The concept of psoriatic disease (PsD) derives from that of psoriatic arthritis (PsA), from which it evolved. The first step in this process was the concept of PsA; the second was the description of the wide clinical spe...The concept of psoriatic disease (PsD) derives from that of psoriatic arthritis (PsA), from which it evolved. The first step in this process was the concept of PsA; the second was the description of the wide clinical spectrum of PsA; and the third was the introduction of the new concept of PsD. This article describes this conceptual evolution and discusses emerging pathological implications deriving from it.
A series of reports is summarized in which measurement of quality of life (QOL) in various immune-mediated inflammatory diseases (IMID), the parameters that contribute to QOL, and the interrelationship between inflammato...A series of reports is summarized in which measurement of quality of life (QOL) in various immune-mediated inflammatory diseases (IMID), the parameters that contribute to QOL, and the interrelationship between inflammatory diseases in specific organ systems and psychosocial domains are explored. Current treatment trials in IMID include QOL measures, particularly clinical trials of biologic therapy. There is increasing evidence that several available therapies benefit QOL. Among the factors that contribute to QOL, fatigue, depression, and stress are common and deserve attention from clinicians managing these patients.
Chronic disabling conditions, such as immune-mediated inflammatory diseases (IMID), adversely affect patients in terms of physical suffering and pain, impaired function, and diminished quality of life. These persistent r...Chronic disabling conditions, such as immune-mediated inflammatory diseases (IMID), adversely affect patients in terms of physical suffering and pain, impaired function, and diminished quality of life. These persistent relapsing diseases have a significant influence on individual employment status and work-related productivity. In addition to the significant burden on patients and their families, IMID represent a sizable burden to society due to high healthcare and non-healthcare related costs. Non-healthcare related, or indirect, costs - primarily associated with decreased work productivity, disability payments, and early retirements - are typically greater contributors than direct healthcare costs to the total costs associated with IMID. This article discusses the socioeconomic impact of several IMID, including rheumatoid arthritis, inflammatory bowel disease, ankylosing spondylitis, and psoriasis.
Compelling evidence suggests that inflammation contributes to the development of depression. Many depressed individuals have higher levels of proinflammatory mediators, which appear to interact with many of the pathophys...Compelling evidence suggests that inflammation contributes to the development of depression. Many depressed individuals have higher levels of proinflammatory mediators, which appear to interact with many of the pathophysiological domains of depression, including neuroendocrine function, neurotransmitter metabolism, and synaptic plasticity. This is further supported by observation that therapeutic administration of interferon-α (IFN-α) leads to depression in a significant proportion of patients. These findings suggest that targeting proinflammatory cytokines and their signaling pathways may represent a unique therapeutic opportunity to treat depression and related conditions, such as labile anger, irritability, and fatigue.
Evidence that psychological stress can increase inflammation and worsen the course of immune-mediated inflammatory disease (IMID) is steadily accumulating. The majority of data supporting this hypothesis come from studie...Evidence that psychological stress can increase inflammation and worsen the course of immune-mediated inflammatory disease (IMID) is steadily accumulating. The majority of data supporting this hypothesis come from studies in patients with inflammatory bowel disease (IBD). While there is no evidence to suggest that stress is a primary cause of IBD, many, although not all, studies have found that patients with IBD experience increased stress and stressful life events before disease exacerbations. Further, the disease itself can cause psychological stress, creating a vicious cycle. In addition to reviewing the epidemiological evidence supporting a stress-IMID relationship, this article also briefly discusses how stress-related changes in neural, endocrine, and immune functioning may contribute to the pathogenesis of immune diseases, IBD in particular. The effects of different pharmacological and nonpharmacological interventions, including stress management and behavioral therapy, on stress, mood, quality of life (QOL), and activity of the underlying IMID are also summarized.
Fatigue, a systemic feeling of exhaustion, is a common symptom of many chronic illnesses, including immune-mediated inflammatory diseases (IMID). IMID-related fatigue is associated with disease activity and pain and has...Fatigue, a systemic feeling of exhaustion, is a common symptom of many chronic illnesses, including immune-mediated inflammatory diseases (IMID). IMID-related fatigue is associated with disease activity and pain and has detrimental effects on patient quality of life and overall well-being. Thus, routine assessment and management of fatigue in clinical practice is important. This article provides an overview of the prevalence, correlates, and predictors of fatigue in IMID. There is also discussion of the effects of different treatments on fatigue outcomes, as well as management recommendations.
