The clinical and health status of patients with recent-onset rheumatoid arthritis

Validity of the extended activities of daily living scale

Scales that measure independence in the basic self-care activities of daily living (ADLs) suffer from ceiling effects when applied to an outpatient population. The instrumental activities of daily living (IADL) measures, which assess the performance of tasks required for independence at home are more appropriate. However, validity evaluation of IADL measures seldom goes beyond content validity and little is known about their sensitivity to change. The aim of this study was to evaluate the construct validity of the extended ADL scale (EADL) and to test its sensitivity to change. Three hundred and sixty-one consecutive acute stroke admissions were recruited and surveyed at one, six and 12 months after stroke, using the EADL. There were the expected correlations with the Barthel Index, Nottingham Health Profile, Geriatric Depression Score and the London Stroke Satisfaction Score. Logistic regression analysis showed that, although men were more mobile, they were less likely to carry out domestic and kitchen tasks. Also, nonwhites were more disabled, owner-occupiers had higher leisure scores and those living alone had higher kitchen scores. Analysis of effect sizes showed that the EADL is sensitive to the changes that occur after stroke and would be sensitive to the effect of an intervention that produced a change in independence of two or more ADLs. The EADL is a valid measure of the performance of instrumental ADLs and is sensitive to clinically important changes.

Quantifying the economic burden of productivity loss in rheumatoid arthritis

OBJECTIVE

In light of the large number of recent studies and systematic reviews investigating the cost of RA, this article examines the methods used to assess the impact of RA on employment and work productivity, and provides an overview of the issues surrounding work productivity loss in the RA population.

METHODS

A review of the published literature was conducted in order to identify relevant articles. These articles were then reviewed and their methodologies compared. The various methods used to calculate economic loss were then explained and discussed.

RESULTS

We found that although methods of lost productivity and associated costs varied between studies, all suggest that RA is associated with significant burden of illness. Economic analyses that exclude indirect costs will therefore underestimate the full economic impact of RA. However, the methods used to calculate productivity loss have a significant impact on the results of indirect cost analyses, and should be selected carefully when designing such studies. Several factors relating to the disease, the job and socio-demographics have been found to predict work disability.

CONCLUSIONS

Consideration of these factors is vital when measuring the extent of both absenteeism and presenteeism, and will allow for more accurate estimation of the impact of RA on work productivity. This information may also guide interventions aiming to prevent or postpone work disability and job loss.

New considerations on the management of osteoporosis in Central and Eastern Europe (CEE): summary of the "3rd Summit on Osteoporosis-CEE", November 2009, Budapest, Hungary

INTRODUCTION

In November 2009, the "3rd Summit on Osteoporosis-Central and Eastern Europe (CEE)" was held in Budapest, Hungary. The conference aimed to tackle issues regarding osteoporosis management in CEE identified during the second CEE summit in 2008 and to agree on approaches that allow most efficient and cost-effective diagnosis and therapy of osteoporosis in CEE countries in the future.

DISCUSSION

The following topics were covered: past year experience from FRAX® implementation into local diagnostic algorithms; causes of secondary osteoporosis as a FRAX® risk factor; bone turnover markers to estimate bone loss, fracture risk, or monitor therapies; role of quantitative ultrasound in osteoporosis management; compliance and economical aspects of osteoporosis; and osteoporosis and genetics. Consensus and recommendations developed on these topics are summarised in the present progress report.

CONCLUSION

Lectures on up-to-date data of topical interest, the distinct regional provenances of the participants, a special focus on practical aspects, intense mutual exchange of individual experiences, strong interest in cross-border cooperations, as well as the readiness to learn from each other considerably contributed to the establishment of these recommendations. The "4th Summit on Osteoporosis-CEE" held in Prague, Czech Republic, in December 2010 will reveal whether these recommendations prove of value when implemented in the clinical routine or whether further improvements are still required.

The use of the Behavioral Pain Scale to assess pain in conscious sedated patients

BACKGROUND

Assessing pain in mechanically ventilated critically ill patients is a great challenge. There is a need for an adequate pain measurement tool for use in conscious sedated patients because of their questionable communicative abilities. In this study, we evaluated the use of the Behavioral Pain Scale (BPS) in conscious sedated patients in comparison with its use in deeply sedated patients, for whom the BPS was developed. Additionally, in conscious sedated patients, the combination of the BPS and the patient-rated Verbal Rating Scale (VRS-4) was evaluated.

METHODS

We performed a prospective evaluation study in 80 nonparalyzed critically ill adult intensive care unit patients. Over 2 mo, nurses performed 175 observation series: 126 in deeply sedated patients and 49 in conscious sedated patients. Each observation series consisted of BPS ratings (range 3-12) at 4 points: at rest, during a nonpainful procedure, at retest rest, and during a routine painful procedure. Patients in the conscious sedated state also self-reported their pain using the 4-point VRS-4.

