Improving the reporting of clinical research

A demand for transparency

Persistence with teriparatide in postmenopausal osteoporosis; impact of a patient education and follow-up program: the French experience

SUMMARY

This study evaluated the 18-month persistence with teriparatide in 5413 postmenopausal osteoporotic women who were enrolled in an education and follow-up program. Analysis showed that the persistence rate was 81.5% for women who follow the program, higher than for existing oral antiresorptive treatments.

INTRODUCTION

An education and follow-up program was developed after launch of teriparatide in France in September 2004, to help women to follow the treatment. The objective of this study was to evaluate the persistence with teriparatide in postmenopausal osteoporotic women following this program.

METHODS

Data about persistence are available for the period September 2004 to June 2007. Persistence is defined as the percentage of patients still on treatment at the end of the 18-month course, and it has been compared to the data provided by the French universal health insurance system.

RESULTS

Since the launch of teriparatide in France in September 2004, 5413 postmenopausal women (mean age 72.3 +/- 14.5 years) with osteoporosis and vertebral fractures (mean 3.9 +/- 2) have participated in the program. The persistence rate at 15 months was 81.5%, and our analysis suggested that a majority of patients completed the 18-month treatment course. The main reason for discontinuation was adverse events (46.7%). Data of the French Universal Health Insurance suggest that the persistence may be close to 0% for women who are not in the program.

CONCLUSIONS

Postmenopausal osteoporotic women treated by teriparatide and enrolled in an education and follow-up program have a high persistence rate.

ARTIST (osteoarthritis intervention standardized) study of standardised consultation versus usual care for patients with osteoarthritis of the knee in primary care in France: pragmatic randomised controlled trial

OBJECTIVE

To evaluate the impact of standardised consultations on patients with osteoarthritis of the knee.

DESIGN

Open pragmatic cluster randomised controlled trial.

SETTING

Primary care in France.

PARTICIPANTS

198 primary care rheumatologists, each of whom had to include two consecutive patients who met the American College of Rheumatology criteria for osteoarthritis of the knee.

INTERVENTIONS

Standardised consultation was provided during three goal oriented visits (education on osteoarthritis and treatment management; information on physical exercises; information on weight loss) or usual care.

MAIN OUTCOME MEASURES

Change in body weight and in time spent on physical exercises (Baecke index) at four months.

RESULTS

336 patients were included (154 allocated to standardised consultation and 182 to usual care). Nine patients were excluded because of lack of baseline data (standardised consultation, n=8; usual care, n=1). At four months, taking into account the clustering effect, the decrease in weight was greater in the standardised consultation group than in the usual care group (mean -1.11 (SD 2.49) kg v -0.37 (2.39) kg; P=0.007). The physical activity score was higher for the standardised consultation group than for the usual care group (mean 0.20 (0.65) v 0.04 (0.78); P=0.013). The standardised consultation and usual care groups did not differ in secondary outcomes, except for global assessment of disease activity (0-10 numeric scale: mean -1.66 (2.26) v -0.90 (2.48); P=0.003) and pain level (0-10 numeric scale: mean -1.65 (2.32) v -1.18 (2.58); P=0.04).

CONCLUSIONS

A structured consultation programme for patients with osteoarthritis of the knee resulted in short term improvement in weight loss and time spent on physical activity.

TRIAL REGISTRATION

Clinical trials NCT00462319.

Sample size calculation for cluster randomized cross-over trials

The cluster randomized cross-over design has been proposed in particular because it prevents an imbalance that may bring into question the internal validity of parallel group cluster trials. We derived a sample size formula for continuous outcomes that takes into account both the intraclass correlation coefficient (representing the clustering effect) and the interperiod correlation (induced by the cross-over design).

Effect of medial tibial plateau alignment on serial radiographs on the capacity to predict progression of knee osteoarthritis

OBJECTIVE

To evaluate the effect of medial tibial plateau (MTP) alignment of serial radiographs on the capacity to detect associations between baseline characteristics and progression of joint space narrowing (JSN) in knee osteoarthritis (OA).

METHODS

Standardised posteroanterior weight-bearing knee radiographs of 83 knee OA patients were obtained at baseline and after 24 months using the non-fluoroscopic fixed-flexion protocol. Minimum joint space width (JSW) of the medial tibiofemoral joint spaces was measured manually in paired radiographs. Progression of JSN was defined by a change in JSW larger than the smallest detectable difference (0.4mm). Satisfactory MTP alignment was present if the distance between the anterior and posterior margins of the MTP was < or = 1mm. Standardised questionnaires were used to record age, sex and body mass index. Medial tibiofemoral JSN and osteophyte severity at baseline were graded with the Osteoarthritis Research Society International (OARSI) atlas.

RESULTS

Progression of JSN was observed in 31 (28.4%) of 109 OA knees. In the sub sample of 48 (44%) OA knees with satisfactory MTP alignment on baseline and 24-month radiographs, 18 (37.5%) knees progressed. Stronger (statistically significant) associations were found between sex, generalised OA, JSN and osteophyte severity at baseline and progression of JSN in the sub sample of radiographs with serial satisfactorily MTP alignment than in all radiographs together.

CONCLUSION

Insufficient quality of MTP alignment on serial radiographs could prevent detection of associations between baseline characteristics and progression of JSN in knee OA. These findings may have implications for longitudinal knee OA studies using the fixed-flexion protocol.

