How aggressive should initial therapy for rheumatoid arthritis be? The Finnish experience.
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Antirheumatic Agents↗
Biomedical subjects
H Kautiainen
Publications and source records attributed to H Kautiainen.
Lymphoma in patients with dermatitis herpetiformis and their first-degree relatives.
BACKGROUND: The risk for lymphoma is increased in both dermatitis herpetiformis (DH) and in coeliac disease. The lymphoma most associated with coeliac disease is enteropathy-associated T-cell lymphoma. OBJECTIVES: To study the occurrence and type of lymphoma in a large series of patients with DH and their first-degree relatives. METHODS: The occurrence of lymphoma was studied in 1104 patients consecutively diagnosed with DH in two university hospitals during 1969-2001. A questionnaire was sent to 341 patients to examine the occurrence of lymphoma in their 1825 first-degree relatives. To analyse whether the DH patients with lymphoma had adhered to a gluten-free diet similarly to the patients without lymphoma, two age- and sex-matched patients with DH served as controls for each index case. Data on the gluten-free diet were collected from prospectively completed dietary forms and also from medical records. RESULTS: Eleven (1%) patients contracted lymphoma 2-31 years after the diagnosis of DH. Eight had B-cell-type lymphoma, two enteropathy-associated T-cell lymphoma and one remained unclassified due to missing material. Three (0.2%) of the first-degree relatives contracted lymphoma, all B-cell type. The 11 DH patients with lymphoma had adhered to a gluten-free diet significantly less strictly than the DH controls without lymphoma. CONCLUSIONS: The present study documents that patients with DH can have both B- and T-cell lymphoma. The DH patients with lymphoma had not adhered as strictly to the gluten-free diet as the control patients without lymphoma. The occurrence of lymphoma in the first-degree relatives was lower than in the patients with DH.
Adult↗
Associations between self-estimated and measured physical fitness among 40-year-old men and women.
The aim was to evaluate whether 40-year-old men and women are able to estimate their level of fitness compared with actual measured physical fitness. Twenty-nine men and 35 women first completed a questionnaire at home and then their physical fitness was measured at laboratory. The index of self-estimated physical fitness was calculated by summing up the scores of self-estimated endurance, strength, speed and flexibility. The index of self-estimated endurance was calculated by summing up the scores of self-estimated endurance and those of the self-estimated distance they could run, cycle, ski and walk. The index of measured physical fitness was calculated by summing up the z-scores of a submaximal bicycle ergometer test, ergojump tests (counter-movement jump and jumping in 15 s), a 30-s sit-up test, hand-grip tests and a sit-and-reach test. The correlation (Spearman) between the indices of self-estimated and measured physical fitness was 0.54 for both sexes, and that between self-estimated endurance and measured endurance was 0.53 for both sexes. Maximal oxygen uptake estimated based on submaximal ergometer test was higher among those with longer self-estimated distance of running, cycling, skiing and walking (P for linear trend <0.001). Our study shows that 40-year-old adults can estimate at group level their fitness according to different categories moderately well. They can also estimate at group level their endurance moderately well by estimating the distance they can run, cycle, ski or walk. However, in some individuals self-estimation of fitness is not in agreement with the results of fitness tests.
Adult↗
Capability for daily activities in old people with rheumatoid arthritis: a population based study.
OBJECTIVE: To describe the functional capacity for daily activities in old people with clinical rheumatoid arthritis (including juvenile rheumatoid arthritis (JRA)) in a population based cohort. METHODS: A cohort of 700 people was randomly collected from the population older than 75 years in a Finnish town. Altogether 601 persons (86%) participated. Data were collected from clinical records and by interview, clinical examination, and questionnaire. Ability to carry out activities of daily living (ADL) was assessed by the Barthel index, and the IADL (instrumental activities of daily living) by the Lawton and Brody questionnaire. RESULTS: 16 people had clinical rheumatoid arthritis (one with JRA). The prevalence was 16/601 (2.7% (95% confidence interval, 1.7% to 4.5%)). Eight patients with rheumatoid arthritis (50%) obtained the best possible ADL figures, while three (19%) had very poor results. Seven (44%) could not dress themselves without help. Three (19%) were unable to walk, and five (31%) could not climb stairs. Sex and age adjusted results showed no statistical difference (ADL and IADL) between patients with clinical rheumatoid arthritis and rest of the cohort. Four patients (25%) had dementia, which was associated with the poor functional capacity. CONCLUSIONS: The prevalence of the disease was unexceptional. The ability of old people with rheumatoid arthritis to carry out activities of daily living did not differ from the general population, but the disease may lead to severe disability on an individual level, especially when associated with dementia. It therefore remains a considerable challenge to the health care and social systems.
