Relative efficiencies of physician/assessor global estimates and patient questionnaire measures are similar to or greater than joint counts to distinguish adalimumab from control treatments in rheumatoid arthritis clinical trials

OBJECTIVE: To estimate relative efficiencies of the 7 rheumatoid arthritis (RA) Core Data Set measures to distinguish adalimumab from control treatments in 4 clinical trials. METHODS: Four adalimumab clinical trials were analyzed for arithmetic and percentage changes for each Core Data Set measure from baseline to endpoint: 3 assessor/physician measures -- swollen joints, tender joints, and global estimate; 1 laboratory test -- C-reactive protein; and 3 patient measures -- physical function, pain, and global estimate. Relative efficiencies of each measure to distinguish adalimumab from control group responses were assessed, with tender joint count as the referent measure. RESULTS: Relative efficiencies were in a similar range for physician/assessor, patient, and laboratory measures, with some variation between trials. Among physician/assessor measures, relative efficiencies for global estimates were greater than for swollen and tender joint counts in 8/8 comparisons. Among patient measures, relative efficiencies for global estimates were greater than for physical function and pain scores in at least 6/8 comparisons. Among all measures, relative efficiencies for patient global estimates were greater than for swollen joint counts in 5/8 comparisons, and for tender joint counts in 8/8 comparisons. CONCLUSION: Patient and physician/assessor measures distinguished adalimumab from control treatment groups in similar ranges. Among all measures, physician/assessor global estimate was most efficient, and tender joint count least efficient, in all 4 trials. This information suggests that while joint counts are the most specific measure to assess RA, their sensitivity to detect treatment effects in patients with RA is generally no greater, and usually less, than other measures.     

Successful treatment of rheumatoid arthritis is associated with a reduction in serum sE-selectin and thrombomodulin level

The aim of this study was to investigate the changes in serum levels of endothelial cell injury markers, soluble (s) E-selectin and thrombomodulin (TM), in patients with rheumatoid arthritis (RA) before and after antirheumatic drug treatment and to assess the relationship between these changes and clinical responses to the drug treatment. Eleven patients with RA having active arthritis and 12 healthy volunteers were enrolled in the study. They were monitored by clinical and laboratory parameters while receiving a combination of methotrexate, hydroxychloroquine and sulphasalazine. Pre- and post-treatment clinical and laboratory parameters, including sE-selectin and sTM levels, were measured. The ages of the patients were comparable with those of the control groups. Significant improvements were detected in erythrocyte sedimentation rate, C-reactive protein, hemoglobin, morning stiffness, patients global assessment, physicians global assessment, number of tender joints and number of swollen joints improved at the end of the therapy (for each parameter p<0.05). Significant improvements were detected in clinical and laboratory parameters. In the patient group there were significant decreases in the levels of sTM and sE-selectin after treatment (p<0.05). The patient group had significantly higher sTM and sE-selectin levels than the control group at the beginning of the study (p<0.01), but the difference returned to normal after the treatment (p>0.05). The sE-selectin and sTM levels significantly correlated with each other, and also with clinical and laboratory findings. Combination treatment successfully treated RA patients. sE-selectin and sTM levels probably reflect disease activity and can be helpful in monitoring disease status and response to therapy.Abbreviations ARDS Adult respiratory distress syndrome - ALT Alanine aminotransferase - ALP Alkaline phosphates - AST Aspartate - CRP C-reactive protein - CBC Complete blood count - DIC Disseminated intravascular coagulation - DMARD Disease-modifying antirheumatic drugs - ESR Erythrocyte sedimentation rate - GGT -glutamyl transpeptidase - HCQ Hydroxychloroquine - MTX Methotrexate - NSAID Non-steroidal anti-inflammatory drugs - PMN Polymorphonuclear - RA Rheumatoid arthritis - SSZ Sulphasalazine - TM Thrombomodulin     

Health-related quality of life in rheumatoid arthritis: therapeutic education plus pharmacological treatment versus pharmacological treatment only

