EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update.

OBJECTIVE: New modes of action and more data on the efficacy and safety of existing drugs in psoriatic arthritis (PsA) required an update of the EULAR 2019 recommendations for the pharmacological treatment of PsA. METHODS: Following EULAR standardised operating procedures, the process included a systematic literature review and a consensus meeting of 36 international experts in April 2023. Levels of evidence and grades of recommendations were determined. RESULTS: The updated recommendations comprise 7 overarching principles and 11 recommendations, and provide a treatment strategy for pharmacological therapies. Non-steroidal anti-inflammatory drugs should be used in monotherapy only for mild PsA and in the short term; oral glucocorticoids are not recommended. In patients with peripheral arthritis, rapid initiation of conventional synthetic disease-modifying antirheumatic drugs is recommended and methotrexate preferred. If the treatment target is not achieved with this strategy, a biological disease-modifying antirheumatic drug (bDMARD) should be initiated, without preference among modes of action. Relevant skin psoriasis should orient towards bDMARDs targeting interleukin (IL)-23p40, IL-23p19, IL-17A and IL-17A/F inhibitors. In case of predominant axial or entheseal disease, an algorithm is also proposed. Use of Janus kinase inhibitors is proposed primarily after bDMARD failure, taking relevant risk factors into account, or in case bDMARDs are not an appropriate choice. Inflammatory bowel disease and uveitis, if present, should influence drug choices, with monoclonal tumour necrosis factor inhibitors proposed. Drug switches and tapering in sustained remission are also addressed. CONCLUSION: These updated recommendations integrate all currently available drugs in a practical and progressive approach, which will be helpful in the pharmacological management of PsA.

Enhancing current guidance for psoriatic arthritis and its comorbidities: recommendations from an expert consensus panel.

OBJECTIVES: Existing guidelines for psoriatic arthritis (PsA) cover many aspects of management. Some gaps remain relating to routine practice application. An expert group aimed to enhance current guidance and develop recommendations for clinical practice that are complementary to existing guidelines. METHODS: A steering committee comprising experienced, research-active clinicians in rheumatology, dermatology and primary care agreed on themes and relevant questions. A targeted literature review of PubMed and Embase following a PICO framework was conducted. At a second meeting, recommendations were drafted and subsequently an extended faculty comprising rheumatologists, dermatologists, primary care clinicians, specialist nurses, allied health professionals, non-clinical academic participants and members of the Brit-PACT patient group, was recruited. Consensus was achieved via an online voting platform when 75% of respondents agreed in the range of 7-9 on a 9-point scale. RESULTS: The guidance comprised 34 statements covering four PsA themes. Diagnosis focused on strategies to identify PsA early and refer appropriately, assessment of diagnostic indicators, use of screening tools and use of imaging. Disease assessment centred on holistic consideration of disease activity, physical functioning and impact from a patient perspective, and on how to implement shared decision-making. For comorbidities, recommendations included specific guidance for high-impact conditions such as depression and obesity. Management statements (which excluded extant guidance on pharmacological therapies) covered multidisciplinary team working, implementation of lifestyle modifications and treat-to-target strategies. Minimising corticosteroid use was recommended where feasible. CONCLUSION: The consensus group have made evidence-based best practice recommendations for the management of PsA to enhance the existing guidelines.

Guselkumab in Patients with Scalp Psoriasis: A post hoc Analysis of the VOYAGE 2 Phase III Randomized Clinical Trial.

Scalp psoriasis affects approximately 80% of patients with psoriasis and can negatively impact their quality of life. This post hoc analysis of the VOYAGE 2 Phase III randomized clinical trial evaluated scalp response to guselkumab treatment and its association with skin response and patient-reported outcomes. The study included patients with moderate-to-severe plaque psoriasis and baseline scalp psoriasis who were initially randomized to receive guselkumab. Patients were divided into 3 groups based on their achievement of a Psoriasis Area and Severity Index 90 response at week 28: responder continuation, non-responder continuation and responder withdrawal. In all 3 groups, mean Psoriasis Area and Severity Index head and scalp-specific Investigator's Global Assessment scores improved through week 28. In the responder withdrawal group, these scores worsened after treatment withdrawal at week 28, but remained stable through week 48 in both continuation groups. Trends in Dermatology Life Quality Index and Psoriasis Symptoms and Signs Diary itch scores mirrored those of mean scalp-specific Investigator's Global Assessment scores through week 48. Within-subject correlations were 0.83 between scalp-specific Investigator's Global Assessment and Psoriasis Area and Severity Index head scores and 0.78 between scalp-specific Investigator's Global Assessment and Psoriasis Symptoms and Signs Diary itch scores. Through week 252, Psoriasis Area and Severity Index head scores remained stable in the responder continuation group, improved in the non-responder continuation group and rapidly improved by week 84 in the responder withdrawal group after retreatment.

