Disability and health-related quality of life are associated with restricted social participation in young adults with juvenile idiopathic arthritis.

OBJECTIVES: To describe a cohort of Finnish juvenile idiopathic arthritis (JIA) patients, to recognize those young adults who are at risk of becoming socially restricted by their long-term rheumatic disease, and to assess which areas of self-rated health-related quality of life (HRQoL) are associated with the emergence of restricted social participation. METHODS: A total of 195 young adults with JIA completed questionnaires addressing demographics, health behaviour, physical activity, functional ability, HRQoL, depressive symptoms, and self-esteem. Patients were classified as having non-restricted social participation if they were engaged in studying, working, maternity leave, or military service, and restricted social participation if they were unemployed or on disability pension. RESULTS: Of the patients, 162 (83%) were considered as having non-restricted social participation and 33 (16%) restricted social participation. Among patients with restricted social participation, five (15%) were on disability pension and 28 (85%) were unemployed. Patients with restricted social participation participated less in leisure-time non-physical activities (p = 0.033), felt more disturbed during their leisure time (p = 0.010), had lower self-esteem (p = 0.005), and had higher disability scores (p = 0.024). HRQoL scores revealed statistically significant differences between the groups: physical functioning (p = 0.043), social functioning (p = 0.016), and emotional well-being (p = 0.049) were all lower in patients with restricted social participation. CONCLUSIONS: Socially restricted patients showed a higher degree of disability, and lower levels of physical functioning, self-esteem, emotional well-being, and social functioning. These patients should be recognized earlier and interventions provided to enhance their social participation.

Pain interference and associated factors in young adults with juvenile idiopathic arthritis.

Objective: Pain is a common and distressing feature of juvenile idiopathic arthritis (JIA). Pain interference (PI) is underexplored in long-term conditions such as JIA. The aim of this study was to explore the factors associated with PI in young adults with JIA. Methods: All consecutive JIA patients aged 18-30 years in three tertiary rheumatology and rehabilitation centres in Finland between September 2015 and April 2016 were included. The patients completed questionnaires addressing demographics, disability, depressive symptoms, pain anxiety, pain intensity, and PI. PI was measured with a single item from the RAND-36 questionnaire. Five response categories were coded into three groups: patients reporting 'extremely', 'quite a bit' or 'moderate' were classified as having significant PI; 'a little bit' as having minor PI; and 'not at all' as having no PI. A leisure-time physical activity metabolic equivalent of task (LTPA MET) was calculated. Statistical comparisons between PI and categorical variables were made using chi-squared or Fisher-Freeman-Halton tests. Results: Of the total 195 patients, 97 (50%) patients reported PI. PI was associated with a wide spectrum of sociodemographic and disease-related variables. Pain intensity scores were higher in patients expressing greater PI (p < 0.001). Greater PI was associated with higher disability (p < 0.001), higher pain anxiety scores (p < 0.001), lower LTPA MET (p = 0.027), and poorer leisure-time activity (p < 0.001). Conclusions: PI is common in young adults with JIA. We suggest that PI should be taken into account in future outcome studies exploring the impact of pain in children and young adults with JIA.

Prevalence of antibodies against Chlamydia trachomatis and incidence of C. trachomatis-induced reactive arthritis in an early arthritis series in Finland in 2000.

OBJECTIVE: To study the prevalence of different serotypes of Chlamydia trachomatis antibodies and the incidence of C. trachomatis-induced reactive arthritis (ReA) among patients with early arthritis in a defined population. METHODS: Serum samples were collected from a cohort of 122 adult patients in the age group 18-65 years included in the Kuopio 2000 Arthritis Survey. Antibodies against C. trachomatis serotypes C, E, and G were studied using enzyme immunoassay (EIA) tests among patients and in a control cohort of 78 adults without any joint symptoms. The incidence assessment for Chlamydia-induced ReA was based on a ligase chain reaction (LCR) test in urine and clinical symptoms and signs appropriate for ReA. RESULTS: Of 122 patients, with the baseline diagnosis of rheumatoid arthritis (RA) in 11, spondyloarthropathy (SpA) in 28, and undifferentiated arthritis (UA) in 83 cases, 42 (34%) showed immunoglobulin (Ig)G or IgA antibodies against at least one serotype C, E, or G. Among the patients with UA the prevalence was significantly increased compared with the controls (p = 0.010). C. trachomatis-induced ReA arthritis was diagnosed in only three patients with the LCR test. On this basis the incidence of C. trachomatis-induced arthritis was 5.4/100 000 [95% confidence interval (CI) 1.1-15.7] in the age group 18-65 years. CONCLUSION: Antibodies against C. trachomatis were most common in patients with UA reflecting the fact that cases with chlamydia-induced ReA are included in this subgroup.

Sensitivity and specificity of autoantibodies binding to citrullinated carboxyterminal telopeptides of types I and II collagens in an early arthritis series.

