Dr. Chan explained, “To improve outcomes in OA, we need to do a better job of defining it and understanding mechanisms behind it. Though we do not typically think of ‘phenotypes’ when we think of OA, we also instinctively know that the ‘wear-and-tear’ conception of OA is not the whole picture either, as illustrated by those pesky Heberden nodes.”

She continued, “In the past decade, more advanced imaging and lab methods, statistical tools, and machine learning have contributed to more sophisticated phenotyping attempts. This work has become so relevant and critical that in 2020, a panel of 25 osteoarthritis researchers published a framework for doing this work. Defining phenotypes and endotypes will lead to a better understanding of the natural history of the various types of OA and allow for better treatment paradigms rather than the limited and rather blunt instruments of pain management and joint replacement surgery that we currently use.”

Read the full article at Medscape.com.

Dr. Chan explained, “In rheumatology, the use of cannabis and cannabinoids is seductive for patients who worry about potential adverse effects of disease modifiers, or who are frustrated by their chronic pain.”

She cited a recent study that found the prevalence of cannabis use tripled between 2014 and 2019 from 6.3% to 18.4%. Yet, the patients who used cannabis products had poorer pain control than nonusers.

Dr. Chan stated, “When it comes to medical marijuana, the popularity of the subject has outpaced the state of our knowledge. So much remains unknown regarding the mechanisms and efficacy of medical marijuana. The FDA has issued guidance for conducting research on this and related compounds, and before long, one hopes, we will have more clarity about it.”

Read the full article at Medscape.com.

According to Dr. Chan, pain is a good indicator of RA progression. “It’s especially telling if you start on medication and you get better, and then later on you start to develop pain again,” she said. For patients who change their habits or activities to accommodate their joints – for instance, avoiding clothes with buttons because they are unable to button them, these subtle behavior changes can also indicate RA progression. “You might think that [these changes] are not a big deal because you can easily adjust how you do things and feel fine, but you want to bring that to your doctor’s attention,” noted Dr. Chan.

If there is pain or tenderness in new joints, it is important that your doctor knows about any new joint symptoms, cited Dr. Chan. One of the ways your physician can monitor your RA is by counting how many swollen and tender joints you have during each visit, she explained. It’s a sign the disease has progressed whenever new joints are added to the list.

Looking at your joints can also help detect RA progression. There are various ways that the joints may look different. For example, your finger or wrist joints may deviate to the side and bend toward your pinky if you developed an ulnar deviation, cited Dr. Chan. It’s worth notifying your doctor any time your joints look different because these structural changes could be a sign of rheumatoid arthritis progression, she added.

Read the full article at Self.com.

Dr. Chan noted, “One of the defining characteristics of hypermobile EDS is that patients can have chronic widespread pain. Patients with classic EDS and vascular EDS also can have joint hypermobility, but widespread pain is not disease-defining. Widespread pain is also common among patients with non-EDS joint hypermobility. The pathogenesis of the pain is unclear; some unsubstantiated hypotheses include reliance on musculotendinous structures for stability in the hypermobile joint, or that the hypermobile joint may be more susceptible to repetitive use injuries. Pain amplification, akin to that seen in fibromyalgia, may play a role and may explain other functional issues such as chronic gastrointestinal distress.”

Dr. Chan cited, “There is no cure for EDS. The goals of treatment are symptom management and injury prevention. Whether or not the joint hypermobility is syndromic, physical therapy is generally considered the mainstay of treatment, but high-quality evidence is lacking. A handful of small randomized controlled trials have demonstrated that some physical therapy results in better outcomes compared with no intervention at all.”

She continued, “Psychosocial support is key to the management of the patient’s pain. The clinician should offer validation that the pain is legitimate even if poorly understood. Accompanying anxiety and depression can be managed with psychotherapy. Cognitive-behavioral therapy is an effective modality for the management of chronic pain in other contexts. Pharmacologic agents commonly used for chronic pain management, such as tricyclic antidepressants, gabapentinoids, and serotonin-norepinephrine reuptake inhibitors may reduce the degree of pain.” Dr. Chan added, “Patients with vascular EDS, which can be catastrophic, should be made aware of the symptoms of potential complications, including severe abdominal pain (indicating arterial or organ rupture), chest pain (pneumothorax), and vision loss (retinal detachment). A baseline echocardiogram for all EDS patients and magnetic resonance angiography or CT angiography for those with vascular EDS may be helpful, although there is no protocol for ongoing monitoring. Ophthalmic complications can occur in a variety of the EDS syndromes, so regular ophthalmology exams are recommended to check for retinal and scleral fragility.”

Read the full article at Medscape.com.

Dr. Chan explained the study objective, key findings and what clinicians should be aware of, and areas warranting further research.

