Biologic treatments in rheumatoid arthritis and juvenile idiopathic arthritis

A number of biological approaches to the management of inflammtory arthropathies have been explored. These include the development of IL-1 receptor antagonists and TNF antagonists. Four biological agents are currently marketed in Europe. Most studies have revolved around Rheumatoid Arthritis, but an increasing number of studies are now completed or ongoing in the other inflammatory joint diseases. These studies are reviewed in this article with a view to guiding practice and usage in the Maltese Islands.peer-reviewe

Calcium, vitamin D and bone

Calcium, protein and vitamin D are the main nutrients relevant to bone health. This short article discusses the importance of vitamin D and its relation to calcium homeostasis. The various causes, clinical manifestations and treatment are outlined.peer-reviewe

Translation and validation of the Fatigue Severity Scale, Pittsburgh Sleep Quality Index and Modified Health Assessment Questionnaire into the Maltese language, in a cohort of Maltese Systemic Lupus Erythematosus patients

PURPOSE: The assessment of fatigue, sleep quality and functional disability requires the use of validated instruments such as the Fatigue Severity Scale (FSS), the Pittsburgh Sleep Quality Index (PSQI) and the Modified Health Assessment Questionnaire (mHAQ) respectively. The aim of this study was to translate and validate these instruments into the Maltese Language. METHOD: Forward translation from the original English version into Maltese was carried out by two translators. The two versions were compiled to produce a preliminary initial Maltese translation. This was translated back into English by two other translators. This led to the development of the pre-final version of the Maltese translation, which was pilot-tested in 20 bilingual patients with systemic lupus erythematosus. RESULTS: Psychometric testing revealed good reliability of the Maltese translation of the three questionnaires. Cronbach’s alpha of the Maltese versions of the FSS, PSQI and mHAQ were 0.877, 0.859 and 0.897 respectively, showing good internal consistency. Validity of the Maltese version of the FSS was shown, since it had a significant positive correlation with visual analogue scale for fatigue (r=0.809, p<0.001). CONCLUSION: The Maltese translations were thus finalised, and could be used for clinical assessment or research purposes.peer-reviewe

Seronegative spondyloarthropathies : a review : part I: classification and differential diagnosis

The seronegative spondyloarthropathies comprise a group of non-rheumatoid disorders with similar clinical, laboratory and genetic features. Recognition of new clinical features has supported the notion that they all form part of a clinical spectrum. These features and the classification of the seronegative spondyloarthropathies are discussed in the review.peer-reviewe

Seronegative spondyloarthropathies : a review : part II: genetics and pathogenesis

In none of the spondyloarthropathies is the pathogenesis well understood. Much of the investigation into the aetio-pathogenesis of these diseases has focused on the association with HLA-B27 and the known triggering potential of certain infectious agents. In this article the author describes that the HLA linked genes which is subdivided into three groups, class I, class II and class III, which are structurally and functionally distinct from each other.peer-reviewe

Cardiovascular risk assessment and management in rheumatoid arthritis : are guidelines being followed?

Aim: The aim of the audit was to determine whether the cardiovascular risk assessment and management in rheumatoid arthritis patients at Mater Dei Hospital is in concordance with the recommendations by the European League Against Rheumatism (EULAR). Background: Patients who suffer from rheumatoid arthritis have an increased risk of morbidity and mortality from cardiovascular disease. This is due to both the high prevalence of traditional risk factors, and systemic inflammation. Method: This audit was carried out retrospectively on 91 patients by using the medical notes to collect data on demographics, co-morbidities, drug history and cardiovascular risk assessment and management over a two year period (August 2010 to July 2012). The data was then analysed in order to assess whether the management of cardiovascular risk in rheumatoid arthritis patients was in concordance with EULAR recommendations. Results: Cardiovascular risk factors were documented as follows over the two year period audited: weight in 27.5%, BMI in 0%, smoking status in 72.5%, blood pressure in 72.5%, blood glucose in 72.5% and lipid profile in 54.9%. Smoking cessation advice was given in 15.8% and advice on other lifestyle changes in 14.3%. 81.1% of hypertensive patients were on treatment recommended as first-line by the guidelines and HbA1c was adequately controlled in 85.7% of diabetic patients in whom it was monitored. Conclusion: Cardiovascular risk factors are highly prevalent in rheumatoid arthritis patients. This audit identified aspects of cardiovascular risk assessment that require improvement. This would enable a better identification of cardiovascular risk factors that could be treated in order to reduce the patients’ cardiovascular morbidity and mortality.peer-reviewe

