RADAI-5 to monitor rheumatoid arthritis.

Providing the physician with sufficient information about the disease course can be regarded as the most important requirement for any disease assessment tool besides easy applicability and time-sparing documentation. Applying the RADAI-5 in daily routine provides the patient's view at any time completing the questionnaire. In a first study, the RADAI-5 resulted to be highly significantly correlated to the RADAI, and all composite indexes. Changes of the RADAI-5, the DAS28-ESR, and the CDAI were significantly correlated, indicating the instrument's sensitivity to change. A second study including 392 RA patients led to the establishment of thresholds for disease activity categories according to the RADAI-5, as follows: 0.0 up to 1.4 for a remission-like state, 1.6 up to 3.0 for mild disease activity, 3.2 up to 5.4 for moderate and from 5.6 up to 10.0 for high disease activity. In a third study, remission according to the RADAI-5 appeared to be highly specific for the ACR/EULAR criteria for remission The RADAI-5 questionnaire constitutes an easily applicable tool for routine RA monitoring, providing physicians with reliable information about the disease course and sensitivity enough to sound the alarm should complications occur.

Comparison of three rheumatoid arthritis disease activity scores in clinical routine.

OBJECTIVE: To evaluate whether the revised disease activity cut-off values for the Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI) are in congruence with the Disease Activity Score including a 28-joint count (DAS28) disease activity criteria in daily clinical routine. PATIENTS AND METHODS: A total of 570 rheumatoid arthritis (RA) outpatients were assessed and categorized according to the DAS28, the SDAI, and the CDAI. These results were compared to the respective DAS28 disease activity categories. Statistical evaluation was carried out by calculating alpha, the Spearman rank correlation, and kappa-statistics. RESULTS: DAS28, SDAI, and CDAI levels were significantly correlated to one another on a group level (p < 0.001). Internal consistency was the highest for the CDAI (alpha = 0.783) and the lowest for the DAS28 (alpha = 0.664). Kappa-statistics revealed a substantial degree of agreement with respect to mild, moderate, and high disease activity according to the three scores, with exceptions concerning the definition of a remission-like state. Further categorization showed that an additional 44% of patients were found to be in remission according to the DAS28 disease activity criteria relative to those defined by the SDAI or the CDAI disease activity categories respectively. CONCLUSION: The revised SDAI limits for disease activity and the respective CDAI thresholds proved to be in congruence with the DAS28 disease activity categories in daily clinical routine. The SDAI and the CDAI were found to be more stringent in defining remission.

A tool for the assessment of hand involvement in rheumatic disorders in daily routine--the SF-SACRAH (short form score for the assessment and quantification of chronic rheumatic affections of the hands).

OBJECTIVE: To establish a questionnaire for quantification of hand involvement in osteoarthritis (OA) of the hands and rheumatoid arthritis (RA) meeting daily routine requirements. PATIENTS AND METHODS: The smallest number of questions of the modified score for the assessment and quantification of chronic rheumatic affections of the hands (M-SACRAH) providing reasonable reliability was identified by factor analysis and calculating Cronbach's alpha, subsequently resulting in a five-item scale, the short form-SACRAH (SF-SACRAH), which was then administered to 176 RA and 71 hand-OA (HOA) patients simultaneously with the M-SACRAH. Additionally, patient's satisfaction (PatSAT) with disease status was assessed (according to the Austrian school marking system from 1 to 5). Gamma was calculated to assess the agreement of the SF-SACRAH with the M-SACRAH and between the single corresponding questions of different formats. The Wilcoxon rank test was applied to estimate the relationship between PatSAT and the SF-SACRAH. RESULTS: Alpha for the SF-SACRAH in 176 RA and 71 HOA patients amounted to 0.869 and to 0.897, respectively, indicating high internal consistency. In both patient groups the SF-SACRAH was found to be significantly correlated to the M-SACRAH (both P(s)<0.01). Agreement between the corresponding questions of both scales was significant in both patient groups by calculating gamma (average gamma 0.683 in HOA and 0.847 in RA). PatSAT and SF-SACRAH values were highly significantly correlated (P<0.001) proving the score's external validity. CONCLUSION: The SF-SACRAH proved to be a brief and practicable tool to assess hand involvement in OA and RA meeting the requirements of daily routine.

