Agreement of Physicians and Nurses Performing Tender and Swollen Joint Counts in Rheumatoid Arthritis.

OBJECTIVE: The aims of this study were to assess the agreement of physicians and nurses performing tender and swollen joint counts (TJCs/SJCs) in rheumatoid arthritis (RA) and identify factors that might influence their examinations including patient age, sex, race, RA disease duration, body mass index, RA disease activity level, comorbid fibromyalgia, comorbid osteoarthritis, and levels of acute-phase reactants. METHODS: Seventy-two RA participants underwent TJCs/SJCs of 28 joints using a standardized protocol by 2 nurses and 2 rheumatologists. Demographic, laboratory, radiographic, and clinical data were obtained to assess the influence of these factors on TJCs/SJCs. Intraclass correlations (ICCs) among examiners were determined for TJCs/SJCs. Nurse-physician differences and agreement of individual joints were evaluated using Cohen κ. Analysis of variance was performed to detect differences in means between examiners for TJCs/SJCs. Intraclass correlation and Fisher Z tests were used to identify factors influencing TJCs/SJCs. RESULTS: Agreement was strong among these nurses and physicians for total TJCs/SJCs (ICC = 0.84/ICC = 0.79, respectively). κ was best for hand joint tenderness and poorest for shoulder swelling. Some significant differences in mean TJCs/SJCs were found between examiners. Fibromyalgia significantly reduced agreement of both TJCs and SJCs. Agreement of TJC was significantly reduced when patients had lower disease activity, greater work impairment, lower mental health quality of life, and elevated erythrocyte sedimentation rate, whereas female sex, assessor's perception of but not radiographic hand osteoarthritis, and elevated C-reactive protein significantly reduced agreement for SJC. CONCLUSIONS: Strong agreement was found among nurses and physicians for total 28-joint counts, with agreement at individual joints being stronger for tenderness than swelling. Fibromyalgia significantly reduced ICCs of TJCs/SJCs.

Internet-enhanced management of fibromyalgia: a randomized controlled trial.

Both pharmacological and non-pharmacological interventions have demonstrated efficacy in the management of fibromyalgia (FM). Non-pharmacological interventions however are far less likely to be used in clinical settings, in part due to limited access. This manuscript presents the findings of a randomized controlled trail of an Internet-based exercise and behavioral self-management program for FM designed for use in the context of a routine clinical care. 118 individuals with FM were randomly assigned to either (a) standard care or (b) standard care plus access to a Web-Enhanced Behavioral Self-Management program (WEB-SM) grounded in cognitive and behavioral pain management principles. Individuals were assessed at baseline and again at 6 months for primary endpoints: reduction of pain and an improvement in physical functioning. Secondary outcomes included fatigue, sleep, anxiety and depressive symptoms, and a patient global impression of improvement. Individuals assigned to the WEB-SM condition reported significantly greater improvement in pain, physical functioning, and overall global improvement. Exercise and relaxation techniques were the most commonly used skills throughout the 6 month period. A no-contact, Internet-based, self-management intervention demonstrated efficacy on key outcomes for FM. While not everyone is expected to benefit from this approach, this study demonstrated that non-pharmacological interventions can be efficiently integrated into routine clinical practice with positive outcomes.

ANCA-associated small vessel vasculitis: clinical and therapeutic advances.

The antineutrophil cytoplasmic antibodies-associated small vessel vasculitides are an encompassing group of diseases defined by serologic and anatomic criteria. Their diverse phenotype is an ongoing diagnostic challenge, and early diagnosis is paramount in optimizing outcomes and minimizing morbidity. Therapies targeted at components of the immune system, both cellular and cytokine, have been assessed as both inducers and sustainers of remission. As current data provide clarity in pathogenesis, treatment options and strategies have been evaluated to improve outcomes. However, challenges remain in limiting disease flares and therapy-associated morbidities, and cures are achieved only in cases in which a clear culprit exists.

Leukocytoclastic vasculitis associated with tumor necrosis factor-alpha blocking agents.

OBJECTIVE: To describe the clinical features of leukocytoclastic vasculitis (LCV) associated with the use of tumor necrosis factor-alpha (TNF-alpha) blockers. METHODS: The Adverse Events Reporting System (AERS) of the US Food and Drug Administration (FDA) was queried for reports of patients who developed LCV during or after starting etanercept or infliximab from date of approval of each agent through September 6, 2002. RESULTS: Thirty-five cases of LCV were identified, 20 following etanercept administration and 15 following infliximab administration. Seventeen of the 35 (48.5%) were biopsy-proven cases and the others had skin lesions that were clinically typical for LCV. Twenty-two of 35 (62.8%) patients had complete or marked improvement of skin lesions upon stopping the TNF-alpha blocker. Three patients who had received etanercept had continuing lesions despite discontinuation of the drug; one of these patients improved when switched to infliximab. One patient who received infliximab was reported to have continuing lesions despite discontinuation of the drug and treatment with prednisone and antihistamines. Six patients experienced a positive rechallenge (recurrence of LCV on restarting therapy with a TNF-alpha blocker) and 3 patients a negative rechallenge phenomenon. LCV lesions improved in patients despite continuing use of concomitant medications reportedly associated with LCV. CONCLUSION: Therapy with TNF-alpha blocking agents may be associated with the development of LCV. Skin lesions improved on discontinuation of anti-TNF-alpha therapy in most patients. Other causes of LCV should be excluded, and evaluation for systemic involvement with appropriate investigations is recommended.

