Epidemiology of connective tissue disorders

Interstitial Lung Disease: A Review

Importance

Interstitial lung disease (ILD) consists of a group of pulmonary disorders characterized by inflammation and/or fibrosis of the lung parenchyma associated with progressive dyspnea that frequently results in end-stage respiratory failure. In the US, ILD affects approximately 650 000 people and causes approximately 25 000 to 30 000 deaths per year.

Observations

The most common forms of ILD are idiopathic pulmonary fibrosis (IPF), which accounts for approximately one-third of all cases of ILD, hypersensitivity pneumonitis, accounting for 15% of ILD cases, and connective tissue disease (CTD), accounting for 25% of ILD cases. ILD typically presents with dyspnea on exertion. Approximately 30% of patients with ILD report cough. Thoracic computed tomography is approximately 91% sensitive and 71% specific for diagnosing subtypes of ILDs such as IPF. Physiologic assessment provides important prognostic information. A 5% decline in forced vital capacity (FVC) over 12 months is associated with an approximately 2-fold increase in mortality compared with no change in FVC. Antifibrotic therapy with nintedanib or pirfenidone slows annual FVC decline by approximately 44% to 57% in individuals with IPF, scleroderma associated ILD, and in those with progressive pulmonary fibrosis of any cause. For connective tissue disease-associated ILD, immunomodulatory therapy, such as tocilizumab, rituximab, and mycophenolate mofetil, may slow decline or even improve FVC at 12-month follow-up. Structured exercise therapy reduces symptoms and improves 6-minute walk test distance in individuals with dyspnea. Oxygen reduces symptoms and improves quality of life in individuals with ILD who desaturate below 88% on a 6-minute walk test. Lung transplant may improve symptoms and resolve respiratory failure in patients with end-stage ILD. After lung transplant, patients with ILD have a median survival of 5.2 to 6.7 years compared with a median survival of less than 2 years in patients with advanced ILD who do not undergo lung transplant. Up to 85% of individuals with end-stage fibrotic ILD develop pulmonary hypertension. In these patients, treatment with inhaled treprostinil improves walking distance and respiratory symptoms.

Conclusions and Relevance

Interstitial lung disease typically presents with dyspnea on exertion and can progress to respiratory failure. First-line therapy includes nintedanib or pirfenidone for IPF and mycophenolate mofetil for ILD due to connective tissue disease. Lung transplant should be considered for patients with advanced ILD. In patients with ILD, exercise training improves 6-minute walk test distance and quality of life.

Neurological Manifestations of Connective Tissue Disorders

Connective tissue disorders (CTD) are a group of disorders affecting the connective tissues. Usually the musculoskeletal and the vascular system is impacted. Along with these systems, the nervous system is also involved in CTD, which leads to various neurological manifestations. The pathophysiology of neurological complications of CTD is caused by various factors and is complicated. Disturbed immune complexes, chronic inflammation, and autoimmunity in which the body attacks its cells are considered to be responsible for the neurological complications of CTD. Additionally, the vascular symptoms that lead to decreased blood flow to the brain are also responsible for the neurological manifestations of CTD in diseases like systemic lupus erythematosus (SLE). In SLE, vessel wall integrity is compromised, which may lead to decreased blood flow leading to neurological complications. CTD can manifest a variety of neurological complications. These neurological complications can be classified into symptoms affecting the peripheral nervous system, central nervous system, and the autonomic nervous system. Some of the common neurological complications of CTD are headaches, seizures, ataxia, neuropathies leading to cranial nerve palsies, myelopathies, tremors, encephalitis, and cerebral infarction. Cranial nerve palsies can disturb sensations, vision, hearing, and mastication. Neuropsychiatric symptoms are also commonly observed in CTD. Cognitive dysfunction can be caused due to neuropsychiatric problems. Some of the cognitive dysfunctions are lack of concentration, memory loss, confusion, and coma. In this review, we will address various neurological manifestations of CTD.

Spectrum of and Factors Associated with Eye Disorders among Rheumatoid Arthritis Patients Attending Tertiary Hospital in Uganda

Background

Ocular morbidities associated with rheumatoid arthritis (RA) have not received much attention in Africa, particularly in sub-Saharan Africa. They are among the commonest (40%) extra-articular organ involvement in RA. If undiagnosed, there is a potential risk of them causing visual impairment or blindness. There is no documented study in Uganda on the magnitude of eye disorders among RA patients.

Aim

To determine the spectrum of eye disorders and associated factors among patients with RA attending Mulago National Referral Hospital.

Methods

A hospital based cross-sectional study was conducted among adults with RA attending the rheumatology clinic between July 2021 and September 2021. Clinical and sociodemographic data were collected, and ophthalmologic examinations were performed on all consenting participants. Modified Poisson regression with robust standard error was used to determine factors associated with eye disorders.

Results

Overall, 105 patients with RA were enrolled, of which, 53 (50.5%) had eye disorders. The commonest disorder (54.7%, n=29) was dry-eye syndrome. Factors that were significantly associated with eye disorders were age 36-55 years (aPR 1.56, p=0.015), duration of RA >5 years (aPR 1.81, p=0.001), use of hydroxychloroquine >5 years (aPR 1.77, p=0.041), dose of oral steroids >10 mg/day (aPR 1.49, p=0.034), and history of both diabetes and hypertension (aPR 1.87, p=0.014).

Conclusion

The prevalence of eye disorders among patients with RA was high, with the commonest being dry-eye syndrome. We recommend that ocular examinations be performed on every patient at the time of RA diagnosis for early detection of eye disorders.

Expert Opinion Guidance on the Detection of Early Connective Tissue Diseases in Interstitial Lung Disease

There is a significant variation in symptoms and clinical presentation of connective tissue disorders (CTD) associated with interstitial lung disease (ILD) (CTD-ILD). This presents difficulties in the diagnosis and treatment of CTD-ILD. Early detection and treatment of CTD-ILD using a multidisciplinary approach have been shown to enhance patient outcomes. This exercise aims to explore clinical components to develop a screening tool for pulmonologists for early detection of CTD in ILD and to provide a framework for a multidisciplinary approach in managing CTD-ILD. This in turn will lead to early treatment of CTD-ILD in collaboration with rheumatologists. A panel of 12 leading rheumatologists from the Middle East and North Africa (MENA) region met virtually to select the most relevant clinical findings to aid in identifying CTD-ILD. Twelve panellists opted to investigate seven of the most common inflammatory autoimmune disorders. The panel discussed how to improve the early detection of CTD-ILD. Clinical characteristics were categorized, and a nine-item questionnaire was created. A biphasic algorithm was developed to guide early referral to a rheumatologist based on the presence of one of nine clinical features of CTD (Phase 1) or the presence of CTD-specific antibodies (Phase 2). A brief questionnaire has been developed to serve as a simple and practical screening tool for CTD-ILD detection. Additional research is needed to validate and evaluate the tool in longitudinal cohorts.

Current experimental methods to investigate the impact of specialized pro-resolving lipid mediators on Sjögren's syndrome

Sjögren's syndrome is a chronic inflammatory autoimmune disease characterized by diminished secretory function of the exocrine glands. Although extensive investigation has been done to understand Sjögren's syndrome, the causes of the disease are as yet unknown and treatments remain largely ineffective, with established therapeutic interventions being limited to use of saliva substitutes with modest effectiveness. A primary feature of Sjögren's syndrome is uncontrolled inflammation of exocrine tissues and previous studies have demonstrated that lipid-based specialized pro-resolving mediators reduce inflammation and restores tissue integrity in salivary glands. However, these studies are limited to a single specialized pro-resolving lipid mediator's family member resolvin D1 or RvD1 and its aspirin-triggered epimer, AT-RvD1. Consequently, additional studies are needed to explore the potential benefits of other members of the specialized pro-resolving lipid mediator's family and related molecules (e.g., additional resolvin subtypes as well as lipoxins, maresins and protectins). In support of this goal, the current review aims to briefly describe the range of current experimental methods to investigate the impact of specialized pro-resolving lipid mediators on Sjögren's syndrome, including both strengths and weaknesses of each approach where this information is known. With this article, the possibilities presented by specialized pro-resolving lipid mediators will be introduced to a wider audience in immunology and practical advice is given to researchers who may wish to take up this work.

