[Cost-effectiveness analysis of fracture liaison services in Catalonia]

OBJECTIVE

To assess the cost-effectiveness of Fracture Liaison Service (FLS) compared to the standard of care for secondary prevention of fragility fractures form the perspective of the Catalan Health Service.

METHODS

Cost-utility assessment through a Markov model that simulated disease progression of a patients' cohort candidates to initiate antiosteoporotic treatment after a fragility fracture. A time horizon of 10 years and a 6-month duration per cycle was established. Clinical, economics and quality of life parameters were obtained from the literature and derived from four Catalan FLS. The Catalan Health Service perspective was adopted, considering direct health costs expressed in 2022 euros. A 3% discount rate was applied on costs and outcomes. Uncertainty was assessed through multiple sensitivity analyses.

RESULTS

Compared to the standard of care, FLS would promote antiosteoporotic initiation and persistence, reducing the incidence and mortality associated with subsequent fragility fractures. This incremental clinical benefit was estimated at 0.055 years and 0.112 quality-adjusted life years (QALYs) per patient. A higher cost (€1,073.79 per patient) was estimated, resulting into an incremental cost-utility ratio of €9,602.72 per QALYs gained. The sensitivity analyses performed were consistent, corroborating the robustness and conservative approach of the base-case.

CONCLUSIONS

The introduction of FLS for the secondary prevention of FF would represent a cost-effective strategy from the Catalan Health Service perspective.

Vertebral fractures are increased in rheumatoid arthritis despite recent therapeutic advances: a case-control study

Prevalence and risk factors of vertebral fractures in postmenopausal RA women were assessed in 323 patients and compared with 660 age-matched women. Of patients, 24.15% had at least one vertebral fracture vs.16.06% of controls. Age, glucocorticoids and falls were the main fracture risks. Vertebral fractures were associated with disease severity.

INTRODUCTION

There is little quality data on the updated prevalence of fractures in rheumatoid arthritis (RA) that may have changed due to advances in the therapeutic strategy in recent years. This study was aimed at analysing the prevalence and risk factors of vertebral fractures in postmenopausal women with RA and comparing it with that of the general population.

METHODS

We included 323 postmenopausal women diagnosed with RA from 19 Spanish Rheumatology Departments, randomly selected and recruited in 2018. Lateral radiographs of the thoracic and lumbar spine were obtained to evaluate morphometric vertebral fractures and the spinal deformity index. We analysed subject characteristics, factors related to RA, and fracture risk factors. The control group consisted of 660 age-matched Spanish postmenopausal women from the population-based Camargo cohort.

RESULTS

Seventy-eight (24.15%) RA patients had at least one vertebral fracture. RA patients had increased fracture risk compared with controls (106 of 660, 16.06%) (p = 0.02). Logistic regression analysis showed that age (OR 2.17; 95% CI 1.27-4.00), glucocorticoids (OR 3.83; 95% CI 1.32-14.09) and falls (OR 3.57; 95% CI 1.91-6.86) were the independent predictors of vertebral fractures in RA patients. The subgroup with vertebral fractures had higher disease activity (DAS28: 3.15 vs. 2.78, p = 0.038) and disability (HAQ: 0.96 vs. 0.63, p = 0.049), as compared with those without vertebral fractures.

CONCLUSION

The risk of vertebral fracture in RA is still high in recent years, when compared with the general population. The key determinants of fracture risk are age, glucocorticoids and falls. Patients with vertebral fractures have a more severe RA.

Comparison of total, free and bioavailable 25-OH vitamin D determinations to evaluate its biological activity in healthy adults: the LabOscat study

Determination of different forms of 25-OHD (total, free and bioavailable) in healthy young women does not offer additional advantages over standard 25-OHD_T for evaluating vitamin D deficiency. In these subjects 25-OHD_T values <15 ng/ml would be more appropriate for defining this deficiency.

INTRODUCTION

Determination of 25-OH vitamin D serum levels (25-OHD) constitutes the method of choice for evaluating vitamin D deficiency. However, vitamin D-binding protein (DBP) may modulate its bioavailability thereby affecting correct evaluation of 25-OHD status. We analysed the impact of the determination of 25-OHD (total, free and bioavailable) on the evaluation its biologic activity (estimated by serum PTH determination) in healthy young women.

