Consecutive Rheumatoid Arthritis Patients Research Articles

Intermetatarsal Bursitis, a Novel Feature of Juxtaarticular Inflammation in Early Rheumatoid Arthritis Related to Clinical Signs: Results of a Longitudinal Magnetic Resonance Imaging Study.

Intermetatarsal bursae in the forefeet possess a synovial lining similar to joints and tendon sheaths. Inflammation of these bursae (intermetatarsal bursitis [IMB]) was recently identified as specific for early rheumatoid arthritis (RA). The present study was undertaken to determine if IMB is indeed an RA feature by assessing the following: 1) the association with other local inflammatory measures (synovitis, tenosynovitis, and osteitis), 2) the association with clinical signs, and 3) whether it responds to disease-modifying antirheumatic drug (DMARD) therapy similarly to other local inflammatory measures. One hundred fifty-seven consecutive early RA patients underwent unilateral contrast-enhanced 1.5T forefoot magnetic resonance imaging (MRI) at diagnosis. MRIs were evaluated for IMB presence and for synovitis, tenosynovitis, and osteitis in line with the RA MRI Scoring (RAMRIS) system (summed as RAMRIS inflammation). MRIs at 4, 12, and 24 months were evaluated for IMB presence and size in patients who had IMB at baseline and received early DMARD therapy. Logistic regression and generalized estimating equations were used. Anti-citrullinated protein antibody (ACPA) stratification was performed. Sixty-nine percent of RA patients had ≥1 IMB. In multivariable analysis on bursa level, presence of IMB was independently associated with local presence of synovitis and tenosynovitis, with odds ratios (OR) of 1.69 (95% confidence interval [95% CI] 1.12, 2.57) and 2.83 (95% CI 1.80, 4.44), respectively, but not osteitis. On the patient level, IMB presence was most strongly associated with tenosynovitis (OR 2.92 [95% CI 1.62, 5.24]). IMB presence was associated with local joint swelling (OR 2.7 [95% CI 1.3, 5.3]) and tenderness (OR 1.7 [95% CI 1.04, 2.9]) independent of RAMRIS inflammation. During treatment, IMB size decreased between 0 and 12 months. This decrease associated with decrease in RAMRIS inflammation, which was driven by synovitis decrease. Within ACPA-positive and ACPA-negative RA, similar results were obtained. IMB particularly accompanies inflammation of the synovial lining of joints and tendon sheaths, showed a similar treatment response after DMARD initiation, and associates with typical clinical signs. These findings suggest that IMB represents a frequently present novel RA feature of juxtaarticular synovial inflammation.

EVALUATION OF QUALITY OF LIFE SCALES ACCORDING TO DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS

Objective: In addition to disease activity in rheumatoid arthritis patients; variables such as pain, fatigue, depression, anxiety, and sleep quality are also associated with quality of life. We aimed to evaluate the relationship between disease activity and quality of life scales in rheumatoid arthritis. 
 Methods: In this cross-sectional study, 92 consecutive rheumatoid arthritis patients who applied to Ankara City Hospital Rheumatology outpatient clinic in January-December 2020 were included. Demographic, clinical features and laboratory data were recorded. DAS28 for disease activity and pain-visual analogue score(VAS) and fatigue-VAS, hospital anxiety-depression(HAD), Pittsburgh Sleep Quality Index (PSQI), and Nottingham Health Profile (NHP) forms for quality of life assessment were filled by one-on-one interviews. Patients were grouped according to disease activity such as: “Low-DAS28 group” and “High-DAS28 group”.
 Results: In comparison with DAS28, pain-VAS, and fatigue-VAS, and some NHP scores (such as the total score and pain, physical activity, and fatigue subgroup scores) were statistically significantly higher in the High-DAS28 group than the Low-DAS28 group. However, no difference was found in HAD scores. Except the sleep disorder subgroup was higher in the High-DAS28 group, total and other subgroups scores of the PSQI were similar.
 Conclusion: Improving the quality of life in patients with rheumatoid arthritis is one of the main objectives of treatment. A high disease activity seems to be more affecting the patients in terms of pain-VAS, fatigue-VAS, NHP total scores and NHP-pain, NHP physical activity subgroups than other the quality of life scales in patients with rheumatoid arthritis.

