Patient-defined flares and disease activity worsening in 222 patients with psoriatic arthritis from 14 countries

ObjectivesTo explore patient-defined flares in psoriatic arthritis (PsA), compared to an increase in disease activity in psoriatic arthritis (DAPSA) and to analyze the validity of a patient-reported flare question.MethodsReFlap (NCT03119805) was a longitudinal study in 14 countries of consecutive patients with definite PsA. Patients were seen twice in the context of usual care, 4.5 ± 2.2 months apart. Flares were reported by patients and physicians at the second visit using a single question. DAPSA worsening was defined as a change to a higher DAPSA category. Agreement between the definitions of worsening was calculated by prevalence adjusted bias adjusted kappa (PABAK). Validity of patient-reported flare was assessed by comparing patients with versus without flare and transition to flares.ResultsIn 222 patients, mean disease duration 10.8 ± 8.3 years, 127 (58.8%) males: disease activity was low (mean DAPSA 11.5 ± 14.0); 63.3% received a bDMARD. Patient-reported flares between the 2 visits were seen in 27% patients (for these patients, mean 2.2 ± 3.7 flares per patient, mean duration 12.6 ± 21.0 days per flare). Physician- reported flares were seen in 17.6% and worsening in DAPSA in 40.1% of patients. Agreement between definitions was moderate (PABAK = 0.32-0.59). Patients in flare had significantly more active disease than patients not in flare for all outcomes (all P < 0.001). At the patient-level, transition to flare state was associated to a worsening in disease activity and impact outcomes.ConclusionsPatient flares were frequent and were associated with active and symptomatic disease. These findings provide preliminary validation for patient-reported flares in PsA.     

Atherosclerosis progression in psoriatic arthritis patients despite the treatment with tumor necrosis factor-alpha blockers: A two-year prospective observational study

ObjectiveTo evaluate the progression of subclinical atherosclerosis in Psoriatic Arthritis (PsA) patients treated with anti-tumor necrosis factor (TNF)-α agents.MethodsThirty-two PsA patients classified according to the CASPAR criteria and attending the Rheumatology Unit of the University of Padua Medical Center were enrolled in a two-year prospective, observational study. In accordance with the ASAS/EULAR recommendations on the management of these patients, those studied were prescribed biological agents [etanercept (n = 21), adalimumab (n = 6), infliximab (n = 5)]. Plasma lipids, inflammatory biomarkers, including C-reactive protein (CRP), interleukin-6 (IL-6), vessel endothelium growth factor (VEGF), osteoprotegerin (OPG), and TNF-α, as well as Disease Activity Score 28 calculated with CRP (DAS 28-CRP) were evaluated at baseline and after two years of treatment. Bilateral carotid B-mode ultrasound measurements [the mean-intima media thickness (mean-IMT), the mean maximum-IMT (M-Max)] of each carotid artery segment (common, bulb, and internal carotid artery) and the post-occlusion flow-mediated dilation (FMD) of the brachial artery were also assessed at baseline and after two years.ResultsDespite an improvement in the DAS 28-CRP score (P < 0.0005) and lower low-density lipoprotein cholesterol (P < 0.013) and triglyceride (P < 0.036) values, there was a significant progression in both the mean-IMT (P < 0.0005) and M-Max (P < 0.0005). Moreover, no recovery in FMD (P = ns) was observed after two years of anti TNF-α treatment. Serum TNF-α levels were increased (P = 0.003) and OPG values were decreased (P = 0.011) at the end of follow- up with respect to baseline values.ConclusionsDespite improvement in clinical status, arterial remodelling was observed in the PsA patients who were treated with anti TNF-α agents for two years.     

