Serum Levels of Hyaluronic Acid in Patients with Psoriatic Arthritis

The purpose of this study was to evaluate the serum levels of hyaluronic acid (HA) in a group of patients with psoriatic arthritis (PsA), with special emphasis on the relationships between HA levels and clinical parameters of joint and skin activity. Thirty-four patients with PsA, 34 patients with rheumatoid arthritis (RA) and 49 healthy volunteers participated in the study. Assessment of joint disease in patients with PsA included duration of morning stiffness, number of tender and swollen joints, right and left grip, the presence of inflammatory back pain and Schober’s test. The current severity of skin involvement was graded according to the Psoriasis Area Severity Index (PASI). Serum levels of HA were measured by a radiometric assay. The mean HA serum levels of patients with PsA and RA were significantly increased in comparison with healthy controls (107 ± 39.6 μg/dl in patients with PsA, whereas in patients with RA it was 168 ± 32.4 μg/dl and 36.7 ± 5.5 μg/dl in healthy controls). A highly significant correlation was found between levels of HA and index of skin involvement, but no association was found between HA levels and clinical parameters of joint severity. We conclude that in this cohort of patients with PsA, HA levels clearly reflected psoriatic skin involvement although it did not correlate with joint disease. Received: 18 June 1999 / Accepted: 5 April 2000     

Serum levels of IL-10, IL-6, IL-1ra, and sIL-2R in patients with psoriatic arthritis

Our objective was to evaluate the levels of interleukin-6 (IL-6), soluble receptors of IL-2 (sIL-2R), IL-10, and IL-1 receptor antagonists (IL-1ra) in the serum of patients with psoriatic arthritis (PsA) and to assess the correlation between these levels and parameters of clinical activity of skin and joint disease. In total, 34 patients with PsA and ten healthy volunteers participated in the study. Assessment of joint disease included duration of morning stiffness, number of tender and swollen joints, right and left grip, the presence of inflammatory spinal back pain, and Schober test. Current severity of skin disease was graded according to the psoriasis area and severity index (PASI). Erythrocyte sedimentation rate (ESR) was determined as a marker of disease activity. Serum levels of IL-6, sIL-2R, IL-1ra, and IL-10 were measured by an enzyme immunoassay kit. Significantly higher serum levels of IL-6, sIL-2R, IL-1ra, and IL-10 were found in patients with PsA in comparison with healthy volunteers. A statistically significant correlation was found between levels of sIL-2R and PASI, whereas no association was found with clinical parameters of joint severity. Levels of IL-1ra correlated with the number of tender and swollen joints. No correlation was found between levels of IL-6, IL-10, and clinical parameters of skin and joint severity. In the group of patients with PsA, serum levels of sIL-2R clearly correlated with severity of skin disease, whereas levels of IL-1ra were associated with joint severity. Received: 18 June 1999 / Accepted: 1 October 1999     

Associations of Isokinetic Knee Extensor and Flexor Strength with Steroid Use and Walking Ability in Women with Rheumatoid Arthritis

Seventy-five women with rheumatoid arthritis according to the 1987 criteria of the American Rheumatism Association were examined. Mean age was 61.9 ± 12.5 years, mean disease duration 14 years. Sixty-three were or had been on steroids (median cumulative prednisolone dose 2.5 g). Maximal voluntary knee extensor and flexor strength (Nm) was assessed at 30°/s by an isokinetic dynamometer. Walking ability was expressed as walking and stair-climbing time (s). Markers of disease activity included number of swollen and tender joints, pain as recorded by the patients on a visual analogue scale (VAS), and disability as scored by the Stanford Health Assessment Questionnaire (HAQ). Muscle strength, walking time (50 m) and stair-climbing time were reduced on average by 30%, and increased by 28% and 54% (p<0.0001), respectively, compared to 67 age-, weight- and height-matched healthy women. Associations between muscle strength and cumulative or current steroid dose were not found after correction for age and disease duration. Significant linear correlations were found between knee extensor strength and walking time (r=−0.78, p<0.0001) and stair-climbing time (r=−0.76, p<0.0001). Similar correlations were found for flexor strength. The correlations remained significant (R_partial ranging from −0.64 to −0.69, p<0.0001) in multiple regression analyses adjusting for age, height, weight, disease duration, number of swollen and tender joints, and VAS and HAQ scores. In conclusion, negative effects of steroids on muscle strength were not demonstrated. Leg muscle strength is an important and independent determinator of walking ability in RA. Received: 18 September 2000 / Accepted: 22 December 2000     

