Simon Bowman

The Queen Elizabeth Hospital, Tarndarnya, South Australia, Australia

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Publications (139)721.45 Total impact

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    ABSTRACT: Sjögren's syndrome (SjS) is a systemic autoimmune disease that mainly affects the exocrine glands, leading to generalized mucosal dryness. However, primary SjS may initially present with non-sicca (systemic) manifestations. When these features appear before the onset of an overt sicca syndrome, we may talk of an underlying 'occult' SjS. The European League Against Rheumatism (EULAR) has promoted and supported an international collaborative study group (EULAR-SS Task Force) aimed at developing consensual recommendations to provide a homogeneous approach to the patient with primary SjS presenting with systemic involvement. This review summarizes the key factors that should be taken into account in the diagnostic approach in a patient with suspected SjS according to the main clinical patterns of presentation, and is especially focused on organ-specific systemic disease presentations, including a consensus set of recommendations in order to reach an early diagnosis. Close collaboration with the different specialties involved through a comprehensive multidisciplinary approach is essential in SjS patients presenting with systemic involvements.
    No preview · Article · Dec 2015 · Expert Review of Clinical Immunology
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    ABSTRACT: Background Fatigue is a debilitating condition with a significant impact on patients' quality of life. Fatigue is frequently reported by patients suffering from primary Sjogren's Syndrome (pSS), a chronic autoimmune condition characterised by dryness of the eyes and the mouth. However, although fatigue is common in pSS, it does not manifest in all sufferers, providing an excellent model with which to explore the potential underpinning biological mechanisms. Methods Whole blood samples from 133 fully-phenotyped pSS patients stratified for the presence of fatigue, collected by the UK primary Sjogren's Syndrome Registry, were used for whole genome microarray. The resulting data were analysed both on a gene by gene basis and using pre-defined groups of genes. Finally, gene set enrichment analysis (GSEA) was used as a feature selection technique for input into a support vector machine (SVM) classifier. Classification was assessed using area under curve (AUC) of receiver operator characteristic and standard error of Wilcoxon statistic, SE(W). Results Although no genes were individually found to be associated with fatigue, 19 metabolic pathways were enriched in the high fatigue patient group using GSEA. Analysis revealed that these enrichments arose from the presence of a subset of 55 genes. A radial kernel SVM classifier with this subset of genes as input displayed significantly improved performance over classifiers using all pathway genes as input. The classifiers had AUCs of 0.866 (SE(W) 0.002) and 0.525 (SE(W) 0.006), respectively. Conclusions Systematic analysis of gene expression data from pSS patients discordant for fatigue identified 55 genes which are predictive of fatigue level using SVM classification. This list represents the first step in understanding the underlying pathophysiological mechanisms of fatigue in patients with pSS.
    Full-text · Article · Dec 2015 · PLoS ONE
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    ABSTRACT: Objective: Ultrasonography (US) is a sensitive tool in the diagnosis of major salivary gland abnormalities in primary Sjögren's syndrome (pSS). The aim of this systematic review was to assess the metric properties of this technique. Methods: PUBMED and EMBASE databases were searched. All publications between January 1988 and January 2013 were considered. Data were extracted from the articles meeting the inclusion criteria according to US definition of salivary gland scoring system and metric properties studied. The type and number of glands tested, study design and metric properties according to OMERACT filter (truth, discrimination, feasibility) were assessed. Results: Of 167 publications identified initially with PUBMED and EMBASE, 31 met the inclusion criteria. The number of pSS patients varied among the studies from 16 to 140. The diagnosis of pSS was in line in most of the cases with the American-European Consensus Group (AECG) classification criteria for Sjögren's syndrome. The US examination was performed in suspected pSS only in studies in which the sensitivity ranged from 45.8 to 91.6% and specificity from 73 to 98.1%. There was heterogeneity in regard to the definition of US in B-mode and few studies used US in colour Doppler. Few studies reported reliability of US and sensitivity to change in pSS. Conclusion: US is a valuable tool for detecting salivary gland abnormalities in pSS. Its reliability has been poorly investigated and there is considerable variation in the definition of US abnormalities. Further studies are required to validate and standardize the US definition of salivary gland in pSS.