METHODS

173 premenopausal women (aged 35-45 yrs.) were included. We analysed serum values of total 25-OHD (25-OHD_T), DBP, albumin, PTH and bone formation (PINP,OC) and resorption (NTx,CTx) markers. Free(25-OHD_F) and bioavailable (25-OHD_B) serum 25-OHD levels were estimated by DBP and albumin determinations and also directly by ELISA (25-OHD_F-2). We analysed threshold PTH values for the different forms of 25-OHD and the correlations and differences according to 25-OHD_T levels <20 ng/ml.

RESULTS

62% of subjects had 25-OHD values <20 ng/ml and also had significantly lower 25-OHD_F and 25-OHD_B values, with no significant differences in bone markers and PTH values. The PTH threshold value was similar for all forms of 25-OHD (∼70 pg/ml). Women with PTH values >70 had lower 25-OHD_T (15.4 ± 1.4 vs. 18.3 ± 2.7, p < 0.05) and 25OHD_B values (1.7 ± 0.2 vs. 2.2 ± 0.09, p < 0.05). The different forms of 25OHD were significantly intercorrelated, with marginal correlations between PTH and 25-OHD_T (r = -0.136, p = 0.082).

CONCLUSIONS

Determination of different forms of 25-OHD in healthy young women does not offer additional advantages over standard 25-OHD_T for evaluating vitamin D deficiency. In these subjects 25-OHD_T values <15 ng/ml would be more appropriate for defining this deficiency.

The 11q23.3 genomic region-rs964184-is associated with cardiovascular disease in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is an inflammatory disease associated with high risk of cardiovascular (CV) events. Recently, the rs964184 polymorphism has been associated with coronary artery disease in nonrheumatic Caucasian individuals. 2160 Spanish RA patients were genotyped for the rs964184 polymorphism. Sex, age at diagnosis and traditional CV risk factors (diabetes mellitus, dyslipidemia and smoking habit) were associated with increased risk of CV events. Interestingly, RA patients carrying the rs964184 GG genotype had significantly higher risk of CV events than those with CC genotype [hazard ratio (HR) = 2.91, 95% confidence interval (CI): 1.36-6.26, P = 0.006] after adjusting the results for sex, age at diagnosis and traditional CV risk factors. Our results indicate that rs964184 polymorphism is associated with CV disease in RA.

Influence of MHCIITA rs3087456 and rs4774 polymorphisms in the susceptibility to cardiovascular disease of patients with rheumatoid arthritis

OBJECTIVES

MHCIITA is a major regulator of MHC expression that has been reported to be involved in the susceptibility to rheumatoid arthritis (RA) and myocardial infarction. In this study we investigated the potential association of two MHCIITA gene polymorphisms with cardiovascular (CV) risk in patients with RA.

METHODS

1302 patients fulfilling the 1987 ACR classification criteria for RA were genotyped for the MHCIITA rs3087456 and rs4774 gene polymorphisms to determine the influence of MHCIITA variants in the development of CV events. The potential influence of these polymorphisms in the development of subclinical atherosclerosis was also analysed in a subgroup of patients with no history of CV events by the assessment of two surrogate markers of atherosclerosis; brachial and carotid ultrasonography to determine endothelial function and carotid artery intima-media thickness, respectively.

RESULTS

No statistically significant differences in the allele or genotype frequencies for each individual MHCIITA gene polymorphism between RA patients who experienced CV events, or not, were found. This was also the case when each polymorphism was assessed according to results obtained from surrogate markers of atherosclerosis. Also, in assessing the combined influence of both MHCIITA gene polymorphisms in the risk of CV disease after adjustment for gender, age at time of disease diagnosis, follow-up time, traditional CV risk factors, and shared epitope status, patients with CV events only showed a marginally decreased frequency of the MHCIITA rs3087456-rs4774 G-G allele combination (p=0.08; odds ratio: 0.63 [95% confidence interval: 0.37-1.05]).

CONCLUSIONS

Our data do not support an influence of MHCIITA rs3087456 and rs4774 polymorphisms in the increased risk of CV events of patients with RA.

Efficacy of a holding unit to reduce access block and attendance pressure in the emergency department

BACKGROUND

Access block, the inability of patients in the emergency department (ED) to access hospital beds, is a contributing factor to overcrowding in the ED. The effect of a holding unit (HU) on access block and some medical management indicators is presented.

