Psoriatic arthritis: improvement in outcomes but persistent sex difference - 5-year follow-up study of a Norwegian outpatient clinic population.

OBJECTIVE: This study aimed to explore long-term changes in disease activity and remission rates, and potential sex-related differences in these outcomes, in psoriatic arthritis (PsA) patients treated in an outpatient clinic. METHOD: This prospective longitudinal cohort study included 114 patients. The Disease Activity Index for Psoriatic Arthritis (DAPSA), clinical DAPSA (cDAPSA), 28-joint Disease Activity Score (DAS28), Simplified and Clinical Disease Activity Indices (SDAI, CDAI), Boolean remission for PsA, and minimal and very low disease activities (MDA, VLDA) were assessed. For group characteristics, parametric statistics and linear regression were used. RESULTS: At 5 year follow-up, improvement was noted for multiple measures reflecting disease activity and patient-reported outcomes. Statistically significant increases in remission rates were observed using DAS28 (+21.2%), CDAI (+9.7%), and cDAPSA (+7.6%), but not SDAI, DAPSA, Boolean remission, MDA, or VLDA. During the study period, the proportion of patients treated with biological disease-modifying anti-rheumatic drugs (bDMARDs) increased from 37.7% to 48.3% (p = 0.007). At baseline, women reported higher pain and fatigue, and had higher tender joint counts, DAPSA, cDAPSA, SDAI, CDAI, and DAS28 than men. Despite higher mean baseline C-reactive protein, men more often achieved remission, regardless of the definition applied. A higher proportion of men than women was treated with bDMARDs (baseline: 46.6% vs 28.6%; follow-up: 58.6% vs 33.9%). CONCLUSION: This study adds evidence supporting recent improvements in PsA outcomes. Women had higher disease activity and were less likely to achieve remission than men. Despite progress in achieving remission goals, there is still room for improvement in therapeutic approaches for PsA patients.

Perceived influence of health status on sexual activity in patients with psoriatic arthritis.

Objective: To examine the prevalence of self-reported problems with sexual activity among psoriatic arthritis (PsA) patients, and to explore potential associations of such problems with various demographic, musculoskeletal, and dermatological disease variables. Method: Consecutive PsA patients were recruited from an outpatient clinic. Data collected included demographics, measures of musculoskeletal and skin disease activity, and treatments. Perceived effect of health status on sexual activity was assessed using question number 15 from the health-related quality of life instrument 15D; this was explored in univariate and multivariate logistic regression analyses. Results: The study assessed 135 patients (mean age 52.1 years, disease duration 8.7 years, 51.1% male). Mean scores included Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) 2.9, Disease Activity index for PSoriatic Arthritis (DAPSA) 18.2, patient global assessment (PGA) 36.0 mm, pain 33.7 mm, fatigue 45.1 mm, modified Health Assessment Questionnaire (mHAQ) 0.42, Psoriasis Area Severity Index (PASI) 2.5, and Dermatology Life Quality Index (DLQI) 3.4. Twenty-four patients (17.8%) reported that their health status had a large negative effect and 111 (82.2%) that it had no or little effect on their sexual activity. In univariate analyses, a statistically significant association with impaired sexual activity was found for longer disease duration and higher MASES, DAPSA, PGA, fatigue, and mHAQ scores, but not for demographic variables or variables reflecting skin psoriasis involvement (PASI, DLQI). In adjusted analyses, only PsA disease duration remained independently associated with impaired sexual activity. Conclusion: One in five PsA patients perceived that their health status had a negative impact on sexual activity. Disease duration and measures reflecting musculoskeletal involvement, but not measures reflecting skin psoriasis involvement, appeared to be associated with impaired sexual activity.

High risk of positive Trendelenburg test after using the direct lateral approach to the hip compared with the anterolateral approach: a single-centre, randomized trial in patients with femoral neck fracture.

