Effect of the COVID-19 induced phase of massive telehealth uptake on end-user satisfaction.

BACKGROUND: COVID-19 has resulted in a massive increase in telehealth utilisation. AIMS: To determine the user and clinician satisfaction during this period and compare to a pre-COVID-19 cohort. METHODS: A prospectively collected voluntary questionnaire following the telehealth appointment at a tertiary-level hospital with all adult and paediatric-based specialities was conducted over two time periods: COVID-19 (16 March 2020 to 15 April 2020) and pre-COVID-19 (1 January 2019 to 31 December 2019). There were four groups of participants: patients; parents; adult-based clinicians; and paediatric-based clinicians. The outcomes assessed included perceived standard of care, willingness for repeat telehealth consultations, and patient and parental perceptions of safety. RESULTS: Five thousand and thirty-three telehealth consultations occurred in the COVID-19 period with 1757 questionnaires completed, compared to 1917 consultations with 271 questionnaires completed in the pre-COVID-19 period. Clinicians were more likely to have previously used telehealth in both time periods than end-users. In COVID-19, 1240 actual onsite hospital outpatients' visits were prevented. All groups reported a good overall impression of the telehealth quality; patients/parents scored higher compared to clinicians: 3.6/4 versus 3.3/4, P = 0.02 (pre-COVID-19) and 3.3/4 versus 2.8/4, P = 0.001 (COVID-19). The majority of patients and parents (90%, 1379/1528) felt safer by having a telehealth appointment compared to a face-to-face appointment in the COVID-19 pandemic. All participant groups reported an overall good standard of care, good levels of engagement and were strongly willing to use telehealth again in both of the study time periods. Patients and parents consistently rated higher than clinicians. CONCLUSIONS: During a rapid increase in its utilisation and scope due to the COVID-19 pandemic, telehealth was generally well accepted by patients, parents and clinicians, which was consistent with pre-COVID-19 experiences.

Reasons for Biologic and Targeted Synthetic Disease-modifying Antirheumatic Drug Cessation and Persistence of Second-line Treatment in a Rheumatoid Arthritis Dataset.

OBJECTIVE: To provide real-world evidence about the reasons why Australian rheumatologists cease biologic (b) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARD) when treating patients with rheumatoid arthritis (RA), and to assess (1) the primary failure rate for first-line treatment, and (2) the persistence on second-line treatments in patients who stopped first-line tumor necrosis factor inhibitors (TNFi). METHODS: This is a multicenter retrospective, noninterventional study of patients with RA enrolled in the Australian Optimising Patient outcome in Australian RheumatoLogy (OPAL) dataset with a start date of b/tsDMARD between August 1, 2010, and June 30, 2017. Primary failure was defined as stopping treatment within 6 months of treatment initiation. RESULTS: Data from 7740 patients were analyzed; 6914 patients received first-line b/tsDMARD. First-line treatment was stopped in 3383 (49%) patients; 1263 (37%) were classified as primary failures. The most common reason was "lack of efficacy" (947/2656, 36%). Of the patients who stopped first-line TNFi, 43% (1111/2560) received second-line TNFi, which resulted in the shortest median time to stopping second-line treatment (11 months, 95% CI 9-12) compared with non-TNFi. The longest second-line median treatment duration after first-line TNFi was for patients receiving rituximab (39 months, 95% CI 27-74). CONCLUSION: A large proportion of patients who stopped first-line TNFi therapy received another TNFi despite evidence for longer treatment persistence on second-line b/tsDMARD with a different mode of action. Lack of efficacy was recorded as the most common reason for making a switch in first-line treatment of patients with RA.

Outcomes of patients admitted to hospital medical units with back pain.

