Susanna M. Proudman

Description:This two-part study examined the attitudes and preferences of people with rheumatoid arthritis (RA) toward blood flow restricted resistance training (BFR-RT), and assessed the acceptability and impact of a progressive upper and lower body BFR-RT intervention. Part one was a cross-sectional survey (N = 97) examining exercise preferences of people with RA, and their openness to BFR-RT. Part two was a single group trial (N = 12) examining the feasibility, acceptability, and impact of BFR-RT on muscle strength, functional capacity, quality of life, and pain, in people with RA. Survey results indicated people with RA would prefer BFR-RT if it was supervised by an exercise professional, be no more than three sessions per week, and commence at low-to-moderate intensity. The BFR-RT intervention in part two aligned with the part one results, had high acceptability (100% "liked" the program), session adherence (81%), and elicited significant (p < 0.05) improvements in strength, functional lower extremity related physical performance, and pain. However, no improvements in quality of life were observed (p > 0.05). BFR-RT is viewed positively by people with RA, and when delivered in a way that aligns with their preferences, is acceptable, has high adherence, and can improve strength and function, and reduce pain.

Description:Objective: To develop a quality standard, termed a Clinical Care Standard (CCS), for the diagnosis and management of rheumatoid arthritis (RA). Methods: A Working Group with consumer representation cocreated guiding principles and quality statements for RA care through a series of workshops. The process was informed by consumer recommendations, clinical practice guidelines, and international quality criteria. A national survey of healthcare professionals (HCPs) and consumers was conducted to establish consensus. For each quality statement, respondents were asked to indicate, on a scale of 1-9, (1) if it is a priority area for improvement in RA care, and (2) their agreement with the content of the statement. For (1) and (2), respectively, scores between 1 and 4 indicated it was not a priority and disagreement; 5 and 6 indicated it was important but not critical and moderate agreement; and 7 to 9 indicated it was high priority and agreement. Criteria for inclusion were a mean score ≥ 7 for priority and a mean score ≥ 7 for content. Results: The Working Group formulated 13 quality statements and established 7 guiding principles for RA care. The survey was completed by 605 consumers and 308 HCPs. The predefined criteria for inclusion were met by 12/13 quality statements. Conclusions: The Australian Rheumatology Association has developed the first CCS for RA in Australia. This standard will serve as an important lever for HCPs and services, consumer organizations, and policy makers to improve the quality of care for adults with RA.

Description:Objective: Artificial intelligence (AI) has demonstrated the potential to improve efficiency and reliability of radiographic scoring in rheumatoid arthritis but lacks sufficient evidence to justify clinical use. We developed and rigorously validated a deep learning model to automate radiographic scoring against two external test sets, drawing upon state of the art reporting guidelines to clarify present barriers to implementation. Methods: AI algorithms were trained to predict the Sharp van der Heijde score in hands and feet using a cohort of 157 patients and 1470 radiographs. External replication was undertaken in test datasets from two hospitals (n=253 patients, 589 radiographs). Alongside standard performance metrics to measure error and agreement, we reported subgroup performance, conducted an exploratory analysis of error, and demonstrated relationships with functional outcomes. Results: Our AI system underperformed compared to manual scoring, with lower agreement between the AI and consensus score than between the two manual scorers. The AI system was better at ranking scores than achieving absolute agreement, with intraclass correlation coefficients ranging from 0.03 to 0.27 while Spearman's correlation coefficients were consistently higher, ranging from 0.16 to 0.55. Conclusions: The performance of the AI systems developed for automating radiographic scoring in RA is insufficient to justify use in research or clinical practice. Large, diverse, and thoroughly described longitudinal datasets will be indispensable in the development and rigorous evaluation of algorithms. Achieving this is key to the ongoing precise evaluation of clinical outcomes in rheumatoid arthritis to enable further improvements to patient care.

