Lung function in rheumatoid arthritis. A clinic survey

The Autoimmune Ecology

Autoimmune diseases (ADs) represent a heterogeneous group of disorders that affect specific target organs or multiple organ systems. These conditions share common immunopathogenic mechanisms (i.e., the autoimmune tautology), which explain the clinical similarities they have among them as well as their familial clustering (i.e., coaggregation). As part of the autoimmune tautology, the influence of environmental exposure on the risk of developing ADs is paramount (i.e., the autoimmune ecology). In fact, environment, more than genetics, shapes immune system. Autoimmune ecology is akin to exposome, that is all the exposures - internal and external - across the lifespan, interacting with hereditary factors (both genetics and epigenetics) to favor or protect against autoimmunity and its outcomes. Herein, we provide an overview of the autoimmune ecology, focusing on the immune response to environmental agents in general, and microbiota, cigarette smoking, alcohol and coffee consumption, socioeconomic status (SES), gender and sex hormones, vitamin D, organic solvents, and vaccines in particular. Inclusion of the autoimmune ecology in disease etiology and health will improve the way personalized medicine is currently conceived and applied.

Contrasting diagnosis performance of forced oscillation and spirometry in patients with rheumatoid arthritis and respiratory symptoms

OBJECTIVES

Pulmonary involvement in rheumatoid arthritis is directly responsible for 10% to 20% of all mortality. The best way to improve the prognosis is early detection and treatment. The forced oscillation technique is easy to perform and offers a detailed exam, which may be helpful in the early detection of respiratory changes. This study was undertaken to (1) evaluate the clinical potential of the forced oscillation technique in the detection of early respiratory alterations in rheumatoid arthritis patients with respiratory complaints and (2) to compare the sensitivity of forced oscillation technique and spirometric parameters.

METHODS

A total of 40 individuals were analyzed: 20 healthy and 20 with rheumatoid arthritis (90% with respiratory complaints). The clinical usefulness of the parameters was evaluated by investigating the sensibility, the specificity and the area under the receiver operating characteristic curve. ClinicalTrials.gov: NCT01641705.

RESULTS

The early adverse respiratory effects of rheumatoid arthritis were adequately detected by the forced oscillation technique parameters, and a high accuracy for clinical use was obtained (AUC.0.9, Se = 80%, Sp = 95%). The use of spirometric parameters did not obtain an appropriate accuracy for clinical use. The diagnostic performance of the forced oscillation technique parameters was significantly higher than that of spirometry.

CONCLUSIONS

The results of the present study provide substantial evidence that the forced oscillation technique can contribute to the easy identification of initial respiratory abnormalities in rheumatoid arthritis patients that are not detectable by spirometric exams. Therefore, we believe that the forced oscillation technique can be used as a complementary exam that may help to improve the treatment of breathing disorders in rheumatoid arthritis patients.

Incidence of and risk factors for interstitial pneumonia in patients with rheumatoid arthritis in a large Japanese observational cohort, IORRA

Interstitial lung disease (ILD) is a frequently encountered and sometimes life-threatening complication among patients with rheumatoid arthritis (RA). In this study, we aim to clarify the incidence of and risk factors for ILD using a large observational cohort of RA patients. We analyzed the database from a large observational cohort of Japanese RA patients, the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort. We defined as interstitial pneumonia (IP) computed tomography (CT) pattern of nonspecific interstitial pneumonia or diffuse alveolar damage. Newly developed IP was identified from patient reports over 2.5 years (April 2004 to October 2006) and was confirmed by extensive medical record, chest X-ray radiograph, and CT. The raw and age/gender-adjusted incidence of IP were reported. IP risk factors were analyzed using a nested case-control design was employed using conditional logistic regression analysis with a stepwise method. Thirty-seven patients among 5,699 RA patients were diagnosed with newly developed IP, including 18 cases with methotrexate-induced pneumonitis (MTX-IP) and 15 cases with IP associated with RA (RA-IP). The age-adjusted incidence of MTX-IP among total patients, males, and females was 3.775, 6.667, and 1.013 per 1,000 cases, respectively, and of RA-IP among total patients, males, and females was 1.056, 1.452, and 0.677 per 1,000 cases, respectively. Conditional logistic regression analysis after stepwise variable selection identified male gender, increased Japanese version of the Health Assessment Questionnaire (J-HAQ) score, decreased pain visual analog scale (VAS), and elevated erythrocyte sedimentation rate as significant risk factors for MTX-IP, while the only risk factor for RA-IP was male gender. The incidence of and risk factors for IP in RA patients were determined in a large observational cohort of RA patients in Japan.

