OBJECTIVE: To examine the macroscopic vascular pattern of early synovitis in psoriatic arthritis (PsA), reactive arthritis (ReA), and rheumatoid arthritis (RA) and to assess the reliability of the grading features for synovitis. METHODS: Forty-four patients (14 PsA, 12 ReA, and 18 RA) with knee synovitis who were undergoing arthroscopy were assessed. Video recordings of the examination were scored independently by 3 arthroscopists who were blinded to the patient's identity and clinical details. Features of vascularity, villous formation, pannus, granularity, and capillary hyperemia were recorded and kappa values (-1 or =0.8) for features of vascularity, villous hypertrophy, and pannus. Seventy-three percent of the PsA and ReA patients had predominantly tortuous, bushy vessels; 89% of the RA patients had mainly straight, branching vessels. CONCLUSION: The distinct vascular patterns in PsA and ReA compared with those in RA may reflect different specific vascular factors in the pathogenesis of these arthritides. Vascularity and villous hypertrophy are the most reliable features of synovitis grading.

Adult↗

PubMed1999

The relationship between synovitis and bone changes in early untreated rheumatoid arthritis: a controlled magnetic resonance imaging study.

OBJECTIVE: The interrelationship between synovitis and bone damage in rheumatoid arthritis (RA) is a subject of controversy. Using magnetic resonance imaging (MRI), this study followed the bone changes in early RA and determined their relationship to synovitis. METHODS: Thirty-one patients with early RA who had swelling of the metacarpophalangeal (MCP) joints and 31 healthy control subjects with no clinical evidence of arthritis underwent MRI of the second through fifth MCP joints of the dominant hand by use of a 1.5T scanner. Coronal T1-weighted and T2-fat suppressed (FS) sequences were performed to evaluate bone edema, and gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA) pulse sequences were obtained to evaluate synovitis. Bony abnormalities were described as bone edema (low signal on T1-weighted sequences and intermediate/high signal on T2 FS sequences adjacent to the bone cortex) or as bone cysts (circular juxtacortical abnormalities with low signal on T1-weighted images and with very high signal on T2 FS sequences). Contrast and noncontrast MRI films were scored in a blinded manner, and Fisher's exact probability test was used to determine differences between groups. RESULTS: Twenty-one of the 31 RA patients (68%) had bone edema, which was seen in 43 of 124 joints (35% of joints) and 3 of the 31 control subjects had bone edema seen in 3 of 124 joints (2% of joints) (P < 0.0001). Thirty RA patients (97%) had Gd-DTPA-confirmed MCP joint synovitis, and bone edema was seen in 40 of the 75 joints with Gd-DTPA-proven synovitis (53%), but in only 3 of 49 without (6%) (P < 0.0001). CONCLUSION: MCP joint bone edema is present in the majority of patients with RA at presentation, but is seen only occasionally in normal control subjects. The fact that bone edema occurred rarely in the absence of synovitis in patients with RA suggests that bony changes in RA are secondary to synovitis.

Adult↗

PubMed1999

The relationship between pityriasis rubra pilaris and inflammatory arthritis: case report and response of the arthritis to anti-tumor necrosis factor immunotherapy.

Pityriasis rubra pilaris (PRP) refers to a group of erythematous, scaling dermatologic conditions that have been associated with seronegative arthritis. We report a case of polyarthritis in a young man with PRP in which magnetic resonance imaging suggested an entheseal-based pathology for the joint disease. The arthritis, but not the skin condition, demonstrated dramatic response to anti-tumor necrosis factor immunotherapy.

Adolescent↗

PubMed1999

Persistence of mild, early inflammatory arthritis: the importance of disease duration, rheumatoid factor, and the shared epitope.

OBJECTIVE: To determine the factors that predict clinical outcome at 6 months for patients with mild, early inflammatory arthritis. METHODS: Sixty-three patients with mild, untreated, early arthritis were given a single dose of corticosteroids at presentation. Administration was intramuscular if disease was polyarticular (n = 53) or intraarticular if patients had <5 synovitic joints (n = 10). The primary outcome measure was clinical disease remission or persistence of arthritis at 6 months following injection. RESULTS: At 6 months following injection, 49 of the 63 patients (78%) had persistent inflammatory joint disease. The other 14 (22%) had clinical disease remission. Regression analysis showed that only disease duration was significantly associated with persistent arthritis (P < 0.05). The other significant factor (by chi-square test) was the presence of the shared epitope (SE). Of the patients fulfilling the American College of Rheumatology (ACR) criteria at presentation (51% of the total), 53% with disease duration of < or = 12 weeks at presentation had persistent disease 6 months later, compared with 94% of those who presented with disease duration of >12 weeks. CONCLUSION: The strongest predictor of persistent disease was a disease duration of >12 weeks. Rheumatoid factor and SE were also predictors to a lesser extent. Patients who both fulfilled the ACR classification criteria for rheumatoid arthritis (RA) and had a short disease duration included some with an excellent prognosis. Therefore, 12 weeks may be a more appropriate disease duration to use for the RA classification criteria. Administering a bolus of corticosteroids may be a useful diagnostic/therapeutic approach.

