Association of rheumatoid arthritis with mortality in chronic kidney disease: a cohort study.

BACKGROUND: Rheumatoid arthritis (RA) is associated with an increased risk of cardiovascular disease (CVD) as well as with an increased risk of chronic kidney disease (CKD), also a known cardiovascular risk factor. However, it is not known if RA is a predictor of adverse outcomes in patients with CKD. We hypothesized that among a cohort of patients with CKD, RA would be associated with an increased risk of mortality. MATERIALS AND METHODS: We conducted a retrospective study of 3939 participants with CKD from the prospective Chronic Renal Insufficiency Cohort (CRIC) study. The primary outcome of interest was all-cause mortality. Secondary outcomes included CKD progression (defined as end-stage kidney disease or 50% decline in estimated glomerular filtration rate), cardiovascular endpoints, and composite of myocardial infarction, cerebrovascular accident, heart failure, or death. Multivariable Cox proportional hazards regression was utilized, adjusting for potential confounders including age, sex, race/ethnicity, body mass index, current smoker, and education. RESULTS: The study cohort included 83 participants with RA on a disease modifying anti-rheumatic drug (DMARD). In the adjusted analysis, CKD-RA status was significantly associated with an increased risk of death (adjusted HR, aHR, 1.73 (1.27, 2.35)) and composite outcome (aHR 1.65 (1.27-2.15)) even after adjusting for traditional risk factors. Similar statistically significant associations were observed between CKD-RA and other secondary outcomes except for CKD progression. CONCLUSION: RA was associated with higher mortality among individuals with CKD but not progressive renal decline. Further studies evaluating the mechanisms behind this association are needed. Key Points • Rheumatoid arthritis (RA) is associated with an increased risk of cardiovascular disease (CVD) as well as with an increased risk of chronic kidney disease (CKD), also a known cardiovascular risk factor. However, it is not known if RA is an independent predictor of adverse outcomes in patients with CKD • In this study, we observed that CKD patients with RA experience higher mortality as well as an increased risk of CVD compared to patients with CKD without comorbid RA • These data provide rationale for more aggressive monitoring for CVD in patients with CKD and RA. They also underscore the need for determining which interventions can help decrease the burden of mortality in these patients.

Telemedicine Use During the COVID-19 Pandemic by Resilient Rheumatology Providers: A National Veterans Affairs Follow-up Survey.

OBJECTIVE: To assess rheumatology provider experience and practices at Veterans Affairs (VA) facilities during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We performed an anonymized follow-up national cross-sectional survey (November 5, 2020 to January 1, 2021) to assess provider resilience, experience, practices, views, and opinions about changes to medications and laboratory monitoring of veterans with rheumatic diseases. RESULTS: Of the 143 eligible VA rheumatology providers, 114 (80%) responded. Compared to the original survey, fewer providers reported using telephone visits (78% vs 91%, P = 0.009), and more used clinical video telehealth (CVT; 16% vs 7%, P = 0.04) or in-person visits (76% vs 59%, P = 0.007). Most providers were somewhat or very comfortable with the quality of clinical encounters for established but not new patients for telephone, video-based VA Video Connect (VVC), and CVT. The mean 2-item Connor-Davidson Resilience Scale score was 6.85 (SD 1.06, range 0-8), significantly higher than the original April-May 2020 survey score of 6.35 (SD 1.26; P = 0.004). When adjusted for age, sex, and ethnicity, high provider resilience was associated with significantly higher odds of comfort with technology and the quality of the VVC visit for the following: (1) established patients (odds ratio [OR] 1.72, 95% CI, 0.67-4.40 and OR 4.13, 95% CI 1.49-11.44, respectively) and (2) new patients (OR 2.79, 95% CI 1.11-7.05, and OR 2.69, 95% CI 1.06-6.82, respectively). CONCLUSION: Reassuringly, VA rheumatology providers became increasingly comfortable with video visits during the first 10 months of the COVID-19 pandemic. High provider resilience, and its association with better quality CVTs, raise the possibility that video visits might be an acceptable substitute for in-person visits under appropriate circumstances.

Management of Rheumatic Diseases During the COVID-19 Pandemic: A National Veterans Affairs Survey of Rheumatologists.

