A scoping review of triage approaches for the referral of patients with suspected inflammatory arthritis, from primary to rheumatology care.

We aimed to (1) identify existing triage approaches for referral of patients with suspected inflammatory arthritis (IA) from primary care physicians (PCP) to rheumatologists, (2) describe their characteristics and methodologies for clinical use, and (3) report their level of validation for use in a publicly funded healthcare system. The comprehensive search strategy of multiple databases up to October 2023 identified relevant literature and focussed on approaches applied at the PCP-Rheumatologist referral stage. Primary, quantitative studies, reported in English were included. Triage approaches were grouped into patient conditions as defined by the authors of the reports, including IA, its subtypes and combinations. 13952 records were identified, 425 full text reviewed and 55 reports of 53 unique studies were included. Heterogeneity in disease nomenclature and study sample pretest probability was found. The number of published studies rapidly increased after 2012. Studies were mostly from Europe and North America, in IA and Axial Spondyloarthritis (AxSpa). We found tools ranging the continuum of development with those best performing, indicated by the area under the receiver operating curve (AUC) >0.8), requiring only patient-reported questions. There were AUCs for some tools reported from multiple studies, these were in the outstanding to excellent range for the Early IA Questionnaire (EIAQ) (0.88 to 0.92), acceptable for the Case Finding AxSpa (CaFaSpa) (0.70 to 0.75), and poor to outstanding for the Psoriasis Epidemiology Screening Tool (PEST) (0.61 to 0.91). Given the clinical urgency to improve rheumatology referrals and considering the good.

The Association of Rheumatologist Supply and Multidisciplinary Care With Timely Patient Access to Rheumatologists: Evidence From British Columbia, Canada.

OBJECTIVE: The objective was to understand how the expansion of rheumatology supply and the introduction of multidisciplinary care was associated with access to rheumatology services. METHODS: We accessed Population Data BC, a longitudinal database with de-identified individual-level health data on all residents of British Columbia, Canada, to analyze physician visits and prescribing from 2010-2011 to 2019-2020. We calculated access as the time from referral to first rheumatologist visit and, for people with rheumatoid arthritis (RA), time to first disease-modifying antirheumatic drug (DMARD). Associations between lag time, patient characteristics, and system variables were explored using quantile regression. RESULTS: Over the study period, there were 149,902 new rheumatologist visits, with 31% more visits in 2019-2020 than in 2010-2011. The proportion of first visits for patients with inflammatory arthritis increased from 28% to 51%. The median time from referral to first visit decreased by 22 days (35%) from 63 days (interquartile range 21-120 days) in 2010-2011. For people with RA, time from referral to DMARD decreased by 4 days (6%) to 62 days. Male sex, living in metropolitan areas, and having a rheumatologist who used a multidisciplinary care assessment code were associated with shorter times from referral to first DMARD. CONCLUSION: Access to rheumatology care improved, and the increased proportion of patients with IA in the first visits case-mix indicates that rheumatologist supply and incentives for multidisciplinary care may have improved referral patterns. However, time to DMARDs for people with RA remained long, and we found signals of unequal access for female patients and people living outside of metropolitan areas.

Onset of depression and anxiety among patients with gout after diagnosis: a population-based incident cohort study.

BACKGROUND: Gout may be associated with an increased incidence of mental health disorders, however, published findings have been limited and inconsistent. Therefore, our objective was to conduct a population-based cohort study to evaluate the incidence of depression and anxiety after gout diagnosis. METHODS: We used linked population-based administrative health data in British Columbia, Canada that includes information on demographics, outpatient visits, and inpatient visits from the period of January 1, 1990 to March 31, 2018. We assessed depression and anxiety using validated International Classification of Diseases, 9th and 10th Revision coding algorithms. We applied multivariable Cox proportional hazard models to evaluate incident depression and anxiety among patients with gout in comparison to non-gout controls, adjusting for age, sex, neighbourhood income quintile, residence, comorbidities, and health care utilization. RESULTS: We included 157,426 incident cases of gout (60.2% male; mean age 57.1 years) and 157,426 non-gout controls (60.2% male; mean age 56.9 years). The incidence rate of depression among individuals with gout and non-gout controls was 12.9 (95% confidence interval [CI] 12.7-13.2) and 11.1 (95% CI 10.9-11.4) per 1000 person-years, respectively. The incidence rate of anxiety for those with gout was 5.4 (95% CI 5.3-5.5) per 1000 person-years and for non-gout controls was 4.6 (95% CI 4.4-4.7) per 1000 person-years. Individuals with gout had an increased onset of depression (adjusted hazard ratio [aHR], 1.08; 95% CI 1.05-1.11) and anxiety (aHR, 1.10; 95% CI 1.05-1.14) compared to non-gout controls. CONCLUSION: Our population-based study shows an increased incidence of depression and anxiety following gout diagnosis in comparison to non-gout controls. Findings suggest the importance of considering psychiatric impacts in addition to the physical impacts of gout.

