American Journal of Industrial Medicine, Apr 1, 2011
Background The risk of developing clinical connective tissue disease (CTD) has been reported to b... more Background The risk of developing clinical connective tissue disease (CTD) has been reported to be increased among individuals with silica exposure. Methods We reviewed the medical records of individuals reported to the Michigan Silicosis Surveillance system from 1985 to 2006 to confirm the diagnosis of silicosis and determine the presence of CTDs. Results From 1985 to 2006, 1,022 cases were confirmed to have silicosis. Medical records of 790 cases were available. Thirty-three individuals had rheumatoid arthritis (RA) [prevalence 4.2% (prevalence ratio (RR) ranged from 2.26, 95% CI: 1.57-3.25 to 6.96, 95% CI: 2.93-16.53) depending on the reference rate used], two had scleroderma [prevalence 0.3% (RR 28.3, 95% CI: 6.09-129.98)], one had systemic lupus erythematosus [prevalence 0.1% (RR 2.53, 95% CI: 0.30-21.64)], two had Sjogrens syndrome [prevalence 0.3% (RR 0.42, 95% CI: 0.09-2.08)], and six had anti-neutrophil cytoplasm antibody (ANCA) vasculitis [prevalence 0.8% (RR 25.3, 95% CI: 6.34-101.04)]
To investigate the incidence of venous thromboembolism (VTE) and cerebrovascular events in a comm... more To investigate the incidence of venous thromboembolism (VTE) and cerebrovascular events in a community-based incidence cohort of patients with giant cell arteritis (GCA) compared to the general population. A population-based inception cohort of patients with incident GCA between January 1, 1950 and December 31, 2009 in Olmsted County, Minnesota and a cohort of non-GCA subjects from the same population were assembled and followed until December 31, 2013. Confirmed VTE and cerebrovascular events were identified through direct medical record review. The study population included 244 patients with GCA with a mean ± SD age at diagnosis of 76.2 ± 8.2 years (79% women) and an average length of follow-up of 10.2 ± 6.8 years. Compared to non-GCA subjects of similar age and sex, patients diagnosed with GCA had a higher incidence (%) of amaurosis fugax (cumulative incidence ± SE: 2.1 ± 0.9 versus 0, respectively; p = 0.014) but similar rates of stroke, transient ischemic attack (TIA), and VTE. Among patients with GCA, neither baseline characteristics nor laboratory parameters at diagnosis reliably predicted risk of VTE or cerebrovascular events. In this population-based study, the incidence of VTE, stroke and TIA was similar in patients with GCA compared to non-GCA subjects.
To compare the outcomes between vascular surgery and endovascular procedures in a cohort of patie... more To compare the outcomes between vascular surgery and endovascular procedures in a cohort of patients with Takayasu arteritis (TA). A retrospective cohort study was conducted of patients with TA who underwent vascular interventions at a tertiary center between 1984 and 2009. The American College of Rheumatology criteria for TA were used to select patients. Disease activity was assessed according to the Kerr criteria. Data are reported using descriptive statistics and Kaplan-Meier methods for complication rates. The cohort included 66 patients with TA who underwent 119 vascular procedures (surgery 93; endovascular repair 26). The most frequent indication for vascular surgery and endovascular procedure was arm claudication (surgical group 43%, endovascular repair group 31%). In 59% of the vascular surgical procedures and in 38% of endovascular procedures, the disease was active within 1 month of intervention. The most frequent arterial lesion requiring intervention was the aorta (28%) ...
