Noninfectious Autoimmune Scleritis: Recognition, Systemic Associations, and Therapy.

PURPOSE OF REVIEW: The aim of this review is to provide the information necessary for recognizing scleritis in rheumatology patients, recognize associated systemic diseases in scleritis patients referred to rheumatology, and choose the best conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic therapy, based on the most recent data. RECENT FINDINGS: Scleritis is most often associated with systemic conditions, particularly autoimmune conditions. Rheumatologists should be most vigilant about rheumatoid arthritis and ANCA-associated vasculitis. A recent systemic association has been found with IgG4-related disease as well. Most of the therapeutic decisions are based on observational data. Most recently, there is increasing evidence of the role of rituximab for refractory disease. Scleritis is a severe inflammatory ocular condition that leads to complications including vision loss. It can precede a systemic autoimmune disease diagnosis, especially in the case of vasculitis. Prompt recognition and adequate therapy are needed in order to avoid serious ocular complications. There is an unmet need for (1) head-to-heat trials on csDMARDs and biologic drugs for the treatment of idiopathic scleritis and (2) randomized controlled trials on the treatment of refractory cases.

Efficacy of Combination Therapy with the JAK Inhibitor Baricitinib in the Treatment of COVID-19.

Coronavirus disease-19 (COVID-19), resulting from infection with SARS-CoV-2, spans a wide spectrum of illness. In severely ill patients, highly elevated serum levels of certain cytokines and considerable cytolytic T cell infiltrates in the lungs have been observed. These same patients may bear low to negligible viral burdens suggesting that an overactive immune response, often termed cytokine storm, contributes to the severity of COVID-19. We report the safety and efficacy of baricitinib combined with remdesivir and dexamethasone in a retrospective review of 45 hospitalized patients with COVID-19 pneumonia at a tertiary academic medical center. Patients received 7-day course of baricitinib, 5-day course of remdesivir, and 10-day course of dexamethasone. Clinical status and biomarkers were obtained daily. Outcomes assessed include mortality, duration of hospitalization, presence of shock, need for supplemental oxygen, need for non-invasive ventilation, need for mechanical ventilation, and development of thrombosis. Obesity and multiple medical comorbidities were associated with hospitalization in the setting of COVID-19. Treated patients demonstrated rapid declines of C-reactive protein (CRP), ferritin and D-dimer with gradual improvement in hemoglobin, platelet counts, and clinical status. Only 2 of 45 (4.4%) treated patients required mechanical ventilation after initiating treatment, and there were six deaths (13.3%). Only 2 of 45 (4.4%) treated patients required mechanical ventilation after initiating treatment. There were six deaths (13.3%) and these were associated with lower BMI. These findings support the utility of immunosuppression via JAK inhibition in moderate to severe COVID-19 pneumonia. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s42399-022-01121-4.

Efficacy of Combination Therapy With The JAK Inhibitor Baricitinib In The Treatment of COVID-19.

BACKGROUND: Coronavirus disease-19 (COVID-19), resulting from infection with SARS-CoV-2, spans a wide spectrum of illness. In severely ill patients, highly elevated serum levels of certain cytokines and considerable cytolytic T cell infiltrates in the lungs have been observed. These same patients may bear low to negligible viral burdens suggesting that an overactive immune response, often termed cytokine storm, contributes to the severity of COVID-19. We report the safety and efficacy of baricitinib combined with remdesivir and dexamethasone in 45 hospitalized patients with COVID-19 pneumonia at a tertiary academic medical center. METHODS: Retrospective review of 45 patients hospitalized with COVID-19 pneumonia. Patients received 7-day course of baricitinib, 5-day course of remdesivir and 10-day course of dexamethasone. Clinical status and biomarkers were obtained daily. Outcomes assessed include mortality, duration of hospitalization, presence of shock, need for supplemental oxygen, need for non-invasive ventilation, need for mechanical ventilation and development of thrombosis. RESULTS: Obesity and multiple medical comorbidities were associated with hospitalization in the setting of COVID-19. Treated patients demonstrated rapid declines of C-reactive protein (CRP), ferritin and D-dimer with gradual improvement in hemoglobin, platelet counts and clinical status. Only 2 of 45 (4.4%) treated patients required mechanical ventilation after initiating treatment and there were six deaths (13.3%).Only 2 of 45 (4.4%) treated patients required mechanical ventilation after initiating treatment. There were six deaths (13.3%) and these were associated with lower BMI. CONCLUSIONS: These findings support the utility of immunosuppression via JAK inhibition in moderate to severe COVID-19 pneumonia.

Resolution of Osseous Sarcoidosis with Methotrexate.