Overlap Syndrome in a Male Presenting With Progressive Lower Limb Weakness: A Case Report

Overlap syndrome refers to a large group of inflammatory rheumatic conditions characterized by the co-existence of clinical manifestations that include different organ systems and meet the criteria of more than one rheumatic disease. Overlap syndromes are less common compared with the conditions they encompass, for example, the global prevalence of systemic lupus erythematosus (SLE) is estimated to be 43.7 per 100,000 persons, of which only around 3.4-6.3% present with SLE-myositis overlap. Although rare, overlap syndromes commonly include lupus, rheumatoid arthritis, scleroderma, and myositis. Because overlap syndrome can manifest in several ways and has an unpredictable course, it poses a challenge to multidisciplinary teams that examine and treat patients. Therefore, we must not disregard any signs and symptoms as they might have a huge impact on the progression of the disease and the overall outcome of the treatment. We present a rare case of SLE-myositis overlap syndrome in a 44-year-old male. He initially presented with gradual weakness in the proximal muscles of the bilateral lower limb. This patient was diagnosed as having SLE with positive 5g protein/24 hours, anti-nuclear, low C3, anti-U1RNP, anti-Ro, and anti-La antibodies, as well as membranous lupus nephritis evident by the results of renal biopsy. The diagnosis of myositis was also made according to the history and evaluation of the patient, the high titer of muscle enzymes creatine kinase level, and MRI result. Although the patient tested positive for anti-U1RNP, he did not meet the criteria of mixed connective tissue disease. Eventually, the patient was found to have overlap syndrome. The prevalence of overlap between SLE and myositis is relatively rare and varies from 3.4% to 6.3%. To our knowledge, no study has discussed or reported its prevalence among males.

Effect of the COVID-19 outbreak on emergency transport of children by an emergency medical service system: a population-based, ORION registry study

BACKGROUND

Coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2, has spread rapidly around the world.

OBJECTIVE

To assess the effect of the COVID-19 pandemic on the emergency medical service (EMS) and hospital admission course for children transported by ambulance.

METHODS

This study was a retrospective, descriptive study with a study period from January 1, 2018 to December 31, 2020 using the Osaka Emergency Information Research Intelligent Operation Network (ORION) system. All children who were transported by ambulance in Osaka Prefecture were included. The main outcome of this study was the rate of difficult-to-transfer cases, which was calculated by univariate and multivariate Poisson regression analyses.

RESULTS

Over the 3 years between January 1, 2018 and December 31 2020, 1,436,212 patients were transported to hospitals by ambulances in Osaka Prefecture, with children accounting for 102,473 (37,064, 39,590, and 25,819, in 2018, 2019, and 2020, respectively). Poisson regression analysis showed that children were negatively associated with difficult-to-transfer cases (risk ratio (RR) 0.35, 95% CI 0.33 to 0.37). With reference to 2018, 2020 was not significantly associated with difficult-to-transfer cases in children (RR 1.14, 95% CI 0.99 to 1.32, P = 0.075), but was significantly related (RR 1.24, 95% CI 1.21 to 1.27, P < 0.001) to difficult-to-transfer cases in the general population.

CONCLUSION

Children were consistently associated with a reduced RR for difficult-to-transfer cases, even in the COVID-19 pandemic in 2020.

Autoimmune connective tissue diseases and aortic valve replacement outcomes: a population-based study

Aims

Patients with autoimmune connective tissue diseases (CTDs) have a high burden of valvular heart disease and are often thought of as high surgical risk patients.

Methods and results

Patients undergoing aortic valve replacement (AVR) were identified in the Nationwide Readmissions Database between January 2012 and December 2018. Patients with a history of systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, mixed C, Sjögren syndrome, polymyositis, and dermatomyositis were included in the CTD cohort. Patients undergoing coronary artery bypass grafting concomitantly with AVR were excluded. A total of 569 600 hospitalizations were included, of which16 531 (2.9%) had CTD. CTD patients were more likely to be females, with higher rates of heart failure, pulmonary hypertension, and more likely to be insured by Medicare. CTD patients had lower mortality than non-CTD patients [odds ratio (OR) 0.66; 95% confidence interval (CI): 0.59–0.74] and stroke [OR 0.87; 95% (CI): 0.79–0.97]. CTD patients undergoing SAVR had lower mortality [OR 0.69; 95% (CI): 0.60–0.80] and stroke [OR 0.86; 95% (CI): 0.75–0.98). CTD patients undergoing TAVR had lower mortality outcomes [OR 0.67; 95% (CI): 0.56–0.80]; however, they had comparable stroke outcomes [OR 0.97; 95% (CI): 0.83–1.13, P = 0.69].

Conclusions

Outcomes for patients with CTD requiring AVR are not inferior to their non-CTD counterparts. A comprehensive heart team selection of patients undergoing AVR approaches should place CTD history under consideration; however, pre-existing CTD should not be prohibitive of AVR interventions.

Contemporary demographics, diagnostics and outcomes in non-bacterial thrombotic endocarditis

OBJECTIVE

Non-bacterial thrombotic endocarditis (NBTE) is a syndrome characterised by cardiac valve vegetations and/or thickening due to non-infective mechanisms. Nowadays, a premortem diagnosis of NBTE is possible based on echocardiographic findings. Therefore, to better characterise this disease, we performed a contemporary review of the epidemiology, demographics, diagnosis and clinical outcomes of these patients.

METHODS

Adults with a diagnosis of NBTE seen within the Mayo Clinic Enterprise from December 2014 to December 2021 were included. NBTE diagnosis was identified by clinicians representing at least two specialties including cardiology, infectious diseases, rheumatology and oncology. Patients with positive blood cultures, infective endocarditis, culture-negative endocarditis and denial of research authorisation were excluded. All patients had a 1-year follow-up.

RESULTS

Forty-eight cases were identified; mean age was 60.0±13.8 years, 75% were female. The most prevalent comorbidities were malignancy (52.1%) and connective tissue disease (37.5%). Valvular abnormalities included 41 (85.4%) patients with vegetations, 43 (89.6%) patients with thickening and 26 (54.2%) with moderate to severe regurgitation. Thirty-eight (79.2%) patients had an embolic event (stroke in 26 (54.2%) patients) within 1 month of NBTE diagnosis and 16 (33.3%) patients died within 1 year of NBTE diagnosis. Metastatic tumours and lung cancer were associated with 1-year all-cause mortality (p=0.0017 and p=0.0004, respectively).

CONCLUSIONS

NBTE was more prevalent in females and embolic complications were the most frequent clinical finding. Overall, patients with NBTE had a poor prognosis, particularly in those with lung cancer or metastatic tumours. Further studies in patients with NBTE are needed given its morbidity and mortality.

Prevalence and spectrum of eye disorders among patients with rheumatoid arthritis and systemic lupus erythematosus in a tertiary hospital in Northern Nigeria

Purpose:

The aim of this study was to determine the spectrum of eye disorders in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE).

