Measuring health status in psoriatic arthritis: the Health Assessment Questionnaire and its modification

OBJECTIVE: The Health Assessment Questionnaire (HAQ) has proven to be a reliable and valid measure of outcome for a variety of arthritides. A recent modification of HAQ for spondyloarthropathy (HAQ-S) has also been reported. Our purpose was to evaluate the HAQ and HAQ-S as outcome measures in the assessment of patients with psoriatic arthritis (PsA). METHODS: The HAQ, including HAQ-S was administered to all patients attending our Psoriatic Arthritis Clinic between June and December, 1993. Clinical and radiological assessments were performed according to a standard protocol that measures disease activity, fibrositic tender points (TP), disease severity and damage. Analysis was performed using SAS for the PC. RESULTS: The patient population included 114 patients, 70 men and 44 women with a mean age of 49.3 years and a mean arthritis duration of 15.1 years. The mean HAQ score was 0.50, while the mean HAQ-S score was 0.53 (scores range 0 to 3 for this instrument). The overall HAQ and HAQ-S disability scores were highly correlated with several clinical measures of function, including grip strength (r = -0.63 and -0.59, respectively). American College of Rheumatology functional class (r = 0.59 and 0.60, respectively), as well as the number of fibrositic TP (r = 0.54 and 0.57, respectively). These disability scores also correlated highly with the overall number of actively inflamed joints (r = 0.49 and 0.50, respectively); however, they correlated only moderately or poorly with other measures of disease activity such as morning stiffness, total number of joint effusions, erythrocyte sedimentation rate (ESR) and the PASI score for psoriasis and with all measures of disease severity. A similar pattern of correlations was found between the individual subscales of the HAQ and HAQ-S and the clinical measures of function, activity, and severity, as well as between the pain scale and the various clinical measures. However, the correlations are generally lower. CONCLUSION: Our data suggest that HAQ and HAQ-S capture clinical measures of function and pain in PsA but do not correlate with disease severity. The HAQ and its modification for spondyloarthropathy may reflect fibromyaglia as a measure of pain and tenderness in these patients. Thus, the clinical assessment of disease activity and both clinical and radiological assessments of joint damage remain important outcome measures in PsA.     

The assessment of functional status in rheumatoid arthritis: a cross cultural, longitudinal comparison of the Health Assessment Questionnaire and the Groningen Activity Restriction Scale

OBJECTIVE: To compare a disease specific measure of functional status, the Health Assessment Questionnaire (HAQ) with a generic measure of functional status, the Groningen Activity Restriction Scale (GARS) in a cross cultural and longitudinal setting. Besides the comparison of psychometric properties, sex differences were also studied. METHODS: In a sample of 634 patients with rheumatoid arthritis (RA) (290 from The Netherlands, 116 from France, 228 from Norway), the psychometric properties (Cronbach's alpha and rho) of the GARS and the HAQ were compared among countries. The sensitivity for change between T1 and T2 was tested by means of the standardized response mean for a one year followup; furthermore, the relative efficiency of both instruments was computed. A t test was used to trace sex differences. RESULTS: The psychometric properties of both the HAQ and the GARS were very good. Both form unidimensional scales of hierarchically ordered items; alpha and rho are > 0.91 for both instruments. For patients who improved between T1 and T2, measured by the Ritchie Articular Index, the standardized response mean of the HAQ and the GARS were moderate, whereas for patients who worsened, the standardized response means were small. The results based on the relative efficiency were ambiguous. Furthermore, the mean score for women on the HAQ was 0.25 higher in contrast to scores for men. The GARS did not yield different scores for women and men. CONCLUSION: The internal consistency of the GARS and the HAQ are comparable. The HAQ has yielded different results for women and men. Therefore, when the HAQ is used, sex differences should be taken into account. With respect to sensitivity to change, the GARS and the HAQ obtained much better results for patients who improved in contrast to patients who worsened. The GARS was found to be more sensitive to change for patients who improved.     

