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ID PMID Title PublicationDate abstract
18203329 Etanercept reduces synovitis as measured by magnetic resonance imaging in patients with ac 2008 Mar OBJECTIVE: To demonstrate the efficacy of etanercept to reduce synovitis as measured by magnetic resonance imaging (MRI) as early as 6 weeks after starting treatment in patients with active rheumatoid arthritis (RA). METHODS: Twenty-two patients with active RA despite disease modifying antirheumatic drug (DMARD) treatment were included in this prospective, controlled study. Patients were randomized in 2 groups. In the treatment group, etanercept was added at usual doses during 6 weeks. In the control group, patients continued with prior DMARD therapy. MRI of the dominant wrist and 2nd-5th MCP joints were obtained at baseline and at 6 weeks and evaluated according to OMERACT recommendations. Results of changes in synovitis in the treatment group were compared with changes in the control group. RESULTS: Changes in synovitis measured by MRI of the hand (OMERACT evaluation) in the etanercept group showed a significant reduction after 6 weeks of treatment compared with no changes in the control group. Reduction of synovitis in the treatment group also showed good correlation with decrease of various clinical and laboratory measures. CONCLUSION: In patients with active RA despite DMARD therapy, etanercept, but not placebo, reduced synovitis as measured by MRI after 6 weeks.
18815153 Effects of a modular behavioural arthritis education programme: a pragmatic parallel-group 2008 Nov OBJECTIVES: Rheumatology guidelines recommend people with RA receive behavioural self-management education. This study developed a modular behavioural group programme and evaluated its longer term effects on pain, physical and psychological status. METHODS: People with RA or PsA were randomized to a modular behavioural or standard information-focused education programme, both delivered by experienced rheumatology health professionals at one large district general hospital. Outcome measures were pain, self-efficacy, fatigue, functional ability, psychological status and use of health behaviours (exercise, joint protection, fatigue and cognitive symptom management). Using an intent-to-treat analysis outcomes were compared at 6 and 12 months with analysis of covariance. RESULTS: Out of 498 referred patients, 218 agreed to participate, met entry criteria and were randomized; 51 withdrew before education. Of the remaining patients, 86 attended the behavioural and 81 the standard programmes. Participants were aged 55.4 yrs (s.d. 12.42) with disease duration of 7.39 (s.d. 6.88) yrs (53% <5 yrs). At 6 months, the behavioural group had better pain (P = 0.01), fatigue (P = 0.01), functional ability (P = 0.05) and self-efficacy (P = 0.01) scores and greater use of health behaviours. At 12 months, they continued to have better pain (P = 0.03), self-efficacy (P = 0.001) and psychological status (P = 0.0001) scores and greater use of some health behaviours. CONCLUSION: Attending a modular behavioural education programme is effective for at least 1 yr in enabling people with RA and PsA to reduce pain, improve psychological status and self-manage their condition.
17849126 [Assessment of musculoskeletal pain]. 2007 Oct Persons suffering from chronic musculoskeletal pain and applying for disability claims, should be assessed according to the biopsychosocial disease model. Interdisciplinary guidelines give advice on how to proceed. The claims assessor representing somatic disciplines has to recognize those subjects whose pain is not sufficiently explainable by the extent of physical damage but show typical signs of chronification (generalization of the pain extent, further body complaints, symptoms of depression), to recommend further assessment by a psychiatric or psychosomatic specialist. Technical findings must not be overestimated or the pain complaints of the subjects rejected as deliberate feigning. The extent of the pain and the underlying (physical and psychosocial) disorders have to be assessed by a consistent description of the implications for all areas of life.
17284303 Immunomodulatory properties of mesenchymal stem cells: a review based on an interdisciplin 2007 Multipotent mesenchymal stromal cells isolated from bone marrow and other sites are currently being studied to determine their potential role in the pathogenesis and/or management of autoimmune diseases. In vitro studies have shown that they exhibit a dose-dependent antiproliferative effect on T and B lymphocytes, dendritic cells, natural killer cells and various B cell tumour lines--an effect that is both cell contact and soluble factor dependent. Animal models of autoimmune disease treated with multipotent mesenchymal stromal cells have mostly exhibited a positive clinical response, as have a limited number of patients suffering from acute graft versus host disease. This review summarizes the findings of a 1-day meeting devoted to the subject with the aim of coordinating efforts.