SDAI/CDAI levels in rheumatoid arthritis patients are highly dependent on patient's pain perception and gender.

OBJECTIVE: To determine whether the Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI) are equally applicable for the total population with rheumatoid arthritis (RA). METHODS: Five hundred and fifty-seven outpatients with RA [432 females, 125 males; median age 64 years (range 18-85); median disease duration 48 months (range 2-548)] were enrolled consecutively in this cross-sectional study. SDAI, CDAI, patient's assessment of pain on the visual analogue scale (VAS) 0-100, rheumatoid factor (RF), and disease duration were recorded. Linear regression analysis was performed for each confounding factor. RESULTS: The median SDAI for all 557 patients was 11.6 (range 0.07-46.60) and the median CDAI was 10.7 (0.00-42.10). The median SDAI was 12.2 (0.07-46.60) in females and 8.0 (0.10-35.20) in males. The respective medians for the CDAI were 11.3 (0.00-42.10) and 7.1 (0.00-32.00). These differences were highly statistically significant (p<0.001). Patient's assessment of pain on the VAS 0-100 scale had a median value of 32 mm. Regression analysis revealed a highly significant relationship between SDAI/CDAI levels and patient's pain rating (SDAI: r = 0.660, p<0.001; CDAI: r = 0.671, p<0.001). On multiple regression analysis, pain exerted a highly significant influence on SDAI and CDAI levels (p<0.001), whereas age, disease duration, and RF were not correlated with either level. CONCLUSION: SDAI and CDAI values are highly dependent on the patient's pain perception and gender. The effects of patient's age, disease duration, and RF were inconclusive with respect to the values of the respective disease activity indexes.

[European League Against Rheumatism evidence-based recommendations for diagnosis and management of gout]. / Evidenzbasierte Empfehlungen der "European League Against Rheumatism" zur Diagnostik und Therapie der Gicht.

Gout cannot be regarded a benign disease, as it is unfortunately often misunderstood. In view of the lack of recent evidence-based recommendations for the diagnosis and management of gout, the European League Against Rheumatism (EULAR) decided to commission a task force to develop such recommendations. A literature search was performed to comprehensively assess the clinical and epidemiological aspects, diagnostic tools, as well as effectiveness of therapeutic measures and the overall management. Subsequently, consensus among the participating experts should be achieved by applying a Delphi process. As a result of this project 10 recommendations for diagnosis of gout as well as 12 recommendations with respect to the management of the disease could be elaborated. Gout can be regarded as a disease with excellent prognosis in the light of the diagnostic and therapeutic possibilities available. However, this only holds true if all these possibilities are applied in the appropriate manner in daily routine. It constituted the primary goal of the EULAR project to deliver a substantial contribution to improve routine care of affected patients.

Lack of agreement between patients' and physicians' perspectives of rheumatoid arthritis disease activity changes.

OBJECTIVE: To obtain information on changes in patients' satisfaction (PATSAT) and physicians' global assessment (PhGASS) with regard to rheumatoid arthritis (RA) activity fluctuations. METHODS: Eighty-eight RA outpatients out of 207 investigated were assessed for 3 months on average after the initial evaluation. PATSAT (1 = excellent to 5 = unsatisfactory), PhGASS (visual analogue scale 1-100), and the 28-joint Disease Activity Score (DAS28) were assessed as at the first evaluation. The only prerequisite for enrolment was any therapeutic change at the first visit. Changes in PATSAT (SATCH) and PhGASS (PhGACH) were categorized and subsequently related to the DAS28 changes. Statistical evaluation was carried out by the Kruskal-Wallis test, the Mann-Whitney U-test, and by kappa statistics. RESULTS: To achieve a positive SATCH (n = 26/88 patients), a median DAS28 reduction of -1.06 (-25.0%) was necessary, whereas a considerably lower median increase of +0.16 (+10.5%) caused a negative SATCH. PhGASS (n = 38/88 patients) changed positively on a median DAS28 reduction of -0.82 (-16.0%), whereas it worsened at a mean DAS28 increase of +0.55 (+16.5%). Approximately 60% congruence between SATCH and PhGACH could be observed (kappa = 0.139). The DAS28 values preceding a positive SATCH and PhGACH were significantly higher (p < 0.001) than before a negative change. CONCLUSION: The patients' perspective with respect to improvement or worsening of RA is asymmetric. In contrast to the physicians' perspective, patients require greater improvement to be satisfied and less deterioration to be dissatisfied. These results may provide additional guidance in considerations about defining response and non-response in RA.

