The research focuses on the diagnosis of renal disorders, the risk of venous thromboembolism after total knee replacement (TKR), and the care of pediatric and young adult patients with rheumatologic diseases. There are also studies related to the care of rheumatology patients during the COVID-19 pandemic.

“While there have been significant advances in science over the years, there are areas of unmet needs warranting continued investigation,” said S. Louis Bridges, Jr., MD, PhD, Physician-in-Chief, Chair of the Department of Medicine and Chief of the Division of Rheumatology at HSS. “HSS has a relentless focus on improving patient care through innovation and discovery. By spearheading multi-center studies, clinical trials, and laboratory-based research, we continue to improve the quality of life for patients affected by rheumatic and musculoskeletal conditions.”

What follows are some highlights from the meeting:

Geographical Variations in COVID-19 Perceptions and Patient Management: A National Survey of Rheumatologists

A study led by HSS rheumatologist Bella Mehta, MBBS, MS, looked at the perceptions and behaviors of rheumatologists in the United States regarding the risk of COVID-19 for patients with autoimmune disorders and how those patients were managed with immunosuppressive and anti-inflammatory medications. The 271 respondents were asked whether patients with rheumatic diseases were at higher risk of COVID-19 and whether the pandemic had led them to reduce the use, dosage, or frequency of biologics or steroids. Overall, the survey found geographical variations regarding perceptions of patients’ risk of COVID-19, with responses that were significantly different in the Northeast region of the United States compared with other regions.

Can a Clinical Disease Activity Index Based on Patient-Reported Joint Counts (PT-CDAI) Be Used to Inform Target-Based Care in Telemedicine? An Analysis of 2 Early RA Cohort Studies 

A team that included HSS rheumatologist Vivian P. Bykerk, BSc, MD, FRCPC, looked at data from two cohort studies on patients with early rheumatoid arthritis (RA) that compared patient and physician assessment of tender and swollen joints. This research is important because COVID-19 has forced rheumatologists to shift from in-person clinical visits to telemedicine, which limits their ability to carry out complete joint exams. The study found that patient and physician assessments had good agreement when it came to identifying active versus controlled disease activity. In addition, the researchers reported that predictors of higher discrepancies between patient and physician assessments may help identify patient subsets that could benefit the most from more physician-guided training at joint self-assessments as well as more probing questioning during telehealth visits to confirm active synovitis.

Characterization of Antiphospholipid Antibody-Associated Nephropathy: An International Survey of Renal Pathology Society Members

A survey led by HSS rheumatologist Medha Barbhaiya, MD, MPH, sought to determine whether pathologists worldwide use uniform criteria to distinguish antiphospholipid antibody-associated nephropathy (aPL-N) from other forms of thrombotic microangiopathy. The study was done in parallel with an international effort to develop new classification criteria for antiphospholipid syndrome. The web-based survey included 780 members of an international Renal Pathology Society; 111 renal pathologists responded, representing 33 countries. The participants were asked to determine whether two acute and eight chronic aPL-N features were consistent with acute or chronic aPL-N without and were not provided with serology information. Results from the survey indicated that more than 90% of pathologists worldwide agreed that the renal pathologic features most specific for aPL nephropathy are noninflammatory glomerular or small arterial microthrombi and organized microvascular thrombi with recanalization. In the absence of serologic data, more than 75% of pathologists indicated lack of specificity of chronic glomerular or small arterial changes. These findings indicate the importance of serologic test results in biopsy interpretation and suggest higher specificity for certain acute or chronic features.

The Risk of Venous Thromboembolism After Septic Total Knee Replacement (TKR) Revision Is Double the Risk After Aseptic TKR Revision: An Analysis of Administrative Discharge Data

A team led by HSS rheumatologist  Anne R. Bass, MD, assessed the 90-day risk of postoperative venous thromboembolism (VTE) in people who underwent revision TKR surgery. Although it was already known that infection can increase the risk of thrombosis by triggering coagulation pathways, the impact of infection in this context was not well understood. The study, which included 25,441 of these surgeries performed between 1998 and 2014, used data from the New York Statewide Planning and Research Cooperative System. Overall, 69% of these revisions were for mechanical causes (aseptic), 28% were for infection (septic), and 3% were related to a periprosthetic fracture. The researchers found that the risk of VTE after septic revision surgery was double the risk after aseptic revision surgery, and was 2.6-fold higher after revision surgeries for fracture. These findings point to the importance of taking infection and fracture status into account when planning VTE prophylaxis for patients having revision surgery.

