Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis : Fundamentals Of Care for UveitiS (FOCUS) Initiative

Supplemental material available at www.aaojournal.org. Supported by AbbVie, Inc., and the Fundamentals of Care for Uveitis Initiative National Faculty. This manuscript was developed subsequent to an AbbVie-sponsored literature review of noninfectious, nonanterior uveitis. The meeting was conducted to understand the available literature regarding the management of patients with noninfectious, nonanterior uveitis. The program involved a total of 139 experts from 28 countries, who were selected for participation by AbbVie. However, AbbVie was not involved in the development of the manuscript. The authors maintained complete control over the content and this manuscript reflects the opinions of the authors. AbbVie selected the discussion participants and reviewed the final manuscript draft for scientific accuracy, but the authors determined the final content. All authors made substantial contributions to the article or critically revised it for important intellectual content and approved the final manuscript. AbbVie provided funding to invited participants, including honoraria for their attendance at the meetings. Travel to and from the meetings was reimbursed. No payments were made to the authors for the development of this manuscript. Dhinakaran Sambandan, PhD, and Shula Sarner, PhD, of Lucid Partners, Burleighfield House, Buckinghamshire, United Kingdom, provided medical writing and editorial support to the authors in the development of this manuscript; financial support for these services was provided by AbbVie. AbbVie reviewed the manuscript, but was not involved in the methodology, data collection and analysis, or completion of this manuscript.Peer reviewedPublisher PD

Practice of ultrasound-guided arthrocentesis and joint injection, including training and implementation, in Europe: results of a survey of experts and scientific societies

Objectives. To document the practice and training opportunities of US-guided arthrocentesis and joint injection (UGAJ) among rheumatologists in the member countries of the European League Against Rheumatism (EULAR). Methods. An English-language questionnaire, containing questions on demographics, clinical and practical aspects of UGAJ, training options in UGAJ for rheumatologists, UGAJ education in the rheumatology training curriculum and other structured education programmes in UGAJ was sent to three different groups: (i) all national rheumatology societies of EULAR; (ii) all national societies of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB); and (iii) 22 senior rheumatologists involved in EULAR musculoskeletal US training from 14 European countries, who were also asked to circulate the questionnaire among relevant colleagues. Results. Thirty-three (75%) of 44 countries responded to the questionnaire (61.3% of national rheumatology societies, 25% of the national US societies and 100% of expert ultrasonographers). In the majority of countries (85%) 80%) rate of rheumatologists performing conventional joint injection in most of the surveyed countries. The reported variations in practice and the lack of available structured training programmes for trainees in most countries indicates the need for standardization in areas including training guideline

2015 recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative

Therapy for polymyalgia rheumatica (PMR) varies widely in clinical practice as international recommendations for PMR treatment are not currently available. In this paper, we report the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) recommendations for the management of PMR. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology as a framework for the project. Accordingly, the direction and strength of the recommendations are based on the quality of evidence, the balance between desirable and undesirable effects, patients'and clinicians'values and preferences, and resource use. Eight overarching principles and nine specific recommendations were developed covering several aspects of PMR, including basic and follow-up investigations of patients under treatment, risk factor assessment, medical access for patients and specialist referral, treatment strategies such as initial glucocorticoid (GC) doses and subsequent tapering regimens, use of intramuscular GCs and disease modifying anti-rheumatic drugs (DMARDs), as well as the roles of non-steroidal anti-rheumatic drugs and non-pharmacological interventions. These recommendations will inform primary, secondary and tertiary care physicians about an international consensus on the management of PMR. These recommendations should serve to inform clinicians about best practices in the care of patients with PMR

Guidance on noncorticosteroid systemic immunomodulatory therapy in noninfectious uveitis: fundamentals of care for uveitis (focus) initiative

Topic: An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics. Clinical Relevance: The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents. Methods: An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic reviewof the literature (English language studies from January 1996 through June 2016; Medline [OVID], the Central Cochrane library, EMBASE,CINAHL,SCOPUS,BIOSIS, andWeb of Science). Publications included randomized controlled trials, prospective and retrospective studies with sufficient follow-up, case series with 15 cases or more, peer-reviewed articles, and hand-searched conference abstracts from key conferences. The proposed statements were circulated among 130 international uveitis experts for review.Atotal of 44 globally representativegroupmembersmet in late 2016 to refine these guidelines using a modified Delphi technique and assigned Oxford levels of evidence. Results: In total, 10 questions were addressed resulting in 21 evidence-based guidance statements covering the following topics: when to start noncorticosteroid immunomodulatory therapy, including both biologic and nonbiologic agents; what data to collect before treatment; when to modify or withdraw treatment; how to select agents based on individual efficacy and safety profiles; and evidence in specific uveitic conditions. Shared decision-making, communication among providers and safety monitoring also were addressed as part of the recommendations. Pharmacoeconomic considerations were not addressed. Conclusions: Consensus guidelines were developed based on published literature, expert opinion, and practical experience to bridge the gap between clinical needs and medical evidence to support the treatment of patients with noninfectious uveitis with noncorticosteroid immunomodulatory agents

