Risk factors for herpes zoster in rheumatoid arthritis patients: the role of tumour necrosis factor-α inhibitors

AIM

To determine whether exposure to tumour necrosis factor (TNF)-α inhibitors increases the risk of herpes zoster (HZ) among people with rheumatoid arthritis (RA).

METHODS

We performed a cohort study of people with RA participating in the Australian Rheumatology Association Database. We identified self-reported cases of HZ and verified using medical records. For the primary analysis, we only included doctor-verified cases. For TNF-α inhibitor exposed groups, we excluded HZ episodes that occurred before TNF-α inhibitor initiation, and for the control group we excluded HZ episodes that occurred prior to 2000 or RA diagnosis. The risk of HZ among participants exposed versus not exposed to TNF-α inhibitors was compared using Cox proportional hazards models including significant covariates affecting the risk. Adjusted hazard ratios (HR) were calculated for TNF inhibitors as a class and for individual agents.

RESULTS

Among 2157 active RA participants, there were 442 self-reported cases of HZ. From 346 responses from doctors, 249 cases were verified and four were false positives (false positive rate 1.6%). Crude incidence of verified HZ in the entire RA cohort was 15.9/1000 person-years (95% confidence interval (CI): 13.5-18.8). An increased risk of HZ was found for all TNF-α inhibitors combined (fully adjusted HR 1.71; 95% CI: 1.00-2.92) and adalimumab (fully adjusted HR 2.33; 95% CI: 1.22-4.45), but in the fully adjusted model was not increased with etanercept (fully adjusted HR 1.65; 95% CI: 0.90-3.03). No increased risk was found with infliximab (HR 1.29; 95% CI: 0.37-4.47).

CONCLUSIONS

TNF-α inhibitors are associated with an increased risk of HZ in people with RA compared with those who have not been exposed.

Effect of treatment with biological agents for arthritis in Australia: the Australian Rheumatology Association Database

BACKGROUND

The Australian Rheumatology Association Database (ARAD), a voluntary national registry, has been established to collect health information from Australian patients with inflammatory arthritis for the purpose of monitoring the benefits and safety of new treatments, in particular the biological disease-modifying anti-rheumatic drugs (bDMARDs). These drugs are proving to be very effective, yet little is known of their long-term effectiveness or safety. Patient registries that systematically gather data on large cohorts of unselected patients are increasingly believed to be an essential means of answering questions of the long-term effectiveness and safety of new drugs. The aim of this report is to describe the role, development and structure of ARAD and provide some preliminary data.

METHODS

As of 1 August 2006, 563 patients with rheumatoid arthritis prescribed a bDMARD have been enrolled in ARAD, involving 105 rheumatologists from across Australia.

RESULTS

The data collected will enable examination of multiple domains of patient responses to bDMARDs, including quality of life, health-care utilization, incidence of adverse events and the effects of therapy switching.

CONCLUSION

Evidence-based information about the long-term outcome of bDMARD therapy is essential for clinicians, consumers, policy-makers, drug development companies and approval agencies, to enable better care and improved outcomes for patients with inflammatory arthritis.

Assessment of the radioanatomic positioning of the osteoarthritic knee in serial radiographs: comparison of three acquisition techniques

OBJECTIVE

Recent studies using various standardized radiographic acquisition techniques have demonstrated the necessity of reproducible radioanatomic alignment of the knee to assure precise measurements of medial tibiofemoral joint space width (JSW). The objective of the present study was to characterize the longitudinal performance of several acquisition techniques with respect to long-term reproducibility of positioning of the knee, and the impact of changes in positioning on the rate and variability of joint space narrowing (JSN).

METHODS

Eighty subjects were randomly selected from each of three cohorts followed in recent studies of the radiographic progression of knee osteoarthritis (OA): the Health ABC study (paired fixed-flexion [FF] radiographs taken at a 36-month interval); the Glucosamine Arthritis Intervention Trial (GAIT) (paired metatarsophalangeal [MTP] radiographs obtained at a 12-month interval), and a randomized clinical trial of doxycycline (fluoroscopically assisted semiflexed anteroposterior (AP) radiographs taken at a 16-month interval). Manual measurements were obtained from each radiograph to represent markers of radioanatomic positioning of the knee (alignment of the medial tibial plateau and X-ray beam, knee rotation, femorotibial angle) and to evaluate minimum JSW (mJSW) in the medial tibiofemoral compartment. The effects on the mean annualized rate of JSN and on the variability of that rate of highly reproduced vs variable positioning of the knee in serial radiographs were evaluated.

