Rheumatoid Arthritis: Wolfe F

Aletaha D, Landewe R, Karonitsch T, Bathon J, Boers M, Bombardier C, Bombardieri S, Choi H, Combe B, Dougados M, Emery P, Gomez-Reino J, Keystone E, Koch G, Kvien TK, Martin-Mola E, Matucci-Cerinic M, Michaud K, O'Dell J, Paulus H, Pincus T, Richards P, Simon L, Siegel J, Smolen JS, Sokka T, Strand V, Tugwell P, van der Heijde D, van Riel P, Vlad S, van Vollenhoven R, Ward M, Weinblatt M, Wells G, White B, Wolfe F, Zhang B, Zink A, Felson D, Anonymous00358, Anonymous00359. · Medical University of Vienna, Vienna, Austria. · Arthritis Rheum. · Pubmed #18821648 No free full text.

Abstract: OBJECTIVE: To make recommendations on how to report disease activity in clinical trials of rheumatoid arthritis (RA) endorsed by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR). METHODS: The project followed the EULAR standardized operating procedures, which use a three-step approach: 1) expert-based definition of relevant research questions (November 2006); 2) systematic literature search (November 2006 to May 2007); and 3) expert consensus on recommendations based on the literature search results (May 2007). In addition, since this is the first joint EULAR/ACR publication on recommendations, an extra step included a meeting with an ACR panel to approve the recommendations elaborated by the expert group (August 2007). RESULTS: Eleven relevant questions were identified for the literature search. Based on the evidence from the literature, the expert panel recommended that each trial should report the following items: 1) disease activity response and disease activity states; 2) appropriate descriptive statistics of the baseline, the endpoints and change of the single variables included in the core set; 3) baseline disease activity levels (in general); 4) the percentage of patients achieving a low disease activity state and remission; 5) time to onset of the primary outcome; 6) sustainability of the primary outcome; 7) fatigue. CONCLUSION: These recommendations endorsed by EULAR and ACR will help harmonize the presentations of results from clinical trials. Adherence to these recommendations will provide the readership of clinical trials with more details of important outcomes, while the higher level of homogeneity may facilitate the comparison of outcomes across different trials and pooling of trial results, such as in meta-analyses.

Caplan L, Russell AS, Wolfe F. · No affiliation provided · J Rheumatol. · Pubmed #16206335 links to  free full text

This publication has no abstract.

Wolfe F, Caplan L, Michaud K. · No affiliation provided · J Rheumatol. · Pubmed #15570626 links to  free full text

This publication has no abstract.

Pincus T, Sokka T, Wolfe F. · No affiliation provided · Arthritis Rheum. · Pubmed #11407680 links to  free full text

This publication has no abstract.

Pincus T, Wolfe F. · No affiliation provided · J Rheumatol. · Pubmed #11128653 No free full text.

This publication has no abstract.

Wolfe F. · No affiliation provided · Scand J Rheumatol. · Pubmed #10380833 No free full text.

Abstract: Psychological factors influence the results of self-reports of pain, function and global severity in questionnaires such as the HAQ, SF-36 and the WOMAC. Persons with psychological distress use more resources, including medications, and have greater rates of work disability and joint surgery. Psychological status is influenced only very slightly by disease severity and tends to remain relatively constant over the course of the rheumatic disease. The psychological status of patients with differing rheumatic diseases is similar, and patients with rheumatoid arthritis do not have special psychological problems or psychological characteristics.

Michaud K, Wolfe F. · University of Nebraska Medical Center, Omaha, Nebraska 68198-6270, USA. · Best Pract Res Clin Rheumatol. · Pubmed #17870034 No free full text.

Abstract: Rheumatoid arthritis (RA) is often characterized by the burden of swollen joints, pain, and decreased physical function, but less understood are the many manifestations of additional health conditions that are associated with RA and its treatments. First brought to light with observations of increased mortality in RA, studies noted the increased rates of cardiovascular and infection events. The chronic, debilitating, autoimmune nature of RA affects the patient directly or indirectly in almost all organ systems, from cardiovascular problems and infections to depression and gastrointestinal ulcers. On average, the established RA patient has two or more comorbid conditions. It should be the responsibility of the rheumatologist to take these and the risk of additional conditions into account when treating the patient. This chapter reviews important comorbidities in patients with RA, their prevalence, and their relation to RA.

