Arthritis Care & Research最新文献

Objective: Not much is known regarding musculoskeletal ultrasound (MSUS) practices of rheumatologists in the United States. We sought to determine the current use of MSUS among past participants of the Ultrasound School of North American Rheumatologists (USSONAR) training program and, by extension, MSUS practicing rheumatologists and to understand barriers to its MSUS use.

Methods: An online survey was sent to 374 participants in the 8-month USSONAR blended course (Fundamentals in MSUS and Train the Trainer) between 2009 and 2020. Each respondent had a unique identifier linked to their total number of submitted practice scans and examination scores during training.

Results: The survey response rate was 28.1% (105/374), comprising 82% adult and 18% pediatric rheumatologists. Of the respondents, 71% were MSUS certified: 86.7% performed and/or interpreted diagnostic MSUS, 81.0% performed/interpreted procedural MSUS, 59.8% billed for at least 50% of diagnostic studies, and 78.8% billed for at least 50% of procedural studies. The top reasons for not doing diagnostic and procedural ultrasonography were lack of administrative support and limited time, respectively. For 25% of diagnostic ultrasonography and 12.9% of procedural ultrasonography, billing was done less than 50% of the time. Of the respondents, 78.0% reported that USSONAR training made them better rheumatologists.

Conclusion: Most USSONAR-trained rheumatologists are certified, practicing both diagnostic and procedural MSUS and billing for most of their work. However, a substantial number of studies are not being billed due to time constraints, limited administrative support, and legal liability. Participants agreed that USSONAR training made them better rheumatologists.

Objectives: The objective of this study is to evaluate whether adding oral glucocorticoids to immunosuppressive therapy improves skin scores and ensures safety in patients with early diffuse cutaneous systemic sclerosis (dcSSc).

Methods: We performed an emulated randomized trial comparing the changes from baseline to 12±3 months of the modified Rodnan skin score (mRSS: primary outcome) in early dcSSc patients receiving either oral glucocorticoids (≤20 mg/day prednisone-equivalent) combined with immunosuppression (treated), or immunosuppression alone (controls), using data from the European Scleroderma Trials and Research Group. Secondary endpoints were the difference occurrence of progressive skin or lung fibrosis, and scleroderma renal crisis. Matching propensity score was used to adjust for baseline imbalance between groups.

Results: We matched 208 patients (age 49 years; 33% male; 59% anti-Scl70), 104 in each treatment group, obtaining comparable characteristics at baseline. In the treated group, patients received a median prednisone dose of 5 mg/day. Mean mRSS change at 12±3 months was similar in the two groups (decrease of 2.7 [95% CI 1.4 - 4.0] in treated vs. 3.1 [95% CI 1.9 - 4.4] in control, p = 0.64). Similar results were observed in patients with shorter disease duration (≤ 24 months) or with mRSS ≤22. There was no between-group difference for all prespecified secondary outcomes. A case of scleroderma renal crisis occurred in both groups.

Conclusions: We did not find any significant benefit of adding low-dose oral glucocorticoids to immunosuppression for skin fibrosis, and at this dosage, glucocorticoid did not increase the risk of scleroderma renal crisis.

Objective: Organ damage in systemic sclerosis (SSc) in individual organs such as the lungs may be prevented by immunosuppressive drugs (IS). A new measure of global organ damage, the Scleroderma Clinical Trials Consortium Damage Index (SCTC-DI), has allowed us to investigate whether IS may reduce global organ damage accrual in early SSc.

Methods: This was a retrospective study of patients with < 2 years disease duration in Canadian and Australian SSc cohorts. Patients with either limited cutaneous (lcSSc) or diffuse cutaneous (dcSSc) SSc were observed separately and divided into ever or never exposed to IS groups. The SCTC-DI was the outcome and inverse probability of treatment weighting (IPTW) was used to balance the study groups and to fit a marginal structural generalized estimating equation (GEE) model.

Results: In the lcSSc cohort, there were 210 subjects of which 34% were exposed to IS at some time. Exposure to IS was associated with lower damage scores. In the dcSSc cohort, there were 192 subjects of which 76% were exposed to IS at some time. Exposure to IS was not associated with damage scores.

Conclusion: In this retrospective observational cohort study, using IPTW to adjust for confounders, we found a protective effect of the use of IS on damage accrual in lcSSc. We were unable to determine such an effect in dcSSc but unknown confounders may have been present and prospective studies of IS in dcSSc should include the SCTC-DI to determine the possible effect of IS on damage accrual.

Objectives: This work aimed to evaluate the pharmacokinetics, efficacy, and safety of upadacitinib, an oral selective JAK inhibitor, in pediatric patients with polyarticular-course juvenile idiopathic arthritis (pcJIA).

Methods: In an open-label, phase 1 study (SELECT-YOUTH), enrolled patients, aged 2 to <18 years with pcJIA, received bodyweight-based upadacitinib doses using a twice-daily (BID) oral solution or once-daily (QD) extended-release tablet based on their body weight and ability to swallow tablets. The study included a 7-day pharmacokinetic assessment, followed by a long-term efficacy and safety evaluation for up to 156 weeks, including an additional long-term safety cohort. This interim analysis included available pharmacokinetic and safety data and efficacy data collected through Week 48.

