International league of associations for rheumatology recommendations for the management of psoriatic arthritis in resource-poor settings

Background

Psoriatic arthritis (PsA) is a challenging heterogeneous disease. The European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and PsA (GRAPPA) last published their respective recommendations for the management of PsA in 2015. However, these guidelines are primarily based on studies conducted in resource replete countries and may not be applicable in countries in the Americas (except Canada and USA) and Africa. We sought to adapt the existing recommendations for these regions under the auspices of the International League of Associations for Rheumatology (ILAR).

Process

The ADAPTE Collaboration (2009) process for guideline adaptation was followed to adapt the EULAR and GRAPPA PsA treatment recommendations for the Americas and Africa. The process was conducted in three recommended phases: set-up phase; adaptation phase (defining health questions, assessing source recommendations, drafting report), and finalization phase (external review, aftercare planning, and final production).

Result

ILAR recommendations have been derived principally by adapting the GRAPPA recommendations, additionally, EULAR recommendations where appropriate and supplemented by expert opinion and literature from these regions. A paucity of data relevant to resource-poor settings was found in PsA management literature.

Conclusion

The ILAR Treatment Recommendations for PsA intends to serve as reference for the management of PsA in the Americas and Africa. This paper illustrates the experience of an international working group in adapting existing recommendations to a resource-poor setting. It highlights the need to conduct research on the management of PsA in these regions as data are currently lacking.

Key Points • The paper presents adapted recommendations for the management of psoriatic arthritis in resource-poor settings. • The ADAPTE process was used to adapt existing GRAPPA and EULAR recommendations by collaboration with practicing clinicians from the Americas and Africa. • The evidence from resource-poor settings to answer clinically relevant questions was scant or non-existent; hence, a research agenda is proposed.

Electronic supplementary material

The online version of this article (10.1007/s10067-020-04934-7) contains supplementary material, which is available to authorized users.

Rates of hip and knee joint replacement amongst different ethnic groups in England: an analysis of National Joint Registry data

OBJECTIVE

Despite a health care system that is free at the point of delivery, ethnic minorities may not always get care equitable to that of White patients in England. We examined whether ethnic differences exist in joint replacement rates and surgical practice in England.

DESIGN

373,613 hip and 428,936 knee National Joint Registry (NJR) primary replacement patients had coded ethnicity in Hospital Episode Statistics (HES). Age and gender adjusted observed/expected ratios of hip and knee replacements amongst ethnic groups were compared using indirect standardisation. Associations between ethnic group and type of procedure were explored and effects of demographic, clinical and hospital-related factors examined using multivariable logistic regression.

RESULTS

Adjusted standardised observed/expected ratios were substantially lower in Blacks and Asians than Whites for hip replacement (Blacks 0.33 [95% CI, 0.31-0.35], Asians 0.20 [CI, 0.19-0.21]) and knee replacement (Blacks 0.64 [CI, 0.61-0.67], Asians 0.86 % [CI, 0.84-0.88]). Blacks were more likely to receive uncemented hip replacements (Blacks 52%, Whites 37%, Asians 44%; P < 0.001). Black men and women aged <70 years were less likely to receive unicondylar or patellofemoral knee replacements than Whites (men 10% vs 15%, P = 0.001; women 6% vs 14%, P < 0.001). After adjustment for demographic, clinical and hospital-related factors, Blacks were more likely to receive uncemented hip replacement (OR 1.43 [CI, 1.11-1.84]).

CONCLUSIONS

In England, hip and knee replacement rates and prosthesis type given differ amongst ethnic groups. Whether these reflect differences in clinical need or differential access to treatment requires urgent investigation.

Inflammatory arthritis in HIV positive patients: A practical guide

Background

Musculoskeletal manifestations of the human immunodeficiency virus (HIV) have been described since the outset of the global HIV epidemic. Articular syndromes that have been described in association with HIV include HIV-associated arthropathy, seronegative spondyloarthropathies (SPA) (reactive arthritis, psoriatic arthritis (PsA) and undifferentiated SPA), rheumatoid arthritis (RA) and painful articular syndrome.

