Kathryn Gibson

The Co-Expression of Activating and Inhibitory Leukocyte Immunoglobulin-Like Receptors in Rheumatoid Synovium

Rheumatoid arthritis (RA) is a chronic inflammatory synovitis, with destruction of juxtaarticular cartilage and bone, likely mediated by lipid mediators, cytokines, and proteases released from inflammatory leukocytes. The mechanisms regulating leukocyte activation in rheumatoid synovium are not fully elucidated. A new family of cell surface proteins termed leukocyte immunoglobulin-like receptors (LIRs) has been shown in vitro to modulate cellular responses through immunoreceptor tyrosine-based inhibitory motifs or through association with the Fc receptor gamma chain that contains immunoreceptor tyrosine-based activation motifs. We studied the expression of inhibitory and activating LIRs in the synovium of six RA patients, three osteoarthritis patients, and three controls by immunohistochemistry. The synovium from patients with early RA showed extensive expression of the inhibitory LIR-2 and the activating LIR-7 on macrophages and neutrophils. Some mast cells and endothelial cells expressed LIR-7. There was limited expression of LIRs in synovium from two patients with long-standing RA, patients with osteoarthritis, and controls. LIR-2 recognizes MHC class I molecules. We therefore suggest that LIRs may regulate the activation of infiltrating leukocytes in synovial tissue and are a potential therapeutic target.

Enhancing evaluation in an undergraduate medical education program.

Approaches to evaluation of medical student teaching programs have historically incorporated a range of methods and have had variable effectiveness. Such approaches are rarely comprehensive, typically evaluating only a component rather than the whole program, and are often episodic rather than continuous. There are growing pressures for significant improvement in academic program evaluation. The authors describe an initiative that arose after a radical reorganization of the undergraduate medical education program at the University of New South Wales in part in response to feedback from the accrediting authority. The aim was to design a comprehensive, multicomponent, program-wide evaluation and improvement system. The framework envisages the quality of the program as comprising four main aspects: curriculum and resources; staff and teaching; student experience; and student and graduate outcomes. Key principles of the adopted approach include the views that both student and staff experiences provide valuable information; that measurement of student and graduate outcomes are needed; that an emphasis on action after evaluation is critical (closing the loop); that the strategies and processes need to be continual rather than episodic; and that evaluation should be used to recognize, report on, and reward excellence in teaching. In addition, an important philosophy adopted was that teachers, course coordinators, and administrators should undertake evaluation and improvement activities as an inherent part of teaching, rather than viewing evaluation as something that is externally managed. Examples of the strategy in action, which provide initial evidence of validation for this approach, are described.

They just scraped off the calluses: a mixed methods exploration of foot care access and provision for people with rheumatoid arthritis in south-western Sydney, Australia

BackgroundThere is little indication that foot health services in Australia are meeting modern day recommendations for Rheumatoid Arthritis (RA) patients. The overall objective of this study was to explore the current state of foot health services for patients with RA with an emphasis on identifying barriers to the receipt of appropriate foot care in South-West Sydney, New South Wales, Australia.MethodsA mixed (quantitative and qualitative) approach was adopted. Indications for appropriate access to foot care were determined by comparing the foot health, disease and socio-demographic characteristics of patients with unmet foot care demands, foot care users and patients with no demands for foot care. Perceptions of provision of, and access to, foot care were explored by conducting telephone-based interviews using an interpretative phenomenology approach with thematic analysis.ResultsTwenty-nine participants took part in the cross-sectional quantitative research study design, and 12 participants took part in the interpretative phenomenological approach (qualitative study). Foot care access appeared to be driven predominantly by the presence of rearfoot deformity, which was significantly worse amongst participants in the foot care user group (p = 0.02). Five main themes emerged from the qualitative data: 1) impact of disease-related foot symptoms, 2) footwear difficulties, 3) medical/rheumatology encounters, 4) foot and podiatry care access and experiences, and 5) financial hardship.ConclusionsFoot care provision does not appear to be driven by appropriate foot health characteristics such as foot pain or foot-related disability. There may be significant shortfalls in footwear and foot care access and provision in Greater Western Sydney. Several barriers to adequate foot care access and provision were identified and further efforts are required to improve access to and the quality of foot care for people who have RA. Integration of podiatry services within rheumatology centres could resolve unmet needs of people with RA by permitting rapid access to expert-led multidisciplinary foot care for people with RA.

Improved management of acute gout during hospitalization following introduction of a protocol

Aim:  To determine whether implementation of a protocol to manage in‐hospital acute gout has improved the care of patients by non‐rheumatologists.

Premature Mortality: A Neglected Outcome in Rheumatic Diseases?

Prevention of premature death may be viewed as a primary goal of medical care, even at this time when the focus of care has shifted primarily from inpatient management of acute events, to outpatient management of chronic diseases and health maintenance. Indeed, a substantial component of modern medical care in the developed world is directed to treatment of asymptomatic individuals who have a diagnosis of hypertension, hypercholesterolemia, or other chronic diseases. This practice is based almost entirely on epidemiologic evidence that the correction of biomarkers, which predict high mortality outcomes such as elevated blood pressure or serum cholesterol, by a “treat-to-target” strategy improves survival. In contrast to the asymptomatic status of most individuals with hypertension or hypercholesterolemia, most patients with chronic rheumatic diseases experience symptomatic disease that reduces work capacity and general quality of life. Furthermore, premature mortality is seen in the natural history of many rheumatic diseases (1), including osteoarthritis (OA) (2,3), gout (4,5), rheumatoid arthritis (RA) (1,6–12), systemic lupus erythematosus (SLE) (13), psoriatic arthritis (14), Sj€ ogren’s syndrome (15), ankylosing spondylitis (16), systemic sclerosis (17), polymyositis (18), vasculitis (19), and others (1) (Table 1). Mortality in severe RA may be comparable to mortality in Hodgkin’s disease or coronary artery disease (6). Standard mortality ratios (SMRs) of 4.8 for vasculitis and 1.55 for OA (Table 1) are similar to those of 4.55 for acquired immunodeficiency syndrome (AIDS) and 1.61 for human immunodeficiency virus (HIV) infection in 1997–2003 (20). SMRs of 2.4–48 for SLE, systemic sclerosis, vasculitis, and polymyositis are similar to or higher than that for type II diabetes mellitus: 2.26 in 1995 (21). Yet how many doctors, much less patients and the general public, are aware that rheumatic diseases may be associated with mortality rates as high as seen in “fatal” neoplastic or cardiovascular diseases? The problem of premature mortality in rheumatic diseases is raised by an informative, well-executed study in this issue of Arthritis Care & Research concerning mortality trends in Canadian RA patients over the last 2 decades (11). The report indicates that mortality rates in RA decreased from 1996 to 2009, consistent with reports of improved mortality outcomes associated with methotrexate as well as biologic agents (22–25). However, mortality rates in the general population also decreased, similarly to RA. Therefore, the standard mortality ratio of approximately 1.5 in people with RA compared to the general population (50% higher likelihood of mortality) has remained unchanged (11). Similar data have been reported from the UK (12) and France (8,10), suggesting generalizable findings, although both reductions (25,26) and increases (7) of RA mortality relative to the general population also have been reported. These differences may be explained in part by differences in populations and methodology, and by evidence that optimistic observations about mortality outcomes over short periods may not be sustained over 10 years or more (9). Mortality is a lagging indicator, and improved mortality rates may not become apparent for decades after new treatments and strategies become available; perhaps we may anticipate better results in the future. However, very few rheumatology centers collect long-term mortality data, and it may remain difficult to raise awareness of increased mortality rates, much less to document improved survival, to the medical and general communities. Mortality has long been neglected in rheumatology. One of the authors (TP) has attempted to call attention to mortality in rheumatic diseases, initially in 1986 (6), in this journal in 1995 (27), in an editorial in 2004 (28), and in an entire issue of a journal in 2008 (1), but reports remain sparse. A simple search at Google Scholar for publications in 2010–2013 concerning “mortality,” “epidemiology,” and a “specific disease” (e.g., OA, RA), revealed a minimum of 999 for the listed cardiovascular and neoplastic diseases and maximum of 203 for any rheumatic disease (Table 2). Some of these patterns may be attributed to the relative rarity of many rheumatic diseases, but not for common conditions such as OA and gout. Theodore Pincus, MD, Joel A. Block, MD: Rush University Medical Center, Chicago, Illinois; Kathryn A. Gibson, MD, PhD: Liverpool Hospital, Liverpool, New South Wales, Australia. Dr. Pincus is president of Health Report Services and owns copyrights and trademarks for MDHAQ and RAPID3. Address correspondence to Theodore Pincus, MD, Rush University Medical Center, Division of Rheumatology, 1611 West Harrison Street, Suite 510, Chicago IL 60612. E-mail: tedpincus@gmail.com. Submitted for publication October 14, 2014; accepted in revised form January 20, 2015.

Provision of foot health services for people with rheumatoid arthritis in New South Wales: a web-based survey of local podiatrists

BackgroundIt is unclear if podiatric foot care for people with rheumatoid arthritis (RA) in New South Wales (NSW) meets current clinical recommendations. The objective of this study was to survey podiatrists’ perceptions of the nature of podiatric foot care provision for people who have RA in NSW.MethodsAn anonymous, cross-sectional survey with a web-based questionnaire was conducted. The survey questionnaire was developed according to clinical experience and current foot care recommendations. State registered podiatrists practising in the state of NSW were invited to participate. The survey link was distributed initially via email to members of the Australian Podiatry Association (NSW), and distributed further through snowballing techniques using professional networks. Data was analysed to assess significant associations between adherence to clinical practice guidelines, and private/public podiatry practices.Results86 podiatrists participated in the survey (78% from private practice, 22% from public practice). Respondents largely did not adhere to formal guidelines to manage their patients (88%). Only one respondent offered a dedicated service for patients with RA. Respondents indicated that the primary mode of accessing podiatry was by self-referral (68%). Significant variation was observed regarding access to disease and foot specific assessments and treatment strategies. Assessment methods such as administration of patient reported outcome measures, vascular and neurological assessments were not conducted by all respondents. Similarly, routine foot care strategies such as prescription of foot orthoses, foot health advice and footwear were not employed by all respondents.ConclusionsThe results identified issues in foot care provision which should be explored through further research. Foot care provision in NSW does not appear to meet the current recommended standards for the management of foot problems in people who have RA. Improvements to foot care could be undertaken in terms of providing better access to examination techniques and treatment strategies that are recommended by evidence based treatment paradigms.

Is a patient questionnaire without a joint examination as undesirable as a joint examination without a patient questionnaire

Patient questionnaires have gained increasing prominence in the treatment of rheumatic diseases over the last few decades. Three patient self-report scores for physical function, pain, and patient global estimate are included in the rheumatoid arthritis (RA) core dataset1. These 3 scores distinguish active from control treatments in RA clinical trials involving leflunomide2, methotrexate2, anakinra3, adalimumab4, abatacept5, and certolizumab6, at levels of significance similar to formal joint counts or laboratory tests. Patient physical function scores generally are more significant than radiographic scores or laboratory test results in the prognosis of severe longterm RA outcomes such as work disability and premature mortality7,8,9,10. Routine Assessment of Patient Index Data (RAPID3), an index of only the 3 patient-reported RA Core Data Set measures, is correlated significantly with standard indices that require a formal joint count, such as DAS28 (28-joint Disease Activity Score) and CDAI (Clinical Disease Activity Index)11,12. A RAPID3 score of ≤ 3/30 with 1 or 0 swollen joints, RAPID3≤3+≤SJ1, provides remission criteria comparable to Boolean13, SDAI (Simplified Disease Activity Index), CDAI, and DAS2814 criteria in far less time than a formal joint count, in studies of the French ESPOIR early arthritis cohort15 … Address correspondence to Dr. Pincus, Division of Rheumatology, NYU Hospital for Joint Diseases, 301 East 17th St., Room 1608, New York, New York 10003, USA. E-mail: tedpincus{at}gmail.com

MDHAQ/RAPID3 scores in patients with osteoarthritis are similar to or higher than in patients with rheumatoid arthritis: a cross-sectional study from current routine rheumatology care at four sites

