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Schmukler J, Li T, Pincus T. Physician estimate of inflammation vs global assessment in explaining variations in swollen joint counts in rheumatoid arthritis patients. Rheumatol Adv Pract 2024; 8:rkae057. [PMID: 38800575 PMCID: PMC11116827 DOI: 10.1093/rap/rkae057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/16/2024] [Indexed: 05/29/2024] Open
Abstract
Objective To analyse patients with RA for inflammatory activity by physician estimate of global assessment (DOCGL) vs an estimate of inflammatory activity (DOCINF) to explain variation in the swollen joint count (SJC). Methods Patients with RA were studied at routine care visits. Patients completed a multidimensional health assessment questionnaire (MDHAQ) and the physician completed a 28-joint count for swollen (SJC), tender (TJC) and deformed (DJC) joints and a RheuMetric checklist with a 0-10 DOCGL visual numeric scale (VNS) and 0-10 VNS estimates of inflammation (DOCINF), damage (DOCDAM) and patient distress (DOCSTR). The disease activity score in 28 joints with ESR (DAS28-ESR), Clinical Disease Activity Index (CDAI) and Routine Assessment of Patient Index Data 3 (RAPID3) were calculated. Individual scores and RA indices were compared according to Spearman correlation coefficients and regression analyses. Results A total of 104 unselected patients were included, with a median age and disease duration of 54.5 and 5 years, respectively. The median DAS28-ESR was 2.9 (Q1-Q3: 2.0-3.7), indicating low activity. DOCINF was correlated significantly with DOCGL (ρ = 0.775). Both DOCGL and DOCINF were correlated significantly with most other measures; correlations with DOCGL were generally higher than with DOCINF other than for SJC. In regression analyses, DOCINF was more explanatory of variation in SJC than DOCGL and other DAS28-ESR components. Conclusions Variation in SJC is explained more by a 0-10 DOCINF VNS than the traditional DOCGL or any other measure in RA patients seen in routine care. DOCINF on a RheuMetric checklist can provide informative quantitative scores concerning inflammatory activity in RA patients monitored over long periods.
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Affiliation(s)
- Juan Schmukler
- Division of Rheumatology, Department of Medicine, Rush University School of Medicine, Chicago, IL, USA
| | - Tengfei Li
- Division of Rheumatology, Department of Medicine, Rush University School of Medicine, Chicago, IL, USA
| | - Theodore Pincus
- Division of Rheumatology, Department of Medicine, Rush University School of Medicine, Chicago, IL, USA
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Huang PJ, Chen YW, Yen TH, Liu YT, Lin SP, Chen HH. Investigation of changes in ankylosing spondylitis disease activity through 2021 COVID-19 wave in Taiwan by using electronic medical record management system. Sci Rep 2023; 13:349. [PMID: 36611127 PMCID: PMC9823247 DOI: 10.1038/s41598-023-27657-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
We aim to investigate the alteration in disease activity of ankylosing spondylitis (AS) individuals before, during, and after the COVID-19 wave in Taiwan by using electronic medical-record management system (EMRMS). We identified 126 AS individuals from the single center, and gathered data of the three disease activities (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI], Ankylosing Spondylitis Disease Activity Score with erythrocyte sedimentation rate [ASDAS-ESR], and Ankylosing Spondylitis Disease Activity Score with C-Reactive Protein [ASDAS-CRP]) by using EMRMS before (7 February to 1 May, 2021), during (2 May to 24 July, 2021), and after the COVID-19 wave (25 July to 16 October, 2021). We compared the disease activity measures of the three phases through a paired t test. Among the 126 individuals, CRP was significantly higher during the COVID-19 wave (0.2 (0.1, 0.5) mg/dl, p = 0.001) than before the wave (0.2 (0.1, 0.4) mg/dl), ESR (8.0 (4.0, 15.0) mm/h, p = 0.003) and ASDAS-ESR (1.4 (1.0, 1.9), p = 0.032) were significantly higher after the wave than during the wave (6.0 (3.0, 12.0) mm/h and 1.2 (0.9, 1.8) mm/h) e. ESR, CRP, ASDAS-ESR and ASDAS-CRP were all significant higher after COVID-19 wave than before. The disease activities of AS individuals in Taiwan worsened after 2021 COVID-19 wave in Taiwan.
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Affiliation(s)
- Pei-Ju Huang
- grid.413814.b0000 0004 0572 7372Department of Family Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yun-Wen Chen
- grid.410764.00000 0004 0573 0731Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705 Taiwan, ROC ,grid.410764.00000 0004 0573 0731Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan ,grid.260542.70000 0004 0532 3749Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Tsai-Hung Yen
- grid.410764.00000 0004 0573 0731Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705 Taiwan, ROC ,grid.410764.00000 0004 0573 0731Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan ,grid.260542.70000 0004 0532 3749Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yen-Tze Liu
- grid.413814.b0000 0004 0572 7372Department of Family Medicine, Changhua Christian Hospital, Changhua, Taiwan ,grid.260542.70000 0004 0532 3749Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Shih-Ping Lin
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan, ROC. .,Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan. .,Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
| | - Hsin-Hua Chen
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan, ROC. .,Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan. .,Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan. .,School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan. .,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan. .,Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine & Big Data Center, Chung Hsing University, Taichung, Taiwan.
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Butcher NJ, Monsour A, Mew EJ, Chan AW, Moher D, Mayo-Wilson E, Terwee CB, Chee-A-Tow A, Baba A, Gavin F, Grimshaw JM, Kelly LE, Saeed L, Thabane L, Askie L, Smith M, Farid-Kapadia M, Williamson PR, Szatmari P, Tugwell P, Golub RM, Monga S, Vohra S, Marlin S, Ungar WJ, Offringa M. Guidelines for Reporting Outcomes in Trial Protocols: The SPIRIT-Outcomes 2022 Extension. JAMA 2022; 328:2345-2356. [PMID: 36512367 DOI: 10.1001/jama.2022.21243] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Complete information in a trial protocol regarding study outcomes is crucial for obtaining regulatory approvals, ensuring standardized trial conduct, reducing research waste, and providing transparency of methods to facilitate trial replication, critical appraisal, accurate reporting and interpretation of trial results, and knowledge synthesis. However, recommendations on what outcome-specific information should be included are diverse and inconsistent. To improve reporting practices promoting transparent and reproducible outcome selection, assessment, and analysis, a need for specific and harmonized guidance as to what outcome-specific information should be addressed in clinical trial protocols exists. OBJECTIVE To develop harmonized, evidence- and consensus-based standards for describing outcomes in clinical trial protocols through integration with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 statement. EVIDENCE REVIEW Using the Enhancing the Quality and Transparency of Health Research (EQUATOR) methodological framework, the SPIRIT-Outcomes 2022 extension of the SPIRIT 2013 statement was developed by (1) generation and evaluation of candidate outcome reporting items via consultation with experts and a scoping review of existing guidance for reporting trial outcomes (published within the 10 years prior to March 19, 2018) identified through expert solicitation, electronic database searches of MEDLINE and the Cochrane Methodology Register, gray literature searches, and reference list searches; (2) a 3-round international Delphi voting process (November 2018-February 2019) completed by 124 panelists from 22 countries to rate and identify additional items; and (3) an in-person consensus meeting (April 9-10, 2019) attended by 25 panelists to identify essential items for outcome-specific reporting to be addressed in clinical trial protocols. FINDINGS The scoping review and consultation with experts identified 108 recommendations relevant to outcome-specific reporting to be addressed in trial protocols, the majority (72%) of which were not included in the SPIRIT 2013 statement. All recommendations were consolidated into 56 items for Delphi voting; after the Delphi survey process, 19 items met criteria for further evaluation at the consensus meeting and possible inclusion in the SPIRIT-Outcomes 2022 extension. The discussions during and after the consensus meeting yielded 9 items that elaborate on the SPIRIT 2013 statement checklist items and are related to completely defining and justifying the choice of primary, secondary, and other outcomes (SPIRIT 2013 statement checklist item 12) prospectively in the trial protocol, defining and justifying the target difference between treatment groups for the primary outcome used in the sample size calculations (SPIRIT 2013 statement checklist item 14), describing the responsiveness of the study instruments used to assess the outcome and providing details on the outcome assessors (SPIRIT 2013 statement checklist item 18a), and describing any planned methods to account for multiplicity relating to the analyses or interpretation of the results (SPIRIT 2013 statement checklist item 20a). CONCLUSIONS AND RELEVANCE This SPIRIT-Outcomes 2022 extension of the SPIRIT 2013 statement provides 9 outcome-specific items that should be addressed in all trial protocols and may help increase trial utility, replicability, and transparency and may minimize the risk of selective nonreporting of trial results.
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Affiliation(s)
- Nancy J Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Monsour
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Emma J Mew
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, Connecticut
| | - An-Wen Chan
- Department of Medicine, Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - David Moher
- Centre for Journalology, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Evan Mayo-Wilson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Caroline B Terwee
- Amsterdam University Medical Centers, Vrije Universiteit, Department of Epidemiology and Data Science, Amsterdam, the Netherlands
- Department of Methodology, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Alyssandra Chee-A-Tow
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Ami Baba
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Frank Gavin
- public panel member, Toronto, Ontario, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lauren E Kelly
- Department of Pharmacology and Therapeutics, University of Manitoba, Winnipeg, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Leena Saeed
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Lehana Thabane
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Askie
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | | | - Mufiza Farid-Kapadia
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Paula R Williamson
- MRC-NIHR Trials Methodology Research Partnership, Department of Health Data Science, University of Liverpool, Liverpool, England
| | - Peter Szatmari
- Cundill Centre for Child and Youth Depression, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter Tugwell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Robert M Golub
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Suneeta Monga
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sunita Vohra
- Departments of Pediatrics and Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Susan Marlin
- Clinical Trials Ontario, Toronto, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Wendy J Ungar
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Duivenvoorden R, Vart P, Noordzij M, Soares dos Santos AC, Zulkarnaev AB, Franssen CFM, Kuypers D, Demir E, Rahimzadeh H, Kerschbaum J, Jager KJ, Turkmen K, Hemmelder MH, Schouten M, Rodríguez-Ferrero ML, Crespo M, Gansevoort RT, Hilbrands LB. Clinical, Functional, and Mental Health Outcomes in Kidney Transplant Recipients 3 Months After a Diagnosis of COVID-19. Transplantation 2022; 106:1012-1023. [PMID: 35320154 PMCID: PMC9038249 DOI: 10.1097/tp.0000000000004075] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/25/2021] [Accepted: 01/03/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Kidney transplant patients are at high risk for coronavirus disease 2019 (COVID-19)-related mortality. However, limited data are available on longer-term clinical, functional, and mental health outcomes in patients who survive COVID-19. METHODS We analyzed data from adult kidney transplant patients in the European Renal Association COVID-19 Database who presented with COVID-19 between February 1, 2020, and January 31, 2021. RESULTS We included 912 patients with a mean age of 56.7 (±13.7) y. 26.4% were not hospitalized, 57.5% were hospitalized without need for intensive care unit (ICU) admission, and 16.1% were hospitalized and admitted to the ICU. At 3 mo follow-up survival was 82.3% overall, and 98.8%, 84.2%, and 49.0%, respectively, in each group. At 3 mo follow-up biopsy-proven acute rejection, need for renal replacement therapy, and graft failure occurred in the overall group in 0.8%, 2.6%, and 1.8% respectively, and in 2.1%, 10.6%, and 10.6% of ICU-admitted patients, respectively. Of the surviving patients, 83.3% and 94.4% reached their pre-COVID-19 physician-reported functional and mental health status, respectively, within 3 mo. Of patients who had not yet reached their prior functional and mental health status, their treating physicians expected that 79.6% and 80.0%, respectively, still would do so within the coming year. ICU admission was independently associated with a low likelihood to reach prior functional and mental health status. CONCLUSIONS In kidney transplant recipients alive at 3-mo follow-up, clinical, physician-reported functional, and mental health recovery was good for both nonhospitalized and hospitalized patients. Recovery was, however, less favorable for patients who had been admitted to the ICU.