Wolfe F. · National Data Bank for Rheumatic Diseases, Arthritis Research Center Foundation and the University of Kansas School of Medicine, Wichita, Kansas 67214, USA. · J Rheumatol Suppl. · Pubmed #15053452 No free full text.

Abstract: There have been 4 major longitudinal data banking efforts within the United States: ARAMIS, the Western Consortium, and the individual data banks of Drs. Ted Pincus and Fred Wolfe. ARAMIS began in the 1970s, and helped to develop the language and methodology of rheumatology data banks using biannual surveys. The National Data Bank for Rheumatic Diseases used the ARAMIS model beginning in the late 1990s to form a very large contemporary rheumatology data bank. Hybrid models using both survey data and clinical data were put into practice by Pincus and Wolfe, and by Paulus at the Western Consortium.

Pincus T, Ferraccioli G, Sokka T, Larsen A, Rau R, Kushner I, Wolfe F. · Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University School of Medicine, 203 Oxford House, Nashville, TN 37232-4500, USA. · Rheumatology (Oxford). · Pubmed #12468813 links to  free full text

Abstract: Earlier reports, including a comprehensive 1983 review, had indicated that slowing of radiographic progression was relatively unusual in treatment of rheumatoid arthritis (RA) using traditional disease modifying anti-rheumatic drugs. However, in recent years, slowing of radiographic progression has been documented in a number of clinical trials, as well as long-term observational studies, with use of (in alphabetical order) adalimumab, anakinra, corticosteroids, cyclophosphamide, cyclosporin, etanercept, gold salts, infliximab, leflunomide, methotrexate and sulphasalazine. At this time, disease modification is a realistic goal in the clinical care of patients with RA. Documentation of improved long-term outcomes requires long-term observational data over 5-20 yr to supplement data from randomized controlled clinical trials over 6-24 months.

Wolfe F. · National Data Bank for Rheumatic Diseases-Arthritis Research Center Foundation and University of Kansas School of Medicine, Wichita, Kansas, USA. · Arthritis Res. · Pubmed #12110152 No free full text.

Abstract: Although functional outcome is frequently discussed and written about, it is often not clear what functional outcome is and how it can be measured. This paper introduces the concept of latent and observed measures of functional disability, and distinguishes between disability as a process measure and disability as an outcome measure. Using the Health Assessment Questionnaire as the main functional outcome measure in rheumatoid arthritis, we propose and discuss several methods for determining disability, and describe the implications of altering the disability course.

Wolfe F, Choi HK. · National Data Bank for Rheumatic Diseases, Arthritis Research Centre Foundation, University of Kansas School of Medicine, Wichita, Kansas 67214, USA. · Ann Rheum Dis. · Pubmed #11602461 links to  free full text

This publication has no abstract.

Wolfe F, Rehman Q, Lane NE, Kremer J. · National Data Bank for Rheumatic Diseases--Arthritis Research Center Foundation, Inc., Wichita, Kansas 67214, USA. · J Rheumatol. · Pubmed #11469485 No free full text.

Abstract: Our aim was to investigate the practices and standards by which disease modifying antirheumatic drugs (DMARD) and biologics are and have been prescribed. We reviewed the literature and examined data from patients with rheumatoid arthritis (RA) participating in a national cohort: the National Data Bank for Rheumatic Diseases (NDB). Four pathways for DMARD prescription were identified: (1) A time-based pyramidal approach (the RA pyramid); (2) a severity-based pyramid in which the most effective treatment is given to those with more active disease; (3) a cost-based pathway in which the primary goal is cost containment--this pathway intertwines with the severity-based pathway; and (4) a patient preference pathway where treatment is geared to patient needs and wishes regardless of severity. Data show that the time-based and severity-based pathways are not generally used in contemporary expert practice, and that patients with all degrees of severity and disease duration are receiving DMARD and biologic treatment. With the abandonment of the pyramid and the development of effective therapy, rheumatic disease care has swung away from the imperative of time and severity-based treatment to the imperative of care based on patient preference. It is the standard of practice to treat patients with mild and early disease with aggressive therapy, with the goal of limiting subsequent damage and retarding progression, and with the realistic purpose of relieving symptoms. The standard may at times be in conflict with the goals of insurers, but there is no legitimate medical reason for such limitations.

