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1.
J Bone Miner Res ; 2020 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-32020683

RESUMO

Several professional organizations have recommended tramadol as one of the first-line or second-line therapies for patients with chronic noncancer pain and its prescription has been increasing rapidly worldwide; however, the safety profile of tramadol, such as risk of fracture, remains unclear. This study aimed to examine the association of tramadol with risk of hip fracture. Among individuals age 50 years or older without a history of hip fracture, cancer, or opioid use disorder in The Health Improvement Network (THIN) database in the United Kingdom general practice (2000-2017), five sequential propensity score-matched cohort studies were assembled, ie, participants who initiated tramadol or those who initiated one of the following medications: codeine (n = 146,956) (another commonly used weak opioid), naproxen (n = 115,109) or ibuprofen (n = 107,438) (commonly used nonselective nonsteroidal anti-inflammatory drugs [NSAIDs]), celecoxib (n = 43,130), or etoricoxib (n = 27,689) (cyclooxygenase-2 inhibitors). The outcome was incident hip fracture over 1 year. After propensity-score matching, the included participants had a mean age of 65.7 years and 56.9% were women. During the 1-year follow-up, 518 hip fracture (3.7/1000 person-years) occurred in the tramadol cohort and 401 (2.9/1000 person-years) occurred in the codeine cohort. Compared with codeine, hazard ratio (HR) of hip fracture for tramadol was 1.28 (95% confidence interval [CI] 1.13 to 1.46). Risk of hip fracture was also higher in the tramadol cohort than in the naproxen (2.9/1000 person-years for tramadol, 1.7/1000 person-years for naproxen; HR = 1.69, 95% CI 1.41 to 2.03), ibuprofen (3.4/1000 person-years for tramadol, 2.0/1000 person-years for ibuprofen; HR = 1.65, 95% CI 1.39 to 1.96), celecoxib (3.4/1000 person-years for tramadol, 1.8/1000 person-years for celecoxib; HR = 1.85, 95% CI 1.40 to 2.44), or etoricoxib (2.9/1000 person-years for tramadol, 1.5/1000 person-years for etoricoxib; HR = 1.96, 95% CI 1.34 to 2.87) cohort. In this population-based cohort study, the initiation of tramadol was associated with a higher risk of hip fracture than initiation of codeine and commonly used NSAIDs, suggesting a need to revisit several guidelines on tramadol use in clinical practice. © 2020 American Society for Bone and Mineral Research.

2.
Artigo em Inglês | MEDLINE | ID: mdl-31628482

RESUMO

OBJECTIVES: 3-hydroxy-3-methylglutaryl coenzyme-A (HMG Co-A) reductase inhibitors (statins) are standard treatment for hyperlipidaemia. In addition to lipid-lowering abilities, statins exhibit multiple anti-inflammatory effects. The objectives of this study were to determine whether treatment of patients with RA with lovastatin decreased CRP or reduced disease activity. METHODS: We conducted a randomized double-blind placebo-controlled 12 week trial of lovastatin vs placebo in 64 RA patients with mild clinical disease activity but an elevated CRP. The primary efficacy end point was the reduction in mean log CRP. Secondary end points included disease activity, RF and anti-CCP antibody titres. Mechanistic end points included levels of serum cytokines. Safety was assessed; hepatic and muscle toxicities were of particular interest. RESULTS: Baseline features were similar between groups. No significant difference in mean log CRP reduction between the two groups was observed, and disease activity did not change from baseline in either treatment group. Mechanistic analyses did not reveal significant changes in any biomarkers. A post hoc analysis of subjects not using biologic therapy demonstrated a significantly greater proportion achieving ⩾20% reduction in CRP from baseline in the lovastatin group compared with placebo (P-value = 0.007). No difference was observed in subjects receiving biologics. Lovastatin was well tolerated with no serious safety concerns. CONCLUSION: This study showed no anti-inflammatory or clinical effects on RA disease activity after 12 weeks of treatment with lovastatin. Lovastatin had a modest effect on CRP in subjects not using biologics, suggesting statins may be anti-inflammatory in selected patients. TRIAL REGISTRATION: ClinicalTrials.gov, http://clinicaltrials.gov, NCT00302952.