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Affiliation(s)
- Raphaël Duivenvoorden
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Priya Vart
- Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Marlies Noordzij
- Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Alex B. Zulkarnaev
- Surgical Department of Transplantation and Dialysis, Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - Casper F. M. Franssen
- Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Dirk Kuypers
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Erol Demir
- Division of Nephrology, Department of Internal Medicine, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Hormat Rahimzadeh
- Department of Nephrology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Julia Kerschbaum
- Austrian Dialysis and Transplant Registry, Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Kitty J. Jager
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam University Medical Center, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Kultigin Turkmen
- Division of Nephrology, Department of Internal Medicine, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
| | - Marc H. Hemmelder
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
- CARIM School for Cardiovascular Disease, University of Maastricht, Maastricht, the Netherlands
| | - Marcel Schouten
- Department of Internal Medicine, Tergooi Hospital, Hilversum, the Netherlands
| | | | - Marta Crespo
- Department of Nephrology, Hospital del Mar and& Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Ron T. Gansevoort
- Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Luuk B. Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
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Wongvibulsin S, Frech TM, Chren MM, Tkaczyk ER. Expanding Personalized, Data-Driven Dermatology: Leveraging Digital Health Technology and Machine Learning to Improve Patient Outcomes. JID INNOVATIONS 2022; 2:100105. [PMID: 35462957 PMCID: PMC9026581 DOI: 10.1016/j.xjidi.2022.100105] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/13/2021] [Accepted: 01/07/2022] [Indexed: 11/30/2022] Open
Abstract
The current revolution of digital health technology and machine learning offers enormous potential to improve patient care. Nevertheless, it is essential to recognize that dermatology requires an approach different from those of other specialties. For many dermatological conditions, there is a lack of standardized methodology for quantitatively tracking disease progression and treatment response (clinimetrics). Furthermore, dermatological diseases impact patients in complex ways, some of which can be measured only through patient reports (psychometrics). New tools using digital health technology (e.g., smartphone applications, wearable devices) can aid in capturing both clinimetric and psychometric variables over time. With these data, machine learning can inform efforts to improve health care by, for example, the identification of high-risk patient groups, optimization of treatment strategies, and prediction of disease outcomes. We use the term personalized, data-driven dermatology to refer to the use of comprehensive data to inform individual patient care and improve patient outcomes. In this paper, we provide a framework that includes data from multiple sources, leverages digital health technology, and uses machine learning. Although this framework is applicable broadly to dermatological conditions, we use the example of a serious inflammatory skin condition, chronic cutaneous graft-versus-host disease, to illustrate personalized, data-driven dermatology.
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Affiliation(s)
- Shannon Wongvibulsin
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tracy M. Frech
- Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee, USA
| | - Mary-Margaret Chren
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric R. Tkaczyk
- VA Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, School of Engineering, Vanderbilt University, Nashville, Tennessee, USA
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Miravite J, Calvo S, Cooper K, Raymond D, Ooi HY, Lubarr N, Bressman S, Saunders-Pullman R. The minimal clinically important change in the motor section of the Burke-Fahn-Marsden Dystonia Rating Scale for generalized dystonia: Results from deep brain stimulation. Parkinsonism Relat Disord 2021; 93:85-88. [PMID: 34856447 DOI: 10.1016/j.parkreldis.2021.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 11/02/2021] [Accepted: 11/13/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The minimal clinically important difference (MCID) describes the smallest change in an outcome that is considered clinically meaningful. The Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) is the most frequently rating scale assessing the efficacy of deep brain stimulation therapy (DBS) for dystonia. To expand our understanding, we evaluated the MCID thresholds for the BFMDRS motor subscale (MS) using physician-reported outcomes. METHODS We assessed the MCID thresholds for the BFMDRS using movement disorder specialist ratings of videotapes from patients with genetically determined dystonia (Tor1A and THAP1) who underwent bilateral globus pallidum internum (GPi) DBS. We calculated the effect size of the BFMDRS-MS change and determined the MCID thresholds using the Clinical Global Impression of Change (CGIC). RESULTS Twelve participants with a median age at DBS of 44.5 (range:27-68) had baseline and follow-up BFMDRS-MS with a median post-DBS follow-up of 5.5 years. Based on descriptive analysis, patients with good improvement after DBS according to the CGIC [8/12 (67%)] had a median BFMDRS-MS score reduction of 77% [Interquartile range (IQR):66.2;91.0) with an effect size of 0.39, and those with non-improvement [4/12 (33%)], had a median BFMDRS-MS score reduction of 62% (IQR:36.6;83.6). CONCLUSIONS Our MCID estimates can be utilized in clinical practice in judging clinical relevance. However, further larger, powered studies are needed to simultaneously determine and compare MCID using patient and physician-reported outcomes in segmental and generalized dystonia in genetic and non-genetic populations.
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Affiliation(s)
- Joan Miravite
- Department of Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, USA
| | - Sara Calvo
- Research Unit, Hospital Universitario Burgos, Spain
| | - Kathryn Cooper
- Department of Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, USA
| | - Deborah Raymond
- Department of Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, USA
| | - Hwai Yin Ooi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, USA
| | - Naomi Lubarr
- Department of Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, USA
| | - Susan Bressman
- Department of Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, USA
| | - Rachel Saunders-Pullman
- Department of Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, USA
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Parewa M, Burman AS, Brahma A, Rutten L, Sadhukhan S, Misra P, Gupta B, Saklani N, Michael J, Basu A, Ali SS, Koley M, Saha S. Individualized Homeopathic Medicines in the Treatment of Generalized Anxiety Disorder: A Double-Blind, Randomized, Placebo-Controlled, Pilot Trial. Complement Med Res 2021; 28:407-418. [PMID: 33662951 DOI: 10.1159/000514524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 01/15/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Evidence favoring homeopathy in generalized anxiety disorder (GAD) remains scarce. The objective of this pilot trial was to test feasibility of a definitive trial in future. We also experimented whether individualized homeopathic medicines (IH) plus psychological counseling (PC) can produce significantly different effects beyond placebo plus PC in the treatment of GAD. METHODS A double-blind, randomized, placebo-controlled, parallel arm, pilot trial was conducted on 62 GAD patients at the National Institute of Homoeopathy, India. GAD-7 questionnaire and Hamilton Anxiety Scale (HAM-A) were used as the primary and secondary outcomes, respectively, measured at baseline and 3 months. Patients received either IH plus PC (n = 31) or identical-looking placebo plus PC (n = 31). Intention-to-treat sample was analyzed to detect group differences using unpaired t tests. RESULTS Recruitment and retention rates were 56 and 90%, respectively. Mean age was 31.5 years; 56.5% were male. GAD-7 reductions were non-significantly higher in IH than placebo (p = 0.122). Group differences on HAM-A favored IH significantly (p = 0.018). Effect sizes were small to medium. Calcarea carbonica was the most frequently indicated medicine. No serious adverse events happened. CONCLUSIONS A small but positive direction of anxiolytic effect was observed favoring homeopathy over placebo. A definitive trial appeared feasible in future.
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Affiliation(s)
- Maneet Parewa
- Department of Repertory, National Institute of Homoeopathy, affiliated to The West Bengal University of Health Sciences, Government of West Bengal, Kolkata, India,
| | - Avijit Shee Burman
- Department of Forensic Medicine and Toxicology, National Institute of Homoeopathy, affiliated to The West Bengal University of Health Sciences, Government of West Bengal, Kolkata, India
| | - Arabinda Brahma
- Consultant Psychiatrist, Kolkata Police Hospital and Bharat Sevasram Sangha Hospital, Kolkata, India
| | - Lex Rutten
- Independent Researcher, VHAN, Dutch Association of Homeopathic Physicians, Breda, The Netherlands
| | - Satarupa Sadhukhan
- Department of Organon of Medicine and Homoeopathic Philosophy, National Institute of Homoeopathy, Ministry of AYUSH, Government of India, affiliated to The West Bengal University of Health Sciences, Government of West Bengal, Kolkata, India
| | - Pankhuri Misra
- Department of Materia Medica, National Institute of Homoeopathy, Ministry of AYUSH, Government of India, affiliated to The West Bengal University of Health Sciences, Government of West Bengal, Kolkata, India
| | - Bharti Gupta
- Department of Pediatrics, National Institute of Homoeopathy, Ministry of AYUSH, Government of India, affiliated to The West Bengal University of Health Sciences, Government of West Bengal, Kolkata, India
| | - Nitin Saklani
- Department of Repertory, National Institute of Homoeopathy, affiliated to The West Bengal University of Health Sciences, Government of West Bengal, Kolkata, India
| | - James Michael
- Department of Organon of Medicine and Homoeopathic Philosophy, National Institute of Homoeopathy, Ministry of AYUSH, Government of India, affiliated to The West Bengal University of Health Sciences, Government of West Bengal, Kolkata, India
| | - Anamika Basu
- House Staff, Mahesh Bhattacharyya Homoeopathic Medical College & Hospital, Government of West Bengal, affiliated to The West Bengal University of Health Sciences, Government of West Bengal, Howrah, India
| | - Sk Swaif Ali
- House Staff, Mahesh Bhattacharyya Homoeopathic Medical College & Hospital, Government of West Bengal, affiliated to The West Bengal University of Health Sciences, Government of West Bengal, Howrah, India
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Tahir H, Moorthy A, Chan A. Impact of Secukinumab on Patient-Reported Outcomes in the Treatment of Ankylosing Spondylitis: Current Perspectives. Open Access Rheumatol 2020; 12:277-292. [PMID: 33273869 PMCID: PMC7705257 DOI: 10.2147/oarrr.s265806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/06/2020] [Indexed: 12/17/2022] Open
Abstract
Ankylosing spondylitis (AS) is a chronic rheumatic disease involving inflammation of the joints and spine, which carries a substantial, life-long burden for the patient. Secukinumab is a fully human anti-interleukin-17A monoclonal antibody, approved in the USA and EU for the treatment of AS. In this narrative review, we searched PubMed with the aim of consolidating the recent literature regarding the impact of secukinumab on patient-reported outcomes in patients with AS. A large clinical trial program has demonstrated the efficacy of secukinumab in relieving the signs and symptoms of AS. Most importantly from a patient perspective, secukinumab has produced improvements in a range of patient-reported outcomes (PROs), including pain, fatigue, quality of life and work productivity, as well as composite measures including patient-reported elements, such as the Bath indices and Assessment of SpondyloArthritis international Society (ASAS) response criteria. Benefits to patients were rapid, and sustained in the long term (up to 5 years). The positive effect of secukinumab was seen regardless of whether patients had previously been treated with anti-tumor necrosis factor (TNF) therapies. Greater improvements in PROs were associated with patients being anti-TNF-naïve, of a younger age, with shorter disease duration and higher objective measures of inflammation at baseline. The available real-world evidence suggests that the effects of secukinumab on PROs in clinical practice are consistent with those seen in clinical trials, and evidence in a real-world setting continues to be collected.
