheumatologists examined patients and reported 28‐TJC and 28‐SJC. After watching a joint examination video for training physicians, patients discussed their training needs for self‐examination, with discussion analyzed using thematic analysis. Self‐examination techniques were determined by consensus. Finally, patients self‐examined and reported 28‐TJC and 28‐SJC. Reliability between the first and second patient‐reported 28‐TJCs and 28‐SJCs and rheumatologist pair‐reported 28‐TJC and 28‐SJC was determined with the intraclass coefficient. Results The reliability for patient self‐reported joint counts was higher for the 28‐TJC than for the 28‐SJC. Reliability improved following rheumatologist examination and training. Patients identified a preference for practical information rather than detailed information on joint anatomy and pathophysiology. Clear definitions of “swollen” and “tender” were important; patients found the concept of “tenderness” difficult. Techniques for self‐examination and reporting of joint counts were agreed on and demonstrated in an instructional video. Conclusion Training increased reliability of patient‐reported joint counts. Patients with RA identified important aspects of training for self‐examination and reporting of joint counts. An 8‐minute instructional video was codeveloped; the next step is the evaluation of the video’s impact on patient‐reported joint counts.
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Affiliation(s)
- Rebecca Grainger
- University of Otago, Wellington, New Zealand.,Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | | | - Simon Stebbings
- University of Otago, Dunedin School of Medicine, New Zealand.,Dunedin Hospital, Dunedin, New Zealand
| | - Andrew A Harrison
- University of Otago, Wellington, New Zealand.,Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - William J Taylor
- University of Otago, Wellington, New Zealand.,Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - Lisa K Stamp
- University of Otago, Christchurch, New Zealand.,Christchurch Hospital, Christchurch, New Zealand
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25
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Mandl P, Studenic P, Supp G, Durechova M, Haider S, Lehner M, Stamm T, Smolen JS, Aletaha D. Doubtful swelling on clinical examination reflects synovitis in rheumatoid arthritis. Ther Adv Musculoskelet Dis 2020; 12:1759720X20933489. [PMID: 32612711 PMCID: PMC7309376 DOI: 10.1177/1759720x20933489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/19/2020] [Indexed: 11/17/2022] Open
Abstract
Aims The aim of this study was to evaluate the implication of doubtful joint swelling on clinical examination with respect to objective markers of synovitis by ultrasound (US) in patients with rheumatoid arthritis (RA). Methods Two independent observers performed a modified 28 swollen joint assessment (28SJC), in which joints could be graded as either definitely swollen, non-swollen, or doubtfully swollen. Two examiners blinded to clinical information performed US assessment of the hands. We performed descriptive statistics and models to analyse the links between clinical assessment and objective markers of inflammation. Results A total of 1204 joints were evaluated in 43 RA patients; 93% (40/43) of patients had ⩾1 joint with doubtful swelling (range: 0-4/patient). Inter-reader reliability for the modified 28SJC was good (0.74). Generally, both grey scale (GS) and power Doppler (PD) discriminated across not swollen, doubtful, and swollen joints. GS signals discriminated better than PD between doubtful swelling and no swelling [odds ratio (OR) for GS: 5.2; 95% confidence interval (CI) 1.2-23.3 versus OR for PD 1.7; 95% CI 0.2-13.0], whereas PD discriminated better than GS between swelling and doubtful swelling (OR for PD: 28.7; 95% CI 3.6-228.2 versus GS: 1.7; 95% CI 0.3-8.4). Joint osteophytes did not increase the degree of doubtfulness. Conclusion Clinical doubt in the assessment of joint swelling constitutes an intermediate state between unequivocal swelling and the lack thereof also regarding the objectively quantified level of inflammation. In order to increase sensitivity for joint inflammation, the historical clinical approach of considering doubtful swelling the absence of swelling should be revisited to interpret clinical doubtfulness as an indication of swelling.
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Affiliation(s)
- Peter Mandl
- Division of Rheumatology, Department of Rheumatology, Medical University of Vienna, 18-20, Währinger Gürtel, Vienna, 1180, Austria
| | - Paul Studenic
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Gabriela Supp
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Martina Durechova
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Stefanie Haider
- Orthopedic Hospital Speising, Institute of Physical Medicine und Orthopaedic Rehabilitation, Vienna, Austria
| | - Michaela Lehner
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Tanja Stamm
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
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26
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Coras R, Sturchio GA, Bru MB, Fernandez AS, Farietta S, Badia SC, Diez BR, de Agustín de Oro JJ. Analysis of the correlation between disease activity score 28 and its ultrasonographic equivalent in rheumatoid arthritis patients. Eur J Rheumatol 2020; 7:118-123. [PMID: 32716834 PMCID: PMC7431356 DOI: 10.5152/eurjrheum.2020.20038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/24/2020] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE To study the differences between disease activity score 28 (DAS28) index and an ultrasound (US) approach using index echographic disease activity score (ECODAS). METHODS This was a cross-sectional study in patients diagnosed with rheumatoid arthritis (RA). Demographic, clinical, and laboratory data were collected. We created a US index (ECODAS) evaluating the joints with synovitis using gray scale US (GSUS) and power Doppler US (PDUS) and calculated the formula of DAS28 index with both variables substituting tender joint for GSUS and swollen joint for PDUS (ECODAS1) and vice versa (ECODAS2). RESULTS A total of 58 patients (65.5% women and 34.5% men) were included in the study. There was no significant difference between the 2 US indexes. We obtained a Pearson's correlation coefficient (Pearson's r) of 0.56 (p<0.00001) between DAS28 and ECODAS1 and of 0.57 (p<0.00001) between DAS28 and ECODAS2, respectively. However, for patients with a high disease activity [DAS28>5.1, tender joint count (TJC, high)], the correlation was poor (0.18) and ECODAS indexes were significantly lower (p=0.001). The correlation increased (0.86, p<0.001) when we excluded the tender joints and the joints with GS-positive synovitis in both the scores. CONCLUSION US reduces the bias in the evaluation of patients with RA with a high value in DAS28 index. We found a clear difference between DAS and ECODAS when TJC was high. The results suggest that joint tenderness reported by the patient is not a good reflection of inflammation. More studies are needed to find a new combined clinical and sonographic index that would better assess the disease activity in patients with RA.
