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ID PMID Title PublicationDate abstract
21429651 Bronchial inflammation, respiratory symptoms and lung function in Primary Sjögren's syndr 2011 Jul INTRODUCTION: There is no information available regarding the relationship between the respiratory symptoms or lung function and bronchial inflammation, measured by induced sputum. OBJECTIVES: Description of the clinical characteristics, radiographic images and lung function of patients suffering from Primary Sjögren Syndrome (PSS), and to assess the relationship with the inflammatory airway profile. METHODS: We analysed clinical, radiology, lung function tests, bronchial hyperresponsiveness and inflammatory data in the induced sputum from 36 consecutive patients with PSS. RESULTS: A total of 58% of patients had hoarseness and 42% had cough and dispnea. No lung dysfunction was observed, although 46% (n=16) had a positive bronchial response. Lymphocytosis >2.6% in induced sputum was observed in 69% of all sputa. There was chronic cough in 29% of patients with lymphocytosis (n=24), whereas 73% were normal (n=11) (P=.02). The duration time of cough was less for the former (P=.02). On the contrary a positive bronchial response was associated with lymphocytosis >2.6% (P=.02). Lipophages were present in 55% of pathological sputa (n=22) (index >15) versus 18% of the non-pathological ones (n=11) (P=.05). CONCLUSION: Hoarseness, cough and dyspnea are frequent respiratory symptoms in PSS, although there is a wide variation in the relationship with bronchial responsiveness and airway inflammation. Lymphocytosis in the airways is another site of the infiltrative process in PSS, and the induced sputum is a complementary tool in the identification of active inflammatory process.
23770876 An Unusual Presentation of Adult Onset Still's Disease. 2012 Oct Adult onset still's disease usually presents with high grade intermittent fever, polyarthritis, salmon pink evanescent rash and hepatosplenomegaly. Pulmonary involvement in the form of pneumonitis, as a presenting feature is very rare. We report a case of a young lady who presented with fever, cough and respiratory distress. Chest X-ray revealed patchy infiltration in left upper lung zone. She was subsequently diagnosed as Adult onset Still's disease. There was no improvement in clinical condition despite five days of antibiotics. On trans-bronchial lung biopsy (TBLB) proved she had interstitial pneumonitis and responded dramatically to steroid treatment.
22100284 Arthritis after infection with Chikungunya virus. 2011 Jun Chikungunya virus (CHIKV) is an emerging alphavirus responsible for several infectious outbreaks in the world. After an acute stage of illness characterised by a fever-arthralgia syndrome and rash, joint disorders due to CHIKV infection can sometimes persist for several months or years. Chronic arthritis after this emerging disease is well documented, and similarities to rheumatoid arthritis have been described. Knowledge of the geographical epidemiology of CHIKV infection is crucial for better control of the disease. Thus, recent outbreaks have led to several studies, which have highlighted the need for a better understanding of the clinical features of Chikungunya (CHIK) and beginning knowledge of the pathophysiogenesis, which can lead to further research.
23320166 Work productivity in rheumatoid arthritis: relationship with clinical and radiological fea 2012 Objective. To assess the relationship between work productivity with disease activity, functional capacity, life quality and radiological damage in patients with rheumatoid arthritis (RA). Methods. The study included consecutive employed patients with RA (ACR'87), aged over 18. Demographic, disease-related, and work-related variables were determined. The reduction of work productivity was assessed by WPAI-RA. Results. 90 patients were evaluated, 71% women. Age average is 50 years old, DAS28 4, and RAQoL 12. Median SENS is 18 and HAQ-A 0.87. Mean absenteeism was of 14%, presenting an average of 6.30 work hours wasted weekly. The reduction in performance at work or assistance was of 38.4% and the waste of productivity was of 45%. Assistance correlated with DAS28 (r = 0.446; P < 0.001), HAQ-A (r = 0.545; P < 0.001) and RAQoL (r = 0.475; P < 0.001). Lower total productivity was noticed in higher levels of activity and functional disability. Patients with SENS > 18 showed lower work productivity than those with SENS < 18 (50 versus 34; P = 0.04). In multiple regression analysis, variables associated with reduction of total work productivity were HAQ-A and RAQoL. Conclusion. RA patients with higher disease severity showed higher work productivity compromise.
