The OPTIMA study: assessing a new cinacalcet (Sensipar/Mimpara) treatment algorithm for secondary hyperparathyroidism

BACKGROUND AND OBJECTIVES

Cinacalcet, a novel calcimimetic, targets the calcium-sensing receptor to lower parathyroid hormone (PTH), calcium, and phosphorus levels in dialysis patients with secondary hyperparathyroidism (SHPT). This study compared the efficacy of a cinacalcet-based regimen with unrestricted conventional care (vitamin D and phosphate binders) for achieving the stringent National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) targets for dialysis patients.

STUDY DESIGN

In this multicenter, open-label study, hemodialysis patients with poorly controlled SHPT were randomized to receive conventional care (n = 184) or a cinacalcet-based regimen (n = 368). Doses of cinacalcet, vitamin D sterols, and phosphate binders were adjusted during a 16-wk dose-optimization phase with the use of algorithms that allowed cinacalcet to be used with adjusted doses of vitamin D. The primary end point was the proportion of patients with mean intact PTH < or =300 pg/ml during a 7-wk efficacy assessment phase.

RESULTS

A higher proportion of patients receiving the cinacalcet-based regimen versus conventional care achieved the targets for PTH (71% versus 22%, respectively; P < 0.001), Ca x P (77% versus 58%, respectively; P < 0.001), calcium (76% versus 33%, respectively; P < 0.001), phosphorus (63% versus 50%, respectively; P = 0.002), and PTH and Ca x P (59% versus 16%, respectively, P < 0.001), and allowed a 22% reduction in vitamin D dosage in patients receiving vitamin D at baseline. Achievement of targets was greatest in patients with less severe disease (intact PTH range, 300 to 500 pg/ml) and the cinacalcet dose required was lower in these patients (median = 30 mg/d).

CONCLUSIONS

Compared with conventional therapy, a cinacalcet-based treatment algorithm increased achievement of KDOQI treatment targets in dialysis patients in whom conventional therapy was no longer effective in controlling this disease.

[The impact of preoperative function and pain on early patient-centred outcome after total hip arthroplasty]

AIM

It was the purpose of this prospective study to investigate the impact of preoperative functional status and pain on the early patient-centred outcome after total hip arthroplasty (THA).

METHODS

67 consecutive patients scheduled for THA were included in this study. Outcome was analysed with the Western Ontario and McMaster Universities' (WOMAC) Osteoarthritis Index preoperatively and after ten days and 12 weeks, respectively. Patients were grouped with regard to their preoperative function and pain according to the WOMAC Osteoarthritis Index. Statistical analysis was performed using a multivariate regression model considering further confounding variables (age, gender, affected side, duration of surgery, and anchorage of THA).

RESULTS

All patients showed a significant functional improvement both at ten days postoperatively and after three months, respectively. Patients with a higher degree of disability preoperatively had a larger relative functional improvement according to their WOMAC score compared to patients who initially were less deteriorated. However, the latter had the better absolute scores postoperatively. Multiple regression analysis revealed gender (OR: -11.85, 95% CI: -22.65 to -1.06, p=0.03) and preoperative WOMAC score (OR: 0.34, 95% CI: 0.09 to 0.59, p<0.01) to be significant prognostic variables at ten days postoperatively. After three months, age (OR: 0.43, 95% CI: 0.04 to 0.82, p=0.03) was the only variable predicting the patient-centred outcome.

CONCLUSION

In our study sample, patient-related variables did significantly influence the patient-centred outcome after ten days (gender and WOMAC) and at three months postoperatively (age) whereas procedure-related variables did not have any impact.

International study of health care organization and financing: development of renal replacement therapy in Germany

The German health system represents the case of a global budget with negotiated fees and competing medical insurance companies. Physicians in private practice and non-profit dialysis provider associations provide most dialysis therapy. End-stage renal disease (ESRD) modalities are well integrated into the overall health care system. Dialysis therapy, independent of the mode of treatment, is reimbursed at a weekly flat rate. Mandatory health insurance covers health expenses, including those related to ESRD, for more than 90% of the population. Both employees and employers contribute to the premium for this insurance. Private medical insurance covers the remainder of the population. Access to treatment, including dialysis therapy, is uniformly available.