BACKGROUND: Hospital admissions for patients with back pain are increasing. Despite their significant contribution to the healthcare burden, they remain largely unstudied. AIM: To investigate the management and clinical outcomes of patients with acute back pain admitted to hospital under general medicine units when compared to a rheumatology unit. METHODS: A 36-month retrospective, observational study on patients presenting to the emergency department with back pain who were subsequently admitted to one of three general medicine units (GM) or a rheumatology unit (RU). Differences in patient demographics, management and clinical outcomes were assessed using Chi-squared tests for categorical variables and Kruskall-Wallis tests for continuous variables. Multivariate associations of two primary outcomes, length of stay (LOS) and complications were examined using generalised estimating equations. RESULTS: Data from 712 admissions from 594 patients across the four inpatient units were used for this study. Common discharge diagnoses were musculoskeletal/non-specific back pain (41%), disc-related illness (22%), vertebral fracture (14%) and sciatica (14%). Non-English speaking background (NESB), age ≥ 80 years, disc-related disease, vertebral fracture and sciatica were statistically significantly associated with both increased LOS and complications. The presence of comorbidities was associated with more complications. GM admission was associated with a longer LOS and more complications than RU admission. CONCLUSION: Multiple factors associated with an increased LOS and complications were identified, including older patients and patients of NESB. Given the observed variations in back pain management between general and specialty units, strategies to standardise care should be considered.

Effectiveness of biologics in Australian patients with rheumatoid arthritis: a large observational study: REAL.

BACKGROUND: The comparative effectiveness of biologic treatment regimens in a real world Australian population is unknown. AIM: To assess the effectiveness of biological disease-modifying anti-rheumatic drugs (bDMARD) as monotherapy or in combination with methotrexate and/or other conventional DMARD (cDMARD) for the treatment of rheumatoid arthritis (RA). METHODS: A retrospective, non-interventional study was conducted that investigated the use of bDMARD in adult patients with RA in routine clinical practice. Data were extracted from the Optimising Patient Outcomes in Australian Rheumatology - Quality Use of Medicines Initiative database. Real-world effectiveness was measured using the 28-joint disease activity score (DAS28) and clinical disease activity index (CDAI) by treatment group at baseline, weeks 12 and 24. RESULTS: A total of 2970 patients was included with a median (min-max) age of 60.0 (19.0-94.0) years and median (min-max) duration of RA before first bDMARD treatment of 6.0 (0.2-58.3) years. A total of 1177 patients received more than one bDMARD during the analysis period of 1 January 1997 to 15 August 2015. Patients had 4922 treatment 'episodes' (defined as a cycle of continuous individual bDMARD prescribing in a single patient). Patients received a mean (SD) of 1.7 (1.0) episodes of treatment with median (min-max) treatment duration of 0.7 (0-11.8) years; median treatment duration was higher with the first treatment episode. bDMARD were most commonly initiated in combination with methotrexate (73.9% of episodes) and least commonly as monotherapy (9.9% of episodes). Median (min-max) baseline DAS28 decreased from 5.3 (0-8.7) with the first bDMARD to 3.7 (0-8.8) with the second. Median baseline CDAI similarly decreased. CONCLUSIONS: Patients tended to persist longer on their first bDMARD treatment. bDMARD as monotherapy or in combination appear to be accepted treatment strategies in the real world.

Psoriatic arthritis treatment regimens, therapy duration and reasons for cessation in the biologics era: a multi-centre Australian study.

AIM: To describe the treatment regimens, duration of therapy and reasons for disease-modifying antirheumatic drug (DMARD) cessation in a large psoriatic arthritis (PsA) cohort. METHODS: A retrospective non-interventional multi-centre study using Audit4 electronic medical records, with de-identified, routinely collected clinical data from rheumatology practices in the OPAL consortium (Optimising Patient outcomes in Australian rheumatoLogy) during November 2015. Baseline characteristics, type and duration of conventional and biologic DMARDs (cDMARD and bDMARD, respectively), disease activity (Disease Activity Score of 28 joints C-reactive protein [DAS28-CRP]), and reasons for treatment cessation were recorded. RESULTS: A total of 3422 rheumatologist-diagnosed PsA patients were included: 60% female, mean age 54 years and disease duration 10 years. Of patients with treatment recorded (n = 2948), 46% were on cDMARD monotherapy, 19% bDMARD monotherapy, 13% combination bDMARD and cDMARDs, 11% combination cDMARDs and 10% no DMARDs. Of those with DAS28-CRP results (n = 494), the highest mean DAS28-CRP was 3.32 on combination cDMARDs, and the lowest was 2.19 on bDMARD monotherapy. Median duration on cDMARD monotherapy was 33.5 months (n = 2232), on bDMARD monotherapy 110.1 months (n = 751), on combination bDMARD and cDMARDs 68.5 months (n = 559). The most common reasons for cessation of cDMARD monotherapy was adverse reactions (41%), for bDMARD monotherapy lack of efficacy (26%), and for combination bDMARD and cDMARDs treatment completed or no longer required (37%). CONCLUSION: Most PsA patients were prescribed DMARD therapies with a large proportion receiving cDMARDs. Patients on combination cDMARD therapies had the highest DAS28-CRP results. Adverse reactions were the most common reason for cessation of cDMARD monotherapy, whereas for bDMARD monotherapy it was lack of efficacy.

