Translation into Brazilian Portuguese, cultural adaptation and validatation of the systemic lupus erythematosus quality of life questionnaire (SLEQOL).

OBJECTIVES: Translate into Brazilian Portuguese, cross cultural adaptation and assess the reliability and validity of the Systemic Lupus Erythematosus Quality of Life Questionnaire (SLEQOL). STUDY POPULATION: 107 SLE patients, answered the SLEQOL questionnaire. TRANSLATION: into Portuguese and cross-cultural adaptation was performed in accordance with studies on questionnaire translation methodology into other languages. RELIABILITY: Was analyzed using three interviews with different interviewers, two on the same day (interobserver) and the third within 14 days of the first assessment (intraobserver). VALIDITY: Validity was assessed by correlating clinical and quality of life parameters with the SLEQOL. STATISTICAL ANALYSIS: A descriptive analysis of the study sample. Reproducibility was assessed using an intraclass correlation coefficient (ICC). Internal consistency was assessed using Cronbach's alpha coefficient. To assess validity we used Pearson's correlation coefficient. Five percent was the level of significance adopted for all statistical tests. RESULTS: The SLEQOL was translated and culturally adapted. The main findings were: a 0.807 internal consistency correlation coefficient for all questions and domains. The inter and intraobserver correlation coefficients were 0.990 and 0.969 respectively. Validation showed good correlation with theSF-36 and poor correlation with lupus activity or damage indices. CONCLUSIONS: The quality of life parameter has been increasingly taken into account for chronic diseases. To date there are no tools to assess Quality of Life in Systemic Lupus Erythematosus (SLE) written in the Portuguese language. The questionnaire is valid and reliable for SLE patients in Brazil.

Resource utilisation and cost of ankylosing spondylitis in Brazil.

OBJECTIVES: The present study describes resource utilisation in patients with ankylosing spondylitis (AS) treated at a tertiary public health facility over a one-year period. It also investigates the direct and indirect costs for society associated with the treatment of AS. METHODS: Ninety AS patients were selected consecutively, and data was analysed retrospectively for one year. Resource utilisation was evaluated through systematic interviews with all patients. Demographic, socioeconomic, and clinical variables were recorded, and questionnaires evaluating quality of life, function, and disease activity were also applied (ASQoL, SF-36, HAQ-S, BASFI, and BASDAI). Estimates of indirect costs were performed using the human-capital approach based on the society perspective. RESULTS: Most of the patients were men (79%), with a mean age and disease duration of 40 and 16 years, respectively. The mean HAQ-S, BASFI and BASDAI scores were 1, 5, and 4, respectively. The mean ASQoL score for the sample was 8, and the mean Short-Form-36 scores were between 48 (body pain and general health) and 81 (emotional role). The average monthly household income for the group was US$ 520. The patients had an average of 6 outpatient visits, 6 physical therapy visits and 30 laboratory exams per patient, per year. The average total cost for society was US$ 4,597 per patient per year, of which 45% were direct costs and 55% were indirect costs. CONCLUSIONS: Ankylosing spondylitis is a disease that represents a considerable burden to Brazil. It is extremely important to carry out studies that assess the costs of chronic diseases, especially in developing nations, in order to determine the best manner of allocating the already scanty resources in such regions.

Comparison of the responsiveness of the Brazilian version of the Western Ontario Rotator Cuff Index (WORC) with DASH, UCLA and SF-36 in patients with rotator cuff disorders.

