Rheumatology Specialty Research Articles

SP0035 Rheumatology Training in Europe: An Overview

Rheumatology specialty training is the period in which trainees lay the foundation of their knowledge, skills and professional behavior essential to a high quality practice as rheumatologists. This training has...

AB1249 The situation of ultrasound in the spanish rheumatology

BackgroundUltrasonography has been recently introduced in rheumatology. Since 1996 the Spanish Society Rheumatology has developed a training program and today, 15 years later, we feel that it is time to...

Understanding the Immunogenicity Concept

Immunogenicity is just one of the many benefits of our immune system and is defined as the ability of different substances to trigger an adaptive cellular and humoral cell immune response that is longterm and leads to immunological memory. In rheumatology and other medical specialties such as dermatology, gastroenterology, neurology and immunology, biological proteins derived from biotechnology are increasingly used as therapeutic agents. These proteins, like many other exogenous agents can induce humoral and cellular immune responses. However, in recent years we have noticed how these concepts have been interpreted haphazardly, and sometimes in the wrong way from the point of view of their clinical significance. The immune response or immunogenicity which can be triggered by a therapeutic protein has been proposed as a cause of potential clinical events, including hypersensitivity reactions, decreased effectiveness of the therapeutic molecule and induction of immune processes, including the formation of antibodies against the protein in question.1,2 The most dreaded immunogenicity in clinical terms occurs due to the so-called neutralizing anti-drug antibodies which, as their name implies, have the ability to bind the agent (drug) and neutralize it, preventing its biological or therapeutic function.3 Many factors can influence the immunogenicity of therapeutic proteins, including those inherent to the patient, the disease itself or those related to the product itself. The determinants of patient-related immunogenicity that may predispose unwanted immune responses include the underlying disease, genetic factors and baseline immune status, including associated immunomodulatory therapy. Furthermore, product related factors also influence the probability of inducing an immune response; for example, the route of administration, the type of protein, aspects of the manufacturing process, impurity profile or excipients and formulation characteristics, stability, degradation products or aggregates, dosage, the dosing interval and treatment duration.4–6 The immune response mechanism directed against therapeutic biological molecules seems to be due to “transient” loss of

History of vasculitis: The life and work of Adolf Kussmaul

Adolf Kussmaul is well known for his contributions to the science of medicine and the specialty of rheumatology. A much-loved teacher and respected physician and researcher, Kussmaul's desire to understand disease, his careful clinical observations, and his innovative thinking in medical technology mark him as a pioneer in modern rheumatology.

Tuberculosis screening in prescribers of anti-tumor necrosis factor therapy in the European Union

Physician offices and hospital-based settings in 24 European Union countries. To assess the awareness of tuberculosis (TB) risk, performance of TB screening and factors predicting TB screening among prescribers of tumor necrosis factor alpha (TNF-α) agents. A total of 915 prescribers (441 rheumatologists, 266 gastroenterologists and 208 dermatologists) of anti-TNF agents participated in a 41-item survey between March and May 2010. Multivariate analyses were conducted to identify predictors of TB screening. Overall, ≥88% of physicians identified TB reactivation as an adverse effect associated with anti-TNF use. Self-reported TB screening ranged from 73% of gastroenterologists in the five foremost industrialized economies (G5) countries to 92% of rheumatologists in non-G5 countries. Factors predictive of TB screening included rheumatology or gastroenterology specialty, higher awareness of TB reactivation as a risk, greater adherence to TB testing guidelines, larger caseloads of patients with severe disease, practicing in a major industrialized country and greater number of anti-TNF agents for which risk-related information had been received. Most physicians reported being aware of the attendant risk for reactivation of latent TB infection with anti-TNF treatments. Results suggest that distributing pertinent educational materials is an effective component of a risk minimization strategy to promote TB screening among anti-TNF prescribers.

