Previous Diagnosis Of Rheumatoid Arthritis Research Articles

Juxta-articular nodules with transepidermal elimination in a patient with Raynaud’s phenomenon: the challenging differential diagnosis between rheumatoid nodule and granuloma annulare

We report the case of a 51-year-old female who presented with firm, painful papules and nodules for 9 months, in the extensor proximal metacarpophalangeal and interphalangeal joints in both hands. She did not have a previous diagnosis of rheumatoid arthritis. She also denied arthralgia or arthritis. The patient had livedo reticularis and a history compatible with Raynaud’s phenomenon was reported. The histopathological exam showed well- developed confluent palisaded granulomas with homogenous eosinophilic necrobiosis, with signs of initial transepidermal elimination and no mucin. Thus, we are faced withthe challenging differential diagnosis of rheumatoid nodule preceding rheumatoid arthritis versus perforating juxta-articular granuloma annulare (pseudorheumatoid nodule).

Temporomandibular Joint ‘Mice:’ Report of Two Cases

Background: The temporomandibular joint (TMJ) is subject to frequent loading, related mostly to its functional capabilities, and it commonly exhibits bone remodeling. The physiological adaptability and tolerance might be compromised and signs of degenerative change will appear. The presence of loose calcified bodies in the TMJ space might suggest osteochondritis dissecans or synovial chondromatosis, and patients may have symptoms of pain, joint sounds and limitation in the range of motion of the jaw.Methods: In this paper, two cases with radiological loose and detached bone bodies in the TMJ suggestive of osteochondritis dissecans are discussed, including medical history, clinical findings, radiological appearance and treatment.Results: The first case is a 66-year-old female with systemic conditions who presented with TMJ crepitus. The second case is a 55-year-old female with a previous diagnosis of rheumatoid arthritis who has jaw clicking and facial pain. Panoramic imaging in both cases revealed joint loose bodies, and conservative treatment was implemented.Conclusions: The use of panoramic imaging as a preliminary diagnostic approach is useful to identify the presence of TMJ alterations. The management for these “joint mice” ranges from conservative treatment to surgical options.Practical implications: A conservative approach includes physical therapy and activity modification to improve muscle mobility and increase range of motion of the TMJ. Close monitoring will identify the need to intervene with a surgical procedure.

Depressive symptoms are associated with impaired sleep, fatigue, and disease activity in women with rheumatoid arthritis

ObjectivesTo investigate the associations between sleep quality, fatigue, disease activity and depressive symptoms in women with rheumatoid arthritis (RA).MethodsFemale patients with previous diagnosis of RA from a Rheumatology Outpatient Clinic at a tertiary referral centre, in Fortaleza, Brazil, were consecutively recruited into the study. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI); fatigue by the Fatigue Severity Scale (FSS); daytime sleepiness by the Epworth Sleepiness Scale (ESS); and depressive symptoms by the Beck Depression Inventory II (BDI-II). RA activity was measured by the disease activity score (DAS28).ResultsOne hundred ten women (mean age ± SD = 51.1 ± 13.0 y) were included in the study. On average, patients with depressive symptoms (BDI-II > 13), as compared to those without, showed poorer sleep quality (PSQI: 10.09 ± 4.1 vs 7.33 ± 3.55; p = 0.001 respectively), more fatigue (FSS: 4.69 ± 1.89 vs 3.34 ± 1.8; p = 0.001) and higher disease activity level (DAS28: 4.36 ± 1.53 vs 3.7 ± 1.39; p = 0,047). The logistic regression analysis showed that sleep quality is an independent predictor of depressive symptom severity.ConclusionDepressive symptoms, impaired sleep and fatigue are common in women with RA. Poor sleep is associated with greater frequency and severity of depressive symptoms in these patients, suggesting that screening for sleep and mood problems may be relevant both in clinical research and routine patient care. Future studies investigating the impact of measures to promote healthy sleep on depressive symptom control in this patient population are warranted.