    No preview · Article · Dec 2015 · Rheumatology (Oxford, England)
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    Simon J. Bowman · Benjamin A. Fisher
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    ABSTRACT: The article by Seror et al. in Arthritis Research & Therapy reports data from the 15 French patients in the open-label BELISS (Efficacy and Safety of Belimumab in Subjects With Primary Sjögren's Syndrome, NCT01160666) study of belimumab in primary Sjögren’s syndrome. The study identifies that higher baseline levels of natural killer cells in the peripheral blood and salivary glands are associated with non-response to belimumab therapy. Although caution is required given the open-label nature of the trial, this study adds to data already suggesting a role for natural killer cells in primary Sjögren’s syndrome and, importantly, indicates a need for therapeutic stratification.
    Preview · Article · Dec 2015 · Arthritis Research & Therapy
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    ABSTRACT: Aims: 1. to assess the prevalence of periodontitis among patients with primary Sjögren's syndrome (pSS) and comparator groups of patients with rheumatoid arthritis (RA) and osteoarthritis (OA). 2. To perform a pilot study to compare serum antibody responses to 10 oral/periodontal bacteria in these patient groups and a historical comparator group of patients with periodontitis. Materials and methods: Standard clinical periodontal assessments were performed on 39 pSS, 36 RA and 23 OA patients and "In-house" antibody ELISAs for serum antibodies against 10 oral/periodontal bacteria were performed in these groups. Results: 46% of the pSS group, 64% of the RA group and 48% of the OA group had moderate/severe periodontitis. These frequencies did not reach statistical significance between groups. Raised antibody levels to P. denticola were found in the pSS, RA and periodontitis groups compared to the OA group. Significant between group differences were seen for A. actinomycetemcomitans, P. intermedia, and C. showae. None of these differences were specifically associated with pSS. Conclusion: This study showed no increase in periodontitis in pSS patients. Although the P. denticola data is of interest, identifying bacterial triggering factors for pSS will likely require alternative strategies including modern techniques such as microbiome analysis. This article is protected by copyright. All rights reserved.
    No preview · Article · Dec 2015 · Journal Of Clinical Periodontology
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    ABSTRACT: Background/Purpose: Primary Sjögren’s Syndrome (pSS) is an autoimmune disease which targets secretory glands and results in dryness. In addition pSS patients frequently experience symptoms of fatigue, pain, low mood and have difficulty performing daily activities and subsequently have poor quality of life. There is currently no curative treatment and medical interventions focus on the symptomatic management of dryness. The aim of this study is to identify independent predictors for each of the SF-36 domains in order to identify targets for future therapy interventions with pSS patients. The goal is to identify potential interventions to be delivered by non-medical health care professionals in order to improve the ability to perform daily activities, facilitate taking on life roles and improve quality of life. Methods: 149 PSS patients diagnosed according to the American European Consensus Criteria were recruited from 12 sites across England. Participants completed the SF-36 questionnaire and measurements of anxiety and depression (Hospital Anxiety and Depression Scale HADs), functional status (ImprovedHAQ), pain (visual analogue scale (VAS), fatigue (VAS), mental fatigue (VAS), dryness (VAS), cognitive failures (Cognitive Failures Questionnaire) and recorded their age and disease duration. Significant correlates of each of the SF-36 domain were identified and multiple regression analysis performed for each of the domains to determine partial regression coefficients. Model robustness was determined by hierarchical regression analysis testing the sensitivity of the model to the order of inclusion. Results: With one exception, PSS patients scored significantly worse than the norm-based scores for all domains of the SF-36, including Physical Functioning, Role Physical, Bodily Pain, Vitality, Social Functioning, Role Emotional and Mental Health (p<0.001). General Health was the exception and there was no significant difference between the pSS patients and the norm-based scores. All SF-36 domains correlated significantly with anxiety, depression, cognitive failures, mental fatigue, pain, fatigue and dryness (p<0.001). Fatigue and depression were the main predictors of poorer Role Physical and Social Functioning domain scores (all p≤0.006). Fatigue was a predictor of Bodily Pain (p<0.001) and pain was an independent predictor of poor Physical Functioning (p<0.001). Depression and pain were the main independent predictors of the Vitality domain (p≤0.006) and the General Health domain (p≤0.043). The main predictors of the Role Emotional domain were fatigue, anxiety and depression (p≤0.037) and of the Mental Health domain were disease duration and cognitive failures (p≤0.026). Conclusion: This study demonstrates that fatigue and depression, followed by anxiety and pain are key predictors of the reduced ability to perform daily activities, take on life roles and quality of life. These factors should be addressed during therapeutic interventions with PSS patients presenting with these symptoms. This in turn could support PSS patients to carry out daily activities, take on social and physical life roles and improve their quality of life.
