Abstract Objective The aim of this study was to assess the relationship between self-reported non-adherence, non-trough drug levels, immunogenicity and conventional synthetic DMARD (csDMARD) co-therapy in TNF inhibitor (TNF-i) drug response in PsA. Methods Serum samples and adherence questionnaires were collected at baseline, 3, 6 and 12 months for PsA patients prescribed TNF-i. Non-trough adalimumab (ADL) and etanercept (ETN) drug levels were measured at 3 and 6 months using commercially available ELISAs. Clinical response was assessed using PsA response criteria (PsARC) and change in 28-joint DAS (ΔDAS28) between baseline and 3, 6 and 12 months. Results In 244 PsA patients (52.5% ADL and 47.5% ETN), self-reported non-adherence was associated with PsARC non-response over 12 months using generalized estimating equation (GEE) modelling (P = 0.037). However, there was no significant difference between non-trough ADL or ETN drug levels based on self-reported non-adherence. Higher ETN levels at 3 months were associated with PsARC response at 3 (P = 0.015), 6 (P = 0.037) and 12 months (P = 0.015) and over 12 months using GEE modelling (P = 0.026). Increased ADL drug levels at 3 months were associated with greater ΔDAS28 at 3 months (P = 0.019). ADL anti-drug antibody-positive status was significantly associated with lower 3- and 6-month ADL levels (P < 0.001) and ΔDAS28 and PsARC response at 3, 6 and 12 months. Meanwhile, MTX co-therapy was associated with a reduction in immunogenicity at 3 and 6 months (P = 0.008 and P = 0.024). Conclusion Although both were associated with reduced response, the objectively measured non-trough drug levels showed more significant associations with drug response than self-reported non-adherence measures.
Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck"). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?"). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it … he said that hasn't worked as good as he'd wanted to … but the pain has gone"). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about"). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interest.
It is accepted that seronegative spondyloarthritides such as Ankylosing Spondylitis (AS) are frequently misdiagnosed or diagnosed late in the disease course; early diagnosis and subsequent treatment improves patient symptoms and reduces the likelihood of permanent functional impairment. The presence of inflammatory back pain (IBP) is a key diagnostic symptom, yet few non-specialist doctors are confident in identifying it 1. To aid diagnosis well validated criteria exist to guide non-expert clinicians and help flag patients potentially suffering with IBP 2. Little is known about the true frequency of IBP in the primary care population, with the only study estimating the prevalence at 15% 3. Prevalence of AS is estimated at 0.2-1.2% 4.
Objectives
To determine the prevalence of inflammatory back pain in a UK General Practice population.
Methods
For a six month period in 2011 all patients aged between 18 and 40 years presenting to their General Practitioner for the first time with back pain in two UK medical practices were screened using the ASAS inflammatory back pain criteria. The two practices involved serve a population of 26500 patients. Those answering positively to 4 or more of the questions were defined as suffering IBP and referred to a local rheumatology service for further investigation.
Results
During the six month study period 55 patients presented to their GP with their first episode of back pain. All were white Caucasian. Six patients (11%) were defined as suffering inflammatory back pain as per ASAS criteria; 5 were male (83%) and 1 female (17%). 50% of these patients were subsequently diagnosed with a seronegative spondyloarthritis.
Conclusions
In our study population the prevalence of inflammatory back pain was 11%; 50% of these patients were diagnosed with Ankylosing Spondylitis. Our study involved a small sample size; further work is required to more confidently estimate the prevalence of inflammatory back pain in patients presenting to their General Practitioner.
References
NE Foster. Barriers and progress in the treatment of low back pain. BMC Medicine 2011; 9: 108. Sieper J, Van der Heijde D, Landewe R, Burgos-Vagas R, Collantes-Esteves E. New criteria for inflammatory back pain in patients with chronic back pain. Ann Rheum Dis 2009; 68: 784-788. Underwood MR, Dawes P. Inflammatory Back Pain in Primary Care Rheumatology 1995; 34: 1074-77. Sieper J, Rudwaleit M, Khan MA, Braun J. Concepts and Epidemiology of Spondyloarthropathy Best Practice & Res Clin Rheumatol 2006; 20: 401-417
Poor diet is the top modifiable mortality risk factor globally, accounting for 11 million deaths annually with half being from diet-linked atherosclerotic cardiovascular disease (ASCVD). Yet, most of the world cannot afford a healthy diet-as the hidden costs of the inadequate global food system total over USD 13 trillion annually-let alone the much more clinically, financially, and ecologically costly and resource-intensive medical interventions required to address the disease progression and acute complications of ASCVD. Yet, AI is increasingly understood as a force multiplying revolutionary technology which may catalyze multi-sector efforts in medicine and public health to better address these significant health challenges. This novel narrative review seeks to provide the first known overview of the state-of-the-art in clinical interventions and public health policies in healthy diets for ASCVD, accelerated by health equity-focused AI. It is written from the first-hand practitioner perspective to provide greater relevance and applicability for health professionals and data scientists. The review summarizes the emerging trends and leading use cases in population health risk stratification and precision public health, AI democratizing clinical diagnosis, digital twins in precision nutrition, and AI-enabled culinary medicine as medical education and treatment. This review may, therefore, help inform and advance the evidence-based foundation for more clinically effective, financially efficient, and societally equitable dietary and nutrition interventions for ASCVD.
