THU0539 IMPACT OF BODY MASS INDEX ON THE AGREEMENT BETWEEN ULTRASOUND- AND CLINICAL ASSESSMENTS OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS: MULTICENTRE AND CROSS-SECTIONAL STUDY

Background:

Clinical assessment of swollen joint count (SJC) in rheumatoid arthritis (RA) might be affected by obesity in terms of obesity-related excess adipose tissue.

Objectives:

To compare the level of agreement between synovitis evaluated by Power Doppler ultrasound (PDUS) and clinical examination (SJC as component of SDAI) in obese (O) (i.e. Body Mass Index (BMI) >30) versus non-obese (NO) (BMI≤30) RA patients.

Methods:

RA patients ≥18 years fulfilling 2010 ACR-EULAR criteria were included in the cross-sectional multicentre (13 centres) French observational RABODI study (ClinicalTrials.gov Identifier:NCT03004651). Clinical synovitis was evaluated on 44 joints. ESR and CRP were collected and SDAI, DAS28, DAS were calculated. A standard US examination on 44 joints was performed by an independent investigator blinded to clinical data. US synovitis was defined by a synovial hypertrophy ≥1 and PD signal≥1 on a semi-quantitative scale according to the EULAR-OMERACT scoring system. Levels of agreement between number of synovitis defined by PDUS and clinical examination were compared in O versus NO patients using Chi2 test, and Kappas (k) and ORs were calculated. A patient was considered “discordant” if ≥1 joint was discordantly classified by PDUS and clinical examination. SDAI was calculated and compared, with SJC defined either by clinical examination or PDUS.

Results:

121 patients were included: mean (SD) age of 58.5 (12.7) years, mean disease duration of 11.1 (9.7) years. 81% were female, 84.3% anti-CCP positive, 63.6% had erosive disease. Mean SDAI was 12.6 (±10.2). 53 (43.8%) had a BMI >30 and 68 (56.2%) ≤30. 59 (48.7%) and 62 (51.2%) had a SDAI≤11 and >11, respectively. The 2 groups were comparable, except for weight (mean (SD) 65.4 (13.5) vs 96.7 (14.7) kg, p< 0.001), some comorbidities (diabetes, asthma and fibromyalgia more frequent in O patients), tender joint count (mean 4.04 (±5.23) in NO vs 7.38 (±8.64) in O, p=0.021). Mean number of SJC was 2.4 (3.3), and PDUS 6.7 (±6.3). Levels of agreement between clinical and PDUS findings were comparable in O vs. NO patients regarding SDAI and other scores (Table). Patients with ≥3 discordant joints were numerically higher in O patients compared to NO (26/53 (49.1%) vs 22/68 (32.4%), p=0.062). At the joint level, discordance was higher in O patients in MCP4 (p=0.057), wrist (p=0.089).

Table.

Level of agreement between PDUS synovitis and SJC in obese versus normally weighted RA patients

Score with PDUS vs. SJCBMI ≤ 30N=68BMI > 30N=53OR(95%CI)P*SDAINon-Discordant (ND)63461.92(0.57-6.42)0.28Discordant (D)57Kappa0.850.73DAS28ND62471.32(0.4-4.35)0.64D66Kappa0.810.77DAS44ND63520.24(0.03-2.14)0.23D51Kappa0.830.96≥1 synovitisND51351.54(0.7-3.4)0.28D1718Kappa0.500.32

Conclusion:

In RA patients, despite a perceived higher difficulty to clinically detect SJ in O patients, the discrepancy between clinically- and PDUS defined synovitis was not significantly higher than in NO patients, and did not impact the extend of the definition of disease activity level.

Disclosure of Interests:

Gael Mouterde: None declared, Federico Manna: None declared, Benoit Le Goff: None declared, Jean-David Albert: None declared, Sandrine Jousse-Joulin: None declared, Frederique Gandjbakhch: None declared, Damien LOEUILLE: None declared, Philippe Gaudin Speakers bureau: Lilly, Muriel PIPERNO: None declared, BANAL Frédéric: None declared, Bénédicte Jamard: None declared, Carine Salliot: None declared, Nicolas Molinari: None declared, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Maria-Antonietta D’Agostino: None declared, Cédric Lukas: None declared

OP0125 LYMPHOMAS COMPLICATING RHEUMATOID ARTHRITIS: RESULTS OF A FRENCH MULTI-CENTRE CASE-CONTROL STUDY

Background:

Rheumatoid arthritis (RA) is associated with an increased risk of non-Hodgkin B-cell lymphoma (B-cell NHL).

Objectives:

1)To study the characteristics of B-cell NHL complicating RA

2)To identify the factors associated with their occurrence.

Methods:

A multi-centre case-control study was performed in France. Cases were patients with RA fulfilling the ACR-EULAR 2010 criteria, who developed a B-cell NHL after the diagnosis of RA. Cases were reported following a call for observations by the “Club Rhumatismes et Inflammation” network, registries from the French society of Rheumatology (AIR, ORA and REGATE) and the ESPOIR cohort. For each case, 2 control patients were drawn at random from patients in the ESPOIR cohort with RA fulfilling the ACR-EULAR 2010 criteria; cases and controls were matched on age (age at lymphoma diagnosis for cases and age at the 10-year ESPOIR visit for controls). Patients with associated Sjögren’s syndrome were excluded. Cases and controls characteristics were compared for parameters associated with the occurrence of lymphoma.

