Alfred Cividino

A Long-Term Study of Hydroxychloroquine Withdrawal on Exacerbations in Systemic Lupus Erythematosus

The ability of antimalarials to moderate severe disease activity in systemic lupus erythematosus (SLE) is plausible but undemonstrated. We evaluated the long-term effectiveness of maintaining treatment with hydroxychloroquine sulphate (HCQ) to prevent major flares in quiescent SLE. Forty-seven patients with quiescent SLE who had been randomized to take HCQ (n = 25) or placebo (n = 22) as part of a 24-week withdrawal trial were evaluated for an additional 3 years. The primary outcome was time to a major flare of SLE which resulted in either the institution of or an increase in the current dosage of prednisone of 10 mg/day or more, or institution of therapy with immunosuppressive agents. Secondary outcomes included the specific subtype of these major flares (glomerulonephritis, vasculitis or other) and hospitalization for an exacerbation of SLE. An intent-to-treat analysis was conducted. Over the 42 months of study, 11 of 22 (50%) patients randomized initially to placebo, and seven of 25 (28%) patients randomized to continue treatment experienced a major flare. The relative risk of major flare for those randomized to continue HCQ compared with controls was 0.43 (95% CI: 0.17, 1.12). The relative risks for subtypes of flares were 0.26 (95% CI: 0.03, 2.54) for nephritis, 0.51 (95% CI: 0.09, 3.08) for vasculitis and 0.65 (95% CI: 0.17, 2.41) for flares characterized by other symptoms. The relative risk of hospitalization for major flare for patients randomized to continue hydroxychloroquine was 0.58 (95% CI: 0.13, 2.60). While the results are not statistically significant, they are compatible with the clinical belief that HCQ has a long-term protective effect against major disease flares in SLE and suggest that on average, HCQ use reduces major flares by 57% (95% CI: 83% reduction to 12% increase).

Serious infections in a population‐based cohort of 86,039 seniors with rheumatoid arthritis

To assess risk and risk factors for serious infections in seniors with rheumatoid arthritis (RA) using a case–control study nested within an RA cohort.

Quality of life in systemic lupus erythematosus patients during more and less active disease states: Differential contributors to mental and physical health

OBJECTIVE To identify determinants of mental and physical health as a function of disease state in patients with systemic lupus erythematosus (SLE). METHODS A sample of 129 SLE patients (mean age 42.01 years; SD 11.09) was recruited from 9 immunology/rheumatology clinics across Canada. Patients completed questionnaires assessing psychological distress, social support, coping, stress, and health-related quality of life. Physicians rated disease activity (using the revised Systemic Lupus Activity Measure; SLAM-R) and damage (using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index). Mental and physical health composite scores were derived from the Medical Outcomes Study Short Form 36. Patients were subdivided into more active (SLAM-R > or = 10; n = 38) or less active disease states (n = 91). RESULTS Better mental health was predicted by more education and less emotion-oriented coping in the patients in a more active disease state (P = 0.0001; R2 = 0.46). Better mental health was predicted by less stress, less emotion-oriented coping and more task-oriented coping in patients during a less active disease state (P = 0.0001; R2 = 0.45). Better physical health was predicted by more emotion-oriented coping in patients in a more active disease state (P = 0.04; R2 = 0.11). Better physical health was predicted by less stress and younger age in patients during a less active disease state (P = 0.0001; R2 = 0.20). CONCLUSION The positive association between emotion-oriented coping and better physical health in patients during a more active disease state suggests that this style of coping may be more adaptive in situations that are considered uncontrollable (e.g., SLE flare). Predictors of mental health were similar to those found in the literature, especially for SLE patients in a less active disease state.

Counterbalancing Patient Demands With Evidence: Results From a Pan-Canadian Randomized Clinical Trial of Brief Supportive-Expressive Group Psychotherapy for Women With Systemic Lupus Erythematosus

Objective: To evaluate the effect of Brief Supportive-Expressive Group Psychotherapy as an adjunct to standard medical care in reducing psychological distress, medical symptoms, and health care costs and improving quality of life in women with systemic lupus erythematosus (SLE). Methods: A randomized clinical trial was conducted with 133 SLE female patients from 9 clinics across Canada. Clinical and psychosocial measures were taken at baseline, posttreatment, and 6 and 12 months posttreatment. Outcomes assessed were psychological distress, quality of life, disease activity, health service utilization, and diminished productivity. Results: Intention-to-treat analyses revealed that there were no clinically important group differences on any of the outcome measures. Conclusion: Although both groups improved over time on several measures (e.g., decreases in psychological distress, stress, and emotion-oriented coping), these changes could not be attributed to the psychotherapeutic intervention. Thus, evidence does not support the referral of these patients to this type of intervention.

Quality care in seniors with new-onset rheumatoid arthritis: A Canadian perspective†

To estimate the percentage of seniors with rheumatoid arthritis (RA) receiving disease‐modifying antirheumatic drugs (DMARDs) within the first year of diagnosis.

Gold induced thrombocytopenia: 12 cases and a review of the literature

Gold induced thrombocytopenia is immune mediated, with the production of platelet associated IgG leading to peripheral platelet destruction. An association with HLA-DR3 has been demonstrated. Corticosteroid therapy is effective in treatment, although other modes of therapy may be as efficacious.

Effect of rheumatologist education on systematic measurements and treatment decisions in rheumatoid arthritis: the metrix study.

