When does rheumatoid arthritis begin and why do we need to know?
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Age of Onset↗
Biomedical subjects
M H Weisman
Publications and source records attributed to M H Weisman.
Updated consensus statement on tumour necrosis factor blocking agents for the treatment of rheumatoid arthritis (May 2000).
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Antirheumatic Agents↗
The role of generalized pain and pain behavior in tender point scores in fibromyalgia.
OBJECTIVE: To determine and assess the significance of the independent role of pain, pain behavior, depression, and weekly stress in tender point scores in objectively diagnosed fibromyalgia (FM) patients. METHODS: One hundred eleven patients with FM recruited from the community and private and university based clinics participated in a comprehensive evaluation of their pain, psychological distress, and pain behavior. Tender point assessment was carried out across 18 discrete sites according to American College of Rheumatology criteria. Pain was assessed with a composite index of 4 pain measures; psychological distress consisted of measures of stress and depression, and pain behavior was measured by an objective index derived from a 10 minute videotaped sequence in which 5 pain behaviors were recorded. RESULTS: Multiple regression analyses revealed that high pain, high pain behavior, and shorter illness duration were related independently to tender point scores. Measures of depression and weekly stress were not independently related to tender point scores. CONCLUSION: Tender point scores are related to generalized pain and pain behavior tendencies in patients with FM, and do not independently reflect generalized psychological distress.
Adult↗
High-dose versus low-dose D-penicillamine in early diffuse systemic sclerosis: analysis of a two-year, double-blind, randomized, controlled clinical trial.
OBJECTIVE: To test the hypothesis that systemic sclerosis (SSc) patients taking high-dose D-penicillamine (D-Pen) would have greater softening of skin, lower frequency of renal crisis, and better survival than patients taking low-dose D-Pen. METHODS: Seventeen centers enrolled 134 SSc patients with early (< or =18 months) diffuse cutaneous scleroderma into a 2-year, double-blind, randomized comparison of high-dose D-Pen (750-1,000 mg/day) versus low-dose D-Pen (125 mg every other day). All 134 patients were followed up for a mean+/-SD of 4.0+/-1.1 years to assess the frequencies of new-onset scleroderma renal crisis (SRC) and mortality. RESULTS: Sixty-eight patients completed 24 months of drug treatment. The course of the modified Rodnan skin thickness score in the 32 high-dose and the 36 low-dose D-Pen completers was not different at 24 months: the skin score dropped 4.8+/-10.3 (mean+/-SD) units in the high-dose group and 6.9+/-8.4 units in the low-dose group (P = 0.384 by t-test; favoring low-dose D-Pen) from 20.4+/-10.3 in the high-dose and 19.9+/-6.6 in the low-dose D-Pen group at study entry. The incidences of SRC and mortality were not different (P > 0.38 by Cox proportional hazards and by chi-square test) in the 66 high-dose patients (8 developed SRC and 8 died) compared with the 68 low-dose patients (10 developed SRC and 12 died). Of the 20 adverse event-related withdrawals, 80% occurred in the high-dose D-Pen group. CONCLUSION: The course of the skin score and the frequencies of SRC and mortality in the high-dose D-Pen group were not different from those in the low-dose D-Pen group. Eighty percent of the adverse event-related withdrawals occurred in the high-dose D-Pen patients. Although this study cannot answer the question of whether low-dose D-Pen is effective, it does suggest that there is no advantage to using D-Pen in doses higher than 125 every other day.
Adult↗
The Prosorba column for treatment of refractory rheumatoid arthritis: a randomized, double-blind, sham-controlled trial.
