Prediction of 20-year outcome at onset of seropositive rheumatoid arthritis. What factors influence functional ability in patients with rheumatoid arthritis. Do they alter over time? Long-term outcome in rheumatoid arthritis: a simple algorithm of baseline parameters can predict radiographic damage, disability, and disease course at 12-year followup. Interrelationship of outcome measures and process variables in early rheumatoid arthritis. A comparison of radiologic damage, physical disability, joint counts, and acute phase reactants. MRI of the wrist in early rheumatoid arthritis can be used to predict functional outcome at 6 years. Leukocyte protein calprotectin and outcome in rheumatoid arthritis Development of radiographic damage during the first 5-6 yr of rheumatoid arthritis. A prospective follow-up study of a Swedish cohort. EFFECTS OF HYDROXYCHLOROQUINE AND SULPHASALAZINE ON PROGRESSION OF JOINT DAMAGE IN RHEUMATOID ARTHRITIS Radiographic damage in large joints in early rheumatoid arthritis: relationship with radiographic damage in hands and feet, disease activity, and physical disability. Radiographic outcome of recent-onset rheumatoid arthritis: a 19-year study of radiographic progression. The relationship between disease activity, joint destruction, and functional capacity over the course of rheumatoid arthritis. Estimation of a numerical value for joint damage-related physical disability in rheumatoid arthritis clinical trials Prognostic factors of 10-year radiographic outcome in early rheumatoid arthritis: a prospective study Treatment of poor-prognosis early rheumatoid arthritis. A randomized study of treatment with methotrexate, cyclosporin A, and intraarticular corticosteroids compared with sulfasalazine alone. Factors predicting death, survival and functional outcome in a prospective study of early rheumatoid disease over fifteen years. Incidence of severe outcome in rheumatoid arthritis during 20 years. Only high disease activity and positive rheumatoid factor indicate poor prognosis in patients with early rheumatoid arthritis treated with “sawtooth” strategy COBRA combination therapy in patients with early rheumatoid arthritis: long-term structural benefits of a brief intervention. Predictive factors of 5-year health assessment questionnaire disability in early rheumatoid arthritis. The 5-yr HAQ-disability is related to the first year's changes in the narrowing, rather than erosion score in patients with recent-onset rheumatoid arthritis. Prognostic factors for radiographic damage and physical disability in early rheumatoid arthritis. A prospective follow-up study of 147 patients. Hip involvement in seropositive rheumatoid arthritis. Survivorship analysis with a 15-year follow-up. Monetary value of lost productivity over a five year follow up in early rheumatoid arthritis estimated on the basis of official register data on patients’ sickness absence and gross income: experience from the FIN-RACo trial A 10 year prospective followup of patients with rheumatoid arthritis 1986-96. Association between baseline radiographic damage and improvement in physical function after treatment of patients with rheumatoid arthritis. The influence of sex on rheumatoid arthritis: a prospective study of onset and outcome after 2 years. Long-term course and outcome of functional capacity in rheumatoid arthritis: the effect of disease activity and radiologic damage over time.
OBJECTIVE With the advent of new and expensive antirheumatic treatments with potentially serious side effects , it would be essential to identify as early as possible those rheumatoid arthritis ( RA ) patients who have a poor prognosis . Here study was made of the prognostic value of different markers recorded at the onset of RA . METHODS At the 20-year follow-up of our prospect i ve study , 66 patients had rheumatoid factor-positive ( RF+ ) RA . At commencement of follow-up ( disease duration < 6 months ) , the prognostic value of 19 demographic , laboratory , clinical and radiographic variables was tested to explain the 20-year Larsen score for peripheral joints and the Health Assessment  Question naire ( HAQ ) index using Somers'd for asymmetrical associations . RESULTS An association was observed between onset blood platelets ( 0.17 ) , serum IgG ( 0.18 ) , the onset Larsen score ( 0.33 ) and the 20-year Larsen score . Old age ( 0.30 ) , serum orosomucoid ( 0.17 ) , the function score ( 0.28 ) , morning stiffness ( 0.28 ) , and grip strength ( 0.24 ) were associated with the 20-year HAQ . CONCLUSION The correlation between the investigated entry variables and end-point outcome was poor . In our discussion we conclude that the most important prognostic factor in RF + RA is the treatment OBJECTIVES To describe the changes in functional ability ( FA ) taking place over 5 yr in patients with rheumatoid arthritis ( RA ) starting disease-modifying anti-rheumatic drug ( DMARD ) therapy  , to investigate the factors having most influence upon FA and to compare these factors at baseline and after 5 yr of treatment . METHODS Three hundred and sixty-six patients with active RA were studied as part of a 5-yr r and omized controlled study of DMARD therapy . FA was assessed by  Health Assessment Question naire  ( HAQ )  score every 6 months . Multiple linear regression was used to identify factors affecting FA at baseline and at 5 yr . The independent variables used were age , sex , visual analogue scale ( VAS ) pain , Ritchie articular index , C-reactive protein ( CRP ) , Larsen score and log-transformed morning stiffness ( EMS ) . RESULTS Mean HAQ score was 1.64 at baseline , improved by 21 % at 1 yr and gradually returned towards baseline levels by 5 yr . At baseline only 34 % of variance in HAQ score could be explained ; the most significant explanatory variables were the Ritchie articular index and CRP . At 5 yr the variance explained was 60 % . The Ritchie articular index remained the strongest factor followed by VAS pain , log(10 ) EMS and Larsen score . CONCLUSIONS Improvement in function did occur after commencement of the first DMARD therapy but was not maintained to 5 yr . The most consistent factor affecting function was joint tenderness . Global pain and duration of EMS were of lesser importance . Disease activity measures such as