Jennifer H. Ku

Patients with Retinal Vasculitis Rarely Suffer from Systemic Vasculitis

OBJECTIVES Systemic vasculitis is often mistakenly assumed to be a common cause of retinal vasculitis. We sought to determine the relationship between retinal vasculitis and systemic vasculitis. METHODS A selected review was performed on 1390 charts of patients attending the uveitis clinic at the Oregon Health and Science University between 1985 and 2010. Included in the review were all patients with diagnoses commonly associated with retinal vasculitis and all patients who were diagnosed with a systemic vasculitis. Retinal vasculitis was identified by perivascular exudates, intraretinal hemorrhage, or cotton wool spots as seen on clinical examination or by vascular occlusion or leakage as identified by fluorescein angiogram. RESULTS Two hundred seven or 14.9% of patients with uveitis had retinal vasculitis as a component of the intraocular inflammation. Thirty-five patients had retinal vasculitis that was primary, ie, not associated with a systemic disease, and the dominant manifestation of the uveitis. Fourteen of the patients with retinal vasculitis had Behcets disease. Only 11 of the 1390 patients with uveitis had a systemic vasculitis. Of these 11, four had retinal vasculitis including 1 secondary to a cytomegalovirus retinitis. Thus, systemic vasculitis was directly responsible for 1.4% or 3 of 207 cases of retinal vasculitis. Nonvasculitic systemic diseases such as sarcoidosis (n = 13), syndromes confined to the eye such as pars planitis (n = 36), and intraocular infections (n = 29) were far more common causes of retinal vasculitis. CONCLUSIONS Retinal vasculitis is a relatively common feature of uveitis. Patients with retinal vasculitis, however, rarely suffer from 1 of the classical systemic vasculitides.

Initiation of Anti-TNF Therapy and the Risk of Optic Neuritis: From the Safety Assessment of Biologic ThERapy (SABER) Study

PURPOSE To evaluate the incidence of optic neuritis (ON) in patients using anti-tumor necrosis factor (TNF) alpha therapy. DESIGN Retrospective, population-based cohort study. METHODS We identified new users of anti-TNF therapy (etanercept, infliximab, or adalimumab) or nonbiologic disease-modifying antirheumatic drugs (DMARDs) during 2000-2007 from the following data sources: Kaiser Permanente Northern California, Pharmaceutical Assistance Contract for the Elderly, Tennessee Medicaid, and National Medicaid/Medicare. Within this cohort, we used validated algorithms to identify ON cases occurring after onset of new drug exposure. We then calculated and compared ON incidence rates between exposure groups. RESULTS We identified 61 227 eligible inflammatory disease patients with either new anti-TNF or new nonbiologic DMARD use. Among this cohort, we found 3 ON cases among anti-TNF new users, occurring a median of 123 days (range, 37-221 days) after anti-TNF start. The crude incidence rate of ON across all disease indications among anti-TNF new users was 10.4 (95% CI 3.3-32.2) cases per 100 000 person-years. In a sensitivity analysis considering current or past anti-TNF or DMARD use, we identified a total of 6 ON cases: 3 among anti-TNF users and 3 among DMARD users. Crude ON rates were similar among anti-TNF and DMARD groups: 4.5 (95% CI 1.4-13.8) and 5.4 (95% CI 1.7-16.6) per 100 000 person-years, respectively. CONCLUSION Optic neuritis is rare among those who initiate anti-TNF therapy and occurs with similar frequency among those with nonbiologic DMARD exposure.

The tolerability of linezolid in the treatment of nontuberculous mycobacterial disease

Nontuberculous mycobacteria (NTM) disease is increasingly common and more prevalent than tuberculosis (TB) in many areas of the world [1, 2]. Treatment is challenging due to the multidrug-resistant nature of these organisms, and the need for prolonged multidrug therapy [2–4]. Linezolid can be tolerated long-term in the treatment of nontuberculous mycobacterial disease http://ow.ly/FilUm

The course of retinal vasculitis

Aims To determine if characteristics of retinal vasculitis correlate with ocular complications, or the response to different lines of treatment. Materials and methods We performed a computerised database analysis of 56 patients evaluated for uveitis at the Casey Eye Institute from September 1985 until May 2010. All patients had non-infectious retinal vasculitis and at least 1 year of follow-up. Results Although occlusive vasculitis was rare, retinal neovascularisation occurred much more commonly in the occlusive vasculitis subgroup than among the non-occlusive vasculitis subgroup (p<0.01). Epiretinal membrane (ERM) was found more commonly in the retinal vasculitis patients who presented with cotton wool spots and intraretinal haemorrhage compared to retinal vasculitis patients who presented with sheathing noted on clinical examination (p<0.01). Smoking was significantly related to vision loss. Age at presentation below 40 years correlated with therapy beyond oral corticosteroids Conclusions The heterogeneity of retinal vasculitis should be considered in providing prognostic information. Neovascularisation occurs more commonly in occlusive retinal vasculitis, and ERM is diagnosed more frequently in conjunction with cotton wool spots and intraretinal haemorrhage rather than just vascular sheathing. Cigarette use predicts visual loss and patients who are relatively young often receive treatment beyond oral corticosteroids.