OBJECTIVE: To investigate the responsiveness of the Brazilian version of the Western Ontario Rotator Cuff Index (WORC) and compare it with the Disabilities of Arm, Shoulder and Hand questionnaire (DASH), the University of California Los Angeles Shoulder Rating Scale (UCLA), and the Short-Form 36 questionnaire (SF-36) in patients with rotator cuff disorders. METHODS: The four questionnaires were administered to 30 patients at baseline and 3 months after treatment (physiotherapy or surgery). The patients were divided into two groups: those who improved after treatment (n=20) and those who did not (n=10) based on an anchor-based strategy to distinguish between the two groups and assess responsiveness. The t-test, the t-value of the paired t-test, the effect size (ES), and the standardized response mean (SRM) were calculated. RESULTS: All four questionnaires registered statistically significant changes (p<0.05) in the "improved" group between baseline and 3 months after treatment, and no changes in patients who did not improve. All four instruments showed higher ES and SRM values for the patients who improved than those who did not. WORC registered moderate to high ES and SRM values for the "improved" group, as did the UCLA and DASH. The ES and SRM values measured by the SF-36 ranged from small to large, the physical subscales being more responsive than the other subscales. CONCLUSION: The Brazilian version of the WORC (like UCLA, DASH and SF-36 physical subscales) proved responsive to change and suitable for use in the short-term follow-up of patients after rotator cuff interventions.

[Diagnosis and therapeutical management offered to rheumatoid arthritis patients in Brazil--rheumatologists' answers from an assessment questionnaire]. / Conduta no diagnóstico e tratamento dos pacientes com artrite reumatóide no Brasil--respostas dos médicos a um questionário de avaliação.

OBJECTIVES: The aim of this study was to evaluate in relation to diagnosis and treatment for Rheumatoid Arthritis (RA) patients Brazilian population, and compare the management offered to patients who are followed up in the public and private sectors. MATERIAL AND METHODS: An electronic questionnaire was sent to 650 rheumatologists, members of the Brazilian Rheumatology Society (SBR) and who were attending adult RA patients in the public and/or private sector, who had a contact e-mail address available in the SBR register and agreed to take part in the survey. RESULTS: The rheumatologists estimated that 51.7% of the patients had had their disease diagnosed and of these, 56.1% were undergoing treatment. It was also estimated that 53.9% of the RA patients that was under treatment were being followed up by rheumatologists. The mean time interval estimated by the rheumatologists, between the appearance of the first symptoms of RA and the diagnosis made by a doctor, was greater among the patients who sought attendance in public services (1.8 years). There was no difference in clinical and radiographic assessment measures between the two types of service, with the exception of the application of HAQ, which was used more in public services. The principal drug association reported in both types of services was methotrexate and chloroquine. The rate of usage of associations between biological agents and methotrexate ranged from 6 to 8%. The main treatment-related difficulties were: access to the health system (public services) and cost of medication (private services). CONCLUSION: Approximately 50% of RA patients are being diagnosed and half of these are under treatment. There was no great difference in attendance within the public and private systems for these patients, whereas the main difficulty for the public system was access to attendance, for the private system it was the cost of the medication.

Prevalence of musculoskeletal manifestations in the adult Brazilian population: a study using copcord questionnaires.

OBJECTIVE: To estimate the prevalence of musculoskeletal manifestations in the population of Vitoria, Brazil, using the COPCORD questionnaire. METHODS: This was a cross-sectional study of 578 people with an age range of 18-65. The sample was probabilistic and stratified according to sex, age and socio-economic class, proportional to the 2000 demographic census data of the Brazilian Institute of Geography and Statistics-IBGE. The COPCORD core questionnaire was used for all subjects, and a rheumatologist evaluated those patients who presented pain and/or functional disability. Laboratory tests and radiographs were carried out in some patients to confirm the diagnosis. RESULTS: One hundred and seventy-six patients (30.4%) with a mean age of 41 (SD 13) and predominantly female had pain. Among the patients with pain, 23.2% were unable to do daily living activities. One hundred and thirty (73.9%) were evaluated by a rheumatologist. CONCLUSION: The prevalence of musculoskeletal manifestations evaluated by the COPCORD questionnaire was 30.4%.

Clinical risk factors for osteoporotic fractures in Brazilian women and men: the Brazilian Osteoporosis Study (BRAZOS).