Variability in Resource Consumption in Patients With Spondyloarthritis in Spain. Preliminary Descriptive Data From the emAR II Study

ObjectiveOur objective was to describe the variability in the management of spondyloarthritis (SA) in Spain in terms of healthcare resources and their use. MethodsA review of 1168 medical files of patients seen in randomly selected Spanish hospital rheumatology departments. We analyzed demographic variables and variables related to the consumption of health resources. ResultsThe total number of visits to rheumatology were 5908 with a rate of 254 visits/100 patient-years. The total number of visits to rheumatology specialty nurses was 775, with a rate of 39 visits/100 patient-years, and there were 446 hospitalizations, representing a rate of 22 per 100 patient-years. The number of admissions due to SA was 89, with a rate of 18 admissions/100 patient-years. Total visits to other specialists were 4307 with a rate of 200/100 patient-years. The total number of orthopedic surgeries was 41, which leads to a rate of 1.8 surgeries/100 patient-years. ConclusionsThe data regarding visits to the rheumatologist and prosthetic surgery of patients with in Spain are similar to most studies published in our environment, however, other aspects concerning the use of health resources are different compared to other countries. These data may help to understand and improve organizational aspects of management of SA in Spanish hospitals.

Variabilidad en el consumo de recursos en pacientes con espondiloartritis en España. Datos descriptivos preliminares del estudio emAR II

ObjectiveOur objective was to describe the variability in the management of spondyloarthritis (SA) in Spain in terms of healthcare resources and their use. MethodsA review of 1168 medical files of patients seen in randomly selected Spanish hospital rheumatology departments. We analyzed demographic variables and variables related to the consumption of health resources. ResultsThe total number of visits to rheumatology were 5,908 with a rate of 254 visits/100 patient-years. The total number of visits to rheumatology specialty nurses was 775, with a rate of 39 visits/100 patient-years, and there were 446 hospitalizations, representing a rate of 22 per 100 patient-years. The number of admissions due to SA was 89, with a rate of 18 admissions/100 patient-years. Total visits to other specialists was 4,307 with a rate of 200/100 patient-years. The total number of orthopedic surgeries was 41, which leads to a rate of 1.8 surgeries/100 patient-years. ConclusionsThe data regarding visits to the rheumatologist and prosthetic surgery of patients with in Spain is similar to most studies published in our environment, however, other aspects concerning the use of health resources are different compared to other countries. This data may help to understand and improve organizational aspects of management of SA in Spanish hospitals.

New Journal Section on Musculoskeletal Pain

Pain Medicine , recognizing a fundamental change in the understanding and management of musculoskeletal pain, is establishing a new musculoskeletal pain section in the journal that will feature clinical and basic research articles. Musculoskeletal pain disorders constitute a group of conditions that cross classical medical disciplines, encompassing the specialties of rheumatology, neurology, physical medicine and rehabilitation, anesthesia, and urogynecology, as well as touching other medical disciplines. The knowledge base of certain clinical conditions, especially myofascial pain syndromes (MPS) and fibromyalgia (FM), was so limited in the recent past that diagnosis and treatment clearly lagged behind other fields of medicine and were not evidence-based. It would not come as a surprise if amulets were prescribed for these conditions. Indeed, some of the popular treatments, popular particularly among long-time sufferers of these conditions, were little more than that, based on subsequent studies of treatment effectiveness. Among discounted treatments are S-adenosylmethionine (SAMe), guaifenisin, dehydroandrosterone (DHEA), and oral magnesium supplements for the treatment of FM, although they still maintain some currency among patients today. The intent of this section is to explore the broad fields of joint and periarticular pain conditions …

Access to pediatric subspecialty care: A population study of pediatric rheumatology inpatients in California

To examine trends in the specialty care hospitalization of pediatric rheumatology patients and determine how nonclinical factors influence access. This study used California's Office of Statewide Health Planning and Development discharge database to perform a retrospective population analysis of pediatric rheumatology hospitalizations in California between 1999 and 2007. We used logistic regression to examine the relationship between hospitalization in specialty care centers with a pediatric rheumatologist and nonclinical patient characteristics. A total of 18,641 pediatric discharges revealed that 57% were discharged from a specialty care center with a pediatric rheumatologist. Multivariate analysis showed that the factors associated with increased utilization of specialty care centers with a pediatric rheumatologist were public insurance (odds ratio [OR] 1.62, 95% confidence interval [95% CI] 1.51-1.74; P < 0.0001), being Hispanic (OR 1.29, 95% CI 1.19-1.40; P < 0.0001) or Asian non-Hispanic (OR 1.39, 95% CI 1.26-1.54; P < 0.0001), and high pediatric rheumatology specialty care bed supply (OR 2.79, 95% CI 2.49-3.14; P < 0.0001). A decreased utilization of specialty care centers with a pediatric rheumatologist was seen for patients ages <1 year (OR 0.45, 95% CI 0.40-0.52; P < 0.0001), ages 1-4 years (OR 0.50, 95% CI 0.46-0.55; P < 0.0001), ages 5-9 years (OR 0.68, 95% CI 0.62-0.75; P < 0.0001), ages 15-18 years (OR 0.51, 95% CI 0.47-0.56; P < 0.0001), males (OR 0.75, 95% CI 0.70-0.80; P < 0.0001), and patients residing farther away from a specialty care center with a pediatric rheumatologist (OR 0.57, 95% CI 0.51-0.63; P < 0.0001). Nonclinical factors play an increasingly important role in the hospitalization patterns of pediatric rheumatology patients in California. Understanding these factors is crucial if we are to ensure that the variation in access to care reflects clinical need.

