Adrenocorticotropic hormone response to hypoglycemic stress was preserved by a single bedtime 3-mg dose of prednisolone in patients with rheumatoid arthritis

Abstract

We have studied the effect of low-dose prednisolone administered before sleep on the hypothalamic–pituitary–adrenal axis and the symptoms of patients with rheumatoid arthritis (RA). Plasma adrenocorticotropic hormone (ACTH) and serum cortisol levels were measured in the basal state and after hypoglycemic stress induced by the insulin tolerance test in 21 patients receiving prednisolone at 3–5?mg daily. The patient's global assessment of their disease activity scores on a 100-mm visual analogue scale (VAS) and self-reporting of their functional status using the health assessment questionnaire (HAQ) were evaluated. While both the cortisol and the ACTH responses were impaired dose-dependently in patients treated with prednisolone, the ACTH response was maintained in patients treated with a single daily 3-mg dose of prednisolone before sleep. There was an inverse correlation between the extent of the ACTH response and disease activity as revealed by the VAS (r = 0.521, P < 0.05). There was also a weak correlation between VAS and the self-rating depression scale (SDS) (r = 0.443), especially when only patients with an HAQ score > 10 were included in order to exclude any possible contribution of the limitations in the activities of daily living to the SDS score (r = 0.859, P < 0.05). These results suggest that a single daily low dose (3?mg) of prednisolone administered before sleep maintains the ACTH response in RA patients, and patients with a good ACTH response appear to be less depressed and have milder symptoms.     

Lipoprotein(a) and Lipids in Relation to Inflammation in Rheumatoid Arthritis

The aim of this study is to evaluate whether lipoprotein(a) (Lp(a)) acts as the acute phase reactant and whether changes of lipids are related to inflammation in rheumatoid arthritis (RA). Lp(a) and lipids were measured after an overnight fast, before and after 14 days use of antiinflammatory agents and correlated with laboratory findings in 21 untreated RA patients and 19 healthy controls. Nine (42.3%) of 21 RA patients and 6 (31.6%) of 19 controls had high Lp(a) levels (> 30 mg/dl) and the Lp(a) level was higher in RA patients compared with controls (27.1 ± 5.3 vs 19.0 ± 4.2 mg/dl) without significant difference (p > 0.05). There was no significant correlation between ESR and Lp(a) and lipids in RA patients except for HDL cholesterol (r=–0.563, p = 0.008). After antiinflammatory agent use for 14 days, change in ESR (ESRsample1–ESRsample2) was significantly and negatively correlated to changes in total and HDL cholesterols in RA patients. In conclusion, although Lp(a) tended to be higher in RA, we could not find a distinct acute phase pattern of Lp(a). But changes in total and HDL cholesterols were negatively correlated with inflammation in RA. Our data support the phenomenon that dyslipoproteinemia observed in RA is associated with inflammation. Received: 6 August 1999 / Accepted: 25 January 2000     

How does the Short Form 36 Health Questionnaire (SF-36) in Rheumatoid Arthritis (RA) Relate to RA Outcome Measures and SF-36 Population Values? A Cross-Sectional Study

The aim of the study was to show that the SF-36 is a practical tool for use on outpatients with RA, to examine the relationship between the SF-36 and indices of outcome in RA, and to compare the results with population norms and other disease states. Eighty-six consecutive RA patients attending the Haywood Hospital in Stoke-on-Trent and starting or changing second-line therapy were enrolled. Disease outcome was assessed using the American College of Rheumatology core set and all subjects completed the SF-36 health questionnaire. The cohort had moderately active disease (median ESR 46) and appreciable disability (median HAQ 1.875). Impairment of health status was moderate to marked by the SF-36, with significant differences from population norms and chronic disease states such as low back pain. Good correlations were observed between HAQ and physical function (r>0.75, p<10^–6) and HAQ and social function (r>0.61, p<10^–6). In contrast, SF-36 scales for physical and emotional role showed no association with activity measures. We concluded that, SF-36 is a practical tool for use in patients with RA. HAQ is associated with its physical and social function scales. Other SF-36 scales, such as physical and emotional role, are not associated with activity core set measures; this suggests different information is involved. RA has a considerable impact on health status compared to other diseases. Received: 28 June 1999 / Accepted: 16 December 1999     

