Methotrexate in the treatment of ankylosing spondylitis

There have been few well-conducted studies into the efficacy of methotrexate in Ankylosing spondylitis. The results of a new prospective study in 51 patients are presented in this issue but the clinical response was poor. A recurring theme, however, is the promising effect noted on peripheral joints compared with that on the axial skeleton. Recent histological and magnetic resonance imaging evidence suggests that synovitis and subchondral bone marrow changes offer a more rational explanation for widespread joint destruction than does enthesitis alone. Furthermore, enthesis lesions close to synovial joints occur frequently and may be intimately linked with peripheral joint synovitis. At the moment there is no hard evidence of efficacy in axial disease, but these observations raise the possibility that suppression of synovitis might help in the spine, and that enthesitis might respond wherever it is anatomically. Thus further long-term, placebo-controlled studies are needed to address specifically the issues of enthesitis. spinal symptom relief and the suppression of long-term ankylosis.

Serum YKL-40 concentrations in patients with early rheumatoid arthritis: relation to joint destruction

OBJECTIVE

YKL-40 is a secretory glycoprotein of chondrocytes, synovial cells, macrophages, and neutrophils. The aims were to determine serum YKL-40 in patients with early rheumatoid arthritis (RA) and seek associations with early joint erosions.

METHODS

YKL-40 was measured by ELISA in serum samples collected every three month for 36 months from patients with early RA. The patients were treated with DMARDs and some were allocated to additional prednisolone.

RESULTS

Serum YKL-40 was higher in RA patients compared with controls (98 vs. 42 microg/l, p<0.001). The mean serum YKL-40 during the study correlated with the progression in Larsen score (Pearson's test: p=0.004). Patients with a persistently high serum YKL-40 had larger progression in Larsen score compared with patients with normal serum YKL-40 (median progression: 7 vs. 0, p=0.003).

CONCLUSION

These data suggest that elevated serum YKL-40 is related to progression in joint destruction in early RA patients.

Patient education for adults with rheumatoid arthritis

BACKGROUND

Because of the unpredictability people with arthritis face on a daily basis, patient education programmes have become an effective complement to traditional medical treatment giving people with arthritis the strategies and the tools necessary to make daily decisions to cope with the disease.

OBJECTIVES

To assess the effectiveness of patient education interventions on health status in patients with rheumatoid arthritis.

SEARCH STRATEGY

We searched MEDLINE, EMBASE and PsycINFO and the Cochrane Controlled Trials Register. A selection of review articles (see references) were examined to identify further relevant publications. There was no language restriction.

SELECTION CRITERIA

Randomised controlled trials (RCT's) evaluating patient education interventions that included an instructional component and a non-intervention control group; pre- and post-test results available separately for RA, either in the publication or from the studies' authors; and study results presented in full, end-of-study report.

MAIN RESULTS

Twenty-four studies with relevant data were included. We found significant effects of patient education at first follow-up for scores on disability, joint counts, patient global assessment and psychological status. Physician global assessment was not assessed in any of the included studies. The two separate dimensions of psychological status: anxiety and depression showed no significant effects, nor did the dimensions of pain and disease activity. At final follow up no significant effects of patient education were found.

REVIEWER'S CONCLUSIONS

Patient education as provided in the studies reviewed here had moderate short-term effects on patient global assessment, and small short-term effects on disability, joint counts and psychological status. There were no long-term benefits.

Prediction of successful application for disability benefits for people with arthritis using the Health Assessment Questionnaire

BACKGROUND

Many eligible people with arthritis do not receive disability benefits. Application forms are lengthy and complex, and doctors and nurses are often unsure which patients would qualify.

AIM

To investigate how severe disability on the Health Assessment Questionnaire (HAQ) relates to successful application for disability benefits by people with osteoarthritis (OA) and rheumatoid arthritis (RA).

METHOD

RA patients attending a hospital out-patient rheumatology clinic and patients with OA or RA in two general practices completed an HAQ and were asked about receipt of disability benefits. Those scoring 2 or more on the HAQ (severe disability) and not in receipt of benefits were offered professional help to complete applications for Disability Living Allowance (DLA) or Attendance Allowance (AA).

RESULTS

Eighty per cent of patients with an HAQ score of 2 or more were already in receipt of benefits. Seventy-nine per cent of the new applicants applied successfully, the average benefit being in excess of 2580 pounds per annum.

CONCLUSION

This initial study suggests that people who score 2 or more on the HAQ should be encouraged to apply for disability benefits. A test of the generalizability of these findings and the success rate associated with lower HAQ scores should be undertaken.

Shape of the intercondylar notch of the human femur: a comparison of osteoarthritic and non-osteoarthritic bones from a skeletal sample

OBJECTIVES

To compare objectively the shape of the intercondylar notch in human osteoarthritic and non-osteoarthritic femora.

METHODS

A sample of 96 human femora from a large skeletal population were selected for study. These femora included subjects with evidence of late stage osteoarthritis (that is, with eburnation present) and subjects with no such evidence. The distal end of the femur, viewed axially, was recorded with a video camera, and digitised computer images were produced. The outline of the intercondylar notch was extracted and represented mathematically as two functions. A functional principal components analysis was used to identify important modes of shape variation. These variations in shape were compared between eburnated and non-eburnated femora.

