Cigarette smoking and rheumatoid arthritis

The prevalence and risk factors of rheumatoid arthritis-associated interstitial lung disease: a systematic review and meta-analysis

BACKGROUND

Interstitial lung disease (ILD) is the most widespread and fatal pulmonary complication of rheumatoid arthritis (RA). Existing knowledge on the prevalence and risk factors of rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is inconclusive. Therefore, we designed this review to address this gap.

MATERIALS AND METHODS

To find relevant observational studies discussing the prevalence and/or risk factors of RA-ILD, EMBASE, Web of Science, PubMed, and the Cochrane Library were explored. The pooled odds ratios (ORs) / hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated with a fixed/ random effects model. While subgroup analysis, meta-regression analysis and sensitivity analysis were carried out to determine the sources of heterogeneity, the I2 statistic was utilized to assess between-studies heterogeneity. Funnel plots and Egger's test were employed to assess publication bias. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, our review was conducted.

RESULTS

A total of 56 studies with 11,851 RA-ILD patients were included in this meta-analysis. The pooled prevalence of RA-ILD was 18.7% (95% CI 15.8-21.6) with significant heterogeneity (I2 = 96.4%). The prevalence of RA-ILD was found to be more likely as a result of several identified factors, including male sex (ORs = 1.92 95% CI 1.70-2.16), older age (WMDs = 6.89, 95% CI 3.10-10.67), having a smoking history (ORs =1.91, 95% CI 1.48-2.47), pulmonary comorbidities predicted (HRs = 2.08, 95% CI 1.89-2.30), longer RA duration (ORs = 1.03, 95% CI 1.01-1.05), older age of RA onset (WMDs =4.46, 95% CI 0.63-8.29), positive RF (HRs = 1.15, 95%CI 0.75-1.77; ORs = 2.11, 95%CI 1.65-2.68), positive ACPA (ORs = 2.11, 95%CI 1.65-2.68), higher ESR (ORs = 1.008, 95%CI 1.002-1.014), moderate and high DAS28 (≥3.2) (ORs = 1.87, 95%CI 1.36-2.58), rheumatoid nodules (ORs = 1.87, 95% CI 1.18-2.98), LEF use (ORs = 1.42, 95%CI 1.08-1.87) and steroid use (HRs= 1.70, 1.13-2.55). The use of biological agents was a protective factor (HRs = 0.77, 95% CI 0.69-0.87).

CONCLUSION(S)

The pooled prevalence of RA-ILD in our study was approximately 18.7%. Furthermore, we identified 13 risk factors for RA-ILD, including male sex, older age, having a smoking history, pulmonary comorbidities, older age of RA onset, longer RA duration, positive RF, positive ACPA, higher ESR, moderate and high DAS28 (≥3.2), rheumatoid nodules, LEF use and steroid use. Additionally, biological agents use was a protective factor.

National burden of rheumatoid arthritis in Canada, 1990-2019: findings from the Global Burden of Disease Study 2019 - a GBD collaborator-led study

OBJECTIVE

The objectives of this study were: (1) to describe burden of rheumatoid arthritis (RA) and trends from 1990 to 2019 using the Global Burden of Diseases, Injuries and Risk Factors Study (GBD) data, (2) to describe age and sex differences in RA and (3) to compare Canada's RA burden to that of other countries.

METHODS

Disease burden indicators included prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs) and disability-adjusted life-years (DALYs). GBD estimated fatal and non-fatal outcomes using published literature, survey data and health insurance claims. Data were analysed by Bayesian meta-regression, cause of death ensemble model and other statistical methods. DALYs for Canada were compared with DALYs of countries with similarly high Socio-Demographic Index values.

RESULTS

In Canada, the RA prevalence rate increased by 27% between 1990 and 2019, mortality rate decreased by 27%, YLL rate decreased by 30%, YLD increased by 27% and DALY rate increased by 13%, all age standardised. The decline in RA mortality and YLL rates was especially pronounced after 2002. The disease burden was higher in females for all indicators, and DALY rates were higher among older age groups, peaking at age 75-79 years. Prevalence and DALYs were higher in Canada compared with global rates.

CONCLUSION

Trends in RA burden indicators over time and differences by age and sex have important implications for Canadian policy-makers, researchers and care providers. Early identification and management of RA in women may help reduce the overall burden of RA in Canada.

Vasculitis Leading to Gangrene: An Early Presentation in a Rheumatoid Arthritis Patient

Vasculitis is a late complication in rheumatoid arthritis (RA) and is seen in RA patients with long-standing disease. Rheumatoid vasculitis affects small-to-medium-sized vessels. In a few patients, vasculitis develops early in the course of the disease. Here, we report the case of a 32-year-old female who presented with gangrene in the second and third digits of the right foot and gangrene in the second digit of the left foot. She was on hydroxychloroquine and methotrexate for one year since the diagnosis of RA. The patient then developed Raynaud's phenomenon and blackish discoloration of toes. She was started on pulse methylprednisolone, aspirin, nifedipine, and pentoxifylline. As no improvement was seen, intravenous cyclophosphamide was started. There was no improvement even after starting cyclophosphamide, and the gangrene further worsened. Eventually, after consulting the surgical team, it was decided to amputate the digits. The second digits in both feet were subsequently amputated. Hence, a physician should always be careful in checking for signs of vasculitis in RA patients early in the course of the disease as well.

Association between malignancy risk and Janus kinase inhibitors versus tumour necrosis factor inhibitors in Korean patients with rheumatoid arthritis: a nationwide population-based study

OBJECTIVE

To determine the risk of malignancy in Korean patients with rheumatoid arthritis (RA) receiving Janus kinase inhibitors (JAKis) compared with tumour necrosis factor inhibitors (TNFis).

METHODS

A retrospective cohort of patients with RA initiating their first JAKi or TNFi was established using the Korean National Health Insurance database between 2015 and 2019. They were followed up from treatment initiation to the occurrence of malignancy, drug discontinuation, death or until December 2019. Baseline features of the patients were balanced through inverse probability of treatment weighting (IPTW) using a propensity score. A Cox proportional hazard model was established to estimate the HR for malignancy risk in JAKi users compared with TNFi users.

RESULTS

A total of 4929 patients (1064 JAKi-treated and 3865 TNFi-treated patients) were included, and the observation periods were 1288.6 person-years (PYs) for JAKi users and 6823.8 PYs for TNFi users. The incidence rates of overall malignancy were 0.54 per 100 PYs (95% CI 0.26 to 1.14) in JAKi users and 0.85 per 100 PYs (95% CI 0.66 to 1.10) in TNFi users. In IPTW analysis with a balanced sample (4101 JAKi-treated and 5131 TNFi-treated patients), HR was 0.83 (95% CI 0.55 to 1.27) for overall malignancy: 0.77 (95% CI 0.50 to 1.19) for solid malignancy and 2.86 (95% CI 0.41 to 20.00) for haematological malignancy.

