Rheumatism Foundation Hospital Research Articles

FRI0056 Joint damage in patients with rheumatoid arthritis over 15-20 years – are there differences between women and men?

BackgroundRheumatoid arthritis (RA) is suggested to be a more severe disease in women than in men as disease activity appears higher in women and men meet remission criteria more often...

Beware of the biologicals—hospitals may die: the Rheumatism Foundation Hospital, Heinola, Finland (1951–2010)

The first patient entered the Rheumatism Foundation Hospital, Heinola, Finland in July 1951. From that point on, the hospital helped patients suffering from rheumatic disorders. Specialists in the hospital actively developed treatments and published a large number of scientific articles in international journals. The hospital was well known internationally among people working in the field. Progress in the development of disease-modifying medication (biological agents in particular) has dramatically improved the life of patients with rheumatic diseases, but all effective treatments may also have adverse effects. In this article, we briefly review the history of the Rheumatism Foundation Hospital, which was closed permanently in March 2010 due to bankruptcy. The economical difficulties were caused primarily by the progress made in disease-modifying therapy, which decreased the need of rehabilitation and operative treatment of patients with rheumatic diseases. It seems that a great success in biological agents can carry "serious adverse effects", which may kill hospitals. This is an important primary observation, which should be noticed when the future of specialised institutes is planned.

Diabetes, coeliac disease, multiple sclerosis and chronic arthritis in first‐degree relatives of patients with juvenile idiopathic arthritis

To evaluate the occurrence of autoimmune diseases in first-degree relatives of children with juvenile idiopathic arthritis (JIA) and to compare the figures with published population data. Families of the 362 children with recently diagnosed JIA admitted to Rheumatism Foundation Hospital, Finland, from 1996 to 2001 were contacted by questionnaires regarding autoimmune diseases in family members. Data were collected on type 1 diabetes, coeliac disease, multiple sclerosis and chronic arthritis, consisting mainly of JIA, rheumatoid arthritis, spondyloarthropathy or psoriatic arthritis. In all, 21.4% of the 355 families with a patient with JIA had members with type 1 diabetes, coeliac disease, multiple sclerosis or chronic arthritis. Thirty-three mothers and 23 fathers had type 1 diabetes, coeliac disease, multiple sclerosis or chronic arthritis in 15.2% (95% CI 11.6-19.4) of the families, and 23 mothers and 15 fathers had chronic arthritis in 10.7% (95% CI 7.7-14.5) of the families. When compared with available research data, the prevalences of rheumatoid arthritis, spondyloarthropathy, psoriatic arthritis, paediatric type 1 diabetes and JIA (in siblings) were increased in JIA families. Coeliac disease was as prevalent as in the population. Autoimmune diseases cluster in families with a child with JIA.

An evaluation of dry eye symptoms and signs in a cohort of children with juvenile idiopathic arthritis

To determine the prevalence of dry eye symptoms and signs in children with juvenile idiopathic arthritis (JIA). A total of 192 children with JIA: 48 oligo-, 39 extended oligo-, 79 polyarthritis, and 26 with other types of arthritis (eight juvenile spondyloarthritis, five juvenile psoriatic arthritis, three mixed connective tissue diseases, two systemic onset arthritis, and eight undetermined arthritis) were interviewed for dry eye symptoms and tested with Schirmer test with anesthetic. Two thirds of the patients were female and the mean age of the patients was 13.1 years (range 10-16) and the mean duration of arthritis was six years (SD 4, 4). Thirty-one percent of the patients had a history of uveitis. Dry eye was defined as Schirmer test score </= 5 mm in five minutes. The type of arthritis, a history of uveitis, and the ocular and systemic medication used were evaluated for their correlation with dry eye symptoms and signs by using chi-square tests and the Mann-Whitney Monte Carlo analysis. Altogether 17% of this cohort had decreased basal tear secretion. The most common symptoms of dry eye were discharge secretion, itching, and watering. The intensity of symptoms and signs did not correlate. The type of arthritis, a history or presence of uveitis, and the medication used did not correlate with the occurrence of dry eyes. Dry eye symptoms and signs are common in JIA, and Schirmer test with anesthetic is a useful tool in evaluating these patients.

