Immunoglobin G4-related disease (IgG4-RD) is a rare fibro-inflammatory disease of unknown etiology that has been recently recognized. It can cause fibro-inflammatory masses in almost every organ of the body and is associated with dense lymphoplasmacytic infiltration of IgG4-postitive plasma cells, storiform fibrosis and elevated levels of serum IgG4.1 IgG4-RD is a systemic disease that may…
It started with an inhaler. Like many of you, I am a rheumaÂtologist. And like you, I see some patients more often their own primary care provider. This is so often the case that I have gradually devolved into their backup, all-purpose doctor. I am the doc they notify when they get hospitalized for pneumonia…
Last month I expressed my thoughts on the valuable and varied opportunities the ACR offers for professional and personal growth. Such engagement not only provides an opportunity to connect with your rheumatology colleagues, but also to have a positive impact on patients, supporters and all consumers of healthcare. ACR and ARHP members from every aspect…
Many trainees tell me they’re attracted to rheumatology because it demands becoming a complete physician. We need knowledge of the brain, eye, lung, kidney, liver, skin, bones and vascular system to be effective rheumatologists. And because our diseases are frequently multisystem diseases, rheumatologists must be the quintessential collaborators. For more than 30 years, I’ve directed…
Editor’s note: In this occasional feature, we first present a series of images (this page) for your review, and then a brief discussion of the findings and diagnosis. Before you read the discussion, examine these images carefully and draw your own conclusions. History A 39-year-old white woman with a three-year history of seropositive rheumatoid arthritis…
Click here for the case. Discussion Image 1 demonstrates two nodules in the right lung, one over the lateral costophrenic sulcus (2.4 x1.7 cm, not shown); and another in the middle lobe (3.1 x 2.6 cm), with lobulated and spiculated margins (red arrow). There was no lymphadenopathy or pleural effusion. Of note, a normal chest…
Patients with scleroderma, systemic sclerosis (SSc), myositis and rheumaÂtoid arthritis (RA) may develop interstitial lung disease (ILD), which affects a patient’s breathing and quality of life. Prospective studies have revealed that in patients with SSc a greater rate of decline of forced vital capacity (FVC) is associated with increased mortality. Although corticosteroids are commonly used…
Eosinophilia is usually defined as an eosinophil count of more than 500/microL in peripheral blood.1 An eosinophil count of more than 1,500 is referred to as hypereosinophilia (HE); hypereosinophilic syndrome (HES) is defined as HE associated with organ dysfunction attributable to eosinophilia.2 Eosinophilia can occur due to infectious, malignancy, autoimmune or allergic etiologies. However, a…
A yearlong pilot study that evaluated the safety and efficacy of belimumab in a small group of patients with early diffuse systemic sclerosis found no significant difference in the number of adverse events between those treated with the drug and those who received a placebo. Currently, no drugs are approved specifically for the treatment of…
Calciphylaxis is a poorly understood and life-threatening ischemic vasculopathy characterized by calcification of the small- and medium-size arteries in the skin, subcutaneous tissue and internal organs, which leads to thrombosis, tissue necrosis and painful skin ulcerations that won’t heal. The disease has a 50–80% mortality rate. Although affected patients typically have end-stage renal disease (ESRD)…
Rheumatologists often rely on magnetic resonance imaging (MRI) in the evaluation of suspected muscular diseases. Here, we describe a case in which unexpected findings on MRI pointed to a diagnosis rarely considered as a mimicker of rheumatologic disease. The Case A 19-year-old man of Middle Eastern descent was admitted to our hospital for evaluation of…
Baltimore—Rheumatologists and meteorÂologists share more in common than you might suspect, said Dr. Rebecca Manno, assistant professor of medicine for the Division of Rheumatology at Johns Hopkins University, Baltimore, and assistant director of the Johns Hopkins Vasculitis Center. At a March 8 meeting of the Maryland Society for the Rheumatic Diseases, Dr. Manno used the…
Retirement is not always the closing chapter of a long career. For some rheumatologists, it’s the start of new, fulfilling storylines. “I never thought I wouldn’t practice medicine until I was physically unable to do it anymore,” says Harry Gewanter, MD, who retired from his Richmond, Va., pediatric rheumatology practice two years ago. Dr. Gewanter…
In your daily contact with rheumatology patients, you likely come across several who have type 1 or 2 diabetes. Are you doing all you can to maximize their treatment? Most physicians know about the damaging health effects of uncontrolled diabetes. From vision loss to kidney failure to nerve damage, those with diabetes require regular vigilance…
We are sad to report that Nathan Wei, MD, FACR, passed away March 27 from aggressive cancer. Dr. Wei was a passionate, compassionate, fiercely independent innovator, student and teacher, who carved out his own way of doing things, always in the pursuit of excellent patient care. He was unafraid to embrace cutting-edge medical services for…
In July 2017, Todd A. Graham, MD, a practicing orthopedic surgeon in South Bend, Ind., was fatally shot after getting into a heated dispute with a patient and her husband over a requested opioid prescription.1 The murder of Dr. Graham is a tragic example of the potential dangers of physician-patient disagreements. Rheumatology patients often endure…
A patient’s gait, or how they walk, is an important predictor of the biomechanical load distribution that affects osteoarthritis (OA). This understanding comes from a growing body of literature in bioÂmechanics to test and treat patients with OA, which takes into account a very practical treatment: a patient’s shoes. A focus on flexible footwear, along…
We have entered the second year of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. It’s no secret that the costs of medical care—17.1% of the U.S. gross national product compared with 9.8% in Great Britain, 10.7% in Canada and 11.6% in France—have become an overwhelming driver for change….
