Screening Tools for Spondyloarthritis in Patients With Psoriasis, Uveitis, and Inflammatory Bowel Disease: A Scoping Review.

OBJECTIVE: Extramusculoskeletal manifestations of spondyloarthritis (SpA) may precede the development of articular features. Patients seen in ophthalmology, dermatology, and gastroenterology clinics with uveitis, psoriasis, or inflammatory bowel disease (IBD) may have undiagnosed SpA. We set out to identify and evaluate screening tools for SpA in patients with psoriasis, uveitis, and IBD and determine factors that influence the performance of these instruments. METHODS: This scoping review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, and Web of Science were searched from inception to January 2022. RESULTS: We identified 13 screening tools for psoriatic arthritis, 2 SpA screening tools for uveitis, and 3 SpA screening tools for IBD. All screening tools were patient-oriented questionnaires except for the Dublin Uveitis Evaluation Tool, a physician-applied algorithm. The questionnaires varied in length, scoring method, cutoff score, and spectrum of included SpA features. Average completion time was less than five minutes. Across the three patient populations, the sensitivities and specificities of these screening tools were comparable in the primary validation cohorts. Sensitivities and specificities were generally lower in secondary validation studies, with marked variability among cohorts. CONCLUSION: Our results highlight the heterogeneity and limitations of existing SpA screening tools. Although these tools show promise for use within a specific target population, none are generalizable to all patients with extramusculoskeletal manifestations at risk of SpA. Future studies should explore the utility of a generic patient-oriented SpA screening tool that can be applied to patients with psoriasis, uveitis, or IBD; is easy to use and comprehend; and captures all clinical domains of SpA.

Axial Spondyloarthritis Treatment Recommendations and Disease Activity Monitoring in Clinical Practice: Results of an Online Survey.

OBJECTIVE: Clinical practice guidelines are not always followed consistently. To better understand potential barriers to the implementation of treatment recommendations in axial spondyloarthritis and ankylosing spondylitis (axSpA/AS), an online survey was conducted. METHODS: Email invitations were sent to US rheumatology care providers in January 2023. The questionnaire included 20 questions, with an estimated completion time of 5-7 minutes. RESULTS: One hundred four of 441 (24%) invitees participated, including 80/104 (77%) board-certified rheumatologists and 20/104 (19%) fellows. Survey participants identified UpToDate (85%), treatment guidelines (74%), and colleagues (54%) as relevant sources of knowledge for managing axSpA/AS. Of the participants, 64% and 53% considered themselves to be at least moderately familiar with the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network (ACR/SAA/SPARTAN) and Assessment of Spondyloarthritis international Society/European Alliance of Associations for Rheumatology (ASAS/EULAR) treatment recommendations for axSpA/AS, respectively. Whereas 69% of participants agreed or strongly agreed that disease activity scores are useful for making treatment decisions in axSpA/AS, only 37% measure patient-reported outcomes (PROs) frequently (≥ 50% of clinic visits) while 82% do so for C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). PROs are typically recorded during clinic encounters (65%) and CRP/ESR are obtained after the visit (86%). Of the participants, 57% and 47% considered the Bath Ankylosing Spondylitis Disease Activity Index and Ankylosing Spondylitis Disease Activity Score to be at least moderately useful for measuring disease activity in axSpA/AS, respectively; 41% and 37% thought the same about the ASAS 20% improvement criteria and Clinical Disease Activity Index, respectively. CONCLUSION: Treatment guidelines are an important resource for rheumatologists who manage patients with axSpA/AS. Although there is general agreement that disease activity monitoring is important, the implementation of the respective recommendations is lacking. Reasons may include lack of familiarity and an underdeveloped infrastructure to efficiently collect PROs.

"Reading" the room: healthcare chaplains' challenges, insights and variations in entering rooms and engaging with patients and families.

Recent research has described broad types of healthcare chaplains' activities, but many questions remain about how these professionals perform these tasks, whether variations occur, and if so, in what ways. Twenty-three chaplains were interviewed in-depth. Chaplains described engaging in highly dynamic processes, involving both verbal and non-verbal interactions. They face challenges and vary in ways of starting interactions, using verbal and non-verbal cues, and communicating through physical appearance. In these processes, when entering patients' rooms, they seek to "read the room," follow patients' leads, look for cues, match the energy/mood in the room, and adjust their body language appropriately, while maintaining open-ended stances. They face choices of what, if anything, to communicate through clothing (e.g., wearing clerical collars or crosses) and can confront additional challenges with members of groups different than their own, at times requiring further sensitivity. These data, the first to examine challenges chaplains confront entering patients' rooms and engaging in non-verbal communication, can enhance understandings of these issues, and help chaplains and other healthcare professionals provide more sensitive and astute context-based care. These findings thus have critical implications for education, practice, and research concerning chaplains and other providers.

