The relationship between fatigue, coping behavior, and inflammation in patients with rheumatoid arthritis

This research investigated the relationships among the severity of inflammation, the extent of fatigue, and fatigue symptoms, and the relationship between fatigue and coping behavior in patients with rheumatoid arthritis (RA). Our study group consisted of 177 female patients with RA (105 women with CRP > 0.5 mg/dl and ESR > 30 mm/h (inflammatory group) and 72 women with CRP ≦ 0.5 and ESR ≦ 30 (noninflammatory group)) and 81 age-matched healthy women (control group) who were given self-assessment questionnaires. The extent of fatigue was higher in the inflammatory group than in the noninflammatory and control groups. The characteristics of fatigue symptoms in the inflammatory group were “decline in the strength to carry on the activities of daily life” and “difficulty in performing daily activity.” The patients in the inflammatory group adopted a technique of "reducing the burden on the body" as a pattern of coping behavior for reducing fatigue. The extent of fatigue and fatigue symptoms perceived by RA patients is strongly related to the severity of inflammation, and these patients adopt a coping behavior in response to the extent of fatigue and subjective symptoms. Received: October 6, 1999 / Accepted: May 25, 2000     

How to grow bone to treat osteoporosis and mend fractures

There is a need for “anabolic” drugs that can directly stimulate bone growth, improve bone microarchitecture, accelerate fracture healing, and, thus, restore bone strength to osteoporosis patients and, hopefully, regenerate eroded bone in arthritis patients. The anabolic agents currently leading the way to the clinic are the parathyroid hormone (PTH) and some of its adenylyl cyclase-stimulating fragments. This article is a summary of what is known about how PTHs stimulate bone growth. The controversial bone anabolic activities of the cholesterol-lowering lipophilic statins are also described, and mechanisms by which they may stimulate bone growth are presented. Finally, evidence is presented for the body’s “fat-ostat” cytokine —leptin— indirectly restraining bone growth via a hypothalamic factor, while at the same time serving as a local PTH-like autocrine/paracrine stimulator of osteoblast activity, as well as an inhibitor of osteoclast generation.     

Association between fibromyalgia and sexual dysfunction in women

The objective of the study was to review the association between fibromyalgia (FM) and sexual dysfunction in women and possible mechanisms of such association. PubMed, MEDLINE, and EMBASE databases (1950–2008) were searched for the key words “fibromyalgia”, “chronic pain”, “sexual dysfunction”, “female”, “sexuality”, “depression”, and “quality of life”. All relevant articles in English and secondary references were reviewed. All reviewed studies showed that FM is associated with sexual dysfunction in women. The major findings were as follows: decreased sexual desire and arousal, decreased experience of orgasm, and increased pain with intercourse. FM, sexual dysfunction, and depression may be interrelated with the depressive mood responsible for desire and arousal problems. On the other hand, in FM patients, the threshold at which sensory input becomes painful is lower than normal that can explain pain on intercourse. Additional studies are needed to evaluate the casual relationship and mechanism of association between FM and sexual dysfunction in women.     

Subsets in Psoriatic Arthritis formed by Cluster Analysis

The aim of the study was to create subgroups among psoriatic arthritis patients on the basis of dermatological features, clinical pattern of arthritis, and laboratory, immunological and radiological findings. Data on 100 patients were expressed in a standardised form and entered into hierarchical cluster analysis according to Ward”s method. Seven subgroups were created. Fifty-six patients with mild psoriasis were sorted into a “polyarticular group”. Two “RA-like groups” were formed, differing from each other serologically and in axial involvement. In an “oligoarticular group” (18 patients) serious skin disease and female gender predominancy were found to be characteristic. Eight patients with polyarticular arthritis were assigned to an “erythrodermal group”, in which polyarticular arthritis, mutilating, severe arthritis and a history of erythroderma were characteristic. Close to this group on the dendrogram eight women were sorted into a “distal form”. Sausage fingers were frequent, and nail dystrophy was present in every case. In a “pustular group” (three patients) the different type of skin involvement was considered and nail dystrophy was common. In the newly created subgroups not only the arthritic status, but also the type of the skin disease, played a determining role. Received: 23 November 1999 / Accepted: 7 July 2000     

Improvement of functional ability in children with juvenile idiopathic arthritis by treatment with etanercept