OBJECTIVE: To evaluate the efficacy and safety of the Prosorba column as a treatment for rheumatoid arthritis (RA) in patients with active and treatment-resistant (refractory) disease. METHODS: A sham-controlled, randomized, double-blind, multicenter trial of Prosorba versus sham apheresis was performed in patients with RA who had failed to respond to treatment with methotrexate or at least 2 other second-line drugs. Patients received 12 weekly treatments with Prosorba or sham apheresis, with efficacy evaluated 7-8 weeks after treatment ended. Patients were characterized as responders if they experienced improvement according to the American College of Rheumatology (ACR) response criteria at the efficacy time point. A data safety monitoring board (DSMB) evaluated interim analyses for the possibility of early completion of the trial. RESULTS: Patients in the trial had RA for an average of 15.5 years (range 1.7-50.6) and had failed an average of 4.2 second-line drug treatments prior to entry. After the completion of treatment of 91 randomized patients, the DSMB stopped the trial early due to successful outcomes. Of the 47 patients in the Prosorba arm, 31.9% experienced ACR-defined improvement versus 11.4% of the 44 patients in the sham-treated arm (P = 0.019 after adjustment for interim analysis). When results from 8 additional patients, who had completed blinded treatments at the time of DSMB action, were added to the analysis (n = 99), results were unchanged. The most common adverse events were a short-term flare in joint pain and swelling following treatment, a side effect that occurred in most subjects at least once in both treatment arms. Other side effects, although common, occurred equally as frequently in both treatment groups. CONCLUSION: Apheresis with the Prosorba column is an efficacious treatment for RA in patients with active disease who have failed other treatments.
Adult↗
The soluble CD40 ligand sCD154 in systemic lupus erythematosus.
We found that the plasma of patients with active systemic lupus erythematosus (SLE) could induce a human B-cell line (Ramos) to express high levels of immune accessory molecules that are commonly found on blood B cells of patients with active SLE. The ability of SLE plasma to induce such phenotypic changes could be abrogated by neutralizing antibodies specific for the CD40 ligand (CD154) but not by antibodies to TNF-alpha. Immunoprecipitation studies with anti-CD154 identified a 20-kDa protein in the plasma of SLE patients with active disease, but not in plasma of normal donors, indicating that such plasma contained soluble CD154 (sCD154). Using a quantitative ELISA method, we found that the plasma of patients with active disease had levels of sCD154 that were significantly higher than those found in plasma of normal donors. Levels of CD154 transcripts in SLE blood lymphocytes correlated with the relative concentrations of sCD154 found in SLE plasma. Furthermore, plasma levels of sCD154 correlated with the titers of anti-double-stranded DNA autoantibody and with clinical disease activity. These studies indicate that sCD154 of patients with SLE may act as a functional ligand for CD40 that is associated with SLE disease activity.
Adult↗
Clinical, serologic, and immunogenetic features of familial idiopathic inflammatory myopathy.
OBJECTIVE: To describe the clinical, serologic, and immunogenetic features of familial idiopathic inflammatory myopathy (IIM) and to compare these with the features of sporadic IIM. METHODS: Clinical signs and symptoms, autoantibodies, HLA-DRB1 and DQA1 alleles, and GM/KM phenotypes were compared among 36 affected and 28 unaffected members of 16 unrelated families in which 2 or more blood relatives developed an IIM. In addition, findings in patients with familial IIM were compared with those in 181 patients with sporadic IIM. The families included 3 pairs of monozygotic twins with juvenile dermatomyositis, 11 families with other siblings or relatives with polymyositis or dermatomyositis, and 2 families with inclusion body myositis. RESULTS: The clinical features of familial IIM were similar to those of sporadic IIM, although the frequency of myositis-specific autoantibodies was lower in familial than in sporadic IIM. DRB1*0301 was a common genetic risk factor for familial and sporadic IIM, but contributed less to the genetic risk of familial IIM (etiologic fraction 0.35 versus 0.51 in sporadic IIM). Homozygosity at the HLA-DQA1 locus was found to be a genetic risk factor unique to familial IIM (57% versus 24% of controls; odds ratio 4.2, corrected P = 0.002). CONCLUSION: These findings emphasize that 1) familial muscle weakness is not always due to inherited metabolic defects or dystrophies, but may be the result of the development of IIM in several members of the same family, and 2) multiple genetic factors are likely important in the etiology and disease expression of familial IIM, as is also the case for sporadic myositis, but DQA1 homozygosity is a distinct risk factor for familial IIM.