CONCLUSION

Malignancy risk in Korean patients with RA was not increased with JAKi use compared with TNFi use.

Glucose as a Potential Key to Fuel Inflammation in Rheumatoid Arthritis

Glucose is the most important source of energy and homeostasis. Recent investigations are clarifying that glucose metabolism might be altered in rheumatoid arthritis (RA), which would play a role in the inflammatory phenotype of rheumatoid synovial fibroblasts. It may also play a role in a variety of autoimmune diseases’ pathophysiology by modulating immune responses and modifying autoantigen expressions. The research into glucose and its metabolism could lead to a better understanding of how carbohydrates contribute to the occurrence and duration of RA and other autoimmune diseases.

Systematic Evaluation of Rheumatoid Arthritis Risk by Integrating Lifestyle Factors and Genetic Risk Scores

Background

Effective identification of high-risk rheumatoid arthritis (RA) individuals is still a challenge. Whether the combined effects of multiple previously reported genetic loci together with lifestyle factors can improve the prediction of RA risk remains unclear.

Methods

Based on previously reported results and a large-scale Biobank dataset, we constructed a polygenic risk score (PRS) for RA to evaluate the combined effects of the previously identified genetic loci in both case-control and prospective cohorts. We then evaluated the relationships between several lifestyles and RA risk and determined healthy lifestyles. Then, the joint effects of healthy lifestyles and genetic risk on RA risk were evaluated.

Results

We found a positive association between PRS and RA risk (OR = 1.407, 95% confidence interval (CI) = 1.354~1.463; HR = 1.316, 95% CI = 1.257~1.377). Compared with the low genetic risk group, the group with intermediate or high genetic risk had a higher risk (OR = 1.347, 95% CI = 1.213~1.496; HR = 1.246, 95% CI = 1.108~1.400) (OR = 2.169, 95% CI = 1.946~2.417; HR = 1.762, 95% CI = 1.557~1.995). After adjusting for covariates, we found protective effects of three lifestyles (no current smoking, regular physical activity, and moderate body mass index) on RA risk and defined them as healthy lifestyles. Compared with the individuals with low genetic risks and favorable lifestyles, those with high genetic risks and unfavorable lifestyles had as high as OR of 4.637 (95%CI = 3.767~5.708) and HR of 3.532 (95%CI = 2.799~4.458).

Conclusions

In conclusion, the integration of PRS and lifestyles can improve the prediction of RA risk. High RA risk can be alleviated by adopting healthy lifestyles but aggravated by adopting unfavorable lifestyles.

Factors associated with mortality in rheumatoid arthritis-associated interstitial lung disease: a systematic review and meta-analysis

Background

Interstitial lung disease (ILD) is a common and potentially life-threatening complication for rheumatoid arthritis (RA) patients. However, there is a lack of clear prognostic factors in rheumatoid arthritis-associated interstitial lung disease (RA-ILD) patients. The purpose of this study was to complete a systematic review and meta-analysis of the factors associated with mortality in RA-ILD patients.

Methods

Medline, EMBASE and the Cochrane Library were searched up to September 1, 2020. The Newcastle–Ottawa Scale (NOS) was applied to assess the methodological quality of the eligible studies. Study characteristics and magnitude of effect sizes were extracted. Then, pooled hazard ratios (HRs) with the corresponding 95% confidence intervals (CIs) and pooled risk ratios (RRs) with 95% CIs were calculated to assess the factors associated with mortality in RA-ILD.

Results

Twenty-three of 3463 articles were eligible, and ten factors associated with mortality for RA-ILD were evaluated in the meta-analysis. Older age (HRs = 1.04, 95% CI 1.03–1.05), male sex (HRs = 1.44, 95% CI 1.21–1.73), having a smoking history (HRs = 1.42, 95% CI 1.03–1.96), lower diffusing capacity of the lung for carbon monoxide (DLCO)% predicted (HRs = 0.98, 95% CI 0.97–1.00), forced vital capacity (FVC)% predicted (HRs = 0.99, 95% CI 0.98–1.00), composite physiological index (CPI) (HRs = 1.04, 95% CI 1.02–1.06), usual interstitial pneumonia (UIP) pattern on HRCT (HRs = 1.88, 95% CI 1.14–3.10 and RRs = 1.90, 95% CI 1.50–2.39), emphysema presence (HRs = 2.31, 95% CI 1.58–3.39), and acute exacerbation of ILD (HRs = 2.70, 95% CI 1.67–4.36) were associated with increased mortality in RA-ILD, whereas rheumatoid factor (RF) positive status was not associated.

Conclusions

Through this systematic review and meta-analysis, we found that older age, male sex, smoking history, higher CPI, lower DLCO% predicted, lower FVC% predicted, UIP pattern on HRCT, emphysema presence and acute exacerbation of ILD were associated with an increased risk of mortality in RA-ILD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01856-z.

Rheumatoid arthritis-associated interstitial lung disease: an overview of epidemiology, pathogenesis and management

Interstitial lung disease (ILD) accounts for the major cause of morbidity and mortality in rheumatoid arthritis (RA). However, little is known of the pathogenesis, diagnosis and treatment of RA-associated ILD. In this review, we describe our present understanding and ongoing research in RA-ILD. Its aetiology does appear to associate with anti-cyclic citrullinated peptide antibodies, MUC5B mutation and smoking. Another focus of this article is on recent diagnostic methods in RA-ILD. Compared with other methods, high-resolution computed tomography (HRCT) imaging is a main method for the evaluation of ILD in RA patients. Pulmonary function is better suited for assessing progression. An important topic relates to therapeutic intervention. Disease-modifying anti-rheumatic drugs (DMARDs) in RA lack strong evidence in the onset or worsening of ILD. The available literature support that methotrexate, leflunomide, abatacept and rituximab play beneficial roles in the prevention and treatment of RA-ILD.

Mechanisms of lung disease development in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes joint inflammation and damage. Extra-articular manifestations occur in many patients and can include lung involvement in the form of airway or parenchymal inflammation and fibrosis. Although the pathophysiology of articular RA has been extensively investigated, the mechanisms causing airway and parenchymal lung disease are not well defined. Infections, cigarette-smoking, mucosal dysbiosis, host genetics and premature senescence are all potentially important contributors to the development of lung disease in patients with RA. RA-associated lung disease (which can predate the onset of articular disease by many years) probably originates from chronic airway and alveolar epithelial injury that occurs in an individual with a genetic background that permits the development of autoimmunity, leading to chronic inflammation and subsequent airway and lung parenchymal remodelling and fibrosis. Further investigations into the specific mechanisms by which lung disease develops in RA will be crucial for the development of effective therapies. Identifying mechanisms by which environmental and host factors cooperate in the induction of autoimmunity in the lung might also help to establish the order of early events in RA.

