Best Pract Res Clin Rheumatol
· 2014 Apr · PMID 24974066
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Measurement of health outcomes in pediatric rheumatic diseases is a critical component of clinical practice and research studies. Measures should include the biological, physical, and psychosocial dimensions of health. H...Measurement of health outcomes in pediatric rheumatic diseases is a critical component of clinical practice and research studies. Measures should include the biological, physical, and psychosocial dimensions of health. Health outcome measures are developed systematically, often using consensus methods. Prior to implementation into practice, health outcome measures must undergo evaluation of measurement properties such as reliability, validity, and responsiveness. There are several health outcome measures available for juvenile idiopathic arthritis, juvenile systemic lupus erythematosus, and juvenile dermatomyositis, many of which are composite measures of disease activity. In addition, tools exist for measuring physical functioning and health-related quality of life. There is increasing focus on the incorporation of patient-reported or parent-reported outcomes when measuring the health state of patients with pediatric rheumatic diseases. Further work is required to determine the optimal health outcome measures and approach for eliciting the patient's perception of their health state in pediatric rheumatology.
Anxiety and depression are common among patients with rheumatic diseases. This study aims to explore which factors are associated with self-reported anxiety and depression in a well-defined cohort of spondyloarthritis (S...Anxiety and depression are common among patients with rheumatic diseases. This study aims to explore which factors are associated with self-reported anxiety and depression in a well-defined cohort of spondyloarthritis (SpA) patients. In 2009, 3,711 patients from the SpAScania cohort were sent a postal questionnaire to assess health-related quality of life (HRQoL) and physical and mental functioning. The Hospital Anxiety and Depression Scale measured anxiety (HADS-A) and depression (HADS-D), subscales 0-21, best-worst. HADS ≥8 indicates possible cases of anxiety or depression. One-way ANOVA (p < 0.05) tested for differences among the SpA subtypes in HADS scores. Linear regression analysis adjusted for age, gender, and disease duration was used to test for associations between HADS and independent variables. In total, 2,167 (58 %) patients (52 % females, mean age 55.4 years) returned the questionnaire. In total, 683 (32 %) cases were classified as "possible anxiety" and 305 (14 %) as "possible depression" cases with mean (SD) HADS-A 5.9 (4.3) and HADS-D 4.4 (3.6). There were no differences among the SpA subtypes in HADS-A and HADS-D. HADS-A and HADS-D were associated with lower education, lower physical activity (HADS-D only), chronic pain problems, more fatigue, lower general health, lower HRQoL, lower level of functioning, higher disease activity, and lower self-efficacy. Associations with anxiety and/or depression appear multifactorial in patients with SpA including both personal and disease-related factors. Since these comorbidities are increased in SpA and treatable, they should be screened for in clinical practice, possibly with instruments like the HADS.
Clin Rheumatol
· 2014 Jun · PMID 24810702
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The American College of Rheumatology, the Spondyloarthritis Research and Treatment Network, and the Spondylitis Association of America have begun collaborating on a project to develop treatment guidelines for axial spond...The American College of Rheumatology, the Spondyloarthritis Research and Treatment Network, and the Spondylitis Association of America have begun collaborating on a project to develop treatment guidelines for axial spondyloarthritis. The project will use the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method, which is based on systematic literature reviews and quantitative evidence summaries, to develop treatment recommendations for the use of pharmacological interventions, rehabilitation, surgery, preventive care, and disease monitoring in patients with ankylosing spondylitis and axial spondyloarthritis.
Best Pract Res Clin Rheumatol
· 2014 Feb · PMID 24792950
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Osteoarthritis (OA) is one of the 10 most disabling diseases in developed countries and worldwide estimates are that 10% of men and 18% of women aged over 60 years have symptomatic OA, including moderate and severe forms...Osteoarthritis (OA) is one of the 10 most disabling diseases in developed countries and worldwide estimates are that 10% of men and 18% of women aged over 60 years have symptomatic OA, including moderate and severe forms. Total joint replacement (TJR) is considered the most effective treatment for end-stage OA in those who have exhausted available conservative interventions. The demand for TJR is continually rising due to the ageing population; in the United States, more than 1 million TJRs were performed in 2010 and the number of procedures is projected to exceed 4 million in the US by 2030. It has been estimated that of all hip and knee replacements performed, approximately one quarter of the patients may be considered inappropriate candidates. Predicting who will benefit from TJR and who will not would seem critical in terms of containing the current and projected expenditure as well as improving satisfaction in TJR recipients. Few formal predictive tools are available to aid referring clinicians to determine those likely to be good or poor responders to surgery and current available tools tend to focus on disease severity alone with little consideration of risk factors that may predict a poor outcome or impede an effective response to surgery. This review examines the tools available to assist with assessing appropriateness for TJR; investigates the modifiable risk factors associated with poor outcome; and identifies areas for future research in selecting those appropriate for joint replacement.
