Quality of life in patients with established rheumatoid arthritis: A phenomenographic study

Evidence for telemedicine heterogeneity in rheumatic and musculoskeletal diseases care: a scoping review

Telemedicine and digital health represent alternative approaches for clinical practice; indeed, its potential in healthcare services for prevention, diagnosis, treatment, rehabilitation, and disease monitoring is widely acknowledged. These are all crucial issues to consider when dealing with chronic Rheumatic and Musculoskeletal Diseases (RMDs). The aim was to determine the current state of telemedicine in the field of rheumatology, considering the tools and devices in use as well as the Patient Reported Outcomes. A scoping review was performed following the PRISMA-ScR, retrieving articles through five databases from 1990 to 2022. Inclusion criteria were as follows: (I) adult patients with RMDs, (II) original research papers in the English language with available abstracts, and (III) telehealth and telemedicine are provided as healthcare services. Within the 62 included studies, multiple tools of telemedicine were used: 21/62 websites/online platforms, 18/62 mobile applications, 16/62 telephone contacts, 5/62 video-consultations, and 1/62 wearable devices. Outcomes were classified based on the economic, clinical, and humanistic framework. Clinical outcomes assessed through digital tools were pain, disease activity, and serum uric acid levels. Humanistic outcomes have been grouped according to four categories (e.g., mental and physical function, health management, and health perception). The heterogeneity of digital tools in the field of rheumatology highlights the challenge of implementing reliable research into clinical practice. Effective telerehabilitation models have been presented, and the use of a tight control strategy has also been mentioned. Future research should focus on establishing studies on other RMDs as well as summarizing and formulating clinical guidelines for RMDs. Key Points • Evidence for the usefulness of telemedicine and digital health for managing and monitoring rheumatic and musculoskeletal diseases is progressively increasing. • Several digital tools effectively measure clinical and humanistic and patient reported outcomes in rheumatic and musculoskeletal diseases. • Integrating diverse digital tools in rheumatology is challenging yet promising. • Future research should focus on developing standardized recommendations for practical use of telemedicine in daily practice.

Targeted Macrophage Re-Programming: Synergistic Therapy With Methotrexate and RELA siRNA Folate-Liposome in RAW264.7 Cells and Arthritic Rats

Rheumatoid arthritis (RA) is a chronic autoimmune disorder characterized by joint inflammation and destruction. Current treatments, such as Methotrexate (MTX), though effective, often face limitations such as high plasma Cmax and lack of sustained release. This study explores a synergistic approach to RA therapy using folate-liposomal co-delivery of MTX and RELA siRNA (short interfering RNA), targeting RAW264.7 macrophage repolarization via nuclear factor kappa B (NF-κB) pathway inhibition. Extensive in vitro characterizations demonstrate the stability and biocompatibility of this therapy via folate-liposomes. In the collagen-induced arthritis (CIA) rat model, treatment leads to reduced synovial inflammation and improved mobility. The combined MTX and RELA siRNA approach indirectly inhibits inflammatory cytokines, rheumatoid factor (RF), and C-reactive protein (CRP). Targeted macrophage delivery shows marked therapeutic effects in RAW264.7 murine macrophages, potentially modulating M1 to M2 polarization. This research presents a promising avenue for innovative RA therapies by inhibiting the inflammatory cascade and preventing joint damage.

Inequalities in health care use among patients with arthritis in China: using Andersen's Behavioral Model

BACKGROUND

This study sought to assess socioeconomic-related inequalities in health care use among arthritis patients in China and to analyze factors associated with this disparity.

METHODS

This study used data from the 2018 China Health and Retirement Longitudinal Study. 3255 arthritis patients were included. The annual per capita household expenditure was used to divide individuals into five categories. We calculated actual, need-predicted, and need-standardized distributions of health care use by socioeconomic groups among people with arthritis. The concentration index (Cl) was used to assess inequalities in health service use. Influencing factors of inequalities were measured with the decomposition method.

RESULTS

The outpatient and inpatient service use rates among 3255 arthritis patients were 23.13% and 21.41%, respectively. The CIs for actual outpatient and inpatient services use were 0.0449 and 0.0985, respectively. The standardized CIs for both outpatient and inpatient services use increase (CI for outpatient services use = 0.0537; CI for inpatient services use = 0.1260), indicating the emergence of a significant pro-rich inequity. Annual per capita household expenditure was the chief positive contributor to inequity for both outpatient (104.45%) and inpatient services use (105.74%), followed by infrequently social interaction (22.60% for outpatient services use) and Urban Employee Basic Medical Insurance (UEBMI) (11.90% for inpatient services use). By contrast, UEBMI also provided a high negative contribution to outpatient services use (-15.99%).

CONCLUSIONS

There are significant pro-rich inequalities in outpatient and inpatient services use among patients with arthritis, which are exacerbated by widening economic gaps. Interventions to address inequalities should start by improving the economic situation of lower socioeconomic households.

Identification of Motivational Determinants for Telemedicine Use Among Patients With Rheumatoid Arthritis in Germany: Secondary Analysis of Data From a Nationwide Cross-Sectional Survey Study

BACKGROUND

Previous studies have demonstrated telemedicine to be an effective tool to complement rheumatology care and address workforce shortage. With the COVID-19 outbreak, telemedicine experienced a massive upswing. An earlier analysis revealed that the motivation of patients with rheumatic and musculoskeletal diseases to use telemedicine is closely connected to their disease. It remains unclear which factors are associated with patients' motivation to use telemedicine in certain rheumatic and musculoskeletal diseases groups, such as rheumatoid arthritis (RA).

OBJECTIVE

This study aims to identify factors that determine the willingness to try telemedicine among patients diagnosed with RA.

METHODS

We conducted a secondary analysis of data from a German nationwide cross-sectional survey among patients with RA. Bayesian univariate logistic regression analysis was applied to the data to determine which factors were associated with willingness to try telemedicine. Predictor variables (covariates) studied individually included sociodemographic factors (eg, age, sex) and health characteristics (eg, health status). All the variables positively and negatively associated with willingness to try telemedicine in the univariate analyses were then considered for Bayesian model averaging analysis after a selection based on the variance inflation factor (≤ 2.5) to identify determinants of willingness to try telemedicine.

RESULTS

Among 438 surveyed patients in the initial study, 210 were diagnosed with RA (47.9%). Among them, 146 (69.5%) answered either yes or no regarding willingness to try telemedicine and were included in the analysis. A total of 22 variables (22/55, 40%) were associated with willingness to try telemedicine (region of practical equivalence %≤5). A total of 9 determinant factors were identified using Bayesian model averaging analysis. Positive determinants included desiring telemedicine services provided by a rheumatologist (odds ratio [OR] 13.7, 95% CI 5.55-38.3), having prior knowledge of telemedicine (OR 2.91, 95% CI 1.46-6.28), residing in a town (OR 2.91, 95% CI 1.21-7.79) or city (OR 0.56, 95% CI 0.23-1.27), and perceiving one's health status as moderate (OR 1.87, 95% CI 0.94-3.63). Negative determinants included the lack of an electronic device (OR 0.1, 95% CI 0.01-0.62), absence of home internet access (OR 0.1, 95% CI 0.02-0.39), self-assessment of health status as bad (OR 0.44, 95% CI 0.21-0.89) or very bad (OR 0.47, 95% CI 0.06-2.06), and being aged between 60 and 69 years (OR 0.48, 95% CI 0.22-1.04) or older than 70 years (OR 0.38, 95% CI 0.16-0.85).

CONCLUSIONS

The results suggest that some patients with RA will not have access to telemedicine without further support. Older patients, those not living in towns, those without adequate internet access, reporting a bad health status, and those not owning electronic devices might be excluded from the digital transformation in rheumatology and might not have access to adequate RA care. These patient groups certainly require support for the use of digital rheumatology care.