21996051 A non-innovator version of etanercept for treatment of arthritis. 2011 Nov Etanercept is a soluble tumor necrosis factor (TNF) receptor originally approved for treatment of moderate-to-severe rheumatoid arthritis, juvenile rheumatoid arthritis, and psoriatic arthritis. We have developed a non-innovator version of the recombinant protein etanercept, with the investigational name AVG01 (trade name AVENT™), using a novel expression vector-based technology. Here we show, by extensive analytical characterization, that AVG01 is highly similar to the reference product Enbrel® and demonstrates similar efficacy in pre-clinical studies.
21626028 Changes and significance of IL-25 in chicken collagen II-induced experimental arthritis (C 2012 Aug Rheumatoid arthritis (RA) is an autoimmune inflammatory disease. It is a systemic inflammatory disease, characterized by chronic, symmetrical, multi-articular synovial arthritis. IL-25 (IL-17E) is a member of the recently emerged cytokine family (IL-17s), which is expressed in Th2 cells and bone marrow-derived mast cells. Unlike the other members of this family, IL-25 is capable of inducing Th2-associated cytokines (IL-4, IL-5, and IL-13) and also promotes the release of some pro-immune factors (IL-6 and IL-8). IL-25 is also a pleiotropic factor, which constitutes a tissue-specific pathological injury and chronic inflammation. In this study, we used chicken collagen II-induced experimental arthritis (CIA) model in DBA/1 mice to investigate the relationship between IL-25 and other inflammatory factors, revealing the possible mechanism in CIA. Our results showed that the expression level of IL-25 was enhanced in the late stage of CIA, and IL-17 was increased in the early stage of the disease. It is well known that IL-17 has a crucial role in the development of RA pathogenesis, and IL-25 plays a significant role in humoral immune. For reasons given above, we suggested that the IL-25 inhibited IL-17 expression to some extent, while enhancing the production of IL-4. It was confirmed that IL-25 not only regulated the cellular immune, but also involved the humoral immune in rheumatoid arthritis.
22904612 Sustained maintenance of clinical remission after adalimumab dose reduction in patients wi 2012 PURPOSE: The primary purpose of this study was to evaluate the proportion of psoriatic arthritis (PsA) patients maintaining clinical remission after adalimumab (ADA) dose reduction compared with patients with rheumatoid arthritis. Secondary purposes include evaluating the proportion of PsA patients who achieve remission, the duration of remission after ADA dose reduction, time to relapse, psoriasis course, and the frequency of adverse events at the end of follow-up. METHODS: This was a single-center, prospective, follow-up, case-control study of 76 consecutive patients (35 females, 41 males; mean age 46 ± 10.2 years) who met the classification criteria for psoriatic arthritis and required anti-tumor necrosis factor therapy according to Group for Research and Assessment of Psoriasis and Psoriatic Arthritis recommendations. The 76 patients were compared with 55 patients (40 females, 15 males; mean age 50 ± 11.6 years) who satisfied the American College of Rheumatology criteria for rheumatoid arthritis and received the same treatment. Case patients and controls were recruited from January 2008 to December 2010. At baseline, PsA patients and controls received 40 mg of ADA every other week, usually with methotrexate (10 to 20 mg/weekly). In the presence of clinical remission, ADA dose was reduced to 40 mg every 4 weeks in both groups. RESULTS: Fifty-three of the 76 (69.7%) PsA patients and 17 of the 55 (30.9%) rheumatoid arthritis (P < 0.019) controls achieved remission after a mean time of 5.1 ± 1.2 and 6.3 ± 1.6 months, respectively (P = nonsignificant). After halving the dose of ADA, 47 of the 53 (88.6%) PsA patients and three of the 17 (17.6%) controls maintained remission (P = 0.016) over a mean follow-up period of 28.9 ± 8.4 and 24.2 ± 6.4 months, respectively. No significant changes in Psoriatic Arthritis Severity Index scores were observed. The mean time to relapse was 8.3 ± 3.4 months in six case patients and 7.2 ± 4.2 in 14 controls (P = not significant). No serious adverse events occurred in either group. CONCLUSION: Clinical remission is possible in a high percentage of patients with early PsA receiving ADA. Such remission is maintained in a high proportion of subjects after ADA dose halving, with relevant advantages in terms of patient compliance, drug-exposure risk, and economic burden.
