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Background: Perioperative dysglycaemias are a risk for harm but guidelines to improve glucose management are poorly adhered to. Aim: To determine whether a specialized team and diabetes education improves the implementation of guidelines and glucose values. Methods: We conducted a prospective study of 611 nonselected, consecutive patients attending for elective hip or knee arthroplasty. The first 209 patients received conventional care and the following 402 patients received intervention (Acute Glucose Service, AGS) in two chronological groups; either perioperatively (AGS1) or also preoperatively (AGS2). The AGS-team provided diabetes education, identified the patients with diabetes risk and adjusted the medication when needed. Capillary plasma glucose (CPG) was repeatedly measured and glycated haemoglobin (HbA1c) obtained before and after the surgery. The study objectives were to evaluate the staff actions when hyperglycaemia was severe (CPG >10 mmol/L), and to assess improvement of the glycaemic values and the complication rate within 3 months. Results: None of the severely hyperglycaemic events in the reference group were treated according to guidelines. In the AGS 1 group, 50% and in the AGS2 group, 53% were appropriately managed (p 7.8 mmol/L at least twice) and of severe hyperglycaemia (CPG >10 mmol/L) decreased in all patient groups. The medians of the highest, mean and variability of CPG values improved. The mean HbA1c improved significantly within AGS 2. There was no association between improved glycaemic care and early complications. Conclusions: AGS intervention significantly improves adherence to guidelines and glucose values. acceptedVersion

Perioperative dysglycaemia is associated with deleterious outcomes but guidelines to improve glucose management are poorly or inconsistently adhered to. We evaluated glucose management among diabetic and non-diabetic patients undergoing elective hip or knee arthroplasty.Capillary plasma glucose (CPG) was measured prospectively four times daily of 209 patients undergoing elective hip or knee surgery. Actions of the attending teams to CPG values and detection of patients at risk were analysed.A total of 209 patients were enrolled. All diabetic patients on insulin (6/6) had hyperglycaemia (≥7.8 mmol/l) more than twice and severe hyperglycaemia (10 mmol/l) at least once. Of the 27 diabetic patients not on insulin 26 (96.3%) had CPG ≥ 7.8 mmol/l ≥ 2 times and 17 (63%)10 mmol/l. The corresponding figures of the 176 non-diabetic patients were 137 (77.8%) and 61 (34.7%). Severe hyperglycaemia occurred in 54/176 (30.1%) of the non-diabetic patients with pre-operative HbA1c 42 mmol/mol and random plasma glucose 7.8 mmol/l. Of the 84 hyperglycaemic episodes 10 mmol/l, none was treated. Patients with a FINDRISC score ≥ 12 (corresponding to moderate to high risk of diabetes) and hyperglycaemia went unnoticed.Hyperglycaemia is common among elective orthopaedic surgery patients with or without diabetes. More than 80% of the 209 patients had hyperglycaemia and 40% had severe hyperglycaemia. None of the patients was treated according to guidelines and none of the patients at risk of hyperglycaemia or diabetes was noticed. There is an obvious need for further education and support by diabetes specialists.Clinical trials, gov. NCT03306810.

Objective Frequent monitoring of patients with early rheumatoid arthritis (RA) is required for achieving good outcomes. This study was undertaken to investigate the influence of text message (SMS)-enhanced monitoring on early RA outcomes. Methods We randomized 166 patients with early, disease-modifying antirheumatic drug-naive RA to receive SMS-enhanced follow-up or routine care. All patients attended visits at 0, 3, and 6 months, and a follow-up visit at 12 months. Treatment was at the physicians' discretion. The intervention included 13 SMSs during weeks 0-24 with questions concerning medication problems (yes/no) and disease activity (patient global assessment [PtGA], scale 0-10). Patients were contacted if response SMSs indicated medication problems or PtGA exceeded predefined thresholds. Primary outcome was 6-month Boolean remission (no swollen or tender joints and normal C-reactive protein levels). Quality of life (QoL; measured by the Short Form 36 survey) and Disease Activity Score in 28 joints (DAS28) were assessed. Results Six and 12-month follow-up data were available for 162 and 157 patients, respectively. In the intervention group, 46% of the patients (38 of 82) reported medication problems and 49% (40 of 82) reported text message PtGAs above the alarm limit. Remission rates at 6 months (P = 0.34) were 51% in the intervention group and 42% in the control group. These rates were 57% and 43% at 12 months (P = 0.17) in the intervention and control groups, respectively. The respective mean ± SD DAS28 scores for the intervention and control groups were 1.92 ± 1.12 and 2.22 ± 1.11 at 6 months (P = 0.09); and 1.79 ± 0.91 and 2.08 ± 1.22 at 12 months (P = 0.28). No differences in QoL were observed. Conclusion The study did not meet the primary outcome despite a trend favoring the intervention group. This may be explained by the notably high overall remission rates.

Objective.To evaluate the development of radiological changes of the cervical spine in patients with rheumatoid arthritis (RA) in the NEO-RACo trial treated with an intensive, remission-targeted combination of conventional synthetic disease-modifying antirheumatic drugs (csDMARD) and additional infliximab (IFX) or placebo (PLA) for the first 6 months.Methods.Ninety-nine patients with early, DMARD-naive RA were treated with a triple combination of csDMARD and prednisolone, and randomized to double-blindly receive either IFX (FIN-RACo+IFX) or PLA (FIN-RACo+PLA) infusions during the first 6 months. After 2 years the treatment strategies became unrestricted, but the treatment goal was strict NEO-RACo remission. At the 10-year visit, radiographs of the cervical spine were taken of 85 patients (38 in the FIN-RACo+IFX group and 47 in the FIN-RACo+PLA group). The study was registered at ClinicalTrials.gov (NCT 00908089).Results.There were 4/85 patients (4.7%) with cervical spine involvement (CSI) by 10 years. Atlantoaxial subluxation was found in 2/85 patients (2.4%), both in the FIN-RACo+IFX group, and none in the FIN-RACo+PLA group. Atlantoaxial impaction was found in 1/85 patients (1.2%) in the FIN-RACo+IFX group. Subaxial subluxation was found in 1/85 patients (1.2%).Conclusion.Early and intensive remission-targeted treatment has reduced the incidence of CSI and our results show that intensive treatment also prevents its development in the long run.

Background and aimsPain is an evident factor affecting the quality of life in all age groups. The objective was to examine the prevalence of self-reported SF-36 bodily pain and pain-related factors in community-dwelling older adults.MethodsOne thousand four hundred and twenty adults aged 62–86 years self-reported SF-36 bodily pain during the previous month. For the analysis, four pain groups were formed (group I [0–45, moderate to very severe pain intensity and interference], group II [47.5–70], group III [77.5–90], and group IV [100, no pain at all]). Additional questionnaire-provided data regarding education, wealth, life habits, and morbidity, as well as clinical data were considered.ResultsThe overall pain prevalence was 78% (SF-36 bodily pain score ConclusionsA high prevalence of intense and interfering pain was reported. Multiple factors that were found to relate to pain have previously been demonstrated to associate with social exclusion. Increasing attention should be paid to distinguishing these factors in patients with pain, as well as targeted pain assessment and measures to improve the sense of community among older adults.ImplicationsThere is a lack of large studies that examine a wide scale of pain-related factors in the older adult population. To distinguish subjects with multiple such factors would help medical professionals to target their attention to patients at a high risk of chronic pain.

The debate whether an elevated level of serum uric acid (SUA) is an independent marker of cardiovascular risk is still going on. We examined morbidity and mortality related to SUA and hyperuricemia in a well-characterized population with very long follow-up. Study included 4696 participants (aged 30-59 years at baseline) of the coronary heart disease (CHD) Study of the Finnish Mobile Clinic Health Examination Survey. Adjusted hazard ratios (HRs) of hyperuricemia (defined as ≥360 µmol/l and ≥420 µmol/l) and SUA quintiles for mortality and adverse cardiovascular outcomes are reported. During the mean follow up of 30.6 years there were 2723 deaths, 887 deaths for CHD of which 340 were classified as sudden cardiac deaths, 1642 hospitalizations due to CHD and 798 hospitalizations due to congestive heart failure. After adjusting to baseline risk factors and presence of cardiovascular diseases as well as the use of diuretics there were no significant differences in the risk of any of the outcomes when analyzed either according to quintiles of SUA or using a cut-off point SUA ≥360 µmol/l for hyperuricemia. Only a rare finding of hyperuricemia SUA ≥420 µmol/l among women (n = 17, 0.9%) was independently associated with significantly higher risk of mortality (adjusted HR: 2.59, 95% CI: 1.54-4.34) and a combination end-point of major adverse cardiac events (MACEs) (HR: 2.69; 95% CI: 1.56-4.66). SUA was not an independent indicator of morbidity and mortality, with the exception of particularly high levels of SUA among women.