Impact of key manifestations of psoriatic arthritis on patient quality of life,functional status,and work productivity: Findings from a real-world study in the United States and Europe

ObjectivesTo determine the individual impact of key manifestations of psoriatic arthritis (PsA) on quality of life (QoL), physical function, and work disability.MethodsData from the Adelphi 2018 PsA Disease-Specific Programme, a multinational, cross-sectional study of PsA patients, were used. PsA manifestations included peripheral arthritis (number of joints affected), psoriasis (body surface area [BSA]), axial involvement (inflammatory back pain [IBP] and sacroiliitis) enthesitis, and dactylitis. General, and disease-specific QoL, physical function, and work disability were measured with EQ-5D-5L, PsAID-12, HAQ-DI, and WPAI, respectively. Multivariate regression adjusting for potential confounders evaluated the independent effect of PsA manifestations on each outcome.ResultsAmong the 2222 PsA patients analysed, 77.0% had active psoriasis and 64.4% had peripheral arthritis; 5.9%, 6.8%, 10.2%, and 3.6% had enthesitis, dactylitis, IBP, or sacroiliitis, respectively. Mean EQ VAS scores were significantly poorer in patients with vs. without enthesitis (59.9 vs. 75.6), dactylitis (63.6 vs. 75.4), and with greater peripheral joint involvement (none: 82.5; 1–2 affected joints: 74.1; 3–6 joints: 74.2; > 6 joints: 65.0). Significantly worse mean PsAID-12 scores were associated with vs. without enthesitis (4.39 vs. 2.34) or dactylitis (4.30 vs. 2.32), and with greater peripheral joint involvement (none: 1.21; 1–2 joints: 2.36; 3–6 joints: 2.74; > 6 joints: 3.92), and BSA (none: 1.49; > 3–10%: 2.96; > 10%: 3.43). Similar patterns were observed with HAQ-DI and WPAI scores.ConclusionMost PsA manifestations were independently associated with worse general, and PsA-specific QoL, physical function, and work disability, highlighting the need for treatments targeting the full spectrum of PsA symptoms to lower the burden of disease.     

Análise da associação da fadiga com variáveis clínicas e psicológicas em uma série de 371 pacientes brasileiros com artrite reumatoide

ObjectivesFatigue is a highly subjective and extremely common symptom in patients with rheumatoid arthritis although it is difficult to characterize and define. The aim of this study was to assess fatigue in a cohort of Brazilian patients, and to analyze the relationship between fatigue and disease‐specific variables.Methods371 Brazilian patients diagnosed with rheumatoid arthritis according to the 1987 American College of Rheumatology classification criteria were prospectively investigated. Demographic, clinical and laboratorial data were obtained from hospitals records. The number of painful joints, bone mass index, disease duration, quality of life, functional capacity, anxiety and depression were recorded. Fatigue was evaluated using the subscale of Fatigue Assessment of Chronic Illness Therapy (FACIT‐FATIGUE scale).ResultsThe median fatigue score was 42.0 (10.0), negatively correlated with functional capacity (‐0.507; P < 0.001), anxiety and depression (‐0.542 and ‐0.545; P < 0.001 respectively), and predominantly with physical domain of Short Form 36‐item quality of life questionnaire (SF‐36P: 0.584; P < 0.001). The scores were not associated with the erythrocyte sedimentation rate (‐0.118; P < 0.05), C‐reactive protein (‐0.089; P < 0.05), disease activity (‐0.250; P < 0.001) or the number of painful joints (‐0.135; P < 0.01). Confidence interval of 95% was applied for all measures.ConclusionsIn this series of Brazilian patients with rheumatoid arthritis, we suggest a new significance for fatigue complains as an independent parameter not related with number of painful joints, disease or inflammatory activity scores. Psychological and functional impairments appear to be more related to fatigue. Additional studies and inclusion of standard measures for monitoring fatigue complains are required.     