Adrenal Cortex Hormones↗

PubMed1999

Evaluation of finger ultrasound in the assessment of bone status with application of rheumatoid arthritis.

Osteoporosis associated with active rheumatoid arthritis (RA) has been demonstrated in both the axial and peripheral skeleton, especially the periarticular regions more directly affected by the disease. Quantitative ultrasound (QUS) is a recently accepted tool for the assessment of bone status, and therefore could be used to monitor bone changes in RA patients. In a cross-sectional study we measured ultrasound velocity (Ad-SOS) through the proximal phalanges in three groups of female subjects. These included: 51 patients with rheumatoid arthritis (group 1), 44 general practitioner (GP)-referred patients for osteopenia (group 2) and 52 young healthy volunteers (group 3). For groups 1 and 2 bone mineral density (BMD) of the lumbar spine and proximal femur were also measured. For the RA patients BMD of the hand, measurement of hand function (HAQ and grip strength) and disease activity (ESR and CRP) were also assessed. The precision of long-term Ad-SOS measurements on volunteers gave a root mean square coefficient of variation (CV) of 0.7% and standardized CV of 3.6%. No statistically significant effect of dominance was observed in the measured Ad-SOS between the dominant and non-dominant hand (r = 0.96, p < 0.001). Ad-SOS was found to be significantly different in the three groups (p < 0.0001). Ad-SOS was highly dependent on age (r = -0.67), with a gradual reduction (-5.2 m/s per year) after the age of 30 years for female patients in both group 1 and group 2. Ad-SOS was significantly correlated with lumbar spine, femoral neck and hand BMD, with correlation coefficients of 0.49, 0.51 and 0.72 respectively for RA patients. Finger ultrasound was moderately correlated with measures of hand function, with coefficients of 0.37 and 0.39 for HAQ and grip strength respectively. Hand BMD also correlated to the same power with these parameters. Neither finger ultrasound nor BMD was significantly correlated with ESR and CRP (measures of disease activity). We have demonstrated that bone status can be assessed quickly and cheaply using a portable QUS device. Ad-SOS relates to the measure of hand function in RA patients. Longitudinal studies are required to determine the usefulness of finger ultrasound for monitoring disease progression or the effect of treatment in RA.

Adult↗

PubMed1999

The protein synthetic response to feeding: a fundamental question revisited.

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Animals↗

PubMed1999

Established rheumatoid arthritis.

Currently the diagnosis of rheumatoid arthritis (RA) may be difficult; the ACR criteria appear most sensitive and specific in long-standing disease. Without clear definition or diagnostic criteria for early disease it is difficult to define late or established RA. The distinction between early and established RA has been further blurred by recent imaging studies that suggest even in what is currently termed early disease, there is evidence of joint damage. The natural history of RA suggests that most patients with clinic-diagnosed RA have a progressively disabling course, but evidence is growing that modern therapeutic strategies result in better long-term outcomes, especially when applied early in the disease course. In established disease, quantitative markers such as C-reactive protein (CRP) give prognostic information, but in the pre-erosive, early phase of the disease the qualitative markers such as rheumatoid factor (RF) and shared epitope are crucial. As rheumatologists, our major aims must remain: (1) to diagnose the disease as early as possible; (2) to identify those patients with poor prognosis who will benefit most from targeted therapy; and (3) to aim for more intensive disease control irrespective of disease duration.

Arthritis, Rheumatoid↗

PubMed1999

COX-1, COX-2: so what?

The discovery of the second isoform of cycloxygenase has led to a rapid expansion in basic science, pharmacology and clinical data. With the completion of phase II studies of the new COX-2 specific inhibitors this review examines some of the implications of the new data.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1999

Disease modification in rheumatoid arthritis with leflunomide.

Rheumatoid arthritis (RA) is characterized by chronic inflammation and irreversible destruction of articular cartilage and bone. Disease progression as assessed by radiographic imaging of structural joint damage is a key outcome measure in RA. Joint damage is especially rapid during early phases of RA, thus the current trend of early aggressive therapy with disease-modifying antirheumatic drugs (DMARDs). Radiographic analysis of disease progression with the novel DMARD leflunomide was compared to methotrexate and sulfasalazine in two large, placebo-controlled, randomized Phase III studies (N = 580). The results as indicated by changes in x-ray scores indicate that leflunomide and both active comparators slow disease progression significantly better than placebo (P < or = 0.01). Slowing of disease progression with leflunomide was similar to sulfasalazine at 6 months but better than methotrexate (P < or = 0.049) at 12 months. These data verify the ability of leflunomide to slow disease progression and confirm its disease-modifying potential.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1999

Vision of the future in arthritis care.

