JCR: Journal of Clinical Rheumatology最新文献

Abstract: Drug persistence is a crucial measure of long-term efficacy, safety, and patient satisfaction. Lack of persistence can increase healthcare costs and morbidity and mortality rates. This review aimed to consolidate available data on drug persistence for various biological treatments used as the primary intervention for psoriatic arthritis and identify factors associated with nonpersistence. Reports indicate variable 1-year persistence rates for biologic therapies, ranging from 37% to 73%. Specifically, tumor necrosis factor inhibitors have shown fluctuating 1-year persistence rates ranging from 32% to 85%. IL-12/23 and IL-23 inhibitors demonstrate persistence rates of 25% to 89%, whereas data for IL-17 and JAK inhibitors are more limited, ranging from 51% to 77%. Factors such as female sex and a higher burden of comorbidities have been associated with an increased risk of nonpersistence, although evidence regarding other factors remains scarce. The significant variability in reported persistence rates may be attributed to differences in treatment gaps and methodologies across studies. Addressing and mitigating the factors leading to nonpersistence is essential for improving treatment outcomes in psoriatic arthritis.

Background: Shared decision-making (SDM) is a principle of humanistic, patient-centered health care within the field of rheumatology. However, clear communication between patients and their clinicians regarding the benefits and risks of immunomodulators may be challenging in a clinical setting. The design-thinking process is a human-centered approach to quality improvement that can help to identify insights to uphold high-quality communication.

Methods: The development process adhered to the Stanford design thinking process framework, encompassing 5 stages: (1) empathize, (2) define, (3) ideate, (4) prototype, and (5) test. During the empathy stage, quality improvement members spent 4 hours immersed in the clinical setting observing how patients and clinicians engage in SDM conversations. These observations were augmented by unstructured debriefing sessions to better understand the needs and drivers of high-quality SDM. Following this, a rapid ideation workshop was convened to generate creative solutions. These led to rapid prototyping and testing, yielding a final product.

Results: The iterative design process identified 4 critical needs: (1) ensuring comprehensibility of materials, (2) upholding accuracy of information, (3) balancing standardization with individualization, and (4) promoting retention of knowledge. During the rapid ideation workshop, the concept of a Worksheet for Immunomodulator Shared Decision-Making (WISDM) was introduced and selected for further elaboration. This led to the creation of 5 prototypes for methotrexate, which were subsequently tested. These were reconciled and modified to make a final product.

Conclusion: The WISDM template contains 7 elements that support SDM. Forty-five WISDMs were created for 23 immunomodulators. Further investigation will focus on how WISDMs exactly impact SDM.

Objective: Diagnosis of periprosthetic joint infection (PJI) in patients with inflammatory arthritis (IA) is challenging, as features of IA flares can mimic infection. We aimed to cross-sectionally determine if the optimal tests to diagnose PJI in osteoarthritis were present in patients with IA flares.

Methods: We enrolled patients from October 2020 to July 2022 in 3 groups: (a) PJI-total joint arthroplasty patients undergoing revision for infection, (b) IA Flare-IA patients with a flaring native joint, and (c) IA Aseptic-total joint arthroplasty patients with IA undergoing aseptic arthroplasty revision. We compared blood and synovial fluid markers between the cohorts using Kruskal-Wallis and Fisher exact tests to assess marker sensitivity and specificity.

Results: Of 52 cases overall, 40% had rheumatoid arthritis, 20% psoriatic arthritis, and 11% osteoarthritis (in PJI group). PJI cases had higher C-reactive protein (CRP) and synovial fluid polymorphonuclear neutrophil percentage (%PMN). Alpha-defensin tested positive in 93% of PJI cases, 20% of IA Flares, and 6% of IA Aseptic (p < 0.01). Synovial white blood cell count >3000/μL and positive alpha-defensin were highly sensitive (100%) in diagnosing infection; however, specificity was 50% for white blood cell counts and 79% for alpha-defensin. PJI diagnosis was nearly 5 times more likely with positive alpha-defensin and almost 6 times more likely with %PMNs >80. Blood markers interleukin-6, procalcitonin, and d-dimer were neither sensitive nor specific, whereas erythrocyte sedimentation rate and CRP showed 80% sensitivity, but 47% and 58% respective specificities.

Conclusions: Although synovial %PMNs, CRP, and alpha-defensin are sensitive tests for diagnosing PJI, they are less specific and may be positive in IA flares.

Objectives: Pulmonary arterial involvement (PAI) is one of the most common causes of mortality in Behçet's disease (BD). In this study, we aimed to evaluate the clinical features, course, and recurrence risk factors of BD-associated PAI.

