Björn Svensson

Assessing Disability in Patients with Rheumatoid Arthritis: Use of a Swedish Version of the Stanford Health Assessment Questionnaire

The validity and reliability under Swedish conditions of a translated and slightly modified version of the Stanford Health Assessment Questionnaire (HAQ), referred to here as the ADL questionnaire, was studied. Sixty-four patients with definite/classical rheumatoid arthritis (RA) participated in the major part of the investigation. In addition, inter-observer reliability was studied in the testing of 15 other patients with RA. The questionnaire was filled in by the patients twice (ADL Tests 1 and 2) with a one-week interval between. A physiotherapist or occupational therapist also assessed each of the patients on a sample of ADL functions (ADL Test 3). Joint mobility, grip-strength, pain, Ritchie index and ESR were likewise checked. Results indicated inter-observer reliability to be high for the ADL (r(S) = 0.98), for joint mobility (r(S) = 0.86), and for the Ritchie index (r(S) = 0.83). The test-retest reliability for the ADL questionnaire which the patients filled in (Tests 1 and 2) was high r(S) = 0.91. Results of the ADL questionnaires the patients completed were found to correlate fairly closely with the observations of the therapists, r(S) = 0.71. The validity of the scoring system was found to be sufficient, using Wards cluster analysis for comparing the original HAQ scores with scores on all the questions included in the questionnaire. Thus, the translated and somewhat modified version of the ADL questionnaire studied here appears to possess a high degree of reliability and validity in assessing patients with RA.

EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases

Objective: To develop evidence-based recommendations for the management of systemic glucocorticoid (GC) therapy in rheumatic diseases. Methods: The multidisciplinary guideline development group from 11 European countries, Canada and the USA consisted of 15 rheumatologists, 1 internist, 1 rheumatologist–epidemiologist, 1 health professional, 1 patient and 1 research fellow. The Delphi method was used to agree on 10 key propositions related to the safe use of GCs. A systematic literature search of PUBMED, EMBASE, CINAHL, and Cochrane Library was then used to identify the best available research evidence to support each of the 10 propositions. The strength of recommendation was given according to research evidence, clinical expertise and perceived patient preference. Results: The 10 propositions were generated through three Delphi rounds and included patient education, risk factors, adverse effects, concomitant therapy (ie, non-steroidal anti-inflammatory drugs, gastroprotection and cyclo-oxygenase-2 selective inhibitors, calcium and vitamin D, bisphosphonates) and special safety advice (ie, adrenal insufficiency, pregnancy, growth impairment). Conclusion: Ten key recommendations for the management of systemic GC-therapy were formulated using a combination of systematically retrieved research evidence and expert consensus. There are areas of importance that have little evidence (ie, dosing and tapering strategies, timing, risk factors and monitoring for adverse effects, perioperative GC-replacement) and need further research; therefore also a research agenda was composed.

Radiographic osteoarthritis of the knee classified by the Ahlbäck and Kellgren & Lawrence systems for the tibiofemoral joint in people aged 35-54 years with chronic knee pain

OBJECTIVES To determine the prevalence of tibiofemoral radiographic knee osteoarthritis (OA) in people aged 35–54 years associated with chronic (> 3 months) knee pain using two different radiographic grading systems. METHODS Population based postal survey in a random sample of inhabitants in a district in southern Sweden followed by clinical examination and plain posteroanterior, weight bearing radiographical examination. The Ahlbäck criteria (focusing on joint space narrowing) and the Kell- gren & Lawrence classification for knee OA were used for diagnosing tibiofemoral OA. RESULTS A questionnaire was sent to 2000 randomly selected people aged 35–54 years. The response rate was 92.6%. Fifteen per cent of these people reported chronic knee pain. This group (n=279) was offered a clinical and radiographic examination of the knee joint and 204 persons agreed to participate. According to the Kellgren & Lawrence classification 28 subjects had OA of the knee grade 2 or more and 16 grade 3 or more. Radiographically detected OA of the knee according to Ahlbäck was found in 20 cases. The minimum prevalence of radiological tibiofemoral knee OA with knee pain was thus 1.5% for Kellgren & Lawrence grade 2 or more, 0.9% for grade 3 or more, and 1.1% according to the Ahlbäck classification. The agreement between the Kellgren & Lawrence grades 2–3 versus Ahlbäck grade I as well as grade 3–4 versus Ahlbäck grade I–II was good (κ 0.76 and 0.78 respectively). CONCLUSION The prevalence of radiographic tibiofemoral OA combined with chronic knee pain in people aged 35–54 years was around 1% as estimated by either the Kellgren & Lawrence or the Ahlbäck classifications systems. Prospective follow up of this cohort should elucidate the significance of knee pain as a sign of developing OA.

