Cancer Risk and Mortality in Hospitalized Patients With Idiopathic Inflammatory Myopathies in Western Australia.

OBJECTIVE: To compare cancer incidence, type, and survival between patients with idiopathic inflammatory myopathies (IIMs) in Western Australia (WA) and the general population. METHODS: Administrative health data for hospitalized patients with incident IIM (n = 803, 56.5% female, median age 62.0 yrs), classified by a validated algorithm as polymyositis (PM; 36.2%), dermatomyositis (DM; 27.4%), inclusion body myositis (IBM; 17.1%), overlap myositis (OM; 10.7%), and other IIM (8.6%), were linked to WA cancer and death registries for the period of 1980 to 2014. Cancer incidence rates (CIRs) before and after IIM diagnosis as well as cancer mortality were compared with age-, sex-, and calendar year-matched controls (n = 3225, 54.9% female, median age 64 yrs) by rate ratios (RRs) and Kaplan-Meier survival estimates. RESULTS: The prediagnosis CIR was similar for patients with IIM and controls (6.57 vs 5.95; RR 1.11, 95% CI 0.88-1.39) and for patients evolving to DM (n = 220) or other IIM subtypes (6.59 vs 6.56; RR 1.01, 95% CI 0.38-3.69). During follow-up, CIR was higher for all DM (4.05, 95% CI 3.04-5.29), with increased CIR for lung cancer vs controls (1.05 vs 0.33; RR 3.18, 95% CI 1.71-5.47). Cancer post diagnosis shortened life span by 59 months for patients with IIM (103 vs 162 months, P < 0.01), but reduced survival rates were observed only in patients with DM and IBM. CONCLUSION: Cancer risk was not increased prior to IIM, but CIR for lung cancer was increased following DM diagnosis. As cancer reduced survival only in patients with DM and IBM, these data support a strategy of limited cancer screening in IIM.

Long-term incidence, risk factors and complications for venous thromboembolism in patients with systemic lupus erythematosus.

AIM: To compare frequency, incidence rates (IR), risk factors and outcomes of a first venous thromboembolic event (VTE) between patients with systemic lupus erythematosus (SLE) and controls. METHODS: Using state-wide longitudinal hospital data from Western Australia (WA), we recorded venous thrombosis (VT) and pulmonary embolism (PE) in patients with SLE (n = 1854, median age 40, 86% female) and matched hospitalised controls (n = 12,107, median age 40 years, females 88.6%) in the period 1985-2015. Results presented are medians, frequency, IR per 1000 person years (PY) and odds, rate, or adjusted hazard ratios (OR/RR/a-HR) with 95% confidence intervals (CI). RESULTS: Patients with SLE had significantly higher odds (12.8 vs 3.3%; OR 4.26, CI 3.60-5.05) and IR for a first VTE (10.09 vs 1.52; RR 6.64; CI 5.56-7.79). Over the three study decades, the IR for PE declined in patients with SLE from 7.74 to 3.75/1000 PY (p < .01) with no changes observed for VT or in controls. VTE recurred more frequently in patients with SLE (24.1% vs 10.2 %) (p < .01). Antiphospholipid antibodies (aPL) (a-HR 4.24, CI 2.50-7.19), serositis (a-HR 2.70, CI 1.86-3.91), lupus nephritis (a-HR 1.75 CI 1.25-2.33) and thrombocytopenia (a-HR 1.65 (1.10-2.49) were the strongest disease risk factors for VTE only in patients with SLE, while arterial hypertension, smoking and obesity were independent VTE risk factors for both groups. VTE was not associated with an increased risk for arterial events, but PE increased the risk for pulmonary hypertension (PH) in both patients with SLE (a-HR 6.47, CI 3.73-11.23) and controls (a-HR 9.09, CI 3.50-23.63). VTE increased the risk of death in both patients with SLE (a-HR 2.02, CI 1.50-2.70) and controls (a-HR 6.63, CI 5.21-8.42) after 10 years of follow-up. CONCLUSIONS: VTE affected 12.8% of patients with SLE at six times the VTE rate in controls with aPL as the strongest, but not the only risk factor in SLE. The risk of PH was increased in both groups following PE, but VTE did not associate with an increased risk of arterial events.

