A meta-analysis of left ventricular dysfunction in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory arthritis affecting the spine, presenting a considerable morbidity risk. Although evidence consistently indicates an elevated risk of ischemic heart disease among AS patients, debates persist regarding the likelihood of these patients developing left ventricular dysfunction (LVD). Our investigation aimed to determine whether individuals with AS face a greater risk of LVD compared to the general population. To accomplish this, we identified studies exploring LVD in AS patients across five major databases and Google Scholar. Initially, 431 studies were identified, of which 30 met the inclusion criteria, collectively involving 2933 participants. Results show that AS patients had: (1) poorer Ejection Fraction (EF) [mean difference (MD): -0.92% (95% CI: -1.25 to -0.59)], (2) impaired Early (E) and Late (atrial-A) ventricular filling velocity (E/A) ratio [MD: -0.10 m/s (95% CI: -0.13 to -0.08)], (3) prolonged deceleration time (DT) [MD: 12.30 ms (95% CI: 9.23-15.36)] and, (4) a longer mean isovolumetric relaxation time (IVRT) [MD: 8.14 ms (95% CI: 6.58-9.70)] compared to controls. Though AS patients show increased risks of both systolic and diastolic LVD, we found no significant differences were observed in systolic blood pressure [MD: 0.32 mmHg (95% Confidence Interval (CI): -2.09 to 2.73)] or diastolic blood pressure [MD: 0.30 mmHg (95% CI: -0.40 to 1.01)] compared to the general population. This study reinforces AS patients' susceptibility to LVD without a notable difference in HTN risk.

Shoulder arthroplasty for inflammatory arthritis is associated with higher rates of medical and surgical complications: a nationwide matched cohort analysis from 2016-2020

BACKGROUND

Inflammatory arthritis (IA) represents a less common indication for anatomic and reverse total shoulder arthroplasty (TSA) than osteoarthritis (OA). The safety and efficacy of anatomic and reverse TSA in this population has not been as well studied compared to OA. We analyzed the differences in outcomes between IA and OA patients undergoing TSA.

METHODS

Patients who underwent primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) from 2016-2020 were identified in the Premier Healthcare Database. Inflammatory arthritis (IA) patients were identified using International Classification of Diseases, Tenth Revision, diagnosis codes and compared to osteoarthritis controls. Patients were matched in a 1:8 fashion by age (±3 years), sex, race, and presence of pertinent comorbidities. Patient demographics, hospital factors, and patient comorbidities were compared. Multivariate regression was performed following matching to account for any residual confounding and 90-day complications were compared between the 2 cohorts. Descriptive statistics and regression analysis were employed with significance set at P < .05.

RESULTS

Prior to matching, 5685 IA cases and 93,539 OA controls were identified. Patients with IA were more likely to be female, have prolonged length of stay and increased total costs (P < .0001). After matching and multivariate analysis, 4082 IA cases and 32,656 controls remained. IA patients were at increased risk of deep wound infection (OR 3.14, 95% CI 1.38-7.16, P = .006), implant loosening (OR 4.11, 95% CI 1.17-14.40, P = .027), and mechanical complications (OR 6.34, 95% CI 1.05-38.20, P = .044), as well as a decreased risk of postoperative stiffness (OR 0.36, 95% CI 0.16-0.83, P = .002). Medically, IA patients were at increased risk of PE (OR 2.97, 95% CI 1.52-5.77, P = .001) and acute blood loss anemia (OR 1.27, 95% CI 1.12-1.44, P < .0001).

DISCUSSION AND CONCLUSION

Inflammatory arthritis represents a distinctly morbid risk profile compared to osteoarthritis patients with multiple increased surgical and postoperative medical complications in patients undergoing aTSA and rTSA. Surgeons should consider these potential complications and employ a multidisciplinary approach in preoperative risk stratification of IA undergoing shoulder replacement.

Prognostic factors associated with failure of total elbow arthroplasty

Aims

The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA).

Methods

Electronic literature searches were conducted using MEDLINE, Embase, PubMed, and Cochrane. All studies reporting prognostic estimates for factors associated with the revision of a primary TEA were included. The risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and the quality of evidence was assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. Due to low quality of the evidence and the heterogeneous nature of the studies, a narrative synthesis was used.

Results

A total of 19 studies met the inclusion criteria, investigating 28 possible prognostic factors. Most QUIPS domains (84%) were rated as moderate to high risk of bias. The quality of the evidence was low or very low for all prognostic factors. In low-quality evidence, prognostic factors with consistent associations with failure of TEA in more than one study were: the sequelae of trauma leading to TEA, either independently or combined with acute trauma, and male sex. Several other studies investigating sex reported no association. The evidence for other factors was of very low quality and mostly involved exploratory studies.

Conclusion

The current evidence investigating the prognostic factors associated with failure of TEA is of low or very low quality, and studies generally have a moderate to high risk of bias. Prognostic factors are subject to uncertainty, should be interpreted with caution, and are of little clinical value. Higher-quality evidence is required to determine robust prognostic factors for failure of TEA.

Reviews for multimorbidity risk in people with inflammatory conditions: a qualitative study

BACKGROUND

People with inflammatory rheumatological conditions (IRCs) are at high risk of developing other conditions including cardiovascular disease and mood disorders.

AIM

To explore perspectives of people with IRCs and healthcare practitioners (HCPs) on the content and delivery of a review consultation aimed at identification and management of multiple long-term conditions.

DESIGN & SETTING

Semi-structured interviews and focus groups with people with IRCs and HCPs.

METHOD

People with IRCs participated in individual semi-structured interviews by telephone or online platform. HCPs (including primary and secondary care clinicians) participated in online focus groups. Data were transcribed verbatim and analysed using inductive thematic analysis.

RESULTS

15 people with IRCs were interviewed; three focus groups with HCPs were conducted. Two main themes were identified: reflecting on the value of review consultations and what would a new review look like. Overall, people with IRCs and HCPs reflected that access to reviews is inequitable, leading to duplication of reviews and fragmentation in care. People with IRCs, at times, had difficulty conceptualising reviews, especially when discussing their future risk of conditions. People suggested that preparation before the healthcare review could align patient and HCP agendas as part of a flexible and person-centred discussion.

CONCLUSION

Any review introduced for people with IRCs must move beyond a "tick-box" exercise. To gain maximum value from a review, preparation from both patient and HCP may be required alongside a person-centred approach whilst ensuring they are targeted at people most likely to benefit.

Unraveling the Diagnosis of Hypocomplementemic Urticarial Vasculitis Syndrome

Hypocomplementemic urticarial vasculitis syndrome (HUVS) is a rare condition characterized by immune complex-mediated urticarial lesions with histological features of leukocytoclastic vasculitis, low serum complement levels, and is frequently associated with systemic manifestations. Its pathophysiology is poorly understood. We present a patient who presented with abdominal pain and skin rash. Extensive work-up was performed including skin biopsy, and the presence of angioedema, oral ulcers, low complement level, leukocytic vasculitis, and persistent eosinophilia ultimately led to the diagnosis of HUVS. This case highlights the importance of recognizing and differentiating HUVS from other cutaneous diseases, which in turn helps to optimally manage these patients.

Structural Features and Physiological Associations of Human 14-3-3ζ Pseudogenes

There are about 14,000 pseudogenes that are mutated or truncated sequences resembling functional parent genes. About two-thirds of pseudogenes are processed, while others are duplicated. Although initially thought dead, emerging studies indicate they have functional and regulatory roles. We study 14-3-3ζ, an adaptor protein that regulates cytokine signaling and inflammatory diseases, including rheumatoid arthritis, cancer, and neurological disorders. To understand how 14-3-3ζ (gene symbol YWHAZ) performs diverse functions, we examined the human genome and identified nine YWHAZ pseudogenes spread across many chromosomes. Unlike the 32 kb exon-to-exon sequence in YWHAZ, all pseudogenes are much shorter and lack introns. Out of six, four YWHAZ exons are highly conserved, but the untranslated region (UTR) shows significant diversity. The putative amino acid sequence of pseudogenes is 78-97% homologous, resulting in striking structural similarities with the parent protein. The OMIM and Decipher database searches revealed chromosomal loci containing pseudogenes are associated with human diseases that overlap with the parent gene. To the best of our knowledge, this is the first report on pseudogenes of the 14-3-3 family protein and their implications for human health. This bioinformatics-based study introduces a new insight into the complexity of 14-3-3ζ's functions in biology.