Adrenocorticotropic hormone and dehydroepiandrosterone sulfate levels of rheumatoid arthritis patients treated with glucocorticoids

To assess adrenal function with respect to the presence or absence of steroid therapy, we investigated differences in the blood levels of adrenocorticotropic hormone (ACTH) and dehydroepiandrosterone sulfate (DHEAS) in relation to steroid (prednisolone) administration in 123 patients with rheumatoid arthritis (RA). Levels of ACTH and DHEAS were significantly lower in the steroid-treated group than in the non-treated group (ACTH: 11.79 pg/ml vs 27.92 pg/ml) (DHEAS: 418.12 ng/ml vs 883.91 ng/ml) (P < 0.0001). We observed no steroid dose-related differences in ACTH levels. However, DHEAS levels showed a slight decrease at a prednisolone dose of 2.5 mg/day, with a significant decrease being observed at a dose of 5 mg/day when statistical adjustments were made for age and sex (P < 0.0001). At doses of 7.5 mg/day or greater, DHEAS levels were significantly lower than those for 5 mg/day (P < 0.0006). These results suggest that low-dose prednisolone reduces adrenal function in patients with RA. We recommend that doses of prednisolone should be limited to 5 mg/day or less in consideration of adrenal function when treating RA patients. The measurement of ACTH and DHEAS may be useful for evaluating adrenal function in patients with RA.     

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     

Assessment of cervical pain and function in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is characterized by inflammation of the synovial membrane, which can lead to deformities and functional disability. Unlike the dorsal and lumbar spine, the cervical spine is often affected by RA. The objective of this paper is to assess cervical pain and function in patients with RA and correlate these variables with overall function, quality of life, and radiographic findings on the cervical spine. One hundred individuals aged 18 to 65 years were divided into study group (50 patients with rheumatoid arthritis) and control group (50 healthy individuals, paired for gender and age). Patients with prior surgery, prior trauma or other symptomatic cervical spine condition were excluded. The visual analogue pain scale (VAS), Neck Pain and Disability Scale (NPDS), SF-36, HAQ and X-rays were used for evaluation purposes. Mean disease duration was 11.1 years. The cervical VAS was 2.4 cm and 1.3 cm for the study and control groups, respectively (p = 0.074). Statistical differences were found in NPDS scores, mean = 26.7 and 6.9, and HAQ scores, mean = 1.1 and 0.1, for the study and control groups, respectively (p < 0.001). SF-36 scores were statistically worse in the study group, except for the vitality, social aspects and mental health subscales. There was a positive correlation between the NPDS and VAS (r = 0.54) and between the NPDS and HAQ (r = 0.67). There was a negative correlation between the NPDS and SF-36 functional capacity domain (r = −0.53) and physical limitation domain (r = −0.58). The radiographic findings revealed more prevalent anterior atlanto-axial subluxation (p = 0.030), listhesis in neutral posture (p = 0.037), listhesis in extension (p = 0.007), degenerative alteration of C4–C5 segment (p = 0.023), size of C2 spinal canal (p = 0.002) and C3 spinal canal (p = 0.029) in the study group. Patients with RA have poorer cervical function than healthy individuals, although there is no difference in cervical pain.     

