Yasser El Miedany

Recent Developments in Management of Psoriatic Arthritis

Until recently, little attention has been paid to psoriatic arthritis, perhaps because the disease was thought to be mild and infrequent. However, it has become clear that the disease may be severe in a significant proportion of the patients and may be more prevalent than initially considered. Recent studies supported the increasing clinical evidence that disruption of specific immune interactions can improve psoriasis and its musculoskeletal manifestations. Agents being evaluated for the treatment of psoriasis and psoriatic arthritis include, TNF-α antagonists: infliximab and etanercept, an anti-CD11a monoclonal antibody, efalizumab, and a soluble LFA-3-IgG fusion protein, alefacept. However, in concordance with the advent of new and emerging therapies, similar development in the measures of the disease activity and severity is highly required. This article gives an overview of the new developments in clinical assessment and management of psoriasis and its associated musculoskeletal manifestation. With the understanding of the disease immunopathogenesis, this review will outline a new suggested algorithm for management of psoriasis in its different clinical forms incorporating the new biologic agents with the conventional modalities.

Co-morbidity index in rheumatoid arthritis: time to think

Rheumatoid arthritis patients are clinically complex, and the interplay of their disease activity together with the other associated conditions may lead to increased morbidity and mortality. The recent advances in the disease management attracted the attention to its associated co-morbidities and highlighted the need for a tool to provide clinicians and potential payers with a clinically powerful measure of the disease burden and prognosis. Predicting outcome or co-morbidity probability has been previously implemented successfully for calculating 10-year fracture probability (FRAX) as well as for predicting 1-year patient mortality using co-morbidity data obtained (Charlson index). Developing a specific rheumatoid arthritis-independent tool able to predict morbidity, mortality, cost and hospitalization would be a step forward on the way to achieve full disease remission. The co-morbidity index should be used both at baseline as well as a continuous variable in analyses. It should be implemented regularly in the clinical assessment as a confounder of outcomes. This article will review the redefined health outcomes in rheumatoid arthritis and the concept of co-morbidity index for patients with inflammatory arthritis. It will also present a proposed co-morbidity index for rheumatoid arthritis patients.

Simulation in Medical Education

Simulation is an interactive educational tool that is increasingly used in medical education, and there is mounting evidence to support its role in improving knowledge, behaviours, as well as skill outcomes. Simulation is not a technology but a technique, which aims at mimicking or magnifying a real experience that is performed under supervision and guidance from a professional educator in a fully interactive manner. Equipment and facilities often dominate the discussion when taking about simulation-based education; however, effective learning using simulation as a methodology usually involves facilitators as well as simulated patients. Using simulation to improve safety will require full integration of its applications into the routine structures and practices of healthcare. Various leading forces and enactment mechanisms are required to drive simulation forward. By itself, simulation does not guarantee learning, but within the proper environment, it is a tool of paramount importance for modern curricula oriented by the adult learning theory. The future of simulation in healthcare depends on the commitment and creativity of the healthcare simulation community to see that improved patient safety using this tool becomes a reality. This chapter will discuss the art and science of simulated learning, the simulation fidelity continuum (low to high, multimode) and how it can be tailored to the learner’s needs. It will also discuss using simulation for assessment, how to design an effective simulation-based medical education activity as well as approach to evaluation of a simulation learning activity. It will expand to include curriculum integration and simulated learning in rheumatology and then will conclude with future directions of simulation-based education.

e-Learning, Adaptive Learning and Mobile Learning

Electronic learning, or e-learning, describes the use of information technology or the Internet for learning activities. The integration of e-learning into undergraduate, graduate and continuing medical education is consistent with adult learning theory and presents a revolution in medical education. Technology is a powerful tool for effective teaching and deeper learning. Incorporating technology into teaching and learning activities introduces new thinking about teaching effectively. It also increases opportunities to invent new learning experiences for students that will take us further beyond traditional classroom or lecture-based learning. This chapter will start by discussing the differences between e-learning, e-teaching and e-training, followed by the reasons for introducing e-learning in the medical education process. It will discuss also components of e-learning, the e-learning and the science of adult learning and the role of the teacher in e-learning. It will expand to discuss the perceptual as well as blended learning, to conclude on the future of e-learning.

