Rheumatoid Arthritis

CHICAGO — Less invasive hip and knee arthroplasty techniques continue to progress and bring new advantages for patients, said Dr. Bryan J. Nestor.

Anterior two-incision total hip arthroplasty (THA), only recently touted as being “revolutionary,” is falling into disfavor and many surgeons have abandoned this approach, said Dr. Nestor at a symposium sponsored by the American College of Rheumatology. “There are indications that the two-incision THA causes significant gluteus medius and minimus muscle destruction, so muscle sparing it's probably not,” he said. Furthermore, the piriformis and conjoint tendons, which are the external rotators of the hip, are ruptured or damaged in about 70% of patients, “and you can't repair them. But most humbling has been the high complication rate associated with this procedure in the hands of very experienced total hip surgeons: femoral fracture, neuropraxia, a 25% incidence of lateral femoral cutaneous nerve palsies, and a 5%–10% reoperation rate,” said Dr. Nestor of the Hospital for Special Surgery, New York.

The approach favored by Dr. Nestor is the posterior mini-incision THA. With this procedure, surgeons can gradually decrease the lengths of their incisions. It also affords good direct visualization and works well with cemented or uncemented components. The dislocation rate with posterior mini-incision THA is unchanged from that of the standard approach, recovery may be less painful, and it produces only one relatively small scar. Patient body mass index should ideally be under 30 kg/m

“It's important to avoid the mini incision in complicated THA; patients who require hardware removal, osteotomy correction, or bone grafting at the time of the procedure are not candidates for a limited exposure to the hip,” Dr. Nestor said, going on to describe the procedure: “The incision is placed along the posterior border of the greater trochanter, about 6–10 cm in length. It's slightly angulated anteriorly at the distal point, and it's centered on a point midway between the tip of the trochanter and the vastus ridge. Proximal extension of the incision facilitates femoral exposure, and distal extension facilitates acetabular exposure,” he said.

Dr. Nestor is heading an ongoing study comparing 55 patients (62 hips) who underwent the mini posterior approach with 38 patients (46 hips) who had the standard surgical approach. Most of the stems were cemented. From 6-week to 1-year follow-up, there was no difference in clinical performance as measured by the Harris Hip Score. In addition, there were no significant differences in cup positioning, femoral component positioning, blood loss, or complications between the two groups. “Interestingly, there were more superficial wound problems in the standard approach than in the mini approach, and that probably reflects the larger body mass index of patients in the standard incision group,” he said, concluding that the mini THA incision can be done safely.

CHICAGO — Less invasive hip and knee arthroplasty techniques continue to progress and bring new advantages for patients, said Dr. Bryan J. Nestor.

Anterior two-incision total hip arthroplasty (THA), only recently touted as being “revolutionary,” is falling into disfavor and many surgeons have abandoned this approach, said Dr. Nestor at a symposium sponsored by the American College of Rheumatology. “There are indications that the two-incision THA causes significant gluteus medius and minimus muscle destruction, so muscle sparing it's probably not,” he said. Furthermore, the piriformis and conjoint tendons, which are the external rotators of the hip, are ruptured or damaged in about 70% of patients, “and you can't repair them. But most humbling has been the high complication rate associated with this procedure in the hands of very experienced total hip surgeons: femoral fracture, neuropraxia, a 25% incidence of lateral femoral cutaneous nerve palsies, and a 5%–10% reoperation rate,” said Dr. Nestor of the Hospital for Special Surgery, New York.

The approach favored by Dr. Nestor is the posterior mini-incision THA. With this procedure, surgeons can gradually decrease the lengths of their incisions. It also affords good direct visualization and works well with cemented or uncemented components. The dislocation rate with posterior mini-incision THA is unchanged from that of the standard approach, recovery may be less painful, and it produces only one relatively small scar. Patient body mass index should ideally be under 30 kg/m

“It's important to avoid the mini incision in complicated THA; patients who require hardware removal, osteotomy correction, or bone grafting at the time of the procedure are not candidates for a limited exposure to the hip,” Dr. Nestor said, going on to describe the procedure: “The incision is placed along the posterior border of the greater trochanter, about 6–10 cm in length. It's slightly angulated anteriorly at the distal point, and it's centered on a point midway between the tip of the trochanter and the vastus ridge. Proximal extension of the incision facilitates femoral exposure, and distal extension facilitates acetabular exposure,” he said.