The objective of the study is to investigate the functional ability, i.e., the physical aspect of the health-related quality of life and its determining factors during therapy with etanercept in children with juvenile idiopathic arthritis (JIA). Assessment of the Child Health Assessment Questionnaire (CHAQ), the number of active joints, duration of morning stiffness, ESR, C-reactive protein, parent’s global assessment of the overall patient’s well-being, physician’s global assessment of the overall disease activity, concomitant treatment with methotrexat, number of aids/devices needed, and calculation of the PedACR-score. Data of 437 children were analyzed for disease severity and impact of the disease on functional abilities. Data of 114 children with a complete data set and a continuous treatment for at least 24 months were used for analysis of the impact of treatment on functional abilities. Before treatment with etanercept, patients with systemic arthritis and seropositive or seronegative polyarthritis were disabled more heavily than those with other subtypes of JIA. There was a correlation between high CHAQ scores and the number of active joints, aids/devices needed, parent’s global assessment of the overall patient’s well-being, morning stiffness, physician’s global assessment of the overall disease activity, and C-reactive protein (P < 0.005). Of the eight areas, “dressing and grooming”, “arising”, “eating”, “walking”, “hygiene”, “reach”, “grip” and “activities”, the latter was most severely affected. 96.5, 93.8, and 90.3% of the patients reached a PedACR-30, -50 and -70 score upon treatment with etanercept for 24 months. The areas of eating and walking were best before therapy and showed highest improvement with therapy. Under therapy with etanercept patients of all JIA subgroups significantly improved their functional ability (P < 0.0001), but patients with polyarthritis less frequently improved their physical functioning. Disease activity and the physical aspect of health-related quality of life including functional ability improved significantly during therapy with etanercept in children with JIA. Duties of everyday life were easier to accomplish.     

Empowering assisted living front-line care staffs to better care for alzheimer’s and dementia residents

Creating a feeling of empowerment among front-line care staff members may assist in better coping and achievement of quality care with a growing assisted living resident population who have Alzheimer’s disease or other forms of Dementia. The purpose of this qualitative research study was two fold in nature: (1) identify the training needs of front-line care staff members, and (2) create a training manual which would empower these front-line care staff workers to conduct their care duties in a more confident, effective, and sensitive manner. The first phase of this research was conducted with 24 front-line care staff in three assisted-living facilities in Illinois, New Mexico, and Florida, all women 18-69 years of age (M=36.8, SD=7.3), with 6 months to 10 years work experience in this job (M=2.19 years, SD=2.3 years). All reported that they had not received sufficient training in caring for this growing segment of the resident population. Based on responses to a needs-analysis questionnaire (n=24), a “Dementia-related Care Training” manual was developed. The following four themes emerged from needs analysis responses, and were the bases for the training modules: (1) experiencing the meaning of Alzheimer’s disease or other forms of Dementia, (2) acknowledging residents’ changing care needs over time, (3) realizing the importance of individualized care for residents, and (4) empowering front-line care staff members in the care process. The training manual was administered at the same three locations with some participants from the original sample (n=18), in order to receive feedback about the manual’s effectiveness and usefulness for a front-line care staff. Post-training feedback indicated that using such a training manual in an on-going manner would increase front-line care staffs’ job satisfaction and job commitment, as well as reduce job stress through better on-the-job coping skills learned. overseeing the licensing of all of the Brookdale owned and managed properties (67 total) throughout the United States. She also assists with staff training at the properties according in to state regulations. Ms Gurnik is a member of both ASA and LSN (Life Services Network). Her on-going research focuses on “quality of life” ageing issues related to caregiving, the workplace, retirement adjustment, and later-life education. Her area of specialty is industrial gerontology, the study of the ageing workforce.     

Measuring educational needs among patients with rheumatoid arthritis using the Dutch version of the Educational Needs Assessment Tool (DENAT)

The Educational Needs Assessment Tool (ENAT) was developed in the United Kingdom (UK) to systematically assess the educational needs of patients with arthritis. The aim of the present study was to describe the educational needs of Dutch patients with rheumatoid arthritis (RA) by using the Dutch version of the ENAT (DENAT). The original UK version of the ENAT, comprising 39 items grouped into seven domains, was translated into Dutch according to international guidelines for cross-cultural translation and adaptation. The DENAT was then sent to a random sample of 319 RA patients registered at the outpatient clinic of a university hospital. For each domain (score range 1–5, equalling low–high educational needs), a median score with the inter-quartile range was computed. The Kruskal–Wallis test was used to determine possible associations between educational needs and age, disease duration, gender and educational background. The response rate was 165 out of 319 (52%). The median educational needs scores were 2.5 for “managing pain”, 3.0 for “movement”, 2.0 for “feelings”, 4.0 for “arthritis process”, 4.0 for “treatments from health professionals”, 3.5 for “self-help measures” and 2.5 for “support systems”. Lower age and shorter disease duration were associated with more educational needs in the domain “support systems”. In addition, younger patients had more educational needs regarding managing pain and feelings than older patients. There were no associations between gender or educational background and educational needs. The DENAT has demonstrated its ability to identify individual educational needs of Dutch patients with RA. The lower age and shorter disease duration were associated with more educational needs. The practical applicability of the DENAT needs further research. An erratum to this article can be found at     

