Journal of Rheumatology最新文献

Objective: To assess the utility of a metagenomic microbial plasma cell-free DNA next-generation sequencing assay (Karius Test [KT]) in the evaluation of patients in an outpatient rheumatology practice.

Methods: All patients with a KT ordered and obtained by a rheumatology provider in the outpatient setting from January 1, 2020, through December 31, 2022, were retrospectively identified. Demographic, clinical, laboratory, radiologic, histopathology, and microbial studies were abstracted. Indication for KT testing was categorized. KT results were defined based on positive result and clinical relevance regarding the symptoms under investigation at the time of the rheumatologic investigation. Review of cases 3 months after KT was undertaken to determine clinical outcome.

Results: One hundred fifty patients with a KT were included (52.7% female, mean age 52 years). The reason for KT was evaluation of atypical presentation of rheumatic disease (80%), assessing flare vs infection in patients on immunosuppression (16.7%), and fever of unknown origin (3.3%). Twenty-four (16%) KTs were positive, 6 of which were considered clinically relevant and altered the final diagnosis and treatment. Of the 126 negative KTs, 5 (4%) were found to have a clinically relevant infection by conventional testing methodologies.

Conclusion: In this large retrospective cohort study, the most frequent reason for KT utilization was an atypical presentation of rheumatic disease. One out of 4 positive KTs altered the final diagnosis and treatment. False negative rates were low. KT has utility in outpatient rheumatology assessments. Further delineation of which patients are best suited for KT testing remains to be defined.

Objective: Despite the high risk for permanent vision loss in elderly individuals with giant cell arteritis (GCA), initiation of subcutaneous tocilizumab (TCZ) is often delayed. We used chart review for GCA patients prescribed subcutaneous TCZ to investigate delays in drug initiation.

Methods: We included 82 patients with GCA at the University of Washington prescribed subcutaneous TCZ between 2017 and 2024. Time from medication request to medication approval/start and cost of TCZ were compared by insurance payor using 1-way ANOVA. Use of copay assistance, prior authorization requirement, drug manufacturer/foundation medication coverage, and switches to intravenous (IV) TCZ were compared by insurance using Pearson chi-square or Fisher exact tests.

Results: For all patients with GCA, the mean time between request and first dose was 43 days; the mean time between request and insurance approval was 17 days, and the mean time between medication approval and medication start was 30 days. Patients with Medicare or Medicare Advantage paid significantly more out-of-pocket for the first month of TCZ ($1399 vs $823, P < 0.01) and had significantly higher rates of copay assistance (P < 0.01) and full coverage of medication by the drug manufacturer or foundation (P = 0.04).

Conclusion: Patients with GCA experienced significant delays in starting TCZ therapy. In addition, patients on Medicare or Medicare Advantage plans had significantly higher out-of-pocket costs compared to other patients. These delays and costs are excessive for a vulnerable population with a potentially disabling disease. Further research is needed to investigate causes of delays, the high cost of medication, and effects on clinical outcomes.

Objective: To develop a web-based self-monitoring tool including motivational elements to improve empowerment of patients with rheumatoid arthritis (RA).

Methods: Following a design-thinking approach, the development included 3 iterative, cocreative phases involving different stakeholders. In the empathize and define phase, 2 focus groups gave insight into patients' wishes and needs regarding self-monitoring with an application. During the ideation phase, 2 cocreation sessions were organized to establish the content of the application and consider motivational elements. For the prototyping and testing phase, usability was assessed through both formative (heuristics evaluation) and summative (system usability scale [SUS] 0-100; ≥ 68 was considered good to excellent) evaluations.

Results: The focus group meetings resulted in a shortlist of what to monitor (physical function, quality of life, pain, fatigue, mental well-being, and social participation) and preferences on how to monitor (single-item questions, 0-10 scale, use as needed). The cocreation sessions revealed preference for empathetic dialogues with an avatar for self-monitoring. Setting goals, adding notes, sharing results, and receiving tips could further increase motivation for use. Initial experiences regarding heuristics of the tool were generally positive and confirmed by a mean SUS score of 84.4 (SD 11.6). Points for improvement included simplifying login procedures, adding notifications, and adjusting the avatar's tone of voice.

Conclusion: A web-based self-monitoring application (MyRA) was developed, with an avatar that asks patients through dialogues to score 6 domains, with graphical displays, diary functionality, and practical tips. Further studies are needed to confirm its usability and effectiveness in empowering patients.

Objective: Systemic sclerosis (SSc) often presents alongside other connective tissue disorders, termed "overlap syndrome (OS)." This study aimed to characterize patients with SSc with OS compared to those without OS in a tertiary university hospital in Brazil.

Methods: A retrospective analysis of demographic, clinical, and laboratory data from 787 SSc patients was performed using electronic medical records. Patients were classified based on the 2013 American College of Rheumatology/European Alliance of Associations for Rheumatology criteria for SSc and additional criteria for systemic lupus erythematosus (SLE), idiopathic inflammatory myopathy (IIM), Sjögren disease (SjD), and rheumatoid arthritis (RA). Statistical analysis, including univariate and multivariate methods, identified factors associated with OS.

