Modified Health Assessment Questionnaire Research Articles

Assessment of long-term articular damage and function in rheumatoid arthritis patients

Aim of the workThis study aimed to assess long-term articular damage and function in rheumatoid arthritis (RA) patients in relation to the type of treatment. Early disease modifying anti-rheumatic drug (DMARD) therapy has not been evaluated in this study. Patients and methodsOne hundred and fifty RA patients (141 females and 9 males) with disease duration more than five years and disease activity score-28 (DAS-28) <3.2 were included in this study. Sixty patients received disease modifying anti-rheumatic drugs (DMARDs) (group A), 60 received DMARDs and corticosteroids (CS) (group B), and 30 patients received CS only (group C). The functional outcome was assessed using the Modified Health Assessment Questionnaire (MHAQ). The articular damage was measured by using Rheumatoid Arthritis Articular Damage (RAAD) Score. The van der Heijde modification of the Sharp erosion score was used to define the plain X-ray of both hands and feet. ResultsThe mean age of the patients was 49.3 ± 11.5 years, and disease duration was 12 ± 7.9 years. There was a significant difference between the RAAD, visual analogue scale and MHAQ scores among the three groups (p = 0.001), with higher score in group C followed by B. By using Multiple regression analysis to examine the relationship between RAAD score and other independent variables there was a significant association of the RAAD score with higher X-ray score (p < 0.001) and with patients taking steroids only (p = 0.001). ConclusionAlthough, use of corticosteroids may help to control the disease activity, but it increases the risk of overall joint damage.

Power Doppler ultrasound in the evaluation of hand joints in rheumatoid arthritis patients in clinical remission: Association with composite index scores and functional status

BackgroundEvaluation of remission in Rheumatoid Arthritis (RA) largely relies on composite scores based on clinical and laboratory assessments however, patients can fulfill clinical remission criteria as defined by composite scores, yet still have evidence of synovitis detectable on imaging. Aim of the workTo evaluate hand and wrist joints in patients with RA in clinical remission using power Doppler (PD) ultrasonography and to study the association between ultrasonographic findings and composite index scores. Patients and methodsThis study was conducted on 50 RA patients in clinical remission. Ten matched healthy subjects were included as control. The modified health assessment questionnaire (MHAQ) was assessed in the patients; disease activity was calculated using a composite index score including disease activity score (DAS28) and clinical disease activity index (CDAI). Ultrasonographic assessment of the hand and wrist joints was performed. ResultsThe mean age of the patients was 50.9 ± 9.2 years, disease duration was 10.6 ± 5.5 years and were 38 females and 12 males. The mean DAS28 was 2.3 ± 0.3. On ultrasonographic examination, 14 (28%) patients had normal synovium, while 18 (36%) showed synovial hypertrophy without evidence of inflammation and 18 (36%) had PD signals. DAS28 was higher in patients with PD signals (2.36 ± 0.3) compared to those without synovitis (2.3 ± 0.28). There was a significant correlation between PD activity and CDAI (p = 0.005), MHAQ (p = 0.002) and disease duration (p = 0.023). ConclusionPower Doppler ultrasound can detect residual inflammation in RA patients in clinical remission and its scores were signficantly associated with the clinical disease activity index and functional status.

Clinical Significance of Periodontitis in Rheumatoid Arthritis Patients: Association with Disease Activity and Functional Status

Objectives: To evaluate frequency of periodontitis (PD) in rheumatoid arthritis (RA) patients and relate it with clinical characteristics, disease activity, functional status, anti-cyclic citrullinated peptide (anti-CCP) and radiographic scores.Methods: The study included 60 RA patients and 30 controls. Clinical Disease activity index (CDAI), Modified Health Assessment Questionnaire (MHAQ), visual analogue scale of pain and Scott's modification to Larsen scoring method were assessed. Rheumatoid factor (RF) positivity and anti-CCP titer were measured. Periodontal examination was performed and relevant indices calculated.Results: The mean age of the patients was 49.1 ± 13 years and they were 52 females and 8 males. PD was present in 71.7% of RA patients versus 46.7% in control (p=0.02). PD was predominantly generalized (p=0.004) with moderate-severe degree (p=0.01). Age (p=0.007), disease duration (p<0.0001), morning stiffness (p=0.01), CDAI (p<0.0001), MHAQ (p=0.02), CRP (p=0.02), anti-CCP titer (p=0.01) and methotrexate treatment (p=0.005) were significantly higher in RA-PD versus RA. However, gender, smoking, oral hygiene, erythrocyte sedimentation rate, RF, anti-CCP positivity and radiographic scoring were insignificantly different. PD positivity was 96.3%, predominant generalized in 92.6%, moderate (40.7%) and severe degree (37%) in early RA versus (51.5%, 24.2%, 24.2%, 12.1% respectively) in late RA patients. All PD indices were higher in early patients (p ≤ 0.05) while teeth loss (p=0.03) was higher in late cases. CDAI, VAS and ACPA titer all significantly correlated with PD indices (p<0.05).Conclusion: Periodontitis is frequent in RA patients’ especially in early cases and is remarkably associated to disease activity and reduced functional status.

