OBJECTIVE: To review the available literature on the diagnostic and predictive value of acute-phase reactants in adult undifferentiated peripheral inflammatory arthritis (UPIA) as an evidence base for generating multinat...OBJECTIVE: To review the available literature on the diagnostic and predictive value of acute-phase reactants in adult undifferentiated peripheral inflammatory arthritis (UPIA) as an evidence base for generating multinational clinical practice recommendations in the 3e Initiative in Rheumatology. METHODS: A systematic literature search was carried out using Medline, Embase, the Cochrane Library, and abstracts presented at the 2007 and 2008 meetings of the American College of Rheumatology and European League Against Rheumatism, searching for prognostic and diagnostic markers of acute-phase reactants in adult UPIA. Articles that fulfilled predefined inclusion criteria were systematically reviewed, and the quality was appraised. Likelihood ratios (LR), sensitivity, and specificity for diagnostic and prognostic outcomes were calculated. RESULTS: A total of 18 publications out of 3699 identified references were included in the review. Only a small number of studies with significant heterogeneity, including different outcome measures and different cutoff values, were eligible for review, so pooling data was not possible. Overall, LR showed poor diagnostic and prognostic performance for most investigated acute-phase reactants. Available data showed some value for erythrocyte sedimentation rate in establishing a diagnosis in patients with undifferentiated arthritis; some prognostic and diagnostic value for C-reactive protein; some prognostic value for plasma viscosity in predicting persistence of arthritis; and some diagnostic value for sulfhydryl levels and matrix metalloproteinase-3 in establishing a diagnosis of rheumatoid arthritis. CONCLUSION: There is little published evidence concerning the diagnostic and predictive value of acute-phase reactants in patients with UPIA. Studies were heterogeneous, and "undifferentiated arthritis" was not well defined or was equivocally defined. The role of acute-phase reactants in diagnosing and predicting outcome in patients presenting with undifferentiated arthritis is limited.
OBJECTIVE: To review the diagnostic and prognostic value of history/physical examination among patients with undifferentiated peripheral inflammatory arthritis (UPIA). METHODS: We conducted a systematic review evaluating...OBJECTIVE: To review the diagnostic and prognostic value of history/physical examination among patients with undifferentiated peripheral inflammatory arthritis (UPIA). METHODS: We conducted a systematic review evaluating the association between history/physical examination features and a diagnostic or prognostic outcome. RESULTS: Nineteen publications were included. Advanced age, female sex, and morning stiffness were predictive of a diagnosis of rheumatoid arthritis (RA) from UPIA. A higher number of tender and swollen joints, small/large joint involvement in the upper/lower extremities, and symmetrical involvement were associated with progression to RA. Similar features were associated with persistent disease and erosions, while disability at baseline and extraarticular features were predictive of future disability. CONCLUSION: History/physical examination features are heterogeneously reported. Several features predict progression from UPIA to RA or a poor prognosis. Continued measurements in the UPIA population are needed to determine if these features are valid and reliable predictors of outcomes, especially as new definitions for RA and disease states emerge.
OBJECTIVE: To systematically review the differential diagnosis and minimal clinical investigation used prior to making a diagnosis of undifferentiated peripheral inflammatory arthritis (UPIA). METHODS: A systematic liter...OBJECTIVE: To systematically review the differential diagnosis and minimal clinical investigation used prior to making a diagnosis of undifferentiated peripheral inflammatory arthritis (UPIA). METHODS: A systematic literature search was performed for articles published between January 1950 and December 2008 in Medline and Embase, and for abstracts presented at the 2007 and 2008 meetings of the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR). Studies including defined cohorts of patients with UPIA were retrieved according to predefined inclusion/exclusion criteria. Selected studies were systematically reviewed and relevant data extracted. Baseline characteristics were also recorded to obtain a clinical picture of patients classified as UPIA. RESULTS: Seventy-four articles were included. Of those, 52 reported baseline characteristics. Tremendous variation existed among studies, reflecting the different inclusion/exclusion criteria used. Rheumatoid arthritis, spondyloarthropathies, osteoarthritis, crystal arthritis, connective tissue diseases, and infections were the most common diagnoses of exclusion for UPIA and made up the other subsets of patients in cohorts with mixed populations. The baseline investigation undertaken prior to diagnosis of UPIA was reported in 7 articles. History, physical examination, tender and swollen joint count, rheumatoid factor, HLA-B27, erythrocyte sedimentation rate, C-reactive protein, and radiographs of hands and feet were the only items mentioned in at least 50% of the reports. CONCLUSION: Studies of UPIA are heterogeneous. Few studies reported on the minimal clinical investigation necessary to arrive at a diagnosis of UPIA. Differential diagnosis usually consisted of the most common rheumatologic conditions but could be vast.
