RheumNow Podcast Medical Selfies (5.24.19) Save
RheumNow Podcast Medical Selfies (5.24.19) by Dr. Cush
Transcription
Hi, it's the 05/24/2019. This is the RheumNow podcast. I'm Doctor. Jack Cush, executive editor of roomnow.com here to talk to you about why selfie pics may not be a bad idea, why ILD is up and coming, how to assess it, how to treat it, and then a few things about joint replacement. We'll start out with a study about Ankara Associated Vasculitis.
In this particular study, they looked at some of the predictors of relapse and they looked at eighty six patients with and without hematuria. These are ANCA associated vasculitis patients who had achieved remission as far as proteinuria and other renal manifestations. But they looked at patients who had hematuria and those who didn't. And ultimately they looked at the predictive value of hematuria. And in the patients who had achieved remission with a successful therapy, they found that those who had hematuria still were likely to have a higher rate of relapse of their ANCA associated vasculitis.
So I don't know about you, but how do you assess patients with ANCA associated vasculitis? Of course, you know, are many manifestations you can look at, you know, there's ENT, upper respiratory, lower respiratory, other manifestations. In particular, they looked at renal outcomes in this particular study, and there I generally tend to, base my opinions on things like hypertension, serum creatinine, creatinine clearance, protein, and sometimes hematuria, but I've never thought of hematuria as being a very strong prognostic feature. That's sort of what this study says that hematuria should be looked at and can be used in assessing patients over time. Fibromyalgia patients have a lot of pain, they end up seeing a lot of doctors, and some of those doctors are surgeons.
Hence, a lot of my patients with fibromyalgia often have needless surgery because if you go to a surgeon repeatedly, they're going to offer you surgery and if it's for things like, you know, breast reduction, surgery for back and mid back pain, or hysterectomies for pelvic pain, etc. I worry about my patients with fibromyalgia, I tell them do not have surgery unless A) it's life threatening or B) you have a second opinion says that you will benefit from this. There was an interesting study that looked recently at patients who have fibromyalgia undergo knee replacements. And not surprisingly, they prove that fibromyalgia patients who have knee replacement surgery are thirty to fifty percent more likely to have unsuccessful outcomes, including things like surgical complications, the need for revision, mechanical worsening, or postoperative infections. I think this is important because again, you should tell your patients unless it's life threatening or game changing, don't jump in.
And they should be warned that you know, with your diagnosis, you're more likely to have untoward consequences of joint replacement surgery. An interesting study looked at lupus patients and joint replacement surgery. This looked at the national US inpatient sample study that looked at almost thirty thousand patients who had knee replacements in lupus patients and compared that to over eight million non lupus patients who had also knee replacements and ultimately they showed when they corrected for age and made other adjustments in their analyses they showed that lupus patients had no greater rate of surgical outcome disasters, meaning they had no higher rate of implant infection, revisions or even mortality from surgery. Lupus patients did have, a higher need for transfusions and they did have longer hospital stays and overall greater hospital costs. And lastly, we were more likely to be discharged to an inpatient facility for rehab I would assume.
They did not look at things like lupus outcomes. So during surgery do lupus patients have more lupus outcomes? That wasn't part of the study but they did look at surgical outcomes and I guess the good news is that you can tell your lupus patients who may need to have, joint replacement surgery that they can successfully go through this assuming that their lupus is under good control at the time they have surgery. I posted a tweet last week that I thought was important and it made the weekend Twitter run and I think it's important for you to see this. There's a study from a pediatric dermatology journal and in this particular study they compared 40 patients, a small sample, who they who they had given instructions to the parents about how to take pictures, and they gave some instructions on how to take pictures using their smartphones and some no instructions and then compared that to what happened when the patient parents with pictures showed up and the dermatologist made the diagnosis.
