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Objectives: Patients with systemic rheumatic diseases (SRDs) are at risk of admission to the intensive care unit (ICU). Data concerning these critically ill patients are limited to few retrospective studies., Methods: This is a single-centre retrospective study of patients with SRDs admitted to an ICU at the Vienna General Hospital between 2012 and 2020. Single-predictor and multiple logistic regression analysis was performed to identify potential outcome determinants., Results: A total of 144 patients accounting for 192 ICU admissions were included. Connective tissue diseases (CTDs), vasculitides and rheumatoid arthritis were the most common SRDs requiring ICU admission. Leading causes for ICU admission were respiratory failure and shock, as reflected by a high number of patients requiring mechanical ventilation (60.4%) and vasopressor therapy (72.9%). Overall, 29.2% of admissions were due to SRD-related critical illness. In 70.8% patients, co-existent SRD not responsible for the acute critical illness was documented. When comparing these subgroups, CTDs and vasculitides had a higher frequency in the patients with SRD-related critical illness. In a significantly higher proportion of patients in the SRD-related subgroup, diagnosis of SRD was made at the ICU. ICU and 6-month mortality in the overall population was 20.3% and 38.5%, respectively. Age, glucocorticoid therapy prior to hospital admission and disease severity were associated with poor outcome., Conclusions: In this study, respiratory failure was the leading cause of ICU admission as reflected by high rates of required mechanical ventilation. Despite considerable severity of critical illness, survival rates were comparable to a general ICU population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To study the balance between the supply and need for rheumatology care in Austria. In addition, to investigate rheumatologists' work-hours, the amount of time rheumatologists dedicate to care for patients with rheumatic and musculoskeletal diseases (RMD), with non-RMD problems, and other professional activities such as research, teaching, and administration. Methods: A questionnaire covering aspects of professional activities was sent to all 215 rheumatologists registered with the Austrian Medical Association. The data collected was set in relation to the need calculated on the basis of recommendations put forward by the German society of rheumatology. Results: 149 of the 215 rheumatologists (69.0%) responded. Median weekly working time was 50 h (IQR 45-60). 47.4% of the working time was spent for care of patients with RMD. The remaining time was dedicated to patients with non-rheumatic diseases (19.6%), research and teaching (8.4%), and administration (24.5%). The number of full-time equivalents (FTE, based on a 40-h work-week) available for rheumatology care, thus, was calculated to be 178.5. Based on disease prevalence/incidence estimates and on the time allocation results of this survey, our study resulted in a need of 4.29 rheumatologists per 100.000 adult inhabitants (301.79 for an adult population of 7.03 × 10 6 ). Conclusion: The study demonstrated a substantial mismatch between the available supply and the need for rheumatology care. The results of our study are a conservative estimate, which should be taken into consideration for future healthcare workforce planning. In particular, the rising need for rheumatologists should be met by increasing the numbers of those specialists., (Copyright © 2020 Puchner, Vavrovsky, Pieringer, Hochreiter and Machold.)

Musculoskeletal (MSK) diseases affect a substantial proportion of the population. Specialist consultations were offered at the workplace for people with musculoskeletal (MSK)-complaints. We analyzed data on pain and well-being as well as health economic data at baseline. Lasting effects of the consultation were analyzed at a follow-up-interview after 12 months. Baseline data of 344 individuals were available. Occupations were divided into physically highly demanding (HD) or less demanding. Women reported significantly higher pain levels and less QoL than men. Sick leave days were significantly more in HD-workers. Independent of workload, significantly higher percentages of women had cervical- and upper limb-pain than men, with significantly higher pain in upper limbs in HD-workers. 235 participants were available for telephone-follow-up. QoL and MSK-pain improved significantly. Yearly out-of-pocket spendings for treatments significantly increased. NSAID use significantly decreased, whereas use of non-drug musculoskeletal-medical-services was significantly higher after one year. Regarding MSK-symptoms in gainfully employed individuals, the study showed significantly different workload-dependent differences in QoL. Significant effects of a consultation by a MSK-specialist were shown in terms of improved MSK-pain and overall well-being. This workplace-centered consultation had significant effects on beneficial health-behavior such as decreased use of NSAID and increased engagement in gymnastics and physiotherapy.

Background: In the present study, we explored the effects of immediate induction therapy with the anti-tumour necrosis factor (TNF)α antibody infliximab (IFX) plus methotrexate (MTX) compared with MTX alone and with placebo (PL) in patients with very early inflammatory arthritis., Methods: In an investigator-initiated, double-blind, randomised, placebo-controlled, multi-centre trial (ISRCTN21272423, http://www.isrctn.com/ISRCTN21272423 ), patients with synovitis of 12 weeks duration in at least two joints underwent 1 year of treatment with IFX in combination with MTX, MTX monotherapy, or PL randomised in a 2:2:1 ratio. The primary endpoint was clinical remission after 1 year (sustained for at least two consecutive visits 8 weeks apart) with remission defined as no swollen joints, 0-2 tender joints, and an acute-phase reactant within the normal range., Results: Ninety patients participated in the present study. At week 54 (primary endpoint), 32% of the patients in the IFX + MTX group achieved sustained remission compared with 14% on MTX alone and 0% on PL. This difference (p < 0.05 over all three groups) was statistically significant for IFX + MTX vs PL (p < 0.05), but not for IFX + MTX vs MTX (p = 0.10), nor for MTX vs PL (p = 0.31). Remission was maintained during the second year on no therapy in 75% of the IFX + MTX patients compared with 20% of the MTX-only patients., Conclusions: These results indicate that patients with early arthritis can benefit from induction therapy with anti-TNF plus MTX compared with MTX alone, suggesting that intensive treatment can alter the disease evolution., Trial Registration: The trial was registered at http://www.isrctn.com/ISRCTN21272423 on 4 October 2007 (date applied)/12 December 2007 (date assigned). The first patient was included on 24 October 2007.

