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Showing papers in "The Journal of Rheumatology in 1988"


Journal Article
TL;DR: WOMAC is a disease-specific purpose built high performance instrument for evaluative research in osteoarthritis clinical trials and fulfil conventional criteria for face, content and construct validity, reliability, responsiveness and relative efficiency.
Abstract: Within the context of a double blind randomized controlled parallel trial of 2 nonsteroidal antiinflammatory drugs, we validated WOMAC, a new multidimensional, self-administered health status instrument for patients with osteoarthritis of the hip or knee. The pain, stiffness and physical function subscales fulfil conventional criteria for face, content and construct validity, reliability, responsiveness and relative efficiency. WOMAC is a disease-specific purpose built high performance instrument for evaluative research in osteoarthritis clinical trials.

7,147 citations



Journal Article
TL;DR: A good functional prognosis in the great majority of the patients with possible ankylosing spondylitis still maintained good or sufficient functional capacity, indicating a good functional prediction in theGreat majority of patients with AS.
Abstract: Eighty-eight patients with possible ankylosing spondylitis (AS) were selected for this followup study. They showed normal or at most suspicious radiographic findings of the sacroiliac joints. After 5 years' followup, 24, and after 10 years 32 patients (59% of the 54 finally available, 36% of the 88 original patients) had definite AS. In 12 individuals, AS could be excluded. Of the 10 remaining patients, 6 still had possible, and 4 had undifferentiated spondyloarthropathy. A comparison between HLA-B27 positive and negative patients showed a significantly increased frequency of definite AS or possible and undifferentiated spondyloarthropathy (p less than 0.05) in the group of HLA-B27 positive patients. The development of AS was characterized by a prolonged course: radiological sacroiliitis became evident after at least 9 +/- 6 years, radiological signs of spinal involvement after 11 +/- 6 years mean disease duration. After 18 +/- 6 years 25 (78%) of 32 patients with AS still maintained good or sufficient functional capacity, indicating a good functional prognosis in the great majority of the patients.

355 citations


Journal Article
TL;DR: The FDI provided important and clinically useful current and predictive information regarding RA status, utilization of services, and mortality that was not available through conventional testing and the data suggest that such information can be easily and inexpensively obtained.
Abstract: We administered the Stanford Health Assessment Questionnaire functional disability questionnaire to a cohort of 400 patients with rheumatoid arthritis (RA) every 6 months during a mean followup of 3.1 years. Simple classification into 3 groups based on Functional Disability Index (FDI) scores (0-1, 1.1-2, 2.1-3) identified patients with increasingly more severe scores for clinical, psychological, and demographic variables; and FDI scores at entry predicted increased inpatient and outpatient utilization of services, and mortality. The FDI provided important and clinically useful current and predictive information regarding RA status, utilization of services, and mortality that was not available through conventional testing. Our data suggest that such information can be easily and inexpensively obtained.

291 citations


Journal Article
TL;DR: It is suggested that depression is a frequent disorder among persons with rheumatoid arthritis and attention to specific interventions for depression in conjunction with the treatment of the RA is suggested.
Abstract: Operationalized diagnostic criteria for depression were used to assess 137 (76% male, 24% female) patients with rheumatoid arthritis (RA). Forty-two percent met criteria for some form of depression. Discriminant function analysis revealed a significant relationship between the presence or history of depression and higher levels of pain, but not between current depression and common indicators of RA activity or severity. These results suggest that depression is a frequent disorder among persons with RA. The importance of patient appraisal of disease and assessment of repeated depressive episodes is discussed. Attention to specific interventions for depression in conjunction with the treatment of the RA is suggested.

267 citations


Journal Article
TL;DR: Dietary supplementation with fish oil was compared with an olive oil supplement over a 12-week period in patients with rheumatoid arthritis receiving established conventional therapies, with an improvement in tender joint score and grip strength seen at 12 weeks but not in the olive oil treated group.
Abstract: In a double blind noncrossover study, dietary supplementation with fish oil (18 g/day), was compared with an olive oil supplement over a 12-week period in patients with rheumatoid arthritis receiving established conventional therapies. An improvement in tender joint score and grip strength was seen at 12 weeks in the fish oil treated group but not in the olive oil treated group. The more subjective measures of mean duration of morning stiffness and analogue pain score improved to a similar extent in both groups, although statistical significance was only achieved in paired analyses in the olive oil treated group. Production of leukotriene B4 by isolated neutrophils stimulated in vitro was reduced by 30% in the fish oil treated group and unchanged in the olive oil treated group.