Wolfe F, O'Dell JR, Kavanaugh A, Wilske K, Pincus T. · National Data Bank for Rheumatic Diseases, Arthritis Research Center Foundation, Inc. and University of Kansas School of Medicine, Wichita, Kansas, USA. · J Rheumatol. · Pubmed #11409143 No free full text.

Abstract: There is general agreement regarding the most appropriate examinations and methods to use to evaluate change in status in randomized controlled trials (RCT). However, no guidelines exist to aid in determining and evaluating actual status rather than change in status, particularly when applied to individual patients with rheumatoid arthritis (RA). In addition, methods appropriate for clinical trials may not be useful in evaluating individual patients because of time constraints. This report reviews current methods of evaluation and develops modified methods, based on data bank research that will be useful in clinical practice and in the evaluation of RCT and observational studies. Using data from longitudinal observational data banks, further reduction in the number of joints examined is evaluated to reconcile the time constraints of clinical practice with the need to maintain reliability and validity. Percentile methods to determine severity status are applied to the variables used in RCT and extended further to observational studies and routine clinical practice. Shortened joint counts, based on modifications of the Ritchie method, are identified that allow for examination of groups of 18 (clinical-18) and 16 (clinical-16) joints, the clinical-16 omitting the metatarsophalangeal joints. Using percentile charts, actual severity valuations are given to the variables evaluated in the clinic as well as in RCT. Disease activity status of clinic patients can be determined quantitatively thus allowing clinicians further insight into the status and prognosis of their patients. By quantifying disease activity severity, clinicians and 3rd party payers can better evaluate the appropriateness of and response to disease modifying antirheumatic drugs and biologic therapies. Further, RCT can be evaluated as to severity status of patients participating, and the generalizability of RCT can be better evaluated.

Wolfe F, Cush JJ, O'Dell JR, Kavanaugh A, Kremer JM, Lane NE, Moreland LW, Paulus HE, Pincus T, Russell AS, Wilskie KR. · National Data Bank for Rheumatic Diseases-Arthritis Research Center Foundation, Inc. and University of Kansas School of Medicine, Wichita, Kansas, USA. · J Rheumatol. · Pubmed #11409141 No free full text.

This publication has no abstract.

Wolfe F, Strand V. · Arthritis Research Center Foundation, 1035 N. Emporia, Suite 230, Wichita, KS 67214, USA. · Curr Rheumatol Rep. · Pubmed #11177770 No free full text.

Abstract: Recent clinical development programs for new therapeutic agents in rheumatoid arthritis have included assessment of radiographic progression comparing changes with treatment to placebo and active controls. Studies now use reliable methods of assessment and sufficient study length to detect radiographic changes. Although patient populations and characteristics differ, and radiographic scoring methods vary, the direction of a series of studies appears to indicate that leflunomide (LEF), methotrexate (MTX), sulfasalazine (SSZ), etanercept, infliximab, and IL-1ra are all effective in retarding radiographic progression, as measured by erosions and joint space narrowing. Interpretation of radiograph data in future trials will be aided by utilization of common reading methods and by continuing comparison across differing rheumatoid arthritis protocol populations.

Hawley DJ, Wolfe F, Pincus T. · National Data Bank for Rheumatic Diseases, Wichita, Kansas 67214, USA. · Clin Exp Rheumatol. · Pubmed #10589363 No free full text.

Abstract: AIMS: To describe the utilization of combination therapy in the treatment of rheumatoid arthritis (RA). METHODS: Review of published articles and abstracts, and patient/physician questionnaire data. RESULTS: Combination therapy was rarely used in the early 1980s and is now (1999) used for about 25% of RA patients in the US. Physician and patient surveys indicate that methotrexate plus hydroxychloroquine is the most commonly used combination in North America, and physician surveys indicate that methotrexate plus sulfasalazine is the most commonly used combination in Europe. Patient questionnaire data indicate that 13.4% of patients in the US take methotrexate and hydroxychloroquine, and between 11% and 15% of patients with recent onset of RA receive treatment with disease-modifying antirheumatic drug (DMARD) combinations. CONCLUSIONS: Combination therapy with agents such as hydroxychloroquine and methotrexate is used in up to 25% of RA patients in the US, but the use of "aggressive combination therapy" is unusual. Whether combination therapy as currently practiced is beneficial remains to be determined.

