Investigating Asthma, Allergic Disease, Passive Smoke Exposure, and Risk of Rheumatoid Arthritis

Association between secondhand smoke exposure and rheumatoid arthritis in US never-smoking adults: a cross-sectional study from NHANES

While smoking is widely acknowledged as a risk factor for rheumatoid arthritis (RA), the connection between secondhand smoke (SHS) exposure and RA in never-smoking adults remains limited and inconsistent. This study aims to explore and quantify this association using serum cotinine levels. We conducted a cross-sectional study with 14,940 adults who self-report as never smokers, using National Health and Nutrition Examination Survey data from 1999 to 2018. Based on previous literature, SHS exposure was categorized into four groups according to serum cotinine levels. Compared to individuals in the unexposed group (serum cotinine < 0.05 ng/mL), the adjusted odds ratio (OR) for RA was 1.37 (95% CI 1.14-1.64, p = 0.001) in the low exposure group (serum cotinine at 0.05 to 0.99 ng/mL) after adjusting for covariates. However, no significant association was found in the moderate exposure group (serum cotinine at 1 to 10 ng/mL) or the heavy exposure group (serum cotinine ≥ 10 ng/mL). Furthermore, we detected a non-linear, positively saturated correlation between the cotinine levels after log2 transformation and RA, with a turning point at approximately - 2.756 ng/mL (OR = 1.163, 95% CI 1.073-1.261, p = 0.0002). The stability of the results was confirmed by subgroup analysis.

Rheumatoid arthritis: prediction of future clinically-apparent disease, and prevention

PURPOSE OF REVIEW

This review discusses updates in the prediction and prevention of future rheumatoid arthritis (RA).

RECENT FINDINGS

In individuals with musculoskeletal symptoms and elevated antibodies to citrullinated proteins (ACPA) without clinical inflammatory arthritis (IA), a 'simple' score has a positive predictive value (PPV) of ∼28% for clinical IA/RA within 1 year, and a comprehensive score (including ultrasound) has a PPV of ∼71% for clinical RA within 5 years. Controlled clinical trials in individuals at-risk for future RA have been performed using corticosteroids, rituximab, atorvastatin, methotrexate, hydroxychloroquine and abatacept. Abatacept modestly reduced rates of incident clinical RA and imaging inflammation within the trials, rituximab delayed clinical IA, and methotrexate improved function, symptoms and imaging inflammation. Vitamin D with or without omega 3 fatty acids reduced incidence of autoimmune diseases, including RA. While not proven in controlled clinical trials, observational studies suggest exercise, weight loss and smoking cessation may reduce progression to clinical RA.

SUMMARY

Prediction and prevention of RA is advancing although there are no currently approved interventions for prevention. Future studies should include deeper evaluation of the pathophysiology of RA development to improve prediction and identify key pathways to target in future clinical trials, as well as develop infrastructure to support prevention-related research.

Low-frequency and rare genetic variants associated with rheumatoid arthritis risk

Rheumatoid arthritis (RA) has an estimated heritability of nearly 50%, which is particularly high in seropositive RA. HLA alleles account for a large proportion of this heritability, in addition to many common single-nucleotide polymorphisms with smaller individual effects. Low-frequency and rare variants, such as those captured by next-generation sequencing, can also have a large role in heritability in some individuals. Rare variant discovery has informed the development of drugs such as inhibitors of PCSK9 and Janus kinases. Some 34 low-frequency and rare variants are currently associated with RA risk. One variant (19:10352442G>C in TYK2) was identified in five separate studies, and might therefore represent a promising therapeutic target. Following a set of best practices in future studies, including studying diverse populations, using large sample sizes, validating RA and serostatus, replicating findings, adjusting for other variants and performing functional assessment, could help to ensure the relevance of identified variants. Exciting opportunities are now on the horizon for genetics in RA, including larger datasets and consortia, whole-genome sequencing and direct applications of findings in the management, and especially treatment, of RA.

Higher Risk of Rheumatoid Arthritis in Patients With Chronic Rhinosinusitis: Prospective Association in the U.K. Biobank and Genetic Evidence by Mendelian Randomization Analysis

BACKGROUND

Previous studies have shown that respiratory diseases are associated with an increased risk of rheumatoid arthritis (RA). However, whether there is a correlation between chronic rhinosinusitis (CRS) and RA is not known. Due to the high incidence of CRS, it remains to be clarified whether we should pay additional attention to RA risk in the huge population of CRS.

METHODS

We used a 2-sample Mendelian randomization (MR) analysis to explore the causal effects of CRS on the incidence of RA. The inverse variance weighted (IVW) approach was used as the main analysis in the MR randomization study. Then, we used the data from the U.K. Biobank to examine the association between RA and CRS at the individual level in a prospective cohort. We identified patients with CRS at the time of recruitment and further followed the incidence of RA until 2021. The risk of developing RA in patients with CRS was determined by a multivariate Cox regression model. We used 3 multivariate Cox models to adjust for individual characteristics, lifestyle factors and concomitant diseases, respectively.

RESULTS

The MR analysis by the IVW model suggested that the odds ratio of RA associated with genetically predicted CRS was 2.39 (95% CI [1.08-5.30]; p  =  .032). In the first multivariate model adjusting for individual characteristics, CRS was associated with a 47% increase of risk of developing RA (hazard ratio [HR]  =  1.47; 95% CI [1.12-1.90]). In the second multivariate model adjusting for lifestyle factors, the HR of RA associated with CRS was 1.48 (95% CI [1.15-1.90]). In the third multivariate model, chronic sinusitis was associated with a 32% increase in RA risk (HR  =  1.32; 95% CI [1.03-1.70]).

CONCLUSION

CRS has a genetically causal effect on the incidence of RA, and the risk of RA is greatly higher in CRS at the individual level. This is the first study to reveal an association between CRS and RA. Due to the high incidence of CRS, it is recommended that additional attention should be paid to the increased RA risk in patients with CRS compared to that in common people.

Association between sinusitis and incident rheumatic diseases: a population-based study

OBJECTIVES

To determine whether antecedent sinusitis is associated with incident rheumatic disease.

METHODS

This population-based case-control study included all individuals meeting classification criteria for rheumatic diseases between 1995 and 2014. We matched three controls to each case on age, sex and length of prior electronic health record history. The primary exposure was presence of sinusitis, ascertained by diagnosis codes (positive predictive value 96%). We fit logistic regression models to estimate ORs for incident rheumatic diseases and disease groups, adjusted for confounders.

RESULTS

We identified 1729 incident rheumatic disease cases and 5187 matched controls (mean age 63, 67% women, median 14 years electronic health record history). After adjustment, preceding sinusitis was associated with increased risk of several rheumatic diseases, including antiphospholipid syndrome (OR 7.0, 95% CI 1.8 to 27), Sjögren's disease (OR 2.4, 95% CI 1.1 to 5.3), vasculitis (OR 1.4, 95% CI 1.1 to 1.9) and polymyalgia rheumatica (OR 1.4, 95% CI 1.0 to 2.0). Acute sinusitis was also associated with increased risk of seronegative rheumatoid arthritis (OR 1.8, 95% CI 1.1 to 3.1). Sinusitis was most associated with any rheumatic disease in the 5-10 years before disease onset (OR 1.7, 95% CI 1.3 to 2.3). Individuals with seven or more codes for sinusitis had the highest risk for rheumatic disease (OR 1.7, 95% CI 1.3 to 2.4). In addition, the association between sinusitis and incident rheumatic diseases showed the highest point estimates for never smokers (OR 1.7, 95% CI 1.3 to 2.2).

CONCLUSIONS

Preceding sinusitis is associated with increased incidence of rheumatic diseases, suggesting a possible role for sinus inflammation in their pathogenesis.

Global research trends in DNA methylation in rheumatoid arthritis: A bibliometric analysis and visual analysis

Rheumatoid arthritis (RA) is a prevalent autoimmune disorder with a significant global economic burden. Epigenetic modifications, particularly DNA methylation, play a crucial role in RA. This study conducted a bibliometric analysis to explore the evolving trends and predominant themes in RA and DNA methylation research over the past two decades. A total of 1800 articles met the inclusion criteria, and the analysis revealed consistent growth in the literature, with a notable increase in output after 2019. The research involved 70 countries, 2139 academic institutions, 23,365 unique authors, and 58,636 co-cited authors. The United States emerged as a dominant contributor in this research domain. The significance of DNA methylation in shaping research directions for RA management is increasingly evident. Recent investigations have shed light on the pivotal role of DNA methylation in RA, particularly in characterizing synovial tissue and exploring the underlying mechanisms of disease pathogenesis. This study provides valuable insights into the landscape of DNA methylation research in RA and highlights the importance of epigenetics in autoimmune diseases.

