Perspectives and experiences of COVID-19 vaccination in people with autoimmune and inflammatory rheumatic disease

OBJECTIVE

People with autoimmune and inflammatory rheumatic disease (AIIRD) are at an increased risk of morbidity from COVID-19. While COVID-19 vaccination is effective at reducing disease complications, there have been significant levels of vaccine hesitancy in people with AIIRD. We aimed to understand vaccine hesitancy and promote shared decision-making by describing the experiences and perspectives of people with AIIRD who had concerns with COVID-19 vaccinations.

METHODS

Adults with AIIRD on immunosuppressive medications who expressed concerns regarding the COVID-19 vaccination were purposively sampled until thematic saturation. Individual semi-structured interviews were conducted and analysed using reflexive thematic analysis.

RESULTS

Sixteen adults with an AIIRD were interviewed. Thematic analysis yielded four themes: heightened sense of vulnerability; determining individual suitability; desperate for freedom and relief; deterred by scepticism.

CONCLUSIONS

The perspectives of people with AIIRD towards the COVID-19 vaccination were shaped by a sense of vulnerability. The decision-making experience was challenging, resulting from struggles with handling information, dealing with external pressures, and facing negativity.

PRACTICE IMPLICATIONS

A collaborative approach, involving close family and friends and avoiding negativity and pressure can improve engagement and support decision-making around COVID-19 vaccination. Clearly addressing potential risks of vaccination may prevent subsequent regret and hesitancy if they arise.

Menetrier’s disease exacerbating ulcerative colitis and relieved by gastrectomy

Ménétrier’s disease (MD) is a rare gastropathy characterised by giant rugal folds which can present with nausea, vomiting, abdominal pain and protein losing gastropathy. We report a 21-year-old woman with comorbid MD and ulcerative colitis (UC). Management was complicated by limited treatment options for MD, significant symptom burden, worsening nutrition and difficulty determining which disease was the predominant cause of symptoms. Since age 18 the patient experienced recurrent UC flares characterised by diarrhoea, persistent vomiting and corticosteroid dependence. Endoscopic assessment demonstrated concurrent MD and active UC. Octreotide and cetuximab were trialled given persistent hypoalbuminaemia and suspicion for MD associated protein-losing gastropathy. UC management comprised dose-optimised infliximab and methotrexate. Repeat endoscopic assessment demonstrated improvement in UC without corresponding improvement in symptoms or hypoalbuminaemia. Nasojejunal feeding and parenteral nutrition failed to significantly improve nutritional status and accordingly the patient proceeded to radical total gastrectomy. Postoperatively, MD-associated symptoms and hypoalbuminemia resolved completely.

A patient expectations questionnaire for determining criteria for entrustment decisions

INTRODUCTION

To train health professionals for patient-centered care, patient engagement in medical curriculum development and assessment is widely recommended. But there are few published methods on how to consult with patients effectively, particularly when creating entrustable professional activities (EPAs). In this mixed-method study, we developed a questionnaire for facilitating patient input when developing EPA assessment criteria.

METHODS

We developed a questionnaire for documenting patient expectations of their doctors which included: patient interviews to identify questionnaire items, expert validation, cognitive interviews with respondents, and finally, pilot testing. For the pilot testing, 87 participants with a variety of health problems from medical/surgical wards and outpatient clinics at a tertiary hospital were recruited. The final questionnaire included open-ended and ranking-style questions.

RESULTS

Using the questionnaire, patients could identify their key expectations of their doctors when managing their current medical problem. Most patients wrote clear, brief free-text responses directly applicable to EPA descriptors that were time-efficient to analyze.

CONCLUSIONS

The questionnaire is a feasible method of recording patient expectations, enabling educators to consult with and include patient perspectives when developing criteria for entrustment decisions in a diverse range of clinical contexts.

Systematic review and meta-analysis on prevalence of metabolic syndrome in psoriatic arthritis, rheumatoid arthritis and psoriasis

BACKGROUND

Psoriatic arthritis (PsA), rheumatoid arthritis (RA) and psoriasis (PsO) are associated with systemic inflammation and increased cardiovascular mortality and morbidity. Metabolic syndrome (MetS) is associated with systemic inflammation, and conditions associated with MetS, such as obesity, are associated with difficulty in attaining minimal disease activity (MDA) in individuals with inflammatory arthritis. This systematic review aims to determine whether there is an increased prevalence of MetS in PsA populations compared with PsO and RA populations.

METHODS

A systematic review was conducted to assess the prevalence of MetS in PsA, PsO, and RA populations following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The quality of the studies reviewed was assessed using the Joanna Briggs Institute Checklist for Prevalence Studies.

