Autoantibodies to cyclic citrullinated peptide 2 (CCP2) are superior to other potential diagnostic biomarkers for predicting rheumatoid arthritis in early undifferentiated arthritis

We evaluated the diagnostic value of anti-cyclic citrullinated peptide 2 (anti-CCP2) antibodies and other potential diagnostic biomarkers (IgM rheumatoid factor, anti-agalactosyl IgG antibodies, matrix metalloproteinase 3, C-reactive protein) for predicting early development of rheumatoid arthritis (RA). Patients were defined as having recent-onset undifferentiated arthritis (UA) if they had developed arthritis in two or more joints within the previous 2 years and could not be classified with a well-defined arthropathy. Baseline levels of biomarkers were measured in blood samples collected at the entry of the study and the patients were followed for 1 year to monitor development of RA. Diagnoses of RA and non-RA arthropathies were made according to individual standard diagnostic criteria. A total of 146 patients were enrolled in the study. In the follow-up year, 18 patients developed RA, 54 developed non-RA arthropathies, and 60 remained in the UA category. The sensitivity and specificity of the presence of anti-CCP2 antibodies for the diagnosis of RA were 83.3 and 93.0%, respectively. The positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of anti-CCP2 antibodies for RA (65.2, 97.2, and 91.7%, respectively) were higher than for any other biomarker. Combination of anti-CCP2 with any other biomarker only slightly improved each diagnostic value compared to the presence of anti-CCP2 alone. Among the anti-CCP2-positive patients, the average titer was significantly higher in those with RA than in non-RA or UA patients (163.7 +/- 138.4 vs 55.2 +/- 72.0 U/ml, p = 0.017). Anti-CCP2 antibodies are superior to any other single biomarker for predicting early development of RA in patients with recent-onset UA and the diagnostic value of anti-CCP2 alone is similar to that for biomarker combinations. Moreover, the anti-CCP2 antibody titer is useful to discriminate between patients at high risk for early developing RA from those at risk of developing non-RA arthropathies.     

Physical activity coaching of patients with rheumatoid arthritis in everyday practice: a long-term follow-up

Objectives. To investigate the long‐term effects on perceived general health, disease activity, pain, activity limitation and cognitive behavioural factors of a one‐year coaching programme performed in ordinary physical therapy practice to promote the adoption of health‐enhancing physical activity in patients with early rheumatoid arthritis (RA). Methods. A total of 228 patients with early RA, from 10 rheumatology clinics in Sweden, were randomly assigned to an intervention group (IG; n = 94) or a control group (CG; n = 134). The IG was coached by physical therapists during the first year to adopt health‐enhancing levels of physical activity (30 minutes/day, moderately intensive, ≥4 days/week). No coaching was given during the subsequent year between post‐intervention and follow‐up. Follow‐up assessment consisted of a postal questionnaire on physical activity and of visual analogue scales for ratings of general health perception and pain. The Health Assessment Questionnaire Disability Index (HAQ) and the Disease Activity Score in 28 joints (DAS 28) were collected at regular medical check‐ups. Results. Sixty‐five (69%) participants in the IG and 92 (69%) in the CG completed the entire study period by filling in the follow‐up questionnaire on physical activity two years after baseline. The intervention seemed to lack any significant influence on long‐term outcome. However, different patterns of change in physical activity behaviour were observed in the two groups. Conclusions. No long‐term improvement in perceived general health or other outcomes were found in the follow‐up. This may partly be because the intervention lacked several important behavioural elements for physical activity maintenance. Copyright © 2011 John Wiley & Sons, Ltd.     

Personalized diet and exercise recommendations in early rheumatoid arthritis: A feasibility trial

Background

Physical activity and diet have a positive influence on disease activity and cardiovascular risk in patients with rheumatoid arthritis (RA).

Objective

We tested the feasibility and effect of a brief individualized counselling intervention on physical activity levels and fitness, and dietary intake, compared with standard of care.

Methods

Thirty patients with inflammatory arthritis (<1 year duration) were assigned to standard of care or the intervention, which consisted of individualized visits with a dietetic intern and physiotherapist at two time points, to review age‐specific strategies on diet and exercise. Primary outcomes included anthropometric measurements (height, weight, waist and hip circumference), nutritional intake, physical activity (pedometer steps) and physical fitness. Disease activity measures and biochemical testing (blood pressure measurement, inflammatory markers, cholesterol profile and random glucose) were collected. The changes in these outcomes from baseline to 6 months were assessed using paired t‐tests between groups.