23055009 Role of Tai Chi in the treatment of rheumatologic diseases. 2012 Dec Rheumatologic diseases (e.g., fibromyalgia, osteoarthritis, and rheumatoid arthritis) consist of a complex interplay between biologic and psychological aspects, resulting in therapeutically challenging chronic conditions to control. Encouraging evidence suggests that Tai Chi, a multi-component Chinese mind-body exercise, has multiple benefits for patients with a variety of chronic disorders, particularly those with musculoskeletal conditions. Thus, Tai Chi may modulate complex factors and improve health outcomes in patients with chronic rheumatologic conditions. As a form of physical exercise, Tai Chi enhances cardiovascular fitness, muscular strength, balance, and physical function. It also appears to be associated with reduced stress, anxiety, and depression, as well as improved quality of life. Thus, Tai Chi can be safely recommended to patients with fibromyalgia, osteoarthritis, and rheumatoid arthritis as a complementary and alternative medical approach to improve patient well-being. This review highlights the current body of knowledge about the role of this ancient Chinese mind-body medicine as an effective treatment of rheumatologic diseases to better inform clinical decision-making for our patients.
21755025 Definition of nonresponse to analgesic treatment of arthritic pain: an analytical literatu 2011 Our objective was to develop a working definition of nonresponse to analgesic treatment of arthritis, focusing on the measurement of pain on the 0-100 mm pain visual analog scale (VAS). We reviewed the literature to assess the smallest detectable difference (SDD), the minimal detectable change (MDC), and the minimal clinically important difference (MCID). The SDD for improvement reported in three studies of rheumatoid arthritis was 18.6, 19.0, and 20.0. The median MDC was 25.4 for 7 studies of osteoarthritis and 5 studies of rheumatoid arthritis (calculated for a reliability coefficient of 0.85). The MCID increased with increasing baseline pain score. For baseline VAS tertiles defined by scores of 30-49, 50-65, and >65, the MCID for improvement was, respectively, 7-11 units, 19-27 units, and 29-37 units. Nonresponse can thus be defined in terms of the MDC for low baseline pain scores and in terms of the MCID for high baseline scores.
23201923 Type I interferons in Sjögren's syndrome. 2013 Mar Sjögren's syndrome is a chronic autoimmune disease characterized by lymphocytic infiltration of the salivary and lachrymal glands resulting in dry eyes and mouth. Genetic predisposition, pathogenic infections and hormones have been implicated in the pathogenesis of the disease. Studies in the last several years have revealed marked over-expression of the type I interferon (IFN)-inducible genes in the peripheral blood and salivary glands of patients with Sjögren's syndrome. The expression of the type I IFN-inducible genes in Sjögren's syndrome also positively correlates to titers of anti-Ro and anti-La autoantibodies, which are typical for this disease. Plasmacytoid dendritic cells (pDC) are the major source of type I IFN production and activated pDC are detected in minor salivary gland biopsies from patients with primary Sjögren's syndrome. In addition, polymorphisms in genes important both for the production and response to type I IFN are associated to increased risk for Sjögren's syndrome. Because type I IFN bears a variety of biological functions, such as defense against viral infections and activation of the immune system, these results suggest that the type I IFN system has an important role in the pathogenesis of Sjögren's syndrome. A variety of mechanisms causing an activation of the type I IFN system are discussed in this review. Given the pivotal role of type I IFN in the disease process, therapeutic interventions targeting the type I IFN signaling pathway have the potential to benefit the patients with elevated type I IFN status and such hypothesis needs to be carefully evaluated in clinical development.
22365784 Outcome measures for primary Sjögren's syndrome. 2012 Aug Lymphocytic infiltration of different exocrine and non-exocrine epithelia is the pathological hallmark of primary Sjögren's syndrome, whereas involvement of salivary and lachrymal glands with the clinical counterpart of dry eye and dry mouth are the predominant features of the disease, together with fatigue and musculoskeletal pain. In addition, systemic manifestations, like arthritis, skin vasculitis, peripheral neuropathy, glomerulonephritis, may also be present in a consistent number of patients. As result, clinical features in SS can be divided into two facets: the benign subjective but disabling manifestations such as dryness, pain and fatigue, and the systemic manifestations. In the past decades, a core set of domains, which included sicca symptoms, objective measurements of tear and saliva production, fatigue, quality of life, disease activity and damage was indicated as essential for outcome assessment in this disorder. Afterwards, great efforts have been made to develop valid tools for the assessment of different domains. Specific questionnaires such as the Profile of Fatigue and Discomfort (PROFAD) and Sicca Symptoms Inventory (SSI) have been proposed as dedicated tools for the evaluation of patients symptoms, whereas different composite indexes have been suggested for the assessment of disease activity and damage. Some of these preliminary studies served as bases of an international project supported by EULAR, aimed at developing two consensus disease activity indexes: the EULAR Sjögren's Syndrome Patients Reported Index (ESSPRI), and the EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI), a systemic activity index to assess systemic manifestations. A detailed and critical review of all these indexes is provided in this article. Both EULAR indexes showed, in recent studies, to be feasible, valid, and reliable instruments. After their final validation, which is currently in process, they could be used as consensus outcome criteria in therapeutic trials and in clinical practice.
