Coronary artery disease risk factors in the Johns Hopkins Lupus Cohort: prevalence, recognition by patients, and preventive practices

Known risk factors for coronary artery disease are very common in the Hopkins Lupus Cohort, in spite of the fact that the average patients age is only 38.3 years. Three or more known risk factors were found in 53% of patients. Risk factors for CAD were common even in patients not on a regimen of prednisone therapy during their cohort follow-up. Hypercholesterolemia increased significantly with greater average prednisone dose. Despite the frequency of risk factors, patients' awareness of the risk of CAD was low, with only 16.9% of patients believing they were at high risk for developing CAD within 5 years. In general, awareness of individual risk factors was lower in black than in white patients with SLE. Preventive practices were most commonly addressed towards hypertension. Preventive practices directed against obesity, hypercholesterolemia, and smoking were underutilized. Whether these known risk factors are sufficient in and of themselves to explain the high frequency of CAD in the cohort (8%) or whether they are "enabling" factors acting upon endothelium damaged by immune-complex disease cannot be addressed by this study. However, both further investigation of these risk factors and attention to lifestyle and pharmacologic approaches to risk factor reduction are indicated by this study.

The American College of Rheumatology 1991 revised criteria for the classification of global functional status in rheumatoid arthritis

OBJECTIVE

To develop and validate revised criteria for global functional status in rheumatoid arthritis (RA).

METHODS

Revised criteria were formulated and tested for criterion and discriminant validity in 325 patients with RA.

RESULTS

The revised criteria developed are as follows: class I = able to perform usual activities of daily living (self-care, vocational, and avocational); class II = able to perform usual self-care and vocational activities, but limited in avocational activities; class III = able to perform usual self-care activities but limited in vocational and avocational activities; class IV = limited in ability to perform usual self-care, vocational, and avocational activities. Usual self-care activities include dressing, feeding, bathing, grooming, and toileting; vocational and avocational activities are both patient-desired and age-, and sex-specific. The distribution properties of this classification schema were superior to those of the original Steinbrocker criteria. Mean Health Assessment Questionnaire scores were significantly (P less than 0.0001) different between, and increased across, the 4 classes.

CONCLUSION

Although there are limitations inherent in the use of global ordinal scales, the American College of Rheumatology revised criteria will be useful in describing the functional consequences of RA. A more detailed quantitative measure of physical disability should be used, however, for optimal monitoring of patients' clinical status in office practice and clinical research.

Human immunodeficiency virus infection is not associated with Reiter's syndrome. Data from three large cohort studies

The cohorts presented are the largest available and the only ones for which suitable controls exist. They suggest that RS occurs in less than 1% of individuals infected with HIV. Additionally, infection with HIV is no independently associated with RS. Rather, previously described arthritogenic agents are implicated.

Incidence and risk factors for gout in white men

OBJECTIVE

To identify potentially modifiable risk factors for the development of gout.

DESIGN

Longitudinal cohort study (The Johns Hopkins Precursors Study).

PARTICIPANTS

Of 1337 eligible medical students, 1271 (95%) received a standardized medical examination and questionnaire during medical school. The participants were predominantly male (91%), white (97%), and young (median age, 22 years) at cohort entry.

OUTCOME MEASURE

The development of gout.

RESULTS

Sixty cases of gout (47 primary and 13 secondary) were identified among 1216 men; none occurred among 121 women (P = .01). The cumulative incidence of all gout was 8.6% among men (95% confidence interval, 5.9% to 11.3%). Body mass index at age 35 years (P = .01), excessive weight gain (greater than 1.88 kg/m2) between cohort entry and age 35 years (P = .007), and development of hypertension (P = .004) were significant risk factors for all gout in univariate analysis. Multivariate Cox proportional hazards models confirmed the association of body mass index at age 35 years (relative risk [RR] = 1.12; P = .02), excessive weight gain (RR = 2.07; P = .02), and hypertension (RR = 3.26; P = .002) as risk factors for all gout. Hypertension, however, was not a significant risk factor for primary gout.

CONCLUSIONS

Obesity, excessive weight gain in young adulthood, and hypertension are risk factors for the development of gout. Prevention of obesity and hypertension may decrease the incidence of and morbidity from gout; studies of weight reduction in the primary and secondary prevention of gout are indicated.

