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1.
Artigo em Inglês | MEDLINE | ID: mdl-33544963

RESUMO

BACKGROUND: Reports of mortality risks among individuals with GCA have been mixed. Our aim was to evaluate all-cause mortality among individuals with GCA relative to the general population over time. METHODS: We performed a population-based study in Ontario, Canada, using health administrative data. We studied a cohort of 22,677 GCA patients aged ≥50 years identified using a validated case definition (with 81% positive predictive value, 100% specificity). General population comparators were residents aged ≥50 years without GCA. Deaths were ascertained from vital statistics. Annual crude, age/sex-standardized and age- and sex-specific all-cause mortality rates were determined for individuals with and without GCA between 2000 and 2018. Standardized mortality ratios (SMRs) were estimated. RESULTS: Age- and sex-standardized mortality rates were significantly higher for GCA patients than comparators, and trending to increase over time with 50.0 (95% confidence interval (CI) 34.0, 71.1) deaths per 1000 GCA patients in 2000 and 57.6 (95% CI 50.8, 65.2) deaths per 1000 in 2018, whereas mortality rates in the general population significantly declined over time. The annual SMRs for GCA patients generally increased over time with the lowest SMR occurring in 2002 (1.22; 95% CI 1.03, 1.40) and the highest in 2018 (1.92; 95% CI 1.81, 2.03). GCA mortality rates were more elevated for males than females. CONCLUSION: Over a 19-year period, mortality rates were increased among GCA patients relative to the general population and more premature deaths were occurring in younger age groups. The relative excess mortality for GCA patients did not improve over time.

2.
Semin Arthritis Rheum ; 51(1): 219-229, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33385862

RESUMO

C-reactive protein (CRP) is routinely assessed as a marker of systemic inflammation in rheumatoid arthritis (RA). However, it is also an immune regulator that plays an important role in inflammatory pathways associated with RA and promotes atherogenic effects. Comorbidities linked to systemic inflammation are common in RA, and CRP has been associated with the risk for cardiovascular disease, diabetes, metabolic syndrome, pulmonary diseases, and depression. The relationship between systemic inflammation, CRP, and comorbidities in RA is complex, and it is challenging to determine how changing CRP levels may affect the risk or progression of these comorbidities. We review the biological role of CRP in RA and its implications for disease activity and treatment response. We also discuss the impact of treatment on CRP levels and whether reducing systemic inflammation and inhibiting CRP-mediated inflammatory pathways may have an impact on conditions commonly comorbid with RA.

3.
Curr Opin Rheumatol ; 33(2): 122-127, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33481429

RESUMO

PURPOSE OF REVIEW: Systemic sclerosis (scleroderma, SSc) is a rare multisystem autoimmune disease characterized by autoantibodies, vasculopathy, and fibrosis of the skin and internal organs. This review aims to provide an overview and summary of the recent epidemiological studies in systemic sclerosis. RECENT FINDINGS: Global trends of scleroderma demonstrate greater prevalence of SSc in European, North, and South American patients compared with East Asian patients. However, the greatest prevalence (47 in 100 000), was found among the indigenous peoples in Canada. Phenotypical differences exist depending on the age of presentation with greater internal organ involvement and disease acceleration present in older patients. Sex differences include greater severity of disease expression, relative prevalence of diffuse cutaneous SSc, and organ involvement in males versus females. New studies conflict with previous data reporting greater proportion of pulmonary arterial hypertension in females. Furthermore, the effect of low median household income is demonstrated as a factor increasing risk of death in SSc patients. SUMMARY: Understanding the epidemiological factors in SSc enables patient care through patient classification, prognostication, and monitoring. Future research may emphasize enrichment of SSc patients in randomized trials who are more likely to progress or be treatment responsive, focused screening, and personalized patient care through the creation and validation of new SSc criteria and subsets.