Adolescent↗
Early deaths with thrombolytic therapy for acute myocardial infarction in corticosteroid-dependent rheumatoid arthritis.
Intravenous thrombolytic therapy has become standard treatment for acute myocardial infarction (AMI). We describe three patients with long-standing seropositive rheumatoid arthritis (RA) on chronic corticosteroid therapy who experienced very early (1-6 h) mortality after the use of intravenous thrombolytic therapy for the treatment of AMI. All three patients likely experienced electromechanical dissociation (EMD). Their charts were evaluated in depth, and the literature was reviewed in regard to possible etiopathologic mechanisms. Within 1-6 h of apparently successful thrombolytic therapy for AMI, these three patients experienced sudden and profound bradycardia and hypotension and could not be resuscitated. The potential occurrence of EMD in all three patients raises the possibility of accelerated myocardial rupture, as EMD is one of the clinical hallmarks of this condition. As suggested by the three clustered cases, this heretofore undescribed association between sudden unexpected cardiac death and thrombolytic therapy for AMI in patients with seropositive, corticosteroid-dependent RA suggests that further study and observation are needed. This deleterious association, if verified, has important implications for the treatment of AMI in patients who have RA and are corticosteroid dependent.
Aged↗
Corticosteroids and systemic lupus erythematosus pancreatitis: a case series.
OBJECTIVE: To determine whether (1) corticosteroids cause pancreatitis in patients with systemic lupus erythematosus (SLE); (2) SLE pancreatitis occurs in the setting of a generalized SLE flare; and (3) corticosteroids can be used to treat SLE pancreatitis. METHODS: A total of 8 patients over a 10 year period with pancreatitis and SLE were identified retrospectively from a hospital database at the University of California San Diego Medical Center. RESULTS: All 8 patients received therapeutic doses of corticosteroids as part of their treatment for SLE and pancreatitis. All patients manifested both clinical and biochemical resolution of their pancreatitis with the administration of corticosteroids. No patient in our study experienced immediate complications related to corticosteroids. Only 2 of the 8 patients manifested active concurrent systemic disease related to the SLE. CONCLUSION: Corticosteroids do not cause pancreatitis in patients with SLE, and they should be administered during episodes of acute pancreatitis if clinically necessary. Pancreatitis does not tend to occur in the setting of a generalized SLE flare.
Acute Disease↗
Breast implants in patients with differentiated and undifferentiated connective tissue disease.
OBJECTIVE: To assess the frequency of breast implantation and the relationship of the implants to the onset of symptoms in patients with differentiated and undifferentiated connective tissue disease (CTD). METHODS: We evaluated an inception cohort of patients with differentiated and undifferentiated CTD and symptoms of < 12 months duration when enrolled in 1983-1987. The risk of having breast implants in those patients with early symptoms of CTD was determined in comparison with that in a non-concurrent control group. RESULTS: Only 3 of 323 women in the cohort had historical, physical, or chest radiographic evidence of breast implantation. In 1 of the 3 patients, the symptoms of CTD began before the breast implantation. The odds ratio was calculated at 1.15, with a 95% confidence interval ranging from 0.23 to 3.41. CONCLUSION: This study showed an absence of significant risk for prior breast implantation surgery in patients with well-defined or undifferentiated CTD.
Adolescent↗
Reduction in circulating dsDNA antibody titer after administration of LJP 394.
