2015 American College of Rheumatology Workforce Study: Supply and Demand Projections of Adult Rheumatology Workforce, 2015-2030.

OBJECTIVE: To describe the character and composition of the 2015 US adult rheumatology workforce, evaluate workforce trends, and project supply and demand for clinical rheumatology care for 2015-2030. METHODS: The 2015 Workforce Study of Rheumatology Specialists in the US used primary and secondary data sources to estimate the baseline adult rheumatology workforce and determine demographic and geographic factors relevant to workforce modeling. Supply and demand was projected through 2030, utilizing data-driven estimations regarding the proportion and clinical full-time equivalent (FTE) of academic versus nonacademic practitioners. RESULTS: The 2015 adult workforce (physicians, nurse practitioners, and physician assistants) was estimated to be 6,013 providers (5,415 clinical FTE). At baseline, the estimated demand exceeded the supply of clinical FTE by 700 (12.9%). By 2030, the supply of rheumatology clinical providers is projected to fall to 4,882 providers, or 4,051 clinical FTE (a 25.2% decrease in supply from 2015 baseline levels). Demand in 2030 is projected to exceed supply by 4,133 clinical FTE (102%). CONCLUSION: The adult rheumatology workforce projections reflect a major demographic and geographic shift that will significantly impact the supply of the future workforce by 2030. These shifts include baby-boomer retirements, a millennial predominance, and an increase of female and part-time providers, in parallel with an increased demand for adult rheumatology care due to the growing and aging US population. Regional and innovative strategies will be necessary to manage access to care and reduce barriers to care for rheumatology patients.

Valoración previa a la inmunosupresión farmacológica en Reumatología / (Pre-assessment of pharmacological immunosuppression in Rheumatology)

ResumenEn los últimos 15 años se han desarrollado terapias y esquemas terapéuticos para inducir la remisión a la gran mayoría de enfermedades reumatológicas. La mejoría clínica lograda se consigue a expensas de una inmunosupresión más agresiva y específica, lo que conlleva un aumento en el riesgo de infecciones. La principal causa de muerte de las enfermedades autoinmunes, en los primeros 5 años de evolución, es la infección secundaria a la inmunosupresión. El objetivo del presente trabajo fue elaborar un documento de consenso con el afán de reducir este riesgo, basado en la mejor evidencia médica disponible, utilizando los recursos disponibles en el hospital para disminuir la morbimortalidad de los pacientes que reciben estas terapias. Contar con un documento de consenso permitirá minimizar los efectos secundarios y mejorar la acción terapéutica, con mayores oportunidades de remisión y una más adecuada utilización del recurso institucional.

AbstractIn the last 15 years therapies and therapeutic schemes have been developed to induce remission to the vast majority of rheumatologic diseases. The clinical improvement achieved is at the cost of a more aggressive and specific immunosuppression, which leads to an increase in the risk of infections. The main cause of death of autoimmune diseases in the first 5 years of evolution is infection secondary to immunosuppression. The objective of the present study was to develop a consensus document with the aim of reducing this risk of infection, based on the best available medical evidence, using the resources available in our hospital to reduce the morbidity and mortality of patients receiving these therapies. Having a consensus document will allow us to minimize side effects and improve therapeutic action with greater opportunities for referral and better utilization of institutional resources.

Ten years of METEOR (an international rheumatoid arthritis registry): development, research opportunities and future perspectives.

