Rheumatology Research Articles

Negotiating Professional Tasks in a Hospital: A Qualitative Study of Rheumatologists and Occupational Therapists in the Management of Hand Osteoarthritis.

Societal change and rise in demand for healthcare call for new health professional practices and task redistribution. Through negotiated order theory, this study explores how hospital rheumatologists (RT) and occupational therapists (OT) negotiate professional tasks in the clinical management of hand osteoarthritis. Fourteen qualitative interviews and 16 observations in clinical consultations were conducted in two hospitals specialized in rheumatology in Norway. Participants included eight OTs, six RTs, and patients in consultations. Data were analyzed using reflexive thematic analysis. Three themes were developed from codes: hierarchical ordering of hospital work impacts interprofessional negotiations; diagnostic organization of tasks preserves RT authority; and evidence-based recommendations in rheumatology enhance OT responsibilities. Overall, RTs and OTs enact tasks in succession where higher-ranking RTs establish a diagnosis and decide the subsequent in-hospital trajectory entrenched in a medical knowledge system. When medicine does not hold evidence-based treatment alternatives for patients, OTs respond by providing therapeutic interventions that are legitimized through international recommendations in rheumatology when they equip patients with tools to cope with chronic illness. Negotiations over tasks do not take place from equal power positions when status and knowledge hierarchies frame professional practices. The enactment of tasks is concurrently highly influenced by the arena of the workplace, where the two professional groups both cross boundaries and work together in concert despite professional differences in order to meet patient interests and provide relevant healthcare.

Psoriatic Arthritis: Differential Features at the Time of Clinical Presentation in a Large Cohort of Patients with Polyarthralgia.

Most patients with psoriatic arthritis begin with cutaneous psoriasis, which is why all early detection strategies are based on screening in the dermatological consultation and referral to a rheu matologist. However, there are cases of patients who consult initially for musculoskeletal symptoms, mostly joint pain, regardless of family and/or personal history of psoriasis. This study aimed to esti mate the frequency of psoriatic arthritis in a cohort of patients who consulted for polyarthralgia and to determine the differential features, at the time of clinical presentation, in relation to both patients with final diagnosis other than psoriatic arthritis and patients with diagnosis of rheumatoid arthritis. Consecutive patients with polyarthralgia (including arthralgia of the hands) were included. Clinical examination, laboratory tests, ultrasound with power Doppler of both hands, and radiography of both hands and feet were performed at baseline. All patients were followed up and the definitive diagnosis of psoriatic arthritis was established. A total of 1055 were included, 88 (8.3%) ended with diagnosis of psoriatic arthritis. Diagnosis of psoriatic arthritis was positively associated with a family history of psoriasis (odds ratio=4.14), pso riasis (odds ratio=78.94), radiographic erosions (odds ratio=5.74), and ultrasound with at least 1 joint with positive power Doppler (odds ratio=7.11). In comparison with rheumatoid arthritis patients, diagnosis of psoriatic arthritis was positively associated with psoriasis (odds ratio=433.42) and family history of psoriasis (odds ratio=41.63). On the other hand, it was negatively associated with positivity, for both rheumatoid factor (odds ratio=0.03) and anti-cyclic citrullinated peptide antibodies (odds ratio=0.06). The frequency of psoriatic arthritis was 8.3% and was associated with a personal and/or family history of psoriasis, radiographic erosions, and inflammatory involvement by Power Doppler Ultrasound (PDUS). In comparison with rheumatoid arthritis patients, psoriatic arthritis was associated with a personal and/or family history of psoriasis, while the presence of both rheumatoid factor and/ or anti-cyclic citrullinated peptide antibodies was shown to be a protective factor for the diagnosis of psoriatic arthritis.