AIMS: The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty. PATIENTS AND METHODS: A total of 150 patients who were treated between February 2014 and July 2017 were included. Patients were allocated to undergo hemiarthroplasty using either an anterolateral or a direct lateral approach, and were followed for 12 months. The mean age of the patients was 81 years (69 to 90), and 109 were women (73%). Functional outcome measures, assessed by a physiotherapist blinded to allocation, and patient-reported outcome measures (PROMs) were collected postoperatively at three and 12 months. RESULTS: A total of 11 patients in the direct lateral group had a positive Trendelenburg test at one year compared with one patient in the anterolateral group (11/55 (20%) vs 1/55 (1.8%), relative risk (RR) 11.1; p = 0.004). Patients with a positive Trendelenburg test reported significantly worse Hip Disability Osteoarthritis Outcome Scores (HOOS) compared with patients with a negative Trendelenburg test. Further outcome measures showed few statistically significant differences between the groups. CONCLUSION: The direct lateral approach in patients with a femoral neck fracture appears to be associated with more positive Trendelenburg tests than the anterolateral approach, indicating a poor clinical outcome. Cite this article: Bone Joint J 2019;101-B:793-799.

Biomarkers of muscle damage increased in anterolateral compared to direct lateral approach to the hip in hemiarthroplasty: no correlation with clinical outcome : Short-term analysis of secondary outcomes from a randomized clinical trial in patients with a displaced femoral neck fracture.

In this study, we found elevated levels of serum CK in the anterolateral approach to the hip compared to the direct lateral approach in patients with a displaced femoral neck fracture. No correlation was found between levels of CK and functional outcomes. INTRODUCTION: To compare increase in serum creatine kinase (CK) and its association with functional outcome between the muscle-sparing anterolateral approach and the direct lateral approach to the hip in patients with displaced femoral neck fracture (FNF). METHODS: In this randomized trial, we enrolled eligible patients between 70 and 90 years of age with FNF. Patients were allocated to an uncemented hemiarthroplasty inserted through a direct lateral or an anterolateral approach. The primary endpoints were pain and patient satisfaction assessed by the Visual Analogue Scale (VAS). Among secondary endpoints was increase in CK at 24 and 48 h compared to baseline and its association with surgical parameters, Timed up and Go Test (TUG), Harris Hip Score (HHS), and the presence of a Trendelenburg sign using correlation analysis. This paper reports on increase in serum CK and its association with functional outcome. RESULTS: At 24 h, there was a mean increase from baseline in total CK of 228 U/L (95% CI 187 to 269; P < 0.001). There was a difference between groups at 24 h in CK increase with higher levels in the anterolateral group (mean difference 80 U/L; 95% CI - 0.5 to 162; P = 0.05). Likewise, at 48 h, there was a mean difference of 117 U/L (95% CI 22 to 212; P = 0.01). No correlation was found between CK values and functional assessments. CONCLUSIONS: Compared with the direct lateral approach, the anterolateral approach yielded higher levels of postoperative CK. However, there was no correlation between levels of CK and functional outcome. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02028468.

Exploring the relationship between demographic and disease-related variables and perceived effect of health status on sexual activity in patients with axial spondyloarthritis: associations found only with non-disease variables.

OBJECTIVE: To explore the relationship between demographic and disease-related variables and the perceived effect of health status on sexual activity in patients with axial spondyloarthritis (ax-SpA). METHOD: The study assessed 379 ax-SpA patients consecutively recruited from two rheumatology outpatient clinics. Data collection included information on demographics, markers and measures of ax-SpA disease, treatment, comorbidity, and health-related quality of life (HRQoL) using the Short Form-36. The perceived effect of health status on sexual activity was assessed using question 15 in the HRQoL instrument 15D. RESULTS: The mean age of the patients was 45.6 years, 66.5% were men, 87.3% were human leucocyte antigen-B27 positive, and mean disease duration was 13.9 years. A total of 312 patients (82.3%) reported their health status to have no/little effect and 17.7% patients reported their health status to have a large negative effect on their sexual activity. In univariate analysis, increased body mass index (BMI), smoking, alcohol consumption, unemployed status, low physical activity, comorbidities, and higher disease activity (Bath Ankylosing Spondylitis Questionnaire), impaired body movement and lower HRQoL were associated with a large effect on sexual activity. In adjusted analyses, only female gender, high BMI, current smoking, and low HRQoL showed significant associations. CONCLUSION: Approximately 20% of ax-SpA patients reported a large negative effect on their sexual activity. Female gender, high BMI, current smoking, and reduced HRQoL were associated with health status having a large effect on sexual activity, whereas no measures reflecting ax-SpA disease showed an independent association.

Vitamin C and E supplementation blunts increases in total lean body mass in elderly men after strength training.

