Risk factors of oesophagitis in arthritic patients.

BACKGROUND: The risk factors that precipitate the occurrence of oesophageal mucosal injury in patients on continuous nonsteroidal anti-inflammatory drug (NSAID) therapy are unknown. METHODS: Outpatients who regularly consumed NSAIDs for osteoarthritis were recruited from a rheumatology clinic into a prospective case-control study. All patients answered a structured interview and underwent upper gastrointestinal endoscopy. RESULTS: Of 450 eligible patients, 195 (43%) consented to be interviewed and undergo upper gastrointestinal endoscopy. Oesophagitis was diagnosed in 41 of these 195 patients (21%). The occurrence of gastric or duodenal ulcer in individual patients did not predict the concomitant damage of the oesophageal mucosa. Young age (odds ratio: 1.79 per decade of life; 95% confidence interval: 1.11-2.86) and hiatus hernia (odds ratio: 3.72; 95% confidence interval: 1.63-8.49) both increased the risk of developing oesophagitis. When questioned, all oesophagitis patients revealed at least one gastrointestinal symptom, heartburn being named most frequently (odds ratio: 4.78; 95% confidence interval: 2.04-11.17). The type of anti-inflammatory medication, the use of alcohol and the use of nicotine were not associated with any significant risk for erosive oesophagitis. CONCLUSIONS: Patients on chronic NSAID therapy for rheumatological disease suffer frequently from erosive oesophagitis. While the risk may be higher in patients with a pre-existing tendency for gastro-oesophageal reflux, any concomitant history of NSAID-induced peptic ulcer disease does not add to the risk. Erosive oesophagitis should be considered especially in patients on NSAIDs who complain of heartburn.

The foot pad in rheumatoid arthritis measurement and possible effects on foot disability.

The human foot pad is essential in buffering stress and strain during ambulation. Foot pad atrophy has been associated with foot pain, limping gait, callous formation, and foot ulcers. We report a method to measure foot pad thickness and have investigated its measurement reliability. Two podiatrists independently and bilaterally measured fore and rear foot pads on lateral view radiographs of weight bearing for 78 patients with rheumatoid arthritis. The intrarater coefficient on the fore and rear foot pads was 0.90 or higher, whereas the interrater reliability ranged from 0.73 to 0.92. These results suggest foot pad measurement is simple, practical, and reproducible for measuring foot pad atrophy. This measurement will help identify patients at risk for foot pain and/or ulceration so that appropriate orthotics and soft tissue supplements may be recommended.

Comparison of sulfasalazine and placebo in the treatment of ankylosing spondylitis. A Department of Veterans Affairs Cooperative Study.

OBJECTIVE: To determine whether sulfasalazine (SSZ) at a dosage of 2,000 mg/day is effective for the treatment of active ankylosing spondylitis (AS) that is not controlled with nonsteroidal antiinflammatory drug therapy. METHODS: Two hundred sixty-four patients with AS were recruited from 15 clinics, randomized (double-blind) to SSZ or placebo treatment, and followed up for 36 weeks. Treatment response was based on morning stiffness, back pain, and physician and patient global assessments. RESULTS: While longitudinal analysis revealed a trend favoring SSZ in the middle of treatment, no difference was seen at the end of treatment. Response rates were 38.2% for SSZ and 36.1% for placebo (P = 0.73). The Westergren erythrocyte sedimentation rate declined more with SSZ treatment than with placebo (P < 0.0001). AS patients with associated peripheral arthritis showed improvement that favored SSZ (P = 0.02). Adverse reactions were fewer than expected and were mainly due to nonspecific gastrointestinal complaints. CONCLUSION: SSZ at a dosage of 2,000 mg/day does not seem to be more effective than placebo in the treatment of AS patients with chronic, longstanding disease. SSZ is well tolerated and may be more effective than placebo in the treatment of AS patients with peripheral joint involvement. This effect is more pronounced in treatment of the peripheral arthritis in this subgroup of AS patients.

Comparison of sulfasalazine and placebo in the treatment of psoriatic arthritis. A Department of Veterans Affairs Cooperative Study.