Background Pain is a frequent and inevitable factor affecting the quality of life among older people. Several studies have highlighted the ineffectiveness of treating chronic pain among the aged population, and little is known about the prevalence of analgesics administration among community-dwelling older adults. The objective was to examine older adults’ prescription analgesic purchases in relation to SF-36 pain in a population-based setting. Methods One thousand four hundred twenty community-dwelling citizens aged 62–86 years self-reported SF-36 bodily pain (pain intensity and pain-related interference) scores for the previous 4 weeks. The Social Insurance Institution of Finland register data on analgesic purchases for 6 months prior to and 6 months after the questionnaire data collection were considered. Special interest was focused on factors related to opioid purchases. Results Of all participants, 84% had purchased prescription analgesics during 1 year. NSAIDs were most frequently purchased (77%), while 41% had purchased paracetamol, 32% opioids, 17% gabapentinoids, and 7% tricyclic antidepressants. Age made no marked difference in purchasing prevalence. The number of morbidities was independently associated with analgesic purchases in all subjects and metabolic syndrome also with opioid purchases in subjects who had not reported any pain. Discussion Substantial NSAID and opioid purchases emerged. The importance of proper pain assessment and individual deliberation in terms of analgesic contraindications and pain quality, as well as non-pharmacological pain management, need to be highlighted in order to optimize older adults’ pain management.

Objectives Children with juvenile idiopathic arthritis (JIA) may be predisposed to serious pneumonia due to modern disease-modifying anti-rheumatic treatment. In this nationwide retrospective study with clinical data, we describe the pneumonia episodes among children with JIA. Methods Patients under 18 years of age with JIA and pneumonia during 1998–2014 were identified in the National Hospital Discharge Register in Finland. Each individual patient record was reviewed, and detailed data on patients with JIA and pneumonia were retrieved, recorded, and analyzed. If the patient was hospitalized or received intravenous antibiotics, the pneumonia was considered serious. Results There were 157 episodes of pneumonia among 140 children with JIA; 111 episodes (71%) were serious (80% in 1998–2006 and 66% in 2007–2014). The mean age of the patients was 9 years. Forty-eight percent had active JIA and 46% had comorbidities. Disease-modifying anti-rheumatic drugs (DMARD) were used at the time of 135 episodes (86%): methotrexate (MTX) by 62% and biologic DMARDs (bDMARD) by 30%. There was no significant difference in the use of bDMARDs, MTX and glucocorticoids between the patient groups with serious and non-serious pneumonia episodes. During six of the episodes, intensive care was needed. Two patients (1.3%) died, the remaining ones recovered fully. Conclusions Although the incidence of pneumonia and the use of immunosuppressive treatment among children with JIA increased from 1998 to 2014, the proportion of serious pneumonias in these patients decreased. There was no significant difference in the use of anti-rheumatic medication between patients with serious and non-serious pneumonia.Key Points• The incidence of serious pneumonias decreased from 1998 to 2014 among children with juvenile idiopathic arthritis (JIA).• There was no significant difference in the use of the disease-modifying anti-rheumatic medication between JIA patients with serious and non-serious pneumonias.• Active JIA, comorbidities, and combination medication were associated with nearly half of the pneumonias.

Objectives: Evidence of the economic burden and long-term outcomes of juvenile idiopathic arthritis (JIA) remains scarce. Our aim was to explore healthcare costs and long-term outcomes in adult patients with JIA. Method: We identified all adult patients (>= 18 years) with JIA who visited Jyvaskyla Central Hospital rheumatology unit between May 2007 and March 2016. We considered individual medians of time-dependent clinical variables. These data were linked to administrative data from the area from the fiscal year 2014, which include information on all public healthcare contacts. Healthcare utilization is presented as direct costs in euros (EUR). Factors affecting direct costs were assessed with a generalized linear model. Results: In 218 patients, median 28-joint Disease Activity Score with three variables (DAS28-3) was = 30 years, and median Health Assessment Questionnaire (HAQ) score was

Objectives RA and its medication, especially TNF-α inhibitors, increase the risk of clinical tuberculosis (TB) infection. We aimed to investigate the clinical manifestations, incidence and temporal changes in TB occurring concurrently with rheumatic diseases (RDs) between 1995 and 2007. Methods We combined the register of the Social Insurance Institution of Finland and the National Infectious Disease Register to find adult patients with reimbursed DMARDs and with a TB notification between 1995 and 2007. After reviewing the medical records, we described their clinical manifestations and medications, explored TB incidence trends using Poisson regression, and compared the incidence of TB with that of the general population. Results We identified 291 patients with both TB and rheumatic disease (RD), 196 of whom had RA. Between 1995 and 2007, the incidence of TB in adult RD decreased from 58.8 to 30.0 per 100 000 (trend P < 0.001, average marginal effect −3.4/100 000 per year, 95% CI −4.4, −2.4). Compared with the general population, the incidence was ∼4-fold. Among RD patients, pulmonary TB was the most common form of TB (72.6%). Disseminated TB was present in 56 (19.6%) patients. Conclusion The incidence of TB among RD patients was ∼4-fold that of the general population, and it declined between 1995 and 2007. Disseminated TB was present in nearly 20% of patients.

Objectives: Healthcare service needs have changed with the use of effective treatment strategies. Using data from the modern era, we aimed to explore and compare health service-related direct costs in juvenile idiopathic arthritis (JIA), psoriatic arthritis (PsA), rheumatoid arthritis (RA), and axial spondyloarthritis (AxSpA).Methods: We linked a longitudinal, population-based clinical data set from Finland's largest non-university hospital's rheumatology clinic with an administrative database on health service-related direct costs in 2014. We compared all-cause costs and costs of comorbidities between adult patients with JIA, PsA, RA, and AxSpA (including ankylosing spondylitis). We also characterized patients with high healthcare resource utilization.Results: Cost distributions were similar between rheumatic diseases (p=0.88). In adulthood, patients with JIA displayed a similar economic burden to much older patients with other inflammatory rheumatic diseases. A minority were high utilizers: among 119 patients with JIA, 15% utilized as much as the remaining 85%. For PsA (213 patients), RA (1086), and AxSpA (277), the high-utilization proportion was 10%. Both low and high utilizers showed rather low disease activity, but in high utilizers, the patient-reported outcomes were slightly worse, with the most distinct differences in pain levels. Of health service-related direct costs, index rheumatic diseases comprised only one-third (43.6% in JIA) and the majority were comorbidity costs.Conclusions: Patients with JIA, PsA, RA, and AxSpA share similar patterns of healthcare resource utilization, with substantial comorbidity costs and a minority being high utilizers. Innovations in meeting these patients' needs are warranted.

Background: Respiratory tract infections are among the leading causes of hospitalization in rheumatoid arthritis (RA) and Streptococcus Pneumoniae (Sp) is one of the most frequent pathogens involved. For these patients, the CDC recommends a combined vaccination scheme (CVS) using two types of Sp vaccines but evidence on its effectiveness remains insufficient.1 Objectives: To assess the impact of the combined vaccination scheme on the incidence of Sp infections in patients with RA treated with DMARD. Methods: A cohort was nested in a register including patients with RA who were prescribed a bDMARD or tsDMARD -either naive or switch- from 2000 to March 2019. The target outcomes were invasive pneumococcal disease (IPD) and all-cause community-acquired pneumonia (CAP), as defined by relevant MedDRA codes. Demographic and clinical features were also retrieved. Each participant centre informed about the date when they implemented a systematic Sp vaccination protocol and whether they were using the CVS. Those not adopting this practice were excluded from the analysis. Crude incidence rates (IRs) were calculated for each outcome as well as for its combination (combined variable defined as “Sp infections”). Exposure was split into two periods, considering the date when the CVS was officially recommended in Spain (May 2015). The incidence rate ratio (IRR) comparing pre and post implementation periods was estimated with a Poisson regression model adjusted for sex, age and comorbidities (Charlson Index). Results: 1704 patients were included, their characteristics are shown in table 1. One centre was excluded for not using any Sp vaccination protocol while the remaining ones reported using the CVS. Crude IRs by periods (pre and post CVS implementation) and age groups are shown in table 2. The IRR of the post-vaccination period after adjusting for age, sex and comorbidities (Charlson index) was 0.40 (95% CI: 0.29 - 0.56), p Conclusion: The incidence of Sp infections experienced a decrease in RA patients taking bDMARD or tsDMARD after the introduction of the stepwise combined vaccination scheme that is not related to age, sex or comorbidities. References: [1] Furer V, et al. Ann Rheum Dis 2019;0:1–14 Disclosure of Interests: Sebastian C Rodriguez-Garcia Speakers bureau: Novartis Farmaceutica, S.A., Merck Sharp & Dohme Espana, S.A., Sanofi Aventis, UCB Pharma, Carlos Sanchez-Piedra: None declared, Raul Castellanos-Moreira Speakers bureau: Lilly, MSD, Sanofi, UCB, Dolores Ruiz-Montesinos: None declared, Victoria Hernandez: None declared, Manuel Pombo: None declared, Fernando Sanchez-Alonso: None declared, Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme Espana, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution), Juan Jesus Gomez-Reino: None declared

