Can Ultrasound Be Used to Predict Loss of Remission in Patients with RA in a Real-life Setting? A Multicenter Cohort Study.

OBJECTIVE: Several studies have suggested that patients with rheumatoid arthritis (RA) presenting with ultrasound (US) synovitis despite clinical remission have more subsequent flares than those who show both clinical and sonographic remission. The objective of our study was to investigate whether these results could be translated to a real-life setting. METHODS: We compared the time from the first US performed in clinical remission to loss of remission (defined by a DAS28 > 2.6 or the need for stepping up treatment with disease-modifying antirheumatic drugs) within the Swiss Clinical Quality Management cohort of patients with RA, and we adjusted for relevant confounders. Analyses were repeated for different definitions of US-detected synovitis (US+) using greyscale, Doppler, and combined modes based on previously validated scores, and they were adjusted for relevant confounders. RESULTS: There were 318 RA patients with 378 remission phases included. Loss of clinical remission was observed in 60% of remission phases. Residual US synovitis was associated with a shorter duration of clinical remission (median 2-5 mos) and a moderately increased hazard ratio (HR) for loss of remission (HR 1.2-1.5), with the highest HR for the combined US score. The association between US+ and loss of remission was strongest when the US measurement had taken place early in remission (shorter median duration of 6-20 mos) and when followup time was limited to the first 3 or 6 months (most HR between 2-4). CONCLUSION: US-detected synovitis, particularly when US is performed early in clinical remission, has a moderate predictive power for loss of remission in a real-life setting.

Safety and efficacy of extracorporeal shock wave therapy (ESWT) in calcinosis cutis associated with systemic sclerosis.

OBJECTIVES: Calcinosis cutis is a frequent, difficult to treat manifestation of systemic sclerosis (SSc) associated with high morbidity. The aim of this prospective, controlled, monocentric study was to assess safety and efficacy of extracorporeal shock wave therapy (ESWT) for calcinosis cutis of the finger in SSc patients. METHODS: A 12-week proof of concept study in which 4 SSc patients with calcinosis cutis were treated at one painful finger with high-energy, focused ESWT, in 3 sessions with one-week interval between each session. A second, untreated finger, served as control. The outcome parameters were: change in pain, change in size of calcification measured by ultrasound (US) and computed tomography (CT) and of the force by pressing the finger against a Dolorimeter. RESULTS: Pain was reduced (by 91% and 60%) in the treated finger in two out of four patients. There was no change in the control fingers. The size of the calcinosis in the treated finger was reduced in three (US) and four patients (CT). Inter-assessor agreement was acceptable for US volume measures (ICC=0.863). CONCLUSIONS: We could show promising evidence for safety and efficacy of ESWT for chronic, treatment resistant calcinosis cutis in SSc patients, thus justifying the initiation of larger multicentre controlled trials.

The Effect of Comedication With a Conventional Synthetic Disease-Modifying Antirheumatic Drug on Drug Retention and Clinical Effectiveness of Anti-Tumor Necrosis Factor Therapy in Patients With Axial Spondyloarthritis.

OBJECTIVE: To explore the effect of comedication with conventional synthetic disease-modifying antirheumatic drugs (DMARDs) on drug retention and clinical effectiveness of tumor necrosis factor inhibitors (TNFi) in patients with axial spondyloarthritis (SpA). METHODS: The study included all patients starting treatment with a TNFi in a large prospective cohort of axial SpA patients (Swiss Clinical Quality Management in axial SpA). Crude drug retention was analyzed using the Kaplan-Meier method, and in adjusted analyses, Cox proportional hazards regression was used to model TNFi discontinuation. We evaluated multiple disease activity measures and validated clinical response criteria over time. RESULTS: A total of 2,765 TNFi treatment courses were included from 1,914 patients with axial SpA, 20.4% in combination with a conventional synthetic DMARD. In unadjusted analyses, the monotherapy group had significantly shorter median TNFi retention time (32.7 months) compared to the cotherapy group (39.1 months) (P = 0.04). In multivariate adjusted analyses, the monotherapy group had significantly lower TNFi retention, with a hazard ratio (HR) of 1.17 (95% confidence interval [95% CI] 1.01-1.35). This effect was even larger when only infliximab-treated patients were considered, with an HR for monotherapy of 1.36 (95% CI 1.06-1.74). Clinical response rates were almost identical at 1 year, with a change in the Bath Ankylosing Spondylitis Disease Activity Index of -2.02 and -2.00 (P = 0.83) and a change in the Ankylosing Spondylitis Disease Activity Score using C-reactive protein of -1.14 and -1.12 (P = 0.45) in the monotherapy and cotherapy groups, respectively. CONCLUSION: We demonstrate an association between the combination of a TNFi with conventional synthetic DMARDs and improved drug retention in patients with axial SpA, particularly in the subgroup of patients with infliximab.

