Clinical assessment of the 1987 American College of Rheumatology criteria for rheumatoid arthritis.

Scand J Rheumatol. 1996;25(5):277-81

Authors: Levin RW, Park J, Ostrov B, Reginato A, Baker DG, Bomalaski JS, Borofsky M, Gardiner M, Leventhal L, Louthrenoo W, von Feldt J, Kolasinski S, Schumacher HR

The 1987 American College of Rheumatology (ACR) criteria for the classification of rheumatoid arthritis (RA) were clinically assessed. These criteria do not include findings of synovial fluid (SF) analysis and require no exclusion criteria. We have studied sequential patients with arthritis seen in four rheumatology centers in the Philadelphia area. Classifications by the ACR criteria were compared with our clinical diagnoses. Two hundred ninety eight patients were evaluated, 113 with RA and 185 with other diagnoses. Classifications as RA by the ACR criteria corresponded to our clinical diagnosis in 95% of the cases, corroborating the high sensitivity previously reported. However, we found a lower specificity (73%) than that reported (89%). False positive classifications as RA were found in 71% of patients with psoriatic arthritis, 48% of patients with SLE, and 31% of patients with gout. The specificity could be improved to 89% by excluding disorders with obvious distinguishing extraarticular features such as psoriasis or by SF findings of monosodium urate crystals. Awareness of these possible sources of confusion will further increase the teaching and epidemiologic value of these useful simplified criteria.

PMID: 8921919 [PubMed - indexed for MEDLINE]

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Systematic review of treatments for psoriatic arthritis: an evidence based approach and basis for treatment guidelines.

J Rheumatol. 2006 Jul;33(7):1417-21

Authors: Kavanaugh AF, Ritchlin CT,

Psoriatic arthritis (PsA) is a chronic systemic inflammatory disorder characterized by the association of arthritis and psoriasis. In addition to a heterogeneous and variable clinical course, PsA is complex and multifaceted and may include prominent involvement in the peripheral and axial diarthrodial joints, the skin and nails, and in periarticular structures such as entheses. A central mission of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) is to develop guidelines, based upon the best scientific evidence, for the optimal treatment of patients with PsA. We outline the specific methods and procedures used in this evidence-based, systematic review of treatments for PsA, which we hope will provide a basis for future treatment guidelines.

PMID: 16724373 [PubMed - indexed for MEDLINE]

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Guidelines of care for the management of psoriasis and psoriatic arthritis Section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: Case-based presentations and evidence-based conclusions.

J Am Acad Dermatol. 2011 Feb 7;

Authors: Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A, Koo JY, Lebwohl M, Leonardi CL, Lim HW, Van Voorhees AS, Beutner KR, Ryan C, Bhushan R

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In the first 5 parts of the AmericanAcademy of Dermatology Psoriasis Guidelines of Care, we have presented evidence supporting the use of topical treatments, phototherapy, traditional systemic agents, and biological therapies for patients with psoriasis and psoriatic arthritis. In this sixth and final section of the Psoriasis Guidelines of Care, we will present cases to illustrate how to practically use these guidelines in specific clinical scenarios. We will describe the approach to treating patients with psoriasis across the entire spectrum of this fascinating disease from mild to moderate to severe, with and without psoriatic arthritis, based on the 5 prior published guidelines. Although specific therapeutic recommendations are given for each of the cases presented, it is important that treatment be tailored to meet individual patients’ needs. In addition, we will update the prior 5 guidelines and address gaps in research and care that currently exist, while making suggestions for further studies that could be performed to help address these limitations in our knowledge base.

PMID: 21306785 [PubMed - as supplied by publisher]

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Semin Arthritis Rheum. 2009 Feb;38(4):320-35

