Radiographic joint space in rheumatoid elbow joints. A 15-year prospective follow-up study in 74 patients

OBJECTIVE: To evaluate radiographically the humeroulnar (HU) and humeroradial (HR) joint spaces in patients with long-term rheumatoid arthritis (RA). METHODS: An inception cohort of 74 patients with RA were followed for 15 yr. At the end-point, 148 elbows were radiographed by a standard method. The HU and HR joint spaces were examined from the anteroposterior radiographs by measuring the shortest tangential distance in the middle of the joints. Destruction of the elbow joints, assessed with the Larsen method on a scale of 0-5, was studied in relation to the joint-space measurements. RESULTS: Mean (s.d.) HU joint space (n=148) in RA patients was 2.5 (1.1) mm, range 0-4 mm [2.9 (0.8) mm in men and 2.4 (1.1) mm in women]. Mean (s.d.) HR joint space (n=140) was 2.3 (0.9) mm, range 0-4 mm [2.5 (0.8) mm in men and 2.3 (1.0) mm in women]. HU and HR spaces of the affected joints (Larsen grades 2-5) [1.9 (s.d. 1.1) and 1.8 (0.9) mm respectively] were notably narrower than those of the unaffected (Larsen grades 0-1) joints [3.1 (0.7) and 2.9 (0.6) mm]. All the joints graded as Larsen 4 or 5 (n=13) had a value of 0 mm for both joint spaces. Both the HU and the HR joint-space narrowing was associated with increasing destruction (Larsen grading) of the joint. [r= -0.69 (95% CI -0.77 to -0.60) and r= -0.70 (-0.78 to -0.60)]. The monotonic narrowing was significantly increasing from unaffected (Larsen 0, 1), slightly (2), moderately (3) to severely (4, 5) affected joints (P<0.001). A step in this process occurred between Larsen grades 3 and 4, when the mean joint space diminished from 1.4 and 1.5 respectively to 0 mm. CONCLUSIONS: Joint-space narrowing is a frequent consequence of rheumatoid affection of the elbow joint. HR joint space decreases together with HU joint space; however, the HR joint space is already slightly narrower at the start. The narrowing is a rather late phenomenon, occurring only after erosive destruction. This should be borne in mind when using the Larsen method to evaluate changes in the elbow joint.     

Radiographic joint space in rheumatoid acromioclavicular joints: a 15 year prospective follow-up study in 74 patients.

OBJECTIVE: To evaluate radiographically the acromioclavicular joint space in patients with long-term rheumatoid arthritis (RA). METHODS: A cohort of 74 patients with RA was followed prospectively for 15 yr. At the end point, 148 shoulders were radiographed with a standard method. The acromioclavicular (AC) joint space was examined from the radiographs with a method developed previously for population studies; the joint space was measured at its superior and inferior border, and the average of the two measurements, the integral space, calculated. RESULTS: Mean AC joint space in RA patients was 4.9 (S.D. 3.7), range 0-20.5 mm; 6.2 mm (S.D. 5.1) in men and 4.5 mm (S.D. 3. 0) in women. An AC joint space wider than 7 mm in men was found in 11 (31%) out of 36 joints and wider than 6 mm in women in 17 (15%) out of 112 joints. Joint space widening was associated (r=0.87, 95% CI 0.82-0.90) with increasing destruction (Larsen grading) of the joint and it seems to be an inevitable consequence of AC joint affection in RA. Joint space widening is more progressive on the caudal side because of the nature of the erosive destruction. Degeneration with joint space narrowing was observed in 8 (11%) patients (11 joints, 7%; three bilateral). CONCLUSIONS: The largest value of the joint space may be used when evaluating rheumatoid AC joint space. In RA patients, a joint space of >7 mm in men and >5 mm in women is a sign of destructive AC joint affection.     

