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Resumen Introducción. La artritis reumatoide es una enfermedad autoinmunitaria, crónica y deformante asociada con discapacidad. Quienes la padecen reciben inmunosupresores y tienen un gran riesgo de desarrollar tuberculosis. La prueba de intradermorreacción a la tuberculina se utiliza como tamización en quienes van a recibir terapia biológica. Objetivo. Evaluar la frecuencia de positividad en la prueba de intradermorreacción a la tuberculina en una cohorte de pacientes con artritis reumatoide. Materiales y métodos. Se hizo un estudio descriptivo de corte transversal de una cohorte de pacientes con artritis reumatoide a quienes se les practicó la prueba de tuberculina antes de iniciar la terapia biológica o en el momento del cambio de tratamiento. Los pacientes presentaban enfermedad moderada o grave y eran candidatos para iniciar o cambiar de terapia biológica. Se definió el valor de ≥6 mm como punto de corte para la positividad de la prueba y se hizo un análisis descriptivo de cada una de las variables. Resultados. Se incluyeron 261 pacientes con artritis reumatoide, 92 % de ellos eran mujeres, la edad promedio fue de 55 años (desviación estándar, DE=13,92) y el tiempo desde el diagnóstico era de 12,3 años (DE=8,54). La frecuencia de positividad de la prueba fue de 15,71 % (n=41). Nueve de los 41 pacientes positivos habían recibido la prueba previamente (entre 1 y 6 años antes), todos con resultado negativo; 18 (43,9 %) de ellos venían recibiendo tratamiento con glucocorticoides y todos los 41 (100 %) recibían metotrexate. Conclusiones. La frecuencia de positividad de la prueba de tuberculina en pacientes colombianos con artritis reumatoide fue de aproximadamente 16 %. Se recomienda optimizar las estrategias para detectar esta condición y darle un tratamiento oportuno y, así, disminuir el riesgo de reactivación de la tuberculosis. Abstract Introduction: Rheumatoid arthritis is an autoimmune, chronic, and deforming condition associated with disability. Patients are immunosuppressed and at high risk of developing tuberculosis. The tuberculin skin test is used to screen candidates for biological therapy. Objective: To evaluate the frequency of positivity of the tuberculin skin test in a cohort of Colombian patients with rheumatoid arthritis. Materials and methods: We conducted a descriptive cross-sectional study including patients with rheumatoid arthritis receiving the tuberculin skin test prior to the start or at the time of the change of biological therapy. The patients' condition was moderate or severe and they were candidates for initiation or change of biological therapy. We defined the value of ≥6 mm as the cut-off point for a positive tuberculin skin test and performed a descriptive analysis for each of the variables considered. Results: In total, 261 patients with rheumatoid arthritis were included, 92 % of whom were women; the average age was 55 years (SD=13.92) and the time from diagnosis, 12.3 years (SD=8.54). The frequency of positive tuberculin skin tests was 15.71% (n=41). Of the 41 positive patients, nine had previously had the test (1 to 6 years before), all of them with negative results; 18 of these were receiving glucocorticoids (43.9%) and all of them (100%) were being treated with methotrexate. Conclusions: The frequency of positivity of the tuberculin skin test in these Colombian patients diagnosed with rheumatoid arthritis was around 16%. We reco0mmend optimizing strategies aimed at an optimal detection of this condition and the timely initiation of treatment to reduce the risk of tuberculosis reactivation.

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. Key Points• This article contributes with new information concerning the proportion of patients with RA who have one or more unhealthy lifestyle factors.• Every second patient in the two included cohorts reported two or more unhealthy lifestyle factors.• Two or more unhealthy lifestyle factors were more common in men than in women but were not necessarily associated with measures of disease impact.• In order to adhere to a healthier lifestyle, a large proportion of the patients need to change more than one lifestyle habit, which entails a challenge for both the patients and the health professionals.

