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Crowson CS, Atkinson EJ, Kronzer VL, Kimbrough BA, Arment CA, Peterson LS, Wright K, Mason TG, Bekele DI, Davis JM, Myasoedova E. Comorbidity clusters in patients with rheumatoid arthritis identify a patient phenotype with a favourable prognosis. Ann Rheum Dis 2024; 83:556-563. [PMID: 38331589 PMCID: PMC11017091 DOI: 10.1136/ard-2023-225093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/24/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVES We aimed to cluster patients with rheumatoid arthritis (RA) based on comorbidities and then examine the association between these clusters and RA disease activity and mortality. METHODS In this population-based study, residents of an eight-county region with prevalent RA on 1 January 2015 were identified. Patients were followed for vital status until death, last contact or 31 December 2021. Diagnostic codes for 5 years before the prevalence date were used to define 55 comorbidities. Latent class analysis was used to cluster patients based on comorbidity patterns. Standardised mortality ratios were used to assess mortality. RESULTS A total of 1643 patients with prevalent RA (72% female; 94% white; median age 64 years, median RA duration 7 years) were studied. Four clusters were identified. Cluster 1 (n=686) included patients with few comorbidities, and cluster 4 (n=134) included older patients with 10 or more comorbidities. Cluster 2 (n=200) included patients with five or more comorbidities and high prevalences of depression and obesity, while cluster 3 (n=623) included the remainder. RA disease activity and survival differed across the clusters, with cluster 1 demonstrating more remission and mortality comparable to the general population. CONCLUSIONS More than 40% of patients with prevalent RA did not experience worse mortality than their peers without RA. The cluster with the worst prognosis (<10% of patients with prevalent RA) was older, had more comorbidities and had less disease-modifying antirheumatic drug and biological use compared with the other clusters. Comorbidity patterns may hold the key to moving beyond a one-size-fits-all perspective of RA prognosis.
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Affiliation(s)
- Cynthia S Crowson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth J Atkinson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Lynne S Peterson
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kerry Wright
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas G Mason
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Delamo I Bekele
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John M Davis
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elena Myasoedova
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
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Kimbrough BA, Crowson CS, Lennon RJ, Davis JM, Strangfeld A, Myasoedova E. Multiple morbidities are associated with serious infections in patients with rheumatoid arthritis. Semin Arthritis Rheum 2024; 65:152386. [PMID: 38244447 PMCID: PMC10954402 DOI: 10.1016/j.semarthrit.2024.152386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/15/2023] [Accepted: 01/11/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVE To assess the association between a comprehensive list of morbidities and serious infection (SI) in patients with rheumatoid arthritis (RA). METHODS This study evaluated SI risk associated with 55 comorbidities using a population-based inception cohort including all adult patients with incident RA from 1999 through 2014 with follow up through 2021. Morbidities and SI were ascertained using previously validated international classification of disease (ICD)-9 and ICD-10 codes. Conditional frailty models were utilized to analyze the association between each morbidity and SI: Model 1 adjusted for age, sex, and calendar year; Model 2 adjusted for factors in Model 1 and the Rheumatoid Arthritis Observation of Biologic Therapy (RABBIT) Risk Score of Infections; and Model 3 adjusted for factors in Model 1 and the Mayo SI Risk Score. RESULTS 911 patients (70 % female, mean age 56 years, 66 % seropositive) were included. There were 293 SI among 155 patients (17 %), corresponding to an incidence of 3.9 SI per 100 person-years. Eighteen SI were fatal. Risk of SI was significantly increased in 27 of 55 morbidities in Model 1, 11 morbidities in Model 2, and 23 morbidities in Model 3. Additionally, several morbidities included in the RABBIT and Mayo risk scores continued to have large effect sizes despite adjustment. Serious infection risk increased by 11-16 % per morbidity in the three models. CONCLUSIONS Several morbidities are associated with an increased risk for SI. Future risk scores may include morbidities identified in this study for improved SI risk assessment.