Quality of sleep in patients with chronic low back pain: a case-control study

Animal experiments and studies in humans clearly show that the relation between pain (acute and chronic) and sleep quality is two-way: sleep disorders can increase pain, which in turn may cause sleep disorders. Sleep disorders and chronic low back pain are frequent health problems and it is unsurprising that the two can co-exist. This study was conducted to evaluate if sleep disorders and chronic pain associated are more frequently than one would expect. The objective of the study was to compare sleep quality in a population of patients with chronic low back pain and a control population. Sleep quality was assessed in 101 patients with chronic low back pain (CLBP) and in 97 sex- and age-matched healthy control subjects using the Pittsburgh Sleep Quality Index [PSQI; score from 0 (no disorder) to 21]. The French version of the Dallas Pain Questionnaire (DPQ) was used to assess the impact of low back pain on patients’ quality of life. This impact was taken as nil in the healthy controls. The patients with CLBP and the controls were comparable in age, sex, and height, but mean bodyweight was higher in the CLBP group (70.3 ± 14.5 vs. 61.8 ± 11.4 kg; P < 0.05). The patients with CLBP were also more frequently on sick leave than the controls (32.3%; n = 31 vs. 0.0% n = 0; P < 0.001). Coffee, tea, and cola intakes were comparable in the two groups. Patients with CLBP had statistically higher scores in all items of the PSQI than the healthy controls. The mean PSQI was 4.7 ± 3.2 for the healthy controls and 10.9 ± 7.9 for the patients with CLBP (P < 0.0001). Sleep disorders were greater when the impact of CLBP on daily life (the four aspects of the DPQ) was greater [P < 0.0001]). The sleep of the patients with CLBP was significantly altered compared with that of the healthy controls, in proportion to the impact of low back pain on daily life. Our findings do not indicate whether sleep disorders are a cause or a consequence of CLBP. The exoirements comply with the current laws of the country in which it was performed.     

Effect of biologics on fatigue in psoriatic arthritis: A systematic literature review with meta-analysis

Objectives

Fatigue is a significant issue in psoriatic arthritis. The objective was to assess the effect of biological disease modifying antirheumatic drugs and apremilast on fatigue in psoriatic arthritis randomised controlled trials and to compare this effect with the effect in the same trials, on pain, through a systematic literature review and meta-analysis.

The relationship between kinesiophobia and health-related quality of life in patients with rheumatoid arthritis: A controlled cross-sectional study

ObjectivesTo evaluate the kinesiophobia and kinesiophobia-related factors in patients with rheumatoid arthritis (RA) and provide a better perspective on the relationship between kinesiophobia and patients’ health-related quality of life (HRQoL).MethodsA total of 88 patients (67 females, 21 males) with RA and 93 healthy volunteers (67 females, 26 males) were included in the study between March 2020 and July 2020. Kinesiophobia was evaluated using the Tampa Scale of Kinesiophobia (TSK) and HRQoL was evaluated using the 36-item Short-Form Health Survey (SF-36). The Fatigue Severity Scale (FSS), Beck Depression Inventory (BDI), Health Assessment Questionnaire Disability Index (HAQ-DI), International Physical Activity Questionnaire (IPAQ) (Short Form) were completed by all participants.ResultsThe median age was 52.0 (IQR, 45.0-58.0) years in the RA group and 50.0 (IQR, 41.5-56.0) years in the control group. Age and sex were not significantly different between the groups. The median TSK score was 45.0 (IQR, 39.0-49.75) in the RA group, 39.0 (IQR, 37.0-43.0) in the control group (P < 0.001). The median FSS, BDI, and HAQ-DI scores were higher and the median HRQoL domains were lower in the RA group than in the control group (P < 0.05). Multivariate linear regression analysis including age, sex, education level, body mass index (BMI), morning stiffness duration, Disease Activity Score in 28 joints, FSS, BDI, visual analog scale and IPAQ scores variables showed that FSS scores (B = 1.07, P < 0.05), BDI scores (B = 0.24, P < 0.05), and BMI (B = 0.22, P < 0.05) were independent variables for kinesiophobia in patients with RA (R² = 0.32). TSK was a predictive variable for HAQ-DI (B = 0.03, P < 0.001), the physical functioning domain of the HRQoL (B = -1.18, P < 0.001), the bodily pain domain of the HRQoL (B = -0.78, P < 0.05), respectively.ConclusionPhysicians should have awareness of kinesiophobia in patients with RA. Educating patients about kinesiophobia, developing strategies for avoiding kinesiophobia, and specific treatment strategies with a multidisciplinary approach may improve HRQoL and disability.     