Importance: High-dose immunosuppressive therapy and autologous hematopoietic stem cell transplantation (HSCT) have shown efficacy in systemic sclerosis in phase 1 and small phase 2 trials., Objective: To compare efficacy and safety of HSCT vs 12 successive monthly intravenous pulses of cyclophosphamide., Design, Setting, and Participants: The Autologous Stem Cell Transplantation International Scleroderma (ASTIS) trial, a phase 3, multicenter, randomized (1:1), open-label, parallel-group, clinical trial conducted in 10 countries at 29 centers with access to a European Group for Blood and Marrow Transplantation-registered transplant facility. From March 2001 to October 2009, 156 patients with early diffuse cutaneous systemic sclerosis were recruited and followed up until October 31, 2013., Interventions: HSCT vs intravenous pulse cyclophosphamide., Main Outcomes and Measures: The primary end point was event-free survival, defined as time from randomization until the occurrence of death or persistent major organ failure., Results: A total of 156 patients were randomly assigned to receive HSCT (n = 79) or cyclophosphamide (n = 77). During a median follow-up of 5.8 years, 53 events occurred: 22 in the HSCT group (19 deaths and 3 irreversible organ failures) and 31 in the control group (23 deaths and 8 irreversible organ failures). During the first year, there were more events in the HSCT group (13 events [16.5%], including 8 treatment-related deaths) than in the control group (8 events [10.4%], with no treatment-related deaths). At 2 years, 14 events (17.7%) had occurred cumulatively in the HSCT group vs 14 events (18.2%) in the control group; at 4 years, 15 events (19%) had occurred cumulatively in the HSCT group vs 20 events (26%) in the control group. Time-varying hazard ratios (modeled with treatment × time interaction) for event-free survival were 0.35 (95% CI, 0.16-0.74) at 2 years and 0.34 (95% CI, 0.16-0.74) at 4 years., Conclusions and Relevance: Among patients with early diffuse cutaneous systemic sclerosis, HSCT was associated with increased treatment-related mortality in the first year after treatment. However, HCST conferred a significant long-term event-free survival benefit., Trial Registration: isrctn.org Identifier: ISRCTN54371254.

In light of the recent emergence of new therapeutics for rheumatoid arthritis, such as kinase inhibitors and biosimilars, a new nomenclature for disease-modifying antirheumatic drugs (DMARDs), which are currently often classified as synthetic (or chemical) DMARDs (sDMARDS) and biological DMARDs (bDMARDs), may be needed. We propose to divide the latter into biological original and biosimilar DMARDs (boDMARDs and bsDMARDs, respectively, such as abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab or tocilizumab, but also emerging ones like clazakizumab, ixekizumab, sarilumab, secukinumab or sirukumab) and the former into conventional synthetic and targeted synthetic DMARDs (csDMARDs and tsDMARDs, respectively). tsDMARDs would then constitute only those that were specifically developed to target a particular molecular structure (such as tofacitinib, fostamatinib, baricitinib or apremilast, or agents not focused primarily on rheumatic diseases, such as imatinib or ibrutinib), while csDMARDs would comprise the traditional drugs (such as methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, gold salts and others). The proposed nomenclature may provide means to group and distinguish the different types of DMARDs in clinical studies and review articles.

Objective: Sonography, as compared with clinical assessment, is a sensitive tool for evaluating synovitis in rheumatoid arthritis (RA). However, differences between these assessment tools may depend on how joint activity (i.e., an active joint) is defined. The present study was undertaken to compare clinically active joints with sonographically active joints in patients with RA, applying different sonographic definitions of an active joint., Methods: Sonographic assessment of the finger and wrist joints (total of 11 joints) of each hand was performed in RA patients whose disease was in remission (Clinical Disease Activity Index ≤2.8; n = 60). Gray-scale (GS) and power Doppler (PD) ultrasound signals for synovitis were evaluated on a 4-point scale (grade 0 = none, grade 3 = severe). The sensitivity and specificity of swollen joint counts were investigated using, as reference, increasingly stringent sonographic definitions of an active joint. Sonographic findings were also assessed for correlations with other clinical variables, including the Health Assessment Questionnaire (HAQ) disability index (DI). Followup analyses were performed after 6-12 months., Results: GS ultrasound signals yielded positive findings for synovitis in 67.2% of the 1,320 joints assessed, and PD ultrasound signals indicated signs of synovitis in 20.4% of the joints assessed. Clinical identification of joint swelling was 100% specific for sonographic joint activity, independent of the stringency of the sonographic definition used; maximum sensitivity of the swollen joint counts was 25% for the most stringent definition (i.e., GS grade 3 and PD grade 3). Furthermore, patients with a higher-grade PD signal (grade 3) showed a higher HAQ DI score compared to patients with lower-grade PD signals (mean ± SD HAQ DI 0.45 ± 0.62 versus 0.20 ± 0.35). A higher grade of PD signal at baseline was found in joints that were assessed as clinically swollen at the consecutive followup visit., Conclusion: Low-grade PD and GS ultrasound signals may not necessarily reflect the presence of active synovitis in RA joints. High-grade PD signals correlate well with the presence of clinical joint swelling and clinical disease activity, and a higher grade of PD signal is associated with higher degrees of functional impairment., (Copyright © 2013 by the American College of Rheumatology.)