To evaluate characteristics of relapse, relapse rates, treatment and outcomes among patients with... more To evaluate characteristics of relapse, relapse rates, treatment and outcomes among patients with biopsy-proven GCA in a large, single-institution cohort. We conducted a retrospective review of all patients with biopsy-proven GCA from 1998 to 2013. Demographic, clinical, laboratory and treatment data at presentation and during follow-up were collected. Comparisons by relapse rate were performed using chi-square tests. Prednisone discontinuation by initial oral dose ≤40 and >40 mg/day was compared using Cox models. The cohort included 286 patients [74% female, mean age at diagnosis 75.0 years (s.d. 7.6), median follow-up 5.1 years). During follow-up, 73 patients did not relapse, 80 patients had one relapse and 133 had two or more relapses. The first relapse occurred during the first year in 50% of patients, by 2 years in 68% and by 5 years in 79%. More patients with established hypertension (P = 0.007) and diabetes (P = 0.039) at GCA diagnosis were in the high relapse rate group (...
ABSTRACT Background Giant cell arteritis (GCA) is the most common systemic vasculitis and patient... more ABSTRACT Background Giant cell arteritis (GCA) is the most common systemic vasculitis and patients with GCA frequently experience one or more relapses during treatment. In order to address differential lengths of followup, relapse rates provide a novel method to evaluate patients with GCA at risk for more frequent relapses. Objectives To evaluate the relapse rates, characteristics, predisposing factors, and relationship with mortality in a large single-institution cohort of patients with biopsy-proven GCA. Methods A retrospective review was performed to identify all patients with biopsy-proven GCA from 1 January 1998 through 31 December 2013. Demographic, clinical, and laboratory data at presentation and each follow up visit were collected. Relapse was defined as recurrence of clinical manifestations compatible with spectrum of GCA and/or increase in inflammatory markers (ESR/CRP), not otherwise explainable, which required reintroduction or increased dose of glucocorticoid therapy. Comparisons between relapse and no-relapse groups were performed using Chi-square and Kruskal-Wallis tests. Results The cohort included 286 patients with biopsy-proven GCA (213 females and 73 males, mean [±SD] age 75.0 [±7.6] years) with a mean (±SD) follow-up of 6.0 (±3.9) years. The mean (±SD) number of visits was 14.2 (±8.4) and the mean (±SD) visit rate per person per year was 3.3 (±2.6). During follow-up, 73 patients did not have a relapse, 80 patients had one relapse and 133 had two or more relapses. The first relapse occurred during the first year in 50% of patients (by 2 years in 68% and by 5 years in 79%). Among all relapse visits, 28.6% of relapses were related to abnormal lab markers only, 24.2% were related to flare symptoms only, and 47.2% represented flare symptoms and abnormal lab markers. The most common relapse symptoms were polymyalgia rheumatica (33.1%), headache (32.3%), malaise (20.6%) and scalp tenderness (7.8%). The median relapse rate observed was 0.4 [IQR 0.21, 0.64] relapses per year. We further evaluated patients in three groups; no relapse, low relapse rate (<0.5 relapses/yr), and high relapse rate (≥0.5 relapses/yr). A lower proportion of females were in the no relapse group (63%) than in the <0.5 relapses/yr (79%) or the ≥0.5 relapses/yr (78%) groups (p=0.034). A higher proportion of patients with hypertension (p=0.007), diabetes (p=0.039) and prior history of venous thrombosis (p=0.041) were present in the ≥0.5 relapse/yr group compared to the no relapse and <0.5 relapse/yr groups. In this cohort, neither the presence of relapse [HR 0.80, (0.47, 1.36); p=0.41] nor the number of relapses [HR 0.99 (0.83, 1.19); p=0.94] were associated with excess mortality. Conclusions Patients with biopsy-proven GCA have a high risk of relapse during follow up. Women with GCA tend to relapse more than men. Patients with established hypertension or diabetes at time of GCA diagnosis have a higher frequency of relapse. Relapses were not predictive of higher mortality. Disclosure of Interest None declared