Interstitial lung disease in Egyptian patients with rheumatoid arthritis: Frequency, pattern and correlation with clinical manifestations and anti-citrullinated peptide antibodies level

IntroductionInterstitial lung disease (ILD) represents 13% of the overall mortality in rheumatoid arthritis (RA) patients. Aim of the workTo determine the frequency and pattern of ILD among RA patients, correlate it with clinical manifestations and with anti-citrullinated peptide antibodies (ACPA) titer. Patients and methodsThis study included 88 RA patients. ILD was diagnosed by high-resolution computed tomography (HRCT) and assessed by a severity score. Disease activity was assessed by clinical disease activity index (CDAI) and functional status by the modified health assessment questionnaire (MHAQ). Serum ACPA titer was assayed by ELISA. ResultsThe mean age of the patients was 50.15±9 years, disease duration was 10.2±6.2 years and they were 75 females and 13 males. ACPA was positive in 84 (95.5%). The frequency of ILD among RA patients was 71.6%. ILD patterns were: usual interstitial pneumonia (UIP) 62%, non-specific interstitial pneumonia (NSIP) 27%, others (Cryptogenic and mixed) in 11%. In RA-ILD, the mean ACPA titer was 225±121.5 U/mL versus 154.3 ±121.8 U/mL in RA only. In RA-ILD, ACPA titer negatively correlated with morning stiffness, CDAI, MHAQ and six-minute walk test (r=−0.3, p=.008, r=−0.6, p<.0001, r=−0.5, p<.0001 and r=−0.5, p<.0001 respectively), while it significantly correlated with IPF severity score (r=0.09, p<.0001) and erythrocyte sedimentation rate (ESR) (r=0.5, p<.0001). ConclusionILD frequency has increased among RA patients due to improved detection by HRCT. High titer of ACPA was associated with extent and patterns of severity of ILD in RA patients. When high ACPA titer is associated with low CDAI score, physician could suspect lung involvement.

Disease Activity of Juvenile Idiopathic Arthritis during and after Pregnancy: A Prospective Multicenter Study.

To study disease activity in women with juvenile idiopathic arthritis (JIA) during and after pregnancy. There is little previous knowledge about this topic. Our study included 135 pregnancies in 114 women with JIA. Disease activity was assessed at 7 timepoints before, throughout, and after pregnancy with the Disease Activity Score-28-C-reactive protein 3 (DAS28-CRP3). Scores assessed at each visit were analyzed in a linear mixed model. The same statistical method was used to study self-reported physical function, pain, and mental health. Almost 80% of the women were in remission or had low disease activity during and after pregnancy. Although disease activity was stable throughout the study period, we found that DAS28 6 weeks postpartum increased significantly compared to the first trimester (2.78 vs 2.51, p = 0.005) and third trimester (2.78 vs 2.56, p = 0.011), respectively. DAS28 decreased significantly between 6 weeks and 12 months postpartum (2.78 vs 2.54, p = 0.014). Self-reported mental health was significantly better 6 weeks postpartum than before pregnancy (Medical Outcomes Study Short Form-36 Mental Health subscale 80.7 vs 76.5, p = 0.039). Self-reported pain was stable. Physical function was significantly worse in the third trimester of pregnancy than postpartum (Modified Health Assessment Questionnaire 0.57 vs 0.39, p < 0.001). In women with JIA, disease activity was highest 6 weeks postpartum, but altogether low and stable in the period from planning pregnancy to 1 year after delivery.

