Duration Of Early Morning Stiffness Research Articles

AB0761 Are we treating-to-target in spondyloarthritis (SpA)? A cross sectional analysis from the Asia Pacific League of Associations for Rheumatology (APLAR) SpA Registry

BackgroundData on the extent of treat-to-target (T2T) recommendations application in SpA patients across Asia Pacific region is lacking. APLAR SpA Registry aimed to assess the utility of T2T on long term clinical outcomes, and to improve disease management and inform health care policy.ObjectivesTo provide a snapshot of the registry including demographics, disease activity and medication use.MethodsPatients fulfill the CASPAR 2006 for psoriatic arthritis (PsA) and 2009 ASAS criteria for axial spondylitis (AxSpA) were recruited. This cross sectional analysis included the first 188 patients recruited across 7 Asia Pacific regions (Hong Kong, Singapore, Korea, Thailand, India, Qatar & Pakistan).Results83 patients PsA and 115 AxSpA patients were included. They had moderate inflammation (DAPSA: 19.61±14.29, ASDAS: 2.32±1.07). Majority of PsA patients received conventional synthetic disease-modifying drug (csDMARDs, 81%) with relatively low prevalence of biologic DMARDs (bDMARDs) (24%). Most AxSpA patients used NSAIDs (79%) while nearly half of them received bDMARDs (49%). Other details listed in Table 1. Prevalence of bDMARDs use in our registry was lower than that from the USA (Corrona PsA Registry, 59%), Turkey & Canada (PsArt-ID, 40%) and the Netherlands AxSpA registry (56%) (1-3). Regarding T2T, 28% and 44% of PsA patient achieved minimal disease activity (MDA) and Disease Activity in Psoriatic Arthritis low disease activity (DAPSA LDA) respectively. The proportion of patients achieving target in other cohorts were 46% for MDA (PsArt-ID) and 46% for DAPSA LDA (Corrona) (1, 2). 37% and 47% of AxSpA patient achieved Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)<4 and Ankylosing Spondylitis Disease Activity Score (ASDAS) LDA. Proportion of patients achieving ASDAS LDA were similar to the Netherlands registry for patients with ASDAS LDA or BASDAI<4 (Figure 1A)(3). Patient on bDMARD were more likely to achieve treatment target (Figure 1B). There were no significant difference between socio-economic status and disease features between bDMARD user and non-user.Table 1.Demographics, clinical features and disease activity of patientsPsA (n=83)AxSpA (n=115)Age50.012.836.512.4Male n, %4251%8583%Asian n, %83100%10196%Disease duration, years7.17.35.27.6Any sacroiliitis n, %10299%HLA B27, positive n, %9189%Duration of early morning stiffness, min30392529Tender joint count7901Swollen joint count3400No. of dactylitis digit1100PASI4.05.0SPRACC1201BASDAI2.82.0ESR, mm/h31262016CRP, mg/L10151127HAQ-DI0.610.610.390.51DAPSA19.6114.29ASDAS CRP2.321.07Data given in mean SD unless stated. No. of case from Hong Kong 40; Singapore 46; Korea 24; Thailand 20, India 15; Qatar 10; Pakistan 33; HLA - human leucucyte antigen; PASI - psoriasis area and severity index; SPRACC - Spondyloarthritis Research Consortium of Canada Enthesitis Index; BASDAI - Bath Ankylosing Spondylitis Disease Activity Index; ESR - erythrocyte sedimentation rate; CRP - C-reactive protein; HAQ-DI - Health assessment questionnaire disability index; DAPSA - Disease activity in Psoriatic Arthritis; ASDAS - Ankylosing Spondylitis Disease Activity ScoreFigure 1.(A) Achievement of LDA in APLAR SpA registry and other registry and (B) use of bDMARDs among patients in APLAR SpA registry with or without achieving LDAConclusionPatient using bDMARDs were more likely to achieve treatment target. We expect that when T2T is widely applied, better outcomes will be reported in future.

