Mortality of patients with rheumatoid arthritis requiring intensive care: a single-center retrospective study

Predictors of serious infections in rheumatoid arthritis-a prospective Brazilian cohort

BACKGROUND

Infections increase mortality and morbidity and often limit immunosuppressive treatment in rheumatoid arthritis patients.

OBJECTIVE

To analyze the occurrence of serious infections and the associated factors in a cohort of rheumatoid arthritis patients under real-life conditions.

METHODS

We analyzed data from the REAL, a prospective observational study, that evaluated Brazilian RA patients, with clinical and laboratory data collected over a year. Univariate and multivariate analyses were performed from the adjustment of the logistic regression model Generalized Estimating Equations (GEE), with the primary outcome being the occurrence of serious infection, defined as need for hospitalization or use of intravenous antibiotics for its treatment.

RESULTS

841 patients were included with an average follow-up time of 11.2 months (SD 2.4). Eighty-nine serious infections occurred, corresponding to 13 infections per 100 patient-years. Pulmonary fibrosis, chronic kidney disease (CKD) and central nervous system disease increased the chances of serious infection by 3.2 times (95% CI: 1.5-6.9), 3.6 times (95% CI: 1.2-10.4) and 2.4 times (95% CI: 1.2-5.0), respectively. The use of corticosteroids in moderate doses increased the chances by 5.4 times (95% CI: 2.3-12.4), and for each increase of 1 unit in the health assessment questionnaire (HAQ), the chance increased 60% (95% CI: 20-120%).

CONCLUSION

The use of corticosteroids at moderate doses increased the risk of serious infection in RA patients. Reduced functionality assessed by the HAQ and comorbidities were other important factors associated with serious infection in this cohort.

[Therapeutic options in juvenile idiopathic arthritis : Surgical and conservative orthopedic rheumatological treatment]

The treatment of juvenile idiopathic arthritis (JIA) has made substantial progress within the last 25 years. Modern medicinal treatment enables inflammatory activity of the disease to be controlled in most of the cases. Mutilating courses of disease, which were formerly the rule have now become the exception. Today remission of disease is the aim of pediatric rheumatological treatment. Apart from effective control of inflammation this includes complete restoration of functional abilities of affected joints and the surrounding structures also affected. To achieve this goal a holistic and foresighted view of each patient's course is required. Therefore, even in an apparently uncomplicated course of disease in some cases of JIA it is advisable to plan an early interdisciplinary consultation including the pediatric rheumatologist and the orthopedic surgeon, in order to discuss an early surgical intervention, which can then be carried out in a timely manner, if necessary. This article provides an overview of the orthopedic rheumatological indications and options.

Performance of a pre-administration infection screening questionnaire in patients with rheumatoid arthritis administered biological disease-modifying antirheumatic drugs

AIM

Pre-administration screening of active infections is imperative for the safe use of biological disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA). However, a standardized screening method is lacking. We therefore implemented a novel systematic screening method with a simple predetermined questionnaire on infections and assessed its effectiveness.

METHODS

We retrospectively reviewed medical records of individuals for whom intravenous bDMARDs were administered for RA from January 2016 to April 2019. We evaluated the performance of the new screening method based on physicians' assessments. In addition, a survey was administered to nurses, regarding their assessment of the usefulness of this new screening. The incidence of infections was also assessed.

RESULTS

A total of 1636 cases underwent this new screening. The new screening method showed high sensitivity (0.97) and specificity (0.89) with a negative predictive value of 99.9%, as determined based on the physician's decision. Administration of bDMARDs was postponed in 37 (2.5%) patients, and there was only one case in which the screening failed to note an active infection. The nurses' survey demonstrated high agreement (87.5%) about the usefulness of this screening on the grounds of clarity, simplicity, ease, and time-saving effects. There was no significant increase in infections after implementation of this method.

CONCLUSIONS

Systematic screening with a predetermined simple questionnaire is effective as an infection screening method, with a high negative predictive value. This approach contributes to high satisfaction of nurses and a time-efficient practice by focusing on screen-positive cases without increasing infections.

