Natural course of joint destruction and fluctuation of serum C1q levels in patients with rheumatoid arthritis

How do symptoms of each joint contribute to global pain, disease activity and functional disability in rheumatoid arthritis?-A comprehensive association study using a large cohort

BACKGROUND

Established assessment tools for patients with rheumatoid arthritis (RA), including disease activity scores (DASs), disease activity indexes (DAIs), visual analog scales (VASs), and health assessment questionnaires (HAQs), are widely used. However, comparative associations between joint involvement and disease status assessment tools have rarely been investigated.

METHODS

We included a dataset of 4016 patients from a large RA cohort from 2012 to 2019. The tenderness and swelling of each joint were counted as a symptom, with 70 and 68 affected joints throughout the body, respectively. The relative contribution of various joints to the disease status assessment tools, VAS scores, and functional disability indexes was analyzed using multiple regression analysis.

RESULTS

The wrist showed the most significant contribution overall, especially in DASs and VASs, while the metacarpophalangeal and proximal interphalangeal joints made significant contributions to DASs and DAIs, but not to VASs and HAQs. The shoulder and the elbow significantly contributed to HAQs, but only the shoulder did to the VASs. The knee universally contributed to all of the tools, but the ankle played a minor but important role in most assessment tools, especially in HAQs. Similar but different contribution ratios were found between the sets of DASs, DAIs, VASs, or HAQs.

CONCLUSIONS

Each joint makes a unique contribution to these assessment tools. The improvement or aggravation of symptoms in each joint affects the assessment tools in different manners.

Circulating C1q levels in health and disease, more than just a biomarker

C1q is the recognition molecule of the classical pathway of the complement system. By binding to its targets, such as antigen-bound immunoglobulins or C-reactive protein, C1q contributes to the innate defense against infections. However, C1q also plays several other roles beyond its traditional role in complement activation. Circulating levels of C1q are determined in routine diagnostics as biomarker in several diseases. Decreased C1q levels are present in several autoimmune conditions. The decreased levels reflect the consumption of C1q by complement activation and serves as a biomarker for disease activity. In contrast, increased C1q levels are present in infectious and inflammatory diseases and may serve as a diagnostic biomarker. The increased levels of C1q are still incompletely understood but are suggested to modulate the adaptive immune response as C1q is known to impact on the maturation status of antigen-presenting cells and C1q impacts directly on T cells leading to decreased T-cell activity in high C1q conditions. In this review, we provide a comprehensive overview of the current literature on circulating levels of C1q in health and disease, and discuss how C1q can both protect against infections as well as maintain tolerance by regulating adaptive immunity.

Surgical Management of the Lumbar Spine in Rheumatoid Arthritis

STUDY DESIGN

Narrative review.

OBJECTIVE

To provide an overview on the diagnosis and surgical management of rheumatoid involvement of the lumbar spine. Rheumatoid arthritis (RA) is a chronic inflammatory disease of synovial joints, most commonly appendicular followed by axial. Although cervical spine involvement of RA is well documented, data on lumbar spine involvement and surgical management remains limited.

METHODS

Using PubMed, studies published prior to November 2018 with the keywords "RA, etiology"; "RA, spine management"; "RA, surgical management"; "RA, treatment"; "RA, DMARDs"; "RA, lumbar spine"; "RA, spine surgical outcomes"; "RA, imaging" were evaluated.

RESULTS

The narrative review addresses the epidemiology, manifestations, imaging, surgical complications, and operative and nonoperative management of RA involvement of the lumbar spine.

CONCLUSIONS

Rheumatoid involvement of the lumbar spine can present with lower back pain, neurogenic claudication, radiculopathy, spinal deformity, and instability. Patients with RA have significantly higher rates of vertebral fractures and complications following surgical intervention. However, in the setting of instability and spinal deformity, thoughtful surgical planning in conjunction with optimal medical management is recommended.

Establishment of anti-C1q monoclonal antibodies to measure serum C1q levels discriminating disease severity subsets of rheumatoid arthritis within 5 years of onset

Objectives: To establish anti-C1q monoclonal antibodies which can measure serum C1q levels discriminating disease severity subsets of rheumatoid arthritis (RA) within 5 years of onset.Methods: In this multi-centre, longitudinal, observational study, 122 RA patients [102 females, baseline age 58.5 years, rheumatoid factor (RF) positivity 78.7%, serum C-reactive protein (CRP) 1.2 mg/dl, and concomitant methotrexate (MTX) 4.9 mg/week (29.5%)] within 5 years of onset (disease duration 21.0 months) were enrolled from 1985 to 2000. Patients were not treated by more than 8 mg/week of MTX or biologics which may strongly affect the course of joint destruction. Disease severity at 10-15 years of onset was classified according to the number of destructed joints of overall 68 joints on plain radiographs (36 patients were mild RA group involving only peripheral joints and 86 were severe RA group involving large axial joints). Baseline serum C1q levels were evaluated by ELISA with newly developed 4 monoclonal anti-C1q antibodies, and compared between two groups as well as conventional RA disease activity markers.Results: There were no significant differences between two groups in baseline conventional RA disease activity markers such as RF, erythrocyte sedimentation rate, CRP, and matrix metalloproteinase-3. However, compared to mild RA group, severe RA group showed higher baseline serum C1q levels (μg/ml) evaluated by anti-C1q monoclonal antibodies of no.33 (104.8 ± 22.3 vs. 118.3 ± 19.3; p = .0024), no. 40 (102.6 ± 21.9 vs 121.2 ± 22.3; p = .000069), no. 54 (102.1 ± 22.5 vs. 119.3 ± 26.9; p = .00052), and no. 76 (105.6 ± 21.8 vs. 122.6 ± 26.4; p = .00043). Receiver operating characteristic curve analysis revealed that in patients with serum C1q levels of ≥110.5 μg/ml (measured by antibody no. 40), 78.9% (75/95) belonged to severe RA group.Conclusion: Measuring serum C1q levels of RA within 5 years of onset by newly developed anti-C1q antibodies may be useful in predicting the prognosis of disease severity evaluated by the extent of joint destruction.

Complement in the Initiation and Evolution of Rheumatoid Arthritis

The complement system is a major component of the immune system and plays a central role in many protective immune processes, including circulating immune complex processing and clearance, recognition of foreign antigens, modulation of humoral and cellular immunity, removal of apoptotic and dead cells, and engagement of injury resolving and tissue regeneration processes. In stark contrast to these beneficial roles, however, inadequately controlled complement activation underlies the pathogenesis of human inflammatory and autoimmune diseases, including rheumatoid arthritis (RA) where the cartilage, bone, and synovium are targeted. Recent studies of this disease have demonstrated that the autoimmune response evolves over time in an asymptomatic preclinical phase that is associated with mucosal inflammation. Notably, experimental models of this disease have demonstrated that each of the three major complement activation pathways plays an important role in recognition of injured joint tissue, although the lectin and amplification pathways exhibit particularly impactful roles in the initiation and amplification of damage. Herein, we review the complement system and focus on its multi-factorial role in human patients with RA and experimental murine models. This understanding will be important to the successful integration of the emerging complement therapeutics pipeline into clinical care for patients with RA.

Clinical benefit of 1-year certolizumab pegol (CZP) add-on therapy to methotrexate treatment in patients with early rheumatoid arthritis was observed following CZP discontinuation: 2-year results of the C-OPERA study, a phase III randomised trial

Objectives

To investigate the clinical impact of 1-year certolizumab pegol (CZP) therapy added to the first year of 2-year methotrexate (MTX) therapy, compared with 2-year therapy with MTX alone.

