Search

To provide an approach to primary and secondary prevention of thrombotic events and obstetric complications in patients with antiphospholipid antibodies (aPL) with or without antiphospholipid syndrome (APS), particularly in association with systemic lupus erythematosus (SLE). The available evidence would suggest that direct oral anticoagulants are inferior to warfarin at prevention of recurrent thrombosis, particularly in patients with a history of arterial thrombosis or triple aPL positivity. Novel therapies currently being considered for APS include eculizumab, and B cell inhibitors, which may have a role in refractory or resistant APS. Patients should be risk-stratified for risk of thromboembolism, and traditional cardiovascular risk factors addressed. Primary prophylaxis with aspirin should be considered in patients with SLE and aPL. Secondary prevention for APS is with warfarin with an INR of 2.0–3.0. Pregnant SLE patients with aPL/APS are managed with aspirin and heparin.

Despite erosions being as prevalent in feet as in hands in patients with rheumatoid arthritis (RA), their development in relation to synovitis and bone marrow edema (BME) have mainly been studied in hands. This study examines the prevalence and longitudinal trajectory of erosions, BME, and synovitis in metatarsophalangeal joints (MTPJs) in patients with early RA over 2 years of treatment. We also describe correlations between erosions, synovitis, and BME at the joint level. Magnetic resonance imaging (MRI) of the most symptomatic forefoot was acquired at baseline, year 1, and ≥ 2 years. Metatarsophalangeal joints 2-5 were scored by a radiologist for erosions, synovitis, and BME according to OMERACT guidelines. Patients were treated per standard of care. Thirty-two patients with early RA were included. Significant reductions in overall synovitis scores, MTPJ2, and MTPJ3 synovitis scores were seen between year 1 and ≥ 2 years. Overall BME scores improved in year 1 and were sustained at ≥ 2 years. BME improved in MTPJ2, MTPJ3, and MTPJ4. Overall erosions did not significantly change. Positive correlations were seen between changes in synovitis and BME in MTPJ2 and MTPJ5. In patients with early RA, standard of care was associated with overall reductions in synovitis by year 2, BME by year 1, and no progression in overall erosion scores on MRI. MTPJ2 and MTPJ3 appeared to be the most active joints. Improvements in synovitis were noted in MTPJ2 and MTPJ3 and reductions in BME in MTPJ2, MTPJ3, and MTPJ4, while other MTPJs did not progress. Key Points • This is one of the few MRI studies that examined longitudinal changes in imaging outcomes in early RA at the joint level in feet. • Erosions, synovitis, and bone marrow edema (BME) visualized on magnetic resonance imaging were most prevalent in metatarsophalangeal joints (MTPJ) 2 and 3 in patients with early rheumatoid arthritis (RA). • Standard of care was associated with improvements in synovitis in MTPJ2 and MTPJ3 and improvements in BME in MTPJ2, MTPJ3, and MTPJ4 over 2 years of treatment.

Despite erosions being as prevalent in feet as in hands in patients with rheumatoid arthritis (RA), their development in relation to synovitis and bone marrow edema (BME) have mainly been studied in hands. This study examines the prevalence and longitudinal trajectory of erosions, BME, and synovitis in metatarsophalangeal joints (MTPJs) in patients with early RA over 2 years of treatment. We also describe correlations between erosions, synovitis, and BME at the joint level. Magnetic resonance imaging (MRI) of the most symptomatic forefoot was acquired at baseline, year 1, and ≥ 2 years. Metatarsophalangeal joints 2-5 were scored by a radiologist for erosions, synovitis, and BME according to OMERACT guidelines. Patients were treated per standard of care. Thirty-two patients with early RA were included. Significant reductions in overall synovitis scores, MTPJ2, and MTPJ3 synovitis scores were seen between year 1 and ≥ 2 years. Overall BME scores improved in year 1 and were sustained at ≥ 2 years. BME improved in MTPJ2, MTPJ3, and MTPJ4. Overall erosions did not significantly change. Positive correlations were seen between changes in synovitis and BME in MTPJ2 and MTPJ5. In patients with early RA, standard of care was associated with overall reductions in synovitis by year 2, BME by year 1, and no progression in overall erosion scores on MRI. MTPJ2 and MTPJ3 appeared to be the most active joints. Improvements in synovitis were noted in MTPJ2 and MTPJ3 and reductions in BME in MTPJ2, MTPJ3, and MTPJ4, while other MTPJs did not progress. Key Points • This is one of the few MRI studies that examined longitudinal changes in imaging outcomes in early RA at the joint level in feet. • Erosions, synovitis, and bone marrow edema (BME) visualized on magnetic resonance imaging were most prevalent in metatarsophalangeal joints (MTPJ) 2 and 3 in patients with early rheumatoid arthritis (RA). • Standard of care was associated with improvements in synovitis in MTPJ2 and MTPJ3 and improvements in BME in MTPJ2, MTPJ3, and MTPJ4 over 2 years of treatment.