21874354 Anti-arthritic effect of GN1, a novel synthetic analog of glucosamine, in the collagen-ind 2011 Dec OBJECTIVE: Glucosamine is a naturally occurring amino monosaccharide that maintains the elasticity and strength of the cartilage tissues. It has been used to treat osteoarthritis in humans; however, in severe conditions of inflammation and pain, glucosamine alone is not enough, and it is important to improve its biological activity. Our research group has recently taken an interest in the synthetic manipulation of amino sugars to develop some efficient pharmacophores, e.g., β-D-glucosamine, to combat rheumatoid arthritis, and tested its anti-arthritic effects in the collagen-induced arthritis (CIA) model in rats. METHODS: Arthritis was induced in female Sprague-Dawley rats by multiple intradermal injections of bovine type II collagen and challenged again with the same antigen preparation 7 days later. Arthritis was evaluated by arthritic score, body weight loss, paw volume measurement, and histological changes. RESULTS: The animals in the arthritic control group showed a gradual decrease in their body weight and concurrent increase in the paw volumes compared to the normal control group. In contrast, increased hind paw swelling was significantly suppressed with no further noticeable reduction in body weight in the glucosamine (p < 0.05) and GN1-treated (p < 0.02) arthritic animals. Histopathological evaluation of isolated knee joints by grading system and classification of the stages in arthritic lesion development revealed suppression of the inflammatory changes in the GN1-treated animals. Moreover, both the pro-inflammatory markers C-reactive protein (CRP) and low-density lipoprotein (LDL) levels were found to be significantly decreased in animals treated with GN1 (p < 0.03 for CRP and p < 0.05 for LDL) compared to the arthritic control group. CONCLUSION: These results suggest that GN1 has both anti-arthritic and anti-inflammatory properties. Its effects in the CIA model suggest that it could be useful in the treatment of rheumatoid arthritis.
21497524 Genetics and genomics of Sjögren's syndrome: research provides clues to pathogenesis and 2011 Jun PURPOSE: Although the key inciting events that drive the progression from autoantibodies to clinical disease remain to be clarified, new light has been shed on the factors contributing to disease susceptibility and the role of genetic factors in determining Sjögren's syndrome (SS) disease phenotypes. The purpose of this article is to provide an update on the role of genetic markers in the susceptibility to and pathogenesis of SS. This article also discusses how genomic and proteomic technology can help in the design of specific therapeutics. KEY FINDINGS: Recent evidence suggests that inflammatory genes associated with interferon pathways, and specific regulatory genes that control the maturation and proliferation of B cells, contribute to the pathogenesis of SS. Both gene expression profiling technology and gene association studies have been used to identify these key biological pathways. Molecularly, defined subsets of pSS patients are also being revealed by these studies. Previously, identified gene loci that predispose to multiple autoimmune disorders have been confirmed supporting the paradigm of "general" autoimmune disease genes. Association of SS with many additional susceptibility loci are likely to be established through ongoing genome-wide association scans (GWAS). Clues from genetic studies suggest that targeting B cells will prove to be an effective way of reducing the systemic manifestations of pSS and are supported by early clinical trials. SUMMARY: Genome-wide technologies are likely to identify new genes and molecular pathways in the pathogenesis of SS that will be useful not only to identify patients at risk for SS, but also to identify subsets of patients at risk for variable levels of disease severity. In the future, these studies could identify novel biomarkers that will lead to significant advances in management by providing the means to tailor therapeutic strategies to individual patients.