The constancy of work-related empowerment

This study describes experiences of work empowerment among staff members at the Rheumatism Foundation Hospital in Helsinki, Finland. The data were collected on two occasions in 2004 and 2005 using a structured questionnaire with background variables and items concerning verbal, behavioural and outcome empowerment. The questionnaires were sent to all (n1=115, n2=112) members of multidisciplinary teams at the Rheumatism Foundation Hospital, with the exception of physicians, departmental secretaries and administrative personnel. The response rate at both data collections was 58%. The data were analysed by statistical methods. No statistically significant differences were seen in work empowerment between the two data collections. Perceptions of work-related empowerment were relatively strong. Work-related empowerment appears to be relatively constant and independent of changes in the organization. Indeed there is good reason to ask whether work empowerment is primarily a function of the individual employee's strengths and competencies.

Organizational change and work-related empowerment

This study describes the views of multidisciplinary teams on work-related empowerment in a transitional organization. The data were collected between September 2003 and January 2004 (n=115) and one year later (n=112) using a self-administered questionnaire consisting of verbal and behavioural items, empowerment outcomes, and factors promoting and impeding empowerment. The target population consisted of all members working in multidisciplinary teams at the Rheumatism Foundation Hospital in Finland. The response rate was 58% at both data collections. The data were analysed statistically using SPSS software. The multidisciplinary teams rated their work empowerment quite highly. The number of empowerment promoting factors was lowest for the category of future orientedness, consisting of continuity of work, opportunities for advancement, and access to information. The number of impeding factors was also highest for the same category of future orientedness, consisting here of organizational bureaucracy and hierarchy, authoritarian leadership, poor access to information, and short working periods. It is important not to underestimate the impacts of organizational changes: they have a direct effect on the work environment and may contribute to higher rates of dissatisfaction, burnout and absenteeism among health care workers.

Changes in bone mineral density in premenopausal women with rheumatoid arthritis during a two-year follow-up

Objective To ascertain changes in axial bone mineral in premenopausal women with severe rheumatoid arthritis (RA) treated with and without prednisolone (PRED), we conducted a two-year follow-up study of axial bone mineral density (BMD) and bone mineral content (BMC). Methods Premenopausal RA women ( n = 74) attending wards in the Rheumatism Foundation Hospital, Heinola, Finland were consecutively recruited for a follow-up study of BMD. BMD measurements in the lumbar spine and left proximal femur (femoral neck) were performed using dual X-ray absorptiometry at baseline and after two years. BMD is expressed as BMC per projectional area g/cm 2. The Larsen score of 0–100 was assessed at the check-ups. Two RA groups were analyzed: patients receiving prednisolone ( n = 48), RA with PRED group and without prednisolone ( n = 26), RA without PRED group. The control group ( n = 43) comprised age-matched, premenopausal healthy women. Results The patients in the RA with PRED group had lower BMD values than those in the RA without PRED group at commencement of follow-up. The mean weight-adjusted BMD percentage change in the lumbar spine to two years was −1.5% in the RA with PRED group, +0.6% in the RA without PRED group and −0.6% among the controls; a significant difference ( P = 0.030) was found between the RA groups. The mean BMC percentage change to two years in the lumbar spine was −2.2% in the RA with PRED-group ( P = 0.003), +0.0 in the RA without PRED-group and −0.6% in the control group. Accordingly, the mean weight-adjusted BMD percentage change in the femoral neck to two years was −2.6% in the RA with PRED group, +0.4% in the RA without PRED group and −0.9% among the controls; the difference between the RA groups being again significant ( P = 0.049). The mean BMC percentage change to two years in the femoral neck was −1.9% ( P = 0.006), −0.4% and −0.8%, respectively. Mean BMD decreased significantly in both lumbar spine ( P = 0.002) and femoral neck ( P < 0.001) only in the RA with PRED group. However, in spite of statistical findings above, when BMD is expressed as BMC per projectional area there was no statistically significant difference between the three groups in the change in BMC or projectional area in the lumbar spine or femoral neck. There was no significant correlation between the change in BMD in lumbar spine or femoral neck and the change in Larsen score among the RA groups. Conclusions We conclude that according to BMC, premenopausal RA women both with and without prednisolone treatment and controls lost bone statistically similarly. It seems that the role of RA itself in the multifactorial development of axial bone mass during the first decade of severe RA is not the most essential issue. We assume that this role will be less important with better treatment of RA than our patients received. The amount of bone loss during treatment with low-grade prednisolone remains controversial.

