Use of simple analgesics in rheumatoid arthritis.

The usefulness of anti-inflammatory drugs in rheumatoid arthritis (RA) is beyond dispute. The role of simple analgesics is less clear and has been disputed. A survey of 21 rheumatologists indicated that a majority sometimes supplemented anti-inflammatory treatment of RA with simple analgesics. A random sample of 120 RA patients treated by the same doctors revealed that 47% ranked pain relief as the most desirable objective of their treatment and 54% were taking analgesics regularly. Of those receiving analgesics as well as non-steroidal anti-inflammatory drugs 48% considered the former to be the more effective preparations. Almost half the patients on analgesics were taking drugs without the knowledge of the rheumatologists, who may have underestimated their patients' desire for pain relief.     

Serum and synovial fluid interleukin-17 concentrations in rheumatoid arthritis patients: Relation to disease activity,radiographic severity and power Doppler ultrasound

Aim of the workTo investigate serum and synovial fluid levels of IL-17 in rheumatoid arthritis (RA) patients, and its correlation with disease activity and severity.Patients and methods20 RA patients together with 20 primary knee osteoarthritis (KOA) patients and 15 healthy individuals matched for age and sex as control groups were enrolled in this study. Both RA and KOA patients presented with knee effusion. Paired samples of serum and synovial fluid (SF) were collected from RA, OA patients and serum samples from the healthy individuals. RA disease activity was assessed using DAS-28 score and power Doppler ultrasound (PDUS) according to the European League against Rheumatism (EULAR). Radiographic damage was evaluated according to Larsen score.ResultsSerum levels of IL-17 were significantly elevated in RA patients compared to controls (p < 0.001). Also, SF of IL-17 was significantly higher in RA patients compared to OA patients (p < 0.001). In addition, synovial level of IL-17 was significantly higher in RA patient compared to their serum level (p < 0.001). Regarding disease activity grading among RA patients, significant differences (p < 0.05) in mean serum and synovial IL-17 levels were reported being higher in severe active disease. Positive correlations of serum and SF IL 17 levels with PDUS findings and Larsen score were reported.ConclusionSerum and synovial IL-17 levels were significantly elevated in RA patients which clarifies its possible role in RA pathogenesis and correlates positively with disease activity parameters, PDUS findings and Larsen score. Thus targeting IL-17 may provide a promising role in suppressing RA.     

Evaluation of serum calprotectin level as a biomarker of disease activity in rheumatoid arthritis and osteoarthritis patients

Aim of the workTo measure the levels of serum calprotectin (CLP) in rheumatoid arthritis (RA) and osteoarthritis (OA) patients and to assess its association with disease activity, severity and functional status.Patients and methodsA total of 30 RA and30 OA patients and 30 controlswere included. Rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP), Disease activity score (DAS28), health assessment questionnaire (HAQ) and RA medical records-based index of severity (RARBIS) were assessed in RA patients. Western Ontario and McMaster Osteoarthritis index (WOMAC) and Kellgren-Lawrence (KL) grading scale were assessed in OA patients and serum CLP levels were measured.ResultsThe mean age of RA and OA patients was 48.6 ± 8.6 and 50.8 ± 9.3 years respectively andthe majority of studied groups were females. CLP was significantly higher in RA patients in comparison to OA patients and healthy control (2.70 ± 2.08 vs. 1.18 ± 0.35 vs 1.11 ± 0.24 μg/ml); p < 0.0001). Serum CLP correlated with swollen joint count (SJC) (r = 0.7, p < 0.0001), tender joint count (TJC) (r = 0.73, p < 0.0001), patient global assessment (PGA) (r = 0.51, p = 0.004), Physician global assessment (PhGA) (r = 0.58, p = 0.001), HAQ (r = 0.6,p < 0.0001), erythrocyte sedimentation rate (ESR) (r = 0.5, p = 0.005), DAS28 (r = 0.69, p < 0.0001), RARBIS (r = 0.66, p < 0.0001). At a cut-off value of 2.5 µg/ml CLP can significantly differentiate active RA patients from those in remission (AUC 0.896; p < 0.0001) at a sensitivity of 83.3%, specificity of 88.9%, and accuracy of 86.7%.CLP was significant predictor for RA activity.ConclusionThe serum CLP levels were significantly high in RA patients compared to OA patients and controls and these high levels were associated with disease activity, severity, and functional status.     

