Rheumatoid arthritis may take an unfavourable course leading to rapid functional decline in a certain percentage of patients. Early identification of these patients is desirable. The aim of this study was to evaluate clinical and laboratory parameters for their value in the prediction of bad outcome. A total of 172 patients with early arthritis were followed for 3 years. Higher initial values for erythrocyte sedimentation rate, IgG and IgM rheumatoid factor, serum concentration of cartilage oligomeric matrix protein, Health Assessment Questionnaire score, Larsen score of feet, disease activity score, and swollen and tender joint count predicted worse outcome. An association with the presence of IgA rheumatoid factor or anti-cyclic-citrullinated peptide could not be established. We conclude that prognosis in an individual with rheumatoid arthritis depends on many factors. The determination of independent prognostic factors for progression of rheumatoid arthritis is a valuable tool in early arthritis to select patients for more aggressive therapy.

OBJECTIVE:To compare late onset with adult onset rheumatoid arthritis.METHODS:Fifty-eight patients with late onset rheumatoid arthritis (LORA) were compared to 117 patients with adult onset rheumatoid arthritis (AORA) with respect to clinical and functional parameters. Furthermore, in 104 patients serum cartilage oligomeric matrix protein (COMP) was measured. Results were compared by means of ANOVA and possible influences of age, gender and clinical parameters were evaluated by Spearman rank correlation.RESULTS:Except a different distribution in gender (40% males in the LORA group) and a higher ESR, no differences could be found with respect to clinical parameters. However, a significantly higher HAQ score and significantly higher serum-COMP levels could be shown in the LORA group. HAQ scores correlated not only with disease activity parameters (C-reactive protein, disease activity score) but also with the age. Serum-COMP levels did show a correlation with the age as well, but not with disease activity.CONCLUSION:It is concluded that the higher serum-COMP levels in late onset rheumatoid arthritis could be due to concomitant osteoarthritic processes in larger joints, which are not symptomatic. The age dependence of the HAQ score is only weak, but may be the reason why patients with LORA show a worse functional capacity compared to patients with adult onset rheumatoid arthritis.

Bei 58 von 175 Patienten mit chronischer Polyarthritis lag der Krankheitsbeginn nach dem 60. Lebensjahr. Es konnten somit 58 Patienten mit Alters-Polyarthritis mit den 117 Patienten mit Erwachsenenen-Polyarthritis bezüglich klinischer Parameter und der Funktionskapazität verglichen werden. Bei 104 Patienten wurde zusätzlich das Cartilage Oligomeric Matrix Protein (COMP) im Serum bestimmt.    Neben den bekannten Unterschieden zwischen den beiden Krankheitsentitäten – der Anteil der Männer lag bei Alters-Polyarthritis nur gering unter dem der Frauen, die Blutsenkungsgeschwindigkeit war bei Alters-Polyarthritis erhöht – fand sich bei Patienten mit Alters-Polyarthritis ein signifikant schlechterer funktioneller Wert gemessen am HAQ (Health Assessment Questionnaire) und ein signifikant höherer Serum-COMP-Wert. In Korrelationsuntersuchungen konnte gezeigt werden, dass beide Parameter altersabhängig waren. Während der HAQ auch mit den Entzündungsparametern positiv korrelierte, konnte ein solcher Zusammenhang für Serum-COMP nicht nachgewiesen werden.    Es wird daraus geschlossen, dass bezüglich der Krankheitsaktivität aber auch der funktionellen Kapazität und des COMP-Spiegels kein sicherer direkter Unterschied zwischen den Krankheitsentitäten besteht. Die gefundenen Unterschiede könnten altersabhängig sein, insbesondere begleitende arthrotische Prozesse in großen Gelenken könnten zu höheren COMP-Spiegeln im Alter beitragen.

98 patients were admitted for rehabilitation after knee arthroplasty (85 females, 13 males). 58 patients were younger than 70, 40 patients were 70 or more years old. Patients were examined at admittance (about 2 months after surgery), 4 weeks later and one year after surgery. Pain, consumption of analgesics, walking distance, joint mobility, activity of daily living were recorded and compared with gender, age, bodymass index, type of prosthesis, number and type of concomitant diseases. Inpatient rehabilitation resulted in a significant improvement of nearly all parameters in the study group. It turned out that none of the patient variables had an influence on the result of the rehabilitation; a trend could be seen only with the diagnosis - the results of patients with rheumatoid arthritis were not as good as with osteoarthritis patients. In aged patients, inpatient rehabilitation after knee arthroplasty had an equally beneficial effect as seen in younger patients.