Results

Thirteen patients in the intervention group and 10 in the control group completed the study. There were non‐significant trends in improvements in physical activity, low‐density lipoprotein cholesterol level and nutritional intake (vitamin C, iron, fibre, vitamin A and folate) in the intervention group.

Conclusions

Poor enrolment and high dropout rates in this short‐term study highlighted the difficulty of behavioural change. Those continuing in the study and who received the intervention demonstrated a non‐significantly improved activity level and nutritional intake that may benefit long‐term outcomes.     

Imaging in early arthritis

Imaging can play a vital role in the evaluation of patients with early arthritis. Various imaging methods can be utilized to aid with diagnosis, predict prognosis and follow disease progression and treatment response. Previously, conventional radiography was the principal method used to evaluate and follow bone damage in patients with inflammatory arthritis. More recently the use of magnetic resonance imaging and ultrasonography has gained wider acceptance and popularity due to the ability of these multiplanar techniques to image both bone changes and soft tissue abnormalities, including synovitis. This chapter discusses the current imaging modalities used in the evaluation of patients with early arthritis, as well as the use of imaging in establishing the extent of disease, in prognosis and in monitoring disease course. Current data on imaging of patients with early arthritis due to rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis is reviewed.     

类风湿性关节炎血脂异常影响因素研究进展

类风湿性关节炎(rheumatoid arthritis,RA)是由人体免疫系统受损而导致的疾病,主要表现为对称性多关节炎症,其发病机制目前尚不明确。RA发病过程中,其病程发展可能会因细胞因子及炎症介质的异常表达而受到影响,炎症程度及发病范围取决于致炎细胞因子与抗炎细胞因子间的失衡程度。     

类风湿关节炎患者抗环瓜氨酸肽抗体与人类白细胞抗原-DR4等位基因相关性研究

目的 研究类风湿关节炎(RA)及未分类关节炎(痛)(UA)患者抗环瓜氨酸肽(CCP)抗体与人类白细胞抗原(HLA)-DR4等位基因相关性.方法 对91例RA患者,46例UA患者,35名健康志愿者,均为浙江汉族人,应用酶联免疫吸附试验(ELISA)法检测血清抗CCP抗体,序列特异性引物聚合酶链反应(PCR-SSP)检测HLA-DR4等位基因.结果 RA组、UA组HLA-DR4阳性率分别为47.2%、45.6%,均以DRB1*0405为主,分别为25.3%、23.9%.RA组、UA组患者的抗CCP抗体与HLA-DR4具有相关性(r=613,0.703,P＜0.01).与HLA-DRB1*0405具有弱相关性(r=0.304,P＜0.01;r=0.333,P＜0.05). 2组HLA-DR4阳性患者抗CCP抗体水平明显高于HLA-DR4阴性患者,差异有统计学意义(P＜0.01).抗CCP抗体、HLA-DR4均阳性患者红细胞沉降率(ESR)、C反应蛋白(CRP)、血小板水平明显升高,晨僵时间延长,关节肿胀度积分升高,与二者阴性患者比较,差异有统计学意义(P＜0.05或P＜0.01).对UA组患者3个月后随访,抗CCP抗体、HLA-DR4在早期RA的阳性率为94.7%(18/19).结论 抗CCP抗体与HLADR4、DRB1*0405相关;抗CCP抗体、HLA-DR4均阳性反映了RA病情活动性;联合检测抗CCP抗体、HLA-DR4或DRB1*0405有助于RA早期诊断;抗CCP抗体可能在HLA-DR4等遗传因素参与下介导了RA发病.     

Pathologic acromioclavicular and sternoclavicular manifestations in rheumatoid arthritis,spondyloarthropathy and calcium phosphosphate deposition disease

Aim: To assess if acromioclavicular and sternoclavicular joint findings share specificity with those of peripheral joints for distinguishing among the major forms of erosive arthritis. Methods: The clavicles from skeletons of 392 individuals with documented spondyloarthropathy, rheumatoid arthritis and calcium pyrophosphate deposition disease (CPDD) were macroscopically examined for erosion presence and character and for reactive new bone formation. Results: Examination of the bones of individuals with documented rheumatoid arthritis, spondyloarthropathy and calcium pyrophosphate deposition disease revealed specificity of acromioclavicular and sternoclavicular joint alterations for the underlying arthritis. Conclusions: Acromioclavicular and sternoclavicular erosions have equivalent diagnostic specificity to that of peripheral joints, facilitating diagnosis when erosions are not recognized in the latter. Such joint involvement was so common in individuals with other evidence of CPPD that its presence should suggest the likelihood of that diagnosis.     

