Patient's global assessment of disease activity and patient's assessment of general health for rheumatoid arthritis activity assessment: are they equivalent?

OBJECTIVES

To assess (A) determinants of patient's global assessment of disease activity (PTGL) and patient's assessment of general health (GH) scores of rheumatoid arthritis (RA) patients; (B) whether they are equivalent as individual variables; and (C) whether they may be used interchangeably in calculating common RA activity assessment composite indices.

METHODS

Data of 7023 patients from 30 countries in the Quantitative Standard Monitoring of Patients with RA (QUEST-RA) was analysed. PTGL and GH determinants were assessed by mixed-effects analyses of covariance models. PTGL and GH equivalence was determined by Bland-Altman 95% limits of agreement (BALOA) and Lin's coefficient of concordance (LCC). Concordance between PTGL and GH based Disease Activity Score 28 (DAS28), Clinical Disease Activity Index (CDAI) and Routine Assessment of Patient Index Data 3 (RAPID3) indices were calculated using LCC, and the level of agreement in classifying RA activity in four states (remission, low, moderate, high) using κ statistics.

RESULTS

Significant differences in relative and absolute contribution of RA and non-RA related variables in PTGL and GH ratings were noted. LCC of 0.64 and BALOA of -4.41 to 4.54 showed that PTGL and GH are not equivalent. There was excellent concordance (LCC 0.95-0.99) for PTGL and GH based DAS28, CDAI and RAPID3 indices, and >80% absolute agreement (κ statistics 0.75-0.84) in RA activity state classification for all three indices.

CONCLUSIONS

PTGL and GH ratings differ in their determinants. Although they are individually not equivalent, they may be used interchangeably for calculating composite indices for RA activity assessment.

Citrullination under physiological and pathological conditions

Citrullination, one of the enzymatic posttranslational modifications has become a hot topic of recent research as it is involved in various physiological and pathological processes. Antibodies against citrullinated proteins called anti-citrullinated protein antibodies, are the hallmark (diagnostic and prognostic factors) of rheumatoid arthritis, and are specific for the disease. Citrullination has an important role in the normal function of the immune system, skin keratinization, the insulation of neurons and the plasticity of the central nervous system including its essential role in gene regulation. Abnormal citrullination has been proposed to play a role in multiple sclerosis and Alzheimer's disease, and recent research has drawn attention to its implication in tumorigenesis. Still, it is unclear whether citrullination is the cause or the consequence of these pathological alterations. Here, we discuss crucial aspects of citrullination during both physiological and pathological conditions.

Disease burden of psoriatic arthritis compared to rheumatoid arthritis, Hungarian experiment

The objectives of this study were to assess the costs of psoriatic arthritis (PsA) in Hungary and to identify key cost drivers among demographic and clinical variables and to compare cost-of-illness of PsA and rheumatoid arthritis (RA). Cross-sectional retrospective survey of 183 consecutive patients from eight rheumatology centres was conducted. Mean direct medical, direct non medical, indirect and total costs were 1,876, 794, 2,904 and 5,574 euros/patient/year, respectively. Total costs were in significant linear relationship with health assessment questionnaire score and psoriatic area severity index. Costs of RA were higher in all domains than of PsA. Our study was the first from the Eastern European region that provides cost-of-illness data on PsA. Our study revealed that functional status and severity of skin symptoms were the key cost drivers. The costs of PsA in Hungary were lower than in the high-income European countries.

Specific expression of PAD4 and citrullinated proteins in lung cancer is not associated with anti-CCP antibody production

