RSS 1.0Primary Care, Community and Therapies
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Cutaneous vasculitis in systemic lupus erythematosus : epidemiology and risk factors over a 20-year follow-upObjectives: Cutaneous vasculitis (CV) is common in SLE, but the epidemiology and risk factors remain unclear. We aimed to identify the trends and risk factors for CV in patients with SLE over a period of 20 years. Methods: The Birmingham Lupus Cohort is an observational longitudinal cohort of SLE patients. Patients were enrolled within 3 years of meeting their fourth ACR criterion. Disease activity, laboratory test results and treatment records were collected. A multivariable shared frailty Cox proportional hazard model was used to identify clinical, laboratory, and treatment-related variables associated with the development of CV. Results: We included 392 patients: 92.5% were female. The median (IQR) duration of follow up was 9.2 (5.1-14.7) years. CV occurred in 27% of SLE patients, of whom 43.3% had two or more CV events. This study demonstrated a marked decline in the incidence rates of CV, decreasing from 34.4% (95% CI: 29.7, 39.3) during the first three years after enrolment to 2.1% (95% CI: 0.05, 11.5) after 18 years of follow-up. Development of CV was associated with Raynaud's phenomenon, constitutional, mucocutaneous, musculoskeletal, haematological, and cardiovascular involvement, anti-Sm antibodies, anti-dsDNA and hypocomplementemia. However, the use of azathioprine and antimalarials was inversely associated with the development of CV. Patients with CV were more likely to develop at least 1 item of organ damage. Conclusions: The incidence rates of CV in SLE decreased over the follow-up period and CV is associated with defined clinical, serological and treatment-related factors.
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Quality indicators for the primary and community care of musculoskeletal conditions : a systematic reviewObjectives: To identify, appraise, and synthesize common themes from quality indicator (QI) sets designed for the assessment, management, and rehabilitation of musculoskeletal (MSK) conditions in primary and community care contexts. Data sources: A systematic search was performed on six databases (MEDLINE, EMBASE, AMED, Web of Sciences Core Collection, The Cochrane Library, and The Health Management Information Consortium), public repositories, and the websites of organizations involved in the reporting of MSK QIs. Study selection: Potential QI sources were screened for relevance using an a priori criteria. After the screening of 1493 titles, abstracts, 71 articles were reviewed independently by two authors, of which 25 met our criteria and were therefore included within the review. Data extraction: The development of the QI sets was appraised using the AIRE instrument. Key characteristics of QI sets were extracted and tabulated. Nine out of 25 QI sets had "high" developmental methodology quality. A total of 410 QIs were identified from 25 QI sets. Data synthesis: A narrative synthesis was undertaken to identify common themes among QIs. Themes were mapped against improvement drivers mentioned in recent British primary/community MSK care policy directives. Finally, "Draft Indicators" were synthesized from common themes identified. Eleven overarching themes were synthesized: policy and governance; optimizing access and provision of care; staffing and spending; optimizing assessment and diagnosis; optimizing patient education and self-management; pharmacology and injection guideline adherence; optimizing personalized care; optimizing imaging, investigations, and referral; public health management relevant to MSK conditions; optimizing patient experience; and optimizing patient outcomes. Conclusions: This review has identified common themes among QIs that focus on optimizing assessment, investigations, and treatment decisions for the primary/community care of MSK conditions. This work represents a valuable resource to commissioners, service managers, and clinicians internationally who resource, monitor, manage, assess, and rehabilitate individuals with MSK conditions.
