Impact of comorbidities on fatigue in rheumatoid arthritis patients: Results from a nurse-led program for comorbidities management (COMEDRA)

Objectives

To analyze the factors associated with fatigue focusing on comorbidities in a large cohort of rheumatoid arthritis (RA).

Validity of the rheumatoid arthritis impact of disease (RAID) score and definition of cut-off points for disease activity states in a population-based European cohort of patients with rheumatoid arthritis

Objectives

To assess the validity of the rheumatoid arthritis impact of disease (RAID) for measuring disease activity of rheumatoid arthritis (RA) and to determine cut-off values for defining the disease activity states.

Lumbar fusion outcomes in patients with rheumatoid arthritis

Although outcomes after cervical fusion in rheumatoid arthritis (RA) patients are widely published, outcomes of lumbar fusion in RA patients has not been reported. Ninteen patients with RA, identified using ICD-9 and CPT codes, who underwent instrumented posterolateral lumbar fusion were matched for age, gender, smoking status, date, and level of surgery to a contemporaneous non-RA group. Medical records and radiographs were reviewed by the primary author who had no role in the treatment of these patients. The average age was 64 years in the RA group and 65 years in the non-RA group. The male to female ratio was 2:17 and 1:18, respectively. There were three smokers and two diabetics in each group. An average of 1.5 levels was fused in each group. Average follow-up was 24 and 27 months, respectively. In the RA group, 15 patients were taking DMARDs with 7 of those also taking oral steroids; 4 patients were taking NSAIDs only. There were seven complications (37%) in the RA group versus four (21%) in the non-RA group; wound infections in three patients (16%) in the RA group versus one (5%) in the non-RA group; and non-union in two patients (11%) in the RA group versus three (16%) in the non-RA group. Clinical outcomes were similar between the two groups with 74% of patients achieving good to excellent results in the RA group compared to 63% in the non-RA group (p = 0.692). Surgeons and their RA patients who undergo an instrumented lumbar fusion can expect a slightly higher complication rate than patients without RA which may be related to osteopenia and immunosuppression.     

Economic analysis of a nurse-led programme for comorbidities management of rheumatoid arthritis patients

Objectives

Rheumatoid arthritis (RA) cause major functional, psychological, social and occupational repercussions for patients and has important economic consequences for society. The principal objective of this work was to determine the economic pertinence of a staff nurse specialised in preventive management for these patients.

Clinical characteristics and outcomes in polyarticular septic arthritis

Objectives

Septic polyarthritis is rarer than septic monoarthritis, but associated with higher mortality. Septic polyarthritis may be difficult to distinguish clinically from noninfectious inflammatory arthritis. We describe one of the largest samples of septic polyarthritis with the aim of distinguishing septic monoarthritis from polyarthritis.

Immunogenicity of tocilizumab in patients with rheumatoid arthritis

Objective

The immunogenicity of tocilizumab (TCZ) has been poorly studied. We assessed the immunogenicity of TCZ and serum TCZ trough levels in rheumatoid arthritis (RA) patients and the preexisting TCZ-specific CD4+ T cell repertoire in healthy controls.

Persistence of ultrasound synovitis in patients with rheumatoid arthritis fulfilling the DAS28 and/or the new ACR/EULAR RA remission definitions: Results of an observational cohort study

ObjectiveThe primary aim of the study was to evaluate whether rheumatoid arthritis (RA) patients considered to be in remission according to clinical criteria sets still had persisting ultrasound (US) synovitis. We further intended to evaluate the capacity of our US score to discriminate between the patients with a clinically active disease versus those in remission.MethodsThis is an observational study nested within the Swiss Clinical Quality Management in Rheumatic Diseases (SCQM) rheumatoid arthritis cohort. A validated US score (SONAR score) based on a semi-quantitative B-mode and Doppler (PwD) score as part of the regular clinical workup by rheumatologists in different clinical settings was used. To define clinically relevant synovitis, the same score was applied to 38 healthy controls and the 90st percentile was used as cut-off for ‘relevant’ synovitis.ResultsThree hundred and seven patients had at least one US examination and concomitant clinical information on disease activity. More than a third of patients in both DAS28 and ACR/EULAR remission showed significant gray scale synovitis (P = 0.01 and 0.0002, respectively) and PwD activity (P = 0.005 and 0.0005, respectively) when compared to controls. The capacity of US to discriminate between the two clinical remission groups and patients with active disease was only moderate.ConclusionThis observational study confirms that many patients considered to be in clinical remission according the DAS and the ACR/EULAR definitions still have residual synovitis on US. The prognostic significance of US synovitis and the exact place of US in patients reaching clinical remission need to be further evaluated.     