240 citations



Journal Article
TL;DR: An index of functional impairment and a system of scoring joint tenderness for use in the assessment of ankylosing spondylitis showed changes in short term clinical trials of antiinflammatory drugs; these changes were highly correlated with the patient's overall assessment of his own clinical condition.
Abstract: We describe an index of functional impairment and a system of scoring joint tenderness for use in the assessment of ankylosing spondylitis. The functional index consists of 20 questions and the articular index is based on the scoring of a total of 10 joint responses after movement or firm digital pressure. These indices are simple to establish and not time consuming. They have a high degree of intra- and interobserver reproducibility. The indices showed changes in short term clinical trials of antiinflammatory drugs; these changes were highly correlated with the patient's overall assessment of his own clinical condition.

193 citations


Journal Article
TL;DR: Pathergy test was positive in 6/18 and 5/19 carried HLA-B5, suggesting that the previously established association of HLA -B5 in Behçet's syndrome is mainly true for hospital based populations, and was less commonly positive in milder disease.
Abstract: We conducted a field survey to establish the prevalence of Behcet's syndrome among all the inhabitants aged 10 years or older in a village in northern Turkey. The prevalence of Behcet's syndrome was 19/5,131. There were 13 females and 6 males. None had eye involvement. Pathergy test was positive in 6/18 (33%) and 5/19 carried HLA-B5 (26%), suggesting that the previously established association of HLA-B5 in Behcet's syndrome is mainly true for hospital based populations. Moreover, the pathergy test was less commonly positive in milder disease.

189 citations


Journal Article
TL;DR: Psychological and clinical factors in patients with rheumatoid arthritis are investigated by studying 400 patients at 6 month intervals over a mean 3.1 (1.2 SD) years utilizing the Arthritis Impact Measurement Scales psychological scales.
Abstract: We investigated psychological and clinical factors in patients with rheumatoid arthritis (RA) by studying 400 patients at 6 month intervals over a mean 3.1 (1.2 SD) years utilizing the Arthritis Impact Measurement Scales psychological scales. Entry clinical and demographic variables explained 25% of the variance in psychological scores. Patients with RA had scores similar to those with other rheumatic disorders (n = 441), and scores remained stable over the study period. Development of depression was associated with socioeconomic not clinical factors, and disease activity appeared to have a limited effect on psychological status. Initial psychological scores were associated with subsequent pain levels and number of physician visits.

185 citations


Journal Article
TL;DR: The simple subdivision of scleroderma based on the early extent of clinical skin involvement has been found to be useful in predicting longterm outcome in this highly variable disease.
Abstract: A longitudinal study was carried out on 177 patients with scleroderma between 1953 and 1983. Patients were classified into 3 types according to the extent of skin sclerosis within one year of presentation: Type 1 with sclerodactyly only; Type 2, skin stiffness proximal to the metacarpophalangeal joints but sparing the trunk; and Type 3, diffuse skin stiffness including the trunk. Ten year survival was 71% in Type 1, 58% in Type 2 and 21% in Type 3. Quality of life was best in Type 1, intermediate in Type 2 and worst in Type 3. Nailfold capillary abnormalities did not discriminate between the types, but anticentromere antibody correlated strongly with Type 1. The simple subdivision of scleroderma based on the early extent of clinical skin involvement has been found to be useful in predicting longterm outcome in this highly variable disease.

Journal Article
TL;DR: Predictors of future function, employment, and medical utilization were drawn from 21 clinical, demographic, and psychosocial variables using multivariate techniques to support the importance of education and self-rated health as correlates of back related disability.
Abstract: We prospectively studied outcomes for 179 patients with low back pain. Predictors of future function, employment, and medical utilization were drawn from 21 clinical, demographic, and psychosocial variables using multivariate techniques. Education, previous episodes, and whether the patient "always feels sick" were independently associated with most outcome measures, but prescribed therapy and physical findings were not. These 3 items created a scale defining subgroups with 3-fold differences in outcomes (e.g., 35% functionally improved in the worst group vs 93% in the best, p less than 0.001). Data from a national survey supported the importance of education and self-rated health as correlates of back related disability.