the CRP exerted an influence in the earlier , more active stages of disease : radiographic damage assumed greater importance as the arthritis progressed OBJECTIVES To predict the long-term outcome of rheumatoid arthritis ( RA ) with respect to radiographic damage , disability , and disease course using baseline variables , and to construct decision trees identifying patients on an individual level at the extremes of the outcome spectrum of these 3 dimensions . METHODS The 12-year outcome of 112 female RA patients from a prospect i ve inception cohort was assessed by measuring the tertiles of radiographic damage ( measured by the modified Sharp/van der Heijde method , SHS ) , disability ( measured by the Health Assessment Question naire , HAQ ) , and severe disease course as defined by patients with either the 33 % highest cumulative disease activity ( area under the curve of all observed disease activity scores ) or the highest tertile of radiographic damage . Patients in the lowest ( mild ) and highest tertile ( severe ) of each outcome measure were identified . All baseline parameters known to be associated with each outcome ( demographic and socioeconomic parameters ; disease duration ; disease activity measures ; laboratory measures including rheumatoid factor , HLA typing , percentage agalactosyl IgG , functional and radiographic measures ) were entered into cross-vali date d stepwise logistic regression models to find the best predictive combination of baseline parameters for each of the outcomes . Using the results of the logistic regression models , simple decision trees were constructed to categorize patients at an individual level in a particular prognostic group . RESULTS After 12 years , the lowest and highest tertiles were , respectively , 42.3 and 189 for the SHS and 0.37 and 1.25 for the HAQ . Fifty-five patients had a severe disease course . Mild and severe radiographic damage could be predicted with an accuracy of 90 % and 85 % , respectively . Mild and severe HAQ could be predicted with an accuracy of 90 % and 84 % , respectively , and severe disease course with an accuracy of 81 % . The baseline variables found to be predictive of all 3 outcome measures were very similar and consisted of combinations of the following baseline parameters : swollen joint count ( SJC ) , Ritchie score , rheumatoid factor ( RF ) , the presence of erosions , and the HAQ score . Additional knowledge of the HLA typing hardly improved the accuracy of the prediction . To predict outcome at the individual level , simple decision trees were constructed using the RF , HAQ , SJC , and presence of erosions at baseline . CONCLUSION The present study shows that prediction of outcome in long-term RA is possible and can be done using widely available baseline parameters OBJECTIVE To investigate the relationship between different outcome and process measures in early rheumatoid arthritis ( RA ) . METHODS A 3-year prospect i ve study of 149 patients with early RA ( symptoms < 1 year at entry ) . Results of serial measurements of process variables were transformed into time integrated values for comparison with the outcome measures . RESULTS A highly significant correlation was found between the acute phase response , swollen joints , and radiological progression whereas none of these measures correlated with joint tenderness . Physical disability as estimated by the Health Assessment Question naire ( HAQ ) however , appeared to be determined by joint tenderness rather than by joint swelling . CONCLUSION In early RA , joint swelling and acute phase reactants appear to be the most appropriate process variables for the prediction of radiological outcome , whereas joint tenderness is a strong determinant of physical disability ( HAQ ) OBJECTIVES To determine whether magnetic resonance ( MR ) scans of the dominant wrist of patients with early rheumatoid arthritis ( RA ) can be used to predict functional outcome at 6 years ' follow up . METHODS  Dominant wrist MR scans were obtained in 42 patients with criteria for RA at first presentation . Patients were followed up prospect ively for 6 years , and further scans obtained at 1 year ( 42 patients ) and 6 years ( 31 patients ) . Two radiologists scored scans for synovitis , tendonitis , bone oedema , and erosions . The Stanford Health Assessment Question naire ( HAQ ) score , indicating functional outcome , and st and ard measures of disease activity were assessed at 0 , 1 , 2 , and 6 years . The physical function component of the SF-36 score ( PF-SF36 ) was also used as a functional outcome measure at 6 years . RESULTS Baseline MR parameters , including bone oedema score and the total baseline MR score , were predictive of the PF-SF36 at 6 years ( R2 = 0.22 , p = 0.005 and R2 = 0.16 , p = 0.02 , respectively ) . The PF-SF36 score correlated strongly with the HAQ score at 6 years ( rs = -0.725 , p<0.0001 ) ; none of the baseline MR parameters predicted the 6 year HAQ score . The total MR score obtained at 1 year was predictive of the 6 year HAQ ( R2 = 0.04 , p = 0.01 ) . St and ard clinical and radiographic measures at baseline were not predictive of the 6 year PF-SF36 , but when combined in a model with baseline MR oedema score , prediction increased from 0.09 to 0.23 , or 23 % of the 6 year variance . CONCLUSION MR imaging of the wrist  in patients with early RA can help to predict function at 6 years and could be used to plan aggressive management at an earlier stage Objective : To determine if calprotectin is predictive for outcome in patients with rheumatoid arthritis ( RA ) . Methods : Fifty six RA in- patients with variable disease duration were prospect ively followed for five years . Clinical and laboratory data were collected to assess disease activity . Health Assessment Question naire ( HAQ ) and radiographic scores ( of h and s and wrists ) as described by Larsen were used as outcome measures .  Plasma calprotectin levels were determined with ELISA technique . Results : Significant correlations ( r ) were found cross-sectionally at follow-up between  calprotectin concentration and other known parameters of disease activity and severity : CRP ( r= 0.67 ) , investigator 's global assessment of disease activity ( r= 0.57 ) , Waaler titre ( r= 0.50 ) , HAQ score ( r= 0.48 ) and number of swollen joints ( r= 0.48 ) .  