Disease characteristics in high versus low titers of rheumatoid factor or anti-citrullinated peptide antibody in rheumatoid arthritis patients

Aim of the workTo evaluate the impact of the level of rheumatoid factor (RF) or anti-citrullinated peptide antibody (ACPA) positivity on the clinical manifestations, disease activity, functional status, and treatment strategy among rheumatoid arthritis (RA) patients. Patients and methodsIn this study, 120 consecutive RA patients were grouped according to the level of RF or ACPA positivity. Group 1: patients with low positive RF or ACPA and Group 2: those with high titer. Disease activity score (DAS28) and functional status using modified health assessment questionnaire (MHAQ) were assessed ResultsThe patients mean age was 46.9 ± 10.9 years and female to male ratio was 7:1. 44 (36.7%) patients had low positive RF/ACPA titers, 59 (49.2%) had high titers and 17 (14.2%) had negative RF/ACPA and were excluded. Patients' global assessment of disease activity was significantly higher among patients with high RF/ACPA titer compared to those with low titer (p = 0.04) and MHAQ tended to be higher (p = 0.058). Subcutaneous nodules (p = 0.037) were more frequent among those with high RF/ACPA titer. The cumulative (p = 0.012) and the current (p = 0.006) steroid doses administered both turned out to be significantly higher in the high positive RF/ACPA patient group. ConclusionPatients with high titer RF and\\or ACPA have factors that may contribute to poor outcome as the presence of reduced functional status which indicated by the higher MHAQ score, the need for higher daily and cumulative steroid doses as an indirect indicator of increased disease activity and in turn poor outcome.

NT-proBNP and sRAGE levels in early rheumatoid arthritis

Objective Several biomarkers of cardiovascular function are found to be increased in rheumatoid arthritis (RA), with some suggesting a relationship with disease activity and improvement with adequate anti-rheumatic treatment. Promising biomarkers include N-terminal pro-brain natriuretic peptide (NT-proBNP) and the soluble receptor form of advanced glycation end-products (sRAGE). The objective of this study was to investigate associations between NT-proBNP and sRAGE levels and markers of inflammation and disease activity in early RA patients and their changes during (effective) anti-rheumatic treatment. Method Data from 342 consecutive early RA patients participating in the ‘Parelsnoer’ cohort were used. At baseline and after 6 months’ disease activity, NT-proBNP and sRAGE levels were assessed. Results After 6 months, NT-proBNP decreased from 83 pmol/L (mean) at baseline to 69 pmol/L at follow-up (p < 0.001), while sRAGE increased from 997 pg/mL to 1125 pg/mL (p < 0.001). A larger decrease in erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) was associated with larger changes in NT-proBNP and sRAGE. For every point decrease in ESR, there was a 1.7-point decrease in NT-proBNP and a 2.2-point increase in sRAGE. For CRP, these values were 1.7 and 2.7, respectively (p < 0.001). Conclusion Suppressing inflammation, independently of achieving remission, increases sRAGE levels and decreases NT-proBNP levels significantly. Whether this translates into a decrease in incident cardiovascular disease remains to be elucidated.

Sexual Dysfunction and Quality of Life in Patients with Rheumatoid Arthritis.

Background: Sexual health is a major component of human well-being. As repeatedly shown in research, satisfaction with sex life and sexual fulfillment correlate positively with quality of life (QoL) in most of its aspects. It is thus true that a reduced quality of one’s sex life and lack of sexual fulfillment can contribute to poorer QoL overall. The aim of this study is to describe an assessment of sexual dysfunction and factors affecting sexual dysfunctions of patients with rheumatoid arthritis (RA). Material and methods: 171 consecutive RA patients (mean age 48.3 ± 14.6) attending the rheumatology outpatient clinic. Standardized questionnaires used in the study were the sexological questionnaire, WHOQOL-BREF to assess QoL level, Disease Acceptance Scale, and VAS scale to assess pain intensity. Results: The mean duration of the disease in the study group was 13 ± 9 years, mean score of subjective assessment of mobility was 6.2 ± 1.6, and the mean score of the DAS-28 was 4.0 ± 1.9. The study group presented a mean level of disease acceptance (AIS 29.6 ± 11.6). The comparative analysis showed significant differences in reaching orgasm and declared sexual dysfunctions. These problems occurred more often in women than in men (34.2% vs. 18% and 43% vs. 40%, respectively). In univariate analysis, factors correlating positively with the frequency of declaring sexual dysfunction were subjective motor score less < 6 points, AIS < 36 points, WHOQOL-BREF < 59 points, disease activity ≥3.5 points, and VAS > 3. In multivariate logistic regression analysis, independent factors positively correlating with frequency of sexual dysfunction declaration were general QoL (β = 1.255; p = 0.035) and pain limiting social life (β = 1.564; p = 0.030). The absence of comorbidities correlated negatively and reduced the prevalence of sexual dysfunction (β = −1.030; p = 0.043). Patients with reduced QoL and patients with pain limiting social life had 3.5 and 4.8 times higher risk of sexual dysfunction than other patients, respectively. In contrast, those without comorbidities were 2.8 times more likely to be free of sexual dysfunction than those diagnosed with other chronic diseases besides RA. Conclusions: Sexual dysfunction is an emerging problem in both men and women with RA. The absence of comorbidities is an independent determinant of sexual dysfunction, whereas poor QoL and pain limiting social life are independent determinants that exacerbate sexual dysfunction in both genders.