Best Pract Res Clin Rheumatol
· 2014 Feb · PMID 24792949
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Technological advances throughout the 20th century enabled an increase in arthroscopic knee surgery, particularly arthroscopic debridement for osteoarthritis (OA) and arthroscopic partial meniscectomy for symptomatic men...Technological advances throughout the 20th century enabled an increase in arthroscopic knee surgery, particularly arthroscopic debridement for osteoarthritis (OA) and arthroscopic partial meniscectomy for symptomatic meniscal tear in the setting of OA. However, evaluation of the outcomes of these procedures lagged behind their rising popularity. Not until the early 2000s were rigorous outcomes studies conducted; these showed that arthroscopic debridement for OA was no better than a sham procedure in relieving knee pain or improving functional status, and that patients who underwent arthroscopic partial meniscectomy for a degenerative meniscal tear generally did not show more improvement than those who underwent sham meniscal resection or an intensive course of physical therapy. Though the number of arthroscopic knee procedures for OA performed each year has begun to decline, there remains a significant gap between the evidence and actual practice. Further investigation is needed to shore up the evidence base and bring policy and practice in line with rigorous research.
Roemer FW, Eckstein F, Hayashi D
… +1 more, Guermazi A
Best Pract Res Clin Rheumatol
· 2014 Feb · PMID 24792944
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Osteoarthritis (OA) is the most prevalent joint disorder with no approved disease-modifying treatment available. The importance of imaging in assessing all joint structures involved in the disease process, including arti...Osteoarthritis (OA) is the most prevalent joint disorder with no approved disease-modifying treatment available. The importance of imaging in assessing all joint structures involved in the disease process, including articular cartilage, meniscus, subarticular bone marrow, and synovium for diagnosis, prognostication, and follow-up, has been well recognized. In daily clinical practice, conventional radiography is still the most commonly used imaging technique for the evaluation of a patient with known or suspected OA and radiographic outcome measures are still the only approved end point by regulatory authorities in clinical trials. The ability of magnetic resonance imaging (MRI) to visualize all joint structures in three-dimensional fashion including tissue ultrastructure has markedly deepened our understanding of the natural history of the disease. This article describes the roles and limitations of different imaging modalities for clinical practice and research in OA, with a focus on radiography and MRI and an emphasis on the knee joint.
BACKGROUND: Recently, many countries, including Canada, evaluated rheumatologists' acceptance and agreement with a set of 10 Treat to Target (T2T) recommendations for rheumatoid arthritis (RA), developed by an internatio...BACKGROUND: Recently, many countries, including Canada, evaluated rheumatologists' acceptance and agreement with a set of 10 Treat to Target (T2T) recommendations for rheumatoid arthritis (RA), developed by an international task force. In this study, the Canadian T2T steering committee evaluated how Canadian patients with RA perceive these recommendations. OBJECTIVES: The objectives of this study were to assess the current state of RA management in Canada from a patient perspective and to assess whether and to what extent Canadians with RA agree with each of the 10 T2T recommendations and to compare the results with a previous survey completed by physicians. METHODS: Participating rheumatologists were asked to invite consecutive RA patients to complete a 20-question survey. The survey was designed to assess relevant sociodemographic variables, the current treatment, and the approach to RA management as seen from the patient's perspective, as well as their agreement with the T2T recommendations. RESULTS: A total of 959 patients (77% were female) were recruited by 22 participating rheumatologists from 6 Canadian provinces. Patients had a mean age of 59.1 years and mean disease duration of 12.9 years. Approximately 72% of patients were on methotrexate (76.1% combination therapy), and 36.7% were treated with biologics (6.4% monotherapy, 30.3% combination therapy). The agreement with T2T recommendations ranged from 8.6 for recommendation 4 (frequency of adjustment of drug therapy) to 9.5 for recommendation 8 (maintenance of treatment targets). These results are comparable to a previous physicians' survey except that there was more acceptance on the part of patients for more frequent visits (recommendation 5; patient agreement score was 9.06 vs physician agreement score of 6.92) and evaluations for adjustments of therapy (recommendation 6 patient agreement score was 9.39 vs physician agreement score of 7.49) to achieve the stated goal. CONCLUSIONS: The results of this survey showed that Canadian patients are being treated for their RA according to the published treatment recommendations with combination disease-modifying antirheumatic drugs and biologics and a small percentage with oral corticosteroids. The majority of patients seems to be satisfied with their management and is in agreement with the T2T recommendations, although they tended to place greater emphasis than did physicians on flexibility of visit frequency and detailed assessments.