The aim of this study was to investigate the effects of vitamin C and E supplementation on changes in muscle mass (lean mass and muscle thickness) and strength during 12 weeks of strength training in elderly men. Thirty-four elderly males (60-81 years) were randomized to either an antioxidant group (500 mg of vitamin C and 117.5 mg vitamin E before and after training) or a placebo group following the same strength training program (three sessions per week). Body composition was assessed with dual-energy X-ray absorptiometry and muscle thickness by ultrasound imaging. Muscle strength was measured as one-repetition maximum (1RM). Total lean mass increased by 3.9% (95% confidence intervals: 3.0, 5.2) and 1.4% (0, 5.4) in the placebo and antioxidant groups, respectively, revealing larger gains in the placebo group (P = 0.04). Similarly, the thickness of m. rectus femoris increased more in the placebo group [16.2% (12.8, 24.1)] than in the antioxidant group [10.9% (9.8, 13.5); P = 0.01]. Increases of lean mass in trunk and arms, and muscle thickness of elbow flexors, did not differ significantly between groups. With no group differences, 1RM improved in the range of 15-21% (P < 0.001). In conclusion, high-dosage vitamin C and E supplementation blunted certain muscular adaptations to strength training in elderly men.

Risk factors for osteoporosis and factors related to the use of DXA in Norway.

UNLABELLED: To evaluate the case-finding strategy for osteoporosis in Norway, a questionnaire concerning risk factors for osteoporosis and history of osteodensitometry was mailed to a population-based cohort of 6000 men and 6000 women. Suboptimal examination rates among high risk and reallocation of scanning capacity to seemingly low-risk individuals was found. PURPOSE: In Norway, a case-finding strategy for osteoporosis has been used. No data exist regarding the efficacy of this approach. The aim was to examine the prevalence of risk factors for osteoporosis and factors related to the use of dual X-ray absorptiometry (DXA) in Norway. METHODS: Questionnaires regarding previous history of DXA, risk factors for osteoporosis and fracture were sent to an age-stratified, nationwide cross-sectional sample of 6000 men and 6000 women aged 40-90 years, drawn from the Norwegian Civil Registration System. RESULTS: Valid responses (6029) were included. Twenty-two point three percent of women and 3.8 % of men had been examined by DXA. Suboptimal examination rates among high risk (e.g., current/previous glucocorticoid treatment or previous low-energy fracture) and reallocation of scanning capacity to seemingly low-risk individuals was found. Of all DXA, 19.5 % were reported by women without any risk factor for osteoporosis, similarly by 16.2 % of men. Distance to DXA facilities and current smoking were inversely related to probability of reporting a DXA. CONCLUSIONS: Suboptimal examination rates among high risk and reallocation of scanning capacity to seemingly low-risk individuals were found. Distance to DXA, current smoking, and male sex constituted possible barriers to the case-finding strategy employed. Cheap and more available diagnostic tools for osteoporosis are needed, and risk stratification tools should be employed more extensively.

High incidence of vertebral and non-vertebral fractures in the OSTRA cohort study: a 5-year follow-up study in postmenopausal women with rheumatoid arthritis.

UNLABELLED: A 5-year follow-up study was performed in female RA patients with established disease looking at vertebral fractures, scored on spinal X-rays, and non-vertebral fractures. We found a high incidence rate of vertebral and non-vertebral fractures in these patients compared to population-based studies. INTRODUCTION: The aim of this study is to investigate the incidence of vertebral and non-vertebral fractures over a 5-year period in a cohort of postmenopausal patients with established rheumatoid arthritis (RA). METHODS: One hundred and fifty female patients with established RA were included into the OSTRA cohort. The cohort was assessed at baseline and at 5 years for incident vertebral and non-vertebral fractures. Spinal X-rays were taken at baseline and at follow-up and scored using the semi-quantitative method according to Genant. RESULTS: At 5 years, 102 patients (68%) were examined and included in the present analysis. At baseline, the mean age was 61 years, disease duration 17 years, body mass index 25.5 kg/m(2) and 65% of the patients were rheumatoid factor positive. Fifteen percent were treated with bisphosphonates, 25% received calcium supplementation and 20% vitamin-D supplementation at baseline. During the 5-year follow-up, a total of 16 patients out of 102 patients (16%) had a new non-vertebral fracture [annual incidence of 3.2 (95% CI 1.8-5.5) per 100 patients/year]. In 18 patients out of 97 patients (19%), new vertebral fractures were identified on spinal X-ray [annual incidence of 3.7 (95% C.I. 2.2-5.8) per 100 patients/year]. CONCLUSIONS: We found a high incidence of vertebral and non-vertebral fractures in a cohort of women with established RA compared to population-based studies.

