The U.S. Veterans Health Administration national giant cell arteritis (GCA) database cohort: incident ophthalmic complications in biopsy-negative GCA patients.

INTRODUCTION/OBJECTIVES: This study aimed to identify the incidence of ophthalmic complications of giant cell arteritis (GCA) among subjects with negative temporal artery biopsy (TAB) and to determine if duration of prednisone exposure relative to GCA diagnosis was associated with ophthalmic complications in TAB-negative subjects. METHOD: The U.S. Veterans Health Administration (VHA) national database was queried for subjects between 1999 and 2017 with ICD-9/-10 diagnosis code for GCA, procedure code for TAB, and ICD-9/-10 diagnosis code for blindness, anterior or posterior ischemic optic neuropathy, or branch or central retinal artery occlusion. Pharmacy data regarding prednisone dispensation were collected. A Cox proportional hazard model was performed using ophthalmic complication by 1 year as the outcome variable in TAB-negative subjects, adjusting for age, TAB length, TAB laterality, and prednisone dose relative to GCA diagnosis date. RESULTS: Incident ophthalmic complication occurred by 1 year in 9.6% with positive TAB and in 6.2% with negative TAB. The majority of complications occurred within the first month for both groups. Compared to a reference group of prednisone initiation 0-14 days prior to GCA diagnosis, ophthalmic complications in TAB-negative subjects were significantly higher when prednisone initiation was delayed 14-28 days after GCA diagnosis. CONCLUSIONS: A substantial number of TAB-negative subjects accrued an incident ICD-9/-10 code for ophthalmologic complication within a year after diagnosis, most occurring within the first month. Delaying prednisone initiation 14-28 days after GCA diagnosis in TAB-negative subjects led to a 3.5-fold higher rate of ophthalmic events occurring by 1 year. Key Points • This study provides an incidence rate of ophthalmic complication by one year in biopsy-negative subjects suspected of having GCA. • Delaying prednisone initiation 14-28 days after GCA diagnosis in TAB-negative GCA subjects led to a 3.5-fold higher rate of ophthalmic events occurring by 1 year.

Determinants of Positive Temporal Artery Biopsies in the Veterans Health Administration National Database Cohort.

OBJECTIVE: This study sought to determine the effect of temporal artery biopsy (TAB) postfixation length, laterality, age, and prior prednisone exposure on TAB positivity utilizing the Veterans Health Administration national database. METHODS: Subjects with procedure code for TAB between 1999 and 2017 were queried, and pathology reports were reviewed manually. Demographic, laboratory, and prescription data were extracted. Multivariate analyses and logistic regression were run using Stata, version 13.0. RESULTS: A total of 3,057 pathology reports were reviewed; 306 biopsies (10%) were designated positive. The likelihood of a positive TAB significantly correlated with TAB postfixation length of >3.0 cm (odds ratio [OR] 1.58 [95% confidence interval (95% CI) 1.06, 2.36], P < 0.05) as well as with bilateral biopsy in 1 sitting (OR 1.83 [95% CI 1.29, 2.59], P < 0.01). Positive TAB also significantly correlated with age >71 years. Prednisone administration up to and beyond 42 days prior to TAB did not influence TAB result. CONCLUSION: This retrospective study examined predictors of TAB positivity and utilized national data collected on US veterans over the span of 18 years. The results suggest consideration of pursuing initial bilateral TAB or achieving a TAB postfixation length of at least 3 cm to improve yield. The results also agree with prior studies showing that pre-TAB steroid exposure does not appear to affect yield even up to and beyond 42 days prior to biopsy.

Pharmacist-managed titration of urate-lowering therapy to streamline gout management.

The treat-to-target approach for serum uric acid is the recommended model in gout management according to the 2012 American College of Rheumatology (ACR) guidelines. Adherence to urate-lowering therapy (ULT) can be difficult for patients due to barriers, which include medication burden, financial hardship, and lack of medical literacy. Our aim was to create a pharmacist-managed referral for the titration of ULT to target serum uric acid (sUA) levels in a complex patient population. We utilized a clinical database to query patients seen at a rheumatology clinic over a 12-month period with an ICD-10 diagnosis for gout. The referral criteria were indications for ULT per the 2012 ACR guidelines. Rheumatology providers, consisting of attendings, fellows, and a physician assistant, were asked to refer the identified patients to the pharmacist-managed titration program. The intervention group consisted of 19 referred patients and the control group consisted of 28 non-referred patients. The baseline sUA (median (IQR)) at the time of referral was 8.8 (2) mg/dL for the intervention group and 7.6 (2.8) mg/dL for the control group (p = 0.2). At the end of the study period, the sUA was 6.1 (1.4) mg/dL for the intervention group and 6.8 (3.2) mg/dL for the control group (p = 0.08). At the end of the study period, 6 of 19 (32%) intervention group and 7 of 28 (25%) control group were at goal (p = 0.3). A newly instituted pharmacist-managed titration program was able to achieve lower average sUA levels in referred patients compared to demographically similar individuals who received standard gout management.

Demographic, Clinical, and Immunologic Correlates among a Cohort of 50 Cocaine Users Demonstrating Antineutrophil Cytoplasmic Antibodies.

OBJECTIVE: Cocaine/levamisole-associated autoimmunity syndrome (CLAAS) is a poorly understood form of drug-induced autoimmunity. Our goals were to better characterize the spectrum of clinical and immunologic features of CLAAS, to identify demographic risk factors, and to generate new hypotheses regarding pathogenesis. METHODS: CLAAS subjects were identified between 2001 and 2015 at the University of Washington Medical Center, Harborview Medical Center, and affiliated clinics in Seattle, Washington, USA. Demographic, clinical, and immunologic variables were collected and correlated using contingency and logistic regression analyses. We used similar analyses to compare CLAAS subjects with all individuals exhibiting antineutrophil cytoplasmic antibodies (ANCA+) or cocaine use (Cocaine+) in an associated deidentified clinical data repository. RESULTS: We identified 50 CLAAS subjects. Compared to all Cocaine+ individuals (n = 2740), CLAAS subjects were more likely to be female and less likely to self-identify as black/African American. CLAAS subjects showed several ANCA patterns, including anti-MPO (myeloperoxidase)/anti-PR3 (proteinase 3) dual reactivity, a finding that appears to be specific to CLAAS. Hematologic, renal, and skin abnormalities were most frequently reported, including neutropenia and skin purpura. Finally, we observed strong, independent associations between the cytoplasmic ANCA (C-ANCA) pattern and mortality. CONCLUSION: We identify sex and race as important risk modifiers in the developing CLAAS among cocaine users. The development of C-ANCA was associated with increased mortality. Moreover, we confirm the enriched presence of anti-MPO/anti-PR3 dual reactivity in CLAAS, further supporting the diagnostic utility of this feature.