Rheumatoid Arthritis: Hassell A

Choy EH, Smith CM, Farewell V, Walker D, Hassell A, Chau L, Scott DL, Anonymous00454. · Sir Alfred Baring Garrod Clinical Trials Unit, Academic Department of Rheumatology, King's College School of Medicine, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK. · Ann Rheum Dis. · Pubmed #17768173 No free full text.

Abstract: OBJECTIVE: Treating early active rheumatoid arthritis (RA) with disease modifying antirheumatic drug (DMARD) monotherapy achieves incomplete outcomes and intensive treatment seems preferable. As the relative benefits of combining two DMARDs, one DMARD with glucocorticoids and two DMARDs with glucocorticoids are uncertain we defined them in a factorial trial. METHODS: A 2-year randomised double-blind factorial trial in patients with RA within 2 years of diagnosis treated with methotrexate studied the benefits of added ciclosporin, 9 months intensive prednisolone or both (triple therapy). The primary outcome was the number of patients with new erosions. Secondary outcomes included Larsen's x-ray scores, disability, quality of life and adverse events. Findings: 1391 patients were screened and 467 randomised. Over 2 years 132 (28%) changed therapy and 88 (19%) were lost to follow-up. The number of patients with new erosions was reduced by nearly half by adding ciclosporin or prednisolone (p = 0.01 and 0.03); both treatments reduced increases in Larsen's x-ray scores by over 2 units (p = 0.008 and 0.003). A further reduction in erosive damage was seen with combined use of both treatments. Their effects on erosive damage appeared independent. Triple therapy reduced disability and improved quality of life compared with methotrexate; ciclosporin and prednisolone acted synergistically. More patients withdrew because of adverse events with triple therapy, without an increase in serious adverse effects. CONCLUSIONS: This study confirms the existence of a "window of opportunity" in early RA, when intensive combination therapy produces sustained benefits on damage and disability. Although methotrexate-prednisolone combinations reduce erosive damage, the synergistic effect of two DMARDs is needed to improve quality of life.

Harrison MJ, Hassell A, Dawes PT, Scott DL, Knight SM, Davis MJ, Mulherin D, Symmons DP. · arc Epidemiology Unit, The University of Manchester, Department of Rheumatology, University Hospital of North Staffordshire NHS Trust, Oxford Road Manchester, M13 9PT, UK. · Rheumatology (Oxford). · Pubmed #17264089 links to  free full text

Abstract: OBJECTIVES: The overall status in rheumatoid arthritis (OSRA) instrument is a simple summary of health status, including disease activity (OSRA-A) and damage (OSRA-D) scores. Despite evidence of the validity of the OSRA, uptake has been low. This study aimed to assess the responsiveness and re-examine the validity of the OSRA using the measures from the British Rheumatoid Outcome Study Group (BROSG) randomized controlled trial of aggressive vs symptomatic treatment of rheumatoid arthritis (RA) patients. METHODS: 466 patients were recruited. Outcome measures included the OSRA, the OMERACT core set and the DAS28, and were collected at baseline and annually for the 3 yrs of the trial. X-rays of the hands and feet were taken at baseline and 3 yrs. Patients were assigned a Townsend score (a measure of social deprivation) according to area of residence. Construct validity was assessed by correlating the OSRA with a range of outcome measures, and testing for the known inequality in RA outcome between patients classified by social deprivation. Responsiveness to change was assessed against self-reported change over the first year of the trial. RESULTS: The OSRA-A and OSRA-D measures demonstrated construct validity, performing as hypothesized. The OSRA-A was the most responsive measure in the BROSG trial in detecting patient reported improvement and deterioration. The OSRA-D demonstrated similar responsiveness to alternative measures. CONCLUSIONS: Our results demonstrate the validity and responsiveness of the OSRA, and its potential for inclusion in clinical trials. More important, as the OSRA is quick and easily calculated, uses routinely collected information, and provides useful quantitative information about a patient's status and progress it is suitable for use in the routine clinic.

Hooper H, Ryan S, Hassell A. · Primary Care Sciences Research Centre, Keele University, Stoke-on-Trent, UK. · Musculoskeletal Care. · Pubmed #17041983 No free full text.

Abstract: OBJECTIVE: This study aimed to explore the effects of participants' perceptions of support, ways of coping and feelings of control, on their accounts of well-being. METHODS: Semi-structured interviews were conducted with 10 patients with rheumatoid arthritis (RA) and explored the dynamics of participants' accounts of coping with their everyday lives. RESULTS: Four categories of coping mechanisms were evident in all participants' accounts: support during the medical consultation, nurse support, social support, and comparative strategies. This paper focuses on just one of the themes that emerged from our analysis. Further insight into coping mechanisms was provided by the prevalence of comparative coping strategies. A comparison with previous disease states was used by every participant. This comparison enhanced their sense of control and fostered a sense of well-being. Social comparison was used by seven participants to show themselves how fortunate they were in relation to others with RA. CONCLUSION: Comparative coping has been identified as an important strategy adopted by these participants that could be explored in further intervention-based studies of coping.

