Rheumatoid Arthritis: Carr A

Griffith J, Carr A. · Duke of Cornwall Rheumatology Unit, Royal Cornwall Hospitals Trust, Treliske, Truro, TR1 3LJ, UK. · Best Pract Res Clin Rheumatol. · Pubmed #11358416 No free full text.

Abstract: Rheumatoid arthritis has a significant impact on patients' physical, emotional and social functioning that often occurs very early in the disease with the onset of symptoms. Patients therefore come to their consultation with the rheumatologist, having often experienced these symptoms over a period of some months, with specific expectations (for reassurance and diagnosis) and their own understanding and beliefs about the aetiology and prognosis of their symptoms. Information and advice given by rheumatologists will be rejected by patients if it cannot be accommodated within these lay beliefs. The diagnosis itself can cause a variety of reactions, including relief, disbelief, anger, fear and devastation. Following diagnosis, patients are faced with the problems of adapting to a new self-concept, managing their symptoms and trying to assimilate the large amount of information that they are given about their disease, its treatment, preferred health behaviours, prognosis and so on. There are a number of ways in which health professionals can reduce this impact in early disease. Eliciting patients' lay beliefs about the cause of their symptoms will ensure that information given in the consultation is relevant to individual patients and is presented in a way that has meaning for them. Determining patients' expectations of the rheumatologist will ensure that patients' needs for information and reassurance are met and that unrealistic or inappropriate expectations can be discussed and re-negotiated. Understanding patients' attitudes towards treatment interventions will inform shared clinical decision-making and promote adherence. Obtaining this information in the context of a time-limited consultation can be assisted by the use of validated clinical tools, presented as self-completed questionnaires. Further research is needed to determine the content, frequency, timing and methodology of educational interventions in early rheumatoid arthritis and to improve the understanding of the complex interaction between lay beliefs and disease outcome.

Hewlett S, Carr M, Ryan S, Kirwan J, Richards P, Carr A, Hughes R. · Academic Rheumatology Unit, University of Bristol. · Musculoskeletal Care. · Pubmed #17042002 No free full text.

Abstract: BACKGROUND: It has been shown previously that patients with rheumatoid arthritis (RA) can generate a wide range of outcomes that they consider important in treatment. It is not known if these outcomes are generally important in the wider RA patient community. OBJECTIVES: (1) To examine whether recent patient-generated outcomes are generalizable within a wider RA population; (2) to assess the relative importance of each outcome; and(3) to explore whether any important outcomes have been omitted. METHODS: A questionnaire, listing 23 outcomes previously generated by RA patients, was distributed through three rheumatology centres in the UK. Patients gave an importance score to each outcome (0-3), selected their top three most important outcomes, and then listed any outcomes of personal importance that were missing. RESULTS: 323 questionnaires were returned (65%). All outcomes were deemed important. Independence, pain, and mobility were most frequently selected by patients in their top three outcomes but were not chosen by 61-66% of patients. The next most commonly chosen outcomes related to feeling well and fatigue. Factor analysis revealed six reasonably distinct groupings: general well-being (11.9% explained variance), day-to-day functioning(10.6%), emotional and psychological well-being (10.6%), social role and confidence (10%), physical symptoms (9.5%) and medication issues (7.9%). CONCLUSION: Outcomes generated by patients as important in RA, are generalizable and inclusive. The most important (independence, pain and mobility) are routinely treated and measured. The next most important (feeling well, fatigue) are infrequently addressed and deserve urgent consideration for measurement, treatment and research.

Adamopoulos IE, Sabokbar A, Wordsworth BP, Carr A, Ferguson DJ, Athanasou NA. · Department of Pathology, University of Oxford, Nuffield Orthopaedic Centre, Oxford OX3 7LD, UK. · J Pathol. · Pubmed #16278818 No free full text.

Abstract: To determine whether synovial fluid (SF) macrophages isolated from the SF of osteoarthritis (OA), rheumatoid arthritis (RA) and pyrophosphate arthropathy (PPA) joints are capable of osteoclast formation, and to investigate the cellular and humoral factors required for this to occur, SF macrophages (CD14+) were isolated from the knee joint SF from patients with OA, RA and PPA and cultured for up to 14 days with macrophage-colony stimulating factor (M-CSF) and soluble receptor activator for nuclear factor-kappaB ligand (RANKL) or tumour-necrosis factor-alpha (TNFalpha) and interleukin-1alpha (IL-1alpha). Osteoclast differentiation was assessed by expression of tartrate-resistant acid phosphatase (TRAP) and vitronectin receptor (VNR), F-actin ring formation and lacunar resorption. Osteoclast formation and lacunar resorption was seen in RANKL-treated cultures of SF macrophages isolated from OA, RA and PPA joints with the largest amount of resorption noted in RA and PPA SF macrophage cultures. In TNFalpha/IL-1alpha-treated RA and PPA SF macrophage cultures, osteoclasts capable of lacunar resorption were also formed. Lacunar resorption was more extensive in RANKL than TNFalpha/IL-1alpha-treated cultures. These findings indicate that SF macrophages are capable of differentiating into mature osteoclasts capable of lacunar resorption. M-CSF in combination with RANKL or TNFalpha/IL-1alpha was required for osteoclast formation. As inflammatory synovial fluids contain an increase in the number of macrophages and an increase in the amounts of RANKL, TNFalpha and IL-1alpha, these findings suggest that one means whereby bone erosions may form in rheumatoid or crystal arthritis is by differentiation of synovial fluid macrophages into osteoclasts.

Carr A, Hewlett S, Hughes R, Mitchell H, Ryan S, Carr M, Kirwan J. · Academic Rheumatology, University of Nottingham, Nottingham, UK. · J Rheumatol. · Pubmed #12672221 No free full text.

Abstract: Our aim was to explore the patient's perspective of outcomes in rheumatoid arthritis (RA) to identify which outcomes are important to patients and how patients calibrate what constitutes a meaningful change in those outcomes. A qualitative study was performed using focus groups in 5 clinical centers in different geographical locations in the UK. Each group contained 6 to 9 patients with RA who were purposefully sampled to include men and women with a range of age, disease duration, functional disability, work disability, and current disease activity. Each focus group lasted around 1 h and addressed 3 questions: What outcomes from treatment are important to RA patients? What makes patients satisfied or dissatisfied with a treatment? How do patients decide that a treatment is working? Patients identified as important not only physical outcomes such as pain and disability, but also fatigue and a general feeling of wellness. The relative importance of these outcomes depended on the stage of disease and on specific situations, such as a disease flare. Satisfaction was influenced by communication, access to treatment, and treatment efficacy. Treatment efficacy was related to symptom reduction, with the magnitude of reduction necessary for efficacy dependent on the stage of disease. For example, large changes were deemed necessary with disease of long duration, while in early disease, even small changes could be important. Our data support existing knowledge of the importance of pain and mobility as treatment outcomes, but raise new and important issues: Some outcomes of importance to patients are not currently measured and there are no measures available to capture them. Existing measures need to be calibrated to take account of the differing importance of outcomes at different stages of disease and variations in the magnitude of change within the same outcome that indicate treatment efficacy.