Individualized measurement of quality of life in older adults: development and pilot testing of a new tool

We describe theoretical background, development, and piloting of a measure for quality of life in older adults that specifically takes into account the subjective perspective. Although quality of life is usually subjectively assessed, normative thresholds for “the good life” are most often set by a third party. The new tool FLQM asks for respondents to name, rate, and weight those domains in life that are most important for their life-satisfaction solely from their own point of view. Construct validity was pilot-tested in two samples of elders (N ₁ = 44; N ₂ = 90). Correlations were in the medium range in both studies and support the questionnaire’s validity. There were no age or gender differences on total score. However, in Study 1 as well as in Study 2 older subjects named significantly fewer domains than did younger participants. Further, in Study 1 the overall number of distinct domains generated by the participants diminished with age—the “interindividual pool of domains” shrank. Implications of this age-associated narrowing of domainscope are discussed on a background of adaptation theories. Concluding, the new questionnaire seems apt to assess older peoples’ quality of life even in a physically very ill population, but needs further testing, especially regarding its reliability. This is currently being undertaken in a larger longitudinal sample to assure psychometric properties.     

Travel as pilgrimage in late adulthood

Wishing to make sense of their life experiences, many people who choose to travel during their later years visit places that are, essentially, personal “pilgrimage sites.” In this article, author Grethe Knudsen explores how travel can help older learners through the “self-actualization” process. About the author: Grethe Knudsen is a Ph.D. student who takes tour groups to Turkey on a yearly basis. She is a retired academic who is enjoying “late adulthood.”     

Reactive arthritis following BCG immunotherapy for urinary bladder carcinoma: a systematic review

Intravesical instillation of Bacillus Calmette-Guerin (BCG) is used with efficacy and safety in the treatment of patients with intermediate and high-risk superficial bladder carcinoma. Arthralgia and/or arthritis is one of the rare severe complications following intravesical BCG immunotherapy. We searched MEDLINE in order to analyze the frequency of this clinical complication, its pathogenesis and outcome. The electronic search was conducted using the following key words: “BCG immunotherapy” and “Arthritis, arthralgias and BCG immunotherapy”. At the end of a process of abstract analysis, 48 papers were included in the systematic review. All the selected papers, except one that was a clinical review, described at least one case of arthritis after BCG therapy. The BCG immunotherapy resulted to be safe and efficacious in the treatment of bladder cancer; the development of reactive arthritis is rare and can evolve in a chronic process. The review of the literature highlighted that reactive arthritis following BCG intravesical instillation is a complication usually well controlled with the discontinuation of the immunotherapy and nonsteroidal anti-inflammatory drugs (NSAIDs) treatment. Only a small portion of patients with a particular genetic background will develop a chronic process.     

Outcome measures and medical progress: Why outcome measures are needed in childhood arthritis

In this review, the historical process leading to the current status of outcome measurements will be discussed and the recent quality-of-life instruments to explore the mental, emotional, and social “hidden morbidity” of children with juvenile arthritis will be analyzed.     

Enthesitis in seronegative spondyloarthropathies with special attention to the knee joint by MRI: a step forward toward understanding disease pathogenesis

Seronegative spondyloarthropathies are a unique group of disorders sharing similar clinical characteristics (e.g., inflammatory back pain, spondylitis, sacroiliitis, uveitis, inflammatory bowel disease, skin rashes, and enthesitis). Clinical and genetic similarities suggest that they also share similar causes or pathophysiologies. Rheumatoid factor (RF) is characteristically negative in this group of disorders, hence collectively termed seronegative spondyloarthropathies (SpA). They include psoriatic arthritis, ankylosing spondylitis, reactive arthritis, ulcerative colitis, and Crohn’s disease. “Enthesitis”, the term used to describe inflammation at tendon, ligament, or joint capsule insertions, is considered a common feature in this domain and was included in the European Spondyloarthropathy Study Group criteria for the classification of SpA. Evaluation of entheseal-related changes at different joints by MRI became an important item on the research agenda in both differentiated and undifferentiated arthritis. Most of the research focused on MRI findings in the hand and wrist joints among patients with RA and SpA and support two patterns of inflammation “RA” phenotype where synovial involvement is the primary target of inflammation and “SpA” pattern where enthesitis comes first followed by synovitis. In this review, we summarize the literature on enthesitis in SpA and focus on MRI findings in the knee joint in the SpA group of disorders and subclinical synovitis among patients with skin psoriasis.     

