Epidemiology of rheumatoid arthritis in Finland

Comorbidities and Causes of Death of Patients With Asbestosis

OBJECTIVE

Comorbidities are common and affect the prognosis of patients with interstitial lung diseases, but few previous studies have investigated patients with asbestosis.

METHODS

We collected comorbidities and death causes of 116 patients with asbestosis treated in Oulu University Hospital. Causes of death were confirmed by autopsy in 68% of the cases.

RESULTS

The most common comorbidities of asbestosis patients were pleural plaques (96%) and coronary artery disease (CAD; 67%). The prevalence of rheumatoid arthritis was 8.6%. The most common underlying causes of death were asbestosis (36%), CAD (24%), and lung cancer (LC) (10%). CAD and LC were associated with shorter survival in adjusted analyses.

CONCLUSIONS

Patients with asbestosis have multiple comorbidities. Prevention and treatment of CAD and LC may influence the prognosis of asbestosis patients.

Global epidemiology of rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic autoimmune disease that predominantly affects the joints. The prevalence of RA varies globally, with generally a higher prevalence in industrialized countries, which may be explained by exposures to environmental risk factors, but also by genetic factors, differing demographics and under-reporting in other parts of the world. Over the past three decades, strong trends of the declining severity of RA probably reflect changes in treatment paradigms and overall better management of the disease. Other trends include increasing RA prevalence. Common risk factors for RA include both modifiable lifestyle-associated variables and non-modifiable features, such as genetics and sex. A better understanding of the natural history of RA, and of the factors that contribute to the development of RA in specific populations, might lead to the introduction of specific prevention strategies for this debilitating disease.

Tuberculosis in people with rheumatic disease in Finland 1995-2007: a nationwide retrospective register study

Objectives

RA and its medication, especially TNF-α inhibitors, increase the risk of clinical tuberculosis (TB) infection. We aimed to investigate the clinical manifestations, incidence and temporal changes in TB occurring concurrently with rheumatic diseases (RDs) between 1995 and 2007.

Methods

We combined the register of the Social Insurance Institution of Finland and the National Infectious Disease Register to find adult patients with reimbursed DMARDs and with a TB notification between 1995 and 2007. After reviewing the medical records, we described their clinical manifestations and medications, explored TB incidence trends using Poisson regression, and compared the incidence of TB with that of the general population.

Results

We identified 291 patients with both TB and rheumatic disease (RD), 196 of whom had RA. Between 1995 and 2007, the incidence of TB in adult RD decreased from 58.8 to 30.0 per 100 000 (trend P < 0.001, average marginal effect -3.4/100 000 per year, 95% CI -4.4, -2.4). Compared with the general population, the incidence was ∼4-fold. Among RD patients, pulmonary TB was the most common form of TB (72.6%). Disseminated TB was present in 56 (19.6%) patients.

Conclusion

The incidence of TB among RD patients was ∼4-fold that of the general population, and it declined between 1995 and 2007. Disseminated TB was present in nearly 20% of patients.

A Systematic Review about the Efficacy and Safety of Tripterygium wilfordii Hook.f. Preparations Used for the Management of Rheumatoid Arthritis

Tripterygium wilfordii Hook.f. (TWHF) is a traditional Chinese herb long used for rheumatoid arthritis (RA) treatment, in modern times, often in the form of various Tripterygium wilfordii Hook.f. preparations (TWPs). This systematic review and meta-analysis focuses on analyzing the clinical efficacy and safety of TWPs in the treatment of RA. Databases were searched to collect the randomized controlled trials (RCTs) on TWPs treating RA published on or before April 10, 2017. Data from 11 studies were included in this meta-analysis. Compared with the control group, TWPs can increase effectiveness, while decreasing erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), C-reactive protein (CRP), and risk of adverse events. TWPs treatment was also more effective than treatment by conventional western medicine (CWM) and Chinese patent medicine or placebo (COP). TWPs significantly decreased the risk of adverse events compared with the CWM group, but not compared with the COP group. Current evidence shows that TWPs are more effective than other western or Chinese medicines we included in this meta-analysis for RA treatment with relatively lower toxicity.

Prevalence of rheumatoid arthritis in the United States adult population in healthcare claims databases, 2004-2014

This study aimed to determine the prevalence of rheumatoid arthritis in the United States (US) adult insured population from 2004 to 2014. This was an observational, retrospective, cross-sectional study based on US administrative health insurance claims databases (Truven Health MarketScan^® Research database and IMS PharMetrics Plus database). Trends in RA prevalence focusing on the 10-year period covering January 1, 2004-December 31, 2014 were analyzed using a validated algorithm for the identification of RA. Prevalence rates in the databases were determined and age- and gender-adjusted rates were projected to the US population in 2014. Analysis of data from the two databases indicated that the RA prevalence rate in commercially insured adult US population ranged from 0.41 to 0.54% from 2004 to 2014. The prevalence varied substantially by gender and age in each year and increased gradually across the years for most subgroups. In 2014, out of 31,316,902 adult patients with continuous enrollment in the Truven Health MarketScan^® Research database, 157,634 (0.50%) patients met our criteria for RA. Similarly, out of 35,083,356 adult patients in the IMS PharMetrics Plus database, 139,300 (0.50%) patients met our criteria for RA. In 2014, the overall age-adjusted prevalence of RA ranged from 0.53 to 0.55% (0.29-0.31% for males and 0.73-0.78% for females). The prevalence of RA in the US appeared to increase during the period from 2004 to 2014, affecting a conservative estimate of 1.28-1.36 million adults in 2014.

