Mindfulness Meditation: An Interesting Opportunity for the Rheumatologist

Mindfulness meditation is a mental technique which cultivates attentional focus and stability by directing the mind to remain connected to the present experience, moment by moment. Scientific literature in healthy subjects have correlated mindfulness training to improvements in stress, anxiety and depressed mood. Moreover, basing on evidence we can state that mindfulness may have an important role in treating somatic conditions such as psoriasis, cancer, HIV, infection, irritable bowel syndrome, heart disease, hypertension, lung disease, diabetes mellitus, and chronic pain. Although, researches specifically conducted on rheumatologic conditions are limited, some studies of the highest quality about mindfulness interventions in chronic pain have been in patients with osteoarthritis, fibromyalgia and rheumatoid arthritis. In rheumatic diseases, mindfulness meditation may have favourable effects on mental health, in particular on mood states and depression, and on different aspects of physical condition, through a variety of pathways including reduced inflammation, decreased sympathetic activation and improved neuroendocrine function. Thus, Mindfulness meditation is a good opportunity for patients thanks to its safety and it may be a powerful tool that can help the clinicians to manage the patient and improve the relationship between the patient and his illness and his bod

Is telemedicine a golden opportunity or a dangerous roundabout for chronic rheumatic diseases? A narrative review

Introduction: Telemedicine (TM) reported a great increase from 50% to 150% in health care to RMDs patients during the COVID-19 period, but conflicting opinions in the literature are still present. Aim: to investigate the results of literature on TM in terms of feasibility (patients’ satisfaction, accessibility, clinical outcomes and barriers), discussing its integration for the future in a nursing perspective during and after COVID-19 period. Methods: the team that conducted the narrative review was composed by two rheumatology and research nurses (MRM, KEA) and a rheumatologist (MMC), who discussed the relevance of the research question and agreed on the search strategy. Pubmed and Google Scholar databases were searched. The inclusion criteria were: original and quantitative research papers in English with available abstract/full text, on adult patients with RMDs in accordance with the American College of Rheumatology (ACR) and/or European Alliance of Associations of Rheumatology (EULAR) classification criteria, exposed to any kind of technologies during and after COVID19 period, investigating any kind of patient/clinical reported outcomes. Results: TM could be considered as an integration to standard clinical care in Rheumatology, especially for patients with a stable or low disease activity and rheumatic diagnosis. The choice of the candidates and the assessment of their E-health literacy level are necessary prior including them in TM programs. In addition, healthcare professionals need to be trained in this new modality of providing care. Conclusion: hybrid models of telehealthcare might be a balanced solution, improving efficiency of the consultation, continuity of care and providing a patient-centred approach

Biomechanical podiatric evaluation in an Italian cohort of patients with Systemic Sclerosis: a pilot study

OBJECTIVE: Foot problems are often present in Systemic Sclerosis (SSc) patients, however studies regarding podiatric problems related to SSc are lacking and there are no data evaluating the foot biomechanical changes. The aim of the present pilot study was to evaluate podiatric problems in an Italian cohort of SSc patients by assessing received podiatric services, foot pain and disability and biomechanical foot deformity. MATERIAL AND METHODS: 25 consecutive SSc patients were enrolled from the Division of Rheumatology, University of Florence. All SSc patients were assessed by: Standards of Care for People with Foot Musculoskeletal Health problems: Audit Tool, Foot Function Index (FFI), Weight and non-weight bearing foot joint assessment, (Foot Posture Index (FPI) and Gait Cycle), Health Assessment Questionnaire (HAQ) and Medical Outcomes Survey Short Form 36 (SF-36). RESULTS: Audit Tool - Only 7 (28%) out of the 25 patients with SSc had a specific podiatric assessment and treatment: no patient received a foot health assessment within the first 6 months of disease diagnosis and no patient received information about foot involvement. 1 patient (4%) received foot assessment every year; 1 patient (4%) received specific information about the disease and 5 patients (20%) received information about the benefits of using adapted footwear and insoles. FFI - Values of pain, disability and activity limitations, reported in FFI, are 4.7±5.1, 5.1±3.2 and 3.2±3.1 (M±DS), respectively. Non-weight bearing foot joint assessment shows a rearfoot varus deformity in 64% of patients, forefoot varus deformity in 42% and 6% forefoot valgus deformity. Weight bearing foot joint assessment, through FPI shows a pronated foot 20% of patients with and 34% with highly pronated overall foot posture. Gait analysis shows that 64% of patients has a contact of the calcaneus in invertion while 36% in eversion. In the midstance, 78% have the foot in pronation and 22% in supination, while in propulsion 12% presents a takeoff of the foot in supination and 88% in the pronation. HAQ result is 1.13±0.80, SFI and SMI scales of SF-36 have scores of 32.38±10.65 and 38.67±11.40, respectively. CONCLUSION: Our results shows that podiatric problems in SSc patients are common, serious but foot assessment and health care are inadequate. Thus, foot health information should be improved in order to better empower patients to self-manage low risk problems and help identify high-risk problems, which require specialist care

