Rheumatoid Arthritis

The Substance Abuse and Mental Health Services Administration has published a new fact sheet on providing pain management while keeping a patient from becoming psychologically dependent on opioids.

To order free copies of “Pain Management Without Psychological Dependence: A Guide for Healthcare Providers,” contact the National Clearinghouse for Alcohol and Drug Information by calling 800-729-6686.

The Substance Abuse and Mental Health Services Administration has published a new fact sheet on providing pain management while keeping a patient from becoming psychologically dependent on opioids.

To order free copies of “Pain Management Without Psychological Dependence: A Guide for Healthcare Providers,” contact the National Clearinghouse for Alcohol and Drug Information by calling 800-729-6686.

The Substance Abuse and Mental Health Services Administration has published a new fact sheet on providing pain management while keeping a patient from becoming psychologically dependent on opioids.

To order free copies of “Pain Management Without Psychological Dependence: A Guide for Healthcare Providers,” contact the National Clearinghouse for Alcohol and Drug Information by calling 800-729-6686.

Concomitant use of abatacept can significantly improve physical and mental health and physical functioning in patients with rheumatoid arthritis who have had an inadequate response to methotrexate treatment, reported Dr. Anthony Russell of the University of Alberta, Edmonton.

Dr. Russell and his colleagues analyzed health-related quality of life data from the Abatacept in Inadequate responders to Methotrexate (AIM) trial, a 1-year, randomized, double-blind, placebo-controlled, phase III trial conducted at 116 sites worldwide.

The AIM trial was designed to evaluate once-monthly abatacept as an adjunct to methotrexate (MTX) for treatment of rheumatoid arthritis (RA) in patients who continued to have active disease despite MTX therapy. An earlier report describes the primary efficacy and safety results of the AIM study (Ann Intern Med 2006;144:865–76). The AIM study population consisted of RA patients who had persistent, active disease despite treatment with MTX for at least 3 months.

Participants also were required to be at least 18 years old; to have had RA for at least 1 year since diagnosis; to have functional status I, II, or III disease; and to have active disease, defined as 10 or more swollen joints, 12 or more tender joints, and C-reactive protein levels of 10 mg/L or higher. Patients were required to maintain a steady dose of MTX for at least 28 days before enrollment.

Patients were not allowed to take any other disease-modifying antirheumatic drugs (DMARDs) during the study, and patients were required to undergo washout of other DMARDs at least 28 days before randomization.

Patients were randomized 2:1 to receive a fixed dose of abatacept (approximately 10 mg/kg) or placebo by intravenous infusion on days 1, 15, and 29 for the first month and every 28 days thereafter for up to 12 months. All patients remained on MTX at a weekly dose of 15 mg or greater throughout the study.

A total of 652 patients participated in the trial, with 433 in the abatacept-MTX group and 219 patients in the placebo-MTX group. The mean age of the patients was 51.5 years, and the mean disease duration was 8.6 years.

Health outcomes were assessed using the Medical Outcomes Study Short Form (SF)-36 Health Survey, consisting of eight scales covering physical and mental health, and the Health Assessment Questionnaire (HAQ), designed to assess physical functioning. Both questionnaires were self-administered. Patients completed the SF-36 at baseline and at months 1, 3, 6, and 12. Patients completed the HAQ at baseline, at days 15 and 29 within the first month of treatment, and every 28 days thereafter.

“[T]he physical functioning of these patients is comparable to that of patients with congestive heart failure in the general U.S. population,” wrote Dr. Russell. In both treatment groups mean baseline scores were approximately one standard deviation below the U.S. population norm for most of the eight subscales of the SF-36.

The mean physical component summary (PCS) scores of the SF-36 were 30.6 for the abatacept-MTX group and 30.7 for the placebo-MTX group at baseline, approximately two SD below the U.S. population norm of 50. Baseline mean scores in the mental component summary (MCS) of the SF-36 were 41.8 in the abatacept-MTX group and 40.8 in the placebo-MTX group, approximately one SD below the U.S. population norm of 50.

Differences between the two treatment groups in quality-of-life measures emerged within the first month of treatment. Relative to the placebo-MTX group, the abatacept-MTX group showed significant improvement by day 29 for five of the eight SF-36 subdomains: self-reported bodily pain, role physical, general health, vitality, and social functioning.

“After 3 months of treatment, the difference between abatacept and placebo widened for all of the SF-36 domains,” reported Dr. Russell (Ann. Rheum. Dis. 2007 [Epub doi: 10.1136/ard.2006.057018]).

For each of the various health outcome categories, investigators calculated the proportion of patients in each treatment group whose score improved by at least 0.5 SD over the 12-month study period. Significant differences were observed in the abatacept-MTX group relative to the placebo-MTX group after 12 months in the proportion of patients who showed improvement in PCS (67.2% vs. 51.1%, respectively) and in HAQ (72.4% vs. 55.2%, respectively).

“Combined abatacept and MTX treatment produces significant improvements across a wide range of health-related quality of life domains in patients with RA,” concluded Dr. Russell.

The project was supported financially by Bristol-Myers Squibb, makers of Orencia (abatacept).

Concomitant use of abatacept can significantly improve physical and mental health and physical functioning in patients with rheumatoid arthritis who have had an inadequate response to methotrexate treatment, reported Dr. Anthony Russell of the University of Alberta, Edmonton.

Dr. Russell and his colleagues analyzed health-related quality of life data from the Abatacept in Inadequate responders to Methotrexate (AIM) trial, a 1-year, randomized, double-blind, placebo-controlled, phase III trial conducted at 116 sites worldwide.

The AIM trial was designed to evaluate once-monthly abatacept as an adjunct to methotrexate (MTX) for treatment of rheumatoid arthritis (RA) in patients who continued to have active disease despite MTX therapy. An earlier report describes the primary efficacy and safety results of the AIM study (Ann Intern Med 2006;144:865–76). The AIM study population consisted of RA patients who had persistent, active disease despite treatment with MTX for at least 3 months.

Participants also were required to be at least 18 years old; to have had RA for at least 1 year since diagnosis; to have functional status I, II, or III disease; and to have active disease, defined as 10 or more swollen joints, 12 or more tender joints, and C-reactive protein levels of 10 mg/L or higher. Patients were required to maintain a steady dose of MTX for at least 28 days before enrollment.

Patients were not allowed to take any other disease-modifying antirheumatic drugs (DMARDs) during the study, and patients were required to undergo washout of other DMARDs at least 28 days before randomization.

Patients were randomized 2:1 to receive a fixed dose of abatacept (approximately 10 mg/kg) or placebo by intravenous infusion on days 1, 15, and 29 for the first month and every 28 days thereafter for up to 12 months. All patients remained on MTX at a weekly dose of 15 mg or greater throughout the study.

A total of 652 patients participated in the trial, with 433 in the abatacept-MTX group and 219 patients in the placebo-MTX group. The mean age of the patients was 51.5 years, and the mean disease duration was 8.6 years.

Health outcomes were assessed using the Medical Outcomes Study Short Form (SF)-36 Health Survey, consisting of eight scales covering physical and mental health, and the Health Assessment Questionnaire (HAQ), designed to assess physical functioning. Both questionnaires were self-administered. Patients completed the SF-36 at baseline and at months 1, 3, 6, and 12. Patients completed the HAQ at baseline, at days 15 and 29 within the first month of treatment, and every 28 days thereafter.

“[T]he physical functioning of these patients is comparable to that of patients with congestive heart failure in the general U.S. population,” wrote Dr. Russell. In both treatment groups mean baseline scores were approximately one standard deviation below the U.S. population norm for most of the eight subscales of the SF-36.

The mean physical component summary (PCS) scores of the SF-36 were 30.6 for the abatacept-MTX group and 30.7 for the placebo-MTX group at baseline, approximately two SD below the U.S. population norm of 50. Baseline mean scores in the mental component summary (MCS) of the SF-36 were 41.8 in the abatacept-MTX group and 40.8 in the placebo-MTX group, approximately one SD below the U.S. population norm of 50.

Differences between the two treatment groups in quality-of-life measures emerged within the first month of treatment. Relative to the placebo-MTX group, the abatacept-MTX group showed significant improvement by day 29 for five of the eight SF-36 subdomains: self-reported bodily pain, role physical, general health, vitality, and social functioning.

“After 3 months of treatment, the difference between abatacept and placebo widened for all of the SF-36 domains,” reported Dr. Russell (Ann. Rheum. Dis. 2007 [Epub doi: 10.1136/ard.2006.057018]).

