[The carpus-metacarpus-index distance: a measurement for quantifying radiological lesions in rheumatoid polyarthritis. Comparison with Larsen's scores and Steinbrocker's index]

The carpus-to-digits distance measured on a posteroanterior roentgenogram of the hands and wrists takes into account 18 different joints. This study demonstrates that the carpus-to-digit distance is a simple, reproducible score which reliably reflects progression of roentgenological rheumatoid arthritis lesions and is correlated with Larsen's lesion score and with Steinbrocker's index, but not with Larsen's erosion score during the first two years after onset of the disease. Larsen's erosion score and similar parameters should be preferred for clinical studies of recent-onset rheumatoid arthritis. The carpus-to-digit distance, which requires neither a reference film not observer training, is appropriate for long-term clinical studies.

Diacerhein in the treatment of osteoarthritis of the hip

OBJECTIVE

To determine the efficacy and safety of diacerhein, a potential new therapeutic agent with properties differing from those of existing nonsteroidal anti-inflammatory drugs (NSAIDs), and of a combination of diacerhein and an NSAID (tenoxicam) in the treatment of osteoarthritis (OA) of the hip.

METHODS

Two hundred eighty-eight patients with painful OA of the hip were enrolled in an 8-week randomized, double-blind, placebo-controlled, 2 x 2 factorial design study. Four treatment groups were defined: 1) diacerhein placebo and tenoxicam placebo, 2) tenoxicam and diacerhein placebo, 3) diacerhein and tenoxicam placebo, and 4) diacerhein and tenoxicam. The daily dosages of diacerhein and tenoxicam were 100 mg and 20 mg, respectively.

RESULTS

Analyses of efficacy showed no interaction between diacerhein and tenoxicam in terms of efficacy, a clinically significant rapid (< or = 2 weeks) and persisting effect of tenoxicam during the 8 weeks of the study, and a slow-acting (6 weeks) effect of diacerhein. Moderate, transient diarrhea was the most frequent side effect observed in the diacerhein group (37%) compared with the placebo group (4%).

CONCLUSION

Both tenoxicam and diacerhein appear to be superior to placebo, and neither agent appears to significantly enhance or detract from the efficacy of the other when they are administered concomitantly. The onset of action of diacerhein appears to be delayed (> or = 4 weeks).

Epidural lipomatosis. Interest of magnetic resonance imaging in a weight-reduction treated case

An obese patient with bilateral sciatic pain had epidural lipomatosis on magnetic resonance examination. Treatment that used a weight-reduction program eliminated the symptoms, and after magnetic resonance imaging, revealed reduction of the lipomatosis deposits.

Evidence for GM-CSF receptor expression in synovial tissue. An analysis by semi-quantitative polymerase chain reaction on rheumatoid arthritis and osteoarthritis synovial biopsies

Granulocyte macrophage colony stimulating factor (GM-CSF) is one of the main cytokines involved in tissue damage during rheumatoid arthritis (RA). To investigate the expression of the GM-CSF receptor (GM-CSF-R) in the synovial tissue of osteoarthritic (OA) and RA patients, biopsy specimens were obtained ex vivo during therapeutic arthroscopy. A semi-quantitative polymerase chain reaction (PCR) technique was performed using specific primers for the alpha chain of the GM-CSF-R and for beta-actin. The PCR products were analyzed after slot-blotting and hybridization with specific cDNA probes. Both RA (n = 11) and OA (n = 7) samples were positive. No significant overexpression correlating with the clinical or histological disease status of the patients was observed. In conclusion, GM-CSF-R could be detected in the synovial tissue where it can mediate the effects of this cytokine locally produced during RA inflammation.