Menstruation-Related Disorders-Dysmenorrhea and Heavy Bleeding-as Significant Epiphenomena in Women With Rheumatic Diseases

: Background: In women with rheumatic diseases (RDs) menstruation-related disorders have never been investigated. The aim of this study was to evaluate gynecological symptoms/disorders in fertile age women with RDs. Materials and methods: All patients (n = 200) filled up a self-administered questionnaire on their gynecological history, menstrual cycle pattern, menstrual-related symptoms, and quality of life (QoL). The RD group was then compared to a control group of 305 age-matched fertile age women. Results: Among patients with RDs, 58% had arthritis, 40% connective tissue diseases (CTDs), and 1.5% systemic vasculitis. No differences were observed between CTDs and arthritis, except for a family history of HMB which was more common among women with CTDs (p < .01). When compared to controls, women with RDs reported more frequent heavy menstrual bleeding (HMB) during adolescence (51.7 and 25.4%, respectively; p = .0001) and adult life (37.7 and 25.9%, respectively; p = .0065). Also, dysmenorrhea in adolescence was significantly more common among cases (55.6 and 45.4%, respectively; p = .0338). Gynecological pain (dysmenorrhea, non-menstrual pelvic pain, dyspareunia, dysuria, and dyschezia) in patients with RDs was more frequent than in controls (p = .0001, .0001, .0001, .0001, .0002, respectively). Considering women who reported moderate and severe symptoms in RDs, dysmenorrhea and dyspareunia remain significantly more frequent in women with RDs than in controls (p = .0001; p = .0022; respectively). QoL scores were significantly reduced in women with RDs, either in physical (p = .0001) and mental domains (p = .0014) of short-form 12. Conclusion: Women affected by RDs frequently presented menstruation-related disorders; thus, female patients with RDs should be questioned about gynecological symptoms and referred to the gynecologist for an accurate evaluation

2022 update

Funding Information: This study was funded by European League Against Rheumatism. Publisher Copyright: © Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.Objectives: To provide an update of the EULAR rheumatoid arthritis (RA) management recommendations addressing the most recent developments in the field. Methods: An international task force was formed and solicited three systematic literature research activities on safety and efficacy of disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids (GCs). The new evidence was discussed in light of the last update from 2019. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned to and participants finally voted on the level of agreement with each item. Results: The task force agreed on 5 overarching principles and 11 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); GCs; biological (b) DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab including biosimilars), abatacept, rituximab, tocilizumab, sarilumab and targeted synthetic (ts) DMARDs, namely the Janus kinase inhibitors tofacitinib, baricitinib, filgotinib, upadacitinib. Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target) and tapering in sustained clinical remission is provided. Safety aspects, including risk of major cardiovascular events (MACEs) and malignancies, costs and sequencing of b/tsDMARDs were all considered. Initially, MTX plus GCs is recommended and on insufficient response to this therapy within 3-6 months, treatment should be based on stratification according to risk factors; With poor prognostic factors (presence of autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD should be added to the csDMARD; after careful consideration of risks of MACEs, malignancies and/or thromboembolic events tsDMARDs may also be considered in this phase. If the first bDMARD (or tsDMARD) fails, any other bDMARD (from another or the same class) or tsDMARD (considering risks) is recommended. With sustained remission, DMARDs may be tapered but should not be stopped. Levels of evidence and levels of agreement were high for most recommendations. Conclusions: These updated EULAR recommendations provide consensus on RA management including safety, effectiveness and cost.publishersversionepub_ahead_of_prin

Patient preferences for systemic sclerosis treatment: A descriptive study within an Italian cohort

