Outpatient Rheumatology Research Articles

Male rheumatoid arthritis patients at substantially higher risk for cardiovascular mortality in comparison to women

BackgroundPatients with rheumatoid arthritis (RA) are at an increased risk for developing cardiovascular diseases. While advice regarding cardiovascular risk screening and management in RA patients has been incorporated in several guidelines in recent years, its implementation and adherence is still poor. ObjectivesTo assess the cardiovascular disease risk in new diagnosed RA patients and evaluate whether advice to initiate preventive medical treatment of high risk patients was followed. MethodsAll patients with a recent diagnosis of RA, aged 40–70 years, were screened between May 2019 and December 2022 for cardiovascular diseases and risk factors within the first year after diagnosis at the outpatient rheumatology clinic, as part of standard care. Screening included a physical examination with blood pressure measurement, and laboratory tests with lipid profile tests. All patients and their general practitioner (GP) received an overview with their cardiovascular risk profile and a calculated 10-year cardiovascular mortality risk. Cardiovascular risk was defined as low (<1%), intermediate (1–5%), high (5–10%) and very high (>10%). The national pharmacy network was consulted to check whether or not patients started preventive medication after screening. ResultsA total of 125 RA patients was included in this study. The mean age was 56 years and 78% was female. Median RA disease duration at screening was 6 months. Six patients (5%) indicated to have been screened before, and used antihypertensive medication. During screening, hypertension was found in 57% of male patients and 43% of female patients and dyslipidemia was found in 36% in male and 32% in female patients. 46% of male patients and 21% of female patients currently smoked. A high or very high 10-year cardiovascular mortality risk was found in 50% of male patients, but in only 4% of female patients. Only 26% of (very) high risk patients started antihypertensive or statin medication after screening. ConclusionsAn increased cardiovascular disease risk is often present in newly diagnosed RA patients, especially male patients, with a large proportion having undiagnosed and untreated hypertension and hypercholesterolemia. Even with structural screening and informing of the patients and GPs, treatment of cardiovascular risk factors in high risk patients remains insufficient. CV risk screening needs to be part of standard care for RA patients, with clear agreement on the responsibilities between primary and secondary care. Awareness of the importance of CVD risk screening needs to improve among both RA patients themselves and the GPs to ultimately reduce the cardiovascular burden of our patients. Obviously, a better collaboration between GPs and rheumatologists is urgently needed to lower the cardiovascular burden of our patients.

Virgin Coconut Oil in Paste Form as Treatment for Dyspareunia and Vaginal Dryness in Patients With and Without Rheumatic Autoimmune Diseases: An Efficacy and Safety Assessment Pilot Study.

Introduction The use of virgin coconut oil (VCO) as an over-the-counter (OTC) treatment for vaginal dryness and dyspareunia (VDD) in the general population has increased worldwide despite the absence of evidence-based studies supporting its efficacy. The principal objective of our pilot study was to scientifically validate the significant benefits and safety of using intra- and peri-vaginal application of VCO in paste form (VCOPF)for the treatment of VDDin patients with and without rheumatic autoimmune diseases (RAD). Additionally, multiple psychosocial, sexuality, and disease activity variables were also assessed. Methods A survey study of patients with chronic VDD, with and without RAD, treated with a single proprietary brand of VCOPF via the 'CocoRelief' protocolcontinuously for at least six months in an outpatient rheumatology practice setting. We evaluated the comparison of group characteristics, treatment outcomes, and satisfaction questions by Fisher's exact test or chi-square test for independence for categorical variablesand two-sample t-tests for continuous variables. Results Of the 53 respondents, 31 (58%) had an RAD and 22 (42%) did not. Rheumatoid arthritis and primary Sjogren's syndrome comprised 75% of the RAD group. The non-RAD cohort had both a higher baseline mean of intercourse pain (on a scale of 0-5) before VCOPF use (4.4 (SD 1.1) vs 3.9 (SD 1.0)(p = 0.094)) and a higher mean intercourse pain after VCOPF (2.0 (SD 1.3) vs 1.3 (SD 1.1) (p = 0.039)). VDD decreased by 55% in the non-RAD and 66% in the RAD population. Although not statistically significant (p = 0.195), VCOPF was at worst comparable to estrogen-containing therapies (ECT). No adverse events (AE) were documented. Conclusion A high percentage of women with VDD, with and without RAD, needlessly continue to experience quality-of-life-altering physical and psychosocial morbidity due to the underutilization and lack of awareness of VCO-containing therapy. The small sample size, non-blinded, non-randomized, pilot platform, and the use of a non-validated assessment toolrepresentthe principal limiting factors. This study revealed that VCOPF, when used in paste form via the CocoReliefprotocol, provided statistically significant long-term VDD-related efficacy not inferior to ECT without AE in patients with and without RAD. VCOPF is, therefore, likely to be a useful, cost-effective alternative in a substantial percentage of patients with and without RAD, particularly in women hesitant to utilize ECT due to cost and/or fear of adverse effects.