The association between cannabis and codeine use: a nationally representative cross-sectional study in Canada.

BACKGROUND: Due to the growing use of cannabis for the purposes of pain relief, evidence is needed on the impact of cannabis use on concurrent analgesic use. Therefore, our objective was to evaluate the association between the use of cannabis and codeine. METHODS: We conducted a cross-sectional study using data from the nationally representative Canadian Tobacco, Alcohol and Drugs Survey (2017). The primary explanatory variable was self-reported use of cannabis within the past year. The outcome was the use of codeine-containing product(s) within the past year. We used multivariable binomial logistic regression models. RESULTS: Our study sample comprised 15,459 respondents including 3338 individuals who reported cannabis use within the past year of whom 955 (36.2%) used it for medical purposes. Among individuals who reported cannabis use, the majority were male (N = 1833, 62.2%). Self-reported use of cannabis was associated with codeine use (adjusted odds ratio [aOR] 1.89, 95% CI 1.36 to 2.62). Additionally, when limited to cannabis users only, we found people who used cannabis for medical purposes to be three times more likely to also report codeine use (adjusted odds ratio [aOR] 2.96, 95% CI 1.72 to 5.09). DISCUSSION: The use of cannabis was associated with increased odds of codeine use, especially among individuals who used it for medical purposes. Our findings suggest a potential role for healthcare providers to be aware of or monitor patients' use of cannabis, as the long-term adverse events associated with concurrent cannabis and opioid use remain unknown.

The impact of introducing multidisciplinary care assessments on access to rheumatology care in British Columbia: an interrupted time series analysis.

BACKGROUND: In 2011 the British Columbia (BC) Ministry of Health introduced a new fee-for-service billing code that allowed "Multidisciplinary Care Assessment" (MCA). This change has the potential to change access to and quality of care for patients. This study aimed to explore the impact on access to rheumatology services in the province. METHODS: Fee-for-service rheumatology billings were evaluated for each rheumatologist 2 years before and after use of the MCA code. Numbers of 1) unique patients and 2) services provided per month were used as proxy measures of access to care. A multiple-baseline interrupted time series model assessed the impact of the MCA on levels and trends of the access outcomes. RESULTS: Our analysis consisted of 82,360 patients cared for by 26 rheumatologists who billed for an MCA. In our primary analysis we observed a sustained increase in the mean number of unique patients of 4.9% (95% CI: 0.0% to 9.9%, p = 0.049) and the mean number of services of 7.1% (95% CI: 1.0% to 13.6%, (p = 0.021), per month provided by a rheumatologist, corresponding to the initial use of MCA. CONCLUSION: The introduction of the MCA code was associated with an initial increase in the measures of access, which was maintained but did not increase over time. Our study suggests that the use of Multidisciplinary Care Assessment can contribute to expanding and/or sustaining access to care for people with complex chronic conditions, like rheumatic diseases.

RetINal Toxicity And HydroxyChloroquine Therapy (INTACT): protocol for a prospective population-based cohort study.

