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Although nailfold capillaroscopy (NFC) appears to have a bright future in clinical practice, the lack of familiarity with the technique and how to interpret its outcomes is major barriers which have made nailfold capillaroscopy an underutilized method in standard clinical practice. Traditional methods for assessment and measurement of capillary patterns, density, and blood flow are falling behind and face some challenges. In fact, there have been calls for improvement, hence the recent publication of the standardization of NFC by the EULAR Study Group on Microcirculation in Rheumatic Diseases. Nailfold capillaroscopy has the advantage of being a non-invasive technique that provides a window into the digital microcirculation. This paved the way for a rapidly growing interest in using capillaroscopy parameters as outcome measures in research. In standard clinical practice, whilst its main application is in the identification of an underlying systemic sclerosis spectrum disorder in patients presenting with Raynaud's phenomenon, its use has expanded to include other clinical features possibly suggestive of an underlying connective tissue disease. This article presents the challenges, provides tips, and highlights the exciting potential of nailfold capillaroscopy in standard practice.

Objective To assess concordance among criteria for inactive disease (ID) and low disease activity (LDA) in juvenile idiopathic arthritis (JIA) and to seek factors driving discordance. Methods The frequency of fulfillment of existing criteria was evaluated in information on 10,186 patients extracted from 3 cross-sectional data sets. Patients were divided up according to the functional phenotypes of oligoarthritis and polyarthritis. Concordance between criteria was examined using weighted Venn diagrams. The role of each individual component in explaining discordance between criteria was assessed by calculating the absolute number and percentage of instances in which the component was responsible for discrepancy between definitions. Results Criteria for ID were met by 28.6–41.1% of patients with oligoarthritis and by 24.0–33.4% of patients with polyarthritis. Criteria for LDA were met by 44.8–62.4% of patients with oligoarthritis and by 44.6–50.4% of patients with polyarthritis. There was a 57.9–62.3% overlap between criteria for ID and a 67.9–85% overlap between criteria for LDA. Parent and physician global assessments and acute-phase reactants were responsible for the majority of instances of discordance among criteria for ID (8.7–15.5%, 10.0–12.3%, and 10.8–17.3%, respectively). Conclusion We found fair concordance between criteria for ID and LDA in JIA, with the main drivers of discordance for ID being physician and parent global assessments and acute-phase reactants. This observation highlights the need for further studies aimed to evaluate the impact of subjective physician and parent perception of disease remission and of laboratory measures of inflammatory activity on the definition of ID.

Introduction Fibromyalgia syndrome (FMS) is a chronic condition characterized by generalized body pain, and mood disturbances of unknown etiology. Electromagnetic hypersensitivity (EHS), where patients report “hypersensitivity” to electro-magnetic fields (EMF). They wonder whether aches and pains, headaches, depression, sleeping disorders, could be associated with EMF exposure. Aim of the work Is to investigate if fibromyalgia symptoms and scores are affected by the exposure to EMF. Patients and methods This study included 80 FMS patients. The numerical pain rating scale (NPRS), Montgomery-Asberg Depression Rating Scale (MADRS) and the revised fibromyalgia impact questionnaire (FIQR) were used. A patient self-reporting questionnaire invented by the authors in Arabic for the frequency and intensity of EMF exposure was validated and used. Results The mean age of the patients was 38.7 ± 11 years and mean disease duration 4.5 ± 2.4 years. The male to female ratio was 1:2.8. A near-by cellular phone or electric tower did not significantly affect disease scores (p > 0.05), Microwave users appeared to have higher wide spread pain index (WPI) and system severity (SS) scores than non-users, but the difference was not statistically significant (p = 0.08 and 0.06) respectively. FMS scores significantly increased with higher TV watching duration, while MADRS score significantly decreased with higher cellular phone use indices. MADRS depression score was increased with shorter distance from electric tower, though not statistically significant (p = 0.76) Conclusion This study highlights a possible pathological link between fibromyalgia and exposure to electromagnetic radiation. Excess exposure to electromagnetic devices could be one of the underlying or at least augmenting factors of fibromyalgia symptoms.

The prevalence of sarcopenia with osteoporosis results in a higher risk of falling and fractures. It was noted that patients who had completed their planned 5-year denosumab therapy course as treatment for these conditions started to sustain falls.To assess (a) whether denosumab has a unique dual effect on both bone and muscle in comparison to other anti-resorptive agents and (b) its effectiveness in the follow-up period post-treatment completion compared to other anti-resorptive agents.One hundred thirty-five patients diagnosed to have postmenopausal/senile osteoporosis and who were prescribed denosumab were compared to a control group of 272 patients stratified into 2 subgroups - 136 prescribed alendronate and 136 prescribed zoledronate. All patients were assessed for: BMD (DXA), falls risk (FRAS), fracture risk (FRAX), and sarcopenia measures. All were re-assessed after 5 years of denosumab/alendronate therapy and 3 years of zoledronate and 1 year after stopping the osteoporosis therapy.No significant baseline demographic differences between the 3 groups. On completion of the 5-year denosumab therapy, there was significant decrease in falls risk (P = 0.001) and significant improvements in all sarcopenia measures (P = 0.01). One-year post-discontinuation of denosumab, a significant worsening of both falls risk and sarcopenia measures (P = 0.01) noticed.Denosumab displayed positive impact and significant improvements in BMD and sarcopenia measures. It also enhanced multidirectional agility as depicted by Timed Up and Go (TUG). Collectively, this would explain the reduction of falls risk which got worse on stopping the medication. Key points • The coexistence of osteoporosis and sarcopenia has been recently considered in some groups as a syndrome termed 'osteosarcopenia'. • Bone and muscle closely interact with each other not only anatomically, but also at the chemical and metabolic levels. • Denosumab displayed positive impact and significant improvements in all sarcopenia measures, and enhanced multidirectional agility with consequent reduction in falls risk. • Denosumab can be considered as a first osteoporosis therapeutic option in this group of patients presenting with osteosarcopenia manifestations.

Autoimmune rheumatic diseases (ARDs), which include all types of inflammatory arthritis as well as systemic Lupus, are known to have a detrimental effect on both fertility and pregnancy outcomes. Consequently, reproductive health care is considered a principle constituent of comprehensive care for all patients with rheumatic ailments seen in the standard practice. Whilst pregnancy-associated complications have been reported in lupus, rheumatoid arthritis, and Sjogren's syndrome, in some conditions such as lupus, antiphospholipid syndrome, inflammatory myopathies, and vasculitis, the pregnancy may accelerate the disease progression. Furthermore, the activity of some diseases such as lupus and antiphospholipid syndrome may be augmented by some contraceptive methods. Therapeutically, some patients are prescribed medications, such as methotrexate and mycophenolate which have potentially teratogenic effect. Therefore, to be able to help those patients, family planning should be patient-centred with decision-making tailored to the individual's disease status. For those healthcare professionals interested in reproductive health care for their patients living with autoimmune rheumatic diseases, this review summarizes the available information in the literature and offers practical suggestions of patient-centred care in a dedicated rheumatology-led pregnancy clinic. Key Points • Autoimmune disorders, particularly systemic inflammatory rheumatic diseases, affect many women, often during childbearing age. • Pregnancies in this cohort of patients with rheumatic diseases is considered to be of high risk, because of the potential for complications during periods of active disease and the possible impact of medications used on both the pregnancy outcomes as well as the baby. • There are high chances of successful and safe pregnancies particularly if pre-pregnancy planning and screening for maternal and fetal risks are undertaken, and pregnancy takes place while the disease is well controlled. Encouraging the patients, who are in their childbearing period, to initiate discussions about family planning and pregnancy, with their treating rheumatologists, would be an ideal approach to close this gap of information exchange. • Targeted patients' education is expected to improve the information quality and promote more collaborative decision-making with regard to motherhood and healthcare choices.