RESULTS

A statistically significant difference in the shape of the intercondylar notch was found between the two groups. The difference related mostly to the shape of the edge of the medial condyle: in the non-osteoarthritic group this tended to exhibit a concavity; in the osteoarthritic group it tended to be straight.

CONCLUSIONS

This observed difference may be a predisposing factor to the development of osteoarthritis. The morphology of the intercondylar notch is related to the functioning of and possible damage to the cruciate ligaments, and damage to the cruciate ligaments is a known risk factor for osteoarthritis. Alternatively, this difference may be due to bony remodelling secondary to the onset of osteoarthritis, perhaps in response to altered biomechanics.

Values for function in rheumatoid arthritis: patients, professionals, and public

BACKGROUND

Although many disability questionnaires measure fact very efficiently, they do not allow for consideration of the relevance of that disability to the patient. Data suggest that professionals misinterpret the relevance of disability for the patient and thus, also, the outcome of treatment.

OBJECTIVES

Firstly, to examine agreement on levels of importance for the items on a validated disability scale (Health Assessment Questionnaire (HAQ) and Modified HAQ (MHAQ)), within groups of patients with rheumatoid arthritis, health professionals, and controls. Secondly, to see if functional items important to patients are included in the HAQ, and whether the HAQ items are important to patients.

METHODS

25 patients with RA, 25 rheumatology health professionals, and 25 healthy controls were asked to rate the importance of the HAQ (20 items) and MHAQ (eight domains). Before seeing the HAQ, patients were asked to generate items of function important to them.

RESULTS

Only a slight-fair agreement within each group was found for the level of importance of the HAQ and MHAQ, and also within any combination of the groups (kappa values <0.38). Most of the functional items valued by patients were contained on the HAQ (70%), and no HAQ items were consistently rated as unimportant.

CONCLUSION

Patients, professionals, and healthy controls do not agree on the importance of disabilities. These data support the need to assess the personal impact of disability, as well as disability itself. Individual importance of disability weighted by level of disability is proposed as a model for calculating the personal impact of disability. A new tool to assess the personal impact of disability is being developed.

Systemic low-dose glucocorticoid treatment in rheumatoid arthritis

Glucocorticoids provide a large, immediate improvement in the symptoms of rheumatoid arthritis. At doses acceptable for long-term treatment, however, symptoms gradually re-emerge. Relatively low doses of glucocorticoids can, for several years, substantially retard the rate of joint destruction shown on radiographs. This differential effect implies the coexistence of two pathologic processes within diseased joints. Long term, low dose glucocorticoid therapy probably increases the risk of serious adverse effects, but an evidence-based case can be made for the limited use of low dose glucocorticoid treatment in early disease.

Effects of long-term glucocorticoid therapy in rheumatoid arthritis

Radiographic erosions develop in about two thirds of patients with rheumatoid arthritis (RA). Glucocorticoids offer rapid and substantial control of the symptoms of inflammation in the short and medium term. Data are reviewed which suggest that this benefit may not last into the longer term (more than 1 year). However, recent studies provide unequivocal evidence that joint destruction can be halted in this disease. Also, by separating the short-term anti-inflammatory effect from a more prolonged suppression of joint destruction, these studies have shed light on the underlying pathological processes. The evidence from these therapeutic clinical trials strengthens the view that inflammation and joint destruction are parallel processes, loosely linked by the underlying cause of RA, but progressing to some extent independently. It is intriguing to speculate that different effects of glucocorticoids might relate to their different modes of action outlined elsewhere in this symposium.

Links between radiological change, disability, and pathology in rheumatoid arthritis

The relationship between the development of radiographic joint destruction in rheumatoid arthritis and its longterm consequences for the patient is not well understood. Two objectives for further research have been identified: elucidating this relationship and relating pathological processes to the features visible on radiographs. Extrapolation from a proposed model suggests that if radiographic progression is suppressed early in the disease, it might take many years before the benefit can be clearly appreciated against a background of variation within individual patients. Two approaches have recently been brought to bear on this issue, including a detailed modeling of medium term observations from a single dataset and a review of a large number of published studies. There are a number of reservations about the notion of a minimum clinically important change, but one possibility for defining such a change for radiographs is in relation to longterm functional outcome.

Minimum clinically important difference: the crock of gold at the end of the rainbow?

The minimum clinically important difference (MCID), like the crock of gold at the end of the rainbow, is attractive but unattainable. Empirical data on how rheumatologists make clinical decisions show a wide variety of approaches and lack of agreement in decision making. Clinical importance needs to consider the magnitude of both the benefits and adverse events. A proposal for future attempts to define MCID could explore links between short term changes in outcomes to improvement in disability outcome many years later. Defining response to treatment could be explored using different approaches and involving patients and other professional groups.

Patient-initiated hospital follow-up for rheumatoid arthritis

OBJECTIVES

To evaluate the clinical efficacy, cost and acceptability of a shared care system of patient- or general practitioner (GP)-initiated hospital review in rheumatoid arthritis (RA).

METHODS

A 2-yr randomized controlled trial of routine rheumatologist-initiated review was compared with a shared care system. Shared care patients had no routine follow-up but patients or GPs initiated access to rapid review by the multidisciplinary team via a nurse-run helpline. Control patients had a rheumatologist-initiated medical review at intervals of 3-6 months. Clinical and psychological status, resource use, and patient and GP satisfaction and confidence were assessed. Three-monthly clinical data were assessed (blind) for safety monitoring, with failure set at a 20% increase in pain, disability or disease activity.