Gene-respiratory disease interactions for rheumatoid arthritis risk

OBJECTIVE

We aimed to identify gene by respiratory tract disease interactions that increase RA risk.

METHODS

In this case-control study using the Mass General Brigham Biobank, we matched incident RA cases, confirmed by ACR/EULAR criteria, to four controls on age, sex, and electronic health record history. Genetic exposures included a validated overall genetic risk score (GRS) for RA, a Human Leukocyte Antigen (HLA) GRS for RA, and the MUC5B promoter variant, an established risk factor for RA-associated interstitial lung disease (ILD). Preceding respiratory tract diseases came from diagnosis codes (positive predictive value 86%). We estimated attributable proportions (AP) and multiplicative odds ratios (OR) with 95% confidence intervals (CI) for RA for each genetic and respiratory exposure using conditional logistic regression models, adjusting for potential confounders.

RESULTS

We identified 653 incident RA cases and 2,607 matched controls (mean 54 years, 76% female). The highest tertile of the overall GRS and the HLA GRS were both associated with increased RA risk (OR 2.28, 95% CI 1.89,2.74; OR 2.02, 95% CI 1.67-2.45). ILD and the HLA GRS exhibited a synergistic relationship for RA risk (OR for both exposures 4.30, 95% CI 1.28,14.38; AP 0.51, 95% CI-0.16,1.18). Asthma and the MUC5B promoter variant also exhibited a synergistic interaction for seropositive RA (OR for both exposures 2.58, 95% CI 1.10,6.07; AP 0.62, 95% CI 0.24,1.00).

CONCLUSION

ILD-HLA GRS and asthma-MUC5B promoter variant showed synergistic interactions for RA risk. Such interactions may prove useful for RA prevention and screening.

Effect of Chronic Rhinosinusitis on the Risk of Development of Rheumatoid Arthritis

PURPOSE

Several studies have reported a possible link between chronic rhinosinusitis (CRS) and rheumatoid arthritis (RA). However, it remains unclear whether CRS could influence the risk of developing RA. Therefore, in this study, we focused on examining the association between CRS and RA.

METHODS

A total of 14,867 individuals with CRS and 14,867 without CRS were enrolled after 1:1 propensity score match from a nationwide longitudinal cohort database in South Korea. RA incidence was assessed using person-years at risk, and the hazard ratio (HR) was examined using the Cox proportional hazards model.

RESULTS

The incidence of RA (per 1,000 person-years) was 6.51 for those with CRS, 6.55 for those with CRS without nasal polyps (CRSsNP), and 5.96 for those with CRS with nasal polyps (CRSwNP). We found that CRS individuals had a significantly increased risk of subsequent RA development with an adjusted HR of 1.41, regardless of the phenotype (adjusted HR was 1.42 in CRSsNP and 1.37 in CRSwNP patients). Moreover, the risk of developing RA over time was relatively higher within the first 4 years after the diagnosis of CRS.

CONCLUSIONS

Our nationwide population-based cohort study suggests that CRS may be associated with a subsequent increase in RA events, regardless of the phenotype. Therefore, physicians should consider RA risk when diagnosing and treating CRS patients.

Increased Risk of Rheumatoid Arthritis in Patients With Asthma: A Genetic Association Study Using Two-Sample Mendelian Randomization Analysis

OBJECTIVE

Observational studies have explored the association between asthma and some types of arthritis, including rheumatoid arthritis and osteoarthritis, but the results are largely contradictory. We aimed to investigate the causal effects of asthma on arthritis, including osteoarthritis, rheumatoid arthritis, gout, and ankylosing spondylitis.

METHODS

Two-sample Mendelian randomization (MR) analysis was used to investigate the causal effects of asthma on each arthritis. The genetic instruments for asthma were obtained from a large genome-wide association study of asthma. The inverse-variance weighted (IVW) method was used as the main analysis of MR. Bonferroni-adjusted P value threshold was used to account for multiple comparisons.

RESULTS

MR-IVW analysis suggested that adult-onset asthma (AOA) was associated with increased risk of rheumatoid arthritis. The odds ratio for rheumatoid arthritis associated with AOA and childhood-onset asthma (COA) were 1.018 (95% confidence interval [95% CI], 1.011-1.025; P < 0.001) and 1.006 (95% CI 1.001-1.012; P = 0.046), respectively. For osteoarthritis, gout, or ankylosing spondylitis, all the MR analyses showed no significant causal effects of AOA or COA on them. We also performed a reverse MR analysis to explore the causal effects of rheumatoid on all asthma, allergic asthma, or nonallergic asthma and found no significant causal effects on them.

CONCLUSION

Genetically predicted AOA predisposes patients to an increased risk of rheumatoid arthritis but has no causal effects on osteoarthritis, gout, and ankylosing spondylitis. The result of COA on rheumatoid arthritis is suggestive of potential causal relationship but needs to be confirmed in further studies.

Association of rheumatoid arthritis with bronchial asthma and asthma-related comorbidities: A population-based national surveillance study

Background

The aim of this study was to investigate the impact of rheumatoid arthritis (RA) on the prevalence of bronchial asthma and asthma-related comorbidities. We also aimed to identify the influence of RA on interrelationship between asthma and asthma-related comorbidities.

Methods

From the Korean National Health and Nutrition Examination Survey, participants &gt;40 years of age who completed questionnaires and spirometry tests were enrolled. Patient data on RA, asthma, allergic rhinitis, atopic dermatitis, chronic obstructive pulmonary disease (COPD), sinusitis, otitis media, and body mass index (BMI) were collected. Logistic regression and network analyses were performed.

Results

A total of 14,272 subjects were enrolled, among which, 334 (2.4%) had RA. RA was significantly associated with asthma (OR 2.32; 95% CI 1.51–3.57), allergic rhinitis (OR 1.51; 95% CI 1.08–2.10), and sinusitis (OR 1.64; 95% CI 1.08–2.50). The network analysis of total patients revealed a positive interrelationship between asthma and allergic rhinitis, sinusitis, otitis media, atopic dermatitis, BMI, and RA. The interrelationship between asthma and sinusitis was stronger in the RA group. Of note, the relationship between asthma and BMI was distinctively found only in the RA group (r = 0.214, P &lt; 0.05). In patients with asthma, the prevalence of obesity was 64% in the presence of RA, and 40% in the absence of RA (P = 0.034).

Conclusion

This study supports the positive association of RA with asthma, allergic rhinitis, and sinusitis. Our analysis suggests a notable interrelationship between the presence of asthma and higher BMI values in patients with RA, indicating that asthma is more obesity-related in patients with RA.

Asthma and atopic dermatitis as risk factors for rheumatoid arthritis: a bidirectional mendelian randomization study

BACKGROUND

Previous observational studies have shown an association between asthma, atopic dermatitis (AD) and rheumatoid arthritis (RA). However, the bidirectional cause-effect chain between asthma and AD and RA has not been proven yet.

METHODS

We performed bidirectional two-sample Mendelian randomization (TSMR) and selected single nucleotide polymorphisms (SNPs) associated with asthma, AD, and RA as instrumental variables. All of the SNPs were obtained from the latest genome-wide association study in Europeans. Inverse variance weighted (IVW) was the main method used in MR analysis. MR-Egger, weighted model, simple model, and weighted median were used for quality control. The robustness of the results was tested by sensitivity analysis.

RESULTS

Asthma was found to be the largest effect size for RA susceptibility using the IVW method (OR, 1.35;95%CI, 1.13-1.60; P, 0.001), followed by AD (OR, 1.10;95%CI, 1.02-1.19; P, 0.019). In contrast, there was no causal relationship between RA and asthma (IVW: P = 0.673) or AD (IVW: P = 0.342). No pleiotropy or heterogeneity was found in the sensitivity analysis.

CONCLUSION

Findings from this study showed a causal relationship between genetic susceptibility to asthma or AD and increased risk of RA, but do not support a causal relationship between genetic susceptibility to RA and asthma or AD.