PURPOSE To compare the effectiveness of a web-based exercise consultation to a ‘face to face’ consultation in increasing the physical activity levels of phase three cardiac rehabilitation patients over a period of six weeks. METHODS Sixty-nine subjects volunteered to take part in the study prior to entering a phase three cardiac rehabilitation programme. These subjects were randomly assigned to a web-based consultation group, a traditional ‘face to face’ group, or a control group receiving no physical activity counselling (twenty-three subjects per group). All three groups completed a 7-day recall questionnaire to measure physical activity levels both at baseline and at a follow-up of six weeks. Focus groups were conducted to allow a greater understanding of the quantitative results obtained. RESULTS All subjects (n=69) completed baseline and follow-up measurements. All three groups significantly increased physical activity levels from baseline measurements (p = 0.003, p = 0.000 and p = 0.038 respectively). All three interventions were equally effective in producing this increase in physical activity levels. Qualitative results indicated that interaction with an exercise consultant was an important feature in all three interventions. In addition, the positive environment within the cardiac rehabilitation centre played a major role in encouraging subjects to adhere to their exercise programmes. CONCLUSIONS The results from this study have shown that all three interventions; web-based consultation, traditional consultation and the control group, were equally effective in producing significant increases in physical activity within the study period of six-weeks. This suggests that not only do service providers have different options as to which intervention to utilize, depending on the resources available, but that patients can also state a preference as to the method of intervention used. KEY Words CORONARY HEART DISEASE; CARDIAC REHABILITATION; EXERCISE CONSULTATION; PHYSICAL ACTIVITY. ABBREVIATIONS CHD, Coronary Heart Disease, MI, myocardial infarction, CR, cardiac rehabilitation, CABG, Coronary Artery Bypass Graft.
With the increased use of anti-TNF medication in rheumatology, gastroenterology and dermatology there is greater awareness of anti-TNF induced paradoxical inflammation. Psoriatic lesions are the most common form of anti-TNF induced paradoxical inflammation. Palmopustulosis type psoriasis is much more common in the anti-TNF associated group compared to the normal population. Anti-TNF induced Lupus like reactions (ATIL) and the onset or exacerbation of inflammatory bowel disease (IBD) are also well documented. These conditions cause significant morbidity and can prove challenging in diagnosis and treatment.
Objectives
During our routine clinic work a significant number of patients developed anti-TNF induced paradoxical inflammation in the form of psoriasis, ATIL and IBD. In order to understand this phenomenon better we analysed this cohort of patients.
Methods
Patients with a diagnosis of paradoxical inflammation in the form of psoriatic lesions, ATIL and IBD were recorded. ATIL can be challenging to diagnose. Clinical features include typical skin changes and photosensitivity. Systemic manifestations are varied and include fatigue, myositis, arthritis and serositis. Typically immunological changes include an increased titre ANA and development of dsDNA. In patients identified with paradoxical inflammation a case review was performed to look for common patterns. We have also reviewed the literature regarding the possible immunological explanations that have been postulated.
Results
The cases have been summarised in Table 1. Out of a cohort of 275 patients currently taking anti-TNF medication we found 7 patients with a confirmed paradoxical inflammatory reaction. The length of time taking anti-TNF prior to the onset of paradoxical inflammation was variable, from 8 months to 3 years. Humira was involved in most cases and this outcome is interesting. 2 of these were psoriatic in nature, 4 were ATIL and 1 was a flare up of previously diagnosed inflammatory bowel disease. In the patients with psoriasis, 1 was of plaque psoriasis, which resolved on stopping the anti-TNF medication. The patient with palmopustular type did not resolve despite stopping anti-TNF. However another anti-TNF drug has been started, as the patient9s Rheumatoid Arthritis is very active. Of the 4 diagnosed with ATIL, 2 had a significant rise in their ANA titre, 3 had detectable dsDNA levels. One patient developed La and Jo-1 antibodies. These cases resolved on stopping the anti-TNF drug. 1 patient developed a re-activation of previously diagnosed and quiescent Crohn9s disease that resolved on drug withdrawal.
Conclusions
Anti-TNF induced paradoxical inflammation is an important diagnosis to recognise as it can be treated by withdrawal of the drug. This usually results in resolution of symptoms and this was seen in our cohort. In some patients, a switch to another TNF drug has been successful without recurrence of paradoxical inflammation, however this remains a risk. Thankfully with ATIL lupus nephritis and end organ damage is rare. Immunological changes occur frequently with paradoxical inflammation so it is important to check immunology prior to starting anti-TNF therapy. It is important to recognise that a change in immunology is common with anti-TNF (and other biologic therapies) so they must be correlated with clinical symptoms.
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