Influence of gender on assessments of disease activity and function in early rheumatoid arthritis in relation to radiographic joint damage

OBJECTIVE

To evaluate gender differences in score on 28-joint Disease Activity Score (DAS28), Health Assessment Questionnaire (HAQ) and Signals Of Functional Impairment (SOFI) and to relate these scores to radiographic joint destruction.

METHODS

In all, 549 patients with early RA (62% women) from the BARFOT (for "Better Anti-Rheumatic FarmacOTherapy") study were included. At baseline, 1, 2 and 5 years DAS28, HAQ and SOFI scoring, and radiographs of hands and feet were performed. The radiographs were scored using the van der Heijde-Sharp score.

RESULTS

In women the DAS28 was significantly higher than in men due to higher scores for general health and tender joints. Likewise, HAQ and VAS pain were rated significantly higher in women. The SOFI score was worse in men during the first 2 years, depending on higher upper limb scores. Total Sharp score (TotSharp), erosion score and joint space narrowing score did not differ between the sexes at any time point. The DAS28 area under the curve (AUC) correlated significantly with TotSharp at 5 years in both genders (r = 0.316, r = 0.313) mainly owing to swollen joints and erythrocyte sedimentation rate (ESR). The SOFI AUC correlated significantly with TotSharp in women (r = 0.135 to 0.220) but not in men.

CONCLUSIONS

Despite a similar degree of radiographic joint destruction women had, compared with men, worse scores for DAS28 and HAQ, possibly due to higher pain perception and less muscular strength and perhaps because men overestimate their functional capacity.

Sex: a major predictor of remission in early rheumatoid arthritis?

BACKGROUND

The treatment goal of early rheumatoid arthritis is remission. This study reports remission rates in clinical practice using a cohort of patients with early rheumatoid arthritis.

METHODS

698 patients with early rheumatoid arthritis were included. Mean age at inclusion was 58 years and mean disease duration was 6.4 months; 64% of the patients were women, 56% were positive for antibodies to cyclic citrullinated peptide and 60% were positive for rheumatoid factor. Remission was defined as a disease activity score <2.6, with or without ongoing treatment with drugs for rheumatoid arthritis.

RESULTS

After 2 years, 261 of 689 patients were in remission (37.9%), and after 5 years, the remission rate was 38.5%. However, only 26.1% were in remission at both these time points. Multiple logistic regression analyses found sex to be a main predictor for remission. Thus, significantly fewer women were in remission after 2 years (32.1% v 48%, p = 0.001) after 5 years (30.8% v 52.4%, p = 0.001) and at both these time points (19.1% v 39.3%, p = 0.001). Although disease activity was not with certainty more pronounced in women at onset of disease, the disease course became markedly worse in women. The disparity in remission frequency between women and men could not be explained by differences in disease duration, age or treatment with disease modifying antirheumatic drugs or glucocorticoids.

CONCLUSIONS

Early remission of rheumatoid arthritis by 28-joint Disease Activity Score<2.6 was as frequent or more frequent in this study than in most previous reports. Importantly, women had more severe disease with a considerably lower remission rate than men, although the disease activity before treatment seemed similar.

Moderately intensive exercise in a temperate pool for patients with rheumatoid arthritis: a randomized controlled study

OBJECTIVES

The aim of this study was to evaluate the effects of moderately intensive pool exercise therapy on patients with rheumatoid arthritis (RA).

METHODS

Forty-six patients with chronic RA were randomly assigned to a treatment group and a control group. The treatment group (n = 20) exercised in a temperate pool twice a week for 12 weeks. The control group (n = 23) continued with their previous activities. Aerobic capacity, measured by means of a submaximum bicycle test, and the physical component of the SF-36 were chosen as the primary outcome measures. Two tests of muscle endurance were chosen as the secondary outcome measure. Additional functional tests and instruments were included.

RESULTS

No significant differences between the groups were found for the primary outcome measures. Significant improvements in the following aspects of muscular function (P < 0.05) were found in the treatment group when their performance was compared with that of the control group: isometric shoulder endurance, grip force, dynamic endurance of lower extremities (chair test) and muscle function of lower extremities. Significant improvements were also found for vitality (SF-36) compared with the control group. The improvements in the training group were maintained for 3 months.

CONCLUSIONS

Pool exercise therapy of moderate intensity significantly improved muscle endurance in the upper and lower extremities in patients with RA, while no impact on aerobic capacity was found. However, the study population was small and there is a need for further studies with larger populations.

Rheumatology outcomes: the patient's perspective. A multicentre focus group interview study of Swedish rheumatoid arthritis patients

OBJECTIVES

Patients with rheumatoid arthritis (RA) and clinicians have different views about benefits from treatments. More knowledge is needed about how patients assess outcomes in order to update current measurements.

METHODS

Focus group interviews were performed at four Swedish rheumatology clinics. A total of 25 patients with RA were included, representing a wide range of ages and disease duration. Predetermined topics relating to important outcomes from and satisfaction/dissatisfaction with RA treatments were discussed.

