Cumulative patient-based disease activity monitoring in rheumatoid arthritis - predicts sustained remission, flare and treatment escalation

OBJECTIVE

Patient-based Disease Activity Score 2 (PDAS2) had been developed for RA patients to self-assess and record disease activity in between clinic visits. This study explored the clinical utility of time-integrated cumulative PDAS2 (cPDAS2) on predicting sustained remission or low disease activity state (LDAS), flare and treatment escalation.

METHODS

We recruited 100 patients to record PDAS2 at home fortnightly between two consecutive clinic visits. Rheumatologists adjusted treatment according to disease activity recorded during clinic consultation while blinded to home PDAS2 scores. cPDAS2 calculated from the area-under-curve of all PDAS2 scores were compared with disease activities at both visits. cPDAS2 and ΔcPDAS2 (change from PDAS2 at the first visit) were tested to determine their ability to predict ACR/EULAR remission, SDAI flare-up (from remission/LDAS to moderate/high disease activity) and treatment escalation. Optimal cut-points were determined by Receiver Operator Characteristic curve.

RESULTS

Mean age of the patients was 59 years, mean RA duration 14 years, 90% were female, 71% seropositive and 64% in remission/LDAS. The home PDAS2 completion rate was 92%. PDAS2 scores were done 7.5 times every 15 days over a 16-week follow-up (all medians). The sensitivity of cPDAS2 in predicting Boolean/SDAI remission at two visits, DAS28, SDAI and CDAI remission or LDAS were 93%, 84%, 73% and 80% respectively. cPDAS2 ≥ 0.29 predicted flare (P = 0.04), with specificity 79% and negative predicting value (NPV) 88%. Rheumatologists' decision to escalate treatment was predicted by (cPDAS2 ≥ 4.33 and ΔcPDAS2 ≥ 0.059) (P = 0.007) with specificity 88% and NPV 89%, and (cPDAS2 ≥ 4.33 or ΔcPDAS2 ≥ 0.059) (P = 0.02) with both sensitivity and NPV 100%.

CONCLUSION

PDAS2 monitoring at home is feasible. cPDAS2 is useful to predict flare and treatment escalation.

The Forkhead box transcription factor FOXM1 is required for the maintenance of cell proliferation and protection against oxidative stress in human embryonic stem cells

Human embryonic stem cells (hESCs) exhibit unique cell cycle structure, self-renewal and pluripotency. The Forkhead box transcription factor M1 (FOXM1) is critically required for the maintenance of pluripotency in mouse embryonic stem cells and mouse embryonal carcinoma cells, but its role in hESCs remains unclear. Here, we show that FOXM1 expression was enriched in undifferentiated hESCs and was regulated in a cell cycle-dependent manner with peak levels detected at the G2/M phase. Expression of FOXM1 did not correlate with OCT4 and NANOG during in vitro differentiation of hESCs. Importantly, knockdown of FOXM1 expression led to aberrant cell cycle distribution with impairment in mitotic progression but showed no profound effect on the undifferentiated state. Interestingly, FOXM1 depletion sensitized hESCs to oxidative stress. Moreover, genome-wide analysis of FOXM1 targets by ChIP-seq identified genes important for M phase including CCNB1 and CDK1, which were subsequently confirmed by ChIP and RNA interference analyses. Further peak set comparison against a differentiating hESC line and a cancer cell line revealed a substantial difference in the genomic binding profile of FOXM1 in hESCs. Taken together, our findings provide the first evidence to support FOXM1 as an important regulator of cell cycle progression and defense against oxidative stress in hESCs.

Tight control early rheumatoid arthritis clinic in Hong Kong: a pilot study

OBJECTIVE

To evaluate disease activity in early rheumatoid arthritis patients in daily practice 1 year after applying a tight control treatment strategy aimed at lowering disease activity (Disease Activity Score 28, ≤ 3.2).

DESIGN

Single-arm open trial with historical controls.

SETTING

Regional hospital, Hong Kong.

PATIENTS

All new rheumatoid arthritis patients (onset < 2 years) attending the tight control clinic from October 2008 to October 2009 were recruited. All the patients were followed up every 3 to 6 weeks and clinically assessed using the Disease Activity Score 28. Disease-modifying agent treatment was stepped up according to a preset protocol ladder and patient tolerance. The treatment target was to achieve a Disease Activity Score 28 of 3.2 or below (low disease activity). These patients were compared to matched historical controls in the rheumatology clinic.

RESULTS

Twenty patients in the tight control early rheumatoid arthritis clinic were recruited. Their disease activities were brought into better control than historical control patients who were followed up every 12 weeks. At week 52, clinical variables showed greater improvements in the intensive care group; respective mean scores (based on the Disease Activity Score 28 system) were 2.7 versus 4.2 (P<0.001); respective mean Health Assessment Questionnaire scores were 0.2 versus 1.3 (P<0.001).

CONCLUSION

Outcomes of patients attending our locally adapted tight control clinic were consistent with previous reports in the literature. The clinic reduced rheumatoid arthritis activity faster and better. It entailed more frequent follow-up and monitoring, however. To address this strategy more objectively, a randomised trial with parallel controls is necessary.

Can commonly-used fan-driven air cleaning technologies improve indoor air quality? A literature review

Air cleaning techniques have been applied worldwide with the goal of improving indoor air quality. The effectiveness of applying these techniques varies widely, and pollutant removal efficiency is usually determined in controlled laboratory environments which may not be realized in practice. Some air cleaners are largely ineffective, and some produce harmful by-products. To summarize what is known regarding the effectiveness of fan-driven air cleaning technologies, a state-of-the-art review of the scientific literature was undertaken by a multidisciplinary panel of experts from Europe, North America, and Asia with expertise in air cleaning, aerosol science, medicine, chemistry and ventilation. The effects on health were not examined. Over 26,000 articles were identified in major literature databases; 400 were selected as being relevant based on their titles and abstracts by the first two authors, who further reduced the number of articles to 160 based on the full texts. These articles were reviewed by the panel using predefined inclusion criteria during their first meeting. Additions were also made by the panel. Of these, 133 articles were finally selected for detailed review. Each article was assessed independently by two members of the panel and then judged by the entire panel during a consensus meeting. During this process 59 articles were deemed conclusive and their results were used for final reporting at their second meeting. The conclusions are that: (1) None of the reviewed technologies was able to effectively remove all indoor pollutants and many were found to generate undesirable by-products during operation. (2) Particle filtration and sorption of gaseous pollutants were among the most effective air cleaning technologies, but there is insufficient information regarding long-term performance and proper maintenance. (3) The existing data make it difficult to extract information such as Clean Air Delivery Rate (CADR), which represents a common benchmark for comparing the performance of different air cleaning technologies. (4) To compare and select suitable indoor air cleaning devices, a labeling system accounting for characteristics such as CADR, energy consumption, volume, harmful by-products, and life span is necessary. For that purpose, a standard test room and condition should be built and studied. (5) Although there is evidence that some air cleaning technologies improve indoor air quality, further research is needed before any of them can be confidently recommended for use in indoor environments.