The Effects of Contextual Factors on Hospital Chaplains: A Qualitative Study.

Critical questions arise about how contextual factors affect hospital chaplains. We interviewed 23 chaplains in-depth. Hospitals' religious or other institutional affiliation, geography, and leadership can influence chaplains both explicitly/directly and implicitly/indirectly-for example, in types/amounts of support chaplains receive, scope of chaplains' roles/activities, amounts/types of chaplains' interactions, chaplains' views of their roles and freedom to innovate, and patients', families' and other providers' perceptions/expectations regarding spiritual care. These data have critical implications for research, practice, and education.

Barriers and facilitators faced by hospital chaplains in communicating with lesbian, gay, bisexual, transgender and questioning patients.

OBJECTIVES: Chaplains address religious, spiritual and existential issues with heterosexual patients but critical questions arise of whether chaplains do so with lesbian, gay, bisexual, transgender and questioning (LGBTQ) patients, too, and if so, how. METHODS: Chaplains were interviewed for ∼1 h each. Four spontaneously discussed LGBTQ issues. RESULTS: Chaplains described several challenges communicating with LGBTQ patients. These patients may confront existential, spiritual/religious questions, but be wary of religion, and hence of chaplains, whom they may thus reject. Chaplains can help LGBTQ patients, addressing existential, spiritual and/or religious issues and related parental rejections these patients may then face. Yet LGBTQ patients vary widely: while some eschew chaplains, others are receptive. These providers may also not always know patients' LGBTQ status, and may vary in sensitivity towards these issues, and not always succeed in overcoming families' religion-based homophobia. CONCLUSION: Chaplains can potentially help LGBTQ patients in crucial ways, but face obstacles that need to be carefully recognized, examined and addressed through, practice, research and enhanced education of chaplains, medical staff, patients, family members and others. PRACTICE IMPLICATIONS: Chaplains and other providers should be more aware of, and ready to address the potential existential, spiritual and religious issues that LGBTQ patients may confront.

Muslim patients in the U.S. confronting challenges regarding end-of-life and palliative care: the experiences and roles of hospital chaplains.

INTRODUCTION: Hospital chaplains aid patients confronting challenges related to palliative and end-of-life care, but relatively little is known about how chaplains view and respond to such needs among Muslim patients, and how well. METHODS: Telephone qualitative interviews of ~ 1 h each were conducted with 23 chaplains and analyzed. RESULTS: Both Muslim and non-Muslim chaplains raised issues concerning Islam among chaplains, doctors and patients, particularly challenges and misunderstandings between non-Muslim providers and Muslim patients, especially at the end-of-life, often due to a lack of knowledge of Islam, and misunderstanding and differences in perspectives. Due to broader societal Islamophobia, Muslim patients may fear or face discrimination, and thus not disclose their religion in the hospital. Confusion can arise among Muslim patients and families about what their faith permits regarding end-of-life care and pain management, and how to interpret and apply their religious beliefs in hospitals. Muslims hail from different countries, but providers may not fully grasp how these patients' cultural practices may also vary. Chaplains can help address these challenges, playing key roles in mediating tensions and working to counteract Muslim patients' fears, and express support. Yet many Muslim immigrants don't know what "chaplaincy" is and/or prefer a chaplain of their own faith. Muslim chaplains can play vital roles, having expertise that can heighten trust, and educating non-Muslim colleagues, providing in-depth understanding of Islam (e.g., highlighting how Islam is related to Judaism and Christianity) and correcting misconceptions among colleagues. Hospitals without a Muslim chaplain can draw on local community imams. CONCLUSIONS: These data highlight how mutual sets of misunderstandings, especially concerning patients' and families' decisions about end-of-life care and pain management, can emerge among Muslim patients and non-Muslim staff that chaplains can help mediate. Non-Muslim chaplains and providers should seek to learn more about Islam. Muslim patients and families may also benefit from enhanced education and awareness of chaplains' availability and scope, and of pain management and end-of-life options. These data thus have several critical implications for future practice, education, and research.

Exiting Patients' Rooms and Ending Relationships: Questions and Challenges Faced by Hospital Chaplains.

These data, the first to explore chaplains' challenges in ending visits/relationships with patients/families, has critical implications for practice, education, and research. Questions arise about the scope/boundaries of chaplains' relationships with patients/families. Interviews were conducted with 23 chaplains who face questions/challenges regarding how to end visits and interactions, including individual conversations and ongoing relationships with patients/families. Chaplains confront uncertainties and rely on verbal- and non-verbal cues to gauge how long to stay with each patient/family, and they are sometimes unsure. These data have critical implications for practice, education, and research.