Concordance with the British Society of Rheumatology (BSR) 2010 recommendations on eligibility criteria for the first biologic agent

Aims: The aim of this study is to assess concordance with the British Society of Rheumatology (BSR) 2010 recommendations on the use of biologic therapy in Rheumatoid Arthritis (RA). The Disease Activity Score in 28 joints (DAS 28), a composite numerical score is included in these recommendations to assess disease activity and response to treatment. Methods: Clinical notes of fifty patients who were commenced on biologic treatment between March 2010 and June 2011 were reviewed for documentation of DAS 28 scores at baseline, after approximately 6 months of commencement of treatment and at approximately 6 monthly intervals during treatment. Results: Twenty two patients were eligible for this audit. Of these patients only half had a DAS 28 score performed prior to starting treatment, four patients had the score performed within 3-9 months of commencement of therapy and only 2 patients had continuous scores performed at six monthly intervals during treatment. Conclusions: This audit shows that we are not adhering to the BSR recommendations. In order to improve our adherence we plan to train all staff in contact with patients on biologic treatment to perform DAS 28 scores and have a DAS 28 calculator readily available at out patients. A proforma is being developed for patients on biologic therapy to ensure that DAS 28 scores are performed at baseline and during treatment.peer-reviewe

Concordance of gout management with European League against Rheumatism recommendations in hospital practice

Aim: To assess the concordance of gout management with the European League Against Rheumatism (EULAR) gout recommendations in hospital practice. Methods: This was a retrospective review of case notes of patients presenting to rheumatology outpatients between June and December 2009 under the care of 2 consultant rheumatologists. Data collected consisted of demographics, time lag to specialist referral, comorbidities, details about acute and recurrent attacks, lifestyle advice and use of urate lowering therapies. Documented management was assessed for concordance with the EULAR recommendations. Results: Thirty consecutive patients (27 males, 3 females) attending Rheumatology clinic at Mater Dei Hospital were recruited. Mean age at the time of survey was 59.4 ± 10.7 years, while mean age at diagnosis was 51.1 ± 14 years. Documentation of lifestyle advice was recorded for alcohol reduction (83%), weight loss (43%), diet (13%), and exercise (13%). Adequate control of comorbidities was attained in hyperlipidaemia (71%), diabetes mellitus (55%) and hypertension (30%). Advice about smoking cessation was given to 37%. Uric acid levels below target were achieved in 47%. The mean uric acid level at time of survey was 379 ± 146 μmol/l. This was significantly less than that at presentation (p=0.001). Conclusions: Current treatment of gout is poorly concordant with many of the EULAR recommendations. Documentation of lifestyle modifications advice is infrequent except for alcohol reduction. A significant number of patents on allopurinol still have hyperuricaemia implying that more aggressive management is required to improve standard of care. A proforma has been developed to make and help sustain the necessary improvements.peer-reviewe

Epigenetic aging signatures in mice livers are slowed by dwarfism, calorie restriction and rapamycin treatment

Background: Global but predictable changes impact the DNA methylome as we age, acting as a type of molecular clock. This clock can be hastened by conditions that decrease lifespan, raising the question of whether it can also be slowed, for example, by conditions that increase lifespan. Mice are particularly appealing organisms for studies of mammalian aging; however, epigenetic clocks have thus far been formulated only in humans. Results: We first examined whether mice and humans experience similar patterns of change in the methylome with age. We found moderate conservation of CpG sites for which methylation is altered with age, with both species showing an increase in methylome disorder during aging. Based on this analysis, we formulated an epigenetic-aging model in mice using the liver methylomes of 107 mice from 0.2 to 26.0 months old. To examine whether epigenetic aging signatures are slowed by longevity-promoting interventions, we analyzed 28 additional methylomes from mice subjected to lifespan-extending conditions, including Prop1df/df dwarfism, calorie restriction or dietary rapamycin. We found that mice treated with these lifespan-extending interventions were significantly younger in epigenetic age than their untreated, wild-type age-matched controls. Conclusions: This study shows that lifespan-extending conditions can slow molecular changes associated with an epigenetic clock in mice livers

Concordance with the British Society of Rheumatology (BSR)

Abstract Aims: The aim of this study is to assess concordance with the Britis