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Affiliation(s)
- Hasan Tahir
- Royal Free London NHS Trust, London, UK
- Division of Medicine, University College London, London, UK
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Controversy and Debate on Meta-epidemiology. Paper 1: Treatment effect sizes vary in randomized trials depending on the type of outcome measure. J Clin Epidemiol 2020; 123:27-38. [DOI: 10.1016/j.jclinepi.2019.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 01/30/2023]
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Serban S, Dietrich T, Lopez-Oliva I, de Pablo P, Raza K, Filer A, Chapple ILC, Hill K. Attitudes towards Oral Health in Patients with Rheumatoid Arthritis: A Qualitative Study Nested within a Randomized Controlled Trial. JDR Clin Trans Res 2019; 4:360-370. [PMID: 31009578 DOI: 10.1177/2380084419833694] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Patients with rheumatoid arthritis (RA) present a higher incidence and severity of periodontitis than the general population. Our study, Outcomes of Periodontal Treatment in Patients with Rheumatoid Arthritis (OPERA), was a randomized waiting-list controlled trial using mixed methods. Patients randomized to the intervention arm received intensive periodontal treatment, and those in the control arm received the same treatment with a 6-mo delay. AIM The nested qualitative component aimed to explore patients' experiences and priorities concerning oral health and barriers and facilitators for trial participation. METHODS Using purposive sampling until thematic saturation was reached, we conducted 21 one-to-one semistructured interviews with randomized patients in either of the 2 treatment arms as well as with patients who did not consent for trial participation. RESULTS The patients described their experiences about RA, oral health, and study participation. Previous experiences with dental care professionals shaped patients' current perceptions about oral health and the place of oral health on their list of priorities compared with other conditions. Patients also highlighted some of the barriers and facilitators for study participation and for compliance with oral health maintenance. The patients, in the control arm, presented their views regarding the acceptable length of waiting time for the intervention. CONCLUSION The associations between periodontal and systemic health are increasingly recognized by the literature. Our study provided an insight into RA patients' experiences and perceptions about oral health. It also highlighted some of the barriers and facilitators for participating in a periodontal interventional study for this group. We hope that our findings will support the design of larger interventional periodontal studies in patients with RA. The complex challenges faced by the burden of RA and the associated multimorbidities in this patient group might highlight opportunities to improve access to oral health services in this patient population. KNOWLEDGE TRANSFER STATEMENT This article provided insights into the experiences and perceptions of rheumatoid arthritis patients about their oral health to improve patient participation in a definitive clinical trial.
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Affiliation(s)
- S Serban
- Periodontal Research Group, School of Dentistry, Institute of Clinical Sciences, University of Birmingham, and Birmingham Dental Hospital (Birmingham Community Healthcare NHS Foundation Trust), Edgbaston, Birmingham, UK.,Dental Public Health and Health Services Research Group, School of Dentistry, University of Leeds, Leeds, UK
| | - T Dietrich
- Periodontal Research Group, School of Dentistry, Institute of Clinical Sciences, University of Birmingham, and Birmingham Dental Hospital (Birmingham Community Healthcare NHS Foundation Trust), Edgbaston, Birmingham, UK
| | - I Lopez-Oliva
- Periodontal Research Group, School of Dentistry, Institute of Clinical Sciences, University of Birmingham, and Birmingham Dental Hospital (Birmingham Community Healthcare NHS Foundation Trust), Edgbaston, Birmingham, UK
| | - P de Pablo
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Rheumatology, Sandwell and West Birmingham Hospital NHS Trust, Birmingham, UK
| | - K Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Rheumatology, Sandwell and West Birmingham Hospital NHS Trust, Birmingham, UK
| | - A Filer
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - I L C Chapple
- Periodontal Research Group, School of Dentistry, Institute of Clinical Sciences, University of Birmingham, and Birmingham Dental Hospital (Birmingham Community Healthcare NHS Foundation Trust), Edgbaston, Birmingham, UK
| | - K Hill
- Periodontal Research Group, School of Dentistry, Institute of Clinical Sciences, University of Birmingham, and Birmingham Dental Hospital (Birmingham Community Healthcare NHS Foundation Trust), Edgbaston, Birmingham, UK
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Voshaar MAHO, Moghadam MG, Vonkeman HE, Ten Klooster PM, van Schaardenburg D, Tekstra J, Visser H, van de Laar MAFJ, Jansen TL. Measuring Disease Exacerbation and Flares in Rheumatoid Arthritis: Comparison of Commonly Used Disease Activity Indices and Individual Measures. J Rheumatol 2017; 44:1118-1124. [PMID: 28507187 DOI: 10.3899/jrheum.160915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate and compare the utility of commonly used outcome measures for assessing disease exacerbation or flare in patients with rheumatoid arthritis (RA). METHODS Data from the Dutch Potential Optimalisation of (Expediency) and Effectiveness of Tumor necrosis factor-α blockers (POET) study, in which 462 patients discontinued their tumor necrosis factor-α inhibitor, were used. The ability of different measures to discriminate between those with and without physician-reported flare or medication escalation at the 3-month visit (T2) was evaluated by calculating effect size (ES) statistics. Responsiveness to increased disease activity was compared between measures by standardizing change scores (SCS) from baseline to the 3-month visit. Finally, the incremental validity of individual outcome measures beyond the Simplified Disease Activity Score was evaluated using logistic regression analysis. RESULTS The SCS were greater for disease activity indices than for any of the individual measures. The 28-joint Disease Activity Score, Clinical Disease Activity Index, and Simplified Disease Activity Index performed similarly. Pain and physician's (PGA) and patient's global assessment (PtGA) of disease activity were the most responsive individual measures. Similar results were obtained for discriminative ability, with greatest ES for disease activity indices followed by pain, PGA, and PtGA. Pain was the only measure to demonstrate incremental validity beyond SDAI in predicting 3-month flare status. CONCLUSION These results support the use of composite disease activity indices, patient-reported pain and disease activity, and physician-reported disease activity for measuring disease exacerbation or identifying flares of RA. Physical function, acute-phase response, and the auxiliary measures fatigue, participation, and emotional well-being performed poorly.
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Affiliation(s)
- Martijn A H Oude Voshaar
- From the Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente, Enschede; Department of Rheumatology, VU University Medical Center and Reade Medical Center, Amsterdam; Department of Rheumatology, University Medical Center Utrecht, Utrecht; Department of Rheumatology, Rijnstate Medical Center, Arnhem; Department of Rheumatology, Viecuri Medical Center, Venlo, the Netherlands; Department of Rheumatology, University Hospital Leuven, Leuven, Belgium.,M.A. Oude Voshaar, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; M. Ghiti Moghadam, MD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Department of Rheumatology, University Hospital Leuven, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; H.E. Vonkeman, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; P.M. ten Klooster, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; D. van Schaardenburg, MD, PhD, Department of Rheumatology, VU University Medical Center and Reade Medical Center; J. Tekstra, MD, PhD, Department of Rheumatology, University Medical Center Utrecht; H. Visser, MD, PhD, Department of Rheumatology, Rijnstate Medical Center; M.A. van de Laar, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; T.L. Jansen, MD, PhD, Department of Rheumatology, Viecuri Medical Center
| | - Marjan Ghiti Moghadam
- From the Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente, Enschede; Department of Rheumatology, VU University Medical Center and Reade Medical Center, Amsterdam; Department of Rheumatology, University Medical Center Utrecht, Utrecht; Department of Rheumatology, Rijnstate Medical Center, Arnhem; Department of Rheumatology, Viecuri Medical Center, Venlo, the Netherlands; Department of Rheumatology, University Hospital Leuven, Leuven, Belgium. .,M.A. Oude Voshaar, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; M. Ghiti Moghadam, MD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Department of Rheumatology, University Hospital Leuven, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; H.E. Vonkeman, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; P.M. ten Klooster, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; D. van Schaardenburg, MD, PhD, Department of Rheumatology, VU University Medical Center and Reade Medical Center; J. Tekstra, MD, PhD, Department of Rheumatology, University Medical Center Utrecht; H. Visser, MD, PhD, Department of Rheumatology, Rijnstate Medical Center; M.A. van de Laar, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; T.L. Jansen, MD, PhD, Department of Rheumatology, Viecuri Medical Center.
| | - Harald E Vonkeman
- From the Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente, Enschede; Department of Rheumatology, VU University Medical Center and Reade Medical Center, Amsterdam; Department of Rheumatology, University Medical Center Utrecht, Utrecht; Department of Rheumatology, Rijnstate Medical Center, Arnhem; Department of Rheumatology, Viecuri Medical Center, Venlo, the Netherlands; Department of Rheumatology, University Hospital Leuven, Leuven, Belgium.,M.A. Oude Voshaar, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; M. Ghiti Moghadam, MD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Department of Rheumatology, University Hospital Leuven, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; H.E. Vonkeman, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; P.M. ten Klooster, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; D. van Schaardenburg, MD, PhD, Department of Rheumatology, VU University Medical Center and Reade Medical Center; J. Tekstra, MD, PhD, Department of Rheumatology, University Medical Center Utrecht; H. Visser, MD, PhD, Department of Rheumatology, Rijnstate Medical Center; M.A. van de Laar, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; T.L. Jansen, MD, PhD, Department of Rheumatology, Viecuri Medical Center
| | - Peter M Ten Klooster
- From the Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente, Enschede; Department of Rheumatology, VU University Medical Center and Reade Medical Center, Amsterdam; Department of Rheumatology, University Medical Center Utrecht, Utrecht; Department of Rheumatology, Rijnstate Medical Center, Arnhem; Department of Rheumatology, Viecuri Medical Center, Venlo, the Netherlands; Department of Rheumatology, University Hospital Leuven, Leuven, Belgium.,M.A. Oude Voshaar, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; M. Ghiti Moghadam, MD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Department of Rheumatology, University Hospital Leuven, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; H.E. Vonkeman, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; P.M. ten Klooster, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; D. van Schaardenburg, MD, PhD, Department of Rheumatology, VU University Medical Center and Reade Medical Center; J. Tekstra, MD, PhD, Department of Rheumatology, University Medical Center Utrecht; H. Visser, MD, PhD, Department of Rheumatology, Rijnstate Medical Center; M.A. van de Laar, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; T.L. Jansen, MD, PhD, Department of Rheumatology, Viecuri Medical Center
| | - Dirkjan van Schaardenburg
- From the Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente, Enschede; Department of Rheumatology, VU University Medical Center and Reade Medical Center, Amsterdam; Department of Rheumatology, University Medical Center Utrecht, Utrecht; Department of Rheumatology, Rijnstate Medical Center, Arnhem; Department of Rheumatology, Viecuri Medical Center, Venlo, the Netherlands; Department of Rheumatology, University Hospital Leuven, Leuven, Belgium.,M.A. Oude Voshaar, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; M. Ghiti Moghadam, MD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Department of Rheumatology, University Hospital Leuven, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; H.E. Vonkeman, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; P.M. ten Klooster, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; D. van Schaardenburg, MD, PhD, Department of Rheumatology, VU University Medical Center and Reade Medical Center; J. Tekstra, MD, PhD, Department of Rheumatology, University Medical Center Utrecht; H. Visser, MD, PhD, Department of Rheumatology, Rijnstate Medical Center; M.A. van de Laar, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; T.L. Jansen, MD, PhD, Department of Rheumatology, Viecuri Medical Center
| | - Janneke Tekstra
