Long-term efficacy of a 2-year MRI treat-to-target strategy on disease activity and radiographic progression in patients with rheumatoid arthritis in clinical remission: 5-year follow-up of the IMAGINE-RA randomised trial.

OBJECTIVE: To investigate whether a 2-year MRI treat-to-target strategy targeting the absence of osteitis combined with clinical remission, compared with a conventional treat-to-target strategy targeting clinical remission only (IMAGINE-rheumatoid arthritis (RA) trial) improves clinical and radiographic outcomes over 5 years in patients with RA in clinical remission. METHODS: IMAGINE-more was an observational extension study of the original 2-year IMAGINE-RA randomised trial (NCT01656278). Clinical examinations and radiographs (hands and feet) were obtained yearly. Prespecified coprimary outcomes at year 5 were Disease Activity Score in 28 joints C reactive protein (DAS28-CRP) remission rate (DAS28-CRP<2.6) and no radiographic progression (van der Heijde-modified Sharp score (vdHSS) ≤0) from baseline. Secondary outcomes included 5-year changes in radiographic, MRI and clinical measures of disease activity and physical function. RESULTS: In total 131 patients, 86 women (67%), mean age 61.2, disease duration 9.5 years, median baseline DAS28-CRP 1.9 (IQR 1.6-2.2) and vdHSS 16.0 (IQR 7.0-36.0) were included in the study; 59 (59%) patients from the original MRI treat-to-target group and 72 (72%) from the conventional group. At year 5, 47 patients (80%) in the MRI treat-to-target group vs 54 patients (75%) in the conventional treat-to-target group were in DAS28-CRP remission (OR 2.00 (95% CI 0.76 to 5.28); p=0.16) while 14 patients (24%) vs 19 patients (26%) had no radiographic progression (OR 0.70, (95% CI 0.28 to 1.71); p=0.43). CONCLUSION: A 2-year combined MRI and clinical treat-to-target strategy, compared with a conventional clinical treat-to-target strategy alone, had no effect on the long-term probability of achieving DAS28-CRP remission and of avoiding radiographic progression.

One-Year Follow-Up after Multimodal Prehabilitation Interventions in Radical Cystectomy.

Multimodal prehabilitation is the process of enhancing physiological, nutritional, and psychological resilience to increase patients' functional capacity before major cancer surgery and aims to empower the patient to withstand the pending stress of major surgery and ultimately to improve long-term outcomes. The effect of physical prehabilitation to counteract the physical decline in surgical cancer patients has been documented; however, long-term results have not yet been published. This follow-up study aims to evaluate 1-year results on the efficacy of physical prehabilitation after bladder cancer surgery. The efficacy of prehabilitation was measured over the course of 1 year in 107 patients randomized to (1) pre- and rehabilitation or (2) standard care divided by n = 50 in the intervention (I) and n = 57 in the standard group (S). Physical function was measured by muscle leg power, and nutritional status was expressed with handgrip strength. Prehabilitation in major bladder cancer surgery can significantly improve physical function with 19.8 Watt/kg (p = 0.04), lean body mass (p = 0.047) and body cell mass (p = 0.03), and regained nutritional status one year after surgery. The results demonstrate that the restoration of physical function is vital to a full recovery.

Occurrence and Prediction of Flare After Tapering of Tumor Necrosis Factor Inhibitors in Patients With Axial Spondyloarthritis.

