Jeremy J. Kaye

Self-Report Questionnaire Scores in Rheumatoid Arthritis Compared with Traditional Physical, Radiographic, and Laboratory Measures

STUDY OBJECTIVEnTo assess whether scores on a simple self-report questionnaire to depict the clinical status of patients with rheumatoid arthritis are correlated with traditional measures of physical, radiographic, laboratory, functional, and global status.nnnDESIGNnThe self-report questionnaire was administered at the same time the following variables were assessed: American Rheumatism Association functional class, joint count, hand radiograph, erythrocyte sedimentation rate, rheumatoid factor titer, walking time, grip strength, button test, and global self-assessment.nnnSETTINGnUniversity rheumatology clinic, the rheumatology clinic of a Veterans Administration hospital, and a private rheumatology practice.nnnPATIENTSnThe study included 259 patients who met the criteria of the American Rheumatism Association for a diagnosis of definite or classic rheumatoid arthritis.nnnINTERVENTIONSnStandard rheumatologic care for patients with rheumatoid arthritis.nnnMEASUREMENTS AND MAIN RESULTSnSelf-report questionnaire scores were significantly correlated with the joint count, radiographic score, erythrocyte sedimentation rate, grip strength, button test, walking time, American Rheumatism Association functional class, and global self-assessment. Patients were categorized into five questionnaire score categories of 1.00, indicating no dysfunction, and 1.01 to 1.50, 1.51 to 2.00, 2.01 to 3.00, and 3.01 to 4.00, indicating progressive dysfunction. In these five categories, more than ten involved joints were seen in 11%, 37%, 67%, 79%, and 100% of patients, respectively, and erythrocyte sedimentation rates greater than 20 mm/h in 29%, 49%, 64%, 74%, and 85% of patients, respectively. Similar results were seen for other physical and radiographic measures. The questionnaire score was as effective in explaining other measures of clinical status as was any other available measure.nnnCONCLUSIONSnA simple self-report questionnaire provides information similar to many traditional measures in rheumatoid arthritis and appears to be an attractive, cost-effective approach to assessing and monitoring quantitatively the status of an individual patient.

Associations of HLA-DR4 with rheumatoid factor and radiographic severity in rheumatoid arthritis

Possible associations between HLA-DR4 and laboratory, radiographic, joint count, functional, and demographic measures of clinical status were analyzed in 154 white patients with rheumatoid arthritis. Overall, 65 percent of the patients were HLA-DR4 positive, similar to other series. HLA-DR4 was associated significantly with the presence of rheumatoid factor and more severe radiographic changes. HLA-DR4 was not associated with significant differences in demographic, joint count, or functional measures of clinical status. HLA-DR1 was not associated significantly with differences in the presence of rheumatoid factor, radiographic changes, or other measures of clinical status. Selective associations of HLA-DR4 with rheumatoid factor and radiographic scores were more marked in men than in women. Patients who were putatively homozygous for HLA-DR4 were all seropositive and had more severe radiographic changes than patients who were heterozygous for HLA-DR4.

Observer variation in quantitative assessment of rheumatoid arthritis part II. A simplified scoring system

A new and more comprehensive simplified scoring system to provide quantitative assessment of radiographic findings in rheumatoid arthritis was studied by six observers with different levels of expertise. Since the observers, film set, and joints scored were the same as in a prior study of a more detailed scoring method, a precise comparison of the results was made. Interobserver variation with the simplified scoring system was small; there were highly significant correlations of the total radiographic scores for all observers (R = .898-.978, P less than .001). There were highly significant correlations between scores obtained with the simplified scoring system and those obtained with the more detailed method (R = .920-.955, P less than .001). When the same joints were evaluated by the two methods, a significantly greater number of possible observations could be scored with the simplified scoring system than with the more detailed method (X2 = 131.07, P less than .001). The simplified scoring system required 2.3 times less time to use in the hands of experienced observers.

Observer variation in quantitative assessment of rheumatoid arthritis: Part I. Scoring erosions and joint space narrowing

Six observers, including two bone and joint radiologists, two general radiologists, and two senior radiology residents, compared scores to quantitate radiographic findings in the hands and wrists of patients with rheumatoid arthritis. In the scoring system used, erosions and joint-space narrowing are graded separately. This scoring system differs from other methods in that equivocal findings are not scored, while ankylosis, subluxation, and dislocation are scored, and data from postoperative joints are included. Total radiographic scores were highly significantly correlated for all observers (R = .908-.958, P less than .001), as were subtotal scores for erosions (R = .723-.931, P less than .001) and joint-space narrowing (R = 0.843-0.966, P less than .001). Analysis of proximal interphalangeal, metacarpophalangeal, and wrist-joint scores showed highly significant correlations for all observers in each location. Highly significant correlations were found among three separate readings of two bone and joint radiologists (R = .950-.961, P less than .001). This scoring system provides highly consistent and reproducible results, even in the hands of less experienced observers.

Bony ankylosis in rheumatoid arthritis: Associations with longer duration and greater severity of disease

Hand and wrist radiographs of 203 patients with rheumatoid arthritis were examined for bony ankylosis. Forty-eight patients (23.6%) showed ankylosis, including 34 with more than one joint fused. The distribution of ankylosed joints was 32.4% midcarpal, 29.5% common carpometacarpal, 15.8% radiocarpal, 15.8% proximal interphalangeal, and 6.5% metacarpophalangeal. Patients with ankylosis had significantly higher radiographic erosion, joint space narrowing, and malalignment scores than those without ankylosis (all P less than .001). Patients with ankylosis had significantly longer duration of disease (P less than .001) and physical examinations showed more limited motion and deformity (both P less than .001). More patients with ankylosis had subcutaneous nodules (P less than .05). Functional testing with grip strength and the button test revealed poorer performance in patients with ankylosis (both P less than .001). Questionnaires revealed patients with ankylosis had more difficulty with activities of daily living (P less than .001) and had more limited activity (P less than .01); physicians estimated more limited functional capacity (P less than .001). Thus, radiographic bony ankylosis was a relatively common feature of rheumatoid arthritis, and a marker of patients whose disease was clinically, radiographically, and functionally more severe.

Volar Plate Fractures

Rupture of the volar plate of the proximal interphalangeal joint, usually secondary to hyper-extension injury, may be accompanied by a radiographically evident avulsion fracture at the base of the middle phalanx. Findings were reviewed in 55 patients with 58 cases of volar plate fracture. This fracture should be specifically looked for in a patient with the typical history, since it may be the only radiographic evidence of a potentially disabling injury.

Problems with the steinbrocker staging system for radiographic assessment of the rheumatoid hand and wrist

Hand and wrist radiographs of 202 patients with rheumatoid arthritis were graded with the classical Steinbrocker Staging System, and were also assigned quantitative scores for joint space narrowing, erosion, and malalignment according to a detailed scoring method. Steinbrocker Stage scores were correlated significantly with total detailed scores (r = 0.60 to 0.66, P less than 0.001). However, the ranges of detailed total and subtotal scores among the various Steinbrocker Stage scores were broad, with considerable overlap. Practical problems in applying the Steinbrocker staging method were identified in 26.5% of the hands graded with the Steinbrocker method. Additionally, analysis of scoring data showed discrepancies between the scoring methods in 25.2% of the hands examined; one-half of these discrepancies were felt to result from the global or overall approach of the Steinbrocker method in contrast to individual joint analysis. Asymmetry in assigned stages between right and left hands was found in 15.8% of patients. The detailed scoring method, although more time-consuming, appears superior to the Steinbrocker Stage for quantitative assessment of patient radiographic status in rheumatoid arthritis.