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Affiliation(s)
- Roxana Coras
- Unit of Rheumatology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Mireia Barceló Bru
- Unit of Rheumatology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Sandra Farietta
- Unit of Rheumatology, Vall d'Hebron University Hospital, Barcelona, Spain
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27
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Grainger R, Townsley HR, Ferguson CA, Riley FE, Langlotz T, Taylor WJ. Patient and clinician views on an app for rheumatoid arthritis disease monitoring: Function, implementation and implications. Int J Rheum Dis 2020; 23:813-827. [PMID: 32424997 DOI: 10.1111/1756-185x.13850] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 12/15/2022]
Abstract
AIM Best practice management for rheumatoid arthritis (RA) involves regular clinical assessment of RA disease activity. This is not achievable with current rheumatology systems of care. We aimed to use opinions from people with RA and their specialist rheumatology healthcare professionals to inform development of a mobile app for people with RA for recording their disease activity data for potential integration into clinical service, and assess usability of the app. METHOD In phase 1 we interviewed nine people with RA and seven healthcare professionals. In phase 2 we developed an app with professional software developers. In phase 3 we evaluated app usability for people with RA using the System Usability Scale (SUS). RESULTS Interview data showed four themes regarding functionality and implementation of a patient-held app in RA care: (a) variable app acceptance and readiness; (b) app use to reduce barriers; (c) pros and cons of patient-reported outcomes; and (d) allocation of clinics by need. The app developed has high usability in people with RA using the app on their own device for a month (SUS 79.5, n = 16) or using the app on a study device for 10 minutes (SUS 83, n = 100). CONCLUSION People with RA and healthcare professionals have clearly identified features, benefits and risks of an app for self-assessment of RA and incorporation into clinical care. An app developed informed by these opinions has high usability. Next steps are development and validation of a method of patient-performed joint counts, and implementation, with evaluation, in the clinical setting.
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Affiliation(s)
- Rebecca Grainger
- University of Otago Wellington, Wellington, New Zealand.,Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | | | | | | | - Tobias Langlotz
- Department of Information Science, University of Otago, Dunedin, New Zealand
| | - William John Taylor
- University of Otago Wellington, Wellington, New Zealand.,Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand
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28
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Kroon FPB, Damman W, van der Plas JL, van Beest S, Rosendaal FR, van der Heijde D, Kloppenburg M. Self-reported painful joint count and assessor-reported tender joint count as instruments to assess pain in hand osteoarthritis. Rheumatology (Oxford) 2020; 59:1094-1098. [PMID: 31535691 PMCID: PMC7850158 DOI: 10.1093/rheumatology/kez395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/02/2019] [Accepted: 08/07/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate self-reported and assessor-reported joint counts for pain and their value in measuring pain and joint activity in hand OA patients. METHODS A total of 524 patients marked painful joints on hand diagrams. Nurses assessed tenderness upon palpation. Pain was measured with a visual analogue scale pain and the Australian/Canadian hand OA index subscale pain. Synovitis and bone marrow lesions in right hand distal/proximal interphalangeal joints on MRI served as measure of joint activity. Agreement was assessed on the patient (intraclass correlation coefficient, Bland-Altman plot) and joint level (percentage absolute agreement). Correlations with measures of pain and joint activity were analysed, and joint level associations with synovitis/bone marrow lesions were calculated. RESULTS Self-reported painful joint count (median 8, interquartile range 4-13) was consistently higher than assessor-reported tender joint count (3, 1-7). Agreement between patients and nurses on overall scores was low. Percentage absolute agreement on the joint level was 61-89%. Joint counts correlated similarly but weakly with measures of pain and joint activity (r = 0.14-0.38). On the joint level, assessor-reported tenderness was more strongly associated with synovitis/bone marrow lesions than self-reported pain. CONCLUSION In hand OA, self- and assessor-reported joint counts cannot be used interchangeably, and measure other pain aspects than questionnaires. Assessor-reported tenderness was most closely related to MRI-defined joint activity.
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Affiliation(s)
| | - Wendy Damman
- Department of Rheumatology, Leiden, The Netherlands
| | | | | | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Margreet Kloppenburg
- Department of Rheumatology, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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29
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Raine C, Austin K, Giles I. Mechanisms determining the amelioration of rheumatoid arthritis in pregnancy: A systematic review. Semin Arthritis Rheum 2020; 50:1357-1369. [PMID: 32224046 DOI: 10.1016/j.semarthrit.2020.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/17/2020] [Accepted: 03/13/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND The phenomenon of pregnancy-induced remission of rheumatoid arthritis (RA) was first reported by Philip Hench in 1938. Despite extensive efforts, the underlying scientific basis has remained elusive. A number of different potential mechanisms have been investigated. We have undertaken a systematic review of the available peer-reviewed articles involving pregnant patients with RA in order to establish the depth of current scientific understanding of this important topic. METHODS This review was conducted according to guidelines of preferred reporting items for systematic reviews and meta-analyses. Studies were identified by a thorough search of multiple databases including Medline, PubMed and EMBASE. Search terms used were different combinations of the keywords: rheumatoid arthritis, inflammatory arthritis, pregnancy, mechanisms, disease activity, relapse and remission. Non-English language articles and studies that were not directly relevant were excluded. Two independent reviewers (CR and KA) screened the retrieved articles by reading the title and abstract to identify studies that addressed potential mechanisms determining RA activity in pregnancy. Articles were further refined after reading the full text. A data extraction sheet was developed for the purpose of this review and used by the independent reviewers. RESULTS After exclusion of irrelevant, duplicate and foreign language articles, a final total of 37 original articles were identified. The largest body of literature concerned glycosylation of immunoglobulins, with 9 published articles. There is evidence of an association between increasing levels of galactosylation of immunoglobulins and reduced RA disease activity in pregnancy. Other identified articles comprised 5 on cytokine changes in pregnancy, 5 on human leucocyte antigen (HLA) incompatibility, 5 on changes in peripheral blood mononuclear cell (PBMC) gene expression; 4 on changes in corticosteroids; 3 on pregnancy associated α2-glycoprotein; 2 on changes in rheumatoid factor (RF)/anti-citrullinated protein antibody (ACPA); and 1 each on microchimerism, gamma delta T cells, regulatory T cells, and mannose-binding lectin. The results of these studies were heterogenous and occasionally conflicting. Selected studies varied greatly in terms of population size, methodology and use of controls and disease activity assessments. CONCLUSION This systematic review has found that the cause of the pregnancy-induced amelioration of RA remains to be determined, despite extensive efforts. It is unclear which of the various transitory changes in pregnancy may be responsible for initiating downstream anti-inflammatory immunological mechanisms. We discuss limitations of the current literature and suggest areas for future study.
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Affiliation(s)
- Charles Raine
- Rayne Institute, University College London Centre for Rheumatology Research, University Street, London WC1E 6JF, United Kingdom.
| | - Keziah Austin
- Department of Rheumatology, University College London Hospital, 250 Euston Rd, London NW1 2PG, United Kingdom.
| | - Ian Giles
- Rayne Institute, University College London Centre for Rheumatology Research, University Street, London WC1E 6JF, United Kingdom.