OBJECTIVE: Patients with axial spondyloarthritis (axSpA) in clinical remission tapered tumor necrosis factor inhibitor (TNFi) therapy according to a clinical guideline. Over a 2-year follow-up period, we aimed to investigate flare frequency, dose at which flare occurred, type of flare, and predictors thereof. METHODS: Patients in clinical remission (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI] < 40, physician global score < 40, and without disease activity the previous year) tapered TNFi to two-thirds the standard dose at baseline, half at week 16, one-third at week 32, and discontinued at week 48. Flares were defined as BASDAI flare (BASDAI ≥ 40 and change ≥ 20 since inclusion), and/or clinical flare (development of inflammatory back pain, musculoskeletal or extraarticular manifestations, and/or Ankylosing Spondylitis Disease Activity Score [ASDAS] ≥ 0.9), and/or magnetic resonance imaging (MRI) flare (≥ 2 new or worsened inflammatory lesions). RESULTS: Of 108 patients, 106 (99%) flared before 2-year follow-up: 29 patients (27%) at two-thirds standard dose, 21 (20%) at half dose, 29 (27%) at one-third dose, and 27 (25%) after discontinuation. Regarding type of flare, 105 (99%) had clinical flares, 25 (24%) had BASDAI flares, and 23 (29% of patients with MRI at flare available) had MRI flares. Forty-one patients (41%) fulfilled the Assessment of SpondyloArthritis international Society (ASAS) definition of clinically important worsening (≥ 0.9 increase since baseline). Higher baseline physician global score was an independent predictor of flare after tapering to two-thirds (OR 1.19, 95% CI 1.04-1.41, P = 0.01). Changes in clinical and/or imaging variables in the 16 weeks prior to tapering did not predict flare. CONCLUSION: Almost all (99%) patients with axSpA in clinical remission experienced flare during tapering to discontinuation, but in over half of these patients, flare did not occur before receiving one-third dose or less. Higher physician global score was an independent predictor of flare.

Extracellular matrix turnover biomarkers reflect pharmacodynamic effects and treatment response of adalimumab in patients with axial spondyloarthritis-results from two randomized controlled trials.

OBJECTIVE: To investigate if extracellular matrix (ECM) blood-based biomarkers reflect the pharmacodynamic effect and response to TNF-α inhibitor therapy (adalimumab, ADA), in patients with axial spondyloarthritis (axSpA). METHODS: We investigated ECM biomarkers in two randomized, double-blind, placebo-controlled trials of axSpA patients (DANISH and ASIM, n = 52 and n = 49, respectively) receiving ADA 40 mg or placebo every other week for 12 and 6 weeks, respectively, and thereafter ADA to week 48. Serum concentrations of degraded type I (C1M), II (C2M, T2CM), III (C3M), IV (C4M), VI (C6M), type X (C10C) collagen; metabolite of C-reactive protein (CRPM), prolargin (PROM), citrullinated vimentin (VICM), calprotectin (CPa9-HNE); and formation of type II (PRO­C2), III (PRO­C3), and VI (PRO­C6) turnover of type IV collagen (PRO-C4) were measured at baseline and weeks 6 or 12, 24, and 48. The pharmacodynamic effect and treatment response to ADA was evaluated by linear mixed models, and correlations between biomarkers and clinical scores were assessed by Spearman's correlation. RESULTS: C1M, C3M, C4M, C6M, CRP, PRO-C4, and CPa9-HNE levels declined after 6 or 12 weeks in patients receiving ADA compared to placebo (all p < 0.05). Patients with AS Disease Activity Score C-reactive protein (ASDAS CRP) major improvement and/or clinically important improvement had significantly higher C1M, C3M, C4M, C6M, and PRO-C4 levels than patients with no/low improvement at baseline (all p < 0.05). Baseline levels of biomarkers showed weak to moderate correlations with ASDAS and structural damage scores. CONCLUSION: ECM metabolites showed a pharmacodynamic effect and were associated with ASDAS response during TNF-α inhibitor treatment in patients with axSpA.

Future Perspectives on Prehabilitation Interventions in Cancer Surgery.

OBJECTIVE: This article provides a map of key knowledge gaps regarding the evidence supporting prehabilitation and its integration with enhanced recovery after surgery (ERAS) programs. Filling this lack of knowledge with future research will further establish the effectiveness of prehabilitation. DATA SOURCES: These are electronic databases including PubMed and CINAHL. CONCLUSION: Future efforts must embrace the elderly frail or cognitively impaired patient with specific needs to further promote restoration of postoperative function throughout the surgical pathway. Prehabilitation should be coupled and integrated within the existent concept of the ERAS framework, to facilitate the continuous evolution of screening, assessment, and optimization of high-risk surgical patients who are at risk of not being restored to physical and psychological function after surgery, including independence. IMPLICATIONS FOR NURSING PRACTICE: In the future, the ERAS nurse will be an essential figure of the prehabilitation program, proactively coordinating the assessment, optimization, and adjustment of perioperative comorbidity and guiding the rehabilitation process to improve patients' outcomes. These skills and characteristics will be required to provide optimal nursing care in the context of an integrated prehabilitation ERAS pathway.