OBJECTIVE: To assess the experience, views, and opinions of rheumatology providers at Veterans Affairs (VA) facilities about rheumatic disease health care issues during the COVID-19 pandemic. METHODS: We performed an anonymized cross-sectional survey, conducted from April 16 to May 18, 2020, of VA rheumatology providers. We assessed provider perspectives on COVID-19 issues and resilience. RESULTS: Of the 153 eligible VA rheumatologists, 103 (67%) completed the survey. A significant proportion of providers reported a ≥50% increase related to COVID-19 in visits by telephone (53%), video-based VA video connect (VVC; 44%), and clinical video telehealth with a facilitator (29%). A majority of the responders were somewhat or very comfortable with technology for providing health care to established patients during the COVID-19 pandemic using telephone (87%), VVC (64%), and in-person visits (54%). A smaller proportion were comfortable with technology providing health care to new patients. At least 65% of rheumatologists considered telephone visits appropriate for established patients with gout, osteoporosis, polymyalgia rheumatica, stable rheumatoid arthritis, stable spondyloarthritis, or osteoarthritis; 32% reported a rheumatology medication shortage. Adjusted for age, sex, and ethnicity, high provider resilience was associated with significantly higher odds ratios (ORs) of comfort with technology for telephone (OR 3.1 [95% confidence interval (95% CI) 1.1-9.7]) and VVC visits for new patients (OR 4.7 [95% CI 1.4-15.7]). CONCLUSION: A better understanding of COVID-19 rheumatic disease health care issues using a health-system approach can better inform providers, improve provider satisfaction, and have positive effects on the care of veterans with rheumatic disease.

Shared decision-making in gout treatment: a national study of rheumatology provider opinion and practice.

To assess rheumatologists' views and practices related to shared decision-making (SDM) in gout treatment. We performed a cross-sectional electronic survey of rheumatologists at U.S. Veterans Affairs (VA) medical centers, assessing views and practices related to SDM in gout. Of the 154 VA rheumatology providers eligible, 90 responded (response rate, 58%). Fifty-eight percent were female, the mean age was 51 years (standard deviation, 9.6), 42% had > 20 years of experience in medical practice. Rheumatologists reported routinely offering a choice to their patients for (1) starting urate-lowering therapy (ULT) for gout vs. doing nothing (70%); (2) choosing NSAIDs, corticosteroids, or colchicine for the treatment of acute flares (67%); and (3) choosing NSAIDs, corticosteroids, or colchicine for anti-inflammatory prophylaxis when starting ULT (51%). Very few rheumatologists offered choice regarding (4) choosing allopurinol vs. febuxostat as the first ULT (16%) and (5) taking daily ULT long-term vs. intermittently (15%). Rheumatologists perceived that a large proportion of patients were often or sometimes unsure of the best choice for these five decisions, 34%, 76%, 76%, 52%, and 54%, respectively. Similar proportions of rheumatologists felt that patients were uninformed about both medication benefits and risks, unclear about the personal importance of the benefits and risks, and unsupported in decision-making. For the five decisions respectively, rheumatologists supported SDM with patients in 76%, 56%, 58%, 27%, and 25%. The majority of VA rheumatologists incorporated SDM in several gout treatment decisions. Rheumatologists also recognized that patients need better support to participate in SDM in gout. Key Points: • Rheumatologists offered shared decision-making to gout patients for 3 key treatment decisions. • Rheumatologists perceived that many patients were unsure of the best choice for these decisions. • Rheumatologists felt that patients were uninformed about medication benefits/risks and unsupported in decision-making.

How to use biologic agents in patients with rheumatoid arthritis who have comorbid disease.

Although biologic disease modifying anti-rheumatic drugs (bDMARDs) have improved the quality of life of patients with rheumatoid arthritis, side effects remain a problem, especially for patients with pre-existing comorbidities. Randomized controlled trials of such drugs in rheumatoid arthritis typically exclude patients with comorbidities and are of short duration, so they do not provide data on adverse events in these people. Other data sources such as national bDMARD registries are limited by the preselection of patients for both conventional synthetic chemical compound disease modifying anti-rheumatic drugs (csDMARDs) and bDMARDs, and although these databases document comorbidity, they rarely report its severity. This too limits definitive statements on the progression or resolution of pre-existing disease. Although bDMARDs may not be contraindicated in patients with rheumatoid arthritis and certain comorbid diseases, additional assessments or precautions are recommended. This review summarizes current data on the use of bDMARDs in people with rheumatoid arthritis and common comorbid diseases. It provides an evidence base for doctors and their patients when discussing and selecting the appropriate bDMARDs.

Disease characteristics and treatment patterns in veterans with rheumatoid arthritis and concomitant hepatitis C infection.