Expert consensus on clinical detection of rheumatoid arthritis related autoantibodies

Rheumatoid arthritis (RA) is a common chronic and systemic autoimmune disease. Early diagnosis and standard treatment are the keys to control the disease and improve the prognosis. A variety of autoantibodies such as rheumatoid factor and anti-citrullinated peptide/protein antibodies can be detected in serum of patients with rheumatoid arthritis, which are important for early diagnosis and differential diagnosis of RA, judgment of disease severity and prognosis evaluation. The standardization of autoantibody detection related to rheumatoid arthritis is very important for its clinical application. Under the organization of the Committee of the Autoantibodies Detection of Rheumatology and Immunology Physicians Committee of Chinese Medical Doctor Association, expert consensus on clinical application of rheumatoid arthritis related autoantibodies detection were established by a joint group of Chinese multi-disciplinary experts. The consensus aims to standardize the detection of RA associated autoantibodies, and to provide a reference for clinicians and laboratory technicians to use and interpret rheumatoid arthritis-related autoantibodies in daily practice.

Perspectives on poetry in rheumatology

Perspectives on poetry in rheumatology

The patient journey in knee osteoarthritis-variations in diagnosis, patient characteristics, and treatment by physician specialty

The patient journey in knee osteoarthritis-variations in diagnosis, patient characteristics, and treatment by physician specialty

Women’s past, present, tomorrow in rheumatology

Women’s past, present, tomorrow in rheumatology

Specific Footwear Might Reduce Pain from Knee Osteoarthritis

The American College of Rheumatology does not recommend modified shoes to relieve pain in patients with knee osteoarthritis (OA) because outcome data

Thank you to the reviewers of Rheumatology Advances in Practice

Thank you to the reviewers of <i>Rheumatology Advances in Practice</i>

Comparison of clinical and immunological features between clinically amyopathic dermatomyositis and typical dermatomyositis

OBJECTIVE To study the differences between clinically amyopathic dermatomyositis (CADM) and typical dermatomyositis (DM) on clinical and immunological features. METHODS By collecting clinical data of 106 CADM patients and 158 DM patients from January 2010 to June 2019 in the department of Rheumatology and Immunology, Peking University People's Hospital, the clinical characteristics and immunological features in the two groups were compared, and the distribution characters and the clinical meanings of myositis autoantibodies were discussed in the two groups respectively. Myositis autoantibodies were measured by immunoblotting according to the manufacturers' instructions. RESULTS In the aspects of clinical manifestations, CADM presented more with onset of interstial lung diseases (ILD) compared with DM (20.7% vs. 7.6%, P=0.002), and CADM-ILD was more likely to be acute ILD (58.3% vs. 26%, P < 0.001), and there were no differences between CADM and DM in cutaneous manifestations, accompanied with connective tissue disease (CTD) and malignancy. In CADM, the positive rate of rheumatoid factors and antinuclear antibodies was lower in DM. The most common myositis specific autoantibodies (MSAs) in CADM were anti-MDA5 (36%), anti-PL-7 (11.2%) and anti-TIF-1γ (10.1%). The most common MSAs in DM were anti-Jo-1 (19.2%), anti-TIF-1γ (11.5%) and anti-MDA5 (11.5%). Anti-MDA5 was correlated with acute ILD and skin ulceration both in CADM and DM; in CADM, skin ulceration was not associated with the titer of anti-MDA5; while in DM, skin ulceration was associated with high titer of anti-MDA5. In DM, anti-TIF-1γ was correlated with heliotrope eruption, V/shawl neck sign, perionychia erythma and malignancy, and higher rate of malignancy was seen in all titers of the anti-TIF-1γ positive patients. In CADM, anti-TIF1-γ showed no correlation with clinical manifestations. The most common myositis associated autoantibody was anti-Ro-52 both in CADM and DM. In CADM, anti-Ro-52 was associated with Raynaud's phenomenon and chronic ILD, while in DM, anti-Ro-52 was associated with mechanic's hands, noninfectious fever and accompanied CTD. CONCLUSION Compared with DM, ILD is more likely to be acute in CADM. It is different between CADM and DM about the distribution of myositis autoantibodies and the clinical significance of the same myositis antibody, and the clinical significance of some myositis antibodies is related to titers.