Methods

We carried out a computer-assisted search of PubMed for the medical literature from January 1981 to January 2015 using the keywords HIV, acquired immune-deficiency syndrome, rheumatic manifestations, arthritis, spondyloarthropathy, anti-TNF and disease modifying antirheumatic drugs. Only English language literature was included and only studies involving adult human subjects were assessed.

Results

There are challenges in the management of inflammatory arthritis in patients who are HIV-positive, including difficulties in the assessment of disease activity and limited information on the safety of immunosuppressive drugs in these individuals.

Conclusions

This review focuses on the clinical characteristics of the inflammatory articular syndromes that have been described in association with HIV infection and discusses the therapeutic options for these patients.

Travel- and immigration-related problems in rheumatology

Health problems are self-reported by up to 64% of travellers to the developing world. Traditionally, rheumatic symptoms are accorded little significance, but many travellers do return home with musculoskeletal complaints. The assessment of these patients is often hindered by the Western clinician's lack of familiarity with the types of infections that the patient may have encountered while travelling. Standard serological tests for autoimmune diseases can be unreliable in the setting of concomitant tropical infection, and these infections themselves can have musculoskeletal manifestations. Even in the absence of tropical infection, laboratory investigation of musculoskeletal symptoms in individuals of different ethnicities is challenging due to genetic and physiological variation. This review focusses on addressing the impact global migration has had on rheumatological clinical practice.

An unusual foreign body in the ear of an elderly Nigerian patient

This was a case of an incidental finding of an unusual foreign body in the right ear of an elderly Nigerian patient. The mode of presentation, the manner of discovery and how it was managed successfully were highlighted. We reported this case to create awareness, and encourage physicians to always observe effluents obtained from irrigation of body cavities for confirmation of diagnosis and documentation.

Lymphoproliferative disorder due to sulphasalazine

We present the case of a 57-year-old man who had been on sulphasalazine for 20 years for seropositive non-erosive rheumatoid arthritis and developed a lymphoproliferative disorder, which resolved completely on cessation of sulphasalazine. This is the first report of lymphoproliferative disorder secondary to sulphasalazine. Lymphoproliferative disorders are well recognised with methotrexate and cyclosporine, and recognition of this disorder is critical due to the fact that a number of patients' symptoms will resolve completely with discontinuation of the drug and will not need further treatment. This case report discusses the literature on lymphoproliferative disorders as well as differential diagnoses like drug rash with eosinophilia and systemic symptoms (DRESS) syndrome.

Rheumatology training in the United Kingdom: the trainees' perspective

BACKGROUND

Rheumatology training has undergone significant changes in the last decade with Calmanization, implementation of the New Deal for junior doctors and newer educational strategies for improving musculoskeletal training, like a core curriculum. However, concerns have been expressed about the quality of postgraduate training programmes in the UK.

OBJECTIVES

First, to assess current trainees' perceptions of the quality of core and subspecialty training, the impact of workload on training, and to explore demographic variations in training experience. Secondly, to identify educational strategies that trainees felt would enhance their training.

METHODS

The questionnaire was initially distributed to all specialist registrars attending the BSR Annual Meeting in Brighton in April 2002. Subsequently, the questionnaire was posted to all registrars on the Joint Committee for Higher Medical Training list with a reminder after 4 weeks.

RESULTS

Trainees rated positively training in routine patient care, musculoskeletal examination and injection skills while training in primary care rheumatology, epidemiology, paediatric rheumatology and sports medicine was rated negatively. There is agreement that the reduction in junior doctors' hours has adversely affected training, and issues relating to workload have overtaken training issues. Trainees undertaking dual accreditation are more likely to feel this. Educational strategies deemed to enhance training included training workshops focused on specific topics, such as musculoskeletal radiology (89.2%), and an adequate debriefing session after an out-patient clinic (81.6%). An independently administered, reliable and valid scale for quality of training could be used to assess regional variations in training and monitoring quality.

CONCLUSIONS

The changes to junior doctors' hours, the working patterns of doctors and service commitments have all affected the quality and time available for certain aspects of rheumatological training. A major effort to enhance quality is necessary to ensure that the objectives of training are met within the intended training budget.

A national qualitative survey of community-based musculoskeletal services in the UK

OBJECTIVE

To determine the characteristics of community-based musculoskeletal services provided by primary care organizations within the UK.

METHODS

Members of five professional groups within UK primary care organizations (n=461) were sent a questionnaire.