An Analysis of Rheumatoid Arthritis Hospitalizations

Background

We used a large United States (US) population-based database to analyze the reasons for hospitalization of rheumatoid arthritis (RA) patients.

Methods

The International Classification of Diseases, Tenth Revision (ICD-10) code was used to search for hospitalizations in 2017 in the National Inpatient Sample (NIS) database with RA as the principal or secondary diagnosis. The reasons for hospitalization were divided into 19 categories based on their principal discharge ICD-10 diagnosis code. We also ranked the five most common specific reasons for hospitalization.

Results

There were over 35 million discharges included in the 2017 NIS database; 565,440 hospitalizations had either a principal or secondary ICD-10 code for RA. The top five reasons for RA hospitalization by ICD-10 code categories were as follows: cardiovascular (CV): 93,825 (16.59%), rheumatologic: 82,785 (14.64%), respiratory: 66,895 (11.83%), infection: 62,660 (11.09%), and injury/poisoning: 56,460 (9.96%). Sepsis was the most common principal diagnosis for RA hospitalizations.

Conclusion

CV diseases were the most common ICD category, and sepsis was the most common principal diagnosis for RA hospitalizations. Management of medical comorbidities (such as CV) and prevention of infection is essential for reducing the rates of RA hospitalizations.

Prognostic factors for the short-term mortality of patients with rheumatoid arthritis admitted to intensive care units

Background

Patients with rheumatoid arthritis (RA) have high mortality risk and are frequently treated in intensive care units (ICUs).

Methods

This was a retrospective observational study. This study included 67 patients (20 males, 47 females) with RA who were admitted at the ICU of our institution for ≥48 h between January 2008 and December 2017. We analyzed the 30-day mortality of these patients and the investigated prognostic factors in RA patients admitted to our ICU.

Results

Upon admission, the median age was 70 (range, 33–96) years, and RA duration was 10 (range, 0–61) years. The 5-year survival after ICU admission was 47%, and 30-day, 90-day, and 1-year mortality rates were 22, 27, and 37%, respectively. The major reasons for ICU admission were cardiovascular complications (24%) and infection (40%) and the most common ICU treatments were mechanical ventilation (69%), renal replacement (25%), and vasopressor (78%). In the 30-day mortality group, infection led to a fatal outcome in most cases (67%), and nonsurvival was associated with a significantly higher glucocorticoid dose, updated Charlson’s comorbidity index (CCI), and acute physiology and chronic health evaluation (APACHE) II score. Laboratory data obtained at ICU admission showed that lower platelet number and total protein and higher creatinine and prothrombin time international normalized ratio (PT-INR) indicated significantly poorer prognosis. The multivariate Cox proportional hazard model revealed that nonuse of csDMARDs, high updated CCI, increased APACHE II score, and prolonged PT-INR were associated with a higher risk of mortality after ICU admission.

Conclusion

Our study demonstrated that the nonuse of csDMARDs, high updated CCI, elevated APACHE II score, and coagulation abnormalities predicted poorer prognosis in RA patients admitted to the ICU.

Analysis of the relationship between systemic inflammation and diastolic dysfunction in patients with heart failure and rheumatoid arthritis

Aim. To study the relationship of the systemic inflammation with the morphological and functional myocardial parameters in patients with heart failure (HF) due to hypertension and coronary artery disease in combination with rheumatoid arthritis (RA).

Material and methods. The study included 57 women with NYHA class I-II HF. Patients were divided into two comparable groups: group 1 (n=31) — patients with HF and seropositive RA (Steinbrocker X-ray stage I-III); group 2 (n=26) — HF patients without RA.

Results. A comparative analysis of morphological and functional parameters did not reveal significant differences: left ventricular ejection fraction in groups 1 and 2 were 51,06±5,6% and 51,6±6,4%, respectively (p=0,7); the ratio of peak velocity blood flow in early diastole to peak velocity flow in late diastole (E/A) was 0,9±0,1 and 0,8±0,1, respectively (p=0,7). For other echocardiographic parameters, differences were also not detected (p>0,05). Nevertheless, significant regression model was created between the RA activity score (DAS28), rheumatoid factor, and E/A was created: R=0,5; R2 =0,3; F=2,6; p=0,04.