Authors: Mease PJ

OBJECTIVES: To identify and describe measures that can be used to assess the impact of psoriatic arthritis (PsA) on patient functioning and health-related quality of life (HRQOL). METHODS: A literature search of the PubMed database to identify papers describing assessment tools for quality of life and function in rheumatic diseases. RESULTS: Many tools have been developed that can be used to assess the impact of rheumatic disease on patient functioning and HRQOL. Although several disease-specific tools have been developed for rheumatoid arthritis, ankylosing spondylitis, and psoriasis, few have been developed specifically for PsA, a condition that affects both skin and joints. However, several have been adopted from their use in other conditions and used in clinical trials, such as the Health Assessment Questionnaire and Short Form 36 and have shown good performance characteristics. The Psoriatic Arthritis Quality of Life questionnaire, a recently developed disease-specific instrument, has good internal consistency, validity, and reliability. Initiatives are underway by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis to evaluate Psoriatic Arthritis Quality of Life responsiveness to treatment in clinical trials, in addition to other projects intended to improve the assessment of quality of life and function in PsA. These efforts are influenced by “lessons learned” from assessment tools in rheumatoid arthritis, ankylosing spondylitis, and psoriasis. CONCLUSIONS: Assessing the impact of PsA and its treatment on patient function and quality of life is critical to improving patient outcomes, and therefore, valid and reliable tools that can be easily used in both clinical trials and clinical practice are being developed and refined.

PMID: 18304610 [PubMed - in process]

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Arthritis Res Ther. 2008;10(1):R17

Authors: Zeng QY, Chen R, Darmawan J, Xiao ZY, Chen SB, Wigley R, Le Chen S, Zhang NZ

INTRODUCTION: Epidemiological studies of rheumatic diseases have been conducted during the past 20 years in China. The aim of this study was to clarify prevalence rates of common rheumatic diseases in China. METHODS: Relevant reports of population-based surveys conducted from 1980 to 2006 were retrieved. Studies using the World Health Organization-International League of Associations for Rheumatology COPCORD (Community Oriented Program for Control of Rheumatic Diseases) protocol and those that did not employ this protocol but were published in recognized journals were identified and analyzed. RESULTS: Thirty-eight surveys including 241,169 adults from 25 provinces/cities were pooled for analysis. The prevalence of rheumatic complaints ranged from 11.6% to 46.4%, varying by locality, study protocol and age of the people surveyed. Prevalence of symptomatic osteoarthritis (OA) varied from 5.1% to 20.8%, with common sites of involvement being the lumbar spine, knee joint and cervical spine. Compared with rates of radiographic and symptomatic knee OA in the USA, elderly men in Beijing exhibited similar prevalence rates and elderly women exhibited a higher prevalence. The prevalence of hip OA and hand OA was much lower in Chinese than in Caucasian populations, but both kinds of OA were more common in coal miners. The prevalence of ankylosing spondylitis ranged from 0.2% to 0.54% among Han ethnic Chinese and were lower among mixed ethnic populations. The prevalence of psoriatic arthritis ranged from 0.01% to 0.1%, and that of reactive arthritis was 0.02%; undifferentiated spondyloarthropathy was identified in 0.64% to 1.2% of the individuals included in the surveys. The prevalence of rheumatoid arthritis (RA) ranged from 0.2% to 0.93%, with the highest rate being reported from a Taiwan urban area. In mainland China there were no significant differences in prevalence of RA between the northern and southern parts of China, or between different ethnic groups. The prevalence of hyperuricemia increased after the 1980s. The prevalence of gout was found to have increased in recent decades from 0.15% to 1.98%, apart from in the Taiwan aborigines, among whom the highest prevalence rate of 11.7% was recorded. The prevalence of primary Sjögren’s syndrome in Beijing was 0.77% by the Copenhagen criteria and 0.33% by the San Diego criteria. The prevalence of soft tissue rheumatism was 2.5% to 5.7%. Fibromyalgia was seldom observed in China. CONCLUSION: Rheumatic diseases are common in China. The prevalence of rheumatic complaints varied with the locality surveyed. The prevalence of OA is comparable with that in Western countries but varies in terms of joint involvement. The prevalence of ankylosing spondylitis is similar to that in Caucasians. Except in Taiwan, the prevalence of RA in China is lower than that in developed countries. The prevalence of hyperuricemia and gout increased after the 1980s, but it remains lower than that in developed countries. More studies are required to evaluate prevalence rates among minority groups in the west and northwest parts of China, and further study is needed to address fibromyalgia in China.