This study was aimed at answering the question of whether a four-week inpatient early rehabilitation programme, i.e. within the first two months following total hip replacement surgery, will have a favourable impact as compared to later-onset inpatient rehabilitation measures; a total of 219 patients was studied: 137 were admitted during the first two months post-op (group A), 45 within three to four months post op (group B), and 37 patients were admitted at a later date (group C). Assessments were carried out for pain, walking performance and self-help status (scores) as well as for mobility, gait patterns, walking aids, walking speed, and disablement. In group A patients, significant improvement was achieved for all of these parameters: at the end of the rehabilitation programme (2.4 months post-op) these patients already were more mobile than group B patients at the time of admission (3.3 months post-op). In group B, improvements were found for several parameters. At a later time, the natural healing process had brought about so good a baseline situation in the group C patients that no further improvement was possible. The 162 patients treated successfully, i.e. where score reductions occurred, had been admitted significantly (p = 0.0001) earlier (2.9 months post-op) than the remaining 57 patients (5.7 months post-op). Some 14 months after programme participation, follow-up examinations were possible for 90 patients of group A, and for 27 patients from groups B and C. Further significant improvements had occurred in group A patients only, notably relative to muscle strength and reduction of walking aids. It is concluded from our data that inpatient early rehabilitation will achieve the greatest effect and will substantially reduce the recovery phase with its mobility limitations and daily living handicaps.

159 patients were examined approximately 15 months after hip arthroplasty. 116 of these patients have had at that time point a postoperative 4 week hospital stay for rehabilitation. A score that considered pain at motion and at rest, maximal walking capacity and activity of daily living was used for evaluation. The preoperative conditions did not differ between patients that had their postoperative hospital stay for rehabilitation (n = 116) and those that did not (n = 43). The results at the time of examination were regarded as excellent (group 1; score 3) in 64 (40.3%) patients, as good (group 2; score 4) in 56 (35.2%) patients and as poor (group 3; score > or = 5) in 39 (24.5%) patients. The amount of patients with a hospital stay for rehabilitation was significantly (p = 0.025) higher in the patient groups with excellent or good results in comparison with the patients with poor postoperative outcome. The most excellent results were obtained in patients who had their rehabilitation within the first two months after surgery (p = 0.008). Apart from the above mentioned score the following-additionally assessed-parameters differed significantly between the 3 groups: hip mobility; pain elicited by pressure on the operated joint; pain in the contralateral hip or knee joints; consumption of analgetics; walking time for 15 meters; degree of handicap as assessed by the patient or the occupational therapist or the physician; coping with household activities (for females only). We conclude that a poor result of hip arthroplasty may be due not only to degenerative joint disease of the lower limbs but also (or in combination) to the lack of a postoperative hospital stay for rehabilitation.

159 patients were examined approximately 15 months after hip arthroplasty. 116 of these patients have had Lit that time point a postoperative 4 week hospital slay for rehabilitation. A score that considered pain at motion and at rest, maximal walking capacity and activity of daily living was used for evaluation. The preoperative conditions did nor differ between patients that had their postoperative hospital stay for rehabilitation (n = 116) and those that did not (n = 43). The results at the time of examination were regarded as excellent (group 1, score 3)in 64 (40.3%) patients, as good (group 2; score 4) in 56 (35.2%) patients and as poor (group 3: score > or = 5) in 39 (24.5%) patients. The amount of patients with a hospital stay for rehabilitation was significantly (p = 0.025) higher in the patient groups with excellent or good results in comparison with the patients with poor postoperative outcome. The most excellent results were obtained in patients who had their rehabilitation within the first two months after surgery (p = 0.008). Apart from the above mentioned score the following - additionally assessed - parameters differed significantly between the 3 groups: hip mobility; pain elicited bq pressure on the operated joint; pain in the contralateral hip or knee joints; consumption of analgetics; walking lime for 15 meters; degree of handicap as assessed by the patient or the occupational therapist or the physician; coping with household activities (for females only). We conclude that a poor result of hip arthroplasty may be due not only to degenerative joint disease of the lower limbs but also (or in combination) to the lack of a postoperative hospital slay for rehabilitation.

Aim of the study: To evaluate various symptoms/findings for their ability as prognostic markers in MTX-therapy in patients with rheumatoid arthritis.

