Social network size of female patients with rheumatoid arthritis compared to healthy controls.

UNLABELLED: To estimate how rheumatoid arthritis (RA), the disease duration, and level of physical disability, influence the total size of patients' social network and the size of different subsets. Two hundred sixty four female patients (mean age 57 yrs) with RA of more than 6 yrs duration (mean 20 yrs) were compared to 61 healthy controls matched for sex, age, and residential area. Network size was measured by Social Network Delineation Questionnaire (SNDQ), physical disability by Health Assessment Questionnaire (HAQ). RA patients had a significantly smaller total network compared to the healthy controls (RA: 15.8 persons; CONTROLS: 18.1), mostly due to a significant difference in the subset of important others in favour of the controls (RA: 1.1; CONTROLS: 2.3). There were no significant differences regarding the network size of family, friends, and neighbours. The same results remained after statistical control for sociodemographic variables. Neither disease duration nor physical disability had any significant association with network size. The interaction analysis did, however, show that non-working patients with long disease duration (> 15 yrs) had fewer important others than occupationally active patients. Furthermore, a high degree of physical disability was related to a smaller number of friends for patients > 57 yrs than for equally disabled patients below this age. Most patients with RA seem to maintain contact with the family network-members, despite the challenges connected with chronic disease.

Recent onset arthritis in the elderly: a 5 year longitudinal observational study.

OBJECTIVE: To study the spectrum of diagnoses, course, and outcome of recent onset arthritis after the age of 60, presenting as rheumatoid arthritis (RA)-like disease. METHODS: A 5 year longitudinal observational study enrolled 92 consecutive patients (median age 73 yrs, 54/38 women/men, median duration of arthritis 12 weeks at inclusion). RESULTS: Forty-eight percent were classified as having RA according to the 1987 American Rheumatism Association criteria, 52% as non-RA (41.4% undifferentiated seronegative polyarthritis, 10.8% oligoarthritis with polymyalgic symptoms). Symmetrical involvement of small and medium size joints was more predominant in the RA (91 and 84%, respectively) than the non-RA patients (58 and 52%). The patients with RA compared to non-RA had more active and serious disease at onset, reflected by significant differences in number of swollen joints (median values 18 and 9, respectively), duration of morning stiffness (75 and 10 min), physician's global assessment of disease activity (45 and 28 mm on visual analog scale), and Health Assessment Questionnaire (HAQ) score for functional disability (1.8 and 1.0). Improvement during the course was observed in disease process variables as well as in HAQ disability score for both RA and non-RA patients. Risk factors for a poor 5 year functional outcome were female sex (OR 4.24), diagnosis of RA (OR 3.28), and baseline HAQ score > or =1.4 (OR 3.52). The median change in radiological progression (Larsen-Dale index) was zero. Twenty patients died during followup, the majority from cardiovascular diseases, infections, and malignancies. Mortality compared to the age and sex matched general population was increased for rheumatoid factor (RF) positive patients (standardized mortality ratio 272). Mortality risk factors within the patient cohort were male sex (OR 4.35), age (OR 1.17), and having RF+ RA (OR 11.93). CONCLUSION: Arthritis in the elderly is a heterogeneous group of arthritides with an overall favorable functional prognosis. The subgroup of women with elderly onset RA with functional disability at onset is at risk for a less favorable functional outcome. Mortality was increased for the patients with RF+ elderly onset RA only.

Helicobacter pylori--a trigger of reactive arthritis?

Four cases of reactive arthritis (ReA) related to Helicobacter pylori (HP) are presented. These were identified by IgG, IgM and IgA ELISA tests performed on sera obtained from a 2-year prospective study on 186 patients with a clinical picture suggesting ReA as a possible diagnosis. If anti-HP IgM and IgA or IgG were positive, the case was considered related to HP. Three out of four HP ReA patients were originally classified as "possible ReA", i.e. having a clinical picture of ReA but without any identified triggering microorganism. IgG antibodies against cagA and vacA were detected in three and two cases respectively. The HP ReA patients did not present with typical clinical or laboratory features differentiating them from ReA induced by Chlamydia trachomatis (N = 25) or enteropathogenic bacteria (N = 27). However, compared to findings in patients with ReA due to enteropathogenic bacteria the number of active joints was higher (six versus two), duration of arthritis longer (3.9 weeks versus 2 weeks) and the CRP (C-reactive protein) lower (43 versus 59). Our findings suggest that HP may be included in the list of possible arthritis triggering microbes.

