Diagnostic Performance of Red Cell Distribution Width in Adult Iraqi Patients with Ankylosing Spondylitis

Background. Ankylosing spondylitis (AS) is a chronic, progressive inflammatory rheumatic disease that leads to structural damage, functional impairment, and decrease in the quality of life. Red cell distribution width (RDW) is a part of the complete blood count (CBC) and estimates erythrocyte variability. Objective. To analyse RDW in patients with AS and to evaluate the relationships with acute phase reactants (APRs) and disease activity index. Patients and Methods. A total of 100 patients with AS (78 males and 22 females) were diagnosed according to the modified New York classification criteria for AS and 146 (99 males: 47 females) healthy individuals matched in age and sex as controls enrolled in the study. Demographic data, disease activity scores using Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), medical history, C-reactive protein (CRP), erythrocytes sedimentation rate (ESR), and complete blood count (CBC) were measured. Results. The mean age for patients and controls was 38.0 ± 9.0 and 35.8 ± 9.0 years, respectively (p=0.057). RDW was significantly higher in patients with AS compared with controls (14.133 ± 1.613 versus 12.299 ± 1.031, p < 0.001). There was a direct correlation of RDW with both ESR and CRP (P < 0.001); RDW had r=0.38 for C-reactive protein (CRP) and r=0.413 for ESR. Also BASDAI was directly correlated with RDW (r=0.326 p<0.001). RDW was a valid measure to differentiate between patients with AS and controls (AUC=0,84, p<0.001) and at optimum cut-off value>13% has highest accuracy (78.9%) with very good sensitivity test (81%) and NPV (85.6%) as well as good specificity (77.4%) and PPV (71.1%). Conclusion. RDW was higher in AS patients compared with controls and was directly correlated with ESR, CRP, and BASDAI. RDW was a valid simple measure with good accuracy to differentiate between patients with AS and controls.

Burden of Depression among Working-Age Adults with Rheumatoid Arthritis

Objective. This study estimated the excess clinical, humanistic, and economic burden associated with depression among working-age adults with Rheumatoid Arthritis (RA). Methods. A retrospective cross-sectional study was conducted among working-age (18 to 64 years) RA patients with depression (N=647) and without depression (N=2,015) using data from the nationally representative Medical Expenditure Panel Survey for the years 2009, 2011, 2013, and 2015. Results. Overall, 25.8% had depression. In adjusted analyses, adults with RA and depression compared to those without depression were significantly more likely to have pain interference with normal work (severe pain: AOR = 2.22; 95% CI = 1.55, 3.18), functional limitations (AOR = 2.17; 95% CI = 1.61, 2.94), and lower mental health HRQoL scores. Adults with RA and depression had significantly higher annual healthcare expenditures ($14,752 versus 10,541, p<.001) and out-of-pocket spending burden. Adults with RA and depression were more likely to be unemployed and among employed adults, those with depression had a significantly higher number of missed work days annually and higher lost annual wages due to missed work days. Conclusions. This study highlights the importance of effectively managing depression in routine clinical practice of RA patients to reduce pain and functional limitations, improve quality of life, and lower direct and indirect healthcare costs.

Physical Examination Tools Used to Identify Swollen and Tender Lower Limb Joints in Juvenile Idiopathic Arthritis: A Scoping Review

Background. Juvenile idiopathic arthritis (JIA) is the most common form of rheumatic disease in childhood and adolescents, affecting between 16 and 150 per 100,000 young persons below the age of 16. The lower limb is commonly affected in JIA, with joint swelling and tenderness often observed as a result of active synovitis. Objective. The objective of this scoping review is to identify the existence of physical examination (PE) tools to identify and record swollen and tender lower limb joints in children with JIA. Methods. Two reviewers individually screened the eligibility of titles and abstracts retrieved from the following online databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL. Studies that proposed and validated a comprehensive lower limb PE tool were included in this scoping review. Results. After removal of duplicates, 1232 citations were retrieved, in which twelve were identified as potentially eligible. No studies met the set criteria for inclusion. Conclusion. Further research is needed in developing and validating specific PE tools for clinicians such as podiatrists and other allied health professionals involved in the management of pathological lower limb joints in children diagnosed with JIA. These lower limb PE tools may be useful in conjunction with existing disease activity scores to optimise screening of the lower extremity and monitoring the efficacy of targeted interventions.

