Autoantibodies Targeting Ficolin‐2 in Systemic Lupus Erythematosus Patients With Active Nephritis

Objective

Systemic lupus erythematosus (SLE) is a multisystem inflammatory disease characterized by the production of various autoantibodies. The aim of this study was to investigate the presence of anti–ficolin‐2 antibodies in SLE patients and to evaluate the association between the levels of these autoantibodies, clinical manifestations, and disease activity.

Methods

This is a comparative study using a cohort of 165 SLE patients and 48 healthy subjects. SLE patients were further divided into 2 groups (low disease activity [SLE Disease Activity Index (SLEDAI) score ≤4, n = 88] and high disease activity [SLEDAI score >4, n = 77]). Clinical manifestations were defined according to the physician in charge. Active lupus nephritis (LN) was documented by kidney biopsy. Detection of anti–ficolin‐2 antibodies was performed by enzyme‐linked immunosorbent assay.

Results

Levels of anti–ficolin‐2 autoantibodies were significantly higher in SLE patients as compared to healthy subjects and associated with SLEDAI score. They were found to be positive in 61 of 165 SLE patients (37%). The presence of anti–ficolin‐2 antibodies was significantly related only to renal involvement, with a very high prevalence (86%) of anti–ficolin‐2 antibodies in SLE patients with active LN. Patients with active proliferative LN had significantly more positive anti–ficolin‐2 antibodies than those with nonproliferative LN. The combination of anti–ficolin‐2, anti–ficolin‐3, and anti‐C1q demonstrated a very high specificity (98%) for the diagnosis of active LN.

Conclusion

Our results support the usefulness of anti–ficolin‐2 as a complementary serologic biomarker for the diagnosis of active lupus with renal manifestations.

     

Increased Insulin Resistance and Glucagon Levels in Mild/Inactive Systemic Lupus Erythematosus Patients Despite Normal Glucose Tolerance

Objective

To assess insulin sensitivity in patients with systemic lupus erythematosus (SLE) in response to a meal tolerance test (MTT).

Methods

In this cross‐sectional study, 33 adult females with mild/inactive SLE (SLE group) and 16 age‐ and body mass index–matched female healthy controls (CTRL group) underwent an MTT and were assessed for insulin sensitivity and beta cell function. Skeletal muscle protein expressions of total and membrane insulin‐dependent glucose transporter 4 (GLUT‐4) were also evaluated (SLE group: n = 10, CTRL group: n = 5); muscle biopsies were performed after MTT. Further measurements included inflammatory cytokines, adipocytokines, physical activity level, body composition, and food intake.

Results

SLE and CTRL groups showed similar fasting glucose, glucose response, and skeletal muscle GLUT‐4 translocation after MTT. However, the SLE group demonstrated higher fasting insulin levels (P = 0.01; effect size [ES] 1.2), homeostatic model assessment insulin resistance (IR) (P = 0.03; ES 1.1), insulin‐to‐glucose ratio response to MTT (P = 0.02; ES 1.2), fasting glucagon levels (P = 0.002; ES 2.7), glucagon response to MTT (P = 0.0001; ES 2.6), and a tendency toward lower Matsuda index of whole‐body insulin sensitivity (P = 0.06; ES ?0.5) when compared with the CTRL group. Fasting proinsulin‐to‐insulin ratio and proinsulin‐to‐insulin ratio response to MTT were similar between groups (P > 0.05), while the SLE group showed a higher insulinogenic index when compared with the CTRL group (P = 0.02; ES = 0.9).

Conclusion

We have identified that SLE patients had a bi‐hormone metabolic abnormality characterized by increased IR and hyperglucagonemia despite normal glucose tolerance and preserved beta cell function and skeletal muscle GLUT‐4 translocation. Strategies capable of ameliorating insulin sensitivity to reduce the risk of type 2 diabetes mellitus and cardiovascular disease in SLE may require more than targeting IR alone.

