The effect of drugs on hand function in rheumatoid arthritis

In 30 inpatients with diagnosis of rheumatoid arthritis according ACR criteria we evaluated efficacy of non steroid-antiinflammatory drugs (NSAIDs) and corticosteroids (CS) on pain, morning stiffness and grip strength. NSAIDs and combination of NSAIDs and CS showed statistically significant analgesic effect (P < 0.005). Combination of NSAIDs and CS statistically significant shortened morning stiffness comparing NSAIDs or CS as single drug. Grip strength didn't rise in any investigated group. This could be explained with long disease duration (11.69 years). Morning stiffness is symptom not related only to extracellular fluid cumulation in affected areas but also to other progressive and longlasting disease signs.     

Early diagnosis of rheumatoid arthritis

On the basis of own observations of courses the author adopts a definite attitude to the early symptomatology of the rheumatoid arthritis. During the first weeks of the rheumatoid arthritis the following symptoms are found: articular syndromes, more frequently in form of obstinate polyarthralgias, mono-oligoarthritis, accompanied by morning rigidity and accelerated BSR as well as impairment of the general condition. In the majority of the patients only the tentative diagnosis rheumatoid arthritis may be made. After a one to three months' course of the disease the diagnosis becomes more probable. It is above all based on constancy and symmetry, characteristic localisation of the articular process, morning rigidity, radiologically paraarticular loosening of the structure and morphological symptoms of an acute and subacute synovialitis. 6 to 12 months after the beginning of the disease a clinical picture forms which allows to make the diagnosis of a certain or classical rheumatoid arthritis in accordance with the criteria of the ARA. The occurrence of a high activity of multiple affection of the joints (permanent symmetrical polyarthritis including the small joints of the hands and feet), distinctive morning rigidity, high fever and much accelerated BSR, beginning with the first weeks of the disease, speaks for the possibility of the development of an arthrovisceral form of the course of rheumatoid arthritis.     

Only high disease activity and positive rheumatoid factor indicate poor prognosis in patients with early rheumatoid arthritis treated with "sawtooth" strategy

OBJECTIVES: To investigate the prognostic significance of clinical and genetic markers on the outcome of patients with recent-onset rheumatoid arthritis (RA) treated actively with slow acting antirheumatic drugs (SAARDs). METHODS: A total of 142 consecutive patients with early RA (median disease duration of 7 months) were treated according to the "sawtooth" strategy and prospectively followed up for an average of 6.2 years. Several clinical parameters at start as well as genetic markers were related to the functional outcome (ARA Functional class and HAQ disability score) and radiographic joint damage (Larsen's score) at the latest visit. RESULTS: In logistic regression analysis only Mallya score (including morning stiffness, pain scale, grip strength, Ritchie's articular index, haemoglobin, and erythrocyte sedimentation rate) at baseline, and Mallya score and rheumatoid factor (RF) positivity at one year were found to be of significance with respect to the radiographic outcome of the patients. Furthermore, at the latest visit HAQ score was related to radiographic score. At baseline the mean ages of the DR4 positive patients and the patients with RA associated DR alleles were statistically significantly lower than those without the above mentioned risk factors (44 v 49, p = 0.03 and 41 v 53, p = 0.04, respectively). However, these genetic markers had no prognostic significance on the functional or radiographic outcome of the patients. CONCLUSION: High clinical disease activity at baseline and RF positivity especially at one year after the institution of SAARD treatment are the best predictors of poor prognosis in early RA. However, from the clinical point of view, the disease outcome of an individual patient with early RA, cannot be predicted accurately enough by present means.     

Muscle strength in healthy people and in patients suffering from recent-onset inflammatory arthritis

Neuromuscular function was compared among 20 patients with relatively recent onset (symptomatic period 17 +/- 24 months) rheumatoid arthritis (RA) (experimental group; EG), and 20 age- and sex-matched healthy people (control group; CG). The comparison was repeated after a period of 6 months, when 16 patients had carried out progressive strength training. At baseline maximal grip strength and maximal dynamic unilateral strength of the knee extensors in the EG were significantly (P < 0.05) lower in comparison to the CG. The groups did not differ from each other in maximal isometric strength of the trunk flexors and extensors or the knee extensors. The 6-month dynamic strength training in the EG resulted in significant increases in maximal dynamic strength of the knee extensors (P < 0.001), in isometric grip strength (P < 0.001) and in isometric strength of the trunk flexors (P < 0.05) and extensors (P < 0.05) to the level of the healthy controls. Only minor changes took place in explosive strength and maximal isometric strength of the knee extensors. Erythrocyte sedimentation rate (P < 0.001), Ritchie's articular index (P < 0.01) and modified health assessment questionnaire (P < 0.01) improved significantly during the training period. The results suggest that inflammatory arthritis decreases dynamic and/or isometric muscle strength in selected muscle groups of the body already in the early stages of disease. However, progressive dynamic strength training rapidly increases the neuromuscular performance capacity of the patients even to the level of healthy people without detrimental effects on disease activity.     

