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Hi. This is QD Clinic. I'm Jack Cush with RheumNow. QD Clinic is brought to you by RheumNow's virtual coverage of ACR twenty twenty, your ticket to a smarter, better you. Today, we're gonna discuss triage rheumatology.

I recently heard the term triage and led me to I kinda know what it is, but I wanted to look it up. And it's actually an interesting story. It goes way back to the Napoleonic Wars and whatnot. It comes from a French verb triere. Excuse me.

I'm a Brooklyn guy living in Texas with a bad capacity for Spanglish trying to pronounce a French word, And that French verb means to sort. And that's what triage means. It's meant that you sort it. Actually had its applicability in the Napoleonic Wars, and again and again in World War I, where French doctors were asked to make the decision. Is this soldier, this injured soldier, likely to live, unlikely to live, or in need of immediate care that would make a difference one way or the other?

So it's about assigning degrees of urgency. It's about rationing services, and this became a really important issue for us during the COVID crisis when our clinics changed. Our ability to interact with patients changed. Face to face meetings took a dive. If you look at the, RheumNow report from today, Monday, you'll see that, a recent study shows that outpatient visits are now back up to their pre pandemic levels.

And it showed at least across the board, a lot of patients, a lot of ambulatory clinics looked at, at least a 60% drop in outpatient visits was seen during April and May, and it's slowly come back up. But we're still struggling with, I think, a number of changes as a result of the pandemic. The question is, are we doing any triage for our patients, or are you back to normal? During COVID, the idea of what encompassed an urgent visit was written about by me in a blog called Urgent or Not. And there, I think I defined what I thought was an urgent visit.

Red flag conditions, gout, septic arthritis, acute monarchitis. Any new acute inflammatory arthritis, especially the more polyarticular. Actually, monoarticular is quite worrisome too. Worsening of polyarthritis, fever, neurologic symptoms, or ocular symptoms that might be uveitis. Those are urgent conditions.

Maybe even more urgent, maybe emergent would be things like stridor, seizures, high fevers, new thrombotic events. And then in certain conditions, like AS, spinal trauma in someone with AS, or in myositis, someone with dysphagia, dysphonia, or rhabdo and trauma, or tea colored urine. And then lastly, someone with PSS, worsening hypertension and possible renal crisis. You know, so there are good definitions for what needs to be triaged, especially during times when you're contracting services. Is that appropriate now or not?

It's for you to decide. But is it appropriate for rheumatologists to be triaging their clinics? There's fifty five million Americans who have arthritis, but yet the four thousand nine hundred and fifty that the ACR says we have in rheumatologic services, they can't take care of those patients, and there's only about 3,200 prescribing in the trench rheumatologists in The United States, so you need to be very selective about what you do. Or, you can just take all comers and fill your schedule. I think rheumatologists have been a little too complacent in their business model designs and said, I'll take care of everyone.

Well, that's great. There are a lot of people who are not getting your services. So, would make a pitch that we actually have some triage to our clinics. The problem is triage requires effort. There are those rheumatologists often in either big practices or academic centers, where to get into rheumatology clinic, your chart has to be reviewed by the chart reviewer who's got his own set of rules about what gets in and what does not get in.

So we bring in the patients I want to see, and we deter the unmentionables so that they can go somewhere else, you know, whether that's osteoarthritis, chronic pain, fibromyalgia, CPRS, POTS. You know, there's a lot of things that rooms don't want to see, because our it goes back to triage. How likely is it that the intervention, our intervention, is going to make a difference in the so it could be that you wanna be a super rheumatologist, a super room where I only see one thing. You know, I only see polymyositis patients or dermatomyositis. That's my area of expertise, that's all I'm gonna say.

I think that's reasonable for some of you, but there are very few people that are doing this. The bottom line is triage could be an important part of your life and your practice, and maybe how you live even after COVID. Tune in for more QD clinics this week. Welcome to QD clinic. Hi.