     

Relationship Between Poverty and Mortality in Systemic Lupus Erythematosus

Objective

A prior study established that concurrent poverty, persistent poverty, and exiting poverty were associated with the subsequent extent of damage accumulation in systemic lupus erythematosus (SLE). In this study, we examined whether concurrent poverty affects mortality after taking extent of damage accumulation into account.

Methods

Analyses were conducted on 807 persons with SLE participating in the University of California–San Francisco Lupus Outcomes Study in 2009, stratified by whether they lived in households with incomes ≤125% of the federal poverty level in that year. We used Cox proportional hazards regression to estimate the risk of mortality as a function of poverty status, with and without adjustment for demographics; lupus status, including extent of disease damage; overall health status; health behaviors; and health care characteristics.

Results

Among 807 individuals interviewed in 2009, 71 (8.8%) had died by 2015, 57 (8.3%) among the nonpoor and 14 (12.1%) among the poor (P = 0.18). With adjustment only for age, poverty in 2009 was associated with an increased risk of mortality (hazard ratio [HR] 2.14 [95% confidence interval (95% CI) 1.18–3.88]) through 2015. However, after adjustment for extent of damage and age, poverty was no longer associated with an increased risk of mortality (HR 1.68 [95% CI 0.91–3.10]). Among those who died, those who were poor lived 13.9 fewer years (95% CI 6.9–20.8; P < 0.0001).

Conclusion

The principal way that poverty results in higher mortality in SLE is by increasing the extent of damage accumulation.

     

Multicenter Delphi Exercise to Identify Important Key Items for Classifying Systemic Lupus Erythematosus

Objective

The American College of Rheumatology and the European League Against Rheumatism embarked on a project to reevaluate classification criteria for systemic lupus erythematosus (SLE). The first phase of the classification project involved generation of a broad set of items potentially useful for classification of SLE and their selection for use in a subsequent forced‐choice decision analysis.

Methods

A large international group of expert lupus clinicians was invited to participate in a 2‐step process to generate, rate, and select items based on their importance in diagnosing early and established SLE, via a web‐based survey.

Results

A total of 135 and 147 experts were invited to participate in the item‐generation and item‐reduction process, respectively. Of 145 items generated, item reduction resulted in 40 candidate items moving forward to the next phase. Key features for classifying both early and established SLE included characteristic autoantibodies, specific renal features, and skin manifestations. A small majority (51%) stated that 1 organ system would be sufficient for classifying SLE, but that additional typical laboratory features (antinuclear antibody, anti–double‐stranded DNA) would be required. Notably, 85% of the expert group would positively classify SLE if renal pathology alone showed lupus nephritis.

Conclusion

The Delphi exercise resulted in a set of 40 candidate criteria for the classification of SLE for subsequent assessment. This study comprised the largest panel ever involved in the development of SLE classification criteria, providing a broadly representative view of the current approach to classification of SLE.

     

Risk of Allergic Conditions in Children Born to Women With Systemic Lupus Erythematosus

Objective

Limited evidence suggests a potentially increased risk of allergic conditions in offspring born to women with systemic lupus erythematosus (SLE). In a large population‐based study, we aimed to determine if children born to mothers with SLE have an increased risk of allergic conditions compared to children born to mothers without SLE.

Methods

Using the Offspring of SLE Mothers Registry, we identified children born live to mothers with SLE and their matched controls, and ascertained the number of allergic conditions (asthma, allergic rhinitis, eczema, urticaria, angioedema, and anaphylaxis) based on ≥1 hospitalization or ≥1 or 2 physician(s) visit(s) with a relevant diagnostic code. We adjusted for maternal age, education, race/ethnicity, obstetrics complications, calendar year of birth, sex of the child, and maternal medication.

Results

There were 509 women with SLE who had 719 children, while 5,824 matched controls had 8,493 children. The mean ± SD followup period was 9.1 ± 5.8 years. Compared to controls, more children born to mothers with SLE had evidence of allergic conditions (43.9% [95% confidence interval (95% CI) 40.4–47.6] versus 38.1% [95% CI 37.0–39.1]). In multivariate analysis (n = 9,212), children born to mothers with SLE had an increased risk of allergic conditions versus control children (odds ratio 1.35 [95% CI 1.13–1.61]).