17254316 Antibody-induced arthritis: disease mechanisms and genes involved at the effector phase of 2006 During the development of rheumatoid arthritis (RA) autoantibodies to IgG-Fc, citrullinated proteins, collagen type II (CII), glucose 6 phosphoisomerase (G6PI) and some other self-antigens appear. Of these, a pathogenic effect of the anti-CII and anti-G6PI antibodies is well demonstrated using animal models. These new antibody mediated arthritis models have proven to be very useful for studies involved in understanding the molecular pathways of the induction of arthritis in joints. Both the complement and FcgammaR systems have been found to play essential roles. Neutrophils and macrophages are important inflammatory cells and the secretion of tumour necrosis factor-alpha and IL-1beta is pathogenic. The identification of the genetic polymorphisms predisposing to arthritis is important for understanding the complexity of arthritis. Disease mechanisms and gene regions studied using the two antibody-induced arthritis mouse models (collagen antibody-induced arthritis and serum transfer-induced arthritis) are compared and discussed for their relevance in RA pathogenesis.
18478203 Co-contraction in RA patients with a mobile bearing total knee prosthesis during a step-up 2008 Aug It was hypothesized that rheumatoid arthritis (RA) patients with a total knee prosthesis that allows axial rotation of the bearing (MB) will show more co-contraction to stabilize the knee joint during a step-up task than RA patients with a fixed bearing total knee prosthesis (FB) where this rotational freedom is absent while having the same articular geometry. Surface EMG, kinematics and kinetics about the knee were recorded during a step-up task of a MB group (n = 5), a FB group (n = 4) and a control group (n = 8). Surface EMG levels of thigh muscles were calibrated to either knee flexion or extension moments by means of isokinetic contractions on a dynamometer. During the step-up task co-contraction indices were determined from an EMG-force model. Controls showed a higher active ROM during the step-up task than the patient group, 96 degrees versus 88 degrees (P = 0.007). In the control group higher average muscle extension, flexion and net moments during single limb support phase were observed than in the patient group. During the 20-60% interval of the single limb support, MB patients showed a significant higher level of flexor activity, resulting in a lower net joint moment, however co-contraction levels were not different. Compared to the control group arthroplasty patients showed a 40% higher level of co-contraction during this interval (P = 0.009). Control subjects used higher extension moments, resulting in a higher net joint moment. Visual analysis revealed a timing difference between the MB and FB group. The FB group seems to co-contract approximately 20% later compared to the MB group. RA patients after total knee arthroplasty show a lower net knee joint moment and a higher co-contraction than controls indicating avoidance of net joint load and an active stabilization of the knee joint. MB and FB patients showed no difference in co-contraction levels, although timing in FB is closer to controls than MB subjects. Since visual analysis revealed a timing difference between the MB and FB group, this may express compensation by coordination. Rehabilitation programs for RA patients should include besides muscle strength training, elements of muscle-coordination training.
