The patient activity scale-II is a generic indicator of active disease in patients with rheumatic disorders

The problem of residual pain in the assessment of rheumatoid arthritis activity

Residual pain is a major unmet medical need observed in patients suffering from rheumatoid arthritis (RA), which decreases their quality of life, even after achieving remission or low disease activity. The article has two aims: 1) to present mechanisms involved in the pathophysiology of residual pain, both inflammatory and non-inflammatory, i.e. neuropathic and nociplastic pain, as well as secondary pain syndromes, i.e. osteoarthritis and fibromyalgia, which can contribute to residual pain; 2) to show the limitations of current disease activity measures recommended by European Alliance of Associations for Rheumatology (EULAR) and American College of Rheumatology (ACR), which raise the need for a separate assessment of pain, and examples of methods that could be used by medical professionals to assess the pain and make a differential diagnosis. In conclusion, establishing a valid method to assess pain is essential to identify the pathomechanism of residual pain and to create treatments tailored specifically to individual RA patients.

Platelet-Rich Plasma for Rheumatoid Arthritis: A Case Series

Rheumatoid Arthritis (RA) is a chronic disease characterized by severe inflammation that leads to degradation of articular cartilage and the formation of bony erosions. Currently, certain anesthesiologist-led pain management clinics have begun to take on a collaborative role in the treatment of patients with RA, as this progressive disease impairs work capacity due to chronic pain. We present three clinical cases in which platelet-rich plasma (PRP) was used for the treatment of RA in patients seeking a new therapy for pain control and improved range of motion, specifically in certain joints of the hand. The Patient Activity Scale II was employed as a standardized method to assess RA disease severity, recorded on the day of injection, at one month, at three months, and at six months. All of the included patients, ages 49, 60, and 63, had an established diagnosis of RA affecting the proximal interphalangeal and metacarpophalangeal joints of the hand. Over the course of six months, two out of three patients reported a 20% reduction in pain from the initial visit and a 30% improvement in overall well-being. The third patient noted a 50% decrease in pain from the initial visit and a 50% improvement in overall well-being. PRP treatment consistently resulted in functional improvement for each of the three patients treated, while also reducing long term pain and inflammation. Initial clinical and laboratory studies have shown that autologous plasma rich in platelets serves as a source of an abundance of growth factors once activated. The multitude of these growth factors injected into and around the diseased joints improves functionality in patients with RA indicating PRP may be a safe and beneficial therapy in patients with RA primarily affecting the joints of the hand.

Evaluation of Patient Reported Safety and Efficacy of Cannabis From a Survey of Medical Cannabis Patients in Canada

With the medical use of cannabis permitted in Canada since 2001, patients seek to use this botanical drug to treat a range of medical conditions. However, many healthcare practitioners express the need for further scientific evidence around the use of medical cannabis. This real-world evidence study aimed to address the paucity of scientific data by surveying newly registered medical cannabis patients, before beginning medical cannabis treatment, and at one follow up 6 weeks after beginning medical cannabis treatment. The goal was to collect data on efficacy, safety and cannabis product type information to capture the potential impact medical cannabis had on patient-reported quality of life (QOL) and several medical conditions over a 6-week period using validated questionnaires. The 214 participants were mainly male (58%) and 57% of the population was older than 50. The most frequently reported medical conditions were recurrent pain, post-traumatic stress disorder (PTSD), anxiety, sleep disorders [including restless leg syndrome (RLS)], and arthritis and other rheumatic disorders. Here we report that over 60% of our medical cannabis cohort self-reported improvements in their medical conditions. With the use of validated surveys, we found significant improvements in recurrent pain, PTSD, and sleep disorders after 6 weeks of medical cannabis treatment. Our findings from patients who reported arthritis and other rheumatic disorders are complex, showing improvements in pain and global activity sub-scores, but not overall changes in validated survey scores. We also report that patients who stated anxiety as their main medical condition did not experience significant changes in their anxiety after 6 weeks of cannabis treatment, though there were QOL improvements. While these results show that patients find cannabis treatment effective for a broad range of medical conditions, cannabis was not a remedy for all the conditions investigated. Thus, there is a need for future clinical research to support the findings we have reported. Additionally, while real-world evidence has not historically been utilized by regulatory bodies, we suggest changes in public policy surrounding cannabis should occur to reflect patient reported efficacy of cannabis from real-world studies due to the uniqueness of medical cannabis's path to legalization.

Experiences of Patients With Rheumatic Diseases in the United States During Early Days of the COVID-19 Pandemic

OBJECTIVE

Patients with rheumatic diseases such as rheumatoid arthritis (RA) and lupus have increased risk of infection and are treated with medications that may increase this risk yet are also hypothesized to help treat COVID-19. We set out to understand how the COVID-19 pandemic has impacted the lives of these patients in the United States.

METHODS

Participants in a US-wide longitudinal observational registry responded to a supplemental COVID-19 questionnaire by e-mail on March 25, 2020, about their symptoms, COVID-19 testing, health care changes, and related experiences during the prior 2 weeks. Analysis compared responses by diagnosis, disease activity, and new onset of symptoms. Qualitative analysis was conducted on optional free-text comment fields.