Smoking Is a Risk Factor for Relapse of Antimyeloperoxidase Antibodies-Associated Vasculitis

BACKGROUND/OBJECTIVE

Several studies have identified predictors of relapse in antineutrophil cytoplasmic antibody-associated small-vessel vasculitis. However, the role of smoking as a risk factor of relapse has not been elucidated. Therefore, this study aimed to evaluate whether a history of smoking is a dose-dependent independent risk factor for antineutrophil cytoplasmic antibody-associated small-vessel vasculitis relapse.

METHODS

This multicenter retrospective cohort study included 122 patients with granulomatosis with polyangiitis and microscopic polyangiitis (MPA) from 9 nephrology centers in Japan. Dose-response relationships between cigarette smoking and outcomes were assessed using multivariate Cox proportional hazards models, adjusted for clinically relevant factors. The primary outcome was the time from remission to first relapse.

RESULTS

During the observation period (median, 41 months; interquartile range, 23-66 months), 118 (95.8%) and 34 (21.7%) patients experienced at least 1 remission and 1 relapse, respectively. A log-rank test showed that smoking was significantly associated with relapse (p = 0.003). Multivariate Cox proportional hazards models found current smoking to be associated with relapse (adjusted hazard ratio, 7.48; 95% confidence interval, 2.73-21.0). An association between the risk of relapse and cumulative pack-years of smoking was also noted (p = 0.004). Smoking, however, was not associated with remission.

CONCLUSIONS

Smoking is a significant and dose-dependent risk factor for relapse of MPA. All patients with MPA who smoke should be encouraged to quit.

Analysis of differentially expressed genes in rheumatoid arthritis and osteoarthritis by integrated microarray analysis

BACKGROUND

Rheumatoid arthritis (RA) and osteoarthritis (OA) were two major types of joint diseases. This study aimed to explore the mechanism underlying OA and RA and analyze their difference by integrated analysis of multiple gene expression data sets.

METHODS

Gene expression data sets of RA and OA were downloaded from The Gene Expression Omnibus. Shared and specific differentially expressed genes (DEGs) in RA and OA were identified by integrated analysis of multiple gene expression data sets. Functional annotation and protein-protein interaction (PPI) network construction of OA- and RA-specific DEGs were performed to further explore the molecular mechanisms underlying RA and OA and analyze the mechanism differences between them.

RESULTS

Compared with normal controls, 3757 and 2598 DEGs were identified in RA and OA, respectively. Among them, 2176 DEGs were RA-specific DEGs and 1017 DEGs were OA-specific DEGs. Moreover, the expression of 17 DEGs played opposite pattern in RA and OA compared with normal controls. Chemokine signaling pathway and oxidative phosphorylation were significantly enriched pathways for RA- and OA-specific DEGs, respectively. BIRC2 and CSNK1E were respective hub genes of RA- and OA-specific PPI network.

CONCLUSION

Our findings provided clues for the specific mechanism and developing specific biomarkers for RA and OA.

Side effects of methotrexate therapy for rheumatoid arthritis: A systematic review

Methotrexate (MTX) is used as an anchor disease-modifying anti-rheumatic drugs (DMARDs) in treating rheumatoid arthritis (RA) because of its potent efficacy and tolerability. MTX benefits a large number of RA patients but partially suffered from side effects. A variety of side effects can be associated with MTX when treating RA patients, from mild to severe or discontinuation of the treatment. In this report, we reviewed the possible side effects that MTX might cause from the most common gastrointestinal toxicity effects to less frequent malignant diseases. In order to achieve regimen with less side effects, the administration of MTX with appropriate dose and a careful pretreatment inspection is necessary. Further investigations are required when combining MTX with other drugs so as to enhance the efficacy and reduce side effects at the same time. The management of MTX treatment is also discussed to provide strategies for occurred side effects. Thus, this review will provide scholars with a comprehensive understanding the side effects of MTX administration by RA patients.

Prevalence of osteoarthritis and association between smoking patterns and osteoarthritis in China: a cross-sectional study

Objective

The aims of this study were to estimate the prevalence of radiographic osteoarthritis (OA) and to assess the association between smoking patterns and OA prevalence in adults aged 50 years or older belonging to the Shanxi province of China.

Methods

A cross-sectional study in the rural regions of the Shanxi province was conducted among 2638 Chinese adults (aged ≥50 years). Demographic characteristics and behavioral information were collected through epidemiological surveys. All participants with joint pain underwent plain radiographic examination and were diagnosed by a professional orthopedist. Associations between smoking patterns and the prevalence of OA were assessed using binary logistic regression modeling.

Results

Among 2638 individuals (men, 50.3% and women, 49.7%; mean age, 61.5 years) included in the analysis, 49.8% had radiographic OA and 27.5% had knee OA. The prevalence of radiographic OA was higher in women than in men (P<0.001). After adjusting for potential confounding factors, there was a nonsignificant correlation between smoking and OA prevalence in the multivariate model. Odds ratios (ORs) for all types of OA and knee OA were higher in active and passive smokers than in nonsmoking individuals after adjustments (OR 1.374; 95% confidence interval [CI] 1.049–1.802; OR 1.440; 95% CI 1.059–1.958, respectively).

Conclusions

This study showed that smoking may not be an independent risk factor for OA; however, there was a positive correlation between active and passive smoking and OA.

Rheumatoid Vasculitis: A Diminishing Yet Devastating Menace

PURPOSE OF REVIEW

Rheumatoid vasculitis (RV) is an unusual complication of long-standing rheumatoid arthritis, which is characterized by the development of necrotizing or leukocytoclastic vasculitis involving small or medium-sized vessels. In this review, we aim to provide an update on the epidemiology, pathogenesis, clinical presentation, and management of this challenging extra-articular manifestation.

RECENT FINDINGS

RV is heterogenous in its clinical presentation depending on the organ and size of blood vessels involved. The most common organs involved are the skin and peripheral nerve. Based on recent population studies, the incidence has significantly decreased with early recognition and the advent of immunosuppressive drugs and biologics; however, the mortality rates remain high. RV remains a serious extra-articular manifestation of RA that needs to be promptly recognized and treated. No consensus is available on treatment, given the ongoing debate of whether the biologics can trigger or treat RV.

Incidence of Chronic Persistent Rheumatoid Arthritis and the Impact of Smoking: A Historical Twin Cohort Study

OBJECTIVE

To assess the incidence of chronic persistent rheumatoid arthritis (RA) in a population-based cohort of twins and to determine the impact of smoking.

METHODS

In a historical cohort study on twins born in 1920 to 1982, we identified 157 cases of RA among 45,280 responders (response rate 80%). Information on smoking was obtained by questionnaire and interview. A mixed-effects Poisson regression model was used to estimate incidence rate ratios with age, sex, smoking duration, and smoking intensity as covariates. We used the SplitLexis procedure in the Epi R package to study a possible effect of period or cohort in addition to age on the variation of the incidence.