PMID: 18237382 [PubMed - indexed for MEDLINE]

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Arthritis Res Ther. 2008;10(1):201

Authors: Zenz R, Eferl R, Scheinecker C, Redlich K, Smolen J, Schonthaler HB, Kenner L, Tschachler E, Wagner EF

Activator protein 1 (AP-1) (Fos/Jun) is a transcriptional regulator composed of members of the Fos and Jun families of DNA binding proteins. The functions of AP-1 were initially studied in mouse development as well as in the whole organism through conventional transgenic approaches, but also by gene targeting using knockout strategies. The importance of AP-1 proteins in disease pathways including the inflammatory response became fully apparent through conditional mutagenesis in mice, in particular when employing gene inactivation in a tissue-specific and inducible fashion. Besides the well-documented roles of Fos and Jun proteins in oncogenesis, where these genes can function both as tumor promoters or tumor suppressors, AP-1 proteins are being recognized as regulators of bone and immune cells, a research area termed osteoimmunology. In the present article, we review recent data regarding the functions of AP-1 as a regulator of cytokine expression and an important modulator in inflammatory diseases such as rheumatoid arthritis, psoriasis and psoriatic arthritis. These new data provide a better molecular understanding of disease pathways and should pave the road for the discovery of new targets for therapeutic applications.

PMID: 18226189 [PubMed - indexed for MEDLINE]

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Semin Arthritis Rheum. 2008 Oct;38(2):101-9

Authors: Narváez J, Sirvent E, Narváez JA, Bas J, Gómez-Vaquero C, Reina D, Nolla JM, Valverde J

OBJECTIVE: The diagnosis of rheumatoid arthritis (RA) is sometimes difficult to establish early in the disease process, particularly in the absence of its classic hallmarks. Our aim was to compare the practical usefulness of magnetic resonance imaging (MRI) of the hand versus anticyclic citrullinated peptide (anti-CCP) antibody testing to confirm the diagnosis of clinically suspected RA in the absence of rheumatoid factor (RF) and radiographic erosions. METHODS: We prospectively included patients with early inflammatory arthritis and strong clinical suspicion of RA, in whom initial complementary tests (RF and radiographs of hands, wrists, and feet) did not provide unequivocal confirmation of the diagnosis. In all patients, anti-CCP antibodies were assessed and contrast-enhanced MRI of the most affected hand was performed according to a specifically designed protocol. The MRI criterion for the diagnosis of RA was either the presence of synovitis with bone erosions or bone marrow edema, which is currently considered to be a forerunner of erosions. RESULTS: In the 40 patients (28 women), the mean age at diagnosis was 54 +/- 6 years and the median duration of symptoms was 4 +/- 2.6 months (range 1.5 to 12). Final diagnoses at 1-year follow-up were RA in 31 patients, undifferentiated arthritis in 7 (5 self-limiting), and psoriatic arthropathy (PsA) and antisynthetase syndrome in 1 patient each. Anti-CCP antibodies were positive only in 7 patients, all of whom were finally diagnosed with RA. The prevalence of anti-CCP positivity in our series of seronegative RA patients was thus 23% (7/31); in these patients the anti-CCP antibodies had a specificity of 100% (95% CI: 71.7 to 100) and sensitivity of 23% (95% CI: 9.6 to 41.1). Use of the MRI criterion led to the correct diagnosis in 100% of patients with RA and to false-positive results (1 with PsA and 1 with antisynthetase syndrome). The MRI criterion had a specificity of 78% (95% CI: 40.0 to 97.2) and sensitivity of 100% (95% CI: 90.8 to 100) for identification of seronegative RA. CONCLUSION: Although the tests are not mutually exclusive, in our experience MRI is more helpful than anti-CCP antibody determination in confirming the diagnosis of clinically suspected early RA in patients in whom the diagnosis cannot be confirmed using conventional methods.

PMID: 18221987 [PubMed - indexed for MEDLINE]

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Ann Rheum Dis. 2008 Oct;67(10):1417-21