Clinical and laboratory features of patients with rheumatoid arthritis diagnosed at rheumatology services in the Brazilian municipality of Cascavel, PR, Brazil

INTRODUCTION

Brazilian epidemiological studies on rheumatoid arthritis are scarce, thus all data currently available originate from the international literature.

OBJECTIVES

To determine the incidence and some clinical and laboratory characteristics of patients with rheumatoid arthritis in the municipality of Cascavel, state of Paraná, Brazil.

PATIENTS AND METHODS

Data were collected between August 2010 and July 2011 in all health services of the municipality of Cascavel that provided health care in Rheumatology: a university-affiliated hospital, a public outpatient clinic and four private clinics.

RESULTS

We identified 38 patients diagnosed with rheumatoid arthritis, resulting in an estimated incidence of 13.4 cases per 100,000 inhabitants/year. Thirty two patients were females, whose mean age was 47.6 years. The age group with the highest incidence was over 40 years. The mean time between first symptoms and diagnosis was 12.4 months. Rheumatoid factor was positive in 68.4% of the patients, and 18.4% already had radiological abnormalities at diagnosis. The pharmacological treatment of patients was also assessed and proved to be in accordance with those found in the literature.

CONCLUSION

The incidence of rheumatoid arthritis obtained in the municipality of Cascavel was lower than those reported in international studies.

Prevalence and incidence of rheumatoid arthritis in South Korea

Several studies of rheumatoid arthritis (RA) incidence and prevalence indicate that occurrence of the disease varies significantly among different populations. We aimed to estimate the prevalence and incidence of RA in South Korea. We used Korean National Health Insurance (NHI) claims data to estimate the prevalence of RA in 2007-2009 and the incidence of RA in 2008. On the basis of our previous validation study, the presence of RA was defined by the diagnostic code for RA with biologic or non-biologic disease-modifying anti-rheumatic drugs in the same claim in each year. To estimate the incidence of RA, we identified cases of RA in 2008 and set the 12-month period prior to 2008 as a disease-free period. Among the incident case of 2008, only patients who continued treatment in 2009 were defined as true incident case of RA in 2008. The corresponding prevalence estimates were 0.26 % (95 % CI 0.25-0.27) in 2006, 0.27 % (95 % CI 0.26-0.28) in 2007, and 0.27 % (95 % CI 0.26-0.28) in 2008. The incidence of RA in 2008 was estimated at 42/100,000 (95 % CI 29.3-54.7) in the general population of South Korea. Data gathered nationwide through the NHI yielded estimates of RA prevalence and incidence in South Korea. This study is the first report of nationwide prevalence and incidence of South Korea and those are comparable to values for other countries in Asia.

Systematic review and meta-analysis of the efficacy and safety of existing TNF blocking agents in treatment of rheumatoid arthritis

Background and Objectives

Five-tumour necrosis factor (TNF)-blockers (infliximab, etanercept, adalimumab, certolizumab pegol and golimumab) are available for treatment of rheumatoid arthritis. Only few clinical trials compare one TNF-blocker to another. Hence, a systematic review is required to indirectly compare the substances. The aim of our study is to estimate the efficacy and the safety of TNF-blockers in the treatment of rheumatoid arthritis (RA) and indirectly compare all five currently available blockers by combining the results from included randomized clinical trials (RCT).

Methods

A systematic literature review was conducted using databases including: MEDLINE, SCOPUS (including EMBASE), Cochrane library and electronic search alerts. Only articles reporting double-blind RCTs of TNF-blockers vs. placebo, with or without concomitant methotrexate (MTX), in treatment of RA were selected. Data collected were information of patients, interventions, controls, outcomes, study methods and eventual sources of bias.

Results

Forty-one articles reporting on 26 RCTs were included in the systematic review and meta-analysis. Five RCTs studied infliximab, seven etanercept, eight adalimumab, three golimumab and three certolizumab. TNF-blockers were more efficacious than placebo at all time points but were comparable to MTX. TNF-blocker and MTX combination was superior to either MTX or TNF-blocker alone. Increasing doses did not improve the efficacy. TNF-blockers were relatively safe compared to either MTX or placebo.

Conclusions

No single substance clearly rose above others in efficacy, but the results of the safety analyses suggest that etanercept might be the safest alternative. Interestingly, MTX performs nearly identically considering both efficacy and safety aspects with a margin of costs.