Epidemiology of venous thromboembolism after lower limb arthroplasty: the FOTO study

BACKGROUND

In view of recent substantial changes in the management of orthopedic surgery patients, a study was performed in order to update data on the epidemiology of venous thromboembolism (VTE) in patients undergoing lower limb arthroplasty according to contemporary practise.

METHODS

We performed a prospective observational study of a cohort of consecutive patients hospitalized for total hip or knee replacement in June 2003. The primary study outcome was the incidence of symptomatic VTE at 3 months. All events were adjudicated by an independent critical event committee.

RESULTS

Data from 1080 patients (mean age 68.0 years) were available; 63.2% were undergoing total hip replacement and 36.8% total knee replacement. Pharmacological thromboprophylaxis was administered for a mean time of 36 days. Injectable antithrombotics were used in more than 99% of patients, irrespective of the type of surgery. The incidence of the primary study outcome was 1.8% (20 events; 95% CI: 1.0-2.6%). The incidences were 1.3% and 2.8% in hip and knee surgery patients, respectively. There were two pulmonary embolisms, both in knee surgery patients; neither was fatal. Thirty-five per cent of VTEs occurred after hospital discharge. An age of at least 75 years and the absence of ambulation before hospital discharge were the only significant (P < 0.05) predictors of VTE. The rate of clinically significant bleeding was 1.0% and the rate of death was 0.9%.

CONCLUSIONS

The incidence of symptomatic VTE after lower limb arthroplasty is low, even if there is still a need to improve thromboprophylaxis, notably in patients undergoing knee arthroplasty.

The design and assessment of prospective randomised, controlled trials in orthopaedic surgery

Randomised controlled trials represent the gold standard in the evaluation of outcome of treatment. They are needed because differences between treatment effects have been minimised and observational studies may give a biased estimation of the outcome. However, conducting this kind of trial is challenging. Several methodological issues, including patient or surgeon preference, blinding, surgical standardisation, as well as external validity, have to be addressed in order to lower the risk of bias. Specific tools have been developed in order to take into account the specificity of evaluation of the literature on non-pharmacological intervention. A better knowledge of methodological issues will allow the orthopaedic surgeon to conduct more appropriate studies and to better appraise the limits of his intervention.

Individualising the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) function subscale: incorporating patient priorities for improvement to measure functional impairment in hip or knee osteoarthritis

Objective:

Recommended outcome measures in osteoarthritis are standardised scales identical for each patient. As patient-specific scales are of increasing interest when considering patient priorities in outcome assessment, this study aims to validate individualised forms of the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) function subscale.

Patients and Methods:

WOMAC function subscale data were prospectively obtained from 1218 outpatients with hip or knee osteoarthritis requiring non-steroidal anti-inflammatory drugs. Patients also rated the importance to remove disability in each activity of the WOMAC function subscale, and selected the five activities they considered the most important to be improved upon. After treatment, patients again completed the WOMAC function subscale. Several individualisation methods were evaluated: methods whereby the score of each item is multiplied by, or added to, its importance, and methods based on the five most important activities (WOMAC top 5). Psychometric properties of individualised scales were compared to those of the WOMAC function subscale.

Results:

The missing data rate was 11%, 13% and 2% for the WOMAC function, its individualised forms and the WOMAC top 5, respectively. Combining severity and importance of each item did not improve the properties of the scales. The WOMAC top 5 was the most responsive scale (standardised response mean: 0.96 vs 0.80, p<0.001).

Conclusion:

Because of its better responsiveness, ease of use, low missing data rate and ability to highlight patient priorities, the WOMAC top 5 could be an interesting tool in therapeutic evaluation in hip or knee osteoarthritis.

Long-term effects of infliximab on bone and cartilage turnover markers in patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is associated with systemic bone loss, subchondral bone erosion and cartilage degradation under the control of pro-inflammatory cytokines, including tumour necrosis factor alpha (TNFalpha). Therefore, we tested the hypothesis that administration of infliximab, an anti-TNFalpha drug in the treatment of RA, would modulate systemic and local bone resorption and reduce cartilage degradation.

METHODS

We performed a prospective study of a multicentric cohort of 48 women, mean (SD) age 54.2 (12.1) years old, with severe RA for 11.4 (7.8) years, who started infliximab after failure of other disease-modifying antirheumatic drugs. At baseline and 6, 22 and 54 weeks after initiating Infliximab therapy we measured the following biochemical markers: pro-collagen serum type I N-terminal propeptide (PINP), a marker of bone formation; serum C-terminal cross-linked telopeptide of type I collagen (CTX-I), a marker of cathepsin K-mediated bone collagen degradation believed to reflect systemic bone resorption; serum C-terminal cross-linked telopeptide of type I collagen (ICTP), an index of matrix metalloprotease (MMP) mediated type I collagen degradation reflecting preferential joint metabolism; and urinary CTX-II a biochemical markers of cartilage degradation. Total hip and lumbar spine bone mineral density (BMD) was assessed at baseline, and after 6 and 12 months by dual-energy x-ray absorptiometry (DXA). No patient received bisphosphonates while 77% were under oral glucocorticoids.