Decreased Risk of Parkinson's Disease After Rheumatoid Arthritis Diagnosis: A Nested Case-Control Study with Matched Cases and Controls.

Background:Rheumatoid arthritis (RA) and the genetic risk landscape of autoimmune disorders and Parkinson’s disease (PD) overlap. Additionally, anti-inflammatory medications used to treat RA might influence PD risk.Objective:To use a population-based approach to determine if there is an association between pre-occurring rheumatoid arthritis (RA) and later-life risk of PD.Methods:The study population was 3.6 million residents of Sweden, who were alive during part or all of the follow-up period; 1997–2016. We obtained diagnoses from the national patient registry and identified 30,032 PD patients, 8,256 of whom each was matched to ten controls based on birth year, sex, birth location, and time of follow-up. We determined the risk reduction for PD in individuals previously diagnosed with RA. We also determined if the time (in relation to the index year) of the RA diagnosis influenced PD risk and repeated the analysis in a sex-stratified setting.Results:Individuals with a previous diagnosis of RA had a decreased risk of later developing PD by 30–50% compared to individuals without an RA diagnosis. This relationship was strongest in our conservative analysis, where the first PD diagnosis occurred close to the earliest PD symptoms (odds ratio 0.47 (CI 95% 0.28–0.75, p = 0.0006); with the greatest risk reduction in females (odds ratio 0.40 (CI 95% 0,19–0.76, p = 0.002).Discussion:Our findings provide evidence that individuals diagnosed with RA have a significantly lower risk of developing PD than the general population. Our data should be considered when developing or repurposing therapies aimed at modifying the course of PD.

Characteristics of Chikungunya virus infection in patients with established rheumatoid arthritis.

The aim of this study is to describe both clinical and treatment needs in six patients who had a previous diagnosis of rheumatoid arthritis (RA) and were infected with Chikungunya virus (CHIKV). We report RA patients who acquired CHIKV infection, treated from the Fundación Valle del Lili Hospital, Cali, Colombia, between August 2014 and September 2015. Data of demographic information, clinical and laboratory findings, DAS28 score, dose of glucocorticoids (GC), or conventional or DMARD use was collected before, during CHIKV infection, and 6months of follow-up. Five women and one man were analyzed, with an average age of 66years, who had been receiving low doses of GC (4mg of prednisolone/day on average). Two patients were being treated with methotrexate (MTX) and etanercept, one with MTX and other with etanercept, with an average DAS28 of 2.00 at the last control consultation. At the time of CHIKV infection, they presented an average DAS28 of 3.98, requiring more than double their usual dose of GC (average dose 8.75mg/day of prednisolone). One patient required a change from etanercept to adalimumab and three others started rituximab, tocilizumab, and tofacitinib as second-line medication. A case series of patients with RA in remission are presented, who when contracting CHIKV infection developed exacerbation of their underlying disease, which in general was difficult to control. An increase in the doses of GC and change or induction to the use of second-line medications (anti-TNF, anti-CD20, or Janus kinase inhibitor) were required. Key Points • The clinical outcome of RA patients with CHIKV infections is not well known. • A group of RA patients, who were in clinical remission, were affected during the 2014-2015 CHIKV epidemic and treated in a hospital in southwestern Colombia, and had severe reactivation of their RA. • Some patients with RA in remission and who had CHIKV infection required an increase in the glucocorticoid, in addition to starting second-line medications (anti-TNF, anti-CD20, or Janus kinase inhibitor) or their modification.