1 Institute for Rheumatology in Baden, Austria 2 Ludwig Boltzman Institute for Gerontology. Vienna. Austria 3 Clinic for Rheumatic Diseases for the Social Insurance Company for Trade and Industry, Baden, Austria 4 Clinic for Rheumatic Diseases for the Agricultural Social Insurance Company, Baden, Austria

The diagnostic value of chest X-ray following the ILO standards was compared with bronchoalveolar lavage (BAL) and the histology of transbronchial forceps biopsy in 83 patients with collagen vascular diseases. BAL in the middle lobe was considered abnormal in case of increased cell count per milliliter and/or lymphocytosis and/or neutrophil granulocytosis and this was found in 32 out of 42 cases (76.2%) with, and in 33 of out 41 cases (80.5%) without abnormal radiological finding. Pathological changes in the histology were found in 14 out of 20 cases (70.0%) with and in 40 out of 63 cases (63.5%) without abnormal chest X-ray in the upper lobe from which the transbronchial forceps biopsy specimens were obtained. In histological specimens obtained from transbronchial forceps biopsy, only fibrosis correlated with abnormal radiological findings in this region. Other inflammatory processes defied prediction by chest X-ray. This suggests that, regardless of chest X-ray findings, BAL should be performed together with transbronchial forceps biopsy for the histological examination of patients with collagen vascular diseases in which interstitial lung involvement is suspected.

Population studies suggest an association between RA and, depending on the ethnic background, HLA-DR1 and/or -DR4. One standard regimen for the treatment of RA is the use of gold compounds like SATM to arrest progression of the disease. In the present study, the immunogenetic background of RA patients developing side effects upon SATM treatment was determined. A total of 53 patients under SATM therapy were tested for their HLA-DRB and -DQ alleles by DNA typing; a significantly higher frequency of HLA-DR1 (p < 0.004, uncorrected) was observed in patients presenting with mucocutaneous side effects (MCT) when compared with patients without MCT. The RR was 6.85. Thus, HLA-DR1 seems to be a marker for the susceptibility of gold adverse reactions.

Bronchoalveolar lavage (BAL) was performed on 13 asymptomatic patients with sero (rheumatoid factor)-negative arthritis (SNA); (6 with peripheral psoriatic arthritis, 2 with axial psoriatic arthritis, 3 with ankylosing spondylitis, 2 with sacroiliitis). BAL revealed a significant decrease of neutrophil granulocytes and an increase of B-lymphocytes in patients with SNA in comparison with 64 patiénts with rheumatoid arthritis (RA; 24 seronegative, 39 seropositive) and 15 healthy controls. Patients with SNA and RA had a significant increase of lymphocytes, especially T, T-helper and activated cells. In addition patients with RA had a significant increase of natural killer cells and a lower percentage of alveolar macrophages and T-suppressor cells. Transbronchial biopsy was performed on 9 patients with SNA and on 59 patients with RA. Abnormal histologic features of lung tissue were observed in 4 out of 9 patients with SNA (2 with fibrosis, 1 with follicular lymphoid hyperplasia, 1 with desquamative interstitial pneumonitis). The abnormal lung histology in RA patients was more pronounced, however, the differences between SNA and RA were not significant. The data from BAL and histology suggest, that the pulmonary involvement in SNA and RA is caused by an unspecified immunologic process.

In the present study the ratio of antigen-bound anti-IgG-Fab antibodies (hidden aFab) to free aFab was found to be significantly increased in patients with adult onset rheumatoid arthritis (AORA) as compared to late onset rheumatoid arthritis (LORA). The overall amount of aFab was similar in both groups. The difference was only seen in seropositive patients. Within the seropositive AORA group, the aFab ratio was correlated with the duration and the stage of disease but not with the patients' age at investigation. This might reflect a higher affinity of anti-Fab antibodies and/or a greater diversity of the idiotypic repertoire in adult onset disease resulting in the formation of immune complexes, the stability of which might be enhanced further by the presence of rheumatoid factors. Although a pathophysiological involvement of aFab cannot be concluded from our observations, it is conceivable that different immunoregulatory mechanisms could be operative in RA with onset at different ages.

Bronchoalveolar lavage (BAL) was performed on 70 RA patients, 28 without extra-articular manifestations, nine with pulmonary involvement, 13 with sicca-syndrome, 20 with other extra-articular manifestations such as renal involvement, cutaneous vasculitis and rheumatoid nodules. Fifteen patients without rheumatic or pulmonary disease served as the control group. Compared with the control group RA patients showed a statistically significant increase of lymphocytes, especially of activated (DR+)T(CD3+)-helper (CD4+) cells, resulting in a significantly diminished percentage of alveolar macrophages, B(CD21+)-lymphocytes, T-suppressor (CD8+) cells and an increased CD4/CD8 ratio. This cell distribution pattern was more pronounced in RA patients with lung involvement with significant differences to the other RA patients with regard to lymphocytes, DR positive cells and CD4 positive/DR positive cells. It is concluded that these results indicate an altered balance of immunocompetent cells not only in the joints but also in the lung. The changes are more distinct if local manifestations can be diagnosed clinically.

