Hydroxychloroquine and visual screening in a rheumatology outpatient clinic

OBJECTIVE—To review 10 years' data relating to visual screening of patients taking hydroxychloroquine.
METHODS—Following baseline visual assessment, ophthalmic monitoring was carried out at six monthly intervals on 758 patients while on hydroxychloroquine. This consisted of corrected visual acuity, central field screening with a red Amsler grid, slit lamp examination, and retinoscopy.
RESULTS—None of the patients suffered visual impairment from retinal toxicity, though 12 reported visual disturbance. This was related to ocular muscle imbalance in four. In the remainder, none of the ocular findings was directly attributable to hydroxychloroquine. Ten patients reported defects when tested with a red Amsler grid. None was related to retinal toxicity. Seven patients developed corneal drug deposits which cleared on stopping or reducing the dose of hydroxy-chloroquine.
CONCLUSIONS—The findings support the view that following baseline ophthalmic examination for patients receiving hydroxychloroquine, regular ophthalmic screening is not required if the daily dose is less than 6.5 mg kg^-1 and the cumulative dose is less than 200 g.

     

Specialist interventions at the rheumatology outpatient clinic

SIR, As rheumatologists we are under significant pressure toreduce the waiting times for new patients in the outpatientclinic. As there is restricted clinic time available for newand review patients, it has been suggested that ‘stable’review patients should be discharged to primary care. We believethere exists a perception that review patients with rheumaticdisease require little intervention or adjustment to treatmentand do not need to     

Biologicals in rheumatology: Austrian experiences from a rheumatic outpatient clinic

The efficacy of biological agents has been shown in several randomized clinical trials. However, little is known regarding the performance of these drugs in daily rheumatological care. Totally, 173 patients treated with biological agents (infliximab, etanercept, adalimumab, anakinra) were retrospectively analyzed between November 2001 and December 2005 at an Austrian rheumatic outpatient clinic. In total, 224 courses of treatment with biological agents were followed up. Among the 93 drug discontinuations observed, the most frequent causes were inefficacy (56.5%) and side effects (31.9%). In 74 patients (51%), the first biological agent was withdrawn after a median treatment period of 10.7 (range 0–80) months. A second biological agent was given to 36 patients, a third to 11 and a fourth to 3 patients. Our data underline the necessity of large observational studies to assess the full spectrum of patients treated with biological agents in clinical routine. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Questionnaire study of the use of surgical shoes prescribed in a rheumatology outpatient clinic.

Our questionnaire study was undertaken to ascertain the proportion of patients who use an appliance and to what extent, up to a year after being prescribed. Twenty-four percent no longer used the appliance. Two-thirds wore their orthosis for more than 6 hours/day. Half the patients had surgical shoes--moulded and bespoke, most found their shoes of benefit. Moulded shoes were found to be worn more frequently and to be more comfortable, easier to put on and more attractive. Patients reported a significantly greater improvement in their condition with moulded shoes than with bespoke shoes.     

Predictors of bone mineral density and osteoporosis in patients attending a rheumatology outpatient clinic

The aim of this study was to evaluate determinants of bone mineral density (BMD) and osteoporosis in patients attending our rheumatology outpatient clinic. A cross-sectional analysis of 320 patients with rheumatism (248 noninflammatory and 72 inflammatory arthropathies) was done. Bone mineral density was measured in the lumbar spine (posteroanterior and lateral views) using dual-energy X-ray absorptiometry. Single and multiple analyses were used to assess associations between BMD and potential risk factors including age, height, weight, body mass index (BMI), alkaline phosphatase (ALP), calcium (Ca), phosphorous (P), magnesium (Mg), spot urine calcium/creatinine (Ca/Cr) ratio, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), total cumulative dose and mean daily dosage of prednisolone, and duration of therapy. In these patients, there were significant correlations between BMD and age (r = -0.372, P = 0.000), height (r = 0.308, P = 0.000), weight (r = 0.145, P = 0.011), and ALP (r = -0.262, P = 0.000). By multiple regression analysis, age and ALP were found to be significant predictors of BMD (r(2) = 0.253, P < 0.01). Two hundred eighty-three of the patients had osteoporosis. Multiple logistic regression analysis showed that age and ALP were significant determinants for osteoporosis. These observations suggest that age and ALP were the major determinants of BMD and osteoporosis in these patients, suggesting a contribution of increased bone metabolism to loss of bone in cases of rheumatism.     

