Faculty Bibliography

OBJECTIVES/OBJECTIVE:To explore patterns of real-world early RA (ERA) care across countries. METHODS:An online survey was disseminated to practising rheumatologists across Europe and the US, also made accessible on social media between April and May 2015. Survey questions (n=38) assessed the structure and setting of ERA clinics, times to diagnosis and treatment, patient monitoring, guideline use and data recording. RESULTS:A total of 212 rheumatologists from 39 countries (76% European) completed the survey. 62% had an ERA clinic based at a university hospital. Patient referral to rheumatology was mainly (78%) via primary care; 44% had an agreed ERA local referral pathway, 15% a national pathway. Only 16% had dedicated ERA clinics, the majority being practitioners in Northern Europe with access to a local or national referral pathway. Data for research were collected by 42%. Treatment guidelines were followed by the majority, especially rheumatologists practising in Europe. Variations existed in the use of initial DMARDs with treatment decisions reported to be influenced by international/national guidelines in 71%/61%. No significant relationship between country gross national income and the availability of ERA clinics was seen. CONCLUSIONS:This study provides comparative benchmark information regarding the global provision of ERA care. Substantial variations exist in referral and early assessment pathways with guidelines having a most apparent impact in Northern Europe. Provision of an ERA service does not appear to be constrained by cost, with conceptual factors, e.g. clinician engagement, perhaps playing a role. These initial insights could potentially help harmonise ERA management across countries.

Opinion statement: Osteoarthritis is a progressive degenerative disease of the joints in which the articular cartilage within the joints deteriorates with associated juxta-articular bone formation. While the etiology of OA is still under investigation, preclinical studies have determined that the Wnt/beta-catenin signaling and bone morphogenic signaling pathways are important for the formation and repair of the joint tissues, and the effects are on both the phenotype and function of the joint tissue cells. In addition, individuals with polymorphisms in the gene, FRZB, that codes for the wnt signaling protein secreted frizzled related protein 3 (sFRP3) have higher risk of developing OA. A number of proof-of-concept preclinical studies have been performed on inhibitors of the Wnt signaling pathway, and have altered the disease progression. Proof of concept studies assessing the regenerative capacity of mesenchymal stem cells as treatments for painful knee OA have reported both encouraging and discouraging results. Therefore, the identification of the molecular pathways that are responsible for joint formation and repair has led to the development of new novel interventions for the treatment of OA that are now entering clinical trials. The ability to slow or reverse the progression of osteoarthritis may soon be within our reach.

Game consoles, handheld units, and laptops are commonly used by children. Students at schools in St. Louis, Missouri, were asked to complete questionnaires asking about type, duration, and pain levels in their wrists and fingers related to the devices they used. Roughly, 75% of students were found to be using one of the devices. Younger age, female gender, and longer playing duration were associated with increase wrist and finger pain. Use of gaming and laptops, especially in younger children and with longer duration of use, is associated with increased pain in fingers and wrists.

BACKGROUND:The effect of IL-1 blocking therapy on mucocutaneous manifestations of Behçet's disease is incompletely understood. METHODS:Six patients with Behçet's disease and ongoing oral/genital ulcers for ≥1 month were enrolled into an adaptive, two-phase clinical trial and included in the analysis. Study duration was 6 months with extension up to 16 months. All were treated non-blinded with anakinra 100 mg subcutaneous daily with the option to escalate the dose to 200 mg in partial responders after 1 month and 300 mg after 6 months. Patients recorded the number and severity of ulcers in daily diaries. The primary outcome was remission defined as no ulcers on physical exam for two consecutive monthly visits between months 3 and 6. Secondary outcomes included the number and severity of patient-reported ulcers, patient/physician global scores, and standardized disease activity scores. RESULTS:Two of six patients achieved the primary outcome. Five of six patients had improvement in the number and severity of ulcers. Non-statistically significant improvements were seen in secondary outcomes. Over the entire study, patients reported ≥1 oral and ≥1 genital ulcer on 665 (66%) and 139 (14%) days, respectively. On anakinra 200 mg vs 100 mg, patients reported fewer days with oral ulcers (65% vs 74% of days, p = 0.01) and genital ulcers (10% vs 22% of days, p < 0.001) and milder oral ulcer severity (p < 0.001). Increase of anakinra to 300 mg did not result in further improvements. Adverse events were notable for mild infections. CONCLUSION/CONCLUSIONS:Anakinra at an optimal dose of 200 mg daily had an acceptable safety profile and was partially effective in the treatment of resistant oral and genital ulcers in Behçet's disease. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov. NCT01441076 . Registered on 24 September 2011.

