Psychometric evaluation of the Moroccan version of the Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for use in patients with ankylosing spondylitis

The objectives of this study are to translate, adapt in the Moroccan cultural context, and validate in patients with ankylosing spondylitis (AS) the Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The cross-cultural adaptation of the BASFI and BASDAI was obtained in accordance with the guidelines for translation of the health status measures. Eighty-five patients with AS were included in the study. The test–retest reliability and the internal consistency were analyzed, and both questionnaires were assessed for external construct validity. Structural validity was analyzed with correlation matrix. Twenty-four-hour test–retest reliability was good: BASFI intraclass correlation coefficient (ICC) = 0.96 (confidence interval (CI) at 95%, 0.93–0.97), BASDAI ICC = 0.93 (CI at 95%, 0.90–0.95). Cronbach’s alpha was 0.90 for the BASFI and 0.86 for BASDAI. The construct validity of the instruments was evaluated. The BASFI showed a strong validity when correlating its results with Schober’s test (r = −0.56), occipital wall distance (r = 0.46), chest expansion (r = −0.46), BASDAI (r = 0.54), Bath Ankylosing Spondylitis Metrology Index (r = 0.70), Bath Ankylosing Spondylitis Global Score (BAS-G; r = 0.58), Bath Ankylosing Spondylitis Radiology Index (r = 0.61), and the radiological changes in sacroiliac joints (r = 0.54). A good correlation was observed between the BASDAI and the spinal pain (r = 0.53), the number of nocturnal awakenings (r = 0.57), the morning stiffness (r = 0.65), the enthesic index (r = 0.47), the BAS-G (r = 0.53), the BASFI (r = 0.54), and the erythrocyte sedimentation rate (r = 0.41; for all p < 0.001). The correlation matrix showed an intermediate correlation between items. The Moroccan version of the BASFI and the BASDAI showed adequate reliability and validity. These instruments can be used in the clinical evaluation of Moroccan and Arabic-speaking patients with AS.     

DNA Ploidy Status and Prognosis in Colorectal Cancer: A Meta-Analysis of Published Data

Purpose In colorectal cancer, the negative effect of aneuploidy has been a controversy for more than 20 years. Studies to determine a survival-deoxyribonucleic acid content relationship have conflicting results. A systematic literature search followed by a meta-analysis of published studies addressing prognostic effect of aneuploidy for patients who underwent surgical treatment of colon and rectal cancer was conducted. Methods The main outcome measure was the five-year overall mortality rate after surgical resection. For the selected studies, we estimated this outcome for three subsets of patients through separate meta-analyses: 1) for all patients with colorectal cancer; 2) only between patients with Stage II colon cancer; and 3) only for studies in which follow-up losses were declared. The presence of publication bias was assessed with a funnel plot for asymmetry. Results A total of 5,478 patients with colorectal cancer were represented in 32 studies (Group 1), we estimated a reduction in the five-year overall mortality from 43.2 percent for aneuploid tumors to 29.2 percent for diploid tumors (combined relative risk = 1.44; 95 percent confidence interval = 1.34–1.55; P < 0.001). In addition, 357 patients with Stage II colon cancer (Group 2) extracted from three studies had an absolute reduction of 14.3 percent in five-year overall mortality favoring diploid tumors (combined relative risk = 1.93; 95 percent confidence interval = 1.29–2.89; P = 0.001). Lastly, of 14 studies in which follow-up losses were declared (Group 3), 2,221 patients were represented and a 15.7 percent mortality reduction was measured favoring patients with diploid tumors (combined relative risk = 1.44; 95 percent confidence interval = 1.3–1.61; P < 0.001). Conclusions Patients who undergo an aneuploid colorectal cancer surgical resection have a higher risk of death after five years. This finding may ultimately impact survival of patients with node-negative colon cancer through adjuvant therapy. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.     

