Rheumatoid Arthritis

BRIGHTON, ENGLAND – Although patients with rheumatoid arthritis may be aware that regular exercise is good for them, many are afraid to be physically active for fear of damaging their joints.

Other results of an online survey show that a large percentage of patients with rheumatoid arthritis (RA) are unsure of what exercises they can or should perform, and they feel that health care professionals do not always have adequate knowledge to advise them.

"Exercise is now a very important component within the management of RA," Ms. Rebecca-Jane Law of the School of Sport, Health, and Exercise Sciences at Bangor (Wales) University said April 12, at the British Society for Rheumatology Annual Conference.

"The benefits of high-intensity exercise in RA include improvements in aerobic capacity, strength, physical function, and psychosocial well-being," she added. Ms. Law noted that the use of exercise is a far cry from when bed-rest and splinting was advised back in the 1960s (Ann. Rheum. Dis. 1963;22:91-9) and that the view that exercise might detrimentally affect disease activity or cause exacerbation had been refuted.

However, despite the known benefits of exercise in RA – which might also potentially include improvement of cardiovascular health and prevention of muscle wasting and osteoporosis – RA patients tend to be less active than is the general population. To determine why this might be, Ms. Law and her associates developed an online questionnaire to survey the perceptions of patients towards exercise.

The 32-item questionnaire was based on previous research involving 18 patients with RA who participated in four focus groups. The discussions focused on two main areas: the effects of exercise on the joints and what affected whether people exercised or not. (Rheumatology 2010;49:2444-51).

A total of 247 patients with RA participated in the subsequent online survey. The mean age of the study cohort was 52 years, the mean disease duration was 9 years, and 88% were female. Physical activity was categorized as being low, medium, or high, with 24.5%, 36.9%, and 38.6% of patients, respectively falling into each of these categories.

Noting that only one-quarter of respondents were classed as having low physical activity, which is perhaps encouraging, Ms. Law commented that all the respondents were members of the U.K. National Rheumatoid Arthritis Society (NRAS), so may have been more proactive in the management of their disease than perhaps others with RA were.

Results showed the validity of the questionnaire and that it could be useful in examining patient perceptions in relation to exercise and joint health.

Most respondents (72%) felt that exercise was helpful for RA, although 44% were worried about causing harm to their joints and 52% saying they did not want to exercise because their joints hurt when they did so.

Under half (42%) said they knew what exercises to do and only 19% felt that health care professionals exhibited the knowledge necessary to advise on exercise.

Multiple guidelines – issued independently by the National Institute for Health and Clinical Excellence, the British Society for Rheumatology and the British Health Professionals in Rheumatology, the American College of Sports Medicine, and the European League Against Rheumatism – recommend that aerobic strengthening and mobility exercises be incorporated into patient care.

However, as these results suggest, not all health care professionals are perhaps familiar with this guidance. Or, if they are, they are not able to demonstrate to patients that they know what exercises should be performed, when, how often, and for how long.

Examining health care professional perceptions toward exercise in RA is a future avenue of research, Ms. Law suggested, as is clarifying exercise recommendations to help patients. The ACSM FITT principle, which covers the frequency, intensity, timing and, type of exercise, might be a useful starting point.

Ms. Law declared she had no conflicts of interest.

BRIGHTON, ENGLAND – Although patients with rheumatoid arthritis may be aware that regular exercise is good for them, many are afraid to be physically active for fear of damaging their joints.

Other results of an online survey show that a large percentage of patients with rheumatoid arthritis (RA) are unsure of what exercises they can or should perform, and they feel that health care professionals do not always have adequate knowledge to advise them.

"Exercise is now a very important component within the management of RA," Ms. Rebecca-Jane Law of the School of Sport, Health, and Exercise Sciences at Bangor (Wales) University said April 12, at the British Society for Rheumatology Annual Conference.

"The benefits of high-intensity exercise in RA include improvements in aerobic capacity, strength, physical function, and psychosocial well-being," she added. Ms. Law noted that the use of exercise is a far cry from when bed-rest and splinting was advised back in the 1960s (Ann. Rheum. Dis. 1963;22:91-9) and that the view that exercise might detrimentally affect disease activity or cause exacerbation had been refuted.

However, despite the known benefits of exercise in RA – which might also potentially include improvement of cardiovascular health and prevention of muscle wasting and osteoporosis – RA patients tend to be less active than is the general population. To determine why this might be, Ms. Law and her associates developed an online questionnaire to survey the perceptions of patients towards exercise.

The 32-item questionnaire was based on previous research involving 18 patients with RA who participated in four focus groups. The discussions focused on two main areas: the effects of exercise on the joints and what affected whether people exercised or not. (Rheumatology 2010;49:2444-51).

A total of 247 patients with RA participated in the subsequent online survey. The mean age of the study cohort was 52 years, the mean disease duration was 9 years, and 88% were female. Physical activity was categorized as being low, medium, or high, with 24.5%, 36.9%, and 38.6% of patients, respectively falling into each of these categories.

Noting that only one-quarter of respondents were classed as having low physical activity, which is perhaps encouraging, Ms. Law commented that all the respondents were members of the U.K. National Rheumatoid Arthritis Society (NRAS), so may have been more proactive in the management of their disease than perhaps others with RA were.

Results showed the validity of the questionnaire and that it could be useful in examining patient perceptions in relation to exercise and joint health.

Most respondents (72%) felt that exercise was helpful for RA, although 44% were worried about causing harm to their joints and 52% saying they did not want to exercise because their joints hurt when they did so.

Under half (42%) said they knew what exercises to do and only 19% felt that health care professionals exhibited the knowledge necessary to advise on exercise.

Multiple guidelines – issued independently by the National Institute for Health and Clinical Excellence, the British Society for Rheumatology and the British Health Professionals in Rheumatology, the American College of Sports Medicine, and the European League Against Rheumatism – recommend that aerobic strengthening and mobility exercises be incorporated into patient care.

However, as these results suggest, not all health care professionals are perhaps familiar with this guidance. Or, if they are, they are not able to demonstrate to patients that they know what exercises should be performed, when, how often, and for how long.

Examining health care professional perceptions toward exercise in RA is a future avenue of research, Ms. Law suggested, as is clarifying exercise recommendations to help patients. The ACSM FITT principle, which covers the frequency, intensity, timing and, type of exercise, might be a useful starting point.

Ms. Law declared she had no conflicts of interest.

BRIGHTON, ENGLAND – Although patients with rheumatoid arthritis may be aware that regular exercise is good for them, many are afraid to be physically active for fear of damaging their joints.

Other results of an online survey show that a large percentage of patients with rheumatoid arthritis (RA) are unsure of what exercises they can or should perform, and they feel that health care professionals do not always have adequate knowledge to advise them.

"Exercise is now a very important component within the management of RA," Ms. Rebecca-Jane Law of the School of Sport, Health, and Exercise Sciences at Bangor (Wales) University said April 12, at the British Society for Rheumatology Annual Conference.

"The benefits of high-intensity exercise in RA include improvements in aerobic capacity, strength, physical function, and psychosocial well-being," she added. Ms. Law noted that the use of exercise is a far cry from when bed-rest and splinting was advised back in the 1960s (Ann. Rheum. Dis. 1963;22:91-9) and that the view that exercise might detrimentally affect disease activity or cause exacerbation had been refuted.

However, despite the known benefits of exercise in RA – which might also potentially include improvement of cardiovascular health and prevention of muscle wasting and osteoporosis – RA patients tend to be less active than is the general population. To determine why this might be, Ms. Law and her associates developed an online questionnaire to survey the perceptions of patients towards exercise.

The 32-item questionnaire was based on previous research involving 18 patients with RA who participated in four focus groups. The discussions focused on two main areas: the effects of exercise on the joints and what affected whether people exercised or not. (Rheumatology 2010;49:2444-51).

A total of 247 patients with RA participated in the subsequent online survey. The mean age of the study cohort was 52 years, the mean disease duration was 9 years, and 88% were female. Physical activity was categorized as being low, medium, or high, with 24.5%, 36.9%, and 38.6% of patients, respectively falling into each of these categories.

Noting that only one-quarter of respondents were classed as having low physical activity, which is perhaps encouraging, Ms. Law commented that all the respondents were members of the U.K. National Rheumatoid Arthritis Society (NRAS), so may have been more proactive in the management of their disease than perhaps others with RA were.

Results showed the validity of the questionnaire and that it could be useful in examining patient perceptions in relation to exercise and joint health.

Most respondents (72%) felt that exercise was helpful for RA, although 44% were worried about causing harm to their joints and 52% saying they did not want to exercise because their joints hurt when they did so.

Under half (42%) said they knew what exercises to do and only 19% felt that health care professionals exhibited the knowledge necessary to advise on exercise.

Multiple guidelines – issued independently by the National Institute for Health and Clinical Excellence, the British Society for Rheumatology and the British Health Professionals in Rheumatology, the American College of Sports Medicine, and the European League Against Rheumatism – recommend that aerobic strengthening and mobility exercises be incorporated into patient care.

However, as these results suggest, not all health care professionals are perhaps familiar with this guidance. Or, if they are, they are not able to demonstrate to patients that they know what exercises should be performed, when, how often, and for how long.

Examining health care professional perceptions toward exercise in RA is a future avenue of research, Ms. Law suggested, as is clarifying exercise recommendations to help patients. The ACSM FITT principle, which covers the frequency, intensity, timing and, type of exercise, might be a useful starting point.

Ms. Law declared she had no conflicts of interest.

Increasing disease activity in rheumatoid arthritis is associated with a higher risk for both outpatient infections and more serious infections requiring hospitalization in patients receiving stable therapy.

Moreover, this finding was true even among patients with mild disease activity, according to Dr. Karen Au of the division of rheumatology at the University of California, Los Angeles.

In a study published in the May issue of Annals of the Rheumatic Diseases, Dr. Au and her colleagues looked at 6,246 patients with RA who were listed on the CORRONA (Consortium of Rheumatology Researchers of North America) registry, which includes data contributed by 80 academic and private practices across the United States.

The patients’ mean age was 60 years; 75% were women. CDAI (Clinical Disease Activity Index) scores were available for 6,020 patients. DAS28 (disease activity score based on a 28-joint count) was calculated throughout the study period for 3,666 patients (Ann. Rheum. Dis. 2011;70:785-91).

"To minimize confounding related to recent changes in disease-modifying medications on the rate of infections, we limited the study to RA patients on stable therapy" (defined as no change in the dose of either methotrexate, TNF (tumor necrosis factor) inhibitor, corticosteroid, or any other disease-modifying anti-rheumatic drug over three consecutive visits spanning at least 6 months), according to the researchers.

Overall, 2,282 infections were reported during the study period, from March 2002 to December 2007; 1,382 patients had one or more outpatient infections and 50 patients had serious infections that required hospitalization.

Most of the infections tallied (2,223 of the total 2,282) were of an outpatient nature.

When outpatient infections alone were considered, researchers found that for all patients with CDAI scores less than 10 of a possible 76 (corresponding to the mildest class of disease), there was a 14% increase in outpatient infections for each 5-point increase in score, after the researchers controlled for covariates including body mass index, smoking, disease duration, therapy, and coexisting cardiovascular disease (incidence rate ratio, 1.14; P = .003).

And although no further linear relationship was noted, patients with moderate (CDAI scores of 10-22) and high (CDAI scores greater than 22) disease activity had increased infections, compared with patients with mild disease activity, although only the moderate category was statistically significant (IRR for moderate activity, compared with low activity, 1.19; 95% confidence interval, 1.06-1.34; IRR for high activity, 1.07; 95% CI 0.90-1.27).