Results:

A total of 54 cases were included and matched to 108 controls. Lymphomas were mostly diffuse large B-cell lymphomas (n=26, 48.2%)(Figure 1). EBV positivity was found in 4 cases among 27 tested (14.8%). Cases had a mean age of 63.5 years (SD=10.9), and had a mean RA duration of 12.4 years (SD=10.5) at the time of diagnosis of lymphoma; there was no significant difference with controls (p=0.47 and p=0.40 respectively). The mean duration of follow-up after the diagnosis of lymphoma was 5.2 years (SD=5.8). In univariate analysis, factors associated with occurrence of B-cell NHL were: male gender (OR=3.3, 95%CI: 1.7-6.7), positive ACPA (OR=5.1, 95%CI: 2.0-15.7), positive Rheumatoid Factor (RF) (OR=3.9, 95%CI=1.6-12.2), erosions on X-rays (OR=15.4, 95%CI: 6.9-37.7) and DAS28 (OR=2.0, 95%CI: 1.5-2.7). Methotrexate, TNF-blockers and the number of previous biologics were not associated with the occurrence of B-cell NHL. Hydroxychloroquine and sulfasalazine were more frequent in cases versus control, which could be linked to a date bias. Erosions and DAS28 remained significant in multivariate analysis(Table 1).

Conclusion:

This study revealed an association between markers of activity (DAS28), severity (erosions) and autoimmune B-cell activation (RF and ACPA) and the risk of B-cell NHL in patients with RA, supporting the continuum between autoimmunity and lymphomagenesis in RA.

Figure 1.

Disclosure of Interests:

Joanna KEDRA: None declared, Raphaèle Seror Consultant of: BMS UCB Pfizer Roche, Philippe Dieudé: None declared, Arnaud Constantin: None declared, ERIC TOUSSIROT: None declared, Elias Kfoury: None declared, Charles Masson: None declared, Divi Cornec: None declared, Jean-Jacques Dubost: None declared, Laurent Marguerie: None declared, Sebastien Ottaviani: None declared, Franck Grados: None declared, Rakiba Belkhir: None declared, olivier fain: None declared, Philippe Goupille Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Christelle Sordet: None declared, Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Peggy Philippe: None declared, Muriel PIPERNO: None declared, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Olivier Lambotte Consultant of: BMS France, MSD, Astra Zeneca, Incyte, Christophe Richez Consultant of: Abbvie, Amgen, Mylan, Pfizer, Sandoz and UCB., Jérémie SELLAM: None declared, Thomas Sene: None declared, Guillaume Denis: None declared, Thierry Lequerre: None declared, Xavier Mariette Consultant of: BMS, Gilead, Medimmune, Novartis, Pfizer, Servier, UCB, Gaetane Nocturne: None declared

Autologous chondrocyte implantation for traumatic full-thickness cartilage defects of the knee in 14 patients: 6-year functional outcomes

BACKGROUND

Autologous chondrocyte implantation (ACI) was introduced in 1987 in Sweden by Brittberg and Peterson for the treatment of severe chondral defects of the knee. Here, our objective was to evaluate mid-term outcomes of ACI in young athletic patients with deep chondral defects of the knee after trauma.

HYPOTHESIS

ACI is effective in filling full-thickness chondral defects of the knee.

PATIENTS AND METHODS

We prospectively monitored 14 patients, with International Cartilage Repair Society grade III or IV lesions, who underwent ACI between 2001 and 2006. Standard evaluation measurements were used. Mean age at surgery was 37.7 years (range, 30-45). A history of surgery on the same knee was noted in ten (67%) patients. The defect was on the medial femoral condyle in 11 patients, lateral femoral condyle in two patients, and both femoral condyles in one patient. Mean defect surface area after debridement was 2.1cm(2) (1-6.3).

RESULTS

After a mean follow-up of six years, improvements were noted in 12 (86%) patients, with an International Knee Documentation Committee (IKDC) score increase from 40 (27.6-65.5) to 60.2 (35.6-89.6) (P=0.003) and a Brittberg-Perterson score decrease from 54.4 (11.8-98.2) to 32.9 (0-83.9) (P=0.02), between the preoperative assessment and last follow-up. The visual analogic scale pain score decreased from 66.3 (44-89) to 23.2 (0-77) (P=0.0006). In two (14%) patients, no improvements were detectable at last follow-up. The remaining 12 patients were satisfied and able to resume sporting activities, albeit at a less strenuous level. Two ACI-specific complications occurred, namely, periosteal hypertrophy treated with debridement in one patient and transplant delamination in another.

DISCUSSION

Our findings are consistent with previous reports but cover a longer follow-up period. Although the outcomes are promising, longer follow-ups are needed to confirm the long-term effectiveness of ACI.

LEVEL OF EVIDENCE

IV, prospective therapeutic study.

Subregional femorotibial cartilage morphology in women--comparison between healthy controls and participants with different grades of radiographic knee osteoarthritis

OBJECTIVE

To identify subregional differences in femorotibial cartilage morphology between healthy controls and women with different grades of radiographic knee osteoarthritis (OA).

DESIGN

158 women aged > or =40 years were studied. Weight-bearing extended anterior-posterior (AP) and Lyon schuss radiographs were obtained and the Kellgren Lawrence grade (KLG) determined. 97 women had a body mass index (BMI)< or =28, no symptoms, and were AP KLG0. 61 women had a BMI> or =30, symptoms in the target knee, and mild (KLG2=31) to moderate (KLG3=30) medial femorotibial radiographic OA in the AP views. Coronal spoiled gradient echo water excitation sequences were acquired at 3.0 Tesla. Total plate and regional measures of cartilage morphology of the weight-bearing femorotibial joint were quantified.