Power Doppler ultrasonography is useful for assessing disease activity and predicting joint destruction in rheumatoid arthritis patients receiving tocilizumab—preliminary data

To evaluate the responsiveness of power Doppler ultrasonography (PDUS) in comparison with conventional measures of disease activity and structural damage in rheumatoid arthritis (RA) patients receiving tocilizumab (TCZ). Seven RA patients with active arthritis were enrolled in the study and prospectively monitored for 12 months. They were treated with TCZ (8 mg/kg) every 4 weeks as monotherapy or in combination with disease-modifying antirheumatic drugs (DMARDs). Clinical, laboratory, and ultrasound examinations were conducted at baseline, 1, 3, 6, 9, and 12 months. Power Doppler (PD) signals were graded from 0 to 3 in 24 joints, and total PD score was calculated as the sum of scores of individual joints. One-year radiographic progression of the hands was estimated by using Genant-modified Sharp scoring. The averages of the clinical parameters rapidly improved, and all patients achieved good response within 6 months based on standard 28-joint Disease Activity Score (DAS28). Although the average total PD score declined in parallel with clinical improvement, radiography of the hands showed progression of destruction in the joints where PD signals remained, even among clinical responders. ΔSharp score correlated with the time-integrated value (TIV) of total PD scores (Δtotal Sharp score: r = 0.77, P = 0.04; Δerosion: r = 0.78, P = 0.04; Δjoint-space narrowing (JSN): r = 0.75, P = 0.05), but not with TIVs of clinical parameters including DAS28. PDUS can independently evaluate disease activity in RA patients receiving TCZ and is superior to DAS28, especially in predicting joint destruction.     

Galectin-3 gene (<Emphasis Type="Italic">LGALS3</Emphasis>) +292C allele is a genetic predisposition factor for rheumatoid arthritis in Taiwan

Galectin-3 is a beta-galactoside-binding lectin which is involved in modulating inflammation and apoptosis. Elevated expression of galectin-3 has been demonstrated in synovium of rheumatoid arthritis (RA). The aim of our study is to investigate the genetic polymorphisms of galectin-3 in association with RA. Polymorphisms of galectin-3 gene (LGALS3) were compared between 151 RA patients and 182 healthy subjects in Taiwan. Variants at two LGALS3 single nucleotide polymorphism (SNP) sites (rs4644 and rs4652, corresponding to LAGLS3 +191 and +292) were genotyped by polymerase chain reaction (PCR) followed by restriction fragment length polymorphism (RFLP) and sequence-specific oligonucleotide probe hybridization, respectively. The allelic carriage of LGALS3 +292C was increased in patients with RA (66.9% in RA vs. 52.7% in controls, odds ratio = 1.8, 95% confidence interval = 1.2–2.8, p = 0.009). These results implicate that the genetic polymorphisms in galectin-3 gene may contribute to development of RA.     

Association of interferon-gamma gene polymorphism (+874A) with arthritis manifestation in SLE

Systemic lupus erythematosus (SLE) is a complex autoimmune disease in which genetic factors strongly influence susceptibility. Cytokines such as the interferon-gamma (IFNG) gene play a key role in controlling the immunity and inflammation, and therefore their polymorphisms may affect these genes’ expression levels among individuals. We investigated the frequency of IFNG gene intron (+874) polymorphism, previously reported to be associated with IFNG production, in SLE patients compared to a control group. This population-based case–control study includes 154 SLE patients and 154 healthy control subjects with similar ethnic backgrounds. The genotyping was determined by polymerase chain reaction sequence-specific primer method and using the Chi-squared test for analyzing the association between this single-nucleotide polymorphism and SLE. The allele frequencies of the IFNG (+874) gene polymorphism were not significantly different between SLE patients and control subjects (72.7 vs 77%). However, there was a significant association between A dominance model of inheritance with arthritis (odds ratio = 7.64, 95% confidence interval = 1.56–41.64, P = 0.006, P _c = 0.03). The result suggested that the +874 intron polymorphism of IFNG can be used as the marker for SLE susceptibility with arthritis in the Thai population.     

