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Allan Gelber, M.D.
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Abstract 516 6 year RCT of Patient-initiated Review versus Regular Physician-initiated Follow-up in RA The delivery of care to patients with RA can be limited by inadequate numbers of rheumatologists and crowded clinic scheduling. Allowing patients to schedule follow-up visits with their rheumatologist only when they deem necessary may serve to free up clinic time and conserve overall cost. Here, Hewlett et al examine the safety of one such strategy in which physician-initiated follow-up visits were replaced with patient-initiated visits. Methods: Patients with RA of two years duration or greater were randomized into one of two groups. Patients assigned to Group #1 (Direct Access) did not receive routine follow-up appointments. Rather, follow-up was initiated by the patient and organized by a nurse who assessed and set up appointments to either OT/PT or to the rheumatologist within 10 days of request. Follow-up could also be initiated by the patient's primary care physician. Patients assigned to Group #2 (Control) received appointments per-usual by their rheumatologist. PT/OT was prescribed only by the primary rheumatologist. Neither patients nor health care providers were blinded to group assignment. Indicators of emotional status, psychological instruments (including assessments of patient confidence and satisfaction), grip strength, range of motion at the knee and elbow, number of radiographic erosions on hand radiographs, and laboratory assessment (plasma viscosity, CRP, hemoglobin) were collected at baseline, and after 24, 48 and 72 months. Results: 209 of 302 screened patients were evenly randomized into the two groups. Groups were evenly matched for baseline disease characteristics (apart from grip strength, which was higher in the Direct Access group. Disease duration was shorter in the Direct Access group, 7 years compared to 10 years in the Control group). 68 patients in the Direct Access group and 52 in the control group completed the study to 72 months. Non-completers tended to have longer disease duration at entry and less ROM at the knee and elbow. At 72 months of follow-up, scores for disease activity and psychological factors were similar in the two groups except for less deterioration in elbow range of motion in the Direct Access group. However, confidence and satisfaction were maintained in the Direct Access group, but fell 10% in the Control group (p<0.002). Patients in the Direct Access group had fewer visits over the 72 month study period with a calculated cost savings of 27%. Conclusions: Patient-initiated direct access to follow-up is as safe as and more cost effective than Physician-initiated routine follow-up. Editorial Comments: The two and four year data from this study have previously been published. These results would seem to contradict Abstract 515, which advocates tight control of RA through aggressive treatment and monitoring. There are a number of methodological problems, including lack of blinding and high dropout rate of patients with more severe disease, which may seriously biased the results. For example, outcomes may not differ between the two groups because most of the severely affected individuals dropped out, leaving patients with relatively mild disease in the study. We also do not know from the data presented whether important differences in pharmacological treatments existed between the two groups. It is also notable that as many as one third of eligible patients declined participation in the study. The patients who actually entered the study may have differed significantly in disease characteristics, beliefs about disease, etc from those who declined. Nonetheless, in the current climate with too few rheumatologists, this is an admirable example of forward thinking for a new model for care. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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Abstract 1782 Is Birthweight Associated with Risk of Rheumatoid Arthritis? Data From a Large Prospective Cohort Study On the basis that birth weight is related to several highly prevalent medical disorders in the United States, including adult onset diabetes mellitus, hypertension and coronary heart disease, Mandl et al examined the relationship of birthweight to risk of developing rheumatoid arthritis. In the Nurses Health Study database, which consisted of 121,701 married women, a total of 623 new cases of RA developed between 1976-2000. A series of medical and obstetric set of parameters was ascertained from the participants, assessed prior to the onset of RA. These included age at menarche, age at first birth, total lifetime breast feeding, oral contraceptive use, postmenopausal hormone use, and, birthweight. Results: The investigators found that a birthweight > 10 lbs versus one between 7-8.5 lbs. was associated with a doubling in risk of developing RA. This heightened risk persisted after adjustment for multiple demographic and clinical variables. When the outcome of RA was restricted to only those cases seropositive for rheumatoid factor, the heightened risk persisted. This doubling in risk of developing RA for those in the highest birthweight group could not be explained by history of maternal diabetes or childhood socioeconomic status. Editorial Comments: The findings of this study are intriguing. In contrast to the inverse relationship of birthweight to the other chronic medical disorders listed above, it was high rather than low birth weight that predicted an increase in risk of future RA. Though it is not readily apparent just how valid recalled birthweight is in an adult population, it would seem unlikely that any potential bias could have crept into the study from this consideration. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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Abstract 971 Cigarette Smoking Increased Rheumatoid Arthritis Risks in Postmenopausal Women and Men Independently of Baseline C-reactive Protein (CRP) and Prolactin (PRL) Levels This study examined the relationship of cigarette smoking to the risk of developing rheumatoid arthritis. Using a community-based cohort established in 1974, individuals who did and did not develop rheumatoid arthritis over 20 years of follow-up were compared with regard to their smoking history. Four age- and gender-matched controls were selected per case with rheumatoid arthritis. Of note, Masi et al found that smoking status, particularly in the women, was related to an increase in risk of developing RA. The 25 postmenopausal women with RA manifested a greater than three-fold increased frequency of moderate smoking, whereas the highest smoking group had a ten-fold increased risk. Among the men in the study, only the heaviest smokers manifested an increased risk of RA, three-fold greater than the non-smokers. In an effort to explain the mechanism by which smoking may mediate this heightened risk of developing RA, the investigators incorporated measurements of C-reactive protein and of prolactin in their analyses, the former being an inflammatory marker and the latter a marker of immunomodulation. The inclusion of these markers in the statistical model did, not, however, adequately explain the risk associated with smoking. Editorial Comments: Given the high population prevalence of smoking and of rheumatoid arthritis, it bears further attention to try to understand the link between this behavior and risk of developing RA. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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Abstract 1783 Dietary Fat Intake and Risk of Rheumatoid Arthritis There is great interest, particularly in the lay media, about the relation of diet to risk of arthritis. In this regard, Garcia et al examined the relationship between intake of total fat and specific types of dietary fat to the risk of developing RA in women. The investigators examined the Nurses Health Study database, consisting of 121,701 female nurses who completed a food frequency questionnaire every 4 years, from 1980-1998. Results: Among this group, 90,980 women completed the questionnaire, and 468 new cases of RA were identified between 1980 and 2000. Based on the dietary information culled over a series of questionnaires, long term patterns of dietary fat intake were determined. These data demonstrated that higher intake of total fat, saturated fat, monounsaturated fatty acid, and of oleic acid were each associated with a modestly reduced risk of developing rheumatoid arthritis. In contrast, a heightened risk of RA was associated with greater intake of omega-3 polyunsatured fat, eicosapentaenoic acid, and docosahexaenoic acid. Editorial Comments: It is apparent that of the various different fats evaluated in this study, some were associated with a modest increase, whereas others demonstrated a modest decrease in risk of developing rheumatoid arthritis. Thus, these analyses did not yield a definitive answer, in one direction of the other, regarding the risk of developing rheumatoid arthritis associated with particular types of fat in the diet. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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Abstract 975 Prognostic Importance of Low Body Mass Index (BMI) on Cardiovascular Mortality in Rheumatoid Arthritis There is increased recognition that cardiovascular disease represents the leading cause of mortality among those afflicted with rheumatoid arthritis. What factors account for this excess cardiovascular mortality profile, however, remain to be clearly defined. These investigators speculated that body mass index (kg/m2) may be related to cardiovascular mortality, and examined this relationship in the well characterized Rochester Minnesota population-based cohort. In particular, all patients diagnosed with rheumatoid arthritis over the 40 year period from 1955 to 1995 were compared to an age- and gender-matched comparison cohort of non-RA subjects. A total of 603 members of the cohort with RA and 563 without RA were studied. Results: Cardiovascular disease was the primary cause of death in 176 RA patients and 127 non-RA subjects. Kremers et a demonstrated that body mass index (BMI), at the lowest end of the BMI range, had a distinctly greater risk of cardiovascular mortality in those with compared to those without RA. They showed first that in the general population, those who were particularly lean (BMI < 20) had a slightly reduced risk of mortality than those in the normal range of BMI values. In contrast, those with rheumatoid arthritis who were in the leanest category of BMI had more than a two-fold greater risk of cardiovascular mortality compared to non-RA patients with mid-range BMI (> 20 and <30). This excess risk persisted after adjustment for age, gender, cardiac history, smoking, diabetes and hypertension. Editorial Comments: These data suggested that active systemic inflammation, often associated with and representing the presumptive cause of low BMI in RA, plays an important role in predicting risk of cardiovascular mortality among patients with RA. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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Novel Risk Factors for Cardiovascular Disease in Rheumatoid Arthritis Abstract 1845 Cardiovascular Risk Profile and Mortality in a Population-Based Cohort of Rheumatoid Arthritis (RA) Patients over a 40-Year Period Methods: All patients in the Olmstead County, Minnesota database with RA from 1/1/1955 to 1/1/1995 were identified. Medical records were scrutinized for traditional cardiac risk factors, incident cardiovascular events, deaths, and RA disease characteristics and severity over this period and followed until 1/1/2001. Results: The records of 603 consecutive patients with RA were reviewed. Of the 354 deaths encountered, 50% were directly from a cardiovascular cause. In an additional 10.2% of deaths, cardiovascular causes were contributory. In a multivariate analysis after adjusting for traditional cardiac risk factors, age, gender, and RF status, factors associated with risk of cardiovascular mortality included elevated baseline ESR, large-joint swelling at baseline, development of rheumatoid vasculitis, development of rheumatoid lung disease, development of rheumatoid nodules, and development of radiographic joint destruction. Conclusions: Adjusting for traditional cardiac risk factors, independent risk factors for cardiovascular mortality in RA include high baseline ESR, large-joint swelling at baseline, and development of - vasculitis, rheumatoid lung disease, nodules, and radiographic joint destruction. Editorial Comments: These results help solidify the premise that lifetime burden of inflammation has a mechanistic and likely dose-related effect on the development of cardiovascular disease. All of the identified risk factors are linked, in a general and non-specific way, to elevated inflammatory status. Thus, they do help to pinpoint the individual mechanisms potentially responsible for the observed increase in cardiovascular related mortality. Abstract 1846 Risk of Heart Failure among Patients with Rheumatoid Arthritis (RA) Methods: All patients in the Olmstead County, Minnesota database with RA from 1/1/1955 to 1/1/1995 were identified and paired with age- and gender-matched non-RA controls. Medical records were scrutinized for the development of incident heart failure according to the Framingham criteria. Results: 575 RA patients without heart failure at the time of RA diagnosis and 559 non-RA matched control patients were analyzed.