Though a relatively uncommon manifestation of sarcoidosis, some clinicians are tasked with managing osseous involvement of disease, and the optimal treatment approach in this setting is not well established. Previous studies have shown variable efficacy for osseous sarcoidosis utilizing multiple agents alone or in combination, often using imaging follow-up in conjunction with clinical assessment to evaluate response to treatment. We present a case of widespread skeletal involvement of sarcoidosis without evidence of concurrent pulmonary disease demonstrating marked clinical improvement and near-complete resolution of imaging abnormalities on magnetic resonance imaging (MRI) following the use of methotrexate as the primary pharmacologic agent.

Nurse telephone education for promoting a treat-to-target approach in recently diagnosed rheumatoid arthritis patients: A pilot project.

OBJECTIVE: The aim of the present study was to implement a nurse telephone education programme for patients with recently diagnosed rheumatoid arthritis (RA) that promotes shared decision-making and a treat-to-target approach. METHODS: This was a pilot project of newly diagnosed adult RA patients conducted between November 2015 and December 2016. A rheumatology clinic nurse telephoned patients to offer disease education. A toolkit was mailed to patients. Measures included call attempts, call time, a qualitative description of free-text notes and the proportion of patients who adhered to their next clinic visit. Data were analysed descriptively and qualitatively. RESULTS: Twenty-six patients participated in the nurse calls. Most patients were female (65%), with a median age of 54 years (range 22-78 years). Median call length was 14.5 min, with a range of 8-23 min. Qualitative notes indicated that patients overwhelmingly supported the nurse calls. Nineteen patients (73%) were adherent to their follow-up visit. CONCLUSION: This preliminary project successfully implemented an educational programme that included a nurse-facilitated, RA-specific, telephone call and toolkit. This educational programme could be a model for similar educational efforts by other clinics.

Order From Chaos: An Initiative to Improve Opioid Prescribing in Rheumatology Using Lean A3.

OBJECTIVE: Use an established quality improvement method, Lean A3, to improve the process of opioid prescribing in an academic rheumatology ambulatory clinic. METHODS: This retrospective pre-postintervention analysis of rheumatology records included patients prescribed opioids at least once during the study period. Lean A3 was used to develop a Controlled Substance Visit Protocol to standardize eight recommended elements of the opioid prescribing workflow. Analyses included changes in the recommended workflow elements and changes in opioid prescribing volume. RESULTS: Improvements were observed in seven of the eight recommended elements. Patient education, including treatment agreements and consent forms (39% completion for both preimplementation) increased to 78% and 80%, respectively (P < 0.001 for both). Risk assessment, as measured by the Current Opioid Misuse Measure, increased from 0.5% to 76% (P < 0.001). Best practices in prescribing, including prescribing in multiples of seven to avoid weekend refill requests, increased from 1% to 79% (P < 0.001). Monitoring parameters, including standardized functional assessment (0% vs. 86%), prescription drug monitoring program queries (49% vs. 84%), and urine testing (1% vs. 32%) all increased (P < 0.001). Visits scheduled at least quarterly for patients on chronic opioids did not change (P = 0.18). Overall, the number of patients prescribed opioids (185 vs. 160; P < 0.001) and annual prescription opioid morphine milligram equivalents (MMEs) (1 933 585 MME vs. 1 386 368 MME; P < 0.001) decreased. CONCLUSION: The Lean A3 method is a successful quality improvement tool for improving and sustaining opioid prescribing within a single academic rheumatology clinic. This method has potential applicability to similar clinics interested in improving opioid prescribing.

Subspecialty choice: why did you become a rheumatologist?

OBJECTIVE: To determine the reasons trainees choose rheumatology as a subspecialty and to review the literature on career choices among physicians, particularly regarding the choice of subspecialty. METHODS: A questionnaire was designed to identify and analyze factors that influence rheumatology fellows to join the field of rheumatology. The questionnaire was administered online and answers were collated through the American College of Rheumatology Training and Workforce Committee, Subcommittee on Medical Student and Resident Recruitment. We reviewed the medical literature, using Medline and PubMed to find references to career choice among medical trainees. RESULTS: The majority of rheumatology fellows had their initial exposure to rheumatology as second-year and third-year medical students, and >75% solidified their decision during internship and residency. Clinical rotations in rheumatology and exposure to role models and mentors were the most influential factors. Approximately 40% of rheumatology fellows cite their intellectual interest in the field as the most important contributor to their decision. CONCLUSION: Career decision-making occurs throughout medical training. Exposure to clinical experiences and mentors are particularly influential and may have an impact during medical school, as well as during internal medicine residency training. These findings suggest that there are a variety of opportunities throughout medical training to influence career decision-making and improve recruitment into rheumatology. Additional financial resources that support recruitment efforts may be required, and followup studies assessing the effects of these efforts should be done.