Objectives: An unmet need for reliable, validated and widely accepted outcome measures for trials in Behcets syndrome (BS) was identified through: a systematic review; a survey among Behcets experts; and an outcome measures interest group meeting during the 16th International Conference on BS The OMERACT BS Working Group has been working to advance outcome measures in BS with the goal of creating a core set of data-driven measures for use in clinical trials for BS starting with a Delphi. This abstract describes the results for round one of the Delphi. Methods: A list of possible domains and outcomes was prepared using the results of a systematic literature review on outcomes assessed in previous Behcets studies, qualitative patient interviews, and expert opinion. A three round Delphi has begun among physicians from different specialties experienced in BS and among patients with BS. The patient survey was the same as the physician survey with medical terms explained. The web based survey was formatted in both English and Turkish and emailed to 123 physicians and 130 patients. Agreement by more than seventy percent of either physicians or patients resulted in an item accepted. Results: 74 physicians and 35 patients participated in Round 1. The physicians were experts in BS from 21 countries and from within a wide range of specialties, including Rheumatology, Ophthalmology, Internal Medicine, Dermatology, Gastroenterology, and Neurology. Among the participating patients there was good representation of each type of organ involvement please see Table 1 for results. In addition to these domains, more than seventy percent of patients endorsed the assessment of pain, fatigue, sleep, sexual functioning, psychological functioning, and acute phase reactants in all trials of BS. Conclusions: Multiple disease related domains in BS have been identified by physicians and patients as important to address in clinical trials, suggesting that a core set for all trials will be needed and subdomains for subsets of disease will also be useful. Rating and ranking of these domains and subdomains in the next two rounds will enable the development of a core set of domains to be assessed in trials of BS

BACKGROUND: Rheumatoid arthritis (RA) afflicts approximately 1.5 million American adults and is a major cause of disability. As disease severity worsens, individuals with RA may experience functional decline that can impact dietary intake. OBJECTIVE: The objective of this study is to assess the diet quality of individuals with RA using the Healthy Eating Index (HEI)-2010 and examine associations between diet quality and disease activity and functional status. METHODS: This cross-sectional study assessed diet quality and disease activity and functional status in adults with RA. Participants completed seven-day weighed food records, which were scored using the HEI-2010. Participants had a fasting blood draw and completed the Multidimensional Health Assessment Questionnaire to determine disease activity and functional status. RESULTS: The mean age of individuals with RA ( N = 84) was 53 +/- 14 years, and 86.9% were female. The mean HEI-2010 total score was 58.7 +/- 15.9, with 7.1% of participants scoring "good", 58.3% "fair", and 34.5% "poor". Most participants did not adhere to recommended intakes of total fruit, total vegetables, whole grains, fatty acids, refined grains, sodium, and empty calories. An unadjusted multiple linear regression model found duration of morning stiffness and C-reactive protein concentration to be significant variables to inversely predict HEI-2010 total score. CONCLUSIONS: The diet quality of many individuals with RA needs improvement and may be related to functional disability associated with RA. Healthcare providers should encourage individuals with RA to meet dietary guidelines and maintain a healthy diet. Moreover, healthcare providers should be aware of the potential impacts of functional disability on diet quality in individuals with RA.