There has been much speculation on the importance of emotional factors in patients with immune-mediated inflammatory disease (IMID); it is only in the past 10 years that well designed, large-cohort studies have been able...There has been much speculation on the importance of emotional factors in patients with immune-mediated inflammatory disease (IMID); it is only in the past 10 years that well designed, large-cohort studies have been able to clarify this relationship. This article provides an overview of evidence on the occurrence of depression and anxiety in IMID, and the role of these comorbidities as risk factors for onset of IMID, as well as the degree to which they affect the course of disease and treatment outcomes.
Uveitis, defined as an intraocular inflammatory disease, is one of the main causes of visual impairment in the working-age population. The condition often coexists with other immune-mediated inflammatory diseases (IMID)...Uveitis, defined as an intraocular inflammatory disease, is one of the main causes of visual impairment in the working-age population. The condition often coexists with other immune-mediated inflammatory diseases (IMID) and greatly contributes to reduced quality of life (QOL) in affected individuals. While visual acuity remains the most commonly used measure of visual function in patients with uveitis, the US National Eye Institute Visual Function Questionnaire is frequently used to assess their health-related QOL. However, despite intuition that coexisting uveitis might exaggerate already impaired QOL in patients with IMID, specific questions related to their visual functioning are rarely included in clinical trials or assessed in daily practice. We provide an overview of the occurrence and significance of uveitis in patients with IMID, its consequences, and the role of tumor necrosis factor-α inhibitors in overall treatment approaches.
It has been well established that children with a chronic disease, including those with inflammatory bowel disease (IBD) and juvenile idiopathic arthritis (JIA), report lower health-related quality of life (HRQOL) as com...It has been well established that children with a chronic disease, including those with inflammatory bowel disease (IBD) and juvenile idiopathic arthritis (JIA), report lower health-related quality of life (HRQOL) as compared to their healthy peers. Over the past 20 years there has been a significant emphasis on the development of measures of function and HRQOL for application in JIA and pediatric IBD. Several of the instruments currently used to assess HRQOL in children with immune-mediated inflammatory diseases (IMID), including the Juvenile Arthritis Quality of Life Questionnaire (JAQQ) and IMPACT questionnaire for pediatric IBD, were developed and validated by Canadian-based research teams. This review describes several disease-specific and generic instruments used to assess QOL in children with IBD or JIA. It also provides an overview of findings from several outcomes studies that applied the described tools in assessing HRQOL in children and adolescents with these conditions.
There is no doubt that patients with immune-mediated inflammatory diseases (IMID) have a significantly impaired quality of life (QOL). Pain and disability often leave these patients helpless and frustrated. The recogniti...There is no doubt that patients with immune-mediated inflammatory diseases (IMID) have a significantly impaired quality of life (QOL). Pain and disability often leave these patients helpless and frustrated. The recognition that addressing physical and psychological functioning plays a significant role in an overall treatment approach led to the inclusion of QOL measures as secondary outcomes in clinical trials with IMID patients. To that end, both generic and disease-specific instruments have been utilized. Measurement of health-related QOL (HRQOL) and patient-reported outcomes (PRO) in a controlled manner allows for better understanding of the correlation between different aspects of disease activity and QOL. In addition, the effects of different therapeutic options on HRQOL-related outcomes can be further evaluated. This 3-part section describes key QOL-related complaints of patients with IMID affecting joints, skin, or gut. An overview of the strengths and weaknesses of various commonly used HRQOL instruments is provided. Finally, the influence of anti-tumor necrosis factor-α agents on HRQOL outcomes, as assessed in recent clinical trials, is highlighted.
