Development of the M-SACRAH, a modified, shortened version of SACRAH (Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands)

OBJECTIVES: The Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (SACRAH) is a self-administered questionnaire assessing functional status, stiffness and pain in patients suffering from hand osteoarthritis (HOA) as well as rheumatoid arthritis (RA) of the hand. It consists of 23 questions in three domains, to be answered on 100 mm visual analogue scales (VAS). Our goal was to shorten the original SACRAH by elimination of redundant questions in order to make it easier to use for patients and physicians. METHODS: Following an arbitrary procedure employing high intervariable correlations, redundant questions were eventually eliminated. To validate the shortened version, 60 patients with HOA, recruited at four rheumatological centres in Austria, completed the original SACRAH as well as the shortened version. Fifty-five patients suffering from RA of the hands treated at the Second Department of Medicine, Humanis Klinikum Stockerau, also completed both questionnaires. RESULTS: A total of 11 questions (nine from the function domain and two from the pain domain) were eliminated, leading to the modified score consisting of 12 questions. Comparing the results of SACRAH and M-SACRAH, as well as the domain scores in individual patients, correlation coefficients were r = 0.978 for HOA patients (P < 0.0001) and r = 0.986 for RA patients (P < 0.0001). CONCLUSION: M-SACRAH, the shortened and simplified version of the original SACRAH questionnaire, proved to be as reliable and as representative as SACRAH for hand status in individual HOA and RA patients.     

Mapping hand functioning in hand osteoarthritis: comparing self-report instruments with a comprehensive hand function test

OBJECTIVE: To determine which self-report instruments best explain hand functioning measured by a generic comprehensive hand function test. METHODS: Six questionnaires currently used in hand osteoarthritis (OA), namely, the Arthritis Impact Measurement Scales 2 Short Form (AIMS2-SF), the Australian/Canadian Osteoarthritis Hand Index (AUSCAN), the Cochin scale, the Functional Index of Hand OA (FIHOA), the Health Assessment Questionnaire (HAQ), and the Score for Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (SACRAH), were administered once in 100 patients with hand OA together with the Jebsen-Taylor Hand Function Test (JTHFT). In addition, 3 other hand function tests with short administration time were used: the Moberg Picking-Up Test (MPUT), the Button Test (BT), and grip strength. The Short Form 36 was used to describe health status. The relationship between the instruments and the JTHFT was determined by correlation analyses. RESULTS: AIMS2-SF total scores had the highest raw correlation coefficient to the JTHFT, followed by AIMS2-SF upper body limitation subscale, SACRAH stiffness subscale, and SACRAH total score. If controlled for age, the HAQ had the highest correlation coefficient. Of the 3 short hand function tests, the MPUT showed the highest raw correlation coefficient to the JTHFT; if controlled for age, the BT had the highest correlation coefficient. CONCLUSION: To comprehensively assess hand functioning in patients with hand OA, we recommend using both a self-report instrument used more generally in various arthritides and a self-report instrument specifically developed for hand OA. If a short test is preferred, we recommend using the MPUT or BT.     

A randomized controlled trial of homeopathy in rheumatoid arthritis

OBJECTIVE: To test the hypothesis that homeopathy is effective in reducing the symptoms of joint inflammation in rheumatoid arthritis (RA). METHOD: This was a 6-month randomized, cross-over, double-blind, placebo-controlled, single-centre study set in a teaching hospital rheumatology out-patient clinic. The participants of the study were 112 patients who had definite or classical RA, were seropositive for rheumatoid factor and were receiving either stable doses of single non-steroidal anti-inflammatory drugs (NSAIDs) for > or =3 months or single disease-modifying anti-rheumatic drugs (DMARDs) with or without NSAIDs for > or =6 months. Patients who were severely disabled, had taken systemic steroids in the previous 6 months or had withdrawn from DMARD therapy in the previous 12 months were excluded. Two series of medicines were used. One comprised 42 homeopathic medicines used for treating RA in 6cH (10(-12)) and/or 30cH (10(-30)) dilutions (a total of 59 preparations) manufactured to French National Pharmacopoeia standards, the other comprised identical matching placebos. The main outcome measures were visual analogue scale pain scores, Ritchie articular index, duration of morning stiffness and erythrocyte sedimentation rate (ESR). RESULTS: Fifty-eight patients completed the trial. Over 6 months there were significant decreases (P<0.01 by Wilcoxon rank sum tests) in their mean pain scores (fell 18%), articular indices (fell 24%) and ESRs (fell 11%). Fifty-four patients withdrew before completing the trial. Thirty-one changed conventional medication, 10 had serious intercurrent illness or surgery, 12 failed to attend and three withdrew consent. Placebo and active homeopathy had different effects on pain scores; mean pain scores were significantly lower after 3 months' placebo therapy than 3 months' active therapy (P=0.032 by Wilcoxon rank sum test). Articular index, ESR and morning stiffness were similar with active and placebo homeopathy. CONCLUSIONS: We found no evidence that active homeopathy improves the symptoms of RA, over 3 months, in patients attending a routine clinic who are stabilized on NSAIDs or DMARDs.     