Patient priorities of care in rheumatology outpatient clinics: a qualitative study

Objective: To provide more understanding of what rheumatoid arthritis (RA) patients want and need from an outpatient visit. Methods: 25 patients who experienced care in a nurse practitioner clinic (n = 10), junior doctor clinic (n = 9) or consultant clinic (n = 6) in a large teaching hospital in West Yorkshire were interviewed about their perceptions and experiences of care. Interviews were approximately 1¹/₂ hours in duration and were carried out in a neutral environment by a research nurse. Interview data were subjected to atheoretical content analysis, which resulted in the identification of emergent themes. Results: Five main themes emerged from the analysis of interview data: 1) patients want to be communicated to clearly and effectively and value positive relationships with practitioners. These help to give patients confidence in the care they are receiving; 2) patients want to feel in control of their condition and tend to refuse interventions as a way of gaining control; 3) patients want to be given clear explanations during consultations, and want information in oral and written forms; 4) patients want to be able to access practitioners between scheduled appointments as a way of gaining reassurance; and 5) patients want to feel valued by society through having their difficulties appreciated and understood by others. Conclusion: This research adds to the body of evidence on what patients want from their rheumatology care, and each theme has clear implications for future practice. Copyright © 2007 John Wiley & Sons, Ltd.     

Patient satisfaction with information provided at an outpatient clinic for respiratory diseases

A survey of 374 unselected patients attending the Respiratory Outpatient Department of a teaching hospital revealed that most patients reported receiving information about the treatment of their disease, but only one-quarter received information about its prognosis. Patients reported receiving satisfactory answers to their requests for information on most occasions, and the overall satisfaction rate with information offered was 88.3%.Patients who had attended the clinic on five or more occasions felt that they had received more information on all items compared with those with fewer than five visits, although the increase was statistically significant only for information on treatment. Patients over 75 years of age generally reported less information than younger patients. The great majority (88.4%) of patients preferred verbal information, but 23% also expressed a desire for written information as well.More attention should be paid to the needs of the elderly and to education about the nature and prognosis of disease. Printed material should also be more widely used.     

Factors affecting patient satisfaction with outpatient rheumatology phone visits during the COVID-19 pandemic

Clinical Rheumatology - The aim was to evaluate patient satisfaction with virtual care, and identify factors associated with level of satisfaction. Surveys were mailed to all patients who had a...     

Analysis of a pediatric rheumatology clinic population

This analysis evaluates the role of a pediatric rheumatology clinic in assessing children with suspected rheumatic diseases and establishes relative disease frequencies in a clinic population. The study population comprised 875 children referred to a pediatric rheumatology clinic serving a population of 290,000 children. The mean annual referral rate was 113 patients. A diagnosis was established in 580 (66%) of whom 337 (58%) had a rheumatic disease. Of those with a rheumatic disease 156 (46%) had juvenile rheumatoid arthritis, 104 (31%) a spondyloarthropathy, 62 (18%) a connective tissue/collagen vascular disorder and 15 (5%) a variety of other conditions. Of the 243 diagnosed as having a nonrheumatic disease 79 (33%) had a mechanical or traumatic cause for musculoskeletal symptoms, 33 (14%) had an infection, 15 (6%) a neoplastic disorder and 71 (29%) a variety of other disorders. In addition, 45 children (19%) were evaluated because of family histories of rheumatic diseases or questionably abnormal symptoms or signs; after evaluation all these children were considered to be normal. The remaining group comprised 295 subjects (34%) for whom a definite diagnosis has not been made. In addition to diagnosing and caring for children with rheumatic disorders a pediatric rheumatology clinic serves to identify nonrheumatic conditions and provides information concerning relative frequencies and epidemiologic characteristics of childhood rheumatic diseases.     

Screening for genetic haemochromatosis in a rheumatology clinic

Background: Recent data indicate that the prevalence of genetic haemochromatosis (GH) is greater than previously recognised and suggest that this disease is underdiagnosed. Aims: To determine the prevalence of GH in a rheumatology clinic population. Methods: Over a 12 month period 339 consecutive patients, mean age 67.0 years, attending a rheumatology clinic were screened for iron overload. Results: Twenty three patients had elevated initial screening tests (transferrin saturation [Tf %] > 55% ferritin > 500 μg/L). Repeat fasting Tf % and ferritin concentrations were obtained in 20 of these patients. Twelve patients had persistently elevated results, and of these patients four had liver biopsy tissue hepatic iron indices consistent with GH. One patient in the group had the diagnosis established by liver biopsy just before the screening commenced. Thus, the prevalence of GH in this population was 1.5% - five times that anticipated for the general population. Three of the patients with GH presented with an arthropathy which was not characteristic of the disease. The increased prevalence of GH in this group of patients with peripheral arthropathy provides an excellent justification for the routine screening of patients with peripheral arthritis for the exclusion of iron overload.     

