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We aimed to assess patient preferences for the characteristics and outcomes of biologic and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) to manage psoriatic arthritis.We conducted a discrete choice experiment in patients with psoriatic arthritis from 3 rheumatology centers in Sydney, Australia. We assessed preferences for different attributes of biologic medications. The route and frequency of medications had a range of 5 levels, and the following 7 attributes had a range of 3 levels: the ability to attend to normal activities, improvements in joint pain, enthesitis and skin disease, chance of disease remission, risk of infection, and risk of severe adverse events. Multinomial logit models including a latent class model were used to calculate preferences.Of the 150 participants, 58.3% were female, with a median age of 53.5 years. The attributes in order of preference using the β coefficient in absolute values (95% confidence interval [95% CI]) were as follows: oral route compared to subcutaneous and intravenous routes (β coefficient 1.00 [fixed parameter]), avoiding severe side effects (β coefficient 0.72 [95% CI 0.50, 0.95]), increasing ability to attend to normal activities (β coefficient 0.66 [95% CI 0.36, 0.96]), avoiding infections (β coefficient 0.38 [95% CI 0.23, 0.53]), improvement in enthesitis pain (β coefficient 0.28 [95% CI 0.20, 0.36]), improvement in psoriasis (β coefficient 0.28 [95% CI 0.20, 0.36]), increasing chance of remission (β coefficient 0.27 [95% CI 0.19, 0.36]), and improvement in joint pain (β coefficient 0.26 [95% CI 0.00, 0.52]).When choosing biologic medications, patients with psoriatic arthritis preferred oral medications. Patients prioritized avoiding severe complications, maintaining the ability to attend to work and normal activities, and avoiding infection over clinical measures of efficacy.

Background Total knee arthroplasty (TKA) and total hip arthroplasty (THA) surgeries are among the most common elective procedures. Moderate to severe postoperative pain during the subacute period (defined here as the period from hospital discharge to 3 months postoperatively) is a predictor of persistent pain 12 months postoperatively. This review aimed to examine the available postdischarge pharmacological interventions, including educational and prescribing strategies, and their effect on reducing pain during the subacute period after TKA or THA. Methods We searched seven electronic databases from inception to April 22, 2021. Published randomized controlled trials of adults who underwent TKA or THA and received a pharmacological-based intervention commencing within 1 week after hospital discharge and conducted for up to 3 months postoperatively were compared with any treatment. Two reviewers independently extracted data on the primary outcome, pain intensity. This review was registered prospectively on PROSPERO (ID: CRD42021250384). Results Four trials involving 660 participants were included. Interventions included changing analgesic prescribing practices upon hospital discharge and education on analgesic use. Providing multimodal non-opioid analgesia in addition to reduced opioid quantity was associated with lower subacute pain (coefficient –0.81; 95% confidence interval –1.33 to –0.29; P = 0.003). Education on analgesic use during multidisciplinary home visits was effective for reducing pain intensity during the subacute period (6.25 ± 10.13 vs 35.67 ± 22.05; P Conclusions Interventions involving the provision of multimodal non-opioid analgesia and education on analgesic use show positive effects on reducing pain intensity during the subacute period after TKA and THA.

We investigated frailty and refracture risk among older adults with a minimal trauma fracture. After adjusting for age, sex, and site of initial fracture, increasing frailty was associated with an increased risk subsequent fracture. These results indicate the need to routinely screen for frailty following an initial fracture among older adults.Minimal trauma fractures are common among older adults, and frailty increases risk of an initial minimal trauma fracture. This study was undertaken to estimate the risk of subsequent fracture based on frailty status at the time of an initial fracture.The study population was older adults presenting to hospital, aged 60 years or more, with a minimal trauma fracture. Frailty was estimated using a cumulative deficit approach. The risk of subsequent fracture based on increasing cumulative frailty deficit item group, adjusted for sex, age, and site of initial fracture, was estimated using Cox's proportional hazard model.Between January 2014 and December 2020, 12,115 older adults presented to hospital (8371 women [69%]), with an initial minimal trauma fracture. The average age was 80 years (SD 9.5). Subsequent fractures identified during the follow-up period occurred in 1137 (9.4%) of study participants. The incidence of subsequent fracture ranged from 25.0 per 1000 older adults (95% confidence interval (CI) 22.4 to 27.8) among the lowest frailty deficit group (1 deficit item) to 31.8 per 1000 (95% CI 28.0 to 35.8) among the highest frailty deficit group (4 to 12 deficit items). After adjusting for age, sex, and site of initial fracture, an increasing number of frailty deficit items was associated with increased risk subsequent fracture (p-value for trend = 0.008).Our results indicate that following an initial minimal trauma fracture, frailty independently increases the risk of a subsequent fracture. Therefore, it is important at the time of an initial fracture that older women and men are screened for the presence of frailty, and models of care are implemented to reduce the risk of subsequent fracture among this vulnerable group of older adults.