Dr. Nestor is heading an ongoing study comparing 55 patients (62 hips) who underwent the mini posterior approach with 38 patients (46 hips) who had the standard surgical approach. Most of the stems were cemented. From 6-week to 1-year follow-up, there was no difference in clinical performance as measured by the Harris Hip Score. In addition, there were no significant differences in cup positioning, femoral component positioning, blood loss, or complications between the two groups. “Interestingly, there were more superficial wound problems in the standard approach than in the mini approach, and that probably reflects the larger body mass index of patients in the standard incision group,” he said, concluding that the mini THA incision can be done safely.

CHICAGO — Less invasive hip and knee arthroplasty techniques continue to progress and bring new advantages for patients, said Dr. Bryan J. Nestor.

Anterior two-incision total hip arthroplasty (THA), only recently touted as being “revolutionary,” is falling into disfavor and many surgeons have abandoned this approach, said Dr. Nestor at a symposium sponsored by the American College of Rheumatology. “There are indications that the two-incision THA causes significant gluteus medius and minimus muscle destruction, so muscle sparing it's probably not,” he said. Furthermore, the piriformis and conjoint tendons, which are the external rotators of the hip, are ruptured or damaged in about 70% of patients, “and you can't repair them. But most humbling has been the high complication rate associated with this procedure in the hands of very experienced total hip surgeons: femoral fracture, neuropraxia, a 25% incidence of lateral femoral cutaneous nerve palsies, and a 5%–10% reoperation rate,” said Dr. Nestor of the Hospital for Special Surgery, New York.

The approach favored by Dr. Nestor is the posterior mini-incision THA. With this procedure, surgeons can gradually decrease the lengths of their incisions. It also affords good direct visualization and works well with cemented or uncemented components. The dislocation rate with posterior mini-incision THA is unchanged from that of the standard approach, recovery may be less painful, and it produces only one relatively small scar. Patient body mass index should ideally be under 30 kg/m

“It's important to avoid the mini incision in complicated THA; patients who require hardware removal, osteotomy correction, or bone grafting at the time of the procedure are not candidates for a limited exposure to the hip,” Dr. Nestor said, going on to describe the procedure: “The incision is placed along the posterior border of the greater trochanter, about 6–10 cm in length. It's slightly angulated anteriorly at the distal point, and it's centered on a point midway between the tip of the trochanter and the vastus ridge. Proximal extension of the incision facilitates femoral exposure, and distal extension facilitates acetabular exposure,” he said.

Dr. Nestor is heading an ongoing study comparing 55 patients (62 hips) who underwent the mini posterior approach with 38 patients (46 hips) who had the standard surgical approach. Most of the stems were cemented. From 6-week to 1-year follow-up, there was no difference in clinical performance as measured by the Harris Hip Score. In addition, there were no significant differences in cup positioning, femoral component positioning, blood loss, or complications between the two groups. “Interestingly, there were more superficial wound problems in the standard approach than in the mini approach, and that probably reflects the larger body mass index of patients in the standard incision group,” he said, concluding that the mini THA incision can be done safely.

STOCKHOLM — It may be wrong to assume that patients with psoriasis and joint pain have psoriatic arthritis, according to data presented at an international conference on psoriasis and psoriatic arthritis by Dr. Elinor Mody.

“Joint pain in patients with psoriasis does not necessarily equal psoriatic arthritis,” said Dr. Mody, a rheumatologist at Brigham and Women's Hospital in Boston.

She and her colleagues assessed 71 consecutive patients with psoriasis and musculoskeletal pain who presented to a combined dermatology/rheumatology clinic. Average patient age was 53 years and 52% of the studied patients were women. All were evaluated by both a dermatologist and a rheumatologist.

Based on the Moll and Wright criteria (Semin. Arthritis Rheum. 1973;3:55–78), 41% were diagnosed with psoriatic arthritis alone. Based on the American College of Rheumatology criteria for osteoarthritis of the hand, and knee and hip radiographs, 27% were diagnosed with osteoarthritis alone. In addition, 3% were diagnosed with gout and 14% had no specific diagnosis. Fourteen percent were diagnosed with both psoriatic arthritis and osteoarthritis.

“These findings highlight that patients with psoriasis and musculoskeletal pain can have a variety of conditions causing this pain and cannot be assumed to have psoriatic arthritis,” said Dr. Mody.

Differentiating between psoriatic arthritis and other arthropathies can be difficult but is “extremely important as psoriatic arthritis is deforming and crippling and requires aggressive early therapy,” said Dr. Mody. “Better methods are needed for screening for psoriatic arthritis in a patient with psoriasis.”

