Publications by authors named "Rebecca Grainger"

86 Publications

Are we just dishing out pills constantly to mask their pain? Kaiāwhina Māori health workers' perspectives on pain management for Māori.

N Z Med J 2021 Oct 8;134(1543):19-29. Epub 2021 Oct 8.

Department of Medicine, University of Otago, Wellington, New Zealand.

Aim: To explore kaiāwhina (Māori community health workers) perspectives on supporting whānau Māori with chronic pain, and to understand their views on the use of online resources for pain management.

Method: A Māori-centred, qualitative design using focus groups as the primary data collection method. Analysis using the general inductive approach.

Results: Thirteen kaiāwhina working in the Greater Wellington region took part in the focus groups. Four key themes were identified: (1) treatment of chronic pain in primary health relies exclusively on medication, (2) health literacy approaches to pain management are urgently required, (3) Māori have significant unmet need for culturally responsive pain management, and (4) the availability of, and referral practices to, specialist pain services are inadequate for Māori communities.

Conclusion: Current chronic pain management was predominantly biomedical, and educational strategies lack health literacy approaches. Primary health services exclude traditional Māori methods of treating chronic pain and do not focus on whānau wellbeing. The lack of referral for Māori to specialist services highlights the existing health inequities for Māori. Developing new initiatives (both in-person and online) to address chronic pain management for Māori must be Māori-led and co-designed with whānau to result in holistic solutions for Māori.
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October 2021

Association Between Tumor Necrosis Factor Inhibitors and the Risk of Hospitalization or Death Among Patients With Immune-Mediated Inflammatory Disease and COVID-19.

JAMA Netw Open 2021 Oct 1;4(10):e2129639. Epub 2021 Oct 1.

Division of Rheumatology, Department of Medicine, University of California, San Francisco, San Francisco.

Importance: Although tumor necrosis factor (TNF) inhibitors are widely prescribed globally because of their ability to ameliorate shared immune pathways across immune-mediated inflammatory diseases (IMIDs), the impact of COVID-19 among individuals with IMIDs who are receiving TNF inhibitors remains insufficiently understood.

Objective: To examine the association between the receipt of TNF inhibitor monotherapy and the risk of COVID-19-associated hospitalization or death compared with other commonly prescribed immunomodulatory treatment regimens among adult patients with IMIDs.

Design, Setting, And Participants: This cohort study was a pooled analysis of data from 3 international COVID-19 registries comprising individuals with rheumatic diseases, inflammatory bowel disease, and psoriasis from March 12, 2020, to February 1, 2021. Clinicians directly reported COVID-19 outcomes as well as demographic and clinical characteristics of individuals with IMIDs and confirmed or suspected COVID-19 using online data entry portals. Adults (age ≥18 years) with a diagnosis of inflammatory arthritis, inflammatory bowel disease, or psoriasis were included.

Exposures: Treatment exposure categories included TNF inhibitor monotherapy (reference treatment), TNF inhibitors in combination with methotrexate therapy, TNF inhibitors in combination with azathioprine/6-mercaptopurine therapy, methotrexate monotherapy, azathioprine/6-mercaptopurine monotherapy, and Janus kinase (Jak) inhibitor monotherapy.

Main Outcomes And Measures: The main outcome was COVID-19-associated hospitalization or death. Registry-level analyses and a pooled analysis of data across the 3 registries were conducted using multilevel multivariable logistic regression models, adjusting for demographic and clinical characteristics and accounting for country, calendar month, and registry-level correlations.

Results: A total of 6077 patients from 74 countries were included in the analyses; of those, 3215 individuals (52.9%) were from Europe, 3563 individuals (58.6%) were female, and the mean (SD) age was 48.8 (16.5) years. The most common IMID diagnoses were rheumatoid arthritis (2146 patients [35.3%]) and Crohn disease (1537 patients [25.3%]). A total of 1297 patients (21.3%) were hospitalized, and 189 patients (3.1%) died. In the pooled analysis, compared with patients who received TNF inhibitor monotherapy, higher odds of hospitalization or death were observed among those who received a TNF inhibitor in combination with azathioprine/6-mercaptopurine therapy (odds ratio [OR], 1.74; 95% CI, 1.17-2.58; P = .006), azathioprine/6-mercaptopurine monotherapy (OR, 1.84; 95% CI, 1.30-2.61; P = .001), methotrexate monotherapy (OR, 2.00; 95% CI, 1.57-2.56; P < .001), and Jak inhibitor monotherapy (OR, 1.82; 95% CI, 1.21-2.73; P = .004) but not among those who received a TNF inhibitor in combination with methotrexate therapy (OR, 1.18; 95% CI, 0.85-1.63; P = .33). Similar findings were obtained in analyses that accounted for potential reporting bias and sensitivity analyses that excluded patients with a COVID-19 diagnosis based on symptoms alone.

Conclusions And Relevance: In this cohort study, TNF inhibitor monotherapy was associated with a lower risk of adverse COVID-19 outcomes compared with other commonly prescribed immunomodulatory treatment regimens among individuals with IMIDs.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.29639DOI Listing
October 2021

Predictors of hospitalization in patients with rheumatic disease and COVID-19 in Ireland: data from the COVID-19 global rheumatology alliance registry.

Rheumatol Adv Pract 2021 13;5(2):rkab031. Epub 2021 May 13.

Department of Rheumatology, Mater Misericordiae Hospital, Dublin.

Objectives: Given the limited data regarding the risk of hospitalization in patients with rheumatic disease and coronavirus disease 2019 (COVID-19) in Ireland, we used the COVID-19 Global Rheumatology Alliance (GRA) registry data to study outcomes and their predictors. The primary objective was to explore potential predictors of hospitalization.

Methods: We examined data on patients and their disease-related characteristics entered in the COVID-19 GRA provider registry from Ireland (from 24 March 2020 to 31 August 2020). Multivariable logistic regression was used to assess the association of demographic and clinical characteristics with hospitalization.

Results: Of 105 patients, 47 (45.6%) were hospitalized and 10 (9.5%) died. Multivariable logistic regression analysis showed that age [odds ratio (OR) = 1.06, 95% CI 1.01, 1.10], number of co-morbidities (OR = 1.93, 95% CI 1.11, 3.35) and glucocorticoid use (OR = 15.01, 95% CI 1.77, 127.16) were significantly associated with hospitalization. A diagnosis of inflammatory arthritis was associated with lower odds of hospitalization (OR = 0.09, 95% CI 0.02, 0.32).

Conclusion: Increasing age, co-morbidity burden and glucocorticoid use were associated with hospitalization, whereas a diagnosis of inflammatory arthritis was associated with lower odds of hospitalization.
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http://dx.doi.org/10.1093/rap/rkab031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244588PMC
May 2021

How is family health history discussed in routine primary healthcare? A qualitative study of archived family doctor consultations.

BMJ Open 2021 Oct 5;11(10):e049058. Epub 2021 Oct 5.

Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand.

Objectives: Family health history underpins genetic medicine. Our study aimed to explore language and patterns of communication relating to family health history observed in interactions between general practitioners (GPs) and their patients within routine primary care consultations.

Design: Secondary analysis of patient and GP routine consultation data (n=252).

Participants: Consultations that included 'family health history' were eligible for inclusion (n=58).

Primary Outcomes: A qualitative inductive analysis of the interactions from consultation transcripts.

Results: 46/58 conversations about family health history were initiated by the GP. Most discussions around family history lasted for between approximately 1 to 2 min. Patients were invited to share family health history through one of two ways: non-specific enquiry (eg, by asking the patient about 'anything that runs in the family); or specific enquiry where they were asked if they had a 'strong family history in relation to a particular condition, for example, breast cancer. Patients often responded to either approach with a simple no, but fuller negative responses also occurred regularly and typically included an account of some kind (eg, explaining family relationships/dynamics which impeded or prevented the accessibility of information).