Radial and lumbar bone mineral density after wrist synovectomy in rheumatoid arthritis. A minimum 2-year follow-up in 10 unilaterally operated patients

Bone mineral density (BMD) of both radii and lumbar vertebrae was measured by single-photon absorptiometry and dual X-ray absorptiometry, respectively, before and 2.1-4.8 years after a unilateral wrist synovectomy in 10 patients with rheumatoid arthritis. Radial BMD on the operated side significantly increased after synovectomy, while that on the non-operated side did not change. Lumbar BMD significantly decreased after the operation. The grip strength of the operated side increased significantly after synovectomy, while there were no changes in the grip strength on the non-operated side. These findings suggest that wrist synovectomy results in pain relief and improves use, thereby increasing the BMD of the operated radius.     

Radiographic outcome of recent-onset rheumatoid arthritis: a 19-year study of radiographic progression

OBJECTIVE: To describe the longitudinal radiographic course of rheumatoid arthritis (RA), and to identify and quantitate predictors of radiographic progression. METHODS: This prospective, longitudinal study of radiographic progression and clinical predictors of RA involved 256 patients with RA who were seen within the first 2 years of disease (mean 0.77 years) and were followed up for up to 19 years. Participants underwent a total of 6,278 clinical assessments (mean 24.5) and 934 paired radiographs (mean 3.1, range 2-6). Clinical assessments at every visit included determination of the erythrocyte sedimentation rate (ESR), grip strength, pain scores, tender joint counts, and anxiety and depression measurements. Regression analyses utilized time-integrated predictors. RESULTS: Overall, radiographic progression rates, as measured by the summary Sharp scores, appeared constant over the course of RA. The strongest correlate of progression was the time-integrated ESR (rho=0.53). This association grew stronger with time. At 0-5 years, 5-10 years, 10-15 years, and 15-20 years, correlations were 0.40, 0.50, 0.65, and 0.74, respectively, and for the period 10-20 years, the correlation was 0.67. In multivariate models, the mean ESR, mean grip strength, rheumatoid factor positivity, and tender joint count were independent predictors of radiographic progression. CONCLUSION: Radiographic damage occurs at a constant rate in RA, and is not greater early in RA or reduced later in the course of the illness. Acute-phase reactants are, by far, the strongest determinants of progression.     

Treatment of rheumatoid hand synovitis with a regional block technique

This study reports a novel technique for treating painful rheumatoid hand synovitis using a regional block technique. Nine patients with symptomatic rheumatoid hand synovitis were treated. Assessments of symptoms, grip strength and synovial swelling were made in each hand before the injection, and at 1 and 4 weeks after the procedure. A sphygmomanometer cuff was inflated, on the side of the patients most symptomatic hand, to 220mmHg and a solution of hydrocortisone sodium succinate 50mgs and lignocaine 10mls 0.5% was injected intravenously. The cuff was deflated slowly after 20 minutes. The injected hand improved symptomatically in 7 patients at 1 week, and further improvement was reported in 6 of these 7 at 1 month. Mean grip strength increased significantly in the injected hand both at 1 week (p = 0.01) and 1 month (p = 0.018). There was no change in the other hand. This technique is safe, reduced hand pain and improved grip strength in these patients with rheumatoid hand synovitis.     

Effects of detraining subsequent to strength training on neuromuscular function in patients with inflammatory arthritis

The effects of detraining subsequent to strength training on neuromuscular function were examined in 39 recent-onset rheumatoid arthritis (RA) patients. Eighteen age- and sex-matched healthy people (H) served as controls. Patients were randomly allocated either to the experimental group (PE), who carried out progressive strength training for 6 months, or to the control group (PC), who maintained only their habitual physical activities. After 6 months, PE returned to their earlier physical activities and strength training was terminated. At baseline, the maximal strength of the trunk extensors (not significant), grip strength and maximal dynamic strength and the shape of the force-time curve of the knee extensors were lower in PE and PC (P < 0.05-0.001) than in H. Strength training in PE led to remarkable increases (P < 0.05-0.001) in the maximal strength of all muscle groups without changes in the shape of the force-time curve. The increases in muscle strength in PE obtained by strength training were lost to a great degree during the detraining period for the isometric trunk extension (P < 0.01) and flexion (P < 0.01) strength and for the dynamic knee extension strength (P < 0.05), but not for the grip strength. In PC, trunk extension and flexion strength decreased significantly throughout the study period. At the post-test, all the strength values in both patient groups were much lower than in H. RA is a chronic disease which seems to need continuous physical exercise with sufficient intensity to minimize/prevent the loss of muscle strength and functional capacity.     

