International league of associations for rheumatology recommendations for the management of psoriatic arthritis in resource-poor settings.

BACKGROUND: Psoriatic arthritis (PsA) is a challenging heterogeneous disease. The European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and PsA (GRAPPA) last published their respective recommendations for the management of PsA in 2015. However, these guidelines are primarily based on studies conducted in resource replete countries and may not be applicable in countries in the Americas (except Canada and USA) and Africa. We sought to adapt the existing recommendations for these regions under the auspices of the International League of Associations for Rheumatology (ILAR). PROCESS: The ADAPTE Collaboration (2009) process for guideline adaptation was followed to adapt the EULAR and GRAPPA PsA treatment recommendations for the Americas and Africa. The process was conducted in three recommended phases: set-up phase; adaptation phase (defining health questions, assessing source recommendations, drafting report), and finalization phase (external review, aftercare planning, and final production). RESULT: ILAR recommendations have been derived principally by adapting the GRAPPA recommendations, additionally, EULAR recommendations where appropriate and supplemented by expert opinion and literature from these regions. A paucity of data relevant to resource-poor settings was found in PsA management literature. CONCLUSION: The ILAR Treatment Recommendations for PsA intends to serve as reference for the management of PsA in the Americas and Africa. This paper illustrates the experience of an international working group in adapting existing recommendations to a resource-poor setting. It highlights the need to conduct research on the management of PsA in these regions as data are currently lacking.Key Points• The paper presents adapted recommendations for the management of psoriatic arthritis in resource-poor settings.• The ADAPTE process was used to adapt existing GRAPPA and EULAR recommendations by collaboration with practicing clinicians from the Americas and Africa.• The evidence from resource-poor settings to answer clinically relevant questions was scant or non-existent; hence, a research agenda is proposed.

Rates of hip and knee joint replacement amongst different ethnic groups in England: an analysis of National Joint Registry data.

OBJECTIVE: Despite a health care system that is free at the point of delivery, ethnic minorities may not always get care equitable to that of White patients in England. We examined whether ethnic differences exist in joint replacement rates and surgical practice in England. DESIGN: 373,613 hip and 428,936 knee National Joint Registry (NJR) primary replacement patients had coded ethnicity in Hospital Episode Statistics (HES). Age and gender adjusted observed/expected ratios of hip and knee replacements amongst ethnic groups were compared using indirect standardisation. Associations between ethnic group and type of procedure were explored and effects of demographic, clinical and hospital-related factors examined using multivariable logistic regression. RESULTS: Adjusted standardised observed/expected ratios were substantially lower in Blacks and Asians than Whites for hip replacement (Blacks 0.33 [95% CI, 0.31-0.35], Asians 0.20 [CI, 0.19-0.21]) and knee replacement (Blacks 0.64 [CI, 0.61-0.67], Asians 0.86 % [CI, 0.84-0.88]). Blacks were more likely to receive uncemented hip replacements (Blacks 52%, Whites 37%, Asians 44%; P < 0.001). Black men and women aged <70 years were less likely to receive unicondylar or patellofemoral knee replacements than Whites (men 10% vs 15%, P = 0.001; women 6% vs 14%, P < 0.001). After adjustment for demographic, clinical and hospital-related factors, Blacks were more likely to receive uncemented hip replacement (OR 1.43 [CI, 1.11-1.84]). CONCLUSIONS: In England, hip and knee replacement rates and prosthesis type given differ amongst ethnic groups. Whether these reflect differences in clinical need or differential access to treatment requires urgent investigation.

Inflammatory arthritis in HIV positive patients: A practical guide.

BACKGROUND: Musculoskeletal manifestations of the human immunodeficiency virus (HIV) have been described since the outset of the global HIV epidemic. Articular syndromes that have been described in association with HIV include HIV-associated arthropathy, seronegative spondyloarthropathies (SPA) (reactive arthritis, psoriatic arthritis (PsA) and undifferentiated SPA), rheumatoid arthritis (RA) and painful articular syndrome. METHODS: We carried out a computer-assisted search of PubMed for the medical literature from January 1981 to January 2015 using the keywords HIV, acquired immune-deficiency syndrome, rheumatic manifestations, arthritis, spondyloarthropathy, anti-TNF and disease modifying antirheumatic drugs. Only English language literature was included and only studies involving adult human subjects were assessed. RESULTS: There are challenges in the management of inflammatory arthritis in patients who are HIV-positive, including difficulties in the assessment of disease activity and limited information on the safety of immunosuppressive drugs in these individuals. CONCLUSIONS: This review focuses on the clinical characteristics of the inflammatory articular syndromes that have been described in association with HIV infection and discusses the therapeutic options for these patients.

Travel- and immigration-related problems in rheumatology.

Health problems are self-reported by up to 64% of travellers to the developing world. Traditionally, rheumatic symptoms are accorded little significance, but many travellers do return home with musculoskeletal complaints. The assessment of these patients is often hindered by the Western clinician's lack of familiarity with the types of infections that the patient may have encountered while travelling. Standard serological tests for autoimmune diseases can be unreliable in the setting of concomitant tropical infection, and these infections themselves can have musculoskeletal manifestations. Even in the absence of tropical infection, laboratory investigation of musculoskeletal symptoms in individuals of different ethnicities is challenging due to genetic and physiological variation. This review focusses on addressing the impact global migration has had on rheumatological clinical practice.