Objective: To determine whether therapeutic education added to conventional drug therapy reduced disability and pain in patients with early rheumatoid arthritis (RA). Methods: Fourty-three patients with RA, 29F/14 M, were included in a randomized, controlled trial and assigned to a control group receiving conventional pharmacological treatment only (n=21), or an intervention group receiving therapeutic education added to conventional pharmacological treatment (n=22). The main outcome variable was self-reported disability on the Stanford health assessment questionnaire (HAQ). Results: At 18 months, patients in the intervention group had less disability (HAQ), pain intensity, number of tender and swollen joints, and patient’s and physician’s global assessments (p=0.003, 0.031, 0.003, 0.001, 0.014, and 0.004, respectively) compared with baseline, and improvements in disability and number of tender and swollen joints (p=0.024, 0.040, and 0.003, respectively), compared with controls. Conclusions: Patients receiving pharmacological treatment and therapeutic education had a better evolution than those receiving only pharmacological treatment.     

Clinical effects of actarit in rheumatoid arthritis: improvement of early disease activity mediated by reduction of serum concentrations of nitric oxide

OBJECTIVE: We previously reported the presence of high serum concentrations of nitric oxide (NO) in patients with rheumatoid arthritis (RA). In this study we evaluated the effect of actarit on patients with early and advanced stages of RA and the relationship between RA activity and serum NO levels. METHODS: Thirty-seven RA patients who were undergoing care at Sasebo Chuo Hospital were entered into the study. Patients were divided into two groups based on the severity of their disease: group I (stages I and II) and group II (stages III and IV). NO concentrations in serum samples were measured by the chemiluminescence method. RESULTS: Morning stiffness, the number of tender and swollen joints, grip strength, pain score, modified Health Assessment Questionnaire score (mHAQ), ESR, CRP and the Lansbury index significantly improved during 24 weeks of treatment in group I. Patients in group II did not show improvement in morning stiffness, pain score, ESR or CRP during treatment. The concentrations of NO in group I were significantly reduced at 8 weeks after administration of actarit. Those in group II showed a delayed response; a significant decrease in NO occurred at 20 weeks. The improvement in the number of tender and swollen joints, grip strength, pain score, mHAQ and Lansbury index noted in group I preceded the fall in NO concentrations. CONCLUSION: Our results demonstrate that actarit improves disease activity in early phase RA by suppressing serum NO levels. The results suggest that NO is a useful marker for monitoring improvement in the early stages of RA.     

Immediate and delayed effects of treatment at the Dead Sea in patients with psoriatic arthritis

The purpose of this study was to evaluate the immediate and delayed effects of balneotherapy at the Dead Sea on patients with psoriatic arthritis (PsA). A total of 42 patients with PsA were treated at the Dead Sea for 4 weeks. Patients were randomly allocated into two groups: group 1 (23 patients) and group 2 (19 patients). Both groups received daily exposure to sun ultraviolet rays and regular bathing at the Dead Sea. Group 1 was also treated with mud packs and sulfur baths. Patients were assessed by a dermatologist and a rheumatologist 3 days before arrival, at the end of treatment, and at weeks 8, 16, and 28 from the start of treatment. The clinical indices assessed were morning stiffness, right and left hand grip, number of tender joints, number of swollen joints, Schober test, distance from finger to floor when bending forward, patient's self-assessment of disease severity, inflammatory neck and back pain and psoriasis area and severity index (PASI) score. Comparison between groups disclosed a similar statistically significant improvement for variables such as PASI, morning stiffness, patient self-assessment, right and left grip, Schober test and distance from finger to floor when bending forward. For variables such as tender and swollen joints, and inflammatory neck and back pain, improvement over time was statistically significant in group 1. Addition of mud packs and sulfur baths to sun ultraviolet exposure and Dead Sea baths seems to prolong beneficial effects and improves inflammatory back pain. Received: 27 April 1999 / Accepted: 23 September 1999     

Clinical and ultrasound evaluation of the response to tocilizumab treatment in patients with rheumatoid arthritis: a case series

