Objectives

Farming and agricultural pesticide use have been associated with two autoimmune rheumatic diseases, rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). However, risk associated with other residential or workplace insecticide use is unknown.

Methods

We analyzed data from the Women’s Health Initiative Observational Study (n=76,861, post-menopausal, age 50-79 years). Incident cases (n=213; 178 RA, 27 SLE, and 8 both) were identified based on self-report and use of disease modifying anti-rheumatic drugs at year 3 of follow-up. We examined self-reported residential or workplace insecticide use (personally mixing/applying by self and application by others) in relation to RA/SLE risk, overall and in relation to farm history. Hazard ratios (adj.HR) and 95% confidence intervals (CI) adjusted for age, race, region, education, occupation, smoking, reproductive factors, asthma, other autoimmune diseases and co-morbidities.

Results

Compared to never use, personal use of insecticides was associated with increased RA/SLE risk, with significant trends for greater frequency (adj.HR 2.04; 95%CI 1.17, 3.56 for ≥ 6 times/year) and duration (HR 1.97; 95% CI 1.20, 3.23 for ≥ 20 years). Risk was also associated with long-term insecticide application by others (adj.HR=1.85; 95% CI 1.07, 3.20 for ≥20 years), and frequent application by others among women with a farm history (adj.HR 2.73; 95% CI 1.10, 6.78 for ≥ 6 times/year).

Conclusions

These results suggest residential and workplace insecticide exposure is associated with risk of ARD in post-menopausal women. Although these findings require replication in other populations, they support a role for environmental pesticide exposure in development of autoimmune rheumatic diseases.

Background

Classification criteria for systemic sclerosis (SSc) are being updated.

Objective

To select a set of items potentially useful for the classification of SSc using consensus procedures including the Delphi and nominal group techniques (NGT).

Methods

Items were identified through two independent consensus exercises performed by the Scleroderma Clinical Trials Consortium (SCTC) and the EULAR Scleroderma Trials and Research Group (EUSTAR). The first-round items from both exercises were collated and redundancies were removed leaving 168 items. A 3-round Delphi exercise was performed using a 1–9 scale (1=completely inappropriate and 9=completely appropriate) and a consensus meeting using NGT. During the last Delphi, the items were ranked on a 1–10 scale.

Results

Round 1: 106 experts rated the 168 items. Those with a median score <4 were removed, resulting in a list of 102 items. Round 2: The items were again rated for appropriateness and subjected to a consensus meeting using NGT by European and North American SSc experts (n=16), resulting in 23 items. Round 3: SSc experts (n=26) then individually scored each of the 23 items in a last Delphi round, using an appropriateness score (1–9) and ranking their 10 most appropriate items for classification of SSc. Presence of skin thickening, SSc-specific autoantibodies, abnormal nailfold capillary pattern and Raynaud’s phenomenon ranked highest in the final list that also included items indicating internal organ involvement.

Conclusion

The Delphi exercise and NGT resulted in a set of 23 items for classification of SSc which will be assessed for their discriminative properties in a prospective study.

Objective

Use of synthetic vitamin A derivatives (e.g. isotretinoin used for severe acne) and high doses of preformed vitamin A have been implicated in the pathogenesis of hyperuricemia and gout, whereas a trial reported that β-carotene may lower serum uric acid (SUA) levels. We evaluated the potential population impact of these factors on SUA in a nationally representative sample of US adults.

Methods

Using data from 14,349 participants aged 20 years and older in the Third National Health and Nutrition Examination Survey (1988–1994), we examined the relation between serum retinol, β-carotene, and uric acid levels using weighted linear regression. Additionally, we examined the relation with hyperuricemia using weighted logistic regression.

Results

SUA levels increased linearly with increasing serum retinol levels, whereas SUA levels decreased with increasing serum β-carotene levels. After adjusting for age, sex, dietary factors, and other potential confounders, the SUA level differences from the bottom (referent) to top quintiles of serum retinol levels were 0, 0.16, 0.31, 0.43, 0.71mg/dL (P for trend < 0.001) and for β-carotene were 0, −0.15, −0.29, −0.27, −0.40 mg/dL (P for trend < 0.001). Similarly, the multivariate odds ratios of hyperuricemia from the bottom (referent) to top quintiles of serum retinol levels were 1.00, 1.30, 1.83, 2.09, and 3.22 (P for trend <0.001) and for β-carotene were 1.00, 0.85, 0.68, 0.73, and 0.54 (P for trend <0.001). The graded associations persisted across subgroups according to cross-classification by both serum retinol and β-carotene levels.

