Associations of smoking and alcohol consumption with disease activity and functional status in rheumatoid arthritis

Functional disability and disease activity are affected by social determinants of health in patients with rheumatoid arthritis

BACKGROUND

The relationship between social determinants of health (SDH) and disease outcomes in rheumatoid arthritis (RA) is not well documented.

METHODS

Data were extracted from the Ontario Best Practices Research Initiative (OBRI) registry for patients between January 2008 and April 2022. Adjusted mixed models analysis was used to investigate the effect of baseline SDH on disease activity (Clinical Disease Activity Index (CDAI)) and functional disability (Health Assessment Questionnaire-Disability Index (HAQ-DI)) 12 months after enrollment. The analyses were completed on multiple imputed data.

RESULTS

There were 2651 patients with a mean age of 58.1 years (SD 12.9). The majority (77.8%) were female. Greater improvements in physical function were seen in patients who were full-time employed (difference =  - 0.20; 95% CI - 0.28, - 0.11), part-time employed (difference =  - 0.10; 95% CI - 0.19, - 0.02), or retired (difference =  - 0.17; 95% CI - 0.25, - 0.08), compared to unemployed, those with highest income ($75,000 or more) (difference =  - 0.23; 95% CI - 0.37, - 0.09). Caucasian was also associated with a positive impact on functional ability (difference =  - 0.09; 95% CI - 0.17, - 0.02). In contrast, smokers had smaller improvements in physical function (difference = 0.07; 95% CI 0.002, 0.14). Interestingly, women had greater improvement in CDAI (difference =  - 2.40; 95% CI - 3.29, - 1.51), while they reported less improving in their physical function (difference = 0.33; 95% CI 0.27-0.39). Achieving CDAI low disease activity/remission state was also more common in females.

CONCLUSIONS

Our findings suggest that disease activity and functional disability are affected by different SDH factors. The effects of SDH should be better understood and addressed by rheumatologists to provide equitable healthcare for all patients with RA. Key points • This study explored a comprehensive panel of social determinants of health and their relationship to clinical outcomes. • Previously unreported factors such as employment status and income were found to influence clinical outcomes. • Our findings can help physicians to identify high-risk patients who may benefit from additional attention to their social background.

The relationship between physical performance and alcohol consumption levels in Russian adults

Investigating the relationship between alcohol consumption and physical performance, we used data from the 2015-2018 Know Your Heart study on 4215 adults aged 35-69 from Arkhangelsk and Novosibirsk, Russia. We classified participants' drinking status into non-drinking, non-problem drinking, hazardous drinking, and harmful drinking based on their self-reported drinking behaviors. To evaluate physical performance, we developed a Composite Physical Performance Scale (CPPS), which combined the results of three functional tests: grip strength (GS), closed-eyes balance, and chair rises (CR). We applied multivariable linear regression to assess the relationship between alcohol consumption and CPPS score, and ordinal logistic regression to explore the associations between alcohol consumption and the three functional tests separately. The results showed that harmful drinking was associated with lower CPPS scores compared to non-problem drinking. Among harmful drinking men, the decrease in CPPS scores was explained by all three tests equally and exceptionally by GS among women. Non-drinking was also associated with decreased CPPS, linked to lower GS and CR scores in men, and only lower GS scores in women. The study revealed a reduced physical performance in the non-drinking and harmful drinking groups compared to non-problem drinking.

Associations of classical HLA alleles with depression and anxiety

Immune dysregulation has been widely observed in patients with psychiatric disorders. This study aims to examine the association between HLA alleles and depression and anxiety. Using data from the UK Biobank, we performed regression analyses to assess the association of 359 HLA alleles with depression and anxiety, as determined by Patient Health Questionnaire (PHQ) score (n = 120,033), self-reported depression (n = 121,685), general anxiety disorder (GAD-7) score (n = 120,590), and self-reported anxiety (n = 108,310). Subsequently, we conducted gene environmental interaction study (GEIS) to evaluate the potential effects of interactions between HLA alleles and environmental factors on the risk of depression and anxiety. Sex stratification was implemented in all analysis. Our study identified two significant HLA alleles associated with self-reported depression, including HLA-C*07:01 (β = -0.015, p = 5.54 × 10-5 ) and HLA-B*08:01 (β = -0.015, p = 7.78 × 10-5 ). Additionally, we identified four significant HLA alleles associated with anxiety score, such as HLA-DRB1*07:01 (β = 0.084, p = 9.28 × 10-5 ) and HLA-B*57:01 (β = 0.139, p = 1.22 × 10-4 ). GEIS revealed that certain HLA alleles interacted with environmental factors to influence mental health outcomes. For instance, HLA-A*02:07 × cigarette smoking was associated with depression score (β = 0.976, p = 1.88 × 10-6 ). Moreover, sex stratification analysis revealed significant sex-based differences in the interaction effects of certain HLA alleles with environmental factors. Our findings indicate the considerable impact of HLA alleles on the risks of depression and anxiety, providing valuable insights into the functional relevance of immune dysfunction in these conditions.

Appraising causal risk and protective factors for rheumatoid arthritis

Aims

Mendelian randomization (MR) is considered to overcome the bias of observational studies, but there is no current meta-analysis of MR studies on rheumatoid arthritis (RA). The purpose of this study was to summarize the relationship between potential pathogenic factors and RA risk based on existing MR studies.

Methods

PubMed, Web of Science, and Embase were searched for MR studies on influencing factors in relation to RA up to October 2022. Meta-analyses of MR studies assessing correlations between various potential pathogenic factors and RA were conducted. Random-effect and fixed-effect models were used to synthesize the odds ratios of various pathogenic factors and RA. The quality of the study was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology using Mendelian Randomization (STROBE-MR) guidelines.

Results

A total of 517 potentially relevant articles were screened, 35 studies were included in the systematic review, and 19 studies were eligible to be included in the meta-analysis. Pooled estimates of 19 included studies (causality between 15 different risk factors and RA) revealed that obesity, smoking, coffee intake, lower education attainment, and Graves' disease (GD) were related to the increased risk of RA. In contrast, the causality contribution from serum mineral levels (calcium, iron, copper, zinc, magnesium, selenium), alcohol intake, and chronic periodontitis to RA is not significant.

Conclusion

Obesity, smoking, education attainment, and GD have real causal effects on the occurrence and development of RA. These results may provide insights into the genetic susceptibility and potential biological pathways of RA.

The Role of Rheumatologist in Smoking Cessation of Ankylosing Spondylitis Patients: A Single-Center Cross-Sectional Study

OBJECTIVES

Smoking has a well-established detrimental effect on the prognosis and treatment success in patients with ankylosing spondylitis. It is important to encourage and convince patients to quit smoking. We aimed to evaluate the contribution of rheumatologists to smoking cessation in patients with ankylosing spondylitis.

METHODS

This single-center cross-sectional study was conducted in a tertiary research hospital between March 2022 and June 2022. The data related to demographics, smoking status, duration of smoking, average number of cigarettes smoked per day, reasons for quitting smoking, and methods of quitting smoking were obtained through face-to-face interviews.

RESULTS

This study was carried out on 308 patients. A total of 102 ankylosing spondylitis patients quit smoking. Of the patients who quit smoking, 39 (38.3%) patients quit smoking with a recommendation of a rheumatologist and 29 (28.4%) patients quit because of their concerns related to ankylosing spondylitis disease. The most commonly used methods for quitting smoking were herbal supplements in 40 (39.2%) patients and medication for smoking cessation in 40 (39.2%) patients.

CONCLUSIONS

It has been shown that about one-fifth of ankylosing spondylitis patients are not questioned by a rheumatologist about smoking. On the other hand, it was seen that the factor with the greatest effect on those who quit smoking was the rheumatologist. Therefore, rheumatologists should question all ankylosing spondylitis patients about smoking and encourage smokers to quit in order to achieve better outcomes in the long term.