A case of concurrent Kikuchi-Fujimoto Disease and Neuropsychiatric Lupus in a Patient with Rheumatoid Arthritis and Systemic Lupus Erythematosus Overlap Syndrome

Kikuchi-Fujimoto disease is a rare, self-limited, histiocytic necrotizing lymphadenitis characterized by cervical lymphadenopathy and fever. An association has been made between the presence of this disease and systemic lupus erythematosus. We describe a unique case of a 31 year old female with a previous diagnosis of rheumatoid arthritis and lupus overlap syndrome who presented with severe headache and subsequently developed altered level of consciousness and seizures. She underwent an extensive assessment which included investigations for an infectious cause, numerous imaging studies, a lymph node biopsy, a bone marrow biopsy, and a brain biopsy resulting in a final diagnosis of concurrent Kikuchi-Fujimoto disease and lupus-associated encephalitis. In these overlap patients, neurological involvement is usually mild. In contrast, our patient presented with severe neuropsychiatric involvement eventually requiring ICU admission. This case highlights the difficulty of diagnosing and managing neuropsychiatric lupus in these complex overlap patients. Early recognition is important to avoid unnecessary and potentially harmful interventions and treatments.

Are There Differences in Gait Mechanics in Patients With A Fixed Versus Mobile Bearing Total Ankle Arthroplasty? A Randomized Trial.

Total ankle arthroplasty (TAA) is an alternative to arthrodesis, but no randomized trial has examined whether a fixed bearing or mobile bearing implant provides improved gait mechanics. We wished to determine if fixed- or mobile-bearing TAA results in a larger improvement in pain scores and gait mechanics from before surgery to 1year after surgery, and to quantify differences in outcomes using statistical analysis and report the standardized effect sizes for such comparisons. Patients with end-stage ankle arthritis who were scheduled for TAA between November 2011 and June 2013 (n=40; 16 men, 24 women; average age, 63years; age range, 35-81years) were prospectively recruited for this study from a single foot and ankle orthopaedic clinic. During this period, 185 patients underwent TAA, with 144 being eligible to participate in this study. Patients were eligible to participate if they were able to meet all study inclusion criteria, which were: no previous diagnosis of rheumatoid arthritis, a contralateral TAA, bilateral ankle arthritis, previous revision TAA, an ankle fusion revision, or able to walk without the use of an assistive device, weight less than 250 pounds (114kg), a sagittal or coronal plane deformity less than 15°, no presence of avascular necrosis of the distal tibia, no current neuropathy, age older than 35years, no history of a talar neck fracture, or an avascular talus. Of the 144 eligible patients, 40 consented to participate in our randomized trial. These 40 patients were randomly assigned to either the fixed (n=20) or mobile bearing implant group (n=20). Walking speed, bilateral peak dorsiflexion angle, peak plantar flexion angle, sagittal plane ankle ROM, peak ankle inversion angle, peak plantar flexion moment, peak plantar flexion power during stance, peak weight acceptance, and propulsive vertical ground reaction force were analyzed during seven self-selected speed level walking trials for 33 participants using an eight-camera motion analysis system and four force plates. Seven patients were not included in the analysis owing to cancelled surgery (one from each group) and five were lost to followup (four with fixed bearing and one with mobile bearing implants). A series of effect-size calculations and two-sample t-tests comparing postoperative and preoperative increases in outcome variables between implant types were used to determine the differences in the magnitude of improvement between the two patient cohorts from before surgery to 1year after surgery. The sample size in this study enabled us to detect a standardized shift of 1.01 SDs between group means with 80% power and a type I error rate of 5% for all outcome variables in the study. This randomized trial did not reveal any differences in outcomes between the two implant types under study at the sample size collected. In addition to these results, effect size analysis suggests that changes in outcome differ between implant types by less than 1 SD. Detection of the largest change score or observed effect (propulsive vertical ground reaction force [Fixed: 0.1±0.1; 0.0-1.0; Mobile: 0.0±0.1; 0.0-0.0; p=0.0.051]) in this study would require a future trial to enroll 66 patients. However, the smallest change score or observed effect (walking speed [Fixed: 0.2±0.3; 0.1-0.4; Mobile: 0.2±0.3; 0.0-0.3; p=0.742]) requires a sample size of 2336 to detect a significant difference with 80% power at the observed effect sizes. To our knowledge, this is the first randomized study to report the observed effect size comparing improvements in outcome measures between fixed and mobile bearing implant types. This study was statistically powered to detect large effects and descriptively analyze observed effect sizes. Based on our results there were no statistically or clinically meaningful differences between the fixed and mobile bearing implants when examining gait mechanics and pain 1year after TAA. Level II, therapeutic study.