METHODS

In October 2002 an HU was opened with 16 beds for patients coming from the ED. Every morning all the patients are moved from the HU to a conventional unit; if there are not enough unoccupied beds, elective admissions are cancelled. For the previous and subsequent years after the opening of the HU, the following factors were analysed: (1) number of patients visiting the ED; (2) number of urgent admissions; (3) length of stay in the ED; (4) number of patients waiting for an in-hospital bed in the ED at 08.00 h; (5) number of elective admissions; and (6) number of cancelled elective admissions.

RESULTS

Although there was an increase of 3.1% in the number of patients visiting the ED during the first year following the opening of the HU compared with the previous year, the number and percentage of urgent admissions remained unchanged. In the same period the mean number of patients waiting for a bed in the ED decreased by 55.6% (9.1 vs 4.0 patients per day). However, the mean length of stay in the ED increased by 6.9% (p<0.001). The number and percentage of cancelled elective admissions were similar in the two periods of the study.

CONCLUSION

The opening of an HU has led to an improvement in the access block.

Impact of antiplatelet therapy in the development of severe ischemic complications and in the outcome of patients with giant cell arteritis

OBJECTIVE

To evaluate whether concomitant treatment with low-dose aspirin or other antiplatelet agents have an impact on the risk of severe ischemic complications and in the outcome of patients with giant cell arteritis (GCA).

METHODS

A retrospective follow-up study of an unselected population of 121 patients with GCA.

RESULTS

Thirty-seven patients (30.5%) received antiplatelet therapy before the onset of GCA symptoms and continued taking it during the corticosteroid treatment (30 received aspirin and 7 other antiplatelet agents). No statistically significant reduction in the incidence of ischemic manifestations (including jaw claudication, visual manifestations, cerebrovascular accidents, ischemic heart disease, and limb claudication due to large artery stenosis) was observed in this group compared with the remaining patients. When we analyzed follow-up data, we found no significant differences between groups in terms of frequency of relapses and percentage of patients recovered from GCA. Corticosteroid requirements among patients in long-lasting remission were lower in those under antiplatelet therapy, but this reduction was fairly modest, statistically non significant and thus of uncertain clinical significance. Similar results were found when only aspirin exposed patients (n=30) were compared to non-exposed patients. Logistic regression analysis showed that antiplatelet therapy (p=0.54, OR 1.31; 95% CI: 0.54-3.19) had not an independent protective effect against ischemic events when adjusted for age, sex, and the presence of atherosclerotic risk factors.

CONCLUSION

We did not observe a significant benefit derived from the use of antiplatelet therapy in either the incidence of severe ischemic events or the disease outcome. Although our results do not discard a potential therapeutic effect of high-dose aspirin, they do not confirm its suggested protective effect in preventing ischemic complications when used at antiplatelet doses.

Usefulness of bone densitometry in postmenopausal women with clinically diagnosed vertebral fractures

OBJECTIVE

To analyse whether bone mineral density (BMD) assessment is required in postmenopausal women presenting with low trauma vertebral fracture.

METHODS

Women with vertebral fracture diagnosed over a 10 year period were recruited from our database. The following were excluded: (a) patients with high energy trauma; (b) patients with malignancies; (c) patients with a metabolic bone disease other than osteoporosis. All postmenopausal women were included in whom BMD had been evaluated at both the lumbar spine and femoral neck by dual energy x ray absorptiometry during the six months after the diagnosis. Patients with a potential cause of osteoporosis other than age and menopause were not considered. A total of 215 patients were identified.

RESULTS

The mean (SD) age of the patients was 65.9 (6.9) years. BMD at the lumbar spine was 0.725 (0.128) g/cm(2) and the T score was -2.94 (1.22); BMD at the femoral neck was 0.598 (0.095) g/cm(2) and the T score was -2.22 (0.89). The BMD of the patients was significantly lower than that of the general population at both the lumbar spine and femoral neck. When the lowest value of the two analysed zones was considered, six patients (3%) showed a normal BMD, 51 (23.5%) osteopenia, and 158 (73.5%) osteoporosis. The prevalence of osteoporosis at the femoral neck increased with age; it was 25% in patients under 60, 35% in patients aged 60-70, and 60% in patients over 70.