Conclusion. As a result of the study, significant direct moderate correlation of the RA activity score (DAS28) with E/A ratio was revealed in the group of patients with HF and RA. The data obtained may indicate an unfavorable prognosis of HF with an increase in RA activity.

Burn center admissions of patients with autoimmune rheumatic diseases: clinical characteristics and outcomes

The ojective of this study was to describe the reasons for admission to the burn center of patients with autoimmune rheumatic diseases (ARD), identify their clinical characteristics, and assess their outcomes relative to the non-ARD patients. We conducted a retrospective study of ARD patients admitted to a burn center from 2011 to 2018, and they were compared with a non-ARD group of patients. Medical records were reviewed for patients' clinical characteristics, including demographics, ARD diagnosis, laboratory studies, and APACHE II score. Additionally, we evaluate the reason for admission in the burn center, management during the burn center stay, complications, outcomes including length of stay, and mortality during the hospital stay. Among the 1094 adult patients admitted during the study period, 30 (2.7%) had a new or prior diagnosis of ARD. The most common ARD associated with admission in the burn center was rheumatoid arthritis (RA) (37%, n = 11) followed by systemic lupus erythematosus (SLE) (33%, n = 10). Burn injuries (47%, n = 14), and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) (30%, n = 9) were the most frequent admission reasons. Compared with the non-ARD group (n = 52), ARD patients were more likely to be females (60% vs. 24%, P = 0.004), to receive glucocorticoids (50% vs. 6.9%; P < 0.05), require renal replacement (20% vs. 5%, P < 0.05) and enteral nutrition (63% vs. 24%; P < 0.05) during their burn stay. The non-ARD group was more likely to be admitted for burn injuries (81% vs 46%, P < 0.01). RA and SLE were the most common ARD, and burn injuries, followed by SJS/TEN, the most frequent causes associated with burn admissions. ARD patients were more likely to be female, received glucocorticoids, require renal replacement, and enteral nutrition during the burn stay.

Mortality of Sepsis in Patients With Rheumatoid Arthritis: A Single-Center Retrospective Analysis and Comparison With a Control Group

INTRODUCTION/BACKGROUND

Patients with rheumatoid arthritis (RA) have a high risk of infections that may require intensive care unit (ICU) admission in case of resulting sepsis. Data regarding the mortality of these patients are very limited. This study investigated clinical characteristics and outcomes of patients with RA admitted to the ICU for sepsis and compared the results to a control cohort without RA.

METHODS

All patients with RA as well as sex-, age-, and admission year-matched controls admitted to the ICU of a university hospital for sepsis between 2006 and 2019 were retrospectively analyzed. Mortality was calculated for both the groups, and multivariate logistic regression was used to determine independent risk factors for sepsis mortality. The positive predictive value of common ICU scores was also investigated.

RESULTS

The study included 49 patients with RA (mean age 67.2 ± 9.0 years, 63.3% females) and 51 matched controls (mean age 67.4 ± 9.5 years, 64.7% females). Among the patients with RA, 42.9% (n = 21) were treated with conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) and 30.6% (n = 15) received glucocorticoids only. Seven (14.3%) patients received biologic (b) DMARDs. The hospital mortality was higher among patients with RA (42.9% vs 15.7%, P = .0016). Rheumatoid arthritis was independently associated with mortality in multivariate logistic regression (P = .001). In patients with RA, renal replacement therapy (P = .024), renal failure (P = .027), and diabetes mellitus (P = .028) were independently associated with mortality. Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), and Sequential Organ Failure Assessment (SOFA) scores were good predictors of sepsis mortality in patients with RA (APACHE II area under the curve [AUC]: 0.78, P = .001; SAPS II AUC: 0.78, P < .001; SOFA AUC 0.78, P < .001), but their predictive power was higher among controls.

CONCLUSIONS

Hospital sepsis mortality was higher in patients with RA than in controls. Rheumatoid arthritis itself is independently associated with an increased sepsis mortality. Renal replacement therapy, renal failure, and diabetes were associated with an increased mortality. Common ICU scores were less well predictors of sepsis mortality in patients with RA compared to non-RA controls.