While patient-centered care is widely advocated in the management of rheumatic diseases, it can be challenging to implement, particularly for patients with complex systemic conditions. Patient-centered care involves identifying and integrating the patient's experiences, attitudes, and preferences in decision-making. Qualitative research is used to describe patient perspectives and priorities that may not always be expressed in clinical settings. Systematic reviews of qualitative studies can provide new and more comprehensive evidence of patients' beliefs and priorities across different populations and healthcare settings and are increasingly being reported across medical specialties, including rheumatology. In rheumatology, they have been used to examine topics including medication-taking and adherence, coping with systemic sclerosis and conservative management and exercise in osteoarthritis. By referencing recent examples of systematic qualitative reviews in the rheumatology literature, this article will outline the methodology and methods used, and provide an approach to guide the appraisal of reviews. We aim to give the reader a practical understanding of systematic reviews of qualitative literature and elucidate how knowledge gained from such reviews can be applied to improve the care of patients with rheumatic conditions.

Shared care between rheumatologists and dermatologists is advocated for patients with psoriasis and psoriatic arthritis, but care provided by rheumatologists and dermatologists is often siloed, leading to inconsistencies in patient care and outcomes. This study aimed to describe rheumatologists’ and dermatologists’ perspectives on shared care. Face-to-face semi-structured interviews were conducted with 15 rheumatologists and 12 dermatologists across 27 centers in Australia. Transcripts were thematically analyzed. Five themes were identified: uncertainties in disciplinary tensions (lacking expertise to make diagnosis, hesitation managing outside of scope, doubting screening tools, defaulting to own disciplinary priorities, hampered by lack of evidence), working in fragmented care (frustration with working in silos, striving to coordinate with primary care, persevering despite inequities in access to care, overwhelmed by managing comorbidities, under-resourced for complexity), building trusting relationships (establishing a culture of collaboration, seeking reliable cross-specialty help, depending on unique skills), prioritizing efficiency (minimizing burden for patients, avoiding resource overuse, deferring to pragmatic decisions), and strengthened by integrated care models (improving the timeliness and accuracy of care, centering on patient goals and understanding, enhancing cross-specialty partnerships, providing opportunities for education and training). Rheumatologists and dermatologists endeavor to provide comprehensive care to their patients in disjointed healthcare settings but are hampered by a lack of training and a sense of feeling overburdened in the management of comorbidities. Interdisciplinary models are perceived to improve the care of patients but are limited by financial barriers to implementation and concerns about wasting health resources and improperly burdening patients.

Objective.The OMERACT-Adherence meeting was convened to discuss the conceptual and methodological challenges in developing a core domain set (Adherence-CDS) for trials of interventions for medication adherence in rheumatology.Methods.Forty participants from nine countries participated.Results.Four ideas emerged: for adherence trials, the Adherence-CDS could include adherence and the condition-specific CDS; many factors affect adherence and are intervention targets, contextual factors, or outcome domains; adherence is a critical factor in drug trials; and standardized adherence measures are needed.Conclusion.Despite the challenges, the meeting clarified an approach to developing an Adherence-CDS that complements existing OMERACT work and methodology.

Introduction Decision-making regarding medications to manage psoriatic arthritis is complex because of multiple disease manifestations and comorbidities. Fear of side effects from systemic medications and misalignment in priorities between patients with psoriatic arthritis and rheumatologists makes shared decision-making challenging. We aimed to describe the perspectives of patients with psoriatic arthritis on shared decision-making around medication taking. Methods Face-to-face semi-structured interviews were conducted with 25 adult patients with psoriatic arthritis in Australia. Transcripts were thematically analyzed. Results Five themes were identified: lacking agency in decision making (denied choice, knowledge asymmetry, desperation and necessity, restricted by unfair eligibility criteria, automated approach); overwhelmed by potential harms (daunted by aggressive therapy, anticipating lifestyle disruption from side effects, jeopardizing fertility and pregnancy, avoiding relapse); gaining confidence (discernable benefit in function and mental health, sharpening knowledge over time, expertise of family and peers, empowered by information); opting for alternatives (pursuing normality, suspicion of over-medicalization, seeking comprehensive solutions); and developing trust and fortifying collaboration (assurance through a personable approach, seeking consistency, supported in decisional power, resolution through respectful negotiation). Conclusions Patients with psoriatic arthritis lack agency in making treatment decisions and are overwhelmed by the potential harms of systemic medication. Improving knowledge and trust with medical teams in a supportive and collaborative environment, and strategies for managing risks and side-effects may improve decision-making about pharmacological management of psoriatic arthritis.

