Peripheral joint damage in rheumatoid arthritis and prognostic factors

The progressive joint damage reflected in radiographs of the hands and the wrists constitutes the most objective outcome measure in rheumatoid arthritis (RA) and is representative of the total damage that a RA patient has sustained. The radiological course and outcome of RA may range among individuals, thus, making therapeutic decision challenging. Ideally, the intensity of treatment should be based on reliable prognostic factors of disease outcome, especially in our days when aggressive treatment with biologic agents is available. Plenty of studies have shown that various factors, including patients’ demographic characteristics, clinical measures of baseline, markers of inflammation, serum autoantibodies [rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies and others], genetic background (HLA-DRB1 genotype) and early imaging damage in hands, are associated with worse radiographic outcome. However, there is no absolute agreement between studies. The aim of the present study was to determine baseline prognostic factors of radiographic damage, as well as to describe the long-term clinical and radiological outcome in RA in North-Western Greece. In this observational study conducted for the period 1990-2008, 144 RA patients with disease duration less than 5 years at entry and X-rays of the hands and the wrists available at baseline and at 5 and 10 years of follow-up were studied. Records of the patients were reviewed and demographic, clinical, laboratory, immunological and radiological characteristics at the time of disease diagnosis, at the end of the follow-up period, and at regular intervals in between were recorded. The clinical improvement was measured according to American College of Rheumatology (ACR) criteria for response to the treatment. The sets of the radiographs at the three time points were reviewed by the same examiner, who was blind for patients’ identity, and were scored using Larsen’s criteria in chronological order (score 0 to 140). The number of erosive joints was also evaluated. Baseline parameters were initially tested in univariate analysis, and then those presenting a statistically significant association with Larsen score at 10 years were included in a logistic regression model in order to determine relevant independent prognostic factors. Most patients received traditional therapy with disease modifying antirheumatic drugs (DMARDs). A significant clinical improvement was noted, associated with a decrease of acute-phase reactants along the three time points in our cohort. A significant proportion of the 144 RA patients achieved the ACR 20% and ACR 50% response criteria at 10 years. On the contrary, the radiological damage, in terms of increase in Larsen score and the number of erosive joints, was aggravated. However, the radiological course observed in our cohort of Greek patients was milder than those reported for North-European populations. The average annual progression rate was 2.13 ± 1.28 points/year between baseline and 5 years, and 1.81 ± 1.34 points/year between 5-10 years (statistical significant difference, p=0.001). At 10 years, 18 (12.5%) patients had no erosions, while 126 (87.5 %) patients had at least one eroded joint and 63 (43.8%) presented with at least five eroded joints. Among the clinical and laboratory parameters at 10 years, a significant association with the final Larsen score was found only with rheumatoid nodules and C-reactive protein (CRP). Larsen score at 10 years was negatively correlated with grip strength. The timeaverage values of swollen joint count (SJC), erythrocyte sedimentation rate (ESR) and CRP over 10 years were also associated with the final Larsen score.Η καταστροφή των αρθρώσεων που απεικονίζεται στις ακτινογραφίες των χεριών και των καρπών αποτελεί την πιο αντικειμενική μεταβλητή έκβασης στη ΡΑ και είναι αντιπροσωπευτική της συνολικής καταστροφής που έχει υποστεί στις αρθρώσεις του ένας ασθενής με ΡΑ. Η ακτινολογική πορεία και έκβαση στη ΡΑ μπορεί να ποικίλει μεταξύ των ασθενών καθιστώντας δύσκολη την επιλογή της κατάλληλης θεραπείας. Θεωρητικά, η επιλογή μιας επιθετικότερης θεραπείας θα έπρεπε να βασίζεται σε αξιόπιστους προγνωστικούς παράγοντες της έκβασης της νόσου, ιδιαίτερα στις μέρες μας όπου είναι πια διαθέσιμοι οι βιολογικοί παράγοντες. Διάφορες μελέτες έχουν δείξει ότι ποικίλοι παράγοντες, συμπεριλαμβανομένων των δημογραφικών χαρακτηριστικών των ασθενών, των κλινικών παραμέτρων της γραμμής εκκίνησης, των δεικτών φλεγμονής, των αυτοαντισωμάτων του ορού (RF, αντισώματα αντι-CCP κ.ά.) του γενετικού υποστρώματος (HLA-DRB1) και της πρώιμα απεικονιζόμενης δομικής βλάβης, σχετίζονται με την ακτινολογική έκβαση. Ωστόσο, δεν υπάρχει απόλυτη συμφωνία μεταξύ των αποτελεσμάτων των μελετών αυτών. Ο πρωταρχικός σκοπός της παρούσας μελέτης ήταν ο καθορισμός προγνωστικών παραγόντων της ακτινολογικής καταστροφής μακροπρόθεσμα. Επιπρόσθετα, στόχος ήταν η περιγραφή της κλινικής και ακτινολογικής πορείας και έκβασης της ΡΑ στη ΒΔ Ελλάδα. Στην παρούσα 10ετή μελέτη παρατήρησης, η οποία διενεργήθηκε για τη χρονική περίοδο 1990-2008, συμπεριελήφθησαν 144 ασθενείς με ΡΑ, οι οποίοι είχαν διάρκεια νόσου μικρότερη των 5 ετών κατά τη γραμμή εκκίνησης και επιπλέον διέθεταν ακτινογραφίες χεριών και καρπών σε 3 χρονικά σημεία: γραμμή εκκίνησης, 5ο έτος και 10ο έτος. Έγινε ανασκόπηση των αρχείων των ασθενών και κατεγράφησαν τα δημογραφικά, κλινικά, εργαστηριακά, ανοσολογικά και ακτινολογικά χαρακτηριστικά τη στιγμή της διάγνωσης της νόσου, στο τέλος της περιόδου παρακολούθησης και ανά τακτά ενδιάμεσα χρονικά διαστήματα. Η κλινική βελτίωση εκτιμήθηκε σύμφωνα με τα κριτήρια απόκρισης στη θεραπεία που έχουν προταθεί από το Αμερικάνικο Κολέγιο της Ρευματολογίας (ACR). Οι ακτινογραφίες των χεριών και των καρπών στα 3 χρονικά σημεία αξιολογήθηκαν από τον ίδιο εξεταστή (ΜΕΘ), ο οποίος δεν γνώριζε την ταυτότητα των ασθενών. Η βαθμολόγηση των ακτινολογικών βλαβών έγινε κατά χρονολογική σειρά σύμφωνα με τα κριτήρια του Larsen (βαθμός 0 έως 140). Επιπρόσθετα, εκτιμήθηκε και ο αριθμός των διαβρωμένων αρθρώσεων στις 3 χρονικές στιγμές. Οι παράμετροι της γραμμής εκκίνησης δοκιμάστηκαν πρώτα σε μονοπαραγοντική ανάλυση. Ακολούθως οι μεταβλητές που παρουσίαζαν στατιστικά σημαντική συσχέτιση με το βαθμό Larsen στο 10ο έτος συμπεριελήφθησαν σε ένα μοντέλο λογιστικής παλινδρόμησης για τον καθορισμό σχετικών ανεξάρτητων προγνωστικών μεταβλητών