Objective: It remains disputed how much the risk of Staphylococcus aureus bacteraemia (SAB) is increased in patients with rheumatoid arthritis (RA), and the extent to which orthopaedic implants explain the risk. We assessed SAB incidence rates (IRs) and incidence rate ratios (IRRs), comparing RA patients with a general population cohort (GPC) and individuals with versus without orthopaedic implants.Method: Danish residents aged ≥ 18 years without prior RA or SAB (=GPC) were followed up for RA and microbiologically verified SAB events (1996-2017). IRRs were calculated by age- and sex-stratified Poisson regression adjusted for age, comorbidities, calendar year, and socioeconomic status.Results: The GPC comprised 5 398 690 individuals. We identified 33 567 incident RA patients (=RA cohort) (median follow-up 7.3 years, IQR 3.6-12.3). We observed 25 023 SAB events (n = 224 in the RA cohort). IRs per 100 000 person-years were 81.0 (RA cohort) and 29.9 (GPC). IRs increased with age. Adjusted IRRs in 18-59-year-old RA patients were 2.6 (95% confidence interval 1.8-3.7) for women and 1.8 (1.1-3.1) for men, compared with same sex and age group GPC. IRRs declined with age. Compared with the GPC without implants, IRRs for RA patients with implants ranged from 1.9 (1.3-2.8) (women ≥ 70 years) to 5.3 (2.2-12.8) (18-59-year-old men).Conclusion: In this nationwide registry-based cohort study RA was a risk factor for SAB, and orthopaedic implants further increased the risk. Clinicians should be aware of potential SAB in patients with RA and orthopaedic implants. Objective: It remains disputed how much the risk of Staphylococcus aureus bacteraemia (SAB) is increased in patients with rheumatoid arthritis (RA), and the extent to which orthopaedic implants explain the risk. We assessed SAB incidence rates (IRs) and incidence rate ratios (IRRs), comparing RA patients with a general population cohort (GPC) and individuals with versus without orthopaedic implants.Method: Danish residents aged ≥ 18 years without prior RA or SAB (=GPC) were followed up for RA and microbiologically verified SAB events (1996-2017). IRRs were calculated by age- and sex-stratified Poisson regression adjusted for age, comorbidities, calendar year, and socioeconomic status.Results: The GPC comprised 5 398 690 individuals. We identified 33 567 incident RA patients (=RA cohort) (median follow-up 7.3 years, IQR 3.6-12.3). We observed 25 023 SAB events (n = 224 in the RA cohort). IRs per 100 000 person-years were 81.0 (RA cohort) and 29.9 (GPC). IRs increased with age. Adjusted IRRs in 18-59-year-old RA patients were 2.6 (95% confidence interval 1.8-3.7) for women and 1.8 (1.1-3.1) for men, compared with same sex and age group GPC. IRRs declined with age. Compared with the GPC without implants, IRRs for RA patients with implants ranged from 1.9 (1.3-2.8) (women ≥ 70 years) to 5.3 (2.2-12.8) (18-59-year-old men).Conclusion: In this nationwide registry-based cohort study RA was a risk factor for SAB, and orthopaedic implants further increased the risk. Clinicians should be aware of potential SAB in patients with RA and orthopaedic implants.

Rheumatoid arthritis (RA) is a chronic inflammatory condition which can result in pain and functional disability. It is also associated with an increased occurrence of comorbidities, including an increased risk of certain cancers such as lung cancer and lymphoma. The aetiopathogenesis of this increased cancer risk is likely multifactorial and includes shared risk factors as well as chronic inflammation. There is also a concern that the treatment for RA itself may increase this risk further, particularly treatment with biologic disease modifying anti-rheumatic drugs (DMARDs). This paper aims to review the evidence for the increased risk of cancer in RA as well as the latest evidence exploring the association between DMARDs and tumorigeneses. It also discusses the evidence for management of patients with biologic DMARDs in the setting of existing cancer.

This review assesses the risk assessment of cardiovascular disease (CVD) in rheumatoid arthritis (RA) and how non-invasive imaging modalities may improve risk stratification in future. RA is common and patients are at greater risk of CVD than the general population. Cardiovascular (CV) risk stratification is recommended in European guidelines for patients at high and very high CV risk in order to commence preventative therapy. Ideally, such an assessment should be carried out immediately after diagnosis and as part of ongoing long-term patient care in order to improve patient outcomes. The risk profile in RA is different from the general population and is not well estimated using conventional clinical CVD risk algorithms, particularly in patients estimated as intermediate CVD risk. Non-invasive imaging techniques may therefore play an important role in improving risk assessment. However, there are currently very limited prognostic data specific to patients with RA to guide clinicians in risk stratification using these imaging techniques. RA is associated with increased risk of CV mortality, mainly attributable to atherosclerotic disease, though in addition, RA is associated with many other disease processes which further contribute to increased CV mortality. There is reasonable evidence for using carotid ultrasound in patients estimated to be at intermediate risk of CV mortality using clinical CVD risk algorithms. Newer imaging techniques such as cardiovascular magnetic resonance and CT offer the potential to improve risk stratification further; however, longitudinal data with hard CVD outcomes are currently lacking.