Mapping hand functioning in hand osteoarthritis: Comparing self‐report instruments with a comprehensive hand function test

Objective

To determine which self‐report instruments best explain hand functioning measured by a generic comprehensive hand function test.

Methods

Six questionnaires currently used in hand osteoarthritis (OA), namely, the Arthritis Impact Measurement Scales 2 Short Form (AIMS2‐SF), the Australian/Canadian Osteoarthritis Hand Index (AUSCAN), the Cochin scale, the Functional Index of Hand OA (FIHOA), the Health Assessment Questionnaire (HAQ), and the Score for Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (SACRAH), were administered once in 100 patients with hand OA together with the Jebsen‐Taylor Hand Function Test (JTHFT). In addition, 3 other hand function tests with short administration time were used: the Moberg Picking‐Up Test (MPUT), the Button Test (BT), and grip strength. The Short Form 36 was used to describe health status. The relationship between the instruments and the JTHFT was determined by correlation analyses.

Results

AIMS2‐SF total scores had the highest raw correlation coefficient to the JTHFT, followed by AIMS2‐SF upper body limitation subscale, SACRAH stiffness subscale, and SACRAH total score. If controlled for age, the HAQ had the highest correlation coefficient. Of the 3 short hand function tests, the MPUT showed the highest raw correlation coefficient to the JTHFT; if controlled for age, the BT had the highest correlation coefficient.

Conclusion

To comprehensively assess hand functioning in patients with hand OA, we recommend using both a self‐report instrument used more generally in various arthritides and a self‐report instrument specifically developed for hand OA. If a short test is preferred, we recommend using the MPUT or BT.     

Valdecoxib is associated with improved dyspepsia-related health compared with nonspecific NSAIDs in patients with osteoarthritis or rheumatoid arthritis

OBJECTIVES: Dyspepsia and related gastrointestinal (GI) symptoms are commonly reported by patients taking nonspecific nonsteroidal anti-inflammatory drugs (NSAIDs) and significantly impact treatment effectiveness, cost, and quality of life. This study sought to evaluate dyspepsia-related health in osteoarthritis (OA) and rheumatoid arthritis (RA) patients taking valdecoxib compared with patients taking nonspecific NSAIDs. METHODS: Analysis of two separate, double-blind, placebo-controlled studies: one in RA patients randomized to placebo, valdecoxib (10 and 20 mg once daily [o.d.]) and naproxen (500 mg twice daily [b.i.d.]); one in OA patients randomized to placebo, valdecoxib (10 and 20 mg o.d.), diclofenac (75 mg b.i.d.), or ibuprofen (800 mg three times daily [t.i.d.]). Study population comprised patients with RA in flare or clinically documented OA who required chronic symptomatic treatment with NSAIDs/analgesics. Dyspepsia-related health was evaluated at baseline and weeks 2, 6, and 12 (or early termination) using the validated Severity of Dyspepsia Assessment (SODA) questionnaire. This patient self-report tool consists of scales for evaluating dyspepsia pain intensity, nonpain symptoms, and satisfaction. Analysis was based on the intent-to-treat population with the last observation carried forward. RESULTS: Valdecoxib was significantly better at endpoint than standard doses of naproxen, diclofenac, and ibuprofen for pain intensity scores (p < 0.05), and provided significantly improved nonpain symptom and satisfaction scores compared with naproxen for patients with RA (p < 0.05). For RA patients, the difference between valdecoxib and naproxen pain intensity scores were clinically meaningful; at all the time points, significantly fewer patients receiving valdecoxib reported severe dyspepsia pain intensity increases (>/=10 points) than those receiving naproxen. At 12 wk, fewer patients receiving valdecoxib reported severe dyspepsia pain intensity increases versus those receiving ibuprofen and diclofenac. CONCLUSIONS: The GI tolerability of valdecoxib is superior to that of nonspecific NSAIDs, and therefore can potentially have a favorable impact on patient quality of life.     

