Carolyn L. Bell

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.

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) Veterans 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.

Hydroxychloroquine in the treatment of rheumatoid arthritis

One hundred eight patients with rheumatoid arthritis received hydroxychloroquine for six to 24 months and were studied retrospectively to examine long-term efficacy and predictors of a favorable response to the drug. Response was classified in terms of reduction of active joint count and morning stiffness. Thirteen patients (12 percent) showed a complete remission. Fifteen patients (14 percent) had a 75 percent or greater response. Forty patients (37 percent) had a 30 to 75 percent response. Thirty-two (30 percent) had no response. Toxicity occurred in eight patients (7 percent) before clinical efficacy could be assessed. Seven of the 68 with response had a flare of disease after initial improvement. Of multiple clinical and laboratory parameters tested, only a stronger baseline grip strength was found to be statistically significant (p less than 0.001) in predicting a favorable response. Thus, hydroxychloroquine is an effective drug in the management of rheumatoid arthritis.

Decline in rheumatoid vasculitis prevalence among US veterans: a retrospective cross-sectional study.

OBJECTIVE To examine trends in the prevalence of rheumatoid vasculitis in a national US population comprising both hospitalized and ambulatory patients with rheumatoid arthritis (RA). METHODS In this serial cross-sectional study, we analyzed data on hospitalized and ambulatory patients spanning 22 years (1985-2006) and 10 years (1997-2006), respectively, to determine the prevalence of rheumatoid vasculitis, as defined by the International Classification of Diseases, Ninth Revision. Our search encompassed data collected on a predominantly male study population during 10 million hospitalizations and outpatient visits, and included annual data on >37,000 RA patients. To test for a decrease in rheumatoid vasculitis prevalence, breakpoint analysis was performed using stepwise Chow and Durbin-Watson tests. RESULTS There was a clear decline in the prevalence of rheumatoid vasculitis, and this decline remained evident even after accounting for a decreased number of hospitalizations among RA patients. Peak prevalence occurred among hospitalized patients in the 1980s, and prevalence gradually declined throughout the 1990s. Furthermore, simultaneous breakpoints representing a significant drop in rheumatoid vasculitis prevalence between the years 2000 and 2001 were demonstrated for both inpatients (P < 0.000) and outpatients (P < 0.003). The prevalence of vasculitis dropped 53% among inpatients and 31% among outpatients between 2000 and 2001. CONCLUSION Our results demonstrate a significant decline in rheumatoid vasculitis prevalence after 2000 in this nationwide sample of hospitalized and ambulatory patients. The clear, consistent drop in prevalence provides an opportunity for the formulation of causal hypotheses, including consideration of the impact of biologic agents used to treat RA, on rheumatoid vasculitis.

Academic Disqualification and Persistence to Graduation by Financial Aid Category and Academic Ability.

In this longitudinal study of 21,243 students, the academic disqualification and persistence to graduation by financial aid category and academic ability were studied. Students who had greater financial need disqualified at higher rates and persisted to graduation at lower rates. However, when financial aid categories were stratified by academic ability, academic ability was a better indicator of disqualification and persistence to graduation than was financial aid category. These data may provide clues to determine where financial intervention with institutional need-based aid may be most beneficial and how programmatic interventions may be appropriate.

Does the concordance concept serve patient medication management

Objectives — To assess how people with arthritis evaluate and calibrate their complex medication regimens. Building on these findings, to explore how the concept of concordance helps to describe a patient‐provider partnership model which can aid optimum medication regimen selection, calibration and management of chronic conditions.

Hydroxychloroquine sulfate in rheumatoid arthritis: Long-term response rate and predictive parameters

Review of the records of 108 patients with rheumatoid arthritis who were treated with hydroxychloroquine sulfate for at least six months revealed that 63 percent responded: 12 percent achieved complete remission (no joint pain or tenderness, two or less joints with trace swelling); 14 percent showed a 75 percent response (75 percent or greater reduction in active joint count and 50 percent or greater reduction in morning stiffness); and 37 percent had between 30 percent (30 percent or greater reduction in active joint count and morning stiffness) and 75 percent response. Once response was obtained, flare-up of rheumatoid arthritis was uncommon. Only two of 108 patients developed retinopathy (subclinical); it resolved with drug discontinuation and did not cause visual deficits. Better grip strength and radiographs showing little articular damage at baseline might predict response to treatment with hydroxychloroquine. However, even though early disease may be more responsive, long-term rheumatoid arthritis does not preclude a good response to hydroxychloroquine.

Sacral insufficiency fractures

Abstract Insufficiency fractures of the sacrum commonly occur as a result of osteoporosis, usually without a history of trauma. If a high index of suspicion is not present, subtle findings on radiograph may be missed. As the mean age of the population increases, this entity will become more frequent. Metabolic disorders, inflammatory diseases, corticosteroids, malignancies, and irradiation are other predisposing factors to sacral insufficiency fractures. Patients may present with acute back pain or radiculopathy that simulates compression fractures, metastatic disease, herniated nucleus pulposus, and spinal stenosis. In this report we review the literature on sacral insufficiency fractures and discuss the spectrum of clinical manifestations, laboratory and imaging findings, associated disorders, and response to therapy.

A Puzzling Case of Persistent Purpura

D I ght t the s as r an p s v p s RESENTATION 21-year-old woman presented to the emergency dep ent with a history of flank pain, gross hematuria, and esions. The right-sided flank pain began 4 days prio resentation and did not radiate. She also developed rbital bruises, identical to those experienced 7 mo arlier when she had been diagnosed with biopsy-pro eukocytoclastic vasculitis. A review of systems was notable for subjective fe hills, and night sweats. Additional medical history inclu ephrolithiasis, migraine headaches, and cold urticaria. Vas itis and associated tender skin lesions were treated with m trexate, 10 mg weekly, and prednisone, 6 mg daily; m rexate minimized prednisone use. Sumatriptan was used eeded for headaches. The patient was a graduate student studying rehabi ion psychology and was engaged to be married. She d se of tobacco, alcohol, and recreational drugs, and she ot traveled abroad. There was no family history of mmune disease, bleeding disorders, or renal disease.