Clinical presentation, treatment and outcome of Takayasu's arteritis in southern Chinese: a multicenter retrospective study.

To study the clinical presentation, treatment and outcome of southern Chinese patients with Takayasu's arteritis (TA). This is a retrospective chart review study of 78 patients managed in 14 public hospitals in Hong Kong between the years 2000 and 2010. Patients were identified from the hospital registry using the ICD-10 diagnostic code of the disease. The classification of TA was based on the American College of Rheumatology (ACR) or modified Ichikawa's criteria. Demographic data, clinical presentation, angiographic findings, pattern of vascular involvement (Numano's classification), treatment and outcome of these patients were presented. 78 patients were studied (82% women, age at presentation 34.2 ± 14 years). The estimated point prevalence of TA was 11/million population. The commonest initial manifestations were hypertension (62%) and vascular ischemic symptoms (38%). Systemic symptoms occurred in nine (12%) patients only. The proportion of patients fulfilling the angiographic subtypes of the Numano's classification was: types I (13%), IIa (4%), IIb (12%), III (12%), IV (20%) and V (39%), respectively. Thirty-two patients (41%) were treated with high-dose glucocorticoids (GCs) and 22 patients (28%) received additional non-GC immunosuppressive drugs. Vascular complications occurred in 26 (33%) patients and revascularization surgery was performed in 23(29%) patients. Three (4%) patients died of vascular complication at a median of 8 years after disease onset. TA is rare in southern Chinese patients of Hong Kong. Most patients present with ischemic symptoms during the stenotic phase of the disease. Although mortality is low, a significant proportion of patients developed vascular stenosis that required surgical interventions. More awareness of TA as a differential diagnosis of non-specific systemic symptoms with elevated inflammatory markers in younger patients is needed for earlier diagnosis.

Raloxifene for prevention of glucocorticoid-induced bone loss: a 12-month randomised double-blinded placebo-controlled trial.

OBJECTIVES: To study the efficacy of raloxifene in preventing bone mineral density (BMD) loss in women receiving long-term glucocorticoids (GC). The study took the form of a parallel-group randomised double-blinded placebo-controlled trial. METHODS: Postmenopausal women without hypercoagulability risk factors who were prevalent GC users were randomised to receive either raloxifene (60 mg/day) or placebo (1 tablet/day) on top of calcium (1000 mg/day) and calcitriol (0.25 µg/day). BMD of the hip and spine (primary outcome), bone turnover markers and new vertebral fractures (secondary outcomes) at month 12 were assessed. RESULTS: Between December 2006 and December 2008, 114 patients were recruited (age 55.3±7.7 years). The duration and dose of prednisolone received was 62.2±64 months and 6.7±5.9 mg/day, respectively. Baseline vertebral fracture was present in six (5%) patients. In all, 57 patients were allocated to each of the treatment arms. Demographic data, osteoporotic risk factors and BMD at various sites were similar between the two groups of patients. At month 12, a significant gain in the lumbar spine (+1.3±0.4%; p=0.004) and total hip BMD (+1.0±0.4%; p=0.01) was observed in patients treated with raloxifene but a significant decrease in BMD of the lumbar spine (-0.9±0.4%; p=0.045) and hip (-0.8±0.3%; p=0.01) occurred in the placebo group. The femoral neck BMD did not change significantly in favour of raloxifene. Three new fractures developed exclusively in the patients treated with placebo. Bone formation (serum osteocalcin and procollagen type I N-terminal) and resorption (urine deoxypyridinoline and type I collagen) markers decreased significantly in the raloxifene group but not in patients treated with placebo. Leg cramps were numerically more frequent in the raloxifene group (7% vs 0%) but thromboembolism was not reported in any patients. CONCLUSIONS: In postmenopausal women receiving long-term GCs, raloxifene is well tolerated and significantly increases spinal and hip BMD after 12 months of treatment.

Prevalence of the antiphospholipid syndrome and its effect on survival in 679 Chinese patients with systemic lupus erythematosus: a cohort study.

