Rheumatoid Arthritis

Manufacturers of computed tomography machines have agreed to a standardized set of features that will help ensure that patients receive the appropriate radiation dose when being scanned.

In a conference call with reporters, Dave Fisher, executive director of the Medical Imaging & Technology Alliance (MITA), said that the industry had been working for years to make CT machines safer and that the timing of the announcement was not related to either the Food and Drug Administration's recent heightened interest in radiation or a recent House Energy & Commerce Health Subcommittee hearing.

The five CT manufacturers—General Electric, Siemens, Philips, Toshiba, and Hitachi—all agreed to participate in the MITA “dose check” initiative, said Mr. Fisher.

There are three new main safety features. First, machine operators will receive an on-screen alert—possibly in the form of a pop-up window—when they exceed recommended dose levels. The alert is akin to a yellow caution flag, said Mr. Fisher. The recommended dose—the reference dose—will be determined by clinicians at hospitals and imaging centers, not manufacturers, he said.

The second safeguard will also likely come as a pop-up window: a warning if the dose reaches hazardous levels that could result in burns, hair loss, or other injuries. This “red flag” can be configured to prevent the scan, Mr. Fisher said.

Clinicians, not manufacturers, will have the power to determine whether they want to block a scan or have some other series of instructions or steps to prevent harm, he said.

Manufacturers have agreed to a standardized method of image storage so that they can be incorporated into a registry—if such a registry is developed, as the Obama administration has proposed. The new features will not likely be available until late 2010 or early 2011, Mr. Fisher said. They may come as software upgrades to older machines or add-ons to new scanners being developed now. The process may be delayed if the FDA decides that the features need regulatory clearance, he said.

Manufacturers of computed tomography machines have agreed to a standardized set of features that will help ensure that patients receive the appropriate radiation dose when being scanned.

In a conference call with reporters, Dave Fisher, executive director of the Medical Imaging & Technology Alliance (MITA), said that the industry had been working for years to make CT machines safer and that the timing of the announcement was not related to either the Food and Drug Administration's recent heightened interest in radiation or a recent House Energy & Commerce Health Subcommittee hearing.

The five CT manufacturers—General Electric, Siemens, Philips, Toshiba, and Hitachi—all agreed to participate in the MITA “dose check” initiative, said Mr. Fisher.

There are three new main safety features. First, machine operators will receive an on-screen alert—possibly in the form of a pop-up window—when they exceed recommended dose levels. The alert is akin to a yellow caution flag, said Mr. Fisher. The recommended dose—the reference dose—will be determined by clinicians at hospitals and imaging centers, not manufacturers, he said.

The second safeguard will also likely come as a pop-up window: a warning if the dose reaches hazardous levels that could result in burns, hair loss, or other injuries. This “red flag” can be configured to prevent the scan, Mr. Fisher said.

Clinicians, not manufacturers, will have the power to determine whether they want to block a scan or have some other series of instructions or steps to prevent harm, he said.

Manufacturers have agreed to a standardized method of image storage so that they can be incorporated into a registry—if such a registry is developed, as the Obama administration has proposed. The new features will not likely be available until late 2010 or early 2011, Mr. Fisher said. They may come as software upgrades to older machines or add-ons to new scanners being developed now. The process may be delayed if the FDA decides that the features need regulatory clearance, he said.

Manufacturers of computed tomography machines have agreed to a standardized set of features that will help ensure that patients receive the appropriate radiation dose when being scanned.

In a conference call with reporters, Dave Fisher, executive director of the Medical Imaging & Technology Alliance (MITA), said that the industry had been working for years to make CT machines safer and that the timing of the announcement was not related to either the Food and Drug Administration's recent heightened interest in radiation or a recent House Energy & Commerce Health Subcommittee hearing.

The five CT manufacturers—General Electric, Siemens, Philips, Toshiba, and Hitachi—all agreed to participate in the MITA “dose check” initiative, said Mr. Fisher.

There are three new main safety features. First, machine operators will receive an on-screen alert—possibly in the form of a pop-up window—when they exceed recommended dose levels. The alert is akin to a yellow caution flag, said Mr. Fisher. The recommended dose—the reference dose—will be determined by clinicians at hospitals and imaging centers, not manufacturers, he said.

The second safeguard will also likely come as a pop-up window: a warning if the dose reaches hazardous levels that could result in burns, hair loss, or other injuries. This “red flag” can be configured to prevent the scan, Mr. Fisher said.

Clinicians, not manufacturers, will have the power to determine whether they want to block a scan or have some other series of instructions or steps to prevent harm, he said.

Manufacturers have agreed to a standardized method of image storage so that they can be incorporated into a registry—if such a registry is developed, as the Obama administration has proposed. The new features will not likely be available until late 2010 or early 2011, Mr. Fisher said. They may come as software upgrades to older machines or add-ons to new scanners being developed now. The process may be delayed if the FDA decides that the features need regulatory clearance, he said.

MARINA DEL REY, CALIF. — Thinking about learning ultrasound? You are not alone, according to Dr. Kambiz Motamedi of the radiology department at the University of California, Los Angeles.

In Europe, rheumatologists have been using ultrasound (US) in their offices for years. The use of diagnostic US is catching on among U.S. rheumatologists, too. The American College of Rheumatology is offering its first US course this summer.

Studies, mostly done overseas, suggest its diagnostic value (Rheumatology 2009;48:1,092-7).

Uptake has been slower in the United States because MRI is more readily available and US has a steep learning curve, Dr. Motamedi said during a presentation and workshop on US.

But US is “becoming more and more popular,” among U.S. rheumatologists, he said.

A recent, small study suggests that even self-taught rheumatologists can become proficient ultrasonographers (Arthritis Care Res. 2010;62:155-60).

US is useful to look at superficial structures, including muscles, tendons, ligaments, nerves, and blood vessels, said Dr. Mihaela Taylor of the division of rheumatology at UCLA, who collaborated with Dr. Motamedi on the presentation and workshop.

It has higher soft-tissue resolution than does CT, Dr. Motamedi noted, although CT remains the standard for visualizing bone.

US also can visualize superficial joint structures, and pick up bone erosions, Baker's cysts, fluid behind the patella, and even meniscal tears, if they are in the periphery of the meniscus, acacording to Dr. Motamedi.

Joints can also be seen in motion, meaning that US can help guide joint injections.

“Ultrasound can't replace all that MRI [or CT] does, but it helps diagnose a lot of pathology,” Dr. Motamedi said.

Painless, noninvasive, relatively inexpensive, and free of radiation, it's also readily accepted by patients, Dr. Taylor said.

Although magnetic resonance imaging remains the standard for visualizing deep anatomical structures, such as those of the knee, US is a valid alternative, especially for claustrophobic patients and those with pacemakers or other MRI contraindications. The general concept of US is easy to grasp: Sound waves emitted from a probe are bounced off body structures. Their reflections back to the probe indicate the structure's density. Bone reflects as white. Less-dense structures—those that contain more water—reflect as darker shades.

What's closest to the probe (usually skin) appears at the top of the screen. What's farther away appears lower down.

Anything below bone cortex is artifact. Ultrasound does not penetrate bone, Dr. Taylor said.

Higher sound-wave frequencies mean better resolution but less penetration; lower frequencies penetrate more deeply but give less resolution.

It's helpful to keep the probe in motion and tilt it from side to side to help differentiate structures, Dr. Taylor said.

Information about the American Colege of Rheumatology's US course is at www.rheumatology.org/education/clinicalsymposia/mus.asp

Disclosures: Dr. Motamedi and Dr. Taylor each reported having no relevant financial conflicts.

MARINA DEL REY, CALIF. — Thinking about learning ultrasound? You are not alone, according to Dr. Kambiz Motamedi of the radiology department at the University of California, Los Angeles.

In Europe, rheumatologists have been using ultrasound (US) in their offices for years. The use of diagnostic US is catching on among U.S. rheumatologists, too. The American College of Rheumatology is offering its first US course this summer.

Studies, mostly done overseas, suggest its diagnostic value (Rheumatology 2009;48:1,092-7).

Uptake has been slower in the United States because MRI is more readily available and US has a steep learning curve, Dr. Motamedi said during a presentation and workshop on US.

But US is “becoming more and more popular,” among U.S. rheumatologists, he said.

A recent, small study suggests that even self-taught rheumatologists can become proficient ultrasonographers (Arthritis Care Res. 2010;62:155-60).

US is useful to look at superficial structures, including muscles, tendons, ligaments, nerves, and blood vessels, said Dr. Mihaela Taylor of the division of rheumatology at UCLA, who collaborated with Dr. Motamedi on the presentation and workshop.

It has higher soft-tissue resolution than does CT, Dr. Motamedi noted, although CT remains the standard for visualizing bone.

US also can visualize superficial joint structures, and pick up bone erosions, Baker's cysts, fluid behind the patella, and even meniscal tears, if they are in the periphery of the meniscus, acacording to Dr. Motamedi.

Joints can also be seen in motion, meaning that US can help guide joint injections.

“Ultrasound can't replace all that MRI [or CT] does, but it helps diagnose a lot of pathology,” Dr. Motamedi said.

Painless, noninvasive, relatively inexpensive, and free of radiation, it's also readily accepted by patients, Dr. Taylor said.

Although magnetic resonance imaging remains the standard for visualizing deep anatomical structures, such as those of the knee, US is a valid alternative, especially for claustrophobic patients and those with pacemakers or other MRI contraindications. The general concept of US is easy to grasp: Sound waves emitted from a probe are bounced off body structures. Their reflections back to the probe indicate the structure's density. Bone reflects as white. Less-dense structures—those that contain more water—reflect as darker shades.

What's closest to the probe (usually skin) appears at the top of the screen. What's farther away appears lower down.

Anything below bone cortex is artifact. Ultrasound does not penetrate bone, Dr. Taylor said.

Higher sound-wave frequencies mean better resolution but less penetration; lower frequencies penetrate more deeply but give less resolution.