PURPOSE: Hydroxychloroquine (HCQ) is an important medication for patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and other rheumatic diseases. Although it is well-tolerated and cost-effective, the risk of HCQ retinal toxicity is of increasing concern. The aim of this study is to re-examine the HCQ retinal toxicity incidence rate, risk factors and clinical course after discontinuation. METHODS: We designed a prospective population-based cohort study in adult patients with SLE or RA, currently receiving HCQ for five or more years, who are residents of British Columbia (BC), Canada. Based on administrative data, we identified 5508 eligible participants (1346 SLE and 4162 RA). They will participate in annual or biannual retinal screening over 5 years in alignment with the recently revised American Academy of Ophthalmology guidelines. To standardise procedures for retinal screening, imaging, diagnostic criteria, severity staging and data transfer, a consensus meeting was convened in December 2019 with participation of BC retinal specialists and the research team. Agreement was attained on: use of spectral domain-optical coherence tomography as the primary objective screening modality; classification of images into categories of normal, equivocal or abnormal; and transferring the equivocal and abnormal images plus corresponding subjective test results via cloud-based server from each clinic to a reading centre. Confirmation of HCQ retinal toxicity diagnoses and severity staging will be performed by three independent and masked reviewers. The incidence of HCQ retinal toxicity will be calculated, accounting for the competing risk of death. Hazard ratios for each risk factor will be calculated for the risk of HCQ retinopathy, after adjusting for confounders. We will also estimate the risk of HCQ retinal toxicity progression over 5 years. ETHICS AND DISSEMINATION: This study has received approval from the University of British Columbia Clinical Research Ethics Board (H20-00736) and the Vancouver Coastal Health Research Institute.

Indications and diagnostic outcome of antineutrophil cytoplasmic antibody testing in hospital medicine: a pattern of over-screening.

INTRODUCTION/OBJECTIVE: Antineutrophil cytoplasmic antibodies (ANCA) serology can aid in the diagnosis and classification of ANCA-associated vasculitides (AAV). However, it is often ordered in patients without clinical manifestations of vasculitis. In this retrospective chart review, we aim to better understand the clinical practices on ANCA testing. METHODS: We retrospectively reviewed patients' charts for the indications and diagnostic outcomes of ANCA tests. All ANCA tests ordered at two Canadian hospitals (a community hospital and an academic tertiary hospital) between January and December 2016 were included in the study. Descriptive statistics are used. RESULTS: A total of 302 ANCA tests were included. The majority (n = 198, 65.6%) were ordered without an indication for testing. For those patients with at least 1 clinical manifestation of AAV (n = 104), 25% were ANCA positive and 18.3% resulted in a diagnosis of AAV. In comparison, among those without a clinical manifestation of AAV (n = 198), only 1.5% were ANCA positive and none was diagnosed with AAV. All patients diagnosed with AAV had at least 1 indication for ANCA testing. The three most common clinical presentations in patients with a final diagnosis of AAV were glomerulonephritis (81.8%), pulmonary hemorrhage (45.5%), and multiple lung nodules (31.8%). CONCLUSION: To our knowledge, this is the first study that evaluates patients with both positive and negative ANCA test results in an inpatient setting. We demonstrated a low rate of ANCA positivity and AAV diagnosis in patients without clinical manifestations of AAV. Overall, there is a high rate of ANCA testing without an indication at our academic institution. This over-testing may be curbed by strategies such as a gating policy, culture changes, and clinician education. Key Points • AAV is a clinical-pathological diagnosis, and despite the usefulness of ANCA testing, it does not confirm nor rule out AAV. • ANCA testing for the diagnosis of AAV is generally only indicated when there is a clear manifestation of AAV. • Although patients with AAV may occasionally present without classic signs and symptoms, the diagnostic utility of ANCA serology in this setting is low, and testing is more likely to result in a false-positive or false-negative test. • If clinical suspicion remains high despite negative ANCA testing, clinicians should seek consultation with a rheumatologist.

Rheumatology health care providers' views and practices on obesity and smoking cessation management in rheumatoid arthritis.

OBJECTIVE: To assess rheumatology health care providers' (HCPs) knowledge, beliefs, self-efficacy, practices, and perceived barriers pertaining to weight management and smoking cessation counselling in patients with rheumatoid arthritis (RA). METHOD: We administered an online survey to collect self-reported data on rheumatology HCPs' knowledge, beliefs, self-efficacy, perceived barriers, and practices related to weight management and smoking cessation counselling. Participants were recruited through invitation emails (with anonymous survey links) sent by three Canadian rheumatology organizations. RESULTS: Fifty-nine rheumatology HCPs (15 nurses, 44 physicians) completed the survey (response rate: 11%). Over 85% correctly identified associations between obesity, or smoking, and more severe or active RA, as well as poorer response to treatment. All but one participant agreed that it was part of their responsibility to discuss these issues with patients, but 78% (46/59) felt not or slightly confident in their ability to help patients quit smoking or achieve clinically significant weight loss. The majority did not routinely assist patients in accessing appropriate resources or providers (only 42% did for obesity, 36% for smoking), send referrals (2-44%, depending on referral), or offer relevant educational materials (15% for obesity, 20% for smoking). Common barriers included competing demands and lack of time, training, access to expertise, and knowledge of available programs. CONCLUSION: Most rheumatology HCPs understood the implications of cigarette smoking and obesity in RA and accepted responsibility in addressing these issues. However, they lacked the time, training, confidence, and knowledge of local resources to do so effectively. There is a need to bridge this gap. Key Points • Training through medical and nursing school as well as residency on weight management and smoking cessation counselling was nearly unanimously described as poor or fair. • Most rheumatology health care providers understood the implications of cigarette smoking and obesity in rheumatoid arthritis and accepted responsibility in addressing these issues; however, they lacked the time, training, confidence, and knowledge of local resources to do so effectively. • There is a need to bridge the gap between health care providers' intentions and actions, and this may include the development of guides outlining local weight management and smoking cessation expertise, programs, referral processes, and educational materials.