RESULTS

The annual incidence of chronic persistent RA was 18.8 per 100,000 person-years, ages 15-73 years (females 25.2, males 12.0), increasing with age to a maximum at age 60 years in females and age 70 years in males. The incidence rate ratio among ever-smoking patients was 1.96 (95% confidence interval [95% CI] 1.43-3.76), 1.93 (95% CI 1.00-3.7) after 30 pack-years, and 1.034 (P < 0.001) per year of smoking, implying a doubling of risk after 20 years regardless of sex and smoking intensity. We did not detect significant period or cohort effects.

CONCLUSION

The incidence of chronic persistent RA is lower than the incidence figures reported in inception cohorts. Smoking duration, but not intensity, doubled the risk of RA after 20 years of smoking in both sexes.

Connective Tissue Disorder-Associated Vasculitis

Vasculitides secondary to connective tissue diseases are classified under the category of 'vasculitis associated with systemic disease' in the revised International Chapel Hill Consensus Conference (CHCC) nomenclature. These secondary vasculitides may affect any of the small, medium or large vessels and usually portend a poor prognosis. Any organ system can be involved and the presentation would vary depending upon that involvement. Treatment depends upon the type and severity of presentation. In this review, we describe secondary vasculitis associated with rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, relapsing polychondritis, systemic sclerosis, Sjogren's syndrome and idiopathic inflammatory myositis, focusing mainly on recent advances in the past 3 years.

Association between direct and indirect smoking and osteoarthritis prevalence in Koreans: a cross-sectional study

OBJECTIVES

To assess the association between smoking patterns and knee and hip joint osteoarthritis (OA) prevalence in Koreans aged 50 years or older with focus on knee OA.

DESIGN

Cross-sectional study using nationally representative data.

SETTING

Data were collected at portable Health Examination Centres in Korea.

PARTICIPANTS

Data of 9064 participants of the 5th Korean National Health and Nutrition Examination Survey (2010-2012) aged 50 years or older who received knee or hip joint X-rays out of 31,596 total surveyees were analysed.

PRIMARY OUTCOME MEASURES

OA prevalence by smoking behaviour (current smoking, past smoking, indirect smoking and non-smoking).

SECONDARY OUTCOME MEASURES

Estimated risk of OA by smoking amount, period, pack-years and indirect smoking exposure time to assess the association between smoking-related factors and knee OA by calculating ORs and adjusting for covariates in a complex sampling design. A multinomial logistic regression analysis and backward elimination method was used.

RESULTS

OA prevalence in Koreans aged 50 years or older was 13.9%, with prevalence about 3.5 times higher in women (men 5.7%, women 20.1%). ORs for knee and hip joint OA prevalence by smoking behaviour in male indirect-smokers were lower than those in non-smokers in age and sex (OR 0.271; 95% CI 0.088 to 0.828), and selective adjustments (OR 0.314; 95% CI 0.102 to 0.966). All other analyses for smoking behaviour and total OA prevalence, and knee OA prevalence were not significantly different. Associations between smoking amount, period, pack-years and knee OA prevalence were non-significant in ever-smokers. Associations between indirect smoking exposure time and knee OA prevalence were also non-significant.

CONCLUSIONS

This study found that though direct and previous smoking and OA prevalence were not associated, there was a weak relationship between indirect smoking and OA.

Inflammatory Articular Disease in Patients with Inflammatory Bowel Disease: Result of the Swiss IBD Cohort Study

BACKGROUND

Inflammatory bowel diseases (IBD) are systemic conditions that commonly display extraintestinal manifestations. Inflammatory articular disease (IAD: axial or peripheral) is the most common extraintestinal manifestation. The aim of this study was to evaluate the prevalence and the clinical characteristics associated with IAD in patients with IBD.

METHODS

We analyzed patients enrolled in the Swiss IBD cohort study. IAD was defined as persistent or recurrent joint pain with an inflammatory pattern (night pain, progressive relief during the day, morning stiffness lasting at least 30 minutes) or the presence of arthritis as diagnosed by the physicians. A multivariate logistic regression was performed to analyze which disease characteristics were independently associated with the presence of IAD.

RESULTS

A total of 2353 patients with IBD, 1359 with Crohn's disease, and 994 with ulcerative colitis (UC) were included. Forty-four percent of patients fulfilled the criteria for IAD, whereas 14.5% presented with other extraintestinal manifestations. IAD was associated with Crohn's disease, with female sex, with older age, and generally in patients with more active intestinal disease. Only in UC, IAD was further associated with tobacco smoking and with increasing body mass index.

CONCLUSIONS

This population of patients with IBD displays a high prevalence of IAD. IAD was more strongly associated with Crohn's disease than UC. Other risk factors for IAD were female sex, advanced age, active digestive disease, and tobacco consumption in patients with UC, which is interesting given the established association between smoking and other inflammatory arthritides.

Rheumatoid vasculitis: an update

PURPOSE OF REVIEW

Rheumatoid vasculitis is the most serious extra-articular complication of rheumatoid arthritis, with high morbidity and mortality noted in multiple prior reports. Recent studies have expanded our understanding of this entity in the era of modern immunosuppressive therapy. New clinical predictors and possible protective factors have also been identified.

RECENT FINDINGS

This review provides an update on the epidemiology, clinical correlates, predictors, therapy and outcomes of rheumatoid vasculitis over the past decade. During this time, there has been increasing use of the treat-to-target management practices and incorporation of biologic response modifiers that have revolutionized rheumatoid arthritis treatment with better disease control and overall improved outcomes. The incidence of rheumatoid vasculitis has declined significantly in the past several decades, but morbidity and mortality continue to remain high, despite aggressive treatment with cyclophosphamide or biologic agents. Hydroxychloroquine and low-dose aspirin may have a protective role. There is ongoing debate about the role of newer biological therapies in prevention, treatment or even as a trigger for rheumatoid vasculitis.

SUMMARY

Rheumatoid vasculitis remains a rare yet challenging extra-articular manifestation of rheumatoid arthritis with high morbidity and mortality, despite aggressive use of disease-modifying therapy.

Lung disease in rheumatoid arthritis

Rheumatoid arthritis (RA) affects approximately 1% of the US population frequently has extra-articular manifestations. Most compartments of the lung are susceptible to disease. Interstitial lung disease (ILD) and airways disease are the most common forms of RA-related lung disease. RA-ILD carries the worst prognosis and most often manifests in a histologic pattern of usual interstitial pneumonia or nonspecific interstitial pneumonia. There have been no large, well-controlled prospective studies investigating therapies for RA-ILD. Treatment usually entails immunomodulatory agents. Further studies are needed to better understand pathogenic mechanisms of disease that lead to lung involvement in these patients.