RESULTS

KLG2 participants displayed, on average, thicker cartilage than healthy controls in the medial femorotibial compartment (particularly anterior subregion of the medial tibia (MT) and peripheral [external, internal] subregions of the medial femur), and in the lateral femur. KLG3 participants displayed significantly thinner cartilage than KLG0 participants in the medial weight-bearing femur (central subregion), in the external subregion of the MT, and in the internal subregion of the lateral tibia. These differences were generally unaffected when possible effects of demographic covariates were considered.

CONCLUSIONS

The results indicate that in femorotibial OA regional cartilage thickening and thinning may occur, dependent on the (radiographic) disease status of the joint. These changes appear to display a heterogeneous spatial pattern, where certain subregions are more strongly affected than others.

Change in regional cartilage morphology and joint space width in osteoarthritis participants versus healthy controls: a multicentre study using 3.0 Tesla MRI and Lyon–Schuss radiography

Objective:

Cartilage morphology displays sensitivity to change in osteoarthritis (OA) with quantitative MRI (qMRI). However, (sub)regional cartilage thickness change at 3.0 Tesla (T) has not been directly compared with radiographic progression of joint space narrowing in OA participants and non-arthritic controls.

Methods:

A total of 145 women were imaged at 7 clinical centres: 86 were non-obese and asymptomatic without radiographic OA and 55 were obese with symptomatic and radiographic OA (27 Kellgren–Lawrence grade (KLG)2 and 28 KLG3). Lyon–Schuss (LS) and fixed flexion (FF) radiographs were obtained at baseline, 12 and 24 months, and coronal spoiled gradient echo MRI sequences at 3.0 T at baseline, 6, 12 and 24 months. (Sub)regional, femorotibial cartilage thickness and minimum joint space width (mJSW) in the medial femorotibial compartment were measured and the standardised response means (SRMs) determined.

Results:

At 6 months, qMRI demonstrated a −3.7% “annualised” change in cartilage thickness (SRM −0.33) in the central medial femorotibial compartment (cMFTC) of KLG3 subjects, but no change in KLG2 subjects. The SRM for mJSW in 12-month LS/FF radiographs of KLG3 participants was −0.68/−0.13 and at 24 months was −0.62/−0.20. The SRM for cMFTC changes measured with qMRI was −0.32 (12 months; −2.0%) and −0.48 (24 months; −2.2%), respectively.

Conclusions:

qMRI and LS radiography detected significant change in KLG3 participants at high risk of progression, but not in KLG2 participants, and only small changes in controls. At 12 and 24 months, LS displayed greater, and FF less, sensitivity to change in KLG3 participants than qMRI.

Serum concentrations of type II collagen biomarkers (C2C, C1, 2C and CPII) suggest different pathophysiologies in patients with hip osteoarthritis

BACKGROUND

Cartilage destruction in osteoarthritis (OA) involves excessive degradation and increased synthesis of cartilage matrix macromolecules including type II collagen and proteoglycans. Cartilage biomarkers exist for the measurement of cartilage matrix turnover and may reveal differences in patients with OA.

OBJECTIVE

To determine whether there are detectable differences in and relationships between biomarkers of type II collagen (CII) degradation (C2C, C1, 2C) and synthesis (CP II) in patients with only hip OA (OHOA) and those suffering from multiple sites OA (MSOA).

PATIENTS AND METHODS

Fifty-six patients classified as MSOA or OHOA. Minimum hip joint space width (Min JSW) measured by computer from standard radiographs. Serum measurement of CII synthesis C-propeptide (CPII) and cleavage of type II (C2C) and types I and II (C1, 2C) collagens. Aggrecan metabolism was assessed by serum CS 846 assay. Step to step logistic regression to determine the effect of the quantitative data on the assignment to each subgroup.

RESULTS

Twenty-four subjects were classified with MSOA. Among the 32 OHAO patients, 15 had bilateral hip OA and 17 had unilateral hip OA. The latter were classified with "Isolated hip OA" (IHOA). CPII levels were significantly lower in patients with MSOA than in those with OHOA (99.9+/-50.3ng/mL versus 141.9+/-81.2ng/mL, p=0.04. OR= 0.18 for CPII >120 ng/mL, p<0.005). C2C levels were also lower in MSOA (9.7+/-2.3ng/mL) versus OHOA (11.4+/-3.2ng/mL, p=0.03. OR= 0.26 for C2C >10 ng/mL, p=0.02). There was an inverse correlation between min JSW and C2C only in patients with IHOA (r=0.50, p= 0.02).

CONCLUSION

Hip OA, in patients with MSOA, might be related to alteration in CII metabolism which may result in a deficient type II collagen repair process. The significant relationship between C2C and JSW in IHOA suggests that this marker is of value in assessing cartilage degradation patients with involvement of a single joint.

Head-to-head comparison of the Lyon Schuss and fixed flexion radiographic techniques. Long-term reproducibility in normal knees and sensitivity to change in osteoarthritic knees

OBJECTIVE

The Lyon Schuss (LS) and fixed flexion (FF) views of the knee are superior to a conventional standing anteroposterior view in evaluating joint space narrowing (JSN) in osteoarthritis (OA). Both position the knee identically but only the LS aligns the medial tibial plateau (MTP) with the x-ray beam fluoroscopically. The present study provides the first head-to-head comparison of the LS and FF views.

METHODS

At baseline and 12 months, 62 OA and 99 control knees were imaged twice on the same day with LS and FF views. Minimum joint space width (mJSW) was measured by computer and MTP alignment was assessed from the distance between anterior and posterior margins of the MTP (intermargin distance, IMD). Reproducibility of measurements of mJSW and sensitivity to change were evaluated.

RESULTS

In normal knees, JSW did not vary over 12 months with either view. In OA knees, 12-month mJSN was 0.22 (0.43) mm with the LS view and -0.01 (0.46) mm with the FF view (p = 0.0002 and p = 0.92, respectively). Mean IMD was only half as large in LS as in FF views (0.9 (0.5) mm vs 1.9 (1.2) mm, p<0.0001).

