Rheumatoid Arthritis

Interstitial lung disease in the connective tissue diseases

The connective tissue diseases (CTDs) are inflammatory, immune-mediated disorders in which interstitial lung disease (ILD) is common and clinically important. Interstitial lung disease may be the first manifestation of a CTD in a previously healthy patient. CTD-associated ILD frequently presents with the gradual onset of cough and dyspnea, although rarely may present with fulminant respiratory failure. Infection and drug reaction should always be ruled out. A diagnosis of idiopathic ILD should never be made without a careful search for subtle evidence of underlying CTD. Treatment of CTD-ILD typically includes corticosteroids and immunosuppressive agents.

What is causing my arthritis, doctor? A glimpse beyond the usual suspects in the pathogenesis of rheumatoid arthritis

Rheumatoid arthritis (RA) is a common, but heterogeneous, disease. Usually, when it comes to the pathogenesis of RA the physician faces a complex network of cytokines and cells of the immune system-the so-called effector level. However, is this network 'the cause' of the disease? Or is this rather the level most physicians are somewhat familiar with, as modern anti-rheumatic medications are having their targets there? In this review, we are looking beyond the usual culprits from the physician's perspective and discuss how other factors, such as genes, epigenetics, environmental factors, local joint characteristics or processes of aging might influence the clinical phenomenon RA.

Prevalence of immune disease in patients with wounds presenting to a tertiary wound healing centre

Chronic leg ulcers are a significant cause of morbidity and mortality and account for considerable healthcare and socioeconomic costs. Leg ulcers are a recognised complication of immune disease, and the purpose of this study was to establish the prevalence of immune disease in a cohort of patients with chronic wounds, and to compare wound outcomes in the subjects with and without immune disease. Retrospective chart review was completed on consecutive patients scheduled with the plastic surgeon in the Georgetown University Center for Wound Healing between 1 January 2009 and 31 March 2009. Of the 520 patients scheduled for appointments, 340 were eligible for inclusion. The prevalence of immune disease was higher than expected with 78 of 340 patients (23%) having associated immune disease. At presentation, wounds in patients with immune disease had a significantly larger mean surface area [33·4 cm(2) (69·05) compared to 22·5 cm(2) (63·65), P = 0·02]. Split thickness skin graft (STSG) and bioengineered alternative tissue (BAT) graft data was available on 177 grafts from 55 subjects. There was a significantly lower response rate to STSG in subjects with immune disease (50% compared to 97%, P = 0·0002), but response rates to BAT were not different. The association between immune diseases and chronic wounds may provide unique insights into pathways of wound healing, and warrants further study.

Pulmonary tuberculosis and tuberculous arthritis of knee joint associated with rheumatoid arthritis treated with anti-tumor necrosis factor (TNF)-alpha medication: a case report

Tuberculosis infection (TB) is one of the most important problems for the rheumatoid arthritis (RA) patients treated with anti-TNF agents. Pulmonary tuberculosis is the most common clinic form of the TB in these patients. However, tuberculosis arthritis is very rare. We present here a 72-year-old Caucasian woman with seropositive RA, treated with etanercept/adalimumab for the last 2 years, who presented with resistant knee pain and joint effusion. We believe that this treatment caused the tuberculosis in this patient, which is the most worried complication. Interestingly, tuberculosis was in the knee joint at this time.

Certolizumab pegol: a new biologic targeting rheumatoid arthritis

The past decade has been an exciting period for clinical research and patient care in rheumatoid arthritis. This is mostly due to targeted biologic agents that have changed the outcome of this disease. Certolizumab pegol (Cimzia(®), UCB Inc., GA, USA), which targets TNF-α with a different mechanism of action than widely used biologics, was initially investigated for Crohn's disease but has now been shown to be effective for rheumatoid arthritis. There have been three significant clinical trials demonstrating the efficacy of certolizumab pegol in active rheumatoid arthritis; two with combination methotrexate and one with monotherapy. This article will summarize the data from those trials and compare some of the characteristics of certolizumab pegol to conventional disease-modifying antirheumatic drugs and other biologic agents. Treatment recommendations are beyond the scope of this review; however, with many options available, there will be annotations on current trends in the care of this chronic disease.

Pulmonary manifestations of rheumatoid arthritis

Pulmonary disease is a major source of morbidity and mortality in rheumatoid arthritis, manifesting most commonly as interstitial lung disease, airways disease, rheumatoid nodules, and pleural effusions. The diagnostic assessment of respiratory abnormalities is complicated by underlying risk for infection, the use of drugs with known pulmonary toxicity, and the frequency of lung disease related to rheumatoid arthritis itself. Evaluation and management of rheumatoid arthritis-associated pulmonary disease frequently necessitates a multidisciplinary approach.

The relationship between self-care agency, disability levels and factors regarding these situations among patients with rheumatoid arthritis

AIMS AND OBJECTIVES

To assess the relationship between self-care agency scores, disability levels and factors regarding these situations among Turkish patients with rheumatoid arthritis.

BACKGROUND

Rheumatoid arthritis is characterised by severe to slight synovial joint inflammation that can lead to pain, stiffness and joint destruction with subsequent physical deformities, disabilities and reduced self-care. Self-care is an important component of comprehensive chronic disease management such as rheumatoid arthritis. If patients have high levels of self-care and adhere to rheumatoid arthritis treatment, it can be expected that they will have fewer symptoms and better functional capabilities.