RESULTS

Of the 7061 participants invited to participate, 530 responded, with RA as the most frequent diagnosis (61%). Eleven participants met COVID-19 screening criteria, of whom two sought testing unsuccessfully. Six others sought testing, three of whom were successful, and all test results were negative. Not quite half of participants (42%) reported a change to their care in the prior 2 weeks. Qualitative analysis revealed four key themes: emotions in response to the pandemic, perceptions of risks from immunosuppressive medications, protective measures to reduce risk of COVID-19 infection, and disruptions in accessing rheumatic disease medications, including hydroxychloroquine.

CONCLUSION

After 2 weeks, many participants with rheumatic diseases already had important changes to their health care, with many altering medications without professional consultation or because of hydroxychloroquine shortage. As evidence accumulates on the effectiveness of potential COVID-19 treatments, effort is needed to safeguard access to established treatments for rheumatic diseases.

Rasch analysis suggests that health assessment questionnaire II is a generic measure of physical functioning for rheumatic diseases: a cross-sectional study

Background

Versions of the Health Assessment Questionnaire (HAQ) are commonly used to measure physical functioning across multiple rheumatic diseases but there has been no clear demonstration that any HAQ version is actually generic. This study aimed to show that the HAQ-II instrument is invariant across different rheumatic disease categories using the Rasch measurement model, which would confirm that the instrument is generic.

Methods

HAQ-II responses from 882 consecutive rheumatology clinic attendees were fitted to a Rasch model. Invariance across disease was assessed by analysis of variance of residuals implemented in RUMM2030. Rasch modeled HAQ-II scores across disease categories were compared and the mathematical relationship between raw HAQ-II scores and Rasch modeled scores was also determined.

Results

The HAQ-II responses fitted the Rasch model. There was no substantive evidence for lack of invariance by disease category except for a single item (“opening car doors”). Rasch modeled scores could be accurately obtained from raw scores with a cubic formula (R² 0.99). Patients with rheumatoid arthritis had more disability than patients with other kinds of inflammatory arthritis or autoimmune connective tissue disease.

Conclusions

The HAQ-II can be used across different rheumatic diseases and scores can be similarly interpreted from patients with different diseases. Transforming raw scores to Rasch modeled scores enable a strictly linear, interval scale to be used. It remains to be seen how that would affect interpretation of change scores.

Trial registration

ANZCTR ACTRN12617001500347. Registered 24th October 2017 (retrospectively registered).

Monitoring rheumatoid arthritis using an algorithm based on patient-reported outcome measures: a first step towards personalised healthcare

Objectives

The objective of this proof of concept study was to evaluate alerts generated by a patient-reported outcome measure (PROM)-based algorithm for monitoring patients with rheumatoid arthritis (RA).

Methods

The algorithm was constructed using an example PROM score of an equally weighted mean of visual analogue scale (VAS) general health, VAS disease activity and VAS pain. Based on the PROM score, red flags are generated in 2 instances: the target level of disease activity is not met; change in disease activity surpasses an early alert threshold. To reduce false alarms, 3 consecutive red flags are needed to trigger an alert to the physician. Time series data from patients included consecutively in the practice-based Nijmegen Early RA cohort were analysed to select an appropriate autoregressive integrated moving average (ARIMA) model. This allowed for advanced interpolation of PROM scores and weekly data evaluation. Alerts were evaluated against disease-modifying antirheumatic drug (DMARD)/biologic medication intensification registered in the cohort.

Results

Data of 165 patients followed in their second year postdiagnosis were analysed. In 89.8% of 716 visits, the algorithm did not generate an alert and medication was not escalated. Positive predictive value, sensitivity and specificity were 24.6%, 55.6% and 69.7%, respectively. Comparable performance was found when analyses were stratified for baseline Disease Activity Score 28-joint count (DAS₂₈) level.

Conclusions

When using the algorithm to screen scheduled visits, the overall chance of missing patients in need of medication intensification is low. These findings provide evidence that an off-site monitoring system could aid in optimising the number and timing of face-to-face consultations of patients with their rheumatologists.

Outcome assessments in rheumatoid arthritis

Increasing evidence suggests low disease activity or remission is achievable in rheumatoid arthritis (RA). Using a treat to target strategy (T2T) has been shown to achieve these targets of remission or low disease activity in RA. In order to successfully treat to target, rheumatologists need reliable measures of disease activity to switch and/or escalate therapy to achieve or maintain therapeutic targets. Multiple disease-activity measures have been developed for both research and clinical practice. For clinical practice, the American College of Rheumatology (ACR) has recommended the PAS, PAS II, RAPID 3, CDAI, DAS 28, and SDAI for measuring disease activity in rheumatoid arthritis. Each of these measures has strengths and limitations, but they all accurately reflect disease activity, discriminate well between disease states, and are feasible to perform in the clinical setting. Implementation in the clinical setting can be optimized through leveraging technology and systems redesign. Tools such as web-based and smartphone applications have been developed to increase the ease with which these measures can be deployed. Disease-activity measurement in rheumatoid arthritis is included in the rheumatoid arthritis quality measures group in the Centers for Medicare and Medicaid Services' incentive-based Physician Quality Reporting System.