Association between passive smoking and the risk of rheumatoid arthritis: a systematic review and meta-analysis

In order to provide a basis for the prevention of RA, this systematic review and meta-analysis evaluated the association between passive smoking and the risk of developing RA. We searched electronic databases, including PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and Embase, for published literature from the establishment to March 2022. Then we included subject-related cohort studies and case-control studies, and two researchers independently screened and extracted relevant data. Finally, we performed a meta-analysis, cumulative meta-analysis, and dose-response meta-analysis using the Stata software and evaluated the included literature for the level of evidence. This meta-analysis included three case-control and three cohort studies. There was only a small amount of statistical heterogeneity among the studies (I² = 34.9%). According to the study results, the risk of RA was 12% higher in passive smokers than in unexposed individuals. In subgroup analysis, a 12% increase in the prevalence of RA was observed in those exposed to passive smoking in adulthood. The developing RA rate was 34% higher in individuals exposed to passive smoking during childhood than in unexposed individuals. As time progressed and with the inclusion of extensive sample studies in the cumulative meta-analysis, the precision of the overall incidence effect values gradually increased. A dose-response meta-analysis showed no statistical significance that the risk of RA increased with the number of passive smoking years. Passive smoking may relate to the risk of RA, especially in childhood exposures.

Arthritis and incident pulmonary diseases in middle-aged and elderly Chinese: a longitudinal population-based study

BACKGROUND

The coexistence of arthritis and pulmonary abnormalities has long been observed, but the causal inter-relationships among them are still uncertain especially in elderly adults.

METHODS

We extracted data from The China Health and Retirement Longitudinal Study (CHARLS). A total of 7534 participants without chronic lung diseases or/and asthma at the baseline and have complete follow-up information were included. Multivariate Cox proportional hazards models were used to estimate the adjusted hazard ratios (HRs) for developing chronic lung diseases or asthma. We also utilized generalized linear models to examine the association between arthritis and baseline peak expiratory flow (PEF).

RESULTS

During 50,615 and 51,975 person-years of follow-up, 629 and 188 participants incident chronic lung diseases and asthma, respectively. Compared to those without arthritis, participants with arthritis had a higher risk of chronic lung diseases (HR = 1.54, 95%CI = 1.31-1.81, P = 1.23 × 10^-7) and asthma (HR = 1.70, 95%CI = 1.27-2.28, P = 3.78 × 10^-4). Arthritis subjects demonstrated significantly lower PEF than those without arthritis [β =  - 11.85 (95%CI =  - 17.56, - 6.14), P = 4.81 × 10^-5]. The results were stable after excluding these participates who incident chronic lung diseases or asthma in the first 1 year of follow-up.

CONCLUSION

Arthritis increased the risk of pulmonary diseases among middle-aged and elderly Chinese. Early detection and treatment of pulmonary abnormalities among arthritis patients could help decrease the mortality and reduce the global burden of arthritis. Key Points • The coexistence of arthritis and pulmonary abnormalities has long been observed, but whether arthritis status can trigger pulmonary disorders is still uncertain. • Arthritis status are associated with increased risk of pulmonary diseases (chronic lung diseases/asthma) among middle-aged and elderly Chinese. • Early detection and treatment of pulmonary abnormalities among arthritis patients could help decrease the mortality and reduce the global burden of arthritis.

Racial Differences in Multimorbidity and Comorbidities in Rheumatoid Arthritis

OBJECTIVE

To identify differences in multimorbidity and individual comorbidities among individuals with rheumatoid arthritis (RA), separated by race and ethnicity.

METHODS

This case-control study within OptumLabs Data Warehouse from 2010 to 2019 matched RA cases (defined by 2 codes plus prescription of an RA drug) to non-RA controls 1:1 on age, sex, race and ethnicity, region, index date of RA, and insurance coverage duration. We defined multimorbidity as the presence of ≥2 or ≥5 validated comorbidities. Logistic regression models calculated adjusted odds of multimorbidity with 95% confidence intervals (95% CIs) within each race and ethnicity.

RESULTS

We identified 154,391 RA cases and 154,391 controls (mean age 59.6, 76% female). Black enrollees had the most multimorbidity ≥2/≥5 (73.1%, 34.3%); Asian enrollees had the least (52.4%, 17.3%). Adjusted odds of multimorbidity ≥2 and ≥5 in RA cases versus controls was 2.19 (95% CI 2.16-2.23) and 2.06 (95% CI 2.02-2.09), respectively. This increase was similar across race and ethnicity. However, we observed elevated occurrence of certain comorbidities by race and ethnicity versus controls (P < 0.001), including renal disease in White enrollees (4.7% versus 3.2%) and valvular heart disease in Black and White enrollees (3.2% and 2.8% versus 2.6% and 2.2%).

CONCLUSION

Multimorbidity is a problem for all RA patients. Targeted identification of certain comorbidities by race and ethnicity may be a helpful approach to mitigate multimorbidity.

Primary antibody deficiency-associated arthritis shares features with spondyloarthritis and enteropathic arthritis

OBJECTIVE

The clinical spectrum of primary antibody deficiencies (PADs) and especially common variable immunodeficiency (CVID) includes various autoimmune disorders. We studied the prevalence and the features of articular rheumatic disease in a cohort of patient with PADs.

METHODS

In this retrospective cohort study, complete clinical data of 268 patients with PADs, mainly consisting of patients with CVID, visiting the immunology outpatient clinic of a German tertiary hospital between 2018 and 2021 were collected. Those included case history, physical examination, laboratory as well as radiological findings.

RESULTS

Inflammatory arthritis was diagnosed in 16.4% of studied patients and was significantly more common among patients with PAD-associated enteropathy (OR 13.39, p=0.0001), splenomegaly (OR 6.09, p=0.0001) or atopic diseases (OR 3.31, p=0.021). Given HLA-B27 status, the involvement of the axial skeleton and the presence of features, such as anterior uveitis, inflammatory bowel disease, psoriasis and/or dactylitis, 75% of studied patients fulfilled the Assessment of Spondyloarthritis International Society classification criteria.

CONCLUSION

PAD-associated arthritis frequently shares features with spondyloarthritis (SpA) and enteropathic arthritis. The latter may suggest the interconnected pathomechanisms of inflammatory arthritis in SpA and PADs.

Associations Between Allergies, Walking, Sedentary Time, and Low Back Pain

PURPOSE

To examine associations between allergies, low back pain (LBP), walking, and sedentary time in a representative sample of adults aged 50 years and older.

DESIGN

A cross-sectional, correlational study.

METHODS

We used the 2014-2015 Korean National Health and Nutrition Examination Survey. Allergies of interest included allergic rhinitis, asthma, and atopic dermatitis. Adequate walking was defined as walking five or more days per week. Sedentary time was categorized as <7 h vs. ≥7 h. Logistic regression was performed to examine the association between allergies and LBP, controlling for demographics and lifestyle. Subgroup analyses were conducted to investigate the role of walking and sedentary lifestyle in LBP among those with or without allergies.

RESULTS

Of 4,897 respondents, 23.1% reported LBP. After controlling for covariates, individuals with allergies were 1.68 times more likely to have LBP than those without allergies. In the non-allergy group, those with inadequate walking and sedentary lifestyles were nearly twice as likely to report LBP than those with adequate walking and without sedentary lifestyles. However, this trend was not observed in the patients with allergy diagnoses.

CONCLUSIONS

We confirmed associations between lifetime allergy diagnosis and LBP. A protective role of physical activity and non-sedentary lifestyle in LBP remained only among those without allergies.

CLINICAL IMPLICATIONS

Nurses should emphasize the impact of allergies on LBP. The advantages of walking and non-sedentary lifestyles for preventing or relieving chronic conditions should be routinely included in patient education; however, their preventive role in LBP should be underscored for those without allergies.

Epidemiologic Opportunities and Challenges in Studying Environmental Risk Factors for Rheumatic Diseases

Most rheumatic diseases have a stronger environmental than hereditary etiology. This article summarizes the key environmental risk factors for rheumatic diseases, the data sources that generated these findings, and the key pitfalls with existing research that every rheumatology clinician should know. Emerging research opportunities hold promise to revolutionize this field, and soon.

