The development and initial validation of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index for systemic lupus erythematosus

OBJECTIVE

To develop and perform an initial validation of a damage index for systemic lupus erythematosus (SLE).

METHODS

A list of items considered to reflect damage in SLE was generated through a nominal group process. A consensus as to which items to be included in an index was reached, together with rules for ascertainment. Each center submitted 2 assessments, 5 years apart, on 2 patients with active and 2 with inactive disease, of whom 1 had increased damage and the other had stable disease. Analysis of variance was used to test the factors physician, time, amount of damage, and activity status.

RESULTS

Nineteen physicians completed the damage index on 42 case scenarios. The analysis revealed that the damage index could identify changes in damage seen in patients with both active and inactive disease. Patients who had active disease at both time points had a higher increase in damage. There was good agreement among the physicians on the assessment of damage in these patients.

CONCLUSION

This damage index for SLE records damage occurring in patients with SLE regardless of its cause. The index was demonstrated to have content, face, criterion, and discriminant validity.

The anatomical basis for disease localisation in seronegative spondyloarthropathy at entheses and related sites

The 2 major categories of idiopathic inflammatory arthritis are rheumatoid arthritis and the seronegative spondyloarthropathies. Whilst the synovium is the primary site of joint disease in the former, the primary site in the latter is less well defined. However, it has recently been proposed that enthesitis-associated changes in the spondyloarthropathies are primary and that all other joint manifestations are secondary. Nevertheless, some of the sites of disease localisation have not been adequately explained in terms of enthesitis. This article summarises current knowledge of the structure, function, blood supply, innervation, molecular composition and histopathology of the classic enthesis (i.e. the bony attachment of a tendon or ligament) and introduces the concept of 'functional' and articular 'fibrocartilaginous' entheses. The former are regions where tendons or ligaments wrap-around bony pulleys, but are not attached to them, and the latter are synovial joints that are lined by fibrocartilage rather than hyaline cartilage. We describe how these 3 types of entheses relate to other, and how all are prone to pathological changes in spondyloarthropathy. We propose that the inflammatory responses characteristic of spondyloarthropathies are triggered at these seemingly diverse sites, in genetically susceptible individuals, by a combination of anatomical factors which lead to higher levels of tissue microtrauma, and the deposition of microbes.

Fear of progression in chronic diseases: psychometric properties of the Fear of Progression Questionnaire

OBJECTIVE

The aim of this study was the development and psychometric testing of a new psychological questionnaire to measure the fear of progression (FoP) in chronically ill patients (cancer, diabetes mellitus and rheumatic diseases).

METHODS

The Fear of Progression Questionnaire (FoP-Q) was developed in four phases: (1) generation of items (65 interviews); (2) reduction of items--the initial version of the questionnaire (87 items) was presented to 411 patients, to construct subscales and test the reliability; (3) testing the convergent and discriminative validity of the reduced test version (43 items) within a new sample (n=439); (4) translation--German to English.

RESULTS

The scale comprised five factors (Cronbach's alpha >.70): affective reactions (13 items), partnership/family (7), occupation (7), loss of autonomy (7) and coping with anxiety (9). The test-retest reliability coefficients varied between .77 and .94. There was only a medium relationship to traditional anxiety scales. This is an indication of the independence of the FoP. Significant relationships between the FoP-Q and the patient's illness behaviour indicate discriminative validity.

CONCLUSIONS

The FoP-Q is a new and unique questionnaire developed for the chronically ill. A major problem and source of stress for this patient group has been measuring both specifically and economically the FoP of an illness. The FoP-Q was designed to resolve this problem, fulfill this need and reduce this stress.

Calcinosis in Rheumatic Diseases

BACKGROUND

Calcinosis, or dystrophic soft-tissue calcification, occurs in damaged or devitalized tissues in the presence of normal calcium/phosphorus metabolism. It is often noted in the subcutaneous tissues of connective tissues diseases--primarily systemic lupus erythematosus, scleroderma, or dermatomyositis--and may involve a relatively localized area or be widespread. The calcinotic accumulations may lead secondarily to muscle atrophy, joint contractures, and skin ulceration complicated by recurrent episodes of local inflammation and infection.