It's helpful to keep the probe in motion and tilt it from side to side to help differentiate structures, Dr. Taylor said.

Information about the American Colege of Rheumatology's US course is at www.rheumatology.org/education/clinicalsymposia/mus.asp

Disclosures: Dr. Motamedi and Dr. Taylor each reported having no relevant financial conflicts.

MARINA DEL REY, CALIF. — Thinking about learning ultrasound? You are not alone, according to Dr. Kambiz Motamedi of the radiology department at the University of California, Los Angeles.

In Europe, rheumatologists have been using ultrasound (US) in their offices for years. The use of diagnostic US is catching on among U.S. rheumatologists, too. The American College of Rheumatology is offering its first US course this summer.

Studies, mostly done overseas, suggest its diagnostic value (Rheumatology 2009;48:1,092-7).

Uptake has been slower in the United States because MRI is more readily available and US has a steep learning curve, Dr. Motamedi said during a presentation and workshop on US.

But US is “becoming more and more popular,” among U.S. rheumatologists, he said.

A recent, small study suggests that even self-taught rheumatologists can become proficient ultrasonographers (Arthritis Care Res. 2010;62:155-60).

US is useful to look at superficial structures, including muscles, tendons, ligaments, nerves, and blood vessels, said Dr. Mihaela Taylor of the division of rheumatology at UCLA, who collaborated with Dr. Motamedi on the presentation and workshop.

It has higher soft-tissue resolution than does CT, Dr. Motamedi noted, although CT remains the standard for visualizing bone.

US also can visualize superficial joint structures, and pick up bone erosions, Baker's cysts, fluid behind the patella, and even meniscal tears, if they are in the periphery of the meniscus, acacording to Dr. Motamedi.

Joints can also be seen in motion, meaning that US can help guide joint injections.

“Ultrasound can't replace all that MRI [or CT] does, but it helps diagnose a lot of pathology,” Dr. Motamedi said.

Painless, noninvasive, relatively inexpensive, and free of radiation, it's also readily accepted by patients, Dr. Taylor said.

Although magnetic resonance imaging remains the standard for visualizing deep anatomical structures, such as those of the knee, US is a valid alternative, especially for claustrophobic patients and those with pacemakers or other MRI contraindications. The general concept of US is easy to grasp: Sound waves emitted from a probe are bounced off body structures. Their reflections back to the probe indicate the structure's density. Bone reflects as white. Less-dense structures—those that contain more water—reflect as darker shades.

What's closest to the probe (usually skin) appears at the top of the screen. What's farther away appears lower down.

Anything below bone cortex is artifact. Ultrasound does not penetrate bone, Dr. Taylor said.

Higher sound-wave frequencies mean better resolution but less penetration; lower frequencies penetrate more deeply but give less resolution.

It's helpful to keep the probe in motion and tilt it from side to side to help differentiate structures, Dr. Taylor said.

Information about the American Colege of Rheumatology's US course is at www.rheumatology.org/education/clinicalsymposia/mus.asp

Disclosures: Dr. Motamedi and Dr. Taylor each reported having no relevant financial conflicts.

MARINA DEL REY, CALIF. — Like rheumatologists everywhere, Dr. Joan M. Bathon, director of the Johns Hopkins Arthritis Center, sometimes has to rely on clinical trial and error to find the right medications for her patients.

It would be a tremendous help to be able to predict treatment response, and ways to do that may be coming to the clinic in the not-too-distant future, she said at rheumatology seminar sponsored by the University of California, Los Angeles.

Dr. Bathon said she usually starts RA patients on methotrexate. It generally takes 2-4 months to tell if the drug is working.

If methotrexate fails to bring RA under full control, Dr. Bathon said she will add a second agent. If a low to moderate level of disease activity remains, she'll add sulfasalazine, leflunomide, or hydroxychloroquine, depending on patient preference. With more severe residual disease activity, she's likely to add a tumor necrosis factor (TNF) inhibitor.

If one TNF inhibitor doesn't work, she'll try another. If the patient fails two TNF therapies, abatacept or rituximab are the next options, although rituximab is being used more cautiously these days since being linked with progressive multifocal leukoencephalopathy, she said.

Tocilizumab (Actemra)—which was approved by the Food and Drug Administration earlier this year as the first interleukin-6 receptor-inhibiting monoclonal antibody—is also an option if TNF inhibitors fail. The rheumatology community is still figuring out its place in the treatment paradigm, she said.

Research into biomarkers to predict treatment response may make that possible, Dr. Bathon said during her presentation.

While biomarkers for disease progression, treatment toxicity, and other aspects of RA care are also being sought, the biggest efforts are going into finding biomarkers for treatment response, according to Dr. Bathon.

Knowing, for instance, the particular molecular pathway—TNF, B cell, or T cell—that is most active in an individual RA patient would indicate if that patient would benefit from a TNF inhibitor such as etanercept, a B-cell depleter such as rituximab, or some other therapy.

Research into biomarkers for TNF inhibitor response is particularly active.

One study recently found that polymorphism in a TNF-alpha promoter gene (-308 G greater than A SNP) is associated with higher serum levels of TNF-alpha in RA patients, suggesting that the polymorphism is a weak predictor of response to anti-TNF therapy (Rheumatology Reports 2009 [doi:10.4081/rr.2009.e1]).

“If you have this, a TNF [inhibitor] may be the drug of choice,” Dr. Bathon said.

Another recent study measured an array of autoantibodies and cytokines in 93 patients from three different ethnic groups. A 24-biomarker signature was discovered that predicted good to excellent response, as well as lack of response, to etanercept (Arthritis Res. Ther. 2009;11:115).

Disclosures: Dr. Bathon said she had no relevant financial disclosures.

MARINA DEL REY, CALIF. — Like rheumatologists everywhere, Dr. Joan M. Bathon, director of the Johns Hopkins Arthritis Center, sometimes has to rely on clinical trial and error to find the right medications for her patients.

It would be a tremendous help to be able to predict treatment response, and ways to do that may be coming to the clinic in the not-too-distant future, she said at rheumatology seminar sponsored by the University of California, Los Angeles.

Dr. Bathon said she usually starts RA patients on methotrexate. It generally takes 2-4 months to tell if the drug is working.

If methotrexate fails to bring RA under full control, Dr. Bathon said she will add a second agent. If a low to moderate level of disease activity remains, she'll add sulfasalazine, leflunomide, or hydroxychloroquine, depending on patient preference. With more severe residual disease activity, she's likely to add a tumor necrosis factor (TNF) inhibitor.

If one TNF inhibitor doesn't work, she'll try another. If the patient fails two TNF therapies, abatacept or rituximab are the next options, although rituximab is being used more cautiously these days since being linked with progressive multifocal leukoencephalopathy, she said.

Tocilizumab (Actemra)—which was approved by the Food and Drug Administration earlier this year as the first interleukin-6 receptor-inhibiting monoclonal antibody—is also an option if TNF inhibitors fail. The rheumatology community is still figuring out its place in the treatment paradigm, she said.

Research into biomarkers to predict treatment response may make that possible, Dr. Bathon said during her presentation.

While biomarkers for disease progression, treatment toxicity, and other aspects of RA care are also being sought, the biggest efforts are going into finding biomarkers for treatment response, according to Dr. Bathon.

Knowing, for instance, the particular molecular pathway—TNF, B cell, or T cell—that is most active in an individual RA patient would indicate if that patient would benefit from a TNF inhibitor such as etanercept, a B-cell depleter such as rituximab, or some other therapy.

Research into biomarkers for TNF inhibitor response is particularly active.

One study recently found that polymorphism in a TNF-alpha promoter gene (-308 G greater than A SNP) is associated with higher serum levels of TNF-alpha in RA patients, suggesting that the polymorphism is a weak predictor of response to anti-TNF therapy (Rheumatology Reports 2009 [doi:10.4081/rr.2009.e1]).

“If you have this, a TNF [inhibitor] may be the drug of choice,” Dr. Bathon said.

Another recent study measured an array of autoantibodies and cytokines in 93 patients from three different ethnic groups. A 24-biomarker signature was discovered that predicted good to excellent response, as well as lack of response, to etanercept (Arthritis Res. Ther. 2009;11:115).

Disclosures: Dr. Bathon said she had no relevant financial disclosures.

MARINA DEL REY, CALIF. — Like rheumatologists everywhere, Dr. Joan M. Bathon, director of the Johns Hopkins Arthritis Center, sometimes has to rely on clinical trial and error to find the right medications for her patients.

It would be a tremendous help to be able to predict treatment response, and ways to do that may be coming to the clinic in the not-too-distant future, she said at rheumatology seminar sponsored by the University of California, Los Angeles.

Dr. Bathon said she usually starts RA patients on methotrexate. It generally takes 2-4 months to tell if the drug is working.

If methotrexate fails to bring RA under full control, Dr. Bathon said she will add a second agent. If a low to moderate level of disease activity remains, she'll add sulfasalazine, leflunomide, or hydroxychloroquine, depending on patient preference. With more severe residual disease activity, she's likely to add a tumor necrosis factor (TNF) inhibitor.

If one TNF inhibitor doesn't work, she'll try another. If the patient fails two TNF therapies, abatacept or rituximab are the next options, although rituximab is being used more cautiously these days since being linked with progressive multifocal leukoencephalopathy, she said.

Tocilizumab (Actemra)—which was approved by the Food and Drug Administration earlier this year as the first interleukin-6 receptor-inhibiting monoclonal antibody—is also an option if TNF inhibitors fail. The rheumatology community is still figuring out its place in the treatment paradigm, she said.

Research into biomarkers to predict treatment response may make that possible, Dr. Bathon said during her presentation.

While biomarkers for disease progression, treatment toxicity, and other aspects of RA care are also being sought, the biggest efforts are going into finding biomarkers for treatment response, according to Dr. Bathon.