Investigating the Variables Associated with Physical Exercise Status among United States Adults with Arthritis

Background/Objectives: Arthritis is a chronic, debilitating condition affecting millions of United States (US) adults. Regular physical exercise is particularly important for adults with arthritis. This study aimed to investigate the characteristics associated with regular physical exercise in US adults with arthritis. Methods: This cross-sectional database study used 2021 Medical Expenditure Panel Survey data and included US adults (age ≥ 18) alive with arthritis. A multivariable logistic regression model was developed to test the association of the following variables with regular physical exercise (defined as moderate-vigorous intensity exercise for ≥30 min ≥5 times weekly; yes, no): age, sex, Hispanic, race, census region, marriage status, schooling, employment, health insurance, household income, mental health, general health, smoking status, chronic conditions, pain, and functional limitations. Results: Overall, 5091 people (regular physical exercise n = 2331, no regular physical exercise n = 2760) were involved in this analysis. Most were female, non-Hispanic, white, married, had schooling beyond high school, were unemployed, had private health insurance, had mid-high household income, had good mental health, had good general health, were non-smokers, had two or more chronic conditions, had little/moderate pain, and did not have a functional limitation. In multivariable logistic regression analysis, male vs. female sex (odds ratio [OR] = 1.440, 95% confidence interval [CI] = 1.185-1.749), employed vs. unemployed (OR = 1.277, 95% CI = 1.005-1.624), good vs. poor general health (OR = 2.174, 95% CI = 1.673-2.824), little/moderate vs. quite a bit/extreme pain (OR = 1.418, 95% CI = 1.109-1.818), and no functional limitation (OR = 1.592, 95% CI = 1.282-1.980) were associated with higher odds of reporting regular physical exercise, while Midwest vs. West census region (OR = 0.698, 95% CI = 0.521-0.935) was associated with lower odds of reporting regular physical exercise. Conclusions: This study identified variables associated with regular physical exercise among US adults with arthritis. Further work is needed to develop interventions for characteristics that may help increase exercise and, subsequently, health outcomes in this population.

Limited Physical Functioning in United States Adults with Arthritis: Findings from the 2021 Medical Expenditure Panel Survey

There is little published research on limited physical functioning in United States (US) adults with arthritis. The objective of this cross-sectional 2021 Medical Expenditure Panel Survey (MEPS) database study was to investigate the variables associated with limited physical functioning in US adults with arthritis. Logistic regression tested the associations of predisposing, enabling, and need variables with the dependent variable (limited physical functioning). This study included 5102 US adults with arthritis, reflecting an estimated weighted population of 64,136,870 US adults with arthritis. In the final multivariable logistic regression model, age ≥ 70 and ages 60-69 (vs. 18-49 years), female (vs. male) sex, having quite a bit/extreme or moderate (vs. little) pain, and having 6+ or 4-5 (vs. 0-1) comorbid conditions were all associated with higher odds of the person stating they had limited physical functioning. Whereas high school or less (vs. more than high school), being employed (vs. unemployed), being married (vs. not married), having excellent/very good or good (vs. poor) general health, and exercise (vs. no exercise) were each associated with lower odds of the person reporting they had limited physical functioning. Future work may be considered to explore these variables in greater detail.

Development of a Risk Prediction Model for Adverse Skin Events Associated with TNF-α Inhibitors in Rheumatoid Arthritis Patients

Background: Rheumatoid arthritis (RA) is a chronic inflammatory disorder primarily targeting joints, significantly impacting patients' quality of life. The introduction of tumor necrosis factor-alpha (TNF-α) inhibitors has markedly improved RA management by reducing inflammation. However, these medications are associated with adverse skin reactions, which can vary greatly among patients due to genetic differences. Objectives: This study aimed to identify risk factors associated with skin adverse events by TNF-α in RA patients. Methods: A cohort study was conducted, encompassing patients with RA who were prescribed TNF-α inhibitors. This study utilized machine learning algorithms to analyze genetic data and identify markers associated with skin-related adverse events. Various machine learning algorithms were employed to predict skin and subcutaneous tissue-related outcomes, leading to the development of a risk-scoring system. Multivariable logistic regression analysis identified independent risk factors for skin and subcutaneous tissue-related complications. Results: After adjusting for covariates, individuals with the TT genotype of rs12551103, A allele carriers of rs13265933, and C allele carriers of rs73210737 exhibited approximately 20-, 14-, and 10-fold higher incidences of skin adverse events, respectively, compared to those with the C allele, GG genotype, and TT genotype. The machine learning algorithms used for risk prediction showed excellent performance. The risk of skin adverse events among patients receiving TNF-α inhibitors varied based on the risk score: 0 points, 0.6%; 2 points, 3.6%; 3 points, 8.5%; 4 points, 18.9%; 5 points, 36.7%; 6 points, 59.2%; 8 points, 90.0%; 9 points, 95.7%; and 10 points, 98.2%. Conclusions: These findings, emerging from this preliminary study, lay the groundwork for personalized intervention strategies to prevent TNF-α inhibitor-associated skin adverse events. This approach has the potential to improve patient outcomes by minimizing the risk of adverse effects while optimizing therapeutic efficacy.

The Effects of Exercise Training on Functional Capacity and Quality of Life in Patients with Rheumatoid Arthritis: A Systematic Review

Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic inflammation. The purpose of this systematic review is to evaluate the effectiveness of exercise training on functional capacity and quality of life (QoL) in patients with RA. We performed a search in four databases, selecting clinical trials that included community or outpatient exercise training programs in patients with RA. The primary outcome was functional capacity assessed by peak VO2 or the 6 min walking test, and the secondary outcome was QoL assessed by questionnaires. Seven studies were finally included, identifying a total number of 448 patients. The results of the present systematic review show a statistically significant increase in peak VO2 after exercise training in four out of seven studies. In fact, the improvement was significantly higher in two out of these four studies compared to the controls. Six out of seven studies provided data on the patients' QoL, with five of them managing to show statistically significant improvement after exercise training, especially in pain, fatigue, vitality, and symptoms of anxiety and depression. This systematic review demonstrates the beneficial effects of exercise training on functional capacity and QoL in patients with RA.

Development and validation of the rheumatoid arthritis scale among the system of quality of life instruments for chronic diseases QLICD-RA (V2.0)

Rheumatoid Arthritis is a more serious threatening to people and suitable for QOL measurement. A few specific QOL instruments are available without considering Chinese culture. The present study was aimed to develop and validate the Rheumatoid Arthritis Scale among the System of Quality of Life Instruments for Chronic Diseases (QLICD-RA V2.0). The data collected from 379 patients with RA was used to evaluate the psychometric properties of the scale. The reliability was evaluated by the internal consistency Cronbach's α, test-retest reliability Pearson correlation r and intra-class correlation (ICC). We evaluated the construct validity and criteria-related validity by correlation analysis and structural equation modeling. We compared the differences in scores of QLICD-RA before and after treatment and used the Standard Response Mean (SRM) to assess the responsiveness. The results showed that the internal consistency coefficient Cronbach's α values were greater than 0.70. The correlations r and ICCs were greater than 0.80. The correlation analysis and structural equation modeling confirmed good construct validity and criterion-related validity. The SRM ranges from 0.07 to 0.27 for significant domains/facets. It concluded that QLICD-RA (2.0) is a reliable and valid instrument to measure QOL among patients with RA.

Naturopathic Interventions for Reduction of Perceived Pain in Patients Suffering from Arthritis: A Systematic Review and Meta-Analysis

Arthritis affects millions of lives with its pervasive effects on physical health and quality of life. Addressing the complexities of managing symptoms such as swelling, inflammation, and pain requires prolonged treatment. Naturopathy is a treatment method that enhances the body's innate ability to restore optimal health through a holistic approach including natural products and lifestyle modifications. This systematic review addresses the intersection of naturopathy and arthritis treatment to provide current evidence about its potential benefits. Four databases (PubMed, AYUSH Research Portal, Web of Science, and Google Scholar) were searched with the keywords "Naturopathy" AND "Arthritis". Randomized, non-randomized, and cross-over studies in English were included. Studies reporting perceived pain using a visual analogue scale (VAS) were selected for meta-analysis. A total of 15 studies were included in the systematic review. The studies were from Denmark, Egypt, France, Hungary, Israel, Italy, Spain, and Turkey, and the study periods ranged from 1992 to 2017. They suggested that naturopathic treatment modalities like exercise, mud compress, sand bath, or hydrotherapy may be used in addition to conventional modes of treatment for added benefit. There was a diversity of naturopathic treatment modalities and outcome evaluation methods. Most studies used mud compress or mud baths with reported improvement of symptoms. The meta-analysis of 10 studies (11 sets of data) showed a significant improvement in pain measured by VAS. The studies included in the review have a high level of heterogenicity. There is a need for more studies and uniform assessment methods with standardization of interventions for robust evidence. More clinical trials from countries where naturopathy is approved treatment modalities are needed.

Ultrasound imaging of the dorsalis pedis artery as an early indicator of the precursory changes for rheumatoid vasculitis: A case series

Introduction

Clinical verification of rheumatoid vasculitis (RV) persists as a mid-to-late diagnosis with medical imaging or biopsy. Early and subclinical presentations of RV, in particular, can remain underdiagnosed in the absence of adequate diagnostic testing. In this study, the research demonstrated the precursory changes for RV in patients with rheumatoid arthritis (RA) using non-invasive ultrasound imaging of a peripheral vessel.

Method

Six participants were recruited: three participants with (RA) and three age- and gender-matched healthy controls. All participants completed a Foot Health Survey Questionnaire (FHSQ), and participants with RA completed a Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5). Bilateral B-mode and Doppler ultrasound of the dorsalis pedis artery (DPA) was performed. The degree of inflammation, lumen and artery diameters, lumen diameter-to-artery diameter ratio and peak systolic velocity in the proximal DPA were compared between the two groups.

