Poster Session 3.

Rheumatoid arthritis: aetiopathogenesis

allopurinol, suppressed both plasma and articular XOR activity at <0.3% of
normal levels. However, XOR inactivation was associated with greater increase of knee swelling at 24 and 48 hrs post i.a. mBSA, compared with
controls (mean increase SEM of knee diameter from baseline of 3.30.5,
2.00.3 and 1.90.2 mm in the TG, SG and AG groups (n=14 each group),
respectively;p<0.05, TG vs. SG (ANOVA, Dunnetts post-test). Mean ratio of articular nitrotyrosine-tyrosine (SEM) was increased in the XORinactivated group, compared with controls: 12.30.7, 9.60.8 and 10.40.5
pg/g in the TG, SG and AG groups, respectively; p<0.05, TG vs. SG. No
erosive joint damage was observed.
Conclusions: XOR inactivation was associated with increased joint swelling
and articular tyrosine nitration in acute AIA. This may suggest a novel, protective role for XOR in inflammatory arthritis.
Supported by arc.uk

340. THE ASSOCIATION OF THE "SHARED EPITOPE" WITH SYNOVIAL

IMMUNOHISTOCHEMICAL CHANGES IN EARLY RHEUMATOID ARTHRITIS

Background: The relationship of rheumatoid arthritis (RA) with the "shared

epitope" is well recognised. The "shared epitope" is located on the short arm
of chromosome 6 and encodes for a sequence of amino acids that lie in close
proximity to T cell receptor. It is thought to modify an individuals immune
response. In Caucasian populations DR4 and DR1 are the most commonly
expressed alleles. Its presence is associated with a more aggressive disease
process and a worse prognosis. The aim of this study was to determine if the
expression of this genotype influences the pathological changes that occur
within the synovium in early RA.
Methods: Thirteen patients with early RA were genotyped from a peripheral blood sample for the "shared epitope" using an automated polymerase
chain reaction technique. A synovial tissue sample was obtained using a
blind needle technique prior to commencement on treatment. Up to three
biopsies were analysed from each patient. This tissue was stained using
an immunohistochemical technique for T cells (CD3), T helper cells (CD4),
cytotoxic T cells (CD8), B cells (CD20), blood vessels (Factor VIII) and
macrophages (CD68). Each marker was quantified using a manual counting
technique to give an average percentage positive cell count for each biopsy.
The CD68 marker was analysed by determining the percentage area of positivity per biopsy. Statistical comparisons between groups of "shared epitope"
positive and negative were made using the students independent sample t
test.
Results: Six patients were shared epitope positive- 2 for 0101, 3 for 0401
and 1 compund hetereozygote, 0101 0401. CD3, CD4 and CD8 postive cells
were present in significantly higher numbers in patients that were " shared
epitope" positive (p=0.000, p=0.000 and p=0.004 respectively). There was
no difference in blood vessel or macrophage counts between the two groups.
Conclusions: The "shared epitope" genotype is associated with the level
of inflammatory infiltrate within the synovium in early RA. Patients carrying
the "shared epitope" have a higher T cell, T helper and cytotoxic T cell infiltrate. These T cells are thought to play an important role in the initiation
and perpetuation of the inflammatory process in early RA. This is a potential explanation of the erosive joint disease process often seen in patients
carrying these alleles. There did not appear to be a relationship with other
inflammatory changes within the synovium which may imply that the effect
of the "shared epitope" is limited to T cells. These findings however would
need to be verified on a larger patient cohort.

341. THE ASSOCIATION BETWEEN HLA GENES AND RADIOLOGICAL

EROSIONS IN MALAYSIAN PATIENTS WITH RHEUMATOID ARTHRITIS
S.S. Yeap 1 , A. Mohd 1 , G. Kumar 2 , K.F. Kong 3 , E.M.L. Goh 1 , S.K. Chow 1 ,
M.E. Phipps 3 . 1 Department of Medicine, Faculty of Medicine, University of
Malaya, Kuala Lumpur, Malaysia; 2 Department of Radiology, Faculty of
Medicine, University of Malaya, Kuala Lumpur, Malaysia; 3 Department of
Allied Health Sciences, Faculty of Medicine, University of Malaya, Kuala
Lumpur, Malaysia
Background: The HLA-DRB genes have been shown to influence disease
susceptibility and severity in rheumatoid arthritis (RA) but this has not been
studied in Malaysian patients. The aim of this study was to assess the relationship between the HLA-DRB1 genes with disease severity, as assessed
by radiological erosions, in Malaysian patients with RA.

Methods: In this cross-sectional study, we studied 61 RA patients who fulfilled the American College of Rheumatology criteria for the diagnosis of RA.
They had HLA-DRB1 genotyping done by phototyping. X-rays of the hands
and wrists were done and the radiological grading and erosive score was calculated according to the Larsen-Dale Method. Demographic data and treatment given to the patients were obtained from their case records.
Results: 56 females and 5 males from three different ethnic groups were
studied: Malay (n = 9), Chinese (n = 30) and Indian (n = 22). The average age
of the subjects was 51.7 9.7 years. The median duration of disease was
8 years (range 2-36). 57 (93.4%) patients had erosions; with the presence
of rheumatoid factor in 80%, HLA-DR4 in 40%, HLA-DRB10405 in 24%
and the shared epitope (SE) in 31% of them. Only 10 patients (16.4%) had
extra-articular features present. 60 patients had been on at least one type of
DMARD with a median duration of 39 months (range 0192) and the median
delay in starting DMARDs was 24 months (range 0180). We found that
the presence of rheumatoid factor, HLA-DR4 and HLA-DRB10405 were not
significantly associated with a worse erosive score or the presence of extraarticular features. Patients who possessed the SE had a worse erosive score
compared to those who did not (p = 0.05). A delay in starting DMARD was
associated with a worse erosive score (p = 0.011, R2 = 0.325). However,
after controlling for the delay in starting DMARDs, the erosive score was
no longer significantly associated with SE (partial correlation coefficient p =
0.08). In contrast, the erosive score and delay in starting DMARD correlation
remained significant after controlling for SE (partial correlation coefficient p
= 0.05).
Conclusions: In Malaysian patients with RA, the major determinant of the
erosive score was the delay in starting DMARD therapy, rather than the presence of the SE. This would confirm the urgency of early DMARD treatment
of all, including Asian, RA patients, to minimise future joint damage and maximise long-term function.

