Effect of daily low dose prednisone,divided or single daily dose,in the treatment of African Americans with early rheumatoid arthritis

Determine the effect of daily low divided or single daily dose of prednisone on the longitudinal change in the number of tender and swollen joints and HAQ scores in African Americans (AA) with early rheumatoid arthritis (RA) from the Consortium for the Longitudinal Evaluation of African Americans with Early Rheumatoid Arthritis (CLEAR) 1 Registry. In a prospective, multicenter observational cohort study, AA with early RA were enrolled and followed longitudinally for up to 5 years. 345 were enrolled. The mean age at enrollment was 51 years and 82% were women. At baseline, the prevalence of low dose prednisone use was 77% and median prednisone dose was 10 mg. At enrollment 238 patients were on single daily and 107 on divided daily doses of prednisone. There was a significant reduction during follow-up in the number of tender and swollen joints and in the HAQ scores in all patients. Cohort retention was 54%. The adjusted mean number of tender joints was approximately 2–3 joints lower for patients on divided daily dose compared to a single daily dose in follow up. The rate of osteopenia and osteoporosis at 5 years remained similar to baseline prevalence and no difference in the treatment groups. At 5 years the percentage of patients with hypertension was lower in the divided daily prednisone group. During the 5 years of follow-up, clinical outcomes improved in all AA patients with early RA. Reduced number of tender joints was associated with divided daily low doses of prednisone. Hypertension was less in those treated with divided daily doses of prednisone.     

Mud compress therapy for the hands of patients with rheumatoid arthritis

Objective The aim of this study was to evaluate the efficacy of home treatment with mud compresses for the hands of patients with rheumatoid arthritis (RA).Methods Forty-five patients suffering from RA were enrolled in a double-blind, randomized, controlled study. Twenty-two were treated with true mud compresses (treatment group) and 23 were treated with attenuated mud compresses (control group). The compresses were applied in the patients homes five times a week during a 3-week period. Patients were assessed four times: at baseline, upon completion of the 3-week treatment period, 1 month after the treatment, and 3 months after conclusion of the treatment period. Positive response was defined as reductions of 30% or more in the number of tender and swollen joints, 20% or more in physician global assessment of disease activity, and 20% or more in patient global assessment of the severity of joint pain.Results In the treatment group, significant reductions in the number of swollen and tender joints and patients global assessments of pain severity was observed at all post-treatment assessments. Significant improvement in the scores of physician global assessment was seen at the end of therapy and 1 month later. In the control group, no improvement in the number of swollen and tender joints or physician global assessment was found in any post-treatment evaluation. However, a significant reduction in patient global assessment of joint pain severity was reported at the end of therapy and 3 months after concluding treatment.Conclusion Treatment with mud compresses relieves pain affecting the hands and reduces the number of swollen and tender joints in the hands of patients suffering from RA. This treatment can augment conventional medical therapy in these patients.     

Pain and joint mobility explain individual subdimensions of the health assessment questionnaire (HAQ) disability index in patients with rheumatoid arthritis

OBJECTIVE: To explore the associations between individual subdimensions of the health assessment questionnaire (HAQ) and clinical variables in patients with rheumatoid arthritis. METHODS: 304 patients with rheumatoid arthritis (73% female, mean (SD) age, 58 (13) years; disease duration 6 (9) years, 69% rheumatoid factor positive) completed the HAQ for functional capacity (0-3) and a 100 mm visual analogue scale for pain. Grip strength, range of motion of the large joints, Larsen score for radiographic damage of hand and foot joints, and the number of tender and swollen joints were recorded. A logit regression model was used to study associations between subdimensions of the HAQ and other variables. RESULTS: Mean (range) total HAQ score was 0.92 (0 to 2.88) and varied from 0.73 to 1.04 in the subdimensions. Disability was lowest in the "walking" and highest in the "reach" subdimension. Pain was an explanatory variable in all individual subdimensions. Decreased grip strength, limitation of shoulder and wrist motion, and a larger number of swollen and tender joints in the upper extremities were related to several subdimensions. A higher pain score and swollen joint count in the upper extremities, decreased grip strength, and limited motion of wrist, shoulder, and knee joints explained increased disability (higher total HAQ scores). CONCLUSIONS: In patients with rheumatoid arthritis, pain and range of movements of joints have the greatest impact on individual subdimensions of the HAQ. Extent of radiographic damage in peripheral joints and the number of swollen and tender joints are of lesser importance for function.     