Intubation difficulties in patients with rheumatoid arthritis

Background : Fibreoptic intubation has been suggested to be the best method to manage a compromised airway. This retrospective study was designed to compare endotracheal intubation with the help of a rigid laryngoscope or a fibrescope in patients with rheumatoid arthritis.
Methods : Intubation difficulties with the laryngoscope and the fibrescope in patients with rheumatoid arthritis were investigated during a period of five and a half years. The anaesthesia records were used for analysis. The patients were divided into two groups (group I with 41 patients and group II with 37 patients) reflecting the change in the routine airway management in patients with rheumatoid arthritis in our hospital from the beginning of 1993. Before that time the patients were usually intubated orotracheally under general anaesthesia, but since 1993 rheumatoid patients with anticipated difficulties in endotracheal intubation have been preferably intubated fibreoptically awake under sedation and topical anaesthesia with a fibrescope.
Results : Major difficulties in endotracheal intubations were encountered in 13% of patients in group I and in 8% in group II. On two occasions in group I tracheostomy was needed. In one of these patients, emergency tracheostomy was performed. In the latter group, the main reason for prolonged fibreoptic intubations was lack of experience.
Conclusion : The introduction of fibreoptic intubation technique has had a favourable influence on the safety in the airway management of surgical patients with rheumatoid arthritis.     

Concordance between clinical and ultrasound findings in rheumatoid arthritis

BackgroundClinical joint examination is less time-consuming than ultrasound in rheumatoid arthritis. Knowledge of clinical and ultrasound concordance of joints groups could help in selecting joints for a best ultrasonographic assessment.ObjectiveTo evaluate concordance between clinical examination and ultrasound of joints in a heterogeneous group of patients with rheumatoid arthritis.MethodForty patients were included in a prospective, transversal, single-center study, whatever disease activity, duration or treatment. In each patient, 40 joints were evaluated for a total of 1600 joints. Synovitis was scored using clinical examination, B-mode, power Doppler and both B-mode and power Doppler. Concordance between swelling joint by clinical examination, synovitis thickening by B-mode (grade 1 or higher) and inflammation by power Doppler (grade 1 or higher) was assessed by computing the kappa coefficient.ResultsClinical joint examination and ultrasound concordance was very low at the shoulders and metatarsophalangeal joints (κ < 0.1) and was low at wrists (κ: 0.23 to 0.30). B-mode and power Doppler found 2.4 and 1.4 more synovitis than swollen joint count using clinical examination and up to 30 times more at metatarsophalangeal joints. Concordance was strong at tibio-talar joints (κ: 0.65 to 0.82) and moderate at others joints sites (κ: 0.4 to 0.6).ConclusionAssessment of a heterogeneous group showed that ultrasound adds information to clinical examination, most notably at the shoulders, wrists and metatarsophalangeal joints. Concordance was moderate to strong at other joint sites.     

