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To assess patient perspective and professional practice of intraarticular therapies (IATs) across Europe, an expert international multidisciplinary panel designed two open web-based surveys: one targeting people who had experienced at least two IATs (44 items); and one targeting health care providers (HCPs) (160 items). Surveys were disseminated via patient and professional associations and social media. A descriptive analysis was performed. The surveys were answered by 200 patients and 186 HCPs from 26 countries, showing that IAT is routinely performed by rheumatologists (97%) and orthopaedic surgeons (89%), with specific training being compulsory in a few countries. The most frequent indications for IAT are arthritis (76%), osteoarthritis (74%), crystal arthritis (71%) and bursitis (70%); the most frequently injected joints are knee (78%) and shoulder (70%); and the most used compounds are glucocorticoids. The majority of HCPs report informing patients about side-effects (73%), benefits (72%), and the nature of the procedure (72%), which coincides with 27% of patients reporting that they had not been informed about benefits or potential complications of IATs; 73% of patients had not been asked whether they wanted an anaesthetic. Few HCPs (10%) obtain written consent (56% get oral consent, being mandatory for 32%), a procedure deemed necessary by 41% of the patients. 50% of patients reported a clear benefit of IAT and 20% experienced complications including pain, impaired mobility, rashes, or swelling. In summary, the practice of IAT is variable across Europe, and although patients perceive it as relatively safe and usually effective procedure, some gaps were identified.

ObjectivesTo establish evidence-based recommendations to guide health professionals using intra-articular therapies (IAT) in adult patients with peripheral arthropathies.MethodsA multidisciplinary international task force established the objectives, users and scope and the need for background information, including systematic literature reviews) and two surveys addressed to healthcare providers and patients throughout Europe. The evidence was discussed in a face-to-face meeting, recommendations were formulated and subsequently voted for anonymously in a three-round Delphi process to obtain the final agreement. The level of evidence was assigned to each recommendation with the Oxford levels of evidence.ResultsRecommendations focus on practical aspects to guide health professionals before, during and after IAT in adult patients with peripheral arthropathies. Five overarching principles and 11 recommendations were established, addressing issues related to patient information, procedure and setting, accuracy, routine and special aseptic care, safety issues and precautions to be addressed in special populations, efficacy and safety of repeated joint injections, use of local anaesthetics and aftercare.ConclusionWe have developed the first evidence and expert opinion-based recommendations to guide health professionals using IAT. We hope that these recommendations will be included in different educational programmes, used by patient associations and put into practice via scientific societies to help improve uniformity and quality of care when performing IAT in peripheral adult joints.

ObjectiveTo summarise the evidence on intra-articular therapies (IAT) to inform the 2020 EULAR recommendations.MethodsAn overview of systematic reviews (SR) including randomised-controlled trials (RCTs) of IAT in adults with arthropathies was performed up to July 2020. Pain, function, and frequency of adverse events were the main efficacy and safety outcomes, respectively. Quality was assessed with the A MeaSurement Tool to Assess Systematic Reviews (AMSTAR)-2 tool.ResultsOf 184 references identified, 16 met the inclusion criteria, and a search of their reference lists identified 16 additional SRs. After quality assessment, 29 were finally included. Of these, 18 focused on knee osteoarthritis (KOA), 6 on hip osteoarthritis (HOA), 3 on shoulder capsulitis (SC), and 3 on rheumatoid arthritis. Overall, hyaluronic acid showed a small effect on pain and function in KOA but not in HOA or shoulder capsulitis. Intra-articular glucocorticoids showed a small effect in pain and function in KOA and function in HOA and SC. Platelet-rich plasma showed benefit in pain and function in KOA but not in HOA. Mesenchymal stem cells behaved similarly. Most SR results were of moderate quality and RCTs included often presented a high risk of bias, mainly due to inadequate blinding and heterogeneous results. All interventions were well tolerated with no clear safety differences.ConclusionsThis overview underlines that most IAT currently used in KOA, HOA, and SC exert small effects and are well tolerated. However, no firm conclusions can be drawn for inflammatory arthritis due to the limited data found.

