Background: Presenteeism is an economic concept that is difficult to identify, measure, and value. Rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) are three chronic auto-immune conditions that increase levels of presenteeism. Workplace interventions (WPIs) help individuals to manage their health condition at work. Existing methods used to quantify the impact of presenteeism are unable to adequately inform the employer of the productive benefits of WPIs. The overall aim of this thesis was to appraise current methods used to quantify presenteeism and to develop methods to value the impact of presenteeism suitable for use in economic evaluations (EE) of WPIs. Methods: Two systematic reviews were conducted: 1) to assess the extent to which self-report measure of presenteeism were underpinned by economic theory; and 2) to explore if, and how, productivity was quantified and included in EE of WPIs for musculoskeletal conditions (MSDs). Thematic analysis methods were used to analyse qualitative data collected from working individuals with RA, AS or PsA (n=22) that explored the extent to which measures of health status (EQ5D; SF6D) and capability (ICECAP-A) capture the impact on ability to work caused by RA, AS or PsA. Econometric methods were used to specify prediction models that included measures of health status, capability and presenteeism, using a sample of 542 working people with RA and AS. Results The first systematic review identified 24 self-report measures of presenteeism; all, except one measure were not underpinned by economic theory. The second systematic review identified 20 EE of WPIs for MSDs. Absenteeism was included in all studies (n=20); however, presenteeism was included in only four. The qualitative data confirmed measures of health status and capability had the ability to capture those aspects of RA, AS and PsA that impact an individual’s ability to work. The best performing prediction model used an OLS specification including SF6D, age and gender to predict presenteeism measured by the WPAI. Conclusion: The results suggest that HRQoL measures, specifically the SF6D, can be used to capture and predict levels of presenteeism caused by RA, AS and PsA.

This research investigated the role of coping strategies in reducing the pain experience of rheumatoid arthritis (RA) patients over a seven-day period. Sixty-three patients completed a twice-daily structured dairy consisting of an eight scale revision of the Ways of Coping (WOC), the depression subscale of the Affects Balance Scale (ABS), and a pain visual analogue scale (VAS). Multivariate analyses for repeated measures identified two coping strategies, Self-Care and Positive Reappraisal, as significantly effective in pain reduction. Self-Care includes behavioral attempts to manage the symptoms of RA. Positive Reappraisal involves cognitive efforts to redefine pain experience in positive terms. The other six coping strategies also demonstrated a trend to increased use on days when pain decreased. These data imply that intraindividual approaches in examining the coping/pain association have potential benefit for determining a causal relation between coping and pain. / Medicine, Faculty of / Cellular and Physiological Sciences, Department of / Graduate

The literature is replete with reports of osteoporosis in rheumatoid arthritis, but the mechanism of bone loss remains obscure. This is probably due to the overlap with bone loss of aging and the menopause, whose exact mechanisms are also poorly understood. Against this background, a study was designed to evaluate generalised bone loss in young, premenopausal (if female), patients with rheumatoid arthritis. The protocol was designed to record demographic data, as well as information pertaining to the disease. Cortical bone mass was measured at the metacarpals and left femur, using an automated, computer-controlled technique. Trabecular bone was evaluated at the left femur (Singh index) as well as at the 3rd lumbar vertebra (Saville index). Bone kinetics were studied by the measurement of urinary excretion of calcium, phosphate and hydroxy-praline (resorption) and serum alkaline phosphatase (formation). Disease activity was measured clinically and with laboratory indices. Physical activity was indirectly measured by quantitating the disability, using the Keitel function test as well as a modified health assessment questionnaire (HAQ). The radiograph of the right wrist was scored by the Larsen index. The carpometacarpal ratio was also calculated from the radiograph. Numerous statistical techniques were applied in the analysis of the data. Healthy volunteers were used as controls. Patients with SLE were also studied, in order to compare the 2 inflammatory diseases. Patients with RA had generalised cortical bone loss (metacarpal and femur) (p < 0.001). Trabecular bone measurements were not significantly different from normals, using the crude radiographic techniques. Duration of disease was the most important clinical determinant of this bone loss. The relative contributions of disease activity and lack of physical activity to the loss of bone could not be adequately separated using conventional statistical techniques. Corticosteroid therapy did not promote metacarpal bone loss in these subjects, but may have contributed to thinning of the femoral cortex. Nonsteroidal anti-inflammatory drugs and disease modifying agents did not seem to influence the extent of the bone loss. Nutritional status and skinfold thickness did not correlate with bone mass. Dietary factors played no role in the genesis of bone loss, but may have had some effect on disease activity. Metacarpal measurements showed a sensitivity of 80% and specificity of 85% in discriminating between osteopaenic and normopaenic groups with RA. Osteopaenia could not be adequately predicted in the absence of metacarpal measurements. Metacarpal bone loss in RA was due to endosteal resorption, while in SLE it was due to periosteal resorption. The semi-automatic technique for measurement of metacarpal bone mass showed good reproducibility among 5 observers and at 2 different centres. The pathogenesis of bone loss in RA was multifactorial, the largest contribution probably coming from a humoral factor in the circulation, closely related to disease activity. Ionised calcium was elevated in 55% of RA patients, but only 5% of SLE patients. Serum PTH levels were normal in 99% of the RA subjects. Elevations in alkaline phosphatase. (25%) probably reflected disease activity rather than increased bone formation. Factor analysis of 27 variables showed that disease activity was central to the development of OP in RA. CS therapy tended to be used in the presence of active disease. Disability was not an important determinant of bone loss in RA, but may be a useful measure of activity of the disease. This study did not evaluate the relationships with sex hormonal status or vitamin D metabolism. Future research should aim at cohort analysis at 2 different periods, in order to improve our understanding of the pathogenesis of bone loss in RA.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2010.