Conclusions: Family health history is regarded as a genetic test and is embedded in the sociocultural norms of the patient from whom information is being sought. Our findings highlight that it is more complex than asking simply if 'anything' runs in the family. As the collection of family health history is expected to be more routine, it will be important to also consider it from sociocultural perspectives in order to help mitigate any inequities in how family history is collected, and therefore used (or not) in a person's healthcare. Orientating an enquiry away from 'anything' and asking more specific details about particular conditions may help facilitate the dialogue.
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http://dx.doi.org/10.1136/bmjopen-2021-049058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8493894PMC
October 2021

Early experience of COVID-19 vaccination in adults with systemic rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance Vaccine Survey.

RMD Open 2021 09;7(3)

Medicine, Division of Rheumatology, University of Washington, Seattle, Washington, USA.

Background: We describe the early experiences of adults with systemic rheumatic disease who received the COVID-19 vaccine.

Methods: From 2 April to 30 April 2021, we conducted an online, international survey of adults with systemic rheumatic disease who received COVID-19 vaccination. We collected patient-reported data on clinician communication, beliefs and intent about discontinuing disease-modifying antirheumatic drugs (DMARDs) around the time of vaccination, and patient-reported adverse events after vaccination.

Results: We analysed 2860 adults with systemic rheumatic diseases who received COVID-19 vaccination (mean age 55.3 years, 86.7% female, 86.3% white). Types of COVID-19 vaccines were Pfizer-BioNTech (53.2%), Oxford/AstraZeneca (22.6%), Moderna (21.3%), Janssen/Johnson & Johnson (1.7%) and others (1.2%). The most common rheumatic disease was rheumatoid arthritis (42.3%), and 81.2% of respondents were on a DMARD. The majority (81.9%) reported communicating with clinicians about vaccination. Most (66.9%) were willing to temporarily discontinue DMARDs to improve vaccine efficacy, although many (44.3%) were concerned about rheumatic disease flares. After vaccination, the most reported patient-reported adverse events were fatigue/somnolence (33.4%), headache (27.7%), muscle/joint pains (22.8%) and fever/chills (19.9%). Rheumatic disease flares that required medication changes occurred in 4.6%.

Conclusion: Among adults with systemic rheumatic disease who received COVID-19 vaccination, patient-reported adverse events were typical of those reported in the general population. Most patients were willing to temporarily discontinue DMARDs to improve vaccine efficacy. The relatively low frequency of rheumatic disease flare requiring medications was reassuring.
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http://dx.doi.org/10.1136/rmdopen-2021-001814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8424419PMC
September 2021

COVID-19 in Pregnant Women With Rheumatic Disease: Data From the COVID-19 Global Rheumatology Alliance.

J Rheumatol 2021 Sep 1. Epub 2021 Sep 1.

The views expressed here are those of the authors and participating members of the COVID-19 Global Rheumatology Alliance, and do not necessarily represent the views of the American College of Rheumatology (ACR), the European Alliance of Associations for Rheumatology (EULAR), the (UK) National Health Service (NHS), the National Institute for Health Research (NIHR), or the (UK) Department of Health, or any other organization. B.L. Bermas, MD, UTSouthwestern Medical Center, Dallas, Texas, USA; M. Gianfrancesco, MPH, PhD, A.M. Seet, MPH, J. Yazdany, MPH, MD, Division of Rheumatology, School of Medicine, University of California, San Francisco, California, USA; H.L. Tanner, MBChB, FRACP, University of Queensland School of Clinical Medicine, Faculty of Medicine, Queensland, Australia; M.C. Aguiar, MD, Hospital General Agustin O'Horan, Merida, Mexico; N.K. Al Adhoubi, MD, FRCP, Rheumatology Unit, Royal Hospital, Muscat, Oman; S. Al Emadi, MBBS, FRCPC, Hamad Medical Corporation, Doha, Qatar; B.M. Cunha, MD, PhD, Sarah Network of Rehabilitation Hospitals, Brasília, Brazil; R. Flood, MB, BCh, BAO, Tallaght University Hospital, Tallaght, Dublin, Ireland; D.A. Kusevich, MD,PhD, V.A. Nasonova Research Institute of Rheumatology, Moscow, and Anikina Clinic, Vidnoe, Russia; E.M. McCarthy, MB, MRCPI, Manchester University Foundation Trust, Manchester, UK; N.J. Patel, MD, Massachusetts General Hospital, Boston, Massachusetts, USA; E.M. Ruderman, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; S.E. Sattui, MD, MS, Hospital for Special Surgery, New York, New York, USA; S. Sciascia, MD, PhD, Center of Research of Immunopathology and Rare Diseases/Nephrology and Dialysis Unit, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, Turin, Italy; F. Siddique, MD, Loyola University Medical Center, Maywood, Illinois, USA; M.O. Valenzuela-Almada, MBBS, A. Duarte-Garcia, MD, MS, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA; L.M. Wise, MD, University of Southern California, Los Angeles, California, USA; A.B. Worthing, MD, Arthritis & Rheumatism Associates, PC, and Georgetown University Medical Center, Washington, DC, USA; J. Zell, MD, University of Colorado, Aurora, Colorado, USA; S. Bhana, MD, Crystal Run Healthcare, Middletown, New York, USA; W. Costello, Irish Children's arthritis network (iCan), Tipperary, Ireland; R. Grainger, MBChB, PhD, FRACP, Department of Medicine, University of Otago, Wellington, New Zealand; L. Gossec, MD, PhD, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, and Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Rheumatology Department, Paris, France; J.S. Hausmann, MD, Program in Rheumatology, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; K. Hyrich, MD, PhD, FRCPC, Centre for Epidemiology Versus Arthritis, The University of Manchester, and National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK; S. Lawson-Tovey, BA, National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, and Centre for Genetics and Genomics Versus Arthritis, The University of Manchester, Manchester, UK; J.W. Liew, MS, MD, Boston University School of Medicine, Boston, Massachusetts, USA; E. Sirotich, BSc, Department of Health Research, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; J.A. Sparks, MD, MMSc, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; P. Sufka, MD, Healthpartners, St. Paul, Minnesota, USA; Z.S. Wallace, MD, MSc, Rheumatology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; P.M. Machado, MD, PhD, Centre for Rheumatology & Department of Neuromuscular Diseases, University College London, and National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, and Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK; A. Strangfeld, MD, Epidemiology Unit, German Rheumatism Research Centre (DRFZ) Berlin, Berlin, Germany; M.E.B. Clowse, MD, MPH, Duke University School of Medicine, Durham, North Carolina, USA; P.C. Robinson, MBChB, PhD, FRACP, Associate Professor, University of Queensland School of Clinical Medicine, Faculty of Medicine, Queensland, Australia, and Royal Brisbane & Women's Hospital, Metro North Hospital & Health Service, Herston, Queensland, Australia. EMR declares consulting for AbbVie, Amgen, BMS, Horizon, Janssen, Lilly, Novartis, and Pfizer; and research grants from Corrona and Pfizer, all unrelated to this work. SES declares funding from the Vasculitis Clinical Research Consortium and Vasculitis Foundation outside the submitted work. LMW declares consulting for Aurinia outside the submitted work. SB declares nonbranded consulting for AbbVie, Horizon, Pfizer, and Novartis. ADG declares grants from the Centers for Disease Control and Prevention, the Rheumatology Research Foundation Scientist Development Award, the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, the Women's Health Career Enhancement Award, and the Eaton Family Career Development Award. RG declares AbbVie, Cornerstones, Janssen, and Pfizer, all outside the submitted work. LG declares research grants from Amgen, Galapagos, Janssen, Lilly, Pfizer, Sandoz, Sanofi; and consulting fees from AbbVie, Amgen, BMS, Biogen, Celgene, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis, and UCB, all outside the submitted work. JSH declares grants from the Rheumatology Research Foundation and salary support from the Childhood Arthritis and Rheumatology Research Alliance (CARRA); and consulting for Novartis, Biogen, and Pfizer (< $10,000), all unrelated to this work. KH declares honoraria from AbbVie, and grants from BMS, Pfizer, and UCB. JWL declares research funding from Pfizer unrelated to this work. JAS declares research support from Amgen and BMS, and performed consultancy for BMS, Gilead, Inova, Janssen, and Optum, unrelated to this work. ZSW declares grant support from BMS and Principia, and has received consulting fees from MedPace and Viela Bio for unrelated work. PMM declares consulting/speaker's fees from AbbVie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche, and UCB, all unrelated to this manuscript, and is supported by the NIHR, University College London Hospitals, Biomedical Research Centre. AS declares lecture honoraria from AbbVie, BMS, Celltrion, MSD, Pfizer, Roche, and UCB, outside the submitted work. MEBC declares consulting for GSK, AstraZeneca, and UCB; and grants from GSK and Pfizer, outside the submitted work. JY declares personal fees from AstraZeneca, personal fees from Eli Lilly, and grants from Pfizer and Gilead, outside the submitted work. PCR declares personal feesAbbVie, Atom Bioscience, Gilead, Eli Lilly, Novartis, Roche, UCB, BMS, Janssen, and Pfizer, all outside the submitted work. The remaining authors declare no competing interests relevant to this article. Address correspondence to Assoc. Prof. P.C. Robinson, University of Queensland School of Clinical Medicine, Royal Brisbane & Women's Hospital, Herston, Queensland 4006, Australia. Email: Accepted for publication August 11, 2021.