17394228 Measuring fatigue in rheumatoid arthritis: a systematic review of scales in use. 2007 Apr 15 OBJECTIVE: Fatigue is an important outcome for patients with rheumatoid arthritis (RA). The purpose of this study was to identify the scales being used to measure RA fatigue, and to systematically examine the evidence for their validation. METHODS: Articles measuring fatigue in RA were sought using the terms RA and fatigue, and RA and tiredness, plus scale, questionnaire, inventory, and checklist. Index articles reporting identifiable RA fatigue data were examined for the fatigue scale used. Index and validation articles for each scale were reviewed for evidence supporting scale validation to measure RA fatigue using a standardized checklist of content, face, criterion, and construct validity, reliability, and sensitivity to change. RESULTS: A total of 61 index articles used 23 different fatigue scales to measure RA fatigue on 71 occasions. Seventeen scales had either no data on validation in RA or limited evidence. Reasonable evidence of validation was identified for 6 scales, each also having some evidence of sensitivity to change: ordinal scales, the Short Form 36 vitality subscale, the Functional Assessment of Chronic Illness Therapy Fatigue Scale, visual analog scales (VAS), the Profile of Mood States, and the RA-specific Multidimensional Assessment of Fatigue scale (MAF). However, the 4 generic scales would benefit from further validation in patients with RA, the VAS requires standardization, and the MAF would benefit from further sensitivity data. CONCLUSION: It was possible to identify evidence of reasonable validation for 6 of 23 scales being used to measure RA fatigue. Researchers and clinicians should select scales to measure RA fatigue carefully.
18035324 B cells in rheumatoid arthritis. 2007 Dec Though its etiology remains unknown thus far, the role that autoimmune processes play in rheumatoid arthritis (RA) pathogenesis has been widely proven. Given the easier accessibility of humoral components, the first feature of this contribution to be recognized has been the occurrence of the so-called rheumatoid factor in a large proportion of RA patients. This antibody recognizes the Fc portion of human IgG. By investigating RA pathologic processes and also through experimental models where immune complexes play a fundamental role, many other autoantibodies have then come to our knowledge to be associated with the disease. Their presence and persistence implies that clones of autoreactive B cells survive and proliferate in RA patients under a continuous stimulation. Whether this is a mechanism of disease initiation or just an epiphenomenon is still unclear but no doubt exists that autoantibodies represent a very useful tool in both diagnostic and prognostic terms. Being much more than simple autoantibody producers, B cells are able to secrete many important cytokines and to efficiently present antigens to T lymphocytes in the synovial environment. All of these functions are essential in the development of RA, and lately have claimed attention as B cell depletion has become a common and effective strategy of treatment in RA.
19019892 Contribution of Fcgamma receptor IIIA gene 158V/F polymorphism and copy number variation t 2009 Nov BACKGROUND: Fcgamma receptors (FcgammaRs) are potent immune modulators. FcgammaR genes encompass a complex region, polymorphic by both single nucleotide polymorphisms (SNPs) and copy number variation (CNV). The heterogeneity of rheumatoid arthritis (RA) combined with the genetic complexity of FcgammaR genes may be the cause of inconsistent findings in previous RA studies on FcgammaR SNPs. There is increasing evidence that anti-citrullinated peptide antibody (ACPA)-positive RA and ACPA-negative RA have a different genetic background. OBJECTIVE: To investigate whether FcgammaRIIIA 158V/F SNP associates differently with ACPA-positive and ACPA-negative RA and to assess if the FcgammaRIIIA gene CNV affects the association of the FcgammaRIIIA 158V/F SNP with RA and whether the FcgammaRIIIA gene CNV confers risk for RA. METHODS: 945 patients with RA and 388 healthy controls, all Dutch-Caucasians, were included in the study. FcgammaRIIIA 158V/F SNP was genotyped using Sequenom. CNV of the FcgammaRIIIA gene was determined in 456 patients with RA and 285 controls using multiplex ligation-dependent probe amplification. Associations between genotypes and RA were analysed, stratifying for the presence/absence of ACPA and CNV. RESULTS: In all patients with RA the FcgammaRIIIA 158V/F SNP was not associated with RA. In ACPA-positive RA (n = 358), the VV genotype was more prevalent in cases than in controls (18.4% vs 13.2%, OR = 1.5, p = 0.05). After stratification for CNV the VV genotype was associated with RA in general (n = 426) (OR = 1.6, 95% CI 0.97 to 2.6, p = 0.05) and with ACPA-positive RA (n = 135) (OR = 2.1, 95% CI 1.2 to 3.8, p = 0.009) but not with ACPA-negative RA. The distribution of CNV was not significantly different between patients with RA and controls. CONCLUSION: The FcgammaRIIIA 158 VV genotype confers risk for ACPA-positive RA; this association increased slightly after correction for CNV of the FcgammaRIIIA gene. CNV itself is not associated with RA susceptibility.
