Changing trends in serious extra-articular manifestations of rheumatoid arthritis among United State veterans over 20 years.

OBJECTIVES: The purpose of this study was to examine prevalence trends of serious extra-articular manifestations (EAMs) in a data set representing both hospitalized and ambulatory patients with RA. METHODS: This retrospective cohort study used serial cross-sectional data to examine the prevalence of serious EAMs in patients with RA from 1985 to 2006 across the United States (US) Veteran's Health Administration system. Serious EAMs included rheumatoid carditis, RA lung disease, FS and pooled EAM rates included previously reported vasculitis prevalence as queried by ICD-9 searches. Statistical analysis employed auto-regression and time series analysis using the Chow and Durbin-Watson tests to detect breakpoints and linear time-trends. RESULTS: Among 3 million veterans, including >35,000 RA patients annually, we noted declining RA hospitalizations emphasizing the importance of examining both the inpatient and outpatient settings to assess EAM prevalence. Individual EAM trends varied, demonstrating linear declines in FS, increases in RA lung disease and significant breakpoint declines in carditis and pooled serious EAMs. Pooled EAM prevalence dropped around 2000, from an early linear trend peak of 10% among inpatients, to <7% among both inpatients and outpatients by 2006. CONCLUSIONS: Overall, serious EAMs of RA have declined among US veterans in both the inpatient and outpatient settings, with the exception of RA lung disease likely reflecting improved detection. Breakpoints in pooled EAM prevalence appear to demonstrate consistent, true declines in severe RA extra-articular disease around 2000. Future work should explore the relationship between temporal EAM trends and specific RA therapies including adoption of biological agents.

Antisynthetase syndrome presenting as rheumatoid-like polyarthritis.

BACKGROUND: The antisynthetase syndrome is a systemic inflammatory disease associated with anti-tRNA synthetase antibodies and consisting of the clinical features of inflammatory myopathy arthritis, interstitial lung disease (ILD), fever, Raynaud syndrome, and rash. It rarely presents with symmetric arthritis as the initial manifestation of the disease. OBJECTIVE: The aim of the study was to describe the clinical, laboratory, and radiographic characteristics of patients with antisynthetase syndrome who presented with symptoms of inflammatory arthritis, mimicking rheumatoid arthritis (RA) at the time of initial evaluation. METHODS: Six cases derived from a single university-based rheumatology clinic in Wisconsin are presented. The major clinical, laboratory, radiographic, and histopathologic data are described. RESULTS: All 6 patients demonstrated symmetric synovitis involving the hands. Five patients met the American College of Rheumatology classification criteria for RA. Three patients had nail-fold capillary abnormalities, and 4 patients were observed to have Raynaud phenomenon. Three patients demonstrated a cytoplasmic pattern when testing for antinuclear antibodies by immunofluorescent assay, and all had t-RNA synthetase antibodies. Two patients had positive rheumatoid factors, but none had strongly positive cyclic citrullinated peptide antibodies. None of the patients demonstrated radiographic erosions. All patients had evidence of ILD by imaging or pulmonary function testing. Prognosis was generally favorable, although disease severity and treatment varied considerably. CONCLUSION: In patients who present with features mimicking but atypical for RA, such as early ILD, nail-fold capillary abnormalities, Raynaud phenomenon, cytoplasmic antinuclear antibody pattern, negative cyclic citrullinated peptide antibody status, and nonerosive arthritis, the antisynthetase syndrome should be considered.

An effective curriculum for teaching third-year medical students about medical errors and disclosure.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires disclosure of medical errors related to sentinel events. At the University of Wisconsin School of Medicine and Public Health, we have developed an effective curriculum for teaching third-year medical students this content. The instructional program lasts a half day and consists of large group lectures combined with small group exercises. Lecture information is provided by patient relations, hospital administrators, and hospital defense attorneys. In small groups, students are given 2 clinical case scenarios to role play on disclosure facilitated by a physician and a legal representative. Student evaluations rate this course highly.

Mortality and cardiovascular burden of systemic lupus erythematosus in a US population-based cohort.

OBJECTIVE: To examine the mortality and cardiovascular disease (CVD) burden among a population-based cohort of patients with systemic lupus erythematosus (SLE) with previously described late mean onset and low rates of organ-threatening disease. METHODS: This retrospective population-based cohort study investigated incident cases of SLE diagnosed from 1991-2008 and followed through March 2009 to examine rates of death and CVD events: myocardial infarction, stroke, or congestive heart failure hospitalization. Cases were identified using the 1997 update of the 1982 American College of Rheumatology SLE criteria. Searches included electronic records, chart audits, and state death matches, with physician review. Age-matched and sex-matched population comparisons facilitated relative event rate calculations. RESULTS: Seventy incident SLE cases had late mean onset (52 years), with an incidence of 5 cases per 100,000/year. Matched comparisons showed similar baseline rates of hypertension, hyperlipidemia, and diabetes. However, patients with SLE experienced more CVD in the 2 years preceding SLE diagnosis (OR 3.8, 95% CI 1.8, 8.0). The estimated 10-year mortality rates were 26% for SLE subjects versus 19% for comparisons, hazard ratio (HR) 2.1, p<0.01. Adjusted for prior CVD, SLE cases still demonstrated increased hazards of mortality (HR 1.9, p=0.01) and CVD event or death (HR 1.8, p=0.01). CONCLUSION: This incident SLE cohort demonstrated nearly doubled mortality and CVD event hazards compared to age-matched and sex-matched comparisons, even after accounting for higher CVD events in the 2 years preceding SLE diagnosis. This raises research questions regarding delayed SLE diagnosis versus accelerated CVD prior to SLE, particularly in older-onset SLE.

Rheumatoid arthritis.

Preview The physical effects of rheumatoid arthritis go beyond joint pain and destruction. The disease may take a toll on numerous organ systems and has been shown to increase morbidity and mortality. How does it affect the lungs? The heart? The nervous system? In this article, Dr Bell answers these and other questions about the extra-articular manifestations of rheumatoid arthritis.