Calprotectin  at baseline was not identified as an independent predictor for HAQ or radiographic progression in the multivariate analysis . Conclusion : The results confirm calprotectin as a good measure of disease activity and joint inflammation in RA . However , the level of calprotectin at baseline was not predictive for radiographic damage or functional impairment five years later The objective of this study was to describe the development of radiographic damage in patients with RA and to search for predictors of radiographic progression over 5 yr . One hundred and thirteen patients , 75 female and 38 male , mean age 53 yr , with definite RA and mean disease duration of 11.4 months , were followed prospect ively for 5 yr at an out-patient clinic .  Radiographs of the h and s and feet were performed annually , and evaluated according to Larsen . The predictive value of demographic , clinical and laboratory variables at study start was evaluated . A stepwise logistic regression model was applied . We found that radiological joint damage occurred early and was significantly progressive during the 5 study years . The rate of progression was most prominent during the first 2 yr . At study start , 53 % of the patients had no detectable erosions , but only 11 % remained non-erosive . Twenty-six per cent of the patients with the initial presence of erosions did not progress substantially and needed no aggressive therapy . High joint damage progression during the first year , female gender and high baseline ESR could predict 57 % of the patients with high total radiographic progression . Age , disease duration , rheumatoid factor , genetic factors , active joint count and the presence of erosions at study start had no predictive value The effects of hydroxychloroquine and sulphasalazine on progression of joint damage shown by X-rays were compared in a double-blind , r and omised trial in 60 patients with rheumatoid arthritis not previously treated with slow-acting antirheumatic drugs .  X-rays of the h and s and feet at the start and after 24 and 48 weeks of treatment were available for 28 patients treated with hydroxychloroquine  and 22 treated with sulphasalazine .  Erosions and joint space narrowing were scored by a single observer unaware of treatment . At baseline there were no significant differences in demographic , clinical , or radiographic characteristics between the treatment groups . Patients withdrawn because of lack of effect were included in the analysis . The median number of erosions was lower in the sulphasalazine than the hydroxychloroquine group at 24 weeks of treatment ( 2.5 vs 10 ) and the difference was significant at 48 weeks ( 5 vs 16 ; p less than 0.02 ) . The difference in median total score of joint damage was significant at 24 weeks ( 6.5 vs 17 ; p less than 0.02 ) and at 48 weeks ( 8 vs 33 ; p less than 0.02 ) . The increase in number of erosions and total score was significantly greater in the hydroxychloroquine than the sulphasalazine group , both after 24 weeks and after 48 weeks of treatment An assessment of the onset of radiographic damage in the large joints ( hip , knees , shoulders , elbows , ankles and tarsus ) in patients with early rheumatoid arthritis , and the relationship of the progression of large joint damage with joint damage in h and s and feet , with physical disability , and with cumulative disease activity , was performed in a prospect i ve 6 yr follow-up study . Large joint damage appeared to be an early phenomenon with 20 % of the patients having some damage in at least one large joint within 1 yr , and 50 % of the patients within 6 yr after disease onset . Radiographic damage in large joints was significantly related to the damage in h and s and feet , the physical disability index , and the cumulative disease activity . The initial disease activity at study entry was the only prognostic factor that reached significance OBJECTIVE To describe the longitudinal radiographic course of rheumatoid arthritis ( RA ) , and to identify and quantitate predictors of radiographic progression . METHODS This prospect i ve , longitudinal study of radiographic progression and clinical predictors of RA involved 256 patients with RA who were seen within the first 2 years of disease ( mean 0.77 years ) and were followed up for up to 19 years . Participants underwent a total of 6,278 clinical assessment s  ( mean 24.5 ) and 934 paired radiographs ( mean 3.1 , range 2 - 6 ) . Clinical assessment s at every visit included determination of the erythrocyte sedimentation rate ( ESR ) , grip strength , pain scores , tender joint counts , and anxiety and depression measurements . Regression analyses utilized time-integrated predictors . RESULTS Overall , radiographic progression rates , as measured by the summary Sharp scores , appeared constant over the course of RA . The strongest correlate of progression was the time-integrated ESR ( rho=0.53 ) . This association grew stronger with time . At 0 - 5 years , 5 - 10 years , 10 - 15 years , and 15 - 20 years , correlations were 0.40 , 0.50 , 0.65 , and 0.74 , respectively , and for the period 10 - 20 years , the correlation was 0.67 . In multivariate models , the mean ESR , mean grip strength , rheumatoid factor positivity , and tender joint count were independent predictors of radiographic progression . CONCLUSION Radiographic damage occurs at a constant rate in RA , and is not greater early in RA or reduced later in the course of the illness . Acute-phase reactants are , by far , the strongest determinants of progression OBJECTIVE To investigate the relationship between functional capacity , disease activity , and joint destruction over the course of rheumatoid arthritis ( RA ) . METHODS The followup data on 378 patients with early RA ( duration < 1 year ) , included in an open , prospect i ve study since 1985 at the Department of Rheumatology of the University Medical Center Nijmegen , were used .  