CONCLUSIONS

LS and FF radiographs offer similar reproducibility in JSW measurement. However, presumably due to its superiority in aligning the MTP, the LS view is much more sensitive to JSN in OA knees.

Differences in biomarkers of type II collagen in atrophic and hypertrophic osteoarthritis of the hip: implications for the differing pathobiologies

BACKGROUND

Cartilage destruction in osteoarthritis (OA) involves the excessive degradation and increased synthesis of cartilage matrix macromolecules including type II collagen (CII) and proteoglycans. The lack of osteophytes (atrophic form of OA) has been shown to be a disease severity factor in hip OA. Since osteophyte formation involves endochondral ossification and a cartilage intermediate, atrophic OA may also exhibit differences in cartilage turnover compared to hypertrophic OA. Cartilage serum biomarkers may offer an opportunity to identify such differences in patients.

AIM

To determine whether serum levels of cartilage biomarkers can distinguish between the presence and absence of osteophyte formation in patients with atrophic and hypertrophic hip OA.

PATIENTS AND METHODS

Fifty-six patients (mean age/standard deviation (SD): 62/11; mean body mass index (BMI)/SD: 27/11) with symptomatic hip OA (American College of Rheumatology criteria; mean Lequesne index/SD: 8.3/4) were classified as having an atrophic or hypertrophic form of OA, according to the absence or presence, respectively, of any osteophyte on a standard radiograph of the pelvis. Minimum joint space width (minJSW) and angles of dysplasia [centre-edge (CE) and head-neck-shaft (HNS)] were determined by computerized measurements. The following serum markers were used which are commercial kits from Ibex Diagnostics (Montreal, QC): proteoglycan aggrecans turnover: CS 846; CII synthesis: C-propeptide (CPII), cleavage by collagenase of type II (C2C) and type I and II (C1,2C) collagens.

STATISTICS

Patients with atrophic and hypertrophic OA were compared for each variable and step to step logistic regression was used to determine the effect of variables on the belonging to each group. Correlations were examined using linear regression or Spearman test.

RESULTS

CPII serum levels were significantly lower in the atrophic OA patients (77.3 vs 117.4 ng/mL). There were no significant differences between groups for C2C, C1,2C and CS 846 . CPII and C2C concentrations were highly correlated in hypertrophic OA (P=0.002) but not in atrophic OA (P=0.8).

CONCLUSION

Atrophic hip OA is characterized by reduced synthetic activity involving type II collagen synthesis. This could account in part for the absence of osteophyte formation. The highly significant correlation between CPII and C2C in hypertrophic but not in atrophic OA suggests that the physiological coupling between CII formation and degradation may be lost in atrophic OA. These differences may therefore help explain the absence of osteophyte in atrophic OA and its association with more rapid disease progression.

Superiority of the Lyon schuss view over the standing anteroposterior view for detecting joint space narrowing, especially in the lateral tibiofemoral compartment, in early knee osteoarthritis

OBJECTIVE

To evaluate the validity of using the conventional anteroposterior (AP) radiograph of the knee in order to identify joint space narrowing (JSN) at an early stage of osteoarthritis (OA).

METHODS

Grading of JSN using a 0-5 score and quantitative measurement of joint space width (JSW) of the medial and lateral compartments of the tibiofemoral joint in AP and fluoroscopically assisted posteroanterior Lyon schuss (LS) radiographs of 202 patients with knee OA.

RESULTS

Knees without definite JSN (score <2) were twice as common in AP than in LS radiographs (36.1% vs 18.8%). The number of knees showing definite medial JSN was identical in both views but four knees showing a medial OA in AP view were classified differently in the LS radiographs (three bicompartmental OA and one lateral OA). The frequency of lateral JSN was approximately twice as great in the LS view as in the AP view. JSN score was significantly higher (p<0.001) and JSW was significantly smaller (p<0.01) in the LS view than in the AP view. In knees with definite JSN, JSW of the compartment with no narrowing was significantly (p<0.04) larger than in knees that did not exhibit definite JSN. Medial JSW and lateral JSW were inversely correlated (p<0.001).

CONCLUSIONS

The standing AP radiograph performed poorly in identifying both the location of JSN in patients with early tibiofemoral OA (especially, lateral OA) and the severity of JSN. The LS radiographs are preferable to standing AP views for the selection of patients for therapeutic trials of structure-modifying OA drugs.

Epidemiological, clinical, biological and radiological differences between atrophic and hypertrophic patterns of hip osteoarthritis: a case-control study

OBJECTIVE

Lack of osteophytes (atrophic form) has been shown to be a factor in the severity of hip osteoarthritis (OA). The aim of this study was to determine the epidemiological, radiological and biological differences between the hypertrophic and atrophic forms of hip osteoarthritis.

METHODS

25 patients with symptomatic hip OA (ACR criteria) and classified as having an atrophic form of OA based on the lack of osteophytes on standard radiograph of the pelvis, were matched for joint space width with 25 subjects with evidence of the hypertrophic form of hip OA. OA radiological severity was assessed using a scoring system and by computer measurement of the joint space width. Angles of hip dysplasia were measured. Serum hyaluronic acid, cartilage oligomeric matrix protein, collagenase, Type I procollagen, C-terminal crosslinking telopeptide of type I collagen and tissue inhibitor of métalloproteases-1 were assayed by immunoassay and C-reactive protein by ultrasensitive immunonephelemetry. Statistical analysis was performed using logistic regression, taking into account age, sex, body mass index, and bilaterality.