Clinical implications of milk fat globule-epidermal growth factor 8 (MFG-E8) and vitamin D levels in patients with rheumatoid arthritis and primary knee osteoarthritis

Aimof the work to determine serum levels of vitamin D and Milk fat globule-epidermal growth factor 8 (MFG-E8) in rheumatoid arthritis (RA) and primary knee osteoarthritis (OA) compared to healthy controls and their possible associations. Patients and methods: The study included 30 RA and 30 primary knee OA patients as well as 25 control. The  disease activity was measured by disease activity score 28 (DAS28) in RA. The functional status was estimated by Western Ontario and McMaster Universities index (WOMAC index) in OA. While the assessment of pain was measured by the visual analog scale (VAS) in both RA and OA. Serum vitamin D and MFG-E8 levels were measured using enzyme-linked immunosorbent assay (ELISA). Results: The mean age of RA patients was 41.1 ± 9.2 years; 25 females and 5 males (F:M 5:1) and a disease duration of 6.9 ± 4.6 years. The mean age of OA patients was 48.7 ± 8.3 years; 28 females and 2 males (F:M 14:1) and disease duration was 5.4 ± 3.3 years. The mean vitamin D was significantly lower in RA (9.7 ± 5.04 ng/ml) than OA (16.4 ± 4 ng/ml) and controls (17.7 ± 3.4 ng/ml), p < 0.0001. The mean MFG-E8 serum level was significantly lower in RA and OA patients (4.9 ± 2.4 ng/mland 5.3 ± 1.2 ng/ml) than in controls (9.1 ± 3 ng/ml), p < 0.0001.Vitamin D significantly correlated with MFG-E8 (r = 0.6, p = 0.002) in RA and both inversely correlated with DAS28 (r = -0.66, p < 0.0001 and r = -0.58, p < 0.0001 respectively). Vitamin D (9.7 ng/ml) and MFG-E8 (4.9 ng/ml) significantly predicted RA (p < 0.0001) at specificity (100%) and sensitivity (66.7%). MFG-E8 at cut-off 5.3 ng/ml significantly predicted OA at specificity of 88% and sensitivity 86.7%.Conclusion: An association between low serum vitamin D and MFG-E8 levels with RA and the disease activity has been determined. Low MFG-E8 was associated with OA.     

Behçet's disease in patients of German and Turkish origin living in Germany: a comparative analysis

OBJECTIVE: To evaluate the relationship between ethnic origin and manifestations of Beh?et's disease (BD) in patients of German and Turkish origin living in Germany. METHODS: Between 1995 and 2000, 32 patients of German and 33 patients of Turkish origin living in Germany were evaluated for the entire spectrum of disease manifestations, disease severity, HLA associations, sex, age at disease manifestation, and time to diagnosis. RESULTS: There were no statistically significant differences between German and Turkish patients. There was no association of sex or HLA-B51 with any manifestation of BD. The only significant difference between the 2 groups was the median time from the first manifestation of the disease to diagnosis, which was 0 years for the Turkish, but 3.5 years for the German patients (p = 0.0005). Additionally, 4 patients of German origin had been misdiagnosed as having spondyloarthropathy (SpA) before the final diagnosis of BD was made (12%). In comparison to Turkish patients living in Turkey (data from the literature), only 2 differences were found: one concerned the frequency of ocular involvement (lower in the patients in Turkey), and the other the male to female ratio, which was reported as 1.03:1 in Turkey, but 3.7:1 in Germany. CONCLUSION: Our results do not favor an ethnic influence on the expression of BD. Environmental influences may be responsible for the higher frequency of ocular manifestations and the higher male to female ratio in patients living in Germany compared to those living in Turkey.     