Methods: BD patients who were followed up in Marmara University BD outpatient clinic between 1990 and 2023 were included. All data were acquired from the medical records of the patients. PAIs were classified according to the type of the vascular involvement as thrombosis or aneurysm. Factors affecting the risk of relapses were determined using multivariate Cox regression analysis.

Results: Among 1350 BD patients, 110 (8.1%) had PAI. The mean age (SD) of patients with PAI was 42.4 (11.6) years, and the male/female ratio was 2.2 (76/34). Thirty-two (29.1%) of 110 patients were asymptomatic. Asymptomatic patients with PAI were significantly younger (p = 0.031) than the symptomatic group. Also, a greater prevalence of females (p = 0.001) and higher recurrence rates (p = 0.019) were observed in the symptomatic group. Pulmonary arterial thrombosis was seen in 104 (94.5%) and aneurysms in 9 patients (6.6%). At least one PAI relapse was observed in 31 patients (28.2%). In multivariate analysis, the Cox regression model was significant (p = 0.013), and not starting anticoagulants independently increased the PAI relapse risk (hazards ratio, 4.36; 95% confidence interval, 1.14-24.1; p = 0.042).

Conclusions: Pulmonary arterial thrombosis is the main presentation type of PAI in BD, whereas aneurysmatic formation is rare. Despite immunosuppressive treatment, relapses occur during follow-up in one third of patients with PAI. When anticoagulant therapy is added to immunosuppressive therapy, the relapse rate in BD patients with PAI is significantly reduced.

Objective: We evaluated a behaviorally designed intervention utilizing gamification and social support to improve physical activity and reduce symptoms in patients with osteoarthritis of the knee (KOA).

Methods: Veterans with KOA, aged 40-80 years, were enrolled in this randomized controlled trial. Participants received a Fitbit and completed a 2- to 4-week baseline period. A Web-based platform administered biweekly surveys after randomization and tracked physical activity. Participants selected a daily step goal that was 33%, 40%, or 50% above their baseline. The intervention arm received game playing aspects and a social support partner to advance weekly step performance while the control arm only received weekly updates. The primary outcome was the change in steps per day averaged over 2-week intervals. We used mixed effects regression, adjusting for baseline step count. Secondary outcomes assessed the change in KOOS (Knee Injury and Osteoarthritis Outcome Score) over 32 weeks.

Results: Thirty-one participants were included in the final analysis. Most participants were male (90.3%), Black (70.96%), had a mean (SD) age of 60 (13) years, and body mass index of 33.7 (5.9) kg/m2. Participants that received the intervention walked a total of 1119 (95% confidence interval: -562, 2799) more steps per day (p = 0.19). The effect was greatest in the first 6 months (1491 [-272, 3254], p = 0.10). Compared with controls, those that received the intervention had improvement over time in total KOOS (mean 2-week change +0.62 [0.031, 1.20] vs -0.38 [-1.04, 0.28], p = 0.02) and several subscales.

Conclusions: This intervention demonstrated promise for promoting greater physical activity and improving symptoms in patients with KOA.

Background/objective: Despite advances in clinical care and treatment options, adolescents with lupus continue to experience adverse health outcomes. Poor adherence to medication regimens is a major contributor to these negative outcomes. The utility of short message service (SMS) in tracking barriers to adherence prospectively remains untested for adolescents with lupus. Our objectives were (1) feasibility of incorporating a Health Insurance Portability and Accountability Act (HIPAA)-compliant SMS text messaging application into REDCap and (2) acceptability of using SMS text messaging to track barriers to medication adherence in adolescents with lupus.

Methods: This study is a 12-week pilot cohort study of adolescents with SLE per the 1997 revised American College of Rheumatology. A REDCap-embedded HIPAA-compliant text messaging application was used to send biweekly messages with survey link to track medication adherence. Measures were completed. Descriptive statistics were used to summarize demographics, medical, and acceptability data. Response to text messages and survey completion rates were reported as a measure of feasibility.

Results: Most eligible adolescents approached agreed to participate (n = 17, 71% enrollment rate). The cellphone ownership rate among adolescents eligible for participation was 92%. Nine subjects responded to all text messages sent (53% response and completion rate). Eleven subjects (65%) responded to two thirds of the text messages. Overall, 77% of enrolled subjects completed at least half of the surveys sent. Reminders to complete surveys were sent to 30% of enrolled adolescents.

Conclusions: This study shows that embedding a HIPAA-compliant SMS text message application in REDCap is feasible and can be used to engage adolescents with chronic conditions in monitoring between clinic visits.