4.
J Rheumatol ; 2020 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-33262302

RESUMO

OBJECTIVE: To compare differences in clinical activity and remuneration between male and female rheumatologists and to evaluate associations between physician gender and practice sizes and patient volume, accounting for rheumatologists' age, and calendar year effects. METHODS: We conducted a population-based study in Ontario, Canada between 2000-2015 identifying all rheumatologists practicing as full-time equivalents (FTE) or above and assessed differences in practice sizes (number of unique patients), practice volumes (number of patient visits), and remuneration (total fee-for-service billings) between male and female rheumatologists. Multivariable linear regression was used to evaluate the effects of gender on practice size and volume separately, accounting for age and year. RESULTS: The number of rheumatologists practicing at or above one FTE increased from 89 to 120 from 2000 to 2015, with the percentage of females increasing from 27.0% to 41.7%. Males had larger practice sizes and practice volumes. Remuneration was consistently higher for males (between $46,000-$102,000 annually). Our adjusted analyses estimated that in a given year, males saw a mean of 606 (95% CI 107-1105) more patients than females did, and had 1,059 (95% CI 345- 1773) more patient visits. Among males and females combined, there was a small but statistically significant reduction in mean annual number of patient visits, and middle-aged rheumatologists had greater practice sizes and volumes than their younger/older counterparts. CONCLUSION: On average, female rheumatologists saw fewer patients and had fewer patient visits annually relative to males, resulting in lower earnings. Increasing feminization necessitates workforce planning to ensure that populations' needs are met.

5.
Artigo em Inglês | MEDLINE | ID: mdl-33342087

RESUMO

OBJECTIVE: Systemic lupus erythematosus is a chronic autoimmune disease with varied and unpredictable levels of disease activity. The ability to self-manage lupus is important in controlling disease activity. Our objective was to determine levels of patient activation toward self-management in lupus. METHODS: We used baseline results from the MyLupusGuideTM study that had recruited 541 lupus patients from ten centers. We used the Patient Activation Measure (PAM), a validated self-reported tool designed to measure activation towards self-management ability, as our primary variable and examined its association with demographic, disease-related, patient-provider communication and psychosocial variables captured in our study protocol. Univariable and multivariable linear regressions were performed using linear mixed models, with a random effect for centers. RESULTS: The average age was 50±14 years, 93% were female, 74% were Caucasian and the average disease duration was 17±12 years. The mean PAM score was 61.2±13.5 with 36% of participants scoring in the two lower levels, indicating low activation. Variables associated with low activation included being single, lower physical health status, lower self-reported disease activity, lower self-efficacy, use of more emotional coping and less distraction and instrumental coping strategies, and perceived lack of clarity in patient-doctor communication. CONCLUSION: Low patient activation was observed in more than one third of lupus patients indicating a large proportion of patients perceived that they are lacking in lupus self-management skills. These results highlight a modifiable gap in perceived self-management ability among patients with lupus.

6.
Ann Rheum Dis ; 2020 Nov 06.
Artigo em Inglês | MEDLINE | ID: mdl-33158881

RESUMO

OBJECTIVES: Janus kinase inhibitors (JAKi) have been approved for use in various immune-mediated inflammatory diseases. With five agents licensed, it was timely to summarise the current understanding of JAKi use based on a systematic literature review (SLR) on efficacy and safety. METHODS: Existing data were evaluated by a steering committee and subsequently reviewed by a 29 person expert committee leading to the formulation of a consensus statement that may assist the clinicians, patients and other stakeholders once the decision is made to commence a JAKi. The committee included patients, rheumatologists, a gastroenterologist, a haematologist, a dermatologist, an infectious disease specialist and a health professional. The SLR informed the Task Force on controlled and open clinical trials, registry data, phase 4 trials and meta-analyses. In addition, approval of new compounds by, and warnings from regulators that were issued after the end of the SLR search date were taken into consideration. RESULTS: The Task Force agreed on and developed four general principles and a total of 26 points for consideration which were grouped into six areas addressing indications, treatment dose and comedication, contraindications, pretreatment screening and risks, laboratory and clinical follow-up examinations, and adverse events. Levels of evidence and strengths of recommendations were determined based on the SLR and levels of agreement were voted on for every point, reaching a range between 8.8 and 9.9 on a 10-point scale. CONCLUSION: The consensus provides an assessment of evidence for efficacy and safety of an important therapeutic class with guidance on issues of practical management.

