Claire E.H. Barber

Infections in the lupus patient: perspectives on prevention.

Purpose of reviewInfections are one of the most common causes of morbidity, hospitalization and death in patients with systemic lupus erythematosus (SLE). The aim of the review is to describe an approach to screening and prevention of infections in patients with SLE based on recent evidence. Recent findingsThis review summarizes what is known about the incidence and risk factors for infection in SLE as well as the limitations of the current literature. An approach to screening for infections such as tuberculosis and viral hepatitis is described as well as use of prophylactic agents and vaccinations. SummaryWe recommend screening for infectious comorbidities such as tuberculosis and viral hepatitis at the first clinical encounter in patients with lupus in addition to recommending pneumococcal vaccination and yearly influenza vaccination. There is currently limited evidence to support antibiotic prophylaxis for SLE patients on immunosuppressive agents to prevent penumocystis or to support screening for cytomegalovirus and further study is required. Lastly, timely antibiotic treatment in patients with lupus who are hospitalized with infectious complications is important, as delayed antibiotic treatment may be associated with increased mortality.

Development of System-level Performance Measures for Evaluation of Models of Care for Inflammatory Arthritis in Canada

Objective. To develop system-level performance measures for evaluating the care of patients with inflammatory arthritis (IA), including rheumatoid arthritis (RA), psoriatic arthritis, ankylosing spondylitis, and juvenile idiopathic arthritis. Methods. This study involved several methodological phases. Over multiple rounds, various participants were asked to help define a set of candidate measurement themes. A systematic search was conducted of existing guidelines and measures. A set of 6 performance measures was defined and presented to 50 people, including patients with IA, rheumatologists, allied health professionals, and researchers using a 3-round, online, modified Delphi process. Participants rated the validity, feasibility, relevance, and likelihood of use of the measures. Measures with median ratings ≥ 7 for validity and relevance were included in the final set. Results. Six performance measures were developed evaluating the following aspects of care, with each measure being applied separately for each type of IA except where specified: waiting times for rheumatology consultation for patients with new onset IA, percentage of patients with IA seen by a rheumatologist, percentage of patients with IA seen in yearly followup by a rheumatologist, percentage of patients with RA treated with a disease-modifying antirheumatic drug (DMARD), time to DMARD therapy in RA, and number of rheumatologists per capita. Conclusion. The first set of system-level performance measures for IA care in Canada has been developed with broad input. The measures focus on timely access to care and initiation of appropriate treatment for patients with IA, and are likely to be of interest to other arthritis care systems internationally.

Impact of a Rheumatology Consultation Service on the Diagnostic Accuracy and Management of Gout in Hospitalized Patients

Objective. To determine if a hospital rheumatology consultation service improves diagnostic accuracy and adherence to treatment recommendations for gout. Methods. This was a retrospective, single-center, case-control study of consecutive hospitalized patients with gout. Demographic, diagnostic, and treatment variables were compared in patients with and without a rheumatology consultation (controls). American College of Rheumatology (ACR) preliminary criteria for the classification of acute gout and the European League Against Rheumatism (EULAR) recommendations were used to determine diagnostic accuracy. Adherence to EULAR drug management recommendations and Quality Indicators for treatment were compared between groups. Results. In total, 138 patients were studied. The mean (SD) age was 71.3 (13.4) years and 70% were men. Forty-eight (35%) patients had gout on admission, 90 (65%) during their hospital stay, and 8 (6%) had multiple attacks. A total of 79 (57%) patients had a rheumatology consultation. These patients had more joints involved (p < 0.001), more frequent synovial fluid analysis (p < 0.001), and fulfilled ACR classification criteria more frequently than those who did not have a rheumatology consultation (65% vs 37%; p = 0.002). Intraarticular corticosteroid use was more common (44% vs 12%; p < 0.001) in patients who were seen by rheumatology. In contrast, colchicine was used more frequently in controls (63% vs 40%; p = 0.006). Patients seen by rheumatology were more likely to use nonsteroidal antiinflammatory drugs or colchicine for gout prophylaxis while titrating allopurinol to target (p = 0.033). Conclusion. A rheumatology consultation service for hospitalized patients with gout significantly improved the diagnostic accuracy and adherence to established guidelines for short and longterm treatment.

