P. Williams

Interstitial lung disease has a poor prognosis in rheumatoid arthritis: results from an inception cohort

OBJECTIVES Pulmonary complications of RA are well described. Although some are benign, interstitial lung disease (ILD) has a poor prognosis. Few RA inception cohorts have reported the natural history of ILD related to RA (RA-ILD). We examine its incidence, outcome and prognostic indicators. METHODS Extra-articular features and comorbidity have been recorded yearly in a well-established inception cohort of RA with a 20-year follow-up. Standard clinical, laboratory and radiological measures of RA were recorded at baseline and yearly. Details of deaths were provided by a national central register. RESULTS Out of 1460 patients, 52 developed RA-ILD, half either at baseline or within 3 years of onset. The annualized incidence was 4.1/1000 (95% CI 3.0, 5.4) and the 15-year cumulative incidence 62.9/1000 (95% CI 43.0, 91.7). Incidence of RA-ILD was associated with older age, raised baseline ESR and HAQ. Evidence to implicate any drug effect (e.g. MTX) was lacking. Of these patients, 39 died, attributed to RA-ILD in 28. Median survival following diagnosis of RA-ILD was 3 years. CONCLUSIONS RA-ILD is an important and early feature of RA. It is related to disease activity and has a poor prognosis. Further studies are required to determine whether screening for pulmonary disease would identify these patients at an earlier stage.

Prospective study of the radiological changes in hands, feet, and cervical spine in adult rheumatoid disease.

Annual radiographs of hands, feet, and cervical spine were taken in 100 patients with rheumatoid arthritis from the first year of disease for a mean follow-up period of 9.5 years. Seventy-six patients developed peripheral erosive disease and 54 developed rheumatoid changes of the cervical spine, of whom 34 (63%) had subluxations. The severity of rheumatoid neck damage correlated strongly with the severity of peripheral erosive disease (p = 0.002). Cervical subluxation was more likely to occur in patients with erosions of the hands and feet which deteriorated progressively with time (p = 0.018). The timing and severity of cervical subluxation coincided with the progression of peripheral erosive disease in 26 of these 34 patients (76.5%). The other 8 patients with cervical subluxation (23.5%) had none or only mild peripheral erosions, but their subluxations did not progress with time. There were 9 patients with marked cervical subluxations which deteriorated relentlessly, and they all also had severe progressive erosive disease of the hands and feet. One of these patients developed a cervical myelopathy, and 2 other patients with normal neurological signs had upper cervical fusions performed for severe occipital headache. This small group of rheumatoid patients who are at risk of developing cervical myelopathy cannot be predicted with certainty, but can be selected out at an early stage by performing regular radiographs of hands, feet, and cervical spine.

An evaluation of the strengths and weaknesses of a register of newly diagnosed rheumatoid arthritis, 1986-2010.

OBJECTIVES To evaluate the strengths and weaknesses of a register of management and outcomes of recently diagnosed RA, and allow comparisons between rheumatology centres on good clinical practice and guidelines. METHODS A register of newly diagnosed RA was initiated in 1986 in nine different regions of England, later expanded to UK-wide membership in 2002. Standardized data collection includes disease activity, function, radiological damage, therapy, hospitalizations, major comorbidity and mortality. A centralized database generates individual reports and comparative data for each centre yearly. Aims have been compared with actual achievements and any changes over 25 years. RESULTS Thirty rheumatology centres have recruited 2866 patients. Study outputs have included peer-reviewed scientific publications and contributions to the recent National Audit Office report on RA. Referral times into secondary care have changed little over 25 years, but time to initiation of drug therapies has decreased. Delays between publication of clinical trial evidence and management guidelines and their implementation in normal clinical practice are illustrated by relatively infrequent use of combination therapies at diagnosis. Consecutive case recruitment, centre participation and follow-up were reportedly compromised by local funding issues. Centre participants report a benefit from feedback of actual clinical practice compared with recommended standards of care. CONCLUSIONS Most of the original objectives have been achieved. Cohort studies based predominantly in District General Hospitals provide unique insights into the natural history and impact of RA, its management, the translation of research findings into clinical practice and provide participating centres with important clinical governance and professional development opportunities.

The Effect of Disease Severity and Comorbidity on Length of Stay for Orthopedic Surgery in Rheumatoid Arthritis: Results from 2 UK Inception Cohorts, 1986–2012

Objective. To examine factors predicting length of stay (LoS) for orthopedic intervention in rheumatoid arthritis (RA). Methods. LoS for orthopedic intervention was examined in 2 consecutive, multicenter inception cohorts: the Early RA Study (n = 1465, 9 centers) and the Early RA Network (n = 1236, 23 centers). Date, type of orthopedic procedure, and LoS were recorded and validated against national data, the UK National Joint Registry, and the UK Hospital Episode Statistics database. Clinical, laboratory, and radiographic measures and comorbidity recorded at baseline and annually were examined for their predictive power on LoS using regression analysis. Results. A total of 770 of 2701 patients (28.5%) had 1602 orthopedic interventions: 40% major (mainly total hip/knee replacements), 24% intermediate (mainly hand/wrist and ankle/foot surgery), and 16% minor (mainly soft tissue surgery). Median (interquartile range) LoS was 8 (5–13), 3 (1–5), and 1 (0–2) days for major, intermediate, and minor interventions, respectively. Older age predicted longer LoS (p < 0.001) whereas a more recent operation year predicted shorter LoS (p < 0.001). Markers of active disease, namely low hemoglobin, high Health Assessment Questionnaire, and high Disease Activity Scores in the first year all predicted longer LoS for all types of surgery (p = 0.001, p < 0.001, p = 0.05, respectively). Presence of 1 or more major comorbidities predicted longer LoS (p < 0.001). Conclusion. Comorbidity and standard clinical and laboratory markers of disease activity affect the LoS for orthopedic surgery in RA, which has important clinical and economic implications, providing a target for improving patient outcomes.