Chronic arthropathy occurs in approximately two thirds of patients with hereditary haemochromatosis (HH). The aim was to study inflammatory and structural lesions in patients with HH with (HH-A) and ...without arthropathy (HH-WA) using ultrasonography.
This was a cross-sectional study of 26 patients with HH-A, 24 with HH-WA and 37 with hand osteoarthritis (HOA). Clinical examination was performed in 68 joints, and we retrieved data on hand function, pain and global disease activity (all using a visual analogue scale (VAS)), morning stiffness and ferritin levels. Standard x-ray and ultrasound were conducted in 36 joints (hands, hips, knees and ankles), and we graded grey scale synovitis (GSS), power Doppler ultrasound (PD), osteophytes, erosions, tenosynovitis and cartilage damage semi-quantitatively in accordance with prior publications.
Ultrasound revealed a high proportion of inflammatory changes in HH-A; GSS was found in 96.2% and PD signals in 80.8% of patients (median GSS score 9, PD score 2.5). The frequency of these findings was similar in HOA. Inflammation was also common in HH-WA, yielding GSS in 83.3% and PD signals in 50.0% of patients. Cartilage damage was most prominent in HH-A as compared to HH-WA and HOA (median scores 11.0, 2.5 and 2.0, respectively). The prevalence and extent of erosions and osteophytes were similar in all groups. None of the ultrasound scores was associated with pain or function; GSS, PD, osteophyte and cartilage scores correlated with x-ray-verified structural damage.
A high prevalence of ultrasound-verified inflammation and cartilage damage was found in HH-A, and to a lesser extent in HH-WA. These findings were associated with x-ray-verified damage but not with clinical scores of pain and function.
ObjectiveTo perform a systematic literature review (SLR) on different outcomes of remote care compared with face-to-face (F2F) care, its implementation into clinical practice and to identify drivers ...and barriers in order to inform a task force formulating the EULAR Points to Consider for remote care in rheumatic and musculoskeletal diseases (RMDs).MethodsA search strategy was developed and run in Medline (PubMed), Embase and Cochrane Library. Two reviewers independently performed standardised data extraction, synthesis and risk of bias (RoB) assessment.ResultsA total of 2240 references were identified. Forty-seven of them fulfilled the inclusion criteria. Remote monitoring (n=35) was most frequently studied, with telephone/video calls being the most common mode of delivery (n=30). Of the 34 studies investigating outcomes of remote care, the majority addressed efficacy and user perception; 34% and 21% of them, respectively, reported a superiority of remote care as compared with F2F care. Time and cost savings were reported as major benefits, technical aspects as major drawback in the 13 studies that investigated drivers and barriers of remote care. No study addressed remote care implementation. The main limitation of the studies identified was the heterogeneity of outcomes and methods, as well as a substantial RoB (50% of studies with high RoB).ConclusionsRemote care leads to similar or better results compared with F2F treatment concerning efficacy, safety, adherence and user perception outcomes, with the limitation of heterogeneity and considerable RoB of the available studies.
Modern ultrasonography enables clinicians to sensitively assess the progression of inflammatory joint and tendon disease, and to investigate vasculitides, connective tissue diseases and nerve ...lesions. Despite the advantages of musculoskeletal ultrasonography for diagnostic, prognostic and monitoring purposes, fewer than 10% of European rheumatologists use this technique in routine clinical practice. The reliability and limitations of rheumatic ultrasonography remain a concern, although good interobserver and intraobserver agreement in results from ultrasonography have been demonstrated among experienced sonographers. International recommendations for assessments and ultrasonography training courses are available, and will improve the standardization of the use of these techniques. In clinical practice, ultrasonography can complement the diagnostic evaluation of patients with rheumatic disease and might have value in confirming and extending clinical findings. Musculoskeletal ultrasonography can also be a valuable follow-up tool to monitor disease activity and support treatment decisions for specific patients. Furthermore, ultrasonography-guided articular injections provide better precision and a higher success rate for synovial fluid aspiration than clinically-guided injections. In the future, three-dimensional ultrasonography techniques, the fusion of ultrasonography and other imaging methods, and real time sonoelastography will be interesting new fields of investigation.
Abstract Objectives To study the association of clinical and/or ultrasound variables with patients′ (PGA) and physicians′ (EGA) global assessment of disease activity in Psoriatic Arthritis (PsA). The ...correlation of these parameters with the discordance between PGA and EGA, as well as with PGA/EGA changes over 6 months was also investigated. Methods Prospective study of 83 consecutive PsA patients with 2 visits scheduled 6 months apart. All patients underwent the following assessments: tender (TJC) and swollen joint count (SJC), PASI, dactylitis and Leeds enthesitis index. PGA, patients′ level of pain (pain VAS), EGA, and HAQ were also recorded. Grey scale (GS) and Power Doppler (PD) ultrasound were performed at 68 joints (evaluating synovia and tendons) and 14 entheses. Regression analyses were performed to assess the association of these variables with PGA and EGA. Two new variables ‘PGAminus EGA′ and ‘PGAchange-EGAchange′ were developed to explore the discrepancy between PGA and EGA and the consistency of PGA/EGA changes over time, respectively. Results The parameters explaining most of PGA and EGA variability were pain VAS (30.5%) and SJC (48.5%), respectively. The correlation between EGA and joint counts was stronger in patients with high versus low levels of ultrasound verified inflammation. PGAminus EGA was mainly explained by pain and SJC. Pain was the most important predictor of PGA change whereas TJC and HAQ were more closely associated with EGA changes. ‘PGAchange-EGAchange′ was linked to pain and SJC. Ultrasound scores were not linked with either of these variables. Conclusions Pain VAS and joint counts are the most important clinical parameters explaining patients′ and physicians′ perception of disease activity, whereas the correlation of active inflammation as verified by sonography with these factors is limited.