Knowing, for instance, the particular molecular pathway—TNF, B cell, or T cell—that is most active in an individual RA patient would indicate if that patient would benefit from a TNF inhibitor such as etanercept, a B-cell depleter such as rituximab, or some other therapy.

Research into biomarkers for TNF inhibitor response is particularly active.

One study recently found that polymorphism in a TNF-alpha promoter gene (-308 G greater than A SNP) is associated with higher serum levels of TNF-alpha in RA patients, suggesting that the polymorphism is a weak predictor of response to anti-TNF therapy (Rheumatology Reports 2009 [doi:10.4081/rr.2009.e1]).

“If you have this, a TNF [inhibitor] may be the drug of choice,” Dr. Bathon said.

Another recent study measured an array of autoantibodies and cytokines in 93 patients from three different ethnic groups. A 24-biomarker signature was discovered that predicted good to excellent response, as well as lack of response, to etanercept (Arthritis Res. Ther. 2009;11:115).

Disclosures: Dr. Bathon said she had no relevant financial disclosures.

MARINA DEL REY, CALIF. — Rheumatoid arthritis patients with well-controlled disease may benefit from performing fat-burning exercises accompanied by resistance training—such as weight lifting—to preserve or even build muscle mass, according to Dr. Joan M. Bathon.

A seemingly fit patient with well-controlled rheumatoid arthritis (RA) and a normal body mass index may still have excess body fat, elevated C-reactive protein (CRP) levels, and increased coronary artery disease risk, said Dr. Bathon, professor of medicine and director of the Johns Hopkins Arthritis Center in Baltimore.

RA's chronic inflammation can waste muscles, she explained at a rheumatology seminar sponsored by the University of California, Los Angeles. Appendicular fat correlates with disability, and visceral fat correlates with coronary artery disease, she said. When patients have well-controlled RA, their high CRP levels might be coming not from the inflamed joints, but rather from fat deposits, and might signal an increased risk of coronary artery disease.

Dr. Bathon and her colleagues performed anthropomorphic measurements and dual-energy x-ray absorptiometry (DXA) scanning to assess fat:muscle ratio in 72 men and 117 women with RA and moderate disability. A single CT image of the abdomen in the axial plane was used to assess the amount of visceral fat.

Women with RA and BMIs below 25 kg/m

Disclosures: Dr. Bathon said she had no relevant disclosures.

A seemingly fit RA patient with a normal body mass index may have a number of heart disease risk factors.

Source © Luc Ubaghs/iStockphoto.com

MARINA DEL REY, CALIF. — Rheumatoid arthritis patients with well-controlled disease may benefit from performing fat-burning exercises accompanied by resistance training—such as weight lifting—to preserve or even build muscle mass, according to Dr. Joan M. Bathon.

A seemingly fit patient with well-controlled rheumatoid arthritis (RA) and a normal body mass index may still have excess body fat, elevated C-reactive protein (CRP) levels, and increased coronary artery disease risk, said Dr. Bathon, professor of medicine and director of the Johns Hopkins Arthritis Center in Baltimore.

RA's chronic inflammation can waste muscles, she explained at a rheumatology seminar sponsored by the University of California, Los Angeles. Appendicular fat correlates with disability, and visceral fat correlates with coronary artery disease, she said. When patients have well-controlled RA, their high CRP levels might be coming not from the inflamed joints, but rather from fat deposits, and might signal an increased risk of coronary artery disease.

Dr. Bathon and her colleagues performed anthropomorphic measurements and dual-energy x-ray absorptiometry (DXA) scanning to assess fat:muscle ratio in 72 men and 117 women with RA and moderate disability. A single CT image of the abdomen in the axial plane was used to assess the amount of visceral fat.

Women with RA and BMIs below 25 kg/m

Disclosures: Dr. Bathon said she had no relevant disclosures.

A seemingly fit RA patient with a normal body mass index may have a number of heart disease risk factors.

Source © Luc Ubaghs/iStockphoto.com

MARINA DEL REY, CALIF. — Rheumatoid arthritis patients with well-controlled disease may benefit from performing fat-burning exercises accompanied by resistance training—such as weight lifting—to preserve or even build muscle mass, according to Dr. Joan M. Bathon.

A seemingly fit patient with well-controlled rheumatoid arthritis (RA) and a normal body mass index may still have excess body fat, elevated C-reactive protein (CRP) levels, and increased coronary artery disease risk, said Dr. Bathon, professor of medicine and director of the Johns Hopkins Arthritis Center in Baltimore.

RA's chronic inflammation can waste muscles, she explained at a rheumatology seminar sponsored by the University of California, Los Angeles. Appendicular fat correlates with disability, and visceral fat correlates with coronary artery disease, she said. When patients have well-controlled RA, their high CRP levels might be coming not from the inflamed joints, but rather from fat deposits, and might signal an increased risk of coronary artery disease.

Dr. Bathon and her colleagues performed anthropomorphic measurements and dual-energy x-ray absorptiometry (DXA) scanning to assess fat:muscle ratio in 72 men and 117 women with RA and moderate disability. A single CT image of the abdomen in the axial plane was used to assess the amount of visceral fat.

Women with RA and BMIs below 25 kg/m

Disclosures: Dr. Bathon said she had no relevant disclosures.

A seemingly fit RA patient with a normal body mass index may have a number of heart disease risk factors.

Source © Luc Ubaghs/iStockphoto.com

Major Finding: For every 10-year increase in age, the chance of a patient with RA receiving more intensive treatment reduces by approximately 22%.

Data Source: Repeat cross-sectional study of 290 patients with RA.

Disclosures: Dr. Ma and Dr. Deighton declared no conflicts.

BIRMINGHAM, ENGLAND — Elderly patients with rheumatoid arthritis are treated less intensively than their younger counterparts, despite experiencing similar levels of disease activity.

Data from a cross-sectional study that was conducted at two centers in the United Kingdom show that for every 10-year increase in age, the chance of an RA patient's receiving more intensive treatment is reduced by approximately 22%.

“Unfortunately, the elderly population is not well represented in clinical studies,” said Dr. Margaret H.Y. Ma, a clinical research fellow at King's College Hospital in London.

“In routine clinical practice, we see a much larger proportion of elderly patients, and it is unclear currently how well we treat this population,” Dr. Ma said at the annual meeting of the British Society for Rheumatology.

The incidence and prevalence of RA increases with age, and it is in the elderly (aged 65 years and older) that disease-related disabilities usually have the greatest impact. Therefore, the aim of the study was to examine the effects of age and other variables on the treatment of RA.

Dr. Ma reported that the study, performed in 2009-2010 and involving 290 participants, was a repeat of a similar investigation that was performed in 2007-2008 and involved 236 people. The original and repeat cohorts of patients were similar in terms of age (58 and 59 years, respectively), sex (79% vs. 81% female), and ethnicity (70% vs. 72% white; 20% vs. 19% Afro-Caribbean). Treatment plans also were similar between the cohorts (80% vs. 81% taking disease-modifying antirheumatic drugs [DMARDs]; 11% vs. 11% taking steroids; 15% vs. 17% taking biologics). Patients in the repeat study, however, were more likely to have longer disease duration (10 years vs. 8.3 years) as well as a lower 28-joint disease activity score, or DAS28 (4.1 vs. 3.78), than did those who took part in the original study.

Both studies showed that there was a significant effect of age and disease activity on the chances that patients would be given more intensive therapy. While older patients were less likely to receive treatment increases (odds ratio, 0.83 in the original study and 0.82 in the repeat study), higher disease activity was associated with more intensive therapy (OR, 2.15 and 2.39, respectively).

Adjustment for possible confounding factors revealed that age and disease activity were the only determinants of treatment changes.

In the 2009-2010 cohort, the percentage of patients aged 65 years and older on DMARDs, steroids, and biologics was 77%, 11%, and 11%, whereas the percentage of those younger than 65 years who took these drugs was 83%, 19%, and 19%. When investigators compared patients aged 65 years or older vs. those younger than 65 years, they found that there were no differences in disease activity, with both age groups exhibiting a similar spectrum of disease activity in both the original and repeat studies. However, for the same DAS28, elderly patients were less likely than younger patients to receive an increase in therapy if they had more moderate disease, Dr. Ma reported.

Physicians treat very active disease more aggressively, Dr. Chris Deighton, consultant rheumatologist at the Derbyshire Royal Infirmary, Derby, England, commented. “If they have moderate disease, then there is probably more of a negotiation that takes place” between the patient and physician, he said.

Major Finding: For every 10-year increase in age, the chance of a patient with RA receiving more intensive treatment reduces by approximately 22%.

Data Source: Repeat cross-sectional study of 290 patients with RA.

Disclosures: Dr. Ma and Dr. Deighton declared no conflicts.

BIRMINGHAM, ENGLAND — Elderly patients with rheumatoid arthritis are treated less intensively than their younger counterparts, despite experiencing similar levels of disease activity.

Data from a cross-sectional study that was conducted at two centers in the United Kingdom show that for every 10-year increase in age, the chance of an RA patient's receiving more intensive treatment is reduced by approximately 22%.

“Unfortunately, the elderly population is not well represented in clinical studies,” said Dr. Margaret H.Y. Ma, a clinical research fellow at King's College Hospital in London.

“In routine clinical practice, we see a much larger proportion of elderly patients, and it is unclear currently how well we treat this population,” Dr. Ma said at the annual meeting of the British Society for Rheumatology.

The incidence and prevalence of RA increases with age, and it is in the elderly (aged 65 years and older) that disease-related disabilities usually have the greatest impact. Therefore, the aim of the study was to examine the effects of age and other variables on the treatment of RA.