Health care and burden of illness in systemic lupus erythematosus compared to rheumatoid arthritis: results from the National Database of the German Collaborative Arthritis Centres

During the past 20 years, outcome studies in the rheumatic diseases have, on the one hand, given increasing evidence of the unfavourable long-term prognosis of rheumatoid arthritis (RA) and on the other hand determined continuous improvement of prognosis in systemic lupus erythematosus (SLE). The aim of the study was to investigate how this translates into the current spectrum of patients with rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) seen by rheumatologists in Germany and to compare aspects of the burden of disease, disease outcomes and treatment between these two important rheumatic diseases using a large clinical database. Current health care was analysed with data from the German rheumatological database of 10 068 patients with RA and 1248 patients with SLE seen by rheumatologists in 2001. In addition, of a total of 3546 patients with SLE and 24 969 patients with RA seen at the German Collaborative Arthritis Centres between 1994 and 2001, 3465 cases of SLE were matched by age, sex, disease duration and referral status with a corresponding RA case. There were considerable differences in treatment of patients before referral to a rheumatologist and in rheumatologic care. In 2001, patients with SLE were treated by their rheumatologists mainly with antimalarials (AM, 37%), azathioprine (29%) and nonselective NSAIDs (16%). Of them, 61% received at least one immunosuppressive drug (including AM) plus glucocorticoids. In RA, methotrexate was the predominant medication (63%), and 56% received at least one immunosuppressive drug plus glucocorticoids. Matched pairs analysis showed that SLE patients with a short disease duration were almost equally burdened by pain, functional limitations and reduced health status as RA patients. After a disease duration of >10 years, however, patients with RA showed poorer outcomes than those with SLE: RA patients reported significantly more often severe pain (30% in RA versus 17% in SLE) and poor global health status (52 versus 38%), and their disease activity as well as severity was rated higher by the rheumatologists. In conclusion, comparing large groups of RA and SLE patients we found a similar burden in early but not in late disease. Taking into account limitations as to the generalizability of the results (recruitment in rheumatologic care, cross-sectional data, underestimation of SLE-specific outcomes), the discrepancy between the high increase in disease-related negative outcomes with longer disease duration in RA but not in SLE indicates a better long-term prognosis in SLE concerning the items observed. The great disparity in treatment intensity between rheumatologists and nonrheumatologists shows that the involvement of a specialist is needed equally in both diseases.     

Physician role conflict and resulting career changes

OBJECTIVE: To evaluate gender and generational differences both in the prevalence of role conflict and in resulting career changes among married physicians with children. STUDY DESIGN: Cross-sectional survey. PARTICIPANTS: We sent a survey to equal numbers of licensed male and female physicians (1,412 total) in a Southern California county; of the 964 delivered questionnaires, 656 (68%) were returned completed. Our sample includes 415 currently married physicians with children, 64% male and 36% female. MEASUREMENTS AND MAIN RESULTS: The prevalence of perceived role conflict, of career changes for marriage, and of career changes for children were evaluated. Types of career changes were also evaluated. More female than male physicians (87% vs 62%, p<.001) and more younger than older female physicians (93% vs 80%, p<.01) and male physicians (79% vs 54%, p<.001) experienced at least moderate levels of role conflict. Younger female and male physicians did not differ in their rates of career change for marriage (57% vs 49%), but female physicians from both age cohorts were more likely than their male peers to have made career changes for their children (85% vs 35%, p<.001). Younger male physicians were twice as likely as their older peers to have made a career change for marriage (49% vs 28%, p<.001) or children (51% vs 25%, p<.001). The most common type of career change made for marriage or children was a decrease in work hours. CONCLUSIONS: Most physicians experience role conflict, and many adjust their careers in response. Flexible career options may enable physicians to combine professional and family roles more effectively. Presented as a poster at the Society for General Internal Medicine Southern California Regional meeting, February 1995, and at the 19th annual meeting, Washington, DC, May 2–4, 1996. Supported in part by grants from the UCLA Academic Senate Committee on Research, UCLA Stein/Oppenheimer Endowment, and the Long Beach Chapter of the American Medical Women’s Association. All conclusions in this paper are those of the authors and do not necessarily reflect the views of the West Los Angeles VAMC, UCLA, the Stein/Oppenheimer Endowment or the American Medical Women’s Association.     