The relationship between disease activity and depression in Egyptian patients with rheumatoid arthritis

Aim of the workTo estimate the prevalence of depression and its relationship with disease activity parameters in Egyptian patients with RA.Patients and methodsA cross sectional study was conducted on 170 patients with RA. The following values were assessed for each patient: erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), swollen and tender joint counts (SJC and TJC), disease activity score 28 (DAS28), health assessment questionnaire score (HAQ), visual analogue scale (VAS) of pain and hospital anxiety and depression scale-depression subscale (HADS-D).ResultsThe prevalence of depression was 15.29% (26 RA patients). In the depressed RA patients, positive significant correlations were found between HADS-D score and age, disease duration, HAQ score, VAS, DAS28 score and CRP. However, no significant correlation was found between HADS-D score and ESR, number of swollen and tender joints. No significant difference (P > 0.05) was found between depressed male and female patients with RA.ConclusionPatients with RA and co-morbid depression have worse health outcomes. RA cases should be monitored for accompanying depression during follow-up. The identification and treatment of depression in RA paramount to the overall management of 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     

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.     

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.     

Patients with active rheumatoid arthritis but only few tender and swollen joints: a subgroup with impaired short term outcome

The disease activity score of 28 joints (DAS28) is now commonly used for the guidance of treatment decisions in rheumatoid arthritis (RA). The goal of this work was to determine whether patients with DAS28 > 3.2 but less than 2 swollen and 2 tender joints respond differently to treatment than patients with a higher number of active joints. One hundred and ninety two patients with active RA treated in a rheumatology hospital as in-patients were studied prospectively. At admission (T1), release (T2) and 3 months after release (T3) disease activity (DAS28-CRP at T1 + 2, RADAI at T1 + 3), pain (numeric scale at T1 − 3) and function (FFbH at T1 + 3) were measured. A total of 148 patients had two or more (group 1) and 44 less than 2 swollen and tender joints at admission (group 2) but both groups had similar over all DAS28-scores. The groups significantly differed in their outcome after 3 months: group 1 had a significant better reduction of disease activity, pain and functional deficit (p < 0.001 for the fulfilment of defined response criteria and p < 0.05 for comparison of the mean values for pain and function) in comparison to group 2. Although the numbers were small sub-analysis suggested that the differences might be due to a better response to newly administered DMARD and TNF-alpha-inhibitor therapy in group 1. Active RA patients with less than 2 swollen and 2 tender joints represent a subgroup with lower response to treatment with DMARD or TNF-alpha-inhibitors. This has to be taken into account in the management of these patients.     

Effects of probiotic therapy on the activity and activation of mild rheumatoid arthritis--a pilot study

OBJECTIVE: To study the effects of Lactobacillus rhamnosus GG (LGG) on rheumatoid arthritis (RA). METHODS: Twenty-one RA patients were randomised to receive 2 capsules of LGG or a placebo twice daily in double-blind fashion for 12 months. Arthritis activity was evaluated by clinical examination, HAQ index, and laboratory tests (e.g. ESR, CRP, pro- and anti-inflammatory cytokines). RESULTS: There were no statistical differences in the clinical parameters, biochemical variables and HAQ index between the study groups over the intervention period. The mean number of tender and swollen joints decreased from 8.3 to 4.6 in the Lactobacillus group and from 5.5 to 4.8 in the placebo group (p = 0.41). According to the global assessment the RA activity was reduced in 71% (LGG group) vs. 30% (controls) (p = 0.15). Serum IL-1 beta increased slightly in the LGG group (p = 0.07), but no differences were seen in IL-6, TNF-alpha, MPO, IL-10 or 1L-12. CONCLUSIONS: Although there were no statistical significant differences in the activity of RA, more subjects in the LGG group reported subjective well being. More studies on the effects of probiotic bacteria in RA are needed.     

