Digital health in musculoskeletal care: where are we heading?

BMC Musculoskeletal Disorders launched a Collection on digital health to get a sense of where the wind is blowing, and what impact these technologies are and will have on musculoskeletal medicine. This editorial summarizes findings and focuses on some key topics, which are valuable as digital health establishes itself in patient care. Elements discussed are digital tools for the diagnosis, prognosis and evaluation of rheumatic and musculoskeletal diseases, coupled together with advances in methodologies to analyse health records and imaging. Moreover, the acceptability and validity of these digital advances is discussed. In sum, this editorial and the papers presented in this article collection on Digital health in musculoskeletal care will give the interested reader both a glance towards which future we are heading, and which new challenges these advances bring

Review Article Socio-economic determinants of micronutrient intake and status in Europe: a systematic review

Objective To provide the evidence base for targeted nutrition policies to reduce the risk of micronutrient/diet-related diseases among disadvantaged populations in Europe, by focusing on: folate, vitamin B-12, Fe, Zn and iodine for intake and status; and vitamin C, vitamin D, Ca, Se and Cu for intake. Design MEDLINE and Embase databases were searched to collect original studies that: (i) were published from 1990 to 2011; (ii) involved gt 100 subjects; (iii) had assessed dietary intake at the individual level; and/or (iv) included best practice biomarkers reflecting micronutrient status. We estimated relative differences in mean micronutrient intake and/or status between the lowest and highest socio-economic groups to: (i) evaluate variation in intake and status between socio-economic groups; and (ii) report on data availability. Setting Europe. Subjects Children, adults and elderly. Results Data from eighteen publications originating primarily from Western Europe showed that there is a positive association between indicators of socio-economic status and micronutrient intake and/or status. The largest differences were observed for intake of vitamin C in eleven out of twelve studies (5-47 %) and for vitamin D in total of four studies (4-31 %). Conclusions The positive association observed between micronutrient intake and socio-economic status should complement existing evidence on socio-economic inequalities in diet-related diseases among disadvantaged populations in Europe. These findings could provide clues for further research and have implications for public health policy aimed at improving the intake of micronutrients and diet-related diseases

Effectiveness of TNF-inhibitors, abatacept, IL6-inhibitors and JAK-inhibitors in 31 846 patients with rheumatoid arthritis in 19 registers from the 'JAK-pot' collaboration

Background JAK-inhibitors (JAKi), recently approved in rheumatoid arthritis (RA), have changed the landscape of treatment choices. We aimed to compare the effectiveness of four current second-line therapies of RA with different modes of action, since JAKi approval, in an international collaboration of 19 registers. Methods In this observational cohort study, patients initiating tumour necrosis factor inhibitors (TNFi), interleukin-6 inhibitors (IL-6i), abatacept (ABA) or JAKi were included. We compared the effectiveness of these treatments in terms of drug discontinuation and Clinical Disease Activity Index (CDAI) response rates at 1 year. Analyses were adjusted for patient, disease and treatment characteristics, including lines of therapy and accounted for competing risk. Results We included 31 846 treatment courses: 17 522 TNFi, 2775 ABA, 3863 IL-6i and 7686 JAKi. Adjusted analyses of overall discontinuation were similar across all treatments. The main single reason of stopping treatment was ineffectiveness. Compared with TNFi, JAKi were less often discontinued for ineffectiveness (adjusted HR (aHR) 0.75, 95% CI 0.67 to 0.83), as was IL-6i (aHR 0.76, 95% CI 0.67 to 0.85) and more often for adverse events (aHR 1.16, 95% CI 1.03 to 1.33). Adjusted CDAI response rates at 1 year were similar between TNFi, JAKi and IL-6i and slightly lower for ABA. Conclusion The adjusted overall drug discontinuation and 1 year response rates of JAKi and IL-6i were similar to those observed with TNFi. Compared with TNFi, JAKi were more often discontinued for adverse events and less for ineffectiveness, as were IL-6i.Peer reviewe

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update

Objectives: To provide an update of the European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) management recommendations to account for the most recent developments in the field. Methods: An international task force considered new evidence supporting or contradicting previous recommendations and novel therapies and strategic insights based on two systematic literature searches on efficacy and safety of disease-modifying antirheumatic drugs (DMARDs) since the last update (2016) until 2019. A predefined voting process was applied, current levels of evidence and strengths of recommendation were assigned and participants ultimately voted independently on their level of agreement with each of the items. Results: The task force agreed on 5 overarching principles and 12 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GCs); biological (b) DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, sarilumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (the Janus kinase (JAK) inhibitors tofacitinib, baricitinib, filgotinib, upadacitinib). Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target) and tapering on sustained clinical remission is provided. Cost and sequencing of b/tsDMARDs are addressed. Initially, MTX plus GCs and upon insufficient response to this therapy within 3 to 6 months, stratification according to risk factors is recommended. With poor prognostic factors (presence of autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD or JAK inhibitor should be added to the csDMARD. If this fails, any other bDMARD (from another or the same class) or tsDMARD is recommended. On sustained remission, DMARDs may be tapered, but not be stopped. Levels of evidence and levels of agreement were mostly high. Conclusions: These updated EULAR recommendations provide consensus on the management of RA with respect to benefit, safety, preferences and cost

