Characterizing systemic sclerosis in Northern California: focus on Asian and Hispanic patients.

OBJECTIVE: Previous studies suggest that Asian and Hispanic patients with systemic sclerosis (SSc) may have more severe disease than their Caucasian counterparts. The purpose of this study is to compare the clinical features of a group of Asian, Hispanic, and Caucasian patients with SSc in Northern California. METHODS: We performed a cross-sectional study of patients receiving care at Stanford University Medical Center, Palo Alto Veterans Affairs Hospital, Santa Clara Valley Medical Center and San Francisco General Hospital between 1996 and 2006. Patients included in the analyses fulfilled the American College of Rheumatology criteria for SSc and could be classified as Caucasian, Asian, or Hispanic. Analyses using Caucasians as the reference group were performed. RESULTS: One hundred and ninety-nine patients met the criteria for SSc, and 165 of these patients were classified as Caucasian (47%), Asian (26%), or Hispanic (27%). Disease subtype did not differ significantly among the three groups. Asian patients were less likely to have digital ulcers (26% vs. 47%, p=0.02) or anemia (26% vs. 45%, p=0.04) than Caucasians, and Hispanic patients had a lower frequency of lung disease than Caucasians (48% vs. 67%, p=0.04), but there were no other significant differences in disease manifestations. CONCLUSION: In our cohort of SSc patients living in Northern California, clinical manifestations in Asian and Hispanic patients did not differ substantially from Caucasians. Further research is necessary to confirm these results and to investigate gene-environment interactions which may affect the clinical expression of disease in different racial groups.

Bleeding complications in patients on celecoxib and warfarin.

PURPOSE: Non-selective non-steroidal anti-inflammatory drugs (nNSAIDs) used in combination with warfarin are associated with an approximately 3-fold increased risk of upper gastrointestinal bleeding (UGIB) compared with warfarin alone. Celecoxib, a selective inhibitor of cyclo-oxygenase 2 (COX-2), is associated with less gastric mucosal injury and platelet dysregulation than nNSAIDs. We compared rates of bleeding complications in patients taking celecoxib and warfarin with those taking warfarin alone. SUBJECTS AND METHODS: We performed a retrospective analysis using data from our Protime Clinic and pharmacy databases from January 2001 to April 2004. We identified 123 patients who took celecoxib and warfarin concurrently (overlap group). We compared rates of bleeding complications in this group with 1022 control patients who were taking warfarin alone. Bleeding complications were defined as major if they resulted in hospitalization, blood transfusion or death. RESULTS: During approximately 1063 months of exposure to both celecoxib and warfarin, 10 bleeding complications were identified, only one of which was considered major. No patients had UGIB. In the control group, 116 bleeding complications were identified over approximately 16 520 months of exposure to warfarin alone, with 101 minor and 15 major events, including six episodes of UGIB. The relative risk of all bleeding complications was 1.34 (95% CI: 0.70-2.57) in the overlap vs. control groups, and for major bleeds was 1.04 (95% CI: 0.14-7.85). CONCLUSIONS: There is a mild but non-significant increase in bleeding complications in patients taking celecoxib and warfarin compared with those taking warfarin alone.

Time perspective predicts the progression of permanent organ damage in patients with systemic lupus erythematosus.

Patients whose perspective is oriented to the future more than to the present may have better long-term health outcomes. We examined if time perspective predicted future organ damage in patients with systemic lupus erythematosus (SLE). We assessed the time perspectives of 87 patients with SLE using a questionnaire at a baseline visit. Permanent organ damage was assessed by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index during the same visit, and reassessed after a median of 4.6 years. Patients who were oriented more to the future were less likely to have an increase in the Damage Index than those oriented more to the present. In a multivariate analysis, each 1-point increase in the degree of orientation to the future (on a scale of 1-6) was associated with a 22% decrease in the likelihood that the Damage Index would increase over time (odds ratio 0.78; 95% confidence interval 0.64-0.94; P = 0.009). Other measures that predicted an increase in the Damage Index were lower education levels, greater health locus of control attributed to chance and greater health locus of control attributed to powerful others. In conclusion, time perspective is a significant predictor of future organ damage in SLE. Patients who have a greater orientation to the future are less likely to develop permanent organ damage.

Low-intensity treatment of depression in primary care: is it problematic?

