Expert assessment of patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common inflammatory disease of the locomotor system associated with early loss of function and joint destruction. A relevant number of patients with RA withdraw from employment within the first years. To give a medical opinion on patients with RA regarding ability for work requires thorough knowledge of the disease, its characteristic deformities and prognostic indicators as well as knowledge of the essential examinations and instruments for the estimation of functioning and disability.     

Clinical reliability of shoulder function assessment in patients with rheumatoid arthritis

A model for functional assessment and a dynamic test of the shoulder joint were designed and tested for normal variation and clinical inter- and intra-rater reliability. The functional assessments, which covered four common shoulder functions, were compared with assessments of pain, recordings of active motion range and the results of a Health Assessment Questionnaire, in eight patients with rheumatoid arthritis according to the ARA criteria. Intra-rater reliability was satisfactory for all four functions and inter-rater reliability was satisfactory for the hand-raising and hand-to-opposite-shoulder functions but less so for hand-behind-back and hand-to-neck. A second test-retest study in 15 patients, with a slight modification of one of the functional tests, confirmed the results and improved the reliability of the modified test. The reliability of the dynamic test and of the active motion range measurement was less satisfactory or not satisfactory. No significant correlation was found between shoulder functional assessment and the Fries index, but there were positive significant correlations between active motion range and shoulder functions. It is concluded that the method presented for evaluating shoulder functions has satisfactory reliability and in the first test-retest study was more reliable than conventional motion range measurement of the shoulder joint.     

Responsiveness of the shoulder function assessment scale in patients with rheumatoid arthritis

OBJECTIVES: To investigate the responsiveness of the Shoulder Function Assessment scale (SFA) in patients with rheumatoid arthritis (RA). METHODS: In 35 patients with RA receiving a (peri-)articular injection because of local shoulder complaints the SFA, impact of shoulder function on activities of daily living, active shoulder range of motion (ROM), the 28 joint count Disease Activity Score (DAS28), and the Health Assessment Questionnaire (HAQ) were measured before and 4-6 weeks after treatment. Responsiveness was determined using the standardised response mean (SRM), effect size (ES), and responsiveness ratio (RR). RESULTS: Overall, significant improvement was seen according to the SFA (mean change 10.9 (95% confidence interval 6.5 to 15.3)), active shoulder ROM (except external rotation), and the impact of shoulder function on daily activities. In addition, the DAS28 and HAQ scores improved significantly. The responsiveness of the SFA was excellent, with the SRM, ES, and RR being -0.86, -1.16, and 1.28, respectively. CONCLUSIONS: In addition to its good validity and reliability, the SFA proved to have a high sensitivity to clinical changes in patients with RA who received local treatment for shoulder complaints.     

A clinical and biochemical assessment of prinomide in patients with rheumatoid arthritis

Prinomide (CGS-10787B), a potential disease modifying drug, was evaluated clinically and biochemically in 15 patients with active rheumatoid arthritis. The single group study design included monthly assessments of 7 clinical measures and 22 laboratory measures. Twelve patients completed 24 weeks' therapy with prinomide 1.2 g/day. All clinical variables showed improvement which consistently reached statistical significance for articular index from Week 8 (p less than 0.01), for summated change score from Week 12 (p less than 0.01) and for pain score from Week 16 (p less than 0.05). Sustained significant improvement in laboratory variables was seen by Week 2 for erythrocyte sedimentation rate and platelet count (both p less than 0.05), and by Week 4 for plasma viscosity (p less than 0.01), IgG, IgA, IgM (all p less than 0.05).     

Efficacy of certolizumab pegol across baseline rheumatoid factor subgroups in patients with rheumatoid arthritis: Post-hoc analysis of clinical trials

Aim

Certolizumab pegol (CZP), an Fc-free, PEGylated tumor necrosis factor inhibitor (TNFi), has shown rapid and sustained reduction in signs and symptoms of rheumatoid arthritis (RA). Elevated rheumatoid factor (RF) level has been associated with RA disease progression and poorer TNFi response. We assessed the efficacy of CZP in patients with early and established RA across baseline RF levels.

Methods

This post-hoc analysis included data from 6 trials: C-OPERA (NCT01451203), pooled RAPID trials (RAPID-1 [NCT00152386], RAPID-2 [NCT00160602], J-RAPID [NCT00791999], RAPID-C [NCT02151851]), and EXXELERATE (NCT01500278). Patients who received CZP or placebo/comparator with methotrexate (MTX) were categorized by baseline RF quartiles. Efficacy was assessed with Disease Activity Score-28 erythrocyte sedimentation rate (DAS28-ESR).

