BackgroundLearning in small group tutorials is appreciated by students and effective in the acquisition of clinical problem-solving skills but poses financial and resource challenges. Interactive seminars, which accommodate large groups, might be an alternative. This study examines the educational effectiveness of small group tutorials and interactive seminars and students' preferences for and satisfaction with these formats.MethodsStudents in year three of the Leiden undergraduate medical curriculum, who agreed to participate in a randomized controlled trial (RCT, n = 107), were randomly allocated to small group tutorials (n = 53) or interactive seminars (n = 54). Students who did not agree were free to choose either format (n = 105). Educational effectiveness was measured by comparing the participants' results on the end-of-block test. Data on students' reasons and satisfaction were collected by means of questionnaires. Data was analyzed using student unpaired t test or chi-square test where appropriate.ResultsThere were no significant differences between the two educational formats in students' test grades. Retention of knowledge through active participation was the most frequently cited reason for preferring small group tutorials, while a dislike of compulsory course components was mentioned more frequently by students preferring interactive seminars. Small group tutorials led to greater satisfaction.ConclusionsWe found that small group tutorials leads to greater satisfaction but not to better learning results. Interactive learning in large groups might be might be an effective alternative to small group tutorials in some cases and be offered as an option.

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Background Observational cohort studies and clinical trials have shown that early initiation of DMARD-therapy is associated with less disease persistency (a higher frequency of DMARD-free sustained remission).1 It has been suggested that disease processes in the very early phase are less matured and therefore more susceptible to disease modifying treatment; this period is called the therapeutic window of opportunity. It has been suggested that this period encompasses the first three months of the disease but there are almost no data on the timelines. Objectives We set out to increase the comprehension of the time when the window “closes”. We therefore explored the symptom duration at treatment onset in relation to achieving DMARD free sustained remission in RA-patients included in two early arthritis cohorts. Methods RA patients treated with conventional DMARDs that were included in the Leiden Early Arthritis Clinic and ESPOIR, were studied. In both cohorts symptom onset was defined as the first symptoms (either pain or swelling) as reported by the patient. The outcome, DMARD-free sustained remission, was defined as the absence of clinical arthritis after cessation of DMARDs for the entire follow-up period and for at least 1 year. In the Leiden EAC the maximal follow-up was 15 years, in ESPOIR 4 years. For each cohort time-dependent ROC-curves were constructed to define the optimum cut-off of symptom duration. Analyses were performed when RA was defined according to the 1987 or the 2010 criteria. In the Leiden EAC sub-analyses were performed in ACPA-positive and ACPA-negative RA. Results In total, 157/864 (18%) of the Leiden EAC RA patients (1987 criteria) achieved remission within 15 years and 26/558 (5%) of the ESPOIR 1987-RA patients within 4 years of follow-up. In both cohorts patients were middle aged (mean 56.7±SD 15.6 and 50.9±11.9 years) and the majority were female subjects (66% and 77%) and ACPA positive (54% and 50%). In both cohorts the relation between symptom duration at treatment onset and DMARD-free sustained remission was not linear. The AUCs were all low (<0.62). The symptom duration after which the chance on DMARD-free sustained remission decreased was 14.1 (95%CI 11.6-15.4) weeks in the Leiden EAC and 15.3 (95%CI 10.7-28.0) weeks in ESPOIR. When analysing 2010 RA, the cut off was 14.7 weeks (12.7-19.7) in the Leiden EAC and 13.0 weeks (5.4-104) in ESPOIR. Furthermore, in ACPA-positive RA it was 14.6 (7.6-78.3) weeks and in ACPA negative RA 18.9 weeks (10.4-59.0). Conclusions The association between symptom duration at treatment initiation and disease persistency is not linear. The present data imply that the window of opportunity starts to close 13-19 weeks after symptom onset. More detailed studies on this subject are needed. References van Nies JA et al. What is the evidence for the presence of a therapeutic window of opportunity in rheumatoid arthritis? A systematic literature review. ARD 2013 [epub] Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular....