Neuropsychiatric symptoms in Systemic Lupus Erythematosus: mixed methods analysis of patient-derived attributional evidence in the international INSPIRE project

OBJECTIVE

Attribution of neuropsychiatric symptoms in systemic lupus erythematosus (SLE) relies heavily on clinician assessment. Limited clinic time, variable knowledge, and symptom under-reporting contributes to discordance between clinician assessments and patient symptoms. We obtained attributional data directly from patients and clinicians in order to estimate and compare potential levels of direct attribution to SLE of multiple neuropsychiatric symptoms using different patient-derived measures.

METHODS

Quantitative and qualitative data analysed included: prevalence and frequency of neuropsychiatric symptoms, response to corticosteroids, and concurrence of neuropsychiatric symptoms with non-neuropsychiatric SLE disease activity. SLE patients were also compared with controls and inflammatory arthritis (IA) patients to explore attributability of neuropsychiatric symptoms to the direct disease effects on the brain/nervous system.

RESULTS

We recruited 2,817 participants, including 400 clinicians. SLE patients (n = 609) reported significantly higher prevalences of neuropsychiatric symptoms than controls (n = 463) and IA patients (n = 489). SLE and IA patients' quantitative data demonstrated multiple neuropsychiatric symptoms relapsing/remitting with other disease symptoms such as joint pain. Over 45% of SLE patients reported resolution/improvement of fatigue, positive sensory symptoms, severe headache, and cognitive dysfunction with corticosteroids. Evidence of direct attributability in SLE was highest for hallucinations and severe headache. SLE patients had greater reported improvement from corticosteroids (p= 0.008), and greater relapsing-remitting with disease activity (p< 0.001) in the comparisons with IA patients for severe headache. Clinician and patients reported insufficient time to discuss patient-reported attributional evidence. Symptoms viewed as indirectly related/non-attributable were often less prioritised for discussion and treatment.

CONCLUSION

We found evidence indicating varying levels of direct attributability of both common and previously unexplored neuropsychiatric symptoms in SLE patients, with hallucinations and severe headache assessed as the most directly attributable. There may also be-currently under-estimated-direct effects on the nervous system in IA and other systemic rheumatological diseases.

Rheumatic adverse events of immune checkpoint inhibitors in cancer immunotherapy

INTRODUCTION

The advent of immune checkpoint inhibitors (ICIs) in cancer treatment has marked a transformative era, albeit tempered by immune-related adverse events (irAEs), including those impacting the musculoskeletal system. The lack of precise epidemiologic data on rheumatic irAEs is attributed to factors such as potential underrecognition, underreporting in clinical trials, and the tendency to overlook manifestations without immediate life-threatening implications, further complicating the determination of accurate incidence rates, while the complete understanding of the mechanisms driving rheumatic irAEs remains elusive.

AREAS COVERED

This literature review comprehensively examines rheumatic irAEs in cancer patients undergoing ICI therapy, encompassing epidemiology, risk factors, mechanisms, clinical manifestations, and current management guidance for prevalent conditions such as inflammatory arthritis, polymyalgia rheumatica, and myositis. Less frequent rheumatic and musculoskeletal irAEs are also explored, alongside insights into ongoing clinical trials testing therapeutic and preventive strategies for irAEs. A thorough literature search on Medline and the National Cancer Institute Clinical Trials Database was conducted up to October 2023 to compile relevant information.

EXPERT OPINION

In light of the evolving landscape of cancer immunotherapy, there is a compelling need for prospective longitudinal studies to enhance understanding and inform clinical management strategies for rheumatic irAEs.

Clinical profile, treatment and quality of life of patients with psoriatic arthritis in Malaysia: A population-based cross-sectional study

Psoriatic arthritis (PsA) is a major comorbidity of psoriasis and may lead to irreversible joint damage and disability. This study aims to describe the clinical profile, treatment and quality of life (QoL) of patients with PsA in Malaysia. This is a multicentre retrospective cross-sectional study of psoriasis patients who were notified to the Malaysian Psoriasis Registry (MPR) from January 2007 to December 2018. Of 21 735 psoriasis patients, 2756 (12.7%) had PsA. The male to female ratio was 1:1. The mean age of psoriasis onset for PsA patients was 34.73 ± 14.44 years. They had a higher rate of family history of psoriasis (26% vs. 22.4%, p < 0.001), scalp (82.7% vs. 81.0%, p = 0.04) and nail involvement (73.3% vs. 53.3%, p < 0.001), obesity (62.6% vs. 54.4%, p < 0.001), dyslipidaemia (23.8% vs. 15.4%, p < 0.001), hypertension (31.1% vs. 22.7%, p < 0.001) and diabetes mellitus (20.9% vs. 15.2%, p < 0.001) compared to non-PsA patients. More than half (54.3%) had severe psoriasis [(body surface area >10% and/or Dermatology Life Quality Index (DLQI) >10)]. Most had oligo-/monoarthropathy (40.3%), followed by distal interphalangeal arthropathy (31.3%), symmetrical polyarthropathy (28.3%), spondylitis/sacroiliitis (8.2%) and arthritis mutilans (3.2%). Nearly 40% of PsA patients received systemic treatment, but only 1.6% received biologic agents. QoL was more significantly affected in PsA than in non-PsA patients (mean DLQI 10.12 ± 7.16 vs. 9.52 ± 6.67, p < 0.001). One in eight patients with psoriasis in Malaysia had PsA. They had a higher incidence of comorbidities, severe disease, impaired QoL and were more likely to receive systemic and biological treatment compared to non PsA patients.

Rheumatoid Arthritis Is Not a Contraindication to Unicompartmental Knee Arthroplasty

BACKGROUND

Rheumatoid arthritis (RA) has historically been considered a contraindication for unicompartmental knee arthroplasty (UKA). However, the widespread use of disease-modifying antirheumatic drugs has substantially improved the management of RA and prevented disease progression. The objective of this study was to ascertain whether RA impacts UKA revision-free survivorship.

METHODS

Patients undergoing UKA from 2010 to 2021 were identified in an administrative claims database (n = 105,937) using Current Procedural Terminology code 27446. All patients who underwent UKA who had a diagnosis of RA with a minimum of 2-year follow-up (n = 1,422) were propensity score matched based on age, sex, and Elixhauser Comorbidity Index to those who did not have RA (n = 1,422). Laterality was identified using the 10th Revision of International Classification of Diseases codes. The primary outcome was ipsilateral revision to total knee arthroplasty (TKA) within 2 years, and the secondary outcome was ipsilateral revision at any time.

RESULTS

Among the 1,422 patients who had a UKA and a diagnosis of RA, 37 patients (2.6%) underwent conversion to TKA within 2 years, and 48 patients (3.4%) underwent conversion to TKA at any point. In comparison, 28 patients (2.0%) in the propensity-matched control group underwent conversion to TKA within 2 years, and 40 patients (2.8%) underwent conversion to TKA at any point. Statistical analysis revealed no significant difference in conversion to TKA between patients who had and did not have RA, either within 2 years (P = .31) or anytime (P = .45).

CONCLUSIONS

Patients who had RA and underwent UKA did not have an increased risk of revision to TKA compared to those who did not have RA. This may indicate that modern management of RA could allow for expanded UKA indications for RA patients.

Resident Synovial Macrophages in Synovial Fluid: Implications for Immunoregulation in Infectious and Inflammatory Arthritis

Objectives

Resident synovial macrophages (RSM) provide immune sequestration of the joint space and are likely involved in initiation and perpetuation of the joint-specific immune response. We sought to identify RSM in synovial fluid (SF) and demonstrate migratory ability, in additional to functional changes that may perpetuate a chronic inflammatory response within joint spaces.

Methods

We recruited human patients presenting with undifferentiated arthritis in multiple clinical settings. We used flow cytometry to identify mononuclear cells in peripheral blood and SF. We used a novel transwell migration assay with human ex-vivo synovium obtained intra-operatively to validate flow cytometry findings. We used single cell RNA-sequencing (scRNA-seq) to further identify macrophage/monocyte subsets. ELISA was used to evaluate the bone-resorption potential of SF.

Results

We were able to identify a rare population of CD14dim, OPG+, ZO-1+ cells consistent with RSM in SF via flow cytometry. These cells were relatively enriched in the SF during infectious processes, but absolutely decreased compared to healthy controls. Similar putative RSM were identified using ex vivo migration assays when MCP-1 and LPS were used as migratory stimulus. scRNA-seq revealed a population consistent with RSM transcriptionally related to CD56+ cytotoxic dendritic cells and IDO+ M2 macrophages.

