Coalition for Health and Gender Equity (CHANGE)-a protocol for a global cross-sectional survey of health and gender equity in rheumatology.

Objectives: The primary aim of the CHANGE survey is to determine the current state of gender equity within rheumatology, and secondarily, to review the physician perspective on bullying, harassment and equipoise of opportunities within rheumatology. Methods: The CHANGE e-survey is a cross-sectional self-reported questionnaire adapted from EULAR's gender equity in academic rheumatology task force. The survey was launched in January 2023; it is available in six languages and distributed widely via rheumatology organizations and social media. Eligible participants include rheumatologist physicians and rheumatology health-care professionals. Survey responses will undergo descriptive analysis and inter-group comparison aiming to explore gender-based discrimination using logistic regression, with subgroup analyses for country/continent variations. Conclusion: This e-survey represents a comprehensive global initiative led by an international consortium, aimed at exploring and investigating the gender-related disparities and obstacles encountered by rheumatologists and rheumatology health-care professionals across diverse communities and health-care environments. By pursuing this initiative, we aim to take the broader rheumatology community a step closer to understanding the underlying origins of inequities and their determinants. Such insights are pivotal in identifying viable interventions and strategies to foster gender equity within the field. Ultimately, our collective objective is to ensure equitable access to opportunities for every individual, irrespective of gender, thereby promoting inclusivity and fairness across the entire spectrum of professional practice and career development.

Gender equity in rheumatology leadership in the Asia-Pacific.

Objectives: This study aimed to explore gender equity in rheumatology leadership in the Asia-Pacific region as represented by the member national organizations (MNOs) of the Asia-Pacific League of Associations for Rheumatology (APLAR). Methods: We conducted a retrospective cross-sectional review of gender representation among the presidents of MNOs of APLAR in April 2022. We used the official website of each organization to acquire names and terms in the office of current and past presidents of each organization. The binary gender of each president was estimated using the name-to-gender inference platform Gender API (https://gender-api.com/). Proportions of male and female presidents were estimated for each organization. Data were compared for presidencies commencing before and in/after the year 2000. Results: We found a significant gap in gender parity, with most presidents in the region being men (210 of 252, 83%). More than one-third (7 of 19, 36.8%) of the MNOs had all male presidents, although the proportion of women improved from 7 to 25% in/after 2000 (P = 0.0002). A statistically significant increase in female representation was observed in Australia (P = 0.0268, from 7 to 39%) and New Zealand (P = 0.0011, where the proportion of female presidents increased from 0 to 45%), but not in other countries. Conclusion: A significant gap in gender parity exists in rheumatology leadership in the MNOs of APLAR. Trends suggest improvement over the last two decades, although statistically significant improvement is limited to a small number of countries.

Combination of methotrexate and sulfasalazine is an efficacious option for axial spondyloarthritis in a resource-limited, real-world clinical setting: a prospective cohort study.

OBJECTIVE: Evaluation of response to combination conventional synthetic DMARD (csDMARD) therapy with methotrexate (MTX) and sulfasalazine (SSZ) in active axial spondyloarthritis (axSpA) patients without peripheral arthritis (group 1) as compared to active axSpA with peripheral arthritis (group 2), who are economically constrained for biologicals. METHODS: A prospective, observational, single-centre, cohort study on 150 consecutive active axSpA patients who were already initiated on the above mentioned combination csDMARD therapy and satisfying the other pre-defined eligibility criteria, was conducted between July 2016 and July 2017 using ASAS20 response as primary outcome measure at 3 and 6 months post treatment. RESULTS: ASAS20 response at 3 months was achieved in 31/58 (53.4%) and in 24/36 (66.6%) in groups 1 and 2, respectively (p = 0.2); at 6 months, these figures were 45/76 (59.2%) and 28/44 (63.6%), respectively (p = 0.6). Similarly, there was significant reduction in mean ASAS NSAID index from 29.6 to 14 over 6 months from baseline (p = 0.001), and it was similar in both groups. Using BASDAI ≥ 4 to define active disease, a 34% reduction in requirement of biologicals was also observed. CONCLUSION: In resource-limited population, treatment with combination of methotrexate and sulphasalazine over a period of 6 months is equally efficacious in patients with active axSpA with and without peripheral arthritis, as evidenced by improved ASAS20 response rates, reduction in NSAID use and fewer patients switching to biologicals. Key Points • Combination of MTX+SSZ was efficacious and safe in active axSpA patients who had economic hardships to use biologicals. • This benefit in axSpA patients was similar between those without any peripheral arthritis and those with. • MTX+SSZ combination therapy also demonstrated NSAID sparing action. • Combination of MTX and SSZ prevented escalation to biological therapy as per a BASDAI score driven policy.