RESULTS

Parallel or near-parallel alignment was achieved significantly more frequently with the fluoroscopically guided positioning used in the semiflexed AP protocol than with either the non-fluoroscopic FF or MTP protocol (68% vs 14% for both FF and MTP protocols when measured at the midpoint of the medial compartment; 75% vs 26% and 34% for the FF and MTP protocols, respectively, when measured at the site of mJSW; P<0.001 for each). Knee rotation was reproduced more frequently in semiflexed AP radiographs than in FF radiographs (66% vs 45%, P<0.01). In contrast, the FF technique yielded a greater proportion of paired radiographs in which the femorotibial angle was accurately reproduced than the semiflexed AP or MTP protocol (78% vs 59% and 56%, respectively, P<0.01 for each). Notably, only paired radiographs with parallel or near-parallel alignment exhibited a mean rate of JSN (+/-SD) in the OA knee that was more rapid and less variable than that measured in all knees (0.186+/-0.274 mm/year, standardized response to mean [SRM]=0.68 vs 0.128+/-0.291 mm/year, SRM=0.44).

CONCLUSION

This study confirms the importance of parallel radioanatomic alignment of the anterior and posterior margins of the medial tibial plateau in detecting JSN in subjects with knee OA. The use of radiographic methods that assure parallel alignment during serial X-ray examinations will permit the design of more efficient studies of biomarkers of OA progression and of structure modification in knee OA.

Power Doppler 'blanching' after the application of transducer pressure

The aim of this study was to determine if transducer pressure modifies power Doppler assessments of rheumatoid arthritis synovium at the metacarpophalangeal joints and metatarsophalangeal joints. Five rheumatoid arthritis patients of varying degrees of 'disease activity' and damage were assessed with power Doppler ultrasound scanning of the dominant hand second to fifth metacarpophalangeal joints. Two rheumatoid arthritis patients had their dominant foot first to fifth metatarsophalangeal joints assessed with power Doppler ultrasound. Ultrasonography was performed with a high frequency transducer (14 MHz) with a colour mode frequency of 10 Mhz, and a standard colour box and gain. In the joint that showed the highest power Doppler signal, an image was made. A further image was taken after transducer pressure was applied. In all patients, there was increased flow to at least one joint. After pressure was applied, power Doppler signal intensity markedly reduced in all images and in some there was no recordable power Doppler signal. Increased transducer pressure can result in a marked reduction or obliteration in power Doppler signal. This power Doppler 'blanching' shows the need for further studies to evaluate sources of error and standardization before power Doppler ultrasound becomes a routine measure of 'disease activity' in rheumatoid arthritis.

Prevention of recurrent miscarriage for women with antiphospholipid antibody or lupus anticoagulant

BACKGROUND

A range of treatments have been proposed to improve pregnancy outcome in recurrent pregnancy loss associated with antiphospholipid antibody (APL). Small studies have not resolved uncertainty about benefits and risks.

OBJECTIVES

To examine outcomes of all treatments given to maintain pregnancy in women with prior miscarriage and APL.

SEARCH STRATEGY

We searched the Pregnancy and Childbirth Group's Trials Register (30 May 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (1966 to June 2003), EMBASE (1988 to June 2003), Lupus (volume one to eight, 1991 to 1999) and conference proceedings from the International Symposium on APL up to 1999.

SELECTION CRITERIA

Randomised or quasi-randomised, controlled trials of interventions in pregnant women with a history of pregnancy loss and APL.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed quality and extracted data for studies up to December 1999. One review author performed this for studies after 1999.

