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Seminars in Arthritis and Rheumatism
Limited data exist on the effect of rheumatoid arthritis (RA) on maternal postpartum outcomes. Using a real-world, electronic health record (EHR) cohort, we assessed maternal postpartum outcomes in RA.
In a large, de-identified EHR, we identified possible RA deliveries using ≥1 delivery ICD-9 or ICD-10-CM codes and a validated RA algorithm. RA cases were required to be diagnosed by a rheumatologist on chart review. Maternal postpartum outcomes included rates of blood transfusion, rates of infection up to 6 weeks postpartum defined by a clinician, and length of hospital stay. We also identified deliveries to women without autoimmune diseases.
We identified 202 deliveries occurring after RA diagnosis and 596 deliveries to controls without autoimmune diseases. Postpartum infection rates were similar among RA patients and controls (8% vs. 4%, p=0.10), as were red blood cell transfusion rates (2% vs. 2%, p=1.00). RA case status was not significantly associated with postpartum infection (OR=2.10, 95% CI 0.88 – 4.98, p=0.09) but was significantly associated with preterm birth (OR=2.11, 95% CI 1.38 – 3.23, p=0.001). Corticosteroid use during pregnancy was common at 41%, while tumor necrosis factor inhibitor use was 13%. After adjusting for age at delivery and race, corticosteroid use at delivery was not associated with postpartum maternal infections but was associated with a significantly lower birthweight in RA cases.
Women with RA have an increased risk of adverse pregnancy outcomes, particularly preterm birth. Our study highlights, however, that maternal postpartum outcomes such as postpartum infection and blood transfusion are not significantly increased in RA patients.
Rheumatoid arthritis (RA) is a chronic, autoimmune disease commonly affecting females of child-bearing age . Studies on birth outcomes to women with RA are limited and conflicting. Some studies indicate that women with well controlled RA have birth outcomes similar to the general population . In contrast, other larger studies have noted higher rates of preterm birth, preeclampsia, eclampsia, and cesarean section , , , , . There is a gap, however, in studies assessing maternal postpartum outcomes such as postpartum infections, rates of blood transfusion, and length of hospital stay in RA. One small study of 38 patients noted that infection rates in RA were no different than controls , but a larger administrative database study found an increased risk for wound complications and venous thromboembolism in women with RA .
Similarly, there is a lack of robust data on the effect of RA medications on maternal postpartum outcomes. Specifically, the effect of corticosteroid use on pregnancy outcomes in RA has been controversial. While historically prednisone use had been deemed relatively safe in pregnancy, recent studies show that prednisone use, even at low doses, may be associated with preterm birth [2,9]. Contemporary studies, however, have not investigated the effect of corticosteroid use on maternal postpartum infections.
Electronic health records (EHRs) provide an efficient and cost-effective method to study deliveries to RA patients. These methods can more quickly amass a larger sample compared to single-center, prospective cohort studies. Further, EHR-based studies have longitudinal, dense data that is more comprehensive than administrative database studies and allow for chart review for accurate phenotyping. Using a large, de-identified EHR and validated phenotypes for RA and deliveries, we assembled a cohort of RA deliveries. We assessed the impact of demographics, RA disease characteristics, and RA medications on maternal postpartum outcomes including infection, blood transfusions, and length of stay.
The Synthetic Derivative
Following approval from the Institutional Review Board of Vanderbilt University Medical Center (VUMC), we used a de-identified version of VUMC's electronic health record (EHR) called the Synthetic Derivative. The Synthetic Derivative contains clinical information on over 3.2 million unique patients since 1990 . VUMC's patient population draws from a large area of the southern United States and is a key tertiary care center in the region. The Synthetic Derivative contains all available EHR
Deliveries to control mothers
We initially identified 250 control mothers and excluded 2 mothers with missing delivery data and 24 mothers with autoimmune diseases discovered on chart review resulting in 224 deliveries. A list of the autoimmune diseases in the controls is included in Supplemental Table 3 with the most common conditions being type 1 diabetes (n=9), ulcerative colitis (n=5), and Hashimoto's thyroiditis (n=3). We then analyzed 224 control mothers with 596 pregnancies. Mean age at delivery was 27±7
In a large, real-world EHR study of RA and control deliveries, we examined maternal postpartum and delivery outcomes. Rates of maternal postpartum infection and blood transfusion were similar in RA compared to control deliveries, while mean but not median length of stay was significantly longer in RA deliveries. Limited data exists on maternal postpartum outcomes in RA. Our results provide reassuring data for certain postpartum outcomes and provides additional data on the risk of
In conclusion, women with RA have an increased risk of adverse fetal outcomes such as preterm birth, lower birthweight, and shorter gestational age. Our study, however, provides reassurance that maternal outcomes such as postpartum infection and blood transfusion may not be adversely affected. Corticosteroid use at time of delivery increased the risk of lower weight babies and postpartum infections in RA mothers, while TNF inhibitor use did not. Given this information, rheumatologists should
Declaration of Competing Interest
This work was supported by the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases (1K08 AR072757–01, Barnado); National Institutes of Health/National Center for Research Resources (UL1 RR024975, VUMC); National Institutes of Health/National Center for Advancing Translational Sciences (ULTR000445, VUMC); the Rheumatology Research Foundation (K Supplement Award, Barnado).