Results

Overall, 316, 1537, and 908 patients were included in C-OPERA, pooled RAPID trials, and EXXELERATE, respectively. Patient demographics and baseline disease characteristics were similar between treatment groups and across RF quartiles. DAS28-ESR low disease activity (LDA) and remission (REM) rates were numerically higher in the CZP + MTX group than PBO + MTX group at weeks 12 and 24, across RF quartiles. LDA and REM rates in the CZP + MTX groups were comparable across RF quartiles at weeks 12 and 24. Mean DAS28-ESR decreased from week 0 to week 24 in the CZP + MTX groups, across RF quartiles.

Conclusion

CZP showed steady efficacy across baseline RF quartiles in patients with early and established RA, over 24 weeks. CZP treatment may be considered in patients with RA irrespective of baseline RF levels and time from diagnosis.     

Genotoxicity assessment using micronuclei assay in rheumatoid arthritis patients

OBJECTIVES: This study investigated whether: (i) rheumatoid arthritis (RA) patients have more micronuclei (MN) than healthy controls; (ii) methotrexate (MTX) treated RA patients have more MN than those not using MTX, and (iii) folic acid supplementation decreases the number of MN in MTX treated patients. METHODS: MN assays were performed in oral mucosa sweeps of 50 consecutive MTX treated RA patients, 30 consecutive RA patients not receiving MTX and 39 healthy controls. MTX treated RA patients were then randomly placed in a cross-over design to receive folic acid supplementation, and MN assays were repeated after 6 weeks. RESULTS: The MTX-RA patients had a mean age of 46 +/- 10 yrs and a mean disease duration of 12 +/- 9 yrs; 80% were women. The MTX dose range was 8.7 +/- 1.5 mg/week and the mean duration of use was 16 +/- 18 months. In the non-MTX RA group, the mean age was 48 +/- 14 yrs, the mean disease duration was 13 +/- 9 yrs, and 87% were women. At baseline, the number of MN were significantly higher in RA patients as compared with controls (3.31 +/- 2.3 vs 0.8 +/- 0.8, p <0.001). No difference in MN numbers was observed between users and non-users of MTX. Folic acid supplementation did not decrease the MN number in the MTX treated RA patients. CONCLUSIONS: Genotoxicity, as assessed by the MN assay, is increased in RA patients. These results suggest that genotoxicity is associated with RA itself and not with MTX use. Folic acid supplementation had no effect on the number of MN.     

Disease activity assessment and patient-reported outcomes in patients with early rheumatoid arthritis

Quantitative assessment of disease activity and patient-reported outcomes are recognized as valuable in the management of rheumatoid arthritis (RA). Complexities of assessment of RA include challenges concerning measures themselves, as a gold standard measure for disease status does not exist. This article discusses the hurdles in the implementation of quantitative assessment of RA in usual clinical care and also provides an example to monitor patients with early RA.     

Quantitative assessment of periarticular osteopenia in patients with early rheumatoid arthritis: a preliminary report

BACKGROUND: Involvement of the metacarpophalangeal (MP) joints is one of the major problems in patients with rheumatoid arthritis (RA). Although several data about the cumulative influence of steroid intake on bone are available, the course of demineralisation in RA has not been described by quantitative methods until now. PATIENTS AND METHODS: Computed tomography (CT) sections of 96 MP joints in 12 RA patients and of 32 MP joints in four age-matched healthy controls were investigated. Patients were classified according to Steinbrocker. Densitometric evaluation of subchondral bone density was performed by CT osteoabsorptiometry (CT-OAM). Quantitative CT-OAM was used to evaluate mineralisation of the articular surfaces in MP joints. RESULTS: In the distal articular surface of MP joints, the number of density maxima was reduced from 3 to 2.1+/-0.3, 1.9+/-0.5 and 1.3+/-0.3 in RA patients with early, mild to moderate, and severe disease, respectively. Means of calcium concentrations were 633.4+/-35. 3 mg Ca2+/mL, 518.9+/-56.2 mg Ca2+/mL, 497.7+/-23.8 mg Ca2+/mL and 455.1+/-28.6 mg Ca2+/mL for controls and RA patients with early, mild to moderate, and severe RA, respectively. Mineralisation of the distal articular surface was significantly reduced in all groups of RA patients [probability (p) = 0.005]. Regarding the number of density maxima, no differences were detected in the proximal articular surface of normal and RA fingers. However, mineralisation of the proximal articular surface was significantly reduced in all groups of RA patients (p = 0.004). Means of calcium concentrations of the proximal articular surface were 494.1+/-48.5 mg Ca2+/mL, 413.0+/-16.2 mg Ca2+/mL, 406.0+/-51.4 mg Ca2+/mL, 390,4+/-41.1 mg Ca2+/mL for controls and RA patients with early, mild to moderate, and severe RA, respectively. CONCLUSION: Patients with early and untreated RA show loss of mineralisation and altered morphology of the MP joints of the hand, even before corticosteroid therapy. CT-OAM provides evidence for an early alteration of functional anatomy in MP joints.     