Rheumatoid arthritis: clinical aspects

342. CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IN ADULTS &
CHILDREN WITH ARTHRITIS IN A DISTRICT GENERAL HOSPITAL
SETTING
K. Hurley 1 , S.S. Hamdulay 2 , A. Steuer 2 , A. Hall 2 , H. Chapel 1 , B.L. Ferry 1 .
1 Immunology, Wexham Park Hospital, Slough, United Kingdom;
2 Rheumatology, Wexham Park Hospital, Slough, United Kingdom
Background: Rheumatoid Factor (RF) has limited specificity and sensitivity
for the diagnosis of RA. Anti-cyclic-citrullinated peptide (anti-CCP) antibodies have demonstrated moderate sensitivity and high specificity in the diagnosis of rheumatoid arthritis. The antibody has been associated with erosive
disease and poor functional outcome. The aim of this study was to assess
the clinical significance of anti-CCP antibodies in patients with juvenile idiopathic arthritis (JIA), rheumatoid arthritis (RA) and other rheumatic diseases
attending a district general rheumatology outpatient department.
Methods: 45 patients with JIA (9 polyarticular, 15 oligoarticular, 9 extended
oligoarticular, 5 systemic JIA, 4 psoriatic subset, 2 enthesitis subset, 1 unclassified), 32 adult RA (fulfilling the ARA criteria for diagnosis) and 41
other rheumatic diseases presenting to the rheumatology outpatients were
screened for anti-CCP antibodies. Clinical features, disease duration and RF
were compared in these groups. Anti-CCP was measured using a validated
ELISA assay (DiaSorn, UK).
Results: JIA; Of this group 3/45 (6.6%) patients were anti-CCP+ (1 poly JIA,
2 psoriatic). All JIA patients with erosive disease were anti-CCP-.
RA; 30/32 (94%) RA patients were anti-CCP+. Of those which were positive 70%, had symmetrical joint disease and 80% had erosions. 24/32 (75%)
patients with RA were RF +. 5 (15%) of the anti-CCP+ patients were RF-.
4 of these patients had symmetrical, polyarticular disease. 4/30 (10%) antiCCP+ patients had a duration of disease of less than 2 years. In this cohort anti-CCP has a diagnostic sensitivity of 94% and specificity of 93%,
compared to 81% and 83% for RF. Other Rheumatic Diseases;3/41 (7%)
patients were anti-CCP+ (1 adult psoriatic arthritis, 1 CREST and 1 mixed
Anti-CCP abs, RF and Erosions In Disease Groups

JIA (n=45)
RA (n=32)
Inflammatory (n=19)
Undifferentiated (n=3)
Non-Inflammatory (n=19)

CCP+ve

RF +ve

Erosions

3 (7%)
30 (94%)
3 (16%)
0
0

1 (2%)
26 (81%)
7 (37%)
0
0

7(16%)
27 (84%)
1(5%)
0
0

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C.F. Matthews 1 , P. Maxwell 2 , G.D. Wright 1 , D. Middleton 3 , B. Bresnihan 4 ,

O. FitzGerald 4 , P.W. Hamilton 2 , M.M.E. Rooney 1 . 1 Department of
Rheumatology, Musgrave Park Hospital, Belfast, County Antrim, United
Kingdom; 2 Department of Quantitative Pathology, Queens University of
Belfast, Belfast, County Antrim, United Kingdom; 3 Department of Tissue
Typing, Belfast City Hospital, Belfast, County Antrim, United Kingdom;
4 Department of Rheumatology, St Vincents University Hospital, Dublin,
County Dublin, Ireland

ii133

Friday, 23 April 2004

ii134

Friday, 23 April 2004

Poster Session 3. Rheumatoid arthritis: clinical aspects

connective tissue disease). The negative patients included 19 other inflammatory arthropathies (including psoriatic, SLE, reactive), 3 undifferentiated
polyarthritis and 19 non-inflammatory arthropathies. 7/41 (17%) of these patients were RF+.
Conclusions: Anti-CCP is not useful in the management of JIA. Anti-CCP
antibodies have high diagnostic specificity and sensitivity in RA. The higher
than expected sensitivity may be attributed to the high proportion of patients
with advanced disease in this cohort. Anti-CCP was present in both early
and established RA. The high specificity of this test makes it diagnostically
useful, particularly in those patients that are negative for RF.
Study funded by Roche Pharmaceuticals

343. THE PREDICTIVE VALUE OF ANTIBODIES TO CYCLIC

CITRULLINATED PEPTIDE IN VERY EARLY INFLAMMATORY ARTHRITIS
K. Raza 1 , G.M. Breese 2 , K.Y. Lee 3 , T. Potter 2 , C.D. Buckley 1 , C. Gordon 1 ,
M. Salmon 1 , G.D. Kitas 2 . 1 MRC Centre for Immune Regulation, Division of
Immunity and Infection, University of Birmingham, Birmingham B15 2TT,
United Kingdom; 2 Department of Rheumatology, Dudley Group of Hospitals
NHS Trust, Dudley, DY1 4SE, United Kingdom; 3 Department of Radiology,
City Hospital, Dudley Road, Birmingham B18 7QH, United Kingdom

Anti-CCP antibody and RF for the prediction of the development of RA in patients with
very early inflammatory arthritis
RF
RF antiRF latex
RF latex
RF ELISA
RF ELISA
latex ELISA CCP +ve and anti- +ve or anti- +ve and anti- +ve or anti+ve +ve +ve
CCP +ve
CCP +ve
CCP +ve
CCP +ve
Sensitivity (%)
Specificity (%)
PPV (%)
NPV (%)

63
96
83
89

63
95
79
88

63
96
83
89

58
100
100
88

67
96
84
90

58
100
100
88

67
90
70
89

Conclusions: In a very early inflammatory arthritis clinic, the presence of

RF together with anti-CCP antibodies has a very high specificity and positive
predictive value for the development of RA. However, in a cross-sectional
study anti-CCP antibodies and RF were also found in patients with SLE and
IBD.

344. STRUCTURAL DAMAGE AS MEASURED BY RADIOGRAPHS

ACCELERATES BETWEEN YEARS TWO AND THREE IN EARLY
RHEUMATOID ARTHRITIS - IMPORTANT IMPLICATIONS FOR TREATMENT
AND TRIAL DESIGN
J. Dixey 1 , C. Sollymossy 1 , P. Jones 2 , A. Young 1 , T. McCourt 1 ,
L. Waterhouse 1 . 1 On Behalf of the Early Rheumatoid Arthritis Study
(ERAS), St Albans City Hospital, St Albans, Hertfordshire, United Kingdom
Background: Several different types and rates of radiological progression
have been described in rheumatoid arthritis (RA), including linear, curvilinear, fast-slow, slow-fast, sigmoid curves. The rate of x-ray damage is an important factor in decisions concerning use of disease modifying drugs. Only
a few studies have examined the relationship between function and x-ray