RESULTS

Two hundred and nine established RA patients participated, of whom 182 were evaluable. Safety-net failures were not different between groups. Shared care patients had less pain (24 months, 3.9 cm on a 10-cm visual analogue scale vs 4.8 cm for controls; P: < 0.05), a smaller increase in pain over 2 yr (+ 0.4 cm vs +1.6 cm for controls; P: < 0.01), greater self-efficacy (6, 15, 18, 21 months, P: < 0.05), used 33.5% less resources (208 ponds sterling per patient per year vs 313 pound sterling for controls; P: < 0.001) and were more confident in the system (6, 9, 12, 18, 21, 24 months, P: < 0.01 to P: < 0.001).

CONCLUSIONS

A patient-initiated system for hospital review over 2 yr offers some clinical benefit compared with the traditional system, using fewer resources and attracting greater patient confidence. Longer-term assessment of the system would be appropriate.

General practitioners miss disability and anxiety as well as depression in their patients with osteoarthritis

BACKGROUND

General practitioners (GPs) integrate physical, psychological, and social factors when assessing patients, particularly those with chronic diseases. Recently, the emphasis has been on assessment of depression but not of other factors.

AIM

To determine functional disability, psychological morbidity, social situation, and use of health and social services in patients with osteoarthritis and examine GP knowledge of these factors.

METHOD

Two hundred patients completed a validated postal questionnaire about functional disability (Health Assessment Questionnaire [HAQ]), mood (Hospital Anxiety and Depression Scale [HAD]), employment status, who they lived with, welfare benefits received, and use of health and social services. A similar questionnaire was completed by the patient's GP, including a HAQ. However, a three-point scale was used to assess depression and anxiety.

RESULTS

Forty-seven per cent of patients were moderately or severely disabled (HAQ > 1). GPs underestimated functional disability: mean patient HAQ = 1.04 (95% confidence interval [CI] = 0.92-1.16), mean GP HAQ = 0.74 (95% CI = 0.65-0.83), and there was low correlation between patient and GP scores (kappa = 0.24). There was moderate prevalence of depression and high prevalence of anxiety, which the GP often did not recognise: patient depression = 8.3% (95% CI = 4.1%-12.8%), GP depression = 6.0% (95% CI = 2.4%-9.6%), kappa = 0.11; patient anxiety = 24.4% (95% CI = 17.8%-31.0%), GP anxiety = 11.9% (95% CI = 6.9%-16.9%), kappa = 0.19. Only 46% of severely disabled patients (HAQ > 2) were receiving disability welfare benefits. GPs were often unaware of welfare benefits received or the involvement of other professionals.

CONCLUSION

GPs frequently lack knowledge about functional disability, social factors, and anxiety as well as depression in their patients with osteoarthritis.

Relationship between disease severity and responses by blood mononuclear cells from patients with rheumatoid arthritis to human heat-shock protein 60

The hypothesis that T-cell responses to the 60 000 MW family of heat-shock proteins (hsp) may be related to the severity of rheumatoid arthritis (RA) was examined. Peripheral blood mononuclear cells (PBMC) from most normal individuals and both early and established RA patients proliferated in vitro in response to human hsp 60 and mycobacterial hsp 65 as well as tetanus toxoid (TT) and mycobacterial purified protein derivative (PPD). PBMC from some patients with established RA gave responses to hsp 60 that were above the normal range and/or peaked earlier than PBMC from normal individuals. The responses of PBMC from established RA to hsp 65, but not PPD or TT, were also higher than those from normal individuals, but the peak responses to all three antigens appeared delayed. Thus a selective increase in responsiveness to hsp 60 develops with disease duration in many RA patients. Six assessments of disease activity and severity were made but apart from rheumatoid factor titre, they were unrelated to the proliferative response. Similarly, disease activity and severity did not differ between those RA patients whose hsp 60 stimulated cells produced interferon-gamma and those who did not, although patients whose hsp 60-stimulated T cells produced interleukin-4 (IL-4) and/or IL-10, appeared to have less disease activity and severity than those who did not. Significant negative correlations were found between IL-10 production by hsp 60-stimulated cells and disease assessments. It is considered that RA is less severe in those patients whose hsp 60-stimulated cells produce T-helper 2 type cytokines.

Focal myositis - a new presentation

This article is a case report and review of literature of a very rare condition, not previously written in general surgical literature, including a new presentation

Non-aspirin, non-steroidal anti-inflammatory drugs for osteoarthritis of the knee

OBJECTIVES

To determine whether there is a difference in the relative efficacy of individual non-steroidal anti-inflammatory drugs (NSAIDs) when used in the management of osteoarthritis (OA) of the knee.

SEARCH STRATEGY

We searched Medline (1966-1995) and Bids Embase (Jan-Dec, 1980-1995). The searches were limited to publications in the English language, and were last perfomed in November 1996. We used modified Cochrane Collaboration search strategy to identify all randomised controlled trials. The MeSH heading osteoarthritis was combined with the generic names of the 17 non-aspirin NSAIDs licensed in the UK for the management of OA in general practice. The search of Embase used the term "osteoarthritis" if present in the abstract, title or keywords, and was combined with the generic names of the 17 non-aspirin NSAIDs, only if they were mentioned in the title, abstract or keywords.