Objective. - Making a differential diagnosis of psoriatic arthritis (PsA) is not straightforward. This is partly because of its heterogeneous presentation and partly because many patients with PsA are initially diagnosed with psoriasis and treated in primary care or by dermatologists, with referral to rheumatologists being delayed. Once diagnosed, optimal disease control requires frequent specialist monitoring, adjustment or switching of therapies, and management of comorbidities and concomitant diseases, as well as attention to patients' overall well-being. Given the breadth of expertise that diagnosis and management of PsA requires, we sought to define a collaborative, structured framework that supports the optimisation of multidisciplinary care for patients with PsA in Europe. Methods. - An expert panel comprising four rheumatologists, three dermatologists, two specialist nurses and one psychologist-from Spain, the United Kingdom, The Netherlands, Germany, France and Italy-met face-to-face to take part in a modified Delphi exercise. Results. - The result of this exercise is a set of recommendations that are based on combining published evidence with the panel's extensive clinical experience. Recommendations can be implemented in a number of ways, but the central call-to-action of this framework is the need for improved collaboration between dermatologists (or primary care physicians) and rheumatologists. This could occur in a variety of different formats: standard referral pathways, multidisciplinary physician meetings to discuss patient cases, or 'one stop', combined clinics. Conclusion. - We anticipate that when the majority of patients with PsA receive regular multidisciplinary care, improved patient outcomes will follow, although robust research is needed to explore this assumption. (C) 2021 Les Auteurs. Publie par Elsevier Masson SAS au nom de Societe franc, aise de rhumatologie.

ObjectiveTo establish European League Against Rheumatism (EULAR) points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older.MethodsPoints to consider were developed in accordance with EULAR standard operating procedures for EULAR-endorsed recommendations, led by an international multidisciplinary task force, including patient research partners and different health professionals from 10 European countries. Level of evidence and strength of recommendation were determined for each point to consider, and the mean level of agreement among the task force members was calculated.ResultsTwo overarching principles and seven points to consider were formulated based on scientific evidence and the expert opinion of the task force. The two overarching principles focus on shared decisions between patients and non-physician health professionals and involvement of different non-physician health professionals in prevention and management of fragility fractures. Four points to consider relate to prevention: identification of patients at risk of fracture, fall risk evaluation, multicomponent interventions to prevent primary fracture and discouragement of smoking and overuse of alcohol. The remaining three focus on management of fragility fractures: exercise and nutritional interventions, the organisation and coordination of multidisciplinary services for post-fracture models of care and adherence to anti-osteoporosis medicines. The mean level of agreement among the task force for the overarching principles and the points to consider ranged between 8.4 and 9.6.ConclusionThese first EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older serve to guide healthcare practice and education.

To update the European League Against Rheumatism (EULAR) recommendations for the role of the nurse in the management of chronic inflammatory arthritis (CIA) using the most up to date evidence. The EULAR standardised operating procedures were followed. A task force of rheumatologists, health professionals and patients, representing 17 European countries updated the recommendations, based on a systematic literature review and expert consensus. Higher level of evidence and new insights into nursing care for patients with CIA were added to the recommendation. Level of agreement was obtained by email voting. The search identified 2609 records, of which 51 (41 papers, 10 abstracts), mostly on rheumatoid arthritis, were included. Based on consensus, the task force formulated three overarching principles and eight recommendations. One recommendation remained unchanged, six were reworded, two were merged and one was reformulated as an overarching principle. Two additional overarching principles were formulated. The overarching principles emphasise the nurse’s role as part of a healthcare team, describe the importance of providing evidence-based care and endorse shared decision-making in the nursing consultation with the patient. The recommendations cover the contribution of rheumatology nursing in needs-based patient education, satisfaction with care, timely access to care, disease management, efficiency of care, psychosocial support and the promotion of self-management. The level of agreement among task force members was high (mean 9.7, range 9.6-10.0). The updated recommendations encompass three overarching principles and eight evidence-based and expert opinion-based recommendations for the role of the nurse in the management of CIA.

