Quantitative measures for assessing rheumatoid arthritis in clinical trials and clinical care

Multicenter study of the natural history and therapeutic responses of patients with chikungunya, focusing on acute and chronic musculoskeletal manifestations - a study protocol from the clinical and applied research in Chikungunya (REPLICK network)

BACKGROUND

Chikungunya is associated with high morbidity and the natural history of symptomatic infection has been divided into three phases (acute, post-acute, and chronic) according to the duration of musculoskeletal symptoms. Although this classification has been designed to help guide therapeutic decisions, it does not encompass the complexity of the clinical expression of the disease and does not assist in the evaluation of the prognosis of severity nor chronic disease. Thus, the current challenge is to identify and diagnose musculoskeletal disorders and to provide the optimal treatment in order to prevent perpetuation or progression to a potentially destructive disease course.

METHODS

The study is the first product of the Clinical and Applied Research Network in Chikungunya (REPLICK). This is a prospective, outpatient department-based, multicenter cohort study in Brazil. Four work packages were defined: i. Clinical research; ii) Translational Science - comprising immunology and virology streams; iii) Epidemiology and Economics; iv) Therapeutic Response and clinical trials design. Scheduled appointments on days 21 (D21) ± 7 after enrollment, D90 ± 15, D120 ± 30, D180 ± 30; D360 ± 30; D720 ± 60, and D1080 ± 60 days. On these visits a panel of blood tests are collected in addition to the clinical report forms to obtain data on socio-demographic, medical history, physical examination and questionnaires devoted to the evaluation of musculoskeletal manifestations and overall health are performed. Participants are asked to consent for their specimens to be maintained in a biobank. Aliquots of blood, serum, saliva, PAXgene, and when clinically indicated to be examined, synovial fluid, are stored at -80° C. The study protocol was submitted and approved to the National IRB and local IRB at each study site.

DISCUSSION

Standardized and harmonized patient cohorts are needed to provide better estimates of chronic arthralgia development, the clinical spectra of acute and chronic disease and investigation of associated risk factors. This study is the largest evaluation of the long-term sequelae of individuals infected with CHIKV in the Brazilian population focusing on musculoskeletal manifestations, mental health, quality of life, and chronic pain. This information will both define disease burden and costs associated with CHIKV infection, and better inform therapeutic guidelines.

The effects of golimumab on patient centric outcomes amongst rheumatoid arthritis patients in Greece. The GO-Q study

This study aimed at assessing the impact of golimumab on health-related quality of life (HRQoL) and other patient-reported outcomes (PROs) in patients with rheumatoid arthritis (RA) in real-world settings. GO-Q was an observational, prospective, 12-month study, which recruited patients with moderate-to-severely active RA initiating golimumab treatment per label in rheumatology clinics and private practices. Primary endpoint was the change in PROs [EuroQol-5 Dimensions-3 Levels (EQ-5D-3L) questionnaire, Health Assessment Questionnaire Disease Index (HAQ-DI), and Work Productivity and Activity Index for RA (WPAI:RA)] after 12 months of treatment. Other endpoints included Disease Activity Score for 28 joints with erythrocyte sedimentation rate (DAS28-ESR), healthcare resource utilization, and golimumab adherence. Changes in continuous variables from baseline were evaluated with the paired t test. One hundred forty-five patients were recruited. The mean [standard deviation (SD)] EQ-5D-3L index increased significantly at 12 months versus baseline [from 0.427 (0.206) to 0.801 (0.229); p < 0.0001], with changes as early as 3 and 6 months (both p < 0.0001). Accordingly, there were statistically significant changes in all WPAI:RA domains from baseline to 3, 6, and 12 months (p < 0.0001). Patients' function improved gradually from the third month until the end of follow-up (p < 0.0001 for all time-points). Thirty (27.3%) and 60 (54.6%) patients achieved remission (DAS28-ESR < 2.6) and low disease activity (DAS28-ESR ≤ 3.2), respectively, at 12 months. Adherence rate to golimumab was high (mean [SD] 90.3% (7.5) at 12 months). In patients with moderate-to-severely active RA, golimumab significantly improved HRQoL, physical function, and work productivity and activity, with improvements in disease activity over 12 months in real-world settings.

Reduced cardiorespiratory fitness is a mediator of excess all-cause mortality in rheumatoid arthritis: the Trøndelag Health Study

Objectives

Investigate if low cardiorespiratory fitness (CRF) was associated with and acted as a mediator of excess all-cause mortality rate in persons suffering from rheumatoid arthritis (RA) compared with the general population.

Methods

All-cause mortality was analysed using Cox regression modelling in patients with RA (n=348) and controls (n=60 938) who took part in the second (1995–1997) and third (2006–2008) waves of the longitudinal population-based Trøndelag Health Study in Norway. A mediation analysis was performed to investigate if excess relative risk of mortality in RA was mediated by low estimated CRF (eCRF).

Results

During the follow-up until 31 December 2018 (mean 19.3 years), the mortality rate among patients with RA (n=127, 36.5%) was higher than among controls (n=12 942, 21.2%) (p<0.001). Among controls and patients with RA, 51% and 26%, respectively, had eCRF above the median for their age and sex (p<0.001). The final Cox model included RA status and eCRF, adjusted for hypertension, body mass index, smoking, cholesterol, diabetes and creatinine. eCRF below median for sex and age category was associated with increased mortality (p<0.001). The total excess relative risk of mortality in patients with RA was 28% (95% CI 2% to 55%, p=0.035), in which RA itself contributed 5% and the direct and indirect contributions of low eCRF accounted for 23%.

Conclusions

Low eCRF was an important mediator of the increased all-cause mortality rate found in RA. Our data indicate that patients with RA should be given advice to perform physical activity that increases CRF, along with optimised treatment with antirheumatic drugs, from the time of diagnosis.

Instruments for Outcome Evaluation of Specific Domains in Primary Sjögren's Syndrome

Primary Sjögren’s syndrome (pSS) is a systemic autoimmune disorder characterized by very heterogeneous features. The spectrum of this disorder may vary from benign but disabling symptoms such as dryness, due to lachrymal and salivary involvement, pain and fatigue, to systemic, potentially severe, manifestations that may involve any organ. In recent decades, the arrival of biotechnological therapy has offered new opportunities for the treatment of this—until now—orphan disease. Currently, the possible use of these new drugs in therapeutic trials has made it necessary to have reliable outcome measures to evaluate their efficacy in this disease. A great effort has been made in multicenter, often multinational, studies to develop and validate instruments capable of assessing the different disease-related features. The adoption in therapeutic trials of the newly developed outcome measures aimed at assessing systemic features and patient reported symptoms has often yielded disappointing results. These negative data have been ascribed, on the one hand, to the trial design not being completely appropriate, and, on the other hand, to the fact that a single instrument may be not sufficient to cover the great clinical heterogeneity of the disease features. There is now growing belief that composite end points that include instruments that are able to assess the various aspects of the disease may be more properly and successfully used in future therapeutic trials.

The Clinical Disease Activity Index and the Routine Assessment of Patient Index Data 3 for Achievement of Treatment Strategies

OBJECTIVE

To compare the Clinical Disease Activity Index (CDAI) with the Routine Assessment of Patient Index Data 3 (RAPID3) from 2 large United States registries.

METHODS

Using a cross section of clinic visits within 2 registries, we determined whether the outcome of each metric would place the patient in remission (REM), low (LDA), moderate (MDA), or high disease activity (HDA) using the CDAI, with the assumption that a patient in MDA or HDA would be a candidate for acceleration of treatment.