Dr. Ma reported that the study, performed in 2009-2010 and involving 290 participants, was a repeat of a similar investigation that was performed in 2007-2008 and involved 236 people. The original and repeat cohorts of patients were similar in terms of age (58 and 59 years, respectively), sex (79% vs. 81% female), and ethnicity (70% vs. 72% white; 20% vs. 19% Afro-Caribbean). Treatment plans also were similar between the cohorts (80% vs. 81% taking disease-modifying antirheumatic drugs [DMARDs]; 11% vs. 11% taking steroids; 15% vs. 17% taking biologics). Patients in the repeat study, however, were more likely to have longer disease duration (10 years vs. 8.3 years) as well as a lower 28-joint disease activity score, or DAS28 (4.1 vs. 3.78), than did those who took part in the original study.

Both studies showed that there was a significant effect of age and disease activity on the chances that patients would be given more intensive therapy. While older patients were less likely to receive treatment increases (odds ratio, 0.83 in the original study and 0.82 in the repeat study), higher disease activity was associated with more intensive therapy (OR, 2.15 and 2.39, respectively).

Adjustment for possible confounding factors revealed that age and disease activity were the only determinants of treatment changes.

In the 2009-2010 cohort, the percentage of patients aged 65 years and older on DMARDs, steroids, and biologics was 77%, 11%, and 11%, whereas the percentage of those younger than 65 years who took these drugs was 83%, 19%, and 19%. When investigators compared patients aged 65 years or older vs. those younger than 65 years, they found that there were no differences in disease activity, with both age groups exhibiting a similar spectrum of disease activity in both the original and repeat studies. However, for the same DAS28, elderly patients were less likely than younger patients to receive an increase in therapy if they had more moderate disease, Dr. Ma reported.

Physicians treat very active disease more aggressively, Dr. Chris Deighton, consultant rheumatologist at the Derbyshire Royal Infirmary, Derby, England, commented. “If they have moderate disease, then there is probably more of a negotiation that takes place” between the patient and physician, he said.

Major Finding: For every 10-year increase in age, the chance of a patient with RA receiving more intensive treatment reduces by approximately 22%.

Data Source: Repeat cross-sectional study of 290 patients with RA.

Disclosures: Dr. Ma and Dr. Deighton declared no conflicts.

BIRMINGHAM, ENGLAND — Elderly patients with rheumatoid arthritis are treated less intensively than their younger counterparts, despite experiencing similar levels of disease activity.

Data from a cross-sectional study that was conducted at two centers in the United Kingdom show that for every 10-year increase in age, the chance of an RA patient's receiving more intensive treatment is reduced by approximately 22%.

“Unfortunately, the elderly population is not well represented in clinical studies,” said Dr. Margaret H.Y. Ma, a clinical research fellow at King's College Hospital in London.

“In routine clinical practice, we see a much larger proportion of elderly patients, and it is unclear currently how well we treat this population,” Dr. Ma said at the annual meeting of the British Society for Rheumatology.

The incidence and prevalence of RA increases with age, and it is in the elderly (aged 65 years and older) that disease-related disabilities usually have the greatest impact. Therefore, the aim of the study was to examine the effects of age and other variables on the treatment of RA.

Dr. Ma reported that the study, performed in 2009-2010 and involving 290 participants, was a repeat of a similar investigation that was performed in 2007-2008 and involved 236 people. The original and repeat cohorts of patients were similar in terms of age (58 and 59 years, respectively), sex (79% vs. 81% female), and ethnicity (70% vs. 72% white; 20% vs. 19% Afro-Caribbean). Treatment plans also were similar between the cohorts (80% vs. 81% taking disease-modifying antirheumatic drugs [DMARDs]; 11% vs. 11% taking steroids; 15% vs. 17% taking biologics). Patients in the repeat study, however, were more likely to have longer disease duration (10 years vs. 8.3 years) as well as a lower 28-joint disease activity score, or DAS28 (4.1 vs. 3.78), than did those who took part in the original study.

Both studies showed that there was a significant effect of age and disease activity on the chances that patients would be given more intensive therapy. While older patients were less likely to receive treatment increases (odds ratio, 0.83 in the original study and 0.82 in the repeat study), higher disease activity was associated with more intensive therapy (OR, 2.15 and 2.39, respectively).

Adjustment for possible confounding factors revealed that age and disease activity were the only determinants of treatment changes.

In the 2009-2010 cohort, the percentage of patients aged 65 years and older on DMARDs, steroids, and biologics was 77%, 11%, and 11%, whereas the percentage of those younger than 65 years who took these drugs was 83%, 19%, and 19%. When investigators compared patients aged 65 years or older vs. those younger than 65 years, they found that there were no differences in disease activity, with both age groups exhibiting a similar spectrum of disease activity in both the original and repeat studies. However, for the same DAS28, elderly patients were less likely than younger patients to receive an increase in therapy if they had more moderate disease, Dr. Ma reported.

Physicians treat very active disease more aggressively, Dr. Chris Deighton, consultant rheumatologist at the Derbyshire Royal Infirmary, Derby, England, commented. “If they have moderate disease, then there is probably more of a negotiation that takes place” between the patient and physician, he said.

BIRMINGHAM, ENGLAND — Two-thirds of rheumatoid arthritis patients in the United Kingdom do not receive any foot care, despite a high prevalence of foot pathology known to be associated with the disease, according to new study findings.

Conservative foot treatment is often bypassed, with many patients going straight to surgery if foot problem develops, judging from data from the Early Rheumatoid Arthritis Study (ERAS), which has been collecting data since 1987 and now has over 9 years of follow-up data available.

“This is the largest study to date to look at patients with rheumatoid arthritis and conservative foot care and foot surgery on a national level,” said Michael R. Backhouse, a doctoral student in musculoskeletal disease at the University of Leeds (England).

“The striking finding that two-thirds of patients did not receive any foot care is unfortunately consistent with previously described suboptimal service provision across the country,” he reported.

Foot pathology is estimated to occur in up to 90% of RA patients (Foot Ankle Int. 1994;15:608-13; Acta Orthop. 2008;79:257-61), with about 10% developing foot ulcers (Arthritis Rheum. 2008;15;59:200-5) and almost half unable to perform basic foot care themselves (Musculoskeletal Care. 2009;7:57-65). Few data exist on the value of conservative and surgical foot interventions, however, with little randomized, controlled trial evidence.

Using data from the ERAS inception cohort, Mr. Backhouse and associates aimed to describe the use of foot care services and surgery in patients with early RA.

The mean age of the 1,237 patients they studied was 54 years at the onset of disease, with a median disease activity score of 4.09, and with 82% ever identified as being rheumatoid factor positive.

Erosions were identified on x-ray in 79% of patients, with 34% showing evidence of rheumatoid nodules.

Follow-up data were available for all recruited patients at 3 years, for 1,123 patients (91%) at 5 years, and for 680 (55%) at 9 years.

Overall, only 36% (n = 444) of patients received foot care, of which the majority (82%) had consulted a podiatrist. The remainder had seen an orthotist or had surgery.

Within the first 9 years of follow-up, 54 foot operations were performed in 38 patients (3%). The time to surgery ranged from 7 months to 81 months, with a median of 51 months. Over half (n = 22) of the patients who received surgery, however, had never seen a podiatrist.

Over the more than 9 years of follow-up, 101 operations were performed on the feet of 71 patients (6%), with 47 patients having one operation, 19 patients having two procedures, 4 patients undergoing three surgeries, and 1 patient requiring four interventions.

The time to the first operation ranged from 7 months to 221 months, with a median time to surgery of 79 months. The location of surgery was the metatarsophalangeal joint in the majority of patients (67%), with the other locations being the soft tissue (24%), and ankle or hindfoot (9%).

More women than men accessed podiatry and surgical services, and younger patients were more likely than were older patients to undergo surgery instead of conservative therapy, “although there is no real justification for the latter,” Mr. Backhouse observed.

He noted that one limitation of the study was that patient recruitment began before the publication of the U.K. guidelines on RA treatment and before the routine use of biologic therapies. However, the timing also meant that there are now long-term data on the development of foot problems and their management in this RA population.

Disclosures: Arthritis Research UK and the Bupa Foundation funded the ERAS study. Mr. Backhouse had no conflicts of interest to declare.

Foot pathology is estimated to occur in up to 90% of patients with RA, with about 10% developing foot ulcers and close to half unable to care for their own feet.

Source © Joe_Potato/iStockphoto.com

BIRMINGHAM, ENGLAND — Two-thirds of rheumatoid arthritis patients in the United Kingdom do not receive any foot care, despite a high prevalence of foot pathology known to be associated with the disease, according to new study findings.

Conservative foot treatment is often bypassed, with many patients going straight to surgery if foot problem develops, judging from data from the Early Rheumatoid Arthritis Study (ERAS), which has been collecting data since 1987 and now has over 9 years of follow-up data available.

“This is the largest study to date to look at patients with rheumatoid arthritis and conservative foot care and foot surgery on a national level,” said Michael R. Backhouse, a doctoral student in musculoskeletal disease at the University of Leeds (England).

“The striking finding that two-thirds of patients did not receive any foot care is unfortunately consistent with previously described suboptimal service provision across the country,” he reported.

Foot pathology is estimated to occur in up to 90% of RA patients (Foot Ankle Int. 1994;15:608-13; Acta Orthop. 2008;79:257-61), with about 10% developing foot ulcers (Arthritis Rheum. 2008;15;59:200-5) and almost half unable to perform basic foot care themselves (Musculoskeletal Care. 2009;7:57-65). Few data exist on the value of conservative and surgical foot interventions, however, with little randomized, controlled trial evidence.

Using data from the ERAS inception cohort, Mr. Backhouse and associates aimed to describe the use of foot care services and surgery in patients with early RA.

The mean age of the 1,237 patients they studied was 54 years at the onset of disease, with a median disease activity score of 4.09, and with 82% ever identified as being rheumatoid factor positive.

Erosions were identified on x-ray in 79% of patients, with 34% showing evidence of rheumatoid nodules.

Follow-up data were available for all recruited patients at 3 years, for 1,123 patients (91%) at 5 years, and for 680 (55%) at 9 years.