Measurement of disease activity in psoriatic arthritis. Extended report

OBJECTIVE: To determine whether activity indices, generally accepted in rheumatoid arthritis (RA) are useful and valid to measure disease activity in psoriatic arthritis (PsA) patients with peripheral arthritis. METHODS: 38 PsA patients were studied before and after a one year DMARD treatment. Extended and reduced tender and swollen joint counts, Ritchie articular index, Health Assessment Questionnaire HAQ) score, erythrocyte sedimentation rate (ESR) morning stiffness, the patient's and the assessor's global assessment (PGA and AGA) were recorded. Disease activity scores, EULAR, ACR and Clegg improvement criteria were calculated. RESULTS: All indices correlated well before and after treatment with AGA (r > 0.337, p < 0.042), except morning stiffness and tender joint counts. After treatment, PGA correlated well only with the 68 and 28 tender joint counts, ESR and HAQ (r > 0.340, p < 0.05). The response to DMARD treatment was well characterized with the changes in the number of tender and swollen joint counts, and DAS4, DAS3, DAS28. The changes correlated with the PGA and AGA. The level of agreement between Clegg and the EULAR improvement criteria with both extended and reduced joint count was comparable (p < 0.01). CONCLUSION: The well-known activity indices generally accepted in RA, as tender and swollen joint count, DAS3, DAS4, DAS28, are useful and valid indices measuring arthritis activity in PsA with peripheral arthritis. The correlation between Clegg and EULAR improvement classification indices were similar. Both seemed to characterize changes authenticated during DMARD treatment.     

Adsorptive granulocyte/monocyte apheresis for the treatment of refractory rheumatoid arthritis: an open pilot multicentre trial

OBJECTIVE: To assess the efficacy and safety of adsorptive granulocyte and monocyte apheresis (GCAP) in patients with refractory rheumatoid arthritis (RA). METHODS: Patients with active and refractory RA were treated with weekly GCAP sessions using a column filled with acetate beads (Adacolumn) over five consecutive weeks. Clinical assessments and response to therapy were analysed at weeks 5, 7, 12 and 20 in an open multicentre trial. The primary outcome measure of clinical response was 20% improvement in the American College of Rheumatology criteria (ACR20) at week 20. EULAR (European League Against Rheumatism) response criteria, based on the disease activity score for 28 joints (DAS28) and disability using the Health Assessment Questionnaire (HAQ), were also assessed. RESULTS: Of 27 patients, 81.5% were women with mean disease duration of 14.4 yr. The mean number of previous disease-modifying antirheumatic drugs (DMARDs) was 3.7, and 48.1% of patients had previously failed on biologicals. On an intention-to-treat basis, 40.7% of patients achieved an ACR20 and 44.4% a therapeutic EULAR response at week 20. These percentages were 50 and 54.5% in 22 patients who completed the trial. In the 10 completers who had previously failed on biologicals, an ACR response was achieved in four patients (ACR20, two; ACR50, one; ACR70, one). A significant decrease was recorded in different ACR response components, including the tender joint and swollen joint counts, pain score and patient and physician global disease assessments, as well as the DAS28 index; most of them improved after week 5. ESR and CRP, but not the HAQ score, had decreased significantly at week 20. The treatment was well tolerated and only one serious adverse event related to the study procedure was documented (sepsis due to a catheter infection). CONCLUSIONS: GCAP treatment led to significant clinical improvement in a subset of patients with RA who had failed to respond to DMARDs or biologicals. Further large, placebo-controlled studies are warranted to fully assess the therapeutic value of GCAP for refractory RA.     

Functional disability and health-related quality of life in South Africans with rheumatoid arthritis and systemic lupus erythematosus

There is a paucity of data on the impact of chronic rheumatic diseases on functional disability and overall health-related quality of life (HRQOL) in Africans. Materials and methods: We compared Black South Africans (BSA) with rheumatoid arthritis (RA) (n=50) and systemic lupus erythematosus (SLE) (n=50) to geographically and ethnically matched controls cared for at a tertiary care facility. The modified health assessment questionnaire (mHAQ) and Medical Outcome Study short-form 36 (SF-36) scores and indices of disease activity and organ damage were collected from each group. Results: Compared to the controls, both the RA and SLE groups fared significantly worse in respect of all the domains and summary scales of the SF-36. Compared to the SLE group, the RA group scored significantly worse with respect to the mHAQ disability index (mHAQ-DI), physical function and bodily pain (BP) SF-36 subscales, and SF-36 summary physical component score (SF-PCS). In the RA group, both the mHAQ-DI and SF-PCS correlated strongly (p<0.005) with the tender joint count, patient global assessment, 28-joint composite disease activity score, physician global assessment, and pain score. The SF-PCS showed only a weak inverse correlation with the swollen joint count (r=−0.29, p<0.05). In the SLE group, the systemic lupus erythematosus disease activity index correlated inversely best with the SF-36 general health subscale (r=−0.56, p<0.0001) and, to a lesser extent, with the mental health, BP, and vitality subscales, and SF-PCS and SF-mental component summary scores. Conclusion: Both RA and SLE have profound effects on HRQOL in BSA, with BP and physical disability particularly worse in RA patients. Disease activity, rather than organ damage or sociodemographic characteristics, correlates best with certain aspects of functional disability and HRQOL in both RA and SLE. Further longitudinal studies are needed to assess the clinical utility of measures of functional disability and HRQOL in this population.     