Efficacy of pre and rehabilitation in radical cystectomy on health related quality of life and physical function: A systematic review.

Objective: The efficacy of prehabilitation or rehabilitation interventions on radical cystectomy (RC) patient reported outcomes (PROs), and patient centered outcome has not yet been thoroughly explored in prior reviews, therefore the aim of this review is to evaluate the efficacy of a single or multi-modal prehabilitation or/and postoperative rehabilitation interventions compared to standard treatment on postoperative complications after RC. Methods: We performed a three-step search strategy in PubMed, Cinahl, Embase, Cochrane Library, and Web of Science. We used Covidence for the screening of articles, risk of bias assessment, and data-extraction. GRADE was used to assess the risk of bias in outcomes across studies. Where meta-analysis was possible, we used the random effect method due to substantial heterogeneity. The remaining outcomes were summarized narratively. Results: We identified fourteen studies addressing one of the outcomes. None of the studies provided evidence to support that prehabilitation and/or rehabilitation interventions can improve global health related quality of life (HRQoL) in RC surgery or can reduce postoperative complications significantly. However, preoperative and postoperative education in stoma care can significantly improve self-efficacy and we found significant added benefits of sexual counseling to intracavernous injections compared to injection therapy alone. Likewise, an intensive smoking and alcohol cessation intervention demonstrated a significant effect on quit rates. Physical exercise is feasible and improves physical functioning although it does not reduce the postoperative complications. Conclusions: Currently, no evidence of efficacy of prehabilitation and/or rehabilitation interventions to improve the overall HRQoL or postoperative complications after RC exists. We found evidence that education in stoma care improved self-efficacy significantly. Adequately powered randomized controlled trials (RCTs) are needed to generate high-quality evidence in this field.

From fast-track to enhanced recovery after surgery in radical cystectomy pathways: A nursing perspective.

Objective: The purpose of this narrative review is to summarize existing knowledge and evidence about the establishment of enhanced recovery after surgery (ERAS) pathways with emphasize on radical cystectomy (RC), and the emerging and prominent role of nursing within the ERAS pathway. The current status of implementation and adherence to ERAS protocol in RC is discussed and the impact on primary outcomes according to ERAS is summarized. Methods: The review was conducted based on a focused search in PubMed and CINAHL. Results: The goal of a modern RC enhanced recovery protocols (ERPs) anno 2022 is to have a positive impact on patient care from diagnosis throughout recovery with focus on the quality, rather than speed, of recovery. This may be more in alignment with the patient's needs and preferences. Conclusions: Nursing has been in the forefront since the establishment of ERAS, and the nurse-coordinator must be skilled in evidence-based medicine and have excellent communicative competencies to support the patient journey. Implementation of ERAS have reduced hospitalization by improved minimal surgery, optimized anesthetic regimes without increasing readmission rates. It is not known which items can reduce post-operative complications. In the future, nurses should seek a more prominent and leading role during the implementation process and take responsibility for continued education of the staff. Likewise, future nursing interventions will focus on early identification of modifiable risk factors, and a deeper exploration of the patients personally needs and preferences to upcoming surgery could optimize adherence throughout the pathway, which may add to positive outcomes.

Patient reported outcome measures assessing quality of life in patients with an intestinal stoma: A systematic review.