In Canada, little is known about residents' self-confidence to diagnose/treat musculoskeletal (MSK) disease and factors affecting pursuit of a rheumatology career. Our study explored these factors. An online survey (descriptive cross-sectional design) was distributed to Canadian postgraduate year (PGY) 1 and 2 internal medicine (IM) residents. Questions probed self-confidence in rheumatology and factors influencing subspecialty career choice. Frequencies were determined and responses compared between PGY-1 and PGY-2 using univariate statistical analyses. Fifty-four IM residents completed the survey. PGY-2 residents were statistically more certain in subspecialty decidedness and had higher levels of self-confidence to diagnose/treat MSK disease and perform a physical exam. "Quality of life" was the most encouraging factor for a rheumatology career choice followed by "job opportunities" and "previous clinical exposure." Although 50% of PGY-1 residents had completed a rheumatology clinical rotation, 76% indicated that increased knowledge would affect rheumatology career choice. Only 38% were interested in novel rheumatology education. No difference in rheumatology exposure, rheumatology clinical rotation completion year, or rheumatology career choice was observed. Our research confirms findings from similar United States (US) and United Kingdom (UK) studies that suggest that increased MSK knowledge positively influences residents' confidence to diagnose/treat MSK disease. Our study differs with Canadian PGY-1 and PGY-2 IM residents by evaluating self-confidence to diagnose/treat MSK disease separately from self-confidence to perform a physical exam. Significant differences between first and second year trainees suggest types/quality of rheumatology experiences (e.g., case complexity, diagnostic problem-solving competency) may affect self-confidence to diagnose/treat MSK disease factors and rheumatology career choice.

Patient non-adherence is a common and important problem in clinical medicine. Some cases of patient non-adherence are cases in which the patient disagrees with the physician’s recommended treatment based on particular reasons. In this chapter, by drawing upon the science and technology studies literature, specifically the discussion by Collins and Evans and also Wynne of how best to understand scientific controversies, I relate their ideas to the analogous conflict that may occur within a clinical encounter. I draw upon their recognition of the importance of contributory expertise and interactional expertise in providing legitimate knowledge. I also draw upon Wynne’s idea of the ‘negotiation of meanings’ as an important element of the clinical interaction. To resolve potential conflicts between patient and physician before they develop into ‘non-adherence’, I propose the need for a new epistemological framework that recognizes legitimate knowledge offered by the patient as well as the physician. By situating this patient expertise framework within the paradigm of person-centred medicine, and by assuming the goal of medical treatment to be treatment of suffering , patient expertise becomes centralized as a means of determining the nature of patient suffering. Two aspects of the patient’s tacit knowledge - the body aspect and the meaning aspect - both of which are context-dependent and directly accessible only to the patient, are thus recognized as knowledge essential to the success of the interaction. The physician’s role becomes that of both medical expert and possessor of interactional expertise, by which the physician recognizes and includes patient expertise in the treatment decision. Finally, the patient expertise framework must also involve recognizing and incorporating the ‘negotiation of meanings’ into the development of a treatment plan. By acknowledging the importance of patient expertise and the negotiation of meanings, this patient expertise framework should dissolve the problem of patient non-adherence that derives from the patient disagreeing with the therapeutic plan.

Summary Patient non-adherence is a common and important concern in clinical medicine. Some cases of patient non-adherence are cases in which the patient disagrees with the physician's recommended treatment based on particular reasons. Drawing upon science and technology studies literature, specifically the discussion by Collins and Evans and Wynne of how best to understand scientific controversies, I relate their ideas to the analogous conflict that may occur within a clinical interaction. I draw upon their recognition of the importance of contributory expertise and interactional expertise in providing legitimate knowledge. I also draw upon Wynne's idea of the ‘negotiation of meanings’ as an important element of the clinical interaction. To resolve potential conflicts between patient and physician before they develop into ‘non-adherence’, I propose the implementation of a new epistemological framework that recognizes legitimate knowledge offered by the patient as well as the physician. By situating this patient expertise framework within the paradigm of patient-centred medicine, and by assuming the goal of medical treatment to be treatment of suffering, patient expertise becomes centralized as a means of determining the nature of patient suffering. Two aspects of the patient's tacit knowledge – the body aspect and the meaning aspect – both of which are context-dependent and directly accessible only to the patient, are thus recognized as knowledge essential to the success of the interaction. The physician's role becomes that of both medical expert and possessor of ‘interactional expertise’, by which the physician recognizes and includes patient expertise in the treatment decision. By recognizing and incorporating the negotiation of meanings into the development of a treatment plan, this epistemological model of patient expertise should prevent cases of non-adherence based on disagreement.