Materials and Methods:

A cross-sectional hospital-based study was conducted among 100 consecutive patients with RA and SLE. A semi-structured questionnaire was used to obtain details of patients’ sociodemographics, type of rheumatic disease, and prescribed medications. Each patient had a detailed examination of the anterior and posterior segments of the eye. Refraction, intraocular pressure measurement, Schirmer’s test, tear breakup time, gonioscopy, and dilated fundoscopy were also done. Fundus photograph, central visual field assessment, and optical coherence tomography were done as necessary. Analysis was done with the Statistical Package for Social Sciences (SPSS) version 25. Statistical significance was set at P < 0.05.

Results:

A total of 100 patients consisting of 74 RA and 26 SLE patients were evaluated. The female: male ratio was 4.3: 1 for RA, and all SLE patients were females. The prevalence of eye disorders was 42% in all patients; it was 41.9% and 42.3% among RA and SLE patients, respectively. The most common eye disorders were dry eye (38), refractive errors (18), and cataract (16). The mean age of RA patients with eye disorders (52.19 ± 16.17 years) was significantly higher than those without eye disorders (42.30 ± 13.14 years) (P = 0.005).

Conclusion:

Eye disorders are common in RA and SLE. Comprehensive eye examination should be done on all RA and SLE patients at diagnosis and before commencement of medications, and patients should be referred promptly for evaluation when they have eye complaints.

Potential for novel imaging techniques to monitor early disease progression in connective tissue disease vasculopathy

Vasculopathy associated with connective tissue diseases (CTD) has diverse clinical presentations and complex underlying pathology. Existing imaging techniques remain inadequate for assessing vasculopathy in CTD, particularly in earlier stages of pathogenesis. Novel imaging techniques, such as optical coherence tomography, near-infrared spectroscopy and superb microvascular imaging, demonstrate potential in monitoring disease progression at earlier stages prior to systemic complications.

Successful Prepectoral Breast Reconstruction in a Patient With Systemic Sclerosis

Patients with connective tissue diseases have been shown to be at higher risk for complications after surgery. In this report, we describe a case of a patient with long-standing, stable systemic sclerosis (SS), diagnosed approximately 28 years ago, who underwent nipple-sparing mastectomy and immediate reconstruction with prepectoral tissue-expander placement. She subsequently had uneventful implant-based reconstruction with adjunctive fat grafting. To our knowledge, this is the first reported case of implant-based prepectoral reconstruction after mastectomy in a patient with SS.

Autoimmune Connective Tissue Disease Following Carbon Monoxide Poisoning: A Nationwide Population-Based Cohort Study

Background

In addition to hypoxia, oxidative stress and inflammation due to carbon monoxide (CO) poisoning cause adverse health effects. These mechanisms are related to the occurrence of autoimmune connective tissue disease, but studies on the association between CO poisoning and autoimmune connective tissue disease are limited. We conducted a study to evaluate the occurrence of autoimmune connective tissue disease following CO poisoning.

Methods

We identified participants with CO poisoning diagnosed between 1999 and 2012 from the Nationwide Poisoning Database and selected participants without CO poisoning from the Taiwan National Health Insurance Research Database with matching age and index dates at a 1:3 ratio. Sex, underlying comorbidities, and monthly income were also included in the analyses. We followed up the participants until 2013 and made comparison of the risk of autoimmune connective tissue disease between participants with and without CO poisoning.

Results

The 23,877 participants with CO poisoning had a higher risk for autoimmune connective tissue disease than the 71,631 participants without CO poisoning (adjusted hazard ratio [AHR], 3.5; 95% confidence interval [CI], 3.1–3.9) after adjustment for sex, diabetes, Lyme disease, herpes zoster, infectious mononucleosis, hepatitis, HIV infection, liver disease, renal disease, non-CO poisoning or drug abuse, malignancy, hypertension, hyperlipidemia, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and monthly income. An increased risk was observed even after 4 years of follow-up (AHR, 3.6; 95% CI, 3.0–4.4).

Conclusion

The risk of autoimmune connective tissue disease increased following CO poisoning. Close follow-up of the patients with CO poisoning for the development of connective tissue disease is recommended, and further investigation of the detailed mechanisms is warranted.

Social deprivation in Scottish populations with pulmonary hypertension secondary to connective tissue disease and chronic thromboembolic disease

Socioeconomic factors have been shown to have an adverse impact on survival in some respiratory diseases. Studies from the USA and China have suggested worse survival in idiopathic pulmonary arterial hypertension in low socioeconomic groups. We looked at the effect of deprivation on the outcomes in patients with connective tissue disease-associated pulmonary hypertension (CTDPH) and chronic thromboembolic pulmonary hypertension (CTEPH) in a retrospective observational study.

Data were obtained from 232 patients with CTDPH and 263 with CTEPH who were under the care of the Scottish Pulmonary Vascular Unit, Glasgow, UK. We used Cox proportional hazards regression to assess for a relationship between deprivation and survival.

We found no difference in survival across deprivation quintiles in the CTDPH (p=0.26) or CTEPH cohorts (p=0.18). We constructed multivariate models using enrolment time, age, sex and body mass index, with no significant change in findings. There was no difference between expected and observed population distribution of CTDPH (p=0.98) and CTEPH (p=0.36). Whilst there was no difference in presenting functional class in the CTDPH group, the CTEPH patients in more deprived quintiles presented in a worse functional class (p=0.032). There was no difference between quintiles of CTEPH patients who had distal or proximal disease (p=0.75), or who underwent surgery (p=0.5).

Increased social deprivation is not associated with worse survival in patients with CTDPH and CTEPH managed in the Scottish National Health Service. Whilst there is no evidence of referral barriers in CTDPH, this may not be the case in CTEPH, as lower deprivation was associated with worse functional class at presentation.

Increased social deprivation is not associated with worse survival in patients with connective tissue disease-associated pulmonary hypertension or chronic thromboembolic pulmonary hypertension managed in the Scottish NHShttps://bit.ly/32KbzSv

Predicting Resolvin D1 Pharmacokinetics in Humans with Physiologically-Based Pharmacokinetic Modeling

Sjögren’s syndrome (SS) is an autoimmune disease with no effective treatment options. Resolvin D1 (RvD1) belongs to a class of lipid‐based specialized pro‐resolving mediators that showed efficacy in preclinical models of SS. We developed a physiologically‐based pharmacokinetic (PBPK) model of RvD1 in mice and optimized the model using plasma and salivary gland pharmacokinetic (PK) studies performed in NOD/ShiLtJ mice with SS‐like features. The predictive performance of the PBPK model was also evaluated with two external datasets from the literature reporting RvD1 PKs. The PBPK model adequately captured the observed concentrations of RvD1 administered at different doses and in different species. The PKs of RvD1 in virtual humans were predicted using the verified PBPK model at various doses (0.01–10 mg/kg). The first‐in‐human predictions of RvD1 will be useful for the clinical trial design and translation of RvD1 as an effective treatment strategy for SS.

Clinical features of dermatomyositis associated with anti-MDA5 antibodies by age

OBJECTIVES

Anti-melanoma differentiation-associated gene 5 (MDA5) autoantibody-positive and age at onset ≥60 years are poor prognosis factors in polymyositis (PM) and dermatomyositis (DM) associated with interstitial lung disease (ILD) among Japanese patients. However, the influence of age on the clinical features of anti-MDA5 autoantibody-positive patients with DM remains unclear.

METHODS

We retrospectively examined 40 patients with DM and anti-MDA5 autoantibodies according to age. We compared patients aged <60 and ≥60 years with respect to clinical features including laboratory test findings, high-resolution lung computed tomography data, treatment content, and complications such as infections and prognosis. We also examined clinical features between surviving and deceased patients in the older patient group.