I'm doctor Jack Cush with RheumNow. RheumNow is gonna cover the ACR, the ACR Convertulence meeting. Convertulence. Isn't that what they're calling it? Today's case is really about I'm not stupid.

I keep telling myself that. I'm not stupid. The case that made me think this, a 29 year old gal, is hospitalized for about two weeks. This is a number of months ago. She's hospitalized with some general malaise, not feeling good.

Fever is around a hundred, hundred and one, not necessarily predictable. She lost about 10 pounds in weight. On admission to the hospital, she really didn't have bad labs, you know, mild elevations of LFTs, mild sed rate increase, but chest X-ray showed, widening of the mediastinum. She had a mediastinal mass, so actually a sort of para aortic mediastinal mass. And as you can imagine, a big workup ensues by the infectious disease division and the rheumatology division.

So, you know, plethora labs and the ANA one thousand's all come back, you know, all test negative. Imaging shows some interesting results. She, on PET CT, had some, increased signal in her parotid, although there was no parotid symptoms nor parotid swelling on exam. Abdominal CT showed some mild increase in the size of liver and spleen and a retrocural node. And as you can might might guess that the consideration at this point is that the patient may have IgG4 related disease.

The differential diagnosis also included a multitude of infections, sarcoidosis, TB, lymphoma. But in the end, you know, it was felt that we needed to get a biopsy of that retro, or para aortic, mass, the retro the mediastinal mass, and that was ultimately done. The interesting thing was the patient, never received any steroids, never received any, interventions other than a course of antibiotics during the workup, which didn't make any difference. The patient was discharged, kind of slowly got better, and now the patient's being seen almost six months later, has done very well, really has almost no symptoms, maybe some mild, night sweats. Weight is good, no joint, no systemic manifestations.

And, the biopsy was done. Actually, the mass was removed and came back with fibrosing mediastinitis. So at this point, I'm thinking IgG4, right? I don't know. And I keep saying, Uh-oh, you could be stupid on this one.

You know, I know about IgG4, I've read about it, I've written about it, I almost diagnosed it in two or three people. They didn't have it in the end. And I'm now in a teaching clinic with a resident going over this case thinking, All right, we have, I think, enough evidence to make the diagnosis, but do we, and do we treat? And you know what? I'm not stupid.

And you know why I'm not stupid? Because I'm surrounded by peers and trainees. In the clinic, we had two attendings, we had three fellows, two residents, two medical students, and I just say, Hey, Doctor. B, we got this case. I give them the quick rundown and ask them, What do you think?

And what was great about this whole exercise was it turned into a discussion that involved everyone, even though everyone's seeing their own patients, taking care of their own case, everyone gets sucked into this conversation because it's really interesting. Is this really, you know, IgG4? How are we going to better make the disease? Were there IgG4 cells in the biopsy? Yes, there were.

How many? Well, it wasn't didn't say. What was the ratio of IgG4 to IgG cells? You know, though we we are actually lacking some information we need to really be totally complete here. But fibrosing mediastinitis is not an uncommon subset within this group, and the question is, are we going to treat?

So what I am presenting here is partly an IgG4 related story, but also the, I think, the wonders of working with others, the wonders of working in a teaching clinic with trainees, the wonders of working alongside your peers because when you're feeling the least bit stupid, they can remind you, Hey, you're not so stupid, and they can educate you just as you may educate them. So the great thing about this is, you know, I know I'm good at what I do, but I know I'm not always great at what I do. But I am great when I'm surrounded by my peers. I can be better when I'm surrounded by trainees. Everybody brings something to the table.

And this is kind of important when considering, how we're going to learn at the ACR. You know, we learn a lot when we go to these meetings because you're surrounded by peers, there's a lot of discussion and whatnot, but next, you know, next month, we're gonna have a virtual meeting where this is a bigger challenge. How are you gonna interact? How are you going to, learn from your peers? Again, I I think there are many ways that you can do this.

We're working on doing this at RheumNow. You give us two hours. We'll give you the meeting, and we're hoping to interact with you on that which is covered during the meeting. Tune in tomorrow for another QD clinic. Welcome to QD clinic.