Low overall mortality of Turkish residents in Germany persists and extends into a second generation: merely a healthy migrant effect?*

Summary objective  To test the hypothesis that as a minority with lower socio-economic status, Turkish residents in Germany might experience a higher mortality than Germans.
methods  All-cause mortality rates by age group and sex of Turkish and German adults for the time period 1980–94 were calculated from death registry data and mid-year population estimates.
results  The age-adjusted mortality rate (per 100000) of Turkish males aged 25–65 years resident in Germany was 299 in 1980 and 247 in 1990, consistently half that of German males. The mortality of Turkish females in Germany was 140 in 1990, half that of German females. Mortality of Turkish males/females in Ankara was 835 and 426 in 1990.
conclusion  In view of the socio-economic status of Turkish residents in Germany the large mortality difference compared to Germans is unexpected. It cannot be fully explained by a selection at the time of hiring (healthy migrant effect) because it lasts over decades and extends into the second generation. A healthy worker effect is unlikely because Turkish residents have a lower employment rate than Germans. There is little evidence for movement of gravely ill persons back to Turkey. An 'unhealthy re-migration effect' in which socially successful migrants with a lower mortality risk stay in the host country while less successful ones return home even before becoming manifestly ill would partly explain our findings.     

Comparison of general internists,family physicians,and rheumatologists managing patients with symptoms of osteoarthritis of the knee

Objective . To evaluate the nature, risks, and benefits of osteoarthritis (OA) management by primary care physicians and rheumatologists. Methods . Subjects were 419 patients followed for symptoms of knee OA by either a specialist in family medicine (FM) or general internal medicine (GIM) or by a rheumatologist (RH). Management practices were characterized by in-home documentation by a visiting nurse of drugs taken to relieve OA pain or to prevent gastrointestinal side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and by patient report (self-administered survey) of nonpharmacologic treatments. Changes in outcomes (knee pain and physical function) over 6 months were measured with the Western Ontario and McMaster Universities Osteoarthritis Index. Results . Patients of RHs were 2-3 years older (P = 0.035) and tended to exhibit greater radiographic severity of OA (P = 0.064) and poorer physical function (P = 0.076) at baseline than the other 2 groups. In all 3 groups, knee pain and physical function improved slightly over 6 months; however, between-group differences were not significant. Compared to drug management of knee pain by FMs or RHs, that by the GIMs was distinguished by greater utilization of acetaminophen and nonacetylated salicylates (P = 0.008), lower prescribed doses of NSAIDs (P = 0.007), and, therefore, lower risk of iatrogenic gastroenteropathy (P < 0.001). In contrast, patients of RHs were more likely than those of FMs and GIMs to report that they had been instructed in use of isometric quadriceps and range-of-motion exercises (P ≦ 0.001), application of heat (P = 0.051) and cold (P < 0.001) packs, and in the principles of joint protection (P = 0.016). Neither physician specialty nor specific management practices accounted for variations in patient outcomes. Conclusion . This observational study identified specialty-related variability in key aspects of the management of knee OA in the community (i.e., frequency and dosing of NSAIDs, use of nonpharmacologic modalities) that bear strong implications for long-term safety and cost. However, changes in knee pain and function over 6 months were unrelated to variations in management practices.     