RESULTS

The participants' initial outcome assessments included physical and psychosocial items, which comprised overall treatment goals such as impairment in social roles, fatigue, daily activities and self-confidence. The identified themes were 'Normal life', 'Physical capacity', 'Independence' and 'Well-being'. Satisfaction with treatment was associated with the quality of communication between staff and the patient. The participants assumed this as a prerequisite for a treatment to work. Patients wanted to be accepted as experts on their own bodies, and expected all clinicians to be experts on RA. This made it possible for patients to 'take charge' of their life situation. Good resources for and access to rheumatology care were desired.

CONCLUSIONS

Suggesting a holistic approach to rheumatology care, the study results indicate that the illness and outcomes have to be evaluated within an individual RA patient's total life situation, described in the identified themes: 'Normal life', 'Physical capacity', 'Independence' and 'Well-being'. Development and validation of measurements covering these issues is suggested. More research is needed about communication and how patients experience their roles in the rheumatology clinic.

Prediction of radiological outcome in early rheumatoid arthritis in clinical practice: role of antibodies to citrullinated peptides (anti-CCP)

OBJECTIVE

To investigate the role of anti-cyclic citrullinated peptide antibody (anti-CCP) for the prediction of radiological outcome in patients with early rheumatoid arthritis.

METHODS

Anti-CCP was assessed at baseline in 379 patients with early rheumatoid arthritis (disease duration <1 year). Radiological joint damage and progression were assessed by Larsen score after two years of follow up (end point) and used as outcome variables. The prognostic value of anti-CCP and other demographic and disease related baseline variables were assessed by univariate and multivariate analyses, including calculation of odds ratios (OR), predictive values, and multiple logistic regression models.

RESULTS

The presence of anti-CCP was associated with significantly higher Larsen score both at baseline and at end point. Univariate predictor analysis showed that anti-CCP had the highest significant OR for radiological joint damage and progression after baseline Larsen score, followed by rheumatoid factor, erythrocyte sedimentation rate (ESR), C reactive protein, age, smoking status, and sex. In stepwise multiple regression analyses, baseline Larsen score, anti-CCP, and ESR were selected as significant independent predictors of the radiological outcomes.

CONCLUSIONS

There is good evidence for an association of anti-CCP with radiological joint changes in rheumatoid arthritis. Anti-CCP is an independent predictor of radiological damage and progression. Though prediction in early rheumatoid arthritis is still far from perfect, the use of anti-CCP in clinical practice should make it easier for rheumatologists to reach judicious treatment decisions.

Treatment of early RA in clinical practice: a comparative study of two different DMARD/corticosteroid options

OBJECTIVES

To study the outcome in clinical practice of first DMARD and/or corticosteroid (CS) treatment in patients with recent onset rheumatoid arthritis (RA).

PATIENTS

245 patients with active RA, not previously treated with DMARDs or CS, were randomised to one of two treatment groups, T1 = 7.5-15 mg of prednisolone (PRE) daily for one to three months followed, if needed, by methotrexate (MTX) in a weekly dose of 5-15 mg in addition to the lowest possible dose of PRE or T2 = sulfasalazine (SAL), supplemented with lowest possible CS dose if needed.

METHODS

The EULAR individual response criteria were applied and remission was defined as a final DAS28 < 2.6. Function was assessed by the HAQ and radiographic progression by Larsen scores. A patient who managed to remain on the allocated treatment for two years was described as a "completer".

RESULTS

After 2 years of treatment, 70% of the patients in T1 and 63% in T2 were responders (30% and 33% "good responders", respectively). In T1 29% and in T2 19% were in remission. There was a significant functional improvement in both groups but radiographic progression occurred. The mean decrease in HAQ and increase in the Larsen score were similar in the two groups. One-third of the patients were non-completers, 19% from T1 and 47% from T2. Non-completers had, compared with completers, a significantly lower rate of individual response and remission. Completers and non-completers had similar functional improvement and similar radiological progression.

CONCLUSIONS

Individual response and remission was reduced in patients who did not complete their first DMARD/CS treatment option. Treatment failures were significantly more frequent in the sulfasalazine plus optional CS than in the CS plus optional methotrexate treatment group.

Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study

OBJECTIVE

To evaluate the effects of 6 months of pool exercise combined with a 6 session education program for patients with fibromyalgia syndrome (FM).

METHODS

The study population comprised 58 patients, randomized to a treatment or a control group. Patients were instructed to match the pool exercises to their threshold of pain and fatigue. The education focused on strategies for coping with symptoms and encouragement of physical activity. The primary outcome measurements were the total score of the Fibromyalgia Impact Questionnaire (FIQ) and the 6 min walk test, recorded at study start and after 6 mo. Several other tests and instruments assessing functional limitations, severity of symptoms, disabilities, and quality of life were also applied.

RESULTS

Significant differences between the treatment group and the control group were found for the FIQ total score (p = 0.017) and the 6 min walk test (p < 0.0001). Significant differences were also found for physical function, grip strength, pain severity, social functioning, psychological distress, and quality of life.

CONCLUSION

The results suggest that a 6 month program of exercises in a temperate pool combined with education will improve the consequences of FM.