The continuous measurement of anti-CCP-antibodies does not help to evaluate the disease activity in anti-CCP-antibody-positive patients with rheumatoid arthritis

Anti-cyclic citrullinated peptide antibody (CCP-AB) are used for diagnosis of rheumatoid arthritis (RA). It is still unknown if the extent of CCP-AB levels is useful to assess the disease activity or the individual follow-up as an individual activity parameter. We investigated 40 patients with a known RA who were positive for CCP-AB. Correlation between disease activity (DAS 28) and the amount of levels of CCP-AB in all patients over time as well as the individual follow-up were analysed. A weak correlation between CCP-AB and DAS 28 [r = 0.19; p = 0.001] was found. The individual correlation between CCP-AB titre and DAS 28 ranged between r = −1 and r = 1, so a strong positive and also a strong negative correlation was seen in single patients. In patients with erosive RA the correlation was significantly more positive than in patients with non-erosive RA. Because the correlation between CCP-AB levels and parameters of disease activity measured by DAS 28 is very low, we conclude for monitoring the disease activity to use simply and established parameters like morning stiffness, HAQ or ESR. The individual follow-up of the levels of CCP-AB is by the moment not useful for monitoring the disease activity.     

Prevalence of overweight in Moroccan patients with rheumatoid arthritis and its relationships with disease features

We aimed to estimate the prevalence of overweight in Moroccan patients with rheumatoid arthritis (RA) and its relationships with disease activity, functional disability, structural damage, and immunological status. Two hundred fifty patients with RA were consecutively included. Patients’ characteristics were specified. The following data were collected: age, disease duration, disease activity (evaluated with physical examination data, biological tests (erythrocyte sedimentation rate and C-reactive protein), and the disease activity score (DAS28)), radiographic changes (assessed by the Sharp’s method), functional disability (assessed by using the Health Assessment Questionnaire), extra-articular manifestations, immunological status, and treatment details. Overweight was defined according to the body mass index (BMI) values: underweight, <18.5; normal weight, 18.5–24.9; overweight, 25–29.9; and obesity, ≥30. The mean age of patients was 46.31 ± 12.64 years. The mean disease duration was 9.46 ± 8.43 years. Seventy-five patients (30%) were overweight, 42 (16.8%) were obese, and 133 (53.2%) were normal. Increased BMI was associated with the activity of disease (DAS28) (r = 0.426), structural damage (Sharp total score) (r = 0.297), the rate of rheumatoid factor (r = 0.311), and with the rate of anti-cyclic citrullinated protein antibodies (for all p ≤ 0.01). There were no statistically significant differences in BMI according to gender, dose and duration of corticosteroids, or functional impairment. In our sample, overweight seems to be prevalent in our RA patients. Overweight seems to occur independently of treatment and shown to be mainly associated to disease activity, structural damage, and immunological status. Large studies are needed to confirm those results.     

Development and validation of handy rheumatoid activity score with 38 joints (HRAS38) in rheumatoid arthritis patients receiving infliximab