Results

The mean RADAI-5 score (5.4 ± 0.8 out of 10) indicated moderate disease activity amongst participants with RA. Inflammation was observed in the DPA wall in all participants with RA, compared to no inflammation observed in the control group (Friedmans two-way analysis: χ2 = 15.733, P = 0.003). Differences between groups for inflammation, lumen diameter and lumen diameter-to-artery diameter ratio were found (P < 0.034), without differences for artery diameter and peak systolic velocity (P > 0.605). DPA wall inflammation did not correlate with FHSQ scores (r = -0.770, P = 0.073).

Conclusion

Despite moderate RA disease activity, this is the first study to demonstrate the use of ultrasound to observe inflammation in small vessel disease. Our findings suggest ultrasound imaging may be a viable screening tool to demonstrate arterial wall inflammation, indicating the precursory changes of RV.

The Extent and Nature of Functional Limitations According to the Health Assessment Questionnaire Disability Index in Patients with Rheumatoid Arthritis and Severe Functional Disability

BACKGROUND

For a subgroup of people with rheumatoid arthritis (RA) and severe disability, insight into their limitations is crucial for adequate treatment.

AIM

To describe the extent and nature of functional limitations in people with RA and severe disability and to explore the associations of the extent of the functional limitations with patient characteristics, disease characteristics, and outcome measures.

METHODS

Baseline data of 215 participants in an RCT on the (cost-)effectiveness of longstanding physiotherapy were used. Functional limitations were assessed with the Health Assessment Questionnaire Disability Index (HAQ-DI). The total HAQ-DI including eight domain scores were calculated. Associations between high HAQ-DI scores (≥2, yes/no) and other variables were examined using the Student's t-test or Chi-squared test where appropriate.

RESULTS

The participants (90% women, age 58.8 ± 12.8 years) had a mean HAQ-DI score of 1.7 ± 0.5. The majority (56%) showed a moderate-to-severe disability in all domains. Higher HAQ-DI scores seemed to be associated with advanced age, longer disease duration, unemployment, joint replacements, and outcomes for daily functioning and physical quality of life, but not with measures of disease activity.

CONCLUSIONS

Our findings indicate that a comprehensive assessment of all areas of daily activities in this subgroup is necessary in order to provide appropriate (non-)pharmacological care.

Does Pizza Consumption Favor an Improved Disease Activity in Rheumatoid Arthritis?

To our knowledge, no studies so far have investigated the role of pizza and its ingredients in modulating disease activity in rheumatoid arthritis (RA). We assessed this question via a recent cross-sectional study including 365 participants from Italy, the birthplace of pizza. Multiple robust linear and logistic regression models were fitted with the tertile consumption categories of each available pizza-related food item/group (i.e., pizza, refined grains, mozzarella cheese, and olive oil) as independent variables, and each available RA activity measure (i.e., the Disease Activity Score on 28 joints with C-reactive protein (DAS28-CRP), and the Simplified Disease Activity Index (SDAI)) as the dependent variable. Stratified analyses were carried out according to the disease severity or duration. Participants eating half a pizza >1 time/week (vs. ≤2 times/month) reported beneficial effects on disease activity, with the significant reductions of ~70% (overall analysis), and 80% (the more severe stratum), and the significant beta coefficients of -0.70 for the DAS28-CRP, and -3.6 for the SDAI (overall analysis) and of -1.10 and -5.30 (in long-standing and more severe RA, respectively). Among the pizza-related food items/groups, mozzarella cheese and olive oil showed beneficial effects, especially in the more severe stratum. Future cohort studies are needed to confirm this beneficial effect of pizza and related food items/groups on RA disease activity.

Trajectories of self-reported pain-related health outcomes and longitudinal effects on medication use in rheumatoid arthritis: a prospective cohort analysis using the Australian Rheumatology Association Database (ARAD)

OBJECTIVE

To determine distinct trajectories of self-reported pain-related health status in rheumatoid arthritis (RA), their relationship with sociodemographic factors and medication use.

METHODS

988 Australian Rheumatology Association Database participants with RA (71% female, mean age 54 years, mean disease duration 2.3 years) were included. Distinct multi-trajectories over 15-year follow-up for five different self-reported pain-related health outcome measures (Health Assessment Questionnaire Disability Index, visual analogue scores for pain, arthritis, global health and the Assessment of Quality of Life utility index) were identified using latent variable discrete mixture modelling. Random effects models were used to determine associations with medication use and biologic therapy modification during follow-up.

RESULTS

Four, approximately equally sized, pain/health status groups were identified, ranging from 'better' to 'poorer', within which changes over time were relatively small. Important determinants of those with poorer pain/health status included female gender, obesity, smoking, socioeconomic indicators and comorbidities. While biologic therapy use was similar between groups during follow-up, biologic therapy modifications (p_linear<0.001) and greater tendency of non-tumour necrosis factor inhibitor use (p_linear<0.001) were observed in those with poorer pain/health status. Similarly, greater use of opioids, prednisolone and non-steroidal anti-inflammatory drugs was seen in those with poorer pain/health status.

CONCLUSION

In the absence of disease activity information, distinct trajectories of varying pain/health status were seen from the outset and throughout the disease course in this RA cohort. More biologic therapy modifications and greater use in anti-inflammatories, opioids and prednisolone were seen in those with poorer pain/health status, reflecting undesirable lived experience of persistent pain in RA.

Nutrition and its role in prevention and management of rheumatoid arthritis

Accumulating research evidence suggests that nutrition might be implicated in the risk of development and in the management of autoimmune disease, including rheumatoid arthritis (RA), characterized by immune-inflammatory response. Nutrition can have direct roles through the provision of pro- or anti-inflammatory foods, and indirect roles through management of co-morbidity management. The review updates on the evidence relating RA risk and management with focus on specific foods such as fish and diets/dietary patterns such as the Mediterranean diet, fasting and elimination diets and oral nutritional supplements including omega-3 polyunsaturated fatty acids (PUFA). Evidence on herbs and spices, beverages, Vitamin D, and probiotics is also reviewed. Diet has been shown to improve disease activity through reducing inflammation and oxidation and through its beneficial effects on the gut microbiota. Based on the existing evidence, it is recommended that as an adjunct to medical treatment, nutrition therapy for RA should be based on an anti-inflammatory Mediterranean diet (MD) supplemented with at least twice a week consumption of oily fish and/or omega-3 PUFA supplements at 2 g/day. The need for rheumatologists to work more closely with registered dietitians in the management of patients particularly in supporting a well-balanced diet according to individual needs, is highlighted.

Health-related quality of life improvement by adalimumab therapy in patients with rheumatoid arthritis in Taiwan: A nationwide prospective study

BACKGROUND

To determine the effects of adalimumab on health-related quality of life (HRQoL) in Taiwanese patients with moderate-to-severe rheumatoid arthritis (RA) (NCT02616380).

METHODS

During a 24-week observational period, 100 biologic-naive patients with RA received 40 mg adalimumab subcutaneously, every 2 weeks. The primary endpoint was a change in Health Assessment Questionnaire-Disability Index (HAQ-DI) score at 24 weeks. The secondary endpoints included change in HAQ-DI at week 12, number and percentage of patients achieving a meaningful improvement in HAQ-DI at weeks 12 and 24, and changes in the 36-Item Short Form Health Survey (SF-36), EuroQol 5-dimension 3-level version (EQ-5D-3L) index, and Work Productivity and Activity Impairment (WPAI) questionnaire scores at weeks 12 and 24.

RESULTS

At weeks 12 and 24, mean changes in HAQ-DI from baseline were -0.34 ± 0.46 and -0.44 ± 0.59 (both p < 0.001), and clinically meaningful improvement in HAQ-DI was achieved by 60.4% and 59.6% of patients, respectively. SF-36, EQ-5D-3L index, and WPAI scores significantly improved ( p < 0.001) from baseline to weeks 12 and 24. Exploratory analyses showed diabetes was significantly associated with changes in HAQ-DI, EQ-5D-3L, and WPAI scores whereas peptic ulcer correlated with changes in the SF-36 physical component summary T-score.

CONCLUSION

HRQoL improved after initiation of adalimumab therapy in Taiwanese patients with moderate-to-severe RA.

The relationship between primary cognitive appraisals, illness beliefs, and adaptation to rheumatoid arthritis: A systematic review and meta-analysis

Rheumatoid arthritis is a chronic disease that negatively affects functioning; however, the relationship between cognitive appraisals and illness-related beliefs and adaptation indices remains unclear.

OBJECTIVE

The aim of this review was to assess the relationship between cognitive appraisals, illness beliefs and indicators of adaptation to life with a chronic disease, such as the severity of depressive symptoms, anxiety, and quality of life.

