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Background Treat-to-target strategies require frequent on-site evaluations of disease activity in patients with rheumatoid arthritis (RA), burdening patients and caregivers. However, this frequency may not be required in patients in a stable low disease activity state. The Routine Assessment of Patient Index Data 3 (RAPID3) is a reliable tool to detect such states in groups but has not been tested to reduce the frequency of on-site evaluations in individual patient care. In Reade, an outpatient rheumatology clinic, patients can complete the questionnaire online prior to consultation, and the results are directly fed into the electronic patient record. Focusing on low disease activity, we retrospectively studied the test characteristics of RAPID3 and its agreement with the DAS28 in our database of routine patient care. Objective To assess the test characteristics and agreement between de DAS28 and the RAPID3 in patients with RA, with a focus on the low disease activity categories. Methods We performed a retrospective database study with available clinical data collected as part of usual care from the electronic medical record at Reade Amsterdam. The dataset comprised RAPID3 assessments followed by a DAS28 within 2 weeks, obtained between June 2014 and March 2021. We dichotomized the disease activity categories for both the RAPID3 and DAS28 into low (remission and low disease activity) and high (moderate and high disease activity). With cutoff values of 2.0 for RAPID3 and 3.2 for DAS28, we calculated test characteristics and agreement (Cohen’s kappa). Results A total of 5009 combined RAPID3 and DAS28 measurements were done at Reade in 1681 unique RA patients. The mean age was 60 years, and 76% of patients were female with a median disease duration of 4 years. Agreement was considered fair (kappa = 0.26). In total, 1426 (28%) of the RAPID3 measurements were classified as low and could be potentially targeted to skip their consultations. The sensitivity to detect low disease activity was 0.39, specificity was 0.93, and the positive predictive value was 0.92. Conclusion We showed that when the RAPID3 classifies a patient into low disease activity state, the accuracy is 92%. Of all consultations, 28% could possibly be postponed following the screening with RAPID3. Key Points• Most studies conclude that the RAPID3 alone is insufficient to monitor the disease activity of RA due to its general overestimation of the disease activity compared with the DAS28.• Our results show that in 92% of the cases patients with a RAPID3 ≤ 2.0 have a DAS28 ≤ 3.2.• We propose a system where the RAPID3 is used to screen for patients in remission/low disease activity, in order to postpone consultations of these patients and reduce the number of unnecessary outpatient clinic visits.

Objective.To survey participants with polymyalgia rheumatica (PMR) to evaluate the face validity, acceptability, and domain match of proposed candidate outcome measures.Methods.A structured, online, anonymous survey was disseminated by patient support groups through their networks and online forums. The candidate outcome measures comprised (1) visual analog scale (VAS) and numerical rating score (NRS) to assess pain; (2) VAS, NRS, and duration to assess stiffness; (3) the modified Health Assessment Questionnaire and Health Assessment Questionnaire Disability Index to assess physical function; and (4) C-reactive protein and erythrocyte sedimentation rate to assess inflammation. Free-text answers were analyzed using descriptive thematic analysis to determine respondents’ views of the candidate instruments.Results.Seventy-eight people with PMR from 6 countries (UK, France, USA, Canada, Australia, and New Zealand) participated in the survey. Most respondents agreed candidate instruments were acceptable or “good to go.” Free-text analysis identified 5 themes that participants considered inadequately covered by the proposed instruments. These related to (1) the variability, context, and location of pain; (2) the variability of stiffness; (3) fatigue; (4) disability; and (5) the correlation of inflammatory marker levels and severity of symptoms, sometimes reflecting disease activity and other times not.Conclusion.Participants reported additional aspects of their experience that are not covered by the proposed instruments, particularly for the experience of stiffness and effect of fatigue. New patient-reported outcome measures are required to increase the relevance of results from clinical trials to patients with PMR.

