Rheumatoid Arthritis

FORT LAUDERDALE, FLA. — The chronic dry mouth that characterizes Sjögren's syndrome can accelerate dental decay in approximately 70% of patients with the disease, Steven J. Kusnick, D.D.S., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who attempt to manage their dry mouth symptoms with gum or mints should be advised to use products that contain the natural sweetener xylitol instead of looking for ones that are merely sugar free because the latter won't prevent tooth decay, said Dr. Kusnick, a general dentist in private practice in Sunrise, Fla., and a specialist in cosmetic and reconstructive dentistry.

Over-the-counter products that contain xylitol include Smints, a brand of mints that stimulate saliva and have xylitol as the first ingredient, Koolerz gum in any flavor, and Starbucks gum in peppermint and cinnamon flavors.

Other tips include reminding patients to drink water throughout the day, use lip balm regularly, and avoid smoking and drinking alcohol. While some patients may realize they need to avoid acidic juices, such as orange and grape, many carbonated drinks, including diet sodas, also contain acid and should be avoided.

Two prescription salivary substitute medications—pilocarpine (Salagen) and cevimeline (Evoxac)—can be an effective adjunct to lifestyle modifications, but many patients are deterred by their side effects, which include flushing, sweating, and headaches.

Salivary substitutes can interact poorly with other medications, so physicians should inquire about all medications before prescribing them. And since Sjögren's patients are predisposed to several specific conditions—including liver disease and glaucoma—comorbitities should be thoroughly investigated since many are contraindications for the use of salivary substitutes.

“The earlier we catch a problem, such as a cavity, the easier it is to treat,” so regular checkups are key.

Dr. Kusnick also recommends that his Sjögren's patients use a standard, nonwhitening toothpaste, rather than any of the whitening formulas. “Whitening toothpastes have an ingredient that makes teeth more sensitive. They can also irritate the soft tissues of the mouth. And they don't whiten your teeth that much,” he explained.

Other rules for basic oral health in general apply to Sjögren's patients as well—floss, and avoid snacks between meals. If patients snack, remind them to rinse their mouths with water afterward.

Fluoride varnish can be helpful to prevent decay in high-risk patients, Dr. Kusnick noted. In patients with gumline decay, power toothbrushes can be helpful in getting the fluoride into the gum area. “If people get a lot of cavities, we give them fluoride trays to use at home,” he added.

When cavities occur, Dr. Kusnick recommends crowns rather than standard fillings. Many Sjögren's patients complain that their fillings fall out, and crowns cover the whole tooth, which makes them more secure. He advises Sjögren's patients to avoid dentures.

For more information about managing dry mouth and a list of additional products with xylitol, visit the Oral Health Education Foundation Web site at www.ohef.org

FORT LAUDERDALE, FLA. — The chronic dry mouth that characterizes Sjögren's syndrome can accelerate dental decay in approximately 70% of patients with the disease, Steven J. Kusnick, D.D.S., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who attempt to manage their dry mouth symptoms with gum or mints should be advised to use products that contain the natural sweetener xylitol instead of looking for ones that are merely sugar free because the latter won't prevent tooth decay, said Dr. Kusnick, a general dentist in private practice in Sunrise, Fla., and a specialist in cosmetic and reconstructive dentistry.

Over-the-counter products that contain xylitol include Smints, a brand of mints that stimulate saliva and have xylitol as the first ingredient, Koolerz gum in any flavor, and Starbucks gum in peppermint and cinnamon flavors.

Other tips include reminding patients to drink water throughout the day, use lip balm regularly, and avoid smoking and drinking alcohol. While some patients may realize they need to avoid acidic juices, such as orange and grape, many carbonated drinks, including diet sodas, also contain acid and should be avoided.

Two prescription salivary substitute medications—pilocarpine (Salagen) and cevimeline (Evoxac)—can be an effective adjunct to lifestyle modifications, but many patients are deterred by their side effects, which include flushing, sweating, and headaches.

Salivary substitutes can interact poorly with other medications, so physicians should inquire about all medications before prescribing them. And since Sjögren's patients are predisposed to several specific conditions—including liver disease and glaucoma—comorbitities should be thoroughly investigated since many are contraindications for the use of salivary substitutes.

“The earlier we catch a problem, such as a cavity, the easier it is to treat,” so regular checkups are key.

Dr. Kusnick also recommends that his Sjögren's patients use a standard, nonwhitening toothpaste, rather than any of the whitening formulas. “Whitening toothpastes have an ingredient that makes teeth more sensitive. They can also irritate the soft tissues of the mouth. And they don't whiten your teeth that much,” he explained.

Other rules for basic oral health in general apply to Sjögren's patients as well—floss, and avoid snacks between meals. If patients snack, remind them to rinse their mouths with water afterward.

Fluoride varnish can be helpful to prevent decay in high-risk patients, Dr. Kusnick noted. In patients with gumline decay, power toothbrushes can be helpful in getting the fluoride into the gum area. “If people get a lot of cavities, we give them fluoride trays to use at home,” he added.

When cavities occur, Dr. Kusnick recommends crowns rather than standard fillings. Many Sjögren's patients complain that their fillings fall out, and crowns cover the whole tooth, which makes them more secure. He advises Sjögren's patients to avoid dentures.

For more information about managing dry mouth and a list of additional products with xylitol, visit the Oral Health Education Foundation Web site at www.ohef.org

FORT LAUDERDALE, FLA. — The chronic dry mouth that characterizes Sjögren's syndrome can accelerate dental decay in approximately 70% of patients with the disease, Steven J. Kusnick, D.D.S., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who attempt to manage their dry mouth symptoms with gum or mints should be advised to use products that contain the natural sweetener xylitol instead of looking for ones that are merely sugar free because the latter won't prevent tooth decay, said Dr. Kusnick, a general dentist in private practice in Sunrise, Fla., and a specialist in cosmetic and reconstructive dentistry.

Over-the-counter products that contain xylitol include Smints, a brand of mints that stimulate saliva and have xylitol as the first ingredient, Koolerz gum in any flavor, and Starbucks gum in peppermint and cinnamon flavors.

Other tips include reminding patients to drink water throughout the day, use lip balm regularly, and avoid smoking and drinking alcohol. While some patients may realize they need to avoid acidic juices, such as orange and grape, many carbonated drinks, including diet sodas, also contain acid and should be avoided.

Two prescription salivary substitute medications—pilocarpine (Salagen) and cevimeline (Evoxac)—can be an effective adjunct to lifestyle modifications, but many patients are deterred by their side effects, which include flushing, sweating, and headaches.

Salivary substitutes can interact poorly with other medications, so physicians should inquire about all medications before prescribing them. And since Sjögren's patients are predisposed to several specific conditions—including liver disease and glaucoma—comorbitities should be thoroughly investigated since many are contraindications for the use of salivary substitutes.

“The earlier we catch a problem, such as a cavity, the easier it is to treat,” so regular checkups are key.

Dr. Kusnick also recommends that his Sjögren's patients use a standard, nonwhitening toothpaste, rather than any of the whitening formulas. “Whitening toothpastes have an ingredient that makes teeth more sensitive. They can also irritate the soft tissues of the mouth. And they don't whiten your teeth that much,” he explained.

Other rules for basic oral health in general apply to Sjögren's patients as well—floss, and avoid snacks between meals. If patients snack, remind them to rinse their mouths with water afterward.

Fluoride varnish can be helpful to prevent decay in high-risk patients, Dr. Kusnick noted. In patients with gumline decay, power toothbrushes can be helpful in getting the fluoride into the gum area. “If people get a lot of cavities, we give them fluoride trays to use at home,” he added.

When cavities occur, Dr. Kusnick recommends crowns rather than standard fillings. Many Sjögren's patients complain that their fillings fall out, and crowns cover the whole tooth, which makes them more secure. He advises Sjögren's patients to avoid dentures.

For more information about managing dry mouth and a list of additional products with xylitol, visit the Oral Health Education Foundation Web site at www.ohef.org

FORT LAUDERDALE, FLA. — Skin manifestations of Sjögren's syndrome may not be unique to the disease, but they require specific interventions and close monitoring, Darren L. Casey, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Sjögren's syndrome affects the body's moisture-producing glands, resulting in chronically dry, itchy, and scaly skin.

Remind patients that they should try to maintain a protective barrier on the skin. “When we wash too aggressively, we get rid of that barrier,” said Dr. Casey, a dermatologist in private practice in Atlanta.

Dr. Casey suggests that patients limit washing to 20 minutes and recommends using Cetaphil, Dove, or Oil of Olay gentle skin cleansers.

Use of emollients such as Aquaphor immediately after a bath or shower can help retain moisture if lotions and creams do not provide relief.

For patients who don't respond to over-the-counter products, prescription humectants such as Carmol 20 and Carmol 40 may help.

He also advises patients to use humidifiers and fragrance-free laundry detergents to reduce irritation of dry skin.

In addition to dry skin, Sjögren's patients may develop red or purple palpable spots related to small vessel disease.

Urticarial vasculitis, which affects some patients, is characterized by hives that last hours to days. When these lesions are biopsied, they show inflammation in the blood vessels.

Medium-sized vessel disease typically manifests as nodules on the hands and feet or as livedo reticularis, characterized by a whorl pattern of pigmentation brought on by constricted blood flow. Medium-sized vessel disease should be a red flag to investigate central nervous system or severe organ involvement.