3.
Artigo em Inglês | MEDLINE | ID: mdl-31162824

RESUMO

OBJECTIVE: Pain is a significant burden for rheumatoid arthritis (RA) patients despite advancements in treatment. We examined the independent contribution of pain centralization to the pain experience of patients with active RA. METHODS: Two hundred and sixty-three RA patients with active disease underwent quantitative sensory testing (QST) including assessment of extra-articular pressure pain thresholds (PPTs), temporal summation (TS), and conditioned pain modulation (CPM). The pain experience was assessed by a pain intensity numeric rating scale and the Patient-Reported Outcomes Measurement Information System (PROMIS® ) Pain Interference computerized adaptive test. We examined associations between QST measures and pain intensity and pain interference. Multiple linear regression models were adjusted for demographic and clinical variables, including swollen joint count and C-reactive protein. RESULTS: Patients with the lowest PPTs (most central dysregulation) reported higher pain intensity than patients with the highest PPTs (adjusted mean difference (95% CI) 1.02 (0.37, 1.67)). Patients with the highest TS (most central dysregulation) had higher pain intensity than those with the lowest TS (adjusted mean difference (95% CI) 1.19 (0.54, 1.84)). CPM was not associated with differences in pain intensity. PPT and TS were not associated with pain interference. Patients with the lowest CPM (most centrally dysregulated) had lower pain interference than patients with the highest CPM (adjusted mean difference (95% CI) -2.35 (-4.25, -0.44)). CONCLUSION: Pain centralization, manifested by low PPTs and high TS, was associated with more intense pain. Clinicians should consider pain centralization as a contributor to pain intensity, independent of inflammation. This article is protected by copyright. All rights reserved.

5.
Rheum Dis Clin North Am ; 45(1): 127-144, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30447741

RESUMO

The field of rheumatology has expanded rapidly in recent years, and innovations in immunology, epigenetics, and bone metabolism continue at an astonishing pace. In this fast changing field, optimizing medical education for rheumatologists is vital for maintaining a competent workforce to meet the needs of patients with rheumatic diseases. Several key challenges lie ahead and efforts to optimize medical education for rheumatologists are discussed in this article.


Assuntos
Educação Médica Continuada/normas , Educação de Pós-Graduação em Medicina/normas , Reumatologia/educação , Currículo , Bolsas de Estudo/normas , Humanos
7.
Arthritis Care Res (Hoboken) ; 71(4): 521-529, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-29885039

RESUMO

OBJECTIVE: The Patient-Reported Outcomes Measurement Information System (PROMIS) is a calibrated item bank used to assess patient-reported outcomes across multiple domains. The purpose of this study was to describe the performance of selected PROMIS measures in patients with rheumatoid arthritis (RA) with active disease who were initiating a disease-modifying antirheumatic drug (DMARD). METHODS: Participants in an ongoing prospective observational study completed 8 PROMIS measures before and after DMARD initiation. Linear regression models were performed to identify cross-sectional associations between baseline PROMIS measures and disease activity, measured using the Clinical Disease Activity Index (CDAI). Paired t-tests were performed to evaluate responsiveness after 12 weeks of DMARD treatment. Associations between changes in PROMIS measures and changes in the CDAI score were assessed using linear regression. RESULTS: Among the 156 participants who completed the first study visit, the mean ± SD baseline CDAI score was 25.5 ± 14.0. Baseline scores for PROMIS measures of physical health, pain, and sleep were associated with the baseline CDAI score (P ≤ 0.05). Among the 106 participants with 12-week data, all PROMIS scores improved after DMARD initiation (P ≤ 0.05). With the exception of depression, changes in all assessed PROMIS measures were correlated with changes in the CDAI score (standardized ßs from |0.23| to |0.38|). CONCLUSION: These data provide support for the utility of PROMIS measures for the assessment of physical and mental health in individuals with active RA. All PROMIS measures improved significantly after DMARD initiation, with the magnitudes of association between changes in PROMIS measures and changes in the CDAI score in the low-to-moderate range.


