Development and validation of a rheumatoid hand functional disability scale that assesses functional handicap

OBJECTIVE

To construct a functional disability scale for the rheumatoid hand and to determine if this scale also assesses functional handicap.

METHODS

Outpatients and inpatients with rheumatoid arthritis (RA) according to the ACR criteria answered a set of questions on their daily hand activities. Intrarater and interrater reliability were examined. Criterion referenced validity, and convergent and divergent validities were investigated. Factor analysis followed by varimax rotation was performed. Spearman's (rs) correlation coefficients between 2 quantitative variables were examined. The level of significance was p < 0.05.

RESULTS

96 patients with RA were recruited. The provisional scale had 41 questions. The elimination process left 18 hand activity questions with 6 levels of answers. The intrarater and interrater reliabilities of the scale were 0.97 and 0.96, respectively. Correlation of the scale's total score with visual analog scale (VAS) measure of functional handicap (rs = 0.78) showed good criterion referenced validity. The scale had good convergence with Revel's Functional Index (rs = 0.91) and a moderate relation to the Hand Functional Index (HFI) (rs = 0.58). The scale had a moderate, fair, or no relation to age, morning stiffness, pain measures, and hand swelling. The scale had 3 main factors by factor analysis. An English translation of the scale was validated.

CONCLUSION

We have developed a practical functional disability scale for rheumatoid hands that also assesses functional handicap. It has 18 hand activity questions and has been validated in a French population.

Forceful epidural injections for the treatment of lumbosciatic pain with post-operative lumbar spinal fibrosis

OBJECTIVE

To evaluate the efficacy of forceful epidural corticosteroid injections in lumbosciatic pain ascribed to post-operative lumbar spinal fibrosis.

METHOD

Randomized controlled study comparing forceful injections via the sacral hiatus of 125 mg prednisolone acetate + 40 ml saline (treatment group) and injections via the same route of 125 mg prednisolone acetate alone (control group). Results were compared after six and 18 months. The main evaluation criterion was a subjective assessment of overall efficacy done by the patient using a seven-level scale.

RESULTS

After six months, the proportion of patients who were relieved of their sciatica was significantly higher in the forceful injection group (n = 29; 45%) than in the control group (n = 31; 19%) (p = 0.03). Success rates for low back pain were 29% and 6% in the forceful injection and control groups, respectively. Among secondary efficacy criteria, nerve root pain evaluated on a visual analog scale and by Schöber's index showed significantly greater improvement in the forceful injection group than in the control group. After 18 months, results were still in favor of the forceful injection group, with success rates of 39% for the sciatica and 31% for the low back pain. The proportion of patients who returned to work was similar in the two groups.

CONCLUSION

Although mediocre overall, the results of forceful epidural corticosteroid injections are better than those of simple epidural injections of a corticosteroid alone. Given the paucity of effective treatments for lumbosciatic pain apparently due to postoperative fibrosis, forceful injections should be given a place in the treatment of this condition.

Arthroscopic evaluation of chondropathy in osteoarthritis of the knee

OBJECTIVE

To evaluate arthroscopic findings as a potential measurement of severity and outcome of chondropathy.

METHODS

110 patients with knee osteoarthritis (OA) were included in a cross sectional study and 41 of them in a one year longitudinal study. The evaluation of OA performed once in the cross sectional study and twice (at entry and after one year) in the longitudinal study, included clinical, radiological and arthroscopic variables evaluating disease activity and severity. Arthroscopy was performed. under local anesthesia in an outpatient procedure using a small arthroscope. Chondropathy was evaluated by the overall assessment of the investigator by visual analog scale and the Société Française d'Arthroscopie (SFA) scoring and grading systems, which represent a composite index taking into account depth, size, and localization of the articular cartilage lesions.

RESULTS

The intrinsic validity of the arthroscopic variables was suggested by highly significant correlation (R2 = 80-85%) between the overall assessment of the investor and the SFA systems. There was also highly significant correlation (p < 0.01) between the arthroscopic and radiological variables. Intraobserver reliability of the arthroscopic quantification of chondropathy was better than interobserver reliability. In the cross sectional study, severity of chondropathy correlated with both age and body mass index. In the longitudinal study there was statistically significant worsening in the severity of chondropathy and statistically significant correlation between the changes in the severity of chondropathy and changes in functional impairment.