    No preview · Conference Paper · Nov 2015
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    ABSTRACT: Objective: To identify numbers of participants in the UK Primary Sjögren's Syndrome Registry (UKPSSR) who would fulfil eligibility criteria for previous/current or potential clinical trials in primary SS (pSS) in order to optimize recruitment. Methods: We did a retrospective analysis of UKPSSR cohort data of 688 participants who had pSS with evaluable data. Results: In relation to previous/current trials, 75.2% fulfilled eligibility for the Belimumab in Subjects with Primary Sjögren's Syndrome study (Belimumab), 41.4% fulfilled eligibility for the Trial of Remicade in primary Sjögren's syndrome study (Infliximab), 35.4% for the Efficacy of Tocilizumab in Primary Sjögren's Syndrome study (Tocilizumab), 31.6% for the Tolerance and Efficacy of Rituximab in Sjögren's Disease study (Rituximab), 26.9% for the Trial of anti-B-cell therapy in pSS study (Rituximab) and 26.6% for the Efficacy and Safety of Abatacept in Patients With Primary Sjögren's Syndrome study (Abatacept). If recent measures of outcome, such as the EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI) score ⩾5 (measure of patient symptoms) and the EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI) score ⩾5 (measure of systemic disease activity) are incorporated into a study design, with requirements for an unstimulated salivary flow >0 and anti-Ro positivity, then the pool of eligible participants is reduced to 14.3%. Conclusion: The UKPSSR identified a number of options for trial design, including selection on ESSDAI ⩾5, ESSPRI ⩾5 and serological and other parameters.
    No preview · Article · Oct 2015 · Rheumatology (Oxford, England)
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    ABSTRACT: Primary Sjögren's syndrome (pSS) is a complex autoimmune disease characterised by local exocrine glandular involvement and systemic multiorgan manifestations. In this review we will discuss the value of the histological examination of the salivary glands in the classification criteria, and more recently as prognostic tool for patient stratification and monitoring. The limitations of the current tools used to assess salivary gland pathology in pSS will also be reviewed in relation to using salivary gland biopsy analysis as an outcome measure in clinical trials.
    No preview · Article · Sep 2015 · Schweizerische medizinische Wochenschrift
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    ABSTRACT: A germline and coding polymorphism (rs2230926) of TNFAIP3 (A20), a central gatekeeper of nuclear factor-kappa B (NF-kB) activation, was recently found associated with primary Sjögren's syndrome (pSS)-associated lymphoma in a French cohort. We aimed to replicate this association. The rs2230926 polymorphism was genotyped in cases and controls of European ancestry from two independent cohorts from UK and France. Case control association tests were performed (Fisher's test) in the two cohorts, followed by a meta-analysis of the two cohorts. The UK cohort included 308 controls and 590 patients with pSS including 31 with a history of lymphoma. The French cohort consisted of 448 controls and 589 patients with pSS including 47 with lymphoma. In both cohorts, the rs2230926 missense polymorphism was not associated with pSS. However, in the UK cohort, the rs2230926G variant was significantly associated with pSS-associated lymphoma (OR=2.74, 95% CI (1.07 to 7.03), p=0.0423, compared with patients with pSS without lymphoma, and OR=3.12, 95% CI (1.16 to 8.41), p=0.0314, compared with healthy controls) as observed in the French cohort. The meta-analysis of the two cohorts confirmed these results (OR=2.48, 95% CI (1.87 to 3.28) p=0.0037 and OR=2.60, 95% CI (1.91 to 3.53) p=0.0031, respectively). This study confirms the role of A20 impairment in pSS-associated lymphoma. Subtle germline abnormalities of genes leading to impaired control of NF-kB activation in B cells continuously stimulated by autoimmunity enhance the risk of lymphoma. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    No preview · Article · Sep 2015 · Annals of the rheumatic diseases
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    ABSTRACT: The series of events leading to tertiary lymphoid organ (TLO) formation in mucosal organs following tissue damage remain unclear. Using a virus-induced model of autoantibody formation in the salivary glands of adult mice, we demonstrate that IL-22 provides a mechanistic link between mucosal infection, B-cell recruitment, and humoral autoimmunity. IL-22 receptor engagement is necessary and sufficient to promote differential expression of chemokine (C-X-C motif) ligand 12 and chemokine (C-X-C motif) ligand 13 in epithelial and fibroblastic stromal cells that, in turn, is pivotal for B-cell recruitment and organization of the TLOs. Accordingly, genetic and therapeutic blockade of IL-22 impairs and reverses TLO formation and autoantibody production. Our work highlights a critical role for IL-22 in TLO-induced pathology and provides a rationale for the use of IL-22-blocking agents in B-cell-mediated autoimmune conditions.