ABSTRACT Background Venous thromboembolic events (VTE) and cerebrovascular accidents (CVA) are se... more ABSTRACT Background Venous thromboembolic events (VTE) and cerebrovascular accidents (CVA) are serious health problems in the general population and appear to be more frequent in patients with chronic inflammatory disorders. Objectives The purpose of the study is to determine the incidence of VTE and CVA in patients with giant cell arteritis (GCA). Methods We retrospectively reviewed a population-based incidence cohort of patients with GCA diagnosed between 1950 and 2009 based on American College of Rheumatology 1990 GCA classification criteria. We compared this cohort with subjects without GCA of similar age, sex, and calendar year from the same population. All subjects were followed longitudinally through all available community medical records until death, migration from Olmsted County or 31 December 2013. The occurrence of VTE (deep venous thrombosis or pulmonary embolism), and CVA (hemorrhagic stroke, ischemic stroke, transient ischemic attack (TIA), amaurosis fugax), were ascertained by review of the medical records. The cumulative incidence of VTE and CVA in patients with and without GCA, adjusted for the competing risk of death, was estimated and compared using methods by Gray. Results The study population included 244 patients with GCA and 240 non-GCA subjects. The GCA cohort consisted of 193 (79%) women and 51 (21%) men, with mean (±SD) age 76.0 (±8.2) years and a median follow-up 10.2 years. The non-GCA cohort consisted of 190 (79%) women and 50 (21%) men, mean age 75.8 (±8.5) years with a median follow-up 10.8 years. The GCA cohort was followed for a total of 2,480 person-years, while the non-GCA cohort was observed for 2588 person-years. Occurrence of VTE prior to GCA incidence/index date was similar between the two cohorts: 10 episodes (4%) in GCA cohort versus 8 episodes (3%) in non-GCA cohort (p=0.81). During follow-up, 16 patients with GCA and 10 non-GCA subjects developed VTE. The 10-year cumulative incidences (±SE) of VTE were 6.3% (±1.6) among patients with GCA and 3.7% (±1.3) among non-GCA patients (p=0.22). CVA had occurred prior to the index date in 18 (7.3%) patients with GCA and 18 (7.5%) non-GCA patients (p=0.96). During follow-up, 30 patients with GCA and 27 non-GCA subjects developed CVA. The 10-year cumulative incidences (±SE) of stroke were similar between patients with GCA [8.5% (±1.9)] and non-GCA subjects [9.2% (±2.0); p=0.94]. The 10-year cumulative incidences (±SE) of TIA were also similar between patients with GCA [2.3% (±1.0)] and non-GCA subjects [1.7% (±0.8); p=0.97]. Patients with GCA had a higher cumulative incidence of amaurosis fugax compared to controls [1.2% (±0.7) versus 0%; p=0.045]. Mean age at first event did not differ between patients with GCA and non-GCA subjects for VTE (81.3 versus 85.9 years; p=0.16) or CVA (80.6 versus 83.8 years; p=0.30). Conclusions In this population based-cohort, patients with GCA were at an increased risk for amaurosis fugax; however, the risk of VTE, stroke and TIA was not increased compared to non-GCA subjects. Disclosure of Interest None declared
Therapeutic Advances in Musculoskeletal Disease, 2014
Rheumatoid arthritis (RA), a chronic autoimmune inflammatory disease of synovial joints, can lead... more Rheumatoid arthritis (RA), a chronic autoimmune inflammatory disease of synovial joints, can lead to chronic pain and structural joint damage, as well as other organ involvement, especially if not adequately controlled. Because it can affect women in their reproductive years, care of pregnant women with RA requires a delicate balance of maintaining disease control while limiting potential toxicity to the fetus and neonate. While most women experience a substantial improvement in disease activity during pregnancy, for some women their RA remains active. It can even manifest itself for the first time during pregnancy or early in the post-partum period. Optimizing disease control prior to conception is key, but utilizing disease-modifying treatments effectively and safely throughout pregnancy and lactation requires open dialogue and shared decision making. This review provides evidence-based recommendations for use of disease-modifying antirheumatic drugs (DMARDs) and biologic response modifiers to guide rheumatologists in their care of pregnant and lactating women with RA and serves as a guide to counsel male patients with RA on family planning decisions.
