Recurrence risk of venous thromboembolism associated with systemic lupus erythematosus: A retrospective cohort study

Background

Recurrence risk of systemic lupus erythematosus (SLE)-associated venous thromboembolism (VTE) is unclear.

Aim

To determine the recurrence risk of SLE-associated VTE overall and by presence of provoking factors and SLE flares.

Methods

A multicenter, retrospective cohort study was conducted among patients with first SLE-associated VTE who discontinued anticoagulation. SLE flares were defined as Systemic Lupus Erythematosus Disease Activity Index 2000 greater than 4. The primary outcome was recurrent VTE. Incidence rates and cumulative incidences were calculated by presence of provoking factors and antiphospholipid syndrome (APS) at index VTE. The hazard ratio (HR) for recurrence after SLE flare-associated index VTE was estimated with Cox regression, adjusted for provoking factor presence and APS.

Results

Eighty patients were included with 21 recurrent VTEs in median 8 years. For provoked index VTE, the recurrence rate in patients without APS was 1.1 per 100 person-years (PY; 95% confidence interval [CI], 0.1-3.1) and in the presence of APS 3.5 per 100 PY (95% CI, 0.9-8.9), yielding cumulative incidences of 7.5% (95% CI, 1.2%-21.7%) and 31.4% (95% CI, 6.3%-61.6%) respectively. For unprovoked index VTE, these analogous rates were 3.8 per 100 PY (95% CI, 1.2-9.0) and 16.7 per 100 PY (95% CI, 4.5-42.7), with cumulative incidences of 33.7% (95% CI, 10.7%-58.9%) and 54.2% (95% CI, 10.7%-84.5%), respectively. Forty-six index VTEs were flare associated, and the adjusted HR for recurrence was 0.4 (95% CI, 0.1-1.8) compared to those without flares at their index VTE.

Conclusion

Antiphospholipid syndrome is the main determinant for recurrence risk of SLE-associated VTE irrespective of presence of a provoking factor. Future research should attempt to confirm that flare-associated VTE has a lower recurrence risk.

The Development and Evaluation of Personalized Training in Shared Decision-making Skills for Rheumatologists

OBJECTIVE

Many factors influence a patient's preference in engaging in shared decision making (SDM). Several training programs have been developed for teaching SDM to physicians, but none of them focused on the patients' preferences. We developed an SDM training program for rheumatologists with a specific focus on patients' preferences and assessed its effects.

METHODS

A training program was developed, pilot tested, and given to 30 rheumatologists. Immediately after the training and 10 weeks later, rheumatologists were asked to complete a questionnaire to evaluate the training. Patients were asked before and after the training to complete a questionnaire on patient satisfaction.

RESULTS

Ten weeks after the training, 57% of the rheumatologists felt they were capable of estimating the need of patients to engage in SDM, 62% felt their communication skills had improved, and 33% reported they engaged more in SDM. Up to 268 patients were included. Overall, patient satisfaction was high, but there were no statistically significant differences in patient satisfaction before and after the training.

CONCLUSION

The training was received well by the participating rheumatologists. Even in a population of rheumatologists that communicates well, 62% reported improvement. The training program increased awareness about the principles of SDM in patients and physicians, and improved physicians' communicative skills, but did not lead to further improvement in patients' satisfaction, which was already high.

Rheumatoid arthritis is not associated with prior tonsillectomy or appendectomy

To re-evaluate a reported association of rheumatoid arthritis (RA) with antecendent tonsillectomy or appendectomy, questionnaires were sent by post to 3673 patients who had been diagnosed as having either RA or osteoarthrosis (OA). Of those who responded 1524 were RA and 1194 OA patients. No significant differences were found between these groups with regard to the frequency of prior lymphoid surgery. This was also the case when the RA group was replaced by its rheumatoid factor (Rf) positive or Rf negative subgroup. A separate analysis of a subgroup consisting of 671 Rf positive RA patients for whom OA control subjects matched for sex and year of birth were available again showed no statistical differences in frequencies of tonsillectomy and appendectomy. Neither did partitioning the group according to the age at which lymphoid surgery was performed bring any association with an increased occurrence of RA to light. We therefore reject the hypothesis that RA is associated with antecedent tonsillectomy or appendectomy.