Objective: Performance of the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) criteria was analysed in an internationally recruited early arthritis cohort (≤16 weeks symptom duration) enrolled in the 'Stop-Arthritis-Very-Early' trial. This sample includes patients with a variety of diseases diagnosed during follow-up., Methods: Two endpoints were defined: Investigators' diagnosis and disease-modifying antirheumatic drug (DMARD) treatment start during the 12-month follow-up. The 2010 criteria were applied to score Patients' baseline data. Sensitivity, specificity, predictive values and areas under the receiver operating curves of this scoring with respect to both endpoints were calculated and compared to the 1987 criteria. The optimum level of agreement between the endpoints and the 2010 classification score ways estimated by Cohen's ϰ coefficients., Results: 303 patients had 12-months follow-up. Positive predictive values of the 2010 criteria were 0.68 and 0.71 for RA-diagnosis and DMARD-start, respectively. Sensitivity for RA-diagnosis was 0.85, for DMARD-start 0.8, whereas the 1987 criteria's sensitivities were 0.65 and 0.55. The areas under the receiver operating curves of the 2010 criteria for RA-diagnosis and DMARD-start were 0.83 and 0.78. Analysis of inter-rater-agreement using Cohen's ϰ demonstrated the highest ϰ values (0.5 for RA-diagnosis and 0.43 for DMARD-start) for the score of 6., Conclusions: In this international very early arthritis cohort predictive and discriminative abilities of the 2010 ACR/EULAR classification criteria were satisfactory and substantially superior to the 'old' 1987 classification criteria. This easier classification of RA in early stages will allow targeting truly early disease stages with appropriate therapy.

Background/objective: Current therapies for psoriatic arthritis (PsA) comprise synthetic drugs and tumour necrosis factor inhibitors. In contrast, other biologicals including rituximab (RTX) are available for treating rheumatoid arthritis (RA). RTX is effective in autoantibody positive RA patients, although some efficacy has been reported in seronegative individuals. RTX has not yet been assessed in PsA. Therefore, an open label study of RTX in PsA was performed., Patients and Methods: Nine patients with PsA and 14 with RA received RTX at 1000 mg twice within 14 days and were evaluated over 6 months., Results: A PsA response criteria response was attained in 56% of patients. DAS28 improved from 6.2 to 4.9 (medians) in PsA and 6.4 to 5.2 in RA, and Health Assessment Questionnaire from 1.5 to 1.0 and from 2.1 to 1.4, respectively (all p≤0.05). Disease Activity index for PSoriatic Arthritis changed from 52.0 to 32.5 (p<0.05); C reactive protein and Psoriasis Area and Severity Index did not change significantly. RTX was tolerated well., Conclusions: In this exploratory open study, RTX exhibited significant efficacy in PsA patients with long-standing disease. Thus, RTX may have efficacy in PsA warranting a randomised controlled clinical trial.

The Study Group for Risk Factors for Rheumatoid Arthritis was established by the EULAR Standing Committee on Investigative Rheumatology to facilitate research into the preclinical and earliest clinically apparent phases of rheumatoid arthritis (RA). This report describes the recommendation for terminology to be used to define specific subgroups during different phases of disease, and defines the priorities for research in this area. Terminology was discussed by way of a three-stage structured process: A provisional list of descriptors for each of the possible phases preceding the diagnosis of RA were circulated to members of the study group for review and feedback. Anonymised comments from the members on this list were fed back to participants before a 2-day meeting. 18 participants met to discuss these data, agree terminologies and prioritise important research questions. The study group recommended that, in prospective studies, individuals without RA are described as having: genetic risk factors for RA; environmental risk factors for RA; systemic autoimmunity associated with RA; symptoms without clinical arthritis; unclassified arthritis; which may be used in a combinatorial manner. It was recommended that the prefix 'pre-RA with:' could be used before any/any combination of the five points above but only to describe retrospectively a phase that an individual had progressed through once it was known that they have developed RA. An approach to dating disease onset was recommended. In addition, important areas for research were proposed, including research of other tissues in which an adaptive immune response may be initiated, and the identification of additional risk factors and biomarkers for the development of RA, its progression and the development of extra-articular features. These recommendations provide guidance on approaches to describe phases before the development of RA that will facilitate communication between researchers and comparisons between studies. A number of research questions have been defined, requiring new cohorts to be established and new techniques to be developed to image and collect material from different sites.

Objectives: Rheumatologist assessment as early as possible is considered essential for patients with inflammatory joint disease. In our Very Early Arthritis Clinic (VEAC), a substantial proportion of initially included and followed patients later stop attendance in the clinic. We questioned attending (AP) and non-attending patients (NAP) regarding current health status and satisfaction with care as well as reasons for discontinuation and current care received by NAP., Methods: VEAC patients first seen between 1996 and 2003 were included. Assessment included the RADAI, HAQ, and visual analogue scales for pain, disease activity, fatigue, satisfaction with current health care. Current (DMARD) treatment was recorded., Results: Among AP, 87% had rheumatoid arthritis (RA) and 13% non-RA. Of NAP, 37% had RA, 23% non-RA and 40% no more rheumatic disease. Satisfaction with health care concerning rheumatic disease was better in AP than NAP. Likewise, most outcome parameters were better in AP. Substantially more RA patients in the AP than NAP group received DMARDs. Apart from the disappearance of arthritis, logistic reasons were given most frequently for discontinuation of attendance. Less than 10% of NAP indicated dissatisfaction with medical care., Conclusions: We found advantages in both disease activity measures and satisfaction with health care for patients receiving continuous care in a highly specialised Rheumatology clinic. Furthermore, different DMARD usage in RA in AP and NAP may indicate significant deficits in treatment quality outside specialist care. Logistic issues associated with access to continuous Rheumatology care for early arthritis patients need improvement.

Objective and Methods: In order to facilitate access and shorten waiting times to rheumatologist assessment, an immediate access clinic (IAC) was established. Patients were assessed at presentation in the clinic and after 6-12 months, either in the clinic or by telephone. Data regarding diagnostic accuracy, pain levels and care were analysed., Results: From February to December 2009, 1036 patients were assessed. 223 (21.5%) patients had symptoms for 3 months or less. 660 were available for re-assessment after 6-12 months. Initial tentative diagnoses were confirmed in over 75% of patients suspected of having rheumatoid arthritis (RA), spondylarthropathy and osteoarthritis. Men suspected of having spondylarthropathy had a significantly longer symptom duration than women (median (IQR) 54.0 (18.0-120.0) vs 24.0 (6.0-66.0) months; p=0.0082). There was no significant gender difference regarding pain. At follow-up, the visual analogue scale for pain in RA patients admitted to further care in the clinic (n=61) had significantly decreased by a median (IQR) of 37.5 mm (10.5-50.5), whereas this improvement was only 6 mm (-26-33.5) in the 22 RA patients followed outside the clinic (p=0.0083)., Conclusions: The IAC resulted in considerable waiting time reduction for rheumatology assessment. A substantial minority was seen before 3 months' symptom duration. 'Positive predictive correctness' of the assessing rheumatologists regarding the presence of inflammatory rheumatic conditions was over 75%. Patients with RA cared for in the clinic had substantially lower pain levels after 6-12 months' follow-up than patients treated elsewhere.