Serum chemokines in patients with psoriatic arthritis treated with cyclosporin A

OBJECTIVE: To investigate the possible effects of neuropeptide Y on steroid release by human granulosa cells in culture. DESIGN: Prospective study. SETTING: A university laboratory and the division of obstetrics and gynecology in a hospital. PATIENT(S): Sixteen normally ovulating women. INTERVENTION(S): Ovulation induction for IVF-ET with an LH-releasing hormone analogue and gonadotropins. MAIN OUTCOME MEASURE(S): E2 and progesterone were assayed in the media conditioned by granulosa cells with the use of a double-antibody RIA. RESULT(S): Neuropeptide Y stimulates E2 production in a dose-dependent fashion. Preincubation for 3 hours with hCG led to a statistically significant increase in neuropeptide Y-induced E2 secretion. In contrast, whereas 3 hours of preincubation with 10(-7) mol/L of neuropeptide Y did not elicit a statistically significant increase in hCG-induced E2 secretion, coincubation for 48 hours significantly increased hCG-stimulated secretion. Unlike E2, progesterone secretion did not undergo any statistically significant or dose-dependent variation after treatment with neuropeptide Y. CONCLUSION(S): Neuropeptide Y plays a role in human ovarian steroidogenesis directly at the level of the granulosa cells of the follicles in the early stage of luteinization. In this way, neuropeptide Y could play an important role in controlling the positive feedback effect exerted by the ovarian steroids on LH-releasing hormone and gonadotropins in humans.     

Acute psychoses in patients with psoriatic arthritis during treatment with sulfasalazine

A 10-year-old boy with acute promyelocytic leukemia (APL) was treated with all-trans-retinoic acid (ATRA) at a dose of 60 mg/m2/day. Recombinant erythropoietin was also used. The patient parents and other relatives, all Jehova's Witnesses, refused any type of hemotherapy. After 43 days of ATRA treatment complete remission was obtained without the use of hemotherapy. This case exemplifies the advantages provided by ATRA treatment in APL.     

Corticosteroid prescribing in rheumatoid arthritis and psoriatic arthritis

Embryos from certain mouse strains are arrested at the 2-cell stage in cell culture ('2-cell block'), whereas those from other strains develop to the blastocyst stage under the same conditions. It was previously shown that blocking embryos can be rescued in culture by aggregation with an excess of 2-cell stages of a non-blocking strain such as CBA x C57BL/6 F2. Here we have employed a LacZ transgene in a blocking strain (NMRI) to follow the fate of rescued blastomeres up to the blastocyst stage. We found that rescued blastomeres can participate in both inner cell mass and trophoblast formation, thus completely overcoming the 2-cell block.     

Clinical comparison of patients with ankylosing spondylitis, Reiter's syndrome and psoriatic arthritis

Between 1976 and 1989, 160 cases of seronegative spondyloarthropathy (SNSA) were admitted to the Department of Medicine at Chulalongkorn Hospital. The prevalence of idiopathic ankylosing spondylitis (IdAS) was 52 cases (32.5%), Reiter's syndrome (RS) 68 cases (42.5%), psoriatic arthritis (PsA) 28 cases (17.5%), reactive arthritis eight cases (5.0%) and Behcet's disease four cases (2.5%). Clinical comparison of the patients with IdAS, RS and PsA showed a male predominance in IdAS (90.2%), RS (97.1%) and PsA (71.4%). There was a significant difference (p < 0.01) between IdAS and PsA, and RS and PsA. The initial articular manifestation usually occurred in the younger age group (IdAS, 22.15; RS, 22.91; and PsA, 30.86 years); however, there was a significant difference (p < 0.05) between IdAS and PsA, and RS and PsA. Initial peripheral arthritis was found in IdAS (51.9%), RS (91.2%) and PsA (92.6%); there was a significant difference (p < 0.001) between IdAS and RS, and IdAS and PsA. The symptom of back pain was found in IdAS (78.8%), RS (38.2%) and PsA (21.4%); there was a significant difference (p < 0.001) between IdAS and RS, and IdAS and PsA. During physical examination, peripheral arthritis was evident in the IdAS (42.2%), RS (88.2%) and PsA (92.2%) patients; likewise sacroiliitis was found in the IdAS (100%) RS (54.4%), and PsA (57.2%) patients. Evidence of ankylosing spondylitis was found in the IdAS (100%), RS (22.1%) and PsA (46.4%) patients. These findings show a significant difference (p < 0.001) between patients with IdAS and RS, IdAS and PsA. Other associated symptoms were similar, particularly evidence of enthesopathy (tendonitis, heel pain, plantar fasciitis), the polyarticular pattern was more common than the mono-articular pattern. Hip joint was significantly (p < 0.05) more commonly involved in patients with IdAS than in those with RS and PsA. Associated symptoms, particularly genital lesion or skin lesion, are specific symptoms for RS and PsA, respectively.     