Overall, only 36% (n = 444) of patients received foot care, of which the majority (82%) had consulted a podiatrist. The remainder had seen an orthotist or had surgery.

Within the first 9 years of follow-up, 54 foot operations were performed in 38 patients (3%). The time to surgery ranged from 7 months to 81 months, with a median of 51 months. Over half (n = 22) of the patients who received surgery, however, had never seen a podiatrist.

Over the more than 9 years of follow-up, 101 operations were performed on the feet of 71 patients (6%), with 47 patients having one operation, 19 patients having two procedures, 4 patients undergoing three surgeries, and 1 patient requiring four interventions.

The time to the first operation ranged from 7 months to 221 months, with a median time to surgery of 79 months. The location of surgery was the metatarsophalangeal joint in the majority of patients (67%), with the other locations being the soft tissue (24%), and ankle or hindfoot (9%).

More women than men accessed podiatry and surgical services, and younger patients were more likely than were older patients to undergo surgery instead of conservative therapy, “although there is no real justification for the latter,” Mr. Backhouse observed.

He noted that one limitation of the study was that patient recruitment began before the publication of the U.K. guidelines on RA treatment and before the routine use of biologic therapies. However, the timing also meant that there are now long-term data on the development of foot problems and their management in this RA population.

Disclosures: Arthritis Research UK and the Bupa Foundation funded the ERAS study. Mr. Backhouse had no conflicts of interest to declare.

Foot pathology is estimated to occur in up to 90% of patients with RA, with about 10% developing foot ulcers and close to half unable to care for their own feet.

Source © Joe_Potato/iStockphoto.com

BIRMINGHAM, ENGLAND — Two-thirds of rheumatoid arthritis patients in the United Kingdom do not receive any foot care, despite a high prevalence of foot pathology known to be associated with the disease, according to new study findings.

Conservative foot treatment is often bypassed, with many patients going straight to surgery if foot problem develops, judging from data from the Early Rheumatoid Arthritis Study (ERAS), which has been collecting data since 1987 and now has over 9 years of follow-up data available.

“This is the largest study to date to look at patients with rheumatoid arthritis and conservative foot care and foot surgery on a national level,” said Michael R. Backhouse, a doctoral student in musculoskeletal disease at the University of Leeds (England).

“The striking finding that two-thirds of patients did not receive any foot care is unfortunately consistent with previously described suboptimal service provision across the country,” he reported.

Foot pathology is estimated to occur in up to 90% of RA patients (Foot Ankle Int. 1994;15:608-13; Acta Orthop. 2008;79:257-61), with about 10% developing foot ulcers (Arthritis Rheum. 2008;15;59:200-5) and almost half unable to perform basic foot care themselves (Musculoskeletal Care. 2009;7:57-65). Few data exist on the value of conservative and surgical foot interventions, however, with little randomized, controlled trial evidence.

Using data from the ERAS inception cohort, Mr. Backhouse and associates aimed to describe the use of foot care services and surgery in patients with early RA.

The mean age of the 1,237 patients they studied was 54 years at the onset of disease, with a median disease activity score of 4.09, and with 82% ever identified as being rheumatoid factor positive.

Erosions were identified on x-ray in 79% of patients, with 34% showing evidence of rheumatoid nodules.

Follow-up data were available for all recruited patients at 3 years, for 1,123 patients (91%) at 5 years, and for 680 (55%) at 9 years.

Overall, only 36% (n = 444) of patients received foot care, of which the majority (82%) had consulted a podiatrist. The remainder had seen an orthotist or had surgery.

Within the first 9 years of follow-up, 54 foot operations were performed in 38 patients (3%). The time to surgery ranged from 7 months to 81 months, with a median of 51 months. Over half (n = 22) of the patients who received surgery, however, had never seen a podiatrist.

Over the more than 9 years of follow-up, 101 operations were performed on the feet of 71 patients (6%), with 47 patients having one operation, 19 patients having two procedures, 4 patients undergoing three surgeries, and 1 patient requiring four interventions.

The time to the first operation ranged from 7 months to 221 months, with a median time to surgery of 79 months. The location of surgery was the metatarsophalangeal joint in the majority of patients (67%), with the other locations being the soft tissue (24%), and ankle or hindfoot (9%).

More women than men accessed podiatry and surgical services, and younger patients were more likely than were older patients to undergo surgery instead of conservative therapy, “although there is no real justification for the latter,” Mr. Backhouse observed.

He noted that one limitation of the study was that patient recruitment began before the publication of the U.K. guidelines on RA treatment and before the routine use of biologic therapies. However, the timing also meant that there are now long-term data on the development of foot problems and their management in this RA population.

Disclosures: Arthritis Research UK and the Bupa Foundation funded the ERAS study. Mr. Backhouse had no conflicts of interest to declare.

Foot pathology is estimated to occur in up to 90% of patients with RA, with about 10% developing foot ulcers and close to half unable to care for their own feet.

Source © Joe_Potato/iStockphoto.com

BIRMINGHAM, ENGLAND — Foot and ankle pain affects more women than men after age 45 years, when osteoarthritis often manifests.

A systematic review of available literature from eight studies from around the world estimated that foot and ankle pain occurs in 15%-30% of women and 10%-20% of men.

It is not clear what proportion of people who have pain have OA, said Martin J. Thomas, a research physiotherapist at the Arthritis Research UK National Primary Care Centre of Keele (England) University.

Mr. Thomas added that the aim of this review was to establish the baseline prevalence of ankle pain in the community in order to have a point of comparison for future work on the prevalence of symptomatic foot and ankle OA.

“Foot pain and foot problems are very common in primary care,” said Dr. Edward Roddy, a consultant rheumatologist at the Haywood Hospital in Stoke-on-Trent, England, and part of the research team at Keele University.

Compared with other regional pain sites, such as the knee and hand, the foot has been studied less and “is just generally less well understood,” Dr. Roddy observed.

The researchers therefore plan to undertake a longitudinal study to better characterize the epidemiology of foot and ankle OA in primary care and determine the likely causes of foot pain.

Already, the team has discovered that foot pain is the most common reason for older adults to consult a general physician.

Dr. Roddy and associates looked at the reasons for musculoskeletal foot consultations in a primary care cohort of people older than 50 years.

They identified 5,706 people who were taking part in the North Staffordshire Osteoarthritis Project (NorStOP), a 3-year, population-based cohort study in which participants from three local general practices had first completed a general health survey.

Patients who reported experiencing any pain in the hands, hips, knees, or feet in the previous 12 months then completed a more specific survey about their regional pain, and their permission was sought for researchers to assess their medical records and to recontact them.

For the current analysis, the team looked at only those patients who reported foot pain or foot problems in the preceding 12 months.

After the exclusion of patients who had not actually consulted in the 18 months before being surveyed, there were 4,402 (71%) people who consented to allowing their medical records to be reviewed.

Linking the NorStOP data to an electronic consultations database revealed that 350 of 3,858 (9%) people in the general population cohort studied actually consulted for foot pain or problems after completing the regional pain survey, whereas 3,508 (91%) who had completed the survey did not subsequently consult.

Looking at the reasons why 9% of people consulted while the remainder who had completed the survey and reported foot pain or problems did not, the researchers found that experiencing foot pain was the most common reason for presenting to a primary care doctor for a musculoskeletal problem (odds ratio, 2.04).

Frequent consultations for other health problems was another significant predictor of consulting for foot pain or problems (OR, 1.65), as was the belief that treatments were effective in controlling disease (OR, 1.54).

“We've only looked at musculoskeletal consultations, so we may have underestimated consultations,” said Dr. Roddy. However, he conceded that the definition of foot pain used was very broad and that further research is needed.

Dr. Roddy said that the next challenge was to try to work out what exactly is causing the foot pain and whether this resulted from OA, another musculoskeletal condition, or perhaps another reason entirely.

The Keele researchers will be performing a study asking people who consult their primary care practitioner to not only complete a questionnaire about their foot problems, but also attend the hospital for clinical examination.

Disclosures: Arthritis Research UK provided financial support for the studies. Dr. Thomas and Dr. Roddy had no relevant financial disclosure or conflicts of interest.

BIRMINGHAM, ENGLAND — Foot and ankle pain affects more women than men after age 45 years, when osteoarthritis often manifests.

A systematic review of available literature from eight studies from around the world estimated that foot and ankle pain occurs in 15%-30% of women and 10%-20% of men.

It is not clear what proportion of people who have pain have OA, said Martin J. Thomas, a research physiotherapist at the Arthritis Research UK National Primary Care Centre of Keele (England) University.

Mr. Thomas added that the aim of this review was to establish the baseline prevalence of ankle pain in the community in order to have a point of comparison for future work on the prevalence of symptomatic foot and ankle OA.

“Foot pain and foot problems are very common in primary care,” said Dr. Edward Roddy, a consultant rheumatologist at the Haywood Hospital in Stoke-on-Trent, England, and part of the research team at Keele University.

Compared with other regional pain sites, such as the knee and hand, the foot has been studied less and “is just generally less well understood,” Dr. Roddy observed.

The researchers therefore plan to undertake a longitudinal study to better characterize the epidemiology of foot and ankle OA in primary care and determine the likely causes of foot pain.

Already, the team has discovered that foot pain is the most common reason for older adults to consult a general physician.

Dr. Roddy and associates looked at the reasons for musculoskeletal foot consultations in a primary care cohort of people older than 50 years.

They identified 5,706 people who were taking part in the North Staffordshire Osteoarthritis Project (NorStOP), a 3-year, population-based cohort study in which participants from three local general practices had first completed a general health survey.

Patients who reported experiencing any pain in the hands, hips, knees, or feet in the previous 12 months then completed a more specific survey about their regional pain, and their permission was sought for researchers to assess their medical records and to recontact them.

For the current analysis, the team looked at only those patients who reported foot pain or foot problems in the preceding 12 months.

After the exclusion of patients who had not actually consulted in the 18 months before being surveyed, there were 4,402 (71%) people who consented to allowing their medical records to be reviewed.