The CEDAR Study: A Longitudinal Study of the Clinical Effects of Conventional DMARDs and Biologic DMARDs in Australian Rheumatology Practice.

OBJECTIVES: To observe the choices of conventional disease modifying antirheumatic drugs (cDMARDs) and biologic DMARDs (bDMARDs) in the management of rheumatoid arthritis (RA) in Australian routine clinical practice, to assess treatment survival and determine the effect of cDMARDs/bDMARDs on disease activity. METHODS: Routinely collected, deidentified clinical data was sourced from 20 Australian rheumatology practices. RA patients aged ≥18 years, who had received cDMARDs/bDMARDs and a recorded subsequent visit, were included. A linear mixed model was used to determine the change over time and the percentage reduction in disease activity was summarized. RESULTS: 12,526 RA patients were included: 72% females, mean age 62 years. cDMARDs and bDMARDs were used in 92% and 30% of patients, respectively. The most commonly prescribed cDMARD was methotrexate (76% patients); median time to stopping treatment was 337 months [95% CI: 279-ND]. Etanercept was the most commonly prescribed bDMARD (12% patients); median time to stopping treatment was 79 months [95% CI: 57-93]. Of 5,341 patients with a first change in medication (cDMARD or bDMARD), 87% had therapy escalation and 13% deescalation. Reduction in DAS28-ESR, 6-month post-DMARDs initiation ranged from 3%, adalimumab, to 14%, leflunomide and tocilizumab. CONCLUSIONS: In this large Australian cohort of unselected community RA patients, the choices of cDMARDs/bDMARDs are aligned with current international guidelines.

Longitudinal study of clinical prognostic factors in patients with early rheumatoid arthritis: the PREDICT study.

AIM: To assess the association between baseline clinical prognostic factors and subsequent Disease Activity Score of 28 joints (DAS28) remission in early rheumatoid arthritis (RA). METHODS: Data were collected using point of care clinical software from participating rheumatology centres. Patients aged 18 years or over whose date of clinical onset of RA was within the previous 12-24 months, who had at least 6 months of follow-up data and a DAS28-ESR (erythrocyte sedimentation rate) score recorded between 12 and 24 months from first being seen for RA were included. Data collected included baseline demographics, mode of disease onset, pattern of joint involvement at onset, smoking status, DAS28, rheumatoid factor (RF), anti-citrullinated peptide antibodies (ACPA), time from symptom onset to presentation and disease activity at baseline. Univariate and multivariate logistic regression of DAS28-ESR remission between 12 and 24 months after first assessment were performed. RESULTS: Data from 1017 patients were analyzed: 70% female; mean age 60 years (SD: 14.7); 70% RF-positive, 58% ACPA-positive. The strongest age and sex adjusted baseline predictors of DAS28-ESR remission at 12-24 months were remission at baseline (odds ratio [OR]: 4.49, 95% CI: 2.17-9.29, P < 0.001), being male (OR: 2.42, 95% CI: 1.46-4.01, P < 0.001), abstaining from alcohol (P < 0.001) and being lower weight (OR: 0.98, 95% CI: 0.97-1.00, P = 0.015). There was no statistically significant association between joint onset patterns, mode of onset, RF, ACPA or smoking status. CONCLUSION: In this observational study, patients with early RA at risk of not achieving remission include those with high disease activity at baseline, women, those who drink alcohol and those with higher body weight.

Epidemiology of inpatient gout in Australia and New Zealand: temporal trends, comorbidities and gout flare site.