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La Noce A, Ernst M. Editor’s Pick: Identifying Shared Features and Addressing Common Challenges in Clinical Trials for Chronic Inflammatory Diseases: An Overview. EUROPEAN MEDICAL JOURNAL 2019. [DOI: 10.33590/emj/10310605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Chronic inflammatory diseases (CID) share many common features, such as debilitating illness, increased mortality, impaired quality of life and productivity, and high economic burden. The approach to treating CID has shifted over the last 20 years from symptom to mechanism of action-targeted therapy following the development of primarily biologic drugs, in which the same therapy can potentially treat multiple diseases. Developing these drugs requires novel strategies and a multidisciplinary approach for implementation. This article provides an overview of shared features for CID clinical trials and addressing common challenges in their planning and execution. Since CID studies often test the same drug for treating different pathologies, knowledge of the drug from previously investigated therapeutic indications can be leveraged when planning clinical trials. Given the variety of CID signs and symptoms, eligibility criteria need to clearly define the target patient population by minimising ambiguity and risk of misunderstanding. Other common challenges include an elevated response in the placebo arm, the subjectivity of investigator assessments, and the use of appropriate patient-reported outcomes. Several measures can help minimise the impact of the aforementioned issues on study outcome, including centralised eligibility review and endpoint adjudication, tight control of background therapy and concomitant medications, and intensive training of assessors. The above common features support an approach to CID as a largely interconnected therapeutic area in which a multidisciplinary approach, application of common strategies, and lessons learnt across different indications represent crucial factors for effectively planning and executing clinical trials.
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Affiliation(s)
- Anna La Noce
- Executive Medical Director, General Medicine, Syneos Health, Italy
| | - Marcin Ernst
- Vice President, General Medicine, Syneos Health, Poland
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Kwan YH, Ong WJ, Xiong M, Leung YY, Phang JK, Wang CTM, Fong W. Evaluation of Mobile Apps Targeted at Patients With Spondyloarthritis for Disease Monitoring: Systematic App Search. JMIR Mhealth Uhealth 2019; 7:e14753. [PMID: 31661080 PMCID: PMC6913729 DOI: 10.2196/14753] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 11/30/2022] Open
Abstract
Background There are many apps developed for patients with spondyloarthritis in the market, but their purpose and quality are not objectively evaluated. Objective The objective of this study was to identify and evaluate existing publicly available, high-quality apps that use validated measurement instruments for monitoring spondyloarthritis disease activity. Methods We conducted a review of apps available on the Apple App Store and the Google Play Store based on a combination of keywords and inclusion and exclusion criteria. Validated disease activity measurement instruments were identified. Data regarding app characteristics, including the presence of validated disease activity measurement, were extracted. The Mobile App Rating Scale (MARS) was used to review the apps for user experience. Results A total of 1253 apps were identified in the app stores, and 5 apps met the criteria and were further analyzed. Moreover, 2 apps (MySpA and Group for Research and Assessment of Psoriasis and Psoriatic Arthritis App) contained some of the validated disease activity monitoring instruments for specific spondyloarthritis subtypes. These 2 apps were also rated good on the MARS (with total mean scores ≥4 out of 5), whereas the other apps scored poorly in comparison. Conclusions There are 2 high-quality spondyloarthritis disease activity monitoring apps publicly available, but they only target 2 spondyloarthritis subtypes—ankylosing spondylitis and psoriatic arthritis. There is a lack of high-quality apps that can measure disease activity for other spondyloarthritis subtypes, and no app that consolidates all validated disease activity instruments across subtypes was available.
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Affiliation(s)
- Yu Heng Kwan
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Wei Jie Ong
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Mengfei Xiong
- Department of Family Medicine, SingHealth, Singapore, Singapore
| | - Ying Ying Leung
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jie Kie Phang
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
| | - Charmaine Tze May Wang
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
| | - Warren Fong
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Examining the cross-sectional and longitudinal effects of anxiety sensitivity on indicators of disease severity among patients with inflammatory arthritis. J Anxiety Disord 2019; 67:102117. [PMID: 31445391 DOI: 10.1016/j.janxdis.2019.102117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/08/2019] [Accepted: 07/24/2019] [Indexed: 12/29/2022]
Abstract
Few studies have investigated anxiety sensitivity (AS) in the context of inflammatory arthritis (IA), despite evidence of a relationship between AS and pain. This study examined cross-sectional and longitudinal relationships between AS and indicators of IA severity in 148 participants with IA. AS and its factors (social, physical, cognitive) were self-reported. Arthritis severity was physician-assessed (disease activity scales) and self-reported (physical function; pain and fatigue). Cross-sectional correlations assessed the association between AS and arthritis severity outcomes. Longitudinal multivariable mixed-effect regressions assessed the association of AS total and AS factors at each visit with disease severity outcomes. All AS factors were significantly and positively correlated (at the same visit) with function, pain, and fatigue. AS total significantly predicted pain, fatigue, and function. Cognitive AS significantly predicted fatigue, and physical AS significantly predicted pain and fatigue. Social AS significantly predicted pain, fatigue, function and weighted joint count (articular burden). AS is associated with several indicators of disease severity among those with IA; unique findings emerged across factors with the broadest disease impact by social AS. The AS factors, especially social AS, may contribute to the development and severity of IA symptoms, which may have implications for interventions.
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Zufferey P, Courvoisier DS, Nissen MJ, Möller B, Brulhart L, Ziswiler HR, Tamborrini G, Ciurea A, D'Agostino MA, Finckh A. Discordances between clinical and ultrasound measurements of disease activity among RA patients followed in real life. Joint Bone Spine 2019; 87:57-62. [PMID: 31557525 DOI: 10.1016/j.jbspin.2019.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/11/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Measurements of disease activity, such as the clinical disease activity score (DAS28) or ultrasound (US) scores, often yield discordant results. This study's objectives were to determine the proportion of disagreements between the two assessment methods in patients with rheumatoid arthritis (RA) and to describe factors associated with discrepancy in assessment. METHODS All RA patients in the Swiss registry for inflammatory arthritides (SCQM) with at least one concomitant DAS28 and US score, were included. Disease activity was categorized as remission, low-to-moderate, and high, based on previously established cut-offs, for both the DAS28 and the US score. A longitudinal analysis was performed among patients who underwent at least two assessments. RESULTS Of 2369 assessments included (1091 patients), 1196 (50.4%) were discordant. The US score both over- and under-estimated disease activity compared to the DAS28 score (23.5% and 26.8% respectively). Clinical and demographic factors significantly associated with discordant results were the individual components of the DAS28 score when US was used as the reference and age, disease duration, and the swollen joint count when the DAS28 was used as the reference. The main US-related factor associated with discordance was the presence of US tenosynovitis. In the longitudinal analysis of 1081 patients, the proportion of disagreements remained essentially unchanged. CONCLUSION Rates of disagreement between clinical and US assessments of disease activity among RA patients are high and remain high during follow-up, even when the US assessors were aware of the clinical examination findings. Both clinical- and ultrasound- related factors were associated with discordances.