Demographics, clinical disease characteristics, and quality of life in a large cohort of psoriasis patients with and without psoriatic arthritis

Innovation What is already known about the topic: psoriasis (PsO) is a common skin disease with major impact on quality of life (QoL). Patient-reported data on QoL from large number of PsO patients with and without psoriatic arthritis (PsA) are limited. What this study adds: In a large cohort referred to a university psoriasis center, patients with PsO and concomitant PsA (~30% in this group) had greater degrees of skin and nail involvement and experienced greater negative impacts on QoL. Despite large numbers of patients with moderate-to-severe disease, use of systemic therapy by community practitioners was uncommon. Background PsO and PsA are common diseases that have marked adverse impacts on QoL. The disease features and patient-reported QoL data comparing PsO and PsA patients are limited. Objective To identify and compare demographics, clinical disease characteristics, and QoL scores in a large cohort of PsO patients with and without PsA. Methods All PsO patients seen in a psoriasis specialty clinic, named the Center of Excellence for Psoriasis and Psoriatic Arthritis, were enrolled in an observational cohort. Demographic, QoL, and clinical data were collected from patient-reported questionnaires and from physical examinations performed by Center of Excellence for Psoriasis and Psoriatic Arthritis dermatologists and a rheumatologists. Cross sectional descriptive data were collected and comparisons between patients with PsO alone and those with concomitant PsA are presented. Results A total of 568 patients were enrolled in the database. Mean age of PsO onset was 28 years and mean disease duration was 18 years. Those with family history had an earlier onset of PsO by ~7 years. Mean body surface area involvement with PsO was 14%. Mean body mass index was 30.7. Prevalence of PsA was 29.8%. PsA patients had a higher mean body surface area compared to patients with PsO alone (16.7% vs 13.4%, P<0.05), higher prevalence of psoriatic nail changes (54.4% vs 36%, P<0.0002), and worse QoL scores as assessed by the Short Form-12 (67 vs 52, P<0.00001), Psoriasis Quality of Life-12 questionnaire (62 vs 71, P<0.01), and Routine Assessment of Patient Index Data 3 (2.3 vs 4.7, P<0.01). Strikingly, 49% of patients with PsO had never received any systemic therapy. Conclusion These data highlight that PsO has marked negative impacts on QoL, while those patients with concomitant PsA are affected to a much greater degree. Despite large numbers of patients presenting with moderate-to-severe disease, use of systemic therapy for both PsO and PsA was uncommon.

Disseminated Nontuberculous Mycobacteria in HIV-Infected Patients, Oregon, USA, 2007–2012

We determined disseminated nontuberculous mycobacteria incidence in the HIV-infected population of Oregon, USA, during 2007–2012 by using statewide laboratory surveillance. We identified 37 disseminated nontuberculous mycobacteria cases among 7,349 patients with median annual incidence of 110/100,000 HIV person-years and the highest incidence in those with CD4 counts <50 cells/mm3 (5,300/100,000 person-years).

Mortality after Respiratory Isolation of Nontuberculous Mycobacteria. A Comparison of Patients Who Did and Did Not Meet Disease Criteria

Rationale: The mortality of patients with respiratory tract isolates of nontuberculous mycobacteria (NTM) and their risk factors for death are not well described. Objectives: To determine age‐adjusted mortality rates for patients with respiratory NTM isolates and their causes of death and to examine whether American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) diagnostic criteria identify those at higher risk of death after NTM isolation. Methods: We linked vital records registries with a previously identified Oregon population‐based cohort of patients with NTM respiratory isolation. We excluded patients with Mycobacterium gordonae (n = 33) and those who died (n = 21) at the time of first isolation. We calculated 5‐year age‐adjusted mortality rates. We used Kaplan‐Meier and Cox proportional hazards analysis to examine the association of ATS/IDSA criteria and other risk factors with death. Results: Of 368 subjects with respiratory NTM isolates in 2005‐2006, 316 were included in the survival analysis. Most (84%) of their cultures isolated Mycobacterium avium complex. 35.1% died in the 5 years following respiratory isolation. Five‐year age‐adjusted mortality rates were slightly higher for those meeting (28.7/1,000) versus not meeting (23.4/1,000) ATS/IDSA criteria. In multivariate analysis, older age (adjusted hazard ratio [aHR], 1.06; 95% confidence interval [CI], 1.04‐1.07) and lung cancer (aHR, 2.77; 95% CI, 1.51‐5.07) were associated with an increased risk of death. A trend was noted between meeting ATS/IDSA criteria and subsequent death (aHR, 1.37; 95% CI, 0.95‐1.97). Among cases, male sex, older age, and immunosuppressive therapy use were independent risk factors for death. Conclusions: In the State of Oregon, patients with NTM respiratory isolates have high mortality, regardless of whether they meet ATS/IDSA criteria for pulmonary NTM disease. Most patients die as a result of causes other than NTM infection.