Treatment of active psoriatic arthritis with the PPARgamma ligand pioglitazone: an open-label pilot study

OBJECTIVES: Psoriatic arthritis (PsA) is an inflammatory joint disease, in which early neovascularization of affected skin and synovial tissue represents an important pathogenetic step in the disease process. Activation of the peroxisome proliferator activated receptor gamma (PPARgamma) showed anti-inflammatory effects in several in vitro and in vivo models (e.g. collagen-induced arthritis) by inhibition of angiogenesis and suppression of proinflammatory cytokines. Therefore, we studied the use of pioglitazone, a PPARgamma agonist originally developed for the treatment of diabetes, in patients with PsA. METHODS: Ten patients with active PsA, seven males and three females, who showed at least two tender and two swollen joints despite stable treatment with an NSAID, were enrolled in this open-label study. All patients received a daily dose of 60 mg pioglitazone while continuing their current NSAID therapy. The primary endpoint was the PsARC (Psoriatic Arthritis Response Criterion); the secondary endpoints included the ACR20 response and improvement in the Psoriasis Area and Severity Index (PASI) in patients with more than 2% skin involvement. Patients were evaluated for endpoints at baseline and after 12 weeks. RESULTS: After 12 weeks, six of 10 patients met the PsARC. The ACR20 response was achieved in five patients. The mean percentage reduction in PASI was 38%, with a clinically meaningful PASI 50 response in two of six patients. Median tender joint count (interquartile range) decreased from 12.0 (8.0-18.0) to 4.0 (2.0-10.0), and the median swollen joint count from 5.0 (4.0-8.0) to 2.0 (1.0-7.0) (P<0.05 for both). Median Health Assessment Questionnaire score changed from 1.0 (0.375-1.375) to 0.75 (0.375-1.0) (P<0.05). Three patients had to be withdrawn from the study due to inefficacy and side-effects. Major side-effects were oedema of the lower extremities and increase in weight. CONCLUSIONS: Treatment with a PPARgamma agonist appears to be a promising therapeutic principle in PsA, but the use of PPARgamma ligands might be limited by side-effects such as increase in weight and fluid retention.     

PSORIATIC ARTHRITIS: OUTCOME OF DISEASE SUBSETS AND RELATIONSHIP OF JOINT DISEASE TO NAIL AND SKIN DISEASE

Subgroups of PsA have been described but their relationshipto the mode of onset of arthritis, to DIP joint disease andto nail and skin disease remains controversial. Therefore, thepattern of disease was documented in 100 patients with PsA inwhom the mode of onset was known. The patients were dividedinto six subgroups: monoarthritis; DIP joint disease only; oligoarthntis;polyarthritis; spondyloarthropathy and arthritis mutilans. Sixty-fourpatients changed pattern. Nail disease (67% of total) was morecommon in patients with DIP joint disease (27% of total) andwas significantly associated with adjacent DIP joint disease.Skin and nail disease severity did not correlate with jointseverity, joint activity or functional status, nor differ betweensubgroups. Therefore, the mode of onset does not predict outcomein the majority. The topographic association of nail diseaseand involvement of the adjacent DIP joints suggests a commonlocal inflammatory mechanism. KEY WORDS: Arthritis, Psoriasis, Nail dystrophy, Spondyloarthropathy, Classification     