Conclusions

These nationally representative data raise concerns that vitamin A supplementation and food fortification may contribute to the high frequency of hyperuricemia in the US population, whereas β-carotene intake may be beneficial against hyperuricemia. The use of β-carotene as a novel preventive treatment for gout deserves further investigation.

Background

Classification criteria for systemic sclerosis (SSc) are being updated jointly by ACR and EULAR. Potential items for classification were reduced to 23 using Delphi and Nominal Group Techniques. We evaluated the face, discriminant and construct validity of the items to be further studied as potential criteria.

Methods

Face validity was evaluated using the frequency of items in patients sampled from the Canadian Scleroderma Research Group, 1000 Faces of Lupus, the Pittsburgh, Toronto, Madrid and Berlin CTD databases. SSc (n=783) were compared to 1071 patients with diseases similar to SSc (mimickers): SLE (n=499), myositis (n=171), Sjögren’s syndrome (n=95), Raynaud’s phenomenon (RP) (n=228), MCTD (n=29), and idiopathic PAH (n=49). Discriminant validity was evaluated using odds ratios (OR). For construct validity, empiric ranking was compared to expert ranking.

Results

Compared to mimickers, SSc are more likely to have skin thickening (OR=427), telangiectasias (OR=91), anti-RNA polymerase III antibody (OR=75), puffy fingers (OR=35), finger flexion contractures (OR=29), tendon/bursal friction rubs (OR=27), anti-topoisomerase-I antibody (OR=25), RP (OR=24), finger tip ulcers/pitting scars (OR=19), anti-centromere antibody(OR=14), abnormal nailfold capillaries (OR=10), GERD symptoms (OR=8), and ANA, calcinosis, dysphagia, esophageal dilation (all OR=6), interstitial lung disease/pulmonary fibrosis (OR=5) and anti-PM-Scl antibody (OR=2). Reduced DLCO, PAH, and reduced FVC had OR<2. Renal crisis and digital pulp loss/acro-osteolysis did not occur in SSc mimickers (OR not estimated). Empiric and expert ranking were correlated (Spearman rho 0.53, p=0.01).

Conclusion

The candidate items have good face, discriminant and construct validity. Further item reduction will be evaluated in prospective SSc and mimicker cases.

Objective

To formulate consensus treatment plans (CTPs) for induction therapy of newly-diagnosed proliferative lupus nephritis (LN) in juvenile systemic lupus erythematosus (jSLE).

Methods

A structured consensus formation process was employed by the members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) after considering the existing medical evidence and current treatment approaches.

Results

After an initial Delphi survey (response rate 70%), a 2-day consensus conference, and two follow-up Delphi surveys (response rates 63–79%), consensus was achieved for a limited set of CTPs addressing the induction therapy of proliferative LN. These CTPs were developed for prototypic patients defined by eligibility characteristics, and included immunosuppressive therapy with either mycophenolic acid orally twice per day, or intravenous cyclophosphamide once per month at standardized doses for six months. Additionally, the CTPs describe three options for standardized use of glucocorticoids; including a primarily oral, a mixed oral/intravenous, and a primarily intravenous regimen. There was consensus on measures of effectiveness and safety of the CTPs. The CTPs were well accepted by the pediatric rheumatology providers treating children with LN, and up to 300 children per year in North America are expected to be candidates for the treatment with the CTPs.

Conclusion

CTPs for induction therapy of proliferative LN in jSLE based on the available scientific evidence and pediatric rheumatology group experience have been developed. Consistent use of the CTPs may improve the prognosis of proliferative LN, and support the conduct of comparative effectiveness studies aimed at optimizing therapeutic strategies for proliferative LN in jSLE.

Objective

Assess a generic measure of health-related quality of life (HRQOL) as an outcome measure in granulomatosis with polyangiitis (Wegener's, GPA)

Methods

Subjects were participants in the Wegener’s Granulomatosis Etanercept Trial (WGET) or the Vasculitis Clinical Research Consortium Longitudinal Study (VCRC-LS). HRQOL was assessed with the Short Form 36 Health Survey (SF-36) that includes physical and mental component summary scores (PCS and MCS). Disease activity was assessed with the Birmingham Vasculitis Activity Score for Wegener’s Granulomatosis (BVAS/WG).