DESIGN

A cross-sectional, design was used.

METHOD

This study was conducted with 467 rheumatoid arthritis patients who applied at the Rheumatology Outpatient Department of Gaziantep University between September 2008-February 2009. The data collection instruments used in this study were the Demographic Data Form, Health Assessment Questionnaire (including disability index and pain scale) and Self-as-Carer Inventory. The frequency, mean, Student's t-test, one-way anova, Kruskal-Wallis, chi-square, correlation and regression analysis were used; p < 0·05 was accepted as statistically significant.

RESULTS

For patients the self-care agency classification of 13·7% and 86·3% were 'moderate' and 'poor', respectively; while the disability levels of 12·2 51·2 and 36·6% were 'mild', 'moderate' and 'severe', respectively; and their pain average was 'moderate'. It was also determined that, as the patients' self-agency scores declined, their disability levels deteriorated even further and their pain levels increased even more.

CONCLUSIONS

In conclusion we found that in Turkish patients with Rheumatoid Arthritis, the higher disability and pain rate were, the lower self-care agency score was.

RELEVANCE TO CLINICAL PRACTICE

Nurses should strive to provide individuals with RA the knowledge, skills and resources necessary for active participation in self-care, as this might promote the capacity for self-care.

Comparison of certolizumab pegol with other anticytokine agents for treatment of rheumatoid arthritis: a multiple-treatment Bayesian metaanalysis

OBJECTIVE

To compare the clinical efficacy of certolizumab pegol (CZP) with that of other anticytokine agents indicated for the treatment of rheumatoid arthritis (RA) with identical therapeutic indication (anti-tumor necrosis factor-α, anti-interleukin 1 or 6), with the objective of determining the noninferiority of CZP.

METHODS

A systematic review was performed to identify randomized controlled trials that assessed the efficacy of anticytokine agents in combination with conventional disease-modifying antirheumatic drugs (DMARD) after 6 months of treatment, using the American College of Rheumatology (ACR) response criteria, in patients with RA who have shown inadequate response to DMARD including methotrexate. Indirect treatment comparisons were carried out by a multiple-treatment Bayesian random-effects metaanalysis. Data were analyzed using the Markov chain Monte Carlo simulation. Noninferiority of CZP was assessed in comparison with a predefined equivalence margin of 5%.

RESULTS

Nineteen placebo-controlled studies were identified: 14 evaluated the efficacy of 5 anti-TNF-α agents (infliximab, etanercept, adalimumab, golimumab, CZP) and 5 evaluated efficacy of 2 anti-interleukin agents (anakinra, tocilizumab). Every treatment showed significant efficacy versus placebo in individual studies. The multiple-treatment metaanalysis showed a highest OR for CZP on ACR20 response. Metaanalysis indicates that the efficacy of CZP according to ACR20 response is superior to that of infliximab, adalimumab, and anakinra, and equivalent or superior to that of etanercept, golimumab, and tocilizumab. According to ACR50 response, the efficacy of CZP is equivalent or superior to that of all other anticytokines.

CONCLUSION

Results of this original multiple-treatment Bayesian metaanalysis indicate that certolizumab pegol is at least as efficacious as the preexisting antirheumatic anticytokine biotherapies.

Everyday ethics and help-seeking in early rheumatoid arthritis

BACKGROUND

Sociological understandings of chronic illness have revealed tensions and complexities around help-seeking. Although ethics underpins healthcare, its application in the area of chronic illness is limited. Here we apply an ethical framework to interview accounts and identify ethical challenges in the early rheumatoid arthritis (RA) experience.

METHODS

In-depth interviews were conducted with eight participants who had been diagnosed with RA in the 12 months prior to recruitment. Applying the concepts of autonomous decision-making and procedural justice highlighted ethical concerns which arose throughout the help-seeking process. Analysis was based on the constant-comparison approach.

RESULTS

Individuals described decision-making, illness actions and the medical encounter. The process was complicated by inadequate knowledge about symptoms, common-sense understandings about the GP appointment, difficulties concerning access to specialists, and patient-practitioner interactions. Autonomous decision-making and procedural justice were compromised. The accounts revealed contradictions between the policy ideals of active self-management, patient-centred care and shared decision-making, and the everyday experiences of individuals.

CONCLUSIONS

For ethical healthcare there is a need for: public knowledge about early RA symptoms; more effective patient-practitioner communication; and increased support during the wait between primary and secondary care. Healthcare facilities and the government may consider different models to deliver services to people requiring rheumatology consults.

omega-3 Fatty acids infusions as adjuvant therapy in rheumatoid arthritis

BACKGROUND

The present study investigated the efficacy and safety of parenteral omega-3 fatty acids (omega-3 FA) in patients with active rheumatoid arthritis (RA).

METHODS

We performed a double-blind, randomized, placebo-controlled study in 23 patients with moderate to severe RA. Patients received either 0.2 g of fish oil emulsion/kg (active) or 0.9% saline (placebo) infusion intravenously for 14 consecutive days, followed by 20 weeks of 0.05 g of fish oil/kg (active) or paraffin wax (placebo) ingested orally as capsules. A decrease in swollen and tender joint counts was the primary efficacy measure.