Cost-effectiveness of adalimumab, etanercept, and tocilizumab as first-line treatments for moderate-to-severe rheumatoid arthritis

OBJECTIVE

The aim of this study was to assess the cost-utility and value of reducing the uncertainty associated with the decision to use first-line biologic treatment (bDMARD) after the failure of one or more traditional drugs (tDMARD) in moderate-to-severe rheumatoid arthritis (msRA) in Finland.

RESEARCH DESIGN AND METHODS

The treatment sequences were compared among 3000 hypothetical Finnish msRA patients using a probabilistic microsimulation model in a lifetime scenario. Adalimumab + methotrexate, etanercept + methotrexate, or tocilizumab + methotrexate were used as first biologics followed by rituximab + methotrexate and infliximab + methotrexate. Best supportive care (BSC), including tDMARDs, was assumed to be used after the exhaustion of the biologics. Methotrexate alone was added as a further comparator. Efficacy was based on ACR responses that were obtained from a mixed treatment comparison. The resources were valued with Finnish unit costs (year 2010) from the healthcare payer perspective. Additional analyses were carried out, including productivity losses. The Health Assessment Questionnaire (HAQ) values were mapped to the EQ-5D values using the tocilizumab trials; 3% annual discounting for costs and quality-adjusted life years (QALY) and extensive sensitivity analyses were completed.

MAIN OUTCOME MEASURES

Incremental cost per QALY gained and multinomial expected value of perfect information (mEVPI).

RESULTS

bDMARDs significantly increase the QALYs gained when compared to methotrexate alone. Tocilizumab + methotrexate was more cost-effective than adalimumab + methotrexate or etanercept + methotrexate in comparison with methotrexate alone, and adalimumab + methotrexate was dominated by etanercept + methotraxate. A QALY gained with retail-priced (wholesale-priced) tocilizumab + methotrexate costs €18,957 (€17,057) compared to methotrexate alone. According to the cost-effectiveness efficiency frontier and cost-effectiveness acceptability frontier (CEAF), tocilizumab + methotrexate should be considered before rituximab + methotrexate, infliximab + methotrexate, and BSC. Based on the CEAF, tocilizumab + methotrexate had a 60-93% probability of being cost-effective with €20,000 per QALY gained (mEVPI €230-2182).

CONCLUSIONS

Tocilizumab + methotrexate is a potentially cost-effective bDMARD treatment for msRA, indicating a low value of additional research information with the international threshold values.

LIMITATIONS

Efficacy based on an indirect comparison (certolizumab pegol, golimumab excluded), fixed treatment sequence after the exhaustion of first bDMARD, Swedish resource use data according to HAQ scores, and inpatient costs assumed to include surgery.

The effectiveness of nurse-led care in people with rheumatoid arthritis: a systematic review

OBJECTIVES

The objective of this systematic review was to determine the effectiveness of nurse-led care in rheumatoid arthritis.

DESIGN

Systematic review of effectiveness.

DATA SOURCES

Electronic databases (AMED, CENTRAL, CINAHL, EMBASE, HMIC, HTA, MEDLINE, NHEED, Ovid Nursing and PsycINFO) were searched from 1988 to January 2010 with no language restrictions. Inclusion criteria were: randomised controlled trials, nurse-led care being part of the intervention and including patients with RA.

REVIEW METHODS

Data were extracted by one reviewer and checked by a second reviewer. Quality assessment was conducted independently by two reviewers using the Cochrane Collaboration's Risk of Bias Tool. For each outcome measure, the effect size was assessed using risk ratio or ratio of means (RoM) with corresponding 95% confidence intervals (CI) as appropriate. Where possible, data from similar outcomes were pooled in a meta-analysis.

RESULTS

Seven records representing 4 RCTs with an overall low risk of bias (good quality) were included in the review. They included 431 patients and the interventions (nurse-led care vs usual care) lasted for 1-2years. Most effect sizes of disease activity measures were inconclusive (DAS28 RoM=0.96, 95%CI [0.90-1.02], P=0.16; plasma viscosity RoM=1 95%CI [0.8-1.26], p=0.99) except the Ritchie Articular Index (RoM=0.89, 95%CI [0.84-0.95], P<0.001) which favoured nurse-led care. Results from some secondary outcomes (functional status, stiffness and coping with arthritis) were also inconclusive. Other outcomes (satisfaction and pain) displayed mixed results when assessed using different tools making them also inconclusive. Significant effects of nurse-led care were seen in quality of life (RAQoL RoM=0.83, 95%CI [0.75-0.92], P<0.001), patient knowledge (PKQ RoM=4.39, 95%CI [3.35-5.72], P<0.001) and fatigue (median difference=-330, P=0.02).

CONCLUSIONS

The estimates of the primary outcome and most secondary outcomes showed no significant difference between nurse-led care and the usual care. While few outcomes favoured nurse-led care, there is insufficient evidence to conclude whether this is the case. More good quality RCTs of nurse-led care effectiveness in rheumatoid arthritis are required.