Diagnostic performance of the Forced Oscillation Technique in the detection of early respiratory changes in rheumatoid arthritis

The objective of this study was to evaluate the clinical potential of the Forced Oscillation Technique (FOT) in the detection of the early alterations in respiratory mechanics of Rheumatoid Arthritis (RA) patients. A total of 36 individuals were analyzed, 18 healthy and 18 with RA. The clinical usefulness of the parameters was evaluated investigating sensibility (Se), specificity (Sp) and the area under the receiver operating characteristic curve (AUC). In the RA group, all the 3 studied parameters obtained high accuracy for clinical use (AUC>0.9), while in spirometric parameters, no parameter obtained appropriate accuracy for clinical use (AUC < 0.7). In conclusion, the parameters obtained by FOT presented adequate Se and Sp, indicating that this technique can be helpful in the evaluation of the early respiratory mechanical alterations in patients with RA.

Pulmonary function tests in interstitial lung disease: what role do they have?

Pulmonary function tests have been widely accepted and utilized in the management of interstitial lung diseases. Although the tests performed have changed little over the past several decades, extensive literature has been published highlighting their clinical role in the diagnosis, staging, prognostication, and follow-up of patients with a wide variety of interstitial lung diseases.

Rheumatoid arthritis lung disease. Determinants of radiographic and physiologic abnormalities

OBJECTIVE

To determine the prevalence and important clinical predictors of radiographic and physiologic abnormalities indicative of rheumatoid arthritis interstitial lung disease (RA-ILD).

METHODS

An unselected cohort of patients with a confirmed diagnosis of RA and known lung disease were identified (n = 336) and evaluated for RA disease activity and severity. Outcomes included abnormalities determined by the pulmonary function tests of forced vital capacity (FVC) and diffusion capacity for carbon monoxide (DLco), and/or chest radiographic findings of interstitial infiltrates. We used multivariable statistical modeling to determine the independent significance of cigarette smoking and other RA-specific factors on the pulmonary abnormalities of interest.

RESULTS

At least 1 of the 3 abnormal findings was identified by pulmonary tests in 32.4% of all patients. These abnormal findings included an FVC < 80% of predicted in 42 patients, a DLco < 80% of predicted in 64 patients, and evidence of radiographic interstitial infiltrates in 40 patients. After statistical adjustment for confounding factors, pack-years of cigarette smoking remained a significant predictor of low DLco (beta = -0.07, 95% confidence interval [95% CI] -0.09, -0.04), low FVC (beta = -0.003, 95% CI -0.006, -0.0004), and interstitial abnormalities on chest radiograph (odds ratio for > or = 25 pack-years = 3.76, 95% CI 1.59, 8.88). The Health Assessment Questionnaire (HAQ) Disability Index (DI) was also an important risk factor for the decline in both the DLco (beta = -1.15, 95% CI -2.00, -0.30) and FVC (beta = -0.23, 95% CI -0.32, -0.13).

CONCLUSION

Although RA disease activity/severity (particularly as defined by the HAQ DI) was important, smoking was the most consistent independent predictor of radiographic and physiologic abnormalities suggestive of ILD in RA.

Perioperative management of the rheumatoid patient

Rheumatoid arthritis is a systemic disease that can affect multiple organ systems of the body. It is a symmetrical polyarthropathy which leads to destruction of cartilage and bone. Before undertaking surgery on the rheumatoid patient, several issues need to be addressed. A thorough evaluation by a multidisciplinary team is essential to decrease any operative risks involved. This is a review of some of the systemic manifestations of rheumatoid arthritis with an emphasis on anesthesiology, and radiological consultation, and perioperative surgical management of rheumatoid drug therapy.

