Small airway obstruction in patients with rheumatoid arthritis

This work was intended to evaluate the prevalence of obstructive small-airway disease in patients with rheumatoid arthritis (RA) and its association with clinical characteristics. Pulmonary function testing (PFT) and high-resolution computed tomography (HRCT) were performed on 189 consecutive RA patients. Each case was diagnosed based on abnormal HRCT findings. We defined obstructive dysfunction of small airways as a forced expiratory flow from 25% to 75% of vital capacity (FEF25–75) value >1.96 residual standard deviation (RSD) below predicted values. We found 19 patients (10.1%) with an interstitial pneumonia (IP) pattern and 15 (7.9%) with a bronchiolitis pattern; the other 155 (82.0%) had no abnormal HRCT patterns. In patients with neither abnormal pattern, median values of percentage predicted for carbon monoxide diffusing capacity (DLCO) and ratio of DLCO to alveolar ventilation (DLco/VA) were within the normal range, but median FEF25–75, forced expiratory flow at 25% of vital capacity (V25), and V25/height were <70% of predicted values. Forty-seven patients (30.3%) in this group had obstructive small-airway dysfunction. Multivariate logistic regression analysis indicated that this type of abnormality is strongly associated with respiratory symptoms [odds ratio (OR) 5.18; 95% confidence interval (CI) 1.70–15.75; p = 0.012), smoking history (OR 2.78; 95% CI 1.10–6.99; p = 0.03), and disease duration >10 years (OR 2.86; 95% CI 1.27–6.48; p = 0.012). Parenchymal micronodules, bronchial-wall thickening, and bronchial dilatation on HRCT scans were also predictive factors for abnormal FEF25–75, although these morphological changes were too limited for us to diagnose these patients with the bronchiolitis pattern. Obstructive dysfunction of small airways is apparently common among RA patients, even among those with neither the IP nor the bronchiolitis pattern on HRCT scans. Factors significantly associated with abnormal FEF25–75 are respiratory symptoms, smoking history, and RA duration

Organizing Pneumonia in Rheumatoid Arthritis Patients: A Case-Based Review

We treated 21 patients with organizing pneumonia (OP) associated with rheumatoid arthritis (RA) or related to biological disease-modifying antirheumatic drugs (DMARDs) at our institution between 2006 and 2014. Among these cases, 3 (14.3%) preceded articular symptoms of RA, 4 (19.0%) developed simultaneously with RA onset, and 14 (66.7%) occurred during follow-up periods for RA. In the case of OP preceding RA, increased levels of anti-cyclic citrullinated peptide antibodies and rheumatoid factor were observed at the OP onset. RA disease activity was related to the development of OP in the simultaneous cases. In the cases of OP developing after RA diagnosis, 10 of 14 patients had maintained low disease activity with biological DMARD therapy at the OP onset, and among them, 6 patients developed OP within the first year of this therapy. In the remaining four patients, RA activity was not controlled at the OP onset. All patients responded well to systemic steroid therapy, but two patients suffered from relapses of articular and pulmonary symptoms upon steroid tapering. In most of the RA patients, DMARD therapy was introduced or restarted during the steroid tapering. We successfully restarted a biological DMARD that had not been previously used for patients whose RA would otherwise have been difficult to control. In this study, we also perform a review of the literature on RA-associated or biological DMARD-related OP and discuss the pathogenesis and management of OP occurring in RA patients

The ideal method of student teaching.

本研究は, これからの附属小学校での教育実習の新しい方法を探るために, まず, 先行研究を基に, 教師に求められる知識について論究し, そこで得た知見から教師に必要な知識を獲得させるための教育実習におけるアプローチ方法について検討することを目的とした。先行研究より, 教師には実践的知識が必要であることが明らかとなったが, 実践的知識とは多義的であり, 複雑なものであるため, その知識の適用範囲は, 広く特定の場面に遭遇しないかぎり, 必要ない知識と成りかねないことわかった。そこで, 教育実習生に反省的な思考を促すカンファレンス的な学びの場を設定することで, 実践的知識の獲得を目指した。アンケートを基にカンファレンス的な学びの場の設定と従来通りの学びの場において比較検討した結果, それほど差がないことが明らかとなったが, カンファレンス的な学びを行った教育実習生の感想では, 反省的な思考が見受けられた。本研究から, 教育実習におけるカンファレンス的な学びの導入は, 教育実習生の思考スタイルの変容や指導教員の自己省察にとっても少なからず効果が認められると考えられる

Mortality in rheumatoid arthritis patients with pulmonary nontuberculous mycobacterial disease: A retrospective cohort study.

ObjectiveThe aim of this study was to compare long-term mortality following diagnosis of pulmonary nontuberculous mycobacterial (NTM) disease between patients with and without rheumatoid arthritis (RA) and to evaluate predictive factors for death outcomes.MethodsWe reviewed the electronic medical records of all patients who were newly diagnosed with pulmonary NTM disease at participating institutions between August 2009 and December 2018. Patients were followed until death, loss to follow-up, or the end of the study. Taking into consideration the presence of competing risks, we used the cumulative incidence function with Gray's test and Fine-Gray regression analysis for survival analysis.ResultsA total of 225 patients (34 RA patients and 191 non-RA controls) were followed, with a mean time of 47.5 months. Death occurred in 35.3% of RA patients and 25.7% of non-RA patients. An exacerbation of pulmonary NTM disease represented the major cause of death. The estimated cumulative incidence of all-cause death at 5 years was 24% for RA patients and 23% for non-RA patients. For NTM-related death, the 5-year cumulative incidence rate was estimated to be 11% for RA patients and 18% for non-RA patients. Gray's test revealed that long-term mortality estimates were not significantly different between patient groups. Fine-Gray regression analysis showed that the predictive factors for NTM-related death were advanced age (adjusted hazards ratio 7.28 [95% confidence interval 2.91-18.20] for ≥80 years and 3.68 [1.46-9.26] for 70-80 years vs. ConclusionsRA patients with pulmonary NTM disease were not at greater risk of long-term mortality compared with non-RA patients. Rather, advanced age, male sex, causative NTM species, and cavitary NTM disease should be considered when predicting the outcomes of RA patients with pulmonary NTM disease