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Patients with nodular prurigo commonly have pre-existing psychological disease that requires treatment concomitant with cutaneous therapies.Patients with nodular prurigo commonly have pre-existing psychological disease that requires treatment concomitant with cutaneous therapies
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Perceptions and experiences of individuals at-risk of rheumatoid arthritis (RA) knowing about their risk of developing RA and being offered preventive treatment: systematic review and thematic synthesis of qualitative studies.Objectives: There is increasing interest in identifying individuals at-risk of rheumatoid arthritis (RA) and initiating early treatment to prevent or delay the onset of arthritis. We aimed to describe the perceptions and experiences of at-risk individuals and to inform the conduct of clinical trials and studies, and clinical practice. Methods: A systematic review and thematic synthesis of qualitative studies was conducted. Two review authors independently screened studies for inclusion, appraised their methodological quality using the Critical Appraisal Skills Programme checklist and assessed confidence in the findings using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in Evidence from Reviews of Qualitative Research approach. Results: Seven studies involving 115 individuals at-risk of developing RA were included. Three major themes (seven subthemes) were identified: understanding the risk of developing RA (knowledge of RA and identification of potential risk factors); preventive interventions to reduce the risk of developing RA (understanding the value and role of preventive interventions, and engagement with preventive interventions); and perceptions of predictive testing for RA (benefits of predictive testing, decision to undertake predictive testing and concerns about predictive testing). Moderate confidence in most review findings was evident. Conclusion: While there are clear benefits in informing individuals at-risk of RA about their risk following predictive testing and offering preventive treatment, there are potential barriers to engagement, intensified by the burden of uncertainty. Identification of the optimum approaches for presenting risk information, including the risks and benefits of engaging with preventive interventions, is urgently needed to support individuals at-risk of RA in their decision making.
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Physical prognostic factors predicting outcome following anterior cruciate ligament reconstruction: A systematic review and narrative synthesis.Background: Anterior cruciate ligament (ACL) injuries are common. Many patients undergo ACL reconstruction (ACLR), with rehabilitation key to successful outcome. Understanding physical prognostic factors is integral to clinical decision-making, but factors predicting outcome are inadequately defined. The objective was to establish physical prognostic factors predicting outcome following ACLR. Methods: A systematic review following a published protocol (CRD42019127732) searched MEDLINE, CINAHL, EMBASE, key journals and grey literature to November 28, 2020. Prospective cohort studies, participants ≥16 years of age who had undergone ACLR were included, with multi-ligament and/or ACL repair surgery, and studies not published in English excluded. Two independent reviewers conducted searches, extracted data, assessed risk of bias (QUIPS) and overall quality of evidence (GRADE). Meta-analysis was not possible, therefore narrative synthesis was performed. Results: 13 studies (16 articles) were included (1 low, 12 high risk of bias). Low-level evidence supports postoperative degenerative changes and poor lower-limb strength predicting poorer outcome long term (KOOS). Very low-level evidence supports greater postoperative quadriceps strength predicting improved functional performance medium term; with lower body mass index predicting improvement of multiple outcome measures. Conclusion: Limited evidence of low or very low-level indicates multiple prognostic factors predicting outcome following ACLR. A high-quality prognostic study is required.
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Predictors of diabetes-related distress before and after FreeStyle Libre-1 use: Lessons from the Association of British Clinical Diabetologists nationwide study.Aim: To identify the baseline demographic and clinical characteristics associated with diabetes-related distress (DRD) and factors associated with improvement in DRD after initiating use of the FreeStyle Libre (FSL) in people living with type 1 diabetes (T1D). Methods: The study was performed using baseline and follow-up data from the Association of British Clinical Diabetologists nationwide audit of people with diabetes who initiated use of the FSL in the United Kingdom. DRD was assessed using the two-item diabetes-related distress scale (DDS; defined as the average of the two-item score ≥3). People living with T1D were categorized into two groups: those with high DRD, defined as an average DDS score ≥3 and those with lower DRD, defined as a DDS score <3. We used a gradient-boosting machine-learning (GBM) model to identify the relative influence (RI) of baseline variables on average DDS score. Results: The study population consisted of 9159 patients, 96.6% of whom had T1D. The median (interquartile range [IQR]) age was 45.1 (32-56) years, 50.1% were women, the median (IQR) baseline body mass index was 26.1 (23.2-29.6) kg/m2 and the median (IQR) duration of diabetes was 20 (11-32) years. The two components of the DDS were significantly correlated (r2 = 0.73; P < 0.0001). Higher DRD was prevalent in 53% (4879/9159) of people living with T1D at baseline. In the GBM model, the top baseline variables associated with average DDS score were baseline glycated haemoglobin (HbA1c; RI = 51.1), baseline Gold score (RI = 23.3), gender (RI = 7.05) and fear of hypoglycaemia (RI = 4.96). Follow-up data were available for 3312 participants. The top factors associated with improvement in DDS score following use of the FSL were change in Gold score (RI = 28.2) and change in baseline HbA1c (RI = 19.3). Conclusions: In this large UK cohort of people living with T1D, diabetes distress was prevalent and associated with higher HbA1c, impaired awareness of hypoglycaemia and female gender. Improvement in glycaemic control and hypoglycaemia unawareness with the use of the FSL was associated with improvement in DRD in people living with T1D.