UNLABELLED: In this work we evaluate the prevalence of the antiphospholipid syndrome (APS) and its impact on survival in Chinese patients with systemic lupus erythematosus (SLE). We studied a prospective cohort of southern Chinese patients who fulfilled ≥4 American College of Rheumatology criteria for SLE. The cumulative rate of survival over time was calculated by the Kaplan-Meier method. APS was defined by the 2006 updated consensus criteria. We evaluated the prevalence and manifestations of APS, and compared the survival of patients with and without APS. We followed 679 patients with SLE (92% women; age of onset, 32.5 ± 14 yr) for 9.7 ± 7.3 years. Sixty-eight (10%) patients died and 33 (4.9%) patients were lost to follow-up. Forty-four (6.5%) patients met the criteria for APS, manifested by the following: ischemic stroke (55%), deep venous thrombosis (32%), obstetric morbidity (14%), cardiovascular events (9%), and peripheral vascular disease (9%). Nine (9/44 [20%]) APS patients died, which was more frequent than the non-APS patients (59/635 [9%]; p = 0.02). The cumulative mortality of patients with APS was 4.6% at 5 years, 7.8% at 10 years, and 22.2% at 15 years, which was not significantly higher than that of non-APS patients (5.4% at 5 years, 9.2% at 10 years, and 11.3% at 15 years; p = 0.14). However, if we considered only patients with APS caused by arterial thrombosis, the presence of APS was significantly associated with mortality (hazard ratio, 2.29; 95% confidence interval, 1.13-4.64; p = 0.02). We conclude that the presence of APS increases the mortality risk of Chinese patients with SLE, which is mainly contributed by arterial thrombotic events. CLINICAL SIGNIFICANCE: 1) APS is infrequent in southern Chinese patients with SLE compared to white patients. 2) Arterial thrombosis is a more common manifestation of APS than venous thrombosis in Chinese SLE patients. 3) APS related to arterial thrombosis is associated with increased mortality in Chinese patients with SLE.

Prevalence of atherosclerotic risk factors and the metabolic syndrome in patients with chronic inflammatory arthritis.

OBJECTIVE: To evaluate the prevalence of the metabolic syndrome in patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), and psoriatic arthritis (PsA). METHODS: Consecutive patients with RA, AS, or PsA who attended our outpatient arthritis clinics between July and November 2009 were recruited for a study of atherosclerotic risk factors and the metabolic syndrome, defined according to the 2009 joint statements using the Asian criteria for central obesity. RESULTS: Nine hundred thirty patients were studied (699 with RA, 122 with AS, and 109 with PsA; 70% women, mean±SD age 51.1±12.7 years). The mean±SD disease duration for patients with RA, AS, and PsA was 5.3±5.4, 6.0±5.6, and 3.6±3.1 years, respectively. The prevalence of metabolic syndrome was significantly higher in PsA (38%) than RA (20%) or AS (11%; P<0.001). The odds ratios (ORs) for the metabolic syndrome compared to age- and sex-matched controls were 0.98 (95% confidence interval [95% CI] 0.78-1.23, P=0.88), 0.59 (95% CI 0.30-1.15, P=0.12), and 2.68 (95% CI 1.60-4.50, P<0.001), respectively, for RA, AS, and PsA. Patients with PsA had a significantly higher prevalence of impaired fasting glucose (30%; P<0.001), low high-density lipoprotein (HDL) cholesterol (33%; P<0.001), high triglycerides level (21%; P=0.008), central obesity (65%; P<0.001), and high blood pressure (56%; P=0.045). In a logistic regression model, the adjusted OR for the metabolic syndrome in PsA was 2.44 (95% CI 1.48-4.01, P<0.001) relative to RA or AS. The adjusted ORs for central obesity, impaired fasting glucose, hypertriglyceridemia, and low HDL cholesterol were also significantly higher in PsA patients. CONCLUSION: Patients with PsA, but not RA or AS, have a significantly higher prevalence of the metabolic syndrome compared to the general population. Among the 3 diseases studied, PsA has the highest prevalence of the metabolic syndrome and is associated with the highest cardiovascular risk.

Venous thromboembolism in southern Chinese patients with systemic lupus erythematosus.