Objective: To describe the experiences of people with systemic sclerosis (SSc) in different European countries of functioning and health and to link these experiences to the WHO International Classification of Functioning, Disability and Health (ICF) to develop a common understanding from a bio-psycho-social perspective., Method: A qualitative multicentre study with focus-group interviews was performed in four European countries: Austria, Romania, Sweden and Switzerland. The qualitative data analysis followed a modified form of 'meaning condensation' and the concepts that emerged in the analysis were linked to the ICF., Results: 63 people with SSc participated in 13 focus groups. In total, 86 concepts were identified. 32 (37%) of these were linked to the ICF component body functions and structures, 21 (24%) to activities and participation, 26 (30%) to environmental factors, 6 (7%) to personal factors and 1 (1%) to the health condition itself. 19 concepts (22%) were identified in all four countries and included impaired hand function, household activities, paid work, drugs, climate and coldness, support from others and experiences with healthcare institutions, non-pharmacological treatment, social security and benefits., Conclusion: Concepts identified in all four countries could be used for guiding clinical assessment, as well as interdisciplinary team care and rheumatological rehabilitation for patients with SSc. For a full understanding of the aspects of the disease that were most relevant to people with SSc, people with SSc from multiple countries needed to be involved.

Objective: The aim of the present study was to explore how contextual factors affect the everyday activities of women and men with rheumatoid arthritis (RA), as evident in their life stories., Methods: Fifteen people with RA, who had retired early due to the disease, were interviewed up to three times, according to a narrative biographic interview style. The life stories of the participants, which were reconstructed from the biographical data and from the transcribed 'told story' were analysed from the perspective of contextual factors, including personal and environmental factors. The rigour and accuracy of the analysis were enhanced by reflexivity and peer-review of the results., Results: The life stories of the participants in this study reflected how contextual factors (such as gender, the healthcare system, the support of families and social and cultural values) shaped their everyday activities. In a society such as in Austria, which is based on traditional patriarchal values, men were presented with difficulties in developing a non-paid-work-related role. For women, if paid work had to be given up, they were more likely to engage in alternative challenging activities which enabled them to develop reflective skills, which in turn contributed to a positive and enriching perspective on their life stories. Health professionals may thus use some of the women's strategies to help men., Conclusion: Interventions by health professionals in people with RA may benefit from an approach sensitive to personal and environmental factors.

Advances in treatment of rheumatoid arthritis have made it possible to profoundly influence signs and symptoms as well as the course of joint destruction in inflammatory arthritis. Earlier and more efficient treatment appears to significantly improve the prognosis of this disease. Despite these advances, cure (the absence of signs and symptoms without further treatment) is still relatively rare, observable in, at most, 20% of the patients. Remission (or a state of very low disease activity), however, has been observed with intense and individually tailored treatment in up to 75% of patients. The use of structured assessments followed by individual modification of the intensity of treatment aiming for remission leads to better clinical responses and radiological outcomes. It remains to be seen whether earlier and more aggressive treatment of patients with not yet 'fully established' rheumatoid arthritis may succeed in preventing at least some of them from progressing to destructive arthritis., (Copyright 2009 Elsevier Ltd. All rights reserved.)

Objective: Specific composite indices assessing disease activity in psoriatic arthritis (PsA) have not yet been sufficiently validated. The objective of this study was to identify instruments best reflecting disease activity in PsA., Methods: Measures for inclusion in clinical trials, as recommended by the OMERACT-7/8 PsA workshops, were assessed. A principal component analysis (PCA) was performed with cross-sectional data of 105 patients with PsA to identify a minimal set of important dimensions for a disease activity assessment tool for PsA. This was compared with components contained in existing composite indices., Results: The PCA revealed four principal components best reflecting disease activity. The first contained patient global and pain assessment; the second contained 66/68 swollen and tender joint counts as main variables; C-reactive protein (CRP) best loaded to the third component; and the fourth was loaded by skin assessment but did not reach significance. When comparing the three significant principal components with items of established composite measures, they were best covered by the Disease Activity Index for Reactive Arthritis (DAREA) which comprises patient pain and global assessments, 66/68 joint counts and CRP., Conclusion: Among the currently available indices used in arthritic conditions, the DAREA best reflects the domains found to be important in PsA.

Background: Glucocorticoids (GCs) are often used as early arthritis treatment and it has been suggested that they induce remission or at least delay the development of rheumatoid arthritis (RA) and the need to start disease-modifying antirheumatic drugs (DMARDs)., Objective: To test the effect of GCs on patients with very early arthritis (symptom duration of <16 weeks) in a randomised controlled trial., Methods: Patients received a single intramuscular injection of 120 mg methylprednisolone or placebo (PL) and were followed up for 52 weeks. Primary end point was drug-free clinical remission, both at weeks 12 and 52. Among secondary outcomes were fulfillment of remission criteria at weeks 2, 12 or 52, time course of 'core set variables' and proportion of patients starting DMARDs., Results: 17.0% of all analysed subjects (65/383) achieved persistent remission: 17.8% (33/185) of the PL group, 16.2% (32/198) of the patients receiving methylprednisolone (OR=1.13, 95% CI 0.66 to 1.92, p=0.6847). Analyses of secondary end points showed significant clinical benefits of the GC only at week 2. These differences subsequently disappeared. DMARDs were started in 162 patients: 50.3% methylprednisolone and 56.7% PL patients had to start DMARD treatment (OR=0.78, 95% CI 0.49 to 1.22, p=0.30). Significantly more patients with polyarthritis than with oligoarthritis received DMARDs (OR=2.84, 95% CI 1.75 to 4.60, p<0.0001)., Conclusions: Neither remission nor development of RA is delayed by GC treatment. Remission is rare in the first year of very early arthritis, occurring in <20% of the patients. Also, the need to start DMARDs was not influenced by GC treatment.