OBJECTIVE: To determine whether sulfasalazine (SSZ) at a dosage of 2,000 mg/day is effective for the treatment of active psoriatic arthritis (PsA) resistant to nonsteroidal antiinflammatory drug therapy. METHODS: Two hundred twenty-one patients with PsA were recruited from 15 clinics, randomized (double-blind) to SSZ or placebo treatment, and followed up for 36 weeks. Treatment response was based on joint pain/ tenderness and swelling scores and physician and patient global assessments. RESULTS: Longitudinal analysis revealed a trend favoring SSZ treatment (P = 0.13). At the end of treatment, response rates were 57.8% for SSZ compared with 44.6% for placebo (P = 0.05). The Westergren erythrocyte sedimentation rate declined more in the PsA patients taking SSZ than in those taking placebo (P < 0.0001). Adverse reactions were fewer than expected and were mainly due to nonspecific gastrointestinal complaints, including dyspepsia, nausea, vomiting, and diarrhea. CONCLUSION: SSZ at a dosage of 2,000 mg/day is well tolerated and may be more effective than placebo in the treatment of patients with PsA.

Comparison of sulfasalazine and placebo in the treatment of reactive arthritis (Reiter's syndrome). A Department of Veterans Affairs Cooperative Study.

OBJECTIVE: To determine whether sulfasalazine (SSZ) at a dosage of 2,000 mg/day is effective in the treatment of reactive arthritis (ReA) that has been unresponsive to nonsteroidal antiinflammatory drug (NSAID) therapy. METHODS: One hundred thirty-four patients with ReA who had failed to respond to NSAIDs were recruited from 19 clinics, randomized (double-blind) to receive either SSZ or placebo, and followed up for 36 weeks. The definition of treatment response was based on joint pain/tenderness and swelling scores and physician and patient global assessments. RESULTS: Longitudinal analysis revealed improvement in the patients taking SSZ compared with those taking placebo, which appeared at 4 weeks and continued through the trial (P = 0.02). At the end of treatment, response rates were 62.3% for SSZ treatment compared with 47.7% for placebo treatment. The Westergren erythrocyte sedimentation rate declined more with SSZ treatment than with placebo (P < 0.0001). Adverse reactions were fewer than expected and were mainly due to nonspecific gastrointestinal complaints. CONCLUSION: SSZ at a dosage of 2,000 mg/day is well tolerated and effective in patients with chronically active ReA.

The Foot Function Index for measuring rheumatoid arthritis pain: evaluating side-to-side reliability.

The Foot Function Index is a validated and reliable instrument for measuring foot pain, disability, and activity restriction in patients with rheumatoid arthritis. For the purposes of orthopaedic studies in which one foot serves as an internal control, we assessed the side-to-side reliability of the seven-question Foot Function Index pain subscale. Thirty patients with rheumatoid arthritis completed visual analog scale pain questionnaires for both feet on two occasions 8 days apart. Internal reliability of the scale was high, with Cronbach's alphas ranging from 0.94 to 0.96, suggesting good left versus right discriminatory abilities. Principal component factor analysis segregated the questions into two large clusters containing predominantly either left or right foot items. Intraclass correlation coefficients were examined for test-retest reliability (separated by side) and for side-to-side reliability (separated by the day of test). The resultant intraclass correlation coefficients were nearly equivalent, ranging from 0.79 to 0.89. Generalizability analysis yielded similar results. Intraclass correlation coefficients and generalizability analysis demonstrate that the majority of variation is best explained by the differences within subjects or between subjects rather than by test-retest or side-to-side differences. We recommend the Foot Function Index as a reliable measurement scale for use in orthopaedic interventional trials.

Impacts of foot orthoses on pain and disability in rheumatoid arthritics.

Rheumatoid arthritis (RA) frequently causes foot pain and swelling that affect ambulation. Pharmaceutical management of pain and disability is standard in clinical practice. The use of functional posted foot orthoses, as an adjunct to pharmaceutical treatment, is a promising treatment for managing foot pain and disability in RA. Its effectiveness, however, has not been rigorously evaluated. We performed a double-blind clinical trial using foot orthoses vs. placebo orthoses in the management of the rheumatoid arthritic foot, while subjects continued customary treatment. On the basis of findings of no effect on disability and pain measures, this study indicates no benefit of functional posted foot orthoses over placebos.