CONCLUSION

We conclude that arthroscopy might be considered a relevant measurement of OA outcome for research purposes.

Features associated with juvenile onset of spondylarthropathies in north Africa

To determine whether juvenile onset of spondylarthropathy is associated with specific features, a prospective, cross-sectional study comparing juvenile-onset and adult-onset spondylarthropathies was conducted in the Maghreb in 523 patients meeting Amor's criteria or the ESSG's criteria for spondylarthropathy. Demographic data and clinical findings at the time of inclusion and during the first two years of the disease were compared in the 437 patients with onset at 16 years of age or older and in the 86 patients with onset before 16 years of age using a Student's t test or a chi-square test. The risk of hip involvement during the course of the disease was estimated using Kaplan-Meier curves and compared in the two groups using a Cox model. Early in the disease, patients in the juvenile onset group were more likely to have peripheral arthritis (52% vs 39%, p = 0.021) and enthesopathies (55% vs 40%, p = 0.002) and less likely to have axial manifestations (41% vs 62%, p = 0.0001), as compared with the adult-onset group. These differences persisted after a follow-up of 9.2 years. Juvenile-onset disease was associated with a greater likelihood of hip involvement (54 +/- 6% vs 34 +/- 3% after ten years, p = 0.012). The male bias was more marked in the juvenile onset group (85%) than in the adult-onset group (72%) (p = 0.016). These data confirm that demographic characteristics, clinical manifestations, and disease severity differ between juvenile-onset and adult-onset spondylarthropathies.

[Imaging of multiple myeloma]

Multiple myeloma (MM) is characterized by a proliferation of plasma cells responsible for osteolytic lesions. Imaging studies are performed in MM to establish diagnosis and prognosis, and may also be used to judge the efficacy of treatment and to detect complications. TO ESTABLISH THE DIAGNOSIS: Conventional radiography demonstrates, at the time of diagnosis, characteristic features in 80% of cases. These lytic lesions involve more often the sites of red marrow. More rarely the only abnormal finding is diffuse osteopenia. Tomodensitometry and, above all, magnetic resonance imaging (MRI), which is a reference method for bone marrow disorders, can be useful for diagnosis in some difficult cases. But the lesions observed, hyposignals on spin echo T1 sequences and hyposignals on T2-weighted gradient echo, are not specific and usually do not allow to distinguish MM from osteolytic metastasis or other bone marrow disorders. TO DETERMINE EXTENT OF DISEASE AND TO EVALUATE PROGNOSIS: According to Durie and Salmon, the extension of home lesions at diagnosis is strongly correlated with the myelomatous measured cellular mass and with survival of patients. But this relation is denied by some authors who have noted that the shortest survival was seen in patients with normal X-rays. TO JUDGE THE EFFICACY OF TREATMENT: Improvement of the radiological abnormalities is observed in nearly 30% of patients responding to a conventional chemotherapy and appears to be an adverse pronostic sign. A good correlation between MRI and the biological response to treatment has also been reported. TO RECOGNIZE COMPLICATIONS OF DISEASE: Conventional radiography is also very important in diagnosis of complications like fractures or vertebral compression. Lastly, MRI is the investigation of first choice in the evaluation of patients with suspected spinal cord compression.

Predictive factors of severity of spondyloarthropathy in North Africa

Both genetic and environmental factors probably influence the severity of Spondyloarthropathies. Hip involvement, which may be used as a marker of disease severity, is more frequent in spondyloarthropathies developed in North Africa. The objective of this study was determine the predisposing factors of hip involvement in spondyloarthropathy in North Africa. Patients fulfilled the Amor or European Spondyloarthropathy Study Group (ESSG) criteria of spondyloarthropathy. The study was retrospective, cross-sectional, multicentre and carried out in North Africa. The data collected were demographic data, socio-cultural factors and clinical presentation at onset. The risk of hip involvement with regard to disease duration was estimated using Kaplan-Meier's method. The predictive value of each variable with regard to time to hip involvement was evaluated using a uni- and then a multivariate Cox proportional hazard model. Five hundred and eighteen patients were included. The risk of hip involvement was estimated at 39+/-3% after 10 yr disease duration. The factors picked up by the multivariate analysis were: diagnostic delay less than 7 yr, age at onset below 24 yr and a combination of 'lower social class' and 'no refrigerator at home'. This study confirms the high prevalence of hip involvement during the course of spondyloarthropathy in North Africa and suggests a role of environmental factors in its appearance.

