Disease Classification Criteria Research Articles

Prevalence of pulmonary artery hypertension in patients of chronic obstructive pulmonary disease and its correlation with stages of chronic obstructive pulmonary disease, exercising capacity, and quality of life

Background:Pulmonary arterial hypertension (PAH) is a complication of chronic obstructive pulmonary disease (COPD) in advance stages, and its presence indicates poor prognosis.Aims and Objective:The present study was design to know the prevalence of PAH in patients with COPD and its correlation with stages of COPD, exercising capacity, and quality of life.Materials and Methods:It is a cross-sectional prevalence study over a period of 1 year from August 2015 to July 2016. The study included 109 COPD patients, diagnosed by spirometry, and severity was determined according Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification criteria. Screening two-dimensional echocardiography was done to determine pulmonary arterial hypertension and exercising capacity assessed by 6 min walk test (6MWT) while the quality of life was assessed by St George respiratory Questionnaire for COPD (SGRQ-C) Questionnaires.Results:Out of 109 patients, PAH was present in 68 (62.4%) cases consisting of mild grade 41 (37.6%), moderate grade 11 (10.1%), and severe grade 16 (14.7%). In GOLD A stage, there were 20 cases of mild PAH and Stage B included 18 cases of mild and 3 cases of moderate PAH. Stage C had 3 cases of mild and 8 cases of moderate PAH while Stage D had 16 cases of severe PAH. In 6MWT, patients with severe grade PAH fail to perform the test while patients with mild to moderate PAH walked short distance. In SGRQ-C Questionnaires symptom, activity, impact, and total score were high with the severity of PAH.Conclusion:The prevalence of PAH in COPD was significant. Therefore, every COPD patient should be evaluated for PAH.

Prevalence of thyroid dysfunction in chronic obstructive pulmonary disease patients in a tertiary care center in North India.

Introduction:Thyroid dysfunction can cause inspiratory and expiratory muscle weakness in patients with or without chronic obstructive pulmonary disease (COPD) Thyroid dysfunction in COPD results in increased frequency of exacerbation thus lead to poor quality of life. It may further increase cardiovascular disease risk thereby increasing mortality.Aims and Objectives:This study was conducted to evaluate the prevalence of thyroid dysfunction and hence that the quality of life of COPD can be improvedMaterials and Methods:This is a cross-sectional – prevalence study. The study was conducted over a period of 1 year from August 2015 to July 2016. The study group was consists of male and female COPD patients diagnosed with spirometry and severity was determined according to the global initiative for chronic obstructive lung disease classification criteria. The patients were enrolled in this study from medicine outpatient department (OPD), respiratory OPD and those admitted to indoor wards of Medicine Department. Patients were screened for thyroid dysfunction.Results:Out of 171 patients, thyroid dysfunction was present in 43 patients. All of them were hypothyroid. The prevalence of thyroid dysfunction was 25%. In Stage A it was 20.5%, Stage B 25.7%, Stage C 23.4%, and in Stage D 30.4%. Thyroid dysfunction was associated with more frequent exacerbation.Conclusion:Thyroid dysfunction is a common extrapulmonary manifestation in COPD patients. It is associated with frequent exacerbations which affect the quality of life in these patients. Early detection and proper management can improve the quality of life in these patients.

Urinary biomarkers may provide prognostic information for subclinical acute kidney injury after cardiac surgery