RESULTS

Of 40 enrolled patients, 13 were classified as old and 27 as young. Older patients had significantly fewer clinical symptoms including arthralgia/arthritis (p < .01), skin ulceration (p = .02), and higher mortality than younger patients (p = .02) complicated with rapidly progressive ILD (RP-ILD), combination immunosuppressive therapy, and strictly controlled infections.

CONCLUSION

Clinical features and mortality of anti-MDA5 autoantibody-positive DM patients were influenced by age. Patients aged ≥60 years had a worse prognosis, and combination immunosuppressive therapy was often ineffective for RP-ILD in older patients.

The Haywain: Anti-synthetase Antibodies in Patients with Inflammatory Diseases: Targeting Monocytes or Neutrophils?

Autoantibiodies against aminoacyl-tRNA synthetases are found in patients suffering from a wide range of autoimmune and inflammatory disorders. Recent data indicate that these antibodies are directed against splice-variants of synthetase genes, the so-called catalytic nulls. Latter molecules have cytokine-like functions and are involved in the regulation of the activation of lymphocytes, monocytes and granulocytes. The potential role of anti-synthetase antibodies as a diagnostic tool and a target for therapeutic interventions is discussed.

The Influence of Connective Tissue Disease in Breast Reconstruction: A National Database Analysis

BACKGROUND

Patients with connective tissue diseases (CTD), or collagen vascular diseases, are at risk of potentially higher morbidity after surgical procedures. We aimed to investigate the complication profile in CTD versus non-CTD patients who underwent breast reconstruction on a national scale.

METHODS

A retrospective analysis of the Healthcare Cost and Utilization Project NIS Database between 2010 and 2014 was conducted for patients 18 years or older admitted for immediate autologous or implant breast reconstruction. Connective tissue disease was defined as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, scleroderma, Raynaud phenomenon, psoriatic arthritis, or sarcoidosis. Independent t test/Wilcoxon-Mann-Whitney was used to compare continuous variables and Pearson χ/Fischer exact test was used for categorical variables. Outcomes of interest were assessed using multivariable linear regressions for continuous variables and multivariable logistic regressions for categorical variables.

RESULTS

There were 19,496 immediate autologous breast reconstruction patients, with 357 CTD and 19,139 non-CTD patients (2010-2014). The CTD patients had higher postoperative complication rates for infection (2.8% vs 0.8%, P < 0.001), wound dehiscence (1.4% vs 0.4%, P = 0.019), and bleeding (hemorrhage and hematoma) (6.7% vs 3.5%, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for bleeding (odds ratio [OR], 1.568; 95% confidence interval [CI], 1.019-2.412). There were a total of 23,048 immediate implant breast reconstruction patients, with 431 CTD and 22,617 non-CTD patients (2010-2014). The CTD patients had a higher postoperative complication rate for wound dehiscence/complication (2.3% vs 0.6%, P < 0.001). They also experienced a longer length of stay (2.31 days vs 2.07 days, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for wound dehiscence (OR, 4.084; 95% CI, 2.101-7.939) and increased length of stay by 0.050 days (95% CI, -0.081 to 0.181).

CONCLUSIONS

Connective tissue disease patients who underwent autologous breast reconstruction had significantly higher infection, wound dehiscence, and bleeding rates, and those who underwent implant breast reconstruction had significantly higher wound dehiscence rates. Connective tissue diseases appear to be an independent risk factor for bleeding and wound dehiscence in autologous and implant breast reconstruction, respectively. This information may help clinicians be aware of this increased risk when determining patients for reconstruction.

Dermatology-specific and all-cause 30-day and calendar-year readmissions and costs for dermatologic diseases from 2010 to 2014

BACKGROUND

Readmissions for skin disease, particularly for the same diagnosis and over time, have not been well studied.

OBJECTIVE

To characterize hospital readmissions for skin disease.

METHODS

A cross-sectional observational study examined the Nationwide Readmissions Database from 2010 to 2014, a national sample of hospital discharges in the United States.

RESULTS

Of the patients in 3,602,599 dermatologic hospitalizations from 2010 to 2014, 9.8% were readmitted for any cause, 3.3% were admitted for the same diagnosis within 30 days, and 7.8% were readmitted for the same diagnosis within the calendar year (CY). The cost of all CY same-cause readmissions was $508 million per year. Mycosis fungoides had the highest 30-day all-cause readmission rate (32%), vascular hamartomas and dermatomyositis had the highest 30-day same-cause readmission rates (21% and 18%, respectively), and dermatomyositis and systemic lupus erythematosus had the highest CY same-cause readmission rates (31% and 24%, respectively). Readmission rates stayed stable from 2010 to 2014. Readmission for the same diagnosis was strongly associated with Medicaid and morbid obesity.

LIMITATIONS

This study is a broad description of hospitalizations for skin disease. Conclusions for individual diseases are not intended.

CONCLUSION

The rates and costs of readmissions for skin diseases remained high from 2010 to 2014. This study identifies diseases associated with high risk of hospital readmission, but disease-specific studies are needed. The diseases and risk factors presented should guide additional studies focused on strategies to reduce readmissions in specific skin diseases.

Multiple microlithiasis in bilateral parotid glands as the initial clinical manifestation of primary Sjögren's syndrome

We report a rare case of Sjögren's syndrome (SS) with multiple microliths in the bilateral parotid glands. A 41-year-old man presented to our department with mild pain in the region of the right parotid gland. The dental examination was negative except for the parotid regions. The right region was moderately swollen and the left mildly swollen. Plain radiography revealed multiple calculi in the bilateral parotid glands. Ultrasonography showed heterogenic parenchyma, with microliths and cystic lesions in the parotid glands and heterogenic echotexture in the submandibular glands. Immunologic tests and the Schirmer test confirmed the diagnosis of SS. As the patient had no classic symptoms of SS, the bilateral multiple microliths were the first sign, facilitating the final diagnosis. Early diagnosis of SS is highly relevant because the proper therapy can be initiated. Adequate follow-up and, especially, control of the disease activity by identifying the predictive factors, are the primary objectives of SS management, enabling personalized treatment of this malignant disease. This case is a good example of how detection of calcifications in the bilateral parotid glands by plain radiography can help diagnose SS at an early stage.

Hospitalizations due to systemic connective tissue diseases: Secular trends and regional disparities in Sweden, 1998-2016

AIM

To investigate secular trends and regional disparities in hospitalizations due to systemic connective tissue diseases (SCTD) in Sweden from 1998 to 2016.

METHOD

We identified all hospital admissions with a principal diagnosis of SCTD (ICD-10 codes: M30-M36) from the Swedish National Patient Register. Joinpoint regression was used to assess secular trends in age-standardized hospitalization rates (ASHR) and proportions of SCTD from all and musculoskeletal disorders hospitalizations. We also assessed the secular trends in the absolute and relative regional disparities of SCTD hospitalizations.

RESULTS

We identified 89 333 SCTD hospitalizations (0.3% of all hospitalizations), of these about 69% were for women and 49% of patients were aged 15-64 years. Polyarteritis nodosa and related conditions (PANRC) and systemic lupus erythematosus (SLE) were the most frequent SCTD among those aged <10 years and 10-54 years, respectively. Joinpoint regression suggested that both rates and proportions of SCTD hospitalizations declined over time. These trends persisted among sex, age and diagnosis subgroups except for PANRC in patients aged 0-19 years who observed an average annual increase of 3.4% (95% CI: 1.8, 5.1) over the study period. There were 2.4-fold (95% CI: 2.3-2.5) difference between the regions with the highest and lowest mean ASHR. There was no statistically significant secular trend in the relative regional disparities, whereas the absolute regional disparity declined over time.