The birth of reproductive rheumatology as a subject of interest in rheumatology has led to improvement of clinical care for patients living with autoimmune rheumatic diseases and paved the way towards setting a specialized pregnancy service within the standard rheumatology practice. In contrast to women, where there has been wealth of literature regarding pregnancy, lactation, and birth outcomes, there is not as much focusing on male sexual health and outcomes among inflammatory arthritis patients. Challenges such as decrease ability to conceive, impaired fertility, erectile dysfunction, and other sexual problems have been raised by male patients living with autoimmune rheumatic diseases. This broad scope gives the reproductive health concept in men another expansion with views to include sexual health problems screening among men attending the standard outpatient rheumatology clinics. This article adds to the paucity of real-life experience and aims at discussing the sexual health from the men perspective and provides a practical approach towards screening, and assessment of men living with autoimmune diseases in standard day to day practice.

The autoimmune rheumatic diseases have a clear predilection for women. Consequently, issues regarding family planning and pregnancy are a vital component of the management of these patients. Not only does pregnancy by itself causes physiologic/immunologic changes that impact disease activity but also women living with inflammatory arthritic conditions face the additional challenges of reduced fecundity and worsened pregnancy outcomes. Many women struggle to find adequate information to guide them on pregnancy planning, lactation and early parenting in relation to their chronic condition. This article discusses the gaps in the care provided to women living with inflammatory arthritis in standard practice and how a rheumatology nurse-led pregnancy clinic would fill such gap, consequently enhance the care provided and ensure appropriate education is provided to these individuals who represent the majority of the patients attending the rheumatology outpatient clinics. Such specialist care is expected to cover the whole journey as it is expected to provide high-quality care before, during and after pregnancy.

IgA vasculitis (IgAV), formerly known as Henoch-Schönlein purpura, is the most common cause of systemic vasculitis in childhood. Given its potential life-threatening systemic complications, early and accurate diagnosis as well as management of IgAV represent a major challenge for health care professionals. This study was carried out to attain an evidence-based expert consensus on a treat-to-target management approach for IgAV using Delphi technique. The preliminary scientific committee identified a total of 16 key clinical questions according to the patient, intervention, comparison, and outcomes (PICO) approach. An evidence-based, systematic, literature review was conducted to compile evidence for the IgAV management. The core leadership team identified researchers and clinicians with expertise in IgAV management in Egypt upon which experts were gathered from different governorates and health centers across Egypt. Delphi process was implemented (two rounds) to reach a consensus. An online questionnaire was sent to expert panel ( n = 26) who participated in the two rounds. After completing round 2, a total of 20 recommendation items, categorized into two sections were obtained. Agreement with the recommendations (rank 7–9) ranged from 91.7–100%. Consensus was reached (i.e. ⩾75% of respondents strongly agreed or agreed) on the wording of all the 20 clinical standards identified by the scientific committee. Algorithms for the diagnosis and management have been suggested. This was an expert, consensus recommendations for the diagnosis and treatment of IgAV and IgA vasculitic nephritis, based on best available evidence and expert opinion. The guideline presented a strategy of care with a pathway to achieve a state of remission as early as possible. Plain Language Summary Given its potential life-threatening systemic complications, early and accurate diagnosis of immunoglobulin A vasculitis represents a major challenge for health care professionals. This work provided cornerstone principles for the management of the condition. Adopting PICO approach and implementing Delphi process a consensus was reached on evidence-based treat-to-target treatment recommendations. This will endorse enhancement and consistency of care of this cohort of patients in standard practice.

Objective.The Outcome Measures in Rheumatology (OMERACT) Shared Decision Making (SDM) Working Group aims to determine the core outcome domain set for measuring the effectiveness of SDM interventions in rheumatology trials.Methods.A white paper was developed to clarify the draft core domain set. It was then used to prepare for interviews to investigate reasons for lack of consensus on it and to suggest further improvements.Results.OMERACT scientists/clinicians (n = 13) and patients (n = 10) suggested limiting the core domain set to outcome domains, removing process domains, and clarifying remaining domains.Conclusion.A revised core domain set will undergo further consensus-building.

To develop and evaluate an illustrated, stand-alone, interactive evidence-based shared decision making (SDM) aid for JIA children; its ability to produce positive perceived involvement of JIA patients in their own management and its impact on their adherence to therapy, school absenteeism and treatment outcomes.The SDM aid was developed to offer information about the disease, risks and benefits of treatment. A multidisciplinary team defined SDM criteria based on international standards (IPDAS). Eight categories emerged as highly important for SDM. Each category was supported by simple illustrations in an interactive style. At the end of each category, the child is asked to make a decision in view of the information given. Ninety-four JIA children were provided with the tool, in a randomised controlled study, in comparison to a control group of 95 JIA patients treated according to standard protocols.A total of 97.5% of the study children reported comprehensibility of more than 90%. The patients' adherence to therapy was significantly (p 0.01) higher in the SDM group, whereas stopping DMARDs for intolerability was significantly higher in the control group at 12 months of treatment. There was a significant improvement in the patient-reported outcomes in the SDM group, and absence from school was significantly higher in the control group (p 0.01).The developed SDM aid offered the children evidence-based information about the pros and cons of treatment options and improved their understanding of the disease and their ability to make an informed decision that is reflected on their adherence to therapy and better treatment outcomes. Key Points • This work represents the second generation of shared decision-making tools. • The developed tool adopts an interactive style and enhances critical thinking, giving the patients the facility of making their own decision regarding their management. • The work gives an example of core domain set of outcomes which can be used for shared decision-making interventions.

Objective: To gain consensus on the Outcome Measures in Rheumatology (OMERACT) core domain set for rheumatology trials of shared decision making (SDM) interventions.Methods: The process followed the OMERACT Filter 2.1 methodology, and used consensus-building methods, with patients involved since the inception. After developing the draft core domain set in previous research, we conducted five steps: (i) improving the draft core domain set; (ii) developing and disseminating whiteboard videos to promote its understanding; (iii) conducting an electronic survey to gather feedback on the draft core domain set; (iv) finalizing the core domain set and developing summaries, a plenary session video and discussion boards to promote its understanding; and (v) conducting virtual workshops with voting to endorse the core domain set.Results: A total of 167 participants from 28 countries answered the survey (62% were patients/caregivers). Most participants rated domains as relevant (81%-95%) and clear (82%-93%). A total of 149 participants (n = 48 patients/caregivers, 101 clinicians/researchers) participated in virtual workshops and voted on the proposed core domain set which received endorsement by 95%. Endorsed domains are: 1-Knowledge of options, their potential benefits and harms; 2-Chosen option aligned with each patient's values and preferences; 3-Confidence in the chosen option; 4-Satisfaction with the decision-making process; 5-Adherence to the chosen option and 6-Potential negative consequences of the SDM intervention.Conclusion: We achieved consensus among an international group of stakeholders on the OMERACT core domain set for rheumatology trials of SDM interventions. Future research will develop the Core Outcome Measurement Set.Clinical significance: Prior to this study, there had been no consensus on the OMERACT core domain set for SDM interventions. The current study shows that the OMERACT core domain set achieved a high level of endorsement by key stakeholders, including patients/caregivers, clinicians and researchers.(c) 2021 Elsevier Inc. All rights reserved.

Autoimmune rheumatic diseases (ARDs), which include all types of inflammatory arthritis as well as systemic Lupus, are known to have a detrimental effect on both fertility and pregnancy outcomes. Consequently, reproductive health care is considered a principle constituent of comprehensive care for all patients with rheumatic ailments seen in the standard practice. Whilst pregnancy-associated complications have been reported in lupus, rheumatoid arthritis, and Sjogren's syndrome, in some conditions such as lupus, antiphospholipid syndrome, inflammatory myopathies, and vasculitis, the pregnancy may accelerate the disease progression. Furthermore, the activity of some diseases such as lupus and antiphospholipid syndrome may be augmented by some contraceptive methods. Therapeutically, some patients are prescribed medications, such as methotrexate and mycophenolate which have potentially teratogenic effect. Therefore, to be able to help those patients, family planning should be patient-centred with decision-making tailored to the individual's disease status. For those healthcare professionals interested in reproductive health care for their patients living with autoimmune rheumatic diseases, this review summarizes the available information in the literature and offers practical suggestions of patient-centred care in a dedicated rheumatology-led pregnancy clinic. Key Points • Autoimmune disorders, particularly systemic inflammatory rheumatic diseases, affect many women, often during childbearing age. • Pregnancies in this cohort of patients with rheumatic diseases is considered to be of high risk, because of the potential for complications during periods of active disease and the possible impact of medications used on both the pregnancy outcomes as well as the baby. • There are high chances of successful and safe pregnancies particularly if pre-pregnancy planning and screening for maternal and fetal risks are undertaken, and pregnancy takes place while the disease is well controlled. Encouraging the patients, who are in their childbearing period, to initiate discussions about family planning and pregnancy, with their treating rheumatologists, would be an ideal approach to close this gap of information exchange. • Targeted patients' education is expected to improve the information quality and promote more collaborative decision-making with regard to motherhood and healthcare choices.