Radiographic remission in seropositive rheumatoid arthritis. A 20-year follow-up study

OBJECTIVE: Rheumatoid arthritis (RA) is in most instances a progressive disease. Very little information is available on halting of the radiographic damage, particularly in later phases of the disease. We studied radiographic remission of RA lasting to the end of follow-up, covering the period 1973-96. METHODS: Radiographs of hands and feet were taken at onset and at 1, 3, 8, 15 and 20 years from entry in 102 cases of recent onset (< 6 months) seropositive and erosive RA. A Larsen score of 0-100 was formed for 20 joints of hands and feet. If the score did not worsen by more than one point between one of the above time points and the end of the study, the patient was considered to be in remission. RESULTS: Remission was confirmed in 27 (26%) of the patients. In 3 cases the remission was from the 1-year check-up, in 5 from the 3-year check-up, in 6 from the 8-year check-up and in 13 cases from the 15-year check-up. Some of the remission cases had a mild disease from the outset, but there were cases in which the disease process had led to marked joint destruction before slowing down. CONCLUSION: This data may serve as a basis for comparison with subsequent cohort studies on new treatments-of-choice.     

Incidence of glenohumeral joint involvement in seropositive rheumatoid arthritis. A 15 year endpoint study

OBJECTIVE: To evaluate the incidence of involvement and nature of destruction of glenohumeral (GH) joints in a prospectively followed cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA). METHODS: At the 15 year followup radiographs of 148 GH joints were evaluated, and the grade of destruction was assessed by the Larsen method. RESULTS: Erosive involvement (Larsen grade 2) was observed in 71/148 (48%) GH joints in 41/74 (55%) patients; 30 patients had bilateral and 11 unilateral involvement. The incidence of mild erosions (Larsen grade 2) was 401148 (27%), and of severe (Larsen 3-5) 31/148 (21%). The 11 most severely involved (Larsen grade 5) joints were seen in 6 (8%) patients. Erosions were most often (61/71 joints) observed on the superolateral articular surface of the humerus. Glenoidal involvement was less common (28/71 joints). The Larsen score (0-100) for peripheral joints correlated significantly with the GH joint Larsen grade on both sides (p < 0.001). CONCLUSION: After 15 years more than half the patients with RA showed definite involvement and 1 in 4 had severe destruction of the GH joint. The greatest destruction was almost always bilateral.     

A 15-year follow-up study on the outcome in patients with early rheumatoid arthritis

This study aimed to investigate the natural course of early rheumatoid arthritis (RA) after treatment for 15 years based on the present data of patients who had been enrolled in a 1 year study of early RA conducted by the Japan Rheumatism Foundation in 1981 and 1982. An examination form was mailed to each doctor who had participated in the previous study requesting them to record the present data of the patients. The patients were requested to fill out the AIMS2 questionnaire. Patients had been randomly assigned into three treatment groups: those treated with gold, with d-penicillamine and without slow acting antirheumatic drugs (SAARDs). Information was obtained concerning 74 of 161 patients who had completed the previous 1 year study. Clinical remission was observed in 20 of 74 patients. The current status of RA by physician’s assessment was reported to be well controlled in 32 of 48 cases (66.7%); however, no remarkable improvement was seen in erythrocyte sedimentation rate (ESR, and the number of painful joints compared with the values at entry 15 years previously. Radiographical stages showed progression and the average score of AIMS2 had deteriorated in most cases. High ESR, progression of joint damage and positive rheumatoid factors at the early stage of RA were suggested to be factors relating to QOL deterioration. These results suggest that it would be difficult to modify the natural course of RA by currently used treatment strategies with SAARDs.     

A 15-year follow-up study on the outcome in patients with early rheumatoid arthritis

Abstract

This study aimed to investigate the natural course of early rheumatoid arthritis (RA) after treatment for 15 years based on the present data of patients who had been enrolled in a 1 year study of early RA conducted by the Japan Rheumatism Foundation in 1981 and 1982. An examination form was mailed to each doctor who had participated in the previous study requesting them to record the present data of the patients. The patients were requested to fill out the AIMS2 questionnaire. Patients had been randomly assigned into three treatment groups: those treated with gold, with d-penicillamine and without slow acting antirheumatic drugs (SAARDs). Information was obtained concerning 74 of 161 patients who had completed the previous 1 year study. Clinical remission was observed in 20 of 74 patients. The current status of RA by physician’s assessment was reported to be well controlled in 32 of 48 cases (66.7%); however, no remarkable improvement was seen in erythrocyte sedimentation rate (ESR, and the number of painful joints compared with the values at entry 15 years previously. Radiographical stages showed progression and the average score of AIMS2 had deteriorated in most cases. High ESR, progression of joint damage and positive rheumatoid factors at the early stage of RA were suggested to be factors relating to QOL deterioration. These results suggest that it would be difficult to modify the natural course of RA by currently used treatment strategies with SAARDs.     