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Affiliation(s)
| | | | | | | | - Laure Brulhart
- Hôpital neuchatelois, La chaud de fonds 2300, Switzerland
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Pope JE, Michaud K. Is It Time to Banish Composite Measures for Remission in Rheumatoid Arthritis? Arthritis Care Res (Hoboken) 2019; 71:1300-1303. [DOI: 10.1002/acr.23862] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Janet E. Pope
- Schulich School of Medicine and Dentistry University of Western Ontario, and St. Joseph's Health Care London Ontario Canada
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and FORWARD, The National Databank for Rheumatic Diseases Wichita Kansas
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Lee SJ, Jeong JH, Lee CH, Ahn BC, Eun JS, Kim NR, Kang JW, Nam EJ, Kang YM. Development and Validation of an 18 F-Fluorodeoxyglucose-Positron Emission Tomography With Computed Tomography-Based Tool for the Evaluation of Joint Counts and Disease Activity in Patients With Rheumatoid Arthritis. Arthritis Rheumatol 2019; 71:1232-1240. [PMID: 30771237 DOI: 10.1002/art.40860] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 02/12/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Clinical joint count assessment is important for detecting synovitis but its reliability is a subject of controversy. This study was undertaken to assess the correlation of positron emission tomography (PET)-derived parameters in 68 joints with disease activity and to compare the reliability of joint counts between PET with computed tomography (CT) and clinical assessment in patients with rheumatoid arthritis (RA). METHODS We enrolled 91 patients with active RA (69 in a development group and 22 in a validation group) who underwent concurrent 18 F-fluorodeoxyglucose (18 F-FDG)-PET-CT and clinical disease activity evaluation. PET-derived parameters were compared with disease activity assessed using clinical joint count parameters. A Disease Activity Score (DAS) using counts of PET-positive joints was developed, and then validation studies were performed in an independent group. RESULTS The number of PET-positive joints (of 28 and 68 joints) was significantly correlated with the swollen joint count (SJC) and tender joint count (TJC) and the DAS in 28 joints using the erythrocyte sedimentation rate (DAS28-ESR). Intraobserver and interobserver reliability of PET for the affected joint counts were excellent. Interobserver reliability between nuclear medicine physicians and rheumatologists was good for the SJC and TJC in both 28 joints and 68 joints. After multivariate analyses, including ESR and patient's global assessment of disease activity (PtGA) in addition to PET-derived parameters, the PET/DAS was derived as (0.063 × number of PET-positive joints in 28 joints) + (0.011 × ESR) + (0.030 × PtGA). A significant correlation between the PET/DAS and the DAS28-ESR was confirmed in the validation group (P < 0.001). CONCLUSION PET-CT could serve as a sensitive and reliable method in the evaluation of disease activity in RA patients, and may be applicable as a research tool, particularly in clinical trials.
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Affiliation(s)
- Sang Jin Lee
- Kyungpook National University Hospital and Kyungpook National University, Daegu, Republic of Korea
| | - Ju Hye Jeong
- Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Chang-Hee Lee
- Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Byeong-Cheol Ahn
- Kyungpook National University Hospital and Kyungpook National University, Daegu, Republic of Korea
| | - Jung Su Eun
- Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Na Ri Kim
- Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jong Whan Kang
- Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Eon Jeong Nam
- Kyungpook National University Hospital and Kyungpook National University, Daegu, Republic of Korea
| | - Young Mo Kang
- Kyungpook National University Hospital and Kyungpook National University, Daegu, Republic of Korea
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Hammer HB, Michelsen B, Sexton J, Haugen IK, Provan SA, Haavardsholm EA, Uhlig T, Kvien TK. Swollen, but not tender joints, are independently associated with ultrasound synovitis: results from a longitudinal observational study of patients with established rheumatoid arthritis. Ann Rheum Dis 2019; 78:1179-1185. [DOI: 10.1136/annrheumdis-2019-215321] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/18/2019] [Accepted: 05/21/2019] [Indexed: 11/04/2022]
Abstract
ObjectivesJoint swelling and tenderness are considered a proxy for inflammation in patients with rheumatoid arthritis (RA). With ultrasound-detected inflammation as reference, our objectives were to explore on patient and joint level the associations between ultrasound synovitis and joint swelling, tenderness and patient-reported joint pain (PRJP).Methods209 patients with established RA were examined six times during 12 months with assessment of 32 joints in upper/lower extremities for joint swelling/tenderness and Grey scale (GS)/power Doppler (PD) synovitis. PRJP was assessed on a manikin. Correlations between different sum scores were at each examination calculated using Spearman’s rho (r), agreement at joint level was examined by Cohen’s kappa and logistic regression models were used to explore the associations between joint assessment and GS/PD scores.ResultsAt patient level, swollen joints were strongly correlated with GS/PD sum scores (r=0.64–0.88), while tender joints were primarily associated with PRJP (r=0.54–0.68). At joint level, GS/PD pathology had higher agreement with swelling (kappa 0.54–0.57) than tenderness (kappa 0.20–0.21) or PRJP (0.23–0.25). Higher percentages of joints were swollen according to increasing GS/PD scores, independently of joint tenderness. However, joints being tender, but not swollen, were not associated with GS/PD scores. Receiver operating curves showed swollen but not tender joints to be associated with GS/PD scores.ConclusionsSwollen joints were strongly associated with ultrasound detected synovitis at both patient and joint level, while this association was not found for tender joints. These results may question if tender joints reflect ongoing inflammation in established RA.
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Chernoff D, Scott Eastman P, Hwang CC, Flake DD, Wang X, Kivitz A, Curtis JR. Determination of the minimally important difference (MID) in multi-biomarker disease activity (MBDA) test scores: impact of diurnal and daily biomarker variation patterns on MBDA scores. Clin Rheumatol 2018; 38:437-445. [PMID: 30159791 DOI: 10.1007/s10067-018-4276-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 08/16/2018] [Accepted: 08/20/2018] [Indexed: 12/11/2022]
Abstract
The Multi-Biomarker Disease Activity (MBDA) score is a validated rheumatoid arthritis (RA) disease activity measure based on 12 serum biomarkers. Here, we evaluate short-term biological variability of MBDA scores to determine the magnitude of change that might be considered clinically meaningful. Twenty-eight adult seropositive RA patients with clinically stable disease and no changes in RA medications for 4 weeks prior to study were enrolled. Nine serum samples were obtained over four consecutive days (non-fasting). MBDA score variation was assessed day-to-day (daily) and within 24 h (diurnal). The standard deviation (SD) of MBDA scores was calculated by a linear mixed model including random effects for patient, day, and time of day. The minimally important difference (MID) was calculated as [Formula: see text]. A subgroup analysis was performed for patients with active RA (moderate or high MBDA score). The SD of MBDA score change in the full cohort was 4.7 in a combined daily-diurnal variation analysis, which corresponds with an MID of 11. The SD of MBDA score change in the subset of patients with active RA (moderate/high MBDA scores) was 3.6. This corresponds with an MID of 8 units in patients with active RA for whom clinicians are most likely to need guidance with respect to therapeutic decisions. Changes in MBDA score ≥ 8 represent a change in RA disease activity that clinicians can use as a benchmark for therapeutic drug efficacy and can be incorporated into a treat-to-target strategy.