Insights on Kawasaki disease and multisystem inflammatory syndrome: relationship with COVID-19 infection

At the beginning of coronavirus disease 2019 (COVID-19) children seemed to be less affected and with milder symptoms than adults. Afterward, however, a warning was released regarding the possible association between COVID-19 and Kawasaki disease (KD) or Kawasaki-like disease. Thereafter, labels of Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS) in Europe and Multisystem Inflammatory Syndrome in Children (MIS-C) in the USA were coined to refer to this new disease entity. The reality is that PIMS-TS/MIS-C resembles certain KD complications such as toxic shock syndrome and macrophage activation syndrome than to classic KD. PIMS-TS/MIS-C and KD share the viral origin (however just supposed for KD) and consequent dysregulated innate immune system inflammatory reaction. PIMS-TS/MISC symptoms occur about 2-4 weeks after the onset of COVID-19 or having been exposed to somebody positive for COVID-19, rather than in the acute phase of the infection. Clinically PIMS-TS/MIS-C affects older children than KD and presents more often with gastrointestinal symptoms, shock, and multi-organ dysfunction. myocarditis is more common in PIMS-TS/MIS-C than coronary artery aneurysms formation seen in KD. There are also differences in laboratory tests and immunology responses in KD and PIMS-TS/MIS-C. Thus PIMS-TS/MIS-C seems to be a new and multifaceted entity, distinct from KD, notwithstanding some common features in both. The dysregulated innate immune system reaction is responsible for PIMS-TS/MIS-C onset and outcome. A multidisciplinary approach, involving paediatric intensivists, paediatric cardiologists, infectious disease specialists, immunologists, and rheumatologists, is needed for the treatment of these children.

Low Bone Mineral Density and Immunological Insights in Postmenopausal Women Affected by Primary Sjandouml;grenandrsquo;s Syndrome

Objective: Osteoporosis is the pathological reduction of bone mineral density (BMD) and the most represented metabolic skeletal disease among population. A reduction in bone mineralization levels is associated with an increased risk of frailty fractures and of healthcare costs. Although there are many evidences bridging rheumatological diseases (such Systemic Sclerosis, Lupus Erythematosus Systemics and Rheumatoid Arthritis) with bone loss, very scarce and contradictory papers evaluate bone health in primary Sjogren's syndrome (pSS). Aim of this retrospective study is to evaluate BMD in pSS and its relationship with inflammatory markers, Ro/SSA and La/SSB antibodies. Methods: Fifty-three postmenopausal pSS were matched with 93 controls and studied for BMD measured by Dual Energy X- ray absorptiometry (DXA). Anti-nuclear antibodies (ANA), anti-extractable nuclear antigens (ENA), Anti- Ro/SSA, and anti-La/SSB antibodies, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were collected too. Mean BMDs of each explored region was compared and osteoporosis’s (OP) prevalence was assessed. Pearson’s analysis and multivariate regression models were built to highlight variables interrelations. Results: BMD was lower in pSS compared to controls, both expressed as g/cm2 and T-score considering lumbar spine and femoral neck. OP prevalence was higher among pSS compared to controls. Weight acted as the best predictor of lumbar BMD in multivariate model. No difference on BMD status was found between pSS with antibodies positivity and altered inflammatory markers with subjects displaying normal sera levels of the abovementioned variables. Conclusions: pSS female patients in an early stage of disease have lower BMD compared to healthy controls. Anti- Ro/SSA and anti/La antibodies and inflammatory markers are not related with BMD.

Is step rate associated with worsening of patellofemoral and tibiofemoral joint osteoarthritis in women and men? The Multicenter Osteoarthritis Study.