Methods

MTX-naïve patients with early rheumatoid arthritis (RA) with poor prognostic factors were eligible to enter Certolizumab-Optimal Prevention of joint damage for Early RA (C-OPERA), a multicentre, randomised, controlled study, which consisted of a 52-week double-blind (DB) period and subsequent 52-week post treatment (PT) period. Patients were randomised to optimised MTX+CZP (n=159) or optimised MTX+placebo (PBO; n=157). Following the DB period, patients entered the PT period, receiving MTX alone (CZP+MTX→MTX; n=108, PBO+MTX→MTX; n=71). Patients who flared could receive rescue treatment with open-label CZP.

Results

34 CZP+MTX→MTX patients and 14 PBO+MTX→MTX patients discontinued during the PT period. From week 52 through week 104, significant inhibition of total modified total Sharp score progression was observed for CZP+MTX versus PBO+MTX (week 104: 84.2% vs 67.5% (p<0.001)). Remission rates decreased after CZP discontinuation; however, higher rates were maintained through week 104 in CZP+MTX→MTX versus PBO+MTX→MTX (41.5% vs 29.3% (p=0.026), 34.6% vs 24.2% (p=0.049) and 41.5% vs 33.1% (p=0.132) at week 104 in SDAI, Boolean and DAS28(erythrocyte sedimentation rate) remission. CZP retreated patients due to flare (n=28) showed rapid clinical improvement. The incidence of overall adverse events was similar between groups.

Conclusions

In MTX-naïve patients with early RA with poor prognostic factors, an initial 1 year of add-on CZP to 2-year optimised MTX therapy brings radiographic and clinical benefit through 2 years, even after stopping CZP.

Trial registration number

NCT01451203.

Risk of low bone mineral density in patients with rheumatoid arthritis treated with biologics

Background

Osteoporosis is a complication of rheumatoid arthritis (RA). We identified risk factors for osteoporosis during treatment with biologics.

Methods

Femoral neck bone mineral density (BMD) was measured in 186 patients with biologics-treated RA. We compared the characteristics of those with BMD ≥70 % of young adult mean (YAM) and those with BMD <70 % of YAM, and undertook multivariable logistic regression analysis to identify risk factors for bone loss.

Results

Mean age and disease duration, the proportion of females, scores in the Modified Health Assessment Questionnaire and history of vertebral fracture were significantly greater in the BMD <70 % of YAM group, but body mass index (BMI) was significantly lower in the BMD <70 % of YAM group. There was no significant difference between the groups in terms of other biomarkers of RA activity, the proportion treated with methylprednisolone, or the duration or choice of biologics. The proportions of patients treated with anti-osteoporosis drugs and parathyroid hormone were significantly higher in the BMD <70 % of YAM group. In the multivariable analysis, advanced age, female, longer disease duration, history of past thoracic or lumbar vertebral fracture, higher Steinbrocker classification and lower BMI were significant factors for BMD <70 % of YAM.

Discussion

We identified risk factors for bone loss in patients with RA treated with biologics. Before suppression of disease activity by biologics, bone loss might already be advanced.

Conclusions

We recommend that patients with RA who possess these risk factors be considered for earlier and more intense treatment to prevent bone loss, as well as addressing RA disease progression.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0732-x) contains supplementary material, which is available to authorized users.

Aggregation of rare/low-frequency variants of the mitochondria respiratory chain-related proteins in rheumatoid arthritis patients

Exome sequencings were conducted using 59 patients having rheumatoid arthritis (RA) and 93 controls. After stepwise filtering, 107 genes showed less than 0.05 of P-values by gene-burden tests. Among 107 genes, NDUFA7 which is a subunit of the complex I in the mitochondrial respiratory chain was selected for further analysis based on previous reports. A case-control study was performed on the three single-nucleotide variants (SNVs) of NDUFA7 with 432 cases and 432 controls. An association was observed between NDUFA7 and RA with severe erosive arthritis. These results together with previous reports suggested the involvement of reactive oxygen species (ROS) in the pathogenesis of RA. In the next step, four SNVs from three genes related to the mitochondrial respiratory chain were selected, which is a major source of ROS, and conducted a case-control study. An association was observed based on a pathway-burden test comprising NDUFA7, SDHAF2, SCO1 and ATP5O: P=1.56E-04, odds ratio=2.16, 95% confidence interval=1.43-3.28. Previous reports suggested the involvement of ROS in the pathogenesis of RA. The aggregation of SNVs in the mitochondria respiratory chain suggests the pivotal role of those SNVs in the pathogenesis of RA with severe erosive arthritis.

Outcome of patients with rheumatoid arthritis treated by step-wise administration of disease-modifying antirheumatic drugs over a 10-year period

Abstract Disease-modifying antirheumatic drugs (DMARDs) are expected to relieve polyarthritis, and thereby improve the patient's quality of life and eventually alter the prognosis of rheumatoid arthritis (RA) or the progressive joint destruction caused by it. DMARDs may cause adverse reactions and become less effective over time in some patients. Using changes in disease activity and X-ray findings as indicators, we retrospectively evaluated the long-term results of the step-wise administration of DMARDs in 200 patients with RA. The patients had been treated with gold compounds, SH compounds, and methotrexate, in this order, over a total of 10 years since initially being diagnosed with the disease in its relatively early stages. The step-wise administration of DMARDs had decreased and controlled RA activity and inflammatory response over the 10 years. Although X-ray findings for the wrists worsened over time in most of the patients, no knee or hip joint destruction was observed in patients in whom disease activity had been controlled well for a long period of time. The progression of destruction of major joints can be prevented in cases in which the Lansbury activity index and C-reactive protein are maintained at levels not more than 30% and 1.5 mg/dl, respectively. Since no drugs are now available which specifically prevent the progression of joint destruction, it is important to control RA activity for as long as possible.

Adjacent-level failures after occipito-thoracic fusion for rheumatoid cervical disorders

INTRODUCTION

The natural history of cervical spine lesions in rheumatoid arthritis (RA) is variable. We have actively performed occipito-thoracic fusion for severe destructive rheumatoid cervical disorders and reported its clinical results and complications. In our previous study, the most frequent complication was the adjacent-level failures caused by the fragile spine. The objective of this study was to determine risk factors for adjacent-level failures after occipito-thoracic fusion.

MATERIALS AND METHODS

Subjects were 35 RA patients (31 females and 4 males) who underwent occipito-thoracic fusion using RRS Loop Spinal System(®) (Robert Reid Inc. Tokyo, Japan), and the incidence and characteristics of adjacent-level failures were investigated. Furthermore, the adjacent-level failures were divided into two types according to their levels, fracture at the lowest level of the fusion area and that at the level inferior to the fusion area, and the characteristics of each type were evaluated.

RESULTS AND CONCLUSION

Nine (26%) of 35 patients suffered adjacent-level failures (10 vertebral fractures). Adjacent-level failures occurred when the distance of fixation was "O-T4" or longer. The long fusion might cause adjacent-level failures due to greater mechanical stress. Seven fractures occurred at the lowest level of the fusion area, and all of them were cured without symptoms by conservative treatment. Three fractures occurred at the level inferior to the fusion area, and one of them needed additional surgery due to sudden paraplegia resulting from collapse of the adjacent vertebra. After occipito-thoracic fusion, burst fractures at the level inferior to the fusion area might cause sudden paraplegia, and therefore a careful observation should be required for patients with these fractures.