Inhalant and Additional Mucosal-Related Environmental Risks for Rheumatoid Arthritis

Rheumatoid arthritis (RA) occurs as the result of a complex interplay of environmental factors in a genetically susceptible individual. There is considerable evidence that the lungs may serve as an initial site of tolerance loss in the generation of RA-related autoimmunity, and several environmental inhalant exposures and lung diseases have been associated with RA risk. There is additional evidence that immune and microbial dysregulation of other mucosal sites, including the oral and gastrointestinal mucosa, may contribute to the development of RA. Epidemiologic evidence linking mucosal exposures to various environmental insults as risk determinants in RA will be reviewed.

Novel insight into the aetiology of rheumatoid arthritis gained by a cross-tissue transcriptome-wide association study

BACKGROUND

Although genome-wide association studies (GWASs) have identified more than 100 loci associated with rheumatoid arthritis (RA) susceptibility, the causal genes and biological mechanisms remain largely unknown.

METHODS

A cross-tissue transcriptome-wide association study (TWAS) using the unified test for molecular signaturestool was performed to integrate GWAS summary statistics from 58 284 individuals (14 361 RA cases and 43 923 controls) with gene-expression matrix in the Genotype-Tissue Expression project. Subsequently, a single tissue by using FUSION software was conducted to validate the significant associations. We also compared the TWAS with different gene-based methodologies, including Summary Data Based Mendelian Randomization (SMR) and Multimarker Analysis of Genomic Annotation (MAGMA). Further in silico analyses (conditional and joint analysis, differential expression analysis and gene-set enrichment analysis) were used to deepen our understanding of genetic architecture and comorbidity aetiology of RA.

RESULTS

We identified a total of 47 significant candidate genes for RA in both cross-tissue and single-tissue test after multiple testing correction, of which 40 TWAS-identified genes were verified by SMR or MAGMA. Among them, 13 genes were situated outside of previously reported significant loci by RA GWAS. Both TWAS-based and MAGMA-based enrichment analyses illustrated the shared genetic determinants among autoimmune thyroid disease, asthma, type I diabetes mellitus and RA.

CONCLUSION

Our study unveils 13 new candidate genes whose predicted expression is associated with risk of RA, providing new insights into the underlying genetic architecture of RA.

A Roadmap for Investigating Preclinical Autoimmunity Using Patient-Oriented and Epidemiologic Study Designs: Example of Rheumatoid Arthritis

Background & Aims

Rheumatoid arthritis (RA) is a prototypic autoimmune disease causing inflammatory polyarthritis that affects nearly 1% of the population. RA can lead to joint destruction and disability along with increased morbidity and mortality. Similar to other autoimmune diseases, RA has distinct preclinical phases corresponding to genetic risk, lifestyle risk factors, autoantibody development, and non-specific symptoms prior to clinical diagnosis. This narrative review will detail observational studies for RA risk and clinical trials for RA prevention as a roadmap to investigating preclinical autoimmunity that could be applied to other diseases.

Methods

In this narrative review, we summarized previous and ongoing research studies investigating RA risk and prevention, categorizing them related to their design and preclinical phases.

Results

We detailed the following types of studies investigating RA risk and prevention: retrospective population-based and administrative datasets; prospective studies (case-control and cohort; some enrolling based on genetics, first-degree relative status, elevated biomarkers, or early symptoms/arthritis); and randomized clinical trials. These correspond to all preclinical RA phases (genetic, lifestyle, autoimmunity, early signs/symptoms). Previous and ongoing randomized controlled trials have enrolled individuals at very elevated risk for RA based on biomarkers, symptoms, imaging abnormalities, or early signs/symptoms.

Conclusion

We detailed the rich variety of study designs that is necessary to investigate distinct preclinical phases of an autoimmune disease such as RA. However, further progress is needed to fully elucidate the pathogenesis of RA that may ultimately lead to prevention or delay of disease onset.

Passive smoking in childhood and adulthood and risk of rheumatoid arthritis in women: results from the French E3N cohort study

Objective

The association between passive smoking exposure in childhood or in adulthood, and the risk of rheumatoid arthritis (RA) has been incompletely investigated. We aimed to assess the relationship between exposure to passive smoking and the risk of incident RA in a French prospective cohort of healthy women.

Methods

The E3N Study (Etude Epidémiologique auprès des femmes de la Mutuelle générale de l’Education Nationale) is a French prospective cohort of women included in 1990. Exposures to passive smoking were assessed using self-reported questionnaires. RA cases were self-reported and subsequently validated. Cox proportional hazards regression models adjusted for age and for potential confounders were used to estimate HRs and 95% CIs for incident RA.

Results

Among 79 806 women, 698 incident cases of RA were identified; 10 810 (13.5%) women were exposed to passive smoking in childhood, and 42 807 (53.6%) in adulthood. Median age at inclusion was 47.8 years. Passive smoking in childhood and in adulthood was associated with RA risk in all models (HRs (95% CIs) 1.24 (1.01 to 1.51) and 1.19 (1.02 to 1.40), respectively). The absolute risk of RA among never smokers with exposure to passive smoking in childhood and/or adulthood (47.6/100 000 person-years) was close to the risk of ever smokers with no passive smoking exposure (47.2/100 000 person-years), while it was highest in ever smokers also exposed to passive smoking (53.7/100 000 person-years).

Conclusion

Exposure to passive smoking in childhood and/or adulthood increases the risk of RA by the same order than active smoking. Such exposure should be suppressed, especially in individuals at risk of RA.

Allergic conditions and risk of rheumatoid arthritis: a Swedish case-control study

Objective

To determine the association of allergic conditions with incident rheumatoid arthritis (RA), especially in relation to smoking history and anti-citrullinated peptide antibody (ACPA) status.

Methods

This case–control study included 3515 incident RA cases and 5429 matched controls from the Epidemiological Investigation of Rheumatoid Arthritis study 1995 to 2016, including questionnaire-based information on eight allergic conditions composed from a list of 59 unique allergies. We used logistic regression and adjusted ORs (aOR) to assess the association between allergic conditions and risk of RA, adjusting for age, sex, residential area, body mass index, education, and smoking, and stratified by smoking and ACPA.

Results

A history of any reported allergy was equally common in RA (n=1047, 30%) as among population controls (n=1540, 29%), aOR 1.04, 95% CI 0.95 to 1.15. Metal, respiratory, food, plant/pollen and chemical allergies were not associated with risk of RA. By contrast, statistically significant associations were observed for animal dander allergy (6% vs 5%, aOR 1.37, 95% CI 1.03 to 1.82), especially in ACPA-positive RA (aOR 1.46 95% CI 1.06 to 2.01) and for atopic dermatitis, in particular for older and ACPA-negative RA (aOR 2.33, 95% CI 1.37 to 3.96 at age 80). Never smokers with allergic rhinitis also had increased risk of developing RA (aOR 1.30, 95% CI 1.00 to 1.68).

Conclusion

Most common allergies do not increase risk of RA, nor do they protect against RA. However, some allergic conditions, notably animal dander allergy, atopic dermatitis and allergic rhinitis, were associated with an increased risk for RA.

Timing of sinusitis and other respiratory tract diseases and risk of rheumatoid arthritis

OBJECTIVE

To investigate the association between timing of respiratory tract diseases and risk of rheumatoid arthritis (RA).

METHODS

This case-control study using the Mass General Brigham Biobank matched incident RA cases, confirmed by ACR/EULAR criteria, with at least seven years preceding electronic health record (EHR) data to three controls on age, sex, and EHR history from RA diagnosis (index date). We ascertained timing (>0-5 years/>5-10 years/>10 years) of the first documented respiratory tract disease prior to index date using diagnosis codes. We estimated odds ratios (OR) with 95% confidence intervals (CI) for RA for each respiratory exposure using logistic regression models, adjusting for potential confounders. We also conducted a stratified analysis by serostatus and smoking.

RESULTS

We identified 625 incident RA cases (median 56 years, 75% female, 57% seropositive) and 1,875 controls. Acute sinusitis was associated with RA only in the >5 to 10 years before RA (OR 3.90, 95% CI:1.90,8.01). In contrast, pneumonia was associated with RA only in the >0 to 5 years before RA (OR 1.73, 95% CI:1.00,3.00), and chronic respiratory tract diseases only >10 years before RA (OR 1.43, 95% CI:1.00,2.05). All respiratory tract diseases tended to show a stronger association with seronegative RA than seropositive RA, although the interaction was statistically significant only for chronic sinusitis (p=0.04). Respiratory diseases showed a nonsignificantly stronger association among smokers than nonsmokers.