RESULTS

BMD remained stable over 1 year. Serum CTX-I levels rapidly decreased by 19% and 28% at week 6 and week 22, respectively (analysis of variance (ANOVA) p = 0.032) values returning to pre-treatment level at week 54. By contrast, ICTP levels progressively declined with a maximal 25% decrease at week 54 (ANOVA p = 0.028). By contrast, PINP levels remained stable over time, which led to a 30 to 40% improvement in bone remodelling balance, as assessed by the ratios PINP/CTX and PINP/ICTP (p<0.05). There was no significant change of urinary CTX-II in the whole population, but a slight decrease (ANOVA p = 0.041) in those with pre-treatment levels above the upper limit of normal range.

CONCLUSIONS

In summary, the improvement in the formation/resorption marker ratio suggests beneficial systemic and local bone effects of infliximab in patients with RA.

Fixed-flexion knee radiography: the sensitivity to detect knee joint space narrowing in osteoarthritis

OBJECTIVES

Independent reports on the longitudinal performance of non-fluoroscopic fixed-flexion knee radiography have not been published. Therefore, we evaluated the sensitivity of fixed-flexion radiography to detect knee joint space narrowing (JSN) over 2 years in patients with osteoarthritis (OA) and compared the effect of reproducibility and quality of medial tibial plateau (MTP) alignment on sensitivity to JSN.

METHODS

Fixed-flexion radiographs of both knees of 193 OA patients were obtained at baseline and after 24 months. Minimum joint space width (JSW) of the medial tibiofemoral joint spaces was measured manually in paired digitised radiographs without knowledge of the chronology. The degree of MTP alignment was assessed by measuring the distance between the anterior and posterior margins of the MTP (intermargin distance [IMD]). Accurate repositioning was achieved if, in the 24-month radiograph, the IMD was reproduced to within 1mm. The quality of MTP alignment was satisfactory if the IMD was <or=1mm.

RESULTS

The mean (standard deviation [SD]) JSN between baseline and 24 months was 0.18 (0.49)mm and the standardised response mean (SRM) was 0.37. The SRM was 0.36 in the knee film pairs (86%) in which the IMD was accurately reproduced after 24 months and 0.52 in the film pairs (42%) with satisfactory MTP alignment on both the baseline and 24-month radiographs.

CONCLUSION

The sensitivity to radiographic JSN on fixed-flexion knee radiographs over 2 years was higher in satisfactorily aligned than accurately reproduced serial pairs of radiographs. These findings have implications for longitudinal knee OA studies using fixed-flexion radiographs.

Arterial phase enhancement and body mass index are predictors of response to chemoembolisation for liver metastases of endocrine tumours

Transcatheter arterial chemoembolisation (TACE) has been reported to be an efficient treatment of liver metastases of endocrine tumours in short series of patients. However, several factors seem to affect its results. The aim of this work is to identify predictors of response to TACE for liver metastases of endocrine tumours. A total of 163 TACE procedures were performed in 67 patients between 1994 and 2004. Forty-four patients were treated with streptozotocin and 23 with doxorubicin. Primary tumour was located in the pancreas for 19 patients, and had been removed in 43. Thirty-eight tumours were functioning. Response rate was 37% (confidence interval [CI] 95%: 28–49%). Median time to progression (TTP) was 14.5 months (CI 95%: 9–41). In multivariate analysis (n=43), predictors of tumour response were body mass index (BMI) (odds ratio [OR]: 1.3; CI 95%: 1.04–1.63; P=0.022), functioning type of tumour (OR: 7.31; CI 95%: 1.26–42.5; P=0.027), arterial phase enhancement on abdominal computed tomography (CT) (OR: 8.11; CI 95%:1.06–62; P=0.044) and use of streptozotocin for cytotoxic agent (OR: 21.3; CI 95%: 1.48–306; P=0.025). Analysis of TTP predictors showed that BMI (hazard ratio [HR]: 0.85; CI 95%: 0.76–0.86; P=0.01) and arterial phase enhancement (HR: 0.3; CI 95%: 0.12–0.73; P=0.008) were associated with delayed progression. This large study confirms the previously reported results of TACE regarding its efficacy for the treatment of liver metastases of endocrine tumours. Arterial phase enhancement on abdominal CT and BMI are predictors of treatment's efficacy. Streptozotocin should be the preferred cytotoxic agent in order to save anthracycline for systemic chemotherapy.

Emergence of Legionella pneumophila Pneumonia in Patients Receiving Tumor Necrosis Factor- Antagonists

BACKGROUND

Patients treated with tumor necrosis factor-alpha (TNF-alpha) antagonists have an increased risk of infection, but infection due to Legionella pneumophila has rarely been described in patients receiving such therapy.

METHODS

A registry involving 486 clinical departments in France was designed by a multidisciplinary group (Recherche Axée sur la Tolérance des Biothérapies [RATIO]) to collect data on opportunistic and severe infections occurring in patients treated with TNF-alpha antagonists. All cases are reported to RATIO in accordance with national health authorities and validated by infectious disease experts. The legionellosis rate among patients treated with TNF-alpha antagonists was compared with the rate in France overall.