Conclusion

Compared to children from the general population, children born to women with SLE may have an increased risk of allergic conditions. Genetics, shared environmental exposures, as well as in utero exposure to maternal autoantibodies and cytokines may mediate this increased risk.

     

Geriatric Assessment of Physical and Cognitive Functioning in a Diverse Cohort of Systemic Lupus Erythematosus Patients: A Pilot Study

Objective

To use multidomain functional assessment, which is commonly performed in geriatric patients but is novel in patients with systemic lupus erythematosus (SLE), to better understand functional impairment in patients with SLE.

Methods

We recruited 60 adult participants (aged 20–39 years [26.7%], 40–59 years [50.0%], and ≥60 years [23.3%]; 80.0% African American and 90.0% female) from an existing cohort of SLE patients. During in‐person visits (from October 2016 to April 2017), we evaluated physical performance (range 0–4, with higher scores indicating better performance), cognitive performance (5 fluid cognition domains; adjusted T scores), and self‐reported measures including physical functioning (T scores), activities of daily living (ADLs), falls, and life‐space mobility.

Results

In the SLE patients, the mean balance score (3.7) and gait speed score (3.4) were high, while the mean lower body strength score was low (1.8). Cognitive performance was average (score of 5.0) for episodic (47.7) and working (48.6) memory and low average for cognitive flexibility (43.7), processing speed (42.6), and attention/inhibitory control (38.8 [>1 SD below average]) when compared with healthy individuals of the same age, sex, race, ethnicity, and education level. Most participants reported the ability to independently perform basic ADLs, but many reported the inability to independently perform instrumental ADLs. Nearly half (45.0%) of participants reported falling in the prior year. Only 40.0% reported unlimited ability to travel without the help of another person. Scores generally did not differ substantially according to age.

Conclusion

Our results suggest a high prevalence of impairment across multiple domains of function in SLE patients of all ages, similar to or exceeding the prevalence observed in much older geriatric populations. Further research into the added value of geriatric assessment in routine care for SLE is warranted.

     

Endothelial Dysfunction in Early Systemic Lupus Erythematosus Patients and Controls Without Previous Cardiovascular Events

Objective

To assess the prevalence and risk factors for endothelial dysfunction detected by peripheral artery tonometry in systemic lupus erythematosus patients with early disease without cardiovascular disease and risk factors.

Methods

All the consecutive adult lupus patients, with a disease duration <5 years, seen in our hospital from December 2014 to March 2016 were considered. We excluded patients with any history of cardiovascular disease or risk factors possibly affecting peripheral artery tonometry. Enrolled patients were matched for sex, age, body mass index, and blood pressure with healthy controls with the same exclusion criteria. Patients and controls received a transthoracic Doppler echocardiogram and an evaluation of endothelial function by peripheral artery tonometry.

Results

Twenty patients (100% female) with a median disease duration of 14 months (range 1–58 months), a mean ± SD age of 42 ± 15 years, and a mean ± SD age at diagnosis of 40 ± 16 years were enrolled and matched with 20 controls. Peripheral artery tonometry showed a significantly higher prevalence of endothelial dysfunction (P = 0.003) and vascular stiffness (P = 0.02), while echocardiography detected a significantly higher prevalence of left ventricular concentric remodeling (P = 0.003), grade I diastolic dysfunction (P = 0.047), and subclinical increase of filling pressures (P = 0.039) in lupus patients compared to controls. Among lupus patients, no features were associated with endothelial dysfunction.

Conclusion

A high rate of endothelial dysfunction and vascular stiffness occurs in early lupus patients without cardiovascular risk factors and disease. Larger studies are needed to confirm our results and to look for patients’ characteristics possibly associated with these abnormalities.