Effects of an exercise model based on functional circuits in an older population with different levels of social participation.

To investigate whether being part of a community organization interfered with older adults' overall functionality. The magnitude of responses to a community exercise program based on functional circuits in socially active and socially non-active older adults was also investigated. A total of 200 older adults aged ≥60 years from Requinoa, Chile, participated in the study. Participants were separated into two groups according to the level of social participation: socially active (SA) and socially non-active (SNA). During an evaluation, data regarding the presence of comorbidities (Charlson Comorbidity Index), disability level (Modified Health Assessment Questionnaire), dynamic balance (Timed Up and Go test), muscle force (handgrip dynamometry) and sociodemographic conditions were collected. Participants followed an exercise program consisting of a functional exercise circuit including balance, resistance and aerobic exercises, twice a week, for 12 weeks. Both the Charlson Comorbidity Index and disability were higher in SNA compared with SA participants on inclusion. Both groups improved disability (Δ-0.25 patients [-0.5 - -0.0625 patients] for SNA and (Δ-0.125 patients [-0.5-0 patients] for SA) and balance (Δ-2 s [-3-0 s] for SNA and (Δ-1 s [-3-0 s] for SA) after training (P < 0.05 for all). Changes from baseline were statistically higher in the SNA group. Handgrip force improved only in participants in the SNA group (Δ1.7 kg [0.6-2.8 kg], P = 0.0001). No differences, however, were observed between the magnitude of improvements of handgrip between groups. Although socially non-active older adults had more comorbidity and disability than their socially active counterparts, they showed a higher response to a community exercise program. Geriatr Gerontol Int 2018; 18: 216-223.

Addressing rural and remote access disparities for patients with inflammatory arthritis through video-conferencing and innovative inter-professional care models.

The aim of the present study was to evaluate whether rheumatoid arthritis (RA) patients followed longitudinally using video-conferencing and inter-professional care support have comparable disease control to those followed in traditional in-person rheumatology clinics. This was a randomized controlled trial for 85 RA patients allocated to either traditional in-person rheumatology follow-up or video-conferenced follow-up with urban-based rheumatologists and rural in-person physical therapist examiners. Follow-up was every 3months for 9months. Outcome measures included disease activity metrics (disease activity in 28 joints with CRP measure score [DAS28-CRP], and RA disease activity index [RADAI]), modified health assessment questionnaire (mHAQ), quality of life (EuroQOL five dimensions questionnaire [EQ5D]) and patient satisfaction (nine-item visit-specific satisfaction questionnaire [VSQ9]). Of 85 participants, 54 were randomized to the video-conferencing team model and 31 to the traditional clinic (control group). Dropout rates were high, with only 31 (57%) from the video-conferencing and 23 (74%) from the control group completing the study. The mean age for study participants was 56years; 20% were male. Mean RA disease duration was 13.9years. There were no significant between-group differences in DAS28-CRP, RADAI, mHAQ or EQ5D scores at baseline or over the study period. Satisfaction rates were high in both groups. We found no evidence of a difference in effectiveness between inter-professional video-conferencing and traditional rheumatology clinic for both the provision of effective follow-up care and patient satisfaction for established RA patients. High dropout rates reinforce the need for consultation with patients' needs and preferences in developing models of care. While use of video-conferencing/telehealth technologies may be a distinct advantage for some patients, there may be loss of travel-related auxiliary benefits for others.

Translation and validation of the Fatigue Severity Scale, Pittsburgh Sleep Quality Index and Modified Health Assessment Questionnaire into the Maltese Language, in a cohort of Maltese Systemic Lupus Erythematosus patients.

PURPOSE:The assessment of fatigue, sleep quality and functional disability requires the use of validated instruments such as the Fatigue Severity Scale (FSS), the Pittsburgh Sleep Quality Index (PSQI) and the Modified Health Assessment Questionnaire (mHAQ) respectively. The aim of this study was to translate and validate these instruments into the Maltese Language.METHOD:Forward translation from the original English version into Maltese was carried out by two translators. The two versions were compiled to produce a preliminary initial Maltese translation. This was translated back into English by two other translators. This led to the development of the pre-final version of the Maltese translation, which was pilot-tested in 20 bilingual patients with systemic lupus erythematosus.RESULTS:Psychometric testing revealed good reliability of the Maltese translation of the three questionnaires. Cronbach’s alpha of the Maltese versions of the FSS, PSQI and mHAQ were 0.877, 0.859 and 0.897 respectively, showing good internal consistency. Validity of the Maltese version of the FSS was shown, since it had a significant positive correlation with visual analogue scale for fatigue (r=0.809, p<0.001).CONCLUSION:The Maltese translations were thus finalised, and could be used for clinical assessment or research purposes.

