Osteoarthritis in weight-bearing wrists?

Improving healthcare consumer effectiveness: an Animated, Self-serve, Web-based Research Tool (ANSWER) for people with early rheumatoid arthritis

BACKGROUND

People with rheumatoid arthritis (RA) should use DMARDs (disease-modifying anti-rheumatic drugs) within the first three months of symptoms in order to prevent irreversible joint damage. However, recent studies report the delay in DMARD use ranges from 6.5 months to 11.5 months in Canada. While most health service delivery interventions are designed to improve the family physician's ability to refer to a rheumatologist and prescribe treatments, relatively little has been done to improve the delivery of credible, relevant, and user-friendly information for individuals to make treatment decisions. To address this care gap, the Animated, Self-serve, Web-based Research Tool (ANSWER) will be developed and evaluated to assist people in making decisions about the use of methotrexate, a type of DMARD. The objectives of this project are: 1) to develop ANSWER for people with early RA; and 2) to assess the extent to which ANSWER reduces people's decisional conflict about the use of methotrexate, improves their knowledge about RA, and improves their skills of being 'effective healthcare consumers'.

METHODS/DESIGN

Consistent with the International Patient Decision Aid Standards, the development process of ANSWER will involve: 1.) creating a storyline and scripts based on the best evidence on the use of methotrexate and other management options in RA, and the contextual factors that affect a patient's decision to use a treatment as found in ERAHSE; 2.) using an interactive design methodology to create, test, analyze and refine the ANSWER prototype; 3.) testing the content and user interface with health professionals and patients; and 4.) conducting a pilot study with 51 patients, who are diagnosed with RA in the past 12 months, to assess the extent to which ANSWER improves the quality of their decisions, knowledge and skills in being effective consumers.

DISCUSSION

We envision that the ANSWER will help accelerate the dissemination of knowledge and skills necessary for people with early RA to make informed choices about treatment and to manage their health. The latest in animation and online technology will ensure ANSWER fills a knowledge translation gap, focusing on the next generation of people living with RA.

Long-term impact of early treatment on radiographic progression in rheumatoid arthritis: A meta-analysis

OBJECTIVE

Although early initiation of disease-modifying antirheumatic drugs (DMARDs) is effective in controlling short-term joint damage in individuals with rheumatoid arthritis (RA), the long-term benefit in disease progression is still controversial. We examined the long-term benefit of early DMARD initiation on radiographic progression in early RA.

METHODS

We identified published and unpublished clinical trials and observational studies from 1966 to September 2004 examining the association between delay to treatment initiation and progressive radiographic joint damage. We included studies of persons with RA disease duration <2 years and DMARD therapy of similar efficacy during followup. The differences in annual rates of radiographic progression between early and delayed therapy were pooled as standardized mean differences (SMDs).

RESULTS

A total of 12 studies met the inclusion criteria. The pooled estimate of effects from these studies demonstrated a significant reduction of radiographic progression in patients treated early (-0.19 SMD, 95% confidence interval [95% CI] -0.34, -0.04), which corresponded to a -33% reduction (95% CI -50, -16) in long-term progression rates compared with patients treated later. Patients with more aggressive disease seemed to benefit most from early DMARD initiation (P = 0.04).

CONCLUSION

These results support the existence of a critical period to initiate antirheumatic therapy, a therapeutic window of opportunity early in the course of RA associated with sustained benefit in radiographic progression for up to 5 years. Prompt initiation of antirheumatic therapy in persons with RA may alter the long-term course of the disease.