The impact of temporal artery biopsy for the diagnosis of giant cell arteritis in clinical practice in a tertiary university hospital.

BACKGROUND:Temporal artery biopsy (TAB) is useful in assisting with giant cell arteritis (GCA) diagnosis but lacks sensitivity. The aim of our study was to assess the diagnostic impact of TAB histology in patients with suspected GCA on hospital admission. METHODS:A prospectively maintained database was queried for all TABs performed between 1-1-2000 until 31-12-2017 at the University Hospital of Ioannina. Thus, inclusion criteria were made on the grounds of every patient that underwent a TAB during the above-mentioned period, regardless of demographic, clinical and laboratory data. RESULTS:Two hundred forty-five TABs were included (149 females and 96 males), with a mean age of 64.5 (±3.5) years. The mean symptoms duration until admission to the hospital was 8.6 (±1.3) weeks and all had elevated acute phase reactants on admission. The reasons of admission were fever of unknown origin (FUO) in 114 (46.5%) patients, symptoms of polymyalgia rheumatica (PMR) in 84 (34.3%), new headache in 33 (13.5%), anemia of chronic disease (ACD) in 8 (3.32%) and eye disturbances in 6 (2.5%) patients. Positive results were found in 49 (20%) TABs. More specifically, in 14% of patients with FUO, 21% in those with PMR, while in patients with a new headache the percentage was 27%. Finally, 5 out of 6 (83.3%) of patients with ocular symptoms and only one (12.5%) of those suffering from ACD. Visual manifestations and FUO are correlated with a positive TAB. CONCLUSION:It seems that TAB is useful in assisting with GCA diagnosis, but lacks sensitivity