Effects of an educational–behavioral joint protection program on people with moderate to severe rheumatoid arthritis: a randomized controlled trial

The aim of this study was to asses the effects on pain, disability, and health status of an educational–behavioral joint protection program in a group of moderate–severe rheumatoid arthritis (RA) patients. Eighty-five subjects with RA in treatment with anti-tumor necrosis factor alpha (TNFα) drugs (infliximab) were enrolled into the study and randomized into either an experimental group (46, EG) or a control group (39, CG). We organized four EG meetings, which included information on pathophysiology and evolution of RA, joint protection during normal activities of daily living, suggestions on how to adapt the surrounding environment, and self-learning exercises to perform at home. Sociodemographic characteristics and degree of knowledge of the disease, measured by the Health Service Interview (HSI), were recorded at baseline. The outcome measures included the Visual Analogue Scale (VAS), the Arthritis Impact Measurement Scale 2 (AIMS2), and the Health Assessment Questionnaire (HAQ), which were administered at the beginning and end of the trial. Thirty-six patients from the EG (7 men and 29 women; mean age 54.2 years) and 34 from the CG (6 men and 28 women; mean age 52.2 years) completed the trial. No statistical differences in baseline evaluations were found between the two groups. According to the answers given on the HSI, the majority of our patients had poor knowledge of RA and its consequences. After a mean time of 8 months, the patients receiving educational training displayed a significant decrease, compared to the CG, in the VAS (p = 0.001), HAQ (p = 0.000), and physical (p =0.000), symptoms (p = 0.049), and social interaction (p = 0.045) scores on the AIMS2, but not in other items. Our study showed that 8 months after attending an educational–behavioral joint protection program, subjects with moderate–severe RA presented less pain and disability and thus an enhanced health status. This approach may efficiently complement drug therapy in these patients.     

Hormonal Responses to Exercise Stress Test in Patients with Fibromyalgia Syndrome

Twenty patients with fibromyalgia syndrome (FMS) and 20 matched healthy controls were subjected to an exercise stress test above their anaerobic threshold. Serum samples for the measurement of growth hormone (GH), insulin-like growth factor-1 (IGF-1), prolactin (PRL), adrenocorticotrophic hormone (ACTH) and cortisol were taken prior to and after the test at 30-min intervals. Compared to the controls, the patients with FMS displayed significantly lower basal GH levels and slightly, though significantly, higher prolactin levels. Following the exercise test there was a significant increase in the mean GH level in the patient group (P = 0.0474) and a significant decrease in the control group (P = 0.0286) 1 hour after the exercise. A slight decrease in ACTH levels in the control group was observed (P= 0.0002), but there was no significant change in FMS patients. Cortisol levels were significantly lower in both groups after the exercise (P= 0.0001). These results suggest the possibility of a perturbation in hormonal response to exercise in patients with FMS. Received: 25 August 2000 / Accepted: 30 May 2001     

Disability and patient’s appraisal of general health contribute to depressed mood in rheumatoid arthritis in a large clinical study in Japan

The aim of this study was to evaluate the factors responsible for depressed mood in rheumatoid arthritis (RA). Clinical and laboratory measures were collected from 4558 RA patients enrolled in a large clinical cohort study for RA conducted at the Institute of Rheumatology, Tokyo Women's Medical University (IORRA study). A two-question depressed screening included in the U.S. Preventive Services Task Force recommendation were utilized to identify “depressed patients.” A total of 1875 (41.1%) were identified as “depressed patients” who presented with symptoms suggestive of depression. Patient's Visual Analog Scale (VAS) for general health (43.3 mm vs 24.6 mm, P < 0.0001) and pain (40.9 mm vs 23.8 mm, P < 0.0001) and the disability index scores measured by the Health Association Questionnaire (HAQ) (0.986 vs 0.574, P < 0.0001) were significantly higher in depressed patients than in nondepressed patients. The presence of three or more comorbidities (odds ratio [OR] 2.157, P < 0.0001), infection (OR 1.754, P < 0.0001), and joint surgery (OR 1.878, P < 0.0001) were significantly correlated with depressed mood in RA. The results of the Generalized Linear Model analysis showed that HAQ disability index (P < 0.0001) and patient's VAS for general health (P < 0.0001) were also strongly and significantly associated to the response variable “probability of depressed patients.” Patient appraisal of poor general health and greater disability were associated with depressed mood in RA.     