The aim of this study was to examine patterns of care and outcomes of depressed patients under primary care during acute phase treatment. A cohort of depressed patients was assessed 6-8 weeks after starting pharmacotherapy in four large primary care clinics in a health maintenance organization. These patients (n = 1671) were receiving antidepressant treatment for a new episode of depression. To calculate main outcome measures, Structured Clinical Interview for Depression evaluated prior history and current depression status. Visit and pharmacy refill data described use of health services and antidepressant medication. Six to eight weeks after starting antidepressant therapy, 33.2% of patients had 0-3 depressive symptoms and no prior history of depression, an additional 42.3% also reported 0-3 symptoms but were at high risk of relapse, and 24. 5% were persistently depressed with 4 or more depressive symptoms. In the initial 6 weeks of treatment, these three groups showed similar use of antidepressant medication and health services. About 50% in each group had no follow-up visit for depression and 32%-42% had not refilled their antidepressant prescription. In general, depressed patients under primary care obtained low-intensity pharmacotherapy and inconsistent follow-up visits during initial acute phase treatment. Six weeks after starting antidepressant medicine, many were still symptomatic or recovered but had a high risk of depression relapse. Patients with unfavorable outcomes did not receive more intensive management than the one-third who had favorable outcomes.

Psychosocial correlates of morbidity in women with systemic lupus erythematosus.

OBJECTIVE: Modifiable psychosocial factors that are associated with health outcomes may provide new opportunities for treatment. We investigated the associations of various psychosocial factors with 3 measures of morbidity in women with systemic lupus erythematosus (SLE). METHODS: We collected information on 16 social, psychological, behavioral, and medical care factors in a cross sectional survey of 100 women with SLE, and related these to measures of physical disability (assessed by the Health Assessment Questionnaire Disability Index), SLE activity (assessed by the Systemic Lupus Activity Measure), and cumulative organ damage (assessed by the SLICC/ACR Damage Index). RESULTS: In multivariate analyses, greater physical disability was significantly associated with higher depression scale scores and higher body mass indexes. Greater SLE activity was associated with less adequate social support. Greater cumulative organ damage was associated with lower self-esteem and a time orientation that favored the present over the future. Financial barriers to medical care, knowledge about SLE, health locus of control, marital status, and health behaviors including compliance with medications, smoking, alcohol use, and exercise, were not significantly associated with any measure of morbidity. CONCLUSION: Selected psychosocial factors are associated with morbidity in SLE, but differ with the measure of morbidity examined.

Clinical and laboratory features of patients of Vietnamese descent with systemic lupus erythematosus.

The prevalence rate and disease manifestations of systemic lupus erythematosus (SLE) have been noted to vary among different ethnic groups. There has been no description in the English literature of SLE in the Vietnamese population. This is the first report, which details the clinical and laboratory features as well as an estimation of the prevalence of SLE in patients with a Vietnamese ancestry living in the United States. We performed a retrospective chart review of clinical and laboratory features of patients of Vietnamese descent with SLE. The case finding was performed by a review of the rheumatology clinic records at two large teaching hospitals in Santa Clara County searching for patients with SLE with a Vietnamese surname. In addition, we recruited patients by contacting all of the rheumatologists practicing in the county. Twenty-three patients of Vietnamese descent were identified with SLE in Santa Clara County. The estimated prevalence of SLE in the patients of Vietnamese descent was 42 cases per 100 000 persons. Eighty-seven per cent of the cases were born in Vietnam. The clinical and laboratory features of SLE were similar to prior published reviews except for a relatively high prevalence of anti-RNP antibody (54%). The patients with anti-RNP antibody exhibited features of overlap syndrome. There was a high rate of exposure to tuberculosis (TB). Fifty-eight per cent of patients had a positive purified protein derivative (PPD) skin test and 27% of patients had a history of clinical TB. Forty-four per cent of patients had evidence of hepatitis B exposure. The prevalence of SLE in the Vietnamese population in Santa Clara County is similar to that of other Asian populations. There was a relatively high prevalence of anti-RNP antibody in our patient group which was associated with overlap features. As expected in an immigrant population from Southeast Asia, there was a high rate of prior exposure to tuberculosis and hepatitis B. Clinicians should diligently screen for these infections and appropriately prophylaxe and treat patients.

Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care.

