Beyond the symptoms: Personalizing giant cell arteritis care through multidimensional patient reported outcome measure.

BACKGROUND: Giant Cell Arteritis (GCA) is the commonest form of systemic vasculitis in people over the age of 50. Published research highlighted the lack of a disease-specific patient reported outcomes (PROMs) for GCA. OBJECTIVES: To assess the validity, reliability and responsiveness to change of a devised disease specific patient self-reported outcome measures questionnaire for Giant Cell Arteritis (GCA). METHODS: The GCA-PROMs was conceptualized based on frameworks outlined in the OMERACT developed core set of Outcome Measures for Large-Vessel Vasculitis and the guiding principles of the FDA guidance. Initially, cognitive interviews were conducted to identify item pool of questions. Item selection and reduction was achieved based on patients as well as an interdisciplinary group of specialists. Rasch and internal consistency reliability analyses were implemented. RESULTS: A total of 54 GCA patients completed the questionnaire. The GCA-PROMs questionnaire was reliable as demonstrated by a high standardized alpha (0.878-0.983). Content construct assessment of the GCA-PROMs functional disability and QoL revealed significant correlation (p< 0.01) with both HAQ and EQ-5D. Changes in functional disability, QoL showed significant (p< 0.01) variation with diseases activity status in response to therapy. CONCLUSIONS: The developed GCA-PROMs questionnaire is a reliable and valid instrument for assessment of GCA patients. A stratified treatment regimen depending on the individual patient's risk factors as well as preferences and associated comorbidities is the best approach to tailored patient management.

Consensus evidence-based clinical practice guidelines for the diagnosis and treat-to-target management of osteoporosis in Africa: an initiative by the African Society of Bone Health and Metabolic Bone Diseases.

The objective of this consensus statement is to inform the clinical practice communities, research centres and policymakers across Africa of the results of the recommendations for osteoporosis prevention, diagnosis and management. The developed guideline provides state-of-the-art information and presents the conclusions and recommendations of the consensus panel regarding these issues. PURPOSE: To reach an African expert consensus on a treat-to-target strategy, based on current evidence for best practice, for the management of osteoporosis and prevention of fractures. METHOD: A 3-round Delphi process was conducted with 17 osteoporosis experts from different African countries. All rounds were conducted online. In round 1, experts reviewed a list of 21 key clinical questions. In rounds 2 and 3, they rated the statements stratified under each domain for its fit (on a scale of 1-9). After each round, statements were retired, modified or added in view of the experts' suggestions and the percent agreement was calculated. Statements receiving rates of 7-9 by more than 75% of experts' votes were considered as achieving consensus. RESULTS: The developed guidelines adopted a fracture risk-centric approach. Results of round 1 revealed that of the 21 proposed domains, 10 were accepted whereas 11 were amended. In round 2, 32 statements were presented: 2 statements were retired for similarity, 9 statements reached consensus, whereas modifications were suggested for 21 statements. After the 3rd round of rating, the experts came to consensus on the 32 statements. Frequency of high-rate recommendation ranged from 83.33 to 100%. The response rate of the experts was 100%. An algorithm for the osteoporosis management osteoporosis was suggested. CONCLUSION: This study is an important step in setting up a standardised osteoporosis service across the continent. Building a single model that can be applied in standard practice across Africa will enable the clinicians to face the key challenges of managing osteoporosis; furthermore, it highlights the unmet needs for the policymakers responsible for providing bone health care together with and positive outcomes of patients' care.

Toward electronic health recording: evaluation of electronic patient reported outcome measures (e-PROMs) system for remote monitoring of early systemic lupus patients.

The study aimed to assess the value of evaluation of electronic patient reported outcome measures (e-PROMs) in the assessment and management of SLE disease activity flares, its association with adherence to therapy as well as organ damage. A randomized, controlled crossover study was carried out over a 24-month duration. One hundred forty-seven SLE patients meeting the revised American College of Rheumatology (ACR) criteria were enrolled. Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was used to assess disease activity, whereas organ damage was scored using the Systemic Lupus International Collaborating Clinics (SLICC)/ACR Damage Index. In the first 12 months, the patients were assessed every 3 months. At 12 months, the patients were randomized into a cohort of 73 patients who continued their care in the same style and 74 patients who completed an online e-PROMs questionnaire on monthly basis for another 12-month period. The data captured were then retrospectively analyzed at the end of the 24-month study period. At the end of the first year of the study, the mean SLEDAI and SDI scores were 8.72 (6.1) and 1.9 (2.2). At the end of the second year, the mean SLEDAI and SDI scores in the e-PROMs cohort were 3.1 (2.6) and 1.2 (1.3), whereas in the control group, the scores were 7.63 (6.7) and 1.8 (2.3), respectively (p < 0.01). Adjusting for possible confounding variables, the number of flares, regardless of their severity, was associated with damage accrual (OR 2.03, 95% CI 1.34 to 2.83, p < 0.001). Adherence to therapy was significantly (p < 0.1) higher in the e-PROMs group. e-PROMs was equivalent to PROMs paper format and has a potential disease-modifying effect as it facilitated close monitoring of disease activity with an option of management escalation whenever indicated.