Prevalence of rheumatoid arthritis in the eastern Black Sea region of Turkey

AIM

The aim of this study was to estimate the prevalence of rheumatoid arthritis (RA) in the eastern Black Sea region of Turkey.

METHOD

The study was carried out between March 2003 and March 2005 by the Karadeniz Technical University Medical Faculty Department of Physical Medicine and Rehabilitation in the urban area in the eastern Black Sea region of Turkey, which has a population of 459021 (according to the 2000 national census). A total of 6103 subjects, 20 years old or over, were selected by the sampling method; 3023 (49.5%) women and 3080 (50.5%) men were included in the study. The diagnosis of RA was performed based on fulfilling the American College of Rheumatology (ACR) criteria.

RESULTS

Fifty-nine patients were diagnosed with RA according to the ACR criteria, of which 11 were male and 48 female. The prevalence of RA was 1% (95% CI: 0.75-1.25) in the general population, 1.6% (95% CI: 1.15-2.05) in women and 0.35% (95% CI: 0.14-0.56) in men. The female/male ratio was 4.3 : 1.0, showing that RA prevalence was statistically significantly higher in women (P <0.005).

CONCLUSION

Our study demonstrates that RA is a common disease in Turkish society.

Dietary fish and fish oil and the risk of rheumatoid arthritis

BACKGROUND

Intake of fish oil and oily fish has been reported to improve clinical symptoms in people who have rheumatoid arthritis. Whether the intake of oily fish and fish oil might also protect against the development of rheumatoid arthritis is not known.

OBJECTIVE

We investigated the association between intake of oily fish and fish oil supplements and the risk of rheumatoid arthritis in a population-based case-control study.

METHODS

The study comprised 1889 incident cases of rheumatoid arthritis and 2145 randomly selected controls recruited from a geographically defined area of Sweden during 1996-2005. Data on the consumption of oily fish and fish oil supplements 5 years preceding enrollment had been obtained through a questionnaire. We calculated odds ratios (ORs) for the development of rheumatoid arthritis, using logistic regression to adjust for age, residential area, body mass index, smoking, and alcohol consumption.

RESULTS

Compared with subjects who never or seldom consumed oily fish, the OR for developing rheumatoid arthritis was 0.8 (95% confidence interval = 0.6-1.0) for subjects who consumed oily fish 1-7 times a week. The results did not change notably when stratifying the cases for rheumatoid factor or for antibodies to citrullinated peptide antigens. Similar results were seen for subjects consuming oily fish 1-3 times a month. Cases and controls did not differ in their consumption of fish oil supplements.

CONCLUSION

Intake of oily fish was associated with a modestly decreased risk of developing rheumatoid arthritis.

Willingness to pay for improvement of physical function among rheumatoid arthritis patients as measured by Health Assessment Questionnaire

The main objective of this study was to assess the symptoms and functional difficulties caused by rheumatoid arthritis through application of the willingness to pay (WTP) method. Structured questionnaire study was conducted among 242 RA patients. The subjects were asked to evaluate their functional capacity using visual analog scales (VAS) for all the 20 questions in the Health Assessment Questionnaire (HAQ). Each VAS was followed by a question asking how much the respondent would be willing to pay on a monthly basis for a 50% improvement with the function in question. These were combined with later collected data on clinical status and use of RA-related health services. The average WTP varied greatly in the examined 20 different functions. The total WTP average on a 50% improved functional capacity amounted to <euro> 567.05 per month. Patients with lower functional capacity (HAQ 1.2 or more) were ready to contribute significantly (p < 0.001) more (705 euros/month) than those with better functional status (199 euros/month). Subjects, whose financial standing was better, reported a higher total WTP (r = 0.218, p < 0.01). On average, the total WTP of the respondents equaled 18.44% of the disposable net monthly income per person of the household. However, the variation was quite substantial. WTP among patients with rheumatoid arthritis was best depicted through the functional capacity of the patient, the possible time the patient had retired, and the global feeling of pain. In conclusion, monetary value is a concrete way of portraying subjective valuation. WTP method is suitable for assessing functional deficits of rheumatoid arthritis.

Infectious causes of death in patients with rheumatoid arthritis: an autopsy study

OBJECTIVE

To study mortality from infections and accuracy of pre-mortem diagnoses in patients with rheumatoid arthritis (RA) autopsied during a 40-year period.

METHODS

We investigated infectious causes of death, findings at autopsy, and clinicians' estimation of cause of death in 369 consecutively autopsied RA and 371 autopsied non-RA patients with same sex, age at death, and year of autopsy. We also compiled clinical features of RA patients from medical records available and examined the association between these and infectious causes of death.

RESULTS

Deaths from any infection were more frequent in RA (36%) than in non-RA (26%) patients. In both groups, respiratory and urinary tract infections were the most common infectious causes of death. More RA patients died from urinary tract infections than non-RA patients. In approximately half of the patients in both groups, infection as a cause of death was unrecognized before death, with no major change occurring over the 40-year study period.