Functional capacity , disease activity , and joint destruction were assessed using the  Health Assessment Question naire disability index ( HAQ DI ) , the Disease Activity Score ( DAS ) , and a modification of the sharp radiographic damage score  , respectively . Multiple linear regression was used to model the data collected at 0 , 3 , 6 , and 9 years after study start , to investigate which variables influenced functional capacity during the disease course . A general linear mixed model for longitudinal data , which included the variables identified as significant in the multiple linear regression models and several interaction terms between the variables , was run . RESULTS On average , the functional capacity of the patients , as measured by the HAQ DI , worsened over the course of the disease after an initial improvement . After an initial reduction in the extent of disease activity , the mean DAS remained more or less stable over the course of the disease . The mean modified sharp joint damage score worsened over the course of the disease , with a slower progression rate later in the disease . In the multiple linear regression at 0 , 3 , and 6 years after study start , disease activity was found to be an important factor influencing functional capacity , and at 6 and 9 years , joint damage had an important effect on functional capacity . Furthermore , at 6 and 9 years , there was an interaction effect of joint destruction with disease activity . In the general linear mixed model , disease activity , joint damage , and an interaction effect of disease activity and joint damage were the main factors explaining functional capacity . CONCLUSION The effect of disease activity and joint destruction on functional capacity changes over the course of the disease . In early RA , functional capacity is most associated with disease activity , and in late disease , with joint damage Background Joint damage is an important outcome in trials of rheumatoid arthritis ( RA ) , usually assessed by Total Sharp Score ( TSS ) . It is currently unknown how it translates numerically into disability by the Health Assessment Question naire ( HAQ ) . Objective To determine the units of HAQ score corresponding to one TSS unit . Methods A short-term observational trial of  glucocorticoids in RA ( the ‘ BEst LIfe with Rheumatoid Arthritis ’ ( BELIRA ) trial ) was evaluated , using r and omised controlled clinical trial ( RCT ) data for confirmation . For each trial arm HAQ , TSS and the Simplified Disease Activity Index ( SDAI ) were assessed . Based on the hypothesis that short-term HAQ changes will mostly be due to changes of disease activity , activity HAQ ( ACT-HAQ ) at end point ( EP ) was determined and remaining disability defined as damage related ( DAM-HAQ ) . Using TSS at EP , the HAQ units corresponding to a TSS unit were estimated . Results In BELIRA , one TSS unit corresponded to a mean of 0.017 HAQ units ; to account for other causes of irreversible disability , the 25th percentile was used : 0.011 HAQ units/TSS unit . In RCT trial arms , the HAQ/TSS were similar ( 0.013 and 0.015 in established and early RA , respectively ; 25th percentile : 0.010 ) . The correlation between DAM-HAQEP and TSS was r=0.829 . Over 5 years , damage would amount to an increase of irreversible HAQ of 0.33 on placebo , 0.13 on disease-modifying antirheumatic drugs ( DMARDs ) and 0.03 on TNF inhibitors+methotrexate ( MTX ) . Conclusion An approach to estimate the numerical relationship between HAQ and damage as 0.01 HAQ points/TSS unit is presented , although the linear relationship may not be generally valid . This allows the assessment of functional correlates of radiographic changes in trials Introduction The objectives of this study were to determine the predictive factors of long-term radiographic outcome of rheumatoid arthritis ( RA ) and to describe the relationship between joint damage and disability over the course of the disease . Methods A cohort of 191 patients with early RA referred from primary care physicians were prospect ively followed for 10 years . To determine the predictive factors of radiographic outcome , univariate analysis of the relationship between baseline values and outcome measures was undertaken using a chi-squared or Fisher 's exact test . Stepwise multiple logistic regression was also performed to select independent prognostic factors . Results From data available for 112 patients , univariate analysis revealed a total Sharp score at 10 years that was significantly correlated with erythrocyte sedimentation rate ( ESR ) , presence and level of IgA rheumatoid factor , presence of an anti-citrullinated protein antibody ( ACPA ) , serum level of matrix metalloproteinase-3 and radiographic score at baseline . Logistic regression identified the baseline erosion score to be the most important baseline parameter as an independent prognostic factor of total radiographic score at 10 years ( odds ratio = 5.64 ; 95 % confidence interval = 1.78 to 17.86 ) . After excluding radiographic scores from the entry parameters , the presence of ACPA and ESR were also predictive of the final total Sharp score . The Health Assessment Question naire ( HAQ ) score was strongly correlated with disease activity parameters , such as disease activity score and pain , at baseline and at three , five and 10 years . No correlation was found between total radiographic Sharp score and HAQ score throughout the study . Conclusions In this prospect i ve study , baseline radiographic score , ESR and ACPA were the best predictive factors of 10-year radiographic outcome in early RA . HAQ disability was associated with disease activity throughout the 10-year follow-up but not with joint damage . This discrepancy with previous reports may be due in part to the early start of therapy with disease-modifying anti-rheumatic drugs OBJECTIVE To determine whether a regimen of methotrexate , cyclosporin A , and corticosteroids introduced at onset in poor-prognosis rheumatoid arthritis ( RA ) can produce a significant improvement in outcome compared with st and ard monotherapy with sulfasalazine ( SSZ ) . METHODS Eighty-two consecutive patients presenting with new , untreated RA of less than 12 months ' duration who fulfilled criteria for poor long-term outcome were r and omized to receive either combination therapy ( n = 40 ) or SSZ alone ( n = 42 ) . The primary outcome measures were remission and American College of Rheumatology ( ACR ) criteria for 20 % improvement at 48 weeks . RESULTS After 48 weeks , the numbers of patients who met the