CONCLUSION

Sinusitis and other respiratory diseases are associated with increased risk of RA, especially 5 years before RA onset. RA may begin many years before clinical onset.

Etiology and Risk Factors for Rheumatoid Arthritis: A State-of-the-Art Review

Rheumatoid arthritis (RA) is the most common systemic inflammatory rheumatic disease. It is associated with significant burden at the patient and societal level. Extensive efforts have been devoted to identifying a potential cause for the development of RA. Epidemiological studies have thoroughly investigated the association of several factors with the risk and course of RA. Although a precise etiology remains elusive, the current understanding is that RA is a multifactorial disease, wherein complex interactions between host and environmental factors determine the overall risk of disease susceptibility, persistence and severity. Risk factors related to the host that have been associated with RA development may be divided into genetic; epigenetic; hormonal, reproductive and neuroendocrine; and comorbid host factors. In turn, environmental risk factors include smoking and other airborne exposures; microbiota and infectious agents; diet; and socioeconomic factors. In the present narrative review, aimed at clinicians and researchers in the field of RA, we provide a state-of-the-art overview of the current knowledge on this topic, focusing on recent progresses that have improved our comprehension of disease risk and development.

Association of sinusitis and upper respiratory tract diseases with incident rheumatoid arthritis: A case-control study

OBJECTIVE

We aimed to determine whether specific respiratory tract diseases are associated with increased rheumatoid arthritis (RA) risk.

METHODS

This case-control study within the Mass General Brigham Biobank matched newly diagnosed RA cases to three controls on age, sex, and electronic health record history. We identified RA using a validated algorithm and confirmed by medical record review. Respiratory tract disease exposure required one inpatient or two outpatient codes at least two years before index date of RA clinical diagnosis or matched date. Logistic regression models calculated odds ratios (OR) for RA with 95% confidence intervals (CI), adjusting for confounders. We then stratified by serostatus ("seropositive" was positive rheumatoid factor and/or anti-citrullinated protein antibodies) and smoking.

RESULTS

We identified 741 RA cases and 2,223 controls (both median age 55, 76% female). Acute sinusitis (OR 1.61, 95% CI:1.05,2.45), chronic sinusitis (OR 2.16, 95% CI:1.39,3.35), and asthma (OR 1.39, 95% CI:1.03,1.87) were associated with increased risk of RA. Acute respiratory tract disease burden during the pre-index exposure period was also associated with increased RA risk (OR 1.30 per 10 codes, 95% CI:1.08,1.55). Acute pharyngitis was associated with seronegative (OR 1.68, 95% CI:1.02,2.74) but not seropositive RA; chronic rhinitis/pharyngitis was associated with seropositive (OR 2.46, 95% CI:1.01,5.99) but not seronegative RA. Respiratory tract diseases tended towards higher associations in smokers, especially >10 packyears (OR 1.52, 95% CI:1.02,2.27; p=0.10 for interaction).

CONCLUSION

Acute/chronic sinusitis and pharyngitis and acute respiratory burden increased RA risk. The mucosal paradigm of RA pathogenesis may involve the upper respiratory tract.

Challenges to Vaccination against SARS-CoV-2 in Patients with Immune-Mediated Diseases

Aberrant deployment of the immune response is a hallmark pathogenic feature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related disease (COVID-19), possibly accounting for high morbidity and mortality, especially in patients with comorbidities, including immune-mediated disorders. Immunisation with SARS-COV-2 vaccines successfully instructs the immune system to limit viral spread into tissues, mitigate COVID-19 manifestations and prevent its most detrimental inflammatory complications in the general population. Patients with immune-mediated diseases have been excluded from vaccine registration trials, foreclosing the acquisition of specific efficacy and safety data. In this review, we aimed to summarise and critically discuss evidence from real-world studies addressing this issue to provide a comprehensive view of the impact of vaccination practices in patients with allergy, autoimmunity or immunodeficiency. We analysed clinical and laboratory data from 34 studies involving more than 13,000 subjects with various immune disorders who were vaccinated with mRNA- DNA- or inactivated viral particle-based vaccines. These data globally support the safe and effective use of SARS-CoV-2 vaccines in patients with immune-mediated diseases, although patient-tailored strategies to determine vaccination timing, vaccine choice and background therapy management are warranted to optimise vaccination outcomes. More data are needed regarding patients with primary immunodeficiencies.

Passive Smoking Throughout the Life Course and the Risk of Incident Rheumatoid Arthritis in Adulthood Among Women

OBJECTIVE

To investigate passive smoking throughout the life course and the risk of rheumatoid arthritis (RA), while accounting for personal smoking.

METHODS

We analyzed the Nurses' Health Study II prospective cohort, using information collected via biennial questionnaires. We assessed the influence of 1) maternal smoking during pregnancy (in utero exposure), 2) childhood parental smoking, and 3) years lived with smokers since age 18. Incident RA and serostatus were determined by medical record review. Using the marginal structural model framework, we estimated the controlled direct effect of each passive smoking exposure on adult incident RA risk by serologic phenotype, controlling for early-life factors and time-updated adulthood factors including personal smoking.

RESULTS

Among 90,923 women, we identified 532 incident RA cases (66% seropositive) during a median of 27.7 years of follow-up. Maternal smoking during pregnancy was associated with RA after adjustment for confounders, with a hazard ratio (HR) of 1.25 (95% confidence interval [95% CI] 1.03-1.52), but not after accounting for subsequent smoking exposures. Childhood parental smoking was associated with seropositive RA after adjustment for confounders (HR 1.41 [95% CI 1.08-1.83]). In the controlled direct effect analyses, childhood parental smoking was associated with seropositive RA (HR 1.75 [95% CI 1.03-2.98]) after controlling for adulthood personal smoking, and the association was accentuated among ever smokers (HR 2.18 [95% CI 1.23-3.88]). There was no significant association of adulthood passive smoking with RA (HR 1.30 for ≥20 years of living with a smoker versus none [95% CI 0.97-1.74]).

CONCLUSION

We found a potential direct influence of childhood parental smoking on adult-onset incident seropositive RA even after controlling for adulthood personal smoking.

Autoimmunity in 2019

Based on the PubMed data, we have been performing a yearly evaluation of the publications related to autoimmune diseases and immunology to ascertain the relative weight of the former in the scientific literature. It is particularly intriguing to observe that despite the numerous new avenues of immune-related mechanisms, such as cancer immunotherapy, the proportion of immunology manuscripts related to autoimmunity continues to increase and has been approaching 20% in 2019. As in the previous 13 years, we performed an arbitrary selection of the peer-reviewed articles published by the major dedicated Journals and discussed the common themes which continue to outnumber peculiarites in autoimmune diseases. The investigated areas included systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), psoriatic arthritis (PsA), autoantibodies (autoAbs), and common therapeutic avenues and novel pathogenic mechanisms for autoimmune conditions. Some examples include new pathogenetic evidence which is well represented by IL21 or P2X7 receptor (P2X7R) in SLE or the application of single-cell RNA sequencing (scRNA-seq), mass cytometry, bulk RNA sequencing (RNA-seq), and flow cytometry for the analysis of different cellular populations in RA. Cumulatively and of interest to the clinicians, a large number of findings continue to underline the importance of a strict relationship between basic and clinical science to define new pathogenetic and therapeutic developments. The therapeutic pipeline in autoimmunity continues to grow and maintain a constant flow of new molecules, as well illustrated in RA and PsA, and this is most certainly derived from the new basic evidence and the high-throughput tools applied to autoimmune diseases.

Etiologies of Rheumatoid Arthritis: Update on Mucosal, Genetic, and Cellular Pathogenesis

Purpose of Review

Over the last few years, the scientific community has made significant progress in understanding the etiology of rheumatoid arthritis (RA). In this review, we summarize those key findings and trends.

Recent Findings

New data strongly implicates respiratory exposures, obesity, diet and microbiome, genetics, and their interactions in the etiology of RA. Furthermore, anti-posttranslationally modified protein antibodies (AMPAs) and abnormal glycosylation may be additional biomarkers for RA. Finally, functional genomics techniques implicate loss of certain macrophage populations and proliferation of synovial fibroblasts in RA.

Summary

These findings support the notion that RA originates at mucosal sites, augmented by genetic predisposition, and mediated by certain cell types including macrophages and fibroblasts. Weight loss, physical activity, and diet are additional modifiable factors beyond smoking cessation that can reduce risk of RA. Future epidemiologic and translational studies leveraging multi-omics approaches will help map the precise sequence of events in RA pathogenesis.