Prediction of Creatinine Clearance from Serum Creatinine in Patients with Rheumatoid Arthritis: Comparison of Six Formulae and One Nomogram

The estimation of glomerular filtration rate is important for the medical treatment of patients with rheumatoid arthritis (RA). However, the determination of endogenous creatinine clearance (Clcr) from a 24-h urine collection is an unreliable and time-consuming procedure. We therefore tested the accuracy of six equations and one nomogram for the prediction of Clcr from serum creatinine (Scr) in 38 patients with RA and 20 controls. A positive correlation was found for all methods in the controls (r= 0.83–0.94) and RA patients (r= 0.51–0.69). The methods did not overestimate Clcr in RA. In the RA group the simple formula published by Cockcroft [Clcr = ((140 − age) × body weight)/(72 × Scr), × 0.85 for females] showed the best correlation with the measured Clcr. In RA the Cockroft formula can reliably be used to predict Clcr from Scr. Received: 8 February 1999 / Accepted: 4 June 1999     

Melatonin in elderly patients with insomnia.– A systematic review

Summary Background Melatonin is a hormone and antioxidant produced by the pineal gland of which four neurobiological roles have been claimed in the aged population: anti-ageing agent; free-radical scavenger; regulator of circadian rhythm; endogeneous sleep-inducer. The „melatonin replacement” hypothesis states that 1) the well-evidenced age-related decline contributes to insomnia and that 2) replacement with physiological doses of melatonin improves sleep. The aim of this review was to determine the evidence for the efficacy of melatonin in elderly insomniacs. Methods MEDLINE‘s database from 1990–2000 was searched with „melatonin”, „geriatrics” and „(frail)-elderly” as major subheadings. This resulted in 78 articles: only studies with empirical treatment data were reviewed (N=12). Results Six reports (abstract, research letter, retrospective case study, 3 open label studies) showed a trend towards efficacy of melatonin: sleep quality improved and in patients with Alzheimer‘s disease sundowning was reduced.?   In 6 double blind, randomised crossover trials, a total number of 95 patients (mean ages: 65–79yrs) were treated. Melatonin doses ranged from 0.5mg to 6mg; most took a single dose 30–120min before bedtime. In 3 studies a slow release form was used. Sleep quality was objectively measured by wrist actigraphy (n=4) and polysomnography (n=2), and additionally subjective sleep quality was assessed (n=2). Sleep latency decreased significantly in 4 studies. In 3 studies other measures of sleep quality (sleep efficiency, total sleep time and wake time during sleep) improved. Subjective sleep quality did not improve. No early-morning sleepiness occurred. Comparison of the studies suggests that melatonin is most effective in elderly insomniacs who chronically use benzodiazepines and/or with documented low melatonin levels during sleep. Conclusion There is sufficient evidence that low doses of melatonin improve initial sleep quality in selected elderly insomniacs. However, larger randomized controlled trials, with less strict inclusion criteria are necessary to yield evidence of effectiveness (i.e. clinical and subjective relevance) in geriatric patients who suffer from insomnia, before wide-spread use can be advocated. Received: 26 June 2001/Accepted: 10 July 2001     

Etanercept in the treatment of rheumatoid arthritis: clinical follow-up over one year by ultrasonography

We evaluated clinically and sonographically the effects of etanercept therapy in patients with rheumatoid arthritis (RA) over 12 months of treatment. Eighteen patients affected by RA who were non-responders or partial responders to disease modifying therapy were commenced on Etanercept treatment. Before starting therapy (T0) and at 12 months (T1), the following parameters were evaluated: erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analogue scale (VAS) for pain, number of painful and swollen joints, health assessment questionnaire (HAQ) and disease activity score in 28 joints (DAS 28). Musculoskeletal ultrasound (US) was performed in the following joints: second and fifth metacarpophalangeal, third interphalangeal, wrist and knee joints and a semiquantitative score (0–3) calculated and used to indicate the presence of a localised inflammatory process (synovitis, tenosynovitis, bursitis) and/or structural damage (bone erosion and cartilaginous change). An overall score was calculated based on the sum of the single scores to obtain a comprehensive score indicative of the global pathological change. The US global scores significantly reduced between T0 and T1 (p < 0.0001). The following laboratory and clinical parameters also significantly reduced: ESR (p < 0.0001), CRP (p < 0.02), VAS (p < 0.001), number of total swollen joints (p < 0.001), number of total painful joints (p < 0.01), HAQ scores (p < 0.05) and DAS 28 (p < 0.0001). A positive response to treatment with Etanercept was demonstrated both by US examination of several joints and by clinical evaluation of several parameters. US is a useful tool in the monitoring of biologic therapy in RA, assessing both inflammatory and destructive changes.     