To study the effect of baseline rheumatoid factor (RF) levels on response to standard disease mod... more To study the effect of baseline rheumatoid factor (RF) levels on response to standard disease modifying anti-rheumatic drug (DMARD) combination treatment over time in patients with rheumatoid arthritis (RA).
Objective: Rheumatoid factor (RF) positivity has been associated with an unfavourable outcome in ... more Objective: Rheumatoid factor (RF) positivity has been associated with an unfavourable outcome in rheumatoid arthritis (RA). Our study aimed to find a baseline RF cut-off level that would determine the response to standard disease modifying anti-rheumatic drug (DMARD) combination treatment.
The aim of this study was to determine the clinical correlates and predictors of rheumatoid vascu... more The aim of this study was to determine the clinical correlates and predictors of rheumatoid vasculitis (RV). A retrospective cohort of patients with RV evaluated at a tertiary referral centre between 1 January 2000 and 1 January 2010 was identified. RV cases were compared in a 1:2 ratio to controls (RA without vasculitis) to identify risk factors for developing RV. Eighty-six RV cases (58% women, 88% white) were identified. Histopathological confirmation was available for 58% of patients. Cutaneous vasculitis was the most common presentation, followed by vasculitic neuropathy. The median age at presentation was 63 years and the median duration of RA was 10.8 years. One third were current smokers. The majority were seropositive and had elevated inflammatory markers. Treatment was with a range of immunomodulating agents. At 6 months, 38% of patients achieved complete remission, 52% had partial improvement and 10% noted no clinical improvement. Thirty-six per cent relapsed by 5 years a...
To examine trends in glucocorticoid (GC) use and dosing among patients diagnosed with rheumatoid ... more To examine trends in glucocorticoid (GC) use and dosing among patients diagnosed with rheumatoid arthritis (RA) over time. A population-based inception cohort of RA patients diagnosed during 1980-2007 was followed longitudinally through their medical records until death, migration, or December 31, 2008. GC start and stop dates were collected, along with doses in prednisone equivalents. The study population comprised 349 patients (68% women) diagnosed in 1980-1994 and 464 (69% women) diagnosed in 1995-2007, with a median followup of 15.3 and 5.7 years, respectively. A higher proportion of patients started GCs in their first year of disease in 1995-2007 (68% versus 36%; P < 0.001), but the starting dose (mean 8.7 versus 10.3 mg; P = 0.08) and cumulative dose in the first year of use (mean 1.8g [mean daily dose 4.9 mg] versus 2.1 gm [mean daily dose 5.8 mg]; P = 0.48) were not different. A higher proportion also discontinued GCs in their first year of disease in the 1995-2007 cohort...
Fecal incontinence is a common problem in women, which often enforces life changes owing to embar... more Fecal incontinence is a common problem in women, which often enforces life changes owing to embarrassment and social stigma. It is frequently not reported or diagnosed. Age, obstetric trauma, pelvic surgery, chronic diarrhea, obesity and other medical conditions, such as diabetes and stroke, increase the risk of fecal incontinence. Preventive strategies include avoiding diarrheal triggers, discouraging the routine use of episiotomies, early recognition and management of obstetric injuries and possibly pelvic floor muscle exercises after childbirth. Treatment options are available and should be discussed with the patient. These, in order of progression, are education and medications for diarrhea or constipation, supportive care, biofeedback training and surgery.
The burden of comorbid diseases is high among patients with rheumatoid arthritis (RA). These are ... more The burden of comorbid diseases is high among patients with rheumatoid arthritis (RA). These are often systemic manifestations of RA but may be chronic conditions that predate or develop post-RA diagnosis. Increased mortality in RA is predominantly from nonarticular causes. The expanded armamentarium of disease-modifying drugs and biologics available has revolutionized management of articular disease but has made safe treatment of RA more complex. Drug-induced organ injury and side effects need to be kept in mind when initiating or modifying therapy.