Activities of Daily Living↗
Predictors of productivity loss in early rheumatoid arthritis: a 5 year follow up study.
OBJECTIVE: To explore baseline risk factors for productivity loss and work disability over 5 years in patients with early, active RA. PATIENTS AND METHODS: In the FIN-RACo trial, 195 patients with recent onset RA were randomised to receive either a combination of DMARDs with prednisolone or a single DMARD for 2 years. At baseline, 162 patients were working or available for work. After 5 years' follow up, data on sick leave and retirement were obtained from social insurance registers or case records. The cumulative duration of sick leaves and RA related disability pensions was counted for each patient. To analyse predictors of productivity loss, the patients were divided into four groups according to duration of work disability per patient year. RESULTS: Patient's and physician's global assessment of RA severity > or =50 and HAQ score > or =1.0 were risk factors for extension of productivity loss (OR (95% (CI) 1.77 (1.00 to 3.16), 1.85 (1.03 to 3.32), and 1.78 (1.01 to 3.14), respectively). Additional risk factors were low education level (2.40 (1.18 to 4.88)) and older age (1.03 (1.00 to 1.06)); combination treatment was a protective factor (0.59 (0.35 to 0.99)). CONCLUSION: At baseline, the risk of future productivity loss is best predicted by education level, age, global assessments of RA severity, and HAQ score.
Arthritis, Rheumatoid↗
Favourable social functioning and health related quality of life of patients with JIA in early adulthood.
OBJECTIVE: To evaluate the social functioning and health related quality of life (HRQoL) in patients with juvenile idiopathic arthritis (JIA) in early adulthood. METHODS: The patient files of the Rheumatism Foundation Hospital were screened to identify patients born in 1976-1980 diagnosed as having JIA. HRQoL was measured by the RAND 36-item health survey 1.0; spousal relationships and educational and employment status were assessed by questionnaire. The patients were invited to a follow up study. Age and sex matched controls from the community were identified in the Finnish population registry. RESULTS: Of 187 patients identified, 123 participated. Spousal relationships, educational level, and employment status were similar to controls. HRQoL in JIA patients was similar to controls except on the physical functioning scale. At follow up 35% of patients were in remission. Patients with active disease had poorer HRQoL in the physical component than those in remission or controls. The extended oligoarthritis group had the lowest physical and mental score in HRQoL compared with the other JIA subgroups. The patient's own evaluation was the explanatory factor in both the physical and mental component of HRQoL. CONCLUSION: Social functioning and HRQoL were similar in JIA patients and age, sex, and municipality matched controls. However, patients with extended oligoarthritis attained significantly lower scores in the physical and mental component of HRQoL than oligo- or polyarthritis patients. Special attention in everyday care should be paid to those patients who have active disease or the extended oligoarthritis type of disease.
Adult↗
Laboratory markers of systemic inflammation as predictors of bloodstream infection in acutely ill patients admitted to hospital in medical emergency.