RESULTS

At baseline, both swollen and tender joint counts were not significantly different between patients in the treatment and placebo groups. Twenty patients completed the infusion portion of the study, and 13 completed the oral portion. Swollen joint count was significantly lower in the omega-3 FA group compared with the placebo group after 1 week of infusion (P = .002) as well as after 2 weeks of infusion (P = .046). Tender joint count also tended to be lower in the omega-3 FA group, although this did not reach statistical significance. Both swollen and tender joint counts were significantly lower in the omega-3 FA group compared with the placebo group during and at the end of oral treatment.

CONCLUSION

Our pilot study indicates that parenteral omega-3 FAs are well tolerated and improve clinical symptoms of RA. Subsequent oral administration of omega-3 FAs may prolong the beneficial effects of the infusion therapy. These results warrant validation in larger multicenter studies.

Real-World Anti-Tumor Necrosis Factor Treatment in Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis: Cost-Effectiveness Based on Number Needed to Treat to Improve Health Assessment Questionnaire

Objective.

To determine the effectiveness and cost-effectiveness of anti-tumor necrosis factor (anti-TNF) medications in a real-world environment for the treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) using the Health Assessment Questionnaire (HAQ).

Methods.

We created a database of patients with RA, PsA, or AS treated with anti-TNF agents (etanercept, infliximab, or adalimumab) at a large outpatient rheumatology clinic. Patient characteristics, baseline HAQ prior to treatment, subsequent yearly HAQ, and reasons for termination were collected. The cost based on percentage of patients achieving ≥ 0.2 improvement in HAQ (minimal clinically important difference, MCID) was calculated using the 2008 direct cost (Cdn) of the medication.

Results.

Data were available on 297 patients (206 with RA, 57 PsA, 34 AS). The mean age was 55 years, with 12 years of disease, and the mean baseline HAQ (standard error, SE) was 1.37 (0.04). The changes in HAQ (SE) at Years 1, 2, and 3 were −0.31 (0.04), −0.24 (0.06), and −0.27 (0.07) for annual cost to achieve MCID of $41,636, $42,077, and $42,147, respectively. The number needed to treat (NNT) was 1.94 (RA), 1.88 (PsA), and 2.30 (AS). There were no statistical differences between the diseases studied.

Conclusion.

We obtained data on the effectiveness and cost-effectiveness of anti-TNF drugs using the HAQ score, which is known to be an excellent predictor of work disability, morbidity, and mortality. HAQ scores decreased with treatment and were sustained throughout the 3–5 years of followup. The NNT of approximately 2 seems favorable and was similar between diseases.

Organ-specific autoantibodies in patients with rheumatoid arthritis treated with adalimumab: a prospective long-term follow-up

BACKGROUND

Rheumatoid arthritis (RA) is frequently associated with organ or non-organ-specific autoantibodies or overt autoimmune disorders. Aim of our study was to assess the prevalence and concentration of a panel of organ-specific autoantibodies in patients with RA and to evaluate their relationship with clinical manifestations and treatment efficacy.

METHODS

Clinical and serological data from 20 patients with active RA (3M/17F), aged from 28 to 80 years and 50 healthy controls were analyzed. All patients fulfilled the 1987 American College of Rheumatology (ACR) classification criteria for RA and were treated with adalimumab and methotrexate. At baseline and after 6 months of therapy we tested anti-thyroid antibodies for thyroperoxidase (TPOAb) and thyroglobulin (TgAb) using an automated immunochemiluminescence assay (Immulite 2000, DPC, Los Angeles, CA), and anti-tissue transglutaminase (anti-tTG) using the ELISA assay (Phadia, Freiburg, Germany). Anti-smooth muscle (SMA), anti-liver kidney microsome (LKM), anti-parietal cells (APCA), anti-mitochondrial (AMA) and anti-liver cytosolic protein type 1 (LC1), anti-adrenal gland (ACA), anti-pancreatic islet (ICA) and anti-steroid-producing cell (stCA) antibodies were analyzed using a commercially available indirect immunofluorescence methods. Statistics were performed by the SPSS statistical software for Windows, using non parametric tests.

RESULTS

At baseline 6 out of 20 (30%) patients were positive for TPOAb and 8 (40%) for TgAb. After 6 months of treatment 5 (25%) patients had TPOAb and 8 (40%) TgAb. At baseline and after 6 months of treatment only 1 (5%) patient tested positive for IgA anti-tTG (celiac disease was confirmed by intestinal biopsy), and no patients had IgG anti-tTG. However, in RA patients IgG anti-tTG levels significantly increased during treatment (p = 0.017) and were higher than in healthy individuals both at baseline (p = 0.028) and after 6 months of treatment (p = 0.001). Only 1 (5%) patient was positive for APCA and no patient was positive for the other anti-organ-specific antibodies either at baseline or after 6 months of treatment.

CONCLUSION

The prevalence of organ-specific antibodies does not seem to change during anti-TNF treatment in RA patients. However, a slight and probably irrelevant increase of IgG anti-tTG antibody levels was observed.

Could hormones make a difference in the treatment of juvenile rheumatoid arthritis?