Can foot orthoses prevent hallux valgus deformity in rheumatoid arthritis? A randomized clinical trial.

Hallux valgus deformity is the most commonly observed forefoot deformity in patients with rheumatoid arthritis. This 5-year, double-blind, randomized clinical trial compared treatment orthoses with placebo orthoses for the prevention of hallux valgus deformity in the rheumatoid arthritic foot.One hundred and two subjects with active rheumatoid arthritis and with foot pain and minimal radiographic changes of the feet participated in the study. They were recruited from five arthritis clinics in the Chicago metropolitan area that are affiliated with or are teaching clinics of area medical schools. Patients were followed for 3 years.Eighty-one subjects completed the study. In a logistic regression analysis, the treatment group was 73% less likely to develop hallux valgus deformity compared with the control group (adjusted odds ratio 0.27, 95% confidence interval 0.078, 0.916 p = .04). These findings suggest that foot orthoses can prevent or slow the progression of hallux valgus deformity.

Biomechanical aspects of occupation and osteoarthritis of the hip: a case-control study.

OBJECTIVE: Our study was designed to examine the association between biomechanical aspects of occupation and hip osteoarthritis (OA). METHODS: Ninety-nine cases of primary hip OA and 233 controls were recruited from the outpatient clinics of a Department of Veterans Affairs Hospital. Subjects were mailed a questionnaire which asked about lifetime participation in various occupational and recreational activities, body mass, medical conditions and demographic information. Occupational work load was defined based on the joint compression forces produced by an occupational activity. Activities which produced joint compression forces at least twice body weight were considered heavy. Activities which produced joint compression forces less than body weight were considered light. All others were considered intermediate. Based on responses to the questionnaire, subjects were classified as exposed to heavy, intermediate or light work. RESULTS: Using light work as the reference category, subjects in the intermediate work category had 2.0 times and those in the heavy work category had 2.4 times the odds of having hip OA. Logistic regression was used to control for possible confounding. After adjusting for cancer, football and obesity at age 40, subjects who performed heavy work for at least 15 years had 2.4 times the odds of having hip OA compared to subjects who had performed light work. A test for trend in the odds of hip OA with increasing levels of exposure to heavy work was significant. CONCLUSION: The biomechanical aspects of occupation may contribute to the risk of hip OA.

Healing of NSAID-induced gastric ulcers with a synthetic prostaglandin analog (enprostil).

OBJECTIVE: Conventional ulcer therapy has not been proven effective in healing gastric ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs) if the NSAIDs are continued. Our objective in this study was to determine whether a prostaglandin analog is an effective treatment for such NSAID-induced lesions. METHODS: To make this determination, we conducted a 9-wk double-blind trial comparing placebo with enprostil 35 micrograms twice daily and three times daily. Use of antacids was not allowed. Three centers entered 145 patients with chronic inflammatory arthritis and osteoarthritis, mean age 63 yr, who required continuous fixed-dose NSAID therapy within the range of therapeutic dosage. The minimum entrance criterion was the presence of either four gastric erosions or one gastric ulcer. Two pretreatment endoscopies within a 2-wk interval were performed to establish the presence of stable baseline gastric lesions. Endoscopy was repeated at wk 6 and 9 during treatment. All groups were similar with regard to age distribution, sex, weight, height, smoking usage, and alcohol consumption. RESULTS: The ulcer healing rates were 14%, 57%, and 68% at 6 wk and 19%, 68%, and 74% at 9 wk for the groups receiving placebo, enprostil twice daily, and enprostil three times daily, respectively (p < 0.01). Complete mucosal healing of all erosions and ulcers at 9 wk occurred in 59% of enprostil-treated patients and in 10% of placebo-treated patients. Additional gastric erosions and gastric ulcers developed in 16% of placebo patients and 4% of the enprostil patients. Eighteen percent of enprostil patients withdrew early from the study due to adverse experiences, such as diarrhea and abdominal pain. CONCLUSION: We concluded that during continued NSAID therapy 1) enprostil 35 micrograms (taken either twice daily or three times daily) heals NSAID-induced gastric ulcers and erosions and protects the mucosa from further NSAID-induced gastric injury; 2) gastric ulcers and erosions rarely heal spontaneously, and 3) enprostil results in a high incidence of diarrhea.