Anti-citrullinated protein antibodies (ACPAs), produced against citrullinated proteins, are diagnostic and prognostic markers of rheumatoid arthritis (RA). The underlying mechanism that explains the connection of smoking, citrullination [catalyzed by peptidyl arginine deiminases (PADs)] and ACPAs is still unclarified in RA. Thus, we searched for a non-arthritic model in which an increased cell death allows the formation of autoantibodies. Data supporting that lung cancer might be a good candidate are as follows: (i) smoking plays a role in its pathogenesis, (ii) the disease is frequently accompanied by paraneoplastic syndrome, (iii) smoking increases citrullination in the lung, (iv) various types of malignancies are associated with increased citrullination and (v) lung cancer tissue shows similarities with RA synovium. Serum PAD4, rheumatoid factor (RF) and ACPA levels were measured in 42 lung cancer patients; expression of cytokeratin 7 (CK7), PAD4 and citrullinated proteins was visualized in 113 lung cancer tissues. All parameters were analyzed in correlation with smoking history. None of the patients had polyarthritis or autoimmune disease. Significantly increased RF levels were associated with higher PAD4 levels in smoker lung cancer patients compared with non-smokers. Both PAD4 and citrullination immunostaining strongly correlated with that of CK7 in lung cancer, however, did not differ according to smoking history. Two of 30 smoker lung cancer patients had high anti-cyclic citrullinated peptide levels. In conclusion, PAD4 and citrullination may be helpful in distinguishing lung cancer from healthy tissue. Smoking, abnormal serum PAD4 and RF levels may not be sufficient for the production of ACPAs and development of autoimmunity.

Comparison of the Psoriatic Arthritis Quality of Life (PsAQoL) questionnaire, the functional status (HAQ) and utility (EQ-5D) measures in psoriatic arthritis: results from a cross-sectional survey

OBJECTIVES

To compare the Psoriatic Arthritis Quality of Life (PsAQoL) instrument, the Health Assessment Questionnaire (HAQ) as a measure of functional status, and the generic health status (utility) measure the EuroQoL (EQ-5D) in terms of ability to assess disease severity in psoriatic arthritis (PsA).

METHODS

The differences between known groups and correlations of the PsAQoL, the HAQ and the EQ-5D with clinical measures were analysed in a sample of 183 PsA patients.

RESULTS

Different severities of PsA determined by known groups were distinguished well by all three questionnaires; more severe disease was associated with significantly worse values of the instruments. The correlations revealed a strong relationship between each of the measures, and with the patients' pain on the visual analogue scale (VAS), the patient global VAS, and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and a weak relationship with the disease duration and the Psoriasis Area Severity Index (PASI). The PsAQoL also correlated strongly with the 28-joint Disease Activity Score (DAS28).

CONCLUSIONS

The PsAQoL, the HAQ, and the EQ-5D are able to distinguish well across levels of PsA severity.

Work disability remains a major problem in rheumatoid arthritis in the 2000s: data from 32 countries in the QUEST-RA study

INTRODUCTION

Work disability is a major consequence of rheumatoid arthritis (RA), associated not only with traditional disease activity variables, but also more significantly with demographic, functional, occupational, and societal variables. Recent reports suggest that the use of biologic agents offers potential for reduced work disability rates, but the conclusions are based on surrogate disease activity measures derived from studies primarily from Western countries.

METHODS

The Quantitative Standard Monitoring of Patients with RA (QUEST-RA) multinational database of 8,039 patients in 86 sites in 32 countries, 16 with high gross domestic product (GDP) (>24K US dollars (USD) per capita) and 16 low-GDP countries (<11K USD), was analyzed for work and disability status at onset and over the course of RA and clinical status of patients who continued working or had stopped working in high-GDP versus low-GDP countries according to all RA Core Data Set measures. Associations of work disability status with RA Core Data Set variables and indices were analyzed using descriptive statistics and regression analyses.

RESULTS

At the time of first symptoms, 86% of men (range 57%-100% among countries) and 64% (19%-87%) of women <65 years were working. More than one third (37%) of these patients reported subsequent work disability because of RA. Among 1,756 patients whose symptoms had begun during the 2000s, the probabilities of continuing to work were 80% (95% confidence interval (CI) 78%-82%) at 2 years and 68% (95% CI 65%-71%) at 5 years, with similar patterns in high-GDP and low-GDP countries. Patients who continued working versus stopped working had significantly better clinical status for all clinical status measures and patient self-report scores, with similar patterns in high-GDP and low-GDP countries. However, patients who had stopped working in high-GDP countries had better clinical status than patients who continued working in low-GDP countries. The most significant identifier of work disability in all subgroups was Health Assessment Questionnaire (HAQ) functional disability score.