The prevalence of rheumatoid arthritis in Sweden.

The aim of this study was to ascertain the prevalence of rheumatoid arthritis (RA) in a Swedish general adult population. A questionnaire about chronic pain was mailed to a total of 3928 subjects who were chosen as a random sample of the population in two communities in the county of Halland. All persons answering affirmatively to questions intended to identify patients with RA were invited to a clinical examination. X-rays of hands and feet, and analyses of rheumatoid factor and C reactive protein were performed provided that the patients fulfilled two or more of the five clinical items of the 1987 ARA criteria. Furthermore, non-participants were searched for in a patient register and in medical records from the local rheumatology unit in an attempt to identify further cases. Using the modified 1987 ARA criteria for population studies the prevalence rate of RA was calculated to 0.51% (95%, CI = 0.31-0.79).

Palmoplantar pustulosis and sternocostoclavicular arthro-osteitis.

Seventeen patients with shoulder pain and radiographic involvement of the sternoclavicular or sternocostal joints, or both, are described. Eleven of these patients also had palmoplantar pustulosis. Histological examination of the joints showed chronic and subacute inflammation, increased osteoblastic activity, and cartilage degeneration. Propionibacterium acnes was cultured in tissue samples from seven of the 15 biopsied patients, a finding at variance with those of previous reports. The possibility that sternoclavicular arthro-osteitis is of infectious origin should be the subject of further investigation. Non-steroidal anti-inflammatory drugs (NSAIDs) may provide pain relief, possibly owing to their inhibitory action on osteoblasts. In cases of severely restricted movement or severe pain resection of the medial clavicle may be considered.

Dynamic versus Static Training in Patients with Rheumatoid Arthritis

Sixty-seven patients with classical or definite rheumatoid arthritis (RA) were studied concerning the effects of standardized physical training on muscle function in the lower extremities. The patients were randomly assigned to four different training groups and were given 6 weeks of training supervised by a physiotherapist at a health care centre. The groups differed according to type (dynamic or static) and extent (12 or 4 times) of training. During this training period as well as for an additional 3 months, the patients carried out programs of exercise at home (either dynamic or static). A significantly greater increase in function during the 6-week period as regards muscle strength, endurance, aerobic capacity, and functional ability was found for the dynamic as compared with the static groups. The findings at follow-up 3 months later were similar. The effectiveness of the programs did not vary with the extent of training. In conclusion, in RA patients, dynamic training gives a greater increase in physical capacity than does static training.

THE SIGNIFICANCE OF CASE MATERIAL SELECTION FOR THE SURVIVAL OF CADDIS LARVAE

SUMMARY (1) Young larvae of Potamophylax cingulatus construct their cases of leaf discs, but as the larvae grow, the material used to construct the cases changes to pieces of bark and then to mineral particles. The relative amount of secretion used for the construction of the leaf cases was low compared to that used for cases of older larvae. As the larvae grew and the cases changed, there was an increase in the pressure which the cases could withstand before collapsing. (2) Larvae with leaf cases were more often taken by trout when they were on a sandy bottom than when they were on a leaf bottom, while the predation on larvae with mineral cases was the same, irrespective of bottom type. Larvae inhabiting natural leaf cases were more vulnerable to trout predation when the portions of the cases extending beyond the tube inhabited by the larvae were cut off. Larvae with mineral cases suffered a much lower predation than did those with leaf cases. (3) Information from South Sweden and North America supported the hypotheses that: (a) most summer species make mineral cases whilst autumn species preferably construct organic cases; (b) the final larval length of mineral case makers is small compared to that of organic case makers, and (c) the tendency to use case enlargement is most pronounced among the organic case makers. These adaptations could all be related to the selection pressure by predation.