Background Morning stiffness is common in Rheumatoid Arthritis (RA). It has been part of the classification criteria for decades but is not part of the 2010 criteria for RA. Nevertheless, information on morning stiffness is still used in daily practice in the diagnostic process. Surprisingly, large-scale studies on the value of morning stiffness are lacking. We aimed to further establish the diagnostic and prognostic ability of morning stiffness in patients with arthralgia and with early arthritis by evaluating data of 4,991 patients included in 5 data sets. Objectives We aimed to determine: (1) whether morning stiffness is valuable in patients with arthralgia to identify patients with arthritis, (2) whether morning stiffness in patients is helpful in differentiating RA from other forms of early arthritis, (3) whether within RA morning stiffness is associated with an unfavourable disease course and (4) which duration of morning stiffness has an optimal discriminative ability for diagnosis. Methods Arthralgia patients referred to the Early Arthritis Recognition Clinics (EARC) of Leiden (n=865) and Groningen (n=212) and to the REACH-study (n=353, Rotterdam) were studied; the outcome of this cross-sectional comparison was the presence of arthritis at physical examination. Early arthritis patients included in the Leiden Early Arthritis Clinic (n=2748), and ESPOIR (n=813) were studied on developing RA (fulfilling the 2010 criteria within the first year). The long-term outcomes DMARD-free sustained remission and radiological progression over 7 and 2-years were studied in 2010-RA patients included in the Leiden EAC (n=1073) and ESPOIR (n=645). Morning stiffness was present in case the duration was ≥60 minutes. Sensitivity analyses were performed for other durations and for the severity (visual analogue scales). The duration that had the optimal discriminative ability was determined using ROC-curves. Results Morning stiffness (≥60 minutes) was associated with the presence of arthritis in arthralgia patients in the Leiden EARC OR1.55 (95%CI 1.05-2.29), Groningen EARC OR1.73 (0.80-3.75) and REACH OR1.61 (1.02-2.54). When investigating morning stiffness in early arthritis, it was found that patients that developed RA more often suffered from morning stiffness (OR in Leiden EAC 3.07 (2.61-3.61), in ESPOIR 2.28 (1.55-3.34)), also after adjustments for age, gender, ACPA, RF, SJC and ESR (Leiden EAC OR 1.75 (1.34-2.28), ESPOIR OR 1.68 (1.03-2.74)). Sensitivity analyses on ≥30 and ≥90minutes or using VAS morning stiffness yielded comparable results. Among the arthralgia patients and the early arthritis patients the AUCs were low, the optimal discriminative ability of morning stiffness for diagnosis was around 30 minutes. Morning stiffness was not associated with radiological progression or DMARD-free sustained remission. Conclusions Morning stiffness in arthralgia and early arthritis is independently associated with arthritis and RA-development respectively. These data support the incorporation on information on morning...

Background Baseline erosions are characteristic for Rheumatoid Arthritis (RA) and predictive for the severity of structural damage during the disease. The mechanisms leading to baseline erosions being a strong predictor for radiological progression are unknown. Objectives We aimed to increase this understanding. We therefore explored several hypotheses in an observational cohort study and a cross-sectional MRI-study. First, it was presumed that patients with baseline erosions are more advanced in their disease, reflected by a longer symptom duration. This means that baseline erosions could act as a mediator between the symptom duration at baseline and radiological damage over time. Furthermore, patients with baseline erosions might represent a more severe disease subset that is characterized by the presence of auto-antibodies. Alternatively, patients with baseline erosions might have more inflammation (systemic or local), which drives the association between baseline erosions and joint damage over time. Methods 3,256 Hands and feet radiographs of 653 early RA-patients assessed during 7-years of disease were scored using the Sharp-van der Heijde-method. Multivariate regression analyses and mediation models1 were used to explore the association between baseline erosions, symptom duration, ACPA, RF, swollen joint counts, acute phase reactants and radiological damage over time. We also investigated whether baseline erosions were associated with local MRI detected subclinical inflammation in a second dataset of 67 RA-patients whom underwent a 1.5T MRI and had hands and feet radiographs at baseline. Here 603 joints (MCP2-5 and MTP1-5) were scanned and scored according to RAMRIS. Data on MRI-inflammation were compared with clinical inflammation and baseline radiological erosions. Results Patients with baseline erosions had, at any point in time during 7-years, 3.45 times more joint damage than patients without erosions (p<0.001, 95%CI 3.00-3.98). Baseline erosions were an independent predictor in the multivariate regression analysis. Mediation analyses revealed that baseline erosions were not a mediator between symptom duration, systemic or local clinical inflammation (ESR, SJC) or auto-antibodies (ACPA, RF) and radiological damage. Subclinical MRI-inflammation was studied in relation to erosions, revealing that 83% of the non-swollen joints with baseline erosions had subclinical MRI-inflammation compared to 25% of the non-swollen joints without baseline erosions (OR 15.2 95%CI 3.1-102.1). The association between MRI-inflammation and baseline erosions was independent of symptom duration, ESR, SJC and auto-antibodies. Conclusions Baseline erosions are a predictor for future joint damage, independent of known predictors as time, auto-antibodies or clinical measurable inflammation. Subclinical inflammation is suggested as an underlying mechanism. References Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J ...