Faculty Bibliography

Introduction: Mucocutaneous lesions can be disabling in Behcet's syndrome patients who experience these lesions frequently and can be an important cause of impaired quality of life. Apremilast may be a safe and effective alternative for the treatment of oral and genital ulcers in Behcet's syndrome. Areas covered: This review covers the current data on the efficacy and safety of apremilast in BS patients with mucocutaneous involvement coming from a Phase 2 placebo controlled trial as well as the patient important outcomes reported in the same trial. Observational data in a small number of Behcet's syndrome patients with different types of involvement, inadequately controlled with other treatment modalities was also reviewed. Expert opinion: Topical measures and colchicine are traditionally tried as the initial treatment modality for mucocutaneous lesions of Behcet's syndrome. However these measures may not be sufficient for optimal control of oral and genital ulcers. Immunosuppressive agents such as azathioprine and TNF inhibitors or interferon-alpha are being used for patients with resistant manifestations. However adverse events may limit the use of these agents. Apremilast is a promising agent for the management of BS patients with mucocutaneous lesions due to its efficacy and favourable safety profile.

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.

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.

OBJECTIVE: The Outcome Measures in Rheumatology (OMERACT) Vasculitis Working Group has been working toward developing a data-driven core set of outcome measures for use in clinical trials of Behcet's syndrome [Behcet disease (BD)]. This paper summarizes the group's work through OMERACT 2016, discussions during the meeting, and the future research agenda. METHODS: Qualitative patient interviews were conducted among 20 patients with BD who have different types of organ involvement. A 3-round Delphi among BD experts and patients was initiated to identify domains, subdomains, and outcomes to be assessed in clinical trials of BD. The results of these studies were discussed during OMERACT 2016 and next steps were planned. RESULTS: Patients' perspectives and priorities were identified through qualitative interviews that identified candidate domains and subdomains for inclusion in the Delphi and characterized some shortcomings of the currently used patient-reported outcomes in BD. The first round of the Delphi was completed and several domains or subdomains were endorsed by the experts and/or the patients. Because many more items were endorsed than would be feasible to assess during a clinical trial, rating and ranking of items by physicians and patients was planned as a next critical step. The challenges of assessing specific organ system involvement was also discussed. CONCLUSION: The OMERACT Behcet Syndrome Working Group research program will identify core domains for assessment in BD with the goal of developing a core set of outcome measures for use in all trials of BD with the option to incorporate additional outcomes for specific organ involvement.

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.

BACKGROUND: In the United States, there is racial/ethnic disparity in the care of rheumatoid arthritis (RA), yet there are limited data regarding the impact of varied health care systems on treatment outcomes. OBJECTIVE: The aim fo this study was to compare the frequencies of use of disease-modifying antirheumatic drugs and biologic agents in racial minorities with RA in a single-payer and variable-access health systems. METHODS: Rheumatoid arthritis disease status was examined in the Ethnic Minority Rheumatoid Arthritis Consortium (EMRAC) and Veterans Affairs Rheumatoid Arthritis Registry (VARA); frequencies of prednisone and disease-modifying antirheumatic drugs and biologic agent use at enrollment were documented. Comparisons in frequencies of RA therapies between RA cohorts and white and nonwhite racial subsets were evaluated. RESULTS: The combined cohorts provided 2899 subjects for analysis (EMRAC = 943, VARA = 1956). Routine Assessment of Patient Index Data 3 and Disease Activity Score in 28 Joints scores were equivalent (cohort, racial subsets), as was biologic agent use (26% vs. 28%) between whites and nonwhites. Disease-modifying antirheumatic drug use was greater in EMRAC nonwhites compared with their white counterparts, but similar to all VARA patients (33% vs. 22% [P < 0.001], 36%, 39%, respectively). However, biologic agent use was significantly greater in EMRAC versus VARA patients (37% vs. 22%, P < 0.001). In VARA patients, there was no difference in biologic agent use among racial subsets (22% vs. 21%). In EMRAC patients, biologic agent use was greater in whites than in nonwhites (EMRAC white 45% vs. EMRAC nonwhite 33%, P < 0.001; odds ratio, 1.66) and compared with all VARA subjects (EMRAC white 45% vs. all VARA 22%, P < 0.001; odds ratio, 2.91). Younger age, advanced education, longstanding disease, and severe disease were associated with biologic agent use. CONCLUSIONS: When compared with more variable-access systems, a VA system of care that includes a single-payer insurance may afford equality in use of biologic agents among different racial subsets.

PURPOSE OF REVIEW: Behcet's syndrome is more common in certain geographic regions, however, can be seen outside of these areas and need to be included in the differential diagnosis of many patients, as it has overlapping features with many rheumatologic conditions. RECENT FINDINGS: Especially in regions with immigrant populations, there seem to be similarities to originating countries in Behcet's prevalence, but the syndrome is not limited to those from certain backgrounds and can be seen in others also. There is emerging evidence that even though the prevalence of Behcet's may be similar to that of endemic areas, in nonendemic regions the condition may be less severe, suggesting potential environment agents in determining the severity of the disease. In addition, women seem to be overrepresented in nonendemic areas and may explain part of the reason for less severe symptoms, as Behcet's tends to be more severe in men. SUMMARY: The somewhat different presentation of Behcet's syndrome in nonendemic areas needs to be considered when thinking about Behcet's in the differential diagnosis of patients. Research into potentially less severe form of the disease in nonendemic areas may provide new clues to the pathogenesis of this condition.