RESULTS

The response rate by organization was 71% (328/461). Respondents described 350 community-based musculoskeletal services, 233/328 (71%) organizations had one or more musculoskeletal services within their community. Five main forms of service provision were: a scanning service, a rehabilitation service, physiotherapy services, joint or soft tissue injections and the implementation of integrated care pathways. In 162 services, patients were assessed, reviewed or triaged, by a 'non-consultant' health-care professional (physiotherapist or general practitioner), at an intermediate level between primary and secondary care. The purpose of the service was described in 292/350 services, only 39/350 had clear evaluation strategies and 53/350 had consideration of individual training needs.

CONCLUSIONS

There are a wide range of musculoskeletal services flourishing within the community sector, whose quality may be variable. Whilst there is good evidence to suggest systematic planning of these services, we are concerned about the lack of data to support their effectiveness in terms of clinical outcomes, monitoring of service delivery standards and ongoing professional development of service providers. Commissioners of such services must ensure they have taken account of the evidence base and met any identified needs of local populations. Services should have a clear purpose with an appropriate evaluation strategy, and well-defined dissemination mechanisms. An integrated educational strategy for staff within the service must be sensitive to issues relating to accreditation, appraisal and revalidation.

The value of masters educational programmes for specialist registrars in rheumatology

The training of junior doctors has undergone major changes in recent years. There is now more structure, with defined assessment time points leading to a Certificate of Specialist Training. This certificate provides documentation indicating that the trainee has undergone a satisfactory period of training and that they are sufficiently competent to practise as a specialist, unsupervised. The changes have led to re-examination of the role of, and educational provision for, research training as well as clinical training. In this article we review these issues and argue that the development of masters educational programmes may help to address several concerns.

Improving the quality of care of musculoskeletal conditions in primary care

OBJECTIVE

To determine the support services general practitioners (GPs) need when working with patients who have musculoskeletal problems and their educational needs in order to deliver an improved service.

METHODS

GPs (n=446) on the Sheffield and Barnsley principal lists were sent a questionnaire (53.8% response rate). Semistructured interviews of a purposive sample of 10 GPs were analysed qualitatively to increase understanding of the research objectives.

RESULTS

GPs were self-confident in managing common musculoskeletal conditions such as gout (86% of GPs who replied), back pain (69%), osteoarthritis (62%) and sporting injuries (58%) entirely within the surgery. Despite high levels of confidence in diagnosing non-specific pain syndromes, 68% of GPs would refer to a rheumatologist. Most GPs (68%) were happy with their current referral rates to physiotherapists and 65% of GPs in this sample provided a personal injection service. Reduction of inappropriate prescribing of non-steroidal anti-inflammatory drugs would be helped by better patient education materials on treatments (90%) and more resources for the primary care physiotherapy service (85%). Half of the GPs had had specific musculoskeletal training within the last 5 yr. Half of the GPs planned to update their knowledge and skills in the next year, 64% of these preferring a taught interactive course, 50% wanting to sit in with a consultant in clinic and 46% preferring to learn as part of a personal learning plan.

CONCLUSIONS

GPs feel confident managing the majority of musculoskeletal conditions within the surgery provided they have adequate support in terms of opportunities for appropriate education, particularly joint injection techniques, ongoing consultant support for complex cases with poor outcomes, particularly non-specific pain syndromes, adequate access to physiotherapy, and a multidisciplinary approach to pain control and inappropriate prescribing.

The use of intravenous pulsed methylprednisolone in the treatment of systemic-onset juvenile chronic arthritis

An open prospective study using i.v. methylprednisolone in children with juvenile chronic arthritis (JCA) who had had a systemic exacerbation of disease is described. Eighteen children aged from 3 to 14 yr and 9 months (mean 9.7 yr) were treated. Ten patients (55%) had a loss of all systemic features 1 month after the pulse, and eight (45%) had a reduction in the active joint count. At this time, five of the patients on oral prednisolone had achieved a reduction in dosage. Also at 1 month, a reduction in erythrocyte sedimentation rate was observed in 11 patients (61%) and of C-reactive protein in 11 of 16 (72%). Altogether, 13 patients (72%) had a good response, while a further three (16%) went into remission. Our conclusions are that pulse methylprednisolone provides good short-term benefit in patients with systemic-onset JCA; no serious side-effects were noted. Further long-term studies are warranted.