Vera-Llonch M, Massarotti E, Wolfe F, Shadick N, Westhovens R, Sofrygin O, Maclean R, Yuan Y, Oster G. · Policy Analysis Inc., Brookline, MA 02445, USA. · Rheumatology (Oxford). · Pubmed #18356179 links to  free full text

Abstract: OBJECTIVE: To assess cost-effectiveness of abatacept in patients with moderately to severely active RA and inadequate response to MTX. METHODS: We developed a simulation model to depict progression of disability [in terms of the HAQ Disability Index (HAQ-DI)] in women aged 55-64 yrs with moderately to severely active RA and inadequate response to MTX. At model entry, patients were assumed to receive either only MTX or MTX plus abatacept. Patients were then tracked from model entry until death. Future health-state utilities and medical-care costs (except study therapy) were estimated based on predicted values of the HAQ-DI. The model was estimated using data from a Phase III clinical trial of abatacept plus various secondary sources. Cost-effectiveness was expressed in terms of incremental cost (2006 US$) per quality-adjusted life-year (QALY) gained over alternatively 10 yrs and a lifetime. Costs and health effects were both discounted at 3% annually. RESULTS: Over 10 yrs, abatacept would yield 1.2 additional QALYs (undiscounted) per patient (4.6 vs 3.4 for MTX) at an incremental (discounted) cost of $51,426 ($103,601 vs $52,175, respectively); over a lifetime, corresponding figures were 2.0 QALYS (6.8 vs 4.8) and $67,757 ($147,853 vs $80,096). Cost-effectiveness was [mean (95% CI)] $47,910 ($44,641, $52,136) per QALY gained over 10 yrs and $43,041 ($39,070, $46,725) per QALY gained over a lifetime. Findings were robust in sensitivity analyses. CONCLUSION: Abatacept is cost-effective by current standards of medical practice in patients with moderately to severely active RA and inadequate response to MTX.

Benito-Garcia E, Michaud K, Wolfe F. · Department of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA. · J Rheumatol. · Pubmed #17611980 No free full text.

Abstract: OBJECTIVE: To evaluate the risk of gastrointestinal (GI) symptoms and ulcers associated to the use of low-dose aspirin (ASA) among patients with rheumatoid arthritis (RA) and osteoarthritis (OA) treated with cyclooxygenase-2 (COX-2) drugs, to clarify the controversy in the literature. METHODS: Using a longitudinal databank, a prospective study using Cox proportional hazards models was performed in patients receiving COX-2 therapy for RA or OA to examine the effect of ASA on GI events. In 4 separate analyses patients reported dyspeptic symptoms and GI ulcers at semiannual intervals for up to 3 years. Ulcers were validated by review of medical records. RESULTS: Among 4240 patients taking COX-2-specific inhibitors, with no ulcer at study start, the age- and sex-adjusted hazard ratios for the effect of ASA on the development of epigastric pain, heartburn, nausea, and ulcers, without these previous events, were 1.11 (95% CI 0.97-1.29), 1.00 (95% CI 0.88-1.15), 1.32 (95% CI 1.13-1.54), and 1.27 (95% CI 0.78-2.05). The use of a propensity score to account for the risk of ASA prescription showed an even lower effect of ASA among all GI variables. This risk occurs within the setting of no prior GI symptoms or GI events, and independently of the use of proton pump inhibitors, other GI drugs, other nonsteroidal antiinflammatory drugs, prednisone, or methotrexate. CONCLUSION: In actual practice, the use of low-dose ASA has a small effect on the risk of developing dyspeptic symptoms in a group of patients with rheumatic disease.