Comorbidity and Physical Therapy

Outpatient physical therapy and rehabilitation provides services for a a diversity of musculoskeletal conditions such as spinal, joint, and soft tissue pains, as well as wide range of injuries, medical ailments, and post-surgical conditions. Having a baseline information about these patients referred for physical therapy and their associated comorbidities, to start their rehabilitation programs, help in guiding the treating physiatrist / therapist to set the most appropriate management plan for the patient, avoid strenuous exercises which might have negative impact on his/her medical condition, and assist in monitoring the patient’s response to therapy. Considering a full profile for the patient helps also in setting the appropriate patient education program tailored to the patient needs and organizing the appropriate patients’ group therapy services. On the research level, such data helps researchers in reclassifying the outpatient subpopulations, and evaluating the outcomes of physical therapy professional programs. It also helps in considering what to emphasize in musculoskeletal and orthopedic rehabilitation courses. Therefore, assessment of patients, for their associated comorbidities became a vital part of the patients’ pre-physiotherapy evaluation. Musculoskeletal conditions booked its place as the most prevalent referral cause for physiotherapy management. This might explain why majority of the studies carried out to assess comorbidity in patients referred for physiotherapy included patients referred mainly for specific musculoskeletal conditions such as low back pain and arthritis. This chapter will discuss the prevalence of comorbid conditions in physical therapy population as well as the association between physical therapy and comorbidity. It will also review the impact of comorbidities on physiotherapy courses, and how to set up targeted rehabilitation programs tailored for patients living with comorbidity(ies). It will also discuss the barriers to comprehensive patient management and inclusion of comorbidity assessment in standard clinical practice.

PROMs for Sjögren’s Syndrome

Sjogren’s syndrome is an autoimmune syndrome combining rheumatoid arthritis and lupus symptoms with xerostomia and dry eyes. Therefore, when you are in doubt whether the patient might have rheumatoid or lupus, it is usually Sjogren’s. The symptoms in Sjogren’s syndrome are commonly stratified into “benign” and “systemic” (or extraglandular). However, although some of the symptoms are called “benign,” the complaints of dry or painful eyes/mouth, fatigue, and joint or muscle ache are considered by many patients to be their greatest cause of disability. In view of the facts that the sicca symptoms and fatigue are mainly reported by the patients, and that the patients in standard clinical practice tend to focus more on the disease burden and its impact on their lives; patient-reported outcome measures (PROMs) has booked its place in the assessment and monitoring of Sjogren’s syndrome patients. This chapter reviews these patient-reported features, their relationships with objective assessment of the disease activity, and their validity as reliable outcome measures to assess response to current and potential therapies in both standard medical practice and clinical trials.

PROMs for Rheumatoid Arthritis

Patient-reported outcomes are reports coming directly from patients about how they feel or function in relation to a health condition and its therapy without interpretation by healthcare professionals or anyone else. Challenges of using patient-reported outcome measures (PROMs) in standard clinical practice were attributed, in the past, to clinicians’ skepticism, time and resources for the implementation, validity of the PROMs tool, unfamiliarity with the interpretation of patient’s scores, and implementation costs. However, these concerns are diminishing now, as PROMs has booked its place in the management of inflammatory arthritic patients. In view of the fact that there is no surrogate outcome measure available to capture the patient’s disease activity status, well-being, and response to treatment, PROMs has been endorsed as a primary outcome in clinical research studies. PROMs directly measure treatment benefit beyond survival, disease activity, and physiologic markers, and are often the outcomes of greatest importance to patients. Recently, PROMs has progressed from the generic phase into a “disease-specific” era. This chapter will discuss the evolving role of PROMs in the assessment and management of patients suffering from rheumatoid arthritis, how it helped in transforming patient-centered care concept into reality, and whether PROMs can be utilized as a biomarker for rheumatoid arthritis patients.

PROMs and Musculoskeletal Ultrasonography

Identification of the morphologic inflammatory as well as structural joint changes using musculoskeletal ultrasonography, both early and late in the arthritis disease process, paved the way for its use as a disease activity marker and to set up a “Treat to Target” program tailored to the patient’s inflammatory status. In addition, validation studies revealed its true benefits to the patients as reflected in the improvement of their reported outcomes. Furthermore, ultrasound enhances the doctor–patient consultation in that it provides an immediate visual aid to help educate the patient about their disease and the importance of its management. The recent perception redefining outcome measures in arthritic patients highlighted the link between the structural and patient reported outcomes. This chapter will discuss the concept of musculoskeletal ultrasound-detected morphologic joint affection as well as the current understanding of arthritic joint ultrasonography and its association with patient reported outcome measures underscoring a potential added value in daily practice.

PROMs for Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a relatively common condition that results from median nerve entrapment at the wrist and is characterized by distinctive clinical manifestations. However, in spite of being the most common compression neuropathy in the upper extremity, it still lacks the gold standard for diagnosis. Furthermore, the existing objective measures for assessment have failed to show significant correlations with post-management clinical outcomes whether the treatment approach adopted was conservative or surgical. This paved the way for patient reported outcome measures to be a key indicator of the syndrome’s diagnosis as well as treatment outcomes. This chapter will outline the role of patient reported outcome measures in the diagnosis and management of CTS. It will also discuss the newly introduced “carpal tunnel response” and its value in optimizing outcomes in carpal tunnel syndrome patients. It aims at improving the quality and efficiency of the patients’ care in standard practice by outlining the role of the patient reported data in the appropriate information gathering and decision-making processes involved in CTS diagnosis and management.