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abortion, accupuncture, ACE inhibitors, acne, ADHD, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anorexia, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, beta carotene, beta-blockers, bipolar disorder, birth, bleeding, blindness, blood pressure, body dysmorphic disorder, body mass, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cataracts, cervical cancer, chemotherapy, child psychiatry, children, cholesterol, clinical trial, clopidogrel, Clostridium difficile, cognitive behavioural therapy, colectomy, colic, colorectal cancer, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, Crohn's, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, DNA, Down's syndrome, eating disorders, echinacea, ECT, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, euthanasia, exercise, fat, fertility, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, haemodialysis, hearing, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, IBD, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, invasive candidiasis, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, Marfan syndrome, media, medical ethics, medical research, medication, meningitis, mental illness, metabolic syndrome, migraine, miscarriage, mortality rate, MRSA, multiple sclerosis (MS), NCHDs, nephrology, neurology, OAB, obesity, obstetrics, occupational health, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, practice, pre-eclampsia, pregnancy, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, radiotherapy, rectal cancer, reproductive health, research, resuscitation, rheumatoid arthritis, rheumatology, rhinitis, salt, SARS, schizophrenia, screening, seizures, self harm, sexual abuse, sexual health, sexually transmitted infections, SGA, sinusitis, skin cancer, sleep disorders, smoking, smoking ban, spinal injury, sports medicine, statins, stress, stroke, substance abuse, suicide, supplement, surgery, syncope, technology, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamins, weight, WHO, women's health, World Health Assembly

«Previous article | Next article»

Exchanging knowledge in rheumatology

The recent 3e National Meeting brought together 20 of Ireland's rheumatologists to discuss the best ways to investigate and follow up undifferentiated peripheral inflammatory arthritis

For the past two years, Irish consultant rheumatologists have been fortunate enough to participate in a novel alternative to traditional medical education.

Recently, the 3e (evidence, experts, exchange) National Meeting, sponsored by an unrestricted educational grant from Abbott, brought together 20 of Ireland’s rheumatologists allowing them to collaborate with not only each other, but also their peers in 17 different countries, from all over Europe and South America, as well as Australia and Canada.

Multinational effort
The concept of the 3e meetings is to enable a multinational collaborative effort in providing national recommendations for rheumatic disease management in daily practice, which

are later collated and transformed into a set of multinational recommendations, published at the end of the programme.

The theme of this year’s meeting (which was the second to be held in Ireland) was how to investigate and follow up undifferentiated peripheral inflammatory arthritis (UPIA).

The 3e meetings afford doctors the opportunity to meet and share their personal experiences in relation to pertinent issues such as this, with a view to ultimately enhancing patient care, explained Dr Joe Devlin, Consultant Rheumatologist and Principal Investigator of the 3e Scientific Committee.

“Undifferentiated peripheral inflammatory arthritis is a fairly common presentation, but when you first see patients you don’t know what type of arthritis it is yet. Patients are in pain and they want to know what they have and what the outlook is,” he said.
Rheumatology management has undergone a paradigm shift over the past 12 years and Dr Devlin explained that the 3e meetings play a role in making sure that the latest available information is used when making clinical decisions.

“The concept behind the 3e meetings is to analyse the huge amount of data that is out there by way of a systematic literature review, and combine this with the expertise of the senior clinicians in the specialty in order to produce recommendations that are clinically useful. Any opportunity that brings a large number of clinicians together is hugely important.”

Attendees at this year’s meeting were asked to debate on and vote for or against ten research questions, as agreed by the international 3e scientific committees.

There was also a national question, submitted by the Irish committee, which had not made the final shortlist but was debated at the Irish meeting.

Recommendations
Dr Devlin commenced proceedings by asking the first question: what is the diagnostic and predictive value of genetic markers (eg. HLA-B27, HLA-DR4, shared epitope)?