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Affiliation(s)
- David Chernoff
- Crescendo Bioscience Inc., 341 Oyster Point Blvd, South San Francisco, CA, USA.
| | - P Scott Eastman
- Crescendo Bioscience Inc., 341 Oyster Point Blvd, South San Francisco, CA, USA
| | - Ching Chang Hwang
- Crescendo Bioscience Inc., 341 Oyster Point Blvd, South San Francisco, CA, USA
| | - Darl D Flake
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT, USA
| | - Xingbin Wang
- Crescendo Bioscience Inc., 341 Oyster Point Blvd, South San Francisco, CA, USA
| | - Alan Kivitz
- Altoona Center for Clinical Research, 1125 Old Rte 220 N, Duncansville, PA, USA
| | - Jeffrey R Curtis
- The University of Alabama at Birmingham, 510 20th Street S, Birmingham, AL, USA
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Nasonov EL, Olyunin YA, Lila AM. RHEUMATOID ARTHRITIS: THE PROBLEMS OF REMISSION AND THERAPY RESISTANCE. ACTA ACUST UNITED AC 2018. [DOI: 10.14412/1995-4484-2018-263-271] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Rheumatoid arthritis (RA) is an immunoinflammatory (autoimmune) rheumatic disease of unknown etiology, which is characterized by chronic erosive arthritis and systemic visceral organ damage that results in early disability and shorter patient survival. Despite RA treatment advances associated with the design of novel drugs and the improvement of treatment strategies to achieve remission in many patients, there are still many theoretical and clinical problems concerning both the definition of the concept of remission, its characteristics and types and approaches to the optimum policy of symptomatic and pathogenetic drug therapy at different stages of the disease, the use of which will be able to rapidly induce and maintain remission in the long-term. Further investigations are needed to study the nature of heterogeneity of pathogenetic mechanisms of RA and approaches to early diagnosis, to improve methods for monitoring disease activity and biomarkers for the efficiency of and resistance to therapy and, finally, to develop differentiation therapy, including those related to a search for new therapeutic targets.
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Inter-observer agreement of standard joint count examination and disease global assessment in a cohort of Egyptian Rheumatoid Arthritis patients. ACTA ACUST UNITED AC 2017; 15:258-263. [PMID: 29276053 DOI: 10.1016/j.reuma.2017.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 10/03/2017] [Accepted: 10/13/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To assess the inter-observer agreement of standard joint count between experienced Rheumatology professor (Prof) and young Rheumatology fellow (candidate), and to compare disease global assessment between professor, young candidate and patients. METHODS This study included one hundred rheumatoid arthritis patients. For all patients independent clinical evaluation was done by two rheumatologists (professor and candidate) for detection of tenderness in 28 joints and swelling in 26 joints. The study also involved global assessment of disease activity by the provider (Prof and candidate) (EGA) as well as by the patient (PGA). The EGA was determined without previous knowledge of the patient's laboratory test results. RESULTS A highly significant accordance (correlation) between professor and candidate was found in both the number of tender joints (p<0.001) (r=0.946), and the number of swollen joints (p<0.001) (r=0.797). Regarding swollen joints, the highest agreement was in right knee (0.929), while poor agreement was found in the right 5th MCP (0.049). Regarding tender joints, the highest analogy was in the right elbow (0.899), in contrast to the left 3rd PIP (0.462) which showed the least congruence. Agreement study using kappa measurement for disease global assessment showed: moderate agreement (between professor and candidate) (0.405), fair agreement between (professor and patient) (0.213), fair agreement between (candidate and patient) (0.367). CONCLUSION Inter-observer reliability was better for TJCs than SJCs. Regarding SJCs agreement was better in large joints such as the knees compared to the small joints such as the MCPs. Disease global assessment may show discrepancy between patients and physicians.
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Bergstra SA, Chopra A, Saluja M, Vega-Morales D, Govind N, Huizinga TWJ, van der Helm-van Mil A. Evaluation of the joint distribution at disease presentation of patients with rheumatoid arthritis: a large study across continents. RMD Open 2017; 3:e000568. [PMID: 29299341 PMCID: PMC5729295 DOI: 10.1136/rmdopen-2017-000568] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/20/2017] [Accepted: 11/26/2017] [Indexed: 11/12/2022] Open
Abstract
Background Genetic and environmental risk factors for rheumatoid arthritis (RA) are population dependent and may affect disease expression. Therefore, we studied tender and swollen joint involvement in patients newly diagnosed with RA in four countries and performed a subanalysis within countries to assess whether the influence of autoantibody positivity affected disease expression. Methods Patients with symptom duration <2 years fulfilling the American College of Rheumatology/European League Against Rheumatism 2010 RA classification criteria were selected from METEOR (Measurement of Efficacy of Treatment in the Era of Outcome in Rheumatology), an international observational database, and the Dutch Leiden Early Arthritis Clinic. Indian (n=947), Mexican (n=141), South African (n=164) and Dutch (n=947) autoantibody-positive and negative patients with RA, matched by symptom duration, were studied for swollen and tender joint distribution. Results Between countries, the reported distribution of swollen joint distribution differed, with more knee synovitis in Mexico, South Africa and India compared with the Netherlands (37%, 36%, 30% and 13%) and more elbow (29%, 23%, 7%, 7%) and shoulder synovitis (21%, 11%, 0%, 1%) in Mexico and South Africa compared with India and the Netherlands. Since the number of autoantibody-negative patients in Mexico and South Africa was limited, Indian and Dutch autoantibody-positive and negative patients with RA were compared. The number of swollen and tender joints was higher in autoantibody-negative patients, but the overall distribution of involved joints was similar. Conclusion Joint involvement at diagnosis does not differ between autoantibody-positive and negative patients with RA in India and the Netherlands. However, joint involvement is reported differently across countries. More research is needed whether these differences are cultural and/or pathogenetic.
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Affiliation(s)
- Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arvind Chopra
- Department of Rheumatology, Center for Rheumatic Diseases, Pune, India
| | - Manjit Saluja
- Department of Rheumatology, Center for Rheumatic Diseases, Pune, India
| | - David Vega-Morales
- Department of Rheumatology, Universidad Autonoma de Nuevo Leon, San Nicolas de los Garza, Nuevo Leon, Mexico
| | - Nimmisha Govind
- Department of Rheumatology, University of the Witwatersrand, Johannesburg, South Africa
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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Ferreira RJO, Dougados M, Kirwan JR, Duarte C, de Wit M, Soubrier M, Fautrel B, Kvien TK, da Silva JAP, Gossec L. Drivers of patient global assessment in patients with rheumatoid arthritis who are close to remission: an analysis of 1588 patients. Rheumatology (Oxford) 2017; 56:1573-1578. [PMID: 28859325 DOI: 10.1093/rheumatology/kex211] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives ACR/EULAR Boolean remission in RA is frequently not obtained solely due to a patient global assessment (PGA) >1/10 (a condition often designated as near-remission). This study aimed to assess which domains of impact could explain an elevated PGA in near-remission patients. Methods We performed an ancillary analysis of data from three cross-sectional studies in patients with established RA. Three disease activity states were defined: remission (tender and swollen joint counts, CRP and PGA all ⩽1), near-remission (tender and swollen joint counts, and CRP are all ≤1 but PGA >1) and non-remission. Physical and psychological domains were assessed using the RA Impact of Disease 0-10 (numeric rating scale) as explanatory factors of PGA. Univariable and multivariable linear regression analyses were performed to explain PGA. Results A total of 1588 patients (79.1% females) were analysed. The mean disease duration was 13.0 years (s.d. 9.8) and the 28-joint DAS with four variables was 3.2 (s.d. 1.4). Near-remission [mean PGA 3.6 (s.d. 1.9)] was more frequent (19.1%) than remission (12.3%). Scores of RA Impact of Disease domains were similar in near-remission and non-remission patients. In near-remission, PGA was explained (R2adjusted = 0.55) by pain (β = 0.29), function (β = 0.23), physical well-being (β = 0.19) and fatigue (β = 0.15). Conclusion Near-remission was more frequent than remission. These patients, despite having no signs of significant inflammation, report an impact of disease similar to the non-remission patients. PGA in near-remission seems to be driven by physical rather than psychological domains. Selecting the best therapy for these patients requires a better understanding of the meaning of PGA, both globally and in individual patients.