SELECTION CRITERIA

All double blind, randomised controlled trials, in the English language, comparing the efficacy of two non-aspirin NSAIDs in the management of osteoarthritis of the knee, were selected. Only trials with subjects aged 16 years and over, with clinical and/or radiological confirmation of the diagnosis of OA knee were included. Studies which compared one "trial" NSAID with one "reference" NSAID were included provided they were non-aspirin NSAIDs available in the UK and were licensed for the treatment of OA by general practitioners. Trials which were placebo-controlled and which also involved the comparison of two NSAIDs were also included.

DATA COLLECTION AND ANALYSIS

The methodological design of each study was scored according to a pre-determined system. The three main outcome measures of pain, physical function and patient global assessment were chosen based on the core set agreed upon by OMERACT (Outcome Measures in Rheumatology Clinical Trials). These were used to determine the power of each trial. The equivalency of NSAID doses was calculated using the percentage of the recommended maximum daily dose. Sample size estimates for the detection of clinically relevant changes in outcome measures used in the assessment of OA knee were used for power calculations. These calculations were performed to determine whether the trials were of a sufficient size to detect clinically relevant differences which were statistically significant. The calculations incorporate estimates of standard deviation, and minimum, median and maximum differences (delta) between drugs which are deemed to be clinically important. The number of "withdrawals due to lack of efficacy" was also selected as an outcome measure for this review. The Peto odds ratio and 95% confidence intervals were calculated where possible. The results of studies which compared the same trial and reference NSAIDs were combined where possible.

MAIN RESULTS

Of the 1151 trials identified by the search strategy, 22 involved knee osteoarthritis only. Sixteen of these trials fulfilled the inclusion criteria and were entered in the review. Eight NSAIDs were represented in these trials. Etodolac was represented in 11 trials. The reference NSAID in these trials was piroxicam (n=3), naproxen(n=3), diclofenac (n=3), indomethacin (n=1), and, nabumetone (n=1). The reported methodological design of the trials was poor, with a median score of 3 (out of a maximum of 8). The results of the trials comparing the same trial and reference NSAIDs were pooled for the outcome "withdrawal due to lack of efficacy". For the comparison, etodolac vesus piroxicam, the odds ratio favoured etodolac i.e. patients receiving etodolac were less likely to withdraw due to lack of efficacy. The dose of etodolac used in each of these three studies, however, was greater than the corresponding dose of piroxicam (based on percentage maximum daily dose). The significance of these results is therefore questionable. For the comparisons etodolac versus diclofenac, and etodolac versus naproxen, there were no clear differences betw

Increased serum C reactive protein may reflect events that precede radiographic progression in osteoarthritis of the knee

OBJECTIVE

Raised serum C reactive protein (CRP) and hyaluronate (HA) concentrations predict the progression of knee osteoarthritis (OA) in the long term but the consistency of these relations with time is unknown. The purpose of this work was therefore to determine if raised CRP and HA at entry and three years before entry (-3 years) predict radiological progression of knee OA in a group of patients between entry and five years.

METHODS

Knee radiographs from 90 patients with knee OA at entry and five years follow up were assessed for progression of disease over five years. The concentrations of serum CRP and HA were measured at entry (n=90) and also in 40 serum samples available from -3 years. Odds ratios (OR) for predicting progression were calculated by logistic regression.

RESULTS

Serum CRP at entry was not predictive of progression between entry and five years (OR 1.12, 95% CI 0.81, 1.55) but serum CRP at -3 years was predictive of progression (OR 1.90, 95% CI 1.01, 3.28). Serum HA concentration at entry predicted progression between entry and five years (OR 2.32, 95% CI 1.16, 4.66).

CONCLUSION

These results are consistent with previous reports relating to HA, and suggest that raised serum CRP reflects events that precede a period of later radiographic progression in knee OA. However, because of the large overlap between groups, the serum CRP or HA concentration are not good predictors of individual patient progression and have a poor sensitivity and specificity.

Using the Larsen index to assess radiographic progression in rheumatoid arthritis

To describe the Larsen index and its strengths and weaknesses. I reviewed the original publication, a number of published modifications, tests of reproducibility, and some clinical studies that have used the index. The Larsen index is essentially a grading of erosion severity that has satisfactory reproducibility for use in groups of patients. The Larsen index can clearly distinguish different rates of erosive progression in groups of patients with different characteristics or treatments. Recent studies using the Larsen index have identified clear treatment effects. Difficulty in measuring the success of previous treatments designed to hold back the progression of erosions relates to the inefficacy of those treatments, not insensitivity of the Larsen index.