Rheumatologists’ adherence to a disease activity score steered treatment protocol in early arthritis patients is less if the target is remission

To compare rheumatologists’ adherence to treatment protocols for rheumatoid arthritis (RA) targeted at Disease Activity Score (DAS) ≤2.4 or <1.6. The BeSt-study enrolled 508 early RA (1987) patients targeted at DAS ≤2.4. The IMPROVED-study included 479 early RA (2010) and 122 undifferentiated arthritis patients targeted at DAS <1.6. We evaluated rheumatologists’ adherence to the protocols and assessed associated opinions and conditions during 5 years. Protocol adherence was higher in BeSt than in IMPROVED (86 and 70 %), with a greater decrease in IMPROVED (from 100 to 48 %) than in BeSt (100 to 72 %). In BeSt, 50 % of non-adherence was against treatment intensification/restart, compared to 63 % in IMPROVED and 50 vs. 37 % were against tapering/discontinuation. In both studies, non-adherence was associated with physicians’ disagreement with DAS or with next treatment step and if patient’s visual analogue scale (VAS) for general health was ≥20 mm higher than the physician’s VAS. In IMPROVED, also discrepancies between swelling, pain, erythrocyte sedimentation rate, and VASgh were associated with non-adherence. Adherence to DAS steered treatment protocols was high but decreased over 5 years, more in a DAS <1.6 steered protocol. Non-adherence was more likely if physicians disagreed with DAS or next treatment step. In the DAS <1.6 steered protocol, non-adherence was also associated with discrepancies between subjective and (semi)objective disease outcomes, and often against required treatment intensification. These results may indicate that adherence to DAS-steered protocols appears to depend in part on the height of the target and on how physicians perceive the DAS reflects RA activity.     

Surgical management of the rheumatoid hand: consensus and controversy among rheumatologists and hand surgeons

OBJECTIVE: Rheumatoid arthritis (RA) is a common cause of debilitating hand deformities, but management of these deformities is controversial, characterized by large variations in the surgical rates of common RA hand procedures. We conducted a national survey evaluating potential differences in physicians' management of RA hand deformities. METHODS: We mailed a survey instrument to a random national sample of 500 rheumatologists and 500 hand surgeons in the US. We evaluated physicians' attitudes toward the other specialties' management of common RA hand deformities and toward the indications for performing rheumatoid hand surgery. RESULTS: We found 70% of rheumatologists consider hand surgeons deficient in understanding the medical options available for RA, while 73.6% of surgeons believe rheumatologists have insufficient knowledge of the surgical options for RA hand diseases. However, 66.9% of surgeons and 79.5% of rheumatologists had no exposure to the other specialty during training. The 2 physician groups disagree significantly on the indications for commonly performed RA hand procedures such as metacarpophalangeal joint arthroplasty (p < 0.001), small joint synovectomy (p < 0.001), and distal ulna resection (p = 0.001). When physicians do not agree with others' management of RA hand deformities, only 62.4% of surgeons and 61.9% of rheumatologists relay their concern to the other specialty. CONCLUSION: Rheumatologists and hand surgeons have minimal interdisciplinary training, communicate with each other infrequently, and significantly disagree on the indications for RA hand surgery. Research must focus on the surgical outcomes of RA hand procedures and on improving communication between rheumatologists and hand surgeons.     

Prevalence and risk factors of knee osteoarthritis in Huang-Pu District, Shanghai, China

Objectives A community-based survey on the prevalence of knee osteoarthritis (OA) and associated factors was carried out in Shanghai, Peoples Republic of China.Methods Of 2,305 registered residents 40 years of age, 2,093 were examined by interview and questionnaire. One hundred ninety knee pain-positive and 510 knee pain-negative subjects received radiography.Results Radiographic knee OA (RKOA) was found in 72.1% (137/190) of symptomatic and 41.6% (212/510) of asymptomatic subjects (SKOA and AsKOA, respectively). The estimated prevalences of symptomatic and asymptomatic knee OA in the community were 7.2% and 37.4%, respectively. Women had higher SKOA prevalence than men (9.8% vs 3.7%, P<0.01). Compared with Caucasians, the urban Shanghai population had a higher prevalence of tibiofemoral joint OA.Conclusions There was a higher proportion of SKOA than AsKOA (72.1% vs 41.6%), and SKOA was significantly more associated with disability (81.0% vs 26.9%, P<0.01). The prevalence of SKOA increased with age, from 1.3% in the 40–49-year-old age group to 13.2% in the 70+ group. Age, body mass index, and female gender were associated risk factors for knee OA.     