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Affiliation(s)
- Ricardo J O Ferreira
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra.,Health Sciences Research Unit: Nursing (UICiSA:E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
| | - Maxime Dougados
- Faculty of Medicine, Paris Descartes University.,Department of Rheumatology, AP-HP, Hôpital Cochin.,INSERM (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - John R Kirwan
- Academic Rheumatology Unit, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Cátia Duarte
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra.,Clínica Universitária de Reumatologia, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Maarten de Wit
- Patient Research Partner, EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland.,Department of Medical Humanities, VU University Medical Centre, Amsterdam, The Netherlands
| | - Martin Soubrier
- Department of Rheumatology, CHU Clermont-Ferrand, Clermont-Ferrand
| | - Bruno Fautrel
- Faculty of Medicine, UPMC University Paris 06, GRC-UPMC 08 (EEMOIS).,Department of Rheumatology, AP-HP, Pitié Salpêtrière Hospital, Paris.,CRI IMIDIATE, French Clinical Research Infrastructure Network, Toulouse, France
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - José A P da Silva
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra.,Clínica Universitária de Reumatologia, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Laure Gossec
- Faculty of Medicine, UPMC University Paris 06, GRC-UPMC 08 (EEMOIS).,Department of Rheumatology, AP-HP, Pitié Salpêtrière Hospital, Paris
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Khan NA, Spencer HJ, Nikiphorou E, Naranjo A, Alten R, Chirieac RM, Drosos AA, Géher P, Inanc N, Kerzberg E, Ancuta CM, Müller R, Ørnbjerg L, Sokka T. Intercentre variance in patient reported outcomes is lower than objective rheumatoid arthritis activity measures: a cross-sectional study. Rheumatology (Oxford) 2017; 56:1395-1400. [PMID: 28575509 DOI: 10.1093/rheumatology/kex076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Indexed: 01/18/2023] Open
Abstract
Objective To assess intercentre variability in the ACR core set measures, DAS28 based on three variables (DAS28v3) and Routine Assessment of Patient Index Data 3 in a multinational study. Methods Seven thousand and twenty-three patients were recruited (84 centres; 30 countries) using a standard protocol in the Quantitative Standard Monitoring of Patients with RA study. Analysis of variance (ANOVA) and mixed-effect analysis of covariance models were used to model the relationship between study centre and different patient-reported and physician-reported RA activity measures. These models were built to adjust for the remaining ACR core set measure (for each ACR core set measure or each composite index), socio-demographics and medical characteristics. ANOVA and analysis of covariance models yielded similar results, and ANOVA tables were used to present variance attributable to recruiting centre. Results The proportion of variances attributable to recruiting centre was lower for patient reported outcomes (PROs: pain, HAQ, patient global) compared with objective measures (joint counts, ESR, physician global) in all models. In the full model, variance in PROs attributable to recruiting centre ranged from 1.53% for patient global to 3.71% for HAQ compared with objective measures that ranged from 5.92% for physician global to 9.25% for ESR; and was lower for Routine Assessment of Patient Index Data 3 (2.6%) compared with DAS28v3 (11.75%). Conclusion Intercentre variability in PROs is lower than objective measures of RA activity demonstrating that PROs may be more comparable across centres, and the need for standardization of objective measures.
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Affiliation(s)
- Nasim Ahmed Khan
- Division of Rheumatology, University of Arkansas for Medical Sciences.,Central Arkansas Veterans Healthcare System
| | - Horace Jack Spencer
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Elena Nikiphorou
- Department of Rheumatology, The Whittington Hospital NHS Trust, London, UK
| | - Antonio Naranjo
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr Negrin, University of Las Palmas, Las Palmas, Spain
| | - Rieki Alten
- Department of Internal Medicine, Rheumatology, Schlosspark-Klinik, Teaching Hospital Charite, Berlin, Germany
| | | | - Alexandros A Drosos
- Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Pál Géher
- 1st Department of Rheumatology, Hospitaller Brothers of St John of God, Budapest, Hungary
| | - Nevsun Inanc
- Division of Rheumatology, School of Medicine, University of Marmara, Istanbul, Turkey
| | - Eduardo Kerzberg
- Department of Rheumatology, University of Buenos Aires, Buenos Aires, Argentina
| | - Codrina Mihaela Ancuta
- Rheumatology 2 Department, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Rüediger Müller
- Division of Rheumatology, Immunology and Rehabilitation, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Lykke Ørnbjerg
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet Glostrup, Denmark
| | - Tuulliki Sokka
- University of Eastern Finland, Faculty of Health Sciences, Kuopio and Jyvaskyla Central Hospital, Jyvaskyla, Finland
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43
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Defining Skin Ulcers in Systemic Sclerosis: Systematic Literature Review and Proposed World Scleroderma Foundation (WSF) definition. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017; 2:115-120. [PMID: 30569018 DOI: 10.5301/jsrd.5000236] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose There is a lack of a valid, definition for skin ulcers in SSc to be used in clinical trials. Our aim was to develop a consensus definition for SSc-skin ulcers based on the results of a systematic literature review (SLR) for skin ulcer definitions and expert opinion; and to evaluate its face validity, reliability and feasibility. Methods SLR for skin ulcer definitions was conducted using PubMed, Web of Science, and Cochrane library for articles published from inception to January 1st, 2016. SSc experts were to discuss the definitions' categories and vote for the relevant terms. Reliability of the definition were tested in a second expert meeting, seven SSc experts evaluated 7 SSc pts with skin lesions twice. Face validity and feasibility evaluated by sending out case report forms(CRFs) to 4 SSc experts, they were asked to use the definition in 5 pts each. Results A total of 3464 abstracts and titles were screened, and 446 articles were fully evaluated. Of these, 66 met eligibility criteria and skin ulcer definitions were extracted. SSc experts discussed, refined and voted on the consensus definition using nominal process. Kappa for inter-, intra-rater rater agreement was 0.51, 0.90 respectively. The mean time to decide if the lesion is an ulcer was 7.4 sec. All investigators endorsed the face validity of the new definition in the CRFs. Conclusion Using a SLR and a nominal technique, we developed a preliminary consensus-based definition of SSc-skin ulcers. Face validity, feasibility and reliability were demonstrated for the developed definition.