Background: There is none defined competences framework for Rheumatology Nursing at the moment in Spain. This fact leads to an heterogeneous roles and interventions in each Rheumatology department which has not ever been described nor quantified. Objectives: To describe and quantify the rheumatology Nursing interventions in the Valencian Region (Spain). Methods: A descriptive study was performed by the completion of an online questionnaire with a list of clinical and research intervention. The questionnaire was sent to the Head of Rheumatology Department of 33 public hospitals from the Valencian Region. Results: 32 hospitals of the Valencian Region fulfilled the questionnaire: 15 from Valencia, 13 from Alicante and 4 from Castellon. 50% of the hospitals had a Rheumatology nurse. In those hospitals, 50% had only 1 Rheumatology nurse working at the moment. The maximum Rheumatology nurses working in the same hospitals were 4; 2 hospitals used to have a Rheumatology nurse but do not have it anymore at this moment. 11 hospitals have an auxiliary nurse (3 of them without nurses and 8 with nurses). The year of incorporation of the Rheumatology nurse in the Department was quite heterogeneous, being the earlier in 1992 and the last incorporation in 2017. The nurses worked mainly in a Rheumatology department full time (68.75%). The 81% of the hospitals had an specific nursing agenda but only 7 hospitals had a monographic nurse-led clinic (osteoporosis nurse-led clinic -25%-, intravenous treatments nurse-led clinic -12.5%- or cardiovascular risk nurse-led clinic -6.25%) Nurses clinical interventions are very heterogeneous covering the patient clinical management and practice nurses intervention activities. Nurses organized patient education workshops in 25% hospitals. In 11 hospitals, nurse undertook teaching activities. 56% participating in scientific workshops/congress, 44% teaching undergraduated nurses/registered nurses and 37.5% teaching other healthcare professionals. In 11 hospitals, nurses undertook research activities. In 2 hospitals an specific research nurse was available. 56% of nurses participated in clinical trials, 50% participated in research projects and 50% participated in scientific congress. 25% of nurses lead research projects. In 12 hospitals, nurses belong to a scientific society; in 11 hospitals, nurses participated in regional, national and/or international nurses working groups. Conclusion: In at least 50% of the hospitals from the Valencian Region, nurse activity was registered. There are heterogeneous clinical activities performed by nurses. This fact raised the issue of the importance of having unified criteria for nurse’s intervention and competences framework comparable in each and every hospital. Teaching and research were also a common interventions mentioned. These activities are necessary for a constant recycling and updating of the nurses and will help to gain the necessary visibility for the rheumatology nurses. Disclosure of Interests: None declared

Background Treatment with rituximab (RTX) for rheumatologic diseases may produce hypogammaglobulinemia (hypoglb) (1,2), and that way increase the risk to acquire certain infections (3,4). There are no stablished guides to evaluate and treat hypoglb in these patients. In our hospital, the percentage of patients who develop hypoglb and severe infections is unknown. Objectives To analyse the effect of RTX on immunoglobulin (Ig) levels and to evaluate the severe infections and hepatitis B reactivations that could be related to this treatment. Methods This is a descriptive, retrospective study of patients followed up in the Rheumatology Unit of the Alicante General University Hospital (HGUA) who had received at least one course of RTX. Clinical characteristics and laboratory parameters were obtained from the electronic charts: type of disease, posology and total amount of RTX, Ig levels before and after treatment with RTX, the concomitant treatment with disease-modifying drugs (DMDs), hepatitis B virus’s (HBV) reactivations and infections that required hospitalization. Hypoglb was assessed when IgG Results Finally 106 patients were included, 85 women (80.2%) and 21 men (19.8%). The more frequent conditions were rheumatoid arthritis (47.2%), Sjogren syndrome (16%), Systemic Lupus Eritematosus (13.2%), vasculitis (6.6%) and other connective tissue diseases (10.4%). Characteristics of the sample are shown in table 1. A correct follow up of the Ig levels during the treatment was shown to be undergone in 87.7% of the cases. It was found that 35.8% of the patients presented hypoglb and 13,2% presented severe infections after receiving RTX. No HBV reactivations were found. Among the patients with hypoglb, 78.9% received concomitant treatment with other immunosuppressants (methotrexate 23.6%, leflunomide 23.6%). Hypoglb was more frequent in rheumatoid arthritis (44%), lupus (42.8%) and vasculitis (28.6%). Through simple logistic regression hypoglb during treatment was associated with the presence of previous hypoglb (p=0.025), higher doses received (p=0.01) and longer treatment (p=0.003). In the multiple logistic regression, only low levels of Ig before treatment turned out to be an independent risk factor for hypoglb during treatment (OR 6.86; IC 1.25-37.57). The IgM and IgA levels, but no the IgG levels were significantly lower in patients who has severe infections. Conclusion Hypogammaglobulinemia happens in a third of the patients who receive RTX, especially in those who have low previous IgG levels; therefore a follow up during the treatment should be encouraged. Low IgM and IgA levels during the treatment could also be associated with severe infections. References [1] Christou EAA. Int Rev Immunol. 2017;3:352. [2] Roberts DM. Journal of Autoimmunity 2015;57:60 [3] Gea-Banacloche, JC; Seminars in Hematology 2010;47:187. [4] Salliot C.Ann Rheum Dis 2009;68:25 Disclosure of Interests Andres Fierro: None declared, Mariano Andres: None declared, Jenny de la Torre-Aboki: None declared, Paloma Vela-Casasempere Grant/research support from: UCB, Abbvie, Pfizer, Roche, Bristol-Myer-Squibb (another research, not BIOBADASER related), Consultant for: UCB, Lilly, Pfizer, Roche, Bristol-Myer-Squibb, Speakers bureau: Roche, UCB, MSD, Pfizer, GSK, BMS, Lilly, Maria Paz Martinez-Vidal: None declared