Work‐related empowerment of the multidisciplinary team at the Rheumatism Foundation Hospital

Carried out as part of a staff development project, this study describes the experiences of work-related empowerment within a multidisciplinary team at the Rheumatism Foundation Hospital in Finland. The data were collected using a structured questionnaire consisting of background variables and questions concerning verbal, behavioural and outcome empowerment. The questionnaire was sent to all members of the multidisciplinary team at the Rheumatism Foundation Hospital, with the exception of physicians, departmental secretaries and administrative personnel. The response rate was 58%. The data were examined using statistical methods. The multidisciplinary team felt quite strong verbal and behavioural empowerment, but was less confident in terms of outcome empowerment. Several factors were found to be associated with the different fields of empowerment. In conclusion, the multidisciplinary team felt quite strong work-related empowerment.

Erector spinae SEMG activity during forward flexion and re-extension in ankylosing spondylitis patients

Objective: To compare erector spinae muscle (ESM) activity as measured by surface electromyography (SEMG) in lumbar flexion from the upright position in men with ankylosing spondylitis (AS) and healthy males, and to study associations between pain, lumbar mobility and ESM activity. Methods: Surface EMG was undertaken at the L1-2 and L4-5 levels in 11 men with AS taking part in a rehabilitation course at the Rheumatism Foundation Hospital, and in 10 pain-free male controls, while the subjects were bending forward. Results: During full flexion ESM SEMG activity was significantly greater in patients with AS than in the controls. Relaxation was evident during flexion in all of the controls but in only some patients with AS. Lumbar mobility correlated negatively with ESM activities. No relationship between pain and ESM activity was evident. Some AS patients reported pain while ESM activity was being measured. Conclusion: Decreased lumbar mobility rather than pain explains ESM activity during full flexion in patients with AS.

Cervical spine disorders in patients with rheumatoid arthritis and amyloidosis.

The aim of this radiographic study was to ascertain the extent of inflammatory cervical spine disorders in patients with rheumatoid arthritis (RA) complicated by secondary amyloidosis (SA). The study involved 147 patients with RA and SA, whose cervical spine radiographs were available. They were treated at the Rheumatism Foundation Hospital, Heinola, during the period 1989-2000 and had had RA for a mean of 24 years. The inflammatory abnormalities of the cervical spine were studied from radiographs taken at or after the diagnosis of SA during flexion and extension. One-hundred and eleven (76%) patients had subluxations, impaction or apophyseal joint ankylosis. Atlantoaxial impaction (AAI) was seen in 76 (52%) patients and anterior atlantoaxial subluxation (AAS) in 59 (40%). Apophyseal joint ankylosis was the third most frequent finding, seen in 34 (23%) cases. A combination of AAI and apophyseal joint ankylosis was noted in 26 (18%) patients. Eight (5%) patients had undergone surgery on the cervical spine. In conclusion, inflammatory and destructive changes are frequent in the cervical spine of patients with RA and SA. Characteristic changes are AAI and AAS. RA patients with SA have more severe disease than those in epidemiological studies when cervical spine disorders are concerned.

