OBJECTIVE To explore the associations of thigh computed tomography (CT)-derived measures of body composition with functional outcomes in patients with rheumatoid arthritis (RA). METHODS Patients with RA underwent bilateral mid-femoral quantitative CT for measurement of thigh fat area (TFA), muscle area (TMA), and muscle density (TMD). The associations of thigh composition measures with disability and physical performance, measured with the Health Assessment Questionnaire (HAQ), Valued Life Activities (VLA) scale, and Short Physical Performance Battery (SPPB), were explored for the total cohort and by gender, controlling for pertinent demographic, lifestyle, and RA disease and treatment covariates. RESULTS A total of 152 RA patients were studied. Among potential determinants of TMD, higher age, higher duration of sedentary activity, longer RA duration, higher tender joint count, higher serum IL-6 levels, use of glucocorticoids, and non-use of hydroxychloroquine were all significantly associated with lower TMD in multivariable modeling. RA characteristics accounted for 77% of the explainable variability in TMD. When co-modeled, higher TFA and lower TMD, but not lower TMA, were significantly and independently associated with higher HAQ scores, lower SF-36 total physical scores, lower composite SPPB scores, and a greater proportion of affected obligatory VLAs. CONCLUSIONS Thigh CT-derived measures of body composition, particularly fat area and muscle density, were strongly associated with disability and physical performance in RA patients, with RA disease features as potential determinants. Efforts to reduce fat and improve muscle quality may reduce disability in this population with impaired physical functioning.

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Georges Albert Edouard Brutus Gilles de la Tourette (1857-1904), a French neurologist and pupil of Jean Martin Charcot at the Salpêtrière hospital in Paris, has gained common recognition through his description of the 'Maladie des Tics'. This complex neuropsychiatric disorder, later known as the 'Tourette's syndrome', nowadays is accepted as a specific entity of movement disorders. Gilles had started working under Charcot (1825-1893), the first physician to occupy a designated chair of neurology of neuropsychiatric history, in 1884. Then the Salpêtrière hospital was a centre of intensive research with an emphasis on hysteria and hypnosis. Tourette took an interest in hysteria, but also dedicated himself to various other neuropsychiatric disorders and to neuropathology. He published scientific works on epilepsia, neurasthenia and syphilitic myelitis. Although he devoted much time to his neuropsychiatric research and the publication of articles in medical journals, his career did not make significant progress, despite Charcot's unrestricted support. One reason was, that he disregarded questions, answers and problems, which were outside his interest fields. Hence, he was accused for having acquired an extremely filtered and one-sided knowledge. Also, his alienated and critical behaviour, which had not helped him to find many friends over the years, prevented him from professional promotion. In 1893 an assassination attempt on Gilles de la Tourette raised considerable public interest: Gilles was shot in his appartement in the Rue de l'Université 39 by a young woman, who had been his patient in the Salpêtrière and who claimed that she had been hypnotized without her agreement and thereby had lost her mental health. However, the patient was diagnosed with a disease nowadays called paranoid schizophrenia and therefore hypnosis was not attributed to any part of the disease. Due to episodes of melancholia and phases of delusions of grandeur and megalomania Gilles de la Tourette was forced to leave his hospital appointment in 1901. These symptoms and the corresponding neurological signs were attributed to the paretic neurosyphilis. He was institutionalized to the psychiatric hospital Cery near Lausanne, Switzerland. In the course of the following three years he became increasingly psychotic and demented, suffered from epileptic seizures and finally died in hospital on 22nd May 1904.

Objective To explore the contributions from and interactions between articular swelling and damage, psychosocial factors, and body composition characteristics on walking speed in rheumatoid arthritis (RA). Methods RA patients underwent the timed 400 meter long-corridor walk. Demographics, self-reported levels of depressive symptoms and fatigue, RA characteristics, and body composition [using whole-body dual-energy X-ray absorptiometry (DXA), and abdominal and thigh computed tomography (CT)] were assessed and their associations with walking speed explored. Results A total of 132 RA patients had data for the 400 meter walk, among whom 107 (81%) completed the full 400 meters. Significant multivariable indicators of slower walking speed were older age, higher depression scores, higher reported pain and fatigue, higher swollen and replaced joint counts, higher cumulative prednisone exposure, non-treatment with disease-modifying anti-rheumatic drugs (DMARDs), and worse body composition. These features accounted for 60% of the modeled variability in walking speed. Among specific articular features, slower walking speed was primarily correlated with large/medium lower-extremity joint involvement. However, these articular features accounted for only 21% of the explainable variability in walking speed. Having any relevant articular characteristics was associated with a 20% lower walking speed among those with worse body composition (p<0.001) compared with only a 6% lower speed among those with better body composition (p-value for interaction=0.010). Conclusions Psychosocial factors and body composition are potentially reversible contributors to walking speed in RA. Relative to articular disease activity and damage, non-articular indicators were collectively more potent indicators of an individual's mobility limitations.

Background Lung ultrasound (LUS) is a clinician-performed evidence-based imaging modality that has multiple advantages in the evaluation of dyspnea caused by multiple disease processes, including COVID-19. Despite these advantages, few hospitalists have been trained to perform LUS. The aim of this study was to increase adoption and implementation of LUS during the 2020 COVID-19 pandemic by using recurrent assessments of RE-AIM outcomes to iteratively revise our implementation strategies. Methods In an academic hospital, we implemented guidelines for the use of LUS in patients with COVID-19 in July 2020. Using a novel “RE-AIM dashboard,” we used an iterative process of evaluating the high-priority outcomes of Reach, Adoption, and Implementation at twice monthly intervals to inform revisions of our implementation strategies for LUS delivery (i.e., Iterative RE-AIM process). Using a convergent mixed methods design, we integrated quantitative RE-AIM outcomes with qualitative hospitalist interview data to understand the dynamic determinants of LUS Reach, Adoption, and Implementation. Results Over the 1-year study period, 453 LUSs were performed in 298 of 12,567 eligible inpatients with COVID-19 (Reach = 2%). These 453 LUS were ordered by 43 out of 86 eligible hospitalists (LUS order adoption = 50%). However, the LUSs were performed/supervised by only 8 of these 86 hospitalists, 4 of whom were required to complete LUS credentialing as members of the hospitalist procedure service (proceduralist adoption 75% vs 1.2% non-procedural hospitalists adoption). Qualitative and quantitative data obtained to evaluate this Iterative RE-AIM process led to the deployment of six sequential implementation strategies and 3 key findings including (1) there were COVID-19-specific barriers to LUS adoption, (2) hospitalists were more willing to learn to make clinical decisions using LUS images than obtain the images themselves, and (3) mandating the credentialing of a strategically selected sub-group may be a successful strategy for improving Reach. Conclusions Mandating use of a strategically selected subset of clinicians may be an effective strategy for improving Reach of LUS. Additionally, use of Iterative RE-AIM allowed for timely adjustments to implementation strategies, facilitating higher levels of LUS Adoption and Reach. Future studies should explore the replicability of these preliminary findings.