Ultrasound-detected tenosynovitis as a risk factor for flares in rheumatoid arthritis patients in clinical remission.

Our objective was to investigate the value of ultrasound (US) detected synovitis and tenosynovitis as risk factors for short term flare in rheumatoid arthritis (RA) patients in clinical remission. Consecutive RA patients in clinical remission (DAS28 ERS < 2.6) for at least 3months underwent Power Doppler ultrasound (PDUS) examination of 1st to 6th extensor compartments at the wrist, 2nd to 5th finger flexor, posterior tibial tendon, and peroneal tendons. To assess synovitis, carpal joints, 1st to 5th metacarpophalangeal (MCP) joints, and 2nd to 5th interphalangeal proximal (IPP) joints were bilaterally examined. Synovitis and tenosynovitis were defined according to OMERACT. Patients were followed for 1year. Disease flare was defined as an increase in disease activity generating the need for a change in therapy by the attending rheumatologist. Ninety patients were included. After 1year of follow-up, 26 patients (29%) experienced a flare. At baseline 39%, 23% and 8% had US-detected synovitis, tenosynovitis or both, respectively. In the 1-year period after the baseline US examination, US-detected tenosynovitis (RR: 4.9; 95% CI: 2.2-10.8) was associated with an increased risk of exacerbation. This association was not shown with US-detected synovitis (RR: 1.3; 95% CI: 0.76-2.2). In the multivariate analysis, only subclinical tenosynovitis (OR: 9.8; 95% CI: 2.5-39.1; p = 0.001) and baseline DAS28 (OR: 5.7; 95% CI: 1.1-31.6; p = 0.047) were significantly associated with an increased risk of having a flare. In our study, subclinical tenosynovitis was associated with disease flare in patients with RA in clinical remission. • Synovitis and tenosynovitis are risk factors for short term flare in RA patients in clinical remission. • Subclinical tenosynovitis, but not synovitis, was associated with disease flare in patients with unstable remission. • Ultrasound-detected tenosynovitis could be useful to predict relapses in RA patients in clinical remission.

High patient global assessment scores in patients with rheumatoid arthritis otherwise in remission do not reflect subclinical inflammation.

To assess whether high patient global assessment (PGA) scores by patients with rheumatoid arthritis (RA) otherwise in remission reflect subclinical inflammation. Cross-sectional, single-center study, including consecutive RA patients. Remission states were defined based on the ACR/EULAR Boolean definition: 4V-remission (tender and swollen 28-joint counts (TJC28/SJC28), C-reactive protein (CRP), and PGA all≤1), PGA-near-remission (the same, except PGA>1), and non-remission (any of TJC28, SJC28, CRP>1). A blinded expert musculoskeletal ultrasonographer scanned 44 joints, 38 tendon sheaths, 4 bursae on the same day of the clinical evaluation. Each structure was assessed for the presence of Grey Scale synovial hypertrophy (GS) and Power Doppler (PD), both scored using a semi-quantitative scale (0-3 points). The Global OMERACT-EULAR Synovitis Score (GLOESS, 0-132, primary outcome), and a global tenosynovitis/bursitis score (GTBS) were compared between remission states, using non-parametric tests. Different sensitivity analyses comparing GS and PD subscores were performed. In total, 130 patients (mean age 63 years, 86% female, average disease duration 14 years) were included 40 being in 4V-remission, 40 in PGA-near-remission, 50 in non-remission. 4v-remission and PGA-near-remission presented similar median (IQR) GLOESS, [6 (5-11) and 4 (1-7), P>0.05, respectively] and GTBS [0 (0-1) and 0 (0-2), P>0.05, respectively]. The same was observed in GS, PD scores, and in global synovitis score considering only the 16 joints not included in 28-joint counts. These observations were confirmed in patients with≤5 years disease duration. Subclinical inflammation is not present among persons with elevated PGA who are otherwise in remission. PGA-near-remission patients would be exposed to the risk of overtreatment if current treatment recommendations were strictly followed. This study supports the need to reconsider the role of PGA in definitions used to target immunosuppressive therapy and to provide a separate and enhanced focus to the patient's experience of the disease.