RESULTS

We identified significant disparities between the 2 indices in final disease categorization using each index system. For patients identified in LDA by CDAI, RAPID3 identified 20.4% and 28.3% as LDA in Corrona and the Brigham and Women's Rheumatoid Arthritis Sequential Study (BRASS), respectively. For patients identified as MDA by CDAI, RAPID3 identified 36.2% and 31.1% as MDA in Corrona and BRASS, respectively, with the greatest disparities within each system identified for LDA and MDA activity by the CDAI (20.4% and 36.2% agreement of RAPID3 with CDAI, respectively, in Corrona and 28.3% and 31.1% agreement in BRASS). Overall comparison between CDAI and RAPID3 in the 4 disease categories resulted in estimated k = 0.285 in both. The RAPID3 scores indicated the potential for treat-to-target acceleration in 34.4% of patients in REM or LDA based on CDAI in Corrona and 27.7% in BRASS, respectively.

CONCLUSION

The RAPID3, based on patient-reported outcomes, shows differences with CDAI categories of disease activity. The components of CDAI are not highly correlated with RAPID3, except for patient global assessment. These differences could significantly affect the decision to advance treatment when using a treat-to-target regimen.

Frailty syndrome in rheumatoid arthritis and symptomatic osteoarthritis: an emerging concept in rheumatology

Musculoskeletal conditions such as rheumatoid arthritis (RA) and symptomatic osteoarthritis (OA) were the leading cause of disability in developed countries and disproportionately affects older adults. Frailty is an emerging concept in rheumatology, which represents an important construct to aid in the identification of in- dividuals who are vulnerable to adverse events and less favourable outcomes. The prevalence of frailty among the community-dwelling population increases with age: it ranges from 7% to 10% in those aged over 65 years and to 20-40% among octogenarians. Among patients with RA, the prevalence of frailty is comparable to, or even greater, that of older geriatric cohorts and pre-frailty, a condition including a major health vulnerability between robust and frail, is much more prevalent in RA than in geriatric cohorts. Clinical OA is also associated with frailty and pre-frailty in older adults in European countries. The overall prevalence of clinical OA at any site was 30.4%; frailty was present in 10.2% and pre-frailty in 51.0 %. The diagnosis of frailty is usually clinical and based on specific criteria, which are sometimes inconsistent. Therefore, there is an increasing need to identify and vali- date robust biomarkers for this condition. In the literature, different criteria have been validated to identify frail older subjects, which mainly refer to two conceptual models: the Physical Frailty (PF) phenotype proposed by Fried and the cumulative deficit approach proposed by Rockwood. The purpose of this review was to quantita- tively synthesize published literature on the prevalence of frailty in RA and OA and summarize current evidence on the validity and practicality of the most commonly used screening tools for frailty.

NEMO score in nailfold videocapillaroscopy is a good tool to assess both steady state levels and overtime changes of disease activity in patients with systemic sclerosis: a comparison with the proposed composite indices for this disease status entity

Background

In previous studies, we demonstrated that the NEMO score, i.e. the cumulative number of microhaemorrhages (MHEs) and microthromboses (MTs), observed in nailfold videocapillaroscopy was a good indicator of the steady state level of disease activity (DA) in patients with systemic sclerosis (SSc) when the European Scleroderma Study Group (EScSG) index was considered the gold standard.

Aim of the study

To verify whether the NEMO score could be (i) a valid tool to assess DA, even when the modified European Scleroderma Trials and Research (EUSTAR) index was considered to be the comparator, and (ii) a sensitive method to capture the DA overtime changes.

Patients and methods

The NEMO score and the EScSG and EUSTAR indices were contemporarily assessed at baseline (T0) and after a follow-up of 4–56 months (T1) in 98 patients with SSc. The differences (Δ) between the T1 and T0 values of the NEMO score and the EScSG and EUSTAR indices were calculated and compared to each other.

Results

NEMO score values were very closely correlated with the corresponding values of the EScSG and EUSTAR indices both at T0 and T1 observations (p < 0.0001 in all cases with the exception of the correlation with EScSG values at T1 (p < 0.03)). The values of the two composite DA indices were also strictly related to each other in both T0 and T1 observations (p < 0.0001).

Receiver operating characteristic (ROC) curve analysis showed the NEMO score had a good sensitivity and specificity in classifying patients with a predefined level of DA (scores ≥ 3.0 and ≥ 2.5 for the EScSG and EUSTAR indices, respectively, p < 0.0001 in both cases).

Δ values of the NEMO score were significantly correlated with the corresponding values of both the EScSG and EUSTAR indices. Weighted Cohen’s k level of agreement between Δ values of the NEMO score and those of the EScSG and EUSTAR indices was moderate (0.55 and 0.59, respectively).

Conclusions

NEMO score proves to be a feasible, non-invasive, and valid tool to assess steady state levels and changes over time of DA in patients with SSc. Thus, it can represent an alternative or complementary method to measure this disease status entity in this disorder.

Real benefits of ultrasound evaluation of hand and foot synovitis for better characterisation of the disease activity in rheumatoid arthritis

Objectives

Optimal management of rheumatoid arthritis (RA) depends on accurate evaluation of disease activity. Foot synovitis is not included in the most used RA outcome measure (DAS-28 score). The aim of this study was to investigate how musculoskeletal ultrasound (MSK-US) examination of hand and feet correlate with the disease activity score (DAS-28 score). We also explored whether performing MSK-US assessments of hands alone compared with hands and feet underestimates the disease activity in RA.

Methods

This is a real-life cross-sectional study of 101 patients (51 with RA and 50 with other musculoskeletal conditions) with inflammatory small joint pain, who underwent MSK-US examination of hands and feet.

Results

MSK-US-detected hand synovitis was found in 18/51 (35.3%) RA patients and 16/50 (32%) of those with other musculoskeletal conditions (p = 0.96), while foot synovitis was detected in 18/51 (35.3%) and 12/50 (24%) patients, respectively (p = 0.78). DAS-28 did not correlate with any of the US outcome measures in patients with RA. Six out of 13 (46.1%) RA patients in remission, 7/14 (50%) with low disease activity and 18/32 (56.2%) with moderate disease activity (according to DAS-28 definition) had active synovitis as assessed by the MSK-US examination of their hands and feet. MSK-US-detected synovitis led to treatment escalation in 26/51 (51%) RA patients.

Conclusion

This study emphasises that MSK-US examination of hands and feet has led to optimised management of the majority of RA patients, which would have not been possible otherwise, because of the lack of correlation between DAS-28 assessment and MSK-US outcomes.

Key Points

• The most used disease activity score in rheumatoid arthritis (DAS-28) did not correlate with US outcome measures derived from hands and feet examination.

• DAS-28 did not differentiate between RA patients with subclinical active synovitis versus well-controlled disease on US.

• As a result of US examination of the hands and feet, 51% RA patients had their immunosuppressive treatment optimised.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06187-8) contains supplementary material, which is available to authorized users.

The Patient-Reported Outcomes Thermometer-5-Item Scale (5T-PROs): Validation of a New Tool for the Quick Assessment of Overall Health Status in Painful Rheumatic Diseases

Objective

To investigate the construct validity, reliability (internal consistency and retest reliability), and feasibility of the patient-reported outcomes thermometer–5-item scale (5T-PROs), a new tool to measure overall health status in patients with painful chronic rheumatic diseases such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (axialSpA), and fibromyalgia (FM).