The 3e attendees agreed that:

l There is no single genetic marker that can be confidently used to predict a diagnosis of a specific arthropathy from an initial presentation of UPIA.

l The shared epitope alone has some utility in predicting outcome but on the basis of current evidence cannot be recommended for routine clinical practice (e.g. erosions, mortality, cardiovascular death).

Dr Sandy Fraser then asked: what is the diagnostic and predictive value of history and physical examination for UIPA?

The 3e delegates agreed:

l In undifferentiated peripheral inflammatory arthritis, the features of patient history and physical examination which may be useful for diagnosis and prognosis include:

l Age

l Gender

l Symptom duration

l Morning stiffness

l Functional limitation

l Recent Infection

l Family history

l Tender joint count

l Swollen joint count

l Joint distribution

l Extra articular features of any inflammatory arthritis

l Despite the lack of available evidence, repeat evaluation of those elements open to variation at intervals which may be of prognostic and diagnostic use include:
1. Morning stiffness
2. Functional limitation
3. Total joint count
4. Swollen joint count
5. Joint distribution
6. Extra articular features of any inflammatory arthritis.

Dr Trevor Duffy continued the session by asking: which clinical assessments of disease activity (e.g. DAS, SDAI, CDAI) should be done at baseline and repeated at which interval in patients with UPIA? The experts agreed that:

l As yet, no scale can be recommended for routine clinical practice when assessing or following patients with UPIA.

Dr Bobby Coughlan then discussed the diagnostic and predictive value of x-ray and asked the group if it should be done at baseline and, if so, repeated at which interval in patients with UPIA?

The 3e group recommended that:

l Erosions on the hand, wrist and foot x-rays early in the course of arthritis indicate that there is an increased risk of developing RA

l The absence of erosions early in the course of arthritis does not preclude the diagnosis of RA

l Despite the absence of evidence it may be useful to repeat the x-rays at intervals of at least one year.

Dr Trevor Duffy then discussed the role of ultrasound and MRI in UPIA. The expert group agreed that:

l MRI of the hand and wrist may be of value in predicting the development of RA in patients with UPIA of the hand and wrist

l Further study is now required to define the role of ultrasound and MRI in this population

Also accepted by the delegates was Question 6, which looked at the presence of antibodies and their role in RA diagnosis and prognosis.
The delegates concluded that:

l The presence of anti-cyclic citrullinated peptides (anti-CCP) and rheumatoid factor (RF) in an individual with undifferentiated peripheral inflammatory arthritis are both independently predictive of the diagnosis of RA at follow-up

l The absence of RF and anti-CCP does not exclude RA

l Both anti-CCP and RF are also independently associated with radiographic progression and disease persistence in this setting

l Anti-keratin (AKA) and anti-perinuclear factor (APF) may also be helpful in predicting the development of RA in UPIA.

Dr Coughlan then went on to discuss the diagnostic and predictive value of acute phase reactant testing and asked should these be done at baseline and then repeated at which interval in patients with undifferentiated arthritis.

The delegates agreed that:

l A normal acute phase response does not signify the absence of progression to chronic disease

l Elevated acute phase response in early inflammatory arthritis is an indicator of possible progression to chronic disease

l Despite the absence of evidence, repeat testing in parallel with clinical evaluation is recommended.

Prof Oliver FitzGerald discussed the contribution of synovial biopsy in undifferentiated peripheral inflammatory arthritis.

The expert group recommendations were:

l Based on the evidence, synovial biopsy has limited diagnostic or prognostic use in patients presenting with UIPA

l It is an accepted clinical practice that synovial biopsy is useful in the diagnosis of certain specific illnesses such as sarcoidosis, pigmented villonodular synovitis (PVNS) and infection.