RESULTS

We report a 1-year consecutive series of 10 cases of L. pneumophila pneumonia in France in 2004, including 6 cases treated with adalimumab, 2 treated with etanercept, and 2 treated with infliximab. The median patient age was 51 years (range, 40-69 years). Eight patients were treated for rheumatoid arthritis, 1 was treated for cutaneous psoriasis, and 1 was treated for pyoderma gangrenosum. The median duration of TNF-alpha antagonist treatment at onset of infection was 38.5 weeks (range, 3-73 weeks). Eight patients were receiving concomitant treatment with corticosteroids, and 6 were receiving treatment with methotrexate. The relative risk of legionellosis when receiving treatment with a TNF-alpha antagonist, compared with the relative risk in France overall, was estimated to be between 16.5 and 21.0. We also report a second episode of confirmed legionellosis following the reintroduction of infliximab therapy.

CONCLUSIONS

L. pneumophila pneumonia is a potentially severe but curable infection that might complicate anti-TNF-alpha therapy. In patients receiving anti-TNF-alpha who develop pneumonia, legionellosis should be systematically investigated, and first-line antibiotic therapy should be efficient against L. pneumophila.

Fear-avoidance beliefs about back pain in patients with subacute low back pain

The fear-avoidance beliefs of patients with subacute low back pain (LBP) considered at risk for chronic disabling LBP are not well known. The objectives of this cross-sectional descriptive survey, conducted in secondary care practice, were to assess fear-avoidance beliefs about back pain in patients with subacute LBP and to seek an association between physician or patient characteristics and level of fear-avoidance beliefs. A total of 286 rheumatologists completed a self-administered questionnaire assessing physicians' demographic, professional data, personal history of back pain, and back pain fear-avoidance beliefs (on the Fear-Avoidance Belief Questionnaire [FABQ]) and 443 patients with sLBP completed one on pain, perceived handicap and disability (Quebec Back Pain Disability Scale), anxiety and depression (Hospital Anxiety Depression questionnaire), and back pain beliefs (FABQ). Mean FABQ scores for rheumatologists for physical activities (FABQ Phys) and occupational activities (FABQ Work) were 9.2+/-4.4 (range 0-21) and 16.7+/-6.9 (range 2-37), respectively, and patient scores were 16.7+/-5.2 and 19.3+/-12.4, respectively. A total of 68% of patients and 10% of physicians had a high rating on the FABQ Phys (>14). Patients' fear-avoidance beliefs about physical activity were associated with low level of education (odds ratio [OR] 4.19; 95% confidence interval [CI] 1.83-9.57), patients' perceived disability (OR 1.05; CI 1.03-1.07), and physicians' high FABQ Phys score (OR 5.92; CI 1.31-26.32). Here we show that fear-avoidance beliefs about back pain were high in patients with subacute LBP and their rheumatologists.

Changes in airway inflammation following nasal allergic challenge in patients with seasonal rhinitis

BACKGROUND

Seasonal allergic rhinitis could predispose to the development of chronic bronchial inflammation as observed in asthma. However, direct links between nasal inflammation, bronchial inflammation and airway responsiveness in patients with seasonal allergic rhinitis and without asthma are not fully understood. The aim of this study was to analyse the changes induced by allergic nasal challenge outside the pollen season in airway responsiveness and bronchial inflammation of patients with seasonal allergic rhinitis.

METHODS

Nine patients were evaluated after either grass pollens or placebo nasal challenge in a randomized cross-over double-blinded trial. Nasal parameters were recorded hourly and airway responsiveness was assessed by methacholine challenge. Cytological examinations and cytokine measurements were performed in nasal lavage and induced sputum. Eosinophil activation was investigated by eosinophil-cationic protein expression and secretion.

RESULTS

Airway responsiveness was increased after allergic nasal challenge. Total eosinophils and eosinophils expressing eosinophil-cationic protein were increased in induced sputum after allergic nasal challenge. Both eosinophil number and eosinophil-cationic protein concentration in induced sputum were correlated to methacholine responsiveness.

CONCLUSIONS

These results suggest that eosinophils participate to the bronchial inflammation in patients with seasonal allergic rhinitis following allergic nasal challenge outside the pollen season and might explain changes in airway responsiveness.

Outcome of subacute low back pain: influence of patients' and rheumatologists' characteristics

OBJECTIVES

To assess the outcome of subacute low back pain, to identify the characteristics of patients and physicians which were related to outcome and to evaluate the influence of rheumatologists' beliefs about back pain on their following the guidelines for physical and occupational activity.

METHODS

DESIGN

a longitudinal descriptive survey.

SETTING

a secondary care practice in France.

PARTICIPANTS

266 rheumatologists; 440 patients with subacute low back pain.

OUTCOME MEASURES

the main outcome measure was persistence of back pain 3 months after baseline evaluation. A self-administered questionnaire for physicians assessed attitudes and beliefs about back pain [Fear-Avoidance Beliefs Questionnaire (FABQ)], and one for patients assessed pain, perceived handicap and disability (Quebec Scale), anxiety and depression (Hospital Anxiety Depression Questionnaire), and beliefs about back pain (FABQ).

RESULTS

Forty per cent of patients had persistent low back pain at 3 months; 5.5% of these had sciatica. A total of 10% of rheumatologists and 68% of patients at baseline had a high FABQ physical score (phys; >14). Determinants of outcomes were work-related back pain [odds ratio (OR) = 3.37; 95% confidence interval (CI) 1.08-5.17], anxiety (OR = 2.41; 95% CI 1.44-4.09), sex (female OR = 2.03; 95% CI 1.30-3.18) and patients' beliefs about back pain at work (OR = 1.02; 95% CI 1.00-1.05). Physicians with high FABQ physical scores were less likely to follow guidelines on prescribing rest and occupational activity for back pain.