Influence of long-term low-dose methotrexate therapy on periarticular and generalized osteoporosis in rheumatoid arthritis

Abstract

Our objective was to evaluate the effect of low-dose methotrexate therapy on periarticular and generalized osteopenia in patients of rheumatoid arthritis (RA). Fifty-five women received one of four therapeutic regimens. The periarticular radial bone mineral density (BMD) was analyzed by dual energy X-ray absorptiometry. Generalized osteopenia was assessed by measuring the BMD and height of the lumbar spine (L₂-L₄). Vertebral deformity was also assessed on plain Xray film. Physical activity, age and menopausal status were similar among the four treatment groups. The decrease of lumbar BMD was greatest in the group given steroids plus another disease modifying antirheumatic drug (DMARD), followed by the steroid/methotrexate group, methotrexate group and the other DMARD group. The decreases of lumbar vertebral height was greatest in the steroid/methotrexate group, followed by the steroid/DMARD group, methotrexate group and the other DMARD group. Vertebral compression was found in 22% of the steroid/methotrexate group and 14% of the steroid/DMARD group. Radial periarticular BMD was significantly lower in patients with active wrist joint synovitis than in patients without synovitis, but was increased by methotrexate therapy. We conclude that low-dose methotrexate did not increase lumbar osteopenia or vertebral compression in RA patients and might preven periarticular osteopenia by suppressing synovitis     

Influence of long-term low-dose methotrexate therapy on periarticular and generalized osteoporosis in rheumatoid arthritis

Our objective was to evaluate the effect of low-dose methotrexate therapy on periarticular and generalized osteopenia in patients of rheumatoid arthritis (RA). Fifty-five women received one of four therapeutic regimens. The periarticular radial bone mineral density (BMD) was analyzed by dual energy X-ray absorptiometry. Generalized osteopenia was assessed by measuring the BMD and height of the lumbar spine (L₂-L₄). Vertebral deformity was also assessed on plain Xray film. Physical activity, age and menopausal status were similar among the four treatment groups. The decrease of lumbar BMD was greatest in the group given steroids plus another disease modifying antirheumatic drug (DMARD), followed by the steroid/methotrexate group, methotrexate group and the other DMARD group. The decreases of lumbar vertebral height was greatest in the steroid/methotrexate group, followed by the steroid/DMARD group, methotrexate group and the other DMARD group. Vertebral compression was found in 22% of the steroid/methotrexate group and 14% of the steroid/DMARD group. Radial periarticular BMD was significantly lower in patients with active wrist joint synovitis than in patients without synovitis, but was increased by methotrexate therapy. We conclude that low-dose methotrexate did not increase lumbar osteopenia or vertebral compression in RA patients and might preven periarticular osteopenia by suppressing synovitis     

Study on sensitivity and specificity of diagnostic criteria for early rheumatoid arthritis

Sensitivity and specificity were compared among the American College of Rheumatology (ACR) 1987 classification criteria, the Yamasaki diagnostic criteria, and the Japan Rheumatism Association (JRA) diagnostic criteria for early rheumatoid arthritis (RA). The study included 90 patients who consulted our department for the first time within 1 year after onset and were suspected of having RA (final diagnosis: RA 45 cases, non-RA 45 cases). We investigated whether physical and laboratory findings at the first examination met these three sets of criteria to determine the sensitivity and specificity of each set of diagnostic criteria. Moreover, the sensitivity and specificity of each item in the diagnostic criteria set were similarly determined. The sensitivity of the ACR 1987 classification criteria, the Yamasaki diagnostic criteria, and the JRA diagnostic criteria for early RA were 71.1%, 88.9%, and 95.6%, respectively, and their specificities were 100%, 93.3%, and 77.8%, respectively. In a study on each diagnostic item, observation for 1 week was considered to be sufficient for morning stiffness, swelling in three joint areas, and symmetrical swelling, while observation for a more prolonged period seemed to be necessary for swelling of the finger and hand joints. The Yamasaki diagnostic criteria are appropriate for the diagnosis of early RA, while the JRA diagnostic criteria are suitable for screening. Received: July 13, 1999 / Accepted: May 25, 2000     