Early diagnosis and therapy of persisting (or chronic) polyarthritis is essential for preventing permanent damage. The guidelines of the German Society for Rheumatology recommend referral to a rheumatologist 6 weeks (at the latest) after symptom onset. DMARD therapy should be initiated within 12 weeks. Even earlier, high titer rheumatoid factor, detectable antibodies to CCP, or early erosion, constitute firm arguments for initiating DMARD therapy in patients with arthritis. At this time point, fast acting combination therapy frequently achieves remission or at least low disease activity. Since TNF blockers are not commonly available for first line therapy, corticosteroids should accompany DMARD initiation. Sufficient capacity in early consultation at arthritis clinics, optimized communication with primary care physicians and sensibilisation of the entire population are essential to prevent permanent damage in as many patients as possible.

As resources in health care systems become increasingly scarce, rheumatologists may need to provide evidence that their quality of care uses the allocated resources effectively by achieving a good outcome for patients with rheumatoid arthritis (RA). In order to assess quality, it has been recommended in other areas of medicine to gather data according to appropriate outcome measures, preferably in electronic databases, enabling identification of benchmarks to compare the outcome quality of different clinical settings. Available electronic applications commonly comprise a database for data processing and storage, as well as a tool for regularly measuring and following disease activity in individual patients. Access to aggregated data makes it possible to monitor disease activity in individual patients over time in relation to treatment. In addition, electronic applications should allow the extraction of patient data according to special characteristics for analysis. In this way, such electronic applications can provide a central database that can be used for monitoring patients in routine care, case studies or general research, as well as facilitating comparisons of quality of care in different centres or in different countries for reference purposes.

Objectives: To obtain data on the care received by individuals counselled during a public health awareness campaign on painful musculoskeletal conditions (MSC)., Methods: Easy non-formal access to rheumatologists/pain specialists was offered using a mobile unit (Rheuma-Bus) at widely accessible sites. Clients were asked to assess their severity of pain using a 100 mm visual analogue scale (VAS). Age, gender, disease duration, diagnosis if known, current and previous treatment as well as tentative diagnoses assigned and recommendations given to each individual by the counselling physicians were recorded., Results: Average (SD) VAS pain rating was 59 (20.6) mm. Approximately 40% of clients had never consulted a physician for their condition before, but had lower pain scores than those who had seen a physician. Patients with inflammatory MSC had higher pain scores than those with non-inflammatory conditions. More than 2% of the clients had a newly detected inflammatory rheumatic disease., Conclusions: Many individuals having painful MSC seek medical help only when a very high threshold of pain is reached. Even while under treatment, the high mean pain scores suggest neglect of MSC that are not adequately recognised as important contributors to disability and decreased quality of life.

Objectives: Despite early recognition and disease modifying anti-rheumatic drug (DMARD) treatment, a sizable proportion of early rheumatoid arthritis (RA) patients show radiological progression. This study was performed to determine the frequency of erosive arthritis and the pace of radiological progression in an inception cohort of patients with very early RA (

Current treatment strategies aim to achieve clinical remission in order to prevent the long-term consequences of rheumatoid arthritis (RA). Several composite indices are available to assess remission. All of them include joint counts as the assessment of the major 'organ' involved in RA, but some employ reduced joint counts, such as the 28-joint count, which excludes ankles and feet. The aim of the present study was to determine the relevance of excluding joints of the ankles and feet in the assessment of RA disease activity and remission. Using a longitudinal observational RA dataset, we analyzed 767 patients (80% female, 60% rheumatoid factor-positive), for whom joint counts had been recorded at 2,754 visits. We determined the number of affected joints by the 28-JC and the 32-JC, the latter including ankles and combined metatarso-phalangeal joints (as a block on each side). Several findings were supportive of the validity of the 28-joint count: (a) Absence of joint swelling on the 28-joint scale had a specificity of 98.1% and a positive predictive value (PPV) of 94.1% for the absence of swelling also on the 32-joint scale. For absence of tender joints, the specificity and PPV were 96.1% and 91.7%, respectively. (b) Patients with swollen or tender joints in the 32-JC, despite no joint activity in the 28-JC, were clearly different with regard to other disease activity measures. In particular, the patient global assessment of disease activity was higher in these individuals. Thus, the difference in the joint count was not relevant for composite disease activity assessment. (c) The disease activity score based on 28 joints (DAS28) may reach levels higher than 2.6 in patients with feet swelling since these patients often have other findings that raise DAS28. (d) The frequency of remission did not change when the 28-JC was replaced by 32-JC in the composite indices. (e) The changes in joint activity over time were almost identical in longitudinal analysis. The assessment of the ankles and feet is an important part in the clinical evaluation of patients with RA. However, reduced joint counts are appropriate and valid tools for formal disease activity assessment, such as done in composite indices.

Objective: To explore the effect of infrared radiation of a tiled stove on patients with hand osteoarthritis (OA)., Methods: A randomized controlled crossover study was performed with 45 patients with hand OA. This sample was randomly assigned to two groups: group A [first 3 hours spent three times a week during 3 weeks in a heated tiled stove room ('Stove Period') and after 2 weeks without treatment this group was observed for another 3 weeks ('Control Period')]; and group B (first assigned to the control period and the stove period following the treatment-free period). Assessments included the visual analogue scale (VAS) for general pain, pain in the hands, and global hand function, grip strength, the Moberg Picking-up Test (MPUT), the Australian/Canadian Osteoarthritis Hand Index (AUSCAN), and the Medical Outcomes Study (MOS) 36-item Short-Form Health Status Survey (SF-36)., Results: Fourteen (31%) patients improved on the VAS for general pain at the end of the tiled stove period as compared to 10 patients (22%) during the control period (p = 0.314, chi2-test). The AUSCAN pain domain showed a significant improvement after the tiled stove period (p = 0.034). Others pain parameters analysed (VAS for pain in hands and SF-36 bodily pain) showed moderate but not significant improvement (p = 0.682 and p = 0.237, respectively) compared to the control period., Conclusion: This study did not prove positive effects of the tiled stove exposure, although the numerical improvement in all pain measures suggests some possible positive effects on this symptom of hand OA.