Meaningful patient engagement in inflammatory arthritis: development of the Patient Motivation Questionnaire.

The objective of this study is to develop a questionnaire for evaluating the patient's "motivation" and assess the psychometric properties of that measure in patients with chronic inflammatory arthritis. Using Rasch analysis and questions item pool, content analysis, and semi-structured group discussion, the questionnaire was developed including 10-item scale (0-10 on VAS scale). Construct validity was assessed by correlating the questionnaire score to parameters of disease activity (DAS-28, ASDAS, and DAPSA scores), functional disability, quality of life, patient self-helplessness measure, as well as the patients' compliance to therapy. Reliability and comprehensibility and sensitivity to change were also assessed. The questionnaire was assessed in 432 RA, 415 psoriatic arthritis patients, and 232 ankylosing spondylitis patients. Dimensionality analysis revealed a 1-factor solution, explaining 98% of the total variance. It showed acceptable validity as it correlated significantly with disease activity measures: DAS-28: r = -0.85, ASDAS: r = -0.86, and DAPSA: r = -0.89. It also correlated significantly with functional disability score: r = -0.91, QoL: r = -0.90, as well as patient self-helplessness: r = -0.88. The questionnaire was reliable (Cronbach's alpha 0.958) and had no misfitting items. In addition, it was comprehensible (9.4) and sensitive to change (p < 0.01). The patient motivation score showed significant (p < 0.01) variation with the medication compliance. The measure is a patient-reported tool that is valid, reliable, comprehensible, and unidimensional scale that reflects the patients' motivation and engagement. The measure has good psychometric properties indicating that it can be used at the individual patient level to tailor management and monitor changes.

Optimizing therapy in inflammatory arthritis: prediction of relapse after tapering or stopping treatment for rheumatoid arthritis patients achieving clinical and radiological remission.

This study aims to assess clinical, lab/immunological or imaging (joint ultrasonography) markers able to predict disease relapse in RA patients in sustained remission when tapering or stopping their treatment. One hundred fifty-seven RA patients in clinical remission (DAS-28 <2.6 for >6 months), receiving treatment with sDMARDs and bDMARD therapy, were randomly allocated into any of five groups: Group 1: continue full dose DMARDs and taper biologic therapy by 50 % (31 patients); Group 2: taper both DMARDs and biologic therapy dose by 50 % (32 patients); Group 3: taper DMARDs by 50 % and stop biologic therapy (31 patients); Group 4: stop both DMARDs and biologic therapy (31 patients); Group 5: continue medications without change (31 patients). Forty joints were assessed ultrasonographically (DAS-28 joints + ankles + metatarsophalangeal joints) and prospectively monitored for 12 months. The primary endpoint was sustained remission for 12 months. Patients were considered as having a relapse when the DAS-28 score was >3.2 and anti-rheumatic treatment was escalated. The frequency of relapse was 41.9 % in Group 1, 59.3 % in Group 2, 67.7 % in Group 3, 77.4 % in Group 4 and 6.5 % in Group 5. Relapse rates were significantly higher in patients whose ultrasound scores raised within 3 months of stopping their medications (P < 0.001 for both GS and PD scores). Cox regression identified ACPA positivity (at baseline) and progression of functional disability (at 2 months) as predictors for relapse. Tapering therapy is feasible in RA patients. Tailored dynamic approach is advised. Joint ultrasonographic assessment, ACPA positivity and worsening functional disability predicted relapse within a short term after discontinuation of the treatment. RA patients whose DAS-28 score was <2 were more likely to remain in remission.

Adopting patient-centered care in standard practice: PROMs moving toward disease-specific era.