OBJECTIVES

To review the classification, pathogenesis, clinical features, and treatment of calcinosis in rheumatic diseases.

METHOD

A MEDLINE search of articles from 1972 to 2004 was conducted utilizing the index word "calcinosis" with the coindexing terms "scleroderma," "lupus," "dermatomyositis," and "dystrophic calcification."

RESULTS

Calcinosis may be the source of both pain and disability in connective tissue disease patients. Illustrative cases of patients with severe calcinosis are described. The literature available was critically reviewed. While warfarin, colchicine, probenecid, bisphosphonates, diltiazem, minocycline, aluminum hydroxide, salicylate, surgical extirpation, and carbon dioxide laser therapies have been used, no treatment has convincingly prevented or reduced calcinosis.

CONCLUSIONS

Calcinosis is common in the conditions reviewed and a number of agents have been used for treatment. However, the approach to calcinosis management is disorganized, beginning with the lack of a generally accepted classification and continuing with a lack of systematic study and clinical therapeutic trials.

Clinical associations of anticentromere antibodies and antibodies to topoisomerase I. A study of 355 patients

Anticentromere antibodies (ACA) and anti-topoisomerase I (anti-topo I) were assayed in serum samples from 355 patients: 89 with proximal scleroderma; 54 with CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias), without proximal scleroderma; 154 with primary and secondary Raynaud's disease; and 58 with other rheumatic diseases, without Raynaud's disease. Sera from healthy control subjects were also assayed. Using immunoblotting techniques, anti-topo I was detected in 28% of the patients with proximal scleroderma; using immunodiffusion techniques, this antibody was found in only 20% of the same group of patients. Anti-topo I and ACA were found primarily in patients with scleroderma, CREST syndrome, and Raynaud's phenomenon. ACA identified patients with less severe disease, whereas anti-topo I identified patients with skin and cardiac involvement and patients with malignancies.

Histopathology of intestinal inflammation related to reactive arthritis

This study has identified a group of patients with inflammatory chronic, or relapsing acute arthritis who even in the absence of gastrointestinal symptoms have histological evidence of ileocolitis. At colonoscopy simultaneous biopsies of the terminal ileum and colon were taken from 108 patients with reactive arthritis (n = 55) or ankylosing spondylitis (n = 53), 47 patients with other rheumatic diseases and 19 control patients suffering from colonic polyps, adenocarcinoma, or chronic constipation. All control patients and all but one patient with rheumatoid arthritis, juvenile chronic arthritis, systemic lupus erythematosus, lumbar back ache, and psoriatic arthritis did not have histological evidence of acute or chronic inflammatory bowel disease. In contrast, in 30 of 35 (56.6%) patients with ankylosing spondylitis, and in 37 of 55 (67%) patients with reactive arthritis, regardless of HLA B27 phenotype, there was histological evidence of inflammatory bowel disease with features either of acute enterocolitis, or early Crohn's disease. Only 18 of 67 (27%) of the patients with histological gut inflammation, however, had intestinal symptoms.

Surgical pathology of noninfectious ascending aortitis: a study of 45 cases with emphasis on an isolated variant

BACKGROUND

Aortitis is emerging as an important cause of ascending aortic aneurysm in the elderly. Its features have not been described in a surgical population.

DESIGN

Retrospective clinicopathologic review of 45 cases of active noninfectious aortitis among 513 consecutive ascending aortic resections (1985 to 1999).

METHODS

Clinical data were collected from medical records. Histopathologic features were recorded during review of slides stained with hematoxylin-eosin and Verhoeff-van Gieson. Cases were categorized by predefined clinical criteria. Clinicopathologic features were compared among groups, with emphasis on unsuspected aortitis without systemic arteritis.

RESULTS

The 2 largest groups were isolated aortitis (47%) and giant cell arteritis (31%). Other aortitis groups included Takayasu (14%), rheumatoid (4%), and unclassified (4%). Patients with isolated aortitis and giant cell arteritis were generally women (80%; mean age 73 y). All 6 with Takayasu arteritis were women (mean age 26). Although giant cell arteritis and isolated aortitis were histologically indistinguishable, their clinical courses differed substantially. Among 21 patients with isolated aortitis (2 treated with corticosteroids), only 10% later developed aortic aneurysms. In contrast, of 14 patients with giant cell arteritis (11 treated with corticosteroids), 21% subsequently developed aneurysms (P=0.09).