Disease Activity and Health-Related Quality of Life Among Patients With Rheumatoid Arthritis With Different Alcohol Consumption Habits

OBJECTIVE

Multiple studies have found a relationship between alcohol consumption and disease activity in rheumatoid arthritis (RA), although reverse causation has been suggested to explain the association. We aimed to study the relationship between alcohol consumption and disease activity, disease progression, and health-related quality of life in patients with RA.

METHODS

We followed up 1,228 patients with newly diagnosed RA from a population-based case-control study, Epidemiological Investigation of Rheumatoid Arthritis (EIRA). Drinkers and non-drinkers were compared to evaluate risk of unfavorable outcomes regarding disease activity and health-related quality of life. Odds ratios with 95% confidence intervals were calculated using logistic regression models.

RESULTS

Non-drinkers at baseline had higher disease activity and estimated their pain as more severe compared to drinkers. At 1 year of follow-up, non-drinkers reported higher swollen and tender joint counts and experienced more pain and fatigue, lower global health scores, and lower health-related quality of life. The inverse relationship between alcohol consumption and RA-specific outcomes was also observed when comparing drinkers and non-drinkers who had not changed their alcohol consumption habits at or after the year of disease onset. Those who stopped drinking postbaseline experienced higher disease activity, more pain, and lower health-related quality of life at 1 year of follow-up, compared to drinkers, although there was no difference in disease activity at baseline between drinkers who continued versus discontinued drinking. Our findings argue against bias due to reverse causation.

CONCLUSION

Alcohol consumption was associated with lower disease activity and higher health-related quality of life in RA patients in a dose-dependent manner.

Rheumatoid arthritis and the risk of preterm birth

During pregnancy, many diseases are correlated with different adverse outcomes. In turn, pregnancy affects the body, leading to increased disease susceptibility. This interplay between diseased states and pregnancy outcomes is illustrated in the effect of the chronic autoimmune disorder, rheumatoid arthritis (RA), and the adverse outcome, preterm birth (PTB). RA is a systemic disorder characterized by inflammation of the joints and other body organs. Joint pain and swelling are the most prominent manifestations of RA during pregnancy. However, the exact role of RA on PTB among pregnant women has yet to be established. This review highlighted the immunologic mechanisms involved in PTB in pregnant patients with RA. The immune cell population in pregnant women with RA exhibited higher activity of macrophages, dendritic cells, neutrophils, helper T (Th) 1 cells, and Vδ1 cells, but lower activity of CD4 + CD25^high T regulatory (CD24 + CD25^high T_reg ), Th2, and Vδ2 cells. Increased pro-inflammatory cytokines IL-6, TNF-α, and IFN-γ and decreased anti-inflammatory cytokines IL-12 and IL-10 are also exhibited by pregnant patients with RA. This review also discussed factors that may predict the risk of PTB in RA. These include disease activity and severity of RA, laboratory parameters (cytokines and immune cell population), and sociodemographic factors such as ethnicity, smoking, alcohol intake, and the level of education. Current findings on the underlying immunological mechanisms of RA can help identify possible strategies to prevent PTB.

Smoking, but not use of complementary and alternative medicine predicts residual functional disability in patients with inflammatory arthritis on biologic disease-modifying anti-rheumatic drugs: Results from the Singapore National Biologics Register

AIMS

To describe inflammatory arthritis (IA) patients initiating biologic disease-modifying anti-rheumatic drugs (bDMARDs) who use complementary and alternative medicine (CAM), and determine the impact of CAM on predicting modified Health Assessment Questionnaire (mHAQ) at 6 months.

METHODS

This was a prospective inception cohort study of patients ≥21 years old initiating a bDMARD for IA after July 2016. Data were obtained via questionnaires and abstraction from medical records. Baseline characteristics between ever-CAM and CAM non-users were compared. CAM as a predictor of mHAQ ≥1 at 6 months after bDMARD initiation was analyzed using multivariate logistic regression, adjusting for other baseline characteristics.

RESULTS

We recruited 299 patients (36.2% male, mean age 49.0 years). There were 45.8% who had rheumatoid arthritis, 54.2% had a spondyloarthropathy, median disease duration of 1.1 years and median mHAQ of 0.4. Compared to CAM non-users, ever-CAM users had a lower mean body mass index, were less likely to speak English, and more likely to smoke and drink alcohol. There was no association of CAM use with high mHAQ and no interaction with smoking. Smoking (odds ratio [OR] 938.9; 95% CI 3.20-275 884.1), baseline mHAQ (OR 252.2; 95% CI 5.34-11 899.2) and Charlson's Comorbidity Index score ≥4 (OR 237.4; 95% CI 1.22-46 184.4) independently predicted high mHAQ at 6 months.

CONCLUSIONS

CAM use was not associated with high mHAQ at 6 months. Smoking was an independent predictor of residual functional disability at 6 months, even after adjusting for age, comorbidity and baseline mHAQ. Greater emphasis on smoking cessation may improve long-term functional outcomes in IA patients on bDMARDs.

The association of trace elements with arthritis in US adults: NHANES 2013-2016

BACKGROUND

Arthritis is a common chronic disease, and is a major cause of disability and chronic pain in adults. Considering inflammatory responses is closely related with trace elements (TEs), the role of TEs in arthritis has attracted much attention. This study aimed to assess the association between TEs and arthritis.

METHODS

Concentrations of TEs in whole blood [cadmium (Cd), lead (Pb), mercury (Hg), selenium (Se), and manganese (Mn)] and serum [copper (Cu) and zinc (Zn)] were measured in adults who participated in the US National Health and Nutrition Examination Survey. Logistic regression model and Bayesian kernel machine regression model were used to explore the association between TEs and arthritis.

RESULTS

The levels of five TEs (Pb, Hg, Cd, Se, and Cu) in the arthritis group changed significantly. Three TEs were found to be associated with an increased risk of arthritis: Pb [OR (95% CI): 2.96 (2.18, 4.03), p-value for trend (P-t) < 0.001], Cd [OR (95% CI): 2.28 (1.68, 3.11), P-t < 0.001], Cu [OR (95% CI): 2.05 (1.53, 2.76), P-t < 0.001]. The Relative Excess Risk of Interaction was 0.35 (95% CI: 0.06-0.65) and 0.38 (95% CI: 0.11-0.64), respectively, suggesting that Hg ions and Se ions have positive additional interactions with alcohol consumption, which reduced the risk of arthritis. Subgroup analysis showed that Pb ions and Cd ions were significantly correlated with osteoarthritis and rheumatoid arthritis.

CONCLUSION

Elevated concentrations of Pb, Cd, and Cu were associated with increased risk of arthritis. Drinking with high levels of Hg or Se may be a protective factor for arthritis. Future studies are warranted to validate these findings in prospective studies.

2021 EULAR recommendations regarding lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases

OBJECTIVES

A European League Against Rheumatism taskforce was convened to review the literature and develop recommendations on lifestyle behaviours for rheumatic and musculoskeletal diseases (RMDs).

METHODS

Six lifestyle exposures (exercise, diet, weight, alcohol, smoking, work participation) and seven RMDs (osteoarthritis, rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis, systemic lupus erythematosus, systemic sclerosis, gout) were considered. The taskforce included health professionals in rheumatology, geriatricians, epidemiologists, public health experts, people with RMDs and exposure domain experts. Systematic reviews were conducted to gather available evidence, from which recommendations were developed.

RESULTS

Five overarching principles and 18 specific recommendations were defined based on available evidence. The overarching principles define the importance of a healthy lifestyle, how lifestyle modifications should be implemented, and their role in relation to medical treatments. Exercise recommendations highlight the safety and benefits of exercise on pain and disability, particularly among people with osteoarthritis and axial spondyloarthritis. The diet recommendations emphasise the importance of a healthy, balanced diet for people with RMDs. People with RMDs and health professionals should work together to achieve and maintain a healthy weight. Small amounts of alcohol are unlikely to negatively affect the outcomes of people with RMDs, although people with rheumatoid arthritis and gout may be at risk of flares after moderate alcohol consumption. Smokers should be supported to quit. Work participation may have benefits on RMD outcomes and should be discussed in consultations.