OBJECTIVES: Atherosclerotic cardiovascular disease risk is increased in rheumatoid arthritis (RA). Wave reflection occurs at arterial branching points, which are particularly prone to atherosclerosis. We explored the relationship of wave reflection with atherosclerosis in RA. METHODS: One hundred and sixty three RA patients (110 white, 31 Asian, 17 black and 5 of mixed ancestry) without cardiovascular disease participated. Arterial stiffness, wave reflection, pressure pulsatility, plaque in the extracranial carotid artery tree and the mean of the left and right common carotid arteries intima-thickness were determined. Associations were identified in multivariable regression models. RESULTS: One SD increase in reflected wave pressure (OR (95% CI) = 2.54 (1.41-4.44), p=0.001), reflection magnitude (OR (95% CI) = 1.84 (1.17-2.89), p=0.008), central pulse pressure (OR (95% CI) = 1.89 (1.12-3.22), p=0.02) and peripheral pulse pressure (OR (95% CI) = 2.09 (1.23-3.57), p=0.007) were associated with plaque. The association of wave reflection with plaque was independent of arterial stiffness and pressure pulsatility, and was present in both hypertensive and normotensive RA patients. In receiver operator characteristic curve analysis, the optimal cutoff value for reflected wave pressure in predicting plaque presence was 25 mmHg with a sensitivity, specificity, positive predictive value and negative predictive value of 45.2%, 89.3%, 78.6% and 66.2%, respectively; a reflected wave pressure of >25 mmHg was associated with plaque in univariate and adjusted analysis (p

Objective: To assess the incidence of chronic persistent rheumatoid arthritis (RA) in a population-based cohort of twins and to determine the impact of smoking. Methods: In a historical cohort study on twins born in 1920 to 1982, we identified 157 cases of RA among 45,280 responders (response rate 80%). Information on smoking was obtained by questionnaire and interview. A mixed-effects Poisson regression model was used to estimate incidence rate ratios with age, sex, smoking duration, and smoking intensity as covariates. We used the SplitLexis procedure in the Epi R package to study a possible effect of period or cohort in addition to age on the variation of the incidence. Results: The annual incidence of chronic persistent RA was 18.8 per 100,000 person-years, ages 15–73 years (females 25.2, males 12.0), increasing with age to a maximum at age 60 years in females and age 70 years in males. The incidence rate ratio among ever-smoking patients was 1.96 (95% confidence interval [95% CI] 1.43–3.76), 1.93 (95% CI 1.00–3.7) after 30 pack-years, and 1.034 (P < 0.001) per year of smoking, implying a doubling of risk after 20 years regardless of sex and smoking intensity. We did not detect significant period or cohort effects. Conclusion: The incidence of chronic persistent RA is lower than the incidence figures reported in inception cohorts. Smoking duration, but not intensity, doubled the risk of RA after 20 years of smoking in both sexes.

BACKGROUND: Past and recent research suggests that psychological and biological factors may increase women's risk of coronary heart disease (CHD). This study examined the prevalence and correlates of self-reported heart disease among Jewish women from the Negev, a socio-economically and culturally unique region in south of Israel. METHOD: A cross-sectional design was used. We interviewed over the phone 526 randomly-selected women (mean age: 44.3+/-14.2 years) about background variables (e.g., education), biomedical risk factors (e.g., body mass index or BMI), self-reported inflammatory diseases (rheumatoid arthritis or RA, urinary infections), psychosocial factors (depression, hopelessness, self-esteem, social-support) and self-rated health and heart disease. RESULTS: Prior physician diagnosis of heart disease was reported by 8.2% of women. Age, economic difficulties, diabetes, hypertension, BMI, physical exercise, RA and urinary infections were significantly associated with reported heart disease. Of all psychosocial factors considered, hopelessness and self-esteem significantly distinguished heart disease cases from non-cases. In a multiple logistic regression, poor self-esteem, RA and hypertension were significant independent correlates of self-reported heart disease. CONCLUSIONS: Pending replication with objective measures of heart disease and a prospective design, poor self-esteem and RA may prove to be new CHD risk factors in women.