To date, over 2 million patients worldwide have been treated with anti-tumor necrosis factor (TNF) therapies, dramatically improving the treatment outcomes of immune-mediated inflammatory diseases (IMID). Observations fr...To date, over 2 million patients worldwide have been treated with anti-tumor necrosis factor (TNF) therapies, dramatically improving the treatment outcomes of immune-mediated inflammatory diseases (IMID). Observations from clinicians have identified some curious disconnects between clinical and radiographic outcomes, and the paradoxical occurrence of anti-TNF therapy-induced IMID such as psoriasis or reactivation of uveitis and Crohn's disease. These observations point to the need for a better understanding of the mechanisms underlying the ability of anti-TNF therapies to reduce inflammation and how this is linked to the pathogenesis of IMID.
The introduction of anti-tumor necrosis factor (TNF) therapies has dramatically improved the treatment of immune-mediated inflammatory diseases and provides treatment options for patients who do not respond to convention...The introduction of anti-tumor necrosis factor (TNF) therapies has dramatically improved the treatment of immune-mediated inflammatory diseases and provides treatment options for patients who do not respond to conventional disease-modifying antirheumatic drugs. However, the use of anti-TNF therapies still needs to be optimized. Dropoff rates, patients' lack of response, and toxicity are issues that need to be addressed to render these therapies more effective for more patients.
Tumor necrosis factor (TNF) plays a crucial role in the pathogenesis of immune-mediated inflammatory diseases (IMID). As a result, the inhibition of TNF is an important therapeutic avenue in the treatment of these pathop...Tumor necrosis factor (TNF) plays a crucial role in the pathogenesis of immune-mediated inflammatory diseases (IMID). As a result, the inhibition of TNF is an important therapeutic avenue in the treatment of these pathophysiologically diverse disease states. This section discusses TNF, its receptors, and its role in immunoregulation and inflammation, as well as the currently available anti-TNF-based therapies.
Immune-mediated inflammatory diseases (IMID) represent a diverse group of chronic conditions that share common pathways. Although the etiology of IMID has yet to be identified, it is well known that both genetic and envi...Immune-mediated inflammatory diseases (IMID) represent a diverse group of chronic conditions that share common pathways. Although the etiology of IMID has yet to be identified, it is well known that both genetic and environmental factors play an important role in the development of these disorders. Genome-wide association (GWA) studies and GW nonsynonymous single-nucleotide polymorphism (nsSNP) scans have recently led to identification of genes commonly found in several different IMID as well as those that are disease-specific. Current epidemiological, clinical, and experimental evidence has also confirmed an association between IMID and a large number of seemingly unrelated environmental factors, which include smoking, diet, drugs, geographical and social status, stress, and microbial agents. Data supporting the involvement of each of these factors in predisposing to, triggering, or modulating the course or outcome of IMID vary from strong to tenuous. The notion of shared genetic pathways creates new and powerful approaches for discovering the full spectrum and potential of susceptible genes in these potentially disabling chronic conditions. Insights relating to a specific immune pathway could provide targets for therapeutic interventions.
Immune-mediated inflammatory diseases (IMID) present a group of common and highly disabling chronic conditions that share inflammatory pathways. Several incidence and prevalence studies of IMID during the past decades ha...Immune-mediated inflammatory diseases (IMID) present a group of common and highly disabling chronic conditions that share inflammatory pathways. Several incidence and prevalence studies of IMID during the past decades have reported a considerable variation of the disease occurrence among different populations. Overall, the estimated prevalence of IMID in Western society is 5%-7%. This article provides an overview of studies of the incidence, prevalence, natural history, and comorbidities of IMID.
