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Auanassova A, Yessirkepov M, Zimba O, Ahmed S, Mruthyunjaya P. Diagnostic delays in systemic vasculitides. Rheumatol Int 2024; 44:1003-1011. [PMID: 38587659 DOI: 10.1007/s00296-024-05582-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/12/2024] [Indexed: 04/09/2024]
Abstract
Systemic vasculitides are among the less common disorders encountered in routine rheumatology practice. The low incidence and heterogeneous presentation at onset can potentially lead to delayed diagnosis. Not recognizing these in the early phase may prove detrimental, as some vasculitis may progress to a catastrophic course with major morbidity or mortality. The causes of diagnostic delay may vary among different types of vasculitis and may also be disease-, patient-, or physician-related. Disease-related factors include the myriad presentations with diverse and non-specific symptoms, mimicking other conditions like infections. In addition, some forms have prolonged prodromal phases before evident organ damage. Limited awareness among healthcare professionals, particularly outside rheumatology, and a lack of readily available diagnostic tools contribute to missed diagnoses. Delays in seeking care due to non-specific symptoms or lack of access to specialist care can worsen outcomes. The economic burden also increases with delayed diagnosis and damage accrual when the disease remains unrecognized or untreated for prolonged periods. Although the causes of vasculitis are numerous, including secondary causes, in this review, we focus on diagnostic delays in primary vasculitides and suggest potential steps to identify and treat these diseases early. These include educating both healthcare professionals and the public about the signs and symptoms of vasculitis; expanding the rheumatology workforce and facilitating timely referrals; implementing readily available and reliable tests for early detection; and streamlining care and diagnostic pathways. Such measures have the potential to improve the overall outcomes of the disease, with prolonged remission, minimal damage accrual, and improved quality of life.
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Affiliation(s)
- Akerke Auanassova
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Marlen Yessirkepov
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Olena Zimba
- Department of Clinical Rheumatology and Immunology, University Hospital in Krakow, Krakow, Poland
- National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
- Department of Internal Medicine #2, Danylo Halytsky Lviv National Medical University, L'viv, Ukraine
| | - Sakir Ahmed
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, 751024, India
| | - Prakashini Mruthyunjaya
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, 751024, India.
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Kim YE, Ahn SM, Oh JS, Hong S, Lee CK, Yoo B, Kim YG. Incidence of and risk factors for myelodysplastic syndrome in patients with rheumatologic diseases. Rheumatology (Oxford) 2024; 63:1305-1312. [PMID: 37498607 DOI: 10.1093/rheumatology/kead374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/22/2023] [Accepted: 07/02/2023] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVE We investigated the incidence of and risk factors for myelodysplastic syndrome (MDS) in patients with rheumatologic disease. METHODS We conducted a retrospective cohort study of patients who were diagnosed with rheumatologic diseases at a tertiary care hospital between May 2009 and July 2022 and identified the patients who were subsequently diagnosed with MDS. Each patient with MDS was matched with five age- and sex-matched controls chosen from the cohort of patients with each specific rheumatologic disease. RESULTS During a total follow-up of 55 841 person-years (PY), MDS occurred in 64 patients, yielding an incidence rate of 1.15/1000 PY {median age 57.0 years [interquartile range (IQR) 41.0-69.0], median duration to MDS diagnosis 6.5 years (IQR 3.0-9.0)]. In an age-matched analysis, SLE was a significant risk factor for MDS [adjusted hazard ratio 2.61 (CI 1.19, 36.06), P = 0.01]. Refractory cytopenia with multilineage dysplasia was the most common phenotype of MDS (35.9%), and more than half of the patients had karyotypes with a favourable prognosis (54.7%). Compared with matched controls, RA, SLE and AS patients with MDS had lower levels of haemoglobin at the time of diagnosis of rheumatologic disease. Furthermore, the MDS patients with SLE and Behçet's disease had higher levels of glucocorticoid use in terms of frequency of use and mean dose than control patients. CONCLUSION SLE is a significant risk factor for MDS among patients with rheumatologic diseases. A lower haemoglobin level at the time of diagnosis of rheumatologic disease was associated with the future development of MDS.