The patient's perspective and rheumatoid arthritis disease activity indexes.

BACKGROUND: Monitoring disease activity in rheumatoid arthritis (RA) patients by composite indexes is regarded as obligatory when following the recent recommendations for therapy. Whether these recommendations and the patient's perspective are in congruence is a crucial question with respect to the patient's compliance. The aim of the study was to obtain information on the patient's perspective with respect to the disease activity indexes used most often. METHODS: Two hundred and seven RA patients (157 female, 50 male; mean age 59.03 yr, 17-86 yr) were enrolled in this cross-sectional evaluation. The patients' satisfaction [PATSAT (Austrian school mark system) 1 = excellent to 5 = unsatisfactory] and the patients' attitude to therapy (PATATT 1 = reduction, 2 = no change, 3 = increase) were assessed and related to the 28-joint Disease Activity Score (DAS28), the Simplified Disease Activity Index (SDAI) and the Modified Health Assessment Questionnaire (M-HAQ). Statistical evaluation was carried out by applying the Mann-Whitney U test, calculating chi2 and ANOVA. RESULTS: According to the DAS28 and the M-HAQ, patients were at a moderately active disease stage and had low functional deficiency. PATSAT was significantly correlated to the disease activity indexes (all PS < or = 0.002). The mean DAS28 (2.56) at PATSAT 1 was within the remission range, whereas at PATSAT 5 a mean of 5.52 indicated highly active disease. PATATT was found to be related to PATSAT, but did not completely parallel it. Reduction of therapy was intended at a mean DAS28 of 2.87, whereas a request for an increase did not occur before a mean DAS28 of 4.92. CONCLUSION: The patients' therapeutic attitudes are somewhat in line with their satisfaction, which mirrors disease activity to a great extent, though not with the common therapeutic recommendations. The DAS28 proved to be superior to both other indexes taking account of the patient's perspective. These results may provide guidance in patient care and education as well as therapeutic strategies.

Development of the M-SACRAH, a modified, shortened version of SACRAH (Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands).

OBJECTIVES: The Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (SACRAH) is a self-administered questionnaire assessing functional status, stiffness and pain in patients suffering from hand osteoarthritis (HOA) as well as rheumatoid arthritis (RA) of the hand. It consists of 23 questions in three domains, to be answered on 100 mm visual analogue scales (VAS). Our goal was to shorten the original SACRAH by elimination of redundant questions in order to make it easier to use for patients and physicians. METHODS: Following an arbitrary procedure employing high intervariable correlations, redundant questions were eventually eliminated. To validate the shortened version, 60 patients with HOA, recruited at four rheumatological centres in Austria, completed the original SACRAH as well as the shortened version. Fifty-five patients suffering from RA of the hands treated at the Second Department of Medicine, Humanis Klinikum Stockerau, also completed both questionnaires. RESULTS: A total of 11 questions (nine from the function domain and two from the pain domain) were eliminated, leading to the modified score consisting of 12 questions. Comparing the results of SACRAH and M-SACRAH, as well as the domain scores in individual patients, correlation coefficients were r = 0.978 for HOA patients (P < 0.0001) and r = 0.986 for RA patients (P < 0.0001). CONCLUSION: M-SACRAH, the shortened and simplified version of the original SACRAH questionnaire, proved to be as reliable and as representative as SACRAH for hand status in individual HOA and RA patients.

The DAS28 in rheumatoid arthritis and fibromyalgia patients.

