Intradisciplinary team meeting for teledermatology: an aid to improving clinician confidence.

A weekly teledermatology intradisciplinary team (IDT) meeting, attended by consultant dermatologists and dermatology trainees, was established at our centre in July 2020 to help with the diagnosis and management of challenging 2-week-wait skin cancer teledermatology cases. To assess the usefulness of the meeting, an electronic survey of attendees (consultants n = 7; trainees n = 4) was performed 6 months after introduction. The results showed that 71.4% of consultants and 100% of trainees felt the IDT meeting improved their confidence in assessing dermoscopic photographs and in managing patients via teledermatology; 100% of attendees considered the meeting would improve patient safety; and 85.7% of consultants and 100% of trainees found the meeting contributed to their professional development, demonstrating its educational value. A retrospective analysis of patient outcomes before and after implementation of the IDT meeting demonstrated an increase in the direct discharge rate from 44.7% to 56.3% and a reduction in biopsy rate from 39.6% to 30.2% (n = 400; P = 0.02). The teledermatology IDT meeting is a model that could be introduced at other centres to support clinician confidence in teledermatology, and to help with clinical decision-making and teledermatology training.

Cutaneous larva migrans: an unusual souvenir from a Scottish holiday.

Cutaneous larva migrans acquired in western Scotland. A reminder that with a warming climate, conditions conventionally restricted to the tropics may be contracted in the British Isles in the absence of foreign travel.

Using family and staff experiences of a botulinum toxin-A service to improve service quality.

BACKGROUND: The decision for families to proceed with botulinum toxin-A (BoNT-A) injections for managing childhood conditions involving hypertonia can be complex. Family-centred care is a service model that facilitates supporting families in this decision-making process. Understanding families' experiences of services is critical to developing family-centred care. The aim of this project was therefore to increase understanding of the experiences of families of children attending a BoNT-A service in order to improve the service and its family-centred approach to care. METHOD: Sixteen staff of a BoNT-A service participated in a patient journey mapping exercise. Nine families of the service participated in in-depth interviews. Interviews were audio-recorded and transcribed verbatim. Data from the staff session and interviews were analysed independently using grounded, hermeneutic thematic analysis. RESULTS: Staff sessions revealed 5 core themes that related to impacting on the family experience. Family interviews revealed 4 core themes, with 7 subthemes and 1 latent theme. CONCLUSIONS: Areas of importance identified by families relating to BoNT-A treatment included acknowledgement of individual needs, care coordination, empowerment of families and patients, consistency in service delivery, and the distressing nature of appointment and decision-making. Comparison of the data from the staff patient journey mapping and family interviews suggested that staff have a good but incomplete understanding of the factors important to families, highlighting the need for consumer engagement in establishing family-centred care. The themes identified can guide the provision of family-centred BoNT-A injection clinics.

Embedding research in clinical practice: differences in attitudes to research participation among clinicians in a tertiary teaching hospital.

Despite a drive to increase research in healthcare settings, clinician participation in research remains infrequent. This paper describes an online survey comparing attitudes with research participation among clinicians (doctors, nurses and allied health professionals) at an Australian tertiary children's hospital. Differences between professional groups support the existence of different professional cultures surrounding research, suggesting that multiple strategies are required to improve participation in research.

Active screening at entry for tuberculosis among new immigrants: a systematic review and meta-analysis.

Although there is no evidence that imported tuberculosis increases the incidence of the disease in host countries, the rise in migration worldwide raises concerns regarding the adequacy of surveillance and control of immigrant-associated tuberculosis in low incidence countries. Assessing the performance of screening of immigrants for tuberculosis is key to rationalizing control policies for the detection and management of immigrant-associated tuberculosis. We performed a systematic review and meta-analysis to determine the yield of active screening for tuberculosis among new immigrants at the point of entry. The yield for pulmonary tuberculosis was 3.5 cases per 1,000 screened (95% CI 2.9-4.1; I(2) = 94%); for refugees, asylum seekers and regular immigrants the estimates were 11.9 (95% CI 6.7-17.2; I(2) = 92%), 2.8 (95% CI 2.0-3.7; I(2) = 96%) and 2.7 (95% CI 2.0-3.4; I(2) = 81%), respectively. The yield estimates for immigrants from Europe, Africa and Asia were 2.4 (95% CI 1.3-3.4; I(2) = 51.5%), 6.5 (95% CI 3.2-10.0; I(2) = 62%) and 11.2 (95% CI 6.2-16.1; I(2) = 95%), respectively. These results provide useful data to inform the development of coherent policies and rational screening services for the detection of immigrant-associated tuberculosis.