RESULTS

BPS scores during painful procedures were significantly higher than those at rest, both in deeply sedated patients (5.1 [4.8-5.5] vs 3.4 [3.3-3.5], respectively) and conscious sedated patients (5.4 [4.9-5.9] vs 3.8 [3.5-4.1], respectively) (mean [95% confidence interval]). For both groups, scores obtained during the nonpainful procedure and at rest did not significantly differ. There was a strong correlation between nurses' BPS ratings and conscious sedated patients' VRS-4 ratings during the painful procedure (r(s) = 0.67, P < 0.001). At rest and during nonpainful procedures, 98% of the observations were rated as acceptable pain (VRS 1 or 2) by both nurses and patients. During painful procedures, nurses rated the pain higher than patients did in 16% of the observations and lower in 12% of the observations.

CONCLUSION

The BPS is a valid tool for measuring pain in conscious sedated patients during painful procedures. Thus, for noncommunicative and mechanically ventilated patients, it may be regarded as a bridge between the observational scale used by nurses and the VRS-4 used by patients who are able to self-report pain.

A randomized, controlled trial of emotional disclosure in rheumatoid arthritis: can clinician assistance enhance the effects?

Emotional disclosure by writing or talking about stressful life experiences improves health status in non-clinical populations, but its success in clinical populations, particularly rheumatoid arthritis (RA), has been mixed. In this randomized, controlled trial, we attempted to increase the efficacy of emotional disclosure by having a trained clinician help patients emotionally disclose and process stressful experiences. We randomized 98 adults with RA to one of four conditions: (a) private verbal emotional disclosure; (b) clinician-assisted verbal emotional disclosure; (c) arthritis information control (all of which engaged in four, 30-min laboratory sessions); or (d) no-treatment, standard care only control group. Outcome measures (pain, disability, affect, stress) were assessed at baseline, 2 months following treatment (2-month follow-up), and at 5-month, and 15-month follow-ups. A manipulation check demonstrated that, as expected, both types of emotional disclosure led to immediate (post-session) increases in negative affect compared with arthritis information. Outcome analyses at all three follow-ups revealed no clear pattern of effects for either clinician-assisted or private emotional disclosure compared with the two control groups. There were some benefits in terms of a reduction in pain behavior with private disclosure vs. clinician-assisted disclosure at the 2-month follow-up, but no other significant between group differences. We conclude that verbal emotional disclosure about stressful experiences, whether conducted privately or assisted by a clinician, has little or no benefit for people with RA.

Work disability among two cohorts of women with recent-onset rheumatoid arthritis: a survival analysis

OBJECTIVE

To analyze factors associated with leaving employment among women with newly diagnosed rheumatoid arthritis (RA).

METHODS

Women with RA were recruited from a national sample of rheumatologists in 1987 and 1998. Inclusion criteria were RA diagnosis <18 months earlier, age >or=18 years, and no other disabling health condition. The 1987 and 1998 cohorts comprised 48 and 91 women, respectively. Data were collected by telephone for 4 years. Survival analysis was conducted using Kaplan-Meier curves and a proportional hazards generalized linear model to assess whether the time to stopping work differed between the cohorts and to identify baseline predictors and time-varying covariates of leaving work.

RESULTS

Most patients were age <50 years, married, had >12 years of education, and were white. Fifteen patients (31%) in the 1987 cohort and 24 patients (26%) in the 1998 cohort stopped working in the observation periods. Kaplan-Meier survival curves for each cohort were not significantly different. Multivariate analyses demonstrated that married women (P = 0.03) and those with joint deformities (P = 0.00) were more likely to stop working. A significant flares by cohort interaction (P = 0.01) indicated that, in comparison with patients in the 1998 cohort, those in the 1987 cohort with <2 disease flares had the lowest risk of stopping work and those with >or=2 flares had the greatest risk.

CONCLUSION

Unexpectedly, the cumulative rate of stopping work among women in the 1998 study did not differ from that among women diagnosed >16 years earlier. However, disease flares greatly affected employment in the 1987 but not the 1998 cohort, possibly indicating that newer medications were effective in maintaining functional status among those with more severe disease activity, measured by number of flares, in the 1998 group.

Disability, social support, and distress in rheumatoid arthritis: results from a thirteen-year prospective study

OBJECTIVE

To examine the strength and stability of the relationships between disease-related factors (joint tenderness, pain, and functional disability), social support, and distress over time, and to investigate to what extent disease-related factors and social support can predict distress in short-term and long-term rheumatoid arthritis (RA).

METHODS

The study was a Dutch extension of the European Research on Incapacitating Diseases and Social Support and started with 292 patients. After 5 waves of data collection, 129 patients remained. Composite measures were computed following the area under the curve approach. Interaction terms were computed between functional disability and social support satisfaction. Correlational and hierarchical regression analyses were performed.