Bestandsaufnahme der ambulanten rheumatologischen Versorgung in Deutschland

Aim

To gather information on current organizational structures in rheumatologic ambulatory health care in Germany. Based on the results recommendations on future structures will be discussed.

Methods

This study involved data collection and statistical analysis via a structured 10-page questionnaire among the members of the German Association of Rheumatologists. The questions concerned a variety of topics including information on office structures, patient structure, structure of services offered, co-operation with colleagues and hospitals, quality assurance measures, economic factors, and a subjective assessment of the health care structures in rheumatology by the participants.

Results

Data obtained from 197 rheumatologists who participate in health care were analyzed. In this paper results concerning the organizational as well as the medical ambulatory health care structure will be presented. Data on economic factors will be presented in part 2 of this study.

Conclusions

The organization of ambulatory treatment regarding processes and treatment differences between office-based physicians and rheumatologic outpatient departments in hospitals was very homogeneous. However, physicians in the eastern regions treated significantly more patients compared with the western parts of Germany. This difference was also observed between the north and south. Differences in patient groups (e.g. underlying diseases) were reported between different sub-groups of rheumatologists (e.g. internal specialists vs. GP vs. orthopedic rheumatologists). Integrated health care, as promoted by German social law, did not play a major role. Overall there was a high level of self-initiated training of physicians and participation in education of patients and other physicians.     

Lower prevalence of asthma and atopy in Turkish children living in Germany.

Ethnic origin has been reported to affect the prevalence of atopic diseases in several studies in different parts of the world. However, little is known about the prevalence of asthma and atopy in immigrants living in Europe. The objective of this study was to evaluate the prevalence of asthma and atopy in Turkish children living in Germany and to investigate the role of ethnic origin on the development of asthma and atopy in this population. In a cross-sectional survey the prevalence of physician-diagnosed asthma, atopy, skin-prick tests and bronchial hyperresponsiveness (BHR) to cold dry air challenge was assessed in 7,445 school children aged 9-11 yrs, living in Munich, south Germany. Questionnaires were distributed to the parents for self-completion and children underwent skin prick tests and cold air hyperventilation challenge. The Turkish children showed a significantly lower prevalence of asthma (5.3 versus 9.4%, p<0.05) than their German peers. Furthermore, atopy, as assessed by skin prick tests (24.7 versus 36.7%, p<0.001) and BHR (3.9 versus 7.7%, p<0.001), was less common in Turkish children. In multivariate regression models controlling for potential explanatory factors, Turkish origin still showed a significantly lower risk of developing asthma, atopic sensitization and BHR. The prevalence of childhood asthma was therefore shown to be lower in Turkish children living in Germany than in Turkey. These findings suggest that the lower prevalence of asthma and allergy in Turkish children living in Germany might be attributable to a selection bias affecting the parents of these children, as healthy individuals may have decided to come to Germany for work.     