© 2019, American College of Rheumatology This is the peer reviewed version of the following article: Step Rate and Worsening of Patellofemoral and Tibiofemoral Joint Osteoarthritis in Women and Men: The Multicenter Osteoarthritis Study, which has been published in final form at https://onlinelibrary.wiley.com/doi/full/10.1002/acr.23864. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions.Objective: To determine the association of self-selected walking step rate with worsening of cartilage damage in the patellofemoral (PF) joint and tibiofemoral (TF) joint compartments at a 2-year follow-up visit. Methods: The Multicenter Osteoarthritis Study (MOST) is a prospective cohort of men and women with or at risk of knee osteoarthritis. Self-selected step rate was measured using an instrumented GAITRite walkway (CIR Systems) at the 60-month visit. Cartilage damage was semiquantitatively graded on magnetic resonance images at the 60- and 84-month visits in the medial and lateral PF and TF compartments. Step rate was divided into quartiles, and logistic regression was used to determine the association of step rate with the risk of worsening cartilage damage in men and women separately. Analyses were adjusted for age, body mass index, and knee injury/surgery. Results: A total of 1,089 participants were included. Mean ± SD age was 66.9 ± 7.5 years, mean ± SD body mass index was 29.6 ± 4.7 kg/m2, and 62.3% of the participants were women. Women with the lowest step rate had increased risk of lateral PF (risk ratio [RR] 2.1 [95% confidence interval (95% CI) 1.1–3.8]) and TF (RR 1.8 [95% CI 1.1–2.9]) cartilage damage worsening 2 years later compared to those with the highest step rate. Men with the lowest step rate had increased risk of medial TF cartilage damage worsening 2 years later (RR 2.1 [95% CI 1.1–3.9]). Conclusion: Lower step rate was associated with increased risk of cartilage damage worsening in the lateral PF and TF compartments in women and worsening medial TF joint damage in men. Future research is necessary to understand the influence of step rate manipulation on joint biomechanics in women and men.

A PAN-POSITIVE, RAPIDLY PROGRESSIVE PULMONARY RENAL PUZZLER

SESSION TITLE: Fellows Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: A 78-year-old male with history of aortic sclerosis and anemia was admitted with two weeks of dyspnea, profound weakness, cough, and orthopnea On presentation he was afebrile and hemodynamically stable with normal oxygen saturations but was notably tachypneic which improved on simple nasal cannula On exam he had bilateral crackles to auscultation posteriorly with no peripheral edema Labs revealed hemoglobin 5 6g/dL with MCV 112 1, new acute kidney injury with creatinine 1 8mg/dL, and mildly elevated total and indirect bilirubin B-type natriuretic peptide was 518pg/mL Chest x-ray showed bilateral left greater than right hazy opacities CASE PRESENTATION: Initial concern was for Covid-19 with superimposed bacterial pneumonia Despite broad-spectrum antibiotics he declined over the following two days and was ultimately intubated He was noted to have a small blood clot in his posterior oropharynx at intubation Following two negative Covid-19 rt-PCR he underwent bronchoscopy with BAL that showed no blood in large airways but grossly bloody lavage return from right middle lobe and lingula Further workup was significant for elevated CRP (150 mg/dL), ANA 1:320 (homogenous) with weakly positive anti-histone antibodies, elevated anticardiolipin and anti-beta-2 microglobulin IgM, and positive p-ANCA with titer 1:640 and elevated anti-MPO and anti-PR3 Due to worsening creatinine he underwent renal biopsy which revealed crescentic necrotizing glomerulonephritis without thrombotic microangiopathy, and with IgG and C3 deposition After initiation of high dose steroids and rituximab the patient rapidly improved, was extubated and transferred to the floor Plasma exchange was deferred due to stabilization Further chart review revealed that he had been taking hydralazine for several years in increasing doses, most recently increased two months prior to his presentation DISCUSSION: Diffuse alveolar hemorrhage should be suspected in patients with systemic symptoms, anemia, and pulmonary infiltrates High dose steroids should be empirically started if there is high suspicion for inflammatory cause, particularly in the presence of concurrent renal dysfunction Immunomodulatory agents such as cyclophosphamide or rituximab should then be initiated based on serologies or pathology, as well as plasma exchange in patients with rapidly declining renal function or diffuse alveolar hemorrhage with respiratory compromise CONCLUSIONS: Unexpected overlap in rheumatologic markers should prompt consideration of drug-induced vasculitis Hydralazine induced vasculitis in particular is commonly associated with dual ANCA positivity with concurrent antiphospholipid and antihistone antibodies Renal biopsy shows pauci-immune crescentic glomerulonephritis and may also show IgM, IgG and C3 deposits without immune complexes Management consists of halting the offending agent and long-term immunosuppression Reference #1: Babar, F , Posner, J N , & Obah, E A (2016) Hydralazine-induced pauci-immune glomerulonephritis: intriguing case series with misleading diagnoses Journal of community hospital internal medicine perspectives, 6(2), 30632 Reference #2: Dobre, M , Wish, J , & Negrea, L (2009) Hydralazine-induced ANCA-positive pauci-immune glomerulonephritis: a case report and literature review Renal failure, 31(8), 745-748 DISCLOSURES: No relevant relationships by Natalie Achamallah, source=Web Response