Past discussions about the challenges of using patient-reported outcome measures (PROMs) in clinical practice included clinicians' skepticism, time and resources for the implementation, validity of the PROMs, unfamiliarity with the interpretation of PROMs, and costs of implementation. However, these concerns are diminishing now as PROMs has confirmed its place in the management of patients with inflammatory arthritic conditions where there is no surrogate outcome measure available to capture the patient's well-being and response to treatment. Therefore, PROMs has been endorsed as a primary outcome in clinical trials. PROMs directly measure treatment benefit beyond survival, disease, and physiologic markers, and are often the outcomes of greatest importance to patients. Recently, PROMs has progressed from the generic phase into a 'disease-specific' era. This article will discuss the evolving role of PROMs in the assessment and management of patients suffering from inflammatory arthritic conditions and how it can help in transforming patient-centered care concept into reality.

Early psoriatic arthritis: facing the challenge.

Early diagnosis and initiation of therapy has become a primary objective in clinical rheumatology. As psoriatic arthritis causes deformities and joint damage leading to impaired quality of life and function as well as increased mortality risk, there was an urgent call for action aiming at inducing remission of the active inflammatory process. Until the year 2000 there were no treatments that led to a reduction in progression of joint damage. However, with the advent of anti-tumour necrosis factor agents, it is now possible to arrest the progression of damage in these patients. Therefore, the concept of window of opportunity, that is early assessment and management in specialist clinics, has been extended to psoriatic arthritis with successful outcomes among psoriatic arthritis patients similar to those with rheumatoid arthritis. Although all this sounds plausible, early psoriatic arthritis assessment remains limited to research as setting up this type of service in standard clinical practice faces several challenges that would need tackling. The objective of this article is to provide an overview of these challenges and suggest a paradigm for use in standard clinical practice to identify early psoriatic arthritis patients.

Sexual dysfunction in rheumatoid arthritis patients: arthritis and beyond.

Rheumatoid arthritis treatment has been shown to improve quality of life. There is little data regarding the impact of the disease and treatments on sexual function. The aim of this study was to describe the results of an assessment of sexual activity/sexual satisfaction of rheumatoid arthritis patients, identify the sexual dysfunction features, and assess their association with disease activity/disease activity parameters and other systemic risk factors/comorbidities. Consecutive rheumatoid arthritis patients attending the outpatient rheumatology clinic completed the multidimensional patient-reported outcome measures questionnaire. There are three questions screening for sexual dysfunction: patients who ticked any of the boxes were further assessed. Men completed the Sexual Health Inventory for Men; whereas women completed the Female Sexual Function Index. All patients underwent clinical assessment of disease activity parameters and cardiovascular risk. Among 231 rheumatoid arthritis patients included in this study, 49/91 (53.8%) men and 64/140 (45.7%) women reported sexual dysfunction. Among men, erectile dysfunction significantly correlated (p < 0.01) with pain score, cardiovascular disease, age, disease activity, fatigue score, intramuscular steroid injection, and tender joint count. Among women, sexual dysfunction was significantly correlated (p < 0.01) with occurrence of secondary Sjogren's syndrome, pain score, cardiovascular disease, hip joint involvement, disease activity, and tender joint count. Sexual dysfunction is common among rheumatoid arthritis patients. Erectile dysfunction in men, and problems with orgasm, arousal, and satisfaction in women, were the most prevalent manifestations. The significant correlation of sexual dysfunction with CVD may help to identify patients at high risk of cardiovascular disorders.

Assessment of the utility of visual feedback in the treatment of early rheumatoid arthritis patients: a pilot study.