Results

Data from 180 subjects in the WGET (median follow-up = 2.3 years, mean number of visits = 10) and 237 subjects in the VCRC-LS (median follow-up = 2.0 years, mean number of visits = 8) were analyzed. One unit increase in BVAS/WG corresponded to a 1.15 unit (95%CI: 1.02; 1.29) decrease in PCS and a 0.93 (95%CI: 0.78; 1.07) decrease in MCS in the WGET and by 1.16 for PCS (95%CI: 0.94; 1.39) and 0.79 for MCS (95%CI: 0.51; 1.39) in the VCRC-LS. In both arms of the WGET study, SF-36 measures improved rapidly during the first 6 weeks of treatment followed by gradual improvement among patients achieving sustained remission (0.5 improvement in PCS per three months), but worsened slightly (0.03 decrease in PCS per three months) among patients not achieving sustained remission (p = 0.005).

Conclusion

HRQOL, as measured by SF-36, is reduced among patients with GPA. SF-36 measures are modestly associated with other disease outcomes and discriminate between disease states of importance in GPA.

Objective

There is increasing evidence of the impact of SLE on employment, but few studies have had sufficient sample size and longitudinal follow-up to estimate the impact of specific manifestations or of increasing disease activity on employment.

Methods

Data derive from the UCSF Lupus Outcomes Study, a longitudinal cohort of 1204 persons with SLE sampled between 2002 and 2009. Of the 1204, 484 were working at baseline and had at least one follow-up interview. We used the Kaplan-Meier method to estimate the time between onset of thrombotic, neuropsychiatric, or musculoskeletal manifestations or of increased disease activity and work loss, and Cox proportional hazards regression to estimate the risk of work loss associated with the onset of specific manifestations, the number of manifestations, and increased activity, with and without adjustment for sociodemographic, employment, and SLE duration.

Results

By four years of follow-up, 57%, 34%, and 38% of those with thrombotic, musculoskeletal, and neuropsychiatric manifestations, respectively, had stopped working as had 42% of those with increased disease activity. On a bivariable basis, the risk of work loss was significantly higher among persons 55–64, and those with increased disease activity and each kind of manifestation. In multivariable analysis, older age, shorter job tenure, thrombotic and musculoskeletal manifestations, greater number of manifestations, and high levels of activity increased the risk of work loss.

Conclusions

Incident thrombosis and musculoskeletal manifestations, multiple manifestations, and increased disease activity are associated with the risk of work loss in SLE.

Background

Disease-modifying anti-rheumatic drugs (DMARDs) are recommended for virtually all patients with rheumatoid arthritis (RA). We investigated the use of DMARDs in patients with RA in a nationally representative sample of visits to US physicians in the National Ambulatory Care Medical Survey (NAMCS).

Methods

We analyzed NAMCS visit data from 1996 through 2007 if the physician noted a diagnosis of RA. DMARD utilization was based on the medications listed by the physician. We used generalized linear models to examine the adjusted associations between DMARD use and potential predictors.

Results

Among 859 visits with a diagnosis code of RA were identified over the study period, 404 (47%, 95% confidence interval (CI) 44-50%) had an associated DMARD. The percentage of RA visits with DMARDs increased slightly over the twelve years (p = 0.048), with biologic DMARDs increasing to 20% of visits after their introduction (p for trend < 0.001). In fully adjusted models, Black race was associated with a 30% reduction in DMARD prescribing (risk ratio, RR, 0.70, 95% CI 0.48 – 1.00). A visit to a rheumatologist was the strongest correlate of DMARD prescribing (RR 2.33, 95% CI 1.89 – 2.86). Among visits to non-rheumatologists, Blacks were significantly less likely than Whites to receive a DMARD (RR 0.39, 95% CI 0.17-0.92), but not among visits with rheumatologists (RR 0.81, 95% CI 0.52-1.27).

Conclusions

In the NAMCS survey, most visits coded with RA did not have an associated DMARD prescription. Blacks were less likely to receive DMARDs than Whites, particularly when visiting non-rheumatologists.

Objective

To examine the productivity of patients with scleroderma (SSc) both outside and within the home in a large observational cohort.

Methods

162 patients completed the Work Productivity Survey. Patients indicated whether or not they were employed outside of the home, how many days/month they missed work (employment or household work) due to SSc and how many days/month productivity was decreased ≥ 50%. Patients also completed other patient-reported outcome measures. We developed binomial regression models to assess the predictors of days missed from work (paid employment or household activities). The covariates included: type of SSc, education, physician and patient global assessments, HAQ-DI, FACIT-Fatigue, and Center of Epidemiologic Studies Depression Scale – Short Form (CESD).