Anti-CCP antibody testing as a diagnostic and prognostic tool in rheumatoid arthritis.

Rheumatoid arthritis is both common and chronic, with significant consequences for multiple organ systems. Better understanding of its pathophysiology has led to the development of targeted therapies that have dramatically improved outcomes. The key to therapeutic success lies in identifying individuals who will have severe destructive disease as early as possible, so that effective treatment can be initiated before irreversible damage occurs. Anti-cyclic citrullinated peptide (anti-CCP) antibody testing is particularly useful in the diagnosis of rheumatoid arthritis, with high specificity, presence early in the disease process, and ability to identify patients who are likely to have severe disease and irreversible damage. However, its sensitivity is low, and a negative result does not exclude disease. Anti-CCP antibodies have not been found at a significant frequency in other diseases to date, and are more specific than rheumatoid factor for detecting rheumatoid arthritis. We discuss anti-CCP antibody testing in rheumatoid arthritis, with an emphasis on diagnostic performance, prognostic capability, and relevance to pathogenesis and new treatment paradigms in rheumatoid arthritis.

Methotrexate use in rheumatoid arthritis is associated with few clinically significant liver function test abnormalities.

OBJECTIVE: To determine the frequency of liver function tests (LFT) abnormalities associated with methotrexate (MTX) use in the treatment of rheumatoid arthritis (RA). METHODS: A retrospective chart review for demographic information, RA-specific history, medication history, complications of therapy, results of all available blood tests (specifically aspartate aminotransferase (AST), alanine aminotransferase (ALT), complete blood count (CBC), albumin, creatinine), and liver biopsy reports was conducted for RA patients, who were currently using or have used MTX in the past. RESULTS: A total of 2791 LFTs were performed among 182 RA patients with 94 abnormal results. 152 patients (83.5%) with 2007 LFT evaluations demonstrated no abnormal results, compared with 30 patients (16.5%) who had at least one abnormal LFT in 784 tests. Twenty-two of the 30 patients with at least one LFT abnormality (73.3%) continued treatment despite the elevation without further evaluation or change in therapy, and subsequent LFT assessments were within normal limits. 128 patients (70.3%) remained on MTX at the time of our study. The most common reason for discontinuation was inadequate response. CONCLUSIONS: MTX appears to be associated with very few clinically significant hepatic side effects. In view of these data, consideration as to revision of the current MTX monitoring guidelines in the direction of less frequent monitoring, especially in patients with no risk factors for liver disease, may be considered.

Increased renal tubular cell excretion by patients receiving chronic therapy with gold and with nonsteroidal anti-inflammatory drugs.

Using rheumatoid arthritis patients who were receiving gold as models, we evaluated the renal effects of the chronic administration of very low doses of a nephrotoxic drug. The heavy metal gold has been shown to increase urinary enzyme excretion when it is given in usual doses for the treatment of rheumatoid arthritis. It is not clear whether the increased urine enzyme excretion caused by long-term drug therapy represents injury to the kidney or whether it is merely an effect of the drug. Urinary N-acetyl-beta-glucosaminidase and renal tubular cell excretion rates were measured in 19 patients who were receiving chronic treatment with gold and with nonsteroidal anti-inflammatory drugs for rheumatoid arthritis, in 10 patients who were receiving nonsteroidal anti-inflammatory drugs, and in 8 healthy control subjects. No subjects showed evidence of kidney disease. Both renal tubular cell and enzyme excretion rates were elevated in the gold-treated group. This showed that there was increased renal tubular cell turnover in this group, which suggests low level renal tubular injury and not merely an effect of the usual dose of gold.

Mitral valve disease of systemic lupus erythematosus. A cause of severe congestive heart failure reversed by valve replacement.

Libman-Sacks endocarditis caused progressive life-threatening mitral regurgitation necessitating mitral valve replacement in an 18 year old woman with systemic lupus erythematosus (SLE). Although Libman-Sacks endocarditis is frequently seen at autopsy in patients with SLE, hemodynamically significant valvular disease due to that lesion is quite rare. We found no previous reports describing mitral regurgitation in a patient with SLE which has necessitated surgical intervention.

Aortic insufficiency and mitral regurgitation in patients with systemic lupus erythematosus and the antiphospholipid syndrome.