Pro-inflammatory, cytotoxic CD4(+)CD28(-) T-cells with known defects in apoptosis have been investigated as markers of premature immuno-senescence in various immune-mediated diseases. In this study ...we evaluated the influence of polyclonal antilymphocyte globulins (ATG-Fresenius, ATG-F) on CD4(+)CD28(-) T-cells in vivo and in vitro.
Surface and intracellular three colour fluorescence activated cell sorting analyses of peripheral blood mononuclear cells from 16 consecutive transplant recipients and short-term cell lines were performed. In vivo, peripheral levels of CD3(+)CD4(+)CD28(-) T-cells decreased from 3.7 ± 7.1% before to 0 ± 0% six hours after ATG-F application (P = 0.043) in 5 ATG-F treated but not in 11 control patients (2.9 ± 2.9% vs. 3.9 ± 3.0%). In vitro, ATG-F induced apoptosis even in CD4(+)CD28(-) T-cells, which was 4.3-times higher than in CD4(+)CD28(+) T-cells. ATG-F evoked apoptosis was partially reversed by the broad-spectrum caspase inhibitor benzyloxycarbonyl (Cbz)-Val-Ala-Asp(OMe)-fluoromethylketone (zVAD-fmk) and prednisolon-21-hydrogensuccinate. ATG-F triggered CD25 expression and production of pro-inflammatory cytokines, and induced down-regulation of the type 1 chemokine receptors CXCR-3, CCR-5, CX3CR-1 and the central memory adhesion molecule CD62L predominately in CD4(+)CD28(-) T-cells.
In summary, in vivo depletion of peripheral CD3(+)CD4(+)CD28(-) T-cells by ATG-F in transplant recipients was paralleled in vitro by ATG-F induced apoptosis. CD25 expression and chemokine receptor down-regulation in CD4(+)CD28(-) T-cells only partly explain the underlying mechanism.
Monoclonal gammopathy of undetermined significance (MGUS), a premalignant condition, is associated with various chronic inflammatory rheumatic diseases (RDs) and is frequently observed as an ...incidental finding during routine work-up. The association of MGUS and chronic RDs is well established, but the impact of RDs on the risk of transformation into overt multiple myeloma (MM) has not been evaluated so far. MGUS patients diagnosed between January 2000 and August 2016 were identified and screened for concomitant RDs. RDs were grouped into antibody (Ab)-mediated RDs and non-Ab–mediated RDs (polymyalgia rheumatica, large-vessel giant cell arteritis, spondyloarthritis, and gout). Progression to MM was defined as a categorical (yes/no) or continuous time-dependent (time to progression) variable. Of 2935 MGUS patients, 255 (9%) had a concomitant RD. MGUS patients diagnosed with non-Ab–mediated RDs had a doubled risk of progression compared with those without a concomitant RD (hazard ratio, 2.1; 95% CI, 1.1-3.9; P = .02). These data translate into a 5-year risk of progression of 4% in MGUS patients without rheumatologic comorbidity, 10% in those with concomitant non-Ab–mediated RDS, and 2% in those with Ab-mediated RDs. By using the complex risk stratification model that includes myeloma protein (M-protein) concentration, immunoglobulin type, and level of free light chain ratio as variables, patients with non-Ab–mediated RDs (n = 57) had the highest risk for progression (hazard ratio, 6.8; 95% CI, 1.5-30.7; P = .01) compared with patients with Ab-mediated RDs (n = 77). Chronic inflammatory diseases have an impact on the risk of MGUS progressing into overt MM, with a doubled risk of transformation observed in patients with non-Ab–mediated RDs. Future research can elucidate whether comorbidities such as RDs should be included in currently applied prognostic MGUS scores.
•The MGUS transformation risk varied depending on the diagnosed RDs.•The risk of progression is doubled for MGUS patients with non-Ab–mediated RDs compared with those without concomitant RDs.