The Relationship between Platelet Indices and Ultrasound, Clinical, Laboratory Parameters of Disease Activity in Patients with Rheumatoid Arthritis.

(1) Background: A proper assessment of disease activity is crucial for the management of a patient with rheumatoid arthritis (RA). Platelets seem to be involved in joint inflammation pathophysiology. Platelet indices (PIs) are markers of platelet activation, and include platelet count (PC), mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PCT). The purpose of the study was to assess the relationship between PIs and disease activity markers, both systemic (clinical, laboratory) and local (ultrasound, US), in patients with RA; (2) Methods: The study group consisted of 131 consecutive RA patients. The following assessments were performed: joint counts, Disease Activity Score (DAS28), complete blood cell counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and US of 24 small joints; (3) Results: Mean values of PIs remained within the normal reference ranges. Values of PC, PCT, PDW were significantly associated with disease activity markers, both clinical (DAS28, joint counts) and laboratory (CRP, ESR). In patients with high disease activity, PC, PCT were significantly higher and PDW lower. PC was positively correlated with Power Doppler US (PDUS) score. In patients with features of RA severity (antibodies positivity, extra-articular manifestations) PC and PCT were positively associated with all US parameters (Grey Scale US, PDUS, Global scores); (4) Conclusions: In patients with RA, PC and PCT may serve as positive disease activity markers and PDW may serve as a negative marker. PIs may be used as reliable, inexpensive markers of RA systemic activity; they may also serve as markers of local inflammation in the joints affected by RA.

Humoral Response to Microbial Biomarkers in Rheumatoid Arthritis Patients.

Background/Objective: Chronic humoral immune response against multiple microbial antigens may play a crucial role in the etiopathogenesis of rheumatoid arthritis (RA). We aimed to assess the prevalence and magnitude of antibody response against various bacterial and viral immunogen peptides in the sera of RA patients compared with the general population. Methods: Polyclonal IgG antibodies (Abs) specific for peptides derived from Porphyromonas gingivalis (RgpA, Kpg), Aggregatibacter actinomycetemcomitans (LtxA1, LtxA2), Mycobacterium avium subsp. paratuberculosis (MAP4027), Epstein–Barr virus (EBNA1, EBVBOLF), and human endogenous retrovirus (HERV-W env-su) were detected by ELISA in serum samples from 148 consecutive RA patients and 148 sex and age-matched healthy controls (HCs). In addition, the presence of a relationship between the positivity and the titer of antibodies and RA descriptors was explored by bivariate correlation analysis. Results: RA patients exhibit a higher prevalence of humoral immune response against all tested peptides compared to HCs with a statically significant difference for MAP4027 (30.4% vs. 10.1%), BOLF (25.7% vs. 8.1%), RgpA (24.3% vs. 9.4%), HERV W-env (20.3% vs. 9.4%), and EBNA1 (18.9% vs. 9.4%) peptides. Fifty-three (35.8%) out of 148 RA serum and 93 (62.8%) out of 148 HCs were negative for all pathogen-derived peptides. There was a significant correlation between OD values obtained by ELISA test against all peptides (p < 0.0001). We also found an increased titer and prevalence of Abs against LtxA1 and LtxA2 in seropositive vs. seronegative RF (p = 0.019, p = 0.018). Conclusion: This study demonstrates a significantly increased humoral response against multiple pathogens in patients with RA and implies that they could be an important factor in the pathogenesis of the disease. Therefore, the role of each individual pathogen in RA needs to be further investigated.

Moderate and High Disease Activity Predicts the Development of Carotid Plaque in Rheumatoid Arthritis Patients without Classic Cardiovascular Risk Factors: Six Years Follow-Up Study.