AIM: Living with a stoma can greatly influence quality of life. The purpose of this systematic review was to identify all patient reported outcome measures (PROMs) assessing health related quality of life (HRQoL) or similar constructs related to an intestinal stoma and to evaluate their level of validation. METHODS: The study was reported in line with PRISMA guidelines. The protocol was registered in PROSPERO prior to the study. Eligible studies were any study investigating psychometric properties of a stoma-specific PROM. The databases MedLine, Embase, CINAHL and Cochrane Libraries were searched for eligible studies. Studies were screened on title and abstract, then full-text for eligibility. Data extraction on the study populations, PROM characteristics, psychometric properties as well as quality assessment using the COSMIN Risk of Bias checklist was performed. RESULTS: In total, 40 studies were included concerning the development and/or validation of 21 PROMs. For most PROMs, few psychometric properties were assessed. In general, quality of content validity was poor, quality of construct validity and reliability was good. Assessment of responsiveness was lacking. CONCLUSION: This systematic review offers an overview of existing PROMs measuring stoma-related HRQoL and their psychometric properties. A large number of PROMs exist and their measures overlap considerably. The PROMs generally have a low level of validation, emphasizing the need for future studies to further validate existing PROMs, rather than developing new ones.

Prospective versus retrospective recordings of comorbidities and complications in bladder cancer patients undergoing radical cystectomy - a randomized controlled trial.

BACKGROUND: Patients undergoing radical cystectomy are predominantly elderly with many comorbidities and high risk of complications. Studies on comorbidity and complications following cancer surgery are often based on data collected retrospectively from records. However, prospective registration is often considered a more valid source of information. Therefore, it is relevant to investigate if the amount and severity of complications and comorbidities is valid when using retrospective registration compared to a more meticulous prospective registration. OBJECTIVE: To investigate the difference in registered comorbidities and complications between prospective and retrospective data collection in patients with bladder cancer undergoing radical cystectomy. METHOD: Seventy-three bladder cancer patients undergoing radical cystectomy were randomized to receive prospective or retrospective collection of data regarding comorbidities and complications. Data in the prospective arm was collected daily during hospitalization, 14-days after discharge and 90-days postoperatively. In the retrospective arm, medical records were reviewed retrospectively at 90-days. Comorbidities were compared using the Charlson Comorbidity Index (CCI) and complications were reported as overall, minor and major dependent on Clavien Dindo Classification (CDC). The primary endpoint was the difference in overall complication rate. RESULTS: No statistically significant difference in CCI was observed with median [IQR] 2[0;3] and 1[0;2] (p = 0.21). No statistically significant difference was found regarding all, minor (CDC I-II) or major (CDC III-V) complications at all three time points. CONCLUSION: No statistically significant difference in comorbidity and complications between retrospectively and prospectively collected data was observed. We find that retrospective collected data is reliable when strict reporting guidelines are used in this single-centre study.

Tapering of TNF inhibitors in axial spondyloarthritis in routine care - 2-year clinical and MRI outcomes and predictors of successful tapering.

OBJECTIVES: In a 2-year follow-up study of patients with axial spondyloarthritis (axSpA) in clinical remission who tapered TNF inhibitor (TNFi) treatment according to a clinical guideline, we aimed to investigate the proportion who successfully tapered/discontinued therapy and baseline predictors thereof. The proportion regaining clinical remission after flare and the progression on MRI/radiography were also assessed. METHODS: One-hundred-and-nine patients (78 [72%]/31 [28%] receiving standard and reduced dose, respectively) in clinical remission (BASDAI < 40, physician global score < 40) and no signs of disease activity the previous year tapered TNFi as follows: to two-thirds of standard dose at baseline, half at week 16, one-third at week 32 and discontinuation at week 48. Patients experiencing clinical, BASDAI or MRI flare (predefined criteria) stopped tapering and escalated to previous dose. Prediction analyses were performed by multivariable regression. RESULTS: One hundred and six patients (97%) completed 2 years' follow-up; 55 patients (52%) had successfully tapered: 23 (22%) receiving two-thirds, 15 (14%) half, 16 (15%) one-third dose and 1 (1%) discontinued. In patients at standard dose at baseline (n = 78), lower physician global score was the only independent predictor of successful tapering (odds ratio [OR] = 0.79 [95% CI: 0.64, 0.93]; P = 0.003). In the entire patient group lower physician global score (OR = 0.86 [0.75, 0.98]; P = 0.017), lower Spondyloarthritis Research Consortium of Canada (SPARCC) Sacroiliac Joint Erosion score (OR = 0.78 [0.57, 0.98]; P = 0.029) and current smoker (OR = 3.28 [1.15, 10.57]; P = 0.026) were independent predictors of successful tapering. At 2 years, 97% of patients were in clinical remission. Minimal changes in imaging findings were observed. CONCLUSION: After 2 years following a clinical guideline, 52% of patients with axSpA in clinical remission had successfully tapered TNFi, only 1% discontinued. Baseline physician global score was an independent predictor of successful tapering.