RESULTS

Compared to hypertrophic OA, atrophic OA affected chiefly elderly women and was characterized by a smaller centre-edge angle and diffuse superior femoral head migration. It was less frequently bilateral. No statistically significant difference was found in the biological data between the two groups.

CONCLUSION

An atrophic bone response in hip OA occurs chiefly in women and is associated with poor coverage of the femoral head. Serum biomarkers able to demonstrate differences between the atrophic and hypertrophic patterns of OA are lacking.

Cross sectional evaluation of biochemical markers of bone, cartilage, and synovial tissue metabolism in patients with knee osteoarthritis: relations with disease activity and joint damage

OBJECTIVE

To analyse the relations between the urinary levels of type II collagen C-telopeptide (CTX-II) and glucosyl-galactosyl pyridinoline (Glc-Gal-PYD)-two newly developed biochemical markers of type II collagen and synovial tissue destruction respectively-disease activity and the severity of joint destruction in patients with knee osteoarthritis (OA). The clinical performance of these two new markers was compared with that of a panel of other established biochemical markers of connective tissue metabolism.

METHODS

The following biochemical markers were measured in a group of 67 patients with knee OA (mean age 64 years, median disease duration eight years ) and in 67 healthy controls: for bone, serum osteocalcin, serum and urinary C-telopeptide of type I collagen (CTX-I); for cartilage, urinary CTX-II, serum cartilage oligomeric matrix protein (COMP), and serum human cartilage glycoprotein 39 (YKL-40); for synovium, urinary Glc-Gal-PYD, serum type III collagen N-propeptide (PIIINP), serum hyaluronic acid (HA); and for inflammation, serum C reactive protein. Biochemical markers were correlated with pain and physical function (WOMAC index) and with quantitative radiographic evaluation of the joint space using the posteroanterior view of the knees flexed at 30 degrees.

RESULTS

All bone turnover markers were decreased in patients with knee OA compared with controls (-36%, -38%, and -52%, p<0.0001 for serum osteocalcin, serum CTX-I and urinary CTX-I, respectively). Serum COMP (+16%, p=0.0004), urinary CTX-II (+25%, p=0.0009), urinary Glc-Gal-PYD (+18%, p=0.028), serum PIIINP (+33%, p<0.0001), and serum HA (+ 233%, p<0.0001) were increased. By univariate analyses, increased urinary Glc-Gal-PYD (r=0.41, p=0.002) and decreased serum osteocalcin (r=-0.30, p=0.025) were associated with a higher total WOMAC index. Increased urinary CTX-II (r=-0.40, p=0.0002) and Glc-Gal-PYD (r=-0.30, p=0.0046) and serum PIIINP (r=-0.29, p=0.0034) were the only markers which correlated with joint surface area. By multivariate analyses, urinary Glc-Gal-PYD and CTX-II were the most important predictors of the WOMAC index and joint damage, respectively.

CONCLUSION

Knee OA appears to be characterised by a systemic decrease of bone turnover and increased cartilage and synovial tissue turnover. CTX-II, Glc-Gal-PYD, and PIIINP may be useful markers of disease severity in patients with knee OA.

Glucosamine sulfate modulates dysregulated activities of human osteoarthritic chondrocytes in vitro

OBJECTIVE

The efficacy of glucosamine sulfate (GS) in the symptomatic treatment of patients with osteoarthritis (OA) is suggested to be mediated by still unknown effects on the altered OA cartilage.

DESIGN

Using human OA chondrocytes in culture, the effects of GS on protein synthesis, caseinase, collagenase, phospholipase A2 (PLA2) and protein kinase C (PKC) activities as well as production of nitric oxide and cyclic AMP were studied in both cells and culture medium.

RESULTS

GS significantly reduced PLA2 activity, and more modestly collagenase activity, in the OA chondrocytes in a dose-dependent manner. By contrast, PLA2 and collagenase activity of the culture medium was not modified. No effects on caseinase activity was seen. GS significantly and dose-dependently increased protein synthesis. GS did not modify nitric oxide and cAMP production but significantly increased PKC production.

CONCLUSION

GS modified cultured OA chondrocyte metabolism by acting on PKC, cellular PLA2, protein synthesis and possibly collagenase activation. Extrapolation of the effect to the in-vivo situation remains hypothetical but they might represent some possible mechanisms of action of the drug in human.

[Primary nutritional and drug prevention of atherosclerosis]

Atherosclerosis results from a multifactorial process. For that reason, primary prevention of cardiovascular diseases requires several measures that should exhibit antiatherogenic, antithrombotic, antioxidative and antihypertensive properties. Two types of therapeutic strategies can be individualized. Nutritional interventions are the first line measures for population wide primary prevention in subjects at low risk of developing atheroscleric diseases. In high risk individuals who have either one major risk factor (LDL cholesterol above 190 mg/dL) or several additional risk factors, dietary measures must be frequently combined with drug treatments. However, the cost-effectiveness ratio should be weighed prior to any treatment especially with statins. Dietary measures consist to reduce caloric intakes in overweight subjects, or more generally to adopt eating patterns which correspond to the following recommendations: (i) proteins = 15% of total calories; (ii) saturated and polyunsatured fats = 10% each; (iii) carbohydrates plus monounsaturated fats = 65%. Such dietary instructions permit individual dietary changes, just by adjusting the carbohydrates/monounsaturates balance, the sum of both nutrients remaining in all cases equal to two-thirds to total calories. Drug treatments are only indicated after secondary dietary failure. They are generally based on the use of statins since the efficacy of these treatments has been clearly established by such preventive trials as the WOSCOP Study, provided that the therapeutic interventions result in significant reduction of LDL cholesterol levels over several years. Antiplatelet agents (aspirin), antihypertensive therapies, antioxidant supplementations with vitamins E or C are also recommended in some individuals for completing the beneficial effects of the above mentioned measures.

