Does cigarette smoking influence disease expression, activity and severity in early rheumatoid arthritis patients?

OBJECTIVE: To investigate the association of cigarette smoking with clinical expression, disease activity and severity in a cohort of Greek patients with early rheumatoid arthritis (RA). METHODS: From January 1993 until December 2002, 293 patients with early RA were diagnosed and followed up in our rheumatology clinic. All patients fulfilled the American College of Rheumatology criteria for RA, had disease duration of less than one year, without prior treatment of disease modifying anti-rheumatic drugs (DMARDs) or steroids. The patients were treated with at least one DMARD, and 287 of them had a last follow up during the year 2004. The demographic, personal, clinical, laboratory, radiological and therapeutic features were compared at entry and at the last follow-up, according to their smoking habits at entry. RESULTS: Among the 293 patients, 6 were lost to follow-up, thus 287 patients were evaluated. There were 200 females (67.7%) and 87 males (30.3%). Eighty-two (28.6%) were current smokers, 21 (7.3%) ex-smokers and 184 (64.1%) non-smokers at presentation. RA smoker patients displayed the disease at a younger age than the non-smokers. Additionally, the smokers presented at disease onset more prominent features of articular involvement as was evaluated by the higher number of total joint count with tenderness and swelling and by the higher disease activity for 28 joint indices score (DAS-28). Smokers also presented a higher Larsen's score and higher frequency of IgM and IgA rheumatoid factors as compared to non-smokers. At the end of the study, the smoker patients presented more active and severe disease as evaluated by the higher total number of tender and swelling joint count, the higher DAS-28, and higher Larsen's score as compared to non-smokers. Furthermore, the smokers more frequently had rheumatoid nodules than the ex-smokers and non-smokers. The association of smoking with disease activity and severity was independent of sex, age, educational level, alcohol consumption, and follow-up duration. Finally, no significant differences were observed concerning the therapeutic procedure among the three groups. CONCLUSIONS: In our early RA patients, cigarette smoking was associated with increased disease activity, and severity, independently of several other possible confounders and despite the early disease treatment.     

Early rheumatoid arthritis: can we predict its outcome?

Abstract
The continuing trend towards more aggressive treatment of rheumatoid arthritis (RA) has seen an increasing interest in the early phase of this chronic inflammatory disease. Optimal benefit from present and emerging therapies is limited by our prognostic abilities during this period. The present review attempts to outline first the many methodological issues encountered in studies of early RA, and second the extent to which each major outcome measure can be explained, both by readily available clinical variables and by HLA-DR genotyping. The evidence supporting the clinical usefulness of genotyping is discussed separately. Based on this information, a clinically appropriate approach to the management of early RA and the identification of patients suitable for experimental therapies is suggested. (Intern Med J 2001; 31: 168–180)     

Is early rheumatoid arthritis the same disease process as late rheumatoid arthritis?

Thoughts on treatment for the early control of synovitis have stimulated research on pathobiological events at the site of inflammation in patients with early rheumatoid arthritis. Several studies have thus been conducted to examine synovial biopsy samples at various stages of the disease. The most important conclusion from these studies is that all features of chronic synovial inflammation can be observed in so-called early rheumatoid arthritis. This suggests that no arguments exist for the effect of therapeutic intervention on synovitis varying in different phases of rheumatoid arthritis. In end-stage rheumatoid arthritis, factors that are secondary to the disease may contribute to the perpetuation of synovial inflammation. Mutations in key regulatory genes could play a role in the autonomous progression of the disease. In addition, it is conceivable that the release of bone and cartilage fragments might elicit an inflammatory response in patients with destructive rheumatoid arthritis.     

Minocycline induced autoimmune disease in rheumatoid arthritis: a missed diagnosis?

Minocycline is one of the major drugs for acne and is effective in rheumatoid arthritis (RA). We describe the first case of drug induced lupus secondary to the use of minocycline in a patient with RA. The dificulties of making this diagnosis as well as the implications for its pathogenesis are discussed.     

Autoantigenic posttranslational modifications of proteins: does it apply to rheumatoid arthritis?

There are many posttranslational modifications of proteins of which all are homeostatically important either to carry out a particular structural or functional role or to allow efficient recycling of the amino acid constituents. An important feature of the modified proteins is the acquisition of autoantigenicity. That notion should have been recognized for years with the modifications of immunoglobulin G that constitute new targets for rheumatoid factors. Citrullination or the deimination of arginine residues in proteins creates epitopes that are targeted by rheumatoid autoantibodies with a diagnostic sensitivity and specificity of 40% to 70% and 92% to 99%, respectively. The how, when, and why of the responsible break in tolerance are largely speculative but apoptosis, multiple genetic and environmental influences are likely required. Identifying citrullinated proteins as autoantigens has resulted in new diagnostic and prognostic autoantibody markers for RA and studying the citrullination process and its nature and role in cell biology has provided new insights into its pathogenesis.     