Best Pract Res Clin Rheumatol
· 2013 Oct · PMID 24315150
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Low back pain is a challenge for clinicians and researchers, due to the large variability in clinical presentation, lack of consensus regarding diagnostic criteria or clinical classification; wide variation in course and...Low back pain is a challenge for clinicians and researchers, due to the large variability in clinical presentation, lack of consensus regarding diagnostic criteria or clinical classification; wide variation in course and prognosis, and limited success in identifying effective treatments. However, increasing research efforts has generated an expanding body of evidence on the epidemiology, prognosis and treatment of back pain. This paper presents four key developments in research and clinical practice, and describes how these can influence the future direction of back pain research: (1) the increasing awareness of the impact of low back pain on population health; (2) new approaches to describing and investigating course and prognosis of back pain; (3) the need to better understand the bio-psycho-social mechanisms or pathways that explain impact and long-term outcomes in order to inform intervention research; and (4) the potential for stratified models of care to improve patient outcomes and efficiency of care for back pain.
Foster NE, Hill JC, O'Sullivan P
… +1 more, Hancock M
Best Pract Res Clin Rheumatol
· 2013 Oct · PMID 24315146
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Stratified care for back pain involves targeting treatment to subgroups of patients based on their key characteristics such as prognostic factors, likely response to treatment and underlying mechanisms. It aims to tailor...Stratified care for back pain involves targeting treatment to subgroups of patients based on their key characteristics such as prognostic factors, likely response to treatment and underlying mechanisms. It aims to tailor therapeutic decisions in ways that maximise treatment benefit, reduce harm and increase health-care efficiency by offering the right treatment to the right patient at the right time. From being called the 'Holy Grail' of back pain research over a decade ago, stratified care is becoming the zeitgeist in research and clinical practice. In this chapter, we introduce and evaluate the quality and underpinning evidence for three examples of stratified care for back pain to highlight their general principles, research design issues and clinical practice implications. We include consideration of their merits for implementation in practice. We conclude with a set of remaining, key research questions.
Best Pract Res Clin Rheumatol
· 2013 Oct · PMID 24315144
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A large body of evidence suggests that psychological factors, including emotions, beliefs and avoidant behaviours, are linked to poor outcomes in low back pain. At the same time, the evidence from trials of psychological...A large body of evidence suggests that psychological factors, including emotions, beliefs and avoidant behaviours, are linked to poor outcomes in low back pain. At the same time, the evidence from trials of psychological interventions suggests that they improve outcomes mostly in the short term and against passive controls only. These suboptimal results may be due to low competency or fidelity in delivery, or inadequate matching of treatment methods with specific patient problems. Most importantly, there is insufficient theoretical guidance and integration in the design, selection and delivery of methods that precisely target known process of pathology. We identify several new directions for research and opportunities to improve the impact of psychological interventions and to change clinical practice. These include better ways to conceptualise and deliver reassurance at early stages of back pain, utilising models such as the psychological flexibility model to guide treatment development, and essentially extend the fear-avoidance model.
Best Pract Res Clin Rheumatol
· 2013 Aug · PMID 24315053
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The use of biological disease-modifying antirheumatic drugs (bDMARDs) has changed the face of rheumatoid arthritis (RA). Achieving remission, normal function and prevention of joint damage are now possible for many patie...The use of biological disease-modifying antirheumatic drugs (bDMARDs) has changed the face of rheumatoid arthritis (RA). Achieving remission, normal function and prevention of joint damage are now possible for many patients with RA. In clinical practice, however, particularly with cost considerations, bDMARDs are usually prescribed after failure of one or more conventional synthetic DMARDs. With evidence that early treatment has a greater impact than later on, the question regarding initial bDMARD therapy and their potential role within a window of opportunity to influence disease outcomes remain. The increasing emphasis on early diagnosis and research into the preclinical phase of the disease also heralds the question, 'Can bDMARDs prevent the development of RA?' The aim of this review is to review randomised controlled trials with bDMARDs as initial therapy in early RA and to discuss their role in early disease.