The optimisation of intensive treatment strategies in early Rheumatoid Arthritis

Introduction The last decades meant a revolution for the treatment of patients with early Rheumatoid Arthritis (RA). In the past, patients were treated conservatively and treatment was only intensified when disease escalated, leading to structural damage and functionality loss in many RA patients. Nowadays, it is clear that early, intensive treatment with a clear predefined treatment target leads to excellent clinical outcomes for the majority of patients with early RA. First of all, it is shown that the earlier the treatment is started in RA, the better outcome the patient has. However, no information on the current extent of treatment delay was available for Flanders before this thesis. Secondly, many attempts are made to tailor treatment to an individual patient based on prognostic factors, to improve further disease outcome such as structural damage. However, algorithms combining these prognostic factors to aid a physician in his treatment choice were not yet tested in daily practice. Thirdly, many intensive treatment options exist nowadays to treat a patient with early RA. Yet, debate is ongoing on the exact content of this intensive treatment. Objectives The objectives of this research project were to determine: the treatment delay, defined as the time between symptom onset and treatment initiation in Flanders the reliability of classical prognostic factors in daily clinical practice the optimal intensive treatment strategy for every patient with RA Results In chapter 1, we demonstrated that in Flanders only one on five of newly diagnosed RA patients are treated in a timely fashion. Patients expressing more severe disease characteristics at baseline seemed to present themselves earlier to the treating rheumatologist than those without. Moreover, a difference in treatment delay between the different types of rheumatology practices was found. Patients treated in academic and general hospitals showed longer treatment delays than those treated in private practices. Furthermore, patient-related delay contributed the most to overall treatment delay in Flanders. Further research showed that aside of clinical characteristics, psychosocial factors also contributed to this patient-related delay. More research is needed to unravel the patient’s help seeking behaviour. In chapter 2, we firstly showed that composite algorithms using classical prognostic markers to predict structural damage in patients with early RA could not be reliably used in daily practice. No patients that developed rapid structural damage could be correctly identified by using these composite algoithms. Further in chapter 2, we showed that a combination of classical DMARDs with a GC bridging scheme seemed more effective than DMARD monotherapy in achieving higher remission rates and less radiographic progression after two years of treatment in our observational early RA cohort. Patients in this cohort were selected by the treating physician based on the presence of classical prognostic factors to receive a more conservative therapy if the RA profile of the patient seemed less severe at baseline. Hence, classical prognostic factors seem at the moment unreliable to base treatment choice upon in daily practice. In chapter 3, we presented the results of the CareRA RCT, showing firstly that in patients with poor prognosis markers after 16 weeks of treatment DMARD combinations with a high or moderate dose glucocorticoid (GC) remission induction scheme were not superior to Methotrexate (MTX) only with a moderate dose GC remission induction scheme. The efficacy of the three compared treatment strategies was similar. Yet, the safety profile was more advantageous for MTX only with a moderate GC scheme. Furthermore, we showed that MTX monotherapy with a moderate dose GC remission induction scheme seems more efficacious than MTX monotherapy without GCs in patients presenting without poor prognosis markers after 16 weeks of treatment. Most remarkable was the comparable safety profile between both treatments. Lastly, we investigated the efficacy and safety in the CareRA trial after one year of treatment for both patients with or without poor prognosis. The results confirmed the findings at week 16. The overarching conclusion regarding the third objective of this thesis is thus that MTX with an initial moderate dose glucocorticoid remission induction scheme seems to fit all patients with RA, with a high efficacy and acceptable safety profile. Conclusion Firstly, treatment delay is found to be too long in Flanders. Secondly, current classical biomarkers are not reliable in daily practice to guide treatment choice. Thirdly, MTX only combined with an initial moderate dose glucocorticoid remission induction scheme is very efficacious and safe for all patients with RA. We hope to have added essential evidence for an improved treatment outcome for every patient with RA with this thesis.status: publishe

Primus inter pares: the choice of biologic drugs in rheumatoid arthritis

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The Effect of Meditation, Mindfulness, and Yoga in Patients with Rheumatoid Arthritis