Predicting physical activity and sarcopenia-related health outcomes in women with rheumatoid arthritis: A test of the self-determination theory.

This study aimed to examine a hypothetical model of physical activity (PA) and health outcomes related to sarcopenia in women with rheumatoid arthritis (RA) based on self-determination theory. Cross-sectional study. This study included 214 women diagnosed with RA from the outpatient rheumatology department of a university-affiliated hospital in South Korea. Data were collected from September 2019 to August 2020 through structured questionnaires and anthropometric measurements and analysed using path analysis to test the hypothesized model. The primary health outcomes were perceived health status and sarcopenia-related health (thigh circumference, handgrip strength and sarcopenia risk). The final model's fit indices were adequate. Physical activity was directly affected by motivation for PA, while depression, self-efficacy for PA, health care provider's autonomy support and basic psychological needs satisfaction indirectly affected PA. Physical activity directly affected perceived health status and thigh circumference, while perceived sarcopenia risk and handgrip strength were directly affected by disease activity and age. Patients were involved in a questionnaire-based survey.

Cardiovascular risk factors among Jordanian patients with rheumatoid arthritis: A cohort study.

To determine the frequency of risk factors for cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) in Jordan. During this study, 158 patients with RA were enlisted from the outpatient rheumatology clinic at King Hussein Hospital of the Jordanian Medical Services, from 1 June 2021, to 31 December 2021. Demographic data and disease duration were recorded. After 14 h of fasting, venous blood samples were drawn to determine the levels of cholesterol, triglyceride, high-density lipoprotein, and low-density lipoprotein. History of smoking, diabetes mellitus, and hypertension was recorded. Body mass index and Framingham's 10-year risk score (FRS) were calculated for each patient. Disease duration was noted. The mean age of the male population was 49.29 years and that of the female population was 46.06 years. Most of the study population were female (78.5%) and 27.2% of the study population had one modifiable risk factor. The most frequent risk factors observed in the study were obesity (38%) and dyslipidemia (38%). Diabetes mellitus was the least frequent risk factor, with a frequency of 14.6%. The FRS differed significantly between the sexes, with the risk score of men being 9.80, whereas that of women was 5.34 (p < .00). Regression analysis revealed that age increased the odds ratio of diabetes mellitus, hypertension, obesity, and a high-to-moderate FRS by 0.7%, 10.9%, 0.33%, and 10.3%, respectively. Rheumatoid arthritis patients have increased chances of developing cardiovascular risk factors leading to cardiovascular events.

The Prevalence of Dry Eye Syndrome in Rheumatoid Arthritis Patients in Saudi Arabia

STUDY AIM: The purpose of this study is to identify the prevalence of dry eye syndrome among Rheumatoid Arthritis patients in the Kingdom of Saudi Arabia.&#x0D; &#x0D; METHODS: This is a cross sectional study which includes 268 Rheumatoid Arthritis patients from Rheumatology Outpatient Clinic at King Khalid University Hospital in Riyadh, Kingdom of Saudi Arabia. Data collection was obtained through McMonnies questionnaire, which is used for dry eye syndrome screening. Data analysis included descriptive statistics computed for continuous variables, including means, standard deviation, minimum and maximum values, as well as 95% confidence interval (CI).&#x0D; &#x0D; RESULTS: Out of 268 Rheumatoid Arthritis patients, 79.9% were females and 20.1% were males, as Rheumatoid Arthritis is more common in females. Among females, a majority lied above the age of 45 with a percentage of 70.6%. Among our cohort, 59.3% (95% CI: 53.3&amp;ndash;65) of Rheumatoid Arthritis patients had dry eye syndrome with 12.6% males and 87.4% females. The prevalence of dry eye syndrome was significantly associated with the duration of diagnosis of Rheumatoid Arthritis as 66.7% of patients who are diagnosed for more than 10 years had dry eye syndrome.&#x0D; &#x0D; CONCLUSION: In our cohort, 59.3% of patients had dry eye syndrome and 47.4% of them were aged above 45 years and 11.9% were between 25-45 years old. Females were more commonly affected with dry eye syndrome with a percentage of 87.4%. Therefore, screening for Dry Eye Syndrome in RA patients has a significant clinical value.

Beliefs, Experiences, and Openness Regarding Dietary Interventions: Data From an Urban Hispanic Population With Rheumatic Disease in the US.

