Polymyalgia rheumatica prevalence in a population-based sample

Human leucocyte antigens and Japanese patients with polymyalgia rheumatica: the protective effect of DRB1*09:01

OBJECTIVE

The hallmarks of the chronic inflammatory disease polymyalgia rheumatica (PMR) include pain, and morning stiffness in areas of the neck, shoulder and pelvic girdle. The human leucocyte antigen (HLA) gene was reported to be an important risk factor for PMR, but it has not been analysed precisely, especially in populations other than Europeans.

METHODS

Genotyping of DRB1 and DQB1 was performed in Japanese PMR patients (n=270) and controls (n=413). Associations between allele carrier and genotype frequencies were determined for PMR.

RESULTS

DRB1*04:05 was associated with a predisposition to PMR (p=0.0006, Pc=0.0193, OR 1.85, 95% CI 1.31 to 2.62). DRB1*09:01 was associated with protection against PMR (p=1.46×10-5, Pc=0.0004, OR 0.40, 95% CI 0.26 to 0.61). A shared epitope (SE) associated with PMR (p=3.07×10-6, OR 2.11, 95% CI 1.54 to 2.88). DQB1*03:03 (p=0.0010, Pc=0.0140, OR 0.52, 95% CI 0.35 to 0.77) was associated with protection against PMR and DQB1*04:01 (p=0.0009, Pc=0.0140, OR 1.82, 95% CI 1.28 to 2.58) was associated with predisposition to PMR. A gene dosage effect was observed for DRB1*09:01 and DQB1*03:03, but not for DRB1*04:05, SE or DQB1*04:01. Haplotype and logistic regression analyses suggested a protective effect for DRB1*09:01.

CONCLUSION

This study is the first to demonstrate predisposing associations of DRB1*04:05, SE, and DQB1*04:01, and protective associations of DRB1*09:01 and DQB1*03:03 with PMR in Japanese patients. Our data indicate HLA has predisposing and protective effects on the pathogenesis of PMR.

Polymyalgia Rheumatica

BACKGROUND

Polymyalgia rheumatica (PMR) is among the most common inflammatory rheumatic diseases in older adults. Presumed risk factors include female sex, previous infections, and genetic factors. No epidemiological data on PMR in Germany have been available until now.

METHODS

This review is based on publications retrieved by a selective literature search in PubMed. Moreover, the administrative incidence and prevalence of PMR in the years 2011-2019 was determined from data of the AOK Baden-Württemberg statutory health insurance carrier for insurees aged 40 and older. In addition, we quantified the number of consultations with physicians involved in the diagnosis.

RESULTS

The annual age- and sex-standardized incidence and prevalence of PMR from 2011 to 2019 were 18.6/100 000 persons and 138.8/100 000 persons, respectively. The incidence was higher in women than in men (21.8/100 000 vs. 12.8/100 000 persons per year). 60% of the cases were diagnosed in primary care practices. The treatment of PMR with orally administered glucocorticoids usually results in a treatment response within a few days to weeks. Approximately 43% of patients experience recurrent symptoms within a year, requiring adjustment of the glucocorticoid dose. For older patients with impaired physical ability, additional non-pharmacological treatment with exercise programs plays an important role.

CONCLUSION

PMR usually takes an uncomplicated course under treatment and can be managed in primary care, but these patients are often multimorbid and require frequent follow-up. Along with research on the etiology of the disease, further studies are needed to identify the risk factors for a chronic course and to evaluate the potential effects of non-pharmacological measures.