Health-related quality of life (HRQOL) is an important measure of a patient's perception of his/her illness. Over the past 3 decades, numerous instruments have been developed to measure HRQOL in various patient populatio...Health-related quality of life (HRQOL) is an important measure of a patient's perception of his/her illness. Over the past 3 decades, numerous instruments have been developed to measure HRQOL in various patient populations, with 2 basic approaches: generic and disease-specific. While generic measures have broad application across different types and severity of diseases, disease-specific measures are designed to assess particular diseases or patient populations. All HRQOL instruments, however, must be valid and have high reliability and responsiveness. Validity ensures that the instrument measures what it is supposed to measure. Reliable instruments are able to reproducibly differentiate between subjects. Responsive evaluative measures are able to detect important changes in HRQOL during a period of time, even if those changes are small. HRQOL measures should also be interpretable, meaning that the differences in scores that correspond to small, moderate, and large HRQOL changes are easily identifiable. This article describes the steps in the development of HRQOL instruments from the conceptual framework to creation and testing. Several examples of generic and disease-specific instruments commonly used to evaluate HRQOL in patients with immune-mediated inflammatory diseases (IMID) are provided.
OBJECTIVE: To develop an algorithm for identification of undifferentiated peripheral inflammatory arthritis (UPIA). METHODS: An algorithm for identification of UPIA was developed by consensus during a roundtable meeting...OBJECTIVE: To develop an algorithm for identification of undifferentiated peripheral inflammatory arthritis (UPIA). METHODS: An algorithm for identification of UPIA was developed by consensus during a roundtable meeting with an expert panel. It was informed by systematic reviews of the literature used to generate 10 recommendations for the investigation and followup of UPIA through the 3e initiative. The final recommendations from the 3e UPIA Initiative were made available to the panel to guide development of the algorithm. The algorithm drew on the clinical experience of the consensus panel and evidence from the literature where available. RESULTS: In patients presenting with joint swelling a thorough evaluation is required prior to diagnosing UPIA. After excluding trauma, the differential diagnosis should be formulated based on history and physical examination. A minimum set of investigations is suggested for all patients, with additional ones dependent on the most probable differential diagnoses. The diagnosis of UPIA can be made if, following these evaluations, a more specific diagnosis is not reached. Once a diagnosis of UPIA is established, patients should be closely followed as they may progress to a specific diagnosis, remit, or persist as UPIA, and additional investigations may be required over time. CONCLUSION: Our algorithm presents a diagnostic approach to identifying UPIA in patients presenting with joint swelling, incorporating the dynamic nature of the condition with the potential to evolve over time.
OBJECTIVE: To critically appraise the validity of activity indices used in the followup of patients with undifferentiated peripheral inflammatory arthritis (UPIA). METHODS: A systematic review was performed in Medline, E...OBJECTIVE: To critically appraise the validity of activity indices used in the followup of patients with undifferentiated peripheral inflammatory arthritis (UPIA). METHODS: A systematic review was performed in Medline, Embase, the Cochrane Library, and abstracts presented at the 2007 and 2008 meetings of the American College of Rheumatology and European League Against Rheumatism. Selection criteria were: patients with UPIA, the assessment of instruments to evaluate disease activity, and assessment of validity of the instruments. Two reviewers screened titles and abstracts independently and collected data using ad hoc standard forms. RESULTS: The search yielded 179 articles and 834 abstracts, of which 4 articles and 1 abstract were included. We found no study that validated Disease Activity Score (DAS), Clinical Disease Activity Index (CDAI), or Simplified Disease Activity Index (SDAI). Included studies addressed validation of 4 questionnaires: WHO Disability Assessment Schedule (WHODAS), London Handicap Scale (LHS), Disease Repercussion Profile (DRP), and the Health Assessment Questionnaire (HAQ); and 3 indexes: RA Disease Activity Index (RADAI), McGill Range of Motion Index (McROMI), and NOAR Damaged Joint Count (NOAR-DJC). Questionnaires were self-administered and feasible; RADAI was the most feasible index. Internal consistency was studied in the questionnaires (Cronbach's α > 0.83). Responsiveness was tested in the DRP, LHS, and HAQ, but the approach to study sensitivity to change was poorly explained, with no clear intervention. Construct validity, examined by means of convergence with other instruments, was generally moderate, and slightly higher for the RADAI. CONCLUSION: No instrument of disease activity has been fully validated for use in UPIA. We found no direct evidence of what is the most useful index to follow up patients with UPIA.