OBJECTIVES: The aim of this study is to ascertain systemic sclerosis patients’ preferences regarding the formulations of the medications they use. METHODS: We undertook questionnaires and interviews aimed at understanding systemic sclerosis patients’ preferences with respect to the medications they used. RESULTS: Among 160 systemic sclerosis patients, we found that the majority does not have difficulty taking their medication. However, preferences were identified (81.25% – 65/80 – preferred oral meds and 47.50% – 38/80 – disliked rectal/vaginal meds), as well as some systemic sclerosis patients have significant difficulties using their medications. In fact, factors such as swallowing and fine finger motion difficulties were frequent, while intravenous/intramuscular/subcutaneous medicines were usually not preferred because they are felt as inconvenient (intravenous = 33.4% and subcutaneous/intramuscular = 10%) or painful (intravenous = 37.50% and subcutaneous/intramuscular = 10%) CONCLUSION: Most systemic sclerosis patients are able to take their medication despite having some difficulties. However, as there were clear preferences, we could improve patients’ adherence to drug therapy if taking these preferences into account

Mindfulness Program in Sjögren's Syndrome and Non-Sjögren's Sicca Syndrome Patients: A Pilot Study on Quality of Life and Psychological Distress

Background: Sjo¨gren’s syndrome (SS) is a chronic autoimmune disease with ocular and oral dryness and a wide spectrum of symptoms leading to psychological distress and reduced quality of life (QoL). Subsequently, emotional disorders increase mucosal dryness by causing pathological vicious cycles. The aim of the present pilot study was to investigate the effect of a Mindfulness-Based Stress Reduction (MBSR) protocol on perceived stress, awareness, mood states, mental and physical health, and discomfort associated with mucosal dryness in patients with primary SS (pSS) and non-Sjo¨gren’s sicca syndrome (nS-SS). Methods: Twenty-one patients with pSS or nS-SS participated in a MBSR program, lasting eight weeks. Patients were assessed by clinimetric tools for health-related QoL (Short Form 36 [SF-36]), fatigue and discomfort (Profile of Fatigue and Discomfort-Short Form), QoL related to oral health (Oral Health Related Quality of Life in Primary Sjo¨gren’s), perceived stress (Perceived Stress Scale [PSS]), mindful attention and awareness (Mindful Attention Awareness Scale), and mood states (Profile of Mood State [POMS]) at the beginning of the study, at the end of the MBSR program, and after a follow-up period. Results: SS patients showed a significant improvement after the MBSR program for mental health measured by the SF-36 scale (P < 0.001), PSS (P < 0.05), and all subscales of POMS (total score, anger, confusion, depression, fatigue, tension and vigor; P < 0.05). Conclusions: This pilot study shows mindfulness training to be very useful as an additional and effective approach to a multidisciplinary care plan in patients with pSS and nS-SS

A Practical Approach to the Management of Digital Ulcers in Patients With Systemic Sclerosis A Narrative Review

IMPORTANCE Digital ulcers (DUs) occurring on the fingers in patients with systemic sclerosis (SSc) are associated with substantial pain and disability and are often challenging to treat. However, careful clinical assessment and prompt intervention (wound bed management and systemic pharmacologic treatment) may modify the clinical course. OBJECTIVES To provide a practical approach to the assessment and management of SSc-DUs and highlight unmet needs and research priorities. EVIDENCE REVIEW A narrative review of the extant literature was undertaken to provide a broad overview of current knowledge and augmented by expert opinion. FINDINGS Half of the patients with SSc have a history of DUs, and there is a point of prevalence of approximately 10%. Digital ulcers are often very painful and affect all aspects of physical, social, and family life as well as occupation. Digital ulcers are associated with a severe disease course. Systemic sclerosis DUs, particularly those occurring on the fingertips, represent a vascular ischemic complication, although other etiopathogenic factors play an important role. To guide management, a structured clinical approach is required, including DU definition, classification, and categorization. Digital ulcers require a multidisciplinary approach with close cooperation between physicians and specialist nursing and other allied health professionals to guarantee the appropriate treatment and provide patient education. Local wound bed management is necessary for all DUs and is combined with systemic (pharmacologic) treatments. When treating a DU, the clinician should actively review the therapeutic strategy to prevent further DUs, including the level of systemic disease control, and monitor closely for the development of DU complications, including infection and progression to gangrene. Despite a wide available therapeutic armory, a number of unmet needs and challenges remain that that require resolution to optimize DU management. CONCLUSIONS AND RELEVANCE A practical approach to DU management, including local wound bed management and systemic treatments, is useful. Digital ulcers are of interest to a broad range of dermatologists, rheumatologists, and other physicians providing care for patients with SSc. Careful clinical assessment and prompt intervention can substantially modify the clinical course of DUs in SSc