AIM: To assess the epidemiology of inpatient gout in Australia and New Zealand during the years 2009-2014. METHODS: Using the Health Roundtable Limited (HRT) dataset, all patients with a coded ICD10 primary or secondary discharge diagnosis of gout from a HRT participating Australian or New Zealand hospital between the years 2009 and 2014 were identified. The number of inpatient gout admissions, length of stay, body site of gout flare, temporal trends and comorbidities were assessed. RESULTS: During 2009-2014, the number of gout admissions increased significantly in Australia and New Zealand. The rate of inpatient gout admissions relative to the population and total HRT admissions rose in Australia and stayed static in New Zealand. Lower limb presentations were the commonest anatomical site of gout in admitted patients. Length of stay over the course of the study decreased both in patients admitted for gout and in those in the entire HRT dataset. Patients admitted for gout have longer length of stay compared to patients admitted for other reasons. Cardiovascular disease, infection and stroke were the commonest conditions that were complicated by an episode of inpatient gout. There was no influence of month or season on the pattern of gout admissions. CONCLUSION: The number of gout admissions rose in Australia numerically and as a proportion of the total population and total admissions. Gout is an increasing problem affecting individuals and the community as a whole in Australia.

Patients with Rheumatoid Arthritis in the Australian OPAL Cohort Show Significant Improvement in Disease Activity over 5 Years: A Multicenter Observational Study.

OBJECTIVE: To evaluate disease activity trends in a large cohort of Australian patients with rheumatoid arthritis (RA) from 2009 to 2014. METHODS: This is a multicenter, cross-sectional, noninterventional study of patients with RA treated in Australia. Patients with RA treated at participating OPAL (Optimising Patient outcome in Australian RheumatoLogy) clinics were included in the study. Data, deidentified by patient, clinic, and clinician, were identified using a purpose-written electronic medical record. Patient demographics, disease onset, medications, and disease measures were analyzed. The Disease Activity Score at 28 joints (DAS28) was used to classify patients into the disease activity states of remission: low disease activity, moderate disease activity (MDA), and high disease activity. Choice of therapy was at the discretion of the treating clinician. RESULTS: At the time of analysis, the database contained 15,679 patients with RA, 8998 of whom fulfilled the inclusion criteria. Mean age was 63.2 years, mean disease duration was 13.8 years, and the majority were women (72.4%). A total of 37,274 individual DAS28-erythrocyte sedimentation rate scores were recorded for the 8998 patients. The frequency of remission increased significantly from 36.7% in 2009 to 53.5% in 2014 (p < 0.001), and that of MDA decreased from 33% (2009) to 22.2% (2014). The use of biologic disease-modifying antirheumatic drugs for the patients in remission increased from 17% in 2009 to 36.9% in 2014. CONCLUSION: Contemporary management of RA in Australia shows improvements in disease activity toward the target of remission over a 5-year period.

Rheumatoid arthritis referrals and rheumatologist scarcity: a prioritization tool.

OBJECTIVE: To assess whether applying the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria for rheumatoid arthritis (RA) to primary care referrals improved triage decisions and reduced waiting times, and to determine the sensitivity and specificity of this strategy. METHODS: The 2010 ACR/EULAR criteria for RA were prospectively applied over 8 months to all new adult rheumatology referrals with possible inflammatory arthritis. If the referral contained insufficient information, a request was sent for more information. Joint count was based on physician report, and definite swelling was not required. Referrals meeting triage criteria were offered an appointment within 6 weeks. Data were collected on rheumatologist diagnosis, disease-modifying antirheumatic drug (DMARD) use, and waiting times. RESULTS: Of 457 referrals screened, 180 met inclusion and exclusion criteria, and 143 had sufficient data after requests for information. Seventy-one referrals met triage criteria, and of the 63 attending the appointment, 25 (40%) received a rheumatologist diagnosis of RA. Seventy-two referrals did not meet criteria, and 1 of 49 attending (2%) had RA. The characteristics of the tool for a diagnosis of RA were sensitivity 96%, specificity 56%, positive predictive value 40%, and negative predictive value 98%. Median wait times for referrals fulfilling and not fulfilling triage tool criteria were 7.9 weeks and 45.4 weeks, respectively. CONCLUSION: Implementing the 2010 ACR/EULAR criteria for RA as a prioritization tool for primary care referrals improved the number of patients subsequently diagnosed with RA. Waiting time was reduced for RA patients. Applying this strategy in areas of rheumatologist scarcity may permit earlier DMARD treatment.