Characteristics of aneurysmal subarachnoid hemorrhage associated with rheumatic disease

Spontaneous subarachnoid hemorrhage (SAH) occurs due to intracranial aneurysm rupture in most cases. Rheumatic disease may cause vessel wall inflammation, which can increase the risk of rupture. However, the characteristics of SAH with rheumatic disease are unknown. This study aimed to evaluate SAH features in patients with rheumatic disease. We retrospectively analyzed clinical data of 5066 patients from the Nagasaki SAH Registry Study who had been diagnosed with aneurysmal SAH between 2001 and 2018. We evaluated the SAH characteristics in patients with rheumatic disease using multivariable logistic regression analysis. In total, 102 patients (2.0%, 11 men and 91 women, median age 69.0 [57.0-75.5]) had rheumatic disease. In these patients, univariate logistic regression analysis showed that sex, hypertension, family history of SAH, smoking history, World Federation of Neurosurgical Societies grade on admission, aneurysm size, multiple aneurysms, treatment, and symptomatic spasms were associated with SAH. Multivariable logistic regression analysis showed that characteristics independently associated with SAH in rheumatic disease were female sex (odds ratio [OR] 3.38; 95% confidence interval [CI] 1.81-6.93, P < 0.001), hypertension (OR 0.60; 95% CI 0.40-0.90, P = 0.012), family history of SAH (OR 0.18; 95% CI 0.01-0.80, P = 0.020), small ruptured aneurysms (OR 1.50; 95% CI 1.02-2.24, P = 0.048), and multiple aneurysms (OR 1.69; 95% CI 1.09-2.58, P = 0.021) in comparison with SAH without rheumatic disease. In conclusion, SAH in patients with rheumatic disease was characterized by small multiple aneurysms, regardless of the low incidence of hypertension and family history of SAH.

Patient-reported involvement of the eighth cranial nerve in giant cell arteritis

INTRODUCTION

The frequency of eighth nerve lesions in patients with giant cell arteritis (GCA) has rarely been examined. However, sudden onset deafness has been recorded as a presenting feature of GCA on several occasions. This study sought to establish how common this and other symptoms of eighth nerve involvement are in a large retrospective survey.

METHODS

We contacted 170 patients with GCA and 250 matched PMR patients, inviting them to participate in a questionnaire survey of symptoms of eighth nerve dysfunction. We compared the presence of deafness, tinnitus, loss of balance and vertigo in both groups and examined the relationship between the onset of these symptoms and other features of GCA.

RESULTS

A total of 317 patients were recruited. The percentage of patients with symptoms of possible vestibulocochlear disease prior to commencement of steroid therapy was significantly greater among GCA patients than PMR patients for all domains. Hearing loss which was twice as common in GCA as in PMR (53% vs 26%) [p = 0.001]. Deafness was concurrent in 35% of GCA patients with other symptoms and 45% reported colocation with headache. Recovery with steroids occurred in 56% of these.

CONCLUSION

Symptoms of eighth nerve dysfunction are present in over half of patients with GCA. Recovery with steroids was predicted by concurrence with headache in terms of both timing and location. It appears that eighth nerve involvement, especially acute hearing loss, is a not infrequent feature of GCA and often responds well to steroid therapy. Clinicians should enquire about these symptoms when evaluating a patient for possible GCA.Key Points• Deafness is a frequent presenting feature of giant cell arteritis.• Vertigo, tinnitus and loss of balance are also often reported by GCA sufferers.• Steroid therapy is more likely to relieve these symptoms if they are ipsilateral and concurrent with headache.

Contemporary prevalence estimates for giant cell arteritis and polymyalgia rheumatica, 2015

OBJECTIVE

There are no estimates of the prevalence of giant cell arteritis (GCA) or polymyalgia rheumatica (PMR) in a US population in the current millennium. The purpose of this study was to estimate the 2015 prevalence of GCA and PMR in a US population-based setting.

METHODS

Cohorts of incident GCA in 1950-2009 and incident PMR in 1970-2014 were previously identified among residents of Olmsted County, Minnesota. Prevalence estimates were obtained from the age-, sex-, and calendar year-specific incidence rates and adjusted to the US white 2010 population aged ≥50 years. Confidence intervals (CI) were computed using bootstrap sampling.

