Medicine

HSS rheumatologists dedicated a significant portion of our clinical and research activities in 2021 to understanding the impact of COVID-19 on our patients. Medha Barbhaiya, MD, MPH, and Lisa Mandl, MD, MPH, mobilized our COVID-19 registry, surveying more than 10,000 HSS rheumatology patients over the course of 2020 and 2021 to provide us with a clearer picture of our patients’ overall health and well-being. This commitment has resulted in a steady stream of publications on topics including pregnancy, long-haul COVID, flares in rheumatic disease and the use of immunomodulating therapies such as rituximab in rheumatic patients during the pandemic. Robert Spiera, MD, and Kyriakos Kirou, MD, led studies that found significant diminished efficacy of COVID vaccines among patients receiving these therapies.

This year also saw the publication of a new American College of Rheumatology (ACR) guideline for the treatment of juvenile idiopathic arthritis, for which Karen Onel, MD, Chief of the Division of Pediatric Rheumatology, served as lead author. The new guideline places greater emphasis on recommendations for early use of disease-modifying therapies, immunization and shared decision making with parents, caregivers and patients.

HSS rheumatologists also put forward important work harnessing big data to yield thought-provoking new perspectives on clinical outcomes. Bella Mehta, MBBS, MS, and colleagues in the Integrative Rheumatology and Orthopaedics Center published studies examining racial disparities in care among patients undergoing hip or knee joint arthroplasty. This work provides information essential to helping us understand barriers to care and develop increasingly effective interventions at the patient and system levels.

In August, the FDA approved anifrolumab for the treatment of adult patients with moderate to severe systemic lupus erythematosus (SLE) who are already receiving standard therapy. Much of the groundwork for the development of this drug was done at HSS in the early 2000s in the lab of Mary K. “Peggy” Crow, MD, Physician-in-Chief Emerita at HSS and Co-Director of the Mary Kirkland Center for Lupus Research at the HSS Research Institute. Encouragingly, this drug has shown particular promise for patients with more severe disease.

Several of our rheumatologists also received prestigious recognitions this year. New faculty member and former HSS fellow Nilasha Ghosh, MD, MS, was named a 2021 Distinguished Fellow by the ACR. Anne Bass, MD, received the ACR’s 2021 Distinguished Fellowship Program Director Award. Dr. Onel was appointed to the Pain Management Expert Panel of the Arthritis Foundation. In addition, Physician-in-Chief S. Louis Bridges, MD, PhD, completed a two-year term as President of the Rheumatology Research Foundation.

In February 2022, clinician-scientist Timothy B. Niewold, MD, joined the HSS faculty as Vice Chair of Research in the Department of Medicine. Dr. Niewold, who completed his rheumatology fellowship at HSS in 2007 under the mentorship of Dr. Crow, is an internationally renowned researcher known for his work in autoimmune diseases. He came to HSS from NYU Langone Health, where he served as Director of the Colton Center for Autoimmunity. Joining Dr. Niewold are clinician-scientists Theresa Wampler Muskardin, MD, who studies rheumatoid arthritis, as well as Ruth Fernandez Ruiz, MD, and Ashira Blazer, MD, who are focused on lupus.

Jinich S, Schultz K, Jannat-Khah D, Spiera R. B-cell reconstitution is strongly associated with COVID-19 vaccine responsiveness in rheumatic disease patients treated with rituximab. Arthritis Rheumatol. 2021 Dec 15. doi: 10.1002/art.42034. Epub ahead of print. PMID: 34908241.

It has been recognized that patients treated with B cell-depleting agents are less likely to demonstrate a serologic response to COVID vaccines, and shorter time from last rituximab exposure is associated with a greater likelihood of a poor serologic response. In this retrospective study of 56 rituximab-treated rheumatic disease patients, the authors further demonstrated that vaccine responsiveness was much more likely in patients who were reconstituting B cells; having detectable B cells had a > 90% positive predictive value for achieving serologic positivity. Assessment of B cell reconstitution should be incorporated into strategies to maximize likelihood of vaccine responsiveness in rituximab-treated patients.