Comparison of safety, efficacy and cost between oral pulse cyclophosphamide versus intravenous cyclophosphamide pulse therapy in severe systemic lupus erythematosus.

OBJECTIVES: The aim of this study is to compare efficacy, toxicity and cost between oral and intravenous cyclophosphamide (CYC) pulse therapy in inducing remission (Systemic Lupus Erythematosus Disease Activity Index [SLEDAI] <3) in severe SLE. METHODS: We retrospectively checked the hospital records of patients between the years 2000 and 2018, who had been administered oral cyclophosphamide pulse and intravenous (IV) cyclophosphamide pulse. SLEDAI at baseline and after 6 months of therapy were noted. The statistical analysis was done using Mann-Whitney U test. The cost was also calculated. RESULTS: We included 45 patients in this study, 21 in the oral pulse group and 24 in the IV group. The median age of patients in the oral and IV groups were 29 (interquartile range [IQR] 22-37) and 26 (IQR 19.25-0.75) years respectively. Median SLEDAI at baseline was comparable between the 2 groups (oral 18.0 [IQR 15.0-26.0]; IV 14.5 [IQR 11.0-20.0] P = .151). At the end of 6 months of treatment, it was 0.0 (IQR 0.0-4.0) in the oral group, as against 2.0 (IQR 0.0-5.5) in IV group (P = .676). There was no major adverse event in either group. Oral cyclophosphamide pulse therapy was more economical as compared to IV cyclophosphamide [630 Indian National rupees( INR)/ 8.85 US dollars(USD) in the IV arm and 50 INR/0.7 USD in the oral arm] (P < .001). CONCLUSION: This study concludes that oral cyclophosphamide pulse therapy is an economical option and there was no difference in efficacy and safety between oral cyclophosphamide pulse therapy and IV pulse cyclophosphamide therapy.

Progress towards universal health coverage in the context of rheumatic diseases in India.

AIM: This study aims to measure current situation with regard to access and financial protection towards healthcare for rheumatic diseases (RDs) in India. METHOD: The first part of this study is quantitative, and uses the data generated by the 71st Round of National Sample Survey 2014, which measured self-reported morbidity, choice of provider and utilization of services and out of pocket expenditure (OOPE) incurred on healthcare services in a sample of 65 932 households and 333 104 individuals from all across India. The second qualitative part of the study was done in one sample district to understand the barriers to access and financial protection. RESULTS: 3.5% of all hospitalizations in the preceding one year and 9.9% of all ambulatory care in the preceding 15 days of this study period were due to RDs. Cost of care for RDs was three times higher in private sector. Cost on medicines comprised the largest share in both sectors. 54% of the households faced catastrophic health expenditure at 10% threshold (CHE-10) and this was nine times higher in private provisioning (OR: 8.8, CI: 6.8-11.4). 24% of the households had to borrow or sell household assets to meet the hospitalization expenditure. Insurance had marginal impact and it did not help in preventing household from facing CHE-10 for the lowermost three economic quintiles. There was significant unmet health care needs and lack of continuity of care of RDs in India. CONCLUSION: Addressing the gaps in access and financial protection for patients with RDs need greater emphasis in policy as well as implementation, if the country has to achieve Universal Health Coverage.

