Clinical implications of depression in rheumatoid arthritis

The clinical implications of depression in the context of rheumatoid arthritis are described. An overview of the diagnostic criteria for depression is provided, with specific focus on major depression and the associated subtypes. The neurobiological literature on major depression is briefly reviewed and the implications of the depression literature for the care of persons with rheumatoid arthritis are discussed.     

Coexistent rheumatoid arthritis and systemic lupus erythematosus: clinical, serological, and phenotypic features.

The clinical and serological features and HLA phenotypes are reported for 11 patients with coexistent features of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). All patients had a symmetrical small joint polyarthritis and features of SLE such as rash, photosensitivity, oral ulceration, serositis, cytopenia, and biopsy proved lupus nephritis. Eight had hypocomplementaemia. Autoantibodies were characteristic of the two diseases: all patients had rheumatoid factor and antibodies to double stranded DNA, eight (73%) had antibodies to collagen, and five (46%) had antibodies to Ro (SS-A). There was also an overlap of HLA phenotypes. Six patients were DR4 and seven were DR2 or DR3 positive, and of the five patients who were DR4 negative, four shared class I alleles often associated with DR4. If RA and SLE share a common autoimmune dysfunction, those patients who have the two diseases do so because they have genetic determinants of both.     

Isolated nail fold vasculitis in rheumatoid arthritis.

OBJECTIVES--To establish the clinical significance of isolated nail fold vasculitis in patients with rheumatoid arthritis (RA). METHODS--Patients attending hospital with established RA were assessed by a single observer using unaided vision. Isolated nail fold vasculitis (NFV) was diagnosed as small nail edge or nail fold lesions without any evidence of other extra-articular or systemic vasculitis. Patients were followed prospectively. RESULTS--Thirty patients with isolated NFV were identified and followed for a median interval of 22 months. Three patients died within three months of diagnosis and six developed complications possibly indicative of extra-articular disease: xerostomia (three), pericarditis (one), pleural effusion and empyaema (one), pulmonary fibrosis (one). No patient developed systemic vasculitis. CONCLUSION--Isolated NFV has a favourable prognosis compared with systemic vasculitis. There is a low risk of developing systemic or extra-articular disease.     

Rheumatoid factors in rheumatoid arthritis and vasculitis

Summary To study the occurrence of rheumatoid factors (RF) in relation to the activity of rheumatoid arthritis and the occurrence of vasculitis, RF of IgM, IgA, and IgG classes were measured in sera from 35 patients with definite or classic rheumatoid arthritis (RA) using ELISA. For 26 patients, the RF levels were studied longitudinally and compared with changes in the articular index. Although IgM RF was occasionally found in patients without RA, IgA and/or IgG RF were almost exclusively associated with RA. The titers of IgM, IgA, and IgG RF were significantly higher in sera from patients with clinically diagnosed rheumatoid vasculitis than in sera from patients without vasculitis. No significant correlation between changes in the articular index and changes in titer of any class-specific RF could be found for the group of RA patients as a whole. However, in individual patients, increases or decreases in IgM and IgG RF titer were significantly correlated with an increase or decrease in the articular index.     

Leucapheresis in severe rheumatoid arthritis.

Two patients with severe seropositive rheumatoid arthritis previously unresponsive to conventional therapy have been treated with leucapheresis. This technique involves continuous cell separation daily to remove primarily lymphocytes. Clinical improvement was recorded with the use of standard rheumatological measures of inflammation. It is concluded that leucapheresis may help in the management of severely active rheumatoid arthritis when conventional therapy has been unsuccessful.     

Comparison of serial synovial fluid cytology in rheumatoid arthritis: delineation of subgroups with prognostic implications.

Serial synovial fluid samples were obtained from patients with rheumatoid arthritis and analysed cytologically. Positive correlations in the serial samples between proportions of polymorphs and ragocytes were found. Based upon the serial synovial fluid cytology, distinct subgroups of rheumatoid joints emerged. Comparison of clinical findings in these subgroups showed that the joints with high ragocyte proportion had a significantly poorer outcome. This study therefore identifies two distinct subgroups of rheumatoid joints on the basis of the nature of the cellular reaction within the joint fluid, which usually holds true during subsequent clinical relapse. Identification of these groups may have prognostic significance.     