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Affiliation(s)
- Bradly A Kimbrough
- Division of Rheumatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Cynthia S Crowson
- Division of Rheumatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Quantitative Health Sciences Division of Clinical Trials and Biostatistics, Mayo Clinic, 200 1st ST SW, Rochester, MN 55905, USA
| | - Ryan J Lennon
- Department of Quantitative Health Sciences Division of Clinical Trials and Biostatistics, Mayo Clinic, 200 1st ST SW, Rochester, MN 55905, USA
| | - John M Davis
- Division of Rheumatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Anja Strangfeld
- Epidemiology and Health Services Research, German Rheumatism Research Centre (DRFZ) Berlin and Charite University Medicine, Charitéplatz 1, Berlin 10117, Federal Republic of Germany
| | - Elena Myasoedova
- Division of Rheumatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Kimbrough BA, Crowson CS, Davis JM, Matteson EL, Myasoedova E. Decline in Incidence of Extra-Articular Manifestations of Rheumatoid Arthritis: A Population-Based Cohort Study. Arthritis Care Res (Hoboken) 2024; 76:454-462. [PMID: 37691141 PMCID: PMC10924769 DOI: 10.1002/acr.25231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/07/2023] [Accepted: 09/05/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE The focus of this study was to assess changes in the cumulative incidence of extra-articular manifestations of rheumatoid arthritis (ExRAs) and associated mortality risk. METHODS This study evaluated trends in occurrence of ExRAs using a population-based inception cohort that included all adult patients with incident rheumatoid arthritis (RA) from 1985 through 2014 meeting the 1987 American College of Rheumatology criteria. Patients were divided into two cohorts based on the incidence date of RA, 1985 to 1999 and 2000 to 2014. The occurrence of ExRAs was determined by manual chart review, and the 10-year cumulative incidence was estimated for each ExRA in both cohorts. Cox proportional hazard models were used to determine associations between specific demographic and RA disease characteristics and ExRAs and between ExRAs and mortality. RESULTS There were 907 patients included, 296 in the 1985 to 1999 cohort and 611 in the 2000 to 2014 cohort. The 10-year cumulative incidence of any ExRA decreased significantly between the earlier and later cohorts (45.1% vs 31.6%, P < 0.001). This was largely driven by significant declines in subcutaneous rheumatoid nodules (30.9% vs 15.8%, P < 0.001) and nonsevere ExRAs (41.4% vs 28.8%, P = 0.001). Identified risk factors for the development of any ExRAs include rheumatoid factor positivity (hazard ratio [HR] 2.02, 95% confidence interval [CI] 1.43-2.86) and current smoking (HR 1.61, 95% CI 1.10-2.34). Mortality was increased in patients with either nonsevere (HR 1.83, 95% CI 1.18-2.85) or severe ExRAs (HR 3.05, 95% CI 1.44-6.49). CONCLUSIONS The incidence of ExRAs has decreased over time. Mortality remains increased in patients with ExRAs.
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Affiliation(s)
- Bradly A. Kimbrough
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Cynthia S. Crowson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Department of Quantitative Health Sciences Division of Clinical Trials and Biostatistics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - John M. Davis
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Eric L. Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Elena Myasoedova
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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Kronzer VL, Kimbrough BA, Crowson CS, Davis JM, Holmqvist M, Ernste FC. Incidence, Prevalence, and Mortality of Dermatomyositis: A Population-Based Cohort Study. Arthritis Care Res (Hoboken) 2023; 75:348-355. [PMID: 34549549 PMCID: PMC8934743 DOI: 10.1002/acr.24786] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/07/2021] [Accepted: 09/14/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We aimed to determine the population-based incidence, prevalence, and mortality of dermatomyositis (DM) using European Alliance of Associations for Rheumatology (EULAR)/American College of Rheumatology (ACR) criteria. METHODS This population-based cohort study included incident DM from January 1, 1995 to December 31, 2019. We manually reviewed all individuals with at least 1 code for DM or polymyositis to determine if they met EULAR/ACR criteria, subspecialty physician diagnosis, and/or Bohan and Peter criteria. We age- and sex-adjusted incidence and prevalence estimates to the US non-Hispanic White year 2000 population and estimated prevalence on January 1, 2015. Standardized mortality ratios (SMRs) with 95% confidence intervals (95% CIs) compared observed to expected mortality adjusting for age, sex, and year. RESULTS We identified 40 cases of verified DM, with 29 cases incident in Olmsted County from 1995 to 2019. The mean age was 57 years, 26 (90%) were female, and 12 (41%) had clinically amyopathic DM (CADM). The median follow-up time was 8.2 years. The overall adjusted incidence of DM was 1.1 (95% CI 0.7-1.5) per 100,000 person-years, and prevalence was 13 (95% CI 6-19) per 100,000. The SMR was significantly elevated among the myopathic DM cases (3.1 [95% CI 1.1-6.8]) but not CADM cases (1.1 [95% CI 0.2-3.3]). The positive predictive value of ≥2 DM codes was only 40 of 82 (49%). CONCLUSION This population-based study found that DM incidence and prevalence were higher than previously reported. Mortality was significantly elevated for myopathic DM but not for CADM.