This case series evaluates the clinical and ultrasound response to tocilizumab treatment in patients with rheumatoid arthritis (RA). Six patients with active RA (DAS28 ≥ 3.2) for ≥6 months, refractory to conventional DMARDs or anti-TNF agents, received tocilizumab 8 mg/kg every 4 weeks, as monotherapy or in combination with DMARDs, for 6 months. The following clinical parameters were assessed monthly: number of tender joints (28 and 44 joints), number of swollen joints (28 and 44 joints), DAS28-ESR, DAS28-CRP, VAS score, global health status, health assessment questionnaire, patient global assessment of disease activity, physician global assessment of disease activity, functional assessment of chronic illness therapy (FACIT), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). All patients also underwent a gray-scale ultrasonography (US) assessment with power Doppler evaluation at each visit. All clinical parameters improved during the study, versus baseline. This improvement was statistically significant for most parameters 2 months following tocilizumab initiation and was sustained to the end of the observation period. The number of tender joints (44-joint evaluation), the FACIT score, and ESR and CRP concentrations were significantly improved versus baseline values after the first month of tocilizumab treatment. The course of US evaluations mirrored that of clinical parameters; a faster and more evident response was observed for foot joints, with respect to hand joints. This case series suggested the rapid clinical benefit of tocilizumab. Ultrasound assessment showed that the onset of this effect was faster in the foot joints than in the hand joints.     

Morning stiffness in patients with early rheumatoid arthritis is associated more strongly with functional disability than with joint swelling and erythrocyte sedimentation rate

OBJECTIVE: To compare the level of morning stiffness in a cohort of patients with early rheumatoid arthritis (RA), assessed on a self-report questionnaire, to levels of patient self-report scores and clinical and laboratory variables. METHODS: A total of 337 patients with recent onset RA since 1998 were assessed for tender and swollen joint counts, erythrocyte sedimentation rate (ESR), physician global assessment, and radiographs of the hands and feet, as well as Multidimensional Health Assessment Questionnaire (MDHAQ) scores for functional disability, pain, fatigue, global status, morning stiffness, and number of symptoms. Regression models were used to estimate possible associations between these variables and morning stiffness. RESULTS: At study entry, 70 patients (21%) reported no morning stiffness, 52 (15%) reported morning stiffness < 15 minutes, 52 (15%) for 16-59 minutes, and 163 (49%) for >/= 1 one hour. At baseline and in longitudinal analyses, morning stiffness was significantly associated with functional disability scores on the MDHAQ and with other patient self-report data, and was associated at lower levels with swollen and tender joint counts and erythrocyte sedimentation rate (ESR). CONCLUSION: The degree of morning stiffness appears to reflect functional disability and pain more than traditional markers of inflammation such as joint counts and ESR in patients with early RA. Inclusion of morning stiffness as a marker of inflammatory activity in classification criteria for RA, inclusion criteria for most clinical trials in RA, and RA remission criteria, may be open to reassessment.     

Efficacy of an Andrographis paniculata composition for the relief of rheumatoid arthritis symptoms: a prospective randomized placebo-controlled trial

Andrographis paniculata (Burm. f.) Wall ex Nees (Acanthaceae) possesses anti-inflammatory effects, attributed to the main constituent andrographolide proposed as alternative in the treatment of autoimmune disease. A prospective, randomized, double blind, and placebo-controlled study in patients with rheumatoid arthritis (RA) was performed. Tablets (Paractin®) made of an extract of A. paniculata (30% total andrographolides) were administered three times a day for 14 weeks, after a 2-week washout period to 60 patients with active RA. The primary outcomes were pain intensity measured using a horizontal visual analog pain scale (VAPS). In addition, ACR, EULAR, and SF36 clinical parameters were recorded. The intensity of joint pain decreased in the active vs placebo group at the end of treatment, although these differences were not statistically significant. A significant diminishing for week in tender joint ?0.13 95% confidence interval (CI; ?0.22 to 0.06; p?=?0.001), number of swollen joints ?0.15 95%CI (?0.29 to ?0.02; p?=?0.02), total grade of swollen joint ?0.27 95%CI (?0.48 to ?0.07; p?=?0.010), number of tender joints ?0.25 95%CI (?0.48 to ?0.02; p?=?0.033), total grade of swollen joints ?0.27 95%CI (?0.48 to ?0.07; p?=?0.01), total grade of tender joints ?0.47 95%CI (?0.77 to ?0.17; p?=?0.002) and HAQ ?0.52 95%CI (?0.82 to ?0.21; p?p?A. paniculata could be a useful “natural complement” in the treatment of AR; however, a larger trial and a more extended period of treatment is necessary in order to corroborate these results.     