To address this need, Dr. Mody and her colleagues developed the psoriatic arthritis screening and evaluation (PASE) questionnaire intended for physicians to use to screen patients with psoriasis for evidence of psoriatic arthritis. The self-administered questionnaire includes 15 five-choice questions, separated into symptom and function subscales.

Forty-five consecutive patients (24 women) answered the questionnaire prior to systemic therapy. A rheumatologist and a dermatologist working together diagnosed 27 patients with psoriasis alone and 18 with psoriatic arthritis.

Patients with psoriatic arthritis had a median total PASE score of 53, compared with a median score of 40 for patients with psoriasis alone—a difference that was statistically significant. With a total score cutoff of 47—a score of 47 or greater indicates psoriatic arthritis—sensitivity of PASE was 83% and specificity was 70%.

“These patients need to be reevaluated periodically,” said Dr. Mody. She and here colleagues recommend repeating the PASE every 6–12 months in patients with psoriasis and joint pain.

The median function score for patients with psoriatic arthritis was 27, compared with 19 for those with psoriasis alone. The median symptom score for patients with psoriatic arthritis was 24, compared with 21 for those with psoriasis alone.

The researchers are planning to assess retest reliability of the PASE, as well as to investigate changes in PASE scores following the initiation of therapy.

STOCKHOLM — It may be wrong to assume that patients with psoriasis and joint pain have psoriatic arthritis, according to data presented at an international conference on psoriasis and psoriatic arthritis by Dr. Elinor Mody.

“Joint pain in patients with psoriasis does not necessarily equal psoriatic arthritis,” said Dr. Mody, a rheumatologist at Brigham and Women's Hospital in Boston.

She and her colleagues assessed 71 consecutive patients with psoriasis and musculoskeletal pain who presented to a combined dermatology/rheumatology clinic. Average patient age was 53 years and 52% of the studied patients were women. All were evaluated by both a dermatologist and a rheumatologist.

Based on the Moll and Wright criteria (Semin. Arthritis Rheum. 1973;3:55–78), 41% were diagnosed with psoriatic arthritis alone. Based on the American College of Rheumatology criteria for osteoarthritis of the hand, and knee and hip radiographs, 27% were diagnosed with osteoarthritis alone. In addition, 3% were diagnosed with gout and 14% had no specific diagnosis. Fourteen percent were diagnosed with both psoriatic arthritis and osteoarthritis.

“These findings highlight that patients with psoriasis and musculoskeletal pain can have a variety of conditions causing this pain and cannot be assumed to have psoriatic arthritis,” said Dr. Mody.

Differentiating between psoriatic arthritis and other arthropathies can be difficult but is “extremely important as psoriatic arthritis is deforming and crippling and requires aggressive early therapy,” said Dr. Mody. “Better methods are needed for screening for psoriatic arthritis in a patient with psoriasis.”

To address this need, Dr. Mody and her colleagues developed the psoriatic arthritis screening and evaluation (PASE) questionnaire intended for physicians to use to screen patients with psoriasis for evidence of psoriatic arthritis. The self-administered questionnaire includes 15 five-choice questions, separated into symptom and function subscales.

Forty-five consecutive patients (24 women) answered the questionnaire prior to systemic therapy. A rheumatologist and a dermatologist working together diagnosed 27 patients with psoriasis alone and 18 with psoriatic arthritis.

Patients with psoriatic arthritis had a median total PASE score of 53, compared with a median score of 40 for patients with psoriasis alone—a difference that was statistically significant. With a total score cutoff of 47—a score of 47 or greater indicates psoriatic arthritis—sensitivity of PASE was 83% and specificity was 70%.

“These patients need to be reevaluated periodically,” said Dr. Mody. She and here colleagues recommend repeating the PASE every 6–12 months in patients with psoriasis and joint pain.

The median function score for patients with psoriatic arthritis was 27, compared with 19 for those with psoriasis alone. The median symptom score for patients with psoriatic arthritis was 24, compared with 21 for those with psoriasis alone.

The researchers are planning to assess retest reliability of the PASE, as well as to investigate changes in PASE scores following the initiation of therapy.

STOCKHOLM — It may be wrong to assume that patients with psoriasis and joint pain have psoriatic arthritis, according to data presented at an international conference on psoriasis and psoriatic arthritis by Dr. Elinor Mody.

