Introduction to Gestaltometer

The treatment change Gestaltometer (c) is a tool designed to record key outcome data. Combined scores as below do not include data on a patients wishes, or steroid dose. These are important , since “remission” whilst on high dose steroids is clearly a flawed concept. Similarly tight control is not possible if a patient’s preference is to remain on their current “imperfect” medication. The tool aims to guide learners in to whether a change in medication is required. Please not the Gestaltometer score is purely for guidance, in the same way as the SDAI and DAS scores.

This link will take you to an on line version of the Gestaltometer with a clickable joint counter      however you will not be able to access and use the tool without asking me for the password!

See below an image of the tool. If you wish to access the html / javascript / php codes please contact me. This can be added inside EMRs eg Oscar.

 

 

 

 

The collection of valid outcome data in rheumatoid arthritis is essential. Outcome measures include:

• Functional assessments such as the Health Assessment Questionnaire,
• Inflammatory markers eg CRP ESR
• Radiological outcomes, eg x rays MRI
• Pain scores
• Swollen joint count
• Combined scores eg SDAI, CDAI, DAS28

SDAI The SDAI is defined as the simple sum of the following:

• Tender joint count (using 28 joints)
• Swollen joint count (using 28 joints)
• Patient global assessment (0 to 10 scale)
• Physician global assessment (0 to 10 scale)
• C-reactive protein level (mg/dL)

CDAI = SDAI without CRP

DAS28

In order to calculate the DAS28, information about some disease variables is needed.

· Number of swollen joints *

· Number of tender joints *

· Erythrocyte Sedimentation Rate (ESR)

· Patient’s “global disease activity” measured on a Visual Analogue Scale of 100 mm

*Based on 28 joints; shoulders, elbows, wrists, MCPs PIPs, knees

DAS28 = 0.56 * sqrt(tender28) + 0.28 * sqrt(swollen28) + 0.70 * ln(ESR) + 0.014 * GH

The treatment change Gestaltometer (C) is a tool designed to record key outcome data. Combined scores as above do not include data on a patients wishes, or steroid dose. These are important , since “remission” whilst on high dose steroids is clearly a flawed concept. Similarly tight control is not possible if a patient’s preference is to remain on their current “imperfect” medication. The tool aims to guide learners in to whether a change in medication is required. Please not the Gestaltometer score is purely for guidance, ion the same way as the SDAI and DAS scores.

This link will take you to an on line version of the Gestaltometer with a clickable joint counter

 

 

Remission and Response

The ACR criteria for clinical remission in rheumatoid arthritis

Five or more of the following requirements must be fulfilled for at least 2 consecutive months

1. Duration of morning stiffness not exceeding 15 minutes

2. No fatigue

3. No joint pain (by history)

4. No joint tenderness or pain in motion

5. No soft tissue swelling in joints or tendon sheaths

6. Erythrocyte sedimentation rate (Westergren method) < 30 mm/h for a female or 20 mm/h for a Male

EULAR remission criteria recommend use of either of the following definitions as the primary and the other as a secondary outcome measure:

• SDAI ≤3.3
• 
  OR
• All of the following:

• Swollen and tender joint counts (using 28 joint count) each ≤1
• Patient global assessment (on a 0 to 10 scale) ≤1
• CRP (expressed in mg/dL) ≤1

For clinical practice consider using :

CDAI ≤2.8

 

 

Using DAS

For improvement from baseline

Good > 1.2

Moderate > 0.6 < 1.2

None < 0.6

DAS28 at end point:

Mild < 3.2

Moderate 3.2 – 5.1

Severe > 5.1