Mechanical thrombectomy in acute stroke – Five years of experience in Poland

Objectives Mechanical thrombectomy (MT) is not reimbursed by the Polish public health system. We present a description of 5 years of experience with MT in acute stroke in Comprehensive Stroke Centers (CSCs) in Poland. Methods and results We retrospectively analyzed the results of a structured questionnaire from 23 out of 25 identified CSCs and 22 data sets that include 61 clinical, radiological and outcome measures. Results Most of the CSCs (74%) were founded at University Hospitals and most (65.2%) work round the clock. In 78.3% of them, the working teams are composed of neurologists and neuro-radiologists. All CSCs perform CT and angio-CT before MT. In total 586 patients were subjected to MT and data from 531 of them were analyzed. Mean time laps from stroke onset to groin puncture was 250±99min. 90.3% of the studied patients had MT within 6h from stroke onset; 59.3% of them were treated with IV rt-PA prior to MT; 15.1% had IA rt-PA during MT and 4.7% – emergent stenting of a large vessel. M1 of MCA was occluded in 47.8% of cases. The Solitaire device was used in 53% of cases. Successful recanalization (TICI2b–TICI3) was achieved in 64.6% of cases and 53.4% of patients did not experience hemorrhagic transformation. Clinical improvement on discharge was noticed in 53.7% of cases, futile recanalization – in 30.7%, mRS of 0–2 – in 31.4% and mRS of 6 in 22% of cases. Conclusion Our results can help harmonize standards for MT in Poland according to international guidelines

Wczesne efekty terapii lekami anty-TNF u chorych na zesztywniające zapalenie stawów kręgosłupa – badanie obserwacyjne

Celem badania była ocena wczesnej skuteczności leczenia anty-TNFu chorych na zesztywniające zapalenie stawów kręgosłupa (ZZSK).Badaniem objęto 34 osoby (10 kobiet i 24 mężczyzn w wieku średnio39 lat), chorych na aktywną postać ZZSK, zakwalifikowanych doleczenia anty-TNF w programie terapeutycznym Narodowego FunduszuZdrowia (NFZ) (tab. I). Kryteria kwalifikacji do leczeniaokreślone przez NFZ obejmowały: rozpoznanie ZZSK na podstawiezmodyfikowanych kryteriów nowojorskich, aktywną i ciężką postaćchoroby stwierdzaną przynajmniej dwukrotnie wodstępie 12 tygo dniprzy niezmiennym leczeniu oraz nieskuteczność co najmniej dwóchleków z grupy niesteroidowych leków przeciwzapalnych (NLPZ)stosowanych w maksymalnej tolerowanej dawce, każdy kolejnoprzez minimum 3 miesiące. Wśród badanych chorych 19 osób otrzymałoetanercept, a 15 adalimumab.W trakcie comiesięcznych badań u chorych oceniano skutecznośćleczenia na podstawie wskaźników stanu zapalnego, kompleksowychindeksów aktywności choroby (BASDAI, ASDAS), wskaźnikówfunkcjonalnych i jakości życia (BASFI, BASMI, ASQol) (tab. II).Po 12 tygodniach u prawie wszystkich chorych stwierdzono poprawęwg wskaźnika BASDAI 50, odpowiadała ona poprawie 20-procentowejwg ASAS. Poprawę 40- i 60-procentową wg ASAS stwierdzonou 88,2% i 52,9% chorych (ryc. 1–3).Nie zaobserwowano istotnych różnic w skuteczności leczeniaw zależności od czasu trwania i zaawansowania choroby orazstosowanego leku. Większy stopień poprawy wg skal BASDAIi ASDAS obserwowano u chorych z wyjściowym dużym stężeniembiałka C-reaktywnego (CRP). Istotna statystycznie poprawa dotycząca wskaźników stanu zapalnego (OB, CRP) dokonywała sięw ciągu pierwszych 4 tygodni leczenia, natomiast w ciągu pozo -stałych 8 tygodni parametry te nie zmniejszały się istotnie. Poprawamierzona kompleksowymi indeksami aktywności choroby (BASDAIi ASDAS), ogólną oceną wg pacjenta i lekarza, indeksami funkcjonalnymii jakości życia (BASMI, BASFI i ASQol) postępowała prawie linio -wo przez 12 tygodni leczenia (ryc. 4, 5)

