JCR: Journal of Clinical Rheumatology最新文献

Background: Reproductive health is a critical issue for women with autoimmune rheumatic diseases (ARDs), yet significant gaps in knowledge and practices persist. While prior studies have largely focused on populations in high-income countries or specialized clinics, there is limited evidence addressing the reproductive health behaviors and challenges in middle-income settings, where disparities in health care access and counseling are pronounced. This study aims to assess reproductive health knowledge, contraceptive use, and pregnancy planning among Mexican women with ARDs, identifying specific areas for improvement in education and counseling to bridge these gaps.

Methods: A cross-sectional study was conducted involving 725 women aged 18 to 50 years diagnosed with ARDs, recruited from 5 hospitals in Mexico between August 2023 and February 2024. Participants completed the Rheum Reproductive Behavior questionnaire, which assessed reproductive health knowledge, contraceptive use, and family planning behaviors. Statistical analyses included descriptive statistics and logistic regression to identify factors associated with reproductive health practices.

Results: Among the 725 participants, 47.29% reported inconsistent contraceptive use, and 47.7% of pregnancies were unplanned. Despite known risks associated with active disease during pregnancy, 36% of participants reported not receiving information on contraception, and 34% did not receive adequate preconception counseling. A large proportion of women lacked sufficient knowledge regarding the impact of their disease on reproductive health, with only 38% feeling well-informed about pregnancy-related risks.

Conclusions: This study identified critical deficiencies in reproductive health knowledge, limited pregnancy planning among Mexican women with ARDs, and that half of the participants reported inconsistent contraceptive use, underscoring a significant gap in counseling and guidance. The findings emphasize the need for targeted educational programs and standardized counseling protocols to improve global reproductive health guidance provided by health care professionals.

Purpose: To assess whether sex and comorbidity are associated with the risk of 90-day readmission and associated mortality after nonelective primary total hip arthroplasty (THA) for hip fracture in the United States.

Methods: We used the 2016-2019 US Nationwide Readmissions Database, a nationally representative dataset of readmissions, to examine 90-day readmission outcomes after primary nonelective THA with a primary diagnosis of hip fracture. Sex and medical comorbidity (Deyo-Charlson Comorbidity Index) were variables of interest. We adjusted for demographics (age), social determinants of health (income, region, insurance payer), and hospital characteristics (control, location/teaching status, bed size). We calculated adjusted odds ratio (aOR) and 95% confidence intervals (CIs) in multivariable-adjusted logistic regression analyses.

Results: Of the 346,030 nonelective primary THAs for hip fracture performed in the United States, 61,443 (17.8%) had a 90-day readmission. For readmitted patients, the mean age was 80.2 years (SD, 9.6), 62.0% were women, and 90.6% had Medicare payer. In multivariable-adjusted analysis, compared with men, women had a lower aOR of 0.75 (95% CI, 0.73-0.77; p  < 0.001) for 90-day readmission and lower aOR of 0.76 (95% CI, 0.69-0.84; p  < 0.001) of in-hospital mortality during readmission, after nonelective primary THA for hip fracture. Deyo-Charlson index scores of 1 and ≥2 were associated with higher aOR of 90-day readmission at 1.53 (95% CI, 1.47-1.59; p  < 0.001) and 2.20 (95% CI, 2.13-2.28; p  < 0.001) and higher in-hospital mortality during readmission, 1.20 (95% CI, 1.01-1.42; p  = 0.04) and 1.69 (95% CI, 1.40-1.97; p  < 0.001), respectively.

Conclusion: In contemporary U.S. national data from 2016 to 2019, medical comorbidity and male sex were each associated with a higher risk of 90-day readmission and in-hospital mortality following primary nonelective THA for hip fracture. Further investigation into mechanisms and pathways of increased risk in men and those with higher medical comorbidity undergoing primary THA for hip fracture is needed, which can lead to the development of pathways for risk reduction and improved outcomes.

Objective: Juvenile idiopathic arthritis is a heterogeneous group of chronic childhood arthritis. We planned to classify patients with oligoarticular, rheumatoid factor (RF)-negative polyarticular and undifferentiated groups according to the International League of Associations for Rheumatology criteria, most of them in other or undifferentiated groups according to the new proposed PRINTO (Pediatric Rheumatology International Trials Organization) criteria, into more homogeneous groups according to their clinical and laboratory findings.

Methods: Two hundred three patients with oligoarticular, RF-negative polyarticular and undifferentiated juvenile idiopathic arthritis were included in the study. Sixteen clinical and laboratory variables were evaluated using TwoStep Cluster analysis. Clinical and laboratory characteristics of the resulting clusters were then compared with each other.