Display omitted
Antiphospholipid antibodies (aPLs) frequently occur in autoimmune and cardiovascular diseases and correlate with a worse clinical outcome. In the present study, we evaluated the association between ...antiphospholipid antibodies (aPLs), markers of inflammation, disease progression and the presence of an intra-aneurysmal thrombus in abdominal aortic aneurysm (AAA) patients. APLs ELISAs were performed in frozen serum samples of 96 consecutive AAA patients and 48 healthy controls yielding positive test results in 13 patients (13.5%) and 3 controls (6.3%; n.s.). Nine of the 13 aPL-positive AAA patients underwent a second antibody testing >12 weeks apart revealing a positive result in 6 cases. APL-positive patients had increased levels of inflammatory markers compared to aPL-negative patients. Disease progression was defined as an increase of the AAA diameter >0.5 cm/year measured by sonography. Follow-up was performed in 69 patients identifying 41 (59.4%) patients with progressive disease. Performing multipredictor logistic regression analysis adjusting for classical AAA risk factors as confounders, the presence of aPLs at baseline revealed an odds ratio of 9.4 (95% CI 1.0-86.8, p = 0.049) to predict AAA progression. Fifty-five patients underwent a computed tomography in addition to ultrasound assessment indicating intra-aneurysmal thrombus formation in 82.3%. Median thrombus volume was 46.7 cm3 (1.9-377.5). AAA diameter correlated with the size of the intra-aneurysmal thrombus (corrcoeff = 0.721, p<0.001), however neither the presence nor the size of the intra-aneurysmal thrombus were related to the presence of aPLs. In conclusion, the presence of aPLs is associated with elevated levels of inflammatory markers and is an independent predictor of progressive disease in AAA patients.
Abstract
PMR is an inflammatory rheumatic disease of elderly people characterized by pain and stiffness in the neck, shoulder and pelvic girdles. No specific diagnostic confirmatory tests exist and ...clinical symptoms, as well as increased acute phase reactants, are unspecific. The diagnostic value of imaging including ultrasound, MRI and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) with/without CT for PMR is increasingly studied. These techniques, particularly FDG-PET/CT, may help to detect underlying GCA in PMR patients with an incomplete response to glucocorticoids and/or recurrent relapses. Recent imaging studies provide novel insights into the anatomical basis of inflammation in PMR, particularly at hip and spine, which may help to distinguish this disease from other mimicking conditions. In this review, we discuss novel insights into the pathoanatomy of PMR, compare the diagnostic values of different imaging techniques and summarize current data on the role of imaging for monitoring and outcome prediction.
Objective To assess the association of clinical and/or serological parameters with ultrasound-defined disease activity in rheumatoid arthritis (RA). Methods Retrospective analysis of 149 consecutive ...RA patients routinely assessed by sonography of the wrists, metacarpo-phalangeal, and proximal interphalangeal joints. Semiquantitative scoring of synovial hypertrophy/effusion and power Doppler (PD) signals was performed. Sonographic remission was defined by the absence of PD signals. Number of tender and swollen joints, global assessment of disease activity by the physician (VAS-phys) and patient (VAS-pt), C-reactive protein (CRP), erythrocyte sedimentation rate, duration of morning stiffness (MS), simplified disease activity index, disease activity score for 28 joints, clinical disease activity index, and health assessment questionnaires were recorded. Results PD signals as a sign of active disease were observed in 117 (78.5%) RA patients. CRP, erythrocyte sedimentation rate, and MS were higher in patients with PD signals than in patients in remission. CRP >5.0 mg/L (normal values 0-5.0 mg/L), MS >15 minutes, or the combination of both revealed odds ratios of 5.0, 3.0, or 18.9, respectively, to indicate sonography-defined active disease. The other parameters showed no association with the presence or absence of PD-signals. Conclusions Sonography-defined disease activity is associated with CRP and MS, whereas current composite scores and its clinical components did not match this definition.
Abstract
Objectives
While >50% of medical students and residents are women, their proportion drastically diminishes within higher ranks and leadership roles; this is known as the ‘leaky pipeline’. We ...aimed to evaluate the leaky pipeline among rheumatologists across Europe and to assess determinants inducing rheumatologists to leave hospitals.
Methods
Experts in the field of economics developed a questionnaire with scientific focus on the leaky pipeline among rheumatologists, which was distributed electronically by national scientific societies of EULAR countries and by individual contacts. We performed common factor analysis, univariate t-tests and multivariate regression analyses to appraise our dataset.
Results
A total of 311 hospital-based rheumatologists from 23/45 EULAR countries (52.7% females, 47.3% males) answered the questionnaire. The presence of the leaky pipeline was evident for the entire sample. Of 64% female rheumatologists only 34.2% of departments’ directors were female, with noteworthy regional differences. Female doctors reported higher intentions to leave their hospital (β = 0.28, P < 0.05) and lower commitment towards their current organization (β = –0.34, P < 0.05) when compared with males. Women reported lower levels of job satisfaction (β = –0.26, P < 0.10), promotion justice (β = –0.55, P < 0.01) and career perspectives (β = –0.26, P < 0.10, one-tailed) than men, explaining their lower organizational commitment.
Conclusion
Female rheumatologists perceive worse job opportunities and satisfaction than males. Many reasons for the leaky pipeline are beyond the control of organizations. Based on our results, organizations should be encouraged to reconsider and adjust their performance management practices to enable an equitable work environment.
PDF