OBJECTIVE: To assess disease characteristics, disease activity, and treatment patterns in rheumatoid arthritis (RA) patients with comorbid hepatitis C virus (HCV) infection. METHODS: RA patients with concomitant HCV were identified within the Veterans Affairs Rheumatoid Arthritis Registry. HCV was defined as at least 1 diagnostic code present in medical record databases. Generalized estimating equations in linear regression models compared component and composite measures of disease activity between HCV-positive and HCV-negative patients over the study period, accounting for within-subject correlations. Similar analysis of pharmacy databases evaluated medication use within each group. RESULTS: Ninety-two of 1,706 registry participants (5.1%) were identified with concomitant HCV. At enrollment, HCV-positive patients were younger (mean ± SD 61.7 ± 7.1 years versus 67.5 ± 11.2 years; P < 0.001), more often African American (35% versus 15%; P < 0.001), and smokers (48% versus 26%; P < 0.001). In unadjusted and adjusted analyses incorporating all study visits, patient-reported outcomes (pain, tender joints, and patient global scores) were higher in HCV-positive patients, contributing to higher disease activity scores. There was no difference in physician-reported outcomes (swollen joints or physician global scores). HCV-positive patients had lower C-reactive protein levels (ß -0.30 [95% confidence interval (95% CI) -0.53, -0.07], P = 0.01). Over all visits, HCV-positive patients were less likely to receive methotrexate (odds ratio [OR] 0.27 [95% CI 0.17, 0.40], P < 0.001), and more likely to receive prednisone (OR 1.41 [95% CI 1.02, 1.97], P = 0.04) and anti-tumor necrosis factor α (anti-TNFα) therapies (OR 1.51 [95% CI 1.04, 2.19], P = 0.03). CONCLUSION: RA patients with concomitant HCV have higher disease activity scores, driven primarily by higher patient-reported measures. HCV-positive patients were more likely to be treated with prednisone and anti-TNFα therapies and less likely to receive methotrexate compared to HCV-negative patients.

Measuring physician adherence with gout quality indicators: a role for natural language processing.

OBJECTIVE: To evaluate physician adherence with gout quality indicators (QIs) for medication use and monitoring, and behavioral modification (BM). METHODS: Gout patients were assessed for the QIs as follows: QI 1: initial allopurinol dosage <300 mg/day for patients with chronic kidney disease (CKD); QI 2: uric acid within 6 months of allopurinol start; and QI 3: complete blood count and creatinine phosphokinase within 6 months of colchicine initiation. Natural language processing (NLP) was used to analyze clinical narrative data from electronic medical records (EMRs) of overweight (body mass index ≥28 kg/m(2) ) gout patients for BM counseling on gout-specific dietary restrictions, weight loss, and alcohol consumption (QI 4). Additional data included sociodemographics, comorbidities, and number of rheumatology and primary care visits. QI compliance versus noncompliance was compared using chi-square analyses and independent-groups t-test. RESULTS: In 2,280 gout patients, compliance with QI was as follows: QI 1: 92.1%, QI 2: 44.8%, and QI 3: 7.7%. Patients compliant with QI 2 had more rheumatology visits at 3.5 versus 2.6 visits (P < 0.001), while those compliant with QI 3 had more CKD (P < 0.01). Of 1,576 eligible patients, BM counseling for weight loss occurred in 1,008 patients (64.0%), low purine diet in 390 (24.8%), alcohol abstention in 137 (8.7%), and all 3 elements in 51 patients (3.2%). Regular rheumatology clinic visits correlated with frequent advice on weight loss and gout-specific diet (P < 0.0001). CONCLUSION: Rheumatology clinic attendance was associated with greater QI compliance. NLP proved a valuable tool for measuring BM as documented in the clinical narrative of EMRs.

Post-traumatic growth following spinal cord injury.