Assuntos
Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Medidas de Resultados Relatados pelo Paciente , Adulto , Idoso , Artrite Reumatoide/psicologia , Feminino , Humanos , Masculino , Estudos Prospectivos
8.
J Clin Rheumatol ; 25(5): 232-236, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30035754

RESUMO

BACKGROUND: The aims of this study were to define changes in catastrophizing that occur with initiation of a new disease-modifying antirheumatic drug (DMARD) and to examine the relationship between changes in Clinical Disease Activity Index (CDAI) and changes in catastrophizing. METHODS: Participants in an ongoing multisite, observational study completed the Pain Catastrophizing Scale (PCS) before and 12 weeks after DMARD initiation. We used multivariable linear regression models to examine the association between changes in CDAI as the exposure and change in pain catastrophizing as the outcome. We also assessed the relationship between changes in each component of CDAI and change in PCS, using multivariable linear regression models. RESULTS: Among the 165 rheumatoid arthritis patients with data on CDAI at both time points, CDAI decreased from 22 to 11.5 on a 76-point scale (p < 0.0001) after 12 weeks. Pain intensity decreased from a median of 5 to 3 on a 10-point numeric rating scale (p < 0.0001), and catastrophizing decreased, from 16.0 to 12.0 on the 52-point PCS (p = 0.0005). Among the 163 with complete data for the regression analysis, changes in CDAI were positively correlated with changes in catastrophizing (standardized ß = 0.19, p = 0.01). Of the components of the CDAI, change in assessor global score was most strongly associated with changes in catastrophizing (standardized ß = 0.24, p = 0.003). CONCLUSIONS: Pain catastrophizing decreases, in conjunction with disease activity, after initiation of a new DMARD. These findings provide support for catastrophizing as a dynamic construct that can be altered with treatment directed at decreasing inflammatory disease activity and pain.


Assuntos
Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Artrite Reumatoide/psicologia , Catastrofização , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Índice de Gravidade de Doença
10.
Arthritis Care Res (Hoboken) ; 70(5): 672-678, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29667375

RESUMO

OBJECTIVE: Due to an aging population, increasing prevalence of rheumatic disease, and a growing supply and demand gap of rheumatology providers, innovative solutions are needed to meet the needs of persons with rheumatic conditions. Nurse practitioners (NPs) and physician assistants (PAs) have been identified as a group of health professionals who could help address the workforce shortage. The Executive Committee of the Association of Rheumatology Health Professionals (ARHP), a division of the American College of Rheumatology (ACR), charged a task force to facilitate the preparation of NPs/PAs to work in a rheumatology practice setting. METHODS: The task force, consisting of private practice and academic rheumatologists, and NPs and PAs, from both adult and pediatric settings, conducted a needs assessment survey of current NPs and PAs to identify mechanisms for acquiring rheumatology knowledge. Through face-to-face and webinar meetings, and incorporating stakeholder feedback, the task force designed a rheumatology curriculum outline to enrich the training of new NPs and PAs joining rheumatology practice. RESULTS: Informed by the needs assessment data and stakeholders, an NP/PA rheumatology curriculum outline was developed and endorsed by the ACR Board of Directors for use by community-based and academic rheumatology practices, whether pediatric or adult, who desire to add NPs and PAs to their practice setting. CONCLUSION: As rheumatology is facing workforce shortages, the ACR/ARHP rheumatology curriculum outline can be utilized to train NPs and PAs and create more efficient integration of NPs and PAs into rheumatology practice.