Lumbar scoliosis in rheumatoid arthritis: epidemiological research with a DXA cohort

STUDY DESIGN

A retrospective cross-sectional study.

OBJECTIVE

The aim of this study was to identify the prevalence of and risk factors for lumbar scoliosis in patients with rheumatoid arthritis (RA) using lumbar images obtained from dual-energy x-ray absorptiometry (DXA).

SUMMARY OF BACKGROUND DATA

The prevalence of lumbar scoliosis in the normal adult population has been reported, but that in patients with RA remains unclear.

METHODS

Subjects comprised 241 patients with RA who underwent annual DXA. Cobb angles of the lumbar spine were measured by lumbar anteroposterior DXA and the prevalence of lumbar scoliosis (curvature ≥10°) was calculated. Correlations between lumbar scoliosis and potential risk factors (age, sex, duration of RA, T score of lumbar spine and hip, medications for RA [daily predonisolone dose, use of biological agents] and osteoporosis, disease activity score-C-reactive protein, progression stage and functional classification of RA, and severity of hand deformity were analyzed.

RESULTS

The prevalence of lumbar scoliosis in patients with RA was 32.0%. Mean Cobb angle was 7.1º ± 5.5º among all subjects, compared with 13.6º ± 4.4º (range, 10º-32º) among subjects with scoliosis. Subjects with scoliosis were significantly older (67.8 yr) than those without (61.6 yr, P < 0.0001). The daily prednisolone dose was significantly higher in subjects with scoliosis (4.14 mg) than in those without (3.46 mg, P = 0.0389). The T score of the hip was significantly smaller in subjects with scoliosis (-1.79) than in those without (-1.26, P = 0.0005). A multivariate logistic regression analysis revealed age as the sole risk factor for lumbar scoliotic changes in patients with RA (odds ratio, 1.068; 95% confidence interval, 1.031-1.107; P = 0.0003).

CONCLUSION

The prevalence of lumbar scoliosis in patients with RA was 32.0%, about 3- or 4-times higher than its prevalence as obtained from previous reports of DXA cohorts irrespective of RA. Increased age represented an independent risk factor for lumbar scoliosis in patients with RA.

LEVEL OF EVIDENCE

4.

Neurological improvement and prognosis after occipito-thoracic fusion in patients with mutilating-type rheumatoid arthritis

INTRODUCTION

Mutilating-type rheumatoid arthritis, the most aggressive type of rheumatoid arthritis, is frequently associated with destructive cervical involvement, both at the high-cervical and subaxial levels, causing significant neurological deficit, and their natural course of the disease and the survival are discouraging. For such cases, we have been actively performing occipito-thoracic fusion since 1991. Although medical treatment for rheumatoid patients has represented a marked improvement, it could not treat all of these patients because of several reasons. Therefore, it is still important to evaluate the past treatment results.

METHODS

We investigated the neurological improvement and prognosis in 51 mutilating-type rheumatoid arthritis patients who underwent occipito-thoracic fusion between 1991 and 2010. The neurological status was evaluated using modified Ranawat classification; class IIIB was subdivided into IIIBa (able to sit upright) and IIIBb (bedridden).

RESULTS

The preoperative neurologic status was IIIBa in 19 patients and IIIBb in 17 patients. 15 of the 19 patients with class IIIBa improved to being able to walk (79 %), whereas only 3 of the 17 patients with class IIIBb improved to being able to walk (18 %) after surgery. Of the 51 patients, 28 died during follow-up; the mean age at death was 67.2 years. The postoperative 5- and 10-year survival rates were 60.3 and 26.4 %, respectively.

CONCLUSION

The neurological improvement and prognosis after surgery was poorer in class IIIBb patients than in the other patient groups. Occipito-thoracic fusion can improve the neurological symptoms and prognosis. However, early surgical intervention is recommended, before a patient becomes bedridden (class IIIBb).

Associations between six classical HLA loci and rheumatoid arthritis: a comprehensive analysis

Although the HLA region contributes to one-third of the genetic factors affecting rheumatoid arthritis (RA), there are few reports on the association of the disease with any of the HLA loci other than the DRB1. In this study we examined the association between RA and the alleles of the six classical HLA loci including DRB1. Six HLA loci (HLA-A, -B, -C, -DRB1, -DQB1 and -DPB1) of 1659 Japanese subjects (622 cases; 488 anti-cyclic citrullinated peptides (CCP) antibody (Ab) positive (82.6%); 103 anti-CCP Ab negative (17.4%); 31 not known and 1037 controls) were genotyped. Disease types and positivity/negativity for CCP autoantibodies were used to stratify the cases. Statistical and genetic assessments were performed by Fisher's exact tests, odds ratio, trend tests and haplotype estimation. None of the HLA loci were significantly associated with CCP sero-negative cases after Bonferroni correction and we therefore limited further analyses to using only the anti CCP-positive RA cases and both anti-CCP positive and anti-CCP negative controls. Some alleles of the non-DRB1 HLA loci showed significant association with RA, which could be explained by linkage disequilibrium with DRB1 alleles. However, DPB1*02:01, DPB1*04:01 and DPB1*09:01 conferred RA risk/protection independently from DRB1. DPB1*02:01 was significantly associated with the highly erosive disease type. The odds ratio of the four HLA-loci haplotypes with DRB1*04:05 and DQB1*04:01, which were the high-risk HLA alleles in Japanese, varied from 1.01 to 5.58. C*07:04, and B*15:18 showed similar P-values and odds ratios to DRB1*04:01, which was located on the same haplotype. This haplotype analysis showed that the DRB1 gene as well as five other HLA loci is required for a more comprehensive understanding of the genetic association between HLA and RA than analyzing DRB1 alone.

Analysis of the affected joints in rheumatoid arthritis patients in a large Japanese cohort

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic inflammatory disorder involving multiple joints. We investigated the distribution of the affected joints and the relationships among this distribution, the disease activity, and the disease duration in Japanese RA patients by cross-sectional analysis using the National Database of Rheumatic Diseases by iR-net in Japan.

MATERIALS AND METHODS

A total of 6408 RA patients registered in the database were analyzed. In each patient, the location of joint swelling and joint tenderness of 68 joints was examined, and the relationships among the distribution of the affected joints, the disease activity as determined using the DAS28-ESR, and the disease duration were analyzed statistically.

RESULTS

For the 6408 RA patients examined, the wrist was the most frequently affected site. There were some differences in the prevalence of tenderness and swelling; tenderness was frequently observed in large joints such as the knee, elbow and shoulder, while swelling was frequently observed in small joints such as the metacarpophalangeal joints. Although the frequency of involvement increased in all joints as disease activity increased, the pattern of distribution was not affected by disease activity. Furthermore, the distribution was not influenced by disease duration.

CONCLUSIONS

Based on the results of this study, we can draw the following conclusions: (1) the wrist was the most affected joint; (2) there was a discrepancy between the distribution of swollen joints and that of tender joints; and (3) the distribution of affected joints was uniform regardless of disease activity.

