Catastrophic health expenses and impoverishment of households of patients with rheumatoid arthritis

BACKGROUND

The cost of certain diseases may lead to catastrophic expenses and impoverishment of households without full financial support by the state and other organizations.

OBJECTIVE

To determine the socioeconomic impact of the rheumatoid arthritis (RA) cost in the context of catastrophic expenses and impoverishment.

PATIENTS AND METHODS

This is a cohort-nested cross-sectional multicenter study on the cost of RA in Mexican households with partial, full, or private health care coverage. Catastrophic expenses referred to health expenses totaling >30% of the total household income. Impoverishment defined those households that could not afford the Mexican basic food basket (BFB).

RESULTS

We included 262 patients with a mean monthly household income (US dollars) of $376 (0–18,890.63). In all, 50.8%, 35.5%, and 13.7% of the patients had partial, full, or private health care coverage, respectively. RA annual cost was $ 5534.8 per patient (65% direct cost, 35% indirect). RA cost caused catastrophic expenses in 46.9% of households, which in the logistic regression analysis were significantly associated with the type of health care coverage (OR 2.7, 95%CI 1.6–4.7) and disease duration (OR 1.024, 95%CI 1.002–1.046). Impoverishment occurred in 66.8% of households and was associated with catastrophic expenses (OR 3.6, 95%CI 1.04–14.1), high health assessment questionnaire scores (OR 4.84 95%CI 1.01–23.3), and low socioeconomic level (OR 4.66, 95%CI 1.37–15.87).

CONCLUSION

The cost of RA in Mexican households, particularly those lacking full health coverage leads to catastrophic expenses and impoverishment. These findings could be the same in countries with fragmented health care systems.

2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis

This first update of the ASAS/EULAR recommendations on the management of ankylosing spondylitis (AS) is based on the original paper, a systematic review of existing recommendations and the literature since 2005 and the discussion and agreement among 21 international experts, 2 patients and 2 physiotherapists in a meeting in February 2010. Each original bullet point was discussed in detail and reworded if necessary. Decisions on new recommendations were made — if necessary after voting. The strength of the recommendations (SOR) was scored on an 11-point numerical rating scale after the meeting by email. These recommendations apply to patients of all ages that fulfill the modified NY criteria for AS, independent of extra-articular manifestations, and they take into account all drug and non-drug interventions related to AS. Four overarching principles were introduced, implying that one bullet has been moved to this section. There are now 11 bullet points including 2 new ones, one related to extra-articular manifestations and one to changes in the disease course. With a mean score of 9.1 (range 8-10) the SOR was generally very good.

2010 Update of the international ASAS recommendations for the use of anti-TNF agents in patients with axial spondyloarthritis

This paper presents the second update of the Assessment in SpondyloArthritis international Society (ASAS) consensus statement on the use of anti-tumour necrosis factor (anti-TNF) agents in patients with axial spondyloarthritis (SpA). A major change from the previous recommendations is that patients fulfilling the ASAS axial SpA criteria, which also include patients fulfilling the modified New York criteria for ankylosing spondylitis, can be treated with anti-TNF agents. This makes an earlier start in the disease process possible. A second major change is the mandatory pretreatment before anti-TNF agents can be started. All patients should have tried a minimum of two non-steroidal anti-inflammatory drugs for a minimum of 4 weeks in total. This is significantly shorter than the previous requirement of 3 months. As previously, patients with axial symptoms require no further pretreatment. Patients with symptomatic peripheral symptoms should normally have had an adequate therapeutic trial of a disease-modifying antirheumatic drug, preferably sulfasalazine. Sulfasalazine is no longer mandatory in this group of patients. Finally, efficacy should be evaluated after at least 12 weeks. The remaining recommendations stayed largely unchanged.

Differential features between primary ankylosing spondylitis and spondylitis associated with psoriasis and inflammatory bowel disease

OBJECTIVE

To describe differential characteristics of axial involvement in ankylosing spondylitis (AS) as compared with that seen in psoriatic arthritis (PsA) and inflammatory bowel disease (IBD) in a cohort of Ibero-American patients.

METHODS

This study included 2044 consecutive patients with spondyloarthritis (SpA; ESSG criteria). Demographic, clinical, disease activity, functional ability, quality of life, work status, radiologic, and therapeutic data were evaluated and collected by RESPONDIA members from different Ibero-American countries between June and December 2006. Patients selected for analysis met modified New York criteria (mNY) for AS.