The prevalences of some rheumatic diseases in western Turkey: Havsa study

To study the prevalence major rheumatic diseases in western Turkey. This survey was conducted in Havsa which have a total population of 18,771. Physicians and interns visited every household, interviewed face to face a questionnaire about the symptoms of rheumatic disorders. The individuals replied positively to any question were examined at the nearest health center. Those have no objective findings related to any rheumatic diseases were excluded. People could not be clinically diagnosed were asked to come to the hospital for further evaluation. A total 17,835 of 18,771 residents participated. We estimated the prevalence of Behçet’s Disease (BD) as 0.019%; ankylosing spondylitis: 0.120%; rheumatoid arthritis: 0.321%; knee osteoarthritis (OA): 5.351%; hand OA: 1.110%; hand and knee OA: 1.958%; total OA: 8.420%; primary Raynaud’s: 1.192%; psoriasis: 0.424 %; psoriatic arthritis: 0.050%; rheumatic fever: 0.318%; rheumatic heart disease: 0.200%; inflammatory bowel disease: 0.023%; lupus: 0.059%; gout: 0.018%; systemic sclerosis: 0.022%; juvenile rheumatoid arthritis: 0.032%; temporal arteritis: 0.020%, and familial Mediterranean fever (FMF) as 0.006%. Figures were adjusted for age-sex of the general Turkish population. The prevalence’s of BD and FMF are considerably lower in Havsa as compared to other regions in Turkey.     

Diagnostik und Behandlung der Osteoporose bei rheumatoider Arthritis vor dem Hintergrund der Leitliniennutzung

In a cross-sectional study the prevalence of osteoporosis and osteopenia in patients with rheumatoid arthritis (ORA study) was investigated. Additionally, patients, their family doctors and rheumatologists were surveyed on their awareness of osteoporosis in RA, prevention, diagnosis, treatment and use of guidelines.In the years 2005 and 2006 a total of 532 patients with RA (98 men, 434 women) aged 23-87 years were consecutively recruited from 9 German centers for rheumatology. Clinical examination included a detailed documentation of osteoporosis medication. Dual-energy X-ray absorptiometry (DXA) was used to measure bone mineral density (BMD) at the lumbar spine and neck of the femur. Questionnaires on osteoporosis were sent to 119 family doctors (87 men, 32 women) and 44 rheumatologists (30 men, 14 women).The survey showed that rheumatologists had a higher awareness of osteoporosis in RA and compared to family doctors they estimated a higher frequency and tested RA patients more often for osteoporosis. In line with osteoporosis guidelines rheumatologists and family doctors saw an indication for densitometry in RA patients on steroid therapy and/or low intensity trauma fractures. In contrast to the 2006 recommendations of osteoporosis guidelines 50% of family doctors and rheumatologists preferred bisphosphonate off-label-therapy for premeopausal women with RA and comorbid glucocorticoid-induced osteoporosis. On the other hand 50% of premenopausal RA patients with osteoporosis did not receive any osteoporosis medication.The survey revealed a high degree of guideline compliance in diagnosing osteoporosis in RA but deficits were observed in the administration of osteoporosis medication, especially in premenopausal women.     

Sonographic evaluation of femoral condylar cartilage in osteoarthritis and rheumatoid arthritis.

Employing a real-time sonographic scanner with a 5 MHz linear probe, the articular cartilage of the knee was studied in four groups of subjects: normal subjects aged 18-36 years and 50-63 years, patients with rheumatoid arthritis (RA) and patients with osteoarthritis (OA). Cartilage thickness was diminished both in RA and in OA knees compared to the two groups of normal joints, even if in RA the reduction was less. The cartilage surface appeared irregular more frequently in OA than in RA. Our survey suggests that the sonographic technique is a useful, non-invasive diagnostic method to study the articular cartilage of the knee.     

Survey of practices regarding management of early rheumatoid arthritis by rheumatologists in France

OBJECTIVE: To describe the practices of rheumatologists in France regarding the initial management of early rheumatoid arthritis (RA) and to estimate the associated costs. METHODS: A questionnaire on the diagnosis and treatment of early RA was sent to the 2485 practicing rheumatologists in France. The results of the 917 completed questionnaires (37% response rate) were analyzed, and initial investigation and treatment costs, including the first month of treatment, were calculated from a socio-economic perspective. RESULTS: For the RA diagnosis, more than 80% of the respondents recommended the erythrocyte sedimentation rate, C-reactive protein, complete blood count, rheumatoid factor, antinuclear antibody and wrist radiographs. In 40% and 60% of the cases, antikeratin antibody, liver enzymes, serum creatine, serum protein electrophoresis and radiographs (chest, foot and knee) were advocated. Initial drugs administered were non-steroidal antiinflammatory agents (88%), analgesics (76%), disease modifying anti-rheutmatic drugs (74% with methotrexate in 46% of cases, followed by hydroxychloroquine [13%], sulfasalazine [8%], leflunomide [7%], intramuscular gold therapy [6%]), and glucocorticoids (21%). Rehabilitation was recommended by 51% of the respondents. The median cost for this initial management was 273 euros (mean 301 euros, range 49-1,336 euros). CONCLUSION: Marked variations occur among French rheumatologists in the initial management of early RA. These data may be helpful in identifying obstacles to physician compliance with recommendations regarding everyday clinical practice and to set up more a specific evaluative study.     