Vitamin D and early rheumatoid arthritis

BackgroundPrevious studies have linked rheumatoid arthritis (RA) risk and disease activity with vitamin D-deficiency (low serum 25-hydroxyvitamin D (25OHD)), but a causal role for vitamin D in RA is still unclear, with conflicting results from many previous studies, partly due to heterogeneity in study design and patient populations. In this study we aimed to (1) analyse serum 25OHD in early inflammatory arthritis, (2) compare 25OHD with disease activity and fatigue in early RA and (3) determine whether low 25OHD is associated with progression to RA.MethodsAn analysis of 790 patients recruited to the Birmingham Early Inflammatory Arthritis Cohort and followed longitudinally to determine clinical outcomes. The following were recorded at baseline: demographic data, duration of symptoms, duration of early morning stiffness (EMS), tender and swollen joint counts, Visual Analogue Scale (VAS) pain/fatigue/EMS, PHQ-9, HAQ and FACIT-Fatigue scores, DAS28-ESR, DAS28-CRP, CRP, ESR, anti-CCP antibody status, rheumatoid factor status, and serum 25OHD (ng/ml). Diagnosis was recorded at 0 and 12 months onwards as either RA, Undifferentiated Inflammatory Arthritis (UIA; synovitis not meeting other classification/diagnostic criteria), Clinically Suspect Arthralgia (CSA; arthralgia of an inflammatory type without synovitis), or Other.ResultsBaseline demographic data were similar between all groups, with median symptom duration of 16.8–34.0 days. Baseline 25OHD was not significantly different between groups [median, interquartile range (IQR): RA 46.7, 30.0–73.3; UIA 51.4, 30.0–72.3; CSA 47.7, 30.3–73.0; Other 39.9, 28.6–62.2]. In RA (n = 335), there were no significant differences between 25OHD and measures of disease activity or fatigue. No association between 25OHD and progression from UIA or CSA to RA was observed.ConclusionsThere was no clear association between serum 25OHD and baseline diagnosis, RA disease activity, or progression from UIA or CSA to RA. Future studies of other vitamin D metabolites may better define the complex role of vitamin D in RA.

THU0094 IN ACPA POSITIVE AT-RISK INDIVIDUALS WITHOUT CLINICAL ARTHRITIS, IS ULTRASOUND SUFFICIENTLY ACCURATE TO PREDICT PROGRESSION TO INFLAMMATORY ARTHRITIS?

Background:In a cohort of Anti-Cyclic Citrullinated Peptide Positive (ACPA+) At-Risk of developing inflammatory arthritis (IA) individuals without clinical synovitis, we previously demonstrated the predictive value of Power Doppler for progression depending on the number of joints involved (1). Here we update these results in a larger population combining all ultrasound (US) features and incorporating them in a multivariable analysis with clinical, genetic, immunological and serological markers.Objectives:To investigate the ability of US to predict progression to clinical arthritis using multivariable Cox analysis with and without including other variables.Methods:In a single centre prospective cohort, 488 at risk ACPA+ individuals with new musculoskeletal symptoms underwent an US scan of 30 small joints and 18 tendons at first visit (metacarpophalangeal, interphalangeal and metatarsophalangeal joints and flexor tendons, and extensor carpi ulnaris). The predictive value of US abnormalities (Power Doppler grade ≥ 1 (PD), Grey Scale grade ≥ 2 (GS), or erosion (E) presence) for progression to IA was analysed using Cox regression analysis and adjusted for tenosynovitis (TSV) presence, age, sex, ≥3 ULN CCP2 antibody titre and/or rheumatoid factor titre (RF), early morning stiffness duration, shared epitope (HLA-DRB1*01, *04 and/or *10), number of small joints tender, elevated CRP and intermittent symptoms. A complete dataset considering all variables was available for 324 patients.Results:Consecutive at-risk ACPA+ individuals (n=488, mean age 50.47 years old, 72.9% women) were followed up for at least 24 weeks or up to progression, for a median of 96 weeks (range 0.43-590). 130 of them (26.7%) developed IA after a median of 51.5 weeks (range 0.43 – 486).Multivariable analysis focusing on intra-articular ultrasound features showed that individuals with 1-3 joints with a PD signal or 1-2 with E were twice as likely to develop IA (Table 1), those with ≥ 4 joints with a PD signal were more than six times more likely (Figure 1). All variables data was available in 324 participants, showing a significant predictive value of TSV presence in ≥1 joint (HR= 1.973, p= 0.024, CI= 1.095-3.553), smoking exposure (HR= 2.597, p= 0.003, CI= 1.369-4.929), shared epitope positivity (HR= 1.979, p=0.044, CI= 1.019-3.843), ≥5 small joints tender (HR= 2.111, p= 0.030, CI= 1.073-5.463), and a high titre CCP and/or RF (HR= 4.334, p= 0.003, CI=1.651-11.374).Table 1.Multivariate Cox analysis of joint ultrasound features: non-adjusted for confoundersJoints InvolvedFeatureHRCIP-valuePPVNPVNSmall joints (wrists excluded)PD ≥1:1-3 joints≥4 joints2.1096.5241.364-3.2623.465-12.289<0.0010.001<0.00144%76.5%78.3%488GS ≥2:1-3 joints≥4 joints0.38120.3%30.8%71.9%E presence in ≥1 joint1.8651.206-2.8840.00547.6%76%Conclusion:In at-risk ACPA+ individuals, ultrasound alone - especially Power Doppler- is a powerful predictive factor of progression to IA, therefore of high clinical value for rheumatologists. The multivariable integrated risk prediction values indicates the role of other factors to be considered in future risk model development.