Objective: To describe coronavirus disease 2019 (COVID-19) and pregnancy outcomes in patients with rheumatic disease who were pregnant at the time of infection.

Methods: Since March 2020, the COVID-19 Global Rheumatology Alliance has collected cases of patients with rheumatic disease with COVID-19. We report details of pregnant women at the time of COVID-19 infection, including obstetric details separately ascertained from providers.

Results: We report on 39 patients, including 22 with obstetric detail available. The mean and median age was 33 years, range 24-45 years. Rheumatic disease diagnoses included rheumatoid arthritis (n = 9), systemic lupus erythematosus (n = 9), psoriatic arthritis/other inflammatory arthritides (n = 8), and antiphospholipid syndrome (n = 6). Most had a term birth (16/22), with 3 preterm births, 1 termination, and 1 miscarriage; 1 woman had yet to deliver at the time of report. One-quarter (n = 10/39) of pregnant women were hospitalized following COVID-19 diagnosis. Two of 39 (5%) required supplemental oxygen (both hospitalized); no patients died. The majority did not receive specific medication treatment for their COVID-19 (n = 32/39, 82%), and 7 patients received some combination of antimalarials, colchicine, anti-interleukin 1β, azithromycin, glucocorticoids, and lopinavir/ritonavir.

Conclusion: Women with rheumatic diseases who were pregnant at the time of COVID-19 had favorable outcomes. These data have limitations due to the small size and methodology; however, they provide cautious optimism for pregnancy outcomes for women with rheumatic disease particularly in comparison to the increased risk of poor outcomes that have been reported in other series of pregnant women with COVID-19.
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http://dx.doi.org/10.3899/jrheum.210480DOI Listing
September 2021

Immediate effect of the COVID-19 pandemic on patient health, health-care use, and behaviours: results from an international survey of people with rheumatic diseases.

Lancet Rheumatol 2021 Oct 22;3(10):e707-e714. Epub 2021 Jul 22.

Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Background: The impact and consequences of the COVID-19 pandemic on people with rheumatic disease are unclear. We developed the COVID-19 Global Rheumatology Alliance Patient Experience Survey to assess the effects of the COVID-19 pandemic on people with rheumatic disease worldwide.

Methods: Survey questions were developed by key stakeholder groups and disseminated worldwide through social media, websites, and patient support organisations. Questions included demographics, rheumatic disease diagnosis, COVID-19 diagnosis, adoption of protective behaviours to mitigate COVID-19 exposure, medication access and changes, health-care access and communication with rheumatologists, and changes in employment or schooling. Adults age 18 years and older with inflammatory or autoimmune rheumatic diseases were eligible for inclusion. We included participants with and without a COVID-19 diagnosis. We excluded participants reporting only non-inflammatory rheumatic diseases such as fibromyalgia or osteoarthritis.

Findings: 12 117 responses to the survey were received between April 3 and May 8, 2020, and of these, 10 407 respondents had included appropriate age data. We included complete responses from 9300 adults with rheumatic disease (mean age 46·1 years; 8375 [90·1%] women, 893 [9·6%] men, and 32 [0·3%] participants who identified as non-binary). 6273 (67·5%) of respondents identified as White, 1565 (16·8%) as Latin American, 198 (2·1%) as Black, 190 (2·0%) as Asian, and 42 (0·5%) as Native American or Aboriginal or First Nation. The most common rheumatic disease diagnoses included rheumatoid arthritis (3636 [39·1%] of 9300), systemic lupus erythematosus (2882 [31·0%]), and Sjögren's syndrome (1290 [13·9%]). Most respondents (6921 [82·0%] of 8441) continued their antirheumatic medications as prescribed. Almost all (9266 [99·7%] of 9297) respondents adopted protective behaviours to limit SARS-CoV-2 exposure. A change in employment status occurred in 2524 (27·1%) of 9300) of respondents, with a 13·6% decrease in the number in full-time employment (from 4066 to 3514).

Interpretation: People with rheumatic disease maintained therapy and followed public health advice to mitigate the risks of COVID-19. Substantial employment status changes occurred, with potential implications for health-care access, medication affordability, mental health, and rheumatic disease activity.

Funding: American College of Rheumatology.
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http://dx.doi.org/10.1016/S2665-9913(21)00175-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8298011PMC
October 2021

The GOUT-36 prediction rule for inpatient gout flare in people with comorbid gout: derivation and external validation.

Rheumatology (Oxford) 2021 Jul 23. Epub 2021 Jul 23.

Department of Medicine, University of Otago, Wellington, New Zealand.

Objectives: To develop and validate a gout flare risk stratification tool for people with gout hospitalised for non-gout conditions.

Methods: The prediction rule for inpatient gout flare was derived from a cohort of 625 hospitalised people with comorbid gout from New Zealand. The rule had four items: (1) no pre-admission GOut flare prophylaxis, (2) no pre-admission Urate-lowering therapy, (3) Tophus and (4) pre-admission serum urate >0.36 mmol/l within the previous year (GOUT-36 rule). Two or more items are required for the classification of high risk for developing inpatient gout flare. The GOUT-36 rule was validated in a prospective cohort of 284 hospitalised people with comorbid gout from Thailand and China.

Results: The GOUT-36 rule had a sensitivity of 75%, specificity of 67% and AUC of 0.71 for classifying people at high risk for developing inpatient gout flare. Four risk groups were developed: low (no items), moderate (one item), high (two items) and very high risk (three or four items). In a population with frequent (overall 34%) in-hospital gout flare, 80% of people with very high risk people developed flare, while 11% of low-risk people had inpatient flare.

Conclusion: GOUT-36 rule is simple and sensitive for classifying people with high risk for inpatient gout flare. The rule may help inform clinical decision and future research on the prevention of inpatient gout flare.
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http://dx.doi.org/10.1093/rheumatology/keab590DOI Listing
July 2021

Abrupt change to telephone follow-up clinics in a regional rheumatology service during COVID-19: analysis of treatment decisions.

