Short- and Long-Term Mortality of Hospitalized Patients With Autoimmune Rheumatic Diseases and Serious Infections: A National Cohort Study

OBJECTIVE

Infectious conditions are a significant cause of mortality in autoimmune rheumatic diseases (ARD). Among patients hospitalized with an infection, we compared in-hospital and long-term (3-year) mortality between those with and without ARD.

METHODS

This retrospective analysis included members of the largest health maintenance organization in Israel, aged > 18 years at the first episode of infection, who required hospitalization during 2003-2019. We compared in-hospital mortality and the results of a 3-year landmark analysis of those who survived the index hospitalization between patients with ARD, according to disease subgroups, and patients without ARD. Additionally, we compared mortality outcomes among patients with ARD, according to subgroup diagnosis, matched in a 1:3 ratio by age, sex, and ethnicity to patients without ARD.

RESULTS

Included were 365,247 patients who were admitted for the first time with the diagnosis of a serious infection. Of these, we identified 9755 with rheumatoid arthritis (RA), 1351 with systemic lupus erythematosus, 2120 with spondyloarthritis (SpA), 584 with systemic sclerosis, and 3214 with vasculitis. In a matched multivariate analysis, the risk for in-hospital mortality was lower among patients with RA (odds ratio [OR] 0.89, 95% CI 0.81-0.97) and SpA (OR 0.77, 95% CI 0.63-0.94). In a similar analysis, the risk of 3-year mortality was lower among patients with RA (hazard ratio [HR] 0.82, 95% CI 0.78-0.86) and vasculitis (HR 0.86, 95% CI 0.80-0.93).

CONCLUSION

Among patients hospitalized for an infection, the risk of in-hospital and 3-year mortality was not increased among those with ARD compared to those without ARD.

Short- and long-term prognosis of acute critically ill patients with systemic rheumatic diseases: A retrospective multicentre study

Patients with systemic rheumatic disease (SRD) share the risks of multi-organ flare-up, cardiovascular diseases, and immunosuppression. Such situations can lead to an acute critical illness. The present study describes the clinical features of SRD patients admitted to the intensive care unit (ICU) and their short- and long- term mortality.We performed a multicentre retrospective study in 10 French ICU in Lyon, France. Inclusion criteria were SRD diagnosis and admission for an acute organ failure. The primary endpoint was ICU mortality.A total of 271 patients were included. SRD included systemic lupus erythematosus (23.2% of included patients), vasculitis (10.7%), systemic sclerosis (10.7%), idiopathic inflammatory myopathy (6.3%), and other connective tissue disorders (rheumatoid arthritis, Sjögren and Sharp syndromes; 50.9%). Initial organ failure(s) were shock (43.5% of included patients), acute kidney injury (30.5%), and acute respiratory failure (23.2%). The cause(s) of ICU admission included sepsis (61.6%), cardiovascular events (33.9%), SRD-flare up (32.8%), and decompensations related to comorbidities (28%). The ICU mortality reached 14.3%. The factors associated with ICU mortality were chronic cardiac failure, invasive ventilation and admission in ICU for another reason than sepsis or SRD flare-up. The median follow-up after ICU discharge was 33.6 months. During follow-up, 109 patients died. The factors associated with long-term mortality included age, Charlson comorbidity index, and ICU admission for sepsis or SRD flare-up.The ICU mortality of patients with SRD was low. Sepsis was the first cause of admission. Cardiovascular events and comorbidities negatively impacted ICU mortality. Admission for sepsis or SRD flare-up exerted a negative effect on the long-term outcome.

Factors associated with COVID-19-related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry

OBJECTIVES

To determine factors associated with COVID-19-related death in people with rheumatic diseases.

METHODS

Physician-reported registry of adults with rheumatic disease and confirmed or presumptive COVID-19 (from 24 March to 1 July 2020). The primary outcome was COVID-19-related death. Age, sex, smoking status, comorbidities, rheumatic disease diagnosis, disease activity and medications were included as covariates in multivariable logistic regression models. Analyses were further stratified according to rheumatic disease category.

RESULTS

Of 3729 patients (mean age 57 years, 68% female), 390 (10.5%) died. Independent factors associated with COVID-19-related death were age (66-75 years: OR 3.00, 95% CI 2.13 to 4.22; >75 years: 6.18, 4.47 to 8.53; both vs ≤65 years), male sex (1.46, 1.11 to 1.91), hypertension combined with cardiovascular disease (1.89, 1.31 to 2.73), chronic lung disease (1.68, 1.26 to 2.25) and prednisolone-equivalent dosage >10 mg/day (1.69, 1.18 to 2.41; vs no glucocorticoid intake). Moderate/high disease activity (vs remission/low disease activity) was associated with higher odds of death (1.87, 1.27 to 2.77). Rituximab (4.04, 2.32 to 7.03), sulfasalazine (3.60, 1.66 to 7.78), immunosuppressants (azathioprine, cyclophosphamide, ciclosporin, mycophenolate or tacrolimus: 2.22, 1.43 to 3.46) and not receiving any disease-modifying anti-rheumatic drug (DMARD) (2.11, 1.48 to 3.01) were associated with higher odds of death, compared with methotrexate monotherapy. Other synthetic/biological DMARDs were not associated with COVID-19-related death.

CONCLUSION

Among people with rheumatic disease, COVID-19-related death was associated with known general factors (older age, male sex and specific comorbidities) and disease-specific factors (disease activity and specific medications). The association with moderate/high disease activity highlights the importance of adequate disease control with DMARDs, preferably without increasing glucocorticoid dosages. Caution may be required with rituximab, sulfasalazine and some immunosuppressants.

Clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) and rheumatic disease: a comparative cohort study from a US 'hot spot'

OBJECTIVE

To investigate differences in manifestations and outcomes of coronavirus disease 2019 (COVID-19) infection between those with and without rheumatic disease.

METHODS

We conducted a comparative cohort study of patients with rheumatic disease and COVID-19 (confirmed by severe acute respiratory syndrome coronavirus 2 PCR), compared in a 1:2 ratio with matched comparators on age, sex and date of COVID-19 diagnosis, between 1 March and 8 April 2020, at Partners HealthCare System in the greater Boston, Massachusetts area. We examined differences in demographics, clinical features and outcomes of COVID-19 infection. The main outcomes were hospitalisation, intensive care admission, mechanical ventilation and mortality.

RESULTS

We identified 52 rheumatic disease patients with COVID-19 (mean age, 63 years; 69% female) and matched these to 104 non-rheumatic disease comparators. The majority (39, 75%) of patients with rheumatic disease were on immunosuppressive medications. Patients with and without rheumatic disease had similar symptoms and laboratory findings. A similar proportion of patients with and without rheumatic disease were hospitalised (23 (44%) vs 42 (40%)), p=0.50) but those with rheumatic disease required intensive care admission and mechanical ventilation more often (11 (48%) vs 7 (18%), multivariable OR 3.11 (95% CI 1.07 to 9.05)). Mortality was similar between the two groups (3 (6%) vs 4 (4%), p=0.69).