Effektivitätsanalyse einer klinikinternen allogenen Knochenbank

BACKGROUND

The EU guidelines 2004/23/EG and 2006/17/EG and their national implementation redefine the framework for allogenic bone banking and transplantation. Against this background an established internal hospital bone bank was analysed concerning threshold of allogenic bone and cost effectiveness in comparison to alternative methods.

METHOD

Over a 30-month period we registered all arrivals and outgoings of our bone bank and their destination. We further noted all declined donations. We analysed all costs incurred and calculated costs for alternative methods.

RESULTS

By means of our bone bank we are currently able to meet our own demand for bone substitutes. The maintenance costs are below the prices of alternative methods. Some donations (8%) have to be discarded due to procedural errors.

CONCLUSION

Maintaining an internal hospital bone bank utilizing fresh-frozen allogenic bone is an efficient and cost-effective method of supplying bone substitutes even under the new EU guidelines if the existing process covers most conditions of the producer authorisation according to section sign 13 AMG. By harmonizing the organizational process it is possible to further improve its effectiveness.

[Significance of a coding engaged orthopaedic surgeon for the illustration quality and compensation of an orthopaedic university department in the German DRG System 2005]

AIM

In the year 2005 the German DRG system underwent further differentiation in many areas compared to previous years. The effects of an improved coding quality by a specifically trained orthopaedic surgeon (KBFA) at an orthopaedic university department are analysed.

METHODS

In a closed sample of 1 277 cases the following parameters were documented after primary coding at discharge and after the final coding by the KBFA: main diagnosis, number of additional diagnoses and procedures, the resulting G-DRG, PCCL, cost weight and revenues. These data were analysed for statistically significant differences and correlations.

RESULTS

The final coding by the KBFA caused a significant (p<0.001) increase in the number of diagnoses and procedures. The intervention of the KBFA changed the DRG grouping in 34 % of the cases. The cost weight increased significantly and the case mix index raised by 0.26 in the complete sample, corresponding to an increased revenue of euro 62 per case and day.

CONCLUSIONS

The establishment of a KBFA in an orthopaedic department improved the quality of revenue-relevant DRG coding and the reflection of the economic complexity level of the cases. Compared to other reports, an above-average increase of cost weight as well as specification depth for diagnoses and procedures was achieved.

[Differentiation of coding quality in orthopaedics by special, illustration-oriented case group analysis in the G-DRG System 2005]

AIM

We introduce a grouping system for clinical practice which allows the separation of DRG coding in specific orthopaedic groups based on anatomic regions, operative procedures, therapeutic interventions and morbidity equivalent diagnosis groups. With this, a differentiated aim-oriented analysis of illustrated internal DRG data becomes possible.

METHODS

The group-specific difference of the coding quality between the DRG groups following primary coding by the orthopaedic surgeon and final coding by the medical controlling is analysed. In a consecutive series of 1600 patients parallel documentation and group-specific comparison of the relevant DRG parameters were carried out in every case after primary and final coding.

RESULTS

Analysing the group-specific share in the additional CaseMix coding, the group "spine surgery" dominated, closely followed by the groups "arthroplasty" and "surgery due to infection, tumours, diabetes". Altogether, additional cost-weight-relevant coding was necessary most frequently in the latter group (84%), followed by group "spine surgery" (65%). In DRGs representing conservative orthopaedic treatment documented procedures had nearly no influence on the cost weight.

CONCLUSIONS

The introduced system of case group analysis in internal DRG documentation can lead to the detection of specific problems in primary coding and cost-weight relevant changes of the case mix. As an instrument for internal process control in the orthopaedic field, it can serve as a communicative interface between an economically oriented classification of the hospital performance and a specific problem solution of the medical staff involved in the department management.