Background Dietary habits have a great influence on physiological health. Even though this fact is generally recognized, people do not eat as healthily as they know they should. The factors that support a healthy diet, on the other hand, are not well known. It is supposed that there is a link between personal traits and dietary habits. Personal traits may also partially explain why some people manage to make healthy dietary changes while some fail to do so or are not able to try to make changes even when they desire to do so. There is some information suggesting that dispositional optimism plays a role in succeeding in improving dietary habits. The aim of this study was to determine the role of optimism and pessimism in the process of dietary changes. Methods Dispositional optimism and pessimism were determined using the revised Life Orientation Test in 2815 individuals (aged 52–76 years) participating in the GOAL study in the region of Lahti, Finland. The dietary habits of the study subjects were analysed. After 3 years, the subjects’ dietary habits and their possible improvements were registered. The associations between dispositional optimism and pessimism, dietary habits at baseline, and possible changes in dietary habits during the follow-up were studied with logistic regression. We also studied if the dietary habits or certain lifestyle factors (e.g. physical exercising and smoking) at baseline predicted success in improving the diet. Results Pessimism seemed to correlate clearly negatively with the healthiness of the dietary habits at baseline – i.e. the higher the level of pessimism, the unhealthier the diet. Optimism also showed a correlation with dietary habits at baseline, although to a lesser extent. Those who managed to improve their dietary habits during follow-up or regarded their dietary habits as healthy enough even without a change were less pessimistic at baseline than those who failed in their attempts to improve their diet or did not even try, even when they recognized the need for a change. Conclusions Pessimistic people are more likely to eat an unhealthy diet than others. Pessimism reduces independently the possibilities to improve dietary patterns.

Background Inflammatory pathways are likely the central link from axial spondyloarthritis to the known increased risk of cardiovascular morbidity. Literature on positron emission tomography imaging together with computed tomography (PET/CT) in the context of spondyloarthritis is limited. Objectives The aim was to grade the inflammatory signals in the sacroiliac joints and aorta in the PET/CT imaging before and after antirheumatic treatment of clinically active axial spondyloarthritis with either sulfasalazine (SSZ), the firstline antirheumatic drug in Finland for axial spondyloarthritis, or adalimumab (ADA). Methods Fourteen patients aged 18–75 years with axial spondyloarthritis and radiologic sacroiliitis as detected either by MRI or X-ray and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and visual analogue scale (VAS)≥4 have been recruited to the pilot study. DMARD-naive patients started SSZ for 12 weeks. Those who failed to reach remission (BASDAI and VAS≥4) with SSZ or were known to be resistant to conventional DMARDs before inclusion, adalimumab was started for 16 weeks. The patients were scanned with 18F-fluorodeoxyglucose (FDG) PET/CT after inclusion and after treatment with SSZ and/or ADA. Target-to-background ratio (TBR) was assessed from the aortic root to abdominal aorta as well as for the sacroiliac joints. For statistical comparisons before and after antirheumatic treatment, paired t-test was used. Mean ±SD are shown. Results Our pilot study comprised of nine patients with ADA and five with SSZ. In the SSZ patients (three men, age 36.0±13.4 years), mean BASDAI was 4.7±1.6 before and 3.4±1.8 after the treatment (p=0.091). In the ADA patients (six men, age 35.1±9.8 years), BASDAI decreased from 4.9±1.2 to 2.3±1.8 (p=0.004). Among the SSZ patients, maximal TBR in sacroiliac joints declined from 2.35±0.55 to 1.51±0.22 (-35.8%, p=0.03) (figure 1). Aortic maximal TBR declined from 2.44±0.46 to 2.07±0.43 (-15.0%, p=0.23). In the ADA patients, maximal TBR in sacroiliac joints was 1.89±0.37 before and 1.90±0.51 after treatment (+0.3%, p=0.97), and in aorta 2.15±0.54 before and 2.37±0.53 after treatment (+10.4%, p=0.19). Conclusions As detected by reduced 18F-FDG uptake, SSZ reduced inflammation in sacroiliac joints. There was also clear trend towards reduction of inflammation in aorta. ADA and SSZ both reduced clinical symptoms, but only ADA reached statistical significance. PET/CT could not show any reduction in FDG uptake in the ADA group. This may be due to the fact that ADA was used as the second line treatment, when the inflammation had already been reduced to the limit detectable by the method. Acknowledgements This study was funded by Abbvie inc. Disclosure of Interest J.-P. Kaijasilta: None declared, A. Kerola: None declared, R. Tuompo: None declared, M. Kauppi: None declared, H. Relas: None declared, A. Loimaala: None declared, H. Koivu: None declared, J. Schildt: None declared, T. Kerola: None declared, K. Eklund: None declared, T. Nieminen Grant/research support from: Abbvie Inc

Felty syndrome is a rare disease defined by neutropenia, splenomegaly, and rheumatoid arthritis. Sometimes the differential diagnosis between Felty syndrome and large granular lymphocyte leukemia is problematic. Recently, somatic STAT3 and STAT5B mutations were discovered in 30-40% of patients with large granular lymphocyte leukemia. Herein, we aimed to study whether these mutations can also be detected in Felty syndrome, which would imply the existence of a common pathogenic mechanism between these two disease entities. We collected samples and clinical information from 14 Felty syndrome patients who were monitored at the rheumatology outpatient clinic for Felty syndrome. Somatic STAT3 mutations were discovered in 43% (6/14) of Felty syndrome patients with deep amplicon sequencing targeting all STAT3 exons. Mutations were located in the SH2 domain of STAT3, which is a known mutational hotspot. No STAT5B mutations were found. In blood smears, overrepresentation of large granular lymphocytes was observed, and in the majority of cases the CD8(+) T-cell receptor repertoire was skewed when analyzed by flow cytometry. In bone marrow biopsies, an increased amount of phospho-STAT3 positive cells was discovered. Plasma cytokine profiling showed that ten of the 92 assayed cytokines were elevated both in Felty syndrome and large granular lymphocyte leukemia, and three of these cytokines were also increased in patients with uncomplicated rheumatoid arthritis. In conclusion, somatic STAT3 mutations and STAT3 activation are as frequent in Felty syndrome as they are in large granular lymphocyte leukemia. Considering that the symptoms and treatment modalities are also similar, a unified reclassification of these two syndromes is warranted.

Objective The Pain Coping Questionnaire (PCQ), the first validated pain coping measurement developed specifically for children, has lacked proper validation in Finnish. The original PCQ by Reid et al. (Pain 1998; 76; 83-96) comprises eight-first-order and three higher-order scales. The aim herein was to determine the factor structure and validity of the Finnish PCQ translation in Finnish children. Methods Exploratory factor analysis was used for the first-order and higher-order classification of 91 recruited patients aged 8-15. Cronbach's alpha was used for reliability. Relationships between the Children's Depression Inventory, patient-reported pain frequency and pain coping strategies were examined. Results Analyses were executed with 38 items; one was excluded. A structure of eight-first-order (Internalizing/Catastrophizing [IC], Positive Self-Statements [PSS], Information Seeking [IS], Seeking Social Support [SSS], Cognitive Distraction [CD], Externalizing [EXT], Behavioural Distraction [BD], Problem Solving [PS]) and three higher-order scales (Approach [APP], Emotion-Focused Avoidance [EFA], Distraction [DIS]) proved the most consistent. Four first-order scales (PSS, CD, EXT, BD) emerged as identical to the original solution. Internal consistency reliability coefficients for all individual first- and second-order scales were satisfactory. A higher CDI score was positively related to EFA and negatively to DIS, and pain frequency positively related to APP and EFA. Conclusion The exploratory factor analysis of the PCQ provided a both culturally and statistically satisfactory structure in the Finnish translation. This supports the reliability and validity of the PCQ in future national use and the value of the questionnaire also outside English-speaking countries. Significance This study showed both culturally and statistically satisfactory factor structure of PCQ in the Finnish translation. This result supports reliability and validity of the PCQ in the national use in the future. The result shows that the PCQ is a reliable method to be used in different linguistic and cultural surroundings and, thus, encourages using it in various countries. The data consist of two patient groups, adolescents with JIA and musculoskeletal pain. Pain and specifically coping with pain are important aspects of clinical work. A valid pain coping scale may enhance distinguishing vulnerable pain coping style in children and adolescent before pain becomes chronic.