CONCLUSIONS

Patients with rheumatic disease and COVID-19 infection were more likely to require mechanical ventilation but had similar clinical features and hospitalisation rates as those without rheumatic disease. These findings have important implications for patients with rheumatic disease but require further validation.

Effects of hydroxychloroquine treatment on QT interval

Background

Hydroxychloroquine (HCQ) has been promoted as a potential treatment of coronavirus disease 2019 (COVID-19), but there are safety concerns.

Objective

The purpose of this study was to determine the effects of HCQ treatment on QT interval.

Methods

We retrospectively studied the electrocardiograms of 819 patients treated with HCQ for rheumatologic diseases from 2000 to 2020. The primary outcome was corrected QT (QTc) interval, by Bazett formula, during HCQ therapy.

Results

Mean patient age was 64.0 ± 10.9 years, and 734 patients (90%) were men. Median dosage of HCQ was 400 mg daily, and median (25th–75th percentile) duration of HCQ therapy was 1006 (471–2075) days. Mean on-treatment QTc was 430.9 ± 31.8 ms. In total, 55 patients (7%) had QTc 470–500 ms, and 12 (1.5%) had QTc >500 ms. Chronic kidney disease (CKD), history of atrial fibrillation (AF), and heart failure were independent risk factors for prolonged QTc. In a subset of 591 patients who also had a pretreatment electrocardiogram, mean QTc increased from 424.4 ± 29.7 ms to 432.0 ± 32.3 ms (P <.0001) during HCQ treatment. Of these patients, 23 (3.9%) had either prolongation of QTc >15% or on-treatment QTc >500 ms. Over median 5.97 (3.33–10.11) years of follow-up, 269 patients (33%) died. QTc >470 ms during HCQ treatment was associated with a greater mortality risk (hazard ratio 1.78; 95% confidence interval 1.16–2.71; P = .008) in univariable but not in multivariable analysis.

Conclusion

HCQ is associated with QT prolongation in a significant fraction of patients. The risk of QT prolongation is higher among patients with CKD, AF, and heart failure, who may benefit from greater scrutiny.

The impact of rheumatological disorders on lymphomas and myeloma: a report on risk and survival from the UK's population-based Haematological Malignancy Research Network

BACKGROUND

Autoimmune inflammatory disease increases the risk of diffuse large B-cell lymphoma (DLBCL) and marginal zone lymphoma (MZL), but findings for other mature B-cell malignancies are equivocal. Furthermore, it has been suggested that the increase in DLBCL is due to the activated B-cell (ABC) subtype; but data on this, and the impact of inflammatory co-morbidities on survival, are sparse and contradictory.

METHODS

Data are from an established UK population-based cohort. Patients (n = 6834) diagnosed between 01/2009 and 08/2015 are included; DLBCL (n = 1771), myeloma (n = 1760), chronic lymphocytic leukaemia (CLL, n = 1580), MZL (n = 936), and follicular lymphoma (FL, n = 787). Information on rheumatological disorders and deaths was obtained by record-linkage to nationally compiled Hospital Episode Statistics, with age-and sex-matched individuals (n = 68,340) from the same catchment population (˜4 million people) providing the comparator.

RESULTS

Significantly increased risks for DLBCL (OR = 2.3, 95% CI 1.8-2.8) and MZL (OR = 2.0, 95% CI 1.5-2.7) were found for those with rheumatological disorders; the site distribution of those with/without rheumatological conditions differing for DLBCL (p = 0.007) and MZL (p = 0.002). No increases in risk were observed for the remaining mature B-cell malignancies, and no associations with survival were detected for DLBCL (age-adjusted HR = 1.2, 95% CI 0.9-1.6) or MZL (age-adjusted HR = 1.0, 95% CI 0.6-1.9). Furthermore, whilst our findings provide evidence for an association with rheumatological disease severity for DLBCL, they offer little support for the notion that the association is driven by an increase in the incidence of the ABC subtype.

CONCLUSION

Our findings support the hypothesis that the chronic activation and proliferation of specific B-cell populations which characterize autoimmune disease increase the potential for the lymphomagenic events that lead to DLBCL and MZL in both males and females; but have no impact on the development of CLL, FL or MM, or on survival.

Mortality causes and outcomes in Indigenous populations of Canada, the United States, and Australia with rheumatic disease: A systematic review

BACKGROUND

Indigenous populations of Canada, America, Australia, and New Zealand have increased rates and severity of rheumatic disease. Our objective was to summarize mortality outcomes and explore disease and social factors related to mortality.

METHODS

A systematic search was performed in medical (Medline, EMBASE, and CINAHL), Indigenous and conference abstract databases (to June 2015) combining search terms for Indigenous populations and rheumatic diseases. Studies were included if they reported measures of mortality (crude frequency, mortality rate, survival, and potential years of life lost (PYLL)) in Indigenous populations from the four countries.

RESULTS

Of 5269 titles and abstracts identified, 504 underwent full-text review and 12 were included. No studies from New Zealand were found. In five Canadian studies of systemic lupus erythematosus (SLE) patients, First Nations ethnicity was associated with lower survival after adjusting for disease and social factors, and an increased frequency of death from lupus and its complications compared to Caucasians was found. All-cause mortality was higher in Native Americans (n = 2 studies) relative to Whites with SLE after adjusting for disease and social factors, but not in those with lupus nephritis alone. Australian Aborigines with SLE frequently developed infection and lupus complications leading to death (n = 3 studies). Mortality rates were increased in Pima Indians in the United States with rheumatoid arthritis (RA) compared to those without RA. One study in Native Americans with scleroderma found nearly all deaths were related to progressive disease.

CONCLUSIONS

Canadian and American Indigenous populations with SLE have increased mortality rates compared to Caucasian populations. Mortality in Canadian and Australian Indigenous populations with SLE, and in Native American populations with RA and scleroderma, is frequently attributed to disease progression or complications. The proportional attribution of rheumatic disease severity and social factors to mortality and complications leading to death between Indigenous and non-Indigenous populations has not been fully evaluated.

Multimorbidity in rheumatic conditions

In recent years, multimorbidity in rheumatic conditions has gained increasing attention. Rheumatologist care for an aging patient population with multiple diseases, therefore multimorbidity is the rule, not the exception. Owing to the high prevalence and the potential interaction of coexisting diseases, multimorbidity needs to be taken into account when treating patients with chronic inflammatory conditions. In this review we address the most prevalent comorbidities in patients with rheumatic conditions and their impact on important outcomes, such as physical function, quality of life, and mortality.