UNLABELLED: The Brazilian Osteoporosis Study (BRAZOS) is the first epidemiological study carried out in a representative sample of Brazilian men and women aged 40 years or older. The prevalence of fragility fractures is about 15.1% in the women and 12.8% in the men. Moreover, advanced age, sedentarism, family history of hip fracture, current smoking, recurrent falls, diabetes mellitus and poor quality of life are the main clinical risk factors associated with fragility fractures. INTRODUCTION: The Brazilian Osteoporosis Study (BRAZOS) is the first epidemiological study carried out in a representative sample of Brazilian men and women aged 40 years or older with the purpose of identifying the prevalence and the main clinical risk factors (CRF) associated with osteoporotic fracture in our population. METHODS: A total of 2,420 individuals (women, 70%) from 150 different cities in the five geographic regions in Brazil, and all different socio-economical classes were selected to participate in the present survey. Anthropometrical data as well as life habits, fracture history, food intake, physical activity, falls and quality of life were determined by individual quantitative interviews. The representative sampling was based on Brazilian National data provided by the 2000 and 2003 census. Low trauma fracture was defined as that resulting of a fall from standing height or less in individuals 50 years or older at specific skeletal sites: forearm, femur, ribs, vertebra and humerus. Sampling error was 2.2% with 95% confidence intervals. Logistic regression analysis models were designed having the fragility fracture as the dependent variable and all other parameters as the independent variable. Significance level was set as p < 0.05. RESULTS: The average of age, height and weight for men and women were 58.4 +/- 12.8 and 60.1 +/- 13.7 years, 1.67 +/- 0.08 and 1.56 +/- 0.07 m and 73.3 +/- 14.7 and 64.7 +/- 13.7 kg, respectively. About 15.1% of the women and 12.8% of the men reported fragility fractures. In the women, the main CRF associated with fractures were advanced age (OR = 1.6; 95% CI 1.06-2.4), family history of hip fracture (OR = 1.7; 95% CI 1.1-2.8), early menopause (OR = 1.7; 95% CI 1.02-2.9), sedentary lifestyle (OR = 1.6; 95% CI 1.02-2.7), poor quality of life (OR = 1.9; 95% CI 1.2-2.9), higher intake of phosphorus (OR = 1.9; 95% CI 1.2-2.9), diabetes mellitus (OR = 2.8; 95% CI 1.01-8.2), use of benzodiazepine drugs (OR = 2.0; 95% CI 1.1-3.6) and recurrent falls (OR = 2.4; 95% CI 1.2-5.0). In the men, the main CRF were poor quality of life (OR = 3.2; 95% CI 1.7-6.1), current smoking (OR = 3.5; 95% CI 1.28-9.77), diabetes mellitus (OR = 4.2; 95% CI 1.27-13.7) and sedentary lifestyle (OR = 6.3; 95% CI 1.1-36.1). CONCLUSION: Our findings suggest that CRF may contribute as an important tool to identify men and women with higher risk of osteoporotic fractures and that interventions aiming at specific risk factors (quit smoking, regular physical activity, prevention of falls) may help to manage patients to reduce their risk of fracture.

Resource utilization and the cost of rheumatoid arthritis in Brazil.

OBJECTIVE: To describe and analyze resource utilization in patients with rheumatoid arthritis (RA) treated at a tertiary public health facility over a one-year period. Costs for the patient and for society associated with the treatment of RA were also investigated. METHODS: One hundred consecutively selected RA patients were included. Resource utilization was evaluated retrospectively for one year. Systematic interviews were used in all patients and demographic, socioeconomic and clinical variables were recorded. RESULTS: One hundred patients were included. Most of the patients were women (92%) and had mean age and disease duration of 51 and 11 years, respectively. The majority of the patients were Steinbroker functional class I (48%). Mean HAQ score for the sample was 0.95 and mean Short-Form-36 scores were between 49.64 (bodily pain) and 70.00 (social functioning). The average monthly household income for the group was US$ 359. The patients had on average 4 outpatient visits and 21 laboratory exams per year. Drugs accounted for 59% of the total cost associated with RA. The average total cost for society was US$ 424.14 per patient per year, of which 95% were direct and 5% indirect costs. CONCLUSION: The management of RA patients is an important financial burden in Brazil. The effort to couple resource utilization with the best available evidence, associated with the limited funds available in the healthcare system (particularly in a developing country), emphasizes the importance of studies that critically evaluate resource utilization and cost in these chronic patients. The systematic use of such studies may prove helpful to optimize the health system.