Autoreactive B cells infected by Epstein-Barr virus (EBV) are suspected to be involved in the etiology of various human chronic autoimmune diseases. This motivated us to study the relationship between peripheral blood EBV load at baseline and treatment response to B cell-depleting therapy in rheumatoid arthritis (RA) patients. Thirty-five RA patients who started treatment with rituximab (RTX) in a routine clinical setting were assessed for baseline disease activity using disease activity score using 28 joint counts (DAS28) (erythrocyte sedimentation rate [ESR]). Treatment response was evaluated 3–7 months after RTX. EBV load in baseline whole blood (WB) samples was determined using quantitative PCR. EBV DNA was detected in 16/35 (46 %) of the WB samples. In these 16 EBV-positive patients, the median viral load was 3.15 (2.68–4.00) log copies/ml. Good/moderate European League Against Rheumatism (EULAR) response was observed in 16/16 of the EBV DNA-positive vs 13/19 EBV DNA-negative patients, p = 0.022. Significant response (DAS28 change >1.2) was observed in 14/16 of the EBV DNA-positive vs 10/19 EBV DNA-negative patients, p = 0.035. The decline in DAS28 after RTX was 2.10 (1.03–4. 78) in the EBV DNA-positive vs 1.47 (−0.7–4.70) in the EBV DNA-negative patients, p = 0.13. EBV load at baseline significantly correlated with change in DAS28 after RTX (τB = −0.261, p = 0.042). Our results suggest that the presence of EBV genome in WB could serve as a predictive marker to RTX therapy in RA.

To compare the incidence of pneumonia in children with juvenile idiopathic arthritis (JIA) to the aged-matched general population and to evaluate the use of anti-rheumatic medication among children with JIA and pneumonia.The National Hospital Discharge Register collects data on ICD-diagnoses of hospital patients in Finland. From this register, patients with JIA under 18 years of age with pneumonia from 1999 through 2014 were identified. The control group consisted of age-matched patients derived from the general population with a diagnosis of pneumonia made in the same calendar year as the pneumonia of the JIA patients. The patient records of the children with JIA were scrutinised for the use of anti-rheumatic medication.We identified 223 pneumonias among the JIA patients (56,161 patient-years) and 53,058 pneumonias in the control group (17,546,609 person-years). The incidence of pneumonia in children with JIA was 386 (annual range 131-639) and in the control group 303 (annual range 225-438) per 100,000 person-years. The incidence of pneumonia increased significantly over time among JIA patients (p=0.013) and in the control group (p0.001). Through 2007-2014 the rate of pneumonia was significantly higher among children with JIA (p0.001) than control children. We found 150 JIA patients with pneumonia confirmed by positive chest radiograph. Altogether 47% of the JIA patients had combination medication. The use of methotrexate and biologic agents increased significantly over time (p=0.016 and p0.001, respectively).The incidence of pneumonia increased in children with JIA and in the general population from 1999 to 2014. During 2007-2014 JIA patients had a significantly higher rate of pneumonia than age-matched controls. The use of active anti-rheumatic medication was common.

Background Immunization to biological drugs can reduce the treatment efficacy and increase the risk of adverse events. Objectives To determine the drug trough concentrations and anti-drug antibody (ADAb) levels of self-injected TNF-inhibitors, in non-selected patients with ankylosing spondylitis (AS) attending the rheumatological outpatient clinic, and to study the patient related factors affecting the immunization to antiTNF drugs. Methods A total of 313 patients with AS were recruited. A blood sample, taken 1–2 days prior to next drug injection, was obtained from 273 patients. Trough concentration of the anti-TNF drugs were measured with capture-ELISA (Promonitor EIA, Progenica), the levels of ADAb with radioimmunoassay (Sanquin Laboratories, The Netherlands), and the serum TNF-blocking capacity by using an in-house reporter gene assay. The clinical activity of AS was assessed using the Bath AS Disease Activity Index (BASDAI), the Bath AS Functional Index (BASFI), and the Maastricht AS Entheses Score (MASES). Results ADAbs were observed in 21% of patients on adalimumab (n=99), in 0% of those on etanercept (n=83), in 3% of those on golimumab (n=79) and in 50% of those on certolizumab pegol (n=12). The BASDAI in ADAb positive patients was 1.4 (sd 1.4) and in the ADAb negative patients 2.0 (sd 1.8 p=0.060). Factors affecting the immunization to biological drug could be further analyzed in patients using adalimumab. Trough drug concentrations of adalimumab correlated with the presence of ADAb (r=-0.54, rp Conclusions The disease activity of AS patients using self injected antiTNF drugs was low. The immunization to adalimumab was relatively common in nonselected AS patient population. However, no clear association was observed between the presense of ADAb and the disease activity. Acknowledgements The study was financially supported by Pfizer Disclosure of Interest J. Hiltunen: None declared, P. Parmanne: None declared, T. Sokka-Isler: None declared, T. Lamberg: None declared, O. Kaipiainen-Seppanen: None declared, P. Isomaki: None declared, M. Kauppi: None declared, L. Pirila: None declared, T. Uutela: None declared, R. Tuompo: None declared, H. Relas: None declared, T. Yli-Kerttula: None declared, H. Valleala: None declared, M. Romu: None declared, T. Rannio: None declared, K. Paalanen: None declared, A. Juha: None declared, P. Ekman: None declared, K. Tadesse: None declared, J. Borodina: None declared, P. Elfving: None declared, R. Peltomaa: None declared, M. Leirisalo-repo: None declared, H. Kautiainen: None declared, S. Jokiranta: None declared, K. Eklund Grant/research support from: Pfizer has supported the study financially, Consultant for: Advisory board meetings BMS, MSD, Pfizer, Abbvie, Speakers bureau: Lectures: BMS, Roche, Pfizer, Novartis

The aim of this study is to find out the outcome of 28 patients who got the diagnosis of primary fibromyalgia (pFM) 26 years ago. In 1986, 56 patients with widespread pain were examined and filled in a base questionnaire (BQ). Of them, 42 fulfilled the Yunus criteria for pFM. Twenty-six years later, addresses of 38 patients were found, and an extensive follow-up questionnaire (FupQ) was mailed to them. Of them, 28 (74%) answered the FupQ. This included nine identical questions with the BQ and questions concerning changes in their symptoms and quality of life (Qol). Three patients (11%) had healed from fibromyalgia (FM), and 23% reported having one or several symptomless periods lasting at least 1 year. In others (n = 25), all but pain and ache showed slight deterioration. Despite the aging and FM, the level of functional ability evaluated by Stanford Health Assessment Questionnaire (HAQ) remained at the same level (BQ 0.41 vs. Fup 0.44, p = 0.82). The sum score of reported symptoms (n = 21) did not change significantly (10.8 (SD 2.9) vs. 11.1 (SD 4.1), p = 0.75). Experienced sleeplessness increased most significantly (27 vs. 65%, p = 0.0034). Exercising did not have a significant influence on the changes of the measured parameters. However, the three healed patients exercised regularly. Symptoms of FM have persisted in most patients for decades without significant deterioration of self-reported functional ability. About one fourth of patients had experienced long symptomless periods during their illness. Three patients (11%) reported that they have healed from FM.