Adrenal androgens dehydroepiandrosterone (DHEA; prasterone) and its sulphated form (DHEA-S) are among the most abundant hormonal steroids in men and nonpregnant women. Deficiencies of these adrenal androgens are associated with autoimmune disorders such as rheumatoid arthritis (RA). Recent studies from our laboratory have also identified low levels of adrenal androgens in the serum and synovial fluid of patients with juvenile rheumatoid arthritis (JRA). These findings support and complement those already published for RA and other autoimmune diseases. Because of the paucity of data on the hormonal status of patients with JRA, studies on the relationship between hypoandrogenicity and predisposition to develop JRA, and/or disease progression have not been conducted. In addition, despite the rapid expansion of research in the clinical use of these adrenal androgens in hyperlipidaemia, atherosclerosis, obesity, diabetes mellitus, insulin resistance and hypertension, their potential beneficial effects in JRA/RA have not been fully investigated. In fact, clinical trials of adrenal androgens in RA have only been conducted for the treatment of systemic lupus erythematosus. Further studies using prospective approaches are necessary to provide a unified consensus on the hormonal status of patients with JRA (as well as those with RA). This overview of our knowledge of the putative role(s) of hormones in arthritis will hopefully stimulate researchers in basic science and rheumatologists to synergistically collaborate in the effective translation of such knowledge to new clinical approaches.

Effects of infliximab therapy on gene expression levels of tumor necrosis factor alpha, tristetraprolin, T cell intracellular antigen 1, and Hu antigen R in patients with rheumatoid arthritis

OBJECTIVE

Tristetraprolin (TTP), T cell intracellular antigen 1 (TIA-1), and Hu antigen R (HuR) are adenine/uridine-rich element binding proteins (ABPs) that affect the production of tumor necrosis factor alpha (TNFalpha) by binding to TNF messenger RNA (mRNA). TTP promotes deadenylation, TIA-1 inhibits translation, and HuR stabilizes TNFalpha mRNA. The aims of this study were to understand the posttranscriptional control of TNFalpha production in patients with rheumatoid arthritis (RA), and to identify parameters that may predict the efficacy of anti-TNFalpha therapy.

METHODS

Peripheral blood mononuclear cells from 38 patients with RA were obtained before therapy and 2 weeks and 54 weeks after administration of the first dose of infliximab, and from 20 healthy control subjects. TNFalpha, TTP, TIA-1, and HuR gene expression levels were analyzed by real-time polymerase chain reaction.

RESULTS

At baseline, TTP and HuR gene expression levels, as well as the TTP:TNFalpha, TTP:HuR, and TIA-1:TNFalpha gene expression ratios were lower in patients with RA than in control subjects, while expression of TNFalpha, TIA-1, and TIA-1:HuR was higher in patients with RA. The TTP:HuR expression ratio decreased significantly after administration of infliximab. Positive correlations were observed between TNFalpha and TTP, TNFalpha and TIA-1, TIA-1 and HuR, and TNFalpha and HuR gene expression in both healthy control subjects and patients with RA. At baseline, the TIA-1:HuR ratio tended to be higher in patients who achieved 50% improvement according to the American College of Rheumatology criteria (ACR50) at week 54 than in those who did not achieve at least an ACR20 response.

CONCLUSION

Differences in ABP gene expression may affect TNFalpha gene expression. A higher TIA-1:HuR expression ratio might correlate with the response to infliximab therapy.

Adaptation of the RAQoL for use in Australia

Quality of life is an important patient-reported outcome of rheumatoid arthritis (RA) in addition to structural and functional outcomes. The RAQoL (Rheumatoid Arthritis Quality of Life questionnaire) was developed in the UK and the Netherlands as a disease-specific tool. It was adapted for use in the Australian social context and the reliability and validity was tested. A lay panel assessed the UK version and adapted the wording for use within Australia. Reliability and validity were assessed by a postal survey of the RAQoL and comparator questionnaires to 100 patients with RA. The RAQoL was easily adapted into Australian-English. Test-retest reliability was high with a Spearman rank correlation coefficient of 0.93. RAQoL scores correlated well with patient-perceived disease activity and severity--indicating good validity. The Australian version of the RAQoL is a valid and reliable tool for the assessment of quality of life. It is practical, easy to administer and has good potential for use in clinical settings and trials in Australia.

Panniculitis: an unusual cutaneous manifestation of rheumatoid arthritis

Specific and nonspecific panniculitis may occur during the course of connective tissue diseases. However, association of panniculitis and rheumatoid arthritis has only rarely been described, and with so few reports, it is difficult to know the significance of this unusual association. We describe 2 patients with rheumatoid arthritis and features of Sjögren syndrome in whom panniculitis developed during the course of the disease. Histologic confirmation of septal panniculitis was established in one case and the panniculitis in this case improved as the arthritis resolved.

Systemische Manifestationen der rheumatoiden Arthritis

Extra-articular manifestations of rheumatoid arthritis are gaining in importance both in rheumatology and other specialities. This report provides information on various organ manifestations and interactions between mere disease-related symptoms and therapeutic effects. Diagnostic radiology plays a crucial role in finding the diagnosis, planning and monitoring of treatment, early detection of complications and drug-related adverse events.