Linking the NorStOP data to an electronic consultations database revealed that 350 of 3,858 (9%) people in the general population cohort studied actually consulted for foot pain or problems after completing the regional pain survey, whereas 3,508 (91%) who had completed the survey did not subsequently consult.

Looking at the reasons why 9% of people consulted while the remainder who had completed the survey and reported foot pain or problems did not, the researchers found that experiencing foot pain was the most common reason for presenting to a primary care doctor for a musculoskeletal problem (odds ratio, 2.04).

Frequent consultations for other health problems was another significant predictor of consulting for foot pain or problems (OR, 1.65), as was the belief that treatments were effective in controlling disease (OR, 1.54).

“We've only looked at musculoskeletal consultations, so we may have underestimated consultations,” said Dr. Roddy. However, he conceded that the definition of foot pain used was very broad and that further research is needed.

Dr. Roddy said that the next challenge was to try to work out what exactly is causing the foot pain and whether this resulted from OA, another musculoskeletal condition, or perhaps another reason entirely.

The Keele researchers will be performing a study asking people who consult their primary care practitioner to not only complete a questionnaire about their foot problems, but also attend the hospital for clinical examination.

Disclosures: Arthritis Research UK provided financial support for the studies. Dr. Thomas and Dr. Roddy had no relevant financial disclosure or conflicts of interest.

BIRMINGHAM, ENGLAND — Foot and ankle pain affects more women than men after age 45 years, when osteoarthritis often manifests.

A systematic review of available literature from eight studies from around the world estimated that foot and ankle pain occurs in 15%-30% of women and 10%-20% of men.

It is not clear what proportion of people who have pain have OA, said Martin J. Thomas, a research physiotherapist at the Arthritis Research UK National Primary Care Centre of Keele (England) University.

Mr. Thomas added that the aim of this review was to establish the baseline prevalence of ankle pain in the community in order to have a point of comparison for future work on the prevalence of symptomatic foot and ankle OA.

“Foot pain and foot problems are very common in primary care,” said Dr. Edward Roddy, a consultant rheumatologist at the Haywood Hospital in Stoke-on-Trent, England, and part of the research team at Keele University.

Compared with other regional pain sites, such as the knee and hand, the foot has been studied less and “is just generally less well understood,” Dr. Roddy observed.

The researchers therefore plan to undertake a longitudinal study to better characterize the epidemiology of foot and ankle OA in primary care and determine the likely causes of foot pain.

Already, the team has discovered that foot pain is the most common reason for older adults to consult a general physician.

Dr. Roddy and associates looked at the reasons for musculoskeletal foot consultations in a primary care cohort of people older than 50 years.

They identified 5,706 people who were taking part in the North Staffordshire Osteoarthritis Project (NorStOP), a 3-year, population-based cohort study in which participants from three local general practices had first completed a general health survey.

Patients who reported experiencing any pain in the hands, hips, knees, or feet in the previous 12 months then completed a more specific survey about their regional pain, and their permission was sought for researchers to assess their medical records and to recontact them.

For the current analysis, the team looked at only those patients who reported foot pain or foot problems in the preceding 12 months.

After the exclusion of patients who had not actually consulted in the 18 months before being surveyed, there were 4,402 (71%) people who consented to allowing their medical records to be reviewed.

Linking the NorStOP data to an electronic consultations database revealed that 350 of 3,858 (9%) people in the general population cohort studied actually consulted for foot pain or problems after completing the regional pain survey, whereas 3,508 (91%) who had completed the survey did not subsequently consult.

Looking at the reasons why 9% of people consulted while the remainder who had completed the survey and reported foot pain or problems did not, the researchers found that experiencing foot pain was the most common reason for presenting to a primary care doctor for a musculoskeletal problem (odds ratio, 2.04).

Frequent consultations for other health problems was another significant predictor of consulting for foot pain or problems (OR, 1.65), as was the belief that treatments were effective in controlling disease (OR, 1.54).

“We've only looked at musculoskeletal consultations, so we may have underestimated consultations,” said Dr. Roddy. However, he conceded that the definition of foot pain used was very broad and that further research is needed.

Dr. Roddy said that the next challenge was to try to work out what exactly is causing the foot pain and whether this resulted from OA, another musculoskeletal condition, or perhaps another reason entirely.

The Keele researchers will be performing a study asking people who consult their primary care practitioner to not only complete a questionnaire about their foot problems, but also attend the hospital for clinical examination.

Disclosures: Arthritis Research UK provided financial support for the studies. Dr. Thomas and Dr. Roddy had no relevant financial disclosure or conflicts of interest.

Fewer minorities have arthritis but they feel its impact far more acutely in terms of pain severity and limitations on function, compared with whites, according to National Health Interview Survey data.

The greater impact of arthritis on minorities may result from their having more physically demanding jobs, limited access to health care, increased willingness to report pain and limitations, unwillingness to use medication, and higher rates of obesity, among other plausible explanations, according to Julie Bolen, Ph.D., of the Centers for Disease Control and Prevention and her associates in their report in the journal Preventing Chronic Disease.

The investigators examined combined data from the 2002, 2003, and 2006 National Health Interview Surveys for the study. Taken together, these annual, CDC-conducted surveys include nationally representative data based on interviews with nearly 86,000 individuals from across the United States.

The 2004 and 2005 surveys were excluded from this study because they did not assess arthritis-attributable work limitation and joint pain, the investigators noted (Prev. Chronic Dis. 2010;7:1–5).

The annualized prevalence of arthritis based on the survey data was 24% for whites, 19% for blacks, 11% for Hispanics, 25% for American Indians/Alaska Natives, 8% for Asians and Pacific Islanders, and 21% for multiracial and “other” respondents.

Overall, 38% of those reporting doctor-diagnosed arthritis also reported activity limitations, 31% of those aged 18-64 years reported work limitations, and 26% reported severe joint pain in the prior month.

Blacks, Hispanics, and multiracial/other individuals were disproportionately affected in regard to limitations and pain: Compared with whites, and after adjusting for age, sex, and body mass index, blacks and Hispanics were about 1.3 times as likely to have activity limitations, 1.6-1.7 times as likely to have work limitations, and 1.8-1.9 times as likely to have severe joint pain.

Multiracial/other individuals were 1.7 times as likely to report activity limitations, 2.2 times as likely to report work limitations, and 1.9 times as likely to report severe joint pain, the investigators found.

No significant differences were noted between whites and American Indians/Alaska Natives, or between whites and Asians and Pacific Islanders on these measures, but the sample sizes for these groups were small and therefore statistical power for detecting differences was limited.

The findings show that although the prevalence of arthritis is lower in blacks and Hispanics, the impact of the disease is worse in these populations, compared with whites, the investigators said.

Although the reasons for the racial and ethnic differences demonstrated by the survey data remain unclear, the development of effective and culturally sensitive interventions tailored to the needs of specific populations are needed and could be aided by the findings, they concluded.

“We must address these stark differences in arthritis impact by using what we know,” Jennifer M. Hootman, Ph.D., an epidemiologist for the CDC National Center for Chronic Disease Prevention and Health Promotion and a coauthor on the study, said in a press statement.

“We can educate those with arthritis about increasing physical activity and self-management and reducing obesity, especially those in groups bearing a disproportionate burden from arthritis,” she added.

The investigators noted that additional study would be useful for examining whether health care access, language barriers, differences in the prevalence of risk factors, and/or cultural differences in understanding the survey questions played a role in the disproportionate effects of arthritis seen in this study.

Efforts to increase the reach of evidence-based public health interventions for improving pain and functional limitations are also needed, they said.

“Future efforts to increase reach should use appropriately tailored interventions such as the Spanish-language health communication campaign Buenos Dias Artritis,” they noted.

Fewer minorities have arthritis but they feel its impact far more acutely in terms of pain severity and limitations on function, compared with whites, according to National Health Interview Survey data.

The greater impact of arthritis on minorities may result from their having more physically demanding jobs, limited access to health care, increased willingness to report pain and limitations, unwillingness to use medication, and higher rates of obesity, among other plausible explanations, according to Julie Bolen, Ph.D., of the Centers for Disease Control and Prevention and her associates in their report in the journal Preventing Chronic Disease.

The investigators examined combined data from the 2002, 2003, and 2006 National Health Interview Surveys for the study. Taken together, these annual, CDC-conducted surveys include nationally representative data based on interviews with nearly 86,000 individuals from across the United States.

The 2004 and 2005 surveys were excluded from this study because they did not assess arthritis-attributable work limitation and joint pain, the investigators noted (Prev. Chronic Dis. 2010;7:1–5).

The annualized prevalence of arthritis based on the survey data was 24% for whites, 19% for blacks, 11% for Hispanics, 25% for American Indians/Alaska Natives, 8% for Asians and Pacific Islanders, and 21% for multiracial and “other” respondents.

Overall, 38% of those reporting doctor-diagnosed arthritis also reported activity limitations, 31% of those aged 18-64 years reported work limitations, and 26% reported severe joint pain in the prior month.

Blacks, Hispanics, and multiracial/other individuals were disproportionately affected in regard to limitations and pain: Compared with whites, and after adjusting for age, sex, and body mass index, blacks and Hispanics were about 1.3 times as likely to have activity limitations, 1.6-1.7 times as likely to have work limitations, and 1.8-1.9 times as likely to have severe joint pain.

Multiracial/other individuals were 1.7 times as likely to report activity limitations, 2.2 times as likely to report work limitations, and 1.9 times as likely to report severe joint pain, the investigators found.

No significant differences were noted between whites and American Indians/Alaska Natives, or between whites and Asians and Pacific Islanders on these measures, but the sample sizes for these groups were small and therefore statistical power for detecting differences was limited.

The findings show that although the prevalence of arthritis is lower in blacks and Hispanics, the impact of the disease is worse in these populations, compared with whites, the investigators said.