Objective: To investigate the perception of values of individual core set measures by rheumatologists, and how it differs across measures and across physicians., Methods: We designed a survey in which 44 international expert rheumatologists explicitly marked positions on the scales of seven core-set measures that in their opinion corresponded to cut-points between remission, low, moderate and high disease activity. The measures comprised swollen and tender joint counts (SJC, TJC), CRP, ESR, patient and evaluator global assessments of activity (PGA, EGA), and the Health Assessment Questionnaire Disability Index (HAQ)., Results: The interpretation of measures across physicians was most consistent for ESR and PGA, while for CRP and joint counts there was most variation. Joint counts and CRP implied active disease at lower relative values (using normalized scales) than did PGA, EGA or ESR (P < 0.01 for most comparisons; Bonferroni-adjusted Wilcoxon signed rank test), and most physicians tended to tolerate higher numbers of tender joints than swollen joints to define similar levels of disease activity. Given these cut-points, more RA patients in a typical cross-sectional cohort would be regarded as being in remission according to joint counts (SJC, 35%; TJC, 55%) than to global scores (PGA, 18%; EGA, 9%), and fewer patients would be regarded as being in remission by physician-derived or laboratory measures than by patient-derived ones., Conclusion: These data give insights into the integrative process of activity evaluation and will be informative for future survey designs, studies using physician opinion as the gold standard for criterion validity of disease activity, and allow 'activity mapping' of values on different scales based on expert opinion.

Effectiveness of therapy with individual disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) is limited, and the number of available DMARDs is finite. Therefore, at some stage during the lengthy course of RA, institution of traditional DMARDs that have previously been applied may have to be reconsidered. In the present study we investigated the effectiveness of re-employed methotrexate in patients with a history of previous methotrexate failure (original course). A total of 1,490 RA patients (80% female, 59% rheumatoid factor positive) were followed from their first presentation, yielding a total of 6,470 patient-years of observation. We identified patients in whom methotrexate was re-employed after at least one intermittent course of a different DMARD. We compared reasons for discontinuation, improvement in acute phase reactants, and cumulative retention rates of methotrexate therapy between the original course of methotrexate and its re-employment. Similar analyses were peformed for other DMARDs. Methotrexate was re-employed in 86 patients. Compared with the original courses, re-employment was associated with a reduced risk for treatment termination because of ineffectiveness (P = 0.02, by McNemar test), especially if the maximum methotrexate dose of the original course had been low (<12.5 mg/week; P = 0.02, by logistic regression). In a Cox regression model, re-employed MTX was associated with a significantly reduced hazard of treatment termination compared with the original course of methotrexate, adjusting for dose and year of employment (hazard ratio 0.64, 95% confidence interval 0.42-0.97; P = 0.04). These findings were not recapitulated in analyses of re-employment of other DMARDs. Re-employment of MTX despite prior inefficacy, but not re-employment of other DMARDs, is an effective therapeutic option, especially in those patients in whom the methotrexate dose of the original course was low.

There is increasing evidence for beneficial effects of early DMARD (disease-modifying antirheumatic drug) therapy over delayed treatment in patients who present with arthritis of recent onset. However, no universal consensus exists concerning the choice of initial drug or whether single drugs or combinations should be given as initial treatments. Recent studies have focused on the benefits of various strategies in which treatments were tailored to achieve low levels of disease activity, as assessed using validated response criteria. These studies demonstrated superiority of 'aggressive' over 'conventional' approaches. Whether the inclusion of tumour necrosis factor antagonists or other biologic targeted therapies in such strategies confers additional benefits in terms of improved long-term outcomes must be clarified by further studies. Assessment of risks in the individual patient, allowing individual 'tailoring' of the initial treatment, would be desirable.

Ultrasound (US) has great potential as an outcome in rheumatoid arthritis trials for detecting bone erosions, synovitis, tendon disease, and enthesopathy. It has a number of distinct advantages over magnetic resonance imaging, including good patient tolerability and ability to scan multiple joints in a short period of time. However, there are scarce data regarding its validity, reproducibility, and responsiveness to change, making interpretation and comparison of studies difficult. In particular, there are limited data describing standardized scanning methodology and standardized definitions of US pathologies. This article presents the first report from the OMERACT ultrasound special interest group, which has compared US against the criteria of the OMERACT filter. Also proposed for the first time are consensus US definitions for common pathological lesions seen in patients with inflammatory arthritis.

Background: Early treatment prevents progression of joint damage in rheumatoid arthritis (RA), but diagnosis in early disease is impeded by lack of appropriate diagnostic criteria., Objective: To study the value of rheumatoid factor (RF), anti-cyclic citrullinated peptide autoantibodies (anti-CCP), and anti-RA33 autoantibodies for diagnosis of RA and prediction of outcome in patients with very early arthritis., Methods: The prospective follow up inception cohort included 200 patients with very early (<3 months) inflammatory joint disease. Autoantibodies were measured at baseline and analysed in a tree based model which aimed at determining the added diagnostic value of testing for anti-CCP and anti-RA33 as compared with RF alone., Results: RA was diagnosed in 102 patients, while 98 developed other inflammatory arthropathies. Receiver operator curve analysis showed an optimum cut off level for RF at 50 U/ml, above which anti-CCP and anti-RA33 had no additional diagnostic value. Remarkably, RF >or=50 U/ml and anti-CCP showed similar sensitivity and high specificity for RA, but overlapped considerably. Anti-RA33 was less specific and did not correlate with RF or anti-CCP. Among patients with RA, 72% showed at least one of these three autoantibodies, compared with 15% of non-RA patients. RF >or=50 U/ml and anti-CCP were predictors of erosive disease, whereas anti-RA33 was associated with mild disease., Conclusions: Stepwise autoantibody testing in early inflammatory joint disease, starting with RF, followed by anti-CCP (in patients with RF <50 U/ml), and finally anti-RA33, should be used as a sensitive and effective strategy for distinguishing patients with RA at high risk for poor outcome.