Results

The average age of patients was 51.8 years and 51% had limited SSc. Of 37% patients employed outside of the home, patients reported missing 2.6 days/month of work and had 2.5 days per month productivity reduced by half. Of the 102 patients who were not employed, 39.4% were unable to work due to their SSc. When we assessed patients for household activities (N = 162), patients missed an average of 8 days of housework/month and had productivity reduced by average of 6 days/month. In the regression models, patients with lower education and poor assessment of overall health by physician were more likely to miss work outside the home. Patients with limited SSc and high HAQ-DI were more likely to miss work at home.

Conclusion

SSc has a major impact on productivity at home and at work. Nearly 40% of patients reported disability due to their SSc.

Objective

To evaluate the association of MRI-based knee cartilage T2 measurements and focal knee lesions with knee pain in knees without radiographic osteoarthritis (OA) among subjects with OA risk factors.

Methods

We studied the right knees of 126 subjects from the Osteoarthritis Initiative database. We randomly selected 42 subjects aged 45–55 years with OA risk factors, right knee pain (WOMAC pain score ≥5), no left knee pain (WOMAC pain score =0) and no radiographic OA (KL-score ≤1) in the right knee. We also selected two comparison groups: 42 subjects without knee pain in either knee and 42 with bilateral knee pain. Both groups were frequency matched to subjects with right knee only pain by gender, age, BMI and KL-score. All subjects underwent 3T MRI of the right knee. Focal knee lesions were assessed and cartilage T2 measurements were performed.

Results

Prevalence of meniscal, bone marrow and ligamentous lesions and joint effusion were not significantly different between the groups (p>0.05), while cartilage lesions were more frequent in subjects with right only knee pain compared to subjects without knee pain (p<0.05). T2 values averaged over all compartments were similar in subjects with right only knee pain (34.4±1.8ms) and with bilateral knee pain (34.7±4.7ms), but significantly higher compared to subjects without knee pain (32.4±1.8ms) (p<0.05).

Conclusion

These results suggest that elevated cartilage T2 values are associated with findings of pain in the early phase of OA, while among morphological knee abnormalities only knee cartilage lesions are significantly associated with knee pain status.

Objective

Statins, among the most commonly prescribed of medications, are associated with a wide range of musculoskeletal side effects. These include a progressive autoimmune myopathy with anti-HMGCR antibodies that requires immunosuppression. However, it remains unknown whether these antibodies are found in statin users with and without self-limited musculoskeletal side effects; this limits their diagnostic utility. The current work assesses the prevalence of anti-HMGCR antibodies in these groups of statin users.

Methods

We determined the prevalence of anti-HMGCR antibodies in (a) 1966 participants (including 763 current statin users) in a sub-study of the community-based Atherosclerosis Risk in Communities (ARIC) Study and (b) 98 French Canadian subjects with familial hypercholesterolemia, including 51 with documented statin intolerance.

Results

No participant in the ARIC sub-study, including those with past or current statin exposure at the time of sample collection, had anti-HMGCR antibodies. Similarly, none of 51 patients with self-limited statin intolerance or 47 statin-tolerant patients on maximal statin therapy were anti-HMGCR positive.

Conclusions

The vast majority patients with and without statin exposure, including those with self-limited statin intolerance, do not develop anti-HMGCR antibodies. Thus, anti-HMGCR antibodies are highly specific for those with an autoimmune myopathy.

Objective

The purpose of this study was to explore whether nontraditional risk factors, such as apolipoprotein C-III (Apo C-III) and its corresponding Apo B lipoprotein (Lp) subclasses, contribute to the risk of cardiovascular disease in rheumatoid arthritis (RA) patients.

Methods

Apolipoprotein and lipoproteins were measured in 152 RA patients by immunoturbidimetric procedures, electroimmunoassay, and immunoprecipitation. Patients had a coronary artery calcium (CAC) score assessed at baseline and at year 3. Differences in the CAC scores between baseline and year 3 were calculated and dichotomized at 0, where patients with a difference score >0 were denoted as progressors and the rest were denoted as nonprogressors. Differences between means were tested with a 2-sided independent Student’s t-test with Satterthwaite’s adjustment. Proportion differences were tested with a chi-square test. Multiple logistic regression was performed to assess the relationship between apolipoprotein and lipoprotein levels and the dichotomized CAC score.

