Arthritis Care & Research最新文献

Objective: To provide evidence-based and expert guidance for the treatment and management of non-renal systemic lupus erythematosus (SLE); treatment and management of lupus nephritis are addressed in a separate guideline.

Methods: Clinical questions for treatment and management of SLE were developed in the PICO format (population, intervention, comparator, and outcome). Systematic literature reviews were developed for each PICO question, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess evidence quality and formulate recommendations. The Voting Panel achieved a consensus of ≥70% agreement on the direction (for or against) and strength (strong or conditional) of each recommendation.

Results: We present recommendations and ungraded, consensus-based good practice statements for the treatment and management of SLE that are applicable to pediatric and adult patients. Recommendations emphasize uniform treatment with hydroxychloroquine, limiting duration of glucocorticoid use, and early introduction of conventional and/or biologic immunosuppressive therapies to achieve and maintain control of SLE inflammation (remission or a low level of disease activity), reduce SLE-related morbidity and mortality, and minimize medication-related toxicities.

Conclusion: This guideline presents direction regarding treatment and management of SLE and provides a foundation for well-informed, shared clinician-patient decision-making. These recommendations should not be used to limit or deny access to therapies, as treatment decisions may vary due to the unique clinical situation and personal preferences of each person with SLE.

Objective: Cognitive impairment is prevalent in Rheumatoid Arthritis (RA), yet risk factors are not well understood. We explored associations between clinical characteristics and cognitive impairment in an RA cohort.

Methods: Data were from a longitudinal RA cohort at Veterans Affairs Puget Sound Health Care System. Cognition was evaluated using the Saint Louis University Mental Status (SLUMS) exam. Demographics and health factors, objectively measured physical function, participant-reported symptoms, RA disease characteristics, and comorbidities were evaluated. Univariable linear regressions explored the association between clinical factors and SLUMS score. Those with p<0.1 in the univariable models were evaluated in separate multivariable linear regressions controlling for age, sex, and years of education.

Results: 145 participants with RA were included, aged 64.5±11.6 years and were predominantly male (74%). Using the SLUMS, 42 (29%) participants had normal cognition, 83 (57%) had mild cognitive impairment, and 20 (14%) had dementia. Physical performance [aβ:0.35 (0.11 to 0.59)], self-reported exhaustion [aβ:-2.22 (-3.44 to -0.99)], pain [aβ:-0.25 (-0.50 to -0.00)], disability [aβ:-1.79 (-3.16 to -0.42)], and trouble falling asleep [aβ:-2.57 (-4.00 to -1.14)] were all independently associated with a lower SLUMS score (all p<0.05).

Conclusion: Cognitive impairment was prevalent in our cohort of Veterans with RA and was associated with several modifiable clinical factors. Future longitudinal studies are needed to determine the directionality of these associations and evaluate interventions for modifiable risk factors that may mitigate cognitive dysfunction.

Objective: Patients with chronic illness share their experiences in online communities and generate rich data on pain management. This study applied natural language processing methods, including large language models (LLMs), to Reddit discussions from lupus communities to characterize multidimensional pain experiences framed in the biopsychosocial model.

Methods: We extracted Reddit posts from the r/Lupus and r/LupusSupport subreddits posted from June 9, 2010, through December 31, 2023. Pain-related posts were identified using a clinically informed pain lexicon. Topic modeling was used to identify thematic patterns, which were then compared with structured summaries generated by LLM instructions that were fine-tuned using the biopsychosocial model of pain. Two reviewers conducted content analysis of the LLM-generated summaries, evaluating thematic accuracy and coverage.

Results: Data from Reddit included 31,785 posts from 10,857 authors. We identified common pain complaints, management strategies, and sociocultural, affective, and nociplastic dimensions of pain. Instruction fine-tuned LLMs produced structured summaries with an average thematic accuracy score of 3.1 of 4 (kappa = .09) and content coverage score of 2.9 of 4 (kappa = .38). Sociocultural features presented in 123 posts (33.8%), including peer support and validation (n = 106) and provider interactions or access issues (n = 35). Nociplastic pain presented in 205 posts (56.3%).

Conclusion: Natural language processing methods can be used to extract rich, multidimensional insights into pain experiences from online communities focused on lupus. These approaches highlight the psychological, social, and cultural facets of pain that may be underrepresented in clinical settings, supporting more patient-centered approaches to care in rheumatology.

Objective: Systemic lupus erythematosus (SLE) and inflammatory arthritis disproportionately affect reproductive-age Hispanic women, who experience more severe disease and worse outcomes. Certain factors may contribute to disparities in reproductive health counseling. This survey-based study examined the association between reproductive health counseling and contraceptive use, considering a variety of demographics and teratogenic medication use in a predominantly Hispanic population in urban Los Angeles.

Methods: An anonymous survey, based on the 2020 American College of Rheumatology Reproductive Health Guideline, was administered to 304 female patients of childbearing age with SLE, rheumatoid arthritis (RA), or juvenile idiopathic arthritis (JIA). Analyses included two-sample t-tests, Pearson's chi-square test, multivariable logistic regression, and Fisher's exact tests, with significance set at P ≤0.05.