American Journal of Industrial Medicine, Apr 1, 2011
Background The risk of developing clinical connective tissue disease (CTD) has been reported to b... more Background The risk of developing clinical connective tissue disease (CTD) has been reported to be increased among individuals with silica exposure. Methods We reviewed the medical records of individuals reported to the Michigan Silicosis Surveillance system from 1985 to 2006 to confirm the diagnosis of silicosis and determine the presence of CTDs. Results From 1985 to 2006, 1,022 cases were confirmed to have silicosis. Medical records of 790 cases were available. Thirty-three individuals had rheumatoid arthritis (RA) [prevalence 4.2% (prevalence ratio (RR) ranged from 2.26, 95% CI: 1.57-3.25 to 6.96, 95% CI: 2.93-16.53) depending on the reference rate used], two had scleroderma [prevalence 0.3% (RR 28.3, 95% CI: 6.09-129.98)], one had systemic lupus erythematosus [prevalence 0.1% (RR 2.53, 95% CI: 0.30-21.64)], two had Sjogrens syndrome [prevalence 0.3% (RR 0.42, 95% CI: 0.09-2.08)], and six had anti-neutrophil cytoplasm antibody (ANCA) vasculitis [prevalence 0.8% (RR 25.3, 95% CI: 6.34-101.04)]
To investigate the incidence of venous thromboembolism (VTE) and cerebrovascular events in a comm... more To investigate the incidence of venous thromboembolism (VTE) and cerebrovascular events in a community-based incidence cohort of patients with giant cell arteritis (GCA) compared to the general population. A population-based inception cohort of patients with incident GCA between January 1, 1950 and December 31, 2009 in Olmsted County, Minnesota and a cohort of non-GCA subjects from the same population were assembled and followed until December 31, 2013. Confirmed VTE and cerebrovascular events were identified through direct medical record review. The study population included 244 patients with GCA with a mean ± SD age at diagnosis of 76.2 ± 8.2 years (79% women) and an average length of follow-up of 10.2 ± 6.8 years. Compared to non-GCA subjects of similar age and sex, patients diagnosed with GCA had a higher incidence (%) of amaurosis fugax (cumulative incidence ± SE: 2.1 ± 0.9 versus 0, respectively; p = 0.014) but similar rates of stroke, transient ischemic attack (TIA), and VTE. Among patients with GCA, neither baseline characteristics nor laboratory parameters at diagnosis reliably predicted risk of VTE or cerebrovascular events. In this population-based study, the incidence of VTE, stroke and TIA was similar in patients with GCA compared to non-GCA subjects.
To compare the outcomes between vascular surgery and endovascular procedures in a cohort of patie... more To compare the outcomes between vascular surgery and endovascular procedures in a cohort of patients with Takayasu arteritis (TA). A retrospective cohort study was conducted of patients with TA who underwent vascular interventions at a tertiary center between 1984 and 2009. The American College of Rheumatology criteria for TA were used to select patients. Disease activity was assessed according to the Kerr criteria. Data are reported using descriptive statistics and Kaplan-Meier methods for complication rates. The cohort included 66 patients with TA who underwent 119 vascular procedures (surgery 93; endovascular repair 26). The most frequent indication for vascular surgery and endovascular procedure was arm claudication (surgical group 43%, endovascular repair group 31%). In 59% of the vascular surgical procedures and in 38% of endovascular procedures, the disease was active within 1 month of intervention. The most frequent arterial lesion requiring intervention was the aorta (28%) ...