Wolfe F, Michaud K, Pincus T. · Arthritis Research Center Foundation, University of Kansas School of Medicine, Wichita, KS 67214, USA. · J Rheumatol. · Pubmed #15996062 No free full text.

Abstract: OBJECTIVE: Key outcomes in rheumatoid arthritis (RA) are evaluated with multi-item ratings scales such as the Health Assessment Questionnaire (HAQ) and visual analog scales (VAS) such as pain and patient and physician global. As VAS scales are easy to use and particularly effective in research and patient care, we studied the characteristics, association, and psychometric properties of a VAS function scale (VAS-F) to determine if it could be used in RA studies and clinical practice. METHODS: A total of 394 patients with RA completed the HAQ, the HAQ-II, and a VAS functional scale. In addition, they completed standard assessments of pain, global, fatigue, sleep problems, joint count, and the Medical Outcome Study Short-Form 36 (SF-36) physical component summary score (PCS) and vitality and total pain scores. RESULTS: The HAQ-II was correlated with VAS-F at 0.76, but distributional characteristics of the HAQ and VAS-F differed, as the VAS-F scale results contained more higher scores as well as more lower scores compared with the HAQ-II and HAQ. Kendall's tau concordance analyses indicated that VAS scales were more concordant with other VAS than with non-VAS scales. Concordance of VAS-F was greatest with VAS global and was similar overall with VAS pain, sleep disturbance, fatigue, and quality of life. By contrast, the PCS, a multi-item scale, was more concordant with HAQ-II and HAQ. There was little to no difference between the VAS-F and the 2 HAQ with regard to concordance with the multi-item joint count, SF-36 vitality, and SF-36 total pain. CONCLUSION: The distribution differences between HAQ and HAQ-II and the VAS-F suggest that patients do not see minor limitations as problematic, but rate major limitations as being particularly limiting and worthy of high ratings. A VAS functional scale represents a patient-weighted functional assessment in which additional interpretation is given to the meaning of the limitations by the patient. VAS-F scales may be suitable for use in the clinic and in research. However, studies to assess sensitivity to change are required to determine the appropriate role of this scale.

Wolfe F, Michaud K. · Arthritis Research Center Foundation, University of Kansas School of Medicine, Wichita, Kansas 67214, USA. · J Rheumatol. · Pubmed #15517621 No free full text.

Abstract: OBJECTIVE: Fatigue is a common and distressing symptom in patients with rheumatoid arthritis (RA) and other rheumatic diseases. Reports have suggested profound improvements in fatigue after onset of anti-tumor necrosis factor-alpha (anti-TNF) therapy. In addition, physician and patient groups now identify fatigue as a very important symptom. However, data to support these observations are lacking. We evaluate the importance of fatigue in relation to other measures of clinical status, describe predictors of fatigue, and investigate fatigue levels in patients treated with anti-TNF therapy. METHODS: A total of 852 patients participated in a symptom-importance preference study. Additional analyses of fatigue and other clinical status variables were performed in up to 21,016 patients with RA and 3815 patients with osteoarthritis (OA) participating in the National Data Bank for Rheumatic Diseases. RESULTS: In ranking studies of the relative importance of fatigue compared with function, pain, cognition, gastrointestinal symptoms, and sleep, 8.0% of patients ranked fatigue as the most important variable, compared with 32.1% for function and 21.5% for pain. Multivariable studies of clinical change over 6 months found that changes in fatigue were weakly associated with changes in health status, in contradistinction to results for pain, function, and depression. Fatigue levels and fatigue predictors were similar in RA and OA patients. RA patients treated with anti-TNF therapy did not have lower fatigue scores compared with those not treated with this type of therapy. CONCLUSION: Among RA patient self-report measures, fatigue is not ranked as important as functional disability, pain, or depression by most patients. This relative ranking is confirmed by examination of clinical improvement data. Fatigue levels and predictors of fatigue are essentially the same in RA and OA. Although anti-TNF therapy lowers fatigue levels, there is no evidence that this effect is greater for anti-TNF therapy than for other RA treatments.