Results

Progressors accounted for almost 60% of the cohort. Progressors had significantly higher levels of triglycerides, very low-density lipoprotein (VLDL) cholesterol, total cholesterol/high-density lipoprotein (HDL), triglycerides/HDL, Apo B, LpA-II:B:C:D:E, LpB:C, Apo B/Apo A-I, Apo C-III, and Apo C-III–heparin precipitate than the nonprogressors. After adjusting for age, sex, statin use (yes/no), and hypertension (yes/no), significant risk factors of progressors were total cholesterol, triglycerides, VLDL cholesterol, LDL cholesterol, Apo B, LpB:C, Apo C-III, and Apo B/Apo A-I.

Conclusion

Apo C-III–containing Apo B lipoprotein subclasses were found to be significantly elevated in progressors compared to nonprogressors. Many of these same lipoproteins were found to be associated with an increase in CAC scores among progressors. These lipoproteins may be considered new risk factors for progression of atherosclerosis in RA patients.

Objectives

To quantify rates of change in quadriceps muscle (QM) and intermuscular fat (IMF) volumes over 2-years in women in the Osteoarthritis Initiative (OAI) study and examine group differences between those with radiographic OA (ROA) and those without (non-ROA).

Methods

The OAI database was queried for women ≥50 years old in the incident and progression cohorts with and without ROA at baseline. Mid-thigh MRI scans (15 contiguous slices, 5 mm slice thickness) of eligible women were randomly selected and anonymized. Image pairs were registered. QM and IMF were segmented in the 12 most proximal matching slices with the segmenter blinded to image time point. Age-adjusted differences in QM and IMF volume changes between groups were tested using ANCOVA.

Results

41 women without ROA (mean (SD) age 60.7 (7.6) yrs) and 45 with ROA (mean (SD) age 64.5 (6.7) yrs) were included. Mean QM and IMF volume changes in the non-ROA group were -4.1 (11.1) cm3 and 3.4 (7.1) cm3, respectively, and -5.4 (13.5) cm3 and 3.1 (7.4) cm3 in the ROA group, respectively. Age-adjusted between-group differences in QM and IMF changes were not significant (p>0.05).

Conclusions

Two-year changes in QM and IMF volume appear consistent with ageing and do not seem to be related to OA status. Direct comparison with a control cohort without OA risk factors could confirm this. Since group assignment was based on baseline data, there may have been women in the non-ROA group who developed radiographic OA over follow-up resulting in some overlap between groups.

Objective

To examine the relationships between knee osteoarthritis (OA) and muscle parameters in a biracial cohort of older adults.

Methods

858 participants in the Health, Aging and Body Composition Study were included in this cross-sectional analysis. Computed tomography (CT) was used to measure muscle area and quadriceps strength was measured isokinetically. Muscle quality (specific torque) was defined as strength per unit of muscle area for both total thigh and quadriceps. Knee OA was assessed based on radiographic features and knee pain. We compared muscle parameters between those with and without radiographic knee OA (+RKOA, −RKOA) and among four groups defined by +/− RKOA with and without pain.

Results

The mean age was 73.5 (2.9) years and mean BMI was 27.9 (4.8) kg/m2. 58% of participants were women and 44% were Black. Compared to − RKOA, +RKOA participants had a higher BMI (30.2 vs. 26.8 kg/m2), larger thigh muscles (117.9 vs. 108.9 cm2), and a greater amount of intermuscular fat (12.5 vs. 9.9 cm2) (all p<0.0001). In adjusted models, +RKOA subjects had significantly lower specific torque (p<0.001), indicating poorer muscle quality, than −RKOA subjects, but there was no difference between groups in quadriceps specific torque. +RKOA/−pain (p<0.05) and +RKOA/+pain (p<0.001) subjects had lower specific torque compared to −RKOA/−pain group. There were no significant differences in quadriceps specific torque among RKOA/pain groups.

Conclusions

Muscle quality was significantly poorer in participants with RKOA regardless of pain status. Future studies should address how lifestyle interventions might affect muscle quality and progression of knee OA.

Objective

Expectations of higher activity levels associated with hip resurfacing arthroplasty (HRA) may be driving better outcomes in this group compared to total hip arthroplasty (THA). Previous studies evaluated expectations before consulting with the surgeon, although these expectations are likely unrealistic and would change after the consultation. We compared HRA and THA patient expectation after consultation with the surgeon.