18158087 Utilization and costs of medical services and prescription medications for rheumatoid arth 2007 Nov BACKGROUND: Rheumatoid arthritis (RA) is a chronic autoimmune disorder characterized by inflammation of synovial tissues that leads to joint swelling, stiffness and pain, and progressive joint destruction. There is currently limited information about demographic differences in the prevalence of RA and the utilization and costs of RA-related prescription medications and medical services among low-income populations. OBJECTIVES: This study assessed the prevalence of RA and the utilization and costs of RA-related medical services and prescription medications among recipients enrolled in a state Medicaid program. METHODS: A retrospective, cross-sectional, descriptive analysis of West Virginia (WV) Medicaid fee-for-service administrative claims data was conducted. Medical services claims for recipients aged between 15 and 64 years with a primary diagnosis code for RA during the calendar year 2003 were extracted. Unique recipient numbers obtained from these claims were used to extract the corresponding prescription claims. Prevalence and health care use rates were calculated by demographic categories. Costs were reported from the perspective of WV Medicaid. RESULTS: A total of 143,211 recipients aged between 15 and 64 years received WV Medicaid benefits. Among these, 1157 recipients (0.81%) had > or = 1 medical service claim (hospitalization, emergency department visit, or office visit) with a primary diagnosis of RA. The mean (SD) age of the sample was 47 (11.1) years. The highest rates of RA by age, sex, and race occurred among recipients aged 45 to 64 years (16.4:1000), females (10.1:1000), and whites (8.2:1000). Office visits accounted for the majority of medical services visits and costs. Among the sample, 67.8% had > or =1 prescription claim for a narcotic analgesic, 58.8% for an NSAID, 48.3% for an oral steroid, 40.1% for a disease-modifying antirheumatic drug, and 12.4% for a biologic agent. Medicaid paid a mean of $2379 per recipient for RA-related health care services. Prescription claims accounted for 74.6% of the total cost of RA care. Biologic agents accounted for the largest proportion (54.1% ) of prescription costs. CONCLUSIONS: The prevalence of RA and rates of health care services utilization for RA among recipients of WV Medicaid differed with regard to demographic characteristics. Utilization of RA-related prescription medication among recipients varied by pharmacotherapy class. This study presents baseline information that might be used as a model for future surveillance RA studies using payer administrative datasets.
17968686 Analysis of SAA1 gene polymorphisms in the Greek population: rheumatoid arthritis and FMF 2007 Dec OBJECTIVE: To address whether or not the rarity of amyloidosis in Greek patients with rheumatoid arthritis (RA) is related to specific alleles of single nucleotide polymorphisms (SNPs) in the 5'-flanking region and the exon 3 of the SSA1 gene. METHODS: The genotypes of the -13T/C SNP in the 5'-flanking region of the SAA1 gene and the two SNPs within exon 3 of SAA1 (2995C/T and 3010C/T polymorphisms) were determined in 88 Greek patients with RA, 14 patients with familial Mediterranean fever (FMF) and 110 healthy controls. Linkage disequilibrium and haplotype frequencies involving -13T/C, 2995C/T and 3010C/T in these populations were tested and estimated, respectively. RESULTS: The genotypic distribution and allelic frequencies were similar in all groups tested. SNPs 2995 and 3010 were in linkage disequilibrium for all study populations (p < 0.05), whereas SNP -13 was not in linkage disequilibrium with either 2995 or 3010 (p > or = 0.05). Two major haplotypes presented in all patients with RA and FMF and controls: -13C; 2995T; 3010C (-13C; alpha) and -13C; 2995C; 3010T (-13C; beta). The -13T allele was linked with the gamma haplotype in Greek patients with RA and controls. The frequency of the -13T allele was found to be very rare in all groups tested. CONCLUSIONS: In conclusion, the rarity of the putative amyloidogenic -13T allele in Greek populations may be related to low prevalence of AA amyloidosis development in Greek RA patients.