The aim of the present study was to determine whether the presence of an infectious focus or of fever alone can predict bloodstream infection and whether levels of C-reactive protein, procalcitonin, interleukin (IL)-6, IL-8, and soluble IL-2 receptor (sIL-2R) improve the diagnosis of community-acquired bloodstream infection. Markers of systemic inflammation were studied in 92 patients with community-acquired infection. On admission to hospital, 54 patients had an infectious focus, 25 had fever without an infectious focus, and 13 had neither. The presence of focus or fever predicted bloodstream infection (n=13 patients) with a sensitivity of 100% (95% confidence interval, 75-100), a specificity of 16% (95%CI, 9-26), a negative predictive value of 100% (95%CI, 75-100), and a positive predictive value of 16% (95%CI, 9-26). Positive predictive values of C-reactive protein, procalcitonin, IL-6, IL-8, and sIL-2R, all measured on admission, were also low (33-44%). Eight febrile patients in whom an infectious focus was found during a 3-day follow-up period had higher on-admission IL-6 (P=0.005) and sIL-2R (P=0.046) levels than did 17 febrile patients without an infectious focus. In conclusion, markers of systemic inflammation do not improve the diagnosis of community-acquired bloodstream infection; however, they may aid in identifying patients with fever due to occult infection.
Acute Disease↗
Long term safety of methotrexate in routine clinical care: discontinuation is unusual and rarely the result of laboratory abnormalities.
OBJECTIVE: To analyse patients with rheumatoid arthritis, treated with methotrexate in a weekly academic rheumatology clinic over 13 years, for continuation of courses and reasons for discontinuation. METHODS: All 248 patients with an analysable longitudinal course who took methotrexate in standard care between 1990 and 2003 were studied. Continuation of courses was analysed using life tables. All abnormal and severely abnormal values for aspartate aminotransferase (AST) >40 U/l, >80 U/l, albumin <35 g/l, <30 g/l, white blood cell (WBC) count <4.0 x 10(9)/l, <3.0 x 10(9)/l, and platelet count <150 x 10(9)/l, <100 x 10(9)/l, were identified. Responses of the clinician and subsequent laboratory values were reviewed. RESULTS: Over 1007 person-years, the probability of continuing methotrexate over five years was 79% (95% confidence interval, 72% to 84%). Severe laboratory abnormalities occurred in 2.9 per 100 person-years, specifically 0.9 for AST >80 U/l, 1.1 for albumin <30 g/l, 0.7 for WBC <3.0 x 10(9)/l, and 0.3 for platelets <100 x 10(9)/l. No severe laboratory abnormality progressed to further severity or clinical disease. Permanent discontinuations of methotrexate occurred in 46 patients (19%), 26 (10% of all patients) for adverse effects, 15 (32.6%) for inefficacy; only two discontinuations resulted from laboratory abnormalities, both of WBC, possibly from other sources. CONCLUSIONS: Methotrexate was associated with a high rate of continuation, and few clinically significant laboratory abnormalities. Discontinuation primarily reflected clinical rather than laboratory findings. Vigilance for methotrexate toxicity is required but methotrexate appears among the safest treatments for rheumatoid arthritis.
Antirheumatic Agents↗
Pain and joint mobility explain individual subdimensions of the health assessment questionnaire (HAQ) disability index in patients with rheumatoid arthritis.
OBJECTIVE: To explore the associations between individual subdimensions of the health assessment questionnaire (HAQ) and clinical variables in patients with rheumatoid arthritis. METHODS: 304 patients with rheumatoid arthritis (73% female, mean (SD) age, 58 (13) years; disease duration 6 (9) years, 69% rheumatoid factor positive) completed the HAQ for functional capacity (0-3) and a 100 mm visual analogue scale for pain. Grip strength, range of motion of the large joints, Larsen score for radiographic damage of hand and foot joints, and the number of tender and swollen joints were recorded. A logit regression model was used to study associations between subdimensions of the HAQ and other variables. RESULTS: Mean (range) total HAQ score was 0.92 (0 to 2.88) and varied from 0.73 to 1.04 in the subdimensions. Disability was lowest in the "walking" and highest in the "reach" subdimension. Pain was an explanatory variable in all individual subdimensions. Decreased grip strength, limitation of shoulder and wrist motion, and a larger number of swollen and tender joints in the upper extremities were related to several subdimensions. A higher pain score and swollen joint count in the upper extremities, decreased grip strength, and limited motion of wrist, shoulder, and knee joints explained increased disability (higher total HAQ scores). CONCLUSIONS: In patients with rheumatoid arthritis, pain and range of movements of joints have the greatest impact on individual subdimensions of the HAQ. Extent of radiographic damage in peripheral joints and the number of swollen and tender joints are of lesser importance for function.