Impact of Tocilizumab Monotherapy on Clinical and Patient-Reported Quality-of-Life Outcomes in Patients with Rheumatoid Arthritis.

IntroductionTocilizumab (TCZ) monotherapy has been proven as an effective treatment for rheumatoid arthritis (RA) in clinical trials. However, there are limited data available regarding the effectiveness of TCZ monotherapy in real-world clinical settings in the United States. The objective of this study was to evaluate the impact of TCZ monotherapy on disease activity and patient-reported outcomes (PROs) in a US-based observational cohort of patients with RA seen in routine clinical practice.MethodsEligible patients had active RA, no prior use of TCZ, and initiated TCZ as monotherapy. Changes in disease activity and PROs were assessed 1 year after TCZ initiation for the overall cohort and stratified by number of prior tumor necrosis factor inhibitors (TNFis; 0, 1, or ≥2). Primary outcomes were change in Clinical Disease Activity Index (CDAI); change in patient global disease activity, pain, fatigue; and the proportions of patients with improvement in modified Health Assessment Questionnaire (mHAQ), morning stiffness, and EQ-5D.ResultsOf 255 eligible TCZ monotherapy initiators, 9.4% were TNFi naive, 36.5% had one prior TNFi, and 54.1% had ≥2 prior TNFis. Clinical and PRO measures indicated that patients were substantially impacted by their disease at baseline. The median decrease in CDAI from baseline to 1 year was 9.8 and median patient global and pain scores improved by 10 mm, indicative of clinically meaningful improvement; the median fatigue score improved by 5 mm. Approximately 26% of patients reported clinically meaningful improvement in mHAQ, 54% experienced improvement in morning stiffness, and 20% to 36% experienced improvement in EQ-5D domains (walking, self-care, usual activities, pain/discomfort, and anxiety/depression). Improvements were similar across TNFi groups.ConclusionsPatients with active, refractory RA who initiated TCZ monotherapy experienced improvements in both composite disease activity scores and PROs at 1 year, regardless of prior TNFi exposure.FundingCorrona, LLC and Genentech.Electronic supplementary materialThe online version of this article (doi:10.1007/s40744-017-0081-3) contains supplementary material, which is available to authorized users.

Serum serotonin in rheumatoid arthritis patients: Relation to rheumatoid factor positivity, clinical manifestations and fibromyalgia

Aim of the workTo estimate serum level of serotonin in rheumatoid arthritis (RA) patients and study its relation with various clinical data, radiographic scores and fibromyalgia. Patients and methodsThis study involved eighty RA patients divided equally according to rheumatoid factor (RF) positivity. Modified Health Assessment Questionnaire, disease activity score in 28-joints (DAS 28), visual analogue scale of pain, Short Form Health Survey for mental and physical health, fibromyalgia questionnaire, RA Articular Damage score and radiological joint damage by van der Heijde modification were assessed. Serum level for serotonin was measured for all patients. ResultsThe mean age of seronegative patients was 41.7±10.7years; 36 females and 4 males and of seropositive (44.9±12.9years and were 34 females and 6 males). Serum serotonin level was high in RA patients compared to control (129.8±99.1ng/ml vs 79.6±54.5ng/ml respectively, p=0.001). Serum serotonin was higher in seropositive than seronegative (155.9±93.2 vs 101.5±99.4ng/ml respectively, p=0.007). Fibromyalgia syndrome (FMS) was associated with a significant lower serotonin level in both groups (p<0.005). High serotonin level was associated with combined disease modifying antirheumatic drugs (p=0.04) in seronegative patients. A lower serotonin level was associated with corticosteroids administration and dry eye (p=0.03, p=0.004 respectively) in seropositive cases. A significant correlation was present between serotonin level with erythrocyte sedimentation rate, vitality energy and mental health (r=0.4, p<0.05) in seropositive patients. ConclusionSerum serotonin level was high in RA, especially in seropositive patients. It demonstrated central antidepressant and peripheral pro-inflammatory role. The SSRI could be of benefit only in RA with FMS.