Low-dose corticosteroids in rheumatoid arthritis. A meta-analysis of their moderate-term effectiveness

Objective. To perform a systematic literature review and meta-analysis of the effectiveness of low-dose corticosteroids in the treatment of rheumatoid arthritis (RA). Methods. After identifying all relevant studies meeting preselected inclusion criteria, we performed 2 meta-analyses. First, we compared the effectiveness of prednisone to placebo and active drug controls (aspirin, chloroquine, or deflazacort) using standard meta-analysis methods for continuous data. Then, to compare the relative effectiveness of prednisone to second-line agents, we used methods similar to prior meta-analyses of second-line agents for RA treatment. Outcomes assessed were the number of tender and swollen joints, grip strength, and the erythrocyte sedimentation rate (ESR). Results. Very few studies directly assessed the effectiveness of corticosteroids for RA treatment, and many were of poor methodologic quality. Only 9 of 34 studies identified by our search met criteria for inclusion. The results of our standard meta-analysis indicated that corticosteroids appeared to be more effective than either placebo or active drug controls in improving most conventional outcome measures (effect size 0.90 for the number of tender joints, 1.05 for the number of swollen joints, and 1.20 for the ESR). In our second comparative meta-analysis, corticosteroids were nearly equivalent to second-line agents previously examined in meta-analyses (combined effect size 0.82). Conclusion. Based on the limited data available, during moderate-term treatment periods averaging slightly over 7 months, corticosteroids appeared to be as effective or more effective than alternative therapies in improving several common RA disease activity measures.     

Anti-tumour necrosis factor-alpha therapy over conventional therapy improves endothelial function in adults with rheumatoid arthritis

Rheumatoid arthritis (RA) is associated with cardiovascular morbidity and mortality and inflammation contributes to related endothelial dysfunction. We aimed to investigate the effect of anti-TNFα therapy on endothelial function in subjects with rheumatoid arthritis. We measured flow-mediated (FMD) and GTN-mediated dilation of the brachial artery before and following 36 weeks of anti-TNFα therapy in nine RA patients and in a group of RA patients on conventional therapy. Thirty-six weeks of anti-TNFα therapy improved FMD relative to those on conventional therapy (8.65 ± 1.50 vs. 1.70 ± 1.36%, P = 0.02). No significant changes in GTN responses were evident. Significant improvements in tender (P = 0.03) and swollen (P = 0.02) joint counts, patients’ global self-assessment (P = 0.01) and DAS-28 scores (P = 0.04) were observed in the anti-TNFα treated group. The addition of anti-TNFα treatment to conventional therapy, in those with severe RA, reduces inflammatory symptoms and improves endothelial function, potentially lowering future atherosclerotic risk     

The prevalence of clinical remission in RA patients treated with anti-TNF: results from the Dutch Rheumatoid Arthritis Monitoring (DREAM) registry