Biologic, histologic and densitometric effects of oral risedronate on bone in patients with multiple myeloma

Recent studies have shown that treatment with bisphosphonates could be effective against the myelomatous skeletal deterioration. However, the mechanisms of action of these drugs in multiple myeloma (MM) have been poorly studied. In the present study, 11 patients with MM and bone lesions were treated orally with 30 mg/day of risedronate for 6 months, and monitored for 6 additional months. Mean serum calcium decreased from day 4, with a concomitant increase in circulating levels of PTH (1-84) and 1,25-(OH)2D. These parameters reached their nadir on day 7 and returned to baseline value during the treatment period. Markers of bone resorption, pyridinoline and deoxypyridinoline decreased from day 7; they were at 50% and 78% of their basal value at the end of treatment and follow-up periods, respectively. A significant reduction of estimates of bone formation (serum alkaline phosphatase and osteoclacin) appeared at month 3 and persisted for the remainder of the 9-month period. Histomorphometric analysis showed a significant reduction of activation frequency, number of osteoclasts and erosion depth. Bone turnover was high at baseline, and normal after treatment, without mineralisation defects. Mean wall thickness was not different before and after treatment. Spinal bone mineral density measured by dual energy X-ray absorptiometry increased (5.3%) at the end of treatment. We conclude that oral risedronate in multiple myeloma induces a noticeable and rapid inhibition of bone resorption.

[Ultrasound attenuation in calcaneus and bone density]

Broadband ultrasound attenuation (BUA) is a new technique for investigating bone status. We evaluated its use in osteoporosis. To assess in vivo reproducibility, we determined the coefficient of variation (cv) on the basis of five measurements (with repositioning) of the same foot in 50 women. The cv was 2.8 +/- 1.7%. BUA values were similar in the right feet and left foot and were correlated with bone density in the calcaneal area investigated (r = 0.8, p < 10(-4). BUA of the calcaneus was correlated with bone density in the lumbar spine, femur, and forearm in 240 healthy postmenopausal women (correlation coefficients 0.36 to 0.55; p < 10(-4)). BUA decreased with age, with a sharper drop during the first years following menopause. Mean broadband ultrasonic attenuation in 37 females with osteoporosis (58.92 +/- 11.59 dB/MHz) is lower than controls (66.10 +/- 15.29 dB/MHz, p = 0.04). Areas under receiver operating characteristic curves, used to evaluate the discriminating value of BUA in osteoporosis and osteopenia, were 0.79 and 0.72, respectively. The kappa coefficient of concordance between BUA and spinal density was 0.59. These data demonstrate that BUA cannot replace bone density measurements. Prospective studies are needed to investigate the potential role of this technique for identifying women at high risk for osteoporotic fractures.

[Evaluation of a quality of life scale (AIMS2) in rheumatology]

OBJECTIVES

To evaluate the feasibility, relevance, and sensitivity of the French version of the revised Arthritis Impact Measurement Scale (AIMS2) in patients with rheumatoid arthritis or osteoarthritis of the hip.

METHODS

translation of the English-language AIMS2 into French using the back-to-back technique; evaluation of feasibility on the basis of a) time needed to complete the AIMS2; b) percentage of questionnaires with at least one missing answer or one answer indicating that the question was misunderstood; evaluation of relevance on the basis of correlations between AIMS2 scores and conventional parameters for evaluating the activity of rheumatoid arthritis (85 patients); evaluation of sensitivity on the basis of total hip replacement-induced improvements in AIMS2 scores versus other conventional scores used to evaluate activity of osteoarthritis of the hip (48 patients).

RESULTS

feasibility, mean time needed to complete the AIMS2 was 23 minutes in rheumatoid arthritis patients and 26 minutes in osteoarthritis patients. Forty per cent of patients failed to answer at least one question and 21% misunderstood at least one question; relevance: conventional parameters used in rheumatoid arthritis accounted for 51% of AIMS2 score variance, suggesting that the AIMS2 provided information not supplied by conventional parameters. SENSITIVITY: after total hip replacement for osteoarthritis, there were statistically significant decreases in all AIMS2 scores (with the exception of function and work).

CONCLUSION

These data suggest that the AIMS2 score is not an easy evaluation tool but is both relevant and sensitive. These findings require confirmation by longitudinal studies.