Magro Checa C, Cohen D, Bollen EL
… +3 more, van Buchem MA, Huizinga TW, Steup-Beekman GM
Best Pract Res Clin Rheumatol
· 2013 Jun · PMID 24238696
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Among the 12 systemic lupus erythematosus (SLE)-related central nervous system (CNS) syndromes defined by the American College of Rheumatology (ACR), demyelinating syndrome and myelopathy are two of the less prevalent an...Among the 12 systemic lupus erythematosus (SLE)-related central nervous system (CNS) syndromes defined by the American College of Rheumatology (ACR), demyelinating syndrome and myelopathy are two of the less prevalent and more poorly understood ones. One important issue concerning demyelinating disease in SLE is that it can be easily misdiagnosed with other central nervous system demyelinating disorders such as multiple sclerosis (MS). A clinically isolated neurological syndrome can be the presenting feature before other concomitant symptoms of SLE appear or definite MS is diagnosed. Although challenging, some diagnostic tests used in clinical practice and research may help to differentiate between these entities. These tests have improved the understanding of the pathogenesis in these diseases, but some points, such as the role of antiphospholipid antibodies in SLE-associated transverse myelitis, remain unclear and are a matter of ongoing debate. This review discusses clinical, pathophysiological, radiological and therapeutic concepts of demyelinating disease of the CNS in SLE, focussing on its differentiation from MS and its relation with other CNS demyelinating processes, such as transverse myelitis, optic neuritis and neuromyelitis optica.
BACKGROUND: Knee arthrocentesis is a commonly performed diagnostic and therapeutic procedure in rheumatology and orthopedic surgery. Classic teaching of arthrocentesis skills relies on hands-on practice under supervision...BACKGROUND: Knee arthrocentesis is a commonly performed diagnostic and therapeutic procedure in rheumatology and orthopedic surgery. Classic teaching of arthrocentesis skills relies on hands-on practice under supervision. Video-based online teaching is an increasingly utilized educational tool in higher and clinical education. YouTube is a popular video-sharing Web site that can be accessed as a teaching source. OBJECTIVE: The objective of this study was to assess the educational value of YouTube videos on knee arthrocentesis posted by health professionals and institutions during the period from 2008 to 2012. METHODS: The YouTube video database was systematically searched using 5 search terms related to knee arthrocentesis. Two independent clinical reviewers assessed videos for procedural technique and educational value using a 5-point global score, ranging from 1 = poor quality to 5 = excellent educational quality. As validated international guidelines are lacking, we used the guidelines of the Swiss Society of Rheumatology as criterion standard for the procedure. RESULTS: Of more than thousand findings, 13 videos met the inclusion criteria. Of those, 2 contained additional animated video material: one was purely animated, and one was a check list. The average length was 3.31 ± 2.28 minutes. The most popular video had 1388 hits per month. Our mean global score for educational value was 3.1 ± 1.0. Eight videos (62 %) were considered useful for teaching purposes. Use of a "no-touch" procedure, meaning that once disinfected the skin remains untouched before needle penetration, was present in all videos. Six videos (46%) demonstrated full sterile conditions. There was no clear preference of a medial (n = 8) versus lateral (n = 5) approach. CONCLUSIONS: A discreet number of YouTube videos on knee arthrocentesis appeared to be suitable for application in a Web-based format for medical students, fellows, and residents. The low-average mean global score for overall educational value suggests an improvement of future video-based instructional materials on YouTube would be necessary before regular use for teaching could be recommended.
Best Pract Res Clin Rheumatol
· 2013 Apr · PMID 23731937
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All medical practice and research must be evidence-based, as far as this is possible. With medical knowledge constantly growing, it has become necessary to possess a high level of information literacy to stay competent a...All medical practice and research must be evidence-based, as far as this is possible. With medical knowledge constantly growing, it has become necessary to possess a high level of information literacy to stay competent and professional. Furthermore, as patients can now search information on the Internet, clinicians must be able to respond to this type of information in a professional way, when needed. Here, the development of viable systematic search strategies for journal articles, books, book chapters and other sources, selection of appropriate databases, search tools and selection methods are described and illustrated with examples from rheumatology. The up-keep of skills over time, and the acquisition of localised information sources, are discussed.