P222 Vitamin D in early rheumatoid arthritis

Abstract Background Rheumatoid arthritis (RA) is the commonest chronic inflammatory arthritis, predominantly affecting small/medium joints and associated with extra-articular features. Previous studies have linked RA risk and disease activity with vitamin D-deficiency, but a causal role for vitamin D in RA is still unclear, partly due to heterogeneous study methods and sample populations. Moreover, no studies have focused specifically on vitamin D status (serum levels of 25-hydroxyvitamin D, 25OHD) in early RA, or whether low 25OHD is linked to progression from undifferentiated inflammatory arthritis to RA. Our objectives were therefore (1) to analyse serum 25OHD in early inflammatory arthritis, (2) to compare 25OHD levels with disease activity and fatigue in early RA and (3) to determine whether low serum 25OHD is associated with progression to RA. Methods We analysed 791 patients enrolled in the Birmingham Early Arthritis Cohort from 2013-19 at Sandwell and West Birmingham Hospitals NHS Trust and University Hospitals Birmingham NHS Trust. We collect baseline demographic data, serum 25OHD (ng/ml), and clinical variables including: duration of symptoms, duration of early morning stiffness (EMS), CRP, ESR, anti-CCP antibody status, Rheumatoid factor status, tender and swollen joint counts, DAS28-ESR, DAS28-CRP, Visual Analogue Scale (VAS) pain/fatigue and FACIT scores. Diagnosis was recorded at 0 and 12 months onwards as either RA, psoriatic arthritis (PsA), Undifferentiated Inflammatory Arthritis (UIA; synovitis not meeting other classification/diagnostic criteria), Clinical Suspect Arthralgia (CSA; arthralgia of an inflammatory type without synovitis), or Other. Data were analysed using SPSSv25. Full ethical approval was given for the study (REC12/WM/0258). Results Baseline demographic data were similar between all groups, with a median symptom duration of 16.8-34.0 days. Baseline 25OHD was not significantly different between groups [median, interquartile range (IQR): RA 46.7, 30.0-73.3; PsA 41.2, 30.0-65.0; UIA 51.4, 30.0-72.3; CSA 47.7, 30.3-73.0; Other 37.0, 24.9-55.3]. In the RA group (n = 335), there were no significant differences between 25OHD and any measures of disease activity/fatigue. Finally, we found no association between 25OHD and progression from UIA (n = 121) or CSA (n = 150) to RA (p = 0.554 and p = 0.741 respectively). Conclusion Overall we found no clear association between serum 25OHD and baseline diagnosis, RA disease activity, or progression from UIA/CSA to RA in this large cohort of early RA patients. Limitations of the study include that we were unable to report on levels of vitamin D metabolites which may be more important than total vitamin D. In addition, we were unable to adjust for supplement use/ time of year the sample was taken due to missing data. Future studies into the role of different metabolites of vitamin D in aetiopathogenesis of inflammatory arthritis would provide invaluable insight into the role of vitamin D in inflammatory arthritis better defining the complex role of vitamin D in RA. Disclosures S.R. Harrison: None. G. Jutley: None. D. Li: None. I. Sahbudin: None. A. Filer: None. M. Hewison: None. K. Raza: None.