OBJECTIVE: To assess the specificity and sensitivity of autoantibodies binding to citrullinated carboxyterminal telopeptides of types I and II collagens in an early arthritis series. METHODS: A cohort of 146 patients from the Kuopio 2000 Arthritis Survey having RA, AS, PsA, ReA, uSpA or undifferentiated arthritis were studied. Autoantibodies binding citrullinated types I and II carboxytelopeptides were measured in two different inhibition ELISA assays. Sera from 135 adult persons were used as controls. RESULTS: In RA, the sensitivities were 0.83 with long type I telopeptide and 0.78 with long type II telopeptide and the respective specificities were 0.94 and 0.93, while the corresponding values in other inflammatory joint diseases were much lower. The likelihood ratio in RA increased with longer peptides from 4.20 to 14.06 for type I telopeptide and from 2.74 to 11.67 for type II telopeptide. CONCLUSION: The antibody assay using long telopeptide from type I collagen was the most specific and sensitive method in every diagnostic category, although in the arthritides other than RA, binding was much less abundant and possibly citrulline-independent.

Serum soluble CD30 in early arthritis: a sign of inflammation but not a predictor of outcome.

OBJECTIVE: To evaluate serum soluble CD30 levels (sCD30) in an early arthritis series and assess their ability to predict the outcome in patients with rheumatoid arthritis (RA) and undifferentiated arthritis (UA) at one year follow-up. METHODS: Serum sCD30 levels were measured by ELISA from 92 adult patients with RA and UA at baseline and from 60 adult controls. The patients were followed up for one year in the Kuopio 2000 Arthritis Survey. Receiver operating characteristic (ROC) curves were constructed to determine cut off points of sCD30 in RA and UA that select the inflammatory disease from controls. Sensitivity, specificity and positive likelihood ratio, and their 95 % CIs were calculated for sCD30 levels in RA and UA. RESULTS: Median serum sCD30 levels were higher in RA 25.1 (IQ range 16.3-38.6) IU/ml (p<0.001) and in UA 23.4 (15.4-35.6) IU/ml (p<0.001) than in controls 15.1 (10.7-20.8) IU/ml. No differences were recorded between RA and UA (p=0.840). Serum sCD30 levels at baseline did not predict remission at one year follow-up. CONCLUSION: Serum sCD30 levels were higher in RA and UA than in controls at baseline but they did not predict remission at one year follow-up in this series.

Mortality in rheumatoid arthritis.

Patients with rheumatoid arthritis (RA) have a substantially reduced life expectancy. The standardized mortality ratio in different studies has ranged from 1.13 to 2.98. This mainly applies to rheumatoid factor (RF)-positive cases, although there is a subgroup of RF-negative cases with an adverse long-term prognosis. Clinically based studies probably overestimate the true shortening of life span and population-based studies may underestimate it. Excess mortality from infection and from renal disease likely reflects the presence of severe disease, whereas most of the added mortality from gastrointestinal causes is treatment related. The reasons for the surplus of mortality from cardiovascular causes are not fully known. RF may have a direct role, and preillness factors such as smoking may predipose patients to RA and also render them susceptible to cardiovascular diseases. The excess mortality associated with RA is appreciably higher than is apparent from the cases in which RA is regarded as an underlying cause of death. The effect of treatment on mortality remains largely unknown.

Stem cell transplantation for treatment of severe autoimmune diseases: current status and future perspectives.

Autoimmune diseases include a heterogeneous group of disorders with variable presentation and severity. Immunosuppressive and immunomodulatory therapies are often used for treatment with considerable success in some cases. These diseases may also be severe and refractory to conventional treatment. Thus more aggressive intervention might be indicated in a subset of patients. Animal studies suggest that high-dose therapy supported by stem cell transplantation may lead to remissions in experimental autoimmune disease models. Anecdotal case reports suggest that the same may be the case in some human autoimmune diseases as well. This review attempts to summarise some current concepts and future perspectives on stem cell transplantation in the treatment of severe autoimmune diseases.

Diverticulosis--a primary cause of life-threatening complications in rheumatoid arthritis.

OBJECTIVE: To assess the role of complicated diverticular disease as a cause of death in rheumatoid arthritis (RA). METHODS: In 1989 there were in Finland 1,666 deaths in subjects entitled to specially reimbursed medication for RA under the nationwide sickness insurance scheme. A retrospective clinical study was performed on these cases. RESULTS: In 12 subjects, four males and eight females, the underlying cause of death was diverticular disease; the expected number was two. The mean age at death was 74 years in males and 80 years in females. The duration of RA ranged from 4 to 22 years (mean 13 years). In none of these cases was the death connected in the death certificate to RA or its treatment, yet all the subjects had been taking antirheumatic medication, usually two or three different drugs, at the time of death. CONCLUSION: Complicated diverticular disease, probably related to antirheumatic medication, is a more important cause of death in patients with RA than is generally recognized.

Shortening of life span and causes of excess mortality in a population-based series of subjects with rheumatoid arthritis.

OBJECTIVES: To obtain information on the shortening of the life span and the causes of excess death in a population-based series of subjects with rheumatoid arthritis (RA). METHODS: The study included all 1666 subjects who had died in Finland in 1989 and were entitled under the nationwide sickness insurance scheme to receive specially reimbursed medication for RA. Demographic data on the Finnish population and sickness insurance statistics were used as the basis for computations. RESULTS: The life span in subjects with RA was shortened by 15-20% from the date of onset of illness. The determinants of excess mortality could be studied in females. About 40% of the excess deaths were due to cardiovascular causes, 30% to infections, 15% to amyloidosis, and the remaining 15% to diverse causes. CONCLUSION: This data provides an enlightened basis for understanding mortality associated with RA.