Internal reliability and convergent validity of the Depression-Happiness Scale with the General Health Questionnaire in an employed adult sample

Salmonella Typhimurium was isolated from a fresh fecal sample of zebra finches (Poephila guttata) in December 1992 on an aviary where a large scale outbreak of S. Typhimurium infection among bengalees (a variety of Lonchura striata) in 1991 had been recorded. The isolates from zebra finches were examined for antibiotic sensitivity and plasmids, which were 60 Mdal, then they showed the same pattern as those of S. Typhimurium isolated at the previous outbreak. This is the first report of S. Typhimurium isolation from zebra finches.     

Patterns of psoriatic arthritis in Orientals

OBJECTIVE: To determine the clinical features of psoriatic arthritis (PsA) in a multiethnic Oriental population and to study the effect of ethnicity on disease patterns. METHODS: A retrospective study of 80 patients with PsA seen at either a rheumatology or dermatology referral center. Patients and case records were reviewed and data abstracted according to a standard protocol. Eighty consecutive patients with psoriasis without PsA seen at the dermatology center were recruited as controls. RESULTS: Asymmetric polyarthritis developing in the 4th decade with an equal male to female ratio was the commonest pattern of arthritis among Chinese, Indians, and Malays. Clinically apparent lumbar spondylitis was significantly more common in Indians than Chinese (10/11 vs 11/20, respectively; p = 0.046), although the prevalence of lumbar spondylitis was similar in all ethnic groups. Eighty-nine percent of subjects required nonsteroidal antiinflammatory drugs and 51% required disease modifying antirheumatic drugs at some time for control of joint disease. PsA was significantly more common among Indians compared to the ethnic distribution of the Singapore population (p < 0.000001). Multiple logistic regression identified Indian ethnicity as a risk factor for the development of PsA (OR 2.39, 95% confidence interval 1.02 to 5.60). CONCLUSION: The commonest pattern of PsA in all ethnic groups was asymmetric polyarthritis. Ethnicity affected the development and presentation of PsA in our series: Indians with psoriasis had double the risk of developing PsA compared to Chinese with psoriasis, and lumbar spondylitis when present in Chinese subjects was asymptomatic in 45%, being detectable only on radiological examination.     

Comparison of the Patient Health Questionnaire and the Older Adult Health and Mood Questionnaire for self-reported depressive symptoms after spinal cord injury.

Objective: To directly compare estimates of potential depressive disorders and clinically significant depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9) and Older Adult Health and Mood Questionnaire (OAHMQ) among participants with spinal cord injury (SCI). Research Design: 727 participants from a hospital in the Southeastern United States were administered the PHQ-9 and OAHMQ during a follow-up survey. We compared the rates of depressive disorders using cutoff scores and diagnostic criteria for each instrument. No independent psychiatric diagnostic interviews were conducted. Results: The PHQ-9 and OAHMQ were significantly correlated (r = .78), and both were correlated with satisfaction with life (r = ?.48, ?.54). Using recommended diagnostic scoring procedures, 10.7% of participants met the diagnostic criteria for major depressive disorder with the PHQ-9; 9.3% met the criteria for major depression based on PHQ-9 ≥ 10; and 19.7% based on PHQ-9 ≥ 15. Using the OAHMQ, 19.7% reported probable major depression and 44.5% clinically significant symptomatology. Conclusions: The measures were highly correlated overall. However, the estimated prevalence of depressive disorders varied substantially between the 2 instruments. These estimates were comparable to those previously reported for each instrument (i.e., higher rates with the OAHMQ). Therefore, differing estimates of depressive disorders reported in the literature using these instruments were largely attributable to the instruments themselves. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

HLA markers and progression in psoriatic arthritis

OBJECTIVE: To investigate whether the addition of all serologically defined HLA antigens to a baseline model further influences the predisposition to disease progression in psoriatic arthritis (PsA). METHODS: Patients with PsA followed prospectively over 19 years were studied. Clinical and laboratory assessments of both active inflammation and clinical damage were performed at 6 month intervals according to a standard protocol. Progression of damage was defined as transition to higher damage states defined by the number of damaged joints. A model that provides estimates of the ratio of transition rates for an individual with the antigen versus one without, and examines the antigen effect on each of the 3 transition rates, was used. HLA antigens were examined in groups by loci under the assumption of common effects across transitions when added to the basic model. The significance levels were examined in comparison with Bonferroni type corrections. Likelihood ratio chi-squared statistics were used as a basis for the significance levels. In total, 292 patients with PsA were included in the study. RESULTS: Only HLA-B22 was added to the original model, which includes HLA-B39, providing risk for progression in early stages, HLA-B27 in the presence of HLA-DR7 providing risk for progression through all states, and DQw3 providing increased risk in the absence of DR7, while in the presence of DR7 it provides "protection." HLA-B22 provides protection from disease progression through all states. CONCLUSION: This study extends our report that HLA antigens serve as markers for disease progression in PsA.     

