Objective. To evaluate barriers that prevent rheumatoid arthritis (RA) patients from achieving Disease Activity Score in 28 joints using the erythrocyte sedimentation rate (DAS28-ESR) scores within the current recommended levels for low disease activity (LDA) or clinical remission (DAS28-ESR score <3.2). Methods. Using an electronic medical record program, clinical data for RA patients treated in Optimising Patient Outcomes in Australian Rheumatology clinics, with a recorded DAS28-ESR score, were collected at one point in time. The data included demographics, medications, disease measures, and the rheumatologist's opinion of the main barriers preventing improvement to the recommended DAS28 score. Results. Of the 4,037 patients with a recorded DAS28-ESR score, 304 patients (7.5%) had high disease activity (HDA) and 1,211 patients (30%) had moderate disease activity (MDA). For 584 HDA or MDA patients, the barriers to disease control (BTCs) were recorded by the rheumatologist when there was no adjustment to disease-modifying antirheumatic drug (DMARD) therapy. The recorded BTCs were irreversible joint damage (19.7%), patient-driven preference (14.7%), noninflammatory musculoskeletal pain (9.2%), insufficient time to assess the effect of recently initiated DMARDs (9.2%), safety concerns (7.5%), comorbidities (6.5%), resistant disease (6.3%), and other less common reasons. These patients received DMARDs (97.4%), including biologic agents (34.1%), methotrexate (74.8%), and oral corticosteroids (41.8%). Conclusion. This study identified clinical situations in which rheumatologists elected to continue RA patients with MDA or HDA on DMARD therapy without adjustment to achieve clinical remission or an LDA target of a DAS28-ESR score <3.2.

In Leishmaniasis, as in many infectious diseases, clinical manifestations are determined by the interaction between the genetics of the host and of the parasite. Here we describe studies mapping two loci controlling resistance to murine cutaneous leishmaniasis. Mice infected with L. major show marked genetic differences in disease manifestations: BALB/c mice are susceptible, exhibiting enlarging lesions that progress to systemic disease and death, whereas C57BL/6 are resistant, developing small, self-healing lesions. F2 animals from a C57BL/6 × BALB/c cross showed a continuous distribution of lesion score. Quantitative trait loci (QTL) have been mapped after a non-parametric QTL analysis on a genome-wide scan on 199 animals. QTLs identified were confirmed in a second cross of 271 animals. Linkage was confirmed to a chromosome 9 locus (D9Mit67–D9Mit71) and to a region including the H2 locus on chromosome 17. These have been named lmr2 and lmr1, respectively.

These results suggest that patients are satisfied with a rheumatology telemedicine service, and may prefer this to extensive travelling. Evaluation in other settings is recommended before generalizing this finding.

Leishmaniasis constitutes a diverse collection of human diseases ranging in severity from a spontaneously healing skin ulcer to overwhelming visceral disease. Worldwide, two million new cases occur each year, and a 10th of the world's population is at risk of infection. 1 Although the disease is highly endemic throughout northern Africa, the Middle East, parts of Europe, and Central and South America, epidemics are well recognised. For example, in southern Sudan more than 10% of the population died from visceral leishmaniasis over the past five years.Outcome of infection is determined by interactions between the host and parasite, which are governed by the genomes of the host and parasite. It is therefore exciting to see that both host and parasite genomes have been targeted for sequence analysis. 2 The leishmania genome project began as a large scale attempt to sequence part of each of the transcripts of all the genes of the organism, and the plan is now to sequence its entire genome. The genetic information from both human and parasite and the emergence of new tools such as microarray technologies will allow us to gain an understanding of the interaction between parasite virulence factors and host response factors. Molecular knowledge of the host-parasite interaction will facilitate targeting of new treatments. MethodsWe chose topics for this article to convey the impact that current research will have on the pathophysiology and treatment of leishmaniasis. We used a variety of sources for the topics, including published original articles and reviews, the internet, and personal communications.