CONCLUSION

There were substantial decreases in the absolute and relative burden of SCTD hospitalizations reflecting possible improvements in disease management in Sweden. The rising trend in PANRC among the youngest children warrants further investigation.

The Role of Long Non-coding RNAs in the Pathogenesis of RA, SLE, and SS

Rheumatoid diseases are a group of systemic autoimmune diseases which affect multiple organs with largely unknown etiology. In the past decade, long non-coding RNAs (lncRNAs) have emerged as important regulators of biological processes and contribute deeply to immune cell development and immune responses. Substantial evidences have been accumulated showing that LncRNAs involved in the pathogenesis of the rheumatoid diseases, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and Sjögren's syndrome (SS). In this review, we summarize literature combined with bioinformatics methods to analyze the unique and common lncRNAs patterns in rheumatoid diseases and try to reveal the important function of lncRNAs in RA, SLE and SS.

Impact of early systemic lupus erythematosus on work disability-results from the Finnish nationwide register 2000-2007

Objectives of this study were to examine work disability (WD) and its leading causes in incident SLE patients. Data were derived from the Finnish nationwide registries to identify all non-retired, 18 to 64-year-old incident SLE patients between 2000 and 2007. Sick benefits and WD pensions and the causes for them were monitored until the end of 2008. A total of 446 working-aged, incident SLE patients available for work force (mean age 42 ± 13 years, 89% females) were found. During the follow-up (median 5.3 years), WD pension was granted to 27 patients. The most common cause was SLE itself (14 patients, 52%), with cumulative incidence of 3.4% (95% CI 1.9 to 5.8) in 5 years and 5.0% (95% CI 3.0 to 8.5) in 8 years, followed by musculoskeletal and psychiatric causes. The age- and sex- adjusted incidence ratio for WD pension in SLE patients due to any cause was 5.4 (95% CI 3.7 to 7.9) compared to the Finnish population. The mean number of WD days was 32 (95% CI 28 to 35) per patient-year among all SLE patients during the follow-up. The study concludes that SLE patients have an increased risk for WD already in early course of the disease.

Biosemantics guided gene expression profiling of Sjögren's syndrome: a comparative analysis with systemic lupus erythematosus and rheumatoid arthritis

BACKGROUND

Sjögren's syndrome (SS) shares many clinical and pathological similarities with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). These autoimmune diseases mostly affect women. In this study, concept profile analysis (CPA) and gene expression meta-analysis were used to identify genes potentially involved in SS pathogenesis.

METHODS

Human genes associated with SS, SLE, and RA were identified using the CPA tool, Anni 2.1. The differential mRNA expression of genes common to SS and SLE (SS-SLE) was determined in female peripheral blood mononuclear cells (PBMCs) using NCBI-GEO2R. Differentially expressed (DE) SS-SLE PBMC genes in common with the SS-SLE CPA-identified genes were analyzed for differential expression in salivary glands or synovial biopsies, and for genes common to SS and RA and SLE and RA, analyzing differential expression in salivary glands in SS, synovial fibroblasts in RA, and synovial fluid in SLE. Among common genes, DE genes found in salivary gland mRNA expression in patients with SS were used for gene enrichment and SS molecular network construction. Secondary analysis was performed to identify DE genes unique to the disease site tissues, by excluding PBMC and CPA common DE genes to complement the SS network.

RESULTS

We identified 22 DE genes in salivary gland datasets in SS that have not previously been clearly associated with SS pathogenesis. Among these, higher levels of checkpoint kinase 1 (CHEK1), V-Ets avian erythroblastosis virus E26 oncogene homolog 1 (ETS1), and lymphoid enhancer binding factor 1 (LEF1) were significantly correlated with higher matrix metalloproteinase 9 (MMP9) levels. Higher MMP9 levels have been implicated in degradation of salivary gland structural integrity, leading to hypo-salivation in patients with SS. Salivary gland mRNA expression of MMP9 and the expression of cytokine CXCL10 were higher in patients with SS. CXCL10 has been shown to increase MMP9 expression and therefore may also play an important role in SS pathogenesis.

CONCLUSION

Using CPA and gene expression analysis, we identified factors targeting MMP9 expression and/or function, namely CHEK1, CXCL10, ETS1, LEF1, and tissue inhibitor of metalloproteinase 1; altered mRNA expression of these could increase expression/activity of MMP9 in a concerted manner, thereby potentially impacting SS pathogenesis.

Treatment of connective tissue disease-associated interstitial lung disease: the pulmonologist's point of view

Interstitial lung disease (ILD) occurs in 15% of patients with collagen vascular disease (CVD), referred to as connective tissue disease (CTD). Despite advances in management strategies, ILD continues to be a significant cause of mortality in patients with CVD-associated ILD (CTD-ILD). There is a lack of randomized, clinical trials assessing pharmacological agents for CTD-ILD, except in cases of ILD-associated systemic sclerosis (SSc). This may be due to the lack of CTD cases available, the difficulty of histological confirmation of ILD, and the various types of CTD and ILD. As a result, evidence-based pharmacological treatment of CTD-ILD is not yet well established. CTD-ILD presents with varying degrees of histology, from inflammation to fibrosis, and a wide spectrum of clinical manifestations, from minimal symptoms to respiratory failure. This renders it difficult for clinicians to make decisions regarding treatment options, observational strategies, optimal timing for interventions, and the appropriateness of pharmacological agents for treatment. There is no specific treatment for reversing fibrosis-like idiopathic pulmonary fibrosis in a clinical setting. This review describes pharmacological interventions for SSc-ILD described in randomized control trials, and presents an overview of recent advances of CTD-ILD-dependent treatments based on the types of CTD.

Anti-nuclear autoantibodies in the general German population: prevalence and lack of association with selected cardiovascular and metabolic disorders-findings of a multicenter population-based study

BACKGROUND

We determined the prevalence of anti-nuclear autoantibodies (ANAs) in the German adult population and examined the association between ANAs and cardiovascular and metabolic disorders.

METHODS

We used data and blood samples from the pretest phases of the German National Cohort, obtained from six of the 18 study centers (n = 1199). All centers applied standardized instruments including face-to-face interviews, anthropometric measurements and collection of blood samples. Self-reported histories of diabetes mellitus, heart attack and elevated blood cholesterol and/or lipids were recorded. Height, weight and blood pressure were measured. ANAs were detected using a semi-automated system (AKLIDES®; Medipan GmbH, Dahlewitz, Germany). A positive ANA was defined as a titer ≥ 1:80. ANA were classified as weakly (1:80 or 1:160), moderately (1:320 or 1:640) or strongly (≥1:1280) positive. Specific autoantibodies against nuclear antigens were detected with second-step assays according to the ANA staining pattern. Associations between the assessed disorders and ANA positivity and pattern were examined using sex and age-adjusted mixed-effects logistic regression models.

RESULTS

Thirty-three percent (95% confidence interval; 31-36%) of the 1196 participants (measurements could not be obtained from three samples) were ANA positive (titer ≥ 1:80). The proportions of weakly, moderately and strongly positive ANA were 29%, 3.3% and 1.3%, respectively. ANA positivity was more common among women than men across all titers (χ², p = 0.03). ANA positivity, even when stratified according to height of titer or immunofluorescent pattern, was not associated with diabetes, elevated blood cholesterol and/or lipids, obesity or hypertension. Second-step autoantibody assays were positive in 41 of the 83 samples (49%) tested, with anti-DFS70 (n = 13) and anti-dsDNA (n = 7) being most frequent. These subgroups were too small to test for associations with the disorders assessed.