ObjectiveThis study aimed to determine the biomarker-specific outcome patterns and short-and long-term prognosis of cardiac surgery–asoociated acute kidney injury (AKI) identified by standard criteria and/or urinary kidney biomarkers. MethodsPatients enrolled (N = 200), originated a German multicenter study (NCT00672334). Standard risk injury, failure, loss, and end-stage renal disease classification (RIFLE) criteria (including serum creatinine and urine output) and urinary kidney biomarker test result (neutrophil gelatinase-associated lipocalin, midkine, interleukin 6, and proteinuria) were used for diagnosis of postoperative AKI. Primary end point was acute renal replacement therapy or in-hospital mortality. Long-term end points among others included 5-year mortality. Patients with single-biomarker-positive subclinical AKI (RIFLE negative) were identified. We controlled for systemic inflammation using C-reactive protein test. ResultsUrinary biomarkers (neutrophil gelatinase-associated lipocalin, midkine, and interleukin 6) were identified as independent predictors of the primary end point. Neutrophil gelatinase-associated lipocalin, midkine, or interleukin 6 positivity or de novo/worsening proteinuria identified 21.1%, 16.9%, 30.5%, and 48.0% more cases, respectively, with likely subclinical AKI (biomarker positive/RIFLE negative) additionally to cases with RIFLE positivity alone. Patients with likely subclinical AKI (neutrophil gelatinase-associated lipocalin or interleukin 6 positive) had increased risk of primary end point (adjusted hazard ratio, 7.18; 95% confidence interval, 1.52-33.93 [P = .013] and hazard ratio, 6.27; 95% confidence interval, 1.12-35.21 [P = .037]), respectively. Compared with biomarker-negative/RIFLE-positive patients, neutrophil gelatinase-associated lipocalin positive/RIFLE-positive or midkine-positive/RIFLE-positive patients had increased risk of primary end point (odds ratio, 9.6; 95% confidence interval, 1.4-67.3 [P = .033] and odds ratio, 14.7; 95% confidence interval, 2.0-109.2 [P = .011], respectively). Three percent to 11% of patients appear to be influenced by single-biomarker-positive subclinical AKI. During follow-up, kidney biomarker-defined short-term outcomes appeared to translate into long-term outcomes. ConclusionsUrinary kidney biomarkers identified RIFLE-negative patients with high-risk subclinical AKI as well as a higher risk subgroup of patients among RIFLE-AKI-positive patients. These findings support the concept that urinary biomarkers define subclinical AKI and higher risk subpopulations with worse long-term prognosis among standard patients with AKI.

(A Critical Appraisal of) Classification of Hypereosinophilic Disorders.

Hypereosinophilia (HE) is a heterogeneous condition that can be reported in various (namely inflammatory, allergic, infectious, or neoplastic) diseases with distinct pathophysiological pathways. In 1975, Chusid et al. published the first diagnostic criteria of hypereosinophilic syndromes (HES). Over the years, as both basic and clinical knowledge improved, several updates have been suggested, with a focus on better distinguishing isolated or asymptomatic eosinophilia from diseases with specific eosinophil-related organ damage. Moreover, underlying molecular and cellular mechanisms of eosinophilia gradually became the cornerstone of successive attempts to classify HE-related diseases. In 2011, the International Cooperative Working Group on Eosinophil Disorders criteria emerged from a multidisciplinary Working Conference on Eosinophil Disorders and Syndromes, and provided substantial contribution to the clarification of general concepts and definitions in the field of HE. Yet, owing to the low prevalence of HE/HES, to the numerous diseases encompassed in the spectrum of HE-related disorders (with sometimes overlapping phenotypes), many questions are left unanswered (e.g., the need to better standardize the use of modern molecular tools, or the clinical relevance of distinguishing different subtypes of idiopathic HES). Here, we review the current state of knowledge in the fields of classification and diagnosis criteria of HE-related diseases, with emphasis on the analysis of both strengths and weaknesses of present concepts and their usefulness in daily practice.

Dietary and Nondietary Triggers of Oral Ulcer Recurrences in Behçet's Disease.