CONCLUSIONS

Aortitis primarily affected women. Patients with isolated aortitis and giant cell arteritis were generally older than 50 years and, by definition, those with Takayasu arteritis were younger. In patients with isolated aortitis, outcomes were generally good, despite the absence of anti-inflammatory therapy. Accordingly, a conservative approach may be warranted for managing this subset of patients with aortitis.

MRI of enthesitis of the appendicular skeleton in spondyloarthritis

Entheses are sites where tendons, ligaments, joint capsules or fascia attach to bone. Inflammation of the entheses (enthesitis) is a well-known hallmark of spondyloarthritis (SpA). As entheses are associated with adjacent, functionally related structures, the concepts of an enthesis organ and functional entheses have been proposed. This is important in interpreting imaging findings in entheseal-related diseases. Conventional radiographs and CT are able to depict the chronic changes associated with enthesitis but are of very limited use in early disease. In contrast, MRI is sensitive for detecting early signs of enthesitis and can evaluate both soft-tissue changes and intraosseous abnormalities of active enthesitis. It is therefore useful for the early diagnosis of enthesitis-related arthropathies and monitoring therapy. Current knowledge and typical MRI features of the most commonly involved entheses of the appendicular skeleton in patients with SpA are reviewed. The MRI appearances of inflammatory and degenerative enthesopathy are described. New options for imaging enthesitis, including whole-body MRI and high-resolution microscopy MRI, are briefly discussed.

Vasculopathy and disordered angiogenesis in selected rheumatic diseases: rheumatoid arthritis and systemic sclerosis

Angiogenesis is important in the pathogenesis of systemic inflammatory rheumatic diseases, a family of related disorders that includes rheumatoid arthritis and systemic sclerosis. Rheumatoid arthritis is the rheumatic disease in which the role of angiogenesis has been studied most extensively. However, whereas rheumatoid arthritis is characterized by excessive angiogenesis, the situation is not as clear cut in other rheumatic diseases. For example, systemic sclerosis is characterized by reduced capillary density with insufficient angiogenic responses. Results with angiogenesis inhibitors are controversial, and there is – in parallel – a wide range of upregulated angiogenic factors such as vascular endothelial growth factor. Dysregulation of angiogenesis in systemic sclerosis is accompanied by other pathogenic processes, including fibrosis, autoimmunity and vasculopathy. Animal models with at least partial features of the vasculopathy observed in systemic sclerosis include wound healing models, graft versus host disease models and, in particular, the University of California at Davis line 200 chicken model of systemic sclerosis.

Rheumatic diseases in North America's indigenous peoples

OBJECTIVES

There are at least 3 million North American Indians and Eskimos in North America. The epidemiology of rheumatic diseases in Native North Americans differs from that described for the remainder of the North American population. An enhanced understanding of rheumatic diseases in these indigenous people may provide valuable clues to the cause of these disorders and improve rheumatologic care.

METHODS

The world literature was searched for all reports of rheumatic diseases in North American Indians and Eskimos. The reports were reviewed and the findings summarized by disease process.

RESULTS

Many Native American groups have high prevalence rates of rheumatoid arthritis (RA), systemic lupus erythematosus, connective tissue diseases, and spondyloarthropathies. There appears to be a correlation between the pattern of rheumatic diseases in Native North Americans and the patterns of migration and ancestry. In general, Amerind Indians have increased rates of RA and connective tissue disease, while Na-Dene Indians and Eskimos have high rates of spondyloarthropathies. The RA seen in Native Americans is generally severe, seropositive, with an early age of onset, and frequent extraarticular manifestations. Many Native American groups have very high frequencies of the RA shared epitope. The majority of Native American and Eskimo groups also have high frequencies of HLA-B27, and some of the world's highest prevalence rates of spondyloarthropathies are described in these groups. Although some groups show a marked tendency to develop either Reiter's syndrome or ankylosing spondylitis, psoriatic and enteropathic arthritis are rare.