EULAR points to consider for the definition of clinical and imaging features suspicious for progression from psoriasis to psoriatic arthritis.

BACKGROUND: The transition from psoriasis (PsO) to psoriatic arthritis (PsA) and the early diagnosis of PsA is of considerable scientific and clinical interest for the prevention and interception of PsA. OBJECTIVE: To formulate EULAR points to consider (PtC) for the development of data-driven guidance and consensus for clinical trials and clinical practice in the field of prevention or interception of PsA and for clinical management of people with PsO at risk for PsA development. METHODS: A multidisciplinary EULAR task force of 30 members from 13 European countries was established, and the EULAR standardised operating procedures for development for PtC were followed. Two systematic literature reviews were conducted to support the task force in formulating the PtC. Furthermore, the task force proposed nomenclature for the stages before PsA, through a nominal group process to be used in clinical trials. RESULTS: Nomenclature for the stages preceding PsA onset, 5 overarching principles and 10 PtC were formulated. Nomenclature was proposed for three stages towards PsA development, namely people with PsO at higher risk of PsA, subclinical PsA and clinical PsA. The latter stage was defined as PsO and associated synovitis and it could be used as an outcome measure for clinical trials evaluating the transition from PsO to PsA. The overarching principles address the nature of PsA at its onset and underline the importance of collaboration of rheumatologists and dermatologists for strategies for prevention/interception of PsA. The 10 PtC highlight arthralgia and imaging abnormalities as key elements of subclinical PsA that can be used as potential short-term predictors of PsA development and useful items to design clinical trials for PsA interception. Traditional risk factors for PsA development (ie, PsO severity, obesity and nail involvement) may represent more long-term disease predictors and be less robust for short-term trials concerning the transition from PsO to PsA. CONCLUSION: These PtC are helpful to define the clinical and imaging features of people with PsO suspicious to progress to PsA. This information will be helpful for identification of those who could benefit from a therapeutic intervention to attenuate, delay or prevent PsA development.

Using learning profiles to inform education priorities: An editors' overview of the Special Issue.

This special issue explores the use of learning profiles for analysing the dynamics of low learning in low- and middle-income countries and informing priorities to address the learning crisis. The 12 papers in the special issue draw on learning data from more than 50 countries and 6 million individuals, with implications for education policy and practice. Taken together, they point to a need to steepen learning trajectories by prioritizing early mastery of foundational skills for all children. The papers show that addressing the learning crisis will not be achieved through more school grade attainment alone, nor through within-country equality across groups (such as girls and boys or rich and poor). Positive examples show that programs focused on foundational learning both improved average learning and reduced inequality. Addressing the learning crisis will require a focus on systems improvement, using foundational learning as a case in point for making the needed systems improvements to steepen learning throughout children's time in school. Learning profiles can provide a guide for education actors aiming to improve learning outcomes.

Maternal history of childhood maltreatment and later parenting behavior: A meta-analysis.

Exposure to maltreatment during childhood (CM) can have deleterious effects throughout the life span of an individual. A parent's history of child maltreatment can also impact his or her own parenting behavior. Theoretically, parents who experienced maltreatment as children may have fewer resources to cope with the challenges of childrearing and may adopt more problematic parenting behaviors. However, empirical studies examining the association between CM and later parenting behavior have yielded mixed results. The aim of this study is to conduct a meta-analysis of studies that have examined the association between exposure to CM and the subsequent parenting outcomes of mothers of 0- to 6-year-old children. A secondary aim is to examine the potential impact of both conceptual and methodological moderators. A total of 32 studies (27 samples, 41 effect sizes, 17,932 participants) were retained for analysis. Results revealed that there is a small but statistically significant association between maternal exposure to CM and parenting behavior (r = -.13, p < .05). Moderator analyses revealed that effect sizes were larger when parenting measures involved relationship-based or negative, potentially abusive behaviors, when samples had a greater number of boys compared to girls, and when studies were older versus more recent. Results are discussed as they relate to the intergenerational transmission of maltreatment and abuse.

A case study illustrating the use of an attachment video-feedback intervention strategy.