MAIN RESULTS

Thirteen studies were found (849 participants). The quality was not high; 50% had clear evidence of allocation concealment. Participant characteristics varied between trials. Unfractionated heparin combined with aspirin (two trials; n = 140) significantly reduced pregnancy loss compared to aspirin alone (relative risk (RR) 0.46, 95% confidence interval (CI) 0.29 to 0.71). Low molecular weight heparin (LMWH) combined with aspirin compared to aspirin (one trial; n = 98) did not significantly reduce pregnancy loss (RR 0.78, 95% CI 0.39 to 1.57). There was no advantage in high-dose, over low-dose, unfractionated heparin (one trial; n = 50). Three trials of aspirin alone (n = 135) showed no significant reduction in pregnancy loss (RR 1.05, 95% CI 0.66 to 1.68). Prednisone and aspirin (three trials; n = 286) resulted in a significant increase in prematurity when compared to placebo, aspirin, and heparin combined with aspirin, and an increase in gestational diabetes, but no significant benefit. Intravenous immunoglobulin +/- unfractionated heparin and aspirin (two trials; n = 58) was associated with an increased risk of pregnancy loss or premature birth when compared to unfractionated heparin or LMWH combined with aspirin (RR 2.51, 95% CI 1.27 to 4.95). When compared to prednisone and aspirin, intravenous immunoglobulin (one trial; n = 82) was not significantly different in outcomes.

AUTHORS' CONCLUSIONS

Combined unfractionated heparin and aspirin may reduce pregnancy loss by 54%. Large, randomised controlled trials with adequate allocation concealment are needed to explore potential differences between unfractionated heparin and LMWH.

Pitfalls in scoring MR images of rheumatoid arthritis wrist and metacarpophalangeal joints

This paper outlines the most important pitfalls which are likely to be encountered in the assessment of magnetic resonance images of the wrist and metacarpophalangeal joints in patients with rheumatoid arthritis. Imaging artefacts and how these can be recognised using various sequences and views are discussed. Normal structures such as interosseous ligaments and nutrient foramina may appear prominent on certain images and need to be identified correctly. Pathological change in the rheumatoid hand involves many tissues and when substantial damage has occurred, it may be difficult to identify individual structures correctly. Bone erosion, bone oedema, synovitis, and tenosynovitis frequently occur together and in close proximity to each other, potentially leading to false positive scoring of any of these. Examples are given to illustrate the various dilemmas the user of this atlas may face when scoring the rheumatoid hand and suggestions are made to assist correct interpretation of what can be very complex images.

The EULAR-OMERACT rheumatoid arthritis MRI reference image atlas: the metacarpophalangeal joints

This paper presents the metacarpophalangeal (MCP) joint magnetic resonance images of the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas. The illustrations include synovitis in the MCP joints (OMERACT RA magnetic resonance imaging scoring system (RAMRIS), grades 0-3), bone oedema in the metacarpal head and the phalangeal base (grades 0-3), and bone erosion in the metacarpal head and the phalangeal base (grades 0-3, and examples of higher grades). The presented reference images can be used to guide scoring of MCP joints according to the OMERACT RA MRI scoring system.

An introduction to the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas

This article gives a short overview of the development and characteristics of the OMERACT rheumatoid arthritis MRI scoring system (RAMRIS), followed by an introduction to the use of the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas. With this atlas, MRIs of wrist and metacarpophalangeal joints of patients with rheumatoid arthritis can be scored for synovitis, bone oedema, and bone erosion, guided by standard reference images.

The development of the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas

Based on a previously developed rheumatoid arthritis MRI scoring system (OMERACT 2002 RAMRIS), the development team agreed which joints, MRI features, MRI sequences, and image planes would best illustrate the scoring system in an atlas. After collecting representative examples for all grades for each abnormality (synovitis, bone oedema, and bone erosion), the team met for a three day period to review the images and choose by consensus the most illustrative set for each feature, site, and grade. A predefined subset of images (for example, for erosion--all coronal slices through the bone) was extracted. These images were then re-read by the group at a different time point to confirm the scores originally assigned. Finally, all selected images were photographed and formatted by one centre and distributed to all readers for final approval.

The EULAR-OMERACT rheumatoid arthritis MRI reference image atlas: the wrist joint

This paper presents the wrist joint MR images of the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas. Reference images for scoring synovitis, bone oedema, and bone erosions according to the OMERACT RA MRI scoring (RAMRIS) system are provided. All grades (0-3) of synovitis are illustrated in each of the three wrist joint areas defined in the scoring system--that is, the distal radioulnar joint, the radiocarpal joint, and the intercarpal-carpometacarpal joints. For reasons of feasibility, examples of bone abnormalities are limited to five selected bones: the radius, scaphoid, lunate, capitate, and a metacarpal base. In these bones, grades 0-3 of bone oedema are illustrated, and for bone erosion, grades 0-3 and examples of higher grades are presented. The presented reference images can be used to guide scoring of wrist joints according to the OMERACT RA MRI scoring system.