The nature and impact of food and other external triggers in recurrences of Behçet's disease (BD)-related oral ulcers (OUs) remain unknown. This survey investigated dietary and nondietary triggers of BD-related OU recurrences. Patients with BD who were followed in 7 French hospital departments completed a self-administered patient questionnaire. General and specific dietary triggering factors were sought in open questions. The questionnaire also included closed questions, notably to evaluate the effect of 6 general triggering situations and 24 selected foods. The results were expressed as number (percentage) of positive responses. Among the 101 questionnaires distributed, 81 were usable. Among the 81 patients, 96% fulfilled the International Criteria for Behçet's Disease classification criteria, and 53% qualified their OU recurrences during the previous 12 months as very discomforting or discomforting. For the 6 general situations suggested, 50 patients (62%) declared ≥1 as a "sure" trigger of OU recurrences. In both open and closed questions, the most frequent triggers were fatigue/stress (37-47% of patients) and food (32-35%). Among the 24 suggested foods, nuts (48%), pineapple (42%), peanuts (32%), Emmental cheese (30%), almonds (23%), lemons (22%), and other cheeses (21%) were the most frequently reported. The corresponding open question gave consistent findings but with lower frequencies. Most patients can identify triggers of recurring BD-related OUs, with fatigue/stress and food representing the most frequent triggers. The management of OU must consider such external factors. The histamine-rich or -liberating properties of the commonly cited OU-triggering foods suggest a hyperreactivity mechanism.

Juvenile Idiopathic Arthritis in Adults: Long-Term Observation of Ukrainian Patients

The assessment of long-term outcome of functional disability and disease activeness in adult patients with juvenile idiopathic arthritis appears to be complicated due to the absence of a unified approach to the classification and estimation of disease activeness, as well as the loss of supervision over a patient because of remission or his/her transition from pediatric to adult rheumatic service. The objective of the research was to determine how adults with the history of juvenile idiopathic arthritis fulfill the classification criteria for adult rheumatic diseases, as well as to assess activeness of these diseases, the degree of functional disorders, and social activeness of patients in Ukraine. Materials and methods. Patients with juvenile idiopathic arthritis older than 18 years and with more than 3 years of disease duration living in different parts of Ukraine were included into the study. Data regarding sociodemographic features, fulfillment of adult classification criteria, Health Assessment Questionnaire, articular and extra-articular Juvenile Arthritis Damage Index and disease activity were analyzed.Results. We observed 122 adult patients with the history of juvenile idiopathic arthritis irrespective of the presence of active inflammation at the moment of the examination. This group included patients from different regions of Ukraine diagnosed with juvenile idiopathic arthritis during 1984-2013. An adult rheumatologist examined all patients and the diagnosis was revised according to the adult classification of rheumatic diseases. Typical diagnostic criteria for rheumatoid arthritis were estimated in 32.8% of patients, ankylosing spondylitis – in 31.1% of patients, undifferentiated arthritis – in 13.9% of patients, Still’s disease – in 4.9% of patients, psoriatic arthritis – in 0.8% of patients, steady clinical laboratory remission – in 16.5% of patients. Most patients (81.8%) with rheumatoid factor positive polyarticular juvenile idiopathic arthritis fell under rheumatoid arthritis criteria in adulthood, and in 85% of patients with enthesitis-related arthritis as well as 53.8% of patients with extended oligoarthritis ankylosing spondylitis developed in adulthood. 68.8% of patients with systemic juvenile idiopathic arthritis, 68% of patients with rheumatoid factor negative polyarthritic subtype and 55% of patients with enthesitis-related arthritis had disability and incapacitation. Minimal disorders of the patients’ general condition according to the Health Assessment Questionnaire in adult age were found in most subtypes of juvenile idiopathic arthritis classified according to the International League of Associations for Rheumatology (extended and persistent oligoarthritis, rheumatoid factor positive polyarthritis, systemic subtype); moderate disorders of the general condition were found in enthesitis-related arthritis and rheumatoid factor negative polyarthritis. Side effects of juvenile idiopathic arthritis according to the articular Juvenile Arthritis Damage Index included severe articular damage being most frequently found in systemic and rheumatoid factor positive polyarthritis subtypes of juvenile idiopathic arthritis, while side effects of juvenile idiopathic arthritis according to the extra-articular Juvenile Arthritis Damage Index included extra-articular damage being found in systemic and rheumatoid factor negative polyarthritis subtypes of juvenile idiopathic arthritis, that was confirmed by the assessment of physical health according to the Short Form Health Survey-36, which was the worst in patients with systemic (40.3±12.6) and rheumatoid factor negative polyarthritis (38.9±9.4) subtypes of juvenile idiopathic arthritis.Conclusions. Further research of remote consequences of juvenile idiopathic arthritis in adult age and long-term observation of such patients require a detailed study to improve diagnostics and provide adequate treatment of rheumatic diseases with juvenile onset in adult age.