To evaluate characteristics of relapse, relapse rates, treatment and outcomes among patients with... more To evaluate characteristics of relapse, relapse rates, treatment and outcomes among patients with biopsy-proven GCA in a large, single-institution cohort. We conducted a retrospective review of all patients with biopsy-proven GCA from 1998 to 2013. Demographic, clinical, laboratory and treatment data at presentation and during follow-up were collected. Comparisons by relapse rate were performed using chi-square tests. Prednisone discontinuation by initial oral dose ≤40 and >40 mg/day was compared using Cox models. The cohort included 286 patients [74% female, mean age at diagnosis 75.0 years (s.d. 7.6), median follow-up 5.1 years). During follow-up, 73 patients did not relapse, 80 patients had one relapse and 133 had two or more relapses. The first relapse occurred during the first year in 50% of patients, by 2 years in 68% and by 5 years in 79%. More patients with established hypertension (P = 0.007) and diabetes (P = 0.039) at GCA diagnosis were in the high relapse rate group (...
ABSTRACT Background Giant cell arteritis (GCA) is the most common systemic vasculitis and patient... more ABSTRACT Background Giant cell arteritis (GCA) is the most common systemic vasculitis and patients with GCA frequently experience one or more relapses during treatment. In order to address differential lengths of followup, relapse rates provide a novel method to evaluate patients with GCA at risk for more frequent relapses. Objectives To evaluate the relapse rates, characteristics, predisposing factors, and relationship with mortality in a large single-institution cohort of patients with biopsy-proven GCA. Methods A retrospective review was performed to identify all patients with biopsy-proven GCA from 1 January 1998 through 31 December 2013. Demographic, clinical, and laboratory data at presentation and each follow up visit were collected. Relapse was defined as recurrence of clinical manifestations compatible with spectrum of GCA and/or increase in inflammatory markers (ESR/CRP), not otherwise explainable, which required reintroduction or increased dose of glucocorticoid therapy. Comparisons between relapse and no-relapse groups were performed using Chi-square and Kruskal-Wallis tests. Results The cohort included 286 patients with biopsy-proven GCA (213 females and 73 males, mean [±SD] age 75.0 [±7.6] years) with a mean (±SD) follow-up of 6.0 (±3.9) years. The mean (±SD) number of visits was 14.2 (±8.4) and the mean (±SD) visit rate per person per year was 3.3 (±2.6). During follow-up, 73 patients did not have a relapse, 80 patients had one relapse and 133 had two or more relapses. The first relapse occurred during the first year in 50% of patients (by 2 years in 68% and by 5 years in 79%). Among all relapse visits, 28.6% of relapses were related to abnormal lab markers only, 24.2% were related to flare symptoms only, and 47.2% represented flare symptoms and abnormal lab markers. The most common relapse symptoms were polymyalgia rheumatica (33.1%), headache (32.3%), malaise (20.6%) and scalp tenderness (7.8%). The median relapse rate observed was 0.4 [IQR 0.21, 0.64] relapses per year. We further evaluated patients in three groups; no relapse, low relapse rate (&lt;0.5 relapses/yr), and high relapse rate (≥0.5 relapses/yr). A lower proportion of females were in the no relapse group (63%) than in the &lt;0.5 relapses/yr (79%) or the ≥0.5 relapses/yr (78%) groups (p=0.034). A higher proportion of patients with hypertension (p=0.007), diabetes (p=0.039) and prior history of venous thrombosis (p=0.041) were present in the ≥0.5 relapse/yr group compared to the no relapse and &lt;0.5 relapse/yr groups. In this cohort, neither the presence of relapse [HR 0.80, (0.47, 1.36); p=0.41] nor the number of relapses [HR 0.99 (0.83, 1.19); p=0.94] were associated with excess mortality. Conclusions Patients with biopsy-proven GCA have a high risk of relapse during follow up. Women with GCA tend to relapse more than men. Patients with established hypertension or diabetes at time of GCA diagnosis have a higher frequency of relapse. Relapses were not predictive of higher mortality. Disclosure of Interest None declared
