Rheumatology workforces are increasingly challenged by too few physicians in face of the growing burden of rheumatic and musculoskeletal diseases (RMDs).Rheumatology is one of the most frequent non-surgical specialty referrals and has the longest wait times for subspecialists.We used a population-based approach to describe changes in the rheumatology workforce, patient volumes and geographic variation in the supply of and access to rheumatologists, in Ontario, Canada, between 2000 and 2019, and projected changes in supply by 2030.Over time, we observed greater feminization of the workforce and increasing age of workforce members.We identified a large regional variation in rheumatology supply.Fewer new patients are seen annually, which likely contributes to increasing wait times and reduced access to care.Strategies and policies to raise the critical mass and improve regional distribution of supply to effectively provide rheumatology care and support the healthcare delivery of patients with RMDs are needed. RésuméLa main-d' oeuvre en rhumatologie est de plus en plus confrontée au manque de médecins et au fardeau croissant des maladies rhumatismales et musculosquelettiques (MRM).La rhumatologie constitue l' une des spécialités non chirurgicales vers lesquelles on aiguille le plus fréquemment des patients, et les délais d' attente pour consulter un surspécialiste y sont les plus longs.Nous avons utilisé une méthode axée sur la population pour décrire les changements dans la main-d' oeuvre en rhumatologie, le volume de patients ainsi que la variation géographique de l' offre et de l' accès aux rhumatologues, en Ontario, au Canada, entre 2000 et 2019; avec une projection des changements de l' offre d'ici à 2030.Au fil du temps, nous avons observé une plus grande féminisation de l' effectif et une augmentation de l'âge de la main-d' oeuvre.Nous avons observé une grande variation régionale dans l' offre en rhumatologie.Moins de nouveaux patients sont vus chaque année, ce qui contribue probablement à l' augmentation des temps d' attente et à une réduction de l' accès aux soins.Il est nécessaire de mettre au point des stratégies et des politiques pour accroître la masse critique et pour améliorer la distribution régionale de l' offre de main-d' oeuvre, et ce, afin de fournir efficacement des soins de rhumatologie et afin de soutenir la prestation de soins de santé aux patients atteints de MRM.
The target outcome in early rheumatoid arthritis (ERA) is now remission. This meta-analysis compared the efficacy of initial methotrexate monotherapy versus combination therapy (methotrexate plus biological agent) for clinical remission and radiographic non-progression among ERA patients with minimal or no previous methotrexate exposure.
Methods
A systematic search was performed for randomised controlled trials of ERA using predefined criteria. A random effects model was used to pool the risk ratio (RR) for clinical and radiographic remission at 52–56 weeks of follow-up.
Results
Seven trials of combination therapy with infliximab, adalimumab, etanercept or abatacept were included. The majority of studies defined clinical remission as a 28-joint disease activity score (DAS28) of 2.6 or less. Radiographic non-progression was primarily defined as a modified total Sharp score change of less than 0.5 units. All trials demonstrated risk estimates in favour of combination therapy: the pooled RR for achieving clinical remission was 1.74 (95% CI 1.54 to 1.98) and for radiographic non-progression was 1.30 (95% CI 1.01 to 1.68). Significant heterogeneity among studies for the latter outcome was detected (p<0.001).
Conclusions
The efficacy of combination therapy with a biological agent is superior to methotrexate monotherapy for remission. Combination therapy has a greater initial effect on clinical remission than radiographic non-progression. Uniform definitions of remission are needed and the proportion of subjects who achieve the combined endpoint of clinical and radiographic remission should be considered as a meaningful outcome in future studies of ERA.
Prevalence studies of metabolic syndrome (MetS) in early rheumatoid arthritis (ERA) are sparse and estimates are variable. Differences by sex and menopausal status have not been formally assessed.
Objectives
We estimated prevalence and factors associated with MetS in ERA patients treated in routine practice settings. Variations by sex, and by menopausal status were also examined.
Methods
Cross-sectional data were analyzed from patients meeting 1987 or 2010 ACR/EULAR RA criteria enrolled in the Canadian Early Arthritis Cohort (CATCH) from January 2007-March 2017. CATCH is a prospective multicenter observational study of patients diagnosed and treated for early inflammatory arthritis (symptoms < 1 year) by a rheumatologist. Participants completed standardized clinical assessments and patient-reported outcome measures. Laboratory testing of metabolic parameters was encouraged, but left to the discretion of the rheumatologist. MetS was defined according to modified WHO criteria1 as ≥ 2 of the following: body mass index (BMI) ≥ 30, hypertension, low high-density lipoprotein (HDL) cholesterol, dyslipidemia, or impaired glucose intolerance (IGT)1. Univariate and multivariable logistic regression was used to estimate crude and adjusted associations between baseline demographic, clinical and lifestyle variables with prevalent MetS in men and in women, respectively.
Results
The sample included 1543 participants; 71% were female and mean(SD) age was 54 (15) years. 476 (31%) of the total sample met criteria for MetS. Participants with MetS were older, more frequently past smokers and reported more comorbid conditions, including cardiovascular disease (CVD) (p<0.0001). MetS prevalence was higher in men (42%) than women (26%, p<0.0001) and higher in post-menopausal (33%) vs. pre-menopausal women (15%, p<0.0001). Post-menopausal women had a higher frequency of hypertension (65%), IGT (32%) and dyslipidemia (21%) compared to pre-menopausal women (p<0.001). In multivariable logistic regression MetS was negatively associated with seropositivity and pulmonary disease in men; with corticosteroid use in menopausal women; and with psychiatric comorbidity in pre-menopausal women.