RESULTS

A total of 1264 patients met the New York criteria for AS: 1072 had primary AS, 147 had psoriatic, and 45 had IBD-associated spondylitis. Median disease duration was comparable among the 3 patient groups. Patients with primary AS were significantly younger (p = 0.01) and presented a higher frequency of males (p = 0.01) than the other 2 groups. Axial manifestations such as inflammatory back pain and sacroiliac pain were significantly more frequent in patients with primary AS (p = 0.05) versus other groups, whereas frequency of dactylitis, enthesitis, and peripheral arthritis was more common in patients with psoriatic spondylitis (p = 0.05). Spinal mobility was significantly more limited in patients with primary AS versus the other 2 groups (p = 0.0001). Radiologic changes according to BASRI total score were equally significant in primary AS. Disease activity (BASDAI), functional ability (BASFI), and quality of life (ASQoL) scores were comparable in the 3 groups.

CONCLUSION

Patients with primary AS had more severe axial involvement than those with spondylitis associated with psoriasis or IBD. Functional capacity, disease activity, and quality of life were comparable among the groups studied.

Validity of the COPCORD core questionnaire as a classification tool for rheumatic diseases

OBJECTIVE

Rheumatic diseases are vastly underdiagnosed and undertreated, particularly among minorities and those of low socioeconomic status. The WHO-ILAR Community Oriented Program in the Rheumatic Diseases (COPCORD) advocates screening of musculoskeletal complaints in the community. The objective of this study was to evaluate the performance of the COPCORD Core Questionnaire (CCQ) as a diagnostic tool for rheumatic diseases.

METHODS

We conducted a cross-sectional study designed in parallel with a large COPCORD survey in Mexico. A subsample of 17,566 questionnaires, selected from 4 of the 5 states included in a national COPCORD survey were included in the analysis as a diagnostic test to evaluate sensitivity, specificity, receiver operating characteristics curve (ROC), and positive likelihood ratio (LR+) of the CCQ as a case-detection tool for rheumatic diagnosis and for the most frequent diagnoses identified in the survey, osteoarthritis, regional rheumatic pain syndromes, and rheumatoid arthritis (RA). Logistic regression with the questions with LR+ ≥ 1 was performed to identify the strength of association (OR) for each question.

RESULTS

Pain in the last 7 days, high pain score (> 4), and previous diagnosis were the questions with highest LR+ for diagnosis, and for diagnosis of RA treatment with NSAID. The variables that contributed most to the model were pain in the last 7 days (OR 2.0, 95% CI 1.8-2.3), NSAID treatment (OR 3.3, 95% CI 3.0-3.7), a high pain score (OR 1.15, 95% CI 1.13-1.17), and having a previous diagnosis (OR 1.4, 95% CI 1.3-1.6). These 4 questions had R(2) = 0.24, p < 0.01, for detection of any rheumatic diagnosis. The single variable that explains 16% (OR 1.33, 95% CI 1.31-134) of variance was a high pain score in the last 7 days.

CONCLUSION

Some variables were identified in the CCQ that could be combined in a brief version for case detection of rheumatic diseases in community surveys. The validity of this proposal has to be tested against the original version.

Epidemiology of rheumatic diseases. A community-based study in urban and rural populations in the state of Nuevo Leon, Mexico

OBJECTIVE

To estimate the prevalence of rheumatic diseases in rural and urban populations using the WHO-ILAR COPCORD questionnaire.

METHODS

We conducted a cross-sectional home survey in subjects > 18 years of age in the Mexican state of Nuevo Leon. Results were validated locally against physical examination in positive cases according to an operational definition by 2 rheumatologists. We used a random, balanced, and stratified sample by region of representative subjects.

RESULTS

We surveyed 4713 individuals with a mean age of 43.6 years (SD 17.3); 55.9% were women and 87.1% were from urban areas. Excluding trauma, 1278 individuals (27.1%, 95% CI 25.8%-28.4%) reported musculoskeletal pain in the last 7 days; the prevalence of this variable was almost twice as frequent in women (33% vs 17% in men); 529 (11.2%) had pain associated with trauma. The global prevalence of pain was 38.3%. Mean pain score was 2.4 (SD 3.4) on a pain scale of 0-10. Most subjects classified as positive according to case definition (99%) were evaluated by a rheumatologist. Main diagnoses were osteoarthritis in 17.3% (95% CI 16.2-18.4), back pain in 9.8% (95% CI 9.0-10.7), undifferentiated arthritis in 2.4% (95% CI 2.0-2.9), rheumatoid arthritis in 0.4% (95% CI 0.2-0.6), fibromyalgia in 0.8% (95% CI 0.6-1.1), and gout in 0.3% (95% CI 0.1-0.5).