Assuntos
Reumatologia/educação , Currículo , Feminino , Humanos , Masculino , Profissionais de Enfermagem/educação , Assistentes Médicos/educação
11.
Arthritis Rheumatol ; 70(6): 817-825, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29399986

RESUMO

OBJECTIVE: Graduate medical education (GME), through fellowship training, plays a critical role in preparing new rheumatologists for our workforce and is an essential component when addressing the gap of excess demand for adult rheumatology care. This study was undertaken to assess the demographic characteristics and employment trends of new entrants entering the rheumatology workforce and the impact this will have on the supply of rheumatologits over the next 15 years. METHODS: Primary and secondary data sources were used to develop an integrated workforce model. Factors specific to new graduates entering the workforce included available and filled fellowship positions, gender shifts, planned work schedules (part-time or full-time), practice settings (academic or non-academic, private practice), and number of international medical graduates (IMGs) anticipating US practice. RESULTS: In 2015, there were 113 adult rheumatology programs, with 431 of 468 available positions filled. Using the 215 actual positions available annually in fellowship programs as a starting point, after all factors were applied, the projected clinical full-time equivalent number entering the workforce each year was 107; this number was affected significantly by gender and generational trends. In addition, 17% of IMGs self-identified their plan to practice outside the US. Confounding predictions included a large proportion of current rheumatologists planning retirement with substantially reduced patient loads by 2030. CONCLUSION: The current US adult rheumatology workforce is in jeopardy of accelerated decline at a time when demands on the workforce face tremendous growth. The current GME training structure cannot support the increased demand. Potential strategies to address this gap include innovative mechanisms for GME funding to increase fellowship training positions, incentives for pursuing rheumatology training (e.g., loan repayment programs), and novel means for recruitment of care to underserved areas of the US.


Assuntos
Educação de Pós-Graduação em Medicina/estatística & dados numéricos , Bolsas de Estudo/estatística & dados numéricos , Mão de Obra em Saúde/tendências , Reumatologia/educação , Adulto , Humanos , Estados Unidos
12.
Arthritis Care Res (Hoboken) ; 70(4): 617-626, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29400009

RESUMO

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.


Assuntos
Prestação Integrada de Cuidados de Saúde/tendências , Necessidades e Demandas de Serviços de Saúde/tendências , Mão de Obra em Saúde/tendências , Determinação de Necessidades de Cuidados de Saúde/tendências , Reumatologistas/tendências , Reumatologia/tendências , Idoso , Feminino , Previsões , Humanos , Masculino , Pessoa de Meia-Idade , Admissão e Escalonamento de Pessoal/tendências , Reumatologistas/provisão & distribução , Fatores de Tempo , Estados Unidos
13.
Arthritis Care Res (Hoboken) ; 70(2): 197-204, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28437846

RESUMO

OBJECTIVE: Pain sensitization may contribute to pain severity in rheumatoid arthritis (RA), impacting disease activity assessment. We examined whether pain processing mechanisms were associated with disease activity among RA patients with active disease. METHODS: The study included 139 subjects enrolled in the Central Pain in Rheumatoid Arthritis cohort. Subjects underwent quantitative sensory testing (QST), including assessment of pressure pain thresholds (PPTs) at multiple sites, conditioned pain modulation, and temporal summation. RA disease activity was assessed using the Clinical Disease Activity Index (CDAI) and its components. We examined cross-sectional associations between QST measures and disease activity using linear regression. RESULTS: Low PPTs (high pain sensitization) at all sites were associated with high CDAI scores (P ≤ 0.03) and tender joint counts (P ≤ 0.002). Associations between PPTs and patient global assessments were also seen at most sites. High temporal summation at the forearm (also reflecting high pain sensitization) was significantly associated with high CDAI scores (P = 0.02), patient global assessment scores (P = 0.0006), evaluator global assessment scores (P = 0.01), and tender joint counts (P = 0.02). Conversely, conditioned pain modulation (a measure of descending inhibitory pain pathways) was associated only with tender joint count (P = 0.03). CONCLUSION: High pain sensitization is associated with elevations in disease activity measures. Longitudinal studies are underway to elucidate the cause-effect relationships between pain sensitization and inflammatory disease activity in RA.