    Full-text · Article · Aug 2015 · Proceedings of the National Academy of Sciences
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    ABSTRACT: Objective: To reach a European consensus on the definition and characterization of the main organ-specific extraglandular manifestations in primary SS. Methods: The EULAR-SS Task Force Group steering committee agreed to approach SS-related systemic involvement according to the EULAR SS Disease Activity Index (ESSDAI) classification and proposed the preparation of four separate manuscripts: articular, cutaneous, pulmonary and renal ESSDAI involvement; muscular, peripheral nervous system, CNS and haematological ESSDAI involvement; organs not included in the ESSDAI classification; and lymphoproliferative disease. Currently available evidence was obtained by a systematic literature review focused on SS-related systemic features. Results: The following information was summarized for articular, cutaneous, pulmonary and renal involvement: a clear, consensual definition of the clinical feature, a brief epidemiological description including an estimate of the prevalence reported in the main clinical series and a brief list of the key clinical and diagnostic features that could help physicians clearly identify these features. Unfortunately we found that the body of evidence relied predominantly on information retrieved from individual cases, and the scientific information provided was heterogeneous. The analysis of types of involvement was biased due to the unbalanced reporting of severe cases over non-severe cases, although the main sources of bias were the heterogeneous definitions of organ involvement (or even the lack of definition in some studies) and the heterogeneous diagnostic approach used in studies to investigate involvment of each organ. Conclusion: The proposals included in this article are a first step to developing an optimal diagnostic approach to systemic involvement in primary SS and may pave the way for further development of evidence-based diagnostic and therapeutic guidelines.
    No preview · Article · Jul 2015 · Rheumatology (Oxford, England)
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    ABSTRACT: Background: Many people with primary Sjögren's syndrome (PSS) experience difficulty with participation1. There are currently few published studies of non-pharmacological therapy interventions aiming to improve participation in PSS patients. Group concept mapping is a robust, equitable, and systematic approach which has been successfully utilised to identify priorities in both healthcare and research2. Objectives: To identify priority patient and stakeholder informed intervention targets for a future therapy intervention package which will aim to improve participation in people with PSS. Methods: We conducted a mixed-methods group concept mapping exercise with PSS patients, adult household members (AHM) and health care professionals (HCP) (n=232). Patient and AHM participants were recruited from 12 sites in England and all the patients fulfilled the American European Consensus Group diagnosis criteria. HCP were recruited from across the UK via email distribution lists and at professional meetings. First participants completed a statement generation brainstorming activity to identify key barriers to being able to participate fully in daily activities of their choosing. Next an individual card sorting activity was completed with a refined statement set, where participants each sorted similar meaning statements into groups. Finally each statement was rated for importance on a 1-5 Likert scale. Multi-dimensional scaling and hierarchical cluster analysis statistical techniques were applied to generate concept maps which are a visual representation of all stakeholders' ideas and priorities. The maps depicted the priority themed clusters of ideas and “Go-zones”, or bivariate plots of the priority ratings by group, which pinpoint the priority statements within each cluster. Potential priority therapy intervention targets were subsequently identified. Results: The concept maps revealed 7 key themes: “Symptoms”, “Patient empowerment”, “Access and co-ordination of healthcare”, “Wellbeing”, “Family and friends”, “Knowledge and support” and “Public awareness”. The Symptoms and Patient empowerment clusters received the greater priority ratings. Within these clusters potential priority non-pharmacological intervention therapy targets included fatigue, pain, swallowing, sleep, support to self-manage and adherence to medication.