The value of the Health Assessment Questionnaire and special patient-generated scales to demonstrate change in systemic sclerosis patients over time

OBJECTIVE: To determine the validity and usefulness of a modified Health Assessment Questionnaire (HAQ) for measurement of disease status and changes in disease status over time in patients with systemic sclerosis (SSc). METHODS: Since 1985, 1,250 patients attending the University of Pittsburgh Scleroderma Clinic have completed a modified HAQ annually. In addition to the standard HAQ questions about disability, the questionnaire includes visual analog scales (VAS) to evaluate SSc organ system symptoms, Raynaud's phenomenon, gastrointestinal (GI) tract and lung involvement, pain, and overall disease severity. In this study, the disability index (DI) (from the HAQ) and the VAS scores (on a 0-3 scale) were compared with various clinical and laboratory features recorded within 3 months of administration of the HAQ and VAS, using t-tests and Spearman's correlation tests. RESULTS: The HAQ DI correlated directly with skin involvement, scleroderma heart or kidney disease, tendon friction rubs, hand contractures, and proximal muscle strength. Over time, the DI correlated with changes in skin score and was a good predictor of survival. There was a significant improvement in the DI during a 2-year time period in patients treated with D-penicillamine. The VAS for digital ulcers, GI symptoms, and lung symptoms correlated very closely with subjective and objective findings for these organ systems. The presence of new digital ulcers or improvement in digital ulcers showed significant associations with the Vascular scale, new GI symptoms or improvement in GI symptoms and institution of H2-blockers showed appropriate strong correlations with the GI scale, and changes in the forced vital capacity had an excellent correlation with the Lung scale (r = 0.58, P < 0.001). By Cox regression analysis, the HAQ DI was one of the best predictors of survival. CONCLUSION: These data provide convincing evidence that a self-administered questionnaire is an accurate and inexpensive tool to measure disease status changes in SSc. Prospective studies with the HAQ administered at regular intervals, as in controlled trials, should be performed to further assess the benefits and limitations of this instrument.     

Interactions of lymphocytes from patients with psoriatic arthritis or healthy controls and cultured endothelial cells

Psoriatic arthritis (PA) is an inflammatory rheumatic disease that can concomitantly occur in patients with psoriasis vulgaris. Psoriatic synovitis shows alterations of the synovial microvasculature. Inflammatory cells adhere to endothelial cells (EC) and migrate through the vascular wall of postcapillary venules located in the subintimal layer of the synovial membrane. The aim of our study was to investigate, first, the phenotype of lymphocytes (LC) of PA patients using flow cytometry (FC) with regard to activation antigens and adhesion molecules; second, the adhesion of LC of PA patients on cultivated resting or activated (with thrombin, LPS, IFN-gamma, or TNF-alpha) human umbilical vein endothelial cells (HUVEC) by counting the Feulgen-stained nuclei of both adherent LC and HUVEC using image analysis; and third, the synthesis of IL-6 and IL-8 in both LC and HUVEC 24 hr after cell contact. These cytokines were determined qualitatively by immunofluorescence and quantitatively at the single-cell level by FC as well as in the supernatants of the cultures using commercial cytokine ELISAs. Fourth, we investigated whether or not the LC adhesion on HUVEC as well as the cytokine production could be inhibited by monoclonal antibodies against LC- or EC-specific adhesion molecules. In contrast to controls PA patients showed an increased surface expression of CD11a, b, and c as well as of CD44 but a reduced surface expression of CD49d/CD29, and CD49e/CD29, and cell-bound fibronectin on CD3+ LC. The activation markers CD25 and HLA-DR were found to be slightly enhanced in PA. The cell adhesion was generally enhanced in PA patients vs controls. It could be reduced with monoclonal antibodies (MoAbs) against CD11a and CD18 on IFN-gamma- or TNF-alpha-activated HUVEC but was generally enhanced after treatment of HUVEC with MoAbs against CD54, CD62E, or CD106. Due to LC adhesion on HUVEC IL-6 and IL-8 were produced in significantly higher amounts in PA patients compared to controls. This effect occurred already in resting but was enhanced in activated HUVEC. While IL-6 is mainly produced by HUVEC but also in smaller quantities by LC, IL-8 is synthesized only by HUVEC and could be modified by preincubation with MoAbs against LC- or EC-specific adhesion molecules in parallel to the cell adhesion. The experiments show that the main adhesion pathway in LC homing of PA patients is the interaction of the LC adhesion molecule CD11a/CD18 with CD54 on EC followed by an enhanced synthesis of proinflammatory and chemotactic cytokines. These results favor the hypothesis that the pathological alterations of the microvasculature in PA patients are generated by altered homing processes.     