Factors associated with osteoarthritis of the hand in males: data from the Baltimore Longitudinal Study of Aging

The association of metabolic and physiologic factors with hand osteoarthritis was studied in 888 Caucasian male subjects aged 17-102 years in the Baltimore Longitudinal Study of Aging. Left-hand radiographs taken between 1958 and 1975 were read by one investigator for grade of osteoarthritis using Kellgren-Lawrence scales. Possible risk factors, assessed at the same visit as the last radiograph during this interval, included age and measures of bone mass, body composition, muscle mass, and muscle strength. Results of bivariate analyses of these cross-sectional data showed that increasing grade of hand osteoarthritis was associated with increasing age; greater mean levels of waist/hip ratio and percentage of body fat; and lower mean levels of percentage of cortical area, grip strength, and forearm circumference. After adjustment for age using residuals from best-fit quadratic regression models, none of these independent variables remained significantly associated with grade of hand osteoarthritis. These data fail to support hypotheses that metabolic and physiologic factors are associated with hand osteoarthritis independent of their known age-related changes.

The history of lupus erythematosus

The history of lupus can be divided into the classical period which saw the description of the cutaneous disorder, the neoclassical period which saw the description of the systemic or disseminated manifestations of lupus, and the modern period which was heralded by the discovery of the lupus erythematosus cell in 1948.

Comparison of different methods of classifying patients with systemic lupus erythematosus

The sensitivity and percent agreement of 3 methods of classifying patients with systemic lupus erythematosus (SLE), the 1982 American Rheumatism Association (ARA) revised criteria and a simple and full classification tree, were compared using data from The Johns Hopkins Lupus Cohort, a prospective study of 198 patients with SLE. The 1982 revised criteria were significantly more sensitive than the simple classification tree, correctly identifying 184 (93%) cases compared to 168 (85%) (p = 0.016). Agreement between these 2 classification schema was noted in 174 (87%) cases with 164 classified correctly and 10 failing to satisfy either criteria set. The full classification tree correctly identified 186 (94%) cases. There was no difference in the sensitivity of either the 1982 revised criteria or the full classification tree by racial group; however, the simple classification tree was significantly less sensitive among black than Caucasian patients (80 vs 91.5% p = 0.038). Our data support the continued use of the 1982 revised ARA criteria for the classification of patients with SLE for clinical and epidemiologic research studies.

Epidemiology and genetics of osteoarthritis

Osteoarthritis is the most common of the arthropathies. Previous population-based epidemiologic studies have estimated the prevalence of osteoarthritis by age, gender, race, and site in many populations. Cross-sectional and retrospective data from these prevalence surveys have been analyzed to identify possible risk factors for the development of osteoarthritis at specific sites. Data from prospective population-based epidemiologic studies including the Framingham Osteoarthritis Study, the Tecumseh Community Health Study, the National Health and Nutrition Examination Survey I Epidemiologic Followup Study, and the Baltimore Longitudinal Study of Aging are being analyzed to estimate the incidence of osteoarthritis by age, gender, and site, and the prognosis of subjects with osteoarthritis at specific sites in terms of morbidity and mortality, as well as to confirm the association of risk factors with the development and progression of osteoarthritis by site. Additionally, the application of techniques of molecular biology to the study of the genetics of familial osteoarthritis has identified hereditary defects in type II collagen that appear to predispose to the early development of osteoarthritis in affected family members. Results of these studies highlight opportunities for the primary and secondary prevention of osteoarthritis.

Epidemiology of osteoarthritis: current concepts and new insights

Osteoarthritis (OA) is the most common of the arthropathies. Previous epidemiologic studies have described the prevalence of OA by age, gender and site in many populations. Cross sectional and retrospective data from these prevalence surveys have been analyzed to identify possible risk factors for the development of OA. Data from prospective epidemiologic studies including the Framingham Study, Tecumseh Community Health Study, and the Baltimore Longitudinal Study of Aging are being analyzed to estimate the incidence of OA by age, gender and site, and confirm the association of risk factors with the development and progression of OA. Results of these studies provide potential opportunities for the primary and secondary prevention of OA.