ObjectivesTo describe the experiences, priorities, and needs of patients with rheumatic disease and their parents during transition from paediatric to adult healthcare.SettingFace-to-face and telephone semistructured interviews were conducted from December 2018 to September 2019 recruited from five hospital centres in Australia.ParticipantsFourteen young people and 16 parents were interviewed. Young people were included if they were English speaking, aged 14–25 years, diagnosed with an inflammatory rheumatic disease (eg, juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, panniculitis, familial Mediterranean fever) before 18 years of age. Young people were not included if they were diagnosed in the adult setting.ResultsWe identified four themes with respective subthemes: avoid repeat of past disruption (maintain disease stability, preserve adjusted personal goals, protect social inclusion); encounter a daunting adult environment (serious and sombre mood, discredited and isolated identity, fear of a rigid system); establish therapeutic alliances with adult rheumatology providers (relinquish a trusting relationship, seek person-focused care, redefine personal–professional boundaries, reassurance of alternative medical supports, transferred trust to adult doctor) and negotiate patient autonomy (confidence in formerly gained independence, alleviate burden on patients, mediate parental anxiety).ConclusionsDuring transition, patients want to maintain disease stability, develop a relationship with their adult provider centralised on personal goals and access support networks. Strategies to comprehensively communicate information between providers, support self-management, and negotiate individualised goals for independence during transition planning may improve satisfaction, and health and treatment outcomes.

Background One in three women and one in five men are expected to experience a minimal-trauma-fracture after the age of 50-years, which increases the risk of subsequent fracture. Importantly, timely diagnosis and optimal treatment in the form of a fracture liaison service (FLS), has been shown to reduce this risk of a subsequent fracture. However, baseline risk of subsequent fracture among this group of FLS patients has not been well described. Therefore, this study aims to estimate absolute risk of subsequent fracture, among women and men aged 50-years or more, presenting to hospital with a minimal-trauma-fracture. Methods Women and men aged 50-years or more with a minimal-trauma-fracture, presenting to hospitals across the South Western Sydney Local Health District between January 2003 and December 2017 were followed to identify subsequent fracture presentations to hospital. Absolute risk of subsequent fracture was estimated, by taking into account the competing risk of death. Results Between January 2003 and December 2017–15,088 patients presented to the emergency departments of the five hospitals in the SWSLHD (11,149, women [74%]), with minimal-trauma-fractures. Subsequent fractures identified during the follow-up period (median = 4.5 years [IQR, 1.6–8.2]), occurred in 2024 (13%) patients. Death during the initial hospital stay, or during a subsequent hospital visit was recorded among 1646 patients (11%). Women were observed to have 7.1% risk of subsequent fracture after 1-year, following an initial fracture; and, the risk of subsequent fracture after 1-year was 6.2% for men. After 5-years the rate among women was 13.7, and 11.3% for men, respectively. Cumulative risk of subsequent fracture when initial fractures were classified as being at proximal or distal sites are also presented. Conclusion This study has estimated the baseline risk of subsequent fracture among women and men presenting to hospital with minimal trauma fractures. Importantly, this information can be used to communicate risk to patients deciding to attend an osteoporosis refracture prevention clinic, and highlight the need for screening, and initial of treatment when indicated, once a minimal-trauma-fracture has occurred.

International audience; OBJECTIVE: The core outcome set for trials in systemic sclerosis (SSc) was developed in 2008 and comprises eleven domains and thirty-one measures, leading to the development of a composite index (CRISS). We aimed to assess the scope, and consistency of outcomes reported in trials of SSc, and the uptake of this core set and CRISS. METHODS: MEDLINE, Cochrane CENTRAL, Embase and clinicaltrials gov were searched to identify randomized trials published from 2000 to 29 April 2018 in adults with limited or diffuse SSc. Outcomes and measures were recorded for each trial, classified into domains and the frequency of outcomes before after publication of the publication of the core set calculated. RESULTS: From 152 trials, 4193 outcomes were classified into 84 domains. The three most common domains were health-related quality of life and function (59%, 130 measures), skin (47%, 59 measures) and pulmonary (45%, 168 measures). After the publication of the core outcome set, no trial reported the complete core set with adherence to each of the eleven domains ranging from 6.1% to 54.4% and adherence to each of the thirty-one measures ranging from 0 to 48.1%. The five measures required for CRISS were reported completely in 11% of trials. CONCLUSION: Despite recognition that uniform acquisition and reporting of outcomes would enable a better evaluation of proposed SSc therapeutics, the outcome domains and measures reported in randomized trials in systemic sclerosis remain very inconsistent, with little impact of the core outcome set. This article is protected by copyright. All rights reserved.