Results: Two clusters were generated as the result of cluster analysis. Cluster 1 had 138 (68%) and cluster 2 had 65 (32%) patients. The main indicators differentiating 2 clusters were wrist and elbow involvement and the number of affected joints. The number of affected joints was 2 (1-8) and 6 (1-26) in cluster 1 and cluster 2 ( p  < 0.001). Wrist and shoulder involvements were seen only in cluster 2 ( p  < 0.001). Ankle, elbow, small joint, and temporomandibular joint involvements were higher in cluster 2. Corticosteroids, disease-modifying antirheumatic drugs, and biologics were used at higher rates, and remissions at the 12th month and last visit were lower in cluster 2.

Conclusions: Our results classified patients with oligoarticular, RF-negative polyarticular, and undifferentiated arthritis into 2 clusters. Wrist and elbow involvements and the number of involved arthritis were the most important factors in differentiating the 2 groups.

Objective: To describe Raynaud phenomenon (RP) management practices for systemic sclerosis (SSc) patients among US community-based rheumatologists.

Methods: We identified all adult SSc patients, diagnosed by a rheumatologist, from the FORWARD Databank between 1999 and 2023. We evaluated longitudinal RP medication use, from data collected by semiannual questionnaires. We evaluated factors associated with RP medication use with multivariable Andersen and Gill Cox proportional models.

Results: Of the 270 SSc patients, 61% received a medication for RP over the median (interquartile range) follow-up of 3.4 (1.3-7.8) years. Calcium-channel blockers were the most chosen overall (48%) and first-line (75%) medication, followed by renin-angiotensin system inhibitors (18% [23%]). The use of RP medications persistently (29%), combination regimens (20%), and advanced therapies (15%; phosphodiesterase-5 inhibitors [PDE5i], endothelin receptor antagonists, or prostaglandin analogs) throughout the follow-up was low. Whereas calcium-channel blocker use has declined, PDE5i use has increased since 2019. Factors associated with initiating medications for RP were hypertension (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.25-1.98), pulmonary disease (HR, 1.25; 95% CI, 1.04-1.52), immunomodulatory use (HR, 1.32; 95% CI, 1.04-1.68), higher annual income (HR, 1.33; 95% CI, 1.02-1.73), and having an insurance (HR, 2.37; 95% CI, 1.04-5.44).

Conclusion: Overall use of RP medication was low with poor maintenance rates in less than one-third of the patients from this community sample. The pattern of RP medication use changed over time with increasing use of PDE5i use since 2019. Although socioeconomic factors had impact on RP medication initiation, there is also a need for education and guideline recommendations to assist community-based rheumatologists in RP management.

Objective: To develop a score for a diagnosis of cytopenias from systemic lupus erythematosus (SLE) activity and determine the usefulness of bone marrow aspirate and biopsy (BMA/BMB) in this population.

Methods: We conducted a cohort study focusing on patients with SLE who underwent BMA/BMB as part of the evaluation for cytopenias. Etiology of cytopenias was categorized into SLE activity, drug-associated toxicity, and other diagnoses. We devised a scoring system, incorporating 5 factors, which were chosen and weighed based on their relative odds ratios on the analyzed models.

Results: A total of 115 patients were enrolled; 84.4% were women, and median age was 31 years (interquartile range [IQR], 23-42). Diagnoses for cytopenias were as follows: SLE activity in 47 patients (40.9%), drug-associated toxicity in 35 patients (30.4%), and other diagnoses in 33 patients (28.7%). Patients with SLE activity exhibited higher Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) scores ( p  = 0.009) and anti-dsDNA levels ( p  = 0.017). To enhance the diagnostic approach for patients with cytopenias secondary to disease activity, we introduced a scoring system with 5 variables: performing BMA/BMB due to suspected activity, absence of severe neutropenia, absence of azathioprine treatment, articular activity, and SLEDAI-2K score >6. The area under the curve was determined to be 0.85, indicating a sensitivity of 87.2% and a specificity of 70.5% when the cutoff value was set to ≥4.5 points.

Conclusion: Disease activity and drug-associated toxicity are the main causes of cytopenias in SLE patients. We developed a scoring system with acceptable diagnostic performance to detect disease activity as the cause of cytopenias in patients with SLE.

Objective: Biological drugs have revolutionized the treatment of rheumatic diseases, but their high cost has contributed to increased prescription drug spending in the United States. The US Food and Drug Administration has approved the use of several biosimilars, medications that are like their reference biologics with comparable safety and effectiveness, for use in rheumatic diseases. We describe a cost reduction project at a large academic medical center aimed at increasing the use of biosimilars for rituximab and infliximab within rheumatology clinics.

