Biomedical subjects
Publications and source records attributed to F Wolfe.
Important contributions to the understanding of rheumatic diseases can be made by clinicians in university and nonuniversity settings performing research as part of ordinary patient-care activities. This article describes in detail cost-effective methodologies that have been used to develop successful, longitudinal research and clinical care databanks. Specific forms and detailed recommendations are also included.
Because they accurately and efficiently tap into important aspects of rheumatic disease status and outcome, health status questionnaires have found increasing use in the clinic, controlled clinical trials, and observational studies. This article reviews utility assessment methodologies as well as generic and disease-specific health status questionnaires relevant to rheumatology.
This article describes a methodology for the establishment and maintenance of a longitudinal rheumatoid arthritis database, addresses concerns regarding validity and reliability of longitudinal data collection in the setting of clinical care and research, and describes and recommends specific variables for minimal, moderate, and extensive levels of database detail.
OBJECTIVE: To investigate relationships between sex, pain threshold and fibromyalgia (FM) symptoms in the general population. METHODS: Data were obtained from a randomized populations survey of 3,006 persons in Wichita, KS and a subsample of 391 who completed a detailed interview and had an examination. Tender point counts, dolorimetry scores, clinical and psychological variables were measured. RESULTS: Dolorimetry scores were 2.04 kg/cm (1.42-2.66) lower in women than men, and women were almost 10 times more likely to have 11 tender points [OR 9.6 (2.00-46.3)] than men. Women are also more likely to have FM symptoms than men: "Pain all over," [OR 3.94 (1.34-11.38)], sleep disturbance [OR 3.06 (1.45-6.46)], fatigue [OR 4.52 (2.03-10.09)], and irritable bowel syndrome [OR 5.23 (1.83-14.96)]. Tender point counts are more correlated with FM symptoms than dolorimetry scores. CONCLUSION: Symptoms of FM are correlated with pain threshold in the general population, but tender point counts correlate better than dolorimetry. These 2 measures of pain threshold assay different but overlapping factors. Pain threshold is lower in women; and women have more FM symptoms. Decreased pain threshold correlates with all of the symptoms of FM, even in those who do not meet criteria for the syndrome. This suggests that decreased pain threshold, as measured by the tender point counts, is an intrinsically important aspect of patient distress, regardless of the extent and kind of concomitant disease; and that much can be learned about patients by employing this examination.
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Radiographs of the hand, hip and knee were screened for evidence of osteoarthritis (OA). Specific sites selected for screening on the postero-anterior radiographs of the hand included the base of the thumb with distal and proximal interphalangeal joints; these regions were examined for formation of marginal osteophytes, joint space narrowing and subchondral lucency. Sites selected from antero-posterior radiographs of the hip included the acetabular and femoral portions of the joint; these regions were examined for joint space narrowing, subchondral lucency, marginal osteophytes and subchondral sclerosis. Sites selected from antero-posterior weight-bearing radiographs of the knee included distal femora and proximal tibiae including the medial and lateral compartments; these regions were examined for joint space narrowing, marginal osteophytes and subchondral sclerosis. Sites selected from axial views of the patellofemoral joint examined the medial and lateral portions; these regions were examined for joint space narrowing, osteophytes, subluxations and subchondral sclerosis. A set of photographic prints was made from the collection of radiographs. These specific features of OA were graded on each print and a subset of prints was selected that best demonstrated the spectrum of severity for each feature of OA. This resultant atlas is offered as an updated guide to standardize interpretation of radiographs prior to and during clinical trials.
OBJECTIVE: To compare the frequency of diffuse idiopathic skeletal hyperostosis (DISH), based on an evaluation of chest radiographs, in 2 populations of patients: those with and without rheumatoid arthritis (RA). METHODS: Cases of RA were obtained from the Wichita Arthritis Center databank and controls from a private cardiology practice. Patients with RA and controls had to be older than 50 years and have a chest radiograph available. All radiographs were read, in haphazard order, by a single reader who classified them as definitely DISH, probably DISH (these 2 categories were considered as having DISH), uncertain, probably not DISH, and definitely not DISH (these 3 groups defined the absence of DISH). Logistic regression was used to investigate the probability of DISH while controlling for age and sex. Analyses were conducted to take into account the sensitivity and specificity of chest radiographs for the diagnosis of DISH. RESULTS: Among 748 radiographs (357 RA and 391 controls), 29 were diagnosed as DISH (21 controls and 8 RA). The mean age for the RA group was 66.2 yrs (SD = 11.9 and 108 (30.2%) were men. Control subjects had a mean age of 69.6 yrs (SD = 11.4 and 139 (35.4%) were men. The DISH patients, compared with those without DISH, were more likely to be male (p = 0.004) and older (p < 0.001). After accounting for age and sex, the relative risk of DISH in RA versus the controls was 0.40 (95% confidence interval: 0.20 to 1.01). After taking into account the sensitivity and specificity in this population, the adjusted prevalence of DISH for the RA group was 1% (95% confidence interval: 0.1 to 3.7) and 3.1% (95% confidence interval: 0.2 to 7.9) for the control group. CONCLUSION: We confirmed the increase in frequency of DISH with increasing age and male sex, but failed to support an increased association of DISH with RA.