Ultrasound evaluation of synovitis in RA: Correlation with clinical disease activity and sensitivity to change in an observational cohort study

ObjectiveTo evaluate the correlation between clinical measures of disease activity and a ultrasound (US) scoring system for synovitis applied by many different ultrasonographers in a daily routine care setting within the Swiss registry for RA (SCQM) and further to determine the sensitivity to change of this US Score.MethodsOne hundred and eight Swiss rheumatologists were trained in performing the Swiss Sonography in Arthritis and Rheumatism (SONAR) score. US B-mode and Power Doppler (PwD) scores were correlated with DAS28 and compared between the clinical categories in a cross-sectional cohort of patients. In patients with a second US (longitudinal cohort), we investigated if change in US score correlated with change in DAS and evaluated the responsiveness of both methods.ResultsIn the cross-sectional cohort with 536 patients, correlation between the B-mode score and DAS28 was significant but modest (Pearson coefficient r = 0.41, P < 0.0001). The same was true for the PwD score (r = 0.41, P < 0.0001). In the longitudinal cohort with 183 patients we also found a significant correlation between change in B-mode and in PwD score with change in DAS28 (r = 0.54, P < 0.0001 and r = 0.46, P < 0.0001, respectively). Both methods of evaluation (DAS and US) showed similar responsiveness according to standardized response mean (SRM).ConclusionsThe SONAR Score is practicable and was applied by many rheumatologists in daily routine care after initial training. It demonstrates significant correlations with the degree of as well as change in disease activity as measured by DAS. On the level of the individual, the US score shows many discrepancies and overlapping results exist.     

Assessment of the functional impact of foot involvement in patients with rheumatoid arthritis

Aim of the workWe aimed to evaluate the impact of foot involvement in patients with rheumatoid arthritis (RA) using the functional foot index (FFI) and to identify predictive factors of the functional impact of foot abnormalities in RA patients.Patients and methodsThis was a cross-sectional study including patients with RA meeting the criteria of the American College of Rheumatology and the European League Against Rheumatism 2010. The main epidemiological data, results of podoscopic and clinical examination of the foot and ankle, biological tests and radiological findings were collected. The presence of foot pain was assessed by a visual analogic scale (0–10), and the functional impact of foot involvement was assessed based on the validated French version of the FFI.ResultsFifty RA patients with an average age of 59.3 ± 9.9 years [39–79] were included, and 80% of them had foot involvement. Foot pain was present in 32 patients (64%), most frequently situated in the forefoot (56%). The average FFI score was 33.67 ± 30.53 [0–92.67]. The following factors had a significant association with the FFI score: an occupation soliciting the feet (p = 0.001), disease duration (p = 0.033, r = 0,302), the Health Assessment Questionnaire (p = 0.0001, r = 0,480), body mass index (p = 0.0001, r = 0,654), the presence of podiatric abnormalities (p = 0.0001) and Visual Analog Scale foot pain (p = 0.0001, r = 0,854). A significant association was also found between the FFI score and the presence of a hallux valgus (p = 0.004), a spread of the forefoot (p = 0.029), a claw of the toes (p = 0.002), a triangular forefoot (p = 0.0001), a quintus varus (p = 0.002), flat feet (p = 0.0001) and a valgus of the hindfoot (p = 0.001).ConclusionDue to the high frequency of foot involvement and its significant functional impact, meticulous examination of the feet and assessment of their functional impact must be one of the parameters for monitoring the disease. Its impact on one’s quality of life can be important.Level of clinical evidence4 (cohort studies, non experimental, observational studies).     