Objective: Several composite scores are available to assess the activity of rheumatoid arthritis (RA). Criteria for remission and active RA based on these continuous scores are important for use in clinical practice and clinical trials. We aimed to reevaluate or to define such criteria for the Disease Activity Score in 28 joints (DAS28) and the Simplified Disease Activity Index (SDAI)., Methods: We sampled patient profiles from an observational RA database that included clinical and laboratory variables. Thirty-five rheumatology experts classified these profiles into 1 of 4 categories: remission, low, moderate, or high disease activity. Cutoff values were estimated by mapping scores on the DAS28 and SDAI to these ratings, and analyses of agreement (kappa statistics) and a diagnostic testing approach (receiver operating characteristic curves) were used to validate the estimates. The final criteria were validated using 2 observational cohorts (a routine cohort of 767 patients and an inception cohort of 91 patients)., Results: Results from the 3 analyses were very similar and were integrated. The criteria for separating remission, low, moderate, and high disease activity based on the SDAI were scores of 3.3, 11, and 26, respectively; those based on the DAS28 were scores of 2.4, 3.6, 5.5, respectively. In the routine cohort, these cutoff values showed substantial agreement (weighed kappa = 0.70) and discriminated between groups of patients with clearly different functional capacities (P < 0.001). In the inception cohort, these cutoff scores differentiated responders (those with a 20% response on the American College of Rheumatology improvement criteria) from nonresponders (P < 0.01), as well as patients with and without radiologic progression (P < 0.05)., Conclusion: New criteria for levels of RA disease activity were determined and internally validated. These criteria, which are based on current and explicit expert judgment, are valuable in this era of rapidly advancing therapeutic approaches.

Objective: To evaluate the interobserver reliability among 14 experts in musculoskeletal ultrasonography (US) and to determine the overall agreement about the US results compared with magnetic resonance imaging (MRI), which served as the imaging "gold standard"., Methods: The clinically dominant joint regions (shoulder, knee, ankle/toe, wrist/finger) of four patients with inflammatory rheumatic diseases were ultrasonographically examined by 14 experts. US results were compared with MRI. Overall agreements, sensitivities, specificities, and interobserver reliabilities were assessed., Results: Taking an agreement in US examination of 10 out of 14 experts into account, the overall kappa for all examined joints was 0.76. Calculations for each joint region showed high kappa values for the knee (1), moderate values for the shoulder (0.76) and hand/finger (0.59), and low agreement for ankle/toe joints (0.28). kappa Values for bone lesions, bursitis, and tendon tears were high (kappa = 1). Relatively good agreement for most US findings, compared with MRI, was found for the shoulder (overall agreement 81%, sensitivity 76%, specificity 89%) and knee joint (overall agreement 88%, sensitivity 91%, specificity 88%). Sensitivities were lower for wrist/finger (overall agreement 73%, sensitivity 66%, specificity 88%) and ankle/toe joints (overall agreement 82%, sensitivity 61%, specificity 92%)., Conclusion: Interobserver reliabilities, sensitivities, and specificities in comparison with MRI were moderate to good. Further standardisation of US scanning techniques and definitions of different pathological US lesions are necessary to increase the interobserver agreement in musculoskeletal US.

Rheumatoid arthritis (RA) therapy rests primarily on the use of disease-modifying antirheumatic drugs (DMARDs). It has been unequivocally shown that DMARD therapy early in the course of RA retards progression of damage and disability to a larger degree compared with delayed institution; the most effective DMARD is methotrexate (MTX). Moreover, combination therapy including intermediate to high doses of glucocorticoids and combinations of MTX with tumour necrosis factor blockers are more effective than monotherapies. However, early DMARD treatment requires early referral of patients and early diagnosis. This is hampered by the current lack of classification criteria for early RA, since the aim is to prevent destruction from occurring, while RA is typically characterized by the presence of erosions. Novel treatment strategies and therapeutic agents allow us to aim for remission rather than improvement of disease activity. Whether a 'window of opportunity' exists during which effective therapy might lead to cure is still an open issue and will be the focus of clinical trials in the near future.

Objective: To compare the content of clinical, occupation-based instruments that are used in adult rheumatology and musculoskeletal rehabilitation in occupational therapy based on the International Classification of Functioning, Disability and Health (ICF)., Methods: Clinical instruments of occupational performance and occupation in adult rehabilitation and rheumatology were identified in a literature search. All items of these instruments were linked to the ICF categories according to 10 linking rules. On the basis of the linking, the content of these instruments was compared and the relationship between the capacity and performance component explored., Results: The following 7 instruments were identified: the Canadian Occupational Performance Measure, the Assessment of Motor and Process Skills, the Sequential Occupational Dexterity Assessment, the Jebson Taylor Hand Function Test, the Moberg Picking Up Test, the Button Test, and the Functional Dexterity Test. The items of the 7 instruments were linked to 53 different ICF categories. Five items could not be linked to the ICF. The areas covered by the 7 occupation-based instruments differ importantly: The main focus of all 7 instruments is on the ICF component activities and participation. Body functions are covered by 2 instruments. Two instruments were linked to 1 single ICF category only., Conclusion: Clinicians and researchers who need to select an occupation-based instrument must be aware of the areas that are covered by this instrument and the potential areas that are not covered at all.