Psoriasis predicts a poor short-term outcome in patients with spondylarthropathy

OBJECTIVE

The outcome of patients with recent-onset spondylarthropathy (SpA) is unclear. Therefore, the objective of this study was to prospectively correlate clinical and laboratory features with functional and radiologic outcome in patients with psoriatic SpA (PsS), undifferentiated SpA (uSpA), and Reiter's syndrome/reactive arthritis (ReA).

METHODS

Patients presenting to an early arthritis clinic with a spondylarthropathy pattern of peripheral arthritis were selected and prospectively followed. Clinical and laboratory features were recorded at baseline, 12 months, and 24 months. Radiographs of affected joints were taken at presentation and at followup.

RESULTS

The cohort consisted of 157 patients: 82 PsS, 59 uSpA, and 16 ReA. Symptom duration at presentation was progressively shorter, and the erythrocyte sedimentation rate/C-reactive protein (ESR/CRP) incrementally higher in ReA, uSpA, and PsS, respectively. There was a higher swollen joint count (SJC) in PsS compared with uSpA. In PsS, strong positive correlations were observed between ESR/CRP and articular indices. Initially, functional impairment was greater in ReA compared with uSpA and PsS but resolved completely in ReA. Clinical remission rates at 2 years were ReA 61% and uSpA 63%, compared with PsS 14%. Remission at 2 years could be predicted in SpA by disease category and presentation SJC. Baseline erosions in PsS (28%) and uSpA (5%) increased to 45% and 25%, respectively, at 2 years.

CONCLUSION

These observations suggest a spectrum within the spondylarthropathy subgroups where at presentation the acute phase markers in ReA and uSpA reflect a systemic process, whereas in PsS they reflect articular manifestations. Although the clinical presentations are indistinguishable, PsS has a more aggressive clinical course with a poorer functional and radiologic outcome.

Magnetic resonance imaging in rheumatoid arthritis: summary of OMERACT activities, current status, and plans

Complementing the 3 papers that precede it, this paper explains the rationale for the activities of an OMERACT working party on magnetic resonance imaging (MRI) evaluation of rheumatoid arthritis (RA), sets out provisional recommendations for the acquisition and scoring of MRI of the hand and wrist in RA, and delineates some of the many residual problems that need to be addressed.

Interreader agreement in the assessment of magnetic resonance images of rheumatoid arthritis wrist and finger joints--an international multicenter study

Magnetic resonance imaging (MRI) allows direct visualization of inflammation and destruction in rheumatoid arthritis (RA) joints. However, MRI scoring methods have not yet been standardized or appropriately validated. Our aim was to examine interreader agreement for a simple system of scoring RA changes on MRI among 5 centers that had not undertaken intergroup calibration. MRI of RA wrist and metacarpophalangeal (MCP) joints were scored by experienced readers in 5 centers in different countries. In substudy 1, 5 sets of 2nd-5th MCP joints from UK [Technique A: 1.5 T, coronal and axial T1 and T2 spin-echo, -/+ fat saturation (FS), -/+ iv gadolinium (Gd)] were scored for synovitis (score 0-3) and bone lesions (0-3). In substudy 2, we evaluated 19 sets of 2nd-5th MCP joints [10 sets from UK (Technique A) and 9 sets from the US (Technique B: 1.5 T; coronal T1 spin-echo and T2* gradient-echo + FS, no Gd)] and 19 wrist joints [9 from the US (Technique B) and 10 from Denmark (Technique C: 1.0 T; coronal and axial T1 spin-echo, no FS, -/+ Gd)]. Synovitis (0-3), bone lesions (0-3), and joint space narrowing (JSN, 0-3) were scored in each MCP joint and in 3 different regions of the wrist. Bone erosions and lesions in each bone were scored 0-5. Substudy 1 served to test and redesign the score sheets. In substudy 2, the scores of synovitis and bone lesions by the 5 groups were the same or differed by only one grade in 73% and 85% of joints, respectively. On MRI that included 2 imaging planes and iv Gd (Techniques A and C), these rates were 86% (synovitis) and 97% (bone lesions). Corresponding intraclass correlation coefficients (quadratic weighted kappas) were 0.44-0.68, mean 0.58 (synovitis), and 0.44-0.69, mean 0.62 (bone lesion), i.e., in the moderate to good range. Unweighted kappa values were in the low to moderate range, generally lowest for JSN (< 0.20), better for synovitis and bone erosions, and best for bone lesions, being generally highest for MRI with 2 planes pre- and post-Gd and in MCPjoints compared with wrists. These preliminary results suggest that the basic interpretation of MRI changes in RA wrist and MCP joints is relatively consistent among readers from different countries and medical backgrounds, but that further training, calibration, and standardization of imaging protocols and grading schemes will be necessary to achieve acceptable intergroup reproducibility in assessing synovitis and bone destruction in RA multicenter studies.