2022 French Society for Rheumatology (SFR) recommendations on the everyday management of patients with spondyloarthritis,including psoriatic arthritis

ObjectiveUpdate the French Society for Rheumatology (SFR) recommendations on the everyday management of patients with spondyloarthritis, including psoriatic arthritis.MethodsFollowing standardized procedures, a systematic literature review was done by four supervised rheumatology residents based on questions defined by a task force of 16 attending rheumatologists. The findings were reviewed during three working meetings that culminated in each recommendation receiving a grade and the level of agreement among experts being determined.ResultsFive general principles and 15 recommendations were developed. They take into account pharmacological and non-pharmacological measures along with treatment methods based on the dominant phenotype present (axial, articular, enthesitis/dactylitis) and the extra-articular manifestations (psoriasis, inflammatory bowel disease, uveitis). NSAIDs are the first-line pharmacological treatment in the various presentations. Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) are not indicated in the axial and isolated entheseal forms. If the response to conventional treatment is not adequate, targeted therapies (biologics, synthetics) should be considered; the indications depend on the clinical phenotype and presence of extra-articular manifestations.ConclusionThis update incorporates recent data (published since the prior update in 2018) and the predominant clinical phenotype concept. It aims to help physicians with the everyday management of patients affected by spondyloarthritis, including psoriatic arthritis.     

Poor sleep in organ transplant recipients: self‐reports and actigraphy

Solid organ transplant recipients are at increased risk of poor sleep due to pharmacotherapy and co‐morbidities, but sleep problems are often unrecognized and untreated. Study aims were to measure rates of occurrence, characteristics, and correlates of poor sleep in recipients. The Pittsburgh Sleep Quality Index (PSQI) and sleep parameters measured by wrist actigraphy were obtained at baseline from 143 kidney, liver, heart, lung, or pancreas transplant recipients enrolled in a psychosocial intervention trial to improve symptoms and quality of life. Rates of poor sleep were determined using accepted clinical cutoffs; 41% (58 of 143) were poor sleepers (PSQI > 8) and 36% used sleep medications in the past month. Fifteen percent reported having obstructive sleep apnea (OSA) and 4% reported restless legs syndrome (RLS). Based on actigraphy (n = 73), 69% lacked sleep efficiency (SE), 32% took >30 min to fall asleep, 88% awakened during the night for more than 30 min, and 25% slept less than six h per night. Obesity and use of psychotropics or sleep medications, and pain were independent risk factors for poor objectively measured sleep. Poor sleep is an undertreated problem in transplantation. Screening for sleep problems and behavioral therapies with sleep hygiene instruction may benefit recipients.     

The investigation of sleep quality and the quality of life in end-stage renal disease patients

Objective To evaluate the sleep quality as well as the quality of life in end-stage renal disease (ESRD) patients, analyze the relationships between them and explore the influence factors. Methods A total of 141 ESRD patients from three hospitals were enrolled. The patients' general information including age, gender, degree of education, income, primary disease and years on dialysis were collected. Pittsburgh Sleep Quality Index (PSQI) was used to assess the sleep quality of the patients, and the life quality was assessed by using Kidney Disease Quality of Life-short form (KDQOL-SF). Results The incidence of sleep disorder was 56% in these 141 ESRD patients. The patients who suffered from sleep disorder had a higher sleep index score in all aspects of PSQI except in usage of sleep medications (P＜0.05). On the aspect of life-quality-associated factors, dialysis-related symptoms (OR=0.944, P=0.026), and change of health status (OR=1.024, P=1.024) were independent risk factors for sleep disorders. As for family-social factors, sleep quality was closely associated with dialysis (r=-0.252, P=0.003), family support (r=-0.174, P=0.040), and BMI (r=-0.189, P=0.025). Further regression analysis found that hemodialysis or peritoneal dialysis (OR= 0.544, P=0.011), poor family support (OR=0.686, P=0.030) were independently risk factors of sleep disorders. Conclusions Poor sleep quality is common in ESRD patients and it is associated with lower quality of life. More attention should be paid on assessment and management of sleep disorder in ESRD patients in order to improve their quality of life.     

