Pancreatic manifestations in rheumatoid arthritis: a national population-based study.

OBJECTIVES: RA is a systemic autoimmune disease characterized by persistent joint inflammation. Extra-articular manifestations of RA can involve different organs including the gastrointestinal (GI) system. Using a large database, we sought to describe the epidemiology of pancreas involvement in RA. METHODS: We queried a multicentre database (Explorys Inc, Cleveland, OH, USA), an aggregate of electronic health record data from 26 major integrated US healthcare systems in the US from 1999 to 2019. After excluding patients younger than 18, a cohort of individuals with Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) diagnosis of RA was identified. Within this cohort, patients who developed a SNOMED-CT diagnosis of acute pancreatitis (AP), chronic pancreatitis (CP) and primary pancreatic cancer (PaCa) after at least 30 days of RA diagnosis were identified. Statistical analysis for multivariate model was performed using Statistical Package for Social Sciences (SPSS version 25, IBM Corp) to adjust for several factors. RESULTS: Of the 56 183 720 individuals in the database, 518 280 patients had a diagnosis of RA (0.92%). Using a multivariate regression model, patients with RA were more likely to develop AP [odds ratio (OR): 2.51; 95% CI: 2.41, 2.60], CP (OR: 2.97; 95% CI: 2.70, 3.26) and PaC (OR: 1.79; 95% CI: 1.52, 2.10). CONCLUSION: In this large database, we found a modest increased risk of AP and CP among patients with RA after adjusting for the common causes of pancreatitis. Further studies are required to better understand this association and the effect of medications used for RA.

Patient-reported experience with patient-reported outcome measures in adult patients seen in rheumatology clinics.

OBJECTIVES: Patient-reported outcome measures (PROMs) are increasingly utilized in the evaluation of patients with rheumatic diseases. The aim of our study was to assess the patient experience with completing PROMs within rheumatology clinics, and identify patient characteristics associated with a more positive experience. METHODS: We conducted a retrospective cross-sectional study of adult patients seen in rheumatology clinics between 1/1/2017 and 6/30/2017. Patients were included in the study if they completed at least one patient-reported experience question following completion of PROMs. Patient characteristics associated with more positive experiences were identified through multivariable proportional odds models. RESULTS: 12,597 adult patients (mean age 59 ± 15; 76% female; 84% white) completed PROMs, as well as questions on their experience completing PROMs. Patients agreed/strongly agreed that PROM questions were easy to understand (97%), useful (84%), helped their physician understand their health (78%), improved communication with their provider (78%) and improved control over their own care (70%). Predictors of better experience with PROMs included being younger, non-white, having lower income, and being a new patient. Worse self-reported health also predicted better experience with PROMs. CONCLUSION: Our study found a positive patient experience with PROMs, which is a crucial component of their successful implementation and utilization. Findings from this study suggest PROMs may be particularly beneficial in new patients, minorities, those with lower income, and worse self-reported quality of life. Collecting PROMs could provide opportunities to improve patient-provider communication and enhance control over care for rheumatology patients who could most benefit.

The influence of collecting patient-reported outcome measures on visit satisfaction in rheumatology clinics.

OBJECTIVES: Patient-reported outcome measures (PROMs) can direct patient-centred care and increase patient satisfaction with the visit. The objective of this study was to assess the relationship between the collection of PROMs and visit satisfaction, as measured by the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey. METHODS: An electronic platform for collection of patient-reported information was implemented in rheumatology clinics between August and September 2016. Adult patients were included in the study if they completed CG-CAHPS after an ambulatory visit. The pre-implementation cohort consisted of patients seen between January and June 2016; the post-implementation cohort consisted of patients seen between January and June 2017. The CG-CAHPS scores were compared between cohorts. Mixed effect models were constructed to identify predictors of visit satisfaction. RESULTS: Characteristics were similar between the 2117 pre- and 2380 post-implementation patients. Visit satisfaction was high in both cohorts but did not differ [odds ratio = 0.97 (95% CI: 0.79, 1.19)]. Predictors of improved satisfaction included being an established patient, being male, older age and reporting higher quality of life. However, sensitivity analyses in the post-implementation cohort suggested that implementing PROMs might convey benefits for new patients, in particular. CONCLUSION: Collection of PROMs had no effect on visit satisfaction in rheumatology clinics, although there might be benefits for new patients. These largely null findings might be attributable to high satisfaction levels in our cohorts or to lack of provider review of PROM data with patients. Further research is indicated to determine the impact of provider communication of PROM results to patients on different domains of visit satisfaction.

Regional distribution of adult rheumatologists.

OBJECTIVE: To analyze the distribution of rheumatology practices in the US and factors associated with that distribution, in order to better understand the supply of the rheumatology workforce. METHODS: Using the American College of Rheumatology membership database, all practicing adult rheumatologist office addresses were mapped with ArcView software. The number of rheumatologists per Core Based Statistical Area (CBSA) was calculated. To investigate whether sociodemographic factors correlated with clustering of rheumatologists, covariates from the 2010 US Census for each CBSA, including age, sex, race/ethnicity, and median household income, were modeled. RESULTS: Many CBSAs, predominantly smaller micropolitan areas, did not have a practicing rheumatologist. For some of these smaller micropolitan areas (with populations of at least 40,000), the closest practicing rheumatologist was more than 200 miles away. However, we also identified several more-populous areas (populations of 200,000 or more) without a practicing rheumatologist. Greater numbers of rheumatologists were more likely to practice in areas with higher population densities and higher median incomes. More rheumatologists were also found in CBSAs in which there were rheumatology training programs. CONCLUSION: These findings demonstrate that many smaller regions of the country have no or few practicing adult rheumatologists. Patients with chronic rheumatic conditions in these areas likely have limited access to rheumatology care. Policy changes could address potential regional rheumatology workforce shortages, but limitations of the current data would need to be addressed prior to implementation of such changes.