Relationship between cigarette smoking and radiographic knee osteoarthritis in Chinese population: a cross-sectional study

The purpose of this paper was to estimate the cross-sectional association between cigarette smoking and radiographic knee Osteoarthritis (OA) in Chinese population. A total of 3,789 subjects (1,796 females and 1,993 males) participated in this study. A subject was diagnosed with radiographic knee OA if Kellgren-Lawrence (K-L) grade ≥2 in at least one leg. The smoking status was classified into four levels based on the daily smoking habit: (1) 0/day; (2) 1-10/day; (3) 11-20/day; and (4) >20/day. Linear trend and multivariable logistic regression were conducted for statistical analysis. The prevalence of radiographic knee OA was 28.4 % among the subjects of this study. An inverse association was observed between cigarette smoking and radiographic knee OA in the linear trend test. Such association remained valid after adjusting the factors of age, gender, body mass index, betel quilt chewing status, physical activity, alcohol drinking status, mean total energy intake and educational level in the multivariable logistic regression. This study suggested a negative association between cigarette smoking and radiographic knee OA in the Chinese population. The findings of this study need to be confirmed by further prospective research.

Vagus nerve stimulation: a new bioelectronics approach to treat rheumatoid arthritis?

There has been a marked improvement in the treatment of rheumatoid arthritis (RA), but most patients do not achieve disease remission. Therefore, there is still a need for new treatments. By screening an adenoviral short hairpin RNA library, we discovered that knockdown of the nicotinic acetylcholine receptor type 7 (α7nAChR) in RA fibroblast-like synoviocytes results in an increased production of mediators of inflammation and degradation. The α7nAChR is intimately involved in the cholinergic anti-inflammatory pathway (CAP). This led us to study the effects of α7nAChR activation in an animal model of RA, and we could show that this resulted in reduced arthritis activity. Accordingly, stimulation of the CAP by vagus nerve stimulation improved experimental arthritis. Conversely, we found aggravation of arthritis activity after unilateral cervical vagotomy as well as in α7nAChR-knockout mice. Together, these data provided the basis for exploration of vagus nerve stimulation in RA patients as a novel anti-inflammatory approach.

Associations of alcohol consumption and mental health with the prevalence of arthritis among US adults: data from the 2012 National Health Interview Survey

The findings of association between alcohol consumption and arthritis are mixed while little is known about age differences in the associations of mental health and behavioral factors with arthritis. This study aimed to estimate the prevalence and associated factors of arthritis among US adults using data from the 2012 National Health Interview Survey. In total, 8,229 adults with arthritis and 26,256 controls were selected from the adult respondents. Weighted univariate and multiple logistic regression analyses were used to estimate the odds ratios (ORs) with 95 % confidence intervals. The overall prevalence of arthritis was 22.1 %. The prevalence increased with age (6.8, 29.6, and 47.9 % for 18-49, 50-64, and 65+ years of age, respectively). The prevalence of mental problems was higher in cases than controls [4 vs. 1 % for serious psychological distress (SPD), 29 vs. 16 % for anxiety, and 26 vs. 11 % for depression, respectively]. Multiple logistic regression analyses showed that being female, older age, smoking, alcohol consumption, obesity, SPD, depression, and anxiety were positively associated with arthritis. Stratified by age, SPD was associated with arthritis only in young adults (18-49 years old) while the ORs of anxiety and depression with arthritis decreased as age increased. Alcohol consumption revealed stronger associations in middle-aged adults and elderly. Using a large nationally representative sample in the USA, alcohol consumption, smoking, SPD, anxiety, and depression were associated with arthritis, and the associations varied across different age groups.

Functional annotation of rheumatoid arthritis and osteoarthritis associated genes by integrative genome-wide gene expression profiling analysis

Background

Rheumatoid arthritis (RA) and osteoarthritis (OA) are two major types of joint diseases that share multiple common symptoms. However, their pathological mechanism remains largely unknown. The aim of our study is to identify RA and OA related-genes and gain an insight into the underlying genetic basis of these diseases.

Methods

We collected 11 whole genome-wide expression profiling datasets from RA and OA cohorts and performed a meta-analysis to comprehensively investigate their expression signatures. This method can avoid some pitfalls of single dataset analyses.

Results and Conclusion

We found that several biological pathways (i.e., the immunity, inflammation and apoptosis related pathways) are commonly involved in the development of both RA and OA. Whereas several other pathways (i.e., vasopressin-related pathway, regulation of autophagy, endocytosis, calcium transport and endoplasmic reticulum stress related pathways) present significant difference between RA and OA. This study provides novel insights into the molecular mechanisms underlying this disease, thereby aiding the diagnosis and treatment of the disease.

Incidence and mortality of obstructive lung disease in rheumatoid arthritis: a population-based study

OBJECTIVE

Pulmonary disease represents an important extraarticular manifestation of rheumatoid arthritis (RA). While the association of RA and interstitial lung disease is widely acknowledged, obstructive lung disease (OLD) in RA is less well understood. We therefore aimed to assess the incidence, risk factors, and mortality of OLD in patients with RA.

METHODS

We examined a population-based incident cohort of patients with RA and a comparison cohort of individuals without RA. OLD was defined using a strict composite criterion. Cox proportional hazards models were used to compare OLD incidence between the RA and comparator cohorts to investigate risk factors and to explore the impact of OLD on patient survival.

RESULTS

A total of 594 patients with RA and 596 subjects without RA were followed for a mean of 16.3 and 19.4 years, respectively. The lifetime risk of developing OLD was 9.6% for RA patients and 6.2% for subjects without RA (hazard ratio [HR] 1.54, 95% confidence interval [95% CI] 1.01-2.34). The risk of developing OLD was higher among male patients, among current or former smokers, and for individuals with more severe RA. Survival of RA patients diagnosed with OLD was worse compared to those without OLD (HR 2.09, 95% CI 1.47-2.97).

CONCLUSION

Patients with RA are at higher risk of developing OLD, which is significantly associated with premature mortality. Effective diagnostic and therapeutic strategies to detect and manage OLD in patients with RA may help to improve survival in these patients.

Rheumatoid arthritis and cardiovascular disease: an update on treatment issues

PURPOSE OF REVIEW

This review examines thresholds for treatment of traditional cardiovascular disease (CVD) risk factors among patients with rheumatoid arthritis (RA) and whether RA-specific treatment modulates cardiovascular risk.

RECENT FINDINGS

There are substantial data demonstrating an increased CVD risk among patients with RA. Both traditional CVD risk factors and inflammation contribute to this risk. Recent epidemiologic studies strengthen the case that aggressive immunosuppression with biologic disease-modifying anti-rheumatic drugs (DMARDs), such as tumour necrosis factor (TNF) antagonists, is associated with a reduced risk of CVD events. However, to date, there are no randomized controlled trials published regarding the management of CVD in RA.

SUMMARY

Epidemiologic evidence continues to accumulate regarding the relationship between the effects of traditional CVD risk factors and RA-specific treatments on cardiovascular outcomes in RA. The field needs randomized controlled trials to better guide management.