Autoimmune rheumatic diseases in the intensive care unit: experience from a tertiary referral hospital and review of the literature

Autoimmune rheumatic diseases (AIRD) are not uncommon in the general population and up to one third of hospitalized patients with AIRD may need admission to intensive care unit (ICU). This paper describes the causes of admission, the clinical features and outcome of 24 AIRD patients admitted to a medical ICU from a third level hospital. Thirteen patients had systemic lupus erythematosus (54.2%), three rheumatoid arthritis (12.5%), three pulmonary renal syndrome (12.5%), two dermatopolymyositis (8.3%), two scleroderma (8.3%) and one antiphospholipid syndrome (4.2%). The main causes for ICU admission were rheumatic disease flare-up (37.5%), infection (37.5%) and complications derived from rheumatic disease (29.1%). Mortality during ICU stay was 16.7% (four patients). Excluding shock requiring vasopressor support, no statistical difference was found between survivors and nonsurvivors; although there was a trend to higher test severity scores (APACHE II, ODIN) in nonsurvivors. Our results reveal a lower mortality rate in AIRD patients admitted to the ICU than reported previously. Severity scores such as APACHE II are predictors of mortality in patients with AIRD in the ICU.

Causes of mortality due to rheumatic diseases in Jerez de los Caballeros (Badajoz) during the 19th century

A total of 26,203 of the deaths in Jerez de los Caballeros (Badajoz) during the 19th century were collected and grouped according to the Bertillon's Classification, in order to study the causes of death from rheumatic diseases. An analysis was made using the Death Registers, those located in the Parish Archives, and files of the Municipal Archives. There were a total of 31 deaths due to rheumatic diseases, with the 65-74 years age group being most frequent. The lack of records may be due to the inaccuracy of the diagnoses. September was the month of increased mortality.

Outcomes and Prognostic Factors in Patients with Rheumatologic Diseases Admitted to the ICU

OBJECTIVE

To assess the outcomes in a large cohort of patients suffering from rheumatic diseases admitted to the ICU of a tertiary university medical center.

METHODS

A retrospective chart analysis was performed in 108 patients suffering from various rheumatic diseases and the outcomes, including morbidity and mortality, were assessed in relation to the underlying diseases, treatments and complications.

RESULTS

Overall, 48 patients with rheumatoid arthritis, five patients with spondyloarthritis, 14 patients with vasculitis, 30 patients with connective tissue diseases and 11 patients suffering from other rheumatologic conditions were admitted to the intensive care unit (ICU). The reasons for ICU admission included infection (30%), cardiovascular complications (22%), gastrointestinal problems (18%), endocrinological disorders (7%), neurological complications (2%) and others (3%). A total of 4% of the admitted patients required close monitoring and 14% suffered from acute exacerbation of the underlying rheumatic disease. The ICU mortality rate was 16%, whereas the overall hospital mortality rate was 20%. Fatal outcomes were related to exacerbation of the rheumatic disease in 14% of the patients, infectious complications in 46% of the patients and other reasons in 41% of the patients. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality.

CONCLUSION

The overall outcomes of critically ill patients with rheumatic diseases are impaired compared to that observed in other patient groups. However, there were no significant differences in outcomes between the different rheumatic disease groups or based on the use of immunosuppressive therapy in this study. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality.

Adalimumab: long-term safety in 23 458 patients from global clinical trials in rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, psoriatic arthritis, psoriasis and Crohn's disease

BACKGROUND

As long-term treatment with antitumour necrosis factor (TNF) drugs becomes accepted practice, the risk assessment requires an understanding of anti-TNF long-term safety. Registry safety data in rheumatoid arthritis (RA) are available, but these patients may not be monitored as closely as patients in a clinical trial. Cross-indication safety reviews of available anti-TNF agents are limited.

OBJECTIVE

To analyse the long-term safety of adalimumab treatment.

METHODS

This analysis included 23 458 patients exposed to adalimumab in 71 global clinical trials in RA, juvenile idiopathic arthritis, ankylosing spondylitis (AS), psoriatic arthritis, psoriasis (Ps) and Crohn's disease (CD). Events per 100 patient-years were calculated using events reported after the first dose through 70 days after the last dose. Standardised incidence rates for malignancies were calculated using a National Cancer Institute database. Standardised death rates were calculated using WHO data.

RESULTS

The most frequently reported serious adverse events across indications were infections with greatest incidence in RA and CD trials. Overall malignancy rates for adalimumab-treated patients were as expected for the general population; the incidence of lymphoma was increased in patients with RA, but within the range expected in RA without anti-TNF therapy; non-melanoma skin cancer incidence was raised in RA, Ps and CD. In all indications, death rates were lower than, or equivalent to, those expected in the general population.

CONCLUSIONS

Analysis of adverse events of interest through nearly 12 years of adalimumab exposure in clinical trials across indications demonstrated individual differences in rates by disease populations, no new safety signals and a safety profile consistent with known information about the anti-TNF class.

Prognostic contributions of the underlying inflammatory disease and acute organ dysfunction in critically ill patients with systemic rheumatic diseases

BACKGROUND

Knowledge about the clinical features, outcomes and predictors of short-term mortality in critically ill patients with systemic rheumatic disease (SRD) requires further characterization.

METHODS

Single center retrospective observational cohort study of 149 critically ill patients with SRD followed in a French medical intensive care unit over a 20-year period. Multivariate logistic regression was used to identify predictors of day-30 mortality.

RESULTS

Most patients (63%) had systemic lupus erythematosus, rheumatoid arthritis, or systemic sclerosis. The critical illness usually developed late after the diagnosis of SRD (median time to ICU admission 82 months, IQR [9-175] in the 127 patients with a previous diagnosis of SRD). Two-thirds of patients were taking immunosuppressive drugs to treat their SRD. Reasons for ICU admission were infection (47%), SRD exacerbation (48%), and iatrogenic complications (11%); the most common organ failure was acute renal failure. Thirty-day mortality was 16%. Predictors of 30-day mortality were the LODS score on day 1 (OR 1.3 (1.06-1.48)), bacterial pneumonia (OR 3.8 (1.03-14.25)), need for vasoactive drugs (OR 7.1 (1.83-27.68)), SRD exacerbation (OR 4.3 (1.15-16.53)), and dermatomyositis (OR 9.2 (1.05-80.78)) as the underlying disease. Year of ICU admission was not significantly associated with 30-day survival.

CONCLUSION

Patients with SRD are mostly admitted in the ICU with infection or SRD exacerbation, and can be treated with immunosuppressive therapy and life-sustaining interventions with acceptable 30-day mortality. Death is associated with both the severity of the acute medical condition and the characteristics of the underlying SRD.

The incidence of macrophage activation syndrome in children with rheumatic disorders

AIM

Macrophage activation syndrome (MAS) is a rare complication of childhood with rheumatic disease. This syndrome has been reported as a complication of many rheumatic diseases, most commonly in systemic onset of juvenile idiopathic arthritis (SoJIA). The aim of this study was evaluation the rate, symptoms and outcome of MAS in a pediatric rheumatology department in Tehran during 10 years.

METHODS

Retrospective review of cases of MAS from the charts of 120 patients with juvenile idiopathic arthritis and systemic lupus erythematosus (SLE). Collected data base of 5 children with MAS from 1998 to 2007, in Children Hospital Medical Center, In Tehran University were collected.