Atraumatic Joint and Limb Pain in the Elderly

Patients who visit the emergency department often have complaints of joint and limb pain. The differential diagnosis, clinical presentation, and treatment choices can be vastly different in the young- or middle-aged population compared with the elderly population, and the concerns of each group must be addressed. The emergency physician is in a unique position in that they are frequently the first to see these individuals and have the opportunity to intervene before permanent disability ensues. Some of the more common etiologies of atraumatic joint and limb pain, including crystal deposition diseases such as gout and pseudogout, osteoarthritis, septic arthritis, and inflammatory arthritides such as rheumatoid arthritis will be addressed in this article. In addition,several arthritides specific to the elderly population such as poly-myalgia rheumatica and associated giant cell arteritis will be covered. Finally a discussion of cervical and lumbar disc disease, as well as gait disorders, and their impact on the elderly, will be presented.

Altered circadian rhythms in rheumatoid arthritis patients play a role in the disease's symptoms

The circadian changes in the metabolism or nocturnal secretion of endogenous corticosteroids (reduction) observed in rheumatoid arthritis (RA) patients are responsible, in part, for the time-dependent changes that are observed in the inflammatory response and related early morning clinical symptoms of the disease. Melatonin (MLT), another circadian nocturnal hormone that is the secretory product of the pineal gland, has been implicated in the time-dependent RA inflammatory reaction with effects that are opposite to those of corticosteroids. As a consequence, altered functioning of the HPA axis (early morning reduced corticosteroid production) and of the pineal gland (night increased MLT production) found in RA patients, seem to be important factors in the appearance and perpetuation of the clinical circadian symptoms of the disease. Consistently, human proinflammatory Th1-type cytokine production (related to MLT stimulation) exhibits a diurnal rhythmicity with peak levels during the night and early morning, at a time when plasma cortisol (inducing the Th2-type cytokine production) is lowest and MLT is highest. Reduced daily light exposure as observed in northern Europe (Estonia), at least during the winter, might explain the higher and more prolonged serum MLT concentrations that were observed in northern RA patients, as well as some epidemiological features versus southern Europe patients.

Anakinra: review of recombinant human interleukin-I receptor antagonist in the treatment of rheumatoid arthritis

BACKGROUND

Interleukin-1 (IL-1) plays an important role in the pathophysiology and progression of rheumatoid arthritis (RA) by contributing to destruction of cartilage, bone, and periarticular tissues. Inhibiting IL-1 synthesis or activity with the use of recombinant human IL-1 receptor antagonist (anakinra) may prove to be an effective approach to the treatment of RA.

OBJECTIVE

The purpose of this article is to review the effects of anakinra in the treatment of RA.

METHODS

A MEDLINE search from 1982 to 2003 was used to identify animal studies and randomized clinical trials of anakinra and other therapies that target IL-1.

RESULTS

Clinical trials of anakinra have shown that it reduces the signs and symptoms of active disease and slows the rate of radiographic destruction in adults with RA. With anakinra 150 mg/d, 43% of patients achieved an American College of Rheumatology (ACR) 20% response, compared with 27% with placebo (P = 0.014). The ACR20 score indicates at least 20% improvement in the ACR composite score, which includes assessment of tender and swollen joint count, and other clinical end points such as pain and disability assessment. Patients treated with anakinra also experienced a 59% reduction in new bony erosion compared with controls (P < 0.001) and a 65% reduction in joint space narrowing as measured by the modified Sharp score (P = 0.020). Injection-site reactions were the most commonly reported adverse event, occurring in 50%, 73%, and 81% of patients receiving anakinra 30, 75, and 150 mg/d, respectively, compared with 25% of patients receiving placebo. Few serious adverse events were reported, and they typically occurred in patients receiving the highest daily dosage.

CONCLUSIONS

IL-1 is an important cytokine in promoting the damage associated with RA. Anakinra is mildly to moderately effective and well tolerated in patients with active RA when used as monotherapy or in combination with methotrexate.

A bullous neutrophilic dermatosis in a patient with severe rheumatoid arthritis and monoclonal IgA gammopathy

A 35-year-old man presented with a 2-month history of itchy grouped vesiculobullae with crusted papules and confluent plaques, distributed symmetrically on the thighs, knees, and elbows. The man had experienced severe disabling seropositive rheumatoid arthritis for 18 years previously. Histologically, subepidermal vesicles were noted, and a dense, diffuse neutrophilic infiltration of the dermis. Direct immunofluorescence studies did not detect IgA deposits. The patient responded well to dapsone (100 mg/d) but not to systemic steroids. This patient's eruption might have been an unusual manifestation of rheumatoid neutrophilic dermatitis.

Do anti-TNF agents have equal efficacy in patients with rheumatoid arthritis?