Among patients for whom DAS28 data were available, there was a 4% increase in outpatient infections for each 0.6-point increase in the score, which persisted throughout the entire DAS28 spectrum (IRR, 1.04; P = .03).

A history of infections increased the likelihood of having an outpatient infection (IRR, 2.84-3.15; P less than .001), as did use of methotrexate, use of TNF inhibitors, and poorer functional class.

Although infections requiring hospitalization were much less frequent among the study participants, the authors were able to identify that for every 0.6-point increase in the DAS28, there was a corresponding significant 25% increase in the rate of infections that required hospitalization.

On the CDAI scale, there was no significant trend between an increasing score and inpatient infections on multivariate analysis, likely because of the small number of inpatient infections observed, according to the authors.

Prednisone use of 7.5 mg daily or more was also independently associated with infections that required hospitalization, as was a history of infection, they noted.

Previous studies have shown that RA patients have a twofold increased risk of developing infections, compared with patients who do not have RA, and they are also at higher risk of serious infections requiring hospitalization, the researchers said.

Indeed, they added, the "continued increased mortality observed in RA patients compared with the general population can be explained partly by a higher susceptibility to infections."

However, until now, the "independent contribution of RA disease activity and associated systemic inflammation is unclear."

The strength of this study, they pointed out, lies in the size and quality of the prospectively collected clinical data in the CORRONA database.

Several of the authors reported contracts and professional affiliations with the CORRONA database. Several also reported financial relationships with multiple pharmaceutical companies, including Amgen, Centocor, Pfizer, Roche/Genentech, and UCB.

Increasing disease activity in rheumatoid arthritis is associated with a higher risk for both outpatient infections and more serious infections requiring hospitalization in patients receiving stable therapy.

Moreover, this finding was true even among patients with mild disease activity, according to Dr. Karen Au of the division of rheumatology at the University of California, Los Angeles.

In a study published in the May issue of Annals of the Rheumatic Diseases, Dr. Au and her colleagues looked at 6,246 patients with RA who were listed on the CORRONA (Consortium of Rheumatology Researchers of North America) registry, which includes data contributed by 80 academic and private practices across the United States.

The patients’ mean age was 60 years; 75% were women. CDAI (Clinical Disease Activity Index) scores were available for 6,020 patients. DAS28 (disease activity score based on a 28-joint count) was calculated throughout the study period for 3,666 patients (Ann. Rheum. Dis. 2011;70:785-91).

"To minimize confounding related to recent changes in disease-modifying medications on the rate of infections, we limited the study to RA patients on stable therapy" (defined as no change in the dose of either methotrexate, TNF (tumor necrosis factor) inhibitor, corticosteroid, or any other disease-modifying anti-rheumatic drug over three consecutive visits spanning at least 6 months), according to the researchers.

Overall, 2,282 infections were reported during the study period, from March 2002 to December 2007; 1,382 patients had one or more outpatient infections and 50 patients had serious infections that required hospitalization.

Most of the infections tallied (2,223 of the total 2,282) were of an outpatient nature.

When outpatient infections alone were considered, researchers found that for all patients with CDAI scores less than 10 of a possible 76 (corresponding to the mildest class of disease), there was a 14% increase in outpatient infections for each 5-point increase in score, after the researchers controlled for covariates including body mass index, smoking, disease duration, therapy, and coexisting cardiovascular disease (incidence rate ratio, 1.14; P = .003).

And although no further linear relationship was noted, patients with moderate (CDAI scores of 10-22) and high (CDAI scores greater than 22) disease activity had increased infections, compared with patients with mild disease activity, although only the moderate category was statistically significant (IRR for moderate activity, compared with low activity, 1.19; 95% confidence interval, 1.06-1.34; IRR for high activity, 1.07; 95% CI 0.90-1.27).

Among patients for whom DAS28 data were available, there was a 4% increase in outpatient infections for each 0.6-point increase in the score, which persisted throughout the entire DAS28 spectrum (IRR, 1.04; P = .03).

A history of infections increased the likelihood of having an outpatient infection (IRR, 2.84-3.15; P less than .001), as did use of methotrexate, use of TNF inhibitors, and poorer functional class.

Although infections requiring hospitalization were much less frequent among the study participants, the authors were able to identify that for every 0.6-point increase in the DAS28, there was a corresponding significant 25% increase in the rate of infections that required hospitalization.

On the CDAI scale, there was no significant trend between an increasing score and inpatient infections on multivariate analysis, likely because of the small number of inpatient infections observed, according to the authors.

Prednisone use of 7.5 mg daily or more was also independently associated with infections that required hospitalization, as was a history of infection, they noted.

Previous studies have shown that RA patients have a twofold increased risk of developing infections, compared with patients who do not have RA, and they are also at higher risk of serious infections requiring hospitalization, the researchers said.

Indeed, they added, the "continued increased mortality observed in RA patients compared with the general population can be explained partly by a higher susceptibility to infections."

However, until now, the "independent contribution of RA disease activity and associated systemic inflammation is unclear."

The strength of this study, they pointed out, lies in the size and quality of the prospectively collected clinical data in the CORRONA database.

Several of the authors reported contracts and professional affiliations with the CORRONA database. Several also reported financial relationships with multiple pharmaceutical companies, including Amgen, Centocor, Pfizer, Roche/Genentech, and UCB.

Increasing disease activity in rheumatoid arthritis is associated with a higher risk for both outpatient infections and more serious infections requiring hospitalization in patients receiving stable therapy.

Moreover, this finding was true even among patients with mild disease activity, according to Dr. Karen Au of the division of rheumatology at the University of California, Los Angeles.

In a study published in the May issue of Annals of the Rheumatic Diseases, Dr. Au and her colleagues looked at 6,246 patients with RA who were listed on the CORRONA (Consortium of Rheumatology Researchers of North America) registry, which includes data contributed by 80 academic and private practices across the United States.

The patients’ mean age was 60 years; 75% were women. CDAI (Clinical Disease Activity Index) scores were available for 6,020 patients. DAS28 (disease activity score based on a 28-joint count) was calculated throughout the study period for 3,666 patients (Ann. Rheum. Dis. 2011;70:785-91).

"To minimize confounding related to recent changes in disease-modifying medications on the rate of infections, we limited the study to RA patients on stable therapy" (defined as no change in the dose of either methotrexate, TNF (tumor necrosis factor) inhibitor, corticosteroid, or any other disease-modifying anti-rheumatic drug over three consecutive visits spanning at least 6 months), according to the researchers.

Overall, 2,282 infections were reported during the study period, from March 2002 to December 2007; 1,382 patients had one or more outpatient infections and 50 patients had serious infections that required hospitalization.

Most of the infections tallied (2,223 of the total 2,282) were of an outpatient nature.

When outpatient infections alone were considered, researchers found that for all patients with CDAI scores less than 10 of a possible 76 (corresponding to the mildest class of disease), there was a 14% increase in outpatient infections for each 5-point increase in score, after the researchers controlled for covariates including body mass index, smoking, disease duration, therapy, and coexisting cardiovascular disease (incidence rate ratio, 1.14; P = .003).

And although no further linear relationship was noted, patients with moderate (CDAI scores of 10-22) and high (CDAI scores greater than 22) disease activity had increased infections, compared with patients with mild disease activity, although only the moderate category was statistically significant (IRR for moderate activity, compared with low activity, 1.19; 95% confidence interval, 1.06-1.34; IRR for high activity, 1.07; 95% CI 0.90-1.27).

Among patients for whom DAS28 data were available, there was a 4% increase in outpatient infections for each 0.6-point increase in the score, which persisted throughout the entire DAS28 spectrum (IRR, 1.04; P = .03).

A history of infections increased the likelihood of having an outpatient infection (IRR, 2.84-3.15; P less than .001), as did use of methotrexate, use of TNF inhibitors, and poorer functional class.

Although infections requiring hospitalization were much less frequent among the study participants, the authors were able to identify that for every 0.6-point increase in the DAS28, there was a corresponding significant 25% increase in the rate of infections that required hospitalization.

On the CDAI scale, there was no significant trend between an increasing score and inpatient infections on multivariate analysis, likely because of the small number of inpatient infections observed, according to the authors.

Prednisone use of 7.5 mg daily or more was also independently associated with infections that required hospitalization, as was a history of infection, they noted.

Previous studies have shown that RA patients have a twofold increased risk of developing infections, compared with patients who do not have RA, and they are also at higher risk of serious infections requiring hospitalization, the researchers said.

Indeed, they added, the "continued increased mortality observed in RA patients compared with the general population can be explained partly by a higher susceptibility to infections."

However, until now, the "independent contribution of RA disease activity and associated systemic inflammation is unclear."

The strength of this study, they pointed out, lies in the size and quality of the prospectively collected clinical data in the CORRONA database.

Several of the authors reported contracts and professional affiliations with the CORRONA database. Several also reported financial relationships with multiple pharmaceutical companies, including Amgen, Centocor, Pfizer, Roche/Genentech, and UCB.

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

BRIGHTON, ENGLAND – The risk of cancer is almost 50% higher in people with rheumatoid arthritis who are treated with nonbiologic agents when compared to the general population, according to data just released from the British Society for Rheumatology Biologics Register.

Although the link between rheumatoid arthritis (RA) and malignancy has been previously identified – particularly with respect to a higher risk of non-Hodgkin’s lymphoma (NHL) – these new data from the British Society for Rheumatology Biologics Register (BSRBR) are from a more-contemporary population of patients who have been treated in the era of widespread use of methotrexate (MTX) and other nonbiologic disease-modifying antirheumatic drugs (DMARDs).

Dr. Eric L. Matteson, who is a professor of medicine at the division of rheumatology at the Mayo Clinic, Rochester, Minn., noted in an interview that the registry findings seem to indicate that overall cancer risk is increased in patients with RA and that this risk is similar in patients exposed to biologics and nonbiologics, with the exception that nonmelanoma skin cancer appears to be somewhat more frequent in the biologics treated patients.

"I think the conclusions arrived at are consistent with previous studies and so not surprising regarding nonbiologics, in particular, methotrexate. A study from Australia by Dr. Rachelle Buchbinder, for example, already reported in 2008 an almost identical finding of 50% increased risk of cancer in patients with RA treated with methotrexate."

There was an estimated 50% excess risk of malignancy among RA patients exposed to MTX relative to the general population (standardized incidence ratio, 1.5; 95% confidence interval, 1.2-1.9). In that study, the risk of non-Hodgkin’s lymphoma was more than five times higher in RA patients than in the general population (SIR, 5.1; 95% CI 2.2-10.0). Other cancers for which there was evidence of increased risk were lung cancer (SIR, 2.9; 95% CI 1.6-4.8) and melanoma (SIR, 3.0; 95% CI 1.2-6.2). (Arthritis Care Res. 2008;59:794-9).

Dr. Matteson qualified his remarks by noting that he did not hear the presentation and assumes methotrexate was the comparator drug.

In reporting the findings, Dr. Louise Mercer, a clinical research fellow at the Arthritis Research UK Epidemiology Unit, University of Manchester, England, where the BRSBR is coordinated, on April 13 at the British Society for Rheumatology Annual Conference (Rheumatology 2011;50:iii37-8, abstract OP18) noted that they set a baseline for analyzing the cancer risk of biologic therapy, compared with conventional RA therapy within the BSRBR patient population – the primary reason the register was set up 10 years ago.

The analysis included 3,727 RA patients treated with nonbiologic DMARDS who were enrolled in the register between 2002 and 2008. Data from the national cancer registry for England and Wales provided information about whether or not they developed cancer. SIRs were used to compare the observed vs. the expected number of cancers and were adjusted for age and gender.