[Predictive factors of perioperative morbidity in revision total hip arthroplasty]

AIM

The awareness and prevention of perioperative morbidity are essential in revision total hip arthroplasty [THA]. Therefore, it was the purpose of this study to assess the rate of perioperative complications following revision THA in order to evaluate the impact of patient- and procedure-related variables.

METHODS

169 consecutive patients with a mean age of 71.7 years suffering from aseptic loosening of their THA were included in this retrospective study. Multivariate logistic regression models with estimation of the odds ratio [OR] and 95% confidence interval [CI] served to analyze the influence of operation duration, gender, revision status, ASA classification, and type of fixation of the primary implant on the perioperative morbidity.

RESULTS

68.6% of the cases were primary revisions, and 31.4% secondary or multiple revisions. 49.7% of the operations involved exchange of the complete implant whereas 39.1% comprised exchange of the cup and 11.2% exchange of the stem only. Mean operation duration was 130 minutes [min] (range: 40-260 min), and mean intraoperative blood loss was 2.6 L (0.5 to 12 L). The rate of intraoperative complications was 10.1 % with a 6.5 % fracture rate. Postoperatively the complication rate was 25.4% with an 8.3% rate of luxations. 11.8% of the patients had revision within the first three weeks after surgery. Regression models showed the significant impact of revision status (primary vs. secondary or multiple: OR 2.90, 95% CI 1.42-5.92) and operation duration (per min starting from the mean operation time: OR 1.01, 95% CI 1.00-1.02) on the resulting complication rate. Analysis of the perioperative complication rate following primary revisions revealed a significant difference (p = 0.03) between patients with cemented (15/36, 41.7%) and non-cemented (8/45, 17.8%) implants.

CONCLUSIONS

Revision status with a three-fold increase in patients with multiple revisions as well as operation duration with a 1 % increase per min starting from the mean operation time significantly influence the perioperative morbidity. Patients with a first revision, furthermore, seem to be at greater risk for an adverse event perioperatively if their implant is fully cemented. These findings should be taken into account prior to initiating surgery.

[The prognostic influence of primary tumour and region of the affected spinal segment in 217 surgical patients with spinal metastases of different entities]

AIM

A retrospective study to evaluate the prognostic influence of the primary tumour and the anatomic level of spinal metastases was carried out.

MATERIAL AND METHODS

Between January 1984 and May 2005, 217 patients were surgically treated because of spinal metastases. The prognostic influence for the survival was analysed for the entity of the primary tumour and the localisation of the spinal metastases.

RESULTS

The median survival of the study group was 8.0 months (range: 0-191.5 months). Mamma carcinoma was the most frequent primary tumour with 62 cases (28.6 %). The spinal level of the metastases did not influence the postoperative survival (p = 0.9058). The entity of the primary tumour showed a significant influence for the postoperative survival (p < 0.0001).

CONCLUSION

In spinal metastases, the entity of the primary tumour was of prognostic value; the localisation of the spinal metastases at different spinal levels did not influence the postoperative survival. Therefore, the evaluation of the primary tumour is mandatory for an estimation of the expected survival.

[Differential diagnoses of avascular necrosis of the femoral head. Articular groin pain in adults]

Early diagnosis and therapy of hip joint complaints in the young adult are often crucial for the prognosis of the joint. Besides avascular necrosis of the femoral head several differential diagnoses are possible, which if left untreated frequently lead to early osteoarthritis. The necessity of joint replacement in middle age often could be avoided by initiating adequate therapy as early as possible. The early diagnosis of aseptic necrosis of the femoral head at an early stage is possible with MRI. Especially in consideration of decreasing budgets MRI is dispensable for other diagnosis, e.g. hip dysplasia, femoroacetabular impingement or coxitis. On the other hand para-articular causes and non-orthopaedic diseases must also be considered, which remain hidden to classic orthopaedic diagnostics. Important differential diagnoses of groin pain in the adult, with emphasis on articular illnesses, are described.