Intern Med J 2021 Jun;51(6):960-964

Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand.

During the 2020 COVID-19 lockdown our rheumatology service provided follow up by phone. We reviewed clinic documents to compare patients serviced, and patient assessment and treatment outcomes. More patients received care during the lockdown but patient rheumatic disease was deemed active less frequently, more patients had no change to disease-modifying anti-rheumatic drugs and patients were less likely to have an intervention arranged. This suggests careful patient selection and appropriate infrastructure should be part of future rheumatology telemedicine.
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http://dx.doi.org/10.1111/imj.15336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8447013PMC
June 2021

Associations of baseline use of biologic or targeted synthetic DMARDs with COVID-19 severity in rheumatoid arthritis: Results from the COVID-19 Global Rheumatology Alliance physician registry.

Ann Rheum Dis 2021 09 28;80(9):1137-1146. Epub 2021 May 28.

Rheumatology Department, Hamad Medical Corporation, Doha, Qatar.

Objective: To investigate baseline use of biologic or targeted synthetic (b/ts) disease-modifying antirheumatic drugs (DMARDs) and COVID-19 outcomes in rheumatoid arthritis (RA).

Methods: We analysed the COVID-19 Global Rheumatology Alliance physician registry (from 24 March 2020 to 12 April 2021). We investigated b/tsDMARD use for RA at the clinical onset of COVID-19 (baseline): abatacept (ABA), rituximab (RTX), Janus kinase inhibitors (JAKi), interleukin 6 inhibitors (IL-6i) or tumour necrosis factor inhibitors (TNFi, reference group). The ordinal COVID-19 severity outcome was (1) no hospitalisation, (2) hospitalisation without oxygen, (3) hospitalisation with oxygen/ventilation or (4) death. We used ordinal logistic regression to estimate the OR (odds of being one level higher on the ordinal outcome) for each drug class compared with TNFi, adjusting for potential baseline confounders.

Results: Of 2869 people with RA (mean age 56.7 years, 80.8% female) on b/tsDMARD at the onset of COVID-19, there were 237 on ABA, 364 on RTX, 317 on IL-6i, 563 on JAKi and 1388 on TNFi. Overall, 613 (21%) were hospitalised and 157 (5.5%) died. RTX (OR 4.15, 95% CI 3.16 to 5.44) and JAKi (OR 2.06, 95% CI 1.60 to 2.65) were each associated with worse COVID-19 severity compared with TNFi. There were no associations between ABA or IL6i and COVID-19 severity.

Conclusions: People with RA treated with RTX or JAKi had worse COVID-19 severity than those on TNFi. The strong association of RTX and JAKi use with poor COVID-19 outcomes highlights prioritisation of risk mitigation strategies for these people.
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http://dx.doi.org/10.1136/annrheumdis-2021-220418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8172266PMC
September 2021

Measuring the Quality of Clinical Skills Mobile Apps for Student Learning: Systematic Search, Analysis, and Comparison of Two Measurement Scales.

JMIR Mhealth Uhealth 2021 04 23;9(4):e25377. Epub 2021 Apr 23.

Education Unit, University of Otago Wellington, Wellington, New Zealand.

Background: Mobile apps are widely used in health professions, which increases the need for simple methods to determine the quality of apps. In particular, teachers need the ability to curate high-quality mobile apps for student learning.

Objective: This study aims to systematically search for and evaluate the quality of clinical skills mobile apps as learning tools. The quality of apps meeting the specified criteria was evaluated using two measures-the widely used Mobile App Rating Scale (MARS), which measures general app quality, and the Mobile App Rubric for Learning (MARuL), a recently developed instrument that measures the value of apps for student learning-to assess whether MARuL is more effective than MARS in identifying high-quality apps for learning.

Methods: Two mobile app stores were systematically searched using clinical skills terms commonly found in medical education and apps meeting the criteria identified using an approach based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 9 apps were identified during the screening process. The apps were rated independently by 2 reviewers using MARS and MARuL.

Results: The intraclass correlation coefficients (ICCs) for the 2 raters using MARS and MARuL were the same (MARS ICC [two-way]=0.68; P<.001 and MARuL ICC [two-way]=0.68; P<.001). Of the 9 apps, Geeky Medics-OSCE revision (MARS Android=3.74; MARS iOS=3.68; MARuL Android=75; and MARuL iOS=73) and OSCE PASS: Medical Revision (MARS Android=3.79; MARS iOS=3.71; MARuL Android=69; and MARuL iOS=73) scored highly on both measures of app quality and for both Android and iOS. Both measures also showed agreement for the lowest rated app, Patient Education Institute (MARS Android=2.21; MARS iOS=2.11; MARuL Android=18; and MARuL iOS=21.5), which had the lowest scores in all categories except information (MARS) and professional (MARuL) in both operating systems. MARS and MARuL were both able to differentiate between the highest and lowest quality apps; however, MARuL was better able to differentiate apps based on teaching and learning quality.

Conclusions: This systematic search and rating of clinical skills apps for learning found that the quality of apps was highly variable. However, 2 apps-Geeky Medics-OSCE revision and OSCE PASS: Medical Revision-rated highly for both versions and with both quality measures. MARS and MARuL showed similar abilities to differentiate the quality of the 9 apps. However, MARuL's incorporation of teaching and learning elements as part of a multidimensional measure of quality may make it more appropriate for use with apps focused on teaching and learning, whereas MARS's more general rating of quality may be more appropriate for health apps targeting a general health audience. Ratings of the 9 apps by both measures also highlighted the variable quality of clinical skills mobile apps for learning.
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http://dx.doi.org/10.2196/25377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8105752PMC
April 2021

Role of Participatory Health Informatics in Detecting and Managing Pandemics: Literature Review.

Yearb Med Inform 2021 Aug 21;30(1):200-209. Epub 2021 Apr 21.

Institute for Medical Informatics, Bern University of Applied Sciences, Bern, Switzerland.

Objectives: Using participatory health informatics (PHI) to detect disease outbreaks or learn about pandemics has gained interest in recent years. However, the role of PHI in understanding and managing pandemics, citizens' role in this context, and which methods are relevant for collecting and processing data are still unclear, as is which types of data are relevant. This paper aims to clarify these issues and explore the role of PHI in managing and detecting pandemics.

Methods: Through a literature review we identified studies that explore the role of PHI in detecting and managing pandemics. Studies from five databases were screened: PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), IEEE Xplore, ACM (Association for Computing Machinery) Digital Library, and Cochrane Library. Data from studies fulfilling the eligibility criteria were extracted and synthesized narratively.

Results: Out of 417 citations retrieved, 53 studies were included in this review. Most research focused on influenza-like illnesses or COVID-19 with at least three papers on other epidemics (Ebola, Zika or measles). The geographic scope ranged from global to concentrating on specific countries. Multiple processing and analysis methods were reported, although often missing relevant information. The majority of outcomes are reported for two application areas: crisis communication and detection of disease outbreaks.

Conclusions: For most diseases, the small number of studies prevented reaching firm conclusions about the utility of PHI in detecting and monitoring these disease outbreaks. For others, e.g., COVID-19, social media and online search patterns corresponded to disease patterns, and detected disease outbreak earlier than conventional public health methods, thereby suggesting that PHI can contribute to disease and pandemic monitoring.
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http://dx.doi.org/10.1055/s-0041-1726486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432992PMC
August 2021

Reply.

Arthritis Rheumatol 2021 09 3;73(9):1767-1768. Epub 2021 Aug 3.

Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1002/art.41745DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251029PMC
September 2021

Clinical and cost-effectiveness of an online-delivered group-based pain management programme in improving pain-related disability for people with persistent pain-protocol for a non-inferiority randomised controlled trial (iSelf-help trial).