CONCLUSION

These results indicate that bone densitometry is not required in postmenopausal women with clinically diagnosed vertebral fractures if it is performed only to confirm the existence of a low BMD.

Nutritional status in patients with rheumatoid arthritis

BACKGROUND

Some chronic diseases have been associated to an impairment of nutritional status.

OBJECTIVE

To analyze nutritional status and its relation to dietary intake, disease activity and treatment in rheumatoid arthritis.

PATIENTS AND METHODS

We have included 93 patients (43 men and 50 women) and 93 age- and sex-matched healthy controls. The assessment of nutritional status included anthropometric (body mass index, tricipital skin fold and midarm muscular circumference) and biochemical (serum albumin, prealbumin and retinol binding protein) parameters. Dietary intake was calculated from a food frequency questionnaire. As a measure of disease activity, we used the Health Assessment Questionnaire, Ritchie index, tender and swollen joint count and C-reactive protein. Statistical analysis was performed in the whole series and in every functional class.

RESULTS

In the whole series, midarm muscular circumference and serum albumin were significantly lower in patients than in controls. All anthropometric parameters and serum albumin were significantly lower in patients in functional class IV than in their respective controls. The dietary intake of energy, carbohydrates, vegetal proteins and lipids was higher in patients than in controls. Midarm muscular circumference and serum albumin had a significant inverse relation with disease activity parameters; body mass index, midarm muscular circumference and serum albumin correlated inversely with the cumulative dose of glucocorticoids.

CONCLUSIONS

Patients with rheumatoid arthritis in functional class IV have an impairment of nutritional status without a deficient dietary intake. The differences found in other functional classes are explained by rheumatoid arthritis itself. Nutritional parameters are related to disease activity and glucocorticoid treatment.

Osteoporotic vertebral fracture in clinical practice. 669 Patients diagnosed over a 10 year period

OBJECTIVE

Few data are available on clinically diagnosed vertebral fracture. Information about osteoporotic vertebral fracture has mainly been obtained via inferences from epidemiological studies of vertebral deformity. We evaluated the characteristics of patients with osteoporotic vertebral fracture diagnosed in a rheumatology department over a 10 year period.

METHODS

Patients with back pain and vertebral fracture diagnosed between January 1990 and December 1999 were recruited from our data base. Patients with high energy trauma, malignancies, and metabolic bone diseases other than osteoporosis were excluded. These variables were analyzed: sex, age at diagnosis, type of osteoporosis (primary vs secondary), number of fractures at diagnosis (single vs multiple), and percentage of admissions and length of stay.

RESULTS

Of the 669 patients, 534 (80%) were women and 135 (20%) were men. Age at diagnosis ranged from 30 to 91 yrs, mean 67.1 +/- 9.1. Secondary osteoporosis was diagnosed in 177 (26%) patients and the frequency was significantly higher in men than women (55% vs 19%; p < 0.001); the most common associations for secondary osteoporosis were oral corticosteroids, chronic obstructive airway disease, and rheumatoid arthritis. At diagnosis, half of the patients presented with multiple fractures. One hundred twenty (18%) patients were admitted; length of stay ranged from 5 to 56 days, mean 15.9 +/- 7.7. The frequency of admissions was higher in men than women (27% vs 16%; p < 0.001), higher in patients with secondary osteoporosis than in those with primary osteoporosis (33% vs 12%; p < 0.001), and higher in patients with multiple fractures than in those with single fractures (27% vs 8%; p < 0.001).

CONCLUSION

Characteristics of patients recruited from a clinical setting differ significantly from those of subjects included in the epidemiological studies. In a rheumatology practice, frequency of secondary osteoporosis, mainly associated with corticosteroid treatment, is notably high. Admission is by no means a rare event.

Value of clinical factors in selecting postmenopausal women with rheumatoid arthritis for bone densitometry

OBJECTIVE

Criteria to decide which patients with rheumatoid arthritis (RA) should be examined by dual energy x ray absorptiometry (DXA) are currently not available. The rheumatologists from Amsterdam have proposed preliminary criteria based on clinical risk factors (age, disease activity, and functional status). These criteria are preliminary and not widely accepted but might be helpful in practice. The value of the proposal in a group of Spanish postmenopausal women with RA is analysed.

