The Impact of the Off-site Monitoring Clinic (Virtual Monitoring Clinic) on the Practice of Outpatient Rheumatology in a Tertiary Centre during the COVID-19 Pandemic

The ongoing pandemic in Singapore is part of a global pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To control the spread of COVID-19 and prevent the healthcare system from being overwhelmed, 'circuit breaker' measures were introduced between 7 April and 1 June 2020 in Singapore. There is thus a crucial need for innovative approaches to the provision and delivery of healthcare in the context of safe-distancing by harnessing telemedicine, especially for patients with chronic diseases who have traditionally been managed in tertiary institutions. We present a summary of how the Virtual Monitoring Clinic has benefited the practice of our outpatient rheumatology service during the COVID-19 pandemic. The virtual consultations address the need for safe-distancing by limiting face-to-face appointments and unnecessary exposure of patients to the hospital where feasible. This approach ensures that the patients are monitored appropriately for drug toxicities and side-effects, maintained on good disease control, and provided with patient education.

Singapore Chapter of Rheumatologists Consensus Statement on the Eligibility for Government Subsidy of Biologic Disease Modifying Antirheumatic Agents for Treatment of Rheumatoid Arthritis (RA)

<p><b>INTRODUCTION</b>Up to 30% of patients with rheumatoid arthritis (RA) respond inadequately to conventional non-biologic disease modifying antirheumatic drugs (nbDMARDs), and may benefit from therapy with biologic DMARDs (bDMARDs). However, the high cost of bDMARDs limits their widespread use. The Chapter of Rheumatologists, College of Physicians, Academy of Medicine, Singapore aims to define clinical eligibility for government-assisted funding of bDMARDs for local RA patients.</p><p><b>MATERIALS AND METHODS</b>Evidence synthesis was performed by reviewing 7 published guidelines on use of biologics for RA. Using the modified RAND/UCLA Appropriateness Method (RAM), rheumatologists rated indications for therapies for different clinical scenarios. Points reflecting the output from the formal group consensus were used to formulate the practice recommendations.</p><p><b>RESULTS</b>Ten recommendations including diagnosis of RA, choice of disease activity measure, initiation and continuation of bDMARD and option of first and second-line therapies were formulated. The panellists agreed that a bDMARD is indicated if a patient has (1) active RA with a Disease Activity Score in 28 joints (DAS28) score of ≥3.2, (2) a minimum of 6 swollen and tender joints, and (3) has failed a minimum of 2 nbDMARD combinations of adequate dose regimen for at least 3 months each. To qualify for continued biologic therapy, a patient must have (1) documentation of DAS28 every 3 months and (2) at least a European League Against Rheumatism (EULAR) moderate response by 6 months after commencement of therapy.</p><p><b>CONCLUSION</b>The recommendations developed by a formal group consensus method may be useful for clinical practice and guiding funding decisions by relevant authorities in making bDMARDs usage accessible and equitable to eligible patients in Singapore.</p>

Septic monoarthritis and osteomyelitis in an elderly man following Klebsiella pneumoniae genitourinary infection: case report

<p><b>INTRODUCTION</b>Klebsiella pneumoniae septic arthritis and osteomyelitis, albeit uncommon in adults, are important sites of disseminated infection. Many case reports have shown K. pneumoniae as a cause of nosocomial transmitted septic arthritis in neonates and children. We report a rare case of an elderly patient with K. pneumoniae genitourinary infection spreading to the liver and other extra hepatic sites like the prostate and peripheral joint.</p><p><b>CLINICAL PICTURE</b>The patient presented with a short history of general malaise, fever and urinary symptoms, associated with an acute monoarthritis of the ankle. On admission, he was in septic shock. Investigations suggested an infective cause, as evidenced by raised total white cell count and pyuria. K. pneumoniae was cultured from both urine and ankle synovial fluid. Imaging confirmed multiple liver and prostatic abscesses, as well as osteomyelitis of the foot bones adjacent to the ankle.</p><p><b>TREATMENT</b>Treatment in this case included surgical drainage of the affected joint and surrounding soft tissue structures, in addition to a 6-week course of systemic antibiotics.</p><p><b>OUTCOME</b>The patient had good clinical response following treatment. In addition, we noted a normalisation of his laboratory parameters and resolution of the intraabdominal and pelvic abscesses.</p><p><b>CONCLUSION</b>This case emphasises the importance of timely and accurate diagnosis followed by appropriate treatment in disseminated K. pneumoniae infection to prevent significant morbidity and mortality.</p>