Phase 1b/3 study of avelumab-based combination regimens in patients with relapsed or refractory diffuse large B-cell lymphoma (R/R DLBCL).

TPS7575 Background: Approximately 50% of patients (pts) with advanced DLBCL are refractory to or relapse following first line R-CHOP therapy. Pts with R/R DLBCL have limited treatment options and a poor prognosis. This study assesses immunotherapy-based regimens containing avelumab (a fully human IgG1 anti–PD-L1 antibody) in combination with utomilumab (a novel 4-1BB agonist), azacitidine, rituximab, and/or conventional chemotherapy (CT; bendamustine) in pts with R/R DLBCL. Methods: JAVELIN DLBCL (NCT02951156) is a global, multicenter, randomized, open-label, 2-component(phase 1b followed by phase 3) study of avelumab-based combination regimens in R/R DLBCL. In phase 1b, up to 84 pts will be randomized 1:1:1 to receive avelumab/rituximab/utomilumab, or avelumab/azacitidine/utomilumab, or avelumab/rituximab/bendamustine. The primary phase 1b objectives are preliminary assessments of dose-limiting toxicities (n = 6 per arm) and efficacy (objective response [OR]; n = 28 per arm). One regimen from phase 1b will be selected for phase 3 evaluation in 220 additional pts randomized 1:1 to the chosen regimen or investigator’s choice CT (rituximab/bendamustine or rituximab/gemcitabine/oxaliplatin). The primary phase 3 objective is to demonstrate progression-free survival (PFS) superiority of the avelumab-based regimen over CT. Overall survival is a key secondary endpoint. Eligible pts have completed up to 4 lines of prior rituximab/multiagent CT, and/or have failed autologous stem cell transplantation (ASCT), or are not eligible for intensive CT or ASCT. Other eligibility criteria include ECOG PS ≤1 and no prior therapy with a checkpoint inhibitor. Treatment with avelumab, utomilumab, and azacitidine will be continued until the pt no longer receives clinical benefit; rituximab and bendamustine are limited to 8 and 6 cycles, respectively. OR and PFS will be assessed per Lugano disease classification criteria. Other secondary efficacy endpoints include disease control, duration of response, time to response, and minimal residual disease burden. Safety, PK, immunogenicity, pt-reported outcomes, and biomarkers will also be evaluated. Clinical trial information: NCT02951156.

Vascular Dementia.

(Reprinted with permission from Lancet 2015; 386:1698-706).

Systematic Literature Review of the Global Incidence and Prevalence of Myelodysplastic Syndrome and Acute Myeloid Leukemia