ObjectivesTo identify the changes in rheumatology service delivery across the five regions of Africa from the impact of the COVID-19 pandemic.MethodsThe COVID-19 African Rheumatology Study Group created an online survey consisting of 40 questions relating to the current practices and experiences of rheumatologists across Africa. The CHERRIES checklist for reporting results of internet e-surveys was adhered to.ResultsA total of 554 completed responses were received from 20 countries, which include six in Northern Africa, six in West Africa, four in Southern Africa, three in East Africa and one in Central Africa. Consultant grade rheumatologists constituted 436 (78.7%) of respondents with a mean of 14.5 ± 10.3 years of experience. A total of 77 (13.9%) rheumatologists avoided starting a new biologic. Face-to-face clinics with the use of some personal protective equipment continued to be held in only 293 (52.9%) rheumatologists’ practices. Teleconsultation modalities found usage as follows: telephone in 335 (60.5%), WhatsApp in 241 (43.5%), emails in 90 (16.3%) and video calls in 53 (9.6%). Physical examinations were mostly reduced in 295 (53.3%) or done with personal protective equipment in 128 (23.1%) practices. Only 316 (57.0%) reported that the national rheumatology society in their country had produced any recommendation around COVID-19 while only 73 (13.2%) confirmed the availability of a national rheumatology COVID-19 registry in their country.ConclusionCOVID-19 has shifted daily rheumatology practices across Africa to more virtual consultations and regional disparities are more apparent in the availability of local protocols and registries.

ObjectivesTo develop recommendations for the management of rheumatic and musculoskeletal diseases (RMDs) during the COVID-19 pandemic.MethodA task force comprising of 25 rheumatologists from the 5 regions of the continent was formed and operated through a hub-and-spoke model with a central working committee (CWC) and 4 subgroups. The subgroups championed separate scopes of the clinical questions and formulated preliminary statements of recommendations which were processed centrally in the CWC. The CWC and each subgroup met by several virtual meetings, and two rounds of voting were conducted on the drafted statements of recommendations. Votes were online-delivered and recommendations were pruned down according to predefined criteria. Each statement was rated between 1 and 9 with 1–3, 4–6 and 7–9 representing disagreement, uncertainty and agreement, respectively. The levels of agreement on the statements were stratified as low, moderate or high according to the spread of votes. A statement was retired if it had a mean vote below 7 or a ‘low’ level of agreement.ResultsA total of 126 initial statements of recommendations were drafted, and these were reduced to 22 after the two rounds of voting.ConclusionsThe preliminary statements of recommendations will serve to guide the clinical practice of rheumatology across Africa amidst the changing practices and uncertainties in the current era of COVID-19. It is recognized that further updates to the recommendations will be needed as more evidence emerges.Key Points• AFLAR has developed preliminary recommendations for the management of RMDs in the face of the COVID-19 pandemic.• COVID-19 is an unprecedented experience which has brought new concerns regarding the use of some disease-modifying anti-rheumatic drugs (DMARDs), and these recommendations seek to provide guidelines to the African rheumatologists.• Hydroxychloroquine shortage has become rampart across Africa as the drug is being used as prophylaxis against COVID-19 and this may necessitate a review of treatment plan for some patients with RMDs.• Breastfeeding should continue for as long as possible if a woman is positive for SARS-CoV-2 as there is currently no evidence that the infection can be transmitted through breast milk.

The onset of the COVID-19 pandemic has led to far-reaching changes in the delivery of healthcare services across Africa. A number of drugs used in the management of rheumatic diseases have been touted to have roles to play in the treatment and/or exacerbation of COVID-19 symptoms and this has resulted in significant changes in the practice of rheumatology. The global rheumatology community has risen to this challenge by demonstrating collaborative partnership, resulting in the establishment of the global rheumatology registry to collect data on rheumatic patients infected with COVID-19.1 In view of the study by Gianfrancesco et al ,2 an online survey consisting of 40 practice and experience questions ((online supplementary file 1) and (online supplementary file 2)) was created by the COVID-19 African Rheumatology Study Group which was formed through the network of the African League of Associations for Rheumatology (AFLAR). The aim of the study was to identify the changes in rheumatology practice and patient behaviour, as well as to highlight key concerns of rheumatologists across Africa resulting from the ongoing COVID-19 pandemic.### Supplementary data [annrheumdis-2020-218273supp001.pdf] ### Supplementary data [annrheumdis-2020-218273supp002.pdf] A total of 554 completed responses were received from 20 African countries. There were 431 (77.8%) responses from Northern Africa, 43 (7.8%) from West Africa, 6 (1%) from Central Africa, 20 (3.6%) from East Africa and 54 (9.8%) from Southern Africa. The scope of practice was adult only in 296 (53.4%), paediatric only in 15 (2.7%) and both in 243 (43.9%). A total of 288 (52.9%) of the respondents practised in academic institutions, while 162 (29.2%) practised primarily in a private setting. Forty-four (7.9%) were using hydroxychloroquine (HCQ) more than before, 19 (3.4%) admitted to have prescribed HCQ to prevent severe COVID-19 disease, 92 (16.6%) …

Made available in DSpace on 2021-06-25T10:38:01Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-11-01 Healthway Objective. To develop a composite disease activity score for systemic JIA (sJIA) and to provide preliminary evidence of its validity. Methods. The systemic Juvenile Arthritis Disease Activity Score (sJADAS) was constructed by adding to the four items of the original JADAS a fifth item that aimed to quantify the activity of systemic features. Validation analyses were conducted on patients with definite or probable/possible sJIA enrolled at first visit or at the time of a flare, who had active systemic manifestations, which should include fever. Patients were reassessed 2 weeks to 3 months after baseline. Three versions were examined, including ESR, CRP or no acute-phase reactant. Results. A total of 163 patients were included at 30 centres in 10 countries. The sJADAS was found to be feasible and to possess face and content validity, good construct validity, satisfactory internal consistency (Cronbach's alpha 0.64-0.65), fair ability to discriminate between patients with different disease activity states and between those whose parents were satisfied or not satisfied with illness outcome (P < 0.0001 for both), and strong responsiveness to change over time (standardized response mean 2.04-2.58). Overall, these properties were found to be better than those of the original JADAS and of DAS for RA and of Puchot score for adult-onset Still's disease. Conclusion. The sJADAS showed good measurement properties and is therefore a valid instrument for the assessment of disease activity in children with sJIA. The performance of the new tool should be further examined in other patient cohorts that are evaluated prospectively. UOC Clinica Pediatrica e Reumatologia IRCCS Istituto Giannina Gaslini Dipartimento di Neuroscienze Riabilitazione Oftalmologia Genetica e Scienze Materno-Infantili (DiNOGMI) Università degli Studi di Genova Dipartimento di Epidemiologia e Biostatistica IRCCS Istituto Giannina Gaslini Faculty of Medicine Ain Shams University Pediatric Rheumatology Division Institute of Child Health Section of Pediatric Rheumatology SRCC Children's Hospital Rheumatology Division Pediatric Department Faculty of Medicine Ramathibodi Hospital Mahidol University Pediatric Rheumatology Clinic R G Kar Medical College Division of Rheumatology IRCCS Ospedale Pediatrico Bambino Gesù Division of Pediatric Rheumatology Institute of Child Health Sir Ganga Ram Hospital Faculty of Medicine Benha University Faculty of Medicine Alexandria University Faculty of Medicine Tanta University Faculty of Medicine Cairo University Pediatric Rheumatology Division Adolescent Health Care Unit Universidade do Estado do Rio de Janeiro Department of Internal Medicine Universidade Federal do Rio de Janeiro Servicio de Inmunología y Reumatología Hospital de Pediatría Garrahan Department of Clinical Sciences and Community Health University of Milan Division of Rheumatology University Hospital Meyer Rheumatology Division National Medical Research Center of Children's Health Sechenov First Moscow State Medical University Department of Immunology Rheumatology and Allergy Queen Rania Children's Hospital Saint-Petersburg State Pediatric Medical University UOC Pediatria a Media Intensità di Cure Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Rheumatology Department Faculty of Medicine Suez Canal University Department of Pediatrics King Faisal Specialist Hospital and Research Center Dipartimento Promise G. D'Alessandro Università degli Studi di Palermo Pediatric Department Hospital das Clínicas Botucatu Medicine University UNESP UOC Pediatria Servizio di Immuno-Reumatologia Pediatrica Azienda Ospedaliera Universitaria Gaetano Martino Messina UO Nefrologia e Reumatologia Pediatrica Azienda Ospedaliera Universitaria Gaetano Martino Department of Pediatrics School of Medicine Institute of Medical Pharmaceutical and Health Sciences Kanazawa University Pediatric Unit Ospedale Vito Fazzi Pediatric Unit AON SS Antonio e Biagio e Cesare Arrigo Children's Hospital Pediatric Department Hospital das Clínicas Botucatu Medicine University UNESP