OBJECTIVE: To examine the safety and immunological effects, in patients with systemic lupus erythematosus (SLE), of LJP 394, a novel B cell toleragen designed to lower dsDNA antibodies. METHODS: Four women with stable SLE were given a 100 mg infusion of LJP 394 and were followed for 4 weeks. Routine safety variables were measured, as well as anti-dsDNA, circulating immune complexes, complement, and complement split products. RESULTS: Anti-dsDNA titers were promptly lowered. At 4 weeks postinfusion, 2 patients' titers remained below baseline and 2 returned to pretreatment levels. Transient increases in some complement split products were noted; however, no adverse clinical events occurred during or immediately after infusion. CONCLUSION: LJP 394 successfully and safely lowered anti-dsDNA in 4 patients with SLE. Immune complex formation and rapid elimination is the most likely explanation for the observed findings.
Adult↗
Severe sore throat as a presenting symptom of adult onset Still's disease: a case series and review of the literature.
We describe our experience with 3 cases and a literature review examining whether sore throat is an early manifestation of adult onset Still's disease (AOSD). From our review of 341 cases in the English literature we noted that 69% of all reported patients displayed sore throat early in the disease course. We propose that sore throat be considered an important early diagnostic manifestation of AOSD because it appears useful in identifying patients in their first month of illness.
Adolescent↗
TNF and anti-TNF treatment in rheumatoid arthritis (RA). What we know and what we still need to know.
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Animals↗
A comparison of behavioral and educational interventions for fibromyalgia.
OBJECTIVE: To compare a comprehensive behavioral intervention with an education/control condition in the treatment of patients with fibromyalgia (FM), and to explore the role of mediators of clinical improvement in both groups. METHODS: The effects of the behavioral and education/control interventions were evaluated across a 10 week treatment period and at 6 month followup on measures of pain, depression, disability, pain behaviors, and intervening variables. The behavioral intervention focused on the development of diverse pain coping skills, while the education/control condition presented information on a range of health related topic without emphasizing skill acquisition. RESULTS: Although improvement across time was found in depression, self-reported pain behaviors, observed pain behaviors, and myalgia scores, no differences in these criteria were found between the behavioral and education/control conditions. Multiple regression analyses revealed that changes in helplessness and passive coping were associated with improvement in a number of clinical outcomes. CONCLUSION: The findings illustrate the value of psychoeducational interventions in decreasing the psychological and behavioral effect of FM, and the value of reducing dysfunctional coping and helplessness in future intervention research.
Adult↗
Psychosocial factors associated with complementary treatment use in fibromyalgia.
OBJECTIVE: To examine the frequency and predictors of reported complementary treatment use in a sample of 111 subjects with fibromyalgia (FM). The perspective was adopted that complementary treatment use represents a form of medical help-seeking that may be subject to a variety of biological, social, and psychological influences. METHODS: Patients with FM were recruited from community and university based clinics and support groups throughout the greater San Diego, California, area. Patients participated in a comprehensive evaluation of their pain, psychological functioning, and disability prior to their potential involvement in a clinical trial designed to help them copy with their condition. They were also administered a rheumatological evaluation to verify their FM and a 20 item questionnaire to assess their use of complementary treatment strategies specifically for coping with FM. RESULTS: Ninety-eight percent of the sample reported the use of at least one strategy over the preceding 6 months. Exercise, bed rest, vitamins, heat treatment, and spirituality/praying were the most frequently used strategies by subjects on a daily basis. Multiple regression analysis revealed that lower age, higher pain, and higher disability were uniquely associated with higher complementary treatment use. The Pain Rating Index, a measure of the subjective severity of pain from the McGill Pain Questionnaire, proved highly significant in explaining the relationship between pain and questionnaire scores. Pain coping strategies and quality of social support did not predict complementary treatment use. CONCLUSION: The findings suggest that poor clinical status is a major predictor of complementary treatment use in FM. However, longitudinal research is recommended to clarify the relationship between clinical status and help-seeking patterns in patients with FM over time.
Adult↗
Lack of association between augmentation mammoplasty and systemic sclerosis (scleroderma).