Satisfaction with rural rheumatology telemedicine service.

AIM: To assess patient satisfaction with the rheumatology telemedicine service provided to a rural town in northern Australia. METHODS: A prospective, questionnaire-based exploratory study of patients seen at the Mount Isa (rural town) rheumatology telemedicine clinics during 2012 was undertaken. Control groups included patients travelling over 3 h to be seen face-to-face in Townsville (tertiary referral centre), and patients seen at the infrequent face-to-face clinic in Mount Isa. A 5-point Likert scale was used to explore themes of communication, confidentiality, physical examination, rapport, medication safety and access. RESULTS: This study evaluated 107 rheumatology outpatients (49 telemedicine, 46 face-to-face Townsville, 12 face-to-face Mount Isa). Patients seen in Mount Isa travelled a median of < 10 km for either the telemedicine or local face-to-face appointments. The patients attending the Townsville face-to-face clinic travelled a median of 354 km. New patients comprised 14% of consultations. Satisfaction with themes related to quality-of-care was high with over 90% selecting 'agree' or 'strongly agree' to these questions. Comparing models of care, there were no statistically significant differences in the rates of those selecting 'strongly agree' across questions, apart from a single question related to rapport which favored the Mount Isa face-to-face model (P = 0.018). When asked whether they would rather travel to Townsville than participate in a telemedicine consultation, 63% of patients selected 'disagree' (17%) or 'strongly disagree' (46%). CONCLUSIONS: These results suggest that patients are satisfied with a rheumatology telemedicine service, and may prefer this to extensive travelling. Evaluation in other settings is recommended before generalizing this finding.

Timely access to specialist medical oncology services closer to home for rural patients: experience from the Townsville Teleoncology Model.

PROBLEM: Prior to 2009, the teleoncology model of the Townsville Cancer Centre (TCC) did not achieve its aims of equal waiting times for rural and urban patients and the provision of reliable, local acute cancer care. From 2007-2009, 60 new patients from Mt Isa travelled to TCC for their first consultation and their first dose of chemotherapy. Six of these patients required inter-hospital transfers and eight required urgent flights to attend outpatient clinics. Only 50% these rural patients (n = 30) were reviewed within one week of their referral, compared with 90% of Townsville patients. DESIGN: A descriptive study. SETTING: TCC provides teleoncology services to 21 rural towns; the largest is Mt Isa, Qld. KEY MEASURES FOR IMPROVEMENT: Specialist review of 90% of urgent cases within 24 hours, and 90% of non-urgent cases within one week of referral via videoconferencing. A 50% reduction in inpatient inter-hospital transfers from Mt Isa to Townsville. STRATEGIES FOR CHANGE: Employment of a half-time medical officer and a half-time cancer care coordinator, and implementation of new policies. EFFECTS OF CHANGE: Between 2009 and 2011, TCC provided cancer care to 70 new patients from Mt Isa. Of these new patients, 93% (65/70) were seen within one week of referral. All 17 patients requiring urgent reviews were seen within 24 hours of referral and managed locally thus eliminating the need for inpatient inter-hospital transfers. LESSONS LEARNT: Provision of timely acute cancer care closer to home requires an increase in the rural case complexity and human resources.

Barriers to optimal disease control for rheumatoid arthritis patients with moderate and high disease activity.