Introduction: Acute myeloid leukemia (AML) consists of a group of relatively well-defined hematopoietic neoplasms, while myelodysplastic syndrome (MDS) comprises a heterogeneous group of hematopoietic stem cell disorders. These disorders may occur de novo or may arise secondary to prior malignancies for which patients received cytotoxic chemotherapy and/or radiation therapy. While AML and MDS are reported in a number of national cancer registries, competing classifications prior to 2001 often preclude comparison of results globally. We conducted a systematic literature review in order to identify global rates of the incidence and prevalence of AML and MDS.Methods: We searched Embase and MEDLINE for published studies and recent conference abstracts on the incidence and/or prevalence of AML and MDS for data collected from 2001-2016. This time period parallels the introduction of the World Health Organization (WHO) classification of hematopoietic neoplasms. Two reviewers independently screened all abstracts and selected articles, and subsequently abstracted multiple data elements including: AML or MDS, geographic region, standardized incidence and/or prevalence rates, years of data collection, disease classification criteria (e.g. WHO, French American British (FAB), ICD-O-3, ICD-9/10), if condition was diagnosed de novo or treatment associated, age category, and gender. Incidence rates and prevalence by sub-disease classification were also abstracted when available.Results: Literature Review: Our search strategy yielded 874 abstracts initially reviewed for applicability. Of these, 84 were selected for article screening; 44 articles were excluded after screening and 40 articles proceeded to data abstraction and were included in analyses. 25 studies reported on MDS incidence and 2 on MDS prevalence; 17 studies reported on AML incidence and 4 on AML prevalence (some studies report both AML and MDS and incidence and prevalence). While the majority of studies are based on existing regional disease registries, a number describe analyses based on administrative claims data, or patient charts. Nine (9) studies reported on therapy associated incidence. Classification of AML or MDS was based on FAB (9 studies), WHO (10 studies), ICD-O-3 (11 studies) or ICD-9/10 (7 studies) criteria. Three studies were classified on the basis of chart review and/or clinical diagnosis by a physician. Regional distribution was: North America (10 studies), Europe (17 studies), Australia (4 studies), and the Rest of World (including 3 studies in Asia, 2 studies in Africa, 2 in South America and 2 in the Middle East).Analysis: Incidence rates are reported in Figure 1 by region for those studies reporting overall rates across clinical factors, age and gender (27 articles). Incidence of AML as a result of treatment for another cancer ranged from 0.06-2.6 per 100,000 and for MDS from 0.06-0.26 per 100,000. In general, incidence rates increased with increasing age in studies that reported results by age group. Prevalence of AML ranged from 0.6-11.0 per 100,000 and for MDS ranged from 0.22-13.2 per 100,000 for all age categories, genders and ethnicities.Discussion:This is the first study to report on the global incidence of AML and MDS and whether or not the disease occurs as a result of treatment for another oncologic condition or occurs de novo. Variation in study designs and heterogeneous population characteristics make interpretation of results challenging. [Display omitted] DisclosuresLubeck:Outcomes Insights: Employment. Danese:Outcomes Insights: Employment. Jennifer:Outcomes Insights: Employment. Miller:Outcomes Insights: Consultancy. Richhariya:Seattle Genetics, Inc.: Employment. Garfin:Seattle Genetics, Inc.: Employment.

Differentiating clinical care from disease prevention: a prerequisite for practicing quaternary prevention

This article contends that the distinction between clinical care (illness) and prevention of future disease is essential to the practice of quaternary prevention. The authors argue that the ongoing entanglement of clinical care and prevention transforms healthy into "sick" people through changes in disease classification criteria and/or cut-off points for defining high-risk states. This diverts health care resources away from those in need of care and increases the risk of iatrogenic harm in healthy people. The distinction in focus is based on: (a) management of uncertainty (more flexible when caring for ill persons); (b) guarantee of benefit (required only in prevention); (c) harm tolerance (nil or minimal in prevention). This implies attitudinal differences in the decision-making process: greater skepticism, scientism and resistance towards preventive action. These should be based on high-quality scientific evidence of end-outcomes that displays a net positive harm/benefit ratio.

Epidemiology of Mixed Connective Tissue Disease, 1985-2014: A Population-Based Study.

To characterize the epidemiology of mixed connective tissue disease (MCTD) from 1983 to 2014. An inception cohort of patients with incident MCTD in 1985-2014 in Olmsted County, Minnesota was identified based on comprehensive individual medical record review. Diagnosis of MCTD required fulfillment of at least 1 of the 4 widely accepted diagnostic criteria without fulfillment of classification criteria for other connective tissue diseases. Data were collected on demographic characteristics, clinical presentation, laboratory investigations, and mortality. A total of 50 incident cases of MCTD were identified (mean age 48.1 years and 84% were female). The annual incidence of MCTD was 1.9 per 100,000 population. Raynaud's phenomenon was the most common initial symptoms (50%), followed by arthralgia (30%) and swollen hands (16%). The diagnosis was frequently delayed with the median time from first symptom to fulfillment of criteria of 3.6 years. At fulfillment of criteria, arthralgia was the most prevalent manifestation (86%), followed by Raynaud's phenomenon (80%), swollen hands (64%), leukopenia/lymphopenia (44%), and heartburn (38%). Evolution to other connective tissue occurred infrequently with a 10-year rate of evolution of 8.5% and 6.3% for systemic lupus erythematosus and systemic sclerosis, respectively. The overall mortality was not different from the general population with a standardized mortality ratio of 1.1 (95% confidence interval 0.4-2.6). This study was the first population-based study of MCTD to provide a complete picture of epidemiology and clinical characteristics of MCTD. MCTD occurred in about 2 persons per 100,000 per year. Evolution to other connective diseases occurred infrequently and the mortality was not affected.