Of 148 malignancies occurring in 10,447 patient-years, 128 were solid cancers – including melanoma, and lung, breast, and colorectal cancers – and 20 were hematologic – including NHL and Hodgkin’s lymphoma. The median time from enrollment in the register to cancer diagnosis was 1.3 years, with 52% of patients dying as a result of incident cancer.

The standardized incidence ratio for all cancers was 1.48. Looking at specific types of malignancy, the highest SIR was recorded for NHL, at 3.73, although the risk of lung cancer was also substantial, with a SIR of 2.71. The SIR for colorectal cancer was 0.96.

Considering these findings, "vigilance for cancer, especially lung cancer and lymphoma should be maintained," Dr. Mercer advised.

"Our experience is that all cancers were increased by about 48%, with quite a marked increase in NHL and lung cancer, said Dr. Deborah Symmons, during a separate presentation at the meeting. An interesting finding, she noted, was that any benefit of NSAID drugs used to treat RA in lowering the risk of colorectal cancer appeared to be "wearing off."

Dr. Symmons, also of the Arthritis Research UK Epidemiology Unit in Manchester and a principle investigator for the BSRBR, explained that this adds to the evidence that, "the cancer risk in our general rheumatoid population is increased for some cancers."

These data are of interest, as they will eventually be used to compare the cancer risk of biologic vs. nonbiologic DMARDs. Such analysis is unlikely to be undertaken any time soon, however, as it is planned to occur when 20,000 years of patient follow-up have been accumulated. To date, there has been no signal that an earlier analysis is warranted.

"In the [anti-TNF] clinical trials, most of which were less than a year [in duration] there was not an increase in cancer except for [nonmelanoma skin cancer]," Dr. Symmons observed. "The cancer risk in observational studies is not increased in the short term," she added, "but we still don’t know what the long-term risk might be."

Echoing her comments were the separate findings of a Wyeth-sponsored study presented as a poster at the meeting. Dr. Peter Taylor of the Kennedy Institute of Rheumatology in London and his associates looked at the risk of malignancy associated with TNF inhibitors in registries and prospective observational studies. They reported a pooled-risk estimate of 1.11 for lymphoma, 1.45 for nonmelanoma skin cancer, and 1.79 for melanoma comparing TNF-treated patients with nonexposed RA patients.

Dr. Taylor and his team said of their findings: "This systematic review and meta-analysis provide reassurance to physicians and patients that treatment of RA patients with TNF inhibitors does not increase the risk of malignancy in general, or of lymphoma in particular, but does appear to increase the risk of skin cancer, including melanoma."

The systemic review and meta-analysis was sponsored by Wyeth. Dr. Taylor has received research grants and honoraria from Abbott, Bristol-Myers Squibb, Pfizer, Roche, Schering-Plough, and UCB. The BSRBR is funded by a grant from the British Society for Rheumatology. The BSR receives funding from Abbott Laboratories, Biovitrum/SOBI, Merck Sharp & Dohme Ltd., Pfizer, Roche, and UCB. This income finances a separate contract between the BSR and the University of Manchester that provides and run the BSRBR. All decisions concerning data analysis, interpretation and publications are made autonomously of any industrial contribution.

Dr. Mercer, Dr. Symmons, and Dr. Matteson declared that they had no personal conflicts of interest.

BRIGHTON, ENGLAND – The risk of cancer is almost 50% higher in people with rheumatoid arthritis who are treated with nonbiologic agents when compared to the general population, according to data just released from the British Society for Rheumatology Biologics Register.

Although the link between rheumatoid arthritis (RA) and malignancy has been previously identified – particularly with respect to a higher risk of non-Hodgkin’s lymphoma (NHL) – these new data from the British Society for Rheumatology Biologics Register (BSRBR) are from a more-contemporary population of patients who have been treated in the era of widespread use of methotrexate (MTX) and other nonbiologic disease-modifying antirheumatic drugs (DMARDs).

Dr. Eric L. Matteson, who is a professor of medicine at the division of rheumatology at the Mayo Clinic, Rochester, Minn., noted in an interview that the registry findings seem to indicate that overall cancer risk is increased in patients with RA and that this risk is similar in patients exposed to biologics and nonbiologics, with the exception that nonmelanoma skin cancer appears to be somewhat more frequent in the biologics treated patients.

"I think the conclusions arrived at are consistent with previous studies and so not surprising regarding nonbiologics, in particular, methotrexate. A study from Australia by Dr. Rachelle Buchbinder, for example, already reported in 2008 an almost identical finding of 50% increased risk of cancer in patients with RA treated with methotrexate."

There was an estimated 50% excess risk of malignancy among RA patients exposed to MTX relative to the general population (standardized incidence ratio, 1.5; 95% confidence interval, 1.2-1.9). In that study, the risk of non-Hodgkin’s lymphoma was more than five times higher in RA patients than in the general population (SIR, 5.1; 95% CI 2.2-10.0). Other cancers for which there was evidence of increased risk were lung cancer (SIR, 2.9; 95% CI 1.6-4.8) and melanoma (SIR, 3.0; 95% CI 1.2-6.2). (Arthritis Care Res. 2008;59:794-9).

Dr. Matteson qualified his remarks by noting that he did not hear the presentation and assumes methotrexate was the comparator drug.

In reporting the findings, Dr. Louise Mercer, a clinical research fellow at the Arthritis Research UK Epidemiology Unit, University of Manchester, England, where the BRSBR is coordinated, on April 13 at the British Society for Rheumatology Annual Conference (Rheumatology 2011;50:iii37-8, abstract OP18) noted that they set a baseline for analyzing the cancer risk of biologic therapy, compared with conventional RA therapy within the BSRBR patient population – the primary reason the register was set up 10 years ago.

The analysis included 3,727 RA patients treated with nonbiologic DMARDS who were enrolled in the register between 2002 and 2008. Data from the national cancer registry for England and Wales provided information about whether or not they developed cancer. SIRs were used to compare the observed vs. the expected number of cancers and were adjusted for age and gender.

Of 148 malignancies occurring in 10,447 patient-years, 128 were solid cancers – including melanoma, and lung, breast, and colorectal cancers – and 20 were hematologic – including NHL and Hodgkin’s lymphoma. The median time from enrollment in the register to cancer diagnosis was 1.3 years, with 52% of patients dying as a result of incident cancer.

The standardized incidence ratio for all cancers was 1.48. Looking at specific types of malignancy, the highest SIR was recorded for NHL, at 3.73, although the risk of lung cancer was also substantial, with a SIR of 2.71. The SIR for colorectal cancer was 0.96.

Considering these findings, "vigilance for cancer, especially lung cancer and lymphoma should be maintained," Dr. Mercer advised.

"Our experience is that all cancers were increased by about 48%, with quite a marked increase in NHL and lung cancer, said Dr. Deborah Symmons, during a separate presentation at the meeting. An interesting finding, she noted, was that any benefit of NSAID drugs used to treat RA in lowering the risk of colorectal cancer appeared to be "wearing off."

Dr. Symmons, also of the Arthritis Research UK Epidemiology Unit in Manchester and a principle investigator for the BSRBR, explained that this adds to the evidence that, "the cancer risk in our general rheumatoid population is increased for some cancers."

These data are of interest, as they will eventually be used to compare the cancer risk of biologic vs. nonbiologic DMARDs. Such analysis is unlikely to be undertaken any time soon, however, as it is planned to occur when 20,000 years of patient follow-up have been accumulated. To date, there has been no signal that an earlier analysis is warranted.

"In the [anti-TNF] clinical trials, most of which were less than a year [in duration] there was not an increase in cancer except for [nonmelanoma skin cancer]," Dr. Symmons observed. "The cancer risk in observational studies is not increased in the short term," she added, "but we still don’t know what the long-term risk might be."

Echoing her comments were the separate findings of a Wyeth-sponsored study presented as a poster at the meeting. Dr. Peter Taylor of the Kennedy Institute of Rheumatology in London and his associates looked at the risk of malignancy associated with TNF inhibitors in registries and prospective observational studies. They reported a pooled-risk estimate of 1.11 for lymphoma, 1.45 for nonmelanoma skin cancer, and 1.79 for melanoma comparing TNF-treated patients with nonexposed RA patients.

Dr. Taylor and his team said of their findings: "This systematic review and meta-analysis provide reassurance to physicians and patients that treatment of RA patients with TNF inhibitors does not increase the risk of malignancy in general, or of lymphoma in particular, but does appear to increase the risk of skin cancer, including melanoma."

The systemic review and meta-analysis was sponsored by Wyeth. Dr. Taylor has received research grants and honoraria from Abbott, Bristol-Myers Squibb, Pfizer, Roche, Schering-Plough, and UCB. The BSRBR is funded by a grant from the British Society for Rheumatology. The BSR receives funding from Abbott Laboratories, Biovitrum/SOBI, Merck Sharp & Dohme Ltd., Pfizer, Roche, and UCB. This income finances a separate contract between the BSR and the University of Manchester that provides and run the BSRBR. All decisions concerning data analysis, interpretation and publications are made autonomously of any industrial contribution.

Dr. Mercer, Dr. Symmons, and Dr. Matteson declared that they had no personal conflicts of interest.

BRIGHTON, ENGLAND – The risk of cancer is almost 50% higher in people with rheumatoid arthritis who are treated with nonbiologic agents when compared to the general population, according to data just released from the British Society for Rheumatology Biologics Register.

Although the link between rheumatoid arthritis (RA) and malignancy has been previously identified – particularly with respect to a higher risk of non-Hodgkin’s lymphoma (NHL) – these new data from the British Society for Rheumatology Biologics Register (BSRBR) are from a more-contemporary population of patients who have been treated in the era of widespread use of methotrexate (MTX) and other nonbiologic disease-modifying antirheumatic drugs (DMARDs).

Dr. Eric L. Matteson, who is a professor of medicine at the division of rheumatology at the Mayo Clinic, Rochester, Minn., noted in an interview that the registry findings seem to indicate that overall cancer risk is increased in patients with RA and that this risk is similar in patients exposed to biologics and nonbiologics, with the exception that nonmelanoma skin cancer appears to be somewhat more frequent in the biologics treated patients.

"I think the conclusions arrived at are consistent with previous studies and so not surprising regarding nonbiologics, in particular, methotrexate. A study from Australia by Dr. Rachelle Buchbinder, for example, already reported in 2008 an almost identical finding of 50% increased risk of cancer in patients with RA treated with methotrexate."

There was an estimated 50% excess risk of malignancy among RA patients exposed to MTX relative to the general population (standardized incidence ratio, 1.5; 95% confidence interval, 1.2-1.9). In that study, the risk of non-Hodgkin’s lymphoma was more than five times higher in RA patients than in the general population (SIR, 5.1; 95% CI 2.2-10.0). Other cancers for which there was evidence of increased risk were lung cancer (SIR, 2.9; 95% CI 1.6-4.8) and melanoma (SIR, 3.0; 95% CI 1.2-6.2). (Arthritis Care Res. 2008;59:794-9).

Dr. Matteson qualified his remarks by noting that he did not hear the presentation and assumes methotrexate was the comparator drug.

In reporting the findings, Dr. Louise Mercer, a clinical research fellow at the Arthritis Research UK Epidemiology Unit, University of Manchester, England, where the BRSBR is coordinated, on April 13 at the British Society for Rheumatology Annual Conference (Rheumatology 2011;50:iii37-8, abstract OP18) noted that they set a baseline for analyzing the cancer risk of biologic therapy, compared with conventional RA therapy within the BSRBR patient population – the primary reason the register was set up 10 years ago.

The analysis included 3,727 RA patients treated with nonbiologic DMARDS who were enrolled in the register between 2002 and 2008. Data from the national cancer registry for England and Wales provided information about whether or not they developed cancer. SIRs were used to compare the observed vs. the expected number of cancers and were adjusted for age and gender.