CONCLUSIONS

These recommendations cover a range of lifestyle behaviours and can guide shared decision making between people with RMDs and health professionals when developing and monitoring treatment plans.

Influence of Smoking on Disease Activity and Quality of Life in Patients With Rheumatoid Arthritis: Results From a Swedish Case-Control Study With Longitudinal Follow-Up

OBJECTIVE

Inconclusive findings have been reported regarding the influence of smoking on disease outcomes in established rheumatoid arthritis (RA). This study was undertaken to investigate the influence of smoking habits on disease activity and health-related quality of life (HRQoL) in RA patients.

METHODS

Patients with newly diagnosed RA (n = 1,531) from the population-based case-control Epidemiological Investigation of Rheumatoid Arthritis study were followed up for up to 3 years after recruitment. Using logistic regression models, the risks of unfavorable outcomes in patients with different smoking habits were compared using self-reported swollen and tender joint counts, the Short Form 36 health survey, the Health Assessment Questionnaire, and the Hospital Anxiety and Depression Scale by calculating odds ratios with 95% confidence intervals.

RESULTS

At 1-year and 3-year follow-up, current smokers reported higher disease activity and lower HRQoL life compared to non-smokers, regarding both physical and mental aspects. Patients who stopped smoking within 1-year post-baseline had less disease activity measured as swollen joint counts at 1-year follow-up compared to those who continued smoking. Patients who stopped smoking after the 1-year follow-up had higher disease activity and lower HRQoL at baseline than smokers who did not quit, and late smoking cessation was not associated with more favorable outcomes compared to continued smoking.

CONCLUSION

Current smoking is associated with increased disease activity and lower HRQoL among RA patients. Smoking cessation within the first year after baseline appears to have a favorable effect on disease activity.

Smoking, alcohol consumption and disease-specific outcomes in rheumatic and musculoskeletal diseases (RMDs): systematic reviews informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A EULAR taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). The aim of this paper was to review the literature on the relationship between smoking and alcohol consumption with regard to RMD-specific outcomes.

METHODS

Two systematic reviews were conducted to identify systematic reviews and meta-analyses, published between 2013 and 2018, related to smoking and alcohol consumption in seven RMDs: osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), systemic sclerosis (SSc) and gout. Two additional systematic reviews were performed to identify original longitudinal studies on smoking and alcohol consumption and disease-specific outcomes.

RESULTS

Nine reviews and 65 original studies on smoking as well as two reviews and 14 original studies on alcohol consumption met the inclusion criteria. While most studies were moderate/poor quality, smoking was significantly associated with poorer outcomes: cardiovascular comorbidity; poorer response to RA treatment; higher disease activity and severity in early RA; axSpA radiographic progression. Results were heterogeneous for OA while there was limited evidence for PsA, SSc and gout. Available studies on alcohol mainly focused on RA, reporting a positive association between alcohol intake and radiographic progression. Five studies assessed alcohol consumption in gout, reporting a significant association between the number and type of alcoholic beverages and the occurrence of flares.

CONCLUSION

Current literature supports that smoking has a negative impact on several RMD-specific outcomes and that moderate or high alcohol consumption is associated with increased risk of flares in RA and gout.

The association between disease duration and mood disorders in rheumatoid arthritis patients

AIMS

The mood disorders have been recognized as common comorbidities of rheumatoid arthritis (RA), however unknown in patients with different RA courses. Therefore, we aimed to investigate the status of mood disorders in early RA and non-early RA patients and further identify the associated factors for mood disorders.

METHODS

Self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were assessed in all enrolled RA patients. Besides clinical assessments, power Doppler and greyscale (GS) ultrasound of 28 joints was performed. The frequency of mood disorders was compared between early RA and non-early RA patients. Multivariate regression was used to identify the associated factors for mood disorders.

RESULTS

Tow hundred one RA patients were enrolled, with 76 early RA (disease duration ≤ 2 years) and 125 non-early RA (disease duration > 2 years). Mood disorders (depression and/or anxiety) were found in 42 (20.9%) patients. Depression was more frequently observed in early RA than non-early RA patients (26.3% vs. 14.4%, P = 0.036). A similar trend for anxiety was also observed in early RA compared to non-early RA patients, although the difference was insignificant (13.2% vs. 5.6%, P = 0.062). Disease duration (OR = 0.991, 95% CI 0.985-0.998, P = 0.009), health assessment questionnaire disability index (HAQ-DI) (OR = 1.045, 95% CI 1.005-1.086, P = 0.029) and GS synovitis score (OR = 1.065, 95% CI 1.017-1.115, P = 0.007) were identified as factors associated with depression. Disease duration (OR = 0.981, 95% CI 0.967-0.995, P = 0.009), HAQ-DI (OR = 1.071, 95% CI 1.013-1.133, P = 0.017) and GS synovitis score (OR = 1.072, 95% CI 1.012-1.136, P = 0.019) were identified to be associated with anxiety.

CONCLUSIONS

Depression and anxiety were almost doubled in frequency in early RA than in long-standing RA patients. RA patients with short disease duration, high HAQ-DI and GS score were more likely to be in depression and anxiety. Key Points • Mood disorders were more frequent in early RA than non-early RA patients. • More attention to psychological status is needed in RA patients. • RA patients with short disease duration, poor physical function and severe synovitis were more likely to have depression and/or anxiety.

Prevalence and Risk Factors of Substance Use Disorder in Rheumatoid Arthritis

Objective

In this study, we aimed to determine the lifetime prevalence of substance use disorder (SUD) in a Canadian rheumatoid arthritis (RA) cohort and factors associated with SUD in RA.

Methods

Participants with RA (N = 154) were recruited via rheumatology clinics as part of a larger cohort study of psychiatric comorbidity in immune‐mediated inflammatory diseases. SUD is defined as the uncontrolled use of a substance despite the harmful consequences of its use. To identify lifetime SUD, the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition was administered to participants. Participants’ sociodemographic and RA clinical characteristics were also assessed. We examined factors associated with lifetime SUD using unadjusted and adjusted logistic regression modeling.

Results

Twenty‐three (14.9%) of 154 participants with RA met the criteria for a lifetime diagnosis of SUD. The majority of the participants were women, were White, had postsecondary education, and were on a disease‐modifying antirheumatic drug. Factors associated with increased odds of SUD were male sex (adjusted odds ratio [aOR]: 3.63, 95% confidence interval [CI]: 1.03‐12.73), younger age (aOR: 0.94, 95% CI: 0.90‐0.98), and ever smoking (aOR: 6.44, 95% CI: 1.53‐27.07).

Conclusion

We found that approximately 1 in 7 individuals with RA had a lifetime diagnosis of SUD, highlighting the importance of identifying and treating SUD in those with RA. In particular, the following factors were associated with higher odds of SUD: male sex, younger age, and smoking behaviors.

Lifestyle factors in patients with rheumatoid arthritis-a cross-sectional study on two Scandinavian cohorts

INTRODUCTION

The risk for cardiovascular diseases and other comorbidities increases with the number of unhealthy lifestyle factors in the general population. However, information on the combined number of unhealthy lifestyle factors in people with rheumatoid arthritis (RA) is scarce.

OBJECTIVES

To study lifestyle factors and the association between disease impact and two or more unhealthy lifestyle factors in two Scandinavian cohorts with RA.

METHODS

We analysed data from two cohorts, Danish (n = 566; mean age 61.82 (SD 11.13) years; 72% women) and Swedish (n = 955; mean age 66.38 (SD 12.90) years; 73% women). Lifestyle factors (tobacco use, BMI, alcohol consumption and physical activity) were dichotomised as healthy vs. unhealthy (range 0-4 unhealthy factors). The association between disease impact and two or more unhealthy lifestyle factors was analysed using logistic regression.