The parameters involved in the Disease Activity Score of 28 joints (DAS28) are not mutually independent, and the evaluation excludes ankle and foot joints. We developed a new quantitative and comprehensive assessment of the activity of rheumatoid arthritis (RA), called the handy rheumatoid activity score, with 38 joints (HRAS38), to overcome these disadvantages of DAS28. Forty-six RA patients who recently completed a 1-year infliximab therapy were evaluated for DAS28 (C-reactive protein; CRP) and HRAS38 at 0, 2, 6, 14, 22, 30, 38, 46, and 54 weeks. The 38-joint evaluation in HRAS38 includes 28 joints of DAS28 except for the shoulder joints, with the addition of ankle and metatarsophalangeal joints. The extent of joint swelling was rated on a scale of 0–3. The HRAS38 score is the cumulative sum of three parameters including: (1) a global assessment of disease activity [visual analog scale (VAS) 0–100 mm] by the patient, (2) swollen joint score based on a 38-joint assessment by a physician (0–114), and (3) serum concentration of CRP (mg/l). Scatter plots of HRAS38 and DAS28(CRP), and subsequent linear regression analysis demonstrated a statistically significant correlation between methodologies (r = 0.846, P < 0.0001). Infliximab treatment resulted in a statistically significant (P < 0.001) decrease in the mean HRAS38 score from 130.5 to 56.5 within 2 weeks of treatment and at 52 weeks of therapy scores were still reduced at 52.5. The mean DAS28(CRP) was also significantly (P < 0.001) reduced from a baseline value of 5.8 to 3.7 after 2 weeks treatment with a final value of 3.2 after 52 weeks of therapy. Infliximab reduced the progression of joint destruction by 85%, for terms before infliximab as determined by radiographic analyses. The degree of progression appeared to be associated with the mean HRAS38, although this observation was not shown to be statistically significant by regression analysis (r = 0.307). The HRAS38 score comprises minimal and independently acquired parameters and is an effective and comprehensive measure of disease activity in RA patients.     

Reliability and validity studies of the Turkish version of the Epworth Sleepiness Scale

The Epworth Sleepiness Scale (ESS) is a self-administered eight-item questionnaire that is widely used in English speaking countries for assessment of daytime sleepiness in adults. The aim of this study was to investigate the reliability and validity of the ESS in the Turkish language. The Turkish version of the ESS (ESStr) was applied to 194 healthy controls and 150 consecutive subjects attending the sleep centre with symptoms of sleep-disordered breathing. Test–retest reliability of the ESStr was tested in a separate group of 30 subjects. The ESStr scores of 60 subjects with mild to severe obstructive sleep apnoea (OSA) were compared with the ESStr scores of 60 healthy controls matched for age, gender, and body mass index (BMI). Concurrent validity with the Functional Outcomes of Sleep Questionnaire (FOSQtr) was also assessed in 12 subjects. The questionnaire had a high level of internal consistency as measured by Cronbach’s alpha (≥0.86). The test–retest intraclass correlation coefficient was r  = 0.81 (95% confidence interval: 0.64–0.90) (p < 0.001) and Spearman’s correlation coefficient was r = 0.80 (p = 0.01). The control group had lower ESStr scores than subjects with sleep-disordered breathing (3.6 ± 3 vs 12.6 ± 6, respectively; p < 0.001). Subjects with mild sleep-disordered breathing also had lower scores of the ESStr than those with moderate and severe sleep-disordered breathing (10 ± 6.2 vs 14 ± 5. and 10 ± 6.2 vs 16 ± 5.4, respectively; both p < 0.05), but there were no significant differences between moderate and severe subjects with sleep apnoea. There were significant correlations between the ESStr and total FOSQtr and its subscales (r  = −0.22 to r = −0.92; all p  = 0.05). Factor analysis of item scores showed that the ESStr had only one factor. The ESStr is a reliable and valid measure of daytime sleepiness. These features and the simplicity of the ESStr make it a valuable measure for clinical management and research.     

Evaluating the association of common LMNA variants with type 2 diabetes and quantitative metabolic phenotypes in French Europids