Methods

Consecutive patients have been involved in this study. The following analyses were performed to establish the validity of the 5T-PROs: (1) principal component factor analysis was used to identify the presence of a relatively small number of underlying latent factors than can be used to represent relations among sets of many variables; (2) Cronbach's alpha was calculated as an indicator of internal consistency; and (3) Pearson product-moment correlations were conducted to assess the convergent validity. The 5T-PROs was also administered a second time (two weeks after the initial administration) to a subset of sample (n = 426) to allow for calculation of test-retest reliability. We used the intraclass correlation coefficient (ICC) as an estimate of test-retest reliability. Additionally, discriminant validity was tested using analysis of variance (ANOVA) with Bonferroni post hoc multiple comparisons, in different disease conditions. Feasibility was analyzed by the time taken in completing the 5T-PROs and the proportion of patients able to complete the 5 item.

Results

1,199 patients (572 with RA, 251 with axialSpA, 150 with PsA, and 226 with FM) were examined. The mean age was 55.7 (standard deviation: 13.1; range: 20 to 80) years. Factor analysis yielded two factors which accounted for 62.54% of the variance of the 5T-PROs. The first factor “Symptom Summary Score” (35.57% of the variance) revealed a good internal consistency (alpha = 0.88); the internal consistency of the second factor “Psychological Summary Score” (26.97% of the variance) was moderate (alpha = 0.69). The reliability of the whole instrument was good (alpha = 0.82). A very high correlation was obtained between Symptom Summary Score and SF-36 PCS and between pain thermometer intensity and SF-36 bodily pain. For all five items and summary scale scores of the SF-36, there was strong evidence that the mean rank of the scores differs significantly between the groups (Kruskal–Wallis tests, p < 0.001). Discriminant validity, assessed by comparing the 5T-PRO dimensions in patients with different states of disease activity, showed that the 5T-PROs show moderate association with the presence of comorbidities. It was also noted that it was inversely correlated (p=0.01) to years of formal education.

Conclusion

The 5T-PROs is easily administered, reliable and a valid instrument for evaluating the extensive multidimensional impact associated with chronic painful rheumatic conditions.

Diagnostic value of a 3-day course of prednisolone in patients with possible rheumatoid arthritis - the TryCort study

Background

In patients with tender and swollen finger joints, the differential diagnosis between rheumatoid arthritis (RA) and osteoarthritis (OA) of the hands can be initially difficult. This prospective study (the TryCort study) was performed to study the diagnostic value of prednisolone in differentiating between RA and hand OA. We present the results of this potentially diagnostic test in patients with possible RA in daily clinical practice by demonstrating the results of a pilot and a validation part of this ‘prednisolone test’ (pred-test).

Methods

We investigated the response to a 3-day course of 20 mg of prednisolone in patients with suspicion of RA. All patients received 1 g of paracetamol per day for 5 days for pain relief. On days 3–5, a morning dose of 20 mg of prednisolone was added. Hand pain was quantified on a 0–10 Numerical Rating Scale, and the subjective percentage of improvement (0–100%) was recorded. Thresholds for response to prednisolone were investigated in a pilot phase with differentiation in response between patients with RA and patients with OA of the hands, both with pain in the hands ≥4. In a validation phase, the best differentiating cut-off of the pilot phase was applied to discriminate responders from non-responders in consecutive patients with hand pain ≥4 referred because of suspected RA. Final diagnoses were made by the expert upon re-examination at week 12. Primary outcomes were the sensitivity and specificity of a positive test in relation to the diagnosis.

Results

A percentage of 40% subjective improvement of pain in the hands on day 3 discriminated best between RA and OA in the pilot phase. Among 95 patients with complete data in the validation phase, RA was diagnosed in about 50%. Patients with RA had more swollen joints, higher C-reactive protein levels and slightly higher Health Assessment Questionnaire scores. The pred-test was positive in 42.1% of all patients (40 of 95). The median percentage of improvement on day 5 was higher in RA than in non-RA: 50% (IQR 30–60%) vs. 20% (IQR 10–30%) (p < 0.001). The sensitivity and specificity of the pred-test were 0.6 (95% CI 0.5–0.8) and 0.8 (95% CI 0.7–0.9), respectively, and the positive and negative predictive values were 0.77 and 0.70, respectively.

Conclusions

To our knowledge, this is the first evaluation of the widely used pred-test that has ever been performed. The pred-test had a moderate sensitivity and a good specificity. We conclude that rheumatologists may use this test in unclear clinical situations to better differentiate between inflammatory and other conditions.

Trial registration

ClinicalTrials.gov identifier: NCT01395251. Registered on 14 Jul 2011.

EudraCT number: 2011-002633-19. Registered on 21 Dec 2011.

Association of micronutrient status with subclinical health complaints in lactovegetarian adults

Background

Micronutrient malnutrition has many adverse effects on human health, not all of which may be clinically evident.

Objective

To explore linkages between subclinical health complaints and micronutrient status in lactovegetarian Indian adults.

Design

Health was assessed in 502 lactovegetarian adults (275 men, 227 women, aged 30.6±9 years) using a structured questionnaire for existing complaints with severity of symptoms on a four-point scale and morbidity over the preceding month. Subjects were categorized as having no complaints (NC), or complaints of mild (MI) or moderate (MD) degree, using cluster analysis. Diet was recorded by a semi-quantitative food frequency questionnaire and nutrient intakes were computed using standard databases. Levels of haemoglobin, vitamin C, retinol, ceruloplasmin, riboflavin (EGRAC), folic acid, vitamin B₁₂ and erythrocyte membrane zinc (RBCMZn) in blood were estimated.

Results

Health complaints of a mild and moderate degree were observed in 30.5% and 24.7% of the subjects, respectively. Average dietary intakes of β-carotene, riboflavin, iron and zinc were observed to be only about half of the recommended dietary intakes. There was a decreasing trend in micronutrient intakes from NC to MD. Intakes of iron, zinc, niacin and thiamin of men from the MI group tended to be lower than in the NC group (p<0.1). Men from the MD group had significantly lower intakes of calcium, zinc and riboflavin than those from the NC group (p<0.05). The intakes of these nutrients in women from NC, MI and MD were not significantly different. Multinomial logistic regression of health status revealed that plasma vitamin C and RBCMZn were negatively associated with MD and RBCMZn with MI.

Conclusions

The study indicates a need to increase micronutrient intakes of vegetarian populations, especially regarding vitamin C and zinc for maintenance of health.

Effect of Xerostomia on the Functional Capacity of Subjects with Rheumatoid Arthritis

OBJECTIVE

To evaluate the intensity of xerostomia and hyposalivation in subjects with rheumatoid arthritis (RA) as well as the effects of these conditions on functional incapacity and disease activity.

METHODS

The study sample comprised 236 individuals of both sexes who had RA. All the individuals were submitted to clinical evaluation and unstimulated sialometry. Functional capacity was determined by using the Health Assessment Questionnaire (HAQ), xerostomia was assessed using the Xerostomia Inventory, and disease activity was evaluated with the 28-joint Disease Activity Score (DAS28). The effect of Sjögren syndrome (SS) was analyzed, and the sample was divided into 2 groups: RA (191 subjects) and RA/SS (45 subjects).