RESULTS

There were 248 incident cases of GCA in 1950-2009 and 790 cases of PMR in 1970-2014. The overall age- and sex-adjusted prevalence rate of GCA on January 1, 2015 was 204 (95% CI: 161-254) per 100,000 population aged ≥50 years. GCA prevalence rate in women was 304 (95% CI: 229-375) and in men was 91 (95% CI: 46-156) per 100,000 population. The overall age and sex adjusted prevalence rate of PMR on January 1, 2015 was 701 (95% CI: 651-750) per 100,000 population. PMR prevalence rate in women was 870 (95% CI: 787-957) and in men was 508 (95% CI: 426-589) per 100,000 population.

CONCLUSION

Prevalence rates of GCA and PMR in 2015 are similar to previously published prevalence estimates in the late 1990s. The health burden of these diseases among older persons continues to be substantial and reflects the need for continued efforts to better manage it.

The prevalence of giant cell arteritis and polymyalgia rheumatica in a UK primary care population

Background

To update community-based prevalence values for Polymyalgia Rheumatic (PMR) and Giant Cell Arteritis (GCA) using case record review supplemented by population survey and subsequent clinical review.

Methods

Clinical data were obtained from case records of a large primary care practice in Norfolk, UK and reviewed for diagnoses of GCA and PMR. In addition postal survey was carried out to capture potentially undiagnosed cases within the practice population. Those screening positive for potential diagnoses of GCA and PMR were invited for clinical review. A cumulative prevalence estimate was subsequently calculated on those diagnosed within the GP practice and subsequently on those fulfilling the various published classification criteria sets. The date of the database lock and mail merge was March 2013.

Results

Through detailed systematic review of 5,159 GP case records, 21 patients had a recorded diagnosis of GCA and 117 had PMR.No new cases were identified among 2,227 completed questionnaires returned from the population survey of a sample of 4,728. The resulting cumulative prevalence estimate in those aged ≥ 55 years meeting the ACR classification criteria set for GCA was 0.25 % (95 % CI 0.11 to 0.39 %) and for five published criteria sets for PMR ranged from 0.91 to 1.53 % (95 % CI ranges 0.65 %, 1.87 %). The prevalence of both conditions was higher in women than in men and in older age groups.

Conclusion

This study provides the first UK prevalence estimate of GCA and PMR in over 30 years and is the first to apply classification criteria sets.

Advances and challenges in the diagnosis and treatment of polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is a common inflammatory condition that often affects people over the age of 50 years. Characteristic symptoms are shoulder and hip girdle pain and prolonged morning stiffness. Markers of inflammation are often elevated. Clinicians are often faced with the challenge of distinguishing PMR from other conditions, particularly rheumatoid arthritis and spondyloarthropathy that can mimic symptoms of PMR in older people. Additionally, there is an association between PMR and giant cell arteritis, a common large-vessel vasculitis which also affects people over the age of 50 years. Imaging of the large vessels in asymptomatic patients with PMR often reveals findings of subclinical vasculitis. Presently, there are no tests that are specific for the diagnosis of PMR and clinicians rely on a combination of history, physical examination, laboratory tests and imaging studies to make a diagnosis. A recent undertaking by the European League Against Rheumatism/American College of Rheumatology has led to the publication of provisional classification criteria of PMR. Ultrasonography, which is being increasingly used by rheumatologists, can greatly aid in the diagnosis of PMR and often shows changes of synovitis and tenosynovitis. Treatment consists of low doses of glucocorticoids which are associated with morbidity. Evaluation of newer biologic therapies targeting inflammatory cytokines is underway. Despite treatment, relapses are common.

[Polymyalgia rheumatica]

Polymyalgia rheumatica is characterized by bilateral pain in the shoulder and pelvic girdles, malaise, morning stiffness and weight loss. The erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) level are elevated. Imaging using ultrasound, magnetic resonance imaging (MRI) or positron emission tomography (PET) displays inflammatory changes in the painful anatomical areas. Nearly all patients are older than 50 years and the average age is 70-75 years. Polymyalgia rheumatica occurs 2-3 times more often in women than in men and some patients exhibit temporal arteritis or giant cell arteritis. Symptoms rapidly decrease with glucocorticoid treatment and the dose can normally be reduced during the course of the disease. Methotrexate may be given only if high glucocorticoid doses do not sufficiently control symptoms. On average treatment can be stopped after 2 years.