CONCLUSIONS

Work disability rates remain high among people with RA during this millennium. In low-GDP countries, people remain working with high levels of disability and disease activity. Cultural and economic differences between societies affect work disability as an outcome measure for RA.

Efficacy and safety of piascledine 300 versus chondroitin sulfate in a 6 months treatment plus 2 months observation in patients with osteoarthritis of the knee

To investigate that a 6-month treatment with avocado soybean unsaponifiable (Piascledine 300 mg) once daily is as effective as with chondroitin sulfate 400 mg three times daily in femorotibial gonarthrosis, and also the carry-over effect for two more months is comparable. Patients were randomized (1:1) to the treatment groups. They received for 6 months 3 capsules chondroitin sulfate per day or one capsule of avocado soybean unsaponifiable (ASU) in a double-dummy technique. A 2-month post-treatment period followed to determine the carry-over effect. Primary efficacy criterion was the change of the WOMAC-index from study begin to end of treatment. Secondary criteria were the changes in Lequesne-index, pain on active movement and at rest, global assessment of efficacy. Three hundred sixty-four patients have been taken up into the trial. Three hundred sixty one patients were eligible for evaluation. One hundred eighty three received ASU 300 mg once daily, one hundred seventy eight chondroitin sulfate three times daily. The WOMAC-index decreased in both groups for approx. 50% to the end of therapy. During the post-treatment observation there was a further slight improvement. There was no statistical significant difference between the treatment groups during the entire observation. All other observed parameters showed the same pattern. The daily intake of rescue medication was reduced continuously. Overall efficacy has been rated excellent and good in more than 80% of the patients in both groups. Both drugs were safe and well tolerated. The first direct comparison between avocado soybean unsaponifiable 300 mg once daily and chondroitin sulfate three times daily reveiled no difference in efficacy or safety aspects between 1 capsule ASU 300 mg per day and 3 capsules chondroitin sulfate per day. It can be assumed that the once daily intake of ASU will lead to a better compliance in routine therapy.

Gene expression and activity of cartilage degrading glycosidases in human rheumatoid arthritis and osteoarthritis synovial fibroblasts

INTRODUCTION

Similar to matrix metalloproteinases, glycosidases also play a major role in cartilage degradation. Carbohydrate cleavage products, generated by these latter enzymes, are released from degrading cartilage during arthritis. Some of the cleavage products (such as hyaluronate oligosaccharides) have been shown to bind to Toll-like receptors and provide endogenous danger signals, while others (like N-acetyl glucosamine) are reported to have chondroprotective functions. In the current study for the first time we systematically investigated the expression of glycosidases within the joints.

METHODS

Expressions of beta-D-hexosaminidase, beta-D-glucuronidase, hyaluronidase, sperm adhesion molecule 1 and klotho genes were measured in synovial fibroblasts and synovial membrane samples of patients with rheumatoid arthritis and osteoarthritis by real-time PCR. beta-D-Glucuronidase, beta-D-glucosaminidase and beta-D-galactosaminidase activities were characterized using chromogenic or fluorogenic substrates. Synovial fibroblast-derived microvesicles were also tested for glycosidase activity.

RESULTS

According to our data, beta-D-hexosaminidase, beta-D-glucuronidase, hyaluronidase, and klotho are expressed in the synovial membrane. Hexosaminidase is the major glycosidase expressed within the joints, and it is primarily produced by synovial fibroblasts. HexA subunit gene, one of the two genes encoding for the alpha or the beta chains of hexosaminidase, was characterized by the strongest gene expression. It was followed by the expression of HexB subunit gene and the beta-D-glucuronidase gene, while the expression of hyaluronidase-1 gene and the klotho gene was rather low in both synovial fibroblasts and synovial membrane samples. Tumor growth factor-beta1 profoundly downregulated glycosidase expression in both rheumatoid arthritis and osteoarthritis derived synovial fibroblasts. In addition, expression of cartilage-degrading glycosidases was moderately downregulated by proinflammatory cytokines including TNFalpha, IL-1beta and IL-17.