Bildgebende Verfahren in der Rheumatologie: Konventionelle Röntgendiagnostik bei der rheumatoiden Arthritis

Conventional radiography is still regarded the gold standard for imaging techniques in rheumatoid arthritis (RA). It is a very important tool for the diagnosis, the differential diagnosis, and the evaluation of the course and prognosis of the disease. Special advantages of conventional radiography are the worldwide availability and experience with the method over decades and the relatively low costs. Moreover, x-rays can be stored and re-evaluated over long periods of time. Joint damage caused by RA can be quantified by means of scoring methods. The amount of destruction correlates well with functional disability over time. The inhibition of damage progression seen on radiographs is the most important characteristic of a DMARD. Typical radiographic changes are part of the ACR classification criteria of RA. Technically, bone structure can be demonstrated with a high local resolution better than with all other imaging techniques, whereas only indirect conclusions can be drawn concerning soft tissue and cartilage lesions. This review includes recommendations given by the "Commission on Imaging Techniques" of the German Society of Rheumatology regarding technical and personal preconditions, costs, indication as well as practical performance of radiography in RA. In addition, radiographic changes that can be expected in RA including destruction and repair are discussed briefly.

Gaps in care for rheumatoid arthritis: A population study

OBJECTIVE

Treatment guidelines for rheumatoid arthritis (RA) now recommend early, aggressive, and persistent use of disease-modifying antirheumatic drugs (DMARDs) to prevent joint damage in all people with active inflammation, and evaluation by a rheumatologist, when possible. This research assesses whether care for RA, at a population level, is consistent with current treatment guidelines.

METHODS

Using administrative billing data from the Ministry of Health in 1996-2000, all prevalent RA cases in British Columbia, Canada were identified. Data were obtained on all medications and all provincially-funded health care services.

RESULTS

We identified 27,710 RA cases, yielding a prevalence rate of 0.76%, consistent with epidemiologic studies. DMARD use was inappropriately low. Only 43% of the entire RA cohort received a DMARD at least once over 5 years, and 35% over 2 years. When used, DMARDs were started in a timely fashion, but were not used consistently. Care by a rheumatologist increased DMARD use 31-fold. Yet, only 48% and 34% saw a rheumatologist over 5 and 2 years, respectively. DMARD use was significantly more frequent, persistent, and more often used as combination therapy with continuous rheumatologist care. DMARDs were used by 84% and 73%, 40%, and 10% of people followed by rheumatologists continuously and intermittently, internists, and family physicians, respectively (P < 0.001). NSAID use, physiotherapy, and orthopedic surgeries were similar across these 4 care groups.

CONCLUSION

RA care in the British Columbia population was not consistent with current treatment guidelines. Efforts to educate family physicians and consumers about the shift in RA treatment paradigms and to improve access to rheumatologists are needed.

Have traditional DMARDs had their day?

This review tries to answer the question of whether in the face of the recently introduced biologics conventional disease-modifying antirheumatic drugs (DMARDs) can still be recommended in the treatment of rheumatoid arthritis (RA). We start with an overview of the oldest conventional DMARD, injectable gold (Au), which was introduced in the treatment of RA in the 1920s. The effect of gold is directed at a number of different sites of the immune system. A significant improvement of clinical and biochemical disease activity parameters as well as an inhibition of X-ray progression has been shown in many studies. Head-to-head comparisons between gold and high-dose methotrexate (MTX) demonstrated no significant difference but some advantages for gold. Since trials comparing biologics with gold will never be performed, an indirect comparison was done by analyzing the results of trials with gold with those with biologics. Conclusions from such comparisons have to be drawn with caution especially since the methodology for performing trials has changed with time. We selected four trials with gold (two open, one placebo-controlled, and one comparison with MTX) and five trials with biologics (three placebo-controlled, one dose escalation study, and one comparison with MTX). In all these trials baseline data regarding swollen joint count (SJC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were roughly comparable and, with the exception of interleukin (IL)-1 RA, demonstrated a similar improvement of over 50% already after 6 months [with faster onset with tumor necrosis factor (TNF)-alpha blockade]. American College of Rheumatology (ACR) response data were not available for the older gold trials. European League Against Rheumatism (EULAR) response criteria could be calculated for the Au/MTX trial and were-for these compounds-only slightly inferior to the results with adalimumab. X-ray response is especially difficult to compare across studies. Although an inhibition with Au and MTX could be demonstrated, this occurred-similar to corticosteroid treatment-earlier and more pronounced with TNF-alpha blockers. We confirm the statement of Weinblatt that the most modern DMARDs do not appear to be much better than the oldest one indicating that conventional DMARDs are not outdated. Therefore, a sufficient trial of conventional DMARDs should precede the introduction of treatment with the very expensive biologics.