Gouty arthritis: the diagnostic and therapeutic impact of dual-energy CT.

OBJECTIVES: To determine the diagnostic and therapeutic impact of dual-energy computed tomography (DECT) in gout. METHODS: Forty-three patients with (n = 20) and without a history of gout (n = 23) showing non-specific soft tissue deposits underwent DECT after unrewarding arthrocentesis. Two blinded, independent readers evaluated DECT for the presence of urate crystals. Clinical diagnosis, clinically suspected urate crystal locations, diagnostic thinking and therapeutic decisions were noted before and after DECT. Clinical 1-month follow-up was obtained. RESULTS: DECT showed urate in 26/43 patients (60 %). After DECT, clinical diagnosis of gout was withdrawn in 17/43 (40 %) and was maintained in 16/43 patients (37 %). In 10/43 patients (23 %) the diagnosis was maintained, but DECT revealed urate in clinically unsuspected locations. In 23/43 patients (53 %), a treatment-change based on DECT occurred. Changes in diagnostic thinking occurred more frequently in patients without a history of gout (p < 0.001), changes in therapeutic decisions more frequently in patients with a history of gout (p = 0.014). Clinical follow-up indicated beneficial effects of DECT-based diagnoses in 83 % of patients. CONCLUSIONS: In patients with or without a history of gout and a recent suspicion for gouty arthritis with an unrewarding arthrocentesis, DECT has a marked diagnostic and therapeutic impact when hyperdense soft-tissue deposits are present. KEY POINTS: • This study evaluates the concept of evidence-based radiology • In patients with suspected gout, DECT can help clinicians make the diagnosis • DECT has a marked impact on therapy • Clinical follow-up after 1 month indicated reliable results of DECT.

Correlation of findings in clinical and high resolution ultrasonography examinations of the painful shoulder.

OBJECTIVE: High resolution ultrasonography is a non-painful and non-invasive imaging technique which is useful for the assessment of shoulder pain causes, as clinical examination often does not allow an exact diagnosis. The aim of this study was to compare the findings of clinical examination and high resolution ultrasonography in patients presenting with painful shoulder. METHODS: Non-interventional observational study of 100 adult patients suffering from unilateral shoulder pain. Exclusion criteria were shoulder fractures, prior shoulder joint surgery and shoulder injections in the past month. The physicians performing the most common clinical shoulder examinations were blinded to the results of the high resolution ultrasonography and vice versa. RESULTS: In order to detect pathology of the m. supraspinatus tendon, the Hawkins and Kennedy impingement test showed the highest sensitivity (0.86) whereas the Jobe supraspinatus test showed the highest specificity (0.55). To identify m. subscapularis tendon pathology the Gerber lift off test showed a sensitivity of 1, whereas the belly press test showed the higher specificity (0.72). The infraspinatus test showed a high sensitivity (0.90) and specificity (0.74). All AC tests (painful arc II(a), AC joint tenderness(b), cross body adduction stress test(c)) showed high specificities ((a)0.96, (b)0.99, (c)0.96). Evaluating the long biceps tendon, the palm up test showed the highest sensitivity (0.47) and the Yergason test the highest specificity (0.88). CONCLUSION: Knowledge of sensitivity and specificity of various clinical tests is important for the interpretation of clinical examination test results. High resolution ultrasonography is needed in most cases to establish a clear diagnosis.

[Relevance and Application of Opioids in the Treatment of Chronic Pain in Switzerland­a National Survey]. / Stellenwert und Einsatz von Opioiden in der Therapie chronischer Schmerzen in Schweizer Arztpraxen--eine nationale Umfrage.