Patients with rheumatoid arthritis (RA) have a higher incidence of subclinical atherosclerosis and cardiovascular (CV) disease. It is postulated that the appearance of accelerated atherosclerosis in these patients is a consequence of the inflammation present in the disease. In this study, we aim to determine if baseline disease activity in patients with RA predicts the future development of carotid plaque. A set of consecutive RA patients without a history of CV events, cancer or chronic kidney disease, who did not show carotid plaque in a carotid ultrasound assessment, were prospectively followed up for at least 5 years. At the time of recruitment, CV risk factors and disease-related data, including disease activity scores, were assessed. At the end of the follow-up, a carotid ultrasound was repeated and patients were divided into two groups; those who developed carotid plaque, and those who did not. A multivariable regression analysis was performed to define the predictors for the development of carotid plaque. One hundred and sixty patients with RA were followed up for an average of 6 ± 1 years. After this time, 66 (41%) of the patients had developed carotid plaque, and 94 (59%) did not. Patients with carotid plaque were significantly older (47 ± 13 vs. 55 ± 9 years, p < 0.001) at baseline, were more frequently diabetic (0% vs. 6%, p = 0.028), and had higher total cholesterol (197 ± 36 vs. 214 ± 40 mg/dL, p = 0.004) and LDL cholesterol (114 ± 35 vs. 126 ± 35 mg/dL, p = 0.037) at the beginning of the study. After multivariable adjustment, patients who were in the moderate and high disease activity (DAS28-CRP) categories displayed a higher odds ratio for the appearance of carotid plaque (OR 2.26 [95% CI 1.02–5.00], p = 0.044) compared to those in the DAS-28-CRP remission category. Remarkably, when patients were divided in patients within the low-risk SCORE category, and patients included in the remaining SCORE categories (moderate, high and very high), the relation between DAS28-CRP and the development of carotid plaque was only significant in the low-risk SCORE category. In conclusion, disease activity predicts the future development of subclinical atherosclerosis in patients with RA.

Handgrip Strength Features in Rheumatoid Arthritis Patients Assessed Using an Innovative Cylindrical-Shaped Device: Relationships With Demographic, Anthropometric and Clinical Variables

To investigate the relationship between handgrip strength (HGs) features, evaluated with an innovative cylindrical-shaped grip device, and demographic, anthropometric and clinical variables, in patients with rheumatoid arthritis (RA). Consecutive RA patients were prospectively enrolled for this cross-sectional study. For each patient were collected demographic, anthropometric, clinical data related to disease activity. HGs was assessed in terms of area under the force–time curve (AUC-FeT), peak grip force and time to reach the curve plateau. The correlations between the variables were studied with the Spearman’s rho correlation coefficient. The receiver operating characteristic (ROC) curve analysis was used to test the discriminant accuracy of HGs features in identifying patients in moderate/high disease activity. A multivariate analysis was performed to estimate the contribution of covariates on the AUC-FeT. A significant correlation was found among AUC-FeT, age, Simplified Disease Activity Index (SDAI), Ultrasound-Clinical Arthritis Activity (US-CLARA) (all at p < 0.0001), and body mass index (BMI) (p = 0.0001). Any correlation was found between HGs and radiographic damage. The discriminatory power of AUC-FeT was good [area under-ROC curve = 0.810 (95% CI 0.746–0.864)]. Variables significantly associated with AUC-FeT in multivariate analysis were age (p = 0.0006), BMI (p = 0.012), gender (p = 0.004), SDAI (p = 0.047) and US-CLARA (p = 0.023). HGs is negatively influenced by demographic (gender and age), anthropometric (BMI), and disease activity variables (SDAI and US-CLARA). These findings highlight the role of HGs in RA patients' functional impairment and disability.

Ultrasound assessment of sarcopenia in patients with rheumatoid arthritis.

To evaluate the efficacy of ultrasound (US) as a diagnostic tool for sarcopenia in patients with rheumatoid arthritis (RA). Female RA patients aged >50 years and matched controls were cross-sectionally assessed. Sarcopenia was diagnosed based on the 2019-updated Asian Working Group for Sarcopenia definition. The cross-sectional area (CSA) and echo intensity (EI) of the biceps brachii, rectus femoris, and EI of the vastus lateralis were examined bilaterally. Correction for subcutaneous fat and calculation of the recorrected EI (rcEI) were performed. We performed logistic regression using both muscle rcEI and CSA with receiver operating curve analysis to evaluate the discriminative performance per muscle group. Seventy-eight consecutive RA patients and 15 age-and sex-matched controls were assessed. Sarcopenia was diagnosed in 34 RA patients (43.6%). The rcEI of examined muscles were significantly higher, whereas CSA were significantly lower in sarcopenic RA patients than in non-sarcopenic patients and matched controls. The combined discriminative performance of rcEI and CSA was superior to those of rcEI or CSA alone. This study suggests the use of US for the diagnosis of sarcopenia in RA patients. The diagnostic performance increases when both echogenicity and CSA are considered together rather than individually.

Should we reconsider the definition of elderly-onset rheumatoid arthritis in an ageing society?