     

Asthma in Children of Mothers With Systemic Lupus Erythematosus and the Role of Preterm Birth

Objective

Systemic lupus erythematosus (SLE) and asthma share inheritable IgE‐related pathophysiology, but the association between maternal SLE and asthma in the offspring has not been explored. Our aim was to investigate the association between maternal SLE during pregnancy and childhood asthma and examine the role of preterm birth as a mediator of the association using Swedish register data.

Methods

Information on 12,000 singleton live births (2001–2013) was collected from the Medical Birth Register. Childhood asthma was defined as at least 1 International Classification of Diseases–coded visit in the National Patient Register. Prevalent maternal SLE at delivery was identified from the Medical Birth Register and the National Patient Register. Risk ratios for asthma were estimated while controlling for confounders. Mediation analysis was used to estimate what percentage of the total effect can be explained by preterm birth (defined as either <34 or <37 weeks of gestation).

Results

We compared 775 children born to mothers with SLE with 11,225 born to mothers without SLE. Ninety seven children of mothers with SLE (13%) were diagnosed with asthma, compared to 1,211 in the unexposed group (11%). The risk ratio for childhood asthma was 1.46 (95% confidence interval 1.16–1.84). In mediation analysis, 20–29% of the total effect of SLE was explained by preterm birth.

Conclusion

Prevalent maternal SLE during pregnancy is associated with an increased risk of asthma in the offspring. While preterm birth can explain a fair proportion of this association, additional unidentified mechanisms also likely play a role.

     

Antinuclear Matrix Protein 2 Autoantibodies and Edema,Muscle Disease,and Malignancy Risk in Dermatomyositis Patients

Objective

Dermatomyositis (DM ) patients typically present with proximal weakness and autoantibodies that are associated with distinct clinical phenotypes. We observed that DM patients with autoantibodies recognizing the nuclear matrix protein NXP ‐2 often presented with especially severe weakness. The aim of this study was to characterize the clinical features associated with anti–NXP ‐2 autoantibodies.

Methods

There were 235 DM patients who underwent testing for anti–NXP ‐2 autoantibodies. Patient characteristics, including muscle strength, were compared between those with and without these autoantibodies. The number of cancer cases observed in anti–NXP ‐2‐positive subjects was compared with the number expected in the general population.

Results

Of the DM patients, 56 (23.8%) were anti–NXP ‐2‐positive. There was no significant difference in the prevalence of proximal extremity weakness in patients with and without anti–NXP ‐2. In contrast, anti–NXP ‐2‐positive patients had more prevalent weakness in the distal arms (35% versus 20%; P = 0.02), distal legs (25% versus 8%; P < 0.001), and neck (48% versus 23%; P < 0.001). Anti–NXP ‐2‐positive subjects were also more likely to have dysphagia (62% versus 35%; P < 0.001), myalgia (46% versus 25%; P = 0.002), calcinosis (30% versus 17%; P = 0.02), and subcutaneous edema (36% versus 19%; P = 0.01) than anti–NXP ‐2‐negative patients. Five anti–NXP ‐2‐positive subjects (9%) had cancer‐associated myositis, representing a 3.68‐fold increased risk (95% confidence interval 1.2–8.6) compared to the expected prevalence in the general population.

Conclusion

In DM , anti–NXP ‐2 autoantibodies are associated with subcutaneous edema, calcinosis, and a muscle phenotype characterized by myalgia, proximal and distal weakness, and dysphagia. As anti–NXP ‐2‐positive patients have an increased risk of cancer, we suggest that they undergo comprehensive cancer screening.

     

Depression Risk in Young Adults With Juvenile‐ and Adult‐Onset Lupus: Twelve Years of Followup

Objective

To compare major depression risk among young adults with juvenile‐onset and adult‐onset systemic lupus erythematosus (SLE), and to determine demographic and health‐related predictors of depression.

Methods

Young adults with SLE ages 18–45 years (n = 546) in the Lupus Outcomes Study completed annual telephone surveys from 2002–2015, including assessment of depression using the Center for Epidemiologic Studies Depression Scale (CES‐D), and self‐report measures of sociodemographics and health characteristics. Juvenile‐onset SLE was defined as age <18 years at diagnosis (n = 115). Repeated‐measures analysis was performed to assess the risk for major depression (CES‐D ≥24) at any point in study, and logistic regression was used to assess for recurrent (present on ≥2 assessments) major depression.