The incidence and severity of rheumatoid arthritis, results from a county register in Oslo, Norway.

OBJECTIVE: To examine the incidence of rheumatoid arthritis (RA) in the community of Oslo, Norway; and to link the incidence to measures of disease severity. METHODS: A register for RA in the county of Oslo was validated to be 85% complete for patients between 20 and 79 years of age. The incidence of RA was calculated from this register for patients with disease onset 1988-1993 (n=550). Data on health related quality of life [Modified Health Assessment Questionnaire (MHAQ), Arthritis Impact Measurement Scale 2 (AIMS2), pain, fatigue] were obtained from a postal survey (response rate 73%). RESULTS: The overall annual incidence of RA over a 6 year period was 25.7/100,000 (females 36.7, males 13.8). The incidence increased with age, from 7.8 in the age group 20-29 to 61.0 between 70 and 79 years. After 5 year followup a clinically important effect on physical function (MHAQ > 1.5) was seen in 38% of the patients, on social functioning (AIMS2 social > 4) in 50%, on mental distress (AIMS2 affect > 4) in 27%, on pain (VAS > 40 mm) in 35%, and on fatigue (VAS > 40 mm) in 41%. CONCLUSION: The incidence of RA was 25.7/100,000 in the population of Oslo. After 5 years, 40-50% had clinically important changes in health status. The annual disease incidence with clinically important effect on physical function after 5 years was 10/100,000 individuals at risk.

Auranofin is safe and superior to placebo in elderly-onset rheumatoid arthritis.

The efficacy, toxicity and possible steroid-sparing properties of auranofin in the treatment of elderly-onset rheumatoid arthritis (EORA) were studied in a 2 yr prospective double-blind placebo-controlled clinical trial. Sixty-five patients with onset of arthritis after the age of 60 yr were randomized to either auranofin 3 mg b.i.d. [n = 31, age 70 (61-84) yr, median (range)] or placebo tablets [n = 34, age 72 (60-81) yr]. Oral prednisolone, starting dose 7.5 or 20 mg daily, was used as a rescue drug in patients with intolerable joint pain and stiffness and with C-reactive protein (CRP) > or = 20 mg/l, and was tapered down according to protocol guidelines. Patients receiving auranofin continued therapy for a longer period of time (55% completers) than those on placebo medication (18% completers). The auranofin group consumed significantly less prednisolone, 2.64 (0-11.85) mg/day [median (range)], compared to 5.0 (0-18.33) mg/day in the placebo group (P = 0.006). No group differences at 2 yr follow-up were found for changes in joint pain (P = 0.49), number of swollen joints (P = 0.61), Health Assessment Questionnaire score (P = 0.18) and radiographic damage score (Larsen-Dale index) of the hands (P = 0.84). Within-group changes in radiographic scores were also insignificant. The drop-out rate due to adverse events was surprisingly higher in the placebo group (41%) than in the auranofin group (10%) and, as expected, higher due to lack of effect (29 and 16%). The results indicate that auranofin is safe, superior to placebo and has steroid-sparing capacity in the treatment of EORA. The favourable radiographic outcome in both groups needs confirmation in future studies.

The prevalence and severity of rheumatoid arthritis in Oslo. Results from a county register and a population survey.

The objective was (1) to examine the prevalence of rheumatoid arthritis (RA) by a county patient register, (2) to cross-validate the register findings by a postal population survey, and (3) to estimate prevalences of disease subsets according to age, sex, and levels of physical disability. The study was performed within a county setting in the city of Oslo with 356,486 inhabitants between 20 and 79 years of age. Prevalence estimates were calculated from a county patient register comprising 1333 patients with RA and a population survey of 10,000 inhabitants. The overall prevalence of RA between 20 and 79 years was 0.437 (95% CI 0.413, 0.461) after adjusting for the incompleteness of the register by a factor of 1.17. Prevalences exceeding 1.0% was only found among females over 60 years. The prevalence of RA with MHAQ scores > or = 1.5 and > or = 2.0 (range 1-4) was 0.225 (95% CI 0.209, 0.243) and 0.099 (0.088, 0.111) respectively. We conclude that RA is less frequent in the city of Oslo than stated in most of the literature. The prevalence of RA with physical disability levels assumed to be associated with increased mortality is less than half of the overall prevalence of 0.4-0.5%.

