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Methods: In this cross-sectional study, we studied 61 RA patients who fulfilled the American College of Rheumatology criteria for the diagnosis of RA.
They had HLA-DRB1 genotyping done by phototyping. X-rays of the hands
and wrists were done and the radiological grading and erosive score was calculated according to the Larsen-Dale Method. Demographic data and treatment given to the patients were obtained from their case records.
Results: 56 females and 5 males from three different ethnic groups were
studied: Malay (n = 9), Chinese (n = 30) and Indian (n = 22). The average age
of the subjects was 51.7 9.7 years. The median duration of disease was
8 years (range 2-36). 57 (93.4%) patients had erosions; with the presence
of rheumatoid factor in 80%, HLA-DR4 in 40%, HLA-DRB10405 in 24%
and the shared epitope (SE) in 31% of them. Only 10 patients (16.4%) had
extra-articular features present. 60 patients had been on at least one type of
DMARD with a median duration of 39 months (range 0192) and the median
delay in starting DMARDs was 24 months (range 0180). We found that
the presence of rheumatoid factor, HLA-DR4 and HLA-DRB10405 were not
significantly associated with a worse erosive score or the presence of extraarticular features. Patients who possessed the SE had a worse erosive score
compared to those who did not (p = 0.05). A delay in starting DMARD was
associated with a worse erosive score (p = 0.011, R2 = 0.325). However,
after controlling for the delay in starting DMARDs, the erosive score was
no longer significantly associated with SE (partial correlation coefficient p =
0.08). In contrast, the erosive score and delay in starting DMARD correlation
remained significant after controlling for SE (partial correlation coefficient p
= 0.05).
Conclusions: In Malaysian patients with RA, the major determinant of the
erosive score was the delay in starting DMARD therapy, rather than the presence of the SE. This would confirm the urgency of early DMARD treatment
of all, including Asian, RA patients, to minimise future joint damage and maximise long-term function.
JIA (n=45)
RA (n=32)
Inflammatory (n=19)
Undifferentiated (n=3)
Non-Inflammatory (n=19)
CCP+ve
RF +ve
Erosions
3 (7%)
30 (94%)
3 (16%)
0
0
1 (2%)
26 (81%)
7 (37%)
0
0
7(16%)
27 (84%)
1(5%)
0
0
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connective tissue disease). The negative patients included 19 other inflammatory arthropathies (including psoriatic, SLE, reactive), 3 undifferentiated
polyarthritis and 19 non-inflammatory arthropathies. 7/41 (17%) of these patients were RF+.
Conclusions: Anti-CCP is not useful in the management of JIA. Anti-CCP
antibodies have high diagnostic specificity and sensitivity in RA. The higher
than expected sensitivity may be attributed to the high proportion of patients
with advanced disease in this cohort. Anti-CCP was present in both early
and established RA. The high specificity of this test makes it diagnostically
useful, particularly in those patients that are negative for RF.
Study funded by Roche Pharmaceuticals
Anti-CCP antibody and RF for the prediction of the development of RA in patients with
very early inflammatory arthritis
RF
RF antiRF latex
RF latex
RF ELISA
RF ELISA
latex ELISA CCP +ve and anti- +ve or anti- +ve and anti- +ve or anti+ve +ve +ve
CCP +ve
CCP +ve
CCP +ve
CCP +ve
Sensitivity (%)
Specificity (%)
PPV (%)
NPV (%)
63
96
83
89
63
95
79
88
63
96
83
89
58
100
100
88
67
96
84
90
58
100
100
88
67
90
70
89
Seropositivity
ESR>20
CRP>5
HCQ
Sex
Age
Odds ratio
Lower 95%limit CI
Probabaility
14.4
13.8
10.5
0.28
2.3
1.9
1.1
1.4
0.05
0.5
106.5
173.2
80.8
1.4
14.0
0.009
0.04
0.02
0.13
0.23
0.19
Background: Anti-cyclic citrullinated peptide (anti-CCP) antibodies are specific markers of established RA. Their frequent presence before clinical disease onset suggests that their detection may predict the development of RA
in very early arthritis patients. With increasing evidence that the first few
months of disease represent a unique therapeutic window in RA, we assessed the predictive value of anti-CCP antibodies for the development of
RA in the context of a very early arthritis clinic.
