Agustín Escalante

Neuropsychiatric syndromes in lupus Prevalence using standardized definitions

Objective:The San Antonio Lupus Study of Neuropsychiatric Disease is a longitudinal study designed to characterize the spectrum of and important risk factors for specific neuropsychiatric systemic lupus erythematosus (NPSLE) syndromes. Methods: Subjects must meet criteria for SLE and must be at least 18 years of age. A standardized medical history, neurologic, rheumatologic, and psychiatric examinations, computerized neuropsychological evaluation, and serologic testing are performed. Results: This report is based on the first 128 subjects (120 women and 8 men) who completed the initial study visit. Data from this initial study visit were evaluated for the prevalence of NPSLE using the American College of Rheumatology case definitions for 19 NPSLE syndromes. One or more NPSLE syndromes were present in 80% of subjects: cerebrovascular disease (2, 2%; ischemic stroke); headaches (73, 57%); mononeuropathy (9, 8%; median 8, ulnar 1); movement disorder (1, 1%; chorea); neuropathy, cranial (2, 2%; trigeminal); polyneuropathy (29, 22%; sensorimotor); seizures (21, 16%; partial); anxiety disorder (27, 24%); major depressive-like episode (37, 28%); mood disorder with depressive features (21, 19%); mood disorder with manic features (3, 3%); mood disorder with mixed features (1, 1%); psychosis (6, 5%). In a subset of 67 patients who received standardized neuropsychological testing, 21% had normal results. In the remainder, the following levels of impairment were seen: 43% mild, 30% moderate, and 6% severe. Conclusions: The prevalence of NPSLE was high in this cohort of unselected patients with SLE. Headaches, cognitive dysfunction, and psychiatric disorders were the most common NPSLE syndromes seen. These results will be easily comparable to other studies also using standardized diagnostic criteria. However, the lack of ethnicity and language-matched normative neuropsychological data may make comparisons of cognitive dysfunction in SLE populations difficult.

How much disability in rheumatoid arthritis is explained by rheumatoid arthritis

OBJECTIVE To measure the proportion of disability explained by disease manifestations compared with nondisease factors in rheumatoid arthritis (RA). METHODS A hypothetical model of the disablement process specific for RA was constructed using the demographic, sociocultural, and clinical characteristics of a consecutive cohort of RA patients. Disability was measured with the modified Health Assessment Questionnaire (M-HAQ) and the physical function scale of the Medical Outcomes Study Short Form 36 (SF-36) questionnaire. Independent variables, grouped according to their position in the RA disablement process model, were sequentially entered in a series of hierarchical regression models. The proportion of variance in disability explained by each group of variables was measured by the groups incremental R2. RESULTS The overall proportion of disability explained by the full model was 59%. Factors in the main disease-disability pathway explained 33%, of which 3% was explained by disease duration, 5% by the Westergren erythrocyte sedimentation rate, 14% by articular signs and symptoms, and 11% by performance-based functional limitations. External modifiers and contextual variables explained 26% of the variance in disability, of which age and sex accounted for 2%, formal education 4%, psychological status 17%, and symptoms of depression 3%. CONCLUSION Both the main disease-disability pathway and factors external to this pathway contribute significantly to disability in RA. These findings provide evidence of the relative influence of psychosocial factors, compared with disease manifestations, on the disability of patients with RA.