CONCLUSION

This is the first regional COPCORD study in Mexico performed with a systematic sampling, showing a high prevalence of pain. COPCORD is a useful tool for the early detection of rheumatic diseases as well as for accurately referring patients to different medical care centers and to reduce underreporting of rheumatic diseases.

Epidemiology of the rheumatic diseases in Mexico. A study of 5 regions based on the COPCORD methodology

OBJECTIVE

To estimate the prevalence of musculoskeletal (MSK) disorders and to describe predicting variables associated with rheumatic diseases in 5 regions of México.

METHODS

This was a cross-sectional, community-based study performed in 5 regions in México. The methodology followed the guidelines proposed by the Community Oriented Program for the Control of the Rheumatic Diseases (COPCORD). A standardized methodology was used at all sites, with trained personnel following a common protocol of interviewing adult subjects in their household. A "positive case" was defined as an individual with nontraumatic MSK pain of > 1 on a visual analog pain scale (0 to 10) during the last 7 days. All positive cases were referred to internists or rheumatologists for further clinical evaluation, diagnosis, and proper treatment.

RESULTS

The study included 19,213 individuals; 11,602 (68.8%) were female, and their mean age was 42.8 (SD 17.9) years. The prevalence of MSK pain was 25.5%, but significant variations (7.1% to 43.5%) across geographical regions occurred. The prevalence of osteoarthritis was 10.5%, back pain 5.8%, rheumatic regional pain syndromes 3.8%, rheumatoid arthritis 1.6%, fibromyalgia 0.7%, and gout 0.3%. The prevalence of MSK manifestations was associated with older age and female gender.

CONCLUSION

The prevalence of MSK pain in our study was 25.5%. Geographic variations in the prevalence of MSK pain and specific diagnoses suggested a role for geographic factors in the prevalence of rheumatic diseases.

Prevalence of rheumatic regional pain syndromes in adults from Mexico: a community survey using COPCORD for screening and syndrome-specific diagnostic criteria

OBJECTIVE

To assess the prevalence of rheumatic regional pain syndromes (RRPS) in 3 geographical areas of México using the Community Oriented Program in the Rheumatic Diseases (COPCORD) screening methodology and validate by expert consensus on case-based definitions.

METHODS

By means of an address-based sample generated through a multistage, stratified, randomized method, a cross-sectional survey was performed on adult residents (n = 12,686; age 43.6 ± 17.3 yrs; women 61.9%) of the states of Nuevo León, Yucatán, and México City. Diagnostic criteria for specific upper (Southampton group criteria) and lower limb (ad hoc expert consensus) RRPS were applied to all subjects with limb pain as detected by COPCORD questionnaire.

RESULTS

The overall prevalence of RRPS was 5.0% (95% CI 4.7-5.4). The most frequent syndrome was rotator cuff tendinopathy (2.36%); followed by inferior heel pain (0.64%); lateral epicondylalgia (0.63%); medial epicondylalgia (0.52%); trigger finger (0.42%); carpal tunnel syndrome (0.36%); anserine bursitis (0.34%); de Quervain's tendinopathy (0.30%); shoulder bicipital tendinopathy (0.27%); trochanteric syndrome (0.11%); and Achilles tendinopathy (0.10%). There were anatomic regional variations in the prevalence of limb pain: Yucatán 3.1% (95% CI 2.5-3.6); Nuevo León 7.0% (95% CI 6.3-7.7); and México City 10.8% (95% CI 9.8-11.8). Similarly, the prevalence of RRPS showed marked geographical variation: Yucatán 2.3% (95% CI 1.8-2.8); Nuevo León 5.6% (95% CI 5.0-6.3); and México City 6.9% (95% CI 6.2-7.7).

CONCLUSION

The overall prevalence of RRPS in México was 5.0%. Geographical variations raise the possibility that the prevalence of RRPS is influenced by socioeconomic, ethnic, or demographic factors.

The efficacy and safety of abatacept in patients with non-life-threatening manifestations of systemic lupus erythematosus: results of a twelve-month, multicenter, exploratory, phase IIb, randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate abatacept therapy in patients with non-life-threatening systemic lupus erythematosus (SLE) and polyarthritis, discoid lesions, or pleuritis and/or pericarditis.

METHODS

In a 12-month, multicenter, exploratory, phase IIb randomized, double-blind, placebo-controlled trial, SLE patients with polyarthritis, discoid lesions, or pleuritis and/or pericarditis were randomized at a ratio of 2:1 to receive abatacept (∼10 mg/kg of body weight) or placebo. Prednisone (30 mg/day or equivalent) was given for 1 month, and then the dosage was tapered. The primary end point was the proportion of patients with new flare (adjudicated) according to a score of A/B on the British Isles Lupus Assessment Group (BILAG) index after the start of the steroid taper.