345. CAN WE PREDICT DEVELOPMENT OF RA IN PRE-RHEUMATOID

PATIENTS?
S.N. Kamath 1 , P.T. Dawes 1 , S. Griffiths 1 , P.W. Jones 2 , A. Brownfield 1 ,
J. Fisher 1 , D.L. Mattey 1 . 1 Haywood Hospital, Staffordshire Rheumatology
Centre, Stoke on Trent, Staffordshire, United Kingdom; 2 Department of
Mathematics, Keele University, Stoke on Trent, Staffordshire, United
Kingdom
Background: In clinical rheumatology there are patients who are classified
as pre-rheumatoids. Essentially, these patients have symptoms suggestive
of RA but do not satisfy the criteria of RA. Usually they have small joint
symptoms, early morning stiffness with normal inflammatory markers. Some
of these patients in due course develop RA. It would be useful to know which
factors at presentation predict the development of RA. This is particularly relevant as the benefits of early DMARD introduction in RA is well recognised.
Methods: A randomised double-blind placebo controlled trial was undertaken in 60 patients with features of pre-rheumatoid disease from 1996 to
2002. Patients included had symptoms suggestive of early synovitis, disease duration >6weeks and <1 year, signs of synovitis in three or more
joints, ESR< 30mm/hr, CRP< 15mg/l and no erosive changes on x-rays of
hands and feet. They did not fulfil the criteria for rheumatoid arthritis at entry.
Patients were randomised to receive HCQ (400mg/daily) or placebo. FBC,
ESR, CRP, early morning stiffness, HAD, patient and physician global assessment, Ritchie index, swollen joint count, PIP score, VAS for pain were
recorded at 3 monthly assessment. X-rays of hand and feet were done for
erosions at baseline, 6 and 12 months. Rheumatoid factor and ANA were
checked at baseline. NSAIDs, analgesics and other medications were left
unchanged. The RCT had approval of the local ethics committee.
Results: 36 female and 24 male patients were included in the study.
Mean and median ages were 48.7 and 50 years respectively.
6/30 patients (20%) in HCQ and placebo groups were seropositive.
10/30 (33.3%) and 14/30 (46.7%) patients developed RA in HCQ and
placebo group respectively over following 2 years.
Table 1 summarises the results of logistic regression analysis that was applied to parameters at baseline.
Table 1. Factors predictive of RA in pre-rheumatoid patients

Seropositivity
ESR>20
CRP>5
HCQ
Sex
Age

Odds ratio

Lower 95%limit CI

Upper 95% limit CI

Probabaility

14.4
13.8
10.5
0.28
2.3

1.9
1.1
1.4
0.05
0.5

106.5
173.2
80.8
1.4
14.0

0.009
0.04
0.02
0.13
0.23
0.19

Conclusions: Serpositivity, ESR>20 and CRP>5 in pre rheumatoid patients

were the strongest predictors for development of RA and were independent
of the treatment group. Female patients seem to be at a higher risk for RA
in keeping with higher prevalence and incidence of RA in women. Altough
no significant difference was found between HCQ and placebo there was a
trend to suggest that the HCQ treated patients were less likely to develop
RA.

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Background: Anti-cyclic citrullinated peptide (anti-CCP) antibodies are specific markers of established RA. Their frequent presence before clinical disease onset suggests that their detection may predict the development of RA
in very early arthritis patients. With increasing evidence that the first few
months of disease represent a unique therapeutic window in RA, we assessed the predictive value of anti-CCP antibodies for the development of
RA in the context of a very early arthritis clinic.
Methods: Anti-CCP antibodies and rheumatoid factor (RF) were measured
in the serum of 221 patients. RF was measured by latex agglutination and
ELISA (Hycor Biomedical; positivity 30 IU/ml) and anti-CCP antibody was
measured by ELISA (Axis-Shield Diagnostics; positivity 5 U/ml). 97 patients had very early inflammatory arthritis (duration 3 months). Outcome
was determined at follow-up with 24 patients being classified as having RA
by 1987 ARA criteria. 124 patients had established diagnoses and were
assessed as part of a cross sectional study (Wegeners granulomatosis
(WG) (n=10), SLE (n=10), ankylosing spondylitis (AS) (n=12), inflammatory
bowel disease (IBD) (n=10), sarcoidosis (n=10), OA (n=10), hyperlipidaemia
(n=20), seropositive RA (n=22), seronegative RA (n=20)).
Results: The sensitivities, specificities, positive and negative predictive values of RF and anti-CCP antibodies alone, or in combination, for the prediction of the development of RA in very early inflammatory arthritis patients
are shown (see table). In the cross-sectional study anti-CCP antibodies were
detected in patients with SLE (10%), sarcoidosis (10%), IBD (20%), seropositive RA (91%) and seronegative RA (30%) but not in patients with WG, AS,
OA or hyperlipidaemia. Anti-CCP antibodies together with RF (by either technique) were detected in patients with SLE (10%) and IBD (10%) but not in
patients with sarcoidosis.

scores, and most have reported positive correlation with late disease. The
aims of this study was to measure rate of xray progression in early RA, and
its association with function.
Methods: Standard clinical and laboratory measures have been recorded
prospectively in a well- described observational (inception) cohort of RA patients recruited from nine centres in England. Baseline, 1yr, 2yr, 3yr and
5yr radiographs of hands and feet were digitized onto CD-RoM and scored
randomly by one observer using Larsens method. 505 patients had a complete x-ray dataset, in whom mean age was 55yrs, 65% were women, and,
at baseline, rheumatoid factor was positive in 73%, and 25% had erosions,
similar to other early RA cohorts at presentation.
Results: By 5 yrs 420 (87%) had evidence of x-ray damage. Mean Larsen
scores showed a linear progression with an accelerated phase between the
second and third years. In contrast, clinical and laboratory measures improved initially from baseline, and appeared to stabilise with only a gradual
worsening after 2 years. Correlation coefficients measured at the same time
(0-5yrs) between Larsen scores and Swollen Joint count, Health Assessment Questionnaire (HAQ), ESR and Disease Activity Score (DAS) were all
low (rs <0.25). Graphic displays will also show that baseline rheumatoid factor titre altered significantly the x-ray progression curves (p<0.00001).
Conclusions: X-ray changes follow an essentially linear progression, but
with an accelerated phase between 2-3 years, when other standard measures of RA remain relatively stable. This finding has important implications
as to the timing of therapeutic interventions in early RA and the design of
trials of disease-modifying drugs.

Poster Session 3. Rheumatoid arthritis: clinical aspects

Friday, 23 April 2004

346. INFLUENCES OF SEROPOSITIVITY AND GENDER ON DISEASE

ACTIVITY SCORE (DAS) IN EARLY RHEUMATOID ARTHRITIS (RA)

Table 1

L. Connell, R. Ramachandran, R. Madhok, H. Capell. Centre for Rheumatic

Diseases, Royal Infirmary on Behalf of the MASCOT Group, Glasgow,
United Kingdom

Low
Borderline
Normal

ESR mm/hr
Patient global mm

seropositive

seronegative

MW

32 (18-51)
55 (45-76)

16 (8-34)
60 (50-80)

P<0.000
P<0.015

Tender joint count was slightly higher in seronegative patients (medians 14

vs 12) but this did not reach significance, Mann Whitney p=0.081. There was
also a trend towards higher pain score and physician global score in the
seronegative group. CRP (17mg/l vs 8mg/l) was significantly higher in the
seropositive patients.
Median HAQ score (1.625) and swollen joint count (10) were the same in the
two groups.
Influence of Gender: The male patient group was older than females (median 58yrs vs 54yrs, p<0.009) and had lower DAS scores (median 3.8 vs
4.06, p<0.011). This lower DAS resulted from fewer symptoms complaints:
inflammatory markers were similar to females. Males also had lower HAQ
scores (1.25 vs 1.625, p<0.001).
Conclusions: These demographic influences are relevant in assessing randomised controlled trials utilising DAS. While the total DAS score is equivalent in seropositive and seronegative patients in this cohort, different components comprise the DAS profile. ESR and CRP are known to influence
outcome and the hybrid nature of the DAS may complicate prognostic predictions. Gender proportions tend to be fairly constant in DMARD studies but
differing responses from males and females are worthy of note.