Concepts and perceptions about the diagnosis and treatment of fibromyalgia in a group of Colombian rheumatologists

RESUMEN Introduccion La fibromialgia es una enfermedad cronica caracterizada por la presencia de dolor musculo esqueletico, usualmente asociada a otros sintomas como depresion, fatiga, trastornos del sueno, entre otros. Los conceptos y las percepciones sobre el diagnostico y el tratamiento de la fibromialgia, entre medicos reumatologos no se conocen objetivamente. El proposito de este estudio es describir los conceptos y percepciones sobre el diagnostico y tratamiento de la fibromialgia, entre un grupo de medicos reumatologos en Colombia. Metodos Estudio descriptivo de corte transversal. A traves de un grupo focal en el que participaron dos reumatologos y un experto en metodos de investigacion cualitativa, se diseno una encuesta para evaluar las percepciones y conceptos que los medicos reumatologos tienen sobre el diagnostico y el tratamiento de la fibromialgia. La encuesta se aplico de forma autoadministrada y anonima a medicos reumatologos pertenecientes a la Asociacion Colombiana de Reumatologia. Resultados Encuesta aplicada a 139 reumatologos. 25,2% (n = 35) considera que no hay suficiente evidencia para considerar la fibromialgia como una enfermedad. 32,4% (n = 45) usa los criterios ACR (American college of Rheumatology) de 1990 para diagnosticar pacientes con fibromialgia, a pesar de que el 92,1% (n = 128) considera que estos criterios no son suficientes para el diagnostico de fibromialgia. Los medicamentos mas formulados para manejo de fibromialgia son los antidepresivos, prescritos por el 90,6% (n = 126) de los encuestados, seguido por anticonvulsivantes 64,7% (n = 90) y analgesicos 26,6% (n = 37). 76,3% (n = 106) de los reumatologos considera que el manejo del paciente con fibromialgia debe tener un enfoque multidisciplinario. 81,3% (n = 113) de los reumatologos considera que el paciente con fibromialgia debe tener como medico tratante principal a un especialista distinto al reumatologo. Conclusion El presente estudio muestra informacion acerca de las percepciones acerca del diagnostico y tratamiento de fibromialgia entre un grupo de reumatologos colombianos, documentandose un frecuente uso de los criterios de clasificacion ACR 1990. En cuanto a tratamiento se observa un alto porcentaje de uso de medicamentos, en especial antidepresivos y analgesicos. La mayoria de los reumatologos considera que los medicos fisiatras, deben ser los lideres del manejo interdisciplinario en el tratamiento del paciente con fibromialgia.