Uveitis in juvenile idiopathic arthritis

The purpose of the present study was to extend our knowledge of the occurrence, characteristics and prognosis of uveitis in patients with juvenile idiopathic arthritis (JIA: arthritis of unknown cause of at least six weeks' duration in a child under 16 years of age). The occurrence of uveitis was examined retrospectively in subjects entitled under the nationwide sickness insurance scheme to receive specially reimbursed medication for JIA in 5/21 central hospital districts in Finland (population basis about 1 300 000 inhabitants) during 1980, 1985 and 1990. A total of 114 children with JIA were found and uveitis was diagnosed in 16% of them. Uveitis was chronic (duration >6 months) in nine cases, the most severe cases being those three in whom uveitis was detected at the onset of arthritis. In 49 sibling pairs with JIA from the Rheumatism Foundation Hospital uveitis was detected in 26%. These 80 familial JIA cases belonging to 37 families with two or three affected siblings were collected from about 2000 children seen at the Hospital during 15 years. The observed concordance rate for uveitis (three pairs) did not differ from that expected (3.4 pairs). Uveitis was chronic in most instances, but its course was usually mild. In the clinic-based cohort of 426 patients with newly diagnosed JIA from the Rheumatism Foundation Hospital the most important determinants of associated uveitis were early onset of arthritis (at the age of 2 to 4 years) and antinuclear antibody (ANA) positivity. During the mean follow-up time of 4.5 years a total of 104 (24%) children with JIA developed uveitis. The condition was in most cases (99 out of 104) asymptomatic and was found early in the disease process, in a majority of cases during the first four years from the onset of arthritis. Proportionally uveitis was as frequent in rheumatoid factor-seronegative polyarthritis as in oligoarthritis and there was no predominance of girls. The prognosis of uveitis in this prospective series was better than that in most earlier reports; complications in 24% of cases, none of the patients became blind. In the above cohort, 372 children had seronegative oligoarthritis or polyarthritis. Within this group, the activity of arthritis was compared between patients with associated uveitis and

The cervical spine in juvenile chronic arthritis

Background context: In patients with juvenile chronic arthritis (JCA) the cervical spine is often affected, leading to pain and functional limitations. Purpose: To describe the frequency of the radiographic abnormalities in the cervical spine of a large series of patients with JCA, examined after skeletal maturity. Study design: Consecutive patients with JCA, who had cervical spine radiographs available taken at adult age (>18 years) were included in the study from one outpatient clinic and one rheumatology ward in the Rheumatism Foundation Hospital, Heinola, Finland. Patient sample: The series consisted of 159 patients fulfilling the diagnostic criteria of the European League Against Rheumatism for JCA. Outcome measures: Evaluation of cervical spine radiographs for inflammatory changes. Methods: Inflammatory changes in the cervical spine radiographs were measured as well as the size of the fourth cervical vertebra. Patient records were studied. The statistical analysis was calculated by Student's t-test or Mann-Whitney U test. Results: In 98 cases (62%) some inflammatory changes were detected in the cervical spine. Apophyseal joint ankylosis was noted in 65 patients (41%), anterior atlantoaxial subluxation in 27 (17 %) and atlantoaxial impaction in 39 (25 %). The fourth cervical vertebra was abnormally small in 41 patients (26%). Conclusions: Radiographically, the most frequent inflammatory change in the cervical spine of patients with JCA was apophyseal joint ankylosis at multiple levels. Atlantoaxial impaction and anterior atlantoaxial subluxation were typical of the upper cervical spine. Clinically, these changes tend to limit neck movements. A small C4 vertebral body was seen in patients with early disease onset and short body stature.

Revisions for aseptic loosening in Souter-Strathclyde elbow arthroplasty: incidence of revisions of different components used in 522 consecutive cases.

We present the prosthesis survival of the 7 most commonly used component types of 522 primary Souter elbow replacements performed in the Rheumatism Foundation Hospital during the years 1982-1997. The cohort comprised 370 female and 33 male patients with a mean age of 57 (20-81) years. 119 patients had a bilateral procedure. The indications for operation in all cases were rheumatoid arthritis and other chronic inflammatory joint disease. The mean duration of the disease at the time of operation was 25 (2-70) years. Elbows were often severely destroyed and, in one thiird of the joints, essential bone structures were missing. Therefore, in 178 cases, the ulnar components were retentive and in the remaining 344 elbows with better bone stock non-retentive. 47 patients had 51 operations for aseptic loosening up to the end of year 2000. In the survival analysis, the general cumulative success rates for the whole study cohort, without revision because of aseptic loosening 5 and10 years after surgery, were 96% and 84%, respectively. Revision was used as an end point. Cumulative success rates of the 7 most commonly used components are presented separately. The highest 5-year-survival rate was 100%, the lowest 93%. The corresponding 10-year-survival rates were 91% and 76%, respectively.