Scyntygrafia kości w diagnostyce reumatoidalnego zapalenia stawów

Celem pracy była ocena przydatności trójfazowej dynamicznejscyntygrafii kości w diagnostyce reumatoidalnego zapalenia stawów.Badaniem objęto 39 chorych hospitalizowanych i diagnozowanychz powodu dolegliwości stawowych. Przeprowadzono diagnostykęobejmującą: badanie podmiotowe, przedmiotowe, badania laboratoryjneoraz obrazowe, w tym trójfazową scyntygrafię kości z użyciemtechnetu 99m. Scyntygraficzne cechy zapalenia stawówstwierdzano, gdy obserwowano wzmożone gromadzenie znacznikawe wszystkich trzech fazach badania.Po ukończeniu diagnostyki rozpoznano u 13 chorych wczesne reumatoidalnezapalenie stawów, u 4 reumatoidalne zapalenie stawów(łącznie 17 pacjentów), a u 1 niezróżnicowane zapalenie stawów.Scyntygrafia kości wykazała cechy zapalenia stawów u 13spośród nich (72,2%), u 4 osób (22,2%) wzmożone gromadzeniestwierdzono tylko w fazie statycznej, a u 1 pacjenta (5,6%) uzyskanoprawidłowy wynik badania. U 21 chorych wykluczono chorobęzapalną stawów (u 19 rozpoznano fibromialgię, u 2 chorobęzwyrodnieniową). W grupie bez zapalenia stawów u 14 pacjentów(66,6%) nie stwierdzono istotnych nieprawidłowości w obraziescyntygraficznym, u 6 (28,6%) występowało wzmożone gromadzenieznacznika w badaniu statycznym, a u 1 chorego (4,8%) opisanoscyntygraficzne cechy zapalenia stawów.Wbadanej grupie czułość scyntygrafii dynamicznej kości w wykrywaniuzapalenia stawów wynosiła 72,2% (95% CI: 57,5–76,8), a swoistość 95,2% (95% CI: 82,8–99,1). Dodatni wynik badaniadynamicznego wskazuje z dużym prawdopodobieństwem naobecność zapalenia stawów [PPV 92,9% (95% CI: 74,2–98,7)].Mniej wiarygodny był ujemny wynik badania [NPV 80% (95% CI:69,5–83,3)]. Wyniki niniejszej pracy wskazują, że trójfazowa scyntygrafia dynamicznakości może mieć zastosowanie w diagnostyce reumatoidalnegozapalenia stawów

Zapalenie tęczówki w chorobach reumatycznych – postępowanie terapeutyczne

Leczenie zapalenia błony naczyniowej oka wymaga szczególnego podejścia, z uwagi na ryzyko istotnych powikłań, włącznie z utratą wzroku. Przyczyny choroby nie zawsze zostają ustalone, jednak znacząca część przypadków ma silny związek z układowymi chorobami tkanki łącznej, w szczególności spondyloartropatiami. Wskazuje to na potrzebę współpracy między okulistą i reumatologiem w celu zapewnienia choremu należytej opieki. W przebiegu leczenia można wyróżnić fazy w zależności od czasu trwania terapii i utrzymywania się objawów choroby. Aktualne dane badawcze uzasadniają zastosowanie miejscowe oraz ogólne glikokortykosteroidów, a także leków immunosupresyjnych w kolejnych liniach leczenia. Artykuł stanowi podsumowanie aktualnych rekomendacji oraz obserwacji klinicznych, jak również przedstawia oparty na nich schemat postępowania terapeutycznego.Treatment of uveitis requires a special approach because of the risk of significant complications, including loss of vision. The causes of the disease cannot always be determined, but a significant proportion of cases have a strong association with systemic connective tissue disorders, particularly spondyloarthropathies. This indicates the need for cooperation between an ophthalmologist and a rheumatologist in order to provide the patient with proper care. Several stages can be distinguished in the course of treatment, depending on the duration of therapy and the persistence of symptoms. Current research data justify the use of topical and systemic corticosteroids, as well as immunosuppressive drugs in subsequent lines of therapy. The article summarizes current recommendations and clinical observations, and presents a therapeutic regimen based on them