For each of the various health outcome categories, investigators calculated the proportion of patients in each treatment group whose score improved by at least 0.5 SD over the 12-month study period. Significant differences were observed in the abatacept-MTX group relative to the placebo-MTX group after 12 months in the proportion of patients who showed improvement in PCS (67.2% vs. 51.1%, respectively) and in HAQ (72.4% vs. 55.2%, respectively).

“Combined abatacept and MTX treatment produces significant improvements across a wide range of health-related quality of life domains in patients with RA,” concluded Dr. Russell.

The project was supported financially by Bristol-Myers Squibb, makers of Orencia (abatacept).

Concomitant use of abatacept can significantly improve physical and mental health and physical functioning in patients with rheumatoid arthritis who have had an inadequate response to methotrexate treatment, reported Dr. Anthony Russell of the University of Alberta, Edmonton.

Dr. Russell and his colleagues analyzed health-related quality of life data from the Abatacept in Inadequate responders to Methotrexate (AIM) trial, a 1-year, randomized, double-blind, placebo-controlled, phase III trial conducted at 116 sites worldwide.

The AIM trial was designed to evaluate once-monthly abatacept as an adjunct to methotrexate (MTX) for treatment of rheumatoid arthritis (RA) in patients who continued to have active disease despite MTX therapy. An earlier report describes the primary efficacy and safety results of the AIM study (Ann Intern Med 2006;144:865–76). The AIM study population consisted of RA patients who had persistent, active disease despite treatment with MTX for at least 3 months.

Participants also were required to be at least 18 years old; to have had RA for at least 1 year since diagnosis; to have functional status I, II, or III disease; and to have active disease, defined as 10 or more swollen joints, 12 or more tender joints, and C-reactive protein levels of 10 mg/L or higher. Patients were required to maintain a steady dose of MTX for at least 28 days before enrollment.

Patients were not allowed to take any other disease-modifying antirheumatic drugs (DMARDs) during the study, and patients were required to undergo washout of other DMARDs at least 28 days before randomization.

Patients were randomized 2:1 to receive a fixed dose of abatacept (approximately 10 mg/kg) or placebo by intravenous infusion on days 1, 15, and 29 for the first month and every 28 days thereafter for up to 12 months. All patients remained on MTX at a weekly dose of 15 mg or greater throughout the study.

A total of 652 patients participated in the trial, with 433 in the abatacept-MTX group and 219 patients in the placebo-MTX group. The mean age of the patients was 51.5 years, and the mean disease duration was 8.6 years.

Health outcomes were assessed using the Medical Outcomes Study Short Form (SF)-36 Health Survey, consisting of eight scales covering physical and mental health, and the Health Assessment Questionnaire (HAQ), designed to assess physical functioning. Both questionnaires were self-administered. Patients completed the SF-36 at baseline and at months 1, 3, 6, and 12. Patients completed the HAQ at baseline, at days 15 and 29 within the first month of treatment, and every 28 days thereafter.

“[T]he physical functioning of these patients is comparable to that of patients with congestive heart failure in the general U.S. population,” wrote Dr. Russell. In both treatment groups mean baseline scores were approximately one standard deviation below the U.S. population norm for most of the eight subscales of the SF-36.

The mean physical component summary (PCS) scores of the SF-36 were 30.6 for the abatacept-MTX group and 30.7 for the placebo-MTX group at baseline, approximately two SD below the U.S. population norm of 50. Baseline mean scores in the mental component summary (MCS) of the SF-36 were 41.8 in the abatacept-MTX group and 40.8 in the placebo-MTX group, approximately one SD below the U.S. population norm of 50.

Differences between the two treatment groups in quality-of-life measures emerged within the first month of treatment. Relative to the placebo-MTX group, the abatacept-MTX group showed significant improvement by day 29 for five of the eight SF-36 subdomains: self-reported bodily pain, role physical, general health, vitality, and social functioning.

“After 3 months of treatment, the difference between abatacept and placebo widened for all of the SF-36 domains,” reported Dr. Russell (Ann. Rheum. Dis. 2007 [Epub doi: 10.1136/ard.2006.057018]).

For each of the various health outcome categories, investigators calculated the proportion of patients in each treatment group whose score improved by at least 0.5 SD over the 12-month study period. Significant differences were observed in the abatacept-MTX group relative to the placebo-MTX group after 12 months in the proportion of patients who showed improvement in PCS (67.2% vs. 51.1%, respectively) and in HAQ (72.4% vs. 55.2%, respectively).

“Combined abatacept and MTX treatment produces significant improvements across a wide range of health-related quality of life domains in patients with RA,” concluded Dr. Russell.

The project was supported financially by Bristol-Myers Squibb, makers of Orencia (abatacept).

WASHINGTON — Nearly half of the effects that contribute to knee osteoarthritis can be explained through heritable traits, Guangju Zhai, Ph.D., reported at the annual meeting of the American College of Rheumatology.

In a group of 114 monozygotic and 195 dizygotic twin pairs (all white females) from the Twins UK registry, heritability accounted for 49% of the total variance of joint space narrowing in the knee and for 47% of osteophytes. The results did not change substantially after adjustments were made for age and body mass index, said Dr. Zhai of St. Thomas' Hospital, London. At baseline and at a follow-up of about 7 years, radiographs of the anteroposterior aspect of patients' knees were obtained while in extension and bearing weight. A full lower-limb x-ray was obtained at the follow-up visit.

About 20% of the patients had joint space narrowing and osteophytes at baseline. About 30% had progression of joint space narrowing or osteophytes at follow-up.

Genetic effects explained 65% of the total variance in knee alignment. Statistical analyses showed that the heritability estimate for knee alignment remained the same after adjustments were made for the presence of knee osteoarthritis, which suggests that they are not likely to share common genetic control.

The heritability of the progression of joint space narrowing or osteophytes appeared to be stronger than heritability was for the mere presence of either sign. About 80% of joint space narrowing could be accounted for through heritable traits, while osteophyte progression was 62% heritable. Adjustments for age and BMI did not change the heritability of joint space narrowing progression, but decreased the heritability of osteophyte progression to 50%, Dr. Zhai said.

WASHINGTON — Nearly half of the effects that contribute to knee osteoarthritis can be explained through heritable traits, Guangju Zhai, Ph.D., reported at the annual meeting of the American College of Rheumatology.

In a group of 114 monozygotic and 195 dizygotic twin pairs (all white females) from the Twins UK registry, heritability accounted for 49% of the total variance of joint space narrowing in the knee and for 47% of osteophytes. The results did not change substantially after adjustments were made for age and body mass index, said Dr. Zhai of St. Thomas' Hospital, London. At baseline and at a follow-up of about 7 years, radiographs of the anteroposterior aspect of patients' knees were obtained while in extension and bearing weight. A full lower-limb x-ray was obtained at the follow-up visit.

About 20% of the patients had joint space narrowing and osteophytes at baseline. About 30% had progression of joint space narrowing or osteophytes at follow-up.

Genetic effects explained 65% of the total variance in knee alignment. Statistical analyses showed that the heritability estimate for knee alignment remained the same after adjustments were made for the presence of knee osteoarthritis, which suggests that they are not likely to share common genetic control.

The heritability of the progression of joint space narrowing or osteophytes appeared to be stronger than heritability was for the mere presence of either sign. About 80% of joint space narrowing could be accounted for through heritable traits, while osteophyte progression was 62% heritable. Adjustments for age and BMI did not change the heritability of joint space narrowing progression, but decreased the heritability of osteophyte progression to 50%, Dr. Zhai said.

WASHINGTON — Nearly half of the effects that contribute to knee osteoarthritis can be explained through heritable traits, Guangju Zhai, Ph.D., reported at the annual meeting of the American College of Rheumatology.

In a group of 114 monozygotic and 195 dizygotic twin pairs (all white females) from the Twins UK registry, heritability accounted for 49% of the total variance of joint space narrowing in the knee and for 47% of osteophytes. The results did not change substantially after adjustments were made for age and body mass index, said Dr. Zhai of St. Thomas' Hospital, London. At baseline and at a follow-up of about 7 years, radiographs of the anteroposterior aspect of patients' knees were obtained while in extension and bearing weight. A full lower-limb x-ray was obtained at the follow-up visit.

About 20% of the patients had joint space narrowing and osteophytes at baseline. About 30% had progression of joint space narrowing or osteophytes at follow-up.

Genetic effects explained 65% of the total variance in knee alignment. Statistical analyses showed that the heritability estimate for knee alignment remained the same after adjustments were made for the presence of knee osteoarthritis, which suggests that they are not likely to share common genetic control.