17008343 The criterion-related validity of the Northwick Park Dependency Score as a generic nursing 2006 Oct OBJECTIVE: To investigate the criterion or concurrent validity of the Northwick Park Dependency Score (NPDS) for determining nursing dependence in different rehabilitation groups, with the Barthel Index (BI) and the Care Dependency Scale (CDS). DESIGN: Cross-sectional study. SETTING: Centre for Rehabilitation of the University Medical Center Groningen, The Netherlands. SUBJECTS: Patients after stroke, spinal cord injury, multitrauma, head injury, amputation, rheumatoid arthritis, diabetes mellitus, lung diseases, tuberculosis and coronary artery disease. One hundred and fifty-four patients were included. MEASURES: The Northwick Park Dependency Score (NPDS), the Barthel Index (BI) and the Care Dependency Scale (CDS). RESULTS: The correlation (rho) between the NPDS and the BI for all groups was -0.87; R2=0.76 (n=154). Per patient group rho varied from -0.70 (R2=0.49) to -0.93 (R2=0.86). The overall correlation between the NPDS and CDS was larger than the criterion of rho=0.60 (r=-0.74; R2=0.55) but was <0.60 in the rheumatoid arthritis and tuberculosis group. The overall correlation between BI and CDS exceeded the criterion (r=0.75; R2=0.56). CONCLUSIONS: The NPDS is a generic nursing dependency instrument that can be used as a valid measure across various patient groups in rehabilitation.
18679134 Drug allergies may be more frequent in systemic lupus erythematosus than in rheumatoid art 2008 Oct OBJECTIVE: To measure the frequency of drug allergies in patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), and register the causal drug, the type, and severity of the reaction. MATERIAL AND METHODS: Direct interview and chart review in patients with RA and SLE were conducted. We registered demographic data, drug allergies, the causal drug, how causality was assessed, and the type and severity of the allergic reaction. We include as drug allergies only those cases in which the result of exposure and re-exposure was known or in which a physician evaluating the original event established the causality link with the suspected drug. Differences between groups were assessed by chi test. RESULTS: Two hundred ninety-three RA and 58 patients with SLE were included. Fifty-three of the patients with RA (18%) and 20 of the patients with SLE (34.3%, P = 0.049) reported drug allergies. Most of them presented skin rash as their clinical expression of allergy (73%); anaphylaxis was reported in 4 cases (5%). Allergy to sulfa drugs is found more frequently in SLE (P = 0.0079). No differences were found when comparing the frequency of other drug allergies, such as penicillin and metamizole. DISCUSSION: Drug allergies are more frequent in SLE than in RA. Sulfa drugs are still the most frequent cause of drug allergies in SLE. Allergies because of drugs forbidden in the United States but easily available in specific ethnic groups are frequent in patients with SLE and RA. Their specific consumption must be intentionally assessed in cases of suspected drug allergies.
18638161 Roles and well-being among healthy women and women with rheumatoid arthritis. 2008 Jul AIM: This paper is a report of a study examining the relationships among number of roles, role quality, role stress, role balance, and psychological well-being in women diagnosed with rheumatoid arthritis. BACKGROUND: A substantial literature exists examining multiple roles in healthy women. However, less is known about multiple roles and well-being in women with a chronic illness such as rheumatoid arthritis. METHODS: A questionnaire study was conducted in 2003 examining four role-related constructs (number of roles, quality of roles, role stress, and role balance) and psychological well-being in healthy women (n = 47) and women diagnosed with rheumatoid arthritis (n = 50). Correlation coefficients and multiple regression analyses were calculated to determine the nature of the relationships among the variables. FINDINGS: The two groups were similar in demographics except for employment, with fewer women with rheumatoid arthritis employed. The two groups differed statistically significantly on psychological well-being. Women with rheumatoid arthritis had a lower mean psychological well-being score than healthy women. Regression analyses revealed that role stress was the only unique predictor of psychological well-being in healthy women, while role balance was the sole unique predictor among women with rheumatoid arthritis. CONCLUSION: Women with rheumatoid arthritis experienced lower levels of well-being than their healthy counterparts. Examination of the relationships among the variables can facilitate the development of interventions to improve these women's mental health. Nurses are in a position to assess the psychosocial needs of women with rheumatoid arthritis and assist those experiencing role stress and role imbalance.