Knee pain and radiographic osteoarthritis interact in the prediction of levels of self-reported disability.

OBJECTIVE: To determine predictors of disability depending on whether joint deformity and pain reporting exist independently or concurrently. METHODS: Subjects were 154 volunteers for an osteoarthritis screening examination. Eligible subjects completed questionnaires for physical function, pain, and depressive symptoms; underwent evoked pain testing for tenderness assessment; and had anteroposterior and lateral radiographs taken of both knees. Two blinded rheumatologists scored the images using Kellgren-Lawrence criteria to determine presence of deformity. RESULTS: Subjects were divided into 3 subgroups based on radiographic evidence of deformity and self-reported pain. Disability was greatest when pain and deformity occurred together (F[2,151] = 18.8, P < 0.0001). Self-reported disability in the absence of deformity was predicted by body mass index, pain threshold, and anxiety symptoms; disability was predicted by the number of osteophytes and depressive symptoms when pain and deformity occurred together. CONCLUSION: Self-reported disability in osteoarthritis of the knee is greatest with concurrent pain and joint deformity. When pain and deformity do not cooccur, disability appears to be related to separate factors, including anxiety and pain threshold (e.g., tenderness).

Infectious etiology of vasculitis: diagnosis and management.

Vasculitides are a heterogeneous group of syndromes characterized by inflammation of the vessel wall. Several microbial pathogens have been known or suspected to cause vasculitis, and the development of molecular biology has promoted the search and confirmation of infectious agents in idiopathic vasculitis. Though several agents present primarily as an infectious process with vasculitis as an occasional manifestation, vasculitis may be the major manifestation of disease. Less definitive, and more controversial, is the role of infection and inflammation of the vessel wall in the pathogenesis of atherosclerotic disease. Clinical features can be nonspecific, and a high index of suspicion is required in order to make a diagnosis of vasculitis. Infection should always be excluded based on appropriate cultures and serologic assays, and, if confirmed, early and aggressive treatment should be instituted. However, in many instances, especially if there is a delay in the diagnosis, surgical intervention becomes necessary to treat the associated anatomic and physiologic sequelae.

Aortitis.

Aortitis is defined as an inflammatory process that involves one or more layers of the aortic wall (internal elastic lamina, tunica media, and adventitia) and can be caused by multiple mechanisms. Clinical features are usually nonspecific and a high index of suspicion is required for making the diagnosis. Although noninvasive imaging studies are being increasingly used in evaluating patients for diagnosis, angiography remains the gold standard for confirming aortic involvement. When tissue is available, pathologic examination can aid in clarifying the diagnosis. Aortitis, irrespective of the underlying cause, frequently displays similar clinical, pathologic, and arteriographic features and therefore understandably presents a therapeutic and diagnostic dilemma. Whatever the cause, early identification and aggressive treatment is required in order to avert the potentially life-threatening sequelae. The treatment of aortitis is determined by the underlying cause. If diagnosed early, infectious aortitis responds to appropriate antimicrobial therapy, whereas noninfectious, immune-mediated aortitis requires immunosuppressive therapy. However, in many instances, primarily because of the delay in diagnosis, surgical intervention is necessary to treat the associated anatomic and physiologic sequelae. Less definitive and more controversial is the role of inflammation in both primary and secondary accelerated atherosclerosis of the aorta and its modality of treatment.

Isolated superior mesenteric artery vasculitis with response to glucocorticoids.

This report describes a patient with abdominal pain at presentation, which on angiography was found to be caused by vasculitis limited to the superior mesenteric artery. He was treated with oral glucocorticoids after an initial 5-day course of pulse therapy and obtained excellent relief of symptoms. Steroids were tapered over 8 months. Repeat angiography revealed complete resolution of the vasculitis with a residual aneurysm of a branch of the left gastric artery, which was resected to avoid the risk of rupture. Histologic analysis revealed thickened intima with myxoid degeneration and no evidence of active vasculitis. Extensive laboratory and clinical investigations did not reveal an underlying connective tissue disorder to account for the gastrointestinal vasculitis. This report of an angiographically defined regional vasculitis involving the superior mesenteric artery with complete clinical as well as radiologic resolution on treatment with glucocorticoids alone emphasizes the need to differentiate between an isolated or regional vasculitis, which has an excellent prognosis, to avoid subjecting the patient to cytotoxic therapy with significant toxicities.