Tradução e adaptação cultural do WORC: um questionário de qualidade de vida para alterações do manguito rotador / Translation and cultural adaptation of WORC: a quality-of-life questionnaire for rotator cuff disorders

OBJETIVO: Realizar a tradução e a adaptação cultural do questionário WORC (The Western Ontario Rotator Cuff Index) para a língua portuguesa para ulterior validação no Brasil. MÉTODOS: O protocolo aplicado consistiu em: 1) Preparação, 2) Tradução, 3) Tradução de volta à língua original (retro-tradução), 4) Interrogatório Cognitivo e 5) Relato de Informações. Ao serem concluídas as etapas de tradução e retro-tradução, as versões foram enviadas para os autores do WORC original, que as aprovaram para continuação do estudo. A versão em Português foi aplicada a 35 pacientes com disfunções do manguito rotador para verificar o nível de compreensão do instrumento. A idade média foi 57 anos (DP=13), 63 por cento eram do sexo feminino e 74 por cento tinham nível de escolaridade de primeiro grau incompleto. A versão brasileira final do WORC foi definida após se conseguir menos que 15 por cento de "não compreensão" em cada item. Para análise das variáveis, foi utilizada estatística descritiva. RESULTADOS: Realizaram-se mudanças e substituições de termos e expressões para obter equivalência cultural do WORC. Alteraram-se também os termos "não compreendidos" pelos pacientes de acordo com as sugestões feitas por eles. CONCLUSÃO: Após a tradução e adaptação cultural do questionário, foi concluída a versão em Português do WORC que está em processo de validação para ser utilizada no Brasil.

OBJECTIVE: To accomplish the translation of WORC (The Western Ontario Rotator Cuff Index) into Portuguese and its cultural adaptation, for future validation in Brazil. METHOD: The protocol applied consisted of: 1) Preparation; 2) Forward translation; 3) Back translation; 4) Cognitive Debriefing; and 5) Information report. After concluding the forward and back-translations, the versions were sent to the authors of the original questionnaire, who gave their approval for the study to be continued. The Portuguese version was applied to 35 patients with rotator cuff dysfunctions to verify the level of understanding of the instrument. The mean age of these patients was 57 years (SD = 13); 63 percent were female and 74 percent had not completed elementary school. The final Brazilian version of WORC was defined after achieving a "no comprehension" rate of less than 15 percent for each item. Descriptive statistics were used to analyze the variables. RESULTS: Some terms and expressions were changed or replaced to obtain cultural equivalence for WORC. The terms that were incomprehensible to the patients were changed in accordance with their own suggestions. CONCLUSION: After the translation and cultural adaptation of the questionnaire, the final Portuguese version of WORC was concluded and it is now undergoing validation for use in Brazil.

The impact of lupus erythematosus cutaneous on the Quality of life: the Brazilian-Portuguese version of DLQI.

OBJECTIVE: To translate into Brazilian-Portuguese, culturally adapt and validate the DLQI. PATIENTS AND METHODS: The DLQI was translated into Brazilian-Portuguese and cultural adaptation was performed following the methodology proposed by Falcão. Inter-observer reliability and validity were assessed. Seventy-one patients with lupus erythematosus with cutaneous lesions selected from the outpatient dermatology clinic had their quality of life assessed by DLQI and SF-36. The validity of the Brazilian-Portuguese version of the DLQI was evaluated by the correlation of DLQI scores with SF-36 component scores and other outcome measures. RESULTS: In the translation and cultural adaptation process the basic structure of DLQI was kept. Very few questions have very slightly modifications. Of the 71 patients, 83% were women and the median (SD) age was 38 (12) years. The patients had a mean (SD) disease duration of 8(6) years. There were 46 patients with active cutaneous lesions and 37 patients with alopecia. The DLQI inter-observer reliability coefficient was 0.96 (p<0.001). The DLQI mean (SD) score was 6.5 (5.6) and most of the SF-36 domains were between 60 and 70. The domains that had the lowest scores were 'general health' (62) and 'mental health' (62). The Pearson correlation coefficient between DLQI and each SF-36 component score were highly statistically significant (p<0.001), despite of being only moderate. As expected there was no correlation between DLQI or each one of the SF-36 components and age, disease duration or number of ACR criteria. Patients with active cutaneous lesions presented statistically significant lower scores of DLQI and SF-36 when compared to patients without active cutaneous lesions. Patients with alopecia presented a statistically significant lower score in DLQI when compared to patients without alopecia. CONCLUSIONS: The results suggest that the Brazilian-Portuguese version of the DLQI is a reliable and valid outcome measure to be used in LE clinical studies.