Although the reasons for the racial and ethnic differences demonstrated by the survey data remain unclear, the development of effective and culturally sensitive interventions tailored to the needs of specific populations are needed and could be aided by the findings, they concluded.

“We must address these stark differences in arthritis impact by using what we know,” Jennifer M. Hootman, Ph.D., an epidemiologist for the CDC National Center for Chronic Disease Prevention and Health Promotion and a coauthor on the study, said in a press statement.

“We can educate those with arthritis about increasing physical activity and self-management and reducing obesity, especially those in groups bearing a disproportionate burden from arthritis,” she added.

The investigators noted that additional study would be useful for examining whether health care access, language barriers, differences in the prevalence of risk factors, and/or cultural differences in understanding the survey questions played a role in the disproportionate effects of arthritis seen in this study.

Efforts to increase the reach of evidence-based public health interventions for improving pain and functional limitations are also needed, they said.

“Future efforts to increase reach should use appropriately tailored interventions such as the Spanish-language health communication campaign Buenos Dias Artritis,” they noted.

Fewer minorities have arthritis but they feel its impact far more acutely in terms of pain severity and limitations on function, compared with whites, according to National Health Interview Survey data.

The greater impact of arthritis on minorities may result from their having more physically demanding jobs, limited access to health care, increased willingness to report pain and limitations, unwillingness to use medication, and higher rates of obesity, among other plausible explanations, according to Julie Bolen, Ph.D., of the Centers for Disease Control and Prevention and her associates in their report in the journal Preventing Chronic Disease.

The investigators examined combined data from the 2002, 2003, and 2006 National Health Interview Surveys for the study. Taken together, these annual, CDC-conducted surveys include nationally representative data based on interviews with nearly 86,000 individuals from across the United States.

The 2004 and 2005 surveys were excluded from this study because they did not assess arthritis-attributable work limitation and joint pain, the investigators noted (Prev. Chronic Dis. 2010;7:1–5).

The annualized prevalence of arthritis based on the survey data was 24% for whites, 19% for blacks, 11% for Hispanics, 25% for American Indians/Alaska Natives, 8% for Asians and Pacific Islanders, and 21% for multiracial and “other” respondents.

Overall, 38% of those reporting doctor-diagnosed arthritis also reported activity limitations, 31% of those aged 18-64 years reported work limitations, and 26% reported severe joint pain in the prior month.

Blacks, Hispanics, and multiracial/other individuals were disproportionately affected in regard to limitations and pain: Compared with whites, and after adjusting for age, sex, and body mass index, blacks and Hispanics were about 1.3 times as likely to have activity limitations, 1.6-1.7 times as likely to have work limitations, and 1.8-1.9 times as likely to have severe joint pain.

Multiracial/other individuals were 1.7 times as likely to report activity limitations, 2.2 times as likely to report work limitations, and 1.9 times as likely to report severe joint pain, the investigators found.

No significant differences were noted between whites and American Indians/Alaska Natives, or between whites and Asians and Pacific Islanders on these measures, but the sample sizes for these groups were small and therefore statistical power for detecting differences was limited.

The findings show that although the prevalence of arthritis is lower in blacks and Hispanics, the impact of the disease is worse in these populations, compared with whites, the investigators said.

Although the reasons for the racial and ethnic differences demonstrated by the survey data remain unclear, the development of effective and culturally sensitive interventions tailored to the needs of specific populations are needed and could be aided by the findings, they concluded.

“We must address these stark differences in arthritis impact by using what we know,” Jennifer M. Hootman, Ph.D., an epidemiologist for the CDC National Center for Chronic Disease Prevention and Health Promotion and a coauthor on the study, said in a press statement.

“We can educate those with arthritis about increasing physical activity and self-management and reducing obesity, especially those in groups bearing a disproportionate burden from arthritis,” she added.

The investigators noted that additional study would be useful for examining whether health care access, language barriers, differences in the prevalence of risk factors, and/or cultural differences in understanding the survey questions played a role in the disproportionate effects of arthritis seen in this study.

Efforts to increase the reach of evidence-based public health interventions for improving pain and functional limitations are also needed, they said.

“Future efforts to increase reach should use appropriately tailored interventions such as the Spanish-language health communication campaign Buenos Dias Artritis,” they noted.

The Food and Drug Administration will regulate the design and manufacture of infusion pumps in the wake of thousands of adverse-event reports, the agency announced in a teleconference.

Over the past 5 years the FDA has received more than 56,000 reports of adverse events, including more than 500 deaths, related to the pumps. During that period there have been 87 recalls of infusion pumps undertaken to address identified safety concerns.

“Infusion pumps rank among the top of most frequently recalled devices for this 5-year period, and they are one of the top categories of devices for reporting of adverse events,” Dr. Jeffrey Shuren, director of the FDA's Center for Devices and Radiological Health, said during the teleconference. “There have been problems with every kind of infusion pump on the market across the entire industry…. In some cases, pumps have actually exploded in a patient's room.”

The problems have ranged from manufacturing defects to software bugs to user error. Dr. Shuren described one case in which a woman who was taking the blood thinner heparin accidentally gave herself 10 times the correct dose. The culprit was “key bounce,” in which someone trying to enter 20, for example, will enter 200 by mistake. The woman died.

The FDA is taking several steps to address the devices' problems at the level of manufacture.

In the interim, the agency is advising clinicians to use several strategies to reduce risk when using infusion pumps: Have a plan in place and be prepared to respond to pump failures; prevent errors by labeling infusion pump channels and tubing; check settings of infusion pumps and check patients for signs of under- or overinfusion; prevent and respond to pump problems by using available resources; and promptly report adverse events to the FDA.

The agency published draft guidance on April 23 recommending that manufacturers of infusion pumps start providing additional information on design and engineering to the agency during premarket review.

The draft guidance document, available on the FDA's Web site, is open for public comment, and the agency plans to hold a public infusion pump workshop on May 25-26.

Dr. Shuren said that the agency plans to move quickly in turning the draft guidance document into an actual set of regulations.

Among other things, the FDA recommends that each premarket submission include a structured, evidence-based discussion of all steps the manufacturer has taken to mitigate risk at each stage of the device's life cycle. That includes device design, manufacture, servicing, maintenance, and use in clinical or home settings.

FDA inspectors will visit production facilities for the first time to examine manufacturing practices.

In addition, manufacturers will need to show that they have tested their pump in the environment in which it is intended to be used and with the types of clinicians and patients who are expected to use it.

The agency offered to help manufacturers with the task of checking the software controlling these devices. Even before premarket review, manufacturers may submit software code to the FDA, whose experts will conduct “static analysis,” an automated diagnostic technique that can detect software problems early in the development process.

Dr. Shuren described the CDRH action as “a marked departure” in the way it has handled such cases in the past.

In response to a reporter's question, he noted that other medical devices have been the subject of large numbers of adverse event reports, citing implantable cardiac defibrillators as an example.

The FDA has established a Web site with detailed information on infusion pump problems and the agency's proposed solutions at www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/default.htm

A white paper on the Infusion Pump Improvement Initiative can be found at www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/ucm205424.htm

The Food and Drug Administration will regulate the design and manufacture of infusion pumps in the wake of thousands of adverse-event reports, the agency announced in a teleconference.

Over the past 5 years the FDA has received more than 56,000 reports of adverse events, including more than 500 deaths, related to the pumps. During that period there have been 87 recalls of infusion pumps undertaken to address identified safety concerns.

“Infusion pumps rank among the top of most frequently recalled devices for this 5-year period, and they are one of the top categories of devices for reporting of adverse events,” Dr. Jeffrey Shuren, director of the FDA's Center for Devices and Radiological Health, said during the teleconference. “There have been problems with every kind of infusion pump on the market across the entire industry…. In some cases, pumps have actually exploded in a patient's room.”

The problems have ranged from manufacturing defects to software bugs to user error. Dr. Shuren described one case in which a woman who was taking the blood thinner heparin accidentally gave herself 10 times the correct dose. The culprit was “key bounce,” in which someone trying to enter 20, for example, will enter 200 by mistake. The woman died.

The FDA is taking several steps to address the devices' problems at the level of manufacture.

In the interim, the agency is advising clinicians to use several strategies to reduce risk when using infusion pumps: Have a plan in place and be prepared to respond to pump failures; prevent errors by labeling infusion pump channels and tubing; check settings of infusion pumps and check patients for signs of under- or overinfusion; prevent and respond to pump problems by using available resources; and promptly report adverse events to the FDA.

The agency published draft guidance on April 23 recommending that manufacturers of infusion pumps start providing additional information on design and engineering to the agency during premarket review.

The draft guidance document, available on the FDA's Web site, is open for public comment, and the agency plans to hold a public infusion pump workshop on May 25-26.

Dr. Shuren said that the agency plans to move quickly in turning the draft guidance document into an actual set of regulations.

Among other things, the FDA recommends that each premarket submission include a structured, evidence-based discussion of all steps the manufacturer has taken to mitigate risk at each stage of the device's life cycle. That includes device design, manufacture, servicing, maintenance, and use in clinical or home settings.

FDA inspectors will visit production facilities for the first time to examine manufacturing practices.

In addition, manufacturers will need to show that they have tested their pump in the environment in which it is intended to be used and with the types of clinicians and patients who are expected to use it.

The agency offered to help manufacturers with the task of checking the software controlling these devices. Even before premarket review, manufacturers may submit software code to the FDA, whose experts will conduct “static analysis,” an automated diagnostic technique that can detect software problems early in the development process.

Dr. Shuren described the CDRH action as “a marked departure” in the way it has handled such cases in the past.

In response to a reporter's question, he noted that other medical devices have been the subject of large numbers of adverse event reports, citing implantable cardiac defibrillators as an example.

The FDA has established a Web site with detailed information on infusion pump problems and the agency's proposed solutions at www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/default.htm

A white paper on the Infusion Pump Improvement Initiative can be found at www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/ucm205424.htm

The Food and Drug Administration will regulate the design and manufacture of infusion pumps in the wake of thousands of adverse-event reports, the agency announced in a teleconference.