Poor quality of life in indian ankylosing spondylitis patients

Background: Ankylosing Spondylitis (AS) is a chronic inflammatory disease that leads to significant disability. We sought to study the impact of the disease activity and functional impairment on QoL in Indian patients with AS. Methods: World Health Organization- Quality of Life-BREF (WHOQoL-BREF) questionnaire was used to measure quality of life (QoL) in 99 adults with AS (modified Rome criteria), 72 healthy individuals, and 20 rheumatoid arthritis patients. Apart from demographic variable such as age, gender, clinical manifestations, and treatment received, disease activity parameters such as duration of early morning stiffness, BASDAI, swollen and tender joint count, Erythrocyte Sedimentation Rate (ESR) and C Reactive Protein (CRP) were also recorded. Presence of damage was assessed using spinal radiographs. All values are in median (IQR). Results: Out of the 99 patients, 5 were females and 5 had juvenile onset AS. Median age was 32 (26-42) years and median disease duration was 6 (1.25-10) years. Forty-three had peripheral arthritis and 18 had enthesitis. Syndesmophytes were present on spinal radiographs in 54 cases. BASDAI correlated negatively with the physical, psychological and environmental domains (P Conclusion: Indian AS patients have poorer quality of life than patients with rheumatoid arthritis and healthy individuals, possibly due to poor control of disease activity.

Nursing sensitive outcomes in patients with rheumatoid arthritis: A systematic literature review

BackgroundAlthough rheumatology nursing has been shown to be effective in managing patients with rheumatoid arthritis, patient outcomes sensitive to nursing interventions (nursing sensitive outcomes) have not been systematically studied. ObjectivesThe objective of this study was to identify and delineate relevant patient outcomes measured in studies that reported nursing interventions in patients with rheumatoid arthritis. DesignA systematic search was conducted from 1990 to 2016. Inclusion criteria were (i) patients with rheumatoid arthritis, (ii) adult population age ≥16years, (iii) nurse as part of the care team or intervention delivery, (iv) primary research only, (v) English language, and (vi) quantitative studies with nursing sensitive outcomes. Data sourcesMedline, CINAHL, Ovid nursing, Cochrane library and PsycINFO databases were searched for relevant studies. Review methodsUsing the predetermined inclusion/exclusion criteria, nine reviewers working in pairs assessed the eligibility of the identified studies based on titles and abstracts. Papers meeting the inclusion criteria were retrieved and full texts were further assessed. Critical Appraisal Skills Programme tools were used to assess the quality of the included studies. Data on nursing sensitive outcomes were extracted independently by two reviewers. The Outcome Measures in Rheumatology comprehensive conceptual framework for health was used to contextualise and present findings. ResultsOf the 820 articles retrieved, 7 randomised controlled trials and 3 observational studies met the inclusion criteria. Seventeen nursing sensitive outcomes were identified (disease activity, clinical effects, pain, early morning stiffness duration, fatigue, patient safety issues, function, knowledge, patient satisfaction, confidence in care received, mental health status, self-efficacy, patient attitude/perception of ability to control arthritis, quality of life, health utility, health care resources, death). These fitted into 10 health intervention domains in keeping with the pre-specified conceptual framework for health: disease status, effectiveness, safety, function, knowledge, satisfaction, psychological status, quality of life, cost, death. A total of 59 measurement instruments were identified comprising patient reported outcome measures (n=31), and biologic measures and reports (n=28). ConclusionsThis review is notable in that it is the first to have identified, and reported, a set of multidimensional outcome measures that are sensitive to nursing interventions in rheumatology specifically. Further research is required to determine a core set of outcomes to be used in all rheumatology nursing intervention studies.