METHODS

A database search was carried out between May 13 and 18, 2022, with no time restrictions. Thirty studies (5 related to cognitive appraisals, 25 related to illness beliefs) were identified.

RESULTS

The studies identified in the review were of satisfactory quality. An analysis of the articles allowed for a meta-analysis focusing on the relationship between the belief related to illness consequences and the severity of depressive symptoms, which gave an overall correlation estimate of 0.50 [0.44-0.56].

CONCLUSION

Both cognitive appraisals and illness beliefs are related to indicators of rheumatoid arthritis adaptation, such as depressive symptom severity, anxiety and acceptance levels. Further longitudinal research would be crucial in further elucidating the impact of cognitive factors on adjustment level and its trajectories over time.

CLINICAL TRIAL REGISTRATION

Review was pre-registered at https://osf.io/gd9cw (DOI:http://10.17605/OSF.IO/GD9CW).

Application of Exploratory Factor Analysis and Item Response Theory to Validate NHANES ADL Scale in Patients Reporting Rheumatoid Arthritis

Background: Several instruments are used for measuring functional limitations among rheumatoid arthritis (RA) patients. However, these instruments are incongruously assessed for their psychometric properties. The National Health and Nutritional Examination Survey (NHANES) uses a generic questionnaire to assess the activities of daily living (ADL) to measure functional limitations among its participants. The psychometric properties of the NHANES-ADL scale were evaluated using a patient examination and survey data. Methods: NHANES-ADL scale was assessed for its internal consistency and factor structure. Scale reliability was assessed with Cronbach's alpha reliability coefficient. Principal component analysis with Promax rotation was used to obtain factor structure. Confirmatory factory analysis was used to calculate fit indices. The graded item response theory model was used to estimate item discrimination, difficulty, and test information. Results: Our sample included 1132 individuals with RA. Exploratory factor analyses of 19-item NHANES ADL scale produced one factor solution and accounted for 35% of variance. The Cronbach alpha of this scale was 0.92. The results of graded item response model indicated items performing well discriminating high and low level of functional ability. A higher slope (α) reflected stronger ability of items to discriminate across the continuum. Conclusions: The NHANES ADL scale showed good reliability, single dimensionality, and validity in RA patients. Studies should explore its test-retest reliability and its ability to reliably measure functional change over time in the future.

Work Ability and Quality of Life in Patients with Rheumatoid Arthritis

BACKGROUND

Reduced work participation has social implications (sickness absence, economic impact) and consequences for the individual patient (impoverishment, depression, limited social interaction). As patients with rheumatoid arthritis (RA) are more likely to experience job loss and/or at-work productivity loss and are at higher risk of sickness absence and, ultimately, permanent work productivity, consideration should be given to the association between work productivity or partial work capacity and quality of life (QoL). The aim of the study was to assess the relationship between QoL and the risk of work disability, as well as to estimate the risk of a future event and identify factors affecting the risk of work disability in RA inpatients.

MATERIAL AND METHODS

This cross-sectional study included 142 inpatients (65 male) aged 47 (38-58) years, who met the established criteria for a diagnosis of RA and treatment with biologic drugs. Only standardized tools were used to examine the patients: WHOQOL-BREF, MFIS and AS-WIS.

RESULTS

An analysis of the QoL scores on the WHOQOL-BREF demonstrated that the patients' QoL was lowest in the physical health domain and highest in the social relationships domain. The median WHOQOL-BREF total score in the group studied was 62.8, which indicates a moderate QoL. The median total score for the risk of work disability (AS-WIS) was 10.1, which indicates that the level of risk of work disability in the patients was higher than the average level reported in the literature. A multivariate analysis showed that the following were significant independent determinants of a higher risk of work disability: low QoL in the WHOQOL-BREF physical health (β = 0.961; p = 0.029) and psychological health (β = 1.752; p = 0.002) domains, being in a relationship (β = 0.043; p = 0.005) and the use of opioids for pain (β = 3.054; p = 0.012).

CONCLUSIONS

RA patients presented with moderate QoL, moderate fatigue (MFIS) and high risk of disability (AS-WIS). There is an association between a high risk of work disability and lower QoL, especially in the physical and psychological health domains. The lower the QoL in those domains, the higher the risk of work disability. The identification of factors increasing the risk of work disability will help in planning tailored interventions to improve at-work productivity loss and thus prevent work disability.

The Relationship between Major Dietary Patterns and Disease Activity of Rheumatoid Arthritis

AIM

Rheumatoid arthritis is an inflammatory illness characterized by persistent and systemic inflammation. There is just a little amount of research on nutrition and RA progression. The goal of this research is to see whether there's a link between main eating trends and RA activity.

METHODS

In Kermanshah, Iran, 183 individuals with RA were studied in cross-sectional research. The American College of Rheumatology's 2010 criteria were used to diagnose RA. The disease activity score 28 and nutritional information from a reliable 147-item food frequency questionnaire were used to assess RA activity. Factor analysis was used to extract dietary patterns.

RESULTS

The researchers discovered three main eating trends, which they named. Individuals in the highest tertile of a high protein anti-inflammatory dietary pattern that emphasizes consumption of dairy products, red meats, white meats, vegetables oils, condiments, vegetables and fruits as well as low in salts and refined grain had lower DAS-28 scores than those in the first tertiles (T3 = 2.09 ± 0.14 vs. T1 = 3.75 ± 0.13; P-value = 0.001) after controlling for potential confounders. Patients in the top tertile of the low fiber dietary pattern had higher DAS-28 scores than those in the bottom tertile (T3 = 3.40 ± 0.15 vs. T1 = 2.95 ± 0.15; P-value = 0.036) than those in the bottom tertile.

CONCLUSION

This research found an inverse connection between RA activity and adopting a high-protein anti-inflammatory dietary pattern. Furthermore, adopting a low-fiber dietary pattern may be linked to increased RA disease activity. To confirm such a relationship, further research is needed in the future.

The protective effects of NE 52-QQ57 against interleukin-33-induced inflammatory response in activated synovial mast cells

Cytokines-mediated immunity is essential for the pathological development of rheumatoid arthritis (RA). Inhibition of signaling has suggested a potential remedial approach to RA. G protein-coupled receptor 4 (GPR4) has been proven to possess a broad range of physiological functions, but its function in synovial mast cells and RA is less reported. In this study, the protective effects of NE 52-QQ57, a GPR4 antagonist, against interleukin (IL)-33-challenged inflammatory response in activated synovial mast cells were investigated. We report that IL-33 amplified GPR4 expression in HMC-1 mast cells. The GPR4 antagonist NE 52-QQ57 alleviated IL-33-caused secretions of IL-17, interferon-γ, and tumor necrosis factor-α in HMC-1 mast cells. Furthermore, we note that NE 52-QQ57 reduced IL-33-induced expressions of matrix metalloproteinase-2 (MMP-2) and MMP-9. Also, NE 52-QQ57 inhibited cyclooxygenase 2 and prostaglandin E2 expression in IL-33-challenged cells. Also, NE 52-QQ57 ameliorated IL-33-induced oxidative stress by reducing mitochondrial reactive oxygen species and 4-hydroxynonenal. Mechanistically, NE 52-QQ57 mitigated IL-33-induced activation of the p38/nuclear factor-κB signaling pathway. We conclude that targeting GPR4 might be a promising strategy for RA treatment.

Perspectives on Subcutaneous Infliximab for Rheumatic Diseases and Inflammatory Bowel Disease: Before, During, and After the COVID-19 Era

The coronavirus disease 2019 (COVID-19) pandemic has prompted significant changes in patient care in rheumatology and gastroenterology, with clinical guidance issued to manage ongoing therapy while minimising the risk of nosocomial infection for patients and healthcare professionals (HCPs). Subcutaneous (SC) formulations of biologics enable patients to self-administer treatments at home; however, switching between agents may be undesirable. CT-P13 SC is the first SC formulation of infliximab that received regulatory approval and may be termed a biobetter as it offers significant clinical advantages over intravenous (IV) infliximab, including improved pharmacokinetics and a convenient mode of delivery. Potential benefits in terms of reduced immunogenicity have also been suggested. With a new SC formulation, infliximab provides an additional option for dual formulation, which enables patients to transition from IV to SC administration route without changing agent. Before COVID-19, clinical trials supported the efficacy and safety of switching from IV to SC infliximab for patients with rheumatoid arthritis and inflammatory bowel disease (IBD), and SC infliximab may have been selected on the basis of patient and HCP preferences for SC agents. During the pandemic, patients with rheumatic diseases and IBD have successfully switched from IV to SC infliximab, with some clinical benefits and high levels of patient satisfaction. As patients switched to SC therapeutics, the reduction in resource requirements for IV infusion services may have been particularly welcome given the pandemic, facilitating reorganisation and redeployment in overstretched healthcare systems, alongside pharmacoeconomic benefits and a reduction in exposure to nosocomial infection. Telemedicine and contactless healthcare have been pushed to the forefront during the pandemic, and a lasting shift towards remote patient management and community/home-based drug administration is anticipated. SC infliximab supports the implementation of this paradigm for future improvements of healthcare value delivered. The accumulation of real-world data during the pandemic supports the high level of confidence, with patients, physicians, and healthcare systems benefitting from its uptake.