Juvenile idiopathic arthritis in adulthood: fulfilment of classification criteria for adult rheumatic diseases, long-term outcomes and predictors of inactive disease, functional status and damage

ObjectivesTo determine how adult juvenile idiopathic arthritis (JIA) patients fulfil classification criteria for adult rheumatic diseases, evaluate their outcomes and determine clinical predictors of inactive disease, functional status and damage.MethodsPatients...

Immunsystem und rheumatische Erkrankungen im Alter

Impairments of the immune system play an important role in all immun-mediated rheumatic diseases. Recently, the following news were reported: · Early aging of the immune system with thymus insufficiency has now been reported for both patients with rheumatoid arthritis and axial spondyloarthritis, without prethymic lack of progenitors at least in rheumatoid arthritis.. · For giant cell arteritis, the most frequent vasculitis in the elderly, an increased expression of IL-17A in temporal artery biopsies coincides with good prognosis and reponse to glucocorticoids.. · Concerning immunosenescence in systemic lupus erythematosus, BAFF appears to have an important role for relapses after B-cell depletion.. For the future it can be anticipated that the use of unified classification criteria for rheumatic diseases (as with the new 2012 EULAR / ACR classification criteria for polymyalgia rheumatica) will ensure better comparability of immunological studies also in the elderly.

Incidence, Outcomes, and Risk Factors of Community-Acquired and Hospital-Acquired Acute Kidney Injury: A Retrospective Cohort Study.

The disease burden and outcomes of community-acquired (CA-) and hospital-acquired acute kidney injury (HA-AKI) are not well understood. The aim of the study was to investigate the incidence, outcomes, and risk factors of AKI in a large Taiwanese adult cohort.This retrospective cohort study examined 734,340 hospital admissions from a group of hospitals within an organization in Taiwan between January 1, 2010 and December 31, 2014. Patients with AKI at discharge were classified as either CA- or HA-AKI based on the RIFLE (risk, injury, failure, loss of function, end stage of kidney disease) classification criteria. Outcomes were in-hospital mortality, dialysis, recovery of renal function, and length of stay. Risks of developing AKI were determined using multivariate logistic regression based on demographic and baseline clinical characteristics and nephrotoxin use before admission.AKI occurred in 1.68% to 2% hospital discharges among adults without and with preexisting chronic kidney disease (CKD), respectively. The incidence of CA-AKI was 17.25 and HA-AKI was 8.14 per 1000 admissions. The annual rate of CA-AKI increased from 12.43 to 19.96 per 1000 people, but the change in HA-AKI was insignificant. Comparing to CA-AKI, those with HA-AKI had higher levels of in-hospital mortality (26.07% vs 51.58%), mean length of stay (21.25 ± 22.35 vs 35.84 ± 34.62 days), and dialysis during hospitalization (1.45% vs 2.06%). Preexisting systemic diseases, including CKD were associated with increased risks of CA-AKI, and nephrotoxic polypharmacy increased risk of both CA- and HA-AKI.Patients with HA-AKI had more severe outcomes than patients with CA-AKI, and demonstrated different spectrum of risk factors. Although patients with CA-AKI with better outcomes, the incidence increased over time. It is also clear that optimal preventive and management strategies of HA- and CA-AKI are urgently needed to limit the risks in susceptible individuals.