[Comparison of patients evaluated for spondylarthropathy in France and Morocco]

The authors compared demographic and clinical data in patients with spondylarthropathy residing in Morocco or in France and searched for factors associated with increased disease severity, with special attention to course of the disease, life style, clinical findings and roentgenographic changes. They carried out univariate analyses (chi-square test, Student's t test) to look for factors associated with hip involvement. Evaluation of the relative risk associated with each factor by determination of the odds ratio and corresponding 95% confidence interval. Statistically significant differences were found between the two groups concerning socioeconomic status and disease characteristics. Patients seen in Morocco had more severe disease, with roentgenographic hip involvement in 48% of cases versus only 16% of patients seen in France (p < 0.0001). Several factors were associated with the presence of hip disease, including residence in Morocco, Maghrebine ethnic origin, patient characteristics (male sex, low body mass index), disease characteristics (high erythrocyte sedimentation rate, young age at onset), and environmental factors (no running water in the home). Patients with spondylarthropathy residing in Morocco had more severe disease than their counterparts living in France; both genetic and environmental factors may explain this difference.

[Hyperparathyroidism disclosed by forward sagging of the head]

An unusual clinical presentation of hyperparathyroidism is reported. The 73-year-old patient was unable to maintain her head upright after ten minutes of walking or standing. Parathyroid adenoma was diagnosed on the basis of ultrasound and pathological findings and parathyroid hormone assays. Following surgery the forward sagging of the head no longer occurred and serum levels of calcium and phosphorus returned to normal. Pathophysiological hypotheses are discussed. No similar cases with isolated weakness of the cervical and dorsal paravertebral muscles has been reported to date.

[Measurements in rheumatology]

Measuring a phenomenon is the first step of the scientific approach. Use of quantitative measurements to evaluate clinical and roentgenological data improves patient follow-up, increases the validity of collected data, encourages critical evaluation of measurement tools, use of reproducible roentgenographic views, and careful planning of investigations with the aim of achieving a predefined goal, and allows more objective assessment of treatment efficacy. Use of quantitative parameters can be expected to improve the quality of care and to reduce health care costs.

[Criteria for classification of spondylarthropathies in children]

BACKGROUND

The term spondylarthropathy is used for several different entities including undifferentiated forms. The latter are particularly frequent in children and often not recognized. Two sets of criteria, the Amor and the European Spondylarthropathy Study Group (ESSG) criteria, primarily devised for adults, were evaluated in a pediatric population.

METHODS

Three hundred and ten consecutive patients referred to one pediatric rheumatology center over 6 months were prospectively assessed, whatever the rheumatic complaint. Twenty two items were analysed for each patient and compared with the criteria proposed by Amor (17 items) and the ESSG (12 items).

RESULTS

The Amor criteria performed better than the ESSG criteria. The sensitivity was 84 and 69.7%, and the specificity 96.1 and 92.2% for the Amor and the ESSG criteria, respectively. The sensitivity for pauci-arthritis was much higher in children, but the specificity was lower than in adults. The sensitivity of spinal involvement was very low in children. The undifferentiated type accounted for 81% of all definite spondylarthropathies. Definite and possible spondylarthropathies were 17% of the total referral over the 6 months, i.e. one patient in 6.

CONCLUSIONS

These two sets of criteria, particularly the Amor criteria, can help pediatricians to recognize the undifferentiated type of spondylarthropathy, in the absence of spinal or any other characteristic manifestation.

Chondroscopy: a new method for scoring chondropathy

The purpose of this study was to evaluate the performance (simplicity, reproducibility, relevance) of chondroscopy as a method for evaluating cartilage damage. Chondroscopy consisted in endoscopic evaluation of the knee using a 2.7-mm Storz arthroscope under local anesthesia and recorded on videotape. Scoring of chondropathy was based on physician's overall assessment using a 100-mm-length visual analogue scale (VAS) and size and grade of cartilage lesions. Reproducibility was evaluated by variability (coefficient of variation [CV]) in the reading of chondroscopic evaluations of five patients five times by one physician and one time each by four different physicians. The correlations between scoring of chondropathy (VAS) and radiological articular joint space narrowing, demographic data (sex, age, weight), and disease characteristics (localization, etiology, activity) were studied in 84 outpatients fulfilling the American College of Rheumatology criteria for the diagnosis of osteoarthritis of the knee. The grade and size of the lesions were both correlated with the physician's overall assessment (r = 0.713 and r = 0.816, respectively). These two variables accounted for 72% of the variance of the VAS (multiple regression analysis). Intraobserver reproducibility was better than interobserver reproducibility (CV, 9% and 37%, respectively). There was a strong correlation between the scoring of chondropathy (VAS) and radiological joint space narrowing (r = .646, P < .0001). Moreover, in 17 of 33 patients without radiological joint space narrowing, VAS was > 20 mm. At variance, the body mass index was the single clinical variable found to correlate with the scoring of chondropathy (r = .282, P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)