To obtain descriptive data on the beliefs, behaviors, and openness regarding dietary changes for rheumatic diseases in an urban US Hispanic patient population with rheumatic disease as foundational data for future intervention design. We distributed a voluntary survey to our primarily Hispanic population at an outpatient rheumatology clinic for 19 weeks. This survey queried individuals' behaviors as they related to dietary intake used for the treatment of rheumatic disease, perceptions of the effect of food groups on rheumatic disease activity, barriers to physician-recommended diets, and willingness to try future interventions. We used descriptive statistics and Pearson's chi-square test to evaluate associations. More than 40% of survey respondents from our primarily (88%) Hispanic population noted a link between what they ate and their underlying rheumatic disease activity. More than one-third of patients had, at some point, modified dietary intake to affect their rheumatic disease. Vegetables, fruit, and white meats were commonly reported to improve disease, while red meat and processed foods were reported to worsen disease. Barriers to following a prespecified diet included cost and lack of knowledge. More than 70% of respondents indicated willingness to attempt certain eating patterns should it help their underlying rheumatic disease. In this primarily Hispanic rheumatic disease patient population, many have not only noted a correlation between dietary intake and rheumatic disease activity but are also open to future nutrition-related interventions. As this population experiences poor rheumatic disease outcomes and a high rate of lifestyle-related comorbidities, an intervention to optimize healthy eating patterns would likely be beneficial as well as acceptable.

Accessibility to and awareness of rheumatology care provided by a nurse - a pilot study

Good medical care depends both on the access to specialists and awareness of patients and healthcare professionals. The purpose of this study was to assess the accessibility to rheumatology outpatient care and the awareness of patients with inflammatory joint diseases with regard to the types of sources and preferences of sources for obtaining information related to their disease and treatment, as well as to establish the extent to which this information is useful to patients. A pilot, cross-sectional, single center, anonymous study was conducted among adult patients with inflammatory joint diseases who were monitored in an outpatient rheumatology room at St George Diagnostic and Consultative Center in Plovdiv. A total of 56 patients were monitored. The questionnaire contained 56 questions, divided into 5 main groups: 1. questions about the disease, 2. questions about the sociodemographic profile of the patients, 3. questions about accessibility to specialized healthcare, 4. questions about the role of the nurse in the training of patients with inflammatory joint disease, and 5. questions evaluating the attitude to the monitoring medical team. The data were analyzed with IBM SPSS V.26, at a statistical significance level of p<0.05 for all analyses. Women predominated among the patients under observation (37, 66%), as well as patients in the age group of 50-79 years (46, 82%). Twenty-four (42.9%) were the patients attending the consulting room twice a year. On-the-spot booking in the consulting room was preferred mainly among patients who lived within 50km (3/16, 19%), while the rest of the patients preferred booking appointments by phone. Forty-five (80%) patients of the total number of patients used subcutaneous biological agents. Among them, the patients whose first application was performed by a nurse in a rheumatology room predominated (44 patients, 96%). All respondents (56, 100%) indicated that they had received self-injection training from a healthcare professional. Patients with inflammatory joint diseases need information to help them manage issues related to their disease and treatment, as well as cope with their physical and psychological needs. Our study shows that patients most commonly use a combination of information sources - they get information from a doctor or from a healthcare professional, i.e. a nurse. We highlighted in the study the crucial role of nurses in improving the access of patients to specialized rheumatology care and satisfying patients' information needs.

OA21 Use of the patient activation measure in rheumatology outpatients

Abstract Background/Aims Our rheumatology department is considering introducing patient-initiated follow-up (PIFU) for patients with stable inflammatory conditions. This will require patients to be motivated and appropriately seek help when required. The 13-item Patient Activation Measure (PAM-13) is a tool that measures patients' knowledge, skills and confidence in managing their health and is categorised into levels of increasing activation - level 1 (disengaged and overwhelmed), level 2 (becoming aware, still struggling), level 3 (taking action), and level 4 (maintaining behaviours, pushing forwards). Our aim was to describe the distribution of patient activation scores in a cross section of patients attending rheumatology return appointments. Methods Clinic patients were asked to complete a form which comprised demographic and disease background information, the PAM-13 and the Arthritis Self Efficacy Score (ASES). All data were anonymised. Demographic details included age, sex, postcode (for Scottish Index of Multiple Deprivation (SIMD) calculation), educational attainment, employment status, living situation, and requirement for assistance with activities of daily living (ADLs). Disease related details were main rheumatological diagnosis, years since diagnosis, patient opinion of disease control, and global health visual analogue score (VAS). Patient Health Questionnaire 2 (PHQ-2) and Generalised Anxiety Disorder 2 (GAD-2) were used to screen for mental ill-health. Results A total of 209 responses were collected. Patients fell into the following activation levels: level 1 - 25.4%, level 2 - 32.5%, level 3 - 24.4%, and level 4 - 17.7%. Patients in level 1 were compared to patients in levels 2 - 4 to establish trends. Those in level 1 less frequently felt that their rheumatic disease was well controlled (52.8% vs 72.4%). Level 1 patients were more likely to live in the most deprived areas (41.5% in SIMD quintile 1 vs 26.9%); had lower rates of full or part time employment (22.7% vs 53.2%) and higher rates of unemployment due to disability (22.6% vs 8.3%); had lower rates of educational attainment (11.3% with university education vs 21.8%); more frequently required assistance with their ADLs (62.3% vs 26.3%) and reported higher levels of depression (58.5% vs 25.6%) and anxiety (41.5% vs 24.4%). Level 1 patients reported lower global VAS (median 50 vs 70) and lower ASES (median 3.8 vs 6). Conclusion 57.9% of our patients fell into low activation levels 1 and 2. Those in the lowest activation group had the highest proportion of patients from areas with high rates of deprivation, lowest rates of employment and higher educational attainment, and highest rates of requiring assistance with ADLs, depression and anxiety. The converse was true for those in the highest level of activation group. These patients may not be appropriate for new PIFU or may require additional, tailored support for it to be safely implemented. Disclosure C.R. Wood: None. J.E. Dale: None.