METHOD: National survey on treatment with opioids among 1206 Swiss general internists and rheumatologists, using a questionnaire. TYPES OF PAIN: More self-declared pain specialists than non-specialists treat neuropathic pain (49,3 vs. 35,8%; p=0,002), whereas other types of pain are similarly often treated by specialists and non-specialists. OPIOID PRESCRIPTION: Pain specialists more often than non-specialists use opioids in visceral (12,8 vs. 5,9%, p=0,004) and postoperative pain (29,3 vs. 20,1%, p=0,013). TUMOR PAIN: Non-specialists rather than specialists prescribe opioids (80,4 vs. 72,8%, p=0,039); younger physicians (<50 years) rather than older ones often prescribe opioids (82,5 vs. 76,9%; p=0,026), and rheumatologists use opioids less often than general internists (43,3 vs. 83,0%, p<0,0001). WHO ANALGESIC LADDER: Specialists more often change directly from level 1 to level 3 analgesics (66,4 vs. 53,8%; p=0,001).

Performance of the new ACR/EULAR classification criteria for systemic sclerosis in clinical practice.

OBJECTIVE: The preliminary classification criteria for SSc lack sensitivity for mild/early SSc patients, therefore, the new ACR/EULAR classification criteria for SSc were developed. The objective of this study was to evaluate the performance of the new classification criteria for SSc in clinical practice in a cohort of mild/early patients. METHODS: Consecutive patients with a clinical diagnosis of SSc, based on expert opinion, were prospectively recruited and assessed according to the EULAR Scleroderma Trials and Research group (EUSTAR) and very early diagnosis of SSc (VEDOSS) recommendations. In some patients, missing values were retrieved retrospectively from the patient's records. Patients were grouped into established SSc (fulfilling the old ACR criteria) and mild/early SSc (not fulfilling the old ACR criteria). The new ACR/EULAR criteria were applied to all patients. RESULTS: Of the 304 patients available for the final analysis, 162/304 (53.3%) had established SSc and 142/304 (46.7%) had mild/early SSc. All 162 established SSc patients fulfilled the new ACR/EULAR classification criteria. The remaining 142 patients had mild/early SSc. Eighty of these 142 patients (56.3%) fulfilled the new ACR/EULAR classification criteria. Patients with mild/early SSc not fulfilling the new classification criteria were most often suffering from RP, had SSc-characteristic autoantibodies and had an SSc pattern on nailfold capillaroscopy. Taken together, the sensitivity of the new ACR/EULAR classification criteria for the overall cohort was 242/304 (79.6%) compared with 162/304 (53.3%) for the ACR criteria. CONCLUSION: In this cohort with a focus on mild/early SSc, the new ACR/EULAR classification criteria showed higher sensitivity and classified more patients as definite SSc patients than the ACR criteria.

Treatment with tumor necrosis factor inhibitors in axial spondyloarthritis: comparison between private rheumatology practices and academic centers in a large observational cohort.

OBJECTIVE: To evaluate the initiation of and response to tumor necrosis factor (TNF) inhibitors for axial spondyloarthritis (axSpA) in private rheumatology practices versus academic centers. METHODS: We compared newly initiated TNF inhibition for axSpA in 363 patients enrolled in private practices with 100 patients recruited in 6 university hospitals within the Swiss Clinical Quality Management (SCQM) cohort. RESULTS: All patients had been treated with ≥ 1 nonsteroidal antiinflammatory drug and > 70% of patients had a baseline Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≥ 4 before anti-TNF agent initiation. The proportion of patients with nonradiographic axSpA (nr-axSpA) treated with TNF inhibitors was higher in hospitals versus private practices (30.4% vs 18.7%, p = 0.02). The burden of disease as assessed by patient-reported outcomes at baseline was slightly higher in the hospital setting. Mean levels (± SD) of the Ankylosing Spondylitis Disease Activity Score were, however, virtually identical in private practices and academic centers (3.4 ± 1.0 vs 3.4 ± 0.9, p = 0.68). An Assessment of SpondyloArthritis international Society (ASAS40) response at 1 year was reached for ankylosing spondylitis in 51.7% in private practices and 52.9% in university hospitals (p = 1.0) and for nr-axSpA in 27.5% versus 25.0%, respectively (p = 1.0). CONCLUSION: With the exception of a lower proportion of patients with nr-axSpA newly treated with anti-TNF agents in private practices in comparison to academic centers, adherence to ASAS treatment recommendations for TNF inhibition was equally high, and similar response rates to TNF blockers were achieved in both clinical settings.