Interleukin-10 promoter polymorphism in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease in which interleukin (IL)-10 plays an important role. There are, however, controversial reports that IL-10 promoter polymorphism may be an independent marker of susceptibility and severity of RA. The aim of the present study was to examine the IL-10 promoter polymorphism in patients with RA. We examined 95 patients with rheumatoid arthritis diagnosed according to the criteria of the American College of Rheumatology. Polymerase chain reaction amplification was used for analysis of the promoter polymorphism of the IL-10 gene. In RA patients, the prevalence of genotypes encoding high expression of IL-10 was observed. Nevertheless, there was no association between IL-10 genotypes and age at disease diagnosis, disease activity in a physicians global assessment, and joint and extra-articular involvement. There was also no correlation between IL-10 polymorphism and disease activity parameters—erythrocyte sedimentation rate, C-reactive protein, number of swollen and tender joints, and duration of morning stiffness. We suggest that IL-10 promoter polymorphism is not a genetic risk factor for RA activity.     

A pilot study of acupuncture as adjunctive treatment of rheumatoid arthritis

We evaluated the efficacy of acupuncture as a useful adjuvant treatment in the management of rheumatoid arthritis (RA). A pilot, randomized, double-blind, and controlled clinical trial was conducted. Forty RA patients with active disease despite stable therapy for at least the preceding 1 month were randomized to receive a standard protocol of acupuncture (AC) or superficial acupuncture at non-acupuncture points (controlAC) for 9 weeks. The primary outcome was achievement of 20% improvement according to the American College of Rheumatology (ACR) 20 criteria after five and ten treatment sessions and after 1 month of follow-up. Secondary measures included Disease Assessment Scale (DAS), tender and swollen joint count, morning stiffness, Health Assessment Questionnaire (HAQ), visual analogue scale (VAS) of pain, physician global assessment of activity disease, physician and patient global assessment of treatment, and inflammatory markers (erythrocyte sedimentation rate and C-reactive protein). There was not significant difference between the groups regarding the number of patients that reached ACR20 at the end of the treatment (p = 0.479). However, after 1 month of follow-up, there was a trend in favor of the AC group, with p = 0,068. Compared with the controlAC, the AC group also demonstrated significant improvement in the patient and physician global assessment of treatment and physician global assessment of disease activity, but there was no difference on other clinical and laboratorial measures. On the other hand, only the AC patients had within group improvement on the variables DAS, HAQ, morning stiffness, patient and physician global assessment of treatment, and physician global assessment of disease activity in comparison to baseline visit. Despite the improvement of some studied variables, there was no significant difference in the proportion of patients that reached ACR20 between the AC and controlAC groups. This negative result can be related to the small sample size, selection of patients, type of acupuncture protocol applied, and difficulties in establishing an innocuous and trustworthy placebo group to studies involving acupuncture.     

SPA therapy in fibromyalgia: a randomised controlled clinic study

Objective: The aim of the present study is to evaluate the effectiveness of spa therapy in the management of fibromyalgia. Methods: Thirty women with fibromyalgia were randomly assigned to either a spa therapy group or a control group. The spa therapy group (n = 16) had spa treatment for 2 weeks in addition to their medical treatment. The control group (n = 14) continued to have their medical treatment and/or daily exercises. An investigator who was blinded for the intervention assessed all the patients for 9 months. Improvements in Fibromyalgia Impact Questionnaire (FIQ), pain and number of tender points were primary outcomes. Secondary outcome measures were improvement in sleep disturbance, fatigue, gastrointestinal symptoms, anxiety, Beck Depression Inventory and patients global evaluation. Results: the spa group was found to be superior to the control group at the end of intervention in terms of FIQ, pain, tender point count, fatigue and patients global assessment. This superiority remained for 6 months in FIQ, 1 month in pain and tender point count. Conclusion: It was concluded that the addition of spa therapy to medical therapy has both short- and long-term beneficial effects in female patients with fibromyalgia.     