To assess the validity, reliability, comprehensibility, and responsiveness to change of an illustrated child/parent multidimensional patient-reported outcome measures (PROMs) questionnaire which can assess construct outcome measures of children with juvenile inflammatory arthritis. A total of 122 children with juvenile idiopathic arthritis were included in this work in a multicenter study. The questionnaire included seven categories: (1) functional ability; (2) health-related quality of life; (3) disease activity measures: pain, global assessment, fatigue, and morning stiffness; (4) self-reported joint tenderness; (5) current medication, side effects, and adherence to therapy; (6) comorbidities; and (7) patient motivation. All the items were supported by illustrations to provide children with a visual impression of what was meant by the questions. The questionnaire has parent and patient versions. The disease activity status was assessed using JADAS-27. The questionnaire was reliable as demonstrated by a high-standardized alpha (0.890–0.978). The questionnaire items correlated significantly (p

Rheumatologic diseases represent a growing health crisis. Primary care physicians encounter a significant number of rheumatologic problems in the course of practice. Millions of work days are lost per year due to osteoarthritis, low back pain and rheumatoid arthritis. The morbidity of arthropathies results in numerous hospitalizations annually. Given the sheer number of patients, primary care physicians cannot rely on referral to rheumatologists to identify, diagnose and manage this growing health need. The general practitioners are an integral part of the healthcare team that needs to recognize the importance of early diagnosis, treatment and holistic care of the patients presenting with musculoskeletal problems. As part of a comprehensive treatment plan, primary care physicians need competency in assessing the patient and understanding the disease and on how to participate in the treatment plan through self-management skills. This will be achieved through a general practitioner-targeted teaching programme. This chapter will discuss why teaching rheumatology in primary care is important, the primary care need, who to teach and what needs to be done. The chapter will then discuss the art of primary care physicians teaching, clinical tips for primary care physicians to use in their standard clinical practice and how can we improve education in the primary care.

The past decade has witnessed a remarkable transformation in the field of rheumatology. The progress has been startling, with major advances in patient treatment attributed to the impressive array of new biologic therapies and the development of new treatment approaches which dramatically improved patient outcomes. However, while the situation has engendered optimism for the future, concerns have been raised about sustaining the momentum. Over recent years, there has been increasing concern among rheumatologists that fewer trainee doctors have been choosing rheumatology as a career. In some regions, training posts have remained unappointed. This unexpected contrast warrants a thorough look at the reasons behind such attitude. This chapter will discuss why do we need to revise ways rheumatology is being taught and its impact on attracting, rather than deterring, junior doctors to the speciality.

Rheumatology is a field of practice that is undergoing many changes, leading to growing demand for rheumatology practitioners to keep up to date about the developments in their field and to implement new findings and recommendations into clinical practice. Research within implementation science has shown that there are numerous barriers to the clinical use of evidence-based knowledge in healthcare. Implementation of evidence-based practice requires a great deal of learning on the part of practitioners. Similar to healthcare professionals working in other medical specialities, it is likely that practitioners in rheumatology face similar challenges. This chapter will discuss barriers to rheumatology learning, educational need of the junior and training rheumatologists and ways to tackle these barriers.

Deborah Palmer, Advanced Nurse Practitioner, North Middlesex University Hospital, and Yasser El Miedany, Consultant Rheumatologist, discuss ways to close the gap between disease control and patient empowerment

Advances in technology led to a heightened interest in exploring the use of this technology in the standard rheumatology practice. Tech-Talks will enable the information at the patients' and rheumatologists' fingertips. As e-rheumatology is an idea whose time has come, this review outlines the e-health's developments and its impact on both the patients and the treating rheumatologists. Also it will discuss the strengths and weaknesses of using apps and mobile health in the day-to-day rheumatology service as well as the ethical and financial aspects of this model of care.

Recent publications have proposed revisions to disease classification criteria, new definitions of early diagnosis and remission, as well as guidelines for implementing treat-to-target strategies for the management of patients with spondyloarthritis. Despite developments leading to this practice-changing approach, the concept of treat to target for spondyloarthritis has not yet been widely accepted or implemented in standard clinical care. By placing greater emphasis on clinical features that manifest early in the disease process, the early and aggressive treatment of the most common forms of spondyloarthritis (namely ankylosing spondylitis and psoriatic arthritis), has been shown to have favorable patient outcomes in reducing synovial inflammation, delaying joint damage, and maintaining functional status. This article discusses the recent concept of Treat to Target in spondyloarthritis and the importance of early diagnosis of both ankylosing spondylitis (AS) and psoriatic arthritis (PsA). It also highlights the main outcome measures for spondyloarthritis patients achieving treatment goals of low levels of disease activity or clinical remission.

Objective.The aim of this Outcome Measures in Rheumatology (OMERACT) Working Group was to determine the core set of outcome domains and subdomains for measuring the effectiveness of shared decision-making (SDM) interventions in rheumatology clinical trials.Methods.Following the OMERACT Filter 2.0, and based on a previous literature review of SDM outcome domains and a nominal group process at OMERACT 2014, (1) an online Delphi survey was conducted to gather feedback on the draft core set and refine its domains and subdomains, and (2) a workshop was held at the OMERACT 2016 meeting to gain consensus on the draft core set.Results.A total of 170 participants completed Round 1 of the Delphi survey, and 116 completed Round 2. Respondents came from 29 countries, with 49% being patients/caregivers. Results showed that 14 out of the 17 subdomains within the 7 domains exceeded the 70% criterion (endorsement ranged from 83% to 100% of respondents). At OMERACT 2016, only 8% of the 96 attendees were patients/caregivers. Despite initial votes of support in breakout groups, there was insufficient comfort about the conceptualization of these 7 domains and 17 subdomains for these to be endorsed at OMERACT 2016 (endorsement ranged from 17% to 68% of participants).Conclusion.Differences between the Delphi survey and consensus meeting may be explained by the manner in which the outcomes were presented, variations in participant characteristics, and the context of voting. Further efforts are needed to address the limited understanding of SDM and its outcomes among OMERACT participants.