Bronchial reactivity and airflow obstruction in rheumatoid arthritis

OBJECTIVES

To investigate the prevalence of airways obstruction and bronchial reactivity to inhaled methacholine in rheumatoid arthritis patients and unselected controls. The control population consisted of patients attending the rheumatology department for minor degenerative joint problems.

METHODS

One hundred patients with rheumatoid arthritis (RA) [72 (72%) women, 28 (28%) men; mean (SD) age 58 (10) years] and fifty controls [30 (60%) women, 20 (40%) men; mean (SD) age 56 (9) years] were studied. Detailed medical, smoking and drug histories were taken; skin prick tests were performed to assess atopy and chest and hand radiographs were performed. Spirometry, flow volume loops and gas transfer factor measurement were performed to detect airflow obstruction and methacholine inhalation tests were carried out to assess bronchial reactivity.

RESULTS

There was no significant difference between rheumatoid arthritis patients and the controls in age, sex, smoking status and atopy on skin prick testing (p < 0.05). A significantly higher number of patients with RA had a history of wheeze compared with the controls (18% v 4%, p < 0.05). FEV1, FVC, FEV1/FVC, FEF25-75%, FEF25%, FEF50% and FEF75% were all significantly lower in the rheumatoid arthritis group (p < 0.05). A significantly higher number of patients with RA compared with controls showed bronchial reactivity to inhaled methacholine [55 (55%) v 8 (16%), p < 0.05]. FEV1, FVC, FEV1/FVC, FEF25-75%, FEF25%, FEF50% and FEF75% were all significantly lower among the patients with RA achieving PD20 FEV1 to inhaled methacholine (p < 0.05).

CONCLUSION

In unselected rheumatoid arthritis patients both airflow obstruction and bronchial reactivity are significantly increased compared with controls.

Pericardial and pulmonary involvement in rheumatoid arthritis in Turkey

Pericardial and lung involvement in rheumatoid arthritis (RA), suspected to be less severe in a developing nation (Turkey), have been evaluated. We have studied clinical, echocardiographic and pulmonary findings (radiological and functional) in 93 consecutive Turkish patients with definite/classical RA. Findings were compared with those of a group of patients with osteoarthritis or local rheumatological conditions (n = 60) in a blind protocol. Fifty patients with systemic lupus (SLE) were studied as a high risk control group for pericardial involvement. While pericardial disease was detected in 5.5% (5/90) of RA patients, it was detected in 6.6% (4/60) of the control patients. SLE patients had a 26% (13/50) prevalence. Interstitial lung disease was found in 27.7% of RA patients but it was present in 6.6% (4/60) of the control patients. We observed that a group of patients with RA in Turkey had a low prevalence of pericardial disease. This is further evidence that RA has a mild course in developing countries.

Is HLA B27 antigen a predictor of cardiac or pulmonary disease in patients with rheumatoid arthritis?

Pericarditis was a frequent echocardiographic finding in 20 HLA B27 positive patients with erosive, seropositive rheumatoid arthritis (RA) and in 20 B27 negative RA controls (35% and 30% respectively). There was no significant difference in echocardiographic 2-D or M-mode measurements between the groups. A 48 hour continuous electrocardiographic monitoring, showed that ventricular extrasystoles were more frequent (p less than 0.01) in the B27 negative patients. Pulmonary diffusion capacity was reduced in 25% of the patients in both groups. There were no association between clinical or laboratory data and the cardiac or pulmonary findings except for the finding of a higher frequency of treatment with corticosteroids in patients with pericarditis.