Polymyalgia rheumatica in 2011

Polymyalgia Rheumatica (PMR) is an inflammatory rheumatic disease that commonly affects individuals over 50 years of age, characterised by pain and morning stiffness of the shoulder and pelvic girdle. PMR can present as 'isolated' form or may be associated with giant cell arteritis. The progress of imaging techniques has helped in understanding different clinical patterns: subclinical vasculitis can occur in at least one-third of PMR patients, causing ischaemic complications. It is considered a polygenic disease and environmental factors may play a role in its pathogenesis, such as viral or bacterial triggers, both in the 'wide' form or assembled with adjuvants in vaccines. The response to steroid therapy is generally dramatic and side effects may occur, as well as the development of glucocorticoid resistance. The optimisation of therapy may require steroid-sparing agents as well as modified-release prednisone as 'nighttime' replacement therapy.

AS03-adjuvanted versus non-adjuvanted inactivated trivalent influenza vaccine against seasonal influenza in elderly people: a phase 3 randomised trial

BACKGROUND

We aimed to compare AS03-adjuvanted inactivated trivalent influenza vaccine (TIV) with non-adjuvanted TIV for seasonal influenza prevention in elderly people.

METHODS

We did a randomised trial in 15 countries worldwide during the 2008-09 (year 1) and 2009-10 (year 2) influenza seasons. Eligible participants aged at least 65 years who were not in hospital or bedridden and were without acute illness were randomly assigned (1:1) to receive either AS03-adjuvanted TIV or non-adjuvanted TIV. Randomisation was done in an internet-based system, with a blocking scheme and stratification by age (65-74 years and 75 years or older). Participants were scheduled to receive one vaccine in each year, and remained in the same group in years 1 and 2. Unmasked personnel prepared and gave the vaccines, but participants and individuals assessing any study endpoint were masked. The coprimary objectives were to assess the relative efficacy of the vaccines and lot-to-lot consistency of the AS03-adjuvanted TIV (to be reported elsewhere). For the first objective, the primary endpoint was relative efficacy of the vaccines for prevention of influenza A (excluding A H1N1 pdm09) or B, or both, that was confirmed by PCR analysis in year 1 (lower limit of two-sided 95% CI had to be greater than zero to establish superiority). From Nov 15, to April 30, in both years, participants were monitored by telephone or site contact and home visits every week or 2 weeks to identify cases of influenza-like illness. After onset of suspected cases, we obtained nasal and throat swabs to identify influenza RNA with real-time PCR. Efficacy analyses were done per protocol. This trial is registered with ClinicalTrials.gov, number NCT00753272.

FINDINGS

We enrolled 43 802 participants, of whom 21 893 were assigned to and received the AS03-adjuvanted TIV and 21 802 the non-adjuvanted TIV in year 1. In the year 1 efficacy cohort, fewer participants given AS03-adjuvanted than non-adjuvanted TIV were infected with influenza A or B, or both (274 [1·27%, 95% CI 1·12-1·43] of 21 573 vs 310 [1·44%, 1·29-1·61] of 21 482; relative efficacy 12·11%, 95% CI -3·40 to 25·29; superiority not established). Fewer participants in the year 1 efficacy cohort given AS03-adjuvanted TIV than non-adjuvanted TIV were infected with influenza A (224 [1·04%, 95% CI 0·91-1·18] vs 270 [1·26, 1·11-1·41]; relative efficacy 17·53%, 95% CI 1·55-30·92) and influenza A H3N2 (170 [0·79, 0·67-0·92] vs 205 [0·95, 0·83-1·09]; post-hoc analysis relative efficacy 22·0%, 95% CI 5·68-35·49).