Objectives: Mind–body therapies (MBTs), including meditation, yoga, and mindfulness, create an interaction between the mind and body to enhance health. MBTs are perceived by both patients and healthcare professionals as valuable in the management of rheumatoid arthritis (RA), but the extent of this contribution is unclear, as are the patient subgroups who benefit most from MBTs. Therefore, this systematic literature review investigates the effects of meditation, mindfulness, and yoga in patients with RA. Methods: We searched four databases (PubMed, Embase, Web of Science (core collection, Chinese and Korean collection), and CINAHL). All studies were screened by two independent reviewers via the title/abstract/full text. The studies included any form of meditation/mindfulness/yoga as an intervention for RA. Animal studies, case reports, non-English articles, qualitative studies, conference abstracts, and articles without full-text access were excluded. Each study was assessed for its quality. Results: Out of 1527 potentially eligible records, 23 studies were included. All three MBTs showed various effects on patient-reported outcomes, such as vitality, functioning, and mental health, as well as on disease activity markers. Mindfulness-based interventions mainly reduced the subjective disease activity parameters (e.g., joint tenderness, morning stiffness, and pain), rather than the objective disease activity parameters (e.g., swollen joints and C-reactive protein (CRP)). RA patients with recurrent depression may benefit more from these non-pharmacological therapies than patients without recurrent depression. Discussion: This systematic literature review found that MBTs show added value in RA management, especially for patients with depressive symptoms. These non-pharmacological approaches, when used in addition to medication, might diminish polypharmacy in specific RA patient populations. Lay Summary: In recent decades, more attention has been given to the management of rheumatoid arthritis (RA) with options other than solely using medication. Such alternative options for patients to increase their quality of life are, for instance, meditation, yoga, and mindfulness. These examples of mind–body therapies (MBTs) are techniques that create an interaction between the mind and the bodily functions in order to obtain relaxation and enhance overall health. Although it is believed that these mind–body techniques are valuable in the management of RA, the extent of their contribution is still unclear, as is the question of if certain subgroups of patients benefit more from these complementary therapies. This systematic literature review investigated the effects of meditation, mindfulness, and yoga in patients with rheumatoid arthritis. A literature search was systematically performed within four different scientific databases by two independent reviewers. Out of 1527 potentially eligible articles, 23 studies were included. All three MBTs showed beneficial effects, which were mostly on the vitality, functioning, and mental health of patients with RA, but also on symptoms related to disease activity. RA patients with recurrent depression seemed to benefit more from these non-pharmacological therapies than patients without recurrent depression. Hence, we can conclude that MBTs show added value in the management of RA

“Keep It Short and Simple”: Perceptions of patients and healthcare professionals on the use of a mobile health app in the care for patients undergoing radical prostatectomy

Abstract Background Patients undergoing radical prostatectomy for localised prostate cancer generally have good long‐term survival rates. However, late recurrences can occur and require lifelong follow‐up. Objective This research aims to investigate different stakeholders' perceptions on the use of mobile health (mHealth) applications for prostate cancer follow‐up after radical prostatectomy. Methods A cross‐sectional qualitative study was conducted to explore stakeholders' perceptions of an mHealth application for follow‐up after radical prostatectomy. Urologists, nurses, and patients treated with radical prostatectomy were interviewed, and data were transcribed and analysed using thematic analysis according to Qualitative Analysis Guide of Leuven. Recommended features for an ideal mHealth application were grouped according to the Persuasive Systems Design model. Results and Limitations A total of 30 stakeholders, consisting of nurse specialists (n = 7), urologists (n = 8), and patients (n = 15), were interviewed. Expected benefits and barriers were mentioned and grouped in five overarching themes: healthcare optimisation, disease management, app compliance, legal and organisational requirements, and patient–mHealth interaction. Stakeholders provided a multitude of suggestions for an ideal mHealth app. Yet, not all types of stakeholders were interviewed, and patient selection limited generalisability of findings. Conclusions Stakeholders indicate that an mHealth app in the care for post‐prostatectomy patients can improve patient care and promote disease management but consider app compliance as a major challenge. Patient Summary We interviewed patients, nurses, and urologists about using an mHealth application for follow‐up after radical prostatectomy. The participants agreed that an mHealth app could improve care optimisation and disease management, but some concerns and barriers were expressed. This resulted in a list of recommended features for an ideal app

Modifiable correlates of illness perceptions in adults with chronic somatic conditions: A systematic review

When individuals become ill, they want to understand and give meaning to their illness. The interpretation of this illness experience, or illness perception, is influenced by a range of individual, contextual, and cultural factors. Some of these factors may be modifiable by nursing interventions. The purpose of this systematic review was to investigate which modifiable factors were correlated with illness perceptions across studies of adults with different chronic somatic diseases. Using search terms tailored to each of four electronic databases, studies retrieved were reviewed by two independent evaluators, and each relevant article was assessed for methodological quality. Results were standardized by calculating correlation coefficients. Fifteen papers on illness perceptions in a variety of chronic diseases met the inclusion criteria. All used standardized measures of illness perceptions. We identified five groups of modifiable correlates of illness perceptions: illness-related factors, psychosocial factors, medication beliefs, information provision and satisfaction with information received, and quality of care. Our findings add to the knowledge of modifiable factors correlated with illness perceptions, including the importance of illness-related factors and psychosocial factors such as anxiety and depression. Knowledge of these correlates can facilitate understanding of patients' illness perceptions and might be useful in tailoring patient education programs.status: publishe