Patients with active rheumatoid arthritis but only few tender and swollen joints: a subgroup with impaired short term outcome

The disease activity score of 28 joints (DAS28) is now commonly used for the guidance of treatment decisions in rheumatoid arthritis (RA). The goal of this work was to determine whether patients with DAS28 > 3.2 but less than 2 swollen and 2 tender joints respond differently to treatment than patients with a higher number of active joints. One hundred and ninety two patients with active RA treated in a rheumatology hospital as in-patients were studied prospectively. At admission (T1), release (T2) and 3 months after release (T3) disease activity (DAS28-CRP at T1 + 2, RADAI at T1 + 3), pain (numeric scale at T1 − 3) and function (FFbH at T1 + 3) were measured. A total of 148 patients had two or more (group 1) and 44 less than 2 swollen and tender joints at admission (group 2) but both groups had similar over all DAS28-scores. The groups significantly differed in their outcome after 3 months: group 1 had a significant better reduction of disease activity, pain and functional deficit (p < 0.001 for the fulfilment of defined response criteria and p < 0.05 for comparison of the mean values for pain and function) in comparison to group 2. Although the numbers were small sub-analysis suggested that the differences might be due to a better response to newly administered DMARD and TNF-alpha-inhibitor therapy in group 1. Active RA patients with less than 2 swollen and 2 tender joints represent a subgroup with lower response to treatment with DMARD or TNF-alpha-inhibitors. This has to be taken into account in the management of these patients.     

Arthritis of the large joints - in particular, the knee - at first presentation is predictive for a high level of radiological destruction of the small joints in rheumatoid arthritis

OBJECTIVE: To investigate the predictive value of the distribution of inflamed joints at first presentation for the severity of the disease course in rheumatoid arthritis (RA). METHODS: Of the 1009 consecutive patients included in the Leiden Early Arthritis Clinic (Leiden, The Netherlands), 285 patients fulfilled the American College of Rheumatology criteria for RA within 1 year of follow-up. Of these, 28 patients achieved remission. Radiographs of hands and feet were scored according to the Sharp-van der Heijde method, and the 28 patients with the most destructive disease were selected. The distribution of inflamed joints of the patients with the extreme disease courses was compared. The association between the distribution of inflamed joints and the level of destruction of the joints of hands and feet in the whole group of patients with RA was assessed using regression analysis. RESULTS: Comparison of patients with extreme disease courses using univariate and logistic regression analyses showed that arthritis of the large joints - in particular, the knee - was associated with severe RA. In the whole group of patients with RA, the total number of swollen joints and the presence of knee arthritis were associated independently with the level of destruction of the small joints. Patients with RA with knee arthritis had higher C reactive protein (CRP) levels than patients without knee arthritis, and investigating the distribution of inflamed joints together with other variables yielded the number of swollen joints, CRP, presence of anti-cyclic citrullinated peptide antibodies and symptom duration as predictors for severity of RA. CONCLUSION: Arthritis of large joints - in particular, the knee - at first presentation is associated with a destructive course of RA.     

The influence of N-acetyltransferase 2 polymorphism on rheumatoid arthritis activity

OBJECTIVE: The N-acetyltransferase polymorphism is involved in the metabolism of many xenobiotics, as well as in susceptibility to some diseases such as rheumatoid arthritis (RA). The aim of this study was to investigate the influence of NAT 2 polymorphism on disease activity in RA patients. METHODS: 70 with RA were enrolled in the study. As a measure of disease activity, the number of swollen and tender joints, the duration of morning stiffness, ESR and CRP as well as disease activity based on a global physician's assessment were evaluated. The NAT2 polymorphism was determined by a polymerase chain reaction-restriction fragment length polymorphism assay (PCR-RFLP). RESULTS: The mean number of swollen and tender joints, as well as the ESR and CRP values, did not differ significantly with the acetylation genotype. Erosive RA was diagnosed in 74.5% of the slow and 40% of the fast acetylators. The risk for the development of erosive RA was 4.39 time greater in slow acetylators than in fast acetylators. CONCLUSION: NAT2 polymorphism may be a genetic risk factor for joint destruction.     