Clinical features and disease outcomes of undifferentiated arthritis in Thailand

Background: Undifferentiated arthritis (UA) comprises arthritis not yet identifiable as a specific rheumatic disease. Few reports exist on the natural course of UA in Thai patients. Objective: To study the clinical features and natural course of UA in Thai patients. Method: A retrospective, analytical study was performed among Thai patients diagnosed with UA seen at Srinagarind Hospital, Khon Kaen, Thailand, between January 2002 and December 2007. Results: The medical records of 95 UA patients were reviewed. The mean age at onset was 40.7 ± 14.7 years (range, 15–78). The female:male ratio was 1.25 : 1.00. Common presentations included asymmetrical oligoarthritis followed by polyarthritis. The knee was the most commonly affected joint, followed by the wrist and ankle. Complete remission occurred within 6 months of onset in 4.2% of cases. A diagnosis was specified in 29 patients (30.5%) during the follow‐up period (which averaged 17.1 ± 24.0 months [range, 6–84]), including reactive arthritis (in 9 patients), undifferentiated spondyloarthropathy (7), rheumatoid arthritis (6), psoriatic arthritis (4), ankylosing spondylitis (1), gout (1) and unclassified connective tissue disease (1). UA was the default diagnosis for 66 patients (69.5%) after 24 months of follow‐up. Hyperglobulinemia was correlated with persistent arthritis (i.e., > 6 months, P = 0.045). The only predictive factor for RA development was old‐age at onset (P = 0.038). Conclusion: The most common presentation of Thai UA was asymmetrical oligoarthritis and most patients had persistent arthritis correlated with hyperglobulinemia. Elderly‐onset, without any radiographic changes or rheumatoid factor, was predictive of RA development during follow‐up.     

Apsoriatic psoriatic arthritis

Numerous features distinguish psoriatic arthritis (PsA) from other arthropathies, including the presence of psoriasis, distal interphalangeal (DIP) joint involvement, nail dystrophy, enthesitis, dactylitis and spinal involvement. Two decades ago, the presence of psoriasis was mandatory in the diagnosis of PsA. Up to 15% of patients had joint disease preceding psoriasis. In this group of patients, it may have been years after the onset of arthritis before the definitive diagnosis of PsA could be made. With advancements in treatment modalities, an accurate and proper diagnosis is relevant to the management of PsA. In their case report appearing in this issue, Taniguchi and Kamatani present a case with classical PsA without skin and nail lesions for 21 years. It may not be that unusual to encounter this in clinical practice, but we think it an opportune time to review the classification criteria and illustrate how the diagnosis of PsA can be made earlier.     

Clinical and psychosocial factors associated with depression and anxiety in Singaporean patients with rheumatoid arthritis

Aim: To assess the frequency of, and factors associated with, depression and anxiety in Singaporean patients with rheumatoid arthritis (RA). Method: One hundred RA patients were recruited in a cross‐sectional study. Socio‐demographics, severity of anxiety and depression, disease activity, levels of serological markers and health‐related quality of life were analyzed. Results: Twenty‐six percent presented with anxiety, 15% with depression and 11% with both. Univariate regression showed that age (P = 0.039), Disease Activity Scale (DAS‐28) (P < 0.001), number of medications (P < 0.001) and rheumatoid factor (RF) (P < 0.001) were positively associated with severity of depression, while income (P = 0.001), education (P = 0.029), self‐perceived social support (P = 0.007), Short form 12 (SF‐12) physical health (P < 0.001) and SF‐12 mental health (P < 0.001) were negatively associated with severity of depression. After adjustment for confounding factors in multivariate regression, income (β = ?0.347, P = 0.018), RF (β = 0.304, P = 0.043) and SF‐12 mental health (β = ?0.501 P = 0.001) remained significantly associated with depression. Univariate regression showed that DAS‐28 (P = 0.009), number of medications (P = 0.004) and RF (P = 0.043) were positively associated with anxiety, while income (P = 0.022), self‐perceived social support (P = 0.04), SF‐12 physical health (P < 0.001) and SF‐12 mental health (P < 0.001) were negatively associated with anxiety. After adjustment for confounding factors, no factors remained significantly associated with anxiety. Conclusion: Low income, high levels of RF and poor mental health were associated with depression in RA. Our findings may help to formulate depression screening strategies. Further research is required to identify the role of RF in depression.