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Research articleImpact of the number of comorbidities on the outcome measures and on the retention rate of the first anti-TNF in patients with Ankylosing Spondylitis. Two-year follow-up in REGISPONSER-AS
Seminars in Arthritis and Rheumatism, Volume 52, 2022, Article 151938
To evaluate the impact of the number of comorbidities on the outcome measures after two years of follow-up in patients with Ankylosing Spondylitis (AS) and to determine whether the number of comorbidities influences the retention rate of the first anti-TNF.
This was an observational and prospective study conducted during 2 years of follow-up in the REGISPONSER-AS registry. The patients were divided into three groups according to the number of comorbidities at baseline (0, 1 or ≥2). Linear regression models adjusted for disease duration, age, sex and smoking were constructed to evaluate the association between the number of comorbidities and the Patient Reported Outcomes (PRO) scores. The impact of the number of comorbidities on PROs over two years of follow-up was evaluated using mixed models for repeated measures adjusted for disease duration, age, sex and smoking. Finally, the retention rate of the first anti-TNF antibody across the three groups was evaluated using a log-rank test.
Patients with two or more comorbidities showed higher scores at baseline and during the two years of follow-up for the Global VAS, BASDAI, ASDAS, and BASFI and worse scores for the physical component of the SF12. A higher probability of discontinuation of the first anti-TNF was found in patients with 2 or more comorbidities compared with the patients in the other groups (38.2% vs. 26.6% vs. 25.4% for ≥2 comorbidities, 0 and 1 comorbidity, respectively), although these differences were not significant (log-rank test: p-value=0.180).
In patients with AS, the presence of 2 or more comorbidities was associated with worse scores on the outcome measures test after two years of follow-up and a greater tendency of discontinuation for the first anti-TNF.
Research articleMacrophage activation syndrome in pediatric Sjögren's syndrome
Seminars in Arthritis and Rheumatism, Volume 53, 2022, Article 151977
Research articleComment on "Macrophage activation syndrome in pediatric Sjögren's syndrome”
Seminars in Arthritis and Rheumatism, Volume 53, 2022, Article 151976(Video) Let's Talk - How Autoimmune Diseases Affect Women and Men Differently
Research articleVariations in Takayasu arteritis characteristics in a cohort of patients with different racial backgrounds
Seminars in Arthritis and Rheumatism, Volume 53, 2022, Article 151971
We aimed to describe differences in disease characteristics and outcomes in Takayasu arteritis (TA) patients with different racial backgrounds.
This was a retrospective cohort study consisting of TA patients seen at specialty vasculitis clinics from five academic hospitals across Canada. Disease features, treatments and outcomes were compared between White and non-White patients.
The cohort included 113 patients, of which 51 were White. Over 50% of the non-White patients were Asian. Compared to non-White patients, White patients had higher CRP and ESR at diagnosis (33.6mg/l versus 9.4mg/l, p=0.033; and 51mm/h versus 24mm/h, p=0.047; respectively), and were less likely to have baseline cardiovascular comorbidities including dyslipidemia (11.8% versus 29%, p=0.037). There were no significant differences between racial groups for other disease characteristics or outcomes.
Patient race did not appear to play a significant role in determining disease characteristics and outcomes when comparing TA patients from various racial backgrounds living in the same country.
Research articleEffects of patient and disease characteristics on global functioning in patients with axial spondyloarthritis in routine care
Seminars in Arthritis and Rheumatism, Volume 55, 2022, Article 152006
The ASAS Health Index (ASAS HI) was developed to assess global functioning in patients with axial spondyloarthritis (axSpA). Influencing factors have not been studied to date, especially the influence of inflammation and structural changes in the spine has remained unclear to date.
To find out whether and to what degree do axial inflammation, radiographic damage and other clinical features influence global functioning of patients with axSpA.
Patient reported outcomes (ASAS HI, pain, BASDAI, BASFI, EQ-5D and SF-36) were assessed, spinal mobility by BASMI and depression by SF-36 scores. Axial inflammation was quantified using the MRI Berlin score and structural damage as detected by conventional radiographs by the modified Stokes AS Spinal Score (mSASSS). Correlation and regression analyses were performed to analyze the association between global functioning and other variables.
A total of 191 axSpA patients with different degrees of global functioning and disease activity was included, 60.2% had r-axSpA. Syndesmophytes were found in 38.5% of patients - with a median mSASSS score of 3.8 (IQR 1.0-18.7) in r-axSpA and 0.0 (IQR 0.0-1.2) in nr-axSpA patients. The mean MRI score was 2.3 (IQR 0.5-7.6). ASAS HI values correlated significantly with BASMI, BASDAI, BASFI, BMI and MRI scores. However, no significant correlation was found for mSASSS and CRP. Regression analyses revealed that global functioning was significantly influenced by disease activity, physical function, obesity and depression but not by structural damage or spinal inflammation as detected MRI.
Our study shows that global functioning is strongly associated with physical function, body weight and depression in patients with axSpA but not with spinal inflammation and structural damage. This may be explained by the relatively low mSASSS of these well treated patients.
Research articleThe incidence and risk factors for venous thromboembolic events in patients with psoriasis and psoriatic arthritis
Seminars in Arthritis and Rheumatism, Volume 53, 2022, Article 151950(Video) 11/30/2016: Rheumatoid Arthritis: RA and Reproductive Health
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