Patient-reported Outcomes as Predictors of Change in Disease Activity and Disability in Early Rheumatoid Arthritis: Results from the Yorkshire Early Arthritis Register.

To assess patient-reported variables as predictors of change in disease activity and disability in early rheumatoid arthritis (RA). Cases were recruited to the Yorkshire Early Arthritis Register (YEAR) between 1997 and 2009 (n = 1415). Predictors of the 28-joint Disease Activity Score (DAS28) and the Health Assessment Questionnaire-Disability Index (HAQ-DI) at baseline and change over 12 months were identified using multilevel models. Baseline predictors were sex, age, symptom duration, autoantibody status, pain and fatigue visual analog scales (VAS), duration of early morning stiffness (EMS), DAS28, and HAQ-DI. Rates of change were slower in women than men: DAS28 fell by 0.19 and 0.17 units/month, and HAQ-DI by 0.028 and 0.023 units/month in men and women, respectively. Baseline pain and EMS had small effects on rates of change, whereas fatigue VAS was only associated with DAS28 and HAQ-DI at baseline. In patients recruited up to 2002, DAS28 reduced more quickly in those with greater pain at baseline (by 0.01 units/mo of DAS28 per cm pain VAS, p = 0.024); in patients recruited after 2002, the effect for pain was stronger (by 0.01 units/mo, p = 0.087). DAS28 reduction was greater with longer EMS. In both cohorts, fall in HAQ-DI (p = 0.006) was greater in patients with longer EMS duration, but pain and fatigue were not significant predictors of change in HAQ-DI. Patient-reported fatigue, pain, and stiffness at baseline are of limited value for the prediction of RA change in disease activity (DAS28) and activity limitation (HAQ-DI).

Development and testing of candidate items for inclusion in a new rheumatoid arthritis stiffness patient-reported outcome measure

To qualitatively develop and test a set of candidate items for a new RA stiffness patient-reported outcome measure (PROM) that capture the patient perspective. This is an essential first step in PROM development, prior to quantitative development, assessment and validation. Focus groups further examined the previously developed stiffness conceptual model and explored the patient perspective regarding stiffness assessment. Data were analysed using thematic analysis. An iterative process of item development was then performed by the expert study team of researchers, patients and clinicians, based on the two qualitative datasets and informed by measurement theory and guidelines. Finally, these candidate items were tested using formal cognitive interview methodology and subsequently refined. Sixteen RA patients from the UK participated in focus groups. Data confirmed the conceptual model of the RA patient experience of stiffness and provided insight into stiffness assessment, including suggestions regarding patient-relevant stiffness assessment categories such as impact, location and timing. These data informed the development of 77 candidate stiffness PROM items, including multiple formats for some. Eleven RA patients participated in cognitive interviews. Minor changes were made to items to enhance understanding and 32 items were removed, resulting in 45 candidate PROM items. Rigorous qualitative methodology and considerable patient involvement has underpinned items for a new RA stiffness PROM with strong content validity. Crucially, patient involvement broadened assessment beyond early morning stiffness duration, which may address existing PROM limitations. Items are now suitable for quantitative item reduction, structural development of the final PROM and validation.

SAT0095 MRI findings are prevalent in ACPA positive patients with musculoskeletal symptoms

BackgroundRheumatoid arthritis (RA) associated autoantibodies including anti-cyclic citrullinated peptide antibodies (ACPA) and rheumatoid factor (RF) may be present years before clinical presentation. The pre-clinical phase of RA may also be...