Methods: Anti-CCP antibodies and rheumatoid factor (RF) were measured
in the serum of 221 patients. RF was measured by latex agglutination and
ELISA (Hycor Biomedical; positivity 30 IU/ml) and anti-CCP antibody was
measured by ELISA (Axis-Shield Diagnostics; positivity 5 U/ml). 97 patients had very early inflammatory arthritis (duration 3 months). Outcome
was determined at follow-up with 24 patients being classified as having RA
by 1987 ARA criteria. 124 patients had established diagnoses and were
assessed as part of a cross sectional study (Wegeners granulomatosis
(WG) (n=10), SLE (n=10), ankylosing spondylitis (AS) (n=12), inflammatory
bowel disease (IBD) (n=10), sarcoidosis (n=10), OA (n=10), hyperlipidaemia
(n=20), seropositive RA (n=22), seronegative RA (n=20)).
Results: The sensitivities, specificities, positive and negative predictive values of RF and anti-CCP antibodies alone, or in combination, for the prediction of the development of RA in very early inflammatory arthritis patients
are shown (see table). In the cross-sectional study anti-CCP antibodies were
detected in patients with SLE (10%), sarcoidosis (10%), IBD (20%), seropositive RA (91%) and seronegative RA (30%) but not in patients with WG, AS,
OA or hyperlipidaemia. Anti-CCP antibodies together with RF (by either technique) were detected in patients with SLE (10%) and IBD (10%) but not in
patients with sarcoidosis.
scores, and most have reported positive correlation with late disease. The
aims of this study was to measure rate of xray progression in early RA, and
its association with function.
Methods: Standard clinical and laboratory measures have been recorded
prospectively in a well- described observational (inception) cohort of RA patients recruited from nine centres in England. Baseline, 1yr, 2yr, 3yr and
5yr radiographs of hands and feet were digitized onto CD-RoM and scored
randomly by one observer using Larsens method. 505 patients had a complete x-ray dataset, in whom mean age was 55yrs, 65% were women, and,
at baseline, rheumatoid factor was positive in 73%, and 25% had erosions,
similar to other early RA cohorts at presentation.
Results: By 5 yrs 420 (87%) had evidence of x-ray damage. Mean Larsen
scores showed a linear progression with an accelerated phase between the
second and third years. In contrast, clinical and laboratory measures improved initially from baseline, and appeared to stabilise with only a gradual
worsening after 2 years. Correlation coefficients measured at the same time
(0-5yrs) between Larsen scores and Swollen Joint count, Health Assessment Questionnaire (HAQ), ESR and Disease Activity Score (DAS) were all
low (rs <0.25). Graphic displays will also show that baseline rheumatoid factor titre altered significantly the x-ray progression curves (p<0.00001).
Conclusions: X-ray changes follow an essentially linear progression, but
with an accelerated phase between 2-3 years, when other standard measures of RA remain relatively stable. This finding has important implications
as to the timing of therapeutic interventions in early RA and the design of
trials of disease-modifying drugs.
Table 1
Low
Borderline
Normal
ESR mm/hr
Patient global mm
seropositive
seronegative
MW
32 (18-51)
55 (45-76)
16 (8-34)
60 (50-80)
P<0.000
P<0.015
Vitamin D
38 (3)
135 (12)
93 (8)
0 min
30 min
45 min
60 min
90 min
120 min
1
2
3
4
5
6
7
8
13.1
9.8
0.9
10.6
1.4
0.9
1.9
0.9
4.4
2.9
1.6
7.3
7.1
0.9
6.5
0.9
11
2.3
7.6
18.2
12.2
6.8
6.9
1.9
17.1
2
22.7
12.8
12.7
14.6
28.4
6.4
5.8
21
31.4
6.7
5.7
8.2
13.9
2
0.9
7.1
21.3
9.5
1.8
4.7
6.5
0.9
Conclusions: The results suggest that low systemic levels of IGF-I and
IGFBP-3 in RA reflect combined partial GH deficiency and target tissue insensitivity probably secondary to decreased GH receptor numbers.
These preliminary results need to be confirmed by direct assessment of IGF1 response to recombinant growth hormone.
Reference
[1] Lemmey A, Maddison PJ et al. J Rheumatol 2001, 28: 29-34
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Background: There are few data concerning the occurrence of falls in patients with rheumatoid arthritis (RA). The aim of this analysis was to determine the one-year period prevalence of falls by age and gender in RA and to
determine the influence of concurrent medical therapy and disability on the
occurrence of falls in this group.
