Objective To compare the prevalence of left ventricular (LV) diastolic dysfunction in subjects with and without rheumatoid arthritis (RA), among those with no history of heart failure (HF), and to determine risk factors for diastolic dysfunction in RA. Methods We conducted a cross-sectional, community-based study comparing cohorts of adult RA and non-RA subjects without a history of HF. Standard 2D/Doppler echocardiography was performed in all participants. Diastolic dysfunction was defined as impaired relaxation (with or without increased filling pressures) or advanced reduction in compliance or reversible or fixed restrictive filling. Results The study included 244 RA subjects and 1448 non-RA subjects. Mean age was 60.5 years in the RA cohort (71% female) and 64.9 years (50% female) in the non-RA cohort. The vast majority (>98%) of both cohorts had preserved ejection fraction (EF≥50%). Diastolic dysfunction was more common in RA subjects at 31% compared to 26% (age and sex adjusted) in non-RA subjects (OR 1.6; 95% CI 1.2, 2.4). RA subjects had significantly lower LV mass, higher pulmonary arterial pressure, and higher left atrial volume index than non-RA subjects. RA duration and IL-6 level were independently associated with diastolic dysfunction in RA even after adjustment for cardiovascular risk factors. Conclusion Subjects with RA have a higher prevalence of diastolic dysfunction than those without RA. RA duration and IL-6 are independently associated with diastolic dysfunction suggesting the impact of chronic autoimmune inflammation on myocardial function in RA. Clinical implications of these findings require further investigation.

OBJECTIVE Inflammation and autoimmunity are associated with increased cardiovascular (CV) risk in rheumatoid arthritis patients. This association may also be present in those without rheumatic diseases. The purpose of this study was to determine whether rheumatoid factor (RF), antinuclear antibody (ANA), and cyclic citrullinated peptide antibody (CCP) positivity are associated with increased risk of CV events and overall mortality in both those with and without rheumatic diseases. METHODS We performed a population-based cohort study of all subjects who had a RF and/or ANA test performed between 1/1/1990 and 1/1/2000, and/or CCP test performed between 9/1/2003 and 1/1/2005, with follow-up until 4/1/2007. Outcomes were ascertained using diagnostic indices from complete medical records, including: CV events [myocardial infarction (MI), heart failure (HF), and peripheral vascular disease (PVD)], and mortality. Cox models were used to analyze the data. RESULTS There were 6783 subjects with RF, 7852 with ANA, and 299 with CCP testing. Of these, 10.4%, 23.9% and 14.7% were positive for RF, ANA and CCP, respectively. Adjusting for age, sex, calendar year, comorbidity and rheumatic disease, RF and ANA positivity were significant predictors of CV events (HR 1.24 & 1.26) and death (HR 1.43 & 1.18). Adjusting for age, CCP positivity was associated with CV events but this association was not statistically significant (HR 3.1; 95% CI 0.8, 12.3). CONCLUSIONS RF and ANA positivity are significant predictors of CV events and mortality in both those with and without rheumatic diseases. These results support the role of immune dysregulation in the etiology of CV disease.

PURPOSE The objective of this study was to determine the impact of lupus nephritis disease activity on maternal and fetal outcomes in pregnant patients with systemic lupus erythematosus (SLE). METHODS Medical records of all pregnant patients with SLE treated at our institution between 1976 and 2007 were reviewed. All patients met American College of Rheumatology classification criteria for SLE. Demographic data, history of lupus nephritis, nephritis disease activity, and maternal and fetal outcomes of pregnancy were abstracted. Active lupus nephritis was defined as the presence of proteinuria > 0.5 g/day and/or active urinary sediment with or without an elevation in serum creatinine (Cr). Quiescent lupus nephritis was confirmed in the presence of proteinuria < 0.5 mg/day and inactive urinary sediment. RESULTS We identified fifty-eight patients with ninety pregnancies. Compared to pregnancies in SLE patients without renal involvement (n=47), pregnancies in patients with active lupus nephritis (n=23) were associated with a higher incidence of maternal complications (57% vs. 11%, p<0.001), whereas those with quiescent lupus nephritis (n=20) were not (35% vs. 11%, p=0.10). Women with active lupus nephritis were more likely to deliver preterm than women without lupus nephritis, median of 34 weeks vs. 40 gestational weeks, respectively (p=0.002), and were more likely to suffer fetal loss (35% vs 9%, p=0.031). CONCLUSION Active, but not quiescent, lupus nephritis during pregnancy is associated with a higher incidence of maternal and fetal complications compared to pregnancies in SLE patients without renal involvement.