Results

Major depression was experienced by 47% of the cohort at least once during the 12‐year study period. In adjusted analyses, juvenile‐onset SLE patients had an increased risk of having a major depressive episode (odds ratio [OR] 1.7 [95% confidence interval (95% CI) 1.0–2.7]) and recurrent episodes (OR 2.2 [95% CI 1.2–4.3]), compared to participants with adult‐onset SLE. Older age, lower educational attainment, and physical function, higher disease activity, and a history of smoking were associated with an increased depression risk. Juvenile‐onset SLE patients had a higher risk of major depression across all educational groups.

Conclusion

Young adults with SLE, particularly those with juvenile‐onset disease, are at high risk for major depression, which is associated with increased disease activity, poorer physical functioning, and lower educational attainment. Early depression intervention in young adults with SLE has the potential to improve both medical and psychosocial outcomes.

     

Developing and Refining New Candidate Criteria for Systemic Lupus Erythematosus Classification: An International Collaboration

Objective

To define candidate criteria within multiphase development of systemic lupus erythematosus (SLE) classification criteria, jointly supported by the American College of Rheumatology and the European League Against Rheumatism. Prior steps included item generation and reduction by Delphi exercise, further narrowed to 21 items in a nominal group technique exercise. Our objectives were to apply an evidence‐based approach to the 21 candidate criteria, and to develop hierarchical organization of criteria within domains.

Methods

A literature review identified the sensitivity and specificity of the 21 candidate criteria. Data on the performance of antinuclear antibody (ANA) as an entry criterion and operating characteristics of the candidate criteria in early SLE patients were evaluated. Candidate criteria were hierarchically organized into clinical and immunologic domains, and definitions were refined in an iterative process.

Results

Based on the data, consensus was reached to use a positive ANA of ≥1:80 titer (HEp‐2 cells immunofluorescence) as an entry criterion and to have 7 clinical and 3 immunologic domains, with hierarchical organization of criteria within domains. Definitions of the candidate criteria were specified.

Conclusion

Using a data‐driven process, consensus was reached on new, refined criteria definitions and organization based on operating characteristics. This work will be followed by a multicriteria decision analysis exercise to weight criteria and to identify a threshold score for classification on a continuous probability scale.

     

Contribution of Socioeconomic Status to Racial/Ethnic Disparities in Adverse Pregnancy Outcomes Among Women With Systemic Lupus Erythematosus

Objective

We examined rates of adverse pregnancy outcomes (APO) by race/ethnicity among women with systemic lupus erythematosus (SLE), with and without antiphospholipid antibodies (aPL), and whether socioeconomic status (SES) accounted for differences.

Methods

Data were from the PROMISSE (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) study, a multicenter study that enrolled 346 patients with SLE and 62 patients with SLE and aPL (50% white, 20% African American, 17% Hispanic, 12% Asian/Pacific Islander). Measures of SES were educational attainment, median community income, and community education. Logistic regression analyses were conducted to determine odds of APO for each racial/ethnic group, controlling first for age and clinical variables, and then for SES.

Results

The frequency of APO in white women with SLE, with and without aPL, was 29% and 11%, respectively. For African American and Hispanic women it was approximately 2‐fold greater. In African American women with SLE alone, adjustment for clinical variables attenuated the odds ratio (OR) from 2.7 (95% confidence interval [95% CI] 1.3–5.5) to 2.3 (95% CI 1.1–5.1), and after additional adjustment for SES, there were no longer significant differences in APO compared to whites. In contrast, in SLE patients with aPL, whites, African Americans, and Hispanics had markedly higher risks of APO compared to white SLE patients without aPL (OR 3.5 [95% CI 1.4–7.7], OR 12.4 [95% CI 1.9–79.8], and OR 10.4 [95% CI 2.5–42.4], respectively), which were not accounted for by clinical or SES covariates.

