Rheumatoid arthritis: explanatory power of specific radiographic findings for patient clinical status

Radiographs of the hands and wrists of 201 patients with rheumatoid arthritis (RA) were scored for erosion, joint space narrowing, and malalignment. The explanatory power of these findings for measures of clinical status was studied with stepwise multiple linear regression analyses. Radiographic scores explained 59.2% of variation in physical joint count deformity scores, 58.5% of variation in limited motion scores, 22.5% of variation in grip strength scores, 20.5% of variation in button test scores, and 13.5% of variation for the American Rheumatism Association (ARA) Functional Class. Malalignment scores best explained variation in physical deformity, limited motion, and button test scores; joint-space-narrowing scores best explained variation in grip strength; erosion scores best explained variation in ARA Functional Class. When age, duration of disease, erythrocyte sedimentation rate, and rheumatoid factor titer were included in the regression analyses, results were similar to those without these variables. Therefore quantitative scores of specific radiographic findings are in themselves explanatory for measures of clinical status.

Quantitative pain assessment for routine care of rheumatoid arthritis patients, using a pain scale based on activities of daily living and a visual analog pain scale

Pain was assessed quantitatively as a component of routine visits of 385 outpatients with rheumatoid arthritis, using a pain scale based on activities of daily living (ADL) and a visual analog scale. The ADL pain scale met psychometric criteria for validity and reliability. Scores on the 2 pain scales were correlated significantly with one another and with other measures of disease status, including joint count, grip strength, walking time, button test, morning stiffness, erythrocyte sedimentation rate, global self-assessment, ADL difficulty, and ADL dissatisfaction scales. Correlations of ADL pain scale scores with other measures were higher than were correlations of visual analog scale scores with other measures, in both unadjusted and adjusted analyses. Significantly more patients completed the ADL pain scale without assistance than the number of those who completed the visual analog pain scale. The ADL pain scale was more sensitive to problems in ADL than were the ADL scales for difficulty and dissatisfaction. The ADL and visual analog pain scales appear to provide useful data for quantitative assessment of pain in the routine care of rheumatoid arthritis patients.

Immunologic studies of rheumatoid arthritis patients treated with methotrexate

Immunologic functions of peripheral blood mononuclear cells were studied in rheumatoid arthritis (RA) patients treated with methotrexate (MTX). Spontaneous IgM rheumatoid factor (IgM-RF) synthesis by unstimulated cultured blood mononuclear cells was seen in only 3 of 18 MTX-treated patients, compared with 31 of 54 RA patients who were not receiving long-acting drugs. Total IgM production by unstimulated cultured mononuclear cells, pokeweed mitogen-induced antibody synthesis, and plasma levels of IgM-RF were also lower in MTX-treated patients than in other RA patients. The numbers of circulating B cells, T4 and T8 cells, the T4:T8 cell ratio, and mitogen-induced proliferation indices were similar in MTX-treated and non-MTX-treated patients. Eleven additional patients were studied prospectively after initiation of MTX therapy. All showed significant decreases in spontaneous IgM-RF synthesis, with declining IgM-RF:IgM ratios, including all of the 9 who were studied during the first 24 hours of treatment. The results indicate that MTX has rapid effects on IgM-RF synthesis, and this action might be associated with its therapeutic efficacy in RA.

Questionnaire, walking time and button test measures of functional capacity as predictive markers for mortality in rheumatoid arthritis

Mortality over 9 years in rheumatoid arthritis was studied according to baseline demographic, disease, therapy and comorbidity variables, and measures of functional capacity variables. Significant differences between patients who survived and died over the next 9 years were seen for 8 variables: age, joint count, oral corticosteroid use, presence of concurrent heart disease, formal educational level, and 3 quantitative measures of functional capacity, questionnaire responses regarding activities of daily living, modified walking time and the button test. Five-year survivals of 50% or less were seen in patients with severely dysfunctional values for the 3 quantitative measures of functional capacity. Increased relative risk of mortality according to functional capacity measures was not explained by age, sex, duration of disease, smoking history, joint count, hand radiograph score, grip strength, morning stiffness, formal educational level, oral corticosteroid or parenteral gold use, or various comorbidities, and was not expected by a majority of physicians.

Bony ankylosis in rheumatoid arthritis. Associations with longer duration and greater severity of disease

Hand and wrist radiographs of 203 patients with rheumatoid arthritis were examined for bony ankylosis. Forty-eight patients (23.6%) showed ankylosis, including 34 with more than one joint fused. The distribution of ankylosed joints was 32.4% midcarpal, 29.5% common carpometacarpal, 15.8% radiocarpal, 15.8% proximal interphalangeal, and 6.5% metacarpophalangeal. Patients with ankylosis had significantly higher radiographic erosion, joint space narrowing, and malalignment scores than those without ankylosis (all P less than .001). Patients with ankylosis had significantly longer duration of disease (P less than .001) and physical examinations showed more limited motion and deformity (both P less than .001). More patients with ankylosis had subcutaneous nodules (P less than .05). Functional testing with grip strength and the button test revealed poorer performance in patients with ankylosis (both P less than .001). Questionnaires revealed patients with ankylosis had more difficulty with activities of daily living (P less than .001) and had more limited activity (P less than .01); physicians estimated more limited functional capacity (P less than .001). Thus, radiographic bony ankylosis was a relatively common feature of rheumatoid arthritis, and a marker of patients whose disease was clinically, radiographically, and functionally more severe.

