2022 American College of Rheumatology Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis.

OBJECTIVE: To develop initial American College of Rheumatology (ACR) guidelines on the use of exercise, rehabilitation, diet, and additional interventions in conjunction with disease-modifying antirheumatic drugs (DMARDs) as part of an integrative management approach for people with rheumatoid arthritis (RA). METHODS: An interprofessional guideline development group constructed clinically relevant Population, Intervention, Comparator, and Outcome (PICO) questions. A literature review team then completed a systematic literature review and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the certainty of evidence. An interprofessional Voting Panel (n = 20 participants) that included 3 individuals with RA achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The Voting Panel achieved consensus on 28 recommendations for the use of integrative interventions in conjunction with DMARDs for the management of RA. Consistent engagement in exercise received a strong recommendation. Of 27 conditional recommendations, 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to additional integrative interventions. These recommendations are specific to RA management, recognizing that other medical indications and general health benefits may exist for many of these interventions. CONCLUSION: This guideline provides initial ACR recommendations on integrative interventions for the management of RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the importance of an interprofessional, team-based approach to RA management. The conditional nature of most recommendations requires clinicians to engage persons with RA in shared decision-making when applying these recommendations.

2022 American College of Rheumatology Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis.

OBJECTIVE: To develop initial American College of Rheumatology (ACR) guidelines on the use of exercise, rehabilitation, diet, and additional interventions in conjunction with disease-modifying antirheumatic drugs (DMARDs) as part of an integrative management approach for people with rheumatoid arthritis (RA). METHODS: An interprofessional guideline development group constructed clinically relevant Population, Intervention, Comparator, and Outcome (PICO) questions. A literature review team then completed a systematic literature review and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the certainty of evidence. An interprofessional Voting Panel (n = 20 participants) that included 3 individuals with RA achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The Voting Panel achieved consensus on 28 recommendations for the use of integrative interventions in conjunction with DMARDs for the management of RA. Consistent engagement in exercise received a strong recommendation. Of 27 conditional recommendations, 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to additional integrative interventions. These recommendations are specific to RA management, recognizing that other medical indications and general health benefits may exist for many of these interventions. CONCLUSION: This guideline provides initial ACR recommendations on integrative interventions for the management of RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the importance of an interprofessional, team-based approach to RA management. The conditional nature of most recommendations requires clinicians to engage persons with RA in shared decision-making when applying these recommendations.

Harnessing translational research in wheat for climate resilience.

Despite being the world's most widely grown crop, research investments in wheat (Triticum aestivum and Triticum durum) fall behind those in other staple crops. Current yield gains will not meet 2050 needs, and climate stresses compound this challenge. However, there is good evidence that heat and drought resilience can be boosted through translating promising ideas into novel breeding technologies using powerful new tools in genetics and remote sensing, for example. Such technologies can also be applied to identify climate resilience traits from among the vast and largely untapped reserve of wheat genetic resources in collections worldwide. This review describes multi-pronged research opportunities at the focus of the Heat and Drought Wheat Improvement Consortium (coordinated by CIMMYT), which together create a pipeline to boost heat and drought resilience, specifically: improving crop design targets using big data approaches; developing phenomic tools for field-based screening and research; applying genomic technologies to elucidate the bases of climate resilience traits; and applying these outputs in developing next-generation breeding methods. The global impact of these outputs will be validated through the International Wheat Improvement Network, a global germplasm development and testing system that contributes key productivity traits to approximately half of the global wheat-growing area.

Climate Dialectics in Psychotherapy: Holding Open the Space Between Abyss and Advance.

The complexity, uncertainty and charged nature of climate change make it a unique stressor that is irreconcilable at an individual level. This experience of impossibility leads to splitting of reactions into polarities, or dialectics, which must be contained to reduce climate distress and held open for generative use towards climate adaptation. We present a dynamic model for addressing climate change material within psychotherapy, wherein these climate dialectics are identified, explored, and held open. Clinical vignettes* illustrate therapeutic work with the particular climate dialectics of Climate Reality-Social Reality, Individual Agency-Collective Agency, Hope-Hopelessness, Certainty-Uncertainty, and Nature as Comfort-Nature as Threat. Situations of climate anxiety, solastalgia, disavowal, and the climate dismissive patient are addressed, as is the therapeutic use of the wordlessness that accompanies our relationship with the natural world. We explore and emphasize how a focus on the containment and transformation of climate anxiety, rather than on its reduction, assists in aligning with new realities and in the reduction of distress. Use of a developmental stage metaphor, attention to climate-specific counter-transference enactments, and emphasis on authentic action are central to this process.

Climate Change and Risk of Completed Suicide.