7.
Eur J Rheumatol ; 7(Suppl 3): S222-S227, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33164736

RESUMO

Systemic sclerosis (SSc) is a heterogeneous disease with variability in autoantibody profiles, skin and internal organ involvement, disease trajectory, and survival. The ability to identify more homogeneous subsets of SSc patients has informed patient care and been an essential aspect of SSc research. In this article, the historic evolution of subsetting systems in SSc are described including clinically based SSc subsetting systems, their utility, strengths, and limitations. There is a shifting paradigm of SSc subsets, including biologic classification of SSc subsets and fully data-driven approaches to SSc subset classification, taking into consideration the needs of the SSc global community in the modern era and the ability to prognosticate patients with SSc.

8.
Clin Exp Rheumatol ; 2020 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-33124575

RESUMO

OBJECTIVES: The purpose of this systematic review was to identify existing guidelines for antimalarial prescribing and monitoring, specifically for hydroxychloroquine, and how these guidelines compare and have evolved over time. METHODS: A literature search was conducted using Embase and Medline to identify guidelines published from 1946-2018. MeSH terms were used and alternative spelling and related words were entered as keywords to broaden results. RESULTS: 243 results were reviewed to obtain 11 recommendations. Ophthalmology sources included the American Academy of Ophthalmology, Royal College of Ophthalmologists and Canadian editorials. The American College of Rheumatology and Canadian Rheumatology Association consensus statements summarised rheumatology recommendations. Recently, American and British guidelines changed from suggesting hydroxychloroquine doses ≤6.5 mg/kg/day to ≤5 mg/kg/day. American guidelines recommended baseline visual field (VF) testing and annual screening after five years. Visual field (VF) testing evolved from the Amsler grid to current recommendations of 10-2 automated VF and spectral-domain optical coherence tomography (SD-OCT). The 2012 Canadian recommendations suggested initial VF testing every two years, with SD-OCT after 10 years. Older British guidelines advocated for baseline and annual assessment with Amsler grids during rheumatology clinic visits. The 2018 British guidelines supported baseline and annual screening after five years with 10-2 VF, SD-OCT and fundus autofluorescence. CONCLUSIONS: The newest recommendations are heterogeneous suggesting lower hydroxychloroquine dosing. Retinal toxicity is irreversible and the risk increases over time. Annual screening after five years with automated VF and SD-OCT may be warranted to detect early changes and discontinue therapy if necessary.

10.
Autoimmun Rev ; 19(11): 102659, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32942034

RESUMO

Undifferentiated Connective Tissue Disease at risk for Systemic Sclerosis (UCTD-risk-SSc), otherwise referred to as very early-early SSc (very early-early diagnosis of systemic sclerosis VEDOSS), is a condition characterized by Raynaud's phenomenon (RP) and either SSc serum marker autoantibodies or a capillaroscopic scleroderma pattern or both, but without satisfying classification criteria for SSc neither features consistent with SSc sine scleroderma. Approximately half the UCTD-risk-SSc patients develop definite SSc over 5-10 years of follow-up. Identifying patients who will undergo such evolution is an unmet need. Predicting at onset which patients with RP are going to develop SSc over time has long been a research objective and still is an unaccomplished task. The present review is devoted to the critical analysis of the nosographic boundaries of the condition and of items predictive of evolution including serological, capillaroscopic and circulating markers. A weighted score, based on serum antinuclear antibody titre, serum marker antibodies positivity and avascular areas has been developed and may identify in the meanwhile patients to be labeled prescleroderma i.e. those probably developing SSc over time. Future research should be directed to investigate unexplored features, validate and improve the performance of the score and highlight the involved pathways to be contrasted in order to identify a targeted therapy hampering the development of overt SSc.