Radiographic measurement of hallux valgus in the rheumatoid arthritic foot.

OBJECTIVE: To develop a method which is objective and quantifiable, as well as reliable and valid for measuring the severity and progression of hallux valgus deformity (HVD). HVD is defined as an increase in the hallux abductus angle (HAA). METHODS: HAA drawn on plain anterioposterior radiographs of the foot was measured in 94 patients with rheumatoid arthritis. The intra and interrater reliability were analyzed. RESULTS: Findings were significant with interclass correlation coefficients ranging from 0.9 to 0.99. Detection of changes in HAA using this method were comparable to the judgment of a panel of experienced clinicians. CONCLUSION: This method is useful in detecting progression of HVD.

Development of a shoulder pain and disability index.

A shoulder pain and disability index (SPADI) was developed to measure the pain and disability associated with shoulder pathology. The SPADI is a self-administered index consisting of 13 items divided into two subscales: pain and disability. Thirty-seven male patients with shoulder pain were used in a study to examine the measurement characteristics of the SPADI. Test-retest reliability of the SPADI total and subscale scores ranged from 0.6377 to 0.6552. Internal consistency ranged from 0.8604 to 0.9507. SPADI total and subscale scores were highly negatively correlated with shoulder range of motion (ROM) supporting the criterion validity of the index. Principal components factor analysis with and without varimax rotation supported the construct validity of the total SPADI and its subscales. High negative correlations between changes in SPADI scores and changes in shoulder ROM indicated the SPADI detected changes in clinical status over short time intervals. The SPADI should prove useful for both clinical and research purposes.

The Foot Function Index: a measure of foot pain and disability.

A Foot Function Index (FFI) was developed to measure the impact of foot pathology on function in terms of pain, disability and activity restriction. The FFI is a self-administered index consisting of 23 items divided into 3 sub-scales. Both total and sub-scale scores are produced. The FFI was examined for test-retest reliability, internal consistency, and construct and criterion validity. A total of 87 patients with rheumatoid arthritis were used in the study. Test-retest reliability of the FFI total and sub-scale scores ranged from 0.87 to 0.69. Internal consistency ranged from 0.96 to 0.73. With the exception of two items, factor analysis supported the construct validity of the total index and the sub-scales. Strong correlation between the FFI total and sub-scale scores and clinical measures of foot pathology supported the criterion validity of the index. The FFI should prove useful for both clinical and research purposes.

The role of expectations and preferences in health care satisfaction of patients with arthritis.

Studies of patient satisfaction have typically been conducted in general patient populations with little attention to patients suffering from specific illnesses. The purpose of this article is to review literature and raise issues relevant to the satisfaction of patients with chronic arthritis. Individuals suffering from a chronic illness such as arthritis may be different from others who seek medical care in their expectations, what they expect from care, and preferences, what they want from care. These differences may occur because patients with chronic arthritis have greater experience with care seeking and increasing recognition of the potential for poor disease outcomes in spite of adequate care. Literature from marketing research and health care which suggests that both expectations and preferences influence satisfaction with care will be reviewed. Then specific hypotheses about expectations and preferences of patients with chronic arthritis will be proposed. Recommendations for future studies of arthritis patient expectations and preferences will be made.

Gold pneumonitis. A case report with electronmicroscopy and electron probe analysis.

A case of classical RA developed severe interstitial pulmonary disease and respiratory failure while on chrysotherapy. A high concentration of gold was found in lung tissue. Electron microscopic and electron probe examinations confirmed the presence of gold in the interstitial and intra-alveolar macrophages. The clinical course and possible pathogenic mechanism were discussed.