Cardiovascular Magnetic Resonance Detects Inflammatory Cardiomyopathy in Symptomatic Patients with Inflammatory Joint Diseases and a Normal Routine Workup

Background. Patients with inflammatory joint diseases (IJD) are more likely to develop cardiovascular disease compared with the general population. We hypothesized that cardiovascular magnetic resonance (CMR) could identify cardiac abnormalities in patients with IJD and atypical symptoms unexplained by routine clinical evaluation. Patients-Methods. A total of 51 consecutive patients with IJD (32 with rheumatoid arthritis, 10 with ankylosing spondylitis, and 9 with psoriatic arthritis) and normal clinical, electrocardiographic and echocardiographic workups, were referred for CMR evaluation due to atypical chest pain, shortness of breath, and/or palpitations. Their CMR findings were compared with those of 40 non-IJD controls who were referred for the same reason. All participants were examined using either a 1.5 T or 3.0 T CMR system. For T1/T2 mapping, comparisons were performed separately for each field strength. Results. Biventricular systolic function was similar between groups. In total, 25 (49%) patients with IJD vs. 0 (0%) controls had replacement-type myocardial fibrosis (p < 0.001). The T2 signal ratio, early/late gadolinium enhancement, and extracellular volume fraction were significantly higher in the IJD group. Native T1 mapping was significantly higher in patients with IJD independent of the MRI field strength (p < 0.001 for both). T2 mapping was significantly higher in patients with IJD compared with controls only in those examined using a 1.5 T MR system—52.0 (50.0, 55.0) vs. 37.0 (33.5, 39.5), p < 0.001. Conclusions. In patients with IJD and a mismatch between cardiac symptoms and routine non-invasive evaluation, CMR uniquely identified a significant proportion of patients with myocardial inflammation. A CMR examination should be considered in patients with IJD in similar clinical settings

Comparative effectiveness and survival of infliximab, adalimumab, and etanercept for rheumatoid arthritis patients in the Hellenic Registry of Biologics: Low rates of remission and 5-year drug survival

Objective: To compare effectiveness, drug survival, and safety between infliximab, adalimumab, and etanercept, in a nationwide cohort of rheumatoid arthritis (RA) patients. Methods: This study is a prospective cohort study of 1208 active RA patients. Effectiveness, drug survival, and serious adverse events during entire follow-up (median 2.9 years) were monitored. Results: EULAR and CDAI responses were comparable between the three agents (EULAR good/moderate responses at 12 months ranged 76-79%). At 12 months, 15-23% achieved remission. For adalimumab and etanercept, adjusted hazard rate (HR) for EULAR/ACR remission (reference: infliximab) was 2.7 and 2.1 (95% confidence interval was 1.7-4.1 and 1.3-3.4, respectively); males (HR 1.6; 1.1-2.4), use of glucocorticoids (HR 2.0; 13-3.0), and swollen joint count > 7 (HR 0.36; 0.24-0.55) were independent predictors. Five-year drug survival was 31%, 43%, and 49% for infliximab, adalimumab, and etanercept, respectively (p = 0.010). Infliximab was associated with significantly more withdrawals due to adverse events. Disease activity, CRP, and use of glucocorticoids predicted efficacy-related drug survival; age, use of methotrexate, and prior DMARDs failures predicted safety-related survival. Risk for serious infections was lower with adalimumab (odds ratio [OR] 0.62; 0.38-1.00) or etanercept (OR 0.39; 0.21-0.72) than infliximab, independent of the effects of age (OR 1.65; 1.37-2.00 per 10 years), tender joint count > 10 (OR 1.86; 1.21-2.86), and glucocorticoids >35 mg/week (OR 1.83; 1.12-2.99). Conclusions: Response rates were comparable among anti-TNF agents. Overall, 5-year drug survival was below 50%, with infliximab demonstrating increased safety-related discontinuations. Remission rates are low in clinical practice. Strategies to increase effectiveness and long-term survival of anti-TNF agents in RA are needed. (C) 2014 Elsevier Inc. All rights reserved