Methods

In a prospective registry setting, patients awaiting HRA were matched to THA patients on age, sex, and preoperative Lower Extremity Activity Scale score (range 1–18, 18 highest activity level). Patients completed a validated 18-item expectations survey preoperatively. Mean overall expectations scores were first compared. Exploratory factor analysis (EFA) was then performed to determine if grouping of individual expectations items represented meaningfully different underlying factors in the 2 groups.

Results

We matched 123 pairs. Mean expectation scores were similar (HRA: 85.2±15.5, THA: 87.3±13.9; p-value=0.249). EFA showed that HRA and THA patients shared in common expectations of 1) pain relief and improvement in daily activities (9 items) and 2) eliminating pain medications, the need for cane and improving sexual activity (3 items). THA patients perceived the remaining 6 items as an overall third expectation of participation in higher-level activities. However, HRA patients perceived a fourth expectation of normal range of motion (2 items) independent of the other higher-level activities (4 items).

Conclusion

Even after consulting with a surgeon, patients’ expectations differed between HRA and THA patients regarding higher-level activities. More counseling of patients seeking hip arthroplasty is thus needed.

Objective

The study aims to examine the threshold in disease activity associated with switching biologic treatment regimens in RA patients in real-world clinical practice.

Methods

Using data from a prospective observational North American cohort of RA patients through 12/30/2009, patients who initiated a new anti-TNF agent with ≥ 6 months of follow-up were identified. Patients were classified as switchers or maintainers depending on whether they continued their anti-TNF treatment or switched (including discontinuation) within 12 months. Level of disease activity measured by CDAI and DAS28 at time of switch (corresponding follow-up visit for maintainers) was examined and random effect multivariable logistic regression was used to adjust for covariates.

Results

Mean age and RA duration among 1,549 eligible patients were 56.1 and 9.6 years, 80% were women, 62% were initiating their 1st biologic and 30% 2nd. At time of switch, the median DAS28 and CDAI were 3.1 and 8.4 among maintainers, and 4.0 and 15.2 among switchers. Maintainers also experienced a greater amount of reduction in disease activity compared with switchers (CDAI: −7.7 vs. −2.3; DAS28: −1.1 vs. −0.3). The threshold to switch decreased over calendar time, with the greatest amount of reduction observed among patients with moderate disease activity.

Conclusion

On average, physicians and patients were willing to continue biologic treatment for patients who are at or near low disease activity. The threshold to switch decreased over time, especially among partial responders.

Objective

Little is known about patterns of use of initial kidney replacement therapies among patients with LN end-stage renal disease (LN ESRD). We aimed to identify sociodemographic and clinical factors associated with variation in initial kidney replacement therapies among LN ESRD patients.

Methods

Patients with incident LN ESRD (1995–2006) were identified in the US Renal Data System. Age, sex, race, ethnicity, medical insurance, employment status, residential region, clinical factors and comorbidities were considered as potential predictors of ESRD treatment choice -- peritoneal dialysis (PD), hemodialysis (HD) or pre-emptive kidney transplantation -- in age-adjusted and multivariable-adjusted logistic regression analyses.

Results

Of 11,317 individuals with incident LN ESRD, 82.0% initiated HD; 12.2% PD, and 2.8% underwent pre-emptive kidney transplantation. Receiving initial PD was significantly associated with earlier calendar year, female sex, higher albumin and hemoglobin, and lower serum creatinine levels. African Americans (vs. Whites), Medicaid beneficiaries and those with no health insurance (vs. private insurance), and those unemployed (vs. employed) had significantly reduced PD initiation. Comorbidities including congestive heart failure, peripheral vascular disease and inability to ambulate were also associated with decreased PD. Many sociodemographic and clinical factors favoring PD were associated with pre-emptive kidney transplant (vs. dialysis) as well.

Conclusion

Few patients with LN ESRD receive initial PD or pre-emptive kidney transplantation. Race, ethnicity, employment and medical insurance type are strongly associated with initial kidney replacement therapy choice. Future studies need to investigate the appropriateness of sociodemographic and clinical variation and the comparative effectiveness of kidney replacement therapies for LN ESRD.

Objective

Develop and validate a shortened version of the Valued Life Activities disability and accommodations scale (VLA) for individuals with rheumatoid arthritis (RA).

