Faculty Bibliography

Background Estimates of global status by doctors (DOCGL) and patients (PATGL) are discordant in about 30-40% of patients with rheumatoid arthritis (RA).1,2 This discordance has been analyzed to date only in RA patients. Objectives To analyze levels of discordance between DOCGL and PATGL in all patients with any diagnosis seen in usual clinical care at a rheumatology setting. Methods Each patient seen at an academic rheumatology clinical setting since 2005 completes a self-report MDHAQ (multidimensional health assessment questionnaire) at each visit, with scales for physical function, pain, PATGL, fatigue, anxiety, depression and quality of sleep, and demographic data. DOCGL was completed by 2 rheumatologists. One random visit of patients seen between 2005 and 2011 was analyzed, patients were classified as PATGL=DOCGL (PATGL and DOCGL within 2 of 10 units), PATGL>DOCGL (PATGL >2 units than DOCGL), and DOCGL>PATGL (DOCGL >2 units than PATGL). Univariate odds ratios were computed to identify variables associated with discordance. Significant variables (p<0.05) were included in multivariate models, with selected variables when indicated. Results In a total of 980 patients studied, 509 (52%) had PATGL=DOCGL, 371 (38%) PATGL>DOCGL, and 100 (10%) DOCGL>PATGL. Patients with PATGL>DOCGL were more likely to be female, have less formal education and have higher MDHAQ scores (Table). In multivariate analysis, higher pain and fatigue scores were independent predictors of PATGL>DOCGL. If MDHAQ scores for pain and fatigue were not included in a second model, female gender, lower education and higher scores for depression and sleep problems were independent predictors of PATGL>DOCGL. In patients with DOCGL>PATGL, only lower fatigue was associated in multivariate analysis with lower odds of discordance (OR=0.88, 95% CI 0.79-0.98). Conclusions 38% of patients estimated their statusas worse than their physicians. These patients were more likely to score higher for pain and fatigue, be female and less educated tha!

Background Behcet's syndrome (BS) is a systemic vasculitis that may different pathogenic mechanisms leading to different manifestations, such as eye, mucocutaneous and GI disease. We started a dedicated Behcet's clinic in 2004 and have treated over 850 patients to date. Objectives To determine the response to therapy depending on type of organ involvement and documentation of improvement with patient reported outcomes. Methods All patients seen at the Center complete MDHAQ, medical history, medication use, Behcet's specific history, ethnic and demographic information forms. In addition a Behcet Syndrome Activity Score (BSAS) is also completed by all Behcet patients. These data are prospectively collected and updated each visit. Patients were divided into eye disease only, GI only, both or none groups and compared for disease activity and medication, specifically azathioprine, use. They could have mucocutaneous disease in addition to above manifestations Results 484 patients (78% female, disease duration 4.8 (7.1) years, age 35.3 (13.8)) were analyzed. 244 patients had no eye or GI disease, 83 had eye, 111 GI and 46 both eye and GI involvement. Both groups of azathioprine treated and untreated patients showed improvement in their disease activity scores but the improvement were more pronounced for GI disease by BSAS. RAPID3 responses were more in the azathioprine treated group with eye and both eye and GI disease. Patients with no eye or GI disease did similarly with or without azathioprine. (Table presented) Conclusions In this cohort of 484 Behcet patients, some treatment response differences were noted between patients with eye or GI involvement vs those who did not have these. Overall, azathioprine, led to better outcomes regardless of organ involvement. It was possible to demonstrate these improvements using patient reported outcomes, RAPID3 and BSAS, as part of routine clinical care

Background The magnitude of the association of cancer with rheumatoid arthritis, especially after anti-TNF use, remains in dispute. We recently proposed (1) an important selection bias was potentially inherent in the registry data especially when the comparator for the sought cancer incidence in RA was the cancer incidence in the "mother population", the population from which the registry is derived from. In a mother population within a given time there would be many patients with cancer who would not have the chance to develop RA since a. a sizeable fraction would die from their disease before having the chance to develop RA; b. The cancer treatment could potentially prevent the development of RA or finally, and particularly in the case of anti-TNF registries, c. If they remained alive and developed cancer the likelihood of them being included in such a registry would be small. All 3 factors could render the incidence ratio (incidence in the registry/incidence in the mother population) less than unity even if biologically there are no real differences in the cancer frequencies between the 2 populations. Lastly this ratio would decrease in time as was observed in the Taiwan registry (1). Objectives We formally surveyed whether the same potential selection bias was present in other manuscripts reporting similar data. Methods We conducted a PubMed search with the search terms "registry" "cancer" and "rheumatoid arthritis" among 7 high-impact rheumatology journals between 2001 and May-2011 (inclusive). First, articles that reported cancer incidence in patients with RA were retrieved in full-text. Among these, those manuscripts which reported an incidence ratio at 2 or more time-points were included in this survey. We specifically sought a. whether the comparisons were made between the registry and a "mother population" and b. the changes in the above described ratio between the first and last time points. Results We retrieved 36 articles among 1274 search results. In 6/36 the incidence ratio compa!