CONCLUSIONS

According to our present data, glycosidases expressed by synovial membranes and synovial fibroblasts are under negative regulation by some locally expressed cytokines both in rheumatoid arthritis and osteoarthritis. This does not exclude the possibility that these enzymes may contribute significantly to cartilage degradation in both joint diseases if acting in collaboration with the differentially upregulated proteases to deplete cartilage in glycosaminoglycans.

[Ankylosing spondylitis in Central and Eastern Europe. Cross-sectional study on treatment modalities, disease activity and quality of life]

OBJECTIVES

To obtain information on the profile of patients with ankylosing spondylitis (AS), disease activity, previous and current treatments, and the proportion and profile of patients treated with conventional medications but considered eligible for anti-tumour necrosis factor (TNF) therapy.

METHODS

Participants were rheumatologists from seven Central and Eastern European countries who were considered experts in the treatment of AS and were to include 3-5 patients who had never received anti-TNF therapy. Rheumatologists were asked to decide whether they considered their patients candidates for anti-TNF therapy.

RESULTS

A total of 1506 patients were analysed. Overall, 61% of AS patients who had never received anti-TNF therapy until the time of the survey were considered candidates for anti-TNF therapy based on the clinical judgement of their rheumatologists. This proportion ranged from 40% in Slovakia to 84% in Romania. Candidates had higher levels of disease activity and functional impairment, and they were more likely to report a lower quality of life. Only 38% of candidates fulfilled the Assessment in Ankylosing Spondylitis (ASAS) recommendations with respect to a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of at least 4 combined with previous use of at least two non-steroidal anti-inflammatory drugs, ranging from 18% in Poland to 57% in Hungary.

CONCLUSION

More than half of AS patients currently treated with other medications may be eligible for anti-TNF therapy. Also, rheumatologists regarded disease activity as the determining factor for starting anti-TNF drugs, but their decision did not always fully comply with the ASAS recommendations, confirming the need for continued exchange among the medical community to increase awareness of the ASAS recommendations.

Women, men, and rheumatoid arthritis: analyses of disease activity, disease characteristics, and treatments in the QUEST-RA study

Introduction

Gender as a predictor of outcomes of rheumatoid arthritis (RA) has evoked considerable interest over the decades. Historically, there is no consensus whether RA is worse in females or males. Recent reports suggest that females are less likely than males to achieve remission. Therefore, we aimed to study possible associations of gender and disease activity, disease characteristics, and treatments of RA in a large multinational cross-sectional cohort of patients with RA called Quantitative Standard Monitoring of Patients with RA (QUEST-RA).

Methods

The cohort includes clinical and questionnaire data from patients who were seen in usual care, including 6,004 patients at 70 sites in 25 countries as of April 2008. Gender differences were analyzed for American College of Rheumatology Core Data Set measures of disease activity, DAS28 (disease activity score using 28 joint counts), fatigue, the presence of rheumatoid factor, nodules and erosions, and the current use of prednisone, methotrexate, and biologic agents.

Results

Women had poorer scores than men in all Core Data Set measures. The mean values for females and males were swollen joint count-28 (SJC28) of 4.5 versus 3.8, tender joint count-28 of 6.9 versus 5.4, erythrocyte sedimentation rate of 30 versus 26, Health Assessment Questionnaire of 1.1 versus 0.8, visual analog scales for physician global estimate of 3.0 versus 2.5, pain of 4.3 versus 3.6, patient global status of 4.2 versus 3.7, DAS28 of 4.3 versus 3.8, and fatigue of 4.6 versus 3.7 (P < 0.001). However, effect sizes were small-medium and smallest (0.13) for SJC28. Among patients who had no or minimal disease activity (0 to 1) on SJC28, women had statistically significantly higher mean values compared with men in all other disease activity measures (P < 0.001) and met DAS28 remission less often than men. Rheumatoid factor was equally prevalent among genders. Men had nodules more often than women. Women had erosions more often than men, but the statistical significance was marginal. Similar proportions of females and males were taking different therapies.