Rheumatic manifestations of infectious diseases in children

Infectious diseases continue to elicit worldwide attention. Many of these diseases have rheumatic manifestations as an incidental or principal feature. Because this is particularly true in children, rheumatic manifestations of infectious diseases in this population continue to be an area of great importance to rheumatologists. A variety of bacteria, viruses, fungi, and parasitic organisms can give rise to infectious diseases with rheumatic manifestations. A high index of clinical suspicion is frequently necessary for an accurate diagnosis. Prompt diagnosis and early and appropriate therapeutic intervention are usually required for a successful, and frequently curative, outcome. Over the past year, studies have addressed the pathogenetic mechanisms and clinical spectrum of the rheumatic manifestations of infectious diseases in children. There has been particular emphasis on septic arthritis, osteomyelitis, sickle-cell disease, and hepatitis C viral infection. There remains the daunting and unfortunate possibility of large numbers of children developing HIV-associated arthritis.

Rheumatic manifestations of infectious diseases in children

Infections associated with rheumatic diseases in children remain an important area of pediatric rheumatology. Early diagnosis and prompt treatment of septic arthritis and osteomyelitis are essential. Rheumatic fever is a significant public health problem particularly in the developing world. A variety of nonbacterial infections are also associated with rheumatic diseases in children. There is also the unfortunate possibility of children developing AIDS-associated rheumatic diseases.

Rheumatic manifestations of tropical diseases

It is becoming increasingly recognized that a variety of tropical infectious diseases may be associated with a wide range of rheumatic infections. These include viral arthropathies such as O'nyong-nyong, chikungunya, and dengue. Parasitic infections such as filariasis, schistosomiasis, and amoebiasis can be associated with various joint problems. Diseases such as tuberculosis, rheumatic fever, leprosy, and brucellosis, although more common in the tropics, continue to present with rheumatic features in Western countries. Thus, with increasing world travel and migration, there is a need for increasing awareness and further study of tropical diseases and their rheumatic manifestations.

IgG glycosylation in association with tropical infections and rheumatoid arthritis in the tropics

Studies conducted in Europe suggest an association between IgG glycosylation abnormalities and rheumatoid arthritis (RA). Glycosylation abnormalities have been shown in other inflammatory diseases such as tuberculosis, systemic lupus erythematosus (SLE) and Crohn's disease. These observations led us to study glycosylation abnormalities among patients with RA and healthy controls in the tropics (sub-Saharan Africa). Using a lectin binding assay, we found that glycosylation differences were present in both groups when compared with British rheumatoid and healthy controls. This suggests that IgG glycosylation abnormalities may occur in association with chronic infections in the tropics.

Antibodies to the 65 kDa mycobacterial stress protein in west Africans with rheumatoid arthritis, tuberculosis and malaria

We have studied IgG antibodies to recombinant mycobacterial 65 kDa heat-shock protein in West African rheumatoid arthritis (RA) patients and local control groups, including those with tuberculosis or malaria. Mean levels were higher among the patients with RA than among healthy controls, but did not achieve statistical significance. Our findings may relate to the level of mycobacterial exposure in West Africa.

Osteoarthritis

There are few studies on the prevalence, pattern or clinical course of osteoarthritis (OA) in the tropics. The studies that have been carried out, however, indicate that on the whole there is a lower prevalence of OA than found in Western countries. In addition, the pattern of joint involvement may be different with less common involvement of the hip relative to the knee and polyarticular OA is uncommon in many parts of the tropics. It also seems likely that a significant number of these patients in the tropics have OA secondary to various infections including pyogenic, tuberculous and parasitic infections. There is an urgent need to confirm these observations and to identify possible genetic, developmental or environmental factors influencing the expression of OA in the tropics. In addition degenerative arthropathies, such as Mseleni's disease, present in some parts of the tropics, merit further study. With increasing life-expectancy and improved health-care in many parts of the tropics, OA will become an increasingly prevalent and important condition with associated morbidity and socio-economic implications for these countries.