- From the Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente, Enschede; Department of Rheumatology, VU University Medical Center and Reade Medical Center, Amsterdam; Department of Rheumatology, University Medical Center Utrecht, Utrecht; Department of Rheumatology, Rijnstate Medical Center, Arnhem; Department of Rheumatology, Viecuri Medical Center, Venlo, the Netherlands; Department of Rheumatology, University Hospital Leuven, Leuven, Belgium.,M.A. Oude Voshaar, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; M. Ghiti Moghadam, MD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Department of Rheumatology, University Hospital Leuven, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; H.E. Vonkeman, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; P.M. ten Klooster, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; D. van Schaardenburg, MD, PhD, Department of Rheumatology, VU University Medical Center and Reade Medical Center; J. Tekstra, MD, PhD, Department of Rheumatology, University Medical Center Utrecht; H. Visser, MD, PhD, Department of Rheumatology, Rijnstate Medical Center; M.A. van de Laar, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; T.L. Jansen, MD, PhD, Department of Rheumatology, Viecuri Medical Center
| | - Henk Visser
- From the Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente, Enschede; Department of Rheumatology, VU University Medical Center and Reade Medical Center, Amsterdam; Department of Rheumatology, University Medical Center Utrecht, Utrecht; Department of Rheumatology, Rijnstate Medical Center, Arnhem; Department of Rheumatology, Viecuri Medical Center, Venlo, the Netherlands; Department of Rheumatology, University Hospital Leuven, Leuven, Belgium.,M.A. Oude Voshaar, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; M. Ghiti Moghadam, MD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Department of Rheumatology, University Hospital Leuven, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; H.E. Vonkeman, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; P.M. ten Klooster, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; D. van Schaardenburg, MD, PhD, Department of Rheumatology, VU University Medical Center and Reade Medical Center; J. Tekstra, MD, PhD, Department of Rheumatology, University Medical Center Utrecht; H. Visser, MD, PhD, Department of Rheumatology, Rijnstate Medical Center; M.A. van de Laar, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; T.L. Jansen, MD, PhD, Department of Rheumatology, Viecuri Medical Center
| | - Mart A F J van de Laar
- From the Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente, Enschede; Department of Rheumatology, VU University Medical Center and Reade Medical Center, Amsterdam; Department of Rheumatology, University Medical Center Utrecht, Utrecht; Department of Rheumatology, Rijnstate Medical Center, Arnhem; Department of Rheumatology, Viecuri Medical Center, Venlo, the Netherlands; Department of Rheumatology, University Hospital Leuven, Leuven, Belgium.,M.A. Oude Voshaar, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; M. Ghiti Moghadam, MD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Department of Rheumatology, University Hospital Leuven, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; H.E. Vonkeman, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; P.M. ten Klooster, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; D. van Schaardenburg, MD, PhD, Department of Rheumatology, VU University Medical Center and Reade Medical Center; J. Tekstra, MD, PhD, Department of Rheumatology, University Medical Center Utrecht; H. Visser, MD, PhD, Department of Rheumatology, Rijnstate Medical Center; M.A. van de Laar, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; T.L. Jansen, MD, PhD, Department of Rheumatology, Viecuri Medical Center
| | - Tim L Jansen
- From the Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente, Enschede; Department of Rheumatology, VU University Medical Center and Reade Medical Center, Amsterdam; Department of Rheumatology, University Medical Center Utrecht, Utrecht; Department of Rheumatology, Rijnstate Medical Center, Arnhem; Department of Rheumatology, Viecuri Medical Center, Venlo, the Netherlands; Department of Rheumatology, University Hospital Leuven, Leuven, Belgium.,M.A. Oude Voshaar, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; M. Ghiti Moghadam, MD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Department of Rheumatology, University Hospital Leuven, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; H.E. Vonkeman, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; P.M. ten Klooster, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente; D. van Schaardenburg, MD, PhD, Department of Rheumatology, VU University Medical Center and Reade Medical Center; J. Tekstra, MD, PhD, Department of Rheumatology, University Medical Center Utrecht; H. Visser, MD, PhD, Department of Rheumatology, Rijnstate Medical Center; M.A. van de Laar, MD, PhD, Arthritis Center Twente, Department of Psychology, Health and Technology, University of Twente, and Arthritis Center Twente, Department of Rheumatology and Clinical Immunology, Medical Spectrum Twente; T.L. Jansen, MD, PhD, Department of Rheumatology, Viecuri Medical Center
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Redondo M, Leon L, Povedano FJ, Abasolo L, Perez-Nieto MA, López-Muñoz F. A bibliometric study of the scientific publications on patient-reported outcomes in rheumatology. Semin Arthritis Rheum 2016; 46:828-833. [PMID: 28087065 DOI: 10.1016/j.semarthrit.2016.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/25/2016] [Accepted: 12/07/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION We have conducted a bibliometric study of the scientific publications on patient-reported outcomes in the field of rheumatology. METHODS SCOPUS was the database used in this bibliometric study. We performed two searches. The main search involved selecting the documents published between 2000 and 2014 limited to top-tier journals addressing rheumatic and musculoskeletal diseases, using specific descriptors together with the operator and main descriptor "patient-reported outcomes" (PROs), and we performed a secondary search, with the following specific descriptors: "pain," "functional capacity," and "fatigue." We used bibliometric indicators for articles distribution (Price's law for the increase of scientific literature and Bradford's law for dispersion of articles). We also calculated the participation index of the different countries. RESULTS A total of 983 original articles were published between 2000 and 2014. Our results confirmed the fulfilment of Price's law (correlation coefficient r = 0.9385 after linear adjustment). The average number of articles per Bradford Zone was 327.6. A total of 30 different journals were published. The type of growth for the descriptors "pain" (r2 = 0.5417 compared to r2 = 0.4839) and "fatigue" (r2 = 06276 compared to r2 = 0.5544) is exponential, whereas it is linear for the descriptor "functional capacity" (r2 = 0.6769 compared to r2 = 0.3779). DISCUSSION This study revealed significant linear growth of patient-related outcomes in global terms, as well as upward trends for most of the citation-based bibliometric indices, especially significant from 2010 to 2014. Pain and fatigue have greater growth as PRO concepts.
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Affiliation(s)
- Marta Redondo
- Health Sciences Faculty, Camilo José Cela University, Madrid, Spain
| | - Leticia Leon
- Health Sciences Faculty, Camilo José Cela University, Madrid, Spain; Department of Rheumatology, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IDISSC), Hospital Clinico San Carlos, Madrid, Spain.
| | | | - Lydia Abasolo
- Department of Rheumatology, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IDISSC), Hospital Clinico San Carlos, Madrid, Spain
| | | | - Francisco López-Muñoz
- Health Sciences Faculty, Camilo José Cela University, Madrid, Spain; Neuropsychopharmacology Unit, Hospital 12 de Octubre Research Institute (i+12), Madrid, Spain
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Scharbatke EC, Behrens F, Schmalzing M, Koehm M, Greger G, Gnann H, Burkhardt H, Tony HP. Association of Improvement in Pain With Therapeutic Response as Determined by Individual Improvement Criteria in Patients With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2016; 68:1607-1615. [PMID: 26990995 PMCID: PMC5129502 DOI: 10.1002/acr.22884] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 02/24/2016] [Accepted: 03/08/2016] [Indexed: 12/24/2022]
Abstract
Objective To use statistical methods to establish a threshold for individual response in patient‐reported outcomes (PROs) in patients with rheumatoid arthritis. Methods We used an analysis of variance model in patients on stable therapy (discovery cohort) to establish critical differences (dcrit) for the minimum change associated with a significant individual patient response (beyond normal variation) in the PRO measures of pain (0–10), fatigue (0–10), and function (Funktionsfragebogen Hannover questionnaire; 0–100). We then evaluated PRO responses in patients initiating adalimumab in a noninterventional study (treatment cohort). Results In the discovery cohort (n = 700), PROs showed excellent long‐term retest reliability. The minimum change that exceeded random fluctuation was conservatively determined to be 3 points for pain, 4 points for fatigue, and 16 points for function. In the treatment cohort (n = 2,788), 1,483 patients (53.2%) achieved a significant individual therapeutic response as assessed by Disease Activity Score in 28 joints (DAS28)–dcrit (≥1.8 points) after 12 months of adalimumab treatment; 68.5% of patients with a DAS28‐dcrit response achieved a significant improvement in pain, whereas approximately 40% achieved significant improvements in fatigue or function. Significant improvements in all 3 PROs occurred in 22.7% of patients; 22.8% did not have any significant PRO responses. In contrast, significant improvements in all 3 PROs occurred in only 4.4% of 1,305 patients who did not achieve a DAS28‐dcrit response at month 12, and 59.1% did not achieve any significant PRO responses. Conclusion The establishment of critical differences in PROs distinguishes true responses from random variation and provides insights into appropriate patient management.
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Affiliation(s)
- Eva C Scharbatke
- Schwerpunkt Rheumatologie/Klinische Immunologie Medizinische Klinik und Poliklinik II, Universität Würzburg, Würzburg, Germany
| | - Frank Behrens
- University Hospital Frankfurt, Goethe University, and Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Project Group Translational Medicine & Pharmacology TMP, Frankfurt am Main, Germany
| | - Marc Schmalzing
- Schwerpunkt Rheumatologie/Klinische Immunologie Medizinische Klinik und Poliklinik II, Universität Würzburg, Würzburg, Germany
| | - Michaela Koehm
- University Hospital Frankfurt, Goethe University, and Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Project Group Translational Medicine & Pharmacology TMP, Frankfurt am Main, Germany
| | - Gerd Greger
- AbbVie Deutschland GmbH & Co. KG, Wiesbaden, Germany
| | - Holger Gnann
- Abteilung Biostatistik, GKM Gesellschaft für Therapieforschung mbH, München, Germany
| | - Harald Burkhardt
- University Hospital Frankfurt, Goethe University, and Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Project Group Translational Medicine & Pharmacology TMP, Frankfurt am Main, Germany
| | - Hans-Peter Tony
- Schwerpunkt Rheumatologie/Klinische Immunologie Medizinische Klinik und Poliklinik II, Universität Würzburg, Würzburg, Germany.
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Pincus T, Chua JR, Gibson KA. Evidence from a Multidimensional Health Assessment Questionnaire (MDHAQ) of the Value of a Biopsychosocial Model to Complement a Traditional Biomedical Model in Care of Patients with Rheumatoid Arthritis. JOURNAL OF RHEUMATIC DISEASES 2016. [DOI: 10.4078/jrd.2016.23.4.212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Theodore Pincus
- Division of Rheumatology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Jacquelin R Chua
- Division of Rheumatology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Kathryn A Gibson
- Rheumatology Department, Liverpool Hospital, University of New South Wales, and Ingham Research Institute, Liverpool, NSW, Australia
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Emery P, Kavanaugh A, Bao Y, Ganguli A, Mulani P. Comprehensive disease control (CDC): what does achieving CDC mean for patients with rheumatoid arthritis? Ann Rheum Dis 2015; 74:2165-74. [PMID: 25139667 PMCID: PMC4680119 DOI: 10.1136/annrheumdis-2014-205302] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 06/10/2014] [Accepted: 07/26/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND This study assessed the impact of simultaneous achievement of clinical, functional and structural efficacy, herein referred to as comprehensive disease control (CDC), on short-term and long-term work-related outcomes, health-related quality of life (HRQoL), pain and fatigue. METHODS Data were pooled from three randomised trials of adalimumab plus methotrexate for treatment of early-stage or late-stage rheumatoid arthritis (RA). CDC was defined as 28-joint Disease Activity Score using C reactive protein <2.6, Health Assessment Questionnaire <0.5 and change from baseline in modified Total Sharp Score ≤0.5. Changes in scores at weeks 26 and 52 for work-related outcomes, Short Form 36 (SF-36) physical (PCS) and mental component scores (MCS), a Visual Analogue Scale measuring pain (VAS-Pain) and Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) were compared between patient groups defined by achievement of CDC at week 26 using linear regression with adjustment for baseline scores. RESULTS Patients with RA who achieved CDC at week 26 (n=200) had significantly greater improvements in VAS-Pain (46.9 vs 26.9; p<0.0001), FACIT-F (13.3 vs 7.5; p<0.0001), SF-36 PCS (19.7 vs 8.9; p<0.0001) and SF-36 MCS (8.1 vs 5.0; p=0.0004) than those who did not (n=1267). Results were consistent at week 52 and among methotrexate-naive patients with early RA, methotrexate-experienced patients with late-stage RA and patients with inadequate response to methotrexate. CONCLUSIONS Patients with RA who achieved CDC at week 26 had improved short-term and long-term HRQoL, pain, fatigue and work-related outcomes compared with patients who do not. These results demonstrate that the joint achievement of all CDC components provides meaningful benefits to patients. TRIAL REGISTRATION NUMBERS DE019: NCT00195702, PREMIER: NCT00195702, OPTIMA: NCT00195702.