347. AN AUDIT OF VITAMIN D LEVELS IN PATIENTS WITH

RHEUMATOID ARTHRITIS
A. Sinclair, N. McAvoy, E.A. Murphy. Department of Rheumatology, Wishaw
General Hospital, Wishaw, ML2 0DP, United Kingdom
Background: Vitamin D deficiency is associated with osteomalacia and increased fracture risk. Recent guidelines (SIGN 71) have recommended calcium and vitamin D supplementation in all elderly housebound individuals.
There is some evidence that patients with RA have an increased risk of vitamin D deficiency [1,2].
We therefore sought to establish the prevalence of vitamin D deficiency and
supplementation in patients with RA attending the rheumatology follow up
clinic, and to establish any correlation with age, disability or disease activity.
Methods: All patients with RA who attended the rheumatology follow up
clinic over two two month periods October/November 2002 and April/May
2003 - and who required a blood sample were invited to participate. Blood
was assayed for ESR, 25OH Vitamin D, Alkaline Phosphatase and gamma
GT. All patients completed a modified Stanford Health Assessment Questionnaire (HAQ), and a drug history was recorded.
Results: 266 patients were recruited. 23 were patients were taking Vitamin D supplements. Vitamin levels were categorised as low (<20nmol/ml),
borderline (20-40nmol/ml) or normal (>40nmol/ml) and the results are summarised in table 1. Figures in brackets are those on supplements.
When the low and normal groups were compared, there was a statistically significant difference for ESR (P=0.02), Alk.Phos. (p=0.03) and HAQ
(p=0.01), but not age.
Conclusions: Vitamin D deficiency is common in patients with RA, independent of age. This may be an important additional risk factor for falls and

Vitamin D
38 (3)
135 (12)
93 (8)

fractures in a group already at increased risk. Routine annual measurement

of Vitamin D is justified in this group to identify those requiring supplementation and will now be incorporated into our routine practice. The audit will be
repeated in two years to assess the impact of this change.
Additionally there is some evidence that Vitamin D can have an ameliorating
effect on RA and other autoimmune disease [3] and we propose further studies to determine any disease modifying effect of Vitamin D supplementation.
References
[1] Haugeberg et al. Arthr.Rheum. 2002; 31: 1720-8.
[2] Kroger et al. Scand.J.Rheumatol. 1993; 22: 172-7.
[3] Deluca HF & Cantorna MT. FASEB J. 2001; 15: 2579-85.

348. INVESTIGATION OF GROWTH HORMONE SECRETION AND

SENSITIVITY IN RHEUMATOID ARTHRITIS
G.A. Mittal 1,4 , S. Marcora 4 , A.B. Lemmey 4 , A. Wayte 2 , P.J. Maddison 1,4 ,
A. Wilton 3,4 . 1 Rheumatology, Ysbyty Gwynedd, Bangor, Gwynedd, United
Kingdom; 2 Clinical Chemistry, Ysbyty Gwynedd, Bangor, Gwynedd, United
Kingdom; 3 Endocrinology, Ysbyty Gwynedd, Bangor, Gwynedd, United
Kingdom; 4 School of Sports, Health and Exercise Sciences, University of
Wales, Bangor, Gwynedd, United Kingdom
Background: Patients with rheumatoid arthritis (RA) exhibit decreased
skeletal muscle bulk due to deregulated metabolism favouring net catabolism
to anabolism. The state of heightened catabolism is further accentuated by
a decrease in anabolism causing significant loss of muscle mass. An up regulated TNF- system results in exaggerated catabolism where as reduced
activity of growth hormone/insulin-like growth factor-1(GH/IGF-1) axis leads
to suppression of anabolism.
We have previously shown that systemic levels of the GH dependent proteins IGF-I and insulin-like growth factor binding protein-3(IGFBP-3) are significantly lower in RA patients than in age and sex matched healthy controls
(Lemmey et al, 2001).
Aim: To investigate whether low levels of systemic IGF-I and IGFBP-3 levels
in RA patients are due to GH deficiency or GH insensitivity.
Methods: Eight RA patients (6 females, mean SD, age 52.5 8.4 years)
known to have severe IGF-I and/or IGFBP-3 deficiency (serum levels less
than 2 SD of mean of controls) were evaluated for GH reserve by insulin
tolerance test (ITT). In a further group of 30 unselected RA patients (22 females, mean age 52 years) and 30 age and sex matched healthy controls,
serum concentration of growth hormone binding protein (GHBP), a peripheral marker of GH receptor number, was measured. All patients were stable
on disease-modifying anti-rheumatic drugs and/or low dose prednisolone.
Results: In all 8 ITT patients plasma glucose fell below 2 m moles/L within
the first 30 minutes coincidental with development of clinical hypoglycaemia.
The mean SD serum GH peak response was 18.73 8.17 m U/L and in 5
patients the peak was less than 20 m U/L (table 1). In the larger group of RA
patients, circulating GHBP was 35% lower than in healthy controls (mean
SD: 1035 627 versus 1585 807 p moles/L; P<0.01).
Table 1: GH levels (mU/L) during course of Insulin tolerance test
Case No.

0 min

30 min

45 min

60 min

90 min

120 min

1
2
3
4
5
6
7
8

13.1
9.8
0.9
10.6
1.4
0.9
1.9
0.9

4.4
2.9
1.6
7.3
7.1
0.9
6.5
0.9

11
2.3
7.6
18.2
12.2
6.8
6.9
1.9

17.1
2
22.7
12.8
12.7
14.6
28.4
6.4

5.8
21
31.4
6.7
5.7
8.2
13.9
2

0.9
7.1
21.3
9.5
1.8
4.7
6.5
0.9

Conclusions: The results suggest that low systemic levels of IGF-I and
IGFBP-3 in RA reflect combined partial GH deficiency and target tissue insensitivity probably secondary to decreased GH receptor numbers.
These preliminary results need to be confirmed by direct assessment of IGF1 response to recombinant growth hormone.
Reference
[1] Lemmey A, Maddison PJ et al. J Rheumatol 2001, 28: 29-34

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Background: DAS scoring is widely used to assess response in RA disease

modifying anti-rheumatic drug (DMARD) studies. The various components of
DAS may vary according to the demographic and clinical features of a study
cohort.
Aims: To evaluate components of DAS scores and the characteristics of
individuals entering a prospective DMARD study according to seropositivity
and gender.
Methods: Baseline characteristics of 700 patients at the time of entry to
a step-up DMARD study were analysed. DAS score comprised swollen joint
count, Ritchie articular index, patient global assessment (100mm visual analogue scale) and ESR.
Results: 77% of the cohort was female and 66% were seropositive for
rheumatoid factor.
Influence of Seropositivity: Median DAS score was 4 in the seropositive and
3.9 in the seronegative group (Mann Whitney, p=118). Seropositive patients
were more likely to be smokers (48% vs 32%). Seronegative patients were
younger (median age 54 vs 56yrs, Mann Whitney p=0.028).
Components of DAS which differed between seropositive and seronegative
groups (medians and interquartile ranges are shown).