Family History of Rheumatic, Autoimmune, and Nonautoimmune Diseases and Risk of Rheumatoid Arthritis

OBJECTIVE

Since comorbidities such as autoimmune diseases may be associated with rheumatoid arthritis (RA) risk, we hypothesized that a family history of these other conditions might also predict RA. Therefore, we aimed to determine the association between family history of 79 comorbidities and RA.

METHODS

This case-control study identified 821 cases of RA in the Mayo Clinic Biobank (positive predictive value 95%) and matched 3 controls to each case based on age, sex, recruitment year, and location. Patients self reported family history and characteristics (adjusted). Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for RA risk according to the presence of family history for each comorbidity, adjusted for body mass index, race, and smoking.

RESULTS

Family history of several conditions was associated with developing RA, including rheumatic autoimmune diseases (ORadj 1.89 [95% CI 1.41-2.52]), pulmonary fibrosis (ORadj 2.12 [95% CI 1.16-3.80]), inflammatory bowel disease (ORadj 1.45 [95% CI 1.05-1.98]), hyper/hypothyroidism (ORadj 1.34 [95% CI 1.10-1.63]), and obstructive sleep apnea (ORadj 1.28 [95% CI 1.05-1.55]). Parkinson's disease and type 2 diabetes mellitus were associated with a statistically decreased risk of RA that did not reach the prespecified significance threshold of P < 0.01 (ORadj 0.70 [95% CI 0.49-0.98] and ORadj 0.81 [95% CI 0.67-0.97], respectively). Analyses among 143 cases of incident RA were similar and also suggested an association with a family history of autism (OR 10.5 [95% CI 2.51-71.3]).

CONCLUSION

Family history of several autoimmune and nonautoimmune comorbidities was associated with increased risk of RA, providing an opportunity to identify novel populations at risk for RA.

Inhalants other than personal cigarette smoking and risk for developing rheumatoid arthritis

PURPOSE OF REVIEW

The current review summarizes the current evidence on inhalants other than personal cigarette smoking and risk for developing rheumatoid arthritis (RA).

RECENT FINDINGS

Personal cigarette smoking has been implicated as an environmental risk factor for seropositive RA, perhaps by inducing autoimmunity at pulmonary mucosa. Since many patients with RA are nonsmokers, other inhalants are being investigated as potential RA risk factors. Recent case-control and cohort studies have investigated passive cigarette smoking, air pollution, inhalant-related occupations, silica, pesticides, household environment, and allergic inhalants as inhalant exposures for RA risk. Inhalant-related occupations and silica inhalants have the most consistent evidence for associations with increased RA risk. However, most studies relied on retrospective designs and had limited ability to adjust for personal cigarette smoking or investigate associations among nonsmokers.

SUMMARY

Several inhalants other than personal cigarette smoking may be associated with increased risk for developing RA. These results support the hypothesis that inhalants, pulmonary mucosal inflammation, and RA pathogenesis may be linked. Future studies are needed to firmly establish the independence of these findings from personal cigarette smoking and to determine the specific inhalants and biologic mechanisms related to RA pathogenesis.

Lifetime Allergy Symptoms in IgG4-Related Disease: A Case-Control Study

OBJECTIVE

The etiology of IgG4-related disease (IgG4-RD) is unknown and there has been controversy over the significance of allergic conditions in IgG4-RD. We examined the prevalence of lifetime allergy symptoms in IgG4-RD and the association between these and IgG4-RD.

METHODS

We identified IgG4-RD patients and non-IgG4-RD controls without autoimmune conditions seen at a single center. IgG4-RD patients were classified using the ACR/EULAR classification criteria. Allergy symptoms were ascertained by questionnaire. We assessed the association of IgG4-RD features with allergy symptoms. We compared the proportion of cases and controls with allergy symptoms using conditional logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) after matching cases and controls 1:1 by age and sex.

RESULTS

Lifetime allergy symptoms were reported by 165 (71%) of 231 IgG4-RD cases. Aero-allergen symptoms were most commonly reported (135, 58%) followed by skin allergy symptoms (97, 42%) and food allergy symptoms (47, 20%). IgG4-RD cases with a history of allergy symptoms were more likely to have head and neck involvement (OR 2.0 [95% CI: 1.1-3.6]) and peripheral eosinophilia (OR 3.3 [95% CI: 1.2-9.0]) than those without allergy symptoms. The prevalence of any allergy symptoms was similar between cases and controls (OR 0.7 [95% CI: 0.4-1.1]); this remained consistent after stratifying by head and neck involvement.

CONCLUSION

Lifetime allergy symptoms are common in IgG4-RD but are not reported more often in IgG4-RD compared to non-IgG4-RD patients without autoimmune conditions. These findings suggest that allergies are not uniquely associated with the pathogenesis or presentation of IgG4-RD.

Respiratory Diseases as Risk Factors for Seropositive and Seronegative Rheumatoid Arthritis and in Relation to Smoking

OBJECTIVE

The link and interplay between different airway exposures and rheumatoid arthritis (RA) risk are unclear. This study was undertaken to determine whether respiratory disease is associated with development of RA, and specifically to examine this relationship by RA serostatus and smoking exposure.

METHODS

Using data from the Epidemiological Investigation of Rheumatoid Arthritis study, this analysis included 1,631 incident RA cases and 3,283 matched controls recruited from 2006 to 2016. Linking these individuals to the National Patient Register provided information on past acute or chronic, upper or lower respiratory disease diagnoses. For each disease group, we estimated adjusted odds ratios (OR_adj ) with 95% confidence intervals (95% CI) for RA, using logistic regression models adjusted for age, sex, residential area, body mass index, and education both overall and stratified by anti-citrullinated protein antibody (ACPA)/rheumatoid factor (RF) status and by smoking status.

RESULTS

Respiratory disease diagnoses were associated with risk of RA, with an OR_adj of 1.2 for acute upper respiratory disease (95% CI 0.8-1.7), 1.4 for chronic upper respiratory disease (95% CI 1.1-1.9), 2.4 for acute lower respiratory disease (95% CI 1.5-3.6), and 1.6 for chronic lower respiratory disease (95% CI 1.5-3.6). These associations were present irrespective of RF or ACPA status, though the association was somewhat stronger for ACPA/RF-positive than ACPA/RF-negative RA. The association between any respiratory disease and RA was stronger for nonsmokers (OR_adj 2.1 [95% CI 1.5-2.9]) than for smokers (OR_adj 1.2 [95% CI 0.9-1.5]).

CONCLUSION

Respiratory diseases increase the risk for both seropositive and seronegative RA, but only among nonsmokers. These findings raise the hypothesis that smoking and airway disease are associated with RA development through partly different mechanisms.

Trajectories of asthma and allergies from 7 years to 53 years and associations with lung function and extrapulmonary comorbidity profiles: a prospective cohort study

BACKGROUND

Longitudinal trajectories of asthma and allergies from childhood to adulthood might be differentially associated with lung function and chronic obstructive pulmonary disease (COPD), but associations with extrapulmonary comorbidities have not been well investigated. We aimed to assess these trajectories and examine their associations with lung function outcomes and profiles of comorbidities.

METHODS

In this prospective cohort study, data for asthma and related allergic conditions (ie, eczema, hay fever, and food allergy) were prospectively collected from the Tasmanian Longitudinal Health Study for participants aged 7-53 years originally recruited in Tasmania, Australia. All surviving individuals in the database with contact details were invited in the most recent follow-up (mean age 53 years). There were no exclusion criteria. With use of latent class analysis, we identified longitudinal trajectories of asthma and allergic conditions from 7-53 years, and profiles of self-reported extrapulmonary conditions recorded at 53 years. The associations between asthma and allergy trajectories and morbidity profiles and lung function at 53 years were investigated with regression models.