Stressful life events antedating chronic childhood arthritis

OBJECTIVE

To investigate associations between antecedent stressful life events and occurrence of juvenile arthritis (JA).

METHODS

The study population comprised patients with JA referred to a pediatric rheumatology clinic between 1981 and 2010. A questionnaire, which was developed as a screening tool by the clinic, was completed at the first clinic visit by patients' parents and, for comparison, by parents of unrelated age, sex, geographically, and temporally matched healthy controls. The entire questionnaire captured a broad array of clinical, demographic, psychosocial, and environmental data, including questions about stressful life events from 686 patients with JA and from 1042 controls.

RESULTS

Patients were more likely to have experienced a serious upset (OR 4.81; p < 0.0001), a currently ill family member (OR 2.29; p < 0.0001), separated parents (OR 1.96; p < 0.0001), or difficulties with interpersonal relationships (OR 2.54; p < 0.0001) prior to first clinic presentation compared to controls. Children with oligoarticular JA were more likely than controls to have experienced a serious upset (OR 3.46; p = 0.008), an ill family member (OR 3.79; CI 2.02, 7.11; p < 0.0001), or problems with interpersonal interactions (OR 3.32; p < 0.0001). Children with polyarticular JA were more likely to have experienced a serious upset (OR 5.68; p < 0.0001), separated parents (OR 2.66; p = 0.001), a deceased parent (OR 6.75, p = 0.017), or problems with interpersonal relationships (OR 2.39; p = 0.009). No significant differences were observed when comparing systemic JA patients to controls.

CONCLUSION

Strong associations between stressful life events antedating the first clinic visit of patients with JA indicate that life event stresses should be identified and addressed when first encountering and managing children with JA.

Combined pulmonary fibrosis and emphysema in connective tissue disease

PURPOSE OF REVIEW

This review discusses combined pulmonary fibrosis and emphysema (CPFE) in the setting of connective tissue disease.

RECENT FINDINGS

CPFE is a recently identified syndrome in smokers or ex-smokers characterized by dyspnea often severe, preserved lung volumes, severely impaired gas exchanges, and an increased risk of pulmonary hypertension associated with a dismal prognosis, and possibly lung cancer. It may be encountered in the setting of connective tissue diseases, especially rheumatoid arthritis and systemic sclerosis, with generally similar features as 'idiopathic' (tobacco-related) CPFE. The diagnosis is based on the presence of both emphysema predominating in the upper lobes and frequently paraseptal, and interstitial abnormalities suggesting pulmonary fibrosis in the lower lung zones with velcro crackles at auscultation. Pathologic radiological correlations are difficult owing to various pathology and difficulties in identifying honeycombing at chest high-resolution computed tomography in the setting of coexistent emphysema. Tobacco smoking is associated with an increased risk of developing most of the individual components of the syndrome (i.e. emphysema, pulmonary fibrosis, pulmonary hypertension, rheumatoid arthritis, and pulmonary fibrosis among patients with rheumatoid arthritis). CPFE impacts modalities of follow-up for pulmonary function and detection of pulmonary hypertension especially in systemic sclerosis.

SUMMARY

The syndrome of CPFE is a distinct pulmonary manifestation in the spectrum of lung diseases associated with connective tissue diseases, especially in smokers or ex-smokers.

What Have We Learned about the Pathogenesis of Rheumatoid Arthritis from TNF-Targeted Therapy?

Studies of cytokine regulation in rheumatoid arthritis led to the development of TNFα inhibitors which are now used for a number of indications, including rheumatoid arthritis, inflammatory bowel disease, psoriasis, psoriatic arthritis, and ankylosing spondylitis. The widespread use of biologics in the clinic offers unique opportunities for probing disease pathogenesis and this paper provides an overview of rheumatoid arthritis, with a particular emphasis on the impact of anti-TNFα therapy on pathogenetic mechanisms. An overview is also provided on the most commonly used animal models that mimic RA, including adjuvant-induced arthritis, collagen-induced arthritis, TNFα-transgenic mice, and the K/BxN and SKG models. These models have led to significant discoveries relating to the importance of pro-inflammatory cytokines in the pathogenesis of rheumatoid arthritis, resulting from disregulation of the normally finely tuned balance of pro- and anti-inflammatory cytokine signalling. In addition, experimental evidence is discussed suggesting how genetic and environmental factors can contribute to disease susceptibility. The role of effector and regulatory T cells is discussed in the light of the relatively disappointing therapeutic effects of T cell modifying agents such as anti-CD4 antibody and cyclosporin. It is concluded that comprehensive analyses of mechanisms of action of biologics and other drugs entering the clinic will be essential to optimise therapy, with the ultimate aim of providing a cure.

Distinguishing features of cancer patients who smoke: pain, symptom burden, and risk for opioid misuse

Although many cancer patients who have pain are smokers, the extent of their symptom burden and risk for opioid misuse are not well understood. In this study we analyzed records of patients being treated for cancer pain, 94 of whom were smokers and 392 of whom were nonsmokers, to determine smoking status group differences. Smokers had significantly higher pain intensity, fatigue, depression, and anxiety than nonsmokers (independent samples t-tests P < .002). Smokers were at higher risk for opioid misuse based on the short form of the Screener and Opioid Assessment for Patients with Pain (SOAPP). Specifically, smokers had more frequent problems with mood swings, taking medications other than how they are prescribed, a history of illegal drug use, and a history of legal problems (chi-square tests P ≤ .002). Changes in pain and opioid use were examined in a subset of patients (146 nonsmokers and 46 smokers) who were receiving opioid therapy on at least 2 of the 3 data time points (consult, follow-up 1 month after consult, follow-up 6 to 9 months after consult). Results based on multilevel linear modeling showed that over a period of approximately 6 months, smokers continued to report significantly higher pain than nonsmokers. Both smokers and nonsmokers reported a significant decline in pain across the 6-month period; the rate of decline did not differ across smokers and nonsmokers. No significant difference over time was found in opioid use between smokers and nonsmokers. These findings will guide subsequent studies and inform clinical practice, particularly the relevancy of smoking cessation.

PERSPECTIVE

This article describes pain, symptom burden, and risk for opioid misuse among cancer patients with pain across smoking status. Smoking appears to be a potential mechanism for having an increased pain and symptom burden and risk for opioid misuse. This improved understanding of cancer pain will inform clinical practice.