Triage of referrals to an outpatient rheumatology clinic: analysis of referral information and triage

OBJECTIVE: Rheumatologists triage referrals in order to assess those patients who may benefit from early intervention. Success of triage strategies requires accurate transfer of clinical information between the primary caregiver and rheumatologist. We describe a prototype triage system and formally evaluate the quality of referral content to a rheumatologist's practice. METHODS: All new referrals were reviewed by a rheumatologist and, based on the information conferred, assigned a grade using a prototype triage system. This grade reflected each case's suspected urgency and guided the timing of consultation. After the initial rheumatologic consultation a post hoc grade was assigned to each case based on the clinical information gathered. Agreement between referral and consultation grades was assessed. All cases graded as urgent at the time of consultation, and thus felt to be truly urgent, were examined for the quality of content of their referral letters. RESULTS: Two hundred six referrals were evaluated. Ninety-six cases (47%) experienced a grade change between referral and consultation. Thirty-five cases (17%) were upgraded to urgent status after consultation, reflecting inappropriately triaged truly urgent patients. Analysis of referral letters for truly urgent cases revealed the absence of a presumptive diagnosis, symptom duration, and documentation of involved joints in over 30% of referrals. CONCLUSION: The absence of basic historical, examination, and laboratory markers accounted for inappropriate triage of urgent cases. Our study recognizes dysfunction within the current model of care and questions the development of standardized referral tools as a solution. Other models of care should be investigated for this patient population.     

Touch screens as a tool in patient care in the IBD outpatient clinic

Objective: We have introduced online touch screens in the waiting room for patients with ulcerative colitis (UC) or Crohn's disease (CD) for recording of symptoms before their consultation. This has made disease activity scores readily available to the physician in our newly established database, ‘Gastrobio’. We wanted to validate the use of touch screens compared to paper questionnaires.

Material and methods: A total of 54 patients with UC and 74 patients with CD were included in the study. The UC patients filled out the Short Health Scale (SHS) and Simple Clinical Colitis Activity Index (SSCAI). The CD patients filled out the SHS and Harvey–Bradshaw Index (HBI). Paper questionnaires and touch screen versions were used in random order and comparison between the two modalities was made by Spearman correlation test, Bland–Altman plots, and Kappa-statistics.

Results: Among the 128 patients, the two SHS scores (SHS touch versus SHS paper) were found to be highly correlated (Spearman correlation; 0.92 for UC and 0.92 for CD). Also, on average, Bland–Altman plots demonstrated a difference close to zero between the two modalities. Agreement between paper version and touch screen version of SCCAI and HBI scores was also high (Kappa-statistics; 78% raw and 98% weighted for SCCAI; 65% raw and 97% weighted for HBI).

Conclusions: It is feasible to introduce touch screens in the outpatient clinic and to have patients record their symptoms before the consultation. However, the study may not be representative for elderly patients.     

The use of PRIME-MD questionnaire in a rheumatology clinic

Objective: To determine whether the Primary Care Evaluation of Mental Disorders 1-page Brief Patient Health Questionnaire (PRIME-MD 1-page PHQ) can serve as: (1) a diagnostic test for fibromyalgia syndrome (FM), or (2) a questionnaire through which internists can be alerted to otherwise hidden mental disorders in patients attending internal medicine clinics. Method: Two hundred and thirteen consecutive patients attending a rheumatology clinic were given the PRIME-MD 1-page PHQ and seen by a rheumatologist who was blind to the PRIME-MD diagnosis. Results: The PRIME-MD 1-page PHQ pointed to Major Depressive Disorder in 33.3% of FM patients, Other Depressive Disorder in 33.3% of FM patients, and Panic Disorder in 22.2% of FM patients (all of whom also had Major Depressive Disorder), as compared to 13.1, 13.1, and 3.0% respectively in patients with other rheumatic disorders. However, when used as a diagnostic test for FM, the PRIME-MD 1-page PHQ did not have adequate diagnostic value. When all the PRIME-MD 1-page PHQ diagnoses were compiled, however, a trend was observed. Compared to the rates of mental disorders in both the normal population and in primary care practices, the rates found in this rheumatology clinic were higher. Conclusions: The PRIME-MD 1-page PHQ is not an adequate diagnostic test for FM. Because FM is primarily a somatization disorder that draws its symptoms from other current diseases, it may in fact be impossible to diagnose FM based on specific symptoms alone. However, the PRIME-MD 1-page PHQ proved to be a useful diagnostic tool in a rheumatology clinic. It helped to alert the physician to the possibility of an elevated frequency of mental disorders that would otherwise have gone unnoticed and untreated.CONFLICT OF INTEREST STATEMENT. Neither author has any conflict of interest in the above.     

Prevalence of functional dyspepsia in an outpatient clinic with primary care physicians in Japan

Background  

Since little is known about the prevalence of patients with functional gastrointestinal disorders (FGID), this study was performed to clarify the prevalence of FGID, especially functional dyspepsia (FD), in new patients of an outpatient clinic with primary care physicians in Japan.