Objective. To determine whether an educational intervention could result in changes in physicians’ practice behavior. Methods. Twenty rheumatologists performed a prospective chart audit of 50 consecutive patients with rheumatoid arthritis (RA) and again after 6 months. Ten were randomized to the educational intervention: monthly Web-based conferences on the value of systematic assessments in RA, recent evidence-based information, practice efficiency, and other topics; this group also read articles on targeting care in RA. The others were randomized to no intervention. Results. One thousand serial RA charts were audited at baseline and 1000 at 6 months, with no between-group differences in patient characteristics: mean disease duration of 10 years; 77% women; 74% rheumatoid factor– positive; mean Disease Activity Score (DAS) 3.7; and 68% taking methotrexate, 14% taking steroids, and 27% taking biologics. At 6 months the intervention group collected more global assessments (patient global 53% preintervention vs 66% postintervention, and MD global 51% vs 60%; p < 0.05) and Health Assessment Questionnaires (37% vs 42%; p > 0.05; p = nonsignificant), whereas controls had no change in outcomes collected. For the intervention group there was a 32% increase in calculable composite scores [such as DAS, Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index; p < 0.05] but no change in the controls. There was more targeting to a low disease state. For those with SDAI between 3.3 and 11, the percentage of patients receiving a change in therapy was 66% in the intervention group and 36% in controls (p < 0.05). When DAS was between 2.4 and 3.6, 57% of the intervention group and 38% of controls made changes to treatment (p < 0.05). Conclusion. Small-group learning with feedback from practice audits is an inexpensive way to improve outcomes in RA.

Stand Up and Be Counted: Measuring and Mapping the Rheumatology Workforce in Canada

Objective. To characterize the practicing rheumatologist workforce, the Canadian Rheumatology Association (CRA) launched the Stand Up and Be Counted workforce survey in 2015. Methods. The survey was distributed electronically to 695 individuals, of whom 519 were expected to be practicing rheumatologists. Demographic and practice information were elicited. We estimated the number of full-time equivalent rheumatologists per 75,000 population from the median proportion of time devoted to clinical practice multiplied by provincial rheumatologist numbers from the Canadian Medical Association. Results. The response rate was 68% (355/519) of expected practicing rheumatologists (304 were in adult practice, and 51 pediatric). The median age was 50 years, and one-third planned to retire within the next 5–10 years. The majority (81%) were university-affiliated. Rheumatologists spent a median of 70% of their time in clinical practice, holding 6 half-day clinics weekly, with 10 new consultations and 45 followups seen per week. Work characteristics varied by type of rheumatologist (adult or pediatric) and by practice setting (community- or university-based). We estimated between 0 and 0.8 full-time rheumatologists per 75,000 population in each province. This represents a deficit of 1 to 77 full-time rheumatologists per province/territory to meet the CRA recommendation of 1 rheumatologist per 75,000 population, depending on the province/territory. Conclusion. Our results highlight a current shortage of rheumatologists in Canada that may worsen in the next 10 years because one-third of the workforce plans to retire. Efforts to encourage trainees to enter rheumatology and strategies to support retention are critical to address the shortage.

Screening for signs and symptoms of rheumatoid arthritis by family physicians and nurse practitioners using the Gait, Arms, Legs, and Spine musculoskeletal examination

To evaluate the sensitivity and specificity of the Gait, Arms, Legs, and Spine (GALS) examination to screen for signs and symptoms of rheumatoid arthritis (RA) when used by family physicians and nurse practitioners.

Safety and effectiveness of adalimumab in a clinical setting that reflects Canadian standard of care for the treatment of rheumatoid arthritis (RA): Results from the CanACT study

BackgroundThis multicenter, open-label, prospective, single cohort study evaluated the effectiveness and safety of adalimumab in a clinical setting reflecting the Canadian standard of care for the treatment of patients with rheumatoid arthritis (RA).MethodsPatients ≥ 18 years of age with a history of active RA ≥ 3 months and fulfilling Canadian requirements for biological therapy received adalimumab 40 mg subcutaneously every other week for 12 weeks. Pre-study DMARD treatment regimens, corticosteroids, or NSAIDs were allowed throughout the study. The primary effectiveness outcome measure was the mean change in 28-joint disease activity score (DAS28) from baseline to Week 12. Secondary measures included the proportion of patients achieving joint remission (DAS28 < 2.6) and low-disease activity (DAS28 < 3.2) at Week 12, and European League Against Rheumatism (EULAR: moderate and good) and American College of Rheumatology (ACR: ACR20, 50, and 70) responses, as well as responses in ACR core components at Weeks 4, 8, and 12. Subgroup analysis included a comparison of patients naïve to biological DMARD (BDMARD) therapy versus BDMARD-experienced patients. Safety was assessed in terms of adverse and serious adverse events.ResultsA total of 879 patients (mean disease duration > 12 years) were enrolled; 772 (87.9%) completed the 12-week period. Adalimumab treatment was associated with rapid and sustained improvements in the signs and symptoms of RA. Significant improvements in mean DAS28 score were observed as early as Week 4. After 12 weeks of adalimumab treatment, 15.3% and 28.9% of patients achieved clinical remission and low-disease activity, respectively. Similarly, significant improvements in ACR core components were observed as early as Week 4, with continued improvements occurring through 12 weeks. Patients naïve to BDMARD therapy demonstrated numerically greater clinical responses when compared with patients who had experienced prior BDMARD therapy, although both subgroups were associated with significant improvements from baseline. The rates and types of adverse events, as well as the results of laboratory measures, demonstrated that adalimumab was generally safe and well-tolerated.ConclusionsThis study demonstrated that, under conditions reflective of the normal clinical practice in Canada, adalimumab is an effective and safe treatment for patients with RA.Trial registrationNCT00649545.