Retinal vasculitis in rheumatoid arthritis: an angiographic study

The authors studied sixty patients affected by classical or definite rheumatoid arthritis (RA), to evaluate the possible existence of retinal vasculitis, by employing fluorescein angiography. Retinal vasculitis was found in 18% of the examined patients, even if no clinical and ophthalmoscopic signs of retinal vessel inflammation were present. The authors suggest that the retina should be examined in RA patients, since retinal vasculitis may be asymptomatic at the beginning, but can represent one of the possible extra-articular manifestations of the disease.     

Clinical and radiological features of atlantoaxial joints in rheumatoid arthritis

Summary Atlantoaxial (AA) instability is frequent radiological finding in patients with rheumatoid arthritis (RA). Mostly no serious neurological disorders are expected in such patients. The purpose of the study was to assess the sagittal spinal canal diameter according to Steel’s rule of third and its relationship to clinical symptoms. Radiological and clinical evaluation was performed in 65 in-patients with RA. Fifty four patients complained of neck pain, 39 had vertebrobasilar symptoms, and 25 mild neurological disorders. A hyperreflexy tendon responses were registered in 16 patients. Only 1 patient had extensor plantar response. Forward AA dislocation was verified in 28 (43%) cases with a mean value of 8.3mm (4–17mm). Still free space for spinal cord in spinal canal was obtained in 62 (95%) of patients, which can explain such a low incidence of serious neurological disorders. Our results suggest an association among duration of disease, atlantodental distance, and sagittal spinal canal diameter. We consider that it is important to detect early the most jeopardized patients on the basis of radiological analysis at C1 level according to Steel’s rule of third and recognize when „safe zone” has exceeded and enters the area of impending spinal cord compression. Received: 12 January 1998 Accepted: 20 May 1999     

Clinical, laboratory and radiographic features in early rheumatoid arthritis

We evaluated disease status in relation to age, sex and disease duration using some short term indices of disease activity, laboratory tests, and radiological features in 315 patients with rheumatoid arthritis of duration varying from 3 to 36 months (mean 12 months). No differences were observed among various age groups in disease duration, female/male ratio, incidence of radiologic lesions and other indices of disease process. Some clinical markers of the disease process such as involvement of the flexor tendons of the hands and Ritchie's index (score greater than 9) were significantly more frequent in the women (p less than 0.0013 and p less than 0.04, respectively). In the patients with disease of recent onset women were slightly more numerous (56%) than men; however, in those with disease duration of 36 months there were significantly more women (72%) (p less than 0.039), suggesting a greater tendency to chronic disease in this sex. Radiological lesions of the small joints of the hands, feet, and/or wrists were found in 37% of the cases with disease duration of up to 4 months and in 91% at 36 months (p less than 0.0001). The lesions were associated significantly more frequently with Ritchie index (p less than 0.02) and with laboratory indices of inflammatory activity (erythrocyte sedimentation rate greater than or equal to 25 mm/h) (p less than 0.001) and immune response (latex test greater than or equal to 80) (p less than 0.0001). Logistic regression analysis showed that the duration of illness is the most important factor correlating with radiologic lesions.     

Clinical features, autoantibodies and HLA-DR antigens in rheumatoid arthritis

HLA-DR4 was associated with seropositive but not seronegative disease in 105 Caucasians with rheumatoid arthritis (RA). There were no clinical or radiological differences between DR4 positive and negative RA groups, although 7 of 8 patients with early disease onset (less than 30 yr) were DR4 positive. High rheumatoid factor (RF) titers were more frequent in DR4 negative RA. A plot of the frequency distribution of RF titers in DR4 negative disease showed a bimodal distribution with seronegative and high titer groups. HLA-DR3 was not associated with high RF titers but was associated with high titers of antinuclear antibodies.     