RESULTS

Totally 120 patients evaluated in this study including 108 JIA and 12 SLE. Five patients (four girls), and (one boy) were considered to have evidence of MAS. The incidence of MAS in our study was 4.2%. This rate for all JIA patients was 3.7% and for SoJIA, SLE and juvenile idiopaticarthritis (JIA) and polyarticular RF negative JIA was 8.2%, 16.7% and 2.8%, respectively. Mean age of MAS onset was 4.9 years, and duration of rheumatologic disease prior to MAS, 22 months. Four cases (80%) had abnormal liver function during the disease course, and coagulopathy. Bone marrow examination supported the diagnosis with definite haemophagocytosis in four cases (80%). The mortality rate was 40%.

CONCLUSION

Although MAS is a rare complication of rheumatologic disorders, because it is potentially fatal it must be thought in each childhood rheumatic disorders with suddenly changes in general condition and decrease peripheral cells.

Epidemiological studies in incidence, prevalence, mortality, and comorbidity of the rheumatic diseases

Epidemiology is the study of the distribution and determinants of disease in human populations. Over the past decade there has been considerable progress in our understanding of the fundamental descriptive epidemiology (levels of disease frequency: incidence and prevalence, comorbidity, mortality, trends over time, geographic distributions, and clinical characteristics) of the rheumatic diseases. This progress is reviewed for the following major rheumatic diseases: rheumatoid arthritis (RA), juvenile rheumatoid arthritis, psoriatic arthritis, osteoarthritis, systemic lupus erythematosus, giant cell arteritis, polymyalgia rheumatica, gout, Sjögren's syndrome, and ankylosing spondylitis. These findings demonstrate the dynamic nature of the incidence and prevalence of these conditions--a reflection of the impact of genetic and environmental factors. The past decade has also brought new insights regarding the comorbidity associated with rheumatic diseases. Strong evidence now shows that persons with RA are at a high risk for developing several comorbid disorders, that these conditions may have atypical features and thus may be difficult to diagnose, and that persons with RA experience poorer outcomes after comorbidity compared with the general population. Taken together, these findings underscore the complexity of the rheumatic diseases and highlight the key role of epidemiological research in understanding these intriguing conditions.

Poor physical fitness and performance as predictors of mortality in normal populations and patients with rheumatic and other diseases

Poor physical function and low muscle strength are significant predictors of mortality in rheumatoid arthritis, other chronic diseases, ageing individuals, and the general population. Poor physical function predicts earlier mortality in diseased and normal populations at levels of significance similar to or greater than most known biomedical predictors such as laboratory tests. This chapter summarizes data concerning the prediction of premature mortality by poor physical fitness and musculoskeletal function, according to performance and self-report measures. The data support recommendations for regular exercise in all individuals whether or not they have a disease, to promote health and longevity.

Palliative care in rheumatic diseases: a first approach

Currently, the main goal in rheumatic research is to achieve remission, even in highly active stages of the disease. However, there is a lack of understanding of how to manage patients when some rheumatic diseases such as vasculitis, connective tissue disease, or rheumatoid arthritis develop fulminant, progressive, and complicated courses. There is a clear role for palliative care to enhance patients' quality of life, but hardly any data exist regarding the prevalence and management of symptoms, and the special needs of these patients and their relatives. Rheumatologists, and palliative and primary care physicians should become more aware of this patient group so as to offer them the care they need. Further research is necessary in this field.

Natural history and therapy of 66 patients with mixed cryoglobulinemia

Cryoglobulinemia, a relatively uncommon disorder, is classified into types I, II, and III, with type II consisting of a monoclonal immunoglobulin possessing activity toward a polyclonal component. Many disease associations and therapies have been described but clinical trials are few, and the natural history, causes, therapy, and pathways of cryoglobulinemia require further investigation. Here, we describe the symptoms, comorbidities, treatments, and response of 66 patients with type II cryoglobulinemia by examining the records of all patients evaluated at Mayo Clinic, Rochester, Minnesota, between 3/2/1994 and 11/27/2000, using our prospective dysproteinemia database. Symptoms varied greatly among patients and during the disease course. Most common were purpura (55% of patients), renal disease (26%), edema (24%), neuropathy (18%), and arthralgia (21%). Renal disease required the most aggressive intervention. Laboratory findings did not correlate with disease manifestations or severity. Only age was a significant predictor of mortality. Ten patients had cryoglobulinemia without an identified comorbidity. Thirty-three patients had viral hepatitis alone, 6 had a lymphoproliferative disorder alone, and 5 had a rheumatologic disease alone. Ten patients had a combination of disorders, such that hepatitis C was identified in a total of 40 patients, lymphoproliferative disorders in 16, and rheumatologic disease in 8. Twenty-two different treatments were administered. Corticosteroids were the most common treatment, followed by interferon with or without ribavirin. Type II cryoglobulinemia is a nonfatal disease most frequently associated with hepatitis C. Treatment is generally directed at the underlying condition. Not all patients require treatment, and many can be followed and treated symptomatically.

[Accelerated atherosclerosis in rheumatic systemic diseases as an example of systemic lupus erythematosus--what is the consequence?]

Large increases in mortality related to premature atherosclerosis with coronary artery disease and stroke have been reported during the last few years in patients with systemic lupus erythematosus (SLE). Studies found relative risks of 5 to 7 for myocardial infarction in SLE patients. The traditional risk factors fail to fully account for accelerated atherosclerosis in SLE and APS, in addition prolonged glucocorticoid therapy and long duration of SLE seem to be of importance. The disease SLE per se is an independent risk factor. The current pathogenic hypothesis for atherosclerosis involves an inflammatory response, autoantibodies, immune complexes (containing antibodies to phospholipids, to oxidized LDLs, and to endothelial cells), CD40/CD40 ligand interactions, and bacterial or viral infections responsible for an immune response. The determination of classic and new risk factors, together with specific autoantibody titers and the use of Doppler carotid ultrasound, are useful methods to detect early atherosclerosis. Therapeutic strategies, including early risk factor intervention and effective control of inflammation, are essential to reduce morbidity and mortality and should be incorporated into the management of connective tissue disease with the goal of protecting patients against atherosclerosis.

2nd conference on heart, rheumatism and autoimmunity, Pescara, Italy, May 19-20, 2005

Systemic autoimmune diseases, which comprise a family of conditions which share common pathogenetic mechanisms, are frequently associated to cardiac involvement and to a high prevalence of ischemic coronary events often occurring at a younger age than in normal population. A large increase in mortality is related to premature atherosclerosis with coronary artery disease and stroke in patients with connective tissue diseases. Coronary heart disease is responsible for 40-50% of the death of patients with rheumatoid arthritis. Moreover, a growing body of evidence supports the view that autoimmune mechanisms are involved in the pathogenesis of cardiovascular disease. Inflammatory heart disease is a rising concern worldwide. Similar mechanisms link autoimmune diseases, including the association of increased disease with proinflammatory cytokines and the importance of regulatory mechanisms in the control of chronic inflammation. The role of the immune system in modulating atherosclerosis has recently been well documented. Studies have revealed that cellular and humoral immunity plays crucial roles in atherogenic plaque formation. This includes macrophages, CD4+ T cells and dendritic cells as well as autoantigens such as oxidized low-density lipoprotein (oxLDL), heat shock proteins and beta2-glycoprotein I. The inflammatory component is not localized to the "culprit" plaque, but it is diffused to the entire coronary vascular bed, and involves also the myocardium. The aim of the conference (2nd conference on heart, rheumatism and autoimmunity) was to focus the attention of the participants on some pathogenetic, clinical and therapeutic aspects at the boundary between cardiology and rheumatology and to encourage the debate among clinicians and basic researchers with different backgrounds and experiences.

