Rheumatology Research Articles

389. Anti-TNF treatments for women with chronic inflammatory diseases: Comparing attitudes and perceptions of physicians in Europe and the US

Introduction Chronic inflammatory disease (CID) activity in Women of Childbearing Age (WoCBA) is associated with higher risk of pregnancy complications and adverse outcomes. Tumour necrosis factor antagonists (anti-TNFs) are effective, but data on utilisation for these patients (pts) are limited. Objective/Hypothesis To understand physicians’ attitudes towards anti-TNF use around pregnancy, and differences between Europe- and US-based physicians. Methods The online survey was conducted in the US (Jul-17) and EU5 (France, Italy, Spain, UK, Germany; Nov/Dec-17). WoCBA were female pts aged 18–45. Participants included rheumatologists (RH) and obstetrician/gynaecologists (OB) among other healthcare professionals (HCPs). Results 203 US HCPs participated (50 RH, 50 OB) and 401 EU5 (152 RH, 114 OB). EU5 HCPs were less inclined to prescribe anti-TNFs for WoCBA; US RH (43%) had the highest proportion prescribed anti-TNFs (EU5 RH: 33%). Both US and EU5 HCPs’ comfort with prescribing anti-TNFs declined with onset of family planning. EU5 RH (61%) and OB (67%) were more likely to recommend stopping anti-TNFs pre-conception than US HCPs (RH: 46%; OB: 62%); similarly, > 50% EU5 RH and OB agreed women should stop anti-TNFs post-conception (US RH: 34%; OB: 54%). These findings may be due to more US RH strongly agreeing on making disease control during pregnancy a priority (42% vs EU5 RH: 25%) and that controlled disease reduces risk of pregnancy complications (US RH: 42%; EU5 RH: 28%), as well as more EU5 (34%) than US RH (12%) being very concerned about adverse events in pregnant pts on anti-TNFs. More EU5 (16%) than US RH (6%) strongly believed breastfeeding pts should not take anti-TNFs; uncertainty was high. Discussion Confidence in clinical management of WoCBA with CID varies, highlighting differences in physicians’ attitudes. Uncertainty and concerns about anti-TNFs for WoCBA are common, emphasising a need for better information/education of HCPs on anti-TNF use before/during/after pregnancy.

Construct a safety implementation process of domiciliary subcutaneous injection of biological agents in the department of rheumatology

Objective To ensure the effectiveness and safety of domiciliary subcutaneous injection of biological agents, a safety implementation process was constructed for the treatment of patients with rheumatic diseases by domiciliary subcutaneous injection of biological agents. Methods Based on analyzing the existing clinical work and consulting the relevant documents, using Delphi expert consultation method, 10 experts and 30 patients were treated with 2 rounds of questionnaire to conduction. Results After 2 rounds of expert consultation, the safety implementation process was developed, including 7 items and 27 sub-items. The positive coefficient of the experts was 100% and 90% respectively, the authority coefficient was 0.84, and the sub projects coordination coefficient was 0.454. Conclusions On the clauses in the safety implementation process of the domiciliary subcutaneous injection of biological agents in the Department of rheumatism which constructed with the Delphi method, experts opinions was consistence, having high credibility of the research results. By systematically managing the home patients who receiving the injective biological agents, transferring the part of the simple treatment from the hospital to the home was acceptance, the effectiveness and safety of domiciliary injection was improved. Key words: Patients in department of rheumatology; Biological agent; Subcutaneous injection; Delphi method; Domiciliary process

Should TNF Inhibitors Be Used in Patients with Prior Malignancies

Rheumatologists often see patients who have rheumatoid arthritis (RA) and histories of malignancy. Past research suggests that tumor necrosis factor

Clinical efficacy and safety of adalimumab for the treatment of 14 cases of severe psoriasis

Objective To evaluate the clinical efficacy and safety of adalimumab for the treatment of severe psoriasis. Methods Between December 2015 and August 2017, 14 patients with severe psoriasis who showed no response to traditional therapy were enrolled into this study. All the patients received subcutaneous injection of adalimumab at an initial dose of 80 mg, which decreased to a dose of 40 mg once every 2 weeks after 1-week treatment. At week 4, 8 and 12, the psoriasis area severity index (PASI) and physician′s global assessment (PGA) scores were recorded, and clinical efficacy and adverse drug reactions were observed. In patients with psoriatic arthritis, the improvement of arthritis was evaluated according to the American College of Rheumatology 20% response criteria (ACR20) . Results All the 14 patients received the drug treatment for at least 12 weeks. At week 4, 8 patients achieved 50% reduction in PASI (PASI 50) . At week 8, 8 patients achieved PASI 75, and 2 of the 8 patients achieved PASI 90. At week 12, 14 patients achieved PASI 75, 7 of them achieved PASI 90, and 3 of them achieved PASI 100. Before the treatment, the average PGA score of the 14 patients were 4.92 ± 0.02, and decreased to 1.21 ± 0.02 at week 12. The arthritis symptom was markedly improved in the 3 patients with psoriatic arthritis. At week 8, 2 patients achieved ACR20, and 3 achieved ACR20 at week 12. There were no serious adverse drug reactions such as serious infections and malignant tumors in any of the patients. Urticaria occurred in 3 patients, and was relieved after antihistamine treatment. Conclusion Subcutaneous injection of adalimumab every other week is markedly effective and safe for the treatment of severe psoriasis with few adverse drug reactions, and it provides a new treatment choice for patients with severe psoriasis who show no response to traditional therapy. Key words: Psoriasis; Arthritis, psoriatic; Biological agents; Adalimumab

