Материал: ABC-of-Rheumatology-ABC-Series-

Microbiology

The differential diagnosis in any acute monoarthropathy must include septic arthritis. This is easily excluded by joint aspiration, with culture of synovial fluid and blood. It is necessary to inform the laboratory if tuberculosis or gonococcal infections are suspected, as specific culture media and techniques are required. Polyarthropathies may be associated with several viral and bacterial infections. Chronic hepatitis B or C or HIV infection may cause polyarthralgia. Acute rheumatic fever, which is still a major killer on a worldwide scale but rare in the Western world, is associated with streptococcal infection (i.e. positive anti-streptolysin O titre or Streptococcus species in blood or throat cultures). The seronegative spondyloarthropathies may be related temporally to a diarrhoeal illness or to urethritis. Organisms often implicated in these diseases include Salmonella, Yersinia, Campylobacter and Chlamydia. Parvovirus B19 has been associated with a self-limiting polyarthritis similar to rheumatoid arthritis. Other viruses such as rubella and human T-lymphotropic virus may present with an arthralgia. Lyme disease is associated with a rash and polyarthropathy and the diagnosis depends on demonstration of antibodies to the spirochaete Borrelia burgdorferi.

Conclusions

Blood tests are useful in terms of assessment, diagnosis and monitoring in rheumatological diseases. There is a trend for laboratories (particularly in the USA) to use “rheumatology screens” with an array of markers often including rheumatoid factor, antinuclear antibody and ESR and CRP. This is not to be recommended, as it leads to many false-positive results. Blood tests should be used judiciously where there is an indication.

Further reading

Hakim G, Clunie A. Haq I. Oxford Handbook of Rheumatology, 2nd edn. Oxford University Press, Oxford, 2002.

Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH, Rheumatology, 4th edn. Mosby, St Louis, 2008.

Playfair JHL, Chain B. Immunology at a Glance, 9th edn. Wiley, Chichester, 2009.

Shipley M, Black CM, Compston J, O’Grabaigh D. Rheumatology. In: Kumar R, Clark M, eds. Clinical Medicine, 5th edn. WB Saunders, Philadelphia, PA, 2002.

OVERVIEW

•Understand the meaning of a multidisciplinary team (MDT).

•Know which professionals make up the MDT.

•Understand the role of each professional and how this contributes to the holistic care of the patient.

•Understand how to refer to each professional and what conditions are managed by each.

•Understand the role of the general practitioner as gate-keeper to the service.

Background

Traditionally, the patient journey involved an initial consultation with a general practitioner (GP), sometimes followed by onward referral to a consultant rheumatologist in secondary care. The consultant, or one of their medical team, would assess the patient and formulate a treatment plan. Whether or not the patient saw anyone else in the team, such as a physiotherapist, depended very much on the local facilities. It would not have been unusual for a patient with a musculoskeletal problem only ever to see their GP and/or a consultant rheumatologist in the course of their treatment.

However, times have changed, and with this comes an increasing recognition of the potential benefits that patients may gain from a multidisciplinary approach to their management. Implicit within this is the changing role of patients themselves: the crucial function of the multidisciplinary team (MDT) is to use different approaches to empower patients to take an active role in their management. A multidisciplinary approach to management is subtly different to “shared care”, where therapists and doctors from primary and secondary care manage patients and share records. Shared care is not a new concept; it has been used for years in diabetic and antenatal care, but is often led by the needs of the doctors and therapists, rather than the needs of the patient.

ABC of Rheumatology, 4th edn. Edited by Ade Adebajo. ©2010 Blackwell Publishing Ltd. 9781405170680.

The changing world of musculoskeletal service provision

Integrated-care pathways (ICPs) have been introduced as a core concept in the UK Department of Health document Musculoskeletal Services (MSK) Framework (Department of Health, 2006). The Framework proposes a redesign for musculoskeletal services, based on the patient’s entire journey. The development of multidisciplinary clinical assessment and treatment services (CATS) is the keystone of the service. CATS bring together skilled professionals from primary and secondary care, including allied health professionals (AHPS), extended-scope physiotherapists (ESPs), GPs with special interest (GPwSI), chiropractors, osteopaths and nurse practitioners, as well as hospital consultants and other specialists.

One of the main targets of the MSK framework is to reduce the waiting time for patients from first presentation to definitive treatment. However, the spin-off from this is an integrated team approach to the patient, according to which patients will be seen and assessed by the most appropriate specialist (doctor or AHP). Consequently there is enhanced opportunity for patient education and promotion of self-management by improving patients’ skills to cope with their pain.