Predictors of the need for total hip replacement in patients with osteoarthritis of the hip

RATIONALE

the natural history and risk factors for hip osteoarthritis are still unknown.

OBJECTIVE

to identify factors predicting a need for total hip replacement at some time during the course of hip osteoarthritis.

PATIENTS AND METHODS

outpatients evaluated between 1981 and 1986 for hip osteoarthritis were studied retrospectively. The date of diagnosis and the characteristics of the patients and hip disease at diagnosis were recorded. The risk of eventual total hip replacement was estimated using the Kaplan-Meier method. Uni- and multivariate Cox proportional hazard models were used to determine the value of each variable for predicting total hip replacement.

RESULTS

we included 149 patients (50 males). The risk of total hip replacement was estimated at 36 +/- 4% five years after diagnosis. Factors with significant effects in the multivariate analysis were age older than 54 years at diagnosis (relative risk 3.15), body mass index greater than 27 (relative risk 2.97), and severe radiological joint space narrowing at diagnosis (relative risk 2.26).

CONCLUSION

this study confirmed the often severe course of hip osteoarthritis and identified several factors possibly associated with rapid progression.

Bone loss during gonadotropin releasing hormone agonist treatment and use of nasal calcitonin

Gonadotropin releasing hormone (GnRH) agonists have shown to be effective in the treatment of several sex-hormone-dependent conditions. However, their use could be limited by the bone loss they induce. To evaluate the use of nasal salmon calcitonin (sCT) in preventing this bone loss, 40 patients with endometriosis were treated for 6 months with triptoreline (3.75 mg monthly) and calcium (1 g daily), and randomized in three groups-placebo, sCT 100 IU daily and sCT 200 IU daily-in a prospective double-masked study. Dual-energy X-ray absorptiometry and biochemical parameters were used to evaluate the benefit of the treatment. At baseline, there were no statistically significant differences between the groups. After 6 months, estradiol and biochemical markers of bone metabolism were at postmenopausal levels, with no difference between the groups. There was no difference in bone loss in the three groups, at all sites. Mean lumbar bone loss was 4.01 +/- 2.59% (mean +/- SD) in this population. In this study dosages of 100 IU and 200 IU daily of nasal sCT were insufficient to prevent bone loss during GnRH agonist treatment.

Bone loss in patients with inflammatory bowel disease: a prospective study

To assess the rate of bone loss in patients with inflammatory bowel disease, we prospectively studied 35 patients (17 women) aged 36 +/- 13 (range 17-60) years, 14 of whom had Crohn's disease and 21 with ulcerative colitis (including 12 with ileoanal anastomosis). Bone mineral density was measured by dual-energy X-ray absorptiometry at the lumbar spine and femoral neck. The follow-up was 19 +/- 8 months. During this period, 14 patients received oral steroids. Lumbar bone density changes expressed as a percentage per year were -3.1 +/- 4.9%, -6.4 +/- 7.5% and +2.0 +/- 4.0% in Crohn's disease and ulcerative colitis without and with ileoanal anastomosis respectively (p = 0.007). The same pattern was observed at the femoral neck. Mean annual lumbar bone density changes were -6.2 +/- 7.0% and +0.9 +/- 3.9% in patients with and without steroids during follow-up (p = 0.002). We conclude that patients with inflammatory bowel disease are at risk of lumbar and femoral bone loss. However, bone loss is not observed in patients with ileoanal anastomosis.