Dr Frances Stafford then asked: which differential diagnoses should be considered in inflammatory arthritis? What are the minimal clinical, laboratory and imaging investigations necessary to confirm and follow-up an undifferentiated arthritis? The group recommended that:

l Differential diagnoses which should be considered in inflammatory arthritis are:
1) RA
2) Osteoarthritis
3) Spondyloarthropathy
4) Crystal disease
5) Trauma
6) Connective tissue
disease
7) Infection
8) Other medical e.g.
sarcoidosis
9) Other rheumatic

And also:

l The minimal clinical, laboratory and imaging investigations necessary to confirm and follow-up an undifferentiated arthritis include:

l Clinical: Demographics, time course, site of inflammation, extra-articular features

l Laboratory: full blood count, erythrocyte sedimentation rate, C-reactive protein, liver function tests, renal, RF. In selected patients the following: cyclic citrullinated peptide antibody, antinuclear antibody, uric acid, antineutrophil cytoplasmic antibodies, urine analysis

l Imaging: x-ray or ultrasound site of inflammation, chest x-ray (certain patients)
The experts added that retesting depends on the clinical context. Prof FitzGerald then asked: What is the predictive value of clinical features, laboratory markers, imaging and genetic makers for persistent disease in UPIA? The 3e group agreed that:

l The presence of anti-CCP/RF is highly predictive of persistent disease in UPIA

l There is some evidence for clinical features (disease duration, morning stiffness and HAQ), pattern of joint involvement (small joints, knees), ≥ 3 joints involved and radiographic erosions being predictive of persistent disease in UPIA

l There is no evidence for genetic markers, MRI or ultrasound in predicting persistence.

The final question was the national question, as worded by the 3e scientific committee.

Dr Grainne Murphy asked: what is the diagnostic and predictive value of glucocorticoids (intra-articular/oral/ intramuscular) in the setting of undifferentiated early peripheral arthritis? The experts agreed:

l There is currently no firm evidence to derive diagnostic or prognostic information from the response to intra-articular or intra-muscular glucocorticoids in the setting of UPIA.

At the closing meeting of the series, members of the scientific committees from each of the 20 countries will meet to merge the national recommendations for the elaboration of multi-national recommendations.

Posted in Musculoskeletal on 03 September 2009
Tags: arthritis

Tagcloud

abortion, accupuncture, ACE inhibitors, acne, ADHD, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anorexia, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, beta carotene, beta-blockers, bipolar disorder, birth, bleeding, blindness, blood pressure, body dysmorphic disorder, body mass, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cataracts, cervical cancer, chemotherapy, child psychiatry, children, cholesterol, clinical trial, clopidogrel, Clostridium difficile, cognitive behavioural therapy, colectomy, colic, colorectal cancer, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, Crohn's, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, DNA, Down's syndrome, eating disorders, echinacea, ECT, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, euthanasia, exercise, fat, fertility, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, haemodialysis, hearing, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, IBD, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, invasive candidiasis, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, Marfan syndrome, media, medical ethics, medical research, medication, meningitis, mental illness, metabolic syndrome, migraine, miscarriage, mortality rate, MRSA, multiple sclerosis (MS), NCHDs, nephrology, neurology, OAB, obesity, obstetrics, occupational health, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, practice, pre-eclampsia, pregnancy, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, radiotherapy, rectal cancer, reproductive health, research, resuscitation, rheumatoid arthritis, rheumatology, rhinitis, salt, SARS, schizophrenia, screening, seizures, self harm, sexual abuse, sexual health, sexually transmitted infections, SGA, sinusitis, skin cancer, sleep disorders, smoking, smoking ban, spinal injury, sports medicine, statins, stress, stroke, substance abuse, suicide, supplement, surgery, syncope, technology, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamins, weight, WHO, women's health, World Health Assembly

«Previous article | Next article»

Exchanging knowledge in rheumatology

The recent 3e National Meeting brought together 20 of Ireland's rheumatologists to discuss the best ways to investigate and follow up undifferentiated peripheral inflammatory arthritis

For the past two years, Irish consultant rheumatologists have been fortunate enough to participate in a novel alternative to traditional medical education.