A Rhesus Macaque Model of Pulmonary Nontuberculous Mycobacterial Disease

In this study, we sought to develop a nonhuman primate model of pulmonary Mycobacterium avium complex (MAC) disease. Blood and bronchoalveolar lavage fluid were collected from three female rhesus macaques infected intrabronchially with escalating doses of M. avium subsp. hominissuis. Immunity was determined by measuring cytokine levels, lymphocyte proliferation, and antigen-specific responses. Disease progression was monitored clinically and microbiologically with serial thoracic radiographs, computed tomography scans, and quantitative mycobacterial cultures. The animal subjected to the highest inoculum showed evidence of chronic pulmonary MAC disease. Therefore, rhesus macaques could provide a robust model in which to investigate host-pathogen interactions during MAC infection.

Triple antibiotic combination therapy may improve but not resolve granuloma annulare

Granuloma annulare is a fairly common entity yet lacks reliable treatment options especially when multiple lesions or dissemination exists. A recent case series suggests that a regimen of three oral antibiotics may prove to be an effective treatment. Our objective is to evaluate the efficacy of once monthly triple antibiotic therapy for granuloma annulare. We conducted an open‐label prospective study of subjects with at least five lesions of granuloma annulare who received once monthly rifampin, ofloxacin, and minocycline for 6 months. Improvement was measured with a novel objective Granuloma Annulare Severity Index (GASI) scoring system. Twenty‐one subjects enrolled. Ten subjects (48%) achieved at least a 50% reduction in their GASI, including three subjects (14%) who reached 75% improvement and one subject (5%) whose skin cleared. Six subjects (29%) had no change or worsening of their granuloma annulare. Median GASI scores decreased significantly by 15 points (p < 0.01), although the clinical significance of this result is unclear. As this was a small open‐label study without a control group, we cannot determine if the results simply reflect the natural course of the disease. The GASI is not a validated assessment tool. Once monthly triple antibiotic use may improve but not clear granuloma annulare over 6 months. Randomized trials may be warranted to further assess this therapy.

Determinants of Patient Satisfaction in an Academic Rheumatology Practice.

BackgroundAlthough patient satisfaction is used as a measure of physician performance and is an essential component of chronic disease management, there is limited understanding about factors affecting satisfaction in rheumatologic settings. ObjectiveOur study aimed to identify factors affecting satisfaction in outpatients with rheumatic diseases by correlating satisfaction with various factors. MethodsWe conducted a cross-sectional cohort study of rheumatology patients at Oregon Health & Science University in 2013. Patient satisfaction ratings were obtained, and data were collected from medical records. Descriptive and quantile regression analyses were performed to describe the population and to model predictors of satisfaction. ResultsWe obtained data from 573 patients, 76% were females, 92% were non-Hispanic white, with a mean age of 50 (SD, 15) years. Female gender (&bgr; = 7.51; 95% confidence interval [CI], 6.16–8.86), older age (&bgr; = 0.10; 95% CI, 0.01–0.20), and follow-up visit (&bgr; = 4.04; 95% CI, 0.14–7.93) had a positive impact on satisfaction, whereas polymyalgia rheumatica (&bgr; = −9.25; 95% CI, −15.25 to −3.25), arthralgia (&bgr; = −8.67; 95% CI, −16.60 to −0.74), myalgia (&bgr; = −8.67; 95% CI, −16.60 to −0.74), gout (&bgr; = −7.5; 95% CI, −14.13 to −0.89), ankylosing spondylitis (&bgr; = −5.20; 95% CI, −9.65 to −0.75), pain (&bgr; = −4.62; 95% CI, −8.43 to −0.81), fibromyalgia (&bgr; = −4.62; 95% CI, −7.80 to −1.44), longer visit duration (&bgr; = −0.08; 95% CI, −0.13 to −0.03), and afternoon appointments (&bgr; = −4.62; 95% CI, −7.04 to −2.20) had an inverse effect. ConclusionsFactors contributing to satisfaction scores differed for median satisfaction level and lower satisfaction level. Most of the factors identified as influencing patient satisfaction were unrelated to the physician or the skills of that physician.