Health status assessment in rheumatoid arthritis. II. Evaluation of a modified Shorter Sickness Impact Profile

OBJECTIVE

To develop a shortened form of the Sickness Impact Profile (SIP) for routine practice.

METHODS

We used data from a study of health status in 99 women with rheumatoid arthritis (RA). A stepwise analysis model used physical discomfort (global rating), self-assessed pain (Body Symptom Scale), mental well-being (Mood Adjective Check List) and joint function (Keitel Index) to define important aspects of health.

RESULTS

Short forms of the SIP for discrimination (53 items), evaluation (25 items) and prediction (28 items) compared well in validity to the original 136-item SIP. The discriminative short form showed excellent reliability (internal consistency), matching the level of the generic SIP. The evaluative and predictive short forms had acceptable but lower internal consistency than the original Profile.

CONCLUSION

We suggest a 64-item core health status questionnaire (SIP-RA) to be included and further tested in the arsenal of routine measurements in outpatients with RA. The questionnaire should include physical (Body care and movement, Mobility), psychosocial (Emotional behavior, Social interaction, Alertness behavior, Communication) and free-standing (Sleep and rest, Home management, Recreation and past-times, Eating) SIP categories, and it will improve the description of patients with RA.

The rheumatic patient's early needs and expectations

During the last few years, studies have revealed that the need for psychosocial support and concrete social services are great in the early stages of the treatment of rheumatic diseases. The ability to keep a job, to do household chores, to participate in leisure activities and to maintain social relations is clearly impaired. Anxiety and depression are not unusual and often associated with weak support from relatives, loneliness and disturbed family relations. Nevertheless, the patients report resilience and determination to cope with the impacts of illness. Crisis intervention, vocational guidance and counselling about problems concerning the disease should be available and offered to the patients. As the patients seem to be unaccustomed to talking about their psychosocial problems, an empathetic and information-seeking attitude on the part of the health care staff is essential.

Prediction of team care effects in outpatients with rheumatoid arthritis

Predictive factors for the outcome of 1-year rheuma-team care were studied in 68 female rheumatoid arthritis (RA) outpatients (mean age 56 years, mean RA duration 15 years). Seventy-three background variables were analyzed in a 4-step statistical model including partial and multivariate correlations in order to disclose the best predictors of change scores of the outcome measures chosen. These concerned disease activity (C-reactive protein, Lansbury articular index), physical joint function (Keitel index), mood (Mood Adjective Check List, MACL), and overall health (Sickness Impact Profile). Between 14 and 47% of the variance of the 1-year outcome change scores was explained by combinations of 2 or 3 predictors out of 12 strong background variables. The lowest value of explained variance was noted for MACL, and the highest for C-reactive protein. Both clinical, social, and self-assessed health data were among the predictors. Our results can provide a guide in the selection of patients with RA for multidisciplinary team care, in the formulation of treatment goals, and the creation of cost-effectiveness schedules.

Health status assessment in rheumatoid arthritis. I. Further work on the validity of the sickness impact profile

In a cross-sectional, longitudinal study, 99 women with rheumatoid arthritis (RA) completed a well established health status measure, the Sickness Impact Profile (SIP), for diagnosis specific evaluation. Using traditional and self-reporting data, we examined SIP relationships that described physical functioning. They related closely to clinical measures. Psychosocial functioning measured by SIP related specifically to mental health and arthritic pain. Importantly, the SIP was sensitive to 1-year pre and posttreatment changes showing both improvement and deterioration. When applied to patients with RA SIP categories could be more appropriately aggregated, e.g., Home management included in the Physical dimension and Communication omitted from the Psychosocial.

Measuring health in rheumatic disorders by means of a Swedish version of the sickness impact profile. Results from a population study

A technique for assessing the overall consequences of disease is introduced, comprising a Swedish version of a behaviour-based measure, the Sickness Impact Profile (SIP). Measurement characteristics of the profile are defined in an epidemiological study of 147 women with rheumatic disorders. The drop-out rate was 7.5%. Cross-cultural evidence of the validity of the SIP was obtained in this study. Test-retest reliability was substantial. A high level of validity of the Swedish version was demonstrated, as assessed by hypothesized significant relationships with selected functional, psychological, and social correlates. The profile was able to describe the various sickness impacts in a specific and sensitive manner. In the epidemiological setting, the subscales representing Ambulation, Body care and movement, Emotional behaviour, Social interaction, Sleep and rest, Home management and Recreation and pastimes, all showed discriminatory capacity. The categories Mobility, Alertness behaviour, Communication, Work, and Eating discriminated less well. The response pattern was recognizably related to rheumatic complaints, emphasizing a broader applicability of this scale in rheumatology.

Toxic epidermal necrolysis with extensive mucosal erosions of the gastrointestinal and respiratory tracts

Toxic epidermal necrolysis with epidermal shedding over almost the entire body occurred in a patient with classical rheumatoid arthritis treated with sulindac, penicillamine and a combination analgesic containing paracetamol and chlormezanone. Erosions in the lower respiratory tract and the intestine contributed to a lethal outcome of the disease and showed a microscopical picture similar to that of the skin involved. The histopathological picture of these extracutaneous lesions have been only briefly reported previously.