Earlier studies revealed that visual feedback has contributed in the management of neuromuscular as well as psychiatric disorders; however, it has not yet been applied in rheumatology. Visual feedback is a relatively new tool that enables the patient to visualize as well as monitor a real-time change of their disease activity parameters as well as the patient's reported outcome measures. Integrating electronic data recording in the standard rheumatology clinical practice made visual feedback possible. To evaluate the feasibility of using the visual feedback in patients with early inflammatory arthritis (EA) and how ubiquitous computing technology can improve the patients' compliance and adherence to therapy, this was a double-blind randomized controlled study, which included 111 patients diagnosed to have EA according to the new ACR/EULAR criteria. All patients received disease-modifying antirheumatic drugs (DMARDs) therapy and monitored regularly over the period of 1 year. By the 6th month of treatment, the patients were randomly allocated to an active group (55 patients) to whom the visual feedback (visualization of charts showing the progression of disease activity parameters) was added to their management protocol, and a control group (56 patients) who continued their standard management protocols. The patients were monitored for another 6-months period. All the patient's disease activity parameters, patient reported outcome measures (PROMs), medications, scores of falls, and cardiovascular risks were recorded electronically. Primary outcome was the change in the patients' adherence to their medications, disease activity score (DAS-28), and PROMs: pain score, patient global assessment, functional disability, and quality of life. Secondary outcome was the answers to a questionnaire completed by every patient in both the active group and control group (using Visual Analogue Scale) by the end of 1 year of management, to rate from the patient's perspective the impact of the management protocol, whether using the standard or visual feedback approach, on them and their disease. The visual feedback provided a significant greater reduction in disease activity parameters as well as improvement of the patients' adherence to antirheumatic therapy (P < 0.01). Also stopping the DMARDs therapy because of intolerance was significantly less in the active group. Concerns about the future was significantly less in the active group whereas inability to coup with daily life and disease stress were significantly more among the control group. The improvement of disease activity parameters was associated with improvement in functional disability and quality of life scores. Mean changes in disease parameters showed no significant differences at 3-6 months of therapy but differences were statistically significant at 12-months follow-up (P < 0.01). Medication compliance was significantly correlated with changes in all measured disease parameters. By recording and monitoring disease activity parameters electronically and incorporating the visual feedback approach into clinical practice, a new experience can be created. Visual feedback enabled the patients to see how they are doing regarding their disease activity and helps to optimize their adherence to their treatment. Visual feedback had a positive and significant impact on the disease activity control.

Incorporating patient reported outcome measures in clinical practice: development and validation of a questionnaire for inflammatory arthritis.

BACKGROUND: Rheumatology is embarking on a fundamental redesign of rheumatic disease care. It has become mandatory not only to recognise disease activity core set data, but also the risks for other co-morbidities associated with inflammatory arthritis. Measurement of patient reported outcomes have become critical in both standard clinical practice and long term observational studies. OBJECTIVES: To assess validity, reliability and responsiveness to change of a patient self-reported questionnaire which can assess construct outcome measures of patients with inflammatory arthritis. METHODS: Four hundred and sixty-two patients with inflammatory arthritis were included in this work. The questionnaire was developed by integrating information obtained from patients suffering from inflammatory arthritis based on the Rasch model for ordered response options. The questionnaire includes assessment for functional disability, quality of life, VAS for joint pain, global status, fatigue, duration of morning stiffness, review of the systems, falls and cardiovascular risks, self-helplessness, as well as self reported joint pain. RESULTS: The questionnaire was reliable as demonstrated by a high-standardised alpha (0.891-0.992). The questionnaire items correlated significantly (p<0.01) with clinical parameters of disease activity. RA patient reported tender joints correlated significantly with the physician's scores (0.842). Changes in functional disability, quality of life as well as self-helplessness scores showed significant (p<0.01) variation with disease activity status. The PROMs questionnaire also showed a high degree of comprehensibility.(9.4). CONCLUSIONS: Integrating patient reported outcome measures into standard clinical practice is feasible and applicable. This version of a multidimensional questionnaire was found to be valid and reliable. It provides informative quantitative measures for the disease activity core set data, and in the mean time, facilitates assessing the patients' health related quality of life measure, cardiovascular and falls risks on an individual basis.

Diagnosis of early arthritis: outcomes of a nurse-led clinic.

Recent data suggest that early treatment of inflammatory arthritis can improve patient outcomes. While rheumatologists recognized this need for early evaluation and treatment, the current load on the rheumatology service nationwide may limit the capacity for timely evaluation. The authors developed a protocol to be applied through a specialized early arthritis clinic that is able to discriminate between different categories of early arthritis, to shortening the time taken to reach the correct diagnosis and provide the appropriate management. A total of 108 patients have been reviewed in the early arthritis clinic over 12 months. It took 3 weeks for the patients to be fully assessed in the rheumatology clinic instead of 16 weeks. Completing the clinic proforma helped the assessor to cover all causes of arthritis/arthralgia. Disease-modifying antirheumatic drug (DMARD) therapy was initiated within a few weeks (2 to 5 weeks) once diagnosis was confirmed, instead of 8 to 10 months previously. This early arthritis clinic model helped to shorten the referral lag time (duration between symptoms onset and first rheumatologist assessment) as well as lag time to DMARD therapy (duration between symptom onset and the institution of DMARD therapy).

