Classifications

• • G—PHYSICS
  • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
  • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
  • G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
  • G16H10/40—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for data related to laboratory analysis, e.g. patient specimen analysis
• • G—PHYSICS
  • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
  • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
  • G16H50/00—ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics
  • G16H50/20—ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics for computer-aided diagnosis, e.g. based on medical expert systems
• • G—PHYSICS
  • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
  • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
  • G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
  • G16H10/20—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for electronic clinical trials or questionnaires
• • G—PHYSICS
  • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
  • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
  • G16H50/00—ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics
  • G16H50/50—ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics for simulation or modelling of medical disorders

Definitions

• the present invention relates to a method for predicting the likelihood of development of rheumatoid arthritis in patients with undiagnosed or undifferentiated arthritis.
• the method may be performed by a computer programmed to differentially diagnose or predict the development of rheumatoid arthritis.
• the invention further relates to the computer program product and to a data carrier with the computer program product.
• RA rheumatoid arthritis
• DMARDs disease-modifying antirheumatic drugs
• Patients that present to the outpatient clinic with a recent-onset arthritis are referred to as having early arthritis. Some of these patients may, at first presentation, have a disease that can be classified according to current arthritis evaluation criteria. For example, patients may be directly diagnosed with rheumatoid arthritis or reactive arthritis. Reactive arthritis is an acute form of arthritis which occurs after a viral or bacterial infection that spontaneously disappears in several weeks or months, and which features the following three conditions: (1) inflamed joints; (2) inflammation of the eyes (conjunctivitis); and (3) inflammation of the genital, urinary or gastrointestinal system.
• UA undifferentiated arthritis
• the present invention relates to a method of predicting whether an individual with undifferentiated arthritis will develop rheumatoid arthritis.
• the method comprises the steps of: a) determining for the individual at least one of the following clinical parameter values: i) the level of C-reactive protein; ii) the presence or absence of Rheumatoid factor; and, iii) the presence or absence of anti-CCP antibodies; b) determining a set of further clinical parameter values comprising at least one of the age of the patient; the gender of the patient; the localization of the joint complaints; the length of the VAS morning stiffness; the number of tender joints; and, determining the number of swollen joints; and, c) predicting the risk of the individual of developing rheumatoid arthritis by correlating the parameter values determined in steps a) and b) with a predefined risk value associated with each particular parameter value.
• step a) of the method at least one of three clinical parameter values, i.e. clinical laboratory test values, are determined. In other embodiments, two of these three values, or all three of these values are determined.
• the values may be determined in vitro in a sample from the individual, such as from a sample of a body fluid (e.g., blood) or a sample of a blood fraction such as serum or plasma.
• the prediction may be made using at least one parameter in group a) and one in group b); at least two parameters in group a) and no parameters in group b); and no parameters in group a) and at least two parameters in group b).
• One of the three clinical parameters to be determined is the level of C-reactive protein.
• levels of high-sensitivity (HS) CRP can be used.
• levels of CRP are determined.
• ESR erythrocyte sedimentation rate
• antibodies to CCP are determined; however, antibodies to other CCP variants such as CCPl or CCP3 may also be used.
• determination of anti-CCP antibody titers may be used in place of determination of anti-CCP positivity or negativity is step a) iii) above.
• Rheumatoid factor (RF) autoantibodies which may be any antibody type, including IgG, IgM and IgA.
• Rheumatoid factor antibody positivity is assessed.
• Rheumatoid factor antibody titer is determined.
• CCP cyclic-citrullinated peptide
• antibodies to CCP2 is determined.
• antibodies to CCPl or CCP3 are determined.
• anti-CCP antibody positivity is assessed.
• anti-CCP antibody titer is determined.
• step a) comprises providing a sample (e.g., a blood sample) of the individual and determining in vitro at least one of: i) the serum level of C-reactive protein; ii) the presence or absence of Rheumatoid factor; or, iii) the presence or absence of anti-CCP antibodies. In other embodiments, two of these or all three of these are determined. In addition, the alternative determinations described above may also be made (ESR, HS CRP, anti-CCP titers, antibodies to CCPl or CCP3, other anti-RF) Ig types.
• step b) of the method at least one of further clinical parameter values are determined comprising at least one of the age of the patient; the gender of the patient; the localization of the joint complaints; the length of the VAS morning stiffness; the number of tender joints; and, determining the number of swollen joints.
• These parameters may be determined by having the patient or healthcare professional answer a questionnaire related to the parameters. The parameters thus need not be determined on the body of the individual.
• VAS morning stiffness is rated on a visual analogue scale (0-100).
• the severity of morning stiffness is used. A 44-joint count for tender and swollen joint may be performed, scoring each joint on a 0-1 scale.