Bone loss in very early inflammatory back pain in undifferentiated spondyloarthropathy: a 1-year observational study.

OBJECTIVE: Bone loss in patients with inflammatory back pain (IBP) suspicious of early undifferentiated spondyloarthropathy is poorly defined. The aim of this study was to examine changes in bone mineral density (BMD) at the hip, lumbar spine and hand in patients with early IBP and to look for possible biomarkers associated with this change. METHODS: In 30 patients with early IBP, clinical data were collected and BMD assessed using dual energy x-ray absorptiometry at baseline, 6 and 12 months. Further imaging performed included MRI of the sacroiliac joints (SIJs) and spine at baseline and x-rays of the SIJs at baseline and after 8 years. RESULTS: After 12 months no significant reduction in hip, spine and hand BMD was seen at the group level. However, hip bone loss was found to be associated with raised baseline C-reactive protein levels, baseline MRI bone marrow oedema of the SIJs and the presence of radiographic sacroiliitis after 8 years. No association was found with change in spine and hand BMD. CONCLUSION: Systemic bone loss in the hip is an early feature of the inflammatory disease process in patients with IBP in undifferentiated spondyloarthropathy and is related to disease activity. These data highlight the importance of aggressive intervention in the early stages of disease in undifferentiated spondyloarthropathy.

Low-energy distal radius fractures in middle-aged and elderly men and women--the burden of osteoporosis and fracture risk : A study of 1794 consecutive patients.

UNLABELLED: One third of 218 men and half of 1,576 women with low-energy distal radius fractures met the bone mineral density (BMD) criteria for osteoporosis treatment. A large proportion of patients with increased fracture risk did not have osteoporosis. Thus, all distal radius fracture patients >or=50 years should be referred to bone densitometry. INTRODUCTION: Main objectives were to determine the prevalence of patients with a low-energy distal radius fracture in need of osteoporosis treatment according to existing guidelines using T-score or=50 years were included. BMD was assessed by dual energy X-ray absorptiometry (DXA) at femoral neck, total hip, and lumbar spine (L2-L4). The WHO fracture risk assessment tool (FRAX(R)) was applied to calculate the 10-year fracture risk. RESULTS: T-scores or=50 years should be referred to bone densitometry, and if indicated, offered medical treatment.

Low-energy distal radius fractures in middle-aged and elderly women-seasonal variations, prevalence of osteoporosis, and associates with fractures.

UNLABELLED: There is a lack of data on the prevalence of osteoporosis in patients with distal radius fractures occurring at the various seasons. The prevalence of osteoporosis is high, both in patients with indoor and outdoor fractures and higher than in controls. All female distal radius fracture patients >or=50 years should be referred for osteoporosis assessment. INTRODUCTION: The objectives of this study in female distal radius fracture patients were to investigate seasonal differences, estimate the prevalence of osteoporosis, and identify factors associated with distal radius fractures compared with controls. METHODS: In a 2-year period, 263 women >/=50 years suffered a low-energy distal radius fracture in the geographic catchment area. The 214 women who met for osteoporosis assessment were age-matched with 191 controls. Bone mineral density was assessed by dual energy X-ray absorptiometry at femoral neck, total hip, and lumbar spine. Demographic and clinical data were collected. RESULTS: The prevalence of indoor fractures showed no seasonal variance. For outdoor fractures, the prevalence was highest in the winter months. The prevalence of osteoporosis among patients with indoor fractures was higher (58.5%) than outdoor fractures without (38.6%) and with snow/ice (36.0%; p < 0.001). The prevalence of osteoporosis was higher in fracture patients (42.5%) than controls (24.1%; p < 0.001), this was also found in the youngest age group 50-59 years (22.2% vs 1.8%; p < 0.001). In conditional logistic regression analyses osteoporosis, current use of glucocorticoids, and living alone were independently associated with distal radius fractures. CONCLUSIONS: Our study highlights that environmental factor, as well as osteoporosis are associated with distal radius fractures in middle-aged and elderly women. Osteoporosis is also frequently found in outdoor patients, thus, all female distal radius fracture patients >or=50 years should be referred for osteoporosis assessment.

Smokers and non smokers with rheumatoid arthritis have similar clinical status: data from the multinational QUEST-RA database.

