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2.
Does This Adult Patient Have Septic Arthritis? Margaretten, Mary E; Kohlwes, Jeffrey; Moore, Dan ...
JAMA : the journal of the American Medical Association,
04/2007, Volume:
297, Issue:
13
Journal Article
Peer reviewed
CONTEXT In patients who present with an acutely painful and swollen joint, prompt identification and treatment of septic arthritis can substantially reduce morbidity and mortality. OBJECTIVE To ...review the accuracy and precision of the clinical evaluation for the diagnosis of nongonococcal bacterial arthritis. DATA SOURCES Structured PubMed and EMBASE searches (1966 through January 2007), limited to human, English-language articles and using the following Medical Subject Headings terms: arthritis, infectious, physical examination, medical history taking, diagnostic tests, and sensitivity and specificity. STUDY SELECTION Studies were included if they contained original data on the accuracy or precision of historical items, physical examination, serum, or synovial fluid laboratory data for diagnosing septic arthritis. DATA EXTRACTION Three authors independently abstracted data from the included studies. DATA SYNTHESIS Fourteen studies involving 6242 patients, of whom 653 met the gold standard for the diagnosis of septic arthritis, satisfied all inclusion criteria. Two studies examined risk factors and found that age, diabetes mellitus, rheumatoid arthritis, joint surgery, hip or knee prosthesis, skin infection, and human immunodeficiency virus type 1 infection significantly increase the probability of septic arthritis. Joint pain (sensitivity, 85%; 95% confidence interval CI, 78%-90%), a history of joint swelling (sensitivity, 78%; 95% CI, 71%-85%), and fever (sensitivity, 57%; 95% CI, 52%-62%) are the only findings that occur in more than 50% of patients. Sweats (sensitivity, 27%; 95% CI, 20%-34%) and rigors (sensitivity, 19%; 95% CI, 15%-24%) are less common findings in septic arthritis. Of all laboratory findings readily available to the clinician, the 2 most powerful were the synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells from arthrocentesis. The summary likelihood ratio (LR) increased as the synovial fluid WBC count increased (for counts <25 000/μL: LR, 0.32; 95% CI, 0.23-0.43; for counts ≥25 000/μL: LR, 2.9; 95% CI, 2.5-3.4; for counts >50 000/μL: LR, 7.7; 95% CI, 5.7-11.0; and for counts >100 000/μL: LR, 28.0; 95% CI, 12.0-66.0). On the same synovial fluid sample, a polymorphonuclear cell count of at least 90% suggests septic arthritis with an LR of 3.4 (95% CI, 2.8-4.2), while a polymorphonuclear cell count of less than 90% lowers the likelihood (LR, 0.34; 95% CI, 0.25-0.47). CONCLUSIONS Clinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis. However, the synovial WBC and percentage of polymorphonuclear cells from arthrocentesis are required to assess the likelihood of septic arthritis before the Gram stain and culture test results are known.
Malar Rash Goglin, Sarah E; Margaretten, Mary E
The New England journal of medicine,
07/2021, Volume:
385, Issue:
2
Journal Article
Peer reviewed
A 34-year-old woman presented with a rash on both cheeks that spared the nasolabial folds and with joint pain in her hands and knees. Laboratory studies showed leukopenia and positive anti-Smith and ...anti-RNP antibodies, and a diagnosis of systemic lupus erythematosus was made.
The neurologic manifestations of primary Sjögren syndrome are varied and can be divided anatomically into 2 categories: peripheral neuropathies and central nervous system (CNS) conditions. Distal ...sensory and sensorimotor neuropathies are the most common manifestations of peripheral nerve disease in primary Sjögren syndrome. CNS manifestations associated with primary Sjögren syndrome include focal central lesions, conditions that mimic multiple sclerosis, encephalitis, aseptic meningitis, cerebellar syndromes, movement disorders, and problems with memory, cognition, and depression. The heterogeneity of neurologic manifestations in primary Sjögren syndrome complicates the approach to treatment, which should be directed toward the underlying neuropathologic mechanism.
Objective
We sought to develop a list of 5 tests, treatments, or services commonly used in rheumatology practice whose necessity or value should be questioned and discussed by physicians and ...patients.
Methods
We used a multistage process combining consensus methodology and literature reviews to arrive at the American College of Rheumatology's (ACR) Top 5 list. Rheumatologists from diverse practice settings generated items using the Delphi method. Items with high content agreement and perceived high prevalence advanced to a survey of ACR members, who comprise >90% of the US rheumatology workforce. To increase the response rate, a nested random sample of 390 rheumatologists received more intensive survey followup. The samples were combined and weighting procedures were applied to ensure generalizability. Items with high ratings underwent literature review. Final items were then selected and formulated by the task force.
Results
One hundred five unique items were proposed and narrowed down to 22 items during the Delphi rounds. A total of 1,052 rheumatologists (17% of those contacted) participated in the member‐wide survey, whereas 33% of those in the nested random sample participated; respondent characteristics were similar in both samples. Based on survey results and available scientific evidence, 5 items (relating to antinuclear antibodies, Lyme disease, magnetic resonance imaging, bone absorptiometry, and biologic therapy for rheumatoid arthritis) were selected for inclusion.
Conclusion
The ACR Top 5 list is intended to promote discussions between physicians and patients about health care practices in rheumatology whose use should be questioned and to assist rheumatologists in providing high‐value care.