The correlation between dietary cholesterol, high plasma lipids and cardiovascular disease is well recognized in many species. The purpose of the present study was to examine the effects of high cholesterol and moderately high fat intake of n-3 polyunsaturated fish oil diets on serum lipids in male rats. Male rats were fed either 21% menhaden oil (Control) or 21% menhaden oil with high (2%) cholesterol (MOC) for eight weeks. Whole blood was collected, and analyzed spectrophotometrically for serum cholesterol, triglycerides and lipoproteins. The selected tissues were carefully removed, weighed and analyzed for lipid profiles. The aortas were removed and lipogenesis determined. The results showed that except for spleen the total percent lipid content of heart, lung, liver, adrenal, kidney and brain was not affected in the MOC group. The percent fat content of spleen but not the weight was elevated by 4 fold compared to control. The hematocrit values in the MOC group were unaltered. Serum cholesterol was elevated by 62%, whereas the serum triglycerides and HDL cholesterol were unaltered in MOC group when compared to the MO control. High cholesterol feeding did not affect aortic lipogenesis in the MOC group compared to the control. These results suggest that cholesterol feeding along with n-3 polyunsaturated fish oil diet did not attenuate the anti-atherosclerotic effects of fish oil with the exception of serum cholesterol.
STUDY DESIGN: This study investigated the use of mechanically elicited electromyograms during the placement of pedicle screws in 89 patients undergoing surgery for spinal stenosis. SUMMARY OF BACKGROUND DATA: Several methods for monitoring nerve roots are available. However, mechanically elicited electromyograms may be more sensitive to mechanical irritation of nerve roots by pedicle screws than by other methods. METHODS: Mechanically elicited electromyograms were recorded in muscle groups innervated by cervical or lumbar nerve roots. Confirmation of surgical activity with the level of the electromyogram was correlated. RESULTS: Results indicated that mechanically elicited electromyograms are extremely sensitive to nerve root irritation. Compared to other methods, electromyograms are a viable alternative. CONCLUSIONS: Results from this study indicated that mechanically elicited electromyograms are sensitive and specific to nerve root firings and should be considered for use during the dynamic phases of surgery.
OBJECTIVE: To determine the risk and causes of death and to quantify mortality predictors in patients with rheumatoid arthritis (RA). METHODS: RA patients (n = 3,501) from 4 centers (Saskatoon n = 905, Wichita n = 1,405, Stanford n = 886, and Santa Clara n = 305) were followed for up to 35 years; 922 patients died. RESULTS: The overall standardized mortality ratio (SMR) was 2.26 (Saskatoon 2.24, Wichita 1.98, Stanford 3.08, Santa Clara 2.18) and increased with time. Mortality was strikingly increased for specific causes: infection, lymphoproliferative malignancy, gastroenterologic, and RA. In addition, as an effect of the SMR of 2.26, the expected number of deaths was increased nonspecifically across all causes (except cancer), with a large excess of deaths attributable to cardiovascular and cerebrovascular diseases. Independent predictors of mortality included age, education, male sex, function, rheumatoid factor, nodules, erythrocyte sedimentation rate, joint count, and prednisone use. CONCLUSION: Mortality rates are increased at least 2-fold in RA, and are linked to clinical severity.
OBJECTIVE: To evaluate the efficacy and tolerability of oral methotrexate (MTX) in rheumatoid arthritis (RA) in a long-term prospective trial. METHODS: One hundred twenty-three patients with RA who completed a 9-month multicenter randomized trial comparing MTX and auranofin enrolled in this 5-year prospective study of MTX. RESULTS: Significant (P = 0.0001) improvement compared with baseline was noted in all clinical disease variables, functional status, and the Westergren erythrocyte sedimentation rate (ESR). "Marked improvement" occurred in 87 (71%) and 85 (69%) of the patients, respectively, in the joint pain/tenderness index and the joint swelling index at the last evaluable visit. Forty-four patients (36%) withdrew during the study. Eight (7%) withdrew due to lack of efficacy, and 8 (7%) due to adverse experiences, including 1 patient with cirrhosis. At 5 years, 64% of patients were still taking MTX and completed the study. CONCLUSION: This large prospective study of long-term MTX treatment demonstrates sustained clinical response and improvement in the Westergren ESR and functional assessment scores, with an acceptable toxicity profile.