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Friday, 23 April 2004

Poster Session 3. Rheumatoid arthritis: clinical aspects

349. RESPONSE RATES TO JOINT INJECTION THERAPY IN

RHEUMATOID ARTHRITIS

351. OCCURRENCE AND RISK FACTORS FOR FALLS IN RHEUMATOID

ARTHRITIS

C. Rao, M.A.S. Bukhari. Rheumatology, Royal Lancaster Infirmary,

Lancaster, Lancashire, United Kingdom

C. Armstrong 1 , C.M. Swarbrick 2 , S.R. Pye 2 , T.W. ONeill 1,2 . 1 Department of

Rheumatology, Hope Hospital, Salford, United Kingdom; 2 ARC
Epidemiology Unit, University of Manchester, Manchester, United Kingdom

350. ARE FLEXION/EXTENSION VIEWS OF THE CERVICAL SPINE

NECESSARY IN PATIENTS WITH REUMATOID ARTHRITIS?
A.S.M. Jawad 1 , A. Malhorta 2 , Z. Chan 2 , M. Adler 1 , O. Chan 2 .
1 Rheumatology Department, The Royal London Hospital, London, E1 4DG,
United Kingdom; 2 Radiology Department, The Royal London Hospital,
London, E1 4DG, United Kingdom
Background: The purpose of the study is to determine whether both flexion
and extension cervical spine views are both necessary in rheumatoid arthritis
and to assess whether serial flexion/extension views are of any additional
benefit.
Methods: A retrospective study was performed on 45 patients with rheumatoid arthritis (fulfilling the ACR criteria) who were clinically suspected to have
subluxation of the cervical spine. The flexion and extension views were analysed separately to diagnose instability. Further views taken on subsequent
presentations were also analysed to look for progression of disease.
Results: The mean age of the patients was 52 years (range 26 78). There
were 37 patients with instability demonstrated on plain cervical spine radiography: C1/2 eleven patients, C2/3 two patients plus one with fusion, C3/4 six
patients, C4/5 twelve patients plus one with fusion,C5/6 three patients, C6/7
one patient, C7/D1 no patient. In 36/37 (97%) of these cases, instability was
better seen on the flexion view. In one patient there was minimal (2mm) posterior retro-spondylolisthesis at additional views of their cervical spine taken
on subsequent occasions. In only one patient was there evidence of minimal
disease progression of disease noted 11 years after the initial radiographs
were performed.
Conclusions: The study demonstrates that cervical spine instability in
rheumatoid arthritis can be diagnosed on a flexion view only (97%) and that
routine follow-up views are not necessary.

Background: There are few data concerning the occurrence of falls in patients with rheumatoid arthritis (RA). The aim of this analysis was to determine the one-year period prevalence of falls by age and gender in RA and to
determine the influence of concurrent medical therapy and disability on the
occurrence of falls in this group.
Methods: A consecutive series of RA patients aged 35 years and over, attending hospital outpatient clinics at Hope hospital, Salford, were asked to
complete an interview-assisted questionnaire which asked about the occurrence of falls in the previous 12 months. Subjects who took part were asked
also about treatment with anti-hypertensives, diuretics, sedative or hypnotics,
anti-depressants, a history of previous hip/knee surgery, and completed the
health assessment questionnaire. Logistic regression was used to determine
the association between these variables and falls in the previous 12 months.
Results: 253 men and women, mean age 62 years, were studied. 84 (33%)
subjects reported falling in the previous year. Of these, 52% had fallen on
more than one occasion. Falls were more frequent in women than men (36%
vs 26%; p=0.15), though there was no important increase in risk with age.
After adjusting for age and gender, those who had fallen in the previous year
were more likely to report taking anti-depressant therapy (OR=2.1; CI=1.0,
4.2), and to have impairment in both walking (OR=1.4; CI=1.0, 1.8) and rising
(OR=1.4; CI=1.0, 1.9). HAQ score was higher in those who reported a fall
than those who did not though the difference was not statistically significant.
Conclusions: In this hospital-based survey, one in three RA patients reported falling in the previous 12 months. Falls were associated with impaired
lower limb function.

352. AUDIT OF INFLUENZA VACCINE UPTAKE BY RHEUMATOID

ARTHRITIS (RA) PATIENTS
L. Connell, M. McDonald, H.A. Capell. Centre for Rheumatic Diseases,
Glasgow Royal Infirmary, Glasgow, United Kingdom
Background: Campaigns promote the influenza vaccine in chronic disease.
RA and related conditions are rarely listed among the specific examples
given. RA patients are known to be more susceptible to infection and some
disease modifying agents (DMARDs) might diminish ability to cope with respiratory infection. The aim of this audit was to identify the proportion of RA
patients on DMARDs who had the influenza vaccine last year and to ascertain the prompts to vaccination or the reasons for non vaccination
Methods: One hundred and fifteen RA outpatients were asked if they had
been vaccinated in the previous year. The source of recommendation or reasons for not having the vaccine were recorded. Age, sex and number and
type of DMARD were documented.
Results: Ninety-five (83%) of the 115 patients were female. Median age was
60 years (range 28 84). Seventy-four (64%) were on single DMARD therapy, 27 (24%) on dual therapy and 14 (12%) on three agents. Four patients
(3%) were on prednisolone.
Sixty-one (53%) of patients received the vaccine. Prompts to vaccination are
shown below (some patients listed more than one prompt).
Source of recommendation
Practice nurse
General practitioner
District nurse
Letter from GP
Poster in GP surgery
GP other
Rheumatology
Media advertising
Other

Number of patients
(percentage of vaccinated patients)
17 (28%)
5 (8%)
4 (7%)
20 (33%)
2 (3%)
3 (5%)
1 (1%)
4 (7%)
8 (13%)

Of those not vaccinated 29 (54%) were not aware that they were entitled to
have the vaccine, 11 (20%) made a choice not to have the vaccine, 7 (13%)
were worried about side effects and 6 (11%) did not perceive themselves to
be at risk. There was a significantly higher vaccination rate in patients aged
65 or over (46% of under 65s, 69% of over 65s, p 0.017, chi square)
Conclusions: This audit shows that there is low uptake of influenza vaccine
amongst DMARD treated RA patients attending our unit. The main reason
for this was lack of awareness. Uptake could be improved by increased patient knowledge of the vaccine. Most patients in this audit were informed
about the vaccine by personal contact with a primary care health professional. Rheumatology services have a role to play in communicating with
patients and primary care about the need for vaccination.