DISEASE COURSE IN EARLY RHEUMATOID ARTHRITIS: AN OBSERVATIONAL STUDY

Background. In rheumatoid arthritis (RA), prompt diagnosis and initiation of disease-modifying treatment during the first months after disease onset – a period called “window of opportunity” – is significantly superior to the delayed start of the same therapy. Clinical remission is more frequently obtained in patients with a disease duration no longer than 4 months and is the main aim of the treatment, therefore the “treat to target” (T2T) and “tight control” strategies were proposed. Objective. The aim of this study is to evaluate the therapy used for patients with early RA (ERA) and the impact of this medication on the clinical outcomes at 12 months after the first evaluation. Methods. Patients with early arthritis who were referred to the Early Arthritis Research Center of Dr. I. Cantacuzino Hospital between 2010-2014 and who fulfilled the 2010 EULAR/ACR Classification Criteria for RA (and who did not satisfy classification criteria for other inflammatory rheumatologic diseases) were enrolled. Only patients who received treatment with Methotrexate (MTX) associated or not with corticosteroids (CS) and patients who fulfilled the classification criteria for RA but did not received any DMARDs therapy were enrolled. Results. Forty-three patients were enrolled in the study, 62.8% females, mean age 55.47±13.71 years, median (interquartile range) DAS28 5.07 (4.31-5.60), SDAI 29.02 (20.92-34.61). At the first presentation, 40 patients (93.0%) received treatment with Methotrexate (MTX) in doses ranging from 5 mg/week to 20 mg/week, with a mean dose of 11.16±4.47 mg/week, the most frequently used doses ranging from 10 mg/week to 15 mg/week. 26 patients (60.5%) received corticosteroids (CS), either oral or intra-articular. During the study both the total number of patients receiving MTX and the mean dose of MTX increased, while the number of patients receiving CS decreased and at the end of the study only low-dose oral CS were still administered in 8 patients. At 12 months, median (interquartile range) DAS 28 was 1.77 (1.43-3.16), SDAI 3.58 (2.32-11.82). The evolution under treatment assessed by DAS28 and SDAI wasn’t significantly different between patients who received, at baseline, MTX in association with CS (mean value: ΔDAS28=-2.58±1.72, ΔSDAI=-20.44±16.49) and those who received MTX monotherapy (mean value: ΔDAS28=-2.91±1.17, ΔSDAI=-21.80±9.89) (p>0.05). There was no significant difference in change from baseline of DAS28 and SDAI at 12 months between patients who received low-dose oral CS and those who received intermittent intra-articular CS (p>0.05). Conclusions. Treatment with MTX and/or CS led to clinical and laboratory improved outcomes at 12 months of follow-up. There was no significant difference regarding long-term outcomes between patients who received low dose oral CS and those who received intra-articular CS. As this study was performed on a relatively small number of real-life patients with ERA, the results obtained should be validated on larger cohorts of patients.

Connective tissue disease-related pulmonary arterial hypertension.

Over the past two decades, there have been several advances in the assessment and management of connective tissue disease-related pulmonary arterial hypertension (CTD-PAH) that improved outcomes of the treatment of this lethal disease, and this will be the focus of this study. Systemic sclerosis is the leading cause of CTD-PAH, followed by systemic lupus erythematosus, mixed connective tissue disease, idiopathic inflammatory myositis, rheumatoid arthritis, and Sjogren's syndrome. Clinical registries have been invaluable in informing about the burden of disease, risk and prognostic factors, and temporal trends with respect to treatment and outcome in CTD-PAH. The major advances have centered on improved disease classification and diagnostic criteria, screening and early diagnosis, the emergence of evidence-based therapies including combination goal-orientated treatment strategies, and the establishment of centers with expertise in PAH.

Recommendations of the ESSR Arthritis Subcommittee for the Use of Magnetic Resonance Imaging in Musculoskeletal Rheumatic Diseases.

This article presents the recommendations of the European Society of Musculoskeletal Radiology Arthritis Subcommittee regarding the standards of the use of MRI in the diagnosis of musculoskeletal rheumatic diseases. The recommendations discuss (1) the role of MRI in current classification criteria of musculoskeletal rheumatic diseases (including early diagnosis of inflammation, disease follow-up, and identification of disease complications); (2) the impact of MRI on the diagnosis of axial and peripheral spondyloarthritis, rheumatoid arthritis, and juvenile spondyloarthritis; (3) MRI protocols for the axial and peripheral joints; (4) MRI interpretation and reporting for axial and peripheral joints; and finally, (5) methods for assessing MR images including quantitative, semiquantitative, and dynamic contrast-enhanced MRI studies.