An unusual foreign body in the ear of an elderly Nigerian patient.

This was a case of an incidental finding of an unusual foreign body in the right ear of an elderly Nigerian patient. The mode of presentation, the manner of discovery and how it was managed successfully were highlighted. We reported this case to create awareness, and encourage physicians to always observe effluents obtained from irrigation of body cavities for confirmation of diagnosis and documentation.

Healthcare provided by a homeopath as an adjunct to usual care for Fibromyalgia (FMS): results of a pilot Randomised Controlled Trial.

OBJECTIVES: To assess the feasibility of a Randomised Controlled Trial (RCT) design of usual care compared with usual care plus adjunctive care by a homeopath for patients with Fibromyalgia syndrome (FMS). METHODS: In a pragmatic parallel group RCT design, adults with a diagnosis of FMS (ACR criteria) were randomly allocated to usual care or usual care plus adjunctive care by a homeopath. Adjunctive care consisted of five in depth interviews and individualised homeopathic medicines. The primary outcome measure was the difference in Fibromyalgia Impact Questionnaire (FIQ) total score at 22 weeks. RESULTS: 47 patients were recruited. Drop out rate in the usual care group was higher than the homeopath care group (8/24 vs 3/23). Adjusted for baseline, there was a significantly greater mean reduction in the FIQ total score (function) in the homeopath care group than the usual care group (-7.62 vs 3.63). There were significantly greater reductions in the homeopath care group in the McGill pain score, FIQ fatigue and tiredness upon waking scores. We found a small effect on pain score (0.21, 95% CI -1.42 to 1.84); but a large effect on function (0.81, 95% CI -8.17 to 9.79). There were no reported adverse events. CONCLUSIONS: Given the acceptability of the treatment and the clinically relevant effect on function, there is a need for a definitive study to assess the clinical and cost effectiveness of adjunctive healthcare by a homeopath for patients with FMS.

Lymphoproliferative disorder due to sulphasalazine.

We present the case of a 57-year-old man who had been on sulphasalazine for 20 years for seropositive non-erosive rheumatoid arthritis and developed a lymphoproliferative disorder, which resolved completely on cessation of sulphasalazine. This is the first report of lymphoproliferative disorder secondary to sulphasalazine. Lymphoproliferative disorders are well recognised with methotrexate and cyclosporine, and recognition of this disorder is critical due to the fact that a number of patients' symptoms will resolve completely with discontinuation of the drug and will not need further treatment. This case report discusses the literature on lymphoproliferative disorders as well as differential diagnoses like drug rash with eosinophilia and systemic symptoms (DRESS) syndrome.

Rheumatology training in the United Kingdom: the trainees' perspective.

BACKGROUND: Rheumatology training has undergone significant changes in the last decade with Calmanization, implementation of the New Deal for junior doctors and newer educational strategies for improving musculoskeletal training, like a core curriculum. However, concerns have been expressed about the quality of postgraduate training programmes in the UK. OBJECTIVES: First, to assess current trainees' perceptions of the quality of core and subspecialty training, the impact of workload on training, and to explore demographic variations in training experience. Secondly, to identify educational strategies that trainees felt would enhance their training. METHODS: The questionnaire was initially distributed to all specialist registrars attending the BSR Annual Meeting in Brighton in April 2002. Subsequently, the questionnaire was posted to all registrars on the Joint Committee for Higher Medical Training list with a reminder after 4 weeks. RESULTS: Trainees rated positively training in routine patient care, musculoskeletal examination and injection skills while training in primary care rheumatology, epidemiology, paediatric rheumatology and sports medicine was rated negatively. There is agreement that the reduction in junior doctors' hours has adversely affected training, and issues relating to workload have overtaken training issues. Trainees undertaking dual accreditation are more likely to feel this. Educational strategies deemed to enhance training included training workshops focused on specific topics, such as musculoskeletal radiology (89.2%), and an adequate debriefing session after an out-patient clinic (81.6%). An independently administered, reliable and valid scale for quality of training could be used to assess regional variations in training and monitoring quality. CONCLUSIONS: The changes to junior doctors' hours, the working patterns of doctors and service commitments have all affected the quality and time available for certain aspects of rheumatological training. A major effort to enhance quality is necessary to ensure that the objectives of training are met within the intended training budget.

A national qualitative survey of community-based musculoskeletal services in the UK.