CONTEXT/OBJECTIVE: Examine the relationship of post-traumatic psychological growth (PTG), depression, and personal and injury characteristics in persons with spinal cord injury (SCI). DESIGN: Cross-sectional survey. SETTING: Community. PARTICIPANTS: Eight hundred and twenty-four adults with SCI. INTERVENTIONS: None. OUTCOME MEASURES: Five items from the Post-traumatic Growth Inventory, reflecting positive change after injury in life priorities, closeness to others, new opportunities being available, stronger faith, and personal strength. RESULTS: Initial structural equation model testing of a conceptual model of personal and injury characteristics, violent etiology, depression, and PTG resulted in a poor fit. Model modifications resulted in an improved fit, but explained only 5% of the variance in PTG. Being female, younger, having less formal education, and less time since injury had significant relationships with PTG, whereas depression, violent etiology, and injury level/severity did not. In each PTG domain, between 54 and 79% of the sample reported at least some positive change after injury. CONCLUSIONS: The results of this study, while promising, explained only a small portion of the variance in PTG. A majority of the sample experienced some positive change after injury, with the greatest change in discovering that they were stronger than they thought they were. Comparing means previously reported in a non-SCI sample of those who experienced trauma, positive change after injury was comparable for each PTG item except for new opportunities being available, which was significantly lower for those with SCI. Future directions of research include the development of theoretical models of PTG after SCI.

Associations of disease activity and treatments with mortality in men with rheumatoid arthritis: results from the VARA registry.

OBJECTIVES: To examine the all-cause mortality rate and factors associated with mortality in US veteran men with RA. METHODS: Men with RA were enrolled and followed until death or censoring. Vital status was ascertained through systematic record review and standardized mortality ratios (SMRs) were calculated using US life tables for men. Multivariate Cox proportional hazards regression was used to examine the independent associations of patient factors including socio-demographics, comorbidity, measures of RA disease activity/severity and medication use with mortality. Measures of RA disease activity and medications were examined as time-varying factors. RESULTS: A total of 138 deaths were observed during 2314 patient-years of follow-up (n=1015 patients), corresponding to a crude morality rate of 5.9 deaths per 100 patient-years (95% CI 5.0, 7.0) and an SMR of 2.1 (95% CI 1.8, 2.5). After multivariate adjustment, factors independently associated with higher mortality risk in men with RA included older age, Caucasian race, low body weight, an increased frequency of rheumatology visits, higher ESR and RF concentrations, increased DAS28, subcutaneous nodules and prednisone use. In contrast, MTX use [hazard ratio (HR) 0.63; 95% CI 0.42, 0.96] was associated with ∼40% lower mortality risk. CONCLUSION: Mortality rates among US male veterans with RA are more than twice those of age-matched men in the general population. These results suggest that optimizing disease control, particularly with regimens that include MTX and minimize glucocorticoid exposure, could improve long-term survival in this population.

Prevalence of vitamin D insufficiency/deficiency in rheumatoid arthritis and associations with disease severity and activity.

OBJECTIVE: 25-hydroxy-vitamin D (25-OH-D) insufficiency/deficiency is increasingly prevalent and has been associated with many chronic diseases, including rheumatoid arthritis (RA). Our purpose was to define the prevalence and associations of 25-OH-D insufficiency/deficiency in a cohort of US veterans with RA. METHODS: vitamin D status (25-OH-D) was assessed in patients with RA using radioimmunoassay on banked plasma collected at enrollment. Insufficiency was defined as concentrations < 30 ng/ml and deficiency as < 20 ng/ml. Associations of 25-OH-D insufficiency/deficiency with patient characteristics obtained at enrollment were examined using multivariate logistic regression, adjusting for age, sex, season of enrollment, and race. RESULTS: patients (850 men, 76% Caucasian) had a mean (SD) age of 64 (SD 11.3) years. The prevalences of 25-OH-D insufficiency and deficiency were 84% and 43%, respectively. After multivariate adjustment, both insufficiency and deficiency were more common with anti-cyclic citrullinated peptide antibody positivity and non-Caucasian race, and in the absence of vitamin D supplementation. 25-OH-D deficiency, but not insufficiency, was independently associated with higher tender joint counts and highly sensitive C-reactive protein levels. CONCLUSION: in a predominantly elderly, male RA population, 25-OH-D insufficiency was highly prevalent. With the increasing adverse health outcomes associated with hypovitaminosis D, screening and supplementation, particularly among minority, seropositive patients with RA, should be performed routinely.

Association of periodontitis with rheumatoid arthritis: a pilot study.