11.
Arthritis Rheumatol ; 2020 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-32852109

RESUMO

OBJECTIVE: To examine the relationship between disease activity and fatigue over time in early rheumatoid arthritis (RA). METHODS: Data were from patients with early RA (duration of symptoms ≤12 months) enrolled in the Canadian Early Arthritis Cohort (CATCH). Patients rated the level of their fatigue over the past week using an 11-point numerical rating scale for up to 5 years of follow-up. Fatigue severity was classified as low (≤2), moderate (>2 but <5), or high (≥5). Fatigue severity ratings in patients who achieved a low disease activity state (Disease Activity Score in 28 joints [DAS28] ≤3.2) were compared to those in patients who did not achieve a low disease activity state within 3 months of cohort entry. RESULTS: Of 1,864 patients included, 88% met RA criteria, and 72% were women. The mean ± SD baseline DAS28 was 4.9 ± 1.5. Nineteen percent of the patients reported moderate baseline fatigue, and 59% reported severe baseline fatigue. Fatigue was correlated with pain and patient global disease activity ratings (r = 0.56-0.67, P < 0.001), and was weakly correlated with the DAS28, tender joint count, swollen joint count, physician global assessment of disease activity, erythrocyte sedimentation rate, and C-reactive protein level. Patients who reported low fatigue by 3 months had significantly lower fatigue throughout follow-up compared to those who had moderate or high fatigue at 3 months (P < 0.001). Patients who achieved a DAS28 ≤3.2 within 3 months had significantly lower fatigue ratings than those with a DAS28 >3.2 (mean ± SD fatigue severity score 2.7 ± 2.6 versus 4.6 ± 3.0; P < 0.001), with improvements in fatigue that persisted through 5 years of follow-up. Maximal improvements in fatigue lagged behind remission by 6 months. CONCLUSION: Fatigue is common in early RA, and improvements may occur after remission. Early treatment response within 3 months after treatment initiation was associated with short-term and long-term improvements in fatigue over time.

12.
Arthritis Rheumatol ; 2020 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-32852124

RESUMO

We are all familiar with Shakespeare's quote from Romeo and Juliet 'A rose by any other name would smell as sweet'. The answer to promotion in rheumatology, if there is gender equality; would be that Rose or Rosendo (the male version of Rose) would have equal opportunity to be promoted in academic rheumatology in the US.

14.
Artigo em Inglês | MEDLINE | ID: mdl-32789456

RESUMO

OBJECTIVES: RA patients are often not in remission due to patient global assessment of disease activity (PtGA) included in disease activity indices. The aim was to assess the lag of patient-reported outcomes (PROs) after remission measured by clinical disease activity index (CDAI) or swollen joint count (SJC28). METHODS: RA patients enrolled in the Ontario Best Practices Research Initiative registry not in low disease state at baseline with at ≥6 months of follow-up, were included. Low disease state was defined as CDAI ≤ 10, SJC28 ≤ 2, PtGA ≤ 2cm, pain score ≤ 2cm, or fatigue ≤ 2cm. Remission included CDAI ≤ 2.8, SJC28 ≤ 1, PtGA ≤ 1cm, pain score ≤ 1cm, or fatigue ≤ 1cm. Time to first low disease state/remission based on each definition was calculated overall and stratified by early vs established RA. RESULTS: A total of 986 patients were included (age 57.4 (12.9), disease duration 8.3 (9.9) years, 80% women). The median (95% CI) time in months to CDAI ≤ 10 was 12.4 (11.4, 13.6), SJC28 ≤ 2 was 9 (8.2, 10), PtGA ≤ 2cm was 18.9 (16.1, 22), pain ≤ 2cm was 24.5 (19.4, 30.5), and fatigue ≤ 2cm was 30.4 (24.8, 31.7). For remission, the median (95% CI) time in months to CDAI ≤ 2.8 was 46.5 (42, 54.1), SJC28 ≤ 1 was 12.5 (11.4, 13.4), PtGA ≤ 1cm was 39.6 (34.6, 44.8), pain ≤ 1cm was 54.7 (43.6, 57.5) and fatigue ≤ 1cm was 42.6 (36.8, 48). Time to achieving low disease state and remission was generally significantly shorter in early RA compared with established RA with the exception of fatigue. CONCLUSION: Time to achieving low disease state or remission based on PROs was considerably longer compared with swollen joint count. Treating to a composite target in RA could lead to inappropriate changes in DMARDs.