HIV infection is not associated with Reiter's syndrome: data from the Johns Hopkins Multicenter AIDS Cohort Study

Reiter's syndrome has been reported to occur in up to 10% of patients with HIV infection. However, no properly controlled epidemiological studies have been conducted to determine whether HIV infection is an independent risk factor or whether the immunodeficiency induced by HIV infection is permissive for infection with other arthritogenic organisms. The prevalence and incidence of Reiter's syndrome were determined in 1133 homosexual/bisexual men enrolled in the Johns Hopkins Multicenter AIDS Cohort Study. There was no difference in the prevalence of Reiter's syndrome at entry into the study in 1984 between 357 HIV-positive and 776 HIV-negative men: five per 1000 in both groups. During 5 years' follow-up, one case of Reiter's syndrome developed among each group of HIV-positive and HIV-negative men. These data fail to support a direct etiological role for HIV infection in the development of Reiter's syndrome.

The longitudinal course of hand osteoarthritis in a male population

In this prospective analysis of the natural history of osteoarthritis (OA) of the hand, the incidence and progression of various radiographic features of OA were examined in 177 men who participated in the Baltimore Longitudinal Study of Aging. Subjects who were less than 60 years old were selected based on the availability of at least 4 hand radiographs taken during at least 20 years of followup, while subjects who were age 60 or older were required to have had at least 4 hand radiographs taken during only 14 years of followup. Individual joints of the hands were graded for the presence and severity of 5 features of OA: osteophytes, joint space narrowing, subchondral sclerosis, lateral deformity, and cortical collapse. They were also graded according to the global Kellgren/Lawrence scale. The incidence and rate of progression of OA, as measured by all scales, increased in progressively older age groups. Cox's proportional hazards models showed that isolated doubtful osteophytes (Kellgren/Lawrence grade 1) and isolated joint space narrowing predicted the development of the radiographic features of OA. The rate of OA progression slowed as the severity increased. We conclude that, in men, the incidence of radiographic features of hand OA increases with age. Regardless of age, the earliest radiographic signs of OA are joint space narrowing and doubtful osteophytes.

Systemic lupus erythematosus

Descriptive epidemiologic studies of SLE have been conducted worldwide; the most extensive data are available for Scandinavia, especially Sweden, and the United States. In the United States, blacks have threefold higher incidence, prevalence, and mortality rates compared with whites; the reasons for this excess, however, remain unknown. Analytic and genetic epidemiologic studies suggest a multifactorial etiology of SLE; results support a polygenic mode of inheritance including important roles for an autosomal dominant "autoimmune" gene and female sex hormones. Although a viral etiology remains attractive, there is little evidence to support such a hypothesis. Rather, other environmental factors including chemical exposures may be important as "triggers" of disease. Finally, observational epidemiologic studies demonstrate an increasingly favorable prognosis for patients with SLE, allowing a better understanding of long-term morbidity and impact on overall health status. Future epidemiologic studies should focus on identifying noninfectious environmental etiologic factors and improving the quality of life for all patients with SLE.

Connective tissue disease in southeast Georgia. A community based study of immunogenetic markers and autoantibodies

HLA antigens, C4 allotypes and T cell antigen receptor (TcR)beta DNA polymorphisms were determined in a community based study of connective tissue diseases (CTD). HLA-B8, DR3 and C4A null phenotypes occurred frequently in Caucasian patients with CTD, especially those with systemic lupus erythematosus (SLE), but were also more commonly found among healthy white controls of this southeast Georgia community. TcR beta gene polymorphisms also showed differential segregation patterns between patients with SLE and scleroderma. High frequencies of ANA and anti-ssDNA antibodies occurred among apparently healthy family members and local controls. Genetic factors predisposing to CTD in a community setting appear to be similar to those reported from referral centers.

Estimating the incidence and prevalence of rare rheumatologic diseases: a review of methodology and available data sources

Where the need for descriptive epidemiology is great, population based registries can be established, at considerable cost, to provide the desired data. In many instances, however, there may be existing data and information systems that provide morbidity information on sufficiently large, well defined populations to allow reasonable estimates of the incidence and prevalence of rare rheumatologic diseases.