CONCLUSIONS

The excess rheumatic disease seen in this population is most likely genetic in origin. Because of the combination of high rates of rheumatic disease and relative genetic homogeneity, Native North Americans represent a singular opportunity to study genetic contributions to rheumatic disease. For clinicians, the index of suspicion for rheumatic diseases in North American Indians and Eskimos should be high, and the severe disease and sometimes atypical presentations kept in mind.

Clinical, radiographic and MRI findings of the temporomandibular joint in patients with different rheumatic diseases

The aim of this study was to investigate the condition of the temporomandibular joint (TMJ) in patients with different rheumatic diseases, and report correlations between the clinical, radiographic and magnetic resonance imaging (MRI) findings. The 67 patients were divided into four groups: 16 with rheumatoid arthritis (RA), 15 with mixed connective tissue disease (MCTD), 18 with ankylosing spondylitis (AS) and 18 with spondyloarthropathy (SPA). They were clinically examined, and panoramic tomography, lateral panoramic radiography and MRI of the TMJ were performed. MRI showed reduced articular cartilage in 25% (4/16) of RA, 0% (0/15) of MCTD, 17% (3/18) of AS and 17% (3/18) of SPA patients. Condylar changes included erosion, osteophytes and abnormal shape. Disc alterations included perforation, abnormal anterior position and decreased movement. These abnormalities were most frequent in RA patients, and least frequent in MCTD and SPA patients. Crepitation and reduced maximum opening of the mouth correlated with abnormalities of the disc and articular cartilage as shown by MRI. Severe condylar erosion in panoramic tomograms significantly correlated with MRI findings of condylar erosion (P<0.01), diminished thickness of condylar cartilage, abnormal condylar shape, and abnormal shape of the temporal surface of the TMJ (P< or =0.001). The presence of crepitation, limited mandibular movement and/or pain on movement of the jaw often indicated structural damage to the TMJ. Panoramic radiographs provide an alternative method to MRI but, to obtain a more detailed anatomic picture, MRI is recommended for patients with acute unexplained pain or as part of preoperative work up. A panoramic recording is not indicated when MRI is planned.

Far-lateral approach to intradural lesions of the foramen magnum without resection of the occipital condyle

OBJECT

The goal of this study was to determine whether drilling out the occipital condyle facilitates surgery via the far-lateral approach by comparing data from 10 clinical cases with that from studies of eight cadaver heads.

METHODS

During the last 6 years at Louisiana State University Health Sciences Center-Shreveport, 10 patients underwent surgery via the far-lateral approach to the foramen magnum. Six of these patients harbored anterior foramen magnum meningiomas, one patient a dermoid cyst, two patients vertebral artery (VA) aneurysms, and an additional patient suffered from rheumatoid disease of the craniocervical junction. The surgical approach consisted of retromastoid craniectomy and C-1 laminectomy. The seven tumors and the pannus of rheumatoid disease were completely excised, and the two aneurysms were clipped without drilling the occipital condyle. In one patient a chronic subdural hematoma was found 3 months after surgery, but no patient displayed any complication associated with surgery. It is significant that in no patient was a cerebrospinal fluid leak present. All patients experienced improved neurological function postoperatively. To compare surgical visibility, eight cadaveric specimens (16 sides) were studied, including delineation of the VA and its segments around the craniocervical junction. Increase in visibility as a function of fractional removal of the occipital condyle was quantified by measuring the degrees of visibility gained by removing one third and one half of the occipital condyle. Removal of one third of the occipital condyle produced a mean increase of 15.9 degrees visibility, and removal of one half produced a mean increase of 19.9 degrees.

CONCLUSIONS

On the basis of their findings the authors conclude that removal of the occipital condyle is not necessary for the safe and complete resection of anterior intradural foramen magnum tumors.