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Background: Joint injections are the most frequently performed procedure

in rheumatological practice but in common with most medical procedures,
the evidence base for their use is poor. No figures exist as to the efficacy of
joint injections in clinical practice. The aim of this study was to assess the
response to joint injections for inflammatory arthritis in terms of the following outcome measures: patient visual analogue score (VAS), physician VAS,
degree of joint swelling and degree of joint tenderness.
Methods: Rheumatoid arthritis patients who were deemed to require joint
injections had the following assessments performed at baseline and at
six weeks and twelve weeks post injection: Patient and physician VAS for
pain, joint tenderness assessed by dolorometry (scale 0-5kg/cm2 ) and joint
swelling (Likert scale: none, mild, moderate, severe). All joints were injected
using triamcinolone. Improvement in each of the measures was obtained by
looking at change scores. Patients who had responded initially to joint injections were assessed to see if response at six weeks predicted response
at twelve weeks using linear regression. Knee and non-knee change scores
were then compared using logistic regression.
Results: 98 patients fulfilling ARA criteria for rheumatoid arthritis received
intraarticular injections, using a standard dose of Triamcinolone acetonide.
The joints injected were as follows: 55 knees, 4 ankles, 22 shoulders, 4 elbows and 13 wrists. The median age of the patients was 63 years (IQR 3370). The median disease duration was 10 years (IQR 3-20) and the median
number of previous injections to the same joint was 1 (IQR 0-8). 87 patients
returned for the 6 week follow up assessment and 73 for the twelve week
assessment. At six weeks, the median improvement in patient VAS was 26
(IQR 9-51) and the median improvement in physician VAS was 29 (IQR 1451). Joint tenderness on dolorometry improved in 62.1% of patients by a
median value of 1kg/cm2 (IQR 0-1.5) and joint swelling improved in 70.1%
by a median value of 1 category on the Likert scale (IQR 0-2). At twelve
weeks, the median improvement in patient VAS was 19 (IQR 5-38) and the
median improvement in physician VAS was 23 (IQR 10-35). Joint tenderness
on dolorometry improved by a median value of 0.5kg/cm2 (IQR 0-1.5) and
joint swelling by a median value of 1 category on the Likert scale (IQR 0-2).
No differences in efficacy were seen between patients undergoing knee injections and those undergoing injections in other joints. Improvement at six
weeks predicted improvement at twelve weeks co-efficient = 0.73 (95%CI
0.6,0.93 p<0.001).
Conclusions: Intrarticular steroid injections improve pain, swelling and joint
tenderness in 60-70% of joints injected. Improvement at six weeks predicts
twelve week improvement.This provides a reasonable estimate of efficacy of
joint injections in inflammatory disease.

Poster Session 3. Rheumatoid arthritis: clinical aspects

353. DIETARY INTAKE AND NUTRITIONAL STATUS OF PATIENTS WITH
RHEUMATOID ARTHRITIS
P. Judd, L. Goodacre, J. Goodacre. Lancashire School of Health and
Postgraduate Medicine, University of Central Lancashire, Preston, Lancs,
United Kingdom

References
[1] Stone J.et al. 1997. Inadequate calcium, folic acide, vitamin E, zinc and
selenium intake in rheumatoid arthritis patients; results of a dietary survey. Seminars in Arthritis and Rheumatism. Vol. 27 180 - 185
[2] Heliovaara M. et al. 1994. Serum antioxidants and risk of rheumatoid
arthritis. Annals of Rheumatic Diseases Vol. 53 51-53
[3] Medical Research Council/Office for National Statistics. National Diet
and Nutrition Survey of adults aged 19-64. Volumes 2 and 3. 2003, Pub
London, HMSO

354. WHICH PATIENTS WITH EARLY RA DEVELOP FAST PROGRESSIVE

DISEASE? PROGNOSTIC FACTORS FOR SEVERE FUNCTIONAL LOSS
FROM AN INCEPTION COHORT WITH 9 YEAR FOLLOW UP
N. Bansback 1 , A. Brennan 1 , A. Young 2 , C. Sollymossy 2 , J. Dixey 2 ,
H. Dart 2 . 1 Operational Research, School of Health and Related Research,
Sheffield, United Kingdom; 2 Early Rheumatoid Arthritis Study (ERAS), St
Albans City Hospital, St Albans, Hertfordshire, United Kingdom
Background: The course of RA is variable between patients, with a small
proportion suffering rapid progression in functional status, leading quickly to
severe disability. In such patients, rapid joint deterioration (measured by radiographic progression) may occur before it is reflected in physical disability.
Identifying these patients using standard clinical and radiological assessments could allow earlier, more targeted aggressive therapy. So far no reliable prognostic factors at early stages are available for functional outcome
in such a patient group. Prognostic models were used on the ERAS data to
find an algorithm useful for clinical decision-making.
Methods: The Early Rheumatoid Arthritis Study (ERAS) has followed 671
patients for at least 10 years. Clinical markers measured include rheumatoid factor, Larsen radiological score, functional grade, number of swollen
and tender joints, grip strength, Health Assessment Questionnaire (HAQ),
haemoglobin, and Disease Activity Score (DAS). Baseline and 1yr clinical,
laboratory and radiological data were used to predict functional grade at 9
years in two groups of patients at 9 years: all patients (n=671) and those
patients (n=219) with an insidious onset (no x-ray erosions and HAQ <1 at
baseline). Logistic regression models were used to estimate risk of long-term
outcome and shown as odds ratio (OR). Models were validated by discrim-

ii137

ination using area under Receiver Operator Characteristic (AUROC) curves

and calibration methods (estimates of slope shrinkage).
Results: Using the whole cohort, HAQ at baseline and 1 year were the
most significant prognostic variables (ORs =1.9 and 4.2 respectively) giving high sensitivity and specificity (AUROC=0.81). In the insidious group
HAQ at 1 year was significant (OR=8.0) but DAS28 (OR=2.4) and Pain
scores(OR=1.0) were also significant factors. Overall discrimination was still
high (AUROC=0.79).
Conclusions: The results suggest an opportunity to identify patients with
rapid progressive disability at an early stage. External validation is necessary to fully determine its clinical use, although we have demonstrated the
value of collecting the HAQ in making clinical decisions. Internal validation
tests give an indication of the generalisabilty of the equation. Future research
is required to identify whether more aggressive therapy in these identified
subgroups of early RA patients will improve long-term prognosis.