BMJ Open 2021 02 4;11(2):e046376. Epub 2021 Feb 4.

Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, Wellington, New Zealand.

Introduction: Persistent non-cancer pain affects one in five adults and is more common in Māori-the Indigenous population of New Zealand (NZ), adults over 65 years, and people living in areas of high deprivation. Despite the evidence supporting multidisciplinary pain management programmes (PMPs), access to PMPs is poor due to long waiting lists. Although online-delivered PMPs enhance access, none have been codesigned with patients or compared with group-based, in-person PMPs. This non-inferiority trial aims to evaluate the clinical and cost-effectiveness of a cocreated, culturally appropriate, online-delivered PMP (iSelf-help) compared with in-person PMP in reducing pain-related disability.

Methods And Analysis: Mixed-methods, using a modified participatory action research (PAR) framework, involving three phases. Phase I involved cocreation and cultural appropriateness of iSelf-help by PAR team members. Phase II: The proposed iSelf-help trial is a pragmatic, multicentred, assessor-blinded, two-arm, parallel group, non-inferiority randomised controlled trial. Adults (n=180, age ≥18 years) with persistent non-cancer pain eligible for a PMP will be recruited and block randomised (with equal probabilities) to intervention (iSelf-help) and control groups (in-person PMP). The iSelf-help participants will participate in two 60-minute video-conferencing sessions weekly for 12 weeks with access to cocreated resources via smartphone application and a password-protected website. The control participants will receive group-based, in-person delivered PMP. Primary outcome is pain-related disability assessed via modified Roland Morris Disability Questionnaire at 6 months post intervention. Secondary outcomes include anxiety, depression, stress, pain severity, quality of life, acceptance, self-efficacy, catastrophising and fear avoidance. Data will be collected at baseline, after the 12-week intervention, and at 3 and 6 months post intervention. We will conduct economic analyses and mixed-method process evaluations (Phase IIA).

Ethics And Dissemination: The Health and Disability Ethics Committee approved the study protocol (HDEC18/CEN/162). Phase III involves dissemination of findings guided by the PAR team as outcomes become apparent.

Trial Registration Number: ACTRN 12619000771156.
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http://dx.doi.org/10.1136/bmjopen-2020-046376DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868244PMC
February 2021

Factors associated with COVID-19-related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry.

Ann Rheum Dis 2021 07 27;80(7):930-942. Epub 2021 Jan 27.

National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.

Objectives: To determine factors associated with COVID-19-related death in people with rheumatic diseases.

Methods: Physician-reported registry of adults with rheumatic disease and confirmed or presumptive COVID-19 (from 24 March to 1 July 2020). The primary outcome was COVID-19-related death. Age, sex, smoking status, comorbidities, rheumatic disease diagnosis, disease activity and medications were included as covariates in multivariable logistic regression models. Analyses were further stratified according to rheumatic disease category.

Results: Of 3729 patients (mean age 57 years, 68% female), 390 (10.5%) died. Independent factors associated with COVID-19-related death were age (66-75 years: OR 3.00, 95% CI 2.13 to 4.22; >75 years: 6.18, 4.47 to 8.53; both vs ≤65 years), male sex (1.46, 1.11 to 1.91), hypertension combined with cardiovascular disease (1.89, 1.31 to 2.73), chronic lung disease (1.68, 1.26 to 2.25) and prednisolone-equivalent dosage >10 mg/day (1.69, 1.18 to 2.41; vs no glucocorticoid intake). Moderate/high disease activity (vs remission/low disease activity) was associated with higher odds of death (1.87, 1.27 to 2.77). Rituximab (4.04, 2.32 to 7.03), sulfasalazine (3.60, 1.66 to 7.78), immunosuppressants (azathioprine, cyclophosphamide, ciclosporin, mycophenolate or tacrolimus: 2.22, 1.43 to 3.46) and not receiving any disease-modifying anti-rheumatic drug (DMARD) (2.11, 1.48 to 3.01) were associated with higher odds of death, compared with methotrexate monotherapy. Other synthetic/biological DMARDs were not associated with COVID-19-related death.

Conclusion: Among people with rheumatic disease, COVID-19-related death was associated with known general factors (older age, male sex and specific comorbidities) and disease-specific factors (disease activity and specific medications). The association with moderate/high disease activity highlights the importance of adequate disease control with DMARDs, preferably without increasing glucocorticoid dosages. Caution may be required with rituximab, sulfasalazine and some immunosuppressants.
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http://dx.doi.org/10.1136/annrheumdis-2020-219498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7843211PMC
July 2021

Novel coronavirus disease-2019 (COVID-19) in people with rheumatic disease: Epidemiology and outcomes.

Best Pract Res Clin Rheumatol 2021 03 23;35(1):101657. Epub 2020 Dec 23.

University of Queensland School of Clinical Medicine, HERSTON, QLD, Australia; Royal Brisbane & Women's Hospital, Metro North Hospital & Health Service, HERSTON, QLD, Australia.

There is concern that people with rheumatic disease, often treated with immunosuppressive or immunomodulatory medication, may be at an increased risk of poor outcomes of novel coronavirus disease-2019 (COVID-19). However, hyperinflammation is a major cause of morbidity and mortality in COVID-19 and treatment with glucocorticoids has been shown to improve outcomes in patients with severe COVID-19. Therefore, uncertainty exists about continuing or withholding immune therapies with the risk of infection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This review covers the current knowledge with respect to the risk of infection and outcomes and risk factors for poor outcomes in patients with rheumatic disease. We also discuss data from other immune-mediated diseases and its relevance to patients with rheumatic disease. In addition, we cover the limitations of the research efforts to date and how the current knowledge translates into practice guidance. Finally, we discuss our vision of the future research agenda.
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http://dx.doi.org/10.1016/j.berh.2020.101657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7756169PMC
March 2021

A Mobile- and Web-Based Health Intervention Program for Diabetes and Prediabetes Self-Management (BetaMe/Melon): Process Evaluation Following a Randomized Controlled Trial.

J Med Internet Res 2020 12 1;22(12):e19150. Epub 2020 Dec 1.

Department of Public Health, University of Otago Wellington, Wellington, New Zealand.

Background: Technology-assisted self-management programs are increasingly recommended to patients with long-term conditions such as diabetes. However, there are a number of personal and external factors that affect patients' abilities to engage with and effectively utilize such programs. A randomized controlled trial of a multi-modal online program for diabetes self-management (BetaMe/Melon) was conducted in a primary care setting, and a process evaluation was completed at the end of the study period.

Objective: This process evaluation aimed to examine the utilization patterns of BetaMe/Melon, identify which components participants found most (and least) useful, and identify areas of future improvement.

Methods: Process evaluation data were collected for intervention arm participants from 3 sources: (1) the mobile/web platform (to identify key usage patterns over the 16-week core program), (2) an online questionnaire completed during the final study assessment, and (3) interviews conducted with a subset of participants following the study period. Participants were classified as "actively engaged" if any usage data was recorded for the participant (in any week), and patterns were reported by age, gender, ethnicity, and diabetes/prediabetes status. The online questionnaire asked participants about the usefulness of the program and whether they would recommend BetaMe/Melon to others according to a 5-point Likert Scale. Of 23 invited participants, 18 participated in a digitally recorded, semistructured telephone interview. Interview data were thematically analyzed.