Antibiotics for treatment of reactive arthritis: a systematic review and metaanalysis.

Objective. To examine the efficacy and safety of antibiotic treatments for reactive arthritis (ReA). Methods. We did a systematic review and metaanalysis of randomized controlled trials of antibiotics for treatment of ReA. We searched electronic databases and conference proceedings up to November 2011. Included trials reported on remission, joint counts, and pain or patient global scores in any language. Results. Twelve trials were eligible for inclusion and 10 provided data for metaanalysis. The pooled relative risk of failure to achieve remission from a random effects model showed no significant benefit of antibiotic treatment on remission (7 trials, 375 participants, RR 0.74, 95% CI 0.49–1.10); however, substantial heterogeneity was observed (I2 = 76.3%, p < 0.0001). The treatment effect did not differ significantly by the type of organism triggering the ReA (chlamydia, 4 trials, RR 0.80, 95% CI 0.63–1.03, vs other microorganisms, 5 trials, RR 0.72, 95% CI 0.29–1.79, metaregression p = 0.477) or use of combination antibiotics (monotherapy, 6 trials, RR 0.70, 95% CI 0.39–1.26, vs combination therapy, 1 trial, RR 0.79, 95% CI 0.63–0.99, metaregression p = 0.466). When unblinded trials were excluded, the treatment effect was attenuated and heterogeneity decreased (RR 0.87, 95% CI 0.70–1.10, I2 = 32.8%, p = 0.19). No significant effects of antibiotic treatment were observed on joint counts, pain, or patient global scores; however, antibiotics were associated with a 97% increase in gastrointestinal adverse events. Conclusion. Trials of antibiotic treatment for ReA have produced heterogeneous results that may be related to differences in study design. The efficacy of antibiotics is uncertain.

Development of Cardiovascular Quality Indicators for Rheumatoid Arthritis: Results from an International Expert Panel Using a Novel Online Process

Objective. Patients with rheumatoid arthritis (RA) have a high risk of premature cardiovascular disease (CVD). We developed CVD quality indicators (QI) for screening and use in rheumatology clinics. Methods. A systematic review was conducted of the literature on CVD risk reduction in RA and the general population. Based on the best practices identified from this review, a draft set of 12 candidate QI were presented to a Canadian panel of rheumatologists and cardiologists (n = 6) from 3 academic centers to achieve consensus on the QI specifications. The resulting 11 QI were then evaluated by an online modified-Delphi panel of multidisciplinary health professionals and patients (n = 43) to determine their relevance, validity, and feasibility in 3 rounds of online voting and threaded discussion using a modified RAND/University of California, Los Angeles Appropriateness Methodology. Results. Response rates for the online panel were 86%. All 11 QI were rated as highly relevant, valid, and feasible (median rating ≥ 7 on a 1–9 scale), with no significant disagreement. The final QI set addresses the following themes: communication to primary care about increased CV risk in RA; CV risk assessment; defining smoking status and providing cessation counseling; screening and addressing hypertension, dyslipidemia, and diabetes; exercise recommendations; body mass index screening and lifestyle counseling; minimizing corticosteroid use; and communicating to patients at high risk of CVD about the risks/benefits of nonsteroidal antiinflammatory drugs. Conclusion. Eleven QI for CVD care in patients with RA have been developed and are rated as highly relevant, valid, and feasible by an international multidisciplinary panel.