The management of elderly-onset rheumatoid arthritis (EORA) is challenging due to progressive functional disability, increased comorbidities, and high drug-related risks. EORA is defined as disease onset after 60 years since 1985. We assessed whether this cut-off age was optimal in a progressively ageing society. This study used two cohorts of consecutive rheumatoid arthritis (RA) patients: the Nippon Medical School (NMS) cohort (n = 204) and the Keio cohort (n = 296). Clinical findings independently correlated with the age of RA onset were selected as 'EORA features' from previously reported EORA characteristics using univariable and multivariable regression analyses. Receiver operating characteristic curve analysis was conducted to determine the cut-off age that best selected patients with all EORA features. Acute onset, negative anti-cyclic citrullinated peptide antibody, and high erythrocyte sedimentation rate were selected as 'EORA features' in both cohorts. Patients with all EORA features were more numerous with age and almost exclusively older than 65years. The optimal EORA cut-off age was 73years with an area under the curve (AUC) of 0.82 in the NMS cohort and 68 with an AUC of 0.93 in the Keio cohort. In the NMS cohort, Health Assessment Questionnaire-Disability Index and comorbidities in patients with disease onset between 60years and the projected cut-off age were similar to those in younger-onset RA, but differed from those in patients with disease onset older than the projected cut-off age. The optimal EORA cut-off age was greater than the conventional definition, but this needs to be validated in different patient populations.

Risk factor analysis of fragility fractures in rheumatoid arthritis: A 3-year longitudinal, real-world, observational, cohort study

ObjectivesTo explore the risk factors for fragility fractures in rheumatoid arthritis (RA) patients using a 3-year longitudinal, observational cohort study.MethodsThis RA registry study included consecutive RA patients in the outpatient clinic of Chang Gung Memorial Hospital since September 1, 2014. The demographics, clinical characteristics, lifestyle, evidence of previous fracture, risk factors according to the Fracture Risk Assessment Tool (FRAX®), and the FRAX score of each participant were recorded. The participants were categorized into the new incident fracture (group A) and no incident fracture (group B) groups based on evidence or absence of new incident fractures and propensity score matching (age and gender, 1:2).ResultsOverall, 477 participants completed the 3-year observation period. After matching, 103 and 206 participants were allocated to groups A and B, respectively. The non-adjusted model revealed, presented as hazard ratio (HR) (95% confidence interval [CI]), that the presence of co-morbidity (1.80 [1.17–2.78], p = 0.008), Health Assessment Questionnaire Disability Index (1.35 [1.07–1.69], p = 0.010), lower baseline hip bone mineral density (0.11 [0.02–0.48], p = 0.004), longer disease duration (1.02 [1.00–1.04], p = 0.026), higher FRAX score of major fracture (1.03 [1.02–1.04], p<0.001) or hip fracture (1.03 [1.02–1.04], p<0.001), and previous fracture history (2.65 [1.79–3.94], p<0.001) were associated with new incident fracture. After adjustment, it was disclosed that a previous fracture is an independent risk factor for fragility fractures in RA patients (2.17 [1.20–3.90], p = 0.010).ConclusionsIn addition to aging and disease-related factors, previous fracture history is the most important risk factor for fragility fractures in RA patients.

Patterns of Response to Different Treatment Strategies in Seropositive Rheumatoid Arthritis Patients in a Tertiary Hospital in South-Western Saudi Arabia: A Retrospective Study.

PurposeTo study the pattern of response to different treatment strategies in seropositive rheumatoid arthritis (RA) patients and to describe our clinical practice in RA management.Patients and MethodsOver a period of two years from April 2018 to April 2020, we conducted a retrospective analysis of data for 288 consecutive seropositive RA patients attending rheumatology clinics and the daycare unit at Aseer Central Hospital. Data were collected on patient demographics, disease duration, extraarticular manifestations, comorbidities and treatment. Disease activity was assessed using the clinical disease activity index (CDAI).ResultsOut of the total 288 patients, 42% (120) are on csDMRADs, while 54% (162) are on bDMRADs and 4% (6) are on tsDMARDs. Of the patients on csDMARDS, 51%, 43% and 7% of them were on remission, low and moderate disease activity, respectively. However, of the patients on non-csDMARDS, 36.3%, 49.4% and 14.3% of them were on remission, low and moderate disease activity, respectively. Failure of csDMARDs was affected by the presence of high disease activity at baseline, extraarticular lung manifestations and coexistent fibromyalgia, with a significant effect of the latter on remission rate. Among patients on non-csDMARDs, 42 (25%) showed one or more therapy changes. Tumor necrosis factor inhibitors were the predominant first-line agents in biologically naive patients (65%) followed by abatacept (18%). Abatacept was the most frequently prescribed second biologic in 52% of cases followed by tocilizumab in 19%.ConclusionThe current clinical practice in our hospital is consistent with the latest American College of Rheumatology (ACR)/The European League Against Rheumatism (EULAR) guidelines. Treat-to-target strategy was achieved in the vast majority of our patients, while remission was observed in almost half of the patients.