OBJECTIVES: Ten years ago, the METEOR tool was developed to simulate treatment-to-target and create an international research database. The development of the METEOR tool and database, research opportunities and future perspectives are described. METHODS: The METEOR tool is a free, online, internationally available tool in which daily practice visits of all rheumatoid arthritis patients visiting a rheumatologist can be registered. In the tool, disease characteristics, patient- and physician-reported outcomes and prescribed treatment could be entered. These can be subsequently displayed in powerful graphics, facilitating treatment decisions and patient-physician interactions. An upload facility is also available, by which data from local electronic health record systems or registries can be integrated into the METEOR database. This is currently being actively used in, among other countries, the Netherlands, Portugal and India. RESULTS: Since an increasing number of hospitals use electronic health record systems, the upload facility is being actively used by an increasing number of sites, enabling them to benefit from the benchmark and research opportunities of METEOR. Enabling a connection between local registries and METEOR is a well established but time-consuming process for which an IT-specialist of METEOR and the local registry are necessary. However, once this process has been finished, data can be uploaded regularly and relatively easily according to a pre-specified format. The METEOR database currently contains data from >39,000 patients and >200,000 visits, from 32 different countries and is ever increasing. Continuous efforts are being undertaken to increase the quality of data in the database. CONCLUSIONS: Since METEOR was founded 10 years ago, many rheumatologists worldwide have used the METEOR tool to follow-up their patients and improve the quality of care they provide to their patients. Combined with uploaded data, this has led to an extensive growth of the database. It now offers a unique opportunity to study daily practice care and to perform research regarding cross-country differences in a large, worldwide setting, which could provide important knowledge about disease and its treatment in different geographic and clinical settings.

Juvenile dermatomyositis at a tertiary care hospital: is there any change in the last decade?

INTRODUCTION: Juvenile dermatomyositis (JDM) is a rare multisystem disorder of childhood primarily involving the skeletal muscles and skin. PATIENTS AND METHODS: The case records of patients with JDM seen at our centre in the last 10 years were reviewed and data on clinical presentation, management, outcome and complications were retrieved. RESULTS: Eighteen patients (nine boys) were diagnosed as JDM with median age at presentation of 12.5 years, duration of illness of 9.25 months and follow-up duration of 24 months. At presentation, rash was seen in all patients, 17 had muscle weakness, fever in 11 and arthritis in six. Gottron's lesions and heliotrope rash were seen in 14 and 11 patients, respectively. Calcinosis was seen in five patients and lipoatrophy in two patients. Four patients had dysphagia, one each had dilated cardiomyopathy and respiratory failure. Electromyograph was abnormal in 15 patients and antinuclear antibodies were positive in nine patients. Prednisolone and methotrexate were used in 17 patients. Other disease-modifying anti-rheumatic drugs used were hydroxychloroquine, azathioprine, cyclophosphamide and cyclosporine. Sixteen patients achieved remission. Five patients had pyogenic infections and one patient died of this. In addition two patients had tuberculosis. CONCLUSION: Compared to our experience in the previous decade we saw more girls, used methotrexate upfront but the median duration of illness and prevalence of calcinosis (30%) was the same, suggesting that we need to improve awareness about JDM among paediatricians for early referral.

Subsequent entry biologics/biosimilars: a viewpoint from Canada.

We have reviewed the issues surrounding the advent of biosimilars in the rheumatoid arthritis biologic field. Our proposals emphasize the need to focus primarily on patient safety and to assess the outcomes of therapy both in the short and longer term.

[Special features of physical therapy for elderly rheumatic patients]. / Besonderheiten der physikalischen Therapie beim älteren Rheumatiker.

The demographic shift is leading to a rapid rise in the number of elderly citizens. Accordingly, the number of geriatric problems is also increasing within the population of rheumatic patients. Geriatric patients are characterized through the triad of high age, multimorbidity and functional deficits. Almost all will show signs of arthritis and other degenerative musculoskeletal illnesses. Inflammatory rheumatic diseases within the geriatric population are found to be mostly in the chronic stage or with defective conditions. Problems typical of this population, such as comorbidities especially in the cardiovascular sector, must be assessed prior to the application of therapeutic concepts. The focus is on activating therapies, such as physiotherapy and occupational therapy, where the functional usefulness is proven. The use of thermal therapy, especially applied in the form of heat, as well as electrotherapy and high frequency therapy are also useful when indicated. Balneotherapy and hydrotherapy, as well as massage therapy and lymphatic drainage, must be adapted to the cardiovascular function of geriatric patients; this applies especially to heart failure patients. Physical therapy concepts in elderly rheumatic patients should preferably be implemented and managed by a multidisciplinary geriatric team.

Care partnerships between family physicians and rheumatologists.