Over the past 5 years the FDA has received more than 56,000 reports of adverse events, including more than 500 deaths, related to the pumps. During that period there have been 87 recalls of infusion pumps undertaken to address identified safety concerns.

“Infusion pumps rank among the top of most frequently recalled devices for this 5-year period, and they are one of the top categories of devices for reporting of adverse events,” Dr. Jeffrey Shuren, director of the FDA's Center for Devices and Radiological Health, said during the teleconference. “There have been problems with every kind of infusion pump on the market across the entire industry…. In some cases, pumps have actually exploded in a patient's room.”

The problems have ranged from manufacturing defects to software bugs to user error. Dr. Shuren described one case in which a woman who was taking the blood thinner heparin accidentally gave herself 10 times the correct dose. The culprit was “key bounce,” in which someone trying to enter 20, for example, will enter 200 by mistake. The woman died.

The FDA is taking several steps to address the devices' problems at the level of manufacture.

In the interim, the agency is advising clinicians to use several strategies to reduce risk when using infusion pumps: Have a plan in place and be prepared to respond to pump failures; prevent errors by labeling infusion pump channels and tubing; check settings of infusion pumps and check patients for signs of under- or overinfusion; prevent and respond to pump problems by using available resources; and promptly report adverse events to the FDA.

The agency published draft guidance on April 23 recommending that manufacturers of infusion pumps start providing additional information on design and engineering to the agency during premarket review.

The draft guidance document, available on the FDA's Web site, is open for public comment, and the agency plans to hold a public infusion pump workshop on May 25-26.

Dr. Shuren said that the agency plans to move quickly in turning the draft guidance document into an actual set of regulations.

Among other things, the FDA recommends that each premarket submission include a structured, evidence-based discussion of all steps the manufacturer has taken to mitigate risk at each stage of the device's life cycle. That includes device design, manufacture, servicing, maintenance, and use in clinical or home settings.

FDA inspectors will visit production facilities for the first time to examine manufacturing practices.

In addition, manufacturers will need to show that they have tested their pump in the environment in which it is intended to be used and with the types of clinicians and patients who are expected to use it.

The agency offered to help manufacturers with the task of checking the software controlling these devices. Even before premarket review, manufacturers may submit software code to the FDA, whose experts will conduct “static analysis,” an automated diagnostic technique that can detect software problems early in the development process.

Dr. Shuren described the CDRH action as “a marked departure” in the way it has handled such cases in the past.

In response to a reporter's question, he noted that other medical devices have been the subject of large numbers of adverse event reports, citing implantable cardiac defibrillators as an example.

The FDA has established a Web site with detailed information on infusion pump problems and the agency's proposed solutions at www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/default.htm

A white paper on the Infusion Pump Improvement Initiative can be found at www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/ucm205424.htm

NEW YORK — A single enzyme, peptidylarginine deiminase, may trigger the autoimmune process that results in rheumatoid arthritis among some people with periodontitis, Dr. Gerald Weissmann said at a rheumatology meeting sponsored by New York University.

Researchers established the association between rheumatoid arthritis and periodontal disease a decade ago (Eur. J. Med. Res. 1998;3:387–92). The same investigators went on to confirm the link, and found that the severity of RA based on a variety of markers—such as swollen joint counts, health assessment questionnaire scores, levels of C-reactive protein, and erythrocyte sedimentation rates—was directly related to the extent of periodontal bone loss in these patients (J. Periodontol. 2001;72:779–87).

The metabolic link that associates the two disorders appears to be a specific family of citrullinated proteins. These proteins have been suggested to act as an auto-antigen in RA, and autoantibodies to these proteins (anti-CCP) are highly specific for RA, according to Dr. Weissmann.

Proteins become citrullinated by the enzyme peptidylarginine deiminase, which is secreted by neutrophils, macrophages, and endothelium. Interestingly, only one bacterium, the oral pathogen Porphyromonas gingivalis the major cause of periodontal disease, produces this enzyme.

One of these citrullinated proteins (deiminated fibrin) may become a systemic immunogen in people who are predisposed to periodontal disease, leading to both periodontal and intra-articular inflammation. The ensuing events—involving the cascade of complement activation, phagocyte stimulation via Fc and C5a receptors, and the release of cytokines, metalloproteinases, and reactive oxygen species—ultimately result in the erosion of bone surrounding teeth and joints.

As further evidence of the link, anti-CCP titers are more predictive of joint damage at 5 years than are rheumatoid factor (RF) titers. Depletion of B cells by rituximab also lowers anti-CCP titers, and to a greater extent than it reduces RF titers (Arthritis Res. 2000;2:249–51), said Dr. Weissmann, research professor of medicine and director of the biotechnology study center at New York University.

Dr. Weissmann traced the rise of rheumatoid diseases in both England and the American colonies to the increased affordability of sugar in the late 18th and early 19th centuries. Before 1773, it was unlikely that working-class residents of the American colonies or London either had access to sugar or developed rheumatoid diseases. Access to sugar became the norm and rheumatoid arthritis became widespread only after the sugar tax was abolished in 1874, he said.

Disclosures: Dr. Weissmann reported no relevant financial relationships.

NEW YORK — A single enzyme, peptidylarginine deiminase, may trigger the autoimmune process that results in rheumatoid arthritis among some people with periodontitis, Dr. Gerald Weissmann said at a rheumatology meeting sponsored by New York University.

Researchers established the association between rheumatoid arthritis and periodontal disease a decade ago (Eur. J. Med. Res. 1998;3:387–92). The same investigators went on to confirm the link, and found that the severity of RA based on a variety of markers—such as swollen joint counts, health assessment questionnaire scores, levels of C-reactive protein, and erythrocyte sedimentation rates—was directly related to the extent of periodontal bone loss in these patients (J. Periodontol. 2001;72:779–87).

The metabolic link that associates the two disorders appears to be a specific family of citrullinated proteins. These proteins have been suggested to act as an auto-antigen in RA, and autoantibodies to these proteins (anti-CCP) are highly specific for RA, according to Dr. Weissmann.

Proteins become citrullinated by the enzyme peptidylarginine deiminase, which is secreted by neutrophils, macrophages, and endothelium. Interestingly, only one bacterium, the oral pathogen Porphyromonas gingivalis the major cause of periodontal disease, produces this enzyme.

One of these citrullinated proteins (deiminated fibrin) may become a systemic immunogen in people who are predisposed to periodontal disease, leading to both periodontal and intra-articular inflammation. The ensuing events—involving the cascade of complement activation, phagocyte stimulation via Fc and C5a receptors, and the release of cytokines, metalloproteinases, and reactive oxygen species—ultimately result in the erosion of bone surrounding teeth and joints.

As further evidence of the link, anti-CCP titers are more predictive of joint damage at 5 years than are rheumatoid factor (RF) titers. Depletion of B cells by rituximab also lowers anti-CCP titers, and to a greater extent than it reduces RF titers (Arthritis Res. 2000;2:249–51), said Dr. Weissmann, research professor of medicine and director of the biotechnology study center at New York University.

Dr. Weissmann traced the rise of rheumatoid diseases in both England and the American colonies to the increased affordability of sugar in the late 18th and early 19th centuries. Before 1773, it was unlikely that working-class residents of the American colonies or London either had access to sugar or developed rheumatoid diseases. Access to sugar became the norm and rheumatoid arthritis became widespread only after the sugar tax was abolished in 1874, he said.

Disclosures: Dr. Weissmann reported no relevant financial relationships.

NEW YORK — A single enzyme, peptidylarginine deiminase, may trigger the autoimmune process that results in rheumatoid arthritis among some people with periodontitis, Dr. Gerald Weissmann said at a rheumatology meeting sponsored by New York University.

Researchers established the association between rheumatoid arthritis and periodontal disease a decade ago (Eur. J. Med. Res. 1998;3:387–92). The same investigators went on to confirm the link, and found that the severity of RA based on a variety of markers—such as swollen joint counts, health assessment questionnaire scores, levels of C-reactive protein, and erythrocyte sedimentation rates—was directly related to the extent of periodontal bone loss in these patients (J. Periodontol. 2001;72:779–87).

The metabolic link that associates the two disorders appears to be a specific family of citrullinated proteins. These proteins have been suggested to act as an auto-antigen in RA, and autoantibodies to these proteins (anti-CCP) are highly specific for RA, according to Dr. Weissmann.

Proteins become citrullinated by the enzyme peptidylarginine deiminase, which is secreted by neutrophils, macrophages, and endothelium. Interestingly, only one bacterium, the oral pathogen Porphyromonas gingivalis the major cause of periodontal disease, produces this enzyme.

One of these citrullinated proteins (deiminated fibrin) may become a systemic immunogen in people who are predisposed to periodontal disease, leading to both periodontal and intra-articular inflammation. The ensuing events—involving the cascade of complement activation, phagocyte stimulation via Fc and C5a receptors, and the release of cytokines, metalloproteinases, and reactive oxygen species—ultimately result in the erosion of bone surrounding teeth and joints.

As further evidence of the link, anti-CCP titers are more predictive of joint damage at 5 years than are rheumatoid factor (RF) titers. Depletion of B cells by rituximab also lowers anti-CCP titers, and to a greater extent than it reduces RF titers (Arthritis Res. 2000;2:249–51), said Dr. Weissmann, research professor of medicine and director of the biotechnology study center at New York University.

Dr. Weissmann traced the rise of rheumatoid diseases in both England and the American colonies to the increased affordability of sugar in the late 18th and early 19th centuries. Before 1773, it was unlikely that working-class residents of the American colonies or London either had access to sugar or developed rheumatoid diseases. Access to sugar became the norm and rheumatoid arthritis became widespread only after the sugar tax was abolished in 1874, he said.

Disclosures: Dr. Weissmann reported no relevant financial relationships.