“We wanted to look at these patients and see if there was anything remarkable about their characteristics -- their arthritis or the medications or the amount of steroid that we use -- that could tell us something about the cancer progression,” said Dr. Chan. “What we found in this study is that the CDAI [Clinical Disease Activity Index] might be an indicator of cancer progression. The worse patients are doing with regard to their joints, the more likely their cancer was to progress,” she noted. “Not necessarily in light of these results, but just in general I think if patients complain of joint pain, the threshold to send them to rheumatology should be low, because we can properly assess whether the condition is inflammatory as opposed to mechanical and help with treatment and monitoring,” she continued. “We have to remember that there are plenty of caveats here. This was a small study, small number of patients, with many different cancers and immunotherapy regimens represented. And the therapeutic strategies we used to treat the arthritis were not protocolized. So, this is by no means a study on which to base bold pronouncements," concluded Dr. Chan. 

Read the full article at MedPagetoday.com.

The first symptom you’ll likely notice is joint pain, explained Dr. Chan. It’s a dull, achy, or sharp pain that comes and goes at first and gets more constant over time, she continued.

OA pain acts up when you move the affected joint, and it may be triggered by a specific activity—like knee pain when you climb stairs or pain in the base of your thumb when you twist open a jar or turn a doorknob, said Dr. Chan. Extended activity (e.g., long walks or prolonged standing) can also lead to pain. It may get worse as you use the joint throughout the day. Conversely, pain from inflammatory arthritis (like rheumatoid) tends to feel better with movement, not worse, she counseled.

OA patients often report feeling stiff and creaky for five or 10 minutes after they’ve been inactive for a while—like when you wake up in the morning or get up after eating dinner or watching a movie, noted Dr. Chan.

One of a few reasons indicating it might be time to see a doctor is if the individual’s joint pain is interfering with an activity they would otherwise enjoy – which is often a telltale sign of OA, cited Dr. Chan.

Read the full article at Healthcentral.com.

“While I do use my Twitter account to learn from colleagues and to promote work that interests me, my primary aim is to participate in civil society as a person,” wrote Dr. Chan.

“Professionally, Twitter is rewarding. It is a space for networking and for promoting one's work. It is a fantastic learning format, as evidenced by the popularity of tweetorials,” she said. “But I find that I cannot separate who I am from what I do. As a rheumatologist, I build long-term relationships with patients. I cannot care for their medical conditions in isolation without also concerning myself with their nonmedical circumstances. For that reason, I have opinions that one might call humanist, and I suspect that I am not alone among rheumatologists,” she continued.

Dr. Chan noted three areas, broadly construed but with huge overlaps, that hold great concern for her which include things that affect all physicians (e.g., race and gender in the workplace; advancement of women in science and technology); things that affect rheumatologists particularly (e.g., access to medications and procedures, etc.); and issues that affect patients (e.g., health insurance being tied to employment, healthcare disparities, etc.) She concluded, “Critics will use "stay in your lane" as shorthand to say x professionals should stick to x (actors to acting, musicians to music, athletes to sports). If only I could. But my humanity won't let me.”

Read the full article at Medscape.com

“Our study found that for every point increase in the clinical disease activity index, the risk of cancer progression increased by 11 percent,” said Dr. Chan. Not only did those whose cancer progressed have more severe arthritis, but they also developed arthritis sooner than those whose cancer didn’t progress – about two months after starting checkpoint inhibitors compared to four months for the others.

Dr. Chan added, “But this is very preliminary data, based on a small group of people with a variety of cancers and treatment regimens. Rheumatologists need to study this issue more closely.”

Read the full article at Survivornet.com.

Dr. Chan and colleagues conducted a multivariable analysis that adjusted for time to onset of arthritis after initiation of ICI therapy and for the use of disease-modifying antirheumatic drugs (DMARDs), each one-point increase in baseline Clinical Disease Activity Index (CDAI) was associated with a 9% increase in the likelihood of cancer progression (HR 1.09, 95% CI 1.00-1.19, P=0.05).

"Untangling the relationship between ICI-arthritis disease severity (e.g., CDAI), ICI-arthritis treatment (e.g., TNF inhibitors), and cancer survival will be critical to the development of safe treatment approaches," the researchers wrote.

Read the full article at Medpagetoday.com.

Dr. Chan noted, “When I first started, I felt like I was being helpful. Walking home in the middle of the 7 PM cheers for healthcare workers frequently left me teary eyed. As horrible as the situation was, I was proud of myself for volunteering to help and appreciative of a broken city's gratitude toward all healthcare workers in general.”

She further stated, “No, I am no hero. But did my volunteering make a difference? It made a difference to me. The overwhelming feeling I am left with isn't pride; it's humility. I feel humbled that I could feel so unexpectedly touched by the lives of people that I had no idea I could feel touched by.”

Read the full article at Medscape.com.