ABSTRACT Background Venous thromboembolic events (VTE) and cerebrovascular accidents (CVA) are se... more ABSTRACT Background Venous thromboembolic events (VTE) and cerebrovascular accidents (CVA) are serious health problems in the general population and appear to be more frequent in patients with chronic inflammatory disorders. Objectives The purpose of the study is to determine the incidence of VTE and CVA in patients with giant cell arteritis (GCA). Methods We retrospectively reviewed a population-based incidence cohort of patients with GCA diagnosed between 1950 and 2009 based on American College of Rheumatology 1990 GCA classification criteria. We compared this cohort with subjects without GCA of similar age, sex, and calendar year from the same population. All subjects were followed longitudinally through all available community medical records until death, migration from Olmsted County or 31 December 2013. The occurrence of VTE (deep venous thrombosis or pulmonary embolism), and CVA (hemorrhagic stroke, ischemic stroke, transient ischemic attack (TIA), amaurosis fugax), were ascertained by review of the medical records. The cumulative incidence of VTE and CVA in patients with and without GCA, adjusted for the competing risk of death, was estimated and compared using methods by Gray. Results The study population included 244 patients with GCA and 240 non-GCA subjects. The GCA cohort consisted of 193 (79%) women and 51 (21%) men, with mean (±SD) age 76.0 (±8.2) years and a median follow-up 10.2 years. The non-GCA cohort consisted of 190 (79%) women and 50 (21%) men, mean age 75.8 (±8.5) years with a median follow-up 10.8 years. The GCA cohort was followed for a total of 2,480 person-years, while the non-GCA cohort was observed for 2588 person-years. Occurrence of VTE prior to GCA incidence/index date was similar between the two cohorts: 10 episodes (4%) in GCA cohort versus 8 episodes (3%) in non-GCA cohort (p=0.81). During follow-up, 16 patients with GCA and 10 non-GCA subjects developed VTE. The 10-year cumulative incidences (±SE) of VTE were 6.3% (±1.6) among patients with GCA and 3.7% (±1.3) among non-GCA patients (p=0.22). CVA had occurred prior to the index date in 18 (7.3%) patients with GCA and 18 (7.5%) non-GCA patients (p=0.96). During follow-up, 30 patients with GCA and 27 non-GCA subjects developed CVA. The 10-year cumulative incidences (±SE) of stroke were similar between patients with GCA [8.5% (±1.9)] and non-GCA subjects [9.2% (±2.0); p=0.94]. The 10-year cumulative incidences (±SE) of TIA were also similar between patients with GCA [2.3% (±1.0)] and non-GCA subjects [1.7% (±0.8); p=0.97]. Patients with GCA had a higher cumulative incidence of amaurosis fugax compared to controls [1.2% (±0.7) versus 0%; p=0.045]. Mean age at first event did not differ between patients with GCA and non-GCA subjects for VTE (81.3 versus 85.9 years; p=0.16) or CVA (80.6 versus 83.8 years; p=0.30). Conclusions In this population based-cohort, patients with GCA were at an increased risk for amaurosis fugax; however, the risk of VTE, stroke and TIA was not increased compared to non-GCA subjects. Disclosure of Interest None declared
Therapeutic Advances in Musculoskeletal Disease, 2014
Rheumatoid arthritis (RA), a chronic autoimmune inflammatory disease of synovial joints, can lead... more Rheumatoid arthritis (RA), a chronic autoimmune inflammatory disease of synovial joints, can lead to chronic pain and structural joint damage, as well as other organ involvement, especially if not adequately controlled. Because it can affect women in their reproductive years, care of pregnant women with RA requires a delicate balance of maintaining disease control while limiting potential toxicity to the fetus and neonate. While most women experience a substantial improvement in disease activity during pregnancy, for some women their RA remains active. It can even manifest itself for the first time during pregnancy or early in the post-partum period. Optimizing disease control prior to conception is key, but utilizing disease-modifying treatments effectively and safely throughout pregnancy and lactation requires open dialogue and shared decision making. This review provides evidence-based recommendations for use of disease-modifying antirheumatic drugs (DMARDs) and biologic response modifiers to guide rheumatologists in their care of pregnant and lactating women with RA and serves as a guide to counsel male patients with RA on family planning decisions.