Background:Despite the known benefits of exercise1, patients with osteoarthritis (OA) and rheumatoid arthritis (RA) are reported to have low levels of physical activity2. Exercise participation is not well studied in psoriatic arthritis (PsA) cohorts. This study aims to explore which factors predict exercise participation across cohorts and specifically in the PsA cohort.Objectives:The primary aim of this study was to determine which clinical factors were predictive of self- reported physical activity levels in patients with PsA. A secondary aim was to explore differences in self-reported physical activity levels amongst patients with PsA, OA and RA.Methods:Patients with the diagnosis of PsA, RA or OA are recruited prospectively at two tertiary hospital rheumatology clinics over 12 months. Demographic data is captured by the multi-dimensional health assessment questionnaire, the international physical activity questionnaire short form captures self-reported physical activity and self-efficacy for exercise (SEE) is assessed using the SEE scale. Clinical data including joint count, body mass index and co-morbidities including fibromyalgia are collected for all patients, in addition to PsA specific data including skin and enthesitis indices.Results:205 patients (PsA n=62, RA n=83, OA n=60) were recruited across two sites. There was no significant difference in self-reported physical activity between OA, RA and PsA cohorts. Fibromyalgia was present in 30% of each cohort. In patients with PsA, univariate analysis showed that co-existent fibromyalgia, age and self-efficacy for exercise were predictors of physical activity levels. Skin disease and enthesitis were not predictors of physical activity in the PsA cohort.Table 1.Univariate Analyses of effect of Clinical Features on Physical Activity levels in PsANon-exercisers versus ExercisersOR (95% CI)P-valueLEI1.35 (0.92-1.97)0.127PASI0.8 (0.6-1.07)0.133DLQI1.03 (0.92-1.16)0.589BMI0.97 (0.91-1.04)0.415DAS280.79 (0.55-1.14)0.205Concurrent Fibromyalgia4.46 (1.37-14.49)0.012Age1.05 (1.00-1.10)0.013Self-efficacy for exercise0.97 (0.95-0.99)0.019Pain1.17 (0.99-1.37)0.061Function1.3 (1.02-1.65)0.031Patient global1.14 (0.96-1.34)0.128Depression0.97 (0.51-1.84)0.930Table 2.Multivariable Analysis on Physical Activity in PsANon-exercisers vs ExercisersOR (95% CI)P-valueConcurrent fibromyalgia5.1 (1.44-18.08)0.0117Age1.05 (1.00-1.11)0.0342Conclusion:In the PsA cohort, fibromyalgia and age were associated with lower levels of physical activity. DLQI, PASI, LEI did not predict physical activity in PsA. Multivariate analysis showed higher pain levels and lower self-efficacy scores were associated with lower physical activity across arthritis groups.References:[1]Der Ananian C, Wilcox S, Watkins K, Saunders RP, Evans AE. (2008). Factors Associated with Exercise Participation in Adults with Arthritis.Journal of Aging and Physical Activity, 16: 125-143[2]Wilcox S, Der Ananian C, Abbott J, Vrazel J, Ramsey C, Sharpe PA, Brady T. (2006). Perceived Exercise Barriers, Enablers, and Benefits Among Exercising and Nonexercising Adults With Arthritis: Results from a Qualitative Study.Arthritis & Rheumatism, 55(4): 616-627Acknowledgments:Joseph DescallarDana GeorgevskyDr Michael OliffeDr Diana ChessmanDepartment of Rheumatology, Liverpool Hospital NSW AustraliaDepartment of Rheumatology, Westmead Hospital NSW AustraliaDisclosure of Interests:None declared

Objective To describe the range and depth of perspectives and experiences of patients with psoriasis and psoriatic arthritis to inform gaps in patient-centered care. Methods We searched MEDLINE, Embase, PsycINFO, and CINAHL to April 2018. Thematic synthesis was used to analyze the findings. Results We included 56 studies involving 1,484 adult patients with psoriasis (n = 1,147) and psoriatic arthritis (n = 337). Six themes (and subthemes) were identified: suffering uncontrollable and ongoing upheaval (dictating life choices and course, disrupting family and social roles, limited by debilitating symptoms, unstoppable and far-reaching fatigue), weighed down by mental load (anxiety provoked by the volatility of symptoms, dreading deterioration, struggling with unrecognized distress, helpless and nihilistic), harboring shame and judgement (marked as unhygienic and contagious, rejected and isolated, hiding away and resenting own appearance, pain and embarrassment in intimacy), demoralized by inadequacies and burden of therapy (disappointed by unmet expectations of treatment benefit, daily drudgery, deterred by unpalatable or inconvenient treatments, disempowered by lack of personalized care), gaining control (making sense of the condition, accepting a new health status, regaining independence and normality, attuning to the body), and making confident treatment decisions (trading off perceptible benefits against safety and convenience, relying on family input, seeking empowering and reassuring relationships). Conclusion Patients with psoriasis and psoriatic arthritis contend with disruption in their functioning, roles, and life course and have unmet expectations about treatment. Enhanced therapeutic relationships, addressing treatment expectations and supporting psychosocial needs may improve satisfaction and outcomes.