Cyclosporine A in the treatment of early rheumatoid arthritis. A prospective, randomized 24-month study

OBJECTIVE: To investigate the efficacy, tolerability and safety of cyclosporine A (CSA) in early rheumatoid arthritis (RA) patients. METHODS: Patients with an early diagnosis of RA, a disease duration of less than 3 years, and without prior disease modifying antirheumatic drug (DMARD) treatment were studied. They randomly received oral CSA (3 mg/kg/day) or oral methotrexate (MTX) (0.15 mg/kg/week). In addition, all patients in both groups received oral prednisone (7.5 mg/day). RESULTS: Fifty-two patients were assigned to the CSA group and 51 to the MTX group. After 24 months of treatment, 48 patients from the CSA group and 48 from the MTX group showed significant clinical improvement. This was evaluated by the duration of morning stiffness, grip strength, the total joint count, joint swelling, and joint tenderness and pain, compared to pre-treatment values. The clinical improvement was also associated with a significant decrease in ESR and CRP values in both groups. No significant radiological deterioration was observed in the CSA patients compared to those treated with MTX after 24 months. Four patients from the CSA group dropped out of the study, two because of a synovitis flare, one because of severe hypertrichosis and one because of severe gingival hyperplasia. Three patients from the MTX group withdrew, one because of disease flare-up and two because of gastrointestinal disturbances. CONCLUSION: Early immunointervention in RA patients appears to be crucial to limit the development of joint damage. Cyclosporine A appears to be effective, well tolerated and safe in the long-term treatment of RA and can therefore be used as a first immunomodulatory drug in the armamentarium for the treatment of RA.     

Fatal bronchiolitis obliterans in a patient with juvenile rheumatoid arthritis receiving chrysotherapy

Bronchiolitis obliterans has been described in adults with rheumatoid arthritis, particularly in association with D-penicillamine treatment, but to our knowledge has not been reported in juvenile rheumatoid arthritis (JRA). We describe a 12-year-old girl with JRA who developed bronchiolitis obliterans after a 6-month course of intramuscular gold. She presented with severe obstructive airway disease (FEV1, 17% predicted) unresponsive to bronchodilators, without obvious pathology on chest radiograph. Despite aggressive immunosuppressive therapy and eventual lung transplantation, she died 3 1/2 years after her initial diagnosis of JRA. Although rare, bronchiolitis obliterans must be considered in the differential diagnosis of respiratory distress in children with JRA.     

Comparison of the results of PCA knee joint endoprosthesis in patients with rheumatoid arthritis and gonarthrosis

Hundred and forty two porous-coated anatomic (PCA) total condylar arthroplasties were performed from 1985 to 1991 in hundred and twenty-four patients, ninety-seven women and twenty-seven men. The diagnosis was osteoarthritis in 96 cases and rheumatoid arthritis in 46 cases. The mean follow-up was 88 months, range from 51 to 137 months. All operated patients were evaluated based on survivorship of the endoprosthesis with the cumulative survivorship method according to Kaplan-Meier method. The end point was defined as endoprosthesis in situ. The overall cumulative survival rate for mean follow up time was 77%. The survival rate of the rheumatoid arthritis group was significantly higher (82.5%) than that of the osteoarthritis group (73.8%). 108 PCA arthroplastes were evaluated regarding Baltimore's score. The mean postoperative Baltimore's score was 68.7. In the rheumatoid arthritis group score was 74.8 and in the osteoarthritis group it was 65.9 but this difference is not statistically significant (p = 0.06).     