Hi. I'm your host, Jack Cush. Today, we're gonna talk about swollen but not painful. ACR twenty twenty is coming up. It's a virtual meeting.

You give us two hours, we'll give you the meeting. Swollen, not painful, what's he talking about? I'm talking about a 61 old white female who shows up in my clinic a few weeks ago. She comes in with a complaint of bilateral pain in her feet, meaning her ankles, really meaning her midfoot. It's going on for about five or six years, started off with an insidious onset of some difficulty, not a lot of pain, not a lot of swelling.

There's no redness or episodic attacks or anything like that. What she notes is that her feet kind of bothered her, and, it's only been recently that they've really bothered her, but they've bothered her because she's developed more and more of a neuropathy over these five years with numbness and tingling, occasionally burning, never had an evaluation, for neuropathy. And now, the feet are bothering her because she has bony abnormalities in the midfoot. And the question is, what's going on? She's sent with a possible diagnosis of gout.

So her what's her past medical history? Osteopenia, vitamin d deficiency, colon cancer that was well treated. Now, she's doing fine with all of those things, taking very little medicine, not taking any medicine for pain. When you do the exam, she's got a bizarre midfoot bilaterally. She's got hypertrophic bone at the tarsometatarsal joints that's very asymmetric even though it involves right and left side.

And again, it's a bizarre looking foot because of, again, this bony overgrowth. Clearly, I'm describing is someone who has a neuropathic joint. And why do I call this a neuropathic joint or arthropathy? Why is this Charcot arthropathy? Because of what I introduced at the top of this segment, swollen but not painful, meaning you get bony, hypertrophic derangement, but not much in the way of pain and often in the presence of neurologic damage.

So, what happens in folks with Charcot or neuropathic joints is that because of the neuropathy, there's a loss of proprioception, and they end up just having a repetitive trauma to those joints. Proprioception actually protects you from a lot of damage, but the loss of damage they get, the pounding that leads to hypertrophic bone. This is very common in diabetics where there's involvement usually of the TMTs. It's also common in patients with syphilis. There it's called tabes dorsalis where the involved joint is usually the knee or hip.

Then bizarrely and uncommonly rarely is syringomyelia, where the shoulder, elbow, and sometimes cervical spine can be involved. There are other causes, calcium pyrophosphate disease, alcoholic neuropathy, amyloidosis, and yaws. You have to look that one up. So, what happens is early on they can develop an acute, neuropathic arthropathy with, effusions. Effusions are usually non inflammatory, they're occasionally hemorrhagic because of the trauma.

But then most people by the time they present as this patient did have chronic disease with chronic damage that looks like exaggerated osteoarthritis on radiographs. Again, the key here is that there's not a lot in the way of pain. There's not a lot you can do. Weight loss, they need pain medicines, you give them pain medicines, splinting may work. Not surprisingly, they don't respond to much, they, don't really respond very well to surgery.

Arthrodesis doesn't work, joint replacements are usually problematic. Again, they suffer from a loss of proprioception, that's going to continue. So, main thing is to make the diagnosis. What is the cause of neuropathy? What is the cause of the neuropathy that leads to Charcot joint?

Not apparent in this patient. She has no history of diabetes. Her recent blood sugar looked to be normal when I looked at it, although we sent off labs, haven't seen them yet, including an a hemoglobin a one c, an RPR, and other tests looking for neuropathic causes. Could she have amyloidosis? Well, then you're gonna have to get a fat pad biopsy.

But again, think we have to sort of go through a process here, to make the diagnosis. Until that time, it's about really making the diagnosis more so than keeping the patient, pain free, because they came in pain free. I think, in this particular patient, we did, refer the patient for, nerve conduction studies to look for and to document, the neuropathy and the type of neuropathy she has. These patients are interesting because they are, uncommon and they can be readily diagnosed on clinical grounds, and, you can say a lot about what happened, you can't necessarily do a lot about what's going to happen in the future. Again, give us two hours, we'll give you the meeting.

Tune in for more QD clinics.