ACR criteria for 20 % improvement were not significantly different between the two groups ( combination 58 % versus SSZ 45 % ) , and similar numbers of patients had persisting clinical remission ( approximately 10 % both groups ) . During the first 3 months , there were significantly greater reductions in parameters of disease activity in the combination group . By 24 weeks , the swollen and tender joint counts , C-reactive protein levels , and erythrocyte sedimentation rates had fallen significantly in both groups , with a greater improvement in the swollen and tender joint count in the combination group . At 48 weeks , the radiographic damage score had increased by a median of 1 ( range 0 - 42.5 ) in the combination group and 1.25 ( range 0 - 72.5 ) in the SSZ group ( P = 0.28 ; although there were significant differences in the scores for the right h and ) . There were significantly fewer withdrawals due to lack of efficacy in the combination group than in the SSZ group ( 1 of 40 versus 10 of 42 ; P = 0.007 ) . In the combination group , dose reduction was needed in 22.5 % because of hypertension and in 22.5 % because of elevated creatinine levels . Over 48 weeks , serum creatinine increased in both groups , but particularly in the combination arm . CONCLUSION In poor-prognosis RA patients , " aggressive " combination therapy led to more rapid disease suppression but did not result in significantly better ACR response or remission rates . This suggests that in poor-prognosis disease , an approach based on identifying patients with poor treatment responses before extra therapy is added ( " step-up " approach ) may be more appropriate than the use of combination therapy in all patients from the outset Sixty-four survivors from a prospect i ve study of early rheumatoid disease were assessed again at a mean of 15.2 years from presentation and their status compared with 29 patients who had died . Eleven of the dead and only two of the survivors had been treated with steroids . There was a small increase in mortality due to the disease itself but only one death was directly caused by it . As might be expected , those who died were older . In the first year of disease , they had lower haemoglobin levels , a lower body mass , higher sedimentation rates and higher levels of blood urea . One-fifth at entry to the study and two-fifths by the time of death , had poor functional capacity . Of 64 survivors , six had poor  functional capacity  at entry and nine after 15 years . Discriminant analysis was performed to identify the most powerful combination of early features predicting a poor functional outcome . A combination including early erosive change , seropositivity , poor grip strength and cervical subluxation predicted the outcome correctly in 73 % of survivors . Almost 60 % of survivors remained with or improved to normal function at 15 years suggesting that morbidity is not as bad as has been suggested in the past OBJECTIVE Information from successive inception cohorts is needed to reveal changes in the endpoint severity of rheumatoid arthritis ( RA ) . We assessed joint destruction and disability 8 - 20 years after the onset of RA to estimate the number of patients with severe disease at the endpoint . METHODS Radiographs of the h and s and feet were taken at onset and at 1 , 3 , 8 , 15 , and 20 years from entry among 103 patients with recent onset ( < 6 mo ) seropositive RA . The  Larsen score of 0 - 100 of 20 joints of h and s and feet , the  Health Assessment Question naire ( HAQ ) index  , and the number of large joint arthroplasties  were used to assess severity . The cumulative number of patients with amyloidosis was recorded . RESULTS The median progression of small joint destruction was 2 - 3 % yearly . At the endpoint 36 % of the patients had Larsen score 50 - 100 and 23 % scored 67 - 100 . The endpoint HAQ index was 2 - 3 in 16 % of the 81 patients investigated . The number of large joint arthroplasties was 29 in 16 patients . A high Larsen score or HAQ was registered in 30 ( 29 % ) patients . The incidence of amyloidosis was 13.6 % ; at the end of the 20 year followup 9 of the 14 patients with amyloidosis had died . CONCLUSION Our prospect i ve 20 year RA study is the first epidemiological survey in which 20 year severity in RA has been determined by 4 clinical measures ; these data will serve as a basis for discussion of methods and comparison with other cohorts in the future OBJECTIVES To investigate the prognostic significance of clinical and genetic markers on the outcome of patients with recent-onset rheumatoid arthritis ( RA ) treated actively with slow acting antirheumatic drugs ( SAARDs ) .  METHODS A total of 142 consecutive patients with early RA ( median disease duration of 7 months ) were treated according to the “ sawtooth ” strategy and prospect ively followed up for an average of 6.2 years . Several clinical parameters at start as well as genetic markers were related to the functional outcome ( ARA Functional class and HAQ disability score ) and radiographic joint damage ( Larsen ’s score ) at the latest visit . RESULTS In logistic regression analysis only Mallya score ( including morning stiffness , pain scale , grip strength , Ritchie ’s articular index , haemoglobin , and erythrocyte sedimentation rate ) at baseline , and Mallya score and rheumatoid factor ( RF ) positivity at one year were found to be of significance with respect to the radiographic outcome of the patients . Furthermore , at the latest visit HAQ score was related to radiographic score . At baseline the mean ages of the DR4 positive patients and the patients with RA associated DR alleles were statistically significantly lower than those without the above mentioned risk factors ( 44 v 49 , p=0.03 and 41 v 53 , p=0.04 , respectively ) . However , these genetic markers had no prognostic significance on the functional or radiographic outcome of the patients . CONCLUSION High clinical disease activity at baseline and RF positivity especially at one year after the institution of SAARD treatment are the best predictors of poor prognosis in early RA . However , from the clinical point of view , the disease outcome of an individual patient with early RA , can not be predicted accurately enough by present means OBJECTIVE