Comparison of pregnancy outcomes between indigenous and non-indigenous lupus patients.

AIM: To compare pregnancy outcomes between IA and non IA lupus patients. BACKGROUND: Pregnancy in lupus patients confers an increased risk of maternal and fetal morbidity. There are no data on pregnancy outcomes for indigenous Australian (IA) patients with lupus. METHODS: Using state-wide longitudinal hospital morbidity data, we studied 702 pregnancies in IA (n = 31) and non-indigenous (NI) patients with lupus (n = 357) in Western Australia and compared rates for live birth (LB), preterm birth (PB) and gestational complications in the period 1985-2015. Results are presented as medians or frequency. RESULTS: IA patients had proportionally more pre-existing renal disease (35 vs 13%, P < 0.01) and lower socio-economic status (P = 0.02). Age at first pregnancy was lower in IA patients (27 vs 30 years, P < 0.001), recorded gravidity was similar (2 vs 2, P > 0.6) and elective termination (n = 138) was more frequent in NI than IA pregnancies (21.1 vs 4.8%, P < 0.01). For continued pregnancies (59 in IA and 505 in NI), respective outcomes were as follows: LB 84.7% versus 91.5% (P = 0.15), spontaneous abortion 13.5% versus 6.9% (P = 0.13), (pre-)eclampsia 8% versus 9.9% (P = 0.89), PB 12% versus 13.4% (P = 0.98) and caesarean delivery 30% versus 47.2% (P = 0.02). Gestational diabetes (26% vs 6.1%), renal flares (20% vs 5.6%) and infections (22% vs 6.3%) were all more frequent in IA lupus pregnancies (all P < 0.001). CONCLUSIONS: The burden of comorbidities was higher in IA patients with lupus due to renal flares, gestational DM and infections. Although PB rates were overall high, they were, however, similar for IA and NI lupus pregnancies, as were LB rates.

The spectrum of idiopathic inflammatory myopathies in Western Australia: epidemiological characteristics and mortality over time.

To determine long term overall and subgroup specific incidence rates and associated mortality for idiopathic inflammatory myopathies (IIM) in a population wide study. We included patients hospitalised between 1980 and 2015 with incident IIM as defined by relevant diagnostic codes for dermatomyositis (DM) polymyositis (PM), inclusion body myositis (IBM), other IIM and overlap myositis (OM) in the Western Australia Health Hospital Morbidity Data Collection (n = 846). Trends over time for annual incidence rate per million population (AIR) were analysed by least square regression and Kaplan-Meier survival and mortality rates (MR)/100 person years compared with a matched control group (n = 3681). The averaged AIR for all IIM was 19 (CI 10.4-27.5) and stable over time with point prevalence reaching 205.3 (CI 185.6-226.6) per million in 2015. Over time, the AIR for DM 5.0 (CI 0.6-9.4) and IBM 3.3 (CI 0.7-9.6) was stable, while AIR decreased for PM (p < 0.01) and increased for other IIM (p < 0.01) and OM (p < 0.01). IBM patients were eldest at diagnosis (68 years, CI 59-77) with male preponderance in IBM (53.4%) and other IIM (55.8%) groups. Crude mortality (54.5 vs 41.3%), MR ratio (6.65 vs 5.91) and 5 (65.8% vs 71.6%) and 10-year (52.5% vs 58.7%) survival were all worse for IIM patients (all p < 0.05). IBM patients had highest MR (10.1; CI 8.38-12.14) and lowest 10-year survival (39.2%). While cardiovascular disease and cancer were predominant causes of death, they were proportionally lower in IIM patients, where respiratory and rheumatic disease were more frequent causes of death. While the overall incidence of IIM in WA was stable over 35 years, the spectrum of IIM has changed significantly with increases especially in other IIM and OM. The overall prognosis with IIM remains guarded with 10-year survival just over 50%.

The temporal association between adverse drug reactions and antirheumatic drugs utilisation in Western Australia: a retrospective study from real-world data (1995-2015).