Occurrence of uveitis in recently diagnosed juvenile chronic arthritis: A prospective study

Objective To examine the occurrence and characteristics of uveitis in patients with recently diagnosed juvenile chronic arthritis (JCA). Design A prospective observational case series. Participants/methods The study covered the new cases detected with JCA (426 children), all of whom were referred to an ophthalmologic consultation during 1989 to 1996 at the Pediatric Department of the Rheumatism Foundation Hospital, Heinola, Finland. Main outcome measures The children with JCA were followed by ophthalmologic and pediatric examinations two to four times a year. The type and course of arthritis and presentation and characteristics of uveitis were examined prospectively. Results Uveitis was detected in 104 of 426 children (24%). Two thirds of all patients and the same proportion of those with uveitis were girls. Proportionally, uveitis was found to be as common among children with oligoarthritis (27%) as among those with seronegative polyarthritis (25%). Antinuclear antibodies (ANA) were detected significantly more frequently in patients with uveitis (66%) than among those without uveitis (37%) ( P < 0.001). The uveitis was asymptomatic in 99 cases; only 5 children had episodes of acute anterior symptomatic uveitis. Uveitis was found before or within 3 months from the onset of recent arthritis in 51 of 104 children (49%) and later on in 53 of 104 children (51%). The mean age at diagnosis of uveitis was 5.9 years (range, 1.1–17.7; median, 4.9 years). The mean period from the diagnosis of JCA to the diagnosis of uveitis was 1.1 years (range, −2.4–6.5; median, 0.3 years). The mean age at diagnosis of JCA was 4.8 years (range, 0.6–15; median, 3.2 years) among those with uveitis and 7.3 years (range, 0.9–16; median, 6.7 years) among those who did not have it ( P < 0.001). Uveitis was ongoing in 63 children at the end of the follow-up period. The mean follow-up time was 4.5 years (range, 0–9.7) for all children and 5.6 years (range, 1.3–9.6) for those with uveitis. In most instances, the visual prognosis was good. In 25 of 104 patients (24%) one or more complications of uveitis were found, but in only three children did the visual acuity decrease to 20/60 or less, and none became blind. All the other patients had visual acuity ≥ 20/40. Conclusions In this patient group, uveitis in JCA frequently appeared very early after the onset of arthritis. The uveitis was significantly more common in patients with an early onset of arthritis combined with ANA positivity. The proportion of children with uveitis was as large in those with polyarthritis as in those with oligoarthritis, with no predilection to girls.

Uveitis in sibling pairs with juvenile idiopathic arthritis.

To ascertain the occurrence and characteristics of uveitis in sibling pairs affected with juvenile idiopathic arthritis (JIA). The sibling series comprised 80 JIA patients from 37 families with two or three JIA children, seen at the paediatric department of the Rheumatism Foundation Hospital in Heinola, Finland. An ophthalmologist examined the children for uveitis two to four times a year and the course of the condition was recorded during the follow-up. Uveitis was diagnosed in 21 of the 80 patients (26%). Three pairs (3.4 pairs expected) were concordant for the presence of asymptomatic uveitis. Two patients with enthesitis-related arthritis had acute unilateral uveitis. Among the remaining cases, uveitis was chronic and continuously active at the end of follow-up in 13 instances, but in spite of this only one patient had impaired vision. HLA allele B27 occurred more frequently in patients with uveitis than in those without uveitis (52 vs 30%, P=0.073) and all six subjects in the pairs concordant for chronic uveitis carried this allele. The observed concordance rate for uveitis did not differ from that expected. Although the uveitis was chronic in most instances, its course was usually mild.

Charnley total hip arthroplasty in ankylosing spondylitis: survivorship analysis of 76 patients followed for 8-28 years.

76 consecutive Charnley low friction hip arthroplasties were performed in 54 (37 men) patients with ankylosing spondylitis from 1971 to 1991 in the Rheumatism Foundation Hospital. Their mean age was 40 (16-67) years. They were followed until the end of 1999. The overall prosthesis survival was 80% at 10 years, 66% at 15 years and 62% at 20 years. The survival of the acetabular component was 91%, 77% and 73% at 10, 15 and 20 years and that of the femoral component 82%, 79% and 77%, respectively. We found no significant risk factor that predicted prosthesis survival.