Children from high-risk environments are more likely to experience problems in development. Many difficulties are linked to early experiences in the context of the emerging attachment relationship. Over the past 20 years, our group has collaborated with government agencies to develop and implement an attachment-based video-feedback intervention strategy (AVI) that targets parental sensitivity and attachment. This case study presents the manner in which a young mother and her 6-month-old son experienced AVI. The study shows how the absence of maternal sensitivity and responsiveness to infant signals, difficulties in helping the child regulate affect, and problems in autonomy support are addressed via eight semi-structured mentoring visits. Discussion focuses on how AVI may be a helpful addition to primary prevention programs.

Living with a total artificial heart: patients' perspectives.

BACKGROUND: Advances in mechanical circulatory support have reduced morbidity and mortality in end-stage heart failure. To date, there have been no published studies examining the psychosocial impact on patients who are supported with a total artificial heart (TAH-t). PURPOSE: The purpose of this study was to describe the lived experience of patients currently supported by the TAH-t awaiting transplant. METHODS: A qualitative method using Giorgi's modification of phenomenologic inquiry guided the investigation, which was conducted at a transplant center located in the mid-Atlantic region of the United States. A purposive sample was selected to reflect participants currently supported by the TAH-t. All participants (9 men, 1 woman; mean age, 48.2 years; nonischemic etiology, 80%) were in-patients on the progressive care unit at the time of the interview and had been supported for at least 30 days. The mean length of device therapy was 84.7 days (range, 33-245 days). FINDINGS: Hope for the future was the overarching theme. Subthemes included reflections, for better or for worse, the secret club, and coping and adaptation. The patients reflected on severity of illness, progress, and expressed optimism. For better or for worse described how symptoms improved but were offset by restrictions imposed by the technology. The secret club described the support provided to help deal with their life situation. Coping and adaptation suggested that the patients came to terms with and accepted their circumstances. CONCLUSIONS: The findings will help clinicians understand patients experiencing a life-changing situation and implications for psychosocial interventions.

Increasing Access to Effective Systemic Treatments in Patients with Moderate-to-Severe Psoriasis: Narrative Review.

Psoriasis is a chronic, immune-mediated inflammatory disease with a worldwide prevalence ranging between 0.51 and 11.43%. It results in a large clinical and social burden, with patients frequently suffering from reduced quality of life, psychologic distress and debilitating comorbidities. Biologic agents are used to establish and maintain disease control in patients with moderate-to-severe psoriasis and are essential to improving quality of life. However, a substantial proportion of patients have limited access to therapy due to economics, health policies and clinical considerations, which creates clinical unmet needs that disadvantage both patients and healthcare professionals. Biosimilars are a cost-effective alternative to off-patent biologic therapies, and there is mounting evidence to suggest they offer a valuable pharmacoeconomic strategy to lower healthcare costs in patients with psoriasis. Furthermore, the introduction of biosimilars can increase the number of patients able to receive biologics, allowing these patients to be treated earlier in the disease course, potentially modifying the course of their disease and reducing the risk of comorbidities. In time, the emergence of additional data, particularly those related to long-term safety, efficacy in extrapolated indications and the effects of switching, should reassure physicians and help overcome the final hurdles for a wider implementation of biosimilars. This review aims to provide an overview of current treatment approaches for patients with moderate-to-severe psoriasis in the biosimilars era and explores both the current challenges and potential opportunities to improve access to high-quality, effective treatments.

Proceedings of the GRAPPA 2022 Executive Retreat.

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) leadership congregated for a strategic planning meeting before the 2022 GRAPPA annual meeting in New York, USA. Meeting aims were to review GRAPPA's performance in relation to its 2016 goals and identify successes and areas for further improvement, identify key GRAPPA priorities and activities for the next 5 years, and explore committee structures to best support these aims.

Developing and maintaining competency with circulatory assist devices: how to meet the challenge.

Heart failure is the only cardiovascular disease that is increasing in prevalence in developing countries. As a result, circulatory assist devices are being used more both as a bridge to heart transplantation and as destination therapy in patients with a failing heart. Nurses must become knowledgeable about these options for their patients. Developing and maintaining competency can be challenging as more devices become available. The principles of adult learners were used by one academic medical center to set up a new circulatory assist program and to maintain ongoing competency among staff working with patients who have these devices.

Defining Pre-Clinical Psoriatic Arthritis in an Integrated Dermato-Rheumatology Environment.