Journal Article
TL;DR: OA is a heterogeneous condition and some site specific associations with obesity are strong, thus there is scope for prevention by weight reduction for some sites.
Abstract: The association between obesity and osteoarthritis (OA), was studied by analysis of data from an epidemiologic survey of a population of 1071 men and 1097 women in The Netherlands. A total of 20 joints and groups of joints were investigated. OA was clearly associated with obesity in the most frequently affected joints, weight bearing as well as nonweight bearing. This association was less strong for severely affected joints than for mildly affected joints. This pattern was neither compatible with a generalized (metabolic) abnormality nor with weight induced mechanical "wear-and-tear". OA is a heterogeneous condition and some site specific associations with obesity are strong, thus there is scope for prevention by weight reduction for some sites.

Journal Article
TL;DR: People with arthritis were significantly impaired in exercise tolerance, flexibility and biomechanical efficiency, and women with RA had a greater aerobic deficit than women with OA.
Abstract: One hundred and twenty patients with symptomatic rheumatoid arthritis (RA) or osteoarthritis (OA) in weight bearing joints (RA = 40; OA = 80) performed subjective maximal graded exercise tests on a motor driven treadmill. Disease related measures were also assessed. Findings from this sample indicated that people with arthritis were significantly impaired in exercise tolerance, flexibility and biomechanical efficiency. Significant differences between diagnoses appeared on a number of disease related measures; however, there was little correlation between disease related measures and exercise tolerance. Women demonstrated a greater aerobic impairment than men; and women with RA had a greater aerobic deficit than women with OA.

Journal Article
M Grönblad1, Y. T. Konttinen, Korkala O, P. Liesi, M Hukkanen, J.M. Polak 
TL;DR: In the synovium of patients with rheumatoid arthritis (RA), free stromal nerves stained with neurofilament antiserum often lacked neuropeptide immunoreactivity, while this was not the case in normalsynovium or synovial samples from patients with osteoarthritis (OA).
Abstract: The presence of neural elements in synovial tissue proper has earlier been suggested on the basis of nonspecific silver impregnation techniques and is now confirmed in a study based on specific demonstration of cytoskeletal neurofilaments and various neuropeptides. With both the neurofilament and neuropeptide antisera, nerves were seen predominantly in a perivascular location, there being fewer nerves freely in the stromal tissue. In the synovium of patients with rheumatoid arthritis (RA), free stromal nerves stained with neurofilament antiserum often lacked neuropeptide immunoreactivity, while this was not the case in normal synovium or synovial samples from patients with osteoarthritis (OA). Furthermore, the intensity of staining of neurotransmitter peptides was weaker in RA than in OA or normal synovial tissue. It is suggested that neurogenic inflammation may play a role in RA and that neuropeptide nerves possibly release their mediators in RA.

Journal Article
TL;DR: A Rheumatology Attitudes Index (RAI) has been modified from the Arthritis Helplessness Index to assess the psychological construct of learned helplessness.
Abstract: A Rheumatology Attitudes Index (RAI) has been modified from the Arthritis Helplessness Index to assess the psychological construct of learned helplessness. The validity of the RAI was established in comparisons to the Arthritis Helplessness Index. The external criterion validity of the RAI was established by identification of statistically significant correlations between RAI scores and physical measures of disease status, including joint count, grip strength, walking time, and button test, as well as with questionnaire self-report scores for difficulty, dissatisfaction and pain in activities of daily living (ADL). Any variation in RAI scores which could be explained by available disease status measures was explained entirely by ADL self-report scores, with no additional explanation by traditional physical measures. Responses to individual RAI statements were significantly correlated with either questionnaire or physical measures of disease status for only 6 of the 15 RAI statements.