Traditional cardiovascular risk factors, inflammation and cardiovascular risk in rheumatoid arthritis

Multiple studies demonstrate an increased cardiovascular (CV) risk associated with RA compared with the general population. While part of this risk appears to be mediated by RA-specific factors, such as long-term inflammation, traditional CV comorbidities also play an important role. We review evidence from previous studies of the relationship between RA and traditional CV comorbidities such as dyslipidaemia, obesity, insulin resistance and diabetes, hypertension, cigarette smoking and physical inactivity. We examine the prevalence and consider the effect of inflammation and RA treatments on these risk factors. Finally, we discuss three widely used CV risk estimators, the Framingham Risk Score, Reynolds Risk Score and the Systematic Coronary Risk Evaluation, and their performance in patients with RA. The traditional CV risk factors that appear to differ significantly between RA cases and controls include insulin resistance, abnormal fat distribution, cigarette smoking and lack of physical activity. Dyslipidaemia, diabetes and hypertension may also be elevated in RA; however, the evidence is conflicting. Overall, we found that the majority of information regarding CV risk factors in RA stems from data collected as covariates for studies on CV disease. A gap in knowledge exists regarding detailed information on individual risk factors in RA, their prevalence and modifications that occur as a result of inflammation or treatment. More studies are needed to develop methods for accurate CV risk estimation in RA.

Rheumatoid arthritis-associated interstitial lung disease

Rheumatoid arthritis (RA) is a systemic inflammatory disorder affecting 1% of the US population. Patients can have extra-articular manifestations of their disease and the lungs are commonly involved. RA can affect any compartment of the respiratory system and high resolution computed tomography (HRCT) of the lung is abnormal in over half of these patients. Interstitial lung disease is a dreaded complication of RA. It is more prevalent in smokers, males, and those with high antibody titers. The pathogenesis is unknown but data suggest an environmental insult in the setting of a genetic predisposition. Smoking may play a role in the pathogenesis of disease through citrullination of protein in the lung leading to the development of autoimmunity. Patients usually present in middle age with cough and dyspnea. Pulmonary function testing most commonly shows reduced diffusion capacity for carbon monoxide and HRCT reveals a combination of reticulation and ground glass abnormalities. The most common pattern on HRCT and histopathology is usual interstitial pneumonia (UIP), with nonspecific interstitial pneumonia seen less frequently. There are no large-scale well-controlled treatment trials. In severe or progressive cases, treatment usually consists of corticosteroids with or without a cytotoxic agent for 6 months or longer. RA interstitial lung disease is progressive; over half of patients show radiographic progression within 2 years. Patients with a UIP pattern on biopsy have a survival similar to idiopathic pulmonary fibrosis.

Pain, nicotine, and smoking: research findings and mechanistic considerations

Tobacco addiction and chronic pain represent 2 highly prevalent and comorbid conditions that engender substantial burdens upon individuals and systems. Interrelations between pain and smoking have been of clinical and empirical interest for decades, and research in this area has increased dramatically over the past 5 years. We conceptualize the interaction of pain and smoking as a prototypical example of the biopsychosocial model. Accordingly, we extrapolated from behavioral, cognitive, affective, biomedical, and social perspectives to propose causal mechanisms that may contribute to the observed comorbidity between these 2 conditions. The extant literature was 1st dichotomized into investigations of either effects of smoking on pain or effects of pain on smoking. We then integrated these findings to present a reciprocal model of pain and smoking that is hypothesized to interact in the manner of a positive feedback loop, resulting in greater pain and increased smoking. Finally, we proposed directions for future research and discussed clinical implications for smokers with comorbid pain disorders. We observed modest evidence that smoking may be a risk factor in the multifactorial etiology of some chronically painful conditions and that pain may come to serve as a potent motivator of smoking. We also found that whereas animal studies yielded consistent support for direct pain-inhibitory effects of nicotine and tobacco, results from human studies were much less consistent. Future research in the emerging area of pain and smoking has the potential to inform theoretical and clinical applications with respect to tobacco smoking, chronic pain, and their comorbid presentation. (PsycINFO Database Record (c) 2011 APA, all rights reserved).

The future of rheumatoid arthritis and hand surgery - combining evolutionary pharmacology and surgical technique

Rheumatoid arthritis is a systemic autoimmune disease of uncertain aetiology, which is characterized primarily by synovial inflammation with secondary skeletal destructions.Rheumatoid Arthritis is diagnosed by the presence of four of the seven diagnostic criteria, defined by The American College of Rheumatology.Approximately half a million adults in the United Kingdom suffer from rheumatoid arthritis with an age prevalence between the second and fourth decades of life; annually approximately 20,000 new cases are diagnosed.The management of Rheumatoid Arthritis is complex; in the initial phase of the disease it primarily depends on pharmacological management. With disease progression, surgical input to correct deformity comes to play an increasingly important role. The treatment of this condition is also intimately coupled with input from both the occupational therapists and physiotherapy.

[Rheumatoid arthritis: a cardiovascular disease?]

Mortality in rheumatoid arthritis (RA) is doubled when compared to the general population. This excess in mortality can be explained in half of cases by cardiovascular (CV) events. The risk of myocardial infarction is increased by about 60% in RA. Mortality secondary to cerebrovascular stroke is increased by 50% even if the incidence of stroke is not increased. Indeed, the risk of fatal CV events is increased in RA when compared to the general population. The increased CV risk cannot be explained only by traditional CV risk factors, even if smoking and changes in lipid profile may be implied. It is mainly related to the chronic inflammatory condition that causes many metabolic disturbances. Other parameters such as treatments used in RA also play a role. Thus, it is essential for proper management of RA patients to be aware of this risk and to treat any modifiable CV risk factors.

Rheumatoid arthritis-associated interstitial lung disease: diagnostic dilemma

Interstitial lung disease (ILD) is an increasingly recognized complication of rheumatoid arthritis (RA) contributing to significantly increased morbidity and mortality. Diagnosis can be challenging since patients are unlikely to report dyspnea due to an overall decrease in physical activity with advanced arthritic symptoms. Additionally, infections, drug toxicity, and environmental toxins can mimic ILD, creating significant diagnostic dilemmas for the clinician. In this paper we will explore an effective clinical algorithm for the diagnosis of RA-ILD. We will also discuss features of drug-related toxicities, infections, and environmental toxins that comprise the main entities in the differential diagnosis of RA-ILD. Finally, we will explore the known and experimental treatment options that may have some benefit in the treatment of RA-ILD.

Associations between pain and current smoking status among cancer patients

There is growing empirical and clinical interest in purported associations between smoking and the aggravation of cancer symptoms and treatment side effects, such as pain. Both pain and smoking are highly prevalent among persons with cancer, and there is recent evidence to suggest that cancer patients who continue to smoke despite their diagnosis experience greater pain than nonsmokers. Accordingly, the main goal of this cross-sectional study was to examine associations between multiple levels of smoking status and several pain-related outcomes among a sample of 224 cancer patients about to begin chemotherapy. Patients completed self-report measures of pain severity, pain-related distress, and pain-related interference, as well as a demographics questionnaire. Results indicated that persons who continued to smoke despite being diagnosed with cancer reported more severe pain than never smokers, F (2, 215)=3.47, p<.05. Current smokers also reported greater interference from pain than either former or never smokers, F (2, 215)=5.61, p<.01. Among former smokers, an inverse relation between pain severity and the number of years since quitting smoking was observed, r (104)=-.26, p<.01. These data suggest that continued smoking despite a cancer diagnosis is associated with greater pain severity and interference from pain; however, future research is warranted to determine the directionality of this relationship.