Pincus T, Strand V, Koch G, Amara I, Crawford B, Wolfe F, Cohen S, Felson D. · Division of Rheumatology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA. · Arthritis Rheum. · Pubmed #12632413 links to  free full text

Abstract: OBJECTIVE: To evaluate the capacity of a pooled index of only the 3 patient self-report questionnaire measures among the 7 American College of Rheumatology (ACR) core data set (Core Data Set) measures to distinguish efficacy of active treatment of rheumatoid arthritis (RA) with leflunomide or methotrexate versus placebo in a randomized, controlled clinical trial, and to compare the results with those obtained using the ACR 20% response criteria (ACR20), Disease Activity Score (DAS), and other pooled indices. METHODS: The 7 ACR Core Data Set measures of 1) joint swelling, 2) joint tenderness, 3) physician global assessment, 4) erythrocyte sedimentation rate (ESR), 5) functional disability, 6) pain, and 7) patient global assessment were combined into the following 5 pooled indices: "All Core Data Set" (all 7 measures), "Assessor Only" (measures 1-3), "Assessor + ESR" (measures 1-4), "Patient Only" (measures 5-7), and "Patient + ESR" (measures 4-7). The capacity of each of these 5 indices to detect differences between active treatment and placebo treatment was compared with that of the ACR20 and the DAS using 4 different analytic methods, each of which presented advantages and limitations. Agreement of the indices with one another and with the ACR20 and the DAS was analyzed according to pairwise kappa statistics and Z scores in multivariate logistic regression models. RESULTS: Each of the 5 indices, including "Patient Only," had a similar capacity to detect greater efficacy of leflunomide and methotrexate versus placebo in this clinical trial, according to each of 4 methods, at similar levels of statistical and clinical significance. CONCLUSION: A pooled index of patient self-report questionnaire Core Data Set measures appears to be as informative as ACR20 responses, DAS scores, and pooled indices of all and assessor-derived Core Data Set measures for distinguishing between active treatment and placebo treatment in this RA clinical trial.

Wolfe F, Michaud K. · University of Kansas School of Medicine and National Data Bank for Rheumatic Diseases, Wichita, Kansas. · Arthritis Rheum. · Pubmed #19404997 No free full text.

Abstract: OBJECTIVE: To determine the incidence of self-reported depression (SRD) in rheumatoid arthritis and to identify and rank clinically useful predictors of depression. METHODS: We assessed 22,131 patients for SRD between 1999 and 2008. We collected demographic, clinical and treatment data, household income, employment and work disability status, comorbidity, scales for function, pain, global, and fatigue, the Regional Pain Scale (RPS), the Symptom Intensity (SI) scale (a linear combination of the RPS and the fatigue scales) and linear combinations of the Health Assessment Questionnaire, pain and global severity. We used logistic regression analyses with multivariable fractional polynomial predictors, and Random Forest analysis to determine the importance of the predictors. RESULTS: The cross-sectional prevalence of self-reported depression was 15.2% (95% confidence interval [95% CI] 14.7-15.7%) and the incidence rate was 5.5 (95% CI 5.3-5.7) per 100 patient years of observation. The cumulative risk of SRD after 9 years was 38.3% (95% CI 36.6-40.1%). Almost all variables were significant predictors in logistic models. In Random Forest analyses, the SI scale, followed by comorbidity, best predicted self-reported depression, and no other variable or combination of variables improved prediction compared with the SI scale. CONCLUSION: Pain extent and fatigue (SI scale) are the dominant predictors of SRD. These variables, also of central importance in the symptomatology of fibromyalgia, are powerful markers of distress. A strong case can be made for the inclusion of these assessments in routine rheumatology practice. In addition, actual knowledge of comorbidity provides important insights into the patient's global health and associated perceptions.

Wolfe F, Boers M, Felson D, Michaud K, Wells GA. · National Data Bank for Rheumatic Diseases and University ofKansas School of Medicine, Wichita, Kansas 67214, USA. · J Rheumatol. · Pubmed #19332634 No free full text.