Treatment of osteoarthritis of the hip and knee: a comparison of NSAID use in patients for whom surgery was and was not recommended

OBJECTIVE: To determine if NSAID use was different between OA (hip and/or knee) patients treated surgically to those treated medically. METHODS: We conducted a case control study, in which cases (n = 433) had had a total joint replacement within a two-year period, while controls (n = 195) had seen a rheumatologist or orthopedic surgeon, and not been recommended for surgery. Current and previous NSAID use was surveyed. RESULTS: Cases were older than controls (70 vs. 64 years, p < 0.0001), and were more likely to have OA in the hips (45% vs. 21%, p < 0.0001), to have severe OA (p < 0.0001), and to be male (42% vs. 28%, p < 0.0008). Potential confounding variables were statistically adjusted using logistic regression. Although disease duration was similar in cases and controls (9.8 years), cases had tried fewer NSAIDs (1.3 +/- 0.05 vs. 2.3 +/- 0.08 in controls, p < 0.0001). Cases were less likely to have taken any NSAID (86% vs. 94% of controls; OR 0.40, p < 0.007) or to have had intra-articular steroids (OR 0.19, p < 0.0001). Two or more NSAIDs were used (ever) in 38% of cases vs. 70% of controls (p < 0.0001); and 3 or more NSAIDs in 5% vs. 38% (p < 0.0001). Women were less apt to have obtained total joint replacements (OR 0.62, p < 0.0001), including TKRs even when adjusting for severity of OA. CONCLUSIONS: NSAIDs are used less by orthopedic surgeons than rheumatologists in our centre. Some subjects were offered a joint replacement without even a failure of medical management. The reasons for differences in prescribing trends are unknown. Referral biases may exist.     

全国多中心类风湿关节炎患者门诊用药费用的调查

目的 了解我国类风湿关节炎(RA)患者的门诊药费情况,分析药费的影响因素和不同人群药费的差别.方法 面对面调查646例RA患者的回顾性用药情况,同时记录患者的一般资料、临床特点及关节功能状态评分.将其中病程1年以上并且药费资料完整的435例纳入分析,根据用药情况估计过去1年的药费,分析了药费与人口学特征、临床特点的关系,并评估不同药物的性价比.结果 ①RA患者过去1年内的人均门诊药费为人民币(8018±17 238)元,其中改善病情药的费用人均(1610±2138)元,占总药费的20%;生物制剂人均(3975±17 071)元,占总药费的49%;非甾体抗炎药的人均费用为(353±829)元,占总药费的4%;植物药人均费用为(1769±3528)元,占总药费的22%;人均激素费用为(48±160)元,外用药(74±386)元,各占药费的1%.②门诊药费相关因素分析显示,伴有关节外表现(OR:2.180,95%CI:1.335～3.558,P=0.002)、患者功能状态差(OR:1.373,95%CI:1.012～1.863,P=0.04.1)为导致药费增高的相关因素.③不同人群的药费分析提示大学以上学历、脑力劳动、月收入>3000元、享受公费医疗的人群的改善病情抗风湿药(DMARDs)的费用高,门诊患者及功能状态好的患者的DMARDs的费用高.④不同药物的性价比分析显示DMARDs药物的性价比更高.结论 RA患者每年药费高,其中生物制剂、改善病情药及植物药占药费的主要部分,伴有关节外表现和患者功能状态差是高药费的相关因素.人群的学历、收入、付费方式均影响各项药费的分布.DMARDs药物的性价比更高.     

High CCL18/PARC expression in articular cartilage and synovial tissue of patients with rheumatoid arthritis

OBJECTIVE: We studied the role of CCL18/pulmonary and activation-regulated chemokine (PARC) in rheumatoid arthritis (RA). METHODS: Human cartilage tissues and synovial membranes were obtained from patients with RA and with osteoarthritis (OA). Sera samples were obtained from RA patients, OA patients, healthy controls, and patients with flu, and synovial fluid (SF) from patients with RA and OA. Real-time PCR was performed with RNA from cartilage samples. Immunohistochemical analysis of CCL18/PARC was done with RA and OA cartilage and synovial tissue. Levels of CCL18/PARC in serum and SF were evaluated by ELISA. RESULTS: CCL18/PARC mRNA was expressed at significantly higher levels in RA cartilage than in OA (p = 0.0001) and control (p < 0.0001) samples. CCL18/PARC mRNA expression was much higher in RA synovial membrane than OA samples (p = 0.0001). All RA cartilage and synovial tissue samples exhibited medium to strong staining for CCL18/PARC. Serum levels of CCL18/PARC were higher in RA patients (156.21 +/- 125.73 ng/ml, n = 71) than in OA patients (64.54 +/- 40.90 ng/ml, n = 12) and controls (28.04 +/- 10.96 ng/ml, n = 20). Levels of CCL18/PARC in RA SF (275.20 +/- 228.16 ng/ml, n = 15) were higher than in OA (33.13 +/- 14.84 ng/ml, n = 6; p = 0.0198). CCL18/PARC levels correlated significantly with rheumatoid factor levels (r = 0.431, p = 0.0040), but not with matrix metalloproteinase-3, erythrocyte sedimentation rate, and C-reactive protein. CONCLUSION: CCL18/PARC was highly expressed in RA articular cartilage and synovial tissue compared with OA samples. Our data indicated that CCL18/PARC levels are not related to the conditions of generalized inflammation, but are related to the pathogenesis of RA.     