Objective. To investigate the incidence of noncardiac vascular disease in patients with rheumatoid arthritis (RA) and its relationship to systemic extraarticular disease in a community-based cohort.Methods. A retrospective medical record review of 609 patients with incident RA diagnosed during 1955-1994 was carried out in Olmsted County, Minnesota. Patients were followed up from 1955 to 2000 (median followup 11.8 years). Incident noncardiac vascular disease and severe extraarticular RA manifestations (including pericarditis, pleuritis, and vasculitis) were recorded according to predefined criteria, and incidence rates were estimated. Using Cox proportional hazards models, the risk (hazard ratio [HR]) of developing vascular events was assessed in patients with and without severe extraarticular RA.Results. Cerebrovascular and peripheral arterial events occurred in 139 patients (22.8%). The 30-year cumulative incidence rates of peripheral arterial events, cerebrovascular events, and venous thromboembolic events were estimated to be 19.6%, 21.6%, and 7.2%, respectively. The presence of severe extraarticular RA manifestations was found to be associated with all subgroups of noncardiac vascular disease except cerebrovascular disease alone (HR 2.3, 95% confidence interval [95% CI] 1.2-4.3 for peripheral arterial events; HR 3.7, 95% CI 1.3-10.3 for venous thromboembolic events; HR 1.5, 95% CI 0.7-3.2 for cerebrovascular events) after adjusting for age, sex, body mass index, smoking, and rheumatoid factor status.

Noninfectious ascending aortitis frequently occurs even in the absence of history, symptoms, or signs of giant cell arteritis (GCA) or PMR. When discovered, such patients should be followed closely, as a majority have additional vascular abnormalities. More studies are needed to determine optimal strategies for surveillance, detection, and treatment of ascending aortitis, which may represent a clinical entity distinct from classical GCA.

Rhino-orbitocerebral mucormycosis (ROCM) caused by more common zygomycetes (e.g., Mucor) is known to cause rapidly fatal infections in immunocompromised patients. Apophysomyces elegans is an emerging zygomycete that has been reported to cause invasive cutaneous and rhino-orbitocerebral infections in immunocompetent individuals. Limited data exist describing the syndrome of ROCM caused by A. elegans. We describe a recent case and performed a comprehensive literature review to delineate the clinical characteristics of ROCM caused by A. elegans. Our case is a 50-year-old man with diabetes mellitus who presented with facial pain and right eye proptosis. Endoscopic sinus sampling revealed A. elegans. He was treated with liposomal amphotericin B and multiple debridements, with no disease on 1.5-year follow-up examination. Seven cases were identified on literature review, including the present case. Most patients (86%) were male, with a mean age of 40 years. Most patients (71%) did not have predisposing medical conditions. Three patients had predisposing head trauma. All presented with facial and/or periorbital pain. All had magnetic resonance imaging or computed tomography of the head showing intraorbital and/or sinus inflammation. Diagnosis was confirmed by histopathology and deep tissue culture in all cases. All patients required eye exenteration and extensive surgical debridement, in addition to intravenous amphotericin B. Six of the seven patients (86%) recovered. ROCM caused by A. elegans is rarely reported in the literature. Most such infections occurred in immunocompetent patients, often after facial trauma. Survival in ROCM caused by A. elegans is favorable in reported cases, with prompt surgical debridement and antifungal therapy. Mucormycosis is a rare necrotizing infection caused by fungi within the class Zygomycetes and the order Mucorales (7). These fungi can cause serious and rapidly fatal infections, particularly in the immunocompromised, such as poorly controlled diabetics with ketoacidosis (17). The genera reported to cause invasive infection include Absidia, Mucor, Rhizomucor, Rhizopus, Apophysomyces, Saksenaea, Cunninghamella, Cokeromyces, and Syncephalastrum, with the first four being the most commonly reported pathogens (7). Apophysomyces elegans is an emerging pathogen that, unlike the other members of Mucorales, has been reported to cause invasive cutaneous and rhino-orbitocerebral infections in immunocompetent individuals (37). In rhino-orbitocerebral infections, inhalation is the natural route of infection. However, traumatic inoculation has been described, particularly with Apophysomyces elegans (17).In 2001, Garcia-Covarrubias et al. reported a review of the literature of mucormycosis attributable to Apophysomyces elegans (17). At that time, there were 21 reported cases of mucormycosis caused by A. elegans since 1985, only 4 of which were rhino-orbitocerebral mucormycosis (ROCM) (2-4, 8-10, 13, 17, 19-22, 24-28, 31, 36-37). Since then, there have been 13 more reported cases of Apophysomyces ...