This service redesign is in keeping with Standards of Care (see http://www.arma.uk.net/care.html) produced by the UK Arthritis and Musculoskeletal Alliance (ARMA), an umbrella organization that brings together a variety of national societies concerned with rheumatic and musculoskeletal diseases. These Standards highlight the importance of a multidisciplinary approach to the management of musculoskeletal conditions; for example, Standard 10 of this document states that “People with inflammatory arthritis should have ongoing access to the local multidisciplinary team, whether this is based in secondary care, or in the community”.

The multidisciplinary team

A few essential ingredients are needed to ensure the success of the MDT (Figure 25.1; Box 25.1). The first, and most important of these, is effective communication. It is vital that members of the team have the opportunity to talk to each other, that they have a shared agenda and that they speak the same language. Second, clinical-care pathways should be developed that, wherever possible, are underpinned by a robust evidence base. The evidence base

should be debated and discussed between members of the MDT to formulate care pathways that are acceptable to the whole team, and to the patient. For care pathways to be translated into effective patient care, all individuals involved must have ownership, be involved in team collaboration and participate actively in their development and subsequent implementation.

General practitioners

The GP is, traditionally, the gate-keeper to musculoskeletal services, although this is changing with initiatives such as Physio-Direct. Most musculoskeletal conditions will be managed solely by the GP with first-line treatment such as advice and prescription of analgesics. However, the GP also fulfils the crucial role of screening for “red-flags”—signs and symptoms of potentially serious disease, which need urgent referral to secondary care. In addition, it is vital

that GPs are able to recognize certain specific diagnoses, such as the early signs of inflammatory arthritis, to facilitate early referral to secondary care (Box 25.2). The British Society for Rheumatology (BSR) has recently published guidelines for the management of rheumatoid arthritis in the first 2 years (Luqmani et al., 2006), which stress the importance of early referral. The Primary Care Rheumatology Society (http://www.pcrsociety.org.uk) and the Arthritis Research Campaign (http://www.arc.org.uk) take an active role in supporting and educating GPs in these important functions.

Onward referral options for the GP will increasingly include a multidisciplinary clinic such as the CATS described above. However, the precise options available will depend upon the local service provision.

Table 25.3 Support agencies available

steroid injections) for soft-tissue and joint conditions. Some podiatrists (podiatric surgeons) are trained to perform foot surgery.

Consultant rheumatologists

Consultant rheumatologists are trained to assess and manage patients with a range of musculoskeletal complaints, ranging from non-specific back and neck pain to complex multi-system conditions such as rheumatoid arthritis. Traditionally, they were the first point of contact for a GP referral into the musculoskeletal service, although, as we have seen, this pattern is changing with the developments in service provision outlined above. Consultants often take on the role of coordinating the MDT and have overall responsibility for ensuring holistic care for the patient. They may be responsible for ensuring clinical governance for the MDT through continuing professional development, appraisal and training of the staff.

Support agencies

Agencies such as the Arthritis Research Campaign (arc) and Arthritis Care (Table 25.3) offer educational resources and direct advice to patients with arthritis. They provide an invaluable service, both to patients and to professionals, who can use their resources as part of their treatment plan.

Wider aspects of team working

These professionals not only work together directly in the care of patients with rheumatoid arthritis, they also collaborate in the

Table 25.4 Wider aspects of team working that contribute to the care of patients with rheumatoid arthritis

drawing up of guidelines for the management of the disease and the production of patient literature (Table 25.4).

Although the multidisciplinary team described in this chapter is based on the new UK model, the role and activities of the multidisciplinary team are generally the same worldwide. It has not been possible to focus on every single professional that may be involved in the complex care of patients with a rheumatological condition. Instead we have highlighted the philosophy of care that can be adapted to suit all conditions and embrace all members of the multidisciplinary team.

References

Department of Health. The Musculoskeletal Framework: A joint responsibility: doing it differently. Department of Health, London, 2006.

Hay EM, Campbell A, Linney S, Wise E, Musculoskeletal GpwSI Working Group. Development of a competency framework for general practitioners with a special interest in musculoskeletal/rheumatology practice.

Rheumatology (Oxford) 2007; 46: 360–362.

Luqmani R, Hennell S, Estrach C et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (the first 2 years). Rheumatology (Oxford) 2006; 45: 1167–1169. Available online at: http://www.rheumatology.org.uk