Radiographic assessment of hip and knee osteoarthritis. Recommendations: recommended guidelines

Pathological lesions of osteoarthritis, demonstrated by conventional radiography, can be assessed by scoring systems and/or measurement with a quite acceptable reproducibility. Scores are recommended for a rough staging of osteoarthritis and of bone changes. Measurement is recommended for assessment of joint space narrowing progression. A good assessment of progression implicates a perfect reproducibility of the radiographic image of the joint. Accuracy of standard radiograph is improved by some views such as the hip profile and the schuss view.

Evaluation of the 'Lequesne's false profile' of the hip in patients with hip osteoarthritis

OBJECTIVES

To compare the value of Lequesne's false profile (LFP) radiograph of the hip and antero-posterior (AP) X-ray of the pelvis in the assessment of joint space narrowing (JSN) and osteophyte (Ost) in patients with hip osteoarthritis (OA).

METHODS

AP and LFP radiographs of the hip were performed using a standardized method in 50 consecutive patients with hip OA. JSN and Ost were graded at different days by a single observer blinded for patients identity, using a six point scale (JSN:0-5) and a four point scale (Ost:0-3) from AP and LFP respectively. Scores obtained from AP and LFP were compared.

RESULTS

Mean JSN grade was significantly higher for LFP (2. 7+/-1.0) than AP (2.4+/-1.2) (P=0.001). It was identical for AP and LFP in 28 patients (56%) while the highest grade was found on LFP in 16 (32%) and on AP in 6 (12%). No significant difference between LFP and AP was found for osteophyte grading.

CONCLUSION

These data suggest that the combination AP+LFP provide more information than AP alone for the evaluation of joint space narrowing in about one third of patients. LFP may be helpful for the radiographic assessment of OA changes particularly in structure modifying drugs evaluation.

Osteoarthritic cartilage fibrillation is associated with a decrease in chondrocyte adhesion to fibronectin

OBJECTIVE

Cartilage destruction in osteoarthritis (OA) is generally accepted as a failed repair process. Cell adhesion is implicated in tissue repair. Therefore, adhesion of OA chondrocytes to extracellular matrix proteins was investigated.

DESIGN

Using chondrocytes from human OA femoral head cartilage, adhesion to fibronectin and type II collagen of cells from distinct areas showing an intact cartilage surface or a fibrillated cartilage surface was studied. Modulation of chondrocyte adhesion by both protein kinase C (PKC) inhibitors and glucosamine sulfate (GS) was also investigated.

RESULTS

A significant (P < 0.05) decrease in adhesion to fibronectin of chondrocytes from fibrillated cartilage, relative to those from grossly normal OA cartilage, was demonstrated. Adhesion to type II collagen was not modified by the chondrocyte origins (either from normal or fibrillated OA cartilage). Adhesion to fibronectin of cells from grossly intact cartilage was decreased by the addition of PKC and calmodulin-dependent kinase inhibitors, W7 and sphingosine, to the cell culture. Adhesion to fibronectin of chondrocytes from fibrillated cartilage was significantly (P < 0.05) increased after glucosamine sulfate treatment.

CONCLUSION

Fibrillation of cartilage from OA femoral head is associated with a defective adhesion of chondrocytes to fibronectin. The process is suggested to be dependent of PKC and/or calmodulin-dependent kinases and potentially reversible. Conceivably, it could play a role in OA cartilage destruction.

Quantitative evaluation of joint space width in femorotibial osteoarthritis: comparison of three radiographic views

OBJECTIVE

Quantitative evaluation of radiographic methods proposed to improve the detection of joint space narrowing (JSN) in femorotibial osteoarthritis (OA).

METHODS

Thirty-two consecutive patients with knee OA and five normal controls had three different weight-bearing radiographs of the knee: (1) anteroposterior film of both knees in full extension (extended knees), (2) anteroposterior film of one knee in extension while the patient was standing on the homolateral foot (standing on homolateral foot), (3) posteroanterior film of both knees flexed at 30 degrees (schuss view). Joint space was analyzed blind using both an evaluation of JSN with a six-grade scale (JSN score) and an image analyser computer measurement of the mean joint space width (mean JSW). The medial compartment of medial femorotibial OA knees, the lateral compartment of lateral femorotibial OA knees, as well as both compartments of control knees, were measured. Extended knee and schuss views were made 1 year later in 10 patients for the evaluation of sensitivity to change.

RESULTS

The JSN scores +/- S.D. in schuss, standing on the homolateral foot and extended knee views were 2.75 +/- 1.31, 1.95 +/- 1.3 and 1.66 +/- 1.27, respectively. The mean JSW +/- S.D. in schuss, standing on the homolateral foot, and extended knee views were 2.9 +/- 1.9 mm, 3.5 +/- 1.6 mm and 3.8 +/- 1.5 mm, respectively. Changes in JSN scores and mean JSW with schuss view increased with OA severity. In controls, JSW of the medial compartment did not vary in the three views. JSW of the lateral compartment of controls was significantly larger in the schuss view. The change in JSW after 1 year was -0.41 mm (P = 0.02) in the schuss view and -0.17 mm (P > 0.05) in the extended knee view.

CONCLUSION

The schuss view is suggested as the most accurate method for the evaluation of JSW in femorotibial OA.

Phospholipase A2 activity in herniated lumbar discs. Clinical correlations and inhibition by piroxicam

STUDY DESIGN

Prospective study of phospholipase A2 activity in the serum and intervertebral discs of patients undergoing surgery for sciatica due to disc herniation.