INTERPRETATION

AS03-adjuvanted TIV has a higher efficacy for prevention of some subtypes of influenza than does a non-adjuvanted TIV. Future influenza vaccine studies in elderly people should be based on subtype or lineage-specific endpoints.

FUNDING

GlaxoSmithKline Biologicals SA.

Polymyalgia rheumatica

Polymyalgia rheumatica is a chronic, inflammatory disorder of unknown cause that affects people over age 50 years. Classic symptoms include pain and long-term morning stiffness of the neck, shoulders, hips, upper arms, and thighs. Although markers of inflammation are often raised, no specific laboratory test exists for the disorder and the diagnosis is based on clinical assessment. Provisional classification criteria were published in April, 2012, by a collaborative initiative of the European League Against Rheumatism and the American College of Rheumatology. Several other disorders can mimic polymyalgia rheumatica. In particular, clinical manifestations can be difficult to differentiate from other forms of inflammatory arthritis such as spondyloarthritis and rheumatoid arthritis. Imaging studies such as ultrasonography and MRI typically show a predominantly periarticular inflammatory process. A subset of patients has an associated inflammatory vasculopathy affecting large arteries (giant cell arteritis). The standard treatment is low-dose glucocorticoids, which provide symptomatic relief for most patients. However, disease relapses are common, and treatment with glucocorticoids is associated with substantial morbidity. Improved understanding of disease pathogenesis might allow for more targeted immunotherapy.

Imbalance between endothelial injury and repair in patients with polymyalgia rheumatica: improvement with corticosteroid treatment

OBJECTIVES

Polymyalgia rheumatica (PMR) is a rheumatic disease that is characterized by intense activation of systemic inflammation. Systemic inflammation has been associated with an imbalance between endothelial injury and repair, defined by an increased number of circulating endothelial microparticles (EMPs) and a reduced number of endothelial progenitor cells (EPCs). We investigated the association between inflammation and endothelial injury and repair in patients with PMR and evaluated the effects of corticosteroid therapy on EMP and EPC levels.

DESIGN, SETTING AND SUBJECTS

We conducted a case-control study in 34 patients with never-treated active PMR and 34 healthy age- and sex-matched controls. Patients with PMR participated in a 1-month intervention open-label study with corticosteroid therapy. Circulating EMPs (CD31+/CD42-) and EPCs (CD34+/KDR+) were quantified by fluorescence-activated cell sorting analysis.

RESULTS

Patients with PMR had an increased EMP/EPC ratio compared with controls [median (IQR): 6.5 (3.0-11.5) vs. 1.1 (0.7-1.5), P < 0.001], because of both increased EMP and reduced EPC levels. Levels of C-reactive protein (CRP) were associated with an increased EMP/EPC ratio (β = 0.48, P = 0.001), irrespective of traditional cardiovascular risk factors. Corticosteroid therapy led to a significant CRP reduction [from 3.9 (1.5-6.7) to 0.6 (0.2-1.2) mg dL(-1) , P < 0.05], paralleled by a consistent 81% decline in the EMP/EPC ratio. CRP and EMP/EPC ratio reductions were significantly correlated (rho = 0.37, P = 0.04).

CONCLUSIONS

Polymyalgia rheumatica is associated with a significant imbalance between endothelial injury and repair, which is dependent on the degree of systemic inflammation. Attenuation of inflammation by short-term corticosteroid therapy might have a role in limiting endothelial fragmentation and promote endothelial repair.

Immunotherapeutic implication of IL-6 blockade

IL-6 is a cytokine featuring redundancy and pleiotropic activity. While IL-6 contributes to host defense against acute environmental stress, continuous IL-6 production plays a significant pathological role in various autoimmune and chronic inflammatory diseases. To counter this drawback, tocilizumab, a humanized anti-IL-6 receptor antibody, was developed. Clinical trials have verified the efficacy of tocilizumab for patients with rheumatoid arthritis, Castleman's disease and systemic juvenile idiopathic arthritis, resulting in approval of this innovative biologic for their treatment. Moreover, a considerable number of case reports and pilot studies have indicated the beneficial effects of tocilizumab on other autoimmune and chronic inflammatory diseases. Further clinical studies to evaluate the efficacy and safety of tocilizumab for these diseases are essential.