Prognosis of patients with systemic rheumatic diseases admitted to the intensive care unit

OBJECTIVE

To determine prognostic factors in patients with systemic rheumatic diseases admitted to the intensive care unit (ICU) and to examine whether the observed mortality rate is predicted using the Acute Physiology And Chronic Health Assessment II (APACHE II) score.

DESIGN AND SETTING

Retrospective study with historical controls in a 31-bed medicosurgical ICU at a university hospital.

PATIENTS AND PARTICIPANTS

Seventy-one patients admitted to the ICU for an acute illness related to a systemic rheumatic disease and/or its treatment and 353 ICU control patients.

RESULTS

Systemic rheumatic diseases were mainly rheumatoid arthritis and vasculitides. In-hospital mortality rate was 28/71 (39%), including 23 patients who died in the ICU. Multivariable logistic regression showed that poor prior health status (Berdit's classification), APACHE II score, and admission for infection were associated with mortality, whereas prior use of immunosuppressive agents was not. APACHE II score at admission was higher in nonsurvivors (22+/-9) than in survivors (17+/-5) (p<0.01). The standard mortality ratio, i.e., the ratio between observed and predicted mortality, was 1.7 in the 71 study patients and 1.0 in the 353 control patients (p<0.0001).

CONCLUSIONS

In patients with systemic rheumatic diseases admitted to the ICU for at least 48 h, poor prior chronic health status, APACHE II score, and infection were prognostic factors for in-hospital mortality. SMR was higher than in a control ICU population.

[The causes of death of patients with rheumatic diseases in Moscow]

The study was held in order to analyze the main causes of death in cases of rheumatic diseases (RD) in Moscow. The authors studied the pathology records of autopsies performed in 1999-2002 in two pathology departments of Moscow clinics. Cases with RD were selected. The study found 165 cases of RD, which constituted 2% of all autopsies performed in these departments. There were 99 cases (60%) of rheumatic heart disease (RHD), 4 cases (2.4%) of rheumatic fever (RF) relapse, 28 cases (17%) of rheumatoid arthritis (RA), 8 cases (4.8%) of systemic lupus erythematosus (SLE), 3 cases (1.8%) of scleroderma systematica (SS), 2 cases (1.2%) of ankylosing spondylitis (AS), 2 cases (1.2%) of systemic vasculitis (SPV), 11 cases (7.3%) of osteoarthrosis, 3 cases (1.8%) of gout, 1 case (0.6%) of polymyositis. The death of patients with RHD had been caused by hemodynamic decompensation (HD) in 54% of the cases, acute cardiovascular collapse (ACC) in 14% of the cases, 6% of the patients had died from thromboembolism (TE) and 26%--from other conditions (intoxication, uremia, brain and lung edema etc). The death of patients with RF was caused by TE in 2 cases, by HD in 1 case and by ACC in 1 case. Secondary amyloidosis resulting in chronic renal failure and uremia occurred in 5 out of 28 cases of RA, HD--in 3, ACC--in 7, TE--in 1, infectious complications--in 5, other complications--in 7 cases. Patients with SLE died from various conditions: uremia in 2 cases, acute adrenal failure in 1 case, infectious complications in 2, ACC--in 2, brain edema--in 1 case. The complications of SS were uremia and intoxication. ACC was the cause of death in cases of gout and SS. The majority of RD cases were patients with RHD. The main cause of death in RD was cardiovascular disorders.

Deaths from arthritis and other rheumatic conditions, United States, 1979-1998

OBJECTIVE

To analyze US trends in deaths from arthritis and other rheumatic conditions (AORC).

METHODS

Multiple cause of death tapes from the National Center for Health Statistics from 1979 to 1998 were reviewed. Age, sex, and race-specific death rates were calculated.

RESULTS

During 1979-1998, the annual number of AORC deaths rose from 5537 to 9367. In 1979, the crude death rate from AORC was 2.46 per 100,000 population; by 1998, it was 3.48. Rates age-standardized to the year 2000 population were 2.75 and 3.51, respectively. Annual crude and age-standardized death rates were higher among women than men and higher among blacks than whites and increased for all groups over the 20 years. Death rates were dramatically higher with increasing age. Three categories of AORC accounted for almost 80% of deaths: diffuse connective tissue diseases (34%), other specified rheumatic conditions (23%), and rheumatoid arthritis (22%).

CONCLUSION

There are marked age, sex, and race-specific disparities in AORC death rates. AORC death rates may be underestimated because of (1) nonrecognition of inflammatory arthritis and (2) attribution of cause of death to conditions made more likely by arthritis, e.g., cardiovascular disease, or to complications from arthritis therapy. Further research into the causes of the disparities in death rates and the increase in death rates for men, women, blacks, and whites is necessary.

The contribution of underlying systemic rheumatic diseases to the mortality in patients admitted for intensive care: a matched cohort study

OBJECTIVE

The aim of this study was to determine the outcome of patients with systemic rheumatic diseases admitted to our medical-intensive care unit (ICU) in comparison to the outcome of patients with non-rheumatic diseases in the same ICU.

METHODS

The hospital files of 50 patients with systemic rheumatic diseases who were treated in the medical-ICU of Hacettepe University Hospital, Ankara between 1995 and 2001 were retrospectively evaluated. 50 patients without any underlying systemic rheumatic diseases admitted to the medical-ICU in the same time period and matched for age, gender and acute physiology and chronic health evaluation scores were included in the control group. ICU outcome was compared between the two groups.

RESULTS

The acute physiology score of the study group was lower than that of the control group (13.4 +/- 5.7 [SD] vs. 17.3 +/- 7.2, p = 0.04). Moreover, the study group received more immunosuppressive treatment but less invasive procedures (i.e. mechanical ventilation and central venous catheterization). Mortality rates (56% vs. 54%, respectively, p = 0.5), lengths of stay in the ICU and in the hospital, the infection rates were similar between the rheumatic disease group and the control group.

CONCLUSION

The presence of a systemic rheumatic disease seems to negatively affect the outcome in patients under intensive care.