FORT LAUDERDALE, FLA. — Skin manifestations of Sjögren's syndrome may not be unique to the disease, but they require specific interventions and close monitoring, Darren L. Casey, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Sjögren's syndrome affects the body's moisture-producing glands, resulting in chronically dry, itchy, and scaly skin.

Remind patients that they should try to maintain a protective barrier on the skin. “When we wash too aggressively, we get rid of that barrier,” said Dr. Casey, a dermatologist in private practice in Atlanta.

Dr. Casey suggests that patients limit washing to 20 minutes and recommends using Cetaphil, Dove, or Oil of Olay gentle skin cleansers.

Use of emollients such as Aquaphor immediately after a bath or shower can help retain moisture if lotions and creams do not provide relief.

For patients who don't respond to over-the-counter products, prescription humectants such as Carmol 20 and Carmol 40 may help.

He also advises patients to use humidifiers and fragrance-free laundry detergents to reduce irritation of dry skin.

In addition to dry skin, Sjögren's patients may develop red or purple palpable spots related to small vessel disease.

Urticarial vasculitis, which affects some patients, is characterized by hives that last hours to days. When these lesions are biopsied, they show inflammation in the blood vessels.

Medium-sized vessel disease typically manifests as nodules on the hands and feet or as livedo reticularis, characterized by a whorl pattern of pigmentation brought on by constricted blood flow. Medium-sized vessel disease should be a red flag to investigate central nervous system or severe organ involvement.

FORT LAUDERDALE, FLA. — Skin manifestations of Sjögren's syndrome may not be unique to the disease, but they require specific interventions and close monitoring, Darren L. Casey, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Sjögren's syndrome affects the body's moisture-producing glands, resulting in chronically dry, itchy, and scaly skin.

Remind patients that they should try to maintain a protective barrier on the skin. “When we wash too aggressively, we get rid of that barrier,” said Dr. Casey, a dermatologist in private practice in Atlanta.

Dr. Casey suggests that patients limit washing to 20 minutes and recommends using Cetaphil, Dove, or Oil of Olay gentle skin cleansers.

Use of emollients such as Aquaphor immediately after a bath or shower can help retain moisture if lotions and creams do not provide relief.

For patients who don't respond to over-the-counter products, prescription humectants such as Carmol 20 and Carmol 40 may help.

He also advises patients to use humidifiers and fragrance-free laundry detergents to reduce irritation of dry skin.

In addition to dry skin, Sjögren's patients may develop red or purple palpable spots related to small vessel disease.

Urticarial vasculitis, which affects some patients, is characterized by hives that last hours to days. When these lesions are biopsied, they show inflammation in the blood vessels.

Medium-sized vessel disease typically manifests as nodules on the hands and feet or as livedo reticularis, characterized by a whorl pattern of pigmentation brought on by constricted blood flow. Medium-sized vessel disease should be a red flag to investigate central nervous system or severe organ involvement.

FORT LAUDERDALE, FLA. — Optimal management of dry eyes associated with Sjögren's syndrome isn't likely to involve just one solution.

Artificial tears come in assorted formulas, and patients can best manage their eye conditions by recognizing that a single product isn't likely to meet their various needs, William B. Trattler, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who complain of burning and irritation from artificial tears should try a preservative-free formula, said Dr. Trattler, an ophthalmologist in private practice in Miami, with a special interest in external eye disease.

Preservative-free drops are typically sold as single-use vials, but a vial can be used in the morning and evening on two consecutive days if kept upright in the refrigerator, Dr. Trattler said. Refrigeration is important to inhibit the growth of bacteria, and cold drops can be more comfortable to use. However, drops with preservatives may be more convenient to keep in a pocket or purse or to carry when traveling.

Natural tears and some artificial products have an oily component to help keep liquid in the eye, Dr. Trattler said. Patients should be encouraged to select drops that meet their needs in various settings. Drops needed when working outside will be different from those needed when viewing a computer screen indoors.

If inflammation is present, patients can try cyclosporine ophthalmic emulsion (Restasis). Approved by the Food and Drug Administration in 2003, Restasis increases tear production and has anti-inflammatory properties, making it a good choice for patients with occluded tear ducts, noted Ashley Behrens, M.D., of Johns Hopkins University in Baltimore.

However, patients should be cautioned when using Restasis, since the effects of overuse of the drug are unknown. In the study that served as the basis for the FDA approval, the drops were used twice daily, but “using them more frequently won't necessarily add benefits,” Dr. Behrens said.

Both ophthalmologists, neither of whom reported a financial interest in any eye care product, recommended that Sjögren's patients use over-the-counter lubricant eye gels for periods of sleep. Warm compresses can provide relief, and specialized moisturizing goggles are available. In addition, patients should be advised to turn off ceiling fans at night.

In treatment-resistant cases, Sjögren's patients can have their tear ducts blocked with punctal plugs. The ducts drain the tears into the nose, and plugging them helps retain fluid in the eye. Cauterization of the tear ducts has the same result, but while plugs can be removed, cauterization permanently closes the ducts.

For patients who develop blepharitis, inflammation of the eyelids, Dr. Trattler recommends baby shampoo and warm compresses. The inflammation occurs when the oil that is a component of normal tears crystallizes on the lids, he explained.

FORT LAUDERDALE, FLA. — Optimal management of dry eyes associated with Sjögren's syndrome isn't likely to involve just one solution.

Artificial tears come in assorted formulas, and patients can best manage their eye conditions by recognizing that a single product isn't likely to meet their various needs, William B. Trattler, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who complain of burning and irritation from artificial tears should try a preservative-free formula, said Dr. Trattler, an ophthalmologist in private practice in Miami, with a special interest in external eye disease.

Preservative-free drops are typically sold as single-use vials, but a vial can be used in the morning and evening on two consecutive days if kept upright in the refrigerator, Dr. Trattler said. Refrigeration is important to inhibit the growth of bacteria, and cold drops can be more comfortable to use. However, drops with preservatives may be more convenient to keep in a pocket or purse or to carry when traveling.

Natural tears and some artificial products have an oily component to help keep liquid in the eye, Dr. Trattler said. Patients should be encouraged to select drops that meet their needs in various settings. Drops needed when working outside will be different from those needed when viewing a computer screen indoors.

If inflammation is present, patients can try cyclosporine ophthalmic emulsion (Restasis). Approved by the Food and Drug Administration in 2003, Restasis increases tear production and has anti-inflammatory properties, making it a good choice for patients with occluded tear ducts, noted Ashley Behrens, M.D., of Johns Hopkins University in Baltimore.

However, patients should be cautioned when using Restasis, since the effects of overuse of the drug are unknown. In the study that served as the basis for the FDA approval, the drops were used twice daily, but “using them more frequently won't necessarily add benefits,” Dr. Behrens said.

Both ophthalmologists, neither of whom reported a financial interest in any eye care product, recommended that Sjögren's patients use over-the-counter lubricant eye gels for periods of sleep. Warm compresses can provide relief, and specialized moisturizing goggles are available. In addition, patients should be advised to turn off ceiling fans at night.

In treatment-resistant cases, Sjögren's patients can have their tear ducts blocked with punctal plugs. The ducts drain the tears into the nose, and plugging them helps retain fluid in the eye. Cauterization of the tear ducts has the same result, but while plugs can be removed, cauterization permanently closes the ducts.

For patients who develop blepharitis, inflammation of the eyelids, Dr. Trattler recommends baby shampoo and warm compresses. The inflammation occurs when the oil that is a component of normal tears crystallizes on the lids, he explained.

FORT LAUDERDALE, FLA. — Optimal management of dry eyes associated with Sjögren's syndrome isn't likely to involve just one solution.

Artificial tears come in assorted formulas, and patients can best manage their eye conditions by recognizing that a single product isn't likely to meet their various needs, William B. Trattler, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who complain of burning and irritation from artificial tears should try a preservative-free formula, said Dr. Trattler, an ophthalmologist in private practice in Miami, with a special interest in external eye disease.

Preservative-free drops are typically sold as single-use vials, but a vial can be used in the morning and evening on two consecutive days if kept upright in the refrigerator, Dr. Trattler said. Refrigeration is important to inhibit the growth of bacteria, and cold drops can be more comfortable to use. However, drops with preservatives may be more convenient to keep in a pocket or purse or to carry when traveling.

Natural tears and some artificial products have an oily component to help keep liquid in the eye, Dr. Trattler said. Patients should be encouraged to select drops that meet their needs in various settings. Drops needed when working outside will be different from those needed when viewing a computer screen indoors.

If inflammation is present, patients can try cyclosporine ophthalmic emulsion (Restasis). Approved by the Food and Drug Administration in 2003, Restasis increases tear production and has anti-inflammatory properties, making it a good choice for patients with occluded tear ducts, noted Ashley Behrens, M.D., of Johns Hopkins University in Baltimore.

However, patients should be cautioned when using Restasis, since the effects of overuse of the drug are unknown. In the study that served as the basis for the FDA approval, the drops were used twice daily, but “using them more frequently won't necessarily add benefits,” Dr. Behrens said.

Both ophthalmologists, neither of whom reported a financial interest in any eye care product, recommended that Sjögren's patients use over-the-counter lubricant eye gels for periods of sleep. Warm compresses can provide relief, and specialized moisturizing goggles are available. In addition, patients should be advised to turn off ceiling fans at night.