Clinical remission and/or minimal disease activity in patients receiving adalimumab treatment in a multinational, open-label, twelve-week study

OBJECTIVE: To evaluate the effect of adalimumab treatment on clinical remission and/or minimal disease activity (MDA) in 6,610 patients with active rheumatoid arthritis (RA) who were enrolled in the Research in Active RA trial, a multinational, open-label, 12-week study with an optional extension period. METHODS: Clinical remission was defined as a Disease Activity Score in 28 joints (DAS28)<2.6, Simplified Disease Activity Index (SDAI) score相似文献   

Pain and joint mobility explain individual subdimensions of the health assessment questionnaire (HAQ) disability index in patients with rheumatoid arthritis

OBJECTIVE: To explore the associations between individual subdimensions of the health assessment questionnaire (HAQ) and clinical variables in patients with rheumatoid arthritis. METHODS: 304 patients with rheumatoid arthritis (73% female, mean (SD) age, 58 (13) years; disease duration 6 (9) years, 69% rheumatoid factor positive) completed the HAQ for functional capacity (0-3) and a 100 mm visual analogue scale for pain. Grip strength, range of motion of the large joints, Larsen score for radiographic damage of hand and foot joints, and the number of tender and swollen joints were recorded. A logit regression model was used to study associations between subdimensions of the HAQ and other variables. RESULTS: Mean (range) total HAQ score was 0.92 (0 to 2.88) and varied from 0.73 to 1.04 in the subdimensions. Disability was lowest in the "walking" and highest in the "reach" subdimension. Pain was an explanatory variable in all individual subdimensions. Decreased grip strength, limitation of shoulder and wrist motion, and a larger number of swollen and tender joints in the upper extremities were related to several subdimensions. A higher pain score and swollen joint count in the upper extremities, decreased grip strength, and limited motion of wrist, shoulder, and knee joints explained increased disability (higher total HAQ scores). CONCLUSIONS: In patients with rheumatoid arthritis, pain and range of movements of joints have the greatest impact on individual subdimensions of the HAQ. Extent of radiographic damage in peripheral joints and the number of swollen and tender joints are of lesser importance for function.     

Declines in number of tender and swollen joints in patients with rheumatoid arthritis seen in standard care in 1985 versus 2001: possible considerations for revision of inclusion criteria for clinical trials

OBJECTIVE: To analyse tender and swollen joint counts in three cohorts of patients with rheumatoid arthritis (RA), with a focus on the proportions of patients who had fewer than 6-12 tender or swollen joints, as possible evidence based information toward more generalisable inclusion criteria for current and future RA clinical trials. METHODS: Tender and swollen joint counts were analysed in three cohorts of patients with RA: 125 in 1985, 138 in 2000, and 232 with early RA in 2001. RESULTS: The median numbers of tender joints were 11, 2, and 4 in 1985, 2000, and in early RA in 2001, respectively. The median numbers of swollen joints were 12, 6, and 5 in 1985, 2000, and 2001, respectively. The numbers of tender joints among 28 assessed were >or=12, >or=6, >or=4, and >or=3 in 47%, 80%, 85%, and 90% of patients in 1985; 20%, 37%, 44%, and 49% in 2000; and 17%, 37%, 50%, and 58% in early RA in 2001. The numbers of swollen joints among 28 assessed were >or=12, >or=6, >or=4, and >or=3 in 51%, 78%, 86%, and 90% of patients in 1985; 20%, 50%, 64%, and 67% in 2000; and 14%, 46%, 58%, and 72% in 2001. The number of patients with >or=6 tender or swollen joints in 1985 was greater than the number with >or=3 joints in 2000 and in early RA in 2001. CONCLUSION: Contemporary cohorts of patients seen in standard care have smaller numbers of tender and swollen joints than in previous times. These findings suggest that revision of inclusion criteria for numbers of tender and swollen joints in contemporary RA clinical trials might improve generalisability.     