Unmet Needs in Rheumatoid Arthritis: A Subgroup of Patients With High Levels of Pain, Fatigue, and Psychosocial Distress 3 Years After Diagnosis

Objective

The study objective was to identify subgroups of patients with rheumatoid arthritis (RA) based on their health status 3 years after diagnosis and to assess potential associations to clinical presentation at diagnosis.

Methods

This observational study included patients with RA with 3‐year follow‐up data from the Swedish Epidemiological Investigation of RA study, collected from 2011 to 2018. Hierarchical agglomerative cluster analysis, based on symptoms of pain, fatigue, sleep quality, mood disturbances, and overall health‐related quality of life (HRQoL), was used to identify subgroups 3 years after diagnosis. Modified Poisson regression was used to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for the associations between the subgroups and patient characteristics at diagnosis.

Results

A total of 1055 individuals constituted the study population, of whom 1011 had complete data on the clustering variables and were therefore eligible for analysis (73% women, median age 58 years). The following three clusters were identified: cluster 1 (466 patients with good health status), cluster 2 (398 patients in an intermediate group), and cluster 3 (147 patients with high levels of pain and fatigue together with markedly impaired HRQoL). Cluster 3 was associated to higher baseline pain (RR: 3.71 [95% CI: 2.14‐6.41]), global health (RR: 6.60 [95% CI: 3.53‐12.33]), and the Stanford Health Assessment Questionnaire (RR: 4.40 [95% CI: 2.46‐7.87]), compared with cluster 1 (highest compared with lowest quartiles). An inverse association was seen for baseline swollen joint count (RR: 0.51 [95% CI: 0.34‐0.85]).

Conclusion

A subgroup of patients with RA experience high levels of pain, fatigue, and psychosocial distress 3 years after diagnosis. This subgroup already displayed pronounced pain and functional disabilities at diagnosis.

The Effect of Periodontal Treatment on Clinical and Biological Indicators, Quality of Life, and Oral Health in Rheumatoid Arthritis Patients: A Quasi-Experimental Study

Non-surgical periodontal therapy (NSPT) has been shown to have systemic effects. It has been suggested that, similar to rheumatoid arthritis (RA), periodontitis (PD) has an impact on general health, in terms of psychological, physical, and social aspects. This study determines the effect of periodontal treatment in RA activity, health-related quality of life, and oral health self-perception before and after periodontal treatment in RA patients. A quasi-experimental, prospective, non-randomized study was conducted, and 52 patients were included in the study. Periodontal parameters and the instruments disease activity score-28 (DAS-28), SF-36, and OHIP-14 were measured at baseline and at 3 months after NSPT. All differences were statistically assessed. The study protocol was registered in Clinical Trials (NCT04658615). No statistically significant differences were found in the scores of DAS-28 before and after the intervention in the group with PD and reduced periodontium. When the effect of periodontal treatment was analyzed in the group of 29 patients who were followed up, it was found that there were statistically significant differences before and after in variables such as psychological distress, emotional role, and mental health, which indicates an improvement in the scores of these variables. NSPT influenced the health-related quality of life measured with SF-36 and OHIP-14 in patients with RA. In conclusion, NSPT has an effect on self-reported quality of life and health indicators more than the RA activity as measured with DAS-28. However, the clinical effect of periodontal treatment in RA patients provides important data to support periodontal care in patients.

Evaluation of the mechanisms of sarcopenia in chronic inflammatory disease: protocol for a prospective cohort study

Background

Several chronic inflammatory diseases co-exist with and accelerate sarcopenia (reduction in muscle strength, function and mass) and negatively impact on both morbidity and mortality. There is currently limited research on the extent of sarcopenia in such conditions, how to accurately assess it and whether there are generic or disease-specific mechanisms driving sarcopenia. Therefore, this study aims to identify potential mechanisms driving sarcopenia within chronic inflammatory disease via a multi-modal approach; in an attempt to help define potential interventions for future use.

Methods

This prospective cohort study will consist of a multi-modal assessment of sarcopenia and its underlying mechanisms. Recruitment will target three chronic inflammatory diseases: chronic liver disease (CLD) (n=50), with a subset of NAFLD (n=20), inflammatory bowel disease (IBD) (n=50) and rheumatoid arthritis (RA) (n=50) both before and after therapeutic intervention. In addition, 20 age and sex matched healthy individuals will be recruited for comparison. Participants will undergo 4 assessment visits at weeks 0, 2, 12 and 24. Visits will consist of the following assessments: blood tests, anthropometrics, functional assessment, quadriceps muscle imaging, actigraphy, quality of life questionnaires, food diary collection and muscle biopsy of the vastus lateralis (at weeks 2 and 24 only). In addition, stool and urine samples will be collected for future microbiome and metabolomics analysis.

Discussion

This is the first study to use a multi-modal assessment model to phenotype sarcopenia in these chronic inflammatory diseases. We hope to identify generic as well as disease-specific mechanisms driving sarcopenia. We appreciate that these cohorts do require separate standards of care treatments which limit comparison between groups.

Ethics and dissemination

The study is approved by the Health Research Authority - West Midlands Solihull Research Ethics Service Committee Authority (REC reference: 18/WM/0167). Recruitment commenced in January 2019 and will continue until July 2021. The study was halted in March 2020 and again in January 2021 with the COVID-19 pandemic. The findings will be disseminated through peer-reviewed publications and conference presentations. All data will be stored on a secure server.

Trial registration

ClinicalTrials.gov Identifier: NCT04734496

Patient Empowerment and Associations with Disease Activity and Pain-Related and Lifestyle Factors in Patients With Rheumatoid Arthritis

BACKGROUND

Empowerment is important to patients with rheumatoid arthritis (RA) because most care is in the form of self-management. The aim was to study levels of empowerment and associated variables in patients with RA and to investigate longitudinal clinical data in patients with low and high empowerment.

METHODS

A postal survey was sent in 2017 to patients with RA from the BARFOT (Better Anti-Rheumatic Pharmacotherapy) cohort that included questions about disease activity, pain-related factors, lifestyle habits, and contained the Swedish Rheumatic Disease Empowerment Scale (SWE-RES-23). The 844 patients who answered the SWE-RES-23 made up the cohort of the present study. Differences in level of empowerment between groups (low, moderate, and high empowerment) were analyzed with ANOVA. Logistic regression analysis was used to study variables associated with low empowerment. Thirdly, we performed comparisons in longitudinal data (15 years) of disease activity, pain, and physical function between the three empowerment groups (low, moderate, and high empowerment).

RESULTS

Patients with low empowerment (n = 282) were significantly older, more often women, and reported worse pain-related factors and physical function and lower moderate and vigorous physical activity compared with those with high empowerment (n = 270). An analysis of longitudinal data found that patients with low empowerment had worse pain and physical function at all time points.

CONCLUSION

Patients with low empowerment have more pain-related symptoms, poorer physical function, and are less physically active. To promote patient empowerment in rehabilitation interventions it is important to identify and support self-management.

Factors detrimental to work productivity and daily activities in systemic lupus erythematosus patients - Analysis of the German LuLa study

OBJECTIVE

The aim of this study was to identify factors associated with impaired work productivity and impaired daily activities in patients with systemic lupus erythematosus (SLE).

METHODS

The LuLa study is a longitudinal patient-reported study. Beyond sociodemographic data, work productivity, daily activities and fatigue, several other clinical outcome parameters (e.g. mental health-related quality of life and physical functioning, disease activity, damage and pain) were surveyed with validated questionnaires. The effects of confounders on work productivity (WPAI 2) and daily activity domains (WPAI 4) were studied by multivariate regression analysis.

RESULTS

A total of 585 patients completed the questionnaire of whom 259 were employed and analysed. The median impairment in work productivity (WPAI 2) was 20% (Q1-3 0-40), and the median impairment in daily activities (WPAI 4) was 30% (Q1-3 10-50%). Multivariate regression analysis revealed that fatigue, pain, disease activity and health-related quality of life affected WPAI 2 and 4. Furthermore, we observed distinct synergistic effects of fatigue, disease activity and pain on both work productivity and daily activities: a higher impact of fatigue was associated with the reported extent of pain or disease activity.