RESULTS

The Xerostomia Inventory showed positive and significant correlation with fatigue (r = 0.243; p < 0.0001), number of painful joints (r = 0.218; p = 0.001), HAQ (r = 0.279; p < 0.0001), and DAS28 (r = 0.156; p < 0.0001). On regression analysis, both xerostomia (OR 3.89, 95% CI 1.84-8.23, p < 0.001) and DAS28 (for severe disease activity: OR 13.26, 95% CI 3.15-55.79, p < 0.001) showed influence on functional incapacity. Forty-five individuals (19.1%) presented with secondary SS, and having this diagnosis was not associated with disease activity or functional capacity.

CONCLUSION

Xerostomia demonstrated an adverse effect on quality of life of subjects with RA, being associated with a reduction in functional capacity. In this clinical setting, xerostomia can be monitored as a marker of worse clinical evolution.

Characteristics of Patients With Early-Onset Arthritis in Latin America: Description of the REPANARC Cohort

BACKGROUND

While many studies have tried to show that early intervention improves the clinical outcomes of early-onset arthritis, only a few were carried out in Latin America.

OBJECTIVES

The aim of this study was to describe the Pan-American Registry of Early-Onset Arthritis (REPANARC) project and report the preliminary outcomes of a cohort of patients.

METHODS

The REPANARC cohort consisted of a sample of patients from 6 Latin American countries. Patients with arthritis of 1 or more joints of 1-year duration or less were assessed by a rheumatologist during 6 consecutive clinical visits for a follow-up period of 2 years. The registry included clinical characteristics, medical history, physical examination, disease activity, analytical chemistries, imaging, current treatment, and a set of patient-reported outcome measures evaluating disability, psychological distress, and quality of life.

RESULTS

A total of 173 patients were included with mean age of 41.9 ± 13.2 years; 83.8% were women. The predominant presentations at onset were insidious, polyarticular, additive, bilateral, and symmetrical. The initial diagnoses were rheumatoid arthritis (50.6%), undifferentiated arthritis (40.5%), and other arthritis (8.9%). With Disease Activity Score in 28 Joints, 76.9% had moderate to high disease activity, and 61.9% had moderate to severe disability (Health Assessment Questionnaire). Considering undifferentiated arthritis, 60.3% persisted undifferentiated, 29.4% evolved as rheumatoid arthritis, 4.4% remained self-limited, and 5.9% to other forms. The frequencies of depression and anxiety were high as measured with the Hospital Anxiety and Depression Scale, and approximately 20% had significant decrements in quality of life measured with the Medical Outcomes Study Short-Form 36 Health Survey Version 2. Mean time from the first symptoms to the first visit to a rheumatologist was 126 days. Shorter delays were confirmed to be associated with better outcomes.

CONCLUSIONS

The REPANARC project is a useful tool to provide valuable information regarding patients with early-onset arthritis attending rheumatology centers in Latin-America.

The History of Patient-Reported Outcomes in Rheumatology

The rheumatology community began incorporating patient-reported outcomes in the early 1980s, helping shift the care of chronic diseases from a narrower biomedical model to a broader biopsychosocial model of health. Early efforts were focused primarily in clinical trials and clinical research, but over the last decade there has been increasing use in routine rheumatology clinical care. More than 250 valid and reliable scales to assess domains of importance to patients with rheumatic conditions have been developed. The approach to measurement continues to be refined. Rheumatology has much to be proud of in contributions to the important field of patient-reported outcomes.

Gray-scale and color duplex Doppler ultrasound of hand joints in the evaluation of disease activity and treatment in rheumatoid arthritis

AIM

To evaluate the role of gray-scale and color duplex-Doppler ultrasound (CDUS) in diagnosis of changes of hand joints and assessment of treatment efficacy in patients with rheumatoid arthritis (RA) by comparing qualitative and quantitative US parameters with clinical and laboratory indicators of disease activity.

METHODS

Ulnocarpal (UC), metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints in 30 patients with RA were examined by gray-scale and CDUS before and after six months of treatment. Morphologic and quantitative Doppler findings (synovial thickness, effusion quantity, vascularization degree, resistance index, velocities) were compared with clinical indicators of disease progression: disease activity score (DAS 28), Health Assessment Questionnaire (HAQ), rheumatoid factor (RF), erythrocyte sedimentation rate (ESR), and C reactive protein (CRP).

RESULTS

Clinical indicators changed significantly after treatment: ESR from 38.1±22.4 mm/h to 27.8±20.9 mm/h (P=0.013), DAS 28 from 5.47±1.56 to 3.87±1.65 (P<0.001), and HAQ from 1.26±0.66 to 0.92±0.74 (P=0.030), indicating therapeutic effectiveness. In all MCP and UC joints we observed a significant change in at least one US parameter, in 6 out of 12 joints we observed a significant change in ≥2 parameters, and in 2 UC joints we observed significant changes in ≥3 parameters. The new finding was that the cut-off values of resistance index of 0.40 at baseline and of 0.55 after the treatment indicated the presence of active disease and the efficacy of treatment, respectively; also it was noticed that PIP joints can be omitted from examination protocol.

CONCLUSION

Gray scale and CDUS are useful in diagnosis of changes in UC and MCP joints of patients with RA and in monitoring the treatment efficacy.

Multi-dimensional health assessment questionnaire in China: reliability, validity and clinical value in patients with rheumatoid arthritis

OBJECTIVE

To evaluate the psychometric properties and clinical utility of Chinese Multidimensional Health Assessment Questionnaire (MDHAQ-C) in patients with rheumatoid arthritis (RA) in China.

METHODS

162 RA patients were recruited in the evaluation process. The reliability of the questionnaire was tested by internal consistency and item analysis. Convergent validity was assessed by correlations of MDHAQ-C with Health Assessment Questionnaire (HAQ), the 36-item Short-Form Health Survey (SF-36) and the Hospital anxiety and depression scales (HAD). Discriminant validity was tested in groups of patients with varied disease activities and functional classes. To evaluate the clinical values, correlations were calculated between MDHAQ-C and indices of clinical relevance and disease activity. Agreement with the Disease Activity Score (DAS28) and Clinical Disease Activity Index (CDAI) was estimated.

RESULTS

The Cronbach's alpha was 0.944 in the Function scale (FN) and 0.768 in the scale of psychological status (PS). The item analysis indicated all the items of FN and PS are correlated at an acceptable level. MDHAQ-C correlated with the questionnaires significantly in most scales and scores of scales differed significantly in groups of different disease activity and functional status. MDHAQ-C has moderate to high correlation with most clinical indices and high correlation with a spearman coefficient of 0.701 for DAS 28 and 0.843 for CDAI. The overall agreement of categories was satisfying.

CONCLUSION

MDHAQ-C is a reliable, valid instrument for functional measurement and a feasible, informative quantitative index for busy clinical settings in Chinese RA patients.

Is tightly controlled disease activity possible with online patient-reported outcomes?

OBJECTIVE

To evaluate the performance of patient-reported outcomes (PRO) as primary indices for identification and prediction of a 28-joint Disease Activity Score (DAS28)>3.2 among patients with rheumatoid arthritis (RA).

METHODS

Patients with RA completed monthly online PRO [Health Assessment Questionnaire (HAQ), Rheumatoid Arthritis Disease Activity Index (RADAI), visual analog scale (VAS) fatigue] and were clinically assessed every 3 months using the DAS28. Simple descriptive statistics, logistic regression, and the Bayesian joint modeling approach were used to analyze the data. The Bayesian joint model combines the scores and changes in the scores of 3 PRO to predict a DAS28>3.2 at the subsequent timepoint.