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Grainger R, Townsley H, White B, Langlotz T, Taylor WJ. Apps for People With Rheumatoid Arthritis to Monitor Their Disease Activity: A Review of Apps for Best Practice and Quality. JMIR Mhealth Uhealth 2017; 5:e7. [PMID: 28223263 PMCID: PMC5340922 DOI: 10.2196/mhealth.6956] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 12/21/2022] Open
Abstract
Background Rheumatoid arthritis (RA) is a chronic inflammatory arthritis requiring long-term treatment with regular monitoring by a rheumatologist to achieve good health outcomes. Since people with RA may wish to monitor their own disease activity with a smartphone app, it is important to understand the functions and quality of apps for this purpose. Objective The aim of our study was to assess the features and quality of apps to assist people to monitor their RA disease activity by (1) summarizing the available apps, particularly the instruments used for measurement of RA disease activity; (2) comparing the app features with American College of Rheumatology and European League against Rheumatism (ACR and EULAR) guidelines for monitoring of RA disease activity; and (3) rating app quality with the Mobile App Rating Scale (MARS). Methods Systematic searches of the New Zealand iTunes and Google Play app stores were used to identify all apps for monitoring of RA disease activity that could be used by people with RA. The apps were described by both key metadata and app functionality. App adherence with recommendations for monitoring of RA disease activity in clinical practice was evaluated by identifying whether apps included calculation of a validated composite disease activity measure and recorded results for future retrieval. App quality was assessed by 2 independent reviewers using the MARS. Results The search identified 721 apps in the Google Play store and 216 in the iTunes store, of which 19 unique apps met criteria for inclusion (8 from both app stores, 8 iTunes, and 3 Google Play). In total, 14 apps included at least one validated instrument measuring RA disease activity; 7 of 11 apps that allowed users to enter a joint count used the standard 28 swollen and tender joint count; 8 apps included at least one ACR and EULAR-recommended RA composite disease activity (CDA) measure; and 10 apps included data storage and retrieval. Only 1 app, Arthritis Power, included both an RA CDA measure and tracked data, but this app did not include the standard 28 tender and swollen joint count. The median overall MARS score for apps was 3.41/5. Of the 6 apps that scored ≥4/5 on the overall MARS rating, only 1 included a CDA score endorsed by ACR and EULAR; however, this app did not have a data tracking function. Conclusions This review found a lack of high-quality apps for longitudinal assessment of RA disease activity. Current apps fall into two categories: simple calculators primarily for rheumatologists and data tracking tools for people with RA. The latter do not uniformly collect data using validated instruments or composite disease activity measures. There is a need for appropriate, high-quality apps for use by rheumatologists and patients together in co-management of RA.
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Affiliation(s)
- Rebecca Grainger
- Rehabilitation Teaching and Research Unit, Department of Medicine, University of Otago Wellington, Wellington, New Zealand.,Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - Hermaleigh Townsley
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Bonnie White
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Tobias Langlotz
- Department of Information Science, University of Otago, Dunedin, New Zealand
| | - William J Taylor
- Rehabilitation Teaching and Research Unit, Department of Medicine, University of Otago Wellington, Wellington, New Zealand.,Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand
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Madsen OR. Stability of clinical outcome measures in rheumatoid arthritis patients with stable disease defined on the basis of the EULAR response criteria. Clin Rheumatol 2016; 35:2403-9. [PMID: 27283868 DOI: 10.1007/s10067-016-3322-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 05/22/2016] [Indexed: 11/26/2022]
Abstract
Natural variation also known as measurement error is assessed in individuals in "steady state." The study aimed to examine inter-visit variations in clinical outcome measures in rheumatoid arthritis (RA) patients with stable disease defined on the basis of the EULAR response criteria. Two hundred thirty-three RA patients with stable disease defined as a change in Disease Activity Score (DAS28-CRP) ≤0.6 between two consecutive visits were identified in the Danish rheumatology registry for biological treatment (DANBIO). Clinical data from a single set of such two visits were extracted for each patient. Using the Bland-Altman method, lower and upper 95 % limits of agreement (LLoA; ULoA) between the consecutive assessments and the bias were calculated for each measure. Associations were characterized by Pearson's r-values and standard errors of estimation (SEE). The mean change in DAS28-CRP was 0.0 ± 0.3. Agreements between the assessments were close on the group level but poor on the individual level. For example, LLoA; ULoA [bias] for patient global assessment (0-100) was -28.3; 29.7 [0.7], for fatigue (0-100) -38.1; 36.3 [-0.9] and for 28 swollen joint count -3.3; 3.3 [0.0]. Inter-visit differences were poorly explained by the baseline values (r [SEE] ranging from 0.15 [12.6] for fatigue to 0.58 [1.4] for 28 tender joint count) and by changes in other outcome variables. In conclusion, outcome measures fluctuated substantially and unpredictably in individual RA patients considered in steady state. The observed between-visit differences may be interpreted to reflect natural variation or measurement error that should be taken into account when monitoring patients in the daily clinic.
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Affiliation(s)
- Ole Rintek Madsen
- Copenhagen Center for Arthritis Research and the DANBIO Registry, Center for Rheumatology and Spine Diseases, Rigshospitalet, DK-2600, Glostrup, Denmark.
- Center for Rheumatology and Spine Diseases, Copenhagen University Hospital Gentofte, DK-2900, Hellerup, Denmark.
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Cheung PP, Mari K, Devauchelle-Pensec V, Jousse-Joulin S, D'Agostino MA, Chalès G, Gaudin P, Mariette X, Saraux A, Dougados M. Predictive value of tender joints compared to synovitis for structural damage in rheumatoid arthritis. RMD Open 2016; 2:e000205. [PMID: 27042336 PMCID: PMC4800805 DOI: 10.1136/rmdopen-2015-000205] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 01/06/2016] [Accepted: 01/07/2016] [Indexed: 02/06/2023] Open
Abstract
Objective To evaluate the predictive value of tender joints compared to synovitis for structural damage in rheumatoid arthritis (RA). Methods A post hoc analysis was performed on a prospective 2-year study of 59 patients with active RA starting on antitumour necrosis factor (TNF). Tenderness and synovitis was assessed clinically at baseline, followed by blinded ultrasound assessment (B-mode and power Doppler ultrasound (PDUS)) on the hands and feet (2 wrists, 10 metacarpophalangeal, 10 proximal interphalangeal and 10 metatarsophalangeal (MTP) joints). Radiographs of these joints were performed at baseline and at 2 years. The risk of radiographic progression with respect to the presence of baseline tenderness or synovitis, as well as its persistence (after 4 months of anti-TNF), was estimated by OR (95% CI). Results Baseline tender joints were the least predictive for radiographic progression (OR=1.53 (95% CI 1.02 to 2.29) p<0.04), when compared to synovitis (clinical OR=2.08 (95% CI 1.39 to 3.11) p<0.001 or PDUS OR=1.80 (95% CI 1.20 to 2.71) p=0.005, respectively). Tender joints with the presence of synovitis were predictive of radiographic progression (OR=1.89 (95% CI 1.25 to 2.85) p=0.002), especially seen in the MTP joints. Non-tender joints with no synovitis were negatively predictive (OR=0.57 (95% CI 0.39 to 0.82) p=0.003). Persistence of tender joints was negatively predictive (OR=0.38 (95% CI 0.18 to 0.78) p=0.009) while persistence of synovitis was predictive (OR=2.41 (95% CI 1.24 to 4.67) p=0.01) of radiographic progression. Conclusions Synovitis is better than tenderness to predict for subsequent structural progression. However, coexistence of tenderness and synovitis at the level of an individual joint is predictive of structural damage, particularly in the MTP joints. Trial registration number NCT00444691.