With the ameliorating prognosis of rheumatoid arthritis (RA), the role of comorbidities as causes of work disability (WD) may increase. The aim of this study was to determine the contribution of psychiatric and cardiovascular (CV) comorbidities as the leading causes of long-term WD among patients with recent-onset RA.Between 2000 and 2007, all incident, working-age and non-retired RA patients were identified from a Finnish nationwide register. From other registers, we identified the RA patients who were granted a permanent or temporary disability pension by 31 December 2008. The incidences of disability pensions with CV diseases (ICD-10 codes I00-I99) or psychiatric disorders (F20-F69) as the leading causes were assessed and compared with the general population.We identified a cohort of 7831 patients with RA. During follow-up, 1095 patients were granted a disability pension. After adjusting for competing risks, the 9-year cumulative incidence of WD caused by RA, a psychiatric comorbidity, or a CV disease was 11.9, 1.3, and 0.5%, respectively. Compared to the general population, the age- and sex-specific standardized incidence ratio (SIR) of WD due to psychiatric comorbidities was 0.99 [95% confidence interval (CI) 0.80-1.23] and due to CV disease 1.75 (95% CI 1.23-2.51).In the study cohort with recent-onset RA, the 9-year cumulative incidence of disability pensions caused by psychiatric or CV comorbidities was only 11% or 4%, respectively, of that caused by RA itself. Compared to the general population, the risk of WD due to CV disease was increased.

Only limited evidence exists on the therapeutic potential of biologic agents in the treatment of myositis. We present a brief review of the literature on off-label experiences of biologic agents in myositis, with a special interest in abatacept. Rituximab has been indicated to be beneficial and well tolerated in one large randomized controlled trial and many smaller studies. Initial data on tumour necrosis factor (TNF) inhibitors are conflicting. There are only a few case reports and mechanistic studies on the treatment of myositis with other biologics, including alemtuzumab, anakinra, tocilizumab and abatacept. We report a patient with severe myositis overlap syndrome, manifesting also as rheumatoid arthritis, peripheral vasculitis and interstitial lung disease. Her myositis was refractory to many conventional and biologic therapies but was well controlled with abatacept. This suggests that abatacept might be a beneficial option for the treatment of refractory myositis and that clinical trials are needed to further investigate its efficacy.

Objective: A systematic review found that an average of 27% of rheumatoid arthritis (RA) patients using tumour necrosis factor (TNF) inhibitors discontinue their treatment within 1year. The aim of this study was to assess drug survival on TNF inhibitors among patients with RA.Methods: Patients were identified from the National Register for Biologic Treatment in Finland (ROB-FIN), which is a longitudinal cohort study established to monitor the effectiveness and safety of biologic drugs in rheumatic diseases. Inclusion was limited to TNF-inhibitor treatments started as the patient's first, second, or third biologic treatment between 2004 and 2014. Follow-up was truncated at 36months. The results of a time-dependent Cox proportional hazards model were reported as adjusted hazard ratios (HRs) with 95% confidence intervals (CIs).Results: Of the 4200 TNF-inhibitor treatment periods identified from ROB-FIN, 3443 periods from 2687 patients met the inclusion criteria. Twenty-seven per cent of the patients discontinued their treatment within 12months. Infliximab (HR 1.8, 95% CI 1.3-2.5) and certolizumab pegol (HR 1.7, 95% CI 1.2-2.3) had lower drug survival compared to golimumab. A similar trend was seen with adalimumab (HR 1.2, 95% CI 0.90-1.7) and etanercept (HR 1.2, 95% CI 0.87-1.6). Concomitant use of methotrexate (MTX) was associated with improved drug survival (HR 0.76, 95% CI 0.64-0.90) in comparison with TNF-inhibitor monotherapy.Conclusions: Golimumab was better in terms of drug survival than infliximab or certolizumab pegol and at least as good as adalimumab and etanercept. Concomitant use of MTX improved drug survival on TNF inhibitors.

Objective To study whether adding initial infliximab to remission-targeted initial combination-DMARD treatment improves the long-term outcomes in patients with early rheumatoid arthritis (RA). Methods Ninety-nine patients with early, DMARD-naive RA were treated with a triple combination of DMARDs, starting with methotrexate (max 25 mg/week), sulfasalazine (max 2 g/day), hydroxychloroquine (35 mg/kg/week), and with prednisolone (7.5 mg/day), and randomised to double blindly receive either infliximab (3 mg/kg; FIN-RACo+INFL) or placebo (FIN-RACo+PLA) infusions during the first 6 months. After 2 years the treatment strategies became unrestricted, but the treatment goal was strict ACR remission. At 5 years the clinical and radiographic outcomes were assessed. Results Ninety-one patients (92%) were followed up to 5 years, 45 in the FIN-RACo+INFL and 46 in the FIN-RACo+PLA groups. At 5 years, the respective proportions of patients in strict ACR and in disease activity score 28 remissions in the FIN-RACo+INFL and FIN-RACo+PLA groups were 60% (95% CI 44% to 74%) and 61% (95% CI 45% to 75%) (p=0.87), and 84% (95% CI 71% to 94%) and 89% (95% CI 76% to 96%) (p=0.51). The corresponding mean (SD) total Sharp/van der Heijde scores at 5 years were 4.3 (7.6), and 5.3 (7.3), while the respective mean Sharp/van der Heijde scores changes from baseline to 5 years were 1.6 (95% CI 0.0 to 3.4) and 3.7 (95% CI 2.2 to 5.8) (p=0.13). Conclusions In early RA, targeted treatment with a combination of traditional DMARDs and prednisolone induces remission and minimises radiographic progression in most patients up to 5 years; adding initial infliximab for 6 months does not improve these outcomes.

BACKGROUND: Mortality from coronary heart disease (CHD) remains at quite notable levels. Research on the risk factors and the treatment of CHD has focused on physiological factors, but there is an increasing amount of evidence connecting mental health and personality traits to CHD, too. The data concerning the connection of CHD and dispositional optimism and pessimism as personality traits is relatively scarce. The aim of this study was to investigate the connection between optimism, pessimism, and CHD mortality. METHODS: This was an 11-year prospective cohort study on a regional sample of three cohorts, aged 52-56, 62-66, and 72-76 years at baseline (N = 2815). The levels of dispositional optimism and pessimism of the study subjects were determined at baseline using a revised version of the Life Orientation Test (LOT-R). Eleven years later, those results and follow-up data about CHD as a cause of death were used to calculate odds. Adjustments were made for cardiovascular disease risk. RESULTS: Those who died because of CHD were significantly more pessimistic at baseline than the others. This finding applies to both men and women. Among the study subjects in the highest quartile of pessimism, the adjusted risk of death caused by CHD was approximately 2.2-fold (OR 2.17, 95 % CI 1.21-3.89) compared to the subjects in the lowest quartile. Optimism did not seem to have any connection with the risk of CHD-induced mortality. CONCLUSIONS: Pessimism seems to be a substantial risk factor for death from CHD. As an easily measured variable, it might be a very useful tool together with the other known risk factors to determine the risk of CHD-induced mortality. BioMed Central open access

Genetic polymorphisms of the IL10 promoter region have been implicated in many autoimmune diseases, including seronegative spondyloarthropathies. We studied three SNPs (IL10-1087, -824, and -597) and two microsatellites (IL10R and IL10G) lying within the promoter region of IL10 for association with susceptibility to and clinical manifestations of ankylosing spondylitis (AS), a common form of spondyloarthritis. Four hundred and sixty-eight individuals from 182 Finnish families affected with AS were studied. No association between individual IL10 promoter region polymorphisms or marker haplotype was observed with susceptibility to AS, but weak association was noted between the IL10-597 and -824 SNPs and age of disease onset (P=0.01 for each SNP). The IL10.G4 allele was associated with BASFI (corrected for disease duration) (P=0.03). We conclude that IL10 promoter polymorphisms have no significant effect on susceptibility to AS, but may play a minor role in determining age of disease onset and disease severity.

Objectives. To determine whether genetic polymorphisms in or near the transforming growth factor beta1 (TGFB1) locus were associated with susceptibility to or severity of ankylosing spondylitis (AS). Methods. Five intragenic single-nucleotide polymorphisms (SNP) and three microsatellite markers flanking the TGFB1 locus were genotyped. Seven hundred and sixty-two individuals from 184 multiplex families were genotyped for the microsatellite markers and two of the promoter SNPs. One thousand and two individuals from 212 English and 170 Finnish families with AS were genotyped for all five intragenic SNPs. A structured questionnaire was used to assess the age of symptom onset, disease duration and disease severity scores, including the BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and BASFI (Bath Ankylosing Spondylitis Functional Index). Results. A weak association was noted between the rare TGFB1 +1632 T allele and AS in the Finnish population (P = 0.04) and in the combined data set (P = 0.03). No association was noted between any other SNPs or SNP haplotype and AS, even among those families with positive non-parametric linkage scores. The TGFB1 +1632 polymorphism was also associated with a younger age of symptom onset (English population, allele 2 associated with age of onset greater by 4.2 yr, P = 0.05; combined data set, allele 2 associated with age of onset greater by 3.2 yr, P = 0.02). A haplotype of coding region SNPs (TGFB1 +869/+915+1632 alleles 2/1/2) was associated with age of symptom onset in both the English parent-case trios and the combined data set (English data set, haplotype 2/1/2 associated with age of onset greater by 4.9 yr, P = 0.03; combined data set, haplotype 2/1/2 associated with greater age of onset by 4.2 yr, P = 0.006). Weak linkage with AS susceptibility was noted and the peak LOD score was 1.3 at distance 2 cM centromeric to the TGFB1 gene. No other linkage or association was found between quantitative traits and the markers. Conclusion. This study suggests that the polymorphisms within the TGFB1 gene play at most a small role in AS and that other genes encoded on chromosome 19 are involved in susceptibility to the disease.