Mortality in rheumatoid disease

This paper provides an overview of rheumatoid disease from the perspective of its impact on mortality. The term, rheumatoid arthritis, may promote the misconception that this disease is relatively trivial and easily managed; therefore, "rheumatoid disease" is preferred. Numerous long-term studies in many settings have established that significant excess mortality is associated with rheumatoid disease, and that this excess mortality is related to cardiovascular disease deaths. Inflammation in rheumatoid and cardiovascular diseases shares the same biologic mechanisms. Severity of extraarticular disease, decline in functional level, and level of inflammatory activity are associated with increased risk of mortality. Detection and measurement of novel inflammatory biomarkers may provide tools to assess prognosis and to monitor therapy. Close attention to the management of traditional cardiovascular risk factors is essential in these patients. Whether disease modifying antirheumatic drug (DMARD) therapy will reduce all-cause and cardiovascular disease mortality in rheumatoid disease is the subject of ongoing studies.

[Russian society and patients with rheumatic diseases]

The morbidity, primary morbidity, temporary incapacity for work and disablement due to rheumatoid diseases registered among Russia's population in the recent 3 years are described on the basis of an analysis of Russian statistics. Issues related with mortality, caused by rheumatic diseases, the related expenses and influence on patients' life quality are under discussion. A conclusion is made on a high social-and-medical importance of the above category of diseases as viewed from the standpoint of society (state), patient and his or her family.

[Analysis of lethal outcomes of rheumatic diseases in Moscow]

AIM

To study the pattern of lethal outcomes due to rheumatic diseases (RD) in Moscow.

MATERIAL AND METHODS

Annual reports of 38 pathological departments of Moscow have been analysed for 1999 and 2000.

RESULTS

RD accounted for 1.8% diagnosis at autopsies (n = 784). RD as the main diagnosis was in 668 cases (1.53%). Diseases of the bone-muscle system caused death 3.5 times less often than rheumatism. As concommitent diseases RD were encountered in 118 cases (0.27%), diseases of the bone-muscle system were registered 2 times less frequently than rheumatism. Chronic rheumatic diseases of the heart were diagnosed in 590 cases (98.5%), rheumatic fever was detected in 9 (1.5%) patients. The main diagnosis of RA, seronegative arthritides, systemic vasculitides, SLE, osteoarthrosis was made in 49, 10 9.3, 12.7, 1.3%, respectively. Such nosological entities as osteoporosis, gout and other microcrystalline arthritides were referred to the group "other rheumatic diseases" and made up 12.7%. As concomitant pathology RA, OA, seronegative spondyloarthritides, SLE, other RD occurred in 54, 8.1, 27, 2.7, 2.7%, respectively.

CONCLUSION

The share of RD in autopsy diagnosis accounts for 1.8% of the total number of necropsies. These figures seem to underestimate the real situation and may be explained by poor registration of RD at autopsy and a fall in the total number of autopsies for the last 10 years. For Moscow and Russia as a whole there is a prevalence of rheumatism mortality (76%), primarily deaths of chronic rheumatic cardiac diseases, over mortality due to diseases of the bone-muscular system (24%).

Pulmonary alveolar hemorrhage in patients with rheumatic diseases in Korea

Pulmonary alveolar hemorrhage (PAH) is a rare and often fatal presenting feature of rheumatic diseases, with high mortality rate ranging from 40% to 90%. This study was undertaken to review the clinical manifestations, disease course, prognosis, and treatment of PAH in rheumatic diseases in Korea. A retrospective analysis was performed from October 1995 to March 1999 at the Samsung Medical Center. Ten cases were diagnosed as having pulmonary hemorrhage with rheumatic diseases that comprised the following: 6 systemic lupus erythematosus (SLE), 3 microscopic polyangiitis (MPA), and 1 mixed connective tissue disease (MCTD). In 80% of the patients in the present series, PAH was the first clinical manifestation of rheumatic diseases. The most consistent systemic manifestation occurring in conjunction with PAH was renal involvement (80%). The overall patient mortality rate was 50% (5/10) in the current series. Our study suggests that PAH often occurs as the first clinical manifestation of rheumatic diseases and needs urgent medical treatment including plasmapheresis in addition to cyclophosphamide and methylprednisolone.

How important is patient education?

The prevalence and disability rate of rheumatic diseases are increasing. It seems that non-medical causes play an important role in the morbidity, disability and mortality of these patients. Efforts to reduce their impact are extremely important. Patient education is thought to be one way to limit disability in rheumatic diseases and to achieve an improvement in quality of life. In this chapter, we review the influence of non-medical causes of morbidity on disease outcome, some basic aspects of education and the evidence of the effectiveness of patient education in diseases such as ankylosing spondylitis, systemic lupus erythematosus, rheumatoid arthritis and fibromyalgia syndrome.

[Outcome of patients with systemic rheumatic diseases admitted to intensive care units: a retrospective study of 39 cases]

PURPOSE

Patients with systemic rheumatic diseases are rarely admitted in intensive care units and very few studies focusing on the prognosis of those patients have been published.

METHODS

Retrospective study over seven years in two intensive care units.

RESULTS

Among 33 patients with systemic disease diagnosed 90 +/- 133 months before admission in the intensive care unit, who were aged 50 +/- 21 years and represented a total of 39 stays in the intensive care unit, the main cause of admission was acute respiratory failure (33%). Mean simplified acute physiology score (SAPS II) was 47 +/- 22. Two-thirds of the patients were under mechanical ventilation. Infection was diagnosed in 33% of the cases and exacerbation of the systemic rheumatic disease in 26%. Nosocomial infection was found in 19 patients (49%). Ten patients died during their stay in the intensive care unit, six from infection, three from an exacerbation of the systemic rheumatic disease, one from an unidentified cause.

CONCLUSION

Even if severity scores of patients suffering from systemic diseases are higher at admission in intensive care units than those of other patients, there is no relevant reason to refuse critical care to these patients.

Risk of developing certain malignancies is related to duration of immunosuppressive drug exposure in patients with rheumatic diseases

OBJECTIVE

To investigate the relationship between the cumulative duration of exposure to immunosuppressive drugs and the risk of developing and/or dying from malignancy in patients with rheumatic diseases attending rheumatology practices throughout Europe.

METHODS

Patients with rheumatic diseases who first started an immunosuppressive drug between 1979 and 1990 were studied. They were followed annually for up to 10 years through their rheumatologists. Information was collected on vital status, the development of malignancy, and starting and stopping dates of immunosuppressive drugs. Person-years of observation were attributed to one of 4 groups according to the cumulative duration of exposure to immunosuppressives. Age and sex adjusted incidence rate ratios (IRR) were calculated by comparing each of the higher 3 groups with the baseline exposure category.

RESULTS

In total 1773 patients, from 15 countries, contributed 12,266 person-years of followup. The principal drugs used were azathioprine, methotrexate, cyclophosphamide, and chlorambucil. Patients in the highest cumulative exposure group had an IRR of 3.74 (95% CI 1.48-9.47) of developing a neoplasm of the immune system or skin or bladder cancer compared to those in the lowest category. A similar pattern was seen when the analysis was confined to patients who took only azathioprine. The risk estimates were unchanged after adjustment for disease duration since first treatment.

CONCLUSION

In addition to any increased risk of malignancy that may be conferred by individual rheumatic diseases, there is a further risk of specific types of malignancy that is related to the duration of exposure to immunosuppressive drugs.