BACKGROUND/OBJECTIVES: Adverse drug reactions (ADRs) can result in morbidity, mortality, and higher healthcare costs. Given the limited information available on ADRs associated with antirheumatic medications, this study aims to analyse and compare ADR reporting for these drugs in the pharmacovigilance datasets of Western Australia (WA) and the United States (US). METHODS: Therapeutic Goods Administration provided WA pharmacovigilance data of selected antirheumatic drugs to from 1995 to 2015. The proportional reporting ratio (PRR) for WA case reports was compared to corresponding USA pharmacovigilance data by assessing the disproportionality of each ADR. clinically significant or true ADRs were determined using the Evans 2001 criteria (n > 2, chi-square > 4, PRR > 2). RESULTS: A total of 232 reports were found in WA, mostly on sixty-nine women aged 45 to 69. Methotrexate, leflunomide, azathioprine, sulfasalazine, and infliximab had the highest reported ADRs, related to gastrointestinal disorders. Patients who used biological agents in WA had 2.7 times the likelihood of reporting true ADRs compared to conventional antirheumatic drugs. The ADR rates in the two datasets were comparable over the study period. CONCLUSIONS: The PRR values of ADRs were consistent between WA and US databases. Methotrexate and infliximab use were commonly associated with ADR reports in WA females, with incidence rates comparable to the US; while patients using biological agents were more likely to report true ADRs than those on conventional antirheumatic drugs in WA.

Antidementia medication acetylcholinesterase inhibitors have therapeutic benefits on osteoporotic bone by attenuating osteoclastogenesis and bone resorption.

This study was designed to determine whether the use of acetylcholinesterase inhibitors (AChEIs), a group of drugs that stimulate acetylcholine receptors and are used to treat Alzheimer's disease (AD), is associated with osteoporosis protection and inhibition of osteoclast differentiation and function. Firstly, we examined the effects of AChEIs on RANKL-induced osteoclast differentiation and function with osteoclastogenesis and bone resorption assays. Next, we investigated the impacts of AChEIs on RANKL-induced nuclear factor κB and NFATc1 activation and expression of osteoclast marker proteins CA-2, CTSK and NFATc1, and dissected the MAPK signaling in osteoclasts in vitro by using luciferase assay and Western blot. Finally, we assessed the in vivo efficacy of AChEIs using an ovariectomy-induced osteoporosis mouse model, which was analyzed using microcomputed tomography, in vivo osteoclast and osteoblast parameters were assessed using histomorphometry. We found that Donepezil and Rivastigmine inhibited RANKL-induced osteoclastogenesis and impaired osteoclastic bone resorption. Moreover, AChEIs reduced the RANKL-induced transcription of Nfatc1, and expression of osteoclast marker genes to varying degrees (mainly Donepezil and Rivastigmine but not Galantamine). Furthermore, AChEIs variably inhibited RANKL-induced MAPK signaling accompanied by downregulation of AChE transcription. Finally, AChEIs protected against OVX-induced bone loss mainly by inhibiting osteoclast activity. Taken together, AChEIs (mainly Donepezil and Rivastigmine) exerted a positive effect on bone protection by inhibiting osteoclast function through MAPK and NFATc1 signaling pathways through downregulating AChE. Our findings have important clinical implications that elderly patients with dementia who are at risk of developing osteoporosis may potentially benefit from therapy with the AChEI drugs. Our study may influence drug choice in those patients with both AD and osteoporosis.

Systemic juvenile idiopathic arthritis: frequency and long-term outcome in Western Australia.