The validity of self-reported diagnosis of rheumatoid arthritis: results from a population survey followed by clinical examinations.

OBJECTIVE: Self-reported diagnoses of rheumatic conditions are frequently used in epidemiological and clinical research. Our objectives were to examine the validity of patient self-reported rheumatoid arthritis (RA); and to assess the predictive value of symptoms, health status measures, and demographic variables with respect to the actual diagnosis. METHODS: A postal survey was performed in Oslo of 10,000 randomly selected individuals between 20 and 79 years of age. Respondents reported musculoskeletal pain, stiffness, rheumatic diagnoses, disability, and mental distress. The patients reporting RA (either according to patient or doctor) were selected for further examination. RESULTS: Of 5886 respondents (3670 with musculoskeletal pain or stiffness) 158 patients (2.7%) reported having RA diagnosed by doctor (n = 107) and/or according to their own opinion (n = 142). RA was confirmed by clinical examination in 35 of these 158 individuals (22%, CI 16,29). Patients with perceived and actual RA differed regarding self-reported presence of swollen joints and disability score. Multivariate analyses failed to identify a set of useful predictors for the correct diagnosis. CONCLUSION: Patient self-reported diagnosis of RA is unreliable for research or clinical purposes.

The value of isotype determination of serum antibodies against Chlamydia for the diagnosis of Chlamydia reactive arthritis.

In clinical rheumatology, the diagnosis of Chlamydia reactive arthritis is difficult because an incomplete form of the disease can closely resemble an undifferentiated seronegative mono/oligoarthritis. We investigated whether measuring specific isotypes of anti-Chlamydia antibodies in serum can improve the diagnosis, by comparing such antibody concentrations in the serum of patients with well-defined disease, i.e. Chlamydia trachomatis sexually acquired reactive arthritis (CT-SARA), with other arthritides. Antibody levels were determined by enzyme-linked immunosorbent assay (ELISA). When considering two different isotypes and their combination, the best sensitivity (63%) was obtained for IgM and/or IgA results with a specificity of 81%. The patients with CT-SARA and SARA had the highest levels of antibodies of all isotypes tested. It is concluded that, in our experimental conditions, only very high values of specific isotypes could indicate a diagnosis of Chlamydia reactive arthritis.

Synovial fluid and serum antibodies against Chlamydia in different forms of arthritis: intra-articular IgA production in Chlamydia sexually acquired reactive arthritis.

Since the presence of Chlamydia has been shown in synovial fluid (SF) from some patients with Chlamydia reactive arthritis, we investigated whether anti-Chlamydia antibodies present in the joint are derived from the circulation or are locally produced. We compared titres of IgG, IgM and IgA antibodies against Chlamydia, and against a control antigen (tetanus toxoid), by an enzyme-linked immunosorbent assay (ELISA), in paired samples of serum and SF from Chlamydia trachomatis sexually acquired reactive arthritis (CT-SARA) patients and from patients with other forms of arthritis. The ratio of serum/SF IgA anti-Chlamydia antibodies was significantly decreased in CT-SARA patients. It is concluded that, in our experimental conditions, we found evidence for intra-articular production of IgA anti-Chlamydia antibodies.

Prediction of diagnosis in acute and subacute oligoarthritis of unknown origin.