RESULTS

In patients with short-term RA, disease-related factors and social support were important in determining distress. Also, a buffering effect of social companionship was found. In total, 51% of the variance in distress in short-term RA could be explained primarily by mean distress over the previous years. In patients with long-term RA, disease-related factors remained important in determining distress, but to a lesser extent. Seventeen percent of the variance in distress in long-term RA could be explained primarily by mean distress over the years before.

CONCLUSION

During the course of the disease, patients may learn to adjust to their disease and its consequences and are able to maintain a normal distress level. The effect of the disease on psychological distress decreased over the years. Some support for the buffering hypothesis of social support was found in short-term RA, but not in long-term RA.

Rheumatoid arthritis: a review of the cutaneous manifestations

Rheumatoid arthritis is a chronic inflammatory arthritis with significant extra-articular manifestations. Of note are unique cutaneous manifestations that the dermatologist may encounter. This article will make the dermatologist more cognizant of these skin findings in patients with this systemic inflammatory disorder. It examines rheumatoid arthritis, focusing on the general nonspecific and disease-specific rheumatoid arthritic skin changes. Classic rheumatoid nodules, accelerated rheumatoid nodulosis, rheumatoid nodulosis, rheumatoid vasculitis, Felty syndrome, pyoderma gangrenosum, interstitial granulomatosus dermatitis with arthritis, palisaded neutrophilic and granulomatosis dermatitis, rheumatoid neutrophilic dermatitis, juvenile rheumatoid arthritis, and adult-onset Still disease are reviewed. Understanding the cutaneous expressions of rheumatoid arthritis may lead to early diagnosis, prompt treatment, and lower morbidity and mortality for the affected persons. Learning objective At the completion of this learning activity, participants should be able to describe rheumatoid arthritis in terms of its epidemiology, etiology, pathogenesis, and general and specific cutaneous manifestations.

The development of emotional distress in 158 patients with recently diagnosed rheumatoid arthritis: a prospective 5-year follow-up study

OBJECTIVES

To describe the development of emotional distress among patients with newly diagnosed rheumatoid arthritis (RA), and to explore for early predictors of elevated distress over time.

METHODS

The study group consisted of 158 early RA patients (64% females) with mean age of 51.4 (SD = 12.7) years at disease onset. The patients were evaluated once a year for up to at least 4 years after baseline. Emotional distress was measured with the Symptom Checklist (SCL-90), disability with the Health Assessment Questionnaire (HAQ), pain with a visual analogue scale (VAS), and disease activity by an active joint count and erythrocyte sedimentation rate (ESR). Questions concerning social support were also included.

RESULTS

Emotional distress decreased slowly for a majority of the patients. The change reached statistical significance in the third year from study start. A minority (12%) showed continuously high and increasing levels of distress. Measures of disease activity were poor predictors of distress. The best predictor of distress over time was distress at baseline. Other predictors were gender, age, civil status, and social support.

CONCLUSIONS

Emotional distress tended to decrease for most patients in this cohort, but a minority showed continuously high levels. Patients at higher risk of developing emotional distress over time had higher levels of distress at baseline, were younger, more often female, and cohabiting, and experienced less social support.

Pain coping and social support as predictors of long-term functional disability and pain in early rheumatoid arthritis

Pain-related avoidance factors and social resources, as assessed by pain coping and social support, are supposed to have lasting effects on functional disability and pain in chronic pain disorders. As a follow-up to a prospective study demonstrating short-term effects after one year (Behaviour Research and Therapy, 36, 179-193, 1998), the role of pain coping and social support at the time of diagnosis was investigated in relationship to the long-term course of functional disability and pain after three and five years in 78 patients with rheumatoid arthritis (RA), taking into account personality characteristics of neuroticism and extraversion, clinical status and use of medication. In line with findings at the one-year follow-up, results showed that more passive pain coping predicted functional disability at the three-year, but not the five-year follow-up. In addition, low levels of social support at the time of diagnosis consistently predicted both functional disability and pain at the three and five-year follow-ups. Results indicate that pain coping and social support, assessed very early in the disease process, can affect long-term functional disability and pain in RA, and suggest that early interventions focusing on pain-related avoidance factors and social resources for patients at risk may beneficially influence long-term outcomes in RA.

Stress-vulnerability factors as long-term predictors of disease activity in early rheumatoid arthritis

OBJECTIVE

Stress-vulnerability factors were studied for their ability to predict long-term disease activity in early rheumatoid arthritis.

METHODS

In a prospective study involving 78 recently diagnosed rheumatoid arthritis (RA) patients, the role of personality characteristics (neuroticism, extraversion), physical and psychological stressors (chronic, disease-related stressors of functional disability, pain, disease impact on daily life, as well as major life events), coping and social support at the time of diagnosis was examined to predict changes in clinical indicators of disease activity 1, 3 and 5 years later.