Rheumatoid arthritis: scientific development from a critical point of view

Rheumatoid arthritis (RA) is classified as a chronic, progressive, systemic autoimmune disorder leading to inflammation, stiffness, defective position and destruction of joints. Finally a complete loss of mobility and functioning can be the result. The fraction of disability varies strongly, for example, a systematic review shows a 50% disability in a period from first occurrence to disability from 4.5 to 22 years. Scientific efforts focused strongly on therapeutic and diagnostic methods during recent years. So far, there is no scientometric approach of the topic rheumatoid arthritis available although there is an increased need to evaluate quality and quantity of scientific research. Density-equalizing algorithms, scientometric methods and large scale data analysis were applied to evaluate the quality and quantity of scientific efforts in the field of rheumatoid arthritis. Data were gained from Pubmed and ISI-Web. During the period 1901–2007, 78,128 items were published by 129 countries including the USA, UK and Germany being the most productive suppliers, representing 45.7% of all publications. Another 23 countries published more than 100 items. In terms of international cooperation the USA proved to be the most successful partner. “Arthritis and Rheumatism”, “Annals of the Rheumatic Diseases” and the “Journal of Rheumatology” are the most prolific journals. The current study is the first analysis of “rheumatoid arthritis” research activities and output. Our analysis revealed single areas of interest, the most prolific journals, authors and institutions dealing with the topic. Nevertheless, statements concerning the scientific quality should be considered critical due to a bias according to self-citation and co-authorship.     

Systematic review of measures and their concepts used in published studies focusing on the treatment of acute inflammatory arthritis

To identify outcome measures and concepts cited in published studies focusing on the treatment of acute inflammatory arthritis, and to identify and quantify the concepts contained in these measures using the International Classification of Functioning, Disability and Health (ICF) as a reference. This ‘research perspective’ is part of the development process for an ICF core set in acute arthritis. Electronic searches of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Pedro and the Cochrane Library from January 2000 to July 2004 were carried out. Data on the outcome measures and patient characteristics for the included studies were extracted. The items of the identified questionnaires and their underlying concepts were specified and then linked to ICF categories using standardized linkage rules. From the 401 abstracts retrieved, 104 studies met the inclusion criteria. From these studies, 38 formal assessment instruments, 62 single clinical measures, 66 technical measures and 14 clinical criteria were identified. A total of 966 concepts were extracted, and 84.7% of these concepts could be linked to ICF categories. The concepts contained in measures named in more than 5% of the studies were represented by 34 second-level ICF categories. Ten (30%) of the 34 categories belong to the component “Body Functions”, 3 (9%) to the component “Body Structures” and 21 (61%) to the component “Activities and Participation”. The ICF provides a valuable reference to identify and quantify the concepts of outcome measures focusing on the management of patients with acute inflammatory arthritis. Our findings indicate there is good agreement on ‘what should be measured’ in acute inflammatory arthritis to allow for a comparison of patient populations.     

Does Blood Pressure Variability Modulate Cardiovascular Risk?

Exactly how hypertension causes end organ damage and vascular events is poorly understood. Yet the concept that underlying “usual” blood pressure (BP) accounts for all BP-related risk of vascular events and for the benefits of BP-lowering drugs has come to underpin clinical guidelines on the diagnosis and treatment of hypertension. This article reviews evidence that variability in BP also predicts risk of stroke and other vascular events independently of mean BP and evidence that drug-class effects on variability in BP explain differences in the effectiveness of BP-lowering drugs in preventing stroke.     

CPPD complicating other forms of inflammatory arthritis

Calcium pyrophosphate deposition (CPPD) disease is confirmed as equally common in rheumatoid arthritis by synovial fluid and macroscopic skeletal examination. Furthermore, differential frequencies in rheumatoid arthritis and spondyloarthropathy provide additional insights to the “lumper–splitter” question.     

Positioning biologic therapy for Crohn’s disease and ulcerative colitis

Over the past decade, the introduction of biologic agents such as tumor necrosis factor-α and α4 integrin leukocyte adhesion molecule inhibitors has provided new and effective treatment options for patients with inflammatory bowel disease (IBD). Recent debates have centered on where biologics should be positioned within the current treatment strategy so as to maximize efficacy while balancing risk. This review highlights the current position biologics hold relative to conventional therapies within the current “step-up” treatment strategy. It also critically appraises emerging data, testing the hypothesis that positioning biologics early in the IBD treatment algorithm (“top-down” strategy) results in superior outcomes compared with the current step-up strategy, in which biologics are used only in patients failing conventional therapies or who are steroid dependent.     