Barbhaiya M, Levine JM, Bykerk VP, Mandl LA. Immunomodulatory and immunosuppressive medication modification among patients with rheumatic diseases at the time of COVID-19 vaccination. The Lancet Rheumatology, 2021. https://doi.org/10.1016/S2665-9913(21)00372-6.

In a survey completed by 2,753 rheumatology patients in the HSS Rheumatology COVID-19 registry, the authors demonstrated that up to 27.9% of immunomodulatory or immunosuppressive regimens were changed around the time of COVID-19 vaccination. Additionally, patients were responsible for most of the medication modifications. Modified medications included biologic disease-modifying antirheumatic drugs (DMARDs), conventional synthetic DMARDs, targeted synthetics DMARDs, and corticosteroids. Some modifications, such as those related to modifying methotrexate dosing schedules prior to COVID vaccine doses, or modifications related to TNF inhibitors or hydroxychloroquine, were not consistent with best practices as advised by the ACR task force at the time of the study. The role of medication modifications at the time of vaccination and subsequent rheumatic disease flares is under analysis. The preliminary data suggest that rheumatologists may play a critical role in disseminating updated evidence-based guidance in real time to patients during the COVID-19 pandemic.

Lieber SB, Nahid M, Paget S, Berman JR, Barbhaiya M, Sammaritano LR, Kirou K, Carrino JA, Rajan M, Sheira D, Mandl LA. Evaluation of a Patient-reported Frailty Tool in Women with Systemic Lupus Erythematosus. J Rheumatol. 2022 Jan;49(1):60-67. doi: 10.3899/jrheum.201466. Epub 2021 Sep 1. PMID: 34470795.

The authors conducted a cross-sectional analysis of 67 women with systemic lupus erythematosus between 18 and 70 years of age in whom frailty status was determined according to both the widely studied Fried phenotype and the FRAIL scale, a brief self-report instrument. Between 18% and 27% of participants in the lupus cohort were frail according to the Fried phenotype and the FRAIL scale, respectively. Frailty was associated with self-report disability using both metrics and remained significant after adjustment for multiple potential confounding factors when the FRAIL scale was used. These findings suggest that the FRAIL scale may be a useful tool to identify frail women with lupus for future research studies or in clinical settings.

Barbhaiya M, Levine JM, Bykerk VP, Jannat-Khah D, Mandl LA. Systemic rheumatic disease flares after SARS-CoV-2 vaccination among rheumatology outpatients in New York City. Ann Rheum Dis. 2021 Jun 22: annrheumdis-2021-220732. doi: 10.1136/annrheumdis-2021-220732. PMID: 34158370.

As part of the HSS COVID-19 Rheumatology Registry, HSS investigators evaluated whether the COVID-19 vaccine may be associated with disease flares in patients with systemic rheumatic diseases (SRDs). Using a web-based survey emailed in March 2021 to 3,545 outpatients at HSS with an SRD, this study demonstrates that >85% of patients did not report an SRD flare post-COVID-19 vaccination. This data may provide some reassurance and help guide vaccine decision-making in patients with SRDs.

Spiera R, Unizony SH, Bao M, Luder Y, Han J, Pavlov A, Stone JH. Tocilizumab vs placebo for the treatment of giant cell arteritis with polymyalgia rheumatica symptoms, cranial symptoms or both in a randomized trial. Semin Arthritis Rheum. 2021 Apr;51(2):469-476. doi: 10.1016/j.semarthrit.2021.03.006. Epub 2021 Mar 18. PMID: 33784598.

Giant cell arteritis (GCA) is a heterogeneous disorder, with some patients presenting with cranial ischemic symptoms such as severe headaches or visual loss and others presenting primarily with systemic complaints related to their underlying inflammatory state including prominent polymyalgia rheumatica–like symptoms. In the GIACTA trial, which included patients with both phenotypes, tocilizumab was demonstrated to be effective in affording disease control and a significant steroid-sparing benefit in GCA. In this post-hoc analysis, the authors demonstrated that tocilizumab afforded benefit in patients presenting with cranial symptoms only.