The heritability of the progression of joint space narrowing or osteophytes appeared to be stronger than heritability was for the mere presence of either sign. About 80% of joint space narrowing could be accounted for through heritable traits, while osteophyte progression was 62% heritable. Adjustments for age and BMI did not change the heritability of joint space narrowing progression, but decreased the heritability of osteophyte progression to 50%, Dr. Zhai said.

Treatment with tumor necrosis factor-blocking agents is more effective than methotrexate monotherapy at easing pain and fatigue in patients with psoriatic arthritis and in improving their general health when used in daily clinical practice, according to investigators of an ongoing longitudinal, observational study in Norway.

In a report of 6-month results, investigators said that 526 patients with psoriatic arthritis improved regardless of whether they received methotrexate (MTX) monotherapy or TNF-blocking agents, but “the improvement was larger with TNF-inhibitors.” Assessments were made using numerous measures of disease activity and health-related quality of life (Ann. Rheum. Dis. 2007 Jan. 9 [Epub doi:10.1136/ard.2006. 064808]).

The patients were part of a larger Norwegian registry—the NOR-DMARD Register—in which five Norwegian rheumatology departments consecutively register all their patients with inflammatory arthropathies, said Dr. M.S. Heiberg, of the department of rheumatology in Diakonhjemmet Hospital in Oslo, Norway, and fellow associates.

The patients had a mean age of 48 years and mean disease duration of 7 years. Almost 50% were females; 35% had erosive disease.

Of the 526 patients, 380 received MTX monotherapy and 146 received the TNF-blocking agents infliximab, etanercept, and adalimumab. Of those receiving anti-TNF therapy, 75% of those on infliximab, 60% of those on etanercept, and 79% of those on adalimumab received comcomitant MTX. Patients receiving anti-TNF therapy generally had more active and severe disease.

In assessing the clinical improvement, adjustments were made for age, gender, number of previous disease-modifying antirheumatic drugs, the presence of erosive disease, the treatment center, and the investigator's global assessment, the investigators said.

The adjusted changes at 3 and 6 months were significantly larger in the anti-TNF group for the following assessments: erythrocyte sedimentation rate, Disease Activity Score-28, a shortened version of the health assessment question (M-HAQ), fatigue and global disease activity on a visual analog scale, and four out of eight dimensions on the Short Form-36 health survey (bodily pain, vitality, role physical, and general health).

For instance, SF-36 scores for bodily pain rose by about 18 in the anti-TNF group and by 10 in the MTX group, while scores for general health rose by 7 and 2, respectively. (Scores are computed with a value from 0 to 100, with 100 being the best possible health state.)

Whether concomitant MTX was given in conjunction with anti-TNF therapy made little difference, a subanalysis showed. Improvements in the measures were similar between the subgroups of anti-TNF therapy.

More studies are needed to further establish the role of traditional drugs, they said.

Treatment with tumor necrosis factor-blocking agents is more effective than methotrexate monotherapy at easing pain and fatigue in patients with psoriatic arthritis and in improving their general health when used in daily clinical practice, according to investigators of an ongoing longitudinal, observational study in Norway.

In a report of 6-month results, investigators said that 526 patients with psoriatic arthritis improved regardless of whether they received methotrexate (MTX) monotherapy or TNF-blocking agents, but “the improvement was larger with TNF-inhibitors.” Assessments were made using numerous measures of disease activity and health-related quality of life (Ann. Rheum. Dis. 2007 Jan. 9 [Epub doi:10.1136/ard.2006. 064808]).

The patients were part of a larger Norwegian registry—the NOR-DMARD Register—in which five Norwegian rheumatology departments consecutively register all their patients with inflammatory arthropathies, said Dr. M.S. Heiberg, of the department of rheumatology in Diakonhjemmet Hospital in Oslo, Norway, and fellow associates.

The patients had a mean age of 48 years and mean disease duration of 7 years. Almost 50% were females; 35% had erosive disease.

Of the 526 patients, 380 received MTX monotherapy and 146 received the TNF-blocking agents infliximab, etanercept, and adalimumab. Of those receiving anti-TNF therapy, 75% of those on infliximab, 60% of those on etanercept, and 79% of those on adalimumab received comcomitant MTX. Patients receiving anti-TNF therapy generally had more active and severe disease.

In assessing the clinical improvement, adjustments were made for age, gender, number of previous disease-modifying antirheumatic drugs, the presence of erosive disease, the treatment center, and the investigator's global assessment, the investigators said.

The adjusted changes at 3 and 6 months were significantly larger in the anti-TNF group for the following assessments: erythrocyte sedimentation rate, Disease Activity Score-28, a shortened version of the health assessment question (M-HAQ), fatigue and global disease activity on a visual analog scale, and four out of eight dimensions on the Short Form-36 health survey (bodily pain, vitality, role physical, and general health).

For instance, SF-36 scores for bodily pain rose by about 18 in the anti-TNF group and by 10 in the MTX group, while scores for general health rose by 7 and 2, respectively. (Scores are computed with a value from 0 to 100, with 100 being the best possible health state.)

Whether concomitant MTX was given in conjunction with anti-TNF therapy made little difference, a subanalysis showed. Improvements in the measures were similar between the subgroups of anti-TNF therapy.

More studies are needed to further establish the role of traditional drugs, they said.

Treatment with tumor necrosis factor-blocking agents is more effective than methotrexate monotherapy at easing pain and fatigue in patients with psoriatic arthritis and in improving their general health when used in daily clinical practice, according to investigators of an ongoing longitudinal, observational study in Norway.

In a report of 6-month results, investigators said that 526 patients with psoriatic arthritis improved regardless of whether they received methotrexate (MTX) monotherapy or TNF-blocking agents, but “the improvement was larger with TNF-inhibitors.” Assessments were made using numerous measures of disease activity and health-related quality of life (Ann. Rheum. Dis. 2007 Jan. 9 [Epub doi:10.1136/ard.2006. 064808]).

The patients were part of a larger Norwegian registry—the NOR-DMARD Register—in which five Norwegian rheumatology departments consecutively register all their patients with inflammatory arthropathies, said Dr. M.S. Heiberg, of the department of rheumatology in Diakonhjemmet Hospital in Oslo, Norway, and fellow associates.

The patients had a mean age of 48 years and mean disease duration of 7 years. Almost 50% were females; 35% had erosive disease.

Of the 526 patients, 380 received MTX monotherapy and 146 received the TNF-blocking agents infliximab, etanercept, and adalimumab. Of those receiving anti-TNF therapy, 75% of those on infliximab, 60% of those on etanercept, and 79% of those on adalimumab received comcomitant MTX. Patients receiving anti-TNF therapy generally had more active and severe disease.

In assessing the clinical improvement, adjustments were made for age, gender, number of previous disease-modifying antirheumatic drugs, the presence of erosive disease, the treatment center, and the investigator's global assessment, the investigators said.

The adjusted changes at 3 and 6 months were significantly larger in the anti-TNF group for the following assessments: erythrocyte sedimentation rate, Disease Activity Score-28, a shortened version of the health assessment question (M-HAQ), fatigue and global disease activity on a visual analog scale, and four out of eight dimensions on the Short Form-36 health survey (bodily pain, vitality, role physical, and general health).

For instance, SF-36 scores for bodily pain rose by about 18 in the anti-TNF group and by 10 in the MTX group, while scores for general health rose by 7 and 2, respectively. (Scores are computed with a value from 0 to 100, with 100 being the best possible health state.)

Whether concomitant MTX was given in conjunction with anti-TNF therapy made little difference, a subanalysis showed. Improvements in the measures were similar between the subgroups of anti-TNF therapy.

More studies are needed to further establish the role of traditional drugs, they said.

CHICAGO — Use of real-time magnetic resonance imaging to guide sacroiliac joint puncture is feasible and safe, and allows for interactive interventions in patients who have refractory sacroiliitis, according to a study presented at the annual meeting of the Radiological Society of North America.

Researchers injected steroids into the sacroiliac joints (SIJs) of 73 patients who had inflammatory back pain and acute sacroiliitis unresponsive to conventional drug therapy for longer than 6 months using real-time magnetic resonance (MR) guidance exposure, Dr. Jan Fritz said at a poster session. The other term for the imaging technique, MR fluoroscopy, is a misnomer; unlike traditional fluoroscopy, MR fluoroscopy does not involve radiation. The entire procedure is performed using an interventional C-shaped open ultrafast MR scanner that provides an image every 1.2 seconds as the needle is being advanced.