    No preview · Conference Paper · Jun 2015
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    ABSTRACT: Background Ultrasonography (US) has been shown to be a sensitive tool to diagnose major salivary gland echotexture abnormalities in primary Sjögren's syndrome (pSS). Objectives The purpose of this study was [1] to assess definitions of the different ultrasonographic components of the salivary glands and [2] to study the reliability of these definitions on static images with an international web exercice. Methods [1]The consensus exercice about definitions was done and discussed between 12 experts on the field of US pSS during 3 annual meetings. All experts were part of the US-pSS study group. [2]Using these preliminary definitions, a reliability exercice was done on static images. A centre (Brest- France) was in charge to send to the participants different representative US images collection of the agreed elementary lesions.30 parotid glands images and 30 submandibular glands images were sent to the experts by mail.They were asked to score each components of each glands in standardized file. Two rounds of exercicewere performed in order to obtain intra and inter reliability. The first round was in January 2014 and the second round was in March 2014. Inter and intra-observer agreements were estimated using the kappa index considering binary variables (agreements are almost perfect k:0.81 to 1.0; substantial: 0.61 to 0.8, moderate: 0.41 to 0.6, fair: 0.21 to 0.4, poor: -1.0 to 0.2). Results All experts were trained for US of salivary gland with at least 5 years of experience. We obtained definitions about 8 different components evaluating the abnormal parenchyma (echogenicity, homogenicity, presence or absence of hyperechoic bands, number of hypoechoic ares, and location of hypoechoic areas, lymph nodes, presence or absence of calcifications, visualisation of posterior border) on salivary glands in pSS patients. Results of the reliability web exercise is shown on table 1. Without practical training session, we showed good results concerning the intra and inter observer reliabilities applying these definitions on US parotid gland and submandibular glands, particularly in taking homogeneity as the main important item in this definition. Reliabilities for calcifications and posterior band were low. Conclusions This is the first consensus-based US definitions on salivary glands and its elementary components. These first results of the reliability exercice on static images without any training showed good results and permit to apply these preliminary definitions in routine practice and for further studies on pSS patients. Disclosure of Interest None declared
    No preview · Article · Jun 2015 · Annals of the Rheumatic Diseases
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    ABSTRACT: Background Tertiary lymphoid organs (TLOs) are organized clusters of immune cells that preferentially form in autoimmune diseases such as Sjogren's syndrome (SS). TLOs are believed to contribute to disease progression and lymphoma development in SS. Within TLOs, the ectopic expression of lymphoid chemokines has been shown to correlate with size/degree of organization of the lymphoid aggregates and with the production of autoantibodies (1,2). Recent observational studies in SS have proposed a relationship between IL22 expression, B cell infiltration and humoral autoimmunity (3,4,5), however they failed to provide a molecular mechanism for this relationship. Objectives To investigate the functional role of IL22 in ectopic B cell recruitment and humoral autoimmunity during TLO formation. Methods Inducible mouse model of TLO formation and autoantibody production by retrograde cannulation of the salivary glands with a replication deficient adenovirus (6) was used to assess the role of IL22 in vivo. Salivary glands of C57BL/6 mice (wildtype;WT) and knockout mice (IL22-/-) were cannulated and sacrificed at different time points post cannulation (p.c.) and analysed by immunofluorescence, flow cytometry and RT-PCR. Results Virus cannulation of WT mice salivary glands leads to TLOs formation and autoantibody production. Increased expression of IL22 was found to occur within hours of salivary gland cannulation with different cell populations involved in its production. Surprisingly, Il22-/- mice and WT mice treated therapeutically with anti-IL22 antibody were characterized by profound defects in TLO maturation. Absence or blocking of IL22 impairs CXCL13 and CXCL12 production, resulting in reduced B cell accumulation within the TLOs and abolition of autoantibody production. IL22 exerts a differential effect depending on the target stromal cell in which IL22Rα is expressed. On igp38+ IL22Rα+ stromal cells, IL22 stimulation regulates CXCL13 expression, independently from but also in synergy with, TNFα and LTβ. Conversely, on epithelial cells, IL22Rα engagement increases CXCL12 production but not CXCL13. This effect is direct, as treatment of isolated stromal and epithelial cells with recombinant IL22 in vitro was sufficient to induce CXCL13 and CXCL12 production by gp38+ stromal cells and EPCAM+ epithelial cells respectively. This dual impairment in chemokine expression is responsible for the reduced B cell accumulation, aberrant follicle maturation and lack of autoantibody production observed in both KO and anti-IL22 treated. Conclusions Here we describe for the first time the functional connection between expression of IL22, aberrant chemokine production and autoantibody response in TLO associated autoimmune diseases such as SS. References Disclosure of Interest None declared