Conclusion

We identified a rare cell population consistent with RSM, indicating these cells are likely migratory and able to initiate or coordinate both acute (septic) or chronic (autoimmune or inflammatory) arthritis. RSM analysis via scRNA-seq indicated these cells are M2 skewed, capable of antigen presentation, and have consistent functions in both septic and inflammatory arthritis.

Noninvasive PET Detection of CD69-Positive Immune Cells Before Signs of Clinical Disease in Inflammatory Arthritis

Rheumatoid arthritis (RA) is the most common inflammatory joint disease, and early diagnosis is key for effective disease management. CD69 is one of the earliest cell surface markers seen at the surface of activated immune cells, and CD69 is upregulated in synovial tissue in patients with active RA. In this study, we evaluated the performance of a CD69-targeting PET agent, [68Ga]Ga-DOTA-ZCAM241, for early disease detection in a model of inflammatory arthritis. Methods: A model of inflammatory arthritis was induced by transferring splenocytes from KRN T-cell receptor transgenic B6 mice into T-cell-deficient I-Ag7 major histocompatibility complex class II-expressing recipient mice. The mice were examined longitudinally by [68Ga]Ga-DOTA-ZCAM241 PET/CT before and 3, 7, and 12 d after induction of arthritis. Disease progression was monitored by clinical parameters, including measuring body weight and scoring the swelling of the paws. The uptake of [68Ga]Ga-DOTA-ZCAM241 in the paws was analyzed and expressed as SUVmean Tissue biopsy samples were analyzed for CD69 expression by flow cytometry or immunostaining for a histologic correlate. A second group of mice was examined by a nonbinding, size-matched Affibody molecule as the control. Results: Clinical symptoms appeared 5-7 d after induction of arthritis. The uptake of [68Ga]Ga-DOTA-ZCAM241 in the joints was negligible at baseline but increased gradually after disease induction. An elevated PET signal was found on day 3, before the appearance of clinical symptoms. The uptake of [68Ga]Ga-DOTA-ZCAM241 correlated with the clinical score and disease severity. The presence of CD69-positive cells in the joints and lymph nodes was confirmed by flow cytometry and immunostaining. The uptake of the nonbinding tracer that was the negative control also increased gradually with disease progression, although to a lesser extent than with [68Ga]Ga-DOTA-ZCAM241 Conclusion: The uptake of [68Ga]Ga-DOTA-ZCAM241 in the inflamed joints preceded the clinical symptoms in the KRN T-cell transfer model of inflammatory arthritis, in accordance with immunostaining for CD69. [68Ga]Ga-DOTA-ZCAM241 is thus a promising PET imaging marker of activated immune cells in tissue during RA onset.

Revision to the musculoskeletal domain of the BILAG-2004 index to incorporate ultrasound findings

OBJECTIVES

To improve the definitions of inflammatory arthritis within the musculoskeletal (MSK) domain of the BILAG-2004 index by incorporating imaging findings and clinical features predictive of response to treatment.

METHODS

The BILAG MSK Subcommittee proposed revisions to the BILAG-2004 index definitions of inflammatory arthritis, based on review of evidence in two recent studies. Data from these studies were pooled and analysed to determine the impact of the proposed changes on the severity grading of inflammatory arthritis.

RESULTS

The revised definition for severe inflammatory arthritis includes definition of 'basic activities of daily living'. For moderate inflammatory arthritis, it now includes synovitis, defined by either observed joint swelling or MSK US evidence of inflammation in joints and surrounding structures. For mild inflammatory arthritis, the definition now includes reference to symmetrical distribution of affected joints and guidance on how US may help re-classify patients as moderate or no inflammatory arthritis. Data from two recent SLE trials were analysed (219 patients). A total of 119 (54.3%) were graded as having mild inflammatory arthritis (BILAG-2004 Grade C). Of these, 53 (44.5%) had evidence of joint inflammation (synovitis or tenosynovitis) on US. Applying the new definition increased the number of patients classified as moderate inflammatory arthritis from 72 (32.9%) to 125 (57.1%), while patients with normal US (n = 66/119) could be recategorized as BILAG-2004 Grade D (inactive disease).

CONCLUSIONS

Proposed changes to the definitions of inflammatory arthritis in the BILAG-2004 index will result in more accurate classification of patients who are more or less likely to respond to treatment.

The Importance of Ultrasound-Guided Synovial Biopsy in the Workup of Seronegative Inflammatory Arthritis: A Case Report

We report a case of a 74-year-old male who presented with typical clinical features of rheumatoid arthritis (RA), as well as elevated markers of inflammation. However, the patient did not respond to multiple RA treatments, and an ultrasound-guided synovial biopsy (UGSB) of the right wrist was performed, which established the diagnosis of amyloidosis. A variety of inflammatory conditions sometimes get misdiagnosed as seronegative RA due to similarities in clinical presentation. This case report highlights the importance of a thorough workup in patients who appear to have seronegative RA. Given the wide availability of ultrasound-guided, minimally invasive synovial biopsies, these procedures should be employed more often to detect rare conditions that may mimic seronegative RA, such as amyloidosis.

The course of cytokine and chemokine gene expression in clinically suspect arthralgia patients during progression to inflammatory arthritis

OBJECTIVES

Autoantibody responses increase years before the onset of inflammatory arthritis (IA) and are stable during transitioning from clinically suspect arthralgia (CSA) to IA. Cytokine and chemokine levels also increase years before IA onset. However, the course in the at-risk stage of CSA during progression to disease or non-progression is unknown. To increase the understanding of processes mediating disease development, we studied the course of cytokine, chemokine and related receptors gene expression in CSA patients during progression to IA and in CSA patients who ultimately did not develop IA.

METHODS

Whole-blood RNA expression of 37 inflammatory cytokines, chemokines and related receptors was determined by dual-colour reverse transcription multiplex ligation-dependent probe amplification in paired samples of CSA patients at CSA onset and either at IA development or after 24 months without IA development. ACPA-positive and ACPA-negative CSA patients developing IA were compared at CSA onset and during progression to IA. Generalised estimating equations tested changes over time. A false discovery rate approach was applied.

RESULTS

None of the cytokine/chemokine genes significantly changed in expression between CSA onset and IA development. In CSA patients without IA development, G-CSF expression decreased (P = 0.001), whereas CCR6 and TNIP1 expression increased (P < 0.001 and P = 0.002, respectively) over a 2 year period. Expression levels in ACPA-positive and ACPA-negative CSA patients who developed IA were similar.

CONCLUSION

Whole-blood gene expression of assessed cytokines, chemokines and related receptors did not change significantly from CSA to IA development. This suggests that changes in expression of these molecules may not be related to the final process of developing chronicity and may have occurred preceding CSA onset. Changes in gene expression in CSA patients without IA development may provide clues for processes related to resolution.

Temporomandibular joint pathologies: pictorial review

In this pictorial review, an introductory paragraph emphasizes the significance of some anatomical aspects for optimal imaging of the temporomandibular joint (TMJ). The most frequent pathologies: internal derangement (ID) and osteoarthritis (OA) are comprehensively discussed and illustrated. Less common conditions: ID and OA-like changes in children and adolescents, idiopathic condylar resorption, inflammatory arthritis, and juvenile idiopathic arthritis are briefly discussed. A short paragraph on differential diagnostics in young patients is included followed by a brief comment on expansile lesions that occasionally may occur in the TMJ.

'I never thought exercise could help improve my sleep': experiences of people with rheumatoid arthritis on the impact of an 8-week walking-based exercise intervention in improving their sleep

Objective

The purpose of this study was to explore the experiences of people with RA of participating in an exercise intervention to improve their sleep.

Methods

Using a qualitative descriptive design, semi-structured face-to-face interviews were conducted with 12 people with RA who had completed an 8-week walking-based exercise intervention to improve their total sleep time, sleep quality and sleep disturbance. Data were analysed using thematic analysis.

Results

Four themes were generated: positive impact of exercise on participants' sleep ('I really didn't think any type of exercise would help me sleep better, if I'm honest'); positive experiences of the exercise intervention ('I learnt so much regarding walking that I didn't even think about'); clear mental health benefits ('If you don't sleep well then it will have a knock-on effect to your mental health'); and achieving empowerment and ownership when exercising ('I feel empowered now and confident that I'm not doing harm to myself').

Conclusion

The findings demonstrated that participants had not expected exercise to improve their sleep. Although there is a growing consensus that exercise will benefit sleep and mitigate some disease symptoms, research is severely lacking in people with RA.