Cultural adaptation and validation of the "Kidney Disease and Quality of Life--Short Form (KDQOL-SF 1.3)" in Brazil.

The objective of the present study was to translate the Kidney Disease Quality of Life -- Short Form (KDQOL-SF 1.3) questionnaire into Portuguese to adapt it culturally and validate it for the Brazilian population. The KDQOL-SF was translated into Portuguese and back-translated twice into English. Patient difficulties in understanding the questionnaire were evaluated by a panel of experts and solved. Measurement properties such as reliability and validity were determined by applying the questionnaire to 94 end-stage renal disease patients on chronic dialysis. The Nottingham Health Profile Questionnaire, the Karnofsky Performance Scale and the Kidney Disease Questionnaire were administered to test validity. Some activities included in the original instrument were considered to be incompatible with the activities usually performed by the Brazilian population and were replaced. The mean scores for the 19 components of the KDQOL-SF questionnaire in Portuguese ranged from 22 to 91. The components "Social support" and "Dialysis staff encouragement" had the highest scores (86.7 and 90.8, respectively). The test-retest reliability and the inter-observer reliability of the instrument were evaluated by the intraclass correlation coefficient. The coefficients for both reliability tests were statistically significant for all scales of the KDQOL-SF (P < 0.001), ranging from 0.492 to 0.936 for test-retest reliability and from 0.337 to 0.994 for inter-observer reliability. The Cronbach's alpha coefficient was higher than 0.80 for most of components. The Portuguese version of the KDQOL-SF questionnaire proved to be valid and reliable for the evaluation of quality of life of Brazilian patients with end-stage renal disease on chronic dialysis.

Cultural adaptation and validation of the "Kidney Disease and Quality of Life - Short Form (KDQOL-SFÕ 1.3)" in Brazil

The objective of the present study was to translate the Kidney Disease Quality of Life - Short Form (KDQOL-SFÕ1.3) questionnaire into Portuguese to adapt it culturally and validate it for the Brazilian population. The KDQOL-SF was translated into Portuguese and back-translated twice into English. Patient difficulties in understanding the questionnaire were evaluated by a panel of experts and solved. Measurement properties such as reliability and validity were determined by applying the questionnaire to 94 end-stage renal disease patients on chronic dialysis. The Nottingham Health Profile Questionnaire, the Karnofsky Performance Scale and the Kidney Disease Questionnaire were administered to test validity. Some activities included in the original instrument were considered to be incompatible with the activities usually performed by the Brazilian population and were replaced. The mean scores for the 19 components of the KDQOL-SF questionnaire in Portuguese ranged from 22 to 91. The components "Social support" and "Dialysis staff encouragement" had the highest scores (86.7 and 90.8, respectively). The test-retest reliability and the inter-observer reliability of the instrument were evaluated by the intraclass correlation coefficient. The coefficients for both reliability tests were statistically significant for all scales of the KDQOL-SF (P < 0.001), ranging from 0.492 to 0.936 for test-retest reliability and from 0.337 to 0.994 for inter-observer reliability. The Cronbach's alpha coefficient was higher than 0.80 for most of components. The Portuguese version of the KDQOL-SF questionnaire proved to be valid and reliable for the evaluation of quality of life of Brazilian patients with end-stage renal disease on chronic dialysis.

Evaluation of the short-form 36-item questionnaire to measure health-related quality of life in patients with idiopathic pulmonary fibrosis.

