Rates of hip and knee joint replacement amongst different ethnic groups in England: an analysis of National Joint Registry data.

OBJECTIVE: Despite a health care system that is free at the point of delivery, ethnic minorities may not always get care equitable to that of White patients in England. We examined whether ethnic differences exist in joint replacement rates and surgical practice in England. DESIGN: 373,613 hip and 428,936 knee National Joint Registry (NJR) primary replacement patients had coded ethnicity in Hospital Episode Statistics (HES). Age and gender adjusted observed/expected ratios of hip and knee replacements amongst ethnic groups were compared using indirect standardisation. Associations between ethnic group and type of procedure were explored and effects of demographic, clinical and hospital-related factors examined using multivariable logistic regression. RESULTS: Adjusted standardised observed/expected ratios were substantially lower in Blacks and Asians than Whites for hip replacement (Blacks 0.33 [95% CI, 0.31-0.35], Asians 0.20 [CI, 0.19-0.21]) and knee replacement (Blacks 0.64 [CI, 0.61-0.67], Asians 0.86 % [CI, 0.84-0.88]). Blacks were more likely to receive uncemented hip replacements (Blacks 52%, Whites 37%, Asians 44%; P < 0.001). Black men and women aged <70 years were less likely to receive unicondylar or patellofemoral knee replacements than Whites (men 10% vs 15%, P = 0.001; women 6% vs 14%, P < 0.001). After adjustment for demographic, clinical and hospital-related factors, Blacks were more likely to receive uncemented hip replacement (OR 1.43 [CI, 1.11-1.84]). CONCLUSIONS: In England, hip and knee replacement rates and prosthesis type given differ amongst ethnic groups. Whether these reflect differences in clinical need or differential access to treatment requires urgent investigation.

Inflammatory arthritis in HIV positive patients: A practical guide.

BACKGROUND: Musculoskeletal manifestations of the human immunodeficiency virus (HIV) have been described since the outset of the global HIV epidemic. Articular syndromes that have been described in association with HIV include HIV-associated arthropathy, seronegative spondyloarthropathies (SPA) (reactive arthritis, psoriatic arthritis (PsA) and undifferentiated SPA), rheumatoid arthritis (RA) and painful articular syndrome. METHODS: We carried out a computer-assisted search of PubMed for the medical literature from January 1981 to January 2015 using the keywords HIV, acquired immune-deficiency syndrome, rheumatic manifestations, arthritis, spondyloarthropathy, anti-TNF and disease modifying antirheumatic drugs. Only English language literature was included and only studies involving adult human subjects were assessed. RESULTS: There are challenges in the management of inflammatory arthritis in patients who are HIV-positive, including difficulties in the assessment of disease activity and limited information on the safety of immunosuppressive drugs in these individuals. CONCLUSIONS: This review focuses on the clinical characteristics of the inflammatory articular syndromes that have been described in association with HIV infection and discusses the therapeutic options for these patients.

An unusual foreign body in the ear of an elderly Nigerian patient.

This was a case of an incidental finding of an unusual foreign body in the right ear of an elderly Nigerian patient. The mode of presentation, the manner of discovery and how it was managed successfully were highlighted. We reported this case to create awareness, and encourage physicians to always observe effluents obtained from irrigation of body cavities for confirmation of diagnosis and documentation.

International league of associations for rheumatology recommendations for the management of psoriatic arthritis in resource-poor settings.

BACKGROUND: Psoriatic arthritis (PsA) is a challenging heterogeneous disease. The European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and PsA (GRAPPA) last published their respective recommendations for the management of PsA in 2015. However, these guidelines are primarily based on studies conducted in resource replete countries and may not be applicable in countries in the Americas (except Canada and USA) and Africa. We sought to adapt the existing recommendations for these regions under the auspices of the International League of Associations for Rheumatology (ILAR). PROCESS: The ADAPTE Collaboration (2009) process for guideline adaptation was followed to adapt the EULAR and GRAPPA PsA treatment recommendations for the Americas and Africa. The process was conducted in three recommended phases: set-up phase; adaptation phase (defining health questions, assessing source recommendations, drafting report), and finalization phase (external review, aftercare planning, and final production). RESULT: ILAR recommendations have been derived principally by adapting the GRAPPA recommendations, additionally, EULAR recommendations where appropriate and supplemented by expert opinion and literature from these regions. A paucity of data relevant to resource-poor settings was found in PsA management literature. CONCLUSION: The ILAR Treatment Recommendations for PsA intends to serve as reference for the management of PsA in the Americas and Africa. This paper illustrates the experience of an international working group in adapting existing recommendations to a resource-poor setting. It highlights the need to conduct research on the management of PsA in these regions as data are currently lacking.Key Points• The paper presents adapted recommendations for the management of psoriatic arthritis in resource-poor settings.• The ADAPTE process was used to adapt existing GRAPPA and EULAR recommendations by collaboration with practicing clinicians from the Americas and Africa.• The evidence from resource-poor settings to answer clinically relevant questions was scant or non-existent; hence, a research agenda is proposed.

