ObjectivesTo study clinical predictors for radiographic progression after 1 year in an early rheumatoid arthritis (RA) trial.MethodsIn the SWEFOT trial population, disease modifying antirheumatic drug (DMARD) naïve RA patients started methotrexate; 3-month responders (DAS28 <3.2) continued (n=147), while non-responders were randomised to addition of sulfasalazine+hydroxychloroquine (n=130) or infliximab (n=128). X-rays were scored by the Sharp-van der Hejde score (SHS) method and radiographic progression was defined as a ≥5 increase after 1 year. Potential baseline predictors of radiographic progression were tested using multivariable logistic regression, adjusted for potential confounders.Results79 of 311 patients with available radiographs at baseline and follow-up had radiographic progression. The following baseline parameters were independent predictors of radiographic progression at 1 year: baseline erosions (adjusted OR=2.29, 95% CI 1.24 to 4.24), erythrocyte sedimentation rate (adjusted OR per tertile increase=1.72, 95% CI 1.12 to 2.65) and C-reactive protein (adjusted OR per tertile increase=1.52, 95% CI 1.03 to 2.26). Current smoking was an independent predictor of radiographic progression (adjusted OR=2.17, 95% CI 1.06 to 4.45). These results remained after further adjustment for treatment strategy. Three-dimensional matrix including current smoking status, erosions and C-reactive protein tertiles showed a 12–63% risk gradient from patients carrying none compared with all predictors. Rheumatoid factor (RF)/anti-cyclic citrullinated peptide (anti-CCP) positivity did not significantly predict radiographic progression using SHS increase ≥5 as cut-off. In a secondary exploratory analysis using cut-off >1, both RF and anti-CCP positivity were significant predictors in the unadjusted, but not the adjusted analyses. The other parameters also remained significant using this lower cut-off.ConclusionsIn addition to previously described predictors, we identified smoking as a strong independent risk factor for radiographic progression in early RA.Trial registration numberNCT00764725.

Most early RA patients who achieve low disease activity after 3-4 months of methotrexate monotherapy continue to have low disease activity during 2 years follow-up, and additional treatment is needed infrequently. Some radiological progression occurs in most patients, and may be marked or severe in some, even despite sustained DAS28 remission. Close monitoring for radiological progression is thus warranted.

IntroductionThis study aimed to assess the utility of musculoskeletal ultrasound (MSUS) in patients with joint symptoms using a probabilistic approach.MethodsOne hundred and three patients without prior rheumatologic diagnosis and referred to our clinic for evaluation of inflammatory arthritis were included. Patients were assessed clinically including joint examination, laboratory testing including acute-phase reactants, rheumatoid factor (RF) and anti citrulinated protein antibody (ACPA), and radiographs of hands and feet if clinically indicated. A diagnostic assessment was then performed by the responsible rheumatologist where the probability of a) any inflammatory arthritis and b) rheumatoid arthritis was given on a 5-point scale ranging from 0 to 20% up to 80 to 100% probability. Subsequently, an ultrasound examination of the wrist, metacarpophalangeal (MCP), proximal interphalangeal (PIP) joints 2 to 5 in both hands, metatarsophalangeal (MTP) joints 2 to 5 in both feet and any symptomatic joints was performed and the results presented to the same rheumatologist. The latter then assessed the diagnostic probabilities again, using the same scale.ResultsThe rheumatologists’ certainty for presence/absence of inflammatory arthritis and rheumatoid arthritis was increased significantly following ultrasound performance. The proportion of patient for whom diagnostic certainty for inflammatory arthritis was maximal was 33.0% before and 71.8% after musculoskeletal ultrasound (P <0.001). With regard to a diagnosis of RA, the proportions were 31.1% pre-test and 61.2% post-test (P <0.001). MSUS findings agreed with the final diagnosis in 95% of patients.ConclusionMusculoskeletal ultrasound, when added to routine rheumatologic investigation, greatly increases the diagnostic certainty in patients referred for the evaluation of inflammatory arthritis. The changes from pre-test to post-test probability quantify the diagnostic utility of musculoskeletal ultrasound in probabilistic terms.