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Affiliation(s)
- Peter P Cheung
- Division of Rheumatology , National University Hospital , Singapore , Singapore
| | | | - Valérie Devauchelle-Pensec
- Department of Rheumatology, CHU de la Cavale Blanche, Boulevard Tanguy Prigent, Brest, France; EA 2216, INSERM ESPRI, ERI29 Université Bretagne Occidentale, Brest, France
| | - Sandrine Jousse-Joulin
- Department of Rheumatology, CHU de la Cavale Blanche, Boulevard Tanguy Prigent, Brest, France; EA 2216, INSERM ESPRI, ERI29 Université Bretagne Occidentale, Brest, France
| | - Maria Antonietta D'Agostino
- Department of Rheumatology , APHP, Ambrose-Paré, Versailles-Saint Quentin en Yvelines University , Boulogne-Billancourt , France
| | - Gérard Chalès
- Department of Rheumatology , Hôpital Sud, CHU Rennes , Rennes , France
| | - Philippe Gaudin
- Department of Rheumatology , University Hospital, Grenoble, Hôpital Sud , Echirolles , France
| | - Xavier Mariette
- Department of Rheumatology , Hôpitaux Universitaires Paris-Sud; Université Paris-Sud; INSERM U1012; Le Kremlin Bicêtre , Paris , France
| | - Alain Saraux
- Department of Rheumatology, CHU de la Cavale Blanche, Boulevard Tanguy Prigent, Brest, France; EA 2216, INSERM ESPRI, ERI29 Université Bretagne Occidentale, Brest, France
| | - Maxime Dougados
- Department of Rheumatology , Hôpital Cochin , Paris , France
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Cheung PP, Lahiri M, Teng GG, Lim AYN, Lau TC, Lateef A, Mak A, Gossec L, March L. A randomized controlled trial for improving patient self-assessment of synovitis in rheumatoid arthritis with education by ultrasonography: the RAEUS Study. Rheumatology (Oxford) 2014; 54:1161-9. [DOI: 10.1093/rheumatology/keu447] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Indexed: 11/12/2022] Open
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Kampling C, Chehab G, Schneider M, Richter JG. [Self-monitoring in inflammatory rheumatic diseases]. Z Rheumatol 2014; 73:706-13. [PMID: 25260817 DOI: 10.1007/s00393-014-1413-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Active involvement of patients in their care has led to better treatment and outcomes. Tight control concepts emphasize the need for regular assessments including patients' active involvement by self-monitoring. METHODS The literature was screened with respect to published experiences of self-monitoring of rheumatoid arthritis and spondyloarthritides. The use of "patient-reported outcome" (PRO) instruments can facilitate self-monitoring. Potentially applicable PROs and their correlations to clinical parameters as well as modern data acquisition modes are presented. RESULTS Some experiences for self-monitoring have been reported. Recommendations from national and international professional rheumatology societies do not yet consider self-monitoring; however, PROs might be used for self-monitoring but instructions for patients on "how to deal with self-monitored PRO values" are missing. CONCLUSION Self-monitoring of inflammatory rheumatic diseases seems feasible. Further evaluation studies are warranted to guarantee an optimized direct patient involvement in their management beyond outpatient care in hospitals and private practices so that they can thus contribute to a better outcome.
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Affiliation(s)
- C Kampling
- Poliklinik für Rheumatologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
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Siemons L, ten Klooster PM, Vonkeman HE, van de Laar MAFJ, Glas CAW. Further optimization of the reliability of the 28-joint disease activity score in patients with early rheumatoid arthritis. PLoS One 2014; 9:e100544. [PMID: 24955759 PMCID: PMC4067329 DOI: 10.1371/journal.pone.0100544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 05/28/2014] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The 28-joint Disease Activity Score (DAS28) combines scores on a 28-tender and swollen joint count (TJC28 and SJC28), a patient-reported measure for general health (GH), and an inflammatory marker (either the erythrocyte sedimentation rate [ESR] or the C-reactive protein [CRP]) into a composite measure of disease activity in rheumatoid arthritis (RA). This study examined the reliability of the DAS28 in patients with early RA using principles from generalizability theory and evaluated whether it could be increased by adjusting individual DAS28 component weights. METHODS Patients were drawn from the DREAM registry and classified into a "fast response" group (N = 466) and "slow response" group (N = 80), depending on their pace of reaching remission. Composite reliabilities of the DAS28-ESR and DAS28-CRP were determined with the individual components' reliability, weights, variances, error variances, correlations and covariances. Weight optimization was performed by minimizing the error variance of the index. RESULTS Composite reliabilities of 0.85 and 0.86 were found for the DAS28-ESR and DAS28-CRP, respectively, and were approximately equal across patients groups. Component reliabilities, however, varied widely both within and between sub-groups, ranging from 0.614 for GH ("slow response" group) to 0.912 for ESR ("fast response" group). Weight optimization increased composite reliability even further. In the total and "fast response" groups, this was achieved mostly by decreasing the weight of the TJC28 and GH. In the "slow response" group, though, the weights of the TJC28 and SJC28 were increased, while those of the inflammatory markers and GH were substantially decreased. CONCLUSIONS The DAS28-ESR and the DAS28-CRP are reliable instruments for assessing disease activity in early RA and reliability can be increased even further by adjusting component weights. Given the low reliability and weightings of the general health component across subgroups it is recommended to explore alternative patient-reported outcome measures for inclusion in the DAS28.
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Affiliation(s)
- Liseth Siemons
- Arthritis Center Twente, Department of Psychology, Health & Technology, University of Twente, Enschede, the Netherlands
- * E-mail:
| | - Peter M. ten Klooster
- Arthritis Center Twente, Department of Psychology, Health & Technology, University of Twente, Enschede, the Netherlands
| | - Harald E. Vonkeman
- Arthritis Center Twente, Department of Psychology, Health & Technology, University of Twente, Enschede, the Netherlands
- Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Mart A. F. J. van de Laar
- Arthritis Center Twente, Department of Psychology, Health & Technology, University of Twente, Enschede, the Netherlands
- Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Cees A. W. Glas
- Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, the Netherlands
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