CAROTID ATHEROSCLEROSIS PREDICTS INCIDENT ACUTE CORONARY SYNDROMES IN RHEUMATOID ARTHRITIS

OBJECTIVE The role of atherosclerosis in the acute coronary syndromes (ACS) that occur in patients with rheumatoid arthritis (RA) has not been quantified in detail. We undertook this study to determine the extent to which ACS are associated with carotid atherosclerosis in RA. METHODS We prospectively ascertained ACS, defined as myocardial infarction, unstable angina, cardiac arrest, or death due to ischemic heart disease, in an RA cohort. We measured carotid atherosclerosis using high-resolution ultrasound. We used Cox proportional hazards models to estimate the association between ACS and atherosclerosis, adjusting for demographic features, cardiovascular (CV) risk factors, and RA manifestations. RESULTS We performed carotid ultrasound on 636 patients whom we followed up for 3,402 person-years. During this time, 84 patients experienced 121 new or recurrent ACS events, a rate of 3.5 ACS events per 100 patient-years (95% confidence interval [95% CI] 3.0-4.3). Among the 599 patients without a history of ACS, 66 incident ACS events occurred over 3,085 person-years, an incidence of 2.1 ACS events per 100 person-years (95% CI 1.7-2.7). The incidence of new ACS events per 100 patient-years was 1.1 (95% CI 0.6-1.7) among patients without plaque, 2.5 (95% CI 1.7-3.8) among patients with unilateral plaque, and 4.3 (95% CI 2.9-6.3) among patients with bilateral plaque. Covariates associated with incident ACS events independent of atherosclerosis included male sex, diabetes mellitus, and a cumulative glucocorticoid dose of ≥ 20 gm. CONCLUSION Atherosclerosis is strongly associated with ACS in RA. RA patients with carotid plaque, multiple CV risk factors (particularly diabetes mellitus or hypertension), many swollen joints, and a high cumulative dose of glucocorticoids, as well as RA patients who are men, are at high risk of ACS.

Glucocorticoid Dose Thresholds Associated With All-Cause and Cardiovascular Mortality in Rheumatoid Arthritis

To delineate daily and cumulative glucocorticoid dose thresholds associated with increased mortality rates in rheumatoid arthritis (RA).

Accuracy of Anticardiolipin Antibodies in Identifying a History of Thrombosis Among Patients With Systemic Lupus Erythematosus

OBJECTIVE To measure the accuracy of anticardiolipin antibodies (aCL) in identifying a history of thrombosis among patients with systemic lupus erythematosus (SLE) or the primary antiphospholipid syndrome (PAPS). PATIENTS AND METHODS Patients with SLE or PAPS who attended our rheumatology clinic between April 1992 and March 1994 were included in a retrospective analysis of the relationship between thrombotic events and aCL. All aCL measurements were performed in the same laboratory by enzyme-linked immunosorbent assay, blinded as to the presence or absence of thrombosis. The diagnostic accuracy of IgG, IgM, and IgA aCL was quantified by means of the receiver operating characteristic area under the curve (ROC AUC) for each isotype. Stratum-specific likelihood ratios and their 95% confidence intervals were calculated to define strata with optimal discriminant power. RESULTS During the period of study, aCL was measured in 117 patients (113 SLE and 4 PAPS), of whom 24 (20.5%) had experienced thrombotic events. The ROC AUC +/- the standard error for IgG aCL was 0.81 +/- 0.05, signifying an 81% accuracy in the identification of a history of thrombosis. In contrast, the accuracy of the IgM and IgA aCL was significantly lower (0.60 +/- 0.08 and 0.54 +/- 0.07, respectively, P < 0.05). Using stratum-specific likelihood ratios, we defined three strata in the IgG aCL scale that discriminate between patients with low, indeterminate, and high probabilities of thrombosis. For IgG aCL levels below 21.4 IgG phospholipid (GPL) U/mL, the posttest probability of thrombosis was 0.07, whereas for IgG aCL levels > or = 65.1 GPL U/mL, the posttest probability of thrombosis was 0.75. For IgG aCL values between 21.4 and 65.0 GPL U/mL, the probability of thrombosis was 0.20, equivalent to the entire cohort. CONCLUSIONS The IgG aCL determinations perform well in the identification of thrombosis in SLE or PAPS, while the IgM and IgA aCL have poor diagnostic accuracy. These findings may have implications for management of these patients.

Recipients of hip replacement for arthritis are less likely to be Hispanic, independent of access to health care and socioeconomic status.