• the set of further clinical parameter values determined in step b) may include the age of the patient; the gender of the patient; the localization of the joint complaints; the length of the VAS morning stiffness; the number of tender joints; and the number of swollen joints.
• other validated instruments for scoring clinical symptoms of RA or other forms of arthritis can be used, including physician assessment of disease activity, 100mm VAS, patient's global assessment of health 100 mm VAS, DAS 28, DAS 44, HAQ, HAQ or Dl.
• a prediction score is calculated as the sum of the risk values for each parameter value.
• the individual risk values for the clinical parameters are preferably defined as between 50% and 150%, between 75% and 125%, or between 80% and 120% of the values in a) - i): a) 0 for less than 5 mg/L C-reactive protein; 0.6 for 5 - 50 mg/L C-reactive protein; 1.6 for more than 50 mg/L C-reactive protein; b) 0 for the absence of the Rheumatoid factor; 0.8 for the presence of the Rheumatoid factor; c) 0 for the absence of anti-CCP antibodies;
• the individual risk values for the clinical parameters are defined as between 75% and 125%, between 80% and 120%, between 90% and 110% of the values in a) - i): a) 0 for less than 5 mg/L C-reactive protein; 0.5 for 5 - 50 mg/L C-reactive protein; 1.5 for more than 50 mg/L C-reactive protein; b) 0 for the absence of the Rheumatoid factor; 1 for the presence of the Rheumatoid factor; c) 0 for the absence of anti-CCP antibodies;
• the risk to develop rheumatoid arthritis may be determined by correlating the prediction score for the individual with the risk associated with that prediction score in accordance with a predetermined probability distribution.
• a prediction score of about 0 correlates with a risk of about 0.0
• a prediction score of about 6-8 correlates with a risk of about 0.5
• a prediction score of about 14 correlates with a risk of about 1.0.
• An example of one predetermined probability distribution is a probability distribution as depicted in Figure 5.
• the methods described herein are applied to individuals that present with a recent-onset arthritis, such as recent-onset undifferentiated arthritis.
• Undifferentiated arthritis is herein defined as arthritis for which no differential diagnosis can be made using available classification criteria, e.g., the American College of Rheumatology (ACR) 1987 classification criteria for rheumatoid arthritis (see e.g. Arnette et al., 1988, Arthritis Rheum. 3Jj 315-324).
• An individual with recent-onset arthritis is herein defined as an individual with complaints dating from are less than one year, preferably less than 6 months.
• the method comprises the steps of: a) reading into a computer a set of at least one of the following clinical parameter values for the individual comprising: i) the serum level of C-reactive protein; ii) the presence or absence of Rheumatoid factor; and, iii) the presence or absence of anti-CCP antibodies; b) reading into the computer a set of further clinical parameter values for the individual comprising at least one of the age of the patient; the gender of the patient; the localization of the joint complaints; the length of the VAS morning stiffness; the number of tender joints; and, determining the number of swollen joints; and, c) having the computer predict the risk of the individual of developing rheumatoid arthritis; whereby the computer comprises a processor and memory, the processor being arranged to read from said memory and write into said memory, the memory comprising data and instructions arranged to provide said processor with the capacity to predict the risk of the individual of developing rheumatoid arthritis by correlating the parameter values determined in steps a
• the computer is a computer as depicted in Figure 1.
• the computer may comprise a processor and memory, the processor being arranged to read from said memory and write into said memory, the memory comprising data and instructions arranged to provide said processor with the capacity to perform a method of predicting whether an individual with undifferentiated arthritis will develop rheumatoid arthritis, wherein the method comprises at least the steps a), b) and c) as herein described above.
• the computer has an input connected to a sample analyser (for analysing body fluid samples, such as e.g.
• the processor is arranged for determining from said analysis data signals: i) the serum level of C-reactive protein; ii) the presence or absence of Rheumatoid factor; and, iii) the presence or absence of anti-CCP antibodies of said sample as clinical parameters.
• the processor may be arranged for calculating a prediction score as the sum of the risk values for each parameter value.
• the processor is arranged for determining the predicted risk for the individual on developing rheumatoid arthritis by correlating the prediction score for the individual with the risk associated with that prediction score in accordance with a predetermined probability distribution as described herein above.
• a sample analyser comprising a computer as described herein above.
• the sample analyser may be an analyser for samples of a body fluid, such as a blood samples or a samples of a blood fraction such as serum or plasma.
• the invention relates to a computer program product comprising data and instructions and arranged to be loaded in a memory of a computer that also comprises a processor, the processor being arranged to read from said memory and write into said memory, the data and instructions being arranged to provide said processor with the capacity to perform a method of predicting whether an individual with undifferentiated arthritis will develop rheumatoid arthritis.