FINDINGS

Between Sept 3, 2012, and Nov 8, 2016, of 6128 individuals invited, 3609 (58·9%) individuals were enrolled. We identified five asthma and allergy trajectories: minimal and least asthma and allergies (n= 1767 [49·0%]); late-onset hay fever, no asthma (n=1065 [29·5%]); early-onset remitted asthma and allergies (n=236 [6·5%]); late-onset asthma and allergies (n=317 [8·8%]); and early-onset persistent asthma and allergies (n=224 [6·2%]); and four profiles of extrapulmonary morbidities: minimal or least disease (n=2206 [61·1%]); dominant mental health disorders (n=861 [23·9%]); dominant cardiovascular diseases or risks (n=424 [11·7%]); and multiple disorders (n=117 [3·2%]). The late-onset asthma and allergies trajectory was predominantly associated with the multiple disorders profile (relative risk ratio 3·3 [95% CI 1·9-5·9]), whereas the other asthma and allergy trajectories were associated only with the dominant mental health disorders profile. Both spirometrically defined and clinical COPD were most strongly associated with the early-onset persistent asthma and allergies trajectory (odds ratio [OR] 5·3 [95% CI 3·2-8·6]) and also with the late-onset asthma and allergies trajectory (OR 3·8 [2·4-6·1]).

INTERPRETATION

Distinct longitudinal trajectories of asthma and allergic disease from childhood to 53 years are associated with different profiles of extrapulmonary comorbidities and varying risk of COPD. These findings can inform a personalised approach in clinical guidelines and management focusing on treatable traits. Comorbidity profiles are a new target for early identification and intervention.

FUNDING

National Health and Medical Research Council of Australia, EU's Horizon 2020, The University of Melbourne, Clifford Craig Medical Research Trust of Tasmania, The Victorian, Queensland & Tasmanian Asthma Foundations, The Royal Hobart Hospital, Helen MacPherson Smith Trust, and GlaxoSmithKline.

Environment and Lifestyle: Their Influence on the Risk of RA

Background: Rheumatoid arthritis (RA) is a complex disease in which environmental agents are thought to interact with genetic factors that lead to triggering of autoimmunity. Methods: We reviewed environmental, hormonal, and dietary factors that have been suggested to be associated with the risk of RA. Results: Smoking is the most robust factor associated with the risk of RA, with a clear gene–environment interaction. Among other inhalants, silica may increase the risk of RA in men. There is less evidence for pesticides, pollution, and other occupational inhalants. Regarding female hormonal exposures, there is some epidemiological evidence, although not consistent in the literature, to suggest a link between hormonal factors and the risk of RA. Regarding dietary factors, available evidence is conflicting. A high consumption of coffee seems to be associated with an increased risk of RA, whereas a moderate consumption of alcohol is inversely associated with the risk of RA, and there is less evidence regarding other food groups. Dietary pattern analyses (Mediterranean diet, the inflammatory potential of the diet, or diet quality) suggested a potential benefit of dietary modifications for individuals at high risk of RA. Conclusion: To date, smoking and silica exposure have been reproducibly demonstrated to trigger the emergence of RA. However, many other environmental factors have been studied, mostly with a case-control design. Results were conflicting and studies rarely considered potential gene–environment interactions. There is a need for large scale prospective studies and studies in predisposed individuals to better understand and prevent the disease and its course.

Patients with asthma have a higher risk of rheumatoid arthritis: A systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate whether patients with asthma have a higher risk of incident rheumatoid arthritis (RA) using systematic review and meta-analysis technique.

METHODS

Potentially eligible studies were identified from Medline and EMBASE databases from inception to May 2020 using search strategy that comprised of terms for "Asthma" and "Rheumatoid arthritis". Eligible cohort study must consist of one cohort of patients with asthma and another cohort of individuals without asthma. Then, the study must effect estimates with 95% confidence intervals (95% CIs) comparing incident RA between the groups. Eligible case-control studies must include cases with RA and controls without RA. Then, the study must explore their history of asthma. Odds ratio (OR) with 95% CIs of the association between asthma status and RA must be reported. Point estimates with standard errors were retrieved from each study and were combined together using the generic inverse variance method.

RESULTS

A total of 22,442 articles were identified. After two rounds of independent review by three investigators, six cohort studies and fourteen case-control studies met the eligibility criteria and were included into the meta-analysis. Meta-analysis of cohort studies found that patients with asthma had a significantly higher risk of RA compared with individuals without asthma with the pooled hazard ratio of 1.42 (95% CI, 1.18 - 1.70). Meta-analysis of case-control studies revealed that patients with asthma had a higher risk of RA compared with individuals without asthma with the pooled odds ratio of 1.33 (95%CI, 0.97 - 1.83). Funnel plot for the meta-analysis of case-control studies was asymmetric, suggesting the presence of publication bias.

CONCLUSIONS

This systematic review and meta-analysis found a significant association between asthma and higher risk of incident RA.

The importance of differences; On environment and its interactions with genes and immunity in the causation of rheumatoid arthritis

The current review uses rheumatoid arthritis (RA) as a prominent example for how studies on the interplay between environmental and genetic factors in defined subsets of a disease can be used to formulate aetiological hypotheses that subsequently can be tested for causality using molecular and functional studies. Major discussed findings are that exposures to airways from many different noxious agents including cigarette smoke, silica dust and more interact with major susceptibility genes, mainly HLA-DR genetic variants in triggering antigen-specific immune reactions specific for RA. We also discuss how several other environmental and lifestyle factors, including microbial, neural and metabolic factors, can influence risk for RA in ways that are different in different subsets of RA.The description of these processes in RA provides the best example so far in any immune-mediated disease of how triggering of immunity at one anatomical site in the context of known environmental and genetic factors subsequently can lead to symptoms that precede the classical inflammatory disease symptoms and later contribute also to the classical RA joint inflammation. The findings referred to in the review have led to a change of paradigms for very early therapy and prevention of RA and to efforts towards what we have named 'personalized prevention'. We believe that the progress described here for RA will be of relevance for research and practice also in other immune-mediated diseases.

Asthma, Chronic Obstructive Pulmonary Disease, and Subsequent Risk for Incident Rheumatoid Arthritis Among Women: A Prospective Cohort Study

OBJECTIVE

Inflamed airways are hypothesized to contribute to rheumatoid arthritis (RA) pathogenesis due to RA-related autoantibody production, and smoking is the strongest environmental RA risk factor. However, the role of chronic airway diseases in RA development is unclear. We undertook this study to investigate whether asthma and chronic obstructive pulmonary disease (COPD) were each associated with RA.

METHODS

We performed a prospective cohort study of 205,153 women in the Nurses' Health Study (NHS, 1988-2014) and NHSII (1991-2015). Exposures were self-reported physician-diagnosed asthma or COPD confirmed by validated supplemental questionnaires. The primary outcome was incident RA confirmed by medical record review by 2 rheumatologists. Covariates (including smoking pack-years/status) were assessed via biennial questionnaires. Multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) for RA were estimated using Cox regression.

RESULTS

We identified 15,148 women with confirmed asthma, 3,573 women with confirmed COPD, and 1,060 incident RA cases during 4,384,471 person-years (median 24.0 years/participant) of follow-up in the NHS and NHSII. Asthma was associated with increased RA risk (HR 1.53 [95% CI 1.24-1.88]) compared to no asthma/COPD after adjustment for covariates, including smoking pack-years/status. Asthma remained associated with increased RA risk when analyzing only never-smokers (HR 1.53 [95% CI 1.14-2.05]). COPD was also associated with increased RA risk (HR 1.89 [95% CI 1.31-2.75]). The association of COPD with RA was most pronounced in the subgroup of ever-smokers age >55 years (HR 2.20 [95% CI 1.38-3.51]).

CONCLUSION

Asthma and COPD were each associated with increased risk of incident RA, independent of smoking status/intensity and other potential confounders. These results provide support for the hypothesis that chronic airway inflammation may be crucial in RA pathogenesis.

The Impact of Cigarette Smoking on Risk of Rheumatoid Arthritis: A Narrative Review

Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic inflammation and subsequent proliferation of synovial tissues, which eventually leads to cartilage and bone destruction without effective treatments. Anti-citrullinated cyclic peptide/protein antibody (ACPA) and rheumatoid factor (RF) are two main characteristic autoantibodies found in RA patients and are associated with unfavorable disease outcomes. Although etiologies and causes of the disease have not been fully clarified yet, it is likely that interactive contributions of genetic and environmental factors play a main role in RA pathology. Previous works have demonstrated several genetic and environmental factors as risks of RA development and/or autoantibody productions. Among these, cigarette smoking and HLA-DRB1 are the well-established environmental and genetic risks, respectively. In this narrative review, we provide a recent update on genetic contributions to RA and the environmental risks of RA with a special focus on cigarette smoking and its impacts on RA pathology. We also describe gene–environmental interaction in RA pathogenesis with an emphasis on cigarette smoking and HLA-DRB1.