Adult-onset idiopathic phosphate diabetes. II. Time-course of clinical, laboratory test, and bone mineral density abnormalities under combined phosphate and calcitriol therapy

STUDY OBJECTIVE

to investigate the time-course of clinical, laboratory test, and bone mineral density abnormalities in patients with mild phosphate diabetes treated for at least one year with calcitriol, 0.5 to 1.5 micrograms, and oral phosphate, 788 to 2300 mg per day, in three divided doses.

PATIENTS AND METHODS

we studied eight patients with mild phosphate diabetes defined as a rate for tubular reabsorption of phosphate of less than 18% with a maximal rate for tubular reabsorption of phosphate (Tm) of less than 0.77 in the absence of any detectable cause of secondary tubular disease. Treatment efficacy was evaluated on the basis of pain severity, pain-related functional disability, serum phosphate and calcium levels, maximal rate for tubular reabsorption of phosphate, and dual-photon absorptiometry-measured bone mineral density.

RESULTS

three patients experienced complete relief of pain and fatigue and were able to resume their normal activities. Partial relief was seen in two other patients. The three remaining patients had no response to treatment. Renal colic occurred in one patient. None of the patients developed hypercalcemia.

Adult-onset idiopathic phosphate diabetes. I. Chronic pseudoinflammatory back pain and osteopenia

STUDY OBJECTIVE

to investigate clinical, laboratory test, and bone mineral density abnormalities in 19 adults with phosphate diabetes of unknown etiology diagnosed in a rheumatology department on the basis of a maximal rate for tubular reabsorption of phosphate (TmPO4/GFR) of 0.77 or less.

RESULTS

there were 14 males and five females with a mean age of 36.7 years (range 20 to 68 years) at symptom onset and 43.9 years (24-70) at diagnosis. Seventeen patients (90%) had back pain and 13 (68%) had nerve root pain. The pain was nocturnal only or both nocturnal and diurnal in 14 cases (74%). Other manifestations were fatigue (n = 7, 37%), myalgia (n = 6, 32%), fracture (n = 6, 32%), renal colic (n = 4, 21%), and pseudodepression (n = 10, 53%). Laboratory test abnormalities were as follows: serum phosphate, 0.72 mmol/L (0.58-0.89); rate for tubular reabsorption of phosphate, 74% (54-84%); maximal rate for tubular reabsorption of phosphate, 0.58 (0.4-0.76); urinary calcium/urinary creatinine > 0.48 in nine patients (47%); and fractional potassium excretion > 20% in seven patients (37%). Normal values were found for serum levels of Ca++, Na++, Mg++, creatinine, cortisol, T3, T4, TSH, 25(OH)D3, and 1,25(OH)2 D3. Tests for glycosuria and amino aciduria were negative. Bone mineral density measurements showed z-scores of -2.13 (+0.9 to -4.25) at L2-L4, and -1.34 (+1.5 to -3.2) at the femoral neck. Bone histology showed osteoporosis with a mild increase in osteoid deposition.

CONCLUSIONS

idiopathic adult-onset phosphate diabetes manifests as chronic back pain and nerve root pain, sometimes with fatigue and depression. Bone mineral density values are decreased and histology shows osteopenia. Differential diagnoses include spondyloarthropathy, disk disease, fibromyalgia, and depression. Determination of the maximal rate for tubular reabsorption of phosphate is the only means of establishing the diagnosis.

Sensitivity to change of various roentgenological severity scoring systems for osteoarthritis of the hip

RATIONALE

joint space assessment on roentgenograms is considered reliable for evaluating the anatomic severity of hip osteoarthritis. Methods for measuring this parameter include the scoring system developed by Kellgren and Lawrence, joint space width measurement, and joint space surface area measurement after digitalization of roentgenograms.

OBJECTIVE

to compare the sensitivity to change of the three above-listed methods.

PATIENTS AND METHODS

the study included patients with hip osteoarthritis meeting ACR criteria for whom two roentgenograms showing evidence of hip osteoarthritis taken 10 to 15 months apart were available. Roentgenograms were read by a single investigator who was unaware of the chronological order of films. Sensitivity to change of the three measurement techniques was determined by calculating standardized response mean (mean change/standard deviation of change).