METHODS

DXA (lumbar spine and femoral neck) was performed in 128 patients recruited from a clinical setting, and the proposed criteria were applied. T and Z scores were established for a Spanish reference population.

RESULTS

The mean (SD) age of the patients was 61.3 (10.7) and mean duration of the postmenopausal period 14.5 (10.1) years. Mean duration of RA was 13.7 (7.7) years. Mean C reactive protein was 22 (21) mg/l; mean erythrocyte sedimentation rate 26 (18) mm/1st h; and mean Health Assessment Questionnaire score 1.25 (0.79). Ninety (70%) patients fulfilled the proposed criteria. Their sensitivity for the diagnosis of osteoporosis (T score < or =-2.5 SD) was 86% and their specificity, 43%. Positive predictive value was 54% and negative predictive value, 79%.

CONCLUSIONS

The proposed criteria seem a good screening method for the selection of those patients with RA whose bone mineral density should be assessed as the sensitivity and negative predictive value are acceptable.

Bone mineral density in patients with type 1 diabetes mellitus

Although osteopenia is often reported as a complication of type 1 diabetes mellitus, its frequency and severity remain unclear, and studies of bone mineral density in type 1 diabetics have yielded conflicting results. We measured bone mineral density at the lumbar spine and femoral neck in 88 Spanish adults with type 1 diabetes mellitus responsible for moderately severe complications. Mean age (+/- SD) was 28.9 +/- 8.8 years, and mean disease duration was 11.2 +/- 6.4 years. As compared to normal Spanish adults, bone mineral density was decreased in the patients at the lumbar spine (Z-score, -0.32 +/- 1.08; P < 0.001) but not at the femoral neck (Z-score, -0.21 +/- 1.03; P non-significant). The magnitude of bone loss in the diabetics was small (T-score, -0.38 +/- 1.13 at the lumbar spine and -0.37 +/- 1.08 at the femoral neck). Only three patients met WHO criteria for osteoporosis at one or both measurement sites. Patients with retinopathy (n = 37) had lower lumbar spine bone mineral density values than patients without retinopathy; however, this difference was no longer present after adjustment for age and disease duration. Bone mineral density values were similar in patients with (n = 13) and without microalbuminuria. Our findings suggest that bone loss is not a major problem in younger type 1 diabetics with short disease durations and no severe diabetic complications.

Weak androgen levels, glucocorticoid therapy, and bone mineral density in postmenopausal women with rheumatoid arthritis

OBJECTIVE

To study dehydroepiandrosterone sulfate (DHEAS) and androstenedione (AND) status in postmenopausal women with rheumatoid arthritis (RA), the effects of glucocorticoid therapy on DHEAS and AND levels, and their relationship with bone mineral density (BMD).

METHODS

Forty-six postmenopausal women with RA were separated into two groups based on whether they had a negative history for glucocorticoid therapy (n = 24) or were currently on glucocorticoid therapy (n = 22). The control group was composed of 39 postmenopausal women who had never received hormone replacement therapy. Serum DHEAS and AND levels were measured using a radioimmunoassay. BMD was determined at the lumbar spine (L2-L4) and femoral neck using a DEXA Hologic QDR-1000 densitometer. Results. RA patients and controls were similar in age, weight, body mass index, and years since menopause. DHEAS and AND levels were lower in the glucocorticoid-treated RA group than in the other two groups. The glucocorticoid-treated RA group also had a significantly lower femoral BMD value than the nonglucocorticoid-treated RA group. Lumbar BMD was similar in the two RA groups and in the controls.

CONCLUSION

Decreases in DHEAS and AND levels in postmenopausal women with RA are probably related to glucocorticoid therapy rather than to the disease itself.