Results: Out of the 215 participants, 198 (92%) received an initial health coaching session, and 160 (74%) were actively engaged with the program at some point during the 16-week core program. Engagement varied by demographic, with women, younger participants, and ethnic majority populations having higher rates of engagement. Usage steadily declined from 50% at Week 0 to 23% at Week 15. Participants ranked component usefulness as education resources (63.7%), health coaches (59.2%), goal tracking (48.8%), and online peer support (42.1%). Although 53% agreed that the program was easy to use, 64% would recommend the program to others. Interview participants found BetaMe/Melon useful overall, with most identifying beneficial outcomes such as increased knowledge, behavioral changes, and weight loss. Barriers to engagement were program functionality, internet connectivity, incomplete delivery of all program components, and participant motivation. Participants suggested a range of improvements to the BetaMe/Melon program.

Conclusions: The program was generally well received by participants; active engagement was initially high, although it declined steadily. Maintaining participant engagement over time, individualizing programs, and addressing technical barriers are important to maximize potential health benefits from online diabetes self-management programs.

Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12617000549325; https://tinyurl.com/y622b27q.
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http://dx.doi.org/10.2196/19150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738254PMC
December 2020

Codevelopment of Patient Self-Examination Methods and Joint Count Reporting for Rheumatoid Arthritis.

ACR Open Rheumatol 2020 Dec 17;2(12):705-709. Epub 2020 Nov 17.

University of Otago, Christchurch, New Zealand.

Objective: To determine whether training increases accuracy of self-reported joint counts in people with rheumatoid arthritis (RA) and describe the knowledge and techniques for self-examination of joints for reporting of RA disease activity.

Methods: This mixed-methods study included 10 patients with RA and four rheumatologists. A rheumatologist presented about joint inflammation and disease monitoring in RA. Patients then self-examined and reported 28-tender joint count (28-TJC) and 28-swollen joint count (28-SJC). Next, two paired rheumatologists examined patients and reported 28-TJC and 28-SJC. After watching a joint examination video for training physicians, patients discussed their training needs for self-examination, with discussion analyzed using thematic analysis. Self-examination techniques were determined by consensus. Finally, patients self-examined and reported 28-TJC and 28-SJC. Reliability between the first and second patient-reported 28-TJCs and 28-SJCs and rheumatologist pair-reported 28-TJC and 28-SJC was determined with the intraclass coefficient.

Results: The reliability for patient self-reported joint counts was higher for the 28-TJC than for the 28-SJC. Reliability improved following rheumatologist examination and training. Patients identified a preference for practical information rather than detailed information on joint anatomy and pathophysiology. Clear definitions of "swollen" and "tender" were important; patients found the concept of "tenderness" difficult. Techniques for self-examination and reporting of joint counts were agreed on and demonstrated in an instructional video.

Conclusion: Training increased reliability of patient-reported joint counts. Patients with RA identified important aspects of training for self-examination and reporting of joint counts. An 8-minute instructional video was codeveloped; the next step is the evaluation of the video's impact on patient-reported joint counts.
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http://dx.doi.org/10.1002/acr2.11197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738803PMC
December 2020

Use of technology in supporting goal setting in rehabilitation for adults: a scoping review.

BMJ Open 2020 11 10;10(11):e041730. Epub 2020 Nov 10.

Department of Occupational Therapy, Tokyo University of Technology, Ohta-ku, Tokyo, Japan.

Objective: To map the extant literature evaluating the use of technology for goal setting in adult rehabilitation and the impact of technology for patient outcomes.

Design: Scoping review.

Methods: MEDLINE (via Ovid), CINAHL (via EBSCO), AMED and Scopus were searched for articles describing observational or interventional studies. ProQuest Dissertations and Theses database were searched for grey literature. Two review authors independently screened all titles and abstracts for potentially relevant articles. We included articles describing studies that had evaluated the development or application of technology to facilitate goal setting in rehabilitation for adults. Articles were excluded if the technology described did not include features to facilitate goal setting or were not in English. Narrative reviews, opinion pieces and editorials were also excluded.

Results: After screening 1640 publications of potential interest, we identified 27 studies for inclusion. These 27 articles described studies involving a total of 16 different technologies including, seven mobile apps, three websites, two mobile apps/website hybrids, two apps and two websites connected to a pedometer. We found that most technologies described were designed to facilitate self-management with goal setting as a feature and that only five included a shared decision moment around goal setting. Only six of the 16 technologies had research providing evidence of effectiveness in terms of improved patient outcomes, with the best evidence of beneficial effects associated with technologies that linked goal setting to pedometer use.

Conclusions: The identified technologies for use in adult rehabilitation that included goal setting as a feature were largely accepted and valued by patients and health professionals. The limited data suggest that there is a need for further research; specific foci may include the impact of incorporation of a shared decision-making moment and evaluation of effectiveness on patient outcomes.
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http://dx.doi.org/10.1136/bmjopen-2020-041730DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656911PMC
November 2020

Association of Race and Ethnicity With COVID-19 Outcomes in Rheumatic Disease: Data From the COVID-19 Global Rheumatology Alliance Physician Registry.

Arthritis Rheumatol 2021 03 2;73(3):374-380. Epub 2021 Feb 2.

University of California, San Francisco.

Objective: Racial/ethnic minorities experience more severe outcomes of coronavirus disease 2019 (COVID-19) in the general US population. This study was undertaken to examine the association between race/ethnicity and COVID-19 hospitalization, ventilation status, and mortality in people with rheumatic disease.

Methods: US patients with rheumatic disease and COVID-19 were entered into the COVID-19 Global Rheumatology Alliance physician registry between March 24, 2020 and August 26, 2020 were included. Race/ethnicity was defined as White, African American, Latinx, Asian, or other/mixed race. Outcome measures included hospitalization, requirement for ventilatory support, and death. Multivariable regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) adjusted for age, sex, smoking status, rheumatic disease diagnosis, comorbidities, medication use prior to infection, and rheumatic disease activity.

Results: A total of 1,324 patients were included, of whom 36% were hospitalized and 6% died; 26% of hospitalized patients required mechanical ventilation. In multivariable models, African American patients (OR 2.74 [95% CI 1.90-3.95]), Latinx patients (OR 1.71 [95% CI 1.18-2.49]), and Asian patients (OR 2.69 [95% CI 1.16-6.24]) had higher odds of hospitalization compared to White patients. Latinx patients also had 3-fold increased odds of requiring ventilatory support (OR 3.25 [95% CI 1.75-6.05]). No differences in mortality based on race/ethnicity were found, though power to detect associations may have been limited.

Conclusion: Similar to findings in the general US population, racial/ethnic minorities with rheumatic disease and COVID-19 had increased odds of hospitalization and ventilatory support. These results illustrate significant health disparities related to COVID-19 in people with rheumatic diseases. The rheumatology community should proactively address the needs of patients currently experiencing inequitable health outcomes during the pandemic.
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http://dx.doi.org/10.1002/art.41567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8467766PMC
March 2021

'Tell someone who cares': Participation action research on workplace engagement of caregivers in aged residential care, NZ.

Australas J Ageing 2021 Jun 30;40(2):e109-e115. Epub 2020 Oct 30.

Department of Medicine, Otago University, Wellington, New Zealand.

Objective: To use participatory action research (PAR) to understand workplace engagement of caregivers in aged residential care (ARC) in New Zealand.

Methods: A PAR study was conducted in a 40-bed ARC facility providing rest home- and hospital-level care in rural New Zealand. The four-step study included an advisory group of caregivers (N = 6) who co-designed the process. Data were collected via verbatim transcripts of four advisory group meetings, five interviews with staff and field notes over a period of six months. The data were analysed using thematic analysis.

Results: A model was developed to describe factors that encouraged caregivers' engagement in their work. Caregivers were more engaged in their workplace when the influencers of 'Communication', 'Contributing to the workplace' and 'Caring for oneself' were present and when they experienced 'feeling valued', 'being heard' and 'being listened to'.