15.
Autoimmun Rev ; 19(9): 102602, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32659476

RESUMO

BACKGROUND: Pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc) is a lethal complication affecting 8-15% of patients. Screening tests such as echocardiography and pulmonary function tests allow for triaging patients for diagnosis by right heart catheterization. Understanding risk factors of SSc-PAH could help differentiate high-risk patients. METHODS: A systematic review was conducted to determine associations with SSc-PAH, including clinical/disease characteristics, antibodies, labs and biomarkers. The frequencies of publications featuring each risk/association were reported. RESULTS: Among 2654 articles, 984 duplicates and 1578 irrelevant articles were removed, leaving 92 articles for manual screening. After excluding 55 papers with small sample sizes, publications from identical cohorts, not English language, or PAH not ascertained by RHC, 37 articles were eligible. A total of 43 factors for SSc-PAH were identified within seven categories. Several associations were due to PAH and risk factors such as dynpnea, right heart failure, and short 6-minute walk distance. Patient characteristics (14), pulmonary physiology (6), antibody profiles (6) and genetics/epigenetics (6) had the most numerous and diverse factors, while biomarkers (4) and other labs (2) features were infrequent. Low carbon monoxide (DLCO) (6), older age (4), longer disease duration (4), positive anticentromere antibodies (ACA) (4), telangiectasias (4), high brain natriuretic peptide (4) were frequent associations. CONCLUSIONS: Risk factors for SSc-PAH such as ACA, older age, longer disease duration limited cutaneous SSc subset and presence of ILD may enrich screening programs. Genes and other antibody profiles are inconsistent and requires further validation.


Assuntos
Hipertensão Arterial Pulmonar , Escleroderma Sistêmico , Envelhecimento , Humanos , Peptídeo Natriurético Encefálico , Hipertensão Arterial Pulmonar/genética , Hipertensão Arterial Pulmonar/imunologia , Fatores de Risco , Escleroderma Sistêmico/genética , Escleroderma Sistêmico/imunologia
18.
Joint Bone Spine ; 87(6): 588-595, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32522598

RESUMO

INTRODUCTION: Autoantibody tests are commonly ordered when screening for rheumatic diseases. Rheumatoid factor (RF) and antinuclear antibody (ANA) have low positive predictive values in general practice. Overuse of diagnostic tests can result in an increase in unnecessary referrals, patient anxiety, and further costs. OBJECTIVE: The objective was to evaluate the utilization patterns, appropriateness, and associated costs of tests including ANA, extractable nuclear antibodies (ENA), anti-double stranded DNA (anti-dsDNA), RF, and HLA-B27 in patients referred to rheumatologists. METHODS: A review was conducted of consecutive referrals (accepted and rejected) using university rheumatologists' practices over one year. Inappropriate investigations, and associated costs were analyzed. Tests were considered appropriate if at least one criterion for a specific disease was provided. RESULTS: Of 638 referrals the most common reported reasons for referral were: spondyloarthropathies (SpA), rheumatoid arthritis (RA), and lupus (SLE). Prior to referral: 61% had undergone ANA testing at least once, ANA was repeated in one third; 19% had ENA and 21% had anti-dsDNA. 20% had ANA testing with no clinical indication. Half of ENA and anti-dsDNA testing was in the context of a negative ANA. RF was requested in 65% and in close to one third, there was no clinical suspicion of inflammatory arthritis. CONCLUSION: Despite the recommendations by CRA Choosing Wisely Campaign, at least 50% of laboratory investigations, including RF, ANA, ENA, and anti-dsDNA, are inappropriately ordered. More selective ordering of the above tests would lead to marked cost reduction.

20.
Curr Treatm Opt Rheumatol ; : 1-4, 2020 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-32355607

RESUMO

Purpose of review: The COVID-19 outbreak has resulted in uncertainty for patients with autoimmune rheumatic diseases for several reasons. They are concerned about their risk of developing COVID-19 as many are immune suppressed from their disease and/or treatment, whether they should stop their advanced therapies, if they will have a worse outcome if/when infected due to their underlying medication condition(s) and if they will have drug availability, especially with press (without much data) coverage suggesting hydroxychloroquine may be used in COVID-19 infection causing diversion of medication supply. This article discusses how the pandemic affects people with systemic autoimmune rheumatic diseases. Recent findings: Preliminarily, articles seem to suggest that patients with rheumatic diseases may not have more infections from SARS-CoV-2 and similar outcomes to age and gender matched patients, but fear of rheumatic medications increasing their risk, drug shortages, and work exposure all are concerns for patients. Recent findings: The long term effects of the pandemic in patients with rheumatic diseases will not be known until much later and likely include stressors flaring disease (fear, illness, job loss, social isolation), post-traumatic stress, flaring due to stopping medications, less physician visits with subsequent under-treatment, and increases in chronic concomitant fatigue, pain, fibromyalgia.

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