Unravelling the mysteries of gout by multimodality imaging.

Gout is a common inflammatory arthritis that manifests as an aggregate of variably symptomatic monosodium urate crystals (MSU) in the joints and surrounding tissues in addition to multisystem involvement such as genitourinary and cardiovascular systems. In recent decades, there has been a documented increase in the prevalence and incidence of gout. Risk factors for gout include obesity, dietary influences, hypertension, renal impairment, and diuretic use. A prompt diagnosis followed by uric acid lowering treatment prior to the onset of bone destruction is the goal in any suspected case of gout. Advanced imaging modalities, such as dual energy computed tomography (DECT) and ultrasonography (US), employed for the diagnosis of gout are each accompanied by advantages and disadvantages. Conventional radiography (CR), although useful in visualizing joint erosions and mineralization, is limited in its ability to diagnose gout flare. Although synovial fluid aspiration remains the gold standard for MSU crystal visualization, less-invasive imaging modalities are preferred to avoid potential complications. DECT and US in particular are useful in the diagnosis of gout. In this review, we will discuss the current state and role of imaging in the detection of gout.

Preferences for treatments to prevent rheumatoid arthritis in Canada and the influence of shared decision-making.

OBJECTIVE: To elicit and compare preferences of patients and first-degree relatives and rheumatologists for preventive treatments for rheumatoid arthritis, understand the influence of shared decision-making, and predict the probability of uptake of the preventive treatments currently being studied. METHODS: An online discrete choice experiment was completed by patients and their first-degree relatives and rheumatologists. Results were analysed using mixed logit model to estimate preferences for the key features of treatments. Preferences for features of treatments were used to predict the probability of uptake of seven preventive treatment options. RESULTS: A total of 108 potential recipients (78 patients and 30 of their first-degree relatives) and 39 rheumatologists completed the survey. Preferences of patients/first-degree relatives and rheumatologists were similar (shared decision-making was most important, followed by the risk of side effects and potential benefit), but subtle differences existed; rheumatologists placed greater importance on certainty in evidence than patients/first-degree relatives, who felt that how a treatment was taken was more important. Predicted uptake suggested that 38% (95% CI 19%, 58%) of patients/first-degree relatives would not take a preventive treatment, compared with 12% (95% CI - 4%, 27%) of rheumatologists. A consistent finding across all groups was a preference for non-biologic disease-modifying anti-rheumatic drugs. CONCLUSION: Only relatively safe options for preventive treatment are likely to be acceptable to at-risk populations. This study of preventive treatments highlights that the preferences of physicians and recipients of treatment should take a central role in the design of clinical studies as well as in decisions to initiate treatments. Key Points • This paper is the first to compare preferences for preventive treatments between rheumatologists and patients and at-risk individuals. • The results of this study indicate that patients and at-risk individuals, as well as rheumatologists, are likely to prefer the safest options as preventive treatment, even if the potential benefit of these is lower. • Although preferences of patients and at-risk individuals are similar to those of rheumatologists, the choice of preventive treatment may differ between groups; this is important as shared decision-making was a critical factor in treatment decision-making. • Preferences of physicians and recipients of treatment should take a central role in the design of clinical studies as well as in decisions to initiate treatments.

eHealth-supported decentralized multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics: proof-of-concept study.