Activities of Daily Living↗
Antibodies against cyclic citrullinated peptide (CCP) and levels of cartilage oligomeric matrix protein (COMP) in very early arthritis: relation to diagnosis and disease activity.
OBJECTIVE: To measure serum levels of antibodies against cyclic citrullinated peptide (anti-CCP antibodies) and serum cartilage oligomeric matrix protein (COMP) in patients with early joint inflammation, and to study the correlation of these two tests with clinical measurements. METHODS: Adult patients with recent-onset arthritis, of <3 months' duration, were referred from primary healthcare centres to rheumatologists. Serum levels of anti-CCP antibodies and COMP at baseline were analysed by enzyme immunoassay (EIA) and compared with clinical baseline data. RESULTS: Sixty-nine patients were included. The specificity of the anti-CCP antibody test for RA was 96%, and the sensitivity was 44%. There was a significant difference between the four diagnosis groups in the anti-CCP antibody test, probability (p)<0.001, whereas no significant differences were found concerning COMP. The baseline serum COMP test correlated with age (p=0.0001), joint score for swollen joints (p=0.02), and C-reactive protein (CRP) (p=0.02). CONCLUSION: This study confirms the high diagnostic specificity of anti-CCP antibodies for rheumatoid arthritis (RA) in a prospective population-based study of very early arthritis. Raised serum COMP levels were common in all diagnosis groups in this series, indicating cartilage involvement in both self-limiting and non-erosive disease.
Adult↗
Nickel allergy and orthodontic treatment.
OBJECTIVES: Tolerance induction to prevent development of nickel allergy has been suggested with permanent dental braces. We wanted to find out which effect orthodontic treatments had had on the development of nickel allergy in university students. STUDY DESIGN: We examined and patch tested 153 students, of whom 113 had a history of pierced skin, and 70 a history of orthodontic treatment roughly 10 years earlier. RESULTS: All except one student with pierced skin were females. Development of nickel allergy was significantly associated with skin piercing (54% compared with 12%). At the time of the study, there was a slight but non-significant difference in the prevalence of nickel allergy between students who had been subjects for orthodontic treatment (49%) compared with non-treated ones (58%) if they had pierced skin. There were no significant differences in the development of nickel allergy among students who had had permanent dental braces before (50%) or after skin piercing (48%). However, from 40 students without skin piercing four of 11 (three males) with a history of permanent braces had developed nickel allergy, as compared with none of 22 (P = 0.008) without orthodontic treatment suggesting possibility of sensitization through dental devices. CONCLUSIONS: Orthodontic treatment may not lead to tolerance induction on all occasions, and sensitization through permanent devices seems to be possible.
Adolescent↗
Oral findings in coeliac disease and Sjögren's syndrome.
OBJECTIVE: Both coeliac disease (CD) and Sjogren's syndrome (SS) have an autoimmune background and increased risk of oral mucosal and dental abnormalities. Individuals suffering concomitantly from CD and SS could even be at a higher risk. STUDY DESIGN: Oral mucosal and dental abnormalities were examined in 20 patients with CD + SS (mean age 61 years) and compared with age- and sex-matched controls with either CD or SS. RESULTS: Oral mucosal changes were most common in SS (80%), followed by CD + SS (65%) and CD (40%). Coeliac-type dental enamel defects were found in 89% in CD + SS and in 88% in CD compared with only 25% in SS (P < 0.001). The median number of teeth was six in the CD + SS, 24 in the CD and 22 in the SS group. The DMF index was higher (P < 0.005) in the CD + SS than in the CD group. CD + SS was characterized by higher salivary flow rate (P < 0.001) and lower inflammatory focus score in the salivary glands (P < 0.01) than SS. CONCLUSIONS: The co-occurrence of CD and SS should be recognized because of its effects on dental and oral mucosal health. A lower salivary gland inflammatory focus score and higher salivary flow rate in CD + SS than in SS suggests that a gluten-free diet treatment may alleviate autoimmune inflammation.