OBJECTIVES

To determine correlations between herniated disc phospholipase A2 and clinical, radiographic, and anatomic signs of common sciatica; to evaluate serum phospholipase A2 activity as a marker of disc phospholipase A2; and to investigate the in vivo effect of piroxicam on disc phospholipase A2.

SUMMARY OF BACKGROUND DATA

Several studies suggest disc inflammation as a mechanism of sciatica due to disc herniation, and phospholipase A2 emerges as a key enzyme of cartilage and disc tissues.

METHODS

Phospholipase A2 activity was determined, using the degradation of a specific substrate, in the serum and discs of 31 patients (14 treated with acetaminophen and 17 treated with piroxicam) undergoing surgery for sciatica due to lumbar disc herniation. Visual analog scale for pain, Dallas Pain Questionnaire, Lasègue's sign, radiographic stage of degeneration of the herniated disc, volume of disc herniation shown by computed tomography, and surgical findings were recorded.

RESULTS

Disc phospholipase A2 activity was independent of the patient's age or sex, the radiologic stage of disc degeneration, and the volume of the herniation, and showed no significant correlation with Lasègue's sign or pain measured on a visual analog scale. The correlation between disc phospholipase A2 and the Dallas category of items measuring the impact of pain on daily activities approached the level of significance (P = 0.07). Disc phospholipase A2 activity was significantly higher in cases of sequestrated discs than in other herniations. Disc phospholipase A2 was significantly correlated with serum phospholipase A2, and was significantly lower in patients treated with piroxicam than in those treated with acetaminophen.

CONCLUSIONS

Disc phospholipase A2 is thought to participate in the physiopathology of sciatica and to bemodulated by nonsteroidal anti-inflammatory drug therapy. Serum phospholipase A2 is suggested as a biologic marker of disc inflammation in patients with sciatica.

[Primary AL-type amyloidosis disclosed by Horton disease]

Primary systemic amyloidosis rarely affects the walls of small and medium-sized vessels. We report a case of primary AL amyloidosis masquerading as giant cell arteritis at the onset of the disease, revealed by the temporal arteritis biopsy, and successfully treated by corticotherapy for three years. Histology of temporal arteritis confirms the diagnosis of amyloidosis (characteristic birefringence with Congo red). We discuss in this case the diagnosis of primary amyloidosis revealed by Horton disease, or the coincidental association of these two diseases.

Progression of digital osteoarthritis: a sequential scintigraphic and radiographic study

Hand radiographs and scintigraphy were obtained initially and at the 4-year follow-up in 15 patients with symptomatic osteoarthritis (OA) of distal and/or proximal interphalangeal joints. For each joint, a 0-15 score was obtained for the OA radiographic lesions read blind by the same observer. An abnormal isotope retention over a bone reference area was assessed and quantified. The predictive value of scintigraphy for the OA radiographic progression was confirmed and shown to be improved by a second investigation. During the study period, the percentage of radiographic OA joints increased from 66.3 to 76.6%, but joints showing an abnormal scan decreased from 40 to 22.5%. Progression of the OA radiographic score was closely related to scintigraphic changes. The mean difference between the final and initial OA score was -0.08 in joints with two normal scans (N = 115), +0.73 in joints showing a first abnormal and a second normal scan (N = 94) and +1.8 in joints with two abnormal scans (N = 14) or a scan becoming abnormal (N = 47). An abnormal scan appears to represent a transient event, and this event is associated with a period of progression of digital OA. Potentially, anti-OA therapies that suppress joint isotope retention might slow down OA progression. The magnitude of joint isotope retention was positively correlated with the OA radiographic score established at the same time (R = 0.61 and P < 0.001), but showed no predictive value for progression of the latter.

[Serum phospholipase A2 activity in osteoarthritis]

Serum phospholipase A2 activity in 67 osteoarthritis patients and 17 controls was determined using a radiolabeled specific substrate. Serum phospholipase A2 activity was significantly higher in osteoarthritis patients (115 +/- 73.6 dpm/h/ml) than in controls (45 +/- 25 dpm/h/ml) (p = 0.002). In 41 osteoarthritis patients, serum phospholipase A2 activity was unrelated to age, time since onset of osteoarthritis symptoms, duration of morning stiffness, Lequesne's index, roentgenographic stage of osteoarthritis, number of joints with osteoarthritis, erythrocyte sedimentation rate, or serum C-reactive protein levels. In 12 osteoarthritis patients who were evaluated twice at a mean interval of 46 days, changes in serum phospholipase A2 activity were unrelated to changes in Lequesne's index. Blind evaluation of long-term joint space loss was performed in 14 patients; serum phospholipase A2 activity increased only in those patients with progressive joint space loss, but the difference was not statistically significant as compared with the controls. These data suggest that serum phospholipase A2 activity is not useful in practice as a marker for osteoarthritis.

[Serum hyaluronic acid in osteoarthritis]

In this prospective study, serum hyaluronate (SH) was assayed using a radiometric method (Pharmacia) in 73 osteoarthritis patients and 39 controls. All assays were performed between 8 h 00 and 9 h 00 a.m. because SH levels exhibit circadian variations. SH levels were significantly higher in patients with osteoarthritis than in controls (92 +/- 66 micrograms/l and 39 +/- 21 micrograms/l, respectively, p = 0.0001). Among 50 patients with osteoarthritis, including 29 with knee involvement and 21 with hip involvement, SH levels were not correlated with morning stiffness, duration of symptoms, Lequesne's algofunctional index, erythrocyte sedimentation rate, C-reactive protein, severity of roentgenographic changes in the affected knee or hip, disease extension, or severity. The lack of any relationship between changes in SH levels and Lequesne's is index values in 25 patients or between SH levels and joint space narrowing evaluated retrospectively in 16 patients, as well as the prompt return to high SH levels after arthroplasty and synovectomy in 14 patients with hip joint osteoarthritis, suggest that this potential marker is not useful for monitoring osteoarthritis in a single joint.