Mediterranean Journal of Rheumatology June 2018 Issue Highlights.

Mediterranean Journal of Rheumatology June 2018 Issue Highlights.

The Diagnosis of Rheumatologic and Degenerative Arthritis by X-ray Sacroiliac Joint Projection

The study best image for diagnosis of fracture, dislocation and unilateral degenerative arthritis of the Sacroiliac joint, this study was performed to obtain the best image of the joint space of the hip joint by giving angle change to the pelvis phantom and the x-ray tube. I received evaluation. The results of the Receiver Operating Characteristic that in the case of simple photographs for the detection of joint arthritis and degenerative arthritis in the prone position, the photograph taken in the prone position raises the buttocks of the opposite side of the test by 25 ° ~ 30 ° and the x-ray tube is perpendicular to the sagittal plane passing 2.5 cm inward from the thorny vertebra In the lying position, lift the Sacroiliac joint of the test side by 25 ° ~ 30 °, and take a 5 ° angle of the x-ray tube angle toward the foot toward the center of the upper bruch spine from it will be helpful to diagnose arthritis. the center of the upper bruch spine to the side of the ankle joints in the transverse direction And posterior direction, it will be helpful to diagnose arthritis.

Interprofessional collaboration in rheumatology rehabilitation – the clash between ideology and practice

Interprofessional collaboration in rheumatology rehabilitation – the clash between ideology and practice

Expression and clinical significance of plasma microRNA-766 in children with polyarticular juvenile idiopathic arthritis

Objective To discuss the expression and clinical significance of microRNA(miR)-766 in children with polyarticular juvenile idiopathic arthritis (poly-JIA). Methods A total of 23 children with poly-JIA who received treatment at the Department of Rheumatology, the Affiliated Children′s Hospital of Capital Institute of Pediatrics, from November 2014 to September 2016, were enrolled as research group, and 24 healthy children at the same age were selected as healthy control group, while 24 children with oligoarticular juvenile idiopathic arthritis (oligo-JIA) and 19 children with juvenile ankylosing spondylitis (JAS) were selected as case-control groups.The expression levels of miR-766 in plasmas were detected by real-time quantitative polymerase chain reaction (qPCR). The clinical diagnostic values were analyzed by operating characteristic curve (ROC). Correlations between the expression levels of miR-766 and clinical, laboratory results were analyzed by conducting Pearson correlation coefficient analysis. Results Compared with the healthy control group and case-control group, the expression levels of miR-766 in poly-JIA group decreased, and the differences were statistically significant (t=6.897, 6.446, 6.218, all P 0.05). Compared with the healthy control group, the area under ROC curve of miR-766 was 0.938 (95%CI: 0.872-1.000), and when the cutoff value of miR-766 was 6.083 pmol/L, the sensitivity was 87.0% and the specificity was 91.7%.Compared with oligo-JIA and JAS, the area under ROC curves of miR-766 was 0.908 (95%CI: 0.819-0.996) and 0.927 (95%CI: 0.865-1.000), respectively.Correlation analysis indicated that the level of miR-766 in plasma of poly-JIA children was positively associated with hemoglobin (r=0.651, P<0.001), but negatively asso-ciated with the 28-joint Disease Activity Score (DAS28) and the percentage of type 1 helper T cells(Th1%) (r=-0.434, P=0.038; r=-0.417, P=0.008). Conclusions The expression levels of plasma miR-766 in poly-JIA are significantly decreasing.miR-766 may serve as an evaluation indicator for the diagnosis and prognosis of poly-JIA. Key words: Polyarticular juvenile idiopathic arthritis; MicroRNA-766; Diagnosis; Child

Mediterranean Journal of Rheumatology March 2018 Highlights.

Mediterranean Journal of Rheumatology March 2018 Highlights.

I135 Why should work matter to rheumatologists?

i135 Why should work matter to rheumatologists?