CONCLUSIONS

The prevalence of ANA positivity in the German general population was similar to values reported from other countries. Contrary to other studies, there was no association with selected self-reported and objectively measured cardiovascular and metabolic variables.

Sjogren's syndrome: Review of the aetiology, Pathophysiology & Potential therapeutic interventions

BACKGROUND

Sjogren's syndrome (SS) is an autoimmune disorder characterised by lymphocytic infiltration of exocrine glands, resulting in glandular dysfunction. Objectives: This study aims to review the aetiology of Sjogren's syndrome, highlight aspects that contribute to the pathophysiology of the disease and explore treatment options that target different mediators of pathogenesis.

MATERIAL AND METHODS

The MEDLINE/PubMed and Google Scholar databases were searched systematically with the terms "Sjogren's syndrome"; "clinical"; "treatment"; "management". Eligible studies had to meet a predefined inclusion criteria.

RESULTS

912 identified studies were evaluated against the inclusion criteria. 25 eligible studies were included for review. Sjogren's syndrome is a multifactorial condition with genetic, environmental and hormonal factors playing a role in establishing the condition. B-cell activating factor (BAFF) is an important mediator in the induction and perpetuation of this condition. Elevated BAFF levels, found in patients with SS, promote growth of B-cells and subsequent production of autoantibody; anti-SSA/Ro. BAFF inhibitors are important potential therapeutic drugs that may be effective in patients with Sjogren's syndrome. Other potential targets include CD20 and CD22 that cause B-cell depletion.

CONCLUSIONS

The pathophysiology of this exocrinopathy has not fully been elucidated. Potential therapeutic interventions include BAFF inhibitors and anti-CD20 and anti-CD22 therapy. However, no clinical trials have been conducted on subjects with Sjogren's syndrome to support existing research. Key words:Sjogren's syndrome, autoimmune, rheumatology.

Poorly recognized age-related downward deviation of the inguinal ligament

Objective:

To determine factors affecting actual inguinal ligament course in live human subjects.

Introduction and hypothesis:

Although the expected inguinal ligament course is supposedly a straight line extending from anterior superior iliac spine to pubic tubercle, the actual inguinal ligament course is frequently depicted a priori by a downward bowing dotted line. There are no studies in a live subject supporting this assumption. We hypothesized this assumption is indeed valid and is related to among other factors a lifelong effect of gravity and lax abdominal musculature on the inguinal ligament course.

Methods:

We retrospectively reviewed 54 consecutive computed tomography scans of the abdomen and pelvis randomly distributed across all age groups. Actual inguinal ligament course was visualized by reconstructing images using Terracon software. Vertical distance from the lowest point of actual inguinal ligament course to the expected inguinal ligament course was measured. We used multiple linear regression analysis to study the correlation between degree of inguinal ligament deviation and several variables.

Results:

Actual inguinal ligament course was below the expected inguinal ligament course in 52 of 54 patients. The mean deviation was 8.2 ± 5.9 mm. Advanced age was significantly associated with greater downward bowing of the inguinal ligament (p = 0.001).

Conclusion:

Actual inguinal ligament course is often well below the expected inguinal ligament course; this downward bowing of the inguinal ligament is especially pronounced with advancing age. Operators need to be mindful as this downward bowing can lead to supra-inguinal sticks causing vascular complications.

Evaluation of myocardial involvement in patients with connective tissue disorders: a multi-parametric cardiovascular magnetic resonance study

BACKGROUND

Severe arrhythmias or heart failure may be surrogates of myocardial involvement in patients with connective tissue disorders (CTD). However, most patients present with unspecific symptoms, normal ECG, and preserved left ventricular ejection fraction (LV-EF). Therefore, timely diagnosis by an accurate technique is crucial. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) has proven value for the detection of focal processes, but due to the often diffuse character of fibrosis/inflammation in CTD patients, CMR mapping techniques might be of incremental value for the assessment of myocardial involvement. Purpose of this study was to evaluate a multi-parametric CMR protocol as a screening tool for myocardial involvement in CTD patients.

METHODS

Forty CTD patients were prospectively enrolled and underwent CMR, twenty healthy volunteers served as control group.

RESULTS

Mean LV-EF was 62 %; LGE prevalence was low (18 %). CTD patients had higher native T1 (1008 vs. 962 ms, p = 0.001), lower post contrast T1 (494 vs. 526 ms, p = 0.008), expanded extracellular volume (ECV) (28 vs. 25 %, p = 0.001), and higher T2 values (53 vs. 49 ms, p < 0.001) compared to controls. Among patients with values higher than the 95 % percentile of healthy controls, native T1 and T2 values seem to be the most promising discriminators.

CONCLUSION

CTD patients showed higher T1, ECV, and T2 values compared to controls, with most significant differences for native T1 and T2, which seem to be independent of the presence of LGE. Our data suggest that CMR mapping techniques are of incremental value in the detection of myocardial involvement in CTD patients.

[Silica-associated systemic sclerosis occurring after an occupational exposure to arc welding]

La sclérodermie systémique liée à l’exposition à la silice cristalline peut apparaître chez les personnes utilisant la soudure à l’arc. Une forme diffuse de sclérodermie a été diagnostiquée chez un plombier-soudeur de 57 ans, qui présentait des polyarthralgies inflammatoires, un phénomène de Raynaud, une sclérodactylie, une sclérose cutanée diffuse, des télangiectasies, une atteinte œsophagienne, une hypertension artérielle pulmonaire et une fibrose pulmonaire associées à la présence d’anticorps anti-nucléosomes. Au cours de son activité professionnelle, le patient était fréquemment exposé à des concentrations atmosphériques élevées de silice cristalline lors de la soudure à l’arc. Le diagnostic d’un syndrome d’Erasmus avec une association d’une sclérodermie systémique à une silicose pulmonaire était retenu. Une déclaration en maladie professionnelle au titre du tableau n°17 en Tunisie a été réalisée.

Ocular Involvement in Systemic Autoimmune Diseases

Eye involvement represents a common finding in patients with systemic autoimmune diseases, particularly rheumatoid arthritis, Sjogren syndrome, seronegative spondyloarthropathy, and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. The eye is a privileged immune site but commensal bacteria are found on the ocular surface. The eye injury may be inflammatory, vascular or infectious, as well as iatrogenic, as in the case of hydroxychloroquine, chloroquine, corticosteroids, and bisphosphonates. Manifestations may affect different components of the eye, with episcleritis involving the episclera, a thin layer of tissue covering the sclera; scleritis being an inflammation of the sclera potentially leading to blindness; keratitis, referring to corneal inflammation frequently associated with scleritis; and uveitis as the inflammation of the uvea, including the iris, ciliary body, and choroid, subdivided into anterior, posterior, or panuveitis. As blindness may result from the eye involvement, clinicians should be aware of the possible manifestations and their management also independent of the ophthalmologist opinion as the therapeutic approach generally points to the underlying diseases. In some cases, the eye involvement may have a diagnostic implication, as for episcleritis in rheumatoid arthritis, or acute anterior uveitis in seronegative spondyloarthritis. Nonetheless, some conditions lack specificity, as in the case of dry eye which affects nearly 30 % of the general population. The aim of this review is to elucidate to non-ophthalmologists the major ocular complications of rheumatic diseases and their specific management and treatment options.

Impact of sex disparities on the clinical manifestations in patients with systemic lupus erythematosus: A systematic review and meta-analysis

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic autoimmune multiorgan disorder of unknown etiology. It affects both men and women, but with different disease manifestations of differing disease severity and in varying proportion, with a female predominance of approximately 90%. There have been numerous studies addressing this issue, especially its implications in relation to optimal sex-tailored treatment and improvement of survival rate; however, further research is warranted. A meta-analysis of studies was performed to compare the impact of sex on the clinical outcomes of SLE in different populations.