Abstract: OBJECTIVE: To examine the prevalence of remission in rheumatoid arthritis (RA) as determined by physicians and patients independently, and to determine the degree of agreement among methods, the strength of predictor variables of remission, and the length of remission. METHODS: Eight hundred patients with RA completed a remission questionnaire on the day of their rheumatologist visit and their rheumatologists completed a separate questionnaire the same day. The question(s) were: "Given all your experience with disease activity in RA, are you [is your patient] currently in remission?". Patients also completed 0-10 visual analog scales for RA activity, pain, and functional limitation. RESULTS: The percentage of patients in remission by physician and patient assessment was 34.8% [95% confidence interval (CI) 31.4-38.2] and 30.9% (95% CI 27.7-34.20), respectively. The percentage of patients classified concordantly (full agreement) was 78.6%, and the associated kappa statistic was 0.54 (95% CI 0.45-0.58). The median duration of remission was 2.0 years. The median RA activity, pain, and functional scores were 1.0, 1.5, and 1.25 for patient-determined remission and 1.5, 1.5, and 1.5 for physician-determined remission. CONCLUSION: Physician and patient estimates of remission in RA are similar (34.8% to 30.9%), and agreement was 78.6% (kappa 0.53). Based on previous data and the observed presence of disease activity, this definition of remission appears to be a measure of minimal disease activity rather than true remission. The problem of remission rates will not be solved until a consensus definition that has relevance in research and the clinic is developed.

Allaire S, Wolfe F, Niu J, LaValley MP, Zhang B, Reisine S. · Boston University School of Medicine, Boston, Massachusetts 02118, USA. · Arthritis Rheum. · Pubmed #19248135 No free full text.

Abstract: OBJECTIVE: To explore, using recent data, whether and how risk factors for rheumatoid arthritis (RA) work disability may differ from previous studies. METHODS: Subjects were 953 individuals with RA from a US cohort who provided data semiannually over 18 months (years 2002-2005). A nested case-control design was used with matching on time of baseline data collection. All subjects were employed at baseline; cases were consistently not employed at followup, whereas controls remained employed. Hierarchical conditional logistic regression assessed the roles of demographic, RA disease, general health, and work factors as predictors of work disability. Recursive partitioning and causal modeling procedures were also used. RESULTS: Sample characteristics were mean age 51 years, 82% female, and 92% white. Older age (odds ratio [OR] 1.2, 95% confidence interval [95% CI] 1.1-1.4) and lower income (OR 1.7, 95% CI 1.0-2.7) predicted work disability, whereas more hours worked (OR 0.9, 95% CI 0.8-0.9) and preference to work full time (OR 0.2, 95% CI 0.1-0.4) or part time (OR 0.4, 95% CI 0.2-0.6) versus not to work were protective in the regression analysis. In recursive partitioning analyses, RA disease factors predicted work disability among older subjects, and functional limitation was the fourth most important factor. Job physical demand was not a significant or important factor. CONCLUSION: In this contemporary data from a large RA cohort, older age, lower income, fewer working hours, and preference not to work were the risk factors for work disability. The impact of disease factors was limited to subjects ages >or=56 years. Job physical demand level had little impact.

Wolfe F, Michaud K. · National Data Bank for Rheumatic Diseases, 1035 N. Emporia, Suite 288, Wichita, KS 67214, USA. · J Rheumatol. · Pubmed #19228653 No free full text.

Abstract: OBJECTIVE: To compare outcome-predictor relationships in fibromyalgia (FM) and rheumatoid arthritis (RA), to provide information regarding the competing hypotheses that FM is a continuum or a discrete disorder. METHODS: We studied 3 outcome variables (work disability, opioid use, depression) and 12 clinical predictor variables in 2,046 patients with FM and 20,374 with RA. We determined whether outcome-predictor relationships were stronger in FM or RA by measuring the areas under the receiver-operating curves. We used fractional polynomial logistic regression to create graphic models for the outcome-predictor relationships. RESULTS: All measures of status and outcome were more abnormal in FM than in RA. Depression was reported in 33.4% of patients with FM compared with 15.1% of those with RA. The predictor-outcome relationship was significantly stronger in RA in 28 of the 36 tests, and not different in the remainder. The relationship between outcome and predictor variables was generally similar in patients with FM and RA. However, unmodeled depression that was not explained by study variables was noted in FM. CONCLUSION: Our data are consistent with the hypothesis that FM is the end of a severity continuum, but that additional psychological factors are an integral part of the syndrome.