RESULTS

A group of 159 patients with RA participated. Stratified summaries of the PRO by DAS28 categories at baseline provided incremental values of the PRO for more active disease. However, on an individual level, the DAS28 and the PRO fluctuated over time. The prediction of subsequent DAS score by a single instrument at single timepoints resulted in moderate sensitivity and specificity. Using the intercept and slope of the combined PRO of the first 3 measurements to predict the DAS28 state at 3 months resulted in a sensitivity of 0.81 and a specificity of 0.92. After 10-fold cross validation, the model had a sensitivity of 0.61 and specificity of 0.75 to identify patients with a DAS28>3.2.

CONCLUSION

PRO showed fluctuating levels of disease activity over time, while on a group level disease activity stayed the same. Using the changes in RADAI, HAQ, and VAS fatigue over time to predict future DAS28>3.2 resulted in moderate performance after the internal cross-validation of the model (sensitivity 0.61, specificity 0.75).

Swedish version of the multi dimensional health assessment questionnaire -- translation and psychometric evaluation

BACKGROUND

Health assessment measurements for patients with Rheumatoid arthritis (RA) have to be meaningful, valid and relevant. A commonly used questionnaire for patients with RA is the Stanford Health Assessment Questionnaire Disability Index (HAQ), which has been available in Swedish since 1988. The HAQ has been revised and improved several times and the latest version is the Multi Dimensional Health Assessment Questionnaire (MDHAQ). The aim of this study was to translate the MDHAQ to Swedish conditions and to test the validity and reliability of this version for persons with RA.

METHODS

Translation and adaption of the MDHAQ were performed according to guidelines by Guillemin et al. The translated version was tested for face validity and test-retest in a group of 30 patients with RA. Content validity, criterion validity and internal consistency were tested in a larger study group of 83 patients with RA. Reliability was tested with test-retest and Cronbach´s alpha for internal consistency. Two aspects of validity were explored: content and criterion validity. Content validity was tested with a content validity index.Criterion validity was tested with concurrent validity by exploring the correlation between the MDHAQ-S and the AIMS2-SF. Floor and ceiling effects were explored.

RESULTS

Test-retest with intra-class correlation coefficient (ICC) gave a coefficient of 0.85 for physical function and 0.79 for psychological properties. Reliability test with Cronbach´s alpha gave an alpha of 0.65 for the psychological dimension and an alpha of 0.88 for the physical dimension of the MDHAQ-S.The average sum of the content validity index for each item was of the MDHAQ-S was 0.94. The MDHAQ-S had mainly a moderate correlation with the AIMS2-SF, except for the social dimension of the AIMS2-SF, which had a very low correlation with the MDHAQ-S.

CONCLUSIONS

The MDHAQ-S was considered to be reliable and valid, but further research is needed concerning sensitivity to change.

Relationship of negative affect and outcome of an opioid therapy trial among low back pain patients

OBJECTIVES

Patients with chronic noncancer pain frequently report symptoms of depression and anxiety (negative affect), which are associated with higher ratings of pain intensity and a greater likelihood of being prescribed chronic opioid therapy. The purpose of this secondary analysis was to test the hypothesis that initial levels of negative affect can predict treatment-related outcomes in a double-blind, placebo-controlled study of extended-release (ER) hydromorphone among opioid-tolerant patients with chronic low back pain.

METHODS

Four hundred fifty-nine (N = 459) patients participated in the titration/conversion phase of a multicenter study, of which 268 were randomized to receive once-daily hydromorphone or placebo. All patients completed the Hospital Anxiety and Depression Scale (HADS) at baseline and were divided evenly into Low (N = 157), Moderate (N = 155), and High (N = 147) negative affect groups based on their scores. Group differences in numerical pain intensity measures at home and in the clinic, Roland-Morris Disability ratings, and measures of symptoms from the Subjective Opiate Withdrawal Scale (SOWS) throughout the trial were analyzed.

RESULTS

Two hundred sixty-eight of the initial 459 subjects who entered the 2 to 4-week titration/conversion phase (pretreatment) were successfully randomized to either placebo or ER hydromorphone; a total of 110 patients then completed this double-blind phase of the study. Those in the Moderate and High negative affect groups tended to drop out more often during the titration/conversion phase because of the adverse effects or lack of efficacy of their prescribed opioid than those in the Low negative mood group (P < 0.05). Overall, those patients in the Moderate and High groups reported significantly higher pain intensity scores in at-home and in-clinic pain intensity ratings (P < 0.05), greater disability on the Roland-Morris Scale (P < 0.01), and more withdrawal symptoms on the SOWS (P < 0.05) than those in the Low group. Higher negative affect scores also predicted less favorable ratings of the study drug during the titration phase (P < 0.05). Interestingly, the High negative affect group showed the most improvement in pain in the placebo condition (P < 0.05).

CONCLUSIONS

Negative affect is associated with diminished benefit during a trial of opioid therapy and is predictive of dropout in a controlled clinical trial.

Interpreting clinical trial results for moderate-to-severe rheumatoid arthritis: practical applications for rheumatology healthcare providers

PURPOSE

To provide a general overview of clinical trials and more specifically define measurements common to rheumatoid arthritis clinical trials for the purpose of providing a foundation for rheumatology healthcare providers to translate clinical trial findings into their clinical practice and enhance their patient education discussions.

DATA SOURCES

English-language publications cited in the MEDLINE database were used to develop the content of this review article.

CONCLUSIONS

The role of rheumatology healthcare providers has evolved to include numerous vital functions, such as expanding communication between specialists and primary care providers, patient education and counseling, assistance with coping strategies, monitoring response to therapy, and administration of therapy. Education regarding clinical trial design, rationale, and discussion of endpoints has not been strongly emphasized for rheumatology healthcare providers who are increasingly introduced to novel agents and need to assimilate findings from clinical trials into daily practice.

IMPLICATIONS FOR PRACTICE

Familiarity with the basics of clinical trial design and efficacy endpoints of new rheumatoid arthritis therapeutics, translation and application of that knowledge into daily practice, and the ability to explain this information with patients will further enhance the ability of the rheumatology healthcare provider to optimize care for their patients with rheumatoid arthritis.

Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy: a randomized controlled clinical trial

OBJECTIVES

To assess whether any benefits from adjunctive homeopathic intervention in patients with RA are due to the homeopathic consultation, homeopathic remedies or both.

METHODS

Exploratory double-blind, randomized placebo-controlled trial conducted from January 2008 to July 2008, in patients with active stable RA receiving conventional therapy. Eighty-three participants from three secondary care UK outpatient clinics were randomized to 24 weeks of treatment with either homeopathic consultation (further randomized to individualized homeopathy, complex homeopathy or placebo) or non-homeopathic consultation (further randomized to complex homeopathy or placebo). Co-primary outcomes: ACR 20% improvement (ACR20) criteria and patient monthly global assessment (GA).

SECONDARY OUTCOMES

28-joint DAS (DAS-28), tender and swollen joint count, disease severity, pain, weekly patient and physician GA and pain, and inflammatory markers.