Relation of glenohumeral and acromioclavicular joint destruction in rheumatoid shoulder. A 15 year follow up study

OBJECTIVES: To evaluate the relation of glenohumeral (GH) and acromioclavicular (AC) joint involvement in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA) followed up prospectively. METHODS: At the 15 year follow up radiographs of 148 shoulders were evaluated, and the grade of destruction of GH and AC joints were assessed by the Larsen method. One GH joint arthroplasty had been performed after 13 years of the disease onset and the preoperative radiograph was evaluated. RESULTS: Erosive involvement (Larsen grade >/= 2) was observed in 96 of 148 (65%) of the shoulders. Both GH and AC joints were affected in 62 of 148 (42%) shoulders. GH joint alone was involved in nine (6%) shoulders and only AC joint was affected in 25 (17%) shoulders. AC joint destruction correlated with the GH joint destruction, r=0.74 (95% confidence intervals (CI) 0.65 to 0.80 ). CONCLUSION: In RA AC joint is affected more often than the GH joint, but in half of the patients both joints are involved. This should be remembered when treating painful rheumatoid shoulder.     

Survival study of rheumatoid arthritis patients in Madrid (Spain). A 9-year prospective follow-up

OBJECTIVE: To determine the risk and causes of death in rheumatoid arthritis (RA) patients in Madrid. METHODS: A longitudinal survival analysis was made. 182 RA patients of the rheumatology clinic of a tertiary care hospital were studied. 42 (23%) males and 140 (77%) females. All were followed-up for a 9-year period or to the date of death. Kaplan-Meier survival curves for both male and female cohorts were performed. The logrank test was used to compare both distributions and to determine the statistical significance. RESULTS: The mortality rate for the RA patient cohort was 15.4 deaths/1000 person-years (10.2/1000 for the female and 34.2/1000 for the male cohorts). The mortality rate ratio was 3.3. The logrank test showed a statistical difference (p=0.0023). The standardized mortality ratio was 1.85 for RA patients. The causes of death were: cardiovascular diseases 5 (21%), infections 5 (21%). amyloidosis 4 (17%), malignant diseases 2 (8%). CONCLUSIONS: Mortality is nearly two times higher in our population of RA patients. Male patients have a much lower survival probability than females. Cardiovascular diseases, infections and amyloidosis were the most common causes of death.     

Need and sequence of large joint replacements in rheumatoid arthritis. A 25-year follow-up study

OBJECTIVE: The aim of the present study was to evaluate the number and sequence of large joint replacements (LJR) performed in long-term rheumatoid arthritis (RA) from an inception cohort of 103 patients with rheumatoid factor (RF)-positive RA followed over 25 years. METHODS: A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Patient documents and radiographs were evaluated in the beginning of 2001 and a complementary interview was arranged to assess the number and sequence (timing) of LJRs performed. RESULTS: The cumulative number of LJRs performed for 22 patients (19 women) during the 25 years of follow-up was 41. Seventeen total hip joint replacements (THR) (42% of the total number of 41 LURs) were performed on 13 patients, median time from the diagnosis to the operation being 14 years; 14 total knee replacements (TKR) (34%) on 11 patients (after a median time of 17 years); 3 total shoulder replacements (TSR) (7%) on 3 patients (median time of 18 years); and 7 total elbow replacements (TER) (17%) on 4 patients (median time of 21 years), respectively. Six patients had undergone three or more LJRs during the follow-up period. CONCLUSION: During our 25 years of follow-up, in 27% of RA patients LUR was needed, and 41% of them needed more than one replacement.     

Alcohol use in families: a 15-year prospective follow-up study

Aims To study the prevalence of adolescents’ problematic alcohol use and its parental predictors: drinking habits and socio‐demographic factors. Design, setting, participants and measurements Questionnaires were sent regularly to the same Finnish families (n = 1132) from the onset of pregnancy (in 1986–87) to the child’s age of 15 years (in 2001–02) (n = 1028). There was a total of three follow‐up points. Findings At 15 years of age, 83% of girls and 79% of boys had used alcohol; 18% of boys and 14% of girls had been drunk more than once a month. The child’s permanent separation from at least one biological parent was the strongest socio‐demographic predictor of adolescents drinking. Fathers’ present heavy drinking and parental early drinking were the best predictors of their children’s problematic alcohol use at the age of 15. Conclusions Knowledge of fathers’ alcohol use and its time of onset may be used to determine children who are at added risk of problematic alcohol use later in life. Special guidance, support and treatment can be targeted to these families.     