CONCLUSION

Back pain commonly persists 3 months later in patients with subacute low back pain. Patients and rheumatologists still have negative beliefs about back pain. Rheumatologists' beliefs influence their following guidelines on physical and occupational activities. National education programmes about low back pain are needed in France.

EULAR report on the use of ultrasonography in painful knee osteoarthritis. Part 2: exploring decision rules for clinical utility

BACKGROUND

Synovial inflammation (as defined by hypertrophy and effusion) is common in osteoarthritis (OA) and may be important in both pain and structural progression.

OBJECTIVE

To determine if decision rules can be devised from clinical findings and ultrasonography (US) to allow recognition of synovial inflammation in patients with painful knee OA.

METHODS

A EULAR-ESCISIT cross sectional, multicentre study enrolled subjects with painful OA knee who had clinical, radiographic, and US evaluations. A classification and regression tree (CART) analysis was performed to find combinations of predictor variables that would provide high sensitivity and specificity for clinically detecting synovitis and effusion in individual subjects. A range of definitions for the two key US variables, synovitis and effusion (using different combinations of synovial thickness, depth, and appearance), were also included in exploratory analyses.

RESULTS

600 patients with knee OA were included in the analysis. For both knee synovitis and joint effusion, the sensitivity and specificity were poor, yielding unsatisfactory likelihood ratios (75% sensitivity, 45% specificity, and positive LR of 1.36 for knee synovitis; 71.6% sensitivity, 43.2% specificity, and positive LR of 1.26 for joint effusion). The exploratory analyses did not improve the sensitivity and specificity (demonstrating positive LRs of between 1.26 and 1.57).

CONCLUSION

Although it is possible to determine clinical and radiological predictors of OA inflammation in populations, CART analysis could not be used to devise useful clinical decision rules for an individual subject. Thus sensitive imaging techniques such as US remain the most useful tool for demonstrating synovial inflammation of the knee at the individual level.

EULAR report on the use of ultrasonography in painful knee osteoarthritis. Part 1: prevalence of inflammation in osteoarthritis

OBJECTIVES

To assess the prevalence of inflammation in subjects with chronic painful knee osteoarthritis (OA), as determined by the presence of synovitis or joint effusion at ultrasonography (US); and to evaluate the correlation between synovitis, effusion, and clinical parameters.

METHODS

A cross sectional, multicentre, European study was conducted under the umbrella of EULAR-ESCISIT.

SUBJECTS

had primary chronic knee OA (ACR criteria) with pain during physical activity >or=30 mm for at least 48 hours. Clinical parameters were collected by a rheumatologist and an US examination of the painful knee was performed by a radiologist or rheumatologist within 72 hours of the clinical examination. Ultrasonographic synovitis was defined as synovial thickness >or=4 mm and diffuse or nodular appearance, and a joint effusion was defined as effusion depth >or=4 mm.

RESULTS

600 patients with painful knee OA were analysed. At US 16 (2.7%) had synovitis alone, 85 (14.2%) had both synovitis and effusion, 177 (29.5%) had joint effusion alone, and 322 (53.7%) had no inflammation according to the definitions employed. Multivariate analysis showed that inflammation seen by US correlated statistically with advanced radiographic disease (Kellgren-Lawrence grade >or=3; odds ratio (OR)=2.20 and 1.91 for synovitis and joint effusion, respectively), and with clinical signs and symptoms suggestive of an inflammatory "flare", such as joint effusion on clinical examination (OR=1.97 and 2.70 for synovitis and joint effusion, respectively) or sudden aggravation of knee pain (OR=1.77 for joint effusion).

CONCLUSION

US can detect synovial inflammation and effusion in painful knee OA, which correlate significantly with knee synovitis, effusion, and clinical parameters suggestive of an inflammatory "flare".

A meta-analysis of patellar replacement in total knee arthroplasty

From individual randomized studies it is unclear whether the patella should be replaced during total knee replacement. We did a meta-analysis to provide quantitative data to compare patellar resurfacing with nonresurfacing during total knee arthroplasty. Only randomized, controlled trials reported between January 1966 and August 2003 comparing patellar replacement with patella retention were included for a total of 12 studies. Two reviewers assessed trial quality and extracted data from papers. The outcomes identified were reoperations for patellar problems, anterior knee pain, knee scores, stair climbing, and patient satisfaction. The resurfaced patella performed better, and we found an increased relative risk (defined by the ratio of the risk of the event in the resurfaced group on the risk of the event in the nonresurfaced group) for reoperation, for significant anterior knee pain, and for significant pain during stair climbing when the patella was left unresurfaced. No differences were observed between the two groups for International Knee Society function score, Hospital for Special Surgery score, and for patient satisfaction. Despite these general findings, forming a definitive conclusion is difficult because many confounding factors, such as component design, surgeon experience, and technical aspects of the surgery, might influence the result in a patient.

Using patients' and rheumatologists' opinions to specify a short form of the WOMAC function subscale

BACKGROUND

The WOMAC (Western Ontario and McMaster Universities) function subscale is widely used in clinical trials of hip and knee osteoarthritis. Reducing the number of items of the subscale would enhance efficiency and compliance, particularly for use in clinical practice applications.