A comparative study of computed digital absorptiometry and conventional dual-energy X-ray absorptiometry in postmenopausal women

The aim of the study was to evaluate whether computed digital absorptiometry (CDA) of the hand might be a useful screening technique for identifying patients with postmenopausal osteoporosis and to compare the results of CDA with those of dual-energy X-ray absorptiometry (DXA) of the lumbar spine and femoral neck. We studied 230 postmenopausal women (mean age 58.4 + 7.9 years). For CDA, bone mineral density (BMD) was measured with an AccuDEXA Schick densitometer in the third middle phalanx of the nondominant hand. For DXA, BMD of the lumbar spine and upper femur was assessed using a DXA Hologic QDR-1000 densitometer. We did a comparative analysis (ANOVA) and linear correlation tests. Sensitivity and specificity of CDA and receiver operating characteristic (ROC) curves for the diagnosis of osteoporosis were calculated. The mean BMD with CDA was 0.445 +/- 0.084 (T-score: -1.27 +/- 1.29). The mean BMD (g/cm2) with DXA at the lumbar spine was 0.877 +/- 0.166 (T-score: -1.52 +/- 1.59) and 0.708 +/- 0.127 at the femoral neck (T-score: -1.12 +/- 1.25). BMD at the lumbar spine and femoral neck correlated positively with CDA of the hand (r = 0.66 and r = 0.65 respectively, p<0.001). When using as cut-off a T-score of -2.5, according to WHO criteria, 76 women (33%) had osteoporosis of the lumbar spine and/or femoral neck with DXA and 42 (18%) with CDA (p<0.001). The kappa score for osteoporosis was 0.33 for CDA versus spinal DXA and 0.35 for CDA versus femoral DXA. With the cut-off level used, sensitivity and specificity of CDA in detecting osteoporosis at the lumbar spine were 0.39 and 0.90, respectively; sensitivity and specificity of CDA in identifying osteoporosis at the femoral neck were 0.58 and 0.87, respectively. The positive predictive value of CDA for osteoporosis was 69% and the negative predictive value was 75%. The area under the ROC curve for osteoporosis was 0.822 +/- 0.028. We conclude that: (a) CDA assessment has a moderate correlation with BMD measured by DXA at the lumbar spine and femoral neck; (b) CDA has a low sensitivity for the diagnosis of osteoporosis compared with spinal and femoral DXA; and (c) predictive values for osteoporosis at both the lumbar spine and femoral neck are acceptable.

Pyarthrosis in patients with rheumatoid arthritis: a detailed analysis of 10 cases and literature review

OBJECTIVES

1) To analyze the clinical features and outcome of patients with rheumatoid arthritis and pyarthrosis seen in a rheumatology department during a 9-year period; 2) To review the available literature about this association in the last decade.

METHODS

From the database of our department, we collected all hospitalized cases of infectious arthritis in native joints between January 1990 and December 1998. In 10 cases (27%), pyarthrosis occurred in patients with rheumatoid arthritis. A detailed analysis of each patient was performed. The literature was reviewed by using MEDLINE from 1990 to 1999.

RESULTS

The mean age of patients was 63.2 years; six were female. Most patients had long-standing disease and poor functional class, and all received glucocorticoid treatment. Mean diagnostic delay was 7.3 days. Causative organisms were Staphylococcus aureus (4 cases), gram-negative bacilli (3 cases), anaerobic bacteria (2 cases), and Streptococcus pneumoniae (n = 1). Two patients died. In all but two patients who survived, joint function worsened.

CONCLUSIONS

Rheumatoid arthritis is a relevant host-related risk factor for septic arthritis. Pyarthrosis in these patients is associated with considerable morbidity and mortality.

Vertebral and rib sarcoidosis: long-term clinical remission with methotrexate

We describe a patient with bilateral hilar lymphadenopathy shown on a chest radiograph and supraclavicular lymphadenopathy. Biopsy of a supraclavicular lymph node showed non-caseating granulomas. A diagnosis of sarcoidosis was made and no treatment was given. One year later she complained of cervical and lumbar pain and decreasing strength of the right hand. Magnetic resonance imaging of the spine showed multiple lesions within the vertebral bodies of six vertebrae, and thoracic computed tomography showed partial destruction of the first right rib. A biopsy of the second lumbar vertebra demonstrated non-caseating granulomas. Corticosteroid treatment was unsuccessful and long-term remission of the symptoms was achieved with a weekly low dose of methotrexate.

Löfgren's syndrome revisited: a study of 186 patients

PURPOSE

To evaluate the clinical features, the results of noninvasive tests and biopsies, and the outcome of patients with Löfgren's syndrome.