ACTH,cortisol and prolactin in active rheumatoid arthritis

Prolactin (PRL) and glucocorticoids are hormones involved in the regulation of the immune system. Rheumatoid arthritis (RA) is an inflammatory condition that presents a diurnal rhythm of disease activity. ACTH, PRL, cortisol, IL-1β and TNF-α circadian rhythms have been studied in active RA (aRA) to evaluate a possible relationship between the neuroendocrine system and immunological activity in rheumatoid patients. ACTH, PRL, cortisol, PRL/cortisol ratio and IL-1β and TNF-α levels were determined in aRA patients and in control subjects at 6.00, 10.00, 14.00, 18.00, 22.00 and 02.00 h. In aRA patients we observed lower ACTH and cortisol levels at 22.00 h and 2.00 h, respectively and higher PRL and PRL/cortisol ratio at 2.00 h when compared to controls. IL-1β and TNF-α reached their highest serum levels in aRA patients at 2.00 and 6.00 h. This study provides evidence that in aRA there could be a temporary and probably causal relationship between diurnal disease activity, hormonal disequilibrium and cytokine secretion. An imbalance in favour of proinflammatory hormones (PRL and cytokines) as opposed to levels of anti-inflammatory hormones could be responsible for the diurnal rhythm of activity disease observed in aRA patients. Received: 26 February 2001 / Accepted: 28 January 2002     

Evaluating obesity in fibromyalgia: neuroendocrine biomarkers, symptoms, and functions

The aim of this study was to investigate the associations between obesity and fibromyalgia syndrome (FMS). This study was conducted at the University of Utah Pain Management and Research Center, Salt Lake City, Utah. Thirty-eight FMS patients were included in this study. Neuroendocrine indices (catecholamines, cortisol, C-reactive protein [CRP], and interleukin-6), symptom measures (Fibromyalgia Impact Questionnaire), sleep indices (Actigraph), and physical functioning (treadmill testing) were measured. Body mass index (BMI) provided the primary indicator of obesity. Approximately 50% of the patients were obese and an additional 21% were overweight. Strong positive associations were found between BMI and levels of IL-6 (r = 0.52) and epinephrine (r = 0.54), and somewhat weaker associations with cortisol (r = 0.32) and CRP (r = 0.37). BMI was also related to maximal heart rate (r = 0.33) and inversely related to distance walked (r = −0.41). BMI was associated with disturbed sleep: total sleep time (r = −0.56) and sleep efficiency (r = −0.44). No associations between self-reported symptoms and BMI were found. This study provides preliminary evidence suggesting that obesity plays a role in FMS-related dysfunction.     

The impact of disease activity, pain, disability and treatments on fatigue in established rheumatoid arthritis