Tumor necrosis factor (TNF) antagonists have dramatically improved the outcomes of rheumatoid arthritis (RA). Three agents currently available in the USA--infliximab, etanercept, and adalimumab--have been designed to modify the biologic effects of TNF. Infliximab and adalimumab are monoclonal antibodies, and etanercept is a soluble protein. The pharmacokinetic and pharmacodynamic properties of each differs significantly from those of the others. All three agents are effective and safe, and can improve the quality of life in patients with RA. Although no direct comparisons are available, clinical trials provide evidence that can be used to evaluate the comparative efficacy of these agents. Infliximab, in combination with methotrexate, has been shown to relieve the signs and symptoms of RA, decrease total joint score progression, prevent joint erosions and joint-space narrowing, and improve physical function for up to 2 years. Etanercept has been shown to relieve the signs and symptoms of RA, decrease total joint score progression, and slow the rate of joint destruction, and might improve physical function. Etanercept is approved with and without methotrexate for patients who have demonstrated an incomplete response to therapy with methotrexate and other disease-modifying anti-rheumatic drugs (DMARDs), as well as for first-line therapy in early RA, psoriatic arthritis, and juvenile RA. Adalimumab relieves the signs and symptoms of RA with and without methotrexate and other DMARDs, decreases total joint score progression, prevents joint erosions and joint-space narrowing in combination with methotrexate, and might improve physical function. When selecting a TNF antagonist, rheumatologists should weigh evidence and experience with specific agents before a decision is made for use in therapy.

Gender differences in prevalence of upper extremity musculoskeletal disorders

A literature review was conducted on the current literature base to determine the strength of support for the hypothesis that women experience higher prevalences of upper extremity musculoskeletal disorders (UEMSDs) than men. Fifty-six articles were reviewed for data on gender differences in frequency, incidence or prevalence rates for musculoskeletal disorders specific to the upper extremities. These articles included both general and working populations. The majority of the studies showed that women had significantly higher incidences of various types of UEMSDs than men. This trend was consistently observed in studies based on self-report or plant/workers compensation records, with and without physical examination, and after adjusting for potential confounders such as age and physical work factors. With men as the referent, the odds ratio (OR) or prevalence ratio (PR) for UEMSDs ranged from 0.85 to 10.05 for self report. For self report combined with physical examination, the OR/PR ranged from 0.66 to 11.4. The OR/PR for carpal tunnel syndrome (CTS) ranged from 0.6 to 2.87 with confounder adjustment. These findings suggest that women do have significantly higher prevalences than men for many types of UEMSDs, even after controlling for the type of data source and confounders such as age or work factors.

Rheumatoid arthritis: proposal for the use of anti-microbial therapy in early cases

Rheumatoid arthritis (RA) is a chronic disease, affecting women more than men, especially in those possessing the "shared epitope" (EQK/RRAA) amino acid sequences present in HLA-DR1/4 molecules. Proteus mirabilis carries sequences showing molecular mimicry to the "shared epitope" and to type XI collagen of hyaline cartilage. Elevated levels of antibodies to P. mirabilis have been reported from 14 different countries involving 1375 RA patients and the microbe has been isolated from urine cultures of such patients. Our working hypothesis is that the disease develops as a result of repeated episodes of Proteus upper urinary tract infections. Prospective studies involving the trial of anti-Proteus measures in RA patients should be evaluated in the management of this disease. Antibiotics, high fluid intake, and fruit extracts, such as cranberry juice, have all been found to be effective in the treatment of urinary tract infections. Such measures could be used as possible additional adjuncts to the standard therapy with NSAIDs and DMARDs.

Kallikrein cascade and cytokines in inflamed joints

Rheumatoid arthritis is a chronic multi-system disease of unknown aetiology. The current hypothesis is that an unknown antigen triggers an autoimmune response in a genetically susceptible individual. The predominant pathological change is that of an inflammatory synovitis, characterised by cellular infiltrates and angiogenesis, with subsequent bone and cartilage destruction. These pathological changes are as a result of the activation of a variety of cells, inflammatory mediators, and effector molecules. The pro-inflammatory kinins and cytokines appear to play a central role in the pathogenesis of rheumatoid arthritis. Sufficient evidence exists that establishes a key role for the kallikrein-kinin cascade in inflamed joints. In addition, there appears to be an inter-relationship between cytokines and kinins in the inflammatory process. Kinins induce the release of cytokines, and cytokines have been shown to augment the effects of kinins. This may lead to an enhancement and perpetuation of the inflammatory process. In this review, we report a first study, correlating markers of disease with the kallikrein-kinin cascade and with cytokines.

Rheumatoid arthritis: current clinical and research directions

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by synovitis and joint erosions. It affects approximately 1% of the adult population in a female/male ratio ranging from 2:1 to 4:1. RA is an insidious disease, typically having an onset of symmetric joint swelling and reaching a peak incidence in the fourth and fifth decades. Extraarticular manifestations include pulmonary, ocular, and vascular disease. The etiology of RA remains unknown. Attempts to discover infectious causes have proven unsuccessful, although environmental influences may trigger a response leading to the development of this autoimmune disease. Genetic associations have been identified, particularly with the major histocompatibility complex class II antigens. Furthermore, twin studies have shown a 30%-50% concordance rate for monozygotic twins. Approximately 70%-80% of patients with RA have rheumatoid factor present in the blood, although its role remains unclear. Hormonal status may influence RA. The majority of RA patients are women, and in 75% of them, the disease improves during pregnancy. RA has significant financial and social implications associated with treatment costs, lost wages, disability, and increased mortality. Mainstays of medical therapy have included nonsteroidal anti-inflammatory and immunosuppressive agents, such as prednisone and methotrexate. Recent advances in the treatment of RA include specific inhibitors of cyclooxygenase II, T cells, blood vessels, cytokines (such as tumor necrosis factor-alpha [TNF-alpha] or interleukin-1 [IL-1]), and adhesion molecules. Additional studies are ongoing with combination interventions. It is anticipated that a better understanding of the basic pathophysiologic mechanisms critical in RA pathogenesis will provide more precise and efficacious therapy.