Evaluation of the Tokuhashi prognosis score and its modifications in 217 patients with vertebral metastases

AIM

The Tokuhashi prognosis score consists of six parameters. The sum of points rated for each parameter can be correlated with the prognosis. This study evaluates the score variations that have been done by different authors and Tokuhashi et al. themselves.

METHODS

Two hundred and seventeen consecutive patients, surgically treated for vertebral metastases, were studied retrospectively. We calculated the original and modified score of Tokuhashi and evaluated the predictive value for the individual life expectancy.

RESULTS

The original and modified Tokuhashi score assured a significant predictive value. Modified criteria by the authors showed the highest reliability between the predicted and real survival, and the patients could be allocated correctly to the desirable instrumentation.

CONCLUSION

The original and modified Tokuhashi score showed a significant predictive value. The modified criteria by the authors showed the highest reliability between predicted and real survival.

Chirurgische Therapie und Evaluation von Prognosefaktoren bei Wirbelsäulenmetastasen durch Nieren-Zell-Karzinome

AIM

The aim of this study was the evaluation of surgical results and prognostic factors in spinal metastases of renal cancer.

METHODS

37 surgical patients with spinal metastases of renal cell carcinoma were retrospectively analysed. In 2 patients the cervical, in 16 patients the thoracic, in 4 patients the thoraco-lumbar and in 16 patients the lumbar spine was involved.

RESULTS

In 11 cases (29.7 %) a combined posterior-anterior spondylodesis with vertebral body replacement, in 26 cases (70.3 %) a single posterior instrumentation was done. Perioperatively, 24 complications appeared, 4 of them were lethal. Postoperatively, the neurological situation was unchanged in 26 patients, dischanged in 4 patients and improved in 7 patients. The level of pain was unchanged in 10 patients, dischanged in 3 patients and improved in 24 patients. The mean postoperative survival was 13.6 months. For the postoperative survival the Karnofsky-Index and the Frankel-Score were univariate highly significant, the factors nutritional condition and latency between the primary tumor and the development of spinal metastases showed a lower significancy. No prognostical influence for the postoperative survival could be detected for the factors gender, age, localisation of the metastases, type of operation and the factor solitary/multiple metastases. The multivariate analyses did not attempt any of the univariate significant prognostic factors for the postoperative survival. The postoperative survival was significantly (p: 0.0030) influenced by postoperative adjuvant therapy (radio- and/or chemotherapy). The analysis of each adjuvant therapy form (i. e. chemo-, radio- and combined therapy) attempts this prognostic effect (p: 0.0229).

CONCLUSION

In most patients with spinal metastases of renal cell carcinoma, the singular posterior intrumentation combined with a decompression is a sufficient therapy. To avoid posterior implant failure, in patients with a prognosticated survival of more than one year, a combined posterior-anterior spondylodesis with vertebral body replacement should be done. The prognostic influence of an adjuvant postoperative treatment in the present study must be interpreted in the context of this small, highly selected patient collective. Further standardized studies should be performed to evaluate the prognostic influence of an adjuvant therapy.

Evaluation of Serum β-Carboxy-Terminal Cross-Linking Telopeptide of Type I Collagen as Marker of Bone Resorption in Chronic Hemodialysis Patients

BACKGROUND

The carboxy-terminal cross-linking telopeptide of type I collagen (beta-CrossLaps, beta-CTX) is released into the circulation during degradation of type I collagen and serves as a marker of bone resorption. beta-CTX is known to undergo a diurnal rhythm in normal individuals and to accumulate in chronic renal failure. beta-CTX has a potential role in noninvasive diagnosis of renal bone disease.

METHODS

Serum beta-CTX was compared to parathyroid hormone (PTH) and other biochemical bone markers in 90 unselected hemodialysis patients.