Education and Social Support as Key Factors in Osteoarthritis Management Programs: A Scoping Review

Systematic reviews of self-management programs for osteoarthritis suggest minimal evidence of benefit and indicate substantial heterogeneity in interventions. The purpose of this scoping review was to describe the nature of self-management interventions provided to patients with osteoarthritis focusing on the inclusion and type of education and social support components. We searched PsycINFO, EMBASE, MEDLINE, and Cochrane Library databases from 1990 to 2016 to identify studies addressing community-based management strategies for osteoarthritis that included aspects of disease-specific education and ongoing social support. Results are presented as a narrative synthesis to facilitate integration of diverse evidence. Data were extracted from 23 studies that met our inclusion and exclusion criteria, describing complex, multicomponent interventions for osteoarthritis. All studies included education components, and 18 of these were osteoarthritis-specific. Social support was most often offered through peers and health care professionals, but also through exercise trainers/instructors and researchers, and lasted between 5 and 52 weeks. We charted positive social interaction offered by peers in group settings and emotional/informational support offered by health care professionals. Overall, descriptions of self-management provided limited documentation of the rationale or content of the programs. This suggests that more precise definitions of the theoretical underpinnings, components, and mechanisms would be useful for greater insight into best practices for osteoarthritis self-management programs.

Biosimilars Have Arrived: Rituximab

A biosimilar is a biologic product that is highly similar to a licensed biologic (“originator”) such that there are no clinically meaningful differences in safety, purity, or potency between the biosimilar and the originator. As patent protection and data exclusivity for the biologic rituximab expire, several potential biosimilars to rituximab are in development, which could soon lead to the availability of numerous rituximab biosimilars. Biosimilars are evaluated using thorough and rigorous analyses of the potential biosimilar versus the originator biological to confirm similar structure, function, and clinical efficacy as well as safety. Approval of a biosimilar is based upon the totality of the evidence demonstrating similarity to the originator. An understanding of the process of the interchangeable designation of a biosimilar is important in the context of patient outcomes. We conducted an analysis of the properties and benefits of rituximab in the treatment of inflammatory diseases, the development and approval of biosimilars, and the potential benefits of rituximab biosimilars. PubMed and ClinicalTrials.gov databases were searched for “biosimilar” and “rituximab” and regulatory and pharmaceutical company web pages were screened regarding biosimilars in development and specific guidelines developed for the approval of biosimilars. The results indicate that, at present, six rituximab biosimilar candidates are undergoing comparative clinical development, and two were recently approved in the European Union. Our analysis indicates rituximab biosimilars are expected to have a continuing role in treating inflammatory conditions such as rheumatoid arthritis.

Reliability and Construct Validity of the SENS Motion® Activity Measurement System as a Tool to Detect Sedentary Behaviour in Patients with Knee Osteoarthritis

Physical inactivity is important to address, and an objective way of measuring inactivity is by accelerometry. The objective of this study was to determine the reliability and construct validity of the SENS motion system to record physical activity and inactivity in patients with knee osteoarthritis. Participants with an age > 40 years and an average weekly pain above 0 on a numeric rating scale (0 = no pain, 10 = worst pain) were included. Participants had a total of two study visits and at each visit participants completed a standardized activity. Data from 24 participants were analysed. A mean agreement of 99% (SD 3%) for sedentary behaviour and a mean agreement of 97% (SD 9%) for active behaviour were found. The agreement for “walking” was 28% (SD 18%). Mean agreement between recordings on the two visits was 96% (SD 8%) for sedentary behaviour and 99% (SD 1%) for active behaviour. The SENS motion activity measurement system can be regarded as a reliable and valid device for measuring sedentary behaviour in patients with knee OA, whereas detection of walking is not reliable and would require further work.

Healthcare Providers’ Recommendations for Physical Activity among US Arthritis Population: A Cross-Sectional Analysis by Race/Ethnicity

Introduction. We examined racial/ethnic disparities in healthcare providers’ recommendations for physical activity among individuals with arthritis and evaluated this association among groups of individuals who adhered to physical activity guidelines and those who did not. Methods. With a cross-sectional design based on Behavioral Risk Factor Surveillance System, we analyzed individuals with self-reported physician-diagnosed arthritis, ≥18 years of age (n = 83,376). Outcome variable was healthcare providers’ recommendations for physical activity. Race/ethnicity was categorized as African American, Hispanic, and White. Associations were examined using multivariate logistic regression. Results. African Americans (Adjusted OR: 0.66; 95% CI: 0.55–0.79) and Hispanics (Adjusted OR: 0.68; 95% CI: 0.56–0.83) were less likely to receive providers’ recommendations. Conclusions. Although the importance of physical activity to improve health outcomes for adults with arthritis, as well as providers’ influence on individuals’ behavior change, is well established, providers are less likely to recommend physical activity to minorities. Further studies are required to identify the causes for this quality-of-care issue.