Professional education is an area in which the department is looking to expand. In May 2022, the Division of Rheumatology is hosting a two-day onsite and livestream continuing medical education event titled “Contemporary Topics in Inflammatory Arthritis.” Top experts in the field will discuss similarities and differences in the pathogenetic mechanisms that underlie inflammatory arthritis, focusing on rheumatoid arthritis and the spondyloarthropathies. Other topics will include biologic and targeted synthetic DMARDs, strategies to enable the rational selection of therapeutic agents for the treatment of individual patients, novel developments in clinical areas related to optimum treatment plans and an update on checkpoint inhibitor–associated arthritis. View the agenda and register.

Presurgical screening (PSS) is a vital component of the quality orthopaedic care that HSS provides. The Perioperative Medicine Service undertook a PSS transformation initiative in February 2021 to enhance that process for the more than 15,000 patients that are seen each year at the main HSS campus in Manhattan. Participating team members determined that providing these appointments in one place to the extent possible would significantly improve the patient experience. As a result, all internists, hospitalists and ancillary staff were centralized in a new model of care so that patients could have their labs, presurgical medical evaluation, imaging and any additional consultations all in one location. This improvement decreased the duration of the presurgical visit by an average of 100 minutes. PSS was also rolled out at HSS Florida in August. The service looks forward to exploring further optimizations to this process in the coming year.

Also in 2021, we were pleased to welcome three new hospitalists to the team: Abdulkader Kasabji, MD, Eugene Medvedev, MD, and Parvin Zawahir, MD.

Tieu J, Cheah JT, Black RJ, Christensen R, Ghosh N, Richards P, Robson J, Shea B, Simon LS, Singhi JA, Tugwell P, Boers M, Garibay MAA, Campochiaro C, Decary S, de Witt M, Fernandez AP, Keen HI, King L, Hinojosa-Azaola A, Hofstetter C, Gaydukova I, George MD, Gupta L, Lyne S, Makol A, Mukhtyar C, Oo WM, Petri M, Pisaniello HL, Sattui SE, Russel O, Teixeira V, Toupin-April K, Uhunmwangho C, Whitstock M, Yip K, Mackie SL, Goodman SM, Hill CL. Improving benefit-harm assessment of glucocorticoid therapy incorporating the patient perspective: The OMERACT glucocorticoid core domain set. Semin Arthritis Rheum. 2021 June 25.

Bass AR, Do HT, Mehta B, Lyman S, Mirza SZ, Parks M, Figgie M, Mandl LA, Goodman SM. Assessment of Racial Disparities in the Risks of Septic and Aseptic Revision Total Knee Replacements. JAMA Netw Open. J2021 July 1.

Chukir T, Goodman SM, Tornberg H, Do H, Thomas C, Sigmund A, Sculco P, Figgie M, Mehta B, Russell LA, Stein E. Periperative Glucocorticoids in Patients with Rheumatoid Arthrits Having Total Joint Replacements: Help or Harm? ACR Open Rheumatol. 2021 July 20.

Echeverria AP, Cohn IS, Danko DC, Shanaj S, Blair L, Hollemon D, Carli AV, Sculco PK, Ho C, Meshulam-Simon G, Mironenko C, Ivashkiv LB, Goodman SM, Grizas A, Westrich GH, Padgett DE, Figgie MP, Bostrom MP, Sculco TP, Hong DK, Hepinstall MS, Bauer TW, Blauwkamp TA, Brause BD, Miller AO, Henry MW, Ahmed AA, Cross MB, Mason CE, Donlin LT. Sequencing of Circulating Microbial Cell-Free DNA Can Identify Pathogens in Periprosthetic Joint Infections. J Bone Joint Surg Am. 2021 Sept 15.

