Telemedicine for follow-up of systemic lupus erythematosus during the 2019 coronavirus pandemic: A pragmatic randomized controlled trial.

INTRODUCTION: Patients with systemic lupus erythematous were vulnerable to severe coronavirus disease 2019 infection and the negative impact of disrupted healthcare delivery. Telemedicine has been a popular alternative to standard in-person care during the pandemic despite the lack of evidence. METHODS: This was a 1-year pragmatic randomized-controlled trial. Patients followed at the lupus nephritis clinic were randomized to either telemedicine or standard follow-up in a 1:1 ratio. Patients in the telemedicine group were followed up via videoconferencing. Standard follow-up group patients continued conventional in-person outpatient care. The primary outcome of the study was the proportion of patients in low disease activity after 1 year. Secondary outcomes included cost-of-illness, safety, and various patient-reported outcomes. RESULTS: From 6/2020 to 12/2021, 144 patients were randomized and 141 patients (telemedicine: 70, standard follow-up: 71) completed the study. At 1 year, 80.0% and 80.2% of the patients in the telemedicine group and standard follow-up group were in lupus low disease activity state or complete remission, respectively (p = 0.967). Systemic lupus erythematous disease activity indices, number of flares and frequency of follow-ups were also similar. There were no differences in the cost-of-illness, quality of life or mental health scores. However, significantly more patients in the telemedicine group (41.4% vs 5.6%; p < 0.001) required switch of mode of follow-up and higher proportion of them had hospitalization during the study period (32.9% vs 15.5%; p = 0.016). Being in the telemedicine group or not in low disease activity at baseline were the independent predictors of hospitalization (odds ratio: 2.6; 95% confidence interval: 1.1-6.1, odds ratio: 2.7, 95% confidence interval: 1.1-6.7, respectively) in the post hoc analysis. CONCLUSIONS: In patients with systemic lupus erythematous, telemedicine predominant follow-up resulted in similar 1-year disease control compared to standard care. However, it needed to be complemented by in-person visits, especially in patients with unstable disease.

Use of telemedicine for follow-up of lupus nephritis in the COVID-19 outbreak: The 6-month results of a randomized controlled trial.

OBJECTIVE: This study aimed to evaluate the short-term patient satisfaction, compliance, disease control, and infection risk of telemedicine (TM) compared with standard in-person follow-up (FU) for patients with lupus nephritis (LN) during the COVID-19 pandemic. METHOD: This was a single-center open-label randomized controlled study. Consecutive patients followed at the LN clinic were randomized to either TM or standard FU (SF) group in a 1:1 ratio. Patients in the TM group received FU via videoconferencing. SF group patients continued conventional in-person outpatient care. The 6-month data were compared and presented. RESULTS: From June to December 2020, 122 patients were randomized (TM: 60, SF: 62) and had at least 2 FUs. There were no baseline differences, including SLEDAI-2k and proportion of patients in lupus low disease activity state (LLDAS), between the two groups except a higher physician global assessment score (PGA) in the TM group. After a mean FU of 19.8 ± 4.5 weeks, the overall patient satisfaction score was higher in the TM group. More patients in the TM group had hospitalization (15/60, 25.0% vs 7/62, 11.3%; p = .049) with higher baseline PGA (OR = 1.17; 95% CI, 1.08-1.26) being the independent predictor. The proportions of patients remained in LLDAS were similar in the two groups (TM: 75.0% vs SF: 74.2%, p = .919). None of the patients had COVID-19. CONCLUSIONS: TM FU resulted in better patient satisfaction and similar short-term disease control in patients with LN compared to standard care. However, it was associated with more hospitalizations and might need to be complemented by in-person visits especially in patients with higher PGA.

Factors Associated With Use of Telemedicine for Follow-Up of SLE in the COVID-19 Outbreak.