Objectives. To evaluate the prevalence of clinical remission and minimal disease activity according to the ACR/European League Against Rheumatism (EULAR) remission, DAS-28 <2.6 and minimal disease activity (MDA) criteria, and to compare the extent of residual disease activity with disability in RA patients after 6 months of treatment with anti-TNF. Methods. In the Dutch Rheumatoid Arthritis Monitoring (DREAM) biologic registry the prevalence of DAS-28 <2.6, MDA and ACR/EULAR remission criteria was assessed. Residual disease activity during MDA or remission was assessed as the percentage of patients with swollen and tender joints, elevated acute-phase reactants and general health on a visual analogue scale (VAS). Disability was evaluated with the HAQ score. Results. Prevalence of DAS-28 <2.6 was 27%, prevalence of MDA was 34% and ACR/EULAR remission was reached by 6% of patients. Residual disease activity was present mostly in the most lenient criteria and occurred most frequently on the level of swollen joint count and VAS score: at least one swollen joint in DAS-28 <2.6, MDA and ACR/EULAR remission was present in, respectively, 51, 54 and 34% of the patients. VAS >1 occurred in, respectively, 67, 69 and 0% of the patients. Modification of the cut-point of the patient-reported outcome increased the prevalence of ACR/EULAR remission, but also the level of disability. Conclusion. MDA and DAS-28 <2.6 are reachable treatment targets in RA with anti-TNF, although residual disease activity might still be present. In turn, ACR/EULAR remission criteria leave little residual disease activity, but might be too stringent for use in daily clinical practice due to the strict cut-point in the patient-reported outcome.     

Declines in number of tender and swollen joints in patients with rheumatoid arthritis seen in standard care in 1985 versus 2001: possible considerations for revision of inclusion criteria for clinical trials

OBJECTIVE: To analyse tender and swollen joint counts in three cohorts of patients with rheumatoid arthritis (RA), with a focus on the proportions of patients who had fewer than 6-12 tender or swollen joints, as possible evidence based information toward more generalisable inclusion criteria for current and future RA clinical trials. METHODS: Tender and swollen joint counts were analysed in three cohorts of patients with RA: 125 in 1985, 138 in 2000, and 232 with early RA in 2001. RESULTS: The median numbers of tender joints were 11, 2, and 4 in 1985, 2000, and in early RA in 2001, respectively. The median numbers of swollen joints were 12, 6, and 5 in 1985, 2000, and 2001, respectively. The numbers of tender joints among 28 assessed were >or=12, >or=6, >or=4, and >or=3 in 47%, 80%, 85%, and 90% of patients in 1985; 20%, 37%, 44%, and 49% in 2000; and 17%, 37%, 50%, and 58% in early RA in 2001. The numbers of swollen joints among 28 assessed were >or=12, >or=6, >or=4, and >or=3 in 51%, 78%, 86%, and 90% of patients in 1985; 20%, 50%, 64%, and 67% in 2000; and 14%, 46%, 58%, and 72% in 2001. The number of patients with >or=6 tender or swollen joints in 1985 was greater than the number with >or=3 joints in 2000 and in early RA in 2001. CONCLUSION: Contemporary cohorts of patients seen in standard care have smaller numbers of tender and swollen joints than in previous times. These findings suggest that revision of inclusion criteria for numbers of tender and swollen joints in contemporary RA clinical trials might improve generalisability.     

Dynamic gadolinium-enhanced magnetic resonance imaging of the wrist in patients with rheumatoid arthritis can discriminate active from inactive disease

OBJECTIVE: To determine the efficacy of dynamic gadolinium-enhanced magnetic resonance imaging (MRI) of the wrist in the evaluation of disease activity in patients with rheumatoid arthritis (RA). METHODS: Thirty-six patients with RA (with different degrees of disease activity) and 5 healthy controls were studied. MRI was performed with a low-field (0.2T), extremity-dedicated machine. After an intravenous bolus injection of gadolinium-diethylenetriamine pentaacetic acid, 20 consecutive fast spin-echo images of 3 slices of the wrist were obtained every 18 seconds. RESULTS: The curves of synovial membrane enhancement identified the following 2 groups: controls and RA patients in remission, and RA patients with active or intermediately active disease. Both the rate of early enhancement (REE) and relative enhancement (RE) were significantly higher in patients with active RA than in those with inactive RA and controls. The REE and RE were significantly correlated with the number of swollen joints (P < 0.00001 and P = 0.003, respectively), the number of tender joints (P < 0.00001 and P = 0.004, respectively), the Ritchie index (P = 0.0002 for both REE and RE), the Disease Activity Score (P = 0.0004 and P = 0.0008, respectively), the Health Assessment Questionnaire (HAQ) (P = 0.0002 and P = 0.0007, respectively), early morning stiffness (P = 0.001 and P = 0.009, respectively), the C-reactive protein level (P = 0.015 and P = 0.03, respectively), the erythrocyte sedimentation rate (P = 0.03, RE only), and alpha2 globulins (P = 0.036 and P = 0.028, respectively). CONCLUSION: Our data support use of dynamic MRI for discriminating active from inactive RA. Enhancement curves are associated not only with laboratory and clinical indicators of inflammation, but also with the HAQ, a relevant predictor of RA functional outcome. This technique can be repeated frequently and is an excellent candidate for the ideal method for the followup of patients with RA.     