RESULTS

Sixty-six percent of Danish and 47% of Swedish respondents reported two or more unhealthy lifestyle factors, most commonly, being overweight/obese and physical inactivity. For Danish participants, two or more unhealthy lifestyle factors were associated with (OR and 95% CI) male gender (1.86; 1.21-2.85), cardiovascular diseases (1.90; 1.28-2.82) and disease duration (0.97; 0.95-0.99). Corresponding findings for the Swedish cohort were male gender (1.42; 1.07-1.89), pain (1.10; 1.04-1.15), fatigue (1.09; 1.04-1.15), physical functioning (1.64; 1.28-2.10) and quality of life (0.35; 0.20-0.60).

CONCLUSION

Many patients, most often male, in both cohorts had two or more unhealthy lifestyle factors. The number of unhealthy lifestyle factors indicates a multifaceted relationship with disease impact.

Alcohol Consumption and Risk of Rheumatoid Arthritis among Chinese Adults: A Prospective Study

Alcohol consumption may be associated with the risk of rheumatoid arthritis (RA), but potential sex-related differences in this association have not been explored. Thus, we utilized 87,118 participants in the Kailuan Study, a prospective cohort initiated in 2006 to study the risk factors of cardiovascular disease in a Chinese population. We included those that did not have RA at baseline (2006), and performed cox proportional hazard modeling to calculate the hazard ratio (HR) and 95% confidence interval (95% CI) of RA according to the levels of alcohol consumption (never or past, light or moderate (<1 serving/day for women, <2 servings/day for men), and heavy (>1 serving/day for women, >2 servings/day for men), adjusting for age, sex, body mass index, and smoking. Diagnoses of RA were confirmed via medical record review by rheumatologists. From 2006 to 2018, we identified 87 incident RA cases. After adjusting for potential confounders, the HR of RA was 1.26 (95% CI: 0.62, 2.56) for participants with light or moderate alcohol consumption and 1.98 (95% CI: 0.93, 4.22) for participants with heavy alcohol consumption) versus non-drinkers. The HR of each 10 g increase in alcohol consumption was 1.11 (95% CI: 0.98, 1.26) (p-trend = 0.09). A significant association between alcohol consumption and RA risk was observed in women, but not in men (p for interaction = 0.06). Among women, each 10 g increase in alcohol consumption was significantly associated with a high risk of RA (HR: 1.56; 95% CI: 1.06, 2.29). In contrast, each 10 g increase in alcohol consumption was not significantly associated with the risk of RA in men (HR: 1.10; 95% CI: 0.97, 1.25). Excluding past drinkers generated similar results. In this prospective Chinese cohort, increasing alcohol consumption was associated with an elevated risk of RA among women, but not in men. These findings highlight the importance of incorporating analysis of sex differences into future studies of alcohol consumption and RA risk.

Exploring the effect of alcohol on disease activity and outcomes in rheumatoid arthritis through systematic review and meta-analysis

To evaluate the effects of alcohol consumption on disease activity in rheumatoid arthritis. EMBASE, Pubmed, the Cochrane Library, and Web of Science were searched until July 29, 2020. English language studies that reported disease activity outcomes in rheumatoid arthritis were included. Studies were excluded if they were reviews, case reports, had fewer than 20 patients, or reported on prevalence but not disease activity in RA. Forest plots were used to determine pooled mean difference and were generated on RevMan5.3. Linear regression was used to determine correlations between alcohol and antibody status, gender, and smoking status. The search identified 4126 citations of which 14 were included. The pooled mean difference in DAS28 (95% CI) was 0.34 (0.24, 0.44) (p < 10⁻⁵) between drinkers and non-drinkers with lower DAS28 in non-drinkers, 0.33 (0.05, 0.62) (p = 0.02) between heavy drinkers and non-drinkers with lower DAS28 in heavy drinkers, and 0.00 (− 0.30, 0.30) (p = 0.98) between low- and high-risk drinkers. The mean difference of HAQ assessments was significantly different between those who drink alcohol compared to those who do not, with drinkers reporting lower HAQ scores (0.3 (0.18, 0.41), p < 10⁻⁵). There was no significant correlation between drinking and gender, smoking status, or antibody positivity. Alcohol consumption is associated with lower disease activity and self-reported health assessment in rheumatoid arthritis. However, drinking has no correlation with smoking, gender, or antibody status.

The association between alcohol consumption and osteoarthritis: a meta-analysis and meta-regression of observational studies

There is conflicting evidence for the association between alcohol consumption and common joint conditions such as Osteoarthritis (OA), which affects millions of people. We sought to determine the true association between alcohol intake and OA. We conducted a PRISMA systematic review and meta-analysis of observational studies that reported associations between alcohol consumption and OA. Pooled estimates of association were represented through odds ratios (ORs). Publication bias was assessed with Funnel and Galbraith plots, and risk of bias was assessed with the Newcastle Ottawa Scale. We included 29 studies and 25,192 subjects with OA and reported an OR between any alcohol consumption and OA of 0.79 (0.68–0.93), suggesting a protective effect. OR of weekly or more frequent use was 0.79 (0.65–0.97). When grouped by covariates, alcohol consumption was negatively associated with radiographic (0.83, 0.70–0.98), hand (0.80, 0.66–0.95) and knee OA (0.85, 0.72–0.99), North American ethnicity and female gender. Subgroup analysis of unadjusted data resulted in an OR of 0.70 (0.55–0.89) but this disappeared upon analysis of studies with data adjusted for any covariate (0.93, 0.78–1.10). Whilst our pooled analysis suggest that weekly or more frequent alcohol consumption was negatively associated with OA, this was not observed when adjusted for confounding factors. Reasons for this include selection bias and lack of longitudinal exposure and adjustment for confounding variables. Therefore, this meta-analysis provides evidence to dispel notions that alcohol use may be protective against OA.

Alcohol as friend or foe in autoimmune diseases: a role for gut microbiome?

Alcohol is well known for promoting systemic inflammation and aggravating multiple chronic health conditions. Thus, alcohol may also be expected to serve as a risk factor in autoimmune diseases. However, emerging data from human and animal studies suggest that alcohol may in fact be protective in autoimmune diseases. These studies point toward alcohol's complex dose-dependent relationship in autoimmune diseases as well as potential modulation by duration and type of alcohol consumption, cultural background and sex. In this review, we will explore alcohol's pro- and anti-inflammatory properties in human and animal autoimmune diseases, including autoimmune diabetes, thyroid disease, systemic lupus erythematosus, rheumatoid arthritis, experimental autoimmune encephalomyelitis and multiple sclerosis. We will also discuss potential mechanisms of alcohol's anti-inflammatory effects mediated by the gut microbiome.

[Depression and anxiety in patients with psoriatic arthritis: Prevalence and associated factors]

OBJECTIVE

To determine the prevalence of depression and anxiety in patients with psoriatic arthritis (PsA), to investigate whether there is a difference in the prevalence of depression and anxiety between PsA and rheumatoid arthritis (RA) patients and to identify associated risk factors for depression and anxiety in PsA patients.

METHODS

PsA and RA patients who visited Department of Rheumatology and Clinical Immunology in Peking University First Hospital from May 2018 to Sep 2019 were recruited. Self-rating anxiety scale and self-rating depression scale were surveyed and compared between PsA and RA patients. Demographics and clinical features including age, gender, disease duration, disease activity score, psoriasis area and severity index (PASI), and medical application were collected. Power Doppler and grey-scale ultrasound of joints, tenosynovitis and enthesis were performed. Multivariate Logistic regression was used to identify the factors associated with mood disorders and the odds ratio of depression and anxiety between the PsA and RA patients.