Secretory sphingomyelinase (S-SMase) activity is elevated in patients with rheumatoid arthritis.

The goals of this study were to determine if secretory sphingomyelinase (S-SMase) activity is elevated in patients with rheumatoid arthritis (RA) compared to control subjects and to examine the relationships of S-SMase activity with functional status, quality of life, and RA disease activity measurements. We collected data on 33 patients who were diagnosed with RA and 17 non-RA controls who were comparable in terms of age, sex, and race. Demographic, clinical data and self-reported measures of fatigue, pain, and physical function were obtained directly from patients and controls. RA patients also completed quantitative joint assessment using a 28-joint count and functional status and quality of life assessment using the Modified Health Assessment Questionnaire (MHAQ). Archived serum samples were used to analyze retrospectively serum S-SMase activity in patients and controls. The mean serum S-SMase activity was 1.4-fold higher in patients with RA (RA 2.8±1.0nmol/ml/h vs. controls 2.0±0.8nmol/ml/h; p=0.014). Spearman's rho correlations between S-SMase activity and oxidant activity, markers of inflammation and endothelial activation with the exception of P-selectin (rho=0.40, p=0.034), measures of disease activity, functional status, and quality of life were not statistically significant in patients with RA. We confirmed that S-SMase activity is higher among RA patients compared to controls, as in other acute and chronic inflammatory diseases. Future studies can build on the present findings to understand more fully the biologic role(s) of S-SMase activity in RA.

Discontinuation of Biologic Therapy in Rheumatoid Arthritis: Analysis from the Corrona RA Registry.

IntroductionDespite the availability of multiple effective therapies, discontinuation/switching of treatment is common for many patients with rheumatoid arthritis (RA). This study was designed to examine initiation of biologic disease-modifying anti-rheumatic drugs (bDMARDs) within the Consortium of Rheumatology Researchers of North America (Corrona) RA Registry, and characterize reasons for discontinuation.MethodsInclusion criteria were: Corrona-registered adults (≥18 years) with RA (2002–2011); age of RA onset: ≥16 years; ≥6 months’ follow-up after initiation of first/subsequent bDMARD. Patients receiving both tumor necrosis factor antagonists and non-TNF antagonists were included. Treatment discontinuation was defined as first report of stopping initial therapy or initiation of new bDMARD at/between visits, using a follow-up physician questionnaire.ResultsOverall, 6209 patients met inclusion criteria and 80.7% received TNF antagonists. Median time to discontinuation/change of therapy was 25.1 months (26.5 months with TNF antagonists vs. 20.5 months with non-TNF antagonists; log-rank p < 0.0001); 82.2, 67.3, and 51.1% of patients remained on therapy at 6, 12, and 24 months, respectively. Reasons for discontinuation were captured for 49.2% of patients, including: loss of efficacy (35.8%); physician preference (27.8%); safety (20.1%); patient preference (17.9%); and no access to treatment (9.0%). Baseline factors with greatest correlation to discontinuation were modified Health Assessment Questionnaire scores, patient-reported anxiety/depression, initiation of bDMARD treatment in 2007–2010 versus 2002–2003, and Clinical Disease Activity Index scores.ConclusionsAlmost one-third of patients in the US discontinue currently available bDMARD therapies for RA by 12 months and almost half by 24 months, most commonly due to loss of efficacy.FundingCorrona LLC and MedImmune.

Impact of hepatitis C virus infection on disease activity, functional status and ultrasonography findings in Egyptian rheumatoid arthritis patients