PRINTO/PRES international website for families of children with rheumatic diseases: www.pediatric-rheumatology.printo.it.

OBJECTIVE: To prepare a website for families and health professionals containing up to date information about paediatric rheumatic diseases (PRD). METHODS: Firstly, paediatric rheumatology centres and family self help associations were surveyed to characterise current clinical practice of physicians providing care for children with PRD, research activities, and training facilities of each centre. Secondly, international consensus was reached on the content of the website. Finally, the website was developed and the texts translated. RESULTS: The web page contains three main sections: (a) description for families of the characteristics of 15 PRD; (b) list of paediatric rheumatology centres; (c) contact information for family self help associations. A version for 45 countries in 52 languages (with another three in progress) is now available on the web. 291 surveys from 171 centres and 102 family associations were received from 42 countries. The median proportion of time spent in paediatric practice in the centres examined was 100%, with 70% of this time dedicated to paediatric rheumatology. 90% of the centres were willing to perform clinical trials in the future. CONCLUSIONS: The PRINTO/PRES website provides a well defined and competent set of information about PRD, with appropriate multiple translated versions and easy web navigational direction.

Ultrasonography versus nerve conduction study in patients with carpal tunnel syndrome: substantive or complementary tests?

OBJECTIVE: Our aim is to assess the optimal discriminatory sonographic criteria and relevant threshold values in patients with carpal tunnel syndrome (CTS) and to evaluate quantitative ultrasonography (US) as a tool for diagnosis and treatment of patients suffering from carpal tunnel syndrome in comparison with electrophysiological study. METHODS: Seventy-eight patients with CTS and 78 asymptomatic controls were assessed and underwent ultrasonography of the wrists. All patients and controls completed a self-administered questionnaire. Electrophysiological testing was done for all patients and control subjects. Data from the patient and the control groups were compared to determine the diagnostic relations in patients with CTS and the grade of severity. RESULTS: There was a high degree of correlation between the conduction abnormalities of the median nerve as detected by electrodiagnostic tests, self-administered assessment and the measurement of the cross-sectional area of the nerve by US (P<0.05). Various levels of disease severity could also be illustrated by US, giving confident results for diagnosis, treatment planning and following the patients with CTS. In 16 patients (17%) tenosynovitis/localized swelling in the tendons in the carpal tunnel was the primary cause of CTS. A cut-off point of 10 mm(2) for the mean cross-sectional area of the median nerve was found to be the upper limit for normal values. Based on the results of this study, an algorithm for evaluation and management of CTS has been suggested. CONCLUSION: High-frequency US examination of the median nerve and measurement of its cross-sectional area should be strongly considered as a new alternative diagnostic modality for the evaluation of CTS. In addition to being of high diagnostic accuracy it is able to define the cause of nerve compression and aids treatment planning; US also provides a reliable method for following the response to therapy.

Cross cultural adaptation and validation of the Arabic version of the Childhood Health Assessment Questionnaire for measuring functional status in children with juvenile idiopathic arthritis.

OBJECTIVE: To cross culturally adapt the American-English version of the Childhood Health Assessment Questionnaire (CHAQ) and to evaluate the validity and reliability of the modified translated version on children with juvenile idiopathic arthritis (JIA). METHODS: A cohort of 62 children suffering from JIA (32 Egyptian, 30 Saudi Arabian) were recruited and asked to participate in the study. Two questions had been changed to suit the Arabic culture and to tackle some aspects that are more typical of the Arabic culture. After modification, translation and back translation of the questionnaire, it was administered to the selected patients as well as their parents and tested for internal consistency, reliability and construct validity by correlating the yield of the questionnaire with other disease activity parameters. The questionnaire was administered again after a one-week interval for evaluation of the reliability of this test. The modified questions were tested for their loyalty to the principal component and their correlation with that of the other unchanged items was compared. RESULTS: CHAQ proved to be valid in clinically discriminating between healthy subjects and patients with different patterns of JIA. Test-retest showed strong reliability with a high percentage of agreement and high kappa values. Internal consistency showed a high value for the standardized Cronbach's alpha (0.951), and this value did not show any significant change when any one of the items was eliminated. The modified questionnaire showed a strong and significant validity when its results were correlated with disease activity parameters. CONCLUSION: The Arabic CHAQ is a reliable and valid instrument that can be administered to Arabic children suffering from JIA and to their parents, to evaluate the patients' functional disability. Its measurement properties were comparable to versions in other languages.