CONCLUSIONS

Infections, especially respiratory and urinary tract infections, are frequent causes of death in RA patients. The high proportion of undiscovered infections as a cause of death highlights the diagnostic difficulty. With a decreasing number of autopsies being performed at present, greater numbers of infections may be under-reported.

Finnish patients with inflammatory bowel disease have fewer symptoms and are more satisfied with their treatment than patients in the previous European survey

OBJECTIVE

Symptoms associated with inflammatory bowel diseases (IBD) have a negative impact on quality of life. The purpose of this study was to assess the quality of life in a large group of Finnish IBD patients and to compare it with that observed in a recent survey covering several other European countries.

MATERIAL AND METHODS

The European Federation of Crohn's and Ulcerative Colitis Associations (EFCCA) questionnaire, comprising questions about IBD symptoms, diagnosis, therapy, extraintestinal manifestations and their impact on patients' quality of life, was sent to 3852 members of the Finnish Crohn and Colitis Association. The response rate was 63%.

RESULTS

IBD was diagnosed by a specialist in over 96% of cases and 94% of patients were continuously followed-up by a specialist. Fifty-eight percent of the patients had had IBD symptoms for over a year before consulting a specialist. The frequency of symptoms was lower in the Finnish patients and 93% of patients were satisfied with their current treatment compared with 76% in the European survey. For Crohn's disease, the rate of surgery was lower than that in the European survey (43% versus 52%). The patients reported improved quality of life after surgery, but 67% of patients with Crohn's disease and 34% with ulcerative colitis reported recurrence of symptoms. Comorbidity with ankylosing spondylitis was 22 times more common than in the general Finnish population and 49% of the patients suffered from joint pain.

CONCLUSIONS

Finnish IBD patients are more satisfied with their treatment than those studied in the European survey. In Finland, gastroenterologists are usually responsible for the care, but the delay before the diagnosis remains long.

The constancy of work-related empowerment

OBJECTIVE

This study describes experiences of work empowerment among staff members at the Rheumatism Foundation Hospital in Helsinki, Finland.

METHODS

The data were collected on two occasions in 2004 and 2005 using a structured questionnaire with background variables and items concerning verbal, behavioural and outcome empowerment. The questionnaires were sent to all (n1=115, n2=112) members of multidisciplinary teams at the Rheumatism Foundation Hospital, with the exception of physicians, departmental secretaries and administrative personnel. The response rate at both data collections was 58%. The data were analysed by statistical methods.

RESULTS

No statistically significant differences were seen in work empowerment between the two data collections. Perceptions of work-related empowerment were relatively strong.

CONCLUSIONS

Work-related empowerment appears to be relatively constant and independent of changes in the organization. Indeed there is good reason to ask whether work empowerment is primarily a function of the individual employee's strengths and competencies.

Costs of rheumatoid arthritis: new estimates from the human capital method and comparison to the willingness-to-pay method

BACKGROUND

Individuals' valuation of changes in health states in monetary terms have been measured by examining changes in the direct and indirect costs of disease and by the willingness-to-pay (WTP) methodology.

METHODS

In 2002, a 2-part study was conducted in Quebec. In one part of the study, 121 rheumatoid arthritis (RA) patients from the McGill University Health Centre were mailed the Stanford Cost Assessment Questionnaire, which enabled the elicitation of direct costs and indirect costs, according to the friction cost and the human capital methods. The other part was a phone survey conducted in a representative sample of the general population and in the same sample of patients, aiming to elicit the societal WTP for a complete cure of RA in the context of 2 different scenarios: a public coverage or private insurance. These estimates were then compared.

RESULTS

Estimates of the cost of illness of RA ranged from 11,717 to 28,498 Canadian Dollars (CAD) depending on the method. These estimates are higher than those previously published in Canada from the 1990s, which is partly due to the recent and costly biological therapies and to a change in the measurement of productivity losses. These estimates are somewhat lower than the societal WTP elicited from the WTP survey, that is, 26,717 and 36,817 CAD per RA case, depending on the public or private health insurance context in which the cure would be available.

CONCLUSION

Given that neither method is ideal, data from both methods would provide an important sensitivity analysis when monetary estimates of health state changes are required.

Progression of radiographic joint damage in different eras: trends towards milder disease in rheumatoid arthritis are attributable to improved treatment

BACKGROUND

Severity of rheumatoid arthritis and progression of radiographic joint damage have decreased over the last decades.

AIM

To examine whether this trend is attributable to an underlying trend towards milder disease or to improved treatment.

METHODS

The study used an inception cohort of patients with early rheumatoid arthritis seen at the Wichita Arthritis Center, Wichita, Kansas, USA, since 1973 and monitored prospectively since their first clinic visit through clinical, radiographic, laboratory, demographic and self-reported data. The radiographic disease progression in patients with disease onset in the 1970s, 1980s and 1990s was compared using a multivariate regression model for longitudinal data. The analysis was adjusted for differences in baseline predictors, type of disease-modifying antirheumatic drugs (DMARDs) and steroid use.