OBJECTIVE: To conduct quantitative and qualitative evaluation of an electronic health (eHealth)-supported decentralized multi-disciplinary care model for gout involving rheumatologists, pharmacist, and dietitian. METHODS: We conducted a 12-month proof-of-concept study. Gout patients with ≥ 1 flare in the past year and serum urate (SUA) ≥ 360 µmol/L within the previous 2 months were followed by participating community rheumatologists on an as-needed basis, received monthly telephone consults with a pharmacist, and one telephone consult with a dietitian. Healthcare professionals were not co-located but had shared access to the rheumatologists' electronic medical records (EMR) for remote communication and collaboration. In quantitative evaluation, the primary outcome was the proportion of patients with SUA < 360 µmol/L at 12 months. In qualitative evaluation, we conducted semi-structured interviews with a subset of patients and applied constructivist grounded theory to gather patients' perspectives. RESULTS: Overall, 35 gout patients (86% males, mean age 60.9 ± 14.9 years) participated. At 12 months, 72% of patients achieved target SUA < 360 µmol/L. Qualitative analysis of interviews with a subset of 12 patients resulted in two themes: (1) experiences with receiving care, including categories of improved knowledge about gout, receiving personalized support, and knowing someone cares, and (2) practical considerations, including categories of optimizing timing of care and coordination and accessibility. CONCLUSION: Our multi-method study shows that a decentralized, multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics with shared EMR access led to gout patients achieving target SUA. It was well-received by patients who perceived better education about gout and personalized care.Key Points• We demonstrated the feasibility and impact of an eHealth-supported, decentralized collaborative care model for gout involving rheumatology, pharmacy, and dietetics• Although prior multi-disciplinary models of care for gout have been reported, the novelty of our model is that healthcare providers are not co-located, lending to potential efficiencies and outreach to patients in rural areas.

Clinical spectrum and therapeutics in Canadian patients with anti-melanoma differentiation-associated gene 5 (MDA5)-positive dermatomyositis: a case-based review.

The objective of the study was to determine the clinical features and treatment course in Canadian patients with dermatomyositis (DM) associated with the anti-melanoma differentiation-associated gene 5 antibody (MDA5). A retrospective chart review of consecutive patients with anti-MDA5 antibody DM from two Canadian tertiary care centre between 2014 and 2018 was done. Twenty-one consecutive cases of anti-MDA5-positive DM were identified. Median age at diagnosis was 52 years, 71% Asians, predominantly Chinese, and 29% Caucasians. In this case series, all patients had either typical DM rash, or vasculopathy and ulceration unique to anti-MDA5-positive DM. 38% of the patients had rapid progressive (RP)-interstitial lung disease (RP-ILD), 33% had chronic ILD and 29% had asymptomatic ILD. Anti-Ro52 positivity was more prevalent in RP-ILD. Mortality was high in the RP-ILD group, with five deaths in eight patients. Lung transplant was life-saving intervention for three of the RP-ILD patients who survived. A review of the literature in treating RP-ILD associated with anti-MDA5 is presented. Although evidence is limited to small case series, cyclophosphamide (CYC) for refractory skin lesions, and CYC or mycophenolate mofetil plus a calcineurin inhibitor or rituximab (RTX) for RP-ILD appear efficacious. This is the largest North American case series of anti-MDA5-positive DM patients to date. There is a wide spectrum of clinical presentation of this entity. Survival is poor in those with RP-ILD; early aggressive immunosuppression and timely lung transplant were life-saving in our patients with RP-ILD.

Preventing rheumatoid arthritis: Preferences for and predicted uptake of preventive treatments among high risk individuals.

OBJECTIVE: To understand preferences for and estimate the likely uptake of preventive treatments currently being evaluated in randomized controlled trials with individuals at increased risk of developing rheumatoid arthritis (RA). METHODS: Focus groups were used to identify key attributes of potential preventive treatment for RA (reduction in risk of RA, how treatment is taken, chance of side effects, certainty in estimates, health care providers opinion). A web-based discrete choice experiment (DCE) was administered to people at-risk of developing RA, asking them to first choose their preferred of two hypothetical preventive RA treatments, and then between their preferred treatment and 'no treatment for now.' DCE data was analyzed using conditional logit regression to estimate the significance and relative importance of attributes in influencing preferences. RESULTS: Two-hundred and eighty-eight first-degree relatives (60% female; 66% aged 18-39 years) completed all tasks in the survey. Fourteen out of fifteen attribute levels significantly influenced preferences for treatments. How treatment is taken (oral vs. infusion ß0.983, p<0.001), increasing reduction in risk of RA (ß0.922, p<0.001), health care professional preference (ß0.900, p<0.001), and avoiding irreversible (ß0.839, p<0.001) or reversible serious side effects (ß0.799, p<0.001) were most influential. Predicted uptake was high for non-biologic drugs (e.g. 84% hydroxycholoroquine), but very low for atorvastatin (8%) and biologics (<6%). CONCLUSION: Decisions to take preventative treatments are complex, and uptake depends on how treatments can compromise on convenience, potential risks and benefits, and recommendations/preferences of health care professionals. This evidence contributes to understanding whether different preventative treatment strategies are likely to be acceptable to target populations.