Kahlenberg CA, Gibbons JAB, Jannat-Khah DP, Goodman SM, Mandl LA, Sculco PK, Goodman SB, Figgie MP, Mehta BY. Use of Total Hip Arthroplasty in Patients Under 21 Years Old: A US Population Analysis. J Arthroplasty. 2021 Aug 9.

Mehta B, Brantner C, Williams N, Szymonifka J, Navarro-Millan I, Mandl LA, Bass AR, Russell LA, Parks ML, Figgie MP, Nguyen JT, Ibrahim S, Goodman SM. Primary Care Provider Density and Elective Total Joint Replacement Outcomes. Arthroplast Today. 2021 Jul 9.

Bass AR, Zhang Y, Mehta B, Do HT, Russell LA, Sculco PK, Goodman SM. Periprosthetic Joint Infection is Associated with an Increased Risk of Venous Thromboembolism Following Revision Total Knee Replacement: An Analysis of Administrative Discharge Data. J Bone Joint Surg Am. 2021 Jul 21.

The primary mission of the Infectious Diseases unit at HSS is the prevention, treatment and study of orthopedic and rheumatologic infections. We remain deeply engaged in our primary mission, as well as in continuing to work with hospital leadership in the midst of the ongoing COVID-19 pandemic.

This year, our faculty reached a number of milestones. Andy Miller, MD, was named chief of the service. He succeeds Barry Brause, MD, who served with distinction in this role for a number of years and who remains the longstanding medical co-director of the HSS Infection Control Committee, which has critical responsibilities in setting policy and reviewing infection-related clinical care.

The prevention and treatment of postoperative orthopaedic infections remains a top priority—in particular infections of joint replacements and of spine surgeries. Over the past two years, new directions have included improvements in specimen collection from arthroplasty patients, in the optimization of protocols for prosthesis debridement with novel agents and in the modern treatment of atypical mycobacterial infections with clofazimine and other advanced antimycobacterial agents. We also developed the HSS Prosthetic Joint Infection (PJI) database, which has led to multiple retrospective published reports and invited presentations on the clinical presentation, treatment and prognosis of PJI.

In August, HSS was recognized for these efforts when Dr. Brause accepted the George C. Cierny III award from the Musculoskeletal Infection Society on behalf of HSS. This award is in recognition of career-long excellence that exemplifies collaboration in patient care and research for musculoskeletal infection. In addition, Dr. Miller, Michael Henry, MD, and other HSS colleagues published a paper on the topic of PJI that received the James A. Rand Young Investigator's Award by the American Academy of Hip and Knee surgeons.

Additionally, Dr. Miller participated in a successful grant application with Chief Value Medical Officer Catherine MacLean, MD, and orthopaedic surgeon Alberto Carli, MD, for $500,000 in funding from the Moore Foundation for the development and study of EMR-based quality indicators for periprosthetic infection.

Echeverria AP, Cohn IS, Danko DC, Shanaj S, Blair L, Hollemon D, Carli AV, Sculco PK, Ho C, Meshulam-Simon G, Mironenko C, Ivashkiv LB, Goodman SM, Grizas A, Westrich GH, Padgett DE, Figgie MP, Bostrom MP, Hong DK, Hepinstall MS, Bauer TW, Blauwkamp TA, Brause BD, Miller AO, Henry MW, Ahmed AA, Cross MB, Mason CE, Donlin LT. Sequencing of Circulating Microbial Cell-Free DNA Can Identify Pathogens in Periprosthetic Joint Infections. J Bone Joint Surg Am. 2021 Sep 15;103(18):1705-1712. doi: 10.2106/JBJS.20.02229. PMID: 34293751.

Levack AE, Turajane K, Yang X, Miller AO, Carli AV, Bostrom MP, Wellman DS. Thermal Stability and in Vitro Elution Kinetics of Alternative Antibiotics in Polymethylmethacrylate (PMMA) Bone Cement. J Bone Joint Surg Am. 2021 Sep 15;103(18):1694-1704. doi: 10.2106/JBJS.20.00011. PMID: 33857030.