Patients with spondyloarthritis are equally satisfied with follow‐up by physiotherapist and rheumatologist

International guidelines recommend that patients with spondyloarthritis (SpA) have lifelong physiotherapy, as physical activity and exercise are essential for optimizing health throughout the course of the disease. The aim of the present study was to investigate if a physiotherapy-led outpatient clinic specializing in SpA could provide satisfactory follow-up as an alternative to standard visits with a rheumatologist (RT). We hypothesized that satisfaction would be similar in patients followed by a physiotherapist (PT) or an RT. A total of 68 patients were randomized to follow-up every fourth month by a PT or RT, for three visits in total. Patient satisfaction was evaluated using the Leeds Satisfaction Questionnaire (LSQ). Function, mobility and disease activity were rated using the Bath Ankylosing Spondylitis Functional Index (BASFI), Mobility Index (BASMI) and Ankylosing Spondylitis Disease Activity Score (ASDAS). Patients were equally satisfied with PT and RT follow-up at the first (p = 0.062) and last (p = 0.710) visit. At the second visit, the RT group was seen by a nurse, and was more satisfied than the PT group (p = 0.015). Function deteriorated in both the PT (p = 0.014) and RT (p = 0.007) groups. Mobility increased in the PT group (p = 0.020). Disease activity was not affected. Patients seem to be equally satisfied with either of the follow-up regimes. The PT-led follow-up did not seem to affect the patients' course of disease negatively. The results indicate that it would be safe to implement a PT-led clinic for patients with SpA in specialist health services, but longer-term follow-up is necessary to support the findings of this study.

Clinical characteristics of adult patients with autoinflammatory diseases presenting as recurrent fever of unknown origin

Objective To analyze the clinical characteristics of adult patients with autoinflammatory diseases (AUID) presenting as recurrent fever of unknown origin (FUO). Methods The clinical and genetic features of 51 adult patients with recurrent FUO, who were suspected of monogenic AUID admitted in adult AUID center Department of Rheumatology, Peking Union Medical College Hospital from April 2015 to March 2017, were prospectively studied. The clinical phenotypes were compared between patients with pathogenic gene mutations and diagnosed as monogenic AUID (gene-positive group), and those without pathogenic gene mutations (gene-negative group). Results Among 51 patients, there were 26 patients with positive monogenic mutations (51.0%); in addition 6 patients were diagnosed as periodic fever-aphthous stomatitis-pharyngitis-adenitis (PFAPA) syndrome. Finally 32 patients (63.0%) were diagnosed as AUID, including 11 cases of familial Mediterranean fever (34.4%), 5 cases of cryopyrin-associated periodic syndrome (15.6%), 5 cases of NLRP12-autoinflammtory disease (15.6%), 2 cases of Blau syndrome (6.3%), 2 cases of Yao syndrome (6.3%), 1 case of tumor necrosis factor-receptor associated periodic syndrome (3.1%), and 6 cases of PFAPA syndrome (18.8%). Among 25 gene-negative patients except 6 cases of PFAPA syndrome, 9 were diagnosed as other diseases, and the diagnosis of AUID was not confirmed in 10 cases (40.0%). Compared with gene-negative group, gene-positive group had more common childhood-onset (30.8% vs. 8.0%, P=0.041), longer disease duration (11.2±10.1 vs. 6.1±5.9, P=0.031), and more common abdominal pain/diarrhea (42.3% vs.12.0%, P=0.015). There were no significant differences in manifestations such as rash, arthralgia/arthritis, thoracic pain, eye inflammation and oral ulcers between two groups. One patient had family history of AUID, and finally diagnosed as Blau syndrome with NOD2 gene mutation. Conclusion AUID is one of the main causes of adult patients with recurrent FUO. Childhood-onset, long disease duration, abdominal pain/diarrhea, and family history of AUID are more common in patients with AUID pathogenic gene variations. Recognizing these symptom patterns can provide the clues, leading to the initiation of gene testing for patients with recurrent FUO. Adults patients with recurrent FUO suspected of AUID should be referred to specialist physicians in adult AUID center. Key words: Fever of unknown origin; Autoinflammatory diseases; Disease attributers

Организация оказания ревматологической помощи населения Республики Казахстан: проблемы и перспективы.

Организация оказания ревматологической помощи населения Республики Казахстан: проблемы и перспективы.

Ревматологическая медсестра: зарубежный опыт, перспективы развития в Республике Казахстан.

Ревматологическая медсестра: зарубежный опыт, перспективы развития в Республике Казахстан.

Перспективы развития компетенций сестринского персонала ревматологического профиля.

Перспективы развития компетенций сестринского персонала ревматологического профиля.

Концепции коморбидности и мультиморбидности в ревматологии. Возможна ли смена парадигм?