Concurrent inflammatory myopathy and myasthenia gravis with or without thymic pathology: A case series and literature review.

OBJECTIVES: The association of myasthenia gravis (MG) and inflammatory myositis (IM) is rare and typically only one of the diseases is present. The management of the 2 diseases differs, therefore it is important to recognize the concomitant presentation. Here, we report a case series of 7 patients with co-existing MG and IM with review of the literature. METHOD: We identified 7 patients with concurrent MG and IM who were followed at the Neuromuscular Disease Program at a tertiary referral center in Vancouver, British Columbia from 2004 to 2017. RESULT: All 7 patients had ocular or bulbar involvement as manifestation of MG. Three patients had simultaneous onset of MG and IM, 2 of whom presented with myasthenia crisis and fulminant myositis. In the other 4 patients, MG was the initial presentation and IM occurred 3-11 years after MG. Among these 7 patients, 4 had underlying thymic pathology, including 2 with benign thymoma and 2 with stage IV thymoma; all 4 patients had antibodies to acetylcholine receptor (AChR). Of the 3 patients with no thymic pathology by imaging or histology, 2 had positive AChR antibody titer. For treatment, the thymoma was resected and chemotherapy was administered if appropriate. Additional immunosuppressive therapies including high-dose glucocorticoid, intravenous immunoglobulin (IVIG), methotrexate, mycophenolate, or cyclosporine were necessary to achieve remission. Two patients with no thymoma had refractory MG and IM, and both responded to rituximab. We also conducted a literature review on the clinical characteristics and management of this condition, and compared the previously reported cases to the patients in our series. CONCLUSION: This is one of the largest case series of MG-IM overlap with or without thymic pathology. In this cohort, the 2 disease entities can occur simultaneously, or one presents before the other. Most of the patients responded well to steroid, acetylcholinesterase inhibitor, and immunosuppressive agents. In very refractory cases, rituximab appeared to be effective, which has not been reported for the treatment of this condition before.

How patients with gout become engaged in disease management: a constructivist grounded theory study.

BACKGROUND: Prior qualitative research on gout has focused primarily on barriers to disease management. Our objective was to use patients' perspectives to construct an explanatory framework to understand how patients become engaged in the management of their gout. METHODS: We recruited a sample of individuals with gout who were participating in a proof-of-concept study of an eHealth-supported collaborative care model for gout involving rheumatology, pharmacy, and dietetics. Semistructured interviews were used. We analyzed transcripts using principles of constructivist grounded theory involving initial coding, focused coding and categorizing, and theoretical coding. RESULTS: Twelve participants with gout (ten males, two females; mean age, 66.5 ± 13.3 years) were interviewed. The analysis resulted in the construction of three themes as well as a framework describing the dynamically linked themes on (1) processing the diagnosis and management of gout, (2) supporting management of gout, and (3) interfering with management of gout. In this framework, patients with gout transition between each theme in the process of becoming engaged in the management of their gout and may represent potential opportunities for healthcare intervention. CONCLUSIONS: Findings derived from this study show that becoming engaged in gout management is a dynamic process whereby patients with gout experience factors that interfere with gout management, process their disease and its management, and develop the practical and perceptual skills necessary to manage their gout. By understanding this process, healthcare providers can identify points to adapt care delivery and thereby improve health outcomes.

Key barriers to gout care: a systematic review and thematic synthesis of qualitative studies.