Journal Article
TL;DR: The factor structure of the Arthritis Helplessness Index was examined using principal components factor analysis with varimax rotation and it is revealed that the 2 subscales of the AHI are more reliable and valid than the total score.
Abstract: The factor structure of the Arthritis Helplessness Index (AHI) was examined using principal components factor analysis with varimax rotation. Data for the initial factor analysis came from a longitudinal study of 368 patients with rheumatoid arthritis (RA). Two slightly negatively correlated (r = -0.21) subscales emerged: internality and helplessness. This analysis was cross-validated twice. Findings reveal that the 2 subscales of the AHI are more reliable and valid than the total score. The 5 item helplessness subscale, in particular, appears to be a highly valid indicator of the degree to which patients with RA feel overwhelmed by their disease.

Journal Article
TL;DR: Fibromyalgia symptoms in individual patients were generally stable over time as assessed by repeated measures and slope analyses, but patients clearly differed from one another in symptom severity.
Abstract: We mailed monthly questionnaires regarding fibromyalgia symptoms to 75 patients during a one-year period. Fibromyalgia symptoms in individual patients were generally stable over time as assessed by repeated measures and slope analyses, but patients clearly differed from one another in symptom severity. Pain, psychological status, and functional disability, but not sleep disturbance or morning stiffness, were the independent explanatory factors for disease severity in regression models. Functional disability has not been recognized previously as an important factor in fibromyalgia severity, but our data suggest that it should be assessed as a process and outcome measure in future fibromyalgia studies.

Journal Article
TL;DR: Frequencies of autoantibodies to Sm, nRNP, Ro (SSA) and La (SSB) were determined by countercurrent immunoelectrophoresis (CIE) and/or enzyme linked immunosorbent assays (ELISA) in 106 whites and 60 blacks with systemic lupus erythematosus.
Abstract: Frequencies of autoantibodies to Sm, nRNP, Ro (SSA) and La (SSB) were determined by countercurrent immunoelectrophoresis (CIE) and/or enzyme linked immunosorbent assays (ELISA) in 106 whites and 60 blacks with systemic lupus erythematosus. Anti-Sm occurred significantly more frequently in blacks (25%) than whites (10%) (p = 0.02), as did anti-nRNP (40% versus 23%; p = 0.03). By CIE, anti-Sm and/or nRNP occurred in 47% of blacks and 24% of whites (p = 0.004), and by ELISA the Sm/nRNP complex was detected in 52% of blacks versus 26% of whites (p = 0.003). Antibodies to Ro and La occurred with equal frequencies between the races.

Journal Article
TL;DR: In 4 of 6 antiphospholipid antibodies, an inverse association with renal disease was observed, and this may reflect the high doses of corticosteroids and cytotoxic drugs received by this group of patients.
Abstract: We evaluated the clinical relevance of 6 antiphospholipid antibodies including cardiolipin and their IgG, IgM and IgA isotypes in 92 patients with systemic lupus erythematosus (SLE). Antiphospholipid antibodies generally had significant associations with thrombocytopenia and a history of false-positive syphilis serologies. In 4 of 6 antiphospholipid antibodies, an inverse association with renal disease was observed. Antiphospholipid antibodies may moderate or protect against renal disease, or this may reflect the high doses of corticosteroids and cytotoxic drugs received by this group. Further studies are needed to determine how many antibody families cause these activities and to elucidate whether certain SLE subgroups possess differing specificities for each of the phospholipids.

Journal Article
TL;DR: This study supports the efficacy of a moderate dose of amitriptyline as an adjunct drug for the treatment of pain in both depressed and nondepressed patients with RA.
Abstract: Forty-seven patients with definite rheumatoid arthritis (RA) were treated in a 32 week, double blind, crossover trial of amitriptyline, desipramine, trazodone, and placebo. All drug regimens produced significant changes on pain measures relative to baseline, but only amitriptyline exceeded placebo. Amitriptyline was associated with a significant reduction in the number of painful/tender joints. Our study supports the efficacy of a moderate dose of amitriptyline as an adjunct drug for the treatment of pain in both depressed and nondepressed patients with RA.