We investigate a range of clinical factors and anti-rheumatic treatments, for their degree of association with rheumatoid arthritis (RA) fatigue in 557 patients. A range of clinical measures concerning disability, pain and disease activity together with drug history were recorded as part of routine clinical visits. Fatigue was measured using the Functional Assessment of Chronic Illness Therapy (FACIT-F) questionnaire. Spearman's correlation (p < 0.05) evaluated FACIT-F against the other clinical measures. Mean FACIT-F was compared between the treatment groups. Multivariate linear regression analysis investigated association between the clinical measures and FACIT-F in more detail. Correlation (p < 0.05) with FACIT-F was the strongest for Health Assessment Questionnaire (HAQ) (r = −0.68), patient global (r = −0.64) and pain (r = −0.62) visual analogue scores. In multivariate models, DAS28, HAQ and pain explained variability in fatigue the best (R ² = 0.54). Further analyses, looking at the sub components of DAS28, show that fatigue is mainly associated with tender joint counts and pain rather than swollen joint counts or erythrocyte sedimentation rate. RA fatigue levels were not significantly different between patients on no treatment, disease modifying anti-rheumatic drugs or biologics. Fatigue in established RA is not specifically influenced by the type of treatment used but is associated with tender joint counts, pain and disability. This finding is in contrast to recent trials in early RA that suggest biologics are better than traditional disease modifying anti-rheumatic drugs for fatigue. This difference in result may be because the origins of fatigue are not the same in early compared with established RA.     

Bone age and factors affecting skeletal maturation at diagnosis of paediatric Cushing’s disease

Paediatric Cushing’s disease (CD) is usually associated with growth retardation, but there are only few published data on skeletal maturation at diagnosis. We analysed factors contributing to skeletal maturation and final height in Asian Indian patients with paediatric CD. We conducted retrospective analysis of 48 patients (29 males; 19 females) with mean age: 14.84 years at diagnosis (range 9–19 years). A single observer using the Greulich Pyle method determined the bone age (BA) of each child. BA delay, i.e. the difference between chronological age (CA) and BA, was compared with clinical and biochemical variables. BA delay was present in 35/48 (73%) patients (mean delay 1.6 years, range 0.5–5 years) and correlated negatively with height SDS (r = −0.594, P < 0.001) and positively with CA at diagnosis (r = 0.247, P < 0.05). There was no correlation with duration of symptoms before diagnosis, basal cortisol, midnight cortisol, ACTH or percentage suppression of low dose dexamethasone suppression cortisol (LDDST). We could not demonstrate any relationship between the duration of history before diagnosis and height SDS at final height. Mean final height SDS in patients was −1.84. We found that most children with CD had delayed BA and correlated significantly with CA and height SDS at diagnosis. Early diagnosis may reduce delay in skeletal maturation and thus contribute to optimal catch-up growth.     

Juvenile Chronic Arthritis in Adult Life: A Study of Long-term Outcome in Patients with Juvenile Chronic Arthritis or Adult Rheumatoid Arthritis

We compared the prognostic factors and outcome of 30 patients with juvenile chronic arthritis (JCA) extending into adult life with those of 30 patients with adult rheumatoid arthritis (RA) at a university adult rheumatology clinic; pairs were matched for sex and duration of disease (mean 8 years). One-third of JCA patients had seronegative polyarticular disease and another third had oligoarticular disease. In a third of the JCA patients, the clinical presentation changed during the follow-up. Over half of the RA patients had seropositive polyarticular and a one-third had seronegative polyarticular disease. Fewer seropositive patients were recorded in the JCA group than in the RA group both at the beginning (16.7% versus 56.7%; p = 0.003) and at the end of the follow-up (14.3% versus 59.3%; p = 0.001). JCA patients developed less radiographic changes than RA patients (46.7% versus 76.7%; p = 0.034); oligoarthritis in the JCA group had the best prognosis whereas seropositive polyarthritis in the RA group had the worst prognosis. Significantly more patients with JCA than RA (60% versus 23%; p = 0.009) were in remission at the end of the follow-up. In conclusion, when studied in adult life, the long-term prognosis is better in patients with JCA than in those with RA. Received: 23 March 1998 / Accepted: 3 November 1998     

The continuous measurement of anti-CCP-antibodies does not help to evaluate the disease activity in anti-CCP-antibody-positive patients with rheumatoid arthritis