OBJECTIVE: To describe care partnerships between family physicians and rheumatologists. METHODS: A random sample (20%, n = 478) of family physicians was mailed a questionnaire, asking if there was at least 1 particular rheumatologist to whom the physician tended to refer patients. If the answer was affirmative, the physician would be considered as having a "care partnership" with that rheumatologist. The family physician then rated, on a 5-point scale, factors of importance regarding the relationship with that rheumatologist. RESULTS: The questionnaire was completed by 84/462 (18.2%) of family physicians; 52/84 (61.9%) reported having rheumatology care partnerships according to our definition. Regarding interactions with rheumatologists, most respondents rated the following as important (score ≥ 4): adequate communication and information exchange (44/50, 88.0%); waiting time for new patients (40/50, 80.0%); clear and appropriate balance of responsibilities (39/49, 79.6%); and patient feedback and preferences (34/50, 68%). Male family physicians were more likely than females to accord high importance to personal knowledge of the rheumatologist, and to physical proximity of the rheumatologist's practice. Regarding relationships with rheumatologists, 30/50 (60.0%) of respondents felt communication and information exchange were adequate, and 35/50 (70.0%) felt they had a clear balance of responsibilities. CONCLUSION: Almost two-thirds of family physicians have rheumatology care partnerships, according to our definition. In this partnership, establishing adequate communication and shorter waiting time seem of paramount importance to family physicians. A balanced sharing of responsibilities and patients' preferences are also valued. Although many physicians reported adequate communication and clear and appropriate balance of responsibilities in their current interactions with rheumatologists, there appears to be room for improvement.

A glimpse into the future: recombinant proteins and small molecules for targeted therapies in rheumatic diseases.

Whether the differences in the clinical picture and in the pathogenesis between rheumatoid arthritis (RA) and ankylosing spondylitis (AS) will lead to different therapeutic approaches is unclear at present. Since anti-TNF-alpha agents and other biologics are not efficacious in all patients new developments are clearly needed.

[Anti-inflammatory and analgesic electrotherapy. Evidence in rheumatology?]. / Antiinflammatorische und analgetische Stromformen: Evidenz in der Rheumatologie?

The objective of this article is an assessment of the evidence on antiinflammatory and analgesic current in rheumatology. Three trials on the effects of TENS (transcutaneous electrical nerve stimulation) with RA-patients (rheumatoid arthritis) showed good analgesic effect, while one study on EMS (electrical muscle stimulation) demonstrated a benefit in muscle strength and function. No anti-inflammatory effect could be verified. The overall validity is limited due to the small number of studies and the methodical quality of the analyzed trials.

Developments in lupus 2006.

Published reports in 2006 on systemic lupus erythematosus are reviewed with regard to preclinical and clinical studies on disturbances of the immune system including co-stimulation, cytokines and recent insights into new therapeutic approaches. Increasing knowledge of components of the innate immune system, such as certain receptors (Toll-like receptors, Fc receptors and complement receptors) and cytokines as well as immune cells (dendritic cells, plasmacytoid cells and neutrophils) supports their immunopathogenic relevance and enhance our understanding of the pathogenic complexity of lupus. Although it remains to be shown which of those could be targets for therapy or biomarkers, lymphocyte-directed therapy is currently under promising clinical investigation.

Biologic therapies in rheumatology: lessons learned, future directions.

During the past decade biologic therapies such as monoclonal antibodies and fusion proteins have revolutionized the management of rheumatic disease. By targeting key cytokines and immune cells biologics have provided more specific therapeutic interventions with less immunosuppression. Clinical use, however, has revealed that their theoretical simplicity hides a more complex reality. Efficacy, toxicity and even pharmacodynamic effects can deviate from those predicted, as poignantly illustrated by the catastrophic effects witnessed during the first-into-human administration of TGN1412. This review summarizes lessons gleaned from practical experience and discusses how these can inform future discovery and development of new biologic therapies for rheumatology.

Team care. Traditions and new trends.

Major changes have occurred in the care of patients with rheumatic diseases over the past decades. Most of these changes have focused on new pharmacological and surgical procedures and methods. However, for different reasons, few of these methods are available to many patients around the world, and thus other forms of care are still needed. For optimal benefit to patients, all aspects of care should be organized and coordinated through team care. This leads to new trends in team care development and research, based on well established traditions and accumulated knowledge.