Background Dermatomyositis – an idiopathic inflammatory myopathy- can be resistant and unresponsive to initial treatments and require chronic therapy. Symptoms including muscle weakness and skin rash can lead to severe complications and impair quality of life. There are a paucity of randomised trials in dermatomyositis, which may not consistently report outcomes that are important to patients and their clinicians. Objectives To assess the scope and consistency of outcomes reported in randomised trials in dermatomyositis. Methods MEDLINE, Embase, CINAHL, PsycINFO were searched to February 2017 for randomised trials in children and adults with dermatomyositis. The frequency and characteristics of the outcome domains and measures reported were then analysed. Similar outcomes were grouped into outcome domains and classified as surrogate, clinical or patient-reported outcomes. The frequency and characteristics of the outcome domains and measures reported were then analysed. Results We included 18 trials (n=844 participants), reporting 680 outcome measures. These were grouped into 27 different outcome domains; including 12 (44%) clinical outcomes, 9 (33%) surrogate/biochemical outcomes, and 6 (22%) patient-reported outcomes. The 5 most frequently reported outcome domains were: physical function (13 trials, 72%), muscle strength (12, 67%), muscle inflammation (12, 67%), biomarkers (11, 61%), and composite i.e. myositis disease activity (10, 56%). Conclusions The majority of outcomes reported in trials in dermatomyositis are clinical outcomes and few are patient-reported. Establishing a core set of patient-important outcomes may improve the consistency and relevance of outcomes reported in trials in dermatomyositis to inform decision-making. Disclosure of Interest None declared

Background: Standardisation of outcome domains and measures in trials in rheumatology has generally improved the consistency and relevance of outcomes reported in rheumatic conditions over the last two decades. The Outcome Measures in Rheumatology (OMERACT) ‘core response set’ for trials in Systematic Sclerosis (SSc) was developed in 2008 and comprises 11 domains and 31 measures1. Objectives: We aimed to assess the scope, and consistency of outcomes reported in trials of SSc, and the uptake of this core response set. Methods: MEDLINE, Cochrane CENTRAL, Embase and clinicaltrials.gov were searched to identify randomised clinical trials published between 2000 and June 2016 in adults with SSc. Outcomes and measures were recorded for each trial and classified into domains. The scope and consistency of domains were compared between those trials published from 2000 to 2010 and 2011 to mid-2016 to determine whether has been uptake of the core domain and measurement set reported. A two-year lag between publication of the core set in 2008 and start of the second-time period was set to allow to allow for core reponse set uptake. Results: Overall 114 trials (4860 patients, median sample size of 33) were identified. The majority of trials were interventions for immunotherapeutic agents or vasodilators and included a total of 2736 measures (of 78 domains), with a mean of 24 measures per trial. The proportion of trials reporting any outcome from the each domain is listed: (% of 2000–2010 trials, % of 2011–2016 trials, change in %): health-related quality of life and function (42.6, 56.5, +13.9); skin (39.7, 47.8, +8.1); pulmonary (33.8, 43.5, +9.7); global health (14.7, 21.7, +7.0); gastrointestinal (4.4, 10.9, +6.5); ; cardiac (13.2, 15.2, +2); biomarkers of ESR/CRP (7.4, 8.7, +1.3%) musculoskeletal (5.9, 6.5, +0.6); Raynaud9s phenomenon (20.6, 19.6, -1.0) renal (14.7, 10.9, -3.8); digital ulcers (23.5, 19.6, -3.9%). Six measures had a greater than 5% increase in reporting frequency across trial periods: HAQ-DI (from 38.2% to 47.8%), SF-36 (from 17.6% to 28.3%), Modified Rodnan Skin Score (from 38.2 % to 47.8%), pulmonary function tests (from 30.9% to 43.5%), measures of dyspnoea (4.4% to 10.9%) and patient global disease (from 10.3% to 21.7%). Conclusions: There was a wide range of domains reported in trials in systemic sclerosis. The uptake of domains and measure as per the core response set is low in SSc trials compared to other rheumatic diseases with only modest improvement in reporting of 6 out of 31 measures. Improvements in reporting of specific measures align with the recent development of a composite response index in systemic sclerosis (CRISS)2. References 1. Khanna D, et al. Development of a provisional core set of response measures for clinical trials of systemic sclerosis, Ann Rheum Dis2008;67:703–9. 2. Khanna D, et al. The American College of Rheumatology Provisional Composite Response Index for Clinical Trials in Early Diffuse Cutaneous Systemic Sclerosis. Arthritis Res Ther2016;68:299–311. Disclosure of Interest: None declared