Combined pulmonary fibrosis and emphysema syndrome in connective tissue disease

OBJECTIVE

Connective tissue diseases (CTDs) are associated with several interstitial lung diseases. The aim of this study was to describe the recently individualized syndrome of combined pulmonary fibrosis and emphysema (CPFE) in a population of patients with CTD.

METHODS

In this multicenter study, we retrospectively investigated data from patients with CTD who also have CPFE. The demographic characteristics of the patients, the results of pulmonary function testing, high-resolution computed tomography, lung biopsy, and treatment, and the outcomes of the patients were analyzed.

RESULTS

Data from 34 patients with CTD who were followed up for a mean±SD duration of 8.3±7.0 years were analyzed. Eighteen of the patients had rheumatoid arthritis (RA), 10 had systemic sclerosis (SSc), 4 had mixed or overlap CTD, and 2 had other CTDs. The mean±SD age of the patients was 57±11 years, 23 were men, and 30 were current or former smokers. High-resolution computed tomography revealed emphysema of the upper lung zones and pulmonary fibrosis of the lower zones in all patients, and all patients exhibited dyspnea during exercise. Moderately impaired pulmonary function test results and markedly reduced carbon monoxide transfer capacity were observed. Five patients with SSc exhibited pulmonary hypertension. Four patients died during followup. Patients with CTD and CPFE were significantly younger than an historical control group of patients with idiopathic CPFE and more frequently were female. In addition, patients with CTD and CPFE had higher lung volumes, lower diffusion capacity, higher pulmonary pressures, and more frequently were male than those with CTD and lung fibrosis without emphysema.

CONCLUSION

CPFE warrants inclusion as a novel, distinct pulmonary manifestation within the spectrum of CTD-associated lung diseases in smokers or former smokers, especially in patients with RA or SSc.

Rheumatoid vasculitis: vanishing menace or target for new treatments?

Rheumatoid vasculitis is a rare but serious complication of rheumatoid arthritis. Herein we examine the pathophysiology, epidemiology, clinical diagnosis, and treatment of rheumatoid vasculitis. Seropositivity, specific HLA variations, and tobacco use are among the genetic and environmental predictors of rheumatoid vasculitis. Fortunately, recent reports have noted declines in the prevalence of rheumatoid vasculitis. Nevertheless, proper recognition of systemic manifestations may assist in pathologically confirming the diagnosis, determining the extent of disease, and guiding treatment. Contemporary treatment reports are discussed in the context of the ongoing debate regarding whether new agents may trigger, treat, or even prevent rheumatoid vasculitis. Evolving genetic, histopathologic, and immunologic studies partnered with ongoing clinical experience with biologics offer promise to inform future prevention and treatment of rheumatoid vasculitis.

The lung in rheumatoid arthritis

Rheumatoid arthritis (RA) is a common inflammatory disease, affecting about 1% of the population. Although a major portion of the disease burden including excess mortality is due to its extra-articular manifestations, the prevalence of RA-associated lung disease is increasing. RA can affect the lung parenchyma, airways, and the pleura; and pulmonary complications are directly responsible for 10 to 20% of all mortality. Even though pulmonary infection and drug toxicity are frequent complications of RA, lung disease directly associated with the underlying RA is more common. The prevalence of a particular complication varies based on the characteristics of the population studied, the definition of lung disease used, and the sensitivity of the clinical investigations employed. An overview of lung disease associated with RA is presented here with an emphasis on parenchymal lung disease, pleural effusion, and airway involvement.

The swollen joint, the thickened artery, and the smoking gun: tobacco exposure, citrullination and rheumatoid arthritis

Autoimmune diseases result from an interplay between susceptibility genes and environmental factors. These interacting etiopathogenetic components converge in a critical step preceding disease, the loss of tolerance to self. In this review, we examine the evidences linking tobacco smoking with the initiation and perpetuation of inflammation affecting both the synovial membrane and the endothelial lining in patients with rheumatoid arthritis. This disease is a compelling argument for the decisive role of environment in the triggering of a human autoimmune disease in genetically prone individuals.

Effects of expectancies and coping on pain-induced motivation to smoke

The prevalence of tobacco smoking among persons with recurrent pain is approximately twice that observed in the general population. Smoking has been associated with the development and exacerbation of several chronically painful conditions. Conversely, there is both experimental and cross-sectional evidence that pain is a potent motivator of smoking. A recent study provided the first evidence that laboratory-induced pain could elicit increased craving and produce shorter latencies to smoke (Ditre & Brandon, 2008). To further elucidate interrelations between pain and smoking, and to identify potential targets for intervention, in the current study, we tested whether several constructs derived from social-cognitive theory influence the causal pathway between pain and increased motivation to smoke. Smokers (N = 132) were randomly assigned to 1 of 4 conditions in this 2 x 2 between-subjects experimental design. Results indicated that manipulations designed to (a) challenge smoking-related outcome expectancies for pain reduction and (b) enhance pain-related coping produced decreased urge ratings and increased latencies to smoke, relative to controls. An unexpected interaction effect revealed that although each manipulation was sufficient to reduce smoking urges, the combination was neither additive nor synergistic. These findings were integrated with those of the extant literature to conceptualize and depict a causal pathway between pain and motivation to smoke as moderated by smoking-related outcome expectancies and mediated by the use of pain coping behaviors.

Prevalence of rheumatoid arthritis in the eastern Black Sea region of Turkey

AIM

The aim of this study was to estimate the prevalence of rheumatoid arthritis (RA) in the eastern Black Sea region of Turkey.

METHOD

The study was carried out between March 2003 and March 2005 by the Karadeniz Technical University Medical Faculty Department of Physical Medicine and Rehabilitation in the urban area in the eastern Black Sea region of Turkey, which has a population of 459021 (according to the 2000 national census). A total of 6103 subjects, 20 years old or over, were selected by the sampling method; 3023 (49.5%) women and 3080 (50.5%) men were included in the study. The diagnosis of RA was performed based on fulfilling the American College of Rheumatology (ACR) criteria.

RESULTS

Fifty-nine patients were diagnosed with RA according to the ACR criteria, of which 11 were male and 48 female. The prevalence of RA was 1% (95% CI: 0.75-1.25) in the general population, 1.6% (95% CI: 1.15-2.05) in women and 0.35% (95% CI: 0.14-0.56) in men. The female/male ratio was 4.3 : 1.0, showing that RA prevalence was statistically significantly higher in women (P <0.005).

CONCLUSION

Our study demonstrates that RA is a common disease in Turkish society.