This report describes a case of fibromyalgia developing following a workplace injury, but in which the issues of compensation and work disability were not relevant. A previously healthy 37-year-old woman developed back and groin pain after lifting a heavy box. Over the next months, pain and allodynia gradually spread over her body, and headaches, sleep disturbance, paresthesias, and bowel symptoms developed for the first time. The pain was constant and severe, invading and interfering with every area of daily function. Surprisingly, no previous case reports or definition of post-traumatic fibromyalgia could be found. This case report, narrated by the patient, suggests that there is such an entity as post-traumatic fibromyalgia, and that central nervous system plasticity plays a central role.
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42 women were randomized to receive either placebo or fluoxetine at 20 mgs per day. Inter and intra group differences in clinical variables were evaluated after 3 and 6 weeks of treatment. Except for self rated anxiety which improved in the placebo treated group at 3 weeks, no differences between groups were noted. For those receiving fluoxetine both AIMS Anxiety (4.0 baseline vs. 3.3, p = 0.04) and Depression scores (2.6 baseline vs. 1.9, p = 0.03) improved at 3 weeks; however, improvement in the Beck Depression Scale did not reach significance (11.8 vs. 9.4, p = 0.34). At 6 weeks, both AIMS Depression (2.6 at baseline and 1.5 at 6 weeks, p = 0.03) and Beck Depression Scales (11.8 at baseline vs. 8.3 at 6 weeks, p = 0.04) showed improvement, as did sleep quality (9.6 vs. 7.6, p = 0.03). But no other variable had a significant change from baseline at either the 3 or 6 week point. Our data do not suggest that fluoxetine improves the signs and symptoms of fibromyalgia.
OBJECTIVES: To determine normal limits for erythrocyte sedimentation rate (ESR) in rheumatology clinics based on observations from patients with noninflammatory disorders (NID); to determine the proportion of patients with osteoarthritis (OA) excluded from clinical trials because of elevated ESR; to determine the proportion of patients with rheumatoid arthritis (RA) meeting ESR criteria for remission, clinical activity, and eligibility for clinical trials; and finally, to explain elevations of ESR in OA. METHODS: Cross sectional and longitudinal study of all rheumatic disease clinic outpatients with RA (N = 1,556, ESR = 12,683) and NID (N = 3,961, ESR = 5,706). RESULTS: For all NID the 90th, 95th percentiles were 33, 40 for women and 23, 31 for men. For patients with OA, 21.2% of women and 8.5% of men had ESR > or = 30 mm/h. ESR in women with OA but not men with OA or those with RA were significantly associated with body mass index. Twenty-nine (29.4) percent of men and 41.6% of women with RA satisfied the ESR remission criterion. When the active disease criterion was considered (ESR > or = 28 mm/h), only 54.5% of men and 62.6% of women, on the average, have active RA. CONCLUSION: The upper limit for normal ESR for women through age 60 is about 38 mm/h. A significant proportion of patients with RA with active disease will satisfy the ACR ESR criterion for remission, but only 54-63% of patients being treated in a rheumatology clinic will have active disease (ESR > or = 28 mm/h). Current use of the ESR as a criterion in clinical trials and remission criteria while based on wide clinical experience is contradictory and may not reflect actual data.
Fibromyalgia can be a difficult diagnosis when confounding factors such as concomitant illnesses and psychosocial abnormalities are prominent. Additionally, some patients who appear to have fibromyalgia will not meet current classification criteria. Criteria for clinical diagnosis are suggested. The diagnosis of fibromyalgia means that the clinical believes that the fibromyalgia construct explains the patient's signs and symptoms; however, not all who satisfy criteria need to be diagnosed or will be helped by verbal diagnosis. Appropriately done, making or withholding diagnosis can help patients improve as well as helping those who are not sick, but are worried, remain healthy (and happier) nonpatients.
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Version 2 of the Arthritis Impact Measurement Scale (AIMS2), together with the Medical Outcomes Study 36-Item Short Form Health Survey provide two state-of-the-art health-status instruments. The Medical Outcomes Study can be used in all illnesses, including rheumatic diseases. The AIMS2 incorporates new items concerning work status, satisfaction, attribution of problems to arthritis, and self-designation of priority areas for improvement. Measure of osteoarthritis and ankylosing spondylitis and review of the measures used to assess these illnesses were comprehensively evaluated, and data on reliability, sensitivity to change, sample size, and clinically significant change were provided this year, supplying an invaluable resource for trialists and clinicians.