Tropical rheumatology. Epidemiology and community studies: Africa

There is still far too little information available on the rheumatic diseases in Africa. Epidemiological studies are required in order to determine the burden of illness from rheumatic diseases on the African continent as well as to identify local risk factors for certain diseases. Such studies will also serve to enable the development of preventative and rehabilitation strategies. Functional disability has to be assessed in relation to the prevailing sociocultural lifestyle on the continent. Measures of disability that reflect this await development whilst regional diagnostic criteria also need to be worked out. The validity of tests and the stability of test reagents in a tropical climate require analysis. Continuing assessment of rheumatological services is essential to ensure their effectiveness and efficiency in the community and in particular to determine health care priorities and the best forms of therapeutic intervention. This will enable judicious use of limited resources. Community surveys in Africa are fraught with constraints and are difficult to undertake owing to a shortage of manpower and financial resources. For this reason, most studies hitherto have been hospital based. Hospital studies though useful lack applicability to the population as a whole and consequently more emphasis on cross-sectional and longitudinal community studies are required. It is hoped that despite the restraints, these studies will be performed.

Tropical rheumatology. Immunological aspects

The presence of auto-antibodies in infectious diseases continues to puzzle and provoke. It is hoped that sequencing studies in particular will yield further clues as to the role and mechanism of production of autoantibodies in infectious diseases. This, in turn, may also provide further insights into the role of auto-antibodies in auto-immune diseases. From a practical clinical viewpoint, the search for improved auto-antibody tests and new diagnostic markers with improved sensitivity and specificity must continue in the tropics. Until this is achieved, the results of auto-antibody tests in persons living in the tropics, persons from the tropics or patients with tropical infections, must be interpreted with caution.

Specificity of IgM antiglobulins produced in rheumatoid arthritis and tropical infections

The measurement of rheumatoid factors is of limited value in West Africa due to the low rheumatoid factor seroprevalence among patients with rheumatoid arthritis and the increased seroprevalence among healthy individuals and those with infectious diseases in the region. Using ELISA methods, we have been able to increase the specificity of rheumatoid factor measurement although the sensitivity of this test remains low. Furthermore, among the infectious diseases studied, there was no preferential binding of rheumatoid factors to the Fab gamma portion of immunoglobulin over the Fc gamma portion.

High levels of anti-type II collagen IgG in west African patients with rheumatoid arthritis

OBJECTIVE

To compare levels of antitype II collagen IgG in West African and British patients with rheumatoid arthritis (RA).

METHODS

IgG levels to native and denatured type II collagen were measured by ELISA:

RESULTS

Serum levels of antinative type II collagen IgG were raised in 17 of 58 (29%) West African patients with RA. In contrast, 14 of 89 (16%) British RA patients had raised levels of antinative type II collagen IgG. Levels of antinative type II collagen IgG were also higher in West African patients with RA than in the British patients.

CONCLUSION

Our results suggest that type II collagen autoimmunity plays a more prominent role in RA in West Africa than in Britain.

DC-ART: preventing or significantly decreasing the rate of progression of structural joint damage

Progressive joint damage, increasing deformity, and declining function characterize rheumatoid arthritis (RA). The evidence suggests structural joint damage is the predominant cause of functional impairment. Structural changes of joints are evaluated by imaging methods. Plain joint radiographs remain the best method for determining the extent and nature of structural changes at present. Newer technologies such as magnetic resonance imaging may eventually replace them. Clinical studies of antirheumatic drugs involving the assessment of prevention or significant decrease in the rate of progression of structural joint damage in RA should meet several standards. All patients who enter a study, whether they continue medication or not, must be assessed on its completion. Studies require sufficient power to determine realistic differences due to therapy. They should last long enough for a reliable analysis of the effects of joint damage; 1 year would be the minimal period for such a study, and 2 years would be preferable. Evaluation should concentrate on erosions and related structural changes in juxtaarticular bone; mapping osteoporotic areas in early disease may be a sensitive and objective measure. Assessments ought to use changes within the hands and wrists to indicate overall progression, with the feet included in evaluating early disease. There should be different therapeutic aims at various stages of RA, focussing on preventing new erosions developing in early disease (< 2 years from diagnosis), preventing new erosions occurring in established disease (2-5 years from diagnosis), reducing the rate erosions develop in established disease (< 5 years from diagnosis), and reducing the rate of joint destruction in late disease (> 5 years from diagnosis).