OBJECTIVE: The authors' goal was to determine whether improved outcomes from enhanced acute-phase (3-month) treatment for depression in primary care persisted. METHOD: They conducted a 19-month follow-up assessment of 156 patients with major depression in the Collaborative Care intervention trials, which had found greater improvements in treatment adherence and depressive symptoms at 4 and 7 months for patients given enhanced acute-phase treatment than for patients given routine treatment in a primary care setting. Sixty-three of the 116 patients who completed the follow-up assessment had received enhanced treatment, and 53 had received routine treatment in primary care. The Inventory for Depressive Symptomatology and the Hopkins Symptom Checklist were used to measure depressive symptoms. Automated pharmacy data and self-reports were used to assess adherence to and adequacy of pharmacotherapy. RESULTS: At 19 months, the patients who had received enhanced acute-phase treatment did not differ from those who had received routine primary care treatment in clinical outcomes or quality of pharmacotherapy. CONCLUSIONS: Even though enhanced acute-phase treatment of depression in primary care resulted in better treatment adherence and better clinical outcomes at 4 and 7 months, these improvements failed to persist over the following year. Continued enhancement of depression treatment may be needed to ensure better long-term results.

Relapse of depression in primary care. Rate and clinical predictors.

OBJECTIVE: To determine the clinical predictors and rate of relapse for major depression in primary care. DESIGN: A cohort study of subjects in 2 randomized trials of depressed patients diagnosed and prescribed antidepressant medicine by primary care physicians. Baseline, 7-month, and 19-month assessments were conducted. SETTING: A large primary care clinic of a staff-model health maintenance organization. PATIENTS: Two hundred fifty-one primary care patients who did not satisfy Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for major depression at 7 months. MAIN OUTCOME MEASURES: Relapse was defined as (1) satisfying DSM-III-R criteria for major depression at 19 months, or (2) reporting an interval episode of 2 weeks or more of depressed mood and symptoms between 7 and 19 months. Predictors examined included demographic characteristics, medical comorbidity, disability, and psychological symptoms. Depressive symptoms were measured by Inventory of Depressive Symptoms and Hopkins Symptoms Checklist. RESULTS: Of the patients, 37.1% reported relapse of depression in the 12-month relapse-risk period. The 2 major risk factors associated with relapse were (1) persistence of subthreshold depressive symptoms 7 months after the initiation of antidepressant therapy (odds ratio, 3.3; 95% confidence interval, 2.74-3.93) and (2) history of 2 or more episodes of major depression, or chronic mood symptoms for 2 years (odds ratio, 2.1; 95% confidence interval, 1.41-2.76). Patients with both risk factors were approximately 3 times more likely to relapse than patients with neither. CONCLUSIONS: The relapse rate among primary care patients treated for depression approached that of specialty samples, with more than one third reporting relapse in 1 year. Clinical characteristics can help target high-risk patients for relapse prevention efforts.

Socioeconomic status and health in women with systemic lupus erythematosus.

OBJECTIVE: Health outcomes of patients with chronic illnesses are commonly worse in people of lower socioeconomic status (SES). We investigated psychosocial factors that may mediate the relationship between SES and measures of morbidity in women with systemic lupus erythematosus (SLE). METHODS: We collected information on SES, psychosocial factors, and health status in a cross sectional survey of 100 women with SLE. SES was rated using the Hollingshead Two-Factor Index, a weighted average of years of formal education and occupational prestige (higher Hollingshead Index=lower SES). Health status measures included the Health Assessment Questionnaire Disability Index (HAQ), the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR), the Systemic Lupus Activity Measure (SLAM), and the SLE Disease Activity Index (SLEDAI). Potential mediators consisted of 18 environmental, medical care, social, psychological, and behavioral factors. RESULTS: Patients with higher Hollingshead Indexes (lower SES) had more functional disability as measured by the HAQ (r=0.22: p=0.03) and more cumulative organ damage as measured by the SLICC/ACR Damage Index (r = 0.19; p=0.06). SES was not related to either the SLAM or SLEDAI. Significant univariate associations were present between the Hollingshead Index and 10 potential mediating variables: household crowding, insurance status, organizational barriers to medical care, depression, health locus of control by powerful others, SLE knowledge, social support, marital status, body mass index, and regular alcohol use. However, in multiple linear regression analyses, only 3 of these variables modified the relationship between Hollingshead Index and the HAQ: more severe depression scores, higher body mass index, and more restricted access to medical care. More severe depression and greater locus of control by powerful others tended to mediate the relationship between low SES and greater organ damage. CONCLUSION: SES is related to morbidity in women with SLE. There are identifiable and potentially modifiable mediators of this relationship.

Systemic vasculitis. Diagnostic clues to this confusing array of diseases.

Systemic vasculitis can be difficult to recognize because of the many types of the disease and the conditions that can mimic it. However, early identification and initiation of treatment (often empirical) are important to avoid severe morbidity. In this symposium article, Dr Bush clearly describes the most common types of vasculitis according to current nomenclature based on the size of affected vessels. Illustrations of common signs of the various types of vasculitis are also included.