RESULTS

the study evaluated 34 hips (68 roentgenograms) in 22 patients (12 females and ten males, mean age 63 +/- 10 years) with osteoarthritis of one (n = 10) or both (n = 12) hips. Standardized response mean were 0.37, 0.33, and 0.16 for joint space width, joint space surface area, and the Kellgren-Lawrence score, respectively.

CONCLUSION

this study suggests that joint space width or surface area may be more sensitive than the Kellgren-Lawrence score for monitoring the course of hip osteoarthritis.

Management of refractory ankylosing spondylitis and related spondyloarthropathies

Ankylosing spondylitis is the prototype of an interrelated group of disorders termed spondyloarthropathies, which include reactive arthritis, psoriatic arthritis, and rheumatic disorders associated with inflammatory bowel disease. It can be difficult to differentiate between these disorders because they may occur simultaneously or sequentially. In addition, some of the clinical characteristics of these diseases, such as enthesiopathy and eye involvement, are similar no matter what the diagnosis. The monitoring, diagnosis, and treatment of these diseases are related more to their clinical presentation than to the precise diagnosis.

Effect of cyclosporin A on interleukin-6 and soluble interleukin-2 receptor in patients with rheumatoid arthritis

OBJECTIVE

To investigate the effect of cyclosporin A (CyA) therapy on circulating concentrations of interleukin-6 (IL-6) and soluble interleukin-2 receptor (sIL-2R) in patients with rheumatoid arthritis (RA).

METHODS

Twenty four RA patients with active disease were studied. Plasma was collected before and after 16 weeks of CyA treatment. IL-6 was measured by B9 bioassay and sIL-2R by enzyme linked immunosorbent assay (ELISA).

RESULTS

The initial median IL-6 concentration of 165 IU/ml decreased significantly to 71 IU/ml after 16 weeks (p < 0.05). Similarly, the initial median plasma sIL-2R value of 665 U/ml decreased significantly to 570 U/ml (p < 0.05). This decrease was accompanied by an improvement in clinical parameters of disease activity. Some association between sIL-2R, IL-6, haemoglobin, and platelets was also observed.

CONCLUSIONS

This study has demonstrated that, in vivo, CyA therapy in RA can significantly reduce circulating concentrations of IL-6 and sIL-2R. Modulation of both T and non-T cell derived cytokines may be one mechanism by which CyA improves rheumatoid disease. Whether this is a direct effect of CyA on the cells within the rheumatoid joint producing these cytokines or an indirect effect mediated by other cytokines which can influence IL-6 and Il-2R values remains to be determined.

Metabolic bone assessment in patients with inflammatory bowel disease

BACKGROUND/AIMS

Patients with inflammatory bowel disease are at risk for osteopenia. To study the metabolic bone status of these patients, a cross-sectional study was conducted.

METHODS

Eighty-four patients (49 women, 35 men) with inflammatory bowel disease, 34 of whom had Crohn's disease and 50 ulcerative colitis (including 18 with prior coloproctectomy and ileoanal anastomosis), underwent clinical, dietary, and spine radiological assessments. Bone metabolism was assessed by measuring serum levels of calcium, phosphate, parathyroid hormone (1-84), 25-hydroxyvitamin D3, 1,25-dihydroxyvitamin D3, and osteocalcin. Lumbar and femoral neck bone mineral densities were measured by dual energy X-ray absorptiometry.

RESULTS

Serum osteocalcin level was decreased in 29 patients (34%), 12 of whom had never undergone steroid therapy. The other biochemical markers of bone metabolism were in the normal range. Thirty-six patients (43%) had osteopenia, and 6 patients (7%) had vertebral crush fractures. Osteopenia was observed in 27 patients (52%) and 9 patients (28%) with and without corticosteroid therapy, respectively. No patient had clinical or biological signs of osteomalacia. Analysis of bone density (lumbar Z score) by a multiple regression analysis showed a statistically significant correlation with age, cumulative corticosteroid doses, sedimentation rate, and osteocalcin level (R2 = 0.76; P = 0.05).

CONCLUSIONS

The results suggest that bone turnover in inflammatory bowel disease is characterized by low bone formation in the presence of normal levels of calcium-regulating hormones.

Are classification criteria for spondylarthropathy useful as diagnostic criteria?