Validity of self‐reported rheumatoid arthritis in a large cohort: Results from the Black Women's Health Study

Objective

To evaluate the positive predictive value (PPV) of 3 case definitions of rheumatoid arthritis (RA) based on self‐reported data on RA diagnosis and use of arthritis medications, and to determine whether a validated screening survey would increase the PPVs in the 3 groups.

Methods

Medical records and physician checklists were reviewed for confirmation of an RA diagnosis among a sample of Black Women's Health Study participants who reported incident RA and were categorized according to reported medications: disease‐modifying antirheumatic drugs (DMARDs) (n = 102), nonsteroidal antiinflammatory drugs (NSAIDs) (n = 100), and no arthritis medications (no meds) (n = 101). PPVs for confirmed RA were calculated for each of the medication groups, both overall and according to the results of the screening survey.

Results

The PPVs of confirmed RA were 76%, 61%, and 29% in the DMARDs, NSAIDs, and no meds groups, respectively. After exclusion of women who reported other rheumatic conditions or who reported taking only prednisone, the PPV increased in the DMARDs group to 88%, but little improvement was seen in the other groups. The PPVs increased somewhat according to results of the screening survey for the DMARDs group (92% for positive screen versus 85% for negative screen; P = 1.00), and increased substantially for the NSAIDs group (89% versus 38%, respectively; P = 0.03), but only 43% of participants completed the survey.

Conclusion

We found that self‐report of RA, along with self‐reported DMARDs, is a useful case definition for identifying confirmed RA. The validated screening survey could be useful for identifying cases of confirmed RA in some, but not all, medication groups.     

Immunohistological analysis of synovial tissue for differential diagnosis in early arthritis.

OBJECTIVE: An early diagnosis in patients presenting with arthritis is important to provide information about prognosis and to initiate treatment. The objective of this study was to determine which markers applied in immunohistological analysis of synovial tissue (ST) specimens could be used to differentiate rheumatoid arthritis (RA) from other forms of arthritis. METHODS: Synovial biopsies were obtained by blind needle techniques from 95 patients with early arthritis. After follow-up of at least 2 yr to verify the diagnosis, the patients could be classified as follows: RA (n=36), undifferentiated arthritis (UA; n=21), osteoarthritis (OA; n=17), reactive arthritis (ReA; n=10), ankylosing spondylitis (AS; n=3), psoriatic arthritis (PsA; n=2) and crystal-induced arthritis (CA; n=6). ST sections were analysed by immunohistochemistry using monoclonal antibodies against CD3, CD4, CD8, CD22 (B cells), CD38 (plasma cells), CD68 (macrophages) and CD55 (fibroblast-like synoviocytes). RESULTS: Logistic regression analysis revealed that the higher scores for the numbers of CD38+ plasma cells and CD22+ B cells in RA were the best discriminating markers comparing RA to non-RA patients (CD38: P=0.0001; CD22: P<0.05). Polychotomous regression analysis comparing three diagnostic categories (1: RA; 2: UA, ReA, AS and PsA; 3: OA and CA) also identified the score for the number of CD38+ plasma cells (P<0.0001) as well as the numbers of CD68+ macrophages in the synovial sublining (P=0.05) as discriminating markers. CONCLUSION: The results suggest that immunohistochemical analysis of ST specimens from early arthritis patients can be used to differentiate RA from non-RA patients. The numbers of plasma cells, B cells and macrophages are especially increased in ST of patients with RA. Future studies in early arthritis patients with clinical features which do not allow an immediate confident diagnosis may clarify the role of this test system in differential diagnosis.     