Climate change is increasingly recognized as having multiple adverse mental health effects, many of which are just beginning to be understood. The elevated rates of suicides observed in some communities affected by climate change and rising rates of suicide in the United States as climate change intensifies have suggested the two may be associated. We searched PubMed and PsycInfo using the terms climate change and suicide, and provide here a review of the current literature on climate change and suicide that explores possible associations and methodological issues and challenges in this research.

Stress, Inflammation and Pain: A Potential Role for Monocytes in Fibromyalgia-related Symptom Severity.

The possibility that immunological changes might contribute to symptom severity in fibromyalgia (FM) prompted this proof-of-concept study to determine whether differences in monocyte subpopulations might be present in persons with FM compared with healthy controls. Relationships were assessed by comparing specific symptoms in those with FM (n = 20) and patterns of monocyte subpopulations with healthy age-matched and gender-matched controls (n = 20). Within the same time frame, all participants provided a blood sample and completed measures related to pain, fatigue, sleep disturbances, perceived stress, positive and negative affect and depressed mood (and the Fibromyalgia Impact Questionnaire for those with FM). Monocyte subpopulations were assessed using flow cytometry. No differences were observed in total percentages of circulating monocytes between the groups; however, pain was inversely correlated with percentages of circulating classical (r = -0.568, p = 0.011) and intermediate (r = -0.511, p = 0.025) monocytes in the FM group. Stress and pain were highly correlated (r = 0.608, p = 0.004) in the FM group. The emerging pattern of changes in the percentages of circulating monocyte subpopulations concomitant with higher ratings of perceived pain and the correlation between stress and pain found in the FM group warrant further investigation. Copyright © 2015 John Wiley & Sons, Ltd.

Recovery Curves for Pediatric Burn Survivors: Advances in Patient-Oriented Outcomes.

IMPORTANCE: Patient-reported outcomes serving as benchmarks for recovery of pediatric burn survivors are lacking, and new approaches using longitudinal cohorts for monitoring their expected recovery based on statistical models are needed for patient management during the early years following the burn. OBJECTIVE: To describe multidimensional patient-reported outcomes among pediatric burn survivors younger than 5 years to establish benchmarks using recovery curve methods. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of pediatric burn survivors younger than 5 years at 12 burn centers. Age-matched nonburned reference groups were studied to define expected results in normal growth and development. The Burn Outcomes Questionnaire for children aged 0 to 5 years (BOQ0-5) was administered to parents of children who had burns and were younger than 5 years. Mixed models were used to generate 48-month recovery curves for each of the 10 BOQ0-5 domains. The study was conducted between January 1999 and December 2008. MAIN OUTCOMES AND MEASURES: The 10 BOQ0-5 domains including play, language, fine motor skills, gross motor skills, emotional behavior, family functioning, pain/itching, appearance, satisfaction with care, and worry/concern up to 48 months after burn injury. RESULTS: A total of 336 pediatric burn survivors younger than 5 years (mean [SD] age, 2.0 [1.2] years; 58.4% male; 60.2% white, 18.6% black, and 12.0% Hispanic) and 285 age-matched nonburned controls (mean [SD] age, 2.4 [1.3] years; 51.1% male; 67.1% white, 8.9% black, and 15.0% Hispanic) completed the study. Predicted scores improved exponentially over time for 5 of the BOQ0-5 domains (predicted scores at 1 month vs 24 months: play, 48.6 vs 52.1 [P = .03]; language, 49.2 vs 54.4 [P < .001]; gross motor skills, 48.7 vs 53.0 [P = .002]; pain/itching, 15.8 vs 33.5 [P < .001]; and worry/concern, 31.6 vs 44.9 [P < .001]). Pediatric burn survivors had higher scores in language, emotional behavior, and family functioning domains compared with healthy children in later months. CONCLUSIONS AND RELEVANCE: This study demonstrates significant deficits in multiple functional domains across pediatric burn survivors compared with controls. Recovery curves can be used to recognize deviation from the expected course and tailor care to patient needs.

BAFF regulates follicular helper t cells and affects their accumulation and interferon-γ production in autoimmunity.