Exact break point of a 50 kb deletion 8 kb centromeric of the HLA-A locus with HLA-A*24:02: the same deletion observed in other A*24 alleles and A*23:01 allele

In a structural aberration analysis of patients with arthritis mutilans, a 50 kb deletion near the HLA-A locus with HLA-A*24:02 allele was detected. It was previously reported that HLA-A*24:02 haplotype harbored a large-scale deletion telomeric of the HLA-A gene in healthy individuals. In order to confirm that the deletion are the same in patients with arthritis mutilans and in healthy individuals, and to identify the break point of this deletion, the boundary sequences across the deletion in A*24:02 was amplified by polymerase chain reaction (PCR) as a 3.7 kb genomic fragment and subjected to nucleotide sequence determination. A comparison of these genomic sequences with those of the non-A*24:02 haplotype revealed that the deleted genomic region spanning 50 kb was flanked by 3.7 kb repetitive element-rich segments homologous to each other on both sides in non-A*24. The nucleotide sequences of the PCR products were identical in patients with arthritis mutilans and in healthy individuals, revealing that the deletion linked to A*24:02 is irrelevant to the onset of arthritis mutilans. The deletion was detected in all other A*24 alleles so far examined but not in other HLA-A alleles, except A*23:01. This finding, along with the phylogenic tree of HLA-A alleles and the presence of the 3.7 kb highly homologous segments at the boundary of the deleted genomic region in A*03 and A*32, may suggest that this HLA-A*24:02-linked deletion was generated by homologous recombination within two 3.7 kb homologous segments situated 50 kb apart in the ancestral A*24 haplotype after divergence from the A*03 and A*32 haplotypes.

Supplemental treatment of rheumatoid arthritis with natural milk antibodies against enteromicrobes and their toxins: results of an open-labelled pilot study

BACKGROUND

Environmental factors, particularly commensal bacteria in the gastrointestinal tract, may be involved in the pathogenesis of rheumatoid arthritis (RA). The aim of this study was to evaluate whether natural milk antibodies against a wide spectrum of pathogenic enteromicobes and their toxins modify the disease activity in RA.

METHODS

Twenty patients with RA, whose disease activity was uncontrolled by authentic medications due to drug resistance, complications and/or risk factors were treated for 3 months with an oral administration of a whey protein concentrate (WPC) containing high levels of natural milk antibodies. Eighteen background-matched RA patients, not supplemented with milk antibody adjunct, were used as controls.

RESULTS

Statistically significant reduction of arthritis symptoms and improvement of intestinal disorders were observed only in the test group: effective in 8 (44%), possibly effective in 2 (12%) and not effective in 8 (44%) of 18 patients treated (2 patients withdrew) based on an ad hoc "evaluation point", the sum of variables that are improved more than 20% among the 8 core variables used for the American College of Rheumatology (ACR) response criteria. This disease modifying effect of the WPC disappeared upon cessation of treatment, but was reappeared upon reintroduction of it. Importantly, 7 of 8 non-responders carry DR15 haplotype (DRB1-1501 and 1502), whereas only 1 of 7 responders was DR15 positive (risk ratio: 6.1). Furthermore, the pre-clinical serum anti-LPS and anti-type II collagen antibody levels in the responders were higher or tended to be higher than those in the non-responders, suggesting that there are 2 sub-types of RA based on an interaction between gastrointestinal pathogens and MHC class II haplotypes.

CONCLUSIONS

The natural milk antibody preparation containing high levels antibodies against pathogenic enteromicrobes and their toxins seems to be effective in a certain RA subset, and deserves more attention as a potential adjunct in the treatment of RA.

TRIAL REGISTRATION NUMBER

UMIN000003128.

Radiographic study on the pattern of wrist joint destruction in rheumatoid arthritis

When planning therapy for rheumatoid arthritis (RA) in the wrist joint, knowing the pattern of joint destruction is important. There were a few studies using the Larsen and modified Larsen method to evaluate RA wrist joint destruction. However, these methods are inadequate for thoroughly assessing the severity of joint destruction because joint bone erosion and joint space narrowing could not be evaluated individually in these methods. To clarify the pattern of RA wrist joint destruction in the different zones of the wrist, we conducted a large-scale radiographic study. We modified the van der Heijde/Sharp method to assess radiographic images. Subjects were 191 RA patients (22 men and 169 women; mean age 57.0 years) who were examined at our center between 2001 and 2003 and underwent plain X-ray of both wrist joints (n = 382). Using X-ray images of the wrist joint, classification was performed based on the severity of wrist joint surface bone erosion and joint space narrowing at different zones, and the results were statistically analyzed. The results showed that joint space narrowing in the midcarpal joint (MCJ) advanced faster than in the radiocarpal joint (RCJ). Conversely, bone erosion in the RCJ advanced faster than in the MCJ. In X-ray diagnosis of RA wrist joint disorders, knowing the pattern of destruction is useful for assessing the presence or absence of early joint destruction and in planning therapy.

Predictors of aggravation of cervical spine instability in rheumatoid arthritis patients: the large joint index

BACKGROUND

Improved rheumatic drugs have provided significant benefits, but activities of daily living are not improved if spinal symptoms are overlooked. Furthermore, the appropriate timing for examining the cervical spine during follow-up is unclear.

METHODS

To evaluate the relations of cervical spine instabilities and an index for cervical spine lesion in rheumatoid arthritis (RA) based on extremity radiographs, we examined preoperative radiographs of 100 RA patients who underwent total knee arthroplasty. Radiographic results for eight large joints (bilateral shoulders, elbows, hips, and knees) were graded as follows: Larsen grade > or = 2 for each joint was scored as 1 point, which we refer to as the "large joint index" (LJI), based on 0-8 points. The associations of radiographic cervical lesions with LJI, Ranawat class, the disease duration, RA drugs, or blood analysis data were evaluated.

RESULTS

Atlantoaxial subluxation (AAS) (> or = 5 mm) was found in 45 patients, vertical subluxation (VS) (< or = 13 mm) in 42, a posterior atlantodental interval (PADI) (<14 mm) in 21, and subaxial subluxation (SAS) (> or = 3 mm) in 23. Most patients with a PADI < 14 mm (19/21, 90%) were complicated with both AAS and VS. LJI had a significant association with AAS (P < 0.0001), VS (P < 0.01), and PADI (P < 0.01). The PADI was significantly lower (P < 0.0001) and the LJI was significantly higher (P < 0.01) in patients of Ranawat class II compared to patients of Ranawat class I. The disease duration, age at surgery, and age at onset were also significantly associated with cervical instabilities.

CONCLUSIONS

PADI should be recognized as a predictor of paralysis with anteroposterior instability and vertical and middle-low cervical spine instability. The LJI proposed in this study has the possibility of being a predictor of cervical lesions. Patients with RA onset at a young age and a long disease duration also have a risk of progression of cervical spine instability.

Clinical output of the rheumatoid cervical spine in patients with mutilating-type joint involvement: for better activities of daily living and longer survival

STUDY DESIGN

Retrospective study.

OBJECTIVE

To gain an insight for the final clinical output of surgically managed cervical lesions in seropositive rheumatoid arthritis (RA) patients with mutilating-type joint involvement (mutilating-RA patients), these patients was followed up until either death or complete bedridden.

SUMMARY OF BACKGROUND DATA

There has been no study reporting the final clinical output of surgically managed cervical lesion in mutilating-RA patients. In our previous study, we reported short- to middle-term result of such patient. The present study further traced those patients and reports the final clinical output.

METHODS

Seventeen seropositive mutilating-RA patients extracted from 504 RA patients were enrolled. Eleven patients underwent surgical treatments, whereas six patients did not. All patients, who underwent operation, have received occipitocervical or occipitocervicothoracic fusion. Neck pain, neurological symptoms and ADL score were completely followed up (i.e., follow-up period>10 years).