Antibodies to synthetic peptide P62 corresponding to the major epitope of rheumatoid arthritis nuclear antigen in a west African population with rheumatoid arthritis

Using a synthetic peptide (P62) we have investigated antibodies to rheumatoid arthritis nuclear antigen (RANA) in 58 West African patients with RA, 51 with malaria, 111 with tuberculosis (TB) and 166 healthy controls by ELISA using a synthetic peptide (P62). As in Western populations the RA sera showed significantly increased levels of anti-P62 antibodies though in our study the mean titres were only elevated twofold above the controls. The levels in malaria and TB were normal. Our data extend previous work by showing that raised anti-P62 antibodies is a consistent finding in RA world-wide including indigenous West African patients.

Seroepidemiological associations between tuberculosis, malaria, hepatitis B, and AIDS in West Africa

Serum samples from 51 patients with malaria, 35 patients with hepatitis B virus infection, 111 patients with tuberculosis, and 166 healthy controls were studied to determine any associations between tuberculosis, malaria, hepatitis B, and AIDS in Nigeria, West Africa. All serum samples were examined for the presence of HIV-1/HIV-2, hepatitis B virus surface antigen (HBsAg), and malaria antibodies. Only one patient was HIV-1 antibody-positive and none HIV-2 antibody-positive. Statistical associations were found between the presence of malaria antibody titres on the one hand and a diagnosis of hepatitis B virus infection (P < 0.05) or tuberculosis (P < 0.05). A stronger association (P < 0.001) was found between the presence of HBsAg and tuberculosis suggesting that HBsAg carriers are at higher risk of contracting tuberculosis.

High prevalence of joint laxity in West Africans

Previous surveys have suggested marked ethnic and geographical variation in the occurrence of joint hypermobility. We investigated the prevalence of joint hypermobility and the influences of age, sex, body mass and occupation in a rural Yoruba population in Nigeria. The study sample consisted of 204 individuals aged 6-66 yr from the townships of Igbo-ora and Eruwa in south western Nigeria. Sixty-eight had reported joint pain as part of a population survey of arthritic disorders and each was age and sex matched with one household and one neighbour control. Joint hypermobility was assessed, at four peripheral sites bilaterally and forward flexion of the trunk, by a single observer using the Beighton score. Each subject had weight and height recorded, answered a brief questionnaire about occupation and joint symptoms and was examined for peripheral joint disease. Only 11 (5%) of the subjects were negative at all five sites whereas 111 (54%) were hypermobile at three or more sites including 23 (11%) positive at all five. Using a score of 4/9 or greater as a cutoff, 88 (43%) were positive, including 35% of males and 57% of females. There was a linear decline with age in females but a more rapid decline only to age 35 yr in males. There was no relation to body mass or occupation. We conclude that joint hypermobility amongst this population is substantially greater than that recorded for other groups but is not associated with joint pain.

The absence of antibodies to malaria and human immunodeficiency virus, and the presence of hepatitis B surface antigen as diagnostic markers of rheumatoid arthritis

Rheumatoid factor is of limited value in the diagnosis of rheumatoid arthritis (RA) in West Africa. Consequent upon previous findings, we have studied the role of the absence of antibodies to malaria and human immunodeficiency virus (HIV) as well as the presence of the hepatitis B surface antigen (HBsAg) as diagnostic markers of rheumatoid arthritis in West Africa. We have found a significant association (p < 0.001) between RA and titre of HBsAg, but only between RA and malaria (p < 0.05) when sera with low malaria antibodies were studied. No correlation between either HBsAg or malaria and rheumatoid factor was found and no RA patient was either HIV-1 or HIV-2 positive.

A double-blind study of the effectiveness of low level laser treatment of rotator cuff tendinitis

Thirty-five patients with rotator cuff tendinitis were randomly allocated to active (CB Medico Master III 830 nm Ga As AL diode) laser or dummy laser treatment twice weekly for 8 weeks. Movement range, painful arc score, resisted movement score and responses to visual analogue scales for night pain, rest pain, movement pain and functional limitation were measured second weekly. All responses improved from baseline but there was no difference between the two groups. These results fail to demonstrate the effectiveness of laser therapy in rotator cuff tendinitis.