General practitioners' knowledge of functional and social factors in patients with rheumatoid arthritis

The care of people with chronic physical disease is an important part of the work of general practitioners (GPs). Knowledge of social and functional factors, and good teamwork with other health and social care professionals, are necessary to provide high quality general practice care. This study investigated functional disability, social situation and the involvement of health and social care professionals in patients with rheumatoid arthritis, and their GPs' knowledge of these factors. Questionnaires were sent to all patients aged 15-74 with rheumatoid arthritis in two general practices, and similar questionnaires were given to their GPs. Functional disability was assessed using the health assessment questionnaire (HAQ), on a scale of 0-3. The GP consultation rate for patients with rheumatoid arthritis in the previous year was 6.9 compared to 3.7 for all patients in the practices, and increased with increasing disability. Sixty-five per cent of patients had a moderate (HAQ > 1 but </= 2) or severe (HAQ > 2) disabiltiy. There was an average difference between patient and GP scores for functional disability on the HAQ of 0.49 (95% confidence interval 0.36-0.62), with GPs scoring lower than patients and the difference increased with increasing disability. Seventy-one per cent of patients had seen a rheumatologist or orthopaedic surgeon in the previous year, but there was little involvement by other members of the primary health care team (PHCT). General practitioners had good levels of knowledge of their patients' employment status and who they lived with, but poor knowledge of most of the welfare benefits they were receiving, and of other health and social care professionals involved. It is concluded that GPs see their patients with rheumatoid arthritis frequently, but are often lacking the knowledge about their patients to provide high quality care. They often only know about aspects of their patients' care in which they are directly involved. Ways are suggested for how this situation could be improved.

Ability of T cells from patients with rheumatoid arthritis to respond to immunoglobulin G

The ability of T cells from rheumatoid factor (RF)-positive patients with rheumatoid arthritis (RA) to respond to immunoglobulin G (IgG) was assessed. Peripheral blood mononuclear cells (PBMC) from RA patients and normal individuals were cultured with and without human IgG or Mycobacterium tuberculosis-purified protein derivative (PPD) for 7 days and their proliferative response measured at intervals by their ability to take up tritiated thymidine. PBMC from 14/26 RA patients proliferated in response to IgG (taking a stimulation index of 3 or above as positive). The peak response varied between individuals but usually occurred on day 5, the same day, or 1 day later than the peak response to PPD. By contrast, PBMC from a significantly lower proportion (1/9) of normal individuals and patients with other arthritides (0/6) responded to IgG, although all responded to PPD. PBMC from 9/14 RA patients responded to Fab fragments of IgG but only 3/9 to the Fc fragment. Higher proliferative responses from RA PBMC were elicited by IgG aggregates than the original IgG preparation, but PMBC from 5/5 normal individuals and 5/6 patients with other arthritides failed to respond to the aggregates. The response to IgG was human leucocyte antigen (HLA)-DR restricted and mediated by CD4+ T cells. It is considered that these results advance the hypothesis that IgG-reactive T cells contribute to the initiation or perpetuation of RA.

The analysis of a bivariate multi-state Markov transition model for rheumatoid arthritis with an incomplete disease history

In many long-term chronic diseases, patients pass through an observable sequence of ordered clinical states as their condition progressively worsens. Often the information on which disease state the patient is in is incompletely recorded, usually with information only available on the occasion of a clinic visit. This article describes a novel analysis of data from a clinical trial, in which several such outcome measures of disease state have been recorded simultaneously. The article is motivated by the analysis of a multi-centre double-blind placebo-controlled clinical study into the effect of continual low dose corticosteroid treatment on the progression of X-ray scores for patients with rheumatoid arthritis. Previous methods of analysis of such data have been based on an independence analysis, thus ignoring any correlation that may exist between the outcomes. This article shows that such an approach can lead to biased underestimates of the covariate effects if an independence model is used. Biased estimates of the covariate effects were found when the model was fitted to the trial data. The bivariate model was also shown to provide a significantly better fit to the data. However, the bivariate model did prove more difficult to fit, and both models demonstrated a highly significant treatment effect with comparable clinical effect.

Conceptual issues in scoring radiographic progression in rheumatoid arthritis

Radiographic scoring systems for rheumatoid arthritis (RA) should be based on current understanding of disease pathology. Evidence suggests that there may be at least two intraarticular pathologies that may result in change in different radiographic features. There is therefore a strong argument for devising a radiographic score based on the observation of features rather than broad categorizations of the total radiographic change. Features may subsequently be amalgamated in relation to other criteria such as sensitivity, specificity, and responsiveness to change, and may be related to subsequent developments in understanding the biology of RA. A second challenge is in elucidating the relationship between radiographic change and the longterm consequences of RA for the patient. Current practice is predicated on the assumption that in the longterm radiographic change correlates well with functional loss and possibly noninflammatory, endstage joint pain. Although hand and feet radiographs broadly represent destructive change in all joints, in cross sectional studies they correlate only moderately with late stage functional loss. The issue may be resolved by longterm observational studies of radiographic change and functional loss. It is recommended that specific radiographic features relevant to joint pathophysiology be used to create a radiographic damage index for comparison with current scoring systems and that longterm observational studies specifically address the relationship between radiographic joint damage and functional outcome.

Systemic glucocorticoid treatment in rheumatoid arthritis--a debate

Arguments are presented for and against the use of oral glucocorticoid treatment in patients with rheumatoid arthritis. Controlled clinical trials, uncontrolled longitudinal observations and accumulated clinical experience are drawn together to place in perspective treatment decisions in routine clinical practice. The evidence points to a relatively short term improvement in symptom control and a longer term benefit in reducing progressive joint destruction, but to this must be added fears about inappropriate prescription of glucocorticoids with consequent adverse effects. Areas requiring further research are highlighted.