Smoking, lung function, and rheumatoid factors

Positive rheumatoid factor (RF) reactions commonly precede the onset of clinically manifest rheumatoid arthritis (RA). Thus if items associated with RF reactions were traced at the community level this might provide clues to the cause of RA. The relations between smoking and lung functions and the occurrence of RA and RFs in a population sample representative of the adult Finnish population were studied. Rheumatoid factor testing was performed for 7124 subjects (89% of the sample) by the sensitised sheep cell agglutination test. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were measured with spirometry. 'False positive' RF reactions occurred twice as often in current smokers and ex-smokers than in those who had never smoked. The prevalence of high titres was fourfold greater among current smokers than among those who had never smoked. These associations were statistically significant and independent of age, FVC, and FEV1 in both sexes. The women with airflow limitation (FEV1/FVC less than 70%) had a significantly increased occurrence of RFs which was independent of their smoking history, but no such relationship was found in men. The results suggest an impact of smoking on RF production; a follow up study may show whether the raised RF titers in smokers will be reflected as an increased incidence of RA.

Bronchiolitis obliterans

Bronchiolitis obliterans in the adult patient is a relatively uncommon and vexing clinical entity. This confusion results because this pathologic finding occurs in a variety of diverse clinical settings. Bronchiolitis obliterans is a fibrotic process that primarily affects the small conducting airways. The lesion results from damage to the bronchiolar epithelium and the repair process leads to excessive proliferation of granulation tissue. The alveoli adjacent to the small airway are almost always involved; however, a considerable portion of the interstitium is usually spared. The findings in these patients may physiologically and radiographically mimic chronic obstructive pulmonary disease (COPD). On the other hand, some of the processes associated with bronchiolitis obliterans result in restrictive or mixed restrictive and obstructive ventilatory defects; consequently, they may be confused with other diffuse infiltrative lung disorders. This review will focus principally on bronchiolitis obliterans in adults, which, until recently, was considered rare. There has been heightened interest in this process in adults because of its association with the connective tissue diseases, its development following toxic fume exposure, its occurrence as a result of chronic graft versus host reactions, and the increasing recognition of patients with idiopathic forms of the disease that have an insidious onset often confused with more common problems such as COPD or idiopathic pulmonary fibrosis.

Rheumatoid arthritis and small airways function. Effects of disease activity, smoking, and alpha 1-antitrypsin deficiency

The sensitive pulmonary function tests of change in maximum expiratory flow (delta Vmax 50) and volume of isoflow were used to determine the effects of rheumatoid arthritis (RA), smoking, and alpha 1-antitrypsin deficiency phenotypes on peripheral airways. Patients were prospectively divided into 4 groups: 14 smokers with RA, 12 nonsmokers with RA, 11 smokers without RA, and 13 nonsmokers without RA. delta Vmax 50 was the most discriminating variable and demonstrated significant small airway obstructive disease in the first 3 groups, with an additive effect in the group of smokers with RA. An increased incidence of the alpha 1-antitrypsin-deficient MS phenotype was seen in the RA smoker group, and this phenotype was associated with severe pulmonary disease.

Airways obstruction in rheumatoid arthritis

Owing to the report of an association between rheumatoid arthritis (RA) and obliterative bronchiolitis we have determined the prevalence of airflow obstruction in unselected patients with RA and normal chest radiographs. Spirometry was performed on 100 patients with rheumatoid arthritis and 84 control subjects matched for age, sex, and smoking habits. Patients with rheumatoid arthritis had significantly lower values for FEV1, FVC, FEV1/FVC, and MMEFR when compared with the controls: 39 patients had abnormal spirometry, and at least 32 showed airways obstruction. The prevalence of airflow obstruction is remarkably high, and we suggest that airway disease may be the commonest form of lung involvement in rheumatoid arthritis.

Seropositive rheumatoid arthritis associated with decreased diffusion capacity of the lung

Sixty-two patients with classical or definite rheumatoid arthritis were subjected to lung function analysis. The various parameters--spirography, plethysmography, blood gas analysis, measurement of lung compliance, and diffusion capacity--were correlated with duration and stage of disease, and with rheumatoid factor titres. A statistically significant correlation was found to exist between Rose-Waaler titre and specific diffusion capacity. Similar results between Rose-Waaler titre and lung compliance, however, were not statistically significant.