Objective: To investigate the factors associated with telemedicine (TM) use for follow-up of Systemic Lupus Erythematous (SLE) patients in the COVID-19 pandemic. Methods: This was a single-centered cross-sectional study conducted in Hong Kong. Consecutive patients followed up at the lupus nephritis clinic were contacted for their preference in changing the coming consultation to TM in the form of videoconferencing. The demographic, socioeconomic, and disease data of the first 140 patients opted for TM and 140 control patients preferred to continue standard in-person follow-up were compared. Results: The mean age of all the participants was 45.6 ± 11.8 years, and the disease duration was 15.0 ± 9.2 years. The majority of them were on prednisolone (90.0%) and immunosuppressants (67.1%). The mean SLEDAI-2k was 3.4 ± 2.4, physician global assessment (PGA) was 0.46 ± 0.62 and Systemic Lupus International Collaborating Clinics (SLICC) damage index was 0.97 ± 1.23. A significant proportion of the patients (72.1%) had 1 or more comorbidities. It was found that patients with higher mean PGA (TM: 0.54 ± 0.63 vs. control: 0.38 ± 0.59, p = 0.025) and family monthly income > USD 3,800 (TM: 36.4% vs. control: 23.6%; p = 0.028) preferred TM, while full-time employees (TM: 40.0% vs. control: 50.7%; p = 0.041) preferred in-person follow-up. These predictors remained significant in the multivariate analysis after adjusting for age and gender. No other clinical factors were found to be associated with the preference of TM follow-up. Conclusion: When choosing the mode of care delivery between TM and physical clinic visit for patients with SLE, the physician-assessed disease activity and patient's socio-economic status appeared to be important.

Effects of RANKL inhibition on promoting healing of bone erosion in rheumatoid arthritis using HR-pQCT: a 2-year, randomised, double-blind, placebo-controlled trial.

OBJECTIVE: To evaluate the effects of denosumab on erosion healing at 2-4 metacarpophalangeal (MCP) head as determined by high-resolution peripheral quantitative CT (HR-pQCT) in patients with rheumatoid arthritis (RA) with stable disease. METHODS: This was a randomised, placebo-controlled, double-blind study. Patients with RA with disease activity score 28 joints (DAS28) ≤5.1 were randomised (1:1) to subcutaneous denosumab 60 mg or placebo once every 6 months for 24 months. The primary outcome was erosion healing at MCP 2-4 on HR-pQCT at 12 months. The effects of denosumab on erosion and joint space parameters on HR-pQCT and radiographs, disease activity and health assessment questionnaire-disability index (HAQ-DI) were also examined. RESULTS: At 24 months, HR-pQCT images were analysed in 98 patients. One-third of the patients achieved sustained low disease activity throughout the study. At 12 months, changes in erosion parameters on HR-pQCT were similar between the two groups. At 24 months, new erosions (19% vs 9%, p=0.009) and erosion progression (18% vs 8%, p=0.019) were more common in the placebo group than the denosumab group. Erosion healing was seen in a significantly higher proportion of patients in the denosumab group (20% vs 6%, p=0.045) at 24 months. No significant changes in joint space parameters on HR-pQCT, van der Heijde-Sharp erosion score, DAS28 and HAQ-DI were observed in the two groups at 12 and 24 months. CONCLUSION: Although no differences in erosion parameters were observed at 12 months, denosumab was more efficacious than placebo in erosion repair on HR-pQCT after 24 months. TRIAL REGISTRATION NUMBER: NCT03239080.

Bone Mass, Microstructure, and Strength Can Discriminate Vertebral Fracture in Patients on Long-Term Steroid Treatment.

Context: Measurement of areal bone mineral density (aBMD) by dual-energy x-ray absorptiometry (DXA) was able to predict fracture risk. High-resolution peripheral quantitative computed tomography (HR-pQCT) yields additional information about volumetric bone mineral density (vBMD), microarchitecture, and strength that may increase our understanding of fracture susceptibility. Objective: To ascertain whether vBMD, microarchitecture, and estimated bone strength derived from HR-pQCT can discriminate vertebral fractures in patients with glucocorticoid-induced osteoporosis (GIOP) independent of aBMD. Design: A cross-sectional case-control study. Setting: Seven regional hospitals in Hong Kong. Patients: A total of 110 patients on long-term glucocorticoids with vertebral fracture, determined radiographically, and 110 patients on long-term glucocorticoids without fracture. Main Outcome Measures: We assessed vBMD, microarchitecture, and bone strength; aBMD; and fracture risk assessment tool (FRAX). Results: Patients with vertebral fracture had lower total vBMD and a thinner cortex at the distal tibia after adjustment for age, sex, and aBMD or FRAX. In the antiresorptive treatment-naive subgroup, patients with vertebral fracture also had lower total vBMD at both the distal radius and the tibia after adjustment for covariates. Lower total vBMD and a thinner cortex were also noticed in the nonosteoporotic or FRAX score of <10% subgroups with vertebral fracture and were also associated with increasing prevalence of vertebral fracture. Conclusion: Patients with GIOP and vertebral fracture have a significant reduction in total vBMD and cortical thinning independent of aBMD and FRAX. These changes may help identify high-risk patients in the subgroups currently considered to have low fracture risk as assessed by DXA or FRAX.