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Affiliation(s)
- Paul Emery
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Yanjun Bao
- AbbVie Inc, North Chicago, Illinois, USA
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van der Heijde D, Joshi A, Pangan AL, Chen N, Betts K, Mittal M, Bao Y. ASAS40 and ASDAS clinical responses in the ABILITY-1 clinical trial translate to meaningful improvements in physical function, health-related quality of life and work productivity in patients with non-radiographic axial spondyloarthritis. Rheumatology (Oxford) 2015; 55:80-8. [PMID: 26316575 PMCID: PMC4676905 DOI: 10.1093/rheumatology/kev267] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To assess the impact of achieving Assessment in SpondyloArthritis international Society 40% (ASAS40) response or an Ankylosing Spondylitis Disease Activity Score inactive disease (ASDAS-ID) state on patient-reported outcomes (PROs) among patients with non-radiographic axial SpA (nr-axSpA). METHODS Data are from ABILITY-1, a phase 3 trial of adalimumab vs placebo in nr-axSpA patients. PROs included the HAQ for Spondyloarthropathies (HAQ-S), 36-item Short Form Health Survey (SF-36) physical component summary (PCS) score and Work Productivity and Activity Impairment Questionnaire. Patients were grouped by clinical response using ASAS40 response and ASDAS disease states at week 12. Changes in PROs from baseline to week 12 were compared between groups using analysis of covariance with adjustment for baseline scores. RESULTS At week 12, 47 of 179 patients were ASAS40 responders and 26 of 176 patients achieved ASDAS-ID (ASDAS <1.3). Compared with non-responders (n = 132), ASAS40 responders (n = 47) had a significantly greater improvement in mean HAQ-S (-0.65 vs -0.05, P < 0.0001), SF-36 PCS (12.4 vs 0.7, P < 0.0001), presenteeism (-24.7 vs -2.2, P < 0.0001), overall work impairment (-23.9 vs -2.5, P < 0.0001) and activity impairment (-33.5 vs -0.9, P < 0.0001) at week 12. Similarly, ASDAS-ID, ASDAS clinically important improvement (ASDAS-CII; improvement >1.1) and major improvement (ASDAS-MI; improvement >2.0) were associated with significantly greater improvements from baseline in the majority of the PROs. CONCLUSION Among nr-axSpA patients, ASAS40, ASDAS-CII and ASDAS-MI response and achievement of ASDAS-ID were associated with statistically significant and clinically meaningful improvements in physical function, health-related quality of life and work productivity in a higher percentage of patients.
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Affiliation(s)
| | | | - Aileen L Pangan
- Immunology Clinical Development, AbbVie Inc., North Chicago, IL and
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Interleukin-1 as a common denominator from autoinflammatory to autoimmune disorders: premises, perils, and perspectives. Mediators Inflamm 2015; 2015:194864. [PMID: 25784780 PMCID: PMC4345261 DOI: 10.1155/2015/194864] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/25/2014] [Indexed: 02/07/2023] Open
Abstract
A complex web of dynamic relationships between innate and adaptive immunity is now evident for many autoinflammatory and autoimmune disorders, the first deriving from abnormal activation of innate immune system without any conventional danger triggers and the latter from self-/non-self-discrimination loss of tolerance, and systemic inflammation. Due to clinical and pathophysiologic similarities giving a crucial role to the multifunctional cytokine interleukin-1, the concept of autoinflammation has been expanded to include nonhereditary collagen-like diseases, idiopathic inflammatory diseases, and metabolic diseases. As more patients are reported to have clinical features of autoinflammation and autoimmunity, the boundary between these two pathologic ends is becoming blurred. An overview of monogenic autoinflammatory disorders, PFAPA syndrome, rheumatoid arthritis, type 2 diabetes mellitus, uveitis, pericarditis, Behçet's disease, gout, Sjögren's syndrome, interstitial lung diseases, and Still's disease is presented to highlight the fundamental points that interleukin-1 displays in the cryptic interplay between innate and adaptive immune systems.
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Dinarello CA. An expanding role for interleukin-1 blockade from gout to cancer. Mol Med 2014; 20 Suppl 1:S43-58. [PMID: 25549233 PMCID: PMC4374514 DOI: 10.2119/molmed.2014.00232] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 01/08/2023] Open
Abstract
There is an expanding role for interleukin (IL)-1 in diseases from gout to cancer. More than any other cytokine family, the IL-1 family is closely linked to innate inflammatory and immune responses. This linkage is because the cytoplasmic segment of all members of the IL-1 family of receptors contains a domain, which is highly homologous to the cytoplasmic domains of all toll-like receptors (TLRs). This domain, termed "toll IL-1 receptor (TIR) domain," signals as does the IL-1 receptors; therefore, inflammation due to the TLR and the IL-1 families is nearly the same. Fundamental responses such as the induction of cyclo-oxygenase type 2, increased surface expression of cellular adhesion molecules and increased gene expression of a broad number of inflammatory molecules characterizes IL-1 signal transduction as it does for TLR agonists. IL-1β is the most studied member of the IL-1 family because of its role in mediating autoinflammatory disease. However, a role for IL-1α in disease is being validated because of the availability of a neutralizing monoclonal antibody to human IL-1α. There are presently three approved therapies for blocking IL-1 activity. Anakinra is a recombinant form of the naturally occurring IL-1 receptor antagonist, which binds to the IL-1 receptor and prevents the binding of IL-1β as well as IL-1α. Rilonacept is a soluble decoy receptor that neutralizes primarily IL-1β but also IL-1α. Canakinumab is a human monoclonal antibody that neutralizes only IL-1β. Thus, a causal or significant contributing role can be established for IL-1β and IL-1α in human disease.
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Affiliation(s)
- Charles Anthony Dinarello
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, Colorado, United States of America; and Department of Medicine, Radboud University, Nijmegen, the Netherlands
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PINCUS THEODORE, GIBSON KATHRYNA, BERTHELOT JEANMARIEM. Is a Patient Questionnaire Without a Joint Examination as Undesirable as a Joint Examination Without a Patient Questionnaire? J Rheumatol 2014; 41:619-21. [DOI: 10.3899/jrheum.140074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
IL-1 is a master cytokine of local and systemic inflammation. With the availability of specific IL-1 targeting therapies, a broadening list of diseases has revealed the pathologic role of IL-1-mediated inflammation. Although IL-1, either IL-1α or IL-1β, was administered to patients in order to improve bone marrow function or increase host immune responses to cancer, these patients experienced unacceptable toxicity with fever, anorexia, myalgias, arthralgias, fatigue, gastrointestinal upset and sleep disturbances; frank hypotension occurred. Thus it was not unexpected that specific pharmacological blockade of IL-1 activity in inflammatory diseases would be beneficial. Monotherapy blocking IL-1 activity in a broad spectrum of inflammatory syndromes results in a rapid and sustained reduction in disease severity. In common conditions such as heart failure and gout arthritis, IL-1 blockade can be effective therapy. Three IL-1blockers have been approved: the IL-1 receptor antagonist, anakinra, blocks the IL-1 receptor and therefore reduces the activity of IL-1α and IL-1β. A soluble decoy receptor, rilonacept, and a neutralizing monoclonal anti-interleukin-1β antibody, canakinumab, are also approved. A monoclonal antibody directed against the IL-1 receptor and a neutralizing anti-IL-1α are in clinical trials. By specifically blocking IL-1, we have learned a great deal about the role of this cytokine in inflammation but equally important, reducing IL-1 activity has lifted the burden of disease for many patients.
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Key Words
- AOSD
- Autoimmune
- Autoinflammatory
- C-reactive protein
- CAPS
- CRP
- DIRA
- FCAS
- FMF
- HIDS
- Inflammation
- NLRP12
- NLRP3
- NOMID
- PAPA
- PASH
- PFAPA
- SAPHO
- SJIA
- TNF receptor associated periodic syndrome
- TRAPS
- adult onset Still's disease
- cryopyrin autoinflammatory periodic syndromes
- deficiency of IL-1Ra
- familial Mediterranean fever
- familial cold autoinflammatory syndrome
- hyper IgD syndrome
- neonatal onset multi-inflammatory diseases
- nucleotide-binding domain and leucine-rich repeat pyrin containing 12
- nucleotide-binding domain and leucine-rich repeat pyrin containing 3
- periodic fever, aphthous stomatitis, pharyngitis, and adenitis
- pyoderma-gangrenosum, acne, and suppurativa hidradenitis
- pyogenic arthritis, pyoderma gangrenosum, and acne
- synovitis, acne, pustulosis, hyperostosis and osteitis
- systemic-onset juvenile idiopathic arthritis
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Affiliation(s)
- Charles A Dinarello
- Department of Medicine, University of Colorado Denver, Aurora, CO, United States; Department of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jos W M van der Meer
- Department of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Abstract
Patient-reported outcomes (PROs) have been successfully developed for a variety of chronic respiratory diseases, such as asthma and cystic fibrosis (CF). They have recently been used to evaluate the efficacy of new medications and assess current patient functioning. Although regulatory bodies have favored PROs that measures symptoms, other domains of functioning, such as treatment burden, should be considered. This review examines current guidelines for the development and application of PROs in clinical trials, describes methods for selecting appropriate measures for paediatric populations, and presents a model incorporating PROs into clinical practice. Guidance on interpretation of these measures and graphic presentation of results are illustrated. PROs can serve as the link between the health care provider and patient to foster collaborative and personalized medicine. This model promotes greater patient responsibility, facilitates communication with providers, encourages shared decision-making, and enhances adherence.
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Hull RD, Townshend G. Long-term treatment of deep-vein thrombosis with low-molecular-weight heparin: an update of the evidence. Thromb Haemost 2013; 110:14-22. [PMID: 23615656 DOI: 10.1160/th12-12-0931] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 03/21/2013] [Indexed: 11/05/2022]
Abstract
This article reviews updated evidence-based knowledge on long-term treatment of deep-vein thrombosis (DVT) with low-molecular-weight heparin (LMWH) or vitamin K antagonists (VKAs). Eleven trials were identified comparing the two treatments in a broad spectrum of patients with DVT and with >100 study participants. Four comparative trials were identified in patients with cancer and DVT (in whom anticoagulation treatment is more complex and bleeding complications more frequent). In the 11 trials in broad patient populations, LMWHs were as effective as VKAs in preventing recurrent venous thromboembolism (VTE), and there were no consistent differences in the incidence of bleeding complications during long-term treatment. In patients with cancer, VTE recurrence was significantly reduced with LMWH versus VKA in two studies, while major bleeding complications did not differ between groups in any of the four trials. Current evidence-based European and American guidelines recommend LMWH over VKA for the long-term treatment of DVT in patients with cancer. LMWH and VKA are recommended over the new oral anticoagulant drugs, for which there are limited data on use in long-term treatment. Post-thrombotic syndrome (PTS), a common complication of DVT, causes considerable morbidity. Long-term use of tinzaparin reduced the risk of PTS compared with VKA in one trial, and a meta-analysis of nine studies in total demonstrated a consistently favourable effect of LMWHs versus VKA on PTS-related outcomes. Given the limited treatment options available for PTS, this suggests that LMWHs provide a useful therapeutic option in any patient particularly at risk of developing PTS.
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Affiliation(s)
- Russell D Hull
- University of Calgary, 2500 University Drive Northwest, Calgary, Alberta T2N 1N4, Canada.