“Joint pain in patients with psoriasis does not necessarily equal psoriatic arthritis,” said Dr. Mody, a rheumatologist at Brigham and Women's Hospital in Boston.

She and her colleagues assessed 71 consecutive patients with psoriasis and musculoskeletal pain who presented to a combined dermatology/rheumatology clinic. Average patient age was 53 years and 52% of the studied patients were women. All were evaluated by both a dermatologist and a rheumatologist.

Based on the Moll and Wright criteria (Semin. Arthritis Rheum. 1973;3:55–78), 41% were diagnosed with psoriatic arthritis alone. Based on the American College of Rheumatology criteria for osteoarthritis of the hand, and knee and hip radiographs, 27% were diagnosed with osteoarthritis alone. In addition, 3% were diagnosed with gout and 14% had no specific diagnosis. Fourteen percent were diagnosed with both psoriatic arthritis and osteoarthritis.

“These findings highlight that patients with psoriasis and musculoskeletal pain can have a variety of conditions causing this pain and cannot be assumed to have psoriatic arthritis,” said Dr. Mody.

Differentiating between psoriatic arthritis and other arthropathies can be difficult but is “extremely important as psoriatic arthritis is deforming and crippling and requires aggressive early therapy,” said Dr. Mody. “Better methods are needed for screening for psoriatic arthritis in a patient with psoriasis.”

To address this need, Dr. Mody and her colleagues developed the psoriatic arthritis screening and evaluation (PASE) questionnaire intended for physicians to use to screen patients with psoriasis for evidence of psoriatic arthritis. The self-administered questionnaire includes 15 five-choice questions, separated into symptom and function subscales.

Forty-five consecutive patients (24 women) answered the questionnaire prior to systemic therapy. A rheumatologist and a dermatologist working together diagnosed 27 patients with psoriasis alone and 18 with psoriatic arthritis.

Patients with psoriatic arthritis had a median total PASE score of 53, compared with a median score of 40 for patients with psoriasis alone—a difference that was statistically significant. With a total score cutoff of 47—a score of 47 or greater indicates psoriatic arthritis—sensitivity of PASE was 83% and specificity was 70%.

“These patients need to be reevaluated periodically,” said Dr. Mody. She and here colleagues recommend repeating the PASE every 6–12 months in patients with psoriasis and joint pain.

The median function score for patients with psoriatic arthritis was 27, compared with 19 for those with psoriasis alone. The median symptom score for patients with psoriatic arthritis was 24, compared with 21 for those with psoriasis alone.

The researchers are planning to assess retest reliability of the PASE, as well as to investigate changes in PASE scores following the initiation of therapy.

STOCKHOLM — The search continues for sensitive and specific classification criteria for psoriatic arthritis.

At an international conference on psoriasis and psoriatic arthritis, the latest results were presented from the classification criteria for psoriatic arthritis (CASPAR) group, an international team of leading psoriatic arthritis researchers. The group has initiated a prospective study to evaluate existing diagnostic criteria as well as to derive new, more accurate criteria, said Philip S. Helliwell, Ph.D., of the rheumatology and rehabilitation research unit at the University of Leeds (England). The group's efforts are modeled on those of the OMERACT (Outcome Measures in Rheumatology) core set for rheumatoid arthritis.

Although clinical and radiologic evidence supports psoriatic arthritis as a separate disease, there's no consensus on diagnostic criteria. Such standardization would enhance research efforts by making patient comparisons easier. Although there are several sets of classification criteria for diagnosing psoriatic arthritis, only one was derived statistically from patient data, Dr. Helliwell said.

A diagnosis according to CASPAR criteria requires established inflammatory articular disease and a score of at least 3 points from the following features: current psoriasis (2 points), history of psoriasis but no evidence of psoriasis (1 point), family history of psoriasis but no evidence of psoriasis (1 point), dactylitis (1 point), juxtaarticular new bone formation (1 point), negative rheumatoid factor (1 point), and nail dystrophy (1 point). These criteria were specific (0.99) and fairly specific (0.91) for the diagnosis of psoriatic arthritis.

The criteria were derived using data collected prospectively from 588 patients with psoriatic arthritis and from 536 controls with other inflammatory arthritis diagnoses at 30 clinics in 13 countries. Of the controls, 71% had rheumatoid arthritis, 14% had ankylosing spondylitis, 7% had undifferentiated arthritis, 3% had connective tissue disorders, and 5% had other diseases.

The researchers collected data on more than 100 clinical and historical features. They also performed x-rays of the spine, hands, and feet. