Warren Fong

The effectiveness of a real life dose reduction strategy for tumour necrosis factor inhibitors in ankylosing spondylitis and psoriatic arthritis

OBJECTIVE To determine feasibility of TNF inhibitor (TNFi) dose reduction for severe AS and PsA patients. METHODS A retrospective study in a real-world setting. Criteria for dose reduction of TNFi included BASDAI < 4 for ⩾6 months in AS; or DAS28-ESR ⩽ 3.2 for ⩾6 months in PsA. TNFi dose was reduced by one-third. Patients who flared (BASDAI > 4 in AS or DAS28-ESR > 3.2 in PsA) were re-escalated to standard treatment dose. RESULTS Twenty-six per cent (33/125) of AS and 18% (15/83) of PsA patients fulfilled criteria and underwent TNFi dose reduction. Fifty-eight per cent (19/33) of AS and 60% (9/15) of PsA patients maintained TNFi dose reduction for mean (s.d) of 1.0 (0.8) years. Reinstating standard dose of TNFi recaptured low disease activity in all patients who failed dose reduction within 24 weeks, with no statistically significant difference in mean BASDAI compared with those maintaining TNFi dose reduction in AS at 24 weeks [mean (s.d) BASDAI 2.4 (1.1) vs 1.9 (1.5), respectively (P = 0.229)]; however in PsA, those who failed dose reduction had higher disease activity compared with patients maintained on TNFi dose reduction at 24 weeks [mean (s.d) DAS28-ESR 2.7 (0.6) vs 1.3 (0.5), respectively (P ⩽ 0.001)]. In PsA, a lower DAS28-ESR prior to dose reduction of TNFi was associated with more successful dose reduction. CONCLUSIONS In a real-world setting, 60% of individuals with severe AS and PsA who achieve low disease activity can successfully reduce the dose of TNFi therapy by a third for a mean of 1 year.

Validity and reliability of the Health Assessment Questionnaire among patients with spondyloarthritis in Singapore

The Health Assessment Questionnaire (HAQ) is a popular tool used to measure disability. Few studies have assessed its psychometric properties in patients with spondyloarthritis (SpA). We therefore aimed to assess the reliability and validity of the HAQ in patients with SpA in Singapore.

IgG4‐related disease in Singapore: a description of two cases and review of the literature

We describe a 42‐year‐old man who presented with painless obstructive jaundice, organomegaly and lymphadenopathy. Biopsy of the ampulla of Vater revealed the presence of increased populations of plasma cells which stained positively for immunoglobulin G4. He was treated with prednisolone and demonstrated significant clinical improvement 1 month later. A further case is described and a review of the literature is also provided.

A systematic review of quality-of-life domains and items relevant to patients with spondyloarthritis

OBJECTIVES To summarize, from the literature, quality-of-life (QoL) domains and items relevant to patients with spondyloarthritis (SpA), and to determine if commonly used SpA patient-reported outcome (PRO) instruments include the identified domains. METHODS We used PRISMA statement for systematic review and searched Medline® , Embase®, and PsycInfo® using relevant keywords. In addition, hand searches of references of the included articles were conducted. All articles were reviewed for inclusion by 2 independent reviewers. QoL domains and items relevant to patients with axial or peripheral SpA were extracted and presented using the adapted World Health Organization Quality-of-Life (WHOQOL) domain framework. SpA PROs were assessed to determine if they included the domains identified. RESULTS We retrieved 14,343 articles, of which 34 articles fulfilled inclusion criteria for review. Twenty-five articles were conducted in the European population. Domains such as negative feelings and activities of daily living were found to be present in 28 and 27 articles, respectively. SpA impacted QoL in all domains of the adapted WHOQOL framework. Domains that differed between types of SpA were financial resources, general levels of independence and medication side effects. Embarrassment, self-image, and premature ageing were items that differed by geographical setting. PROs to capture domains for peripheral SpA were similar for axial SpA. CONCLUSIONS We found that a wide range of domains and items of QoL were relevant to patients with SpA with minimal differences between patients with axial and peripheral SpA. Clinicians may consider using peripheral SpA PROs to measure QoL of patients with axial SpA.

A systematic review of the barriers affecting medication adherence in patients with rheumatic diseases

Medication adherence is a crucial part in the management of rheumatic diseases, especially with many such patients requiring long-term medications. In this paper, we aim to systematically review the literature for the factors associated with medication adherence in the rheumatic patient population. We carried out a systematic literature search using PubMed®, PsychInfo® and Embase ® with relevant keywords and employed the PRISMA® criteria. We included English peer-reviewed articles that studied the factors affecting medication adherence in patients with rheumatic diseases, which were assessed by two independent reviewers. Hand searches were conducted and relevant factors were extracted and classified using the World Health Organization (WHO)’s five dimensions of medication adherence. A simple diagram was drawn to summarise the factors extracted. 1977 articles were identified and reviewed and 90 articles were found to be relevant. A total of 17 factors and 38 sub-factors were identified and categorized based on the WHO’s five dimensions of medication adherence. A hand model for medication adherence was developed to succinctly summarise these dimension to remind clinicians the importance of medication adherence in daily practice. We conducted a systematic review on the various factors including patient, therapy, condition, health system and socioeconomic-related factors that affected medication adherence in rheumatic patients. We found 17 factors and 38 sub-factors that affected medication adherence in this population. This systematic review can facilitate future focused research in unexplored dimensions.

Exploring Product-Specific Attributes of a Community Cardiac Rehabilitation Program in an Asian Urban City

BACKGROUND Cardiac rehabilitation (CR) has been proven to improve long-term outcomes for patients. Despite its benefits, its uptake throughout the world is poor. Factors affecting the motivation and barriers impeding an individual from participating in a CR program have been extensively studied. Nevertheless, knowledge of product-specific factors in affecting participation is lacking. OBJECTIVES To find out cultural-specific product attributes that are important to those contemplating participation in a community-based CR program using Consolidated criteria for Reporting Qualitative research (COREQ) as an anchor. METHODS Participants were recruited from attendees of the CR program at the Singapore Heart Foundation. A literature review was done to identify product-specific attributes that affected participation in CR programs. An interview guide was developed on the basis of the list of product attributes. The analysis was done by two independent analysts using NVivo version 11 (QSR International, Melbourne, Australia) via an inductive approach. Data analysis was carried out with recruitment and interviews ongoing until thematic saturation was reached. RESULTS In total, 13 male and 9 female participants (16 Chinese, 4 Indian, 1 Malay, and 1 Eurasian) aged between 47 and 89 years were interviewed. A total of 8 categories (System, Infrastructure, Environment, Monitoring, Activity, Program, Staff, and Companionship) with 30 subcategories were identified. New themes that have not been explored by previous studies were discovered under five different categories: System, Infrastructure, Environment, Program, and Companionship. CONCLUSIONS This study allows a better understanding of product-specific factors affecting participation in CR programs and serves as a springboard for further research to improve participation in community-based CR programs.

The impact of axial spondyloarthritis on quality of life (QoL): a comparison with the impact of moderate to end-stage chronic kidney disease on QoL

PurposeThe purpose of the study was to assess the impact of axial spondyloarthritis (axSpA) on patients’ quality of life (QoL) compared to patients with moderate to end-stage chronic kidney disease (CKD).MethodsWe conducted secondary analysis of QoL data obtained from patients with axSpA and CKD from 2011 to 2014. QoL was assessed using the SF-36 version 2 and KDQoL-SF for patients with axSpA and CKD, respectively. Patients with CKD were subcategorized to CKD-pre-dialysis, hemodialysis (CKD-HD) and peritoneal dialysis (CKD-PD). Linear regression was used to compare QoL between patients with axSpA and CKD after adjusting for age, gender, ethnicity, education level, and marital status.ResultsA total of 765 patients (mean age 54.6, 63.0% males, 69.0% Chinese) were analyzed, of which 188 (24.5%) had axSpA. Patients with axSpA had poorer SF-36 bodily pain (BP) scores (axSpA: reference; CKD-pre-dialysis β: 11.04, p < 0.001; CKD-HD β: 9.52, p < 0.001; CKD-PD β: 10.35, p < 0.001) and higher general health scores (axSpA: reference; CKD-pre-dialysis β: − 7.87, p < 0.001; CKD-HD β: − 7.14, p < 0.001, CKD-PD β: − 7.25, p < 0.001) as compared to patients with CKD. Generally, patients with axSpA had poorer SF-36 scores than patients with CKD-pre-dialysis and similar SF-36 scores compared to patients with CKD-HD or CKD-PD.ConclusionsThe burden of axSpA on QoL is not trivial and is comparable to patients with CKD-HD or CKD-PD.

The Utility of FDG PET/CT in IgG4-Related Disease with a Focus on Coronary Artery Involvement

PurposeOur case series aims to study the growing use of FDG PET/CT in diagnostic evaluation and follow up of IgG4-RD with emphasis on patients presenting with coronary artery involvement.MethodsWe conducted a search on the nuclear medicine and rheumatology service databases and identified patients with histologically proven IgG4-RD with FDG PET/CT performed at the Singapore General Hospital. The radiological, clinical, and laboratory findings of these patients were analyzed retrospectively.ResultsThe series included ten male and two female patients. The commonest organ involved (five patients) was the pancreas. In three patients, coronary artery involvement manifested as soft tissue masses surrounding the arterial lumens. In these patients, histological diagnosis was established from alternative biopsy sites with abnormal metabolic activity on FDG PET/CT.Correlation between laboratory and metabolic imaging findings was not statistically significant in our series.Four patients had follow-up FDG PET/CT; three showed interval reduction in metabolic activity to baseline. One showed persistent abnormal metabolic activity before a rise in IgG4 levels. The metabolic imaging response was used to guide steroid dose.ConclusionsFDG PET/CT is a useful tool in evaluation and follow-up of IgG4-RD, particularly in identifying alternative biopsy sites in patients who present with coronary artery involvement. Hypermetabolic coronary artery masses on FDG PET/CT should raise clinical suspicion of IgG4-RD. As the coronary artery masses may not show decrease in size after treatment, FDG PET/CT is also useful for metabolic response assessment.

Patient preferences for types of community-based cardiac rehabilitation programme

Introduction Cardiac rehabilitation (CR) improves mortality, morbidity and quality of life of cardiovascular patients. However, its uptake is poor especially in the hospitals due to long travel distances and office hours constraints. Community-based CR is a possible solution. Objectives To understand the type of community-based CR preferred and identify patient characteristics associated with certain programme combinations. Methods A cross-sectional survey was administered to a randomised list of patients at risk for or with cardiovascular diseases at two community-based CR centres. Participants were presented with nine hypothetical choice sets and asked to choose only one of the two alternative programme combinations in each choice set. Attributes include support group presence, cash incentives, upfront deposit and out-of-pocket cost. The counts for each combination were tallied and corrected for repeats. Chi-square test and logistic regression were performed to understand the characteristics associated with the preferred CR combination. Results After correcting for repeats, patients most (85.2%) prefer CR programmes with new group activities, support group, cash rewards, deposit and out-of-pocket cost, and few exercise equipment with physiotherapist presence without the need for monitoring equipment. Patients with more than three bedrooms in their house are less likely (OR 0.367; CI 0.17 to 0.80; P=0.011) to choose the choice with no physiotherapist and few equipment available. Conclusion This is the first study to explore patients’ preferences for different types of community CR. Higher income patients prefer physiotherapist presence and are willing to settle for less equipment. Our study serves as a guide for designing future community-based CR programmes.

Anti-hypertensive medications and injurious falls in an older population of low socioeconomic status: a nested case-control study

BackgroundThis study aimed to determine whether the number of anti-hypertensive medication classes or any change in anti-hypertensive medication were associated with injurious fall among the community-dwelling older population of low socioeconomic status.MethodsUsing data from electronic medical records, we performed a nested case-control study among older Singapore residents (≥60) of low socioeconomic status (N = 210). Controls (n = 162) were matched to each case (n = 48) by age and gender. Variables with p < 0.10 in univariate analysis were included in multivariate analysis. We used conditional logistic regression to assess the associations of the number of anti-hypertensive medication classes and change in anti-hypertensive medication with injurious falls. We also performed stepwise regressions as sensitivity analyses. p < 0.05 was considered statistically significant.ResultsThe mean (±SD) age of participants was 78.1 (± 8.33) years; 127 (60.4%) were female, 189 (90.0%) were Chinese. Those on ≥2 anti-hypertensive medication classes had an increased risk of experiencing an injurious fall compared to those not on any anti-hypertensive medication (OR = 5.45; CI:1.49–19.93; p = 0.01). Among those who were taking anti-hypertensive medication, those who had a change in the medication 180-day prior to injurious fall had a significantly increased risk of experiencing an injurious fall compared to those that did not report any change in anti-hypertensive medication (OR = 3.88; CI:1.23–12.19; p = 0.02). Sensitivity analyses generated consistent findings.ConclusionBoth ≥2 anti-hypertensive medication classes and change in anti-hypertensive medication were associated with an increased risk of experiencing an injurious fall among the older population of low socioeconomic status. Our findings could guide prescribers to exercise caution in the initiation of anti-hypertensive medications or in making medication changes, especially among the older population of low socioeconomic status.