The authors used data from a study conducted under the auspices of the Société Française de Rhumatologie to evaluate the sensitivity and specificity of the individual items of two sets of criteria for spondylarthropathy. The study included 124 patients with spondylarthropathy and 1,964 controls. They found that the spondylarthropathy criteria with the highest sensitivities and specificities were useful not only for classifying patients but also for assisting in the diagnosis of spondylarthropathy.

[Chondroscopy: a new method for measuring osteoarthritis?]

Arthroscopy allows direct visual examination of joint cavity components and is useful for the diagnosis, treatment and evaluation of lesions. We investigated the contribution of arthroscopy to the evaluation of joint cartilage. The severity of cartilage lesions can be assessed using a total 100-mm visual analog scale (0 = no chondropathy; 100 = the worst possible lesions) or a more objective system based on the site, depth, and surface area of the lesions. This latter system was developed by the French Society for Arthroscopy (Société Française d'Arthroscopie) and provides a score and a class (SFA score and SFA grade). We investigated whether this system has the characteristics required of an evaluation tool, i.e., simplicity, reproducibility, clinical relevance, sensitivity to change, and discriminant capacity. Arthroscopy is an invasive procedure. However, we introduced several simplifications, including use of local rather than general anesthesia, performance on an outpatient basis, elimination of the tourniquet (to avoid muscular dysfunction), and use of a small arthroscope. This simplified technique is called chondroscopy. Intra-observer reproducibility is far better than inter-observer reproducibility. We found a good correlation between the two arthroscopy scales (visual analog scale and SFA scale). Chondroscopy and roentgenographic evaluations of cartilage lesions were closely correlated. Changes in the severity of cartilage lesions were correlated with changes in functional impairment. Chondroscopy proved capable of demonstrating statistically significant changes in cartilage lesions due to knee osteoarthritis between two evaluations done only one year apart, even in a small sample of patients (less than 20). A preliminary study of repeated hyaluronic acid injections suggested that chondroscopy may be capable of identifying truly chondromodulating agents.

Predictive factors for the longterm outcome of spondyloarthropathies

OBJECTIVE

To determine the predictive factors of outcome in patients with spondyloarthropathy (European Spondyloarthropathy Study Group or Amor criteria) monitored by a single investigator.

METHODS

Classification of longterm outcome on a 3-grade scale. Candidate predictive factors: presence or not of 12 clinical or biological variables during the first 2 years of the disease, collected by history at the time of the first visit. Univariate analysis to pick up the factors statistically correlated with severity and then odds ratio and 95% confidence interval (CI) for each variable were calculated.

RESULTS

Of the 328 patients with spondyloarthropathy, 151 had a followup of > or = 10 years and minor disease (81), severe (28), or moderate disease (42). Seven variables at entry were correlated with disease severity (odds ratio; CI 95%); hip arthritis (22.85; 4.43-118); erythrocyte sedimentation rate > 30 mm/h (7; 4.84-9.50); poor efficacy of nonsteroidal antiinflammatory drugs (8.33; 2.56-27.10); limitation of lumbar spine (7; 2-25); sausage-like finger or toe (8.45; 1.48-9); oligoarthritis (4.25; 1.38-13.10); onset < or = 16 years (3.47; 1.06-12.75). If none of these factors is present at entry a mild outcome can be predicted (sensitivity: 92.5%; specificity: 78%). If a hip is involved or if 3 factors are present, a severe outcome is predictable (sensitivity: 50%) and a mild disease practically excluded (specificity: 97.5%).

CONCLUSION

Predictive factors of poor or benign longterm outcome could be defined very early after onset of spondyloarthropathy in a set of patients monitored by one observer.