RESULTS

Mean beta-CTX was elevated above the normal range (1.72 +/- 0.93 microg/l); there were large individual variations. Serum beta-CTX was significantly correlated with various PTH assays (r >0.56) and with tartrate-resistant acid phosphatase 5b (TRACP 5b, r = 0.629), bone-specific alkaline phosphatase (r = 0.404) and osteocalcin (r = 0.534, all correlations p < 0.001). The correlation between beta-CTX and PTH was significantly higher than the correlation between TRACP 5b and PTH. Several factors which could confound interpretation of serum beta-CTX were assessed in further studies: (i) There was no recognizable influence of the time of blood sampling (morning dialysis shift versus afternoon dialysis shift) on serum beta-CTX. (ii) Serum beta-CTX was not significantly related to residual diuresis of patients.

CONCLUSIONS

We found a high association between beta-CTX and other established markers of bone and calcium metabolism demonstrating the potential utility of beta-CTX as marker of bone resorption in renal bone disease. However, further studies employing bone histology are still warranted to exactly define the influence of glomerular retention on serum beta-CTX in end-stage renal disease.

Efficacy of once-weekly epoetin alfa

BACKGROUND

Patients with end-stage renal disease requiring hemodialysis are frequently treated with epoetin alfa (recombinant human erythropoietin, rHuEPO) for anemia. The aim of this study was to determine whether successful management of anemia could be maintained by changing the dosing schedule of epoetin alfa from 2 or 3 times per week to once-weekly administration via not only the subcutaneous (s.c.) but also the intravenous (i.v.) route.

METHODS

Patients included in the study had hemodialysis for > 12 months, treatment with epoetin for > or = 6 months and adequate iron stores. The study consisted of a pre-study period (12 weeks), Phase I (4 weeks, patients continued prestudy regimen), Phase II (12 weeks, once-weekly i.v. or s.c. regimen with dose adjustments permitted to maintain target hemoglobin (Hb) concentrations) and Phase III (4 weeks, once-weekly i.v. or s.c. regimen without dose adjustments).

RESULTS

The study was completed by 203 patients (per-protocol population: i.v. group, n = 115, s.c. group, n = 88). In the majority of patients (69.4% overall: i.v. group, 67.0%, s.c. group, 72.7%), the individual Phase I Hb concentrations were maintained within +/-1.0 g/dl (+/-10 g/l) during Phase III. In 79.3% of the patients (i.v. group, 75.7%, s.c. group, 84.1%), a stable Hb concentration (decrease of < or = 1 g/dl (< or = 10 g/l)) was maintained without statistically significant dose adjustments (82.4+/-33.8 - 86.8+/-42.1 IU/kg body weight/week). Hb concentrations decreased from 11.57+/-0.83 g/dl(115.7+/-8.3 g/l) in Phase I to 11.39+/-1.09 g/dl (113.9+/-10.9 g/l) in Phase III (p < 0.05) in the entire group. The weekly dose of epoetin alfa required to maintain the individual target Hb concentrations changed from 85.1+/-34.6 IU/kg in Phase I to 92.1+/-45.1 IU/kg in Phase III in the entire population (p <0.05).

CONCLUSIONS

With once-weekly administration of epoetin alfa, Hb concentrations can be maintained in the majority of stable hemodialysis patients, and only minimal dose adjustments are required.

Fr�hfunktionelle Ergebnisse einer Kurzschaftprothese des H�ftgelenks mit metaphys�r-intertrochant�rer Verankerung

Total hip arthroplasty has become one of the most successful standard procedures in orthopedic surgery. With a more frequent use in young and active patients bone saving procedures become more important. The goal is to save good bone stock for the revision procedure. One example of conservative femoral implants is the Mayo-stem with reported long term results. The stem design allows a metaphyseal intertrochanteric multipoint fixation for primary fixation. The surgical technique is simple. Using a transgluteal approach, the medial preparation of the femoral neck decreases significantly the irritation of the abductor tendons. In a prospective-randomized study, the early functional results with the Mayo-stem were significantly better than the results achieved with a cement-free standard stem. The Mayo-stem may not be indicated for every hip situation. Its use, however, in cases with normal anatomy contributes to save autologeous bone. Therefore, this short stem is a sensible alternative to standard stems.