To study the effect of baseline rheumatoid factor (RF) levels on response to standard disease mod... more To study the effect of baseline rheumatoid factor (RF) levels on response to standard disease modifying anti-rheumatic drug (DMARD) combination treatment over time in patients with rheumatoid arthritis (RA).
Objective: Rheumatoid factor (RF) positivity has been associated with an unfavourable outcome in ... more Objective: Rheumatoid factor (RF) positivity has been associated with an unfavourable outcome in rheumatoid arthritis (RA). Our study aimed to find a baseline RF cut-off level that would determine the response to standard disease modifying anti-rheumatic drug (DMARD) combination treatment.
The aim of this study was to determine the clinical correlates and predictors of rheumatoid vascu... more The aim of this study was to determine the clinical correlates and predictors of rheumatoid vasculitis (RV). A retrospective cohort of patients with RV evaluated at a tertiary referral centre between 1 January 2000 and 1 January 2010 was identified. RV cases were compared in a 1:2 ratio to controls (RA without vasculitis) to identify risk factors for developing RV. Eighty-six RV cases (58% women, 88% white) were identified. Histopathological confirmation was available for 58% of patients. Cutaneous vasculitis was the most common presentation, followed by vasculitic neuropathy. The median age at presentation was 63 years and the median duration of RA was 10.8 years. One third were current smokers. The majority were seropositive and had elevated inflammatory markers. Treatment was with a range of immunomodulating agents. At 6 months, 38% of patients achieved complete remission, 52% had partial improvement and 10% noted no clinical improvement. Thirty-six per cent relapsed by 5 years a...
To examine trends in glucocorticoid (GC) use and dosing among patients diagnosed with rheumatoid ... more To examine trends in glucocorticoid (GC) use and dosing among patients diagnosed with rheumatoid arthritis (RA) over time. A population-based inception cohort of RA patients diagnosed during 1980-2007 was followed longitudinally through their medical records until death, migration, or December 31, 2008. GC start and stop dates were collected, along with doses in prednisone equivalents. The study population comprised 349 patients (68% women) diagnosed in 1980-1994 and 464 (69% women) diagnosed in 1995-2007, with a median followup of 15.3 and 5.7 years, respectively. A higher proportion of patients started GCs in their first year of disease in 1995-2007 (68% versus 36%; P < 0.001), but the starting dose (mean 8.7 versus 10.3 mg; P = 0.08) and cumulative dose in the first year of use (mean 1.8g [mean daily dose 4.9 mg] versus 2.1 gm [mean daily dose 5.8 mg]; P = 0.48) were not different. A higher proportion also discontinued GCs in their first year of disease in the 1995-2007 cohort...
Fecal incontinence is a common problem in women, which often enforces life changes owing to embar... more Fecal incontinence is a common problem in women, which often enforces life changes owing to embarrassment and social stigma. It is frequently not reported or diagnosed. Age, obstetric trauma, pelvic surgery, chronic diarrhea, obesity and other medical conditions, such as diabetes and stroke, increase the risk of fecal incontinence. Preventive strategies include avoiding diarrheal triggers, discouraging the routine use of episiotomies, early recognition and management of obstetric injuries and possibly pelvic floor muscle exercises after childbirth. Treatment options are available and should be discussed with the patient. These, in order of progression, are education and medications for diarrhea or constipation, supportive care, biofeedback training and surgery.
The burden of comorbid diseases is high among patients with rheumatoid arthritis (RA). These are ... more The burden of comorbid diseases is high among patients with rheumatoid arthritis (RA). These are often systemic manifestations of RA but may be chronic conditions that predate or develop post-RA diagnosis. Increased mortality in RA is predominantly from nonarticular causes. The expanded armamentarium of disease-modifying drugs and biologics available has revolutionized management of articular disease but has made safe treatment of RA more complex. Drug-induced organ injury and side effects need to be kept in mind when initiating or modifying therapy.
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Papers by Ashima Makol