SUBJECTS AND METHODS

Patients diagnosed as having Löfgren's syndrome at a university hospital in Barcelona, Spain, from 1974 to 1996, were prospectively followed. Löfgren's syndrome was defined as the association of erythema nodosum or periarticular ankle inflammation with unilateral or bilateral hilar or right paratracheal lymphadenopathy.

RESULTS

Löfgren's syndrome was diagnosed in 186 patients. The mean age was 37 +/- 11 years, and 157 (85%) were women. In 91 patients (49%), symptoms started during the spring (P < 0.0001). Erythema nodosum, periarticular ankle inflammation, or both were present at onset in 173 patients (93%). At the time of diagnosis, 161 patients (87%) had no respiratory symptoms; 151 (81%) had stage I abnormalities on chest radiograph, 29 (16%) stage II, and 6 (3%) stage 0. Five percent of patients had decreased forced vital capacity, and 15% had decreased carbon monoxide diffusing capacity. Extrathoracic involvement was infrequent. Serum angiotensin-converting enzyme levels were increased in 50% of patients. Gallium-67 scans showed hilar uptake in all the studied patients, but it yielded useful additional diagnostic information only in those with normal chest radiographs or with unilateral hilar lymphadenopathy. The diagnosis was proven with biopsy results in 63% of patients. None of the patients without histologic confirmation were subsequently found to have a diagnosis other than sarcoidosis. In the 133 patients who were followed for a mean of almost 5 years, 11 (8%) continued to have active disease, and 8 (6%) had several recurrences between 18 months and 20 years after a complete resolution. A normal serum angiotensin-converting enzyme level at diagnosis was associated with disease resolution without recurrence.

CONCLUSION

Löfgren's syndrome is usually a self-limiting form of sarcoidosis. Histologic confirmation is not necessary in typical cases. In a small number of patients, the disease may remain active or recur long after its onset, although usually with mild organ dysfunction.

Termination of disease-modifying drugs in psoriatic arthritis: study of 109 courses of treatment

Our aim is to study the termination of disease-modifying anti-rheumatic drugs (DMARDs) in psoriatic arthritis (PsA) and the causes of withdrawal. We have reviewed the prospective protocols of patients with PsA and collected the data on treatments and causes of withdrawal. Fifty-four out of 96 patients (48 male and 48 female) have undergone one or more courses of DMARD (n = 109). The life-table analysis shows a survival rate of 6 months for gold sodium thiomalate (GOLD) and sulphasalazine (SSZ), and 16 months for methotrexate (MTX). The Mantel-Haenszel test finds statistical differences between GOLD and MTX. There are no differences between MTX and SSZ or between GOLD and SSZ. The absence of differences for MTX and SSZ could be explained by the heterogeneity of both groups. The most common cause of withdrawal for GOLD and SSZ are adverse effects.

Periarticular ankle sarcoidosis: a variant of Löfgren's syndrome

OBJECTIVE

To focus more attention on the syndrome characterized by periarticular ankle inflammation associated with bilateral hilar adenopathy--some authors regard it as a variant of the Löfgren syndrome, while other suggest it is a distinct clinical entity-- we present a series of 33 cases of periarticular ankle sarcoidosis.

METHODS

Sarcoidosis was diagnosed in 330 patients at Bellvitge Hospital over a 20 year period. The medical charts of patients who presented with periarticular ankle inflammation (swelling of both ankles with acute inflammatory signs and preserved articular motion) were reviewed.

RESULTS

33 patients (10%) were identified. Periarticular ankle inflammation began during the spring in more than one-half (54.5%). The mean age was 33 years and patients were predominantly women (66.6%). Most cases (78.8%) were stage I on chest radiograph. All patients had thoracic gallium scans showing increased hilar/mediastinal uptake. Increased characteristic parotid, lacrimal, and/or submandibular uptake was found in 11 of 13 patients who had head scans. Four of 6 whose scans included the legs had bilateral ankle uptake. Erythema nodosum was present concomitantly in 36.3% of patients. No granulomas were found in 4 biopsies of periarticular ankle tissue. All 24 patients who were followed had inactive disease one year after diagnosis.

CONCLUSION

The association of periarticular ankle inflammation with bilateral hilar adenopathy is an acute form of sarcoidosis that follows a benign course to total remission. It should be regarded as a variant of the Löfgren syndrome.