Achieving guidelines for the treatment of depression in primary care: is physician education enough?

OBJECTIVES: The authors examine whether physician education has enduring effects on treatment of depression. METHODS: Depressed primary care patients initiating antidepressant treatment from primary care clinics of a staff-model health maintenance organization were studied. Quasi-experimental and before-and-after comparisons of physician practices, supplemented with patient surveys, were used to compare the process of care and depression outcomes. Intervention consisted of extensive physician education that spanned a 12-month period. This included case-by-case consultations, didactics, academic detailing (eg, clearly stating the educational and behavioral objectives to individual physicians), and role-play of optimal treatment. Main outcome measures were divided into two groups. Quasi-experimental samples included: (1) antidepressant medication selection and (2) adequacy (dosage and duration) of pharmacotherapy. Survey samples included: (3) intensity of follow-up; (4) physician delivered educational messages regarding depression treatment; (5) patient satisfaction; and (6) depression outcomes. RESULTS: No lasting educational effect was observed consistently in any of the outcomes measured. CONCLUSIONS: There was no enduring improvement in the treatment of depression for primary care patients. Depression treatment guidelines were achieved contemporaneously, however, for intervention patients enrolled in a multifaceted program of collaborative care during the training period. These results suggest that continuing programs of reorganized service delivery to support the role of a primary care physician (eg, on-site mental health personnel, close monitoring of patient progress and adherence), in addition to physician training, are essential for the success of guideline implementation.

Serum complements. Inappropriate use in patients with suspected rheumatic disease.

BACKGROUND: The diagnostic value of serum complement testing is well established in inherited complement deficiencies and glomerulonephritis. Their utility is less certain in diagnosing rheumatic diseases. We noted that complement tests were frequently ordered for patients who were referred to our rheumatology clinic. We sought to determine the clinical rationale for ordering complement tests in our hospital and the effect of the test results in patients with rheumatic diseases. METHODS: We conducted a retrospective medical chart review of patients who had serum complement tests ordered at our hospital. We determined whether the test was ordered as a diagnostic tool in a patient with a suspected rheumatic disease. In these cases, we attempted to correlate the results of the complement tests with the patient's eventual diagnosis. RESULTS: We obtained the medical charts of 130 patients who had 307 complement assays (C3, C4, or total hemolytic complement) performed between October 1988 and July 1989. The tests were ordered for diagnostic reasons in 68% of the patients; 54% of these were ordered by nonspecialists. The complement tests were ordered on 28 patients with suspected rheumatic diseases. The three patients with hypocomplementemia did not have a connective tissue disease. The 10 patients who eventually were diagnosed as having rheumatic disease all had normal serum complement levels. Additionally, we found that 77% of patients had more than one complement assay ordered. The test results were discordant in only 24% of these cases. CONCLUSION: Complement screening is not a useful diagnostic test in most patients with suspected rheumatic disease. Despite their lack of established diagnostic value, these tests were frequently performed in our hospital. Judicious use of complement testing would provide substantial cost savings without a loss of clinically relevant information. When the complement testing is clinically indicated, clinicians should consider using a single C3 assay initially rather than multiple assays unless a hereditary deficiency is suspected.

Nonsteroidal anti-inflammatory drugs. Proposed guidelines for monitoring toxicity.

The most common toxicities of nonsteroidal anti-inflammatory drugs (NSAIDs) are gastropathy, renal dysfunction, and liver function abnormalities. We outline an approach to monitoring patients on long-term NSAID therapy, focusing on the early detection of complications. Gastropathy caused by NSAID use is more common in elderly patients or those with a history of dyspepsia, peptic ulcer disease, or alcohol abuse. Fecal occult blood testing and hemograms are less accurate in detecting gastropathy than direct visualization but are convenient and relatively inexpensive. We recommend the periodic use of these tests to detect NSAID-induced acute or chronic blood loss. Renal toxicity is seen in patients with preexisting renal disease or functional volume depletion and in the elderly. Complications include renal insufficiency, hyponatremia, hyperkalemia, and protein-uria. Renal function should be monitored during the first few weeks of NSAID therapy, especially in high-risk patients, with periodic testing thereafter. Hepatic toxicity is less common but warrants occasional determinations of alanine aminotransferase levels. Elderly patients and those with renal insufficiency or alcohol abuse have a higher risk of complications. Nonsteroidal anti-inflammatory drugs should be used cautiously in those patients at high risk for complications. Strategies can be used to limit toxicity. Patients taking these drugs long term should be monitored periodically for signs of blood loss, renal dysfunction, and hepatic dysfunction.