Antibodies against cyclic citrullinated peptides in infectious diseases—a systematic review

Rheumatoid arthritis (RA) is a disease characterized by symmetrical polyarthritis of the large and small joints, and in the majority of patients, there is a presence of the rheumatoid factor and erosions in the X-ray of the joints. More recently, the presence of anti-cyclic citrullinated peptide antibodies (anti-CCP) in this disease has been described, with diagnostic and prognostic value. Nevertheless, these antibodies have also been described in infectious diseases. The aim of the present study was to make a systematic review of the presence of antibodies against citrullinated peptides in infectious diseases. Search was conducted in the MEDLINE (1966 to 2010), Cochrane, SCielo, and LILACS databases, using the terms: “anti-CCP, anti-MCV, and infectious diseases”; “anti-CCP, anti-MCV, and virus”; “anti-CCP, anti-MCV, and mycobacteria”; “anti-CCP, anti-MCV, and tuberculosis”; “anti-CCP, anti-MCV, and leprosy”; “anti-CCP, anti-MCV, and leishmaniasis”; “anti-CCP, anti-MCV, and HIV”; “anti-CCP and HTLV”; “anti-CCP, anti-MCV, and Chagas disease”; “anti-CCP, anti-MCV, and Lyme disease”, and the corresponding terms in Portuguese. Twenty-five publications were found, which dealt with anti-CCP and infection, and only one on anti-MCV and infection. Of these, 23 were cross-sectional and three cohort studies. Anti-CCP antibodies were found in various frequencies, reaching 37% in tuberculosis. In the other infections, it was a rare finding. In only one publication, anti-MCV was found in only one patient with hepatitis. Since infectious diseases are capable of running their course with osteoarticular symptoms, sometimes difficult to differentiate from RA, additional studies are necessary to define the performance of the test for the detection of anti-CCP antibodies in populations in which the frequency of such infections is high.     

Care-related quality of life in old age

Promoting quality of life is a central theme in recent ageing policies, but what quality of life means in concrete terms for people in different stages of old age is rather unclear. This study presents a multi-dimensional model of care-related quality of life (crQoL) and, based on analyses of three Finnish cross-sectional datasets from the years 2004–2007, examines the distinctions between dimensions of QoL by age and gender, with a special focus on older home care clients. Correlation analyses (Pearson) and stepwise linear regression were applied to analyse variation in QoL by age group and the association between QoL and perceived quality of home care. The results suggest that individual QoL and the priorities of (physical, psychical, social, and environmental) dimensions in the assessment of QoL by older persons vary considerably and exhibit distinct profiles in different stages of ageing. In addition, four dimensions for good care corresponding to the crQoL model were identified and their empirical relevance demonstrated. From the perspective of older people in need of help, home care is not just about giving them the instrumental help they need to perform their daily activities, but rather about giving responsive care that reflects their personal preferences or their view on a “good life”, and treats them with dignity and respect. The criteria for the evaluation of quality of home care should reflect these insights, and policy measures should take these differences into account.     

Preventive home visitation programmes for older people: the role of municipality organisation

The organisational influence on benefits of preventive home visitation programmes for older people has escaped scientific evaluation. This study aims to investigate organisational structures and processes in relation to preventive home visits. As part of a randomised controlled trial investigating whether educational intervention towards municipality health care professionals could enhance active life expectancy, information of municipality leadership, home visit approach, strengths and limitations of communication within the organisation were obtained using individual and focus group interviews. Thirty-four municipalities in four counties participated. Data was systematically condensed using a phenomenological approach upon which general patterns were categorised into a theory-based formal typology of the preventive home visitation management in the municipalities. Three distinct strategies for preventive home visitation programmes were identified. Eighteen municipalities were categorised as “Framework Management”, 15 as “Management by Rules” and one as “Project Management”. Small municipality size was associated with the “Framework Management” type. “Management by Rules” municipalities had higher population densities and their overall expenses for older people were higher. “Framework Management” municipalities used more resources on preventive home visits, communicated better, experienced less staff changing and had higher social capital than “Management by Rules” municipalities. Municipality structures and management processes of preventive home visitation programmes varied considerably in 34 Danish municipalities, but the majority could be categorised as using either a “Framework Management” or a “Management by Rules” strategy. Each strategy is associated with particular advantages and disadvantages, which may explain differences in the overall benefit of the programme between municipalities. This study was supported by grants from the Danish Medical Research Council, the Research Foundation for General Practice and Primary Care, Eastern Danish Research Forum, the County Value-Added Tax Foundation and the Danish Ministry of Social Affairs.