Conclusion

This finding suggests that for African American women with SLE without aPL, SES factors are key contributors to disparities in APO, despite monthly care from experts, whereas other factors contribute to disparities in SLE with aPL.

     

Perspectives of Medical Specialists From Different Disciplines on the Management of Systemic Lupus Erythematosus: An Interview Study

Objective

Systemic lupus erythematosus (SLE) is a complex autoimmune disease that can affect multiple organ systems, with specialists from many disciplines often involved, which may lead to inconsistent care. We aimed to describe the attitudes and perspectives of specialists from different medical disciplines on the management of people with SLE.

Methods

Face‐to‐face semistructured interviews were conducted with rheumatologists (n = 16), nephrologists (n = 16), and immunologists (n = 11) providing care to adults with SLE from 19 centers across Australia in 2015. All interviews were transcribed and analyzed thematically.

Results

Five themes were identified: uncertainties in judgments (hampered by unknown and unclear etiology, inapplicable evidence, comprehending information dispersion), reflexive responses (anchoring to specialty training, anticipating outcomes, avoiding disaster, empathy for the vulnerable), overarching duty to patients (achieving patient priorities, maximizing adherence, controlling the disease, providing legitimate information, having adequate and relevant expertise), safeguarding professional opportunities (diversifying clinical skills, protecting colleagues’ interests), and optimizing access to treatment (capitalizing on multidisciplinary care, acquiring breakthrough therapies).

Conclusion

Specialists strive to deliver evidence‐informed patient‐centered care, but recognize that they are anchored by their training. To overcome uncertainties in clinical management due to lack of high‐quality evidence and specialty silo structures, specialists translated evidence from other disease settings and collaborated with other specialists in routine care. Developing robust evidence, tools to support evidence‐informed decisions, and multidisciplinary shared‐care pathways may improve the management of people with this complex disease.

     

Delays to Care in Pediatric Lupus Patients: Data From the Childhood Arthritis and Rheumatology Research Alliance Legacy Registry

Objective

Prompt treatment for lupus is important to prevent morbidity. A potential barrier to early treatment of pediatric lupus is delayed presentation to a pediatric rheumatologist. To better understand factors contributing to delayed presentation among pediatric lupus patients, we examined differences in demographic and clinical characteristics of lupus patients within the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Legacy Registry with regard to time between symptom onset and presentation to a pediatric rheumatologist.

Methods

We analyzed data from 598 CARRA Legacy Registry participants for differences between those who presented early (within <1 month of symptom onset), between 1–3 months (typical presentation), with moderate delays (3–12 months), and with severe delays (≥1 year). Factors associated with early presentation, moderate delay, and severe delay were determined by multinomial logistic regression.

Results

Forty‐four percent of patients presented early, while 23% had moderate delays and 9% had severe delays. Family history of lupus, absence of discoid rash, and location in a state with a higher density of pediatric rheumatologists were associated with earlier presentation. Younger age, low household income (<$25,000 per year), and a family history of lupus were associated with severe delay.

Conclusion

Delays to care ≥1 year exist in a notable minority of pediatric lupus patients from the CARRA Legacy Registry. In this large and diverse sample of patients, access to care and family resources played an important role in predicting time to presentation to a pediatric rheumatologist.

     

Evaluation of a Methodologic Approach to Define an Inception Cohort of Rheumatoid Arthritis Patients Using Administrative Data

Objective

Identifying incident rheumatoid arthritis (RA) is desirable in order to create inception cohorts. We evaluated an approach to identify incident RA in health plan claims data.

Methods

Both Medicare and commercial claims data were linked to Corrona, a US RA registry. We evaluated the accuracy of year of RA onset in the registry (gold standard) versus different claims algorithms, varying International Classification of Diseases, Ninth Revision codes for RA/arthritis, duration of health plan enrollment preceding diagnosis (minimum of 1 versus 2 years), and use of RA medications. Results were reported as positive predictive values (PPVs) of the claims‐based algorithm for incident RA.