E058 The effects of a pain management programme for patients with an inflammatory arthritis

Abstract Background/Aims This study examines the benefits of Pain Management Programmes (PMPs) for patients with inflammatory arthritis who still report pain and fatigue despite optimal medical management. PMPs are widely recommended (e.g. NICE 2021) for people living with persistent pain, using cognitive behavioural therapy and acceptance and commitment therapy. Programmes aim to enable participants to develop self-management ways of living with their pain, so that pain interferes less in their lives and people feel more confident, and positive about the future. We developed a PMP for patients with an inflammatory rheumatological condition with the additional aim of helping participants to identify when they could self-manage their pain and when they needed healthcare to treat their condition and manage acute pain crises. Methods Patients were offered the programme in an information session, followed by assessment with a psychologist and physiotherapist where treatments options were discussed, among them the PMP. Selection criteria were: any type of inflammatory rheumatological condition and persistent pain diagnosed at least 18 months earlier and relatively stable in terms of current treatment; over the age of 18; and able to speak English. The programme ran for eight weekly, 5-hour sessions, with reviews at one and 9 months afterwards. Groups of between 3-11 patients were run in person by a multidisciplinary team of specialists from both outpatient pain management and rheumatology services. Between April 2016 and September 2020, 45 patients (8 men, 37 women) attended 6 programmes and 33 completed outcome measures on pain, disability and distress on the first and last day and at reviews. Results Post-treatment results showed significant improvement in confidence in managing pain, less interference of pain with everyday life, less fear, greater acceptance and a more positive outlook. Mood, pain intensity and relief from the pain did not change. Improvements gained post-treatment were sustained at one month and nine-months. The effect size of the improvements was medium or large. Conclusion This study shows that attending a PMP can improve quality of life for people with inflammatory arthritis even without reducing pain intensity. Across the programme, patients grew in confidence to engage in life alongside their pain; with significant changes sustained at nine months. However, follow-up outcomes were not returned by two thirds of those who completed the programme, in part due to the pandemic, making it hard to generalise to the wider population of patients. Disclosure K. Corcoran: None. I. Hung: None. R. Stovell: None. J. Manson: None. S. Moore: None. A. Soni: None. A. Williams: None.

P105 Mode of hospital rheumatology appointments in people with rheumatoid arthritis: the impact of the pandemic in England

Abstract Background/Aims During the COVID-19 pandemic rheumatology services were advised to limit face to face contact, with remote telemedicine used instead. Although suitable for some people, issues have been highlighted with telemedicine. The frequency and proportion of remote appointments during the pandemic has not been described, or the socio-demographic characteristics of those accessing remote or in-person rheumatology care. This study aims to describe rheumatology healthcare utilisation and mode of appointment (remote/in-person) in people with rheumatoid arthritis (RA), prior to, and during the pandemic in England. Methods A retrospective prevalent cohort study of people with RA, identified using a validated algorithm, as of 1st April 2019 using electronic health record data (OpenSAFELY). Outpatient rheumatology appointments between 1st April 2019 and 31st March 2022 were identified. For each year, the number of outpatient appointments, mode of appointment (remote/in-person) and patient socio-demographic characteristics were described. Results 130,884 people with RA were identified. Since the start of the pandemic, the proportion of people without any appointments in a 12-month period increased from 28.5% in 2019/20 to 33.3% in 2020/21 and has not recovered. Older people were most frequently not seen (51% of people &amp;gt;80 years in 2020/21 and 2021/22). Of appointments where mode was known, 54.4% of people with appointments in the year from April 2020 were only seen remotely, reducing to 35.1% in the year from April 2021 (Table 1). The proportion with all remote appointments increased with increasing age, comprising 62% of people &amp;gt;80 years in 2020. This age gradient persisted in 2021, though proportions of those &amp;gt;80 years with all-remote appointments was lower (44%). Compared to urban dwellers, a higher proportion of those living in rural areas had all remote appointments in 2020 (58% vs 53%) and 2021 (38% vs 34%). Conclusion During the pandemic, one third of people with RA were not seen at all over a 12-month period and these were more frequently older people. Over half of people were only seen remotely in 2020, decreasing to one-third in 2021. Given the limitations of remote appointments it is unknown whether this increased frequency of remote appointments will impact long-term outcomes. Disclosure R.E. Costello: Shareholder/stock ownership; AstraZeneca. R.J. Hollick: None. M. Parker: None. J. Kennedy: None. B. Mackenna: None. S. Brophy: None. L. Tomlinson: None. J.H. Humphreys: None.