High molecular weight sodium hyaluronate (hyalectin) in osteoarthritis of the knee: a 1 year placebo-controlled trial

Hyaluronic acid is a natural component of cartilage and is considered not only as a lubricant in joints but also as playing a physiological role in the trophic status of cartilage. Hyalectin, a selected fraction of hyaluronic acid extracted from cocks' combs, has exhibited efficacy in animal models of osteoarthritis. To assess the efficacy and tolerability of intra-articular injections of hyalectin, we conducted a prospective, randomized, placebo-controlled trial of 1 years' duration in 110 patients with painful hydarthrodial osteoarthritis of the knee. At entry and once a week for 3 weeks, aspiration of the knee effusion and intra-articular injections of either hyalectin 20 mg (H) or its vehicle (C) were performed. The vehicle acted as the control treatment. Four weeks after the last injection, the improvement was greater in the H group compared with the C group (pain: -35.5 +/- 26.4 mm vs -25.8 +/- 21.4, P = 0.03, Lequesne's functional index: -3.8 +/- 4.3 vs -2.3 +/- 3.3, P = 0.03). During the 1 year follow-up, the need to perform supplementary local therapies (joint fluid aspiration because of painful hydarthrodial episodes and/or local corticosteroid injections) was more frequent in group C (44% vs 30%, P = 0.03). Moreover, at the final visit, the physician's overall assessment of efficacy was in favor of H (77% vs 54%, P = 0.01) and the improvement in the functional index was greater in group H (-4.4 +/- 5.1 vs -2.7 +/- 4.1, P = 0.05). This study suggests that intra-articular injections of hyalectin may (1) improve clinical condition and (2) have a long-term beneficial effect in patients with osteoarthritis of the knee.

Expression of complement receptors (CR1 and CR3) and Fc gamma RIII on polymorphonuclears from patients with spondylarthropathies

We assessed the expression of complement receptors (CR1 and CR3) and Fc gamma RIII on unstimulated and FMLP activated polymorphonuclears (PMNs) by indirect immunofluorescence and flow cytometry using CD35 (CR1), CD11b (CR3) and CD16 (Fc gamma RIII) monoclonal antibodies in 24 patients with spondylarthropathies (SpA) and in 18 healthy subjects. SpA patients were classified into 3 groups according to the severity of the disease (severe = asymmetrical peripheral joint involvement and permanent limitation of spine motion; moderate = one of the two items, mild = none of the items). CR1 and Fc gamma RIII expression were significantly decreased in patients with mild SpA, whereas CR1 and CR3 expression were significantly increased in patients with severe disease as compared to control subjects. In patients with mild disease, CR1 expression increased after FMLP activation, but remained significantly lower than in control subjects. The results were confirmed by immunoelectroblotting. These findings suggest that membrane and intracellular pools of CR1 and CR3 may contribute to the clinical modulation of the spondylarthropathies.

[Comparative efficacy of ketoprofen related to the route of administration (intramuscular or per os). A double-blind study versus placebo in rheumatoid arthritis]

Evidence of the analgesic effects of nonsteroidal antiinflammatory drugs in human diseases is easy to collect. However, demonstration of differences in the activity of NSAIDs according to the route of administration is considerably more difficult. Forty patients with rheumatoid arthritis were given either one intramuscular injection of 100 mg ketoprofen with two placebo capsules or one intramuscular injection of placebo with two 50 mg ketoprofen capsules. Analysis of changes in pain severity over the six-hour study period failed to disclose any statistically significant differences between the two groups. However, time to peak effectiveness (Tmax) was significantly shorter with the intramuscular route (194 +/- 118 minutes) than with the oral route (276 +/- 111 minutes) (p = 0.029). Although intramuscular NSAID therapy is rarely warranted in RA patients, these findings suggest that RA may serve as a clinical model for evaluating the effectiveness of a NSAID according to the route of administration.