OBJECTIVE: Follicular helper T (Tfh) cells are critical for the development of protective antibodies via germinal center (GC) B cell responses; however, uncontrolled Tfh cell expansion activates autoreactive B cells to produce antibodies that cause autoimmunity. The mechanisms that control Tfh cell homeostasis remain largely unknown. The aim of this study was to determine the contribution of BAFF to Tfh cell responses in autoimmunity. METHODS: We analyzed the properties of Tfh cells in lupus-prone mice sufficient or deficient in BCMA. Adoptive transfer studies and mixed bone marrow chimeras were used to test BCMA signaling in T cells. We assessed BAFF stimulation of Tfh cells through in vitro cell cocultures and in vivo depletion studies using flow cytometry. RESULTS: In Nba2 mice, Tfh cells expressed the BAFF receptors BCMA and B lymphocyte stimulator receptor 3 (BR-3) and accumulated in the spleen when BCMA was absent. BCMA deficiency in T cells promoted the expansion of Tfh cells, GC formation, autoantibody production, and interferon-γ (IFNγ) production by Tfh cells through BR-3. IFNγ-producing Tfh cells increased BAFF expression in dendritic cells. Blocking BAFF or IFNγ in vivo reduced Tfh cell accumulation and reduced autoimmunity in BCMA-deficient animals. Moreover, circulating Tfh-like cells that expressed BR-3 (but not BCMA) were elevated in patients with systemic lupus erythematosus, and this correlated with serum BAFF and IFNγ levels. CONCLUSION: In Nba2 mice, BCMA negatively regulates Tfh cell expansion, while BAFF signaling through BR-3 promotes Tfh cell accumulation. Our findings suggest that the balance between BCMA and BR-3 signaling in Tfh cells serves as a checkpoint of immune tolerance.

Variations for Fusarium head blight resistance associated with genomic diversity in different sources of the resistant wheat cultivar 'Sumai 3'.

Fusarium head blight (FHB), caused by Fusarium graminearum, is a serious disease of wheat (Triticum aestivum L.) associated with contamination by the mycotoxin deoxynivalenol (DON). The FHB-resistant wheat cultivar 'Sumai 3' has been used extensively around the world. The existence of variation in FHB resistance among 'Sumai 3' accessions has been discussed. In this study, genetic variation among 'Sumai 3' accessions collected from six countries were identified using SSR markers; our results demonstrate unique chromosome regions in Sumai 3-AUT and Sumai 3-JPN ('Sumai 3' accessions from Austria and Japan, respectively). Field evaluation indicated strong resistance to FHB in Sumai 3-AUT. The polymorphic rate (number of polymorphic markers/number of available markers × 100) based on a DArT array was 12.5% between the two 'Sumai 3' accessions. Genotyping for DNA markers flanking FHB-resistant quantitative trait loci (QTLs) revealed genetic variations for the QTL regions on 5AS and 2DS; however, no variation was observed for the QTL regions on 3BS and 6B. Thus, the variation in FHB resistance among 'Sumai 3' accessions in the field is due to genetic diversity.

Diagnostic approach in patients with suspected vasculitis.

Vasculitides are a heterogeneous group of disorders that share the common feature of inflammation of the blood vessel wall. Vasculitis can be a systemic or localized process and depending on the disorder can affect large, medium, or small vessels. Vascular physicians including interventional radiologists often may be involved early in these cases before the establishment of a diagnosis as these patients may present with manifestations attributable to occlusive vascular syndromes. In this article, we discuss the presenting signs and symptoms of patients with vasculitis as well as laboratory and imaging studies required to further evaluate these disorders and treatment options, which include interventional as well as noninterventional options.

Cranial electrical stimulation improves symptoms and functional status in individuals with fibromyalgia.

To investigate the effects of microcurrent cranial electrical stimulation (CES) therapy on reducing pain and its associated symptoms in fibromyalgia (FM), we conducted a randomized, controlled, three-group (active CES device, sham device, and usual care alone [UC]), double-blind study to determine the potential benefit of CES therapy for symptom management in FM. Those individuals using the active CES device had a greater decrease in average pain (p = .023), fatigue (p = .071), and sleep disturbance (p = .001) than individuals using the sham device or those receiving usual care alone over time. Additionally, individuals using the active CES device had improved functional status versus the sham device and UC groups over time (p = .028).

Structured representation for core elements of common clinical decision support interventions to facilitate knowledge sharing.

At present, there are no widely accepted, standard approaches for representing computer-based clinical decision support (CDS) intervention types and their structural components. This study aimed to identify key requirements for the representation of five widely utilized CDS intervention types: alerts and reminders, order sets, infobuttons, documentation templates/forms, and relevant data presentation. An XML schema was proposed for representing these interventions and their core structural elements (e.g., general metadata, applicable clinical scenarios, CDS inputs, CDS outputs, and CDS logic) in a shareable manner. The schema was validated by building CDS artifacts for 22 different interventions, targeted toward guidelines and clinical conditions called for in the 2011 Meaningful Use criteria. Custom style sheets were developed to render the XML files in human-readable form. The CDS knowledge artifacts were shared via a public web portal. Our experience also identifies gaps in existing standards and informs future development of standards for CDS knowledge representation and sharing.