OA35 Early identification of large vessel vasculitis: a specific benefit of a non-specific symptom pathway?

Abstract Background/Aims Since December 2020 in Cornwall there has been a Non-Specific Symptom Pathway (NSSP): a 2-week-wait pathway by which GPs can access a CT thorax, abdomen &amp; pelvis (CT-TAP) to assess non-specific symptoms where there is a suspicion of malignancy, but conventional 2-week-wait referral criteria are not met. An unexpected consequence of this pathway was the finding of cases of suspected large vessel vasculitis (LVV) being referred to rheumatology outpatients. Methods Cases with a new diagnosis of LVV or cancer were identified using the NSSP database over the period of December 2021- May 2022. Clinical and laboratory features were analysed and compared. During this time period a Logiq E10 US machine was acquired by the department, enabling axillary US to be performed for some of the suspected LVV cases that were referred to rheumatology. Results Of the 241 accepted referrals, 14 patients (5.81%) had a subsequent definite cancer diagnosis, 6 (2.49%) had LVV diagnosed as a direct consequence of the NSSP. 5 (83%) cases of LVV had CRP &amp;gt;60 versus 4 (33%) of the cancer patients where measured. Mean CRP was 38.9 in cancer patients and 82.3 in LVV (normal 0-5mg/L). Mean platelet count was 401 in cancer patients, 510 in LVV patients (normal 150-400x109). 3 LVV patients had immunoglobulins and serum protein electrophoresis tested, of which 2 had significantly raised IgG and 1 was confirmed as polyclonal. In one case, significant thoracic aneurysmal dilatation was identified; a 59-year-old previously healthy woman presented to primary care with fatigue, night sweats and arm pain. Investigations showed anaemia, thrombocytosis, polyclonal high immunoglobulins, CRP 74. CT-TAP via NSSP revealed thoracic aorta wall thickening with aneurysmal dilatation, diameter being 4.5cm at the aortic arch. Subsequently the patient was referred to vascular surgeons and rheumatology. Rheumatology clinic review noted no symptoms of cranial giant cell arteritis or polymyalgia rheumatica. Examination revealed significant blood pressure discrepancy between right and left arms (diastolic difference of 62mmHg) and bilateral axillary bruits. Bilateral axillary artery ultrasound revealed significant intima-media thickening: right distal 1.19mm, left distal 1.37mm (normal less than 0.9mm) consistent with LVV. 10mg Prednisolone and subsequently leflunomide 10mg were initiated with resolution of inflammatory markers and symptoms. Surgical intervention was not felt to be required but regular surveillance continues. Conclusion Polyclonal raised IgG, unexplained raised CRP and thrombocytosis, arm blood pressure discrepancy and axillary bruits may be useful indicator tests for referral to the NSSP. LVV diagnosis normally requires extensive inpatient investigations in patients with pyrexia-of-unknown-origin and can be challenging in the absence of PMR or cranial GCA symptoms. As well as early identification of cancer, NSSP has the additional benefit of detecting cases of LVV that may have otherwise gone unnoticed, including the cases with secondary aneurysmal change. Disclosure R. Machin: None. M. Hughes: None.