RESULTS

While stress-vulnerability factors failed to predict disease activity at the 1-year follow-up, disease activity at the 3- and 5-year follow-ups was predicted by coping and social support at the time of diagnosis, after adjusting for disease activity at first assessment, other biomedical and psychosocial factors and use of medication. Low levels of social support predicted increased disease activity at the 3-year follow-up, and high avoidance coping predicted increased disease activity at the 3- and 5-year follow-ups.

CONCLUSION

Findings indicate the potential prognostic value of avoidance coping and social support for the long-term course of disease activity in early RA and suggest that the effects of these vulnerability factors predominantly operate in the long term.

Tailored cognitive-behavioral therapy in early rheumatoid arthritis for patients at risk: a randomized controlled trial

Recent developments in chronic pain research suggest that effectiveness of cognitive-behavioral therapy (CBT) may be optimized when applying early, customized treatments to patients at risk. For this purpose, a randomized, controlled trial with tailor-made treatment modules was conducted among patients with relatively early rheumatoid arthritis (RA disease duration of <8 years), who had been screened for psychosocial risk profiles. All participants received standard medical care from a rheumatologist and rheumatology nurse consultant. Patients in the CBT condition additionally received an individual CBT treatment with two out of four possible treatment modules. Choice of treatment modules was determined on the basis of patient priorities, which resulted in most frequent application of the fatigue module, followed by the negative mood, social relationships and pain and functional disability modules. Analyses of completers and of intention-to-treat revealed beneficial effects of CBT on physical, psychological and social functioning. Specifically, fatigue and depression were significantly reduced at post-treatment and at the 6-month follow-up in the CBT condition in comparison to the control condition, while perceived support increased at follow-up assessment. In addition, helplessness decreased at post-treatment and follow-up assessment, active coping with stress increased at post-treatment, and compliance with medication increased at follow-up assessment in the CBT condition in comparison to the control condition. Results indicate the effectiveness of tailor-made CBT for patients at risk in relatively early RA, and supply preliminary support for the idea that customizing treatments to patient characteristics may be a way to optimize CBT effectiveness in RA patients.

Responsiveness of the Impact on Participation and Autonomy questionnaire

OBJECTIVE

To evaluate the responsiveness of a newly developed generic questionnaire, the Impact on Participation and Autonomy (IPA), which focuses on 2 aspects of participation: perceived participation and the experience of problems.

DESIGN

Preliminary study of questionnaire responsiveness compared with transition indices. Participants completed 2 assessments, 3 months apart. To measure change, they completed 9 transition indices at the second assessment. One transition index assessed perceived change in general, the other 8 addressed 1 of the specific problem experience items in the IPA.

SETTING

Outpatient clinic of the rehabilitation department of an academic hospital.

PARTICIPANTS

Fifty-seven consecutive persons admitted for multidisciplinary rehabilitation treatment, with various diagnoses, were enrolled in the study; 49 persons completed both assessments.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Standardized response mean (SRM) and area under the receiver operating characteristic curve (AUC) for participation domain scores and problem scores.

RESULTS

SRMs and AUCs for the participation domains ranged from 0.1 to 1.3 and from 50% to 92%, respectively. The SRMs of the items on the experience of problems ranged from 0.4 to 1.5, whereas their AUCs ranged from 56% to 74%.

CONCLUSIONS

The IPA detected within-person improvement over time, but its responsiveness must be confirmed in a larger study sample.

Educational preferences, psychological well-being and self-efficacy among people with rheumatoid arthritis

As a basis for developing interventions to meet the psycho-educational needs of rheumatoid arthritis (RA) outpatients attending a regional hospital have been investigated. Specifically, patients' preferences for interventions addressing education (e.g. the disease and its treatment), self-management (e.g. pain-management, exercise) and the consequences (e.g. emotions, impact on work, family relationships) of RA were examined. In addition, psychological well-being and self-efficacy were examined. Results showed that patients preferred education about the disease and its treatment to be delivered on a one-to-one basis by health professionals. Similarly, emotional issues were believed to be best dealt with one-to-one although this could be with a similar other (i.e. a patient). Group interventions were the preferred format for self-management, exercise and relationship issues, whereas videos were thought to be useful for demonstrating use of aids and how other families cope. None of the participants would welcome computer-based interventions. Psychological well-being (e.g. depression, anxiety) remained stable over a 12-month period. Both physical and psychological health status were correlated with arthritis self-efficacy. The implications of these findings are discussed in relation to development of interventions to better meet the psycho-educational needs of outpatients with RA.

The course of depression in recent onset rheumatoid arthritis: the predictive role of disability, illness perceptions, pain and coping

BACKGROUND

This study aimed to investigate the course of depression for patients with recently diagnosed rheumatoid arthritis (RA) and to investigate predictors of depression.

METHODS

Twenty-two patients with a history of recently diagnosed RA of less than 2 years were assessed on a variety of clinical outcome and process measures on six assessment occasions over a 21-month period. These 22 patients constituted the control group of a controlled trial and received standard outpatient clinic treatment during follow-up.