Rheumatoid factor and response to TNF antagonists in rheumatoid arthritis: Systematic review and meta-analysis of observational studies

ObjectiveTo systematically analyze literature with the aim of examining whether rheumatoid factor (RF) is a predictor of response to tumor necrosis factor (TNF) antagonists in rheumatoid arthritis (RA).MethodsA systematic review and meta-analysis of observational studies were conducted. All studies on the association of baseline RF (titer and/or status) and response to any TNF antagonists, or with enough information to estimate this association were included. Qualitative analysis and meta-analysis using random-effects approach by type of outcome response and RF test was performed. Risk of publication bias was also evaluated.ResultsThe systematic review included 18 studies of 4163 identified articles, involving 5703 patients with homogeneous baseline characteristics. The most common outcome to assess response was European League Against Rheumatism (EULAR) response criteria, normally merging good and moderate categories as response. The weighted mean difference (WMD) of baseline IgM RF titer in meta-analysis was higher in the non-responders group [−101.58 (95% CI −156.58,−46.59) I² = 0.0]. Combined odds ratios (ORs) of positive IgM RF, positive IgA RF, and positive IgG RF to achieve good/moderate response were 1.08 (0.80, 1.47), I² = 40.9%; 0.83 (0.39, 1.73), I² = 39.8%, and 1.30 (0.48, 3.51), I² = 62.9%, respectively. We did not find an association between a positive IgM RF and EULAR good response or remission.ConclusionsThis meta-analysis does not support baseline IgM RF titer as a predictor of response to TNF antagonists in RA. However, this conclusion is hampered by high heterogeneity in the studies included in this meta-analysis.     

Rituximab in rheumatoid arthritis and the risk of malignancies: report from a French cohort

Objective

To determine in real-life conditions the safety of treatment with rituximab (RTX) in patients with rheumatoid arthritis (RA) regarding malignancies.

Methods

Analysis of safety data from a cohort of RA patients who received at least one course of RTX. RA patients with previous malignancies were followed-up and compared to the group of patients with no history of malignancy.

Results

One hundred and eighty-six RA patients, 33 (17.7%) males, the mean age and disease duration were 55.8 ± 13.0 and 14.5 ± 11.1 years, respectively. The mean follow-up was 22.3 ± 15.1 months, corresponding to a follow-up of 346 pt-years of RTX exposure. Among these, 24 (12.9%) patients had a history of a prior malignancy. Five cancers were diagnosed during follow-up with four new malignancies (1 prostate, 1 breast, 1 colon and 1 cervical cancers) and one recurrence of a known breast cancer. The overall cancer rate was 1.45/100 pt-years (95%CI: 0.19 to 2.70), which is comparable to previously studied DMARD-treated cohorts. No new hematopoietic neoplasms were reported and the six lymphomas that have been in remission prior to RTX-therapy remained under follow-up. The baseline demographic and disease characteristics and the cancer-risk of the 24 patients who presented with a prior malignancy were similar to those with no cancer history (162 patients).

Conclusions

Although based on a modest number of observed cancers, and despite selection bias (12.9% of prior malignancies in our RTX treated RA), this observational study suggests that RTX does not increase the cancer risk in RA patients.     

Ultrasound evaluation of synovitis in RA: Correlation with clinical disease activity and sensitivity to change in an observational cohort study

ObjectiveTo evaluate the correlation between clinical measures of disease activity and a ultrasound (US) scoring system for synovitis applied by many different ultrasonographers in a daily routine care setting within the Swiss registry for RA (SCQM) and further to determine the sensitivity to change of this US Score.MethodsOne hundred and eight Swiss rheumatologists were trained in performing the Swiss Sonography in Arthritis and Rheumatism (SONAR) score. US B-mode and Power Doppler (PwD) scores were correlated with DAS28 and compared between the clinical categories in a cross-sectional cohort of patients. In patients with a second US (longitudinal cohort), we investigated if change in US score correlated with change in DAS and evaluated the responsiveness of both methods.ResultsIn the cross-sectional cohort with 536 patients, correlation between the B-mode score and DAS28 was significant but modest (Pearson coefficient r = 0.41, P < 0.0001). The same was true for the PwD score (r = 0.41, P < 0.0001). In the longitudinal cohort with 183 patients we also found a significant correlation between change in B-mode and in PwD score with change in DAS28 (r = 0.54, P < 0.0001 and r = 0.46, P < 0.0001, respectively). Both methods of evaluation (DAS and US) showed similar responsiveness according to standardized response mean (SRM).ConclusionsThe SONAR Score is practicable and was applied by many rheumatologists in daily routine care after initial training. It demonstrates significant correlations with the degree of as well as change in disease activity as measured by DAS. On the level of the individual, the US score shows many discrepancies and overlapping results exist.     