A possible linkage of HLA-DRB haplotypes with Tiopronin intolerance in rheumatoid arthritis

To investigate the relationship between HLA class II genotypes and toxic intolerance during treatment with Tiopronin, a slow-acting drug used in the treatment of rheumatoid arthritis (RA), we studied 40 patients who were divided into two groups: a group of 22 patients without side effects and a group of 18 patients with intolerance to Tiopronin. The PCR-RFLP method was used to determine the HLA-DR, DQ and DP genotypes. The patients in the two groups had similar genetic backgrounds with an expected high frequency of DRI and DR4 alleles. However, DR1/DR4 heterozygosity was significantly increased in patients with intolerance (p = 0.03, Odds Ratio = 10.5). In addition, one intolerant patient had a DR1/DR7 genotype which shared DRw53 (DRB4*0101) with DR1/DR4. Furthermore, two subtypes of DR5, DRB1*1102 and DRB1*1201, were increased among intolerant patients (11.1% vs 0%, p = 0.03, OR = 13.97). In total, DR1/DRw53 heterozygotes, DRB1*1102 and DRB1*1201 represented 61.1% of intolerant patients. Therefore, a detailed HLA class II typing might be useful before RA treatment by Tiopronin to predict and avoid toxic side effects in the patients with increased risk. Further investigation is currently underway.

Efficacy and tolerability of a new formulation of oral tiludronate (tablet) in the treatment of Paget's disease of bone

We sought to assess efficacy and safety of a new oral formulation (tablet) of tiludronate in Paget's disease of bone. We studied 128 patients with Paget's disease in an open-label uncontrolled trial. Patients received a daily dose of 400 mg oral tiludronate (two tablets). Treatment was for 6 months. Serum alkaline phosphatase activity (SAP) and fasting urinary excretion of hydroxyproline/creatine (OH/Cr) were measured every 3 months, as were biochemical parameters reflecting renal, hepatic, and hematologic functions. Analgesic efficacy was self-evaluated from a visual analog scale (VAS). Statistical analysis revealed a significant reduction from baseline in SAP and OH/Cr levels, as well as VAS scores. In the whole population with evaluation under treatment, there was a reduction in initial SAP activity after 3 months (47.2 +/- 2.2%, mean +/- SEM) and 6 months (58.3 +/- 2.3%). In the population with SAP levels above twice the upper limit at inclusion and with evaluation at month 3 and month 6 (n = 96), the reduction in SAP levels was 49.3 +/- 2.4% after 3 months and of 59.5 +/- 2.6% after 6 months (ANOVA time effect, p = 0.0001). Aside from mild gastrointestinal disturbances, as experienced with other oral bisphosphonates, clinical tolerance was good. Exhaustive biochemical investigation failed to reveal significant toxicity of tiludronate tablets at the dose of 400 mg/day. The dose of 400 mg daily of this new formulation appears to be a satisfactory tiludronate regimen for the treatment of Paget's disease of bone.

[Cost of intensive treatment followed by autograft of circulating stem cells. Application to multiple myeloma]

OBJECTIVES

Legitimate efforts to reduce health care costs, especially of intensive protocols including transplantation for haematological diseases, require realistic economic evaluations. We determined the direct cost of intensive chemotherapy associated with total body irradiation and autologous blood stem cell transplantation in patients with multiple myeloma.

METHODS

Ten consecutive patients (7 males, 3 females) with Stage II or II multiple myeloma, who had received no prior treatment and were under the age of 55, were included in the study. Peripheral blood stem cells were collected by successive cytaphereses after a short period of aplasia induced by a CHOP protocol. During this period, the patients were in normal hospital rooms. A VAMP protocol was then administered in three 4-day sessions. Intensive therapy was started 1 month later with CCNU, etoposide, cyclophosphamide and melphalan. Total body irradiation (12 Gy) was performed on days -3, -2, -1. Autologous grafting was done on day 0. The intensive therapy was followed by a period of aplasia and the patients were protected in laminar flow rooms. Regular antibiotic and haematologic protocols were applied. Growth hormone was not given. The patients were seen regularly for follow-up and interferon alpha 2b was prescribed for 5.

RESULTS

The mean cost of the two year treatment was 468,392 +/- 167,467 French francs. Personnel accounted for 36% of the total cost, marrow collection 13%, blood products 9.8%, laboratory tests 8.2% and drugs 7.2%. Little data are available in the literature of comparable cost analyses in other French hospitals or in other countries.

CONCLUSION

Controlled cost/benefit studies should be conducted to enable a rigorous comparison between different therapeutic strategies.