Abstract LB-191: Association of anti-estrogen therapy in breast cancer patients and subsequent risk of rheumatoid arthritis: An electronic health record study

Abstract Background: The use of anti-estrogen (AE) therapies (selective estrogen receptor modulators [SERMs], aromatase inhibitors [AIs]) in breast cancer (BC) patients was recently associated with risk of developing rheumatoid arthritis (RA) (J Rheum 2015;42:55-9). We attempted to replicate and extend these results using electronic health record (EHR) enhanced cancer registry data that assessed specific AE therapies and also accounted for potential confounding by age, smoking status, and chemotherapy use. Methods: Using cancer registry and EHR data, we identified a cohort of BC patients who were newly diagnosed and treated at Mayo Clinic Rochester from 1998-2011 and had no previous diagnosis of RA. Smoking status at diagnosis, BC treatments and RA at diagnosis and during follow-up were identified using validated EHR-based algorithms. Hazard ratios (HRs) and 95% confidence intervals (CI) from a multivariate Cox model were used to estimate the association of AE use with risk of RA, controlling for age, smoking status at BC diagnosis, and BC chemotherapy use. Results: The analytic cohort of 9,244 newly diagnosed BC patients treated and followed at Mayo Clinic had a median age at diagnosis of 59 years (range 18-97); 32% were smokers; and 29% were treated with chemotherapy. During a median follow-up of 49 months (range 1-191), 19 patients developed RA. Compared to BC patients not receiving any AE therapy, those receiving AI monotherapy, but not SERM monotherapy or both SERMs and AIs, were at significantly increased risk of developing RA (Table). AE Therapy# of RA Cases / # patientsHR* (95% CI)P-valueNo AE therapy6/4,0711.00 (reference)SERMs only5/2,5371.20 (0.36 - 3.95)0.77AIs only5/7126.37 (1.77 - 22.92)0.005SERMs then AIs3/1,8750.90AI then SERMs0/490.91 (0.21 - 3.86)*Adjusted for age, smoking status and use of chemotherapy Conclusions: Our findings indicate that the use of AIs for BC therapy, but not SERMs or SERMs followed by AIs, is associated with increased risk for development of RA, when controlling for smoking status and use of chemotherapy. While needing replication, these findings suggest a specific role for AIs in RA development and suggest pathways that could be targeted to prevent this potential treatment complication. Citation Format: Matthew K. Breitenstein, Ming-Fen Ho, Richard M. Weinshilboum, James R. Cerhan, Jyotishman Pathak, Tim Bongartz, Liewei Wang, James N. Ingle. Association of anti-estrogen therapy in breast cancer patients and subsequent risk of rheumatoid arthritis: An electronic health record study. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr LB-191. doi:10.1158/1538-7445.AM2015-LB-191

A case–control study on the association between rheumatoid arthritis and bladder pain syndrome/interstitial cystitis

