Prevalence and Characteristics of Metabolic Syndrome Differ in Men and Women with Early Rheumatoid Arthritis

Objective

Metabolic syndrome (MetS) prevalence in early rheumatoid arthritis (ERA) is conflicting. The impact of sex, including menopause, has not been described. We estimated the prevalence and factors associated with MetS in men and women with ERA.

Methods

A cross‐sectional study of the Canadian Early Arthritis Cohort (CATCH) was performed. Participants with baseline data to estimate key MetS components were included. Sex‐stratified logistic regression identified baseline variables associated with MetS.

Results

The sample included 1543 participants; 71% were female and the mean age was 54 (SD 15) years. MetS prevalence was higher in men 188 (42%) than women 288 (26%, P < 0.0001) and increased with age. Frequent MetS components in men were hypertension (62%), impaired glucose tolerance (IGT, 40%), obesity (36%), and low high‐density lipoprotein cholesterol (36%). Postmenopausal women had greater frequency of hypertension (65%), IGT (32%), and high triglycerides (21%) compared with premenopausal women (P < 0.001). In multivariate analysis, MetS was negatively associated with seropositivity and pulmonary disease in men. Increasing age was associated with MetS in women. In postmenopausal women, corticosteroid use was associated with MetS. Psychiatric comorbidity was associated with MetS in premenopausal women. MetS status was not explained by disease activity or core RA measures.

Conclusion

The characteristics and associations of MetS differed in men and women with ERA. Sex differences, including postmenopausal status, should be considered in comorbidity screening. With this knowledge, the interplay of MetS, sex, and RA therapeutic response on cardiovascular outcomes should be investigated.

Determining the Minimally Important Difference in the Clinical Disease Activity Index for Improvement and Worsening in Early Rheumatoid Arthritis Patients

OBJECTIVE

Simplified measures to quantify rheumatoid arthritis (RA) disease activity are increasingly used. The minimum clinically important differences (MCID) for some measures, such as the Clinical Disease Activity Index (CDAI), have not been well-defined in real-world clinic settings, especially for early RA patients with low/moderate disease activity.

METHODS

Data from Canadian Early Arthritis Cohort patients were used to examine absolute change in CDAI in the first year after enrollment, stratified by disease activity. MCID cut points were derived to optimize the sum of sensitivity and specificity versus the gold standard of patient self-reported improvement or worsening. Sensitivity, specificity, positive predictive values, and negative predictive values were calculated against patient self-reported improvement (gold standard) and for change in pain, Health Assessment Questionnaire (HAQ), and Disease Activity Score in 28 joints (DAS28) improvement. Discrimination was examined using the area under receiver operator curves. Similar methods were used to evaluate MCIDs for worsening for patients who achieved low disease activity.

RESULTS

A total of 578 patients (mean ± SD age 54.1 ± 15.3 years, 75% women, median [interquartile range] disease duration 5.3 [3.3, 8.0] months) contributed 1,169 visit pairs to the improvement analysis. The MCID cut points for improvement were 12 (patients starting in high disease activity: CDAI >22), 6 (moderate: CDAI 10-22), and 1 (low disease activity: CDAI <10). Performance characteristics were acceptable using these cut points for pain, HAQ, and DAS28. The MCID for CDAI worsening among patients who achieved low disease activity was 2 units.

CONCLUSION

These minimum important absolute differences in CDAI can be used to evaluate improvement and worsening and increase the utility of CDAI in clinical practice.

Consequences of delayed therapy with second-line agents in rheumatoid arthritis: a 3 year followup on the hydroxychloroquine in early rheumatoid arthritis (HERA) study

OBJECTIVE

To assess the longterm effect of delaying therapy with second-line agents in patients with early rheumatoid arthritis (RA).

METHODS

One hundred nineteen patients who participated in a 9 month placebo controlled randomized trial of hydroxychloroquine sulfate (HCQ) were followed prospectively for an additional 3 years. Those randomized to HCQ are referred to as the early treatment group and those randomized to placebo as the delayed treatment group. Participants were assessed annually for pain [Arthritis Impact Measurement Scales (AIMS) and Stanford Health Assessment Questionnaire (HAQ)], physical disability (AIMS and HAQ), and the RA global well being scale (AIMS). Conversion of results into standard deviation (SD) units permitted defining a substantial difference as per Felson as > 0.30 SD units and a clinically indistinguishable difference as < or = 0.06 SD units.

RESULTS

One hundred fifteen patients (97%) participated and complete data were available on 104 (87%). Compared to the early treatment group, the delayed group remained worse for both the pain and the physical disability outcomes over the additional 3 year followup. The difference in the RA global well being score became clinically indistinguishable for the early and delayed groups only after the 2 year post-trial assessment. The between-group differences were not explained by post-trial therapy with corticosteroids, other second-line agents, or nonsteroidal antiinflammatory drugs and analgesic preparations.

CONCLUSION

These findings show that a delay in instituting therapy with second-line agents, even a 9 month delay in instituting a moderately powerful second-line agent such as HCQ, has significant effects on longterm patient outcome, and provides strong evidence in support of early therapy in RA.

Application of the correct information unit analysis to the naturally occurring conversation of a person with aphasia

The Correct Information Unit (CIU) analysis for measuring the communicative informativeness and efficiency of connected speech (Nicholas & Brookshire, 1993) was applied to the naturally occurring conversation of a person with moderate aphasia. Results indicated that, in this instance, reliable CIU measures could not be obtained. Intrarater reliability for CIU and %CIU was low, reaching only 72%, and interrater reliability was never greater than 63%. However, reliability of word counts was good. Post hoc analysis of rater disagreements in application of the CIU analysis revealed that the majority (72%) resulted from insufficiencies in the scoring rules that were originally designed to measure single speaker connected discourse. Two descriptive categories of disagreements were identified: interpretations of informativeness and absence of rules. The remaining 28% of disagreements were attributable to human error in the application of scoring rules. Comparison of findings with previous research and implications for future research are discussed.