A systematic review on the cost effectiveness of prophylactic treatments of non-steroidal anti-inflammatory drug (NSAID) induced gastropathy in patients with osteoarthritis or rheumatoid arthritis was conducted. Two reviewers conducted the literature search and the review. Both full and partial economic evaluations published in English, Dutch, or German were included. The criteria list published in the textbook of Drummond was used to determine the quality of the economic evaluations. The methodological quality of three randomised controlled trials (RCTs) in which the economic evaluations obtained probability estimates of NSAID induced gastropathy and adverse events was assessed by a list of internal validity criteria. The conclusions were based on a rating system consisting of four levels of evidence. Ten economic evaluations were included; three were based on RCTs. All evaluations studied misoprostol as prophylactic treatment: in one evaluation misoprostol was studied as a fixed component in a combination with diclofenac (Arthrotec). All economic evaluations comprised analytical studies containing a decision tree. The three trials were of high methodological quality. Nine economic evaluations were considered high quality and one economic evaluation was considered of low methodological quality. There is strong evidence (level "A") that the use of misoprostol for the prevention of NSAID induced gastropathy is cost effective, and limited evidence (level "C") that the use of Arthrotec is cost effective. Although the levels of evidence used in this review are arbitrary, it is believed that a qualitative analysis is useful: quantitative analyses in this field are hampered by the heterogeneity of economic evaluations. Existing criteria to evaluate the methodological quality of economic evaluations may need refinement for use in systematic reviews.

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Peretz Bernstein had verrassend hedendaagse inzichten over groepsdenken, blijkt uit de recente heruitgave van 'The Social Roots of Discrimination: the case of the Jews'. Zijn tijdgenoot en tegenpool Siegfried Kurt Baschwitz vult aan.

Borstvoeding is goed voor moeder en kind. Soms komt het voor dat een kind te weinig borstvoeding en daarmee vocht binnenkrijgt. Als dit gebeurt kan het kind te veel gewicht verliezen en uitdrogen. Maar wat is te veel? Veel verloskundigen hanteren 10% verlies van het geboortegewicht als vuistregel. Maar deze bewering is gebaseerd op ervaring uit de praktijk en niet op weten- schappelijk bewijs. Onze studie heeft bij meer dan 1.500 gezonde, borstgevoede pasgeborenen het gewichts- verlies in de kraamtijd gemeten. Deze resultaten zijn vergeleken met het gewichtsverlies van 83 kinderen met stille ondervoeding of uitdroging aan de borst. Aan de hand hiervan is een richtlijn ontwikkeld om kinderen met uitdroging op te sporen. Deze richtlijn blijkt een betere indicator te zijn van excessief gewichtsverlies dan de 10% vuistregel, omdat deze teveel kinderen als uitgedroogd zou beschouwen.

Contains fulltext : 48816.pdf (Publisher’s version ) (Closed access) Agreement on response criteria in rheumatoid arthritis (RA) has allowed better standardization and interpretation of clinical trial reports. With recent advances in therapy, the proportion of patients achieving a satisfactory state of minimal disease activity (MDA) is becoming a more important measure with which to compare different treatment strategies. The threshold for MDA is between high disease activity and remission and, by definition, anyone in remission will also be in MDA. True remission is still rare in RA; in addition, the American College of Rheumatology definition is difficult to apply in the context of trials. Participants at OMERACT 6 in 2002 agreed on a conceptual definition of minimal disease activity (MDA): "that state of disease activity deemed a useful target of treatment by both the patient and the physician, given current treatment possibilities and limitations." To prepare for a preliminary operational definition of MDA for use in clinical trials, we asked rheumatologists to assess 60 patient profiles describing real RA patients seen in routine clinical practice. Based on their responses, several candidate definitions for MDA were designed and discussed at the OMERACT 7 in 2004. Feedback from participants and additional on-site analyses in a cross-sectional database allowed the formulation of 2 preliminary, equivalent definitions of MDA: one based on the Disease Activity Score 28 (DAS28) index, and one based on meeting cutpoints in 5 out the 7 WHO/ILAR core set measures. Researchers applying these definitions first need to choose whether to use the DAS28 or the core set definition, because although each selects a similar proportion in a population, these are not always the same patients. In both MDA definitions, an initial decision node places all patients in MDA who have a tender joint count of 0 and a swollen joint count of 0, and an erythrocyte sedimentation rate (ESR) no greater than 10 mm. If this condition is not met: * The DAS28 definition places patients in MDA when DAS28 < or = 2.85; * The core set definition places patients in MDA when they meet 5 of 7 criteria: (1) Pain (0-10) < or = 2; (2) Swollen joint count (0-28) < or = 1; (3) Tender joint count (0-28) < or = 1; (4) Health Assessment Questionnaire (HAQ, 0-3) < or = 0.5; (5) Physician global assessment of disease activity (0-10) < or = 1.5; (6) Patient global assessment of disease activity (0-10) < or = 2; (7) ESR < or = 20. This set of 2 definitions gained approval of 73% of the attendees. These (and other) definitions will now be subject to further validation in other databases.