Diagnostic Value of Short Course Low-dose Prednisolone in Patients with Clinically Suspected Seronegative Inflammatory Arthritis - A Retrospective Study

OBJECTIVE

We aim to establish the utility of a trial of low-dose systemic glucocorticoid therapy in the assessment of new clinically suspected inflammatory arthritis patients.

METHODS

We retrospectively identified patients from a private rheumatology practice in Melbourne, Australia between January 1st, 2019, and December 31st, 2021, who presented with clinically suspected inflammatory arthritis and subsequently underwent a trial of low-dose prednisolone (15mg daily weaned over three weeks in 5mg increments). We excluded patients with known autoimmune/ inflammatory disorders or concurrent immunosuppression at presentation. We collected basic participant demographic details and clinical details of their presentation, glucocorticoid response, investigations, and treatment.

RESULTS

We recruited 177 participants with a median age of 52, and 69.5% were female gender. The median symptom time to presentation was 12 months. Hands were the most affected joint in 63.3% and 85% had bilateral disease. Among the participants, 29.4% had synovitis on clinical review and 75.7% had imaging performed as part of the initial assessment. At presentation, the median CRP was 11 and the median ESR was 16. 79.7% of the cohort experienced significant improvement in their arthritis symptoms from low-dose glucocorticoids and 83.6% of the cohort required long-term immunosuppression for an underlying inflammatory condition. Of those who responded to glucocorticoids, 92.1% were diagnosed with an inflammatory condition. Rheumatoid arthritis was the most common overall diagnosis in 28%.

CONCLUSION

An initial trial of low-dose glucocorticoids in undifferentiated arthritis patients is useful in predicting the diagnosis of inflammatory arthritis. It is also a predictor of further long-term steroid-sparing therapy.

An Automatic 3-D Ultrasound and Photoacoustic Combined Imaging System for Human Inflammatory Arthritis

Aiming at a point-of-care device for rheumatology clinics, we developed an automatic 3-D imaging system combining the emerging photoacoustic (PA) imaging with conventional Doppler ultrasound (US) for detecting human inflammatory arthritis. This system is based on a commercial-grade GE HealthCare (GEHC, Chicago, IL, USA) Vivid E95 US machine and a Universal Robot UR3 robotic arm. This system automatically locates the patient's finger joints from a photograph taken by an overhead camera powered by an automatic hand joint identification method, followed by the robotic arm moving the imaging probe to the targeted joint to scan and obtain 3-D PA and Doppler US images. The GEHC US machine was modified to enable high-speed, high-resolution PA imaging while maintaining the features available on the system. The commercial-grade image quality and the high sensitivity in detecting inflammation in peripheral joints via PA technology hold great potential to significantly benefit clinical care of inflammatory arthritis in a novel way.

Characteristics of race/ethnicity in trials leading to anti-rheumatic drug approval for inflammatory arthritis by the US Food and Drug Administration

OBJECTIVE

Presenting the racial/ethnic representation in clinical trials leading to new approvals of inflammatory arthritis (IA) by the US Food and Drug Administration (FDA) to determine the extent of racial/ethnic disparities.

METHODS

Pivotal trials supporting the approval of new indications from July 2012 to June 2022 were collected from Drugs@FDA, the FDA-approved drugs database. More details were then identified by searching Pubmed and the National Institutes of Health trials registry. General characteristics of the approved drugs and demographic data for each pivotal trial, especially the race/ethnicity data, were collected. The enrollment profiles of each race/ethnicity were analyzed and then compared with the 2020 US census data.

RESULTS

From 2012 to 2022, 34 new approvals were identified based on 59 clinical trials. The Black was consistently underrepresented in all subtypes of IA and drugs, while the White was overrepresented compared to the 2020 US census data. For Asian and Hispanic participants, these pivotal trials presented relatively heterogeneities in enrollments. As for the trends over time, increased involvements of White were still observed in rheumatoid arthritis (RA), psoriatic arthritis, and spondyloarthritis, while increased involvements of Black and decreased enrollments of Asian and Hispanic were only observed in RA.

CONCLUSIONS

Despite many efforts to eliminate racial/ethnic disparities, the Black was consistently underrepresented in pivotal clinical trials compared to the 2020 US national race/ethnicity distribution data. The White was consistently overrepresented, and the Hispanic presented heterogeneous results. No evident time trend was observed.

Testing the effectiveness of a Fatigue and Activity Management Education for Work (FAME-W) intervention for individuals with inflammatory arthritis: Study protocol for a randomized control trial

BACKGROUND

A work-focused fatigue management intervention, Fatigue and Activity Management Education for Work (FAME-W) programme was developed for individuals with inflammatory arthritis (IA) to manage fatigue in order to maintain demands of their work activities and tasks. This paper presents the protocol for a randomized control trial that will test the effectiveness and acceptability of FAME-W in improving work performance.

METHODS

This protocol presents a multisite randomized control trial and mixed methods process evaluation. Eligible participants will be aged 18-65 years with a diagnosis of inflammatory arthritis and will be in paid employment. The primary outcome of the study will be Work Role Functioning (WRF) questionnaire, and the secondary outcomes will be fatigue, mood, health-related quality of life (HRQOL) and pain. Data will be collected immediately pre- and post-intervention and at 3 months of follow-up. The process evaluation will consist of focus groups and individual interviews to explore participants' experiences of FAME-W. Occupational therapists delivering the programme will complete a facilitator log to assess the fidelity and quality of intervention implementations. Facilitators will participate in individual interviews to explore intervention delivery and acceptability.

RESULTS

Results will be expected to show that FAME-W will improve work performance by helping participants gain self-management strategies around managing fatigue and other symptoms related to fatigue.

CONCLUSION

It is hoped that FAME-W will be an effective and acceptable intervention for individuals with IA in improving work performance by helping them manage their symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05138445, Registered on 30 November 2021.

Computer vision detects inflammatory arthritis in standardized smartphone photographs in an Indian patient cohort

Introduction

Computer vision extracts meaning from pixelated images and holds promise in automating various clinical tasks. Convolutional neural networks (CNNs), a deep learning network used therein, have shown promise in analyzing X-ray images and joint photographs. We studied the performance of a CNN on standardized smartphone photographs in detecting inflammation in three hand joints and compared it to a rheumatologist's diagnosis.

Methods

We enrolled 100 consecutive patients with inflammatory arthritis with an onset period of less than 2 years, excluding those with deformities. Each patient was examined by a rheumatologist, and the presence of synovitis in each joint was recorded. Hand photographs were taken in a standardized manner, anonymized, and cropped to include joints of interest. A ResNet-101 backbone modified for two class outputs (inflamed or not) was used for training. We also tested a hue-augmented dataset. We reported accuracy, sensitivity, and specificity for three joints: wrist, index finger proximal interphalangeal (IFPIP), and middle finger proximal interphalangeal (MFPIP), taking the rheumatologist's opinion as the gold standard.

Results

The cohort consisted of 100 individuals, of which 22 of them were men, with a mean age of 49.7 (SD 12.9) years. The majority of the cohort (n = 68, 68%) had rheumatoid arthritis. The wrist (125/200, 62.5%), MFPIP (94/200, 47%), and IFPIP (83/200, 41.5%) were the three most commonly inflamed joints. The CNN achieved the highest accuracy, sensitivity, and specificity in detecting synovitis in the MFPIP (83, 77, and 88%, respectively), followed by the IFPIP (74, 74, and 75%, respectively) and the wrist (62, 90, and 21%, respectively).

Discussion

We have demonstrated that computer vision was able to detect inflammation in three joints of the hand with reasonable accuracy on standardized photographs despite a small dataset. Feature engineering was not required, and the CNN worked despite a diversity in clinical diagnosis. Larger datasets are likely to improve accuracy and help explain the basis of classification. These data suggest a potential use of computer vision in screening and follow-up of inflammatory arthritis.

Letrozole-induced inflammatory arthritis and tendinopathy in pediatric rheumatology setting

Musculoskeletal symptoms associated with the use of aromatase inhibitors are a well-known side effect of these drugs and are more prevalent in postmenopausal women. Aromatase inhibitor-associated symptoms are not overt inflammatory processes so are described as arthralgia syndrome. In contrast, aromatase inhibitor-associated inflammatory conditions such as myopathies, vasculitis, and rheumatoid arthritis were also reported. To our knowledge, inflammatory arthritis or tendinopathy associated with aromatase inhibitors were not reported in children despite their increased off-label use in the pediatric setting. Herein, we report a girl with inflammatory arthritis and tendinopathy associated with letrozole treatment.