METHODS

A literature search of the MEDLINE/PubMed and EMBASE databases (until January 2016) was conducted to identify relevant articles. Clinical manifestations reported in these patients were considered as endpoints for this meta-analysis. Two independent reviewers determined eligibility criteria. A fixed-effect model has been used where a small heterogeneity was observed, or else, a random-effect model has been used among the studies. Odd ratio (OR) with 95% confidence interval (CI) was used to express the pooled effect on dichotomous variables, and the pooled analyses were performed with RevMan 5.3.

RESULTS

Sixteen studies consisting of a total of 11,934 SLE patients (10,331 females and 1603 males) have been included in this meta-analysis. The average female-to-male ratio of all the included studies is around 9.3:1. Several statistically significant differences were found: alopecia, photosensitivity, and oral ulcers were significantly higher in female patients (OR 0.36, 95% CI 0.29-0.46, P < 0.00001; OR 0.72, 95% CI 0.63-0.83, P < 0.00001; and OR 0.70, 95% CI 0.60-0.82, P < 0.00001, respectively). Malar rash was significantly higher in female patients (OR 0.68, 95% CI 0.53-0.88, P = 0.003), and arthritis was significantly lower in male patients (OR 0.72, 95% CI 1.25-1.84, P < 0.00001). However, serositis and pleurisies were significantly higher in female patients (OR 1.52, 95% CI 1.25-1.84 P < 0.0001; and OR 1.26, 95% CI 1.07-1.48, P = 0.006, respectively). Renal involvement was higher in male patients (OR 1.51, 95% CI 1.31-1.75, P < 0.00001).

CONCLUSION

The results of this meta-analysis suggest that alopecia, photosensitivity, oral ulcers, arthritis, malar rash, lupus anticoagulant level, and low level of C3 were significantly higher in female lupus patients, whereas renal involvement, serositis and pleurisies, thrombocytopenia, and anti-double stranded deoxyribonucleic acid level were predominant in male patients.

Relation of Nailfold Capillaries and Autoantibodies to Mortality in Patients With Raynaud Phenomenon

BACKGROUND

In incipient Raynaud phenomenon, nailfold capillaroscopy and autoantibody tests are obtained to screen for an emerging connective tissue disease. Whether the presence of abnormal nailfold capillaries and autoantibodies are related to mortality in patients with incipient Raynaud phenomenon is not known.

METHODS AND RESULTS

In 2958 consecutive patients (78% women, median age 45 years) with incipient Raynaud phenomenon without previously known connective tissue disease, nailfold capillaroscopy and laboratory tests for antinuclear antibodies (ANA) and ANA subsets were obtained at initial presentation. During a median follow-up period of 9.3 years, 227 women (9.9% of female patients) and 129 men (20% of male patients) with Raynaud phenomenon died. In comparison with a demographically matched standard population, survival was poorer in patients with Raynaud phenomenon (log-rank test P<0.0001). In patients with Raynaud phenomenon, mortality was higher in men than in women (P<0.0001, Cox proportional hazards model). In women, the presence of abnormal nailfold capillaries, ANA, and anti-Scl-70 antibodies were related to an increase in all-cause mortality. The conjoint presence of abnormal nailfold capillaries and autoantibodies was associated with the highest mortality rates. In men, abnormal nailfold capillaries, and ANA and ANA subsets, as well, were not related to survival. In both sexes, patients' age and serum creatinine were associated with mortality.

CONCLUSIONS

In Raynaud phenomenon, male sex, age, and serum creatinine are related to mortality. Abnormal nailfold capillaries and autoantibodies are associated with an increase in all-cause mortality in female patients, but not in male patients with Raynaud phenomenon.

Contribution of Nail Fold Videocapillaroscopy in Patients with Early Inflammatory Arthritis

BACKGROUND

Early inflammatory arthritis (EIA) a condition defined by joint swelling, with or without morning stiffness, and/or swelling of metacarpophalangeal and/or metatarsophalangeal joints. Nail fold video-capillaroscopy (NVC) is important for the evaluation of microcirculation in vivo. There are limited data about the role of NVC in EIA.

OBJECTIVES

To study the capillaroscopic pattern in patients with EIA.

PATIENTS AND METHODS

27 patients with EIA - 21 women, 6 men, mean age of 41.6±4.2 yrs, mean disease duration of 6.9±3.1 months. Anamnesis and clinical examination were perform to identify clinical signs associated with connective tissue diseases. All the patients were nonsmokers and had no personal medical history of diabetes or non-immune mediated occlusive vascular disease. Blood and urine samples were collected for bio-chemical and immunological evaluation. All the patients were interrogated by NVC.

RESULTS

Raynaud's phenomenon was found in 9 patients, puffy fingers in 2 pts, telangiectasia in 2 pts, Sicca symptoms in 6 pts, malar rash in 2 pts, photosensitivity and psoriasis plaque in one patient. Combined information from clinical exam, NVC and immunological assessment allowed a specific diagnosis in 5 patients.

CONCLUSIONS

Nail fold capillaroscopy assessment can provide further information and has diagnostic value in some cases of early arthritis. Nail fold capillaroscopy assessment contribution to the differential diagnosis in patients with early arthritis is sometimes significant, especially in poorly clinical and immunological defined cases.

Increased risks of deep vein thrombosis and pulmonary embolism in Sjögren syndrome: a nationwide cohort study

OBJECTIVE

Studies of the risks of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients with Sjögren syndrome (SS) in Asia are scant. We evaluated the effect of SS on the incidences of DVT and PE in a nationwide, population-based cohort in Taiwan.

METHODS

We identified patients in Taiwan diagnosed with SS between 1998 and 2008 in the Catastrophic Illness Patient Database and the National Health Insurance Research Database. Each patient with SS was matched to 4 control patients based on age, sex, and index year, and all patients were followed up from the index date to December 31, 2010. We calculated the hazard ratios (HR) and 95% CI of DVT and PE in the SS and comparison cohorts by using Cox proportional hazards regression models.

RESULTS

We followed 8920 patients with SS and a comparison cohort of 35,680 for about 50,000 and 200,000 person-years, respectively. The mean age of the SS and comparison cohorts was 53.5 and 53.1 years, respectively, and 88.9% of the patients were women. The risks of DVT and PE among the patients with SS were a 1.83-fold and 3.29-fold greater, respectively, than those for the general population after adjusting for age, sex, comorbidities, and frequency of hospitalization. The patients with a secondary SS had a greater risk of PE (adjusted HR: 5.06; 95% CI: 1.22-21.1) than those with a primary SS (adjusted HR: 3.21; 95% CI: 1.96-5.23).

CONCLUSION

Patients with SS have a significantly greater risk of developing DVT or PE than the general population.

Laryngeal Involvement in Connective Tissue Disorders. Is it Important for Patient Management?