OBJECTIVE: Rheumatic diseases are vastly underdiagnosed and undertreated, particularly among minorities and those of low socioeconomic status. The WHO-ILAR Community Oriented Program in the Rheumatic Diseases (COPCORD) a...OBJECTIVE: Rheumatic diseases are vastly underdiagnosed and undertreated, particularly among minorities and those of low socioeconomic status. The WHO-ILAR Community Oriented Program in the Rheumatic Diseases (COPCORD) advocates screening of musculoskeletal complaints in the community. The objective of this study was to evaluate the performance of the COPCORD Core Questionnaire (CCQ) as a diagnostic tool for rheumatic diseases. METHODS: We conducted a cross-sectional study designed in parallel with a large COPCORD survey in Mexico. A subsample of 17,566 questionnaires, selected from 4 of the 5 states included in a national COPCORD survey were included in the analysis as a diagnostic test to evaluate sensitivity, specificity, receiver operating characteristics curve (ROC), and positive likelihood ratio (LR+) of the CCQ as a case-detection tool for rheumatic diagnosis and for the most frequent diagnoses identified in the survey, osteoarthritis, regional rheumatic pain syndromes, and rheumatoid arthritis (RA). Logistic regression with the questions with LR+ ≥ 1 was performed to identify the strength of association (OR) for each question. RESULTS: Pain in the last 7 days, high pain score (> 4), and previous diagnosis were the questions with highest LR+ for diagnosis, and for diagnosis of RA treatment with NSAID. The variables that contributed most to the model were pain in the last 7 days (OR 2.0, 95% CI 1.8-2.3), NSAID treatment (OR 3.3, 95% CI 3.0-3.7), a high pain score (OR 1.15, 95% CI 1.13-1.17), and having a previous diagnosis (OR 1.4, 95% CI 1.3-1.6). These 4 questions had R(2) = 0.24, p < 0.01, for detection of any rheumatic diagnosis. The single variable that explains 16% (OR 1.33, 95% CI 1.31-134) of variance was a high pain score in the last 7 days. CONCLUSION: Some variables were identified in the CCQ that could be combined in a brief version for case detection of rheumatic diseases in community surveys. The validity of this proposal has to be tested against the original version.
OBJECTIVE: Back pain (BP) is frequent in the community; its prevalence in México is 6%. Our objective was to determine the prevalence of BP in Mexican communities and determine its most important characteristics. METHODS...OBJECTIVE: Back pain (BP) is frequent in the community; its prevalence in México is 6%. Our objective was to determine the prevalence of BP in Mexican communities and determine its most important characteristics. METHODS: A cross-sectional study of individuals aged > 18 years was conducted in Mexico City and in urban communities in the state of Nuevo León. Sampling in Mexico City was based on community census and in Nuevo León, on stratified, balanced, and random sampling. Procedures included a door-to-door survey, using the Community Oriented Program for the Control of Rheumatic Diseases, to identify individuals with BP > 1 on a visual analog scale in the last 7 days. General practitioners/rheumatology fellows confirmed and characterized BP symptoms. RESULTS: In all, 8159 individuals (mean age 43.7 yrs, two-thirds female) were surveyed and 1219 had BP. The prevalence of nontraumatic BP in the last 7 days was 8.0% (95% CI 7.5-8.7). The mean age of these individuals was 42.7 years, and 61.9% were female. Thirty-seven percent had inflammatory BP [prevalence of 3.0% (95% CI 2.7-3.4)]. Compared with the state of Nuevo Léon, the characteristics and consequences of BP in Mexico City were more severe. In logistic regression analysis, living in Mexico City, having a paid job, any kind of musculoskeletal pain, high pain intensity, and obesity among other variables were associated with BP. CONCLUSION: The prevalence of nontraumatic BP in the last 7 days in urban communities in México is 8.0%. However, clinical features and consequences differed among the communities studied, suggesting a role for local factors in BP.