OBJECTIVE

To develop a short form of the WOMAC function subscale based on patients' and experts' opinions (WOMAC function short form).

METHODS

WOMAC function subscale data (Likert version) were obtained from 1218 outpatients with painful hip or knee osteoarthritis. These patients and their rheumatologists selected the five items that they considered most in need of improvement. The rheumatologists were asked to select the five items for which patients in general are the most impaired. Items that were least important to patients and experts, those with a high proportion of missing data, and those with a response distribution showing a floor or ceiling response were excluded, along with one of a pair of items with a correlation coefficient >0.75.

RESULTS

The WOMAC function short form included items 1, 2, 3, 6, 7, 8, 9, and 15 of the long form. The short form did not differ substantially from the long form in responsiveness (standardised response mean of 0.84 v 0.80).

CONCLUSIONS

A short form of the WOMAC function subscale was developed according to the views of patients and rheumatologists, based on the responses of 1218 patients and 399 rheumatologists. The clinical relevance and applicability of this WOMAC function subscale short form require further evaluation.

First line treatment of knee osteoarthritis in outpatients in France: adherence to the EULAR 2000 recommendations and factors influencing adherence

OBJECTIVES

To document adherence to two parts of the EULAR 2000 recommendations for knee osteoarthritis, concerning non-pharmacological and pharmacological first line management; and to identify factors influencing adherence to the recommendations.

METHODS

In a prospective study, 1030 randomly selected French general practitioners completed questionnaires about three unselected outpatients with osteoarthritis, and about their own practice, knowledge, and agreement with the EULAR 2000 recommendations. Percentages of adherence of their prescriptions to both parts of the recommendation were calculated, and probabilities of non-adherence analysed in relation to patient and physician related characteristics, using multilevel logistic regression analysis.

RESULTS

Data were obtained from 967 physicians and 2430 patients. The EULAR 2000 recommendations were familiar to 79% of the GPs; 99% agreed with the non-pharmacological part and 97% with the pharmacological part. Adherence to the two parts was 74.8% and 73.6%, but 54.2% for both together. Factors increasing adherence to the non-pharmacological recommendation were patient body mass index >35 kg/m(2) (odds ratio 0.11 (95% confidence interval, 0.06 to 0.21)), patient's stated preference for a treatment (OR 0.43 (0.55 to 0.97)), and physician's regular continuance of medical education (OR 0.76 (0.59 to 0.98)); patient's age and duration of symptoms decreased adherence. Factors increasing adherence to the pharmacological recommendation were gastrointestinal disease (OR 0.50 (0.35 to 0.72)) and physician's knowledge of the EULAR recommendations (OR 0.75 (0.60 to 0.93)).

CONCLUSIONS

Although most physicians agreed with the EULAR 2000 recommendations, adherence was only approximately 75% for each of the non-pharmacological and pharmacological recommendations and 54% for both together.

Predictive factors of total hip replacement due to primary osteoarthritis: a prospective 2 year study of 505 patients

OBJECTIVES

To determine the 2 year total hip replacement (THR) rate and to identify factors predictive of THR due to primary osteoarthritis (OA).

METHODS

A 2 year prospective cohort study. Inclusion criteria were primary hip OA, with a history of pain for 6 months, and patients' pain assessment of > or =30 mm on a visual analogue scale (0-100 mm). Predictive factors of THR were identified by univariate then multivariate analysis using logistic regression. Potential predictors considered were demographic, radiographic (localisation and severity of OA), and patients' assessment of symptomatic severity of OA.

RESULTS

Of the 741 patients enrolled, 505 (68.2%) patients, mean (SD) age 64.0 (10.1) years, mean (SD) disease duration 4.7 (5.2) years, had complete 2 year data. There was no difference between the completer and non-completer groups. During follow up, 189/505 (37.4%) patients had a first THR. By multivariate analysis, predictors of THR were Kellgren-Lawrence radiographic grade (grade III: odds ratio (OR) = 3.3 (95% confidence interval (95% CI) 1.7 to 6.4); grade IV: OR = 5.3 (95% CI 2.6 to 10.8)), high mean patient global assessment during the first 6 months (OR = 2.2 (95% CI 1.4 to 3.2)), and previous non-steroidal anti-inflammatory drug (NSAID) intake (OR = 1.5 (95% CI 1.0 to 2.4)). For two of these factors together, OR = 3.0 (95% CI 1.6 to 5.9), for three factors together, OR = 5.6 (95% CI 2.6 to 12.2).

CONCLUSION

The 2 year rate of THR was high in this group of patients with painful hip OA: 37.4%. Radiological grade, mean patient global assessment, and the need for NSAIDs were predictive of THR.

Cerebrospinal fluid MR dynamics and risk of falls in the elderly

RATIONALE AND OBJECTIVES

To investigate the relationship between CSF dynamics and risk of falls of unknown origin in the elderly.

POPULATION AND METHODS

Phase contrast MR studies allowed CSF aqueductal flow quantification on 23 community-dwelling older people initially explored for mild cognitive impairment. Mobility assessment included report of falls, talking walking test, stance test, one leg standing test, up and go test, and measurement of fast gait speed.

RESULTS

History of falls was associated with larger aqueduct, steeper diastolic slopes higher ratios RDV/SD of diastolic volume/CSF systole duration (p</=0.0006). Amplitude CSF parameters, diastolic slopes and RDV/SD appeared correlated with the aqueduct area (p<0.01).