In excess of three quarters of patients with psoriatic arthritis (PsA) have preceding psoriasis (PsO), which offers a clinical biomarker for the recognition of early PsA. Numerous surveys have shown a remarkably high frequency of clinically occult musculoskeletal symptoms in psoriasis patients. Imaging studies, particularly ultrasound, show a high prevalence of subclinical enthesitis and other inflammatory changes in psoriasis subjects. Since a serum biomarker, such as the case of anti-citrullinated protein antibodies (ACPA) in rheumatoid arthritis, neither exists nor seems biologically plausible at this point, this article explores how integration of rheumatological and dermatological assessment can be facilitated for the early recognition of potential PsA. Given that scalp disease is a PsA predictor, but may be managed in the community, then a particular need to access this group is needed. An integrated approach between rheumatology and dermatology can involve joint clinics, parallel clinics with discussion of relevant cases or virtual contact between specialties. Early therapy evaluation and integrated strategies have considerable implications for minimizing suffering and joint damage in PsA.

Managing the failing heart: total circulatory assist--a case study.

Congestive heart failure remains one of the leading causes of cardiac death and disability. As pharmacological therapies have advanced, patients are living longer and more productive lives. However, at some point, these interventions begin to fail. Circulatory assist devices have revolutionized the management of patients with end-stage heart disease. These devices successfully bridge patients to cardiac transplantation. The Syncardia Total Artificial Heart provides biventricular support for the failing heart. This case study illustrates the challenges of caring for patients with such a device.

Regression of Peripheral Subclinical Enthesopathy in Therapy-Naive Patients Treated With Ustekinumab for Moderate-to-Severe Chronic Plaque Psoriasis: A Fifty-Two-Week, Prospective, Open-Label Feasibility Study.

OBJECTIVE: To investigate whether sonographically determined subclinical enthesopathy in patients with moderate-to-severe psoriasis regresses with the use of ustekinumab therapy for skin disease. METHODS: Seventy-three patients with moderate-to-severe psoriasis, who were not treated with systemic therapy and did not have symptoms of psoriatic arthritis (PsA), and 23 healthy volunteers were screened by ultrasound for subclinical enthesitis. Subsequently, 23 patients with psoriasis whose ultrasound results showed inflammatory changes were treated with ustekinumab for 52 weeks. The evolution of sonographic abnormalities of the upper and lower limb entheses was assessed using an extensive gray-scale and power Doppler (PD) ultrasound protocol at weeks 0, 12, 24, and 52. For each parameter, a gray-scale or PD ultrasound score of >0 was determined to be abnormal, and a summative score based on the Glasgow Ultrasound Enthesitis Scoring System was calculated. RESULTS: Of all the patients with psoriasis screened using ultrasound, 49.3% had at least 1 inflammatory entheseal abnormality. Mean ± SD inflammation scores were higher in the patients with psoriasis compared with the healthy volunteers (9.9 ± 6.6 versus 1.0 ± 1.4). With treatment, the mean inflammation scores decreased significantly by 42.2% from week 0 to week 24 (-4.2 [95% confidence interval -6.3, -2.1]; P < 0.001) and by 47.5% by week 42 (-4.7 [95% confidence interval -7.1, -2.3]; P = 0.001). Entheseal structural abnormalities did not change significantly during treatment. CONCLUSION: Within 12 weeks of treatment, interleukin-12 (IL-12)/IL-23 inhibition for psoriasis appears to suppress subclinical enthesopathy, and the suppression is maintained through week 52. Further longitudinal studies are needed to determine whether therapy initiated for skin disease may prevent the development of PsA.

Frequency and predictors of return to incentive spirometry volume baseline after cardiac surgery.

Incentive spirometry (IS) is routinely used in most clinical settings, but evaluation of patient efficacy of IS is not standardized. The purpose of this study was to describe the degree and predictors of return to preoperative IS volume after cardiac surgery. IS volumes were documented in 69 subjects (71% men; mean age, 59 years) undergoing cardiac surgery during the preoperative evaluation and twice daily postoperatively. Nineteen percent of subjects achieved their IS preoperative volume by hospital discharge. Based on highest volume achieved, subjects achieved an average of 75% of their preoperative volume by discharge, and only age and number of bypass grafts predicted return to preoperative IS volume. These data may assist nurses and patients to set realistic goals for postoperative IS volume achievement.

An educational leaflet improves response to invitation for screening for arthritis in patients with psoriasis in primary care, but only in practices in the most deprived areas.