Assuntos
Artralgia/fisiopatologia , Artrite Reumatoide/fisiopatologia , Sensibilização do Sistema Nervoso Central , Percepção da Dor , Limiar da Dor , Adulto , Idoso , Artralgia/diagnóstico , Artralgia/psicologia , Artrite Reumatoide/diagnóstico , Artrite Reumatoide/psicologia , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Índice de Gravidade de Doença , Estados Unidos
14.
Artigo em Inglês | MEDLINE | ID: mdl-28777891

RESUMO

OBJECTIVES: Musculoskeletal ultrasound (MSUS) in rheumatology in the United States has advanced through promotion of certification, standards of use, and core fellowship curriculum inclusion requiring exposure. In order to inform endeavors for curricular integration, the study objectives are to assess current program needs for curricular incorporation, and teaching methods being employed. METHODS: A needs assessment survey (S1) was sent to 113 rheumatology fellowship program directors. For programs that taught MSUS, a,curriculum survey (S2) was sent to lead faculty. Programs were stratified according to program size and use of a formal written curriculum. RESULTS: S1 (108/113; response rate 96%) revealed 94% of programs taught MSUS, with 41% having a curriculum. Curricular implementation was unaffected by program size. Formal curricular adoption of MSUS was favored by 103 (95.3%) directors, with 65.7% preferring it to be optional. S2 (74/101, response rate 73%) noted 41% of programs utilized a formal curriculum. Multiple teaching strategies were used, with common content in general. Use of external courses including USSONAR course was prevalent. Fewer barriers were noted but inadequate time, funding and number of trained faculty still remained. Lack of divisional interest (p = 0.046) and fellow interest (p = 0.012) were noted among programs without a formal curriculum. CONCLUSION: MSUS is taught by a significantly larger number of rheumatology fellowship programs today. Multiple teaching strategies are used with common content. Barriers still remain for some programs. Most program directors favor inclusion of a standardized MSUS curriculum with many favoring it to be optional. This article is protected by copyright. All rights reserved.

15.
Drug Des Devel Ther ; 11: 1221-1231, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28458516

RESUMO

Increased understanding of bone biology has led to the discovery of several unique signaling pathways that regulate bone formation and resorption. The Wnt signaling pathway plays a significant role in skeletal development, adult skeletal homeostasis, and bone remodeling. Sclerostin is an inhibitor of the Wnt signaling pathway. Romosozumab, a humanized monoclonal antibody that binds to sclerostin, prevents sclerostin from exerting this inhibitory effect. Therefore, in the presence of romosozumab, the Wnt signaling pathway is activated leading to bone formation and bone mineral density gain. Clinical studies of romosozumab have shown that this agent is one of the most potent bone anabolic agents in development to date. Romosozumab does not act solely as an anabolic agent, but rather, it has effects on increasing bone formation as well as reducing bone resorption. In the clinical studies, patients tolerated romosozumab well with no major safety signals reported. In a Phase III study, romosozumab as compared to placebo has been shown to reduce vertebral fractures by 73% after 1 year of treatment. Sequential therapy with romosozumab for 1 year followed by denosumab in the second year reduced vertebral fractures by 75% as compared to the group that received placebo for 1 year and denosumab in the second year. Romosozumab holds significant potential, by a novel mechanism of action, to expand our ability to treat osteoporosis. More studies are needed to determine the ideal setting in which romosozumab may be used to optimize osteoporosis treatment.