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Affiliation(s)
- Young-Eun Kim
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Soo Min Ahn
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Seon Oh
- Information Medicine, Big Data Research Center, Asan Medical Center, Seoul, Republic of Korea
| | - Seokchan Hong
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chang-Keun Lee
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bin Yoo
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong-Gil Kim
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Guilpain P. ANCA positivity and the limited expression of vasculitides. Rheumatology (Oxford) 2024; 63:269-270. [PMID: 37540161 DOI: 10.1093/rheumatology/kead389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/22/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Philippe Guilpain
- Department of Internal Medicine and Multi-Organic Diseases, Referral Center for Systemic and Autoimmune Diseases, St Eloi Hospital, Montpellier, France
- University of Montpellier, Montpellier, France
- Inserm U1183, Institute for Regenerative Medicine and Biotherapy (IRMB), St Eloi Hospital, Montpellier, France
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Hanberg JS, Cook C, Fu X, Choi HK, Zhang Y, Wallace ZS. Longitudinal Patterns of Renal Function in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Care Res (Hoboken) 2023; 75:2190-2198. [PMID: 36856264 PMCID: PMC10885164 DOI: 10.1002/acr.25100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 12/19/2022] [Accepted: 02/07/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE A spectrum of chronic kidney disease (CKD) and end-stage renal disease (ESRD) may occur in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The longitudinal trajectory of renal function in AAV is poorly understood. METHODS Patients with ≥2 creatinine measurements, including at baseline (±30 days of treatment initiation), were included from the Mass General Brigham AAV Cohort. We calculated estimated glomerular filtration rate (eGFR). We incorporated longitudinal changes in eGFR into a group-based trajectory model to identify patients with similar patterns of change in renal function. The chi-square test and the Kruskal-Wallis test were used to evaluate differences between groups in categorical variables and non-normally distributed continuous variables, respectively. RESULTS In 255 AAV patients, we identified 4 renal trajectory groups: rapid decline (n = 20), impaired (n = 82), preserved (n = 129), and recovery (n = 24). The rapid decline and impaired groups had greater baseline comorbidity (P = 0.01) and lower prevasculitis eGFR (P = 0.02). Clinically significant CKD (eGFR <60 ml/minute/1.73 m2 ) persisted over 5 years in >75% of the impaired group, compared to <40% of patients in the preserved group (P < 0.001). ESRD occurred most frequently in the rapid decline (100%), followed by the impaired and preserved groups (7% each). Baseline AAV renal involvement was present prior to 95% of ESRD. However, ESRD etiology varied, with 90% of rapid-onset ESRD attributed to vasculitis, versus 17-44% in impaired or preserved groups (P = 0.001). CONCLUSION We identified 4 longitudinal patterns of renal function after AAV diagnosis. Our findings highlight the burden of CKD in AAV and provide a framework for future research into personalized care in this vulnerable population.
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Affiliation(s)
| | | | | | - Hyon K Choi
- Massachusetts General Hospital and Harvard Medical School, Boston
| | - Yuqing Zhang
- Massachusetts General Hospital and Harvard Medical School, Boston
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Gisslander K, de Boer R, Ingvar C, Turesson C, Isaksson K, Jayne D, Mohammad AJ. Can active sun exposure decrease the risk of giant cell arteritis and polymyalgia rheumatica in women? Rheumatol Adv Pract 2023; 7:rkad071. [PMID: 37675201 PMCID: PMC10477307 DOI: 10.1093/rap/rkad071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/28/2023] [Indexed: 09/08/2023] Open
Abstract
Objectives To study if active sun exposure among women affects the risk of developing GCA or PMR in a prospective cohort study with restricted latitudinal variability. Methods We linked the response to questions relating to sun exposure from the Melanoma Inquiry in Southern Sweden (MISS) prospective cohort study in women to the risk of developing GCA or PMR. Healthcare data were gathered from the Skåne Healthcare Register (SHR), covering all public healthcare consultations. The direct effect of active sun exposure on the risk of developing GCA or PMR was assessed using Cox proportional hazards models adjusted for covariates based on a directed acyclic graph. Results A total of 14 574 women were included in the study; 601 women were diagnosed with GCA or PMR (144 and 457, respectively) during the follow-up time. Women with moderate or high sun exposure were not less likely to develop GCA or PMR compared with women that indicated they avoided sun exposure [hazard ratio (HR) 1.2 (CI 0.9, 1.6) and 1.3 (0.9, 1.9), respectively] when adjusted for diabetes, hyperlipidaemia, hypertension, smoking, obesity and stratified by age. Similar patterns were observed when studying only GCA [HR 1.2 (CI 0.7, 2.3) and 1.3 (0.7, 2.6)] and only PMR [HR 1.3 (CI 0.9, 1.8) and 1.4 (0.9, 2.0)]. Conclusion Active sun exposure did not affect the risk of developing GCA or PMR in women in a cohort with restricted latitudinal variability.