Of 148 malignancies occurring in 10,447 patient-years, 128 were solid cancers – including melanoma, and lung, breast, and colorectal cancers – and 20 were hematologic – including NHL and Hodgkin’s lymphoma. The median time from enrollment in the register to cancer diagnosis was 1.3 years, with 52% of patients dying as a result of incident cancer.

The standardized incidence ratio for all cancers was 1.48. Looking at specific types of malignancy, the highest SIR was recorded for NHL, at 3.73, although the risk of lung cancer was also substantial, with a SIR of 2.71. The SIR for colorectal cancer was 0.96.

Considering these findings, "vigilance for cancer, especially lung cancer and lymphoma should be maintained," Dr. Mercer advised.

"Our experience is that all cancers were increased by about 48%, with quite a marked increase in NHL and lung cancer, said Dr. Deborah Symmons, during a separate presentation at the meeting. An interesting finding, she noted, was that any benefit of NSAID drugs used to treat RA in lowering the risk of colorectal cancer appeared to be "wearing off."

Dr. Symmons, also of the Arthritis Research UK Epidemiology Unit in Manchester and a principle investigator for the BSRBR, explained that this adds to the evidence that, "the cancer risk in our general rheumatoid population is increased for some cancers."

These data are of interest, as they will eventually be used to compare the cancer risk of biologic vs. nonbiologic DMARDs. Such analysis is unlikely to be undertaken any time soon, however, as it is planned to occur when 20,000 years of patient follow-up have been accumulated. To date, there has been no signal that an earlier analysis is warranted.

"In the [anti-TNF] clinical trials, most of which were less than a year [in duration] there was not an increase in cancer except for [nonmelanoma skin cancer]," Dr. Symmons observed. "The cancer risk in observational studies is not increased in the short term," she added, "but we still don’t know what the long-term risk might be."

Echoing her comments were the separate findings of a Wyeth-sponsored study presented as a poster at the meeting. Dr. Peter Taylor of the Kennedy Institute of Rheumatology in London and his associates looked at the risk of malignancy associated with TNF inhibitors in registries and prospective observational studies. They reported a pooled-risk estimate of 1.11 for lymphoma, 1.45 for nonmelanoma skin cancer, and 1.79 for melanoma comparing TNF-treated patients with nonexposed RA patients.

Dr. Taylor and his team said of their findings: "This systematic review and meta-analysis provide reassurance to physicians and patients that treatment of RA patients with TNF inhibitors does not increase the risk of malignancy in general, or of lymphoma in particular, but does appear to increase the risk of skin cancer, including melanoma."

The systemic review and meta-analysis was sponsored by Wyeth. Dr. Taylor has received research grants and honoraria from Abbott, Bristol-Myers Squibb, Pfizer, Roche, Schering-Plough, and UCB. The BSRBR is funded by a grant from the British Society for Rheumatology. The BSR receives funding from Abbott Laboratories, Biovitrum/SOBI, Merck Sharp & Dohme Ltd., Pfizer, Roche, and UCB. This income finances a separate contract between the BSR and the University of Manchester that provides and run the BSRBR. All decisions concerning data analysis, interpretation and publications are made autonomously of any industrial contribution.

Dr. Mercer, Dr. Symmons, and Dr. Matteson declared that they had no personal conflicts of interest.

BRIGHTON, ENGLAND – Multiple factors predict whether patients with inflammatory polyarthritis will require treatment with a biologic agent, according to new data from the Norfolk Arthritis Register.

Indeed, younger age, ACPA (anti–citrullinated protein/peptide antibody) positivity, and inefficacy of the first nonbiologic disease-modifying antirheumatic drug, (DMARD) within the first 6 months were associated with a higher chance of requiring biologic treatment with an anti–tumor necrosis factor (TNF) drug or rituximab (Rheumatology [Oxford] 2011;50 [suppl. 3];iii37-9, abstract OP16).

However, none of these baseline predictors is included in the National Institute for Health and Clinical Excellence (NICE) guidelines for prescribing biologic therapy," said Dr. Suzanne Verstappen, who presented the findings at the annual meeting of the British Society for Rheumatology.

More than 800 patients who were enrolled in the Norfolk Arthritis Register (NOAR), a primary care–based inception cohort, were studied, reported Dr. Verstappen, a research fellow at the Arthritis Research UK Epidemiology Unit at the University of Manchester (England). Two groups of patients were identified: those who were recruited in the prebiologic era of 1990-1994 (n = 407), and those who were recruited in 2000-2004 (n = 416), after biologic agents had become widely available in the United Kingdom.

For inclusion in the analysis, all patients had to have at least two swollen joints for 4 or more consecutive weeks. They also had to have symptom duration of less than 24 months, failure to respond to at least one nonbiologic DMARD, and 1 year or more of available follow-up data.

At baseline, the mean age of patients was 53 years in the prebiologic cohort and 57 years in the postbiologic cohort, with women accounting for about 63% of the overall study population. The average symptom duration was 5.4 and 6.7 months, respectively, and the prebiologic-era group had more swollen (seven vs. three) and tender (seven vs. three) joints than did the postbiologic-era group. DAS28 (disease activity score based on a 28-joint count) assessments were also higher at baseline in the prebiologic-era group, compared with postbiologic-era patients (4.5 vs. 3.7), although their use of nonbiologic DMARDs was lower at baseline (34% vs. 65%).

At follow-up, a higher percentage of patients in the 2000-2004 cohort had started to use a biologic agent (10.8% vs. 7.9% for the 1990-1994 cohort). As would be expected, the time before starting a biologic agent for the first time was longer (almost 12 years) for those who were recruited before these agents became available; the later cohort of patients received biologic treatment 3.9 years after recruitment into NOAR.

The most common first biologic agent used in the earlier cohort of patients was infliximab (44%) with etanercept, adalimumab, and rituximab being used in 34%, 19%, and 3% of patients, which reflected the timing of their introduction into U.K. clinical practice. Patients who were recruited later were more likely to receive adalimumab (51%), followed by etanercept (27%) and infliximab (22%).

Patients in both groups had used at least three nonbiologic DMARDs before starting biologic treatment, and around half to two-thirds of patients had also used steroids.

"In both cohorts, ACPA positivity at baseline was the strongest baseline predictor" for receiving biologic therapy, Dr. Verstappen reported. Hazard ratios were 7.58 and 4.66 for the pre- and postbiologic-era groups, respectively.

Patients with two alleles of the shared epitope were also more likely to start biologic therapy early (HR, 3.42 and 3.25 for the pre- and postbiologic-era groups, respectively).

In the postbiologic-era group, younger age was also associated with earlier biologic agent use, compared with older patients (HR, 0.97). Patients in this group were also more likely to receive biologic treatment if they had failed treatment with their first nonbiologic DMARD. (Failure was defined as either stopping the nonbiologic DMARD because of inefficacy or needing a second agent within the first 6 months of treatment.)

Baseline disease activity measures were not associated with the need to receive biologic therapy, although the study did not evaluate cumulative disease activity over time.

"If we identify patients who are ACPA positive and those who have failed their first nonbiologic DMARD very early on in the disease, we could perhaps fast-track them to biologic therapy and reduce long-term disability," Dr. Verstappen concluded.

NOAR is funded by Arthritis Research UK. Dr. Verstappen stated that she had no conflicts of interest.

BRIGHTON, ENGLAND – Multiple factors predict whether patients with inflammatory polyarthritis will require treatment with a biologic agent, according to new data from the Norfolk Arthritis Register.

Indeed, younger age, ACPA (anti–citrullinated protein/peptide antibody) positivity, and inefficacy of the first nonbiologic disease-modifying antirheumatic drug, (DMARD) within the first 6 months were associated with a higher chance of requiring biologic treatment with an anti–tumor necrosis factor (TNF) drug or rituximab (Rheumatology [Oxford] 2011;50 [suppl. 3];iii37-9, abstract OP16).

However, none of these baseline predictors is included in the National Institute for Health and Clinical Excellence (NICE) guidelines for prescribing biologic therapy," said Dr. Suzanne Verstappen, who presented the findings at the annual meeting of the British Society for Rheumatology.

More than 800 patients who were enrolled in the Norfolk Arthritis Register (NOAR), a primary care–based inception cohort, were studied, reported Dr. Verstappen, a research fellow at the Arthritis Research UK Epidemiology Unit at the University of Manchester (England). Two groups of patients were identified: those who were recruited in the prebiologic era of 1990-1994 (n = 407), and those who were recruited in 2000-2004 (n = 416), after biologic agents had become widely available in the United Kingdom.

For inclusion in the analysis, all patients had to have at least two swollen joints for 4 or more consecutive weeks. They also had to have symptom duration of less than 24 months, failure to respond to at least one nonbiologic DMARD, and 1 year or more of available follow-up data.

At baseline, the mean age of patients was 53 years in the prebiologic cohort and 57 years in the postbiologic cohort, with women accounting for about 63% of the overall study population. The average symptom duration was 5.4 and 6.7 months, respectively, and the prebiologic-era group had more swollen (seven vs. three) and tender (seven vs. three) joints than did the postbiologic-era group. DAS28 (disease activity score based on a 28-joint count) assessments were also higher at baseline in the prebiologic-era group, compared with postbiologic-era patients (4.5 vs. 3.7), although their use of nonbiologic DMARDs was lower at baseline (34% vs. 65%).

At follow-up, a higher percentage of patients in the 2000-2004 cohort had started to use a biologic agent (10.8% vs. 7.9% for the 1990-1994 cohort). As would be expected, the time before starting a biologic agent for the first time was longer (almost 12 years) for those who were recruited before these agents became available; the later cohort of patients received biologic treatment 3.9 years after recruitment into NOAR.

The most common first biologic agent used in the earlier cohort of patients was infliximab (44%) with etanercept, adalimumab, and rituximab being used in 34%, 19%, and 3% of patients, which reflected the timing of their introduction into U.K. clinical practice. Patients who were recruited later were more likely to receive adalimumab (51%), followed by etanercept (27%) and infliximab (22%).

Patients in both groups had used at least three nonbiologic DMARDs before starting biologic treatment, and around half to two-thirds of patients had also used steroids.

"In both cohorts, ACPA positivity at baseline was the strongest baseline predictor" for receiving biologic therapy, Dr. Verstappen reported. Hazard ratios were 7.58 and 4.66 for the pre- and postbiologic-era groups, respectively.

Patients with two alleles of the shared epitope were also more likely to start biologic therapy early (HR, 3.42 and 3.25 for the pre- and postbiologic-era groups, respectively).

In the postbiologic-era group, younger age was also associated with earlier biologic agent use, compared with older patients (HR, 0.97). Patients in this group were also more likely to receive biologic treatment if they had failed treatment with their first nonbiologic DMARD. (Failure was defined as either stopping the nonbiologic DMARD because of inefficacy or needing a second agent within the first 6 months of treatment.)

Baseline disease activity measures were not associated with the need to receive biologic therapy, although the study did not evaluate cumulative disease activity over time.

"If we identify patients who are ACPA positive and those who have failed their first nonbiologic DMARD very early on in the disease, we could perhaps fast-track them to biologic therapy and reduce long-term disability," Dr. Verstappen concluded.

NOAR is funded by Arthritis Research UK. Dr. Verstappen stated that she had no conflicts of interest.

BRIGHTON, ENGLAND – Multiple factors predict whether patients with inflammatory polyarthritis will require treatment with a biologic agent, according to new data from the Norfolk Arthritis Register.