The reliability of hospital and pharmaceutical data to assess prevalent cases of chronic obstructive pulmonary disease

Identifying chronic obstructive disease (COPD) cases is required to estimate COPD prevalence, to enroll COPD cohorts and to estimate air pollution health effects. Administrative health data are frequently used to identify COPD cases, though their validity has not been satisfactorily assessed. This paper aims to assess the contribution of pharmaceutical data in detecting COPD cases and to estimate the reliability of hospital/mortality databases in detecting COPD cases. Prevalent COPD cases among 35-plus-year-olds were estimated in four Italian areas in 2006 from hospital/mortality registries and adding pharmaceutical data. Age-specific and age-standardized prevalence rates were calculated in each area. Internal validity of COPD diagnoses from hospital and mortality databases was assessed. Pharmaceutical database was used to confirm the hospital/mortality COPD cases and to examine the selection and misclassification of hospitalized cases. Possible misclassification between COPD and asthma cases was estimated using hospital data. Prevalent COPD cases were 77,098 from hospital/mortality registries, 172,357 when respiratory prescriptions were added. Prevalence ranged from 4.0%-6.7%. Only 22.7% of pharmaceutical COPD cases were hospitalized or died and only 37.2% of hospital/mortality cases consumed respiratory medicines; this last proportion increased to 64.5% among the older cases with a principal diagnosis. COPD cases with a contemporary asthma diagnosis were 3.1%. We found that pharmaceutical data increases COPD prevalence estimates 2.2-2.5 times. Hospitalization does not necessarily indicate COPD severity, COPD as a principal diagnosis confirmed with medicine prescription more likely represented true cases. Misclassification affects asthma cases to greater extent than COPD cases.

Polymyalgia rheumatica and giant cell arteritis: management of two diseases of the elderly

Both polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) present with a broad spectrum of clinical manifestations and almost exclusively occur in the population aged over 50 years. After rheumatoid arthritis, PMR is the second most common autoimmune rheumatic disorder. Visual loss is the most feared complication in temporal arteritis, and extracranial arteries and/or aorta are more often involved in GCA than previously estimated. No specific laboratory parameter exists for diagnosis of PMR. Imaging techniques such as ultrasonography, MRI or 18F-fluorodeoxyglucose PET may be helpful in the diagnosis and evaluation of the extent of vascular involvement in these diseases. This article highlights upcoming new classification criteria for PMR, recent advances of diagnostic and therapeutic procedures as well as ongoing research on biomarkers and corticosteroid-sparing medications, which should improve management of PMR and GCA.

The rate of polymyalgia rheumatica (PMR) and remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome in a clinic where primary care physicians are working in Japan

We analyzed the rate of polymyalgia rheumatica (PMR) and remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome, both characterized as seronegative inflammatory arthritis in elderly, in an outpatient unit where primary care physicians are working in Japan to better understand the epidemiological characteristics of the diseases in Japan. Consecutive outpatients who newly visited at Department of General Medicine, Asahikawa Medical University Hospital, Japan, between April 2004 and March 2010 were analyzed. Each parameter such as age, sex, diagnosis, and biochemical examination was investigated. During the 6 years, 10 or 3 patients were diagnosed as PMR or RS3PE syndrome, respectively. The patients with PMR were 7 women and 3 men, and the average age at diagnosis was 69. Out of all patients aged over 50 (n = 3,347), the rate of PMR was 0.22% in men or 0.36% in women, respectively. On the other hand, RS3PE syndrome was diagnosed in 3 men (76, 76, and 81 years old). The rate of patients with RS3PE syndrome was 0.09% among outpatients aged over 50 indicating that the rate of PMR in an outpatient clinic in Japan is not far from previous findings reported from western countries. When compared with PMR, the rate of RS3PE syndrome was approximately one-third, providing for the first time the rate of RS3PE syndrome when compared with PMR. These epidemilogical data might help us pick up the diseases in primary care setting in Japan.