RESULTS

Among the 114 enrolled PsA patients, 37 (32.5%) had mood disorders, in which 36 (31.6%) with depression and 15 (13.2%) with anxiety. Compared with 201 RA patients, PsA patients showed greater odds for depression [adjusted OR (95%CI): 2.7 (1.1-6.4)]. Depression was more often observed in the PsA than in the RA patients (31.6% vs. 18.9%, P=0.011). The similar trend for anxiety was also observed, although the difference was insignificant (13.2% vs. 8.5%, P=0.185). Age (OR=0.95, P=0.008), psoriasis duration (OR=0.94, P=0.018), pain visual analogue scale (OR=1.47, P=0.011), PASI score (OR=1.07, P=0.007) and presence of ultrasound enthesitis (OR=4.13, P=0.009) were identified as factors associated with depression in the PsA patients. PASI score (OR=1.07, P=0.001) was identified as associated factor for anxiety in the PsA patients.

CONCLUSION

The prevalence of depression and anxiety is elevated in PsA patients. Depression is significantly more prevalent in PsA patients than in RA patients. Younger age, shorter psoriasis duration, worse pain and presence of ultrasound enthesitis are associated with depression, while severe psoriasis rash is associated with both depression and anxiety in PsA patients.

The impact of lifestyle behaviours, physical activity and smoking on morbidity and mortality in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is associated with pain, disability and increased risk of developing comorbidities and premature mortality. While these poor outcomes have improved in line with advances in the treatment of RA, they still persist to some degree today. Physical activity and smoking are two areas of patients' lives where changes may have a substantial impact on the poor outcomes associated with RA. Physical activity in RA has been well studied, with many randomised trials indicating the benefits of physical activity on pain and disability. A number of observational studies have assessed the impact of smoking on RA, also indicating the benefits of quitting smoking on RA-related outcomes, but with less consistent findings, potentially due to epidemiological challenges (e.g. collider bias, recall bias). There are also a number of barriers preventing patients making these positive lifestyle changes, such as lack of time and motivation, lack of knowledge and advice, as well as disease-specific barriers, such as pain and fatigue.

The effect of smoking on disease activity in rheumatoid arthritis - our experience

The aim of this study was to investigate the association of smoking with disease activity, seropositivity, age and gender in patients with rheumatoid arthritis. We included 89 rheumatoid arthritis patients. All patients fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism rheumatoid arthritis classification criteria. Activity of the disease was measured by Disease Activity Score 28-joint count C-reactive protein (DAS28CRP). The subjects were stratified into smoking and non-smoking groups and cross-sectionally analyzed. There were 24 (27%) smokers and 65 (73%) nonsmokers. The mean age of patients was 57.1±8.8 years. The mean DAS28CRP was 5.81 in the smoking group and 5.57 in the non-smoking group, without statistically significant difference between the two groups (p=0.148). Similarly, smokers did not differ significantly from non-smokers according to age (p=0.443), gender (p=0.274), rheumatoid factor positivity (p=0.231), anti-citrullinated protein antibody positivity (p=0.754) or seropositivity (p=0.163). In this study, we found no association between smoking status and disease activity, seropositivity, age or gender in rheumatoid arthritis patients. Furthermore, disease activity was not related to age, gender or seropositivity. Additional studies on the effects of smoking on rheumatoid arthritis activity are needed.

Modifiable Lifestyle Factors Associated With Response to Treatment in Early Rheumatoid Arthritis

Objective

We aimed to evaluate the associations between response to algorithm‐directed treat‐to‐target conventional synthetic disease‐modifying antirheumatic drug therapy and potentially modifiable lifestyle factors, including dietary fish oil supplementation, body mass index (BMI), and smoking history in a rheumatoid arthritis (RA) inception cohort.

Methods

Patients with RA with a duration of less than 12 months were reviewed every 3 to 6 weeks to adjust therapy according to disease response. All patients received advice to take fish oil supplements, and omega‐3 status was measured as plasma levels of eicosapentaenoic acid (EPA). Lifestyle factors and other variables potentially prognostic for 28‐joint Disease Activity Score (DAS28) remission and DAS28 low disease activity (LDA) at the 12‐month visit were included in multivariable logistic regression models.

Results

Of 300 participants, 57.7% reached DAS28 LDA, and 43.7% were in DAS28 remission at 1 year. Increase in plasma EPA was associated with an increase in the odds of being in LDA (adjusted odds ratio [OR] = 1.27; P < 0.0001) and remission (adjusted OR = 1.21; P < 0.001). There was some evidence that the effect of BMI on LDA might be modified by smoking history. An increase in BMI was associated with a decrease in the odds of being in LDA in current and former smokers but had no impact on LDA in patients who had never smoked. There were no meaningful associations between BMI or smoking history and remission.

Conclusion

Omega‐3 status, BMI, and smoking history are potential predictors of outcome in early RA. The possibility of an effect modification by smoking on the predictive value of BMI merits further investigation.

Dietary Habits and Nutrition in Rheumatoid Arthritis: Can Diet Influence Disease Development and Clinical Manifestations?

Rheumatoid arthritis (RA) is a systemic, autoimmune disease characterized by joint involvement, with progressive cartilage and bone destruction. Genetic and environmental factors determine RA susceptibility. In recent years, an increasing number of studies suggested that diet has a central role in disease risk and progression. Several nutrients, such as polyunsaturated fatty acids, present anti-inflammatory and antioxidant properties, featuring a protective role for RA development, while others such as red meat and salt have a harmful effect. Gut microbiota alteration and body composition modifications are indirect mechanisms of how diet influences RA onset and progression. Possible protective effects of some dietary patterns and supplements, such as the Mediterranean Diet (MD), vitamin D and probiotics, could be a possible future adjunctive therapy to standard RA treatment. Therefore, a healthy lifestyle and nutrition have to be encouraged in patients with RA.

Changes in Alcohol Use and Associations With Disease Activity, Health Status, and Mortality in Rheumatoid Arthritis

OBJECTIVE

Better disease activity and quality of life have been observed among patients with rheumatoid arthritis (RA) who drink alcohol. This association might be explained by reverse causality. We undertook this study to identify predictors of change in alcohol use and to evaluate independent associations between alcohol use and RA activity and mortality.

METHODS

Participants in Forward, The National Databank for Rheumatic Diseases, were asked about alcohol use (any versus none), and disease activity was collected through the Patient Activity Scale-II (PAS-II) on semiannual surveys. We identified factors associated with changes in alcohol use and determined associations between alcohol use and disease activity and mortality using linear and logistic regression models, Cox proportional hazards models, and marginal structural models.

RESULTS

A total of 121,280 observations were studied among 16,762 unique participants. Discontinuation and initiation of alcohol were common among drinkers and abstainers (8.2% and 9.2% of observations, respectively). Greater discontinuation and less initiation were observed with greater disease activity, older age, female sex, nonwhite race, obesity, greater comorbidity, low quality of life, low educational level, low income, and work disability. While alcohol users had lower PAS-II (β = -0.15 [95% confidence interval (95% CI) -0.18, -0.11], P < 0.001) and a lower mortality (odds ratio 0.87 [95% CI 0.76, 0.98], P = 0.03) in traditional models, associations were not seen in marginal structural models.

CONCLUSION

Higher disease activity, disability, comorbidity, and poor quality of life contribute to reductions in alcohol use. Active use and changes in use were not associated with disease activity or mortality when adjusting for confounding, suggesting no clear benefit of alcohol consumption in RA.

Impact of the combined presence of erosions and ACPA on rheumatoid arthritis disease activity over time: results from the METEOR registry

Objective

To investigate associations between baseline presence of erosions and/or anti-citrullinated protein antibodies (ACPA) on functional ability, disease activity and treatment survival over time.

Methods

Real life data from newly diagnosed rheumatoid arthritis patients were identified in the international METEOR registry. Patients were grouped according to presence/absence of ACPA and/or erosions at baseline. Associations between the presence of ACPA and/or erosions (four groups) with the change of Disease Activity Score (DAS) and Health Assessment Questionnaire (HAQ) over time were assessed using linear mixed models during maximum 6 or maximum 12 months from baseline. Treatment survival was assessed using multiple failure-times Cox regression.