Relationships among Arthritis Self-efficacy and Background Characteristics in Patients with Rheumatoid Arthritis

Background: A thorough evaluation of variables related to self-efficacy that are unique to each patient population is an important step for developing self-management interventions. Purpose: To determine factors associated with patient self-efficacy for managing pain and other symptoms of rheumatoid arthritis. Methods: This cross-sectional study analyzed secondary data collected for a randomized controlled trial on rheumatoid arthritis conducted from October 2016 to January 2018. A sample of 214 patients was recruited from outpatient rheumatology clinics of one medical center in northern Taiwan. Data included demographic and rheumatoid arthritis-related characteristics and self-report scores for disease activity, health status, health-related quality of life, and arthritis self-efficacy. Results: The mean age of participants was 58.72 years; 86% were female. Hierarchical regression demonstrated predictors of self-efficacy of pain management were a monthly income versus no income, living with other family members, duration (years) of arthritis, and arthritis education/counseling. Health-related quality of life scores for components of physical and mental health were also significant predictors. Predictors of self-efficacy for managing other symptoms were living with other family members in the household, religious beliefs of Buddhism or Taoism vs. none, and physical and mental component scores for health-related quality of life. Conclusions/Implications for Practice: Nurses should focus interventions targeted at adults newly diagnosed with rheumatoid arthritis, who are living alone, in poor health, and have religious beliefs of Buddhism or Taoism.

Disease control in patients with psoriatic arthritis in real clinical practice in Spain: MiDAS study

ObjectiveMiDAS study assessed the percentage of psoriatic arthritis (PsA) patients treated in routine clinical practice who achieved control of disease activity according to Disease Activity in Psoriatic Arthritis (DAPSA) and Minimal Disease Activity (MDA). MethodsObservational, non-interventional, cross-sectional, multicenter study conducted under conditions of routine clinical practice in 36 centers with outpatient rheumatology clinics in Spanish public hospitals. Patients included were adults (≥18 years) with ≥6 months PsA diagnosis according to classification for PsA (CASPAR) criteria and undergoing treatment ≥3 months. The main variable evaluated was the percentage of patients under remission and low disease activity, assessed through DAPSA and MDA. Results313 patients with PsA were included: 54.3% male; with mean age of 54.1±12.2 years and mean disease duration of 10.5±9.0 years. Mean C-reactive protein (CRP) serum levels were 4.9±7.3mg/L. At the study visit, 58.5% of patients were in monotherapy (17.6% biological and 40.9% non-biological) and 41.2% were receiving biological and non-biological therapy.59.4% of patients showed low disease activity (DAPSA≤14) and 19.8% were on remission (DAPSA≤4). Moreover, 51.4% of the patients reached an MDA status (≥5 MDA). ConclusionsAround 40% of PsA patients presented uncontrolled disease, highlighting the need to improve the management of these patients in clinical practice.

Prevalence of Sjögren's syndrome according to 2016 ACR-EULAR classification criteria in patients with systemic lupus erythematosus

BackgroundDiagnosis of SS is a complex task, as no symptom or test is unique to this syndrome. The American-European Consensus Group (AECG 2002) and the American-European classification criteria of 2016 (ACR/EULAR 2016) emerged through a search for consensus. This study aims to assess the prevalence of Sjögren’s Syndrome (SS) in patients with Systemic Lupus Erythematosus (SLE), according to AECG 2002 and ACR-EULAR 2016 classifications, as well as clinical and histopathological features in this overlap. To date, there is no study that has evaluated SS in SLE, using the two current criteria.MethodsThis cross-sectional study evaluated 237 SLE patients at the outpatient rheumatology clinic between 2016 and 2018. Patients were submitted to a dryness questionnaire, whole unstimulated salivary flow (WUSF), “Ocular Staining Score” (OSS), Schirmer’s test I (ST-I), and labial salivary gland biopsy (LSGB).ResultsAfter verifying inclusion and exclusion criteria, a total of 117 patients were evaluated, with predominance of females (94%) and mixed ethnicity (49.6%). The prevalence of SS was 23% according to AECG 2002 and 35% to ACR-EULAR 2016. Kappa agreement between AECG 2002 and ACR-EULAR 2016 were 0.7 (p < 0.0001). After logistic regression, predictors for SS were: anti/Ro (OR = 17.86, p < 0.05), focal lymphocytic sialadenitis (OR = 3.69, p < 0.05), OSS ≥ 5 (OR = 7.50, p < 0.05), ST I positive (OR = 2.67, p < 0.05), and WUSF ≤ 0.1 mL/min (OR = 4.13, p < 0.05).ConclusionThe prevalence of SS in SLE was 23% (AECG 2002) and 35% (ACR-EULAR 2016). The presence of glandular dysfunction, focal lymphocytic sialadenitis, and anti/Ro were predictors of SS in SLE. The greatest advantage of the new ACR-EULAR 2016 criteria is to enable an early diagnosis and identify the overlapping of these two diseases. ACR-EULAR 2016 criteria is not yet validated for secondary SS and this study is a pioneer in investigating prevalence based on the new criteria.

Does Diagnostic Certainty Matter?: Pain-Related Stigma in Adolescents with Juvenile Idiopathic Arthritis.