Systemic juvenile idiopathic arthritis (S-JIA) is a rare but potentially life threatening autoinflammatory condition of childhood. Given the limited data on S-JIA from the Australasian region, we investigated the epidemiological characteristics and long-term disease outcome in S-JIA. All hospitalised patients under the age of 16 years registered with ICD-10-AM code M08.2 in in the period 1999-2014 were identified in longitudinally linked administrative health data across all Western Australian (WA) hospitals. Incidence and point prevalence estimate were per 100,000 population with Poisson regression to analyse the incidence trend. Readmissions with S-JIA as primary diagnosis were considered flares with rates for flare and other complication reported per 100 person years with 95% confidence intervals (CI). Annual S-JIA incidence was 0.61/100,000 (CI 0.28-1.25) (46 incident cases, 71.7% girls, median age 6.5 years) and stable over time as S-JIA point prevalence reached 7.15/100,000 (CI 5.29-7.45) at the end of study. Most incident cases were diagnosed in winter and spring, but documented preceding infections were rare. During a median follow-up of 8 years, disease flares occurred in 24% of patients with higher flares rate in boys (58.3; CI 44.5-74.9) than girls (14.7; CI 9.9-20.9). No deaths occurred and arthroplasty was the main, but uncommon S-JIA complication (4%). However, readmission (86.3; CI 76.4-97.2) and ED visit (73.3; CI 64.2-83.4) rates for illnesses other than S-JIA were substantial. S-JIA is as rare in WA as in other regions and while s-JIA incurred no deaths in the era of biologics, it associated with a significant long-term burden of (co-) morbidity.

Temporal trends in hospitalisation for opportunistic infections in lupus patients in Western Australia.

BACKGROUND: Lupus patients often require aggressive immunosuppressive therapy, which increases the risk for infections. We studied the temporal rates for opportunistic infections (OI) and associated mortality in lupus patients hospitalised in Western Australia. METHODS: All patients hospitalized in the period 1985-2015 with ≥2 ICD based diagnostic codes for SLE were included. OI was defined as a microbiologically confirmed mycobacterial, fungal, or viral infection. Descriptive data are given as median (IQR) and frequency (%) with incidence rates (IR) calculated per 1000 person years and IR trend rates analysed across 10-year periods by least square regression (R2). RESULTS: The study cohort (n = 1408) contained 85.3% females with age at entry 35 years (IQR 22-51). During median follow-up of 21.1 years (IQR 17.5-29.6) hospitalisation for OI occurred in 121 (8.6%) patients with recurrent or multiple OI observed in 42 (34.7%) patients. During 29.771 thousand person years, a total of 295 OI were diagnosed for an overall IR rate of 9.91 (CI 8.82-11.09)/1000 person years which did not decrease significantly over time (R2 0.14). Significant decreases were however seen in the IR for tuberculosis (R2 0.88), cryptococcal (R2 0.98) and pneumocystis (R2 0.98) infections, with increasing IR observed for other mycobacteria (R2 0.99) and aspergillosis (R2 0.55) and little change seen for H Zoster (R2 0.18) and Varicella (R2 0.10) infections. In-hospital death during OI admission occurred in 9/121 patients (7.4%). There was no significant gender difference in IR or outcome of OI. CONCLUSIONS: Hospitalization rates for OI in lupus patients have not changed significantly over time, but there has been a clear shift in the underlying OI. The decrease in mycobacterial and pneumocystis infections suggest successful prophylaxis but the increase in viral and mycotic infections indicate a sustained need to improve prevention of these OI in lupus patients.

Septic arthritis due to Neisseria gonorrhoea in Western Australia.

BACKGROUND: A high prevalence of gonococcal infections has been reported from remote parts of Western Australia, but the occurrence of disseminated infection leading to arthritis has not been studied. AIMS: To investigate the frequency, risk factors and long-term outcome of gonococcal arthritis (GA) in Western Australia (WA). METHODS: A population-based data linkage study of patients with a hospital-based diagnosis of GA in WA between 1990 and 2014. Demographics, standardised incidence rates per million and comorbidity accrued before (lookback 186 months, interquartile range (IQR) 86-267) and after the index hospital contact for GA (follow up 100 months, IQR 60-209) are presented as frequency (%), median (IQR) or rates /1000 months. RESULTS: In total, 98 patients were diagnosed with GA. The annual incidence of GA increased from 1.35 to 2.10 per million between 1990 and 2014, but the rate of GA complicating all gonococcal infections was stable around 0.25%. Female patients with GA (54%; n = 53/98) were younger (24 vs 38 years) and more frequently identified as indigenous (88% vs 49%) than male patients (46%; n = 45/98; P = 0.002). Female patients had higher rates of prior infections (15.5 vs 8.1 per 1000 months; P = 0.002) and diabetes mellitus (15.9% vs 2.5%; P = 0.03) and a longer hospital stay (10 vs 8 days; P = 0.02). GA recurrence rate during follow up was low (2%), but a broad range of comorbidities developed contributing to a 14% crude death rate. CONCLUSIONS: GA stably complicates 0.25% of gonococcal infections in WA with young indigenous females and middle-aged non-indigenous males most affected. Prior infectious disease and diabetes mellitus are potential risk factors for GA in females. GA recurs rarely, but its development reflects a high risk of morbidity and mortality over the following 10 years.