Aims/hypothesis In the present study, we sought to examine the evidence that LMNA variants are associated with type 2 diabetes and quantitative metabolic traits in French Europid individuals. Methods We genotyped 24 single nucleotide polymorphisms (SNPs) spanning the LMNA gene in 3,093 case–control participants. The association between LMNA SNPs and quantitative metabolic traits was also examined in the 1,674 normoglycaemic adults who made up the control cohort. Results SNP rs505058, a synonymous SNP (D446D) in exon 7, showed nominal evidence of association with type 2 diabetes [p = 0.003, odds ratio (OR) 1.30 (95% CI 1.09–1.56)] in French Europids. A meta-analysis of available rs505058 genotype data from 7,819 participants provided support for a modest association of rs505058 with type 2 diabetes [p = 0.003, OR 1.19 (95% CI 1.06–1.35)]. We found no evidence (p = 0.91) that the tag SNP rs4641 is associated with type 2 diabetes. However, a meta-analysis of all available rs4641 genotype data in a total of 15,591 participants produced borderline evidence of association [p = 0.054, OR 1.05 (95% CI 1.00–1.11)]. SNP rs6669212, in the 3′ untranslated region of LMNA, exhibited suggestive associations with WHR (p = 0.013), fasting serum levels of total cholesterol (p = 0.023) and triacylglycerol (p = 0.015). We emphasise that these quantitative trait associations are not corrected for multiple testing. Conclusions/interpretation The available data do not support a major effect of common LMNA variation on type 2 diabetes susceptibility in northern Europeans. Further large-scale studies are required to conclusively establish the extent to which LMNA variants have an impact on quantitative metabolic traits. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorised users.     

High prevalence of low plasma thiamine concentration in diabetes linked to a marker of vascular disease

Aims/hypothesis To assess thiamine status by analysis of plasma, erythrocytes and urine in type 1 and type 2 diabetic patients and links to markers of vascular dysfunction. Methods Diabetic patients (26 type 1 and 48 type 2) with and without microalbuminuria and 20 normal healthy control volunteers were recruited. Erythrocyte activity of transketolase, the concentrations of thiamine and related phosphorylated metabolites in plasma, erythrocytes and urine, and markers of metabolic control and vascular dysfunction were determined. Results Plasma thiamine concentration was decreased 76% in type 1 diabetic patients and 75% in type 2 diabetic patients: normal volunteers 64.1 (95% CI 58.5–69.7) nmol/l, type 1 diabetes 15.3 (95% CI 11.5–19.1) nmol/l, p < 0.001, and type 2 diabetes 16.3 (95% CI 13.0–9.6) nmol/l, p < 0.001. Renal clearance of thiamine was increased 24-fold in type 1 diabetic patients and 16-fold in type 2 diabetic patients. Plasma thiamine concentration correlated negatively with renal clearance of thiamine (r = −0.531, p < 0.001) and fractional excretion of thiamine (r = −0.616, p < 0.001). Erythrocyte transketolase activity correlated negatively with urinary albumin excretion (r = −0.232, p < 0.05). Thiamine transporter protein contents of erythrocyte membranes of type 1 and type 2 diabetic patients were increased. Plasma thiamine concentration and urinary excretion of thiamine correlated negatively with soluble vascular adhesion molecule-1 (r = −0.246, p < 0.05, and −0.311, p < 0.01, respectively). Conclusions/interpretation Low plasma thiamine concentration is prevalent in patients with type 1 and type 2 diabetes, associated with increased thiamine clearance. The conventional assessment of thiamine status was masked by increased thiamine transporter content of erythrocytes.     

Developmental changes of oxalate excretion in enterally fed preterm infants

Summary  To further substantiate gestational age-related changes in oxalate excretion, we studied urinary oxalate excretion in 66 preterm infants born at 23.4–34.7 weeks of gestation. Spot urine of 66 preterm infants was analysed by ion chromatography as soon as they were completely orally fed with enriched breast milk and/or special preterm milk formula (days 7 to 57 of postnatal life). Infants with evidence of renal, gastrointestinal, muscular or metabolic disease were not included. Newborns on parenteral nutrition were excluded. Oxalate/creatinine ratios (Ox/Cr) decreased with gestational age (three age groups: group 1, 23 0/7–28 0/7; group 2, 28 1/7–32 0/7; and group 3, 32 1/7–35 0/7 weeks of gestation). The mean Ox/Cr was highest in group 1 (398.2 mmol/mol ± 116.8; n = 21). Differences between groups 1 + 3 were statistically significant; p = 0.001; those between groups 1 + 2 and between groups 2 + 3 were not. Ox/Cr correlated inversely with gestational and maturational age (r = −0.41, p = 0.001; r = −0.33, p = 0.007) and positively with postnatal age (r = 0.32, p = 0.008). It correlated inversely with birth weight as well as actual weight at sample collection (r = −0.46 and −0.44, p < 0.001). Ox/Cr was significantly linked to energy and carbohydrate intake (r = 0.3 and 0.4, p = 0.03 and 0.001). These results were independent of sex. In the present study we show that urinary oxalate excretion in preterm infants depends on gestational age. Competing interests: None declared The authors B. Bohnhorst and A. M. Das contributed equally.     

