Objective
To develop updated guidelines for the pharmacologic management of rheumatoid arthritis.
Methods
We developed clinically relevant population, intervention, comparator, and outcomes (PICO) ...questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations.
Results
The guideline addresses treatment with disease‐modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high‐risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional).
Conclusion
This clinical practice guideline is intended to serve as a tool to support clinician and patient decision‐making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision‐making process based on patients’ values, goals, preferences, and comorbidities.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
PURPOSE OF REVIEWImplementing shared decision-making (SDM) is a top international priority to improve care for persons living with rheumatoid arthritis. Using SDM tools, such as decision aids improve ...patients’ knowledge and support communication with their clinicians on treatment benefits and risks. Despite calls for SDM in treat-to-target, studies demonstrating effective SDM strategies in rheumatology clinical practice are scarce. Our objective was to identify recent and relevant literature on SDM in rheumatoid arthritis.
RECENT FINDINGSWe found a burgeoning literature on SDM in rheumatoid arthritis that tackles issues of implementation. Studies have evaluated the SDM process within clinical consultations and found that uptake is suboptimal. Trials of newly developed patient decision aids follow high methodological standards, but large-scale implementation is lacking. Innovative SDM strategies, such as shared goals and preference phenotypes may improve implementation of treat-to-target approach. Research and patient engagement are standardizing measures of SDM for clinical uses.
SUMMARYUptake of SDM in rheumatoid arthritis holds promise in wider clinicians’ and patients’ awareness, availability of decision aids, and broader treat-to-target implementation strategies, such as the learning collaborative. Focused attention is needed on facilitating SDM among diverse populations and those at risk of poorer outcomes and barriers to communication.
Eliciting HIV-1-specific broadly neutralizing antibodies (bNAbs) remains a challenge for vaccine development, and the potential of passively delivered bNAbs for prophylaxis and therapeutics is being ...explored. We used neutralization data from four large virus panels to comprehensively map viral signatures associated with bNAb sensitivity, including amino acids, hypervariable region characteristics, and clade effects across four different classes of bNAbs. The bNAb signatures defined for the variable loop 2 (V2) epitope region of HIV-1 Env were then employed to inform immunogen design in a proof-of-concept exploration of signature-based epitope targeted (SET) vaccines. V2 bNAb signature-guided mutations were introduced into Env 459C to create a trivalent vaccine, and immunization of guinea pigs with V2-SET vaccines resulted in increased breadth of NAb responses compared with Env 459C alone. These data demonstrate that bNAb signatures can be utilized to engineer HIV-1 Env vaccine immunogens capable of eliciting antibody responses with greater neutralization breadth.
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•HIV-1 bNAb sensitivity signatures from 4 large virus panels mapped across 4 Ab classes•Non-contact hypervariable region characteristics are critical for bNAb sensitivity•HIV-1 Env 459C used alone as a vaccine can elicit modest tier 2 NAbs in guinea pigs•V2 bNAb signature-guided modifications in 459C enhanced neutralization breadth
HIV-1 Env amino acid signatures associated with sensitivity to broadly neutralizing antibodies were systematically defined from large neutralization panels. V2 signatures were incorporated in a trivalent vaccine to enhance epitope exposure and to include common epitope variants, resulting in increased neutralization breadth against heterologous viruses in a guinea pig model.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Decomposition contributes to global ecosystem function by contributing to nutrient recycling, energy flow, and limiting biomass accumulation. The decomposer organisms influencing this process form ...diverse, complex, and highly dynamic communities that often specialize on different plant or animal resources. Despite performing the same net role, there is a need to conceptually synthesize information on the structure and function of decomposer communities across the spectrum of dead plant and animal resources. A lack of synthesis has limited cross-disciplinary learning and research in important areas of ecosystem and community ecology. Here we expound on the "necrobiome" concept and develop a framework describing the decomposer communities and their interactions associated with plant and animal resource types within multiple ecosystems. We outline the biotic structure and ecological functions of the necrobiome, along with how the necrobiome fits into a broader landscape and ecosystem context. The expanded necrobiome model provides a set of perspectives on decomposer communities across resource types, and conceptually unifies plant and animal decomposer communities into the same framework, while acknowledging key differences in processes and mechanisms. This framework is intended to raise awareness among researchers, and advance the construction of explicit, mechanistic hypotheses that further our understanding of decomposer community contributions to biodiversity, the structure and function of ecosystems, global nutrient recycling and energy flow.
Full text
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BFBNIB, FZAB, GIS, IJS, INZLJ, KILJ, NLZOH, NMLJ, NUK, OILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK, ZRSKP
Objective
To develop updated guidelines for the pharmacologic management of rheumatoid arthritis.
Methods
We developed clinically relevant population, intervention, comparator, and outcomes (PICO) ...questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations.