Ultrasound versus MRI in the evaluation of juvenile idiopathic arthritis of the knee.

OBJECTIVE: To examine the role of ultrasound versus magnetic resonance imaging (MRI) in assessing joint inflammation in patients with juvenile idiopathic arthritis (JIA) of the knee. METHODS: This study was conducted on 38 patients with juvenile idiopathic arthritis (25 girls and 13 boys), whose ages ranged between 2-17 years (mean 8 years), presenting with joint swelling, tenderness, pain on motion and/or limitation of movement. Plain radiography, high-resolution ultrasound and MRI examinations of the knee (before and after contrast administration) were made on all patients. A control group of ten subjects was also examined. RESULTS: Compared to the control group, sonographic examination was found to be of great value as regards the joint effusion, popliteal cysts, lymph nodes and to a lesser extent, the degree of affection of the articular cartilage. MRI was superior in evaluating the extent of synovial proliferation (pannus), thinning out and erosions of articular cartilage, loculated effusions as well as hypoplastic menisci and ligaments, especially after contrast enhancement. CONCLUSION: Ultrasound is a simple, inexpensive and valuable tool in evaluating the initial stages of JIA. In more advanced stages of JIA and also for monitoring the progression of the disease process and response to therapy, MRI examination following gadolinium proved to be superior in evaluation of the joint affection.

Diffuse idiopathic skeletal hyperostosis (DISH): is it of vascular aetiology?

OBJECTIVE: Reassessment of the pathological features of spinal involvement in DISH and studying the possible aetiopathogenetic mechanism/s of DISH in view of clinical, radiological and pathological findings. METHODS: Forty Egyptian patients with DISH were included in this study. They underwent clinical and radiological assessment. Routine lab tests were done in addition to measuring blood sugar, serum lipids and uric acid. Pathologic study of 50 macerated specimens of fused spines fulfilling the criteria of DISH was also performed. A pathologic study of another 50 macerated specimens from normal spines were examined as a control. RESULTS: Radiological assessment showed spinal involvement in 100% of the patients in the lower thoracic region, while it was present in 75%, 70% and 55% in the upper thoracic, lumbar and cervical regions respectively. Pathological study revealed a significant increase in the number and width of nutrient foramina, denoting hypervascularity of the ossified ligaments and vertebrae involved (P < 0.001), in addition to a significant (P < 0.001) increase in the size of the affected vertebrae, pointing to the possible role of a vascular disorder in the disease pathogenesis. Metabolic disorders were evident among our group of patients in the form of obesity (50%), hyperlipidemia (80%), diabetes mellitus (60%), and hypertension (45%). CONCLUSION: DISH is a diffuse systemic condition which is most probably related to abnormal bone cell growth/activity reflecting the influence of metabolic factors that lead to new bone deposition. The vertebral blood supply is a predisposing factor that contributes to the onset/progression and/or localization of DISH.

Altered bone mineral metabolism in patients with osteoarthritis.

OBJECTIVE: Investigation of the relationship between osteoarthritis (OA) and mineral density, and determination of any alteration in bone mineral, metabolism as assessed by biochemical markers of bone resorption and formation. METHODS: Forty females and 20 males were included in the study. Spinal OA as well as knee OA were defined from radiographs and graded according to Lane et al.'s and Spector et al.'s scoring systems. Bone mineral density (BMD) of the lumbar spine was measured by osteo CT. Bone turnover rates were estimated by measuring biochemical markers of bone resorption (urinary deoxypyridinoline) and bone formation (bone-specific alkaline phosphatase). Forty females and 20 males of the same age were studied as a control group. RESULTS: BMD was greater in women with spinal OA as compared to controls (P < 0.05). Also, males with OA had a non-significantly higher BMD than controls. The bone resorption markers were higher than normal values. However, they were lower than the control group. Similarly, the bone formation markers were lower as compared to the control group. CONCLUSION: Spinal OA is associated with higher BMD. This protective effect of spinal OA against osteoporosis may be mediated through decreased rate of bone turnover.

Osteoporosis in older adults with non-insulin-dependent diabetes mellitus: is it sex related?