In treatment-resistant cases, Sjögren's patients can have their tear ducts blocked with punctal plugs. The ducts drain the tears into the nose, and plugging them helps retain fluid in the eye. Cauterization of the tear ducts has the same result, but while plugs can be removed, cauterization permanently closes the ducts.

For patients who develop blepharitis, inflammation of the eyelids, Dr. Trattler recommends baby shampoo and warm compresses. The inflammation occurs when the oil that is a component of normal tears crystallizes on the lids, he explained.

FORT LAUDERDALE, FLA. — Sjögren's syndrome is the second most common autoimmune disorder that affects the musculoskeletal system, and yet the average time to diagnosis is 6 years, said Yvonne Sherrer, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Until more reliable biomarkers for the syndrome are identified, expediting the diagnosis may require physicians to have a higher level of suspicion for some of the less common manifestations of Sjögren's, said Dr. Sherrer, medical director and director of clinical research at the Centre for Rheumatology, Immunology, and Arthritis in Fort Lauderdale.

Although the cause of the Sjögren's is still unknown, researchers suspect that a combination of genetic, environmental, and hormonal factors contribute to predisposition for the disease. Indeed, for every male with the syndrome, an estimated nine women are affected, underscoring the relevance of hormonal influences.

Inflammation of the exocrine glands, the common denominator of Sjögren's syndrome, most obviously affects the eyes, mouth, and vagina, Dr. Sherrer said.

Typically, Sjögren's occurs in the context of a previously diagnosed autoimmune disorder, such as lupus, rheumatoid arthritis, or scleroderma.

The atypical patients with primary Sjögren's “are our most challenging patients, because they don't have an accompanying autoimmune disease,” Dr. Sherrer said. These patients generally present with neuropathy, accelerated dental caries, salivary gland swelling, joint pain without overt arthritis or myositis, and corneal melt. The current international criteria for diagnosing Sjögren's require that patients demonstrate some objective evidence of autoimmunity, in addition to other symptoms. (See box.)

However, the following less typical symptoms may also warrant suspecting Sjögren's syndrome:

▸ Ocular. In addition to extreme dry eyes, patients may suffer from conjunctivitis, keratitis, blepharitis, ulcerations, and perforations.

▸ Ears, Nose, and Throat. Tracheal dryness causes a chronic dry cough in some patients. Nosebleeds, otitis, and sinusitis can be recurring problems.

▸ Oral. Severe dry mouth can cause swallowing problems, which may lead to malnourishment and excessive weight loss. Patients may also have accelerated caries, loss of dentition, and malfunctioning dentures.

▸ Dermatologic/Vascular. Skin rashes are common, and skin eruptions and purpura may occur. Raynaud's phenomenon is a typical vascular manifestation. Vasculitis is always a concern in Sjögren's patients, but symptoms vary depending on the location of the inflammation in the body.

▸ Gastrointestinal. Patients may suffer from esophageal dysmotility. In severe cases, they are at increased risk for pancreatitis, hepatitis, or atrophic gastritis.

▸ Hematologic. Anemia, blood dyscrasias, and cryoglobulinemias are rare but may occur. In addition, Sjögren's patients are at increased risk for lymphoma.

▸ Pulmonary. Lung involvement and coronary involvement are rare but can develop due to dryness of bronchial tubes. Other potential manifestations include bronchitis, bronchitis obliterans-organized pneumonia, and interstitial fibrosis.

▸ Neurologic. Neuropathies tend to be less symmetrical in Sjögren's patients, compared with other conditions. Central nervous system disorders might manifest as changes in cognitive function or as seizures.

▸ Renal. Renal involvement is rare, but when it occurs, it is usually interstitial tube involvement and is more likely to be chronic, compared with highly progressive kidney involvement associated with lupus.

▸ Musculoskeletal. More often than not, patients with Sjögren's have arthralgia, rather than arthritis, but secondary Sjögren's patients may have concurrent arthritis or myositis.

▸ Other. Fibromyalgia occurs in 20%-30% of Sjögren's patients. Sleep disorders, often due to dryness-related discomfort, are common and may contribute to the fibromyalgia. Depression is a common comorbidity, as it is in patients with other autoimmune disease.

Recommended Diagnostic Criteria

The diagnosis of primary Sjögren's syndrome requires that patients meet at least four of the following six criteria:

The patient must have at least one of three ocular symptoms:

▸ Dry eyes for less than 3 months.

▸ Need to use artificial tears more than three times daily.

▸ Sensation of a foreign body in the eye.

The patient must have at least of three oral symptoms:

▸ Persistent dry mouth for more than 3 months.

▸ Swollen salivary glands.

▸ Need to add extra liquid to the mouth in order to swallow.

The patient must have at least one of two ocular signs:

▸ Unanesthetized Schirmer's test result of 5 mm/5 minutes or less in both eyes.

▸ Positive vital dye staining.

The patient must have at least one of three signs of poor salivary gland function:

▸ Abnormal salivary scintigraphy.

▸ Abnormal parotid sialography.

▸ Unstimulated salivary flow rate of 0.1 mL/minute or less.

Positive lip biopsy.

Positive anti-SSA or anti-SSB tests.

Source: “The New Sjögren's Syndrome Handbook” (New York: Oxford University Press, 2005)

FORT LAUDERDALE, FLA. — Sjögren's syndrome is the second most common autoimmune disorder that affects the musculoskeletal system, and yet the average time to diagnosis is 6 years, said Yvonne Sherrer, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Until more reliable biomarkers for the syndrome are identified, expediting the diagnosis may require physicians to have a higher level of suspicion for some of the less common manifestations of Sjögren's, said Dr. Sherrer, medical director and director of clinical research at the Centre for Rheumatology, Immunology, and Arthritis in Fort Lauderdale.

Although the cause of the Sjögren's is still unknown, researchers suspect that a combination of genetic, environmental, and hormonal factors contribute to predisposition for the disease. Indeed, for every male with the syndrome, an estimated nine women are affected, underscoring the relevance of hormonal influences.

Inflammation of the exocrine glands, the common denominator of Sjögren's syndrome, most obviously affects the eyes, mouth, and vagina, Dr. Sherrer said.

Typically, Sjögren's occurs in the context of a previously diagnosed autoimmune disorder, such as lupus, rheumatoid arthritis, or scleroderma.

The atypical patients with primary Sjögren's “are our most challenging patients, because they don't have an accompanying autoimmune disease,” Dr. Sherrer said. These patients generally present with neuropathy, accelerated dental caries, salivary gland swelling, joint pain without overt arthritis or myositis, and corneal melt. The current international criteria for diagnosing Sjögren's require that patients demonstrate some objective evidence of autoimmunity, in addition to other symptoms. (See box.)

However, the following less typical symptoms may also warrant suspecting Sjögren's syndrome:

▸ Ocular. In addition to extreme dry eyes, patients may suffer from conjunctivitis, keratitis, blepharitis, ulcerations, and perforations.

▸ Ears, Nose, and Throat. Tracheal dryness causes a chronic dry cough in some patients. Nosebleeds, otitis, and sinusitis can be recurring problems.

▸ Oral. Severe dry mouth can cause swallowing problems, which may lead to malnourishment and excessive weight loss. Patients may also have accelerated caries, loss of dentition, and malfunctioning dentures.

▸ Dermatologic/Vascular. Skin rashes are common, and skin eruptions and purpura may occur. Raynaud's phenomenon is a typical vascular manifestation. Vasculitis is always a concern in Sjögren's patients, but symptoms vary depending on the location of the inflammation in the body.

▸ Gastrointestinal. Patients may suffer from esophageal dysmotility. In severe cases, they are at increased risk for pancreatitis, hepatitis, or atrophic gastritis.

▸ Hematologic. Anemia, blood dyscrasias, and cryoglobulinemias are rare but may occur. In addition, Sjögren's patients are at increased risk for lymphoma.

▸ Pulmonary. Lung involvement and coronary involvement are rare but can develop due to dryness of bronchial tubes. Other potential manifestations include bronchitis, bronchitis obliterans-organized pneumonia, and interstitial fibrosis.

▸ Neurologic. Neuropathies tend to be less symmetrical in Sjögren's patients, compared with other conditions. Central nervous system disorders might manifest as changes in cognitive function or as seizures.

▸ Renal. Renal involvement is rare, but when it occurs, it is usually interstitial tube involvement and is more likely to be chronic, compared with highly progressive kidney involvement associated with lupus.

▸ Musculoskeletal. More often than not, patients with Sjögren's have arthralgia, rather than arthritis, but secondary Sjögren's patients may have concurrent arthritis or myositis.

▸ Other. Fibromyalgia occurs in 20%-30% of Sjögren's patients. Sleep disorders, often due to dryness-related discomfort, are common and may contribute to the fibromyalgia. Depression is a common comorbidity, as it is in patients with other autoimmune disease.

Recommended Diagnostic Criteria

The diagnosis of primary Sjögren's syndrome requires that patients meet at least four of the following six criteria:

The patient must have at least one of three ocular symptoms:

▸ Dry eyes for less than 3 months.

▸ Need to use artificial tears more than three times daily.

▸ Sensation of a foreign body in the eye.

The patient must have at least of three oral symptoms:

▸ Persistent dry mouth for more than 3 months.

▸ Swollen salivary glands.

▸ Need to add extra liquid to the mouth in order to swallow.