“This allows you patient access while doing a procedure that formerly was done using x-ray fluoroscopy [and] CT, which have the disadvantage of exposure to ionizing radiation,” said Dr. Fritz, with the department of diagnostic radiology at Eberhard Karls University of Tübingen (Germany). “Spondyloarthropathy patients are typically under age 30 and in their reproductive years, and we don't like to expose them to ionizing radiation,” he said.

Each SIJ was injected with 40 mg triamcinolone acetonide using an MR-compatible 20-G puncture needle, they wrote.

Prior to intervention and 3 months after intervention, inflammatory back pain (IBP) was assessed on a visual analog scale, and volume and signal intensity of the sacroiliac bone marrow edema (BME) were quantified on high-field short-TI inversion-recovery (STIR) MR images with a semi-automatic algorithm using Matlab software.

Technical success was achieved in 72 of the 73 patients, most of whom were injected bilaterally, Dr. Fritz said, adding that there were no complications.

In bilateral intervention (n=64), real-time MR guidance (n=36) required a mean time of 40.5 minutes, compared with 55 minutes for intermittent MR imaging guidance (n=28).

Postintervention, IBP decreased by 63%. Volume and signal intensity of the sacroiliac BME decreased by 69% and 64%, respectively, which was a statistically significant difference. Mean remission time was 10 months. “MR fluoroscopy guidance for percutaneous steroid injections into the SIJ is safe and accurate, allowing for shorter interventions. MR fluoroscopy proved to be effective in sacroiliitis unresponsive to conventional drug therapy,” Dr. Fritz concluded.

The red arrows indicate the tip of the needle as it advances toward the site of sacroiliitis in a patient with back pain. Courtesy Dr. Jan Fritz

Use of real-time MRI in younger patients enables them to avoid radiation exposure. DR. FRITZ

CHICAGO — Use of real-time magnetic resonance imaging to guide sacroiliac joint puncture is feasible and safe, and allows for interactive interventions in patients who have refractory sacroiliitis, according to a study presented at the annual meeting of the Radiological Society of North America.

Researchers injected steroids into the sacroiliac joints (SIJs) of 73 patients who had inflammatory back pain and acute sacroiliitis unresponsive to conventional drug therapy for longer than 6 months using real-time magnetic resonance (MR) guidance exposure, Dr. Jan Fritz said at a poster session. The other term for the imaging technique, MR fluoroscopy, is a misnomer; unlike traditional fluoroscopy, MR fluoroscopy does not involve radiation. The entire procedure is performed using an interventional C-shaped open ultrafast MR scanner that provides an image every 1.2 seconds as the needle is being advanced.

“This allows you patient access while doing a procedure that formerly was done using x-ray fluoroscopy [and] CT, which have the disadvantage of exposure to ionizing radiation,” said Dr. Fritz, with the department of diagnostic radiology at Eberhard Karls University of Tübingen (Germany). “Spondyloarthropathy patients are typically under age 30 and in their reproductive years, and we don't like to expose them to ionizing radiation,” he said.

Each SIJ was injected with 40 mg triamcinolone acetonide using an MR-compatible 20-G puncture needle, they wrote.

Prior to intervention and 3 months after intervention, inflammatory back pain (IBP) was assessed on a visual analog scale, and volume and signal intensity of the sacroiliac bone marrow edema (BME) were quantified on high-field short-TI inversion-recovery (STIR) MR images with a semi-automatic algorithm using Matlab software.

Technical success was achieved in 72 of the 73 patients, most of whom were injected bilaterally, Dr. Fritz said, adding that there were no complications.

In bilateral intervention (n=64), real-time MR guidance (n=36) required a mean time of 40.5 minutes, compared with 55 minutes for intermittent MR imaging guidance (n=28).

Postintervention, IBP decreased by 63%. Volume and signal intensity of the sacroiliac BME decreased by 69% and 64%, respectively, which was a statistically significant difference. Mean remission time was 10 months. “MR fluoroscopy guidance for percutaneous steroid injections into the SIJ is safe and accurate, allowing for shorter interventions. MR fluoroscopy proved to be effective in sacroiliitis unresponsive to conventional drug therapy,” Dr. Fritz concluded.

The red arrows indicate the tip of the needle as it advances toward the site of sacroiliitis in a patient with back pain. Courtesy Dr. Jan Fritz

Use of real-time MRI in younger patients enables them to avoid radiation exposure. DR. FRITZ

CHICAGO — Use of real-time magnetic resonance imaging to guide sacroiliac joint puncture is feasible and safe, and allows for interactive interventions in patients who have refractory sacroiliitis, according to a study presented at the annual meeting of the Radiological Society of North America.

Researchers injected steroids into the sacroiliac joints (SIJs) of 73 patients who had inflammatory back pain and acute sacroiliitis unresponsive to conventional drug therapy for longer than 6 months using real-time magnetic resonance (MR) guidance exposure, Dr. Jan Fritz said at a poster session. The other term for the imaging technique, MR fluoroscopy, is a misnomer; unlike traditional fluoroscopy, MR fluoroscopy does not involve radiation. The entire procedure is performed using an interventional C-shaped open ultrafast MR scanner that provides an image every 1.2 seconds as the needle is being advanced.

“This allows you patient access while doing a procedure that formerly was done using x-ray fluoroscopy [and] CT, which have the disadvantage of exposure to ionizing radiation,” said Dr. Fritz, with the department of diagnostic radiology at Eberhard Karls University of Tübingen (Germany). “Spondyloarthropathy patients are typically under age 30 and in their reproductive years, and we don't like to expose them to ionizing radiation,” he said.

Each SIJ was injected with 40 mg triamcinolone acetonide using an MR-compatible 20-G puncture needle, they wrote.

Prior to intervention and 3 months after intervention, inflammatory back pain (IBP) was assessed on a visual analog scale, and volume and signal intensity of the sacroiliac bone marrow edema (BME) were quantified on high-field short-TI inversion-recovery (STIR) MR images with a semi-automatic algorithm using Matlab software.

Technical success was achieved in 72 of the 73 patients, most of whom were injected bilaterally, Dr. Fritz said, adding that there were no complications.

In bilateral intervention (n=64), real-time MR guidance (n=36) required a mean time of 40.5 minutes, compared with 55 minutes for intermittent MR imaging guidance (n=28).

Postintervention, IBP decreased by 63%. Volume and signal intensity of the sacroiliac BME decreased by 69% and 64%, respectively, which was a statistically significant difference. Mean remission time was 10 months. “MR fluoroscopy guidance for percutaneous steroid injections into the SIJ is safe and accurate, allowing for shorter interventions. MR fluoroscopy proved to be effective in sacroiliitis unresponsive to conventional drug therapy,” Dr. Fritz concluded.

The red arrows indicate the tip of the needle as it advances toward the site of sacroiliitis in a patient with back pain. Courtesy Dr. Jan Fritz

Use of real-time MRI in younger patients enables them to avoid radiation exposure. DR. FRITZ

“The first thing you think of when a patient [like this one] walks into your office is medial meniscal tear just because meniscal lesions are so common in a patient in this age group,” said Dr. Hollis G. Potter, chief of magnetic resonance imaging at the Hospital for Special Surgery in New York. “You might also suspect that she might have some early medial osteoarthritis.”

“There wasn't anything glaring in her presentation that directed them to think that she had an inflammatory arthropathy,” said Dr. Potter.

Upon magnetic resonance imaging (MRI), the patient was found to have severe synovial expansion with an inflammatory synovitis. “It was pretty clear that even if her meniscus had been torn—which it wasn't—that wouldn't be the cause of her pain. The cause was really the fact that she had an inflammatory synovitis,” said Dr. Potter.

The synovial proliferation extended into the medial and lateral gutters (see arrows in first image). The patient also had early marginal bony erosion (see arrow in second image) affecting the medial tibial plateau. Together, the synovial proliferation and bony erosion indicated rheumatoid arthritis (RA).

The images were obtained using a cartilage-sensitive sequence used for evaluating articular cartilage.

“We do this for all patients routinely,” said Dr. Potter. The technique allows physicians to noninvasively evaluate the morphologic integrity of the cartilage. “When we find articular lesions, I find it drives patient management more than anything else.”

“It's always been my sense that the purpose of MRI is to find what physicians are not clinically suspecting,” said Dr. Potter, who is also a professor of radiology at Cornell University, New York.

“I find that if the MRI doesn't in fact change the management or affect the management in some way, it's a very expensive test that really hasn't helped anybody at all,” Dr. Potter told RHEUMATOLOGY NEWS in an interview.

