Journal of Rheumatology最新文献

Objective: To describe the psoriatic phenotype associated with psoriatic arthritis (PsA).

Methods: Based on the previously published 4-item Psoriatic Arthritis Uncluttered Screening Evaluation (PURE-4) validation study, this work aims to describe the sociodemographic and clinical characteristics, as well as the PURE-4 questionnaire outcomes, of patients with psoriasis (PsO) who completed the study. It compares those diagnosed with PsA during the study to those with PsO only. The variables compared were age, sex, time since diagnosis of PsO, PsO location, PsO treatment, Psoriasis Area and Severity Index (PASI), and Dermatology Life Quality Index (DLQI).

Results: The study included 253 patients with PsO, from whom 46 developed PsA (28 [60.9%] male; mean age 48.9 [11.1] years) during the study. At baseline, patients who developed PsA had more involvement of PsO in the neck (13% vs 3.4%, P < 0.01), knees (71.4% vs 50%, P = 0.02), hands (40% vs 17.7%, P < 0.01), and feet (22.9% vs 9.8%, P = 0.03) as well as high-impact areas. PASI (8.7 [SD 5.6] vs 6.8 [SD 5.0], P = 0.03) and DLQI (9.9 [SD 6.9] vs 7.6 [SD 6.7], P = 0.09) values were higher among patients with PsA. Peripheral joint pain with swelling (item 4) was the most prevalent item of PURE-4 among patients with PsA, ranging from 67.6% (vs 47.1%; P = 0.03) in Assessment I to 91.7% (vs 45.4%; P < 0.01) in Assessment II.

Conclusion: Greater PsO involvement in neck, knees, hands, and feet as well as in high-impact areas of patients who developed PsA provides additional information on the arthritogenic phenotype of PsO in our study population compared to locations generally linked to arthritis risk, such as the nails or scalp.

Objective: Conventional radiography (CR) and ultrasound (US) are used interchangeably for identification of calcium pyrophosphate deposition (CPPD). The aim of this study was to assess whether combining US and CR offers greater accuracy over either modality alone for the identification of CPPD.

Methods: Consecutive patients scheduled for knee replacement surgery for osteoarthritis were enrolled. Before surgery, patients underwent CR and US of the knee. Menisci and hyaline cartilage were collected and analyzed using polarized light microscopy to confirm the presence of CPPD (gold standard). CR and US were assessed for absence/presence of CPPD by expert radiologists and sonographers. Diagnostic performance statistics were calculated. Poisson models with robust variance estimators were used to determine the likelihood of identifying CPPD.

Results: Fifty-one patients (63% female, mean age 71.4 [SD 8] years) were enrolled. US demonstrated higher overall accuracy than CR for CPPD identification (0.78 vs 0.73). Sequential use of both modalities provided an advantage when only 1 knee site was positive in 1 of the 2 techniques; however, when 2 or 3 sites were positive, no additional advantage was observed. When US was negative, subsequent CR did not improve CPPD detection, but in cases of a negative CR, a positive US increased the likelihood of CPPD by 4.21 times, whereas a negative US substantially reduced the probability of CPPD, increasing the likelihood of its absence by 76%.

Conclusion: US was more accurate than CR for identification of CPPD. Performing both exams can be an added value for CPPD identification only in a few specific cases.

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.