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Affiliation(s)
- Karl Gisslander
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Raïssa de Boer
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Christian Ingvar
- Surgery, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Carl Turesson
- Rheumatology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Karolin Isaksson
- Surgery, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Surgery, Kristianstad Hospital, Kristianstad, Sweden
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Aladdin J Mohammad
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Medicine, University of Cambridge, Cambridge, UK
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A unique case of anti-GBM disease with concomitant anti-PLA2R positivity. BMC Nephrol 2022; 23:337. [PMID: 36271343 PMCID: PMC9587597 DOI: 10.1186/s12882-022-02941-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/14/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Concomitant occurrence of anti-GBM disease and anti-PLA2R positive membranous nephropathy have been previously described. However, to the best of our knowledge, this is the first case report that documents the co-occurrence of the diseases proven by both serologic and histologic methods. CASE PRESENTATION A 51-year-old woman presented to hospital with nausea, bilateral lower extremity edema, dyspnea, dark urine, and then anuria. Symptoms developed one month after an upper respiratory tract infection. Laboratory results showed acute kidney injury, and hypoalbuminemia. Immunologic examination revealed both anti-GBM and anti-PLA2R positivity. Kidney biopsy demonstrated the histological features of Goodpasture's disease and anti-PLA2R positive membranous nephropathy. Steroid, cyclophosphamide, and plasmapheresis were commenced. Despite the combined immunosuppressive, the patient remained on renal replacement therapy. CONCLUSIONS Microbial kidney injury can trigger multiple autoimmune diseases. The simultaneous occurrence of anti-glomerular basement (anti-GBM) disease and membranous nephropathy is extremely rare. Delayed recognition leads to delayed treatment, causing worse renal and patient outcomes, as well as increased financial costs.
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Santos-Jaén JM, Valls Martínez MDC, Palacios-Manzano M, Grasso MS. Analysis of Patient Satisfaction through the Effect of Healthcare Spending on Waiting Times for Consultations and Operations. Healthcare (Basel) 2022; 10:healthcare10071229. [PMID: 35885756 PMCID: PMC9325123 DOI: 10.3390/healthcare10071229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/23/2022] [Accepted: 06/29/2022] [Indexed: 01/14/2023] Open
Abstract
In recent years, public authorities have invested large amounts of public money in trying to reduce waiting times for consultations and operations with the aim of improving the quality of the healthcare system. Our research aims to analyze the effect of these investments on patient satisfaction through the mediating relationship of waiting times for consultations and operations, as well as from a gender perspective. By studying a series of key indicators of the Spanish healthcare system and applying partial least squares structural equation modelling (PLS-SEM), the findings show that the model explains 12.10% of the variance in consultant waiting times, 51.90% in operation waiting times, and 27.00% in patient satisfaction. We found that increased public spending leads to increased patient satisfaction by reducing waiting times. However, no gender-based differences were found. The results provide exciting implications for theory and practice, indicating how policymakers can orient their strategies towards improving patient satisfaction.