OBJECTIVE: To study health-related quality of life (HRQoL) in arthritis rehabilitation performed by multidisciplinary teams in patients with chronic inflammatory arthritis. Predictors of change in health-related quality of life and the proportion of patients with clinical improvement were investigated. DESIGN: Multicentre prospective observational study in 4 European countries. METHODS: HRQoL was measured with the European Quality 5 Dimensions (EQ-5D) and the Short Form 36 Health Survey (SF-36) in 731 patients who underwent multidisciplinary rehabilitation. Potential predictors were physical functioning (Health Assessment Questionnaire (HAQ)), self-efficacy (Arthritis Self Efficacy Scale (ASES)), psychological health (Hopkins Symptom Check List (HSCL-25)), pain/fatigue (numeric rating scales (NRS)), age, sex, diagnosis, comorbidity, education, clinical setting and change of medication during rehabilitation. Analysis of covariance (ANCOVA) was used to assess for potential predictors and interactions. The minimal important differences for HRQoL were analysed. RESULTS: Reporting worse function (b 0.05, p = 0.01), less psychological well-being (b 0.09, p = 0.000), and experiencing more pain (b 0.03, p = 0.000) or fatigue (b 0.02, p = 0.000) at admission predicted improved HRQoL. Change in medication during rehabilitation (b 0.08, p = 0.013) was associated with greater improvement in HRQoL. These EQ-5D findings were supported by SF-36 findings. Positive minimal important differences were noted in 46% (EQ-5D) and 23-47% (SF-36 subscales) of the patients. CONCLUSION: Patients with more severe symptoms experienced the largest gain in HRQoL post-intervention. The results of this study are of value for selecting the right patients for rheumatological team rehabilitation. © 2014 The Authors The European League Against Rheumatism (EULAR) has financially supported the STAR-ETIC by EULAR grant CLI022. This work was supported by Lund University Faculty of Medicine and the Capio’s Research Foundation. The Norwegian arm of this study, the SPOR project, was financed by Extra-stiftelsen Helse og Rehabilitering in Norway.

Objective.To investigate, within the first 2 years of diagnosis with rheumatoid arthritis (RA), associations between disease-related measures and cardiovascular disease (CVD) and mortality in patients with RA onset before and after 65 years of age.Methods.The study population (n = 741; 67.5% women) was derived from the Better Anti-Rheumatic Pharmaco Therapy (BARFOT) early RA cohort, recruited 1993–1999. The mean age was 55 years (SD 14.7). The outcomes were incident CVD events and all-cause mortality until 2010. Area under the curve (AUC) for disease measures at inclusion, 1 and 2 years, and decrease in measures after 1 year were calculated.Results.In all, 177 CVD events and 151 deaths occurred over 10 years of observation. In adjusted Cox regression analyses, seropositivity for rheumatoid factor (RF) or anticitrullinated protein antibodies (ACPA); white blood (cell) count at diagnosis; and AUC of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and visual analog scale (VAS)-pain were associated with higher CVD risk among patients with disease onset before 65 years of age. Among patients with disease onset after 65 years, larger decreases in CRP, ESR, health assessment questionnaire (HAQ), and use of methotrexate decreased CVD risk, whereas use of glucocorticoids heightened CVD risk. AUC of CRP, ESR, HAQ, and HAQ after 2 years was related to risk of death in both age groups. Seropositivity and AUC for VAS-pain in the younger group and use of glucocorticoids in the elderly were associated with poorer survival.Conclusion.Early treatment of RA may improve longterm outcomes. Presence of RF or ACPA associates with CVD and mortality among RA patients with disease onset before 65 years. Age stratification may improve evaluation of risk for CVD and mortality in early RA.

Aims. Patients with rheumatoid arthritis (RA) often report events that they believe may have caused their disease. We attempted to characterize such causal events and the possible relationship between these and outcomes. Methods. Between 1996 and 2004, 1,787 adult patients were included in the Better Anti-Rheumatic FarmacOTherapy (BARFOT) early RA study in Sweden. Six possible causal events at baseline were predefined. Disease Activity Score 28-joint count (DAS28) and treatment were registered at inclusion and at three, six and 12 months. The European League against Rheumatism (EULAR) response criteria were used. Results. A total of 1,652 patients (92%) answered the question about possible causal events. Thirty per cent (490) of the patients believed that some event in particular had caused their RA. Sixteen per cent of the patients thought that infection, 4.4% psychological trauma, 4.1% physical trauma, 2.8% surgery, 1.5% pregnancy and 1.2% vaccination had been the cause. Younger patients attributed previous infection to their RA more often than older patients. There were no differences in EULAR response up to one year between patients who reported some event or infection and patients who did not. RA thought to be caused by infection showed a seasonal trend in the month of onset. Women reported that trauma had been a cause of their RA more often than men. Conclusion. Thirty per cent of the patients reported some causal event and 16% reported infection to be the cause of their RA. There were differences in gender and age in what patients reported as the cause of their RA.