A total of 146 consecutive patients between 18 and 60 yr of age with oligoarthritis of unknown origin (< or = 6 active joints, < or = 8 weeks duration) were examined by a variety of clinical, laboratory and microbiological investigations, and followed longitudinally for 24 weeks. Reactive arthritis was diagnosed in 46 patients (19 induced by Chlamydia trachomatis, 27 by enterobacteria), 62 had undifferentiated arthritis, eight other inflammatory arthritic diseases, 15 acute sarcoid arthritis and 15 non-inflammatory joint diseases. Group differences were found for many baseline variables, but with considerable overlap between the groups. A set of four clinical and laboratory variables (elevated CRP, genitourinary symptoms, metatarsophalangeal joint involvement. HLA B27) could predict reactive arthritis with a sensitivity of 69.2% and a specificity of 93.5%. A wide range of clinical and laboratory examinations are required to determine the final diagnosis in oligoarthritis, but individual and sets of clinical and laboratory measures may give helpful clues for the correct diagnosis.

[Diagnostic evaluation of suspected reactive arthritis]. / Diagnostisk utredning av mistenkt reaktiv artritt.

On the basis of an epidemiological study on recently onset, possible reactive arthritides in Oslo we propose a programme for diagnostic evaluation. Disease symptoms and signs provided little help for an ethiological diagnosis. Therefore a variety of diagnostic tests and examinations are recommended in order to obtain a correct diagnosis; such as clinical examination, chemical and serological blood tests, bacteriological examinations from throat, of stools and of specimens from urethra-cervix, examination of synovial fluid and synovial tissue and X-ray examination of affected joints, sacroiliacal joints and lungs. About one third of the recently onset arthritides in the Oslo study were diagnosed as reactive arthritis, one third as possible reactive arthritis and another third as inflammatory arthritides.

Amplification of plasmid and chromosome Chlamydia DNA in synovial fluid of patients with reactive arthritis and undifferentiated seronegative oligoarthropathies.

OBJECTIVE: To investigate the hypothesis that whole bacteria might be found in the joints of patients with Chlamydia-associated reactive arthritis. METHODS: The presence of 2 plasmid- and 2 chromosome-specific sequences of Chlamydia DNA was investigated by amplification with the polymerase chain reaction, in synovial fluid (SF) samples from 71 patients with various arthropathies. RESULTS: Chlamydia DNA was found in SF samples from 22 patients. CONCLUSION: Whole chlamydiae are likely present in the SF of patients with Chlamydia-associated reactive arthritis.

Acute sarcoid arthritis: occurrence, seasonal onset, clinical features and outcome.

In a 2-yr prospective follow-up study of patients presenting clinically with possible reactive arthritis (ReA), 17 (9%) of the patients turned out to have acute sarcoid arthritis (SA). The number of new cases of SA per year was 2.9/100,000 persons in the city of Oslo between 18 and 60 yr of age. The onset of SA clustered in the spring. All the SA patients presented with bilateral ankle joint involvement and bilateral hilar lymphadenopathy, and ten (59%) presented with the triad of erythema nodosum, arthritis and lung involvement. A prospective follow-up after 104 weeks showed complete remission of arthritis in all 17 cases of SA. The total duration of arthritis [median (range)] was 11 (2-107) weeks. Erythema nodosum was mild and transient in all cases. At week 104, the lung and hilar manifestations had resolved. We conclude that the outcome of SA appeared favourable. Bilateral ankle joint involvement, erythema nodosum and bilateral hilar lymphadenopathy found at the routine chest X-ray examination are important clues for the diagnosis of SA.

A longitudinal study of calprotectin as an inflammatory marker in patients with reactive arthritis.

OBJECTIVE: To examine the value of calprotectin, a major granulocyte protein with bactericide properties, as an inflammatory marker in patients with reactive arthritis. METHODS: Twenty-five patients with Chlamydia-induced and 27 patients with enterobacteria-induced reactive arthritis were analysed. At the first visit and after 3, 12, 24, 52 and 104 weeks, calprotectin concentrations were measured in plasma and when possible, in synovial fluid. C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) were analysed and clinical assessments of disease activity were performed. RESULTS: Of the inflammatory markers, the plasma calprotectin concentrations were the first to normalize during recovery. Calprotectin concentrations in the plasma were highly correlated with CRP and ESR, and calprotectin was found to have high correlation coefficients with the clinical assessments of disease activity. High calprotectin concentrations were found in the synovial fluid. CONCLUSION: The high correlations between calprotectin in plasma and clinical and laboratory markers of inflammation, as well as the rapid normalization following clinical improvement, demonstrate that calprotectin may be used as an inflammatory marker in patients with reactive arthritis.

