Advances in Rheumatology: 2013 ACR Roundup

Adapted from the Spring 2014 issue of Discovery to Recovery


Hospital for Special Surgery had a strong presence at the American College of Rheumatology (ACR) Annual Meeting in San Diego in October, presenting new findings from more than 60 accepted studies.

“HSS rheumatologists demonstrated their strong research productivity and leadership through their presentation of original research, as invited speakers in featured symposia, as moderators for meeting sessions and through participation in ACR committees and collaborative research groups,” says Mary K. Crow, MD, physician-in-chief, Benjamin M. Rosen Chair in Immunology and Inflammation Research and Joseph P. Routh Professor of Rheumatic Diseases in Medicine.

“Our scientists highlighted discoveries that provide new insights into the underlying mechanisms of rheumatic diseases and presented data that can guide clinical care of patients,” says Dr. Crow. “These investigations provide new concepts that will ultimately improve how we diagnose and treat rheumatologic diseases. Some findings can be immediately applied in clinical practice to optimize patient outcomes.” Studies ranged from basic science to population health.

Early RA Treatment Makes a Difference

HSS rheumatologist Vivian Bykerk, MD, and colleagues presented findings that early, effective treatment of rheumatoid arthritis (RA) reduces the amount of joint disability patients experienced two years after their diagnosis. This study points to the importance of finding an effective therapy without delay.

“We believe there is a window in which people have a much better chance of getting RA under good control, often with less intense therapy, and the window may well be within the first three months of developing joint inflammation,” says Dr. Bykerk. “The study’s findings should prompt doctors to warn patients about the hazards of delaying therapy and follow patients more often in the initial phases of treatment.”

Strong Support Systems Linked to Less Pain

HSS investigators also presented research showing a connection between social isolation and pain after hip replacement. Previous studies show that people lacking good social ties are at increased risk of other poor outcomes, such as a heart attack or stroke, compared to those who enjoy the social support of family, friends and community.

Lisa Mandl, MD, MPH, Danielle Ramsden-Stein, MD, and colleagues found that being socially isolated is associated with an almost three times increased risk of having severe pain after hip replacement surgery, even two or more years after surgery.

“We believe further prospective studies should be done to determine whether interventions to evaluate and improve patients’ social ties before surgery could lead to a better pain outcome after hip replacement,” Dr. Mandl notes. “It could be a way to improve outcomes without medication or other costly interventions. I see no downside to helping patients get the social support they may need to improve their quality of life.”

Improving Pregnancy Outcomes

Jane Salmon, MD, senior scientist and Collette Kean Research Chair, and colleagues discovered a biomarker linked to poor pregnancy outcomes in patients with lupus or antiphospholipid syndrome (APS). The study is part of an ongoing, multicenter research initiative led by Dr. Salmon known as PROMISSE, which is funded by the NIH.

“Pregnant women who have lupus or APS are at increased risk for adverse outcomes, particularly preeclampsia, yet identification of those destined for complications has been elusive,” says Dr. Salmon, director of the Lupus and APS Center of Excellence at HSS. The women participating in the study had their blood drawn monthly beginning 12 weeks into pregnancy. HSS scientists then compared clinical information to assays of blood proteins, which led them to identify, for the first time, a biomarker predictive of a poor pregnancy outcome.

Dr. Salmon and coinvestigators found that an imbalance in angiogenic factors (proteins required to support the growth of blood vessels that nourish the developing fetus) is associated with poor pregnancy outcomes in women with lupus.

They discovered that pregnant women with lupus who have increased levels of an anti-angiogenic protein called sFlt1 are at increased risk for placental insufficiency and preeclampsia, a potentially lifethreatening complication. High levels of sFlt1 reduce the activity of other angiogenic proteins that are necessary for the healthy growth of the placenta and maternal blood vessels.

“We now know that measurement of these proteins is a powerful tool to identify pregnant lupus patients at high risk for poor pregnancy outcomes sufficiently early to intervene,” Dr. Salmon says. “Hopefully, this will facilitate trials of novel treatments to prevent these devastating complications.”

Identifying Moral Dilemmas

Another study led by HSS rheumatologist C. Ronald MacKenzie, MD, found that many rheumatologists face moral dilemmas when trying to do what’s best for their patients in the current health care environment. After distributing a survey to ACR members, investigators found that a pressing ethical issue for many rheumatologists is their perceived need to ‘bend’ ethical norms and potentially compromise ethical principles in order to provide the care their patients need.

“Medical care takes place in a social context, and when it includes conditions that are unfair, healthcare practitioners may be forced to struggle with ethical conflicts,” Dr. MacKenzie says. “Awareness is the first step in finding solutions to the challenges that physicians face.” The C. Ronald MacKenzie Chair in Ethics and Medicine at HSS supports medical ethics research.

Improving Patients’ Lives

In addition to these studies presented at the conference, HSS rheumatologists continue to investigate root causes and mechanisms of rheumatic disease. Dr. Crow: “We remain dedicated to discovering new approaches for prevention, diagnosis and treatment to improve the lives of our patients.”

Read the full Discovery to Recovery Spring 2014 issue.

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Lisa Mandl, MD, MPH, talks with a patient.

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