RESULTS

418 patients with rheumatoid arthritis with radiographic follow-up were included. Patients in earlier decades used fewer DMARDs, had longer disease durations and higher tender joint counts at their first visit. Other important predictors of disease progression did not differ significantly between decades of disease onset. The unadjusted rates of radiographic progression differed between decades (analysis of variance, p = 0.01), with a significant trend towards less radiographic progression in more recent times (trend, p<0.001). However, after adjusting for DMARD use, steroid use and baseline predictors, differences between decades vanished (analysis of variance, p = 0.40) and the trend towards less radiographic progression disappeared (trend, p = 0.45).

CONCLUSION

These results suggest that the observed trend towards milder disease in rheumatoid arthritis is attributable to more effective antirheumatic treatment and not to a secular trend.

Work-related empowerment of the multidisciplinary team at the Rheumatism Foundation Hospital

Carried out as part of a staff development project, this study describes the experiences of work-related empowerment within a multidisciplinary team at the Rheumatism Foundation Hospital in Finland. The data were collected using a structured questionnaire consisting of background variables and questions concerning verbal, behavioural and outcome empowerment. The questionnaire was sent to all members of the multidisciplinary team at the Rheumatism Foundation Hospital, with the exception of physicians, departmental secretaries and administrative personnel. The response rate was 58%. The data were examined using statistical methods. The multidisciplinary team felt quite strong verbal and behavioural empowerment, but was less confident in terms of outcome empowerment. Several factors were found to be associated with the different fields of empowerment. In conclusion, the multidisciplinary team felt quite strong work-related empowerment.

Epidemiology and burden of illness of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, generally progressive autoimmune disease that causes functional disability, significant pain and joint destruction, and leads to premature mortality. It is estimated to affect between 0.5 and 1.0% of the adult population worldwide, increases in prevalence with age and affects more women than men. The magnitude of the severe long-term economic consequences of RA has been underestimated in the past. Most patients with the disease require continuous treatment to retard or stop progression and to control disease flares. Many also require surgery, such as total hip or knee replacement. In addition to these direct costs, work disability leads to reduced productivity and early retirement, and as a result, substantial indirect costs. The individual and his or her family must cope with the feeling of loss of contribution to society combined with redefined social roles, and the effects of pain, fatigue, low self-esteem, mental distress and depression. A number of countries in North America and Europe have reported a decline in the incidence of RA in recent years, although geographical differences remain that may be associated with genetic, environmental or cultural factors. Nevertheless, patients with RA have not shared the improvements in survival rates seen with other diseases over the last 40 years, and have a mean reduction in life expectancy of between 5 and 10 years. Disease severity, activity and disability are strongly linked to premature mortality in patients with RA. The high direct and indirect costs associated with RA, together with the substantial morbidity and mortality affecting millions of people worldwide, underline the potential benefits of improved treatments for this chronic disease to patients, their families and society.

Quantification of the influence of cigarette smoking on rheumatoid arthritis: results from a population based case-control study, using incident cases

OBJECTIVE

To quantify the influence of cigarette smoking on the risk of developing rheumatoid arthritis (RA).

METHODS

679 cases and 847 controls included during May 1996-June 2000 in a case-control study, using incident cases, comprising the population aged 18-70 years of a defined area of Sweden, were investigated. A case was defined as a person from the study base who received for the first time a diagnosis of RA using the 1987 American College of Rheumatology criteria, and controls were randomly selected from the study base. Self reported smoking habits among cases and controls, and rheumatoid factor status among cases were registered. The incidence of RA in current smokers, ex-smokers, and ever-smokers, respectively, was compared with that of never-smokers.

RESULTS

Current smokers, ex-smokers, and ever-smokers of both sexes had an increased risk for seropositive RA (for ever-smokers the odds ratio was 1.7 (95% confidence interval (95% CI) 1.2 to 2.3) for women, and 1.9 (95% CI 1.0 to 3.5) for men), but not for seronegative RA. The increased risk was only apparent among subjects who had smoked > or =20 years, was evident at an intensity of smoking of 6-9 cigarettes/day, and remained for up to 10-19 years after smoking cessation. The risk increased with increasing cumulative dose of smoking.

CONCLUSION

Smokers of both sexes have an increased risk of developing seropositive, but not seronegative, RA. The increased risk occurs after a long duration, but merely a moderate intensity, of smoking and may remain for several years after smoking cessation.

Disease activity and health status in rheumatoid arthritis: a case-control comparison between Norway and Lithuania

OBJECTIVE

To compare disease characteristics and health status in patients with rheumatoid arthritis (RA) from two countries, Norway and Lithuania.

METHODS

Patients were recruited from the RA registers in Vilnius (Lithuania) and Oslo (Norway). For each patient from Vilnius, a patient matched for age and sex from the Oslo register was selected. Sociodemographic characteristics, disease process, and health status were compared between the patient groups.