Anti-cyclic citrullinated peptide antibody (CCP-AB) are used for diagnosis of rheumatoid arthritis (RA). It is still unknown if the extent of CCP-AB levels is useful to assess the disease activity or the individual follow-up as an individual activity parameter. We investigated 40 patients with a known RA who were positive for CCP-AB. Correlation between disease activity (DAS 28) and the amount of levels of CCP-AB in all patients over time as well as the individual follow-up were analysed. A weak correlation between CCP-AB and DAS 28 [r = 0.19; p = 0.001] was found. The individual correlation between CCP-AB titre and DAS 28 ranged between r = −1 and r = 1, so a strong positive and also a strong negative correlation was seen in single patients. In patients with erosive RA the correlation was significantly more positive than in patients with non-erosive RA. Because the correlation between CCP-AB levels and parameters of disease activity measured by DAS 28 is very low, we conclude for monitoring the disease activity to use simply and established parameters like morning stiffness, HAQ or ESR. The individual follow-up of the levels of CCP-AB is by the moment not useful for monitoring the disease activity.     

Brazilian-Portuguese version of the Health Assessment Questionnaire for Spondyloarthropathies (HAQ-S) in patients with ankylosing spondylitis: a translation,cross-cultural adaptation,and validation

To translate and cross-culturally adapt to the Brazilian-Portuguese language (BP), five items were added to Health Assessment Questionnaire (HAQ) to validate the resulting HAQ-S BP version for ankylosing spondylitis (AS). The items were translated into BP following translation and back-translation. To assess validity, 25 patients were evaluated using the HAQ, Bath AS Functional Index (BASFI), Bath AS Disease Activity Index (BASDAI), Bath AS Metrology Index (BASMI), and laboratory variables (erythrocyte sedimentation rate, C-reactive protein). One question required modification to adapt culturally to Brazilian conditions. The test–retest and interobserver correlation coefficients were 0.990 (p < 0.05) and 0.993 (p < 0.05), respectively. HAQ-S BP correlated to BASFI (r = 0.574; p < 0.05) and to HAQ (r = 0.963; p < 0.05), but not to BASDAI (r = 0.282), BASMI (r = 0.194), and laboratory variable. Individually, the fifth item referring to driving correlated highly to neck rotation (r = 0.900; p < 0.05), while the HAQ-S BP correlated to the neck rotation component (r = 0.303), but did not reach statistical significance. The HAQ-S BP version demonstrated adequate reproducibility, internal consistency and validity, confirming its utility in the research of AS in Brazil.     

Improvement of the HAQ score by infliximab treatment in patients with RA: its association with disease activity and joint destruction

We conducted a two-year prospective study to clarify the efficacy of infliximab at improving the health assessment questionnaire (HAQ) score and associated factors in 67 patients with advanced rheumatoid arthritis (RA). All patients were scheduled to receive infliximab at a dose of 3 mg/kg at weeks 0, 2, 6 and every eight weeks thereafter through to week 102, and were fully examined at the time of each infusion. Parameters of disease activity such as the serum level of C-reactive protein (CRP), the serum level of matrix metalloproteinase-3 (MMP-3) and the 28-joint disease activity score (DAS28) were obtained, and the functional capabilities of the patients were assessed using the HAQ score. The serum CRP, the MMP-3, the DAS28(CRP) level, and the mean HAQ score decreased rapidly at two weeks after the start of infliximab treatment (CRP from 3.7 to 0.9 mg/dl, MMP-3 from 362.3 to 192.8 ng/ml, DAS28(CRP) from 5.6 to 3.7, and HAQ score from 1.5 to 0.9). Compared with the baseline values, the mean progression of the modified van der Heijde (vdH)–Sharp score after one year was 4.4 ± 5.8 (median: 3.0), and that after two years was 3.1 ± 6.9 (median: 1.0). A 93% reduction in the rate of joint destruction, as measured using the vdH–Sharp score, was estimated after infliximab therapy. Patients with less joint damage (shorter disease duration or lower vdH–Sharp score) regained more of their daily activities. The present study demonstrated the importance of activity control before the progression of irreversible factors, such as joint destruction, for maintaining the functional capacities of RA patients.