Results

Data were included from 701 ACPA‒/erosions‒, 334 ACPA‒/erosions+, 1585 ACPA+/erosions‒ and 1993 ACPA+/erosions+ patients. We found statistically significant differences in DAS and HAQ change over time between the four groups, both after maximum follow-up durations of 6 and of 12 months, but after stratification differences proved small and not clinically meaningful. Patients in the ACPA‒/erosions‒ group were less likely to switch treatment compared with the ACPA+/erosions‒ reference group (p<0.001). The other two ACPA/erosions groups did not differ from the reference group.

Conclusions

In this analysis of worldwide real life data, we found statistically significant, but clinically irrelevant differences in treatment response to initial disease modifying anti-rheumatic drug therapies as measured by DAS and HAQ in ACPA‒/erosions‒, ACPA‒/erosions+, ACPA+/erosions‒ and ACPA+/erosions+ rheumatoid arthritis patients. However, after maximum follow-up durations of 6 and 12 months all groups had a similar response to initial treatment, but with a lower likelihood to switch treatment for ACPA‒/erosions‒ patients during the first year of follow-up.

Diagnostic accuracy of interferon-gamma-induced protein 10 for differentiating active tuberculosis from latent tuberculosis: A meta-analysis

Tuberculin skin test and interferon-gamma release assay are not good at differentiating active tuberculosis from latent tuberculosis. Interferon-gamma-induced protein 10 (IP-10) has been widely used to detect tuberculosis infection. However, its values of discriminating active and latent tuberculosis is unknown. To estimate the diagnostic potential of IP-10 for differentiating active tuberculosis from latent tuberculosis, we searched PubMed, Web of Science, Embase, the Cochrane Library, CNKI, Wanfang, VIP and CBM databases. Eleven studies, accounting for 706 participants (853 samples), were included. We used a bivariate diagnostic random-effects model to conduct the primary data. The overall pooled sensitivity, specificity, negative likelihood rate, positive likelihood rate, diagnostic odds ratio and area under the summary receiver operating characteristic curve were 0.72 (95% CI: 0.68-0.76), 0.83 (95% CI: 0.79-0.87), 0.32 (95% CI: 0.22-0.46), 4.63 (95% CI: 2.79-7.69), 17.86 (95% CI: 2.89-38.49) and 0.8638, respectively. This study shows that IP-10 is a potential biomarker for differentiating active tuberculosis from latent tuberculosis.

Reasons to stop drinking alcohol among patients with rheumatoid arthritis in Sweden: a mixed-methods study

OBJECTIVES

The aims were to identify patients with rheumatoid arthritis (RA) who had stopped drinking alcohol and compare them with patients drinking alcohol, and to explore reasons for stopping drinking alcohol.

DESIGN

A sequential explanatory mixed methods design was used.

SETTING

Six rheumatology clinics in Southern Sweden Better Anti-Rheumatic FarmacOTherapy cohort.

PARTICIPANTS

A total of 1509 patients completed the questions about alcohol and were included in the study. 86 of these had stopped drinking alcohol and 72 responded to the open question and their answers were analysed with qualitative content analysis.

OUTCOME MEASURES

The quantitative data were from a cross-sectional survey assessing disease severity, physical function (Health Assessment Questionnaire, HAQ) and health-related quality of life (EuroQol five dimensions, EQ5D), pain, fatigue, patient global assessment (PatGA) and lifestyle factors, for example, alcohol. The questions assessing alcohol included an open question 'Why have you stopped drinking alcohol?'

RESULTS

The patients who stopped drinking alcohol were older (median (min-max) 69 (36-90) vs 66 (23-95), p=0.011), had worse HAQ (1.00 (0-2.75) vs 0.50 (0-3.00), p<0.001), worse EQ5D (0.69 (-0.02-1.00) vs 0.76 (-0.58-1.00), p<0.001) worse PatGA (5 (0-10) vs 3 (0-10), p<0.001), more pain (5 (0-10) vs 3 (0-10), p<0.001) and more fatigue (6 (0-10) vs 4 (0-10), p<0.001 compared with patients drinking alcohol. The qualitative content analysis revealed five categories describing reasons for patients with RA to stop drinking alcohol: illness and treatment; health and well-being; work and family; faith and belief; and dependences and abuse.

CONCLUSIONS

The patients who had stopped drinking had worse physical functioning and higher levels in pain-related variables. Most stopped drinking due to their illness or a desire to improve health.

Smoking Is Associated with Higher Disease Activity in Rheumatoid Arthritis: A Longitudinal Study Controlling for Time-varying Covariates

OBJECTIVE

Prior studies around the relationship between smoking and rheumatoid arthritis (RA) disease activity have reported inconsistent findings, which may be ascribed to heterogeneous study designs or biases in statistical analyses. We examined the association between smoking and RA outcomes using statistical methods that account for time-varying confounding and loss to followup.

METHODS

We included 282 individuals with an RA diagnosis using electronic health record data collected at a public hospital between 2013 and 2017. Current smoking status and disease activity were assessed at each visit; covariates included sex, race/ethnicity, age, obesity, and medication use. We used longitudinal targeted maximum likelihood estimation to estimate the causal effect of smoking on disease activity measures at 27 months, and compared results to conventional longitudinal methods.

RESULTS

Smoking was associated with an increase of 0.64 units in the patient global score compared to nonsmoking (p = 0.01), and with 2.58 more swollen joints (p < 0.001). While smoking was associated with a higher clinical disease activity score (2.11), the difference was not statistically significant (p = 0.22). We found no association between smoking and physician global score, or C-reactive protein levels, and an inverse association between smoking and tender joint count (p = 0.05). Analyses using conventional methods showed a null relationship for all outcomes.

CONCLUSION

Smoking is associated with higher levels of disease activity in RA. Causal methods may be useful for investigations of additional exposures on longitudinal outcome measures in rheumatologic disease.

Novel methodology to discern predictors of remission and patterns of disease activity over time using rheumatoid arthritis clinical trials data

OBJECTIVES

To identify predictors of remission and disease activity patterns in patients with rheumatoid arthritis (RA) using individual participant data (IPD) from clinical trials.

METHODS

Phase II and III clinical trials completed between 2002 and 2012 were identified by systematic literature review and contact with UK market authorisation holders. Anonymised baseline and follow-up IPD from non-biological arms were amalgamated. Multiple imputation was used to handle missing outcome and covariate information. Random effects logistic regression was used to identify predictors of remission, measured by the Disease Activity Score 28 (DAS28) at 6 months. Novel latent class mixed models characterised DAS28 over time.

RESULTS

IPD of 3290 participants from 18 trials were included. Of these participants, 92% received methotrexate (MTX). Remission rates were estimated at 8.4%(95%CI 7.4%to9.5%) overall, 17%(95%CI 14.8%to19.4%) for MTX-naïve patients with early RA and 3.2% (95% CI 2.4% to 4.3%) for those with prior MTX exposure at entry. In prior MTX-exposed patients, lower baseline DAS28 and MTX reinitiation were associated with remission. In MTX-naïve patients, being young, white, male, with better functional and mental health, lower baseline DAS28 and receiving concomitant glucocorticoids were associated with remission. Three DAS28 trajectory subpopulations were identified in MTX-naïve and MTX-exposed patients. A number of variables were associated with subpopulation membership and DAS28 levels within subpopulations.

CONCLUSIONS

Predictors of remission differed between MTX-naïve and prior MTX-exposed patients at entry. Latent class mixed models supported differential non-biological therapy response, with three distinct trajectories observed in both MTX-naïve and MTX-exposed patients. Findings should be useful when designing future RA trials and interpreting results of biomarker studies.

