Objective To assess surface APRIL (a proliferation-inducing ligand; CD256) expression by circulating myeloid cells in rheumatoid arthritis (RA) and to determine its relationship to disease activity. Methods Peripheral blood mononuclear cells (PBMC) and plasma were obtained from patients with RA and healthy donors. PBMC were stained for flow cytometry to detect surface APRIL and blood cell markers to identify circulating myeloid cell subsets. Based on CD14 and CD16 phenotypes, monocyte subsets described as classical (CD14+CD16−), intermediate (CD14+CD16+), and nonclassical (CD14loCD16+) were identified. Levels of surface APRIL expression were measured by flow cytometry and median fluorescence intensity was used for comparisons. Levels of soluble APRIL in the plasma were determined by ELISA. Disease activity was measured by the Disease Activity Score in 28 joints. Results In patients with RA, total myeloid cells showed expression of surface APRIL that correlated with disease activity and with plasma APRIL levels observed in these patients. In healthy donors, classical monocytes were composed of > 80% of circulating monocytes. However, in patients with RA, the intermediate and nonclassical subsets were elevated and made up the majority of circulating monocytes. In contrast to healthy donors, where high levels of surface APRIL were only observed in nonclassical monocytes, patients with RA showed high levels of surface APRIL expression by all circulating monocyte subsets. Conclusion Surface APRIL is elevated in circulating myeloid cells in patients with RA where it is highly correlated with disease activity. Patients with RA also showed skewing of monocytes toward subsets associated with secretion of tumor necrosis factor-α and/or interleukin 1β.

Objective Finding a balance between clinical and scholarly productivity is a challenge for many academic clinician‐educator rheumatologists. An examination of workload and downstream revenue determines if the financial value generated by services rendered by rheumatologists are proportionate to the financial value created for a health system. A 2005 study found that academic rheumatologists generate $10.02 for every $1.00 they receive for an office visit. Methods A retrospective analysis of ordering and billing practices of 5 full‐time clinician‐educator rheumatologists from August 2017 to February 2019 was conducted. Individual workload is defined as averaged full‐time equivalent workload based on time spent on clinical and academic duties. Academic productivity was reviewed. Revenue‐generating activities that benefited the division directly and downstream revenue were collected. Revenue was extrapolated based on volumes of referrals, publicly available drug costs, and estimated Medicare reimbursement values (average sales price) of representative drugs. Results The total revenue by physician that benefited the division directly was $597,203, with evaluation and management codes accounting for $174,456. Downstream revenue by physician totaled $2,119,437. The largest contributor was from referrals to the hospital‐based infusion center, at $1,287,496. The downstream revenue generated by rheumatologist per dollar of evaluation and management services was found to be $12.14 ($9.37 in 2005 dollars). Conclusion For every $1 generated though office visits by 5 practicing academic rheumatologists at our institution, $12.14 was generated through downstream revenue, which, when adjusted for inflation, shows stability in the value generated by academic rheumatologists ($10.02 versus $9.37).

Rheumatic diseases cover a wide spectrum of conditions, including primary and secondary degenerative joint diseases and autoimmune inflammatory rheumatic diseases. The risks of cardiovascular disease and osteoporosis and resultant fractures in aging female rheumatic disease populations, especially those with autoimmune rheumatic diseases, are increased. Changes in the immune system in aging populations need to be considered especially among patients with autoimmune rheumatic diseases. Immunosenescence is closely aligned to reduced adaptive immunity and increased non-specific innate immunity leading to chronic inflammation of inflammaging. The effective use of disease-modifying antirheumatic drugs to control autoimmune rheumatic diseases may also mitigate factors leading to cardiovascular disease and osteoporosis. Rheumatic diseases, which largely manifest as arthritis, predispose patients to premature joint degeneration and poor bone health and therefore have a higher risk of developing end-stage arthritis requiring joint arthroplasties sooner or more often than other patients without rheumatic disease.

Rheumatoid arthritis is a chronic systemic autoimmune inflammatory arthritis with various extra-articular manifestations. In this first series examining the cutaneous manifestation of rheumatic diseases, we will discuss the most common dermatologic findings in patients with rheumatoid arthritis. Cutaneous lesions are the most common extra-articular findings. Rheumatoid nodules, accelerated rheumatoid nodulosis, and rheumatoid vasculitis are found especially in those with long-standing rheumatoid-factor-positive disease. Several neutrophilic dermatoses such as pyoderma gangrenosum, rheumatoid neutrophilic dermatoses, and Sweet's syndrome are also seen in association with rheumatoid arthritis. Patients may also present with various cutaneous adverse effects related to their arthritis therapy. It is important to recognize these dermatologic manifestations to better understand the underlying disease process, thus optimizing therapy and patient care.

Background/Objective: The aims of this study were to describe the rates and characteristics of nonelective 30-day readmission among adult patients hospitalized for acute gout and to assess predictors of readmission. Methods:We analyzed the 2017 Nationwide Readmission Database.Gout hospitalizations were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification code. Hospitalizations for adult patients were included. We excluded planned or elective readmissions. We utilized χ 2 tests to compare baseline characteristics between readmissions and index hospitalizations. We used multivariate Cox regression to identify independent predictors of readmissions.Results: A total of 11,727 index adult hospitalizations with acute gout listed as the principal diagnosis were discharged alive and included. One thousand five hundred ninety-four (13.6%) readmissions occurred within 30 days. Acute gout was the most common reason for readmission. Readmissions had higher inpatient mortality (2.4% vs 0.1%, p < 0.0001), greater mean age (68.1 vs 67.0 years, p = 0.021), and longer hospital length of stay (5.9 vs 3.8 days, p < 0.0001) compared with index hospitalizations. Charlson Comorbidity Index scores of ≥2 (score 2: adjusted hazards ratio [AHR], 1.67; p = 0.001; score ≥3: AHR, 2.08; p < 0.0001), APR-DRG (All Patients Refined Diagnosis Related Groups) severity levels ≥2 (level 2: AHR, 1.43; p = 0.044; level 3: AHR, 1.83; p = 0.002; level 4: AHR, 2.38; p = 0.002), admission to metropolitan hospital (AHR, 1.83; p = 0.012), atrial fibrillation (AHR, 1.31; p = 0.004), and anemia (AHR, 1.30; p = 0.001) were significantly associated with 30-day readmissions.Conclusions: Acute gout readmissions were associated with worse outcomes compared with index hospitalizations. Charlson Comorbidity Index scores ≥2, APR-DRG severity levels ≥2, admission to metropolitan hospital, atrial fibrillation, and anemia were significant predictors of readmission.