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Prescribing anti-rheumatic drugs in pregnancy and breastfeeding-the British Society for Rheumatology guideline scope.Prescribing anti-rheumatic drugs in pregnancy and breastfeeding-the British Society for Rheumatology guideline scope
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Recurrent severe respiratory infections with low CRP secondary to autoimmune IL-6 deficiency.C reactive protein (CRP) is an inflammatory protein that is often used in conjunction with the clinical presentation of a patient to help with quantifying infection severity and measuring treatment response. We report the case of a patient who presented with severe pneumonias but had a suboptimal CRP response, later diagnosed as having an underlying immunodeficiency. This case exemplifies the need to consider immunodeficiency as an underlying pathophysiological cause in patients presenting with complicated and severe infections.
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Relationship between inflammation and metabolism in patients with newly presenting rheumatoid arthritisBackground: Systemic inflammation in rheumatoid arthritis (RA) is associated with metabolic changes. We used nuclear magnetic resonance (NMR) spectroscopy-based metabolomics to assess the relationship between an objective measure of systemic inflammation [C-reactive protein (CRP)] and both the serum and urinary metabolome in patients with newly presenting RA. Methods: Serum (n=126) and urine (n=83) samples were collected at initial presentation from disease modifying anti-rheumatic drug naïve RA patients for metabolomic profile assessment using 1-dimensional 1H-NMR spectroscopy. Metabolomics data were analysed using partial least square regression (PLS-R) and orthogonal projections to latent structure discriminant analysis (OPLS-DA) with cross validation. Results: Using PLS-R analysis, a relationship between the level of inflammation, as assessed by CRP, and the serum (p=0.001) and urinary (p<0.001) metabolome was detectable. Likewise, following categorisation of CRP into tertiles, patients in the lowest CRP tertile and the highest CRP tertile were statistically discriminated using OPLS-DA analysis of both serum (p=0.033) and urinary (p<0.001) metabolome. The most highly weighted metabolites for these models included glucose, amino acids, lactate, and citrate. These findings suggest increased glycolysis, perturbation in the citrate cycle, oxidative stress, protein catabolism and increased urea cycle activity are key characteristics of newly presenting RA patients with elevated CRP. Conclusions: This study consolidates our understanding of a previously identified relationship between serum metabolite profile and inflammation and provides novel evidence that there is a relationship between urinary metabolite profile and inflammation as measured by CRP. Identification of these metabolic perturbations provides insights into the pathogenesis of RA and may help in the identification of therapeutic targets.
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Rheumatoid arthritis prevention: any takers?Rheumatoid arthritis prevention: any takers?