OBJECTIVE: To assess the prevalence of musculoskeletal (MSK) pain and rheumatic diseases in the southeastern Mexican state of Yucatán. METHODS: Using the Community Oriented Program in the Rheumatic Diseases (COPCORD) met...OBJECTIVE: To assess the prevalence of musculoskeletal (MSK) pain and rheumatic diseases in the southeastern Mexican state of Yucatán. METHODS: Using the Community Oriented Program in the Rheumatic Diseases (COPCORD) methodology, we performed a door-to-door, cross-sectional study generated through a multistage, stratified, randomized method on 3915 adult residents (age 42.7 ± 17.1 yrs; women 61.8%; urban setting 45.7%) of the Mexican state of Yucatán. We used universally accepted criteria for the diagnosis or classification of rheumatoid arthritis (RA), osteoarthritis (OA; knee and hand), fibromyalgia, systemic lupus erythematosus (SLE), gout, ankylosing spondylitis, regional rheumatic pain syndromes, and inflammatory back pain. RESULTS: Nontraumatic MSK pain in the last 7 days was present in 766 (19.6%; 95% CI 18.3-20.8) individuals. MSK pain was more prevalent in women (26.6%) versus men (12.2%; p < 0.01). Self-reported MSK disability occurred in 1.7%. Most MSK pain-related variables were consistently more prevalent in the urban setting. The prevalence of rheumatic disease was: OA 6.8% (95% CI 6.0-7.6); back pain 3.8% (95% CI 3.2-4.4); RA 2.8% (95% CI 2.2-3.3); rheumatic regional pain syndromes 2.3% (95% CI 1.9-2.8); inflammatory back pain 0.7% (95% CI 0.5-1.0); fibromyalgia 0.2% (95% CI 0.1-0.4); gout 0.1% (95% CI 0.07-0.3); and SLE 0.07% (95% CI 0.01-0.2). CONCLUSION: The prevalence of MSK pain was 19.6%. MSK pain was more prevalent in women and in the urban setting. A remarkably high prevalence of RA was found in this population, which suggests a role for geographic factors.
OBJECTIVE: To assess the prevalence of rheumatic regional pain syndromes (RRPS) in 3 geographical areas of México using the Community Oriented Program in the Rheumatic Diseases (COPCORD) screening methodology and validat...OBJECTIVE: To assess the prevalence of rheumatic regional pain syndromes (RRPS) in 3 geographical areas of México using the Community Oriented Program in the Rheumatic Diseases (COPCORD) screening methodology and validate by expert consensus on case-based definitions. METHODS: By means of an address-based sample generated through a multistage, stratified, randomized method, a cross-sectional survey was performed on adult residents (n = 12,686; age 43.6 ± 17.3 yrs; women 61.9%) of the states of Nuevo León, Yucatán, and México City. Diagnostic criteria for specific upper (Southampton group criteria) and lower limb (ad hoc expert consensus) RRPS were applied to all subjects with limb pain as detected by COPCORD questionnaire. RESULTS: The overall prevalence of RRPS was 5.0% (95% CI 4.7-5.4). The most frequent syndrome was rotator cuff tendinopathy (2.36%); followed by inferior heel pain (0.64%); lateral epicondylalgia (0.63%); medial epicondylalgia (0.52%); trigger finger (0.42%); carpal tunnel syndrome (0.36%); anserine bursitis (0.34%); de Quervain's tendinopathy (0.30%); shoulder bicipital tendinopathy (0.27%); trochanteric syndrome (0.11%); and Achilles tendinopathy (0.10%). There were anatomic regional variations in the prevalence of limb pain: Yucatán 3.1% (95% CI 2.5-3.6); Nuevo León 7.0% (95% CI 6.3-7.7); and México City 10.8% (95% CI 9.8-11.8). Similarly, the prevalence of RRPS showed marked geographical variation: Yucatán 2.3% (95% CI 1.8-2.8); Nuevo León 5.6% (95% CI 5.0-6.3); and México City 6.9% (95% CI 6.2-7.7). CONCLUSION: The overall prevalence of RRPS in México was 5.0%. Geographical variations raise the possibility that the prevalence of RRPS is influenced by socioeconomic, ethnic, or demographic factors.
OBJECTIVE: To estimate the prevalence of rheumatic diseases in rural and urban populations using the WHO-ILAR COPCORD questionnaire. METHODS: We conducted a cross-sectional home survey in subjects > 18 years of age in th...OBJECTIVE: To estimate the prevalence of rheumatic diseases in rural and urban populations using the WHO-ILAR COPCORD questionnaire. METHODS: We conducted a cross-sectional home survey in subjects > 18 years of age in the Mexican state of Nuevo Leon. Results were validated locally against physical examination in positive cases according to an operational definition by 2 rheumatologists. We used a random, balanced, and stratified sample by region of representative subjects. RESULTS: We surveyed 4713 individuals with a mean age of 43.6 years (SD 17.3); 55.9% were women and 87.1% were from urban areas. Excluding trauma, 1278 individuals (27.1%, 95% CI 25.8%-28.4%) reported musculoskeletal pain in the last 7 days; the prevalence of this variable was almost twice as frequent in women (33% vs 17% in men); 529 (11.2%) had pain associated with trauma. The global prevalence of pain was 38.3%. Mean pain score was 2.4 (SD 3.4) on a pain scale of 0-10. Most subjects classified as positive according to case definition (99%) were evaluated by a rheumatologist. Main diagnoses were osteoarthritis in 17.3% (95% CI 16.2-18.4), back pain in 9.8% (95% CI 9.0-10.7), undifferentiated arthritis in 2.4% (95% CI 2.0-2.9), rheumatoid arthritis in 0.4% (95% CI 0.2-0.6), fibromyalgia in 0.8% (95% CI 0.6-1.1), and gout in 0.3% (95% CI 0.1-0.5). CONCLUSION: This is the first regional COPCORD study in Mexico performed with a systematic sampling, showing a high prevalence of pain. COPCORD is a useful tool for the early detection of rheumatic diseases as well as for accurately referring patients to different medical care centers and to reduce underreporting of rheumatic diseases.
