Efficacy predictors of a second tumor necrosis factor inhibitor in the treatment of rheumatoid arthritis.

To retrospectively evaluate initial tumor necrosis factor inhibitor (TNFi) failure patients for clinical predictors of response to a 2nd TNFi in our 4282 rheumatoid arthritis (RA) patient database.A cross-sectional retrospective manual chart review of the electronic health record (EHR) was performed on 322 "real world" RA patients who were prescribed 2 TNFis. Response to TNFi was determined by the treating provider who had real time Clinical Disease Activity Index (CDAI) scores to inform treatment decisions. Age, gender, body mass index (BMI), insurance provider, duration of disease, cyclic citrullinated peptide antibody (CCP) and rheumatoid factor (RF) positivity, concomitant disease modifying anti-rheumatic drug therapy, length of time between diagnosis and start of 1st and 2nd TNFi, transient efficacy of 1st TNFi (defined as response to TNFi at 3 months but later lost response), and reason for discontinuation of 1st TNFi were analyzed. A multivariable logistic regression model was used to model response to a 2nd TNFi.Response proportions to the 2nd TNFi were greater in females (161/223, 72.2% response female vs 41/75, 54.7% male, P < .01), those who began their 1st TNFi within 3 months of their RA diagnosis, and in RF+ patients (123/170, 72.4% response seropositive vs 66/110, 60.0% seronegative, P < .03). The higher female response rate was independent of age, BMI, and seropositivity.In RA patients who failed an initial TNFi, female patients and patients with RF+ were more likely to have a clinical response to a 2nd TNFi. In the absence of these predictors, stronger consideration for choosing a biologic with an alternative mechanism of action might be given when the 1st TNFi fails.

Aortitis as a Harbinger of Occult Malignancy.

Noninfectious aortitis can be associated with an occult malignancy. Although glucocorticosteroids are often used, there is no clear evidence-based therapy and there is little consensus regarding treatment. Identifying and treating an underlying trigger is the most efficacious therapy. We present an unusual case initially concerning acute bacterial endocarditis of the native mitral valve; however, aseptic ischemic valvitis manifested on pathology. Concurrent aortitis was diagnosed with angiography. Occult colon adenocarcinoma was discovered during diagnostic abdominal imaging. Treatment of this underlying malignancy was associated with dynamic mitigation of inflammation affecting the entire aorta and a reduction in associated symptoms. This is an unusual case of a paraneoplastic secondary large vessel vasculitis involving the entire aorta, a diagnosis of exclusion but a consideration that can have dramatic impact on both morbidity and mortality.

Improved Gout Outcomes in Primary Care Using a Novel Disease Management Program: A Pilot Study.

OBJECTIVE: To pilot a primary care gout management improvement intervention. METHODS: Two large primary care sites were selected: 1 underwent the intervention, the other, a control, underwent no intervention. The intervention consisted of engagement of intervention-site staff, surveys of provider performance improvement preferences, and onsite live and enduring online education. Electronic health record reminders were constructed. Both the intervention and control sites had 3 quality measures assessed monthly: the percentage of gout patients treated with urate-lowering therapy, the percentage of treated patients monitored with serum urate, and the percentage of treated patients at target serum urate ≤6.0 mg/dl. The intervention-site providers received monthly reports comparing their measures against their peers. RESULTS: By 6 months, the intervention site significantly improved all 3 gout performance measures. The percentage treated increased from 54.4% to 61.1% (odds ratio [OR] 1.19 [95% confidence interval (95% CI) 1.08-1.31]; P < 0.001), the percentage monitored increased from 56.1% to 79.2% (OR 1.52 [95% CI 1.24-1.87]; P < 0.001), and the percentage at goal increased from 26.85% to 43.3% (OR 1.43 [95% CI 1.16-1.77]; P < 0.001). At 6 months after intervention, gout patients at the intervention site were more likely to be monitored (79.2% versus 53.4% [OR 3.54 (95% CI 2.30-5.45)]; P < 0.001) and at goal (43.3% versus 28.3% [OR 1.99 (95% CI 1.33-2.96)]; P < 0.001) than control-site patients. Numbers treated did not significantly improve over the control site. CONCLUSION: A pilot multifaceted gout management program can significantly improve primary care gout management performance.

The Foot That Broke Both Hips: A Case Report and Literature Review of Tumor-Induced Osteomalacia.

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterized by hypophosphatemia and clinical symptoms of osteomalacia. Only discussed as case reports, there is still limited knowledge of this condition as a potentially curable cause of osteomalacia among clinicians and pathologists. In this article, we present a case of tumor-induced osteomalacia in a 59-year-old gentleman followed by an up-to-date review of the existing literature on TIO.

A longitudinal analysis of costs associated with change in disease activity in systemic lupus erythematosus.

OBJECTIVES: To estimate the economic consequences of changes in disease activity on healthcare resource utilization (HRU) and costs. METHODS: A retrospective longitudinal study of systemic lupus erythematosus (SLE) patients receiving care in a regional integrated health delivery system in the US from 01/2004 through 03/2011 was conducted using electronic health records, medical chart reviews, and claims. Eligible patients were ≥18 years old, with ≥1 rheumatologist-confirmed SLE diagnosis and ≥1 eligible rheumatology encounter. Patients were continuously enrolled ≥90 days before and ≥30 days after the encounters. Charts were manually reviewed to estimate SLEDAI scores. Average unit costs of each medical procedure, facility use, and prescription were estimated from a payer perspective (2011 USD) using a managed care claims database. HRU and costs were calculated for the 30-day period surrounding every SLEDAI score date (10 days before and 19 after). Relationships between HRU/costs and SLEDAI scores were estimated using mixed-effect models. RESULTS: Overall, 178 SLE patients were included; mean age was 50.6 years, 91% were female, and 95.5% Caucasian. Patients had a total of 1343 encounters with SLEDAI scores over an average period of 1035 days. Reductions of SLEDAI scores were associated with reductions in HRU and costs. SLEDAI score reductions of 4-points were associated with reductions of 10% HRU and 14% costs over a 30-day period; reductions of 8-points had associated reductions of 19% HRU and 26% costs; and reductions of 10-points had associated reductions of 23% HRU and 31% costs. Annualized, changes in SLEDAI scores are associated with changes of $2485 (SLEDAI score change: 10-6), $4624 (10-2), and $5579 (10-0), respectively. CONCLUSION: Reductions in disease activity were associated with substantial reductions of HRU and costs. LIMITATIONS: Only short-term effects of disease activity change were investigated, disregarding other potential benefits of low disease activity on long-term organ damage prevention or comorbidities.