OBJECTIVE: To compare the DAS28 (Disease Activity Score including a 28-joint count) values of rheumatoid arthritis (RA) and fibromyalgia (FM) patients, and to establish whether high pain levels and impaired mood influence DAS28 values. METHODS: DAS28 values were calculated in 62 consecutive patients with RA and in 26 patients suffering from FM. Values for DAS28 scores as well as for the single items of the patient cohorts were compared using Student's t-tests. To evaluate the item weighting and internal consistency of the total score factor analysis was performed and Cronbach's alpha calculated. RESULTS: RA patients showed a mean DAS28 score of 4.23 (+/-1.2; range 0.77-7.46) and in FM patients the mean DAS28 came to 4.04 (+/-1.13; range 1.19-6.28). DAS28 values of RA and FM patients were not significantly different statistically. Comparing the single components of the score, however, highly significant differences (P<0.0005) occurred between RA and FM patients. Cronbach's alpha for the DAS28 in RA patients amounted to 0.7329, indicating high internal consistency, whereas in FM patients it was 0.4832. CONCLUSION: The DAS28, as expected, proved to be inappropriate to express disease activity in FM patients. DAS28 values for expressing disease activity in RA patients may be flawed by coexisting FM and should therefore be regarded with caution as high pain levels more than impaired mood may lead to higher total scores.

SACRAH: a score for assessment and quantification of chronic rheumatic affections of the hands.

OBJECTIVES: To establish a questionnaire to quantify the extent of the function and activities of the hand in patients with degenerative or inflammatory disease of the hand and finger joints. METHODS: One hundred and seventy-two patients with osteoarthritis (OA, n = 69) or rheumatoid arthritis (RA, n = 103) completed a new questionnaire, the SACRAH, that included 23 visual analogue scales covering the extent of hand function, stiffness and level of pain. SACRAH scores may range from 0 to 100. RESULTS: Comparing all studied patients, there was no significant difference in SACRAH scores between OA and RA patients (34 vs 32, not significant). Scores for both patient groups differed significantly from those for 30 healthy controls. Among patients taking NSAIDs only, individuals suffering from OA (n = 50) scored significantly lower than RA patients (n = 42) (36 vs 48, P < 0.004). Sixty-one RA patients taking DMARDs scored lower than the RA patient group treated with NSAIDs only (20 vs 48, P < 0.0001). Thirty-two RA patients were evaluated longitudinally at their first visit and 3 months after the initiation of DMARDs. Following therapy, SACRAH scores were significantly reduced from 50 to 11 (P < 0.0001). CONCLUSIONS: The questionnaire enables the quantification of compromised hand function, stiffness and pain in OA and RA patients, and is sensitive to therapy-related changes in RA patients.

Peripheral quantitative CT of the forearm: scanner cross-calibration using patient data.

Bone density measurements by peripheral quantitative CT (pQCT) of the distal radius in 87 women (age 38.4 +/- 12.3 years) were obtained on a both a Stratec XCT 900 and an updated version XCT 1400. Axial area, and total and trabecular bone mineral density (BMD) results from both scanners were compared for all patients using linear regression analysis. To achieve scanner calibration we used the intercept and slope of the patients' correlations. The correlations of the patients' values were good for area (r = 0.83) as well as total BMD (r = 0.90) and excellent for trabecular BMD (r = 0.97). The cross-calibration approach in our study provided compatibility of pQCT for trabecular and total ROIs, the clinically mostly utilized volumes of measurement.

Increase of axial and appendicular trabecular and cortical bone density in established osteoporosis with intermittent nasal salmon calcitonin therapy.

The aim of this study was to examine the effect of intranasal administration of salmon calcitonin to a group of 24 postmenopausal women with severe, established osteoporosis (t score < -2.5 SD) and more than one vertebral fracture. The patients were treated with 200 IU of nasal salmon calcitonin daily for 2 months with a subsequent pause of 2 months (3 cycles) and 500 mg calcium daily over a total of 12 months in an open randomized study. The patients were compared with an age matched control group of 18 women of a similar clinical status who were treated with calcium and vitamin D only. In the nasal calcitonin treatment group an increase in the trabecular axial bone density of 2.8% was achieved, as well as increase in trabecular appendicular (forearm) bone density of 1.6%, together with a cortical bone density increase of 1.8% axial and 1% appendicular. Initially, elevated values of urinary deoxypyridinoline were found in 12 women in the nasal calcitonin treatment group; these levels returned to normal under salmon calcitonin nasal therapy and documented the inhibition of increased osteoclastic activity. Cyclic intermittent calcitonin nasal therapy led to a general increase in trabecular and cortical axial and appendicular bone density, marked alleviation of the subjective sensation of pain, and a reduction in the daily dose of accompanying nonsteroidal anti-inflammatory drugs by 50%.