• the method may comprise at least the steps a), b) and c) as herein described above.
• the invention relates to a data carrier provided with this computer program product.
• a patient or healthcare professional enters clinical parameters (b), and one or more laboratory values (a) via entry of data through a web portal, and receives a determination of risk of developing rheumatoid arthritis either through the web portal or sent via email, fax or regular mail.
• Figure 1 shows a schematic example of an embodiment of a computer as may be used in one or more of the embodiments described.
• Figure 2 schematically depicts a flow diagram of a procedure as may be executed by the computer of Figure 1 according to an embodiment of the invention.
• Figure 3 illustrates an exemplary table storing exemplary risk values that are associated with ranges of parameter values for several clinical parameters.
• Figure 4 illustrates and exemplary form that may be used in order to calculate risk values associated with particular parameter values.
• Figure 5 is a graph illustrating a predicted risk of developing rheumatoid arthritis as a function of the total risk value
• Figure 6 illustrates an exemplary table storing exemplary total risk values associated with predicted risk scores.
• the methods described herein are directed to predicting whether an individual with undifferentiated arthritis will develop rheumatoid arthritis.
• One such method comprises the steps of: a) determining for the individual at least one of the following clinical parameter values: i) the level of C-reactive protein (CRP), high-sensitivity C-reactive protein (HS CRP) or erythrocyte sedimentation rate (ESR); ii) the presence or absence of Rheumatoid factor autoantibodies or
• Rheumatoid factor autoantibody titers and, iii) the presence or absence of anti- cyclic citrullinated peptide (CCP) antibodies or anti-CCP antibody titers; b) determining a set of further clinical parameter values comprising at least one of the age of the patient; the gender of the patient; the localization of the joint complaints; the length of the VAS morning stiffness; the number of tender joints; and, determining the number of swollen joints; and, c) predicting the risk of the individual of developing rheumatoid arthritis by correlating the parameter values determined in steps a) and b) with a predefined risk value associated with each particular parameter value.
• CCP cyclic citrullinated peptide
• step a) of the method at least one of three clinical parameter values, i.e. clinical laboratory test values, are determined. In other embodiments, two of these three values, or all three of these values are determined.
• the predictive method may use at least one parameter from group a) and one parameter from group b); at least two parameters from group a) and none from group b); or none from group a) and at least two from group b).
• the values may be determined in vitro in a sample from the individual, such as from a sample of a body fluid (e.g., blood) or a sample of a blood fraction such as serum or plasma.
• CRP C-reactive protein
• ESR erythrocyte sedimentation rate
• Rheumatoid factor is an autoantibody which is directed against endogenous immunoglobulin, for example IgG
• Rheumatoid factor are usually antibodies of the IgM class, although other isotypes may also be determined (e.g. IgG, IgA) in any of the methods described herein.
• RF is considered to be present in a sample from an individual upon demonstration of abnormal amount of serum RF by any method for which the result has been positive in less than 5% of normal subjects. Suitable assays for determining the level of RF are known in the art.
• Rheumatoid factor antibody positivity is assessed.
• Rheumatoid factor antibody titer is determined.
• CCP cyclic-citrullinated peptide
• CCP types include, for example, CCPl, CCP2 and CCP3.
• CCP2 is determined.
• antibodies to CCP are considered to be present in a sample from an individual in case of at least 25 arbitrary units in the ELISA, Immunoscan RA Mark 2 (obtainable from Euro-Diagnostica, Arnhem, The Netherlands).
• Other suitable tests for anti-CCP positivity are described by van Venrooij and van de Putte (2003, Ned Tijdschr Geneeskd. 147(5): 191-4).
• anti-CCP antibody positivity is assessed.
• anti-CCP antibody titer is determined.
• step a) comprises providing a sample (e.g., a blood sample) of the individual and determining in vitro at least one of the following clinical parameters: i) the serum level of C-reactive protein; ii) the presence or absence of Rheumatoid factor; or iii) the presence or absence of anti-CCP antibodies.
• step b) of the method at least one of further clinical parameter values are determined comprising at least one of the age of the patient; the gender of the patient; the localization of the joint complaints; the length of the VAS morning stiffness; the number of tender joints; and, determining the number of swollen joints.
• These parameters may be determined by having the patient or healthcare professional answer a questionnaire related to the parameters. The parameters thus need not be determined on the body of the individual.
• VAS morning stiffness patients are asked to rate the morning stiffness on a visual analogue scale (0-100) whereby preferably the severity of morning stiffness was used instead of duration of morning stiffness (Hazes et al, 1993 J Rheumatol 20:1138-42; Vliet Vlieland et al., 1997, J Clin Epidemiol 50:757-63).