Conclusion: Factors influencing positive changes in workplace engagement were identified that could be considered when implementing organisational change or service development in other ARC facilities. These factors could potentially increase productivity and quality of care at little cost, as well as improve workplace satisfaction.
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http://dx.doi.org/10.1111/ajag.12876DOI Listing
June 2021

Challenges, collaboration, and innovation in rheumatology education during the COVID-19 pandemic: leveraging new ways to teach.

Clin Rheumatol 2020 Dec 16;39(12):3535-3541. Epub 2020 Oct 16.

Department of Medicine, Division of Rheumatology, Allergy, and Immunology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.

The novel coronavirus disease (COVID-19) pandemic has significantly impacted the field of rheumatology, in both the delivery of clinical care and didactic education for our trainees. These changes have generated significant strain for program directors and clinical educators who have had to leverage technology and develop new systems to ensure continued trainee education and assessment. We aim to outline the impacts on formal education programs presented by these unprecedented disruptions, describe the development and deployment of online teaching, reflect on the challenges and opportunities for technology-enabled learning and use of social media for education, and give some international perspectives on impacts on postgraduate rheumatology training outside the USA. With the rapid dissolution of barriers in place during the pre-COVID-19 era, we have the opportunity to assess the efficacy of new methods of care and further integrate technology into teaching and assessment. We propose that a hybrid in-person and technology-enabled learning approach, so-called blended learning, is likely to remain the most desirable future model for supporting trainee learning.
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http://dx.doi.org/10.1007/s10067-020-05449-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7567647PMC
December 2020

Acute respiratory viral adverse events during use of antirheumatic disease therapies: A scoping review.

Semin Arthritis Rheum 2020 10 22;50(5):1191-1201. Epub 2020 Jul 22.

Division of Rheumatology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Electronic address:

Introduction: COVID-19 is an acute respiratory viral infection that threatens people worldwide, including people with rheumatic disease, although it remains unclear to what extent various antirheumatic disease therapies increase susceptibility to complications of viral respiratory infections.

Objective: The present study undertakes a scoping review of available evidence regarding the frequency and severity of acute respiratory viral adverse events related to antirheumatic disease therapies.

Methods: Online databases were used to identify, since database inception, studies reporting primary data on acute respiratory viral infections in patients utilizing antirheumatic disease therapies. Independent reviewer pairs charted data from eligible studies using a standardized data abstraction tool.

Results: A total of 180 studies were eligible for qualitative analysis. While acknowledging that the extant literature has a lack of specificity in reporting of acute viral infections or complications thereof, the data suggest that use of glucocorticoids, JAK inhibitors (especially high-dose), TNF inhibitors, and anti-IL-17 agents may be associated with an increased frequency of respiratory viral events. Available data suggest no increased frequency or risk of respiratory viral events with NSAIDs, hydroxychloroquine, sulfasalazine, methotrexate, azathioprine, mycophenolate mofetil, cyclophosphamide, or apremilast. One large cohort study demonstrated an association with leflunomide use and increased risk of acute viral respiratory events compared to non-use.

Conclusion: This scoping review identified that some medication classes may confer increased risk of acute respiratory viral infections. However, definitive data are lacking and future studies should address this knowledge gap.
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http://dx.doi.org/10.1016/j.semarthrit.2020.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832282PMC
October 2020

Issues in reporting of systematic review methods in health app-focused reviews: A scoping review.

Health Informatics J 2020 12 11;26(4):2930-2945. Epub 2020 Sep 11.

University of Otago Wellington, New Zealand.

No guidelines exist for the conduct and reporting of manuscripts with systematic searches of app stores for, and then appraisal of, mobile health apps ('health app-focused reviews'). We undertook a scoping review including a systematic literature search for health app-focused reviews describing systematic app store searches and app appraisal, for apps designed for patients or clinicians. We created a data extraction template which adapted data elements from the PRISMA guidelines for systematic literature reviews to data elements operationalised for health app-focused reviews. We extracted the data from included health app-focused reviews to describe: (1) which elements of the adapted 'usual' methods of systematic review are used; (2) methods of app appraisal; and (3) reporting of clinical efficacy and recommendations for app use. From 2798 records, the 26 included health app-focused reviews showed incomplete or unclear reporting of review protocol registration; use of reporting guidelines; processes of screening apps; data extraction; and appraisal tools. Reporting of clinical efficacy of apps or recommendations for app use were infrequent. The reporting of methods in health app-focused reviews is variable and could be improved by developing a consensus reporting standard for health app-focused reviews.
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http://dx.doi.org/10.1177/1460458220952917DOI Listing
December 2020

Impact of a comprehensive digital health programme on HbA and weight after 12 months for people with diabetes and prediabetes: a randomised controlled trial.

Diabetologia 2020 12 4;63(12):2559-2570. Epub 2020 Sep 4.

Department of Public Health, University of Otago, Wellington, New Zealand.

Aims/hypothesis: The aim of this RCT was to evaluate the effectiveness of a digital health programme (BetaMe/Melon) vs usual care in improving the control of type 2 diabetes and prediabetes in a primary care population.

Methods: We conducted a randomised parallel-group two-arm single-blinded superiority trial in the primary care setting in two regions of New Zealand. Eligible participants were identified through Primary Health Organisations and participating practices. Eligibility criteria were as follows: age 18-75 years, HbA 41-70 mmol/mol (5.9-8.6%), not taking insulin, and daily access to the internet. BetaMe/Melon is a 12 month mobile-device and web-based programme with four components: health coaching; evidence-based resources; peer support; and goal tracking. Participants were randomised into the intervention or control arm (1:1 allocation) based upon baseline HbA (prediabetes or diabetes range), stratified by practice and ethnicity. Research nurses and the study biostatistician were blind to study arm. Primary outcomes of the study were changes in HbA and weight at 12 months, using an intention-to-treat analysis.

Results: Four hundred and twenty-nine individuals were recruited between 20 June 2017 and 11 May 2018 (n = 215 intervention arm, n = 214 control arm), most of whom were included in analyses of co-primary outcomes (n = 210/215, 97.7% and n = 213/214, 99.5%). HbA levels at 12 months did not differ between study arms: mean difference was -0.9 mmol/mol (95% CI -2.9, 1.1) (-0.1% [95% CI -0.3, 0.1]) for the diabetes group and was 0.0 mmol/mol (95% CI -0.9, 0.9) (0.0% [95% CI -0.1, 0.1]) for the prediabetes group. Weight reduced slightly at 12 months for participants in both study arms, with no difference between arms (mean difference -0.4 kg [95% CI -1.3, 0.5]).

Conclusions/interpretation: This study did not demonstrate clinical effectiveness for this particular programme. Given their high costs, technology-assisted self-management programmes need to be individually assessed for their effectiveness in improving clinical outcomes for people with diabetes.

Trial Registration: www.anzctr.org.au ACTRN12617000549325 (universal trial number U1111-1189-9094) FUNDING: This study was funded by the Health Research Council of New Zealand, the Ministry of Health New Zealand and the Healthier Lives National Science Challenge. Graphical abstract.
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http://dx.doi.org/10.1007/s00125-020-05261-xDOI Listing
December 2020

The COVID-19 Global Rheumatology Alliance: evaluating the rapid design and implementation of an international registry against best practice.

Rheumatology (Oxford) 2021 01;60(1):353-358

Department of Medicine and Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand.

Objectives: As the coronavirus disease 2019 pandemic developed there was a paucity of data relevant to people living with rheumatic disease. This led to the development of a global, online registry to meet these information needs. This manuscript provides a detailed description of the coronavirus disease 2019 Global Rheumatology Alliance registry development, governance structure, and data collection, and insights into new ways of rapidly establishing global research collaborations to meet urgent research needs.