RESULTS

201 Lithuanian patients and 201 Norwegian patients were included. Mean (SD) age in both groups was 55.9 (10.0) years, and 83% were women. Patients from Lithuania were less often employed (27% v 42%; p=0.001), had higher disease activity expressed by the disease activity score (DAS28; mean (SD) 5.3 (1.0) v 4.4 (1.4); p<0.001), had worse physical function by the modified Health Assessment Questionnaire (MHAQ; mean (SD) 2.3 (0.8) v 1.6 (0.5); p<0.001), had more often comorbidity (73% v 53%; p<0.001) and they reported worse general health measured by Short Form-36 Health Survey (SF-36; mean (SD) 23.2 (13.5) v 44.5 (21.3); p<0.001). The proportions of patients who had used disease modifying drugs were similar, but the pattern of use differed.

CONCLUSION

Important differences in employment, disease activity, physical function, and self reported health status were observed in patients with RA from two northern European countries. Socioeconomic inequalities, differences in disease management, and access to specialised health care, as well as methodological issues regarding instruments and data collection are likely explanations. These data support the view that management of RA should be adapted to country-specific needs.

Morbidity and quality of life in adult patients with a congenital abdominal wall defect: a questionnaire survey

BACKGROUND

In children with congenital abdominal wall defects (CAWD), surgical treatment of the abdominal defect and the associated anomalies cause considerable morbidity in the first years of life. Afterward, most of the CAWD patients with correctable anomalies develop as other children. The morbidity and quality of life (QoL) of CAWD patients who have reached their adulthood is less well known and the subject of this study.

METHODS

A 3-part questionnaire was sent to 75 former patients with CAWD, aged 17 years or more. The first part included questions about health, symptoms, and education; the second part consisted of 3 tests of psychosocial functioning; and the third part was a SF-36 questionnaire measuring the QoL.

RESULTS

Of the 75 patients, 57 (76%) answered: (25 males, 32 females); omphalocele (n = 16) gastroschisis (n = 11); median age, 27 (range, 17 to 48) years. With the exception of rheumatoid arthritis (in 7% of patients), the prevalence of acquired diseases in CAWD patients was comparable with that of the general population; 50 of 57 (88%) considered their health good. The most frequent causes of morbidity were disorders in the abdominal scar in 21 (37%) patients, and functional gastrointestinal disorders in 29 (51%) of patients. Low self-esteem was found in 12% of patients, but the QoL and educational level of CAWD patients were not different from that of the general population.

CONCLUSIONS

In CAWD patients the morbidity from acquired disorders is similar to morbidity in the general population. Disorders with the abdominal scar and various functional gastrointestinal disorders are common, but they rarely cause serious problems. The majority of CAWD patients have a quality of life not different from the general population.

Epidemiology and genetics of rheumatoid arthritis

The prevalence of rheumatoid arthritis (RA) is relatively constant in many populations, at 0.5-1.0%. However, a high prevalence of RA has been reported in the Pima Indians (5.3%) and in the Chippewa Indians (6.8%). In contrast, low occurrences have been reported in populations from China and Japan. These data support a genetic role in disease risk. Studies have so far shown that the familial recurrence risk in RA is small compared with other autoimmune diseases. The main genetic risk factor of RA is the HLA DRB1 alleles, and this has consistently been shown in many populations throughout the world. The strongest susceptibility factor so far has been the HLA DRB1*0404 allele. Tumour necrosis factor alleles have also been linked with RA. However, it is estimated that these genes can explain only 50% of the genetic effect. A number of other non-MHC genes have thus been investigated and linked with RA (e.g. corticotrophin releasing hormone, oestrogen synthase, IFN-gamma and other cytokines). Environmental factors have also been studied in relation to RA. Female sex hormones may play a protective role in RA; for example, the use of the oral contraceptive pill and pregnancy are both associated with a decreased risk. However, the postpartum period has been highlighted as a risk period for the development of RA. Furthermore, breastfeeding after a first pregnancy poses the greatest risk. Exposure to infection may act as a trigger for RA, and a number of agents have been implicated (e.g. Epstein-Barr virus, parvovirus and some bacteria such as Proteus and Mycoplasma). However, the epidemiological data so far are inconclusive. There has recently been renewed interest in the link between cigarette smoking and RA, and the data presented so far are consistent with and suggestive of an increased risk.

Could TH1 and TH2 diseases coexist? Evaluation of asthma incidence in children with coeliac disease, type 1 diabetes, or rheumatoid arthritis: a register study

BACKGROUND

Asthma is generally regarded as a disease with strong T(H)2-type cytokine expression, whereas in autoimmune disorders, such as coeliac disease (CD), insulin-dependent diabetes mellitus (IDDM), and rheumatoid arthritis (RA), T(H)1-type expression is seen. According to the cross-regulatory properties of T(H)1 and T(H)2 cells, one would assume that these diseases exist in different patient populations.

OBJECTIVE

We sought to test the hypothesis that asthma could exist in children with T(H)1-type diseases, such as CD, IDDM, and RA.