Objective Efficacy of TNF inhibitors in the treatment of RA assessed in randomized controlled trials (RCTs) may not be fully comparable to routine care owing to the stringent inclusion criteria. The objective of this study was to observe the effectiveness of TNF inhibitors in real-world patients and assess the patients' potential eligibility for the RCTs. Methods RA patients starting a TNF-inhibitor treatment between 2004 and 2014 were identified from the National Register for Biologic Treatment in Finland, which is a longitudinal observational cohort study. Effectiveness was measured using the ACR and EULAR response criteria and by studying the proportion of patients reaching DAS28 remission. The patients' baseline characteristics were compared against the inclusion criteria of 27 RCTs. Results EULAR moderate and good treatment responses at 6 months were achieved by 69 and 40% of the users of the first TNF inhibitor, respectively. ACR20, ACR50 and ACR70 responses were reached by 48, 27 and 13%, respectively. DAS28 remission was reached by 47%. Only 7.6-44% of the patients would have been potentially eligible for the RCTs. The eligible patients had better treatment responses compared with the non-eligible patients. Different TNF inhibitors were mostly equipotent, but the usage of MTX co-therapy had a major influence on treatment response. Conclusion Only a small proportion of patients would have been eligible for RCTs, and the efficacy of TNF inhibitors assessed in them cannot be generalized directly into Finnish routine health care.

Objectives To assess the prevalence of coronary heart disease (CHD) and chronic hypertension among patients with rheumatoid arthritis (RA) at the time of diagnosis, in comparison with age-specific and sex-specific non-RA subjects. Furthermore, the impacts of age at the onset of RA, as well as gender and the presence of rheumatoid factor (RF) on the risk of these comorbidities, were evaluated. Methods A cohort of 7209 RA patients diagnosed between January 2004 and December 2007 was identified, based on a Finnish nationwide register on special reimbursements for medication costs. The presence of CHD and chronic hypertension antedating the diagnosis of RA was identified from the same register. The prevalence of the cardiovascular comorbidities was compared with the general Finnish population, and a standardised rate ratio (SRR) for both these cardiovascular diseases was calculated. Results The risk of having CHD at RA diagnosis was slightly elevated, the SRR being 1.10 (95% CI 1.01 to 1.20). Younger age at the onset of RA seemed to be related with higher SRR for CHD. In a subset analysis, an increased prevalence of hypertension (SRR 1.19, 95% CI 1.10 to 1.30) and CHD (SRR 1.15, 95% CI 1.00 to 1.32) was apparent only among the RF negative RA cases. Conclusions The SRR for CHD is augmented in RA patients already at disease onset, and more pronouncedly in early onset RA. The findings highlight the importance of early prevention of atherosclerosis, regardless of RF status.

ObjectiveEarly treatment of patients with rheumatoid arthritis (RA) with combination treatment starting with methotrexate, sulfasalazine, hydroxychloroquine and prednisolone (FIN-RACo strategy) is superior to monotherapy. A study was undertaken to determine whether infliximab (INFL) added to intensified FIN-RACo treatment for the initial 6 months improves the 2-year outcome.Methods99 patients with early untreated active RA were enrolled in an investigator-initiated, randomised, double-blind, multicentre, parallel-group trial. Primary outcomes were remission and radiological changes at 2 years. All patients started with FIN-RACo. In addition, they were randomised to receive INFL or placebo (Pla) from weeks 4 to 26.ResultsAt 24 months, 66% and 53%, respectively, of the patients in the FIN-RACo+INFL and FIN-RACo+Pla groups were in remission according to the modified American College of Rheumatology (ACR) criteria (p=0.19), 26% and 10% were in sustained modified ACR remission (p=0.042) and 82% in both groups were in remission by 28-joint disease activity score (not significant). Mean changes in the total Sharp-van der Heijde score were 0.2 and 1.4, respectively (p=0.0058).ConclusionsMost patients with early active RA achieve clinical remission and develop negligible joint damage with the intensified FIN-RACo regimen. Adding INFL for the first 6 months delays radiological progression.

Rheumatoid arthritis (RA) is a chronic inflammatory disease which is associated with an increased cardiovascular (CV) burden. Whether the risk is already present at the time of RA diagnosis remains a key area of debate. The aim of this review was to evaluate the existence of both subclinical CV changes, including endothelial dysfunction and atherosclerosis, CV risk factors, as well as CV disease manifestations such as coronary heart disease, myocardial infarction, congestive heart failure and CV death prior to RA diagnosis and during the first few years of the disease. The state of the endothelial function remains controversial in patients with newly diagnosed RA. Studies with impaired brachial artery vasodilatory responses at baseline showed a reversal of the dysfunction after 6-12 months of anti-inflammatory therapy. Morphological evidence of arterial wall atherosclerosis, measured by carotid artery intima-media thickness or the prevalence of carotid plaques, was already present during the first year following RA diagnosis. The risk of coronary heart disease and myocardial infarction is increased even prior to and, at the latest, within 1 year of the clinical onset of RA. The prevalence of hypertension was similar among patients with RA and controls. CV mortality may not increase within the first years of RA diagnosis. In conclusion, the CV risk seems to increase sooner after the RA diagnosis than previously thought. In addition to systematic CV risk assessment, patients with early RA might benefit from being targeted with stricter than conventional CV risk prevention and intervention.

The first patient entered the Rheumatism Foundation Hospital, Heinola, Finland in July 1951. From that point on, the hospital helped patients suffering from rheumatic disorders. Specialists in the hospital actively developed treatments and published a large number of scientific articles in international journals. The hospital was well known internationally among people working in the field. Progress in the development of disease-modifying medication (biological agents in particular) has dramatically improved the life of patients with rheumatic diseases, but all effective treatments may also have adverse effects. In this article, we briefly review the history of the Rheumatism Foundation Hospital, which was closed permanently in March 2010 due to bankruptcy. The economical difficulties were caused primarily by the progress made in disease-modifying therapy, which decreased the need of rehabilitation and operative treatment of patients with rheumatic diseases. It seems that a great success in biological agents can carry "serious adverse effects", which may kill hospitals. This is an important primary observation, which should be noticed when the future of specialised institutes is planned.

To investigate how inflammation and metabolic syndrome (MetS) are associated with adipokine levels in patients with inflammatory arthritis.Fifty-four female patients with arthritis were enrolled in the study. Twenty (37%) of these patients had MetS, which was diagnosed according to the definition of the International Diabetes Federation (IDF). Interleukin (IL)-6 and four adipokines (resistin, leptin, adiponectin, and adipsin) were determined by immunoassay. Healthy women with body mass index (BMI) between 22 and 25 kg/m(2) served as controls.The patients with arthritis had higher levels of resistin than the healthy controls. This difference was clear in patients without MetS (17.4 in patients vs. 10.8 ng/mL in controls, p0.001), and even higher resistin levels were found in the patients with MetS (20.7 ng/mL; p0.001 vs. healthy controls; and p = 0.095 vs. patients without MetS). In the patients with arthritis and MetS, resistin correlated positively with IL-6 (Pearson's r = 0.5, p = 0.03). Leptin levels were increased in arthritis patients with MetS as compared to healthy controls, but not in patients without MetS. The statistically significant difference between patients with MetS and controls remained when leptin was adjusted with BMI. Accordingly, adiponectin levels were lower in patients with MetS than in healthy controls (p0.05). Leptin, adiponectin, and adipsin did not correlate with the inflammatory cytokine IL-6 or with C-reactive protein (CRP).The results show that high resistin levels are associated with arthritis independently of MetS, whereas leptin is increased only in arthritis patients with MetS.