Do outcomes of interposition arthroplasty in young patients differ based on indication? A systematic review

BACKGROUND

Interposition arthroplasty of the elbow is often preferred in young patients compared with implant total elbow arthroplasty. However, research comparing outcomes based on diagnosis in patients with post-traumatic osteoarthritis (PTOA) and inflammatory arthritis following interposition arthroplasty is sparse. Therefore, the purpose of this study was to compare outcomes and complication rates following interposition arthroplasty in patients with PTOA and inflammatory arthritis.

METHODS

A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Embase, and Web of Science databases were queried from inception to December 31, 2021. The search generated 189 total studies, of which 122 were unique. Original studies on interposition arthroplasty of the elbow in the setting of post-traumatic or inflammatory arthritis in patients aged <65 years were included. Six studies that were suitable for inclusion were identified.

RESULTS

The query yielded 110 elbows, of which 85 had received a diagnosis of PTOA and 25, inflammatory arthritis. The cumulative complication rate following the index procedure was 38.4%. The complication rate in patients with PTOA was 41.2% compared with 11.7% in those with inflammatory arthritis. Furthermore, the cumulative reoperation rate was 23.5%. The reoperation rates in PTOA and inflammatory arthritis patients were 25.0% and 17.6%, respectively. The average preoperative Mayo Elbow Performance Index pain score was 11.0, which improved to 26.3 postoperatively. The mean preoperative and postoperative pain scores for the PTOA patients were 4.3 and 30.0, respectively. For the inflammatory arthritis patients, the preoperative pain score was 0 and the postoperative pain score was 45. The overall mean preoperative Mayo Elbow Performance Index functional score was 41.5, improving to 74.0 after the procedure.

CONCLUSIONS

This study found that interposition arthroplasty is associated with a 38.4% complication rate and 23.5% reoperation rate, in addition to positive improvements in pain and function. In patients aged <65 years, interposition arthroplasty may be considered in those unwilling to undergo implant arthroplasty.

Three doses of COVID-19 mRNA vaccine induce class-switched antibody responses in inflammatory arthritis patients on immunomodulatory therapies

Patients with inflammatory arthritis (IA) are at increased risk of severe COVID-19 due to medication-induced immunosuppression that impairs host defenses. The aim of this study was to assess antibody and B cell responses to COVID-19 mRNA vaccination in IA patients receiving immunomodulatory therapies. Adults with IA were enrolled through the Johns Hopkins Arthritis Center and compared with healthy controls (HC). Paired plasma and peripheral blood mononuclear cell (PBMC) samples were collected prior to and 30 days or 6 months following the first two doses of mRNA vaccines (D2; HC=77 and IA=31 patients), or 30 days following a third dose of mRNA vaccines (D3; HC=11 and IA=96 patients). Neutralizing antibody titers, total binding antibody titers, and B cell responses to vaccine and Omicron variants were analyzed. Anti-Spike (S) IgG and S-specific B cells developed appropriately in most IA patients following D3, with reduced responses to Omicron variants, and negligible effects of medication type or drug withholding. Neutralizing antibody responses were lower compared to healthy controls after both D2 and D3, with a small number of individuals demonstrating persistently undetectable neutralizing antibody levels. Most IA patients respond as well to mRNA COVID-19 vaccines as immunocompetent individuals by the third dose, with no evidence of improved responses following medication withholding. These data suggest that IA-associated immune impairment may not hinder immunity to COVID-19 mRNA vaccines in most individuals.

Multimorbidity in rheumatoid arthritis: common mechanistic links and impact and challenges in routine clinical practice

Early identification and management of multimorbidity in patients with rheumatic and musculoskeletal diseases (RMDs), such as RA, is an integral, but often neglected, aspect of care. The prevalence and incidence of conditions such as osteoporosis, cardiovascular disease, pulmonary disease and malignancies, often co-existing with RA, continues to have significant implications for the management of this patient group. Multimorbidity in RMDs can be associated with inflammatory disease activity and target organ damage. Lifestyle factors, such as smoking and inactivity, further contribute to the burden of disease. Inflammation is the underlying factor, not just in RA but also many comorbidities. The current framework of a treat-to-target approach focuses on achieving early remission and inflammatory activity suppression. We describe how the comorbidity burden in people with RMDs impacts on disease outcome and treatment response. The importance of addressing comorbidity at an early stage and adopting a patient centred approach is critical in modern practice.

Inflammatory arthritis and eye diseases: a Mendelian randomization study

Objectives

The aim of this study was to determine causal associations between inflammatory arthritis and eye diseases (disorders of sclera, cornea, iris, and ciliary body [DSCIC] and disorders of choroid and retina [DCR]).

Methods

Genome-wide association studies' summary data of rheumatoid arthritis (RA) from a large-scale meta-analysis were used to identify genetically predicted RA. UK Biobank source data predicted ankylosing spondylitis (AS), psoriatic arthritis (PsA), and juvenile idiopathic arthritis (JIA). Furthermore, data from the FinnGen Biobank were used to identify genetically predicted eye diseases. Two-sample Mendelian randomization analysis was used to assess the causal relationship between inflammatory arthritis and eye diseases in the European population. Inverse-variance weighting (IVW) was used as the primary method, while MR-Egger, weighted median, and MR-PRESSO outlier test were used to detect heterogeneity and pleiotropy.

Results

Genetically determined RA was indeed observed to have a causal effect on DSCIC (odds ratio [OR] = 1.084, p = 2.353 × 10-10) and DCR (OR = 1.151, p = 1.584 × 10-19). AS was causally associated with DSCIC (OR = 1.068, p < 2.024 × 10-8). In addition, PsA was also found to have a causal association with an increased risk of 17.9% for the development of DSCIC (OR = 1.179, p = 0.003). On the flip side, DSCIC increased the risk of JIA (OR = 2.276, p = 0.003).

Conclusion

Our study provided genetic evidence for the causal associations of RA, AS, and PsA with an increased risk of DSCIC, and a causal association between RA and DCR was also identified. In addition, DSCIC greatly increased the risk of JIA.

New-Onset Rheumatic Immune-Mediated Inflammatory Diseases Following SARS-CoV-2 Vaccinations until May 2023: A Systematic Review

A comprehensive, up-to-date systematic review (SR) of the new-onset rheumatic immune-mediated inflammatory diseases (R-IMIDs) following COVID-19 vaccinations is lacking. Therefore, we investigated the demographics, management, and prognosis of new R-IMIDs in adults following SARS-CoV-2 vaccinations. A systematic literature search of Medline, Embase, Google Scholar, LitCovid, and Cochrane was conducted. We included any English-language study that reported new-onset R-IMID in adults following the post-COVID-19 vaccination. A total of 271 cases were reported from 39 countries between January 2021 and May 2023. The mean age of patients was 56 (range 18-90), and most were females (170, 62.5%). Most (153, 56.5%) received the Pfizer BioNTech COVID-19 vaccine. Nearly 50% of patients developed R-IMID after the second dose of the vaccine. Vasculitis was the most prevalent clinical presentation (86, 31.7%), followed by connective tissue disease (66, 24.3%). The mean duration between the vaccine's 'trigger' dose and R-IMID was 11 days. Most (220, 81.2%) received corticosteroids; however, 42% (115) received DMARDs such as methotrexate, cyclophosphamide, tocilizumab, anakinra, IV immunoglobulins, plasma exchange, or rituximab. Complete remission was achieved in 75 patients (27.7%), and 137 (50.6%) improved following the treatment. Two patients died due to myositis. This SR highlights that SARS-CoV-2 vaccines may trigger R-IMID; however, further epidemiology studies are required.

Impact of csDMARDs adherence on clinical remission in patients with new-onset inflammatory arthritis: a prospective cohort study from the ELECTRA database

Background

Major improvements in the management of rheumatoid arthritis (RA) have made clinical remission an achievable and desirable goal but, despite the relevance gained by a profound disease suppression, many patients with RA still miss clinical remission due to several factors influencing disease activity, including treatment adherence.

Objective

To evaluate the effect of adherence to conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) on the achievement of clinical remission in a cohort of patients with new-onset inflammatory arthritis.

Study design

A prospective cohort study was conducted using the ELECTRA database, which consists of clinical data from patients followed at the IRCCS Policlinico San Matteo Foundation (Pavia, Italy), linked to regional administrative healthcare databases.

