Can the patient-reported outcome instruments determine disease activity in rheumatoid arthritis?

OBJECTIVES: The aim of this study was to investigate the indicative value of the patient-reported outcome instruments (PROs) on disease activity in rheumatoid arthritis (RA). METHODS: Three hundred sixty eight patients with RA were included in this cross-sectional study. Disease activity was evaluated using both the Disease Activity Score 28 (DAS 28) and the Clinical Disease Activity Index (CDAI). Patients who had DAS 28 score < 3.60 points and CDAI score <10.00 points were allocated into the "low disease activity" group and those who had DAS 28 score > or = 3.60 points and CDAI score > or = 10.00 points into the "moderate or high disease activity" group. The Health Assessment Questionnaire (HAQ), Nottingham Health Profile (NHP), Rheumatoid Arthritis Quality of Life (RAQoL), and Short Form 36 (SF 36) were used as PROs. Logistic regression analysis was used to find variables, which had an indicative value for disease activity. RESULTS: HAQ, pain and emotional reaction subscales of NHP, and bodily pain, general health and social functioning subscales of SF 36 had independent indicative values, when DAS 28 was used as dependent variable. On the other hand, HAQ, pain and emotional reaction subscales of NHP, and general health and emotional role limitation subscales of SF 36 had indicative values when CDAI was used as dependent variable. DAS 28 and CDAI both showed HAQ as the parameter with the highest odds ratio (OR). But RAQoL had shown no independent indicative value for projecting disease activity. CONCLUSION: It was concluded that HAQ could determine disease activity in RA better than other PROs included in this study (Tab. 4, Ref. 36).

Immunologic and psychosocial status in chronic fatigue syndrome.

OBJECTIVE: The aim of the study was to investigate the immunologic functions and psychosocial status in patients with chronic fatigue syndrome (CFS). METHODS: Twenty-five patients with CFS diagnosed by the international CFS definition criteria and 20 age- and gender-matched healthy controls were recruited. Depression was assessed by Beck Depression Inventory (BDI) and health status was assessed by Nottingham Health Profile (NHP). Monoclonal antibodies (MAbs) were measured to identify the following NK cell subsets: CD3, CD4, CD8 and CD56 and cytokine measurements were performed for IL2r, IL6 and IL8 in both patients and control subjects. RESULTS: The BDI and NHP scores of CFS group were found to be significantly higher than in the control group. The absolute numbers of CD56 cell were also significantly decreased in the patients with CFS compared with the healthy controls. There were no other significant differences of NK cell activity (CD3, CD4 and CD8) and there were significant differences in IL6 and IL2r levels between patients and controls. There were significant correlations between serum IL-6 level and sleep, social isolation and physical ability NHP subscores, and betweenCD56 NK cell activity and emotional reaction NHP sub score in CFS patients. CONCLUSION: Significantly higher ratios of psychological and physical disturbances were found in patients with CFS. Decreased CD56 NK cell activity and increased IL2r levels seem to be important immunopathologic changes in CFS. IL-6 and CD 56 NK cell activity may play an important role in sleep, physical, social, and physicological manifestations of CFS (Tab. 3, Fig. 1, Ref. 36). Full Text in free PDF www.bmj.sk.

Hypothalamic-pituitary-gonadal axis and cortisol in young women with primary fibromyalgia: the potential roles of depression, fatigue, and sleep disturbance in the occurrence of hypocortisolism.

OBJECTIVES: To investigate abnormalities of the hypothalamic-pituitary-gonadal (HPG) axis and cortisol concentrations in young women with primary fibromyalgia (FM); and to determine whether depression, fatigue, and sleep disturbance affect these hormones. METHODS: Follicle stimulating hormone (FSH), luteinising hormone (LH), oestradiol, progesterone, prolactin, and cortisol concentrations in 63 women with FM were compared with those in 38 matched healthy controls; all subjects aged <35 years. The depression rate was assessed by the Beck Depression Inventory (BDI) and patients with high and low BDI scores were compared. Additionally, patients were divided according to sleep disturbance and fatigue and compared both with healthy controls and within the group. RESULTS: No significant differences in FSH, LH, oestradiol, prolactin, and progesterone levels were found between patients with FM and controls, but cortisol levels were significantly lower in patients than in controls (p<0.05). Cortisol levels in patients with high BDI scores, fatigue, and sleep disturbance were significantly lower than in controls (p<0.05). Correlation between cortisol levels and number of tender points in all patients was significant (r = -0.32, p<0.05). CONCLUSION: Despite low cortisol concentrations in young women with FM, there is no abnormality in HPG axis hormones. Because fatigue, depression rate, sleep disturbance, and mean age of patients affect cortisol levels, these variables should be taken into account in future investigations.