Demographic changes during the next 10-20 years will significantly affect the future of arthritis care. Not only will the prevalence of chronic diseases increase among an increasingly aging population, but so will their incidence. The management of chronic diseases will become the primary clinical challenge for many physicians, especially rheumatologists. Patients will present to their rheumatologists expecting an accurate diagnosis to be made at the onset of their symptoms. To do so, clinicians will have to establish the pathophysiologic bases of the different types of arthritis, most likely through the use of sophisticated imaging techniques, such as high-resolution ultrasound. Treatment approaches will become more targeted. Agents that specifically inhibit the cyclooxygenase-2 (COX-2) isozyme will likely be used for symptomatic relief in arthritis patients. Other therapies will be targeted toward cartilage regeneration. suppression of the inflammatory process, and inhibition of metalloproteinases.

Adolescent↗

PubMed1999

Targeted therapies in rheumatoid arthritis: the need for action.

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Antirheumatic Agents↗

PubMed1999

Larsen scoring of digitized X-ray images.

OBJECTIVE: To determine how Larsen scores from digitized X-rays compare to those from film originals. METHODS: A hundred sets of radiographs of patients recruited with early rheumatoid arthritis (RA) were assessed using the Larsen scoring system. Digitized copies of these sets were then viewed on a computer screen and scored according to Larsen in a random order. The quality of the digitized image was also recorded. For each set of X-rays, the signed difference between the score from film and the score from the digitized images was calculated. RESULTS: A total of 95% of the digitized X-ray sets were scored successfully; 5% were not scored due to the images being unreadable. The mean difference between the two sets of scores was -1.2 (95% CI [-2.06, -0.37]). There was no trend in the difference with respect to the mean of the two scores (P>0.1). CONCLUSION: The Larsen scoring of digitized X-ray images has been validated.

Analog-Digital Conversion↗

PubMed1999

The current status of ultrasonography in rheumatology.

Explore the source record for details and available documents.

Arthritis, Rheumatoid↗

PubMed1999

Does the age of onset of rheumatoid arthritis influence phenotype?: a prospective study of outcome and prognostic factors.

OBJECTIVE: To identify factors affecting prognosis in patients with late-onset rheumatoid arthritis (RA). METHODS: A total of 400 patients with RA fulfilling the American College of Rheumatology criteria for diagnosis were prospectively recruited from two hospital rheumatology centres. Of these patients, 214 had disease onset above age 65 yr (LORA) and 186 below age 65 yr (YORA). Follow-up clinical, functional, laboratory and radiological assessments were compared. The Ritchie articular index (RAI) and joint erosions were used as markers of disease activity and damage, respectively. Disability was assessed using the Stanford Health Assessment Questionnaire (HAQ). RESULTS: At median follow-up of 3.6 yr, the frequency of joint erosions was similar (YORA, 51.6%; LORA, 54.2%). The remission rate was greater in the LORA group (YORA, 20.4%; LORA, 45.8%, P < 0.01). Factors associated with the development of erosions were: IgM rheumatoid factor (RF) seropositivity [odds ratio (OR) = 4.24, 95% confidence interval (CI) 2.56, 6.94], HLA DR4 (OR = 2.07, 95% CI 1.28, 3.35) and elevated inflammatory markers (OR = 1.81, 95% CI 1.04, 3.14). Continuous steroid use >3 months for the LORA group was associated with increased erosions (OR = 4.09, 95% CI 1.81, 9.27). LORA patients (OR = 2.99, 95% CI 1.77, 5.02) were more likely to go into remission and IgM RF-seropositive patients less likely to go into clinical remission (OR = 0.47, 95% CI 0.28, 0.77). Female patients with a high HAQ score at presentation experienced a poor functional outcome (female OR = 3.01, 95% CI 1.59, 5.68; high HAQ OR = 3.02, 95% CI 1.98, 4.62). CONCLUSION: LORA can be as damaging as classical RA and joint erosions are often observed at presentation. Being RF seropositive, DR4 positive, and having elevated inflammatory markers at onset, were associated with poor radiological outcome irrespective of age of onset. Being female and having marked disability at presentation were associated with poor functional outcome in both groups. These findings suggest that treatment approaches used in classical YORA should be instituted with equal vigour in patients with LORA.

Adult↗