Joint destruction after glucocorticoids are withdrawn in early rheumatoid arthritis. Arthritis and Rheumatism Council Low Dose Glucocorticoid Study Group

OBJECTIVE

Prednisolone reduced the progression of joint destruction over 2 yr in early, active rheumatoid arthritis. The response to discontinuation of prednisolone under double-blind conditions is now reported.

METHODS

A randomized, double-blind, placebo-controlled trial of prednisolone 7.5 mg daily in addition to routine medication over 2 yr in 128 patients with early rheumatoid arthritis, using radiological progression (changes in the Larsen score) and the development of erosions as primary outcome measures. Study medication was blindly discontinued and follow-up maintained for a further year. Other assessments included disability, joint inflammation, pain and the acute-phase response.

RESULTS

Similar results were obtained when all available radiographs were included for each year of assessment (maximum 114) and when only patients with radiographs at all time points were included (75 patients). In these 75, the mean progression in the prednisolone group was 0.21 Larsen units in year 1, 0.04 units in year 2 and 1.01 units in year 3 (P = 0.587, 0.913 and 0.039 for change within each year, respectively). The equivalent placebo group means were 2.34, 1.00 and 1.63 Larsen units (P = 0.001, 0.111 and 0.012; difference between groups: 2.13, 0.96 and 0.67 units, P = 0.082, 0.02 and 0.622). The percentage of hands which had erosions at each time point was: prednisolone group: 27.8, 29.2, 34.7 and 39.2; placebo group: 28.2, 48.7, 59.0 and 66.5. There was little evidence for a flare in clinical symptoms after discontinuation of prednisolone.

CONCLUSION

Joint destruction resumed after discontinuation of prednisolone. This corroborates the previously reported therapeutic effect and challenges current concepts of disease pathogenesis.

Changes in biochemical markers of joint tissue metabolism in a randomized controlled trial of glucocorticoid in early rheumatoid arthritis

OBJECTIVE

To determine the effects of low-dose prednisolone on joint tissue metabolism in early rheumatoid arthritis (RA).

METHODS

In addition to a range of biochemical markers of cartilage, bone and synovial tissue turnover, levels of pro-matrix metalloproteinase 3 (pro-MMP-3), pro-MMP-1, and cytidine deaminase (CD) were measured in serum from 79 of 128 patients with early RA who took part in the Arthritis and Rheumatism Council Low-Dose Glucocorticoid Study. Serum concentrations of joint tissue metabolites on treatment and off treatment were compared using Student's t-test.

RESULTS

Levels of the keratan sulfate epitope, 5D4, and glycosaminoglycan (GAG) were similar on and off treatment. However, the levels of synovium-derived markers, hyaluronate (HA) and N-propeptide of type III procollagen (PIIINP), were reduced by 23.9% (P < 0.01) and 25.2% (P < 0.001), respectively, during treatment with prednisolone. Serum osteocalcin (OC) was reduced by 25.8% (P < 0.001), while the levels of CD and pro-MMP-3 increased by 31.2% (P < 0.01) and 53.7% (P < 0.001) during prednisolone treatment compared with the off-treatment period.

CONCLUSION

Low-dose prednisolone had no significant effect on markers of cartilage turnover (GAG, 5D4) in early RA, suggesting that early erosions do not involve cartilage surfaces. The reduction in the markers of bone turnover (OC) and synovial tissue turnover (HA and PIIINP) support the general view that prednisolone reduces synovitis and suppresses bone turnover.

Clinical trials and clinical practice: do doctors use the same criteria to judge outcome?

AIMS

The results of clinical trials often seem to have little influence on the practice of individual doctors. This could be because trial information is presented in the style of a scientific experiment which cannot often be clearly related to the context of everyday patient care. We tested the hypothesis that such framing effects would cause doctors to assess the clinical significance of treatment outcomes differently when presented as clinical trial results rather than as individual patient data.

METHODS

Fourteen rheumatologists independently reviewed the same 50 sets of data obtained from patients with rheumatoid arthritis. The data consisted of 10 commonly used clinical and laboratory variables measured before and after a period of treatment. The same data were presented in two formats on two separate occasions. The patient data format was a collection of typed sheets attributing each set of results to an individual patient. The clinical trial format was a professionally printed and bound booklet in which each set of results was laid out as summary results of a small uncontrolled clinical trial. Doctors judged the degree of improvement or deterioration and its clinical importance for each data set for both formats. These changes were converted into units of 'Clinical Importance'.

RESULTS

Although some statistically significant differences emerged in the individual doctors' judgements between the formats none of these was of a clinically important size. The median of the mean trial--patient difference between the formats for all 14 doctors was 0.035 units of clinical importance [95% CI -0.244 to 0.074].

CONCLUSIONS

This evidence does not support the hypothesis that framing effects are a major cause of the failure of clinical trials to influence clinical practice.

What is a safe waiting time for coronary artery bypass surgery?