THE EFFECT OF NON-STEROIDAL ANTI-INFLAMMATORY DRUGS ON FAECAL FLORA AND BACTERIAL ANTIBODY LEVELS IN RHEUMATOID ARTHRITIS

The faecal flora and bacterial antibody levels of 22 patientswith active rheumatoid arthritis (RA) were compared with thoseof 26 patients with osteoarthritis (OA) undergoing comparabletreatment with non-steroidal anti-inflammatory drugs (NSAIDs),and a further 22 patients with OA who were not receiving NSAIDs.Faecal counts of Clostridium perfringens were significantlyhigher in the RA patient group and in those OA patients receivingNSAIDs, compared with those OA patients not taking NSAIDs (P=0.032,P=0.0004 respectively). Total aerobic and anaerobic counts were,however, identical in all three groups. Levels of serum IgA antibody to the alpha toxin of Cl. perfringenswere higher in the RA group and in the OA group taking NSAIDsthan in OA patients not taking NSAIDs (P=0.011, P=0.055). SerumIgG antibody to alpha toxin was higher in the RA group thanin OA patients both on and off NSAIDs (P=0.019, P=0.0072) andalso a group of normal controls (P=0.032). These results suggest that the increased faecal counts of Cl.perfringens together with the associated increased antibodylevels seen in this and previous studies are more likely toresult from NSAID therapy used to treat the disease than froma disease specific changk in bowel flora. KEY WORDS: Rheumatoid arthritis, Cl. perfringens, NSAIDs     

Health-related quality of life in women with symptomatic hand osteoarthritis: a comparison with rheumatoid arthritis patients, healthy controls, and normative data

OBJECTIVE: Data on the burden of disease and impact on health-related quality of life (HRQOL) in hand osteoarthritis (OA) are limited. The goal of this study was to compare HRQOL in patients with hand OA with HRQOL in patients with rheumatoid arthritis (RA), healthy controls, and normative data from the general population. METHODS: A total of 190 women with hand OA were compared with 194 women with RA and 144 healthy women of the same age. Health status was measured using the Short Form 36 (SF-36), Short Form 6D (SF-6D), modified Health Assessment Questionnaire (M-HAQ), pain and fatigue visual analog scales, and grip strength. Scores were compared by analysis of variance and a multivariate analysis of covariance, adjusting for age, number of comorbidities, and years of education. Gaps between patients and population subjects were assessed by calculating S scores on all dimensions of the SF-36. RESULTS: Hand OA and RA patients had worse scores on all assessed dimensions of subjective health compared with healthy controls. RA patients showed poorest general health (SF-36), poorest physical function (M-HAQ, SF-36 physical, grip strength), and highest level of fatigue compared with hand OA patients. Hand OA patients reported poorer mental health. Mean utility scores (SF-6D) in hand OA and RA were 0.64 and 0.63, respectively, with a mean difference compared with healthy controls of 0.13 in hand OA and 0.14 in RA patients. S scores confirmed a marked disparity between individuals with a rheumatic diagnosis (hand OA, RA) and population subjects. CONCLUSION: This study illustrates that patients with hand OA experience a broad impact on HRQOL compared with healthy controls. Fatigue and physical function are worse in RA than hand OA.     

Increased radiographic damage scores at the onset of seropositive rheumatoid arthritis in older patients are associated with osteoarthritis of the hands, but not with more rapid progression of damage

OBJECTIVE: To investigate the impact of patient age at symptom onset on radiographic joint damage at study entry, and on subsequent progression of damage in a cohort of patients with early seropositive rheumatoid arthritis (RA). METHODS: We studied 186 patients with RA of <15 months' duration. All patients had active disease and had not received disease-modifying antirheumatic drugs. At study entry and during followup, total Sharp scores (TSS), RA-associated joint space narrowing (RA-JSN), and erosions were determined on hand and foot radiographs. Baseline radiographs were also scored for osteoarthritis (OA)-related JSN (OA-JSN) and osteophytes. Older patients (>55 years) and younger patients (相似文献   

Steroid injection for osteoarthritis of the hip: a randomized, double-blind, placebo-controlled trial