Recent rheumatoid arthritis clinical trials using radiographic endpoints--updated research agenda

Recent randomized controlled trials of traditional and newly developed therapies provide evidence that we have interventions that potentially slow or prevent structural damage in active rheumatoid arthritis, as measured using radiography. These trials also provide a unique opportunity for exploratory data analysis to generate hypotheses apropos the pathogenesis and determinants of radiographic progression and functional disability; they also facilitate further study of the methodological issues regarding imaging measurement.

Minimal clinically important difference in plain films in RA: group discussions, conclusions, and recommendations. OMERACT Imaging Task Force

Analysis of progression of structural damage on an individual patient level in randomized controlled trials provides extra information in addition to the analysis on a group level. A cutoff level is required to define which patients show progression and which patients do not. The objective of the mimimal clinically important difference (MCID) module for plain films was to elaborate the various concepts to determine a MCID for plain films, and if possible, to define a MCID for specific scoring methods. The module comprised preconference reading material, a plenary session, small group discussions, and a plenary report of the group sessions, combined with interactive voting. The following conclusions and recommendations were made: the smallest detectable difference (SDD) beyond measurement error is a good starting point to define MCID; SDD is study-specific; SDD should be reported for all radiographic endpoints used in a trial as a quality control; the expert panel approach is a reasonable method to define MCID, but defined in this way MCID may be smaller than current SDD; more research is needed to validate expert panel based MCID in different datasets and with different experts; a predictive, data driven MCID is the ultimate goal, but is not yet available; the SDD can be used as a proxy for MCID until a data driven MCID is available; analysis at the group level (comparison of means or medians) should remain primary in studies that include progression of joint damage as outcome measure; the proportion of patients showing more progression than the SDD is a secondary outcome measure.

Minimal clinically important difference in radiological progression of joint damage over 1 year in rheumatoid arthritis: preliminary results of a validation study with clinical experts

To determine the minimal clinically important difference (MCID) between hand and foot films with a 1 year interval assessed with the Sharp/van der Heijde or Larsen/Scott scoring method. Progression scores of the 2 methods were compared with the opinion of an international expert panel on clinical relevance of radiological joint damage in 4 predefined clinical settings. The expert panel consisted of 3 rheumatologists, who evaluated 46 pairs of hand and foot films, taken with 1 year intervals, of patients with early rheumatoid arthritis. Receiver operating characteristics curves analyzed the accuracy of different threshold values (progression scores) of the 2 scoring methods to detect the presence or absence of clinically important difference, as defined by the expert panel as external criterion. The threshold value with the highest accuracy was subsequently chosen as the score representing the MCID. Five Sharp/van der Heijde units and 2 Larsen/Scott units were the best cutoffs. The accompanying sensitivities ranged from 77% to 100% for the Sharp/van der Heijde method and from 73% to 84% for the Larsen/Scott method for the 4 clinical settings. The specificities were between 78% and 84% for the Sharp/van der Heijde method and between 74% and 94% for the Larsen/Scott method. The smallest progression score that can be detected apart from interobserver measurement error, the smallest detectable difference (SDD), was equal to or larger than the calculated MCID, 5 Sharp/van der Heijde units and 6 Larsen/Scott units in our study, if the mean progression scores of the same 2 observers were used. The SDD is a conservative estimate of the MCID; our panel rated progression at or below this level as clinically significant.