• the set of further clinical parameter values determined in step b) may include the age of the patient; the gender of the patient; the localization of the joint complaints; the length of the VAS morning stiffness; the number of tender joints; and the number of swollen joints.
• a prediction score is calculated as the sum of the risk values for each parameter value.
• the individual risk values for the clinical parameters are preferably defined as between 50% and 150%, between 75% and 125%, or between 80% and 120% of the values in a) - i): a) 0 for less than 5 mg/L C-reactive protein; 0.6 for 5 - 50 mg/L C-reactive protein; 1.6 for more than 50 mg/L C-reactive protein; b) 0 for the absence of the Rheumatoid factor;
• the individual risk values for the clinical parameters are defined as between 75% and 125%, between 80% and 120%, or between 90% and 110% of the values in a) - i): a) 0 for less than 5 mg/L C-reactive protein; 0.5 for 5 - 50 mg/L C-reactive protein; 1.5 for more than 50 mg/L C-reactive protein; b) 0 for the absence of the Rheumatoid factor;
• the risk to develop rheumatoid arthritis may be determined by correlating the prediction score for the individual with the risk associated with that prediction score in accordance with a predetermined probability distribution.
• a prediction score of about 0 correlates with a risk of about 0.0
• a prediction score of about 6-8 correlates with a risk of about 0.5
• a prediction score of about 14 correlates with a risk of about 1.0.
• An example of a preferred predetermined probability distribution is a probability distribution as depicted in Figure 5.
• the methods described herein are applied to individuals that present with a recent-onset arthritis, more preferably with recent-onset undifferentiated arthritis.
• a method of predicting whether an individual with undifferentiated arthritis will develop rheumatoid arthritis comprises the steps of: a) reading into a computer a set of clinical parameter values for the individual comprising: i) the serum level of C-reactive protein; ii) the presence or absence of Rheumatoid factor; and, iii) the presence or absence of anti-CCP antibodies; b) reading into the computer a set of further clinical parameter values for the individual comprising at least one of the age of the patient; the gender of the patient; the localization of the joint complaints; the length of the VAS morning stiffness; the number of tender joints; and, determining the number of swollen joints; and, c) having the computer predict the risk of the individual of developing rheumatoid arthritis; whereby the computer comprises a processor and memory, the processor being arranged to read from said memory and write into said memory, the memory comprising data and instructions arranged to provide said processor with the capacity to predict
• Figure 1 shows a schematic example of an embodiment of a computer 10 as may be used in one or more of the embodiments described herein.
• the computer 10 comprises a processor 12 for performing arithmetical operations.
• the processor 12 is connected to memory units that may store instructions and data, such as a tape unit 13, hard disk 14, a Read Only Memory (ROM) 15, Electrically Erasable Programmable Read Only Memory (EEPROM) 16 and a Random Access Memory (RAM) 17.
• the processor 12 is also connected to one or more input devices, such as a keyboard 18 and a mouse 19, one or more output devices, such as a display 20 and a printer 21, and one or more reading units 22 to read for instance floppy disks 23 or CD ROM's 24.
• the computer system 10 comprises program lines readable and executable by the processor 12.
• the computer 10 shown in Figure 1 may also comprise an input output device (I/O) 26 arranged to communicate with other computer systems (not shown) via a communication network 27.
• sample analyser 32 is in data communication with the network 27.
• a local sample analyser 30 is located proximate the computer 10 and a remote sample analyser 32 is positioned remote from the computer 10 and may be in communication with the computer 10 via the network 27.
• any number of sample analysers 30, 32 may be in communication with the computer 10.
• the system does not include a local sample analyser 30, but comprises multiple remote sample analysers 32.
• a server 40 is also in data communication with the network 27.
• the server 40 stores data received from the sample analyser 30,32 and provides this data to the computer 10.
• the server 40 and/or the sample analyser 30,32 are configured to perform operations on data determined by the sample analyser 30,32 in order to determine a predicted risk of an individual developing rheumatoid arthritis, such as by using the systems and methods described below.
• the following description refers to the computer 10 as the device that performs calculations in order to determine a predicted risk of developing rheumatoid arthritis.
• any other computing device, such as the sample analyser 30,32 or the server 40 may also be configured to perform these operations and determine a predicted risk of developing rheumatoid arthritis.
• the computer 10 accesses information and software executing on the server 40 via a graphical user interface, such as a web browser, that is displayed on the display device 20.
• a graphical user interface such as a web browser
• the computer 10 provides an interface for viewing, such as by a physician, data from the sample analyser 30 that is stored on the server 40.
• the user interface that is displayed on the display device 20 may include data received from the sample analyser 30 via the network 27.
• the computer 10 comprises more and/or other memory units, input devices and read devices than are illustrated in Figure 1. Moreover, one or more of them may be physically located remote from the processor 12, if required.