PURPOSE, PATIENTS, AND METHODS: Heart disease has not been well characterized in patients with systemic lupus erythematosus (SLE) and the antiphospholipid syndrome. During a prospective study of cerebrovascular disease in autoimmune disease and SLE, 11 lupus patients were identified with an antiphospholipid syndrome characterized by significant cardiac valvular disease in addition to cerebral infarction, deep vein thromboses, and thrombocytopenia. Patients were reviewed for criteria for systemic lupus and underwent echocardiographic studies and measurements of anticardiolipin antibodies, VDRL, and the lupus anticoagulant. RESULTS: Eight of the 11 patients had aortic insufficiency, two of whom had associated mitral regurgitation. Three patients had mitral regurgitation alone. Microscopic analysis of a surgically excised aortic valve indicated typical Libman-Sacks verrucous endocarditis. Infective endocarditis was ruled out in all patients. CONCLUSION: This report expands previous descriptions of antiphospholipid syndromes by describing a subset of lupus patients with significant aortic and mitral valvulitis in addition to circulating antiphospholipid antibodies, thrombocytopenia, and recurrent thromboses.

Lymphoma in patients with rheumatoid arthritis: association with the disease state or methotrexate treatment.

Although long-term clinical studies have shown no excessive risk of lymphoma in rheumatoid arthritis (RA) patients treated with methotrexate (MTX), an increasing number of reports of this association continue to appear. We describe two cases, review the cases in the world's literature, and summarize their important characteristics. Possible oncogenic mechanisms are discussed. Most lymphoproliferation cases presented here have features of immunosuppression-associated lymphoma. The immunosuppressed state is attributable to a combination of factors, such as RA itself and the actions of MTX. The risk factors for RA patients to develop lymphoma while on MTX include severe disease, intense immunosuppression, genetic predisposition, and an increased frequency of latent infection with prooncogenic viruses such as Epstein-Barr virus (EBV). The spontaneous remission of lymphomas in eight RA patients after MTX was stopped highlights the likely causative role of the drug in the development of these malignancies. If the clinical situation permits, a period of observation for spontaneous remission after MTX is stopped is advisable. The physicians caring for RA patients on MTX should maintain a high surveillance for signs and symptoms suggestive of lymphoma.

Laryngeal involvement in systemic lupus erythematosus.

Laryngeal involvement in systemic lupus erythematosus (SLE) can range from mild ulcerations, vocal cord paralysis, and edema to necrotizing vasculitis with airway obstruction. In this report, four cases showing the range of severity of this disease manifestation are presented, accompanied by a comprehensive review of the literature. The clinical course of 97 patients with laryngeal involvement with SLE are reviewed, of whom 28% had laryngeal edema and 11% had vocal cord paralysis. In the majority of cases, symptoms such as hoarseness, dyspnea, and vocal cord paralysis resolved with corticosteroid therapy. Other, less common causes of this entity included subglottic stenosis, rheumatoid nodules, inflammatory mass lesions, necrotizing vasculitis, and epiglottitis. The clinical presentation of laryngeal involvement in patients with SLE follows a highly variable course, ranging from an asymptomatic state to severe, life-threatening upper airway compromise. With its unpredictable course and multiple causations, this complication remains a diagnostic and therapeutic challenge to physicians involved in the care of patients with SLE.

Neurologic complications of rheumatoid arthritis.

Neurologic complications are common extraarticular manifestations of RA, involving both the peripheral and central nervous systems. Because RA patients suffer from pain, stiffness, and weakness, the detection of neurologic impairment is often difficult. Thus, close vigilance and thoughtful use of various diagnostic methods will help in the early diagnosis of cervical spine involvement, compression neuropathies, peripheral neuropathies, myopathies, and central nervous system involvement. Prompt and timely interventions may prevent permanent neurologic sequelae.

Elderly-onset rheumatoid arthritis.

It is appreciated that age has a modifying effect on the clinical presentations of disorders such as hyperthyroidism and systemic lupus erythematosus. Similarly in EORA, there seems to be a change in the disease phenotype when it is compared to YORA. These differences are significant not only in highlighting the importance of the aging process on the immune system but also because they have medical and therapeutic implications. Improved classification has greatly improved our understanding and treatment of systemic lupus erythematosus, juvenile chronic arthritis, and seronegative spondyloarthropathies. Similarly, appreciating the differences, and similarities, between YORA and EORA should advance the choice of therapeutic options and potentially move closer to defining pathogenesis and origin.

Lymphoma in patients with rheumatoid arthritis: what is the evidence of a link with methotrexate?