This study aims to identify the clinical predictors of arthritis in patients with psoriasis and to evaluate the use of musculoskeletal ultrasonography (US) as a predictor for inflammatory structural progression in psoriatic patients. Measures of association (odds ratio (OR)) were tested, in a prospective, cohort 1-year follow-up study, between structural deterioration and the presence of baseline inflammation, or its persistence. One hundred twenty-six psoriatic patients were prospectively evaluated both clinically and by US at 0, 6, and 12 months for synovitis/ joint damage, enthesitis, and onychopathy. X-ray was performed at 0 and 12 months. One hundred twelve sex and age-matched pasoriatic patients without histories of musculoskeletal symptoms were included as control group. Structural deterioration was observed in 47% of the 5,292 evaluated joints. Clinical variables associated with arthritis risk: BMI 25 (OR = 1.7), body surface area (OR = 1.13), family history (OR = 5.72) and nail involvement (OR = 2.25). BMI 30 was significantly correlated (P 0.01) with shorter time for the onset of arthritis. Baseline synovial score/PD score ≥ 2 was associated with increased risk of structural progression: OR = 1.98 versus 2.61 versus 2.66 (P 0.001) for the clinical versus US-gray scale (GS) versus US-power Doppler (PD) evaluation, respectively. An increased probability for structural progression in the presence of enthesitis was observed (OR = 2.79 and 3.50) for both US-GS and US-PD, whereas OR was 2.46 for clinical examination. Onychopathy was associated with structural joint damage (OR = 2.30). In multivariate logistic regression analysis, persistent of synovitis/enthesitis at 6 months of therapy was predictive of subsequent structural progression. Family history of psoriatic arthritis, large BMI (25), high percentage of psoriatic body surface area, and nail involvement were significantly associated with early onset psoriatic arthritis. Baseline GS score of ≥2, PD score of ≥2, presence of enthesitis, enhanced vascularity at enthesitis, higher GUESS score, and onychopathy, all at base line as well as persistent synovitis and enthesitis at 6 months are predictors of progressive early psoriatic arthritis. Regular ultrasonographic monitoring of these patients is mandatory to assess the progression of their arthritis status.

There are several advantages in using patient-reported outcome measures (PROMs) in standard clinical practice, particularly if a questionnaire is distributed to each patient at each visit as a standard in the infrastructure usual care. The patients, being the most knowledgeable persons concerning their pain and global estimate, do most of the work by completing a questionnaire. Completion of the questionnaire helps the patients prepare for their visit as well as improving doctor-patient communication. Recently, the role of PROMs has expanded from the static phase of capturing and measuring outcomes at a single point of time to a more dynamic role. This dynamic role is aiming at driving improvement not only in the quality of inflammatory arthritis care but also in the patients' reported experience. Therefore, in addition to its value in tailoring treatment targets adapted to the patient's needs, PROMs also have the potential of modifying the disease impact through improving the patients' adherence to therapy and allowing the patients to monitor the changes in their condition. Though more attention has been given to the use of PROMs in routine clinical care, little was published regarding what could be done with the plethora of data gained from PROMs and how dynamic it can be enhancing the "patient-centered care" approach and improving patients' experience. This article highlights the value of adopting PROMs for arthritic patients in standard clinical practice and its impact on long-term patients' management.

Objective.To assess the use of electronic patient-reported outcome measures (ePROM) in standard clinical practice for early rheumatoid arthritis (RA) management, the ePROM ability to enhance clinical care, and how computing technology can improve the patients’ adherence to therapy.Methods.In a double-blinded randomized-controlled study, 211 patients with early RA diagnosed according to American College of Rheumatology/European League Against Rheumatism criteria completed a PROM in paper format at their first clinic visit. Patients were then randomized to Group 1, which completed an ePROM questionnaire monthly, or Group 2, which continued the standard paper PROM format. Over a 12-month period, Group 1 patients were assessed every 3 months in the clinic, whereas Group 2 patients were assessed in the clinic initially monthly for 6 months, then every 3 months. The primary endpoint was the equivalence of outcomes [Routine Assessment of Patient Index Data 3 (RAPID-3) and 28-joint Disease Activity Score (DAS28)] in both groups. The secondary endpoint was the patients’ adherence to their medications.Results.There was no significant difference between disease activity measures as well as DAS28 and RAPID-3 scores at 3, 6, and 12 months of management, although there was a trend toward lower patient-reported tender joint count and functional disability score in the active group versus the control group. The patients’ adherence to antirheumatic therapy was significantly higher (p < 0.01) in the ePROM group, whereas stopping disease-modifying antirheumatic drugs for intolerability was significantly higher (p < 0.01) in the control group at 12 months of treatment.Conclusion.We found ePROM equivalent to standard paper PROM format. Further, it enabled the patients to personally monitor how they are doing regarding their disease activity and helped to optimize their adherence to their treatment.

Background: The use of simulation-based learning in the medical field has many benefits, including patient safety, health care professional confidence, accelerating diagnostic and therapeutic procedures, meeting the unfulfilled demand for medical personnel, and lowering of medical errors. Developing of interactive learning tools for teaching a simulated clinical case studies program, is highly needed to improve specialist nurses and middle grade health care professionals skills and competency. Aim: Assess the outcomes of a simulated problem-based learning educational activity for scoring the Psoriasis Area and Severity Index (PASI). Methods: 33 training health care professionals took part in the simulation activity. Before commencing the teaching program, every participant answered a pre-simulation activity confidence and competence levels questionnaire. The simulation activity was carried out in 3 phases: Phase 1: interactive instructor-learner format; Phase 2: Peer-led tutorial; Phase 3: completely independent student led learning adopting a “Problem solving” approach. At the end, every participant completed a questionnaire for post-simulation activity confidence and competence levels. Results: The percentage of agreement with the reference PASI score was progressively improving which reflects improvement of the learners’ skills after adopting the repetitive learner engagement approach. All participants expressed positive attitudes toward the simulation-based course. The overall mean for the student satisfaction subscale was 4.33/5, whereas the overall mean for the selfconfidence subscale was 4.15/5. Conclusion: Simulation-based teaching is an effective way to teach health care professionals. This approach led to improving attitudes, behaviors, interaction, confidence and overall performance leading to potential increased patient safety and better clinical outcomes. The next step is to implement simulation-based training effectively and efficiently in standard teaching.

Musculoskeletal ultrasound (US) is an excellent tool to diagnose muscle, tendon and ligament injuries, cystic structures and peripheral nerve compression, as well as soft tissue masses, without the risk of ionizing radiation. Musculoskeletal US is now routinely used by a growing number of rheumatology and sports medicine centres throughout UK. In standard clinical practice, US has an extremely useful application in differentiating fluid from soft tissue and identifying the severity of joint inflammation. The work described in this article was carried out to assess patients' feedback regarding the use of US guidance for intra-articular injections and/or the removal of fluid from their inflamed knee joints in a nurse-led clinic. Nineteen patients who had US-guided knee joint injection/aspiration in the clinic were asked to complete a questionnaire regarding their satisfaction with the procedure, and to rate their joint pain and patient global assessment (using numerical visual analogue scale) before the US-guided procedure, and 1 month after. Results revealed a significant improvement (p

For rheumatology patients, telephone helplines can provide rapid access to management, advice, information and support. In many cases, the provision of a telephone helpline reflects an attempt to make care more flexible and patient-based. The ‘direct’ mode advice delivery can only be informally compared with the traditional route of patient access to advice, which often travelled a complex route via overworked medical secretaries or receptionists toward the final destination of medical staff, sometimes engaged in other activities. This article will discuss the challenges facing the rheumatology helpline and how these can be tackled.

Background: Sacroiliac joints (SJ) involvement is a distinctive and charasteristic feature of Spondyloarthritis (SpA) and x-ray is the test routinely used to make a diagnosis. However, x-ray reveals late structural damage but cannot detect active inflammation. The objective of this study was to assess the validity of Doppler ultrasound in SJ. Methods: Prospective blinded and controlled study of SJ, in which three populations were compared. We studied 106 consecutive cases, who were divided into three groups: a) 53 patients diagnosed with SpA who had inflammatory lumbar and gluteal pain assessed by a rheumatologist; b) 26 patients diagnosed with SpA who didn't have SJ tenderness and had normal physical examination; c) control group of 27 subjects (healthy subjetcs or with mechanical lumbar pain). All patients included that were diagnosed with SpA met almost the European Spondyloarthropathy Study Group (ESSG) classification criteria. Physical examination of the SJ included: sacral sulcus tenderness, iliac gapping, iliac compression, midline sacral thrust test, Gaenslen's test, and Patrick s test were used as gold standard. Both SJ were examined with Doppler ultrasound (General Electric Logiq 9, Wauwatosa WI, USA) fitted with a 9-14 Mhz lineal probe. The ultrasonographer was blinded to clinical data. Doppler in SJ was assessed as positive when both Doppler colour and resistance index (RI)