Journal Article
TL;DR: It is proposed that most patients with SLE with deforming arthropathy belong to a subset of SLE rather than representing the coexistence of Sle and RA, and had higher frequency of rheumatoid factor positivity, sicca symptoms and antibodies to native DNA, whereas they had lower incidence of facial rash and photosensitivity than did those without.
Abstract: Forty-one of 858 patients with systemic lupus erythematosus (SLE) developed clinical deformity of their hands. This deformity was clinically and radiologically different from that found in 40 patients with classical or definite rheumatoid arthritis (RA), and tended to appear early in the course of disease. Characteristics of this arthropathy included nonerosive carpal collapse; exceptional erosion of the styloid processes; Z deformity of the thumb; nonerosive ulnar deviation and subluxation of MCP joints; parametacarpophalangeal joint hook formation; scant and asymmetric joint erosions; and swan neck deformity of the fingers. Most of these changes seemed to be due to involvement of the ligaments rather than to the destructive effect of synovitis. Patients with SLE with deforming arthropathy had a higher frequency of rheumatoid factor positivity, sicca symptoms and antibodies to native DNA, whereas they had lower incidence of facial rash and photosensitivity than did those without. Other manifestations did not differ. We propose that most patients with SLE with deforming arthropathy belong to a subset of SLE rather than representing the coexistence of SLE and RA.

Journal Article
TL;DR: MRI was found to be superior to standard radiographs in 2 respects: (1) synovial inflammation was impressively demonstrated on T2 weighted images, whereas plain films merely suggested soft tissue swelling; and (2) T1 and T1 weighted images clearly revealed erosions of several carpal bones which were not noted on standard radiograph.
Abstract: A pilot study comparing standard radiography to magnetic resonance imaging (MRI) was performed on the wrists of 10 patients with early (anatomic Stage I or II) rheumatoid arthritis (RA). MRI was found to be superior to standard radiographs in 2 respects: (1) synovial inflammation was impressively demonstrated on T2 weighted images, whereas plain films merely suggested soft tissue swelling; and (2) T1 and T2 weighted images clearly revealed erosions of several carpal bones which were not noted on standard radiographs. Although the expense of MRI currently precludes its routine use in clinical practice, the apparent sensitivity of this diagnostic modality for detecting early changes in RA might make it an invaluable tool for therapeutic decision making or for assessing response in interventional trials.

Journal Article
TL;DR: The contribution of the lupus anticoagulant to the thrombotic problems, and its possible relationship to the pathogenesis of Libman-Sacks endocarditis are discussed.
Abstract: Two cases of systemic lupus erythematosus with hemodynamically significant mitral valve dysfunction and associated lupus anticoagulant are reported. Both patients underwent valve replacement and both had thrombus formation on the mitral valve, one pre- and the other postoperatively. Both patients suffered a number of extracardiac thromboses at different times in the course of their illness. The contribution of the lupus anticoagulant to the thrombotic problems, and its possible relationship to the pathogenesis of Libman-Sacks endocarditis are discussed.

Journal Article
TL;DR: Testing the feasibility of reducing interobserver variability of the joint examination by agreement on a standard examination showed an improvement in the percent variability related to patient differences, which has a potential for allowing a reduction in sample sizes required for RA clinical trials.
Abstract: This experiment was designed to test the feasibility of reducing interobserver variability of the joint examination by agreement on a standard examination. Six rheumatologists independently examined 6 patients with rheumatoid arthritis (RA) in predetermined order, before and after a standardization of examination techniques. Results of an analysis of variance showed a reduction of the percent of variability due to observers from 13.8%, before standardization, to 3.2% after standardization, and an improvement in the percent variability related to patient differences from 70.7%, before standardization, to 86.3% after standardization. Such a reduction in observer variability has a potential for allowing a reduction in sample sizes required for RA clinical trials.

Journal Article
TL;DR: Observations suggest a possible role of the streptococcus in the pathogenesis of Behçet's disease.
Abstract: Severe symptoms of Behcet's disease were induced after dental treatment in 2 patients with stable Behcet's disease. Similar symptoms were probably induced by the streptococcal antigen skin test in 4 patients. These observations suggest a possible role of the streptococcus in the pathogenesis of Behcet's disease.

Journal Article
TL;DR: Patients who coped by restructuring life goals were found to have better psychological adjustment and functional status than patients who hoped for unrealistic solutions or engaged in self-blame.
Abstract: Our purpose was to investigate the importance of the coping process for patients with rheumatoid arthritis (RA). Eighty-four patients with classic or definite RA were examined. The relationship between coping strategies and psychological status, functional status, pain, and disease activity was analyzed. Coping was measured by an adapted version of the Ways of Coping Scale, and measures of psychological status, life stress, functional status, pain, and disease activity were also obtained. Canonical correlation revealed a significant relationship between the coping process and psychological status. Coping also was significantly related to functional status, but not to pain or disease activity. Patients who coped by restructuring life goals were found to have better psychological adjustment and functional status than patients who hoped for unrealistic solutions or engaged in self-blame.