Conclusions

In this large multinational cohort, RA disease activity measures appear to be worse in women than in men. However, most of the gender differences in RA disease activity may originate from the measures of disease activity rather than from RA disease activity itself.

Natural autoantibodies reactive with glycosaminoglycans in rheumatoid arthritis

Introduction

Although natural autoantibodies make up the majority of circulating immunoglobulins and are also present in high numbers in therapeutically used intravenous immunoglobulin preparations, they have received little attention and their precise role remains largely unknown. An increasing awareness of the importance of posttranslational autoantigen modifications and glycobiology led us to explore carbohydrate-reactive natural autoantibodies in patients with rheumatoid arthritis. This study examined systematic antibodies reactive to glycosaminoglycans (GAGs), the carbohydrate components of proteoglycans that are released in large amounts from degrading cartilage.

Methods

To measure antibodies reactive to six different types of GAGs, a specialised ELISA was used in which the carbohydrates were covalently linked to the plastic surface through a 2 nm spacer. Sera from rheumatoid arthritis patients (n = 66), umbilical cord serum samples (n = 11) and adult controls (n = 54) were studied. In order to explore cross-reactivity with microbial antigens, bacterial peptidoglycans and fungal polysaccharides were used. Sera and synovial fluid samples were also tested using a GlycoChip carbohydrate array to characterise individual carbohydrate recognition patterns. We followed a multistep statistical screening strategy for screening GAG-reactive antibodies as predictive disease markers.

Results

While anti-GAG antibodies were absent in the umbilical cord sera, they were readily detectable in adult controls and were significantly elevated in patients with rheumatoid arthritis (p < 0.001). Anti-GAG antibodies showed significant cross-reactivity among different types of GAGs. They also reacted with bacterial peptidoglycans and fungal polysaccharides. Interestingly, anti-chondroitin sulphate C IgM antibody levels showed inverse correlation both with the Disease Activity Score (DAS) 28 scores and C-reactive protein (CRP) levels in rheumatoid arthritis.

Conclusion

The highly abundant and cross-reactive, GAG-specific natural autoantibodies in serum may serve as novel disease-state markers in patients with rheumatoid arthritis.

[Systemic lupus erythematosus and pregnancy]

Systemic Lupus Erythematosus (SLE) is a disease primarily targeting fertile women. The odds of spontaneous miscarriage, preeclampsia, intrauterine growth restriction is higher in pregnant women with SLE as well as there are increased risks of preterm delivery and perinatal fetal death. The occurrence of spontaneous abortion is closely related to the presence of antiphospholipid antibodies. The disease on its own is not a contraindication of pregnancy but at least a six-month remission is suggested prior conception. The physiological changes in the course of pregnancy might have close resemblance to the symptoms of lupus, therefore these changes should be differentiated from symptoms caused by lupus. For mothers suffering from SLE, regular visits not only to their obstetricians but also to a rheumatologist are also recommended in order to allow at proper time recognition of potential complications and their appropriate treatment. Thorough check of the maternal disease is of high importance not only during but also prior to and following pregnancy. An overview is given of the opportunities of recent diagnosis and opportunities of therapeutic approaches including biological as well as stem cell treatments. The antithrombotics treatment increases the chance of survival and healthy child birth in the case of pregnant women suffering from antiphospholipid syndrome. Although occurring rarely, neonatal SLE has significantly higher morbidity and mortality compared to healthy births. Recent studies show positive results in the case of prophylactic treatment of neonatal lupus. Prenatal care is recommended to be conducted at an institute where the obstetrician is experienced in the possible complications of lupus and where consultation with a rheumatologist, and the treatment of neonates with low birth weight are ensured.