Long-term treatment with transcranial pulsed electromagnetic fields improves movement speed and elevates cerebrospinal erythropoietin in Parkinson's disease.

BACKGROUND: Parkinson's disease is characterized by motor dysfunctions including bradykinesia. In a recent study, eight weeks of daily transcranial stimulation with bipolar pulsed electromagnetic fields improved functional rate of force development and decreased inter-hand tremor coherence in patients with mild Parkinson's disease. OBJECTIVE: To investigate the effect of long-term treatment with transcranial bipolar pulsed electromagnetic fields on motor performance in terms of movement speed and on neurotrophic and angiogenic factors. METHODS: Patients diagnosed with idiopathic Parkinson's disease had either daily 30-min treatment with bipolar (±50 V) transcranial pulsed electromagnetic stimulation (squared pulses, 3ms duration) for three eight-week periods separated by one-week pauses (T-PEMF group) (n = 16) or were included in a PD-control group (n = 8). Movement speed was assessed in a six-cycle sit-to-stand task performed on a force plate. Cerebrospinal fluid and venous blood were collected and analyzed for erythropoietin and vascular endothelial growth factor. RESULTS: Major significant improvement of movement speed compared to the natural development of the disease was found (p = 0.001). Thus, task completion time decreased gradually during the treatment period from 10.10s to 8.23s (p<0.001). The untreated PD-control group did not change (p = 0.458). The treated group did not differ statistically from that of a healthy age matched reference group at completion of treatment. Erythropoietin concentration in the cerebrospinal fluid also increased significantly in the treated group (p = 0.012). CONCLUSION: Long-term treatment with transcranial bipolar pulsed electromagnetic fields increased movement speed markedly and elevated erythropoietin levels. We hypothesize that treatment with transcranial bipolar pulsed electromagnetic fields improved functional performance by increasing dopamine levels in the brain, possibly through erythropoietin induced neural repair and/or protection of dopaminergic neurons.

No difference in knee muscle activation and kinematics during treadmill walking between adolescent girls with and without asymptomatic Generalised Joint Hypermobility.

BACKGROUND: Altered knee muscle activity in children with asymptomatic Generalized Joint Hypermobility (GJH) is reported during isometric contraction, static and dynamic balance tasks and jumping, but has not been studied during gait. Therefore, the aim was to investigate group differences in knee muscle activity simultaneously with knee joint kinematics during treadmill walking between children with and without GJH. METHODS: Girls 14-15 years of age with GJH (inclusion criteria: Beighton score ≥6 of 9 and positive hyperextension ≥10° (one/both knees)) and a matched control group without GJH (inclusion criteria: Beighton score ≤5 and no knee hyperextension ≥10° ) were recruited. In total 16 participants with GJH and 10 non-GJH participants were included in the study. Surface electromyography (sEMG) was measured from the quadriceps, hamstrings and gastrocnemius muscles of the dominant leg during treadmill walking. Maximal voluntary isometric contractions while sitting were used for normalisation of sEMG to % of Maximum Voluntary EMG (%MVE). Knee joint angles during treadmill walking were measured by electrogoniometer. Furthermore, co-contraction index (CCI) was calculated, and presented for muscle groups of hamstrings-quadriceps (HQ) and gastrocnemius-quadriceps (GQ). CCI of medial and lateral sides of the knee, including ratio of the medial and lateral CCI for HQ and GQ were calculated. RESULTS: No group differences were found in demographics, muscle activation level, nor CCI and CCI ratios. However, participants with GJH displayed significantly decreased knee joint angle, mean (153º vs. 156º; p =0.03) and minimum (105º vs. 111º; p=0.01), during treadmill walking compared with controls. CONCLUSION: Muscle activity during gait was not different between participants with GJH and non-GJH participants. However, participants with GJH displayed minor but statistically significant increased knee flexion during gait. Since the clinical consequences of increased knee joint flexion during gait are unknown, future studies should follow a larger cohort longitudinally during overground walking for development of clinical complications in this group.