Resume Objectifs Evaluer la validite, la fiabilite et la sensibilite au changement d’un autoquestionnaire patient qui puisse estimer des criteres d’evaluation chez des patients atteints de spondylarthrite ankylosante (SA)/spondylarthropathie. Methodes Le questionnaire a ete developpe en integrant les informations provenant de patients souffrant de SA/spondylarthropathie, en se basant sur le modele de Rasch. Il inclut l’evaluation du handicap fonctionnel, de la qualite de vie, des EVA relatives a la douleur vertebrale et a la douleur articulaire, l’etat general, la fatigue, la duree de la raideur matinale, une revue des systemes anatomiques, les risques de chute et risques cardiovasculaires, la resignation aussi bien que la douleur articulaire et la douleur des tissus mous autoevaluees. Le questionnaire a ete complete par 267 patients consecutifs atteints de SA (124) et de spondylarthropathie (143). Resultats Le questionnaire de mesure des PRO s’est avere fiable comme l’a demontre un coefficient alpha standardise eleve. Les items du questionnaire etaient significativement correles ( p p Conclusion Le questionnaire PROM est un outil fiable et valide pour l’evaluation de patients souffrant de SA et de spondylarthropathie. Il est court, rapide et comprehensible, ce qui ajoute a son applicabilite. Les donnees sont en faveur de la finalisation d’un autoquestionnaire patient de deux pages, qui fournit, lors de chaque visite chez le rhumatologue, un document quantitatif ecrit par le patient lui-meme.

Objective: To assess the validity, reliability and comprehensibility of the Developed Arabic Multidimensional Health Assessment Questionnaire (Arabic-MDHAQ) for use in standard clinical care of patients with rheumatic diseases. Methods: The multidimensional questionnaire was developed on a one-page sheet. One side includes 10 activities of daily living (Arabic HAQII), four items to assess psychological distress, duration of morning stiffness as well as visual analogue scales for pain, global status, and fatigue. The other side includes review of the systems, falls and cardiovascular risk assessment, the rheumatology attitudes index to assess the psychological construct of helplessness and self-report of joint counts. The questionnaire was completed by consecutive patients with various rheumatic diseases including 85 with rheumatoid arthritis, 57 with fibromyalgia, 57 with osteoarthritis, 18 with psoriatic arthritis and 11 with ulcerative colitis. Results: The test was reliable as demonstrated by a high standardized alpha-value and minimal changes recorded in the second from the first test. The Developed Arabic-MDHAQ correlated significantly with clinical parameters of disease activity as well as inflammatory markers. Changes in both functional and psychological assessment scores showed variation with diseases. The Arabic health assessment questionnaire II (functional disability) was significantly correlated with the original Arabic-HAQ. The psychological assessment items in the Arabic-MDHAQ were significantly correlated with depression as well as anxiety scores as demonstrated by Hamilton scales for depression and anxiety (P

Resume Contexte Les criteres cliniques et neurophysiologiques qui permettent de porter le diagnostic de syndrome du canal carpien (SCC) restent mal definis. Des manifestations compatibles avec un SCC existent souvent en l’absence de mononeuropathie du nerf median. Une meilleure comprehension de la physiopathologie et de l’histoire naturelle du SCC permettrait d’etablir des strategies diagnostiques et therapeutiques plus rationnelles. Objectif Etudier les liens entre les manifestations cliniques de SCC et les resultats des mesures de la conduction nerveuse et de l’echographie, puis en determiner les consequences pour la pratique clinique. Methodes Nous avons inclus 232 malades (163 femmes et 69 hommes âges de 20 a 91 ans) qui presentaient des manifestations compatibles avec un SCC, ainsi que 182 temoins bien portants. Le diagnostic de SCC a ete porte selon les criteres cliniques etablis par l’American Academy of Neurology. Les malades et les temoins ont rempli des questionnaires. Quatre manœuvres cliniques pour le SCC ont ete realisees et sont les suivantes : test de Tinel, test de Phalen, test de Phalen inverse et compression du canal carpien. Des examens sanguins destines a rechercher les causes de SCC secondaire ont ete faits, ainsi qu’une etude de la conduction nerveuse et une echographie du canal carpien et du nerf median. Resultats Parmi les 232 malades, 177 (76.3 %) avaient des anomalies de la conduction nerveuse et 119 (51,3 %) des signes echographiques de tenosynovite en conjonction avec une symptomatologie a l’avant-bras. Les variables anthropometriques ne presentaient aucune difference significative entre les mains affectees et les mains des sujets temoins. Le test de Phalen et la compression du canal carpien etaient plus souvent positifs en cas de tenosynovite, independamment des resultats des mesures de la conduction nerveuse. Les tests de Tinel, Phalen, Phalen inverse et compression du canal carpien etaient plus sensibles pour le diagnostic de tenosynovite que pour celui de SCC (Tinel, 46 % versus 30 % ; Phalen, 92 % versus 47 % ; Phalen inverse : 75 % versus 42 % ; compression du canal carpien, 95 % versus 46 %). De meme, la specificite de ces quatre tests etait meilleure pour la tenosynovite que pour le SCC. Conclusion La sensibilite et la specificite des tests de Tinel, Phalen, Phalen inverse et compression du canal carpien sont meilleures pour la tenosynovite des flechisseurs de la main que pour le SCC. Ces tests peuvent orienter la prise en charge medicale.

Resume Contexte Selon l’hypothese qui prevaut actuellement, l’arthrite indifferenciee debutante peut evoluer vers la chronicite, conduisant a une destruction articulaire, qui est responsable a son tour d’un handicap fonctionnel. Toutefois, elle peut aussi regresser spontanement. Il serait utile de pouvoir predire l’evolution de l’arthrite indifferenciee debutante afin de prendre les meilleures decisions therapeutiques et d’eviter les phenomenes de raisonnement circulaire lors des etudes diagnostiques. L’utilisation en pratique clinique d’une methode de determination du pronostic est fortement recommandee. Objectif Identifier les facteurs qui sont presents initialement et qui indiquent un risque eleve d’evolution vers la chronicite d’une synovite indifferenciee debutante et mettre au point un score pronostique pour l’arthrite inflammatoire debutante que nous appelons une Early Persistant Inflammatory Synovitis Assessment (EPISA). Methodes Une cohorte de 173 malades souffrant d’arthrite inflammatoire debutante a ete etudiee dans une consultation specialisee dans l’arthrite precoce. Nous avons note le nombre d’articulations douloureuses et d’articulations tumefiees, ainsi que le caractere symetrique ou non des arthrites. Les valeurs initiales du score au Health Assessment Questionnaire (HAQ), du facteur rhumatoide et du titre d’anticorps anti-CCP ont ete recueillies. Nous avons exclu les malades qui remplissaient les criteres de classification de la polyarthrite rhumatoide (PR) developpes par l’American College of Rheumatology (ACR) ou les criteres de spondylarthropathie mis au point par l’European Spondyloarthropathy Study Group (ESSG), ainsi que les malades chez qui une affection rhumatismale bien definie a ete diagnostiquee. Les malades inclus dans l’etude ont fait l’objet d’un bilan tous les trois mois pendant 24 mois. Une echographie des metacarpophalangiennes et des interphalangiennes proximales des deux mains a ete realisee initialement, puis apres six mois. Les deux mains et les deux poignets ont ete visualises grâce a l’imagerie par resonance magnetique (IRM). Le diagnostic porte par le rhumatologue apres un an (arthrite chronique ou regression spontanee) constituait le critere d’evaluation principal. Une analyse par regression logistique a permis d’identifier les facteurs independamment lies a l’evolution vers la chronicite. Ces facteurs ont ensuite servi a mettre au point un score pronostique. Une analyse par courbe Receiver Operating Characteristic (ROC) a ete menee afin de mesurer les performances du score et de choisir une valeur seuil privilegiant la sensibilite sur la specificite, puisque cet outil est destine a servir principalement au depistage. Resultats L’arthrite a regresse chez 93 malades et persiste chez 80 malades pendant la periode de suivi. Trois variables etaient independamment associees a l’evolution vers la chronicite : la duree de la raideur matinale, le pourcentage de modification du score HAQ apres trois mois et la presence d’anticorps anti-CCP. Selon l’analyse par courbe ROC, un score superieur a 121 indiquait un risque accru d’evolution vers la chronicite chez un malade vu pour une arthrite inflammatoire debutante. Conclusion Nous avons mis au point un score qui permet de differencier, dans un groupe de malades souffrant d’arthrite inflammatoire debutante, les individus dont l’arthrite regressera de ceux qui evolueront vers l’arthrite chronique. Le score a ete valide dans notre serie. Ce score pourrait etre interessant pour la pratique courante, puisque la capacite a predire l’evolution vers la chronicite permet de guider les decisions therapeutiques.