OBJECTIVE To compare the proportion of Hispanics among recipients of hip replacements for primary articular disorders, recipients of knee replacements for the same reason, and persons hospitalized for other reasons. METHODS Twelve of the 17 accredited hospitals in Bexar County, Texas, in which hip or knee replacement surgery is performed permitted us to review their medical records. From 1993 through 1995, 3,100 elective, non-fracture-related, hip or knee replacements were performed. These individuals were matched by age, sex, hospital, and month of admission with 4,604 persons hospitalized for other reasons. Age, sex, ethnic background, type of medical insurance, median household income by zip code of residence, joint replaced, and surgical diagnosis were abstracted from the medical records. The validity of variables abstracted from the medical records was tested by comparison with self-report data in 115 patients interviewed prior to elective hip or knee replacement surgery. RESULTS During the study period, 2,275 subjects had a total knee replacement and 825 had a total hip replacement. Recipients of hip replacements were significantly less likely to be Hispanic than were recipients of knee replacements (19.5% versus 29.9%; odds ratio [OR] 0.57, 95% confidence interval [95% CI] 0.46-0.71; P < or = 0.001) or persons hospitalized for other reasons (29.4% Hispanic; OR 0.67, 95% CI 0.55-0.81). The under-representation of Hispanics was more pronounced among persons undergoing hip replacement for osteoarthritis compared with recipients of knee replacements for the same disease (OR 0.48, 95% CI 0.37-0.62). This pattern persisted after adjusting for age, sex, type of medical insurance, and median household income by the zip code of residence. Concordance between medical records and self-report data on ethnic background was high (kappa = 0.93). CONCLUSION Recipients of hip replacement are less likely to be Hispanic than are other hospitalized persons with a similar level of access to care. The reasons for this under-representation probably involve factors in addition to lack of access to health care and low socioeconomic status. Further research is needed to understand the nature of such factors.

Disparity in Total Hip Replacement Affecting Hispanic Medicare Beneficiaries

Objective. To compare the utilization of total hip replacement (THR) between Hispanic persons and non-Hispanic persons in a sample with health insurance. Research Design. Case-control study using Medicare claims data. Patients. The cases were Medicare beneficiaries from Arizona, Illinois, New Mexico, or Texas who underwent a primary THR. The controls were Medicare beneficiaries who did not receive a THR, matched by age, sex, and county of residence. Measures. Beneficiary surnames and the race indicator in Medicare records were used to classify beneficiaries’ probability of being Hispanic. Conditional logistic regression was used to estimate the odds of receiving of THR, adjusting for Medicaid eligibility. Results. Six thousand four hundred thirty-seven recipients of a primary THR were matched to 12,874 controls. According to the Medicare race indicator, 1% of recipients of THR and 3.3% of controls were Hispanic (P ≤0.001). The odds of THR decreased as the probability of Hispanic ethnicity increased, from an odds ratio (OR) of 1.00 among beneficiaries with non-Hispanic surnames, to an OR of 0.36 among those with heavily Hispanic surnames (95% CI, 0.31, 0.43). Poverty, as reflected by eligibility for Medicaid, did not modify the low odds of THR among Hispanic persons (OR, 0.25 among Medicaid-eligible Hispanic persons; 95% CI, 0.19, 0.33; and OR, 0.30 among Hispanic persons not Medicaid eligible; 95% CI, 0.24, 0.38). Conclusion. Hispanic persons with Medicare receive THR at lower rates than do non-Hispanic persons. Because Medicare covers THR, our findings suggest that under utilization of THR by Hispanic persons cannot be attributed to lack of health insurance alone.

Symptoms of depression and psychological distress among Hispanics with rheumatoid arthritis.

OBJECTIVE To explore the roles played by Hispanic ethnic background and acculturation to the mainstream English language culture of the United States in the depressive symptoms and mental health of rheumatoid arthritis (RA) patients. METHODS Members of a consecutive cohort of patients with RA were studied cross-sectionally. All underwent a comprehensive clinical and psychosocial evaluation. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale (CES-D), and psychological distress was measured with the Medical Outcomes Study Short Form 36 (SF-36) mental health scale. RESULTS Two hundred thirty-six patients were studied. Women had significantly higher median CES-D scores than men (19 versus 14, P = 0.0004), Hispanics scored higher than non-Hispanics (14 versus 8, P = 0.0002), and foreign-born scored higher than US-born patients (14 versus 10, P = 0.009). Compared with those who were fully acculturated, patients who were partially acculturated were more likely to have a score > or = 16 on the RA-adjusted CES-D (odds ratio [OR] = 1.79, 95% confidence interval [95% CI] 1.37 to 2.35, P < or = 0.001). Among unacculturated patients, the likelihood of a score > or = 16 increased 6-fold (OR = 6.68; 95% CI 3.50 to 12.72; P < or = 0.001). A similar, inverse pattern was observed for the SF-36 mental health scale. In multivariate models accounting for age, sex, education, income, articular pain, deformity, and the level of disability, low acculturation was independently associated with high depressive symptoms, and a Hispanic background was independently associated with lower SF-36 mental health. CONCLUSIONS In this consecutive series of RA patients, Hispanics, particularly those who are not fully acculturated to the mainstream Anglo society, had more depressive symptoms and psychological distress than did non-Hispanics.