OBJECTIVE: To estimate the prevalence of musculoskeletal (MSK) disorders and to describe predicting variables associated with rheumatic diseases in 5 regions of México. METHODS: This was a cross-sectional, community-base...OBJECTIVE: To estimate the prevalence of musculoskeletal (MSK) disorders and to describe predicting variables associated with rheumatic diseases in 5 regions of México. METHODS: This was a cross-sectional, community-based study performed in 5 regions in México. The methodology followed the guidelines proposed by the Community Oriented Program for the Control of the Rheumatic Diseases (COPCORD). A standardized methodology was used at all sites, with trained personnel following a common protocol of interviewing adult subjects in their household. A "positive case" was defined as an individual with nontraumatic MSK pain of > 1 on a visual analog pain scale (0 to 10) during the last 7 days. All positive cases were referred to internists or rheumatologists for further clinical evaluation, diagnosis, and proper treatment. RESULTS: The study included 19,213 individuals; 11,602 (68.8%) were female, and their mean age was 42.8 (SD 17.9) years. The prevalence of MSK pain was 25.5%, but significant variations (7.1% to 43.5%) across geographical regions occurred. The prevalence of osteoarthritis was 10.5%, back pain 5.8%, rheumatic regional pain syndromes 3.8%, rheumatoid arthritis 1.6%, fibromyalgia 0.7%, and gout 0.3%. The prevalence of MSK manifestations was associated with older age and female gender. CONCLUSION: The prevalence of MSK pain in our study was 25.5%. Geographic variations in the prevalence of MSK pain and specific diagnoses suggested a role for geographic factors in the prevalence of rheumatic diseases.
This article summarizes the state of the art of rehabilitation in psoriatic arthritis (PsA). Very little evidence was available to assess the efficacy of rehabilitation. Some data were borrowed from studies on ankylosing...This article summarizes the state of the art of rehabilitation in psoriatic arthritis (PsA). Very little evidence was available to assess the efficacy of rehabilitation. Some data were borrowed from studies on ankylosing spondylitis. Covering certain aspects of the disease by the standard measure of functioning was difficult. However, rehabilitation was considered by the GRAPPA Group (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis), as part of treatment of axial PsA.
This article outlines our case-control, prospective, 6-year followup study to evaluate the frequency of clinical remission and duration of remission episodes in patients with peripheral psoriatic arthritis (PsA). All cas...This article outlines our case-control, prospective, 6-year followup study to evaluate the frequency of clinical remission and duration of remission episodes in patients with peripheral psoriatic arthritis (PsA). All case patients were consecutive new outpatients with peripheral PsA requiring second-line drugs. Controls were consecutive new outpatients with rheumatoid arthritis (RA). Modified American College of Rheumatology criteria for RA were used to assess the remission in patients with PsA. One or more episodes of remission occurred in 57/236 (24.1%) PsA patients and in 20/268 (7.5%) controls (p < 0.001). No significant difference was recorded for duration of remissions between the group receiving traditional disease modifying antirheumatic drug (DMARD) and the anti-tumor necrosis factor (TNF) group: 11 +/- 7.2 and 13.3 +/- 8.1 months, respectively (p = NS). The duration of remission after interruption of therapy was 12 +/- 2.4 months for the PsA group and 3 +/- 1.5 months for patients with RA (p < 0.001). No predictor of remission at diagnosis could be determined by multivariate analysis. Based on our findings, remission is possible in up to 24% of patients with peripheral PsA. It is significantly more frequent, but not longer, in patients receiving anti-TNF drugs compared to those treated with traditional DMARD.