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Affiliation(s)
- José Manuel Santos-Jaén
- Department of Accounting and Finance, University of Murcia, 30100 Murcia, Spain; (J.M.S.-J.); (M.P.-M.)
| | - María del Carmen Valls Martínez
- Mediterranean Research Center on Economics and Sustainable Development, 04120 Almería, Spain;
- Economics and Business Department, University of Almeria, 04120 Almería, Spain
- Correspondence: ; Tel.: +34-950-01-55-35
| | - Mercedes Palacios-Manzano
- Department of Accounting and Finance, University of Murcia, 30100 Murcia, Spain; (J.M.S.-J.); (M.P.-M.)
| | - Mayra Soledad Grasso
- Mediterranean Research Center on Economics and Sustainable Development, 04120 Almería, Spain;
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Pulmonary pattern in systemic vasculitis: granulomatosis, lung cancer or both? Reumatologia 2022; 60:437-443. [PMID: 36683830 PMCID: PMC9847108 DOI: 10.5114/reum.2022.123673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/28/2022] [Indexed: 01/13/2023] Open
Abstract
As clinical manifestations of systemic vasculitides share many common features with other conditions, the rate of diagnostic errors and delayed diagnoses is high. Hence we performed an analysis of the available data regarding misdiagnosis of vasculitis as lung cancer and vice versa, as well as coexistence of vasculitis and lung cancer. The present case-based review highlights the diagnostic challenges encountered when granulomatosis with polyangiitis (GPA) mimics lung cancer. The importance of a multidisciplinary team approach to patients with pulmonary involvement and multisystem manifestations is essential for appropriate planning of further diagnostic steps and for minimizing the delay in correct diagnosis and treatment. In the present case, although computed tomography raised suspicion for lung cancer, further biopsies and laboratory screening for systemic vasculitides rejected malignancy and confirmed the diagnosis of GPA.
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Sreih AG, Cronin K, Shaw DG, Young K, Burroughs C, Kullman J, Machireddy K, McAlear CA, Merkel PA. Diagnostic delays in vasculitis and factors associated with time to diagnosis. Orphanet J Rare Dis 2021; 16:184. [PMID: 33882989 PMCID: PMC8059170 DOI: 10.1186/s13023-021-01794-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 03/30/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Patients with vasculitis, a set of rare diseases, encounter delays in obtaining an accurate diagnosis which can lead to substantial morbidity and increased mortality. This study sought to describe the diagnostic journey of patients with vasculitis and identify factors associated with time to diagnosis. METHODS Patients with vasculitis enrolled in an online registry completed a two-stage study: Stage 1: survey of open-ended questions about patients' diagnostic journeys and perceived factors associated with rapid or delayed diagnosis; Stage 2: survey with specific questions based on data from Stage 1 and additional investigator-identified factors. RESULTS 375 patients with vasculitis participated in Stage 1; 456 patients participated in Stage 2. 85% of patients were seen by a healthcare provider within 3 months of the onset of symptoms. The median time to diagnosis of vasculitis was 7 months. 313/456 (73%) of patients were misdiagnosed initially. 40% of diagnoses were made in a hospital setting; 2% of diagnoses were made at a specialized vasculitis center. 60% of patients had at least 1 visit to an emergency room prior to diagnosis. Unemployment, time to travel to a medical center > 1 h, initial misdiagnosis, and delays in seeing a specialist were all associated with longer times to diagnosis. 373/456 (82%) of patients reported that a delayed diagnosis had negative consequences on their health. CONCLUSION Patients with vasculitis encounter substantial delays in achieving an accurate diagnosis and these delays are associated with negative health consequences. Both patient-related factors and healthcare-related factors are associated with diagnostic delays.
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Affiliation(s)
- Antoine G Sreih
- Division of Rheumatology, University of Pennsylvania, White Building, 5th Floor, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Keri Cronin
- Division of Rheumatology, University of Pennsylvania, White Building, 5th Floor, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | | | - Kalen Young
- The Vasculitis Foundation, Kansas City, MO, USA
| | | | | | - Kirthi Machireddy
- Division of Rheumatology, University of Pennsylvania, White Building, 5th Floor, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania, White Building, 5th Floor, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, White Building, 5th Floor, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
- Vasculitis Patient-Powered Research Network, Philadelphia, PA, USA.
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