Immune Checkpoint Inhibitor-Associated Remitting Seronegative Symmetrical Synovitis With Pitting Edema: Description of a New Entity by CanRIO.

OBJECTIVE: Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is characterized by symmetrical synovitis with pitting edema and negative rheumatoid factor (RF). It has been described in a setting of malignancy, suggesting a paraneoplastic association. With the increasing use of immune checkpoint inhibitors (ICIs) for the treatment of cancers and emergence of immune-related adverse events (irAEs), our objective was to identify and describe cases of ICI-associated RS3PE (ICI-RS3PE) and compare them to non-ICI-RS3PE. METHODS: The Canadian Research Group of Rheumatology in Immuno-Oncology (CanRIO) network is a collaboration of Canadian rheumatologists with experience in the management of patients with rheumatic irAEs (Rh-irAEs). Standardized data on adult patients with Rh-irAE have been collected as part of retrospective and prospective cohorts. In this study, detailed information on all cases of ICI-RS3PE from both cohorts were extracted and analyzed. RESULTS: We identified 11 cases of ICI-RS3PE. The most frequently observed malignancy was nonsmall cell lung cancer (4 of 11), followed by malignant melanoma (2 of 11) and cutaneous squamous cell carcinoma (2 of 11). The median time to onset of ICI-RS3PE was 26 weeks from ICI start and 52 weeks from diagnosis of malignancy. Seven patients had stable cancer prior to onset of ICI-RS3PE, 3 had partial response, and 1 had complete response. All patients received glucocorticoids. Conventional synthetic disease-modifying antirheumatic drugs (csDMARD) were needed in 10 patients. CONCLUSION: ICI-RS3PE may be an independent Rh-irAE, separate from paraneoplastic RS3PE. The symptoms of ICI-RS3PE responded well to glucocorticoids, but concomitant treatment with csDMARDs may be necessary.

A Systematic Review of Quality Measures for Inflammatory Arthritis.

OBJECTIVE: To conduct a systematic review and quality appraisal of quality measures for inflammatory arthritis, including rheumatoid arthritis (RA), spondyloarthritis, psoriatic arthritis (PsA), and juvenile idiopathic arthritis (JIA). METHODS: Embase, MEDLINE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from January 1, 2000, to October 23, 2016, using Medical Subject Headings terms for inflammatory arthritis and quality measures. A "grey literature" search of international arthritis organizations and quality measure libraries was also conducted. Two reviewers independently considered the papers for inclusion, with disagreements resolved by consensus. A modified guideline appraisal tool (AGREE II) was used to appraise the measure development process, which determined final inclusion. Measures were abstracted in duplicate and categorized into themes, measure type, and domains of quality. RESULTS: Thirteen measurement sets were included from 4 countries (United States, Canada, United Kingdom, Netherlands) and 1 European consortium. They included 10 sets on RA and 1 each for PsA, inflammatory arthritis, and JIA. There were 161 unique individual measures (136 process, 20 structure, and 5 outcome). Major themes included assessment, medications, and comorbidities. Measure development methods were varied, including RAND/University of California, Los Angeles appropriateness methodology, prioritization exercises, or other modified-Delphi methods. Inclusion of patients occurred in 77% of development groups. Discussion of barriers to measurement was infrequent. CONCLUSION: Inflammatory arthritis quality measures cover a diversity of themes encompassing process, structure, and outcomes of care across the 6 domains of quality. However, between organizations, measure development is not standardized. Local assessment of measurement feasibility before use outside the original development context is recommended.

Prevalence and risk factors for liver fibrosis detected by transient elastography or shear wave elastography in inflammatory arthritis: a systematic review.

OBJECTIVES: Emerging technologies for monitoring subclinical liver fibrosis include transient elastography (TE) and shear wave elastography (SWE). A systematic review was conducted to assess the prevalence and report on predictors of liver fibrosis as detected by these technologies in inflammatory arthritis (IA) patients, including rheumatoid arthritis, spondyloarthritis and juvenile idiopathic arthritis. METHODS: MEDLINE, EMBASE and Web of Science were searched from inception to 06/27/2016 using search terms for IA or DMARDs and TE/SWE. Studies reporting on prevalence and/or risk factors for liver fibrosis as detected by TE/SWE were included. A meta-analysis was not conducted due to study heterogeneity. RESULTS: Seven cross-sectional and three case-control studies were included. The cut-off values to define liver fibrosis ranged from 5.3-8.6 kPa. The prevalence of liver fibrosis in RA detected by TE/SWE ranged from 3-23%, with higher prevalence found in studies using a 5.3kPa cut-off. In two studies fibrosis was reported in 16-17% of PsA patients with no JIA studies identified. Obesity was the most consistently reported independent predictor of fibrosis in three studies. Liver function tests (LFTs) were found to independently predict increased liver stiffness in one study, while cumulative dose of either methotrexate or leflunomide were predictors in two studies. CONCLUSIONS: Methotrexate or leflunomide cumulative dose was not consistently reported as an independent predictor of liver fibrosis; whereas, obesity was more consistently identified. Of note, LFTs did not consistently predict elevated TE/SWE measures. Further studies are needed to evaluate the prevalence and predictors of liver fibrosis and to explore the utility of using TE/SWE in IA patients.