The Combinatietherapie Bij Reumatoide Artritis ( COBRA ) trial demonstrated that step-down combination therapy with prednisolone , methotrexate , and sulfasalazine ( SSZ ) was superior to SSZ monotherapy for suppressing disease activity and radiologic progression of rheumatoid arthritis ( RA ) . The current study was conducted to investigate whether the benefits of COBRA therapy were sustained over time , and to determine which baseline factors could predict outcome . METHODS All patients had participated in the 56-week COBRA trial . During followup , they were seen by their own rheumatologists and were also assessed regularly by study nurses ; no treatment protocol was specified . Disease activity , radiologic damage , and functional ability were the primary outcome domains . Two independent assessors scored radiographs in sequence according to the Sharp/van der Heijde method . Outcomes were analyzed by generalized estimating equations on the basis of intent-to-treat , starting with data obtained at the last visit of the COBRA trial ( 56 weeks after baseline ) . RESULTS At the beginning of followup , patients in the COBRA group had a significantly lower mean time-averaged 28-joint disease activity score ( DAS28 ) and a significantly lower median radiologic damage ( Sharp ) score compared with those in the SSZ monotherapy group . The functional ability score ( Health Assessment Question naire [ HAQ ] ) was similar in both groups . During the 4 - 5 year followup period , the time-averaged DAS28 decreased 0.17 points per year in the SSZ group and 0.07 in the COBRA group . The Sharp progression rate was 8.6 points per year in the SSZ group and 5.6 in the COBRA group . After adjustment for differences in treatment and disease activity during followup , the between-group difference in the rate of radiologic progression was 3.7 points per year . The HAQ score did not change significantly over time . Independent baseline predictors of radiologic progression over time ( apart from treatment allocation ) were rheumatoid factor positivity , Sharp score , and DAS28 . CONCLUSION An initial 6-month cycle of intensive combination treatment that includes high-dose corticosteroids results in sustained suppression of the rate of radiologic progression in patients with early RA , independent of subsequent antirheumatic therapy OBJECTIVE To determine prognostic factors of disability in early rheumatoid arthritis ( RA ) and to investigate the radiological and functional course of the disease . METHODS A total of 191 patients with early RA ( diagnosed for less than one year ) according to American College of Rheumatology criteria were followed prospect ively for 5 years . At baseline and at endpoint ,  Stanford Health Assessment Question naire ( HAQ ) scores and radiological scores  ( Sharp 's score modified by van der Heijde ) were performed . Correlations between numerous baseline data and HAQ score at endpoint were analyzed , using nonparametric tests . A multilinear regression model was performed to select independent prognostic factors of HAQ disability . RESULTS During the 5-year followup , mean HAQ decreased from 1.3 ( + /- 0.7 ) to 0.6 ( + /- 0.6 ) . There were 98 ( 65.3 % ) patients with a score > 1 point at baseline , but only 46 ( 27.4 % ) after 3 years and 34 ( 21.8 % ) after 5 years . Moreover , 90 % of the patients had an improvement of the disability score . Final HAQ disability was associated with baseline values of HAQ score , Pain , Ritchie index , tender joint count , Disease Activity Score , erythrocyte sedimentation rate ( ESR ) , C-reactive protein ( CRP ) , and erosion . Multivariate analysis selected baseline HAQ score , Ritchie index , ESR , CRP , and presence of erosion as independent prognostic factors of HAQ disability . The probability cutoff in the logistic model was selected to minimize the sum of false positive and false negative values : negative predictive value = 92.71 % , positive predictive value = 46.15 % , p = 0.408 . Sex , age , IgM and IgA rheumatoid factors , other tested autoantibodies , and HLA class II genes did not contribute significantly to prediction of the disability after 5 years . At baseline , mean scores were 3.6 units ( + /- 7.7 ) for total radiological score , 1.7 ( + /- 4.5 ) for erosion score , and 1.9 ( + /- 3.7 ) for joint space narrowing score . After 5 years , they were 17.9 + /- 22.3 , 6.9 + /- 9.5 , and 11.0 + /- 15.4 , respectively . No erosion was present at the start in 58.0 % of patients , compared to 24.2 % and 22.4 % at 3 and 5 years . Global radiographic progression concerned 87 patients ( 55.8 % ) during the 5 years . CONCLUSION During the first 5 years of RA , radiological damage increased progressively in half of the patients , whereas HAQ disability improved in most of them during the same period of time and could be predicted by baseline values of HAQ score , Ritchie index , ESR , CRP , and presence ( or absence ) of erosion OBJECTIVE To evaluate the predictive validity of radiological change on  5-yr disability in rheumatoid arthritis ( RA ) . METHODS The study was design ed to be multicentre , prospect i ve , longitudinal , with a 5-yr follow-up . Participants were RA patients ( ACR criteria ) , with a disease duration of < 1 yr at entry .  Radiographs of the h and s and feet in posteroanterior view at baseline and after 12 months of follow-up ( van der Heijde 's modification of Sharp method ) were used for structural evaluation . Disability was evaluated with  Health Assessment Question naire ( HAQ )  at yr 5 . Analyses consisted of ( i ) correlation existing between the changes in the radiological scores during the first year and the HAQ value at yr 5 and ( ii ) determination of the optimal cut-off in the changes in the radiological scoring system , by ROC curve analysis , in which variable to be explained was disability status at yr 5 , defined by HAQ value of at least 1 . RESULTS Due to missing data and /or lost to follow-up , 135 patients ( out of the 191 recruited patients ) were included in the analyses ( mean change in the radiological score = 4.9 + /- 8.7 points , mean HAQ at yr 5 = 0.62 + /- 0.68 ) . There was a statistically significant correlation between the HAQ-disability status at yr 5 and the changes observed in the radiological