CONCLUSIONS

These preliminary data suggest that disturbances of CSF dynamics could play a role in mobility decline with aging especially in falls of unknown origin.

Detection of small joint synovitis by ultrasonography: the learning curve of rheumatologists

BACKGROUND

Ultrasonography allows assessment of soft tissue structures and has become a valued tool for diagnosing synovitis.

OBJECTIVE

To assess the learning curve for ultrasonography in evaluating synovitis of the small joints in rheumatoid arthritis.

METHODS

Metacarpophalangeal (MCP), metatarsophalangeal (MTP), and proximal interphalangeal (PIP) joints were evaluated using ultrasonography (Esaote AU 5 Epi, linear probe 10-13 MHz) by four rheumatologists, the first being experienced (senior), the others having no (fellows 1 and 2) or little (fellow 3) experience in ultrasonography. For each fellow, the learning curve was divided into blocks. In each block the fellow examined five consecutive patients with the senior; then, blinded to the senior's results, two further patients alone (seven patients examined per block). For each evaluation, the MCP, PIP, and MTP joints were individually tagged as having synovitis or not. The ultrasonography results were compared between fellow and senior for the two last patients of each block, using proportions of agreement and kappa statistics.

RESULTS

70 patients were evaluated (seven practice patients, followed by nine blocks). For fellows 1 and 2, the proportions of agreement were respectively 42% and 47% (kappa = 0 and 0) at the first evaluation, and rose progressively to 82% and 82% (kappa = 0.63 and 0.62) at the ninth evaluation. For fellow 3, initially good results were followed by decreased accuracy.

CONCLUSIONS

Detecting synovitis of the MCP, PIP, and MTP joints using ultrasonography can be done accurately by rheumatologists initially not experienced in this technique. At least 70 examinations were necessary to develop competence.

Management of osteoarthritis (OA) with an unsupervised home based exercise programme and/or patient administered assessment tools. A cluster randomised controlled trial with a 2x2 factorial design

BACKGROUND

Diary recording of pain and disabling activities in osteoarthritis (OA) is widely recommended, but, to our knowledge, its impact on symptoms has not been investigated. Exercise programmes have been shown to be effective when patients are closely supervised by nurses or physiotherapists; however, data are lacking on the efficacy of an unsupervised home based exercise regimen in patients with OA.

OBJECTIVES

To evaluate the clinical efficacy of patient administered assessment tools and an unsupervised home based exercise programme alone or in combination in patients with OA.

METHODS

The study was a 24 week, open cluster randomised controlled trial with a factorial design. Rheumatologists (n = 867) were assigned to four groups according to the treatment given: standardised tools (ST; n = 220), exercises (EX; n = 213), both tools and exercises (ST+EX; n = 213), or usual care (n = 221). Each rheumatologist was to enroll four patients who met the American College of Rheumatology criteria for OA (three with knee OA, one with hip OA). "Tools" consisted of weekly recording of pain and disabling activities in a diary. A home based exercise programme was performed daily at least four times per week with the aid of videotape and booklet. In addition to exercise and assessment, all patients received 12.5 mg or 25 mg of the non-steroidal anti-inflammatory drug rofecoxib once daily. Outcome variables were: pain (measured on a visual analogue scale, 0-100); Western Ontario and McMaster Universities Osteoarthritis Index, function subscale (0-100); and patient assessment of the quality of care (0-100).

RESULTS

Overall, 2957 patients with OA (2216 knee, 741 hip) were included. After 24 weeks, both pain and function improved in the ST, EX, ST+EX, and usual care groups (mean (SD) -17 (27), -20 (29), -15 (27), -19 (29); and -11 (19), -12 (19), -10 (19), -11 (20), respectively), without significant differences between groups. However, patients in the EX and ST+EX groups were more likely to agree that their rheumatologist had done his best to preserve their functional and physical activities.

CONCLUSION

Although patients' assessments favoured the exercise programme, results from this study failed to demonstrate a short term symptomatic effect of the two non-pharmacological treatments (weekly recording of condition and exercise) in patients with OA concurrently receiving nonsteroidal anti-inflammatory drugs.

Randomized clinical trial to assess the effect of an educational programme designed to improve nurses' assessment and recording of postoperative pain

BACKGROUND

The aim of this study was to evaluate the impact of an intervention designed to improve postoperative pain assessment and recording by nurses.

METHODS

This cluster randomized clinical trial included two intervals of 3 months each: a preintervention observational study (period 1) followed by a period of intervention (period 2). Six surgical wards were randomly assigned to receive either an experimental intervention, including educational seminars for nurses on pain, pain assessment and the use of a visual analogue scale (n = 3), or standard care (control group; n = 3). The main outcome measures were the percentage of patients in whom pain was assessed, number of pain assessments per patient and postoperative pain intensity scores.

RESULTS

A total of 2278 patients were included. Significant improvements were found in the percentage of patients in whom pain was assessed and the number of daily pain assessments per patient in the intervention group between periods 1 and 2. In contrast, these outcomes were unchanged between the two intervals in wards randomized to standard care. During period 2, pain scores at 48 h were significantly decreased in the intervention wards compared with those in the control group.