Automated measurement of joint space width in small joints of patients with rheumatoid arthritis

OBJECTIVE: Comparison of performances of 5 (semi)automated methods in measuring joint space width (JSW) in rheumatoid arthritis. METHODS: Change in JSW was determined by 5 measurement methods on 4 radiographs per patient from 107 patients included in the COBRA trial (comparing sulfasalazine alone or in combination with methotrexate and corticosteroids). For each method the number of patients with sufficient available results was assessed (efficiency). An independent repeated measurement was carried out on a random sample of 30 patients' baseline and 1-year radiographs, to evaluate within-method reliability of change scores. Discriminatory ability (DA) of the measurement methods (between the 2 treatment arms) was compared with the DA of the Sharp-van der Heijde score (SHS) and its 2 components (erosion and JSW scores). RESULTS: The overall success rate varied widely between methods. Applying the chosen threshold of a minimum of 50% available joints with a change score per patient resulted in a success rate > 92% in 4/5 methods. Repeatability of measurements was good for most methods (intraclass correlation coefficient > or = 0.80 in 4/5 methods). Almost all measurement methods in 3 followup periods (12/14) showed a lower mean loss of JSW in patients from the intensive treatment group, although this was rarely statistically significant, confirming the known difference in structural damage. JSW as measured by the (semi)automated systems often showed higher DA than the JSW score of the SHS, but was lower than the total SHS and erosion scores. CONCLUSION: Although efficiency of the methods should be improved further, results already show good reliability and encouraging DA of most methods. Optimal information may be obtained with a combination of scoring of erosions and (semi)automated measurement of JSW.     

Prevalence of mutilans-like hand deformities in patients with seropositive rheumatoid arthritis. A prospective 20-year study

This study examined radiographically the prevalence of arthritis mutilans hand deformities in an inception cohort of 68 rheumatoid arthritis (RA) patients. Hand deformities of 103 RF-positive RA patients were evaluated after 8 years, 83 patients after 15 years and 68 patients 20 years after entry. The grade of destruction in the hand joints was assessed by the Larsen method and Larsen scores of 0-50 were determined for both PIP (+IP) and MCP joints. At the end point, 3 patients had Larsen scores > or =40 for both PIP and MCP joints. These three patients had severe resorption in most of the finger joints, but did not demonstrate classical opera-glass hand. The prevalence of mutilans-like hand deformities with RA was 3/68 (4.4%) in a prospective 20-year study.     

Radiographic study of joint destruction patterns in the rheumatoid elbow

Knowledge of the pattern of joint destruction is important for planning the therapeutic approach to rheumatoid arthritis (RA) of the elbow. Accordingly, we carried out a large-scale radiographic study with the objective of elucidating the joint destruction pattern in rheumatoid elbows. From 2001 through 2003, we examined and took plain X-rays of both elbows of 193 RA patients (i.e., 386 elbows), consisting of 18 men and 175 women, with a mean age of 57.0 years. Radiographic images of the elbow joints were used to classify the degree of bone loss in various zones on the elbow joint surface into four grades of severity, and joint destruction was compared between the left and right elbows. In addition, correlation in the extent of bone loss between each of the zones of the same elbow and differences in the extent of bone loss were analyzed statistically. The results showed direct correlations for destruction of the elbow joint surface among the zones for the left and right elbow joints and in the same elbow joint. However, more severe destruction was observed on the radial side of the humeral trochlea, and it was surmised that destruction of the elbow joint must begin at that site and gradually spread mediolaterally. In addition, in the same elbow joint, the correlation in the degree of bone loss between the trochlea of humerus and the trochlear notch was especially strong, indicating that the bone destruction at both sites represented mirror lesions. We conclude that when performing radiographic diagnosis of the joint damage in the rheumatoid elbow, knowledge of this pattern of joint destruction will be useful for assessing whether there is joint destruction in the initial stage and for deciding the therapeutic approach.     

Predictors of mortality in chronic obstructive pulmonary disease. A 15-year follow-up study.