Reactive arthritis: a favorable 2 year course and outcome, independent of triggering agent and HLA-B27.

OBJECTIVE: To study the 2 year course and clinical and radiological outcome of reactive arthritis and to identify possible outcome predictors. METHODS: Patients with chlamydia induced arthritis (n = 25) and arthritis induced by enterobacteria (n = 27), all derived from a 2-year epidemiological study on reactive arthritis (ReA) and possible ReA, were followed prospectively with clinical, laboratory and radiographic examinations. RESULTS: After one year, 40% of patients with chlamydia induced arthritis and 20% of those with enteroarthritis still had clinical signs of arthritis. After 2 years, 100 and 95%, respectively, had recovered. At that time, one patient with enteroarthritis had developed radiographic abnormalities exceeding grade I in peripheral joints. None developed bilateral sacroiliitis during the course. The duration of ReA was found to be independent of the triggering agent, sex, age, duration of arthritis prior to entry, pain, index of active joints, CRP and the presence of HLA-B27. CONCLUSION: Early recognition and elimination of the triggering microbe seems important for the arthritis outcome in ReA. The results do not support the hypothesis that the presence of HLA-B27 heralds a more serious disease course or less favorable outcome, nor that the type of triggering agent predicts the outcome.

[Drug therapy of rheumatoid arthritis. Recommendations to specialists and general practitioners]. / Medikamentell behandling av reumatoid artritt. Anbefalinger for spesialister og allmennpraktiserende leger.

We report from a workshop on pharmacological treatment for rheumatoid arthritis, arranged by the Swedish Medical Product Agency in October 1991. The purpose was to reach consensus and make recommendations concerning treatment with corticosteroids and anti-rheumatic drugs. It was recommended to start treatment with anti-rheumatic drugs as soon as the diagnosis of an active rheumatoid arthritis was established. The selection of drugs for the individual patient should be determined both by patient and drug factors. The therapy requires close monitoring, a co-operative task for the specialist and general practitioner. Use of anti-rheumatic drugs during pregnancy and lactation was not recommended, except for sulphasalazine.

Reactive arthritis: incidence, triggering agents and clinical presentation.

OBJECTIVE: To study the incidence and presenting clinical and microbiological features in subgroups of reactive arthritides. METHODS: In a defined community and during a 2-year period, we studied prospectively patients between 18 and 60 years with onset of suspected reactive arthritis, primarily seen by general practitioners. RESULTS: Annual minimum incidence of Chlamydia induced arthritis (n = 25) was 4.6 and of arthritis triggered by enterobacteria (n = 27) 5.0/100,000 individuals between 18 and 60 years. Triggering infections were asymptomatic in 36 and 26%, respectively. Patients with self-limiting arthritis without identified triggering agents (n = 60, incidence 11.0/100,000) had a normal prevalence of HLA-B27 and a more heterogeneous pattern of arthritis. CONCLUSION: Our epidemiological study confirms suggested high incidence rates of reactive arthritides. Reactive arthritides must be considered in early arthritis, even without symptoms of triggering infections.

[Quality of an outpatient rheumatology clinic. Consumers' evaluation of medical aspects and service]. / Kvalitet ved en reumatologisk poliklinikk. Brukernes vurdering av medisinske tilbud og service.

As part of our quality assurance programme we designed special questionnaires which addressed expectations concerning medical aspects and service at our out-patient rheumatology clinic, and the degree of satisfaction. These questionnaires were answered by 97 patients, 86 referring general practitioners and five rheumatologists. The principle purpose of the consultation with the specialist, both for patients and referring practitioners, was to obtain or confirm the diagnosis. 76% of the patients and 91% of the general practitioners were satisfied with the medical aspect of the consultation. The dissatisfied patients were mainly those with symptomatic diagnoses (pain syndromes) not explained by objective changes. As for the service, long waiting time before consultation or before receiving the specialist's report was the main reason for dissatisfaction among patients and referring practitioners respectively.