Radiologic changes of cervical spine in ankylosing spondylitis

Ankylosing spondylitis (AS) is characterised by its effects on the axial skeleton. The cervical spine is also vulnerable to the disease process. Our aim was to determine the frequency of radiologic changes to the cervical spine and their correlation with clinical variables. We also used the Bath Ankylosing Spondylitis Radiology Index (BASRI) system, which is one of the reliable scoring systems of radiography, to score the global radiologic changes to the cervical and lumbar spine and the hip joints in our AS cohort. There were 181 patients with anteroposterior and lateral full-flexion views on radiography of the cervical spine here included in the study. A radiologist examined the radiologic changes to all anatomical compartments of the cervical spine in detail and graded them according to the BASRI system. We used the clinical and demographic data of our AS cohort to determine their relation to the radiographic changes. Eighty-eight patients (48.6%) showed radiological changes to the cervical spine; to the discovertebral joint 35.9%; the apophyseal joint 26.0%; atlantoaxial articulation 22.1% (atlantoaxial subluxation 13.8%); the costovertebral joint 18.2%; and to the posterior ligamentous attachment 11.6%. Using the BASRI system, 73 patients (40.3%) showed radiologic changes to the cervical spine and were graded as score 1 (1.7%), 2 (22.7%), 3 (6.6%) or 4 (9.4%). Among those graded as normal by the BASRI system, 17 showed some changes to the cervical spine, such as atlantoaxial joint subluxation or narrowing, and severe osteoporosis with no other radiographic changes. Current age, disease duration, inflammatory back pain and cervical symptoms were associated with the radiographic changes to the cervical spine. The BASRI-cervical spine score correlated with the BASRI-lumbar spine and hip joint score, sacroiliitis, disease duration, and duration of inflammatory back pain and cervical symptoms. Our data suggest that radiographic changes to the cervical spine are frequent in AS, and can be predicted in the patients with old age, long duration of disease and inflammatory back pain, and cervical symptoms. Also, the BASRI scoring system showed similar results as a detailed assessment of the cervical spine in our study. Received: 25 August 2000 / Accepted: 14 March 2001     

Systems to assess the progression of finger joint osteoarthritis and the effects of disease modifying osteoarthritis drugs

Our objective was to assess the progression of osteoarthritis (OA) using scoring systems based on the anatomical changes recorded in the finger joints on standard radiographs and to test how far these scoring systems could be used to evaluate the effects of candidate ‘disease modifying osteoarthritis drugs’ (DMOAD). The appearance and growth of osteophytes, narrowing of the joint space and subchondral bone changes allowed the classic OA-associated anatomical lesions to be used to score the progression of finger joint OA. Progression of OA in the finger joints was also assessed by the their evolution through previously described and predictable anatomical phases on standard X-rays. These phases were characterised by complete loss of the joint space preceding or coinciding with the appearance of subchondral cysts eroding the entire subchondral plate, and have been described in ‘inflammatory’ or ‘erosive’ OA. The erosive episodes were followed by processes of remodelling. In order to interfere with the progression of osteoarthritis, two chondroitin sulphates with possible DMOAD effects were used in two series of patients with OA of the finger joints. The patients were included in two separate randomised, double-blind placebo-controlled trials: 46 of them received chondroitin polysulphate and 34 received chondroitin sulphate. Eighty-five patients were kept on placebo medication and were used as controls. All 165 patients were followed for 3 years. Posteroanterior X-rays of the metacarpophalangeal and interphalangeal (IP) finger joints were obtained at the start of this prospective study and at yearly intervals thereafter. Almost 80% of the distal IP and 50% of the proximal IP were affected at study entry. In approximately 40% of the patients the classic picture of OA of the IP joints was complicated by manifest erosive OA changes. The two systems to score the progression of OA (Anatomical Lesion and Anatomical Phase Progression Score System) showed definite progression within 3 years of follow-up, especially in the IP joints. When compared with the placebo controls, none of the chondroitin sulphates prevented OA from occurring in previously normal finger joints. However, when the classic OA-associated anatomical lesions were considered, OA was less progressive in both active treatment groups. Furthermore, fewer patients from both chondroitin sulphate- and chondroitin polysulphate-treated groups developed ‘erosive’ osteoarthritis. In conclusion, conventional radiographs can be used to assess the morbidity and progression of hand OA. The systems used to score the progression of finger joint OA allowed the DMOAD effects of both chondroitin sulphates to be evaluated. The data recorded during these pilot studies should help investigators to design future long-term clinical experiments. Received: 23 July 2001 / Accepted: 12 December 2001     

The Use of Two Different Health Assessment Questionnaires in Turkish Rheumatoid Arthritis Population and Assessment of the Associations with Disability