Correlating MRI with clinical evaluation in the assessment of disease activity of Takayasu's arteritis.

OBJECTIVES: To correlate magnetic resonance imaging (MRI) assessment of disease activity in patients with Takayasu's arteritis with the Indian Takayasu's activity score (ITAS). DESIGN, MATERIALS AND METHODS: We prospectively assessed 20 patients with Takayasu's arteritis from November 2010 to September 2011. RESULTS: We found a statistically significant association between MRI assessment of disease activity and ITAS with a P-value of 0.01. The MRI features suggesting active disease included wall thickening and enhancement. We also analyzed the association between MRI and clinical assessment which was also statistically significant at P = 0.037. CONCLUSION: Our study suggests that there is an association between MRI assessment of disease activity and the ITAS. MRI evaluation of disease activity of Takayasu's arteritis therefore goes hand in hand with ITAS 2010, ITAS - A, erythrocyte sedimentation rate and C-reactive protein. However this needs further investigation from future studies using serial assessments.

TNFα blockers followed by continuation of sulfasalazine and methotrexate combination: a retrospective study on cost saving options of treatment in Spondyloarthritis.

High cost deters continuous use of tumor necrosis factor α blockers (TNFi) in developing countries. The objective of this study was to evaluate outcome and expenditure incurred in Spondyloarthritis (SpA) patients beyond a year of follow-up after receiving four doses of infliximab (IFX) over and above background therapy of methotrexate (MTX) and sulfasalazine (SSZ) combination. Electronic medical records were screened for patients with SpA satisfying the Assessment of Spondyloarthritis International Society (ASAS) criteria between 2008 and 2014. Patients who completed at least 1 year of follow-up after receiving four doses of IFX (5 mg/kg at 0, 2, 6, and 14 weeks) on a background therapy of MTX (10-25 mg/week) and SSZ (2-3 g/day) combination were enrolled after obtaining an informed consent. Primary outcome assessed was "time to disease flare". Changes in acute phase reactants, patient reported outcomes (BASDAI, BASFI), and cost were also assessed. Forty-five patients were enrolled. Mean (SD) duration of follow up after fourth IFX dose was 28.9 (18.7) months. Disease flare occurred in 33.3% (15/45) after a mean (SD) duration of 14.5 (10.8) months as compared to 4-6 months described in literature on discontinuing TNFi. Reduction in ESR, CRP, BASDAI and BASFI continued to be statistically significant at follow-up as compared to baseline. As compared to continuous IFX therapy, this treatment reduced cost by 57.1% for each patient-month of follow-up. Short course IFX dosing followed by continuation of MTX and SSZ combination can prolong time to disease flare and decrease requirement for additional IFX dose in SpA. This regimen could be a cost saving option for patients with SpA.

Does low bone density influence symptoms and functional status in patients with fibromyalgia? Observations from rural South India.

INTRODUCTION: The presence of more than one musculoskeletal disease has been found to impair quality of life (QoL). The influence of low bone mineral density (BMD) on symptoms and function in those with fibromyalgia syndrome (FMS) is unknown. METHODOLOGY: A cross sectional study was carried out on 158 patients attending camps in rural South India. BMD was determined using quantitative ultrasound of the distal radius. Symptoms and function were assessed using a visual analogue scale (VAS) and the Fibromyalgia Impact Questionnaire (FIQ). RESULTS: Low BMD was seen in 81.6% (129/158) of the persons screened. FMS was seen in 37/158 persons, of which 31/37 (83.7%) had low BMD. CONCLUSION: FMS with low bone density leads to higher levels of pain and a poorer QoL compared to those without FMS. Coexisting musculoskeletal problems could also contribute to this. Therefore, medical practitioners and rehabilitation specialists should consider screening for bone density among those with FMS and should use this information to decide appropriate therapies to reduce pain and improve QoL.