RESULTS

The six patients of non-operated group worsened ADL score and resulted in either complete bedridden or death within 3 years. Contrary, 11 operated patients either improved or maintained ADL until their death. Survival rate in 6.2 years was 0% in non-operated group and 27% in operated group, respectively. The present study suggests that the seropositive mutilating-RA patients worsen cervical lesions once they become affected, and are likely to lose their ADL activity.

CONCLUSION

Once seropositive mutilating-RA patients develop major spinal involvement(s), they are likely to undergo a life-threatening stage of the disease during the next 5-10 years. Surgical intervention is advocated not only to treat the neurological compromise but also to sustain their ADL levels during end stage of disease. The sustained ADL, in turn, may contribute to the longevity of these patients by preventing other major life-threatening events.

Multiple pelvic insufficiency fractures in rheumatoid patients with mutilating changes

Multiple insufficiency fractures occurred in two patients with mutilating rheumatoid arthritis (RA), leading to substantial disabilities. Both patients received long-term oral glucocorticoid therapy and underwent multiple lower-extremity surgeries such as total hip arthroplasty (THA) or Total knee arthroplasty (TKA). The multiple fractures were located in the pelvis and lumbosacral region. Fractures in both patients were treated conservatively. Although bony union and resumption of activities were achieved in one patient, the other patient was not able to resume ambulation. For RA patients with combined risk factors for insufficiency fractures, aggressive preventive intervention and careful clinical assessment for early detection and management are warranted.

Long-term efficacy of leflunomide on disease activity and inhibition of joint damage: retrospective comparison with methotrexate for Japanese rheumatoid arthritis patients

We retrospectively compared treatment impact with leflunomide (LEF) or methotrexate (MTX) on retarding joint damage and clinical symptom including a 28-joint-count Disease Activity Score/erythrocyte sedimentation rate (DAS28-ESR) between two similar groups in patients with rheumatoid arthritis (RA) over an approximately 3-year treatment. One group included 29 patients treated with LEF alone (average dose 16.1 mg/day); the other group included 26 patients treated with MTX (average dose 7.4 mg/week) alone or combined with other disease-modifying antirheumatic drugs. At baseline, mean disease duration was 7.1 and 6.9 years, and mean DAS28-ESR was 5.79 and 5.69, respectively. The average DAS28-ESR improvement of 1.750 (from 5.79 to 4.04) in the LEF-treated group was significantly greater than the effect of 1.007 (from 5.69 to 4.68) seen in the MTX group (P = 0.0455), with the same results being observed on European League Against Rheumatism (EULAR) response criteria. Annual changes observed in Larsen score in total joints were 0.030 in the LEF group and 0.085 in the MTX group: LEF retards joint damage significantly better than MTX (P = 0.003). This inhibitory effect was better in small joints (P = 0.004) than in middle and large joints (P = 0.075). A negative correlation was noticed between improved DAS28-ESR and the progression of joint damage in the LEF group (r = -0.7068, P < 0.0001), whereas there was no correlation in the MTX group (r = -0.0311, P = 0.882). In daily clinical practice, LEF showed significant clinical and radiological improvement compared with the standard MTX regimen in Japan.

A combination of biochemical markers of cartilage and bone turnover, radiographic damage and body mass index to predict the progression of joint destruction in patients with rheumatoid arthritis treated with disease-modifying anti-rheumatic drugs

The aim of this study was to evaluate the predictive value of biological, radiological and clinical parameters for the progression of radiographic joint damage in rheumatoid arthritis (RA) patients treated with conventional disease-modifying anti-rheumatic drugs (DMARDs). We analyzed the 145 patients with active RA for less than 5 years who were participating in the prospective 1-year randomized controlled trial of tocilizumab (SAMURAI trial) as a control arm treated with conventional DMARDs. Progression of joint damage was assessed by sequential radiographs read by two independent blinded X-ray readers and scored for bone erosion and joint space narrowing (JSN) using the van der Heijde-modified Sharp method. Multivariate analysis revealed that increased urinary levels of C-terminal crosslinked telopeptide of type II collagen (U-CTX-II), an increased urinary total pyridinoline/total deoxypyridinoline (U-PYD/DPD) ratio and low body mass index (BMI) at baseline were independently associated with a higher risk for progression of bone erosion. In addition to these three variables, the JSN score at baseline was also significantly associated with an increased risk of progression of the JSN score and total Sharp score. High baseline U-CTX-II levels, U-PYD/DPD ratio and JSN score and a low BMI are independent predictive markers for the radiographically evident joint damage in patients with RA treated with conventional DMARDs.

Disease activity and the course of wrist joint deterioration over 10 years in the patients with early rheumatoid arthritis

The objectives of this study were to evaluate the course of radiographic deterioration of the wrist joint with rheumatoid arthritis (RA), and to determine the influence of disease activity on its deterioration. A retrospective study was performed on 122 wrists in 66 patients, who started treatment using disease-modifying antirheumatic drugs within the first year of the disease and followed for more than 10 years without surgical intervention. The mean disease activity score (DAS28-CRP[3]) was high during the first 2 years, followed by a decrease and a flattening of the curve of disease activity. Generally, carpal collapse progressed more in the early stage and decreased linearly over 10 years. Individually, continuous high disease activity and progression in radiographic damage were observed in carpal collapsed groups from early stage of the disease. The cut-off values of the mean DAS28-CRP(3) during year 0-2, which indicated progression to Larsen grade III or more and Schulthess type I (ankylosis) or III (disintegration) at year 10 were 3.34 (sensitivity: 70.9% and specificity: 72.1%) and 3.63 (sensitivity: 74.3% and specificity: 77.0%), respectively. In patients with RA, deterioration of the wrist joint was influenced by disease activity. Identifying this activity and the course of wrist progression may be useful in predicting wrist deterioration.

Radiological features of lumbar spinal lesions in patients with rheumatoid arthritis with special reference to the changes around intervertebral discs

BACKGROUND CONTEXT

Compared with the cervical spine, little attention has been paid to rheumatoid arthritis (RA)-related lumbar disorders. Only a few articles have described the status of the lumbar spine affected by RA based on plain X-ray films and magnetic resonance imaging (MRI).

PURPOSE

To describe the features and prevalence of radiological changes of the lumbar spine of patients with RA and to clarify the correlations of such features with disease activity.

STUDY DESIGN

Transverse radiological study.

PATIENT SAMPLE

We radiographically examined 104 patients with RA whose age ranged from 21 to 78 years (mean, 51.0). In each, the duration of RA exceeded 10 years (mean, 17.7 years).

OUTCOME MEASURES

Clinical outcomes included Ochi's classification, Lansbury index, C-reactive protein (CRP) (mg/dL), rheumatoid factor (RF) (U/mL), and platelet (count/mm). Radiological outcomes included radiography and MRI.

METHODS

One hundred four RA patients were included in this study regardless of the presence/absence of low back pain. We examined discs from L1-2 to L5-S, including endplates, in each patient on plain X-ray films and magnetic resonance images and used a comprehensive grading system to evaluate each feature of the lumbar spine affected by RA based on the present findings and published reports. The correlations of these radiological features with RA activity and Ochi's classification were examined. To quantify disease activity, we determined the Lansbury index, serum CRP (mg/dL), RF (U/mL), and platelet count (count/mm) at the time of radiological examinations.

RESULTS

Of the 104 patients, 47 (45.2%) exhibited a lumbar lesion. There were two types of lumbar disc lesions related to RA: disc narrowing and disc ballooning. The Lansbury index of patients with the most severe lesions was significantly higher than that of patients with less severe lesions (p<.01). The frequency of lumbar involvement also increased as the number of affected peripheral joints increased, and Ochi's classification appeared to be useful in predicting the occurrence of lumbar lesions.