Journal Article
TL;DR: Ten of 12 patients with systemic lupus erythematosus (SLE) who had hemolytic anemia and thrombocytopenic purpura (Evans' syndrome) during their course had evidence of antiphospholipid antibodies, and antibodies to cardiolipin were found in very high levels and were of both IgG and IgM isotypes.
Abstract: Ten of 12 patients with systemic lupus erythematosus (SLE) who had hemolytic anemia and thrombocytopenic purpura (Evans' syndrome) during their course had evidence of antiphospholipid antibodies either because they had a false positive VDRL test (8 patients), a prolonged partial thromboplastin time (5 patients), a lupus anticoagulant (3/4 patients), and/or anticardiolipin antibodies as determined by an ELISA method (7 patients) Antibodies to cardiolipin were found in very high levels (up to 38 standard deviations above the mean of normal controls) and were of both IgG and IgM isotypes The 2 patients with SLE and Evans' syndrome who did not have evidence of antiphospholipid antibodies were studied at the onset of SLE which occurred with Evans' syndrome Although cardiolipin is not a constituent of the cell wall of either platelets or erythrocytes, other phospholipids that cross react antigenically with cardiolipin are and can be exposed through cell damage This could be a mechanism whereby hemolytic anemia and thrombocytopenia could occur in the same patient with SLE Whether absorption of the antiphospholipid antibody during the acute episode of hemocytopenia could occur, and thus prevent its detection at such time, remains undetermined

Journal Article
TL;DR: Therapeutic rules for colchicine have been derived from published experiences with severe toxicity with intravenous col chicine, and absolute contraindications to intravenouscolchicines therapy for acute gout include combined renal and hepatic disease, creatinine clearances below 10 cc/min, and extrahepatic biliary obstruction.
Abstract: Published experiences with severe toxicity with intravenous colchicine have been reviewed. All reported cases reflect inappropriate use of the drug. Therapeutic rules for colchicine have been derived from this information: (1) Single intravenous doses should not exceed 2-3 mg, and cumulative total doses for an attack should not be more than 4-5 mg. (2) Patients should receive no more colchicine by any route for 7 days. (3) Colchicine doses must be reduced in the presence of renal or hepatic disease, and in the older patient with apparently normal renal function. (4) Intravenous colchicine doses should be half the size of oral ones. (5) Absolute contraindications to intravenous colchicine therapy for acute gout include combined renal and hepatic disease, creatinine clearances below 10 cc/min, and extrahepatic biliary obstruction.

Journal Article
TL;DR: This study indicates that cathepsin B-like activity plays a role in the cascade of proteolytic cartilage destruction, chondrocytes and fibroblasts may well be involved in the breakdown of cartilage and ligaments, and Z-Phe-AlaCH2F could be of therapeutic value.
Abstract: The role of cathepsin B, H and L activities in arthritic processes was studied histochemically using specific synthetic substrates in a postcoupling method on unfixed and undecalcified cryostat sections of rat knee joints. Only cathepsin B in synoviocytes, chondrocytes and fibroblasts showed a strong increase in activity due to antigen induced arthritis. The addition of a tissue stabilizer, polyvinyl alcohol, to the incubation medium enabled us to demonstrate extracellular enzymic activity within the articular cartilage matrix of arthritic joints. Both intravenous and oral treatment of the animals with a selective inhibitor of cathepsin B, Z-Phe-Ala fluoromethyl ketone (CH2F), during the development of arthritis suppressed the degree of inflammation and resulted in decreased intracellular and extracellular cathepsin B activity as detected histochemically, and less cartilage damage. Our study indicates that (a) cathepsin B-like activity plays a role in the cascade of proteolytic cartilage destruction, (b) chondrocytes and fibroblasts may well be involved in the breakdown of cartilage and ligaments, and (c) Z-Phe-AlaCH2F could be of therapeutic value.