Epidemiological and clinical aspects relating to the variability of rheumatoid arthritis

OBJECTIVE

To review epidemiological studies dealing with the temporal and geographic variability in the occurrence of rheumatoid arthritis (RA) and clinical studies that address the variability of severity and manifestations among populations.

METHODS

An extensive search of the literature, including a Medline search, was completed. Studies addressing the origin, history, and trends in the occurrence of RA were reviewed first. Next, studies of the prevalence and incidence of RA in different populations were reviewed, and occurrence rates compared. Standardization was attempted by tabulating adult prevalence rates of studies using equivalent sets of criteria. Studies comparing RA patients from two populations were sought next. Finally, studies dealing with explanations of the presumed variability were reviewed.

RESULTS

Temporal variability is indicated by paleopathological evidence that RA has existed in the New World since 4000 BC, whereas there is no evidence that it occurred in Europe before the 17th century, or in Africa before the 20th century. Epidemiological studies show a possible trend of decreasing incidence of RA in the United States and Western Europe, whereas reports from Africa note a rising incidence. In white populations of Europe and America, prevalence is approximately 1%, and incidence is 0.03%. Significantly higher rates are found in some North American Indians, and significantly lower rates in some Asian and African populations, even when the different population structures are taken into account. In the latter populations, different patterns of occurrence from those observed in whites emerge, such as greater female preponderance and a much younger peak age at onset. Direct standardized comparisons of two diverse populations of RA patients showed some differences in expression, severity, or manifestations of RA between populations.

CONCLUSION

The occurrence and manifestations of RA are temporally and geographically variable.

Clinical guidelines for management

Guidelines provide explicit recommendations and seek to influence practice using a formal process to disseminate advice on most effective management in the light of scientific evidence. They provide a framework for the evaluation and treatment of common clinical problems, but are not intended to replace clinical judgement. There is considerable variation in rheumatology practice, fueled by uncertainty about the optimal measurement of disease outcome. Guidelines can help identify and eliminate ineffective or unnecessary care as they are systematically developed statements to assist practitioners and patients' decisions about appropriate health care. There are North American guidelines for the initial evaluation of adult patients with acute musculoskeletal symptoms, the management of rheumatoid arthritis and the management of osteoarthritis. These are discussed together with proposed guidelines for the management of early rheumatoid arthritis and areas of research into the value of guidelines. It is recommended that future work in this area should: (i) identify aspects of current guidelines which are directly related to outcome; (ii) educate clinicians in these aspects of care; (iii) ensure they are introduced into practice and the outcome of care subsequently improves; (iv) regularly update the guidelines to reflect current opinion. Present guidelines that give broadly similar recommendations from North American and UK perspectives. However, the available evidence all points to large variations between how clinicians practise and how they make their decisions and it may be unlikely that laying down exact recipes for practice will necessarily influence the clinician. Guidelines may appear relevant but they could prove to have very limited utility.

Role of cytokines, acute-phase proteins, and chemokines in the progression of rheumatoid arthritis

Rheumatoid arthritis (RA) has no firm etiologic basis. It progresses as an autoimmune disease and evolves into a chronic inflammatory joint disease complicated by recurrent episodes of systemic acute-phase reactions, which sometimes result in amyloidosis. Cytokines play a pivotol role in inflammation and the immune response. Proinflammatory cytokines such as interleukin-1, tumor necrosis factor alpha (TNF-alpha), and interleukin-6 are present at high levels in arthritic joints, and their blood concentration correlates with the severity of the RA. Some of the activities of the proinflammatory cytokines, such as stimulation of leukocyte infiltration and release of their proteolytic enzymes, may be mediated by acute phase proteins (APPs), such as C-reactive protein and serum amyloid A, and by chemokines such as interleukin-8. Cytokines, chemokines, and APPs reciprocally regulate each others' expression and activities, constituting a communication network between fibroblasts, macrophages, lymphocytes, and hepatocytes. Activation of the network results in inflammation and the progressive destruction of joints and systemic symptoms characteristic of RA.

Perioperative management of the rheumatoid patient

Rheumatoid arthritis is a systemic disease that can affect multiple organ systems of the body. It is a symmetrical polyarthropathy which leads to destruction of cartilage and bone. Before undertaking surgery on the rheumatoid patient, several issues need to be addressed. A thorough evaluation by a multidisciplinary team is essential to decrease any operative risks involved. This is a review of some of the systemic manifestations of rheumatoid arthritis with an emphasis on anesthesiology, and radiological consultation, and perioperative surgical management of rheumatoid drug therapy.