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Rituximab 500 mg 6-monthly infusions is an option in maintenance therapy of ANCA-associated vasculitis.Rituximab 500 mg 6-monthly infusions is an option in maintenance therapy of ANCA-associated
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Spontaneously Resolving Joint Inflammation Is Characterised by Metabolic Agility of Fibroblast-Like Synoviocytes.Fibroblast-like synoviocytes (FLS) play an important role in maintaining joint homeostasis and orchestrating local inflammatory processes. When activated during injury or inflammation, FLS undergo transiently increased bioenergetic and biosynthetic demand. We aimed to identify metabolic changes which occur early in inflammatory disease pathogenesis which might support sustained cellular activation in persistent inflammation. We took primary human FLS from synovial biopsies of patients with very early rheumatoid arthritis (veRA) or resolving synovitis, and compared them with uninflamed control samples from the synovium of people without arthritis. Metabotypes were compared using NMR spectroscopy-based metabolomics and correlated with serum C-reactive protein levels. We measured glycolysis and oxidative phosphorylation by Seahorse analysis and assessed mitochondrial morphology by immunofluorescence. We demonstrate differences in FLS metabolism measurable after ex vivo culture, suggesting that disease-associated metabolic changes are long-lasting. We term this phenomenon 'metabolic memory'. We identify changes in cell metabolism after acute TNFα stimulation across disease groups. When compared to FLS from patients with early rheumatoid arthritis, FLS from patients with resolving synovitis have significantly elevated mitochondrial respiratory capacity in the resting state, and less fragmented mitochondrial morphology after TNFα treatment. Our findings indicate the potential to restore cell metabotypes by modulating mitochondrial function at sites of inflammation, with implications for treatment of RA and related inflammatory conditions in which fibroblasts play a role.
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Symptoms in first-degree relatives of patients with rheumatoid arthritis: evaluation of cross-sectional data from the symptoms in persons at risk of rheumatoid arthritis (SPARRA) questionnaire in the PRe-clinical EValuation of Novel Targets in RA (PREVeNT-RA) CohortBackground: First-degree relatives (FDRs) of people with rheumatoid arthritis (RA) have a fourfold increased risk of developing RA. The Symptoms in Persons At Risk of Rheumatoid Arthritis (SPARRA) questionnaire was developed to document symptoms in persons at risk of RA. The aims of this study were (1) to describe symptoms in a cohort of FDRs of patients with RA overall and stratified by seropositivity and elevated CRP and (2) to determine if patient characteristics were associated with symptoms suggestive of RA. Methods: A cross-sectional study of FDRs of patients with RA, in the PREVeNT-RA study, who completed a study questionnaire, provided a blood sample measured for rheumatoid factor, anti-CCP and CRP and completed the SPARRA questionnaire. Moderate/severe symptoms and symmetrical, small and large joint pain were identified and described. Symptoms associated with both seropositivity and elevated CRP were considered suggestive of RA. Logistic regression was used to determine if symptoms suggestive of RA were associated with patient characteristics. Results: Eight hundred seventy participants provided all data, 43 (5%) were seropositive and 122 (14%) had elevated CRP. The most frequently reported symptoms were sleep disturbances (20.3%) and joint pain (17.9%). Symmetrical and small joint pain were 11.3% and 12.8% higher, respectively, in those who were seropositive and 11.5% and 10.7% higher in those with elevated CRP. In the logistic regression model, seropositivity, older age and feeling depressed were associated with increased odds of small and symmetrical joint pain. Conclusions: This is the first time the SPARRA questionnaire has been applied in FDRs of patients with RA and has demonstrated that the presence of symmetrical and small joint pain in this group may be useful in identifying people at higher risk of developing RA.