Results
The guideline addresses treatment with disease‐modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high‐risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional).
Conclusion
This clinical practice guideline is intended to serve as a tool to support clinician and patient decision‐making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision‐making process based on patients’ values, goals, preferences, and comorbidities.
Full text
Available for:
BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
In early 2020, the COVID-19 global pandemic shifted most healthcare to remote delivery methods to protect patients, clinicians, and hospital staff. Such remote care delivery methods include the use ...of telehealth technologies including clinical video telehealth or telephone visits. Prior to this, research on the acceptability, feasibility, and efficacy of telehealth applied to rheumatology, or telerheumatology, has been limited.
Telerheumatology visits were found to be noninferior to in-person visits and are often more time and cost effective for patients. Clinicians and patients both noted the lack of a physical exam in telehealth visits and patients missed the opportunity to have lab work done or other diagnostic tests they are afforded with in-person visits. Overall, patients and clinicians had positive attitudes toward the use of telerheumatology and agreed on its usefulness, even beyond the pandemic.
Although telerheumatology has the potential to expand the reach of rheumatology practice, some of the most vulnerable patients still lack the most basic resources required for a telehealth visit. As the literature on telerheumatology continues to expand, attention should be paid to health equity, the digital divide, as well as patient preferences in order to foster true shared decision-making over telehealth.
Towards Quantifying Carrion Biomass in Ecosystems Barton, Philip S.; Evans, Maldwyn J.; Foster, Claire N. ...
Trends in ecology & evolution,
October 2019, 2019-10-00, 20191001, Volume:
34, Issue:
10
Journal Article
Peer reviewed
Open access
The decomposition of animal biomass (carrion) contributes to the recycling of energy and nutrients through ecosystems. Whereas the role of plant decomposition in ecosystems is broadly recognised, the ...significance of carrion to ecosystem functioning remains poorly understood. Quantitative data on carrion biomass are lacking and there is no clear pathway towards improved knowledge in this area. Here, we present a framework to show how quantities derived from individual carcasses can be scaled up using population metrics, allowing for comparisons among ecosystems and other forms of biomass. Our framework facilitates the generation of new data that is critical to building a quantitative understanding of the contribution of carrion to trophic processes and ecosystem stocks and flows.
Knowledge of carrion biomass in ecosystems is lacking for most biomes and animal species.Quantities derived from individual carcasses can be scaled up using population- and community-level concepts, allowing for comparisons with other forms of biomass within and among ecosystems.New data on carrion biomass will be critical to building a more complete and mechanistic understanding of trophic processes, and general ecosystem stocks and flows.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The use of left ventricular assist devices in treating patients with end-stage heart failure has increased significantly in recent years, both as a bridge to transplantation and as destination ...therapy in those who are ineligible for cardiac transplantation. This increase is based largely on the results of several recently completed clinical trials with the new second-generation continuous-flow devices that showed significant improvements in survival, functional capacity, and quality of life. Additional information on the use of the first- and second-generation left ventricular assist devices has come from a recently released report spanning the years 2006 to 2009, from the Interagency Registry for Mechanically Assisted Circulatory Support, a National Heart, Lung, and Blood Institute–sponsored collaboration between the U.S. Food and Drug Administration, the Centers for Medicare and Medicaid Services, and the scientific community. The authors review the latest clinical trials and data from the registry, with tight integration of the landmark molecular, cellular, and genomic research that accompanies the reverse remodeling of the human heart in response to a left ventricular assist device and functional recovery that has been reported in a subset of these patients.
Full text
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Treatment guidelines for rheumatoid arthritis (RA) include a patient-centered approach and shared decision making, which includes a discussion of patient goals. We describe the iterative early ...development of a structured goal elicitation tool to facilitate goal communication for persons with RA and their clinicians.
Tool development occurred in 3 phases: (1) clinician feedback on the initial prototype during a communication training session; (2) semistructured interviews with RA patients; and (3) community stakeholder feedback on elements of the goal elicitation tool in a group setting and electronically. Feedback was dynamically incorporated into the tool.
Clinicians (n = 15) and patients (n = 10) provided feedback on the tool prototypes. Clinicians preferred a shorter tool deemphasizing goals outside of their perceived treatment domain or available resources; they highlighted the benefits of the tool to facilitate conversation but raised concerns regarding current constraints of the clinic visit. Patients endorsed the utility of such a tool to support agenda setting and preparing for a visit. Clinicians, patients, and community stakeholders reported the tool was useful but identified barriers to implementation that the tool could itself resolve.
A goal elicitation tool for persons with RA and their clinicians was iteratively developed with feedback from multiple stakeholders. The tool can provide a structured way to communicate patient goals within a clinic visit and help overcome reported barriers such as time constraints. Incorporating a structured communication tool to enhance goal communication and foster shared decision making may lead to improved outcomes and higher-quality care in RA.
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