RESULTS

Patients became significantly more depressed over time. A set of five factors were found to consistently predict depression at the following assessment. These were initial level of depression, disability, pain, beliefs about the consequences of arthritis and coping strategies.

CONCLUSIONS

The results confirm the importance of psychological factors in early RA and their relative independence from physical findings. This is the first study to document the importance of illness perceptions in recent onset RA.

Factors affecting emotional instability in female rheumatoid arthritis outpatients with limited functional disorder

Abstract We attempted to identify which background factors were the most important indicators of such psychological problems as emotional instability, a feeling of hopelessness, and suicidal tendencies in female rheumatoid arthritis (RA) outpatients with limited functional disorder. Among female RA patients aged 20 years and older who visited the outpatient clinic, 101 class I and II patients were selected as subjects for the present study. An original questionnaire and a psychological test (CMI) were given to those subjects who had given their written consent to such testing, and an analysis was carried out on 85 patients who returned all the written forms. Their emotional instability was related to factors such as "not being able to understand the nature of RA disease and its treatment," "sense of value had changed after developing RA," "nonuse of drugs," and "duration of disease." A feeling of hopelessness was related to "smoking," and a suicidal tendency was related to "smoking" and "class I." We identified a characteristic correlation between emotional instability and background factors in this study. Paying close attention to these factors may thus be useful in preventing the appearance of psychological problems as well as in developing effective early treatment strategies.

Tumour necrosis factor-alpha blockade: a new era for effective management of rheumatoid arthritis

Tumour necrosis factor (TNF)-alpha inhibitors have emerged as a new treatment option for rheumatoid arthritis (RA). The scientific rationale for targeting TNF-alpha in RA derives from extensive work in the laboratory, showing the importance of this pro-inflammatory cytokine as a mediator of joint inflammation. Proof of principle has now been firmly established in clinical trials where TNF-alpha inhibitors have been shown to decrease the signs and symptoms of joint inflammation and slow radiological progression of joint damage. Presently, the two TNF-alpha inhibitors available for use in RA are etanercept and infliximab. Etanercept is a soluble TNF receptor: Fc fusion protein that competes with the endogenous TNF receptors for TNF-alpha binding. Infliximab is a chimeric anti-TNF-alpha monoclonal antibody, which also binds with high affinity to soluble TNF-alpha. Etanercept and infliximab will be rapidly incorporated into current treatment paradigms, which call for early and intensive treatment of RA using disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, sulfasalazine and hydroxychloroquine. A major drawback to the widespread use of these biologics is their high costs. Some patients with limited financial means may be denied access to these effective anti-inflammatory agents. Moreover, long-term experience with TNF-alpha inhibitor therapy has been limited and concerns linger about the possibility that etanercept and infliximab may cause unforeseen side effects or increase the risk for opportunistic infection. Despite these caveats, TNF-alpha inhibitors represent a major advance for the treatment of RA and will likely spawn new indications for anti-TNF-alpha therapy and the development of novel therapeutic compounds with similar biological activity.

Reliability, repeatability, and sensitivity of the modified shuttle test in adult cystic fibrosis

STUDY OBJECTIVES

The purpose of this study was to investigate the test-retest reliability, repeatability, and sensitivity of the modified shuttle test (MST) in adult patients with cystic fibrosis (CF).

DESIGN

: Prospective study.

SETTING

Adult CF Unit, Belfast City Hospital.

PATIENTS

: Adult patients with CF.

INTERVENTIONS

Test-retest reliability-none; sensitivity-inpatient IV antibiotic therapy for an acute exacerbation of respiratory disease.

MEASUREMENTS

The test-retest reliability and repeatability of the MST was assessed by comparing performance on two consecutive MSTs performed in 12 patients with CF and stable disease. The sensitivity of the MST was assessed by measuring the change in MST performance after 2 weeks of IV antibiotic therapy in 24 patients admitted to hospital with acute exacerbations of their respiratory disease.

RESULTS

In the assessment of test-retest reliability and repeatability (n = 12), there was a significant and strong correlation between trials for distance completed (Pearson's r = 0. 99; p < 0.01), peak heart rate (Pearson's r = 0.99; p < 0.01), peak arterial oxygen saturation (SaO(2); Pearson's r = 0.99; p < 0.01), and peak Borg rating of perceived breathlessness (Pearson's r = 0. 99; p < 0.01). The coefficients of repeatability for these variables were small (coefficient of repeatability: distance completed, 4 shuttles; peak heart rate, 6 beats/min; peak SaO(2), 4%; and peak Borg rating of perceived breathlessness, 0.9). In the assessment of sensitivity (n = 24), the standardized response mean (SRM) for distance completed on MST (SRM = 1.18) was the SRMs for spirometric measures of lung function (FEV(1), SRM = 0.96; FEV(1) percent predicted, SRM = 0.88).