Survey of the enthesopathy of X-linked hypophosphatemia and its characterization in Hyp mice

X-linked hypophosphatemia (XLH) is characterized by rickets and osteomalacia as a result of an inactivating mutation of the PHEX (phosphate-regulating gene with homology to endopeptidases on the X chromosome) gene. PHEX encodes an endopeptidase that, when inactivated, results in elevated circulating levels of FGF-23, a novel phosphate-regulating hormone (a phosphatonin), thereby resulting in increased phosphate excretion and impaired bone mineralization. A generalized and severe mineralizing enthesopathy in patients with XLH was first reported in 1985; we likewise report a survey in which we found evidence of enthesopathy in fibrocartilaginous insertion sites, as well as osteophyte formation, in the majority of patients. Nonetheless, there has been very little focus on the progression and pathogenesis underlying the paradoxical heterotopic calcification of tendon and ligament insertion sites. Such studies have been hampered by lack of a model of mineralizing enthesopathy. We therefore characterized the involvement of the most frequently targeted fibrocartilaginous tendon insertion sites in Hyp mice, a murine model of the XLH mutation that phenocopies the human syndrome in every detail including hypophosphatemia and elevated FGF-23. Histological examination of the affected entheses revealed that mineralizing insertion sites, while thought to involve bone spur formation, were not due to bone-forming osteoblasts but instead to a significant expansion of mineralizing fibrocartilage. Our finding that enthesis fibrocartilage cells specifically express fibroblast growth factor receptor 3 (FGFR3)/Klotho suggests that the high circulating levels of FGF-23, characteristic of XLH and Hyp mice, may be part of the biochemical milieu that underlies the expansion of mineralizing enthesis fibrocartilage.

Enthesitis in patients with psoriatic arthritis, axial spondyloarthritis and healthy subjects assessed by 'head-to-toe' whole-body MRI and clinical examination

OBJECTIVES

To investigate the ability of whole-body MRI (WBMRI) to detect axial and peripheral enthesitis in patients with psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), and in healthy subjects (HS). Furthermore, to develop MRI enthesitis indices based on WBMRI and validate these by use of clinical measures of disease activity.

METHODS

Prospective cross-sectional study of patients with PsA (n=18) and axSpA (n=18) with moderate to high disease activity, and HS (n=12). Enthesitis at 35 individual sites located at upper and lower limbs, chest and pelvis were evaluated by WBMRI and clinical examination, and compared. Three new WBMRI enthesitis indices were developed.

RESULTS

WBMRI allowed evaluation of 888 (53%) of 1680 sites investigated, and 19 (54%) of 35 entheses had a readability >70%. The percentage agreement between WBMRI and clinical enthesitis was 49-100%, when compared at the level of the individual entheses. Enthesitis on WBMRI was observed in 148 (17%) of the entheseal sites, and was frequently present at greater trochanters (55%) and Achilles (43%) and supraspinate (23%) tendon insertions in patients and HS. At the first mentioned two locations enthesitis often appeared without clinical signs of enthesitis. Patients and HS differed significantly in one of the new WBMRI enthesitis scores. Patients and HS differed significantly in one of the new WBMRI enthesitis scores, and this score correlated weakly with BASDAI question 4 (tenderness in relation to entheses), BASDAI and patient global (ρ=0.29-0.31, p<0.05).

CONCLUSIONS

WBMRI is a promising new imaging modality for evaluation of enthesitis in patients with PsA and axSpA, but requires further investigation before clinical use.

Widespread serous membrane involvement by rheumatoid nodules

Images

Enthesitis

Enthesitis is a distinctive pathological feature of spondyloarthritis and may involve synovial joints, cartilaginous joints, syndesmoses and extra-articular entheses. This review focuses on peripheral extra-articular enthesitis, which is a clinical hallmark of spondyloarthritis. The entheses of the lower limbs are more frequently involved than those of the upper limbs, and heel enthesitis is the most frequent. Entheseal pain may be mild or moderate as well as severe and disabling. Peripheral enthesitis may be observed in all forms of spondyloarthritis, including the undifferentiated forms, and may, for a prolonged period, be the only longstanding clinical manifestation of the B27-associated disease process. The conceptual understanding of spondyloarthritis and the ability to image sites of skeletal inflammation accurately, i.e. ultrasound and magnetic resonance imaging, confirm that enthesitis is the primary lesion of spondyloarthritis. This advance has been occurring simultaneously with the therapeutic advances in spondyloarthritis due to the introduction of anti-tumour necrosis factor-alpha agents.