Connective tissue disorders (CTDs) involve multiple organ systems and may have a significant impact on the overall health and quality of life of the affected individuals. The present paper aims to review the current knowledge on the laryngeal manifestations of CDTs, and describe the available diagnostic and treatment options. Systematic literature review in Medline and other database sources. Information from related books was also included. Prospective controlled, double-blind prospective, prospective, and transversal cohort studies, case series, case reports, systematic reviews, and consensus papers. Laryngeal involvement mostly occurs in rheumatoid arthritis (13-75% of patients). It is not uncommon in active and progressive clinical course, though can also occur in silent or inactive CDTs. The crico-arytenoid joint is the most commonly affected site. Common symptoms include throat pain, dyphonia and hoarseness. Careful clinical assessment of the larynx by flexible naso-endoscopy, video-stroboscopy, or direct laryngoscopy, and appropriate imaging are required for pertinent patient management. Stridor is a sign of a life-threatening condition, and may require prompt surgical intervention. However, mild symptomatology may mislead clinicians, and the related diagnosis may be significantly delayed. The current evidence as identified in the present study suggest that laryngeal manifestations of CDTs are often underdiagnosed, due to a range of non- specific symptoms. A multidisciplinary team approach with ENT input is necessary to improve the overall patient management.

Association of HLA-DRB1*15 and HLADQB1*06 with SLE in Saudis

BACKGROUND AND OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by humoral autoimmunity. The etiology of SLE is thought to be multifactorial including environmental, hormonal, and genetic factors. The human leukocyte antigen (HLA) has extensively been associated with the susceptibility to SLE; however, the association is heterogeneous among different ethnic groups. The aim of this study was to determine the association of HLA-A, HLA-B, HLA-DRB1, and HLA-DQB1 with SLE susceptibility in the Saudi population.

DESIGN AND SETTINGS

A total of 86 consecutive SLE patients attending the rheumatology clinic at King Abdulaziz Medical City, Riyadh, were recruited for this study.

METHODS

HLA types were determined by the polymerase chain reaction sequence-specific oligonucleotide (PCR-SSP) method in 86 patients and 356 control subjects.

RESULTS

The following HLA alleles were found to be positively associated with SLE: HLA-A*29 (OR=2.70; 95% CI=1.03-7.08; P=.0035), HLA-B*51 (OR=1.81; 95% CI=1.17-2.79; P=.0066), HLA-DRB1*15 (OR=1.45; 95% CI=0.98-2.29; P=.063), and HLA-DQB1*06 (OR=1.67; 95% CI=1.19-2.36; P=.0032), whereas HLA-DRB1*16 was negatively associated with the disease (OR=0.18; 95% CI=0.02-1.3; P=.055). HLA-DRB1*15 haplotypes were significantly associated with SLE (OR=2.01, 95% CI=1.20-3.68, P=.008); this was mainly due to the HLADRB1*15-DQB1*06 association.

CONCLUSIONS

Our data suggest an association between MHC class I and class II (HLA-A*29, HLA-B*51, HLA-DRB1*15, and HLA-DQB1*06) and susceptibility to SLE in the Saudi population. HLA-DRB1*15-DQB1*06 haplotype showed the highest risk factor for the disease that is similar to what was seen in the African American patients, suggesting shared susceptibility genetic factors among these ethnic groups.

Patient selection for ambulatory cardiac monitoring in the Indian healthcare environment

Cardiovascular disease (CVD) in India comprises the bulk of non-communicable diseases, resulting in 2 million deaths per year. The incidence of CVD in India is estimated to be up to four times higher than in other countries. Though the quantification of the prevalence of rhythm disorders in India is not available, it can be inferred to be proportionately high. Identification and treatment of arrhythmia is limited by several socioeconomic factors including low health insurance penetration, limited reimbursement and high out-of-pocket expenditures. Thus, there exists a need in India to (1) select an appropriate tool that is both high yielding and cost effective and (2) employ a suitable patient selection method. This paper focuses on these two aspects for cardiac arrhythmia diagnosis using ambulatory monitoring technology, while keeping in mind the dynamics of the Indian healthcare setting.

Immune-mediated disorders among women carriers of fragile X premutation alleles

The relative risk of immune-mediated disorders (IMDs) among women carriers of premutation alleles is estimated by a survey for IMDs among 344 carrier women (age 19-81 years; mean 46.35 and SD 12.60) and 72 controls (age 18-87 years; mean 52.40 and SD 15.40). One hundred fifty four (44.77%) women carrier had at least one IMD, as did 20 controls (27.78%). Among women carriers, autoimmune thyroid disorder was the most common (24.4%), then fibromyalgia (10.2%), irritable bowel syndrome (IBS; 9.9%), Raynaud's phenomenon (7.6%), rheumatoid arthritis (RA; 3.8%), Sjögren syndrome (2.6%), systemic lupus erythematosus (SLE; 2.03%), multiple sclerosis (1.74%). Of 55 carriers age 40 or older with FXTAS, 72.73% had at least one IMD, compared to 46.54% of those without FXTAS (n = 159), and 31.58% of controls (n = 57). The estimated odds ratio (OR) for IMD is 2.6 (95% CI 1.2-5.6, P = 0.015) for women with FXTAS relative to those without FXTAS; the likelihood of IMD in carriers without or with FXTAS was also significantly higher than for controls (OR 2.1, 95% CI 1.1-4.2, P = 0.034; OR 5.5, 95% CI 2.4-12.5, P < 0.001, respectively). Similarly, the odds of having an IMD among carriers with FXPOI is about 2.4 times higher when compared to carriers without FXPOI (95% CI 1.1-5.0; P = 0.021). The likelihood of IMD in carriers with or without FXPOI is greater (OR 2.4, 95% CI 1.1-5.0; P = 0.021) compared to that of controls.

Polymyositis following Pandemic Influenza A (H1N1) and 2009-10 Seasonal Trivalent Vaccines

Sporadic associations between inflammatory myopathies with vaccinations were described in the literature, raising the possible trigger value of vaccines in the development of these autoimmune disorders. Here, we reported the clinical history of 3 patients who developed polymyositis complicated by interstitial lung disease (2 cases) and dermatomyositis (1 case), after influenza A (H1N1) vaccination.

The Association of IL-12b Polymorphisms with Systemic Lupus Erythematosus in Chinese Han Population

Background. Systemic lupus erythematosus (SLE) is a complex immune disease. The genetic variation in the IL-12b gene was found to associate with SLE in Caucasian population. In this study, we examined this association in Chinese Han population by a recently developed method, unlabeled probe-based high resolution melting analysis. Methods. A total of 297 SLE patients and 351 controls were recruited. Unlabeled probe-based high resolution melting analysis (HRMA) was used in genotyping. Results. Statistically significant differences were observed in both genotype and allele frequencies for rs6887695 in the SLE patients as compared with the controls. Minor allele (C) of rs6887695 (P = 0.031, OR 0.78, [95% CI 0.63-0.98]) was found to be protective against SLE. The association of SNP rs6887695 with the diagnostic criteria of SLE was also examined. Minor allele (C) exerts protective effect on the incidence of arthritis (P = 0.013, OR = 0.65, 95% CI = 0.47-0.92) and abnormalities of antinuclear antibody (P = 0.022, OR = 0.68, 95% CI = 0.49–0.95). IL-12b SNPs were irrelevant to other diagnostic criteria of SLE. Summary. Polymorphisms of rs6887695 in IL-12b gene were associated with disease risk, as well as arthritis and antinuclear antibody synthesis, of systemic lupus erythematosus in Chinese population.

Social support and invalidation by others contribute uniquely to the understanding of physical and mental health of patients with rheumatic diseases

This study examined whether social support and invalidation (lack of understanding and discounting by others) are differently associated with physical and mental health. Participants were 1455 patients with fibromyalgia, rheumatoid arthritis, ankylosing spondylitis, osteorarthritis, or another rheumatic disease. Participants completed online questionnaires. Social support correlated negatively with discounting responses of others (moderately) and lack of understanding (strongly). Both invalidation and social support were additively associated with patients’ mental health, but only discounting was significantly associated with patients’ physical health. This suggests that improving health of patients with rheumatic diseases requires the consideration of both social support and invalidation.