RESULTS

The pooled prevalence of MetS in PsA populations was 0.46 ± 0.06 (95% CI 0.40-0.51). In comparison, the prevalence of MetS in PsO and RA populations was 0.34 ± 0.03 (95% CI 0.32-0.37) and 0.31 ± 0.04 (95% CI 0.27-0.35), respectively. Patients with PsA were 1.62 ± 0.036 (95% CI 1.50-1.74) and 1.66 ± 0.038 (95% CI 1.54-1.79) times more likely to have MetS compared with PsO and RA populations.

CONCLUSION

The prevalence of MetS is significantly increased in PsA populations compared with PsO and RA populations. Further studies should be performed using a standardized definition of MetS in PsA, RA, and PsO populations to determine whether addressing the metabolic components in MetS offers any therapeutic benefits and in terms of attaining MDA and improving cardiovascular health.

Progression of knee osteonecrosis on MRI

Magnetic resonance imaging (MRI) is regarded as the most specific and sensitive of imaging modalities for the detection and progression of osteonecrosis (ON). We present MRI progression of ON in the knee in a 40-year-old female patient with Sjogren disease-related interstitial nephritis recently initiated on corticosteroids for deteriorating renal function. This case report correlates the degree of surrounding marrow edema with the patient's symptoms.

Understanding Patient Expectations of Health Care: A Qualitative Study

Understanding and measuring patient expectations of health care is central to improving patient satisfaction and delivering patient-centered care. However, most empiric research in this field has focused on measuring patient expectations for specific diseases only. Patient expectations common to a variety of settings and clinical contexts need to be better understood to design measures with wider utility. We aimed to understand how patients express and conceptualize their expectations of health care across a range of clinical contexts and conditions. Semi-structured interviews were conducted with patients presenting to a major metropolitan hospital, informed by interpretive phenomenological analysis. Sampling continued until thematic saturation. Interview topics explored the illness experience, interactions with clinicians, how patients communicated and conceptualized their expectations of health care, and the nature of these expectations. The 26 participants conceptualized and described their expectations in 3 distinct domains: (1) health outcomes, (2) individual clinicians, and (3) the health-care system. Importantly, these domains were consistent across a variety of clinical contexts, participant demographics, and medical conditions. Despite variation in expectations due to individual patient circumstances, we identified 3 conceptual domains within which expectations consistently lie. When designing measurement tools for patient expectations, we suggest incorporating questions specifically addressing the 3 domains we have identified. With such measures, clinicians and health-care providers can be empowered to provide and monitor patient-centered care with outcomes tailored to what patients desire.

Systematic review of depression and anxiety in psoriatic arthritis

AIM

To investigate the point prevalence of depression and anxiety in psoriatic arthritis and putative reductions in these comorbidities with the treatment of psoriatic arthritis.

METHOD

We performed a systematic review in accordance with PRISMA guidelines examining point prevalence of depression and anxiety in psoriatic arthritis as well as effects of treatment for psoriatic arthritis on these psychiatric comorbidities. MEDLINE, EMBASE, EBM Reviews and Cochrane, and PsycINFO were searched from inception to October 2017. Quality of studies was assessed using the Joanna Briggs Institute Checklist for Prevalence Studies. Study and population characteristics were extracted and entered into an electronic database for subsequent descriptive and meta-analysis of point prevalence.

RESULT

Three studies matched inclusion criteria with significant statistical heterogeneity. The prevalence of depression ranged between 9%-22% and anxiety between 15%-30% in patients with psoriatic arthritis. One study matched inclusion criteria for treatment effect analysis, albeit with a high risk of bias and illustrated a benefit of etanercept on the prevalence of depression (9% vs 16%) and anxiety (14% vs 30%) after 24 weeks of treatment.

CONCLUSION

This is the first systematic review of point prevalence of depression and anxiety in patients with psoriatic arthritis. There is a moderate point prevalence of both depression and anxiety in patients with psoriatic arthritis, which is similar or slightly higher than the general population and comparable to that seen in other rheumatic diseases. The effects of treatment for psoriatic arthritis on comorbid depression and anxiety remain unclear.

The ABCs of entrustable professional activities: an overview of 'entrustable professional activities' in medical education

Consultants regularly need to decide whether a trainee can be entrusted to perform a clinical activity independently. 'Entrustable professional activities' (EPA) provide a framework for justifying and better utilising supervisor entrustment decisions for trainee feedback and assessment in the workplace. Since being proposed by Olle ten Cate in 2005, EPA are emerging as an integral part of many international medical curricula, and are being considered by the Royal Australasian College of Physicians in the current review of physician training. EPA are defined as tasks or responsibilities that can be entrusted to a trainee once sufficient competence is reached to allow for unsupervised practice. An example might be to entrust a trainee to 'Initiate and co-ordinate care of the palliative patient' with only off-site or indirect supervision. Rather than attempting to measure directly each of the many separate competencies required to undertake such a complex task, EPA direct the trainee and supervisor's attention to the trainee's performance in a limited number of selected, representative, important day-to-day activities. EPA-based assessment is gaining momentum, amongst significant concerns regarding feasibility of implementation. While the optimal process for designing and implementing EPA remains to be determined, it is an assessment strategy where the over-arching goal of optimal patient care remains in clear sight. This review explores the central role of trust in medical training, the case for EPA and potential barriers to implementing EPA-based assessment.

