The 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for rheumatoid arthritis: Phase 2 methodological report

Objective The American College of Rheumatology and the European League Against Rheumatism have developed new classification criteria for rheumatoid arthritis (RA). The aim of Phase 2 of the development process was to achieve expert consensus on the clinical and laboratory variables that should contribute to the final criteria set. Methods Twenty-four expert RA clinicians (12 from Europe and 12 from North America) participated in Phase 2. A consensus-based decision analysis approach was used to identify factors (and their relative weights) that influence the probability of “developing RA,” complemented by data from the Phase 1 study. Patient case scenarios were used to identify and reach consensus on factors important in determining the probability of RA development. Decision analytic software was used to derive the relative weights for each of the factors and their categories, using choice-based conjoint analysis. Results The expert panel agreed that the new classification criteria should be applied to individuals with undifferentiated inflammatory arthritis in whom at least 1 joint is deemed by an expert assessor to be swollen, indicating definite synovitis. In this clinical setting, they identified 4 additional criteria as being important: number of joints involved and site of involvement, serologic abnormality, acute-phase response, and duration of symptoms in the involved joints. These criteria were consistent with those identified in the Phase 1 data-driven approach. Conclusion The consensus-based, decision analysis approach used in Phase 2 complemented the Phase 1 efforts. The 4 criteria and their relative weights form the basis of the final criteria set.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78048/1/27580_ftp.pd

2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative

Objective The 1987 American College of Rheumatology (ACR; formerly, the American Rheumatism Association) classification criteria for rheumatoid arthritis (RA) have been criticized for their lack of sensitivity in early disease. This work was undertaken to develop new classification criteria for RA. Methods A joint working group from the ACR and the European League Against Rheumatism developed, in 3 phases, a new approach to classifying RA. The work focused on identifying, among patients newly presenting with undifferentiated inflammatory synovitis, factors that best discriminated between those who were and those who were not at high risk for persistent and/or erosive disease—this being the appropriate current paradigm underlying the disease construct “rheumatoid arthritis.” Results In the new criteria set, classification as “definite RA” is based on the confirmed presence of synovitis in at least 1 joint, absence of an alternative diagnosis that better explains the synovitis, and achievement of a total score of 6 or greater (of a possible 10) from the individual scores in 4 domains: number and site of involved joints (score range 0–5), serologic abnormality (score range 0–3), elevated acute-phase response (score range 0–1), and symptom duration (2 levels; range 0–1). Conclusion This new classification system redefines the current paradigm of RA by focusing on features at earlier stages of disease that are associated with persistent and/or erosive disease, rather than defining the disease by its late-stage features. This will refocus attention on the important need for earlier diagnosis and institution of effective disease-suppressing therapy to prevent or minimize the occurrence of the undesirable sequelae that currently comprise the paradigm underlying the disease construct “rheumatoid arthritis.”Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78045/1/27584_ftp.pd

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

Positive Language in the Parent-Child Relationship: Creating an Educational Video for Parents

Parenting is a role recognized across the world for centuries. It is complex and diverse, yet a common feature of cultures encompassing the majority of the world. Classifications of parenting characteristics, such as the attachment or overall parenting style, have been created to try and understand the inner-workings of the parent-child relationship. It has been shown that ethnicities, races, cultures, and/or socioeconomic classes must be taken into account when evaluating the usefulness of the various classifications. These differences in lifestyle carry diverse values and beliefs that are instilled in the family system, affecting preferred styles of parenting and their influences on the family unit. Keeping these variations in mind, it is important to look at what parental behaviors help foster positive and healthy child development. It has been found that positive and supportive parenting fosters a child’s positive self-esteem and aides in the development of a healthy self-image (Kernis, Brown, & Brody, 2000). On the other hand, critical and degrading parenting can lead to the decline of a child’s sense of worth. This makes the language that parents use with their children critical to their development. Research has also shown that open as well as supportive communication between parents and teens contributes to the prevention of risky behaviors in adolescence (Baxter, Bylund, Imes, & Routsong, 2009). This project focuses on that positive language used with children and attempts to promote its practice to the parents with children enrolled at The Children’s Center, located on the Cal Poly Campus, San Luis Obispo. A video was made that focused on the use of concise and clear limits with the follow through of the adult that ultimately provided the child with a firm boundary in an empathetic fashion. The development of the child was taken into consideration as to what behaviors could be expected of the child at that stage. Throughout the video, tools were provided as to how the parent could be more clear and firm in the boundaries, yet still provide that supportive and positive communication that children need to develop. Filmed clips of teachers’ interactions with the children were included as examples of the type of language that could be used in boundary setting scenarios. These exchanges were situations in which the teacher was enforcing a limit that the child was testing. The hope is that this video will provide parents with new language they could use in day to day situations where their child is testing a limit or boundary. This new communication will hopefully enhance parents’ positive interactions with their children at home as well as foster a healthier life-long development of the child