Aged↗
Sustained maintenance of exercise induced muscle strength gains and normal bone mineral density in patients with early rheumatoid arthritis: a 5 year follow up.
OBJECTIVE: To investigate at 5 years whether an initial 2 year home based strength training period imposes sustained effects on muscle strength, bone mineral density (BMD), structural joint damage, and on disease activity in patients with early rheumatoid arthritis (RA). METHODS: Seventy patients were randomised either to perform home based strength training with loads of 50-70% of repetition maximum (EG) or range of motion exercises (CG). Both groups were encouraged to take part in aerobic activities 2-3 times a week. Maximal muscle strength of different muscle groups was measured by dynamometers, and BMD at the femoral neck and lumbar spine by dual x ray densitometry. Disease activity was assessed by the 28 joint disease activity score, and joint damage by x ray findings. RESULTS: 62 patients completed 2 years' training and 59 patients attended check up at 5 years. Mean (SD) maximum muscle strength indices increased from baseline to 2 years-in EG from 212 (78) kg by a mean (95% CI) of 68 (55 to 80) and in CG from 195 (72) kg by 35 (13 to 60) kg-and remained at that level for the next 3 years. Development of BMD in EG tended to be more favourable than that in CG. Muscle strength training was not detrimental to joint structures or disease activity. CONCLUSION: The patients' exercise induced muscle strength gains during a 2 year training period were maintained throughout a subsequent self monitored training period of 3 years. Despite substantial training effects in muscle strength, BMD values remained relatively constant. Radiographic damage remained low even at 5 years.
Adult↗
Validity of the Nottingham Health Profile in a Finnish out-patient population with rheumatoid arthritis.
OBJECTIVE: To assess the quality of life of 122 rheumatoid arthritis (RA) patients using the Nottingham Health Profile (NHP), which is a generic quality-of-life instrument, and to compare the results with those of 99 healthy local control subjects. METHODS: Our patient group represented consecutive out-patients from a central hospital. The NHP contains 38 items, each with a weighted score, that assess subjective distress on six dimensions: mobility, pain, energy, sleep, emotional reactions and social isolation. RESULTS: The median (age-adjusted) NHP scores for mobility, pain and energy showed statistically highly significant differences (P < 0.001) between the RA patients and the control group, indicating a poorer quality of life among the RA patients on all these dimensions. These NHP dimensions were also closely related to patients' experience of their overall health status. The NHP scores for sleep, emotional reaction and social isolation did not differ between the patients and the controls. CONCLUSION: The NHP, an instrument for assessing health-related quality of life, differentiated RA patients from local healthy individuals on the dimensions of mobility, energy and pain.
Adult↗
The costs of early inflammatory joint disease: a population-based study in southern Sweden.
OBJECTIVE: To study the costs and use of healthcare for patients during the first months with early joint inflammation, in a population-based prospective referral study in Southern Sweden. METHODS: Adult patients with arthritis for < 3 months and with onset of symptoms between 1 May 1999 and 1 May 2000 were referred from primary health centres to rheumatologists. Four clinical assessments were performed during a 6-month follow-up period. The direct medical costs for inpatient stays, outpatient visits, visits to general practitioners, and visits to health professionals, as well as costs for medication, radiographs, and laboratory tests were recorded from the onset of the disease up to 6 months of follow-up. Indirect costs for sick leave were also recorded. RESULTS: Fifty-six of 71 referred patients agreed to participate. Thirteen (23%) had RA, 21 (38%) had reactive arthritis (ReA), 14 (25%) had undifferentiated arthritis, and eight (14%) had other arthritides. The median cost per patient in the entire group was USD 3362. The median cost per patient in the RA group was USD 4385, and USD 4085 in the ReA group. There was no statistically significant difference in the median costs per patient in the different diagnostic groups. Sick leave accounted for 44% of the total costs in the entire group, and 46% and 47%, respectively, in the RA and ReA groups. CONCLUSION: The costs of early arthritis are already considerable during the first months of the disease following the onset of the symptoms. The indirect costs due to sick leave accounted for nearly half of the costs.