METHODS

Comparison was made of the cumulative incidence of asthma in children with CD, IDDM, or RA by linking Finnish Medical Birth Register data on the whole 1987 birth cohort (n = 60,254 births) with the data of several national health registers to obtain information on the incidences of these diseases during the first 7 years of life.

RESULTS

The cumulative incidence of asthma in children with CD (24.6%) or RA (10.0%) was significantly higher than in children without CD (3.4%) or RA (3.4%; P < .001 and P = .016, respectively). Asthma tended to be more common in children with IDDM than in children without IDDM.

CONCLUSION

These data indicate that the T(H)1 and T(H)2 diseases can coexist, indicating a common environmental denominator behind the disease processes.

The epidemiology of rheumatoid arthritis

Studies of the descriptive epidemiology of RA indicate a population prevalence of 0.5% to 1% and a highly variable annual incidence (12-1200 per 100,000 population) depending on gender, race/ethnicity, and calendar year. Secular trends in RA incidence over time have been shown in several studies, supporting the hypothesis of a host-environment interaction. People with RA have a significantly increased risk of death compared with age- and sex-matched controls without RA from the same community. The determinants of this excess mortality remain unclear; however, reports suggest increased risk from gastrointestinal, respiratory, cardiovascular, infectious, and hematologic diseases among RA patients compared with controls. Despite extensive epidemiologic research, the etiology of RA is unknown. Several risk factors have been suggested as important in the development or progression of RA. These include genetics, infectious agents, oral contraceptives, smoking, and formal education. Epidemiologic research is an essential contributor to our understanding of RA.

Regional differences in the incidence of rheumatoid arthritis in Finland in 1995

OBJECTIVE

To investigate regional differences in the incidence of rheumatoid arthritis (RA).

METHODS

Those subjects entitled to receive drug reimbursement for chronic inflammatory joint diseases in 11/21 central hospital districts (population base about 1.8 million adults) in Finland during 1995 were studied. The incidence rates from these central hospital districts were compared.

RESULTS

A total of 1213 subjects were entitled to drug reimbursement for chronic inflammatory joint disease which had started at the age of 16 or over. Of these, 598 subjects satisfied the American Rheumatism Association 1987 criteria for RA. The age adjusted incidence of RA was 31.7/100 000 (95% CI 29.2 to 34.4) and varied significantly (p<0.001) among the central hospital districts, ranging from 16.3 to 44.8/100 000.

CONCLUSION

There are regional differences in the incidence of RA. The reasons for these are probably environmental rather than genetic.

The spectrum of inflammatory rheumatic disorders

Classification of the inflammatory rheumatic disorders is challenging. They represent a heterogeneous group of conditions, mostly of unknown aetiology. However, a uniform language is essential in facilitating clinical and epidemiological research and, therefore, several different approaches have evolved by which we can classify these diseases. One way in which inflammatory arthropathies are frequently distinguished is by the number of joints affected at presentation. Therefore, this chapter will discuss the differential diagnosis of a monoarthropathy and polyarthropathy. The epidemiology of many of the less common inflammatory disorders is poorly elucidated, but the current knowledge, together with its strengths and weaknesses, will be discussed. Finally, we will describe the overall burden of the musculoskeletal disorders in the community, and then highlight the role of the rheumatologist in the management of these disabling conditions.

Changes in the incidence and prevalence of rheumatoid arthritis in Kamitonda, Wakayama, Japan, 1965-1996

OBJECTIVE

To evaluate secular trends in the incidence and prevalence of rheumatoid arthritis (RA) in Japan.

METHODS

The incidence and prevalence of RA were determined in a longitudinal population based study in the Kamitonda district, Wakayama, Japan, from 1965 to 1996.

RESULTS

In the study area consisting of about 3000 inhabitants, 16 incident cases, satisfying definite RA by the Rome criteria were detected during the study period. The age and sex adjusted incidence in both men and women combined and the age adjusted incidence in women significantly decreased (p<0.025 and p<0. 01, respectively). The age and sex adjusted prevalence in all inhabitants tended to decrease (p<0.1), and the age adjusted prevalence in women significantly declined (p<0.025). In men, however, neither incidence nor prevalence showed significant change.

CONCLUSIONS

The decline of incidence and prevalence of female RA may be reducible to some environmental changes preferentially occurring more obviously in Japanese women than in men. Because the use of oral contraceptives has been extremely low in Japan, the decline should be explained by other factors.

Epidemiology of the rheumatic diseases

Epidemiologic studies of rheumatic diseases can be broadly divided into those that describe the occurrence of specific disorders, those that attempt to quantify the role of putative risk factors for disease occurrence, and those that define the outcome and factors associated with it. Studies in this area have tended to be hypothesis testing rather than generating new etiologic or related hypotheses. In contrast to many previously published studies, more recent work has been both substantive in size and focused more on true community-based studies with the consequence that estimates of occurrence in risk obtained are likely to reflect more accurately the true nature of any associations observed.