Based on the imaging findings, the patient underwent serologic testing and was placed on appropriate clinical management. This patient was identified with RA early in the disease progression when disease-modifying antirheumatic drugs can make a big difference in slowing disease progression.

Dr. Potter and her colleagues have found another use for MRI in rheumatology: They are investigating synovial recruitment patterns in patients with early, clinically suspected, inflammatory RA—patients who meet the American College of Rheumatology criteria for inflammatory arthritis. In an ongoing, prospective pilot study, they are using MR angiography with a contrast agent to assess neovascularity in areas of inflammatory synovium. The hope is that work like this will help better define patients who are good candidates for therapy with biologic agents, said Dr. Potter.

Synovial expansion with an inflam-matory synovitis (arrows) suggests RA.

Marginal bony erosion (arrow) suggests RA. There is no evidence of meniscal tear. Photos courtesy Dr. Hollis G. Potter

“The first thing you think of when a patient [like this one] walks into your office is medial meniscal tear just because meniscal lesions are so common in a patient in this age group,” said Dr. Hollis G. Potter, chief of magnetic resonance imaging at the Hospital for Special Surgery in New York. “You might also suspect that she might have some early medial osteoarthritis.”

“There wasn't anything glaring in her presentation that directed them to think that she had an inflammatory arthropathy,” said Dr. Potter.

Upon magnetic resonance imaging (MRI), the patient was found to have severe synovial expansion with an inflammatory synovitis. “It was pretty clear that even if her meniscus had been torn—which it wasn't—that wouldn't be the cause of her pain. The cause was really the fact that she had an inflammatory synovitis,” said Dr. Potter.

The synovial proliferation extended into the medial and lateral gutters (see arrows in first image). The patient also had early marginal bony erosion (see arrow in second image) affecting the medial tibial plateau. Together, the synovial proliferation and bony erosion indicated rheumatoid arthritis (RA).

The images were obtained using a cartilage-sensitive sequence used for evaluating articular cartilage.

“We do this for all patients routinely,” said Dr. Potter. The technique allows physicians to noninvasively evaluate the morphologic integrity of the cartilage. “When we find articular lesions, I find it drives patient management more than anything else.”

“It's always been my sense that the purpose of MRI is to find what physicians are not clinically suspecting,” said Dr. Potter, who is also a professor of radiology at Cornell University, New York.

“I find that if the MRI doesn't in fact change the management or affect the management in some way, it's a very expensive test that really hasn't helped anybody at all,” Dr. Potter told RHEUMATOLOGY NEWS in an interview.

Based on the imaging findings, the patient underwent serologic testing and was placed on appropriate clinical management. This patient was identified with RA early in the disease progression when disease-modifying antirheumatic drugs can make a big difference in slowing disease progression.

Dr. Potter and her colleagues have found another use for MRI in rheumatology: They are investigating synovial recruitment patterns in patients with early, clinically suspected, inflammatory RA—patients who meet the American College of Rheumatology criteria for inflammatory arthritis. In an ongoing, prospective pilot study, they are using MR angiography with a contrast agent to assess neovascularity in areas of inflammatory synovium. The hope is that work like this will help better define patients who are good candidates for therapy with biologic agents, said Dr. Potter.

Synovial expansion with an inflam-matory synovitis (arrows) suggests RA.

Marginal bony erosion (arrow) suggests RA. There is no evidence of meniscal tear. Photos courtesy Dr. Hollis G. Potter

“The first thing you think of when a patient [like this one] walks into your office is medial meniscal tear just because meniscal lesions are so common in a patient in this age group,” said Dr. Hollis G. Potter, chief of magnetic resonance imaging at the Hospital for Special Surgery in New York. “You might also suspect that she might have some early medial osteoarthritis.”

“There wasn't anything glaring in her presentation that directed them to think that she had an inflammatory arthropathy,” said Dr. Potter.

Upon magnetic resonance imaging (MRI), the patient was found to have severe synovial expansion with an inflammatory synovitis. “It was pretty clear that even if her meniscus had been torn—which it wasn't—that wouldn't be the cause of her pain. The cause was really the fact that she had an inflammatory synovitis,” said Dr. Potter.

The synovial proliferation extended into the medial and lateral gutters (see arrows in first image). The patient also had early marginal bony erosion (see arrow in second image) affecting the medial tibial plateau. Together, the synovial proliferation and bony erosion indicated rheumatoid arthritis (RA).

The images were obtained using a cartilage-sensitive sequence used for evaluating articular cartilage.

“We do this for all patients routinely,” said Dr. Potter. The technique allows physicians to noninvasively evaluate the morphologic integrity of the cartilage. “When we find articular lesions, I find it drives patient management more than anything else.”

“It's always been my sense that the purpose of MRI is to find what physicians are not clinically suspecting,” said Dr. Potter, who is also a professor of radiology at Cornell University, New York.

“I find that if the MRI doesn't in fact change the management or affect the management in some way, it's a very expensive test that really hasn't helped anybody at all,” Dr. Potter told RHEUMATOLOGY NEWS in an interview.

Based on the imaging findings, the patient underwent serologic testing and was placed on appropriate clinical management. This patient was identified with RA early in the disease progression when disease-modifying antirheumatic drugs can make a big difference in slowing disease progression.

Dr. Potter and her colleagues have found another use for MRI in rheumatology: They are investigating synovial recruitment patterns in patients with early, clinically suspected, inflammatory RA—patients who meet the American College of Rheumatology criteria for inflammatory arthritis. In an ongoing, prospective pilot study, they are using MR angiography with a contrast agent to assess neovascularity in areas of inflammatory synovium. The hope is that work like this will help better define patients who are good candidates for therapy with biologic agents, said Dr. Potter.

Synovial expansion with an inflam-matory synovitis (arrows) suggests RA.

Marginal bony erosion (arrow) suggests RA. There is no evidence of meniscal tear. Photos courtesy Dr. Hollis G. Potter

WASHINGTON — High temperature and humidity appear to increase the risk of recurrent gout attacks independently of other known risk factors, Yuqing Q. Zhang, D.Sc., reported at the annual meeting of the American College of Rheumatology.

“Although the pathophysiology of gout is well understood and efficacious clinical therapies are available, many patients with gout still suffer from recurrent gout attacks” that are brought on by certain risk factors, said Dr. Zhang of Boston University.

Decreases in intravascular volume as a result of perspiration in hot and humid weather can result in high serum uric acid levels because of a reduction in uric acid excretion, Dr. Zhang said.

Only a handful of studies have examined the relationship between risk factors for dehydration and the risk of gout attack recurrence.

Dr. Zhang and his colleagues enrolled 197 patients with a median 5-year history of gout through an online advertisement.

The patients answered a “hazard period” questionnaire on a Web site that asked about risk factors for gout attacks during the 2-day period prior to their report of an attack.

They also filled out a control period questionnaire every 3 months for 1 year to provide data about time intervals during which gout attacks did not occur.

The questionnaires asked about use of dehydrating medication (such as diuretics), alcohol use, food intake (especially foods rich in purine or with little purine), and details of gout attacks when they occurred.

The Weather Underground Web site (www.wunderground.com

As temperature during the 2 days prior to a gout attack increased from the lowest quintile (0–53°F) to the highest quintile (87–105°F), the relative risk of a gout attack doubled.

The dose-response relationship between temperature and recurrent gout attacks seemed to suggest a threshold effect such that when the temperature reached 85°F, the risk of recurrent gout attacks increased dramatically, according to Dr. Zhang.

The relationship between the level of humidity during the 2 days prior to a gout attack and the risk of recurrent attacks followed the pattern for temperature very closely.

High humidity appeared to be the strongest predictor for recurrent gout attacks, but very cold and dry weather also slightly increased the risk of recurrent attacks.

The findings remained significant after controlling for medication use (especially diuretics), alcohol consumption, and purine-rich food intake.

Recurrent gout attacks were not associated with barometric pressure or precipitation.

“In hot and humid weather, subjects with gout may need to increase fluid intake to counteract volume depletion and to prevent a recurrent gout attack,” Dr. Zhang concluded.

WASHINGTON — High temperature and humidity appear to increase the risk of recurrent gout attacks independently of other known risk factors, Yuqing Q. Zhang, D.Sc., reported at the annual meeting of the American College of Rheumatology.

“Although the pathophysiology of gout is well understood and efficacious clinical therapies are available, many patients with gout still suffer from recurrent gout attacks” that are brought on by certain risk factors, said Dr. Zhang of Boston University.