Barriers to the Effective Diagnosis and Management of a Bleeding Patient with Undiagnosed Bleeding Disorder Across Multiple Specialties: Results of a Quantitative Case-Based Survey.

AbstractAbstract 3673 Introduction:While bleeding symptoms may be commonly seen by physicians of multiple specialties, these symptoms frequently belie an underlying yet undiagnosed congenital or acquired bleeding disorder. While it represents a rare bleeding disorder (1-4 cases per 1 million population per year), acquired hemophilia (AH) is a potentially life-threatening cause of unexplained recent-onset or acute bleeding manifested by an abnormal activated partial thromboplastin time (aPTT) that does not correct with 1:1 mixing with normal plasma. Given the rarity of AH, combined with the general lack of familiarity of non-hematologists with this condition, diagnosis of AH poses a clinical challenge, even in patients presenting with a clear picture of bleeding with an isolated prolonged aPTT. Methods:Actively practicing physicians within the specialties of hematology, hematology/oncology, emergency medicine, geriatrics, internal medicine, rheumatology, obstetrics and gynecology, critical care medicine, and general surgery were randomly sampled from the American Medical Association (AMA) Physician Masterfile and completed the 10 minute online survey during January 14–28, 2010. Results:Excluding surgeons and OB/GYNs, 302 physicians (50 to 51 per specialty) had mean ages ranging from 45.6 to 49.1 years, and mean years of practice experience ranging from 14.5 to 19.1.When provided with a hypothetical case report of an elderly female patient with recurrent epistaxis, nearly 90% of physicians in each of the surveyed specialties would have ordered a complete blood count (CBC) and coagulation studies (aPTT, PT, and INR) as part of their initial evaluation. Despite the resulting aPTT being abnormal at 42 seconds, other than hematologists, less than 1/2 would have chosen to repeat the studies. Fewer than 45% of surveyed physicians in all non-hematology specialties would have consulted a hematologist, with emergency medicine physicians least likely to consult (10%), and rheumatologists most likely to consult (43%).Following the patient's second presentation several weeks later with bruising and abdominal/back pain, ≥ 90% of respondents would have ordered both a CBC and coagulation studies as part of their initial evaluation. When these results revealed a markedly changed aPTT of 63 seconds, the majority of respondents would not have repeated coagulation studies. Approximately 75% of internal medicine and geriatrics physicians would have consulted a hematologist at this point, versus 47% and 50%, respectively, in emergency medicine and critical care. Participants across specialties were clear in their preference for a CT scan of the abdomen (80%-84%).Over a hypothetically additional 12 hours of observation, 73% to 94% of respondents would have consulted a hematologist at this point in the patient's clinical presentation, with laboratory studies revealing obvious ongoing blood loss and an aPTT that was at least twice the upper limits of normal; emergency medicine physicians remained least likely to consult. The majority of hematologists would have ordered 1:1 mixing studies with normal plasma to rule out coagulation inhibitors (97%). While approximately 80% or more of physicians in each specialty would have recommended hospital admission at the second presentation, the proportion recommending admission specifically to the ICU increased as the laboratory values deteriorated (worsening anemia and coagulopathy), most noticeably for the emergency medicine gatekeepers (35% to 73%). Conclusion:Given the rarity and high morbidity and mortality of AH, physicians must harbor a high index of suspicion in order to promptly diagnose this condition in patients who present with recent-onset of acute bleeding. As exemplified by the findings of this survey, the determination of the etiology of an abnormal coagulation study should carry equal weight to looking for the site of bleeding, and could be facilitated by consultation with a hematologist. The insights from this survey highlight knowledge and practice gaps that could be the focus of targeted educational initiatives or outreach by hematologists and coagulation laboratories, including diagnostic algorithms and critical pathways to assure proper work-up of abnormal coagulation studies in patients who are not on anticoagulation. Disclosures:Reding:Novo Nordisk Inc.: Consultancy. Cooper:Novo Nordisk Inc.: Employment.