BackgroundHepatitis C virus (HCV) infection is one of the most frequently encountered public health problems in Egypt. It is associated with many autoimmune diseases such as rheumatoid arthritis. Aim of the workTo assess the impact of HCV infection in rheumatoid arthritis (RA) Egyptian patients; its relation to disease activity, functional status and ultrasonography findings. Patients and methodsThe study included 155 RA patients further classified according to the presence of concomitant HCV infection into 2 groups; rheumatoid arthritis (RA) and rheumatoid arthritis/hepatitis C virus (RA/HCV) groups. All patients were subjected to full history taking, thorough clinical examination, laboratory investigations, assessment of disease activity using the disease activity score 28 (DAS28) and assessment of functional status using the modified health assessment questionnaire (MHAQ). Ultrasonography (US) assessment was done using the German US7 score. ResultsBoth DAS28 and MHAQ scores showed significant differences between both the RA and the RA/HCV groups (p<0.001), with higher mean values observed in the RA/HCV group (5.4±1.1 and 1.05±0.79 respectively). Significantly higher US7 synovitis scores were found in the RA/HCV group compared to the RA group (p=0.03). US7 synovitis tenosynovitis scores revealed significant correlations with DAS28 and US7 synovitis scores correlated with MHAQ in both groups. ConclusionConcomitant HCV infection in RA patients had an impact on disease activity. RA patients with concomitant HCV infection (RA/HCV) had higher DAS28 and MHAQ scores, with higher US7 synovitis scores compared to RA patients. US7 score is a valuable objective tool for the assessment of RA disease activity.

Impact of rituximab on patient-reported outcomes in patients with rheumatoid arthritis from the US Corrona Registry

To evaluate the impact of rituximab on patient-reported outcomes (PROs) in a US-based observational cohort of patients with rheumatoid arthritis (RA). Patients with active RA, prior exposure to ≥1 tumor necrosis factor inhibitor (TNFi) and who newly initiated rituximab were identified. Changes in PROs were assessed 1 year after rituximab initiation. PRO measures included Clinical Disease Activity Index (CDAI); patient global disease activity, pain and fatigue (visual analog score; 0–100); morning stiffness (hours); modified Health Assessment Questionnaire (mHAQ; 0–3); and EuroQoL EQ-5D. Of the 667 patients who newly initiated rituximab, baseline PRO and clinical measures indicated that patients were substantially impacted by their RA disease and quality of life; 54% of patients had high disease activity. One year after rituximab initiation, 49.0, 47.1, 49.8, and 23.2% of patients reported clinically meaningful improvements in patient global, pain, fatigue, and mHAQ, respectively. Morning stiffness and EuroQol EQ-5D domains improved in 48 and 19–32% of patients, respectively. These real-world registry data demonstrated that patients with long-standing, refractory RA experienced improvements in PROs 1 year after initiating rituximab.

Association between characteristics of pain and stiffness and the functional status of patients with incident polymyalgia rheumatica from primary care

This paper aims to examine the relationship between different characteristics of pain and stiffness and the functional status of patients with newly diagnosed polymyalgia rheumatica (PMR). Baseline analysis of an inception cohort study was conducted. Patients aged ≥18 years, with a new diagnosis of PMR were recruited from 382 English general practices. Participants were mailed a baseline questionnaire, including separate pain and stiffness manikins and numerical rating scales (NRS), a question on their ability to raise their arms above their head and the modified Health Assessment Questionnaire (mHAQ) to examine participants’ functional status. Linear regression analysis, reported as regression co-efficients (95% confidence intervals (95% CI)), was used to assess the association of pain and stiffness with function, initially unadjusted and then adjusted for age, gender, deprivation status, smoking status, BMI, anxiety and depression. Six hundred fifty two patients responded to the baseline survey (88.5%). The majority (88.2%) reported no, or mild impairment in their functional status. Adjusted linear regression analysis demonstrated that high (NRS ≥8) pain (0.20 (95% CI 0.10–0.28)) or stiffness (0.18 (0.09–0.26)) ratings, an increasing number of sites of pain (0.18 (0.06–0.29)) or stiffness (0.19 (0.08–0.31)) and shoulder pain (0.18 (0.05–0.31)), stiffness (0.10 (0.01–0.20)) and difficulty raising arms above one’s head (0.19 (0.10–0.28)) were all associated with increased functional impairment. The majority of newly diagnosed PMR patients reported no or minimal functional difficulty. However, those who experience severe or widespread pain or stiffness often have significant functional limitation in performing their daily activities and may be a subset worthy of additional focus in primary care.

Can rheumatoid arthritis affect sleep in Egyptian patients?