Diagnosis of early rheumatoid polyarthritis

The diagnosis of rheumatoid arthritis is mainly based on the clinical findings showing in typical cases a bilateral symmetrical polysynovitis predominantly on the small hand and feet joints, without any other extra-rheumatological feature. Even this clinical presentation is very suggestive of the diagnosis, other diagnoses of diseases life and or function threatening (septic arthritis, viral arthritis, arthritis related to hemopathy, systemic vasculitis ...) have to be systematically evocated. The interest of an early diagnosis of rheumatoid arthritis is to facilitate the treatment and the monitoring of the patients since such treatment seems to be more efficient when initiated at an early stage of the disease.     

Night medication in rheumatoid arthritis: II. Combined therapy with indomethacin and diazepam

Seventeen of eighteen patients hospitalized for active rheumatoid arthritis completed a three-day randomized, double-blind comparison of 100 mg indomethacin, 100 mg indomethacin with 10 mg diazepam and matching placebo as night medication. The results showed a consistent pattern in the four functions measured--pain, morning stiffness, sleep score and patient preference. In each, indomethacin proved superior to placebo and the combined therapy better than indomethacin alone. From this it has been concluded that the combination of indomethacin and diazepam should now be considered the treatment of choice for maximum control of night pain and morning stiffness in rheumatoid arthritis.     

A case of interstitial pneumonia in polymyositis difficult to distinguish from gold pneumonitis

Rheumatoid arthritis was diagnosed in a 48-year-old woman. She received a gold compound, and 4 weeks after the start of that therapy, interstitial pneumonia appeared. Findings from a muscle biopsy, and high serum CPK and LDH levels indicated that she suffered from polymyositis rather than rheumatoid arthritis. The result of a drug lymphocyte stimulation test (DLST) for the gold compound was more than 200%. Because the usefulness of the DLST for the gold compound in the diagnosis of gold pneumonitis is not thoroughly established, the DLST was also done in patients with rheumatoid arthritis who were receiving the gold compound without side effects, and in normal subjects. Many of the rheumatoid arthritis patients and some of the normal subjects had a positive response to the gold compound. Therefore a positive response on the DLST for the gold compound does not always support the diagnosis of gold pneumonitis.     

Diagnosis and course of early-onset arthritis: results of a special early arthritis clinic compared to routine patient care

OBJECTIVE: Early arthritis patients referred to an Early Arthritis Clinic (EAC) (n = 233) were compared to 241 patients from the routine out-patient clinic with respect to lag time between the onset of symptoms and the visit to the rheumatologist, clinical presentation and the consistency of the diagnosis after 1 yr. RESULTS: The reduction in median lag time for the EAC patients was at least 3 months. An insidious onset of symptoms was found more often in the rheumatoid arthritis (RA) patients in the routine clinic. In 70% of all cases, a diagnosis could be made after 2 weeks and, if the clinical diagnosis was definite RA, this hardly changed during the following year. Early erosions were seen in 25% of RA patients and were associated with a positive rheumatoid factor (OR 2.08, 95% CI 0.95 4.59). CONCLUSION: An early diagnosis of RA at the EAC is possible and reliable; the high frequency of erosions illustrates the need for early treatment.     

Assessment of disease activity in rheumatoid arthritis using magnetic resonance imaging: quantification of pannus volume in the hands

We attempted to assess whether pannus volume measured by magnetic resonance imaging (MRI) can be used as an indicator of disease activity in rheumatoid arthritis (RA). Eleven women (mean age 46 yr) with uncontrolled RA were studied for 1 yr. Pannus formation in both hands was quantified using MRI at the start of the study, and at 6 and 12 months thereafter. The volume of enhancing pannus (VEP) was compared with changes in the radiological scores, grip strength, joint tenderness counts, joint swelling counts, erythrocyte sedimentation rate (ESR), and serum C-reactive protein (CRP). Patients were classified into three groups based on VEP changes between 0 and 12 months: unchanged (n = 2), decreased (n = 6) and increased (n = 3). VEP at 6 months and at 12 months differed significantly between the three groups. No statistically significant differences were found between the groups in radiographic scores, physical parameters or laboratory parameters despite the fact that some of these parameters changed in the direction indicated by the changes in VEP. VEP can be used as a new indicator to assess disease activity in individual RA patients and, using this parameter, treatment outcome can be assessed in fewer subjects than with traditional measures.     

Recurrent Pseudomonas bronchopneumonia and other symptoms as in cystic fibrosis in a child with type I pseudohypoaldosteronism

The in vitro mechanical properties of 14 wrist extensor tendons salvaged at surgery from patients with inflammatory (rheumatoid) arthritis and noninflammatory arthrosis were measured in uniaxial tension and compared. The rheumatoid tendons had higher extensibility at low stresses, lower stiffness in the linear portion of the stress-strain curve, greater rates of stress relaxation, and lower ultimate strengths than did the nonrheumatoid tendons. Differences in tangent modulus, stress remaining at 100 seconds, and ultimate tensile strength were significant at the 95% confidence level. In vivo, mechanically impaired tendons may play an important role in destabilization of the wrist in patients with rheumatoid arthritis.     