The relative usefulness of various initial findings in predicting survival is reported for 200 patients with chronic obstructive pulmonary disease who have been followed for approximately 15 years. After 5 years of follow-up, subjects 62 or more years of age showed a poorer survival rate than younger subjects. After controlling for age, the per cent predicted forced expiratory volume in 1 sec after administration of bronchodilator was the best indicator of prognosis. In subjects less than 65 years of age, the presence or absence of cor pulmonale further improved the prediction of subsequent mortality. Regardless of initial findings, however, there was wide individual variability in prognosis, and factors relating to this variability remain obscure. No difference in survival rate was noted between the 178 male patients who were enrolled in Chicago 15 years ago and the 100 similarly impaired men enrolled in Tucson approximately 7 years ago.     

The development of emotional distress in 158 patients with recently diagnosed rheumatoid arthritis: a prospective 5-year follow-up study

OBJECTIVES: To describe the development of emotional distress among patients with newly diagnosed rheumatoid arthritis (RA), and to explore for early predictors of elevated distress over time. METHODS: The study group consisted of 158 early RA patients (64% females) with mean age of 51.4 (SD = 12.7) years at disease onset. The patients were evaluated once a year for up to at least 4 years after baseline. Emotional distress was measured with the Symptom Checklist (SCL-90), disability with the Health Assessment Questionnaire (HAQ), pain with a visual analogue scale (VAS), and disease activity by an active joint count and erythrocyte sedimentation rate (ESR). Questions concerning social support were also included. RESULTS: Emotional distress decreased slowly for a majority of the patients. The change reached statistical significance in the third year from study start. A minority (12%) showed continuously high and increasing levels of distress. Measures of disease activity were poor predictors of distress. The best predictor of distress over time was distress at baseline. Other predictors were gender, age, civil status, and social support. CONCLUSIONS: Emotional distress tended to decrease for most patients in this cohort, but a minority showed continuously high levels. Patients at higher risk of developing emotional distress over time had higher levels of distress at baseline, were younger, more often female, and cohabiting, and experienced less social support.     

An 8-year follow-up study of pulmonary function in patients with rheumatoid arthritis

To evaluate longitudinal alterations in pulmonary function, 63 patients suffering from rheumatoid arthritis (RA) with previously reported reduced pulmonary diffusing capacity were re-examined in an 8-year follow-up study. Cross-sectional examination revealed normal values for vital capacity (VC), forced expiratory volume in 1 s (FEV1) and diffusing capacity per litre alveolar volume (KCO). Total diffusing capacity (D_LCO; P>0.0001), maximal expiratory flow at 75% of expired VC (MEF 75; P>0.0001) and MEF 50 (P>0.01) were decreased. Longitudinal evaluation revealed unchanged MEF50, MEF75 and FEV1, whereas increases in D_LCO (P>0.0001) and KCO (P>0.0001) and a decrease in VC (P>0.05) were found. The longitudinal changes in diffusing capacity were unrelated to patient age, disease duration, disease activity in the study period or pulmonary function at the first examination. Thus, in patients suffering from RA, the most prominent functional pulmonary abnormality, decreased diffusing capacity, appeared to improve in the course of time, despite a slight decrease in VC and continued articular disease activity.     

Radiographic joint space width in the fingers of patients with rheumatoid arthritis of less than one year's duration

OBJECTIVE: To determine the radiographic joint space width (JSW) in undamaged metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of patients with early rheumatoid arthritis (RA) and to identify important clinical determinants of JSW. METHODS: Radiographs of patients with RA of <1 year's duration, from an early arthritis cohort at a tertiary care rheumatology clinic, were obtained. JSW was analyzed by joint, finger, age, sex, height, and a number of other clinically relevant variables. Multivariate analysis was also performed, to account for possible confounding between variables. RESULTS: Thirty-eight patients were included in the study. We found that JSW was greater in the MCP joint than the PIP joint (P < 0.0001). JSW was significantly greater in men (P < 0.0001) and increased with increasing height (P < 0.003), but was not associated with age (P < 0.21). In multivariate analyses, sex was shown to be the most important predictor of JSW. CONCLUSION: In patients with early RA, MCP and PIP JSW is significantly associated with sex and height. In studies of RA in which JSW measurements are included as an outcome, these differences may need to be accounted for in the analysis.