Relationship between Retrograde Coronary Blood Flow and the Extent of No-Reflow and Infarct Size in a Porcine Ischemia–Reperfusion Model

Recanalization of an infarct-related artery does not predictably reflect tissue reperfusion. We examined the relationship between coronary blood flow (CBF) pattern during reperfusion and infarcted (IA) and no-reflow (NR) area in a porcine ischemia–reperfusion model. The mid-left anterior descending artery of 18 pigs was occluded for 1 h and reperfused for 2 h. CBF during reperfusion was measured with a transit-time ultrasound flowmeter, while systemic arterial and left atrial pressures were monitored. IA and NR were measured with triphenyl tetrazolium chloride and thioflavin staining, respectively. In 13 pigs, early systolic retrograde CBF developed within the first 30 min and persisted throughout reperfusion. No retrograde CBF was observed in five pigs. Mean retrograde CBF at 2 h of reperfusion predicted a larger IA (r = 0.71; p = 0.001). Time-to-development of retrograde CBF was inversely related to IA (r = −0.55; p = 0.019) and NR (r = −0.62; p = 0.006). A larger IA (OR 1.12, 95% CI 1.01–1.24, p = 0.037) and NR (OR 1.09, 95% CI 1.01–1.18, p = 0.037) predicted the presence of retrograde CBF. Retrograde CBF during recanalization of the infarct-related artery predicts IA and NR and might be used as an index of successful reperfusion at the tissue level.     

Haemoglobin levels are associated with bone mineral density in the elderly: a population-based study

Hypoxemia has been associated with low bone mineral density (BMD) in animal and human models. We assessed the association of haemoglobin levels with ultrasound-derived (UD) T score, Z score and the stiffness index in all 358 subjects aged 75+ living in Tuscania (Italy). Also, we searched for the haemoglobin cutoff levels that might best identify participants with osteoporosis. In the multivariable linear regression analysis, haemoglobin levels were associated among participants with the UD T score [β = 0.13; 95% confidence interval (CI) = 0.01–0.25; p = 0.030], Z score (β = 0.11; 95% CI = 0.01–0.22; p = 0.045) and stiffness index (β = 1.87; 95% CI = 0.51–3.21; p = 0.007) after adjusting for potential confounders. Haemoglobin levels <140 g/L in men and <130 g/L in women best predicted osteoporosis in linear discriminant analysis. Haemoglobin is independently associated with all UD-BMD parameters. Haemoglobin levels <140 g/L in men and 130 g/L in women might be adopted in clinical practice to identify older subjects in whom screening for osteoporosis might yield higher effectiveness.     

The relation of serum vascular endothelial growth factor level with disease duration and activity in patients with rheumatoid arthritis

Vascular endothelial growth factor (VEGF) is known to be involved in the pathogenesis of rheumatoid arthritis (RA). In order to elucidate the association between VEGF levels and RA disease activity, VEGF concentrations were measured in RA patients at different phases and severity levels. Thirty-eight healthy subjects and 40 patients with RA were prospectively included in the study. Subjects were further categorized into four subgroups (high, moderate, low, or remission) using the disease activity score-28 (DAS28) scoring system. VEGF levels were significantly higher in patients than controls (p < 0.001). VEGF levels differed significantly in controls, early and late-phase RA patients (p = 0.002). A significant difference was found between controls and patients with high RA disease activity scores (p < 0.0001). VEGF levels were not correlated with age (r = −0.016; p = 0.921) or sex (r = 0.209; p = 0.921). VEGF values were correlated with erythrocyte sedimentation rate (r = 0.445; p = 0.004), but was not correlated with serum rheumatoid factor levels (r = −0.130; p = 0.424) in the patient group. In conclusion, higher VEGF levels are associated with late phase and high disease activity in RA, independent of age and sex.     