RESULTS

Fifty-six completed treatment phase. No significant differences were observed for either primary outcome. There was no clear effect due to remedy type. Receiving a homeopathic consultation significantly improved DAS-28 [mean difference 0.623; 95% CI 0.1860, 1.060; P = 0.005; effect size (ES) 0.70], swollen joint count (mean difference 3.04; 95% CI 1.055, 5.030; P = 0.003; ES 0.83), current pain (mean difference 9.12; 95% CI 0.521, 17.718; P = 0.038; ES 0.48), weekly pain (mean difference 6.017; 95% CI 0.140, 11.894; P = 0.045; ES 0.30), weekly patient GA (mean difference 6.260; 95% CI 0.411, 12.169; P = 0.036; ES 0.31) and negative mood (mean difference - 4.497; 95% CI -8.071, -0.923; P = 0.015; ES 0.90).

CONCLUSION

Homeopathic consultations but not homeopathic remedies are associated with clinically relevant benefits for patients with active but relatively stable RA.

TRIAL REGISTRATION

Current controlled trials, http://www.controlled-trials.com/, ISRCTN09712705.

Converting modified health assessment questionnaire (HAQ), multidimensional HAQ, and HAQII scores into original HAQ scores using models developed with a large cohort of rheumatoid arthritis patients

OBJECTIVE

The Stanford Health Assessment Questionnaire Disability Index (HAQ) is the gold standard functional status questionnaire in rheumatology, but it is lengthy. Three shorter versions, the modified HAQ (MHAQ), the Multidimensional HAQ (MDHAQ), and the HAQII are often used in outcomes research as HAQ substitutes. We developed conversion formulas between these modified versions and the original HAQ.

METHODS

Analysis was limited to the comparison of rheumatoid arthritis (RA) patients at a random observation when the HAQ was recorded in conjunction with the MHAQ (n = 29,596), the MDHAQ (n = 13,665), or the HAQII (n = 15,823). Development models were randomly limited to 80% of the data (development sample) and the remaining 20% was used for model validation.

RESULTS

Two conversion formulas were developed for each of the MHAQ, the MDHAQ, and the HAQII: a short model and a long model inclusive of questions common to both the modified measures and the original HAQ. Short models explained 81-83%, and long models 82-86%, of the variance. Predicted HAQ values of zero were assigned to all cases with an MDHAQ or HAQII score of zero, with remaining cases used for model estimation. Bland-Altman plots demonstrated good concordance between actual and predicted values for each measure. The validation sample closely approximated the results from the development sample (0.005 ≤ ΔR² ≤ 0.009) for each measure.

CONCLUSION

We have developed and validated highly accurate conversion formulas from the MHAQ, MDHAQ, and HAQII to the original HAQ in a large sample of RA patients. The developed models are useful for conversion of measures in the research setting. Because of substantial variability at the individual patient level, application of the formulas to individual patients is inadvisable.

Factors that influence rheumatologists' decisions to escalate care in rheumatoid arthritis: results from a choice-based conjoint analysis

OBJECTIVE

In order to improve adherence to treatment guidelines and performance indicators advocating tight control of disease activity in rheumatoid arthritis (RA), it is important to gain insight into the factors influencing rheumatologists' decisions whether or not to escalate care. Our objective was to determine the influence of specific attributes relative to a validated measure of disease activity (the Disease Activity Score [DAS]) on rheumatologists' decisions to escalate care.

METHODS

We used a computer-based choice-based conjoint analysis survey to determine the relative importance of 6 attributes on rheumatologists' decisions related to escalation of care in RA. We administered the survey in a convenience sample of rheumatologists attending the 2008 American College of Rheumatology Annual Scientific Meeting. Utilities were calculated using hierarchical Bayes modeling, and these results were used to calculate the relative importance of each attribute.

RESULTS

Rheumatologists assigned the most importance to the DAS score (relative importance of 30.7%) in their decision to escalate care. The age of the patient (21.5%) and erosions (20.5%) were rated as equally important in this decision. The decision to escalate care was least influenced by change in symptoms reported by the patient (11.1%), current treatment (8.9%), and disease duration (7.4%).

CONCLUSION

Our findings suggest that rheumatologists endorse the DAS as a means to guide decision making in RA. We also found that age and erosions are important influences on rheumatologists' decisions to escalate care in RA. Our results add to the literature supporting age bias in RA and suggest that further research is needed to determine how age affects quality of care in clinical practice.

Radiographic measures to assess patients with rheumatoid arthritis: advantages and limitations

Radiographs present several attractive features for the assessment and monitoring of patients with rheumatoid arthritis (RA). Radiographic erosions are the closest to a pathognomonic sign in RA. Radiographs provide a permanent record of permanent damage. Excellent quantitative scoring systems have been developed by Larsen, Sharp, van der Heijde, Genant, Rau, and others. However, quantitative radiographic scoring is used only in research studies and is not included in usual treatment. Furthermore, magnetic resonance imaging and ultrasonography may be more sensitive than radiography in detecting abnormalities. Moreover, treatment of patients with RA should be initiated before evidence of damage. Reports that biologic therapy is superior to methotrexate in preventing radiographic progression are accurate for groups of patients, although methotrexate and other disease-modifying antirheumatic drugs control inflammation in 70% to 80% of patients and most patients present no radiographic progression with methotrexate. Radiographic findings are also much less significant and functional measures are far more significant in the prediction of severe outcomes of RA, including costs and mortality. Whereas prevention of radiographic progression is certainly desirable, it appears that prevention of functional disability is far more important for successful patient outcomes.

Diagnosis and referral of rheumatoid arthritis by primary care physician: results of a pilot study on the city of Pisa, Italy

The aims of the present study were to evaluate, in the city of Pisa: (1) the prevalence of rheumatoid arthritis; (2) the reliability of the prevalence estimated by primary care physicians, using the rheumatologist's diagnosis as the "gold standard" and (3) the economic impact of the disease. The Tuscany registry of primary care physicians constituted the framework from which a sample of subjects was selected. The rheumatoid arthritis (RA) subjects >18 years followed by each primary care physician constituted the population studied. Each general practitioner (GP) was asked to fill out a questionnaire regarding their patients affected by RA and to send it to the tertiary rheumatologic centre, where the diagnosis was confirmed/discarded, the clinical and epidemiological data were collected in a standardized form and a number of data for the estimation of costs were gathered. The estimated prevalence of RA was 5.1 per thousand (CI, 4.4-5.7). The reliability of general practitioners in the diagnosis of rheumatoid arthritis was on the whole 69%. However, when an analysis of every physician was carried out, a high degree of heterogeneity in the prevalence of RA per physician was found. Overall, the mean annual cost per patient with RA was estimated at about 5,878 euro (euro; median, 6,434 euro; inter quartile range, 669-7,052 euro), with a high variability mainly dependent on the degree of patient disability. More than 90% of the overall annual cost per patient was due to the medical and non-medical direct components of costs. The prevalence of RA in Tuscany seems highly comparable with similar prevalence studies in Italy. The annual cost per patient with RA was highly variable and strictly dependent on the level of disability. More than 90% of the overall cost was due to the direct burden of costs.

Test-Retest Reliability of Patient Global Assessment and Physician Global Assessment in Rheumatoid Arthritis

Objective.

As a guide to treatment of rheumatoid arthritis (RA), physicians use measurement tools to quantify disease activity. The Patient Global Assessment (PGA) asks a patient to rate on a scale how they feel overall. The Physician Global Assessment (MDGA) is a similar item completed by the assessing physician. Both these measures are frequently incorporated into other indices. We studied reliability characteristics for global assessments and compared test-retest reliability of both the PGA and the MDGA, as well as other commonly used measures in RA.

Methods.