Clinical course of bucillamine-induced nephropathy in patients with rheumatoid arthritis

Background Bucillamine, a disease-modifying antirheumatic drug widely prescribed in Japan, is reported to be a cause of proteinuria. However, to date, the clinical course of the nephropathy associated with the use of bucillamine has not been described in detail.Methods We analyzed renal biopsy findings from 10 patients with rheumatoid arthritis and concomitant bucillamine-induced nephropathy. Each patient was followed up until proteinuria had resolved.Results Proteinuria appeared 2–11 months after the initiation of the treatment with bucillamine. Nine patients, who stopped bucillamine treatment immediately (within 3 months) after the onset of proteinuria, were diagnosed as having stage I membranous nephropathy. Only one patient, who used bucillamine for 9.5 months after the onset of proteinuria, was diagnosed as having stage II membranous nephropathy. In all patients with stage I membranous nephropathy, the proteinuria disappeared within 7 months after they stopped bucillamine treatment. On the other hand, in the patient with stage II membranous nephropathy, the proteinuria persisted for 14 months after the use of bucillamine was stopped. In all the patients, the proteinuria resolved completely without deterioration of renal function. None of the patients has experienced recurrence of proteinuria.Conclusions In patients with proteinuria induced by treatment with bucillamine, membranous nephropathy is the most common disorder. Immediate withdrawal of bucillamine results in prompt and complete resolution of proteinuria without deterioration of renal function.     

Association of microRNAs genes polymorphisms with rheumatoid arthritis in Egyptian female patients

ObjectiveTo investigate whether miRNA-499 (rs3746444) and miRNA-146a (rs2910164) genes polymorphisms are independent factors for rheumatoid arthritis (RA) in Egyptians, and whether they influence disease severity and activity.MethodsTwo hundred and seventeen RA patients and 245 healthy controls were enrolled in this study. Polymorphisms of miRNA-146a and miRNA-499 genes were detected using polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP).ResultsThe miRNA-499 CT genotype was an independent factor of RA. The miRNA-499 CT, CC genotypes and C allele frequencies were significantly increased in erosive RA group. Moreover, the heterozygote CT had more severe and more active form of the disease compared with homozygote CC or TT. However, we did not find any significant association of miRNA-146a polymorphism with RA risk, severity, and activity.ConclusionThe miRNA-499 polymorphism is an independent factor of RA, and influences disease severity and activity.     

The prevalence of disabling foot pain in patients with early rheumatoid arthritis

BackgroundFoot pain occurs up to 94% in patients with longstanding rheumatoid arthritis (RA) causing ambulation problems and disability. It was thought that these problems occur already early during the disease process but no data are available. The Manchester Foot Pain and Disability Questionnaire (MFPDQ) is a valid tool to assess disabling foot pain which is easy to complete and analyse.ObjectiveTo gather data about the prevalence of foot pain with its consequence on disability in early diagnosed patients with rheumatoid arthritis.MethodA questionnaire asking about foot pain and the MFPDQ were given to 200 patients with RA diagnosed within the last 4 years. The results of the MFPDQ were divided into categories of disability.ResultsOne-hundred and eighty-five participants completed the pain questionnaire and 126 the MFPDQ. Foot pain was reported by 74% of the participants with 64% experiencing pain in the last month and 60% at the time of completing the questionnaires. Results of the MFPDQ showed that 53% of the participants scored moderate disability and 30% severe disability caused by foot pain.ConclusionFoot pain occurs early in patients with RA resulting in moderate to severe disability in the majority of participants.     