Childhood chronic pain conditions are common and vulnerable to stigma. Adolescents with chronic primary pain experience diagnostic uncertainty and describe pain-related stigma experiences across multiple social contexts. Juvenile idiopathic arthritis (JIA) is a childhood autoimmune, inflammatory condition with associated chronic pain, but with well-defined diagnostic criteria. The current study examined pain-related stigma experiences in adolescents with JIA. Four focus groups of 3-7 adolescents with JIA (N = 16), ages 12-17 (Mage = 15.42, SD = 1.82), and parents (N = 13) were conducted to examine experiences of, and reaction to, pain-related stigma. Patients were recruited from an outpatient pediatric rheumatology clinic. Focus group length ranged from 28 to 99 minutes long. Two coders used directed content analysis resulting in 82.17% inter-rater level of agreement. Adolescents with JIA described pain-related stigma experiences predominantly from school teachers and peers, and less from medical providers (e.g., school nurses), and family members after a diagnosis. The primary categories that emerged were (1) Felt Stigma, (2) Internalized Stigma, (3) Anticipatory Stigma/Concealment, and (4) Contributions to Pain-Related Stigma. A common experience of pain-related stigma was the perception by others that the adolescent was too young to have arthritis. In common with adolescents with unexplained chronic pain, our findings indicate that adolescents with JIA experience pain-related stigma in certain social contexts. Diagnostic certainty may contribute to greater support among medical providers and within families. Future research should investigate the impact of pain-related stigma across childhood pain conditions.

Assessing the Burden of Osteoarthritis in Africa and the Middle East: A Rapid Evidence Assessment.

This rapid evidence assessment (REA) was conducted to assess the burden of weight-bearing joint osteoarthritis in the developing countries of Africa and the Middle East. Our REA methodology used a standardized search strategy to identify observational studies, published between January 1, 2010, and April 23, 2020, reporting on outcomes pertaining to the epidemiology and humanistic or economic burden of weight-bearing osteoarthritis. Relevant data from the included studies were used for qualitative analysis. Among the 20 publications reporting on knee osteoarthritis in 10 countries in Africa and the Middle East, 2 also reported on hip, and 1 on foot osteoarthritis. Prevalence of symptomatic/radiographic knee OA was 9-14% among rheumatology outpatients and 31-34% among those with mixed etiology osteoarthritis. Prevalence of knee OA diagnosed by magnetic resonance imaging was 70% among patients ≥40 years of age attending a hospital in Saudi Arabia. Quality-of-life outcomes were reported in 16 publications and suggested a substantial humanistic burden of osteoarthritis, including worse pain, function, and quality of life, and more depression; comparisons between studies were hampered by the variety of tools and scoring scales used, however. No studies reported on economic outcomes. This REA indicates a substantial burden of osteoarthritis in weight-bearing joints in Africa and the Middle East, consistent with publications from other regions of the world.

The Cost-Effectiveness of and Adherence to Disease-Modifying Antirheumatic Drug (DMARD) Therapy in Rheumatoid Arthritis Patients in a Tertiary Care Teaching Hospital in Uttarakhand, India.

Objective This study was conducted with the aim ofevaluating the cost-effectiveness of and adherence to treatment in patients on disease-modifying antirheumatic drug (DMARD) therapy for rheumatoid arthritis (RA) in a tertiary care teaching hospital in Uttarakhand, India. Methodology This prospective observational study was conducted on 150 rheumatoid arthritis patients presenting to the Rheumatology Outpatient Department (OPD) receiving DMARD therapy (approval number AIIMS/IEC/18/160). The patients were followed up for an average of 10.7 weeks and received drugs in four regimens with methotrexate (MTX) (Regimen 1) having the least contribution with a mean of 46.05 Rs, methotrexate + hydroxychloroquine(MTX + HCQ) (Regimen 2) with 174.15 Rs, methotrexate + hydroxychloroquine + leflunomide (MTX + HCQ + Lef) (Regimen 3) with Rs 371.70, and methotrexate + hydroxychloroquine + leflunomide + biological DMARD adalimumab(MTX + HCQ + Lef + bDMARD adalimumab) (Regimen 4) with 17,349.4 Rs.The cost of drug therapy was assessed by calculating the cost of therapy per month for each patient, and adherence was assessed using the Morisky-Green-Levine Scale (MGLS) at the follow-up visit. Results The overall mean cost of DMARD treatment was 205.81 Rs. The overall DMARD therapy cost-effectiveness was Rs 878.14 for a unit change of Disease Activity Score (DAS28). The most cost-effective treatment came out to be Regimen 1 with the least cost of 290.9Rs for a unit change of DAS28, and the least cost-effective was Regimen 4 with 65,661.8 Rs for a unit change of DAS28. At follow-up, among all subjects of the study, 49 (32.7%) subjects showed high adherence, 71 (47.3%) subjects showed medium adherence, and 30 (20%) subjects showed low adherence. Accordingly, the maximum number of participants fell in the category of medium adherence, i.e., 71 (47.4%). Conclusion Our study concluded that the cost burden varied according to the number of DMARDs being given to the patient. The double-drug therapy of methotrexate + hydroxychloroquine had a maximum "high adherence." On a whole, the majority of patients had "medium adherence" to therapy.