OBJECTIVES: To analyse clinical severity/activity of rheumatoid arthritis (RA) according to smoking status. METHODS: The QUEST-RA multinational database reviews patients for Core Data Set measures including 28 swollen and tender joint count, physician global estimate, erythrocyte sedimentation rate (ESR), HAQ-function, pain, and patient global estimate, as well as DAS28, rheumatoid factor (RF), nodules, erosions and number of DMARDs were recorded. Smoking status was assessed by self-report as 'never smoked', 'currently smoking' and 'former smokers'. Patient groups with different smoking status were compared for demographic and RA measures. RESULTS: Among the 7,307 patients with smoking data available, status as 'never smoked,' 'current smoker' and 'former smoker' were reported by 65%, 15% and 20%. Ever smokers were more likely to be RF-positive (OR 1.32;1.17-1.48, p<0.001). Rheumatoid nodules were more frequent in ever smokers (OR 1.41;1.24-1.59, p<0.001). The percentage of patients with erosive arthritis and extra-articular disease was similar in all smoking categories. Mean DAS28 was 4.4 (SD 1.6) in non-smokers vs. 4.0 (SD 1.6) in those who had ever smoked. However, when adjusted by age, sex, disease duration, and country gross domestic product, only ESR remained significantly different among Core Data Set measures (mean 31.7mm in non-smokers vs. 26.8mm in ever smoked category). CONCLUSIONS: RA patients who had ever smoked were more likely to have RF and nodules, but values for other clinical status measures were similar in all smoking categories (never smoked, current smokers and former smokers).

Bone loss in patients with active early rheumatoid arthritis: infliximab and methotrexate compared with methotrexate treatment alone. Explorative analysis from a 12-month randomised, double-blind, placebo-controlled study.

OBJECTIVE: To examine the effect of infliximab plus methotrexate (MTX) compared with placebo plus MTX on bone loss in patients with early rheumatoid arthritis (RA) in a double-blind randomised study design. Further, to explore the associations between bone loss and markers of RA disease. METHODS: All 20 patients with RA (10 patients in each treatment group) had active, early RA. Bone mineral density (BMD) was assessed at the hand, lumbar spine (L2-4) and hip by dual energy x-ray absorptiometry at baseline and 12 months' follow-up. Clinical data were collected at regular visits. RESULTS: BMD loss was significantly reduced in the infliximab group compared with the placebo group at the femoral neck (-0.35% vs -3.43%, p = 0.01) and total hip (-0.23% vs -2.62%, p = 0.03) but not at the hand (-2.09% vs -2.82%, p = 0.82) and spine (-0.75% vs -1.77%, p = 0.71). Measures of disease process and joint damage were found to be independently associated with bone loss. CONCLUSIONS: This study provides strong evidence of a causal link between inflammation and bone loss in RA. The anti-inflammatory effect of infliximab was potent enough to arrest inflammatory bone loss at the hip but not at the spine and hand.

Adalimumab therapy reduces hand bone loss in early rheumatoid arthritis: explorative analyses from the PREMIER study.

OBJECTIVE: The effect of adalimumab on hand osteoporosis was examined and related to radiographic joint damage in the three treatment arms of the PREMIER study: adalimumab plus methotrexate, adalimumab and methotrexate monotherapy. Predictors of hand bone loss were also searched for. METHODS: 768 patients (537 fulfilled 2 years) with rheumatoid arthritis (RA) for less than 3 years, never treated with methotrexate, were included. Hand bone loss was assessed by digital x ray radiogrammetry (DXR) on the same hand radiographs scored with modified Sharp score at baseline, 26, 52 and 104 weeks. For DXR, metacarpal cortical index (MCI) was the primary bone measure. RESULTS: At all time points the rate of percentage DXR-MCI loss was lowest in the combination group (-1.15; -2.16; -3.03) and greatest in the methotrexate monotherapy group (-1.42; -2.87; -4.62), with figures in between for the adalimumab monotherapy group (-1.33; -2.45; -4.03). Significant differences between the combination group and the methotrexate group were seen at 52 (p = 0.009) and 104 weeks (p<0.001). The order of hand bone loss across the three treatment arms was similar to the order of radiographic progression. Older age, elevated C-reactive protein and non-use of adalimumab were predictors of hand bone loss. CONCLUSION: This study supports a similar pathogenic mechanism for hand bone loss and erosions in RA. The combination of adalimumab and methotrexate seems to arrest hand bone loss less effectively than radiographic joint damage. Quantitative measures of osteoporosis may thus be a more sensitive tool for assessment of inflammatory bone involvement in RA.