[Measurement of the hip joint space using automatic digital image analysis]

Joint surface area (JSA) and mean joint space width (MJSW) at the hip were measured using a ICMS-Techline computer program to analyze digitalised frontal weight-bearing roentgenograms of the pelvis. With this technique, the portion of joint space studied is always the same in a given patient and is enclosed within an acute ECS angle whose apex C is the center of the head of the femur and whose ends E and S are the lateral rim of the acetabulum and the highest point of the homolateral sacral wing respectively. ECS varies across individuals but remains constant in a given hip. Twenty hips were included in the first part of the study. For each hip, three roentgenograms were taken at five-minute intervals by three different radiologists who used their own constants (settings, position of the subject). JSA and MJSW are determined five times on each film by two different observers who had no information on the films under study. The interobserver coefficient of variation (CV) was 4.7% for JSA and 3.3% for MJSW. Intra-observer CVs were 2.97 and 3.54% for MJSW and 4.32% and 5.13% for JSA. There was a very close correlation between MJSW and JSA (r = 0.87, p < 0.0001). MJSW was then determined for roentgenograms of 30 hips with osteoarthritis. Results were compared with the values obtained using Lequesne's method of joint space measurement at the site of maximum narrowing. Measurements were performed in a double-blind fashion by two observers. The correlation coefficient was r = 0.89 (p < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma lipid fatty acids and platelet function during continuous subcutaneous insulin infusion in type I diabetes

Eleven insulin-dependent diabetics exhibiting a fair but less than ideal diabetic control (HbA1 = 10.0 +/- 0.6%) were submitted in a random order to two 6 week-study periods of: continuous subcutaneous insulin infusion (CSII) and optimized conventional insulin therapy. Plasma lipids, fatty acids in plasma lipids and platelet function were estimated at baseline and at the end of each study period. Declines in HbA1 were observed at the end of either CSII or conventional period compared with baseline, but the differences were only significant under CSII (P less than 0.02). Plasma lipids and apoproteins remained unchanged at the end of the two study periods compared with baseline. Both CSII and optimized conventional treatment were followed by a significant increase of arachidonate in plasma lipids. A deterioration of the platelet function estimated from ADP or epinephrine-induced platelet aggregation and TxB2 generation by platelets was found under optimized conventional treatment while the platelet function appears to be normal at baseline and under CSII. These data indicate that slight but not sufficient improvements of diabetic control can result in deterioration of the platelet function. It seems that these deleterious effects are mediated through an increased production of arachidonate and in turn of TxB2.

Human remains of Homo sapiens neanderthalensis from the pleistocene deposit of Santa [corrected] Croce Cave, Bisceglie (Apulia), Italy

The paper deals with a Neanderthal human femur, recovered during excavations in Santa [corrected] Croce Cave, Bisceglie. The cave also yielded Mousterian lithic industry and fauna indicating a paleoclimate condition with dry-warm tendency and savannah landscape. Metrical, morphometrical, and morphological analysis, and the comparison with Neanderthal specimens show that the femur belonged to an adult individual. It particularly shows great affinities with the analogous specimens from La Ferrassie 1 and 2, Spy 2, and Fond de Forêt, which are similar in size and, above all, show similar archaic morphological traits.

Neanderthal parietal, vertebrate fauna, and stone artifacts from the Upper Pleistocene deposits of Contrada Ianní di San Calogero (Catanzaro, Calabria, Italy)

Human skeletal remains recovered at a new archaeological site, dating back to the Italian Mousterian age are analyzed. The finds consist of a left parietal of a child about 2-3 years old. The metrical, morphometrical, and morphological traits of this parietal are compared to those of other Neanderthal children. The geological features of the site, its fauna, and stone artifacts recovered there during quarry operations are also analyzed.

Insulinoma with hypoglycemia and normal immunoreactive insulin but with an insulin-like activity restricted to the portal vein

In a 46-year old Caucasian woman, the authors report a B-cell adenoma with plasma immunoreactive insulin (IRI) ranging from 10 to 32 microunits/ml, despite severe spontaneous hypoglycemia. In a peroperative sample withdrawn from the portal vein, normal IRI (40 micromicron/ml) in the presence of high insulin-like activity (290 microunits/ml) was observed by using a biological assay performed on rat epididymal fat tissue. Furthermore, this material did not cross-react with insulin antibodies and was undetectable in systemic venous samples. Although further identification by chromatographic extraction was not performed, the substance secreted by the tumor is probably identical to the non-suppressible insulin-like activity (NSILA) isolated by Froesch and responsible for hypoglycemia in a few cases of extrapancreatic tumors. The absence of this material in systemic samples indicates an immediate removal by a single passage through the liver.

[Induced hyperlipemia test during femur head osteonecrosis]

The authors studied disturbances of lipid clearance in cases of aseptic osteonecrosis of the femoral head by means of an induced intravenous hyperlipemia test. With reference to investigations in 19 patients, the authors first draw attention to the frequency of ethylism and of fatty degeneration of the liver (13 patients). A significant decrease was noted in the coefficient of lipid clearance in the 19 patients. This was particularly marked when fatty degeneration of the liver was present. The etiological role of these anomalies should be considered, as fatty degeneration and hyperlipaemia may also be found in other pathological conditions responsible for primary osteonecrosis of the femoral head (corticotherapy).