Rituximab in patients with rheumatoid arthritis: systematic review

A rheumatoid arthritis terápiájában legújabban alkalmazott gyógyszerek a biológiai szerek. Legutóbb a B-lymphocyta-gátló rituximabot törzskönyvezték rheumatoid arthritis indikációjában. A rituximabot eddig a non-Hodgkin-lymphoma kezelésében alkalmazták. Európai és a magyar reumatológusok ajánlása szerint a rituximab rheumatoid arthritisben azoknak a betegeknek javasolható, akiknél a kórtörténetben eredménytelenség vagy toxicitás miatt sikertelen TNF-α-gátló kezelés szerepel. Célkitűzés: A rituximabkezelés klinikai hatásosságáról rheumatoid arthritisben rendelkezésre álló szakirodalom áttekintése. A rituximabkezelés hatásosságának és biztonságának értékelése. Módszer: A szerzők a MEDLINE- és Cochrane-adatbázisokban megkeresték az összes randomizált, kontrollált rituximabvizsgálatot rheumatoid arthritisben. Elvégezték az adatok metaanalízisét. Eredmények: Az irodalomkeresés során 3 randomizált kontrollált klinikai vizsgálatot azonosítottak a szerzők, amelyekben összesen 1145 beteget követtek. A TNF-α-gátló kezelésre nem reagáló, súlyos gyulladásos tüneteket mutató betegeknél rituximabkezelés mellett 33%-kal több betegnek (95%; KI: 25–41%) javulnak a tünetei az American College of Rheumatology 20 kritérium szerint, mint ha nem kezelnék őket. Majdnem 5-ször nagyobb (relatív kockázat = 4,77; 95%; KI, 3,12–7,31) esélyük van a javulásra, mint kezelés nélkül. A funkcionális állapotot jelző Health Assessment Questionnaire pontszám is szignifikánsan nagyobb mértékben ( p < 0,001) javult a rituximabcsoportban (–0,4 pont), mint a kontrollcsoportban (–0,1 pont). Rituximabkezelés hatására a mérsékelt vagy jó választ adó betegek aránya 38%-kal nagyobb (95% KI, 32–44%) a rituximabkezelési ágon, mint a kontrollcsoportban, a különbség szignifikáns ( p < 0,00001). A rituximab a radiológiai progressziót is javítja a TNF-α-gátló kezelésre nem reagáló betegek között. Következtetések: A rituximab új, hatásos terápiás lehetőség a rheumatoid arthritis terápiájában. A TNF-α-gátló kezelésre nem reagáló vagy azt nem toleráló betegeknél is javulás érhető el.

The effect of physical therapy on beta-endorphin levels

Beta-endorphin (betaE) is an important reliever of pain. Various stressors and certain modalities of physiotherapy are potent inducers of the release of endogenous betaE to the blood stream. Most forms of exercise also increase blood betaE level, especially when exercise intensity involves reaching the anaerobic threshold and is associated with the elevation of serum lactate level. Age, gender, and mental activity during exercise also may influence betaE levels. Publications on the potential stimulating effect of manual therapy and massage on betaE release are controversial. Sauna, mud bath, and thermal water increase betaE levels through conveying heat to the tissues. The majority of the techniques for electrical stimulation have a similar effect, which is exerted both centrally and--to a lesser extent--peripherally. However, the parameters of electrotherapy have not yet been standardised. The efficacy of analgesia and the improvement of general well-being do not necessarily correlate with betaE level. Although in addition to blood, increased brain and cerebrospinal fluid betaE levels are also associated with pain, the majority of studies have concerned blood betaE levels. In general, various modalities of physical therapy might influence endorphin levels in the serum or in the cerebrospinal fluid--this is usually manifested by elevation with potential mitigation of pain. However, a causal relationship between the elevation of blood, cerebrospinal fluid or brain betaE levels and the onset of the analgesic action cannot be demonstrated with certainty.

