Global Perspective on the Impact of the COVID-19 Pandemic on Rheumatology and Health Equity.

Although the public health emergency associated with the COVID-19 pandemic has ended, challenges remain, especially for individuals with rheumatic diseases. We aimed to assess the historical and ongoing effects of COVID-19 on individuals with rheumatic diseases and rheumatology practices globally, with specific attention to vulnerable communities and lessons learned. We reviewed literature from several countries and regions, including Africa, Australia and New Zealand, China, Europe, Latin America, and the US. In this review, we summarize literature that not only examines the impact of the pandemic on individuals with rheumatic diseases, but also research that reports the lasting changes to rheumatology patient care and practice, and health service use. Across countries, challenges faced by individuals with rheumatic diseases during the pandemic included disruptions in health care and medication supply shortages. These challenges were associated with worse disease and mental health outcomes in some studies, particularly among those who had social vulnerabilities defined by socioeconomic, race, or rurality. Moreover, rheumatology practice was impacted in all regions, with the uptake of telemedicine and changes in health care utilization. While many regions developed rapid guidelines to disseminate scientific information, misinformation and disinformation remained widespread. Finally, vaccine uptake among individuals with rheumatic diseases has been uneven across the world. As the acute phase of the pandemic wanes, ongoing efforts are needed to improve health care access, stabilize rheumatology drug supplies, improve public health communication, and implement evidence-based vaccination practices to reduce COVID-19 morbidity and mortality among individuals with rheumatic diseases.

Self-care and healthcare seeking practices among patients with hypertension and diabetes in rural Uganda.

BACKGROUND: Implementing effective self-care practices for non-communicable diseases (NCD) prevents complications and morbidity. However, scanty evidence exists among patients in rural sub-Saharan Africa (SSA). We sought to describe and compare existing self-care practices among patients with hypertension (HTN) and diabetes (DM) in rural Uganda. METHODS: Between April and August 2019, we executed a cross-sectional investigation involving 385 adult patients diagnosed with HTN and/or DM. These participants were systematically randomly selected from three outpatient NCD clinics in the Nakaseke district. Data collection was facilitated using a structured survey that inquired about participants' healthcare-seeking patterns, access to self-care services, education on self-care, medication compliance, and overall health-related quality of life. We utilized Chi-square tests and logistic regression analyses to discern disparities in self-care practices, education, and healthcare-seeking actions based on the patient's conditions. RESULTS: Of the 385 participants, 39.2% had only DM, 36.9% had only HTN, and 23.9% had both conditions (HTN/DM). Participants with DM or both conditions reported more clinic visits in the past year than those with only HTN (P = 0.005). Similarly, most DM-only and HTN/DM participants monitored their weight monthly, unlike those with only HTN (P<0.0001). Participants with DM or HTN/DM were more frequently educated about their health condition(s), dietary habits, and weight management than those with only HTN. Specifically, education about their conditions yielded adjusted odds ratios (aOR) of 5.57 for DM-only and 4.12 for HTN/DM. Similarly, for diet, aORs were 2.77 (DM-only) and 4.21 (HTN/DM), and for weight management, aORs were 3.62 (DM-only) and 4.02 (HTN/DM). Medication adherence was notably higher in DM-only participants (aOR = 2.19). Challenges in self-care were significantly more reported by women (aOR = 2.07) and those above 65 years (aOR = 5.91), regardless of their specific condition(s). CONCLUSION: Compared to rural Ugandans with HTN-only, participants with DM had greater utilization of healthcare services, exposure to self-care education, and adherence to medicine and self-monitoring behaviors. These findings should inform ongoing efforts to improve and integrate NCD service delivery in rural SSA.

Assessment of regional body composition, physical function and sarcopenia among peruvian women aging with HIV: A cross-sectional study.

Management of chronic conditions and optimization of overall health has become a primary global health concern in the care of people living with HIV in the era of highly active antiretroviral therapy (ART), particularly in lower-and-middle income countries where infrastructure for chronic disease management may be fragmented. Alterations in body composition can reflect important changes in musculoskeletal health, particularly among populations at risk for developing fat and muscle redistribution syndromes, such as women with HIV on ART. Given the lack of data on this topic in Latin America and the Caribbean, we designed an exploratory study to measure these outcomes in a population of women aging with HIV in Peru. We conducted a cross-sectional study among Peruvian women with and without HIV aged ≥40 years. Dual X-ray absorptiometry was used to measure trunk and limb lean mass (LM) and fat mass (FM). Physical performance was assessed with the Short Physical Performance Battery (SPPB) and physical strength with a dynamometer. Sarcopenia was assessed based upon EWGSOP criteria. We used linear regression to model associations between body composition, sarcopenia and physical performance scores. 104 women with HIV and 212 women without HIV were enrolled (mean age 52.4±8.2 vs. 56.4±8.8 years, p≤0.001). Among women with HIV, mean years since diagnosis was 11.8±6 and all were on ART. Mean SPPB score was 9.9 vs 10.8 (p<0.001) between both groups. Sarcopenia spectrum was found in 25.9% and 23.1%, respectively. In the multivariable regression analysis, trunk FM and older age were negatively correlated with physical performance among women with HIV. Severe sarcopenia was found among a greater proportion of those with HIV (3.8% vs. 0.9%, p = 0.84), however this finding was not statistically significant. Women with HIV had significantly lower SPPB scores compared to women without HIV, and trunk FM and upper limb LM were independent predictors for the SPPB and Grip Strength tests, respectively. Larger, prospective studies are needed in Latin America & the Caribbean to identify individuals at high risk for sarcopenia and declines in physical function, and to inform prevention guidelines.