Prevalence of long-term oral glucocorticoid prescriptions in the UK over the past 20 years

OBJECTIVE

To assess trends in long-term (i.e. ≥3 months) oral glucocorticoid (GC) prescriptions over the past 20 years.

METHODS

Data of UK adult patients registered between January 1989 and December 2008 with general practices contributing to The Health Improvement Network (THIN) database were obtained. The annual prevalence of long-term oral GC prescriptions was assessed in the whole population and specifically in people with RA, PMR/GCA, asthma, chronic obstructive pulmonary disease (COPD), Crohn's disease and ulcerative colitis (UC). Trends over the 20-year period were estimated using sex- and age-adjusted Poisson regression models.

RESULTS

During the 26 035 154 person-years of follow-up, an average of 0.75% (95% CI 0.74, 0.75) of the study population was prescribed long-term oral GC therapy at any time point. This rose from 0.59% (0.52, 0.67) in 1989 to 0.79% (0.78, 0.80) in 2008. Long-term prescriptions significantly increased in patients with RA [from 10.3% (8.7, 11.9) to 13.6% (12.9, 14.2)] and PMR/GCA [from 57.6% (53.3, 62.0) to 66.5% (65.2, 67.7)], decreased in patients with asthma, COPD and Crohn's disease and remained stable in patients with UC. However, when only incident cases were considered, we found a decreased use of GCs in patients with RA and UC [odds ratio 0.97 (95% CI 0.96, 0.97) and 0.94 (95% CI 0.93, 0.96) per increasing year, respectively].

CONCLUSION

Over the past 20 years, long-term oral GC prescriptions have increased by 34%. Patients newly diagnosed with RA, Crohn's disease or UC are, however, less likely to receive long-term GC prescriptions than patients with a long past medical history of the disease, suggesting changes in physicians' practice.

Stress and autoimmunity

The etiology of autoimmune disease is multifactorial, including genetic, environmental, hormonal, and immunological factors. Nevertheless, the onset of autoimmune disorders remains enigmatic. Physical and psychological stresses have been suggested in the development of autoimmune disease, since numerous animal and human studies demonstrated the effect of stressors on immune function. Moreover, many retrospective studies had found that a high proportion (up to 80%) of patients reported uncommon emotional stress before disease onset. This, however, is not surprising as the disease itself causes significant stress in the patient. Recent reviews discuss the possible role of psychological stress, and of the major stress-related hormones, in the pathogenesis of autoimmune disease and presume that the stress-triggered neuroendocrine hormones lead to immune dysregulation, which ultimately results in autoimmune disease by altering or amplifying cytokine production. However, there is no evidence based research to support this concept. Nonetheless, stress reactions should be discussed with autoimmune patients. Applied implications are discussed, concentrating on the need for multidisciplinary care interventions that target patients' disease symptoms and help them cope with their illness.

Breast cancer stage at time of detection in women with systemic lupus erythematosus

Mounting evidence suggests an increased cancer risk in several autoimmune diseases, including systemic lupus erythematosus (SLE). However, greater scrutiny for cancer in subjects with chronic disease (compared to the general population) might explain this apparent association. If so, one would expect cancers in SLE to be diagnosed at earlier stages than in the general population. This might be particularly evident in cancers where screening is available, such as breast cancer. We linked the University of Pittsburgh lupus cohort with the Pennsylvania Cancer Registry to determine the frequency distribution for stage at diagnosis of invasive breast cancers in the SLE subjects. Data on staging of cancers occurring in the general population of Pennsylvania were obtained from The US Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. A lower percentage of women with SLE presented with localized breast cancer (nine of the 16, 56.2%) compared to the general population of women (63.5%). Although not definitive, this evidence suggests that cancers in SLE are not necessarily diagnosed at earlier stages than in the general population.