Katie Eder, Managing Editor

Many studies that inform current international guidelines for the treatment of psoriatic arthritis (PsA) are of poor quality and lack applicability in clinical practice, according to an analysis published in the August 2014 issue of the 

Journal of the European Academy of Dermatology and Venereology

, a team of researchers in France examined the quality of American and European guidelines that concern PsA care (Table 1). While performing their systematic literature search, the investigators excluded studies that inspected biological therapies, as they noted “PsA treatment has rapidly changed over the lasted decade with the important development of biologics, (but) before starting this treatment, non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticosteroids, and disease modifying antirheumatics drugs (DMARDs) are commonly used.”

Among the 6 selected guidelines, which had been published since 2007, the researchers found “considerable variation in the quality … according to the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument domains” of scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial dependence.

For instance, the guidelines’ scores ranged from 36-83.3% on scope and purpose and 58.3-85.7% on rigor of development, “particularly because of inadequate discussion of procedure for updating,” the analysis authors wrote. Although the guidelines’ range of AGREE scores on editorial independence and clarity of presentation were less problematic, “the lowest domain scores were observed in applicability because of inadequate discussion of all items, particularly of cost implications.”

As a result, the researchers concluded that, “although their rigor of development is of good quality, many of the studies that (the guidelines) included are of poorer quality.”

“All the guidelines recommend an NSAID as first-line treatment in patients when it is not contraindicated, although the data regarding the usefulness of NSAIDs in PsA are limited. Similarly, there is no evidence from clinical trials on the efficacy of intra-articular or systemic corticosteroids in PsA, (and) regarding DMARDs, although many of them are widely used, they do not have a strong published evidence base,” the investigators wrote. “Indeed, there are few evidence-based studies on the treatment of PsA.”

Despite the obvious need for more controlled, high-quality trials on the non-biological treatment of PsA to improve the current guidelines, the researchers relented that such studies are “unlikely to be conducted, given the lack of interest in studying old drugs.” In fact, only one such randomized controlled trial has been published since the release of the most recent PsA treatment guideline, they noted.

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Many studies that inform current international guidelines for the treatment of psoriatic arthritis (PsA) are of poor quality and lack applicability in clinical practice.

International Guidelines for Psoriatic Arthritis Are Based on Weak Evidence

Although the true prevalence of shoulder disorders in general practice remains unknown, an analysis of ultrasound imaging reports published in 

 offers physicians some insight into the underlying causes of shoulder pain.

“As ultrasound is an easily accessible, accurate, relatively cheap, and non-invasive and non-ionising imaging procedure, general practitioners (GPs) frequently refer patients for ultrasound, resulting in a rise in test volume of 100% over the last 6 years,” the study authors 

. “However, at present, there is no clear evidence for using ultrasound for acute shoulder pain.”

With a primary objective to “determine the frequency of the specific ultrasound-diagnosed shoulder disorders of patients with shoulder pain referred from general practice,” Ramon P.G. Ottenheijm, GP/PhD, MD, and colleagues from the Netherlands retrospectively reviewed 240 ultrasound shoulder examinations performed at a hospital in 2011 based on referrals by GPs.

While no shoulder disorders were found on ultrasound for the majority of patients aged <65 years, significantly more full-thickness tears were seen in those aged ≥65 years, the researchers reported. Across the entire patient population, ultrasound imaging most frequently displayed “calcific tendonitis (29%), followed by subacromial-subdeltoid (SASD) bursitis (12%), tendinopathy (11%), partial-thickness tears (11%), full-thickness tears (8%), and acromioclavicular (AC) osteoarthritis (0.4%),” the authors wrote (Table 1).

In a subgroup of 41 patients with 2 disorders diagnosed via ultrasound, calcific tendonitis was again the most prevalent condition, and it was most frequently seen in combination with tendinopathy or SASD bursitis. In fact, 43% of patients with SASD bursitis “had concomitant calcific tendonitis, with a specific calcific bursitis in 10%,” the investigators noted.

“Contrary to findings from secondary care, calcific tendonitis is the most common ultrasound-diagnosed disorder affecting patients who are symptomatic enough and have had symptoms for a sufficient duration to warrant referral by their GP for ultrasound,” the authors concluded, asserting their new findings “imply that patients can be stratified into diagnostic subgroups, allowing more tailored treatment than currently applied” in daily practice.

Although the true prevalence of shoulder disorders in general practice remains unknown, an analysis of ultrasound imaging reports offers physicians some insight into the underlying causes of shoulder pain.

Ultrasound Guides Tailored Treatment for Common Shoulder Disorders

Although many physicians currently snap, store, and share clinical photographs on their smartphones, they often neglect to ask patients for permission to do so, a study published in the July 2014 issue of the 

“Smartphones have evolved to the point that they now routinely integrate a digital camera of an acceptable clinical quality capable of capturing medical images,” Michael Kirk, MBBS, and his colleagues noted in the 

. “This rapid evolution of technology creates the potential to enhance the clinical care of patients … but also brings with it issues of confidentiality, privacy, and policy control.”