Performance of a modified fracture risk assessment tool for fragility fracture prediction among older veterans living with HIV.

OBJECTIVE: Fragility fractures (fractures) are a critical outcome for persons aging with HIV (PAH). Research suggests that the fracture risk assessment tool (FRAX) only modestly estimates fracture risk among PAH. We provide an updated evaluation of how well a 'modified FRAX' identifies PAH at risk for fractures in a contemporary HIV cohort. DESIGN: Cohort study. METHODS: We used data from the Veterans Aging Cohort Study to evaluate veterans living with HIV, aged 50+ years, for the occurrence of fractures from 1 January 2010 through 31 December 2019. Data from 2009 were used to evaluate the eight FRAX predictors available to us: age, sex, BMI, history of previous fracture, glucocorticoid use, rheumatoid arthritis, alcohol use, and smoking status. These predictor values were then used to estimate participant risk for each of two types of fractures (major osteoporotic and hip) over the subsequent 10 years in strata defined by race/ethnicity using multivariable logistic regression. RESULTS: Discrimination for major osteoporotic fracture was modest [Blacks: area under the curve (AUC) 0.62; 95% confidence interval (CI) 0.62, 0.63; Whites: AUC 0.61; 95% CI 0.60, 0.61; Hispanic: AUC 0.63; 95% CI 0.62, 0.65]. For hip fractures, discrimination was modest to good (Blacks: AUC 0.70; 95% CI 0.69, 0.71; Whites: AUC 0.68; 95% CI 0.67, 0.69]. Calibration was good in all models across all racial/ethnic groups. CONCLUSION: Our 'modified FRAX' exhibited modest discrimination for predicting major osteoporotic fracture and slightly better discrimination for hip fracture. Future studies should explore whether augmentation of this subset of FRAX predictors results in enhanced prediction of fractures among PAH.

A Broader View of Risk to Health Care Workers: Perspectives on Supporting Vulnerable Health Care Professional Households During COVID-19.

The COVID-19 pandemic has highlighted both that frontline workers face a new set of personal hazards in health care settings and that there are not well-established recommendations to address the broader risks to these workers and their families. Particularly vulnerable households include dual health care professional households, single-parent health care professional households, and households with health care professionals responsible for a high-risk family member (i.e., an older adult or immunocompromised person). While the demographics of these households are heterogeneous, it is expected that the professional and personal concerns specific to COVID-19 will be similar. These concerns include family safety, balancing full-time work with home-based schooling for children, the looming threat of illness to 1 or both partners, the potential of infecting high-risk family members, and the challenges of planning for the future during uncertain times. To elucidate these concerns in their department, the authors sought input from colleagues in dual health care professional households through an open-ended email communication. Respondents expressed a range of concerns centered on balancing professional and family responsibilities during the COVID-19 pandemic. In this commentary, the authors propose several recommendations in the areas of support networks, leadership and culture, and operations and logistics that health care institutions can adopt to minimize the burden on these vulnerable households during states of emergency. The successful implementation of these recommendations hinges on creating a work environment in which all health care providers feel comfortable voicing their concerns.

Comparative Assessment of Different Health Utility Measures in Systemic Lupus Erythematosus.

In a time of increasing economic constraints, it is crucial that health systems optimize their resource use to ensure that they generate the maximum possible health gain. Therefore, it is necessary for health interventions to be evaluated and compared across therapeutic boundaries. Undertaking such an evaluation a generic utility-based measure is required. But it remains uncertain whether the utility values obtained by direct or indirect methods are comparable and which approach is the most appropriate in Systemic Lupus Erythematosus (SLE) population. In the study, we compared the utility values obtained by an indirect method (EQ-5D) with direct utility instruments, the standard gamble (SG) and visual analog scale (VAS), in SLE patients. The correlations between VAS, EQ-5D and LupusQoL were significant; relative good intraclass correlations or kappa coefficients indicated the reliability of these instruments. A model incorporating the SLEDAI scores and LupusQoL domains of emotional health and pain was a good predictor of VAS. SLEDAI score was a good predictor in the SG regression model. These findings suggested that the VAS and EQ-5D might be valid and reliable measures to assess health related quality of life in SLE patients and represent promising outcome measures for future research in this population.

Needs and priorities in women's health training: perspectives from an internal medicine residency program.

BACKGROUND: Few studies have examined residents' perspectives on the adequacy of women's health (WH) training in internal medicine (IM). This study sought residents' opinions regarding comfort level managing 13 core WH topics, their perceived adequacy of training in these areas, and the frequency with which they managed each topic. The association between reported comfort level and perceived adequacy of training and management frequency was also assessed. METHODS: A 67-item questionnaire was administered from April to June 2009 to 100 (64%) of the 156 residents from the traditional, primary care, and IM-pediatrics residency programs at a single institution. Descriptive and correlation statistics were used to examine the relationships between self-reported comfort level, perceived adequacy of training opportunities, and frequency managing WH issues. Data was stratified by sex, IM program, and post-graduate year (PGY). RESULTS: The majority of residents reported low comfort levels managing 7 of 13 topics. Over half of residents perceived limited training opportunities for 11 of 13 topics. With the exception of cardiovascular disease in women, greater than 75% of residents reported managing the 13 topics five or more times in the prior 6 months. Correlation analysis suggested a linear relationship between low comfort levels and limited training opportunities, and between low comfort levels and low frequency managing WH topics (r=0.97 and r=0.89, respectively). Stratified analyses by sex, IM program, and PGY showed no significant differences. CONCLUSIONS: Key gaps remain in WH training. Our results emphasize the importance of reinforcing WH training with hands-on management opportunities. Understanding institution-specific strengths and weaknesses may help guide the development of targeted initiatives.