OBJECTIVE: To evaluate barriers that prevent rheumatoid arthritis (RA) patients from achieving Disease Activity Score in 28 joints using the erythrocyte sedimentation rate (DAS28-ESR) scores within the current recommended levels for low disease activity (LDA) or clinical remission (DAS28-ESR score <3.2). METHODS: Using an electronic medical record program, clinical data for RA patients treated in Optimising Patient Outcomes in Australian Rheumatology clinics, with a recorded DAS28-ESR score, were collected at one point in time. The data included demographics, medications, disease measures, and the rheumatologist's opinion of the main barriers preventing improvement to the recommended DAS28 score. RESULTS: Of the 4,037 patients with a recorded DAS28-ESR score, 304 patients (7.5%) had high disease activity (HDA) and 1,211 patients (30%) had moderate disease activity (MDA). For 584 HDA or MDA patients, the barriers to disease control (BTCs) were recorded by the rheumatologist when there was no adjustment to disease-modifying antirheumatic drug (DMARD) therapy. The recorded BTCs were irreversible joint damage (19.7%), patient-driven preference (14.7%), noninflammatory musculoskeletal pain (9.2%), insufficient time to assess the effect of recently initiated DMARDs (9.2%), safety concerns (7.5%), comorbidities (6.5%), resistant disease (6.3%), and other less common reasons. These patients received DMARDs (97.4%), including biologic agents (34.1%), methotrexate (74.8%), and oral corticosteroids (41.8%). CONCLUSION: This study identified clinical situations in which rheumatologists elected to continue RA patients with MDA or HDA on DMARD therapy without adjustment to achieve clinical remission or an LDA target of a DAS28-ESR score <3.2.

A multi-center, observational study shows high proportion of Australian rheumatoid arthritis patients have inadequate disease control.

OBJECTIVES: To evaluate the disease activity and current pharmacological interventions used to achieve remission in rheumatoid arthritis (RA) patients in Australia. METHODS: Rheumatoid arthritis patients treated in participating Australian clinics were included in the study. Patient demographics, disease onset, medications and disease measures were analyzed. Data, de-identified to the patient, clinic and clinician were captured using an electronic clinical management program. The disease activity score (DAS28) was used to classify patients into the disease activity states of remission, low disease activity (LDA), moderate disease activity (MDA) and high disease activity (HDA). Choice of therapy was at the discretion of the treating clinician. RESULTS: A total of 5686 patients, 72.9% female, 26.9% male, with mean age 61.1 (SD 13.6) years and mean disease duration of 11.5 (SD 10.5) years were analyzed. DAS28 ESR (erythrocyte sedimentation rate) scores were recorded for 2973 patients, with 41.6% in remission, 18.6% LDA, 31.6% MDA and 8.2% HDA. Of those in remission, 17% received a biological disease modifying anti-rheumatic drug (bDMARD), 73% methotrexate (MTX), 19% leflunomide (LEF) and 28% prednisolone. Of the patients with MDA, 20% received a bDMARD, 76% MTX, 24% LEF and 39% prednisolone. Of the patients in HDA, 27% received a bDMARD, 78% MTX, 31% LEF and 60% with prednisolone. CONCLUSIONS: Cross-sectional assessment of this large cohort of Australian RA patients found a large proportion remain in moderate or high disease activity; suggesting a considerable evidence-practice gap. Improvement in disease control in this group may reduce future health burdens.

The SMILE study -- safety of methotrexate in combination with leflunomide in rheumatoid arthritis.

OBJECTIVE: To assess the safety of treating patients with rheumatoid arthritis with a combination of methotrexate (MTX) and leflunomide (LEF) in comparison to MTX monotherapy, in clinical practice. METHODS: The Safety of Methotrexate in Combination with Leflunomide in Rheumatoid Arthritis (SMILE) study was a multicenter, observational, cross-sectional, retrospective safety study. The study was conducted by the Optimising Patient Outcomes in Australian Rheumatology-Quality Use of Medicines Initiative (OPAL QUMI). Data were deidentified for patient, clinic, and clinician prior to collection from 13 participating rheumatology practices (25 rheumatologists). Comparative analysis of safety for the different treatments, primarily with regard to neutropenia and liver abnormalities, was performed. RESULTS: In total, 2975 patients were included in the study: 74% female, 26% male, mean age 62 years (SD 13.6). Distribution of therapy: MTX monotherapy 52.2%, LEF monotherapy 7.3%, MTX plus LEF 13.9%, and neither MTX nor LEF 26.6%. Comorbid liver disease was reported in 8.1% of patients. Liver function abnormalities were reported in 12% of the MTX monotherapy group, 16% of the LEF monotherapy group, 19% of the MTX-LEF combination group, and 14% of the group not taking either drug. Neutropenia was reported in 2.3% of the MTX monotherapy group, 5.5% of the LEF monotherapy group, 3.9% of the MTX-LEF combination group, and 4.2% of the group not taking either drug. CONCLUSION: The combination of MTX and LEF was well tolerated, with adverse events comparable to those of monotherapy and the other nonbiologic disease-modifying antirheumatic drug treatment group.