Infectious arthritis in patients with rheumatoid arthritis.

Eleven cases of infectious arthritis occurring in patients with rheumatoid arthritis are reported. Staphylococcus aureus was the causative organism in eight patients. Streptococcus anginosus and Streptococcus agalactiae in one patient each, and Mycobacterium tuberculosis in two patients. The mean duration of symptoms before diagnosis was 16 days in patients with pyogenic arthritis. The diagnosis of joint infection caused by Mycobacterium tuberculosis was especially delayed (57 days). Four patients died; they were found to have a longer time to diagnosis and two of them had multiple joint infection. Although Staphylococcus aureus is the microorganism most often affecting patients with rheumatoid arthritis, infection caused by Mycobacterium tuberculosis must also be considered in such patients.     

Two methods of assessment of methotrexate hepatotoxicity in patients with rheumatoid arthritis.

Serial liver biopsy specimens from 18 patients with rheumatoid arthritis receiving a weekly dose of methotrexate 7.5-20 mg for a minimum of 12 months were assessed semiquantitatively and by a microcomputer image analysis system. The semiquantitative histological method showed a significant increase in pericellular collagen and in overall disease while morphometry showed a significant increase in pericellular, perivenular, and portal tract collagen. There was a significant correlation between the two methods, but morphometry had the advantage of objectivity and efficiency. There was no correlation between the increase in collagen and the accumulated dose of methotrexate, which suggests that other factors in addition to methotrexate may contribute to liver injury.     

Clinical assessment of the long-term risk of fracture in patients with rheumatoid arthritis

OBJECTIVE: To determine whether patients with rheumatoid arthritis (RA) have an increased risk of fracture, and to estimate their long-term absolute fracture risk. METHODS: We studied patients with RA ages >or=40 years in the British General Practice Research Database, each matched by age, sex, calendar time, and practice to 3 control patients. Incident fractures, as recorded in the computerized medical records, were ascertained over a median followup of 7.6 years. The fracture rate in RA patients compared with controls was adjusted for smoking, body mass index (BMI), and several clinical risk factors, and Cox proportional hazards models were used to calculate the relative risk (RR) of fracture in RA. A risk score was then developed to provide an estimate of the 5- and 10-year fracture risk among RA patients. RESULTS: There were 30,262 patients with RA, of whom 2,460 experienced a fracture during followup. Compared with controls, patients with RA had an increased risk of fracture, which was most marked at the hip (RR 2.0, 95% confidence interval [95% CI] 1.8-2.3) and spine (RR 2.4, 95% CI 2.0-2.8). Indicators of a substantially elevated risk of fracture (at the hip) included >10 years' duration of RA (RR 3.4, 95% CI 3.0-3.9), low BMI (RR 3.9, 95% CI 3.1-4.9), and use of oral glucocorticoids (RR 3.4, 95% CI 3.0-4.0). Modeling of the long-term risk profiles revealed that, for example, in a woman age 65 years with longstanding RA whose risk factors also included low BMI, a history of fracture, and frequent use of oral glucocorticoids, the 5-year risk of hip fracture was 5.7% (95% CI 5.3-6.1%). CONCLUSION: Patients with RA are at increased risk of osteoporotic fractures. This increased risk is attributable to a combination of disease activity and use of oral glucocorticoids.     

Objective assessment of abnormal gait in patients with rheumatoid arthritis using a smartphone