Objective To compare patients with a primary diagnosis of osteoarthritis (OA) versus rheumatoid arthritis (RA) for scores on a patient self-report MDHAQ/RAPID3 (Multidimensional Health Assessment Questionnaire/Routine Assessment of Patient Index Data 3), and for physician global assessment (DOCGL). Methods All patients with all diagnoses complete an MDHAQ/RAPID3 at all routine rheumatology visits in the waiting area before seeing a rheumatologist at four sites, one in Australia and three in the USA. The two-page MDHAQ includes 0–10 scores for physical function (in 10 activities), pain and patient global assessment [on 0–10 visual analogue scales (VAS)], compiled into a 0–30 RAPID3, as well as fatigue and self-report painful joint count scales. Rheumatologists estimate a 0–10 DOCGL VAS. Demographic, MDHAQ/RAPID3 and DOCGL data from a random visit were compared in patients with RA versus patients with OA using multivariate analysis of variance, adjusted for age, disease duration and formal education level. Results Median RAPID3 was higher in OA versus RA at all four sites (11.7–16.8 vs 6.2–11.8) (p<0.001 at three sites). Median DOCGL in OA versus RA was 5 vs 4, 4 vs 3.7, 2.2 vs 2.5 and 2 vs 1. Patterns were similar for individual RAPID3 items, fatigue and painful joint scales, and in stratified analyses of patients aged 55–70. Conclusion Patient MDHAQ/RAPID3 and physician DOCGL indicate similar or higher disease burden in OA versus RA. Routine MDHAQ/RAPID3 allows direct comparisons of the two diseases. The findings suggest possible revision of current clinical and public policy views concerning OA.

PROMs (MDHAQ/RAPID3) and Physician RheuMetric Measures

Information from a medical history and physical examination are far more prominent in diagnosis and management decisions in rheumatoid arthritis (RA) than vital signs, laboratory tests, or ancillary studies, in contrast to many other prevalent chronic diseases, such as hypertension and diabetes, particularly as laboratory tests have many limitations in rheumatic diseases. Medical history information can be recorded as scores on patient self-report questionnaires, to advance assessment of patient status from traditional “gestalt,” narrative impressions to quantitative data for diagnosis, management, prognosis, and outcomes. An index of only patient self-report measures, RAPID3 (routine assessment of patient index data) on an MDHAQ (multidimensional health assessment questionnaire) is as effective as laboratory tests and indices that include formal joint counts to distinguish active from control treatments in RA clinical trials, to document RA remission or severity status, and to monitor patient status and outcomes in routine care of all rheumatic diseases. Physical function on a patient questionnaire is more significant than radiographs or laboratory tests in the prognosis of severe RA outcomes of work disability, costs, and mortality. The MDHAQ also includes scales for fatigue, self-report joint count, review of systems, exercise, change in status, morning stiffness, recent medical history, and demographic data, and is feasible in busy clinical settings. RAPID3 is calculated in 5 s, versus almost 2 min for indices such as DAS28 and CDAI and is correlated significantly with both these indices. RheuMetric is a quantitative physician checklist that includes four 0–10 scores for a traditional physician global estimate, as well as for inflammation—reversible findings, damage—irreversible findings, and distress—symptoms explained by neither inflammation nor damage. Most indices for most rheumatic diseases, such as DAS28, CDAI, RAPID3, WOMAC, BASDAI, and most others, include at least 1 patient self-report measure, also designed initially to assess inflammation. However, high patient index scores suggesting active inflammation may result from organ damage (e.g., joint, kidney) and/or distress (e.g., fibromyalgia, depression). Recognition of whether clinical findings are reversible, irreversible, and/or distress-related, or 2 or all 3 of these bases, may be viewed as the expertise of a rheumatologist; recording formal quantitative physician scores may document that expertise and contribute to clinical decisions. RheuMetric results indicating that many patients with inflammatory rheumatic diseases also have substantial evidence of damage and/or distress may explain in part why rheumatology visits generally are more complex than many other types of internal medicine patient encounters. MDHAQ/RAPID3 and RheuMetric are recommended in routine rheumatology clinical care, to improve assessment, monitoring, documentation, and outcomes.

A budding surprise from the joint

Notable Cases ism. He was systemically well weight loss. C-reactive prote 10.4 mg/L (reference interval, < debridement and lavage of the a and surgical specimens also sho puted tomography scans of his did not show any evidence of d ther history showed he had fre Reactivation of dormant infections is increasingly recognised with immunosuppression for rheumatic diseases. Septic arthritis from dimorphic fungi is exceedingly rare in non-endemic settings. We describe the first Australian case of Histoplasma capsulatum septic arthritis in a man of Laotian descent who was receiving treatment for seropositive rheumatoid arthritis.