Outcome of a metaphyseal reverse total shoulder replacement in rheumatoid arthritis.

To assess the clinical and radiological results of a metaphyseal reverse total shoulder arthroplasty (rTSA) without diaphyseal stem, in rheumatoid arthritis (RA) patients. Forty-five shoulders in 36 consecutive RA patients (2005-2015) underwent rTSA with a bone impaction technique. Patients were assessed clinically and radiographically preoperatively, at 3weeks, 3months, 6months, 12months post-operatively, and yearly thereafter, using constant score (CS), pain score, subjective shoulder value (SSV) and patient satisfaction score. Forty-four shoulders with mean follow-up of 67months (range 24m-146m (12y)) were available for follow-up. Mean age at surgery was 68.7years (range 39-86). CS improved from 17.5 ± 10.5(SD) (age/sex adjusted 23.9 ± 14.5(SD)) preoperatively to 60.9 ± 17.4 (SD) (age/sex adjusted 86.5 ± 24.5 (SD)) at last follow-up (P < 0.001). Pain score and SSV also significantly improved (p < 0.001). Mean range of movement improved to 140°active forwardflexion, 134°active abduction, 47°active external rotation (AER) and 70°active internal rotation (AIR). The results were maintained over time. Combined early and late complication rate was 15.6%, whichislower than described in the literature for RA. No lucencies, loosening, subsidence or stress shielding were evident radiographically. Metaphyseal rTSA without a diaphyseal stem issuccessful and safe in RA patients. Patients achievegood function and have high satisfaction rates. Case series: Level IV.

Muscle wasting, a neglected complication associated with physical dysfunction in elderly patients with rheumatoid arthritis: a cross-sectional observational study

Objective: Little is known about muscle wasting in elderly patients with rheumatoid arthritis (RA). We examined muscle characteristics and their clinical significance in this group. Method: Consecutive RA patients were recruited and clinical data were collected. Muscle mass and distribution were assessed using bioelectric impedance analysis. Myopenia was defined as an appendicular skeletal muscle mass index (ASMI) ≤ 7.0 kg/m2 (men) and ≤ 5.7 kg/m2 (women). Results: Among the 643 RA patients recruited, 165 (25.7%) were elderly patients (age ≥ 60 years) with a mean age of 65.1 ± 4.5 years. Compared with young patients (age < 60 years), elderly RA patients had significantly higher Disease Activity Score based on 28-joint count–C-reactive protein (DAS28-CRP) (median 3.4 vs 3.2), Health Assessment Questionnaire Disability Index (HAQ-DI) (0.38 vs 0.13), and modified total Sharp score (mTSS) (16 vs 9), and a higher proportion of myopenia (54.5% vs 41.4%; all p < 0.01). Elderly RA patients with myopenia (n = 90, 14.0%) had significantly higher DAS28-CRP (3.6 vs 3.0), HAQ-DI (0.50 vs 0.12), and mTSS (21 vs 7) than young RA patients without myopenia (n = 280, 43.5%; all p < 0.0083). Multivariate logistic and linear regression analyses showed that myopenia, high HAQ-DI, active smoking, hypertension, diabetes, and coronary atherosclerotic heart disease were the main relevant characteristics of elderly RA patients. Age positively correlated with HAQ-DI, and ASMI negatively correlated with HAQ-DI (both p < 0.01). Further mediation analysis showed that ASMI partially mediated the association between age and HAQ-DI. Conclusion: Our data reveal that half of elderly RA patients manifest myopenia which aggravates physical dysfunction as a mediator of age. Myopenia, a neglected complication in elderly RA patients, should be recognized and further investigated.

Predictive value of anti-mutated citrullinated vimentin antibody on one-year radiographic progression in patients with rheumatoid arthritis