Healthcare provided by a homeopath as an adjunct to usual care for Fibromyalgia (FMS): results of a pilot Randomised Controlled Trial.

OBJECTIVES: To assess the feasibility of a Randomised Controlled Trial (RCT) design of usual care compared with usual care plus adjunctive care by a homeopath for patients with Fibromyalgia syndrome (FMS). METHODS: In a pragmatic parallel group RCT design, adults with a diagnosis of FMS (ACR criteria) were randomly allocated to usual care or usual care plus adjunctive care by a homeopath. Adjunctive care consisted of five in depth interviews and individualised homeopathic medicines. The primary outcome measure was the difference in Fibromyalgia Impact Questionnaire (FIQ) total score at 22 weeks. RESULTS: 47 patients were recruited. Drop out rate in the usual care group was higher than the homeopath care group (8/24 vs 3/23). Adjusted for baseline, there was a significantly greater mean reduction in the FIQ total score (function) in the homeopath care group than the usual care group (-7.62 vs 3.63). There were significantly greater reductions in the homeopath care group in the McGill pain score, FIQ fatigue and tiredness upon waking scores. We found a small effect on pain score (0.21, 95% CI -1.42 to 1.84); but a large effect on function (0.81, 95% CI -8.17 to 9.79). There were no reported adverse events. CONCLUSIONS: Given the acceptability of the treatment and the clinically relevant effect on function, there is a need for a definitive study to assess the clinical and cost effectiveness of adjunctive healthcare by a homeopath for patients with FMS.

A comparison of two formulations of indomethacin ('Flexin Continus' tablets and 'Indocid' capsules) in the treatment of rheumatoid arthritis.

A multi-centre, double-blind, crossover study was carried out in 80 patients with rheumatoid arthritis to compare the efficacy and side-effect profiles of two formulations of indomethacin. Patients were allocated at random to receive 75 mg indomethacin per day either as 1 controlled-release tablet at night or as 1 immediate-release capsule given 3-times a day for a period of 4 weeks before being crossed over to receive the alternative treatment for a further 4 weeks. Pain scores, daily symptomatology and the requirement for escape analgesia recorded by both investigator and patient indicated that controlled-release indomethacin tablets, 75 mg given at night, was as efficacous as immediate-release indomethacin capsules given 3-times daily. However, the controlled-release formulation had a superior side-effect profile with a reduced incidence of abdominal/epigastric pain compared to the immediate-release preparation.

A comparison of two formulations of indomethacin ('Flexin Continus' tablets and 'Indocid' capsules) in the treatment of osteoarthritis.

The efficacy and side-effect profiles of two formulations of indomethacin were compared in a multi-centre, double-blind, crossover study in 77 patients with osteoarthritis. Patients were allocated at random to receive 75 mg indomethacin per day either as 1 controlled-release tablet at night or as 1 immediate-release capsule given 3-times daily for a period of 4 weeks, after which patients were crossed over to receive the alternative treatment for a further 4 weeks. Pain scores, daily symptomatology and the requirement for escape analgesia recorded by the investigator and patient indicate that controlled-release indomethacin tablets, 75 mg given at night, were as efficacious as immediate-release indomethacin capsules, 25 mg given 3-times daily, in the treatment of osteoarthritis. The side-effect profiles of the two formulations were similar.

Rheumatoid factor and rheumatoid factor isotypes in loiasis with and without accompanying glomerulonephritis.

We have studied the distribution of rheumatoid factor isotypes amongst patients with loiasis with and without accompanying glomerulonephritis to determine the possible role of rheumatoid factor antiglobulins in this disease. Our findings indicate an increase in both immunoglobulin (Ig) G and IgM rheumatoid factor isotypes in patients with filariasis alone as well as in patients with accompanying glomerulonephritis. No association with IgA rheumatoid factor was found. The raised IgG and IgM rheumatoid factor levels did not correlate with corresponding IgG and IgM levels.

IgG glycosylation in association with tropical infections and rheumatoid arthritis in the tropics.

Studies conducted in Europe suggest an association between IgG glycosylation abnormalities and rheumatoid arthritis (RA). Glycosylation abnormalities have been shown in other inflammatory diseases such as tuberculosis, systemic lupus erythematosus (SLE) and Crohn's disease. These observations led us to study glycosylation abnormalities among patients with RA and healthy controls in the tropics (sub-Saharan Africa). Using a lectin binding assay, we found that glycosylation differences were present in both groups when compared with British rheumatoid and healthy controls. This suggests that IgG glycosylation abnormalities may occur in association with chronic infections in the tropics.

The absence of antibodies to malaria and human immunodeficiency virus, and the presence of hepatitis B surface antigen as diagnostic markers of rheumatoid arthritis.