Polymyalgia rheumatica can be distinguished from late onset rheumatoid arthritis at baseline: results of a 5-yr prospective study.

OBJECTIVE: To describe the pattern of arthropathy and HLA-DRB1 alleles associated with PMR in order to develop a diagnostic algorithm that could help distinguish PMR and RF-negative (RF -ve) late-onset RA (LO-RA) at presentation. METHODS: This was a prospective study of all patients presenting with PMR or LO-RA over a 10-yr period to one physician. Demographic, clinical and laboratory data were collected at presentation and during a minimum of 5 yrs of follow-up. The accuracy of the initial diagnosis was systematically reviewed. RESULTS: One hundred and forty-two patients with LO-RA, 147 with PMR and 42 with PMR + TA were studied. Peripheral synovitis was observed in 23% of the PMR patients. In comparison with RF -ve LO-RA, PMR patients were younger (P < 0.001), myalgia more frequent [100 vs 16% (P < 0.001)] and arthritis of PIP, MCP and wrist were less frequent (P < 0.001). The combination of wrist + MCP/PIP or wrist + PIP + MCP were highly suggestive of RF -ve LO-RA (P < 0.001). HLA-DRB1*0101/0102 and *0401 were significantly increased in PMR patients compared with healthy controls. Plasma viscosity and arthritis in the wrist, in combination with at least one MCP or PIP joint at disease onset, were predictive of whether a non-erosive RF -ve patient would ultimately be diagnosed as having RF -ve LO-RA or PMR (+/-/arthritis). CONCLUSION: Our longitudinal follow-up data were consistent with RF -ve LO-RA being a separate disease entity to PMR despite some phenotypic and immunogenetic similarities at disease onset. A diagnostic algorithm was derived using baseline clinical features to predict the final diagnosis of RF -ve, non-erosive patients.

Cortical hand bone loss after 1 year in early rheumatoid arthritis predicts radiographic hand joint damage at 5-year and 10-year follow-up.

OBJECTIVE: To examine 1-year hand bone loss in early rheumatoid arthritis (RA) as a predictor of radiographic damage at 5-year and 10-year follow-up METHODS: A total of 136 patients with RA (disease duration 0-4 years) were followed for 10 years with clinical data and hand radiographs. Joint damage was scored according to the van der Heijde modification of the Sharp method (vdH Sharp score) and hand bone mineral density (BMD) was measured by digital x ray radiogrammetry (DXR). Group comparisons, correlation analyses and multivariate analyses were performed to evaluate the relationship between hand bone loss and radiographic joint damage. RESULTS: Patients with hand BMD loss at 1 year had a higher median increase in vdH Sharp score compared to patients without loss at 5 years (12 vs 2, p = 0.001) and 10 years (22 vs 4, p = 0.002). In a linear regression model adjusting for age, gender, baseline C-reactive protein (CRP), anti-cyclic citrullinated peptide (CCP), IgM rheumatoid factor (RF) and radiographic damage, absolute hand DXR-BMD loss at 1 year was an independent predictor of radiographic outcome at 5 years (p<0.01) and 10 years (p = 0.02). In a logistic regression model the odds ratio (95% CI) for radiographic progression among patients with hand BMD loss was 3.5 (1.4 to 8.8) and 3.5 (1.4 to 8.4) at 5 and 10 years, respectively. CONCLUSION: Early hand bone loss measured by DXR-BMD is an independent predictor of subsequent radiographic damage. Our findings support that quantitative hand bone loss in RA precedes radiographic joint damage and may be used as a tool for assessment of bone involvement in RA.

Assessment of quality of rheumatoid arthritis care requires joint count and/or patient questionnaire data not found in a usual medical record: examples from studies of premature mortality, changes in clinical status between 1985 and 2000, and a QUEST-RA global perspective.