According to Dr. Chan, lack of finances, health literacy and social support all make dealing with chronic illness much more difficult. However, she suggested, “In the era of electronic health records, the ability of patients to message their doctors in real time is a nice feature — it makes patients feel like we are available to them. Support staff helping patients navigate the health care system, particularly prior authorizations and insurance kinks and the dreaded specialty pharmacies, can be helpful. Providing resources such as patient information pages from the Arthritis Foundation or UpToDate are useful, but a lot of my patients also have really been helped a lot by support groups that the Hospital for Special Surgery [HSS] makes available to patients. This makes patients feel less alone."

Dr. Chan noted, “Investing in oneself is huge and not often talked about. Some important examples include physical health (e.g., time or money spent either in physical therapy or at the gym or other physical activities that patients enjoy) and mental health (a good therapist can make a big difference dealing with issues that come up when one is dealing with a chronic illness)." 

Read the full article at Healio.com/news/rheumatology.

Read the full feature at NYTimes.com.

MDedge Rheumatology spoke to HSS rheumatologist, Karmela Kim Chan, MD, who shared her perspective on the survey outcomes. “Often rheumatologists are the doctors of last resort – when other physicians are unable to figure out the problem, the next step is to seek out rheumatology. It is not uncommon for patients to start their visit with ‘you’re my last hope.’ So there is a lot of pressure placed on us, and I think rheumatologists are susceptible to that pressure. We desperately want to be able to help,” cited Dr. Chan.

Additionally, Dr. Chan explained, “On top of all that, there are administrative burdens. EHRs [electronic health records] are a net-positive, but that doesn’t make charting any less painful. Add to that the daily insurance battles for life-saving treatments, which take up hours that are not compensated. And we still have to worry about patient satisfaction because we have to worry about our reputation.”

Dr. Chan concluded while self-care has its benefits, it doesn’t address the systematic challenges, and suggested letting providers spend more time with patients, providing better support staff and exploring the benefits of scribes.

Read the article at MDedge.com.

Dr. Chan recommended strength training to build and maintain muscle, stating, “The stronger your muscles are, the less wear on your joints." Some patients find relief through regular massage and warm wax therapy. “Warmth is very, very comforting to patients,” explained Dr. Chan. “For example, if someone has arthritis in their hands, I tell them to buy a paraffin bath to soak their hands in.” Application of a cold compress may also help. “While heat is great for loosening up stiff joints, cold is useful when something is acutely inflamed,” she said. “I’m also a big fan of acupuncture. Its very low-risk, so why not try it if it can give a patient a better quality of life?” added Dr. Chan.

Read the article at healthcentral.com.

Proper sleep lowers stress levels, which is a big trigger for patients with PsA. However, if pain of aching joints or discomfort from sensitive skin is keeping you awake at night, it might be time to try a new regimen. “Your doctor may be able to suggest medication specifically to help you sleep better,” said Dr. Chan.

Read the article at healthcentral.com.

The Rheumatologist spoke to Adena Batterman, MSW, LCSW, senior manager of inflammatory arthritis support and education programs at HSS, who explained HSS screens all rheumatology patients at intake, which when appropriate, triggers referrals to mental health services. Batterman said, "As part of a comprehensive psychosocial assessment, social workers screen patients for all issues that may impact your ability to cope with a rheumatic disease." She added, “There is a surprisingly low incidence of rheumatologists asking about these issues in medical encounters. It’s important to make this screening part of a normal exam routine because of the profound impact of depression on RA disease outcomes. It’s all a part of treating the person as a whole.”

Karmela Kim Chan, MD, rheumatologist at HSS, also provided commentary to The Rheumatologist about the barriers to effective depression screening and referral in rheumatology, which include short appointments, and a lack of clear clinical directives about mental health. “There are no treatment guidelines on mental health along the lines of treat to target, for example. But it is very important,” explained Dr. Chan. Psychological symptoms “may alter a patient’s subjective scores for pain or fatigue, so it definitely plays a role in clinical decision making,” she cited. “I won’t shy away from bringing up mental health issues with my patients. Instinctively, we know that when we’re treating someone with a rheumatic disease, there may be a mental health component. It’s important not to forget about this,” she concluded.

Read the article at the-rheumatologist.org.

Healio Rheumatology spoke to Karmela Kim Chan, MD, rheumatologist at HSS, who explained it remains to be seen whether that level of concern is warranted for these patients as the data remains sparse. “We don’t actually know specifically if TNF inhibitors increase the risk of measles. We don’t know if being on a TNF agent affects someone’s immune status — if the TNF blocker somehow causes immunity to measles to wane in someone who has previously been vaccinated. Even so, it seems that in patients who do get measles despite having been vaccinated, the measles case is not as severe,” said Dr. Chan. She added, “It is useful to bear in mind that for the 2018-2019 flu season, the CDC estimates that there were about 40 million influenza illnesses. Compare that to only 971 cases of measles in the first five months of 2019. Just by virtue of likelihood of exposure, our patients are far more likely to suffer with the flu rather than measles.”

Read the full article at Healio.com.