BACKGROUND: Similarities exist in the epidemiology and immunopathogenesis of periodontitis and rheumatoid arthritis (RA), but the associations between their respective disease activities and severities are less well documented. We evaluated the prevalence and severity of periodontitis in United States (U.S.) veterans with RA and their relationship to RA disease activity and severity. METHODS: Patients with RA from an outpatient rheumatology clinic were eligible, and patients with osteoarthritis (OA) served as controls. Dentists, masked to the rheumatologic diagnoses, performed periodontal probing and examined dental panoramic radiographs to assess the presence and severity of periodontitis. Associations of periodontitis with RA were examined using multivariate regression, whereas the association of periodontitis with disease-severity measures in RA was examined using the chi(2) test. RESULTS: Sixty-nine patients with RA (57 males and 12 females) and 35 patients with OA (30 males and five females) were studied. Moderate to severe periodontitis was more prevalent in patients with RA (51%) than controls (26%) (P = 0.03), an association independent of age, race, smoking, diabetes mellitus, and gender. Patients with RA who were seropositive for rheumatoid factor (RF) were more likely to have moderate to severe periodontitis (59%) than patients who were RF negative (15%) (P = 0.02). Likewise, patients with RA who were positive for the anti-cyclic citrullinated peptide (CCP) antibodies were more likely to have moderate to severe periodontitis (56%) than patients who were anti-CCP negative (22%) (P = 0.01). There were no associations of periodontitis status with other measures of RA disease activity or severity. CONCLUSIONS: In a cohort of U.S. veterans, periodontitis was more common and severe in patients with RA compared to patients with OA. Although unrelated to disease activity, the presence of periodontitis in patients with RA was associated with seropositivity for RF and the anti-CCP antibody, which was highly relevant given the associations of these autoantibodies with poor outcomes and disease pathogenesis in RA.

Life satisfaction following spinal cord injury: long-term follow-up.

OBJECTIVE: To determine the course of self-reported life satisfaction in a spinal cord injury (SCI) cohort. DESIGN: Prospective study using longitudinal data from the Injury Control Research Center. PARTICIPANTS: Adult persons with traumatic-onset SCI (n = 207) evaluated at 1, 2, 4, and 5 years postinjury using the Life Satisfaction Index-A. RESULTS: A nonsignificant (P > 0.05) main effect of time was found using a repeated-measures analysis controlling for education and employment status. Several methods were used that provided a range of liberal to conservative estimates for missing data (ie, 38% retention rate at year 5). Subsequent missing data analyses tended to corroborate the finding of a nonsignificant effect of time, although the most conservative methods showed a significant decrease in life satisfaction between year 1 and year 5 postinjury (P < 0.05). Examination of numerous demographic, injury, and treatment-related characteristics at each follow-up time point suggested that the main findings of the study were not merely the result of differential dropout rates. CONCLUSION: Life satisfaction after the first year of injury remains largely the same over the next 4 years. Methodologic and analytic recommendations are discussed.

Outcome of corneal transplantation: can a prioritisation system predict outcome?

BACKGROUND: In 1995 a prioritisation system for patients waiting for corneal transplantation surgery was adopted in British Columbia. In 1997 a routine outcome assessment programme was adopted. The authors sought to determine the outcomes of corneal transplant surgery in the province of British Columbia and to evaluate if they were associated with waiting list prioritisation. METHODS: Since May 1997 all patients who receive a corneal transplant are enrolled in the Eye Bank of British Columbia (EBBC) outcome assessment programme. Each patient fills out a visual function assessment (VFA) questionnaire before and 12 months after surgery. Data on visual acuity, pain, demographics, and other ocular complications are collected from both patients and surgeons before and after operation. RESULTS: 269 patients were enrolled in the programme between May 1997 and April 1998. 12 month follow up showed that visual acuity improved in 69.9% of patients, while it remained the same in 20.8%, and got worse in 5.9%. Overall, at follow up 16.6% of patients had intermittent pain and 5.0% had constant pain. 78.6% of patients who experienced intermittent or constant pain before surgery reported no pain at follow up. Visual function improved in 72.4% of patients, remained the same in 4.1%, and worsened in 23.5%. 88% of patients improved in at least one of the three outcome categories. Patients who had the greatest improvement had been assigned the highest priority for surgery. The 11% of patients who did not improve in any of the three categories (visual acuity, pain, or visual function) were more likely to have a preoperative visual acuity better than 20/60, most likely to have old trauma or Fuchs' dystrophy as their primary diagnosis, and to have had fewer points in the EBBC priority scoring system. CONCLUSION: The finding that patients who had a high preoperative priority score were more likely to have a good outcome suggests that the priority system was accurately identifying patients at greatest need for surgery. These findings also suggest that outcome from corneal transplant surgery is best measured as a combination of clinical indices and patient derived indices. A routine outcome assessment programme and prioritisation system can assist surgeons and eye banks in better case selection and in anticipating both objective and subjective improvement following surgery.