CONCLUSION

Of 104 patients, 47 (45.2%) exhibited abnormalities on X-ray films and MRI. There were two types of disorders, disc narrowing and disc ballooning. Both the Lansbury index and Ochi's classification reflected the severity of lumbar lesions in RA patients.

The mode of destruction in shoulders with rheumatoid arthritis based on radiographic findings

The objective of the present study was to elucidate the mode of rheumatoid arthritis shoulder destruction. The study included 402 shoulders from 201 patients with rheumatoid arthritis. Plain radiographic findings were used to assess and statistically analyze the severity of the glenohumeral joint destruction (GHD) and greater tuberosity destruction (GTD). For both GHD and GTD scores, a statistically significant correlation was found between the left and right sides and also between the GHD and GTD scores within the same shoulder. However, 97 shoulders of 67 patients showed a heterogeneous pattern. An interesting finding was that no patients showed a combination of the GHD type plus the GTD type. Shoulders with rheumatoid arthritis showed statistically significant symmetry and uniform destruction. Even if they showed heterogeneous destruction, there were no cases of a different pattern of heterogeneity on the opposite side. The mode of destruction was not always definite, however.

Radiographic study of joint destruction patterns in the rheumatoid elbow

Knowledge of the pattern of joint destruction is important for planning the therapeutic approach to rheumatoid arthritis (RA) of the elbow. Accordingly, we carried out a large-scale radiographic study with the objective of elucidating the joint destruction pattern in rheumatoid elbows. From 2001 through 2003, we examined and took plain X-rays of both elbows of 193 RA patients (i.e., 386 elbows), consisting of 18 men and 175 women, with a mean age of 57.0 years. Radiographic images of the elbow joints were used to classify the degree of bone loss in various zones on the elbow joint surface into four grades of severity, and joint destruction was compared between the left and right elbows. In addition, correlation in the extent of bone loss between each of the zones of the same elbow and differences in the extent of bone loss were analyzed statistically. The results showed direct correlations for destruction of the elbow joint surface among the zones for the left and right elbow joints and in the same elbow joint. However, more severe destruction was observed on the radial side of the humeral trochlea, and it was surmised that destruction of the elbow joint must begin at that site and gradually spread mediolaterally. In addition, in the same elbow joint, the correlation in the degree of bone loss between the trochlea of humerus and the trochlear notch was especially strong, indicating that the bone destruction at both sites represented mirror lesions. We conclude that when performing radiographic diagnosis of the joint damage in the rheumatoid elbow, knowledge of this pattern of joint destruction will be useful for assessing whether there is joint destruction in the initial stage and for deciding the therapeutic approach.

Upper thoracic myelopathy caused by vertebral collapse and subluxation in rheumatoid arthritis: report of two cases

We report two cases of rheumatoid arthritis (RA) with upper thoracic myelopathy and a review of the literature. Clinical data of a 47-year-old woman (case 1) and a 54-year-old woman (case 2) are described. Case 1 showed a transverse-type myelopathy at the T2 segment level of the spinal cord and case 2 had the same type of myelopathy at the T4 segment level. Case 1 had anterior vertebral subluxation of C7 due to marked vertebral collapse and Case 2 had subluxation of T2 with vertebral destruction. These two patients had the mutilating type of RA with multilevel spontaneous fusion in the cervical spine. The lesions in the thoracic spine might be caused by the severe destructive inflammation that is characteristic in mutilating disease. The vertebral collapse might lead to subluxation of the upper thoracic vertebra, resulting in spinal cord compression. Upper thoracic subluxation might be caused by vertebral collapse due to RA and the increased motion as a compensation for decreased mobility caused by spontaneous fusion in the cervical spine.

The alpha 2 type IX collagen gene tryptophan polymorphism is not associated with rheumatoid arthritis in the Japanese population

The aim of this study was to investigate whether the alpha 2 type IX collagen (COL9A2) polymorphism that introduces tryptophan residue into the collagen triple-helix is a marker of susceptibility to, or severity of, rheumatoid arthritis (RA). The study included 749 Japanese patients with RA. One hundred twenty-four unrelated healthy individuals served as the control subjects. The relationship between the COL9A2 gene polymorphism and clinical manifestations of RA was evaluated. For the number of subjects positive for COL9A2 tryptophan polymorphism, there was no statistically significant difference between RA patients and normal controls. Furthermore, we did not detect any association of COL9A2 tryptophan polymorphism with disease status, least erosive subset, more erosive subset, or mutilating disease. The lack of association of COL9A2 tryptophan polymorphism with RA and the clinical findings in our study implies that the polymorphism may not function as a candidate gene marker for screening RA patients.

Long-term follow-up study of radiocarpal arthrodesis for the rheumatoid wrist

PURPOSE

Pain-free stability of the wrist is a prerequisite for the rheumatoid hand to maintain power and perform various tasks. The purpose of this study was to investigate whether a radiocarpal (radiolunate, radioscapholunate, or radiolunotriquetral) arthrodesis produces a stable wrist and whether the results remain satisfactory for more than 10 years.

METHODS

A retrospective review was performed on 25 wrists of 25 patients with rheumatoid arthritis who had radiocarpal arthrodesis. All patients had a synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure. The indications for radiocarpal arthrodesis included radiographic changes in Larsen-Dale-Eek grades II to IV, midcarpal joint space of greater than 1 mm, and ulnar shift or palmar subluxation of the carpus. The presence of scapholunate dissociation was an optional indication. The mean follow-up period was 13 years (range, 10-18 y) and radiographs taken just before the surgery and 0 to 2 years, 2 to 5 years, 5 to 10 years, and more than 10 years after the surgery were evaluated as were pain relief, swelling, grip power, range of motion, and complications.

RESULTS

Pain was resolved for 22 of the patients and 3 experienced occasional mild pain. Swelling generally decreased, grip power increased significantly, flexion decreased, and forearm rotation increased significantly. The complication rate was low. Radiographically ulnar shift and palmar subluxation improved initially and were maintained at the time of the 10-year follow-up evaluation; carpal collapse improved initially but returned to the preoperative level by the time of the 5-year follow-up evaluation. The midcarpal joint space was preserved in 16 wrists, and all but 1 wrist (in a patient with mutilating type of the disease) remained stable.

CONCLUSIONS

Radiocarpal arthrodesis for treatment of the rheumatoid wrist results in good stability with preservation of motion despite radiographic progression of the disease. We therefore recommend this treatment for the unstable wrist with moderate deterioration.

Results after 24 years of prophylactic surgery for rheumatoid atlantoaxial subluxation

We evaluated the use of surgical stabilisation for atlantoaxial subluxation after a follow-up of 24 years in 50 rheumatoid patients who had some degree of pain but no major neurological deficit.

The mortality of patients treated by atlantoaxial fusion was significantly lower than for those who received conservative treatment. The deaths resulted from infection or comorbid conditions. The significantly high relative risks of mortality from conservative treatment compared with surgical treatment were mutilating disease and susceptible factors on both of the HLA-DRB1 alleles. Relief from pain and neurological and functional recovery were better, and the radiological degree of atlantoaxial translocation was less in those who were surgically treated compared with those who were not. Two patients had superficial local infections after surgery. We conclude that prophylactic atlantoaxial fusion is better than conservative treatment in these patients.