Comparison of phenytoin with auranofin and chloroquine in rheumatoid arthritis--a double blind study

OBJECTIVE: To evaluate efficacy of phenytoin in modifying the course of rheumatoid arthritis (RA) by comparing it to gold (auranofin) and chloroquine. METHODS: A double blind, randomized study of 6 months' duration was conducted at the Nizam Institute of Medical Sciences, Hyderabad, India. One hundred and thirty-two patients with active RA (defined by the 1987 ARA criteria) were entered into the study and randomized into 3 groups: phenytoin, chloroquine, or auranofin. RESULTS: Full data were evaluable in 100 patients who satisfactorily completed the protocol (phenytoin, 35; auranofin, 30; and chloroquine, 35). Twenty-four patients were noncompliant and did not take medication or return for evaluation; 8 patients had the drug withdrawn because of side effects before study completion. For each of the 3 drugs all clinical and laboratory variables improved when pre and posttreatment values (p < 0.05 to 0.001) were compared. There was a greater reduction in posttreatment mean morning stiffness in the chloroquine group than in the phenytoin and auranofin groups (p < 0.05). Posttreatment grip strength was also greatest in the chloroquine group. On the other hand, there were statistically significant decreases in IgM levels in both the phenytoin and auranofin groups (p < 0.001), but not with chloroquine. Among the 53 patients with a disease history of 3-6 months, global outcome was best with phenytoin (16/17), compared to chloroquine (12/18) and auranofin (12/18) (p < 0.03). However, there was no such difference in the 47 patients in all 3 groups with a disease history longer than 6 months. Eight patients had side effects (phenytoin, auranofin, 2; chloroquine, 1) requiring withdrawal of the drug. However, the incidence of side effects was not significantly different for the 3 drugs. CONCLUSION: Our data indicate that phenytoin is comparable to auranofin and chloroquine in its efficacy in RA and may be considered an alternative disease modifying agent for RA.     

Factors associated with the development of vasculitis in rheumatoid arthritis: results of a case-control study

OBJECTIVE: To investigate those characteristics of patients with rheumatoid arthritis (RA) that are associated with the development of rheumatoid vasculitis (RV). METHODS: Demographic and clinical data of 69 patients who had been diagnosed as having RV were compared with those of 138 contemporaneous control patients with RA who were not suspected to have vasculitis. Vasculitis was confirmed histologically in 96% of the subjects with RV. RESULTS: Variables associated with the development of RV were: 1) male gender, presence of increased serum concentrations of rheumatoid factor, joint erosions, subcutaneous nodules, number of disease modifying antirheumatic drugs previously prescribed, treatment (ever) with D-penicillamine or azathioprine; 2) presence of nail fold lesions and any other extrarticular feature one year before the time of diagnosis of RV; 3) treatment with corticosteroids at the time of diagnosis of RV. CONCLUSIONS: The development of RV is associated with male gender, extra-articular features, and a severe course of RA as indicated by the presence of joint destruction and need for intensive treatment with antirheumatic drugs. The strongest association was found with the presence of increased concentrations of rheumatoid factor.     

Incidence of rheumatoid arthritis in Finland during 1980-1990

OBJECTIVE: To obtain information on the incidence of rheumatoid arthritis and on its recent trends in Finland. METHODS: The study covered those subjects entitled to receive specially reimbursed medication for rheumatoid arthritis under the nationwide sickness insurance scheme in five out of 21 central hospital districts in Finland (population basis about one million adults) during three years: 1980, 1985, and 1990. RESULTS: The annual incidence of rheumatoid arthritis in 1980 and 1985, satisfying the American Rheumatism Association 1987 classification criteria, was 39/100,000 of the population > or = 16 years of age. The combined incidence of rheumatoid factor (RF) positive arthritis and RF negative polyarthritis was 46/100,000. A decline of approximately 40% occurred in the number of RF negative rheumatoid arthritis cases in 1990 compared with the earlier years. The declining trend was statistically significant (P = 0.008). CONCLUSION: The decline in incidence of RF negative rheumatoid arthritis in Finland may reflect changes in the environment specifically affecting the risk of RF negative disease.