Radiological and orthopedic score in pediatric hemophilic patients with early and late prophylaxis

 In order to evaluate joint alteration, 17 patients with hemophilia A and B were investigated over a period of 4 years (1993–1997). Patients were subdivided into two groups, according to therapy regimens. In group 1 (n=10) prophylactic treatment was initiated until the third year of life. In group 2 (n=7) patients received prophylactic treatment at the age of 5 years and above. To assess alterations in knee, elbow, and ankle joints, the radiological score and the physical examination score of the Orthopedic Advisory Committee of the World Federation of Hemophilia were used. The sum of the scores of these six joints was defined as the patient-dependent score. Patients of group 1 (median age at the end of observation: 10 years) reached a median radiological score of 1.0 (range: 0–13) and an orthopedic score of 0 (range: 0–4), whereas patients of group 2 (median age: 14 years) had a radiological score of 20 (range: 2–47) and an orthopedic score of 8 (range: 0–12), which shows a significant difference (p<0.01). In both treatment groups a manifestation or progression of arthropathic alteration was seen in those children who had repeated joint bleeding (>5) prior to the onset of prophylactic treatment (r=0.90, p>0.01). Altogether, two of 60 joints in group 1 and 12 of 42 joints in group 2 had a radiological score ≥4. Elbow joints were more often affected than knee and ankle joints. In conclusion, the number of joint bleedings before prophylactic treatment was started influenced the progression of arthropathy even in patients with early onset of prophylaxis. The aim of treatment in severe hemophilia should be early prophylaxis before repeated joint bleeding occurs in order to prevent osteoarthropathic alteration. Received: April 21, 1998 / Accepted: July 2, 1998     

Rheumatoid factor and antibodies against citrullinated peptides in Moroccan patients with rheumatoid arthritis: association with disease parameters and quality of life

We aimed to evaluate the immunological status and its relationships with disease-related parameters of activity, severity and quality of life in Moroccan patients with rheumatoid arthritis (RA). Two hundred forty-five consecutive patients with RA were recruited. The following data were collected: demographic characteristics, disease duration (years), disease activity (evaluated by the disease activity score, DAS28), structural damage (evaluated by Sharp's method as modified by van der Heijde), functional disability (assessed by using the Moroccan version of the Health Assessment Questionnaire, HAQ) and quality of life (by using the Arabic version of the Medical Outcomes Study Short Form 36 Health Survey: the SF-36). Immunological status (rheumatoid factor rate, RF) and antibodies against citrullinated peptides rate (ACPAs) by the Elisa method were examined. ACPAs were detected in 75.1% of patients with a mean rate of 79.2 ± 43.8 UI. RF was detected in 80.8% of patients with a mean rate of 80.1 ± 50.6 UI. Patients with positive RF and ACPAs had higher disease activity, impaired functional ability, severe structural damage, more ocular symptoms and altered aspects of quality of life. In univariate analysis, higher levels of ACPAs were significantly correlated with the age at onset (r = 0.307), disease duration (r = 0.520), disease activity (DAS28) (r = 0.531), Sharp score (r = 0.431), and with the deterioration of all domains of SF-36 (for all p ≤ 0.01). RF levels were correlated with disease duration (r = 0.517), disease activity (r = 0.470), functional disability (r = 0.521), and the alteration of physical domains of SF-36 (for all p ≤ 0.01). In multivariate analysis, the main factors associated to ACPAs and RF levels were functional disability, structural damage and impaired QoL. Furthermore, using the SF-36 scores as dependent variables, the impairment of physical domains and the domain of vitality were significantly associated with ACPA levels while the decrease of the domain of physical function was associated with the level of RF. Our study suggests that the presence and the levels of ACPAs and RF in our RA patients are associated with more active disease, more severe joint damage, worst functional disability and altered aspects of quality of life.     