While bladder pain syndrome/interstitial cystitis (BPS/IC) has been suggested by a number of studies to have autoimmune character, no population-based study to date has been conducted investigating its association with rheumatoid arthritis (RA). This study aimed to examine the association between IC/BPS and having previously been diagnosed with RA. We conducted this study by using administrative claims data sourced from the Taiwan National Health Insurance Database. Our study included 9,269 cases with BPS/IC and 46,345 randomly selected controls. Conditional logistic regression was performed to calculate the odds ratio (OR) for the association between previously diagnosed RA and IC/BPS. RA was found among 202 (2.2%) cases and 504 (1.12%) controls. Conditional logistic regression analysis suggested that when compared with controls, the OR for prior RA among cases was 1.66 (95% CI = 1.47-1.87, P < 0.001) after adjusting for diabetes, hypertension, coronary heart disease, obesity, hyperlipidemia, chronic pelvic pain, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, depression, panic disorder, migraine, sicca syndrome, allergy, endometriosis, asthma, overactive bladder, tobacco use disorder, and alcohol abuse. Additionally, BPS/IC was consistently and significantly associated with a previous diagnosis of RA regardless of prescription drug use; the OR for prior RA among groups prescribed ≤1 type of disease-modifying antirheumatic drug (DMARD), two types of DMARDs, and ≥3 types of DMARDs or TNF-alpha inhibitor when compared to controls were 1.49 (95% CI = 1.28-1.72), 1.91 (95% CI = 1.38-2.68), and 2.36 (95% CI = 1.77-3.17), respectively. There is an association between RA and BPS/IC after adjusting for socio-demographic characteristics and medical co-morbidities.

Associations of systemic diseases, smoking and contact lens wear with severity of dry eye

Systemic diseases, smoking, ocular surgeries and contact lens wear have been linked with dry eye but it is not known if these factors are also associated with severity of dry eye. A cross-sectional investigation was conducted on the effect of various systemic and ocular conditions with respect to the severity of dry eye in Asian patients. Prospective recruitment of consecutive new referral patients from a dry eye clinic was performed. Medical history, dry eye symptoms and clinical assessment were coded in a standardised form and analysed. Out of 510 patients (25% men), mean ± S.D. age 53.0 ± 14.1 years, 25 had previous diagnosis of rheumatoid arthritis, 30 had diabetic mellitus, 41 had thyroid disease, and 33 were current smokers; 23 and 41 patients had previous LASIK and cataract surgery respectively and 90 were current contact lenses wearers. A previous diagnosis of rheumatoid arthritis was associated with more severe superior corneal fluorescein staining (OR = 11.2, 95% CI 4.6-27.4). Generally, with the exception of rheumatoid arthritis, there were no associations between dry eye severity and systemic diseases, smoking, previous ocular surgeries and contact lens wear. Dry eye patients with rheumatoid arthritis tend to have more severe ocular surface damage in the superior cornea.

Joint swelling as a predictor of death from cardiovascular disease in a population study of Pima Indians.

Markers of inflammation have recently been shown to be predictive of cardiovascular disease (CVD). Furthermore, the excess mortality in rheumatoid arthritis (RA), a disease characterized by chronic polyarthritis, is chiefly due to death from CVD. With this background, we studied the effect of inflammation, as reflected by the number of joints with soft tissue swelling, and rheumatoid factor (RF) seropositivity on CVD-related mortality. Mortality rates and rate ratios for all-cause and CVD-related deaths were computed in a longitudinal, population-based cohort of Pima Indians in Arizona from 1965 through 1994. Repeated health examinations were performed, involving systematic assessment of the features of RA, cardiovascular risk factors, serum titers of RF, as well as mortality. The cohort comprised 4,120 subjects (1,861 men, 2,259 women) who were examined an average of 3.5 times during a mean followup of 14 years. During the followup period, 182 CVD-related deaths ocurred. The age- and sex-adjusted CVD-related mortality rates increased significantly with the presence of a higher number of joints with soft tissue swelling (Ptrend = 0.04), and were 2.07 (95% confidence interval [95% CI] 1.30-3.31) times as high in those subjects who had 2 or more swollen joints as in those who had none. There were no significant additional effects on CVD-related mortality when seropositivity for RF or a previous diagnosis of RA were considered. In age- and sex-adjusted proportional hazards analyses, which were controlled for possible confounders, the effect of swollen joints remained significant (mortality rate ratio 1.33, 95% CI 1.04-1.71 per category increase [no swollen joints, 1 swollen joint, at least 2 swollen joints]). Joint swelling is a significant risk factor for CVD-related death, independent of other known risk factors including a diagnosis of RA. This finding supports the hypothesis that inflammatory mechanisms are important for the development of CVD.