• the exemplary processor 12 is shown as one box, however, it may comprise several processing units functioning in parallel or controlled by one main processor unit that may be located remote from one another, as is known to persons skilled in the art.
• the computer 10 is shown as a computer system, but can be any signal processing system with analog and/or digital and/or software technology arranged to perform the functions discussed here.
• the detailed description as given above for the computer 10, may refer to several kind of devices, such as personal computers, servers, laptops, personal digital assistance (PDA), palmtops. All these devices are different kind of computer systems.
• PDA personal digital assistance
• the memory units 13, 14, 15, 16, 17 may comprise program lines readable and executable by the processor 12.
• the programming lines may be such that they provide the computer 10 with the functionality to perform one or more of the methods described below.
• the computer 10 may be connected to a sample analyser 30, 32 by a communication link.
• the sample analyser 30, 32 may be arranged to receive a blood sample, or other biological sample, from an individual and perform measurements on this blood sample.
• the sample analyser 30, 32 may, for instance, be arranged to determine a set of clinical parameter values from the blood sample including: i) the serum level of C-reactive protein; ii) the presence or absence of Rheumatoid factor; and/or, iii) the presence or absence of anti-CCP antibodies.
• computer 10 is arranged for receiving data- signals relating to measurements of a blood sample from the sample analyser 30, 32 so as to determine clinical parameter values for a set of clinical parameters, such as the parameters i) - iii) noted above.
• the connection between the computer 10 and the sample analyser 30 comprises a wired and/or wireless two-way communication link, such as via a direct wired or wireless connection 32 or via the network 27.
• the computer 10 may also comprise multiple connections, each to one of the different sample analysers 30.
• the computer 10 may be arranged to read the at least one clinical parameter as determined by the sample analyser 30, 32, and store the at least one clinical parameter in the memory units 13, 14, 15, 16, 17.
• the computer 10 may also determine the at least one clinical parameter by reading the at least one clinical parameter from memory 13, 14, 15, 16, 17, or from input devices, such as keyboard 18 and mouse 19, or from one or more reading units 22 to read for instance floppy disks 23 or CD ROM's 24.
• the computer 10 may further be arranged to receive a set of further clinical parameter values comprising at least one of the age of the patient; the gender of the patient; the localization of the joint complaints; the length of the VAS morning stiffness; the number of tender joints; and, a number of swollen joints, for example.
• fewer or additional further clinical parameters may be received by the computer 10 and used in developing a predicted risk of developing rheumatoid arthritis.
• the further clinical parameter values are entered into the computer 10 using one or more input devices, such as a keyboard and/or a mouse, in response to information displayed in a graphical user interface that is displayed on the display device 20.
• a graphical user interface may be configured to prompt a user to enter each of a plurality of clinical parameter values.
• each of the entered clinical parameter values are usable to determine a predicted risk of developing rheumatoid arthritis.
• selected clinical parameter values are used in determining a predicted risk of developing rheumatoid arthritis (referred to herein as a "predicted risk").
• a confidence level in the predicted risk increases as the number of clinical parameter values that are entered into the graphical user interface, and are processed by the computer 10, increases.
• the confidence level of the predicted risk may increase as additional clinical parameter values are received and considered in developing the predicted risk.
• the computer 10 may be arranged to read these further parameter values from memory 13, 14, 15, 16, 17, from input devices, such as keyboard 18 and mouse 19, or from one or more reading units 22 to read for instance floppy disks 23 or CD ROM's 24.
• the computer 10 may be arranged to determine a predicted risk of the individual developing rheumatoid arthritis by correlating at least two of the clinical parameter values with a predefined risk value associated with each particular parameter value.
• the predicted risk score may be outputted by the computer 10 using one or more output devices, such as display 20 and printer 21.
• computer 10 may be arranged for transmission of the predicted risk value over the network 27 to another computer system (not shown).
• the predicted risk is transmitted to a remote computing system and displayed to a user via a graphical user interface.
• the predicted risk is transmitted via e-mail to the individual, a physician, and/or another computing system.
• the predicted risk may be transmitted via facsimile or printed and delivered to the individual and/or physician.
• the risk values associated with each of the clinical parameter values and the total risk value for the individual are also transmitted from the computer 10 to another computing device.
• the predicated risk is stored on the server 40 and is accessible to users with proper authorization to view the predicted risk, such as the individual and the individual's healthcare providers.
• Figure 2 schematically depicts a flow diagram of a procedure as may be executed by computer 10, or other computing device, according to an embodiment of the invention. Depending on the embodiment, certain of the actions described below may be removed, others may be added, and the sequence of actions may be altered.
• a first action 100 the computer 10 starts executing the procedure. This action may for instance be triggered by input from a user into a graphical user interface displayed on the display device 20.