RESULTS

A total of 118 patients were randomized to receive abatacept and 57 to receive placebo. The baseline characteristics were similar in the 2 groups. The proportion of new BILAG A/B flares over 12 months was 79.7% (95% confidence interval [95% CI] 72.4, 86.9) in the abatacept group and 82.5% (95% CI 72.6, 92.3) in the placebo group (treatment difference -3.5 [95% CI -15.3, 8.3]). Other prespecified flare end points were not met. In post hoc analyses, the proportions of abatacept-treated and placebo-treated patients with a BILAG A flare were 40.7% (95% CI 31.8, 49.5) versus 54.4% (95% CI 41.5, 67.3), and the proportions with physician-assessed flare were 63.6% (95% CI 54.9, 72.2) and 82.5% (95% CI 72.6, 92.3), respectively; treatment differences were greatest in the polyarthritis group. Prespecified exploratory patient-reported outcomes (Short Form 36 health survey, sleep problems, fatigue) demonstrated a treatment effect with abatacept. The frequency of adverse events (AEs) was comparable in the abatacept and placebo groups (90.9% versus 91.5%), but serious AEs (SAEs) were higher in the abatacept group (19.8 versus 6.8%). Most SAEs were single, disease-related events occurring during the first 6 months of the study (including the steroid taper period).

CONCLUSION

Although the primary/secondary end points were not met in this study, improvements in certain exploratory measures suggest some abatacept efficacy in patients with non-life-threatening manifestations of SLE. The increased rate of SAEs requires further assessment.

The use of methotrexate in children with rheumatic diseases

Methotrexate (MTX) is one of the most useful drugs for the treatment of various rheumatic diseases in children, mainly juvenile idiopathic arthritis (JIA), juvenile dermatomyositis (JDM), and localised scleroderma. MTX is considered the standard treatment of JIA, particularly of those subgroups with polyarticular course. JIA response and remission rates to MTX are the standard for comparison with other drug modifying anti-rheumatic drug (DMARD) and biologic agents in clinical trials. On the other hand, short and long-term data suggest that MTX is a safety drug in the paediatric population with rheumatic diseases. Not surprisingly, MTX is the DMARD of choice in JIA either as monotherapeutic drug or in combination with biologic agents.

Association of HLA DRB1 alleles with juvenile idiopathic arthritis in Mexicans

OBJECTIVE

The aim of the study was to investigate association between HLA class II alleles and juvenile idiopathic arthritis (JIA) in Mexican patients.

PATIENTS AND METHODS

We typed 120 patients with JIA and 99 healthy controls for HLA class II alleles were performed by PCR-SSO. Differences between the whole group of JIA and its subtypes and controls were calculated by using the Xi2; p-values were corrected (pc) with Bonferroni's test.

RESULTS

The alleles HLA-DRB1*01 (pc= 0.00083) and HLA-DRB1*04 (pc=0.0049) were strongly associated with systemic JIA, while HLA-DRB1*11 and HLA-DRB1*14 were found to have decreased frequencies in the patients with systemic JIA compared to the controls. Two alleles were found to have increased frequencies with JIA oligoarthritis subgroup, HLA-DRB1*11 (p=0.01, pc=NS) and HLA-DRB1*13 (p=0.01, pc=NS). The HLA-DRB1*04 was found increased frequencies with susceptibility for RF negative and RF positive polyarthritis JIA subgroups (p correction resulted in loss of significance). In contrast two alleles HLA-DRB1*07 and HLA-DRB1*14 were found decreased frequencies only patients RF positive polyarthritis JIA subgroup compared to the controls (pc=NS).

CONCLUSION

The profile of HLA-DRB1 alleles associations in Mexican with JIA were somewhat distinct from association typically found in Caucasians.

Prevalence of community-acquired and nosocomial infections in hospitalized patients with systemic lupus erythematosus