CONCLUSION

In employed patients with SLE, impaired work productivity and impaired daily activities were frequently reported. Fatigue, pain, disease activity and health-related quality of life demonstrated a detrimental impact, with a synergistic effect of fatigue, disease activity and pain. Hence, both optimized pain management and targeted immunomodulatory therapy are important for preserving active participation in life among patients with fatigue.

Predictors of Quality of Life in Patients With Rheumatoid Arthritis in Pakistan: A Cross-Sectional Study

Introduction Rheumatoid arthritis (RA) is a chronic, progressive inflammatory illness that primarily affects peripheral joints and belongs to systemic connective tissue diseases. Rheumatoid arthritis can cause varied and significant impacts on patients' health, including mental and physical wellbeing. The aim of this study is to analyze the factors affecting the quality of life of rheumatoid arthritis patients. Methodology A cross-sectional study was conducted in the outpatient orthopedics department of Indus Hospital and Health Network. The survey questionnaire was used to collect data from participants. The study's 36-item short-form survey (SF-36) questionnaire was used to assess the quality of life (QoL) among RA patients. Linear regression was used to assess the factors associated with the mental and physical components of QoL. Results A total of 154 patients were interviewed in this study. The mean age of participants was 48.96 (±51.35). Factors that contributed to the physical component of QoL included severity of disease, income, age, comorbidity, and anxiety while factors affecting the mental component of QoL included quality of sleep, anxiety, education, comorbidity, and disease severity. Conclusion Healthcare professionals need to work closely with patients to increase their capabilities of being more independent and controlling all the factors that can affect their QoL.

Lifestyle factors in patients with rheumatoid arthritis-a cross-sectional study on two Scandinavian cohorts

INTRODUCTION

The risk for cardiovascular diseases and other comorbidities increases with the number of unhealthy lifestyle factors in the general population. However, information on the combined number of unhealthy lifestyle factors in people with rheumatoid arthritis (RA) is scarce.

OBJECTIVES

To study lifestyle factors and the association between disease impact and two or more unhealthy lifestyle factors in two Scandinavian cohorts with RA.

METHODS

We analysed data from two cohorts, Danish (n = 566; mean age 61.82 (SD 11.13) years; 72% women) and Swedish (n = 955; mean age 66.38 (SD 12.90) years; 73% women). Lifestyle factors (tobacco use, BMI, alcohol consumption and physical activity) were dichotomised as healthy vs. unhealthy (range 0-4 unhealthy factors). The association between disease impact and two or more unhealthy lifestyle factors was analysed using logistic regression.

RESULTS

Sixty-six percent of Danish and 47% of Swedish respondents reported two or more unhealthy lifestyle factors, most commonly, being overweight/obese and physical inactivity. For Danish participants, two or more unhealthy lifestyle factors were associated with (OR and 95% CI) male gender (1.86; 1.21-2.85), cardiovascular diseases (1.90; 1.28-2.82) and disease duration (0.97; 0.95-0.99). Corresponding findings for the Swedish cohort were male gender (1.42; 1.07-1.89), pain (1.10; 1.04-1.15), fatigue (1.09; 1.04-1.15), physical functioning (1.64; 1.28-2.10) and quality of life (0.35; 0.20-0.60).

CONCLUSION

Many patients, most often male, in both cohorts had two or more unhealthy lifestyle factors. The number of unhealthy lifestyle factors indicates a multifaceted relationship with disease impact.

Validating the Michigan Hand Outcomes Questionnaire in patients with rheumatoid arthritis using Rasch analysis

INTRODUCTION

The Michigan Hand Outcomes Questionnaire (MHQ) is a patient-reported outcome measure previously validated in patients with rheumatoid arthritis (RA) using classical test theory. Rasch analysis is a more rigorous method of questionnaire validation that has not been used to test the psychometric properties of the MHQ in patients with RA. The objective of this study is to evaluate the validity and reliability of the MHQ for measuring outcomes in patients with RA with metacarpophalangeal joint deformities.

METHODS

We performed a Rasch analysis using baseline data from the Silicone Arthroplasty in Rheumatoid Arthritis (SARA) prospective cohort study. All domains were tested for threshold ordering, item fit, targeting, differential-item functioning, unidimensionality, and internal consistency.

RESULTS

The Function and Work domains showed excellent fit to the Rasch model. After making adjustments, the Pain, Activities of Daily Living (ADL) and Satisfaction domains also fulfilled all Rasch model criteria. The Aesthetics domain met the majority of Rasch criteria, but could not be tested for unidimensionality.

CONCLUSIONS

After collapsing disordered thresholds and removing misfitting items, the MHQ demonstrated reliability and validity for assessing outcomes in patients with RA with metacarpophalangeal joint deformities. These results suggest that interpreting individual domain scores may provide more insight into a patient's condition rather than analyzing an overall MHQ summary score. However, more Rasch analyses are needed in other RA populations before making adjustments to the MHQ.

Rheumatoid arthritis and dietary interventions: systematic review of clinical trials

CONTEXT

The impact of various dietary interventions on rheumatoid arthritis (RA), characterized by immune-inflammatory response, has been subject to increased attention.

OBJECTIVE

A systematic review was conducted to update the current knowledge on the effects of nutritional, dietary supplement, and fasting interventions on RA outcomes.

DATA SOURCES

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with prespecification of all methods, Medline and Embase were systematically searched for relevant articles.

DATA EXTRACTION

Data were extracted by 2 independent reviewers.

RESULTS

A total of 70 human studies were identified. Administration of omega-3 polyunsaturated fatty acids at high doses resulted in a reduction in RA disease activity and a lower failure rate of pharmacotherapy. Vitamin D supplementation and dietary sodium restriction were beneficial on some RA outcomes. Fasting resulted in significant but transient subjective improvements. While the Mediterranean diet demonstrated improvements in some RA disease activity measures, outcomes from vegetarian, elimination, peptide, or elemental diets suggested that responses are very individualized.

CONCLUSION

Some dietary approaches may improve RA symptoms and thus it is recommended that nutrition should be routinely addressed.

Driving Ability and Safety in Rheumatoid Arthritis: A Systematic Review

OBJECTIVE

To identify whether rheumatoid arthritis (RA) is associated with driving ability and/or the use of assistive devices or modifications to improve driving ability.

METHODS

We conducted a systematic literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines of RA and driving ability/adaptations by searching multiple databases from inception to April 2018. Eligible studies were original articles in the English language that had quantitative data regarding the study objective and at least 5 RA patients. Similar outcomes were extracted across studies and grouped into categories for review.

RESULTS

Our search yielded 1,935 potential reports, of which 22 fulfilled eligibility criteria, totaling 6,285 RA patients. The prevalence of driving issues in RA was highly variable among the studies. Some of the shared themes addressed in these publications included RA in association with rates of motor vehicle crashes, self-reported driving difficulty, inability to drive, use of driving adaptations, use of assistance by other people for transport, and difficulty with general transportation.

CONCLUSION

Despite variability among individual reports, driving difficulties and the use of driving adaptations are relatively common in individuals with RA. Given the central importance of automobile driving for the quality of life of RA patients, further investigations of driving ability and potential driving adaptations that can help overcome barriers to safe driving are needed.

Health-related quality of life in rheumatoid arthritis: Systematic review and meta-analysis of EuroQoL (EQ-5D) utility scores from Asia

INTRODUCTION

Region-specific health-related quality of life (HRQoL) scores or utility values are representative and pivotal for economic evaluations as they are influenced by the value judgment of the local population. This study systematically reviewed and pooled EuroQoL-5 Dimension (EQ-5D) utility scores of rheumatoid arthritis (RA) across primary studies from Asia.

METHODS

Studies reporting EQ-5D utility scores among adult RA patients from Asian countries were systematically searched in PubMed-Medline, Scopus and Embase since inception through February 2020. Selected studies were systematically reviewed and study quality assessment was performed. Meta-analysis was performed using a random-effect model with subgroup and meta-regression analysis to explore heterogeneity.

RESULTS

Among 1391 searched articles, 37 studies with 31 983 participants were systematically reviewed and meta-analysis was conducted among 31 studies. The pooled EQ-5D scores and EQ-5D visual analog score were 0.66 (95% CI 0.63-0.69, I²  = 99.65%) and 61.21 (50.73-71.69, I²  = 99.56%) respectively with high heterogeneity. For RA patients with no, low, moderate and high disease activity based on Disease Activity Score (DAS)-28, the pooled EQ-5D scores were 0.78 (0.65-0.90), 0.73 (0.65-0.80), 0.53 (0.32- 0.74), and 0.47 (0.32-0.62), respectively. On meta-regression, age of patients (P < .05) was positively associated and use of glucocorticoids (P < .05) was inversely associated with utility values.