Background The current paradigm for early undifferentiated arthritis suggests that persistent synovitis leads to erosive joint damage, which results in functional disability. Discriminating between different forms of early arthritis outcome is relevant for therapeutic decision-making and prevents the occurrence of circularity in diagnostic studies. Implementation of a prognostic model into clinical practice is highly required. Objective To identify the prognostic factors at entry for the persistence of early inflammatory arthritis and to develop a scoring system to assess the outcome in patients presenting with early inflammatory arthritis. Methods A cohort of 173 patients with early inflammatory arthritis, were assessed in a special early arthritis clinic. Case definition of synovitis was assessed clinically by the number of tender joint and swollen joint counts as well as symmetry of the affected joints and data were recorded. Baseline HAQ score, serum rheumatoid factor and anti-CCP titre were monitored. Patients satisfying the American College of Rheumatology classification criteria for RA and the European Spondyloarthropathy Study Group criteria for spondylo-arthropathry were excluded, as well as those with a specific rheumatic diagnosis. All the patients were reviewed every 3 months for 24 months period. Ultrasonography for both MCP and PIP joints, both hands, were performed at day of entry and 6 months after initial assessment. All patients had MRI both hands and wrist joints. The arthritis outcome recorded at 1-year follow up represented the gold standard for the diagnosis. Logistic regression analysis was performed to identify the independent factors (predictors) of persistent arthritis and accordingly a scoring system was invented that involved the predictors revealed from the analysis. A ROC curve was set to display the performance of the scoring system and a cut off point was selected taking into consideration a higher sensitivity than specificity, as this model will be mainly used as a screening tool. Results During the follow up period, 93 patients showed evidence of self-limiting arthritis while 80 showed persistent arthritis. Duration of morning stiffness in minutes, percentage change in HAQ score after 3 months duration and anti-CCP positivity were the predictors of persistent arthritis. ROC curve analysis identified a cut off point of 121 above which the early arthritis patient would be more at risk of developing persistent arthritis. Conclusion Application of a model (scoring system) to stratify patients presenting with early persistent inflammatory arthritis from those with self-limiting disease can be attained. The developed model was found to be valid on the studied cohort. This model is important for standard clinical practice as the value of prediction of persistent arthritis has its great impact not only for identifying the patients but also on the therapeutic outcome as well.

Objectives. To assess the validity, reliability, and responsiveness to change of a patient self-reported questionnaire combining the Widespread Pain Index and the Symptom Severity Score as well as construct outcome measures and comorbidities assessment in fibromyalgia patients. Methods. The PROMs-FM was conceptualized based on frameworks used by the WHO Quality of Life tool and the PROMIS. Initially, cognitive interviews were conducted to identify item pool of questions. Item selection and reduction were achieved based on patients as well as an interdisciplinary group of specialists. Rasch and internal consistency reliability analyses were implemented. The questionnaire included the modified ACR criteria main items (Symptom Severity Score and Widespread Pain Index), in addition to assessment of functional disability, quality of life (QoL), review of the systems, and comorbidities. Every patient completed HAQ and EQ-5D questionnaires. Results. A total of 146 fibromyalgia patients completed the questionnaire. The PROMs-FM questionnaire was reliable as demonstrated by a high standardized alpha (0.886–0.982). Content construct assessment of the functional disability and QoL revealed significant correlation (p<0.01) with both HAQ and EQ-5D. Changes in functional disability and QoL showed significant (p<0.01) variation with diseases activity status in response to therapy. There was higher prevalence of autonomic symptoms, CVS risk, sexual dysfunction, and falling. Conclusions. The developed PROMs-FM questionnaire is a reliable and valid instrument for assessment of fibromyalgia patients. A phased treatment regimen depending on the severity of FMS as well as preferences and comorbidities of the patient is the best approach to tailored patient management.

Resume Objectif. – Identifier des marqueurs cliniques correles a l'infection a Helicobacter pylori ( H. pylori ) chez des patients souffrant de syndrome de Sjogren (SS) et en tirer des consequences pour leur prise en charge. Methodes. – Quatre groupes de patients ont ete etudies. Groupe 1 : 36 patients souffrant d'un SS primitif ; groupe 2 : 31 patients souffrant d'un SS secondaire ; groupe 3 : 46 patients souffrant de connectivites diverses sans syndrome sec, et le groupe 4 : 64 sujets controles sains. Une evaluation clinique a ete faite et un score de manifestations cliniques a ete donne a chaque patient ayant un SS. Les taux seriques d'anticorps IgG et IgM anti- H. pylori ont ete mesures par ELISA. Resultats. – La prevalence et le taux moyen d'infection a H. pylori chez les patients ayant un SS {groupe 1 (80,6 %) et 2 (71 %)} etaient significativement plus eleves que dans les groupes 3 (60,9 %) et 4 (56,3 %) ( p H. Pylori et l'âge, la duree de la maladie, le score global d'activite de la maladie et la Proteine-C-Reactive chez les patients ayant un SS. Par ailleurs, il n'y avait pas de correlation significative avec l'index de masse corporelle et la vitesse de sedimentation (VS). Conclusion. – Les patients souffrant de syndrome de Sjogren sont plus sujets aux infections a H. pylori en comparaison avec les patients souffrant d'autres connectivites. Les taux d'anticorps anti- H. pylori sont correles a l'index de manifestations cliniques, l'âge, la duree de la maladie et la CRP. Nous recommandons de rechercher une infection a H. pylori chez les patients âges souffrant d'un syndrome de Sjogren actif depuis longtemps, surtout ceux atteints d'un SS primitif depuis plus de trois ans.

Until recently, little attention has been paid to psoriatic arthritis, perhaps because the disease was thought to be mild and infrequent. However, it has become clear that the disease may be severe in a significant proportion of the patients and may be more prevalent than initially considered. Recent studies supported the increasing clinical evidence that disruption of specific immune interactions can improve psoriasis and its musculoskeletal manifestations. Agents being evaluated for the treatment of psoriasis and psoriatic arthritis include, TNF-α antagonists: infliximab and etanercept, an anti-CD11a monoclonal antibody, efalizumab, and a soluble LFA-3-IgG fusion protein, alefacept. However, in concordance with the advent of new and emerging therapies, similar development in the measures of the disease activity and severity is highly required. This article gives an overview of the new developments in clinical assessment and management of psoriasis and its associated musculoskeletal manifestation. With the understanding of the disease immunopathogenesis, this review will outline a new suggested algorithm for management of psoriasis in its different clinical forms incorporating the new biologic agents with the conventional modalities.

To investigate the prevalence of hyperprolactinemia in patients with primary Sjogren's syndrome (SS), its clinical significance and its implication to our understanding of the disease pathogenesis.Forty-nine patients with primary SS (44 females and five males) age range 37-66 years were included in this study. All patients underwent clinical assessment for disease manifestations in addition to laboratory assessment for serum prolactin, sex hormones and immunological profile. Fifty healthy subjects (44 females and six males) of matched age were studied as control group.The mean prolactin serum level was significantly higher in SS patients compared to the control group (P0.01). This significant difference was persistent after subgrouping the patients and the controls based on their menstrual history. Hyperprolactinemia (20 ng/ml) was prevalent in 16.3% of SS patients. There was no correlation between serum prolactin levels and hormonal status, autoantibodies as well as systemic manifestations of the disease.Patients with primary SS have moderately increased levels of prolactin. Hyperprolactinemia reflects disease pathology rather than being present in a subset of patients. The presence of elevated prolactin levels was not associated with hormonal status, clinical or immunological manifestations of primary SS.

