Prevalence, severity and clinical correlates of pain in patients with Systemic Sclerosis

Systemic Sclerosis (SSc) is a highly heterogeneous multi-system disease characterized by vasculopathy, immune system activation and fibrosis. Patients are classified into limited or diffuse SSc disease subsets according to the extent of skin involvement. This was the first study to use a large multi-center convenience sample of SSc patients (N=585) to estimate prevalence, severity and associations between clinical variables and pain in SSc and, separately in limited and diffuse subsets. Results from the present study draw attention to the high prevalence of pain in SSc and associations between specific clinical variables and pain, including more frequent episodes of Raynaud's phenomenon, active ulcers, worse synovitis and gastrointestinal symptoms, which may represent potential clinical intervention targets. Subsetting by the extent of skin involvement was only minimally related to pain severity and did not affect associations with clinical variables. More attention to pain and how to best manage it is needed in SSc.La sclérose systémique (SSc) se caractérise par une vasculopathie, une dysfonction auto-immune, et une fibrose diffuse. Les personnes atteintes de SSc sont classifiées comme ayant la SSc limitée ou diffuse selon l'étendue de l'atteinte cutanée. Notre étude est la première grande recherche multicentrique d'un échantillon de convenance (N=585) à estimer la prévalence, la sévérité et les associations entre les manifestations cliniques de la SSc et la douleur. Les résultats démontrent que la prévalence de la douleur est élevée, et que certaines variables cliniques sont associées à celle-ci (syndrome de Raynaud, ulcérations actives, synovites et symptômes gastro-intestinaux) et pourraient donc représenter des cibles d'intervention. L'étendue de l'atteinte cutanée affecte très peu ou pas du tout la sévérité de la douleur et les associations observées avec les variables cliniques. Plus d'attention à la douleur et à des stratégies thérapeutiques qui pourraient diminuer son intensité est nécessaire pour les personnes atteintes de SSc

Excess Heart Disease Risk Associated with Arthritis in the Canadian General Population

This thesis, through three manuscripts, aims to clarify to what extent arthritis may be an independent risk factor for developing heart disease in the general population, underlying mechanisms of the relationship, and who may be most at-risk. Manuscript 1 is a systematic review and meta-analysis of population-based studies that estimated risk of incident myocardial infarction (MI) associated with five major types of arthritis. Results showed that MI-risk was consistently increased across arthritis and was partially explained by a higher prevalence of traditional heart disease risk factors in each type of arthritis. Knowledge gaps from the review were used to inform subsequent secondary analyses of the longitudinal Canadian National Population Health Survey (NPHS) with 16-years of follow up. Manuscript 2 used discrete time survival analysis with time-varying lagged predictors to estimate effects of arthritis on first heart disease event occurrence. Potential variations by age, sex and activity limitation were examined. Results showed that arthritis was independently associated with incident heart disease in all women, with more marked risk in women who also reported activity limitation, but only in men with activity limitation. Manuscript 3 used a novel approach to estimate potential mediating and moderating effects of activity limitation in the arthritis-heart disease relationship and possible differences by obesity and sex/gender in the same longitudinal health survey as manuscript 2. Results showed the proportion of heart disease risk explained by activity limitation varied between men and women, and between obese and non-obese women. Activity limitation explained nearly all of the heart disease risk associated with arthritis in men (90%), most of the heart disease risk in obese women (54%), and part of the heart disease risk in non-obese women (23%). Overall, the thesis results are important for increasing public and healthcare-provider awareness of excess heart disease risk generally associated with arthritis, highlighting sex/gender disparities, and identifying activity limitation as a modifiable intermediate target for prevention strategies to help reduce heart disease risk in people with arthritis.Ph.D

Having More Tender Than Swollen Joints is Associated With Worse Function and Work Impairment in Patients With Early Rheumatoid Arthritis