OBJECTIVE: Our aim was to systematically review the literature on the diagnostic and prognostic value of synovial biopsy in undifferentiated peripheral inflammatory arthritis (UPIA) as an evidence base for generating cli...OBJECTIVE: Our aim was to systematically review the literature on the diagnostic and prognostic value of synovial biopsy in undifferentiated peripheral inflammatory arthritis (UPIA) as an evidence base for generating clinical practice recommendations. The results lead to multinational recommendations in the 3e Initiative in Rheumatology. METHODS: We performed a systematic literature review according to the PICO strategy (Patients, Intervention, Comparator, and Outcome). Using a designed search strategy we ran literature searches using Medline, Embase, the Cochrane Library, and abstracts presented at the 2007 and 2008 meetings of the American College of Rheumatology and European League Against Rheumatism. Articles fulfilling predefined inclusion criteria were reviewed, and quality appraisal was performed. RESULTS: Six publications from a total of 3265 diagnostic and 3271 prognostic studies were included, of which 2 were review articles. Data pooling was impossible because of significant clinical and statistical heterogeneity. Three themes of outcome were identified: anti-citrullinated peptide antibody (ACPA) staining in synovium, immunohistochemistry (CD22, CD38, CD68), and vascular patterns. Prognostic and diagnostic value was poor for these themes, although diagnostic trends favoring a particular diagnosis were identified. In contrast to serological ACPA testing, ACPA staining was shown not to be specific for diagnosis of rheumatoid arthritis (RA). Synovial CD22 and CD38 positivity seem to differentiate between RA and non-RA, while synovial CD38 and CD68 positivity can differentiate among RA, spondyloarthritis (SpA), and other diagnoses. Vascular patterns in undifferentiated arthritis are insufficiently specific to differentiate between SpA and RA. CONCLUSION: There is sparse evidence that synovial biopsy has diagnostic or prognostic value in patients with UPIA in clinical care. We urgently need systematic studies investigating the diagnostic and prognostic potential of synovial markers. A clear, broadly accepted, and unequivocal definition of undifferentiated arthritis is required as a starting point.
OBJECTIVE: To evaluate the diagnostic and prognostic utility of genetic testing in undifferentiated peripheral inflammatory arthritis (UPIA). METHODS: A systematic literature search was performed in Medline, Embase, the...OBJECTIVE: To evaluate the diagnostic and prognostic utility of genetic testing in undifferentiated peripheral inflammatory arthritis (UPIA). METHODS: A systematic literature search was performed in Medline, Embase, the Cochrane Library, and abstracts presented at the 2007 and 2008 meetings of the American College of Rheumatology and the European League Against Rheumatism. The target studies were those evaluating diagnostic or prognostic value of genetic markers specifically in UPIA. Two reviewers independently screened titles and abstracts and reviewed included articles in detail. All data were collected using ad hoc standard forms, permitting the calculation of positive and negative likelihood ratios of each genetic marker for diagnoses of different rheumatic diseases and for the development of relevant outcomes. RESULTS: Of the 3109 articles retrieved, 26 original studies fulfilled criteria of the systematic review. The most frequent diagnosis tested was rheumatoid arthritis, followed by inflammatory polyarthritis, and spondyloarthropathies. The main prognostic outcome evaluated was development of erosions, followed by median Larsen score, remission, Health Assessment Questionnaire (HAQ) score, and persistent synovitis. In total, 122 genetic markers were tested. No genetic marker had a high likelihood ratio for the diagnosis of a specific rheumatic disease. The shared epitope was associated with poor prognosis (erosions, HAQ > 1, mortality, and persistent synovitis). Other genes did not predict outcome in undifferentiated arthritis. Other outcomes for persistent disease or disability were not studied in depth. CONCLUSION: In isolation, no studied genetic marker is very informative of a future diagnosis in patients with UPIA. The shared epitope has a slight association with poor prognosis of UPIA.