OBJECTIVE: To validate the use of the 36-item short-form questionnaire (SF-36) for measuring health-related quality of life (HRQL) in patients with idiopathic pulmonary fibrosis (IPF). DESIGN: : Observational data at a single point in time. SETTING: : A specialized outpatient respiratory clinic. PARTICIPANTS: Thirty-four patients (mean +/- SE age, 58.29 +/- 1.87 years) with IPF and no significant comorbidity. A matched control group for HRQL measurements was composed of 34 normal subjects (mean age, 58.00 +/- 1.89 years). MEASUREMENTS AND RESULTS: Dyspnea was measured by the baseline dyspnea index (BDI). Respiratory function evaluation included FVC, FEV(1), and resting arterial blood gases. IPF patients showed a mean BDI score of 5.21 +/- 0.46. The mean FVC and FEV(1) values were 62.41 +/- 2.96% and 66.41 +/- 3.33%, respectively. The mean PaO(2) was 67 +/- 2.51 mm Hg, and the mean PaCO(2) was 37 +/- 1. 05 mm Hg. Patients scored significantly worse than control subjects with respect to the SF-36 domains of physical functioning, physical role, general health perceptions, vitality, social functioning, emotional role, and mental health index. BDI scores were significantly correlated with five SF-36 components, and FVC and FEV(1) were significantly correlated with two SF-36 components. Significant negative correlations were found between arterial pH and four SF-36 domains. CONCLUSIONS: Patients with IPF have a significant impairment of HRQL in both physical and psychological functioning. Dyspnea is the most important factor influencing the quality of life in these subjects. The SF-36 questionnaire is a valid instrument to evaluate HRQL in IPF patients.

Quality of life in patients with osteoporosis fractures: cultural adaptation, reliability and validity of the Osteoporosis Assessment Questionnaire.

OBJECTIVE: The purpose of this study was to translate into Brazilian-Portuguese the Osteoporosis Assessment Questionnaire (OPAQ), and to evaluate its reliability and validity. METHODS: The OPAQ was translated into Brazilian-Portuguese. This version was then back-translated into an English version which was compared to the original version, and a second Brazilian-Portuguese version was generated. This draft version of the Brazilian-Portuguese OPAQ was administered to 30 patients with lumbar osteoporosis and no fractures. The non-applicable questions were modified and, after being administered again, this Brazilian-Portuguese version of the OPAQ was accepted as definitive. Its reliability was tested in 30 osteoporotic out-patients, and was administered three times to the patients to check the intra/interobserver reliability. The patients were also clinically evaluated using HAQ, FIQ and a numerical rating scale for pain. For all patients the number of fractures and the bone mineral density at the spine were determined. RESULTS: The mean age of the patients was 69 years (54 to 89 years) and the mean number of fractures was 2.72. Twenty-one patients (70%) had had more than one vertebral fracture. All of the questionnaire components, except for mood (c16), presented statistically significant coefficients for intra/interobserver reliability. The highest score was observed for "the fear of falling" (6.70). Correlations between the OPAQ components and the number of fractures, bone density and Z-score were not statistically significant. CONCLUSIONS: This Brazilian-Portuguese version of the OPAQ is a reliable and valid instrument. Other aspects than bone mineral density and the number of fractures have an important influence on the quality of life in patients with osteoporosis and fractures.

Evaluation of the European Spondylarthropathy Study Group (ESSG) preliminary classification criteria in Brazilian patients.

OBJECTIVE: To evaluate the sensitivity and specificity of the ESSG criteria when applied to Brazilian patients with SpA and control patients with other rheumatic diseases. METHODS: Seventy patients with spondylarthropathies and 62 patients with other rheumatic diseases were interviewed, examined and had their charts reviewed. The diagnoses of the diseases were based on published diagnostic guidelines or classification criteria. Data were also collected according to the ESSG criteria. RESULTS: The sensitivity and specificity of the ESSG classification criteria were 98.5% and 88.7%, respectively. The sensitivities of the criteria in the different subgroups of SpA ranged from a low of 97.7% in AS to a high of 100% in other SpA studied. CONCLUSION: Despite differences in the socio-cultural and geographic characteristics and in individual disease frequencies, the ESSG preliminary classification criteria performed well when applied to Brazilian patients.