Objective: To investigate the value of baseline anti-mutated citrullinated vimentin (MCV) antibody for predicting one-year radiographic progression in patients with rheumatoid arthritis (RA). Methods: Consecutive RA patients were recruited from November 2014 to July 2018 at Department of Rheumatology, Sun Yat-sen Memorial Hospital, Clinical data were collected including disease activity score in 28 joints with four variables including C-reactive protein (CRP).Serum anti-MCV antibody at baseline was detected by enzyme-linked immunosorbent assay. X ray assessment of both hands/wrists was performed and assessed according to the Sharp/van der Heijde modified score (mTSS) at baseline and the 12th month. Univariate and multivariate logistic regression analyses were used to identify the risk factors for one-year radiographic progression. Results: Among 220 RA patients recruited, the positive rate of anti-MCV antibody at baseline was 77.7%. Compared with those with negative anti-MCV antibody, RA patients with positive anti-MCV antibody had higher disease activity score in 28 joints with four variables induding CRP [3.8 (2.4, 5.0) vs. 3.1 (2.1, 4.0), P=0.007], more physical dysfunction (21.6% vs. 8.2%, P=0.033) and higher radiographic indicators including mTSS [11 (2, 27) vs. 4 (1, 10), P=0.003], joint space narrowing [JSN, 4 (0, 14) vs. 2 (0, 6), P=0.024] and joint erosion[JE, 5 (1, 18)vs. 3 (0, 5), P=0.003]. After one-year follow-up, sixty-six RA patients (30.0%) developed radiographic progression, the percentage of whom was significantly higher in positive anti-MCV group than that in negative anti-MCV group (33.9% vs.16.3%, P=0.018). Multivariate logistic regression analysis suggested that positive anti-MCV antibody at baseline was an independent risk factor for one-year radiographic progression (OR=2.341, 95%CI 1.002-5.469). Conclusion: Positive anti-MCV antibody at baseline predicts one-year radiographic progression in RA patients. In the future, anti-MCV antibody can be used not only as a supplementary laboratory marker, but also in disease activity assessment and prognosis prediction for RA.

Rheumatoid Arthritis disease activity assessment in routine care: performance of the most widely used composite disease activity indices and patient-reported outcome measures.

Background and aim:To evaluate the convergent and discriminative validity of many continuous composite disease activity indices and patient-reported outcome measures (PROMs) in rheumatoid arthritis (RA).Methods:In consecutive RA patients in moderate or high disease activity, according to the Simplified Disease Activity Index (SDAI) definition, were computed four additional composite disease activity indices, the 28-joint Disease Activity Score – erythrocyte sedimentation rate (DAS28-ESR), the Clinical Disease Activity Index (CDAI), the Chronic Arthritis Systemic Index (CASI), and the Mean Overall Index for RA (MOI-RA), and five PROMs, the Patients’ Activity Scale (PAS), the Rheumatoid Arthritis Impact of Disease (RAID), the 5-item RA Disease Activity Index (RADAI-5), the Routine Assessment of Patient Index Data (RAPID3), and the Clinical Arthritis Activity (PRO-CLARA). Spearman’s rho correlation coefficients were determined to assess their convergent validity, and discriminative performance was calculated by the area under the receiver-operating curve (AUC-ROC). The patients’ opinion of their symptomatic status (PASS) was used as the external criterion.Results:246 RA patients with moderate (29.3%) or high disease activity (70.7%) have been assessed. The indices all showed a significant correlation (p <0.0001 for all). Among the composite disease activity indices, the CDAI was the one that showed the best discriminating ability compared to the PASS (AUC = 0.962), while among the PROMs the RAID was the most performing (AUC = 0.879).Conclusions:CDAI as composite index of disease activity, and RAID as PROM, are the two instruments with the best performances in relation to PASS. The use of validated disease activity measures can help in clinical practice to adopt treat-to-target strategies in RA patients. (www.actabiomedica.it)

Oral Hygiene Status in Rheumatoid Arthritis Patients and Related Factors.

Objectives:To evaluate oral hygiene status in Rheumatoid arthritis (RA) patients, to analyse possible related factors, and to investigate the role of the rheumatologist in information about importance of adequate oral hygiene status in RA patients.Methods:A cross-sectional study that included 100 consecutive RA patients (89% female, mean age 46.7 ± 11.7 years). For each patient, we recorded oral symptoms, oral hygiene status and role of rheumatologist in information on the oral hygiene status. Factors associated with regular brushing (≥2/day) were also analysed.Results:Median disease duration was 8 years (4;2). Dental pain was reported by 74% of patients and bleeding by 51% of them. Regular brushing was noted in 45% of patients. The use of a correct brushing method was noted in 14% of cases. Two patients reported visiting a dentist regularly. Information explaining that poor oral hygiene has a negative impact on RA was delivered by rheumatologist to 11 patients. Regular brushing of teeth was recommended by rheumatologist to 8 patients and 10 patients were advised by their rheumatologist to consult a dentist. Regular brushing was more important in women (48,3% vs 18,2%; p=0.05) and in the literate patients (57,6 vs 31,2%, p<0.01). No association was found between regular brushing, Disease Activity Score 28 (DAS28) and health Assessment Questionnaire (HAQ).Conclusion:This study illustrates bad oral hygiene status in RA patients, which seems more important in men and illiterate patients. It also highlights poor information given by the rheumatologist.