El Zorkany B, Alwahshi HA, Hammoudeh M
… +24 more, Al Emadi S, Benitha R, Al Awadhi A, Bouajina E, Laatar A, El Badawy S, Al Badi M, Al-Maini M, Al Saleh J, Alswailem R, Ally MM, Batha W, Djoudi H, El Garf A, El Hadidi K, El Marzouqi M, Hadidi M, Maharaj AB, Masri AF, Mofti A, Nahar I, Pettipher CA, Spargo CE, Emery P
Although the prevalence of RA in the Middle East and Africa is comparable with that in other parts of the world, evidence indicates that its management in this region is suboptimal for a variety of reasons, including mis...Although the prevalence of RA in the Middle East and Africa is comparable with that in other parts of the world, evidence indicates that its management in this region is suboptimal for a variety of reasons, including misconceptions and misunderstandings about the disease's prevalence and severity in the region, compounded by the lack of local epidemiological and health-economic data around the disease; the perception that RA is a low priority compared with other more prevalent conditions; delayed diagnosis, referral and treatment; and a lack of a region-specific, evidence-based management approach. In the absence of such an approach, the EULAR treatment recommendations may provide a useful starting point for the creation of guidelines to suit local circumstances. However, although agreement with the EULAR recommendations is high, many barriers prevent their implementation in clinical practise, including lack of timely referral to rheumatologists; suboptimal use of synthetic DMARDs; poor access to biologics; lack of awareness of the burden of RA among healthcare professionals, patients and payers; and lack of appropriate staffing levels.To optimise the management of RA in the Middle East and Africa, will require a multi-pronged approach from a diverse group of stakeholders-including local, national and regional societies, such as the African League of Associations in Rheumatology and International League of Associations for Rheumatology, and service providers-to collect data on the epidemiology and burden of the disease; to increase awareness of RA and its burden among healthcare professionals, payers and patients through various educational programmes; to encourage early referral and optimise use of DMARDs by promoting the EULAR treatment recommendations; to encourage the development of locally applicable guidelines based on the EULAR treatment recommendations; and to facilitate access to drugs and the healthcare professionals who can prescribe and monitor them.
Best Pract Res Clin Rheumatol
· 2012 Dec · PMID 23273790
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The recently developed Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial and peripheral spondyloarthritis (SpA) are the first criteria ever to include findings on magnetic res...The recently developed Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial and peripheral spondyloarthritis (SpA) are the first criteria ever to include findings on magnetic resonance imaging (MRI) of the sacroiliac joints. Features indicating sacroiliac joint inflammation on MRI are weighted equally to structural changes on conventional radiography, and thus MRI has become an important tool for use in daily practice to evaluate patients with clinically suspected early spondyloarthritis. However, MRI can also detect structural changes such as erosions and fat infiltrations, and recent studies suggest that assessment of both inflammatory and structural changes of the sacroiliac joints may improve the diagnostic utility of MRI. The present article reviews the evidence for the use of sacroiliac joint and spinal MRI to assess patients with axial and peripheral SpA, focussing on controlled studies of patients with early SpA, which also included patients with mechanical back pain and healthy subjects, published within the last 5 years.
OBJECTIVE: To determine incidence of increased levels of alanine transferase (ALT) >2× upper limit of normal (ULN) in patients receiving methotrexate (MTX), treated according to a dynamic strategy, and to identify predic...OBJECTIVE: To determine incidence of increased levels of alanine transferase (ALT) >2× upper limit of normal (ULN) in patients receiving methotrexate (MTX), treated according to a dynamic strategy, and to identify predictors of ALT of >2× ULN. METHODS: Data of 508 recent-onset rheumatoid arthritis (RA) patients from the BeSt study, randomized to initial monotherapy or combination therapy, were used. Treatment was dynamic, aiming at a disease activity score = ≤ 2.4. ALT was measured every three months. With logistic regression analyses, baseline variables predictive of first ALT of >2× ULN were identified and the association between use of concomitant antirheumatic drugs, the actual and cumulative dose of MTX and ALT of >2× ULN was determined. RESULTS: In total, 498 patients ever initiated MTX, with a total duration on MTX of 1,416 patient-years. In 89 patients, a first incidence of ALT of >2× ULN occurred. Incidence rate was 6.3 per 100 patient-years and cumulative incidence 18 %. ACPA positivity and baseline ALT of >1× ULN were independent predictors of later ALT of >2× ULN (OR 1.8 (95 % CI, 1.1-3.1) and OR 3.1 (95 % CI, 1.6-6.2), respectively). Smoking showed a trend (OR 1.6 (95 % CI, 0.98-2.7)). Mean MTX dosage over time was higher in patients with an ALT of >2× ULN. Patients who did not have an ALT of >2× ULN used more concomitant disease-modifying antirheumatic drugs and longer. CONCLUSIONS: In RA patients treated with MTX according to a dynamic strategy resembling daily clinical practice, incidence of increased ALT of >2× ULN was lower than previously reported, and also without treatment adjustments, persistence was rare. The recommendations for ALT monitoring may be reevaluated.