OBJECTIVE: To perform a systematic literature review of the diagnostic and prognostic value of magnetic resonance imaging (MRI) and ultrasound (US) in patients with undifferentiated peripheral inflammatory arthritis (UPI...OBJECTIVE: To perform a systematic literature review of the diagnostic and prognostic value of magnetic resonance imaging (MRI) and ultrasound (US) in patients with undifferentiated peripheral inflammatory arthritis (UPIA), and to assess if MRI and US should be done at baseline and repeated, and if so, at what interval. METHODS: Medline, Embase, the Cochrane Library, and abstracts presented at the 2007 and 2008 meetings of the American College of Rheumatology and European League Against Rheumatism meetings were searched for diagnostic and prognostic studies of any duration examining the ability of MRI/US to predict outcome of patients with UPIA. Sensitivity, specificity, predictive values, and positive/negative likelihood ratios (LR+/LR-) were calculated. When available, odds ratios were extracted. Quality was appraised using validated scales. RESULTS: Regarding MRI, 11 out of 2595 screened references were included: 2 described pure undifferentiated arthritis (UA) populations and 9, mixed populations. Bone edema (LR+ 4.5) and combination of a distinct MRI synovitis and erosion pattern (LR+ 4.8) increased probability of developing rheumatoid arthritis (RA). Absence of MRI synovitis (LR- 0.2) and absence of a distinct synovitis pattern (LR- 0) decreased probability of developing RA. Regarding US, 2 out of 2111 references were included, both mixed populations; no data could be extrapolated for UPIA. CONCLUSION: MRI bone edema and combined synovitis and erosion pattern seem useful in predicting development of RA from UPIA. The value of US in UPIA remains to be determined. The absence of MRI synovitis seems useful in excluding development of RA. No data were found about the value of repeating MRI/US. Studies evaluating MRI/US in UPIA are scarce, but current knowledge strongly encourages further testing in UA.
OBJECTIVE: To perform a systematic literature review on the diagnostic and predictive value of conventional radiographs (CR) in patients with undifferentiated arthritis (UA). METHODS: We performed an extended search usin...OBJECTIVE: To perform a systematic literature review on the diagnostic and predictive value of conventional radiographs (CR) in patients with undifferentiated arthritis (UA). METHODS: We performed an extended search using Medline, Embase, the Cochrane Library, and abstracts from the 2007 and 2008 meetings of the American College of Rheumatology and the European League Against Rheumatism. Articles were included based on predefined inclusion criteria, and quality was assessed by using validated quality scales. RESULTS: In total, 25 articles were included from 6003 retrieved references. Five articles described a pure UA population, 20 articles described a mixed population [mostly rheumatoid arthritis (RA) and UA]. In studies on UA, erosions on CR were strong predictors of RA diagnosis [positive likelihood ratio (LR+) 3.5-10.9; odds ratio 7.6 and 8.7). In a more heterogeneous mixed population, 20 studies reporting on 11 cohorts found a relationship between CR findings and subsequent diagnosis of RA. LR+ for erosions and/or bony decalcifications ranged from 1.8 to 9.7, and there was greater prevalence of erosions and higher Sharp-van der Heijde score in the RA group at followup. With regard to prognosis in both UA and mixed populations, an association was found between number of abnormalities on CR and poor outcome. CONCLUSION: Several studies, in pure UA and mixed populations, clearly demonstrate that CR are helpful in predicting future diagnosis of RA or worse prognosis. However, absence of abnormalities on CR does not sufficiently exclude RA or other unfavorable outcome.
OBJECTIVE: When patients present with undifferentiated peripheral inflammatory arthritis (UPIA), early diagnosis and evaluation of prognostic factors are decisive steps for therapeutic success. We reviewed published evid...OBJECTIVE: When patients present with undifferentiated peripheral inflammatory arthritis (UPIA), early diagnosis and evaluation of prognostic factors are decisive steps for therapeutic success. We reviewed published evidence on the diagnostic and prognostic performance of autoantibodies and soluble biomarkers in UPIA. METHODS: We conducted a systematic literature search covering studies published until January 2009. Additionally, we screened conference abstracts presented at European League Against Rheumatism and American College of Rheumatology meetings in 2007 and 2008. RESULTS: We included 52 full-text articles and 12 abstracts. The association of anti-cyclic citrullinated peptide antibody (anti-CCP) and rheumatoid factor (RF) with diagnosis of rheumatoid arthritis at followup is compelling, supported by positive likelihood ratios (LR+) ranging between 1.2 and 20.5 for anti-CCP and 1.1 to 13.5 for RF. The same applies to radiographic outcome. For antikeratin antibodies (AKA) and antiperinuclear factor, existing evidence suggests diagnostic usefulness; AKA also showed prognostic value. Diagnostic and prognostic evidence for other autoantibodies and for bone and cartilage biomarkers was scarce, negative, or controversial. CONCLUSION: Among serological tests, unanimous evidence of substantial diagnostic value exists only for anti-CCP and RF, but is scarce for other markers.