Sex and thyroid hormone status in women with rheumatoid arthritis: are there any effects of menopausal state and disease activity on these hormones?

There has been considerable interest in the role of hormones in the aetiopathogenesis of rheumatoid arthritis (RA). In this study, we aimed to investigate sex and thyroid hormone conditions according to menopausal state and disease activation in RA women. Fifty-four women with RA were included in the study. Age-matched 28 women with low back pain were used as controls. Sex and thyroid hormones were evaluated in all patients, which included the measurement of estradiol (E2), progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, thyroid-stimulating hormone (TSH), total (T) and free (F) triiodothyronine (T3) and (T) and (F) thyroxine (T4). The RA patients were subdivided according to their pre-menopausal and post-menopausal status and their disease activation conditions. Mean age was 45.68 (+/-12.5) in women (aged 22-70) with RA and 42.39 (+/-12.45) in controls (aged 22-62). There were no significant differences in sex hormones, but there were statistically significant higher levels of TT3 and TT4 in whole women with RA compared to controls. Lower concentrations of FSH were detected in active RA patients. There were statistically lower concentrations of LH and higher concentrations of TT3 and TT4 in pre-menopausal RA women, while lower concentrations of FSH were detected in post-menopausal RA women. TT3 and FT3 levels of pre-menopausal RA women were significantly higher than post-menopausal RA women. There were no significant differences for all other hormones studied. In conclusion, sex and thyroid hormones have been influenced in women with RA. Reproductive and menopausal conditions should be taken into consideration when sex and thyroid hormones studies are carried out in RA women.

The influence of duration of breastfeeding on bone mass in postmenopausal women of different age groups.

This study examines the influence of duration of breastfeeding on bone mineral density (BMD) and investigates the relationship between duration of breastfeeding and bone mass at four sites in postmenopausal women of different ages. A total of 509 postmenopausal women aged 45-86 years were included in the study. Patients were divided into three groups: never breastfed (n=67), < 96 months (n=157) and > or = 96 months (n=285); they were further classified into two age groups, 40-59 years (n=233) and 60-80 years (n=276). In all patients and in the 40-59 year age group, BMD of the spine was found to be significantly lower in the never-breastfed group, while BMD of the trochanter was significantly lower in the > or = 96 month breastfeeding group. BMD of the spine and femur tended to decrease with longer breastfeeding in all groups, while BMD of the spine and trochanter tended to decrease with longer breastfeeding in the 40-59 year group. Of patients in the 60-80 year group who had never breastfed, spinal BMD was significantly higher than that of the > or = 96 month group, while in the > or = 96 month group trochanter BMD was significantly lower than in other groups. In the never-breastfed group, ward's triangle BMD was significantly higher than that of other groups. There was a significant correlation between duration of breastfeeding and BMD of the spine, neck, trochanter and ward's triangle. The study suggests that duration of breastfeeding has an effect on BMD, and extended breastfeeding leads to lower BMD.

Ochronosis: a case of severe ochronotic arthropathy.

Ochronosis involves primarily the large cartilaginous joint surfaces, ribs, intervertebral discs, ear cartilage etc. We report on a 53-year-old woman with typical alkaptonuric ochronosis with dark urine, blue-black pigmentation of the auriculae and hands, focal brown hyperpigmentation of the sclera, spondylarthropathy and severe shoulder joint involvement.

Regional cerebral blood flow and cytokines in young females with fibromyalgia.