OBJECTIVE: To examine the possible association between augmentation mammoplasty and systemic sclerosis (SSc; scleroderma). METHODS: Eight hundred thirty-seven women with a clinical diagnosis of SSc, recruited as a volunteer sample from 3 university-based, tertiary care scleroderma clinical research centers, and 2,507 race-matched local control women, recruited by the technique of random-digit-dialing and frequency-matched on age, completed a questionnaire providing data on history of augmentation mammoplasty, including possible complications of the procedure. The odds ratio (OR) and 95 percent confidence interval (95% CI) for the association of augmentation mammoplasty with SSc were estimated by multivariate logistic regression analysis with adjustment for age, race and center, and by conditional logistic regression analysis with adjustment for age. RESULTS: Eleven (1.31%) of the 837 cases reported a history of augmentation mammoplasty prior to diagnosis of SSc, compared with 31 (1.24%) of the 2,507 controls. The adjusted OR from the unmatched analysis was 1.07 (95% CI 0.53-2.13), while that from the matched analysis was 1.11 (95% CI 0.55-2.24). CONCLUSION: These results fail to demonstrate a significant association between augmentation mammoplasty and SSc, and are consistent with those reported from other epidemiologic studies.
Adult↗
Comparison of sulfasalazine and placebo in the treatment of ankylosing spondylitis. A Department of Veterans Affairs Cooperative Study.
OBJECTIVE: To determine whether sulfasalazine (SSZ) at a dosage of 2,000 mg/day is effective for the treatment of active ankylosing spondylitis (AS) that is not controlled with nonsteroidal antiinflammatory drug therapy. METHODS: Two hundred sixty-four patients with AS were recruited from 15 clinics, randomized (double-blind) to SSZ or placebo treatment, and followed up for 36 weeks. Treatment response was based on morning stiffness, back pain, and physician and patient global assessments. RESULTS: While longitudinal analysis revealed a trend favoring SSZ in the middle of treatment, no difference was seen at the end of treatment. Response rates were 38.2% for SSZ and 36.1% for placebo (P = 0.73). The Westergren erythrocyte sedimentation rate declined more with SSZ treatment than with placebo (P < 0.0001). AS patients with associated peripheral arthritis showed improvement that favored SSZ (P = 0.02). Adverse reactions were fewer than expected and were mainly due to nonspecific gastrointestinal complaints. CONCLUSION: SSZ at a dosage of 2,000 mg/day does not seem to be more effective than placebo in the treatment of AS patients with chronic, longstanding disease. SSZ is well tolerated and may be more effective than placebo in the treatment of AS patients with peripheral joint involvement. This effect is more pronounced in treatment of the peripheral arthritis in this subgroup of AS patients.
Adult↗
Comparison of sulfasalazine and placebo in the treatment of psoriatic arthritis. A Department of Veterans Affairs Cooperative Study.
OBJECTIVE: To determine whether sulfasalazine (SSZ) at a dosage of 2,000 mg/day is effective for the treatment of active psoriatic arthritis (PsA) resistant to nonsteroidal antiinflammatory drug therapy. METHODS: Two hundred twenty-one patients with PsA were recruited from 15 clinics, randomized (double-blind) to SSZ or placebo treatment, and followed up for 36 weeks. Treatment response was based on joint pain/ tenderness and swelling scores and physician and patient global assessments. RESULTS: Longitudinal analysis revealed a trend favoring SSZ treatment (P = 0.13). At the end of treatment, response rates were 57.8% for SSZ compared with 44.6% for placebo (P = 0.05). The Westergren erythrocyte sedimentation rate declined more in the PsA patients taking SSZ than in those taking placebo (P < 0.0001). Adverse reactions were fewer than expected and were mainly due to nonspecific gastrointestinal complaints, including dyspepsia, nausea, vomiting, and diarrhea. CONCLUSION: SSZ at a dosage of 2,000 mg/day is well tolerated and may be more effective than placebo in the treatment of patients with PsA.
Adult↗