Methods: A consecutive series of RA patients aged 35 years and over, attending hospital outpatient clinics at Hope hospital, Salford, were asked to
complete an interview-assisted questionnaire which asked about the occurrence of falls in the previous 12 months. Subjects who took part were asked
also about treatment with anti-hypertensives, diuretics, sedative or hypnotics,
anti-depressants, a history of previous hip/knee surgery, and completed the
health assessment questionnaire. Logistic regression was used to determine
the association between these variables and falls in the previous 12 months.
Results: 253 men and women, mean age 62 years, were studied. 84 (33%)
subjects reported falling in the previous year. Of these, 52% had fallen on
more than one occasion. Falls were more frequent in women than men (36%
vs 26%; p=0.15), though there was no important increase in risk with age.
After adjusting for age and gender, those who had fallen in the previous year
were more likely to report taking anti-depressant therapy (OR=2.1; CI=1.0,
4.2), and to have impairment in both walking (OR=1.4; CI=1.0, 1.8) and rising
(OR=1.4; CI=1.0, 1.9). HAQ score was higher in those who reported a fall
than those who did not though the difference was not statistically significant.
Conclusions: In this hospital-based survey, one in three RA patients reported falling in the previous 12 months. Falls were associated with impaired
lower limb function.
Number of patients
(percentage of vaccinated patients)
17 (28%)
5 (8%)
4 (7%)
20 (33%)
2 (3%)
3 (5%)
1 (1%)
4 (7%)
8 (13%)
Of those not vaccinated 29 (54%) were not aware that they were entitled to
have the vaccine, 11 (20%) made a choice not to have the vaccine, 7 (13%)
were worried about side effects and 6 (11%) did not perceive themselves to
be at risk. There was a significantly higher vaccination rate in patients aged
65 or over (46% of under 65s, 69% of over 65s, p 0.017, chi square)
Conclusions: This audit shows that there is low uptake of influenza vaccine
amongst DMARD treated RA patients attending our unit. The main reason
for this was lack of awareness. Uptake could be improved by increased patient knowledge of the vaccine. Most patients in this audit were informed
about the vaccine by personal contact with a primary care health professional. Rheumatology services have a role to play in communicating with
patients and primary care about the need for vaccination.
References
[1] Stone J.et al. 1997. Inadequate calcium, folic acide, vitamin E, zinc and
selenium intake in rheumatoid arthritis patients; results of a dietary survey. Seminars in Arthritis and Rheumatism. Vol. 27 180 - 185
[2] Heliovaara M. et al. 1994. Serum antioxidants and risk of rheumatoid
arthritis. Annals of Rheumatic Diseases Vol. 53 51-53
[3] Medical Research Council/Office for National Statistics. National Diet
and Nutrition Survey of adults aged 19-64. Volumes 2 and 3. 2003, Pub
London, HMSO
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Hit/Miss
24%
18%
45%
91%
99%
82%
11%
43%
21%
36%
94%
98%
92%
5%
Miss/Miss
Miss/Miss
Miss/Miss
Hit/Hit
Hit/Hit
Miss/Hit
Miss/Miss
56%
65%
Miss/Miss
47%
32%
36%
88%
68%
61%
Miss/Miss
Miss/Miss
Miss/Miss
There were 72 females and 28 males, aged between 20 and 88 years. Although a greater proportion of patients with early RA were referred within
8 weeks of symptom onset compared with the previous audit, there was no
change in the proportion of patients meeting SIGN criteria in terms of being
seen within 12 weeks of disease onset.
Conclusions: The implementation of SIGN guideline has not resulted in
major change in practice. The lag time between symptom onset and commencement of DMARD treatment is still unacceptably long, largely due to
delay in referral for specialist opinion and also due to long hospital waiting
times.
Reference
[1] Scottish Intercollegiate guideline network. Management of early rheumatoid arthritis. Royal College of Physicians of Edinburgh, December 2000.
assessor 28TJ
assessor 28SJ
physician global
patient global
pain
mhaq
ESR
PCS (SF36)
nhp_physical
nhp_pain
Euroqol
Model 1
(ESR)
Model 2
(-ESR)
0.573
0.467
0.661
0.790
0.713
0.653
0.703
-0.632
0.559
0.608
-0.647
0.599
0.456
0.649
0.900
0.816
0.770
0.297
-0.692
0.650
0.696
-0.685
MCS (SF36)
nhp_energy
nhp_sleep
nhp_social
nhp_emotion
Model 1
(ESR)
Model 2
(-ESR)
-0.316
0.426
0.385
0.263
0.375
-0.371
0.483
0.435
0.332
0.421