A cluster of inflammatory rheumatic diseases in a moisture-damaged office.

OBJECTIVE: To describe a cluster of inflammatory rheumatic diseases in an office workplace that suggests the presence of an environmental trigger. METHODS: There had been an indoor air problem in the workplace since the early 1990s. Large areas of the outer walls of the building were found to be moisture-damaged and contaminated by microbial growth. Case histories of the personnel were studied, and their working areas were related to the areas with highest microbial contamination. The incidence of inflammatory rheumatic diseases was compared with the statistics of the same geographic area. RESULTS: Ten patients with inflammatory rheumatic diseases (3 rheumatoid arthritis, 4 ankylosing spondylitis, 2 Sjögren's syndrome, and one of psoriatic arthritis) entitled to specially reimbursed medication were diagnosed in 1987-2000 (seven cases in 1995-1998). The incidence density ratio computed for the period 1987-2000 was 6.8 (95% confidence interval 3.6-13.0) for all office personnel and 13.2 (6.0-29.0) for those working close to the wall sustaining the worst damage. CONCLUSION: The accumulation of chronic inflammatory rheumatic diseases in a single workplace suggests that some environmental exposure in this damp office had triggered the diseases.

Transient osteoporosis of the hip with joint effusion detected by ultrasonography.

Three cases of transient osteoporosis of the hip and their ultrasonographic findings are presented. Transient osteoporosis of the hip is an uncommon condition with pain in the hip area and limping. The diagnosis is supported by local radiological osteoporosis and other imaging methods. Exclusion of more common entities is required. Effusion of the hip joint detected by ultrasonography is also related to this condition, which must be taken into account in patients with hip pain.

Joint symptoms and diseases associated with moisture damage in a health center.

Rheumatic diseases do not usually cluster in time and space. It has been proposed that environmental exposures may initiate autoimmune responses. We describe a cluster of rheumatic diseases among a group of health center employees who began to complain of symptoms typically related to moldy houses, including mucocutaneous symptoms, nausea and fatigue, within a year of moving into a new building. Dampness was found in the insulation space of the concrete floor below ground level. Microbes indicating mold damage and actinobacteria were found in the flooring material and in the outer wall insulation. The case histories of the personnel involved were examined. All 34 subjects working at the health center had at least some rheumatic complaints. Two fell ill with a typical rheumatoid factor (RF)-positive rheumatoid arthritis (RA), and 10 had arthritis that did not conform to any definite arthritic syndrome (three met the classification criteria for RA). Prior to moving into the problem building one subject had suffered reactive arthritis, which had then recurred. Another employee had undiagnosed ankylosing spondylitis and later developed psoriatic arthritis, and another developed undifferentiated vasculitis. A total of 16 subjects developed joint pains, 11 of these after beginning work at the health center. Three subjects developed Raynaud's symptom. Fourteen cases had elevated levels of circulating immune complexes in 1998, 17 in 1999, but there were only three cases in 2001, when the health center had been closed for 18 months. The high incidence of joint problems among these employees suggests a common triggering factor for most of the cases. As some of the symptoms had tended to subside while the health center was closed, the underlying causes are probably related to the building itself and possibly to the abnormal microbial growth in its structures.

Cost-effectiveness modelling of sequential biologic strategies for the treatment of moderate to severe rheumatoid arthritis in Finland.

OBJECTIVE: The main objective was to compare the cost-effectiveness of therapeutic options in moderate or severe rheumatoid arthritis (RA) when a clinical response to a first TNF-blocker, either etanercept (ETA), adalimumab (ADA), or infliximab (INF), is insufficient. METHODS: Effectiveness criteria were defined as remission (RS), low disease activity (LDAS), and moderate to high disease activity (MHDAS). Cost-effectiveness was derived as cost per day in RS and in LDAS using simulation modelling to assess six sequential biologic strategies over 2 years. Each sequential treatment strategy was composed of three biologic agents and included a first anti-TNF agent, ETA, ADA or INF, followed by either abatacept (ABA) or rituximab (RTX) as a second therapeutic option in case of an insufficient response, followed by another anti-TNF agent in case of further insufficient response. RESULTS: Over two years and taking into account biologic costs, the following estimated mean costs per day in RS and LDAS were respectively of €829 and €428 for the biologic sequence composed of ADA-ABA-ETA, €1292 and €516 for the sequence ADA-RTX-ETA, €829 and €429 for the sequence ETA-ABA-ADA, €1292 and €517 for the sequence ETARTX- ADA, €840 and €434 for the sequence INF-ABA-ETA, and €1309 and €523 for the sequence INF-RTX-ETA. CONCLUSION: The treatment sequences including ABA as the second biologic option appear more cost-effective than those including RTX in a patients with moderate to severe RA and an insufficient response to a first anti-TNF agent.