Decreases in intravascular volume as a result of perspiration in hot and humid weather can result in high serum uric acid levels because of a reduction in uric acid excretion, Dr. Zhang said.

Only a handful of studies have examined the relationship between risk factors for dehydration and the risk of gout attack recurrence.

Dr. Zhang and his colleagues enrolled 197 patients with a median 5-year history of gout through an online advertisement.

The patients answered a “hazard period” questionnaire on a Web site that asked about risk factors for gout attacks during the 2-day period prior to their report of an attack.

They also filled out a control period questionnaire every 3 months for 1 year to provide data about time intervals during which gout attacks did not occur.

The questionnaires asked about use of dehydrating medication (such as diuretics), alcohol use, food intake (especially foods rich in purine or with little purine), and details of gout attacks when they occurred.

The Weather Underground Web site (www.wunderground.com

As temperature during the 2 days prior to a gout attack increased from the lowest quintile (0–53°F) to the highest quintile (87–105°F), the relative risk of a gout attack doubled.

The dose-response relationship between temperature and recurrent gout attacks seemed to suggest a threshold effect such that when the temperature reached 85°F, the risk of recurrent gout attacks increased dramatically, according to Dr. Zhang.

The relationship between the level of humidity during the 2 days prior to a gout attack and the risk of recurrent attacks followed the pattern for temperature very closely.

High humidity appeared to be the strongest predictor for recurrent gout attacks, but very cold and dry weather also slightly increased the risk of recurrent attacks.

The findings remained significant after controlling for medication use (especially diuretics), alcohol consumption, and purine-rich food intake.

Recurrent gout attacks were not associated with barometric pressure or precipitation.

“In hot and humid weather, subjects with gout may need to increase fluid intake to counteract volume depletion and to prevent a recurrent gout attack,” Dr. Zhang concluded.

WASHINGTON — High temperature and humidity appear to increase the risk of recurrent gout attacks independently of other known risk factors, Yuqing Q. Zhang, D.Sc., reported at the annual meeting of the American College of Rheumatology.

“Although the pathophysiology of gout is well understood and efficacious clinical therapies are available, many patients with gout still suffer from recurrent gout attacks” that are brought on by certain risk factors, said Dr. Zhang of Boston University.

Decreases in intravascular volume as a result of perspiration in hot and humid weather can result in high serum uric acid levels because of a reduction in uric acid excretion, Dr. Zhang said.

Only a handful of studies have examined the relationship between risk factors for dehydration and the risk of gout attack recurrence.

Dr. Zhang and his colleagues enrolled 197 patients with a median 5-year history of gout through an online advertisement.

The patients answered a “hazard period” questionnaire on a Web site that asked about risk factors for gout attacks during the 2-day period prior to their report of an attack.

They also filled out a control period questionnaire every 3 months for 1 year to provide data about time intervals during which gout attacks did not occur.

The questionnaires asked about use of dehydrating medication (such as diuretics), alcohol use, food intake (especially foods rich in purine or with little purine), and details of gout attacks when they occurred.

The Weather Underground Web site (www.wunderground.com

As temperature during the 2 days prior to a gout attack increased from the lowest quintile (0–53°F) to the highest quintile (87–105°F), the relative risk of a gout attack doubled.

The dose-response relationship between temperature and recurrent gout attacks seemed to suggest a threshold effect such that when the temperature reached 85°F, the risk of recurrent gout attacks increased dramatically, according to Dr. Zhang.

The relationship between the level of humidity during the 2 days prior to a gout attack and the risk of recurrent attacks followed the pattern for temperature very closely.

High humidity appeared to be the strongest predictor for recurrent gout attacks, but very cold and dry weather also slightly increased the risk of recurrent attacks.

The findings remained significant after controlling for medication use (especially diuretics), alcohol consumption, and purine-rich food intake.

Recurrent gout attacks were not associated with barometric pressure or precipitation.

“In hot and humid weather, subjects with gout may need to increase fluid intake to counteract volume depletion and to prevent a recurrent gout attack,” Dr. Zhang concluded.

TUCSON, ARIZ. — A psychological trait associated with heightened awareness of bodily distress may help to explain why some rheumatoid arthritis patients suffer more from achiness, malaise, and fatigue than do others with similar disease severity, Dr. Ilana M. Braun reported at the annual meeting of the Academy of Psychosomatic Medicine.

The trait, somatic absorption, was closely associated with generalized symptoms of rheumatoid arthritis in 87 patients studied by Dr. Braun, a psychiatrist at Harvard Medical School and Massachusetts General Hospital in Boston. It had no relationship to specific symptoms, such as joint pain, swelling, stiffness, and deformity, or to disease severity.

The magnitude of effect was modest, accounting for just 4% of variability in nonspecific symptoms, but Dr. Braun noted that it was significant statistically—and possibly clinically.

People who score high on measures of absorption have a capacity for deep involvement in sensory events, she said. They have a heightened sense of reality that makes them more sensitive not only to bodily distress, but also to hypnosis and to biofeedback.

“There might be a role for psychiatry in the treatment of rheumatoid arthritis,” she said, questioning whether some patients might respond to these kinds of interventions for nonspecific symptoms.

“It is a personality style that you can target,” Dr. Braun added in an interview. “This is not a disorder. These are perfectly healthy people [mentally]. They just have a certain way of responding to the world.”

While she called for more research into the clinical utility of her finding, Dr. Braun suggested that ultimately it may present rheumatologists with an alternative to increasing medication when patients complain they feel poorly in the absence of specific symptoms. “What I am saying is, for the malaise and the fatigue don't double the dose,” she said. “Send them to the hypnotist.”

The study was supported by a Webb Fellowship from the academy. Dr. Braun enrolled patients from a larger, longitudinal study of rheumatoid arthritis. The largely female population had a median age of 55.5 years. A majority, 85%, had been to college, more than half were employed, and about half were married.

Patients completed the 14-item Rheumatoid Arthritis Symptoms Questionnaire. Dr. Braun and her coinvestigators also used erythrocyte sedimentation rate and a standard 28-joint physical examination by a rheumatologist to measure disease severity. They calculated the total number of medications prescribed for pain and other “disease-modifying agents.”

Assessment of somatic absorption was based on the 29-item Somatic Absorption Scale, a measure derived from the Tellegen Absorption Scale. Dr. Braun said the Somatic Absorption Scale focuses on “absorption as it pertains to somatic or visceral experience.” For example, a subject might be asked whether she could imagine her arm being so heavy she could not move it, or if she notices how her clothes feel against her skin. The Rand Mental Health Inventory was used as well to identify common symptoms that are neither physical nor psychosomatic of prevalent mental disorders.

Dr. Braun reported somatic absorption was significantly more pronounced in younger subjects, people with more severe psychiatric symptoms, African Americans, and Hispanics. Rheumatoid arthritis symptoms with statistically significant ties to somatic absorption were pain in limbs, pain in back, fatigue, generalized aching, and “feeling sick all over.”

In a discussion of the findings, Dr. Stephen J. Ferrando said he found himself looking up the literature on absorption, a personality construct developed in the 1970s to assess which patients might respond to hypnosis and biofeedback.

Dr. Ferrando, a professor of clinical psychiatry and clinical public health at Cornell University in New York, called the findings very interesting and said he looks forward to an analysis of how the subjects fare in the longitudinal study from which the population was drawn.

TUCSON, ARIZ. — A psychological trait associated with heightened awareness of bodily distress may help to explain why some rheumatoid arthritis patients suffer more from achiness, malaise, and fatigue than do others with similar disease severity, Dr. Ilana M. Braun reported at the annual meeting of the Academy of Psychosomatic Medicine.

The trait, somatic absorption, was closely associated with generalized symptoms of rheumatoid arthritis in 87 patients studied by Dr. Braun, a psychiatrist at Harvard Medical School and Massachusetts General Hospital in Boston. It had no relationship to specific symptoms, such as joint pain, swelling, stiffness, and deformity, or to disease severity.

The magnitude of effect was modest, accounting for just 4% of variability in nonspecific symptoms, but Dr. Braun noted that it was significant statistically—and possibly clinically.

People who score high on measures of absorption have a capacity for deep involvement in sensory events, she said. They have a heightened sense of reality that makes them more sensitive not only to bodily distress, but also to hypnosis and to biofeedback.

“There might be a role for psychiatry in the treatment of rheumatoid arthritis,” she said, questioning whether some patients might respond to these kinds of interventions for nonspecific symptoms.

“It is a personality style that you can target,” Dr. Braun added in an interview. “This is not a disorder. These are perfectly healthy people [mentally]. They just have a certain way of responding to the world.”