It turns out in this particular study there was an eighty nine percent concordance between the diagnosis that would have been made using the smartphone only picture then the in person diagnosis made by the dermatologist. Turns out it didn't matter whether the patient had specific instructions on how to take a great picture and whatnot. I think this is important. We often tell our patients if you're flaring and not doing good, or if you're getting rashes, take a picture of things and bring it to the next visit or email it to us and maybe we can manage things more efficiently with that additional bit of information. Your patient's cell phones could be an advantage for you in managing patients.
A new study looked at what happens in Behcet's in a large multicenter Egyptian study of over 1,500 patients, I think 23 Europe centers in Egypt. And they did a sort of analysis to find out was a gender important in how the disease manifests itself. I guess that was the supposition of those doing the study, beforehand. In retrospective analysis they showed in fact males were more likely to have GI involvement, CNS involvement, and DVTs. Women were more likely to have joint disease and more active disease than men.
I can't say that this means a whole lot to me. I see Behcet's, I think American Behcet's is different than Egyptian and Middle Eastern Behcet's. I think we get a lot of aches and pains and oral rather than vaginal ulcers. I don't see much DVT, CNS or GI tract involvement. In fact, I think many patients with Behcet's are really fibromyalgia with a cold sore.
I meant that for comedic value but really it's not much more than that And it's not clear that they're going to benefit from steroids or maybe new therapies in the future like the use of a Primilast. But if you treat a lot of Behcet's patients, I wonder does this fit your profile of what you see. Another center profile their patients, the Toronto Lupus Clinic is a famous lupus clinic, done by, Mary Yurowitz and Daphne Gladman and others, in Toronto, and they have a large number of patients. They followed a cohort of almost 300 patients for a long period of time and came up with these numbers about remission and low disease activity. They define remission as a SLETE I2K of zero and a low disease activity of sleet eye two ks of less than two.
You know, the sleet eye has things like, joint, cytopenia, serositis, CNS involvement, vasculitis, skin disease, renal disease, serologic disease, you know, four or more is what it takes to get into a lupus trial. You know, 10 or more is really active lupus. But their definition of remission was zero for more than ten years and remission, excuse me, LDA, low disease activity state for more than ten years. The numbers that they had in their cohort was actually quite low. Ten percent achieved clinical remission that was prolonged more than ten years, and eighteen percent were able to achieve an LDAS for more than ten years.
Altogether, that's twenty eight percent of their lupus population. They were able to have ten years of very, very low activity. I'm thinking that I might do that well in my clinic. I think I do very well managing lupus and don't need a lot of the newer therapies to manage lupus. But I think this is encouraging data about how aggressive we are that we can keep patients in remission or in LDAS for more than ten years, with effective therapy.
We reported also this week on the influence of insomnia and depression in people with osteoarthritis. In this particular study of I think over 3,000 patients, had half the patients had moderate to severe pain from their osteoarthritis and they looked at the frequency of insomnia and depression. They found that over fifty percent of patients had some element of insomnia and forty five percent had some element of past or current depression. And they showed that the number one driver of health care utilization in this cohort was pain, pain of any cause, mainly osteoarthritis cause. They found the second greatest driver was that of depression, also driving healthcare costs, and then third would have been insomnia.
So the combination of pain from OA plus depression had an additive effect. The same thing can be said for the combination of OA pain plus insomnia had an additive effect on healthcare utilization. So you assume that that it's pain and insomnia can pain and insomnia can drive, pain, excuse me, insomnia and depression can drive pain scores, and that can drive more healthcare utilization, meaning that if you're managing OA patients and they're not well controlled, these are two things that you should be looking in on and managing and paying attention to. A nice report in review comes from Italy on the issue of connective tissue disease patients and their pulmonary assessments. And they asked the question should patients with CTDs undergo PFT testing or imaging?
And there's a lot of good data showing the value of mainly PFTs and somewhat of DLCOs and sometimes high res chest CT scans. They do make the point that RA patients who have rheumatoid associated interstitial lung disease, especially of the UIP type where the prognosis is poor, that, early and then recurrent PFTs with DLCO and high res CTs periodically makes sense in managing and predicting outcomes. With other diseases, certainly you do see ILD in not just in RA, but in scleroderma patients, SLE inflammatory myositis, where there is, probably a prognostic value to PFTs, over, imaging with high res CT. On Twitter, Philip Robinson, asked the question, does it make sense to expose the patients to radiation, to fish for, prognostic data? And I think, other than what I said, UIP and RA ILD, probably not to do recurrent high res CTs.