Results: A total of 57 patients received upadacitinib. The median time to maximum upadacitinib concentration was approximately 3 hours and 1 hour for the tablet and oral solution regimens, respectively; the harmonic mean functional half-life was approximately 5 hours and 2 hours, respectively. Juvenile idiopathic arthritis (JIA) American College of Rheumatology (ACR)30/50/70/90/100 responses at Week 12 were 91.8/89.8/69.4/49.0/32.7%, respectively. Efficacy was generally maintained through Week 48, and improvement in additional efficacy endpoints was also observed. At a median exposure duration of 412 days, 52 of 57 patients reported adverse events, of these 6 experienced serious adverse events. Adverse events were predominately mild to moderate in severity and consistent with the known safety profile of upadacitinib.

Conclusions: This interim analysis demonstrates that the bodyweight-based dosing regimen of upadacitinib was well tolerated and efficacious in pediatric patients with pcJIA.

Objective: Our aim was to determine the most significant barriers to total joint arthroplasty (TJA) for people living in high-poverty communities relative to low-poverty communities.

Methods: We created a 21-question survey based on interviews with underrepresented minority patients with osteoarthritis targeting five barriers to TJA: trust in surgeon, recovery concerns, cost / insurance issues, fear of poor surgical outcomes, and timing considerations. Participants rated the importance of each barrier on a 5-point Likert scale, dichotomized into very / extremely important and not as important. The survey was distributed at New York City clinics and nationally through an arthritis advocacy group. We used geocoding to link addresses to census tracts, defining "high-poverty communities" as those with ≥20% of residents living below the poverty level. Logistic regression models assessed the association between community poverty status and rating barriers as very / extremely important, adjusting for demographic and clinical factors.

Results: Of the 702 survey participants, 16.8% were residents of high-poverty communities. After adjustment, participants from high-poverty communities were more likely to rate trust in surgeon (adjusted odds ratio (aOR): 1.87 [1.24, 2.82]) and fear of poor surgical outcome (aOR: 1.68 [1.08, 2.61]) as very / extremely important.

Conclusion: People from high-poverty communities identified lack of trust in surgeons and fear of poor surgical outcomes as more significant barriers to TJA compared to people from low-poverty communities.

Objectives: Osteoporosis, a known complication of rheumatoid arthritis (RA), increases the risk of hip fracture, which is associated with high morbidity and mortality. Fracture risk estimates in RA patients treated with contemporary treatment strategies are lacking. The objectives were 1) to estimate age- and sex-specific incidence rates and compare the risk of hip fractures in RA relative to age and sex-matched general population controls, and 2) to compare the risk of all-cause mortality in RA and general population controls after hip fracture.

Methods: A longitudinal study of a population-based incident cohort of RA patients diagnosed between 1997 and 2009, followed until 2014, with age- and sex-matched controls from the general population of British Columbia, using administrative health data. Hip fracture outcomes (ICD9-CM codes 820.0 or 820.2; ICD10-CA code S72.0 to S72.2) and mortality at pre-defined intervals after fracture (in-hospital, 90 days, 1-year, 5-year) were identified. Hip fracture incidence rates for RA and controls, and incidence rate ratios (IRR) were calculated. Cox proportional hazards models compared hip fracture and mortality risk in RA vs. controls; logistic regression compared in-hospital mortality risk.

Results: Overall, 1314 hip fractures over 360,521 person-years were identified in 37,616 RA individuals and 2083 over 732,249 person-years in 75,213 controls, yielding a 28% greater fracture risk in RA (IRR 1.28 [95%CI, 1.20;1.37]). Mean age at time of fracture was slightly younger for RA than controls (79.6 + 10.8 vs. 81.6 + 9.3 yrs). Post-fracture mortality risk at 1- and 5-years did not differ between RA and general population controls. Results were similar in a sensitivity analysis including only RA individuals who received disease-modifying antirheumatic drugs (DMARDs).

Conclusion: People with RA had a greater risk of hip fractures, but no greater risk of mortality post fracture, than the general population. The relative risk of hip fractures observed was not as high as previously reported, likely reflecting better treatment of inflammation and management of osteoporosis and its risk factors.

Objective: The National Institute of Health and Care Excellence (NICE) criteria for osteoarthritis (OA) obviate the need for physical exam or imaging, and their use may improve timely diagnosis of OA. However, they have not been validated.

Methods: Within a larger study of individuals with type 2 diabetes, participants with and without self-reported knee pain underwent assessment of the NICE criteria for knee OA by questionnaire (index test), and clinical evaluation for established or possible knee OA by a rheumatologist (reference standard). We calculated the sensitivity, specificity, likelihood ratio positive (LR+) and likelihood ratio negative (LR-) of the NICE criteria and modified NICE criteria without the stiffness criterion.