Infections are an important cause of morbidity and mortality in systemic lupus erythematosus. We aimed to determine the incidence and characteristics of infections in patients hospitalized because of systemic lupus erythematosus, and to identify which factors influence their outcome. The medical records of patients with systemic lupus erythematosus hospitalized between January 2002 and December 2007 were reviewed according to a standardized case form including demographic, clinical, and therapeutic data. The diagnosis of infection was based on clinical findings, the identification of the causative agent or response to antibiotic treatment. The study included 473 patients (mean age 30 +/- 11 years; 421 (89%) female) who were hospitalized for a mean of 13 +/- 9 days. A community-based infection was suspected in 268 (57%) at admission; the diagnosis was confirmed in 96 patients (22%) and ruled out in 20 (4.2%); nevertheless, 152 patients (32%) received antibiotics on an empirical basis. A nosocomial infection was suspected in 63 (13.3%) of 453 patients and was confirmed in 59 (12.5%). The two most common community-acquired and nosocomial infections affected the respiratory and genitourinary tracts. Gram-negative bacteria were major etiological agents isolated. In the multivariate analysis, community-based infections associated with mucocutaneous, renal, or central nervous system disease activity as well as fever, and Mex-SLEDAI at admission and nosocomial infections to azathioprine use, infection at admission, disease duration, and hospitalization >7 days. We conclude that infections are an important cause of hospitalization of systemic lupus erythematosus patients. Risk factors include disease activity, use of immunosuppressants, disease duration, and length of hospital stay.

The safety and efficacy of a JAK inhibitor in patients with active rheumatoid arthritis: Results of a double-blind, placebo-controlled phase IIa trial of three dosage levels of CP-690,550 versus placebo

OBJECTIVE

To determine the efficacy, safety, and tolerability of 3 different dosages of CP-690,550, a potent, orally active JAK inhibitor, in patients with active rheumatoid arthritis (RA) in whom methotrexate, etanercept, infliximab, or adalimumab caused an inadequate or toxic response.

METHODS

Patients (n = 264) were randomized equally to receive placebo, 5 mg of CP-690,550, 15 mg of CP-690,550, or 30 mg of CP-690,550 twice daily for 6 weeks, and were followed up for an additional 6 weeks after treatment. The primary efficacy end point was the American College of Rheumatology 20% improvement criteria (ACR20) response rate at 6 weeks.

RESULTS

By week 6, the ACR20 response rates were 70.5%, 81.2%, and 76.8% in the 5 mg, 15 mg, and 30 mg twice daily groups, respectively, compared with 29.2% in the placebo group (P < 0.001). Improvements in disease activity in CP-690,550-treated patients compared with placebo were seen in all treatment groups as early as week 1. ACR50 and ACR70 response rates significantly improved in all treatment groups by week 4. The most common adverse events reported were headache and nausea. The infection rate in both the 15 mg twice daily group and the 30 mg twice daily group was 30.4% (versus 26.2% in the placebo group). No opportunistic infections or deaths occurred. Increases in mean low-density lipoprotein cholesterol and high-density lipoprotein cholesterol levels, and increases in mean serum creatinine level (0.04-0.06 mg/dl) were seen in all CP-690,550 treatment arms.

CONCLUSION

Our findings indicate that CP-690,550 is efficacious in the treatment of RA, resulting in rapid, statistically significant, and clinically meaningful reductions in the signs and symptoms of RA. Further studies of CP-690,550 in RA are warranted.

Improved pain, physical functioning and health status in patients with rheumatoid arthritis treated with CP-690,550, an orally active Janus kinase (JAK) inhibitor: results from a randomised, double-blind, placebo-controlled trial

OBJECTIVES

To determine the efficacy of CP-690,550 in improving pain, function and health status in patients with moderate to severe active rheumatoid arthritis (RA) and an inadequate response to methotrexate or a tumour necrosis factor alpha inhibitor.

METHODS

Patients were randomised equally to placebo, CP-690,550 5, 15 or 30 mg twice daily for 6 weeks, with 6 weeks' follow-up. The patient's assessment of arthritis pain (pain), patient's assessment of disease activity, Health Assessment Questionnaire-Disability Index (HAQ-DI) and Short Form-36 (SF-36) were recorded.

RESULTS

At week 6, significantly more patients in the CP-690,550 5, 15 and 30 mg twice-daily groups experienced a 50% improvement in pain compared with placebo (44%, 66%, 78% and 14%, respectively), clinically meaningful reductions in HAQ-DI (> or =0.3 units) (57%, 75%, 76% and 36%, respectively) and clinically meaningful improvements in SF-36 domains and physical and mental components.

CONCLUSIONS

CP-690,550 was efficacious in improving the pain, function and health status of patients with RA, from week 1 to week 6.

Antibodies against recombinant heat shock proteins of 60 kDa from enterobacteria in the sera and synovial fluid of HLA-B27 positive ankylosing spondylitis patients

OBJECTIVE

To study the association of HLA-B27 with IgG antibodies to different enterobacterial HSP60s in patients with ankylosing spondylitis (AS).

METHODS

IgG antibodies to 60 kDa enterobacterial HSPs were determined by ELISA in paired samples of sera and synovial fluid from 21 HLA-B27+ ankylosing spondylitis (AS) patients; and in sera from 32 HLA-B27+ AS patients, 35 HLA-B27+ healthy relatives of AS patients, and 60 HLA-B27- healthy individuals with no family members with AS.