18046771 Genetic association with rheumatoid arthritis-Genetic Analysis Workshop 15: summary of con 2007 The papers in presentation group 2 of Genetic Analysis Workshop 15 (GAW15) conducted association analyses of rheumatoid arthritis data. The analyses were carried out primarily in the data provided by the North American Rheumatoid Arthritis Consortium (NARAC). One group conducted analyses in the data provided by the Canadian Rheumatoid Arthritis Genetics Study (CRAGS). Analysis strategies included genome-wide scans, the examination of candidate genes, and investigations of a region of interest on chromosome 18q21. Most authors employed relatively new methods, proposed extensions of existing methods, or introduced completely novel methods for aspects of association analysis. There were several common observations; a group of papers using a variety of methods found stronger association, on chromosomes 6 and 18 and in candidate gene PTPN22 among women with early onset. Generally, models that considered haplotypes or multiple markers showed stronger evidence for association than did single marker analyses.
17590166 The expanding family of interleukin-1 cytokines and their role in destructive inflammatory 2007 Aug Understanding cytokine immunobiology is central to the development of rational therapies for destructive inflammatory diseases such as rheumatoid arthritis (RA) and periodontitis. The classical interleukin-1 (IL-1) family cytokines, IL-1alpha and IL-1beta, as well as IL-18, play key roles in inflammation. Recently, other members of the IL-1 family have been identified. These include six cytokines whose genes are located downstream of the genes for IL-1alpha and IL-1beta on chromosome 2 (IL-1F5-10) and also IL-33, which is the ligand for ST2, a member of the IL-1R/Toll-like receptor (TLR) receptor superfamily. IL-1F6, IL-1F8 and Il-1F9 are agonists and, along with their receptor IL-1Rrp2, are highly expressed in epithelial cells suggesting a role in immune defence in the skin and the gastrointestinal (GI) tract including the mouth. Synovial fibroblasts and articular chondrocytes also express IL-1Rrp2 and respond to IL-1F8, indicating a possible role in RA. IL-33 is associated with endothelial cells in the inflamed tissues of patients with RA and Crohn's disease, where it is a nuclear factor which regulates transcription. IL-33 is also an extracellular cytokine: it induces the expression of T helper 2 (Th2) cytokines in vitro and in vivo as well as histopathological changes in the lungs and GI tract of mice. Therapeutic agents which modify IL-1 cytokines (e.g. recombinant IL-1Ra) have been used clinically and others are at various stages of development (e.g. anti-IL-18 antibodies). This review highlights the emerging data on these novel IL-1 cytokines and assesses their possible role in the pathogenesis and therapy of destructive inflammatory disorders such as RA and periodontitis.
18572481 [Biopharmaceuticals in the treatment of rheumatoid arthritis]. 2008 Jun 9 The current status on the use of biopharmaceuticals in the treatment of rheumatoid arthritis is reviewed. Blocking of TNF-alpha, co-stimulation of CD28+ T-cells and depletion of CD20+ B-cells are all effective ways to diminish inflammation and joint damage. However, not all patients react to these treatments, and the development of biomarkers to predict which patients will benefit from these drugs is therefore warranted.