The impact of diet on disease activity in spondyloarthritis: A systematic literature review

ObjectivesOur study aimed to systematically review the evidence about the effect of diet or dietary supplements on spondyloarthritis (SpA) disease activity.Methodsa systematic literature review (SLR) was conducted in MEDLINE, EMBASE, Cochrane and SCOPUS according to the “PEO” format (Population, Exposure, Outcome). The population was SpA (axial or peripheral, axSpA/pSpA, including Psoriatic Arthritis-PsA); the intervention any kind of diet/dietary supplement; the outcome disease activity. Inclusion criteria were: adult patients, Randomized Controlled Trials (RCTs) and longitudinal studies (so that a pre-and post-intervention assessment were available), papers in English. Risk of bias (RoB) was conducted with different tools according to the design of the study.ResultsLiterature search yielded 1390 publications, of which 15 were finally inlcuded: 12 interventional and 3 observational studies. Among those with the lower RoB: a) 2 RCTs, one at unclear and one at low RoB, failed to show benefit of probiotics in SpA b) Two RCTs at unclear RoB provided evidence that weight loss, but not hypocaloric diet, was associated to MDA achievement in PsA. The remaining interventional studies were at high RoB. Among the observational studies, one study on Mediterranean diet demonstrated an association between diet adherence and a ≥ 20% decrease of ASDAS in axSpA. The other two observational studies were judged of poor quality.Conclusionsweight loss seem to be able to impact disease activity in PsA, while probiotics do not seem useful in SpA; evidence for dietary behaviors is scarce and heterogeneous.     

社区轻度认知功能障碍老年人的交互式群组管理

目的 探讨交互式群组管理对社区轻度认知功能障碍老年人认知功能、日常生活能力和生活质量的效果.方法 采用类实验研究方法,将轻度认知功能障碍老年人分为干预组35例,对照组36例.干预组接受为期12周的交互式群组管理活动,对照组实施常规健康指导.两组在干预前后分别采用蒙特利尔认知评估量表基础版、日常生活能力量袁、阿尔茨海默病生命质量量表进行评价.结果 干预后,干预组认知功能、生命质量得分高于干预前水平和对照组同期水平(均P＜0.01),干预后,干预组日常生活能力得分低于干预前水平(P＜0.05),但与对照组同期水平比较,差异无统计学意义(P＞0.05).结论 交互式群组管理是基于互联网平台和线下群组活动交融,是一种有效的社区轻度认知功能障碍老年人管理模式,可改善其认知功能和生命质量.     

Predictive factors of tumour necrosis inhibitor treatment persistence for rheumatoid arthritis: An observational study in 8052 patients

ObjectivesTo determine whether changes in ultrasonography (US) features of monosodium urate crystal deposition is associated with the number of gouty flares after stopping gout flare prophylaxis.MethodsWe performed a 1-year multicentre prospective study including patients with proven gout and US features of gout. The first phase of the study was a 6-month US follow-up after starting urate-lowering therapy (ULT) with gout flare prophylaxis. After 6 months of ULT, gout flare prophylaxis was stopped, followed by a clinical follow-up (M6 to 12) and ULT was maintained. Outcomes were the proportion of relapsing patients between M6 and M12 according to changes of US features of gout and determining a threshold decrease in tophus size according to the probability of relapse.ResultsWe included 79 gouty patients (mean [± SD] age 61.8 ± 14 years, 91% males, median disease duration 4 [IQR 1.5; 10] years). Among the 49 completers at M12, 23 (47%) experienced relapse. Decrease in tophus size ≥ 50% at M6 was more frequent without than with relapse (54% vs. 26%, P = 0.049). On ROC curve analysis, a threshold decrease of 50.8% in tophus size had the best sensitivity/specificity ratio to predict relapse. Probability of relapse was increased for patients with a decrease in tophus size <50% between M0 and M6 (OR 3.35 [95% confidence interval 0.98; 11.44]).ConclusionA high reduction in US tophus size is associated with low probability of relapse after stopping gout prophylaxis. US follow-up may be useful for managing ULT and gout flare prophylaxis.