Results: Of 304 patients, English speakers were significantly more likely to receive contraception counseling than Spanish speakers (odds ratio [OR] 3.36; 95% confidence interval [CI] 1.52-7.40; P < 0.01). Older age was associated with lower odds of receiving counseling (OR 0.95; 95% CI 0.91-0.98; P = 0.01). Among those on teratogenic medications not desiring pregnancy, contraception counseling was linked to higher odds of using long-acting reversible contraception (OR 5.12; 95% CI 1.26-20.71; P = 0.02). Younger patients, those with SLE (vs RA or JIA), and English speakers had higher odds of perceiving their physician as knowledgeable about reproductive health (all P < 0.05).

Conclusion: Reproductive health counseling was inadequate for Spanish-speaking and older patients. However, reproductive health counseling was positively associated with effective contraception use among patients on teratogenic medications. Clinicians should be aware of these disparities and the potential benefit of counseling to improve highly effective contraception use.

Objective: Rheumatoid arthritis (RA) is associated with interstitial lung disease, bronchiectasis, rheumatoid lung nodules, and lung cancer. Recent guidelines proposed criteria for lung disease screening in RA, but the prevalence of abnormal lung findings in patients with RA is unknown.

Methods: Among all patients screened for lung cancer with low-dose chest computed tomography (CT) in the Mass General Brigham health care system between 2015 and 2023, we identified patients with and without RA. We compared the prevalence of lung nodules, "positive screen" (nodules requiring further imaging or biopsy), fibrotic lung changes, bronchiectasis, and lung cancer between patients with RA and comparators without RA using multivariable logistic regression.

Results: Among consecutive patients screened for lung cancer with clinically indicated low-dose chest CT, we identified 228 patients with RA and 14,805 comparators without RA. "Positive screens" were noted in 26.8% of patients with RA and 22.2% of patients without RA (P = 0.10). Lung cancer was found in 4.8% of patients with RA and 3.6% of patients without RA (P = 0.33). In multivariable models, RA was associated with positive screen (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.02-1.87), fibrotic lung changes (OR 1.77, 95% CI 1.08-2.91), and bronchiectasis (OR 1.64, 95% CI 1.12-2.39).

Conclusion: Patients with RA had higher prevalence of positive screening, fibrotic changes, and bronchiectasis detected by low-dose chest CT performed for lung cancer screening. Approximately one in four patients with RA who met US Preventive Services Task Force lung cancer screening criteria had a positive screen, whereas 1 in 20 had lung cancer. These results emphasize the importance of lung cancer screening among eligible patients with RA and may inform screening strategies for other lung abnormalities.

Objective: We evaluated the ability of Renal Activity Index for Lupus (RAIL) to discriminate active lupus nephritis (LN) in adult patients with active systemic lupus erythematosus (SLE) and differentiate LN treatment response.

Methods: Urine samples from adults with biopsy-proven active Class III and IV LN from TULIP-LN (active-LN-group; NCT02547922) and adults with active, non-renal SLE from TULIP-1 (active-SLE-group; NCT02446912) were utilized and RAIL biomarkers (NGAL, KIM-1, MCP-1, adiponectin, hemopexin, ceruloplasmin) measured in the urine at baseline (both studies); and at Week 12 and Week 24 for TULIP-LN only. The groups were compared at baseline, and changes in RAIL-scores from baseline in the active-LN-group were compared between non-responders and responders over time, i.e., those with complete renal response (CRR), partial renal response (PRR) and urine protein-creatine ratio decrease ≥50% [UPCR50].

Results: At baseline, median [interquartile range (IQR)] concentrations of RAIL biomarkers were significantly higher (P<0.02) in the active-LN-group (n=128) versus the SLE-control-group (n=48), as were RAIL-scores [5.59 (4.31-6.47) versus 3.57 (2.78-4.47); P<0.001]. At Week 12/Week 24 there were 25/31 patients achieving CRR, 39/54 with PRR and 41/63 with UPCR50, respectively. Changes of RAIL-scores from baseline to Week 12/Week 24 significantly differed between non-responders and responders (PRR, CRR, UPCR50: all P<0.0006) with lower scores in responders. For CRR versus non-response, median [IQR] RAIL-scores decreased by -1.3 (-3.64/-0.21) versus -0.39 at Week 12, and -2.30 (-3.63/-1.03) versus -0.88 (-2.20/0.33) at Week 24, respectively.

Conclusions: The RAIL identifies active LN and longitudinally differentiates treatment response in adults with LN.

Objective: Patients and providers encounter challenges when conducting virtual musculoskeletal physical examinations (PEs) during rheumatology telehealth encounters. Guidance for a structured virtual PE could enhance the quality of clinical information gleaned and management decisions made during rheumatology telehealth visits. This study aims to build expert consensus and identify the most essential elements as the first step in defining the virtual rheumatology musculoskeletal PE.

Methods: A team with expertise in rheumatology telehealth, consisting of rheumatology attending physicians, educators, and a patient with rheumatic disease, conducted a modified Delphi to achieve consensus on the items determined to be most essential to the virtual rheumatology musculoskeletal PE. The modified Delphi consisted of two online surveys and a virtual meeting.

Results: The team identified seven items essential to the rheumatology musculoskeletal telehealth PE. These items describe elements in a focused joint examination as well as the assessment for level of activity of inflammatory arthritis. The modified Delphi method excluded maneuvers related to assessment of muscle strength and widespread pain syndromes, determining that these elements were better conducted in person.

Conclusion: A list of PE items most essential to rheumatology musculoskeletal telehealth encounters, supported by expert opinion and established evidence, marks the first step toward standardizing, evaluating, and teaching the virtual rheumatology PE. These items, alongside anticipated future revisions and improvements, promise to enhance the quality of telehealth care delivered to people with rheumatic diseases.