Treatment of hypertrophic osteoarthropathy with zoledronic acid: case report and review of the literature.

OBJECTIVES: Zoledronic acid (ZA) is rarely used to manage hypertrophic osteoarthropathy (HOA). We report our experience with ZA treatment of a patient with HOA and sarcoidosis who had also undergone lung transplant. We also conducted a literature review of the usefulness of bisphosphonates in HOA. METHODS: We performed a PubMed literature search using keywords HOA, periostitis, bisphosphonate, ZA, sarcoidosis, and lung transplant. A PRISMA flow diagram is presented to depict the data collection process, and a case is reported. RESULTS: A 62-year-old woman with bilateral lung transplant as a result of severe pulmonary sarcoidosis developed severe limb pain and inflammatory polyarthritis. HOA was diagnosed in the presence of periostitis with the symptoms. Failure of the refractory bone and joint pain to respond to low doses of prednisone, tramadol, or even pamidronate infusion prompted a trial of a single dose of intravenous ZA. Surprisingly, the pain completely resolved without recurrence. A total of 12 cases of HOA treated with bisphosphonates were retrieved from the literature and reviewed. CONCLUSIONS: Bisphosphonates are generally effective therapy for HOA-related pain. ZA may be even more efficacious and longer lasting than pamidronate for management of the bone and joint pain associated with HOA irrespective of the underlying disorders.

Prevalence of metabolic bone disease among chronic rhinosinusitis patients treated with oral glucocorticoids.

BACKGROUND: The treatment of chronic rhinosinusitis (CRS) often requires chronic or intermittent oral steroid therapy, which has the potential for adverse skeletal effects, including osteoporosis and increased risk of fragility fractures. The purpose of this study was to determine the prevalence of osteopenia/osteoporosis (OP) or low bone density (LBD) in patients with CRS with/without polyposis treated with oral glucocorticoids. METHODS: Retrospective chart analysis was performed at a tertiary-care rhinology practice. Patients with CRS with/without polyposis evaluated between September 2003 and July 2008 were included if they had (1) previous history of oral steroid usage (> or =5 mg daily for at least 3 months) and (2) previous bone mineral density evaluation. RESULTS: A total of 197 patients were included with a mean age of 51.1 years (range, 15-79 years). The primary presenting diagnoses included CRS with polyposis in 176 cases (89.3%) and CRS without polyposis in 21 cases (10.7%). Concomitant asthma was present in 161 patients (81.7%). Overall, the prevalence of low bone mass was 38.6%. Among men >50 years of age and postmenopausal women, the prevalence of osteopenia/OP or LBD was 62.5 and 62.2%, respectively. Comparing men >50 years of age and postmenopausal women to their respective younger populations, both had a statistically higher presence of low bone mass (p < 0.0001), with an odds ratio of 10.6 (3.9-28.7) and 34.6 (7.4-161.5), respectively. There was no statistical difference in the presence of bone loss when comparing groups by gender. A multivariable analysis of common comorbidities revealed age to be the only factor associated with increased risk for OP/osteopenia or LBD. CONCLUSION: Patients with CRS with/without polyposis treated with oral steroids who underwent bone density testing were found to have a high prevalence of LBD. High index of suspicion is required to identify at-risk patients and to initiate careful evaluation and treatment to prevent additional bone-related complications.

A review of Paget's disease of bone with a focus on the efficacy and safety of zoledronic acid 5 mg.

BACKGROUND: Paget's disease of bone, the second most common metabolic bone disease in the United States, is characterized by localized areas of excessive bone resorption coupled with accelerated bone formation, resulting in new bone that is less structurally organized and is weaker than normal bone. Complications of Paget's disease can include bone pain, osteoarthritis, skeletal deformity, hearing loss, and fractures. The objective of this review is to provide a comprehensive overview of current standards of treatment in Paget's disease. SCOPE: A review of literature from 1974 to 2007 was performed on topics such as epidemiology, etiology, treatment of Paget's disease of bone, and bisphosphonates. FINDINGS: Paget's disease affects an estimated 2-7% of persons of age 55 years or older in North America and western Europe. Antiresorptive treatment with bisphosphonates is the standard treatment, but there may be limitations to oral therapy. Intravenous pamidronate is efficacious and has long been available, but its use is hindered by an impractical recommended dosing regimen of 30 mg IV over 4 h for three consecutive days. In two identical, double-blind, 6-month trials, 96% of patients treated with a one-time intravenous treatment of zoledronic acid 5 mg achieved therapeutic response, compared with 74% treated with 60 days of daily oral treatment with risedronate 30 mg (p < 0.001). One limitation of this review is that historical data are not reviewed in the same level of detail as newer treatments, because recent advances in pharmacotherapy of Paget's disease have reduced the clinical utility of the older drugs. CONCLUSION: The etiology of Paget's disease is unclear, but some evidence suggests genetic and viral components. Bisphosphonates restore normal bone turnover and relieve bone pain, but oral formulations may be limited by complicated dosing regimens and poor gastrointestinal absorption. The bisphosphonate, zoledronic acid is administered as a single intravenous infusion and offers antiresorptive efficacy and longer-lasting remission.