CONCLUSIONS

This study demonstrates that the MST is a reliable, repeatable, and sensitive measure of exercise capacity in adult CF. The MST may be of value in determining prognosis, evaluation for lung transplantation, exercise prescription, and establishing the impact of new treatments on the disability associated with CF.

Comparison of knowledge and psychological well-being between patients with a short disease duration (< or = 1 year) and patients with more established rheumatoid arthritis (> or = 10 years duration)

Patients with rheumatoid arthritis (RA) of short disease duration (i.e. < or = 1 year) compared with patients of longer disease duration (i.e. > or = 10 years) in terms of RA knowledge, symptoms of anxiety, symptoms of depression and disease acceptance. In addition, the predictors of psychological distress (i.e. symptoms of anxiety and depression) were examined. Data were collected by self-administered questionnaires. As expected, patients with more established disease were significantly older and had more physical dysfunction. However, there were no statistically significant differences on anxiety, depression, acceptance of illness, pain or knowledge about RA. The need for education regarding RA and its implications was expressed by all participants regardless of disease duration. Illness acceptance beliefs were identified as significant predictors of both anxiety and depression.

Psychosocial predictors of functional change in recently diagnosed rheumatoid arthritis patients

In order to examine the influence of active and passive pain-coping strategies and social support characteristics on the change in functional status in the first stage of the disease in rheumatoid arthritis patients, self-report data and clinical and laboratory measures were collected from 91 patients (70% female, mean age 57 yr) shortly after diagnosis and 1 yr later. Multiple regression analyses indicated that, after taking the influence of demographic variables, disease activity and pain into account, a decrease in functional status (mobility, self-care, grip strength) after 1 yr could be predicted by an initially more frequent use of the passive pain-coping strategies of worrying and resting. A decrease in mobility could be additionally predicted by an initially smaller social network. Results indicate the impact of passive pain-coping strategies and social network characteristics for the prognosis of functional outcome in the first stage of the disease and suggest the early manifestation of avoidance mechanisms, including behavioral, cognitive-emotional and social components, in face of a chronic stressor.

Determinants of psychological distress and its course in the first year after diagnosis in rheumatoid arthritis patients

In order to examine determinants of psychological distress and its course in the first year after diagnosis in rheumatoid arthritis patients, self-report data and clinical and laboratory measures were collected in 91 patients (70% female, mean age 57 years) shortly after diagnosis and 1 year later. Multiple regression analysis indicated that sex, pain and functional status, disease impact on daily life, life events, and perceived social support were related to psychological distress (anxiety and depressed mood) shortly after diagnosis. Coping strategies were related to distress levels only 1 year later. Multiple regression analysis of change in anxiety and depressed mood revealed that a decrease of psychological distress after 1 year could be predicted by male sex, an initially less severe inflammatory activity and an initially more extended social network. In addition, a decrease in distress was related to parallel improvements in clinical status. Results indicate the importance of a multimodal assessment of demographic variables, clinical and life stressors and social resources for the understanding of distress and the identification of risk factors in the first stage of the disease. Personal coping resources appear to become more important predictors of distress in a later phase of the disease.

Considerations for nonsteroidal anti-inflammatory drug therapy: benefits

In a Gallup survey of general practitioners, rheumatologists, and arthritis patients in six European countries, results indicated that nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed by physicians for their patients with arthritis. In addition, the surveyed patients reported that NSAIDs were effective in relieving arthritic pain, the most prominent symptom of their disease. Thus, NSAIDs continue to be useful and valuable drugs in the management of arthritis.

Clinical and public health perspectives and applications of health-related quality of life measurement

Health-related quality of life (HRQL) measures have been developed from the utilitarian ethical perspective of public health medicine which may be contrasted with individual-centered indicators; these emphasise the unique experience of a patient. The impairment-disability-handicap framework provides a more complete description of disease consequences and health outcomes than a generic HRQL indicator. The assessment of reliability and validity of HRQL indicators is often carried out inappropriately: population repeatability is measured when an indicator will be used to examine changes in individuals; between observer variation may be large compared with variation between populations. Content and construct validity are usually measured but the more important predictive validity is neglected. Effect sizes of HRQL indicators are likely to be inflated by use of between subject estimates of variance but the more appropriate within subject variance is seldom reported. HRQL indicators are of very limited value for many clinical and public health tasks: monitoring health of individuals and populations; evaluating the effects of health and social policy; allocating resources; evaluating the effects of treatment. Alternative methods of assessment derived from the impairment-disability-handicap conceptual framework are preferable.

Work disability in early rheumatoid arthritis

OBJECTIVE

To assess the impact of early rheumatoid arthritis (RA) on work status.

METHODS

The employment status of 119 patients who had jobs before the onset of RA was examined. Patients with work disability were compared with those without, for several disease characteristics, therapeutic regimen, and educational level and age.