Methods

We enrolled patients with new-onset active disease between January 2006 and December 2013 and followed them until their first clinical remission or end of follow-up (December 2015). To assess the association of csDMARD adherence with clinical remission, we estimated the csDMARD proportion of days covered (PDC) during follow-up. PDC was added to the main clinical adjustment covariates as a time-dependent variable in a proportional hazard Cox regression model.

Results

The cohort included 324 patients with a mean (SD) age of 58 (13.9) and predominantly female (74.5%). A total of 219 patients (67.6%) achieved clinical remission during follow-up and 85 (26.2%) in the first 6 months (early clinical remission). Cox regression models showed that a 10% increment of PDC increased the probability of achieving clinical remission by 10% (p < 0.001) and the probability of early clinical remission by 21% (p = 0.03).

Conclusion

Patients at disease onset with higher adherence to csDMARDs were more likely to achieve clinical remission and early clinical remission. Our study highlighted the importance of close monitoring of patients to increase their likelihood of following therapeutic indications and achieving favorable disease outcomes, such as lower disability.

COVID-associated arthritis after severe and non-severe COVID-19: A systematic review

AIM

Since the coronavirus outbreak became a global health emergency in 2020, various immune-based effects, such as inflammatory arthritis (IA), have been recorded. This study aimed to determine the role of COVID-19 severity on post-COVID arthritis.

METHODS

We systematically reviewed 95 patients who developed arthritis after severe and non-severe COVID-19 infection by searching the databases, including PubMed, SCOPUS, and EMBASE. We used the term "COVID-associated arthritis" because there was no definite diagnostic method for classifying arthritides after COVID-19 infection, and the diagnosed arthritis types were based on the authors' viewpoints.

RESULTS

After evaluating the data between the two severe and non-severe COVID-19-infected groups of patients, the results showed that the COVID-19 severity may affect the pattern of joint involvement in IA. In both groups, combination therapy, including oral nonsteroidal anti-inflammatory drugs with different types of corticosteroids, was the most common treatment. In addition, the mean age and comorbidities rate was higher in the severe COVID-19 group. Even though the patients in the severe COVID-19 group developed more serious COVID-19 symptoms, they experienced milder arthritis with better outcomes and more delayed onsets that required less aggressive therapy.

CONCLUSION

We conclude that there may be an inverse relationship between COVID-19 severity and arthritis severity, possibly due to weaker immunity conditions following immunosuppressant treatments in patients with severe COVID-19.

Added value of high-resolution ultrasound and MRI in the evaluation of rheumatologic diseases

Rheumatologic diseases are a widespread group of disorders affecting the joints, bones, and connective tissue, and leading to significant disability. Imaging is an indispensable component in diagnosing, assessing, monitoring, and managing these disorders, providing information about the structural and functional alterations occurring within the affected joints and tissues. This review article aims to compare the utility, specific clinical applications, advantages, and limitations of high-resolution ultrasound and magnetic resonance imaging in the context of rheumatologic diseases. It also provides insights into the imaging features of various types of inflammatory arthritis with clinical relevance and a focus on high-resolution ultrasound and magnetic resonance imaging. By understanding the comparative aspects of high-resolution ultrasound and magnetic resonance imaging, it is easier for the treating physicians to make informed decisions when selecting the optimal imaging modality for specific diagnostic purposes, effective treatment planning, and improve patient outcomes. The patterns of soft tissue and joint involvement; bony erosion and synovitis help in differentiating between various type of arthritis. Involvement of various small joints of the hands also gives an insight into the type of arthritis. We also briefly discuss the potential applications of emerging techniques, such as ultrasound elastography, contrast-enhanced ultrasound, and dual-energy CT, in the field of rheumatology.

Revisiting p38 Mitogen-Activated Protein Kinases (MAPK) in Inflammatory Arthritis: A Narrative of the Emergence of MAPK-Activated Protein Kinase Inhibitors (MK2i)

The p38 mitogen-activated protein kinase (p38-MAPK) is a crucial signaling pathway closely involved in several physiological and cellular functions, including cell cycle, apoptosis, gene expression, and responses to stress stimuli. It also plays a central role in inflammation and immunity. Owing to disparate p38-MAPK functions, it has thus far formed an elusive drug target with failed clinical trials in inflammatory diseases due to challenges including hepatotoxicity, cardiac toxicity, lack of efficacy, and tachyphylaxis, which is a brief initial improvement with rapid disease rebound. To overcome these limitations, downstream antagonism of the p38 pathway with a MAPK-activated protein kinase (MAPKAPK, also known as MK2) blockade has demonstrated the potential to abrogate inflammation without the prior recognized toxicities. Such MK2 inhibition (MK2i) is associated with robust suppression of key pro-inflammatory cytokines, including TNFα and IL-6 and others in experimental systems and in vitro. Considering this recent evidence regarding MK2i in inflammatory arthritis, we revisit the p38-MAPK pathway and discuss the literature encompassing the challenges of p38 inhibitors with a focus on this pathway. We then highlight how novel MK2i strategies, although encouraging in the pre-clinical arena, may either show evidence for efficacy or the lack of efficacy in emergent human trials data from different disease settings.

COVID-19 admissions and mortality in patients with early inflammatory arthritis: results from a UK national cohort

OBJECTIVE

To describe the risks and predictors of coronavirus disease 2019 (COVID-19) hospitalization and mortality among patients with early inflammatory arthritis (EIA), recruited to the National Early Inflammatory Arthritis Audit (NEIAA).

METHODS

NEIAA is an observational cohort. We included adults with EIA from Feb 2020 to May 2021. Outcomes of interest were hospitalization and death due to COVID-19, using NHS Digital linkage. Cox proportional hazards were used to calculate hazard ratios for outcomes according to initial treatment strategy, with adjustment for confounders.

RESULTS

From 14 127 patients with EIA, there were 143 hospitalizations and 47 deaths due to COVID-19, with incidence rates per 100 person-years of 0.93 (95% CI 0.79, 1.10) for hospitalization and 0.30 (95% CI 0.23, 0.40) for death. Increasing age, male gender, comorbidities and ex-smoking were associated with increased risk of worse COVID-19 outcomes. Higher baseline DAS28 was not associated with COVID-19 admissions [confounder adjusted hazard ratio (aHR) 1.10; 95% CI 0.97, 1.24] or mortality (aHR 1.11; 95% CI 0.90, 1.37). Seropositivity was not associated with either outcome. Higher symptom burden on patient-reported measures predicted worse COVID-19 outcomes. In unadjusted models, CS associated with COVID-19 death (HR 2.29; 95% CI 1.02, 5.13), and SSZ monotherapy associated with COVID-19 admission (HR 1.92; 95% CI 1.04, 3.56). In adjusted models, associations for CS and SSZ were not statistically significant.

CONCLUSION

Patient characteristics have stronger associations with COVID-19 than the initial treatment strategy in patients with EIA. An important limitation is that we have not looked at treatment changes over time.

Beyond dyadic communication: Network of communication in inflammatory arthritis teams

OBJECTIVE

To explore how communication is perceived and care is negotiated amongst IA healthcare teams by drawing on the perspectives of each team member.

METHOD

This analysis drew on data from an ongoing three-year study exploring team-based IA care. We interviewed 11 participants including two men with IA and their family care providers and healthcare providers. We used a three-staged analytic process and integrated broad tenets of social network theory to understand the relational dimensions of team members experiences.

RESULT

Analysis revealed three themes regarding communication and care: (1) seeking/sharing information, (2) striving to coordinate unified care, and (3) providing patients a voice.

DISCUSSION

This study emphasizes the importance of understanding team dynamics beyond the dyad of patient and care provider. Negotiating power and decision-making in IA care is a dynamic process involving shifting levels of responsibility amongst a care team. Communication-based strategies that extend dyadic interactions may enhance teamwork and health outcomes in chronic conditions.

Online Patient-Reported Outcome Measure Engagement Is Dependent on Demographics and Locality: Findings From an Observational Cohort

OBJECTIVE

Online patient-reported outcome measures (PROMs) enable remote collection of perceptions of health status, function, and well-being. We aimed to explore patterns of PROM completion in patients with early inflammatory arthritis (EIA) recruited to the National Early Inflammatory Arthritis Audit (NEIAA).

METHODS

NEIAA is an observational cohort study design; we included adults from this cohort with a new diagnosis of EIA from May 2018 to March 2020. The primary outcome was PROM completion at baseline, 3 months, and 12 months. Mixed effects logistic regression and spatial regression models were used to identify associations between demographics (age, gender, ethnicity, deprivation, smoking, and comorbidity), clinical commissioning groups, and PROM completion.