The patient must have at least one of two ocular signs:

▸ Unanesthetized Schirmer's test result of 5 mm/5 minutes or less in both eyes.

▸ Positive vital dye staining.

The patient must have at least one of three signs of poor salivary gland function:

▸ Abnormal salivary scintigraphy.

▸ Abnormal parotid sialography.

▸ Unstimulated salivary flow rate of 0.1 mL/minute or less.

Positive lip biopsy.

Positive anti-SSA or anti-SSB tests.

Source: “The New Sjögren's Syndrome Handbook” (New York: Oxford University Press, 2005)

FORT LAUDERDALE, FLA. — Sjögren's syndrome is the second most common autoimmune disorder that affects the musculoskeletal system, and yet the average time to diagnosis is 6 years, said Yvonne Sherrer, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Until more reliable biomarkers for the syndrome are identified, expediting the diagnosis may require physicians to have a higher level of suspicion for some of the less common manifestations of Sjögren's, said Dr. Sherrer, medical director and director of clinical research at the Centre for Rheumatology, Immunology, and Arthritis in Fort Lauderdale.

Although the cause of the Sjögren's is still unknown, researchers suspect that a combination of genetic, environmental, and hormonal factors contribute to predisposition for the disease. Indeed, for every male with the syndrome, an estimated nine women are affected, underscoring the relevance of hormonal influences.

Inflammation of the exocrine glands, the common denominator of Sjögren's syndrome, most obviously affects the eyes, mouth, and vagina, Dr. Sherrer said.

Typically, Sjögren's occurs in the context of a previously diagnosed autoimmune disorder, such as lupus, rheumatoid arthritis, or scleroderma.

The atypical patients with primary Sjögren's “are our most challenging patients, because they don't have an accompanying autoimmune disease,” Dr. Sherrer said. These patients generally present with neuropathy, accelerated dental caries, salivary gland swelling, joint pain without overt arthritis or myositis, and corneal melt. The current international criteria for diagnosing Sjögren's require that patients demonstrate some objective evidence of autoimmunity, in addition to other symptoms. (See box.)

However, the following less typical symptoms may also warrant suspecting Sjögren's syndrome:

▸ Ocular. In addition to extreme dry eyes, patients may suffer from conjunctivitis, keratitis, blepharitis, ulcerations, and perforations.

▸ Ears, Nose, and Throat. Tracheal dryness causes a chronic dry cough in some patients. Nosebleeds, otitis, and sinusitis can be recurring problems.

▸ Oral. Severe dry mouth can cause swallowing problems, which may lead to malnourishment and excessive weight loss. Patients may also have accelerated caries, loss of dentition, and malfunctioning dentures.

▸ Dermatologic/Vascular. Skin rashes are common, and skin eruptions and purpura may occur. Raynaud's phenomenon is a typical vascular manifestation. Vasculitis is always a concern in Sjögren's patients, but symptoms vary depending on the location of the inflammation in the body.

▸ Gastrointestinal. Patients may suffer from esophageal dysmotility. In severe cases, they are at increased risk for pancreatitis, hepatitis, or atrophic gastritis.

▸ Hematologic. Anemia, blood dyscrasias, and cryoglobulinemias are rare but may occur. In addition, Sjögren's patients are at increased risk for lymphoma.

▸ Pulmonary. Lung involvement and coronary involvement are rare but can develop due to dryness of bronchial tubes. Other potential manifestations include bronchitis, bronchitis obliterans-organized pneumonia, and interstitial fibrosis.

▸ Neurologic. Neuropathies tend to be less symmetrical in Sjögren's patients, compared with other conditions. Central nervous system disorders might manifest as changes in cognitive function or as seizures.

▸ Renal. Renal involvement is rare, but when it occurs, it is usually interstitial tube involvement and is more likely to be chronic, compared with highly progressive kidney involvement associated with lupus.

▸ Musculoskeletal. More often than not, patients with Sjögren's have arthralgia, rather than arthritis, but secondary Sjögren's patients may have concurrent arthritis or myositis.

▸ Other. Fibromyalgia occurs in 20%-30% of Sjögren's patients. Sleep disorders, often due to dryness-related discomfort, are common and may contribute to the fibromyalgia. Depression is a common comorbidity, as it is in patients with other autoimmune disease.

Recommended Diagnostic Criteria

The diagnosis of primary Sjögren's syndrome requires that patients meet at least four of the following six criteria:

The patient must have at least one of three ocular symptoms:

▸ Dry eyes for less than 3 months.

▸ Need to use artificial tears more than three times daily.

▸ Sensation of a foreign body in the eye.

The patient must have at least of three oral symptoms:

▸ Persistent dry mouth for more than 3 months.

▸ Swollen salivary glands.

▸ Need to add extra liquid to the mouth in order to swallow.

The patient must have at least one of two ocular signs:

▸ Unanesthetized Schirmer's test result of 5 mm/5 minutes or less in both eyes.

▸ Positive vital dye staining.

The patient must have at least one of three signs of poor salivary gland function:

▸ Abnormal salivary scintigraphy.

▸ Abnormal parotid sialography.

▸ Unstimulated salivary flow rate of 0.1 mL/minute or less.

Positive lip biopsy.

Positive anti-SSA or anti-SSB tests.

Source: “The New Sjögren's Syndrome Handbook” (New York: Oxford University Press, 2005)

A new study puts a twist in the theory that statins could conveniently serve dual purposes in patients with inflammatory diseases that affect both the joints and heart.

Findings from the investigation, involving 5,678 women aged 65 and older, suggest that the use of statins appeared to modestly increase a woman's risk of developing new relatively severe radiographic hip osteoarthritis.

However, statin use did not appear to affect the progression of disease in patients who already had osteoarthritis, reported Mary S. Beattie, M.D., and her associates at the University of California, San Francisco (J. Rheumatol. 2005;32:106-10).

The rationale for the study was based on the fact that while statins are increasingly recognized for their broad anti-inflammatory effects, they have also been shown to increase the production of nitric oxide, which could have a deleterious effect on the cartilage matrix, the investigators said.

The researchers monitored the women, all of whom were white and aged 65 and older, for radiographic evidence of new-onset disease as well as for the progression of established radiographic hip osteoarthritis (RHOA) over an 8-year period. All the women had already been participants in a multicenter study of osteoporotic fractures.

Overall, 7% (397) of the women were statin users, and these women demonstrated nearly twice the risk of developing severe disease, defined radiographically as a summary grade of 3 or greater on the modified Croft scale.

At baseline, 4,933 women had no RHOA in either hip; 566 women had developed new, radiographic evidence of disease in 630 hips by the fifth follow-up visit. Of the 745 women who had RHOA in 936 hips at baseline, the disease worsened in 484 hips among 420 women.

Evidence of new-onset radiographic disease was deemed present if any of five criteria were met: a summary grade of 2 or greater; a minimum joint space (MJS) of 1.5 mm or less; joint space narrowing superolaterally of 2 or greater and superomedially of 3 or greater; or definite osteophytes in any location.

Radiographic progression was deemed present if the MJS decreased by 0.5 mm or more; summary grade increased by 1 or greater; or the osteophyte score increased by 2 or more.

Only 26 (6.5%) of the statin users showed signs of progressive disease. There was a moderate, but not statistically significant, trend toward a decreased risk of OA progression among statin users.

Women who showed signs of progressive RHOA were less likely to be taking vitamin D, compared with women whose disease did not progress (42.6% vs. 51.5%); however, the odds ratio was not statistically significant. There were no significant differences between those with and without RHOA in terms of age, BMI, and walking for exercise.

The study findings are limited by the fact that the investigation included only white women and a small number of statin users.

Evidence suggests that the use of statins can slightly improve symptoms among rheumatoid arthritis patients, Christopher J. Penney, M.D., of the University of Calgary (Alta.), noted in an accompanying editorial.

“The quite modest effect of statins in the management of human rheumatic disease may be related to the dose or to the differences between mouse, man, and test tube,” he said, adding that more prospective trials of statins are needed to determine whether the effects are clinically significant (J. Rheumatol. 2005;32:17-9).

“Obesity is the common denominator for the presence of high cholesterol and hip osteoarthritis in women, and this may explain the results of this trial,” Roy D. Altman, M.D., an osteoarthritis specialist in Agua Dulce, Calif., said in an interview.

The researchers alluded to the relationship between obesity and hip osteoarthritis in women by adjusting for height and weight, but they did not specifically adjust for BMI, noted Dr. Altman, a member of the RHEUMATOLOGY NEWS editorial advisory board.

A new study puts a twist in the theory that statins could conveniently serve dual purposes in patients with inflammatory diseases that affect both the joints and heart.

Findings from the investigation, involving 5,678 women aged 65 and older, suggest that the use of statins appeared to modestly increase a woman's risk of developing new relatively severe radiographic hip osteoarthritis.

However, statin use did not appear to affect the progression of disease in patients who already had osteoarthritis, reported Mary S. Beattie, M.D., and her associates at the University of California, San Francisco (J. Rheumatol. 2005;32:106-10).

The rationale for the study was based on the fact that while statins are increasingly recognized for their broad anti-inflammatory effects, they have also been shown to increase the production of nitric oxide, which could have a deleterious effect on the cartilage matrix, the investigators said.