This study hypothesises that an educational leaflet about psoriatic arthritis (PsA) will improve psoriasis patients' attendance for screening for PsA. A random sample of patients ≥18 years old with a coded diagnosis of psoriasis and no diagnosis of PsA, rheumatoid arthritis or ankylosing spondylitis were identified from five GP surgeries in Yorkshire, UK. Patients were randomised 1:1 to receive study information alone or with the educational leaflet, with an invitation to attend for a screening examination by a dermatologist and rheumatologist. Nine hundred thirty-two invitation packs were sent to recruit 191 (20.5%) participants. One hundred sixty-nine (88.5%) had current or previous psoriasis and 17 (10.1%) had previously undiagnosed PsA. The estimated prevalence of PsA was 18.1% (95% CI: 16.2, 20.1%).The response rate was lower than expected and was not significantly higher when patients received the educational leaflet (22.8 vs 18.3%, p = 0.08). Response rates varied by practice (14.7 to 30.6%). However, deprivation scores for each practice revealed a significant increase in response with the leaflet for deprivation decile of 3 (p < 0.001) but no significant differences in the other practices. An educational leaflet about PsA improves attendance for screening in primary care, but only in those practices with higher levels of socioeconomic deprivation.

Living with pulmonary artery hypertension: patients' experiences.

BACKGROUND: Research on the outcomes of medical therapy in persons with pulmonary artery hypertension (PAH) has increased as new therapeutic options have emerged. Little investigation has been done on the impact of living with PAH despite inferences that quality of life (QOL) improves. PURPOSE: The purpose of this qualitative study was to describe patient experiences of living with PAH and identify factors that may have an impact on QOL. PARTICIPANTS: Participants (n = 11; 8 women, 3 men) were selected from among 42 adult patients, 40 to 72 years of age, followed in an outpatient setting at a tertiary care hospital. Multiple types of treatment modalities were represented including calcium channel blockers, endothelin-receptor antagonists, prostacyclin analog, and lung transplantation. METHODS: Semistructured interviews allowed participants to describe experiences living with PAH. Interviews were recorded on audiotape and transcribed verbatim. Analysis was conducted in accordance with Colaizzi's 7-step process for analysis of phenomenologic data. RESULTS: Two overarching themes emerged indicating that participants experience uncertainty associated with a variety of aspects of this illness but also learn to cope with this uncertainty and move on with their lives. IMPLICATIONS: Assisting patients to cope with the uncertainty associated with this chronic health problem is essential if patients are to successfully adjust to the demands of the illness and its treatment. Attention to the findings of this study should guide health care professionals in their efforts to improve QOL in this patient population.

Ustekinumab in the Treatment of Psoriasis and Psoriatic Arthritis.

Biologics have revolutionized the therapy of the psoriatic disease spectrum. These new classes of drugs also allow deeper insight into the pathogenesis of the disease and highlight the existence of distinct "molecular" disease subgroups as evidenced by the spectrum of clinical response seen. Molecules associated with both the interleukin (IL)-17 and interferon (IFN)γ pathways have important functions in psoriatic inflammation, and both are targeted by drugs acting on the p40 subunit shared by IL-12 and IL-23. These IL-12 family members are upstream of pathways characterized by the production of IFNγ and IL-17 related molecules, including IL-17, IL-22, and CCL20. We here summarize the mode of action and clinical studies of the p40 inhibitor ustekinumab with focus on both psoriasis and psoriatic arthritis.

Postoperative autologous blood salvage drains--are they useful in primary uncemented hip and knee arthroplasty? A prospective study of 186 cases.

There are nearly 43,000 hip replacements and 33,000 knee replacements performed each year in the United Kingdom. Many of these require a blood transfusion. However, there has been increased public concern about the safety of blood transfusion and various techniques are used to decrease the need for allogenic transfusion. Postoperative blood salvage and reinfusion is one of them. We studied 186 consecutive patients who underwent unilateral uncemented hip or knee arthroplasty. Ninety-four had re-infusion drains and 92 had suction drains. We have compared the allogenic transfusion requirements for the two groups. We have analyzed patient and operative factors to determine whether they are predictive for risk of allogenic blood transfusion. Cost analysis was performed to determine whether the use of a re-infusion drain is a cost effective technique. Re-infusion drains significantly decreased the requirements for allogenic blood transfusion (p = 0.001). Twenty-one percent of the re-infusion drain group and 45.7 % of the suction drain group required allogenic blood transfusion. The only preoperative factor that determined whether the patient required allogenic blood transfusion was pre-operative haemoglobin. We found that age, gender, type of surgery (hip replacement or knee replacement) and whether the patient had tourniquet or not (in knee replacement) did not alter the requirements for allogenic blood transfusion. The mean transfusion costs were slightly less for re-infusion drain group (l 182.70 per patient for re-infusion drain group and l 196.75 per patient for suction drain group, p = 0.009). The hospital stay was also significantly reduced (11.0 days for re-infusion drain group as opposed to 12.6 days for suction drain group (p = 0.0248). Based on these findings, re-infusion drains appear as a cost effective means of reducing the requirement for allogenic blood transfusion following primary hip and knee arthroplasty.