Rheumatoid factor is of limited value in the diagnosis of rheumatoid arthritis (RA) in West Africa. Consequent upon previous findings, we have studied the role of the absence of antibodies to malaria and human immunodeficiency virus (HIV) as well as the presence of the hepatitis B surface antigen (HBsAg) as diagnostic markers of rheumatoid arthritis in West Africa. We have found a significant association (p < 0.001) between RA and titre of HBsAg, but only between RA and malaria (p < 0.05) when sera with low malaria antibodies were studied. No correlation between either HBsAg or malaria and rheumatoid factor was found and no RA patient was either HIV-1 or HIV-2 positive.

The pattern of rheumatic disorders seen amongst patients attending urban and rural clinics in west Africa.

There is a growing interest in the study of the pattern of rheumatic disorders in Africa. This has led to our studying the pattern of rheumatic disorders seen among patients attending both urban and rural clinics in West Africa. A wide spectrum of rheumatic diseases was observed among those attending both clinics. Osteoarthritis and soft tissue lesions were most commonly seen while inflammatory joint disease and connective tissue disorders were less commonly observed. We consider that these observations have significant rheumatological health care implications for West Africa and may provide useful aetiopathogenic clues.

Specificity of IgM antiglobulins produced in rheumatoid arthritis and tropical infections.

The measurement of rheumatoid factors is of limited value in West Africa due to the low rheumatoid factor seroprevalence among patients with rheumatoid arthritis and the increased seroprevalence among healthy individuals and those with infectious diseases in the region. Using ELISA methods, we have been able to increase the specificity of rheumatoid factor measurement although the sensitivity of this test remains low. Furthermore, among the infectious diseases studied, there was no preferential binding of rheumatoid factors to the Fab gamma portion of immunoglobulin over the Fc gamma portion.

Thermography of frozen shoulder and rotator cuff tendinitis.

The role of thermography in the diagnosis of soft tissue lesions of the shoulder was evaluated by screening 28 patients with unilateral frozen shoulder and 86 patients with unilateral rotator cuff lesions. Index shoulders were then compared with the normal side. Differences in skin temperature distribution were found in 82% of subjects with frozen shoulder, nearly three-quarters of whom had reduced skin temperature. There was no consistent pattern of shoulder skin temperature found in rotator cuff tendinitis patients (49% normal, 28% reduced, 23% increased). Thermography can be helpful in the diagnosis of frozen shoulder but further studies are required to determine whether it is useful in other soft tissue shoulder lesions.

Massive ascites associated with endometriosis in a Nigerian African.

A case of endometriosis with massive ascites in a 19-year-old Nigerian African is reported. This is an unusual combination and it is likely that most gynecologists and general physicians would never see such a case. The presentation and management of this entity is discussed.

DC-ART: preventing or significantly decreasing the rate of progression of structural joint damage.

Progressive joint damage, increasing deformity, and declining function characterize rheumatoid arthritis (RA). The evidence suggests structural joint damage is the predominant cause of functional impairment. Structural changes of joints are evaluated by imaging methods. Plain joint radiographs remain the best method for determining the extent and nature of structural changes at present. Newer technologies such as magnetic resonance imaging may eventually replace them. Clinical studies of antirheumatic drugs involving the assessment of prevention or significant decrease in the rate of progression of structural joint damage in RA should meet several standards. All patients who enter a study, whether they continue medication or not, must be assessed on its completion. Studies require sufficient power to determine realistic differences due to therapy. They should last long enough for a reliable analysis of the effects of joint damage; 1 year would be the minimal period for such a study, and 2 years would be preferable. Evaluation should concentrate on erosions and related structural changes in juxtaarticular bone; mapping osteoporotic areas in early disease may be a sensitive and objective measure. Assessments ought to use changes within the hands and wrists to indicate overall progression, with the feet included in evaluating early disease. There should be different therapeutic aims at various stages of RA, focussing on preventing new erosions developing in early disease (< 2 years from diagnosis), preventing new erosions occurring in established disease (2-5 years from diagnosis), reducing the rate erosions develop in established disease (< 5 years from diagnosis), and reducing the rate of joint destruction in late disease (> 5 years from diagnosis).

Travel- and immigration-related problems in rheumatology.

Health problems are self-reported by up to 64% of travellers to the developing world. Traditionally, rheumatic symptoms are accorded little significance, but many travellers do return home with musculoskeletal complaints. The assessment of these patients is often hindered by the Western clinician's lack of familiarity with the types of infections that the patient may have encountered while travelling. Standard serological tests for autoimmune diseases can be unreliable in the setting of concomitant tropical infection, and these infections themselves can have musculoskeletal manifestations. Even in the absence of tropical infection, laboratory investigation of musculoskeletal symptoms in individuals of different ethnicities is challenging due to genetic and physiological variation. This review focusses on addressing the impact global migration has had on rheumatological clinical practice.