Resume Objectifs L’objectif de cette etude etait d’etudier le tableau clinique des patients atteints de polyarthrite rhumatoide avec subluxation atloido-axoidienne anterieure (SAAa), subluxation atloido-axoidienne verticale (SAAv ou impression basilaire), ou leur association. Methodes Cent cinquante-six patients ont ete etudies. La SAAa etait diagnostiquee sur des radiographies standard de profil du rachis cervical en flexion. La SAAv etait recherchee radiographiquement par la methode de Sakaguchi-Kauppi. L’amplitude de la mobilite cervicale etait mesuree et la capacite fonctionnelle du patient evaluee. Les donnees cliniques des patients provenaient de leurs dossiers medicaux. Resultats Cent trente-huit (88 %) patients avaient une SAAa et 69 (44 %) une SAAv. Quarante patients (48 %) avaient une SAAa severe combinee a une SAAv, tandis que 11 (21 %) patients avec une SAAa legere ou moderee avaient une SAAv associee. L’amplitude de la mobilite cervicale (ROM) etait reduite chez les patients avec SAAv, par comparaison avec les patients avec SAAa seule. La rotation (p Conclusion Les patients qui presentent des lesions atloido-axoidiennes peuvent ne pas etre douloureux. La cervicalgie, provoquee en position verticale et soulagee lors du repos au lit, est le plus souvent due a une SAAv. L’amplitude de la mobilite cervicale peut etre normale dans la SAAa simple alors que la rotation est typiquement reduite quand survient une SAAv.

Resume Objectifs Decrire les principales dimensions des vertebres cervicales et du canal vertebral cervical dans un groupe de patients atteints d’arthrite junevile idiopathique (AJI) et dans un groupe temoin de patients sans maladie inflammatoire. Methodes Au total, 158 patientes de sexe feminin ont ete incluses dans trois groupes distincts : un groupe ayant une AJI severe et compliquee, un groupe ayant une AJI non severe, un groupe de patientes atteintes d’une fibromyalgie. Les donnees cliniques et radiographiques du rachis cervical ont ete recueillies a l’âge adulte (plus de 17 ans). Resultats Les patientes ayant une AJI severe avaient une surface moyenne des corps vertebraux de C3 a C6, ainsi qu’une largeur et une hauteur des corps vertebraux de C3 a C6, significativement plus basse que les patientes ayant une AJI non severe et que celles ayant une fibromyalgie. La valeur moyenne de la difference maximale entre les surfaces des vertebres contigues de chaque patiente etait significativement plus importante dans le groupe avec AJI severe par rapport aux autres groupes (p = 0,047 ; apres ajustement pour la taille corporelle). Il n’a pas ete observe de difference significative du diametre sagittal moyen du canal vertebral cervical entre les groupes. Conclusions Les modifications inflammatoires du rachis cervical sont frequentes au cours des AJI et il a ete decrit des troubles de croissance des vertebres cervicales. Nous avons trouve que les patientes atteintes d’une forme severe et compliquee d’AJI avaient des corps vertebraux cervicaux de plus petite taille que la moyenne. Chez ces patientes, on observe egalement que les differences entre la taille des corps vertebraux sont plus importantes, traduisant des troubles de la croissance locale. Cela est probablement la consequence de la maladie inflammatoire et/ou de traitements pharmacologiques plus intensifs. Le diametre du canal vertebral cervical n’etait que legerement plus petit chez les patients ayant une AJI severe. En consequence, les troubles de croissance des corps vertebraux n’augmentent pas, en general, le risque de stenose du canal cervical au cours des AJIs.

Objective.To evaluate the 5-year incidence of cervical spine disorders in patients with early rheumatoid arthritis (RA) treated by 2 different disease modifying antirheumatic drug (DMARD) strategies.Methods.In a national, multicenter, prospective FIN-RACo-trial, a cohort of 199 patients with early, clinically active RA was randomly assigned to treatment with a combination of 3 DMARD and prednisolone (Combi group) or with a single DMARD (Single group) with or without prednisolone, aiming to induce remission. After 2 years, the DMARD therapy was unrestricted. Lateral view cervical spine radiographs during full flexion and extension were taken at the 5-year followup visits. The presence of anterior atlantoaxial subluxation (aAAS), atlantoaxial impaction (AAI), and subaxial subluxation (SAS) was assessed in the 149 patients with radiographs available (80 Single and 69 Combi).Results.At the 5-year visits, aAAS, AAI, and SAS were found in 13 (9%), 6 (4%), and 9 (6%) patients, respectively. The corresponding Single/Combi group ratios were 11/2, 5/1, and 5/4. Of the baseline data, only poor physical function [Health Assessment Questionnaire (HAQ); p = 0.024] and Single treatment strategy (p = 0.019) were significantly associated with aAAS. Worse HAQ scores and Disease Activity Score 28 values were found in patients who developed aAAS during the 5-year followup.Conclusion.RA patients with sustained clinical disease activity and poor HAQ are at increased risk of developing aAAS. The development of aAAS during the first 5 years of RA was rare among the patients treated with a combination of DMARD for at least 2 years from the diagnosis. Intensive treatment with traditional DMARD prevents or retards the development of aAAS in patients with recentonset RA.

To describe the effects of rituximab therapy in patients with rheumatoid arthritis (RA) in routine clinical practice in Finland.Data were collected retrospectively from patient records in five rheumatology clinics in Finland. All RA patients treated during 2005-2008 (n = 81) were included. Information on disease-modifying anti-rheumatic drugs (DMARDs), DMARD combinations, and biologics prior to rituximab use was collected as well as treatment responses after initiating rituximab therapy. The Disease Activity Score using 28 joint counts (DAS28) was used to determine disease activity and European League Against Rheumatism (EULAR) responses.Mean disease duration was 14 (range 0-47) years and the median number of prior DMARDs and biologics used were 7 (1-12) and 2 (0-4), respectively. Efficacy analysis was performed on 57 patients with available DAS28 data at treatment onset and follow-up visits. Median DAS28 declined from 6.07 (3.19-7.70) to 3.99 (1.53-6.55) by the first rituximab treatment course. Altogether 77% of the patients achieved a EULAR response, 26% with a good response including 18% with remission. Furthermore, the patients treated concomitantly with DMARDs other than methotrexate (MTX) achieved a EULAR response slightly more often than the patients on MTX (85% vs. 70%) only. A second course of rituximab was given to 48% of the patients on an average of 9 months after initial therapy, with the median DAS28 score declining further to 3.49 (0.1-5.74). Safety and tolerability assessment of the 81 patients indicates rituximab to be well tolerated.Rituximab can effectively control disease activity in patients with active disease and poor response to previous therapies, in combination with MTX but also with other DMARDs.

Resume Objectif Dans le but de verifier les modifications du statut mineral osseux du squelette axial, nous avons realise une etude de suivi sur deux ans de la densite minerale osseuse (DMO) axiale et du contenu mineral osseux (CMO) chez des femmes en premenopause atteintes de polyarthrite rhumatoide (PR) traitees ou non avec de la prednisolone (PRED). Methodes Des femmes en premenopause atteintes de PR ( n = 74) qui se rendaient au Rheumatism Foundation Hospital a Heinola en Finlande ont ete recrutees de maniere consecutive pour un suivi de la DMO. Les mesures de la DMO ont ete prises du rachis lombaire et l'extremite proximale du femur gauche (col femoral) par absorptiometrie biphotonique au debut de l'etude et apres deux annees. La DMO a ete exprimee par le CMO rapporte a la surface de projection, en g/cm 2 . Le score de Larsen entre 0 et 100 a ete evalue a chaque controle. Deux groupes de PR ont ete analyses : les patientes recevant de la prednisolone ( n = 48), groupe PR avec PRED et celles n'en recevant pas ( n = 26), groupe PR sans PRED. Le groupe temoin ( n = 43) etait compose de femmes en premenopause appartenant au meme groupe d'âge. Resultats Au depart, les patientes du groupe PR avec PRED ont une DMO plus faible que celles du groupe PR sans PRED. La moyenne en pourcentage de la modification de la DMO ajustee au poids au niveau du rachis lombaire est –1,5 % dans le groupe PR avec PRED, +0,6 % dans le groupe PR sans PRED et –0,6 % chez les temoins ; une difference significative est observee ( p = 0,030) entre les groupes PR. La moyenne en pourcentage de la modification du CMO deux ans plus tard sur le rachis lombaire est –2,2 % dans le groupe PR avec PRED ( p = 0,003), +0,0 % dans le groupe PR sans PRED et –0,6 % dans le groupe temoin. La moyenne de la modification de la DMO ajustee au poids au niveau du col femoral a deux ans est –2,6 % dans le groupe PR avec PRED, +0,4 % dans le groupe PR sans PRED et –0,9 % chez les temoins ; la encore la difference entre les groupes PR est significative ( p = 0,049). La modification en pourcentage du CMO apres deux ans au niveau du col femoral est –1,9 % ( p = 0,006), –0,4 et 0,8 % respectivement. La DMO moyenne n'a diminue de maniere significative au niveau du rachis lombaire ( p = 0,002) et du col femoral ( p Conclusion D'apres le CMO, la perte de tissu osseux chez les femmes en premenopause, avec ou sans traitement par la prednisolone, et chez les temoins est statistiquement semblable. Il semble que le role de la PR elle-meme dans le developpement multifactoriel de la masse osseuse axiale pendant la premiere decennie de la PR severe ne soit pas la question la plus essentielle. Nous presumons que ce role aura moins d'importance avec un traitement de la PR meilleur que celui recu par nos patientes. La quantite d'os perdu pendant le traitement avec la prednisolone a doses faibles fait toujours l'objet de controverses.