ObjectivesThe correct identification of synovitis is critical for achieving optimal therapy results. Fluorescence optical imaging (FOI) is a novel modality based on the use of an intravenous fluorophore, which enables fluorescent imaging of the hands and wrists with increased focal optical signal intensities in areas of high perfusion and/or capillary leakage. The study objective was to determine the diagnostic utility of FOI in detecting apparent and clinically non-apparent active synovitis.MethodsBilateral hand and wrist joints (n=872) of 26 patients with inflammatory arthritis assessed by standard clinical examination, musculoskeletal ultrasound (MSUS) and FOI were studied. Synovitis was defined as tender and swollen joints on clinical examination, presence of synovial thickening and intra-articular Doppler signals on MSUS, and abnormal focal optical signal intensities on FOI, respectively. Subclinical synovitis was defined as being clinically non-apparent, but positively inflamed on MSUS.ResultsDepending on the standard used to define inflammation, FOI ranged from 73–83% sensitive and 83–95% specific for detecting manifest synovitis. For detecting clinically silent synovitis, the sensitivity, specificity and positive and negative predictive values of FOI were 80%, 96%, 77% and 97%, respectively.ConclusionsThe high degree of agreement between MSUS and FOI suggest its use in clinical practice, especially when MSUS is not available, in order to identify synovitis earlier and with greater confidence. FOI may be particularly useful in identifying patients with clinically non-apparent joint inflammation of the hands and/or wrists.

Abstract-Nowadays, information Systems play effective role in the organizations in a way that they cannot be imagined without these systems. On the other hand knowledge value of organizations are increasing and they prefer to take care of this knowledge. Accordingly, having a knowledge management system that can handle this task is very important. Based on one of the successful models of information systems, management system includes such major factors each one focusing on a part of the system. Meanwhile cloud computing technology has created a revolution in software and hardware processing. So in this paper we try to evaluate the success rate of "Quality of Service" which is one of the major factors of management system based on cloud computing on a higher education system. Index Terms-Knowledge management systems, cloud computing, service quality.  I. INTRODUCTIONNowadays, the new technologies play a widespread role in the world. That is because of its ability to solve everyday problems of many people in addition to decreasing living expenses. As [1] mentions in his article, technology has managed to release IT based companies from exorbitant costs. One of these technologies is cloud computing which has been officially established since 2006. The improvement of this technology has been in such a way that [2] considers it as one of the most important concepts in information technology field. To define the cloud computing in a right way, the best definition is the one that United States National Standards Institute presents [3]: cloud computing is a safe and accurate framework to access different sources of network, such as servers, functional applications, etc. Which could be provided for the users so fast and with minimum costs and efforts.On the other hand [4] claims that the cloud computing and online social networks are suitable platforms to set up the knowledge management systems. Therefore, by expansion of knowledge based organizations, many different studies have been done on the knowledge management systems. According to [5]'s definition, knowledge management systems play a basic role in the system which is defined as: providing an intelligent backup of different users in the organization that play important roles in organizational knowledge graph. One of the most important benefits of these knowledge management systems is to cause the company to obtain a competitive advantage. Moreover, it can cause an increase in work and system quality and speed up the knowledge manufacturing cycle [6]. Therefore, knowledge management systems need a software platform to present their services to company employees for producing, modifying and maintaining of knowledge.In this article we are to investigate the uploading result of a knowledge management system using the cloud computing technology. The main question is whether this new knowledge management system can cause a proper result on the quality of services or not? In the next section we will take a short look at the history of the study, then we will hint the s...

ObjectivesFluorescence Optical Imaging (FOI) is an emerging modality that uses an intravenous fluorophore to display altered microcirculation (abnormal perfusion/capillary leakage) in synovial tissues in the hands. FOI can be analyzed visually (FOI-v) or by using automated Disease ACTivity (DACT). Using musculoskeletal ultrasound (MSUS) as a validated reference measure, we previously showed FOI to be highly sensitive and specific in detecting clinically manifest and silent synovitis in patients with various rheumatic diseases. Here, we analyze whether the same is true for early rheumatoid arthritis (eRA).MethodsHands and wrists ineRA patients were assessed by clinical examination, MSUS and FOI-DACT. Active inflammation was defined as having synovial-hypertrophy/effusions and intra-articular Doppler signaling on MSUS, and as increased optical-intensities on FOI-v. Scores on DACT ≥ 1 was considered indicative of disease activity.Results39 eRA patients were studied [72% females, 56% previous/current smokers, 54% RF(+) and 69% ACCP(+)]. Of the 1326 joints in these patients, 303 were inflamed by clinical assessment, 380 by MSUS, and 400 by FOI-v. The percentages of patients and (mean ± SD) joints by clinical, MSUS and FOI-v were 69%(7.8 ± 8.1), 95%(9.7 ± 7.7), and 95%(10.3 ± 7.2), respectively. Using MSUS as reference, FOI-DACT was 95%(35/37) accurate in identifying patients with active disease, 24%(9/37) of whom had erosive RA. Good correlations noted between MSUS and FOI-v (rho = 0.803; p < 0.001), clinical assessment and FOI-v (rho = 0.732; p < 0.001), and MSUS and clinical (rho = 0.793; p < 0.001). The sensitivity, specificity, NPV and PPV of inflammation by FOI-v was 81%(308/380), 90%(854/946), 61%, and 96% respectively. Of the clinically negative but MSUS positive (145/1023) joints, 68%(98/145) were also FOI-v positive. Remarkably, one patient had 15 joints that were FOI-DACT positive and MSUS negative, but a month later, the same joints became MSUS positive. Although the wrists and MCPs were frequently inflamed, DIP joint inflammation was also seen in 34 and 14 joints in 12 patients by FOI-DACT and MSUS, respectively. Nine of these patients had osteoarthritis by conventional radiography.ConclusionsAs reported for established rheumatic diseases, here we show high correlations and agreements between clinical examination, MSUS and FOI-v in detecting subtle inflammation in early RA as well. Moreover, DACT-FOI emerges as a useful automated quantitative scoring method for synovial inflammation in eRA.Reference Kisten Y, Györi N, af Klint E, et al. 2015 Detection of clinically manifest and silent synovitis in the hands and wrists by fluorescence optical imaging. RMD Open. 1: e000106. doi:10.1136/ rmdopen-2015-000106()