RESULTS

HLA-B27+ patients and healthy individuals showed significantly higher IgG antibody levels to recombinant enterobacterial HSP60s than HLA-B27- healthy controls. The levels of anti-HSP60Sf and anti-HSP60Ec antibodies correlated with disease activity and anti-HSP60Ec antibodies with male gender. No association between enterobacterial HSP60 antibody levels and disease duration was observed. All groups had lower levels of IgG antibodies to rHSP60 from Streptococcus pyogenes (rHSP60 Spy). In paired samples of sera and synovial fluid from B27+ patients, IgG antibodies to enterobacterial HSP60s were detected, but in significantly higher levels in sera than in synovial fluid. The anti-rHSPSpy IgG response in these samples was lower and similar in the three groups.

CONCLUSIONS

A correlation was found between HLA-B27 and the response to recombinat enterobacterial HSP60s. This response could be associated with disease activitir and gender in some proteins and the presence eof IgG antibodies to these proteins in synovial fluid could be associated with the inflammatory process and initiation of AS.

Juvenile idiopathic arthritis. Subgroup characteristics and comparisons between rheumatoid arthritis-like subgroups and ankylosing spondylitis-like subgroups

In terms of adult-onset definitions, rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are rarely diagnosed in children. Adult RA is in most aspects similar to seropositive polyarticular arthritis in children, but AS differs in its clinical presentation according to age at onset. In general, the nomenclature and classifications of arthritis in children encompass subgroups with specific signs or laboratory tests and pathogenic mechanisms that distinguish one clinical form from the other. While one of these subgroups corresponds to RA, the one related to AS usually includes children with undifferentiated SpA and not definite AS. Thus, comparisons of RA and AS in children actually correspond to comparisons of various forms of childhood arthritis, currently classified as juvenile idiopathic arthritis (JIA) and AS in its early undifferentiated form. In this paper, we review these to finally compare the two populations.

Very recent onset arthritis: the value of initial rheumatologist evaluation and anti-cyclic citrullinated peptide antibodies in the diagnosis of rheumatoid arthritis

The objective of this study is to identify baseline factors associated with rheumatoid arthritis (RA) diagnosis at the end of 1-year follow-up in a cohort of patients with very recent onset arthritis. Incident cases with self-reported arthritis (<or=12 weeks) referred by primary care physicians were assessed by a designated rheumatologist who predicted in those with >or=1 swollen joint the diagnosis of RA at the end of follow-up. Patients were regularly seen and diagnosed through follow-up by staff rheumatologists who were blind to diagnostic prediction. Of 119 referrals, 78 (65.5%; age 35.5 +/- 13.5 years; 69 females) were diagnosed at baseline as very recent onset arthritis (median duration 6 weeks (0-12 weeks)); of 75 patients completing 1-year follow-up, 51 (66.5%) were classified as RA; 12 (16%) had self-limited arthritis; and 13 (17.5%) other diagnoses. The characteristics of patients with RA as final diagnosis were polyarthritis, morning stiffness >or=1 h, high counts of swollen joints, and low frequency of systemic symptoms. Rheumatologist prediction of RA and anti-cyclic citrullinated peptide (anti-CCP) antibodies was strongly associated with RA as a final diagnosis in the logistic regression analysis. Sensitivity and specificity of the rheumatologist prediction were 94% and 74%, for anti-CCP antibodies, 56% and 96%; the combination of both variables had a specificity of 100% and a sensitivity of 53%, and a positive predictive value of 98%. The combination of RA as predicted diagnosis by a rheumatologist and anti-CCP antibodies is highly specific for RA diagnosis in patients with very early arthritis.

Toward a valid definition of gout flare: results of consensus exercises using Delphi methodology and cognitive mapping

OBJECTIVE

To identify, in people known to have gout, the testable, key components of a standard definition of gout flare for use in clinical research.

METHODS

Consensus methodology was used to identify key elements of a gout flare. Two Delphi exercises were conducted among different groups of rheumatologists. A cognitive mapping technique among 9 gout experts with hierarchical cluster analysis provided a framework to guide the panel discussion, which identified the final set of items that should be tested empirically.

RESULTS

From the Delphi exercises, 21 items were presented to the expert panel. Cluster analysis and multidimensional scaling showed that these items clustered into 5 concepts (joint inflammation, severity of symptoms, stereotypical nature, pain, and gout archetype) distributed along 2 dimensions (objective to subjective features and general features to specific features of gout). Using this analysis, expert panel discussion generated a short list of potential features: joint swelling, joint tenderness, joint warmth, severity of pain, patient global assessment, time to maximum pain, time to complete resolution of pain, an acute-phase marker, and functional impact of the episode.