• the computer 10 determines at least one clinical parameter using sample analyser 30, 32.
• This action may comprise the steps of 101a) the processor 12 requesting the sample analyser 30, 32 to output data-signals relating to the measured values of a blood sample to the processor 12; 101b) the processor 12 receiving the data-signals, and 101c) the processor 12 (optionally) storing the data-signals relating to the measured values in memory 13, 14, 15, 16, 17.
• the data-signals that are received from the sample analyser 30, 32 comprise parameter values associated with each of one or more clinical parameters, such as, for example, a parameter value indicating a serum level of C-reactive protein in the blood sample and a parameter value indicating presence or absence of Rheumatoid factor in the blood sample.
• action 101a) may also comprise that the processor 12 requests the sample analyser 30, 32 to perform certain measurements on the blood sample relating to determining a set of clinical parameter values, such as clinical parameters values for clinical parameters i) - iii) discussed above before transmitting the data-signals.
• the processor 12 determines at least one of the further clinical parameter values using one or more input devices as described above, or alternatively, from associated data already stored in memory 13, 14, 15, 16, 17.
• the further clinical parameter values may be entered into a computing device, such as computer 10, via a graphical user interface.
• the further clinical parameter values are entered into the computer 10 by a caregiver in response to comments from the individual.
• a user interface is accessible to the individual via a computer in communication with the network, so that the individual may enter the further clinical parameter values for use in this method.
• the computer 10 determines a predicted risk of an individual developing rheumatoid arthritis by correlating each of at least two of the clinical parameter values and further clinical parameter values determined in action 101 and 102 above with predefined risk values that are associated with each particular parameter value. These risk values may then be combined in order to determine a total risk value for the individual. Finally, the total risk value may be associated with a predicted risk of the individual developing rheumatoid arthritis.
• ranges of values for each of the clinical parameter values are associated with particular risk values.
• risk values for particular clinical parameters are determined according to formulas specific to each clinical parameter.
• the total risk value is the sum of each of the risk values that have been associated with the clinical parameter values. In other embodiments, the total risk value may be calculated using only a portion of the risk values.
• ranges of total risk values are each associated with a predicted risk that the individual will develop rheumatoid arthritis.
• the number of ranges of total risk values and the granularity of the predicted risks associated with the ranges may very depending on the application. For example, in one embodiment only two ranges of total risk values are used, where total risk values that are within a first range are associated with predicted risks indicating that an individual is likely to develop rheumatoid arthritis, and total risk values that are within a second range are associated with predicted risks indicating that the individual is not likely to develop rheumatoid arthritis.
• total risk values are associated with one of three predicted risks, such as low, moderate, and high risks of developing rheumatoid arthritis.
• total risk values are each associated with one of a plurality, such as 5, 10, 15, or 20, for example, of different predicted risk scores.
• the predicted risk scores are expressed as a percentage chance that the individual will develop rheumatoid arthritis.
• the predicted risk is determined based on a formula in which the total risk value is a factor.
• ranges of total risk values may not be necessary as each total risk value may result in a different predicted risk.
• the predefined risk values associated with parameter values, or ranges of parameter values may be stored in memory 13, 14, 15, 16, 17 and retrieved from memory 13, 14, 15, 16, 17 by the processor 12 or may be received using input devices as described above.
• the computer 10 outputs the computed predicted risk of an individual of developing rheumatoid arthritis by using one or more output devices, such as display 20 and printer 21 or by transmission of the computed predicted risk to another computer system (not shown), such as via email or storage of the predicted risk on a server that is accessible to other users. Also, the computer 10 may store the computed predicted risk, and/or the risk values and total risk values, in memory 13, 14, 15, 16, 17 or on the server 40.
• action 105 the execution of procedure ends. If needed, the procedure may be resumed at action 101 to execute once more.
• the sample analyser 30, 32 and/or the server 40 comprises a computer, having the components such as those described above with reference to computer 10, that is configured to perform the procedure described in Figure 2.
• the sample analyser 30, 32 and/or server 40 are capable of computing a predicted risk score of the individual developing rheumatoid arthritis by correlating at least two of the clinical parameter values determined above with a predefined risk value associated with each particular parameter value.
• Figure 3 is a table 300 illustrating exemplary risk values that are associated with ranges of parameter values for several clinical parameters.
• risk values are associated with each of nine clinical parameters. In other embodiments, fewer or more clinical parameters may be associated with risk values.
• the table 300 may advantageously be stored in a memory device and accessed by the computer 10 in order to determine risk values for any of the listed parameters.
• the table 300 may be stored in a memory of the computer 10, at the server 40, or at the sample analyser 30, 32.
• the table 300 is converted to a worksheet format, such as will be discussed below with reference to Figure 4, that may be printed or viewed in a graphical user interface.