A new tool to assess Clinical Diversity In Meta-analyses (CDIM) of interventions.

OBJECTIVE: To develop and validate Clinical Diversity In Meta-analyses (CDIM), a new tool for assessing clinical diversity between trials in meta-analyses of interventions. STUDY DESIGN AND SETTING: The development of CDIM was based on consensus work informed by empirical literature and expertise. We drafted the CDIM tool, refined it, and validated CDIM for interrater scale reliability and agreement in three groups. RESULTS: CDIM measures clinical diversity on a scale that includes four domains with 11 items overall: setting (time of conduct/country development status/units type); population (age, sex, patient inclusion criteria/baseline disease severity, comorbidities); interventions (intervention intensity/strength/duration of intervention, timing, control intervention, cointerventions); and outcome (definition of outcome, timing of outcome assessment). The CDIM is completed in two steps: first two authors independently assess clinical diversity in the four domains. Second, after agreeing upon scores of individual items a consensus score is achieved. Interrater scale reliability and agreement ranged from moderate to almost perfect depending on the type of raters. CONCLUSION: CDIM is the first tool developed for assessing clinical diversity in meta-analyses of interventions. We found CDIM to be a reliable tool for assessing clinical diversity among trials in meta-analysis.

The Potential of Prehabilitation in Radical Cystectomy Pathways: Where Are We Now?

OBJECTIVE: The growing recognition of prehabilitation has caused an emerging paradigm shift in surgical cancer care and an integrated component of the cancer care continuum. This narrative review aims to update and inform the urological community of the potential of prehabilitation before radical cystectomy. DATA SOURCES: A nonsystematic narrative review was performed through a database search in PubMed, and CINAHL using the following search terms: enhanced recovery after surgery (ERAS); Frailty; Prehabilitation and/or Rehabilitation; Physical Activity and/or exercises; Nutrition; Nutritional Care; Smoking cessation; Alcohol cessation; Prevention; Supportive Care; and combined with Radical Cystectomy. CONCLUSION: A multimodal and multi-professional approach during the preoperative period may offer an opportunity to preserve or enhance physiological integrity and optimize surgical recovery. Studies indicate a positive effect of prehabilitation on postoperative functional capacity and earlier return to daily activities and health related quality of life. Meaningful outcomes that reflect recovery from a patient's perspective and clinical outcome measures, as well as validating metrics, are necessary to establish whether prehabilitation diminish the risk of developing long-term disability in high-risk patients. IMPLICATIONS FOR NURSING PRACTICE: Uro-oncology nurses are at the forefront in every ERAS program and vital in screening patients ahead of surgery for common risk factors, current impairments, and limitations that can compromise baseline functional capacity. The growing movement to standardize clinical implementation of prehabilitation, indicate there is a clear need for further investigation, optimization of a multimodal approach and an open discussion between health care providers from different areas of expertise who might best support and promote these initiatives.

Organization Factors in the ERAS Bladder Cancer Pathway: The Multifarious Role of the ERAS Nurse, Why and What Is Important?

OBJECTIVE: This paper provides an overview of the multifarious role of nursing in enhanced recovery after surgery (ERAS) in advanced bladder cancer surgery with procedure-specific recommendations in radical cystectomy pathways. DATA SOURCES: Electronic databases including PubMed and CINAHL. CONCLUSION: The growing evidence of preoperative, perioperative, and postoperative interventions and the concept of reacting proactively in ERAS, has led to the paradigm shift in the surgical pathway with establishment of nurse-led multi-professional prehabilitation academies. Moreover, although most patients will recover in real-life at home, there is a need for a change in postoperative and discharge management. Thus, a highly skilled discharge nurse is required to secure a comprehensive, safe discharge plan adjusted to the patient's needs in close cooperation with the primary care setting, family, and survivorship clinic if needed. Limited efforts have been made to evaluate rational principles and goals for rehabilitation after radical cystectomy; an important issue with major patient and perhaps socioeconomic consequences, wherein the ERAS nurse may take the future lead. IMPLICATION FOR NURSING PRACTICE: It has become a governmental demand in many countries to involve the patient and family in treatment decisions and care by using shared decision tools, and to educate and inform each family in concordance with the patient's needs and preferences, and the health care systems must react accordingly. However, to provide person-centeredness care within advanced surgical pathways, there remains a need for thought-leaders, strategic planners, managers, and decision-makers to anchor the process of change and stop "we do it anyway" arguments to defend organizational cultures that are not conducing the evidence-recommend practice.