While she called for more research into the clinical utility of her finding, Dr. Braun suggested that ultimately it may present rheumatologists with an alternative to increasing medication when patients complain they feel poorly in the absence of specific symptoms. “What I am saying is, for the malaise and the fatigue don't double the dose,” she said. “Send them to the hypnotist.”

The study was supported by a Webb Fellowship from the academy. Dr. Braun enrolled patients from a larger, longitudinal study of rheumatoid arthritis. The largely female population had a median age of 55.5 years. A majority, 85%, had been to college, more than half were employed, and about half were married.

Patients completed the 14-item Rheumatoid Arthritis Symptoms Questionnaire. Dr. Braun and her coinvestigators also used erythrocyte sedimentation rate and a standard 28-joint physical examination by a rheumatologist to measure disease severity. They calculated the total number of medications prescribed for pain and other “disease-modifying agents.”

Assessment of somatic absorption was based on the 29-item Somatic Absorption Scale, a measure derived from the Tellegen Absorption Scale. Dr. Braun said the Somatic Absorption Scale focuses on “absorption as it pertains to somatic or visceral experience.” For example, a subject might be asked whether she could imagine her arm being so heavy she could not move it, or if she notices how her clothes feel against her skin. The Rand Mental Health Inventory was used as well to identify common symptoms that are neither physical nor psychosomatic of prevalent mental disorders.

Dr. Braun reported somatic absorption was significantly more pronounced in younger subjects, people with more severe psychiatric symptoms, African Americans, and Hispanics. Rheumatoid arthritis symptoms with statistically significant ties to somatic absorption were pain in limbs, pain in back, fatigue, generalized aching, and “feeling sick all over.”

In a discussion of the findings, Dr. Stephen J. Ferrando said he found himself looking up the literature on absorption, a personality construct developed in the 1970s to assess which patients might respond to hypnosis and biofeedback.

Dr. Ferrando, a professor of clinical psychiatry and clinical public health at Cornell University in New York, called the findings very interesting and said he looks forward to an analysis of how the subjects fare in the longitudinal study from which the population was drawn.

TUCSON, ARIZ. — A psychological trait associated with heightened awareness of bodily distress may help to explain why some rheumatoid arthritis patients suffer more from achiness, malaise, and fatigue than do others with similar disease severity, Dr. Ilana M. Braun reported at the annual meeting of the Academy of Psychosomatic Medicine.

The trait, somatic absorption, was closely associated with generalized symptoms of rheumatoid arthritis in 87 patients studied by Dr. Braun, a psychiatrist at Harvard Medical School and Massachusetts General Hospital in Boston. It had no relationship to specific symptoms, such as joint pain, swelling, stiffness, and deformity, or to disease severity.

The magnitude of effect was modest, accounting for just 4% of variability in nonspecific symptoms, but Dr. Braun noted that it was significant statistically—and possibly clinically.

People who score high on measures of absorption have a capacity for deep involvement in sensory events, she said. They have a heightened sense of reality that makes them more sensitive not only to bodily distress, but also to hypnosis and to biofeedback.

“There might be a role for psychiatry in the treatment of rheumatoid arthritis,” she said, questioning whether some patients might respond to these kinds of interventions for nonspecific symptoms.

“It is a personality style that you can target,” Dr. Braun added in an interview. “This is not a disorder. These are perfectly healthy people [mentally]. They just have a certain way of responding to the world.”

While she called for more research into the clinical utility of her finding, Dr. Braun suggested that ultimately it may present rheumatologists with an alternative to increasing medication when patients complain they feel poorly in the absence of specific symptoms. “What I am saying is, for the malaise and the fatigue don't double the dose,” she said. “Send them to the hypnotist.”

The study was supported by a Webb Fellowship from the academy. Dr. Braun enrolled patients from a larger, longitudinal study of rheumatoid arthritis. The largely female population had a median age of 55.5 years. A majority, 85%, had been to college, more than half were employed, and about half were married.

Patients completed the 14-item Rheumatoid Arthritis Symptoms Questionnaire. Dr. Braun and her coinvestigators also used erythrocyte sedimentation rate and a standard 28-joint physical examination by a rheumatologist to measure disease severity. They calculated the total number of medications prescribed for pain and other “disease-modifying agents.”

Assessment of somatic absorption was based on the 29-item Somatic Absorption Scale, a measure derived from the Tellegen Absorption Scale. Dr. Braun said the Somatic Absorption Scale focuses on “absorption as it pertains to somatic or visceral experience.” For example, a subject might be asked whether she could imagine her arm being so heavy she could not move it, or if she notices how her clothes feel against her skin. The Rand Mental Health Inventory was used as well to identify common symptoms that are neither physical nor psychosomatic of prevalent mental disorders.

Dr. Braun reported somatic absorption was significantly more pronounced in younger subjects, people with more severe psychiatric symptoms, African Americans, and Hispanics. Rheumatoid arthritis symptoms with statistically significant ties to somatic absorption were pain in limbs, pain in back, fatigue, generalized aching, and “feeling sick all over.”

In a discussion of the findings, Dr. Stephen J. Ferrando said he found himself looking up the literature on absorption, a personality construct developed in the 1970s to assess which patients might respond to hypnosis and biofeedback.

Dr. Ferrando, a professor of clinical psychiatry and clinical public health at Cornell University in New York, called the findings very interesting and said he looks forward to an analysis of how the subjects fare in the longitudinal study from which the population was drawn.

The tumor necrosis factor-α-inhibitor drugs adalimumab, etanercept, and infliximab should be used to treat rheumatoid arthritis patients only after 6-month trials of methotrexate and one other disease-modifying antirheumatic drug, the clinical effectiveness agency for England and Wales had ruled.

The TNF-α inhibitors should be prescribed only to those patients who have active rheumatoid arthritis as measured by a disease activity score greater than 5.1—or patients with about 8–10 swollen and tender joints—confirmed at least twice, measured 1 month apart, according to the National Institute for Health and Clinical Effectiveness' final appraisal document.

TNF-α-inhibitor therapy should be done in combination with methotrexate, unless contraindicated, according to NICE. In those instances, patients should receive either adalimumab or etanercept as monotherapy.

Physicians should stop treatment with TNF-α inhibitors after 6 months if the patient does not show an adequate response, defined as an improvement in disease activity score of at least 1.2 points.

Infliximab costs between $14,612 and $17,047 a year, while etanercept and adalimumab both cost $17,982 a year, according to the NICE committee examining the effectiveness of the three drugs.

The committee considered TNF-α-inhibitor medications as first-line or second-line therapy after failure of one disease-modifying antirheumatic drug (DMARD). However, the committee concluded, based on cost and efficacy data, that neither was an appropriate use of National Health Service resources.

For first-line therapy, clinical specialists told the appraisal committee that a large number of patients initially respond well to DMARDs, and both the British Society of Rheumatology and European League Against Rheumatism recommend a trial of at least one DMARD.

As a second-line treatment, the appraisal committee did not believe TNF-α inhibitors had demonstrated cost-effectiveness.

The tumor necrosis factor-α-inhibitor drugs adalimumab, etanercept, and infliximab should be used to treat rheumatoid arthritis patients only after 6-month trials of methotrexate and one other disease-modifying antirheumatic drug, the clinical effectiveness agency for England and Wales had ruled.

The TNF-α inhibitors should be prescribed only to those patients who have active rheumatoid arthritis as measured by a disease activity score greater than 5.1—or patients with about 8–10 swollen and tender joints—confirmed at least twice, measured 1 month apart, according to the National Institute for Health and Clinical Effectiveness' final appraisal document.

TNF-α-inhibitor therapy should be done in combination with methotrexate, unless contraindicated, according to NICE. In those instances, patients should receive either adalimumab or etanercept as monotherapy.

Physicians should stop treatment with TNF-α inhibitors after 6 months if the patient does not show an adequate response, defined as an improvement in disease activity score of at least 1.2 points.

Infliximab costs between $14,612 and $17,047 a year, while etanercept and adalimumab both cost $17,982 a year, according to the NICE committee examining the effectiveness of the three drugs.

The committee considered TNF-α-inhibitor medications as first-line or second-line therapy after failure of one disease-modifying antirheumatic drug (DMARD). However, the committee concluded, based on cost and efficacy data, that neither was an appropriate use of National Health Service resources.

For first-line therapy, clinical specialists told the appraisal committee that a large number of patients initially respond well to DMARDs, and both the British Society of Rheumatology and European League Against Rheumatism recommend a trial of at least one DMARD.