Using a Patient-Engaged Approach to Identify Cross-Cutting Disease Factors Impacting Mental Health in Youth with Rheumatologic Disease

A team including HSS chief of pediatric rheumatology Karen Brandt Onel, MD, examined the mental health experiences of those with juvenile arthritis, juvenile dermatomyositis, or systemic lupus erythematous. It included patients aged 14 to 24 and parents of patients between the ages of 8 and 24. The primary outcome was the presence of any clinical or self-diagnosed mental health problem. The survey included information on cross-cutting disease factors such as disease duration, active disease status, current steroid medication, history of disease flare following remission, and appearance-altering comorbidities (such as psoriasis, stretch marks, alopecia, skin ulceration, and visible scarring). The researchers also examined results by mental health problem (depression, anxiety, and self-harm/suicidal ideation). Overall, they found that certain rheumatologic disease factors, including those that alter appearance, are predictive of mental health problems such as depression or anxiety. The findings will help identify targets for mental health screening in youth with rheumatologic diseases.

New Juvenile Idiopathic Arthritis Quality Measure Set for the Pediatric Rheumatology Care and Outcomes Improvement Network

A team that included HSS pediatric rheumatologist Nancy Pan, MD, reported highlights of new quality measures for the treatment of juvenile idiopathic arthritis. The study also provided information about the performance of these new measures, which were created by the Pediatric Rheumatology Care and Outcomes Improvement Network. The measures take into consideration clinical health importance, scientific validity, and feasibility, as well as best practices. They include both clinical evaluations based in part on the clinical Juvenile Arthritis Disease Activity Score and patient-reported outcomes such as pain, physical function, and overall well-being. An analysis of the new measures found that they are feasible for use on patients with juvenile idiopathic arthritis and can help to maximize quality improvement efforts and optimize the delivery of care.

Juvenile idiopathic arthritis (JIA) is a condition involving joint inflammation that lasts more than six weeks in children or adolescents under 16 years of age. It is the most common form of childhood arthritis, affecting about 1 in 1,000 children and teens in the United States. Scientists believe a combination of genetic predisposing factors and the environment causes JIA but the exact cause is unknown.

Polyarticular JIA is a chronic form of the disease with symptoms of pain, swelling, stiffness or warmth in four or more joints. Younger children may develop a limp or have difficulty using their fingers yet not complain about pain. Symptoms are typically worse first thing in the morning or after a period of rest and improve throughout the day as the child becomes more active.

“Polyarticular JIA looks a lot like rheumatoid arthritis in adults. Early diagnosis is essential to help keep the disease in remission, ensure children meet developmental milestones and delay or prevent joint destruction as they age,” says Nayimisha Balmuri, MD, a third-year pediatric rheumatology fellow at HSS and lead author of the study. “Reported morning joint stiffness may be a better indicator of early disease symptoms than pain since reporting pain can be influenced by cultural factors. Our findings underscore the importance of early referral of suspected cases for expert diagnosis and treatment.”

The study abstract is featured today in a poster presentation at ACR Convergence 2020, the American College of Rheumatology’s annual conference, which is being held virtually this year.

Dr. Balmuri and colleagues, including senior author Karen Brandt Onel, MD, chief of pediatric rheumatology at HSS, identified 1,684 American patients diagnosed with polyarticular JIA using the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from July 2015 through February 2020. The CARRA Registry is a collection of information provided by North American patients and families on childhood-onset rheumatic diseases, including JIA.

The investigators extracted data on the presence and duration of morning joint stiffness. They also examined reported family income, the highest level of guardian-completed education and community poverty level, collectively called social determinants of health, using zip codes and the 2014–2018 American Community Survey. Finally, Dr. Balmuri and colleagues included the rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibody status from patients’ diagnostic lab results as indicators of disease severity. The patients were seven years of age, on average.

The researchers found that children with polyarticular JIA from less affluent families, defined as having an income of $25,000 to $49,000, were twice as likely to report more than an hour of morning joint stiffness compared to children with the condition from families with an income of more than $100,000. This association between reported morning joint stiffness held even after the researchers adjusted the data for age at diagnosis, and RF and CCP status.

“Family income as an indicator for insurance status may indicate that more affluent families can navigate the healthcare system better, ensuring their children see pediatricians sooner and therefore obtain earlier referrals to pediatric rheumatology sub-specialists,” says Dr. Balmuri. “We can’t prove that with our present study, but our findings raise important questions for further research.”

“We hope our findings encourage physicians to ask patients about morning joint stiffness, not just pain, which may streamline the referral process,” Dr. Balmuri says. “Time to referral affects how soon we can initiate multidisciplinary care, which may include medications, physical therapy and occupational therapy that are crucial for improving mobility and joint function over these children’s lifetimes.”