Methods

To shorten the existing VLA measure, item response theory analyses were conducted using data from 449 patients with RA. Next, the resulting 14-item shortened version of the VLA scale (S-VLA) was evaluated by structured interviews among 20 RA patients. Lastly, the S-VLA was administered to 150 RA patients along with other measures including the Health Assessment Questionnaire (HAQ) and SF-36. A random sample of 50 patients completed the S-VLA two weeks later to assess reliability. Item statistics were calculated to evaluate correlations between individual items and S-VLA total score. Correlations between the S-VLA and other measures were used to evaluate validity.

Results

Test–retest reliability was 0.91, while Cronbach’s alpha for the S-VLA was 0.95. None of the 14 items were associated with improved alpha coefficients when omitted. All items were strongly correlated with the S-VLA total score. S-VLA scores were highly positively correlated with HAQ (r=0.81; p≤0.001), patient-reported disease activity (r=0.71; p≤0.001), satisfaction with abilities (r=0.82; p≤0.001), and number of days with activity limitations (r=0.65; p≤0.001). In addition, as hypothesized, the S-VLA was inversely correlated with SF-36 Physical Component Summary score (r=−0.78; p≤0.001) and subscales: Physical Functioning (r=−0.80; p≤0.001), Role Physical (r=−0.67; p≤0.001) and Social Functioning (r=−0.72; p≤0.001).

Conclusions

The S-VLA is a short, valid, and reliable instrument that may prove useful for monitoring disability among individuals with RA.

Objective

Standard treatment for severe granulomatosis with polyangiitis (GPA, previously Wegener’s granulomatosis) is daily oral cyclophosphamide (CYC), a cytotoxic agent associated with ovarian failure. In this study we assessed the rate of diminished ovarian reserve in women with GPA who received CYC versus methotrexate (MTX).

Methods

Patients in the Wegener’s Granulomatosis Etanercept Trial received either daily CYC or weekly MTX and were randomized to etanercept or placebo. For all women under 50, plasma samples taken at baseline or early in the study were evaluated against samples taken later in the study to compare levels of anti-Müllerian hormone (AMH) and follicle stimulating hormone (FSH), endocrine markers of remaining egg supply. Diminished ovarian reserve was defined as AMH<1.0ng/ml.

Results

Of 42 women in this analysis (mean age 35), 24 had CYC exposure prior to enrollment and 28 received the drug during the study. At study entry, women with prior CYC exposure had significantly lower AMH, higher FSH, and a higher rate of early menstruation cessation. For women with normal baseline ovarian function, 6/8 who received CYC during the trial developed diminished ovarian reserve, compared to 0/4 who did not receive CYC (p<0.05). Changes in AMH correlated inversely with cumulative CYC dose (p=0.01), with a 0.74ng/ml decline in AMH for each 10g of CYC.

Conclusion

Daily oral CYC, even when administered for less than 6 months, causes diminished ovarian reserve, as indicated by low AMH levels. These data highlight the need for alternative treatments for GPA in women of childbearing age.

Objective

To determine the relationship between beliefs, motivation, and worries about physical activity and physical activity participation in persons with rheumatoid arthritis.

Methods

A cross-sectional study used baseline data from 185 adults with rheumatoid arthritis enrolled in a randomized clinical trial assessing the effectiveness of an intervention to promote physical activity. Data included patients’ self-reported beliefs that physical activity can be beneficial for their disease, motivation for physical activity participation, worries about physical activity participation, and average daily accelerometer counts of activity over a week’s time. Body mass index, gender, age, race, and disease activity were measured as potential statistical moderators of physical activity.

Results

Physical activity participation was greater for those with higher scores on scales measuring beliefs that physical activity is beneficial for their disease (p for trend= 0.032) and motivation for physical activity participation (p for trend= 0.007) when adjusted for age, gender, body mass index, race, and disease activity. There was a positive but non-significant trend in physical activity participation in relation to worries.

Conclusion

Stronger beliefs that physical activity can be helpful for managing disease and increased motivation to engage in physical activity are related to higher levels of physical activity participation. These data provide a preliminary empiric rationale for why interventions targeting these concepts should lead to improved physical activity participation in adults with rheumatoid arthritis.

Objective

Many patient-reported outcome (PRO) instruments used in systemic sclerosis (SSc) trials are limited by lack of validation, licensing fees, and complicated scoring systems. We assessed the construct validity for discriminative purposes of two new PRO instruments-the Patient Reported Outcomes Measurement Information System 29-item Health Profile (PROMIS-29) and the Functional Assessment of Chronic Illness Therapy-Dyspnea short form (FACIT-Dyspnea), measuring health status and dyspnea in SSc patients.