Objective: To determine the influence of HLA-B27 homozygosity and HLA-DRB1 alleles in the susceptibility to, and severity of, ankylosing spondylitis in a Finnish population. Methods: 673 individuals from 261 families with ankylosing spondylitis were genotyped for HLA-DRB1 alleles and HLA-B27 heterozygosity/homozygosity. The frequencies of HLA-B27 homozygotes in probands from these families were compared with the expected number of HLA-B27 homozygotes in controls under Hardy–Weinberg equilibrium (HWE). The effect of HLA-DRB1 alleles was assessed using a logistic regression procedure conditioned on HLA-B27 and case–control analysis. Results: HLA-B27 was detected in 93% of cases of ankylosing spondylitis. An overrepresentation of HLA-B27 homozygotes was noted in ankylosing spondylitis (11%) compared with the expected number of HLA-B27 homozygotes under HWE (4%) (odds ratio (OR) = 3.3 (95% confidence interval, 1.6 to 6.8), p = 0.002). HLA-B27 homozygosity was marginally associated with reduced BASDAI ( HLA-B27 homozygotes, 4.5 (1.6); HLA-B27 heterozygotes, 5.4 (1.8) (mean (SD)), p = 0.05). Acute anterior uveitis (AAU) was present in significantly more HLA-B27 positive cases (50%) than HLA-B27 negative cases (16%) (OR = 5.4 (1.7 to 17), p HLA-B27 positive cases had a lower average age of symptom onset (26.7 (8.0) years) compared with HLA-B27 negative cases (35.7 (11.2) years) (p Conclusions: HLA-B27 homozygosity is associated with a moderately increased risk of ankylosing spondylitis compared with HLA-B27 heterozygosity. HLA-B27 positive cases had an earlier age of onset of ankylosing spondylitis than HLA-B27 negative cases and were more likely to develop AAU. HLA-DRB1 alleles may influence the age of symptom onset of ankylosing spondylitis.

Objective: To study the prevalence of cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopaedic surgery, and symptoms that might be associated with the disorders. Methods: 194 patients with rheumatoid arthritis were referred for orthopaedic surgery at Jyvaskyla Central Hospital, 154 (79%) of whom volunteered for the present study including clinical examination, laboratory tests, radiographs of the cervical spine, hands, and feet, and self report questionnaires. Definition of anterior atlantoaxial subluxation (aAAS) was >3 mm and of subaxial subluxation (SAS) ⩾3 mm. Atlantoaxial impaction (AAI) was analysed following to the Sakaguchi-Kauppi method. Results: 67 patients (44%) had cervical spine subluxation or previous surgical fusion. The prevalence of aAAS, AAI, SAS, or previous fusion was 27 (18%), 24 (16%), 29 (19%), and 8 (5%), respectively; 69% of patients with cervical spine subluxations (those with fusions excluded) reported neck pain, compared with 65% of patients without subluxations (p = 0.71). The prevalence of occipital, temporal, retro-orbital, and radicular pain in upper extremities was similar in patients with or without cervical spine subluxations (54% v 43%; 17% v 31%; 25% v 24%; 47% v 48%, respectively). However, patients with subluxations were older, had longer disease duration, more active disease, poorer function according to the Health Assessment Questionnaire, and had more often erosive disease. Conclusions: Asymptomatic cervical spine subluxation is common in patients with rheumatoid arthritis waiting for orthopaedic surgery. Regardless of symptoms, the possibility of cervical spine subluxation in patients with severe rheumatoid arthritis should be considered in preoperative evaluation.

Rheumatoid involvement of the 24 joints of the cervical spine leads to prominent changes in the occipito-atlanto-axial area. Eight different subtypes of such changes are recognized, depicted, and defined. The frequencies of these 8 subtypes in rheumatoid arthritis and other arthritides are tabulated. A central role in these disorders is played by a small-size, heavy-duty fitting piece or adapter, atlas, between the occiput and C2. The history of the fate of Atlas, who led the fight of godlike titans against the new gods of Olympos, is recapitulated. In particular, for a short moment Atlas was released from his heavy physical ordeal by another strongman, the heavy-weight wrestler of his times, Heracles. The reasons for the current nomenclature and answer to the question "Why Atlas, why not Heracles" are provided.

Objective: To evaluate the validity and reliability of the Finnish version of the Arthritis Impact Measurement Scales (AIMS2) in Finnish patients with rheumatoid arthritis (RA).Methods: The reliability of the Finnish AIMS2 (Finn‐AIMS2) questionnaire was assessed by test–retest procedure and internal consistency of health‐status scales. Construct validity was assessed by factor analysis, and convergent validity by correlation coefficients, with several disease activity and functional status variables.Results: Internal consistency was 0.79–0.89 and test–retest reliability 0.72–0.97. Factor analysis identified three factors: physical, psychosocial, and pain. There were strong correlations between the Finn‐AIMS2 health‐status scales and the Health Assessment Questionnaire (HAQ).Conclusion: The Finn‐AIMS2 questionnaire is a reliable and valid instrument for measuring health status in middle‐aged Finnish patients with RA. The results also support the applicability of AIMS2 in comparisons in multinational studies.

Objective To study the prevalence of cervical spine subluxations and predictive factors for atlantoaxial subluxations (including anterior atlantoaxial subluxation and atlantoaxial impaction, i.e., vertical subluxation) in patients with rheumatoid arthritis (RA) who were treated early and continuously with disease-modifying antirheumatic drugs for 8–13 years. Methods Radiographs of the cervical spine were obtained in 103 of 110 patients (the 110 surviving patients of the original 135-patient cohort) at their 8–13-year followup visits. The prevalence of cervical spine subluxations was determined. Demographic variables and the first 5-year serial data concerning disease course were analyzed in a logistic regression model to find predictive factors for atlantoaxial subluxations. Results Atlantoaxial subluxations were found in 14 patients (14%), and 5 patients (5%) had subaxial subluxations. Older age at baseline, greater disease activity during the first 5 years, and early erosiveness in peripheral joints predicted the development of atlantoaxial subluxations. Patients who had ≥10% of the maximum possible radiographic damage (by Larsen score) in peripheral joints at 5 years were 15.9 times more likely to develop atlantoaxial subluxations at 8–13 years than patients whose peripheral joint damage remained

The objective of the study was to determine the long-term functional outcome of chronic spondylarthropathy (SpA) when measured by various functional indices. This information is important in the planning of long-term intervention studies and selection of the best follow-up methods. The study group consisted of 65 patients (21 women and 44 men) with SpA. Their mean age was 49 years and the mean age from diagnosis was 12 years. They completed several questionnaires (developed for the evaluation of functional capacity or the state of health of patients with SpA) at the beginning of the study and 3 years later. The questionnaires were: the Bath Ankylosing Spondylitis Functional Index (BASFI), the Dougados Functional Index (DFI), the Health Assessment Questionnaire for Spondylarthropathies (HAQ-S), the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Patient Global Assessment (BAS-G) and Stiffness-VAS (on a visual analogue scale). We also asked the patients to inform us if something had occurred in their lives during the follow-up that might have affected their health. Most of the indices (BASFI, DFI, BASDAI, BAS-G and Stiffness-VAS, but not HAQ-S) showed a statistically significant reduction in the functional capacity or state of health of the patients during the follow-up. Many factors occurring during the 3-year period may have influenced the results of the indices. The natural course of the functional capacity of patients with SpA appears to be one of impairment, when evaluated using these indices. Our experience also showed that it is very difficult to separate any effect of a single treatment intervention (e.g. rehabilitation) in a long-term follow-up study, as so many interfering factors, e.g. life events and health-related factors, may affect the follow-up population over several years.