Preliminary core set of domains and reporting requirements for longitudinal observational studies in rheumatology

Observational and longitudinal observational studies (LOS) provide essential information about the course and outcome of rheumatic disorders that cannot be provided by randomized controlled trials, and they constitute the major clinical scientific communication in rheumatology. There has been no consensus as to the full and appropriate content of LOS. This report defines a core set of domains and reporting requirements for LOS. At the 1998 OMERACT IV Conference a consensus process evaluated the literature of rheumatology in light of the constructs, variables, and outcomes of rheumatology by using introductory lectures, nominal groups, and plenary sessions. The result of this process was to identify 5 "core" domains that should be included in every LOS: Health Status, Disease Process, Damage, Mortality, and Toxicity/Adverse Reactions. Two additional domains, Work Disability and Costs, were recognized as important, but need not be used in all LOS. Eleven subdomains were identified that divided the domains into convenient clinical and conceptual units. A set of reporting requirements was also determined. The core recommendations, which follow on the WHO ICIDH-2 outline, are not disease-specific; the substitution of different "disease process" and "damage" measures make them suitable for many rheumatic disorders. The core set is intended to serve as a core for LOS in almost all rheumatic conditions.

Update in the epidemiology of the rheumatic diseases

The epidemiology of early synovitis syndromes in the community remains of interest. Attempts to identify those cases likely to progress to erosive rheumatoid arthritis have yielded some prognostic features that may be clinically applicable. The incidence of juvenile rheumatoid arthritis appears to fluctuate in a cyclic pattern, suggesting microbial or other environmental factors contributing to its occurrence. In the United States, the frequency of scleroderma varies among racial groups with rising rates noted especially among African-American women. A very high prevalence of scleroderma among Oklahoma Choctaws is providing an opportunity to study interactions of environmental and genetic risk factors. Excess weight in middle-aged women and possibly low intake of antioxidants contribute to the progression of established osteoarthritis of the knee.

Early undifferentiated connective tissue disease. V. An inception cohort 5 years later: disease remissions and changes in diagnoses in well established and undifferentiated connective tissue diseases

OBJECTIVE

To review the diagnoses after 5 years in patients who were identified within 12 months of the onset of well established and undifferentiated connective tissue diseases (CTD); to examine death rates and disease remissions in these patients.

METHODS

This inception cohort of 410 patients was identified in 10 academic rheumatology practices. They had less than one year of signs and/or symptoms of CTD. Diagnoses of specific well established CTD were made using accepted diagnostic and classification criteria. The diagnoses after 5 years were determined.

RESULTS

Patients with well established CTD tended to remain with the original diagnosis. The progression of unexplained polyarthritis to rheumatoid arthritis occurred infrequently. Ten percent of patients with isolated Raynaud's phenomenon progressed to systemic sclerosis (SSc). The 5 year survival was over 90% in all diagnostic categories, with the exception of SSc, in which it was 64%.

CONCLUSION

Patients with a well established CTD usually continued with the same diagnosis. Patients with undifferentiated CTD tended to remain undifferentiated or to remit.

Short and longterm outcomes for patients with systemic rheumatic diseases admitted to intensive care units: a prognostic study of 181 patients

OBJECTIVE

To determine short and longterm outcomes and prognostic factors for patients with systemic rheumatic diseases admitted to intensive care units in 4 teaching hospitals.

METHODS

All adult intensive care unit admissions over a 12 year period for systemic rheumatic diseases were retrospectively assessed. One hundred and eighty-one patients with a mean age of 57 +/- 17 years were studied.

RESULTS

The death rate in intensive care units was 33% (59/181) and in-hospital mortality was 43% (77/181). One hundred and four patients were discharged alive from hospital; 40 died during followup (mean 105 +/- 7 mo). The estimated 5 year survival rate for the discharged patients was 69%. The 4 factors significantly associated with in-hospital mortality by multivariate analysis were simplified acute physiologic score (p = 10(-4)), poor prior health status (p = 10(-4)), corticosteroid administration (p = 0.005), and the reason for admission; mortality was higher in the group admitted to intensive care for infectious complication (55 versus 34% for others; p = 0.006). In contrast, in-hospital mortality was not influenced by age or by systemic rheumatic diseases. Using Cox's model, only age over 60 years was a prognostic factor significantly associated with an increase in longterm mortality (p = 10(-4)).

CONCLUSION

The short term outcome for patients with systemic rheumatic diseases in intensive care units was poor. The longterm prognosis after hospital discharge appeared fair, although the standardized mortality ratio was 5-fold that of a nonselected population. Short and longterm prognoses were similar for different systemic rheumatic disease groups.

Hematopoietic stem cell transplantation in rheumatic diseases other than systemic sclerosis and systemic lupus erythematosus

Hematopoietic stem cells (HSC) are increasingly available as an alternative to whole marrow aspirate for bone marrow transplantation (BMT). They may be derived from an HLA matched individual (allogeneic) or from the patient (autologous). Allogeneic BMT is associated with a 15 to 35% mortality, largely due to graft versus host disease. Autologous HSC are used to rescue the patient after severe immunosuppression, and the transplant related mortality is 3 to 5%. The opportunity to ablate severe autoimmune disease with increased safety is particularly attractive for necrotizing vasculitides, polymyositis/dermatomyositis, primary Sjögren's syndrome, systemic juvenile arthritis, relapsing polychondritis, and Behçet's disease, where correct selection of cases would ensure an acceptable benefit/risk ratio. Rheumatoid arthritis (RA), psoriasis associated arthritis (PsA) and some non-rheumatic diseases such as inflammatory bowel disease (IBD), multiple sclerosis, and type 1 diabetes mellitus may also be candidates, but careful selection of patients with a poor prognosis is necessary. There are allogeneic BMT data from patients with aplastic anemia or leukemia and concurrent RA, PsA, and IBD and also autologous HSC BMT data from animal models to support the concept of cure. Patient studies should proceed using recently published protocol guidelines and centralized data collection.

Infectious complications of immunosuppressive therapy in patients with rheumatic diseases

Infection continues to be a significant cause of morbidity and mortality in patients with rheumatic diseases, and, consequently, early diagnosis and treatment of infection is critical to the successful medical management of these patients. The intensity of immunosuppressive therapy is the dominant risk factor for infection in this patient population. Because the manifestations of infection in patients with rheumatic diseases are highly variable, the clinician must always be vigilant about the possibility of infection even if the clinical presentation is highly suggestive of an exacerbation of the underlying disease. We have stressed a systematic and individualized approach in the diagnostic evaluation of suspected infection in these patients. The first part of the evaluation involves forming a list of the most likely pathogens based on a detailed history and physical examination and the intensity and type of immunosuppressive therapy the patient is receiving. The physician must then formulate a plan designed to establish a diagnosis expeditiously and with the least morbidity.

[Prognosis of systemic diseases diagnosed in intensive care units]

OBJECTIVES

The aims of this study were to evaluate the prognosis of patients with systemic rheumatic disease diagnosed in medical intensive care unit (MICU) and to determine whether the outcome is different for patients with systemic rheumatic disease previously known hospitalized in MICU.