Assuntos
Anticorpos Monoclonais/uso terapêutico , Osteoporose/tratamento farmacológico , Animais , Anticorpos Monoclonais/administração & dosagem , Humanos , Osteoporose/metabolismo
16.
Arthritis Care Res (Hoboken) ; 69(6): 769-775, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-27863135

RESUMO

OBJECTIVE: Measurement is necessary to gauge improvement. US training programs have not previously used shared standards to assess trainees' mastery of the knowledge, skills, and attitudes necessary to practice rheumatology competently. In 2014, the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System began requiring semiannual evaluation of all medicine subspecialty fellows on 23 internal medicine subspecialty reporting milestones. Since these reporting milestones are not subspecialty specific, rheumatology curricular milestones were needed to guide rheumatology fellowship training programs and fellows on the training journey from internist to rheumatologist. METHODS: Rheumatology curricular milestones were collaboratively composed by expanding the internal medicine reporting milestones to delineate the specific targets of rheumatology fellowship training within 6 ACGME core competencies. The 2006 American College of Rheumatology core curriculum for rheumatology training programs was updated. RESULTS: A total of 80 rheumatology curricular milestones were created, defining progressive learning through training; most focus on patient care and medical knowledge. The core curriculum update incorporates the new curricular milestones and rheumatology entrustable professional activities. CONCLUSION: Rheumatology curricular milestones are now available for implementation by rheumatology fellowship training programs, providing a clear roadmap for specific training goals and a guide to track each fellow's achievement over a 2-year training period. The comprehensive core curriculum delineates the essential breadth of knowledge, skills, and attitudes that define rheumatology, and provides a guide for educational activities during fellowship training. These guiding documents are now used to train and assess fellows as they prepare for independent rheumatology practice as the next generation of rheumatologists.


Assuntos
Currículo , Medicina Interna/educação , Reumatologistas/educação , Reumatologia/educação , Competência Clínica/normas , Currículo/normas , Currículo/tendências , Humanos , Medicina Interna/normas , Medicina Interna/tendências , Reumatologistas/normas , Reumatologistas/tendências , Reumatologia/normas , Reumatologia/tendências , Sociedades Médicas/normas , Sociedades Médicas/tendências
17.
Clin Exp Rheumatol ; 35 Suppl 106(4): 106-113, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-27908301

RESUMO

OBJECTIVES: To assess the utility of B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) in detecting and monitoring pulmonary hypertension (PH) in systemic sclerosis (SSc). METHODS: PHAROS is a multicenter prospective cohort of SSc patients at high risk for developing pulmonary arterial hypertension (SSc-AR-PAH) or with a definitive diagnosis of SSc-PH. We evaluated 1) the sensitivity and specificity of BNP≥64 and NT-proBNP≥210 pg/mL for the detection of SSc-PAH and/ or SSc-PH in the SSc-AR-PAH population; 2) baseline and longitudinal BNP and NT-proBNP levels as predictors of progression to SSc-PAH and/or SSc-PH; 3) baseline BNP≥180, NT-proBNP≥553 pg/mL, and longitudinal changes in BNP and NT-proBNP as predictors of mortality in SSc-PH diagnosed patients. RESULTS: 172 SSc-PH and 157 SSc-AR- PAH patients had natriuretic peptide levels available. Median BNP and NT-proBNP were significantly higher in the SSc-PH versus SSc-AR-PAH group. The sensitivity and specificity for SSc-PAH detection using baseline BNP≥64 pg/mL was 71% and 59%; and for NT-proBNP≥210 pg/mL, 73% and 78%. NT-proBNP showed stronger correlations with haemodynamic indicators of right ventricular dysfunction than BNP. Baseline creatinine, RVSP > 40 mmHg, and FVC%:DLco% ratio ≥1.8 were associated with progression from SSc-AR-PAH to SSc-PH but no association with individual or combined baseline BNP and NT-proBNP levels was observed. Baseline and follow-up BNP or NT-proBNP levels were not predictive of death, however, a composite BNP/NT-proBNP group predicted mortality (HR 3.81 (2.08-6.99), p<.0001). CONCLUSIONS: NT-proBNP may be more useful than BNP in the detection and monitoring of PAH in SSc patients, but additional studies are necessary.