Objective: To determine if rheumatologists have changed their views on diagnosis and treatment of early rheumatoid arthritis (RA)., Methods: Three consecutive questionnaires were sent out to international rheumatologists in 1997, 2000, and 2003. The following aspects of early RA were covered: definition; patient referral time; diagnostic means; follow up intervals; and treatment strategies. All initial participants who responded to at least one of the follow up surveys were included in the analysis., Results: RA is now defined by a smaller number of affected joints (monarthritis: 9.8% respondents in 1997 v 17.4% in 2003), and shorter symptom duration (<3 months: 65.5% in 1997 v 85.8% in 2003). Early referrals (<6 weeks) increased (8.9% in 1997 v 17.4% in 2003). Serological test for diagnosis was mostly rheumatoid factor (100% in 2003), but anti-CCP was already used by 17.4% in 2003. Follow up of patients with early RA intensified (every 2 weeks: 16.1% in 1997 v 30.4% in 2003; every month: 47.8% in 2003 v 64.3% in 1997). Treatment with disease modifying antirheumatic drugs (DMARDs) mainly comprised methotrexate, sulfasalazine, and antimalarial drugs. Leflunomide was among the two favourite DMARDs of 10.9% in 2003, whereas no biological agent was so. In 2003, 46.7% respondents started treatment with DMARDs if RA was suspected (30.9% in 1997); no one waited for erosions to occur (7.3% in 1997)., Conclusion: The data obtained in this study suggest that the concept of diagnosing and treating RA early is accepted by a large proportion of the rheumatological community.

Objective: Delay of disease-modifying anti-rheumatic drug (DMARD) therapy is a major contributing factor for poor outcome in rheumatoid arthritis (RA). Although early therapy has been shown to be particularly effective, there is still uncertainty about the optimal time point of DMARD introduction. We wanted to test if a therapeutic window of opportunity may exist within the first few months of the disease., Methods: In this case-control parallel-group study, 20 very early RA (VERA) patients with median disease duration of 3 months were age and gender matched to a group of 20 late early RA (LERA) patients with median disease duration of 12 months until first DMARD initiation. Follow-up time was 36 months. Primary outcome measures were the disease activity score (DAS28) and radiological joint destruction using the Larsen method., Results: Already after 3 months of DMARD therapy we found a significant difference of improvement in favour of the VERA patients in the DAS28. This trend continued over the study period. At study end the DAS28 showed an improvement of 2.8+/-1.5 in the VERA vs 1.7+/-1.2 in the LERA group (P(c)<0.05). The Larsen scores showed a statistically significant retardation of progression in the VERA compared with the LERA., Conclusion: Our results indicate that there is a window of opportunity for highly successful treatment of RA in the first year, and especially within the first 3 months of therapy. Thus, early diagnosis and therapy may be the crucial step in achieving optimal control of disease progression and prognosis in RA.

The Austrian Early Arthritis Registry (Austrian Early Arthritis Action, EAA) enrols and follows patients with inflammatory arthritis of very short (< 12 weeks) duration. Currently, data on 375 patients (almost 2000 individual follow-up examinations) have been entered into the EA database. Evaluations of data from 182 patients with a follow-up of at least one year are available. 65% of these patients have RA, as diagnosed using the ACR classification criteria in a cumulative fashion. Approximately 15% of these patients still have no established diagnosis and are being carried forward and observed as cases of "undifferentiated arthritis". In RA patients, the mean DAS 28 decreased significantly from an initial mean score of 5.5 (high disease activity) into the range of low disease activity. At the end of one year a DAS 28 of < 3.2 was observed in 52% of the RA patients. Radiological progression in these RA patients, who also received treatment very early, appears to be less severe than in other cohorts, although direct comparisons are impossible due to different methods of patient selection. In addition, the serological data from our cohort in cooperation with other study groups will allow development and validation of possible prediction algorithms for early arthritis patients which could improve the diagnostic and therapeutic approach to this patient group.

Tumour necrosis factor alpha (TNF-alpha) is a pro-inflammatory cytokine with various roles in inflammatory processes. Several TNF blockers are currently approved for use in rheumatoid arthritis (RA) as well as in other inflammatory arthropathies. The latest of these compounds is the human monoclonal antibody, adalimumab, which was obtained using phage display technology and successfully produced in a mammalian expression system. Clinical application of this compound led to significant improvement in patients suffering from RA, both as monotherapy and in combination with various disease modifying antirheumatic drugs (DMARDs), including methotrexate (MTX). Moreover, radiographic progression is significantly inhibited and quality of life improved. This article summarises the available information.

Objective: To describe clinical and radiological findings in patients with very early arthritis (< 3 months of symptoms) during one year of observation., Methods: In an Austrian multicenter setting, patients were eligible if they had nontraumatic swelling or pain in at least one joint and laboratory signs of inflammation [elevated erythrocyte sedimentation rate, C-reactive protein, leukocytosis, or rheumatoid factor (RF)] within the last 3 months. Clinical and laboratory assessments were performed every 3 months. Radiographs of hands and feet were taken at entry and after one year. Treatment decisions were left to the discretion of the participating center., Results: In total, 108 patients included between 1996 and 2000 had followup investigations during at least one year; 61.1% of these patients had rheumatoid arthritis (RA). Over 65% of RA diagnoses were made at the first visit. Lag time to referral was significantly longer in patients with RA than in patients with other inflammatory joint diseases (median 8 vs 4 weeks). Disease modifying antirheumatic drugs were started 19 +/- 10 (mean +/- SD) weeks after symptom onset in patients with RA. Patients with RA improved significantly (by American College of Rheumatology response criteria and the Disease Activity Score 28) during the first year. Erosions were present in 12.8% of RA patients' initial radiographs, compared to 27.6% after one year. Odds ratio to develop new erosions during the first year of RA was 9.7 (95% CI 1.05-89.93) in RF+ patients compared to RF- individuals (p < 0.05)., Conclusion: When early referral of patients with arthritis is encouraged, RA can be diagnosed and treatment initiated early, with significant clinical response. Moreover, patients with RA tend to be referred later than patients with other inflammatory joint diseases; RA patients at this very early stage have low frequency of joint damage; and RF predicts erosions in the first year.