355. CHARACTERISTICS OF RHEUMATOID ARTHRITIS PATIENTS WHO

MAINTAIN THE THE REMISSION WITHOUT DMARDs
R. Gupta, V. Marwaha, R. Grover, A. Kumar. Clinical Immunology &
Rheumatology Service, Department of Medicine, All India Institute of
Medical Sciences, New Delhi, Delhi, India
Background: Rheumatoid arthritis is not a curable disease. At present, with
the best available treatment, we can induce remission and maintain the remission by various DMARDs. If DMARDs are stopped there is relapse of
disease activity. Therefore DMARDs are required practically lifelong. There
are few patients who can maintain remission after stopping DMARDs. We
intend to study these patients.
Methods: Patients attending the rheumatology clinic at All India Institute of
Medical Sciences, New Delhi were recruited for the study. Inclusion criteria
were patients having chronic RA treated with DMARDs and achieved remission (ACR criteria) and remained in remission for at least 2 years without
any DMARDs. Their medical records were reviewed and initial presenting
features, disease characteristics and lab parameters were noted. Patients
were followed prospectively in the clinic by consultation.
Results: Total of 423 patients of chronic RA were screened in the clinic. Only
7 patients fulfilled our inclusion criteria. Mean age of the patients at presentation was 37.5 years (range-27-50years), 6 were female. Mean duration of
the disease prior to achieving remission was 9.8 years (4-16 years). Four patients were seronegative and only one patient had erosion at the time of presentation. Only one patient had deformity at presentation, which progressed
to all patients except one at present. Total number of joint involvement at
initial presentation was 8.4 (range 4-14). ESR at presentation ranged from
25-70mm/Ist hr (mean 45.5mm) (westergren method). Extraarticular manifestations were seen in 3 patient secondary sjogren syndrome-1, ILD-1,
sjogren syndrome with ILD- 1.
Six patients were treated with combination DMARDs therapy and 1 with single DMARD. Mean duration of DMARD free remission was 2.4 years (range
2 4 years). One of these patients had relapse after 2 years and 2 months
and restarted again on MTX.
Conclusions: Rheumatoid arthritis is a chronic inflammatory disease and
DMARD free remission is rare and unusal. Although current literature suggest aggressive disease at presentation indicate bad prognosis, but in some
cases they can also maintain the remission without any DMARD as seen in
our study.

356. OUTCOME OF A LARGE SECONDARY CARE INCEPTION COHORT

OF EARLY RA PATIENTS USING A STANDARDISED TREATMENT
PROTOCOL: SETTING STANDARDS FOR OUTCOME IN EARLY RA WITH
CONVENTIONAL DISEASE MODIFYING THERAPIES
M.A. Quinn, P.G. Conaghan, M.J. Green, S. Jarret, A.-.M. Keenan, H. King,
P. Emery. Rheumatology, Leeds Musculoskeletal Institute, Leeds, West
Yorkshire, United Kingdom
Background: The Yorkshire Early Arthritis Register (YEAR) was established
in 1998 to assess outcome of newly diagnosed early RA in the Yorkshire
region. Upto 15 centres participated in the second phase of this study, where
a standardised step up treatment protocol was recommended and clinical
outcome formally assessed over 2 years. The results for 12 months follow
up are presented.
Methods: All patients with a consultant diagnosis of RA with less than 12
months of symptoms were eligible for recruitment. At baseline demographic
data, joint counts, VAS scores for pain, physicians/patients disease activity, fatigue, RAQoL, HAQ and acute phase markers were collected. Followup assessments were undertaken at 3, 6 and 12 months. X-rays of hands
and feet were performed at 0 and 12 months. DAS28 and ACR improvements were calculated at 0, 6 and 12 months. The treatment protocol recommended SSA 2g first line with dose escalation to 3g at 3months, addition

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Background: People with RA may have increased requirements for energy

and nutrients due both to the disease process itself and effects of medication
on nutrients especially folic acid (Stone et al 1997) and antioxidant nutrients
(Heliovaara et al, 1994). This study explored dietary intake, nutritional status
and factors influencing diet in patients with RA.
Methods: 17 patients [5 men, 12 women, age range 55-70 (mean 62.8)]
were recruited from a Department of Rheumatology. Patients completed a
7-day food and drink diary and were invited to attend a focus group. Nutrient intake was calculated from food diaries using standard dietary analysis
software (COMPEAT, Lifeline UK) and the UK food composition database.
Focus groups were recorded and transcribed and analysed using thematic
analysis.
Results: Overall the group were overweight with mean Body Mass Index
(BMI = weightkg/Htm2 ) of 29.5. Seven patients were overweight (BMI 25 29.5), 6 obese (BMI >30), 3 within normal range (BMI 20-24.9), and 1 underweight (BMI<19). However, energy intakes were consistent with estimates in
the UK population (National Diet and Nutrition Survey, (NDNS) 2003). Diets
tended to lack variety and intakes of fruit and vegetables were generally low,
especially in men. Intakes of several nutrients including vitamin C, folate,
potassium, iron, calcium, zinc and non-starch polysaccharides were lower
than those reported in the NDNS population. For men, mean vitamin C intake was particularly low (26mg per day) and less than the recommended
nutrient intake of 40mg per day.
Activity limitation influenced diet in terms of reliance on others to prepare and
buy food. No specific foods were perceived to influence disease status but
weight was identified as a major concern and linked with decreased activity
and the use of prednisolone. Information about diet, received from a range
of sources, was perceived to be confusing and lacking specificity. Medical
endorsement of dietary behaviour was perceived as important.
Conclusions: Locating diet and nutritional status within a wider social context identified a number of factors influencing behaviour and attitudes to diet.
These patients demonstrated low intakes of important nutrients despite apparently adequate energy intakes. Advice may be needed to achieve an appropriate nutrient dense diet, especially if patients attempt to restrict energy
in order to lose weight.

Friday, 23 April 2004

ii138

Friday, 23 April 2004

Poster Session 3. Rheumatoid arthritis: assessment

of MTX at 6 months with HCQ added to non-responders. Primary outcome

was DAS28 at 12 months with secondary outcomes of ACR improvement
and remission rates, HAQ and RAQoL
Results: 718 patients were recruited. Mean age 55yrs, 69% RF positive,
17% erosive, female to male ratio 1.8:1, median symptom duration 6 months.
76% received SSA as per protocol, 11% MTX first-line and 13% other
DMARD. At 12 months mean DAS28 score =3.5 (sd 1.8) with 48% mild, 32%
moderate and 20% severe disease, with significant reductions from baseline.
ACR improvement at 12 months; 60% ACR20, 45% ACR50, 30% ACR70
and 13% ACR90. Significant reductions were also seen in HAQ and RAQoL
(1.375 to 0.875 and 15 to 9 respectively).
Conclusions: A region-wide early arthritis network has been established
and therapy guidelines implemented. The results are comparable to published RCTs. After 1 year of treatment almost half of all patients suffer only
mild disease assessed using the DAS28. However, 20% of patients would
satisfy NICE guidelines for biologic therapies. These data should set the
bench mark for future therapeutic studies in early RA and present the minimum expected outcome for a patient newly presenting with RA.
This research was supported by the arc