Prognostic markers of radiographic progression in early rheumatoid arthritis

OBJECTIVE

To identify prognostic markers that are predictive of progressive erosive disease in patients with early rheumatoid arthritis (RA).

METHODS

The study involved an inception cohort of 111 consecutive patients with RA and a disease duration of <1 year. Patients were treated according to an algorithm designed to avoid overtreatment of mild disease and to accelerate treatment in patients who had continuous disease activity. Patients were evaluated for the presence of clinical and laboratory disease activity markers. We determined the frequency of CD4+,CD28(null) T cells by flow cytometry, HLA-DRB1 gene polymorphisms by polymerase chain reaction (PCR)/sequencing, and 26 single-nucleotide polymorphisms in 19 candidate genes by multiplex PCR and hybridization to an immobilized probe array. Data were analyzed using proportional odds models to identify prognostic markers predictive of erosive progression over 2 years on serial hand/wrist radiographs.

RESULTS

After 2 years, disease activity in 52% of the cohort was controlled by treatment with hydroxychloroquine and nonsteroidal agents. Forty-eight percent of the patients did not develop erosions. Older age, presence of erosions at baseline, presence of rheumatoid factor, rheumatoid factor titer, and HLA-DRB1*04 alleles, particularly homozygosity for HLA-DRB1*04, were univariate predictors of radiographic progression. Promising novel markers were the frequency of CD4+,CD28(null) T cells as an immunosenescence indicator, and a polymorphism in the uteroglobin gene.

CONCLUSION

Clinical disease activity in patients with early RA can frequently be controlled with nonaggressive treatment, but this is not always sufficient to prevent new erosions. Rheumatoid factor titer, HLA-DRB1 polymorphisms, age, and immunosenescence markers are predictors of poor radiographic outcome. A polymorphism in the uteroglobin gene may identify patients who have a low risk of erosive disease.

New concepts in the treatment of rheumatoid arthritis

Recent advances have made rheumatoid arthritis (RA) amenable to treatment. Clinical studies in patients with early and established RA have broadened understanding of its pathogenesis and have fundamentally changed the therapeutic approach to this disease. Quantum leaps in therapy-including the use of early, aggressive therapy, combination therapy, and the introduction of anti-cytokine agents-have improved patients' quality of life, eased clinical symptoms, retarded the progression of joint destruction, and delayed disability. We review clinical evidence supporting these therapeutic approaches. Diagnostic and therapeutic challenges are highlighted, and a decision tree to guide treatment in patients with early or established RA is provided.

Comparison of fixed-flexion positioning with fluoroscopic semi-flexed positioning for quantifying radiographic joint-space width in the knee: test-retest reproducibility

OBJECTIVE

To compare fixed-flexion radiography of the knee with fluoroscopic semi-flexed radiography in terms of the reproducibility of measurements of minimum joint-space width (JSW) in the medial femorotibial joint.

METHODS

Posteroanterior radiographs of the right knees of 18 normal volunteers were acquired with the patients standing on an upright fluoroscopy table, the feet externally rotated 10 degrees and the toes touching the vertical table. Knees were positioned and radiographed with two different techniques: (1) semi-flexed positioning under fluoroscopic guidance using a horizontal X-ray beam; and (2) fixed-flexion positioning, with the knees and thighs touching the vertical table, using 10 degrees caudal beam angulation without fluoroscopy. Foot maps were drawn in each case. Subjects were repositioned and radiographed twice using each technique. The posteroanterior beam angle that optimally projected the medial tibia plateau with the patient in the fixed-flexion position was also determined for each subject in a separate examination using fluoroscopy. Ten patients with osteoarthritis were also examined with the fixed-flexion technique using a conventional radiographic unit. Minimum medial joint-space width (JSW) in the medial femorotibial joint was measured manually with a graduated lens and also with a semi-automated computer algorithm.