When Marilynn “Lynn” Punaro, MD, MACR, isn’t working with medical students, seeing patients in the clinic, participating in translational research or performing leadership duties, she’s enjoying a good book—especially a good mystery. This shouldn’t be a surprise. It was mystery that led Dr. Punaro to a career in pediatric rheumatology more than 30 years ago,…
Since they were first introduced in 2011, immune checkpoint inhibitors (ICIs) have become an important treatment for an expanding list of advanced cancers. Some concerns have been raised around the mechanism of action of these immunotherapy agents, making their use in rheumatic diseases (RD) problematical. An article in the March 2018 issue of Arthritis &…
Certain medications have been associated for decades with the development of drug-induced autoimmunity. New research published in March 2018 in Arthritis & Rheumatology suggests that NETs (neutroÂphil extracellular traps) are potentially implicated in the mechanisms that lead to drug-induced autoimmunity.1 Peter Grayson, MD, MSc, head of the Vasculitis Translational Research Program at the National Institute…
Bad things happen to good rheumatologists—and to their patients—and can have profound personal and professional consequences for the doctor. Sometimes recommended treatments can have predictable, but devastating, side effects. Even if the rheumatologist does everything right according to evidence-based best practice, patients can still have bad outcomes, even die—with resulting feelings of sadness, anger, guilt…
Think back to your time as a trainee. Do you remember an interaction with a consultant in which you learned something, felt your opinion was heard, were empowered to collaborate with the consulting team and knew you were proÂviding outstanding care? We suspect a number of examples come to mind, regardless of the amount of…
In the U.S. today, approximately 45% of pregnancies are unintended or unplanned.1 Although this rate is considerably lower than in the past, women with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) or inflammatory myopathies tend to have better pregnancy outcomes if their disease is well controlled when they conceive. In addition, women taking certain medications…
Bill St.Clair, MD, MACR, says one of the most exciting and proudest moments in his life wasn’t earning his medial degree or seeing his first published article on arthritis and rheumatology. Not even close. It was the 1991 National Collegiate Athletic Association (NCAA) basketball semifinal. Specifically, the basketball game between Duke University and the University…
A 54-year-old woman is establishing care in your clinic after retirement of her previous rheumatologist. Your review of her records suggests that she was diagnosed with systemic lupus erythematosus seven years ago on the basis of symptoms of body pain and fatigue, and serologic evidence of positive ANA 1:40 (speckled) and borderline anti-SSB antibody. She…
FDA to Review Abuse-Deterrent Oxycodone Capsule In June, the FDA will discuss the New Drug Application for Remoxy ER at an Advisory Committee meeting. Remoxy ER is a 12-hour, abuse-deterrent, extended-release oxycodone in a capsule formulation.1 The capsule contains a sticky, thick, high-viscosity formulation to deter unapproved drug administration routes, including injection, smoking or snorting….
Few opportunities exist for rheumatologists in community-based practice who, in addition to taking care of patients, want to test their own observations through research. Limited funding, time constraints and competition from larger academic medical centers are some of the barriers hindering clinical research in this setting. The Rheumatology Research Foundation is addressing this issue with…
The ACR praises Congressional leaders for passing the sweeping spending agreement, which includes a technical provision reversing a Centers for Medicare & Medicaid Services (CMS) policy that would have linked physicians’ quality payment adjustments to Medicare Part B drug costs starting in 2019. The ACR also applauds the inclusion of provisions that permanently repeal Medicare…
A 68-year-old female patient returns to the office for a second round of Inflectra (infliximab-dyyb) infusion for her rheumatoid arthritis with rheumatoid factor of multiple joints without organ or systems involvement. She reports pain, stiffness and swelling in her left and right knees and right elbow and rates the pain at a 9 on a…
Take the challenge. CPT codes: 96413, 96415, 96375, Q5103x20, J1200 ICD-10: M07.9 Coding Rationale This procedure is billed with CPT code 96413 for the initial hour of the intravenous infusion and CPT code 96415 for each additional hour. The patient was given 50 mg of diphenhydramine prior to the infusion to prevent reactions and should…
When coding evaluation and management (E/M) services provided to a patient, one of the most persistent concerns is whether a patient is new or established to the practice. Although this may seem like a simple coding answer, the distinction is an important one, because it enables providers to appropriately bill and receive reimbursement correctly. E/M…