Description:To assess the frequency and determinants of immunosuppressant medication use in systemic sclerosis and changes in prescribing patterns over time. The Australian Scleroderma Cohort Study participants meeting the American College of Rheumatology/European Alliance of Associations for Rheumatology criteria for systemic sclerosis with recorded treatment data were included. The Chi-square, two-sample t-tests or Wilcoxon rank-sum tests were used for between-group comparison as appropriate. Multivariable logistic regression models were used to establish the determinants of the use of immunosuppressants. Of 2019 participants, 60% received immunosuppressants, including 81% of those with diffuse systemic sclerosis and 52% of those with limited systemic sclerosis (p < 0.001). Forty-six percent of patients received prednisolone and 40% disease-modifying anti-rheumatic drugs. Immunosuppressant use was more common in those with severe or inflammatory systemic sclerosis features, including interstitial lung disease, synovitis or myositis. Comparing prescribing patterns early in incident systemic sclerosis from 2007-2014 to 2015-2024, disease-modifying anti-rheumatic drug use increased (35% vs 56%, p < 0.001), while prednisolone use decreased (24% vs 17%, p = 0.046). Immunosuppressants were commenced earlier in incident systemic sclerosis in 2015-2024 versus 2007-2014 (1.8 (interquartile range = 1.0-3.2) vs 2.4 (interquartile range = 1.2-4.0) years, p = 0.011). In multivariable modelling, prednisolone use was associated with diffuse systemic sclerosis (odds ratio = 1.8, 95% confidence interval = 1.4-2.2, p < 0.001), interstitial lung disease (odds ratio = 2.1, 95% confidence interval = 1.7-2.5, p < 0.001), myositis (odds ratio = 2.7, 95% confidence interval = 1.8-4.0, p < 0.001), synovitis (odds ratio = 2.2, 95% confidence interval = 1.8-2.6, p < 0.001) and systemic sclerosis heart involvement (odds ratio = 1.4, 95% confidence interval = 1.0-2.0, p = 0.044). Disease-modifying anti-rheumatic drug exposure was associated with diffuse systemic sclerosis (odds ratio = 2.7, 95% confidence interval = 2.1-3.4, p < 0.001), interstitial lung disease (odds ratio = 2.2, 95% confidence interval = 1.7-2.7, p < 0.001), myositis (odds ratio = 3.6, 95% confidence interval = 2.4-5.5, p < 0.001) and synovitis (odds ratio = 4.2, 95% confidence interval = 3.5-5.2, p < 0.001) and inversely associated with age (odds ratio = 0.7, 95% confidence interval = 0.5-0.8, p < 0.01) and pulmonary arterial hypertension (odds ratio = 0.5, 95% confidence interval = 0.4-0.7, p < 0.001). In subgroups with diffuse systemic sclerosis and limited systemic sclerosis and different autoantibody profiles, findings were generally similar, with interstitial lung disease, synovitis and myositis tending to be associated with prednisolone and/or disease-modifying anti-rheumatic drug use, as was systemic sclerosis heart involvement in diffuse systemic sclerosis (p = 0.038). Immunosuppressant use is common in systemic sclerosis, with broadly similar determinants of usage among subtypes and autoantibody status. These real-world data suggest that disease-modifying anti-rheumatic drug use has increased, with earlier implementation of treatment, and a reduction in use of glucocorticoids.

Description:Objective: Mounting evidence supports an association between the intestinal microbiota and diverse pulmonary pathologies (i.e., gut-lung axis). While intestinal dysbiosis is a feature of systemic sclerosis (SSc), no prior studies have investigated the relationship between intestinal microbiota and SSc-associated interstitial lung disease (ILD) in a multi-national cohort. This study aimed to characterize the intestinal microbiota of SSc-ILD and determine whether specific bacterial species and functional pathways are associated with ILD severity. Methods: SSc patients with and without ILD from seven SSc Centers across five continents provided a stool sample. Shotgun metagenomic sequencing was performed using the Illumina NovaSeq 6000 to characterize microbial composition at the species level. Quantitative image analysis of high-resolution computed tomography scans of the chest was used to measure radiological extent of ILD (QILD). Multivariate sparse partial least squares analyses were employed to identify a species signature of ILD and to determine whether specific species and functional pathways are associated with QILD. Results: Among 285 participants (mean disease duration of 9.8 years), 62.5% had ILD. In a multivariate analysis of all participants, patients with ILD had a unique microbial signature compared to those without ILD characterized by increased abundance of candidate pathobiont species. In a subgroup of SSc-ILD participants (N=103), specific bacterial species and functional pathways were associated with QILD. Conclusions: This multicenter study demonstrates that distinct intestinal bacterial species are linked to the presence and radiological extent of ILD in SSc. These species and/or their metabolic products may influence ILD pathogenesis and represent novel treatment targets.