• a first column 310 lists clinical parameters
• a second column 320 lists possible parameter values associated with each of the clinical parameters
• a third column 330 lists a risk value that is associated with respective ranges of parameter values.
• each of the risk values assigned to an individual are summed in order to determine a total risk value that will be associated with a predicted risk of the individual developing rheumatoid arthritis.
• Risk Values and Total Risk Value for Individual A are exemplary parameter values for two individuals, individual A and individual B, and the associated risk values assigned to the individuals using the table 300.
• the total risk value for individual A is 7.5, while the total risk value for individual B is 10.
• a higher total risk value indicates a higher risk of developing rheumatoid arthritis.
• individual B is more likely to develop rheumatoid arthritis than individual A.
• lower total risk scores may indicate lower risks of developing rheumatoid arthritis.
• these total risk values may now each be associated with a corresponding predicted risk of the individual developing rheumatoid arthritis.
• each of the parameter values for the individuals are entered into a computing device, such as the computer 10 via a graphical user interface, and the computing device determines the risk values associated with each of the parameter values such as by accessing table 300 stored in a memory.
• a user manually selects the risk values associated with particular parameter values and calculates a total risk value.
• Figure 4 illustrates an exemplary checklist 400 that may be used to record clinical parameter values and associate risk values with each of the clinical parameter values.
• a user such as a physician, records information regarding the patient on the checklist 300, and assigns risk values to each of the parameter values associated with the particular parameter value.
• specific parameters, as well as specific risk values associated with each of the parameters are used in determining the total risk value for the individual. However, in other embodiments fewer or more parameters may be used in order to determine a total risk value. Additionally, the risk values associated with parameter values may be higher or lower depending on the specific implementation. For example, in an embodiment that uses only a portion of the parameters listed in Figure 3, the risk values associated with certain parameter values may be adjusted.
• Figure 5 is a graph illustrating a predicted risk of developing rheumatoid arthritis as a function of the total risk value.
• the vertical axis represents a predicted risk of an individual developing rheumatoid arthritis
• the horizontal axis represents an individual's total risk value.
• a total risk value may be associated with a predicted risk using the graph of Figure 5.
• individual A may be assigned a predicted risk of about 60% (see intersection at about point 510).
• a risk score of 60% indicates that the individual has a 60% chance of developing rheumatoid arthritis.
• individual B was assigned a total risk value of 10, which corresponds with a predicted risk of about 90% (see intersection at about point 520). Thus, in this embodiment individual B has about a 90% risk of developing rheumatoid arthritis.
• predicted risk data may be expressed as an algorithm that converts a total risk value to a predicted risk.
• the algorithm may automatically convert the total risk value to a percentage predicted risk that the individual develops rheumatoid arthritis.
• the algorithm calculates the predicted risk after each of the parameter values are entered into, or received by, the computer 10.
• the computer 10 is configured to execute an algorithm to determine a predicted risk score after entry of each parameter value. Accordingly, a physician or user entering parameter values may watch the predicted risk change as additional parameter values are entered into the computer 10.
• Figure 6 illustrates a table 600 storing exemplary total risk values associated with predicted risk scores.
• a total risk value of less than four is associated with a predicted risk score of "low", indicating that the individual has a low predicted risk of developing rheumatoid arthritis.
• a total risk value of greater than 10 is associated with a predicted risk score of "high”, while total risk values in the range of 4-10 are associated with a predicted risk or of "moderate.”
• predicted risk scores illustrated are exemplary, and are not intended to limit the scope of predicted risk scores that may be used in conjunction with the systems and methods described herein.
• the predicted risk scores may be numerical, such as percentages.
• the predicted risk scores may be analogous to grades, such as giving the individual a grade from A-F, where A indicates a very low risk of developing rheumatoid arthritis and F indicates a very high risk of developing rheumatoid arthritis.
• any other type of predicted risk score may be associated with a total risk value and provided to an individual.
• a predicted risk score model was derived using the Leiden Early Arthritis Clinic, an inception cohort containing more than 1900 patients with recent-onset arthritis of whom about 1700 have completed at least one-year follow-up. This cohort started in 1993 at the department of Rheumatology of the Leiden University Medical Center, the only referral center for rheumatology in a health care region of -400,000 inhabitants in the Netherlands. General practitioners were encouraged to refer patients directly when arthritis was suspected; patients were included if physical examination revealed arthritis. At first visit various variables were collected. The rheumatologist answered a questionnaire inquiring about the initial symptoms as reported by the patient: type, localization and distribution of initial joint symptoms, symptom duration and course of start complaints. The smoking and family history were assessed.