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Affiliation(s)
| | | | - Cynthia S. Crowson
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - John M. Davis
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Marie Holmqvist
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Kimbrough BA, Naddaf E, Warrington KJ, Jimenez RE, Koster MJ. Granulomatosis with polyangiitis presenting as obstructive uropathy and vasculitic myopathy. Rheumatology (Oxford) 2022; 62:e136-e137. [PMID: 36053184 DOI: 10.1093/rheumatology/keac506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Rafael E Jimenez
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew J Koster
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
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Kimbrough BA, Warrington KJ, Langenfeld HE, Crowson CS, Carmona EM, Virata AR, Koster MJ. Vasculitis in Patients With Sarcoidosis: A Single-Institution Case Series of 17 Patients. J Clin Rheumatol 2022; 28:217-222. [PMID: 35319536 DOI: 10.1097/rhu.0000000000001839] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Vasculitis in patients with sarcoidosis is rare and can affect any sized blood vessel. Limited information describing this association is available. METHODS A single-institution medical records review study was performed reviewing all patients with a diagnosis code for sarcoidosis and vasculitis between January 1, 1998, and December 31, 2019. Data were abstracted regarding diagnosis, treatment, and outcomes from medical records. Patients were diagnosed with vasculitis based on biopsy and/or arterial imaging. Comparison between patients presenting with large and/or medium vessel vasculitis (L/MVV) versus patients with only small vessel vasculitis (SVV) was performed. RESULTS Seventeen patients were identified during the study period. Nine patients (56% female) had L/MVV, and 8 (50% female) had SVV. Sarcoidosis preceded vasculitis in 4 (44%) L/MVV and 3 (38%) SVV. The mean ± SD age at sarcoidosis diagnosis was 53.2 ± 17.8 and 51.9 ± 11.4 years, and the mean ± SD age at vasculitis diagnosis was 57.4 ± 19.6 and 59.0 ± 13.4 years in L/MVV and SVV, respectively. Number of organ systems involved by sarcoidosis was similar (median [interquartile range], 3 [1-4] L/MVV vs 2.5 [1.75-3.25] SVV). The mean length of follow-up was 11.5 ± 12.8 in L/MVV and 13.1 ± 14.3 years in SVV. Complete response to therapy for vasculitis was observed in 8 of 9 with L/MVV and 7 of 8 with SVV. Four patients with SVV were able to stop all immunosuppression as compared with only 1 patient with L/MVV at the last follow-up. CONCLUSIONS This series observed a comparable number of patients with L/MVV and SVV. Although a variety of treatments were used, most patients achieved remission regardless of vessel size affected. Clinicians should be aware of the overlap between sarcoidosis and vasculitis.