Becoming chaplains: How and why chaplains enter the field, factors involved and implications.

Many questions arise concerning how and why chaplains enter the field. Interviews of ∼1 one hour each were conducted with 23 U.S. chaplains. Chaplains vary widely in professional and personal backgrounds and experiences, which they often draw on in their work. Personal experiences can lead them to enter the field, enhance their empathy and strengthen their commitment. They have frequently faced significant trauma (e.g., parent's death) or helped family and/or friends with end-of-life challenges. Chaplains often entered other fields first (e.g., clergy, business or healthcare), but they often had incomplete or incorrect prior knowledge about the field. Prior experiences can also affect their work (e.g., in recognizing the power of silence). A sense of personal "calling" frequently leads chaplains to find their work deeply rewarding and sustaining. These data, the first to explore how and why chaplains enter the field, have critical implications for future practice, education and research.

When and why patients and families reject chaplains: challenges, strategies and solutions.

Hospital chaplains perform important activities, but critical questions arise about the challenges they may face in working with patients, and how these professionals respond. Thirty-three telephone interviews of approximately 1 hour and were conducted with 21 board-certified chaplains. When asked about their biggest challenges and most rewarding interactions, several chaplains described rejections by patients or families. Patients and families at times rejected chaplains, and did so for six broad types of reasons - not wanting to discuss the disease due to conflicted feelings, including anger or frustration at the patient, the cosmos or God; or wanting to minimize it; wanting a chaplain of their own faith; or of a particular gender or other characteristic; being atheist or wary of religion; or misunderstanding what chaplains do. Patients at times also disagreed with family members about whether to reject a chaplain. Chaplains responded variously: feeling transitory hurt (which generally decreases with experience); respecting patients' autonomy and leaving; exploring reasons for rejection; and revisiting later and often then making helpful connections. These data have important implications for future practice, education and research regarding chaplains and other providers - suggesting, for example, how patients' families and the public might benefit from increased understanding about the field.

How hospital chaplains develop and use rituals to address medical staff distress.

Physicians and nurses face high levels of moral distress and burnout, exacerbated by the COVID-19, yet are often busy, without time for extended interventions. Hospital chaplains have recently been asked to assist staff, but many questions arise concerning whether they do so, and if so, how and when, and whether they may vary in doing so. Thirty-one telephone interviews of ∼1 â€‹h each were conducted with 21 board-certified chaplains to examine these and related issues. Respondents reported how they help staff, often creating, on their own, innovative kinds of practices that appear to take the form of rituals. These rituals vary in audience (physicians, nurses and/or other staff, with or without patients or families), form (from open-ended to structured), formality (from formal to informal), timing (at hospital discharge, time of death or after death), duration (from a few minutes to longer), frequency (from once to several times or ongoing), content (expressing and/or reframing feelings and experiences), and activities (e.g., talking, eating and/or making commemorative objects). Such rituals can help staff cope with death, grief, and other stresses. Challenges arise, including hospital leaders' wariness, resistance or lack of support, and staff time constraints, making briefer sessions more practical. These data highlight how chaplains can assist staff through use of rituals, and learn from innovations/initiatives devised by colleagues elsewhere. Chaplains can thus enhance what they do as individuals and as a profession. These data have critical implications for future research, education and practice for physicians, nurses, hospital administrators, chaplains and others.

Hospital chaplains' communication with patients: Characteristics, functions and potential benefits.

OBJECTIVE: Hospital chaplains communicate with patients concerning spirituality/religion, but many aspects of their interactions have received little attention. METHODS: Telephone qualitative interviews of ~1 h each were conducted with chaplains and analyzed, drawing on grounded theory. RESULTS: We interviewed 21 U.S. chaplains. Chaplains have relatively unique characteristics, having relatively more time to spend with patients, and less rigid and less medicalized agendas, while gaining respect/trust as religious figures. Chaplains can thus provide several critical beneficial functions - e.g., obtaining key information from patients/families that can help with decision-making and with diagnosis and treatment, and conveying medical providers' points of view to patients/families. Consequently, chaplains can serve as mediators between patients/families and providers; and also overcome staff biases and "labelling" of patients, and pursue or encourage psychological interventions, in part because psychotherapists are often unavailable. CONCLUSION: While past research suggested certain ways how chaplains might benefit hospitals, these professionals can aid these institutions and improve patient care in additional vital, tangible ways. PRACTICAL IMPLICATIONS: Hospital administrators, chaplaincy departments, doctors, nurses and others should more fully recognize, encourage and facilitate these functions. Targeted improvements in practice and education can help achieve these goals. The findings suggest, too, several specific questions for further investigation.