Authors: Pedersen OB, Svendsen AJ, Ejstrup L, Skytthe A, Junker P

OBJECTIVE: A nationwide unselected twin population to estimate the relative importance of genetic and environmental effectors in the aetiopathogenesis of psoriatic arthritis (PsA). METHODS: The study comprised three Danish nationwide twin cohorts. In 1994 and 2002 a total of 37 388 and 46 418 Danish twin individuals respectively were asked by questionnaire if they had PsA. Twins reporting PsA were invited to participate in a clinical examination. Patients were classified according to the Moll and Wright and the CASPAR (ClASsification criteria for Psoriatic ARthritis) criteria. Heritability was estimated by probandwise concordance rates and variance component analysis. RESULTS: 228 twin individuals reported PsA. Following diagnostic validation in 164 (70%), 50 probands were diagnosed with PsA according to the Moll and Wright criteria. Five of their co-twins were either dead, had emigrated, or did not participate in the twin study and nine did not respond, resulting in 36 complete pairs. A total of one of 10 monozygotic pairs and one of 26 dizygotic pairs were concordant for PsA, yielding a 6.2% difference in proportions (95% CI: -11%, 37%). Five of 10 monozygotic pairs and four of 26 dizygotic pairs were concordant for psoriatic skin disease implying a 35% difference (95% CI: 2%, 60%, p

PMID: 18218666 [PubMed - indexed for MEDLINE]

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Ann Rheum Dis. 2008 Oct;67(10):1422-6

Authors: Pedersen OB, Svendsen AJ, Ejstrup L, Skytthe A, Junker P

OBJECTIVE: To apply and compare different classification criteria on a representative nationwide sample of psoriatic arthritis (PsA) twins and to estimate the prevalence and incidence of PsA. METHODS: The study comprised three Danish nationwide twin cohorts. In 1994 37 388 Danish twin individuals and in 2002 46 418 twin individuals received a questionnaire, including questions on rheumatic diseases. Twins reporting PsA and their co-twins were classified according to the Moll and Wright and CASPAR (ClASsification criteria for Psoriatic ARthritis) criteria based on interview, clinical examination and scrutiny of medical records. RESULTS: 228 twin individuals reported PsA and 164 (72%) participated in clinical validation. By using the Moll and Wright and CASPAR criteria, 54 and 50 cases were diagnosed with PsA respectively. The positive predictive value of self-reported PsA was 31%. According to the Moll and Wright and CASPAR criteria the prevalence was 0.15% (95% CI: 0.13%, 0.22%) and 0.14% (95% CI: 0.11%, 0.19%) respectively. The annual incidence rate based on new self-reported cases in 2002 was 6/100 000 person-years (95% CI: 3/100 000 person-years, 11/100 000 person-years). CONCLUSIONS: The positive predictive value of self-reported PsA was 31%. The prevalence and incidence figures of PsA were equivalent to the previously reported occurrence in population- and hospital-based studies.

PMID: 18208866 [PubMed - indexed for MEDLINE]

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Semin Arthritis Rheum. 2008 Oct;38(2):83-100

Authors: Davis JC, Mease PJ

OBJECTIVE: The spondyloarthritides are a set of chronic inflammatory diseases that consists of 5 interrelated subsets (ankylosing spondylitis [AS], psoriatic arthritis [PsA], reactive arthritis, arthritis associated with inflammatory bowel disease, and undifferentiated spondyloarthropathy). The aim of this review was to evaluate the classification, genetic susceptibility, pathology, and response to treatment of spondyloarthritis (SpA). METHODS: Searches were conducted of the PubMed database for articles focusing on the classification, pathology, and treatment of SpA. RESULTS: The 5 subsets of SpA share many clinical, immunohistochemical, and genetic features, including the common presence of human leukocyte antigen-B27 and the absence of rheumatoid factor. Evidence suggests that the pathology of SpA is mediated by immune cells. In particular, tumor necrosis factor-alpha appears to be an important driver of inflammation and damage in SpA. A number of different SpA classification criteria have been developed, including the Modified New York Criteria for AS, the European Spondyloarthropathy Study Group criteria, the Amor criteria, as well as criteria for PsA, notably the Moll and Wright criteria and the Classification of Psoriatic Arthritis criteria. Suboptimal efficacy and adverse effects often limit the use of conventional pharmacologic treatments for SpA, including nonsteroidal antiinflammatory drugs and disease-modifying antirheumatic drugs, such as methotrexate and sulfasalazine. Recent evidence has demonstrated that targeted biologic response modifiers, such as TNF-alpha antagonists, are well tolerated and efficacious treatments for SpA. CONCLUSIONS: Significant advances have occurred in our understanding of the pathophysiology, diagnosis, and classification of the spondyloarthritides and effective treatments are available.

PMID: 18166219 [PubMed - indexed for MEDLINE]

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