The Effect of Tobacco Smoking on Musculoskeletal Health: A Systematic Review

This systematic review explored associations between smoking and health outcomes involving the musculoskeletal system. AMSTAR criteria were followed. A comprehensive search of PubMed, Web of Science, and Science Direct returned 243 articles meeting inclusion criteria. A majority of studies found smoking has negative effects on the musculoskeletal system. In research on bones, smoking was associated with lower BMD, increased fracture risk, periodontitis, alveolar bone loss, and dental implant failure. In research on joints, smoking was associated with increased joint disease activity, poor functional outcomes, and poor therapeutic response. There was also evidence of adverse effects on muscles, tendons, cartilage, and ligaments. There were few studies on the musculoskeletal health outcomes of secondhand smoke, smoking cessation, or other modes of smoking, such as waterpipes or electronic cigarettes. This review found evidence that suggests tobacco smoking has negative effects on the health outcomes of the musculoskeletal system. There is a need for further research to understand mechanisms of action for the effects of smoking on the musculoskeletal system and to increase awareness of healthcare providers and community members of the adverse effects of smoking on the musculoskeletal system.

Smoking quantity determines disease activity and function in Chinese patients with ankylosing spondylitis

The objective of this study was to systemically and comprehensively evaluate the associations between smoking and disease outcomes in patients with ankylosing spondylitis (AS). Information on smoking, clinical features, and sociodemographic characteristics was collected by a questionnaire administered directly to the patient. Group differences were analyzed by t test or chi-square test. Logistic regression analysis was conducted with the Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), C-reactive protein, and erythrocyte sedimentation rate as the dependent variables and different stratification of smoking duration, smoking intensity, and cumulative smoking as independent variables. In order to compare our results with previous studies, meta-analysis was performed to calculate standardized mean difference (SMD) for relationship between outcomes and smoking status. A total of 1178 AS patients were analyzed. Compared with non-smokers, the risk of having active disease (BASDAI ≥ 4) was higher in patients who smoked at least 15 years, or 15 cigarettes per day, or 15 pack-years (OR = 1.70 [1.06, 2.73], 1.75 [1.08, 2.82], and 1.97 [1.06, 3.67], respectively); and smokers had increasing risk of BASDAI ≥ 4 with increasing years of smoking, or cigarettes per day, or pack-years (p_-trend = 0.010, 0.008 and 0.006, respectively). The risk of having active disease was higher in patients who smoked at least 15 cigarettes per day or 15 pack-years (OR = 1.74 [1.06, 2.84] and 2.89 [1.56, 5.35], respectively), with increasing number of cigarettes per day and pack-years. Smokers had an increased risk of BASFI ≥ 4 (p_-trend = 0.040 and 0.007, respectively). By meta-analysis, current, former and ever smokers had significantly higher BASDAI (SMD = 0.34 [0.18, 0.48], 0.10 [0.01, 0.19], and 0.27 [0.20, 0.34], respectively) and BASFI (SMD = 0.35 [0.16, 0.55], 0.30 [0.22, 0.39], and 0.35 [0.21, 0.50], respectively) compared to non-smokers. Smoking is a risk factor for greater disease activity and worse functioning in AS patients.

Role of Diet in Influencing Rheumatoid Arthritis Disease Activity

BACKGROUND

Patients with Rheumatoid Arthritis (RA) frequently ask their doctors about which diets to follow, and even in the absence of advice from their physicians, many patients are undertaking various dietary interventions.

DISCUSSION

However, the role of dietary modifications in RA is not well understood. Several studies have tried to address these gaps in our understanding. Intestinal microbial modifications are being studied for the prevention and management of RA. Some benefits of vegan diet may be explained by antioxidant constituents, lactobacilli and fibre, and by potential changes in intestinal flora. Similarly, Mediterranean diet shows anti-inflammatory effects due to protective properties of omega-3 polyunsaturated fatty acids and vitamins, but also by influencing the gut microbiome. Gluten-free and elemental diets have been associated with some benefits in RA though the existing evidence is limited. Long-term intake of fish and other sources of long-chain polyunsaturated fatty acids are protective for development of RA. The benefits of fasting, anti-oxidant supplementation, flavanoids, and probiotics in RA are not clear. Vitamin D has been shown to influence autoimmunity and specifically decrease RA disease activity. The role of supplements such as fish oils and vitamin D should be explored in future trials to gain new insights in disease pathogenesis and develop RA-specific dietary recommendations.

CONCLUSION

Specifically more research is needed to explore the association of diet and the gut microbiome and how this can influence RA disease activity.

Cellular and molecular perspectives in rheumatoid arthritis

Synovial immunopathology in rheumatoid arthritis is complex involving both resident and infiltrating cells. The synovial tissue undergoes significant neovascularization, facilitating an influx of lymphocytes and monocytes that transform a typically acellular loose areolar membrane into an invasive tumour-like pannus. The microvasculature proliferates to form straight regularly-branching vessels; however, they are highly dysfunctional resulting in reduced oxygen supply and a hypoxic microenvironment. Autoantibodies such as rheumatoid factor and anti-citrullinated protein antibodies are found at an early stage, often before arthritis has developed, and they have been implicated in the pathogenesis of RA. Abnormal cellular metabolism and mitochondrial dysfunction thus ensue and, in turn, through the increased production of reactive oxygen species actively induce inflammation. Key pro-inflammatory cytokines, chemokines and growth factors and their signalling pathways, including nuclear factor κB, Janus kinase-signal transducer, are highly activated when immune cells are exposed to hypoxia in the inflamed rheumatoid joint show adaptive survival reactions by activating. This review attempts to highlight those aberrations in the innate and adaptive immune systems including the role of genetic and environmental factors, autoantibodies, cellular alterations, signalling pathways and metabolism that are implicated in the pathogenesis of RA and may therefore provide an opportunity for therapeutic intervention.

Management of rheumatoid arthritis in clinical practice using treat-to-target strategy: Where do we stand in the multi-ethnic Malaysia population?

To evaluate the achievement of treat-to-target (T2T) strategy in rheumatoid arthritis (RA) and identify factors associated with failed treatment target in a public rheumatology center. A cross-sectional study was conducted from June 2015 to February 2016. RA patients with disease duration greater than 2 years and under T2T for over a year were invited to the study. Demographic, clinical data, disease activity score of 28 joints (DAS28), and clinical disease activity index (CDAI) were collected in a single routine clinic visit. Treatment target was defined as DAS28 <3.2 or CDAI ≤10. Retrospective chart review was performed to determine reasons of failed treatment target. A total of 371 patients were recruited and 87.1% were female. Mean age and duration of RA were 53.5 years (SD 10.3) and 9.1 years (SD 6.6), respectively. Ethnic distribution was 49% Chinese, 27% Malay, and 24% Indian. T2T was achieved in 81.7% of the cohort. Non-Chinese ethnicity, positive rheumatoid factor, and treatment with three disease modifying anti-rheumatic drugs (DMARDs) were associated with failed treatment target. After controlling for covariates, Malay ethnicity (OR 2.96; 95% CI 1.47-5.96) and treatment with three DMARDs (OR 2.14; 95% CI 1.06-4.35) were associated with failed treatment target. There was no association between age, gender, duration of RA, BMI, smoking status, anti-citrulinated cyclic peptide, and achievement of T2T. The most common reasons of failed treatment target were inability to escalate DMARDs due to side effects (18.8%), lack of biologics fund (15.6%), and persistent disease despite optimum treatment (14.1%). T2T was successfully implemented. Malay patients need aggressive treatment adaptation to achieve optimal outcome.

Is There a Role for Diet in the Therapy of Rheumatoid Arthritis?

Patients with rheumatoid arthritis (RA) often inquire about dietary interventions to improve RA symptoms. Although the majority of studies of diet and RA were published prior to the start of the twenty-first century, this review discusses the evidence for a relationship between diet, in particular omega-3 fatty acid supplements, vitamin D supplements, alcohol, and the Mediterranean diet and RA disease activity. We review possible mechanisms by which these dietary intakes may affect RA disease activity. Given the complexity of studying the relationship between diet and RA disease activity, we highlight areas deserving further study before specific recommendations can be made to RA patients.

