Quality indicators for osteoarthritis pain management in the primary care setting.

BACKGROUND: Development of valid and feasible quality indicators (QIs) is needed to track quality initiatives for osteoarthritis pain management in primary care settings. METHODS: Literature search identified published guidelines that were reviewed for QI extraction. A panel of 14 experts was assembled, including primary care physicians, rheumatologists, orthopedic surgeons, pain specialists, and outcomes research pharmacists. A screening survey excluded QIs that cannot be reliably extracted from the electronic health record or that are irrelevant for osteoarthritis in primary care settings. A validity screening survey used a 9-point Likert scale to rate the validity of each QI based on predefined criteria. During expert panel discussions, stakeholders revised QI wording, added new QIs, and voted to include or exclude each QI. A priority survey used a 9-point Likert scale to prioritize the included QIs. RESULTS: Literature search identified 520 references published from January 2015 to March 2021 and 4 additional guidelines from professional/governmental websites. The study included 41 guidelines. Extraction of 741 recommendations yielded 115 candidate QIs. Feasibility screening excluded 28 QIs. Validity screening and expert panel discussion excluded 73 QIs and added 1 QI. The final set of 15 prioritized QIs focused on pain management safety, education, weight-management, psychological wellbeing, optimizing first-line medications, referral, and imaging. CONCLUSION: This multi-disciplinary expert panel established consensus on QIs for osteoarthritis pain management in primary care settings by combining scientific evidence with expert opinion. The resulting list of 15 prioritized, valid, and feasible QIs can be used to track quality initiatives for osteoarthritis pain management.

Orthopaedic Management of Gout.

Gout is characterized by the deposition of monosodium urate crystals in patients with chronically elevated blood levels of uric acid. It is the most common form of inflammatory arthritis in the United States and is often comorbid with hypertension, obesity, and chronic kidney disease. Initial presentation is usually an acutely warm, swollen joint, most commonly the first metatarsophalangeal joint, but a variety of locations may be affected. The main treatment for gout is medical management of acute inflammation and chronic uric acid levels, but surgical treatment may be indicated in cases of damage to the surrounding soft tissue, concomitant septic arthritis, symptomatic cartilage loss, or neurologic deficits. Based on the literature to date, gout does not seem to independently affect outcomes after total hip, knee, and ankle arthroplasty, but associated comorbidities affecting outcomes in these patients should be considered.

Neuromyelitis Optica Spectrum Disorders (NMOSD) and Connective Tissue Disease (CTD): an Update for the Rheumatologist.

PURPOSE OF REVIEW: To review the pathophysiology, presentation, and treatment of neuromyelitis optica spectrum disorder (NMOSD) and its association with systemic lupus erythematosus (SLE) and Sjogren's syndrome (SS). RECENT FINDINGS: NMOSD is an autoimmune disorder of the central nervous system that primarily targets astrocytes. Although the prevalence is unknown, the coexistence of NMOSD and SLE/SS is well-recognized. Patients with both NMOSD and SLE or SS require may require unique approaches to diagnosis and management. Coexistence of NMOSD and SLE/SS is important for the rheumatologist and neurologist to be able to recognize. For the rheumatologist, NMOSD and its neurologic symptoms represent a distinct disease process from neurologic complications of the patient's underlying connective tissue disease, and it requires distinct acute and chronic management. For the neurologist, the coexistence of SLE and SS can help to establish a diagnosis of NMOSD, or in some situations, the development of neurologic symptoms secondary to NMOSD can lead to the diagnosis of connective tissue disease.

Positive effect of hydroxychloroquine on lipid profiles of patients with rheumatoid arthritis: A Veterans Affair cohort.

OBJECTIVE: Despite remarkable improvements in rheumatoid arthritis (RA) treatment, there is evidence indicating that the mortality gap between patients with RA and the general population is not closing. The increase in mortality rates in patients with RA is predominantly due to cardiovascular disease (CVD). Literature suggests that important links exist between RA inflammation and atherosclerosis in CVD. Dyslipidemia is a well-known risk factor of atherosclerosis. Previous studies have suggested that antimalarials, chloroquine diphosphate, and hydroxychloroquine (HCQ), used in the treatment of autoimmune diseases, have a beneficial effect on the lipid levels. However, the studies had small sample sizes. We analyzed a Veterans Affair RA cohort of 2,925 patients to characterize the effect of 4 months' use of HCQ on the lipid levels. METHODS: Data for this cohort were obtained from the department of Veterans Affairs administrative database. Individuals (age ≥18 years) with a diagnosis of RA (ICD-9 code) at 2 or more outpatient visits from 1999 to 2009 were identified. Only the patients with at least 1 lipid level measured at 120-180 days before staring HCQ were included. Lipids levels on pre- and poststart dates of HCQ (120-180 days) were compared using student's t-test and adjusted for age, sex, race, C-reactive protein (CRP), and statin use with multivariable regression (analysis of variance/analysis of covariance) for the change in different lipid levels. To give equal weightage to covariables, we conducted an analysis of marginal means for race in each lipid level. All analyses were performed using STATA 11. RESULTS: After adjusting for sex, age, race, statin use, and post CRP values >10 mg/dL using a linear regression, the factor driving the change in the different lipid levels was race (p values for total cholesterol, 0.006; low-density lipoprotein, 0.09; non-high-density lipoprotein [HDL], 0.03; atherogenic index, 0.08; and HDL, 0.17). When considering race individually using marginal means analysis, the race in the subgroup "others" was more influential. CONCLUSION: Our results suggest that sex and race influences the HCQ effect on the lipid profiles in patients with RA. Use of HCQ in males is found to be associated with positive changes in the lipid profiles independent from the use of statins. There is a suggestion that whites and African Americans might be less susceptible to HCQ effect on lipid profiles than other races.