22258489 Responsiveness of disease activity indices ESSPRI and ESSDAI in patients with primary Sjö 2012 Aug OBJECTIVE: To evaluate the responsiveness of the EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI) and EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI) in patients with primary Sjögren's syndrome (pSS) treated with rituximab. METHODS: Twenty-eight patients with pSS treated with rituximab (1000 mg) infusions on days 1 and 15 were included in the study. Data were collected prospectively at baseline and 16, 24, 36, 48 and 60 weeks after treatment. Internal responsiveness was assessed using standardised response means (SRM) and effect sizes (ES). SRM and ES <0.5, 0.5-0.8 and >0.8 were interpreted as small, moderate and large, respectively. External responsiveness was assessed using Spearman correlation coefficients. RESULTS: Median (range) ESSPRI and ESSDAI scores at baseline were 6.7 (0.3-9.0) and 8 (2-18), respectively. Both indices improved significantly after treatment. SRM and ES values for ESSPRI and ESSDAI were ≥0.8 at week 16 and decreased afterwards, and were larger for ESSDAI than for ESSPRI. SRM and ES values for patient's and physician's global disease activity (GDA) and rheumatoid factor broadly followed the pattern of those of ESSPRI and ESSDAI. SRM and ES for stimulated whole salivary flow were small at all time points. At baseline and for most change scores, moderate to good correlations were found between ESSPRI and patient's GDA and between ESSDAI and physician's GDA. Poor association was found between ESSPRI and ESSDAI. CONCLUSIONS: ESSPRI and ESSDAI are sensitive measures of change in disease activity after therapeutic intervention, which supports the usefulness of these indices for future clinical trials in patients with pSS. The responsiveness of ESSDAI was greater than that of ESSPRI.
21345815 EULAR Sjogren's Syndrome Patient Reported Index (ESSPRI): development of a consensus patie 2011 Jun OBJECTIVES: To develop a score for assessment of patients' symptoms in primary Sjögren's syndrome (SS): the EULAR SS Patient Reported Index (ESSPRI). METHODS: Dryness, pain, somatic and mental fatigue were identified as the main symptoms of patients with primary SS, in studies developing the Profile of Fatigue and Discomfort (PROFAD) and Sicca Symptoms Inventory (SSI). It was suspected that a single 0-10 numerical scale for each domain was sufficient to assess these symptoms. These four scales were gathered to form the ESSPRI. 230 patients, from 12 countries completed the ESSPRI, SSI and PROFAD questionnaires and a 0-10 patient global assessment (PGA). Correlations between each symptom and PGA were obtained. Multiple regression modelling, using PGA as 'gold standard' was used to select domains and estimate their weights. RESULTS: PGA had good correlation with dryness, limb pain, fatigue and mental fatigue (r=0.49-0.59, all p<0.0001), but correlated less well with individual dryness features. In multivariate analysis, dryness, limb pain and fatigue, but not mental fatigue, were significantly associated with PGA; weights derived from the regression were identical for these three domains. Thus, ESSPRI was redefined as the mean of the three scales: dryness, limb pain and fatigue. Lastly, ESSPRI significantly correlated with PGA (r=0.70), PROFAD (r=0.73) and SSI (r=0.66). CONCLUSION: ESSPRI is a very simple index designed to measure patients' symptoms in primary SS. It has good construct validity and is well correlated with SSI and PROFAD. ESSPRI should now be validated for use as an outcome measure in clinical trials.
21670967 Adult-onset Still's disease with macrophage activation syndrome successfully treated with 2012 Feb We report a 16-year-old female case of intractable adult-onset Still's disease accompanied by macrophage activation syndrome, who went into full remission after switching from infliximab to etanercept. Although the disease promptly relapsed when etanercept was discontinued, she again responded fully upon the reintroduction of etanercept. Furthermore, the effect of etanercept was apparently enhanced by combining it with a sufficient dose of methotrexate. This combination therapy should be considered as one of treatment options for the disease.
21134433 Ex vivo and in vivo effect of Chinese herbal pill Yi Shen Juan Bi (YJB) on experimental ar 2011 Mar 8 AIM OF THIS STUDY: Chinese herbal pill Yi Shen Juan Bi (YJB), which is a compound herbal drug, has traditionally been used as an anti-rheumatic drug in Chinese local clinics. Thus, we investigated the therapeutic effect of the YJB in rheumatoid arthritis (RA), using Freund's complete induced adjuvant arthritis (AA) in rat model. METHODS: For that purpose, macrophage derived cytokine tumor necrosis factor alpha (TNF-α) and interleukin-1 (IL-1) were measured in ex vivo by enzyme linked immunosorbent assay (ELISA). We also assayed the effect of YJB on peritoneal macrophage derived nitric oxide (NO) in ex vivo by Griess reaction. Prostaglandin E (PGE) in metapedes was assayed by ultraviolet spectrophotometer method. Further synovial Bax level was examined by Western blot analysis. RESULTS: YJB significantly decreased the production of peritoneal macrophages derived TNF-α, IL-1 and NO. YJB also significantly decreased prostaglandin E (PGE) and upregulated the Bax expression in AA rat's synovium. CONCLUSION: YJB is a potential anti-rheumatic agent targeting the inflammatory and immunomodulatory response of macrophages while down regulating the PGE and up-regulating the pro-apoptotic Bax expression. Such characteristics of YJB on AA may be advantageous to the treatment of clinical rheumatoid arthritis.