CONCLUSION

An educational programme dedicated to nurses strongly increased the use of regular pain assessment, and may have contributed to a modest improvement in postoperative analgesia.

Evaluation of clinically relevant changes in patient reported outcomes in knee and hip osteoarthritis: the minimal clinically important improvement

BACKGROUND

In clinical trials, at the group level, results are usually reported as mean and standard deviation of the change in score, which is not meaningful for most readers.

OBJECTIVE

To determine the minimal clinically important improvement (MCII) of pain, patient's global assessment of disease activity, and functional impairment in patients with knee and hip osteoarthritis (OA).

METHODS

A prospective multicentre 4 week cohort study involving 1362 outpatients with knee or hip OA was carried out. Data on assessment of pain and patient's global assessment, measured on visual analogue scales, and functional impairment, measured on the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) function subscale, were collected at baseline and final visits. Patients assessed their response to treatment on a five point Likert scale at the final visit. An anchoring method based on the patient's opinion was used. The MCII was estimated in a subgroup of 814 patients (603 with knee OA, 211 with hip OA).

RESULTS

For knee and hip OA, MCII for absolute (and relative) changes were, respectively, (a) -19.9 mm (-40.8%) and -15.3 mm (-32.0%) for pain; (b) -18.3 mm (-39.0%) and -15.2 mm (-32.6%) for patient's global assessment; (c) -9.1 (-26.0%) and -7.9 (-21.1%) for WOMAC function subscale score. The MCII is affected by the initial degree of severity of the symptoms but not by age, disease duration, or sex.

CONCLUSION

Using criteria such as MCII in clinical trials would provide meaningful information which would help in interpreting the results by expressing them as a proportion of improved patients.

Evaluation of clinically relevant states in patient reported outcomes in knee and hip osteoarthritis: the patient acceptable symptom state

BACKGROUND

The patient acceptable symptom state (PASS) is the value beyond which patients can consider themselves well. This concept can help in interpreting results of clinical trials.

OBJECTIVE

To determine the PASS estimate for patients with knee and hip osteoarthritis (OA) by assessing pain, patient's global assessment of disease activity, and functional impairment.

METHODS

A 4 week prospective multicentre cohort study of 1362 outpatients with knee or hip OA was carried out. Data on assessment of pain and patient's global assessment of disease, measured on visual analogue scales, and functional impairment, measured on the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) function subscale, were collected at baseline and final visits. The patients assessed their satisfaction with their current state at the final visit. An anchoring method based on the patient's opinion was used.

RESULTS

For patients with knee and hip OA, the estimates of PASS were, respectively, 32.3 and 35.0 mm for pain, 32.0 and 34.6 mm for patient global assessment of disease activity, and 31.0 and 34.4 points for WOMAC function score. The PASS varied moderately across the tertiles of baseline scores but not across age, disease duration, or sex.

CONCLUSION

The use of PASS in clinical trials would provide more meaningful results expressed as a proportion of patients in an acceptable symptom state.

[FACT: French national registry of acute coronary syndromes. Specific study of French general hospital centers]

The FACT registry is currently the French registry including the greatest number of patients with acute coronary syndromes.

PURPOSE

The study presents epidemiologic data, modalities and delays for medical admission.

METHOD

Three thousand nine hundred and two patients were included in FACT by 362 French centers of cardiology between 06/01/2003 and 03/02/2003. One thousand eight hundred and ten patients, who had been placed in the cardiology departments of French general hospitals, were isolated from this registry. The French general hospitals represented 50.8% of the 362 centers. In order to clarify the study, these patients were divided into three groups: group A: patients without ST segment elevation but with suggestive ECG modifications; group B: patients with ST segment elevation; group C: all other patients. The results were mainly studied for groups A and B and compared. These results were also compared to those of the FACT registry and of other registries.

RESULTS

The results show that the average delay for admission is 2.9 h after a first delay between the pain and the help of 6.7 h. The first intervening party is a general practitioner (36.4%) then the SAMU (31.6%) and finally the emergency departments (18.7%). 16.6% of the patients from group B undergo pre-hospital thrombolysis. The recommendations of the European Society of Cardiology are widely applied except for the most recent of them since only 27.6% of the patients from group A having a TIMI score > or = 5 receive an anti-GIIB IIIA treatment. The reasons of the non-prescription of the recommended classes are mostly linked to contra-indication and intolerance. The strategy of coronary reopening mainly depends on the presence or the absence in the department of an available medical equipment for angioplasty. If there is one, the percentage of primary angioplasty reaches 54.2% and the percentage of thrombolysis 7.9%. On the opposite, there is 8.3% of angioplasty and 54.2% of thrombolysis for the unequipped centers. The global mortality reaches 5.8% but is inversely proportional to the level of equipment of the departments: 5.9% for the departments with angioplasty, 11% for the departments with coronarography but without angioplasty and 13.8% for the departments without any interventional equipment. Nevertheless, the age of the patients is different and this influences the results: we notice that the less equipped the department is, the older the patients are.

CONCLUSION

The FACT registry and the data from the general hospitals give the opportunity to think about the possibilities to improve the delays of call to the first intervening party (more particularly to the SAMU) but it also allows us to think about how to better organize the geographical distribution giving access to a medical equipment for angioplasty. All these information will also help the cardiologists to gather around the recommendations by convincing them that the benefit/risk ratio is positive.