Use of Ultrasound in the Diagnosis and Management of the Vasculitides.

PURPOSE OF REVIEW: The aim of this review paper is to evaluate the current data regarding clinical use of ultrasound (US) for diagnosis of systemic vasculitis. RECENT FINDINGS: In recent years, US has emerged as an image modality taking a central role in the diagnosis and monitoring of vasculitides by measuring vessel wall inflammation and changes in vessel wall thickness. US has been recognized as an important tool predominantly in the diagnosis of large vessel vasculitis (LVV). Signs like the "halo sign" in temporal arteries of patients with giant cell arteritis (GCA) have demonstrated to be a robust marker. In other types of vasculitides the role of US is not well defined yet but could be of help by diagnosing secondary findings when there is organ involvement, like interstitial lung disease in small vessel vasculitis (SVV). Different modes of ultrasound (US) are being studied for this purpose, especially since it is a non-invasive technique that can limit exposure to ionizing radiation. In conclusion there is clear evidence for the use of US particularly color duplex US (CDS) in the diagnosis of LVV like GCA and Takayasu's arteritis (TAK). Nevertheless, there is urgent need for more data in regard to the use of US in small/medium vessel vasculitis, as well as the role of US in monitoring of patients with LVV.

Serum amyloid A impairs the antiinflammatory properties of HDL.

HDL from healthy humans and lean mice inhibits palmitate-induced adipocyte inflammation; however, the effect of the inflammatory state on the functional properties of HDL on adipocytes is unknown. Here, we found that HDL from mice injected with AgNO3 fails to inhibit palmitate-induced inflammation and reduces cholesterol efflux from 3T3-L1 adipocytes. Moreover, HDL isolated from obese mice with moderate inflammation and humans with systemic lupus erythematosus had similar effects. Since serum amyloid A (SAA) concentrations in HDL increase with inflammation, we investigated whether elevated SAA is a causal factor in HDL dysfunction. HDL from AgNO3-injected mice lacking Saa1.1 and Saa2.1 exhibited a partial restoration of antiinflammatory and cholesterol efflux properties in adipocytes. Conversely, incorporation of SAA into HDL preparations reduced antiinflammatory properties but not to the same extent as HDL from AgNO3-injected mice. SAA-enriched HDL colocalized with cell surface-associated extracellular matrix (ECM) of adipocytes, suggesting impaired access to the plasma membrane. Enzymatic digestion of proteoglycans in the ECM restored the ability of SAA-containing HDL to inhibit palmitate-induced inflammation and cholesterol efflux. Collectively, these findings indicate that inflammation results in a loss of the antiinflammatory properties of HDL on adipocytes, which appears to partially result from the SAA component of HDL binding to cell-surface proteoglycans, thereby preventing access of HDL to the plasma membrane.

Medicaid patients' access to subspecialty care in Connecticut: teaching clinics questionnaire.

OBJECTIVE: To determine whether Medicaid patients have ready access to subspecialty care. METHODS: A survey was administered to training program directors and federal clinic chiefs to ascertain, for each medical and surgical subspecialty, whether their patients had access to care "never, rarely, sometimes, usually, or always." RESULTS: Seventeen respondents indicated that, on average, subspecialty care in Connecticut was available "never, rarely or sometimes," 36% of the time. Results of a smaller national sample, mirrored Connecticut responses. CONCLUSION: Despite government mandates, Medicaid patients have insufficient access to subspecialty care.

Individualized education plans in medical education.

BACKGROUND: Individualized education plans (IEP) are commonly used in nonmedical educational programs to define students' deficiencies and action plans for addressing them. There are no reports of using IEP for medical education. SETTING: Internal medicine residency of a community teaching hospital. METHODS: Residents requiring IEP were identified by a consensus of faculty members. IEPs, overseen by mentors, included: 1. List of deficiencies, 2. Techniques for remediation, 3. Schedule for meetings and re-evaluation of IEP progress. Demographic and evaluative data were abstracted from the performance files of internal medicine residents who served in the program between 2003 and 2010. Characteristics and educational outcomes of those receiving IEPs were compared to those not requiring IEPs. RESULTS: Of 92 residents, 16 received IEPs; 13 for medical knowledge, four for professionalism and one for communication.Average age was greater (35.2 vs 30.3 y; P=0.004) and graduation less recent (8.7 vs 4.8 y; P=0.03). USMLE step I and American Board of Internal Medicine in-service scores were lower in those with IEP (82.6 vs 89.4; P=0.001; 44.6 vs 68.5 percentile relative to same-PGY level; P=0.01). Three residents repeated a PGY year (two successfully) and four completed two to six extra months at the same PGY level. All but two residents in the program between 2003 and 2010 passed Boards on their first attempt; neither had an IEP. Of the 12 with successful IEPs, three graduated to primary-care positions, two to hospitalist positions, and six to subspecialty fellowships; one was lost to follow-up. CONCLUSION: A formal IEP process similar to that employed in nonmedical education was associated with successful graduation and board certification in a majority of medical trainees who required remediation.