RESULTS

Eleven thousand nine hundred eighty-six patients with EIA were included, of whom 5331 (44.5%) completed at least 1 PROM. Patients from ethnic minority backgrounds were less likely to return a PROM (adjusted odds ratio [aOR] 0.57, 95% CI 0.48-0.66). Greater deprivation (aOR 0.73, 95% CI 0.64-0.83), male gender (aOR 0.86, 95% CI 0.78-0.94), higher comorbidity burden (aOR 0.95, 95% CI 0.91-0.99), and current smoker status (aOR 0.73, 95% CI 0.64-0.82) also reduced odds of PROM completion. Spatial analysis identified 2 regions with high (North of England) and low (Southeast of England) PROM completion.

CONCLUSION

We define key patient characteristics (including ethnicity) that influence PROM engagement using a national clinical audit. We observed an association between locality and PROM completion, with varying response rates across regions of England. Completion rates could benefit from targeted education for these groups.

Baseline predictors of disease severity in immune checkpoint inhibitor-induced inflammatory arthritis

OBJECTIVES

To determine baseline risk factors for requiring immunosuppression and having persistent arthritis in patients with immune checkpoint inhibitor-induced inflammatory arthritis (ICI-IA).

METHODS

Participants were adults with rheumatologist diagnosed ICI-IA. The primary outcome was requirement of conventional synthetic (cs) or biologic (b) DMARDs; other outcomes were persistence of IA > 6 months after ICI cessation and requirement of corticosteroids. Logistic regression models evaluated associations between clinical features and primary and secondary outcomes, with adjustment for potential confounders, as appropriate.

RESULTS

126 patients with ICI-IA were included; 53 patients (42%) required a csDMARD/bDMARD. In univariate logistic regressions, higher CDAI, tenosynovitis, longer symptom duration before first rheumatology visit, and longer ICI duration were significantly associated with a higher likelihood of requiring DMARDs; there was a trend toward those treated with prior chemotherapy being less likely to need DMARDs. After adjustment, tenosynovitis, longer symptom duration, and higher CDAI remained associated with requiring DMARDs, while those with prior chemotherapy were significantly less likely to require DMARDs. Combination anti-CTLA-4/PD-1 therapy and steroid use at baseline were associated with a higher risk of persistent IA.

CONCLUSION

Higher levels of disease activity, tenosynovitis, and longer symptom duration prior to rheumatology referral were associated with requiring DMARDs for ICI-IA, while those treated previously with chemotherapy were less likely to require additional immunosuppression. The presence of risk factors for severe disease at baseline may indicate a role for higher initial steroid dose, earlier rheumatology referral, and adoption of immunosuppression beyond steroids to improve outcomes.

Safe and Efficient Use of Tocilizumab in Rheumatoid Arthritis Patient on Maintenance Hemodialysis: A Case Report

Background: Rheumatoid arthritis (RA) is a chronic systemic autoimmune and inflammatory disease. Conventional synthetic and biologic disease-modifying antirheumatic drugs (DMARDs), Janus kinase inhibitors, and rituximab are used to treat the disease. There are no recommendations or guidelines for the treatment of patients with both inflammatory arthritis and end-stage renal disease (ESRD), despite the safety and efficacy of the mentioned drugs. The anti-interleukin-6 receptor antibody tocilizumab (TCZ) has not been used as a long-term therapy for hemodialysis (HD) patients with RA, except in a few case reports. Case Description: We present the case of a 41-year-old patient with RA and ESRD on maintenance HD due to type 1 diabetes-related complications. Due to high RA disease activity, the patient was not a suitable candidate for a kidney transplant. Because TCZ is used to treat both RA and kidney transplant rejection, therapy with a full dose of TCZ was administered. The patient has achieved sustained clinical remission (for the past four years) with no adverse events reported. Conclusions: Herein, we present the safe and effective use of TCZ in an RA patient on HD who is also a candidate for kidney transplant. Consequently, TCZ could be the treatment of choice for RA patients with ESRD who have not achieved disease control (low activity or remission) with conventional synthetic DMARDs. Clinical studies are required to evaluate the efficacy and safety of biologic DMARDs and Janus kinase inhibitors in patients with both inflammatory arthritis and ESRD.

Predictors of inflammatory arthritis among new rheumatology referrals: a cross-sectional study

Objectives

Early diagnosis and treatment of inflammatory arthritis (IA) is essential to optimize disease control. We aimed to identify variables that distinguish IA from non-inflammatory arthropathy by performing a cross-sectional study of rheumatology referral letters and visit records. Further work describes time to assessment and documentation of variables within referral letters.

Methods

We reviewed rheumatology referral letters and new patient visits over a 6-month period. The diagnosis of IA was based on the clinical judgement of the assessing rheumatologist. IA diagnoses included RA, SpAs, unspecified IA, PMR, crystalline arthropathies and remitting seronegative symmetrical synovitis with pitting oedema. Univariate analysis was performed for each variable. Multivariable logistic regression was performed on statistically significant variables.

Results

Of 697 patients referred for arthralgia, 25.7% were diagnosed with IA. Variables predictive of IA included tenderness and swelling on examination and ≥1 h of morning stiffness. Increasing arthralgia duration, fatigue and brain fog were negative predictors. The median time from referral to IA diagnosis was 55 days and 20.7% of these patients were seen within 6 weeks. Among referral letters, documentation of arthralgia duration, morning stiffness or joint examination findings was uncommon (31%, 20.5% and 56.7%, respectively).

Conclusion

We identified positive and negative predictors of IA. Referral letters often missed key information required for the triaging process. Future efforts will be directed towards build a triaging tool to improve the referral quality and capture of those patients with IA who need earlier access to rheumatology care.

Towards Early Diagnosis of Mixed Connective Tissue Disease: Updated Perspectives

Mixed Connective Tissue Disease (MCTD) is an autoimmune disease first described by Sharp et al in 1972, characterized by the presence of anti-Ribonucleoprotein antibodies directed against the U1 complex (anti-U1RNP). The condition shares clinical characteristics with Systemic Lupus Erythematosus, Rheumatoid Arthritis, and Systemic Sclerosis. Diagnosis is quite difficult due to its rarity, the lack of validated classification criteria, and its heterogeneous clinical presentation. While in the early stages its nuanced clinical features might lead to it being incorrectly classified as other Connective Tissue Diseases (CTDs) or even not recognized, in cases of longstanding disease its classification as a CTD is clear but challenging to discriminate from overlap syndromes. MCTD should be considered a distinct entity due to the presence of a specific genetic substrate and the presence of the high titer of a specific autoantibody, anti-U1RNP, present in all the commercial kits for Extractable Nuclear Antigens, and almost always associated with Antinuclear Antibody positivity with a coarse speckled pattern. Except for anti-U1RNP, no specific biomarkers are available to guide clinicians to a correct classification of MCTD, which is arrived at by the association of clinical, serological and instrumental evaluation. In the first stages, the disease is mainly characterized by Raynaud's phenomenon, inflammatory arthritis, puffy fingers, myalgia and/or myositis, and rarely, trigeminal neuropathy. Longstanding disease is generally associated with the development of Pulmonary Hypertension and Interstitial Lung Disease, which are the two main causes of mortality in MCTD. The aim of this review is to summarize current knowledge on the early recognition of MCTD.

Australian recommendations on perioperative use of disease-modifying anti-rheumatic drugs in people with inflammatory arthritis undergoing elective surgery

Disease-modifying anti-rheumatic drugs (DMARDs) are effective treatments for inflammatory arthritis but carry an increased risk of infection. For patients undergoing surgery, there is a need to consider the trade-off between a theoretical increased risk of infection with continuation of DMARDs perioperatively versus an increased risk of disease flare if they are temporarily withheld. We used the Grading of Recommendations Assessment, Development and Evaluation methodology to develop recommendations for perioperative use of DMARDs for people with inflammatory arthritis undergoing elective surgery. The recommendations form part of the National Health and Medical Research Council-endorsed Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis. Conditional recommendations were made against routinely discontinuing conventional synthetic and biologic (b) DMARDs in the perioperative period but to consider temporary discontinuation of bDMARDs in individuals with a high risk of infection or where the impact of infection would be severe. A conditional recommendation was made in favour of temporary discontinuation of targeted synthetic DMARDs in the perioperative period.