The Catholic Baron Willem Vincent van Wyttenhorst (1613-1674) from Utrecht was an enthusiastic collector of paintings. In his translation of Guarini's Il Pastor Fido, Hendrick Bloemaert even lauded Willem Vincent's 'Lofweerdigh cabinet' (commendable cabinet) of paintings. The inventory Wyttenhorst made of his collection between 1651 and 1659 affords insight into various aspects of the seventeenth-century art trade. Not only did he record the subject and maker of around 195 paintings, but also the price and often how he had acquired them. Part of the collection - in particular the finely painted works by Cornelis van Poelenburgh and Herman Saftleven - were auctioned in 1722. Of Willem Vincent van Wyttenhorst's collection approximately 75 paintings can be traced to Herdringen Castle of the Von Furstenberg family and several museums, making it possible to establish the relationship between the dimensions and the quality of execution, and the price they commanded in the seventeenth century. Willem Vincent acquired the greatest number of his paintings between 1630 and 1659, the majority of which were by contemporary masters, some of whom he knew personally. His collection also included several important sixteenth-century pictures by artists such as Cornelis Engebrechtszn, Jan van Scorel and Maerten van Heemskerck, which had come into his possession via his family or via that of his wife Wilhelmina van Bronckhorst. On the one hand, the Wyttenhorst collection is comparable to those of other aristocratic collectors and, on the other hand, to those of well-to-do connoisseurs such as Franciscus de la Boe Sylvius and Hendrick Bugge van Ring of Leiden. Its aristocratic character is evidenced by the prominent place occupied by family portraits: he owned a total Of 41 likenesses, 29 Of which were made for him and his wife. In 1650, Bartholomeus van der Helst needed six weeks to portray Willem Vincent and his wife Wilhelmina van Bronckhorst for the amount Of 330 guilders. Wyttenhorst appears to have preferred highly refined small paintings. Not a single genre was overlooked in the collection. Taking pride of place were approximately go pastoral scenes and Arcadian landscapes, which added to the collection's aristocratic aura. Furthermore, in keeping with his Catholic background, Willem Vincent had relatively many (25) paintings with religious subjects and devotional works. Striking is also the group of about 20 genre scenes with primarily peasant themes. The II flower and fruit still lifes listed in the inventory were purchased by Wilhelmina van Bronckhorst between 1640 and 1642 during her first marriage. Regrettably, the inventory only rarely indicates where the pictures hung. On the basis of the scant information, however, it emerges that Wilhelmina van Bronckhorst's cabinet was richly adorned with a variety of paintings. This cabinet also served as the 'Ahnengalerie' (gallery of forefathers) for the 19 family portraits by Cornelis van Poelenburgh. The exceptional status of the Wyttenhorst collection is reflected by the proportionally very modest number of eight anonymous paintings. Moreover, Willem Vincent describes ten copies, most of which he commissioned. The majority of painters mentioned by Wyttenhorst were active in Utrecht, while the overwhelming majority of non-Utrecht masters were active in Haarlem. Wyttenhorst owned about go paintings by Utrecht Italianates and related painters such as Poelenburgh, De Heus, Both, Berchem and Saftleven. He maintained intensive contact with Cornelis van Poelenburgh and Herman Saftleven, by whom he owned 57 and 18 paintings respectively. Among the Haarlem artists represented by a few works in his collection were Pieter de Molijn, Adriaen van Ostade and Wouwerman. Interestingly, the vast majority of the painters Wyttenhorst mentioned in his inventory are still known or even famous. The collection also comprised several collaborative efforts, such as K Contento by Nicolaes Knupfer, Jan Baptist Weenix and Jan Both. It is notable that Wyttenhorst regularly acquired work by young painters who had just barely begun; a good example is the painting he purchased in 1638 from the then at most A-year-old Nicolaes Berchem. A number of paintings were given to Willem Vincent by relatives and acquaintances. Some works entered his collection through exchange, for example via the Hague collector d'Arminvillers. He also bought the occasional painting from a private individual. In the case of 85 paintings, Wyttenhorst noted that he had bought them directly from a master. He also purchased from art dealers, in particular works by non-Northern