Aim of the workTo investigate sleep problems in rheumatoid arthritis (RA) patients and to correlate sleep scores with disease characteristics and activity. Patients and methods100 RA patients and 40 matched controls were included. Disease activity score (DAS28), visual analogue scale (VAS) for pain, modified health assessment questionnaire (MHAQ) and medical outcomes study short form-36 (SF-36) were assessed and the van der Heijde-modified Sharp score (vdHSS) calculated. The Pittsburgh Sleep Quality Index (PSQI) was used to investigate the sleeping habits, sleep difficulty was assessed using the Athens Insomnia Scale (AIS) and daytime sleepiness was measured using the Epworth Sleepiness Scale (ESS). ResultsThe patients were 84 females and 16 males (F:M 5.25:1) with mean age of 48.1±12.4years, disease duration of 6.9±5.9years, DAS28 was 4.3±1.4, MHAQ was 0.95±0.6 and VAS was 45.2±21.1. The sleep scores PSQI, AIS and ESS were significantly increased in patients (6.98±2.8, 9.6±4.4 and 7.4±2.6) compared to control (2.6±1.9, 2.7±1.8 and 3.3±2.03 respectively; p=0.01 each). Sleep scores tended to be lower in females and were significantly higher in those with positive C-reactive protein. Rheumatoid factor positive patients and those not receiving methotrexate had significantly higher PSQI and AIS scores. Sleep scores significantly correlated with age, erythrocyte sedimentation rate, DAS28, VAS, MHAQ and vdHSS and negatively with SF-36 physical component score (PCS) (p=0.01 for all). Disease duration, DAS28, VAS and SF36 (PCS) were significant risk factors for sleep problems. ConclusionA high frequency of sleep disturbances in RA patients was observed. Interplay of pain, fatigue, activity and disability may lead to poor sleep quality.

Rheumatoid Arthritis: Are psychological factors effective in disease flare?

Rheumatoid arthritis (RA) is clinically an undulant disease, and reasons for flare or remission vary. We aimed to identify factors potentially associated with disease flare and remission. Two hundred and seventy-four patients with RA who were admitted to our center between January 2010 and January 2016 were included. Disease activity was evaluated using disease activity score 28 (DAS 28); functional status was evaluated using the modified Health Assessment Questionnaire (m-HAQ), a questionnaire that comprises flare or remission domains such as psychological stress and mood status, physical trauma, nutrition regimen, infection, antibiotic use, and seasonal weather changes. Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were used to identify if patients had a mood disorder. Four subscales of Arthritis Impact Measurement Scale-2 (AIMS-2) (level of tension, mood, general perception of health, and satisfaction with health) were used to determine patient quality of life. Of the 274 patients, 261 were female (95.3%) and 13 were male (4.7%); the mean age was 52.10±9.41 years. According to patients' perception, the most frequent reasons for joint symptoms were psychological stress/mood disorder (86.1%), followed by infection (49.6%) and trauma (46.4%). The most frequent factors for remission of symptoms were antibiotic use (42.7%), cold weather (34.3%), and hot weather (19%). Psychological stress and mood status are independent factors for relapse periods in patients with RA. These should be considered particularly in patients who are resistant to different treatment regimens and in whom any other reason for disease flare is not obvious.

Use of complementary and alternative medicines is associated with delay to initiation of disease-modifying anti-rheumatic drug therapy in early inflammatory arthritis.

To study the predictors of complementary and alternative medicine (CAM) use in patients with early inflammatory arthritis (EIA), and its impact on delay to initiation of disease-modifying anti-rheumatic drugs (DMARD). Data were collected prospectively from EIA patients aged ≥ 21 years. Current or prior CAM use was ascertained by face-to-face interview. Predictors of CAM use and its effect on time to DMARD initiation were determined by multivariate logistic regression and Cox proportional hazards, respectively. One hundred and eighty patients (70.6% female, 58.3% Chinese), of median (interquartile range [IQR]) age 51.1 (40.9-59.8) years and symptom duration 16.6 (9.2-26.6) weeks were included: 83.9% had rheumatoid arthritis, 57% were seropositive. Median (IQR) Disease Activity Score in 28-joints (DAS28) was 4.3 (2.8-5.7), modified Health Assessment Questionnaire (mHAQ) was 0.38 (0.0-0.88) and 41.3% were CAM users. Chinese race (odds ratio [OR] 5.76 [95%CI 2.53-13.1]), being non-English speaking (OR 2.68 [95% CI 1.18-6.09]), smoking (OR 3.35 [95% CI 1.23-9.15] and high DAS28 (OR 2.73 [95% CI 1.05-7.09] were independent predictors of CAM use. CAM users initiated DMARD later (median [IQR] 21.5 [13.1-30.4] vs. 15.6 [9.4-22.7] weeks in non-users, P = 0.005). CAM use and higher DAS28 were associated with a longer delay to DMARD initiation (hazard ratio [HR] 0.69, 95% CI 0.50-0.95 and 0.63, 95% CI 0.43-0.91, respectively) while higher mHAQ was associated with a shorter delay (HR 1.59, 95% CI 1.08-2.34) and race, education level, being non-English speaking, smoking and seropositivity were not associated. Healthcare professionals should be aware of the unique challenges in treating patients with EIA in Asia. Healthcare beliefs regarding CAM may need to be addressed to reduce treatment delay.