Eosinophilia-myalgia syndrome due to L-tryptophan ingestion. Report of four cases and review of the Maryland experience

Eosinophilia-myalgia syndrome (EMS) is a recently described clinical entity that has been ascribed to taking over-the-counter preparations of the amino acid L-tryptophan. We describe 4 patients with EMS, 3 of whom presented with eosinophilic fasciitis, and we review the epidemiology of EMS reported in Maryland and discuss the possible pathophysiology of the disease. EMS should be considered in the differential diagnosis of severe myalgia, eosinophilia, and eosinophilic fasciitis.

Changes in the incidence and prevalence of rheumatoid arthritis in England and Wales, 1970-1982

Data from the Second and Third National Studies of Morbidity Statistics from General Practice, conducted from 1970 to 1972 and 1981 to 1982, respectively, by the General Practice Research Unit of the Royal College of General Practitioners, were analyzed to estimate morbidity rates of RA and examine changes in these rates over time. The age-adjusted annual incidence of RA in females fell from 3.3 to 2.6 cases per 1,000 person-years from 1970 to 1972 and 1980 to 1981; there was no change observed in males. Over the same time interval, there was a rise in age-adjusted period prevalence of RA in both sexes from 6.4 to 7.5 per 1,000 and 2.8 to 3.5 per 1,000 in females and males, respectively. These data, which should be interpreted with caution, confirm a decline in incidence of RA in females and demonstrate an increase in prevalence of RA in both sexes over the past decade.

Intravenous pulsed steroids in rheumatoid arthritis: a comparative dose study

This prospective, double blind study was undertaken to test the efficacy of intravenous "minipulse" (100 mg) methylprednisolone (MP) therapy versus standard pulse (1000 mg) MP therapy in rheumatoid arthritis (RA). Thirty-six patients with RA synovitis flares were randomized to receive either 100 or 1000 mg MP IV QD x 3 doses. These 2 universally comparable groups exhibited no statistically significant differences in their striking prompt and sustained clinical improvement. These data suggest that minipulse MP is as efficacious as conventional pulse MP in the treatment of RA flares.

Accuracy of creatinine clearance in measuring glomerular filtration rate in patients with systemic lupus erythematosus without clinical evidence of renal disease

We sought to determine whether creatinine clearance (Ccr) gives an accurate measurement of the glomerular filtration rate in patients with systemic lupus erythematosus (SLE) with no clinical evidence of renal disease. Eighteen such SLE patients underwent measurement of Ccr and 99mtechnetium-DTPA clearance (CDTPA). The mean +/- SD Ccr:CDTPA ratio was 1.12 +/- 0.15 (95% confidence interval 1.04-1.20). These results indicate that Ccr gives an accurate measurement of the glomerular filtration rate in the majority of SLE patients who do not have clinical evidence of renal disease.

Learned helplessness in systemic lupus erythematosus: analysis using the Rheumatology Attitudes Index

The Rheumatology Attitudes Index (RAI) was administered to 138 patients with systemic lupus erythematosus (SLE) to determine its reliability and to examine the construct of learned helplessness in patients with this disease. The internal consistency of the RAI was indicated by Cronbach's standardized alpha value (alpha = 0.70). Significant correlations were observed between RAI scores and the Modified Health Assessment Questionnaire Activities of Daily Living difficulty (r = 0.34, P less than or equal to 0.001) and dissatisfaction (r = 0.32, P less than or equal to 0.001) scores, the 10-cm visual analog pain scale (r = 0.42, P less than or equal to 0.001), and the Psychosocial Adjustment to Illness Scale raw total (r = 0.63, P less than or equal to 0.01). These findings support the external validity of the RAI in SLE. In addition, these data suggest that the learned helplessness construct might be relevant to the outcomes of morbidity and mortality in patients with SLE.

Epidemiology of rheumatoid arthritis: update

We have highlighted advances and new developments in the epidemiology of rheumatoid arthritis in four major areas. Further research, as suggested by us and others (48) should focus on understanding the mechanisms which underlie the association of etiologic and protective factors with rheumatoid arthritis, and on identifying and modifying prognostic factors associated with long-term morbidity and mortality among patients with rheumatoid arthritis. Major increases in funding provided by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the Arthritis Foundation will be needed to realize such efforts in the United States.