Increased inflammation and disease activity among current cigarette smokers with rheumatoid arthritis: a cross-sectional analysis of US veterans

OBJECTIVES

Cigarette smoking is a major risk factor for RA and has been associated with increased disease severity and lower rates of disease remission. We hypothesized that inflammation and disease activity would be associated with smoking status and this would be related to levels of ACPA.

METHODS

RA patients from the Veterans Affairs RA registry were studied (n = 1466): 76.9% anti-CCP2 positive, 89% male, median age 63 years (interquartile range 57-72), median disease duration 8.45 years (interquartile range 2.8-18). Baseline serum samples were evaluated for levels of anti-CCP2, RF, 19 distinct ACPAs and 17 cytokines. Smoking status at baseline was recorded as current, former or never. The association of smoking status with cytokines, autoantibodies and disease activity (DAS28) was evaluated.

RESULTS

Among anti-CCP-positive RA patients, RA-associated cytokines (false-discovery rates q < 0.1%) and DAS28 (P < 0.01) were higher in current smokers compared with former or never smokers. DAS28 and cytokine levels were similar between former and never smokers. In contrast, ACPA concentrations were higher among both current and former smokers compared with never smokers, and levels of ACPA were not associated with DAS28 or cytokine levels.

CONCLUSION

Among anti-CCP2-positive RA patients, current smoking status is associated with elevations in pro-inflammatory cytokines and increased RA disease activity. Similar levels of inflammation and disease activity among former and never smokers suggests that the detrimental effects of smoking could be ameliorated through tobacco cessation. The effect of tobacco cessation on RA disease activity should be evaluated prospectively.

Major histocompatibility complex harbors widespread genotypic variability of non-additive risk of rheumatoid arthritis including epistasis

Genotypic variability based genome-wide association studies (vGWASs) can identify potentially interacting loci without prior knowledge of the interacting factors. We report a two-stage approach to make vGWAS applicable to diseases: firstly using a mixed model approach to partition dichotomous phenotypes into additive risk and non-additive environmental residuals on the liability scale and secondly using the Levene's (Brown-Forsythe) test to assess equality of the residual variances across genotype groups per marker. We found widespread significant (P < 2.5e-05) vGWAS signals within the major histocompatibility complex (MHC) across all three study cohorts of rheumatoid arthritis. We further identified 10 epistatic interactions between the vGWAS signals independent of the MHC additive effects, each with a weak effect but jointly explained 1.9% of phenotypic variance. PTPN22 was also identified in the discovery cohort but replicated in only one independent cohort. Combining the three cohorts boosted power of vGWAS and additionally identified TYK2 and ANKRD55. Both PTPN22 and TYK2 had evidence of interactions reported elsewhere. We conclude that vGWAS can help discover interacting loci for complex diseases but require large samples to find additional signals.

Prevalence and risk factors for patient-reported joint pain among patients with HIV/hepatitis C coinfection, hepatitis C monoinfection, and HIV monoinfection

BACKGROUND

To determine the prevalence of patient-reported joint pain among patients with human immunodeficiency virus (HIV)/chronic hepatitis C virus (HCV) coinfection, chronic HCV monoinfection, and HIV monoinfection followed in hepatology and infectious disease outpatient practices.

METHODS

Standardized interviews were performed among 79 HIV/HCV-coinfected, 93 HCV-monoinfected, and 30 HIV-monoinfected patients in a cross-sectional study within hepatology and infectious disease clinics at three centers. The Multi-Dimensional Health Assessment Questionnaire was used to ascertain joint pain and associated symptoms. Information on potential risk factors for joint pain was obtained during the interview and by chart review. Logistic regression was used to determine adjusted odds ratios (aORs) with 95% confidence intervals (CIs) of joint pain associated with risk factors of interest among chronic HCV-infected and HIV-infected patients.

RESULTS

Joint pain was more commonly reported in HCV-monoinfected than HIV/HCV-coinfected (71% versus 56%; p = 0.038) and HIV-monoinfected (71% versus 50%; p = 0.035) patients. A previous diagnosis of arthritis and current smoking were risk factors for joint pain among HCV-infected patients (arthritis: aOR, 4.25; 95% CI, 1.84-9.81; smoking: aOR, 5.02; 95% CI, 2.15-11.74) and HIV-infected (arthritis: aOR, 5.36; 95% CI, 2.01-14.25; smoking: aOR, 6.07; 95% CI, 2.30-16.00) patients.

CONCLUSION

Patient-reported joint pain was prevalent among all three groups, but more common among chronic HCV-monoinfected than either HIV/HCV-coinfected or HIV-monoinfected patients. A prior diagnosis of arthritis and current smoking were risk factors for patient-reported joint pain among both HCV-infected and HIV-infected patients.

Vagus nerve stimulation: a new bioelectronics approach to treat rheumatoid arthritis?

There has been a marked improvement in the treatment of rheumatoid arthritis (RA), but most patients do not achieve disease remission. Therefore, there is still a need for new treatments. By screening an adenoviral short hairpin RNA library, we discovered that knockdown of the nicotinic acetylcholine receptor type 7 (α7nAChR) in RA fibroblast-like synoviocytes results in an increased production of mediators of inflammation and degradation. The α7nAChR is intimately involved in the cholinergic anti-inflammatory pathway (CAP). This led us to study the effects of α7nAChR activation in an animal model of RA, and we could show that this resulted in reduced arthritis activity. Accordingly, stimulation of the CAP by vagus nerve stimulation improved experimental arthritis. Conversely, we found aggravation of arthritis activity after unilateral cervical vagotomy as well as in α7nAChR-knockout mice. Together, these data provided the basis for exploration of vagus nerve stimulation in RA patients as a novel anti-inflammatory approach.

Rheumatoid arthritis and the risk of bipolar disorder: a nationwide population-based study

BACKGROUND

Studies have suggested that chronic inflammation plays an essential role in the pathophysiology of both rheumatoid arthritis (RA) and bipolar disorder. The most common clinical features associated with RA are anxiety and depression. The risk of bipolar disorder among patients with RA has not been characterized adequately.

OBJECTIVE

To determine the association between RA and the subsequent development of bipolar disorder and examine the risk factors for bipolar disorder among patients with RA.

METHODS

We identified patients who were diagnosed with RA in the Taiwan National Health Insurance Research Database. A comparison cohort was created by matching patients without RA with those with RA according to age, sex, and comorbidities. The occurrence of bipolar disorder was evaluated in both cohorts.

RESULTS

The RA cohort consisted of 2,570 patients, and the comparison cohort consisted of 2,570 matched control patients without RA. The incidence of bipolar disorder (incidence rate ratio  = 2.13, 95% confidence interval [CI]  = 1.12-4.24, P =  .013) was higher among patients with RA than among control patients. Multivariate, matched regression models revealed that asthma (hazard ratio [HR]  = 2.76, 95% CI 1.27-5.96, P =  .010), liver cirrhosis (HR  = 3.81, 95% CI  = 1.04-14.02, P =  .044), and alcohol use disorders (HR  = 5.29, 95% CI  = 1.71-16.37, P =  .004) were independent risk factors for the development of bipolar disorder among patients with RA.

CONCLUSION

RA might increase the incidence of bipolar disorder development. Based on our data, we suggest that, following RA diagnosis, greater attention be focused on women with asthma, liver cirrhosis, and alcohol use disorder. Prospective clinical studies of the relationship between RA and bipolar disorder are warranted.

Lifestyle modifications to improve musculoskeletal and bone health and reduce disability--a life-course approach

This review covers the evidence relating to lifestye modification in the big three musculoskeletal conditions: osteoarthritis, osteoporosis and rheumatoid arthritis. Lifestyle is of considerable importance in the first two and there is emerging evidence for rheumatoid arthritis despite it not traditionally being considered a lifestyle disease.