Results: Ninety-one patients (11.6%) had OS, mainly with SLE (29.7%), SjD (26.4%), RA (24.2%), or IIM (19.8%). Patients with OS were younger, with an earlier age at onset (P = 0.004) and at diagnosis (P = 0.003). They presented a higher prevalence of limited SSc (P _trend = 0.06), musculoskeletal symptoms (P < 0.001), neoplasia (P = 0.03), and sicca symptoms (P < 0.001); and were associated with a lower frequency of pulmonary hypertension (P = 0.048) and comorbidities such as diabetes mellitus (P = 0.02) and dyslipidemia (P = 0.02). A higher prevalence of anti-Ro (P = 0.007) and a lower prevalence of anti-Scl70 (P = 0.003) were also observed. Patients with OS were more frequently prescribed glucocorticoids (GCs; P < 0.001), methotrexate (P = 0.01), and leflunomide (P = 0.001). Multivariate analysis identified limited SSc (odds ratio [OR] 3.1), neoplasia (OR 3.4), and use of GCs (OR 8.2) and leflunomide (OR 5.5) with OS. No worse prognosis was observed.

Conclusion: Overall, Brazilian patients with SSc with OS have distinct clinical characteristics but do not have a worse prognosis compared to those without OS.

Systematic reviews (SRs) are a structured means of knowledge synthesis used by a variety of healthcare practitioners to aid in medical decision making. The SR, if conducted rigorously, is considered to be at the top of the hierarchy for research studies. In addition to synthesizing evidence, SRs identify research priorities, address questions that may not be answerable by individual studies, and identify gaps to be addressed in future primary research. There are several steps that need to be taken when developing SRs to provide the best available evidence-the most essential being the assessment of risk of bias (ROB). Several ROB tools have been developed for use according to study design. Increasingly used is the assessment of certainty of evidence using approaches such as those developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group. Whereas ROB is assessed for individual studies, the certainty of evidence is assessed for each critical or important outcome across studies. Analysis can be quantitative (meta-analysis) or qualitative (narrative), with the former intended to develop estimates of the effect measure (ie, the statistic that compares collated data), with confidence limits around that estimate. This review will focus on the steps required to develop SRs, from registration of the review protocol to the conduct, analysis, and reporting, with a focus on the assessment of ROB and certainty of evidence to ensure the development of a methodological and rigorous process.

Objective: Intermediate treatment targets in Still disease have been proposed by the European Alliance of Associations for Rheumatology (EULAR) and the Paediatric Rheumatology European Society (PReS) in 2024. This study aimed to evaluate the utility of the targets in clinical practice.

Methods: Consecutive patients with adult-onset Still disease (AOSD) based on the Yamaguchi criteria who visited Keio University Hospital from April 2012 until May 2024 were retrospectively reviewed. We assessed the achievement rates of the following treatment targets: day 7 (resolution of fever and reduction of C-reactive protein [CRP] by > 50%); week 4 (no fever, reduction of active joint count by > 50%, and normal CRP); month 3 (clinically inactive disease [CID] with < 0.1 mg/kg/day of glucocorticoids [GCs]); and month 6 (CID without GCs). We also assessed the association of treatment target achievement with long-term outcomes including recurrence and discontinuation of GCs.

Results: Sixty-two patients were included in the analysis. The mean age was 50.8 (SD 19.5) years, and 47 (75.8%) were female. The recommended treatment targets were achieved in 67.2% at day 7, 61.1% at week 4, 3.3% at month 3, and 1.7% at month 6. Failure to achieve targets at months 3 and 6 was mainly because of GC usage. During the median observational period of 7.1 years, patients who achieved CID at month 6 had fewer recurrences thereafter (hazard ratio [HR] 0.27, 95% CI 0.11-0.68). Successful GC withdrawal was associated with CID at month 3 and the use of biologic agents at month 6 (HR 2.51, 95% CI 1.15-5.46 and HR 2.29, 95% CI 1.14-4.61, respectively).

Conclusion: The EULAR/PReS intermediate treatment targets for Still disease are useful in the clinical management of AOSD.

Objective: Psoriatic arthritis (PsA) is associated with metabolic and cardiovascular (CV) disease. Studies have suggested that treatment with apremilast is associated with weight loss and other cardiometabolic benefits. This study aimed to examine the effects of apremilast on body weight, body composition, and CV risk factors in patients with PsA.

Methods: This longitudinal, nonrandomized, multicenter trial included adults with active PsA initiating apremilast (30 mg twice daily after a step-up regimen). Patients were followed for 12 months, and measurements were done at baseline and repeated at weeks 26 and 52. Body composition, the primary outcome, was assessed using dual-energy x-ray absorptiometry. Secondary outcomes included disease activity (Disease Activity Score in 28 joints [DAS28] based on C-reactive protein [CRP]), blood pressure (BP), lipids, intima-media thickness, and glucose. Statistical analysis involved mixed models adjusted for relevant covariates.

Results: Forty-four patients were included, with a mean age of 56 (SD 11) years and a median BMI (kg/m²) of 28 (IQR 24-33). A total of 17 patients completed the study, whereas 27 discontinued due to ineffectiveness or side effects. After 1 year of apremilast, significant reductions were observed in multiple body mass measures, including total fat (-7.4 kg; P = 0.005) and android fat (-1.1 kg; P = 0.002). Lean mass remained stable. BP showed minor reduction, whereas lipids, intima-media thickness, and glucose levels did not change. Disease activity improved, with a significant decrease in DAS28-CRP (-0.6; P = 0.01). Android fat correlated most strongly with disease activity reduction (r 0.31; P = 0.004).

Conclusion: This study demonstrates that apremilast reduces fat mass in patients with PsA and suggests beneficial CV and metabolic effects, potentially reducing the risk of CV events.