13,14 Synovial macrophages are the predominant source of interleukin-1␤ and tumor necrosis factor-␣ that are central to the pathogenesis of RA as evidenced by the efficacy of disease-modifying therapies targeted at these cytokines. 15 The joint destruction in RA is likely mediated by proteases derived from macrophages and osteoclasts. Although there is abundant evidence for the presence of activated leukocytes in rheumatoid synovium, the mechanism(s) and regulation of their activation are not fully elucidated and the fundamental underlying etiology of RA remains obscure.Inflammatory responses are likely regulated by a complex network of inhibitory and activating signals. The leukocyte immunoglobulin-like receptors (LIRs), also termed immunoglobulin-like transcripts (ILTs), comprise a new family of cell surface proteins that have been shown in vitro to modulate cellular responses through immunoreceptor tyrosine-based inhibitory motifs (ITIMs) or through association with the Fc receptor ␥ chain that contains an immunoreceptor tyrosine-based activation motif. 16 -18 The inhibitory LIRs (LIRs-1, -2, -3, -5, and -8) display long cytoplasmic domains with two to four ITIMs. These receptors mediate inhibition of cell activation by recruiting the src homology 2 (SH2) domain-containing phosphatase 1 (SHP-1) to inhibit or terminate signaling through nonreceptor tyrosine kinase cascades.

BackgroundThere is little indication that foot health services in Australia are meeting modern day recommendations for Rheumatoid Arthritis (RA) patients. The overall objective of this study was to explore the current state of foot health services for patients with RA with an emphasis on identifying barriers to the receipt of appropriate foot care in South-West Sydney, New South Wales, Australia.MethodsA mixed (quantitative and qualitative) approach was adopted. Indications for appropriate access to foot care were determined by comparing the foot health, disease and socio-demographic characteristics of patients with unmet foot care demands, foot care users and patients with no demands for foot care. Perceptions of provision of, and access to, foot care were explored by conducting telephone-based interviews using an interpretative phenomenology approach with thematic analysis.ResultsTwenty-nine participants took part in the cross-sectional quantitative research study design, and 12 participants took part in the interpretative phenomenological approach (qualitative study). Foot care access appeared to be driven predominantly by the presence of rearfoot deformity, which was significantly worse amongst participants in the foot care user group (p = 0.02). Five main themes emerged from the qualitative data: 1) impact of disease-related foot symptoms, 2) footwear difficulties, 3) medical/rheumatology encounters, 4) foot and podiatry care access and experiences, and 5) financial hardship.ConclusionsFoot care provision does not appear to be driven by appropriate foot health characteristics such as foot pain or foot-related disability. There may be significant shortfalls in footwear and foot care access and provision in Greater Western Sydney. Several barriers to adequate foot care access and provision were identified and further efforts are required to improve access to and the quality of foot care for people who have RA. Integration of podiatry services within rheumatology centres could resolve unmet needs of people with RA by permitting rapid access to expert-led multidisciplinary foot care for people with RA.

ObjectiveRecent studies have suggested that fibromyalgia is inaccurately diagnosed in the community, and that ~75% of persons reporting a physician diagnosis of fibromyalgia would not satisfy published criteria. To investigate possible diagnostic misclassification, we compared expert physician diagnosis with published criteria.MethodsIn a university rheumatology clinic, 497 patients completed the Multidimensional Health Assessment Questionnaire (MD‐HAQ) and the 2010 American College of Rheumatology preliminary diagnostic criteria modified for self‐administration during their ordinary medical visits. Patients were evaluated and diagnosed by university rheumatology staff.ResultsOf the 497 patients, 121 (24.3%) satisfied the fibromyalgia criteria, while 104 (20.9%) received a clinician International Classification of Diseases (ICD) diagnosis of fibromyalgia. The agreement between clinicians and criteria was 79.2%. However, agreement beyond chance was only fair (κ = 0.41). Physicians failed to identify 60 criteria‐positive patients (49.6%) and incorrectly identified 43 criteria‐negative patients (11.4%). In a subset of 88 patients with rheumatoid arthritis (RA), the kappa value was 0.32, indicating slight to fair agreement. Universally, higher polysymptomatic distress scores and criteria‐based diagnosis were associated with more abnormal MD‐HAQ clinical scores. Women and patients with more symptoms but fewer pain areas were more likely to receive a clinician's diagnosis than to satisfy fibromyalgia criteria.ConclusionThere is considerable disagreement between ICD clinical diagnosis and criteria‐based diagnosis of fibromyalgia, calling into question ICD‐based studies. Fibromyalgia criteria were easy to use, but problems regarding clinician bias, meaning of a fibromyalgia diagnosis, and the validity of physician diagnosis were substantial.

Acute gout episodes in hospital are variably investigated and treated with frequent suboptimal management. We recommend establishment of a hospital-wide protocol to support decision-making regarding investigations, treatment and follow up.

Background: Widespread adoption of information and communication technologies (ICT) is a key strategy to meet the challenges facing health systems internationally of increasing demands, rising costs, limited resources and workforce shortages. Despite the rapid increase in ICT investment, uptake and acceptance has been slow and the benefits fewer than expected. Absent from the research literature has been a multi-site investigation of how ICT can support and drive innovative work practice. This Australian-based project will assess the factors that allow health service organisations to harness ICT, and the extent to which such systems drive the creation of new sustainable models of service delivery which increase capacity and provide rapid, safe, effective, affordable and sustainable health care.