Objective Patients with early rheumatoid arthritis (RA) may present with more tender than swollen joints, which can persist. Elevated tender‐swollen joint difference (TSJD) is often challenging, because there may be multiple causes and it may contribute to overestimating disease activity. Little is known about the phenotype and impact of TSJDs on patient function. Our objective was to evaluate the impact of TSJD on functional outcomes in early RA and to see whether associations vary by joint size. Methods Data were from patients with active, early RA (≤12 months) enrolled in the Canadian Early Arthritis Cohort, who completed assessments of general function (Multidimensional Health Assessment Questionnaire [MDHAQ]), upper extremity (UE) function (Quality of Life in Neurological Disorders [Neuro‐QoL] UE scale), and work/activity impairment (Work Productivity and Activity Impairment RA) over their first year of follow‐up. A total of 28 joint counts were performed. TSJDs were calculated. Adjusted associations between TSJDs and functional outcomes were estimated in separate multivariable linear mixed effects models. Separate analyses were performed for large‐ versus small‐joint TSJD. Results Patients (N = 547) were 70% female, mean age 56 (SD 15) years, mean disease duration 5.3 (SD 2.9) months. At baseline, 287 (52%) had TSJD >0 (43% involved large joints and 34% small joints), decreasing to 32% at 12 months. A one‐point increase in TSJD was significantly associated with worse function (MDHAQ: adjusted mean change 0.10, 95% confidence interval [CI] 0.08–0.13; Neuro‐QoL UE function T score: adjusted mean change −0.59, 95% CI −0.76 to −0.43; and greater work impairment: adjusted mean change 1.95%, 95% CI 0.85%–3.05%). Higher large‐joint TSJDs were associated with the worst functional outcomes. Conclusion Having more tender than swollen joints is common in early RA and is associated with worse function, most notably when involving large joints. Early identification and targeted intervention strategies may be needed

Patient and Rheumatologist Perspectives on Tapering DMARDs in Rheumatoid Arthritis: A Qualitative Study

Objectives: To understand the perspectives of patients and rheumatologists for tapering DMARDs in RA. Methods: Using semi-structured interview guides, we conducted individual interviews and focus groups with RA patients and rheumatologists, which were audiotaped and transcribed. We conducted a pragmatic thematic analysis to identify major themes, comparing and contrasting different views on DMARD tapering between patients and rheumatologists. Results: We recruited 28 adult patients with RA (64% women; disease duration 1-54 years) and 23 rheumatologists (52% women). Attitudes across both groups towards tapering DMARDs were ambivalent, ranging from wary to enthusiastic. Both groups expressed concerns, particularly the inability to ‘recapture’ the same level of disease control, while also acknowledging potential positive outcomes such as reduced drug harms. Patient tapering perspectives (whether to and when) changed over time and commonly included non-biologic DMARDs. Patient preferences were influenced by lived experiences, side effects, previous tapering experiences, disease trajectory, remission duration, and current life roles. Rheumatologists’ perspectives varied on timing and patient profile to initiate tapering, and were informed by both data and clinical experience. Patients expressed interest in shared decision making (SDM) and close monitoring during tapering, with ready access to their healthcare team if problems arose. Rheumatologists were generally open to tapering (not stopping), though sometimes only when requested by their patients. Conclusion: The perspectives of patients and rheumatologists on tapering DMARDs in RA vary and evolve over time. Rheumatologists should periodically discuss DMARD tapering with patients as part of SDM, and ensure monitoring and flare management plans are in place.Canadian Institutes of Health Research (CIHR

The effect of rheumatoid arthritis-associated autoantibodies on the incidence of cardiovascular events in a large inception cohort of early inflammatory arthritis

© The Author 2017. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. Objective. RA is associated with an increased risk of cardiovascular events (CVEs). The objective was to estimate independent effects of RA autoantibodies on the incident CVEs in patients with early RA. Methods. Patients were enrolled in the Canadian Early Inflammatory Arthritis Cohort, a prospective multicentre inception cohort. Incident CVEs, including acute coronary syndromes and cerebrovascular events, were self-reported by the patient and partially validated by medical chart review. Seropositive status was defined as either RF or ACPA positive. Multivariable Cox proportional hazards survival analysis was used to estimate the effects of seropositive status on incident CVEs, controlling for RA clinical variables and traditional cardiovascular risk factors. Results. A total of 2626 patients were included: the mean symptom duration at diagnosis was 6.3 months (S.D. 4.6), the mean age was 53 years (S.D. 15), 72% were female and 86% met classification criteria for RA. Forty-six incident CVEs occurred over 6483 person-years [incidence rate 7.1/1000 person-years (95% confidence interval 5.3, 9.4)]. The CVE rate did not differ in seropositive vs seronegative subjects and seropositivity was not associated with incident CVEs in multivariable Cox regression models. Baseline covariates independently associated with incident CVEs were older age, a history of hypertension and a longer duration of RA symptoms prior to diagnosis. Conclusion. The rate of CVEs early in the course of inflammatory arthritis was low; however, delays in the diagnosis of arthritis increased the rate of CVEs. Hypertension was the strongest independent risk factor for CVEs. Results support early aggressive management of RA disease activity and co-morbidities to prevent severe complications