RESULTS

Sixty two percent of the patients, particularly manual workers, reported some kind of work disability (7% worked less, 13% were on sick leave, and 42% had quit their jobs). Forty five patients (38%) stated that they were working without any restrictions; however, only 12 of this latter group (10% of the total group) had not encountered any changes at all within their jobs. The patients who reported work disability had a lower level of education and scored higher for several disease characteristics (erythrocyte sedimentation rate (ESR), joint tenderness, Health Assessment Questionnaire (HAQ), and Groningen Activity Restriction Scale) and were provided with more medication compared with patients without work disability, though only the educational level, disease duration, HAQ and ESR contributed significantly to work disability in logistic regression analysis.

CONCLUSION

Even at an early stage, RA has a considerable impact on work status. This study indicates that work disability is dependent on disease characteristics and on the educational level of the patient.

Concordant and discrepant views of patients' physical functioning

OBJECTIVE

Although considerable research has been done on patient-physician interaction, few studies have examined discrepancies between patients and physicians in their assessments of the patient's physical functioning. One recent study reports such discrepancies between rheumatologists and 41% of their rheumatoid arthritis patients. This article reports data replicating that study and examining the relationships between such discrepancies and a number of other variables.

METHODS

This is a longitudinal study of 158 patients with rheumatoid arthritis who were interviewed 4 times over a 2-year period and who reported their levels of physical functioning on the Arthritis Impact Measurement Scales. At the time of the fourth interview, the rheumatologists rated each patient's physical functioning on the revised criteria published by the American College of Rheumatology.

RESULTS

Rheumatologists' assessments of their patients' physical functioning were discrepant with the patient's assessment for 35% of these patients. Twenty-seven patients were rated as worse than they rated themselves and 28 were rated as better. There were no differences between the concordant and the two discrepant groups in demographic or health status characteristics.

A randomized trial of hydroxychloroquine in early rheumatoid arthritis: the HERA Study

PURPOSE

Studies of the efficacy of hydroxychloroquine in rheumatoid arthritis have had methodological flaws and have failed to produce definitive results. The benefits and toxicity of hydroxychloroquine sulfate in 120 patients with rheumatoid arthritis of less than 2 years duration are assessed.

PATIENTS AND METHODS

A 36-week randomized double-blind, placebo-controlled trial was conducted at two university centers and four community rheumatology private practices. Patients had to have had their disease for less than 2 years and to have never received a second-line drug. Patients were randomly assigned to receive hydroxychloroquine or an equivalent number of placebo tablets in a dose of up to 7 mg/kg per day (maximum 400 mg/day). The initial dose was half the maximum dose and, if after 2 weeks of treatment there had been no side effects, the full dose was prescribed. There were four a priori primary outcomes: (1) a joint index composed of the tender joint count, the swollen joint count, the grip strength, and the duration of morning stiffness; (2) a pain index composed of the pain dimension of the Arthritis Impact Measurement Scales (AIMS) and the visual analog pain scale of the Health Assessment Questionnaire (HAQ); (3) a physical function index composed of the HAQ, the physical disability dimension of the AIMS, and the McMaster-Toronto Arthritis Patient Performance Disability Questionnaire; (4) the psychological function subscale of the AIMS. Secondary outcomes included adverse events, patient and physician global assessments, hematocrit, erythrocyte sedimentation rate (ESR) and corticosteroid usage. An intent-to-treat analysis assessed improvement at 36 weeks by Student's t-test and average improvement over the course of the study by analysis of variance for repeated measures.

RESULTS

Of 148 eligible patients, 120 were randomized. The characteristics of those randomized to hydroxychloroquine compared to placebo were similar at the study onset. At 36 weeks and over the course of the study there was statistically significant improvement in the joint index (P = 0.004, P = 0.034, respectively), the pain index (P = 0.007, P = 0.001, respectively), and the physical function index (P = 0.020, P = 0.011, respectively) in the group receiving hydroxychloroquine compared to the placebo group. There was no improvement in psychological function for hydroxychloroquine compared to placebo (P = 0.837 at 36 weeks, P = 0.89 over the course of the study). Among the secondary outcomes there was significant improvement only in the patient's (P = 0.01) and the outcome assessor's (P = 0.03) assessment of change and a trend towards a fewer number of intra-articular corticosteroid injections (P = 0.05) in the hydroxychloroquine-treated group. There were no important differences in the side effects between hydroxychloroquine or placebo.

CONCLUSION

Over 36 weeks, hydroxychloroquine had a significant benefit on synovitis, pain, and physical disability of recent-onset rheumatoid arthritis, but did not benefit psychological function.

Purine enzymes in rheumatoid arthritis: possible association with response to azathioprine. A pilot study

OBJECTIVE

To study the possible association of purine enzyme activities with response to azathioprine (AZA) treatment in rheumatoid arthritis (RA) and their correlation with parameters of disease activity.