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Chan AW, Tetzlaff JM, Gøtzsche PC, Altman DG, Mann H, Berlin JA, Dickersin K, Hróbjartsson A, Schulz KF, Parulekar WR, Krleza-Jeric K, Laupacis A, Moher D. SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials. BMJ 2013; 346:e7586. [PMID: 23303884 PMCID: PMC3541470 DOI: 10.1136/bmj.e7586] [Citation(s) in RCA: 3182] [Impact Index Per Article: 289.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2012] [Indexed: 02/06/2023]
Abstract
High quality protocols facilitate proper conduct, reporting, and external review of clinical trials. However, the completeness of trial protocols is often inadequate. To help improve the content and quality of protocols, an international group of stakeholders developed the SPIRIT 2013 Statement (Standard Protocol Items: Recommendations for Interventional Trials). The SPIRIT Statement provides guidance in the form of a checklist of recommended items to include in a clinical trial protocol. This SPIRIT 2013 Explanation and Elaboration paper provides important information to promote full understanding of the checklist recommendations. For each checklist item, we provide a rationale and detailed description; a model example from an actual protocol; and relevant references supporting its importance. We strongly recommend that this explanatory paper be used in conjunction with the SPIRIT Statement. A website of resources is also available (www.spirit-statement.org). The SPIRIT 2013 Explanation and Elaboration paper, together with the Statement, should help with the drafting of trial protocols. Complete documentation of key trial elements can facilitate transparency and protocol review for the benefit of all stakeholders.
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Affiliation(s)
- An-Wen Chan
- Women's College Research Institute at Women's College Hospital, Department of Medicine, University of Toronto, Toronto, Canada M5G 1N8
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Matsuda S, Kawahara S, Okazaki K, Tashiro Y, Iwamoto Y. Postoperative alignment and ROM affect patient satisfaction after TKA. Clin Orthop Relat Res 2013; 471:127-33. [PMID: 22903282 PMCID: PMC3528933 DOI: 10.1007/s11999-012-2533-y] [Citation(s) in RCA: 214] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patient satisfaction has increasingly been recognized as an important measure after total knee arthroplasty (TKA). However, we do not know yet how and why the patients are satisfied or dissatisfied with TKA. QUESTIONS/PURPOSES We asked: (1) After TKA, how satisfied are patients and which activities were they able to do? (2) Are patient-derived scores related to physician-derived scores? (3) Which factors affect patient satisfaction and function? METHODS We retrospectively evaluated 375 patients who had undergone 500 TKAs between February 22, 2000 and December 1, 2009. We sent a questionnaire for The 2011 Knee Society Knee Scoring System to the patients. We determined the correlation of patient- and physician-derived scores and factors relating to the five questions relating to satisfaction and the 19 questions relating function. The minimum followup was 2 years (mean, 5 years; range, 2-11 years). RESULTS The mean score for symptoms was 19 (74%), 23 (59%) for patient satisfaction, 10 (64%) for patient expectations, and 53 (53%) for functional activities. We found a poor correlation between the patient-derived and the physician-derived scores. Old age and varus postoperative alignment negatively correlated with the satisfaction. Varus alignment and limited range of motion (ROM) negatively correlated with the expectation. Old age, rheumatoid arthritis, and limited ROM negatively correlated with the functional activities. CONCLUSIONS Most patients did not report symptoms, but they experienced difficulty with activities of daily living after TKA. Patient satisfaction is difficult to measure, but avoiding varus alignment and achieving better ROM appear to be important for increasing satisfaction and meeting expectations.
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Affiliation(s)
- Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
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Sikorskii A, Wyatt G, Tamkus D, Victorson D, Rahbar MH, Ahn S. Concordance between patient reports of cancer-related symptoms and medical records documentation. J Pain Symptom Manage 2012; 44:362-72. [PMID: 22699089 PMCID: PMC3432740 DOI: 10.1016/j.jpainsymman.2011.09.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 09/14/2011] [Accepted: 09/15/2011] [Indexed: 11/26/2022]
Abstract
CONTEXT Two sources of symptom data, patient report and medical records documentation, have been used in studies focusing on chronic conditions. The concordance of patient-reported cancer-related symptoms and clinician reports as documented in the medical records needs to be evaluated. OBJECTIVES To compare patient reports with medical record documentation of 12 disease- and treatment-related symptoms for women with advanced breast cancer undergoing chemotherapy or hormonal therapy for cancer control. METHODS Women (n=384) were recruited from 13 oncology clinics in the midwestern U.S. They completed telephone interviews at intake, five, and 11 weeks, where they reported the presence of 12 symptoms using a checklist. Medical records were abstracted when women completed the study. The concordance between patient reports and medical record documentation was assessed using percent agreement, kappa statistics, and McNemar's tests. Administration of medication for symptoms and patient characteristics were investigated in relation to the agreement of the two sources of data. RESULTS Poor to slight agreement was found, and disagreement was significant for all 12 symptoms. The concordance between symptom presence in the medical record and administration of medication for the management of those symptoms was moderate. Patient characteristics were not associated with agreement, except for age. The agreement was higher for older women for the symptom of mouth sores. CONCLUSION Medical records may not provide adequate documentation of symptoms, and collection of patient-reported symptom data from women with advanced breast cancer is critical to quality clinical management.
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Affiliation(s)
- Alla Sikorskii
- Department of Statistics and Probability, Michigan State University, East Lansing, Michigan 48824-1317, USA.
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Hull R, Butcher P. Value of Patient Self-Assessment in the Diagnosis and Monitoring of Post-Thrombotic Syndrome. Clin Appl Thromb Hemost 2012; 18:345-50. [DOI: 10.1177/1076029612443306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Strand V, Boers M, Idzerda L, Kirwan JR, Kvien TK, Tugwell PS, Dougados M. It's good to feel better but it's better to feel good and even better to feel good as soon as possible for as long as possible. Response criteria and the importance of change at OMERACT 10. J Rheumatol 2012; 38:1720-7. [PMID: 21807792 DOI: 10.3899/jrheum.110392] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The OMERACT patient reported outcomes (PRO) working group evaluated the methodologies for measuring responsiveness to change at the Outcome Measures in Rheumatology (OMERACT) 10 meeting. The outcome measures used in PRO studies are often expressed as continuous data at the group level (e.g., mean change in pain on a 0-100 visual analog scale). This is difficult to interpret and cannot easily be translated to the individual level of response. When interpreting scores at the individual level, it is important to take into account the following 4 main concepts: (1) improvement; (2) status of well-being; (3) onset of action; and (4) sustainability. Information from clinical trials on how many patients showed a response, what the level of response was, and how many patients are doing well, would be extremely useful for physicians. The objective of this article is to outline how continuous data may be reported in a clinically relevant manner. We will describe 5 techniques of reporting continuous variables in clinical studies and discuss the relevance of each.
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Affiliation(s)
- Vibeke Strand
- Department of Immunology/Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
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Evaluation of self-report questionnaires for assessing rheumatoid arthritis activity: A cross-sectional study of RAPID3 and RADAI5 and flare detection in 200 patients. Joint Bone Spine 2012; 79:57-62. [DOI: 10.1016/j.jbspin.2011.03.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2011] [Indexed: 01/23/2023]
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STRAND VIBEKE, RENTZ ANNEM, CIFALDI MARYA, CHEN NAIJUN, ROY SANJOY, REVICKI DENNIS. Health-related Quality of Life Outcomes of Adalimumab for Patients with Early Rheumatoid Arthritis: Results from a Randomized Multicenter Study. J Rheumatol 2011; 39:63-72. [DOI: 10.3899/jrheum.101161] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objective.Rheumatoid arthritis (RA) is associated with significant impairments in health-related quality of life (HRQOL). We evaluated patient-reported outcomes including HRQOL outcomes following adalimumab plus methotrexate (MTX) therapy in patients with early RA.Methods.PREMIER was a phase III, multicenter, randomized, double-blind, active-comparator clinical trial in early RA. Patients aged ≥ 18 years were randomly assigned to receive adalimumab 40 mg every other week (eow) plus weekly MTX, weekly MTX, or adalimumab 40 mg eow for 104 weeks. American College of Rheumatology (ACR) criteria were used to evaluate clinical efficacy and response. Outcomes were assessed using the Health Assessment Questionnaire Disability Index (HAQ-DI), Short-Form 36 Health Survey (SF-36), Short-Form 6 Dimension (SF-6D), visual analog scale (VAS) assessments of global disease activity (patient’s global assessment; PtGA) and pain, Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), and Health Utility Index Mark 3 (HUI-3).Results.Of 799 patients enrolled, 268 received adalimumab plus MTX, 257 received MTX monotherapy, and 274 received adalimumab monotherapy. Patients treated with adalimumab plus MTX demonstrated significant baseline to Week 104 improvements in HAQ-DI (p < 0.0001), SF-36 Physical Component Summary (p < 0.0001), 4 SF-36 domains [physical function (p < 0.0001), bodily pain (p <0.0001), vitality (p = 0.0139), role limitations-physical (p = 0.0005)], SF-6D (p = 0.0152), VAS-PtGA (p < 0.0001), VAS-pain (p < 0.0001), FACIT-F (p < 0.0001), and HUI-3 (p = 0.0034) scores versus patients treated with MTX monotherapy. Both SF-6D and HUI-3 were found to be sensitive preference-based measures for assessing the effects of treatment on multidimensional function. No clinically meaningful differences between adalimumab and MTX monotherapy groups were observed for most measures. For each measure, there was significant association between HRQOL improvement and ACR clinical response.Conclusion.Adalimumab plus MTX significantly improved physical functioning and HRQOL in patients with early RA over 2 years of treatment. (ClinicalTrials.gov identifier NCT00195663).
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Khanna G, Singh JA, Pomeroy DL, Gioe TJ. Comparison of patient-reported and clinician-assessed outcomes following total knee arthroplasty. J Bone Joint Surg Am 2011; 93:e117(1)-(7). [PMID: 22012534 DOI: 10.2106/jbjs.j.00850] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although the necessity of long-term follow-up after total knee arthroplasty is unquestioned, this task may become burdensome as greater numbers of total knee arthroplasties are performed. We sought to use comparisons with clinician-assessed values to determine whether patients could reliably assess their own outcome with use of a combination of American Knee Society Score and Oxford Knee Score questionnaires and self-reported knee motion. We hypothesized that patients would self-report worse pain and function and a similar range of knee motion than clinicians would. METHODS One hundred and forty patients (181 knees) scheduled for routine follow-up at two centers after primary total knee arthroplasty were mailed American Knee Society Score and Oxford Knee Score questionnaires, a set of photographs illustrating knee motion in 5° increments for comparison with the patient's range of knee motion, and a goniometer with instructions. The patient's American Knee Society Score, Oxford Knee Score, and knee motion were then independently assessed within two weeks of the self-evaluation by one of three clinicians who had not been involved with the surgery. Patient-reported and clinician-assessed measures were compared with use of a paired-sample t test and the Spearman correlation coefficient. RESULTS The mean patient-reported American Knee Society pain subscore was 4 points worse than the clinician-assessed score, and the function subscore was 10 points worse (p < 0.001 for both). The mean Oxford Knee Score did not differ significantly between the patient self-assessment and the clinician assessment (p = 0.05). The mean maximum flexion reported by the patient with use of the photographs differed by <1° from the mean value reported by the patient with use of the goniometer or the mean value measured by the clinician; these differences were not clinically important. CONCLUSIONS Patients' self-reported American Knee Society pain and function subscores were worse than the corresponding clinician assessments, but the two Oxford Knee Scores were similar. Range of knee motion may reasonably be self-assessed by comparison with photographs. Long-term follow-up of patients after total knee arthroplasty may be possible with use of patient-reported measures, alleviating the burden of clinic visits yet maintaining contact, but further studies involving other validated instruments is warranted.