Methods

Seventy-three patients participated in a cross-sectional study at a tertiary SSc program. PROMIS-29, FACIT-Dyspnea, and legacy PRO instruments used in clinical trials (Medical Research Council [MRC] Dyspnea Score, St. George’s Respiratory Questionnaire [SGRQ], Health Assessment Questionnaire-Disability Index [HAQ-DI] and Short-Form 36 [SF-36]) were administered. Composite severity scores using an adaptation of the Medsger Disease Severity Index were generated using clinical, diagnostic and laboratory information. PROMIS-29 and FACIT-Dyspnea scores were compared with legacy PRO measures and composite severity scores.

Results

The mean (range) patient age (84% women) was 51 years (22–72). The mean (range) SSc disease duration from the onset of the first non-Raynaud symptom was 7 years (0–45). Spearman correlation coefficients across FACIT-Dyspnea and PROMIS Physical Functioning scores with legacy PRO instruments were generally high (range=0.64–0.86); those between PROMIS and FACIT-Dyspnea with composite disease severity scores were more modest, but statistically significant (range=0.33–0.48, p<0.01).

Conclusion

PROMIS-29 and FACIT-Dyspnea are valid instruments to measure the health status of SSc patients. PROMIS-29 and FACIT-Dyspnea may be preferable to legacy instruments because they are freely available in multiple languages, and simple to administer, score and interpret.

Objective

To examine the relationship between pain, radiographic severity, and a common set of co-occurring centrally-mediated symptoms in women with knee osteoarthritis.

Methods

Participants underwent knee radiographs, and had repeated assessments of pain severity and other centrally-mediated symptoms, such as fatigue, sleep quality, and depression, during a five day home monitoring period. To examine associations between pain severity (the average of pain over the home monitoring period), measures of osteoarthritis radiographic severity (Kellgren Lawrence grade, minimum joint space width), centrally-mediated symptoms, and demographics (age) were used. Symptoms of fatigue, depression, and sleep efficiency were used in a composite measure representing centrally-mediated symptoms.

Results

Using a series of linear regression models in which each variable was entered hierarchically (N = 54), the final model showed 27% of the variance in pain severity was explained by age, radiographic severity, and centrally-mediated symptoms. Centrally-mediated symptoms explained an additional 10% of the variance in pain severity after the other two variables were entered.

Conclusions

Both radiographic severity and centrally-mediated symptoms were independently and significantly associated with pain severity in women with knee osteoarthritis. In addition to more severe radiographic features, women with higher centrally-mediated symptoms had greater pain severity. Treatments for women with symptomatic knee osteoarthritis may be optimized by addressing both peripheral and central sources of pain.

Objective

Temporomandibular joint (TMJ) involvement is common in Juvenile Idiopathic Arthritis (JIA). Dexamethasone iontophoresis (DIP) uses low-grade electric currents for transdermal dexamethasone delivery into deeper anatomic structures. The purpose of this study was to assess the safety and effectiveness of DIP for the treatment of TMJ involvement in JIA, and to delineate variables that are associated with improvement after DIP.

Methods

Medical records of all JIA patients who underwent DIP for TMJ involvement at a larger tertiary pediatric rheumatology center from 1997 to 2011 were reviewed. DIP was performed using a standard protocol. The effectiveness of DIP was assessed by comparing the maximal inter-incisor opening (MIOTMJ) and the maximal lateral excursion (MLETMJ) before and after treatment.

Results

Twenty-eight patients (ages 2– 21 years) who received an average of eight DIP treatment sessions per involved TMJ were included in the analysis. Statistically significant improvement in the median MIOTMJ (p< 0.0001) was observed in 68%. The median MLETMJ (p= 0.03) improved in 69%, and resolution of TMJ pain occurred in 73% of the patients who had TMJ pain at baseline. Side effects of DIP were transient site erythema (86%), skin blister (4%), and metallic taste (4%). Improvement in TMJ range of motion from DIP is associated with lower MIOTMJ, lower MLETMJ, and absence of TMJ crepitus at baseline.

Conclusion

In this pilot study DIP appeared to be an effective and safe initial treatment of TMJ involvement in JIA, especially among patients with decreased TMJ measurements. Prospective controlled studies are needed.