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The Skin of Colour Training Day UK: training the medical workforce in ethnic dermatologyThe Skin of Colour Training Day UK: training the medical workforce in ethnic dermatology
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Level of adherence to vitamin D supplementation guidelines in an antenatal centre in Birmingham, UK, and its effect on biochemical and obstetrical outcomes: a single-centre cross-sectional study.Objectives: A third of pregnant women in the UK are vitamin D deficient, which may confer deleterious consequences, including an increased risk of pre-eclampsia, gestational diabetes mellitus and intrauterine growth restriction. This study aims to determine the proportion of women that met National Institute for Health and Care Excellence (NICE) standards for vitamin D supplementation in pregnancy and compare biochemical and obstetrical outcomes according to supplementation status. Design and setting: This is a single-centre cross-sectional study in an antenatal centre in Birmingham, UK. Participants received a questionnaire regarding their experiences with vitamin D supplementation during their pregnancy with their general practitioner. Serum 25-hydroxyvitamin D and bone profile results were obtained during the same appointment and obstetrical outcomes were collected retrospectively once participants had delivered. Results: 41.8% of participants (n=61) received written and/or verbal advice about supplementation, (NICE standards=100%). 72.6% (n=106) had one or more risk factors for vitamin D deficiency, of which 38.7% (n=41, NICE standards=100%) were asked about supplementation. Among those asked, 85.4% (n=41, NICE standards=100%) received the correct dosage. Compared with the supplementation group, the non-supplementation group had offspring that were 1.40 cm (95% CI 0.01 to 2.80, p=0.04) longer at birth; which was significant after adjusting for confounding factors. No significant differences in any biochemical parameters were observed between supplementation categories (p>0.05). Conclusions: Adherence to NICE standards was suboptimal. This may be attributed to insufficient training for general practitioners on the importance of supplementation, causing them to underestimate the consequences of gestational vitamin D deficiency. Recommendations include implementing a mandatory screening tool to identify 'at-risk' women and providing more clinician training to ensure that supplementation during pregnancy is standard of care.
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'It's just a great muddle when it comes to food': a qualitative exploration of patient decision-making around diet and gout.Objective: Our aim was to understand whether, why and how patients choose to modify their diets after developing gout. Methods: We conducted an inductive thematic secondary analysis of qualitative data from 43 interviews and four focus groups with UK participants with gout (n = 61). Results: Participants commonly initiated dietary changes as part of a self-management strategy for gout. Reasons for making such dietary changes included: desperation; a desire for control; and belief that it would be possible to achieve successful management through diet alone; but not weight loss. Participants who did not make changes or who reverted to previous dietary patterns did so because: they believed urate-lowering therapy was successfully managing their gout; medication allowed normal eating; they did not find 'proof' that diet would be an effective treatment; or the dietary advice they found was unrealistic, unmanageable or irrelevant. Dietary modification was patient led, but patients would have preferred the support of a health-care professional. Beliefs that diet could potentially explain and modify the timing of flares gave patients a sense of control over the condition. However, the belief that gout could be controlled through dietary modification appeared to be a barrier to acceptance of management with urate-lowering therapy. Conclusions: Perceptions about gout and diet play a large role in the way patients make decisions about how to manage gout in their everyday lives. Addressing the reasons why patients explore dietary solutions, promoting the value of urate-lowering therapy and weight loss and drawing on strong evidence to communicate clearly will be crucial in improving long-term clinical management and patient experience.
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Intimate Partner Violence and the Risk of Developing Fibromyalgia and Chronic Fatigue Syndrome.Intimate partner violence (IPV) is a global public health issue with a variety of ill health consequences associated with exposure. Due to the stimulation of chronic stress and inflammatory pathways, childhood abuse has been associated with the subsequent development of functional syndromes such as fibromyalgia and chronic fatigue syndrome (CFS). Although IPV in women appears to elicit similar biochemical responses, this association has not been tested thoroughly in IPV survivors. These functional syndromes are complex in etiology and any indication of their risk factors would benefit health care professionals managing this population. Therefore, we aimed to investigate the association between exposure to IPV with functional syndromes: fibromyalgia and CFS. We conducted a retrospective open cohort study using "The Heath Improvement Network" database between January 1, 1995 and December 1, 2017. A total of 18,547 women who were exposed to IPV were each matched by age to four controls who were not exposed (n = 74,188). The main outcome measures were the risk of developing fibromyalgia and CFS. These were presented as adjusted incidence rate ratios (aIRR) with 95% confidence intervals (CIs). We found that 97 women in the exposed group developed fibromyalgia (incidence rate [IR] = 1.63 per 1,000 person-years) compared to 239 women in the unexposed group (IR = 0.83 per 1,000 person-years). Following adjustment, this translated to an IRR of 1.73 (95% CI = [1.36, 2.22]). Similarly, 19 women developed CFS in the exposed group (IR = 0.32 per 1,000 person-years), compared to 53 in the unexposed group (0.18 per 1,000 person-years), which translates to an aIRR of 1.92 (95% CI = [1.11, 3.33]). Therefore, we have identified an association between a history of IPV in women and the development of these functional syndromes, which may provide more information to inform the biopsychosocial pathway precipitating the development of fibromyalgia and CFS.