BackgroundTo investigate hand bone loss (HBL) measured by digital X-ray radiogrammetry (DXR) in patients with early rheumatoid arthritis (RA) receiving different treatment regimens, and to evaluate if DXR change rates during the first 12 months correlate with radiological damage after 24 months.MethodsFrom the total SWEFOT trial population, 159 patients had hand radiographs correctly timed and taken with same modality to be analyzed with DXR. All patients started treatment with methotrexate. After 3–4 months, patients with DAS28 > 3.2 were randomized to add sulfasalazine and hydroxychloroquine (triple therapy) or infliximab (MTX + INF). Those with DAS28 ≤3.2 were followed in regular care. Radiographic progression over 24 months was scored according to the Sharp van der Heijde score (SHS) and defined as >5 increase in T-SHS over 24 months. Hand bone mineral density (BMD) was measured by DXR at inclusion and 12 months and a change ≥2.5 mg/cm2/month was used as a cut-off for HBL.ResultsIn the MTX responders, triple therapy, and MTX + INF groups, the proportions with HBL were 4.1%, 22.2% and 16.4%, respectively (p = 0.01), and the mean (SD) radiological progression in these groups was 3.91 (6.72), 7.40 (14.63) and 2.72 (4.55) respectively (p = 0.06). Patients with HBL had significantly greater risk for radiographic progression, compared with patients without HBL (odds ratio 3.09, 95% CI =1.20–7.79, p = 0.02).ConclusionsNon-responders to MTX had a significantly greater risk of HBL than MTX-responders, despite the add-on therapies. Patients with HBL during the 12 months had greater risk of radiographic progression after 24 months. Evaluation of HBL may help to identify patients who are at risk of radiographic progression.

Objectives. The aim of this study was to evaluate the association between two semi-quantitative Doppler US scoring systems (SQS), and the quantitative scoring (QS) of Doppler pixel count.Methods. Adult patients with RA and inadequate clinical response to anti-rheumatic therapy were examined with musculoskeletal US (MSUS). Dorsal MSUS of the wrists, MCP and MTP 2–5 were performed. MSUS images with sign of synovitis were collected and the QS was measured. Five assessors blinded to the QS evaluated the images independently, according to either SQS method. Association between QS and SQS was studied using correlations and multilevel models taking into account the clustering of ratings at the rater, patient and joint levels.Results. Analysis of the 1190 ratings revealed a strong correlation (ρ = 0.89, P < 0.0001) and significant associations (P < 0.0001) between QS and SQS. Correlations between QS and SQS according to Szkudlarek et al. (ρ = 0.87, P < 0.0001) or Hammer et al. (ρ = 0.91, P < 0.0001) were similar. A total of 239 (20.1%) images were given a SQS grade that did not match that expected based on initial QS, using pre-defined cut-offs. Main explanations for discrepancies were different perceived region of interest (40.7%) and Doppler pixel count near cut-offs between SQS grades (32.3%).Conclusion. We showed that both SQS methods correlated well with QS to assess synovitis, but SQS methods are intrinsically limited when the Doppler pixel count is close to the cut-offs between the SQS grades. Analysis discrepancies between these methods may help further revision of criteria used to assess disease activity with MSUS in RA.