However, PFTs and DLCOs, yes, and they actually made a case for the FVC being more predictive than the DLCO, in some cases and the LCOs in other cases, but the LCO is not as reproducible as FVC, and repeatedly really both measures should be looked at. Nintedinib, this is a tyrosine kinase inhibitor that's been approved for use in idiopathic pulmonary fibrosis is now under study. ILD and pulmonary fibrosis is a big area of investigation with new trials and new products. Nintedanib is also called OLEV, which is approved as I said, for that indication. It was studied in patients with systemic sclerosis who had, the onset of symptoms within the last seven years not including Raynaud's and had some, CT evidence of ILD.
Five seventy six patients half had diffuse cutaneous sclerosis, and forty eight percent were on background mycophenolate. The primary outcome was FVC change. And what they showed was that if you were on the tyrosine kinase inhibitor, entedinib you had almost half as less half as little, FBC progression over a one year period. At the same time, there were no other changes in scleroderma outcomes, especially the modified Rodnan Skin score, suggesting this may have value in those who have progressive lung disease, but it may not do very much for the underlying systemic sclerosis. And then lastly, there was a trial of a review of the trials of drug therapy with interstitial lung disease that I put up as a reference.
It's a recent report from the Journal of Rheumatology, written by Dinesh Khanna, where he reviews a lot of the therapies that are out there and it's really kind of disappointing. Other than cyclophosphamide, a lot of things don't work, steroids don't work, profanidone doesn't seem to work. But again, these aren't great trials and Bosentan didn't work. Rituximab did work a little bit. But we need better studies and more trials to better know what our options are in patients with interstitial lung disease.
That's it for this week at RheumNow. Go to the website to view these citations and more. Go to roomnow.live where you can see on demand the lecture of your choosing on RA vasculitis, lupus, psoriatic arthritis, ankylosing spondylitis, orthopedics, or even drug safety. We will talk next week.
In this particular study, they looked at some of the predictors of relapse and they looked at eighty six patients with and without hematuria. These are ANCA associated vasculitis patients who had achieved remission as far as proteinuria and other renal manifestations. But they looked at patients who had hematuria and those who didn't. And ultimately they looked at the predictive value of hematuria. And in the patients who had achieved remission with a successful therapy, they found that those who had hematuria still were likely to have a higher rate of relapse of their ANCA associated vasculitis.
So I don't know about you, but how do you assess patients with ANCA associated vasculitis? Of course, you know, are many manifestations you can look at, you know, there's ENT, upper respiratory, lower respiratory, other manifestations. In particular, they looked at renal outcomes in this particular study, and there I generally tend to, base my opinions on things like hypertension, serum creatinine, creatinine clearance, protein, and sometimes hematuria, but I've never thought of hematuria as being a very strong prognostic feature. That's sort of what this study says that hematuria should be looked at and can be used in assessing patients over time. Fibromyalgia patients have a lot of pain, they end up seeing a lot of doctors, and some of those doctors are surgeons.
Hence, a lot of my patients with fibromyalgia often have needless surgery because if you go to a surgeon repeatedly, they're going to offer you surgery and if it's for things like, you know, breast reduction, surgery for back and mid back pain, or hysterectomies for pelvic pain, etc. I worry about my patients with fibromyalgia, I tell them do not have surgery unless A) it's life threatening or B) you have a second opinion says that you will benefit from this. There was an interesting study that looked recently at patients who have fibromyalgia undergo knee replacements. And not surprisingly, they prove that fibromyalgia patients who have knee replacement surgery are thirty to fifty percent more likely to have unsuccessful outcomes, including things like surgical complications, the need for revision, mechanical worsening, or postoperative infections. I think this is important because again, you should tell your patients unless it's life threatening or game changing, don't jump in.