A disturbance in gait pattern is a serious problem in patients with rheumatoid arthritis (RA). The aim of the present study was to examine the utility of the smartphone gait analysis application in patients with RA. The smartphone gait analysis application was used to assess 39 patients with RA (age 65.9?±?10.0?years, disease duration 11.9?±?9.4?years) and age-matched control individuals (mean age, 69.1?±?5.8?years). For all RA patients, the following data were obtained: disease activity score (DAS) 28, modified health assessment questionnaire (mHAQ), and assessment of walking ability. Patients walked 20?m at their preferred speed, and trunk acceleration was measured using a Smartphone. After signal processing, we calculated the following gait parameters for each measurement terminal: peak frequency (PF), autocorrelation peak (AC), and coefficient of variance (CV) of the acceleration peak intervals. The gait parameters of RA and control groups were compared to examine the comparability of the 2 groups. Criterion-related validity was determined by evaluating the correlation between gait parameters and clinical parameters using Spearman??s correlation coefficient. The RA group showed significantly lower scores for the walking speed, AC, and CV than the control group. There were no significant differences in PF. PF (gait cycle) was mildly associated with gait speed (P?<?0.05). AC (gait balance) was moderately associated with the DAS, mHAQ, gait ability, and gait speed (P?<?0.05). CV (gait variability) was moderately associated with the DAS, gait ability, and gait speed (P?<?0.05). This is the first study to examine the use of a smartphone device for gait pattern measurement. The results suggest that some gait parameters recorded using the smartphone represent an acceptable assessment tool for gait in patients with RA.     

HLA-antigens in patients with rheumatoid arthritis

109 patients with rheumatoid arthritis (RA) from the north of the GDR were HLA typed and the antigen frequencies compared with those of a control group. Even in our patients the HLA-DR4 association was demonstrable. But in all studies DR4 association is not strong enough for taking HLA typing as a diagnostic test for RA. There was an immunogenetic heterogeneity in correlation to side effects of therapy with sodium aurothiomalate or D-penicillamine. HLA-DR5 was significantly increased in patients with side effects in comparison to patients without side effects in therapy. Before recommending HLA-DR typing for selection of high risk patients in D-penicillamine therapy these results should be proven in a large patient group or in a second study.     

���ʪ�ؽ��װ鷢ƶѪ���ٴ�����

目的探讨类风湿关节炎(RA)患者中贫血的发生率、严重程度及其与RA病情活动及治疗间的关系。方法对2002-07-2004-04在北京大学人民医院风湿免疫科住院的239例类风湿关节炎患者进行回顾性分析。结果(1)RA患者中贫血的发生率为51.4%,伴发贫血的程度为轻、中度的贫血;(2)RA贫血组患者和RA不伴发贫血组患者在病程、晨僵、血沉、C反应蛋白、双手X线分级方面的差异有显著性。(3)RA贫血患者和RA不伴发贫血患者在白细胞计数及血小板计数方面差异有显著性。(4)RA贫血患者住院前后的Hb水平存在显著性差异。结论(1)贫血是RA最常见的关节外表现之一,伴发贫血程度为轻、中度贫血。(2)RA伴发的贫血与病情活动性相关,病情活动性越高,贫血程度越重;并且贫血程度越重者,关节破坏越重,病情预后差。(3)RA贫血患者的血红蛋白水平可以随着抗风湿治疗后RA病情的好转而上升。     

Quality assessment of websites providing educational content for patients with rheumatoid arthritis

ObjectiveWe performed an environmental scan of currently available websites providing educational information about rheumatoid arthritis (RA) and evaluated the quality of these websites.MethodsWe searched three separate search engines, Google, Bing, and Ask.com, on August 27, 2015, using two search terms, “arthritis” and “rheumatoid.” Only patient education websites were included. Two independent investigators evaluated the accuracy, completeness, technical elements, design and esthetics, readability, usability, and accessibility of the websites. The navigation experience was also evaluated by an adult training expert.ResultsWe identified 46 websites. Nearly all websites (98%) provided accurate information. However, no website covered all essential RA topics. Common essential topics not covered included epidemiology, pathogenesis, treatment and disease monitoring, complications, self-management, risks and benefits of treatment, prognosis, treatment adherence, questions for patients to ask their doctors, and costs. For the technical elements, all websites disclosed their ownership, but the date that the content was last updated was mentioned in only 10 websites, ranging from 2007 to 2015. The mean reading level was grade 12.1 (standard deviation ±2.3). Most websites (78%) were easy to navigate but only 33% were friendly for people with visual and/or hearing impairments. The navigation experience was rated fair or poor in 41% of the websites.ConclusionCurrent patient information on the Internet does not comprehensively address all educational needs of patients with RA, and is often outdated. The findings from our study highlight potential areas for improvement in online education materials for patients with RA.     

Antibodies to dna in patients with rheumatoid arthritis and juvenile rheumatoid arthritis

Antibodies to double-stranded DNA (DSDNA) were found in 18 patients with RA, in 5 patients with JRA, and in 5 patients with undiagnosed connective tissue disease. Five patients had clinical features consistent with both RA and SLE, 11 with only RA, and 5 with only JRA. Based on these observations, the presence of serum anti-DSDNA antibodies should not be used as a sole criterion in the diagnosis of SLE.