Influence of gender on assessments of disease activity and function in early rheumatoid arthritis in relation to radiographic joint damage

Objective: To evaluate gender differences in score on 28-joint Disease Activity Score (DAS28), Health Assessment Questionnaire (HAQ) and Signals Of Functional Impairment (SOFI) and to relate these scores to radiographic joint destruction. Methods: In all, 549 patients with early RA (62% women) from the BARFOT (for “Better Anti-Rheumatic FarmacOTherapy”) study were included. At baseline, 1, 2 and 5 years DAS28, HAQ and SOFI scoring, and radiographs of hands and feet were performed. The radiographs were scored using the van der Heijde–Sharp score. Results: In women the DAS28 was significantly higher than in men due to higher scores for general health and tender joints. Likewise, HAQ and VAS pain were rated significantly higher in women. The SOFI score was worse in men during the first 2 years, depending on higher upper limb scores. Total Sharp score (TotSharp), erosion score and joint space narrowing score did not differ between the sexes at any time point. The DAS28 area under the curve (AUC) correlated significantly with TotSharp at 5 years in both genders (r = 0.316, r = 0.313) mainly owing to swollen joints and erythrocyte sedimentation rate (ESR). The SOFI AUC correlated significantly with TotSharp in women (r = 0.135 to 0.220) but not in men. Conclusions: Despite a similar degree of radiographic joint destruction women had, compared with men, worse scores for DAS28 and HAQ, possibly due to higher pain perception and less muscular strength and perhaps because men overestimate their functional capacity.

Remission achieved after 2 years treatment with low-dose prednisolone in addition to disease-modifying anti-rheumatic drugs in early rheumatoid arthritis is associated with reduced joint destruction still present after 4 years: an open 2-year continuation study

Objective: To evaluate if remission induced by low-dose prednisolone during the first 2 years of rheumatoid arthritis (RA) in the BARFOT glucocorticoid (GC) study had a sustained effect on radiological damage for a total of 4 years. Methods: A total of 150 of 211 eligible patients with RA who had been randomised to the 7.5 mg prednisolone group (P) or no prednisolone group (NoP) in addition to the initial disease-modifying antirheumatic drugs were included. Radiographs of hands and feet were scored using the Sharp–van der Heijde scoring method. A patient was considered to be in remission if the 28-joint count disease activity score was <2.6. Results: Mean (SD) age was 53 (14) and 57 (12) years for the patients in the P and NoP groups, respectively. 64% were female, 64% rheumatoid factor positive, and disease duration at baseline was 6 months. At 2 years the proportion of patients in remission in the P and NoP groups was 55 vs 30%, p = 0.003. Longitudinal analysis showed that over the entire course of the disease, patients on prednisolone had a higher probability of being in remission. Patients in remission at 2 years, compared with those not in remission, had significantly lower total Sharp score, erosion score and joint space narrowing score at 2 and 4 years. The changes in bone mineral density during the 4 years did not differ between those in remission and those with active disease, and were similar in the two treatment groups. Conclusions: Prednisolone 7.5 mg daily in addition to disease-modifying anti-rheumatic drugs increases the rate of remission in patients with early RA, which has a beneficial and sustained effect on radiological damage.

POSTERO-ANTERIOR RADIOGRAM OF THE KNEE IN WEIGHT-BEARING AND SEMIFLEXION Comparison with MR imaging

Purpose: the purpose was four-fold: to assess the reproducibility of p.a. weight-bearing radiograms of the knee and the minimal joint-space (MJS) width measurements in these radiograms; to compare the MJS with MR-detected cartilage defects; to evaluate the location of these cartilage defects; and to estimate the relation between meniscal abnormalities and joint-space narrowing Material and Methods: Fifty-nine individuals, aged 41–58 years (mean 50), with chronic knee pain were examined by means of p.a. weight-bearing radiograms in semi-flexion with fluoroscopic guidance of the knee joint. the MJS was measured with a standard ruler. on the same day MR imaging was performed with proton-density- and T2-weighted turbo spin-echo on a 1.0 T imager. Meniscal abnormalities and cartilage defects in the tibiofemoral joint (TFJ) were noted Results and Conclusion: the p.a. view of the knee and the MJS measurements were reproducible. MJS of 3 mm is a limit in diagnosing joint-space narrowing in knees with MR-detected cartilage defects. There was a high proportion <p<0.001) of meniscal abnormality within the narrowed compartments in comparison with those that were not narrowed. A larger number of the cartilage defects (p<0.05) was found in the medial femoral condyle than in any of the other condyles of the TFJ. the defects had a dorsal location <p<0.001) as shown in the weight-bearing radiograms of the knee in semiflexion