CONCLUSION

Lower EQ-5D scores were associated with severe disease activity, increasing age and female gender among RA patients. The study provides pooled EQ-5D scores for RA patients that are useful inputs for cost-utility studies in Asia.

A New Peracetylated Oleuropein Derivative Ameliorates Joint Inflammation and Destruction in a Murine Collagen-Induced Arthritis Model via Activation of the Nrf-2/Ho-1 Antioxidant Pathway and Suppression of MAPKs and NF-κB Activation

Oleuropein (OL), an olive tree secoiridoid and its peracetylated derivate (Per-OL) have exhibited several beneficial effects on LPS-stimulated macrophages and murine experimental systemic lupus erythematosus (SLE). This study was designed to evaluate dietary Per-OL in comparison with OL supplementation effects on collagen-induced arthritis (CIA) murine model. Three-weeks-old DBA-1/J male mice were fed from weaning with a standard commercial diet or experimental enriched-diets in 0.05 % (w/w) OL, 0.05% and 0.025% Per-OL. After six weeks of pre-treatment, arthritis was induced by bovine collagen type II by tail base injection (day 0) and on day 21, mice received a booster injection. Mice were sacrificed 42 days after the first immunization. Both Per-OL and OL diets significantly prevented histological damage and arthritic score development, although no statistically significant differences were observed between both compounds. Also, serum collagen oligomeric matrix protein (COMP), metalloprotease (MMP)-3 and pro-inflammatory cytokines levels were ameliorated in paws from secoiridoids fed animals. Mitogen-activated protein kinases (MAPK)s and nuclear transcription factor-kappa-B (NF-κB) activations were drastically down-regulated whereas nuclear factor E2-related factor 2 (Nrf2) and heme-oxygenase-1 (HO-1) protein expressions were up-regulated in those mice fed with OL and Per-OL diets. We conclude that both Per-OL and its parent compound, OL, supplements might provide a basis for developing a new dietary strategy for the prevention of rheumatoid arthritis.

Physical and Emotional Burden of Rheumatoid Arthritis in Saudi Arabia: An Exploratory Cross-Sectional Study

Purpose

The aim of this study was to better understand the physical and emotional impacts of rheumatoid arthritis (RA) on the lives of patients in Saudi Arabia, and to determine whether there are any discrepancies between how healthcare providers (HCPs) perceive the feelings of patients with RA and how patients actually feel.

Patients and Methods

An online survey of adults with RA and HCPs was conducted in Saudi Arabia between January and June 2018. The survey used closed-ended questions with nominal and interval scales to cover relationships with others, ability to work and career progression, ability to perform normal activities, and aspirations for the future.

Results

In total, 85 patients and 24 HCPs were surveyed. Patients were more likely than HCPs to feel that the people around them understood the emotional and physical impacts of RA (emotional impact understood: 67% of patients vs 42% of HCPs; physical impact understood: 61% vs 38%, respectively). Additionally, a larger proportion of younger (aged <40 years) than older patients (aged 40-59 and ≥60 years) felt that these impacts were not understood by others. For patients, the greatest barrier to working was difficulty using hands (52% vs 41% of HCPs), whereas HCPs considered pain the greatest barrier (50% vs 38% of patients). Both patients (59%) and HCPs (81%) considered pain to be a common barrier to undertaking everyday activities. Regarding future aspirations, 40% of patients wished to accept their RA despite the barriers it caused.

Conclusion

Discrepancies between how HCPs perceived the feelings of patients with RA and how patients actually felt suggest that HCP-patient communication could be improved. This is the first study of its kind in Saudi Arabia and should help increase awareness of the difficulties and concerns of patients with RA in the Arabic world.

Physiotherapeutic evaluation and intervention proposal on a patient with post-chikungunya chronic arthritis

BACKGROUND

Chikungunya fever is an arboviral disease characterized by a high morbidity rate related to intense and persistent arthralgia, causing a decrease in both quality of life (QoL) and productivity. This study aimed to report functional evaluation and multimodal physiotherapeutic intervention on a patient with post-chikungunya chronic arthritis (PCCA).

CASE PRESENTATION

Woman, 47 years old, resident of the municipality of Belém, state of Pará, northern Brazil, with clinical diagnosis of chikungunya fever marked by fever, swelling, pain in the joints of the hands and feet, and headache. The physiotherapeutic treatment started three months after the diagnosis and consisted of 24 sessions composed of electrotherapy, thermotherapy, and kinesiotherapy resources. The patient progressed from an initial status of intense pain in several joints to low pain in a single joint and showed improvement in all domains of QoL, mainly in limitations by physical and emotional aspects and functional capacity.

CONCLUSIONS

This case report details a proposal of multimodal physiotherapeutic intervention for a patient with functional impairments due to PCCA, suggesting that the use of physiotherapeutic resources may help this process and bring some assistance to those affected by the disease.

Effect of an 8-Week Yoga-Based Lifestyle Intervention on Psycho-Neuro-Immune Axis, Disease Activity, and Perceived Quality of Life in Rheumatoid Arthritis Patients: A Randomized Controlled Trial

Various external stressors and environmental challenges lead to the provocation of the immune system in autoimmune diseases like Rheumatoid arthritis (RA). The inappropriate immune response further triggers the cascade of inflammatory changes resulting in precipitation of symptoms and hampers quality of life (QOL). The underlying psycho-somatic component of the disease requires a holistic approach to its treatment dimension rather than the use of pharmacotherapy. The applicability of mind-body interventions has become essential in today’s fast-paced life. Yoga, a mind-body technique, alters the mind’s capacity to facilitate systemic functioning at multiple organ system levels. Hence, we conducted this study to evaluate the impact of 8 weeks of a yoga-based lifestyle intervention (YBLI) on psycho-neuro-immune markers, gene expression patterns, and QOL in RA patients on routine medical therapy. A total of 66 patients were randomized into two groups: yoga group or non-yoga group and were assessed for a panel of inflammatory cytokines (IL-6, IL-17A, TNF-α, and TGF-β), mind-body communicative markers (BDNF, DHEAS, β-endorphin, and sirtuin) and transcript levels of various genes (IL-6, TNF-α, NFKB1, TGF-β, and CTLA4). We assessed disease activity and QOL using the DAS28-ESR and WHOQOL-BREF questionnaire, respectively. Yoga group observed significant improvements in the levels of markers, which influenced the psycho-neuro-immune axis (p < 0.001) with an estimated effect size from small to medium range. In the yoga group, there was a significant reduction in DAS28-ESR (p < 0.001) and improvement seen in the physical health, psychological, social relationships domains (p < 0.001) of QOL, except environmental (p > 0.05). The yoga group showed downregulation of IL-6, TNF-α, and CTLA4 and upregulation of TGF-β. These results suggest that a decrease in disease activity after yoga practice is associated with a significant reduction in inflammatory cytokines, the elevation of mind-body communicative markers, and normalization of various transcript levels, which improved QOL. Thus the adoption of YBLI improves clinical outcome in RA, and decreases systemic inflammation by its beneficial effects on psycho-neuro-immune axis and normalization of dysregulated transcripts. Thus YBLI may be used for RA patients as an adjunctive therapy.

Renegotiating dimensions of the self: A systematic review and qualitative evidence synthesis of the lived experience of self-managing rheumatoid arthritis

Background

As chronic illnesses, such as rheumatoid arthritis (RA), place an increased burden on health‐care systems, the ability of individuals to self‐manage these diseases is crucial.

Objective

To identify and synthesize the lived experience of self‐management described by adults living with RA.

Design

A systematic search of five electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and ASSIA) was undertaken to identify relevant studies. Data were extracted and quality‐assessed using CASP guidelines. A meta‐synthesis was conducted based on Thomas and Harden's thematic synthesis approach.

Results

The search identified 8423 publications. After removing duplicates, 6527 records remained of which 32 studies met the inclusion criteria. Quality of studies was moderate to high, yet a considerable lack of reflection on researcher bias was evident. Our analysis identified 28 dimensions of self‐management RA across six domains: (a) cognitive‐emotional, (b) behavioural, (c) social, (d) environmental, (e) physical and (f) technological. Cognitive‐emotional experiences dominated the analysis. Renegotiating ‘the self’ (self‐concept, self‐esteem, self‐efficacy) was a key focus of self‐management among individuals with RA.

Conclusion

Our findings highlight the focus of ‘the self’ as a central concern in the self‐management of RA. Standardized self‐management programmes may primarily focus on disease management and daily functioning. However, we suggest that personal biographies and circumstances should move to the fore of self‐management support.

Registration

PROSPERO International Prospective Register of Systematic Reviews 2018: CRD42018100450.

Patient or Public Contribution

Patient and public involvement was not explicit in this review. However, three authors provided a patient perspective on the self‐management of arthritis and autoimmune disease.