SAT0591-HPR Patient Education Programs (PEP) for Patients with Rheumatoid Arthritis (RA): an Updated Systematic Review

BackgroundPatient education (PE) is broadly accepted as an integral part of the management of people with Rheumatoid arthritis (RA)(1), completing clinical care. However, previous reviews, till 2003,(2, 3) concluded that...

A 3 mg/kg starting dose of infliximab in active spondyloarthritis resistant to conventional treatments is efficient, safe and lowers costs

Objective We assessed the efficacy, tolerance and cost of a 3 mg/kg starting dose of infliximab for ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Methods We retrospectively followed-up 45 biologic-naive consecutive patients (11 with axial AS, 24 with axial and peripheral [mixed] AS and 10 with PsA) who were treated between 2002 and 2005 with a 3 mg/kg dose of infliximab after failure of conventional therapies. The following variables were recorded: visual analog scale (VAS) scores of patient's global (G) and pain (P) assessment, duration of early morning stiffness (EMS), disease activity (BASDAI) and functional disability (BASFI). Treatment responses were assessed at 6 and 12 months using the AS assessment score (ASAS)-20% and -40% criteria and BASDAI-50. Results Baseline characteristics of the 29 men and 16 women were (median [range]): G-VAS, 70 [13–100]; P-VAS, 70 [13–100]; EMS, 60 [0–180] minutes; BASDAI, 64.4 [23.9–100]; BASFI, 57.2 [3.5–98.5]. All manifestations regressed significantly ( p < 0.0001) for 39 (86.7%) and 24 (53.5%) patients at 6 and 12 months, respectively; 26 (57.8%) had achieved ASAS-20 responses at 6 months that persisted at 1 year for 20 (44.4%); 19 (42.2%) and 12 (26.7%) satisfied BASDAI 50 criteria at 6 and 12 months, respectively. Interestingly, almost 30% still received low-dose infliximab after 4 years of follow-up. Conclusion An initial dose of 3 mg/kg of infliximab significantly attenuated AS and PsA manifestations in > 40% of the patients, making use of this dose highly advantageous in terms of safety and 33% lower cost.

Glucocorticoid chronotherapy in rheumatoid arthritis

In today's Lancet, Frank Buttgereit and colleagues report a double-blind randomised trial of modified-release prednisone for rheumatoid arthritis. 1 Buttgereit F Doering G Schaeffler A et al. Efficacy of modified-release versus standard prednisone to reduce duration of morning stiffness of the joints in rheumatoid arthritis (CAPRA-1): a double-blind, randomised controlled trial. Lancet. 2008; 371: 205-214 Summary Full Text Full Text PDF PubMed Scopus (288) Google Scholar The tablets release the drug about 4 h after ingestion (a special coating bursts due to penetration of water). The tablets are ingested in the evening and thus prednisone release is adapted to the circadian rhythm of cortisol. In the study, the duration of early morning stiffness was lower than when the same dose of prednisone (standard pill) was taken early in the morning. Efficacy of modified-release versus standard prednisone to reduce duration of morning stiffness of the joints in rheumatoid arthritis (CAPRA-1): a double-blind, randomised controlled trialModified-release prednisone is well tolerated, convenient to administer, and produces a clinically relevant reduction of morning stiffness of the joints in addition to all known therapeutic effects of immediate-release prednisone. Full-Text PDF

Is rheumatoid arthritis a disease that starts in the intestine? A pilot study comparing an elemental diet with oral prednisolone

Objectives: This pilot study aimed to determine if an elemental diet could be used to treat patients with active rheumatoid arthritis and to compare its effect to that of oral...