Pooled metaanalysis of radiographic progression: comparison of Sharp and Larsen methods

Metaanalysis refers to the statistical analysis of results from individual studies for the purpose of integrating the findings. However, numerous biases can threaten the internal validity of metaanalyses. This paper specifically addresses the issue of study heterogeneity in metaanalyses of radiographic progression. It considers the validity of pooling studies that have used either the Sharp score (or its variants) or the Larsen score (or its variants) by examining whether the 2 scoring methods are sufficiently concordant for pooling in terms of content of items, scaling and measurement properties. Despite differences between the Sharp and Larsen methods, they essentially measure the construct of radiographic damage, and as long as the spectrum of radiographic damage in the pooled series is similar, then the scoring methods are robust to pooling. However, where the spectrum of damage is not similar, for example, studies of radiographic progression of early disease compared with late disease, pooling should be exercised with caution.

Evaluation of a new Apo-1/Fas promoter polymorphism in rheumatoid arthritis and systemic lupus erythematosus patients

OBJECTIVE

We looked for an association between the MvaI polymorphism, a recently reported polymorphism on the promoter of the Apo-1/Fas gene, and rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) patients.

METHODS

Two cohorts of Caucasian RA patients (total number = 185) and one cohort of SLE patients (n = 103) were studied. The MvaI polymorphism was typed by polymerase chain reaction and followed by MvaI digestion and gel electrophoresis.

RESULTS

A skewed distribution of MvaI genotypes was found in the first cohort of RA patients (n = 103) compared to the controls, as a result of increased MvaI*2 and decreased MvaI*1 homozygosity. This skewed distribution of genotypes was also observed in RA patients with either early onset of disease or with systemic involvement or progressive disease (assessed by the presence of erosions). The frequency of the MvaI*2 allele was significantly increased in female patients (P = 0.035), patients with extra-articular involvement (P = 0.04) and patients with early onset (P < 0.01), compared to the normals. To confirm these findings, the MvaI polymorphism was also examined in a second cohort of RA patients (n = 82). The results in this cohort did not replicate the associations shown in the first cohort of RA patients. Part of this inconsistency could be attributed to different populations and different parameters collected and analysed. In SLE patients, frequencies of MvaI alleles were not statistically different to the controls. However, MvaI*2 homozygosity was significantly higher in SLE patients with photosensitivity (P = 0.03) or oral ulcers (P = 0.01) than in SLE patients without these features.

CONCLUSION

The role of the Apo-1/Fas gene promoter MvaI polymorphism in RA and SLE is unclear and further substantiation in larger patient samples is needed.

Intraarticular variability of synovial membrane histology, immunohistology, and cytokine mRNA expression in patients with rheumatoid arthritis

OBJECTIVE

To assess the variability of synovial histology, immunohistology, and cytokine mRNA expression at different sites within the knee joints of subjects with rheumatoid arthritis receiving slow acting antirheumatic drugs. The effects of intraarticular bupivacaine and adrenaline, and a comparison of synovial fluid cell and synovial membrane cytokine expression, were also investigated.

METHODS

Arthroscopically directed synovial biopsies were taken at 3 or 4 predetermined sites from the knee joints of 11 patients. Histology for synovial lining layer, sublining cellularity and vascularity, and immunohistology for T cells, T cell subsets, and macrophages were assessed. Messenger RNA expression of interleukins 1beta, 2, 4, 6, 8, 10, granulocyte-monocyte colony stimulating factor, tumor necrosis factor-alpha, and interferon-gamma was detected using the reverse transcription/polymerase chain reaction technique.

RESULTS

Synovial histology, immunohistology, and cytokine mRNA expression did not vary significantly. CD8 cell immunohistology was variable. Intraarticular bupivacaine and adrenaline did not change synovial characteristics. Synovial fluid cell and membrane cytokine expression did not match in 35% of comparisons.

CONCLUSION

Biopsies from the suprapatellar pouch, medial gutter, and cartilage-pannus junction will provide a representative sample of synovial membrane pathology in patients with rheumatoid arthritis.

Imaging in rheumatoid arthritis: results of group discussions

None of the current scoring methods for radiological damage in rheumatoid arthritis (RA) is ideal. The objective for RA imaging at OMERACT IV was to start discussion about the problems and applicability of the current scoring methods for radiological damage and to start discussion on the challenge of new imaging techniques. The RA imaging module comprised preconference reading material, plenary sessions, small group discussions, and a plenary report of the group sessions, combined with interactive voting. The OMERACT filter guided the discussions. Priorities for further research in imaging studies were: (1) pathologies versus features on radiographs; (2) relation with longterm outcome; and (3) definition of minimum clinically important difference.