Recently, the 3e (evidence, experts, exchange) National Meeting, sponsored by an unrestricted educational grant from Abbott, brought together 20 of Ireland’s rheumatologists allowing them to collaborate with not only each other, but also their peers in 17 different countries, from all over Europe and South America, as well as Australia and Canada.

Multinational effort
The concept of the 3e meetings is to enable a multinational collaborative effort in providing national recommendations for rheumatic disease management in daily practice, which

are later collated and transformed into a set of multinational recommendations, published at the end of the programme.

The theme of this year’s meeting (which was the second to be held in Ireland) was how to investigate and follow up undifferentiated peripheral inflammatory arthritis (UPIA).

The 3e meetings afford doctors the opportunity to meet and share their personal experiences in relation to pertinent issues such as this, with a view to ultimately enhancing patient care, explained Dr Joe Devlin, Consultant Rheumatologist and Principal Investigator of the 3e Scientific Committee.

“Undifferentiated peripheral inflammatory arthritis is a fairly common presentation, but when you first see patients you don’t know what type of arthritis it is yet. Patients are in pain and they want to know what they have and what the outlook is,” he said.
Rheumatology management has undergone a paradigm shift over the past 12 years and Dr Devlin explained that the 3e meetings play a role in making sure that the latest available information is used when making clinical decisions.

“The concept behind the 3e meetings is to analyse the huge amount of data that is out there by way of a systematic literature review, and combine this with the expertise of the senior clinicians in the specialty in order to produce recommendations that are clinically useful. Any opportunity that brings a large number of clinicians together is hugely important.”

Attendees at this year’s meeting were asked to debate on and vote for or against ten research questions, as agreed by the international 3e scientific committees.

There was also a national question, submitted by the Irish committee, which had not made the final shortlist but was debated at the Irish meeting.

Recommendations
Dr Devlin commenced proceedings by asking the first question: what is the diagnostic and predictive value of genetic markers (eg. HLA-B27, HLA-DR4, shared epitope)?

The 3e attendees agreed that:

l There is no single genetic marker that can be confidently used to predict a diagnosis of a specific arthropathy from an initial presentation of UPIA.

l The shared epitope alone has some utility in predicting outcome but on the basis of current evidence cannot be recommended for routine clinical practice (e.g. erosions, mortality, cardiovascular death).

Dr Sandy Fraser then asked: what is the diagnostic and predictive value of history and physical examination for UIPA?

The 3e delegates agreed:

l In undifferentiated peripheral inflammatory arthritis, the features of patient history and physical examination which may be useful for diagnosis and prognosis include:

l Age

l Gender

l Symptom duration

l Morning stiffness

l Functional limitation

l Recent Infection

l Family history

l Tender joint count

l Swollen joint count

l Joint distribution

l Extra articular features of any inflammatory arthritis

l Despite the lack of available evidence, repeat evaluation of those elements open to variation at intervals which may be of prognostic and diagnostic use include:
1. Morning stiffness
2. Functional limitation
3. Total joint count
4. Swollen joint count
5. Joint distribution
6. Extra articular features of any inflammatory arthritis.

Dr Trevor Duffy continued the session by asking: which clinical assessments of disease activity (e.g. DAS, SDAI, CDAI) should be done at baseline and repeated at which interval in patients with UPIA? The experts agreed that:

l As yet, no scale can be recommended for routine clinical practice when assessing or following patients with UPIA.

Dr Bobby Coughlan then discussed the diagnostic and predictive value of x-ray and asked the group if it should be done at baseline and, if so, repeated at which interval in patients with UPIA?

The 3e group recommended that:

l Erosions on the hand, wrist and foot x-rays early in the course of arthritis indicate that there is an increased risk of developing RA

l The absence of erosions early in the course of arthritis does not preclude the diagnosis of RA

l Despite the absence of evidence it may be useful to repeat the x-rays at intervals of at least one year.