Scleroderma lung disease,variation in screening,diagnosis and treatment practices between rheumatologists and respiratory physicians

Background: Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) represent the leading causes of death in systemic sclerosis (SSc). Screening for these complications has assumed greater importance, but is not universal. The aim of this study is to determine the self‐reported screening, diagnosis and treatment practices of rheumatologists and respiratory physicians for SSc‐related lung disease. Methods: Email survey of 270 rheumatologists and 600 respiratory physicians. Results: Responses were received from 42 (16%) rheumatologists and 68 (11%) respiratory physicians. Of SSc patients seen by rheumatologists, 17% had ILD and 7.5% had a diagnosis of PAH compared with 31% and 21% for respiratory physicians. Forty per cent of all physicians screened asymptomatic SSc patients without a known diagnosis of ILD or PAH less than annually or not at all. The most commonly used screening investigations were pulmonary function tests (PFT) (95%) and transthoracic echocardiogram (TTE) (78%). In suspected ILD, both groups used high‐resolution computed tomography scans and PFT in >90% of patients. In suspected PAH, both used TTE and PFT (>90%); right heart catheterisation was used by only 50% of physicians. In treatment of ILD, rheumatologists used intravenous (IV) cyclophosphamide more often (CYC) (59% vs 28%, P= 0.003) and more respiratory physicians used oral CYC (44% vs 28%, P= 0.012). In PAH, more respiratory physicians used warfarin (68% vs 40%, P= 0.006). Only approximately 65% of physicians had used specific PAH therapy, which may reflect lack of access to a designated PAH treatment centre. Conclusion: The heterogeneity of responses revealed in this study raises the importance of screening, diagnosis and treatment algorithms in the management of this potentially life‐threatening disease.     

A survey of outcome measurement procedures in routine rheumatology outpatient practice in Australia.

OBJECTIVE: To assess the extent to which quantitative clinical measurement is performed by rheumatologists in the longitudinal followup of patients with rheumatoid arthritis (RA), osteoarthritis (OA), ankylosing spondylitis (AS), and fibromyalgia (FM) in routine outpatient practice in Australia. METHODS: A cross sectional postal survey was conducted using an 18-item self-administered questionnaire sent to Australian Rheumatology Association (ARA) members. RESULTS: Rheumatologists (response rate = 76%, completion rate = 72%) were more likely to longitudinally follow patients with RA and AS than those with OA or FM. There was a high degree of variability in the methods used to monitor patients longitudinally. Many measures used in clinical research were used infrequently in routine clinical practice. In general, the major health status measures surveyed were not used in clinical monitoring. There was a high level of agreement (> 80%) that the characteristics required of an outcome measure for use in clinical practice should include simplicity, brevity, ease of scoring, reliability, validity, and sensitivity to change. CONCLUSION: The majority of Australian rheumatologists perform outcome measurement during the longitudinal followup of their outpatients with RA, AS, OA, and FM. However, the process lacks standardization. High performance health status measures developed for clinical research have not been widely adopted in rheumatology practices. There is agreement on the characteristics required by Australian rheumatologists for measurement procedures used in routine clinical care. Quantitative measurement in clinical practice using standardized procedures is an attainable, but as yet, unrealized opportunity.