Lyme arthritis is rare in Eastern Denmark.

INTRODUCTION The multi-organ disease Lyme borreliosis can cause mainly large joint arthritis. No guideline exists describing how to diagnose Lyme arthritis (LA). The incidence of LA in Denmark remains unknown, but it is considered to be low. The primary aim of this study was to quantify the number of Borrelia burgdorferi serological tests requested from primary and secondary care; secondly, to examine how often LA is diagnosed. METHODS this was a register-based study including B. burgdorferi serological tests analysed at the department of clinical microbiology at Hvidovre and Herlev Hospitals during a two-year period. The results of the tests were categorised into primary and secondary care. A medical record review was made covering all newly referred rheumatological patients with B. burgdorferi serological tests analysed the Department of Clinical Microbiology, Hvidovre Hospital. A model was set up to diagnose LA. RESULTS Most tests were requested by primary care. A total of 146 rheumatology patients were tested for B. burgdorferi of whom 118 were newly referred. Using our model to diagnose LA, we found that three patients had possible LA, whereas one had likely LA, but none were given a final LA diagnosis. Overdiagnosis was not common among rheumatologists. CONCLUSION. The number of requested B. burgdorferi serological tests was highest in primary care. A clear guideline describing how to diagnose LA is needed in primary and secondary care alike. FUNDING none. TRIAL REGISTRATION Under current Danish law, no formal ethical approval was required for this study. Approval for this study was obtained from the Danish Data Protection Agency (no. 2012-58-0004).

Predictors of joint damage progression and stringent remission in patients with established rheumatoid arthritis in clinical remission.

OBJECTIVES: To study if clinical, radiographic and MRI markers can predict MRI and radiographic damage progression and achievement of stringent remission in patients with established RA in clinical remission followed by a targeted treatment strategy. METHODS: RA patients (DAS28-CRP <3.2, no swollen joints) receiving conventional synthetic DMARDs were randomized to conventional or MRI-targeted treat-to-target strategies with predefined algorithmic treatment escalations. Potentially predictive baseline variables were tested in multivariate logistic regression analyses. RESULTS: In the 171 patients included, baseline MRI osteitis independently predicted progression in MRI erosion [odds ratio (OR) 1.13 (95% CI 1.06, 1.22)], joint space narrowing [OR 1.15 (95% CI 1.07, 1.24)] and combined damage [OR 1.23 (95% CI 1.13, 1.37)], while tenosynovitis independently predicted MRI erosion progression [OR 1.13 (95% CI 1.03, 1.25)]. A predictor of radiographic erosion progression was age, while gender predicted progression in joint space narrowing. Following an MRI treat-to-target strategy predicted stringent remission across all remission definitions: Clinical Disease Activity Index remission OR 2.94 (95% CI 1.25, 7.52), Simplified Disease Activity Index remission OR 2.50 (95% CI 1.01, 6.66), ACR/EULAR Boolean remission OR 5.47 (95% CI 2.33, 14.13). Similarly, low tender joint count and low patient visual analogue scale pain and global independently predicted achievement of more stringent remission. CONCLUSION: Baseline MRI osteitis and tenosynovitis were independent predictors of 2 year MRI damage progression in RA patients in clinical remission, while independent predictors of radiographic damage progression were age and gender. Following an MRI treat-to-target strategy, low scores of patient-reported outcomes and low tender joint count predicted achievement of stringent remission. TRIAL REGISTRATION: ClinicalTrials.gov (https://clinicaltrials.gov), NCT01656278.