OBJECTIVE: To determine the characteristics of community-based musculoskeletal services provided by primary care organizations within the UK. METHODS: Members of five professional groups within UK primary care organizations (n=461) were sent a questionnaire. RESULTS: The response rate by organization was 71% (328/461). Respondents described 350 community-based musculoskeletal services, 233/328 (71%) organizations had one or more musculoskeletal services within their community. Five main forms of service provision were: a scanning service, a rehabilitation service, physiotherapy services, joint or soft tissue injections and the implementation of integrated care pathways. In 162 services, patients were assessed, reviewed or triaged, by a 'non-consultant' health-care professional (physiotherapist or general practitioner), at an intermediate level between primary and secondary care. The purpose of the service was described in 292/350 services, only 39/350 had clear evaluation strategies and 53/350 had consideration of individual training needs. CONCLUSIONS: There are a wide range of musculoskeletal services flourishing within the community sector, whose quality may be variable. Whilst there is good evidence to suggest systematic planning of these services, we are concerned about the lack of data to support their effectiveness in terms of clinical outcomes, monitoring of service delivery standards and ongoing professional development of service providers. Commissioners of such services must ensure they have taken account of the evidence base and met any identified needs of local populations. Services should have a clear purpose with an appropriate evaluation strategy, and well-defined dissemination mechanisms. An integrated educational strategy for staff within the service must be sensitive to issues relating to accreditation, appraisal and revalidation.

The value of masters educational programmes for specialist registrars in rheumatology.

The training of junior doctors has undergone major changes in recent years. There is now more structure, with defined assessment time points leading to a Certificate of Specialist Training. This certificate provides documentation indicating that the trainee has undergone a satisfactory period of training and that they are sufficiently competent to practise as a specialist, unsupervised. The changes have led to re-examination of the role of, and educational provision for, research training as well as clinical training. In this article we review these issues and argue that the development of masters educational programmes may help to address several concerns.

Improving the quality of care of musculoskeletal conditions in primary care.

OBJECTIVE: To determine the support services general practitioners (GPs) need when working with patients who have musculoskeletal problems and their educational needs in order to deliver an improved service. METHODS: GPs (n=446) on the Sheffield and Barnsley principal lists were sent a questionnaire (53.8% response rate). Semistructured interviews of a purposive sample of 10 GPs were analysed qualitatively to increase understanding of the research objectives. RESULTS: GPs were self-confident in managing common musculoskeletal conditions such as gout (86% of GPs who replied), back pain (69%), osteoarthritis (62%) and sporting injuries (58%) entirely within the surgery. Despite high levels of confidence in diagnosing non-specific pain syndromes, 68% of GPs would refer to a rheumatologist. Most GPs (68%) were happy with their current referral rates to physiotherapists and 65% of GPs in this sample provided a personal injection service. Reduction of inappropriate prescribing of non-steroidal anti-inflammatory drugs would be helped by better patient education materials on treatments (90%) and more resources for the primary care physiotherapy service (85%). Half of the GPs had had specific musculoskeletal training within the last 5 yr. Half of the GPs planned to update their knowledge and skills in the next year, 64% of these preferring a taught interactive course, 50% wanting to sit in with a consultant in clinic and 46% preferring to learn as part of a personal learning plan. CONCLUSIONS: GPs feel confident managing the majority of musculoskeletal conditions within the surgery provided they have adequate support in terms of opportunities for appropriate education, particularly joint injection techniques, ongoing consultant support for complex cases with poor outcomes, particularly non-specific pain syndromes, adequate access to physiotherapy, and a multidisciplinary approach to pain control and inappropriate prescribing.

The use of intravenous pulsed methylprednisolone in the treatment of systemic-onset juvenile chronic arthritis.

An open prospective study using i.v. methylprednisolone in children with juvenile chronic arthritis (JCA) who had had a systemic exacerbation of disease is described. Eighteen children aged from 3 to 14 yr and 9 months (mean 9.7 yr) were treated. Ten patients (55%) had a loss of all systemic features 1 month after the pulse, and eight (45%) had a reduction in the active joint count. At this time, five of the patients on oral prednisolone had achieved a reduction in dosage. Also at 1 month, a reduction in erythrocyte sedimentation rate was observed in 11 patients (61%) and of C-reactive protein in 11 of 16 (72%). Altogether, 13 patients (72%) had a good response, while a further three (16%) went into remission. Our conclusions are that pulse methylprednisolone provides good short-term benefit in patients with systemic-onset JCA; no serious side-effects were noted. Further long-term studies are warranted.

Rheumatic manifestations of infectious diseases in children.

Infectious diseases continue to elicit worldwide attention. Many of these diseases have rheumatic manifestations as an incidental or principal feature. Because this is particularly true in children, rheumatic manifestations of infectious diseases in this population continue to be an area of great importance to rheumatologists. A variety of bacteria, viruses, fungi, and parasitic organisms can give rise to infectious diseases with rheumatic manifestations. A high index of clinical suspicion is frequently necessary for an accurate diagnosis. Prompt diagnosis and early and appropriate therapeutic intervention are usually required for a successful, and frequently curative, outcome. Over the past year, studies have addressed the pathogenetic mechanisms and clinical spectrum of the rheumatic manifestations of infectious diseases in children. There has been particular emphasis on septic arthritis, osteomyelitis, sickle-cell disease, and hepatitis C viral infection. There remains the daunting and unfortunate possibility of large numbers of children developing HIV-associated arthritis.