OBJECTIVE: To assess the association of non-insulin-dependent diabetes mellitus (NIDDM) with bone mineral density (BMD) and its effect on bone turnover. METHODS: BMD (measured by osteo C.T. of the lumbar spine) and bone resorption (deoxypyridinoline) and formation (alkaline phosphatase bone isoenzyme) markers were measured in 40 female postmenopausal patients with NIDDM and in 40 non-diabetic females of the same age. The same investigations were carried out in 20 males with NIDDM and in 20 normal non-diabetic males. RESULTS: Women with diabetes had significantly (p < 0.01) higher BMD levels than women with normal glucose tolerance. Diabetic females were also significantly overweight (p < 0.001) and had a longer duration after menopause (p < 0.02). Bone resorption markers and bone formation markers were significantly (p < 0.001) higher in the control group compared with the diabetic group. Men with diabetes had BMD levels similar to those men with normal glucose tolerance. Also there was no significant difference on comparing bone resorption and formation markers in the group of diabetic men to the control male group. CONCLUSION: Older women with NIDDM had better BMD than normal women. No difference in bone density by diabetic status were observed in men. That sex difference may be explained by the obesity and the greater androgenecity reported in women with hyperglycemic and hyperinsulinemic conditions.

Validity of the saliva ferning test for the diagnosis of dry mouth in Sjögren's syndrome.

OBJECTIVE: To study the validity of saliva ferning patterns as a diagnostic test for dry mouth in primary or secondary Sjogren's Syndrome (SS). METHODS: Salivary smears were collected from 25 patients with Sjögren's syndrome in the fasting and nonfasting state. All 25 patients had symptomatic xerostomia and xerophthalmia and a positive Shirmer's test. Smears were taken from four sites, the cheek, lower lip, tongue, and saliva. Tests were done for rheumatoid factor, antinuclear antibodies, and anti-Ro(SS-A) antibodies. The salivary smears were air-dried and examined under a light and a polarizing microscope. Smears from 25 healthy subjects were also examined as controls. RESULTS: Three patterns of salivary secretion were identified, namely normal geometric ferning, reindeer antler ferning, and thick branching ferning. All Sjögren's syndrome patients had abnormal salivary smears, usually with a combination of reindeer antler ferning, thick branching ferning, and mucosal squames. This combination was seen in six of the 25 fasting specimens (24%); most of the remaining fasting samples showed the reindeer antler ferning. Reindeer antler ferning alone was found in five fasting and four nonfasting samples: this pattern was absent from five fasting and five nonfasting samples in which mucosal squames were the only abnormal finding. All nonfasting control samples exhibited normal geometric ferning. Smears from the cheek and saliva provided the most illustrative findings. CONCLUSION: The saliva ferning test is a simple, reproducible, and useful diagnostic aid in autoimmune xerostomia, approximately equivalent to Shirmer's test in xerophthalmia.

Effect of low dose methotrexate on markers of bone metabolism in patients with rheumatoid arthritis.

OBJECTIVE: To evaluate markers of bone metabolism in patients with active rheumatoid arthritis (RA) and the effect of weekly low dose methotrexate (MTX) on bone turnover. METHODS: Forty-two menstruating female patients recently diagnosed to have RA (mean age 35.4 years, mean disease duration 1.03 years) were enrolled in this study. Disease activity was assessed by Ritchie articular index, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP); laboratory tests were done for deoxypyridinoline and bone alkaline phosphatase. Drug therapy was started in the form of a weekly MTX dose (range 10-15 mg). Patients were reassessed after 3 and 9 months for the same variables. No patient received steroids before or during the course of the study. RESULTS: Thirty patients continued the study until 9 months. The mean value for deoxypyridinoline and bone alkaline phosphatase on entry were 8.4 and 12.5; mean values of Ritchie articular index and ESR were initially 10.1 and 59 mm, respectively. In patients with active RA deoxypyridinoline was significantly high (p < 0.01), while bone alkaline phosphatase was negatively correlated (p < 0.01). At 3 months deoxypyridinoline levels had fallen to 6.2, while bone alkaline phosphatase had risen to 18.8. At 9 months there was significantly reduced deoxypyridinoline, to 5.5 (p < 0.001), while bone alkaline phosphatase had risen significantly to 30 (p < 0.001) compared with pre-MTX assessment. CONCLUSION: In patients with RA bone metabolism is affected. In active disease, there was decreased bone formation, while bone resorption was increased. The therapy of weekly low dose MTX had improved bone resorption, suggesting that in patients with RA MTX might have a bone protective effect by controlling disease activity.