E. Suresh, N.L. Maiden, V.B. Dhillon, E.R. McRorie. Rheumatic Diseases

Unit, Western General Hospital, Edinburgh, United Kingdom; Rheumatic
Diseases Unit, Western General Hospital, Edinburgh, United Kingdom;
Rheumatic Diseases Unit, Western General Hospital, Edinburgh, United
Kingdom; Rheumatic Diseases Unit, Western General Hospital, Edinburgh,
United Kingdom
Background: The recent SIGN (Scottish Intercollegiate Guidelines Network)
guideline [1] sets out some objectives in terms of referral and management
of early RA (disease duration < 5 years). An earlier review of 82 patients with
early RA seen in our department prior to implementation of SIGN guidelines
identified various deficiencies (see Table 1). In particular, only 18% of patients satisfied SIGN criteria for referral in being seen by the specialist within
12 weeks of disease onset. The aim of our re-audit was to determine whether
publication and subsequent presentation of SIGN guideline to general practitioners in Scotland has resulted in improved care of patients with early RA.
Methods: Patients with early RA whose initial clinic appointment was between January 2001 and April 2003 were identified from the unit database.
Patients with disease duration > 5 years, those referred by other specialists or who had been seen privately before being seen at the NHS clinic,
and those with a diagnostic label of inflammatory arthritis were excluded
from the analysis. The case notes of the first 100 patients who met the inclusion criteria were reviewed and documented management compared to
SIGN recommendations.
Results: (see table 1)
Table 1. omparison of 2000 and 2003 audits
SIGN target (>90%)

Actual in 2000 Actual in 2003

Symptom onset to GP referral < 8 weeks

Patients seen within 12 weeks of symptom onset
Waiting time for clinic appointment < 6 weeks
% of patients commenced on DMARD
SSZ/MTX first choice DMARD
Patients reviewed at second appointment
Documentation of DMARD efficacy
Appropriate gastroprotection for patients
receiving NSAIDs
Appropriate bone protection for
patients receiving corticosteroids
(>7.5 mg prednisolone/day)
Referral to occupational therapist
Referral to physiotherapist

Hit/Miss

24%
18%
45%
91%
99%
82%
11%

43%
21%
36%
94%
98%
92%
5%

Miss/Miss
Miss/Miss
Miss/Miss
Hit/Hit
Hit/Hit
Miss/Hit
Miss/Miss

56%

65%

Miss/Miss

47%
32%
36%

88%
68%
61%

Miss/Miss
Miss/Miss
Miss/Miss

There were 72 females and 28 males, aged between 20 and 88 years. Although a greater proportion of patients with early RA were referred within
8 weeks of symptom onset compared with the previous audit, there was no
change in the proportion of patients meeting SIGN criteria in terms of being
seen within 12 weeks of disease onset.
Conclusions: The implementation of SIGN guideline has not resulted in
major change in practice. The lag time between symptom onset and commencement of DMARD treatment is still unacceptably long, largely due to
delay in referral for specialist opinion and also due to long hospital waiting
times.
Reference
[1] Scottish Intercollegiate guideline network. Management of early rheumatoid arthritis. Royal College of Physicians of Edinburgh, December 2000.

358. VALIDATING PATIENT BASED DISEASE ACTIVITY SCORE (PDAS)

IN RHEUMATOID ARTHRITIS (RA)
B. Khoshaba 1 , D.J. Cooper 2 , A.J. MacGregor 3 . 1 Academic Department of
Rheumatology, Guys Kings St Thomas Hospitals School of Medicine,
London, United Kingdom; 2 Information Services, Guys Kings St Thomas
Hospitals School of Medicine, London, United Kingdom; 3 Department
Rheumatology, Norfolk and Norwich University Hospital NHS Trust,
Norwich, United Kingdom
Background: Rheumatoid arthritis (RA) is a chronic inflammatory and disabling disease, causing disruption to the daily lives of patients. Management
requires regular assessment of disease activity. The traditional assessor
based disease activity assessment is expensive, time consuming and suffers from high inter-observer error. We have previously developed two methods of assessing disease activity using patient-based disease activity score
(PDAS) with or without erythrocyte sedimentation rate (ESR) in a cohort of
205 RA patients. In this study, we validated these models in another different
cohort of patients.
Methods: 289 patients with RA were recruited from outpatient clinics. Patient disease activity was measured by a symptom based disease activity
comprised of visual analogue scale range from 0 to 100mm of self-perceived
disease activity, pain, and fatigue, also early morning stiffness. Patients
recorded the joints they considered being swollen/tender on a mannequin
and completed the Health Assessment Questionnaire (HAQ), short form-36
(SF-36), Nottingham Health profile (NHP) and EuroQol. The ESR was also
recorded. The criterion validity was established by assessing correlation with
disease activity score (DAS28). Construct validity was assessed by correlation with all the other outcome measures. Analysis was carried out using
SPSS package version 10.
Results: The criterion validity is confirmed by high correlation with DAS28
(model with ESR R=0.87, model without ESR R=0.75). High correlation with
other disease activity measures but low correlation with other outcome measures such as mental and social components of SF-36 and NHP confirm
construct validity.
Construct validity: correlation between PDAS models and disease activity measures and
other outcome measures.

assessor 28TJ
assessor 28SJ
physician global
patient global
pain
mhaq
ESR
PCS (SF36)
nhp_physical
nhp_pain
Euroqol

Model 1
(ESR)

Model 2
(-ESR)

0.573
0.467
0.661
0.790
0.713
0.653
0.703
-0.632
0.559
0.608
-0.647

0.599
0.456
0.649
0.900
0.816
0.770
0.297
-0.692
0.650
0.696
-0.685

MCS (SF36)
nhp_energy
nhp_sleep
nhp_social
nhp_emotion

Model 1
(ESR)

Model 2
(-ESR)

-0.316
0.426
0.385
0.263
0.375

-0.371
0.483
0.435
0.332
0.421

Conclusions: PDAS is a valid tool in assessing disease activity in RA. It

may be possible to use PDAS instead of assessor based disease activity
to assess outcome measures in clinical decision making and randomised
control trials.

359. USING PATIENT SELF-ASSESSMENT IN RHEUMATOID ARTHRITIS

TO CONSTRUCT A PATIENT DISEASE ACTIVITY SCORE (PDAS)
B. Khoshaba 1 , D.J. Cooper 2 , A.J. MacGregor 3 , D.L. Scott 1 , E.H.S. Choy 1 .
1 Academic Department of Rheumatology, Guys, Kings College and St
Thomas Hospitals School of Medicine, London, United Kingdom;
2 Department of Information Services, Guys, Kings College and St Thomas
Hospitals School of Medicine, London, United Kingdom; 3 Norfolk and
Norwich Hospital University NHS Trust, Depatment of Rheumatology,
Norwich, United Kingdom
Background: Rheumatoid arthritis (RA) is a chronic inflammatory and disabling disease. Suppressing disease activity, as exemplified by the NICE
guidance on initiating and monitoring biologics treatment, is central to the
management of RA. The current gold standard is the 28 joint disease activity score (DAS28). Two key components of the DAS28 are the number of
tender and swollen joints as determined by an assessor. These are expensive, time consuming and have high inter-observer error. A possible alternative is patient based self-assessment. This study explored and modeled data

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357. THE IMPACT OF THE PUBLICATION OF SIGN GUIDELINES ON

MANAGEMENT OF EARLY RHEUMATOID ARTHRITIS (RA)

Rheumatoid arthritis: assessment