Abnormal T-cell function in patients with psoriatic arthritis: evidence for decreased interleukin 2 production

This paper reviews the use of an intracavitary mold in the radiotherapeutic management of recurrent sub-orbital carcinoma of the maxillary sinus. An overview of the clinical features of antral carcinomas and the concept of brachytherapy in the management of these lesions is presented. Brachytherapy is usually reserved for relatively accessible lesions. Post-surgical and radiation-induced trismus can be a complicating factor, as in the case presented, where the inter-incisal distance was less than three millimeters. To circumvent the problem, a multi-layer antral plug was utilized as a carrier for the radioactive sources, and its construction is described.     

Development of the refined ADL Assessment Scale for patients with Alzheimer's and related disorders

1. Most activities of daily living (ADL) scales currently available for assessment of the older person's functional level were developed for the physically (not cognitively) impaired individual. 2. The Refined ADL Assessment Scale (RADL) measures three dimensions of functional ability: the components of a given task in sequential order, degree of assistance needed to carry out the task, and the amount of time needed to complete the task. 3. Each of the 14 tasks on the RADL is broken down into its simpler component parts, a process called task analysis. 4. The RADL may be used as a guide to providing assistance with the basic ADLs and to evaluate an individual's improvement with treatment.     

Assessment of the psychometric properties of the Adaptive Behavior Scale with psychiatric patients.

This study explored the psychometric properties of the Adaptive Behavior Scale (ABS) using a sample of institutionalized, mentally disturbed adults. 188 clients on extended-care wards of a state-operated inpatient psychiatric facility were assessed with the ABS. An exploratory orthogonal principal-components analysis found three underlying factors: Independent Functioning, Interpersonal Maladaptation, and Intrapersonal Maladaptation. Evidence for the construct validity of the ABS with psychiatric patients was provided by analyses showing that older clients, those who had been currently hospitalized for longer amounts of time, and those with organic or schizophrenic disorders had lower levels of adaptive functioning than did their counterparts. The findings suggest that the ABS may be appropriately used with psychiatric patients. Suggestions for revising the ABS are made, and implications for the clinical use of the instrument are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interleukin-2 is found in the synovium of psoriatic arthritis and spondyloarthritis, not in rheumatoid arthritis

Many factors have been reported to stimulate the release of brain natriuretic peptide (BNP) as well as atrial natriuretic peptide (ANP). In hypertensive patients, however, little is known about whether these factors differ from those in normotensive subjects or if they are influenced by antihypertensive treatment. We measured the plasma concentrations of BNP and ANP in 12 hypertensive patients and examined the chronic effects of beta-adrenoceptor blockade on BNP secretion during exercise with a bicycle ergometer. The exercise raised both plasma BNP and ANP with concomitant increases in systolic blood pressure, heart rate (HR) and plasma norepinephrine (NE) and epinephrine (Epi) before and after treatment. Before treatment, the changes in ANP and BNP correlated with that in HR (p < 0.05). After treatment 4 wk of treatment, the change in ANP correlated with those in NE and Epi as well as HR. Multivariate regression analysis indicated that only NE was a significant stimulus for ANP secretion during the treatment period. As for BNP, HR was the only significant stimulant for its secretion both before and after treatment. In essential hypertension, beta-adrenergic receptor blockade affected the factors stimulating exercise-induced ANP release but not those stimulating BNP release. BNP release, therefore, seems to be stimulated by similar but distinct factors from those that stimulate ANP release.