Calciphylaxis in a morbidly obese woman with rheumatoid arthritis presenting with severe weight loss and vitamin D deficiency.

OBJECTIVE: To present an unusual case of calciphylaxis in an obese patient with inactive rheumatoid arthritis and normal renal function. METHODS: We describe a 46-year-old morbidly obese Caucasian woman who had previously weighed 200 kg and presented with painful leg ulcers following a rapid weight loss of 102 kg in 1 year. RESULTS: The subject was admitted with a 6-week history of painful leg ulcers that progressed to her thighs. Vasculitis and active rheumatoid arthritis were excluded clinically and biochemically. A skin biopsy confirmed calciphylaxis in the context of normal renal function. Serum 25-hydroxyvitamin D was low at 14 ng/mL (reference range, 20 to 200 ng/mL), with an elevated serum parathyroid hormone level of 241 pg/mL (reference range, 10 to 65 pg/mL), but normal serum calcium and phosphorus levels. The skin lesions persisted despite local wound care, daily hyperbaric oxygen, and parenteral sodium thiosulfate therapies. After normalizing the serum vitamin D level through oral supplementation, she responded well to pamidronate infusion with complete healing of the ulcers and regained 13% of her premorbid weight. CONCLUSION: This is the first case of calciphylaxis preceded by weight loss of greater than 100 kg in a patient with hypovitaminosis D who responded to pamidronate therapy.

Matched comparison of GP and consultant rating of electronic discharge summaries.

Queensland Health is implementing a state-wide system to electronically generate and distribute discharge summaries. Previously, general practitioners (GPs) have indicated that the quality of the discharge summary does not support clinical handover. While the electronic system will address some issues (e.g. legibility and timeliness), the quality of the discharge summary content is predominantly independent of method of generation. As discharge summaries are usually generated by interns, we proposed that improvement in the quality of the summary may be achieved through education. This project aimed to compare the perceptions of hospital-based consultant educators and recipient GPs regarding discharge summary content and quality. The discharge summary and audit tool were sent to the recipient GP (n=134) and a hospital consultant (n=14) for satisfaction rating, using a 5- point Likert scale for questions relating to diagnosis, the listing of clinical management, medication, pathology, investigations, and recommendations to GP. Sampling was performed by selecting up to 10 discharge summaries completed by each first-year intern (n=36) in 2009, during the second, third and fourth rotations at the Townsville Hospital until a total of 403 was reached. Matched responses were compared using the Kappa statistic. The response rate was 93% (n=375) and 63% (n=254) for consultants and GPs respectively. Results from this study demonstrated that GPs were more satisfied with discharge summaries than were consultants. An anomaly occurred in three questions where, despite the majority of GPs rating satisfied or very satisfied, a small but proportionally greater number of GPs were very dissatisfied when compared with consultants. Poor or fair agreement between GPs and consultants was demonstrated in medications, pathology results, investigations and recommendations to GP, with GPs rating higher satisfaction in all questions. Lower consultant satisfaction ratings compared with GP ratings suggest that consultants can evaluate discharge summary content to the level required by GPs for clinical handover. Therefore, consultants can appropriately educate interns on discharge summary content for GP needs.

Anti-citrullinated peptide antibody: death of the rheumatoid factor?

Early diagnosis and treatment of rheumatoid arthritis (RA) is necessary to prevent joint damage and long-term disability. High rates of false-negative and false-positive results of the rheumatoid factor (RF) test make it generally unhelpful in the early diagnosis of RA. A new clinical test for RA--the anti-citrullinated peptide antibody (ACPA) test--is now widely available in Australia. Owing to its high specificity (95%), a positive ACPA test result usually confirms a diagnosis of RA in a patient with undifferentiated inflammatory arthritis. The superior specificity of the ACPA test provides an argument for it to replace the RF test in the primary care setting. Performing both tests adds little to the use of the ACPA test alone. An early diagnostic opinion from a rheumatologist is still recommended, as the ACPA and RF tests frequently return negative results in early RA.