Attitudes and perceptions of rheumatologists regarding consultation skills training for specialist trainees: a qualitative study

Within rheumatology specialty training, direct observation and formal assessment of consultation skills rarely occur. This study explored the attitudes and perceptions of rheumatology specialist registrars (SpRs) and consultants regarding consultation skills training and potential barriers to its successful implementation in the context of specialist training. Semi-structured interviews with rheumatology consultants and focus groups with rheumatology SpRs were conducted in four UK deanery regions. All participants value consultation skills training and believe it requires observation of trainees consulting. The skills of consultant trainers in providing feedback on consulting skills are sometimes sub-optimal. Direct, real time observation of trainees is difficult and happens infrequently. Recording consultations is a potentially attractive alternative. Important issues regarding the successful implementation of videotaped consultations include time constraints, consistency in the assessment of consultation skills, and expertise in providing constructive feedback that is individualised and tailored to the trainee's learning needs.

How to achieve and enhance professionalism in rheumatology

Ensuring and maintaining professionalism in medicine is essential, but there are many challenges to the traditional values and methods of achieving this. It is important for the specialty of rheumatology to highlight the importance of professionalism within training and clinical practice and to encourage ways of demonstrating this to patients, public, providers and politicians to gain confidence and avoid over-regulation. Professional attitudes, virtues and behaviour are key to providing the best standards of care for the large and growing number of people with musculoskeletal conditions, in particular, those that are long term. This is important not only for those who are directly in our care but also for those in the community, where the civic aspects of professionalism are central, by generally improving the standards of care through education and by raising priority. The tradition of knowing and working closely with our patients and their organisations is an important way of acquiring, maintaining and demonstrating professionalism within the specialty.

Systemic lupus erythematosus with neuropsychiatric manifestation incurs high disease costs: a cost-of-illness study in Hong Kong

To determine the direct and indirect costs of SLE in Hong Kong, and to ascertain the relationship between neuropsychiatric SLE (NPSLE) and disease costs. A retrospective, cross-sectional, non-randomized cost-of-illness study was performed in a tertiary rheumatology specialty centre in Hong Kong. Participants completed questionnaires on sociodemographics, employment status and out-of-pocket expenses. Healthcare resources consumption was recorded by chart review. The occurrence of NPSLE since onset of SLE was determined using the 1999 ACR nomenclature and standard definitions. Mann-Whitney U-test was used to compare disease costs between patients with and without NPSLE. Multiple linear regression was used to determine the predictors of the costs. Three hundred and six Chinese patients were recruited, with a mean age of 41 years and mean disease duration of 9.6 years. A total of 108 NPSLE events were recorded by 83 patients. The most common manifestations were seizure and cardiovascular disease. The mean annual total costs were USD 13,307 per patient. The direct costs dominated the total costs, and the costs of inpatient care contributed 52% of the direct costs. Patients with NPSLE incurred significantly higher direct and indirect costs compared with those without NPSLE. The number of NPSLE events was an independent explanatory variable associated with both direct and indirect costs. The economic impact of SLE in Hong Kong is considerable and patients with NPSLE incur higher disease costs compared with those without NPSLE. Improvement in prevention of end-organ damage, especially neuropsychiatric manifestation, may reduce costs of SLE patients.

Paediatric infliximab therapy: patients' and parents' perspectives on treatment options

Aim: To assess patients' and parents' perspectives on the impact of infliximab treatment on daily life and the acceptability and feasibility of (infliximab or adalimumab) home treatment, in the light of the perceived value of hospital services. Methods: A descriptive qualitative study was conducted at University College Hospital London. Data were collected via 25 semi-structured interviews with patients (aged 14-19) from both gastroenterology and rheumatology specialties, prescribed infliximab, and their parents. Results: The majority of participants preferred to continue infliximab treatment at their current hospital, rather than be treated in their local hospital or at home. The main reasons were the specialised care in their current hospital, the continuity of care and hospital staff, resistance to the method of adalimumab administration and expected problems with compliance. Hospital services were highly valued and current infliximab treatment at the hospital was considered to have either no impact on family and school life, or to have improved it. Conclusion: Infliximab is an effective therapy for inflammatory bowel diseases and rheumatology conditions in young people, bringing either no negative impact on, or improvement of school and family life. In association with patients' and parents' positive appraisal for hospital services and their confidence in the clinical team, patients and parents do not express a preference for infliximab or adalimumab home treatment, despite current health policy aimed towards therapy closer to, or at, home.