Background Patients with psoriasis and psoriatic arthritis have a lower health related quality of life than the normal population and experience high rates of treatment dissatisfaction1. The complexity of unmet needs in diagnosis and treatment2 necessitate a deep understanding of the experience of people with both conditions to guide development of outcomes important to patients and improve patient centred care. Objectives To describe the perspectives and experiences of patients with psoriasis and psoriatic arthritis. Methods Databases (MEDLINE, Embase, PsycINFO, CINAHL) were searched to October 2016. Thematic synthesis was used to analyse the findings. Results From 46 studies (n=37 psoriasis and n=9 psoriatic arthritis) involving 1290 adult patients with psoriasis (n=1105) and psoriatic arthritis (n=185) we identified six themes (with subthemes): suffering uncontrollable and ongoing upheaval (dictating life choices and course, disrupting role functioning, limited by debilitating symptoms, unstoppable and far reaching fatigue); weighed down by mental load (struggling with unrecognised distress, anxiety provoked by the volatility and constancy of symptoms, depleting motivation and pleasure); harbouring shame and judgement (marked as unhygienic and contagious, rejected and isolated, resenting own appearance, pain and embarrassment in intimacy); demoralised by inadequacies and burden of therapy (disappointed by unmet expectations of treatment benefit, daily drudgery, deterred by unpalatable or inconvenient treatments, disempowered by lack of personalised care, fearing long term side effects); gaining control (making sense of the condition, shutting the disease out, accepting a new health status, attuning to the body); and making confident treatment decisions (trading off perceptible benefits against safety and convenience, relying on family input, reassured by clinician acknowledgement of fears, seeking empowering relationships with clinicians). Conclusions Patients with psoriasis and psoriatic arthritis contend with profound disruption in their functioning, roles and life course; fear deterioration of their health; and have unmet expectations about their treatment and care. Patients with psoriasis feel marked by their disease, stigmatised and rejected by others while patients with psoriatic arthritis experience social withdrawal and depleted motivation due to fatigue, joint impairment and pain. Establishing therapeutic relationships, addressing treatment expectations, and supporting psychosocial needs may help to improve satisfaction and outcomes in patients with psoriasis and psoriatic arthritis. References [1] Katherine M. Mercy, Kenneth B. Gordon, Amy S. Paller. Patient Satisfaction and Quality of Life in Psoriasis and Psoriatic Arthritis. JAMA. 2014;312(24):2676–2677 [2] Helliwell, et al. Qualifying Unmet Needs and Improving Standards of Care in Psoriatic Arthritis. Arthritis Care & Research Vol. 66, No. 12, December 2014, pp 1759–1766 Disclosure of Interest None declared

Aim: To determine whether implementation of a protocol to manage in-hospital acute gout has improved the care of patients by non-rheumatologists. Method: Two systematic case-file reviews were performed to determine the management of acute gout in all episodes occurring in hospitalized patients before (April 2005–December 2006) and after (November 2008–September 2009) introduction of a protocol for acute gout management in a tertiary referral hospital. The protocol targeted non-rheumatologists with primary intentions to continue baseline anti-gout medications on admission, prevent inappropriate prescriptions of colchicine, non-steroidal anti-inflammatory drugs (NSAIDs) and allopurinol in the hospital, encourage invitations for assistance by rheumatology, and promote combination therapy in cases of severe gout. Results: Excluding patients under the primary care of a rheumatologist, 118 cases of acute gout occurring during hospitalization were reviewed before and 89 cases after introduction of the gout protocol. Post-protocol, there was a significant increase in continuation of baseline allopurinol (P = 0.01), significantly less inappropriate prescriptions of colchicine (P

Introduction: This study aimed to determine outcomes of percutaneous vertebroplasty for osteoporotic vertebral compression fractures (VCFs). Methods: Prospective assessment of short-term (≤6 weeks), medium-term (6 months) and long-term (29 months) outcomes of vertebroplasty, followed by a retrospective long-term follow-up of patients treated with vertebroplasty compared with conservative therapy. Outcomes measured were visual analogue scale pain scores, analgesic use, disability scores using the Roland Morris Disability questionnaire and a number of new VCFs. Results: In 27 patients with acute VCFs followed prospectively, vertebroplasty resulted in significant reductions in pain levels (56-mm reduction on a 100-mm scale) and disability scores (11.8-point reduction on a 24-point scale) at all follow-up points up to a mean of 29 months compared with pre-vertebroplasty levels (P

Aim: To review systematically the management of acute gout during hospitalization. Methods: Case-file review of all episodes of acute gout occurring in a large tertiary hospital over a 20-month period. Results: Of 134 acute gout episodes identified, the large majority (118) occurred in patients not admitted under the rheumatology unit. Baseline anti-gout medications were frequently ceased on admission and in 9% of episodes, no pharmacotherapy was prescribed. Delays in initiation of treatment occurred in up to 29% of patients. Acute management included anti-inflammatory monotherapy, or combinations of colchicine, non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. Of patients prescribed colchicine, 26% received >1.5 mg/day and a strong correlation was found between colchicine dose and the occurrence of diarrhoea. NSAIDs were prescribed in 29% of patients with pre-existing renal impairment. Overall, 25% of patients received inappropriate pharmacological management. In patients not under the direct care of the rheumatology unit, in-hospital rheumatology consultation was sought by the treating unit in 34% of episodes. Consultation was sought more frequently in patients with multiple joint involvement, but there were no other obvious differences in baseline clinical characteristics between cases with or without rheumatology involvement. In cases with rheumatology involvement, patients were investigated more frequently, they received more pharmacotherapeutic intervention, in particular combination anti-inflammatory therapy, and they achieved better symptomatic relief and long-term follow up. Conclusion: Acute gout episodes in hospital are variably investigated and treated with frequent suboptimal management. We recommend establishment of a hospital-wide protocol to support decision-making regarding investigations, treatment and follow up.