Clinical expression of rheumatoid arthritis in Chilean patients

In populations such as Northern Europeans in which the HLA-DR4 subtypes DW14 and Dw4 show strong association with rheumatoid arthritis (RA), these alleles and the double allelic dose of the shared epitope are considered severity markers. The clinical expression of RA varies in different populations, which may be determined by variation in the prevalence of these markers. In the present study we analyzed the expression of RA in 112 consecutive Chilean patients and its relation to the prevalence of genetic factors, prompted by our previous observation that DR4 is weakly associated to RA in this population. Mean age was 50 +/- 14 years; 90% were seropositive and 87% were female, with a disease duration of 10 +/- 8 years. Extra-articular manifestations were found in 38% of patients, rheumatoid nodules in 27%, vasculitis in 8%, and Sjogren's syndrome in 29%. Functional capacity (ACR, 1991) I or II: 82%.15% of patients stopped working. Hand radiographs scored according to Steinbrocker in 89 patients: I, 21%; II, 15%; III, 43%; IV, 21%. In this series, patients with less formal education seemed to have more benign arthritis. In 97 controls and in 65 (56%) RA patients the presence of DRB1 alleles corresponding to DR1 and DR4 serotypes, to DR4-Dw subtypes, and homozygocity, were determined by polymerase chain reaction followed by specific oligonucleotide hybridization. The shared epitope was present in 53% of RA patients and in 30% of controls (P = .0048, odds ratio [OR] = 2.64). A double allelic dose of the epitope was present in 15% of RA patients compared with 4% of controls (P = .026, OR = 4.23). In a subgroup of 31 erosive RA patients we did not find a significant association of disease severity with the shared epitope in a single or double allelic dose. None of the DR4 subtypes that associate with RA in other populations was found significantly more prevalent in our patients. The severity of RA in our study compared with published series was intermediate between British patients with severe RA and Greek patients with milder disease. This may be due to the high prevalence of Dwl3*0403 in our population.

Botanical lipids: effects on inflammation, immune responses, and rheumatoid arthritis

OBJECTIVE

This review discusses the rationale and experimental data that led to clinical trials of certain botanical lipids, mainly gammalinolenic acid (GLA), for the treatment of rheumatoid arthritis (RA).

DATA SOURCES

Pertinent articles and reviews, and a bibliographic database in English using the following indexing terms: rheumatoid arthritis, fatty acids, gammalinolenic acid, lymphocytes, and monocytes, were used.

STUDY SELECTION

All clinical trials in which GLA was used to treat arthritis are included in this review. Data from appropriately peer reviewed in vitro and animal experiments evaluating the effects of botanical lipids as regulators of cell activation and immune responses are also reviewed.

DATA SYNTHESIS

GLA treatment is associated with clinical improvement in patients with RA, as evaluated by duration of morning stiffness, joint pain and swelling, and ability to reduce other medications. However, studies vary in terms of duration, GLA dose, whether or not they were placebo controlled, and, if so, what placebo was used, criteria for evaluation, and use of concomitant medication. Studies done in vitro generally indicated that GLA reduces lymphocyte activation and production of mediators of inflammation.

CONCLUSIONS

A small number of studies suggest that GLA is effective treatment for RA patients. Further controlled studies of its use in RA seem warranted.

Second-line agents for rheumatoid arthritis

Second-line agents (disease-modifying agents or slow-acting antirheumatoid drugs) are well established for synovitis that persists despite treatment with non-steroidal anti-inflammatory agents. Indications for their use in the elderly are similar to those in younger people, but the elderly are at higher risk of adverse reactions. Therefore, lower doses, more cautious patient selection and more frequent monitoring for adverse reactions are recommended. Low dose corticosteroids are often effective in the elderly and obviate the need for second-line agents.

Positive selection in autoimmunity: abnormal immune responses to a bacterial dnaJ antigenic determinant in patients with early rheumatoid arthritis

A novel 'multistep molecular mimicry' mechanism for induction of rheumatoid arthritis (RA) by bacterial antigens that activate T lymphocytes previously 'educated' by peptides derived from a class of human histocompatibility antigens is reported here. These antigens have the amino acid sequence QKRAA, which is also present on the Escherichia coli heat-shock protein dnaJ. Synovial fluid cells of early RA patients have strong immune responses to the bacterial antigen, but cells from normal subjects or controls with other autoimmune diseases do not. The activated T cells may cross-react with autologous dnaJ heat-shock proteins that are expressed at synovial sites of inflammation. Our findings may have direct relevance to new strategies for the immune therapy of RA.

The cost-effectiveness of liver biopsy in rheumatoid arthritis patients treated with methotrexate

OBJECTIVE

To assess the cost-effectiveness of liver biopsy in monitoring rheumatoid arthritis (RA) patients for methotrexate (MTX)-induced cirrhosis.

METHODS

A decision analytic model was used to compare a strategy of no biopsy versus strategies of biopsy after 5 years or 10 years of MTX treatment.

RESULTS

Biopsy after 5 years of MTX treatment had a cost-effectiveness ratio of $1,891,830 per year of life saved, while biopsy after 10 years of treatment had a cost-effectiveness ratio of $52,374 per year of life saved. Sensitivity analyses revealed that the cost-effectiveness of biopsy was most dependent on the probability of cirrhosis.

CONCLUSION

Liver biopsy to monitor for MTX-induced cirrhosis in RA patients is not cost effective after 5 years of treatment, and even biopsy after 10 years has a high cost.

Fibromyalgia: chronobiological aspects

The primary fibromyalgia syndrome (Weichteilrheumatismus) shows a circadian rhythm of the symptoms and, moreover, a seasonality of pain severeness. Although the pathophysiologic mechanisms are unknown, the circadian variations are well documented in the literature; the seasonality of pain is sometimes clinically reported. In a study on "healthy" workers, the seasonality of this disease is reported.