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A patient in his 60s had pain and erythema in his left eye and ear, which was preceded a year earlier with pain in his right eye and then his left eye. Laboratory findings were unremarkable other ...than elevated ESR and markedly elevated C-reactive protein levels. What is the diagnosis and what would you do next?
ABSTRACT
BACKGROUND
Arthritis affects 20 % of the adult US population and is associated with comorbid depression. Depression screening guidelines have been endorsed for high-risk groups, including ...persons with arthritis, in the hopes that screening will increase recognition and use of appropriate interventions.
OBJECTIVE
To examine national rates of depression and depression screening for patients with arthritis between 2006 and 2010.
PARTICIPANTS AND DESIGN
We used nationally representative cross-sections of ambulatory visits in the United States from the National Ambulatory Medical Care Survey from 2006 to 2010, which included 18,507 visits with a diagnosis of arthritis. When weighted to the US population, this total represents approximately 644 million visits.
MEASUREMENTS
Visits where arthritis was listed among diagnoses. Outcomes were survey-weighted estimates of depression and prevalence of depression screening among patients with arthritis across patient and physician characteristics.
KEY RESULTS
Of the 644,419,374 visits with arthritis listed, 83,574,127 (13 %) were associated with a comorbid diagnosis of depression. The odds ratio for comorbid depression with arthritis was 1.42 (95 % CI 1.3, 1.5). Depression screening occurred at 3,835,000 (1 %) visits associated with arthritis. When examining the rates of depression screening between ambulatory visits with and without arthritis listed, there was no difference in depression screening rates; both were approximately 1 %. There was no difference in screening rates by provider type. Compared to visits with other common, chronic conditions, the prevalence of depression at arthritis visits was high (13 per 100 visits), although the prevalence of depression screening at arthritis visits was low (0.68 per 100 visits).
CONCLUSIONS
Despite the high prevalence of depression with arthritis, screening for depression was performed at few arthritis visits, representing missed opportunities to detect a common, serious comorbidity. Improved depression screening by providers would identify affected patients, and may lead to appropriate interventions such as mental health referrals and/or treatment with anti-depressants.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Objective
Effective treatments for rheumatoid arthritis (RA) fatigue are limited. We tested the effect of a pedometer‐based intervention on increasing physical activity and decreasing fatigue among ...individuals with RA.
Methods
Participants completed baseline questionnaires; had 1 week of activity monitoring; were randomized to control (education EDUC), pedometer and step‐monitoring diary (PED), or pedometer and diary plus step targets (PED+) groups, and were followed for 21 weeks. At week 10, questionnaires were administered by phone to all participants. During the final week, all participants again had 1 week of activity monitoring. Primary outcomes were changes in average weekly steps and fatigue (Patient‐Reported Outcomes Measurement Information System 7‐item questionnaire) from baseline to week 21. Secondary outcomes were self‐reported disease activity, physical function, pain interference, and depressive symptoms. Changes in steps were tested using a linear mixed model. Changes in fatigue were tested with repeated‐measures models, including baseline, week‐10, and week‐21 scores.
Results
A total of 96 individuals participated. Eight did not complete the 21‐week assessments. Both intervention groups significantly increased steps (+1,441 P = 0.004 for PED and +1,656 P = 0.001 for PED+), and the EDUC group decreased steps (‐747 P = 0.14) (group‐by‐time interaction P = 0.0025). Between‐group changes in fatigue were not significantly different (interaction P = 0.21). Mean changes in fatigue scores from baseline to week 21 were ‐1.6 (with‐group P = 0.26), ‐3.2 (P = 0.02), and ‐4.8 (P = 0.0002) for EDUC, PED, and PED+ groups, respectively. Function and self‐reported disease activity also improved in the PED and PED+ groups.
Conclusion
Provision of pedometers, with and without providing step targets, was successful in increasing activity levels and decreasing fatigue in this sample of individuals with RA.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Objective
To characterize the representation of dark skin color in clinical images across 4 major rheumatology training resources.
Methods
We gathered images of patients with rheumatic diseases from ...the American College of Rheumatology Image Library, UpToDate, the New England Journal of Medicine Images in Clinical Medicine and Clinical Cases filtered by “Rheumatology,” and the 9th edition of Kelley's Textbook of Rheumatology. Investigators used Fitzpatrick's skin phototypes to independently code images depicting visible skin as “light” (skin types I to IV), “dark” (skin types V to VI), or “indeterminate.” The representation of dark skin in clinical images was compared to the representation of Asian, Native American, and Black individuals within the US Census population and within lupus cases nationally.
Results
Of the 1,043 patient images included in the study, 13.4% had dark skin, 84.0% light skin, and 2.6% indeterminate skin color. Dark skin was underrepresented significantly in rheumatology educational materials and lupus images when compared with the representation of Asian, Native American, and Black individuals within the US Census population (13.4% versus 20.6%; χ2 = 32.8, P < 0.001) and in published studies of patients with systemic lupus erythematous (22.6% versus 44.2%; χ2 = 20.0, P < 0.001).
Conclusion
Darker skin tones are significantly underrepresented in major rheumatology clinical image banks. Improving representation of racial and ethnic minorities in rheumatology education materials can better equip trainees to recognize and diagnose cutaneous manifestations of rheumatic diseases in these groups.
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