As a second-line treatment, the appraisal committee did not believe TNF-α inhibitors had demonstrated cost-effectiveness.

The tumor necrosis factor-α-inhibitor drugs adalimumab, etanercept, and infliximab should be used to treat rheumatoid arthritis patients only after 6-month trials of methotrexate and one other disease-modifying antirheumatic drug, the clinical effectiveness agency for England and Wales had ruled.

The TNF-α inhibitors should be prescribed only to those patients who have active rheumatoid arthritis as measured by a disease activity score greater than 5.1—or patients with about 8–10 swollen and tender joints—confirmed at least twice, measured 1 month apart, according to the National Institute for Health and Clinical Effectiveness' final appraisal document.

TNF-α-inhibitor therapy should be done in combination with methotrexate, unless contraindicated, according to NICE. In those instances, patients should receive either adalimumab or etanercept as monotherapy.

Physicians should stop treatment with TNF-α inhibitors after 6 months if the patient does not show an adequate response, defined as an improvement in disease activity score of at least 1.2 points.

Infliximab costs between $14,612 and $17,047 a year, while etanercept and adalimumab both cost $17,982 a year, according to the NICE committee examining the effectiveness of the three drugs.

The committee considered TNF-α-inhibitor medications as first-line or second-line therapy after failure of one disease-modifying antirheumatic drug (DMARD). However, the committee concluded, based on cost and efficacy data, that neither was an appropriate use of National Health Service resources.

For first-line therapy, clinical specialists told the appraisal committee that a large number of patients initially respond well to DMARDs, and both the British Society of Rheumatology and European League Against Rheumatism recommend a trial of at least one DMARD.

As a second-line treatment, the appraisal committee did not believe TNF-α inhibitors had demonstrated cost-effectiveness.

WASHINGTON — Treatment of early rheumatoid arthritis with an intensive methotrexate dosing strategy may provide a better overall clinical outcome than would a conventional approach with the drug, Dr. Johannes W.J. Bijlsma reported at the annual meeting of the American College of Rheumatology.

Management of early rheumatoid arthritis with intensive methotrexate treatment not only produced a higher remission rate than did conventional methotrexate treatment, but was relatively easy to administer in clinical practice, said Dr. Bijlsma of University Medical Center Utrecht (the Netherlands).

In a multicenter, randomized trial, a significantly greater percentage of 148 intensively treated patients went into clinical remission during 2 years of follow-up than did 151 conventionally-treated patients (51% vs. 39%, respectively).

Clinical remission was defined as having no swollen joints, plus meeting two of the three following criteria for at least 6 months: three or fewer tender joints; an erythrocyte sedimentation rate of 20 mm or less in the first hour; and a visual analog scale score of general well-being of 20 mm or less.

The average time to remission in the intensive treatment group was 11 months, compared with 14 months in the conventional treatment group, while the duration of remission for the two groups was 11 months and 9 months, respectively. Both findings were statistically significant; radiographic joint damage was similarly low in both groups, reported Dr. Bijlsma.

Adverse events also occurred at similar rates between the groups.

Conventional treatment consisted of one outpatient visit every 3 months in which the dose of methotrexate was increased by 5 mg/week if the number of swollen joints rose. The investigators could reduce the dose of methotrexate by 2.5 mg/week when patients went into remission.

Patients who received intensive treatment had one outpatient visit every 4 weeks. Their dosing regimen was individually tailored by a computer program that used a predefined set of criteria, noted Dr. Bijlsma.

The investigators increased the methotrexate dose if there was 20% or less improvement in the number of swollen joints, and if there was 20% or less improvement in two of the three previously mentioned criteria.

The dose decreased when the patients had no swollen joints for 3 or more months and had greater than 20% improvement in at least two of the three variables. If a patient in either group reached 30 mg/week methotrexate without a response based on the criteria, the patients then received methotrexate subcutaneously. Those who continued to show no response also received cyclosporine, reported Dr. Bijlsma.

Dosing in the intensive drug regimen was tailored by a computer program. DR. BIJLSMA

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WASHINGTON — Treatment of early rheumatoid arthritis with an intensive methotrexate dosing strategy may provide a better overall clinical outcome than would a conventional approach with the drug, Dr. Johannes W.J. Bijlsma reported at the annual meeting of the American College of Rheumatology.

Management of early rheumatoid arthritis with intensive methotrexate treatment not only produced a higher remission rate than did conventional methotrexate treatment, but was relatively easy to administer in clinical practice, said Dr. Bijlsma of University Medical Center Utrecht (the Netherlands).

In a multicenter, randomized trial, a significantly greater percentage of 148 intensively treated patients went into clinical remission during 2 years of follow-up than did 151 conventionally-treated patients (51% vs. 39%, respectively).

Clinical remission was defined as having no swollen joints, plus meeting two of the three following criteria for at least 6 months: three or fewer tender joints; an erythrocyte sedimentation rate of 20 mm or less in the first hour; and a visual analog scale score of general well-being of 20 mm or less.

The average time to remission in the intensive treatment group was 11 months, compared with 14 months in the conventional treatment group, while the duration of remission for the two groups was 11 months and 9 months, respectively. Both findings were statistically significant; radiographic joint damage was similarly low in both groups, reported Dr. Bijlsma.

Adverse events also occurred at similar rates between the groups.

Conventional treatment consisted of one outpatient visit every 3 months in which the dose of methotrexate was increased by 5 mg/week if the number of swollen joints rose. The investigators could reduce the dose of methotrexate by 2.5 mg/week when patients went into remission.

Patients who received intensive treatment had one outpatient visit every 4 weeks. Their dosing regimen was individually tailored by a computer program that used a predefined set of criteria, noted Dr. Bijlsma.

The investigators increased the methotrexate dose if there was 20% or less improvement in the number of swollen joints, and if there was 20% or less improvement in two of the three previously mentioned criteria.

The dose decreased when the patients had no swollen joints for 3 or more months and had greater than 20% improvement in at least two of the three variables. If a patient in either group reached 30 mg/week methotrexate without a response based on the criteria, the patients then received methotrexate subcutaneously. Those who continued to show no response also received cyclosporine, reported Dr. Bijlsma.

Dosing in the intensive drug regimen was tailored by a computer program. DR. BIJLSMA

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Treatment of early rheumatoid arthritis with an intensive methotrexate dosing strategy may provide a better overall clinical outcome than would a conventional approach with the drug, Dr. Johannes W.J. Bijlsma reported at the annual meeting of the American College of Rheumatology.

Management of early rheumatoid arthritis with intensive methotrexate treatment not only produced a higher remission rate than did conventional methotrexate treatment, but was relatively easy to administer in clinical practice, said Dr. Bijlsma of University Medical Center Utrecht (the Netherlands).

In a multicenter, randomized trial, a significantly greater percentage of 148 intensively treated patients went into clinical remission during 2 years of follow-up than did 151 conventionally-treated patients (51% vs. 39%, respectively).

Clinical remission was defined as having no swollen joints, plus meeting two of the three following criteria for at least 6 months: three or fewer tender joints; an erythrocyte sedimentation rate of 20 mm or less in the first hour; and a visual analog scale score of general well-being of 20 mm or less.

The average time to remission in the intensive treatment group was 11 months, compared with 14 months in the conventional treatment group, while the duration of remission for the two groups was 11 months and 9 months, respectively. Both findings were statistically significant; radiographic joint damage was similarly low in both groups, reported Dr. Bijlsma.

Adverse events also occurred at similar rates between the groups.

Conventional treatment consisted of one outpatient visit every 3 months in which the dose of methotrexate was increased by 5 mg/week if the number of swollen joints rose. The investigators could reduce the dose of methotrexate by 2.5 mg/week when patients went into remission.

Patients who received intensive treatment had one outpatient visit every 4 weeks. Their dosing regimen was individually tailored by a computer program that used a predefined set of criteria, noted Dr. Bijlsma.

The investigators increased the methotrexate dose if there was 20% or less improvement in the number of swollen joints, and if there was 20% or less improvement in two of the three previously mentioned criteria.

The dose decreased when the patients had no swollen joints for 3 or more months and had greater than 20% improvement in at least two of the three variables. If a patient in either group reached 30 mg/week methotrexate without a response based on the criteria, the patients then received methotrexate subcutaneously. Those who continued to show no response also received cyclosporine, reported Dr. Bijlsma.

Dosing in the intensive drug regimen was tailored by a computer program. DR. BIJLSMA

ELSEVIER GLOBAL MEDICAL NEWS