Association between single-nucleotide polymorphisms in theSEC8L1 gene, which encodes a subunit of the exocyst complex, and rheumatoid arthritis in a Japanese population

OBJECTIVE

To identify rheumatoid arthritis (RA) susceptibility genes in a Japanese population by conducting a large-scale case-control association analysis and linkage disequilibrium (LD) mapping on chromosome 7q31-34, a candidate susceptibility locus identified in a preliminary genome-wide scan in 53 Japanese families, using single-nucleotide polymorphisms (SNPs).

METHODS

We prepared 728 dense, evenly spaced SNPs with a minor allele frequency >0.15 in each gene locus on chromosome 7q31-34. Using these SNPs, a 2-stage case-control analysis was performed on 760 RA patients (157 men and 603 women) and 806 non-RA controls (189 men and 617 women). Haplotypes and LD mapping results were assessed based on SNP genotypes in 380 controls.

RESULTS

Forty-eight SNPs showed allele associations (P < 0.05) in the first set of DNA samples (380 RA cases and 380 non-RA controls; first-stage analysis). For 4 of the SNPs in the SEC8L1 gene, the association was replicated (P < 0.05) in the second, independent set of DNA samples (an additional 380 RA cases and 380 non-RA controls; second-stage analysis). When data from the 2 groups were combined, the most significant allele association was observed with SNP 441, an intronic SNP of the SEC8L1 gene (P = 0.000059). The SEC8L1 SNPs with significant allele associations were all located in a single conserved LD block (block 4). Haplotype analysis revealed the disease-risk (P = 0.0015) and disease-protective (P = 0.0000062) haplotypes. Resequencing of coding exons within block 4 did not identify any nonsynonymous SNPs. Real-time quantitative polymerase chain reaction revealed that SEC8L1 was expressed ubiquitously in human tissues, including fibroblast-like synoviocytes from RA patients.

CONCLUSION

Our locus-wide association and LD analyses identified intronic SNPs and haplotypes in the SEC8L1 gene that are strongly associated with RA. We propose that SEC8L1, which encodes a component of the exocyst complex, is a candidate susceptibility gene for RA in the Japanese population.

Long-Term Results of Occipitothoracic Fusion Surgery in RA Patients with Destruction of the Cervical Spine

OBJECTIVE

This is a retrospective study of the outcome of occipitothoracic fusion surgery in rheumatoid arthritis (RA) patients with destruction of the cervical spine, designed to assess the efficacy of halo vest before surgery, the postoperative outcome, and the activities-of-daily living (ADL) problems associated with surgical management. There have been no reports regarding these issues, including surgical effect on subjacent vertebrae.

METHODS

This study included 20 RA patients with destruction of the cervical spine. All patients underwent preoperative halo vest followed by occipitothoracic fusion with an average follow-up of 5 years. The long-term clinical outcomes were analyzed using a modified Ranawat classification.

RESULTS

Before halo application, the neurologic status was assessed as IIIC in 15 patients and IIIB in 5 patients. After halo application, the neurologic status improved in all patients: IIIA in 12 patients and IIIB in 8 patients. After surgery, the neurologic status did not improve in six of the eight IIIB patients but improved to IIIA in two patients. Of the 12 IIIA patients, the neurologic status improved to II in 6 patients but did not improve in the other 6 patients. Patient satisfaction was excellent for 14 patients, good for 3 patients, and fair for only 3 patients (1 had difficulty drinking, another had back pain, and the last had low back pain associated with a compression fracture of the lumbar spine).

CONCLUSIONS

We have performed occipitothoracic fusion surgery in RA patients with destruction of the cervical spine. Preoperative halo vest was very effective for improving the neurologic status, for the general condition, and for an optimal sagittal alignment. Occipitothoracic fusion using unit rods gave satisfactory long-term clinical results compared with the prognosis of patients in whom the disease follows its natural course.

Correlation between severity of rheumatoid arthritis and manner and extent of cervical lesion

Abstract To determine the proper management of treatment for rheumatoid cervical lesions, we investigated the clinical course of the cervical spine in rheumatoid arthritis (RA). The severity of RA was classified into three groups according to the disease subsets advocated by Ochi et al.: the less erosive subset (LES), the more erosive subset (MES), and mutilating disease (MUD). Then the following radiographic assessments were performed on cervical roentogenograms: atlantoaxial subluxation (AAS), vertical subluxation (VS), and subaxial subluxation (SAS). One hundred and seventy-four patients were available for this study. The mean age of the patients was 60.9 years (19-85 years). The average duration from the onset of RA was 19.1 years (10-40 years). Eighty-seven patients were classified as LES, 69 were MES, and 18 were MUD. We found that few patients in the LES group had required an operation on the cervical spine. AAS was seen in about 60% of the MES patients, but few cases had VS or SAS, and most operations were atlantoaxial fusion. All patients in the MUD group had some cervical instabilities. Not only VS but also SAS were seen in more than half of these patients, and many patients had required occipitothoracic fusion.

Laminoplasty for cervical myelopathy caused by subaxial lesions in rheumatoid arthritis

Object. Although controversy exists regarding surgical treatment for rheumatoid subaxial lesions, no detailed studies have been conducted to examine the efficacy of laminoplasty in such cases. To discuss indications for laminoplasty in rheumatoid subaxial lesions, the authors retrospectively investigated clinical and radiological outcomes in patients who underwent laminoplasty for subaxial lesions.

Methods. Thirty patients (11 men and 19 women) underwent laminoplasty for rheumatoid subaxial lesions. The patients were divided into those with mutilating-type rheumatoid arthritis (RA) and those with nonmutilating-type RA according to the number of eroding joints. As of final follow-up examination laminoplasty resulted in improvement of myelopathy in 24 patients (seven with mutilating- and 17 with nonmutilating-type RA) and transient or no improvement in six (five with mutilating- and one with nonmutilating-type RA). In the group with mutilating-type RA, significantly poorer results were displayed (p < 0.05). In most patients preoperative radiographs demonstrated vertebral slippage less than or equal to 5 mm at only one or two levels. Postlaminoplasty deterioration of subaxial subluxation and unfavorable alignment change occurred significantly more often in patients with mutilating-type RA (p < 0.05).

Conclusions. Patients with nonmutilating-type RA can benefit from laminoplasty for myelopathy due to subaxial lesions.

Radiologic findings of the lumbar spine in patients with rheumatoid arthritis, and a review of pathologic mechanisms

We have analyzed the radiologic findings on the lumbar spine and the clinical symptoms in patients with rheumatoid arthritis (RA). A total of 106 patients who fulfilled the revised criteria of the American Rheumatism Association were subjected. All of the patients were asked to fill out a questionnaire about the existence of low back pain, leg pain, and leg numbness. Radiologic features of the lumbar spine, including scoliosis, spondylolisthesis, disc space narrowing, endplate erosion, osteophyte, and osteoporosis, were checked. Radiographs of the cervical spine were also taken. The clinical background of RA, such as mutilating disease or not, was assessed. Forty-two patients (40%) had the symptoms of low back pain. Abnormal radiologic findings in lumbar spine were detected in 57%. The prevalence of clinical symptoms tended to be higher in the patients with endplate erosion. Forty-two percent of the patients had both lumbar and cervical lesions. The prevalence of lumbar lesion was not high in the mutilating type of RA, except for facet erosion and severe osteoporosis. The patients with pulse steroid therapy revealed a higher prevalence of vertebral fracture. From these results, we concluded that lumbar lesions were frequently observed in patients with RA. The possibility of lumbar lesions as well as the lesions in the cervical spine and peripheral joints should be examined in patients with RA.