10年前后RA患者骨质疏松发生情况的横断面对比研究

目的横断面对比10年前后类风湿关节炎(RA)患者骨密度(BMD)的变化和骨质疏松(OP)的发生情况,分析其发生的原因。方法采用DEXA法测定2011年确诊的120例RA患者和120例正常人股骨和腰椎部位BMD,详细记录RA患者各临床及实验室资料。同时与2001年53例RA患者的BMD等资料进行横断面对比。结果①正常人、2001年RA及2011年RA患者3组间OP发生率有明显差别(15.0%、22.6%、34.2%;x2=17.218,P=0.002)。②2001年53例RA患者中,非OP患者的年龄(43.73±15.06 vs 59.25±14.75,t=3.154,P=0.003)、CRP(35.35±31.91 vs 58.74±31.81,t=2.235,P=0.030)明显低于OP组。③2011年120例RA患者中,非OP患者的年龄(48.94±11.98 vs 56.66±14.26,t=3.135,P=0.002)、HAQ(1.39±0.67 vs 1.66±0.73,t=2.067,P=0.041)明显低于OP组。④2001年发生OP与非OP的RA患者中,服用糖皮质激素的患者比例无差别(P>0.05)。2011年发生OP的RA患者中服用糖皮质激素的患者比例为73.2%(30/41),明显高于非OP患者中的53.2%(42/79)(x2=4.501,P=0.034)。⑤与2001年RA相比,2011年RA患者的DAS28更低(6.77±1.38 vs 5.97±1.30,t=3.613,P<0.0001)、关节功能更好(1:18:22:12 vs 9:57:50:3,x2=20.690,P<0.0001),但关节X线分期更差(7:26:12:8 vs 13:27:53:23,x2=13.302,P=0.004)。⑥Logistic Regression分析发现:年龄(OR=1.093,P=0.010,95%CI:1.022～1.169)和CRP(OR=1.025,P=0.037,95%CI:1.002～1.48)为2001年RA患者发生OP的危险因素;年龄(OR=1.047,P=0.012,95%CI:1.010～1.085)和HAQ评分(OR=2.040,P=0.046,95%CI:1.013～4.111)为2011年RA患者发生OP的危险因素。结论 10年前后的横断面对比研究提示,RA患者OP发生率明显高于正常人,且呈上升趋势;高龄和RA疾病活动性是两个不同年度的横断面资料中RA患者发生OP的相同的危险因素。RA患者中糖皮质激素的使用比例的增高,可能是其关节炎症表现好转,但关节X线分期更差及OP发生率更高的原因之一。     

人工全膝关节置换术治疗膝关节类风湿性关节炎中短期疗效随访

目的：为了观察人工全膝关节置换术（ TKA）治疗膝关节类风湿性关节炎（ RA）的中短期治疗效果。方法随访2007至2011年间行TKA治疗的38例（58膝）膝关节RA患者。采用HSS评分、KSS评分、WOMAC评分、VAS视觉疼痛评分对术前及术后患者的膝关节功能进行评价、同时对术后随访影像学资料进行评价;采用SF-36量表对患者健康状况进行评价。结果所有患者均未出现感染且获得平均3.3年（2～6年）随访,膝关节功能均明显改善,患者膝关节HSS评分由术前45.92±13.49分提高到术后88.19±5.98分,两者采用配对t 检验比较差异有统计学意义（ P ＝0.00）,其中优21膝,良34膝,优良率94.83％。膝关节屈曲畸形明显改善,膝关节活动度（ROM）由术前71.81°±32.58°提高到术后100.98°±13.99°,两者比较差异有统计学意义（ P＝0.00）。膝关节假体X线片采用膝关节学会的X线评价与计分系统评价未见假体松动。 SF-36评分中PCS由术前的26.27±3.91分提高到术后48.09±6.65分,两者比较差异有统计学意义（ P＝0.00）;MCS由术前的41.59±5.61分提高到51.83±5.44分,两者比较差异有统计学意义（ P＝0.00）。结论 TKA是治疗膝关节RA的有效方法,可提高患者生活质量。