Health Care Utilization and Costs Associated with Childhood Abuse

Background Physical and sexual childhood abuse is associated with poor health across the lifespan. However, the association between these types of abuse and actual health care use and costs over the long run has not been documented. Objective To examine long-term health care utilization and costs associated with physical, sexual, or both physical and sexual childhood abuse. Design Retrospective cohort. Participants Three thousand three hundred thirty-three women (mean age, 47 years) randomly selected from the membership files of a large integrated health care delivery system. Measurements Automated annual health care utilization and costs were assembled over an average of 7.4 years for women with physical only, sexual only, or both physical and sexual childhood abuse (as reported in a telephone survey), and for women without these abuse histories (reference group). Results Significantly higher annual health care use and costs were observed for women with a child abuse history compared to women without comparable abuse histories. The most pronounced use and costs were observed for women with a history of both physical and sexual child abuse. Women with both abuse types had higher annual mental health (relative risk [RR] = 2.07; 95% confidence interval [95%CI] = 1.67–2.57); emergency department (RR = 1.86; 95%CI = 1.47–2.35); hospital outpatient (RR = 1.35 = 95%CI = 1.10–1.65); pharmacy (incident rate ratio [IRR] = 1.57; 95%CI = 1.33–1.86); primary care (IRR = 1.41; 95%CI = 1.28–1.56); and specialty care use (IRR = 1.32; 95%CI = 1.13–1.54). Total adjusted annual health care costs were 36% higher for women with both abuse types, 22% higher for women with physical abuse only, and 16% higher for women with sexual abuse only. Conclusions Child abuse is associated with long-term elevated health care use and costs, particularly for women who suffer both physical and sexual abuse.     

The predictors of foot ulceration in patients with rheumatoid arthritis: a preliminary investigation

We explored the predictors of foot ulceration in patients with rheumatoid arthritis (RA). The cases were 15 patients with RA reporting foot ulceration in response to a postal survey of patients sampled from a diagnostic register in secondary care (n = 1,130). The controls were 66 patients with RA randomly sampled from the survey respondents (n = 883) after matching for age, sex and disease duration. Patients with co-existent diabetes were excluded. Clinical examination included the assessment of known risk factors for foot ulceration in diabetes including: neuropathy (insensitivity to 10 g monofilament), peripheral vascular disease (ankle brachial pressure index [ABPI]), foot deformity (Platto indices) and raised plantar pressure (PressureStat™ readings). A 44 swollen-joint count, the presence of pre-ulcerative lesions and current steroid therapy were identified through univariate analysis as additional potential predictors in patients with RA. Forward step-wise logistic regression analysis showed that the following variables were significant predictors of ulceration: steroid therapy (OR = 9.70, 95%CI = 2.09–45.11, p = 0.004), abnormal ABPI (OR = 13.45, 95%CI = 1.19–151.43, p = 0.035), the presence of pre-ulcerative lesions (OR = 7.40, 95%CI = 1.51–36.30, p = 0.014) and swollen-joint count (OR = 1.25, 95%CI = 1.02–1.53, p = 0.034). Abnormal sensation, foot deformity and raised plantar pressures were not significant predictors of ulceration. The wide confidence intervals for ABPI were due to sparse data with very few abnormal values, and the results of exact logistic regression (more accurate where data is sparse and case matching employed) found that ABPI was no longer a significant predictor (p = 0.054). The significance of the other predictors did not differ substantially. In this preliminary study, abnormal sensation, foot deformity and raised plantar pressures were not significantly associated with foot ulceration but active disease and current steroid therapy were. The contribution of peripheral vascular disease to risk is unclear and further investigation is needed in a larger cohort.