To assess physicians’ perceptions regarding “issues surrounding the recording and dissemination of medical images using smartphones,” the study authors invited all clinicians and medical students at a metropolitan hospital in Melbourne, Australia, to participate in an online survey on the topic. According to the researchers, the majority of the resulting 134 (32%) responses came from the surgical discipline (45%), followed by medicine (22%), emergency medicine (20%), critical care (7%), and pediatrics (6%). All but one respondent owned a mobile phone equipped with a camera, the authors said.

The survey results indicated that nearly two-thirds (65%) of respondents captured medically sensitive images with a smartphone, yet no consent was obtained in 24% of those cases. Among the physicians who did obtain consent, “only 7% gained written consent, while 78% failed to document the procedure in the patient record,” the researchers discovered.

Of those who snapped clinical photographs on their smartphones, 64% stored the images on their personal device and 82% shared them with someone else, “mostly for input from another physician,” the study authors wrote. However, the physicians’ methods for sharing medical images included non-secure delivery techniques like multimedia-messaging service (MMS), email, and instant messaging, and one respondent alarmingly admitted to uploading such images to a social networking website.

“There has been much debate regarding the ethics and legality of taking clinical photographs using personal cameras … (but) in practice, it appears that these considerations have little impact on clinicians, who most commonly use a personal digital camera,” the researchers concluded. “This study supports the notion that, although clinical photography is commonly used in clinical practice, there is a general lack of understanding regarding policy, image ownership, professional obligation, and risks associated with the use of smartphone technology.”

Although Kirk and his colleagues recognized “the ultimate aim of capturing, storing, and sharing clinical photographs should be to improve the outcome for the individual patient, (and) photography is a useful adjunctive means of accomplishing this goal,” they noted that “users of smartphone cameras for clinical purposes require education into their responsibility regarding patient privacy and photography.”

“The core policies and principles are no different to using a film camera or stand-alone digital camera and, in many organizations, almost certainly already exist,” the authors concluded. “The major difference in using a smartphone camera is the ease of making a clinical photograph publicly available, which presents more of an education issue than a policy issue.”

Although many physicians currently snap, store, and share clinical photographs on their smartphones, they often neglect to ask patients for permission to do so.

Clinical Photos Often Captured on Smartphones without Consent

Although tumor necrosis factor (TNF) inhibitors have dramatically improved management strategies for autoimmune disorders such as rheumatoid arthritis (RA) and inflammatory bowel disease (IBD), the biologic agents also pose a number of significant side effects that physicians must consider.

To help internists navigate and avoid such safety concerns, a team of 4 researchers from the Allegheny Health Network in Pittsburgh, PA, extensively reviewed the adverse effects of available anti-TNF therapies and provided steps to reduce those risks.

Prior to initiating anti-TNF agents like etanercept or infliximab, Jennifer Hadam, MD, and her colleagues advised internists to take a focused clinical history, bring age-appropriate vaccinations up to date, screen for tuberculosis and hepatitis B, and perform a full physical examination “with special attention to skin rashes ... (that) may serve as a baseline to assist with early detection of new rashes associated with anti-TNF therapy,” they 

After gathering that key information, the reviewers recommended remaining alert about the noninfectious complications of TNF inhibitors, which include injection site reactions that are common with subcutaneous agents, infusion reactions caused by infliximab, and paradoxical autoimmune conditions that “range from asymptomatic immunologic alterations … to life-threatening systemic autoimmune diseases,” they noted.

“Interestingly, anti-TNF agents are approved for treating psoriasis and psoriatic arthritis, but psoriasis has paradoxically developed in patients being treated with these drugs for other autoimmune diseases (Figure 1),” the authors warned. “Autoimmune diseases associated with anti-TNF treatment include a lupus-like syndrome, vasculitides, and psoriatic skin lesions. These syndromes warrant stopping the inciting drug and, on occasion, giving corticosteroids.”

Additionally, the researchers said studies have shown patients taking TNF inhibitors can experience cardiovascular side effects — “from nonspecific and asymptomatic arrhythmias to worsening of heart failure” &mdash; and the onset or exacerbation of central nervous system (CNS) demyelinating disorders, including multiple sclerosis (MS). In response to those serious risks, they noted anti-TNF therapy is “contraindicated in patients with NYHA class III or IV heart failure” and “should not be initiated in patients who have a history of demyelinating disease.”

While clinical evidence on the risk of malignancies like non-Hodgkin lymphoma (NHL) and skin cancer with the use of TNF inhibitors is mixed, the review authors said the therapies do increase the risk of infections “ranging from minor to life-threatening bacterial infections, and including the reactivation of granulomatous and fungal infections.” As a result, “TNF inhibitors must be held in the event of a major infection … (and) consultation with an infectious disease specialist is recommended, especially in complex cases,” they wrote.

Nevertheless, Hadam and her colleagues noted the benefits of managing autoimmune diseases with appropriate anti-TNF therapies far outweigh the risks described in their review, though they also emphasized that “physicians must be aware of atypical presentations of infection and understand how their treatment may differ in patients on biologic therapy.”

Although tumor necrosis factor inhibitors have dramatically improved management strategies for autoimmune disorders such as rheumatoid arthritis and inflammatory bowel disease, the biologic agents also pose a number of significant side effects that physicians must consider.

Katie Eder, Managing Editor

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