We studied 122 patients with RA age 17 years or older. Patients who received steroid injection or change in steroid dose at the visit were excluded. Patients completed the HAQ, PGA, visual analog scale for pain (VAS Pain), VAS Fatigue, and VAS Sleep. After seeing their physician, they received another questionnaire to complete within 2 days at the same time of day as clinic visit. Physicians completed the MDGA at the time of the patient’s appointment and at the end of their clinic day. Test-retest results were assessed using intraclass correlations (ICC). “Substantial” reliability is between 0.61–0.80 and “almost perfect” > 0.80.

Results.

Four rheumatologists and 146 patients participated, with 122 questionnaires returned (response rate 83.6%). Test-retest reliability was 0.702 for PGA, 0.961 for MDGA, and 0.897 for HAQ; VAS results were 0.742 for Pain, 0.741 for Fatigue, and 0.800 for Sleep. The correlation between PGA and MDGA was −0.172.

Conclusion.

PGA, MDGA, HAQ, and VAS Pain, VAS Fatigue, and VAS Sleep all showed good to excellent test-retest reliability in RA. MDGA was more reliable than PGA. The correlation between PGA and MDGA was poor.

Rheumatoid factor by laser nephelometry and Waaler–Rose assay: prognostic value in patients with recent‐onset rheumatoid arthritis

OBJECTIVE

To evaluate the prognostic value of rheumatoid factor (RF), detected in the Waaler-Rose agglutination assay and by nephelometry, in patients with recent-onset rheumatoid arthritis (RA).

METHODS

Consecutive patients with new-onset RA between 1993 and 1997 were followed for a median period of 4.7 years. Clinical data at baseline and drug use during the disease course were recorded. Outcome parameters studied were disease process, damage (erosions, joint surgery, extra-articular manifestations, and new co-morbidity), and death. Cut-off levels for RF were >40 IU/mL (nephelometry) and titres 1:160 (Waaler-Rose haemagglutination).

RESULTS

RF tests were negative by both methods in 22% of RA patients (RF- group), while 33% were RF positive by nephelometry only (RF+ group) and 45% were positive by Waaler-Rose and nephelometry (RF++ group). Baseline clinical and laboratory findings as well as the number of subsequently used disease-modifying anti-rheumatic drugs (DMARDs), the number of patients starting and the time spent on steroid therapy were similar in the three RF groups. Odd ratios for death (n = 23), erosions (n = 62), and serious extra-articular disease manifestations (EAMs) (n = 13) as well as patient survival, erosion-free or surgery-free survival rates did not differ between the RF groups. Only rheumatoid nodules were more frequent in RF++ patients.

CONCLUSION

The baseline presence of RF by either Waaler-Rose or nephelometry was not associated with differences in drug therapy, morbidity other than rheumatoid nodules, or mortality in RA patients in the first 5 years of disease. Being immunoglobulin M (IgM) RF positive thus had little impact on RA patient outcome.

The effects of infliximab therapy on the serum proteome of rheumatoid arthritis patients

Introduction

Although the clinical effects of infliximab therapy in rheumatoid arthritis have been documented extensively, the biological effects of this intervention continue to be defined. We sought to examine the impact of infliximab therapy on the serum proteome of rheumatoid arthritis patients by means of a mass spectrometry-based approach.

Methods

Sera from 10 patients with rheumatoid arthritis were obtained prior to and following 12 weeks of infliximab therapy using a standard clinical protocol. The sera were immunodepleted of the 12 highest abundance proteins, labeled by the iTRAQ (isobaric tagging for relative and absolute protein quantification) technique, and analyzed by mass spectrometry to identify proteomic changes associated with treatment.

Results

An average of 373 distinct proteins were identified per patient with greater than 95% confidence. In the 3 patients demonstrating the most robust clinical responses, changes of greater than 20% in the serum levels were observed in 39 proteins following treatment. The majority of these proteins were regulated directly or indirectly by tumour necrosis factor-alpha (TNF-α) and nuclear factor-kappa-B, with acute-phase proteins being uniformly down-regulated. A number of proteins, including members of the SERPIN family and S100A8, were down-regulated irrespective of clinical response.

Conclusions

The present study demonstrates that a robust clinical response to infliximab is associated with the down-regulation of a spectrum of serum proteins regulated by TNF-α, and provides a possible basis for defining the broader biological effects of the treatment in vivo.

Influence of an educational seminar on use of disease activity measurements by rheumatologists in treatment of rheumatoid arthritis

OBJECTIVE

To determine the variables underlying clinical decisions made by rheumatologists when treating patients with rheumatoid arthritis (RA), and to determine the effect of an educational seminar on the use of quantitative disease activity measurements in clinical practice in this population of physicians.

METHODS

Practicing rheumatologists were surveyed on the variables affecting their clinical management of patients with RA by questionnaire. Physicians were divided into 2 groups: the first comprised attenders (Group A) to an educational seminar in the use of the quantitative disease activity measurements in patient management, while the second group comprised nonattenders (Group NA). Both groups were surveyed on their practice behavior before (Survey 1) and 2 to 3 months after (Survey 2) the seminar.

RESULTS

Fifty-two rheumatologists in clinical practice from across the US completed and returned 364 surveys. A significantly greater number of rheumatologists in Group A reported use of disease activity measures following the training seminar (Survey 2), compared to their use pre-meeting and compared to Group NA (p < 0.0001).

CONCLUSION

Our results support employment of an educational seminar on the use of disease activity measurements to increase the use of these quantitative measures in rheumatologic practice.

Measurement of disease activity and damage in Sjögren's syndrome

Sjögren's syndrome (SS) is a systemic autoimmune disease that is characterized by an aggressive autoimmune response to epithelia, with consequent reduction of their secretions accompanied by sicca complaints. Systemic features may also be present in a subset of patients and may require more aggressive therapies. Improvements in knowledge concerning disease pathophysiology, combined with the availability of specifically targeted therapies able to modulate or block some of the most important pathologic mechanisms of the disease, may open totally new perspectives in the therapeutic approach to SS. The absence of reliable and validated outcome measures for SS is a major obstacle in performing clinical trials of new therapies in SS but studies devoted to defining outcome measurement instruments for this disorder have been performed or are in an advanced phases of completion.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

The association between C-reactive protein and the likelihood of progression to joint replacement in people with rheumatoid arthritis: a retrospective observational study

BACKGROUND

This study sought to evaluate the association between systemic inflammation as measured by C-reactive protein and total joint replacement and the association between change in CRP status (low, < or = 10 mg/L and high, >10 mg/L) measured over one year and total joint replacement in patients diagnosed with rheumatoid arthritis.

METHODS

A cohort of patients was selected from The Health Improvement Network (THIN) dataset of anonymised patient-level data from UK general practice with a confirmed chronic rheumatic diagnosis. Surgery-free survival was evaluated using Cox proportional hazards regression models (CPHM).

RESULTS

2,421 cases had at least one CRP measurement of which 125 cases (5.2%) had at least one major joint replacement. In CPHM, each additional unit increase in log mean CRP (range 1 to 6) was associated with a hazard ratio (HR) for major orthopaedic surgery of 1.36 (95% CI 1.10 to 1.67; p = 0.004), after controlling for age at first rheumatoid presentation and average body mass index over the same observation period. Repeated CRP observations around one year apart were recorded in 1,314 subjects. After controlling for confounding factors, in cases whose CRP remained high (>10 mg/L), the HR for joint replacement increased more than two-fold (p = 0.040) relative to cases whose CRP remained low. In patients whose CRP increased from low to high, the HR was 1.86 compared to those who remained in a low state (p = 0.217). By comparison, among those subjects whose CRP was reduced from a high to low state, the hazard ratio was more than halved (1.46) from to those who remained high (p = 0.441). Although underpowered, the trend evident from CRP change corroborates the association of TJR progression with mean CRP.