The researchers monitored the women, all of whom were white and aged 65 and older, for radiographic evidence of new-onset disease as well as for the progression of established radiographic hip osteoarthritis (RHOA) over an 8-year period. All the women had already been participants in a multicenter study of osteoporotic fractures.

Overall, 7% (397) of the women were statin users, and these women demonstrated nearly twice the risk of developing severe disease, defined radiographically as a summary grade of 3 or greater on the modified Croft scale.

At baseline, 4,933 women had no RHOA in either hip; 566 women had developed new, radiographic evidence of disease in 630 hips by the fifth follow-up visit. Of the 745 women who had RHOA in 936 hips at baseline, the disease worsened in 484 hips among 420 women.

Evidence of new-onset radiographic disease was deemed present if any of five criteria were met: a summary grade of 2 or greater; a minimum joint space (MJS) of 1.5 mm or less; joint space narrowing superolaterally of 2 or greater and superomedially of 3 or greater; or definite osteophytes in any location.

Radiographic progression was deemed present if the MJS decreased by 0.5 mm or more; summary grade increased by 1 or greater; or the osteophyte score increased by 2 or more.

Only 26 (6.5%) of the statin users showed signs of progressive disease. There was a moderate, but not statistically significant, trend toward a decreased risk of OA progression among statin users.

Women who showed signs of progressive RHOA were less likely to be taking vitamin D, compared with women whose disease did not progress (42.6% vs. 51.5%); however, the odds ratio was not statistically significant. There were no significant differences between those with and without RHOA in terms of age, BMI, and walking for exercise.

The study findings are limited by the fact that the investigation included only white women and a small number of statin users.

Evidence suggests that the use of statins can slightly improve symptoms among rheumatoid arthritis patients, Christopher J. Penney, M.D., of the University of Calgary (Alta.), noted in an accompanying editorial.

“The quite modest effect of statins in the management of human rheumatic disease may be related to the dose or to the differences between mouse, man, and test tube,” he said, adding that more prospective trials of statins are needed to determine whether the effects are clinically significant (J. Rheumatol. 2005;32:17-9).

“Obesity is the common denominator for the presence of high cholesterol and hip osteoarthritis in women, and this may explain the results of this trial,” Roy D. Altman, M.D., an osteoarthritis specialist in Agua Dulce, Calif., said in an interview.

The researchers alluded to the relationship between obesity and hip osteoarthritis in women by adjusting for height and weight, but they did not specifically adjust for BMI, noted Dr. Altman, a member of the RHEUMATOLOGY NEWS editorial advisory board.

A new study puts a twist in the theory that statins could conveniently serve dual purposes in patients with inflammatory diseases that affect both the joints and heart.

Findings from the investigation, involving 5,678 women aged 65 and older, suggest that the use of statins appeared to modestly increase a woman's risk of developing new relatively severe radiographic hip osteoarthritis.

However, statin use did not appear to affect the progression of disease in patients who already had osteoarthritis, reported Mary S. Beattie, M.D., and her associates at the University of California, San Francisco (J. Rheumatol. 2005;32:106-10).

The rationale for the study was based on the fact that while statins are increasingly recognized for their broad anti-inflammatory effects, they have also been shown to increase the production of nitric oxide, which could have a deleterious effect on the cartilage matrix, the investigators said.

The researchers monitored the women, all of whom were white and aged 65 and older, for radiographic evidence of new-onset disease as well as for the progression of established radiographic hip osteoarthritis (RHOA) over an 8-year period. All the women had already been participants in a multicenter study of osteoporotic fractures.

Overall, 7% (397) of the women were statin users, and these women demonstrated nearly twice the risk of developing severe disease, defined radiographically as a summary grade of 3 or greater on the modified Croft scale.

At baseline, 4,933 women had no RHOA in either hip; 566 women had developed new, radiographic evidence of disease in 630 hips by the fifth follow-up visit. Of the 745 women who had RHOA in 936 hips at baseline, the disease worsened in 484 hips among 420 women.

Evidence of new-onset radiographic disease was deemed present if any of five criteria were met: a summary grade of 2 or greater; a minimum joint space (MJS) of 1.5 mm or less; joint space narrowing superolaterally of 2 or greater and superomedially of 3 or greater; or definite osteophytes in any location.

Radiographic progression was deemed present if the MJS decreased by 0.5 mm or more; summary grade increased by 1 or greater; or the osteophyte score increased by 2 or more.

Only 26 (6.5%) of the statin users showed signs of progressive disease. There was a moderate, but not statistically significant, trend toward a decreased risk of OA progression among statin users.

Women who showed signs of progressive RHOA were less likely to be taking vitamin D, compared with women whose disease did not progress (42.6% vs. 51.5%); however, the odds ratio was not statistically significant. There were no significant differences between those with and without RHOA in terms of age, BMI, and walking for exercise.

The study findings are limited by the fact that the investigation included only white women and a small number of statin users.

Evidence suggests that the use of statins can slightly improve symptoms among rheumatoid arthritis patients, Christopher J. Penney, M.D., of the University of Calgary (Alta.), noted in an accompanying editorial.

“The quite modest effect of statins in the management of human rheumatic disease may be related to the dose or to the differences between mouse, man, and test tube,” he said, adding that more prospective trials of statins are needed to determine whether the effects are clinically significant (J. Rheumatol. 2005;32:17-9).

“Obesity is the common denominator for the presence of high cholesterol and hip osteoarthritis in women, and this may explain the results of this trial,” Roy D. Altman, M.D., an osteoarthritis specialist in Agua Dulce, Calif., said in an interview.

The researchers alluded to the relationship between obesity and hip osteoarthritis in women by adjusting for height and weight, but they did not specifically adjust for BMI, noted Dr. Altman, a member of the RHEUMATOLOGY NEWS editorial advisory board.

SAN ANTONIO — An analysis of the 2002 National Health Interview Survey data has put a specific figure on what clinicians probably already knew intuitively: Almost 40% of arthritis patients have significant physical limitations.

Findings from the survey, which asked the respondents if a physician had ever diagnosed them as having arthritis, indicated that an estimated 21% of U.S. adults had been told they had arthritis.

If the patients responded that they had arthritis, they were then asked if they had any limitations and were asked 12 specific questions about those limitations.

Overall, 38% of the respondents said that they were limited by their condition.

Extrapolated to the population, the figures translate into an estimated 43 million Americans with arthritis, of whom 16 million have limitations from their disease, said Jennifer M. Hootman, Ph.D., an epidemiologist with the Centers for Disease Control and Prevention, Atlanta, at the annual meeting of the American College of Rheumatology.

Among those who reported limitations, 69% reported at least one of the nine specific functional limitations, and 31% either did not specify or reported only that they had limitations in at least one of three general activities, without being specific.

The most common specific limitation was being unable to stoop or bend, reported by 49% of those with limitations.

Others included: inability to stand for 2 hours (47%), walk a quarter of a mile (37%), push a heavy object (32%), climb stairs (30%), and lift and carry 10 pounds (23%).

The general activity that was reported to be limited most commonly was shopping, reported by 17% of those with limitations.

The good news is that of the factors that were found to be associated with physical limitations from arthritis, the most important one, being overweight, defined as a body mass index of greater than 25, was modifiable, Dr. Hootman noted in her presentation.

“Common sense says reducing weight can improve disability,” Dr. Hootman said.

The survey responses did not identify whether the individuals interviewed had osteoarthritis or rheumatoid arthritis.

SAN ANTONIO — An analysis of the 2002 National Health Interview Survey data has put a specific figure on what clinicians probably already knew intuitively: Almost 40% of arthritis patients have significant physical limitations.

Findings from the survey, which asked the respondents if a physician had ever diagnosed them as having arthritis, indicated that an estimated 21% of U.S. adults had been told they had arthritis.

If the patients responded that they had arthritis, they were then asked if they had any limitations and were asked 12 specific questions about those limitations.

Overall, 38% of the respondents said that they were limited by their condition.

Extrapolated to the population, the figures translate into an estimated 43 million Americans with arthritis, of whom 16 million have limitations from their disease, said Jennifer M. Hootman, Ph.D., an epidemiologist with the Centers for Disease Control and Prevention, Atlanta, at the annual meeting of the American College of Rheumatology.

Among those who reported limitations, 69% reported at least one of the nine specific functional limitations, and 31% either did not specify or reported only that they had limitations in at least one of three general activities, without being specific.

The most common specific limitation was being unable to stoop or bend, reported by 49% of those with limitations.

Others included: inability to stand for 2 hours (47%), walk a quarter of a mile (37%), push a heavy object (32%), climb stairs (30%), and lift and carry 10 pounds (23%).

The general activity that was reported to be limited most commonly was shopping, reported by 17% of those with limitations.

The good news is that of the factors that were found to be associated with physical limitations from arthritis, the most important one, being overweight, defined as a body mass index of greater than 25, was modifiable, Dr. Hootman noted in her presentation.

“Common sense says reducing weight can improve disability,” Dr. Hootman said.

The survey responses did not identify whether the individuals interviewed had osteoarthritis or rheumatoid arthritis.

SAN ANTONIO — An analysis of the 2002 National Health Interview Survey data has put a specific figure on what clinicians probably already knew intuitively: Almost 40% of arthritis patients have significant physical limitations.

Findings from the survey, which asked the respondents if a physician had ever diagnosed them as having arthritis, indicated that an estimated 21% of U.S. adults had been told they had arthritis.