Methods: We included patients aged 17 and older with rheumatologic conditions who were prescribed either infliximab or rituximab. A series of educational and electronic health record (EHR) interventions were implemented between 2018 and 2020 to encourage the use of infliximab-dyyb and rituximab-abbs, both biosimilar agents. We measured the change in utilization of these 2 biosimilars between onset of institutional approval through 2023.

Results: During the study period, the overall rate of use of these biosimilars increased from a baseline of <5.0% to 49.4% for infliximab-dyyb and <5.0% to 51.3% for rituximab-abbs. We estimated a total of greater than $3.2 million in cost savings, solely through 2 biosimilar substitutions within 1 specialty clinic at our institution.

Conclusions: Biosimilar use among rheumatology providers in an academic setting can be increased through multimodal interventions including education and EHR modifications. This change has the potential for large cost savings.

Background: Postmenopausal osteoporosis is a prevalent condition characterized by increased bone turnover and reduced bone mass, leading to fragility fractures. Romosozumab, a monoclonal antibody targeting sclerostin, exhibits dual mechanisms of action by stimulating bone formation and inhibiting bone resorption.

Objective: This meta-analysis aimed to study the effects of romosozumab in postmenopausal women compared with other interventions, evaluating changes in bone mineral density (BMD), incidence of new vertebral fractures, bone biomarkers, and safety.

Methods: A systematic search was conducted using 3 databases. Randomized controlled trials evaluating romosozumab in postmenopausal patients with osteoporosis were included. The analyzed variables included BMD, the incidence of new vertebral fractures, markers of bone formation and resorption, and adverse events. Sensitivity analyses and GRADE (Grading of Recommendations Assessment, Development, and Evaluation) assessments were conducted to ensure the robustness and certainty of the finding.

Results: Ten randomized controlled trials with 15,476 patients were included. Romosozumab demonstrated significantly greater improvements in lumbar spine BMD than placebo (mean difference [MD], 13.18; 95% confidence interval [CI], 11.91-14.45; p < 0.00001), denosumab (MD, 5.29; 95% CI, 4.20-6.37; p < 0.00001), teriparatide (MD, 4.35; 95% CI, 4.09-4.61; p < 0.00001), and alendronate (MD, 9.95; 95% CI, 7.51-12.40; p < 0.00001). Romosozumab also showed higher levels of the bone formation marker P1NP (procollagen 1 N-terminal propeptide) than denosumab (standardized mean difference, 1.30; 95% CI, 0.38-2.21; participants = 178; studies = 2; I2 = 83%; p = 0.006) and alendronate (standardized mean difference, 2.06; 95% CI, 1.68-2.45; participants = 366; studies = 2; I2 = 46%; p < 0.00001). Romosozumab reduced the risk of vertebral fractures 4-fold versus placebo (odds ratio, 0.26; 95% CI, 0.13-0.53; participants = 3186; studies = 2; I2 = 0%; p = 0.0002). The present study has some limitations, including potential heterogeneity among the included trials and the need for long-term safety data. Nevertheless, the safety profile of romosozumab was comparable to the comparator interventions.

Conclusions: This comprehensive meta-analysis provides robust evidence that romosozumab is an effective and safe treatment option for postmenopausal osteoporosis, with superior effects on BMD and bone formation biomarkers compared with other interventions. These findings support the use of romosozumab to improve clinical outcomes in this patient population.

Objective: Appreciative Inquiry (AIn) is a strengths-based organizational framework to promote engagement and change. It has shown promise in graduate medical education settings, but how, why, and for whom AIn may drive educational outcomes is underexplored. This realist evaluation examines the causal relationships between contexts, mechanisms, and outcomes at a rheumatology fellowship program in a large tertiary care center that implemented a set of AIn-based interventions. We generate recommendations for leaders in rheumatology fellowship programs on the implementation of AIn-based interventions.

Methods: The realist evaluation was conducted in 3 phases. In phase 1, a scoping review informed the initial program theory. In phase 2, realist interviews were conducted to identify and refine causal relationships between contexts, mechanisms, and outcomes, yielding a final program theory. In phase 3, the final program theory was utilized to generate recommendations for implementation.

Results: The final program theory identified 15 contexts, 10 mechanisms, and 10 outcomes along with 43 context-mechanism-outcome configurations. Through analysis of the final program theory, 3 recommendations were generated: (1) programs must first create permission structures for critical self-reflection through strengths-based feedback, (2) programs must consistently and synergistically apply AIn principles at multiple levels, and (3) programs can sustain AIn-based interventions through the deliberate co-design of virtuous cycles.

Conclusions: This realist evaluation has generated a theory on how AIn may be implemented into rheumatology fellowship programs to drive educational outcomes. Because of the intricate causal relationships, leaders are well-advised to tailor AIn-based interventions based on the context of their training programs.