The temporal association between hospital admissions, biological therapy usage and direct health care costs in rheumatoid arthritis patients.

The Australian Pharmaceutical Benefits Scheme (PBS) has subsidised biological therapy since 2003. We investigated the association between biological therapy for RA hospitalisation rates and health-care costs.Hospital admissions for RA patients between 1995 and 2014 were identified in the Western Australia (WA) Hospital Morbidity Data Collection (ICD codes 714 and M05.00-M06.99). State-specific dispensing data for conventional and biological therapies for RA was obtained from Statistics Australia and expressed as defined daily doses/1000 population/day (DDD) using WA population census. Principal component analysis (PCA) was applied to determine the relationship between DMARDs use and hospital admission rates.A total of 17,125 patients had 50,353 admissions with a diagnostic code for RA. Between 1995 and 2002, the number of RA admissions fell from 7.9 to 2.6/1000 admissions, while conventional therapy use rose from 1.45 to 1.84 DDD. Between 2003 and 2014, RA admissions decreased further to 1.9/1000 hospital admissions, while conventional therapy use increased to 2.19 DDD and biological therapy from 0.01 to 1.0 DDD. In PCA, conventional and biological therapies use had an inverse relationship with hospital admission rates. Annual costs of biological therapy utilisation was 22.5 million in 2003-2014, while the annual cost saving of RA hospital admissions was 9.2 million.The increased use of conventional therapy use for RA has coincided with a significant decline in hospital admissions for RA patients in WA, while a more modest further decline followed biological therapy introduction. Biological therapy was not as cost-effective as conventional in relation to RA hospital admissions costs.

Morbidity and mortality in adult-onset IgA vasculitis: a long-term population-based cohort study.

OBJECTIVES: With sparse data available, we investigated mortality and risk factors in adults with IgA vasculitis (IgAV). METHODS: This was an observational population-based cohort study using state-wide linked longitudinal health data for hospitalized adults with IgAV (n = 267) and matched comparators (n = 1080) between 1980 and 2015. Charlson comorbidity index (CCI) and serious infections (SIs) were recorded over an extensive lookback period prior to diagnosis. Date and causes of death were extracted from the Western Australia Death Registry. Mortality rate (deaths/1000 person-years) ratios (MRRs) and hazard ratio (HR) for survival were assessed. RESULTS: During 9.9 (9.8) years lookback patients with IgAV accrued higher CCI scores (2.60 vs 1.50, P < 0.001) and had higher risk of SI (OR = 8.4, P < 0.001), not fully explained by CCI scores. During 19 years' follow-up, the rate of death in patients with IgAV (n = 137) was higher than in comparators (n = 397) (MRR = 2.06, 95% CI: 1.70-2.50; P < 0.01) and the general population (standardized mortality rate ratio = 5.64, 95% CI: 4.25, 7.53; P < 0.001). Survival in IgAV was reduced at 5 (72.7 vs 89.7%) and 20 years (45.2% vs 65.6%) (both P < 0.05). CCI (HR = 1.88, 95% CI: 1.25, 2.73; P = 0.001), renal failure (HR = 1.48, 95% CI: 1.04, 2.22; P = 0.03) and prior SI (HR = 1.48, 95% CI: 1.01, 2.16; P = 0.04) were independent risk factors. Death from infections (5.8 vs 1.8%, P = 0.02) was significantly more frequent in patients with IgAV. CONCLUSION: Premorbid comorbidity accrual appears increased in hospitalized patients with IgAV and predicts premature death. As comorbidity does not fully explain the increased risk of premorbid infections or the increased mortality due to infections in IgAV, prospective studies are needed.