Diagnosis and risk stratification in patients with anti-RNP autoimmunity.

Anti-RNP autoantibodies occur either in mixed connective tissue disease (MCTD) (with a frequently favorable prognosis), or in systemic lupus erythematosus (SLE) cases with aggressive major organ disease. It is uncertain how to assess for the risk of severe disease in anti-RNP + patients. Following institutional review board-approved protocols, clinical data and blood were collected from patients with known or suspected anti-RNP autoimmunity and normal controls in a cohort study. Samples were screened for parameters of immune activation. Groups were compared based on clinical diagnoses, disease classification criteria, disease activity and specific end-organ clinical manifestations. Ninety-seven per cent of patients satisfying Alarcon-Segovia MCTD criteria also met Systemic Lupus International Collaborating Clinic (SLICC) SLE criteria, while 47% of the anti-RNP + SLE patients also met MCTD criteria. Among SLICC SLE patients, MCTD criteria were associated with reduced rates of renal disease (odds ratio (OR) 4.3, 95% confidence interval (CI) 1.3-14.0), increased rates of Raynaud's phenomenon (OR 3.5, 95% CI 1.3-9.5) and increased serum B-cell maturation antigen, transmembrane activator and CAML interactor and TNFα levels. Circulating immune markers and markers of type I interferon activation were not effective at distinguishing clinical subgroups. Among anti-RNP patients, the question of MCTD versus SLE is not either/or: most MCTD patients also have lupus. MCTD classification criteria (but not a broad set of immune markers) distinguish a subset of SLE patients at reduced risk for renal disease.

Is ultrasound changing the way we understand rheumatology? Including ultrasound examination in the classification criteria of polymyalgia rheumatica and gout.

Ultrasonography (US) is widely used in the diagnosis of rheumatic conditions, and its value for the classification criteria of rheumatic diseases has been recently suggested. According to the EULAR/ACR provisional criteria for polymyalgia rheumatica, adding US to the clinical and serological features will significantly improve the sensitivity of proposed criteria. The ability of high resolution US to detect crystalline deposits of monosodium urate in joints and soft tissues is well recognized. For the first time, the new 2014 ACR/EULAR set of proposed criteria for gout includes advanced imaging techniques for the detection of disease: US and dual-energy computed tomography. Due to low costs and affordability, use of US evaluation for patients with suspected gout will increase both specificity and sensibility of classification criteria. The recent inclusion of US in the classification criteria of various rheumatic diseases, such as PMR and gout, implies that this imaging technique is not only useful as a valued diagnostic tool for individual cases, but also on a larger scale, it will improve doctors' ability to classify diseases. Its use is thus changing our understanding of rheumatic diseases allowing further advances in research and clinical practice.

Treat to Target in Spondyloarthritis: The Time has Come

Recent publications have proposed revisions to disease classification criteria, new definitions of early diagnosis and remission, as well as guidelines for implementing treat-to-target strategies for the management of patients with spondyloarthritis. Despite developments leading to this practice-changing approach, the concept of treat to target for spondyloarthritis has not yet been widely accepted or implemented in standard clinical care. By placing greater emphasis on clinical features that manifest early in the disease process, the early and aggressive treatment of the most common forms of spondyloarthritis (namely ankylosing spondylitis and psoriatic arthritis), has been shown to have favorable patient outcomes in reducing synovial inflammation, delaying joint damage, and maintaining functional status. This article discusses the recent concept of Treat to Target in spondyloarthritis and the importance of early diagnosis of both ankylosing spondylitis (AS) and psoriatic arthritis (PsA). It also highlights the main outcome measures for spondyloarthritis patients achieving treatment goals of low levels of disease activity or clinical remission.