CONCLUSION

A short list of features has been identified and now requires validation against a patient- and physician-defined gout flare in order to determine the best combination of features.

The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis

The field of spondyloarthritis (SpA) has experienced major progress in the last decade, especially with regard to new treatments, earlier diagnosis, imaging technology and a better definition of outcome parameters for clinical trials. In the present work, the Assessment in SpondyloArthritis international Society (ASAS) provides a comprehensive handbook on the most relevant aspects for the assessments of spondyloarthritis, covering classification criteria, MRI and x rays for sacroiliac joints and the spine, a complete set of all measurements relevant for clinical trials and international recommendations for the management of SpA. The handbook focuses at this time on axial SpA, with ankylosing spondylitis (AS) being the prototype disease, for which recent progress has been faster than in peripheral SpA. The target audience includes rheumatologists, trial methodologists and any doctor and/or medical student interested in SpA. The focus of this handbook is on practicality, with many examples of MRI and x ray images, which will help to standardise not only patient care but also the design of clinical studies.

[Guidelines in RA treatment: concepts on safety and recommendations using anti-TNF-alpha inhibitors. Grupo de Estudio de Nuevas Terapias de Enfermedades reumáticas (GENTE)]

Recommendations for the use of Disease-Modifying Antirheumatic Drugs (DMARD) with both conventional and biological agents in Rheumatoid Arthritis (RA) must be based on their safety profile, adverse effects, risks, and advantages. With the purpose of presenting the most updated information about the safety of tumor necrosis factor alpha (TNFalpha) antagonists, in this article we summarize the literature published during the last three years about this sort of biological agents in specific clinical situations, such as risk of developing infections, cancer, cardiovascular diseases, and autoimmunity; as well as their administration to patients who will undergo surgical procedures, pregnant and/or breast-feeding women, and patients who need immunizations. Likewise, in this analysis we offer specific recommendations, based on evidence, for the best anti-TNF-alfa management.

The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part I): classification of paper patients by expert opinion including uncertainty appraisal

OBJECTIVE

Non-radiographic axial spondyloarthritis (SpA) is characterised by a lack of definitive radiographic sacroiliitis and is considered an early stage of ankylosing spondylitis. The objective of this study was to develop candidate classification criteria for axial SpA that include patients with but also without radiographic sacroiliitis.

METHODS

Seventy-one patients with possible axial SpA, most of whom were lacking definite radiographic sacroiliitis, were reviewed as "paper patients" by 20 experts from the Assessment of SpondyloArthritis international Society (ASAS). Unequivocally classifiable patients were identified based on the aggregate expert opinion in conjunction with the expert-reported level of certainty of their judgement. Draft criteria for axial SpA were formulated and tested using classifiable patients.

RESULTS

Active sacroiliitis on magnetic resonance imaging (MRI) (odds ratio 45, 95% CI 5.3 to 383; p<0.001) was strongly associated with the classification of axial SpA. The knowledge of MRI findings led to a change in the classification of 21.1% of patients. According to the first set of candidate criteria (sensitivity 97.1%; specificity 94.7%) a patient with chronic back pain is classified as axial SpA in the presence of sacroiliitis by MRI or x rays in conjunction with one SpA feature or, if sacroilitiis is absent, in the presence of at least three SpA features. In a second set of candidate criteria, inflammatory back pain is obligatory in the clinical arm (sensitivity 86.1%; specificity 94.7%).

CONCLUSION

The ASAS group has developed candidate criteria for the classification of axial SpA that include patients without radiographic sacroiliitis. The candidate criteria need to be validated in an independent international study.

[Treatment guidelines for ankylosing spondylitis and its effect on Mexican rheumatology]

We describe the guidelines for the current treatment of ankylosing spondylitis with an emphasis on the role and outlook of the Mexican rheumatologic community. The topics we analyze include: epidemiological as well as professional, financial, health status, and quality of life aspects. We propose to acknowledge that axial spondyloarthritis is the earliest form of ankylosing spondylitis. Finally we carry out a review of the literature supporting current therapeutic recommendations. Regarding the latter, we approached the ASAS/EULAR recommendations for the treatment of ankylosing spondylitis and their level of agreement with Mexican and other countries' rheumatologists. Finally, we analyzed the recommendations to start tumor necrosis alpha blockers among patients with ankylosing spondylitis.

[Complementary and alternative medicine in patients attending a rheumatology department for the first time. Analysis of 800 patients]

OBJECTIVES

To determine the frequency of the use of complementary and alternative medicine (CAM) in patients attending a rheumatology department in a general hospital for the first time.