To determine the factors that influenced doctors' prioritization and decisions on safe waiting time for coronary artery bypass surgery, 50 'paper patients', based on a random sample of cases who actually had surgery, were assessed by 33 clinicians. We used linear regression models to reflect the impact of clinical and non-clinical 'cues' on safe waiting time and priority decisions. The benefits of surgery tended to be over-estimated. For example, the average perceived gain in life expectancy for patients with left main-stem disease was 6.74 years. However, models incorporating only the perceptions of benefit as independent variables (i.e. the anticipated symptom reduction, MI risk reduction and life expectancy extension), had only modest explanatory power (mean R2 was 0.55 for safe waiting time, and 0.56 for priority decisions). Models which incorporated perceptions of benefit and the cases' clinical and non-clinical characteristics had generally much higher explanatory power (mean R2, 0.83 and 0.86, respectively). Lifestyle and demographic variables had much less impact on the doctors' judgements than the major clinical cues of angina severity and left main-stem stenosis. Demographic and lifestyle cues had different impacts on safe waiting time and priority for about 25% of doctors.

Intra-articular therapy in osteoarthritis

Although intra-articular therapy is widely used in the treatment of osteoarthritis (OA), those controlled clinical trials which include placebo groups suggest that there is little to be gained over joint aspiration alone, or even over a simple needle prick. Glucocorticoids may however offer a small additional symptom benefit over one or two weeks. Viscosupplementation may offer a slightly longer benefit. Intra-articular radiotherapy probably confers no benefit. Serious adverse effects are rare but local effects may occur in up to 10% of patients treated with viscosupplements. Future research should always include a placebo group in clinical studies, should clarify the possible benefits of viscosupplementation and should include in vitro work to consider the biological basis for possible actions of intra-articular therapy.

Prognostic criteria in rheumatoid arthritis: can we predict which patients will require specific anti-rheumatoid treatment?

Longitudinal studies of rheumatoid arthritis (RA) have shown that joint damage often occurs early in the disease. Therefore, the early treatment of RA with "disease modifying" drugs is gaining acceptance. However, many patients presenting with inflammatory polyarthropathy will follow a benign course. Rheumatologists need to be able to target the use of potentially toxic drugs to those cases where the benefits clearly outweigh the risks. This approach requires reliable assessment of the prognosis at an early stage in the disease process. We have critically evaluated a large number of published studies which claim to provide clinically useful information regarding the prognosis of RA.

CONCLUSION

The majority of studies have methodological flaws which limit their value. A small number of published studies exist which provide useful data about estimating the prognosis of RA. Currently evaluated prognostic indicators are only moderately successful and there is an urgent need for methodologically sound research in this area.

Rheumatology out-patient workload increases inexorably

Rheumatology out-patient consultations in the south-west of England from 1 to 30 November 1994 were recorded by standard methods and compared to 1988, 1990, 1991 and 1992. Historical records at one centre provided additional detailed information. There has been an overall increase of 31% in the number of patients seen (30% for follow-up cases, 36% for new referrals), but the mean waiting time for new patient consultations increased from 65 to 108 days. The proportion of new patient consultations with non-arthritic diseases increased by 8.2%, and those with rheumatoid arthritis and polyarthritis decreased by 9.0%. Variation in discharge rates and length of follow-up appointments occurred, but mostly in uncommon diagnostic categories. Referral rates have been rising faster since the introduction of National Health Service reforms than can be accommodated by the increased workload undertaken.

The stated and tacit impact of demographic and lifestyle factors on prioritization decisions for cardiac surgery

In a clinical judgement analysis, we used linear regression models to reflect the impact of clinical and non-clinical cues on priority decisions, by comparing the stated prioritization policies of 30 clinicians with their actual policies as revealed by an appraisal of 50 'paper patients'. Correspondence was modest for some cues, e.g. 25 doctors said they accounted for age, but age only had a significant bearing in the derived decision models of two doctors. Correspondence between the derived and expressed weights was greatest for clinical angina grade and the presence of left main stem stenosis. Correlation between the rank order of importance between the two models was poor for most of the cues, and statistically significant only for smoking. However, stated policies made it appear that lifestyle factors such as smoking habit would influence prioritization decisions for most clinicians but policies derived from actual prioritization decisions seldom related to lifestyle or demographic variables. There were significant differences in the degree of correlation between the two models according to the experience of the clinician. However, correspondence was not significantly better for doctors with cardiological training than those without. The overall contribution of demographic and lifestyle factors to decision making appears to be small, suggesting that they should be omitted from prioritization guidelines.

The relationship between synovitis and erosions in rheumatoid arthritis

If clinically evident synovitis causes erosions, then the two should be highly correlated within individual joints. Separate hand joints (total 2064) were examined for the presence of synovitis (the simultaneous presence of soft-tissue swelling and tenderness) on nine occasions over 2 yr. The cumulative synovitis score was compared to the change in the Larsen score over the same period. The mean correlation between synovitis and erosion progression was r = 0.248 (explained variance = 6%). Of the 216 joints which showed progressive X-ray damage, 44% had a cumulative synovitis score of < 3. When all the joints of one hand were taken together, the correlation was increased to r = 0.418 and for all the joints of both hands taken together it was further increased to r = 0.424. These results argue against there being a direct causal relationship between clinically inflamed synovitis and erosions in rheumatoid arthritis, and question the assumption that erosions and the signs of synovitis represent the same pathological process.