METHODS

Retrospective evaluation, over a ten-year period, of 88 cases of systemic rheumatic disease selected in two groups: group I: diagnosed in MICU, group II: previously known and treated.

RESULTS

Group I: 18 patients with necrotizing vasculitis (n = 6), extra-intestinal manifestations of inflammatory bowel disease (n = 4), systemic lupus erythematosus (n = 3), miscellaneous (n = 5). Group II: 70 patients with rheumatoid arthritis (n = 31), necrotizing vasculitis (n = 12), systemic lupus erythematosus (n = 12), polymyositis (n = 4), extra-intestinal manifestations of inflammatory bowel disease (n = 5), miscellaneous (n = 6). The main admission diagnoses were infectious diseases (p < 0.005) or iatrogenic complications in the group II (p < 0.01) and acute exacerbation of systemic rheumatic disease in the group I (p < 0.0001). Age; simplified acute physiologic score (SAPS); number of acute organ system failure; number of patients requiring mechanical ventilation, haemodialysis or right heart catheterization were not different between the two groups. The durations of mechanical ventilation and stay in the MICU were shorter in the group II (p < 0.005). MICU mortality rate was higher in the group II (p < 0.05), with a five years cumulative proportion of surviving statistically lower (p < 0.05). Mortality rate of the entire population (37.5%) was similar to that of a non-selected population with comparable SAPS. Multivariate analysis showed that SAPS, number of acute organ system failure and iatrogenic complications were the main prognostic factors (p = 0.05).

CONCLUSIONS

The prognosis was better for patients with systemic rheumatic disease diagnosed in MICU. Infectious diseases were the main cause of death, probably in relation with immunosuppressive treatments.

Update on measurement of relevant outcomes in rheumatology

It is now recognized that disease has a multidimensional impact on patients' lives. This impact can be perceived as a spectrum encompassing on one end "hard" disease outcomes such as organ failure and mortality, and on the other end "soft" outcomes such as quality of life or patient satisfaction. This spectrum may be viewed as a framework in measuring both disease impact and response to treatment. In this paper, we review improvements in the methodology of measurement of relevant outcomes and highlight new findings and emerging trends in rheumatology.

[Mortality of geologists in relation to occupational activities]

The study covered mortality among a cohort of geologists working in North-Western Russia. The cohort included 3911 geologists, geophysicists and drillers, whose life was followed during 1977-1992. The standardized relative mortality risk with all death causes equalled 0.58 in general. Risk of mortality with hypertension in the male geologists was 21.7 times higher and for the female ones-25.4 times higher than for general population. Definite dependence between the stronger effects and the longer length of service was seen. The highest standardized relative mortality risk appeared among the drillers. Occupational risk factors for geologists reliably increase risk of mortality with active rheumatism, diseases involving arteries, veins and lymphatic vessels. The male geophysicists tend to have higher incidence of prostatic cancer, and female ones-higher incidence of uterine carcinoma.

Mortality in the rheumatic diseases

OBJECTIVE

To review mortality data in published studies of various rheumatic diseases.

METHODS

A MEDLINE search of the literature on the rheumatic diseases, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, scleroderma, polymyositis, and vasculitis.

RESULTS

Mortality rates higher than expected have been reported in most rheumatic conditions, considerably higher for inflammatory rheumatic diseases. The mortality rates in patients with systemic lupus erythematosus, scleroderma, polymyositis, and vasculitis are often comparable to mortality rates seen in patients with neoplastic or cardiovascular diseases, although the causes of death often are not identified as the rheumatic disease.

CONCLUSION

Mortality has been found to be predicted in most instances by more severe clinical status, and therefore death should not be considered as "unrelated" to the rheumatic disease. These observations may have important implications for clinical care and health policies regarding patients with rheumatic diseases.

Influenza mortality among the elderly in France, 1980-90: how many deaths may have been avoided through vaccination?

STUDY OBJECTIVES

This study aimed to assess total influenza mortality among the elderly (> or = 75 years old) in France, and to evaluate how many deaths may have been avoided through vaccination during the past 10 years.

DESIGN

The monthly mortality rates related to different causes among the elderly were obtained from the national mortality statistics for the period 1978-90. For each cause, the proportion of the registered death rate attributable to influenza was estimated using time series models. Each model analysed the registered death rate for the considered cause as a linear function of the registered influenza death rate for that month, the secular trend, and the seasonal variations. This yielded yearly regression coefficients for influenza. Formulas were subsequently developed to estimate the death rates avoided as a result of influenza vaccination according to the level of vaccine coverage and the hypothetical effectiveness of the vaccine.

MAIN RESULTS

Between 1980 and 1990 registered influenza death rates ranged from 11-81 per 100,000. The number of deaths attributable to influenza but registered as resulting from another cause was up to eight times the number of deaths registered as influenza. Total influenza death rates were estimated as ranging from 28 per 100,000 (1988-89) to 482 per 100,000 (1985-86). At the same time it was estimated that the use of influenza vaccine avoided from 7 per 100,000 deaths in 1981-82 to 697 per 100,000 deaths in 1989-90, depending on the intensity of the epidemic, the vaccine coverage, and the vaccine effectiveness.

CONCLUSIONS

These results support the policy of promoting influenza vaccination among the elderly.

Potential for bias in severity adjusted hospital outcomes data: analysis of patients with rheumatic disease

OBJECTIVE

To examine the predictive validity of MedisGroups, a widely used method of measuring severity of illness, among patients with rheumatic disease and identify determinants of hospital outcomes, after adjusting for severity of illness.

METHODS

Adult medical and surgical patients with rheumatic disease (5421) admitted to an academic medical center in 1988-90 were studied using a retrospective cohort design. Sociodemographic, clinical, and financial data were obtained from computerized hospital information systems. Severity of illness on admission was determined for each patient using MedisGroups, which classifies patients into groups of increasing severity.

RESULTS

MedisGroups admission severity groups were highly related (p < 0.001) to inhospital mortality rates, which were 0.4, 0.8, 5.1 and 16.1%, respectively among patients in 4 groups of increasing severity. Controlling for MedisGroups admission severity using logistic regression, age, admission from the emergency room, and transfer from an acute care hospital were found to be additional independent predictors of mortality. MedisGroups severity groups were also directly related (p < 0.001) to length of stay and total hospital charges. Controlling for admission severity using linear regression, length of stay, and charges were independently related to several other variables; for example, length of stay was greater for patients admitted from the emergency room or transferred from other hospitals and for nonwhites, women, and older patients. Finally, within common individual diagnoses, these factors substantially increased the amount of variance in length of stay and charges explained by MedisGroups alone.

CONCLUSIONS

Our findings demonstrate that after adjusting for severity of illness using MedisGroups, several other easily measured variables were associated with hospital outcomes in patients with rheumatic disease. Thus, generic severity systems, such as MedisGroups, may not adequately adjust outcomes among patients with rheumatic disease. Comparative hospital data based on these systems may be subject to bias.