SUBJECTS AND METHODS

We included consecutive patients attending our rheumatology department for the first time. All the patients completed a self-administered questionnaire containing items on demographic data, and prior diagnosis. The patients were also given a list of 22 different CAM and marked those they had previously used.

RESULTS

Eight hundred patients were studied. Eighty percent were women. The mean age was 44.8±14.9 years and the mean number of years of education was 7±4. The main diagnoses were osteoarthritis (29.4%), rheumatoid arthritis (22.3%), and fibromyalgia (6.5%). Seventy-one percent had previously used CAM, with a median of two (0-14) different types. The most common were vitamin supplements (38%), arnica (18%), Aloe vera (15%) and homeopathy (15%). No significant differences were found in sex, age, educational level, or diagnosis. The use of CAM was more frequent in patients with longer disease duration.

CONCLUSIONS

The frequency of use of CAM is high in patient with rheumatologic manifestations.

[Social costs of the most common inflammatory rheumatic diseases in Mexico from the patient's perspective]

OBJECTIVE

To estimate the social costs of rheumatoid arthritis (RA), ankylosing spondylitis (AS), and gout from the patient's perspective.

METHODS

We carried out a cross-sectional analysis of the cost and resource utilization of 690 RA, AS, and gout patients from 10 medical centers and private facilities in five cities of Mexico. The information was obtained from the baseline of a dynamic cohort. We estimated out-of-pocket expenses, institutional direct costs, and direct medical costs.

RESULTS

The mean (SD) annual out-of-pocket expense (USD) was $610.0 ($302.2) for RA, $578.6 ($220.5) for AS, and $245.3 ($124.0) for gout. Figures correspond to 15%, 9.6%, and 2.5% of the family income. They also represented 26.1%, 25.3%, and 24.4% of the total annual cost per RA, AS, and gout patients, respectively. The expected direct institutional patient/year costs were 1,724.2 for RA, $1,710.8 for AS, and $760.7 for gout. The total patient annual costs were $2,334.3 for RA, $2,289.4 for AS, and $1,006.1 for gout. Most out-of-pocket expenses were used to purchase drugs, pay for laboratory tests, imaging studies, and alternative therapies.

CONCLUSIONS

From the patient's perspective, the cost of RA, AS, and gout represents 25% of direct medical costs. The cost of RA is higher than that for AS and gout.

Undifferentiated spondyloarthritis: a global perspective

This paper reviews the concept and outcome of undifferentiated spondyloarthritis (SpA) as reported in retrospective and prospective studies from different parts of the world. Although the designs and definitions vary across different studies, clearly a significant proportion of patients with undifferentiated SpA will fulfill ankylosing spondylitis within 10 years in association with certain prognostic factors. The paper also examines the concept of axial SpA and its importance as an early indicator of ankylosing spondylitis. Ultimately, the recognition of undifferentiated SpA and axial SpA may lead to early treatment with highly efficacious drugs.

Systemic features and early prognostic factors in Hispanic and non-Hispanic children from the United States of America and Mexico with systemic juvenile idiopathic arthritis

OBJECTIVE

To investigate if the persistence of systemic features is longer in Hispanic children with systemic juvenile idiopathic arthritis (S-JIA) than in non-Hispanic children with S-JIA and to determine early predictors of systemic and articular disease.

METHODS

We performed a multi-center retrospective chart review of patients followed in six pediatric rheumatology centers with onset of S-JIA from 1974 to 2004. Patients were included in the study if they had been followed for > or = 1 year after disease onset. Information collected included demographic, clinical, laboratory and treatment data. Systemic features included fever, rash, lymphadenopathy, hepatosplenomegaly, pericarditis, and pleuritis.

RESULTS

Of the 159 S-JIA patients screened, 120 (75%) met our inclusion criteria. There were 65 boys and 55 girls. The mean follow-up period for Hispanic patients was 5.7 years (SD 4.0) and for non-Hispanic patients was 8.6 years (SD 7.2). There was no significant difference in the presence of systemic features between Hispanic and non-Hispanic patients at 0.5, 1, 2, 4, 6, 8, and 10 years of follow-up. Polyarthritis at the 6-month visit was predictive of systemic features (OR 9.7, 95% CI 1.16-81.35, p = 0.036) and polyarthritis (OR 5.6, 95% CI 1.42-21.8, p = 0.014) at last follow-up.

CONCLUSION

In children with S-JIA, Hispanics did not demonstrate longer persistence of systemic features than non-Hispanics. Polyarthritis at 6 months strongly predicted the development of persistent systemic features and chronic polyarticular disease.