Netherlandish painters via Dirck Matham. These were usually small, modestly priced paintings. In a few instances he acquired a painting at an auction, from an estate, at a market, kermis or from a pedlar. Incidentally, he acknowledged that the latter works were not highpoints in his collection. Thus, in amassing his collection, Willem Vincent used all of the channels available around the mid-seventeenth century. The prices of the paintings acquired by Wyttenhorst differed significantly. The cheapest was a panel of Three deer heads by Jacques Savery at 3 guilders, and the most expensive a Peasant kermis by Herman Saftleven at 500 guilders. A large number of works costing more than 100 guilders are explicitly described as history paintings. The finely executed Arcadian landscapes - often on copper - range in price from 30 to 150 guilders. The prices for works by Italianate painters do not differ much and appear to have depended mostly on their dimensions; the larger ones cost exactly twice as much as the smaller ones. The greatest variation in prices is found among the genre scenes. In the case of several paintings, Wyttenhorst noted that their value had exceeded the purchase price. Unfortunately, there is insufficient information to confirm the accuracy of all of his assertions. There are a few indications that the value of the Peasant sheds by the Saftleven brothers did, indeed, rise around the mid-seventeenth century. Willem Vincent's comment that Jacob Matham's flower and fruit still lifes had sharply increased in value between 1642 and about 1655 is also confirmed by contemporary sources. In addition to the 19 family portraits by Cornelis van Poelenburgh mentioned above, Wyttenhorst owned 17 landscapes by the artist ranging in price between 30 and go guilders. For the eight history paintings listed in the inventory, Willem Vincent paid amounts above 100 guilders, the most expensive being a Passion scene for 464 guilders. Alongside these originals, Wyttenhorst also owned several copies after Poelenburgh by Toussaint Gelton and by the master himself. Their prices serve as a good in-dication of the value attached to the originality of an invention. For these copies after originals - which also were (or had been) in the collection - approximately 1/4 of the price of the original was paid. Wyttenhorst owned several genre scenes and many landscapes by Herman Saftleven. Several of them are described in the inventory as Rhine landscapes. Willem Vincent's Saftlevens included a surprising number of pendants of two (and in one instance a series of four) paintings. On the whole, he appears to have paid more for works by Saftleven than by Poelenburgh. There is insufficient information to allow for a comparison of the prices Wyttenhorst paid for work by Poelenburgh and Saftleven and the value of their work in estate inventories or with the amounts they fetched at auction. However, this is possible with the landscapes by Pieter de Molijn and Dirck Verhaert. In the case of De Molijn, Wyttenhorst paid the master four times more than the price of to guilders most frequently given in estate inventories. An explanation for this enormous discrepancy could be that like Herman Saftleven, De Molijn produced work of diverging quality. He crafted both original, finely executed inventions for art collectors such as Willem Vincent van Wytten-horst as well as small paintings for the open market, which were variations on a basic theme. For a painting by Dirck Verhaert, a Haarlem artist who simply followed popular trends, Wyttenhorst paid the modest amount of 6 guilders, a price that differs very little from the estimated values in estate inventories. On the basis of the above a tentative conclusion can be drawn regarding the services rendered by artists around the mid-seventeenth century who, incidentally, did not depend exclusively on the sale of their own paintings, but also relied on the sale of their pupils' work, the art trade, making assessments, restoration activities and apprenticeship fees. Should a painter like Poelenburgh, Berchem or De Molijn sell a few paintings per month for roughly 40 guilders, their earnings would soon exceed that of the 36 guilders in wages of a trained craftsman. However, this in no way applies to a minor artist such as Dirck Verhaert, who had to settle for 6 guilders per painting. Financial success was thus primarily the reserve of painters with talent and ingenuity. To win the patronage of discerning connoisseurs such as Willem Vincent van Wyttenhorst, an artist had to provide high-quality work and be innovative within a given genre.