23403612 Shuangtengbitong tincture treatment of collagen-induced arthritis via downregulation of th 2013 Feb Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease and may lead to joint damage, synovial membrane destruction and cartilage and bone damage. RA is closely associated with increased expression of interleukin (IL)-6, IL-8, tumor necrosis factor-α (TNF-α) and nuclear transcription factor-κB (NF-κB). Therefore, inhibition of the expression of IL-6, IL-8, TNF-α and NF-κB is a promising strategy for the development of novel anti-RA therapies. The aim of this study was to investigate the effect of shuangtengbitong tincture (STBT) on the expression of IL-6, IL-8, TNF-α and NF-κB in synovial tissues of rats with collagen-induced arthritis (CIA). STBT as a clinical prescription created at Fujian University of Traditional Chinese Medicines (TCM) Affiliated People's Hospital has been shown to be clinically effective in the treatment of RA. The model of Wistar rats with CIA was created using bovine type II collagen. The two treatment groups with CIA were administered STBT (1 ml per time) or Votalin (∼1 cm per time) for ∼1 month continuously. Following treatment, STBT suppressed paw swelling significantly (P<0.05) compared with the model group. STBT also improved pathological changes, STBT-treated rats showed a significant improvement in synovial hyperplasia, inflammatory infiltration, cartilage and bone destruction and other symptoms. The protein expression levels of IL-6, IL-8, TNF-α and NF-κB were markedly suppressed in synovial tissues of STBT-treated and Votalin-treated rats. Our findings demonstrate for the first time that STBT markedly reduces paw swelling, improves pathological changes and increases the expression of IL-6, IL-8, TNF-α and NF-κB in synovial tissues of CIA rats, which may partially explain the anti-RA activity of STBT.
20237930 Successful treatment with intravenous immunoglobulin of severe thrombocytopenia complicate 2012 May Sjogren's syndrome (SS) is a systemic autoimmune disease characterized by xerophthalmia, xerostomia and extraglandular manifestations. Anemia, leukopenia, thrombocytopenia and lymphoproliferative disorders, including lymphoma are well-known extraglandular, hematological complications of SS. We report here a rare case of patient with primary SS who developed pancytopenia with severe thrombocytopenia as an initial manifestation and successfully treated with IV immunoglobulin (IVIG). The present case suggests that pancytopenia with severe thrombocytopenia can be a difficult-to-treat abnormality, and initial manifestation of primary SS and IVIG might be an effective treatment for severe thrombocytopenia refractory to high-dose steroid in primary SS.
22463929 Changing Crohn's disease management: need for new goals and indices to prevent disability 2012 Feb Crohn's disease is a destructive, inflammatory condition. The recent IMPACT survey showed that it has a major impact on quality of life including fatigue, relationships and employment. Although patients are generally satisfied with healthcare services, improvements are needed in the timeliness of diagnosis and in communication between patients and healthcare professionals. Evidence is lacking about what constitutes quality of care and value to patients. Moving forward, value should become the primary goal of healthcare delivery, which is likely to require new treatment goals. Indeed, goals are already evolving beyond symptom control towards deep remission, which encompasses clinical remission together with mucosal healing. The ultimate goals are to prevent bowel damage, reduce long-term disability and maintain normal quality of life. A new treat-to-target approach, with increased monitoring and tighter control of symptoms and inflammation, will be needed. This approach will be enabled by use of biomarkers and new indices such as the Lémann score, which assesses the extent and severity of bowel damage at a specific time-point and over time, and a new disability index for patients with inflammatory bowel disease. These principles have been adopted for managing rheumatoid arthritis where there is now a focus on treat-to-target to achieve early remission. Lessons from rheumatoid arthritis can be translated to Crohn's disease.