If the patients responded that they had arthritis, they were then asked if they had any limitations and were asked 12 specific questions about those limitations.

Overall, 38% of the respondents said that they were limited by their condition.

Extrapolated to the population, the figures translate into an estimated 43 million Americans with arthritis, of whom 16 million have limitations from their disease, said Jennifer M. Hootman, Ph.D., an epidemiologist with the Centers for Disease Control and Prevention, Atlanta, at the annual meeting of the American College of Rheumatology.

Among those who reported limitations, 69% reported at least one of the nine specific functional limitations, and 31% either did not specify or reported only that they had limitations in at least one of three general activities, without being specific.

The most common specific limitation was being unable to stoop or bend, reported by 49% of those with limitations.

Others included: inability to stand for 2 hours (47%), walk a quarter of a mile (37%), push a heavy object (32%), climb stairs (30%), and lift and carry 10 pounds (23%).

The general activity that was reported to be limited most commonly was shopping, reported by 17% of those with limitations.

The good news is that of the factors that were found to be associated with physical limitations from arthritis, the most important one, being overweight, defined as a body mass index of greater than 25, was modifiable, Dr. Hootman noted in her presentation.

“Common sense says reducing weight can improve disability,” Dr. Hootman said.

The survey responses did not identify whether the individuals interviewed had osteoarthritis or rheumatoid arthritis.

CHICAGO — Musculoskeletal symptoms are very common in the morbidly obese, but improve significantly as early as 6 months after gastric bypass surgery, Michele Hooper, M.D., said at the 2004 World Congress on Osteoarthritis.

In a study of 48 consecutive patients, 52% had complete resolution of musculoskeletal symptoms, in weight bearing and non-weight bearing sites, 6 months after surgery. Fibromyalgia symptoms resolved in 90% of patients.

Such benefits may even become more pronounced with time, as weight loss generally plateaus at 24 months and many of the patients were still obese at the time of the study.

While these highly motivated patients may not reflect the general obese population, the benefits seen with weight loss indicate that prevention and treatment of obesity could improve musculoskeletal health and function, said Dr. Hooper of University Hospitals of Cleveland.

She reported on 47 women and one man, mean age 44 years, who were evaluated before and 6 months after laparoscopic or open Roux-en-Y surgery.

The mean weight of the women before surgery was 292 pounds (body mass index 51 kg/m

The percentage of patients with comorbid conditions at baseline decreased after weight loss: hypertension (52% vs. 14%), sleep apnea (46% vs. 14%), depression (33% vs. 14%), gastroesophageal reflux disease (31% vs. 11%), type 2 diabetes (30% vs. 7%), and asthma (30% vs. 7%). Ninety percent of fibromyalgia symptoms resolved.

The dramatic resolution of fibromyalgia symptoms may be due to a decrease in comorbid syndromes, particularly depression, and an increase in physical activity, Dr. Hooper said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Lower extremity musculoskeletal symptoms improved with weight loss, with the exception of hip and trochanteric bursitis complaints.

Upper extremity symptoms improved, with the exception of epicondylitis.

The proportion of patients affected by symptoms decreased significantly as follows: knee symptoms (75% at baseline vs. 44% after weight loss); ankle/foot (46% vs. 8%); shoulder (40% vs. 27%); lumbar spine (38% vs. 15%); hand (35% vs. 21%); carpal tunnel syndrome (31% vs. 15%); hip joint (23% vs. 15%); trochanteric bursitis (29% vs. 17%); and epicondylitis (13% vs. 4%).

At 6 months, scores on the Western Ontario and McMaster University Osteoarthritis (WOMAC) composite index improved 67% from baseline. WOMAC subscales improved for pain (51%), function (74%), and stiffness (64%).

Short Form-36 Health Survey scores significantly improved in seven of eight domains measured, and the remaining one domain, general health, was close to normal at baseline.

“The WOMAC osteoarthritis index offers significant potential for assessing musculoskeletal outcomes in obese subjects after gastric bypass surgery, and should be explored further,” Dr. Hooper said.

“The SF indicates that obesity is associated with a poor quality of life, which improves significantly after weight loss associated with gastric bypass surgery.”

CHICAGO — Musculoskeletal symptoms are very common in the morbidly obese, but improve significantly as early as 6 months after gastric bypass surgery, Michele Hooper, M.D., said at the 2004 World Congress on Osteoarthritis.

In a study of 48 consecutive patients, 52% had complete resolution of musculoskeletal symptoms, in weight bearing and non-weight bearing sites, 6 months after surgery. Fibromyalgia symptoms resolved in 90% of patients.

Such benefits may even become more pronounced with time, as weight loss generally plateaus at 24 months and many of the patients were still obese at the time of the study.

While these highly motivated patients may not reflect the general obese population, the benefits seen with weight loss indicate that prevention and treatment of obesity could improve musculoskeletal health and function, said Dr. Hooper of University Hospitals of Cleveland.

She reported on 47 women and one man, mean age 44 years, who were evaluated before and 6 months after laparoscopic or open Roux-en-Y surgery.

The mean weight of the women before surgery was 292 pounds (body mass index 51 kg/m

The percentage of patients with comorbid conditions at baseline decreased after weight loss: hypertension (52% vs. 14%), sleep apnea (46% vs. 14%), depression (33% vs. 14%), gastroesophageal reflux disease (31% vs. 11%), type 2 diabetes (30% vs. 7%), and asthma (30% vs. 7%). Ninety percent of fibromyalgia symptoms resolved.

The dramatic resolution of fibromyalgia symptoms may be due to a decrease in comorbid syndromes, particularly depression, and an increase in physical activity, Dr. Hooper said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Lower extremity musculoskeletal symptoms improved with weight loss, with the exception of hip and trochanteric bursitis complaints.

Upper extremity symptoms improved, with the exception of epicondylitis.

The proportion of patients affected by symptoms decreased significantly as follows: knee symptoms (75% at baseline vs. 44% after weight loss); ankle/foot (46% vs. 8%); shoulder (40% vs. 27%); lumbar spine (38% vs. 15%); hand (35% vs. 21%); carpal tunnel syndrome (31% vs. 15%); hip joint (23% vs. 15%); trochanteric bursitis (29% vs. 17%); and epicondylitis (13% vs. 4%).

At 6 months, scores on the Western Ontario and McMaster University Osteoarthritis (WOMAC) composite index improved 67% from baseline. WOMAC subscales improved for pain (51%), function (74%), and stiffness (64%).

Short Form-36 Health Survey scores significantly improved in seven of eight domains measured, and the remaining one domain, general health, was close to normal at baseline.

“The WOMAC osteoarthritis index offers significant potential for assessing musculoskeletal outcomes in obese subjects after gastric bypass surgery, and should be explored further,” Dr. Hooper said.

“The SF indicates that obesity is associated with a poor quality of life, which improves significantly after weight loss associated with gastric bypass surgery.”

CHICAGO — Musculoskeletal symptoms are very common in the morbidly obese, but improve significantly as early as 6 months after gastric bypass surgery, Michele Hooper, M.D., said at the 2004 World Congress on Osteoarthritis.

In a study of 48 consecutive patients, 52% had complete resolution of musculoskeletal symptoms, in weight bearing and non-weight bearing sites, 6 months after surgery. Fibromyalgia symptoms resolved in 90% of patients.

Such benefits may even become more pronounced with time, as weight loss generally plateaus at 24 months and many of the patients were still obese at the time of the study.

While these highly motivated patients may not reflect the general obese population, the benefits seen with weight loss indicate that prevention and treatment of obesity could improve musculoskeletal health and function, said Dr. Hooper of University Hospitals of Cleveland.

She reported on 47 women and one man, mean age 44 years, who were evaluated before and 6 months after laparoscopic or open Roux-en-Y surgery.

The mean weight of the women before surgery was 292 pounds (body mass index 51 kg/m

The percentage of patients with comorbid conditions at baseline decreased after weight loss: hypertension (52% vs. 14%), sleep apnea (46% vs. 14%), depression (33% vs. 14%), gastroesophageal reflux disease (31% vs. 11%), type 2 diabetes (30% vs. 7%), and asthma (30% vs. 7%). Ninety percent of fibromyalgia symptoms resolved.

The dramatic resolution of fibromyalgia symptoms may be due to a decrease in comorbid syndromes, particularly depression, and an increase in physical activity, Dr. Hooper said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Lower extremity musculoskeletal symptoms improved with weight loss, with the exception of hip and trochanteric bursitis complaints.

Upper extremity symptoms improved, with the exception of epicondylitis.

The proportion of patients affected by symptoms decreased significantly as follows: knee symptoms (75% at baseline vs. 44% after weight loss); ankle/foot (46% vs. 8%); shoulder (40% vs. 27%); lumbar spine (38% vs. 15%); hand (35% vs. 21%); carpal tunnel syndrome (31% vs. 15%); hip joint (23% vs. 15%); trochanteric bursitis (29% vs. 17%); and epicondylitis (13% vs. 4%).

At 6 months, scores on the Western Ontario and McMaster University Osteoarthritis (WOMAC) composite index improved 67% from baseline. WOMAC subscales improved for pain (51%), function (74%), and stiffness (64%).

Short Form-36 Health Survey scores significantly improved in seven of eight domains measured, and the remaining one domain, general health, was close to normal at baseline.