Assuntos
Hipertensão Pulmonar/diagnóstico , Peptídeo Natriurético Encefálico/sangue , Escleroderma Sistêmico/complicações , Idoso , Progressão da Doença , Feminino , Hemodinâmica , Humanos , Hipertensão Pulmonar/sangue , Hipertensão Pulmonar/fisiopatologia , Masculino , Pessoa de Meia-Idade , Fragmentos de Peptídeos/sangue , Estudos Prospectivos , Sistema de Registros , Escleroderma Sistêmico/sangue
18.
Cleve Clin J Med ; 83(4): 281-8, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27055202

RESUMO

Glucocorticoids, proton pump inhibitors, selective serotonin reuptake inhibitors (SSRIs), certain antiepileptic drugs, and aromatase inhibitors have significant adverse effects on bone. Healthcare providers should monitor the bone health of patients on these agents, supplement their intake of calcium and vitamin D, encourage weight-bearing exercise, and initiate osteoporosis-prevention treatment as indicated.


Assuntos
Anticonvulsivantes/efeitos adversos , Inibidores da Aromatase/efeitos adversos , Densidade Óssea/efeitos dos fármacos , Glucocorticoides/efeitos adversos , Inibidores da Bomba de Prótons/efeitos adversos , Inibidores de Captação de Serotonina/efeitos adversos , Cálcio/uso terapêutico , Suplementos Nutricionais , Humanos , Osteoporose/induzido quimicamente , Osteoporose/prevenção & controle , Fatores de Risco , Vitamina D/uso terapêutico , Vitaminas/uso terapêutico
19.
Arthritis Care Res (Hoboken) ; 68(8): 1166-72, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-26663526

RESUMO

OBJECTIVE: Graduate medical education is a critical time in the training of a rheumatologist, and purposeful evaluation of abilities during this time is essential for long-term success as an independent practitioner. The internal medicine subspecialties collectively developed a uniform set of reporting milestones by which trainees can be assessed and receive formative feedback, providing clarity of accomplishment as well as areas for improvement in training. Furthermore, the reporting milestones provide a schema for assessment and evaluation of fellows by supervisors. The internal medicine subspecialties were also tasked with considering entrustable professional activities (EPAs), which define the abilities of a subspecialty physician who has attained sufficient mastery of the field to be accountable to stakeholders and participate in independent practice. Although EPAs have been established for a few specialties, they had not yet been described for rheumatology. EPAs have value as descriptors of the comprehensive abilities, knowledge, and skills of a practicing rheumatologist. The rheumatology EPAs have a role in defining a specialist in rheumatology upon completion of training, and also represent the ways our specialty defines our abilities that are enduring throughout practice. METHODS: We describe the collaborative process of the development of both the subspecialty reporting milestones and the rheumatology EPAs. The reporting milestones evolved through discussions and collaborations among representatives from the Association of Specialty Professors, the Alliance for Academic Internal Medicine, the American Board of Internal Medicine, and the Accreditation Council for Graduate Medical Education. The EPAs were a product of deliberations by the Next Accreditation System (NAS) working group of the American College of Rheumatology (ACR) Committee on Rheumatology Training and Workforce Issues. RESULTS: Twenty-three subspecialty reporting milestones and 14 rheumatology EPAs were advanced and refined over the course of 3 subspecialty reporting milestone development summits and 3 ACR NAS working group meetings, respectively. CONCLUSION: The subspecialty reporting milestones and rheumatology EPAs presented here stipulate reasonable and measurable expectations for rheumatologists-in-training. Together, these tools aim to promote enrichment and greater accountability in the training of fellows. Additionally, the EPAs define, for all stakeholders, the expertise of a rheumatologist in practice.


Assuntos
Educação de Pós-Graduação em Medicina/métodos , Reumatologistas/educação , Reumatologia/educação , Competência Clínica/normas , Currículo , Humanos , Internato e Residência , Avaliação de Programas e Projetos de Saúde
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