Quality of care of many diseases, such as diabetes, hypertension, hyperlipidemia, and osteoporosis, can be assessed effectively from information in usual medical records concerning blood tests, blood pressure, bone density, etc. However, quality of care of rheumatoid arthritis (RA), as well as most rheumatic diseases, cannot be assessed from usual medical records. The primary basis for this problem involves limitations of laboratory tests and the absence of a single "gold standard" measure in RA Therefore, indices which include laboratory tests, joint counts, and patient questionnaires have been developed. These indices are collected in all RA clinical trials and other clinical research, but not in usual clinical care, a phenomenon which may limit severely possible assessment and improvement of quality and patient outcomes. Patient questionnaires and joint counts, rather than laboratory tests or radiographs in a medical record, are the best measures to assess and monitor RA patient status. Patient questionnaires are the most significant clinical prognostic markers for severe long-term RA outcomes, such as work disability, costs and premature mortality, and are more cost-effective and easily-collected than formal quantitative joint counts in busy clinical settings. The value of patient questionnaires and joint counts in RA is reviewed in three examples from the authors' research concerning premature mortality in RA, changes in patient clinical status between 1985 and 2000, and a QUEST-RA global perspective, to better evaluate the structure, processes, and outcomes of RA care.

Evaluation of bone mineral density, bone metabolism, osteoprotegerin and receptor activator of the NFkappaB ligand serum levels during treatment with infliximab in patients with rheumatoid arthritis.

OBJECTIVES: To examine whether treatment with anti-tumour necrosis factor (TNF) alpha prevents loss of bone mineral density (BMD) at the spine and hip (generalised) and in the hands (local) of patients with rheumatoid arthritis, and to study the changes in markers of bone metabolism, including receptor activator of the NFkappaB ligand (RANKL) and osteoprotegerin (OPG), during anti-TNF treatment. PATIENTS AND METHODS: 102 patients with active rheumatoid arthritis, who were treated with infliximab during 1 year, were included in this open cohort study. The BMD of the spine and hip (dual x ray absorptiometry) and hands dual x ray radiogrammetry was measured before the start of treatment and after 1 year. Changes in osteocalcin formation, beta-isomerised carboxy terminal telopeptide of type 1 collagen (beta-CTx, resorption), RANKL and OPG were determined at 0, 14, 30 and 46 weeks. RESULTS: The BMD of the spine and hip was unchanged during treatment with infliximab, whereas BMD of the hand decreased significantly by 0.8% (p<0.01). The BMD of the hip in patients with a good European League Against Rheumatism response showed a favourable change compared with patients not achieving such a response. Serum beta-CTx and RANKL were both considerably decreased compared with baseline at all time points. The decrease in beta-CTx was associated with the decrease in Disease Activity Score of 28 joints and C reactive protein during the 0-14 weeks interval. CONCLUSION: In patients with rheumatoid arthritis treated with infliximab, spine and hip bone loss is arrested, whereas metacarpal cortical hand bone loss is not stopped. The outcome of the study also supports a relationship between clinical response, in terms of reduced inflammatory activity, and changes in bone loss of the spine, hip and hands.

Hand bone loss in early undifferentiated arthritis: evaluating bone mineral density loss before the development of rheumatoid arthritis.

OBJECTIVES: (1) To examine the change in regional bone mineral density (BMD), including the hands, and assess its role as a predictor of outcome in patients presenting with an early undifferentiated inflammatory arthritis; (2) to examine for associations with the changes in hand BMD. METHODS: 74 patients with undifferentiated hand arthritis of less than 12 months' duration were examined at baseline and then at three, six, and 12 months follow up, including BMD measurement of the femoral neck, spine (L2-4), and the whole hands using dual energy absorptiometry (DXA). RESULTS: During the study, 13 patients were diagnosed as having rheumatoid arthritis, 19 as having inflammatory non-rheumatoid joint disorders, and 42 as having non-inflammatory joint disorders. At the femoral neck and lumbar spine no significant bone loss was seen in any of the three subgroups. At the 12 months follow up the mean (95% confidence interval) hand BMD loss in the patients with rheumatoid arthritis was -4.27% (-1.41 to -7.13); in the inflammatory non-rheumatoid group, -0.49% (-1.33 to +0.35); and in the non-inflammatory joint disorder group, -0.87% (-1.51 to -0.23). In a multivariate linear regression model (including age, rheumatoid factor, mean C reactive protein, mean HAQ score, and cumulative glucocorticoid dose), only mean C reactive protein (p<0.001) and rheumatoid factor (p = 0.04) were independently associated with change in hand BMD during follow up. CONCLUSIONS: Hand DXA provides a very sensitive tool for measuring bone loss in early rheumatoid arthritis and may be useful in identifying patients at high risk of developing progressive disease. Further studies are needed to evaluate the role of hand bone loss as a prognostic factor and outcome measure in rheumatoid arthritis.