Background COVID‐19 has resulted in a massive increase in telehealth utilisation. Aims To determine the user and clinician satisfaction during this period and compare to a pre‐COVID‐19 cohort. Methods A prospectively collected voluntary questionnaire following the telehealth appointment at a tertiary‐level hospital with all adult and paediatric‐based specialities was conducted over two time periods: COVID‐19 (16 March 2020 to 15 April 2020) and pre‐COVID‐19 (1 January 2019 to 31 December 2019). There were four groups of participants: patients; parents; adult‐based clinicians; and paediatric‐based clinicians. The outcomes assessed included perceived standard of care, willingness for repeat telehealth consultations, and patient and parental perceptions of safety. Results Five thousand and thirty‐three telehealth consultations occurred in the COVID‐19 period with 1757 questionnaires completed, compared to 1917 consultations with 271 questionnaires completed in the pre‐COVID‐19 period. Clinicians were more likely to have previously used telehealth in both time periods than end‐users. In COVID‐19, 1240 actual onsite hospital outpatients' visits were prevented. All groups reported a good overall impression of the telehealth quality; patients/parents scored higher compared to clinicians: 3.6/4 versus 3.3/4, P = 0.02 (pre‐COVID‐19) and 3.3/4 versus 2.8/4, P = 0.001 (COVID‐19). The majority of patients and parents (90%, 1379/1528) felt safer by having a telehealth appointment compared to a face‐to‐face appointment in the COVID‐19 pandemic. All participant groups reported an overall good standard of care, good levels of engagement and were strongly willing to use telehealth again in both of the study time periods. Patients and parents consistently rated higher than clinicians. Conclusions During a rapid increase in its utilisation and scope due to the COVID‐19 pandemic, telehealth was generally well accepted by patients, parents and clinicians, which was consistent with pre‐COVID‐19 experiences.

Australia is a vast country with one‐third of the population living outside capital cities. Providing specialist rheumatologist services to regional, rural and remote Australians has generally required expensive and time‐consuming travel for the patient and/or specialist. As a result, access to specialist care for remote Australians is poor. Rheumatoid arthritis is a common disease, but like many rheumatic diseases, it is complex to treat. Time‐dependent joint damage and disability occur unless best evidence care is implemented. The relatively poor access to rheumatologist care allotted to nonmetropolitan Australians therefore represents a significant cause of potentially preventable disability in Australia. Telehealth has the potential to improve access to specialist rheumatologists for patients with rheumatoid arthritis and other rheumatic diseases, thereby decreasing the burden of disability caused by these diseases. Advances in videoconferencing technology, the national broadband rollout and recent Federal government financial incentives have led to a heightened interest in exploring the use of this technology in Australian rheumatology practice. This review summarises the current evidence base, outlines telehealth's strengths and weaknesses in managing rheumatic disease, and discusses the technological, medicolegal and financial aspects of this model of care. A mixed model offering both face‐to‐face and virtual consultations appears to be the best option, as it can overcome the barriers to accessing care posed by distance while also mitigating the risks of virtual consultation.

The combination of MTX and LEF was well tolerated, with adverse events comparable to those of monotherapy and the other nonbiologic disease-modifying antirheumatic drug treatment group.

As in other infectious diseases, the outcome of a Leishmania major infection is closely tied to the T helper cell response type; progressive disease is associated with a predominant Th2 lymphocyte response, healing with a Th1 response. In mice, susceptibility is genetically controlled , with BALB/c (C) mice being susceptible and C57BL/6 (B) mice being resistant. Using a genome-wide scan on two large populations of F2 mice created from these strains, we have shown previously that susceptibility to infection with L. major is controlled by two auto-somal loci: lmr1 at the H2 locus, and lmr2 on chromosome 9. Employing a strategy to identify loci that interact, we show here that lmr1 and lmr2 interact synergistically, and we describe a new locus lmr3, lying on the X chromosome, whose effect depends on a specific lmr1 haplotype.