Secondary amyloidosis has decreased in patients with inflammatory joint disease in Finland.

We studied whether the high incidence of secondary amyloidosis (SA) is a consistent finding in patients with inflammatory joint disease. A total of 4508 biopsies of patients with rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis were studied at the Rheumatism Foundation Hospital during 1987-1997. The results show that the annual number of findings of SA was reduced from 68 to less than 10. We suggest that a change in medication towards more frequent use of cytostatic agents is the reason for the reduction in incidence of SA.

The Giannina Gaslini Children's Hospital

Click to increase image sizeClick to decrease image size Additional informationNotes on contributorsLuisa MassimoJoyce Laing works in the Department of Child and Family Psychiatry, Playfield House, Cupar, Fife, and is a Consultant Art Therapist to Psychiatric Hospitals and Prisons and Chairwoman of the Scottish Society of Art and Psychology.Dr Niculescu Dan, Centrul de Reumatologie, Str. J. (F)ucick no. 5, Bucuresti, RomaniaAnni Vilppula, Department of Medicine, Paimio Hospital, Preitilä, FinlandG. Tausch, Department of Rheumatology, Municipal Hospital of Vienna-Lainz, Wolkersbergenstraße 1, A-1130Wien, AustriaDr Guido Gothoni, Medica Pharmaceutical Company Ltd., P.O. Box 325, SF-00101 Helsinki 10, FinlandA. Elman, Dept. of Rheumatology, Karolinska sjukhuset, Stockholm, SwedenHannu Paitälä, Rheumatism Foundation Hospital, Heinola, FinlandJonas Jonsson, National Bacteriological Laboratory, S-105 21 Stockholm, Sweden

Long-term followup of rheumatoid forefoot surgery.

Rheumatoid forefoot deformities were treated originally at the Rheumatism Foundation Hospital by metatarsal head resection (II-V) and resection of the base of the proximal phalanx of the great toe. Recurrent great toe deformity with pain in numerous cases led to a comparative series of arthrodesis of the first metatarsophalangeal joint with resection of lesser metatarsal heads. At an average followup period of 3 years, the clinical evaluation and patient assessments were slightly in favor of arthrodesis. However, the patients' evaluation at 14 years was slightly in favor of resection. Measured in the plane of the first metatarsophalangeal joint, the recommended fusion position is 15 degrees valgus and 30 degrees dorsiflexion (females) and 25 degrees dorsiflexion (males). The position of the fusion is critical for a successful surgical outcome. Although both surgical methods give good pain relief and patient satisfaction, there is a risk of reoperation in the long term.

Multiallelic polymorphism of the cartilage collagen gene: no association with osteoarthrosis.

To determine whether any of the type II collagen alleles are associated with generalised osteoarthrosis or osteoarthrosis of the finger joints in the genetically isolated Finnish population. Two patient cohorts with evidence for only primary osteoarthrosis and a cohort of healthy control subjects were selected from the Helsinki University Central Hospital and the Rheumatism Foundation Hospital in Finland. Forty one patients with primary generalised osteoarthrosis, 49 patients with osteoarthrosis of the finger joints, and 48 control subjects were included. Two markers of the type II collagen gene, a PvuII polymorphism and a VNTR polymorphism, were analysed from each subject. Four different alleles of the VNTR marker were observed and the relative risks associated with the different VNTR alleles varied between 0.39 and 1.24 among the patients with generalised osteoarthrosis and between 0.67 and 2.33 among the patients with osteoarthrosis of the finger joints. The PvuII polymorphism detected two different alleles and the associated relative risks were 0.82 and 1.82 for the patients with generalised osteoarthrosis, and 1.04 and 0.96 for the patients with osteoarthrosis of the finger joints. A major predisposing allele of the type II collagen gene as the causative factor for osteoarthrosis could be excluded in this population. A spectrum of mutations associated with different alleles of this gene could not be excluded, however. Further, these two forms of cartilage disease can be caused by gene defects with reduced penetrance and the effect of such an allele is easily masked under the high frequency of normal alleles.