[The role of biologic agents in the therapy of ankylosing spondylitis]

Ankylosing spondylitis is a chronic, inflammatory rheumatic disease which etiology and pathogenesis are not yet fully understood. The inflammation involves the spine and also the peripheral joints might be affected in some cases resulting in a progressive ankylosis, restricted mobility, significant disability, loss of productivity and decreased quality of life. Gene technology based new drugs of the past decade, the biologic agents, offer an alternative opportunity for the treatment of ankylosing spondylitis in comparison with the previous drugs with doubtful efficiency. In Hungary infliximab and etanercept has been registered for ankylosing spondylitis. The aim of this study was to evaluate the efficacy of infliximab and etanercept by the available randomised controlled trials. A systematic search of the literature was performed from 01. 01. 2000 to 08. 31. 2005. and the relevant publications were analysed following the concepts of evidence based medicine. 7 double blind, randomised, placebo controlled trials were identified, three for infliximab (n = 389) and four for etanercept (n = 431). Although the inclusion criteria, the duration of the trials and the primary endpoints were different, the results confirm that both drugs significantly decrease symptoms and disease activity, and this effect is sustained during the therapy, nevertheless half of the patients did not achieve the standardised criteria of 50% decrease in disease activity. Both agents are well tolerated by patients. The outcomes of long-term therapy are reassuring by open extension studies of three years. Guidelines for biologic therapy has been developed in Hungary determining the target patient group, the conditions of the therapy and also an arthritis centre network has been established. Though individual admission is feasible, biologic drugs are not under reimbursement in Hungary. High drug costs makes the implementation of this new therapeutic opportunity difficult in the daily medical practice.

ASAS/EULAR recommendations for the management of ankylosing spondylitis

OBJECTIVE

To develop evidence based recommendations for the management of ankylosing spondylitis (AS) as a combined effort of the 'ASsessment in AS' international working group and the European League Against Rheumatism.

METHODS

Each of the 22 participants was asked to contribute up to 15 propositions describing key clinical aspects of AS management. A Delphi process was used to select 10 final propositions. A systematic literature search was then performed to obtain scientific evidence for each proposition. Outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, relative risk, number needed to treat, and incremental cost effectiveness ratio were calculated. On the basis of the search results, 10 major recommendations for the management of AS were constructed. The strength of recommendation was assessed based on the strength of the literature evidence, risk-benefit trade-off, and clinical expertise.

RESULTS

The final recommendations considered the use of non-steroidal anti-inflammatory drugs (NSAIDs) (conventional NSAIDs, coxibs, and co-prescription of gastroprotective agents), disease modifying antirheumatic drugs, treatments with biological agents, simple analgesics, local and systemic steroids, non-pharmacological treatment (including education, exercise, and physiotherapy), and surgical interventions. Three general recommendations were also included. Research evidence (categories I-IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied, depending on the category of evidence and expert opinion.

CONCLUSION

Ten key recommendations for the treatment of AS were developed and assessed using a combination of research based evidence and expert consensus. Regular updating will be carried out to keep abreast of new developments in the management of AS.

[Signal transduction abnormalities in systemic lupus erythematosus]

Engagement of T cell receptors by antigen-presenting cells or stimulation by cytokines determine whether the cell will become activated, anergic or die via apoptosis or necrosis. Ca2+ is a key second messenger that delivers signal from the cell surface, reactive oxygen intermediates and nitric oxide are recently recognized as important mediators of T cell activation. Nitric oxide is a multifunctional intracellular and intercellular messenger induces mitochondrial biogenesis in many cell types, such as lymphocytes. Mitochondria produce reactive oxygen intermediates and store and release Ca2+ in response to activation and death signals. Rapid Ca2+ fluxing is increased while sustained Ca2+ signaling is decreased in lupus T cells. Lupus T cells contain increased numbers and mass of mitochondria. Serum nitric oxide levels and production of nitric oxide by monocytes is increased in patients with systemic lupus erythematosus. Lupus T cells exhibit mitochondrial hyperpolarization and increased mitochondrial mass, which confer predisposition to necrosis rather than apoptosis in response to repetitive activation and death signals. Exposure of normal T cells to nitric oxide dose-dependently increase the mitochondrial mass and mimic rapid and sustained Ca2+ signal abnormalities observed in lupus T cells. Thus increased mitochondrial biogenesis may account for altered Ca2+ handling and represents novel targets for pharmacological intervention in SLE.