RESULTS

Reproducibility errors (root-mean-square SD) for manual and automated JSW measurement were 0.2 mm and 0.1 mm, respectively, for fluoroscopic semi-flexed positioning in volunteers; 0.3 mm and 0.1 mm, respectively, for fixed-flexion positioning in volunteers; and 0.2 mm and 0.1 mm, respectively, for fixed-flexion positioning in osteoarthritic patients. The optimal beam angle for visualizing the joint space was 9.0 degrees +/-3.6 degrees.

CONCLUSION

Fixed-flexion, non-fluoroscopic radiography of the knee can provide reproducible JSW measurement using widely available X-ray equipment. This technique is more feasible for multicenter clinical studies and routine clinical use than are methods that rely on fluoroscopic alignment of the tibial plateau.

How to diagnose rheumatoid arthritis early: a prediction model for persistent (erosive) arthritis

OBJECTIVE

To develop a clinical model for the prediction, at the first visit, of 3 forms of arthritis outcome: self-limiting, persistent nonerosive, and persistent erosive arthritis.

METHODS

A standardized diagnostic evaluation was performed on 524 consecutive, newly referred patients with early arthritis. Potentially diagnostic determinants obtained at the first visit from the patient's history, physical examination, and blood and imaging testing were entered in a logistic regression analysis. Arthritis outcome was recorded at 2 years' followup. The discriminative ability of the model was expressed as a receiver operating characteristic (ROC) area under the curve (AUC).

RESULTS

The developed prediction model consisted of 7 variables: symptom duration at first visit, morning stiffness for > or =1 hour, arthritis in > or =3 joints, bilateral compression pain in the metatarsophalangeal joints, rheumatoid factor positivity, anti-cyclic citrullinated peptide antibody positivity, and the presence of erosions (hands/feet). Application of the model to an individual patient resulted in 3 clinically relevant predictive values: one for self-limiting arthritis, one for persistent nonerosive arthritis, and one for persistent erosive arthritis. The ROC AUC of the model was 0.84 (SE 0.02) for discrimination between self-limiting and persistent arthritis, and 0.91 (SE 0.02) for discrimination between persistent nonerosive and persistent erosive arthritis, whereas the discriminative ability of the American College of Rheumatology 1987 classification criteria for rheumatoid arthritis was significantly lower, with ROC AUC values of 0.78 (SE 0.02) and 0.79 (SE 0.03), respectively.

CONCLUSION

A clinical prediction model was developed with an excellent ability to discriminate, at the first visit, between 3 forms of arthritis outcome. Validation in other early arthritis clinics is necessary.

Healing phenomena of erosive changes in rheumatoid arthritis patients undergoing disease-modifying antirheumatic drug therapy

OBJECTIVE

To describe radiographic healing phenomena and reparative changes of joint destruction in rheumatoid arthritis (RA).

METHODS

Serial radiographs of 6 patients with erosive RA undergoing long-term treatment with disease-modifying antirheumatic drugs (DMARDs) were studied. Radiographs showing healing phenomena were reproduced, and examples of single joints are shown.

RESULTS

The examples show recortication of erosions, filling in of erosions with new bone, and secondary osteoarthrosis with bone sclerosis and osteophyte formation. Commonly use radiographic scoring methods do not have the capacity to account for these reparative changes.

CONCLUSION

Healing phenomena can be observed in RA patients undergoing long-term DMARD treatment. These phenomena can be regarded as clinical end points, and their assessment should be incorporated into existing standardized methods for radiologic evaluation and scoring of RA.