A practical exercise in reading RA radiographs by the larsen and sharp methods

A plenary radiograph reading session was conducted prior to the rheumatoid arthritis imaging group sessions to familiarize participants with radiograph scoring methods and their problems, and to introduce the concept of measurement error. After brief reviews on how to score radiographs using the Larsen and Sharp method, photographic slides of metacarpophalangeal joints of 2 patients were shown. Participants were asked to register their absolute scores on paper, and their progression scores on an interactive voting keypad, allowing immediate visualization of the results. The objectives of the session were clearly met, as evidenced by lively discussions in the groups. Participant mean scores agreed well with the expert scores. Sharp scores showed wider scatter between participants than Larsen scores. This was only partially explained by the greater score range inherent in the method. In addition, participants needed more time to score according to Sharp than Larsen. Participants were sensitized to the challenges of radiographic measurement of damage.

Smallest detectable difference in radiological progression

Omeract IV started a discussion on the development of radiological response criteria in rheumatoid arthritis (RA). Such criteria depend on the definition of what constitutes the minimum clinically important progression of damage. Because such a definition is currently not available, as a first step we have used the concept of random measurement error to determine what is the smallest detectable difference (SDD) in radiological progression between 2 radiographs of a particular patient. Baseline and 12 month radiographs (hands, wrists, feet) of 52 patients representative of the spectrum of radiological progression were selected from a randomized controlled trial of early rheumatoid arthritis (COBRA study) and were read paired and chronologically by 2 observers using the van der Heijde modified Sharp method (0-448 scale) and another 2 observers using the Scott modified Larsen method (0-200). The measurement error of progression was determined using the metric 95% limits of agreement method of Bland and Altman. In the setting of early RA the SDD is 11 modified Sharp score units and 8 modified Larsen score units if there is an equal distribution of baseline damage and progression in the sample and the mean score of the same trained observers is always used. The SDD is 15.5 modified Sharp score units and 11 modified Larsen score units if there is an equal distribution of baseline damage and progression in the sample and the mean score of any 2 trained observers is used. Other SDD were determined depending on the context of measurement. Although this exercise needs repetition in other settings, the SDD is a useful starting point in the development of radiological response criteria.

Introduction to reading radiographs by the Scott modification of the Larsen method

To examine its ability to evaluate progressive radiological damage, the Scott modification of the Larsen score was used for the hands, wrists, and feet (metatarsophalangeal joints) at time zero and at 12 months in 52 patients with early rheumatoid arthritis taking part in a therapeutic intervention study. The major practical difficulty was the technical discrepancy between initial and followup films in some patients. The metrological problems are discussed in the analysis, which compares the score on the same films using the Sharp score.

Methodological issues in radiographic scoring methods in rheumatoid arthritis

Radiographs are important endpoints in clinical trials in rheumatoid arthritis (RA). Several scoring methods exist. However, many methodological issues are unsolved and require more attention. The following issues will be addressed: the abnormalities that should be scored; joints that should be included in a scoring method; whether both right and left hands and feet should be scored; views that should be used; the order in which radiographs should be scored; how data should be evaluated; how intra/interobserver variation and sensitivity to change should be assessed; the optimum number of readers to assess radiographs; the score to be used if there are multiple readers; quality assurance, international training, a validation set of radiographs, and automated scoring of radiographs.

Preliminary core set of domains and reporting requirements for longitudinal observational studies in rheumatology

Observational and longitudinal observational studies (LOS) provide essential information about the course and outcome of rheumatic disorders that cannot be provided by randomized controlled trials, and they constitute the major clinical scientific communication in rheumatology. There has been no consensus as to the full and appropriate content of LOS. This report defines a core set of domains and reporting requirements for LOS. At the 1998 OMERACT IV Conference a consensus process evaluated the literature of rheumatology in light of the constructs, variables, and outcomes of rheumatology by using introductory lectures, nominal groups, and plenary sessions. The result of this process was to identify 5 "core" domains that should be included in every LOS: Health Status, Disease Process, Damage, Mortality, and Toxicity/Adverse Reactions. Two additional domains, Work Disability and Costs, were recognized as important, but need not be used in all LOS. Eleven subdomains were identified that divided the domains into convenient clinical and conceptual units. A set of reporting requirements was also determined. The core recommendations, which follow on the WHO ICIDH-2 outline, are not disease-specific; the substitution of different "disease process" and "damage" measures make them suitable for many rheumatic disorders. The core set is intended to serve as a core for LOS in almost all rheumatic conditions.