Boyle KK, Kapadia M, Chiu YF, Khilnani T, Miller AO, Henry MW, Lyman S, Carli AV. The James A. Rand Young Investigator's Award: Are Intraoperative Cultures Necessary If the Aspiration Culture Is Positive? A Concordance Study in Periprosthetic Joint Infection. J Arthroplasty. 2021 Jul;36(7S):S4-S10. doi: 10.1016/j.arth.2021.01.073. Epub 2021 Feb 2. PMID: 33676815.

While our primary mission is clinical and administrative, the Infectious Diseases Service continues to build an impressive academic and teaching portfolio. As we look ahead, we wish to continue our academic efforts, including expanding our use of national databases to further understand the epidemiology and management of orthopedic infections. Accepted and upcoming publications, including a project regarding the impact of COVID-19 on surgical outcomes, are anticipated.

The Endocrinology Service trained its first fellow, Katherine Noto Haseltine, MD. Dr. Haseltine won the 2021 Best Research Poster Award for her poster entitled “The Effect of Epidural Steroid Injections on Fracture Risk Among Medicare Patients.” Dr. Haseltine joined the service after completing her fellowship at HSS.

Emily Stein, MD, is leading a study examining the consequences of epidural steroid injections on bone health in collaboration with Physiatry and the Pain Management Division. This work was recently highlighted as an oral presentation at the 2021 Annual Meeting of the American Society for Bone and Mineral Research.

Leder B, Mitlak B, Hu M-Y, Hattersley G and Bockman R. Effect of Abaloparatide vs Alendronate on Fracture Risk Reduction in Postmenopausal Women with Osteoporosis. J Clin Endocrinol Metab. 2020 Mar 105(3): 938-943. PMID: 31674644

Chukir T, Haseltine K, Do H, McMahon DJ, Russell L, Stein EM. Clinical Characteristics and Fracture Patterns Among Postmenopausal Women with Isolated Osteoporosis at the Forearm. J Clin Densitom. 2021 Aug 13:S1094-6950(21)0069-X. PMID: 34511326

Kim HJ, Dash A, Cunningham M, Schwab F, Dodwell J, Harrison J, Zaworski C, Krez A, Lafage V, Agarwal S, Carlson B, McMahon DJ, Stein EM. Patients with Abnormal Microarchitecture have an Increased Risk of Early Complications after Spinal Fusion. Bone. 2021 Feb; 143:115731. doi: 10.1016/j.bone.2020.115731. Epub 2020 Nov 4. PMID: 33157283

Zaworski C, Cheah J, Koff MF, Breighner R, Lin B, Harrison J, Donnelly E, Stein EM. MRI-based Texture Analysis of Trabecular Bone for Opportunistic Screening of Skeletal Fragility. J Clin Endocrinol Metab. 2021 Jul 13;106(8): 2233-2241. doi: 10.1210/cinem/dgab342. PMID: 33999148

Krez A, Lane J, Heilbronner A, Park-Min KH, Kaneko K, Pannellini T, Mintz D, Hansen D, McMahon DJ, Kirou KA, Roboz G, Desai, P, Bockman RS, Stein EM. Risk factors for multi-joint disease in patients with glucocorticoid-induced osteonecrosis. Osteoporos Int. 2021 Oct; 32(10):2095-2103. doi: 10.1007/s00198-021-05947-x. Epub 2021 April 20. PMID: 33877383

Several studies are under way evaluating bone anabolic agents. The FAST Healing Trial (Fusion with Anabolics after Spinal Surgery) is being conducted with co-investigators from Metabolic Bone, Orthopaedics, Radiology and Rheumatology. It looks to use anabolics to improve surgical outcomes in patients undergoing spine stabilization. The second is a multicenter trial supported by the National Institutes of Health, for which HSS is the coordinating center, seeking to accelerate pelvic fracture repair with an anabolic agent.

Future goals include focused integration with the HSS Spine Service, with the aim of evaluating spine surgical patients prior to surgery to optimize bone health.