Item does not contain fulltext The OMERACT 6 Minimal Clinically Important Difference/Low Disease Activity Workshop was organized with the aim of meeting the many challenges that exist in determining a low disease activity in rheumatoid arthritis (RA). This article presents an overview of that workshop, including results of the voting, a summary of associated discussions, recommendations, and a proposed research agenda.

A number of reports indicating the growing acceptance of simultaneous therapy with multiple disease-modifying anti-rheumatic drugs (DMARDs), as well as the use of more aggressive treatment measures in the early phases of disease to combat rheumatoid arthritis (RA), have appeared during the last decade. However, only a few randomized controlled clinical trials have been conducted on the use of DMARD combinations in early RA. We review these trials in this article. In two separate one-year studies combination therapy with sulphasalazine (SSZ) and methotrexate (MTX) seemed to offer no benefits compared to either drug used as monotherapy. On the other hand, the DMARD combinations so far proven to be superior to single DMARDs have initially also included a corticosteroid component. In the COBRA study (Combinatietherapie Bij Reumatoide Artritis) the combination of SSZ (2 gm/day), MTX (7.5 mg/week for 40 weeks), and prednisolone (Prd) (initially 60 mg/day, tapered in 6 weekly steps to 7.5 mg/day and stopped after 28 weeks) compared to SSZ alone (2 gm/day) resulted in significantly better clinical outcomes at week 28. Although the difference in clinical response between the treatment arms was lost at week 58, the progression of joint damage remained statistically significantly slower at week 80 in the patients initially assigned to the combination therapy. Furthermore, in the FIN-RACo trial (Finnish Rheumatoid Arthritis Combination Therapy Trial), therapy using a "tailored-steps" strategy with SSZ (1-2 gm/day), MTX (7.5-1.5 mg/week), hydroxychloroquine (300 mg/day), and Prd (up to 10 mg/day) yielded a significantly increased remission rate and less peripheral joint damage at two years than the single DMARD treatment strategy (initially SSZ 2 gm/day), with or without Prd. Adverse effects in both study arms were comparable. Two additional preliminary reports (in abstract form) suggest that intensive local therapy in the form of intra-articular injections added to single or combination therapy improves both local and systemic disease control, with increased remissions and less damage. Although still preliminary, these results should encourage the rheumatological community to treat selected RA patients with DMARD combinations from the very start.

Item does not contain fulltext The MCID (minimal clinically important difference) module of OMERACT 5 developed a research agenda that led to the conclusion that a state of low disease activity for rheumatoid arthritis (RA) would need to be defined. To develop such a definition the various concepts and terminologies, the process for developing an operational definition, and the availability and design of longitudinal datasets for validation needed to be considered. This article describes the process of the MCID/Low Disease Activity State Workshop at OMERACT 6 to develop such a definition.

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