OBJECTIVE: To determine the efficacy of fluoroscopically guided corticosteroid injection for hip osteoarthritis (OA) in a randomized, double-blind, placebo-controlled trial. METHODS: Fifty-two patients with symptomatic hip OA were randomly allocated to receive placebo (10 mg bipuvicaine, 2 ml saline) (n = 21) or corticosteroid treatment (10 mg bipuvicaine, 40 mg triamcinolone hexacetonide) (n = 31). Patients were followed up for 1, 2, 3, and 6 months. The primary outcome measure was the pain improvement response, defined as a 20% decrease in the Western Ontario and McMaster Universities OA Index (WOMAC) pain score (on 5 100-mm visual analog scales [VAS]) (WOMAC20) from baseline to 2 months postinjection. Secondary outcomes were a 50% decrease in the WOMAC pain score (WOMAC50), changes in other WOMAC subscale scores, patient's global assessment of health (on a 100-mm VAS), and Short Form 36 (SF-36) quality of life indices. Analyses were based on the intent-to-treat principle. RESULTS: The mean WOMAC pain score fell 49.2% (decreasing from 310.1 mm to 157.4 mm) at 2 months postinjection in patients receiving corticosteroid, compared with a decrease of 2.5% (from 314.3 mm to 306.5 mm) in the placebo group (P < 0.0001). The proportion of WOMAC20 responders at 2 months' followup was significantly higher in the corticosteroid group (67.7%) compared with the placebo group (23.8%) (P = 0.004); similar proportions of WOMAC50 responders were observed between groups (61.3% in the corticosteroid group versus 14.3% in the placebo group; P = 0.001). Response differences were maintained at 3 months' followup (58.1% responders in the corticosteroid group versus 9.5% responders in the placebo group; P = 0.004). Significant differences in the WOMAC stiffness and physical function scores (P < 0.0001), patient's global health scores (P = 0.005), and SF-36 physical component scores (P = 0.04) were observed, with patients in the corticosteroid group showing greater improvements. There were no differences in the frequency of adverse events between groups. CONCLUSION: This placebo-controlled trial confirms that corticosteroid injection can be an effective treatment of pain in hip OA, with benefits lasting up to 3 months in many cases. Future studies should address questions related to the benefits of repeated steroid injection and the effects of this treatment on disease modification.     

Sonographic assessment of carpal tunnel syndrome in rheumatoid arthritis: prevalence and correlation with disease activity

Carpal tunnel syndrome (CTS) is one of the most frequent extra-articular manifestations of rheumatoid arthritis (RA). High frequency ultrasonography (US) is a sensitive and specific method in diagnosis of CTS. This study is aimed to: firstly assess diameter frequency of CTS in RA with US and compare with a control group; secondly, investigate relationship of CTS with disease activity. One hundred consecutive RA patients (women/men: 78/22) fulfilling ACR 1987 RA criteria and 45 healthy controls (women/control: 34/11) were enrolled into study. Disease activity parameters, RA and CTS patient global assessment and health assessment questionnaire (HAQ-DI) were recorded. Both patient and control group were questioned about secondary causes of CTS, and Katz hand diagram, Boston CTS questionnaire and Phalen ve Tinel tests were applied once for each hand. Wrist joint and carpal tunnel were assessed with US grey scale and power Doppler US, then cross-sectional area of median nerve (CSA) was calculated. Patients with median nerve CSA between 10.0 and 13.0 mm(2) were evaluated with electromyography (EMG). CTS was diagnosed if CSA of median nerve >13.0 mm(2) or CTS was shown with NCS. Although there was no difference between RA patients and controls in age, sex, history of DM (+) and goitre, CTS was more frequent in RA group (respectively, 17.0% vs. 4.4%, P = 0.038). In RA group with CTS, age, history of DM, disease duration, HAQ-DI score, CTS patient global score, Boston symptom severity and functional status scores were elevated compared to without CTS [respectively, 57 (36-73) vs. 50 (24-76), P = 0.041; 35.3% vs. 6.0%, P < 0.001; 108 (12-396) months vs. 72 (6-360) months, P = 0.036; 1.93 (0.75-2.87) vs. 1.125 (0-2.75), P = 0.013; 52 (1-97) vs. 25 (0-91), P = 0.001; 2.81 (1.18-4.17) vs. 2.0 (1.0-4.01), P = 0.01; 3.37 (1.37-5.0) vs. 2.25 (1.0-5.0), P = 0.008]. No difference was found between CTS (+) and (-) RA patients in acute phase reactants, disease activity and US findings (P > 0.05). Sensitivity of Katz hand diagram was higher than Tinel and Phalen tests (respectively, 100, 60.0, 66.7%). Boston symptom and functional scores of RA patients with CTS diagnosed by EMG were increased than patients CTS (-) by EMG [respectively, 3.05 (1.90-4.27) vs. 1.55 (1.0-2.90), P = 0.002; 3.25 (1.73-3.82) vs. 1.12 (1.0-2.10), P = 0.008]. CTS frequency in RA was found higher than normal population, especially in patients with additional risk factors of CTS. There was no relationship between CTS and disease activity. CTS group had long disease duration and worse functional status. CTS could be a result of the chronic course in RA. In patient with CSA between 10 and 13 mm(2), Boston CTS questionnaire might give additional idea about CTS.     