DAS 28 for defining remission in rheumatoid arthritis in Indian patients

Objective To establish DAS 28 and DAS 28-3 scores that best define remission in Indian patients with rheumatoid arthritis (RA). Patients and Methods All patients diagnosed with RA visiting AIIMS, New Delhi over a period of 3 months were recruited. Clinical assessment included 28 joint counts for swelling and tenderness, duration of early morning stiffness, patient global assessment of disease activity, fatigue, joint pains and ESR. DAS 28 and DAS 28-3 scores were calculated and receiver operating characteristics curve analysis was performed to define cutoff values utilizing ‘ACR 5/6’ and ‘ACR 4/5’ remission criteria. Results Subjects included 207 patients (M: 44; F: 163) with mean age of 47.4 ± 12.6 years, median disease duration of 8 [4.12–14] years.‘ACR 5/6’ and ‘ACR 4/5’ criteria for remission were satisfied by 34 (16.42%) and 44 patients (21.25%) patients, respectively. DAS 28 score of 2.94 (sensitivity 84.4%, specificity 85.3%) and DAS 28-3 score of 3.02 (sensitivity 82.1%, specificity 82.4) best defined the ‘ACR 5/6’ remission. Corresponding values using ‘ACR 4/5’ remission were 3.04 (sensitivity 85.9%, specificity 84.1%) for DAS 28 and 3.05 (sensitivity 82.2%, specificity 81.8%) for DAS 28-3. Conclusions A cutoff value < 3 for both DAS 28 and DAS 28-3 defines remission in RA in Indian patients.

The Nottingham Health Profile as a measure of disease activity and outcome in rheumatoid arthritis

Clinical measurement in rheumatoid arthritis (RA) has focused on articular problems. Although measures like the Health Assessment Questionnaire (HAQ) are widely used to determine functional impairment, there is a need to determine the overall effect of RA on general health status. We evaluated the relationship of a generic health status measure-the Nottingham Health Profile (NHP)-to the clinical, laboratory and radiological changes in the EULAR core data set for RA. Two hundred consecutive out-patients with RA were recruited. Their mean age was 58.9 yr and mean disease duration 11.3 yr. Patients completed the NHP and the following assessments were made: the EULAR Core Data Set, the duration of morning stiffness, the Disease Activity Score (DAS), rheumatoid factor (RF) levels, and Larsen's score for X-rays of hands and wrists. RA patients had higher scores on the NHP than both a random population sample and a second sample of patients with a variety of common diseases. NHP scores were not related to age or disease duration in RA. There was little relationship between perceived distress and the Larsen score, RF, ESR and C-reactive protein levels. Moderate associations were seen between NHP scores and disease activity measures, including the number of tender and swollen joints, pain and the duration of early morning stiffness, and also with a disability measure-the HAQ. NHP scores were highly related to disease activity measured by DAS. High DAS scores were associated with high scores in the energy level, pain and sleep sections of the NHP. The NHP gives relevant information about RA patients. They have high scores for pain, physical mobility and energy level sections, and also have high distress for sleep and emotional reactions.

A double blind randomised trial of low power laser treatment in rheumatoid arthritis.

To define the value of low power laser treatment in small joint rheumatoid arthritis. Twenty five women with active disease were recruited. The metacarpophalangeal and proximal interphalangeal joints of one hand were treated with 12 J/cm2 for 30 s with a gallium-aluminium-arsenate laser. The other hand received a sham laser treatment designed so that neither therapist nor patient could distinguish the active laser from the sham laser. Each patient received 12 treatments over four weeks. The following parameters were measured: pain as assessed by visual analogue scale; range of joint movements; grip strength; duration of early morning stiffness, joint circumference, Jebsen's hand assessment; drug usage; total swollen joint counts; Arthritis Impact Measurement Scales; three phase bone scans; haematological and serological tests. A total of 72% of patients reported pain relief but this reduction was reported equally in both hands. No significant changes were seen in other clinical, functional, scintigraphic, or laboratory features. Neither patients nor staff were able to detect which hand was treated with the active laser. When this specific laser and dose regimen was used, low power laser treatment had no objective effect on patients with rheumatoid arthritis. It did appear to produce analgesia through a powerful placebo effect.

Chain breaking antioxidant status in rheumatoid arthritis: clinical and laboratory correlates.