Observer variation in quantitative assessment of rheumatoid arthritis Part II. A simplified scoring system

A new and more comprehensive simplified scoring system to provide quantitative assessment of radiographic findings in rheumatoid arthritis was studied by six observers with different levels of expertise. Since the observers, film set, and joints scored were the same as in a prior study of a more detailed scoring method, a precise comparison of the results was made. Interobserver variation with the simplified scoring system was small; there were highly significant correlations of the total radiographic scores for all observers (R = .898-.978, P less than .001). There were highly significant correlations between scores obtained with the simplified scoring system and those obtained with the more detailed method (R = .920-.955, P less than .001). When the same joints were evaluated by the two methods, a significantly greater number of possible observations could be scored with the simplified scoring system than with the more detailed method (X2 = 131.07, P less than .001). The simplified scoring system required 2.3 times less time to use in the hands of experienced observers.

Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18-64 United States population

Data from the 1978 Social Security Survey of Disability and Work indicate that most chronic diseases in the age 18-64 population are reported significantly more frequently by individuals with fewer than 12 years of formal education. Of the 23 health conditions reported by more than 1% of the population, 19 differed significantly in reported frequencies according to formal educational level. The relative frequencies of any reported condition in individuals with 1-8, 9-11, 12 years, and more than 12 years of formal education, were 3.6, 2.3, 1.4 and 1.0 respectively. Significant trends according to formal educational level were seen for all types of chronic diseases, including cardiovascular, gastrointestinal, musculoskeletal, neoplastic, psychiatric, pulmonary and renal diseases. These trends remained significant for all categories except neoplastic disease when formal education was controlled for age, sex, race and smoking, suggesting that formal educational level may identify a marker in the pathobiology of disease of importance comparable to these other demographic variables.

Observer variation in quantitative assessment of rheumatoid arthritis. Part I. Scoring erosions and joint space narrowing

Six observers, including two bone and joint radiologists, two general radiologists, and two senior radiology residents, compared scores to quantitate radiographic findings in the hands and wrists of patients with rheumatoid arthritis. In the scoring system used, erosions and joint-space narrowing are graded separately. This scoring system differs from other methods in that equivocal findings are not scored, while ankylosis, subluxation, and dislocation are scored, and data from postoperative joints are included. Total radiographic scores were highly significantly correlated for all observers (R = .908-.958, P less than .001), as were subtotal scores for erosions (R = .723-.931, P less than .001) and joint-space narrowing (R = 0.843-0.966, P less than .001). Analysis of proximal interphalangeal, metacarpophalangeal, and wrist-joint scores showed highly significant correlations for all observers in each location. Highly significant correlations were found among three separate readings of two bone and joint radiologists (R = .950-.961, P less than .001). This scoring system provides highly consistent and reproducible results, even in the hands of less experienced observers.

Elevated MMPI scores for hypochondriasis, depression, and hysteria in patients with rheumatoid arthritis reflect disease rather than psychological status

The Minnesota Multiphasic Personality Inventory (MMPI) scales for Hypochondriasis, Depression, and Hysteria were studied in patients with rheumatoid arthritis (RA). The RA patients showed elevated scores on these scales, and these results are similar to those reported in each of 6 published studies. The elevated MMPI scale scores can be explained largely by 5 "disease-related" MMPI statements which met 2 criteria: they were among 11 of the 117 MMPI statements that two-thirds of rheumatologists predicted would be RA-associated; and RA patients and normal subjects differed significantly in their responses to these statements. The responses of RA patients and normal subjects to most other statements in the MMPI Hypochondriasis, Depression, and Hysteria scales were quite similar. In RA patients, responses to "disease-related" statements were correlated with results of measures of disease activity, which indicates that responses to these MMPI items reflect the severity, as well as the presence, of RA. These findings suggest that new criteria are needed for validation of the MMPI as a clinical tool for the recognition of hypochondriasis, depression, and hysteria in a patient who has RA.