Genetic bias in immune responses to a cassette shared by different microorganisms in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease associated with HLA-DRbeta1 alleles which contain the QKRAA amino acid sequence in their third hypervariable region(s). The QKRAA sequence is also expressed by several human pathogens. We have shown previously that an Escherichia coli peptide encompassing QKRAA is a target of immune responses in RA patients. Here we address two questions: first, whether QKRAA may function as an "immunological cassette" with similar, RA-associated, immunogenic properties when expressed by other common human pathogens; and second, what is the influence of genetic background in the generation of these responses. We find that early RA patients have enhanced humoral and cellular immune responses to Epstein-Barr virus and Brucella ovis and Lactobacillus lactis antigens which contain the QKRAA sequence. These results suggest that the QKRAA sequence is an antigenic epitope on several different microbial proteins, and that RA patients recognize the immunological cassette on different backgrounds. ANOVA of immune responses to "shared epitope" antigens in monozygotic twin couples shows that, despite significantly elevated responses in affected individuals, a similarity between pairs is retained, thus suggesting a role played either by hereditary or shared environmental factors in the genesis or maintenance of these responses.

Longterm methotrexate therapy in psoriatic arthritis: clinical and radiological outcome

OBJECTIVE

To determine whether methotrexate (MTX) therapy for 24 months prevents progression of radiographic damage in psoriatic arthritis (PsA).

METHODS

Patients who were given MTX during their attendance at the psoriatic arthritis clinic were enrolled in the study. Patients who had never had MTX and who were matched by damage, actively inflamed joints, sex, and disease duration were identified from the PsA database as controls. The outcome measure was increase in the number of damaged joints.

RESULTS

The study population comprised 38 patients (16 F, 22 M) with a mean age of 44.6 years and disease duration of 11.4 years. Twenty-three patients continued therapy for 24 months. Clinical evaluation revealed that 45% of the patients had > or = 40% improvement in actively inflamed joint count at 6 and 24 months. Radiographs were available for 19 of the 23 patients who took MTX for 24 months, and they were compared to their respective controls. Radiographic damage scores at 24 months showed an increase in the damage score in 63% of the patients. Compared to the matched controls, there was no statistically significant difference in the progression in damage.

CONCLUSION

Our results suggest that compared to other regimens, MTX conferred no advantage with respect to clinical response or longterm damage even after 24 months of therapy.

Reliability of measurements of active and damaged joints in psoriatic arthritis

Our aim was to test the reliability of clinical measurements in psoriatic arthritis. The study involved clinical assessments of inflammatory activity as well as damage in 10 patients with psoriatic arthritis seen at the psoriatic arthritis clinic. Five rheumatologists examined these patients according to a latin square design. For the clinical measurements of actively inflamed joints and damaged joints there was no significant observer effect. This suggests that these are reliable measurements. There was, however, significant observer effect in the radiologic assessment, and further refinement of the measurement is required.

Psoriatic arthritis (PSA)--an analysis of 220 patients

Since 1978, 220 patients with psoriatic arthritis have undergone detailed study at the Women's College Hospital in Toronto, Canada. Clinical, radiological and biochemical data were subjected to computer analysis in order to determine clinical-biochemical correlations within subsets of patients with psoriatic arthritis. Our findings indicate a spectrum of disease patterns and severity. Overall, we found a 40 per cent incidence of deforming, erosive arthropathy, with 17 per cent of patients having five or more deformed joints. ARA stage 3 and 4 radiological joint change occurred in 28 and 14 per cent respectively, and 11 per cent of patients had ARA Class III or IV functional impairment. The asymmetric oligoarthritis previously reported to account for the majority of cases of psoriatic arthritis was not a dominant pattern in our own experience, occurring in only 28 per cent of the series. Polyarthritis was the most common joint pattern, present in 61 per cent with symmetric and asymmetric patterns occurring equally. Our experience suggests that polyarthritis, symmetric or asymmetric, is a more common presentation of the disease than is generally acknowledged. Furthermore, the frequency of deforming destructive arthropathy challenges the concept of psoriatic arthritis as a benign arthropathy.

Avascular necrosis of bone complicating treatment of malignant lymphoma

Over a 15-year period, 12 patients were seen at the Ontario Cancer Institute in whom avascular necrosis of bone development after or during treatment for malignant lymphoma. All but one were treated with systemic chemotherapy that included high-dose intermittent corticosteroids. The average time of onset of symptoms was 34 months (range, eight of 72 months) after an average of 9.0 g of prednisone (range, 1.4 to 18.75 g). The one exception was a patient with Hodgkin's disease treated by pelvic radiation alone who had development of avascular necrosis of the femoral head within one month of irradiation. More than one joint was involved in 58 percent of patients. Six patients required surgery (usually hip replacement) but two patients had no evidence of deterioration over many years (average, seven years) and three patients had minimal symptoms easily controlled by mild analgesics up to six years after diagnosis. The evidence implicating corticosteroids in the development of avascular necrosis is presented and the various hypotheses of pathogenesis are reviewed. The predominance of Hodgkin's disease over non-Hodgkin's lymphomas (5:1) in this and other series and the identification of one patient with Hodgkin's disease with development of avascular necrosis within one month of radiotherapy treatment suggests that Hodgkin's disease itself may predispose to this condition.