The ability of fresh sera to resist attack by peroxyl radicals (TRAP) was found to be significantly lower in 20 patients with rheumatoid arthritis (RA) than in 20 healthy controls, consistent with the existence of a redox stress in RA imposed by inflammation. TRAP values in RA varied inversely with a combination of visual analogue pain scale, duration of early morning stiffness, grip strength, and articular index (reflecting inflammatory activity) using multiple linear regression analysis. The concentration of the antioxidant vitamin ascorbic acid was lower in RA plasma and the oxidation-reduction equilibrium of ascorbic acid was disturbed, giving further support to the existence of a redox stress. The major determinant of TRAP in vitro was found to be serum uric acid in RA and serum vitamin E in controls. Serum urate concentration in RA correlated inversely with oxidative changes in serum albumin and IgG. It is suggested that serum urate might have an antioxidant role under certain conditions by limiting free radical induced oxidative changes to protein during inflammation.

Effects of fish oil supplementation in rheumatoid arthritis.

Sixteen patients with rheumatoid arthritis entered a trial to determine the clinical and biochemical effects of dietary supplementation with fractionated fish oil fatty acids. A randomised, double blind, placebo controlled crossover design with 12 week treatment periods was used. Treatment with non-steroidal anti-inflammatory drugs and with disease modifying drugs was continued throughout the study. Placebo consisted of fractionated coconut oil. The following results favoured fish oil rather than placebo: joint swelling index and duration of early morning stiffness. Other clinical indices improved but did not reach statistical significance. During fish oil supplementation relative amounts of eicosapentaenoic acid and docosahexaenoic acid in the plasma cholesterol ester and neutrophil membrane phospholipid fractions increased, mainly at the expense of the omega-6 fatty acids. The mean neutrophil leucotriene B4 production in vitro showed a reduction after 12 weeks of fish oil supplementation. Leucotriene B5 production, which could not be detected either in the control or in the placebo period, rose to substantial quantities during fish oil treatment. This study shows that dietary fish oil supplementation is effective in suppressing clinical symptoms of rheumatoid arthritis.

Serum interleukin-2-receptor in rheumatoid arthritis: A prognostic indicator of disease activity?

Interleukin-2 (IL-2) is an important growth factor for T lymphocytes. Its effects are mediated by cell surface receptors (IL-2 R) expressed on activated T cells. Receptor protein can be shed from cell membranes and the soluble form (sIL-2 R) is detectable by enzyme linked immunosorbent assay (ELISA). We have studied serial levels of sIL-2 R in the sera of patients with rheumatoid arthritis (RA). In 13 patients with active disease, the mean serum level of sIL-2 R was raised compared to age-matched healthy controls. In 48 samples taken at different times from 13 patients, serum sIL-2 R correlated significantly with Ritchie joint index, duration of early morning stiffness, patient pain score, physician's assessment, erythrocyte sedimentation rate (ESR) and platelet count. In individual patients, serial sIL-2 R serum levels fell with treatment preceding clinical improvement. In four patients where serum sIL-2 R levels fell and clinical improvement occurred, subsequent spontaneous increases of serum sIL-2 R level preceded increased clinical disease activity by up to 2 weeks. Serum sIL-2 R level in RA probably reflects activation of underlying immunopathogenic mechanisms and appears to be an excellent monitor of clinical disease activity. More importantly, a rising level may also predict exacerbation of disease activity.

Failure of oral thiomalate to act as an alternative to intramuscular gold in rheumatoid arthritis.

Ten patients with active rheumatoid arthritis (RA) were entered into a pilot study to evaluate the effectiveness of thiomalic acid as a disease modifying agent and to assess its toxicity. Oral thiomalic acid (100 mg) was given daily for up to six months. Changes in disease activity were recorded monthly and all side effects noted. No patient recorded any improvement in subjective well being, pain score, or duration of early morning stiffness. No significant change occurred in articular index or haemoglobin (Hb); the erythrocyte sedimentation rate (ESR) showed a tendency to increase. Only three patients completed six months' treatment; six withdrew because of toxic reactions (three with rashes and three with severe gastrointestinal upset) and one because of lack of effect. Thiomalic acid alone appears to have no significant antirheumatic activity and is associated with an unacceptably high incidence of adverse reactions.