Dectin-1 in the control of Th2-type T cell responses

Dendritic cells (DCs) are major antigen-presenting cells (APCs) that can induce and control host immune responses. DCs express pattern recognition receptors (PRRs), which can translate external and internal triggers into different types of T cell responses. The types of CD4+ T cell responses elicited by DCs (e.g., Th1, Th2, Th17, Th21, Th22 and regulatory T cells (Tregs)) are associated with either host immunity or inflammatory diseases, including allergic diseases and autoimmune diseases. In particular, the pathogenic functions of Th2-type T cells in allergic immune disorders have been well documented, although Th2-type T cell responses are crucial for immunity against certain parasite infections. Recent evidence also indicates that the inflammatory Th2 signatures in cancers, including breast and pancreatic cancers, are highly associated with poor clinical outcomes in patients. It is thus important to find cellular/molecular targets expressed in DCs that control such inflammatory Th2-type T cell responses. In a recent paper published in The Journal of Immunology, we demonstrated that Dectin-1 expressed on the two major human DC subsets, myeloid DCs (mDCs) and plasmacytoid DCs (pDCs), has opposing roles in the control of Th2-type CD4+ T cell responses. Dectin-1 expressed on mDCs decreases Th2-type CD4+ T cell responses, while Dectin-1 expressed on pDCs favors Th2-type CD4+ T cell responses. This finding expands our understanding of the roles of DCs and Dectin-1 expressed on DCs in the pathogenesis of Th2-associated diseases and in host immunity to microbial infections and cancers

Immune profiles of allergic asthma patients treated with anti-IgE.

Asthma is a chronic inflammatory disease of the airways characterized by bronchial hyper-reactivity, mucus overproduction and airway remodeling and narrowing. Of the various phenotypes of asthma, by far the most common is allergic asthma, in which the airway inflammation is triggered by allergen exposure in sensitized individuals. The diagnosis of allergic asthma is usually done through an allergen prick test; high allergen reactivity is correlated with allergy and these patients should also contain allergen-specific IgE antibodies (abs). One of the more effective medications for moderate-to-severe, uncontrollable allergic asthma is omalizumab, an anti-IgE ab that targets free IgE, thus preventing the continuation of IgE-dependent allergic responses. However, the mechanisms behind how anti-IgE treatment influences the pathophysiologic responses remain to be fully revealed. Additionally, only a 21-64% response rate is seen after 16 weeks, despite the underlying allergy pathogenesis. Thus, in order to better understand the role of IgE in the pathogenesis of human allergic asthma and to identify potential biomarkers for response to anti-IgE therapy, we studied the mechanisms of action of anti-IgE abs in allergic asthma patients through the comparison of immune cell composition and activation status and whole blood transcriptional profiling. By acquiring patient samples before the start of anti-IgE treatment, we were also able to compare healthy donors with allergic asthma patients to gleam additional insights into allergic asthma. This study offers a unique global examination on the impacts of anti-IgE on the immune response, as observed in peripheral blood and also gains a further step towards the development of a biomarker for response to anti-IgE treatment

ACR/EULAR 2010 rheumatoid arthritis classification criteria

Advances in our understanding of the pathogenesis of RA over the past two decades, particularly the identification of cytokines that promote synovial inflammation (e.g. TNF-alpha, IL-1 and IL-6), have led to treatment courses that affect the disease process itself, beyond alleviation of symptoms. In turn, emphasis has shifted to intervention early enough in the disease course to prevent the joint destruction that follows inflammation. Accordingly, in 2010 the ACR and the European League Against Rheumatism (EULAR) put forward revised classification criteria emphasizing RA characteristics that emerge early in the disease course, including ACPAs, a biomarker that predicts aggressive disease. These were in contrast with the 1987 ARA criteria, which distinguished established RA patients from those with other forms of arthritis, and identified patients with later disease. The categories of the 2010 ACR/EULAR criteria are grouped into four classifications, with point scores for each: joint symptoms; serology (including RF and/or ACPA); symptom duration, whether \u3c 6 weeks or \u3e 6 weeks; and acute-phase reactants (CRP and/or ESR). The criteria were developed in a three-phase process, beginning with an analysis of patient cohorts to determine what disease characteristics had persuaded clinicians to initiate MTX therapy, followed by consensus-based decisions and the creation of a scoring system that would predict which patients would go on to develop persistent and/or erosive disease

Evolution of treatment for rheumatoid arthritis

Treatment for RA has changed profoundly over the past 25 years, evolving from a strategy of providing symptomatic relief, to implementation of therapeutic regimens that impact disease activity and ultimately have been shown to slow or arrest structural joint damage. Drug therapy for RA has evolved from salicylates, to NSAIDs, CSs, DMARDs, MTX, and finally to biologic response modifiers. MTX has become the initial drug of choice in most patients with RA, and some do well on MTX monotherapy without the addition of other agents. Combination regimens including MTX and other conventional DMARDs may be an effective early approach to treatment of RA. The biologic response modifiers (biologics) became available in the late 1990s, based on our understanding of the molecular mediators of synovial inflammation in RA. The first biologics inhibited TNF-alpha, a cytokine active in host defences against some infections and malignancies, but which also promotes inflammation and bone erosion. Inhibitors of TNF-alpha are mostly given with MTX, although some can be given as monotherapy. Studies consistently show that combination MTX + TNF-alpha inhibitor therapy leads to better outcomes than with either agent alone. Tight control strategies, employing objective measures, also lead to improved outcomes. When patients fail treatment with one or more TNF-alpha inhibitor + MTX, a number of other possible alternatives may be tried, including treatment with biologics having other mechanisms, such as antibodies to certain ILs, other cytokines and inflammatory mediators. Current therapy for RA is such that progression from symptom onset to significant disability is now no longer inevitable, and RA patients can anticipate comfortable and productive lives on medical therapy