The aim of this study was to compare and evaluate the Health Assessment Questionnaire (HAQ) and Arthritis Impact Measurement Scale (AIMS) in our patient population with rheumatoid arthritis (RA) and also to find some associations with clinical assessment of disability. One hundred and twenty-three consecutive adult patients with RA were included in the study. Pain, and global assessments by patients and physicians were recorded using a 10 cm visual analogue scale. Each patient completed the HAQ and AIMS questionnaires. Correlations among tender and swollen joint counts, erythrocyte sedimentation rate, pain, and AIMS anxiety and depression scores were all investigated. Pearson correlation was used to assess the possible correlations between each questionnaire and clinical variables. Pain and the AIMS subscales of mobility, dexterity, social activity and activities of daily living correlated with global assessments by patients and physicians, and tender joint counts. Depression correlated with pain and disability (HAQ). It was also of note that we observed high intercorrelation between the global assessments of physicians and patients. It was concluded that a measure of functional status, patient global assessment and pain score should be considered as important in the evaluation of RA patients. Measuring psychological well-being also provides further information. The HAQ, with the addition of the anxiety and depression sections of AIMS (CLINHAQ), provides the advantage of a global evaluation of these chronically ill patients. Received: 20 May 1997 / Accepted: 10 August 1998     

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.     

Standardising joint assessment in rheumatoid arthritis

Summary Evaluating joint involvement in rheumatoid arthritis in a key clinical assessment. We investigated the extent of variation in measurement of joint swelling and tenderness and evaluated the impact of training to standardise methods. Eight observers (medical and nursing staff) examined eight rheumatoid patients for joint swelling and tenderness before and after training in clinical methods. The EULAR handbook for joint evaluation was used for training and assessments were based on the 28 joint count. There was extensive variability in both numbers of swollen and tender joints. Coefficients of variation for articular indices recorded by the 8 observers in individual patients were often high (up to a maximum of 204%), indicating considerable differences between observers. Training had an impact on the assessment of the numbers of swollen joints which increased by a mean of 32% (P<0.05) and the number of tender joints which increased by 41% (p<0.01). Training had only a limited impact on the variation among observers in determining the number of swollen and number of tender joints. After training, the mean coefficients of variation were still 59% for swollen joints and 65% for tender joints. These results highlight the extent of variation in clinical assessment of rheumatoid arthritis and show the advantages of training. It leads to increased sensitivity of measurement. Standardisation appears essential for clinical studies.     

Mud compress therapy for the hands of patients with rheumatoid arthritis

Objective The aim of this study was to evaluate the efficacy of home treatment with mud compresses for the hands of patients with rheumatoid arthritis (RA).Methods Forty-five patients suffering from RA were enrolled in a double-blind, randomized, controlled study. Twenty-two were treated with true mud compresses (treatment group) and 23 were treated with attenuated mud compresses (control group). The compresses were applied in the patients homes five times a week during a 3-week period. Patients were assessed four times: at baseline, upon completion of the 3-week treatment period, 1 month after the treatment, and 3 months after conclusion of the treatment period. Positive response was defined as reductions of 30% or more in the number of tender and swollen joints, 20% or more in physician global assessment of disease activity, and 20% or more in patient global assessment of the severity of joint pain.Results In the treatment group, significant reductions in the number of swollen and tender joints and patients global assessments of pain severity was observed at all post-treatment assessments. Significant improvement in the scores of physician global assessment was seen at the end of therapy and 1 month later. In the control group, no improvement in the number of swollen and tender joints or physician global assessment was found in any post-treatment evaluation. However, a significant reduction in patient global assessment of joint pain severity was reported at the end of therapy and 3 months after concluding treatment.Conclusion Treatment with mud compresses relieves pain affecting the hands and reduces the number of swollen and tender joints in the hands of patients suffering from RA. This treatment can augment conventional medical therapy in these patients.     