Arthritis, Reactive↗
Evaluation of the arthritis impact measurement scales (AIMS2) in Finnish patients with rheumatoid arthritis.
OBJECTIVE: To evaluate the validity and reliability of the Finnish version of the Arthritis Impact Measurement Scales (AIMS2) in Finnish patients with rheumatoid arthritis (RA). METHODS: The reliability of the Finnish AIMS2 (Finn-AIMS2) questionnaire was assessed by test retest procedure and internal consistency of health-status scales. Construct validity was assessed by factor analysis, and convergent validity by correlation coefficients, with several disease activity and functional status variables. RESULTS: Internal consistency was 0.79-0.89 and test retest reliability 0.72-0.97. Factor analysis identified three factors: physical, psychosocial, and pain. There were strong correlations between the Finn-AIMS2 health-status scales and the Health Assessment Questionnaire (HAQ). CONCLUSION: The Finn-AIMS2 questionnaire is a reliable and valid instrument for measuring health status in middle-aged Finnish patients with RA. The results also support the applicability of AIMS2 in comparisons in multinational studies.
Activities of Daily Living↗
Can we rely on magnetic resonance imaging when evaluating unstable atlantoaxial subluxation?
OBJECTIVES: To examine whether functional radiography and functional magnetic resonance imaging (MRI) are equally efficient in detecting the extent of unstable anterior atlantoaxial subluxation (aAAS) in rheumatic patients. METHODS: 23 patients with unstable aAAS (diagnosed by functional radiography) were examined by functional MRI because of a neck symptom. Twenty two patients had rheumatoid arthritis and one had juvenile idiopathic arthritis. aAAS was diagnosed if the anterior atlantoaxial diameter (AAD) was >3 mm and was considered unstable if the AAD differed by >2 mm between flexion and extension radiographs. The AAD was measured from radiographs (flexion and extension) and MRI images (flexion and neutral). RESULTS: The extent of aAAS during flexion measured by radiography was greater than that found by MRI in all 23 patients (mean difference 3 mm (95% confidence interval 2 to 4)). In four (17%) patients flexion MRI could not demonstrate aAAS detected by radiography. The difference between the AAD measurements during flexion by these two methods was substantial (that is, >or=4 mm) in nine (39%) cases. Severe aAAS (>or=9 mm) was seen in 15 (65%) patients by functional radiography and in four (17%) by functional MRI. CONCLUSIONS: The magnitude of aAAS was often substantially smaller when measured by functional MRI rather than by functional radiography. Thus one cannot rely on the result of functional MRI alone; functional radiographs are needed to show the size of unstable aAAS. The maximal extent of the subluxation must be taken into account when the possible compression of neural structures is evaluated by MRI.
Adult↗
US assessment of hip joint synovitis in rheumatic diseases. A comparison with MR imaging.
PURPOSE: To assess the significance of ultrasonography (US) in detecting hip joint synovitis in patients with rheumatic diseases. MATERIAL AND METHODS: Forty patients with rheumatic disease and suspected hip joint synovitis underwent MRI and US of the hip joint. In addition to the throughout MRI evaluation, the anterior collum-capsule distance (CCD) was determined by both MRI and US. Thirteen healthy volunteers were examined with MRI to establish the criteria for normal findings in MRI when classifying hip joints to those with synovitis and those without. MRI was used as a gold standard. RESULTS: Synovitis was found using MRI in 31 hips of 22 patients (9 patients had bilateral synovitis). The intraclass correlation was 0.61 between MRI and US in measuring CCD. In classifying hip joint synovitis with US, the sensitivity of the method was 87% and specificity 42%, when the CCD criterion for synovitis was determined to be > or = 7 mm. If the cut-off point was raised to 9 mm, the sensitivity decreased to 61% while specificity increased to 94%. A difference in CCD of > or = 1 mm between the hips as an additional criterion for synovitis increased the number of false-positive findings. CONCLUSION: Measurement of CCD with US proved to be a rather inaccurate method to point out synovitis in rheumatic patients when using MRI as a reference. The main reason for this result was the thickened capsule, which US could not differentiate from a thickened synovium.
Adolescent↗