Confidence amongst Multidisciplinary Professionals in Managing Paediatric Rheumatic Disease in Australia

Objective. Interprofessional collaboration is a crucial component of care for children with rheumatic disease. Interprofessional care, when delivered appropriately, prevents disability and improves long-term prognosis in this vulnerable group. Methods. The aim of this survey was to explore allied health professionals’ and nurses’ confidence in treating paediatric rheumatology patients. Results. Overall, 117 participants were recruited, 77.9% of participants reported being “not confident at all,” “not confident,” or “neutral” in treating children with rheumatic diseases (RD) despite 65.1% of participants reporting having treated >1 paediatric rheumatology case in the past month. Furthermore, 67.2% of participants felt their undergraduate education in paediatric rheumatology was inadequate. “Journals” or “texts books” were used by 49.3% of participants as their primary source of continuing professional development (CPD) and 39.3% of participants indicated that they did not undertake any CPD related to paediatric rheumatology. Small group and online education were perceived to be potentially of “great benefit” for CPD. Conclusion. This paper highlights allied health professionals’ and nurses’ perceived inadequacy of their undergraduate education in paediatric RD and their low confidence in recognising and treating RD. Undergraduate and postgraduate education opportunities focusing on interprofessional collaboration should be developed to address this workforce deficiency.

Knee Fat Pad Volumes in Patients with Hemophilia and Their Relationship with Osteoarthritis

Hemophilic arthropathy is a progressive, disabling condition with poorly understood pathobiology. Since there is an emerging interest to study the role of intra-articular fat pad size and biology in arthritic conditions, we explored fat pad volume changes in hemophilic arthropathy and to what extent they differed from osteoarthritis. We matched a cohort of 13 adult patients with hemophilic arthropathy of the knee with age- and gender-matched cohorts without osteoarthritis (“control cohort”) and with the same degree of radiographic osteoarthritis (“OA cohort”) in 1 : 2 fashion. Infrapatellar fat pad (IPFP) and suprapatellar fat pad (SPFP) volumes were calculated based on magnetic resonance imaging and differences in fat pad volumes, demographics, height, weight, and osteoarthritis scores were evaluated. Fat pad volumes were positively associated with body size parameters in all three cohorts but were unaffected by the degree of osteoarthritis. While IPFP volumes did not differ between cohorts, SPFP volumes expanded disproportionally with weight in hemophilia patients. Our observations indicate that IPFPs and SPFPs behave biologically differently in response to different arthritic stimuli. The exaggerated expansion of the SPFP in hemophilia patients highlights the importance of further studying the implications of fat pad biology for progression of hemophilic arthropathy.

The Influence of Oblique Angle Forced Exercise in Surgically Destabilized Stifle Joints Is Synergistic with Bone, but Antagonistic with Cartilage in an Ovine Model of Osteoarthritis

Large animal models of osteoarthritis are a necessary testing ground for FDA approval of human medicine applications. Sheep models have advantages over other available large animals, but development and progression of osteoarthritis in sheep is exceedingly slow, which handicaps progress in development of potential treatments. We combined oblique angle forced exercise to increase stress on the stifle, with surgical destabilization to hasten the development of osteoarthritis in ewes. Methods for early detection of clinical signs included radiography, urine, and serum biomarker assays and gait analysis and ex vivo we used microcomputed tomography and macroscopic joint analysis. Our model was able to produce clinically detectable signs of osteoarthritis in a relatively short period (14 weeks). Changes in bone were highly correlated between microcomputed tomography and radiographic analysis and changes in cartilage correlated well between urinary glycosaminoglycan levels and serum aggrecanase analyses. Exercise improved the negative effects of destabilization in bone but exacerbated the negative effects of destabilization in cartilage. These observations suggest that we may need to consider treatments for bone and cartilage separately. These results represent an improved large animal model of osteoarthritis with rapid onset of disease and superior detection of bone and soft tissue changes.