The efficacy and safety of rituximab in patients with active rheumatoid arthritis despite methotrexate treatment: results of a phase IIB randomized, double-blind, placebo-controlled, dose-ranging trial

OBJECTIVE: To examine the efficacy and safety of different rituximab doses plus methotrexate (MTX), with or without glucocorticoids, in patients with active rheumatoid arthritis (RA) resistant to disease-modifying antirheumatic drugs (DMARDs), including biologic agents. METHODS: A total of 465 patients were randomized into 9 treatment groups: 3 rituximab groups (placebo [n = 149], 500 mg [n = 124], or 1,000 mg [n = 192] on days 1 and 15) each also taking either placebo glucocorticoids, intravenous methylprednisolone premedication, or intravenous methylprednisolone premedication plus oral prednisone for 2 weeks. All patients received MTX (10-25 mg/week); no other DMARDs were permitted. RESULTS: Significantly more patients who received 2 500-mg or 2 1,000-mg infusions of rituximab met the American College of Rheumatology 20% improvement criteria (achieved an ACR20 response) at week 24 (55% and 54%, respectively) compared with placebo (28%; P < 0.0001). ACR50 responses were achieved by 33%, 34%, and 13% of patients, respectively (P < 0.001), and ACR70 responses were achieved by 13%, 20%, and 5% of patients (P < 0.05). Changes in the Disease Activity Score in 28 joints (-1.79, -2.05, -0.67; P < 0.0001) and moderate to good responses on the European League Against Rheumatism criteria (P < 0.0001) reflected the ACR criteria responses. Glucocorticoids did not contribute significantly to the primary efficacy end point, ACR20 response at 24 weeks. Intravenous glucocorticoid premedication reduced the frequency and intensity of first infusion-associated events; oral glucocorticoids conferred no additional safety benefit. Rituximab was well tolerated; the type and severity of infections was similar to those for placebo. CONCLUSION: Both rituximab doses were effective and well tolerated when added to MTX therapy in patients with active RA. The primary end point (ACR20 response) was independent of glucocorticoids, although intravenous glucocorticoid premedication improved tolerability during the first rituximab infusion.     

类风湿关节炎患者程序化死亡基因5与肿瘤坏死因子-α的表达及其相关性分析

目的 检测类风湿关节炎(RA)及骨关节炎患者血清、滑液中程序化死亡基因(PDCD)5及肿瘤坏死因子(TNF)-α的表达水平,并分析PDCD5与TNF-α表达的相关性,初步探讨PDCD5在RA发病机制中的作用.方法 选取2009年12月至2010年8月50例患者(其中RA 26例,骨关节炎24例),采用酶联免疫吸附试验(ELISA)法检测血清、滑液中PDCD5及TNF-α的含量,统计学分析采用t检验及Pearson直线相关分析.结果 血清中,RA患者的PDCD5含量显著高于骨关节炎患者[(37±33)与(13±14) pg/ml,P＝0.02];滑液中,RA患者的PDCD5含量也显著高于骨关节炎患者[(37±26)与(11±7)pg/ml,P＜0.01].TNF-α在RA患者血清中的含量与骨关节炎患者比较差异无统计学意义(P=0.122),但其在RA患者滑液中的含量显著高于骨关节炎患者(P=0.037).PDCD5与TNF-α在RA及骨关节炎患者的血清中均呈负相关(r=-0.55,P=0.004;r=-0.51,P=0.012),PDCD5与TNF-α在RA患者的滑液中也呈负相关(r=-0.49,P=0.012),但在骨关节炎患者的滑液中无相关(r=-0.353,P=0.09).结论 PDCD5与TNF-α是RA重要的凋亡调控因子,在RA的发生发展过程中发挥重要作用.     