Results

Depending on the algorithm tested and whether patients were enrolled in Medicare or the commercial health plan, the PPVs for incident RA ranged from 68–81%. A 2‐year clean period free of all RA‐related diagnoses and medications was somewhat more optimal although, by comparison, a 1‐year clean period yielded similar PPVs and retained approximately 90% more RA patients for analysis.

Conclusion

Claims‐based algorithms can accurately identify incident RA.

     

Prognostic Significance of Cavitary Lung Nodules in Granulomatosis With Polyangiitis (Wegener's): A Clinical Imaging Study of 225 Patients

Objective

Granulomatosis with polyangiitis (Wegener's) (GPA) is a systemic necrotizing vasculitis in which pulmonary nodules are a common manifestation. Our study examined whether pulmonary nodules, and nodule type (solid versus cavitary), are associated with different disease manifestations and outcomes.

Methods

Demographic, clinical, biologic, and radiologic data at diagnosis and during followup and treatments of GPA patients followed at the Mount Sinai Hospital (Canada) Vasculitis Clinic were analyzed. Patients were separated by the absence of lung nodules, presence of solid nodules only, and presence of cavitary nodules (+/? solid nodules). The study outcomes included followup lung imaging, relapses, and deaths.

Results

Of 225 patients with GPA, 46 had solid nodules only and 44 had cavitary nodules at diagnosis. Demographic and clinical manifestations were similar in the patient subgroups at diagnosis. Cyclophosphamide (CYC) was used for induction after diagnosis in 76.7% of patients with cavitary nodules, compared with 64.7% of patients without nodules and 51.1% of patients with solid nodules (P = 0.04). The mean ± SD followup after diagnosis was 106.6 ± 92.6 months, and 6 of the patients died. In multivariable analysis, diagnosis before 2000 or pulmonary nodule cavitation at diagnosis were associated with relapse, with a hazard ratio of 0.38 (95% confidence interval [95% CI] 0.22–0.65; P < 0.001) and 1.53 (95% CI 1.00–2.33; P = 0.05), respectively, after adjustment for CYC use.

Conclusion

The presence of cavitary nodules led to increased use of CYC but had no impact on survival. Relapse occurred more often, however, in patients with cavitary nodules than in those with solid nodules or no nodules, and should be studied in other cohorts.

     

Trends and Determinants of Osteoporosis Treatment and Screening in Patients With Rheumatoid Arthritis Compared to Osteoarthritis

Objective

To profile osteoporosis (OP) care in patients with rheumatoid arthritis (RA) over the past decade.

Methods

Patients with RA or osteoarthritis (OA) were followed from 2003 through 2014. OP care was defined as receipt of OP treatment (with the exception of calcium/vitamin D) or screening (OPTS). Adjusted trends over followup, and the factors associated with OP care, were examined using multivariable Cox proportional hazards.

Results

OPTS was reported in 67.4% of 11,669 RA patients and in 64.6% of 2,829 OA patients during a median (interquartile range) 5.5 (2–9) years of followup. In patients for whom treatment was recommended by the 2010 American College of Rheumatology (ACR) glucocorticoid‐induced OP (GIOP) guidelines (48.4% of RA patients and 17.6% of OA patients), approximately 55% overall reported OP medication use. RA patients were not more likely to undergo OPTS compared to OA patients (hazard ratio 1.04 [95% confidence interval 0.94–1.15]). Adjusted models showed a stable trend for OPTS between 2004 and 2008 compared to 2003, with a significant downward trend after 2008 in both RA and OA patients. Factors associated with receipt of OP care in RA patients were older age, postmenopausal state, prior fragility fracture or diagnosis of OP, any duration of glucocorticoid treatment, and use of biologic agents.

Conclusion

Approximately half of RA patients for whom treatment was indicated never received an OP medication. OP care in RA patients was not better than in OA patients, and the relative risk of the application of this care has been decreasing in RA and OA patients since 2008 without improvement after the release of the 2010 ACR GIOP guideline.