CONCLUSION

CRP level predicts progression to major joint replacement after standardisation for relevant risk factors as did change in CRP status between low and high states observed over one year.

Targeted assessment of the temporomandibular joint in patients with rheumatoid arthritis

PURPOSE

This observational study was done to identify the signs and symptoms of temporomandibular joint (TMJ) involvement in patients with rheumatoid arthritis (RA) and to assess the association between these and quantitative measurements for the evaluation of rheumatologic disease.

PATIENTS AND METHODS

The sample comprised 61 patients suffering from RA whose signs and symptoms of TMJ were recorded by means of a questionnaire (scale of limited mandibular function) and clinical measurements (pain during jaw movement, limitation of maximal mouth opening, joint sounds, tenderness on TMJ palpation, tenderness on masticatory muscle palpation). These findings were correlated with the quantitative measurements for evaluating RA: duration of the disease, positivity for rheumatoid factor, Health Assessment Questionnaire (HAQ) score, number of edematous and painful joints, and overall assessment of functional status.

RESULTS

In terms of overall figures, 70.5% of the patients presented with at least 1 sign or symptom, 49.2% had at least 1 symptom, and 54.1% had at least 1 sign. The variable pain on movement was associated with the number of painful joints and the overall assessment findings (P < .05). Sound on movement was positively associated with the number of edematous joints (P = .0291). The scale of limited mandibular function was statistically significantly correlated with 4 quantitative measurements (P = .0283 to .0448). The variable pain on palpation of the masticatory muscles was associated with the number of painful joints (P = .0023). Pain on palpation of the TMJ was statistically significantly associated with the HAQ score (P = .0344) and with the number of painful joints (P = .0006).

CONCLUSION

A significant percentage of the patients with RA have signs and symptoms of TMJ involvement, and the scale of limited mandibular function proved to be an important measurement tool.

Development and validation of a patient-based disease activity score in rheumatoid arthritis that can be used in clinical trials and routine practice

OBJECTIVE

Assessor-based disease activity measures such as the Disease Activity Score in 28 joints (DAS28), although widely used in rheumatoid arthritis (RA), have high interobserver variability. We developed and validated a patient-based disease activity score (PDAS) as an alternative assessment.

METHODS

Patients' assessments of swollen or tender joints, visual analog scales for pain and general health, the Health Assessment Questionnaire, and erythrocyte sedimentation rate (ESR) were used to develop the PDAS. In a developmental cohort (204 patients), regression analyses determined the best fit with the DAS28. A validation cohort (322 patients) subsequently evaluated criterion and construct validity against a range of outcome measures, including the Nottingham Health Profile (NHP) and Short Form 36 (SF-36). Sensitivity to change was assessed in 56 patients after 6 months of treatment with disease-modifying antirheumatic drugs or biologics.

RESULTS

In the developmental cohort, the PDAS with ESR (PDAS1) and without ESR (PDAS2) achieved excellent fit with the DAS28 (r = 0.88 and 0.74, respectively). In the validation cohort, the PDAS showed high criterion validity by correlation with the DAS28 (PDAS1: r = 0.89, PDAS2: r = 0.76). Construct validity was demonstrated by high correlations with a range of disease activity measures (r > or = 0.45), whereas low correlations (r < 0.45) with mental and social components of the SF-36 and NHP indicated divergent validity. The PDAS and DAS28 had similar sensitivity to change, determined using effect sizes (DAS28 = 1.03, PDAS1 = 1.02, PDAS2 = 0.77) or standardized response means (DAS28 = 0.79, PDAS1 = 0.77, PDAS2 = 0.73).

CONCLUSION

The PDAS1 and PDAS2 are valid and sensitive tools to assess disease activity in RA. They appear suitable for clinical decision making, epidemiologic research, and clinical trials.

Improving patient care: measurement of outcome in rheumatoid arthritis

Although most people who are seen in rheumatology clinics are suffering from fatigue, pain, functional disability and/or psychological distress, fewer than 15% of healthcare professionals collect any formal quantitative information concerning these problems. In contrast with acute disease in hospital settings where quantitative data concerning functional status or pain are unnecessary, as success or failure of the treatment is obvious within a short period, chronic diseases form a different challenge. Patient-reported outcomes are an attractive option in a busy medical practice, as the time burden is transferred from the clinician to the patient. Furthermore, such information is critical in the documentation of patient outcomes and results of care. This work was carried out to analyse a developed version of a multi-dimensional health assessment questionnaire. This questionnaire has been edited in a 'patient-friendly' format and its applicability is for standard use in a nurse-led clinical practice to monitor patients suffering from chronic inflammatory conditions in a busy rheumatology unit of a district general hospital.

Quantitative measures of rheumatic diseases for clinical research versus standard clinical care: differences, advantages and limitations

No single measure can serve as a 'gold standard' for the diagnosis, prognosis, and monitoring of patients with rheumatic diseases. Therefore, pooled indices of several measures have been developed for patient assessment. Quantitative measures and indices in rheumatology have been used primarily in clinical trials and other clinical research, but not in standard clinical care. Indeed, most standard rheumatology care is conducted without quantitative data other than laboratory tests, which often are uninformative. Some measures used in research have been adapted for standard care. The classical 66/68-joint count with graded scoring for swelling, tenderness, pain on motion, limited motion, and deformity has been shortened for clinical care to a 28-joint count, scored only as 'Yes' or 'No' for swelling or tenderness. Patient questionnaires designed for clinical research can be lengthy, with complex scoring, so that information is not available to help guide clinical decisions. By contrast, patient questionnaires designed for standard care, such as a simple one-page, multi-dimensional health assessment questionnaire (MDHAQ), are short, save time, are easily scored, and are useful in all rheumatic diseases to monitor patient status at each visit and document changes over long periods. More attention to measures for use in standard care could improve care and outcomes for patients with rheumatic diseases.

Monitoring outcomes of arthritis and longitudinal data collection in routine care using a patient questionnaire that incorporates a clinical note on one piece of paper

Patient questionnaires are the quantitative tools available to rheumatologists to monitor their patients' health status and responses to therapy. The Health Assessment Questionnaire (HAQ) and its derivatives have been shown to be the most significant predictors of functional and work disability, costs, joint replacement surgery, and mortality; generally at higher levels of significance than joint counts, radiographs, and laboratory tests. Every encounter of a patient with a rheumatologist provides an opportunity to collect data. Yet patient questionnaires, which can be used in all rheumatic diseases, including osteoarthritis, systemic lupus erythematosus, fibromyalgia, scleroderma, and ankylosing spondylitis, are not included in routine care by most rheumatologists. Questionnaires can be adapted to include a simple subjective-objective-assessment-plan (SOAP) clinical encounter note that helps with data entry and also provides all the necessary information for clinical decision making in one sheet of paper. Data that are feasible to collect in clinical care provide the optimal approach to assessing quantitatively how patients are doing. If data are not collected and recorded, that opportunity, on that day, is lost forever. Rheumatologists would find it valuable to adapt questionnaires to the care they provide for all their patients, to document and improve the care they provide, and add quantitative data to standard clinical care.