First Report of Banana mild mosaic virus Isolated from Plantains (Musa AAB) in Colombia

Plantains (Musa AAB) are important sources of food and income for millions of people in Colombia and other developing countries. Colombia is the largest producer of plantains (2) and the third largest exporter of bananas in the world. In 2001, plants of 'Dominico-Hartón' plantain showing mild chlorotic streak symptoms were observed in northwestern Colombia. Electron microscopy of symptomatic tissue extracts revealed the presence of filamentous virus-like particles approximately 800 nm long. Immunocapture reverse-transcription polymerase chain reaction was performed to test for the presence of Banana mild mosaic virus (BanMMV) as described by J. E. Thomas (unpublished, Queensland Department of Primary Industries, Australia) and Sharman et al. (3). For polymerase chain reaction (PCR), the upstream primer No. 193 (5'-CAC TTA GGT TTG TGT GAT GT-3') (designed in this study by using the computer Program DNAMAN Version 4.13) and the downstream primer Poty1 (5'-GGA TCC CGG GTT TTT TTT TTT TTT TTT V-3') (1,3; J. E. Thomas, unpublished, Queensland Department of Primary Industries, Australia) were used. Amplification products of the expected size (approximately 900 bp) were obtained and sequenced after cloning in a pCR2.1 plasmid vector. Analyses of nucleic acid sequences using the international sequence databases and the BLAST program yielded nucleotide and amino acid sequence similarities of 80 to 83% and 90 to 92%, respectively, with an Australian isolate of BanMMV (GenBank Accession No. AF314662). The coat protein (CP) gene of the Colombian BanMMV isolate consists of 717 nucleotides. When the CP of the Colombian BanMMV isolates (GenBank Accession Nos. AY319331, AY319332, and AY319333) was compared with the CP of the Australian isolate, a highly variable region was observed in the N-terminus region. To our knowledge, this is the first report of BanMMV isolated from plantains in Colombia and the presence of molecular variability in the CP of BanMMV isolates. BanMMV has been found in Colombia associated with Banana streak virus and Cucumber mosaic virus in plantain. References: (1) A. Gibbs and A. Mackenzie. J. Virol.Methods 63:9, 1997 (2) N. S. Price. Infomusa 8(2):26, 1999. (3) M. Sharman et al. J. Virol. Methods 89:75, 2000.

[Modular revision systems in total knee arthroplasty. Possibilities and techniques]

This paper deals with surgical techniques in revision total knee arthroplasty. The principles of exploring the knee joint, removing the implant, and implanting modular revision systems using a three-step technique are described. The opportunities of modern revision systems for reconstruction of bone defects and ligament instabilities are demonstrated. By means of modularity, the implant can be adapted to individual specifications for bone quality, bone defects, and soft tissue conditions. Modular stems allow an additional diaphyseal load transfer. Uncontained bone defects are reconstructed by metal wedges and blocks. By using the range from cruciate-retaining to condylar-constrained systems, the different degrees of instability can be substituted with the least constrained prosthesis. Totally constrained hinge knee prostheses should be used only in extreme cases such as complete loss of collateral ligaments or inability to correct flexion-extension gap mismatches. The results with modular revision systems described in the literature are reviewed.

Influence of PTH assay methodology on differential diagnosis of renal bone disease

BACKGROUND

Determination of plasma parathyroid hormone (PTH) is routinely performed to diagnose and monitor renal bone disease. Recently, a new PTH assay ('whole PTH') using an antibody directed specifically against PTH(1-4) has been introduced. It was the aim of the current study to evaluate whole PTH and parameters derived from whole PTH in renal bone disease.

METHODS

The following measurements were carried out in blood samples from 141 unselected haemodialysis patients: three intact PTH assays (Nichols, Roche Elecsys), Scantibodies total); whole PTH (Scantibodies); bone-specific alkaline phosphatase (bAP); tartrate-resistant acid-phosphatase 5b (TRAP 5b); osteocalcin, 25-hydroxyvitamin D. Parameters derived from whole PTH were: (i) non-PTH(1-84), difference between intact PTH (Scantibodies assay) and whole PTH; (ii) whole PTH/non-PTH(1-84) ratio.