The association of penicillin allergy with outcomes after open ventral hernia repair

BACKGROUND

Up to 11% of patients report a penicillin allergy (PA), with 1-2% demonstrating a true IgE mediated allergy upon testing. PA patients often receive non-beta-lactam antibiotic surgical prophylaxis (non-BLP). This study evaluates the relationship of PA to outcomes after open ventral hernia repair (OVHR).

METHODS

A prospective institutional database was queried for patients undergoing OVHR. Demographics, operative characteristics, and outcomes were evaluated by the reported PA and the administration of beta-lactam prophylaxis (BLP).

RESULTS

Allergy histories were reviewed in 1178 patients. PA was reported in 21.6% of patients, with 55.5% reporting rash or hives, 15.0% airway compromise or anaphylaxis, and 29.5% no specific reaction. BLP was administered to 76.3% of patients, including 22.1% of PA patients and 89.9% of patients without PA. PA patients were more often female (64.6% PA patients vs. 56% non-PA, p = 0.01), with higher rates of chronic steroids, MRSA, anxiety, asthma, COPD, chronic pain, and sleep apnea (p < 0.03 all values). PA patients had higher rates of contaminated cases, including mesh infection and fistula. Of the 683 clean cases, 82.1% received BLP. Of the 117 clean contaminated cases (CDC wound class 2), 82.9% received BLP, which was associated with reduced long-term readmission for hernia complications (21.5 vs. 55%, p = 0.002, OR 0.27, CI 0.09-0.83). In the 120 CDC wound class 3 and 4 patients, 65.8% received BLP. In multivariate analysis, BLP was associated with lower rates of reoperation (OR 0.31, CI 0.12-0.76) and recurrence (OR 0.32, CI 0.11-0.86). BLP was given to 22.1% of the PA patients with no adverse reactions noted.

CONCLUSION

PA patients had more comorbidities and complex ventral hernias. When controlling for contamination and MRSA history, BLP is associated with improved outcomes particularly in contaminated cases. PA may be a risk factor for patient complexity, and further studies are warranted to determine if allergy testing can be warranted in known or anticipated contaminated cases.

Obstructive lung diseases and risk of rheumatoid arthritis

Introduction: Smoking is an established risk factor for both lung diseases and rheumatoid arthritis (RA). Chronic mucosal airway inflammation may result in immune tolerance loss, neoantigen formation, and production of RA-related autoantibodies that increase the subsequent risk of RA. In this review, we aimed to summarize the current evidence supporting the role of obstructive lung diseases and subsequent risk of RA.Areas covered: We identified scientific articles discussing the biologic mechanisms linking mucosal airway inflammation and RA risk. We also identified studies investigating asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, chronic tuberculous and nontuberculous mycobacterial infections, and interstitial lung disease with subsequent risk for RA.Expert opinion: The current evidence supports the hypothesis that mucosal airway inflammation may increase the risk of developing RA. However, most studies investigating this relationship have been retrospective and may not have adequately addressed the role of smoking. Larger prospective studies may provide stronger evidence for obstructive lung disease and RA risk. Determining the role of obstructive lung disease in RA pathogenesis may provide opportunity for RA prevention and screening strategies, while identifying novel biologic mechanisms that could offer targets to improve treatment and outcomes.

Comorbidities As Risk Factors for Rheumatoid Arthritis and Their Accrual After Diagnosis

OBJECTIVE

To determine the prevalence of comorbidities in rheumatoid arthritis (RA), discover which comorbidities might predispose to developing RA, and identify which comorbidities are more likely to develop after RA.

PATIENTS AND METHODS

We performed a case-control study using a single-center biobank, identifying 821 cases of RA (143 incident RA) between January 1, 2009, and February 28, 2018, defined as 2 diagnosis codes plus a disease-modifying antirheumatic drug. We matched each case to 3 controls based on age and sex. Participants self-reported the presence and onset of 74 comorbidities. Logistic regression models adjusted for race, body mass index, education, smoking, and Charlson comorbidity index.

RESULTS

After adjustment for confounders and multiple comparisons, 11 comorbidities were associated with RA, including epilepsy (odds ratio [OR], 2.13; P=.009), obstructive sleep apnea (OR, 1.49; P=.001), and pulmonary fibrosis (OR, 4.63; P<.001), but cancer was not. Inflammatory bowel disease (OR, 3.82; P<.001), type 1 diabetes (OR, 3.07; P=.01), and venous thromboembolism (VTE; OR, 1.80; P<.001) occurred more often before RA diagnosis compared with controls. In contrast, myocardial infarction (OR, 3.09; P<.001) and VTE (OR, 1.84; P<.001) occurred more often after RA diagnosis compared with controls. Analyses restricted to incident RA cases and their matched controls mirrored these results.

CONCLUSION

Inflammatory bowel disease, type 1 diabetes, and VTE might predispose to RA development, whereas cardiovascular disease, VTE, and obstructive sleep apnea can result from RA. These findings have important implications for RA pathogenesis, early detection, and recommended screening.

Asthma and elevation of anti-citrullinated protein antibodies prior to the onset of rheumatoid arthritis

BACKGROUND

Anti-citrullinated protein antibodies (ACPA) are central to rheumatoid arthritis (RA) pathogenesis and may develop at inflamed mucosa. We investigated whether asthma, a disease of airway mucosal inflammation, was associated with elevated ACPA before RA diagnosis.

METHODS

We performed a nested case-control study among women in two prospective cohorts, the Nurses' Health Study (NHS; 1976-2014) and NHSII (1989-2015). Blood was obtained on a subset (NHS: 1989-1990; NHSII: 1996-1999). Cases met 1987 ACR or 2010 ACR/EULAR RA criteria by medical record review and were classified as seropositive (ACPA+ or rheumatoid factor positivity) or seronegative by clinical laboratory testing at diagnosis. We identified RA cases with blood drawn before the date of RA diagnosis (index date), matching each to three controls by age, cohort, year, time from blood draw to index date, and menopause. Pre-RA ACPA elevation for cases was defined as >99th percentile of the control distribution on a research assay composed of autoantibodies targeting citrullinated protein epitopes or positivity on the second-generation commercial assay for cyclic citrullinated peptide. Asthma status and covariates were obtained through biennial questionnaires before blood draw. Conditional logistic regression estimated ORs and 95%CIs for RA by pre-RA ACPA and clinical serostatus, adjusted for matching factors, smoking pack-years, passive smoking, and body mass index (BMI).

RESULTS

We identified 284 incident RA cases and 849 matched controls; mean age at the index date was 61.2 years (SD 10.1). Blood was drawn 9.7 years (mean; SD 5.8) before the index date. We identified 96 (33.8%) RA cases with elevated pre-RA ACPA. At blood draw, 17.7% of pre-RA ACPA+ cases and 6.3% of matched controls (p = 0.0008) reported clinician-diagnosed asthma. After adjusting for matching factors, smoking pack-years, passive smoking, and BMI, asthma was significantly associated with pre-RA ACPA+ RA (OR 3.57, 95%CI 1.58,8.04). Asthma was not associated with overall RA (OR 1.45, 95%CI 0.91,2.31), but was significantly associated with seropositive RA (OR 1.79, 95%CI 1.01,3.18).

CONCLUSIONS

Asthma was strongly associated with ACPA elevation in blood drawn prior to RA diagnosis, independent of smoking. Chronic mucosal airway inflammation may contribute to ACPA development and RA pathogenesis.

Development of Allergic Bronchopulmonary Aspergillosis in a Patient with Crohn's Disease

Allergic bronchopulmonary aspergillosis (ABPA) is an eosinophilic inflammatory condition characterized by exaggerated immune responses to the fungal genus Aspergillus. Pulmonary manifestations in patients with Crohn's disease (CD) are frequent comorbidities. A 66-year-old man with CD treated with an anti-tumor necrosis factor-α antibody presented with dyspnea. Laboratory findings of elevated blood eosinophils and total serum IgE and positive aspergillus-specific antibodies as well as imaging findings of central bronchiectasis and mucoid impaction indicated a diagnosis of ABPA. To our knowledge, this is the first report of ABPA arising in a patient with CD. We discuss the pathophysiological mechanism of this rare complication.