The mortality of rheumatoid vasculitis compared with rheumatoid arthritis

Objective. To determine whether the mortality of patients with rheumatoid vasculitis (RV) is increased in comparison with that of patients with rheumatoid arthritis (RA). Methods. The mortality of all RV patients identified in 1980–1992 (n = 61) was compared with that of 244 RA controls matched for the year the diagnosis was made in the RV cases. Hazard ratios (HR) of death were calculated with a multivariate survival analysis, adjusting for age, sex, comorbidity, treatment, and parameters of RA severity. Results. The unadjusted risk of death (HR) in RV patients compared with RA controls was 1.65 (95% confidence interval [95% CI] 1.05–2.58). After adjustment for prognostic factors, the HR was reduced to 1.26 (95% CI 0.79–2.01), mainly due to removal of the effects of age and sex. No excess mortality was seen in RV patients with severe organ involvement when compared with RV patients without severe organ involvement, although the former patients were treated more often with cytostatic and immunosuppressive drugs. Infection was the main cause of death in the RV patients, and cardiovascular disease in the RA controls. Vasculitis was reported as the cause of death in only 1 RV patient. Conclusion. After allowance for general risk factors such as age and sex, there remains only a slight excess mortality in RV patients compared with RA controls.     

Clinical and radiological features of rheumatoid arthritis in British black Africans

The objective of this study was to determine whether radiographic damage is different in British black African patients with rheumatoid arthritis compared to Caucasian patients. Data on demographics, disease- and disability-related variables were obtained from all black African patients and their age-, gender- and disease-duration-matched Caucasian controls. After all features identifying the patients were concealed, X-rays of hands and feet were scored by using the Sharp/van der Heijde method. Data were analysed using Mann–Whitney U test, t test and χ ² test. Sixty-four patients (32 in each ethnic group) were studied. The median age was 52 years and median disease duration 6 years. Seventy-two percent of patients were female. Black Africans and Caucasians did not differ significantly in rheumatoid factor positivity, disease-modifying anti-rheumatic drugs and biological treatment use. British black African patients had significantly more tender joints and disability. Joint space narrowing was significantly greater in Caucasian patients [48 (27–85) vs 56 (34–107), p = 0.01]. Caucasian patients had more number of erosions (172 vs 220) and higher erosion score; however, the difference in the erosion scores was not statistically significant [2 (0–48) vs 4.5 (0–46), p = 0.17]. Radiographic damage was less severe in black African patients with rheumatoid arthritis compared to their age-, gender- and disease-duration-matched Caucasian controls. A large prospective study is required to confirm the findings of this study and to establish the factors which might be accountable for any differences in the expression of rheumatoid arthritis in this ethnic group.     

Angiogenesis and rheumatoid arthritis: pathogenic and therapeutic implications.

Rheumatoid arthritis can be considered as one of the family of 'angiogenesis dependent diseases'. Angiogenesis in rheumatoid arthritis is controlled by a variety of factors found in the synovial fluid and pannus tissue. Modulation of the angiogenic component of the disease may alter the pathogenesis of the condition, and subsequent cartilage and joint destruction, by reducing the area of the endothelium in the pannus and restricting pannus growth. Current therapeutic strategies exert, to varying extents, an inhibitory effect on the angiogenic process. In particular, the mode of action of the slow acting antirheumatic drugs may be due to their effect on the angiogenic response. The development of novel angiostatic treatments for chronic inflammatory joint disease may lead to a new therapeutic approach in controlling disease progression.     

Clinical features of organizing pneumonia associated with rheumatoid arthritis

Objectives: To clarify the clinical features of organizing pneumonia (OP) associated with rheumatoid arthritis (RA) and to determine whether development of OP is related to RA activity.

Methods: A cross-sectional study was conducted, in which medical records of 499 consecutive RA patients who visited our hospital during one month were reviewed. OP was diagnosed by pathological findings by trans-bronchial biopsy or by clinical features (typical computed tomography findings, no causative agents, good response to glucocorticoids, and lack of response to antibiotics).

Results: Among 499 patients, OP was found in 19 patients and the estimated prevalence was 1.9–4.8%. No differences in clinical features were noted between the OP and non-OP groups. The mean age of OP development was 57.2 years and the period from the onset of RA to OP ranged from ?4 to +34 years. Although 14 patients presented OP after the onset of RA, two developed OP before RA and three developed OP simultaneously with RA. Patients receiving tumor necrosis factor inhibitors also developed OP. RA disease activity just before onset of OP was low in 8 of 14 RA cases. At the onset of OP, only two patients showed exacerbations of arthritis, whereas most patients presented with fever and serum C-reactive protein (CRP) elevations. Glucocorticoids were effective for OP in all patients who received them. Relapse occurred in 4 of 19 cases.

Conclusions: OP develops in approximately 4% of RA patients, which occurs independently from arthritis activity and at any time in RA patients.