Evaluation of posterior long fusion versus conservative treatment for the progressive rheumatoid cervical spine

STUDY DESIGN

Results of the posterior long fusion performed for the progressive cervical lesions of rheumatoid arthritis were compared with the outcomes of those who did not undergo surgical treatment.

OBJECTIVE

To provide a clue as to whether posterior long fusion improves or maintains the impaired daily life activity of the patients with rheumatoid arthritis with progressive, mutilating-type joint involvements.

SUMMARY OF BACKGROUND DATA

To provide optimal treatments for the cervical lesions of patients with rheumatoid arthritis, the natural courses of cervical lesions should be taken into account. In the authors' preliminary study they have retrospectively investigated natural courses of cervical rheumatoid arthritis lesions and have found that the seropositive patients with rheumatoid arthritis with mutilating-type joint involvement are at a high risk of deteriorating the cervical lesion once their cervical spine becomes affected.

METHODS

In the present study 17 seropositive patients with rheumatoid arthritis with mutilating-type joint involvements were studied. Eleven patients underwent surgical treatments (operated group), whereas six patients did not (nonoperated group). All of the operated patients underwent occipitocervical or occipitocervicothoracic fusion supplemented by the Luque's sublaminar wiring and preoperative and postoperative usage of halo-jacket.

RESULTS

The six patients of the nonoperated group worsened the activities of daily living score and resulted in either complete bedridden or in death by the time point of final follow-up. In contrast, all of the 11 operated patients either improved or maintained the activities of daily living score: those operated because of neurologic compromise due to myelopathy improved at least one class in the activities of daily living score, and those operated because of severe occipitocervical pain maintained the activities of daily living with relief of pain.

CONCLUSION

The present study suggests that posterior long fusion may achieve an improvement of activities of daily living, at least, for a certain time period. However, the newly emerging lesions adjacent to the fused segments, which may result from the increased mechanical loads, may finally lead to the impairment of activities of daily living.

The definition and clinical features of the mutilans type of rheumatoid arthritis

Abstract  The mutilans type of rheumatoid arthritis (RA) is refractory to several treatments and involves many types of surgical application. It is difficult to prevent its progress, and it has a poor functional prognosis. However, the definition is not always distinct. In this report, I attempt to clarify the clinical features of the mutilans type of RA and establish an accurate definition of the disease. Previous definitions have been divided into three groups: (1) the mutilans group (Mu-G), which has more than three joints showing severe resorptive bone destruction and joint instability; (2) the suspected mutilans group (sMu-G) which has one to two joints with joint instability or showing no instability but with highly resorptive bone destruction; (3) the Larsen V group (LV-G), which has radiological findings indicating Larsen grade V disease. Patients suffering from rheumatoid arthritis for over 10 years and who do not fall into any of the above groups are referred to as the control group. Among 337 patients who suffered from RA for more than 10 years, 58 were classified as being in the mutilans group, 59 in the suspected Mu-G, 47 in the LV-G, and 173 in the control group. The mutilans group had distinctive features which were different from those of the other groups, which had a radiological finding of Larsen grade V disease or severe resorptive bone destruction without instability. From these data, the definition of the mutilans type of RA should be specified as the Mu-G. Thus, the Mu-G shows a distinctive clinical picture which is unlike that in the other groups. It is important to define the mutilans type of RA clearly because it has a poor prognosis. Early identification will help in the establishment of a treatment plan.

A long-term follow-up study of cervical lesions in rheumatoid arthritis

To determine the natural history of cervical lesions in rheumatoid arthritis, 161 patients who had been followed for a minimum of 5 years were enrolled in this study. The average follow-up period was 10.2 years (range, 5 to 20 years). The severity of the rheumatoid arthritis was classified into three types based on the multiplicity of peripheral joint rheumatoid involvement: a least erosive subset, a more erosive subset, and a mutilating disease subset. Ninety-two patients (57%) had upper cervical involvement, which progressed in the order of anterior atlantoaxial subluxation, anterior atlantoaxial subluxation combined with vertical subluxation, and vertical subluxation alone. Subaxial subluxation was found in 18 patients (11%). In 17 of these 18 patients, upper cervical lesions were also noted. The incidence of cervical involvement in each disease subset was 39% in the least erosive group, 83% in the more erosive group, and 100% in the mutilating disease group. Fifty percent of the patients with cervical involvement had neck pain, and the remaining patients were asymptomatic. Neural involvement occurred in 10 patients. In 7 of these 10 patients, vertical subluxation of the atlas was responsible for the neural deficit. Six patients required surgical intervention because of progressive myelopathy.

The relationship between postoperative results and bone dynamics in RA patients who underwent cementless Ortholoc II TKA: histomorphometric study

Abstract We previously reported a histomorphometric study of iliac bone obtained at the time of cementless total knee arthroplasty (TKA) in patients with rheumatoid arthritis (RA). In this paper, we further extended our analysis to investigate the postoperative results and radiographs after TKA in association with bone metabolism. All the patients were female, ranging in age from 38 to 68 years (mean, 56.8 years). Histomorphometric results demonstrated that bone volume and trabecular thickness were decreased, whereas bone absorption and bone formation rate (BFR) were increased. The bone in patients with mutilating disease (MUD) showed remarkably increased bone turnover and osteoporosis compared with those of the more erosive subset (MES) patients. Sixteen out of the 20 patients were alive at the time of follow-up (follow-up period between 5 years 10 months and 8 years 11 months). Among them, 10 patients could be further examined. Radiolucent lines (RLL) were assessed by the modified Knee Society evaluation (scoring) system. The number of RLL (N-RLL) were correlated with BFR in morphometric examination. In addition, the weight-bearing zones in the N-RLL were more significantly correlated with BFR. The Japanese Orthopedic Association (JOA) score and pain score negatively correlated with eroded bone surface. The present study indicated that bone dynamics, rather than the bone volume at the time of TKA, were involved in the presence of RLL and in pain after surgery for TKA.

Establishment of nurse-like stromal cells from bone marrow of patients with rheumatoid arthritis: indication of characteristic bone marrow microenvironment in patients with rheumatoid arthritis

OBJECTIVE

To investigate the microenvironment of bone marrow (BM) of patients with rheumatoid arthritis (RA).

METHODS

Nurse cell-like BM stromal cell lines were established from BM mononuclear cells of patients with RA. We examined the various characteristics of these cell lines, including morphology, pseudoemperipolesis activity, cell surface markers, cytokine production and hyaluronan (HA) production.

RESULTS

These RA BM nurse cell-like lines (RA-BMNC) were of mesenchymal origin and positive for CD44, CD54 and HLA-DR. They were defined as nurse cells because of pseudoemperipolesis activity that allowed lymphocytes to migrate underneath. RA-BMNC lines produced HA and multiple cytokines including interleukin (IL)-6, IL-7, IL-8 and granulocyte-macrophage colony-stimulating factor (GM-CSF). HA production by BM stromal cells was correlated with pseudoemperipolesis activity. RA-BMNC produced significantly higher levels of IL-6, IL-8 and GM-CSF by co-culture with lymphocytes. The cells also produced IL-1beta, G-CSF and tumour necrosis factor only when co-cultured with lymphocytes. The RA-BMNC maintained the growth of CD14+ myeloid cells unique to severe RA.

CONCLUSION

The present results both indicate that RA-BMNC are nurse cells and suggest that they may play an important role in the pathogenesis of RA.