“The WOMAC osteoarthritis index offers significant potential for assessing musculoskeletal outcomes in obese subjects after gastric bypass surgery, and should be explored further,” Dr. Hooper said.

“The SF indicates that obesity is associated with a poor quality of life, which improves significantly after weight loss associated with gastric bypass surgery.”

CHICAGO — The presence of an impaired metabolism exacerbates the impact of obesity as a risk factor for developing knee osteoarthritis and is associated with reduced physical functioning, Mary Fran Sowers, Ph.D., reported at the 2004 World Congress on Osteoarthritis.

Such findings suggest that “the role of obesity with respect to osteoarthritis and functioning may extend mechanistically beyond that of just simple joint loading,” said Dr. Sowers, an epidemiology professor at the University of Michigan, Ann Arbor.

Current OA treatments should be evaluated for their potential to exacerbate these metabolic derangements, because this exacerbation is likely to diminish treatment efficacy. “An understanding of the added contribution of the obesity subtypes could be very useful in guiding primary and secondary treatment efforts,” Dr. Sowers added at the meeting, sponsored by the Osteoarthritis Research Society International.

Researchers have identified several obesity subtypes, including individuals who are obese but metabolically healthy. This may occur in about 20% of obese persons and is characterized by large amounts of fat mass but normal insulin levels and favorable cardiovascular risk factor profiles.

Another risk group comprises individuals of normal weight who have metabolic profiles more typically seen in the obese. This risk group may account for about 15% of the general population and is characterized by low HDL cholesterol, higher triglyceride levels, and higher levels of inflammatory markers.

A community-based cohort of 775 women aged 43–53 years was evaluated for metabolic obesity, defined on the basis of three body mass index (BMI) cutoff points and the presence of two or more of the following metabolic derangements: diabetes or fasting glucose greater than 125 mg/dL, serum C-reactive protein greater than 2 mg/L, HDL less than 45 mg/dL, triglycerides greater than 200 mg/dL, or a waist-hip ratio greater than 0.81 cm.

The investigators found that 34% of the women were not obese (BMI less than 26 kg/m

Another 31% of the participants were overweight to obese (BMI 26–34 kg/m

Finally, 12% were very obese (BMI greater than 34 kg/m

Among those without a metabolic derangement, the odds of having knee OA were increased among women who were either overweight/obese (odds ratio 1.9) or very obese (OR 7.0), compared with women who were not obese and had no metabolic derangement.

But when obesity was associated with a metabolic derangement, the risk of knee OA was three times higher in overweight or obese women (OR 3.3) and nine times higher in very obese women (OR 9.0), compared with women who were not obese and had no metabolic derangement.

The impact of metabolic disorders and weight on OA risk was consistent across all four of the physical tests: speed measured during walking on gait mats, grip strength, timed walk, and timed stair climbing.

There was no loss in leg strength unless women had an impaired metabolism, and then the loss was most pronounced in individuals with the highest BMI.

Dr. Sowers proposed that metabolic disorders and obesity may affect leg strength by altering glycation products in the muscles, by allowing fatty infiltration of muscle tissue and compromising selective muscle fibers, or by causing innervation problems.

CHICAGO — The presence of an impaired metabolism exacerbates the impact of obesity as a risk factor for developing knee osteoarthritis and is associated with reduced physical functioning, Mary Fran Sowers, Ph.D., reported at the 2004 World Congress on Osteoarthritis.

Such findings suggest that “the role of obesity with respect to osteoarthritis and functioning may extend mechanistically beyond that of just simple joint loading,” said Dr. Sowers, an epidemiology professor at the University of Michigan, Ann Arbor.

Current OA treatments should be evaluated for their potential to exacerbate these metabolic derangements, because this exacerbation is likely to diminish treatment efficacy. “An understanding of the added contribution of the obesity subtypes could be very useful in guiding primary and secondary treatment efforts,” Dr. Sowers added at the meeting, sponsored by the Osteoarthritis Research Society International.

Researchers have identified several obesity subtypes, including individuals who are obese but metabolically healthy. This may occur in about 20% of obese persons and is characterized by large amounts of fat mass but normal insulin levels and favorable cardiovascular risk factor profiles.

Another risk group comprises individuals of normal weight who have metabolic profiles more typically seen in the obese. This risk group may account for about 15% of the general population and is characterized by low HDL cholesterol, higher triglyceride levels, and higher levels of inflammatory markers.

A community-based cohort of 775 women aged 43–53 years was evaluated for metabolic obesity, defined on the basis of three body mass index (BMI) cutoff points and the presence of two or more of the following metabolic derangements: diabetes or fasting glucose greater than 125 mg/dL, serum C-reactive protein greater than 2 mg/L, HDL less than 45 mg/dL, triglycerides greater than 200 mg/dL, or a waist-hip ratio greater than 0.81 cm.

The investigators found that 34% of the women were not obese (BMI less than 26 kg/m

Another 31% of the participants were overweight to obese (BMI 26–34 kg/m

Finally, 12% were very obese (BMI greater than 34 kg/m

Among those without a metabolic derangement, the odds of having knee OA were increased among women who were either overweight/obese (odds ratio 1.9) or very obese (OR 7.0), compared with women who were not obese and had no metabolic derangement.

But when obesity was associated with a metabolic derangement, the risk of knee OA was three times higher in overweight or obese women (OR 3.3) and nine times higher in very obese women (OR 9.0), compared with women who were not obese and had no metabolic derangement.

The impact of metabolic disorders and weight on OA risk was consistent across all four of the physical tests: speed measured during walking on gait mats, grip strength, timed walk, and timed stair climbing.

There was no loss in leg strength unless women had an impaired metabolism, and then the loss was most pronounced in individuals with the highest BMI.

Dr. Sowers proposed that metabolic disorders and obesity may affect leg strength by altering glycation products in the muscles, by allowing fatty infiltration of muscle tissue and compromising selective muscle fibers, or by causing innervation problems.

CHICAGO — The presence of an impaired metabolism exacerbates the impact of obesity as a risk factor for developing knee osteoarthritis and is associated with reduced physical functioning, Mary Fran Sowers, Ph.D., reported at the 2004 World Congress on Osteoarthritis.

Such findings suggest that “the role of obesity with respect to osteoarthritis and functioning may extend mechanistically beyond that of just simple joint loading,” said Dr. Sowers, an epidemiology professor at the University of Michigan, Ann Arbor.

Current OA treatments should be evaluated for their potential to exacerbate these metabolic derangements, because this exacerbation is likely to diminish treatment efficacy. “An understanding of the added contribution of the obesity subtypes could be very useful in guiding primary and secondary treatment efforts,” Dr. Sowers added at the meeting, sponsored by the Osteoarthritis Research Society International.

Researchers have identified several obesity subtypes, including individuals who are obese but metabolically healthy. This may occur in about 20% of obese persons and is characterized by large amounts of fat mass but normal insulin levels and favorable cardiovascular risk factor profiles.

Another risk group comprises individuals of normal weight who have metabolic profiles more typically seen in the obese. This risk group may account for about 15% of the general population and is characterized by low HDL cholesterol, higher triglyceride levels, and higher levels of inflammatory markers.

A community-based cohort of 775 women aged 43–53 years was evaluated for metabolic obesity, defined on the basis of three body mass index (BMI) cutoff points and the presence of two or more of the following metabolic derangements: diabetes or fasting glucose greater than 125 mg/dL, serum C-reactive protein greater than 2 mg/L, HDL less than 45 mg/dL, triglycerides greater than 200 mg/dL, or a waist-hip ratio greater than 0.81 cm.

The investigators found that 34% of the women were not obese (BMI less than 26 kg/m

Another 31% of the participants were overweight to obese (BMI 26–34 kg/m

Finally, 12% were very obese (BMI greater than 34 kg/m

Among those without a metabolic derangement, the odds of having knee OA were increased among women who were either overweight/obese (odds ratio 1.9) or very obese (OR 7.0), compared with women who were not obese and had no metabolic derangement.

But when obesity was associated with a metabolic derangement, the risk of knee OA was three times higher in overweight or obese women (OR 3.3) and nine times higher in very obese women (OR 9.0), compared with women who were not obese and had no metabolic derangement.

The impact of metabolic disorders and weight on OA risk was consistent across all four of the physical tests: speed measured during walking on gait mats, grip strength, timed walk, and timed stair climbing.

There was no loss in leg strength unless women had an impaired metabolism, and then the loss was most pronounced in individuals with the highest BMI.

Dr. Sowers proposed that metabolic disorders and obesity may affect leg strength by altering glycation products in the muscles, by allowing fatty infiltration of muscle tissue and compromising selective muscle fibers, or by causing innervation problems.

WASHINGTON — The presence of pain in older adults is a significant risk factor for clinical depression, Stephen Harkins, Ph.D., said at the annual meeting of the Gerontological Society of America.

Poorly managed pain lowers quality of life in older persons across cultures, said Dr. Harkins, professor in the departments of gerontology, psychiatry, and biomedical engineering at Virginia Commonwealth University in Richmond.

He reviewed data on 2,900 adults (mean age 75 years) from the National Health and Nutrition Examination Survey and 2,081 adults (mean age 78 years) from the Australian Longitudinal Study on Aging. Both studies included data on musculoskeletal pain, including swollen joints and hip, back, knee, and neck pain.