Purpose Evaluate nurse's role in management of patients with rheumatoid arthritis (RA). Methods Modified Delphi with two rounds of questionnaires, followed by in-person meeting. International group of 12 nurses experienced with RA patients receiving biologic therapy. Findings Nurses often spend more time with patients than doctors do. Nurse is in unique position to explore patient needs; educate about treatment, administration, product storage, and self-injection technique; determine readiness for and understanding of treatment; monitor safety and progress; and coordinate care within multidisciplinary setting. Conclusions Nurse's role is complex and vitally important to optimal RA patient care. Additional nurse involvement may address unmet needs. Implications for nursing practice Rheumatology nurses can address unmet patient needs by expanding current roles and by adopting additional functions.

The goal of a nurse-led clinic in the management of rheumatoid arthritis patients is to promote patient independence. Patient education and empowerment are efficacious tools for achieving this. The main nursing care roles are vigilance of physical symptoms, drug toxicity and co-morbidities; management of physical and psychological symptoms; to provide continuity of care. There is evidence supporting the effectiveness of nurse-led clinics and the economic benefits related to it.

To validate the educational needs assessment tool (ENAT) as a generic tool for assessing the educational needs of patients with rheumatic diseases in European Countries.A convenience sample of patients from seven European countries was included comprising the following diagnostic groups: ankylosing spondylitis, psoriatic arthritis, systemic sclerosis, systemic lupus erythematosus, osteoarthritis (OA) and fibromyalgia syndrome. Translated versions of the ENAT were completed through surveys in each country. Rasch analysis was used to assess the construct validity of the adapted ENATs including differential item functioning by culture (cross-cultural DIF). Initially, the data from each country and diagnostic group were fitted to the Rasch model separately, and then the pooled data from each diagnostic group.The sample comprised 3015 patients; the majority, 1996 (66.2%), were women. Patient characteristics (stratified by diagnostic group) were comparable across countries except the educational background, which was variable. In most occasions, the 39-item ENAT deviated significantly from the Rasch model expectations (item-trait interaction χ(2) p0.05). After correction for local dependency (grouping the items into seven domains and analysing them as 'testlets'), fit to the model was satisfied (item-trait interaction χ(2) p0.18) in all pooled disease group datasets except OA (χ(2)=99.91; p=0.002). The internal consistency in each group was high (Person Separation Index above 0.90). There was no significant DIF by person characteristics. Cross-cultural DIF was found in some items, which required adjustments. Subsequently, interval-level scales were calibrated to enable transformation of ENAT scores when required.The adapted ENAT is a valid tool with high internal consistency providing accurate estimation of the educational needs of people with rheumatic diseases. Cross-cultural comparison of educational needs is now possible.

Patients in randomized clinical trials have to adapt themselves to a restricted language to capture the necessary information to determine the safety and efficacy of a new treatment. The aim of this study was to explore the experience of patients with rheumatoid arthritis after completing their participation in a biologic therapy randomized clinical trial for a period of 3 years. A qualitative approach was used. The information was collected using 15 semi-structured interviews of patients with rheumatoid arthritis. Data collection was guided by the emergent analysis until no more relevant variations in the categories were found. The data were analysed using the grounded theory method. The objective of the patients when entering the study was to improve their quality of life by initiating the treatment. However, the experience changed the significance of the illness as they acquired skills and practical knowledge related to the management of their disease. The category “Interactional Empowerment” emerged as core category, as it represented the participative experience in a clinical trial. The process integrates the follow categories: “weight of systematisation”, “working together”, and the significance of the experience: “the duties”. Simultaneously these categories evolved. The clinical trial monitoring activities enabled patients to engage in a reflexive–interpretative mechanism that transformed the emotional and symbolic significance of their disease and improved the empowerment of the patient. A better communicative strategy with the health professionals, the relatives of the patients, and the community was also achieved.