total damage and narrowing scores during the first year ( r = 0.18 , P = 0.046 and r = 0.25 , P = 0.006 , respectively ) . Conversely , the short-term changes in the erosion score were not correlated with subsequent HAQ-disability ( r = 0.084 , P = 0.36 ) . A change of at least 2 points in the total X-ray score was considered as optimal ( sensitivity , specificity , positive and negative predictive values of 66.7 , 53.9 , 32.8 and 82.8 % , respectively ) . CONCLUSION This work shows that early changes in joint damage in patients with recent-onset RA are related to subsequent HAQ-disability . This relationship is due to changes in narrowing , rather than in erosion score , suggesting that the joint narrowing score might be of great importance in the follow-up of RA patients and in the reports of scientific results . The weak performance of the thresholds established using predictive validity for subsequent HAQ-disability compromise their use at the individual level We studied the influence of demographic , clinical , laboratory and genetic features and radiographic damage at onset on the outcome after 2 years in a prospect i ve study of 147 patients with classical or definite RA with disease duration shorter than 1 year at entry . Outcome was determined by physical disability and by radiographic damage of h and s and feet . By means of multiple regression analysis and discriminant analysis outcome was explained from variables at the start and during the first 6 months . No clinical ly relevant conclusions could be made for physical disability due to the low explained variance and small number of patients with bad physical disability . Radiographic damage after 2 years was predicted by high disease activity at the start ( measured as erythrocyte sedimentation rate , C-reactive protein or Disease Activity Score ) combined with DR4 or DR2 ( as a prognostically favourable factor ) and rheumatoid factor positivity . Radiographic damage could be better predicted if disease activity during the first 6 months was included . Absence or presence of progression of radiographic damage could be correctly predicted in 83 % of the patients In a prospect i ve survey of recent arthritis 96 patients had erosive and seropositive rheumatoid arthritis ( RA ) .  Severe radiological changes in the hipjoint ( Larsen grade 3 - 5 ) were observed in 31 ( 32 % ) and acetabular protrusion in five ( 5 % ) patients 15 years after the onset of arthritis . At the end of follow-up  Larsen score 0 - 100 of peripheral joints ( p < 0.015 ) , HAQ ( p < 0.001 ) , ESR ( p < 0.001 ) , and CRP ( p < 0.01 ) were significantly higher in patients with hip joint destruction than in those without . Secondary amyloidosis was found in eight patients with and in three patients without hip involvement ( p = 0.002 ) . In survivorship analysis ( the Larsen 0 - 2 grade hips ) an overall predicted rate of survival was 80 % after 14 years of rheumatoid arthritis . When analyzed according to HLA-B27 the rate of radiological survival for the patients with a positive test was 62 % and 87 % for the others ( p = 0.02 ) . In conclusion , RA patients with high number of destructive peripheral joints ( Larsen score ) and high ESR or CRP should be carefully monitored due to the increased risk of hip destruction Objective : To explore the monetary value of rheumatoid arthritis related loss of productivity in patients with early active disease . Methods : In a prospect i ve cohort sub study of the FIN-RACo Trial , 162 patients with recent onset rheumatoid arthritis , aged 18 to 65 years and available to the workforce , were followed up for five years . Loss of work productivity in euros 2002 was estimated by data on absence for sickness and on income ( human capital approach ) from official data bases . Treatment responses were evaluated by area under the curve ( AUC ) of the ACR-N measure and by increase in number of erosions in radiographs of h and s and feet . The  health assessment question naire  ( HAQ ) at six months was linked to the International Classification of Functioning , Disability and Health ( ICF ) . Results : In all , 120 ( 75 % ) patients , women more often ( 82 % ) than men ( 61 % ) ( p = 0.002 ) , lost work days . The mean lost productivity per patient-year was € 7217 ( 95 % confidence interval ( CI ) , 5561 to 9148 ) : for women , € 6477 ( 4858 to 8536 ) and for men , € 8443 ( 5389 to 12 898 ) . There was an inverse correlation with improvement : € 1101 ( 323 to 2156 ) and € 14 952 ( 10 662 to 19 852 ) for the highest and lowest quartiles of AUC of ARC-N , respectively . Lost productivity was associated with increase in the number of erosions and with disability in “ changing and maintaining body position ” subcategory of the ICF . Conclusions : Despite remission targeted treatment with disease modifying antirheumatic drugs , early rheumatoid arthritis results in substantial loss of productivity . A good improvement in the disease reduces the loss markedly OBJECTIVE To determine the 10 year outcome of hospital patients with established rheumatoid arthritis ( RA ) treated with disease modifying drugs ( DMARD ) .  METHODS All patients with RA of at least a year duration and attending a single clinician were followed prospect ively for 10 years . DMARD treatments changed with time but were continued throughout . Measurements of joint tenderness ( Ritchie Index ) , morning stiffness , grip , and disability ( Health Assessment Question naire , HAQ ) and radiographs of h and s and feet were documented . A record of joint surgery was maintained . Patients who stopped attending the clinic were traced and an accurate record of deaths was obtained from the National Registry of Deaths . Paired clinical indices were compared where available between 0 , 5 , and 10 years . RESULTS At entry there were 289 patients of variable disease duration . Within 10 years , 71 had died ( st and ardized mortality ratio 1.3 ) and 92 were alive but unavailable . Median joint tenderness , morning stiffness , grip strength , and hemoglobin were not significantly different at 0 , 5 , and 10 years . Erythrocyte sedimentation rate ( ESR ) declined but not significantly . By contrast , HAQ scores and radiographs worsened between 0 and 10 years ( p = 0.0004 , p = 0.0001 , respectively ) . There was a trend toward lower ESR values and less disability and the lower radiographic scores in those with 10 - 15 years ' disease duration in 1996 compared with those of similar duration in 1986 . However , worsening of radiographs occurred in patients with short , medium , and long histories of RA . Correlations between disability , radiographic scores , and joint tenderness were apparent at the start and conclusion of the study . At 10 years , 54 ( 19 % ) of the original cohort had undergone at least one large joint replacement . Significantly more women required joint replacement surgery ( chi-square 5.44 , p = 0.02 ) . CONCLUSION Over a 10 year period patients with RA exhibited an excess of deaths and a deterioration of radiographs and function despite regular DMARD treatment and apparent clinical containment . Worsening of radiographs occurred in both relatively early and late disease . There was a steady requirement for surgical large joint replacement with time . This study suggests that in the long term . the effect of DMARD treatments may be less than the expectations derived from short term studies OBJECTIVES To identify factors associated with poor physical function in rheumatoid arthritis and to assess whether baseline joint damage has an impact on improvement in physical function during infliximab treatment . METHODS 428 patients with active rheumatoid arthritis despite methotrexate treatment received methotrexate alone or with infliximab ( 3 mg/kg or 10 mg/kg every four or eight weeks ) for 54 weeks ( the ATTRACT trial ) . Data on clinical outcomes and physical function ( assessed by the health assessment question naire ( HAQ ) ) were collected . Structural damage was assessed using the van der Heijde modification of the Sharp score . Odds ratios ( OR ) for factors associated with severe functional disability ( HAQ > or = 2.0 ) at baseline were estimated using multiple logistic regression analyses , and baseline factors related to the change in physical function after treatment at week 54 were determined . RESULTS Baseline radiographic scores were correlated with baseline HAQ scores . After adjustment for demographic characteristics in the logistic regression model , baseline disease activity scores , radiological joint damage , fatigue , and morning stiffness were found to be associated with severe functional disability ( HAQ > 2.0 ) , with OR values of 2.00 ( 1.53 to 2.63 ) , 1.82 ( 1.15 to 2.87 ) , 1.19 ( 1.05 to 1.34 ) , and 1.07 ( 1.01 to 1.13 ) , respectively . In multiple linear regression analysis , physical disability , joint damage , and fatigue at baseline were correlated with less improvement in physical function after treatment . Infliximab treatment was associated with greater improvement in physical function . CONCLUSIONS Greater joint damage at baseline was associated with poorer physical function at baseline and less improvement in physical function after treatment , underlining the importance of early intervention to slow the progression of joint destruction OBJECTIVE This prospect i ve study analyzed influence of patient 's sex on early rheumatoid arthritis ( RA ) within one year of disease onset and after 2 years ' followup . METHODS A total of 844 consecutive patients , 538 women , with RA of less than 12 months were studied . St and ardized clinical and radiographic assessment s were performed at study entry and after 2 years . The association of several variables at study entry with the outcome variables Disease Activity Score ( DAS28 ) , functional disability measured by the Health Assessment Question naire ( HAQ )  , and , in 390 patients ,  Larsen score  at the  2-year followup  were analyzed in men and women separately . RESULTS At study entry the women were younger compared with the men and the sexes showed different age distributions . The women had higher DAS28 and HAQ scores . However , women below 50 years of age at study entry had milder disease than older women and close to that of men . At 2-year followup the women still had higher DAS28 and HAQ scores compared to men , who had achieved remission in a higher frequency . Larsen score showed no sex difference either at study entry or after 2 years . Presence of rheumatoid factor ( RF ) was associated with lower age at study entry and higher DAS28 at followup in men only . Higher DAS28 and HAQ scores at entry were more strongly correlated with severe disease at followup in women than in men . Presence of the " shared epitope " was not associated with age or the outcome variables DAS28 and Larsen score in either sex . CONCLUSION The disease phenotype in early RA was significantly different between men and women , particularly concerning age , disease activity , and functional capacity . There were differences between the sexes concerning early disease characteristics associated with outcome at 2 years of followup OBJECTIVE To investigate the evolution of functional capacity , disease activity , and joint destruction over time in a 12-year prospect i ve cohort of rheumatoid arthritis ( RA ) patients , and to study the relative contribution of disease activity and joint destruction to the loss of functional capacity . METHODS One hundred thirty-two female patients with recent-onset RA were assessed at 0 , 3 , 6 , and 12 years of followup for functional capacity ( Health Assessment Question naire [ HAQ ] score ) , disease activity ( Disease Activity Score [ DAS ] ) , and joint destruction ( Sharp score of radiologic damage ) . RESULTS The Sharp score deteriorated steadily over time , while the HAQ score and DAS showed a variable course . The DAS correlated strongly with the HAQ score throughout the disease course . The correlation between the Sharp score and the HAQ score was weak at study start , but became strong after 12 years . After 12 years of followup , disease activity was the main determinant of the  HAQ score when entered in a multivariate analysis . CONCLUSION Functional capacity is strongly influenced by disease activity throughout the course of RA . Even in longst and ing RA , disease activity proves to be the main determinant of the HAQ score for functional capacity
OBJECTIVE To summarise the relationship between joint damage and functional disability in rheumatoid arthritis ( RA ) patients .