Dr Trevor Duffy then discussed the role of ultrasound and MRI in UPIA. The expert group agreed that:

l MRI of the hand and wrist may be of value in predicting the development of RA in patients with UPIA of the hand and wrist

l Further study is now required to define the role of ultrasound and MRI in this population

Also accepted by the delegates was Question 6, which looked at the presence of antibodies and their role in RA diagnosis and prognosis.
The delegates concluded that:

l The presence of anti-cyclic citrullinated peptides (anti-CCP) and rheumatoid factor (RF) in an individual with undifferentiated peripheral inflammatory arthritis are both independently predictive of the diagnosis of RA at follow-up

l The absence of RF and anti-CCP does not exclude RA

l Both anti-CCP and RF are also independently associated with radiographic progression and disease persistence in this setting

l Anti-keratin (AKA) and anti-perinuclear factor (APF) may also be helpful in predicting the development of RA in UPIA.

Dr Coughlan then went on to discuss the diagnostic and predictive value of acute phase reactant testing and asked should these be done at baseline and then repeated at which interval in patients with undifferentiated arthritis.

The delegates agreed that:

l A normal acute phase response does not signify the absence of progression to chronic disease

l Elevated acute phase response in early inflammatory arthritis is an indicator of possible progression to chronic disease

l Despite the absence of evidence, repeat testing in parallel with clinical evaluation is recommended.

Prof Oliver FitzGerald discussed the contribution of synovial biopsy in undifferentiated peripheral inflammatory arthritis.

The expert group recommendations were:

l Based on the evidence, synovial biopsy has limited diagnostic or prognostic use in patients presenting with UIPA

l It is an accepted clinical practice that synovial biopsy is useful in the diagnosis of certain specific illnesses such as sarcoidosis, pigmented villonodular synovitis (PVNS) and infection.

Dr Frances Stafford then asked: which differential diagnoses should be considered in inflammatory arthritis? What are the minimal clinical, laboratory and imaging investigations necessary to confirm and follow-up an undifferentiated arthritis? The group recommended that:

l Differential diagnoses which should be considered in inflammatory arthritis are:
1) RA
2) Osteoarthritis
3) Spondyloarthropathy
4) Crystal disease
5) Trauma
6) Connective tissue
disease
7) Infection
8) Other medical e.g.
sarcoidosis
9) Other rheumatic

And also:

l The minimal clinical, laboratory and imaging investigations necessary to confirm and follow-up an undifferentiated arthritis include:

l Clinical: Demographics, time course, site of inflammation, extra-articular features

l Laboratory: full blood count, erythrocyte sedimentation rate, C-reactive protein, liver function tests, renal, RF. In selected patients the following: cyclic citrullinated peptide antibody, antinuclear antibody, uric acid, antineutrophil cytoplasmic antibodies, urine analysis

l Imaging: x-ray or ultrasound site of inflammation, chest x-ray (certain patients)
The experts added that retesting depends on the clinical context. Prof FitzGerald then asked: What is the predictive value of clinical features, laboratory markers, imaging and genetic makers for persistent disease in UPIA? The 3e group agreed that:

l The presence of anti-CCP/RF is highly predictive of persistent disease in UPIA

l There is some evidence for clinical features (disease duration, morning stiffness and HAQ), pattern of joint involvement (small joints, knees), ≥ 3 joints involved and radiographic erosions being predictive of persistent disease in UPIA

l There is no evidence for genetic markers, MRI or ultrasound in predicting persistence.

The final question was the national question, as worded by the 3e scientific committee.

Dr Grainne Murphy asked: what is the diagnostic and predictive value of glucocorticoids (intra-articular/oral/ intramuscular) in the setting of undifferentiated early peripheral arthritis? The experts agreed:

l There is currently no firm evidence to derive diagnostic or prognostic information from the response to intra-articular or intra-muscular glucocorticoids in the setting of UPIA.

At the closing meeting of the series, members of the scientific committees from each of the 20 countries will meet to merge the national recommendations for the elaboration of multi-national recommendations.

Posted in Musculoskeletal on 03 September 2009
Tags: arthritis