Development of key performance indicators to evaluate centralized intake for patients with osteoarthritis and rheumatoid arthritis

IntroductionCentralized intake is integral to healthcare systems to support timely access to appropriate health services. The aim of this study was to develop key performance indicators (KPIs) to evaluate centralized intake systems for patients with osteoarthritis (OA) and rheumatoid arthritis (RA).MethodsPhase 1 involved stakeholder meetings including healthcare providers, managers, researchers and patients to obtain input on candidate KPIs, aligned along six quality dimensions: appropriateness, accessibility, acceptability, efficiency, effectiveness, and safety. Phase 2 involved literature reviews to ensure KPIs were based on best practices and harmonized with existing measures. Phase 3 involved a three-round, online modified Delphi panel to finalize the KPIs. The panel consisted of two rounds of rating and a round of online and in-person discussions. KPIs rated as valid and important (≥7 on a 9-point Likert scale) were included in the final set.ResultsTwenty-five KPIs identified and substantiated during Phases 1 and 2 were submitted to 27 panellists including healthcare providers, managers, researchers, and patients in Phase 3. After the in-person meeting, three KPIs were removed and six were suggested. The final set includes 9 OA KPIs, 10 RA KPIs and 9 relating to centralized intake processes for both conditions. All 28 KPIs were rated as valid and important.ConclusionsArthritis stakeholders have proposed 28 KPIs that should be used in quality improvement efforts when evaluating centralized intake for OA and RA. The KPIs measure five of the six dimensions of quality and are relevant to patients, practitioners and health systems.

Evaluation of Clinical Outcomes and Renal Vascular Pathology among Patients with Lupus

BACKGROUND AND OBJECTIVES The objective of this study was to determine the clinical significance of renal vascular lesions in lupus nephritis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Renal vascular lesions defined as thrombotic microangiopathy, lupus vasculopathy, uncomplicated vascular immune deposits, and arterial sclerosis were evaluated in relation to renal and vascular morbidity and overall mortality. RESULTS Biopsies from 161 patients revealed thrombotic microangiopathy (13), lupus vasculopathy (5), and arterial sclerosis (93). No renal vascular lesions were found in 24.8% of patients. At the time of biopsy, arterial sclerosis or lupus vasculopathy patients were older (arterial sclerosis=37.9±13.0 and lupus vasculopathy=44.4±8.9 versus controls=33.1±8.9 years, P<0.05), and the mean arterial pressure was higher in all groups compared with controls. Nephritis subtype, activity indices, and proteinuria were similar between groups, estimated GFR was lower in arterial sclerosis (70.5±33.3 versus 84.5±26.6 ml/min per 1.73 m(2), P=0.03), and chronicity index (thrombotic microangiopathy=3.5, lupus vasculopathy=4.5, and arterial sclerosis=2.5) was higher in all renal vascular lesions subgroups versus controls (1.0, P<0.05). In 133 patients with similar follow-up, the association between renal vascular lesions and vascular events was significant (Fisher exact test, P=0.002) and remained so after multivariate analysis (exact conditional scores test, P=0.04), where the difference between arterial sclerosis and uncomplicated vascular immune deposits was most noticeable (odds ratio [95% confidence interval]=8.35[0.98, 83.12], P=0.05). The associations between renal vascular lesions, renal outcomes, and death were not significant, likely because of insufficient power. CONCLUSIONS Renal vascular lesions are common in SLE patients with nephritis and may be associated with arterial vascular events.

Multifocal Motor Neuropathy with Conduction Block Following Treatment with Infliximab