Methotrexate hepatotoxicity

Hepatoxicity is a major adverse reaction that can occur during methotrexate treatment of the rheumatic diseases. The pathologic lesions are nonspecific and the pathogenesis is poorly understood. Early studies in psoriasis clearly established a relationship between hepatic injury and several risk factors, particularly alcohol use. Methotrexate hepatoxicity occurs less frequently in rheumatoid arthritis than previously reported in psoriasis patients. Consequently, the American College of Rheumatology guidelines for methotrexate monitoring do not recommend baseline and surveillance liver biopsies in low-risk patients. These guidelines seem to be useful and cost-effective.

Evolutionary medicine and bone loss in chronic inflammatory diseases--A theory of inflammation-related osteopenia

OBJECTIVE

Bone loss is typical in chronic inflammatory diseases such as rheumatoid arthritis, psoriasis, ankylosing spondylitis, systemic lupus erythematosus, multiple sclerosis, inflammatory bowel diseases, pemphigus vulgaris, and others. It is also typical in transplantation-related inflammation and during the process of aging. While we recognized that bone loss is tightly linked to immune system activation or inflamm-aging in the form of acute, chronic active, or chronic smoldering inflammation, bone loss is typically discussed to be an "accident of inflammation."

METHODS

Extensive literature search in PubMed central.

RESULTS

Using elements of evolutionary medicine, energy regulation, and neuroendocrine regulation of homeostasis and immune function, we work out that bone waste is an adaptive, evolutionarily positively selected program that is absolutely necessary during acute inflammation. However, when acute inflammation enters a chronic state due to the inability to terminate inflammation (e.g., in autoimmunity or in continuous immunity against microbes), the acute program of bone loss is a misguided adaptive program.

CONCLUSIONS

The article highlights the complexity of interwoven pathways of osteopenia.

Nailfold capillary microscopy in healthy children and in childhood rheumatic diseases: a prospective single blind observational study

OBJECTIVES

To develop an objective method of nailfold capillaroscopy (NFC), applicable to a wide age range of paediatric patients. To compare the morphological characteristics of the nailfold capillaries in different rheumatology patient groups and controls.

METHODS

A colour digital video camera attached to a stereomicroscope was used to capture nailfold capillary images. Computerised image processing was used to analyse and store data. Subsequent quantitative and qualitative morphological analysis was performed in the following paediatric patient and control groups: 18 children with connective tissue diseases (CTD: juvenile dermatomyositis, systemic sclerosis, and undifferentiated connective tissue disease), eight with systemic lupus erythematosus, nine with primary Raynaud's disease, three with primary vasculitis, 15 with juvenile idiopathic arthritis, 17 healthy children and 20 healthy adults. Images were analysed by a single assessor who was unaware of the patient details.

RESULTS

The NFC technique was simple to perform and gave reproducible results, although some intra- and intersubject variation was noted. Capillary density and width was age related, with younger children having fewer and wider capillaries than older children and adults. Linear capillary density was significantly higher in healthy adults (mean (SD) 8.6 (1.6) capillaries/mm) compared with healthy children (HC 6.9 (0.9) capillaries/mm). The group with CTD had the most abnormal findings, with lower linear density (4.9 (1.7) capillaries/mm) and increased capillary loop width (10.7 (7.3) mm) compared with HC (3.5 (1.7) mm). In addition, 11/18 (61%) patients in the CTD group had more than two definitely abnormal capillaries in at least two nailfolds, an abnormality not seen in other subjects. Two qualitative measures, the degree of avascularity and general disarrangement of capillary pattern, were more commonly observed in the CTD group than in HC. The proportion of tortuous capillaries did not differ significantly between study groups.

CONCLUSIONS

This study is unique in measuring objective quantitative and qualitative parameters of the nailfold vasculature across a wide spectrum of age and disease. Differences in capillary morphology and frequency in children with CTD compared with other paediatric diseases and healthy controls were demonstrated. In the clinical situation, an assessment of the general degree of disarrangement may offer a fast tool for assessment of the nailfold vasculature which correlates well with NFC data.