Indeed, younger age, ACPA (anti–citrullinated protein/peptide antibody) positivity, and inefficacy of the first nonbiologic disease-modifying antirheumatic drug, (DMARD) within the first 6 months were associated with a higher chance of requiring biologic treatment with an anti–tumor necrosis factor (TNF) drug or rituximab (Rheumatology [Oxford] 2011;50 [suppl. 3];iii37-9, abstract OP16).

However, none of these baseline predictors is included in the National Institute for Health and Clinical Excellence (NICE) guidelines for prescribing biologic therapy," said Dr. Suzanne Verstappen, who presented the findings at the annual meeting of the British Society for Rheumatology.

More than 800 patients who were enrolled in the Norfolk Arthritis Register (NOAR), a primary care–based inception cohort, were studied, reported Dr. Verstappen, a research fellow at the Arthritis Research UK Epidemiology Unit at the University of Manchester (England). Two groups of patients were identified: those who were recruited in the prebiologic era of 1990-1994 (n = 407), and those who were recruited in 2000-2004 (n = 416), after biologic agents had become widely available in the United Kingdom.

For inclusion in the analysis, all patients had to have at least two swollen joints for 4 or more consecutive weeks. They also had to have symptom duration of less than 24 months, failure to respond to at least one nonbiologic DMARD, and 1 year or more of available follow-up data.

At baseline, the mean age of patients was 53 years in the prebiologic cohort and 57 years in the postbiologic cohort, with women accounting for about 63% of the overall study population. The average symptom duration was 5.4 and 6.7 months, respectively, and the prebiologic-era group had more swollen (seven vs. three) and tender (seven vs. three) joints than did the postbiologic-era group. DAS28 (disease activity score based on a 28-joint count) assessments were also higher at baseline in the prebiologic-era group, compared with postbiologic-era patients (4.5 vs. 3.7), although their use of nonbiologic DMARDs was lower at baseline (34% vs. 65%).

At follow-up, a higher percentage of patients in the 2000-2004 cohort had started to use a biologic agent (10.8% vs. 7.9% for the 1990-1994 cohort). As would be expected, the time before starting a biologic agent for the first time was longer (almost 12 years) for those who were recruited before these agents became available; the later cohort of patients received biologic treatment 3.9 years after recruitment into NOAR.

The most common first biologic agent used in the earlier cohort of patients was infliximab (44%) with etanercept, adalimumab, and rituximab being used in 34%, 19%, and 3% of patients, which reflected the timing of their introduction into U.K. clinical practice. Patients who were recruited later were more likely to receive adalimumab (51%), followed by etanercept (27%) and infliximab (22%).

Patients in both groups had used at least three nonbiologic DMARDs before starting biologic treatment, and around half to two-thirds of patients had also used steroids.

"In both cohorts, ACPA positivity at baseline was the strongest baseline predictor" for receiving biologic therapy, Dr. Verstappen reported. Hazard ratios were 7.58 and 4.66 for the pre- and postbiologic-era groups, respectively.

Patients with two alleles of the shared epitope were also more likely to start biologic therapy early (HR, 3.42 and 3.25 for the pre- and postbiologic-era groups, respectively).

In the postbiologic-era group, younger age was also associated with earlier biologic agent use, compared with older patients (HR, 0.97). Patients in this group were also more likely to receive biologic treatment if they had failed treatment with their first nonbiologic DMARD. (Failure was defined as either stopping the nonbiologic DMARD because of inefficacy or needing a second agent within the first 6 months of treatment.)

Baseline disease activity measures were not associated with the need to receive biologic therapy, although the study did not evaluate cumulative disease activity over time.

"If we identify patients who are ACPA positive and those who have failed their first nonbiologic DMARD very early on in the disease, we could perhaps fast-track them to biologic therapy and reduce long-term disability," Dr. Verstappen concluded.

NOAR is funded by Arthritis Research UK. Dr. Verstappen stated that she had no conflicts of interest.

CHICAGO – The prevalence of ankylosing spondylitis is greatly underestimated, and diagnosis is typically delayed, according to Dr. Michael Weisman.

A 1998 report by the National Arthritis Data Workgroup stated that there are an estimated 2.1 cases of ankylosing spondylitis (AS) per 1,000 individuals older than age 15 years. But this widely cited estimate that 0.21% of the U.S. population has AS was based on classification criteria that required radiographic evidence of AS, said Dr. Weisman director of the division of rheumatology and professor of medicine at Cedars-Sinai Medical Center, Los Angeles.

"This was not a real epidemiologic survey. This was a grossly underestimated prevalence of AS" in the United States, he said, explaining that the researchers relied on the modified New York criteria for AS, which requires not only clinical features, but radiographic changes.

The problem is that radiographic changes take time, and there is a long preradiographic stage in AS during which patients have symptoms for years before developing x-ray changes in sacroiliac joints.

"So when you use modified New York criteria for classification, and you misuse it for diagnosis, you’re going to grossly underestimate the frequency of this disease in the population," he said.

Additionally, studies consistently show that there is an average delay in diagnosis of at least 7-9 years for AS, he said, noting that this is because AS is hidden from obvious view, imaging techniques are needed to make the diagnosis, and the disease is often not suspected because of "the whole ubiquitous idea of low back pain in the population" (Curr. Opin. Rheumatol. 2000;12:239-47).

Also, that study showed that diagnosis in women is delayed even more than in men, and other studies indicate that women have largely been underdiagnosed, Dr. Weisman said, noting that he was taught during training that AS occurs in a 10:1 male-female ratio. The latest data show that it is more like 3:1.

So how many people really have AS? There have been very few prevalence studies, but the latest compilation of data shows that newer prevalence estimates for AS and spondyloarthritis in general vary widely, from 0.52% to 1.3% in the United States, which suggests that the prevalence may be higher than the current estimated 0.6% prevalence of rheumatoid arthritis in the United States. The estimates of AS/spondyloarthritis in other parts of the world are even higher. The estimated prevalence in Norway, for example, ranges up to 6.7%.

A marked north/south gradient also exists in prevalence, and it mirrors the north/south gradient of HLA (human leukocyte antigen)–B27 gene prevalence in the indigenous populations worldwide, which is "tremendously variable." HLA-B27 positivity is very high in northern areas, along with a higher prevalence of AS in northern areas.

These findings can be helpful for improving diagnosis, he said.

To make a correct – and earlier – diagnosis, use your perspective on inflammatory back pain, Dr. Weisman advised.

"Inflammatory back pain will be, for you, the greatest clue to be able to hone in on this diagnosis," he said.

Onset at a young age, relatively long duration of pain, associated morning stiffness, awakening in the middle of the night, and no improvement with rest are classic signs of inflammatory back pain. In fact, at least one study has shown that among those with chronic back pain, about 5% will have AS; but in those with inflammatory back pain the probability is tripled to about 14%-15%. Adding other features can further improve diagnosis.

An emerging understanding of genetic influences, for example, is proving helpful for diagnosis. Heritability for AS is greater than 90%, with HLA-B serving as the major disease-associated locus. The HLA-B27 gene marker is present in about 90% of AS cases, although only about 5% of HLA-B27–positive individuals develop AS.

"So the current model is that AS is largely a monogenic disease with multiple modifying genes," Dr. Weisman said.

The ERAP1 and IL23R genes are other players.

Assuming a frequency of a low AS prevalence estimate of 0.4%, HLA-B27 confers a probability of having AS of 3.6%. HLA-B27 along with ERAP1 increases that to about 10%, and the addition of both ERAP1 and IL23R increases it further to about 23%, Dr. Weisman said.

If you look at inflammatory back pain patients, and thus assume a lower bound estimate of AS of about 10% in that population, the addition of B27 positivity increases AS likelihood to about 50%. The addition of ERAP1 and IL23R positivity increases AS likelihood to 80%-90%, he said.

However, these genes add only a small amount to the frequency of the genetic association in this disease, and there are certain caveats that must be considered, Dr. Weisman said. For example, the ERAP1 association with AS is not seen in the Chinese population, and the ERAP1 association is only found in those with HLA-B27 positivity, which implies a gene-gene interaction.

There remains a great deal of work to be done to define the genetic bases of AS, he said.

In the meantime, efforts to better determine AS prevalence based on newer classification criteria are underway.

Unlike the modified New York criteria which used clear-cut radiographic sacroiliitis, new classification criteria for axial spondyloarthritis developed by the Assessments in Ankylosing Spondylitis Working Group uses additional features to increase sensitivity. One set of criteria uses HLA-B27 plus two additional features of spondyloarthritis for AS classification, and one uses sacroiliitis on imaging plus one spondyloarthritis feature to make a diagnosis. This increases sensitivity of screening to over 80%, he said (Ann. Rheum. Dis. 2009;68:777-83).

Furthermore, a screening questionnaire developed and published last year by Cedars-Sinai Medical Center to help improve diagnosis and to identify more patients on a population basis using various clinical features will be applied to National Health and Nutrition Examination Survey data from 2009-2010, which included a new survey on inflammatory back pain and spondyloarthritis. Together these seek to provide the first U.S. national inflammatory back pain estimate, and the first national U.S. study of HLA-B27 prevalence, Dr. Weisman said.

"With these two, we’ll be able to find the lower bound of the true prevalence of ankylosing spondylitis in the United States," he said.

Dr. Weisman had no disclosures to report.

CHICAGO – The prevalence of ankylosing spondylitis is greatly underestimated, and diagnosis is typically delayed, according to Dr. Michael Weisman.

A 1998 report by the National Arthritis Data Workgroup stated that there are an estimated 2.1 cases of ankylosing spondylitis (AS) per 1,000 individuals older than age 15 years. But this widely cited estimate that 0.21% of the U.S. population has AS was based on classification criteria that required radiographic evidence of AS, said Dr. Weisman director of the division of rheumatology and professor of medicine at Cedars-Sinai Medical Center, Los Angeles.

"This was not a real epidemiologic survey. This was a grossly underestimated prevalence of AS" in the United States, he said, explaining that the researchers relied on the modified New York criteria for AS, which requires not only clinical features, but radiographic changes.

The problem is that radiographic changes take time, and there is a long preradiographic stage in AS during which patients have symptoms for years before developing x-ray changes in sacroiliac joints.

"So when you use modified New York criteria for classification, and you misuse it for diagnosis, you’re going to grossly underestimate the frequency of this disease in the population," he said.

Additionally, studies consistently show that there is an average delay in diagnosis of at least 7-9 years for AS, he said, noting that this is because AS is hidden from obvious view, imaging techniques are needed to make the diagnosis, and the disease is often not suspected because of "the whole ubiquitous idea of low back pain in the population" (Curr. Opin. Rheumatol. 2000;12:239-47).

Also, that study showed that diagnosis in women is delayed even more than in men, and other studies indicate that women have largely been underdiagnosed, Dr. Weisman said, noting that he was taught during training that AS occurs in a 10:1 male-female ratio. The latest data show that it is more like 3:1.

So how many people really have AS? There have been very few prevalence studies, but the latest compilation of data shows that newer prevalence estimates for AS and spondyloarthritis in general vary widely, from 0.52% to 1.3% in the United States, which suggests that the prevalence may be higher than the current estimated 0.6% prevalence of rheumatoid arthritis in the United States. The estimates of AS/spondyloarthritis in other parts of the world are even higher. The estimated prevalence in Norway, for example, ranges up to 6.7%.

A marked north/south gradient also exists in prevalence, and it mirrors the north/south gradient of HLA (human leukocyte antigen)–B27 gene prevalence in the indigenous populations worldwide, which is "tremendously variable." HLA-B27 positivity is very high in northern areas, along with a higher prevalence of AS in northern areas.

These findings can be helpful for improving diagnosis, he said.

To make a correct – and earlier – diagnosis, use your perspective on inflammatory back pain, Dr. Weisman advised.