Lumbar stiffness but not thoracic radiographic changes relate to alteration of lung function tests in ankylosing spondylitis

Involvement of the costovertebral (CV) and costotransverse (CT) as well as the sacroiliac (SI) joints is known to occur in patients with ankylosing spondylitis (AS). The functional significance of these changes is not clear. We have performed clinical and radiological evaluations and assessed the effect of joint involvement on pulmonary function. We detected radiologic evidence of involvement of the CV joint in 80% of patients and of the CT joint in 60 %. We found a direct relation between the severity of CV, CT and SI joint affliction, and the severity of CV and SI joints were related to time of evolution of the disease. Pulmonary function tests revealed neither restrictive nor obstructive defects. No relation was found between pulmonary function and CV and CT joint affliction. Patients with stiffer spines had a tendency to have pulmonary function tests within the lower limit of the normal range. In patients with AS diaphragmatic breathing might compensate the chest respiration to some extent. Received: 2 July 2001 / Accepted: 1 January 2002     

Seronegative Spondyloarthropathy Initiated by Physical Trauma

We undertook this study to demonstrate the pattern of onset and the course of arthritis on the traumatised joint in spondyloarthropathy (SpA) initiated by physical trauma. Among 288 patients with SpA, 12 (4.2%) whose arthropathies were associated with trauma were reviewed retrospectively. There were seven patients with ankylosing spondylitis (AS), three with juvenile onset AS and two undifferentiated SpA. The type of trauma was direct injury to the joint and injuries at other sites, except in spinal surgery, for example. In eight cases the initial evidence of disease was peripheral arthritis. The disease first occurred in traumatised joints in five cases. Only three cases showed recurrent inflammatory episodes in the traumatised joints throughout the disease course. SpA initiated by trauma initially manifested as peripheral arthritis at the traumatised joints in about half of the cases. Inflammatory episodes preferentially involved other joints apart from the traumatised joints throughout the whole course of the disease. Received: 4 August 1999 / Accepted: 25 January 2000     

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.     

Knee joint destruction driven by residual local symptoms after anti-tumor necrosis factor therapy in rheumatoid arthritis

In patients with rheumatoid arthritis who had symptomatic knee joints at the start of anti-tumor necrosis factor (TNF) therapy, the relationship between local symptoms and knee joint destruction at 94 weeks was retrospectively investigated. Among the patients with rheumatoid arthritis and received anti-TNF therapy, the 32 patients (52 joints) having swollen and/or tender knee joints were included in this study. Changes of disease activity score in 28 joints based on C-reactive protein (DAS28-CRP) and knee joint destruction using Larsen’s grading system 94 weeks after anti-TNF therapy were evaluated. Furthermore, the differences of the DAS28-CRP, swollen and tender knee joints between the patients who showed progression of joint destruction (Progression group) and those who did not (Non-progression group) were investigated. DAS28-CRP showed time-dependent, favorable results. However, progression of joint destruction was observed in 12 out of 52 joints. DAS28-CRP at 0 and 94 weeks after anti-TNF therapy were not different between Progression and Non-progression groups. However, the rate of swollen knee joints was higher in Progression group from 0 week. In addition, the ratio of swollen and/or tender knee joints was higher in Progression group from 22 to 94 weeks after anti-TNF therapy. The disease activity evaluated using DAS28-CRP was improved by anti-TNF therapy, but residual local symptoms in the knee joints were associated with a high incidence of joint destruction progression. We should treat rheumatoid arthritis patients with consideration for the possibility of joint destruction in the knee joints having residual local symptoms to progress.     

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     

Capillaroscopic Findings in Erosive and Nodal Osteoarthritis of the Hands

Osteoarthritis of the hands is a very common disease that can present a large number of different clinic pictures, such as nodal (NOA) and erosive (EOA) forms. EOA in particular is a rare subset of hand osteoarthritis characterised by faster destructive changes involving the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints. In the early stages of the disease the differential diagnosis from other arthritides, such as rheumatoid or seronegative arthritis, may pose a challenge. Nailfold capillaroscopy is a non-invasive technique that allows the in vivo study of the microvascular environment. In this study the authors have compared the capillaroscopic microvascular patterns in 56 patients with EOA, in 46 patients with NOA, and in 50 normal controls. The abnormalities that could be found in EOA patients were similar to those described by some authors in patients with psoriatic arthritis. The authors discuss the significance of these abnormalities and the possible relationship between EOA and psoriatic arthritis. Received: 17 April 2000 / Accepted: 18 September 2000     