Ultrasound assessment of enthesis thickening in psoriatic arthritis patients treated with adalimumab compared to methotrexate

The objective of the study was to combine ultrasonographic (US) with clinical findings for comparing the effect of adalimumab (ADA) to methotrexate (MTX) on the thickness of tendons and enthesis in psoriatic arthritis (PsA) patients. Forty-three consecutive PsA patients were examined at baseline and after 6 and 12 weeks of treatment with ADA or MTX. The US assessment included thickness measurement of the extensor (ET) and flexor tendons (FT) of the second and third finger of both hands, plantar aponeurosis (PA) and the Achilles tendon (AT) bilaterally. Disease activity (DA) was assessed by the number of tender (TJ) and swollen joints (SJ), the number of inflamed enthesis (IE), pain assessment (PAI), and patient (PDAI) and physician (PHDAI) disease activity evaluations by visual activity score (VAS). Nineteen patients received MTX and 24 patients received ADA. All DA parameters improved in both groups. A decrease in thickness of tendons and enthesis was observed only in the ADA group, reaching a level of significance for the left AT (p?=?0.01), left PA (p?=?0.007), the second left FT (p?=?0.04) and the third ET (p?=?0.04). ADA patients showed a trend towards a better response to treatment compared to MTX patients that reach significance at week 6 of treatment for the thickness of left AT (p?=?0.04), left PA (p?=?0.03), the number of TJ (p?=?0.0136), PAI (p?=?0.0028), and PDAI (p?=?0.029). ADA treatment for PsA compared to MTX significantly improved signs of DA and several US parameters. US assessment of enthesis can be an additional useful tool in the monitoring of psoriatic enthesopathy.     

Reliability of self assessed joint counts in ankylosing spondylitis

OBJECTIVE: To determine the reliability of self reported joint counts to assess pain or swelling in ankylosing spondylitis (AS). METHODS: 217 outpatients fulfilling the modified New York criteria for AS were asked to mark painful joints and swollen joints on two mannequins presenting 44 and 40 joints respectively. A doctor or research nurse assessed the same joints for pain and swelling on the same day, after completion by the patient, without information on the results of the patient's assessment. RESULTS: Forty six (21%) patients reported one or more swollen joints (mean number of swollen joints 0.5, range 0-8); the doctor found one or more swollen joints in 54 (25%) of the patients (mean number of swollen joints 0.8, range 0-31). The overall agreement on the number of swollen joints between patients and doctor was moderate (intraclass correlation coefficient (ICC) 0.53). Agreement on individual swollen joints was poor to moderate (kappa 0.1-0.64). 128 (60%) patients reported tender joints (mean number of joints 2.4, range 0-26). The doctors reported one of more tender joints in 50% of the patients (mean number of tender joints 2.2, range 0-34). The overall agreement was also moderate (ICC 0.71). The agreement on individual tender joints was again poor to moderate (kappa 0.19-0.43). There was only high concordance between doctors and patients on the absence of swollen joints (82%). The concordance on the presence of monoarthritis, oligoarthritis, or polyarthritis was low (17-22%). CONCLUSION: Owing to these discrepancies in assessment of individual joints and total number of affected joints, joint counts in AS assessed by doctors cannot be replaced by joint counts reported by the patients. Patients are only able to judge if their joints are not swollen.     

Validation of patient-reported joint counts in rheumatoid arthritis and the role of training

OBJECTIVE: To demonstrate the effectiveness of simple training on improving the ability of patients with rheumatoid arthritis (RA) to assess joint swelling, and to validate the use of a computerized questionnaire, the Health Assessment Questionnaire (HAQ-ulous), to collect patient-reported tender and swollen joint counts. METHODS: Sixty patients completed the HAQ-ulous, reporting pain and swelling of the 28 joints included in the Disease Activity Score-28. A rheumatologist blinded to the patients' responses assessed each joint for the presence of tenderness and swelling. At followup visits, 30 patients received training in distinguishing a swollen joint from a chronically enlarged joint, completed the HAQ-ulous again, and were reassessed by the physician. RESULTS: At the initial visit, a strong correlation was shown between patient- and clinician-reported tender joints [Pearson correlation coefficient (r(p)) = 0.79; p < 0.0001]. Correlation between patient- and clinician-reported swollen joints was less robust (r(p) = 0.41; p = 0.001). Following training at the second visit, agreement between patients and the clinician improved for both tender joints (r(p) = 0.94; p < 0.0001) and swollen joints (r(p) = 0.93; p < 0.0001). CONCLUSION: With simple training in distinguishing swollen joints from chronically enlarged joints, the majority of patients are able to accurately assess joint swelling. Objective tools, such as the HAQ-ulous, that incorporate patient-reported outcomes are a valuable and reliable addition to standard clinical practice for monitoring patients with RA.