OBJECTIVE: To determine whether there is any difference in regional cerebral blood flow (rCBF) and serum cytokine levels and association between clinical parameters and rCBF and serum cytokine levels in young females with fibromyalgia (FM). The other aim was to search whether the depression state has any effect on these two parameters. METHODS: Nineteen women with FM and 20 healthy women had 99mTc-HMPAO brain single-photon-emission computed tomography (SPECT) to evaluate rCBF. Serum interleukin (IL) levels (IL 1 beta, IL 2r, IL 6 and IL 8) were measured. Clinical and psychological evaluation was also carried out in FM patients and healthy controls. RESULTS: The patients with FM had significantly higher radioactivity uptake ratio in right and left caudate nucleus (p = 0.009, p = 0.001, respectively) than healthy controls. There was statistically significant decrease in the 99mTc-HMPAO uptake in the right superior parietal (p = 0.041), gyrus rectalis (p = 0.036) and pons (p = 0.023). FM patients had significantly higher serum IL 2r and IL 8 levels (p = 0.023, p = 0.011, respectively) than controls. Additionally, FM patients had significantly higher Fibromyalgia Impact Questionnaire (FIQ), Health Assessment Questionnaire (HAQ), and Hamilton Depression Rate scale (HDRS) scores (p = 0.000) than controls. Interestingly, the patients with mild depressive symptoms or without (i.e. HDRS-score < or = 16) had significantly higher serum IL 8 levels (p = 0.027) and increased radioactivity uptake ratio in the pons (P = 0.036) than the patients with more severe depressive symptoms (i.e. HDRS-score > 16). With regard to regional cerebral blood flow, significant correlations were detected between RSP and morning stiffness (r = 0.70, p < 0.01) and sleep disturbance (r = -0.53, p < 0.05), and between gyrus rectalis and FIQ score. There were significant correlations between LCN and IL-2 (P = 0.025), between RSP and morning stiffness (P = 0.006), sleep disturbance (P = 0.021) according to multiple regression analysis test. CONCLUSION: This study shows a significant increase in rCBF of caudate nuclei, a reduction in the pons, some cortical regions activity and a increase in IL 8, IL2r levels of young female patients with FM. These findings are more prominent in patients with low HDRS scores.

Intramedullary tuberculoma of the conus medullaris: case report and review of the literature.

OBJECTIVE: To illustrate the dilemmas in the diagnosis and management of intramedullary tuberculomas of the spinal cord. METHODS: Case report of a 32 year-old man with tuberculous meningitis. The presence of unexplained urinary retention and progressive weakness in the legs led to the discovery of an additional tuberculoma of the conus medullaris. SETTING: Dicle University Diyarbakir, Turkey. RESULTS: The patient was on a 1-year course of isoniazid, pyrazinamide and rifampicin, and responded well to conservative treatment. Our patient's unique features were represented by the worsening of neurological symptoms while being treated with adequate anti-tuberculous medication. CONCLUSION: We present a case of intramedullary tuberculoma of the conus medullaris to illustrate the dilemmas in the diagnosis and management of this curable disease, and review of the literature to date.

Management of spinal brucellosis and outcome of rehabilitation.

STUDY DESIGN: Review of cases. OBJECTIVE: To review cases of brucellosis in order to clarify diagnostic guidelines, treatment regimes and prognosis. SETTING: University Hospital, Turkey. METHODS: Study of 11 patients (9 male, 2 female) with either brucellar spondylitis or epidural brucellar abscess. Diagnosis made on clinical presentation, laboratory findings, radiographic evidence and a minimum brucellar anti body of 1 : 160, a positive bacteriological culture and/or histological finding of inflammation of granulomatous tissue. All patients were treated with a combination of oral antibiotics. Surgery was performed in 8 patients. RESULTS: At least 6 months antibiotic therapy using Rifampicin and Doxycycline is recommended. Surgery is indicated in the presence of spinal instability, cord compression or radiculopathy. In our series eight patients required surgery. CONCLUSION: The patients complaining of back pain, particularly in endemic areas should be investigated as possible cases of brucellosis.

Traumatic spinal cord injuries in southeast Turkey: an epidemiological study.

In 1994, a retrospective study of new cases of traumatic Spinal Cord Injury (SCI) was conducted in all the hospitals in Southeast Turkey: 75 new traumatic SCI were identified. The estimated annual incidence was 16.9 per million population. The male/female ratio was 5.8/1. The mean age was 31.3, being 31.25 for male patients and 31.36 for female patients. 70.7% of all patients were under the age of 40. The major causes of SCI were falls (37.3%) and gunshot wounds (29.3%), followed by car accidents (25.3%), and stab wounds (1.3%). Thirty one patients (41.3%) were tetraplegic and 44 (58.7%) paraplegic. In tetraplegic patients the commonest level was C5, in those with paraplegia L1. The commonest associated injury was head trauma followed by fractures of the extremity(ies). Severe head trauma, being a major cause of death, may have obscured the actual incidence of SCI. Most of gunshot injured SCI patients were young soldiers fighting against the rebels. As there was no available data for the rebels with SCI, the actual incidence of SCI in Southeast (SE) Turkey should be higher than that found in this study.