Potential for novel imaging techniques to monitor early disease progression in connective tissue disease vasculopathy.

Vasculopathy associated with connective tissue diseases (CTD) has diverse clinical presentations and complex underlying pathology. Existing imaging techniques remain inadequate for assessing vasculopathy in CTD, particularly in earlier stages of pathogenesis. Novel imaging techniques, such as optical coherence tomography, near-infrared spectroscopy and superb microvascular imaging, demonstrate potential in monitoring disease progression at earlier stages prior to systemic complications.

Incorporating the Clinical Frailty Scale into routine outpatient nephrology practice: an observational study of feasibility and associations.

BACKGROUND: There is an unmet need for routine and accurate prognostication of older adults with end-stage kidney disease (ESKD) and subsequently inadequate advance care planning. Frailty, a clinical syndrome of increased vulnerability, is predictive of adverse health outcomes in the renal population. We propose the Clinical Frailty Scale (CFS) as a feasible tool for routine use in the nephrology outpatient setting to address this unmet need. AIMS: To assess feasibility and associations of incorporating CFS assessment into routine outpatient nephrology practice in the pre-dialysis setting. METHODS: CFS was integrated into the outpatient nephrology clinic proforma. A convenience sample of 138 patients aged >50 years, with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 , attending the outpatient service between September 2018 and April 2019 was included. RESULTS: Eighty-one CFS assessments were completed by nephrologists, nephrology advanced trainees and clinical nurse specialists. CFS completion rates were 79% from the multidisciplinary Low Clearance Clinic and 41% from nurse-led Pre-dialysis Education Clinic. Planned modality of ESKD management varied with degree of frailty (P < 0.001). 21% of patients who had CFS completed were planned for Conservative Management of ESKD, in contrast to only 5% of those who did not have CFS assessment completed (P < 0.001). CONCLUSION: Frailty assessment via CFS was feasible in outpatient practice when integrated into routine clinical assessment in a dedicated clinic. Planned ESKD management varied with the degree of frailty. Completion of frailty assessment, when compared with non-completion, appears to be associated with increased planned conservative management of ESKD.

The global prevalence of rheumatoid arthritis: a meta-analysis based on a systematic review.

The objective is to determine the global population prevalence of rheumatoid arthritis (RA) based on population-based studies and assess factors that influence RA prevalence estimates. Four electronic databases were searched (ProQuest Central, MEDLINE, Web of Science, and EMBASE) for peer-reviewed English publications that report prevalence estimates of RA from 1980 and 2019. We included case-control studies, cross-sectional studies, and prospective or retrospective cohort studies in our search strategy. A random-effect meta-analysis model was used to produce the pooled prevalence estimates. The potential between-study heterogeneity was identified using sensitivity analysis, sub-group and meta-regression analyses. A total of 67 studies were included in the meta-analysis, containing 742,246 RA patients and 211,592,925 healthy controls in the study period. The global RA prevalence estimate was 0.46% (95% confidence interval [CI] 0.39-0.54; I2 = 99.9%) with a 95% prediction interval (0.06-1.27). The RA point-prevalence was 0.45% (95% CI 0.38-0.53%) between 1986 and 2014, while the pooled period-prevalence was 0.46% (95% CI 0.36% and 0.57%) from 1955 to 2015. The highest RA pooled prevalence (0.69%; 95% CI 0.47-0.95) was derived from linked data source studies. Based on meta-regression, the factors that explain the studies' heterogeneity of RA prevalence, including geographical location, the risk bias assessment of studies and sample size. The global prevalence of RA between 1980 and 2019 was 460 per 100,000 population, with variations due to geographical location and study methodology. Linked data are the preferred method to estimate RA population prevalence as they provide the best case ascertainment.