Axillary lymph node in rheumatoid arthritis: Does it associate disease activity?

IntroductionLymph node (LN) in rheumatoid arthritis (RA) has been the focus of recent research work; as it is implicated in disease pathogenesis. Power Doppler ultrasonography (PD-US) is increasingly used for imaging of lymph nodes in conditions other than arthritis.Aim of the workTo assess the axillary LN in RA using PD-US, and to correlate the findings to disease activity.Patients and methodsFourteen Consecutive RA patients were subjected to clinical examination and PD-US of axillary LNs, metacarpophalangeal joints (MCPJs) and wrist joints of the ipsilateral sides. LNs were assessed for cortex/hilum (CH) area ratio, longitudinal/transverse (LT) axis ratio and PD signal type. Joints were assessed for grey scale (GS) score and PD score. GS and PD signals were assigned to each joint in accordance with semi-quantitative 0–3 scales for each. DAS28 score was used for disease activity assessment.ResultsPD-US detected subclinical LN changes in 24/28 of the examined axillae in RA patients. Changes included hypertrophy mainly of the cortical area and amplification of vascularity of the central type. LN changes did not correlate to DAS28 score; rather correlated to GS and PD scores of ipsilateral wrist and MCPJs as assessed by PD-US.ConclusionPD-US detects subclinical axillary LN changes in RA patients. These changes do not correlate to DAS28. Axillary LN changes associate signs of synovitis in ipsilateral wrist and MCPJs as assessed by PD-US. Owing to the small number of patients enrolled, results presented in this work should be considered preliminary.     

Noncardiac vascular disease in rheumatoid arthritis: Increase in venous thromboembolic events?

Objective

To investigate the incidence of noncardiac vascular disease in a community‐based incidence cohort of patients with rheumatoid arthritis (RA) and compare it to that in the general population and to investigate trends in the incidence of noncardiac vascular disease in patients with RA.

Methods

A population‐based inception cohort of patients with incident RA between January 1, 1980 and December 31, 2007 in Olmsted County, Minnesota and a cohort of non‐RA subjects from the same population base was assembled and followed up until December 31, 2008. Venous thromboembolic, cerebrovascular, and peripheral arterial events were ascertained by medical record review.

Results

The study population included 813 patients with RA with a mean ± SD age of 55.9 ± 15.7 years (68% women) and an average length of followup of 9.6 ± 6.9 years. Compared to non‐RA subjects of similar age and sex, patients diagnosed as having RA between 1995 and 2007 had a higher incidence (%) of venous thromboembolism (cumulative incidence ± SE 6.7 ± 1.7 versus 2.8 ± 1.1, respectively; P = 0.005) but similar rates of cerebrovascular and peripheral arterial events. Among patients with RA, the incidence of venous thromboembolic, cerebrovascular, and peripheral arterial events was similar in the 1995–2007 time period compared to the 1980–1994 time period.

Conclusion

Our findings indicate that the incidence of venous thromboembolism is increased in patients with RA compared to non‐RA subjects. The incidence of cerebrovascular events and peripheral vascular disease events is similar in patients with RA compared to non‐RA subjects. Among patients with RA, the incidence of noncardiac vascular disease has remained stable in recent decades.

     

Why does gender influence survival in obstructive sleep apnoea?

The study aim was to compare the mortality risk of men and women diagnosed with obstructive sleep apnoea (OSA) and started on treatment with continuous positive airway pressure (CPAP). From August to December 2003 we reviewed the hospital records of patients who had started on CPAP for OSA between July 1995 and June 1998. Mortality rates were compared between men and women. Associations with mortality risk were determined using univariate and multivariate Cox's proportional hazards regression. The sample comprised 292 men and 47 women. Eight percent of the men and 23% of the women died (p=0.003). Univariate analysis showed increased mortality risk was associated with female sex, greater age when CPAP was started, a pre-treatment minimum nocturnal oxygen saturation (SpO(2)) <75%, a higher Charlson comorbidity index score and discontinuation of CPAP treatment. Female sex remained associated with increased mortality independent of age, minimum SpO(2) and CPAP use, but was not independent of the Charlson score. Women diagnosed with OSA and treated with CPAP demonstrated a 3.44 greater mortality risk than men, mostly due to greater comorbidity.     

Is rheumatoid arthritis disappearing?

During the past decades a number of studies have examined the incidence of rheumatoid arthritis (RA) in different geographical settings and at different times. Some studies from the 1970s and 1980s reported a higher incidence of RA than seen during recent years, where reported incidence numbers seems to have flattened out at a lower level. Besides a real time dependent decline of RA incidence, changing methodology in classification may be an equally important explanation. Today we may assume that annually 25-50 people from a population of 100,000 will develop typical RA.