Results: Our study included 96 participants: mean age 65.4 (SD 8.3) years and 52% were women. Individuals who fulfilled NICE criteria for knee OA (55.2%) included a spectrum of pain severity on a 11-point pain numeric rating scale with a median score of 5 (range: 1-9). Rheumatologist assessment identified 56 (58.3%) participants with symptomatic knee OA. The sensitivity, specificity, LR+, and LR- of NICE criteria for symptomatic knee OA were 0.84 (95% CI 0.74, 0.94), 0.85 (95% CI 0.74, 0.96), 5.6 and 0.19, respectively. For modified NICE criteria, these were 0.89 (95% CI 0.82, 0.97), 0.85 (95% CI 0.74, 0.96), 5.93 and 0.13.

Conclusion: The NICE criteria have high sensitivity and specificity for detecting symptomatic knee OA in a population with type 2 diabetes. We found that a modified version, omitting the stiffness criterion, performed similarly. These criteria should be validated in other settings and populations.

Objective: To investigate occupational and hobby exposures to silica, solvents, and heavy metals and odds of idiopathic inflammatory myositis (IIM) phenotypes, dermatomyositis (DM) and polymyositis (PM) versus inclusion body myositis (IBM), lung disease plus fever or arthritis (LD+), and systemic autoimmune rheumatic disease-overlap myositis (OM).

Methods: The sample included 1390 patients (598 DM, 409 PM, and 383 IBM) ages ≥18 years from a national registry. Of these, 218 (16%) were identified with LD+, i.e., self-reported lung disease with fever and/or arthritis, and 166 (12%) with OM. Questionnaire data on jobs, hobbies, and exposures before diagnosis were evaluated using a rules-based protocol and expert assessment of silica dust, solvents, and heavy metals exposure. We calculated adjusted odds ratios (OR) and 95% confidence intervals (CI) and explored joint effects with smoking.

Results: High silica exposure was associated with an increased odds of having DM (OR=2.02; 95%CI 1.18-3.46, compared to no exposure; p-trend=0.004), LD+ (1.75; 1.10-2.78; p-trend=0.005, versus no LD), and OM (2.07; 1.19-3.61; p-trend=0.020). Moderate to high heavy metals exposure was associated with greater odds of having LD+ (1.49; 1.00-2.14; p-trend=0.026) and OM (1.59; 0.99-2.55, p-trend=0.051). Greater odds of LD+ were seen among smokers with moderate to high silica exposure versus non-smokers with low or no exposure (high-certainty assessment, 2.53; 1.31-4.90; p-interaction=0.061).

Conclusion: These findings, based on a systematic exposure assessment, suggest that occupational and hobby exposures to silica and heavy metals contribute to adult IIM phenotypes, including DM, OM, and LD+, a possible marker for anti-synthetase or other autoantibody-associated lung disease.

Objective: Access to specialized orthopedic care is an important determinant of the decision to undergo total knee replacement (TKR); however, most studies have mainly utilized distance to the nearest high-volume hospital as the primary proxy for access. We applied the two-step floating catchment area (2SFCA) method to develop a more comprehensive TKR access score that accounts for other potential factors, i.e., supply of and demand for this procedure, that also affect access.

Methods: To apply the 2SFCA method, we first estimated TKR demand using the CDC estimates of prevalence of osteoarthritis, which was multiplied by estimates of patients who would potentially benefit from TKR. We then estimated TKR supply using the number of TKRs performed in each hospital, extracted from the CMS MedPAR database. For the nationwide analysis, we estimated the access score for a radius of 55 km around each census tract in the contiguous US. For a subset of the census tracts, we employed a more realistic but more computationally intensive 42-minute driving distance to determine the robustness of the 55 km assumption, and calculated the Spearman rank correlation between the two access scores.

Results: Across the US, the access score was categorized low for 51%, medium for 24%, and high for 25% of census tracts. The Spearman correlation coefficient between these national scores and those with 42-minute driving time was 0.75.

Conclusions: We developed a novel TKR care access score that may enhance quality measures available to patients, providers, payors and researchers.

Objective: This work describes the demographics and practice characteristics of physician assistants/associates (PAs) practicing in rheumatology.

Methods: We examined 2022 cross-sectional data from the National Commission on Certification of PAs (NCCPA). The investigation included demographics and practice characteristics of PAs working in rheumatology compared to those working in all other specialties. We analyzed data using descriptive and bivariate statistics comparing the two groups.

Results: In 2022, 430 PAs self-reported practicing in rheumatology. The median age of these PAs was 39 years, and 84.7% self-identified as female. They primarily (78.8%) worked in office-based private practices and were more likely to engage in telemedicine services (62.5%) than their colleagues in all other specialties. PAs in rheumatology typically worked similar hours as their peers in other medical disciplines but saw a higher proportion of patients in the 61-80 range. At the same time, PAs in rheumatology reported slightly higher job satisfaction and lower burnout symptom rates compared to PAs practicing in other disciplines.

Conclusions: Understanding PAs' characteristics and employment settings in rheumatology is crucial to estimating the health workforce supply and demand in this discipline. Further research should explore the economics of PAs in rheumatology, including aspects of teamwork, scope of practice, patient outcomes, and satisfaction.