Connecting the use of innovative treatments and glucocorticoids with the multidisciplinary evaluation through rule-based natural-language processing: a real-world study on patients with rheumatoid arthritis, psoriatic arthritis, and psoriasis

Background

The impact of a multidisciplinary management of rheumatoid arthritis (RA), psoriatic arthritis (PsA), and psoriasis on systemic glucocorticoids or innovative treatments remains unknown. Rule-based natural language processing and text extraction help to manage large datasets of unstructured information and provide insights into the profile of treatment choices.

Methods

We obtained structured information from text data of outpatient visits between 2017 and 2022 using regular expressions (RegEx) to define elastic search patterns and to consider only affirmative citation of diseases or prescribed therapy by detecting negations. Care processes were described by binary flags which express the presence of RA, PsA and psoriasis and the prescription of glucocorticoids and biologics or small molecules in each cases. Logistic regression analyses were used to train the classifier to predict outcomes using the number of visits and the other specialist visits as the main variables.

Results

We identified 1743 patients with RA, 1359 with PsA and 2,287 with psoriasis, accounting for 5,677, 4,468 and 7,770 outpatient visits, respectively. Among these, 25% of RA, 32% of PsA and 25% of psoriasis cases received biologics or small molecules, while 49% of RA, 28% of PsA, and 40% of psoriasis cases received glucocorticoids. Patients evaluated also by other specialists were treated more frequently with glucocorticoids (70% vs. 49% for RA, 60% vs. 28% for PsA, 51% vs. 40% for psoriasis; p < 0.001) as well as with biologics/small molecules (49% vs. 25% for RA, 64% vs. 32% in PsA; 51% vs. 25% for psoriasis; p < 0.001) compared to cases seen only by the main specialist.

Conclusion

Patients with RA, PsA, or psoriasis undergoing multiple evaluations are more likely to receive innovative treatments or glucocorticoids, possibly reflecting more complex cases.

Could a Gout Attack Cause Non-Arteritic Anterior Ischaemic Optic Neuropathy?

Non-arteritic anterior ischaemic optic neuropathy (NAION) is a common cause of optic neuropathy in individuals over the age of 50. While risk factors such as hypertension, diabetes, and hyperlipidaemia have been identified, recent literature suggests that new risk factors may be associated with NAION. This article reports a case of NAION that occurred concurrently with an acute gout attack in a 78-year-old male patient with no other systemic diseases. We suggest that gout may be a new potential risk factor for NAION as it has the potential to cause inflammation and vascular dysfunction, particularly during acute attacks. The case emphasises the importance of considering gout as a possible risk factor in the aetiology of NAION.

The role of occupational therapy in providing vocational rehabilitation for inflammatory arthritis: A scoping review protocol

INTRODUCTION

Inflammatory arthritis (IA) significantly impacts people's ability to continue in work roles, despite advances in medical management. Employment is acknowledged as important for health and wellbeing. Facilitating work participation and employment reduces social welfare dependence for income, minimising societal cost. Internationally, pathways and processes are developing to maintain people with acquired conditions in the workplace. Occupational Therapy supports this process, with its biopsychosocial approach, giving a framework to consider the complex dynamic of a person's vocational rehabilitation (VR) needs. A scoping review framework was chosen to explore the diverse VR process and emerging focus on Occupational Therapy's role in providing VR for the IA population.

METHODS

The methodological framework for scoping reviews will be used to guide the process and structure of the scoping review. A search strategy will be implemented in all the major peer reviewed databases along with grey literature repositories for English language studies. Study selection will use the PRISMA-ScR flow chart against an agreed eligibility criteria by two independent reviewers. Data extraction from the final selection will be mapped out using tables and a supporting descriptive review reflecting on the original scoping review aim and objectives completed.

DISSEMINATION

Findings will be disseminated at all levels and in various formats to bring them to the attention of clinicians, researchers and policy makers as VR pathways are established and prioritised for the early IA population.

Inflammatory Arthritis in a 19-month-old with Von Hippel-Lindau Disease

Von Hippel-Lindau disease (VHL) is a rare autosomal dominant disease characterized by progressive development of cysts and tumors. Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disorder and the most common arthritis in children. Although the mechanism of pathogenesis is not fully understood, JIA is thought to be a polygenic, autoimmune-mediated disease. Inherited or acquired disorders resulting in immune dysregulation can lead to neoplastic and autoimmune disease, but very few cases of patients with VHL and concomitant autoimmune disease are reported in the literature. Herein, we describe, to the best of our knowledge, the first reported case of a child with VHL and inflammatory arthritis, and we discuss three possible pathophysiologic mechanisms that could link VHL and JIA. Understanding the shared pathophysiology and genetics of both diseases may help guide future direction of targeted therapies and lead to improved clinical outcomes.

Clinical and Histological Features of Prosthetic Joint Infections May Differ in Patients With Inflammatory Arthritis and Osteoarthritis

Background: Patients with inflammatory arthritis are at increased risk of prosthetic joint infections (PJIs), but diagnosis in these patients can be challenging because active inflammatory arthritis produces elevated inflammatory markers that may mimic those seen in PJI. Purpose: In this pilot study, we sought to identify the clinical, microbiologic, and histopathologic features of culture-positive and culture-negative PJI in patients with inflammatory arthritis who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA). We also sought to obtain preliminary data to support a definitive study of optimal methods for PJI diagnosis in patients with inflammatory arthritis. Methods: We performed a retrospective analysis of TKA and THA patients treated for PJI from 2009 to 2018 at a single tertiary care orthopedic institution. Data were extracted from a longitudinally maintained hospital infection database. We reviewed hematoxylin and eosin slides of osteoarthritis and inflammatory arthritis PJI cases matched 3:1, respectively, by age, sex, and culture status. Clinical characteristics were evaluated using the Fisher exact test, χ² test, Student t test, and Mann-Whitney U test where appropriate. Results: A total of 807 PJI cases were identified (36 inflammatory arthritis and 771 osteoarthritis cases). Patients with inflammatory arthritis presented younger, had a higher Charlson Comorbidity Index, more frequently used glucocorticoids, were more likely women, and had a higher proportion of culture-negative PJI compared with osteoarthritis patients. Of the 88 inflammatory arthritis cases reviewed for histopathology, a higher proportion of culture-positive than culture-negative PJI cases had >10 polymorphonuclear leucocytes per high-power field and met Musculoskeletal Infection Society criteria but presented with less chronic inflammation. Conclusions: This retrospective prognostic study suggests that culture-negative PJI may be more frequent in patients with inflammatory arthritis than in those with osteoarthritis. Chronic infections, antibiotic use, or misdiagnosis may be contributing factors to unclear PJI diagnoses among culture-negative cases. This preliminary work supports the need for further studies to assess the differences in clinical features between culture-negative and culture-positive PJI in patients with inflammatory arthritis and the ability of biological diagnostic markers to discriminate between them in this population.

ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis, Crystalline Arthritis, or Erosive Osteoarthritis: 2022 Update

Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity because there is significant overlap of imaging findings among the various types of arthritis. This document provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Gastrointestinal Symptoms Impact Psychosocial Function and Quality of Life in Patients with Rheumatoid Arthritis and Spondyloarthritis: A Cross-Sectional Study

Patients with chronic Inflammatory Arthritis (IA), such as Rheumatoid Arthritis (RA) and Spondyloarthritis (SpA) are more likely to experience psychosocial impairment. Gastrointestinal (GI) symptoms are also present, especially in Spondyloarthritis. No data are available on the relationship between gut and brain manifestations and their impact on daily activities in this setting; thus, this study aimed to assess these symptoms in an IA population and identify potential associations. IA patients and a control group were enrolled. The Patient-Reported Outcome Measurement Instrument System (PROMIS^®) questionnaire was used to evaluate GI and psychosocial domains. The study included 389 subjects (238 controls and 151 with IA); demographic and clinical data were collected for each participant. IA patients reported both higher psychosocial and GI impairment compared with controls. The logistic regression model revealed a strong association between depression and belly pain (p = 0.035), diarrhea (p = 0.017), bloating (p = 0.018), and reflux (p = 0.01); anxiety was associated with belly pain (p = 0.004), diarrhea (p = 0.019), swallowing alterations (p = 0.004), flatulence (p < 0.001) and reflux (p = 0.008). Moreover, fatigue, sleep disorders, and pain interference were associated with almost all GI symptoms, whereas high physical function scores and satisfaction in social roles decreased the odds of most GI symptoms. IA patients had more significant impairment in both dimensions compared with controls. To address reported symptoms and improve the overall quality of life in rheumatologic patients, a new holistic approach is required.