RESULTS

The values generated by the intact PTH assays were comparable. The mean whole PTH concentration was lower than mean intact PTH concentrations (16.9+/-18.1 vs 26.4+/-30.5 pmol/l, Nichols, P<0.05). The correlation coefficients between all four PTH assays were comparable and were very high (r>0.96, ns). The rank order of values generated by the whole PTH assay was statistically not significantly different from the rank order generated by the Nichols intact PTH assay. The median non-PTH(1-84) concentration was 5.2 pmol/l (range 0-49.4). All PTH assays correlated highly significantly with non-PTH(1-84) (correlation coefficients 0.83-0.92). Corrected serum calcium was also associated with non-PTH(1-84) but the correlation was weaker (r=0.28). Regression analysis indicated that the non-PTH(1-84) concentration could be predicted by 76.6-84.6% by the prevailing intact PTH concentrations. Other parameters contributed only marginally to prediction of non-PTH(1-84). In the entire patient group, there was no statistically significant correlation between the whole PTH/non-PTH(1-84) ratio and any of the PTH assays or biochemical bone markers. Eight of 141 patients had a whole PTH/non-PTH(1-84) ratio <1. TRAP 5b, bAP and osteocalcin had high correlations with intact PTH assays and the whole PTH assay (correlation coefficients 0.51-0.56, no significant difference). None of the PTH assays was superior to any other PTH assay in predicting serum concentrations of the bone markers. Therapy with active vitamin D metabolites (n=70) did not alter the results of our analyses.

CONCLUSIONS

With respect to information about bone turnover we were not able to find differences between whole PTH and intact PTH assays. Our data also suggest that whole PTH and intact PTH assays give similar information. (i) The correlation between all PTH assays was very high. (ii) The rank order between whole PTH and Nichols intact PTH assays was comparable. (iii) The association between intact PTH assays and non-PTH(1-84) was very high. Albeit non-PTH(1-84) was mostly determined by the prevailing intact PTH concentration, diagnostic information on parathyroid activity provided by whole PTH or intact PTH, respectively, may differ in individual patients. How often this would happen cannot be answered with the currently available data. Unequivocal structural identification of the non-PTH(1-84) fraction would facilitate the answer to that question. The use of the whole PTH/non-PTH(1-84) ratio as a biochemical bone marker in renal bone disease requires further investigation.

[Radiological changes in the cervical spine in rheumatoid arthritis -- prognostic factors obtained by a cross-sectional study]

OBJECTIVE

The involvement of the cervical spine is the most serious skeletal manifestation of rheumatoid arthritis (RA). Instabilities of the upper cervical spine can lead to neurological complications and signs of vertebrobasilar insufficiency. The study investigates the relationship between the course of the RA and the degree of radiological changes in the cervical spine and describes prognostic factors of cervical spine involvement.

MATERIAL AND METHODS

Clinical data were gathered from 205 patients with RA. Standardized X-ray examination of the cervical spine was performed and arthritic changes were assessed by a semiquantitative score. The association of clinical symptoms with defined radiological changes was evaluated.

RESULTS

Radiological changes in the cervical spine related to RA were found in 67.8% of the patients. Anterior atlantoaxial dislocations were detected in 25.4%, subaxial dislocations in 55.6% and a vertical displacement of the dens in 21.5% of the cases. The degree of radiological changes in the cervical spine was not directly correlated with neurological symptoms. Age above 55 years, disease duration of more than 10 years, an onset of cervical pain later than 11 years after the diagnosis of RA, steroid therapy for more than 5 years, bilateral shoulder involvement and the presence of severe erosive changes in at least one peripheral joint were positively associated with the development of severe changes in the cervical spine. In patients with basilar impression, paraesthesia in the upper extremities was significantly more common.

CONCLUSION

Prognostic factors are helpful for the assessment of risk of cervical spine involvement in RA. Since definite clinical hints for cervical involvement are absent, the cervical spine has to be included in the routine examination of patients with RA.