STUDY DESIGN A candidate gene association study in a longitudinal cohort. OBJECTIVE To investigate the association between polymorphisms at 25 candidate genes and progression of individual radiographic features of lumbar disc degeneration (LDD). SUMMARY OF BACKGROUND DATA LDD is characterized radiographically by the presence of osteophytes and disc space narrowing and is known to have a genetic component. Because of the high prevalence of radiographic features, progression may be a more useful phenotype clinically to study than prevalence itself. METHODS We tested the effect on radiographic progression of LDD of polymorphisms in 25 genes, 24 of which had been previously tested with regards to knee osteoarthritis. The progression traits used were the change in radiographic grade over 9 years in osteophytes, disc space narrowing, and summary Kellgren-Lawrence grade. Lumbar spine radiographs (L1-L5) at baseline and at follow-up were read for 720 women genotyped at the 25 genes participating in the Chingford study. RESULTS Polymorphisms in MMP3, TIMP1, and COX2, which encode molecules involved in inflammatory pathways, were associated with radiographic progression of LDD. The strongest associations observed (statistically significant after correcting for multiple comparisons) were between COX2 and change in osteophyte grade (P < 0.001) and Kellgren-Lawrence grade (P < 2 x 10(-5)), and between the genes for vitamin D receptor (P < 0.002) and a thrombospondin (THSD2) (P < 0.002) and change in osteophyte grade. CONCLUSIONS Our results suggest a role for genes regulating inflammatory pathways in the radiographic progression of spine degeneration. This could prove a fruitful area for future therapeutics for the spine and other joints.

Objective Few data exist concerning the natural history of lumbar spine disc degeneration and associated risk factors. We therefore undertook this study to examine the radiographic progression of lumbar spine disc degeneration over the course of 9 years in a population-based inception cohort of women from the Chingford Study. Methods Seven hundred ninety-six paired lumbar spine radiographs were read by a single reader for anterior osteophytes (AO) and disc space narrowing (DSN) using the Lane atlas at each lumbar disc space (L1–5). Disc degeneration was defined using thresholds of AO and DSN grade 1+ in one or more vertebrae (L1–5) within a subject. Progression was defined as an increase in grade in an affected year-1 vertebra. Potential risk factors were assessed using odds ratios and 95% confidence intervals adjusted for age, body mass index (BMI), and other potential confounders in logistic regression models using the STATA statistical package. Results The mean ± SD age at baseline was 53.8 ± 6.0 years, and mean ± SD BMI was 25.4 ± 4.1 kg/m2. Progression rates for AO and DSN were 4% per annum and 3% per annum, respectively. Progression of DSN was predicted by age, back pain, and radiographic hip and knee osteoarthritis (OA). Progression of AO was predicted by age and radiographic hip OA, with borderline significance for BMI >30 kg/m2. No significant effects were seen for smoking, physical activity, hormone replacement therapy use, multiparity, or hand OA. Conclusion This is the first population-based longitudinal study to assess progression of the individual radiographic features of AO and DSN in lumbar spine disc degeneration. We demonstrated progression rates of 3–4% per annum, with important risk factors for progression, including age, back pain, and radiographic OA at the hip and knee.

Objective. The sternoclavicular joint (SCJ) is commonly affected by rheumatological conditions. Case reports suggest that it may refer pain to distant areas, potentially leading to delays in diagnosis and inappropriately targeted investigations. Therefore, we studied the patterns of pain referral from the SCJ of nine healthy volunteers. Methods. Hypertonic saline was injected into the SCJ of nine normal volunteers and the location of any resulting pain was noted, as was the effect of resisted shoulder abduction and flexion. Composite pain maps were then constructed from individual pain diagrams. Results. An unpleasant, deep aching pain was produced locally in eight subjects and referred to distant sites in all subjects. Tests of shoulder movement had varied and inconstant effects. Conclusions. We demonstrated that the SCJ is capable of referring pain to areas distant from the joint. Knowledge of these referral patterns will enable the SCJ to be considered in patients with pain in these areas. Pain is one of the cardinal symptoms leading to presentation of rheumatic diseases. It is axiomatic that a sound knowledge of the significance of pain in any given anatomical area will facilitate appropriate investigation and treatment. In the proximal upper limb and the lower neck this is particularly pertinent as several structures have the potential to refer pain to the region of the shoulder cowl and lower neck. These include the cervical zygapophyseal joints and intervertebral discs, the acromioclavicular joint and the subacromial space, as well as non-musculoskeletal structures such as the heart and cervical nerve roots. Knowledge of the patterns of pain that may originate from these structures may lead the clinician to consider appropriate diagnostic possibilities for a particular presentation. Conversely, unlikely possibilities could be discounted. The patterns of pain referral from the cervical nerve roots w1x and cervical zygapophyseal joints w2‐ 4x have been studied, as has the pattern from the acromioclavicular joint and subacromial space w5x. However, to-date there have been no similar experimental data on the patterns of pain that may arise from the sternoclavicular joint (SCJ). The SCJ is a diarthrodial joint, divided into medial and lateral compartments by an intra-articular, fibrocartilaginous disc and is the only synovial articulation between the upper limb and the axial skeleton. As a source of referred pain, the SCJ has been implicated in the differential diagnosis of shoulder, subscapular, neck, arm and chest wall pain in case reports and review articles, w 6‐ 8x. Interest in the SCJ is not simply academic. It is affected by common rheumatological pathologies including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, sternoclavicular hyperostosis, infection, hyperparathyroidism, traumatic dislocations and metastases. The SCJ is not seen well on conventional radiographs and is not always included in the rheumatological examination. Therefore, SCJ pathology may be missed or not considered if it has distant, but unrecognized, patterns of referral. We therefore performed a study to determine whether irritation of the SCJ in normal volunteers produced characteristic patterns of pain and to map these patterns. The results demonstrated a surprisingly diverse set of referral patterns, with important clinical implications in the assessment of patients with pain in the neck, arm and shoulder.