Conclusion
Approximately 1 in 3 ERA patients met crietria for MetS. Though men had a higher prevalence of MetS and individual MetS components, post-menopausal women had a similar MetS profile as men, and should equally be considered high risk for CVD development. Characteristics and associations with MetS differed in men and women suggesting sex-specific variations are important considerations for comorbidity screening and surveillance of CVD outcomes in ERA.
Reference
[1] Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med. 1998;15(7):539-53.
This conference report describes six presentations that were given during a Canadian Institutes for Health Research-funded workshop. The goal of the workshop was to discuss key knowledge gaps in the study of outcomes in mothers with rheumatic diseases and their offspring. Presentations focused on epidemiological and methodological issues associated with the reproductive and perinatal health of women with rheumatic diseases. Discussions of relevant recent research allowed for discovery of potential data sources that could facilitate interdisciplinary research and created the opportunity for future collaborations.
Inflammatory arthritis (IA) is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD) and contributes to significant morbidity and mortality. Early identification and treatment of conventional cardiovascular disease (CVD) risk factors are pivotal in mitigating ASCVD risk among the IA population. Equally crucial is the proactive management of inflammatory disease, necessitating a thorough discussion of the risks and benefits, particularly regarding the use of some advanced therapeutic agents indicated for IA, which may carry an increased risk of CVD in high‑risk subgroups. This article reviews the current evidence for optimal CVD screening in IA. We underscore the importance of a holistic approach that incorporates conventional risk assessment tools, biomarkers, imaging techniques, and interdisciplinary cooperation.
A 62‐year‐old man with a history of mechanical aortic valve insertion and ascending aorta replacement in 1997 presented to his family doctor in August 2004 with a two‐week history of melena after recently returning from a six‐month vacation in Mexico. The patient had no other abdominal complaints. He took warfarin but did not take nonsteroidal anti‐inflammatory agents, acetylsalicylic acid or alcohol. The patient had no history of liver or peptic ulcer disease. He had lost 7 kg over the past month, but did not complain of fever or night sweats. On physical examination, vital signs were normal, the second heart sound was mechanical, and there were no abnormal findings. Laboratory investigations showed a borderline microcytic anemia (hemoglobin 76 g/L; mean corpuscular volume 79 fL; mean corpuscular hemoglobin concentration 323 g/L), a therapeutic international normalized ratio (2.6) and an elevated creatinine level (112 µmol/L). His stool was positive for occult blood, although the ferritin level was high (623 µg/L). Other routine blood work was normal. The patient was admitted to hospital for investigation of the anemia.
Disease progression in longitudinal studies of rheumatoid arthritis (RA) is usually assessed by examining a measure of disease over fixed time intervals; results can be presented as the mean of the whole group or, for subgroups sharing common underlying characteristics. These approaches do not addresses individual within-patient changes over time. In contrast, a multi-state model classifies each patient into one of several pre-defined disease states at patient visit and examines moves between disease states over time.
Objectives
The objectives were: (1) to provide a descriptive analysis of patients9 disease states defined by the DAS-28 throughout the first three years of treatment; (2) to determine the time spent in each disease state; and (3) to estimate the probabilities of changing between disease states.
Methods
From a large ongoing prospective study of RA in Ontario, Canada (OBRI), patients who met the following inclusion criteria were selected: 1) incident RA, 2) active disease (≥1 swollen or tender joint) and 3) at least 2 follow-up visits to their rheumatologist. The DAS-28 disease score was collected at each visit and patients were classified in one of four DAS-28 categories, from remission to high disease activity. A multi-state (in this case 4-state) Markov model was fitted to describe patient progression through disease states over time. Traditional assumptions of Markov models are equal intervals between visits, which do not reflect the clinical reality of irregular visits. We fitted a novel Markov model to account for the irregular time intervals considering time as a continuous variable allowing us to examine real-world disease course over time.
Results
There were 3014 visits in 586 patients over the 3-year follow-up window (see figure). At baseline, 43% of patients were in DAS-28 high disease activity, but patients, moved out of this health state rapidly on average 0.17 years, 95% CI (0.19, 0.23). At baseline 9% of patients were in DAS-28 remission, increasing to 30% at 6 months and 45% at 1 year. Once a patient achieved remission, the mean duration before moving to another disease state was 0.81 years, 95% CI (0.67, 0.97). By 1.5 years after initiation of treatment, patients in each disease state remained relatively constant indicating no net movement between health states.
Conclusions
We identified that individual patients transition between disease states rapidly in the first 3 years of treatment when observed in usual care. Our analysis indicates the critical first year of treatment before a steady disease state with no net movement will be reached. Major changes in the first year of treatment especially in the first 6 months could be a result of treat-to target strategy but do not occur as quickly as specified by treat-to-target guidelines indicating possible gaps in care. Future research will adjust for covariates including drug history and demographic factors while also examining between physician differences.