"Inflammatory back pain will be, for you, the greatest clue to be able to hone in on this diagnosis," he said.

Onset at a young age, relatively long duration of pain, associated morning stiffness, awakening in the middle of the night, and no improvement with rest are classic signs of inflammatory back pain. In fact, at least one study has shown that among those with chronic back pain, about 5% will have AS; but in those with inflammatory back pain the probability is tripled to about 14%-15%. Adding other features can further improve diagnosis.

An emerging understanding of genetic influences, for example, is proving helpful for diagnosis. Heritability for AS is greater than 90%, with HLA-B serving as the major disease-associated locus. The HLA-B27 gene marker is present in about 90% of AS cases, although only about 5% of HLA-B27–positive individuals develop AS.

"So the current model is that AS is largely a monogenic disease with multiple modifying genes," Dr. Weisman said.

The ERAP1 and IL23R genes are other players.

Assuming a frequency of a low AS prevalence estimate of 0.4%, HLA-B27 confers a probability of having AS of 3.6%. HLA-B27 along with ERAP1 increases that to about 10%, and the addition of both ERAP1 and IL23R increases it further to about 23%, Dr. Weisman said.

If you look at inflammatory back pain patients, and thus assume a lower bound estimate of AS of about 10% in that population, the addition of B27 positivity increases AS likelihood to about 50%. The addition of ERAP1 and IL23R positivity increases AS likelihood to 80%-90%, he said.

However, these genes add only a small amount to the frequency of the genetic association in this disease, and there are certain caveats that must be considered, Dr. Weisman said. For example, the ERAP1 association with AS is not seen in the Chinese population, and the ERAP1 association is only found in those with HLA-B27 positivity, which implies a gene-gene interaction.

There remains a great deal of work to be done to define the genetic bases of AS, he said.

In the meantime, efforts to better determine AS prevalence based on newer classification criteria are underway.

Unlike the modified New York criteria which used clear-cut radiographic sacroiliitis, new classification criteria for axial spondyloarthritis developed by the Assessments in Ankylosing Spondylitis Working Group uses additional features to increase sensitivity. One set of criteria uses HLA-B27 plus two additional features of spondyloarthritis for AS classification, and one uses sacroiliitis on imaging plus one spondyloarthritis feature to make a diagnosis. This increases sensitivity of screening to over 80%, he said (Ann. Rheum. Dis. 2009;68:777-83).

Furthermore, a screening questionnaire developed and published last year by Cedars-Sinai Medical Center to help improve diagnosis and to identify more patients on a population basis using various clinical features will be applied to National Health and Nutrition Examination Survey data from 2009-2010, which included a new survey on inflammatory back pain and spondyloarthritis. Together these seek to provide the first U.S. national inflammatory back pain estimate, and the first national U.S. study of HLA-B27 prevalence, Dr. Weisman said.

"With these two, we’ll be able to find the lower bound of the true prevalence of ankylosing spondylitis in the United States," he said.

Dr. Weisman had no disclosures to report.

CHICAGO – The prevalence of ankylosing spondylitis is greatly underestimated, and diagnosis is typically delayed, according to Dr. Michael Weisman.

A 1998 report by the National Arthritis Data Workgroup stated that there are an estimated 2.1 cases of ankylosing spondylitis (AS) per 1,000 individuals older than age 15 years. But this widely cited estimate that 0.21% of the U.S. population has AS was based on classification criteria that required radiographic evidence of AS, said Dr. Weisman director of the division of rheumatology and professor of medicine at Cedars-Sinai Medical Center, Los Angeles.

"This was not a real epidemiologic survey. This was a grossly underestimated prevalence of AS" in the United States, he said, explaining that the researchers relied on the modified New York criteria for AS, which requires not only clinical features, but radiographic changes.

The problem is that radiographic changes take time, and there is a long preradiographic stage in AS during which patients have symptoms for years before developing x-ray changes in sacroiliac joints.

"So when you use modified New York criteria for classification, and you misuse it for diagnosis, you’re going to grossly underestimate the frequency of this disease in the population," he said.

Additionally, studies consistently show that there is an average delay in diagnosis of at least 7-9 years for AS, he said, noting that this is because AS is hidden from obvious view, imaging techniques are needed to make the diagnosis, and the disease is often not suspected because of "the whole ubiquitous idea of low back pain in the population" (Curr. Opin. Rheumatol. 2000;12:239-47).

Also, that study showed that diagnosis in women is delayed even more than in men, and other studies indicate that women have largely been underdiagnosed, Dr. Weisman said, noting that he was taught during training that AS occurs in a 10:1 male-female ratio. The latest data show that it is more like 3:1.

So how many people really have AS? There have been very few prevalence studies, but the latest compilation of data shows that newer prevalence estimates for AS and spondyloarthritis in general vary widely, from 0.52% to 1.3% in the United States, which suggests that the prevalence may be higher than the current estimated 0.6% prevalence of rheumatoid arthritis in the United States. The estimates of AS/spondyloarthritis in other parts of the world are even higher. The estimated prevalence in Norway, for example, ranges up to 6.7%.

A marked north/south gradient also exists in prevalence, and it mirrors the north/south gradient of HLA (human leukocyte antigen)–B27 gene prevalence in the indigenous populations worldwide, which is "tremendously variable." HLA-B27 positivity is very high in northern areas, along with a higher prevalence of AS in northern areas.

These findings can be helpful for improving diagnosis, he said.

To make a correct – and earlier – diagnosis, use your perspective on inflammatory back pain, Dr. Weisman advised.

"Inflammatory back pain will be, for you, the greatest clue to be able to hone in on this diagnosis," he said.

Onset at a young age, relatively long duration of pain, associated morning stiffness, awakening in the middle of the night, and no improvement with rest are classic signs of inflammatory back pain. In fact, at least one study has shown that among those with chronic back pain, about 5% will have AS; but in those with inflammatory back pain the probability is tripled to about 14%-15%. Adding other features can further improve diagnosis.

An emerging understanding of genetic influences, for example, is proving helpful for diagnosis. Heritability for AS is greater than 90%, with HLA-B serving as the major disease-associated locus. The HLA-B27 gene marker is present in about 90% of AS cases, although only about 5% of HLA-B27–positive individuals develop AS.

"So the current model is that AS is largely a monogenic disease with multiple modifying genes," Dr. Weisman said.

The ERAP1 and IL23R genes are other players.

Assuming a frequency of a low AS prevalence estimate of 0.4%, HLA-B27 confers a probability of having AS of 3.6%. HLA-B27 along with ERAP1 increases that to about 10%, and the addition of both ERAP1 and IL23R increases it further to about 23%, Dr. Weisman said.

If you look at inflammatory back pain patients, and thus assume a lower bound estimate of AS of about 10% in that population, the addition of B27 positivity increases AS likelihood to about 50%. The addition of ERAP1 and IL23R positivity increases AS likelihood to 80%-90%, he said.

However, these genes add only a small amount to the frequency of the genetic association in this disease, and there are certain caveats that must be considered, Dr. Weisman said. For example, the ERAP1 association with AS is not seen in the Chinese population, and the ERAP1 association is only found in those with HLA-B27 positivity, which implies a gene-gene interaction.

There remains a great deal of work to be done to define the genetic bases of AS, he said.

In the meantime, efforts to better determine AS prevalence based on newer classification criteria are underway.

Unlike the modified New York criteria which used clear-cut radiographic sacroiliitis, new classification criteria for axial spondyloarthritis developed by the Assessments in Ankylosing Spondylitis Working Group uses additional features to increase sensitivity. One set of criteria uses HLA-B27 plus two additional features of spondyloarthritis for AS classification, and one uses sacroiliitis on imaging plus one spondyloarthritis feature to make a diagnosis. This increases sensitivity of screening to over 80%, he said (Ann. Rheum. Dis. 2009;68:777-83).

Furthermore, a screening questionnaire developed and published last year by Cedars-Sinai Medical Center to help improve diagnosis and to identify more patients on a population basis using various clinical features will be applied to National Health and Nutrition Examination Survey data from 2009-2010, which included a new survey on inflammatory back pain and spondyloarthritis. Together these seek to provide the first U.S. national inflammatory back pain estimate, and the first national U.S. study of HLA-B27 prevalence, Dr. Weisman said.

"With these two, we’ll be able to find the lower bound of the true prevalence of ankylosing spondylitis in the United States," he said.

Dr. Weisman had no disclosures to report.

BRIGHTON, ENGLAND – The gait of patients with rheumatoid arthritis undergoes significant variation throughout the day, judging from findings from the DIVIGN study.

There was a 54% improvement in gait velocity overall from the start to the end of a 12-hour assessment period. The mean improvement ranged from -41% to +397%.

The findings suggest that gait velocity should be measured at the same time of day in each patient when used as an outcome measure in clinical practice or in research.

"We all know about morning stiffness and how frequently patients report this, but this is really the first attempt to quantify the effects of early morning stiffness on gait," Michael Backhouse, a podiatrist and Arthritis Research UK doctoral student at the University of Leeds, England, said at the annual meeting of the British Society for Rheumatology.

Mr. Backhouse explained that patients with rheumatoid arthritis (RA) are known to have marked gait abnormalities. This includes decreased gait velocity, reduced stride length, and more time spent in a walking phase called double support where both feet are on the ground before one or the other leg swings forward to take the next step.

To quantify the diurnal variation in gait velocity, the investigators enrolled 31 patients with RA with a median age of 67 years and 10.5 years’ disease duration who were being treated as inpatients at the Chapel Allerton Hospital in Leeds. All patients reported morning stiffness for at least 30 minutes or more every day.

Each patient was asked to walk along a 5.2-m instrumented walkway (GAITRite, CIR Systems Inc.) at five time points throughout the study day; soon after waking (0 hour) at 7 am then at 1-, 3-, 6- and 12-hour intervals. Patients were asked to walk at a self-selected pace and were allowed to use walking sticks or other aids if required.

A visual analog scale was used to determine morning stiffness, and the Health Assessment Questionnaire (HAQ) and Disease Activity Score (DAS) 28 were used to see how changes in gait velocity might influence these disease outcome measures.

The sharpest increases in gait velocity were seen in the first hour of each patient assessment, with continued improvement throughout the day. At baseline, the mean gait velocity for all patients was 37.8 cm/sec., with values at 1, 3, 6, and 12 hours of 43.8 cm/sec., 45.5 cm/sec., 48.1 cm./sec., and 53 cm/sec. These translated into overall improvements of 20.4%, 32.9%, 37.8%, and 54.1% improvements, compared with baseline.

Although no control group of similarly aged individuals without RA was assessed, Mr. Backhouse observed that the expected gait velocity of healthy elderly individuals would be about 80-100 cm/sec.

In addition, stride length increased throughout the day, and patients were better able to steady themselves between steps (i.e., longer duration of the double support walking phase) before moving forward.

"When we looked at absolute gait velocity, that’s how fast patients were actually walking, we found that it did correlate with HAQ, that’s patient-reported physical function, at all time points, but it didn’t correlate at all with DAS28 or current disease activity," Mr. Backhouse reported.

"Gait velocity is perhaps one of the most widely used clinical outcome measure in studies of RA," Mr. Backhouse further observed. "This is probably because gait velocity can be so easily and objectively measured," he continued.

However, as the results of the DIVIGN study show, "there is marked diurnal variation of gait velocity ... and repeat measures should be made at the same time of day to exclude its effects," Mr. Backhouse concluded.

Arthritis Research UK and the National Institute for Health Research (London) funded the study. Mr. Backhouse said he had no conflicts of interest.

BRIGHTON, ENGLAND – The gait of patients with rheumatoid arthritis undergoes significant variation throughout the day, judging from findings from the DIVIGN study.