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Management of bone health in idiopathic inflammatory myopathies : a two-center audit in the United Kingdom and Hong KongBackground: Patients with inflammatory idiopathic myopathies (IIM) face elevated risks of osteoporosis and fragility fracture. Aim: To evaluate current practice relating to bone health in adult patients with IIM in the United Kingdom and Hong Kong (HK). Methods: Patients were identified from IIM patient lists. Demographics, osteoporosis risk factors, DXA scans, and bone protection treatment were recorded. Adherence to regional standards was evaluated for each center. Following this, in the United Kingdom, up-to-date DXA scans were performed. Results: Of 136 patients identified, 51 met selection criteria (UK, n = 20, HK, n = 31). Mean age in the United Kingdom was 59 (IQR 54-66); in Hong Kong, 65 (IQR 52.5-70). Most were female (UK 70%; HK 77%), current or previous steroid treatment was common (UK 90%; HK 100%) and some had experienced fragility fracture (UK 15%; HK 9%). The mean daily dose of prednisolone that patients were prescribed during the study was 12.5 mg (UK) and 14.3 mg (HK). Some patients had had a DXA scan (UK 50%; HK 35%) though several were outdated. Among those with BMD measured (UK, n = 20; HK, n = 11), osteopenia prevalence was 35% (UK) and 36% (HK) while osteoporosis was 5% (UK) and 36% (HK). Notably, 25% (UK) and 64% (HK) exceeded treatment thresholds. Treatments included anti-osteoporotic agents (UK 55%; HK 15%), Vitamin D/calcium supplements (UK 95%; HK 52%), or no treatment (UK 5%, HK 15%). Conclusion: Poor compliance with guidelines exists in both centers, particularly around investigation and monitoring of bone health for IIM patients. Integrated care models and increased resource allocation to bone health are imperative to improve management of this aspect of IIM.
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Understanding the impact of systemic lupus erythematosus on work amongst South Asian people in the UK: An explorative qualitative studySLE has a range of fluctuating symptoms affecting individuals and their ability to work. Although South Asian (SA) patients are at increased risk of developing SLE there is limited knowledge of the impact on employment for these patients in the UK. Understanding ethnicity and disease-specific issues are important to ensure patients are adequately supported at work. Semi-structured interviews were conducted with patients of SA origin to explore how SLE impacted on their employment. Thematic analysis was used to analyse the data which are reported following COREQ guidelines. Ten patients (8 female; 2 male) were recruited from three rheumatology centres in the UK and interviewed between November 2019 and March 2020. Patients were from Indian (n = 8) or Pakistani (n = 2) origin and worked in a range of employment sectors. Four themes emerged from the data: (1) Disease related factors; (2) Employment related factors; (3) Cultural and interpersonal factors impacting on work ability; (4) Recommendations for improvement. Patients' ability to work was affected by variable work-related support from their hospital clinicians, low awareness of SLE and variable support from their employers, and cultural barriers in their communities that could affect levels of family support received. These findings highlight the need for additional support for SA patients with SLE in the workplace.