Resume Objectifs. – Le but de notre etude a ete de determiner la prevalence de l’hyperprolactinemie chez les malades atteints d’un syndrome de Gougerot-Sjogren primaire (SGSp), ainsi que d’en determiner la signification clinique et le role potentiel dans la physiopathologie de la maladie. Materiels et methodes. – Ont ete inclus dans cette etude 49 malades atteints d’un SGSp, 44 femmes et 5 hommes, âges de 37 a 66 ans. Chez tous les malades, ont ete etudiees les manifestations cliniques et les manifestations biologiques comprenant les dosages seriques de la prolactine, l’etude des hormones sexuelles et des parametres auto-immuns. Parallelement, ont ete etudies 50 sujets temoins non malades (44 femmes et 6 hommes), apparies par l’âge et qui ont forme le groupe controle. Resultats. – Le taux serique moyen de la prolactine etait significativement plus eleve chez les malades atteints de SGSp par rapport aux temoins ( p 20 ng/ml) etait de 16,3 % chez les malades atteints de SGSp. Il n’a pas ete trouve de correlation entre le taux de prolactinemie et le statut hormonal, les auto-anticorps ou encore les manifestations cliniques systemiques du SGSp. Conclusion. – Les malades atteints d’un SGSp ont une augmentation moderee du taux de prolactinemie. Cette anomalie semble traduire plus la physiopathologie de la maladie que temoigner d’un sous-groupe particulier de malades. L’existence d’une hyperprolactinemie n’est associee ni avec le statut hormonal, ni avec les manifestations cliniques ou immunologiques du SGSp.

Resume Objectif. – Estimer la valeur diagnostique de l’evaluation quantitative de la glande parotide par echographie et IRM chez des patients atteints du syndrome de Gougerot-Sjogren et evaluer la possibilite d’utiliser ces deux techniques pour predire le score anatomopathologique des biopsies de glandes salivaires dans ce groupe de patients. Methodes. – Des etudes echographiques et IRM de la glande parotide ont ete effectuees chez 47 patients atteints d’un syndrome de Gougerot-Sjogren primaire, 20 sujets temoins apparies pour le sexe et l’âge et 20 sujets presentant des symptomes secs mais sans syndrome de Gougerot-Sjogren. Un score a ete attribue aux patients et aux sujets temoins selon les changements de structure observes par les deux techniques d’imagerie. De plus, une sialographie et une biopsie de glandes salivaires accessoires ont ete faites chez tous les patients et les temoins et un score a ete attribue selon le degre d’atteinte. Resultats. – Une inhomogeneite parenchymateuse a ete observee chez 93,6 % des patients etudies par echographie, tandis qu’une organisation nodulaire a ete constatee dans 97,8 % par l’etude IRM. Les resultats echographiques et IRM sont significativement correles avec le score anatomopathologique des glandes salivaires (r = 0,82 et 0,84 respectivement) ainsi qu’avec le score de sialographie (r = 0,69, 0,60 respectivement). Il y a une bonne correlation entre les resultats echographiques et l’IRM (r = 0,87) chez les patients atteints du syndrome de Gougerot-Sjogren et chez les temoins. Conclusion. – L’echographie et l’IRM sont des outils de sensibilite egale pour le diagnostic de l’atteinte salivaire chez les patients atteints du syndrome de Gougerot-Sjogren. L’evaluation quantitative des images echographiques et celles obtenues avec l’IRM semblent representer un progres pour le diagnostic du syndrome de Gougerot-Sjogren car elles fournissent une bonne prediction du score anatomopathologique des glandes salivaires. L’IRM ne semble pas necessaire comme outil de diagnostic en routine et devrait etre consideree en deuxieme intention dans le cas d’une echographie normale.

Objective. – To test the correlation between clinical improvements in patients with rheumatoid arthritis (RA) as defined by the American College of Rheumatology (ACR) response criteria and functional improvements as assessed by functional measures in the modified Arabic version of the Health Assessment Questionnaire (Arabic-HAQ) and to estimate the sensitivity to change of the Arabic-HAQ, in a prospective study. Methods. – Eighty-two patients with active RA were given methotrexate and followed up prospectively for 12 months. ACR response rates and score improvements on the modified Arabic-HAQ were compared. Results. – The Arabic-HAQ scores showed significant sensitivity to change after 6 and 12 months and were significantly correlated with the ACR response. Percentages of agreement with ACR response levels were high after 6 months and higher still after 12 months. Standardized effect sizes were 2.34 and 2.84 after 6 and 12 months, respectively. Relative efficiency of the total Arabic-HAQ score in relation to the tender joint count was greater than 1. Conclusion. – The Arabic-HAQ is valid and sensitive to functional status changes in patients with RA. The results are comparable to those of the original HAQ. Thus, the Arabic-HAQ can be used to evaluate treatments and to identify changes that are important to RA patients.

Resume Objectif. – Les buts de notre etude ont ete d’evaluer de maniere prospective, dans une population de patients atteints de polyarthrite rhumatoide (PR) : (1) la correlation entre l’amelioration clinique telle qu’elle est definie par les criteres de l’ACR (American College of Rheumatology) et l’amelioration fonctionnelle telle qu’elle est evaluee dans une version transculturelle arabisee de l’indice fonctionnel HAQ (Health Assessment Questionnaire) ; (2) la sensibilite au changement de la version arabisee du HAQ (HAQ-arabise). Patients et methodes. – Notre etude prospective a porte sur 82 patients atteints de PR chez lesquels un traitement par methotrexate etait debute et qui ont ete suivis pendant 12 mois. Les taux de reponse ACR et les ameliorations des scores du HAQ-arabise ont ete compares. Resultats. – Les scores du HAQ-arabise ont montre une sensibilite au changement significative a 6 et 12 mois et etaient significativement correles avec le taux de reponse ACR. Les pourcentages de concordance avec les taux de reponse ACR etaient eleves a 6 mois et encore plus eleves a 12 mois. Les reponses moyennes standardisees etaient de 2,34 a 6 mois et de 2,84 a 12 mois. La capacite relative du HAQ-arabise par rapport au score d’articulations douloureuses etait superieure a 1. Conclusion. – Le HAQ-arabise est une methode valide d’evaluation de l’etat fonctionnel qui a une bonne sensibilite au changement chez les patients atteints de PR. Cette version peut donc etre utilisee pour l’evaluation des traitements et pour identifier des modifications qui seraient d’importance chez les patients atteints de PR.

Objective: To assess the relationship between disease activity, measured by DAS28, and radiographic progression, using X-Ray and US as tools to evaluate structural joint damage and residual inflammation, in early RA patients. Methods: Changes from baseline to week 52 in clinical variables and measures of radiographic progression were compared between early RA patients who received anti-TNF biologic therapy (192 patients), and those who received synthetic DMARD therapy (288 patients). Patients were stratified into: in remission, low (LDA), moderate (MDA) and high (HDA) disease activity at 52-weeks of treatment according to DAS-28 score. Radiographic progression was assessed both at baseline and at 52-weeks using modified Total Sharp Score (mTSS). In addition, US scores for number of erosions, synovial hypertrophy and vascularity were recorded. Results: Whilst there was no significant radiologic progression in the patients who achieved remission, whether treated with synthetic DMARD or biologic therapy; on the other hand, there was a steady increase of joint damage in those who did not achieve remission, mainly in those treated with synthetic DMARD and in favor of the biologic therapy. On comparing the MSS scores at 52-weeks, the biologic therapy cohort who showed LDA (DAS-28: 2.6-3.1), MDA (DAS-28 score > 3.2-5.1) and HDA (>5.1) had significantly (p< 0.001) less number of erosions and joint space narrowing (P< 0.001) as well as US-GS and US-PD scores in comparison to the synthetic DMARD therapy cohort. X-Ray and US parameters showed a discriminating value regarding joint damage particularly in the patients who did not achieve remission, with US parameter showing accurate 95% CI estimate. Conclusion: Using US as a sensitive tool for joint affection assessment, the combination of biologic and DMARDs therapies retards joint damage, independently of its effects on disease activity, contrasting synthetic DMARDs monotherapy.