18528818 Quality of life in middle-aged and older Taiwanese patients with rheumatoid arthritis. 2008 Jun The pain, stiffness, swollen joints and progressive disability caused by rheumatoid arthritis (RA) makes it vital for healthcare providers to identify measures that enhance quality of life (QOL) for sufferers of this chronic disease. To date, very few studies have focused on QOL in middle-aged and older patients with RA in Taiwan. The purpose of this cross-sectional correlational study was to investigate the effects on QOL of disease severity, duration, pain, daily function, and sense of helplessness among middle-aged and older outpatients with RA. RA patients aged 50 and over were recruited (N = 158) from the outpatient clinic of a medical center in Taiwan. Data gathered and analyzed by hierarchical multiple regression included information on demographics, degree of pain, disease activity, daily function, and self- perception of helplessness. Length of time with RA diagnosis, severity of pain, disease activity, daily function, and sense of helplessness were found to correlate negatively with physical QOL (p < .01), and severity of pain, disease activity, daily function, and sense of helplessness were found to correlate negatively with the mental dimension of QOL (p < .01). Under hierarchical multiple regression, RA history, degree of pain, disease activity, daily function, and helplessness were found to explain 63.8% of total variance in the QOL physical component and 26.4% in the mental component. Degree of pain was the most significant factor to predict the QOL physical component (beta = -.627, p = .000). Findings of this study suggest that health care professionals should consider how best to assist patients suffering from RA to relieve pain and delay the onset of disabilities. Findings also suggest that great benefit can be realized by lessening the sense of hopelessness felt by patients.
19017546 Treatment of rheumatoid arthritis with anti-TNF-alpha agents: a reappraisal. 2009 Jan It has been found that tumour necrosis factor(TNF)-alpha plays a pivotal role in the pathogenesis of rheumatoid arthritis (RA), and the development of drugs targeting this molecule has extended the therapeutical approaches to RA patients. A number of observational studies of large patient series have also been published over the last few years, many of which have been based on national registries designed to monitor the efficacy and safety of anti-TNF agents, and allow healthcare institutions to control expenditure. Registry data can also help in identifying clinical and laboratory findings capable of predicting response. It has been suggested that the percentage of responding patients is lower in everyday clinical practice than that observed in RCTs, possibly because of patient selection, the use of a washout period before inclusion (which may artificially increase disease activity), and differences in doses, co-morbidities and adherence to therapy. A number of safety concerns have been raised since the introduction of anti-TNF agents, and they are now contraindicated in patients with advanced heart failure; however, the most widely debated current issues regard infections and neoplastic diseases. Moreover, the marketing of new and expensive biological agents has made strictly necessary to create systems capable of monitoring their safety and effectiveness in everyday practice, including the use of longitudinal observational studies. As the first published registry of anti-TNFalpha-treated patients in Italy, Lombardy Rheumatology Network (LORHEN) is already making its contribution in this direction.
15994280 Clinical practice decision tree for the choice of the first disease modifying antirheumati 2006 Jan OBJECTIVE: To elaborate a clinical practice decision tree for the choice of the first disease modifying antirheumatic drug (DMARD) for untreated rheumatoid arthritis of less than six months' duration. METHODS: Four steps were employed: (1) review of published reports on DMARD efficacy against rheumatoid arthritis; (2) inventory of the information available to guide DMARD choice; (3) selection of the most pertinent information by 12 experts using a Delphi method; and (4) choice of DMARDs in 12 clinical situations defined by items selected in step 3 (28 joint disease activity score (DAS 28): < or =3.2; >3.2 and < or =5.1; >5.1; rheumatoid factor status (positive/negative); structural damage (with/without)-that is, 3 x 2 x 2). Thus, multiplied by all the possible treatment pairs, 180 scenarios were obtained and presented to 36 experts, who ranked treatment choices according to the Thurstone pairwise method. RESULTS: Among the 77 items identified, 41 were selected as pertinent to guide the DMARD choice. They were reorganised into five domains: rheumatoid arthritis activity, factors predictive of structural damage; patient characteristics; DMARD characteristics; physician characteristics. In the majority of situations, the two top ranking DMARD choices were methotrexate and leflunomide. Etanercept was an alternative for these agents when high disease activity was associated with poor structural prognosis and rheumatoid factor positivity. CONCLUSIONS: Starting with simple scenarios and using the pairwise method, a clinical decision tree could be devised for the choice of the first DMARD to treat very early rheumatoid arthritis.