Urological comorbidities in Egyptian rheumatoid arthritis patients: Risk factors and relation to disease activity and functional status

Aim of the work: To assess the urological disorders in rheumatoid arthritis (RA) patients, analyse the risk factors and to find their relation to disease activity and functional status. Patients and methods: 291 RA patients (253 females and 38 males; F:M 6.7:1) and 242 matched controls were included. Urological disorders in the form of urinary tract infections (UTI), urolithiasis and acute urine retention (AUR) were assessed, risk factors were analysed. Disease activity score (DAS-28) and modified health assessment questionnaire (mHAQ) were calculated. Results: RA patients had more frequent urological disorders (38.14%) than controls (20.66%), more UTI (p<0.001) and this difference persisted in females (p<0.001). Urolithiasis tended to be more frequent in RA patients (p=0.3); the difference was significant between the female patients and controls (p=0.04). Urinary stones were comparable between the male patients and controls (p=0.2). RA patients had more AUR (4.8%) than the controls (2.1%) (p=0.07). Asthmatic patients particularly the females had more UTI (p=0.001 and p<0.001 respectively). UTIs were observed with higher steroid doses (p=0.04) and urolithiasis were noticed more in hypertensive female patients (p=0.03). Patients with higher DAS-28 and mHAQ developed more urological comorbidities (p0.49 and p=0.82 respectively). UTI and urolithiasis were detected in patients with higher DAS 28 (p=0.1 and p=0.4 respectively). Conclusion: RA patients were found to have more urological disorders. Bronchial asthma, hypertension and higher steroid doses may increase risk for urinary comorbidities in RA. Patients with higher DAS28 and mHAQ had more urological comorbidities, however without statistically significant difference.

Magnetic resonance imaging versus musculoskeletal ultrasound in the evaluation of temporomandibular joint in rheumatoid arthritis patients

Aim of the workTo evaluate temporomandibular joint (TMJ) affection in rheumatoid arthritis (RA) patients by magnetic resonance imaging (MRI) versus musculoskeletal ultrasound (MSUS) and to correlate the findings with clinical manifestations, disease activity and functional status. Patients and methodsTwenty RA patients (40 TMJ) were included in this study. Disease activity score 28 (DAS28) was assessed and functional status by modified health assessment questionnaire (mHAQ). The TMJs were assessed clinically and functionally according to the Fonesca’s questionnaire. Radiological assessment of the TMJ was performed using panorama X-ray, MSUS and MRI. ResultsThe patients mean age was 47.3±10.03 with a F:M 9:1. Out of 40 TMJs 27 (67.5%) were symptomatic; pain/tenderness in 67.5%, limited mouth opening in 65% and sounds in 47.5%. MRI was superior in detection of TMJ abnormalities compared with MSUS (82.5% vs 77.5%, respectively). The frequencies of TMJ erosions detected by MRI, MSUS and panorama were 80%, 57.5% and 27.5% respectively (p=0.0001). TMJ effusion and disc displacement were comparable by MRI and MSUS (67.5% and 62.5%; p=0.64 and 57.5% and 52.5%; p=0.5,respectively). Only the effusion and disc displacement significantly correlated with the DAS28 and mHAQ. Only the erosions detected by MSUS did not significantly correlate with the Fonesca’s questionnaire. ConclusionDetection of TMJ abnormalities tended to be higher by MRI than by MSUS yet with no difference between both modalities. TMJ erosions, effusion and disc displacement were common in RA patients as detected by MRI and MSUS. Also both were helpful in detecting subclinical TMJ radiographic abnormalities in RA patients.