Agalactosyl IgG in aggregates from the rheumatoid joint

It has been postulated that agalactosyl immunoglobulin G (IgG) self-associates to form pathological aggregates in the rheumatoid joint. To examine this hypothesis, IgG aggregates from synovial fluid (SF) of 22 patients with RA were prepared by precipitation with polyethylene glycol (PEG) 6000. The PEG precipitates and SFs were reduced with 2-mercaptoethanol (2ME) and bound to protein G. This procedure isolated the IgG in the PEG precipitates from other contaminating glycosylated proteins. The levels of galactose and N-acetylglucosamine (GlcNAc) residues present on the reduced IgG were quantified by their ability to bind the lectins Ricinus communis (RCA)120 and Bandeiraea simplicifolia (BS) II. Proportionally less galactose (expressed as a ratio of bound RCA120 to BS II) was present on the IgG from the PEG precipitates than on the IgG in the paired SF (P = 0.001). However, in many cases more RCA120 as well as BS II bound to IgG from PEG precipitates than from the corresponding SF. It is considered that agalactosyl IgG occurs preferentially in RA SF PEG precipitates and that this IgG may also exhibit increased Fab glycosylation.

Low dose corticosteroids in early rheumatoid arthritis. Can these drugs slow disease progression?

The role of corticosteroids in treating rheumatoid arthritis is controversial, but recourse to the available evidence of efficacy should guide patient management decisions. Earlier evidence suggested that symptomatic control could be improved for periods of 6 to 12 months, but not longer, without increasing doses to unacceptably high levels. The effect of corticosteroids on joint destruction has been unclear. Recent findings from a controlled clinical trial show that prednisolone 7.5 mg/day can significantly retard the rate of erosive progression in patients with relatively early disease (< 2 years' duration). These results have implications for both disease management and our understanding of the pathogenesis of joint destruction in rheumatoid arthritis.

Quality of life measures

Quality of life measures have become increasingly popular as outcome measures despite the lack of consensus on a definition of quality of life. This review describes the most frequently used measures, and discusses the conceptual and measurement issues surrounding quality of life measurement. Finally, it tries to place quality of life in the World Health Organization's model of disease impact.

Cytidine deaminase may be a useful marker in differentiating elderly onset rheumatoid arthritis from polymyalgia rheumatica/giant cell arteritis

OBJECTIVE

PMR/GCA is a relatively common inflammatory disease in the elderly population. Clinical differentiation from a polymyalgic onset of RA in the elderly can be difficult. We have examined in a preliminary study the hypothesis that serum cytidine deaminase (CD) may be valuable in the differential diagnosis of these disorders.

METHODS

CD was assayed by a spectrophotometric method in 20 patients with active PMR/GCA, both before and after treatment with prednisolone, and was compared with serum CD levels in 20 patients with active RA.

RESULTS

CD levels were within the normal range (< 10 units/ml) in 36 of the 40 samples from patients with PMR/GCA: The mean CD in pre-treatment samples was 8.64 units/ml (SD 7.09), and after treatment 7.20 units/ml (SD 3.53). The mean serum CD in the RA patients was 21.33 units/ml (SD 8.94), significantly higher than in PMR/GCA (p < 0.0001).

CONCLUSION

Serum CD levels were significantly different when proven PMR was compared with established, long-standing RA. Therefore, serum CD could be a useful diagnostic marker for differentiating PMR/GCA from active RA in older patients.

The effect of glucocorticoids on joint destruction in rheumatoid arthritis. The Arthritis and Rheumatism Council Low-Dose Glucocorticoid Study Group

BACKGROUND

Oral glucocorticoids are widely used to treat patients with rheumatoid arthritis, but their effect on joint destruction, as assessed radiologically, is uncertain.

METHODS

We conducted a randomized, double-blind trial comparing oral prednisolone (7.5 mg daily for two years) with placebo in 128 adults with active rheumatoid arthritis of less than two years' duration. Except for systemic corticosteroids, other treatments could be prescribed. The primary outcome variables were the progression of damage as seen on radiographs of the hand after one and two years, as measured by the Larsen index, and the appearance of erosions in hands that had no erosions at base line. The radiographs were viewed jointly by a radiologist and a rheumatologist who were unaware of the treatment assignment and the time point at which the films were obtained.

RESULTS

The statistical analysis of radiologically detected changes was based on 106 patients for whom there were films obtained at base line and two years later. After two years, the Larsen scores increased by a mean of 0.72 unit in the prednisolone group, indicating very little change, and by 5.37 units in the placebo group, indicating substantial joint destruction (P = 0.004). Of the 212 hands of these patients, 147 (69.3 percent) had no erosions at the start of the study. At two years, 15 of the 68 such hands in the prednisolone group (22.1 percent) and 36 of the 79 such hands in the placebo group (45.6 percent) had acquired erosions (difference, 23.5 percentage points; 95 percent confidence interval, 5.9 to 40.7; P = 0.007). The patients in the prednisolone group had greater reductions than the patients in the placebo group in scores on an articular index and for pain and disability at 3 months; for pain at 6 months; and for disability at 6, 12, and 15 months (all P < 0.05). There was no difference between groups in standardized scores for the acute-phase response. The adverse events were typical of those encountered with antirheumatoid drugs.

CONCLUSIONS

In patients with early, active rheumatoid arthritis, prednisolone (7.5 mg daily) given for two years in addition to other treatments substantially reduced the rate of radiologically detected progression of disease.