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Affiliation(s)
| | | | - Hannah E Langenfeld
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences
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Abstract
BACKGROUND/OBJECTIVE Giant cell arteritis (GCA) is a large-vessel vasculitis with systemic manifestations. A few case reports have described a possible association of GCA with interstitial lung disease (ILD). The primary aim of the present study was to describe the pattern, severity, and course of ILD in patients with GCA. METHODS This medical records review study evaluated adult patients presenting to Mayo Clinic in Rochester, MN, from January 1, 1997, through December 31, 2018, who had the diagnoses of GCA and ILD. Clinical, laboratory, and radiologic data were analyzed. RESULTS In total, 23 patients were in the study. Median (range) age was 78 (58-93) years, and 14 (61%) were women. Six patients (26%) had a cough at GCA diagnosis. At ILD diagnosis, 15 patients had respiratory symptoms, including dyspnea (n = 12, 52%), dry cough (n = 6, 26%), wheezing (n = 1, 4%), and chest pain (n = 1, 4%). On initial chest computed tomography, the most common pattern of ILD was probable usual interstitial pneumonia (n = 7, 30%), indeterminate for usual interstitial pneumonia (n = 5, 22%), and combined pulmonary fibrosis and emphysema (n = 3, 13%). Airway abnormalities were present in 10 patients: 6 with bronchial wall thickening, 2 with bronchiectasis, and 2 with both. At follow-up computed tomography, 8 patients had ILD progression. Three patients with cough improved after initiation of glucocorticoid therapy. CONCLUSIONS Interstitial lung disease and airway abnormalities may be associated with GCA. Although cough may improve, ILD in some patients with GCA may progress despite immunosuppressive therapy.
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Affiliation(s)
| | - Misbah Baqir
- Division of Pulmonary and Critical Care Medicine
| | | | - Amit Vasireddy
- Department of Internal Medicine, Berkshire Medical Center, Pittsfield, MA
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine
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Kimbrough BA, Voth ER, Szostek JH. 61-Year-Old Man With Back Pain, Hematuria, and Lower Extremity Edema. Mayo Clin Proc 2020; 95:801-806. [PMID: 32247353 DOI: 10.1016/j.mayocp.2019.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/02/2019] [Accepted: 09/06/2019] [Indexed: 10/24/2022]
Affiliation(s)
- Bradly A Kimbrough
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Elida R Voth
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Jason H Szostek
- Advisor to residents and Consultant in General Internal Medicine, Mayo Clinic, Rochester, MN.
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Culp WC, Kimbrough BA, Luna S, Maguddayao AJ, Eidson JL, Paolino DV. Use of the electrosurgical unit in a carbon dioxide atmosphere. J Med Eng Technol 2016; 40:29-34. [PMID: 26745650 DOI: 10.3109/03091902.2015.1126365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The electrosurgical unit (ESU) utilizes an electrical discharge to cut and coagulate tissue and is often held above the surgical site, causing a spark to form. The voltage at which the spark is created, termed the breakdown voltage, is governed by the surrounding gaseous environment. Surgeons are now utilizing the ESU laparoscopically with carbon dioxide insufflation, potentially altering ESU operating characteristics. This study examines the clinical implications of altering gas composition by measuring the spark gap distance as a marker of breakdown voltage and use of the ESU on a biologic model, both in room air and carbon dioxide. Paschen's Law predicted a 35% decrease in gap distance in carbon dioxide, while testing revealed an average drop of 37-47% as compared to air. However, surgical model testing revealed no perceivable clinical difference. Electrosurgery can be performed in carbon dioxide environments, although surgeons should be aware of potentially altered ESU performance.
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Affiliation(s)
- William C Culp
- a Department of Anesthesiology , Scott & White Hospital, The Texas A&M University System Health Science Center College of Medicine , Temple , TX , USA
| | - Bradly A Kimbrough
- a Department of Anesthesiology , Scott & White Hospital, The Texas A&M University System Health Science Center College of Medicine , Temple , TX , USA
| | - Sarah Luna
- a Department of Anesthesiology , Scott & White Hospital, The Texas A&M University System Health Science Center College of Medicine , Temple , TX , USA
| | - Aris J Maguddayao
- a Department of Anesthesiology , Scott & White Hospital, The Texas A&M University System Health Science Center College of Medicine , Temple , TX , USA
| | - Jack L Eidson
- b Department of Surgery , Scott & White Hospital, The Texas A&M University System Health Science Center College of Medicine , Temple , TX , USA
| | - David V Paolino
- a Department of Anesthesiology , Scott & White Hospital, The Texas A&M University System Health Science Center College of Medicine , Temple , TX , USA
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