Bronchoalveolar lavage (BAL) and histology of transbronchial forceps biopsy was performed in 59 patients with rheumatoid arthritis (RA) to evaluate the in vivo effects of disease modifying drugs (DMARD). All patients had no clinical pulmonary symptoms and there was no evidence of drug induced alveolitis. Patients were divided into 5 subgroups according to drug treatment: 9 patients taking chloroquine, 15 patients gold, 8 patients penicillamine, 8 patients methotrexate (MTX) and 19 patients not taking DMARD. Duration of DMARD regimen was more than 3 months. No patient was treated with corticosteroids. BAL results revealed an increased percentage of lymphocytes and a diminished proportion of alveolar macrophages in patients treated with gold, penicillamine, MTX and no DMARD. In contrast, patients receiving chloroquine had a normal distribution of lymphocytes and macrophages as seen in a control group of 15 persons. Patients taking MTX showed a normal distribution of T and B lymphocytes and DR positive cells, whereas patients receiving chloroquine, gold, or penicillamine had an elevated proportion of T lymphocytes and DR positive cells and a diminished percentage of B lymphocytes. The latter was also observed in patients not taking DMARD. The percentage of natural killer cells was significantly elevated only in the penicillamine group. Patients receiving gold had higher absolute values of CD3, CD4 and DR positive cells. Abnormal lung histology was associated with an increased percentage of lymphocytes and with higher DR positive cells in BAL. Patients not receiving DMARD had a significantly higher percentage (42.1%) of abnormal histologic features of lung tissue than patients receiving DMARD (17.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

We initiated the present study to predict interstitial lung involvement in rheumatoid arthritis (RA) by means of logistic regression analysis of clinical data, lung function, chest roentgenogram, and serologic parameters. Fifty-eight nonsmoking patients with RA were randomized from the rheumatologic unit and sent for investigation to the pulmonary department. Bronchoalveolar lavage (BAL) was performed in the middle lobe and the BAL fluid was considered abnormal in case of increased cell count per milliliter and/or lymphocytosis and/or neutrophil granulocytosis; these findings or combinations thereof were found in 42 (72.4 percent) of 58 cases. The patients' data that had an impact on the normality of BAL were the sex (p = 0.001), vital capacity (p = 0.028), peripheral blood T-helper cells (OKT4+) (p = 0.025), DR(+)-lymphocytes (p = 0.002), and antinuclear antibodies (p = 0.025). By means of the logistic regression analysis, it was possible to reach high significance in the prediction of interstitial lung involvement, with a sensitivity of 92.9 percent and a specificity of 75.0 percent (p less than 10(-6)). The efficiency of prediction was 87.9 percent. From these results, we conclude that interstitial lung involvement in RA is predictable from laboratory findings that have been yielded by noninvasive diagnostic techniques. These data should be used in clinical routine monitoring and they may help to facilitate the assessment of whether bronchoscopy is indicated.

A method for the detection of circulating immune complexes in the presence of autoantibodies to C1q is described. Solid phase C1q-digestion with bacterial collagenase results in the elimination of the collagen-like region of C1q. Binding of model immune complexes to this modified solid phase C1q is practically unaltered, while reactivity of anti-C1q antibodies is abolished by this procedure. In conjunction with an ELISA using the collagen-like region of C1q as antigen this modified C1q solid phase assay may be used to determine immune complexes and anti-C1q antibodies in the sera of patients with autoimmune rheumatic diseases.

122 patients were admitted 3 months after a lumbar disc operation to a rehabilitation clinic. Conservative treatment during the rehabilitation induced a decrease of low back pain (70 out of 107 patients), of paresis (30/51 patients), and of paresthesia (51/77 patients). More than 20 pre- and post-operative variables were tested with a rank-variance analysis regarding a possible influence on efficacy of the rehabilitation treatment. The success of the conservative treatment measured by improvement of paresis, paresthesia, pain and mobility of lumbar spine was influenced favourably by preoperative paresis (p less than 0.03). Women showed more often than men an improvement of paresis (p = 0.006) immediately after surgery. Patients with a preoperative paresis had a shorter history of radicular symptoms (p = 0.002), an acute onset was seen more often in patients with persistent paresis (p = 0.019). Paresthesia was found more frequently before surgery (p = 0.010) and at begin of rehabilitation (p = 0.006) in patients with paresis compared to patients without paresis. A statistically significant association was also evaluated between decreased lumbar mobility and laminectomy (p = 0.007). Patients with L5/S1 disc operation had a longer duration of radicular symptoms (p = 0.012), a decreased frequency of paresis (p = 0.040), but more often paresthesia (p = 0.001) compared with L4/5 operation.