There was a 54% improvement in gait velocity overall from the start to the end of a 12-hour assessment period. The mean improvement ranged from -41% to +397%.

The findings suggest that gait velocity should be measured at the same time of day in each patient when used as an outcome measure in clinical practice or in research.

"We all know about morning stiffness and how frequently patients report this, but this is really the first attempt to quantify the effects of early morning stiffness on gait," Michael Backhouse, a podiatrist and Arthritis Research UK doctoral student at the University of Leeds, England, said at the annual meeting of the British Society for Rheumatology.

Mr. Backhouse explained that patients with rheumatoid arthritis (RA) are known to have marked gait abnormalities. This includes decreased gait velocity, reduced stride length, and more time spent in a walking phase called double support where both feet are on the ground before one or the other leg swings forward to take the next step.

To quantify the diurnal variation in gait velocity, the investigators enrolled 31 patients with RA with a median age of 67 years and 10.5 years’ disease duration who were being treated as inpatients at the Chapel Allerton Hospital in Leeds. All patients reported morning stiffness for at least 30 minutes or more every day.

Each patient was asked to walk along a 5.2-m instrumented walkway (GAITRite, CIR Systems Inc.) at five time points throughout the study day; soon after waking (0 hour) at 7 am then at 1-, 3-, 6- and 12-hour intervals. Patients were asked to walk at a self-selected pace and were allowed to use walking sticks or other aids if required.

A visual analog scale was used to determine morning stiffness, and the Health Assessment Questionnaire (HAQ) and Disease Activity Score (DAS) 28 were used to see how changes in gait velocity might influence these disease outcome measures.

The sharpest increases in gait velocity were seen in the first hour of each patient assessment, with continued improvement throughout the day. At baseline, the mean gait velocity for all patients was 37.8 cm/sec., with values at 1, 3, 6, and 12 hours of 43.8 cm/sec., 45.5 cm/sec., 48.1 cm./sec., and 53 cm/sec. These translated into overall improvements of 20.4%, 32.9%, 37.8%, and 54.1% improvements, compared with baseline.

Although no control group of similarly aged individuals without RA was assessed, Mr. Backhouse observed that the expected gait velocity of healthy elderly individuals would be about 80-100 cm/sec.

In addition, stride length increased throughout the day, and patients were better able to steady themselves between steps (i.e., longer duration of the double support walking phase) before moving forward.

"When we looked at absolute gait velocity, that’s how fast patients were actually walking, we found that it did correlate with HAQ, that’s patient-reported physical function, at all time points, but it didn’t correlate at all with DAS28 or current disease activity," Mr. Backhouse reported.

"Gait velocity is perhaps one of the most widely used clinical outcome measure in studies of RA," Mr. Backhouse further observed. "This is probably because gait velocity can be so easily and objectively measured," he continued.

However, as the results of the DIVIGN study show, "there is marked diurnal variation of gait velocity ... and repeat measures should be made at the same time of day to exclude its effects," Mr. Backhouse concluded.

Arthritis Research UK and the National Institute for Health Research (London) funded the study. Mr. Backhouse said he had no conflicts of interest.

BRIGHTON, ENGLAND – The gait of patients with rheumatoid arthritis undergoes significant variation throughout the day, judging from findings from the DIVIGN study.

There was a 54% improvement in gait velocity overall from the start to the end of a 12-hour assessment period. The mean improvement ranged from -41% to +397%.

The findings suggest that gait velocity should be measured at the same time of day in each patient when used as an outcome measure in clinical practice or in research.

"We all know about morning stiffness and how frequently patients report this, but this is really the first attempt to quantify the effects of early morning stiffness on gait," Michael Backhouse, a podiatrist and Arthritis Research UK doctoral student at the University of Leeds, England, said at the annual meeting of the British Society for Rheumatology.

Mr. Backhouse explained that patients with rheumatoid arthritis (RA) are known to have marked gait abnormalities. This includes decreased gait velocity, reduced stride length, and more time spent in a walking phase called double support where both feet are on the ground before one or the other leg swings forward to take the next step.

To quantify the diurnal variation in gait velocity, the investigators enrolled 31 patients with RA with a median age of 67 years and 10.5 years’ disease duration who were being treated as inpatients at the Chapel Allerton Hospital in Leeds. All patients reported morning stiffness for at least 30 minutes or more every day.

Each patient was asked to walk along a 5.2-m instrumented walkway (GAITRite, CIR Systems Inc.) at five time points throughout the study day; soon after waking (0 hour) at 7 am then at 1-, 3-, 6- and 12-hour intervals. Patients were asked to walk at a self-selected pace and were allowed to use walking sticks or other aids if required.

A visual analog scale was used to determine morning stiffness, and the Health Assessment Questionnaire (HAQ) and Disease Activity Score (DAS) 28 were used to see how changes in gait velocity might influence these disease outcome measures.

The sharpest increases in gait velocity were seen in the first hour of each patient assessment, with continued improvement throughout the day. At baseline, the mean gait velocity for all patients was 37.8 cm/sec., with values at 1, 3, 6, and 12 hours of 43.8 cm/sec., 45.5 cm/sec., 48.1 cm./sec., and 53 cm/sec. These translated into overall improvements of 20.4%, 32.9%, 37.8%, and 54.1% improvements, compared with baseline.

Although no control group of similarly aged individuals without RA was assessed, Mr. Backhouse observed that the expected gait velocity of healthy elderly individuals would be about 80-100 cm/sec.

In addition, stride length increased throughout the day, and patients were better able to steady themselves between steps (i.e., longer duration of the double support walking phase) before moving forward.

"When we looked at absolute gait velocity, that’s how fast patients were actually walking, we found that it did correlate with HAQ, that’s patient-reported physical function, at all time points, but it didn’t correlate at all with DAS28 or current disease activity," Mr. Backhouse reported.

"Gait velocity is perhaps one of the most widely used clinical outcome measure in studies of RA," Mr. Backhouse further observed. "This is probably because gait velocity can be so easily and objectively measured," he continued.

However, as the results of the DIVIGN study show, "there is marked diurnal variation of gait velocity ... and repeat measures should be made at the same time of day to exclude its effects," Mr. Backhouse concluded.

Arthritis Research UK and the National Institute for Health Research (London) funded the study. Mr. Backhouse said he had no conflicts of interest.

A panel of 18 experts from 10 European countries had some difficulty in defining when the benefits sufficiently outweighed the potential adverse effects of various nonsteroidal anti-inflammatory drugs – with and without a proton pump inhibitor – for 144 profiles of patients with chronic rheumatic diseases.

Panelists generally gave patients with low gastrointestinal or cardiovascular risks the full range of NSAID options. Approximately one-third of the patient-drug matches labeled "inappropriate" by panelists applied to the use of a nonselective NSAID without a PPI, the panelists wrote in Annals of the Rheumatic Diseases (Ann. Rheum. Dis. 2011;70:818-22).

When scoring patient profiles, panelists took into account seven clinical variables: age of 65 years or older, history of upper gastrointestinal problems, use of anticoagulants, use of systemic corticosteroids, intermittent or continuous treatment pattern, cardiovascular risk, and the use of low-dose aspirin (for those patients with cardiovascular risk). Against these variables, panelists considered 10 treatment options: ibuprofen, diclofenac, naproxen, celecoxib, etoricoxib, and each of these drugs plus a PPI. They did not consider costs when making their treatment recommendations, according to Dr. G.R. Burmester of the department of rheumatology and clinical immunology, Charité Medical University Berlin, and his coauthors.

For patients with the lowest gastrointestinal and cardiovascular risks, a nonselective NSAID (ibuprofen, diclofenac, or naproxen) was deemed appropriate. As gastrointestinal risks increased, the cyclooxygenase-2 (COX-2) inhibitors celecoxib and etoricoxib alone or a nonselective NSAID plus PPI were considered appropriate. In cases of high gastrointestinal risk and low to average cardiovascular risk, panelists rated ibuprofen/diclofenac plus PPI, or a COX-2 inhibitor plus PPI, as the most appropriate options. For patients with both high gastrointestinal and cardiovascular risks, avoidance of all NSAIDs was recommended, with the use of diclofenac, naproxen, celecoxib, or etoricoxib plus PPI deemed acceptable if necessary.

In January 2008, the panel established the appropriateness rating of treatment options on a 1-9 scale, with 1 as "inappropriate" and 9 as "appropriate." As defined by the RAND/UCLA appropriateness method, a "treatment had to be considered appropriate if the expected benefits exceeded the potential negative consequences by a sufficient margin." However, the panel did not define "sufficient," which led to most of the disagreement on scoring.

In June 2008, after the panel evaluated the first-round practice ratings and revised the evaluation measures, the second round of rating began with the 144 patient profiles and 10 treatment choices. A treatment with a median score of 7-9 was categorized as appropriate, whereas treatments with a median score of 1-3 were labeled inappropriate and those scoring 4-6 were categorized as uncertain.

An online tool (www.e-hims.com/Sensar) shows the corresponding panel treatment recommendation for various patient data.

Panelists were experts in the fields of rheumatology, orthopedics, cardiology, clinical pharmacology, gastroenterology, family medicine, and geriatrics.

All panelists disclosed receiving honoraria from Pfizer, which supported the study with an unrestricted educational grant. Eleven panelists disclosed other relationships with pharmaceutical companies, including Pfizer.

A panel of 18 experts from 10 European countries had some difficulty in defining when the benefits sufficiently outweighed the potential adverse effects of various nonsteroidal anti-inflammatory drugs – with and without a proton pump inhibitor – for 144 profiles of patients with chronic rheumatic diseases.

Panelists generally gave patients with low gastrointestinal or cardiovascular risks the full range of NSAID options. Approximately one-third of the patient-drug matches labeled "inappropriate" by panelists applied to the use of a nonselective NSAID without a PPI, the panelists wrote in Annals of the Rheumatic Diseases (Ann. Rheum. Dis. 2011;70:818-22).

When scoring patient profiles, panelists took into account seven clinical variables: age of 65 years or older, history of upper gastrointestinal problems, use of anticoagulants, use of systemic corticosteroids, intermittent or continuous treatment pattern, cardiovascular risk, and the use of low-dose aspirin (for those patients with cardiovascular risk). Against these variables, panelists considered 10 treatment options: ibuprofen, diclofenac, naproxen, celecoxib, etoricoxib, and each of these drugs plus a PPI. They did not consider costs when making their treatment recommendations, according to Dr. G.R. Burmester of the department of rheumatology and clinical immunology, Charité Medical University Berlin, and his coauthors.

For patients with the lowest gastrointestinal and cardiovascular risks, a nonselective NSAID (ibuprofen, diclofenac, or naproxen) was deemed appropriate. As gastrointestinal risks increased, the cyclooxygenase-2 (COX-2) inhibitors celecoxib and etoricoxib alone or a nonselective NSAID plus PPI were considered appropriate. In cases of high gastrointestinal risk and low to average cardiovascular risk, panelists rated ibuprofen/diclofenac plus PPI, or a COX-2 inhibitor plus PPI, as the most appropriate options. For patients with both high gastrointestinal and cardiovascular risks, avoidance of all NSAIDs was recommended, with the use of diclofenac, naproxen, celecoxib, or etoricoxib plus PPI deemed acceptable if necessary.

In January 2008, the panel established the appropriateness rating of treatment options on a 1-9 scale, with 1 as "inappropriate" and 9 as "appropriate." As defined by the RAND/UCLA appropriateness method, a "treatment had to be considered appropriate if the expected benefits exceeded the potential negative consequences by a sufficient margin." However, the panel did not define "sufficient," which led to most of the disagreement on scoring.

