Faculty Bibliography

Behcet's syndrome is a systemic vasculitis with an unknown etiology affecting the small and large vessels of the venous and arterial systems. At least two clusters of disease expression have been described. The first includes superficial vein thrombosis, deep vein thrombosis, and dural sinus thrombi. The second includes acne, arthritis, and enthesitis. The presence of these clusters suggests there may be more than one disease mechanism operative in this complex disorder. Recent European League Against Rheumatism guidelines are useful for the management of the disease in organ systems distinct from the vascular, neurological, and gastrointestinal systems. This is because of a lack of controlled studies evaluating such vascular, neurological, and gastrointestinal complications

A multidimensional health assessment questionnaire (MDHAQ) can enhance doctor-patient communication beyond the important function of providing RAPID3 scores, preparing the patient for the encounter and saving time for the doctor. Optimal use of the MDHAQ should include the following actions: 1. the MDHAQ should be distributed to each patient at each visit in the infrastructure of care; 2. the MDHAQ helps the patient prepare for the visit by completing it in the waiting area prior to seeing the physician; 3. the clinician prepares for the visit and saves time by reviewing the MDHAQ before seeing the patient; 4. the clinician scans the review of systems and records the number of positives on the symptom checklist; 5. the clinician reviews the recent medical history information to save time and improve accuracy and completeness of critical information; and 6. routine Assessment of Patient Index Data 3 (RAPID3) scores are recorded in the medical record and entered into a flowsheet, which also includes other MDHAQ scores, laboratory tests, and medications

Methotrexate (MTX) has been the anchor treatment in rheumatoid arthritis (RA) over the last 15 years, and is used in combination with biologic agents to enhance efficacy over the last decade or so. The safety profile of MTX has been studied over 25 years with very few clinically important adverse events in the weekly low-doses used for RA treatment. The importance of MTX in earlier and more aggressive management of RA patients cannot be overstated. MTX courses show some of the longest continuation rates reported in clinical medicine, due to both effectiveness and safety. The safety profile of MTX indicates that it is among the safest of any mediation used for the treatment of any arthritis. Better information on the effectiveness and safety of weekly-low dose MTX should be communicated to all health professionals involved in the management of RA patients

Purpose: To analyze a proposed checklist of 10 quantitative measures, 6 from a patient questionnaire and 4 physician global scores, compiled in less than 20 seconds, to provide quantitative patient history and physical examination (PE) data, which rheumatologists indicate are more important than laboratory tests in clinical decisions in usual care visits. Methods: The 6 quantitative patient measures are from a self-report multidimensional health assessment questionnaire (MDHAQ) for: physical function (FN) (0-10); 21 circle 0-10 visual analog scales for pain (PN), patient global estimate (PTGL), and fatigue (FT); review of 60-symptom checklist (SX); and RAPID3, a 0-30 total of FN+PN+PTGL whcih requires 5 seconds. The 6 scores are compared on a flow sheet to scores at previous visits prior to the traditional patient encounter. The rheumatologist records 4 global estimates for: overall status (0-10), and 3 0-3 global scales for levels of inflammatory activity, joint or other organ damage, and non-inflammatory/fibromyalgia symptoms, recoded 0-10 to compare to other measures. An updated flow sheet report includes the 10 proposed checklist scores, as well as laboratory tests and medications. Mean 1st visit values for the 10 proposed checklist measures were analyzed in all 874 new patients seen at a weekly academic setting from 1996-2007 in 8 groups: rheumatoid arthritis (RA), osteoarthritis (OA), fibromyalgia (FM), systemic lupus erythematosus (SLE), gout, spondyloarthropathy (Spondy), inflammatory polyarthritis (InflPol), connective tissue disease (CTD), and other, as well as demographic data, ESR and CRP, compared using Spearman rank order correlations. Results: The 874 patients appear typical for rheumatic diseases (Table). ESR was >20 mm/Hr in RA, OA, SLE, Spondy, and CTD, while CRP was >10 mg/dL in RA and Spondy. Mean MDHAQ FN was highest in RA and also >3.0 in FM and Spondy. Mean PAIN was highest in FM, and >5 in Spondy, RA and InflPol; PTGL >5 in FM, RA and Spondy; FT >5 in FM, RA, SLE, InflPol, and other. Symptom scores were >20 only in FM. Mean MD global estimates were >=5.0 in all 8 categories - mean 5.7. Estimates were >5 for inflammation in Spondy, RA, gout, InflPol, and CTD; for damage only in RA and OA; and for noninflam/fibro symptoms in FM, SLE, and other. Quantitative demographic, laboratory tests, patient MDHAQ scores, and MD global estimates in 874 new rheumatology patients, by diagnosis, Spondy = Spondylarthropathies. InflPol = Inflammatory Polyarthritis. (Table presented) Conclusion: A proposed checklist of 10 measures, 6 from a MDHAQ and 4 global MD scores, provides quantitative data from a history and PE at each encounter in the infrastructure of rheumatology care, in <20 seconds. These data provide quantitative measures to assess patient status over long periods, treat to target values, and may lead to improved patient outcomes