A randomized double-blind controlled trial of sulphasalazine combined with pulses of methylprednisolone or placebo in the treatment of rheumatoid arthritis.

Thirty-eight patients with rheumatoid arthritis meeting American College of Rheumatism (ACR) criteria were entered in a randomized controlled trial (RCT) of 6 months to assess whether monthly treatment with i.v. methylprednisolone (MP) enhances or accelerates the efficacy of sulphasalazine (SSZ). All patients had failed at least one second-line agent and were randomized to receive SSZ (2g/day) and pulses of MP (5 mg/kg), or SSZ+ (2 g/day) and pulses of saline (SA). A single infusion of 2 h was carried out in both groups for a total of three times (0, 1 and 2 months). The two groups were comparable at baseline regarding their demographic and clinical characteristics. Disease activity was evaluated every 2 months by means of: (1) joint count; (2) morning stiffness; (3) grip strength; (4) visual analogue pain score; (5) health assessment questionnaire; and (6) erythrocyte sedimentation rate. All outcome measures improved significantly in both groups (P < 0.001). Evaluation at each follow-up visit showed no significant differences between the groups in any of the adverse effects attributable to SSZ therapy (one SA vs two MP). Adverse effects attributable to SA/MP therapy were rare and mild. We concluded that repeated pulses of MP during the first 3 months of treatment did not improve the efficacy of SSZ. Therefore, there is no justification for using MP in this way during the induction phase of SSZ therapy.

Patient's preference regarding the option of performing unselective liver biopsy following methotrexate treatment in rheumatoid arthritis.

OBJECTIVE: This study was aimed at the evaluation of patient preferences concerning long-term methotrexate (MTX) therapy and whether or not to perform unselective liver biopsy to detect serious liver disease due to MTX therapy in rheumatoid arthritis (RA). METHODS: Seventeen literate patients with RA consecutively selected from a rheumatic disease unit and 17 rheumatologists (asked to consider themselves as RA patients) were assessed by a trained interviewer. The Bedside Decision Board instrument was used to assess the patient preference. Scenarios described the options in terms of follow-up for RA patients treated with MTX. The benefits and risks of liver biopsy, defined according to the published literature, were presented to RA patients and rheumatologists in an unbiased fashion. RESULTS: Twelve patients (71%) preferred not to be subjected to the liver biopsy within 1 month, even though they had already taken MTX for 3 years, and consequently ran the risk of development of cirrhosis in the long term. Conversely, 12 rheumatologists (71%) preferred to undergo an unselective liver biopsy. CONCLUSION: Given patients' preferences, liver biopsy following long term MTX treatment should not be performed unselectively. It can be postulated that rheumatologists did not perceive liver biopsy as an intimidating procedure or were influenced by the until recently recommended guidelines for following up patients treated with MTX.

The effect of elbow flexion and time of assessment on the measurement of grip strength in rheumatoid arthritis.

Grip strength is one of the traditional outcome measures commonly used in rheumatoid arthritis trials. This study evaluated the degree of morning variation and the effect of elbow flexion in the assessment of grip strength in patients with rheumatoid arthritis. Grip strength was measured in 37 patients (1987 American Rheumatism Association criteria) at 8, 10, and 12 AM with a sphygmomanometer cuff folded on itself, taped permanently, and inflated to 20 mm Hg, with the elbow flexed at 90 degrees. At 10 AM grip strength was also measured with the elbow flexed at 30 and 130 degrees. Mean values for grip strength at 8, 10, and 12 AM were, respectively, 69, 79, and 83 mm Hg. Mean grip strength values with the elbow flexed at 30, 90, and 130 degrees were, respectively, 78, 79, and 75 mm Hg. There was a statistically significant correlation between grip strength and morning stiffness, grip strength and hand function, and grip strength and number of active joints. In rheumatoid arthritis trials, grip strength should be assessed at the same time of the day. Elbow flexion does not play a role in grip strength measurement.