    No preview · Article · Jun 2015 · Annals of the Rheumatic Diseases
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    ABSTRACT: Salivary gland changes, characterised by a focal lymphocytic sialadenitits, play an important role in the diagnosis of primary Sjögren's syndrome (PSS) and were first described over 40 years ago. Recent evidence suggests that minor salivary gland biopsy may also provide information useful for prognostication and stratification, yet difficulties may arise in the histopathological interpretation and scoring, and evidence exists that reporting is variable. With the increasing number of actual and proposed clinical trials in PSS, we review the evidence that might support the role of histopathology as a biomarker for stratification and response to therapy and highlight areas where further validation work is required. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Full-text · Article · Jun 2015 · Annals of the rheumatic diseases
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    ABSTRACT: Background ESSDAI is a validated activity index in primary Sjögren's syndrome more and more used in clinical trials but also for finding biomarkers associated with activity of the disease. In this context, the presence of the biological domain in the ESSDAI score may induce circular reasoning and colinearity of data. Objectives To develop the ClinESSDAI, derived from the ESSDAI score after deleting biological domain, and to validate if by comparison with the original ESSDAI. Methods The 702 fictive vignettes created using data from 96 real cases of pSS for the study of development ESSDAI were used. As for the development of the original score, the assessment by the 39 experts who participated to the development study of disease activity using a scale ranging from 0-10 was used as the “gold standard” for weighting domains in the robust regression model. The explanatory variables included all domain of ESSDAI except the biological domain. The ClinESSDAI was compared to original ESSDAI to assess if it could be a surrogate of the original score by assessing its reproducibility using ESSDAI as gold standard. The validity of ClinESSDAI (including construct validity, reliability and sensitivity to change) was then assessed and compared to that of ESSDAI. Validation populations included the 96 real cases and the 395 patients of the EULAR cohort. Results In the multivariate model, each of the 11 areas was significantly associated with disease activity. The weight of the domains was slightly different from the fields of ESSDAI (table). The ClinESSDAI was an excellent surrogate of the original ESSDAI, since the ICC between ESSDAI and ClinESSDAI were0.98 [0.97; 0.98] for fictive vignettes, 0.99 [0.98; 0.99] for the real case and0.90 [0.87; 0.92] in the EULAR cohort. Psychometric properties of the ClinESSDAI (construct validity, reliability and sensitivity to change) were very close to that of ESSDAI. Conclusions Declination of the ESSDAI score without biological domain appears valid and very close to the original score. In this score, weights of some domains changed. This score will allow an evaluation of disease activity that is independent ofB-cell biomarkers, which will be useful in biological studies to avoid circular reasoning and colinearity of data. In addition, it may be helpful in clinical practice to assess disease activity when immunological tests have not been carried out. Disclosure of Interest None declared
    No preview · Article · Jun 2015 · Annals of the Rheumatic Diseases

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Publication Stats

2k Citations
721.45 Total Impact Points

Institutions

  • 2013-2015
    • The Queen Elizabeth Hospital
      Tarndarnya, South Australia, Australia
  • 2012-2015
    • Queen Elizabeth Hospital Birmingham
      Birmingham, England, United Kingdom
    • The Newcastle upon Tyne Hospitals NHS Foundation Trust
      Newcastle-on-Tyne, England, United Kingdom
  • 2005-2015
    • University Hospitals Birmingham NHS Foundation Trust
      Birmingham, England, United Kingdom
  • 2002-2015
    • University of Birmingham
      • • MRC Centre for Immune Regulation
      • • School of Immunity and Infection
      • • School of Psychology
      Birmingham, England, United Kingdom
  • 2012-2014
    • Newcastle University
      • Institute of Cellular Medicine
      Newcastle-on-Tyne, England, United Kingdom
  • 2009
    • University of Alabama at Birmingham
      Birmingham, Alabama, United States
  • 1998-2006
    • University of Wolverhampton
      Wolverhampton, England, United Kingdom
  • 2001
    • Birmingham and Solihull Mental Health NHS Foundation Trust
      Birmingham, England, United Kingdom