Effect of plasmapheresis on serum beta-endorphin levels

OBJECTIVES

The aim of this study was to examine the effects of plasmapheresis on serum beta-endorphin (BE) levels.

METHOD

The serum BE levels of 12 patients with various autoimmune or hematological disorders were monitored during plasmapheresis therapy.

RESULTS

BE levels increased after the initial session in 8 of 12 patients; in the remaining 4 patients no change (n = 2) or a decline (n = 2) in BE levels was found. However, no further changes were observed during subsequent therapy. During the last session, an elevation in the BE level was detected in 5 patients, with no change in 1 and a decrease in BE level in another 5 patients.

CONCLUSION

Our findings suggest that although plasmapheresis results in an elevation in serum BE levels initially, this change does not persist during subsequent sessions.

Synovial fluid exoglycosidases are predictors of rheumatoid arthritis and are effective in cartilage glycosaminoglycan depletion

OBJECTIVE

To analyze enzymes involved in joint damage by simultaneous investigation of glycosidases and matrix metalloproteinases (MMPs) in patients with various joint diseases.

METHODS

Activities of glycosidases (beta-D-glucuronidase, beta-D-N-acetyl-glucosaminidase, beta-D-N-acetyl-galactosaminidase, beta-D-galactosidase, and alpha-D-mannosidase) were tested at an acidic pH as well as at the original pH of the synovial fluid (SF) samples in parallel with activities of MMP-1 and MMP-9.

RESULTS

Patients with rheumatoid arthritis (RA) were characterized by significantly elevated activities of beta-D-glucuronidase and beta-D-N-acetyl-glucosaminidase in SF compared with patients with osteoarthritis, seronegative spondylarthritis, or acute sports injury. To select the best predictor for distinguishing among patient groups, a stepwise logistic regression analysis was performed; the strongest association was found to be between RA and beta-D-glucuronidase/beta-D-N-acetyl-glucosaminidase activities (measured at the pH of the SF). Further, a significant correlation was observed between the activity of SF beta-D-N-acetyl-glucosaminidase and the level of rheumatoid factor. In vitro digestion of human hyaline cartilage samples revealed that the dominant glycosidases, alone or in combination with MMPs, proved to be effective in depleting glycosaminoglycans (GAGs) from cartilage.

CONCLUSION

These results suggest that exoglycosidases, which are present in the SF of RA patients, may contribute to the depletion of GAGs from cartilage and thereby facilitate the invasion of synovial cells and their attachment to cartilage in RA.

[Hungarian adaptation of a disease-specific quality-of-life questionnaire in patients with ankylosing spondylitis]

INTRODUCTION

Measuring quality of life has growing importance in the field of health technology assessment. It is especially true for chronic diseases, like ankylosing spondylitis, which results in significant impact on patients' quality of life through the intensity and duration of the disease.

OBJECTIVES

To measure the reliability and validity of the Hungarian version of Ankylosing Spondylitis Quality of Life instrument with the intention of its use in clinical and health economic trials and burden of disease studies in Hungary via the introduction of a certain validation process.

METHODS

One of the most important criteria for the validity of quality of life instruments is the standard method used for adapting the questionnaire to foreign languages. The dual method was applied for the Hungarian adaptation of the Ankylosing Spondylitis Quality of Life questionnaire, which was followed by psychometric testing.

RESULTS

High test-retest correlation (0.85) indicated an acceptable degree of reliability with no evidence of excessive random measurement error. The internal consistency of the measure was confirmed (Cronbach's alpha coefficients were 0.87 and 0.91 at Time 1 and Time 2 respectively), with strong evidence that all items were adequately inter-related. The correlations with the NHP at both time points were at the expected levels, providing evidence of convergent and divergent validity.

CONCLUSION

On the basis of results shown above, it is concluded that the Hungarian Ankylosing Spondylitis Quality of Life questionnaire is a reliable and valid measure of quality of life.