And they should be warned that you know, with your diagnosis, you're more likely to have untoward consequences of joint replacement surgery. An interesting study looked at lupus patients and joint replacement surgery. This looked at the national US inpatient sample study that looked at almost thirty thousand patients who had knee replacements in lupus patients and compared that to over eight million non lupus patients who had also knee replacements and ultimately they showed when they corrected for age and made other adjustments in their analyses they showed that lupus patients had no greater rate of surgical outcome disasters, meaning they had no higher rate of implant infection, revisions or even mortality from surgery. Lupus patients did have, a higher need for transfusions and they did have longer hospital stays and overall greater hospital costs. And lastly, we were more likely to be discharged to an inpatient facility for rehab I would assume.
They did not look at things like lupus outcomes. So during surgery do lupus patients have more lupus outcomes? That wasn't part of the study but they did look at surgical outcomes and I guess the good news is that you can tell your lupus patients who may need to have, joint replacement surgery that they can successfully go through this assuming that their lupus is under good control at the time they have surgery. I posted a tweet last week that I thought was important and it made the weekend Twitter run and I think it's important for you to see this. There's a study from a pediatric dermatology journal and in this particular study they compared 40 patients, a small sample, who they who they had given instructions to the parents about how to take pictures, and they gave some instructions on how to take pictures using their smartphones and some no instructions and then compared that to what happened when the patient parents with pictures showed up and the dermatologist made the diagnosis.
It turns out in this particular study there was an eighty nine percent concordance between the diagnosis that would have been made using the smartphone only picture then the in person diagnosis made by the dermatologist. Turns out it didn't matter whether the patient had specific instructions on how to take a great picture and whatnot. I think this is important. We often tell our patients if you're flaring and not doing good, or if you're getting rashes, take a picture of things and bring it to the next visit or email it to us and maybe we can manage things more efficiently with that additional bit of information. Your patient's cell phones could be an advantage for you in managing patients.
A new study looked at what happens in Behcet's in a large multicenter Egyptian study of over 1,500 patients, I think 23 Europe centers in Egypt. And they did a sort of analysis to find out was a gender important in how the disease manifests itself. I guess that was the supposition of those doing the study, beforehand. In retrospective analysis they showed in fact males were more likely to have GI involvement, CNS involvement, and DVTs. Women were more likely to have joint disease and more active disease than men.
I can't say that this means a whole lot to me. I see Behcet's, I think American Behcet's is different than Egyptian and Middle Eastern Behcet's. I think we get a lot of aches and pains and oral rather than vaginal ulcers. I don't see much DVT, CNS or GI tract involvement. In fact, I think many patients with Behcet's are really fibromyalgia with a cold sore.
I meant that for comedic value but really it's not much more than that And it's not clear that they're going to benefit from steroids or maybe new therapies in the future like the use of a Primilast. But if you treat a lot of Behcet's patients, I wonder does this fit your profile of what you see. Another center profile their patients, the Toronto Lupus Clinic is a famous lupus clinic, done by, Mary Yurowitz and Daphne Gladman and others, in Toronto, and they have a large number of patients. They followed a cohort of almost 300 patients for a long period of time and came up with these numbers about remission and low disease activity. They define remission as a SLETE I2K of zero and a low disease activity of sleet eye two ks of less than two.
You know, the sleet eye has things like, joint, cytopenia, serositis, CNS involvement, vasculitis, skin disease, renal disease, serologic disease, you know, four or more is what it takes to get into a lupus trial. You know, 10 or more is really active lupus. But their definition of remission was zero for more than ten years and remission, excuse me, LDA, low disease activity state for more than ten years. The numbers that they had in their cohort was actually quite low. Ten percent achieved clinical remission that was prolonged more than ten years, and eighteen percent were able to achieve an LDAS for more than ten years.