Diss. (sammanfattning) Linköping : Linköpings universitet, 2005. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst., 2004. / Härtill 4 uppsatser.

Human endogenous retroviruses are the remnants of ancient retroviral infections present within our genome. These molecular fossils show similarities with present day exogenous retroviruses but act as typical Mendelian elements that are passed vertically between generations. Despite being repeatedly linked to a number of autoimmune diseases and disorders, no conclusive proof has been identified. Rheumatoid arthritis (RA) is one such disease which has been associated with an increase in HERV expression, compared to controls. In order to elucidate a clear role for HERVs in RA pathogenesis, autoantigens implicated in disease pathogenesis were scanned for sequence homology to retroviral genes. Such epitopes would induce antibodies cross reactive with host proteins, resulting in disease. Short peptides mimicking these regions were synthesised and the prevalence of anti-HERV antibodies was determined in RA patients and disease controls. Additionally, a novel real-time Polymerase Chain Reaction (PCR) assay was developed to accurately quantify levels of HERV-K (HML-2) gag expression, relative to normalised levels of housekeeping gene expression. Both serological and molecular assays showed significant increases in HERV-K (HML-2) activity in RA patients compared to disease controls with CD4+ lymphocytes harbouring the highest activity. The real-time assay was also used to determine whether factors within the synovium could modulate HERVs, resulting in their upregulation. Exogenous viral protein expression and pro-inflammatory cytokines were shown to exert a significant modulatory effect over HERV-K (HML-2) transcription. From this data, it is clear that RA patients have increased levels of HERV-K (HML-2) gag activity compared to controls. Despite this it is likely that factors within the synovium such as exogenous viral expression and pro-inflammatory cytokines also influence HERV-K (HML-2) transcription possibly contributing to a role of bystander activation, i.e. being influenced by external factors, rather than actively contributing to disease processes. The exact role of HERVs in RA pathology remains elusive; however this research proposes several mechanisms by which HERV-K (HML-2) may contribute to disease.

The purpose of this study was to advance knowledge and understanding related to the cognitive response evoked by symptoms in women with rheumatoid arthritis. The mechanisms to achieve this purpose were through: (1) psychometric evaluation of a newly developed instrument: Chronic Fatigue Index (CFI), (2) examining the relationship among the symptoms of RA and components of quality of life for women with RA, and (3) exploring the mechanism by which learned resourcefulness affects the relationship between symptoms and quality of life. The Chronic Fatigue Index (CFI) was evaluated and met minimal levels of reliability and validity. Cronbach alpha reliability estimate for the CFI was.87. Convergent validity was tested through factor analysis. The CFI was found to be a multi-dimensional scale with two distinct factors: chronicity and interference. The factor analytical strategies revealed 46% of the variance in chronic fatigue was supported by these two components. Moderate to strong relationships were found among the symptoms of chronic pain, chronic fatigue, disturbed sleep, and disease flare. To evaluate quality of life in this population a common factor was created through factor analysis. The results of factor analysis revealed three indicators explaining 69% of the variance in quality of life for this population. Chronic pain explained fourteen percent of the variance in learned resourcefulness. The other symptoms and multiplicative terms did not meet the entry criteria. Learned resourcefulness was a weak mediator between the disturbance of chronic pain and quality of life, but successfully moderated the adverse effect of disturbed sleep. Fifty eight percent of the variance in quality of life was explained by the direct path of chronic pain and disturbed sleep on quality of life and the interaction of disturbed sleep and learned resourcefulness. Model respecification suggested that the inclusion of additional variables in the model would increase the explanatory power of the model. The self-regulation framework for symptom appraisal was supported by the findings of this study. Nursing interventions should focus on assisting clients with enhancing their level of learned resourcefulness as it will buffer the adverse effects of the disease process.

Akademisk avhandling--Lund. / Extra t.p., with thesis statement, inserted. Errata slip inserted. Bibliography: p. [117]-125.

Thesis (Ph. D.)--University of Texas Health Science Center at Houston, School of Public Health, 1988. / Includes bibliographical references (leaves 165-175).