Nachruf der Deutschen Gesellschaft für Rheumatologie auf Prof. Dieter Felsenberg

Nachruf der Deutschen Gesellschaft für Rheumatologie auf Prof. Dieter Felsenberg

The COVID-19 war and the battles of rheumatologists

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The way to the rheumatological specialist assistant-a look into the history

The way to the rheumatological specialist assistant-a look into the history

Development a National Minimum Data Set for Acute Rheumatic Fever / Rheumatic Heart Disease Registry in Iran

Background: Rheumatic heart disease remains the major cause of morbidity and mortality among young people in developing countries.The age-standardized prevalence of Rheumatic Heart Disease (RHD) in Iran increased <5% from 1990 to 2013.The most cost-effective strategy to disease control is to provide secondary prevention using registry. The aim of this study was to develop a national Minimum Data Set (MDS) for creating a national registry for Iran. Materials and Methods:this cross‑sectional study, is combination of literature review, data collection from patients medical records, and expert panel approach to design this MDS. The panel consisted of 12 specialists from different universities of medical sciences with expertise in Infectious Diseases (Pediatrics and adults), Rheumatology, Cardiology and Health Information Management (HIM). Expert opinions were calculated using Content Validity Ratio (CVR). Data elements with a CVR of more than 0.56 were selected as the MDS of the registry. Results:Totally, 279 data elements were identified; Of which, 223 data elements were verified and 56 were rejected by experts. In addition, 89 data elements were added as essential by them. Finally, 312 data elements were selected as national MDS of ARF/RHD registry in Iran based. The final data elements divided into two categories: administrative and clinical with 2 and 12 sections, and 42 and 270 data elements, respectively. Conclusions:This developed MDS can be used for designing and recruiting national registry in this field with the aim of collecting all required data across the country, and to make policies for the optimal management of it.

Egypt's groundwork blessing during the COVID-19 pandemic curse: Rheumatologic experience.

Egypt's groundwork blessing during the COVID-19 pandemic curse: Rheumatologic experience.

Palmar Fasciitis and Polyarthritis Syndrome: A Rare Paraneoplastic Syndrome in a Patient With Prostate Carcinoma

A 73-year-old patient was seen in our hospital for treatment of metastatic adenocarcinoma of the prostate (pT 1a N 0 M 1a R 0 , BRCA-2 gene mutation). Prostatectomy and regional radiotherapy were performed and goserelin, a luteinizing hormone-releasing hormone (LHRH) analog, had been started because of disease progression. Castration-resistant progressive disease developed, and enzalutamide was added. A decrease of the prostate-specific antigen (PSA) level was achieved. Before the start of enzalutamide, the patient developed bilateral pain and stiffness of both hands combined with thickening of the hands. The symptoms progressed rapidly to bilateral flexion and extension contractures. The patient became unable to tie his shoelaces and had to use adjusted cutlery to eat. Consultation of the rheumatologist, X-rays, ultrasound and palmar skin biopsy of the hands were performed. The clinical picture resembles descriptions of “palmar fasciitis and polyarthritis syndrome” (PFPAS), a rare paraneoplastic syndrome. Positive effects of immunosuppressive medication have been reported in some cases. In our patient, treatment with oral prednisone (30 mg daily) showed no effect, therefore treatment was switched to methylprednisone pulses and methotrexate. PFPAS is an uncommon paraneoplastic syndrome characterized by rapid onset of bilateral arthritis of the hands, fasciitis of the palms, progressive stiffness and contractures. The scarcity of knowledge about PFPAS makes it difficult to recognize it at an early stage. As a paraneoplastic syndrome, it has been linked to various malignancies. Thus far, PFPAS has been described in only two other cases of prostate cancer. J Med Cases. 2020;11(9):267-270 doi: https://doi.org/10.14740/jmc3522