Altogether, that's twenty eight percent of their lupus population. They were able to have ten years of very, very low activity. I'm thinking that I might do that well in my clinic. I think I do very well managing lupus and don't need a lot of the newer therapies to manage lupus. But I think this is encouraging data about how aggressive we are that we can keep patients in remission or in LDAS for more than ten years, with effective therapy.
We reported also this week on the influence of insomnia and depression in people with osteoarthritis. In this particular study of I think over 3,000 patients, had half the patients had moderate to severe pain from their osteoarthritis and they looked at the frequency of insomnia and depression. They found that over fifty percent of patients had some element of insomnia and forty five percent had some element of past or current depression. And they showed that the number one driver of health care utilization in this cohort was pain, pain of any cause, mainly osteoarthritis cause. They found the second greatest driver was that of depression, also driving healthcare costs, and then third would have been insomnia.
So the combination of pain from OA plus depression had an additive effect. The same thing can be said for the combination of OA pain plus insomnia had an additive effect on healthcare utilization. So you assume that that it's pain and insomnia can pain and insomnia can drive, pain, excuse me, insomnia and depression can drive pain scores, and that can drive more healthcare utilization, meaning that if you're managing OA patients and they're not well controlled, these are two things that you should be looking in on and managing and paying attention to. A nice report in review comes from Italy on the issue of connective tissue disease patients and their pulmonary assessments. And they asked the question should patients with CTDs undergo PFT testing or imaging?
And there's a lot of good data showing the value of mainly PFTs and somewhat of DLCOs and sometimes high res chest CT scans. They do make the point that RA patients who have rheumatoid associated interstitial lung disease, especially of the UIP type where the prognosis is poor, that, early and then recurrent PFTs with DLCO and high res CTs periodically makes sense in managing and predicting outcomes. With other diseases, certainly you do see ILD in not just in RA, but in scleroderma patients, SLE inflammatory myositis, where there is, probably a prognostic value to PFTs, over, imaging with high res CT. On Twitter, Philip Robinson, asked the question, does it make sense to expose the patients to radiation, to fish for, prognostic data? And I think, other than what I said, UIP and RA ILD, probably not to do recurrent high res CTs.
However, PFTs and DLCOs, yes, and they actually made a case for the FVC being more predictive than the DLCO, in some cases and the LCOs in other cases, but the LCO is not as reproducible as FVC, and repeatedly really both measures should be looked at. Nintedinib, this is a tyrosine kinase inhibitor that's been approved for use in idiopathic pulmonary fibrosis is now under study. ILD and pulmonary fibrosis is a big area of investigation with new trials and new products. Nintedanib is also called OLEV, which is approved as I said, for that indication. It was studied in patients with systemic sclerosis who had, the onset of symptoms within the last seven years not including Raynaud's and had some, CT evidence of ILD.
Five seventy six patients half had diffuse cutaneous sclerosis, and forty eight percent were on background mycophenolate. The primary outcome was FVC change. And what they showed was that if you were on the tyrosine kinase inhibitor, entedinib you had almost half as less half as little, FBC progression over a one year period. At the same time, there were no other changes in scleroderma outcomes, especially the modified Rodnan Skin score, suggesting this may have value in those who have progressive lung disease, but it may not do very much for the underlying systemic sclerosis. And then lastly, there was a trial of a review of the trials of drug therapy with interstitial lung disease that I put up as a reference.
It's a recent report from the Journal of Rheumatology, written by Dinesh Khanna, where he reviews a lot of the therapies that are out there and it's really kind of disappointing. Other than cyclophosphamide, a lot of things don't work, steroids don't work, profanidone doesn't seem to work. But again, these aren't great trials and Bosentan didn't work. Rituximab did work a little bit. But we need better studies and more trials to better know what our options are in patients with interstitial lung disease.
That's it for this week at RheumNow. Go to the website to view these citations and more. Go to roomnow.live where you can see on demand the lecture of your choosing on RA vasculitis, lupus, psoriatic arthritis, ankylosing spondylitis, orthopedics, or even drug safety. We will talk next week.
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