Harrison MJ, Tricker KJ, Davies L, Hassell A, Dawes P, Scott DL, Knight S, Davis M, Mulherin D, Symmons DP. · ARC Epidemiology Unit, The University of Manchester, Manchester, UK. · J Rheumatol. · Pubmed #16331758 No free full text.

Abstract: OBJECTIVE: Patients with rheumatoid arthritis (RA) with lower socioeconomic status (SES) are known to have more severe disease, more comorbidity, and higher mortality. It is not known whether SES influences response to treatment in RA. We examined the relationship between area of residence (as a surrogate for SES) and baseline outcome measures and response to treatment, using data from the British Rheumatoid Outcome Study Group randomized controlled trial of aggressive versus symptomatic treatment of long-standing, stable RA. METHODS: A total of 466 patients from 5 centers were recruited to the trial. Baseline data included age, sex, smoking status, and comorbidity. Patients were assigned a Townsend score (a measure of social deprivation) according to their area of residence. Outcome measures including the Disease Activity Score (DAS28), Health Assessment Questionnaire, Medical Outcomes Study Short Form-36, and EuroQol (EQ5D) were recorded at the beginning and end of the 3 year trial. The baseline, 3 year values, and change data were examined by Townsend quintile adjusting for each treatment arm. RESULTS: Significant relationships between increasing social deprivation by area of residence and higher disease activity, higher pain, poorer physical function, poorer emotional aspects of mental health, and lower quality of life were found at baseline (adjusted for age, sex, disease duration, current smoking, treatment center, and treatment group). During the 3 year trial period, patients from the most deprived areas showed greater improvement, with statistically significant greater improvement on DAS28 (p = 0.041) and 28 tender joint count (p = 0.015). CONCLUSION: Area of residence is related to the severity of RA at recruitment and is a predictor of response in a clinical trial situation. The results suggest that measures of SES should be recorded for patients enrolled in clinical trials, longitudinal observational studies, and in the clinical setting.

Symmons D, Tricker K, Harrison M, Roberts C, Davis M, Dawes P, Hassell A, Knight S, Mulherin D, Scott DL, Anonymous00305. · Arc Epidemiology Unit, University of Manchester, Manchester M13 9PT, UK. · Rheumatology (Oxford). · Pubmed #16263778 links to  free full text

Abstract: OBJECTIVE: Patients with rheumatoid arthritis (RA) should start treatment early with the aim of suppressing the inflammatory process completely. It is not known if this strategy should, or can, be continued in later disease. METHODS: In a multicentre, randomized, observer-blinded, controlled trial, 466 patients with established RA (>5 yr), on stable therapy for at least 6 months, were randomized to adequate symptom control/shared care setting (SCSC) or aggressive treatment/hospital setting (ATH). All were reviewed annually by a rheumatologist. The primary outcome after 3 yr was the Health Assessment Questionnaire (HAQ). Others included the OMERACT core set and the Disease Activity Score (DAS) 28. RESULTS: Three hundred and ninety-nine patients completed the trial. There was a significant deterioration in HAQ in both arms. Only the physician global score differed between the arms. CONCLUSIONS: The trial showed no additional benefit of intensified treatment with traditional disease modifying anti-rheumatic drugs (DMARDs) in patients with stable, established RA. It proved hard to suppress C-reactive protein levels. Patients in the SCSC arm were able to initiate treatment changes when their symptoms deteriorated without frequent hospital assessment. Pending further evidence, the model of shared care with annual hospital review is as good as 4-monthly hospital review for these patients.

Ryan S, Hassell A, Dawes P, Kendall S. · Haywood Hospital, Stoke on Trent. · Nurs Times. · Pubmed #12715557 No free full text.

Abstract: Forty patients with rheumatoid arthritis were randomly recruited from an outpatient population for an in-depth, qualitative interview. The aim was to identify factors that influence whether patients feel they have any control over their condition. The data were analysed using Colaizzi's procedural steps. Four major categories that positively influence perceptions of control were identified. These were the reduction of physical symptoms, the matching of social support with perceived need, the provision of information, and the nature of the clinical consultation.

Ryan S, Hassell A, Dawes P, Kendall S. · Staffordshire Rheumatology Centre, The Haywood Hospital, High Lane, Burslem, Stoke-on-Trent ST6 7AG, UK. · Rheumatology (Oxford). · Pubmed #12509626 links to  free full text

Abstract: OBJECTIVE: To identify factors that patients perceive as influencing control in living with the symptoms of rheumatoid arthritis (RA). METHOD: A sample of 40 patients with RA were recruited randomly from an out-patient population. The participants of the sample were interviewed in depth by one researcher to identify perceptions of control. They also completed two self-administered questionnaires, the Health Assessment Questionnaire and the Rheumatology Attitude Index. RESULTS: Four major categories were identified that positively influenced perceptions of control in patients living with the consequences of RA. These included: (i) the reduction of physical symptoms; (ii) social support matching perceived need; (iii) the provision of information; and (iv) the medical consultation. Components of the consultation included patient involvement, provision of information, feedback and reassurance, empathy and access to an expert. CONCLUSION: The categories identified can be influenced by health-care professionals in the management of the patient, and if the medical consultation is utilized to its full potential it can play a major role in enabling patients with RA to manage the daily symptoms of their condition.