Mean scores on the Center for Epidemiologic Studies-Depression (CES-D) scale were similar for older adults in the United States (9.3) and Australia (8.2). Overall, 47% of the adults surveyed reported pain in the past week, and the risk of depression was independently related to the presence, type, and number of musculoskeletal problems. In addition, reports of pain more than doubled an individual's risk for exceeding a score of 20 on the CES-D—the cutoff point for clinical depression.

“The take-home message is that pain increases the probability of scoring high on a depression scale,” said Dr. Harkins, who also is director of the psychophysiology and memory laboratory at the university.

WASHINGTON — The presence of pain in older adults is a significant risk factor for clinical depression, Stephen Harkins, Ph.D., said at the annual meeting of the Gerontological Society of America.

Poorly managed pain lowers quality of life in older persons across cultures, said Dr. Harkins, professor in the departments of gerontology, psychiatry, and biomedical engineering at Virginia Commonwealth University in Richmond.

He reviewed data on 2,900 adults (mean age 75 years) from the National Health and Nutrition Examination Survey and 2,081 adults (mean age 78 years) from the Australian Longitudinal Study on Aging. Both studies included data on musculoskeletal pain, including swollen joints and hip, back, knee, and neck pain.

Mean scores on the Center for Epidemiologic Studies-Depression (CES-D) scale were similar for older adults in the United States (9.3) and Australia (8.2). Overall, 47% of the adults surveyed reported pain in the past week, and the risk of depression was independently related to the presence, type, and number of musculoskeletal problems. In addition, reports of pain more than doubled an individual's risk for exceeding a score of 20 on the CES-D—the cutoff point for clinical depression.

“The take-home message is that pain increases the probability of scoring high on a depression scale,” said Dr. Harkins, who also is director of the psychophysiology and memory laboratory at the university.

WASHINGTON — The presence of pain in older adults is a significant risk factor for clinical depression, Stephen Harkins, Ph.D., said at the annual meeting of the Gerontological Society of America.

Poorly managed pain lowers quality of life in older persons across cultures, said Dr. Harkins, professor in the departments of gerontology, psychiatry, and biomedical engineering at Virginia Commonwealth University in Richmond.

He reviewed data on 2,900 adults (mean age 75 years) from the National Health and Nutrition Examination Survey and 2,081 adults (mean age 78 years) from the Australian Longitudinal Study on Aging. Both studies included data on musculoskeletal pain, including swollen joints and hip, back, knee, and neck pain.

Mean scores on the Center for Epidemiologic Studies-Depression (CES-D) scale were similar for older adults in the United States (9.3) and Australia (8.2). Overall, 47% of the adults surveyed reported pain in the past week, and the risk of depression was independently related to the presence, type, and number of musculoskeletal problems. In addition, reports of pain more than doubled an individual's risk for exceeding a score of 20 on the CES-D—the cutoff point for clinical depression.

“The take-home message is that pain increases the probability of scoring high on a depression scale,” said Dr. Harkins, who also is director of the psychophysiology and memory laboratory at the university.

SAN ANTONIO — The clinical safety and efficacy of etanercept persist for more than 2 years in patients with active ankylosing spondylitis, according to the results of an open-label extension study.

Among 26 patients who entered the open, observational phase following a 12-week blinded study, 21 have continued with etanercept, 25 mg twice weekly, for an additional 102 weeks, Xenofon Baraliakos, M.D., said at the annual meeting of the American College of Rheumatology.

Response was evaluated according to a core set of end points proposed by the Assessments in Ankylosing Spondylitis (ASAS) working group. These included the Bath AS Disease Activity Index (BASDAI) and the ASAS 40, which represents a 40% improvement in several disease domains such as pain, function, and inflammation.

The primary end point was an improvement of 50% or more on the BASDAI, a 10-point visual analog scale that assesses fatigue, spinal pain, peripheral arthritis, enthesitis, and morning stiffness.

At 102 weeks, an intent-to-treat analysis of all 26 patients indicated that 54% maintained both a BASDAI 50% response and an ASAS 40. At week 54, the corresponding percentages were 58% and 62%, said Dr. Baraliakos, who is of the department of rheumatology, Benjamin Franklin Hospital, Free University Berlin.

An analysis that included only the 21 study completers also found that disease activity improved significantly, with a mean BASDAI score of 2.7 at week 102. The baseline BASDAI score in this group of patients had been 6.3, on a 0–10 scale, with 10 being the most severe, Dr. Baraliakos said in a poster session.

The mean C-reactive protein level at week 102 was 5 mg/dL, and the mean erythrocyte sedimentation rate was 9 mg/dL, which represented significant improvements over baseline levels, which had been 15.3 and 22.8, respectively. Similar improvements also were seen on the Bath AS functional and mobility indexes.

This study differed from previous investigations of etanercept in AS in that no concomitant corticosteroids or disease-modifying antirheumatic drugs (DMARDs) were permitted. In an earlier study, 40 patients were treated with the tumor necrosis factor-α blocking agent but were allowed to continue other medications (N. Engl. J. Med. 2002;346:1349–56).

In an interim analysis, the authors of this latest study noted that it was important to evaluate etanercept alone (Arthritis Rheum. 2003;48:1667–75).

SAN ANTONIO — The clinical safety and efficacy of etanercept persist for more than 2 years in patients with active ankylosing spondylitis, according to the results of an open-label extension study.

Among 26 patients who entered the open, observational phase following a 12-week blinded study, 21 have continued with etanercept, 25 mg twice weekly, for an additional 102 weeks, Xenofon Baraliakos, M.D., said at the annual meeting of the American College of Rheumatology.

Response was evaluated according to a core set of end points proposed by the Assessments in Ankylosing Spondylitis (ASAS) working group. These included the Bath AS Disease Activity Index (BASDAI) and the ASAS 40, which represents a 40% improvement in several disease domains such as pain, function, and inflammation.

The primary end point was an improvement of 50% or more on the BASDAI, a 10-point visual analog scale that assesses fatigue, spinal pain, peripheral arthritis, enthesitis, and morning stiffness.

At 102 weeks, an intent-to-treat analysis of all 26 patients indicated that 54% maintained both a BASDAI 50% response and an ASAS 40. At week 54, the corresponding percentages were 58% and 62%, said Dr. Baraliakos, who is of the department of rheumatology, Benjamin Franklin Hospital, Free University Berlin.

An analysis that included only the 21 study completers also found that disease activity improved significantly, with a mean BASDAI score of 2.7 at week 102. The baseline BASDAI score in this group of patients had been 6.3, on a 0–10 scale, with 10 being the most severe, Dr. Baraliakos said in a poster session.

The mean C-reactive protein level at week 102 was 5 mg/dL, and the mean erythrocyte sedimentation rate was 9 mg/dL, which represented significant improvements over baseline levels, which had been 15.3 and 22.8, respectively. Similar improvements also were seen on the Bath AS functional and mobility indexes.

This study differed from previous investigations of etanercept in AS in that no concomitant corticosteroids or disease-modifying antirheumatic drugs (DMARDs) were permitted. In an earlier study, 40 patients were treated with the tumor necrosis factor-α blocking agent but were allowed to continue other medications (N. Engl. J. Med. 2002;346:1349–56).

In an interim analysis, the authors of this latest study noted that it was important to evaluate etanercept alone (Arthritis Rheum. 2003;48:1667–75).

SAN ANTONIO — The clinical safety and efficacy of etanercept persist for more than 2 years in patients with active ankylosing spondylitis, according to the results of an open-label extension study.

Among 26 patients who entered the open, observational phase following a 12-week blinded study, 21 have continued with etanercept, 25 mg twice weekly, for an additional 102 weeks, Xenofon Baraliakos, M.D., said at the annual meeting of the American College of Rheumatology.

Response was evaluated according to a core set of end points proposed by the Assessments in Ankylosing Spondylitis (ASAS) working group. These included the Bath AS Disease Activity Index (BASDAI) and the ASAS 40, which represents a 40% improvement in several disease domains such as pain, function, and inflammation.

The primary end point was an improvement of 50% or more on the BASDAI, a 10-point visual analog scale that assesses fatigue, spinal pain, peripheral arthritis, enthesitis, and morning stiffness.

At 102 weeks, an intent-to-treat analysis of all 26 patients indicated that 54% maintained both a BASDAI 50% response and an ASAS 40. At week 54, the corresponding percentages were 58% and 62%, said Dr. Baraliakos, who is of the department of rheumatology, Benjamin Franklin Hospital, Free University Berlin.

An analysis that included only the 21 study completers also found that disease activity improved significantly, with a mean BASDAI score of 2.7 at week 102. The baseline BASDAI score in this group of patients had been 6.3, on a 0–10 scale, with 10 being the most severe, Dr. Baraliakos said in a poster session.

The mean C-reactive protein level at week 102 was 5 mg/dL, and the mean erythrocyte sedimentation rate was 9 mg/dL, which represented significant improvements over baseline levels, which had been 15.3 and 22.8, respectively. Similar improvements also were seen on the Bath AS functional and mobility indexes.

This study differed from previous investigations of etanercept in AS in that no concomitant corticosteroids or disease-modifying antirheumatic drugs (DMARDs) were permitted. In an earlier study, 40 patients were treated with the tumor necrosis factor-α blocking agent but were allowed to continue other medications (N. Engl. J. Med. 2002;346:1349–56).

In an interim analysis, the authors of this latest study noted that it was important to evaluate etanercept alone (Arthritis Rheum. 2003;48:1667–75).