Antimyeloperoxidase (MPO), perinuclear antineutrophil cytoplasmic antibodies (pANCA), and/or clinically evident vasculitis in patients with scleroderma have been reported only rarely. The clinical significance and prognosis of ANCA-associated vasculitis in systemic sclerosis is uncertain. To report a case and identify the clinical characteristics of scleroderma patients with ANCA-associated vasculitis. Patients with both vasculitis and scleroderma occurring between 1976 to 2006 were identified using an electronic diagnostic index. These diagnoses were confirmed by retrospective review of complete medical records. Clinical features and outcomes recorded included age at vasculitis diagnosis, connective tissue disease (CTD) features, type of scleroderma (limited or diffuse); ANCA serology, vasculitic organ system manifestations; and death. Fourteen cases of scleroderma patients with ANCA-associated and/or small vessel vasculitis were identified. The majority (71%) were female, with mean age at vasculitis diagnosis 53 years. Seven patients (50%) had overlap CTD features, and the majority (79%) had limited variant of scleroderma. All of the 10 patients tested were MPO and pANCA positive. Seven patients (50%) had glomerulonephritis, 11 (79%) pulmonary involvement including 3 with pulmonary-renal syndrome, 6 skin purpura, and 5 mononeuritis multiplex and/or peripheral neuropathy. Six patients (43%) died during followup to 2008. The presence of pANCA-associated small vessel vasculitis is a rarely reported complication of scleroderma. It occurs most commonly in women with limited scleroderma and most commonly includes pulmonary and/or renal involvement, including severe organ-threatening manifestations and death. Further studies are needed to clarify the role and clinical impact of ANCA in scleroderma patients with and without vasculitis.

Objectives ANCA-associated vasculitis (AAV) can affect all age groups. We aimed to show that differences in disease presentation and 6 month outcome between younger- and older-onset patients are still incompletely understood. Methods We included patients enrolled in the Diagnostic and Classification Criteria for Primary Systemic Vasculitis (DCVAS) study between October 2010 and January 2017 with a diagnosis of AAV. We divided the population according to age at diagnosis: &lt;65 years or ≥65 years. We adjusted associations for the type of AAV and the type of ANCA (anti-MPO, anti-PR3 or negative). Results A total of 1338 patients with AAV were included: 66% had disease onset at &lt;65 years of age [female 50%; mean age 48.4 years (s.d. 12.6)] and 34% had disease onset at ≥65 years [female 54%; mean age 73.6 years (s.d. 6)]. ANCA (MPO) positivity was more frequent in the older group (48% vs 27%; P = 0.001). Younger patients had higher rates of musculoskeletal, cutaneous and ENT manifestations compared with older patients. Systemic, neurologic,cardiovascular involvement and worsening renal function were more frequent in the older-onset group. Damage accrual, measured with the Vasculitis Damage Index (VDI), was significantly higher in older patients, 12% of whom had a 6 month VDI ≥5, compared with 7% of younger patients (P = 0.01). Older age was an independent risk factor for early death within 6 months from diagnosis [hazard ratio 2.06 (95% CI 1.07, 3.97); P = 0.03]. Conclusion Within 6 months of diagnosis of AAV, patients &gt;65 years of age display a different pattern of organ involvement and an increased risk of significant damage and mortality compared with younger patients.