In June 2008, after the panel evaluated the first-round practice ratings and revised the evaluation measures, the second round of rating began with the 144 patient profiles and 10 treatment choices. A treatment with a median score of 7-9 was categorized as appropriate, whereas treatments with a median score of 1-3 were labeled inappropriate and those scoring 4-6 were categorized as uncertain.

An online tool (www.e-hims.com/Sensar) shows the corresponding panel treatment recommendation for various patient data.

Panelists were experts in the fields of rheumatology, orthopedics, cardiology, clinical pharmacology, gastroenterology, family medicine, and geriatrics.

All panelists disclosed receiving honoraria from Pfizer, which supported the study with an unrestricted educational grant. Eleven panelists disclosed other relationships with pharmaceutical companies, including Pfizer.

A panel of 18 experts from 10 European countries had some difficulty in defining when the benefits sufficiently outweighed the potential adverse effects of various nonsteroidal anti-inflammatory drugs – with and without a proton pump inhibitor – for 144 profiles of patients with chronic rheumatic diseases.

Panelists generally gave patients with low gastrointestinal or cardiovascular risks the full range of NSAID options. Approximately one-third of the patient-drug matches labeled "inappropriate" by panelists applied to the use of a nonselective NSAID without a PPI, the panelists wrote in Annals of the Rheumatic Diseases (Ann. Rheum. Dis. 2011;70:818-22).

When scoring patient profiles, panelists took into account seven clinical variables: age of 65 years or older, history of upper gastrointestinal problems, use of anticoagulants, use of systemic corticosteroids, intermittent or continuous treatment pattern, cardiovascular risk, and the use of low-dose aspirin (for those patients with cardiovascular risk). Against these variables, panelists considered 10 treatment options: ibuprofen, diclofenac, naproxen, celecoxib, etoricoxib, and each of these drugs plus a PPI. They did not consider costs when making their treatment recommendations, according to Dr. G.R. Burmester of the department of rheumatology and clinical immunology, Charité Medical University Berlin, and his coauthors.

For patients with the lowest gastrointestinal and cardiovascular risks, a nonselective NSAID (ibuprofen, diclofenac, or naproxen) was deemed appropriate. As gastrointestinal risks increased, the cyclooxygenase-2 (COX-2) inhibitors celecoxib and etoricoxib alone or a nonselective NSAID plus PPI were considered appropriate. In cases of high gastrointestinal risk and low to average cardiovascular risk, panelists rated ibuprofen/diclofenac plus PPI, or a COX-2 inhibitor plus PPI, as the most appropriate options. For patients with both high gastrointestinal and cardiovascular risks, avoidance of all NSAIDs was recommended, with the use of diclofenac, naproxen, celecoxib, or etoricoxib plus PPI deemed acceptable if necessary.

In January 2008, the panel established the appropriateness rating of treatment options on a 1-9 scale, with 1 as "inappropriate" and 9 as "appropriate." As defined by the RAND/UCLA appropriateness method, a "treatment had to be considered appropriate if the expected benefits exceeded the potential negative consequences by a sufficient margin." However, the panel did not define "sufficient," which led to most of the disagreement on scoring.

In June 2008, after the panel evaluated the first-round practice ratings and revised the evaluation measures, the second round of rating began with the 144 patient profiles and 10 treatment choices. A treatment with a median score of 7-9 was categorized as appropriate, whereas treatments with a median score of 1-3 were labeled inappropriate and those scoring 4-6 were categorized as uncertain.

An online tool (www.e-hims.com/Sensar) shows the corresponding panel treatment recommendation for various patient data.

Panelists were experts in the fields of rheumatology, orthopedics, cardiology, clinical pharmacology, gastroenterology, family medicine, and geriatrics.

All panelists disclosed receiving honoraria from Pfizer, which supported the study with an unrestricted educational grant. Eleven panelists disclosed other relationships with pharmaceutical companies, including Pfizer.

CHICAGO – Reverse shoulder arthroplasty provides a surgical option for improving pain and ability in patients who have both arthritis and massive rotator cuff tear.

Before the procedure was approved for use in the United States in 2005, patients with this combination of conditions were very difficult to manage, said Dr. Matthew Saltzman at a symposium sponsored by the American College of Rheumatology.

"We didn’t have a solution for this problem for many, many years, but now I think we really do," said Dr. Saltzman, an orthopedic surgeon specializing in shoulder and elbow surgery at Northwestern University, Chicago.

Reverse shoulder arthroplasty basically changes the mechanics of the shoulder. It involves putting the ball in the socket, and putting the socket where the ball used to be, he said, adding that it’s "a strange concept, but it actually works."

"With reverse shoulder arthroplasty, you’re actually medializing the center of rotation, and this can be done to varying degrees depending on the implant design," he said, explaining that the procedure changes the tension on the deltoid muscle and allows the deltoid, rather than the irreparable rotator cuff musculature, to lift the arm.

Dr. Saltzman described two cases involving elderly women who underwent reverse shoulder arthroplasty and had excellent outcomes at 6-12 months. One was an 84-year-old who presented with a massive cuff tear as well as arthritis-related joint damage and loss of the joint space. Like many patients with these conditions, she had severe pain, pseudoparalysis of the shoulder, and resulting lack of function; she was able to lift her arm to only about 20 degrees.

At 6 months after the operation, she had no pain and was able to elevate her arm and rotate the arm out to the side.

The other patient was an 86-year-old who had previously lived independently, but who had slipped on ice and sustained multiple fractures of her shoulder. Although her problem wasn’t arthritis related, the reverse shoulder arthroplasty was successful, and she was able to return to independent living.

Findings from a study involving 240 consecutive reverse shoulder arthroplasty procedures in 232 patients (average age, nearly 73 years) showed that average forward elevation increased from 86 degrees to 137 degrees, and average constant score (a validated measure of shoulder function) improved from 23 to 60 at the latest follow-up, indicating substantial improvement, Dr. Saltzman said (J. Bone Joint Surg. Am. 2007;89:1476-85).

In that study, patients with cuff tear arthropathy, osteoarthritis plus cuff tear, or massive cuff tear fared better, whereas those with posttraumatic arthritis and those undergoing revision arthroplasty had worse outcomes.

Of course, patients need to be healthy enough to withstand surgery, but in appropriately selected patients this procedure provides a really nice result, he said.

"You’re taking a very severe problem and giving people a much better quality of life," he added.

Dr. Saltzman disclosed that he serves on the speakers bureau of Carefusion, has made paid presentations for DJO Surgical, and has received research support from Arthrex.

CHICAGO – Reverse shoulder arthroplasty provides a surgical option for improving pain and ability in patients who have both arthritis and massive rotator cuff tear.

Before the procedure was approved for use in the United States in 2005, patients with this combination of conditions were very difficult to manage, said Dr. Matthew Saltzman at a symposium sponsored by the American College of Rheumatology.

"We didn’t have a solution for this problem for many, many years, but now I think we really do," said Dr. Saltzman, an orthopedic surgeon specializing in shoulder and elbow surgery at Northwestern University, Chicago.

Reverse shoulder arthroplasty basically changes the mechanics of the shoulder. It involves putting the ball in the socket, and putting the socket where the ball used to be, he said, adding that it’s "a strange concept, but it actually works."

"With reverse shoulder arthroplasty, you’re actually medializing the center of rotation, and this can be done to varying degrees depending on the implant design," he said, explaining that the procedure changes the tension on the deltoid muscle and allows the deltoid, rather than the irreparable rotator cuff musculature, to lift the arm.

Dr. Saltzman described two cases involving elderly women who underwent reverse shoulder arthroplasty and had excellent outcomes at 6-12 months. One was an 84-year-old who presented with a massive cuff tear as well as arthritis-related joint damage and loss of the joint space. Like many patients with these conditions, she had severe pain, pseudoparalysis of the shoulder, and resulting lack of function; she was able to lift her arm to only about 20 degrees.

At 6 months after the operation, she had no pain and was able to elevate her arm and rotate the arm out to the side.

The other patient was an 86-year-old who had previously lived independently, but who had slipped on ice and sustained multiple fractures of her shoulder. Although her problem wasn’t arthritis related, the reverse shoulder arthroplasty was successful, and she was able to return to independent living.

Findings from a study involving 240 consecutive reverse shoulder arthroplasty procedures in 232 patients (average age, nearly 73 years) showed that average forward elevation increased from 86 degrees to 137 degrees, and average constant score (a validated measure of shoulder function) improved from 23 to 60 at the latest follow-up, indicating substantial improvement, Dr. Saltzman said (J. Bone Joint Surg. Am. 2007;89:1476-85).

In that study, patients with cuff tear arthropathy, osteoarthritis plus cuff tear, or massive cuff tear fared better, whereas those with posttraumatic arthritis and those undergoing revision arthroplasty had worse outcomes.

Of course, patients need to be healthy enough to withstand surgery, but in appropriately selected patients this procedure provides a really nice result, he said.

"You’re taking a very severe problem and giving people a much better quality of life," he added.

Dr. Saltzman disclosed that he serves on the speakers bureau of Carefusion, has made paid presentations for DJO Surgical, and has received research support from Arthrex.

CHICAGO – Reverse shoulder arthroplasty provides a surgical option for improving pain and ability in patients who have both arthritis and massive rotator cuff tear.

Before the procedure was approved for use in the United States in 2005, patients with this combination of conditions were very difficult to manage, said Dr. Matthew Saltzman at a symposium sponsored by the American College of Rheumatology.

"We didn’t have a solution for this problem for many, many years, but now I think we really do," said Dr. Saltzman, an orthopedic surgeon specializing in shoulder and elbow surgery at Northwestern University, Chicago.

Reverse shoulder arthroplasty basically changes the mechanics of the shoulder. It involves putting the ball in the socket, and putting the socket where the ball used to be, he said, adding that it’s "a strange concept, but it actually works."

"With reverse shoulder arthroplasty, you’re actually medializing the center of rotation, and this can be done to varying degrees depending on the implant design," he said, explaining that the procedure changes the tension on the deltoid muscle and allows the deltoid, rather than the irreparable rotator cuff musculature, to lift the arm.

Dr. Saltzman described two cases involving elderly women who underwent reverse shoulder arthroplasty and had excellent outcomes at 6-12 months. One was an 84-year-old who presented with a massive cuff tear as well as arthritis-related joint damage and loss of the joint space. Like many patients with these conditions, she had severe pain, pseudoparalysis of the shoulder, and resulting lack of function; she was able to lift her arm to only about 20 degrees.

At 6 months after the operation, she had no pain and was able to elevate her arm and rotate the arm out to the side.

The other patient was an 86-year-old who had previously lived independently, but who had slipped on ice and sustained multiple fractures of her shoulder. Although her problem wasn’t arthritis related, the reverse shoulder arthroplasty was successful, and she was able to return to independent living.

Findings from a study involving 240 consecutive reverse shoulder arthroplasty procedures in 232 patients (average age, nearly 73 years) showed that average forward elevation increased from 86 degrees to 137 degrees, and average constant score (a validated measure of shoulder function) improved from 23 to 60 at the latest follow-up, indicating substantial improvement, Dr. Saltzman said (J. Bone Joint Surg. Am. 2007;89:1476-85).

In that study, patients with cuff tear arthropathy, osteoarthritis plus cuff tear, or massive cuff tear fared better, whereas those with posttraumatic arthritis and those undergoing revision arthroplasty had worse outcomes.

Of course, patients need to be healthy enough to withstand surgery, but in appropriately selected patients this procedure provides a really nice result, he said.

"You’re taking a very severe problem and giving people a much better quality of life," he added.

Dr. Saltzman disclosed that he serves on the speakers bureau of Carefusion, has made paid presentations for DJO Surgical, and has received research support from Arthrex.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.