Seronegative oligoarthritis: a 23-year follow-up study

The aim of the study was to investigate the long-term outcome of non-specific seronegative oligoarthritis in adults. The study included 64 adult patients with recent (<6 months) seronegative oligoarthritis (rheumatoid factor negative, number of swollen joints 1–4 during the first 6 months). Follow-up examinations were carried out at onset and at 1, 3 and 8 years from entry. A total of 47 patients attended the 23-year follow-up. The endpoint outcome was good. Seven had mild erosions in the hands or feet. Only one patient with HLA-B27 developed bilateral sacroiliitis. Three patients had retired from work because of joint disease. The functional outcome of the patients analysed by HAQ was very good after 23 years: 0 in 33 and 0.1–0.9 in 12 of the 47 patients. Reclassification revealed a certain heterogeneity: one case each of rheumatoid arthritis, SLE and ankylosing spondylitis, two cases of post-traumatic arthritis, four of osteoarthrosis, and six of possible reactive arthritis. Out of the remaining 49 patients 15 were HLA-B27 positive and 16 had at least one of the psoriasis-related HLA antigens (HLA-B13, 17, w16). In conclusion, our 23-year prospective follow-up study of patients with seronegative oligoarthritis confirms their favourable outcome. The reason is that the endpoint diagnoses seemed to be similar to those of mild spondylarthropathies. Received: 23 August 2001 / Accepted: 6 March 2002     

International spondyloarthritis interobserver reliability exercise--the INSPIRE study: II. Assessment of peripheral joints, enthesitis, and dactylitis

OBJECTIVE: To determine whether the assessments of peripheral joints and enthesitis were reproducible for both AS and PsA with axial disease, and whether dactylitis assessment is reproducible in patients with PsA. METHODS: A group of 20 rheumatologists from 11 countries with expertise in spondyloarthritis (SpA) met for a combined physical examination exercise to assess 10 patients with PsA with axial involvement (9 men, 1 woman, mean age 52 yrs, disease duration 17 yrs) and 9 patients with AS (7 men, 2 women, mean age 38 yrs, disease duration 16 yrs). A modified Latin-square design that enabled assessment of patient, assessor, and order effect was used. Measures included were number of tender and swollen joints, presence of enthesitis using 6 different indices, and dactylitis score. Data were analyzed using intraclass correlation (ICC) adjusted for order of measurements. RESULTS: The majority of the variance was contributed by the patients. There was no order effect. The assessment of tender joints (ICC 0.69) was more reliable than the assessment of swollen joints (ICC 0.54). Moreover, there was better agreement in patients with PsA (ICC 0.78) than in patients with AS (ICC 0.62). There was excellent agreement on the number of active enthesitis sites (ICC 0.86). All the enthesitis indices provided substantial to excellent agreement among observers. Agreement for the dactylitis score was substantial (ICC 0.70). CONCLUSION: The assessment of peripheral joints is more reliable in patients with PsA. Enthesitis instruments can be used reliably in patients with AS and patients with PsA with spinal involvement. The Leeds dactylitis instrument functions well in PsA.     

Psoriatic arthritis in British and Italian patients: a comparative clinical, radiologic, and scintigraphic study

OBJECTIVE: To investigate the similarities and differences in pattern and severity of clinical expression of psoriatic arthritis (PsA) in British and Italian patients. METHODS: Detailed clinical data were obtained on 48 British patients with PsA and compared with the data of 48 Italian patients. A systematic evaluation of joints, spine, and skin was performed. Forty-one British and 42 Italian patients also underwent a whole body bone scintigram. Radiographic details of hands and wrists were also taken. RESULTS: The Italian patients did not differ from their British counterparts with respect to duration of arthritis, sex, clinical subgroups, axial involvement, number of tender and swollen joints, or radiographic score. However, significant differences were found with respect to age, duration of psoriasis, number of joints with deformity and/or loss of function, number of affected joints, and number of "active" joints on scintigraphy, which were all higher in the British group. After correction for age, duration of arthritis, and duration of psoriasis the only significant difference was the number of affected joints. CONCLUSION: Our findings suggest that British patients with PsA are more severely affected than a matched cohort of Italian patients.