The accuracy of administrative health data for identifying patients with rheumatoid arthritis: a retrospective validation study using medical records in Western Australia.

The use of administrative health datasets is increasingly important for research on disease trends and outcome. The Western Australian (WA) Rheumatic Disease Epidemiological Registry contains longitudinal health data for over 10,000 patients with rheumatoid arthritis (RA). Accurate coding for RA is essential to the validity of this dataset. Investigate the diagnostic accuracy of International Classification of Diseases (ICD)-based discharge codes for RA at WA's largest tertiary hospital. Medical records for a sample of randomly selected patients with ICD-10 codes (M05.00-M06.99) in the hospital discharge database between 2008 and 2020 were retrospectively reviewed. Rheumatologist-reported diagnoses and ACR/EULAR classification criteria were used as reference standards to determine accuracy measures. Medical chart review was completed for 87 patients (mean (± SD) age 64.7 ± 17.2 years), 67.8% female). A total of 80 (91.9%) patients had specialist confirmed RA diagnosis, while seven patients (8%) had alternate clinical diagnoses. Among 87 patients, 69 patients (79.3%) were fulfilled ACR/EULAR classification criteria. The agreement between the reference standards was moderate (Kappa 0.41). Based on rheumatologist-reported diagnoses and ACR/EULAR classification criteria, primary diagnostic codes for RA alone had a sensitivity of (90% vs 89.8%), and PPV (90.9% vs 63.6%), respectively. A combination of a diagnostic RA code with biologic infusion codes in two or more codes increased the PPV to 97.9%. Hospital discharge diagnostic codes in WA identify RA patients with a high degree of accuracy. Combining a primary diagnostic code for RA with biological infusion codes can further increase the PPV.

Post-stroke sleep disturbances and rehabilitation outcomes: a prospective cohort study.

BACKGROUND: Poor sleep is common after stroke, and data regarding its effect on rehabilitation outcomes are limited. Controversial evidence was found concerning the effect of sedatives on improving sleep quality in poor sleepers after stroke. AIM: To assess the prevalence of poor sleep in post-stroke patients and its effect on rehabilitation outcomes. METHOD: A total of 104 stroke patients from two major stroke rehabilitation units in Western Australia was enrolled. Sleep quality was assessed using the Pittsburgh Sleep Quality Indexes at baseline and after stroke. The main outcome measures were Functional Independence Measure (FIM) change and length of stay (LOS). Sedative use during this period was also recorded. RESULTS: A total of 29.8% post-stroke patients suffered from poor sleep. There was no relationship between poor sleep and the stroke characteristics, such as severity, side and type, or demographics, such as age and gender. Poor sleep quality was inversely associated with rehabilitation outcomes measured by FIM (Rs. -0.317, P = 0.005). However, there was no significant association between sleep quality and LOS (P = 0.763). Sedatives were used in 18.2% of patients but had no impact on sleep quality or rehabilitation outcomes. CONCLUSION: This research supported that poor sleep was frequent after stroke and had negative effects on rehabilitation outcomes. Use of sedatives was of limited benefit to improve sleep quality, and further studies are required to search for strategies to improve sleep problems after stroke.

Pregnancy outcomes in women with a history of immunoglobulin A vasculitis.