Background Gout is the most common type of inflammatory arthritis in men, with an Australian population prevalence of 0.39% (1, 2). Due to ageing and rising obesity, the global burden of gout is increasing. Global disability adjusted life years (DALYs) for gout rose from 76 000 in 1990 to 114 000 in 2010 (2). Patients with severe gout are known to have low health-related quality of life (HRQOL), especially in regards to physical function (3). Objectives To determine HRQOL in gout patients of South Western Sydney, and the utility of the Gout Impact Scale (GIS). To compare GIS in patients with acute versus non-acute gout, and high frequency of gout attacks versus low frequency of gout attacks. To compare Short Form 36 version 2 (SF36v2) in our gout cohort with normals and other chronic diseases. Methods Postal cross-sectional survey study of adult patients diagnosed with gout recruited from 3 public hospitals and a private clinic. SPSS software facilitated analysis. Results 133/184 patients recruited with a 72.3% response rate. The overall impact of gout on their life was 5.9/10, higher in acute gout vs non-acute gout, mean 6.8 vs 5.2, p Patients with acute gout had higher mean scores for gout concern overall (GCO), gout medication side effects (GMSE), unmet gout treatment need (UGTN), well being during attack (WBDA) and gout concern during attack (GCDA), compared to non-acute gout, p b =0.566, p b =0.508, p Patients with more frequent attacks had higher mean scores for GCO, GMSE, UGTN, WBDA and GCDA, compared to those with less frequent attacks, p Gout patients scored significantly lower in all 8 domains of SF36v2 compared to Australian normative data and diabetics. There was a moderate correlation between WBDA and the mental component summary of SF36v2 (τ b =-0.406, p Conclusions Results of the Gout Impact Scale made sense with greater impact of gout in patients with acute gout or more frequent attacks in all 5 scales, suggesting it is a robust instrument in the diverse gout population. The impact of gout was not confined to just physical domains, but had a significant negative impact on psychological health. References Becker MA et al. Quality of life and disability in patients with treatment failure gout. J Rheumatol. 2009;36(5):1041–8. Smith E et al. The global burden of gout estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(8):1470–6. Hirsh JD et al. Gout disease specific quality of life and the association with gout characteristics. Patient Relat Outcome Meas. 2010;1:1–8. Marin T, Taylor A & Gill T. A population profile of quality of life in south australia population norms for 2008 using the SF36 version 2. Population Research and Outcome Studies Unit. South Australian Department of Health, Adelaide. September 2009. Disclosure of Interest None declared

Background: The association between progression of knee osteoarthritis and progression of osteoarthritis at sites distant from the knee is unclear because of a lack of multisite longitudinal progression data. Objective: To examine the association between radiological progression of knee osteoarthritis and osteoarthritis of the hands, hips, and lumbar spine in a population based cohort. Methods: 914 women had knee x rays taken 10 years apart, which were read for the presence of osteophytes and joint space narrowing (JSN). Progression status was available for hand, hip, and lumbar spine x rays over the same 8 to 10 year period. The association between progression of knee osteoarthritis and osteoarthritis at other sites was analysed using odds ratios (OR) and 95% confidence intervals (CI) in logistic regression models. Results: 89 of 133 women had progression of knee osteoarthritis based on osteophytes, and 51 of 148 based on JSN definition. Progression of JSN in the knee was predicted by progression in lumbar spine disc space narrowing (OR = 2.9 (95% CI 1.2 to 7.5)) and hip JSN (OR = 2.0 (1.0 to 4.2)). No consistent effects were seen for hand osteoarthritis. The associations remained after adjustment for age and body mass index. Conclusions: Progression of knee osteoarthritis is associated with progression of lumbar spine and hip osteoarthritis. This may have implications for trial methodology, the selection of patients for osteoarthritis research, and advice for patients on prognosis of osteoarthritis.