Evaluation of sulphasalazine in the treatment of spondyloarthropathies

Sulphasalazine has been shown to have an effect in patients with spondyloarthropathies, but the clinical indication for its use is controversial and its long term effect has not yet been evaluated. Treatment with sulphasalazine was analysed retrospectively in a group of 372 patients with a wide range of spondyloarthropathies to determine subsets of patients showing differential effects of the drug. One hundred and one patients received sulphasalazine at a mean daily dose of 2 g (ankylosing spondylitis, 54 patients; psoriatic arthritis, 21 patients; reactive arthritis, four patients; arthritis related to inflammatory bowel disease, six patients; undifferentiated spondyloarthropathy, 16 patients). A comparison between treated and untreated patients suggests that only patients with active and severe disease were treated whatever the precise diagnosis or the amount of axial disease in the spondyloarthropathy. After six months of treatment improvement was noted in 59 patients unrelated to their subgroup or amount of axial disease. After a mean follow up of 20 months, 37 patients were still receiving treatment, 33 had discontinued the drug because of inefficacy, 14 because of side effects, six because of remission of the disease, and 11 for other reasons. Comparison between the beginning and end of treatment showed a statistically significant decrease in morning stiffness, erythrocyte sedimentation rate, and daily dose of non-steroidal anti-inflammatory drugs (NSAIDs). It is concluded that: (a) a low percentage of patients with spondyloarthropathy have active disease requiring treatment with sulphasalazine despite the use of NSAIDs (27% in this study); (b) in this subgroup of patients sulphasalazine seems to be of clinically relevant benefit in 59%; and (c) this benefit does not seem to be correlated with either the precise diagnosis of spondyloarthropathy or the amount of axial disease.

Low bone mineral density in patients with inflammatory bowel disease

To assess the prevalence and risk factors for low bone mineral density in inflammatory bowel disease, we studied 61 consecutive patients, mean age 36 +/- 11 years. Twenty-seven had a Crohn's disease and 34 ulcerative colitis (including 13 with ileoanal anastomosis). Three patients, two women and one man (32, 70, and 45 years old, respectively) had vertebral crush fractures. Bone mineral density measured by dual energy x-ray absorptiometry at spine and femoral level was more than 2 SD below normal values in 23% of the patients, all of them having received steroid therapy. Eighteen patients (29%) had never received steroid therapy; their bone mineral density was not different than those who had. Univariate analysis showed a positive correlation between bone mineral density and body weight or oral calcium intakes, and a negative correlation with steroid daily dose. After ileoanal anastomosis, bone mineral density was not different from other groups and showed a positive correlation with time elapsed since coloproctectomy. We concluded that bone mineral density is low in patients with inflammatory bowel disease and exposes them to the risk of bone fracture. Bone mineral density after ileoanal anastomosis may increase with time after surgery.

IX 207-887 in rheumatoid arthritis. A double-blind placebo-controlled study

OBJECTIVE

To determine the efficacy and the safety of IX 207-887 treatment in rheumatoid arthritis. The IX compound [10-methoxy-4H-benzo(4,5)cyclohepta-(1,2-b)thiophene-4-yliden acetic acid] is effective in several animal models of rheumatoid arthritis and has a mechanism of action involving the inhibition of interleukin-1 release.

METHODS

A double-blind, controlled trial of 16 weeks' duration comparing placebo with IX at a daily dosage of 800 mg or 1,200 mg (20 patients/group) was conducted.

RESULTS

Thirteen patients withdrew from the study, 3 because of lack of efficacy (all in the placebo group) and 10 because of side effects (1 in the placebo group [skin rash] and 9 in the IX groups [skin rash in 5, intestinal disturbances in 2, hepatitis in 1, meningitis in 1]). Intent-to-treat analysis showed a statistically significant difference in the variations of clinical and laboratory parameters between the 3 groups. Between-group comparisons showed an improvement in all these variables in the IX groups versus the placebo group. According to Paulus' criteria, 2 of the 20 placebo-treated patients (10%), 9 of the 20 IX 800 mg-treated patients (45%), and 11 of the 20 IX 1,200 mg-treated patients (55%) were considered responders (P = 0.008).

CONCLUSION

The findings of this study suggest that the tolerability of IX is acceptable in rheumatoid arthritis patients, and that IX is an effective slow-acting drug for use in rheumatoid arthritis.