OBJECTIVES: Case series suggest an increased risk of pregnancy complications in women with a history of IgA vasculitis (IgAV); however, no large quantitative studies have examined this possible association to date. We compared pregnancy rates and outcomes between female IgAV patients and controls and assessed flare risk of IgAV during pregnancy. METHODS: Using state-wide hospital morbidity data we compared rates for live birth, preterm birth, abortive outcome and gestational complications between female IgAV patients (International Classification of Diseases-9-Clinical Modification 287.0; International Classification of Diseases-10-Australian Modification D69.0) (n = 121) and non-exposed age-matched controls (n = 284) in Western Australia. Results presented are means compared by Kruskal-Wallis test and proportions with odds ratios (ORs) (95% CI) compared by χ2 testing. RESULTS: There were 247 pregnancies in IgAV patients during which no disease flares were recorded and 556 pregnancies in controls. IgAV patients were younger at first pregnancy (24.7 vs 27.0 years, P < 0.01) and had 43 unsuccessful pregnancies (17.4%) and 204 live births with 17 preterm deliveries (8.3%). Women with IgAV had increased odds of spontaneous abortion (OR 1.9, 95% CI 1.1, 3.1, P = 0.04), preterm delivery (OR 2.0, 95% CI 1.1, 3.9, P = 0.02) and gestational hypertension (OR 4.7, 95% CI 2.3, 9.8). While gravidity did not differ (mean pregnancy number 2.4 vs 2.3, P = 0.36), IgAV patients had over a two-fold greater number of obstetric visits than controls (5.1 vs 2.5, P < 0.01). CONCLUSIONS: Hospitalization for IgAV has little impact on fertility and IgAV rarely flares during pregnancy. However, a history of IgAV associates with increased odds of spontaneous abortions, gestational hypertension and preterm delivery.

Hospitalisation rates and characteristics for adult and childhood immunoglobulin A vasculitis in Western Australia.

BACKGROUND: Immunoglobulin A vasculitis (IgAV) is a systemic small-vessel vasculitis of unknown aetiology. Although commonest in children, onset in adulthood is not unusual. AIM: As Australian data are lacking, we investigated longitudinal hospitalisation rates and characteristics for both adult and paediatric IgAV patients in Western Australia (WA). METHODS: Data were extracted from a state-wide register for all first hospital contacts in WA between 1980 and 2015 for patients with a primary diagnosis of IgAV. Paediatric cases were defined as those <20 years and compared with adult cases for admission rates per 100 000, demographics, complications, length of stay (LOS) and readmission rates. RESULTS: The study cohort included 476 children (median age 5 years; interquartile range (IQR) 3-7) and 144 adults (median age 50 years; IQR 36-77). Childhood admission rates declined from 3.85 to 0.31 over time (P < 0.001) but age at admission and LOS remained unchanged. For adults, admission rates declined from 0.40 to 0.17 (P = 0.02) while age at admission (43 vs 63 years, P = 0.01) and LOS (5 vs 9 days, P = 0.02) increased. More adults had renal (11.8 vs 1.3%, P < 0.01), intestinal (3.5 vs 0.8%, P = 0.04) and infectious (14.6% vs 5.3%, P < 0.01) complications. Readmission was more frequent in childhood cases (23.1% vs 7.6%, P < 0.05) occurring mostly within 30 days of discharge. CONCLUSION: Hospitalisation rates for adults with IgAV now nearly equal those in children as adult IgAV leads to more complications. The sharp decline in childhood IgAV admissions suggests that confidence to manage children with IgAV outside the hospital setting has increased.

Controversy and consensus regarding vitamin D: Recent methodological changes and the risks and benefits of vitamin D supplementation.

A dramatic and sustained surge in vitamin D test numbers has been attributed to the extraskeletal and probable intra/paracrine effects of vitamin D and not the important role of vitamin D in the regulation of extracellular calcium homeostasis and bone metabolism. This review summarizes recent data regarding the skeletal and extraskeletal effects of vitamin D, provides an overview of current methods of 25-hydroxyvitamin D measurement and includes the beneficial and adverse effects of vitamin D replacement. The role of 1,25-dihydroxyvitamin D, 24,25-dihydroxyvitamin D, vitamin D binding protein and free hormone levels are explored and potential future developments in this area are discussed. The adoption of a reference method for the measurement of 25-hydroxyvitamin D, certified reference standards and an independent certification program administered by the Centre of Disease Control is expected to improve routine analytical performance and is a major, crucial step forward. Improvements in accuracy, precision and sensitivity of 25-hydroxyvitamin D measurement is an important prelude to accurately defining the desirable level of 25-hydroxyvitamin D that is associated with the lowest risk for falls and fractures. Finally, the results of ongoing large, prospective, randomized clinical trials such as the Australian D-Health study should clarify the role of vitamin D supplementation in the prevention and management of skeletal and nonskeletal disorders, including vitamin D effects on mortality risk.