The objective is to study the annual incidence and standardized incidence ratio (SIR) of venous thromboembolism (VTE) in a cohort of Chinese patients with systemic lupus erythematosus (SLE). VTE events of SLE patients occurring between 1999 and 2008 were identified from our database, and the annual incidence of VTE was calculated according to the cohort size. SIRs were estimated by the ratios of the incidence of VTE in SLE to the general population. In 2008, 516 SLE patients were in our cohort. The mean age of SLE onset was 32.2 +/- 14 years and the duration of SLE was 9.3 +/- 8.8 years. Fifty-seven percent of the patients had disease duration of > or =5 years. Between 1999 and 2008, 18 episodes of VTE occurred in 14 patients. The incidence of VTE did not show significant fluctuation and the mean annual incidence was 4.2/1,000 patient-year. The reported VTE events were: popliteal vein thrombosis (56%), pulmonary embolism (22%), renal vein, retinal vein, subclavian vein and dural sinus thrombosis (5.6% each). The cumulative risks of VTE since SLE diagnosis were 2.8% and 3.7% at 5 and 10 years, respectively. Compared to the general population, the mean SIR of VTE in SLE patients within this period was 11.9 (7.31-19.6; p < 0.001). The SIR of VTE was highest in patients under the age of 30 years. The presence of the antiphospholipid antibody was independently associated with VTE (HR 4.36 [1.67-11.4]; p = 0.003). Although venous thrombosis is uncommon in Chinese, Chinese patients with SLE are 12 times more prone to VTE than the general population.

Incidence and mortality of systemic lupus erythematosus in a southern Chinese population, 2000-2006.

OBJECTIVE: To study the annual incidence and standardized mortality ratio (SMR) of a longitudinal cohort of Chinese patients with systemic lupus erythematosus (SLE). METHODS: Annual numbers of new cases and deaths in a longitudinal cohort of patients with SLE between 2000 and 2006 retrieved from a database were compared with regional population and death rates expected from the annual death statistics maintained by our hospital and population census data. RESULTS: Our cohort of SLE had grown from 272 to 442 patients from 2000 to 2006. The annual incidence of SLE showed mild fluctuation (mean incidence 3.1/100,000 population; 5.4/100,000 in women). The annual death rate and SMR in year 2000 were 25.7/1000 and 7.88 (range 3.7-16.7; p<0.001), respectively, compared to the general population. A trend of reduction in annual death rates and SMR was observed, the annual death rate and SMR in year 2006 being 6.8/1000 and 2.17 (range 0.7-6.7; p=0.34). The SMR was higher in men than women and had a less obvious trend of improvement. A negative correlation of SMR with age was observed. The SMR of SLE patients aged above 60 years was not significantly higher than expected from population statistics. There was also a trend of fewer deaths due to infection over time. CONCLUSION: In this single-center study, the incidence of SLE remained static. The SMR of SLE was significantly increased in younger patients, indicating a greater effect of the disease on younger individuals. There was a trend of improvement in SMR for SLE in recent years, probably as a result of fewer infectious complications.

Rituximab for refractory rheumatoid arthritis: a 24-week open-label prospective study.

OBJECTIVES: To study the efficacy of rituximab in active rheumatoid arthritis (RA) patients refractory to disease modifying anti-rheumatic drugs (DMARDs) including the tumor necrosis factor (TNF)-alpha antagonists. METHODS: Adult patients with active RA despite adequate therapies with conventional DMARDs or anti-TNFalpha agents for at least 3 months were recruited. Inclusion criteria were: (1) Positive RF / anti-CCP; (2) >/= 6 swollen joints and >/= 8 tender joints; (3) ESR >/= 28 mm/hr or CRP >/= 10 mg/L. Eligible patients were given intravenous rituximab infusions at a dose of 1000 mg on days 1 and 15. Assessment was performed 4-weekly thereafter and included tender joint counts (TJC), swollen joint counts (SJC), physician's and patient's global assessment, patient's pain assessment (VAS 0-100 mm), disability index (HAQ-DI), quality of life (SF36), fatigue score (FACIT-F), ESR and CRP. The DAS28, EULAR and ACR responses at week 24 were evaluated. RESULTS: 10 patients (8 women and 2 men) were studied (mean age: 49 years; mean RA duration 7.4 years). Baseline TJC and SJC were 25.1 +/- 13.2 and 12.8 +/- 5.4 respectively. The mean DAS28 score was 7.1 +/- 0.7, and the mean CRP and ESR levels were 52.3 +/- 60 mg/L and 95.8 +/- 32 mm/hr, respectively. The median number of failed DMARDs was 4 and two patients had failed anti-TNFalpha treatment. At week 24, there was a significant drop in TJC, SJC, ESR and CRP. The HAQ-DI score also decreased from 2.1 to 1.7 (p=0.04) while the total SF-36 score improved from 24.8 to 38.3 (p=0.008). Sixty percent of patients achieved EULAR moderate-to-good response. Half of the patients achieved ACR20 and two achieved ACR50 / 70 response. Only one patient experienced a minor infusion reaction. CONCLUSIONS: Rituximab is effective and well tolerated in patients with refractory RA.