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Affiliation(s)
- Gaurav Khanna
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
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Rigby W, Ferraccioli G, Greenwald M, Zazueta-Montiel B, Fleischmann R, Wassenberg S, Ogale S, Armstrong G, Jahreis A, Burke L, Mela C, Chen A. Effect of rituximab on physical function and quality of life in patients with rheumatoid arthritis previously untreated with methotrexate. Arthritis Care Res (Hoboken) 2011; 63:711-20. [DOI: 10.1002/acr.20419] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Gabay C. Cytokine neutralizers. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00060-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Tiplady B, Goodman K, Cummings G, Lyle D, Carrington R, Battersby C, Ralston SH. Patient-Reported Outcomes in Rheumatoid Arthritis. THE PATIENT: PATIENT-CENTERED OUTCOMES RESEARCH 2010. [DOI: 10.2165/11535590-000000000-00000] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Mease PJ, Woolley JM, Singh A, Tsuji W, Dunn M, Chiou CF. Patient-reported outcomes in a randomized trial of etanercept in psoriatic arthritis. J Rheumatol 2010; 37:1221-7. [PMID: 20395648 DOI: 10.3899/jrheum.091093] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the effects of etanercept treatment on patient-reported outcomes (PRO) in patients with psoriatic arthritis (PsA). METHODS A 24-week double-blind comparison to placebo was followed by a 48-week open-label phase in which all eligible patients received etanercept. PRO were measured using the Stanford Health Assessment Questionnaire Disability Index (HAQ-DI), the Medical Outcomes Study Short-Form (SF-36), the EQ-5D visual analog scale (VAS), and the American College of Rheumatology (ACR) patient pain assessment. RESULTS Beginning at Week 4 and continuing through Week 24 of double-blind treatment, patients treated with etanercept had significantly higher mean percentage improvement in HAQ-DI relative to baseline than patients given placebo (53.6% vs 6.4% at Week 24; p < 0.001). After 48 weeks of open-label treatment with etanercept, the mean percentage change from study baseline was 52.8% for the original etanercept group and 46.9% for the original placebo group, with 41.2% of patients overall achieving a HAQ-DI of 0. Mean changes relative to baseline for SF-36 physical component summary scores, EQ-5D VAS, and ACR pain assessment were also significant in the double-blind period for etanercept compared with placebo (p < 0.001 for all 3 measures). Patients taking placebo achieved similar improvements once they began treatment with etanercept in the open-label period. CONCLUSION Patients with PsA treated with etanercept reported significant improvements in physical function that were almost 10 times the improvement seen with placebo and were maintained for up to 2 years. Almost half of patients treated with etanercept reported no disability by the end of the study.
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Affiliation(s)
- Philip J Mease
- Seattle Rheumatology Associates and Swedish Medical Center, 1101 Madison Street, Seattle, WA 98104, USA.
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Sokka T, Pincus T. Joint counts to assess rheumatoid arthritis for clinical research and usual clinical care: advantages and limitations. Rheum Dis Clin North Am 2010; 35:713-22, v-vi. [PMID: 19962615 DOI: 10.1016/j.rdc.2009.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A joint examination is prerequisite to a diagnosis of rheumatoid arthritis (RA), and quantitative counts of swollen and tender joints are the most specific of the 7 RA Core Data Set measures for patient assessment. Therefore, joint counts are weighted of greater importance than the other 5 Core Data Set measures in American College of Rheumatology response criteria and all RA indices in which it is included. Nonetheless, several limitations to the joint count have been recognized: (1) poor reproducibility with a requirement to be performed by the same observer at each visit; (2) likelihood to improve with placebo treatment as much or more than the other 5 RA Core Data Set measures; (3) similar or lower relative efficiencies than global and patient measures to document differences between active and control treatments in clinical trials; (4) improvement over 5 years while joint damage and functional disability may progress; (5) lower sensitivity in detecting inflammatory activity than ultrasound and magnetic resonance imaging. Most visits to a rheumatologist do not include a formal quantitative joint count. Quantitative patient self-report data are as sensitive to change and as informative about prognosis and outcomes as joint counts. It may be suggested that a careful qualitative (nonquantitative) joint examination, supplemented by quantitative self-report questionnaire scores to interpret physical examination findings, may be adequate to monitor patients and document changes in status in busy clinical settings.
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Affiliation(s)
- Tuulikki Sokka
- Jyväskylä Central Hospital, Jyväskylä, and Medcare Oy, Aänekoski, Finland
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Pincus T, Yazici Y, Bergman MJ. Patient questionnaires in rheumatoid arthritis: advantages and limitations as a quantitative, standardized scientific medical history. Rheum Dis Clin North Am 2010; 35:735-43, vii. [PMID: 19962618 DOI: 10.1016/j.rdc.2009.10.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In many chronic diseases, objective gold standard measures such as blood pressure, cholesterol, and bone densitometry often provide most of the information used to establish a diagnosis and guide therapy. By contrast, in inflammatory rheumatic diseases, information from a patient history usually is considerably more prominent in clinical management. Patient history data can be recorded as standardized, quantitative scientific data through use of validated self-reported questionnaires. Patient questionnaires address the primary concerns of patients and their families. Questionnaire scores distinguish active from control treatments in clinical trials at similar levels to swollen and tender joint counts or laboratory tests. Patient questionnaire data are correlated significantly with joint counts, radiographic scores, and laboratory tests, but usually are far more significant than these measures in the prognosis of severe outcomes of rheumatoid arthritis (RA), including work disability, costs, and premature death. Limitations of patient questionnaires are based on cultural features involving variation in responses among ethnic groups, and a need for translation, although translated questionnaires can be as valuable as a translator. Patient questionnaires do not replace further medical history, physical examination, laboratory tests, and imaging data, and they require interpretation in a context of these standard sources of information at any clinical encounter. Patient questionnaires are useful to monitor patient status in usual clinical care, with almost no effort on the part of the physician and staff if distributed by the receptionist in the infrastructure of office practice.
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Affiliation(s)
- Theodore Pincus
- Division of Rheumatology, Department of Medicine, New York University School of Medicine and NYU Hospital for Joint Diseases, Room 1608, 301 East 17th Street, New York, NY 10003, USA.
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Pincus T, Swearingen CJ, Bergman MJ, Colglazier CL, Kaell AT, Kunath AM, Siegel EL, Yazici Y. RAPID3 (Routine Assessment of Patient Index Data) on an MDHAQ (Multidimensional Health Assessment Questionnaire): Agreement with DAS28 (Disease Activity Score) and CDAI (Clinical Disease Activity Index) activity categories, scored in five versus more than ninety seconds. Arthritis Care Res (Hoboken) 2010; 62:181-9. [DOI: 10.1002/acr.20066] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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McCollum L, Pincus T. A Biopsychosocial Model to Complement a Biomedical Model: Patient Questionnaire Data and Socioeconomic Status Usually Are More Significant than Laboratory Tests and Imaging Studies in Prognosis of Rheumatoid Arthritis. Rheum Dis Clin North Am 2009; 35:699-712, v. [DOI: 10.1016/j.rdc.2009.10.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rintelen B, Sautner J, Haindl PM, Andel I, Maktari A, Leeb BF. Comparison of three rheumatoid arthritis disease activity scores in clinical routine. Scand J Rheumatol 2009; 38:336-41. [DOI: 10.1080/03009740902932835] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Gibbons LJ, Hyrich KL. Biologic therapy for rheumatoid arthritis: clinical efficacy and predictors of response. BioDrugs 2009; 23:111-24. [PMID: 19489652 DOI: 10.2165/00063030-200923020-00004] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic, disabling disease of the synovial joints, thought to be autoimmune in origin. The emergence of biologic therapies has proven to be highly successful in effectively treating RA in the majority of cases. However, the cost of these agents is high and some patients do not respond to these drugs, or they suffer from adverse events. This article will review the currently available data on efficacy and the clinical, genetic, and biomarkers of response to these biologic therapies in RA. The anti-tumour necrosis factor-alpha (anti-TNFalpha) agents, adalimumab, etanercept and infliximab, act to neutralize the pro-inflammatory cytokine. Response to these agents is higher in patients receiving concurrent disease modifying anti-rheumatic drugs or non-steroidal anti-inflammatory drugs, in those with lesser disability, and in non-smokers. Many genetic predictors of response have been investigated, such as the shared epitope, the TNF gene and its receptors, but none have been absolutely confirmed. Synovial expression of TNFalpha has been suggested as a biomarker of response, while anti-cyclic citrullinated peptide antibody and rheumatoid factor (RF)-positivity predict poor response. Newer biologic agents include the interleukin (IL)-1 receptor antagonist anakinra, the B-cell depleting agent rituximab, the selective costimulation modulator abatacept, and the anti-IL-6 receptor monoclonal antibody tocilizumab. No genetic studies of response to these agents have been performed to date. However, it has been reported that low synovial infiltration of B cells and complete B-cell depletion after the first rituximab infusion are predictors of good response to this agent.
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Affiliation(s)
- Laura J Gibbons
- ARC Epidemiology Unit, Epidemiology Research Group, School of Translational Medicine, University of Manchester, Manchester, UK
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Abstract
BACKGROUND In the past decade, a novel class of therapies directed against specific cytokines implicated in the disease process of rheumatoid arthritis (RA), called the 'Biologics' have greatly improved and expanded treatment for RA. Anakinra is an interleukin-1 receptor antagonist that is currently FDA-approved for moderate-severe RA that has been unresponsive to initial disease-modifying anti-rheumatic drugs (DMARD) therapy. OBJECTIVES To evaluate the clinical effectiveness and safety of anakinra in adult patients with rheumatoid arthritis. SEARCH STRATEGY We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2008), MEDLINE (1950 to Week 4 2008) , EMBASE (1980 to Week 5 2008), CINAHL (1982 to November 2007) and reference lists of articles. SELECTION CRITERIA Randomized controlled trials comparing anakinra alone or in combination with DMARDs or biologics to placebo or other DMARDs or biologics in patients >18 years old with rheumatoid arthritis. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. MAIN RESULTS Five trials involving 2876 patients, 781 randomized to placebo and 2065 to anakinra, were included. There was a significant improvement in number of participants achieving ACR20 (38% versus 23%) who were treated with anakinra 50 to 150 mg daily versus placebo after 24 weeks. This 15% increase in patients achieving ACR20 with anakinra versus placebo is felt to be a clinically meaningful, though modest, outcome. Other efficacy data - including ACR50 (18% versus 7%), ACR70 (7% versus 2%), HAQ, visual analog score (VAS), Larsen radiographic scores, and change in erythrocyte sedimentation rate (ESR) - all demonstrated significant improvement with anakinra 50 to 150 mg daily versus placebo as well. There were no statistically significant differences noted in most safety outcomes with treatment with anakinra versus placebo - including number of withdrawals, deaths, adverse events (total and serious), and infections (total and serious). Injection site reactions were significantly increased, occurring in 1235/1729 (71%) versus 204/729 (28%) of patients treated with anakinra versus placebo, respectively. The incidence of serious infections was clinically higher, but not statistically different, in the anakinra (25/1366 patients, 1.8%) versus placebo group (3/534 patients, 0.6%). AUTHORS' CONCLUSIONS Anakinra is a relatively safe and modestly efficacious biologic therapy for rheumatoid arthritis. Although head to head comparison trials have not been carried out, the amount of improvement is notably less when compared to studies using other biologic therapies. More studies are needed to evaluate safety and efficacy, especially in comparison to other therapies, and adverse event data for the long-term use of Anakinra has yet to be assessed.
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Affiliation(s)
- Marty Mertens
- University of Minnesota, 596 Grand Ave., Apt 1, Saint Paul, Minnesota 55102, USA.