Methods: We use previously published recommendations for best practices for registry implementation and describe the development of the Global Rheumatology Alliance registry in terms of these steps. We identify how and why these steps were adapted or modified. In Phase 1 of registry development, the purpose of the registry and key stakeholders were identified on online platforms, Twitter and Slack. Phase 2 consisted of protocol and data collection form development, team building and the implementation of governance and policies.

Results: All key steps of the registry development best practices framework were met, though with the need for adaptation in some areas. Outputs of the registry, two months after initial conception, are also described.

Conclusion: The Global Rheumatology Alliance registry will provide highly useful, timely data to inform clinical care and identify further research priorities for people with rheumatic disease with coronavirus disease 2019. The formation of an international team, easily able to function in online environments and resulting in rapid deployment of a registry is a model that can be adapted for other disease states and future global collaborations.
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http://dx.doi.org/10.1093/rheumatology/keaa483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454885PMC
January 2021

Antirheumatic Disease Therapies for the Treatment of COVID-19: A Systematic Review and Meta-Analysis.

Arthritis Rheumatol 2021 01 19;73(1):36-47. Epub 2020 Nov 19.

Mayo Clinic, Rochester, Minnesota, United States.

Objective: Antirheumatic disease therapies have been used to treat coronavirus disease 2019 (COVID-19) and its complications. We conducted a systematic review and meta-analysis to describe the current evidence.

Methods: A search of published and preprint databases in all languages was performed. Included studies described ≥1 relevant clinical outcome for ≥5 patients who were infected with severe acute respiratory syndrome coronavirus 2 and were treated with antirheumatic disease therapy between January 1, 2019 and May 29, 2020. Pairs of reviewers screened articles, extracted data, and assessed risk of bias. A meta-analysis of effect sizes using random-effects models was performed when possible.

Results: The search identified 3,935 articles, of which 45 were included (4 randomized controlled trials, 29 cohort studies, and 12 case series). All studies evaluated hospitalized patients, and 29 of the 45 studies had been published in a peer-reviewed journal. In a meta-analysis of 3 cohort studies with a low risk of bias, hydroxychloroquine use was not significantly associated with mortality (pooled hazard ratio [HR] 1.41 [95% confidence interval (95% CI) 0.83, 2.42]). In a meta-analysis of 2 cohort studies with some concerns/higher risk of bias, anakinra use was associated with lower mortality (pooled HR 0.25 [95% CI 0.12, 0.52]). Evidence was inconclusive with regard to other antirheumatic disease therapies, and the majority of other studies had a high risk of bias.

Conclusion: In this systematic review and meta-analysis, hydroxychloroquine use was not associated with benefit or harm regarding COVID-19 mortality. The evidence supporting the effect of other antirheumatic disease therapies in COVID-19 is currently inconclusive.
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http://dx.doi.org/10.1002/art.41469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7435536PMC
January 2021

A Tool for Rating the Value of Health Education Mobile Apps to Enhance Student Learning (MARuL): Development and Usability Study.

JMIR Mhealth Uhealth 2020 07 31;8(7):e18015. Epub 2020 Jul 31.

Education Unit, University of Otago Wellington, Wellington, New Zealand.

Background: To realize the potential for mobile learning in clinical skills acquisition, medical students and their teachers should be able to evaluate the value of an app to support student learning of clinical skills. To our knowledge, there is currently no rubric for evaluation of quality or value that is specific for apps to support medical student learning. Such a rubric might assist students to be more confident in using apps to support their learning.

Objective: The objective of this study was to develop an instrument that can be used by health professional educators to rate the value of a mobile app to support health professional student learning.

Methods: Using the literature, we developed a list of potential criteria for the evaluation of educational app value, which were then refined with a student group using a modified nominal group technique. The refined list was organized into themes, and the initial rubric, Mobile App Rubric for Learning (MARuL, version 1), was developed. iOS and Android app stores were searched for clinical skills apps that met our inclusion criteria. After the 2 reviewers were trained and the item descriptions were refined (version 2), a random sample of 10 included apps, 5 for each mobile operating system, was reviewed. Interitem and interrater analyses and discussions with the reviewers resulted in refinement of MARuL to version 3. The reviewers completed a review of 41 clinical skills mobile apps, and a second round of interitem and interrater reliability testing was performed, leading to version 4 of the MARuL.

Results: Students identified 28 items (from an initial set of 144 possible items) during the nominal group phase, and these were then grouped into 4 themes: teaching and learning, user centered, professional, and usability. Testing and refinement with reviewers reduced the list to 26 items. Internal consistency for MARuL was excellent (α=.96), and the interrater reliability as measured by the intraclass correlation coefficient (ICC) was good (ICC=0.66).

Conclusions: MARuL offers a fast and user-friendly method for teachers to select valuable apps to enhance student learning.
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http://dx.doi.org/10.2196/18015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428912PMC
July 2020

Conducting research in a pandemic: The power of social media.

Eur J Rheumatol 2020 Aug 21;7(Suppl 2):S85-S88. Epub 2020 Jul 21.

Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.

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http://dx.doi.org/10.5152/eurjrheum.2020.2066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431333PMC
August 2020

Smartphone Apps Targeting Physical Activity in People With Rheumatoid Arthritis: Systematic Quality Appraisal and Content Analysis.

JMIR Mhealth Uhealth 2020 07 21;8(7):e18495. Epub 2020 Jul 21.

Department of Population Health Sciences, School of Population Health and Environmental Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.

Background: Rheumatoid arthritis (RA) is a disabling, inflammatory joint condition affecting 0.5%-1% of the global population. Physical activity (PA) and exercise are recommended for people with RA, but uptake and adherence tend to be low. Smartphone apps could assist people with RA to achieve PA recommendations. However, it is not known whether high quality, evidence-informed PA apps that include behavior change techniques (BCTs) previously identified as effective for PA adherence are available for people with RA.

Objective: This study aims to systematically identify apps that include goals to facilitate PA for adults with RA and assess app quality and content for the inclusion of relevant BCTs against recommendations for cardiorespiratory, resistance, flexibility, and neuromotor PA and exercise.

Methods: A systematic search of the Apple App Store and Google Play Store in the United Kingdom was conducted to identify English language apps that promote PA for adults with RA. Two researchers independently assessed app quality (mobile app rating scale [MARS]; range 0-5) and content (BCT Taxonomy version 1, World Health Organization, the American College of Sports Medicine, and the European League against Rheumatism recommendations for PA). The completeness of reporting of PA prescription was evaluated using a modified version of the Consensus on Exercise Reporting Template (CERT; range 0-14).

Results: A total of 14,047 apps were identified. Following deduplication, 2737 apps were screened for eligibility; 6 apps were downloaded (2 on the Apple App Store and 4 on the Google Play Store), yielding 4 unique apps. App quality varied (MARS score 2.25-4.17). Only 1 app was congruent with all aspects of the PA recommendations. All apps completely or partially recommended flexibility and resistance exercises, 3 apps completely or partially advised some form of neuromotor exercise, but only 2 offered full or partial guidance on cardiorespiratory exercise. Completeness of exercise reporting was mixed (CERT scores 7-14 points) and 3-7 BCTs were identified. Two BCTs were common to all apps (information about health consequences and instruction on how to perform behavior). Higher quality apps included a greater number of BCTs and were more closely aligned to PA guidance. No published trials evaluating the effect of the included apps were identified.

Conclusions: This review identifies 4 PA apps of mixed quality and content for use by people with RA. Higher quality apps were more closely aligned to PA guidance and included a greater number of BCTs. One high-quality app (Rheumatoid Arthritis Information Support and Education) included 7 BCTs and was fully aligned with PA and exercise guidance. The effect of apps on PA adherence should be established before implementation.
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http://dx.doi.org/10.2196/18495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7404016PMC
July 2020
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