PATIENTS AND METHODS

Lymphocyte activities of hypoxanthine-guanine phosphoribosyl-transferase (HGPRT), adenine phosphoribosyltransferase (APRT), purine nucleoside phosphorylase (PNP) and 5'-nucleotidase (5NT), and erythrocyte activities of thiopurine methyltransferase (TPMT) were measured in 14 healthy controls and 36 patients with RA. Eight patients had not previously been treated with AZA. Response to AZA therapy in 28 patients, determined in a prospective trial, was considered good in nine (group 1), insufficient in seven (group 2). In 12 patients AZA was withdrawn because of adverse reactions (group 3). Disease activity parameters were obtained simultaneously with purine enzyme measurements. Purine enzyme levels in the different groups were compared.

RESULTS

Levels of 5NT activity were significantly lower in patients with RA than in healthy controls. PNP activity was higher in patients with RA not using prednisone compared with those who did and healthy controls. No clear correlation between purine enzyme levels and disease activity parameters was found. 5NT activities were significantly higher in group one than in group three (p = 0.012; alpha = 0.017), and almost significantly higher than in group two (p = 0.03; alpha = 0.017).

CONCLUSIONS

The results indicate that purine enzyme activities in patients with RA differ from healthy controls, are associated with the outcome of AZA treatment and seem not to be associated with disease activity. Our findings may offer a clue to predict the response to AZA therapy in RA.

Methotrexate-related pulmonary complications in patients with rheumatoid arthritis: cluster of five cases in a period of three months

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Early, aggressive therapy for rheumatoid arthritis: concerns, descriptions, and estimate of outcome

The past few years have witnessed changing perceptions about rheumatoid arthritis (RA); it is now considered a serious systemic disease that confers not only physical and social morbidity but also earlier mortality. The long-term outcome of sequential monotherapy based on the therapeutic pyramid has been disappointing. A review of prognostic factors, acute disease activity measures, functional measures, and the results of preliminary trials with combination therapy suggests that specific goals of treatment can be established and that logical, aggressive treatment in early disease can be accomplished. These goals should include prompt control and continuous reduction of the active joint count to < or = 4 and normalization of acute-phase reactants. The "graduated-step paradigm" of treatment designed with these goals in mind is described, and a retrospective series that gives an estimate of outcome with its use is reported.

Self report functional disability scores and the use of devices: two distinct aspects of physical function in rheumatoid arthritis

OBJECTIVES

Self report scores of physical disability and the use of devices or assistance in performing activities are sometimes integrated in one index of physical function, although they are aimed at measuring different dimensions of physical disability. The properties of both parameters were evaluated in two groups of patients with rheumatoid arthritis (RA).

METHODS

A group of patients with RA of recent onset was compared with a group with established disease on four parameters of disability: use of devices, use of personal assistance, and scores on a validated Dutch version of the Health Assessment Questionnaire Disability Index, with and without integrating the use of devices or assistance. Correlation coefficients among disability parameters were calculated. In multiple regression analysis the influence of disease duration on the disability parameters was determined after disease activity, psychological wellbeing, and demographical characteristics had been controlled.

RESULTS

Functional disability scores were mainly related to inflammatory activity and psychological wellbeing, whereas the uses of devices had a strong relation with disease duration, independent of current disease activity. Integrating these parameters of disability yielded a parameter that was still mainly associated with disease activity.

CONCLUSION

Self report scores of functional disability and the use of devices represent distinct dimensions of physical function in RA. Integrating both parameters into one measure of physical disability does not provide an index adequately reflecting both dimensions. The use of both parameters to measure outcome in long term clinical studies is recommended.

Importance of sensitivity to change as a criterion for selecting health status measures

OBJECTIVE

To assess the sensitivity to change over time of four health status instruments in relation to patients with rheumatoid arthritis.

DESIGN

Observational three month study of four self assessed instruments (arthritis impact measurement scales (AIMS), health assessment questionnaire (HAQ), Nottingham health profile (NHP), functional limitations profile (FLP)).

SETTING

One rheumatology unit.

PATIENTS

101 patients with definite or classic rheumatoid arthritis.

MAIN MEASURES

Change scores for dimensions of instruments, as determined by effect size (mean change in score/baseline standard deviation of variable) and conventional rheumatological measures, at baseline and after three months.

RESULTS

Change scores for comparable dimensions (mobility, activities of daily living, household, pain, mood or emotion, and social scales) of the instruments were compared among 30 patients who considered their health status to have improved over three months. For all dimensions of health status the magnitude of change varied considerably according to the instrument. Maximum range in effect size was for social scales (AIMS 0.06, NHP 0.24, FLP 0.60). No single instrument seemed consistently to show the most change over all dimensions.

CONCLUSION

Selection of health status instruments for audit or evaluation may have a considerable impact on the pattern of results obtained, and the "responsiveness" of such scales should be as carefully examined as their reliability and acceptability when selecting outcome measures.