Концепции коморбидности и мультиморбидности в ревматологии. Возможна ли смена парадигм?

Diagnosis and treatment of rheumatoid arthritis:toward the best practice. The best practice for TNF inhibitors.

As of February 2018, 5 originator TNF inhibitors(infliximab, etanercept, adalimumab, golimumab and certolizumab pegol)and biosimilar agents of infliximab and etanercept are available for rheumatoid arthritis(RA)in Japan. The effectiveness of TNF inhibitors considerably improves with concomitant methotrexate regardless of their immunogenicity. The Japan College of Rheumatology guideline for TNF inhibitor use in RA has been updated in March 2017 according to recent evidences. During the remission induction phase, maintenance of drug trough level above effective blood concentration is paramount, while the tapering and withdrawal of TNF inhibitors may be considered after achieving sustained remission.

Ultrasound of the knee in rheumatology

The knee joint, surrounding ligaments, and extensor mechanism (quadriceps and patellar tendon), given their superficial nature, are easily accessible and accurately assessed with high-resolution musculoskeletal (MSK) ultrasound. Its bedside availability, lower cost than magnetic resonance imaging (MRI), and its high sensitivity in the detection of a small effusion, synovitis, and Baker's cyst, together with its ability to be used for needle guidance in invasive procedures, make ultrasound a highly desired diagnostic tool. In this article, we will focus on common rheumatologic indications of MSK ultrasound in the knee and discuss scanning technique and sonographic findings. Transducer positioning and essential sonographic bony landmarks will be reviewed and scanning in two orthogonal planes (both long and short axis of the structure) will be emphasized. With advances in technology, cost reduction, and easy availability, it is expected that more and more clinicians will be utilizing ultrasound in their clinics in management and treatment of rheumatologic diseases. The diagnostic ability of MSK ultrasound is based on an operator's training and experience, the patient's habitus and aptly chosen clinical indications. A good grasp of anatomy, sound ultrasound technique, and knowledge of limitations of ultrasound modality is essential for a safe ultrasound practice. It is also important to keep in mind that ultrasound provides limited information about internal structures such as meniscus and cruciate ligament pathologies and it has a complementary role with MRI.

High-Resolution musculoskeletal ultrasound in India: The present perspective and the future

High-resolution musculoskeletal ultrasound (HRMSK US) has evolved tremendously from being performed in dark lit scanning rooms to being done at a remote setting, being one of its kind of modalities where live streaming is making remote diagnosis possible; like self-scanning by an astronaut in outer space, or, an on field assessment of an acute injury in a high-stake football match , or a hand-held device used for scanning at a remote location, with the images streamed over the net for interpretation. It began as gray scale imaging; however, as power Doppler came into practice, it gave a leap to the use of ultrasound in inflammatory arthritis. Three-dimensional power Doppler, beam steering, sonoelastography, contrast ultrasound, and fusion imaging are the new weapons in the armamentarium of MSK US. The role of MSK US ranges from detecting various changes in rheumatological diseases; be it active synovitis, bony erosions, enthesitis, assessment of crystal deposition, salivary gland changes, and vessel changes, aiding in diagnosis, especially in children. HRMSK US has an established role as a diagnostic tool, both as a primary modality and as an adjunct to other modalities in orthopedic practice and sports medicine also, and has evolved as a primary therapeutic tool in these fields, be it pinpoint-guided steroid injections, platelet-rich plasma injections, and barbotage of calcium deposition in situations such as calcific tendinitis. Even with all these advantages, it is still sparingly used in the practice of rheumatology in India. The authors believe that it is likely to be more widely used in the future given the enormous scope of its applications.

Ultrasound of ankle and foot in rheumatology

Ankle and foot are frequent joints to be involved in arthritis. These joints, being superficial in nature, can be easily accessed by ultrasound. Other advantages of ultrasound are its easy availability, portability, and repeatability. Tenosynovitis, synovitis, tendinosis, bursitis, and enthesopathy are common findings in inflammatory arthritis, which can be easily evaluated by ultrasound. Follow-up and treatment response can also be evaluated with less cost to the patient. High-frequency (7–15 MHz) linear probes with availability of color and power Doppler are ideal for scanning the ankle and foot. Systematic evaluation is the primary requirement for a proper assessment. Ankle is evaluated compartment wise with specific positing for anterior, posterior, medial, and lateral compartments. Foot is evaluated according to the midtarsal joints and metatarsophalangeal and interphalangeal joints. Structured base evaluation of the compartments and joints should be done and the pathologies were noted. Thus, ultrasound of the ankle and foot is a very useful and easily available modality for identifying and distinguishing different rheumatological pathologies such as tendinitis, tenosynovitis, synovitis, bursitis, and enthesopathy of the ankle and foot.