The measurement of helplessness in rheumatoid arthritis. The development of the arthritis helplessness index

We describe the development of the Arthritis Helplessness Index (AHI), a self-report instrument designed to measure patients' perceptions of loss of control with arthritis. The participants in this research were 219 patients with rheumatoid arthritis (RA) who completed a quantity of mailed materials, including the AHI, functional measures and other psychological scales. Significant evidence of reliability and validity of the AHI was found. Greater helplessness correlated with greater age, lesser education, lower self-esteem, lower internal health locus of control, higher anxiety, and depression, and impairment in performing activities of daily living using a health assessment questionnaire. Over one year, changes in helplessness correlated with changes in difficulty in performing activities of daily living. The AHI appears to be a useful measure for further studies in RA and a valuable clinical tool in monitoring the psychological status of patients with RA.

Formal education as a marker for increased mortality and morbidity in rheumatoid arthritis

Increased mortality and morbidity was seen in association with lower formal educational levels in 75 rheumatoid arthritis (RA) patients over 9 years. Nine of the 20 patients with 8 or fewer years of education had died, compared to 10 of 34 with 9-12 years of education, and only one of 21 with more than 12 years of education. Among survivors with functional capacity data available from baseline and 9 year review, declines greater than 20% were seen in 8 of 10, 13 of 21, and 9 of 19 patients in the three education categories. Overall, 79% of grade-school educated, 43% of high-school educated, and 20% of college-educated patients had either died or declined more than 50% in functional capacity. Patients of different formal educational levels were similar at baseline in age, duration of disease, measures of functional capacity, number of involved hand joints, number of severe radiographic changes, use of gold, oral corticosteroids or other therapies, and associations between formal educational level and disease course are not explained by these variables. Formal educational level appears a simple quantitative marker which identifies a surrogate or composite variable associated with increased mortality and morbidity in RA.

Severe functional declines, work disability, and increased mortality in seventy-five rheumatoid arthritis patients studied over nine years

Seventy-five patients with rheumatoid arthritis (RA) were reviewed 9 years after an extensive evaluation which included quantitative measures of functional capacity. These patients had received multiple intraarticular injections of thiotepa with corticosteroids early in their course, but appear demographically and functionally similar to other RA patients who had not received this therapy. Severe morbidity was seen over the 9-year period in the 55 surviving patients, including significantly lower overall functional capacity in 92% of patients studied, lower grip strength in 93%, and longer button test results in 84%. Work disability occurred in 85% of patients under age 65 who had been working full-time at disease onset. There was increased mortality at the 9-year review, similar to most reported series of RA patients from referral centers; however, a significant increase in neoplasia, which was of concern because of the use of intraarticular thiotepa, was not seen. In terms of functional capacity, including responses to questions about ability to perform activities, walking time, and the button test, those patients who had died prior to review had significantly lower baseline values than did those who survived. Of the 75 patients, 20 had died and 51 had lost significant functional capacity over a 9-year period, documented by quantitative measures of functional capacity.

Evidence that retrovirus expression in mouse spleen cells results from B cell differentiation

Induction of endogenous retroviral proteins from spleen cells exposed to lipopolysaccharide (LPS) was studied in individual cells in relation to polyclonal B cell differentiation. After 4 days of culture with LPS, 30 to 40% of cells in many mouse strains stained for cytoplasmic mu heavy chains. A smaller number of lymphoid cells stained for cytoplasmic viral proteins, with a characteristic proportion for each strain, including 21% of lymphoid cells of AKR mice, 125 of DBA/2 cells, 7% of C57BL/6 cells, and 2% of BALB/c cells. More than 75% of retrovirus-positive cells were also mu-chain-positive in all strains. Cells from young (3- to 8-week-old) and old (43- to 46-week-old) mice of several strains showed similar proportions of retrovirus-positive cells typical for each strain, without differences at different ages. The induction of retrovirus proteins, as well as mu-chains, by LPS was markedly inhibited by goat anti-mu-chain antibody added to the culture medium (10 to 100 micrograms/ml). These data suggest that retrovirus induction may result from B cell differentiation.

Evidence that retrovirus expression in mouse spleen cells results from B cell differentiation

Induction of endogenous retroviral proteins from spleen cells exposed to lipopolysaccharide (LPS) was studied in individual cells in relation to polyclonal B cell differentiation. After 4 days of culture with LPS, 30 to 40% of cells in many mouse strains stained for cytoplasmic mu heavy chains. A smaller number of lymphoid cells stained for cytoplasmic viral proteins, with a characteristic proportion for each strain, including 21% of lymphoid cells of AKR mice, 125 of DBA/2 cells, 7% of C57BL/6 cells, and 2% of BALB/c cells. More than 75% of retrovirus-positive cells were also mu-chain-positive in all strains. Cells from young (3- to 8-week-old) and old (43- to 46-week-old) mice of several strains showed similar proportions of retrovirus-positive cells typical for each strain, without differences at different ages. The induction of retrovirus proteins, as well as mu-chains, by LPS was markedly inhibited by goat anti-mu-chain antibody added to the culture medium (10 to 100 micrograms/ml). These data suggest that retrovirus induction may result from B cell differentiation.