Conclusions: Incident heart failure is increased in RA compared to non-RA controls. RF increases this risk. Editorial Comments: These data are consistent with other published reports showing that RA is a risk factor, independent of conventional risk factors, for the development of CHF. The exact mechanism (i.e. inflammatory myocarditis vs. ischemic cardiomyopathy vs. the myocardio-toxic effects of inflammatory cytokines vs. nodular valvular and myocardial involvement) remains unclear. Abstract 1847 Prevalence of Traditional and Novel Cardiovascular Risk Factors and Cardiovascular Events in Rheumatoid Arthritis in a Large Population Based Study Methods: RA cases and non-RA controls were identified from the Third National Health and Nutritional Examination Survey (NHANES III). RA cases were identified by self-report with confirmation by musculoskeletal exam (if age >60) or corroboration with symptoms compatible with ACR 1987 criteria for RA. Data collected included information on history of previous cardiovascular events, traditional cardiac risk factors, and laboratory parameters (fibrinogen, CRP, apo-lipoprotein A and B, folate, homocysteine, Vitamins A and C, alpha-carotenoids, lutein, and lycopene) Results: Of the 33,994 NHANES III participants, 389 cases of self-reported RA with corroborative symptoms and 131 cases of definite RA(via musculoskeletal exam) were identified. 4444 controls were identified. No differences in traditional risk factors or previous cardiovascular events were identified between RA cases and controls. RA cases had significantly higher levels of CRP and fibrinogen than controls. No differences in other laboratory parameters were identified. Conclusions: The prevalence of traditional cardiovascular risk factors and antecedent cardiovascular events is similar in both the RA and non-RA populations. Persons with RA have higher CRP and fibrinogen levels than those without RA. Editorial Comments: Patient self-reported RA is notoriously misleading, as inflammatory and non-inflammatory types of arthritis are commonly confused by the non-health professional. Attempting to corroborate self-reported diagnosis with appropriate symptoms is helpful, but not specific enough to overcome the difficulties with identification of cases. Nevertheless, the findings based on the analysis of definite cases are consistent with prior similar scholarship. Abstract 1848 Cardiovascular Risk Factors and Rheumatoid Arthritis Methods: Subjects were selected from the participants in the Nurses Health Study without previous cardiovascular disease who had both clinical cardiovascular risk factor assessment in 1988 and blood samples analyzed for lipids, homocysteine, vitamin B12, CRP, apo-lipoprotein A, fibrinogen, soluble ICAM, soluble VCAM, Soluble TNF receptors, and osteoprotegrin. Results: 69 RA and 451 non-RA subjects met selection criteria. After adjusting for age, menopausal status, smoking, and BMI, no significant differences were found in traditional cardiovascular risk factors and biomarkers between RA cases and controls. However, RA patients were found to have significantly higher levels of fibrinogen, CRP, soluble ICAM-1, osteoprotegrin, and soluble TNF receptors than controls after adjustment. Conclusions: Traditional cardiovascular risk factors are not increased in women with RA compared to women without RA. Novel inflammatory biomarkers may account for the known increased cardiovascular risk encountered in this population. Editorial Comments This study is limited by small numbers of cases and lack of cardiovascular endpoints. However, the identification of the specific biomarkers is entirely new to the literature and this novelty alone warrants merit. Abstract 1849 Risk Factors for Coronary and Aortic Atherosclerosis in Postmenopausal RA and Healthy Women Methods: Electron-Beam Computed Tomography (EBCT) was performed on post-menopausal women from rheumatology clinics in Pittsburgh, Pennsylvania. These were compared to EBCT measurements from healthy post-menopausal women participating in the Healthy Women Study. Primary outcome variables were Coronary Artery Calcium score (CAC) >100 or Aorta Calcium score (AC) >300. Traditional cardiac risk factors, RA disease characteristics and severity, and history of prior cardiovascular events (by self-report) were collected. Results:
After adjusting for age, RA group with higher CAC than HWS control group. Risk factors associated with CAC>100 included higher total pack-years of smoking, RA disease duration independent of age, and use of plaquenil (this group tended to have a higher CRP and better lipid profile than RA subjects not on plaquenil. Conclusions: Coronary and aortic calcification is more common in postmenopausal women with RA compared with non-RA controls. Editorial Comments: Using hard cardiovascular endpoints (MI, angina, stroke, etc) to compare RA and non-RA populations is problematic due to reporting bias. This study uses a method of determining subclinical cardiovascular disease with a variable that can be modeled as a linear continuum (i.e. accumulation of vascular calcification). This is the first report of coronary calcium scores in RA patients and the results clearly show an increased risk for atherosclerosis in RA compared to controls. As in other RA cardiovascular studies to date, however, the controls were define retrospectively rather than prospectively. Therefore, the results may be confounded by unknown biases and different methodologies. Nonetheless, the results are compelling. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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