MDHAQ/RAPID3 scores in patients with osteoarthritis are similar to or higher than in patients with rheumatoid arthritis: a cross-sectional study from current routine rheumatology care at four sites

Objective

To compare patients with a primary diagnosis of osteoarthritis (OA) versus rheumatoid arthritis (RA) for scores on a patient self-report MDHAQ/RAPID3 (Multidimensional Health Assessment Questionnaire/Routine Assessment of Patient Index Data 3), and for physician global assessment (DOCGL).

Methods

All patients with all diagnoses complete an MDHAQ/RAPID3 at all routine rheumatology visits in the waiting area before seeing a rheumatologist at four sites, one in Australia and three in the USA. The two-page MDHAQ includes 0–10 scores for physical function (in 10 activities), pain and patient global assessment [on 0–10 visual analogue scales (VAS)], compiled into a 0–30 RAPID3, as well as fatigue and self-report painful joint count scales. Rheumatologists estimate a 0–10 DOCGL VAS. Demographic, MDHAQ/RAPID3 and DOCGL data from a random visit were compared in patients with RA versus patients with OA using multivariate analysis of variance, adjusted for age, disease duration and formal education level.

Results

Median RAPID3 was higher in OA versus RA at all four sites (11.7–16.8 vs 6.2–11.8) (p<0.001 at three sites). Median DOCGL in OA versus RA was 5 vs 4, 4 vs 3.7, 2.2 vs 2.5 and 2 vs 1. Patterns were similar for individual RAPID3 items, fatigue and painful joint scales, and in stratified analyses of patients aged 55–70.

Conclusion

Patient MDHAQ/RAPID3 and physician DOCGL indicate similar or higher disease burden in OA versus RA. Routine MDHAQ/RAPID3 allows direct comparisons of the two diseases. The findings suggest possible revision of current clinical and public policy views concerning OA.

A Patient-Centered Approach to Developing Entrustable Professional Activities

PURPOSE

The medical education community is rapidly accepting the use of entrustable professional activities (EPAs) as a means of assessing residents. Stakeholder engagement is advised in developing EPAs, but no studies have investigated the role of patient input. In this qualitative study, the authors investigated what patient input may add to designing a patient-centered EPA.

METHOD

The authors chose "management of acute low back pain (LBP)" as a common, important clinical task on which to base the patient-centered EPA. In 2015, 14 patients who presented to a teaching hospital with acute LBP participated in semistructured interviews exploring their illness experience and expectations of doctors. Clinicians representing multiple disciplines participated in a focus group. The authors used the Framework Method to analyze data, identifying and developing themes, similarities, and differences between patient and clinician input. They used the findings to develop the EPA. Through an iterative procedure of data review and tracking data sources, they determined how patient and clinician input informed each EPA descriptor.

RESULTS

Drawing from their firsthand experience of LBP, patients described unique expectations of trainees which directly informed EPA descriptors. For example, the authors primarily used patients' detailed descriptions of desirable and observable trainee behaviors to inform the required attitudes descriptor.

CONCLUSIONS

Patients can provide unique contributions, complementary to those of clinicians, to EPAs. Consultations with patients led to the development of a patient-centered EPA, which aligned best clinical practice with patient expectations. Educators seeking to apply patient-centered care to EPA development could adopt a similar approach.

Transvaginal ultrasound examination of women with and without pelvic venous congestion

AIM

To determine if transvaginal ultrasound, including power Doppler examination, can distinguish between women with and without pelvic congestion.

MATERIALS AND METHODS

Thirty-six women with pelvic congestion were prospectively examined using transvaginal ultrasonography and standard uterine and ovarian measurements made. Additionally, planimetric measurements of each ovary were taken using an image analysis program to determine the cross-sectional area of ovarian stroma and follicles, if any. Power Doppler images of adnexal vessels were obtained and planimetric estimates of surface area calculated. A congestion score was assigned to each patient, based on vein number, diameter and morphology on grey-scale scanning. Identical measurements were obtained from 19 asymptomatic women and results compared.

RESULTS

There was no significant difference between women with pelvic congestion and controls with respect to power Doppler or grey-scale images of adnexal vessels, or congestion score. However, women with pelvic congestion had significantly larger and multicystic ovaries when compared to controls.

CONCLUSIONS

Transvaginal ultrasound measurements of adnexal vasculature, including power Doppler measurements, cannot reliably distinguish women with pelvic congestion from controls. However, ultrasound may remain useful for diagnosis of pelvic congestion, predominantly because it is able to visualize multi-cystic ovaries in these patients.