Evaluate nurse's role in management of patients with rheumatoid arthritis (RA).Modified Delphi with two rounds of questionnaires, followed by in-person meeting. International group of 12 nurses experienced with RA patients receiving biologic therapy.Nurses often spend more time with patients than doctors do. Nurse is in unique position to explore patient needs; educate about treatment, administration, product storage, and self-injection technique; determine readiness for and understanding of treatment; monitor safety and progress; and coordinate care within multidisciplinary setting.Nurse's role is complex and vitally important to optimal RA patient care. Additional nurse involvement may address unmet needs.Rheumatology nurses can address unmet patient needs by expanding current roles and by adopting additional functions.

ObjectivesThe authors aim to develop European League Against Rheumatism recommendations for the role of the nurse in the management of patients with chronic inflammatory arthritis, to identify a research agenda and to determine an educational agenda.MethodsA task force made up of a multidisciplinary expert panel including nurses, rheumatologists, occupational therapist, physiotherapist, psychologist, epidemiologist and patient representatives, representing 14 European countries, carried out the development of the recommendations, following the European League Against Rheumatism standardised operating procedures.The task force met twice. In the first meeting, the aims of the task force were defined, and eight research questions were developed. This was followed by a comprehensive, systematic literature search. In the second meeting, the results from the literature review were presented to the task force that subsequently formulated the recommendations, research agenda and educational agenda.ResultsIn total, 10 recommendations were formulated. Seven recommendations covered the contribution of nurses to care and management: education, satisfaction with care, access to care, disease management, psychosocial support, self-management and efficiency of care. Three recommendations focused on professional support for nurses: availability of guidelines or protocols, access to education and encouragement to undertake extended roles. The strength of the recommendations varied from A to C, dependent on the category of evidence (1A–3), and a high level of agreement was achieved. Additionally, the task force agreed upon 10 topics for future research and an educational agenda.Conclusion10 recommendations for the role of the nurse in the management of chronic inflammatory arthritis were developed using a combination of evidence-based and expert consensus approach.

Background The Educational Needs Assessment Tool (the ENAT) is a 39-item patient questionnaire originally developed in the UK to assess educational needs of patients with rheumatoid arthritis (RA). The objective of this study was to assess the cross-cultural validity of the ENAT in 7 European countries. Methods The ENAT was translated into Dutch, Finnish, Norwegian, Portuguese, Spanish and Swedish versions by using Beaton's cross-cultural adaptation process, and was completed by a convenience sample of patients with RA in each country. The generated country-specific data were assessed for construct validity and were then pooled and assessed for cross-cultural invariance using Rasch analysis. Results Individual country-specific analysis showed adequate fit to the Rasch model after adjustment for local dependency within domains. When data from the different countries were pooled, the 39 items deviated significantly from Rasch model's expectations (X2 = 977.055, DF = 351, p = 0.000, PSI = 0.976). Again, most items within domains were found to be locally dependent, significantly affecting the fit. Consequently each domain was treated as a unit (i.e. testlet) and the ENAT was re-analysed as a seven-testlet scale resulting into a good fit to the Rasch model (X2 = 71.909; DF = 63; p = 0.207, PSI = 0.951). A test of strict unidimensionality confirmed that all domains contributed to measuring a single construct. Cross-cultural non-invariance was discounted by splitting domains for DIF maintaining an excellent fit to the Rasch model. This allowed calibration of the ENAT into an interval scale. Conclusion The ENAT is a simple tool, which is a valid measure of educational needs of people with RA. Adjustment for cross-cultural non-invariance is available if data from the 7 European countries are to be pooled or compared.

The goal of a nurse-led clinic in the management of rheumatoid arthritis patients is to promote patient independence. Patient education and empowerment are efficacious tools for achieving this. The main nursing care roles are vigilance of physical symptoms, drug toxicity and co-morbidities; management of physical and psychological symptoms; to provide continuity of care. There is evidence supporting the effectiveness of nurse-led clinics and the economic benefits related to it.