• HAQ Health Assessment Questionnaire
• RA RA-patients that did or did not develop RA were compared using the Chi- square test for nominal variables and the student's t-test for continuous variables. Symptom duration was categorized. Subsequently all clinical variables were entered as possible explanatory variables in a logistic regression analysis with the disease outcome (RA or non-RA) at one-year follow-up as the dependent variable. Using a backward selection procedure, the most significant independent variables were identified, using p>0.10 as the removal criteria. In the logistic regression model the predicted probability of RA is related to the covariates via the predictive index: Bl*xl+B2*x2+B3*x3...Bk*xk.
• the B (regression coefficient) of the covariate indicates an estimate of the relative magnitude of the prognostic power of the concerning variable.
• the predictive index for every subject the predicted probability of RA development was calculated.
• For continuous variables (age, VAS- score, tender and swollen joint count, CRP) the effect was studied both as continuous variables and as categorized. Categories were pooled if corresponding regression coefficients were similar. Data on VAS morning stiffness were missing in 160 subjects, data on anti-CCP antibodies in 64 subjects and data on disease duration in 22 subjects. To prevent exclusion of these subjects from the logistic regression analysis, the median value was imputed.
• ROC receiver-operating characteristic
• Morning stiffness mean ⁇ SD 35.5 ⁇ 30.0 53.3 ⁇ 30.1 ⁇ 0.001
• ESR level (mm1 st hr), median (IQR) 17(8-38) 32(19-53) O.001
• HAQ score mean ⁇ SD 0.7 ⁇ 0.6 1.0 ⁇ 0.7 O.001
• Smoking, n(%) 187(48) 84 (47) 1.0
• the resulting model had a fraction of explained variation (Nagelkerke R ) of 0.57 and, when taking a predicted probability of 0.5 as cut off value, predicted 83% of patients correctly.
• the coefficients for the simplified total risk value are listed in Table 2.
• the computing device determines total risk values for an individual using the coefficients indicated in Table 2.
• a worksheet may be used to calculate a total risk value from multiple risk values.
• the total risk value ranges between 0 and 14; a higher score indicates a higher risk to develop RA.
• the total risk value was calculated.
• all UA patients with a total risk value ⁇ 3 did not progress to RA during the one-year follow-up, and all UA patients with a score >11 had progressed to RA during that same period.
• the patients with intermediate scores (4-10) had progressed to RA in increasing frequency at rising scores.
• Cross-validation was used to control for over-fitting. This procedure yielded for every patient a predicted probability of RA, based on the model developed using another patient cohort. The AUC of the cross-validated predictions nearly equalled the AUC of the total risk value: 0.87 (SE 0.015), indicating that over- fitting is not a major problem.
• the outcome of a prediction rule is the diagnosis RA or disease persistence, as the ACR criteria are formulated based on RA patients with longstanding/persistent disease (mean disease duration 8 years) and the reported remission rate in these patients is low: 10-15%. Misclassification may have occurred when patients who presented with UA were treated with any drug that has hampered the progression to RA. In case of misclassification, patients that would normally have progressed to RA would now be classified as non-RA. Exclusion of these misclassified patients, with supposedly high total risk values as they would be prone to develop RA, would result in an increased discriminative ability of the current prediction rule.
• the positive and negative predictive values of the total risk value depend on the chosen cut-off levels. If the upper and lower cut-off values were 8.0 and 6.0, the corresponding positive predictive value and negative predictive value were respectively 84% and 91%. In the original cohort 25% of patients had a total risk value between 6.0 and 8.0; these patients had an equal chance to develop RA or not. In the validation cohort, the total risk value discriminated even better: a hundred percent of patients with a total risk value of 8.0 or higher had progressed to RA and 94% of patients with a total risk value of 6.0 or lower did not develop RA.
• Nell V Machold KP, Eberl G, Stramm TA, Uffman M, Smolen JS. Benefit of very early referral and very early therapy with disease-modifying antirheumatic drugs in patients with early rheumatoid arthritis. Rheumatology (oxford) 2004;43:906-14.
• Vliet Vlieland Th P Zwinderman AH
• Breedveld FC Hazes JM. Measurement of morning stiffness in rheumatoid arthritis clinical trials. J Clin Epidemiol 1997;50:757- 63.
• Van Zuiden Van Riel PL, van Gestel AM, Scott DG. In EULAR handbook of clinical assessments in rheumatoid arthritis. Alphen aan den Rijn, The Netherlands: Van Zuiden
• Van der Heijde DM Plain X-rays in rheumatoid arthritis: overview of scoring methods, their reliability and applicability. Baillieres Clin Rheumatol. 1996; 10:435-53. 16. Harrell FE, Lee KL, Mark DB. Multivariate prognostic models, evaluating assumptions and accuracy, and measuring and reducing errors. Stat Med. 1996; 15:361- 87.

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