Systemic inflammation and cardiovascular risk factors predict rapid progression of atherosclerosis in rheumatoid arthritis

Objective To estimate atherosclerosis progression and identify influencing factors in rheumatoid arthritis (RA). Methods We used carotid ultrasound to measure intima-media thickness (IMT) in RA patients, and ascertained cardiovascular (CV) risk factors, inflammation markers and medications. A second ultrasound was performed approximately 3 years later. We calculated the progression rate by subtracting the baseline from the follow-up IMT, divided by the time between the two scans. We used logistic regression to identify baseline factors predictive of rapid progression. We tested for interactions of erythrocyte sedimentation rate (ESR) with CV risk factors and medication use. Results Results were available for 487 RA patients. The mean (SD) common carotid IMT at baseline was 0.571 mm (0.151). After a mean of 2.8 years, the IMT increased by 0.050 mm (0.055), p≤0.001, a progression rate of 0.018 mm/year (95% CI 0.016 to 0.020). Baseline factors associated with rapid progression included the number of CV risk factors (OR 1.27 per risk factor, 95% CI 1.01 to 1.61), and the ESR (OR 1.12 per 10 mm/h, 95% CI 1.02 to 1.23). The ESR×CV risk factor and ESR×medication product terms were significant, suggesting these variables modify the association between the ESR and IMT progression. Conclusions Systemic inflammation and CV risk factors were associated with rapid IMT progression. CV risk factors may modify the role of systemic inflammation in determining IMT progression over time. Methotrexate and antitumour necrosis factor agents may influence IMT progression by reducing the effect of the systemic inflammation on the IMT.

Determinants of hip and knee flexion range: Results from the San Antonio longitudinal study of aging

OBJECTIVE We analyzed data from the San Antonio Longitudinal Study of Aging, a neighborhood-based study of community-dwelling elderly people, to identify factors that determine the flexion range (FR) of hips and knees. METHODS The FR of hips and knees was measured in a cohort of 687 subjects aged 65 to 79 years. We used multivariate models to examine the associations among the FR of hips and knees, and between these and age, gender, ethnicity, body mass index (BMI), pain and its location, self-reported arthritis, and diabetes mellitus. The functional relevance of hip and knee FR was tested by measuring its association with 50-foot walking velocity. RESULTS More than 90 degrees of flexion in both hips and both knees was observed in 619 subjects (90.1%). Correlations among the FR of hips and knees ranged from 0.54 to 0.80 (P < 0.001 for Spearman r values). Multivariate analysis revealed a pattern of significant associations between each of the joints and its contralateral mate and ipsilateral partner joints that was consistent for both hips and both knees. Using each individual joint as the unit of analysis, the following variables were independently associated with hip or knee FR in multivariate models: rising BMI and female sex with reduced FR of both hips and knees, a Mexican American ethnic background with decreased hip FR, and knee pain with decreased knee FR. The functional importance of the FR of these two important joints was supported by its significant association with walking velocity in a model that adjusted for age, gender, ethnic background, BMI, and hip or knee pain. CONCLUSIONS Most community-dwelling elderly people have a FR of hips and knees that can be considered functional. The ipsilateral and contralateral hip or knee are significant independent determinants of the FR of each of these joints. Obesity, a health problem potentially amenable to preventive and therapeutic interventions, is a factor significantly associated with decreased FR of hips and knees.