A Non-Invasive and Accurate Measurement of Gingival Thickness Using Cone-Beam Computerized Imaging for the Assessment of Planning Immediate Implant in the Esthetic Zone-A Pig Jaw Model.

INTRODUCTION: The objective of the study is to compare the accuracy of the measurement of gingival thickness using cone-beam computerized tomography (CBCT) with direct clinical measurement on a pig jaw model, aiming to provide an alternate and precise method to aid assessment of the gingival biotype before immediate implant placement at the esthetic zone. MATERIALS AND METHODS: Four pig mandibles were categorized separately into 14 different zones with each prominent tooth cusp as one. A high-resolution CBCT image was taken. Measurement of gingival thickness was performed using computer software and was compared with direct clinical measurements. RESULTS: Intraclass correlation coefficient between clinical and CBCT measurements were 0.995 (pig 1), 0.945 (pig 2), 0.966 (pig 3), and 0.932 (pig 4), which indicated a good match between 2 measuring methods. Independent t test showed no significant difference between 2 independent investigators in all aspect of measurements (P > 0.05). CONCLUSION: Measuring gingival thickness using CBCT is a predictable and accurate method to assess the gingival biotype of a patient, so as to predict the suitability of immediate implantation.

Classification of maxillary central incisors-implications for immediate implant in the esthetic zone.

PURPOSE: This is the first study to analyze the positions and angulations of the central maxillary incisors with reference to the alveolus, providing data for clinicians to achieve good esthetic results for immediate implant placement in the esthetic zone. MATERIALS AND METHODS: A total of 300 cone beam images were selected randomly. Five aspects were measured: the thickness of the palatal and buccal bone at their mid-root and apical level and the apical bone height. A classification was established according to the positions and angulations of the tooth. RESULTS: The data from 170 cone beam images were included in the present study. The mean thickness of the buccal bone at the mid-root level was 0.9 ± 0.4 mm and at the apical level was 2.04 ± 1.01 mm. The mean thickness of the palatal bone at the mid-root level was 3.76 ± 1.37 mm and at the apical level was 8.51 ± 2.54 mm. The mean apical bone height was 9.53 ± 2.76 mm. The proportion of incisors positioned more buccally (type B) was 78.8%, 19.4%, and 1.8% positioned midway (type M) and more palatally (type P), respectively. Regarding the angulation, 49.9% were classified as type 2 (toward buccal), 34.7% as type 3 (toward buccal, with the long axis anterior to the A point), and 15.4% were categorized as type 1 (toward palatal or parallel to the alveolus). CONCLUSIONS: We recommend that clinicians appreciate the socket in 3 dimensions to achieve a good outcome. According to the difficulty of achieving good results, the cases were categorized as levels I to III and recommendations were given.

Evidence-based practice in oral and maxillofacial surgery: audit of 1 training center.

PURPOSE: To evaluate the proportion of evidence-based interventions in the field of oral and maxillofacial surgery in a regional training center. PATIENTS AND METHODS: A prospective clinical audit was carried out within the discipline of Oral and Maxillofacial Surgery, University of Hong Kong in February 2004 for a period of 6 months to investigate the extent of evidence-based practice. Consecutive diagnosis and intervention pairs were identified and recorded through standardized charts in randomly selected clinical sessions. A corresponding literature search using Medline and the Cochrane Library was performed to identify best current evidence. Each pair was then analyzed and graded according to the best current evidence. RESULTS: Of 500 cases, 273 were eligible for evaluation while the rest were excluded based on 4 defined exclusion criteria. A majority of interventions (n = 195, 71.4%) were found to be evidence-based. Seventy-eight (28.6%) interventions were found to be not evidence-based. Among the evidence, a majority (56.1%) was level 5 evidence, which are case series or systematic review/meta-analysis of case series, and 36% were level 3 or above, which are randomized control trial (RCT) (level 3), meta-analysis of RCTs (level 2), or systematic review of RCTs (level 1). There was no statistically significant difference in the proportion of evidence-based practice between specialists and trainees in oral and maxillofacial surgery who saw and treated patients. CONCLUSION: This study demonstrated that most interventions prescribed in this oral and maxillofacial surgery training center were evidence-based, and the proportion was comparable with that reported by other specialties.