An increasing number of instances of lymphoma in patients with rheumatoid arthritis who are treated with methotrexate continue to appear. The majority of patients with lymphoproliferation have features of immunosuppression-associated lymphoma. Rheumatoid arthritis itself and the actions of methotrexate concur in leading to a immunosuppressed state. Possible oncogenic mechanisms and the risk factors for patients with rheumatoid arthritis to develop lymphoma while receiving methotrexate include: (i) intense immunosuppression and severe disease in combination with genetic predisposition and; (ii) an increased frequency of latent infection with prooncogenic viruses like Epstein-Barr virus. The aetiological role of methotrexate in the development of these lymphomas is supported by the spontaneous remission of these malignancies in some of patients with rheumatoid arthritis after methotrexate has been stopped. The physicians caring for patients with rheumatoid arthritis receiving methotrexate should be vigilant about signs and symptoms suggestive of lymphoma, mostly in those patients with significant comorbidity, long standing and severe disease who are more likely to be immunosuppressed. If a lymphoma appears in these patients, methotrexate should be stopped. Spontaneous remission may occur and a period of observation is advisable when clinically possible. If functional deterioration appears or there are signs of lymphoproliferative organ invasion after several months then specific antineoplastic treatment should be instituted.

Adapting the systemic lupus erythematosus self-help (SLESH) course for Latino SLE patients.

The Systemic Lupus Erythematosus Self-Help (SLESH) Course is an effective self-management program that provides knowledge and enabling skills to people with systemic lupus erythematosus (SLE) and their families to assist them in coping with the disease. However, many acknowledge that the program has largely failed to meet the needs of people from diverse cultural backgrounds. In order to better understand how the SLESH Course can be more responsive to the needs of people from diverse cultural groups, we conducted a case study to analyze the content, process, and logistics of the course. The purpose of our study was to determine the essential variables to be considered in adapting the program for Latino SLE patients. Utilizing a three-phase approach that involved key-informant interviews, focus groups, and evaluation of skill-building activities, we found that culturally determined health beliefs, language of preference, and outreach efforts are the key variables that must be considered in adapting the SLESH Course for the target population. Culturally determined health beliefs, such as the importance of family roles rather than individual need and an emphasis on the interdependency of family members, need to be considered in adapting self-help programs like the SLESH Course for Latino SLE patients.

Assessing cost-effectiveness analyses in rheumatoid arthritis and osteoarthritis.

Economic considerations are now a source of great concern to clinicians and policy analysts. Many cost-effectiveness analyses have been published in the area of arthritis, most with substantial methodologic deficiencies. The goal of this article is to outline a method for evaluating cost-effectiveness assessment within the field of rheumatology. We do so by critically evaluating 6 cost-effectiveness analyses--2 in rheumatoid arthritis and 4 in osteoarthritis--as a basis for appraising the literature and developing future studies.

Adaptations made by rheumatoid arthritis patients to continue working: a pilot study of workplace challenges and successful adaptations.

OBJECTIVES: The goals of this pilot study were to use qualitative research techniques in a group of currently employed patients with rheumatoid arthritis (RA) to develop categories of challenges encountered in maintaining employment and categories of successful adaptations made to continue working; and to identify obstacles considered to be persistent threats to continued employment. METHODS: Patients were interviewed by telephone with a questionnaire composed of structured-response format and open-ended response format questions focusing on specific challenges and adaptations in the workplace. RESULTS: Of the 22 patients interviewed, 96% were women, mean age was 50 years, 84% were college graduates, and the majority had light physical job demands and high autonomy over their work and hours worked. Patients encountered diverse challenges, such as fatigue, pain, typing, writing, physical requirements, maintaining a pleasant disposition, working overtime, traveling for business, commuting, being on time, not being able to choose rest periods, and environmental issues. Patients also made multiple adaptations to continue working, the most helpful being changing job or altering career path (36%), altering work hours (32%), using more disease-modifying antirheumatic drugs (27%), using car service (23%), sleeping more (18%), and working at home (14%). Patients were not at all confident in their ability to continue working because of RA, and perceived the following persistent threats to continued employment: fatigue (45%), not being able to use hands (45%), not being able to choose rest periods (27%), and commuting problems (18%). In addition, patients confronted psychological stresses, such as dealing with coworkers and supervisors and balancing job and personal roles. These challenges and adaptations included unfavorable work-related occurrences, or "negative work-role events." CONCLUSIONS: Seemingly successfully employed patients with RA faced multiple challenges and made major adaptations to maintain employment and still perceived their employment to be in jeopardy because of RA. The findings of this study have important implications for screening patients at risk for negative work-role events and for possible work-related and social support interventions aimed at preserving employment.