To the Editor: Anti-tumor necrosis factor-α (anti-TNF) therapy is a frequent therapeutic modality in patients with autoimmune disease. There is increased recognition that these agents may cause various inflammatory demyelinating neuropathies. We describe a 36-year-old man with Crohn’s disease who developed multifocal motor neuropathy with conduction block (MMNCB) after treatment with infliximab. He was diagnosed in 1997 with severe fistulizing Crohn’s disease. He was started on infliximab in hospital in February 2000 as he had not responded to treatment with azathioprine, metronidazole, and ciprofloxacin. He had 2 further infusions of infliximab in April and May 2000. On May 30, 2000, he underwent ileocolic resection. Preoperatively he reported mild hand numbness; postoperatively he developed progressive bilateral weakness of his wrists, finger extensors, and interossei as well as marked weakness in the extensors of his toes and moderate weakness of his ankle dorsiflexors. Sensation was preserved. Nerve conduction studies revealed mildly delayed ulnar F-wave latency at 32.7 ms. The remainder of the study was normal. Conduction block was not found. Electromyography revealed reduced recruitment in muscles of the upper and lower extremity, with fibrillation potentials and positive sharp waves identified in tibialis anterior, medial gastrocnemius, extensor digitorum, and first dorsal interosseus. The electrophysiological diagnosis was a motor neuropathy … Address correspondence to Dr. Barber. E-mail: claire.barber{at}utoronto.ca

Gaps in Addressing Cardiovascular Risk in Rheumatoid Arthritis: Assessing Performance Using Cardiovascular Quality Indicators.

Objective. Cardiovascular disease (CVD) is a major comorbidity for patients with rheumatoid arthritis (RA). This study sought to determine the performance of 11 recently developed CVD quality indicators (QI) for RA in clinical practice. Methods. Medical charts for patients with RA (early disease or biologic-treated) followed at 1 center were retrospectively reviewed. A systematic assessment of adherence to 11 QI over a 2-year period was completed. Performance on the QI was reported as a percentage pass rate. Results. There were 170 charts reviewed (107 early disease and 63 biologic-treated). The most frequent CVD risk factors present at diagnosis (early disease) and biologic start (biologic-treated) included hypertension (26%), obesity (25%), smoking (21%), and dyslipidemia (15%). Performance on the CVD QI was highly variable. Areas of low performance (< 10% pass rates) included documentation of a formal CVD risk assessment, communication to the primary care physician (PCP) that patients with RA were at increased risk of CVD, body mass index documentation and counseling if overweight, communication to a PCP about an elevated blood pressure, and discussion of risks and benefits of antiinflammatories in patients at CVD risk. Rates of diabetes screening and lipid screening were 67% and 69%, respectively. The area of highest performance was observed for documentation of intent to taper corticosteroids (98%–100% for yrs 1 and 2, respectively). Conclusion. Gaps in CVD risk management were found and highlight the need for quality improvements. Key targets for improvement include coordination of CVD care between rheumatology and primary care, and communication of increased CVD risk in RA.

Development and Assessment of Users' Satisfaction with the Systemic Lupus Erythematosus Disease Activity Index 2000 Responder Index-50 Website.

Objective. To describe the development of the Systemic Lupus Erythematosus Disease Activity Index 2000 Responder Index-50 (S2K RI-50) Website (www.s2k-ri-50.com) and to assess satisfaction with its training and examination modules among rheumatologists and rheumatology fellows. Methods. The development of the Website occurred in 3 phases. The first was a deployment phase that consisted of preparing the site map along with its content. The content included the S2K RI-50 training manual, the tests and corresponding question bank, and the online adaptive training module, along with the extensive site testing. The second phase included the participation of rheumatologists and trainees who completed the Website modules. The third was a quality assurance phase in which an online survey was developed to determine the satisfaction level of its users. Further modifications were implemented per participants’ recommendations. Results. The site has been online since it was registered in September 2010. Fourteen rheumatologists and rheumatology trainees from different centers reviewed and completed the material contained in the Website. The survey revealed acceptance among rheumatologists for the Website’s content, design, and presentation. The Website was rated as user-friendly and useful in familiarizing investigators with the S2K RI-50. After completion of the training and examination modules, participants reported a suitable level of preparation to implement the S2K RI-50 in clinical trials and research settings in a timely manner. Conclusion. The Website includes training and examination modules that familiarize rheumatologists with the S2K RI-50 and assesses their competence to use the index. This prepares them for the use of the S2K RI-50 in clinical trials and research settings.