Systemische Manifestationen der rheumatoiden Arthritis

Extra-articular manifestations of rheumatoid arthritis are gaining in importance both in rheumatology and other specialities. This report provides information on various organ manifestations and interactions between mere disease-related symptoms and therapeutic effects. Diagnostic radiology plays a crucial role in finding the diagnosis, planning and monitoring of treatment, early detection of complications and drug-related adverse events.

Peripheral neuropathy in an outpatient cohort of patients with Sjögren's syndrome

Peripheral neuropathy is common in patients with Sjögren's syndrome (SS), but its precise prevalence is unknown. Most prior studies were conducted at neurology or rheumatology specialty clinics and likely selected for a more severely affected population. We evaluated 22 SS patients and 10 controls for evidence of neuropathy in an outpatient setting at a regional meeting of the Sjögren's Syndrome Foundation. We performed neurological examinations and nerve conduction studies (NCSs) and measured serum antinuclear antibody (ANA) and SS-A and SS-B antibody levels. Participants filled out a questionnaire pertaining to symptoms, diagnosis, and treatment. We found that signs and symptoms related to small axons were more common in patients with SS than in controls. Complaints of painful distal paresthesias in the feet were noted in 59% of patients but in only 10% of controls, and of abnormal sweating in 41% and 0%, respectively. Examination revealed decreased pinprick sensation in 64% of patients with SS, but in only 30% of controls. Overall, 45% of the patients but none of the controls were thought to have an isolated small-fiber neuropathy. Large-fiber dysfunction (as measured by testing vibration, deep tendon reflexes, and NCSs) was similar between the two groups. We conclude that small-fiber neuropathy is common in patients with SS.

Textbook of Rheumatology

Little progress was made in the understanding of the rheumatic diseases between Sydenham and Musgrave, writing in the 17th century, and the modern epoch in 1948, heralded by rheumatoid factor, the LE cell, and corticosteroids. The 1927 edition of Cecil's classic medical textbook devotes 10 lines to lupus erythematosus and a page and a half to scleroderma, the former under diseases of the mouth, the latter under skin. Boyd's Pathology of 1934 says nothing about either disease. Even the 1940 edition of Comroe's Arthritis devotes but 13 lines to lupus, 13 to scleroderma, and 13 to periarteritis. Epiphenomena were described, connections were not even speculated about (except erroneously to tuberculosis), and underlying mechanisms remained unknown. O, brave new world! This is the fourth edition of one of the standards of the now recognized specialty of rheumatology to be published in just 12 years. Although a couple of pages shorter than

MALTADERM '94: A DIALOGUE BETWEEN THE SISTER SPECIALTIES OF DERMATOLOGY AND RHEUMATOLOGY

Journal Article MALTADERM '94: A DIALOGUE BETWEEN THE SISTER SPECIALTIES OF DERMATOLOGY AND RHEUMATOLOGY Get access Rheumatology, Volume 32, Issue 11, November 1993, Page 971, https://doi.org/10.1093/rheumatology/32.11.971 Published: 01 November 1993

Role of health professionals in patient education.

The specialty of rheumatology in the United Kingdom has derived its methods of educating patients primarily from the experience of other specialties and from the United States. Care must be taken in setting up systems for patient education to ensure that the professionals appointed to these positions have the correct training and skills

Medical problems of adults who were sexually abused in childhood.

The aim of the study was to see whether adults who had been sexually abused in childhood were vulnerable to physical symptoms and therefore investigation and intervention. The case histories of seven patients who were aged 22-39, were under the care of three consultant psychiatrists, had experienced childhood sexual abuse, and had a history of medical or surgical intervention were surveyed. The patients had had a mean of 18 contacts with non-psychiatric consultant teams and a mean of eight operations, with a high rate (66-70%) of normal findings. They had experienced many somatic symptoms, which led to investigations and interventions in the specialties of gynaecology, obstetrics, gastroenterology, urology, rheumatology, haematology, orthopaedics, neurology, and neuropsychiatry. The history of childhood sexual abuse was recognised only in the later stages of this medical and surgical intervention. The possibility of childhood sexual abuse should be considered earlier in such cases to prevent further unnecessary intervention.