Factors that affect the assessment of the quality of life of rheumatoid arthritis patients depending on the prevalence of frailty syndrome

Rheumatoid arthritis (RA) has a large and varied impact on the quality of life as associated with patient health including both physical and mental well-being. The aim of the study was to assess the factors that affect the assessment of the quality of life of RA patients depending on the prevalence of frailty syndrome.

MATERIAL AND METHODS

The study involved 106 patients with RA (82 women; mean age 65.83 ± 5.01), who had been hospitalized in the Silesian Centre for Rheumatology, Rehabilitation and Disability Prevention in Ustron, Poland. The patients that were included in the study were divided into two groups depending on the incidence of frailty syndrome: Group 1 - robust patients and Group 2 - patients with frailty syndrome.

RESULTS

Frailty syndrome was identified in 34.9% of the patients with recognized/diagnosed RA; in women, it was 36.14% and in men, it was 25.92%. The average TFI value was 4.11 ± 2.05; in the physical domain, it was 3.39 ± 1.66; in the mental domain, it was 0.41 ± 0.55 and in the social domain, it was 0.31 ± 0.48. The robust patients assessed their quality of life associated with sleep as being worse compared to patients with recognized frailty syndrome.

CONCLUSION

Frailty syndrome has no significant impact on the assessment of the quality of life of patients with diagnosed RA. The factors that determine quality of life are different in robust patients and in patients with frailty syndrome. The assessment of the quality of life is affected by the degree of an individual's fitness regardless of the occurrence of frailty syndrome.

More Unnecessary Imaginary Worlds - Part 1: The Institute for Clinical and Economic Review's Evidence Report on Janus Kinase (JAK) Inhibitors in Rheumatoid Arthritis

Previous commentaries in the Formulary Evaluation section of INNOVATIONS in Pharmacy have pointed to the lack of credibility in modeled claims for cost-effectiveness and associated recommendations for pricing by the Institute for Clinical and Economic Review (ICER). The principal objection to ICER reports has been that their modeled claims fail the standards of normal science: they are best seen as pseudoscience. The purpose of this latest commentary is to consider the recently released ICER evidence report for Janus Kinase (JAK) Inhibitors. As ICER continues, in the case of JAK Inhibitors, to apply its modeled cost utility framework with consequent recommendations for pricing adjustments, these recommendations also lack credibility. In contrast with previous ICER evidence reports, the present report adopts only a 12-month timeframe, one due, in large part, to ICER being unable to justify assumptions to drive its construction of imaginary worlds beyond 12 months. This commentary emphasizesagain, why the ICER methodology fails to meet the standards of normal science. Claims made by ICER for the competing JAK Inhibitor therapies lack credibility, are impossible to evaluate, let alone replicate across treatment settings. Even so, it is important to examine a number of key elements in the ICER invention of the 12-month JAK Inhibitor imaginary world. While this does not imply any degree of acceptance of the ICER methodology, one element that merits particular attention is thefailure of the ICER modeling to meet logically defensible measurement standards in its application of generic health related quality of life (HRQoL) ordinal metrics to create its QALY claims. The failure to meet the required standards of fundamental measurement means that the cost-per-QALY claims are invalid. This raises the issue of the application of Rasch Measurement Theory (RMT) in instrument development and the potential role of patient centric outcome (PCO) instruments that represent the patient voice in value claims. The case made here is that the ICER approach should be abandoned as an unnecessary distraction. If we are to meet standards for the discovery of new facts in therapy response then our focus must be on proposing credible, evaluable and replicable claims within disease states. Instruments, such as the Rheumatoid Arthritis Quality of Life (RAQoL)questionnaire that build on the common construct that QoL is the extent to which human needs are fulfilled should be the basis for value claims. HRQoL Instruments that are clinically focused and reflect the value calculus of providers and not patients in measuring response by symptoms and activity limitations are irrelevant. This puts to one side the belief that incremental cost-per-QALY models, the construction of imaginary worlds are, in any sense, a 'gold standard'; a meme embraced by the health technology assessment profession. Claims for incremental cost per QALY outcomes and recommendations for pricing and access driven by willingness to pay thresholds are irrelevant to formulary decisions.

Patients with rheumatoid arthritis have an increased risk of incident chronic kidney disease: a systematic review and meta-analysis of cohort studies

OBJECTIVES

Patients with rheumatoid arthritis (RA) may have a higher risk of developing chronic kidney (CKD) compared with general population, but the data on this risk are still not well characterized. This systematic review and meta-analysis aimed to comprehensively investigate this association by reviewing all available studies.

METHODS

A systematic review was performed using MEDLINE and EMBASE database from inception to July 2019 to identify all cohort studies that compared the risk of developing CKD after index date among patients with RA versus individuals without RA. Pooled risk ratio and 95% confidence interval (CI) were calculated using random-effect, generic inverse-variance method of DerSimonian and Laird.

RESULTS

A total of four cohort studies (three retrospective cohort studies and four prospective cohort study) comprising of 1,627,833 participants met the inclusion criteria and were included in the meta-analysis. The overall quality of the included studies was good. The risk of incident CKD was significantly increased among patients with RA with the pooled risk ratio of 1.52 (95% CI 1.28-1.80). The statistical heterogeneity was high with an I² of 82%.

CONCLUSIONS

A significantly increased risk of incident CKD among patients with RA compared with individuals without RA was demonstrated in this study.

Quality of life in Ecuadorian patients with established rheumatoid arthritis

Purpose

To evaluate quality of life in patients with established rheumatoid arthritis (RA) and identify the factors that negatively affect it.

Methods

This was a cross-sectional study with patients with established RA from a rheumatology center in Ecuador. The RA Quality of Life (RAQoL) questionnaire was used to assess QoL and the Health Assessment Questionnaire — disability index (HAQ-DI) questionnaire for functional capacity. In addition, demographics, clinical characteristics, and markers of disease activity were included. Data were analyzed using SPSS 22.

Results

Of 186 patients, 89.8% were women, with a mean age of 51 years, 86.6% had symmetrical polyarticular involvement, 40.3% erosions, 46.8% morning stiffness, 46.8% xerophthalmia, and 39.2% fatigue. Depression was the most frequent comorbidity — 42.5%. The mean HAQ-DI score was 0.8, and 26.9% had functional disability. The mean RAQoL score was 7.2. Xerophthalmia, xerostomia, fatigue, morning stiffness, and depression were related to higher scores in the RAQoL (p<0.05). The mean RAQoL was higher in patients with more disease activity and comorbidities (p<0.05). Likewise, patients with functional disability had a mean RAQoL score of 15.6 versus 4.1 in patients without disability (p<0.05). There were positive correlations between RAQoL and ESR, CRP, painful-joint count, swollen-joint count, VAS of pain, and physician assessment (p<0.05).

Conclusion

QoL is severely affected in patients with RA. Depression, fatigue, morning stiffness, pain, high disease activity, and disability have a negative effect on QoL in RA. Likewise, patients with more comorbidities and extraarticular manifestations show worse QoL.

Attitudes towards Oral Health in Patients with Rheumatoid Arthritis: A Qualitative Study Nested within a Randomized Controlled Trial

INTRODUCTION

Patients with rheumatoid arthritis (RA) present a higher incidence and severity of periodontitis than the general population. Our study, Outcomes of Periodontal Treatment in Patients with Rheumatoid Arthritis (OPERA), was a randomized waiting-list controlled trial using mixed methods. Patients randomized to the intervention arm received intensive periodontal treatment, and those in the control arm received the same treatment with a 6-mo delay.

AIM

The nested qualitative component aimed to explore patients' experiences and priorities concerning oral health and barriers and facilitators for trial participation.

METHODS

Using purposive sampling until thematic saturation was reached, we conducted 21 one-to-one semistructured interviews with randomized patients in either of the 2 treatment arms as well as with patients who did not consent for trial participation.

RESULTS

The patients described their experiences about RA, oral health, and study participation. Previous experiences with dental care professionals shaped patients' current perceptions about oral health and the place of oral health on their list of priorities compared with other conditions. Patients also highlighted some of the barriers and facilitators for study participation and for compliance with oral health maintenance. The patients, in the control arm, presented their views regarding the acceptable length of waiting time for the intervention.

CONCLUSION

The associations between periodontal and systemic health are increasingly recognized by the literature. Our study provided an insight into RA patients' experiences and perceptions about oral health. It also highlighted some of the barriers and facilitators for participating in a periodontal interventional study for this group. We hope that our findings will support the design of larger interventional periodontal studies in patients with RA. The complex challenges faced by the burden of RA and the associated multimorbidities in this patient group might highlight opportunities to improve access to oral health services in this patient population.

KNOWLEDGE TRANSFER STATEMENT

This article provided insights into the experiences and perceptions of rheumatoid arthritis patients about their oral health to improve patient participation in a definitive clinical trial.