OBJECTIVES: Gout care remains highly suboptimal, contributing to an increased global disease burden. To understand barriers to gout care, our aim was to provide a systematic review and thematic synthesis of qualitative studies worldwide reporting provider and patient perspectives and experiences with management. METHODS: We conducted a mapped search of MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Social Sciences Citation Index databases and selected qualitative studies of provider and patient perspectives on gout management. We used thematic synthesis to combine the included studies and identify key themes across studies. RESULTS: We included 20 studies that reported the experiences and perspectives of 480 gout patients and 120 providers spanning five different countries across three continents. We identified three predominant provider themes: knowledge gaps and management approaches; perceptions and beliefs about gout patients; and system barriers to optimal gout care (e.g. time constraints and a lack of incentives). We also identified four predominant themes among gout patients: limited gout knowledge; interactions with health-care providers; attitudes towards and experiences with taking medication; and practical barriers to long-term medication use. CONCLUSION: Our systematic review of worldwide literature consistently identified gaps in gout knowledge among providers, which is likely to contribute to patients' lack of appropriate education about the fundamental causes of and essential treatment approaches for gout. Furthermore, system barriers among providers and day-to-day challenges of taking long-term medications among patients are considerable. These factors provide key targets to improve the widespread suboptimal gout care.

RNA-Seq Analysis of Gene Expression, Viral Pathogen, and B-Cell/T-Cell Receptor Signatures in Complex Chronic Disease.

Background: Chronic fatigue syndrome (CFS) remains poorly understood. Although infections are speculated to trigger the syndrome, a specific infectious agent and underlying pathophysiological mechanism remain elusive. In a previous study, we described similar clinical phenotypes in CFS patients and alternatively diagnosed chronic Lyme syndrome (ADCLS) patients­individuals diagnosed with Lyme disease by testing from private Lyme specialty laboratories but who test negative by reference 2-tiered serologic analysis. Methods: Here, we performed blinded RNA-seq analysis of whole blood collected from 25 adults diagnosed with CFS and 13 ADCLS patients, comparing these cases to 25 matched controls and 11 patients with well-controlled systemic lupus erythematosus (SLE). Samples were collected at patient enrollment and not during acute symptom flares. RNA-seq data were used to study host gene expression, B-cell/T-cell receptor profiles (BCR/TCR), and potential viral infections. Results: No differentially expressed genes (DEGs) were found to be significant when CFS or ADCLS cases were compared to controls. Forty-two DEGs were found when SLE cases were compared to controls, consistent with activation of interferon signaling pathways associated with SLE disease. BCR/TCR repertoire analysis did not show significant differences between CFS and controls or ADCLS and controls. Finally, viral sequences corresponding to anelloviruses, human pegivirus 1, herpesviruses, and papillomaviruses were detected in RNA-seq data, but proportions were similar (P = .73) across all genus-level taxonomic categories. Conclusions: Our observations do not support a theory of transcriptionally mediated immune cell dysregulation in CFS and ADCLS, at least outside of periods of acute symptom flares.

The rising prevalence and incidence of gout in British Columbia, Canada: Population-based trends from 2000 to 2012.

OBJECTIVES: Gout is increasingly recognized as the most common form of inflammatory arthritis worldwide; however, no Canadian data on the disease burden of gout are available. We estimated the prevalence, incidence, prescription patterns, and comorbidity burden of gout in an entire Canadian province [British Columbia (BC)] over the last decade. METHODS: We utilized PopulationData BC, a province-wide database, to estimate temporal trends in the prevalence and incidence of gout from 2000 to 2012, as well as according to age category. Annual estimates were age-sex-standardized using 2012 as the reference. We also examined annual trends in prescription patterns of common gout medications and assessed the comorbidity burden among gout patients in 2012. RESULTS: The 2012 prevalence of gout was 3.8% among the overall population, and the incidence rate was 2.9 per 1000 person-years. Both gout prevalence and incidence increased substantially over the study period. This burden additionally increased according to age category, affecting over 8% of those ages 60-69 years in 2012. Approximately 22% of gout patients received a prescription for urate-lowering therapy (ULT), which remained stable over the study period, while colchicine and oral glucocorticoid use both increased modestly. By 2012, 72%, 52%, and 18% of prevalent gout patients had been diagnosed with hypertension, hyperlipidemia, and diabetes, respectively. CONCLUSIONS: The burden of gout in BC, Canada, is substantial, and both the prevalence and incidence have increased over the past decade, while prescription of ULT remains low. These data support the need to improve gout prevention and care.