Reference curves of radiographic damage in patients with rheumatoid arthritis: application of quantile regression and fractional polynomials

OBJECTIVE

To (1) introduce the methodology of quantile regression and fractional polynomials; (2) test the application of this methodology to develop, conditional on disease duration, preliminary reference curves of radiographic damage in patients with rheumatoid arthritis (RA); and (3) prove the importance of the definition and selection of the reference group when developing reference curves.

METHODS

The study design was cross sectional. The main study factors were disease duration and radiographic damage using the Larsen score. The 2 study samples were 98 patients from a multicenter trial of cyclosporine and 203 patients with RA from a teaching hospital clinic.

RESULTS

Using disease duration as the time dependent covariate we constructed quantile regression reference curves of radiographic damage. The reference curves for the 2 samples differed in shape, location, and slope.

CONCLUSION

Quantile regression and fractional polynomials simplify the construction of reference curves when data cannot be easily modified to meet assumptions of normality, linearity, and constant variance. Quantile reference curves provide clinicians with a useful clinical tool to measure outcome at arbitrary timepoints, to interpret change, and to set treatment objectives. However, the definition and selection of the reference used to construct the reference curves is of critical importance.

Psychological measures: practical issues in observational studies and clinical monitoring

Psychological measures are important because they can influence the expression of pain and physical function in patients with arthritis. A number of instruments are now available that measure psychological distress and how we as individuals manage stress. These instruments have undergone extensive validation, although more work is required to evaluate the performance of these instruments measuring change over time. One way to interpret psychological measures and to evaluate how they change over time is to use normative comparisons that are conditional on time and other relevant covariates, using statistical methods such as quantile regression. Such methods have been used to interpret the developmental, educational, and physical growth of children. We can use similar methods to interpret observational studies and to guide decisions within the context of clinical practice.

Percentile curve reference charts of physical function: rheumatoid arthritis population

OBJECTIVE

To construct percentile curve reference charts of physical function in a population of patients with rheumatoid arthritis (RA); to explore the relationship of age, gender, and disease duration on physical function using percentile curve reference charts; to explore the potential clinical applications of percentile curve reference charts.

METHODS

We surveyed 358 patients with RA from a teaching hospital clinic and 4 rheumatological private practices. The study factors were age, sex, disease duration, and physical function (Health Assessment Questionnaire). The sample percentiles were derived empirically, using the weighted average method, and their distribution-free confidence limits were calculated. Cubic spline interpolation curves were used to smooth the percentile lines.

RESULTS

We constructed percentile curve reference charts of physical function. The best time-dependent variable was increasing disease duration rather than increasing age. There was no overlap of the 95% confidence limits for the 10th, 50th, and 90th percentile curves.

CONCLUSION

Percentile curve reference charts could be used (1) to describe the distribution of health status in a defined population; (2) as an index of change, enabling clinicians to judge the success or failure of therapeutic interventions in terms of movement of their patients' values across percentiles of function; and (3) to set RA management objectives developed from population based norms.

Incomplete Reiter's syndrome with focal involvement of the posterior segment

PURPOSE

To describe an unusual variant of Yersinia-induced, HLA-B27 associated incomplete Reiter's syndrome with focal involvement of the posterior segment.

METHODS

Review of case records of a patient presenting with incomplete Reiter's syndrome which included a reactive arthritis with keratoconjunctivitis and anterior uveitis.

RESULTS

The uveitis progressed to involve the posterior segment with a vitritis and two transient white retinal spots. After resolving, a retinal pigment epithelial (RPE) defect persisted at the site of one of the lesions.

CONCLUSIONS

While involvement of the anterior segment of the globe in Reiter's disease is well recognised, a review of the literature reveals that focal posterior involvement is a rare feature in either Reiter's syndrome or the reactive arthritis group.

Systemic disease presenting as arthritis--a diagnostic approach

It is not uncommon for patients with 'arthritis' to be presenting with a rheumatological manifestation of a systemic disease. Frequently the pain is not even of articular origin. The diagnostic challenge for the practitioner is to determine the nature of the underlying pathologic process. This article sets out to provide some guidelines for diagnosis.