How aggressive should initial therapy for rheumatoid arthritis be? Factors associated with response to 'non-aggressive' DMARD treatment and perspective from a 2-yr open label trial

OBJECTIVE: To determine what baseline factors might be associated with response to an initial mild treatment regimen in patients with early rheumatoid arthritis (RA). METHODS: Open label 2-yr study of 111 consecutive patients with early RA of duration less than 1 yr. None of the patients had previously received disease-modifying anti-rheumatic drugs (DMARDs). All patients were assigned to receive hydroxychloroquine (HCQ) at enrollment, and could also take non-steroidal anti-inflammatory drugs (NSAIDs) and prednisone. At any point during follow-up, patients not fulfilling the American College of Rheumatology (ACR) 50 criteria for improvement and/or who were taking prednisone > 10 mg/day were considered treatment failures and therapy changed to methotrexate (MTX), 7.5-20 mg/week. Clinical, laboratory and immunogenetic factors potentially predictive of treatment assignment at month 24 were evaluated. RESULTS: After 24 months of follow-up, a majority of patients (56/94) were either still on solo DMARD therapy with HCQ (n = 49) or off DMARD therapy with controlled/quiescent disease (n = 4), and 38 patients were taking MTX (including 11 in combination with other DMARDs). At month 24, all but 9 patients met ACR50 criteria for treatment response. Features present at enrollment which were predictors of MTX therapy at month 24 were high pain score, baseline rheumatoid factor titre > 1:40, higher number of swollen joints, and poor patient global assessment. The presence of HLA-C7xx at enrollment was also predictive of need for MTX therapy. CONCLUSIONS: This study suggests that even milder treatment with HCQ is greatly beneficial in patients with early RA. There continue to be very few consistently reliable predictors of treatment needs in patients with this disease.     

血清软骨寡聚基质蛋白检测在关节炎患者中的意义研究

目的 探讨血清软骨寡聚基质蛋白(COMP)在各类关节炎患者中的差别及对类风湿关节炎(RA)软骨破坏放射学改变的早期预测价值.方法 采用酶联免疫吸附试验(ELISA)方法测定并对比分析154例各类关节炎患者血清COMP水平的差异,RA患者各项临床指标及2年后关节放射学改良SHARP(vdH-Sharp)指数评分与COMP行相关性分析.结果 与仅有滑膜损害的其他关节炎患者及正常人群比较,RA患者血清COMP显著升高(P＜0.05).骨关节炎(OA)、银屑病关节炎(PSA)患者与正常人群比较血清COMP亦有差异,而与其他滑膜关节炎患者比较差异不大.RA、OA、PSA患者间血清COMP值比较差异无统计学意义.RA患者2年随访发现COMP与患者关节X线的改良SHARP评分前后差值呈正相关(P＜0.01,r=0.848).但与初诊时的抗环瓜氨酸肽(CCP)抗体、类风湿因子(RF)、关节功能、改良SHARP评分均无相关性,与初诊时的红细胞沉降率(ESR)、C反应蛋白(CRP)、晨僵时间、关节肿胀、压痛指数相关(P＜0.05).结论 COMP在各类软骨受侵犯关节炎尤其是RA患者血清中异常增高,提示其可为RA软骨病变早期诊断及判断软骨病变进展、预后和治疗效果的一项理想指标.     

Development and evaluation of a novel ultrasound score for large joints in rheumatoid arthritis: one year of experience in daily clinical practice

Objective

To introduce and evaluate a new standardized ultrasound (US) score developed for large joints in patients with rheumatoid arthritis (RA).

Methods

A US score was designed to determine the degree of inflammation in the shoulder, the elbow, the hip, and the knee joint in patients with RA (Sonography of Large Joints in Rheumatology [SOLAR] score). Synovitis and synovial vascularity were scored semiquantitatively (grade 0–3) by gray‐scale US (GSUS) and power Doppler US (PDUS). Patients with RA were examined at baseline and 3, 6, and 12 months after initiation of local or systemic therapy (disease‐modifying antirheumatic drugs [DMARDs]/biologic agents). Erythrocyte sedimentation rate, anti–cyclic citrullinated peptide antibodies, and the clinical Disease Activity Score in 28 joints (DAS28) were determined.

Results

A cohort of 199 patients were analyzed and followed up over 12 months. At baseline, before modification of the therapy, patients received either DMARDs (n = 131), DMARDs plus biologic agents (n = 46), biologic monotherapy (n = 8), or no DMARD therapy (n = 14). At baseline, the mean DAS28 score was 4.6 and decreased to 3.2 after 1 year of therapy (P < 0.001). All US scores demonstrated a statistically significant improvement except for the PDUS scores for the shoulder and the hip. In detail, the mean synovitis GSUS score for the knee decreased from 5.2 at baseline to 2.2 after 12 months of followup. The mean GSUS score for the shoulder fell from 2.6 to 1.6, for the elbow fell from 5.2 to 2.6, and for the hip fell from 2.2 to 0.4 (P < 0.05 for each).

Conclusion

The SOLAR score is a feasible tool for the qualitative and quantitative evaluation of large joint involvement in patients with RA using US.