Musculoskeletal Complications of Celiac Disease: A Case-Based Review.

Primary diagnosis of celiac disease (CD) in rheumatology department is not common in daily clinical practice, due to the fact that diarrhoea is usually the dominant symptom. Extra-intestinal manifestations, such as arthralgia, myalgia, osteomalacia, and osteoporosis are not rare in these patients. We present a case of a 66-year-old man, who came to the outpatient rheumatology clinic, complaining of back and knee pain. Osteopenia was observed in plain radiographs, whereas extensive laboratory testing revealed celiac disease, vitamin D deficiency, and extremely low bone mineral density (BMD) due to osteomalacia. Gluten-free diet (GFD) initiation and administration of vitamin D and calcium supplements resulted in significant symptom and BMD improvement over 6 months. A significant proportion of CD patients might present with arthralgia, arthritis, back pain, myalgia, or bone pain. Importantly, up to 75% of patients might have reduced BMD, due to osteoporosis or osteomalacia, while they also carry a significant risk for fracture. However, the introduction of GFD and calcium/vitamin D supplementation significantly ameliorates symptoms and BMD in most cases. Increased awareness of CD's musculoskeletal manifestations by rheumatologists is important for early recognition and management of this condition and its complications.

Joint Mobility among Patients with Trochanteric Bursitis in Erbil-Iraq

Background: Trochanteric bursitis is the inflammation of greater trochanter bursa, which is located lateral to the greater trochanter of the femur. The underlying causes of trochanteric bursitis are multifactorial. Joint mobility considered as one of the possible causes; Joint laxity is a condition in which the range of motion in the joints are greater than normal, which are more in women than men with higher prevalence in young ages. Aim of the study: to assess joint mobility among people with trochanteric bursitis.Patients and Methods: A cross sectional study was conducted in Rheumatology Outpatient clinic in Rizgary Teaching Hospital in Iraqi Kurdistan region between February and December 2021. A sample of 100 Iraqi patients with trochanteric bursitis, and another 100 healthy controls matched in age and sex were studied. Beighton score were performed on patients and controls to assess joint mobility. Results: Joint hypermobility was reported in 24(12%) patients with trochanteric bursitis compared to 29(14.5%) in healthy controls (p= 0.423, OR 0.773; 95%CI 0.412-1.452), no significant differences were detected between the two groups. Joint hypermobility was more in females using cutoff score ≥4 of Beighton score; forty-six among fiftythree hypermobile participants were female, the p-value was 0.001 which was statistically significant.Conclusion: There is no positive correlation between joint hypermobility and the presence of trochanteric bursitis.

Assessment of Knowledge, Attitude, and Practices Regarding Self-medication among Patients Attending the Rheumatology Outpatient Clinic at a Tertiary Care Hospital in West Bengal, India

Introduction: Self-medication is an important health issue. The rising tendency of self-medication has been a cause for concern. Rheumatic patients, being vulnerable to various symptoms like pain and fever, may resort to self-medication. Although several studies have been conducted among different populations, there is a lack of literature focusing on rheumatic disease patients in India. Aim: To investigate the knowledge, attitude, and practice of self-medication among patients attending the Rheumatology Outpatient clinic at a tertiary care centre in eastern India. Materials and Methods: This descriptive cross-sectional study was conducted at the Rheumatology Outpatient Clinic in Medical College Kolkata, a tertiary hospital in West Bengal, India, from July 21, 2021, to September 20, 2021. A total of 105 patients attending the rheumatology outpatient clinic were included in the study. Data were collected by conducting interviews with the patients using prestructured and prevalidated questionnaire after obtaining informed consent. The Knowledge, Attitude, and Practice (KAP) of self-medication were assessed, and the data were statistically analysed using Chi-square tests. Results: The mean age of the study population was 38.77 years±12.56 years. Among the 105 subjects, 61 (58.1%) were suffering from arthritis, 26 (24.8%) from Systemic Lupus Erythematosus (SLE), and 6 (5.7%) from kidney disease. A total of 75 (71.4%) study subjects reported that they knew what self-medication was. The majority of the patients (86.7%) were unaware of the common adverse effects. However, 90 (85.7%) stated that self-medication was generally not beneficial, whereas 9 (8.6%) held the opposite view. A total of 64 (61%) reported having practiced self-medication in the past year. Conclusion: The present study reported a self-medication rate of 61%. Self-medication was found to be more frequent among the younger age group, females, and individuals with higher educational qualifications.