Randomized double blind trial of an extract from the pentacyclic alkaloid-chemotype of uncaria tomentosa for the treatment of rheumatoid arthritis

OBJECTIVE: To evaluate safety and clinical efficacy of a plant extract from the pentacyclic chemotype of Uncaria tomentosa (UT) in patients with active rheumatoid arthritis (RA). METHODS: Forty patients undergoing sulfasalazine or hydroxychloroquine treatment were enrolled in a randomized 52 week, 2 phase study. During the first phase (24 weeks, double blind, placebo controlled), patients were treated with UT extract or placebo. In the second phase (28 weeks) all patients received the plant extract. RESULTS: Twenty-four weeks of treatment with the UT extract resulted in a reduction of the number of painful joints compared to placebo (by 53.2% vs 24.1%; p = 0.044). Patients receiving the UT extract only during the second phase experienced a reduction in the number of painful (p = 0.003) and swollen joints (p = 0.007) and the Ritchie Index (p = 0.004) compared to the values after 24 weeks of placebo. Only minor side effects were observed. CONCLUSION: This small preliminary study demonstrates relative safety and modest benefit to the tender joint count of a highly purified extract from the pentacyclic chemotype of UT in patients with active RA taking sulfasalazine or hydroxychloroquine.     

The synovial grade corresponding to clinically involved joints and a feasible ultrasound-adjusted simple disease activity index for monitoring rheumatoid arthritis

Objectives: To determine which grade of ultrasound (US) synovitis corresponds to clinically involved joints in rheumatoid arthritis (RA) and develops a new US-adjusted composite measure.

Methods: Clinical and US examinations were performed on 137 patients with RA (28 joints). Synovial effusion, hypertrophy, and blood flow were semiquantitatively graded from 0 to 3 using gray scale (GS) and power Doppler (PD) modes. We calculated US-adjusted simple disease activity index (SDAI) and assessed feasibility, and external validity by comparing with erythrocyte sedimentation rate (ESR), and modified health assessment questionnaires (MHAQ).

Results: GS ≥2 and PD ≥0 corresponds to clinically swollen joints, and GS ≥2 and PD ≥1 corresponds to tender joints. The US-adjusted SDAI showed the highest correlation when US-determined swollen joints were defined as PD ≥2 with ESR, and GS ≥3 and PD ≥2 with MHAQ. A feasible US-adjusted SDAI examining only clinically involved joints still showed a higher correlation with ESR and MHAQ than SDAI.

Conclusion: Our composite measure complemented by US only for clinically involved joints is feasible and reliable for monitoring disease activity.     

The Use of Two Different Health Assessment Questionnaires in Turkish Rheumatoid Arthritis Population and Assessment of the Associations with Disability

The aim of this study was to compare and evaluate the Health Assessment Questionnaire (HAQ) and Arthritis Impact Measurement Scale (AIMS) in our patient population with rheumatoid arthritis (RA) and also to find some associations with clinical assessment of disability. One hundred and twenty-three consecutive adult patients with RA were included in the study. Pain, and global assessments by patients and physicians were recorded using a 10 cm visual analogue scale. Each patient completed the HAQ and AIMS questionnaires. Correlations among tender and swollen joint counts, erythrocyte sedimentation rate, pain, and AIMS anxiety and depression scores were all investigated. Pearson correlation was used to assess the possible correlations between each questionnaire and clinical variables. Pain and the AIMS subscales of mobility, dexterity, social activity and activities of daily living correlated with global assessments by patients and physicians, and tender joint counts. Depression correlated with pain and disability (HAQ). It was also of note that we observed high intercorrelation between the global assessments of physicians and patients. It was concluded that a measure of functional status, patient global assessment and pain score should be considered as important in the evaluation of RA patients. Measuring psychological well-being also provides further information. The HAQ, with the addition of the anxiety and depression sections of AIMS (CLINHAQ), provides the advantage of a global evaluation of these chronically ill patients. Received: 20 May 1997 / Accepted: 10 August 1998