Purpose: To analyze whether quantitative scores on a multidimensional health assessment questionnaire (MDHAQ) provide clues to the likelihood of inflammatory versus non-inflammatory symptoms and concomitant fibromyalgia, an important challenge in clinical care, according to a global scale for noninflammatory symptoms completed by a rheumatologist in 50 patients with SLE seen in usual care. Methods: A cross-sectional study was performed in 50 consecutive SLE patients of one rheumatologist seen in usual care. On arrival at the clinic, patients completed a multidimensional health assessment questionnaire (MDHAQ) which includes scales for physical function (FN), 0-10 visual analog scales for pain (PN), global estimate (PTGL) and fatigue (FT), and a review of systems symptom checklist (SX). SLE patients also completed a self-report Systemic Lupus Assessment Questionnaire (SLAQ). The rheumatologist, unaware of MDHAQ and SLAQ scores, recorded a physician global estimate (MDGL) and an estimate of non-inflammatory symptoms, each scored on a 0-3 scale in 0.1 increments, as well as four SLE indices: SLEDAI-2K (SLE Disease Activity Index), BILAG (British Isles Lupus Assessment Group index), SLAM (SLE Activity Measure) with and without laboratory tests, and ECLAM (European Consensus Lupus Activity Measurement). SLE patients with scores of <0.5 on the noninflammatory symptom scale were regarded as low and those with scores >=0.5 high noninflammatory symptoms; the two groups were compared using the Mann-Whitney statistic. Results: The study included 45 women and 5 men, mean age 38.7 years, mean disease duration 7.3 years. Of the 50 patients, 16 had high and 34 low scores for non-inflammatory symptoms. Those with high scores for non-inflammatory symptoms had significantly higher scores for FN, PN, FT, PTGL, SX, SLAQ, and SLAM without laboratory tests, as well as significantly lower CRP. No significant differences were seen patients estimated as high and low scoring patients for SLEDAI, BILAG, SLAM, ECLAM, C3, C4, antiDsDNA, or ESR. Fewer than 50% of low patients had FN, PN, PTGL, or FT >=2, while 100% of high patients had FT >2, and 94% PTGL >2. All patients with high non-inflammatory symptoms (16/16) reported more than 5 SX, compared to 15/34 (44%) low patients, and 12/16 (75%) high patients reported >10 SX, compared to 6/34 (18%) low patients. (Table Presented) Conclusion: High scores for dysfunction, pain, fatigue, global estimates, and number of symptoms are common in SLE patients with high versus low levels of non-inflammatory symptoms. SLE indices do not distinguish between patients with high versus low levels of non-inflammatory symptoms. A simple global scale to estimate non-inflammatory symptoms may be informative in therapeutic decisions, particularly if consistent with patient questionnaire patterns