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van der Kooij SM, de Vries-Bouwstra JK, Goekoop-Ruiterman YPM, Ewals JAPM, Han KH, Hazes JMW, Kerstens PJSM, Peeters AJ, van Zeben D, Breedveld FC, Huizinga TWJ, Dijkmans BAC, Allaart CF. Patient-reported outcomes in a randomized trial comparing four different treatment strategies in recent-onset rheumatoid arthritis. Arthritis Care Res (Hoboken) 2008; 61:4-12. [DOI: 10.1002/art.24367] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Gioe TJ, Pomeroy D, Suthers K, Singh JA. Can patients help with long-term total knee arthroplasty surveillance? Comparison of the American Knee Society Score self-report and surgeon assessment. Rheumatology (Oxford) 2008; 48:160-4. [PMID: 19106165 DOI: 10.1093/rheumatology/ken439] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To compare patient self-report of knee flexion, extension, range of motion (ROM) and American Knee Society (AKS) Pain, Knee and Functional scores with a clinician assessment. METHODS A total of 239 consecutive total knee arthroplasty (TKA) patients (290 knees) were mailed surveys with an AKS questionnaire and lateral knee photographs that showed knee ROM in 10 degrees increments to compare their operated knee(s) ROM. Patients were subsequently seen in clinic and their ROM, AKS Pain, Knee and Functional scores were measured. Patient- and physician-reported measures were compared using independent sample t-test and correlated using Spearman's correlation coefficient. A priori rules for comparisons were based on previously published reports. RESULTS A total of 286 knees had both survey and clinic data available and constituted the analytic set. Patient-reported and physician-assessed extension, flexion and ROM were: 3 +/- 4.8 degrees vs 1.4 +/- 4.3 degrees (P < 0.001), 111.4 +/- 14.6 degrees vs 110 +/- 12.8 degrees (P = 0.04) and 108.6 +/- 16.8 vs 108.6 +/- 14.3 degrees (P = 0.98). There was a moderate correlation between patient and physician assessments (extension = 0.31; flexion = 0.44; ROM = 0.42; P < or = 0.001 for all). Patient-reported and physician-assessed AKS Pain, Knee and Functional scores were: 35.8 +/- 15.6 vs 43.9 +/- 11.1 (P < 0.001), 79.8 +/- 20 vs 88.9 +/- 13.3 (P < 0.001) and 57.7 +/- 23.1 vs 65.7 +/- 26.4 (P < 0.001), respectively. Patient- and physician-assessed AKS Pain, Knee and Functional scores had moderate-high correlation (r = 0.49, 0.49 and 0.70; P < or = 0.001 for all). CONCLUSION Long-term surveillance of TKA patients may be possible using a self-report AKS, but the average 8- to 10-point difference between patient- and physician-reported AKS scores (patients reporting poorer scores) represents a substantial impact on this outcome instrument. Since patient-reported responses have clear value in global assessment, further evaluation with other validated outcome instruments is warranted.
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Affiliation(s)
- T J Gioe
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Department of Veterans Affairs Medical Center, Section 112E, 1 Veterans Drive, Minneapolis, MN 55417, USA.
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Takeda H, Suzuki Y, Takeda Y, Nishise S, Fukui T, Fujishima S, Orii T, Otake S, Sato T, Suzuki K, Nakamuara Y, Kawata S. A multi center study of granulocyte and monocyte adsorption apheresis therapy for ulcerative colitis-clinical efficacy and production of interleukin-1 receptor antagonist. J Clin Apher 2008; 23:105-10. [PMID: 18449931 DOI: 10.1002/jca.20164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Granulocyte and monocyte adsorption apheresis (GCAP) is a useful strategy for intractable ulcerative colitis, but its mechanisms of therapy is not fully explained. Previously, depleting activated granulocytes and monocytes (GMs) and modifying product of proinflammatory cytokines had been proposed. In addition, activated GMs are releasing anti-inflammatory cytokines, interleukin-1 receptor antagonist (IL-1ra) that may contribute to the clinical efficacy of GCAP therapy. Hence, to investigate contribution of IL-1ra as well as to confirm clinical efficacy of this therapy based on clinical activity index (CAI), we performed a multicenter study. Twenty-five of 38 (65.8%) patients achieved remission state (CAI < or = 4) and two of 38 (5.3%) revealed clinical improvement. Almost effective cases significantly decreased CAI even at 3rd session of GCAP. Plasma level of IL-1ra from outflow of the GCAP column at 30 min was significantly increased rather than inflow. Median exact elevated level of IL-1ra was 221 pg/ml and median of increasing ratio was 1.6 times. Furthermore, the responsive patients, who well released the IL-1ra at outflow more than 100 pg/ml compared with inflow, tended to show clinical effectiveness. While, the increased ratio of IL-1ra in effective cases did not differ from ineffective cases, and there were no significant relationship with improvement of CAI score. These conflict results suggest that the increase of IL-1ra at outflow is not a direct factor to the clinical improvement, but the induction of clinical improvement is accompanied by the release of IL-1ra. The IL-1ra may be involved in the multiple steps for the improvement induced by GCAP.
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Affiliation(s)
- Hiroaki Takeda
- Division of Endoscopy, Yamagata University Hospital, Yamagata, Japan.
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Evangelou E, Tsianos G, Ioannidis JPA. Doctors' versus patients' global assessments of treatment effectiveness: empirical survey of diverse treatments in clinical trials. BMJ 2008; 336:1287-90. [PMID: 18495634 PMCID: PMC2413393 DOI: 10.1136/bmj.39560.759572.be] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To examine whether doctors' global assessments of treatment effects agree with patients' global assessments. DESIGN Survey of trials included in systematic reviews of treatments for diverse conditions. DATA SOURCES Cochrane database of systematic reviews. Data extracted Data on patients' global assessments and on doctors' global assessment for the same treatment against the same comparator. MAIN OUTCOME MEASURES Relative odds ratio (ratio of odds ratios of global improvement with the experimental intervention versus control according to doctors compared with patients), and improvement rates according to doctors and patients. RESULTS Doctors' global assessments were compared with patients' global assessments for 63 different treatment comparisons (240 trials) in 18 conditions. The summary relative odds ratio across the comparisons was not significant (0.98, 95% confidence interval 0.88 to 1.08; I(2)=0%, 95% confidence interval 0% to 30%). In 62 of the 63 comparisons the effects of treatment rated by patients and by doctors did not differ beyond chance, but for single comparisons the confidence intervals were large. Rates of improvement on average did not differ between doctors' assessments and patients' assessments (summary relative odds ratio 0.98, 0.88 to 1.06; I(2)=0%, 0% to 24%). CONCLUSION Doctors' global assessments of the effects of treatments are on average similar to those of patients.
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Affiliation(s)
- Evangelos Evangelou
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina 45110, Greece
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Choy EH, Khoshaba B, Cooper D, MacGregor A, Scott DL. Development and validation of a patient-based disease activity score in rheumatoid arthritis that can be used in clinical trials and routine practice. ACTA ACUST UNITED AC 2008; 59:192-9. [PMID: 18240256 DOI: 10.1002/art.23342] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Assessor-based disease activity measures such as the Disease Activity Score in 28 joints (DAS28), although widely used in rheumatoid arthritis (RA), have high interobserver variability. We developed and validated a patient-based disease activity score (PDAS) as an alternative assessment. METHODS Patients' assessments of swollen or tender joints, visual analog scales for pain and general health, the Health Assessment Questionnaire, and erythrocyte sedimentation rate (ESR) were used to develop the PDAS. In a developmental cohort (204 patients), regression analyses determined the best fit with the DAS28. A validation cohort (322 patients) subsequently evaluated criterion and construct validity against a range of outcome measures, including the Nottingham Health Profile (NHP) and Short Form 36 (SF-36). Sensitivity to change was assessed in 56 patients after 6 months of treatment with disease-modifying antirheumatic drugs or biologics. RESULTS In the developmental cohort, the PDAS with ESR (PDAS1) and without ESR (PDAS2) achieved excellent fit with the DAS28 (r = 0.88 and 0.74, respectively). In the validation cohort, the PDAS showed high criterion validity by correlation with the DAS28 (PDAS1: r = 0.89, PDAS2: r = 0.76). Construct validity was demonstrated by high correlations with a range of disease activity measures (r > or = 0.45), whereas low correlations (r < 0.45) with mental and social components of the SF-36 and NHP indicated divergent validity. The PDAS and DAS28 had similar sensitivity to change, determined using effect sizes (DAS28 = 1.03, PDAS1 = 1.02, PDAS2 = 0.77) or standardized response means (DAS28 = 0.79, PDAS1 = 0.77, PDAS2 = 0.73). CONCLUSION The PDAS1 and PDAS2 are valid and sensitive tools to assess disease activity in RA. They appear suitable for clinical decision making, epidemiologic research, and clinical trials.
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Affiliation(s)
- Ernest H Choy
- Sir Alfred Baring Garrod Clinical Trials Unit, Academic Department of Rheumatology, King's College London, London, UK.
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Trotti A, Colevas AD, Setser A, Basch E. Patient-reported outcomes and the evolution of adverse event reporting in oncology. J Clin Oncol 2007; 25:5121-7. [PMID: 17991931 DOI: 10.1200/jco.2007.12.4784] [Citation(s) in RCA: 236] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Adverse event (AE) reporting in oncology has evolved from informal descriptions to a highly systematized process. The Common Terminology Criteria for Adverse Events (CTCAE) is the predominant system for describing the severity of AEs commonly encountered in oncology clinical trials. CTCAE clinical descriptors have been developed empirically during more than 30 years of use. The method of data collection is clinician based. Limitations of the CTC system include potential for incomplete reporting and limited guidance on data analysis and presentation methods. The Medical Dictionary for Regulatory Activities (MedDRA) is a comprehensive medical terminology system used for regulatory reporting and drug labeling. MedDRA does not provide for severity ranking of AEs. CTC-based data presentations are the primary method of AE data reporting used in scientific journals and oncology meetings. Patient-reported outcome instruments (PROs) cover the subjective domain of AEs. Exploratory work suggests PROs can be used with a high degree of patient engagement and compliance. Additional studies are needed to determine how PROs can be used to complement current AE reporting systems. Potential models for integrating PROs into AE reporting are described in this review. AE reporting methods will continue to evolve in response to changing therapies and growing interest in measuring the impact of cancer treatment on health status. Although integration of PROs into AE reporting may ultimately improve the comprehensiveness and quality of collected data, it may also increase the administrative burden and cost of conducting trials. Therefore, care must be used when developing health outcomes and safety data collection plans.
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Affiliation(s)
- Andy Trotti
- Division of Radiation Oncology, H. Lee Moffitt Cancer Center at University of South Florida, Tampa, FL 33612-9416, USA.
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de La Mata Llord J, González Crespo R, Maese Manzano J. Tratamiento de la artritis reumatoide con anakinra: revisión sistemática. ACTA ACUST UNITED AC 2007; 3:153-8. [DOI: 10.1016/s1699-258x(07)73613-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Accepted: 03/28/2007] [Indexed: 12/01/2022]
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Zatarain E, Strand V. Monitoring disease activity of rheumatoid arthritis in clinical practice: contributions from clinical trials. ACTA ACUST UNITED AC 2007; 2:611-8. [PMID: 17075600 DOI: 10.1038/ncprheum0246] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2005] [Accepted: 03/13/2006] [Indexed: 11/09/2022]
Abstract
Rheumatoid arthritis is a heterogeneous and progressive autoimmune disease, and patients with this condition show varied responses to treatment. Practical, reliable, individually tailored measures of disease activity and treatment responses are needed. Outcome measures used in randomized, controlled trials, including American College of Rheumatology response criteria and Disease Activity Scores, identify when treatment should be initiated or changed, but can be time consuming and impractical in daily practice. Simplified disease activity indices, abbreviated joint counts and patient-report questionnaires are more-convenient ways to assess therapeutic responses in the clinic. Patient-reported measures of physical function, pain and global disease activity best differentiate the results of active treatment from those of placebo treatment in randomized, controlled trials. Improvements in physical function closely reflect changes in health-related quality of life. Recent trials have demonstrated limited correlations between clinical responses and radiographically demonstrated responses; both should be assessed on a regular basis. It is recommended that three domains be assessed in the clinic for therapeutic responses: patient-reported measures of physical function and/or global disease activity; physician assessment of disease activity; and imaging of the hands and/or feet on a biannual basis. Problematic joints and cervical spine involvement should be followed as clinically indicated. Measures of improvement for individually relevant physical activities need to be defined for each patient.
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Affiliation(s)
- Ernesto Zatarain
- Division of Immunology and Rheumatology at Stanford University School of Medicine, Palo Alto, CA 94035, USA.
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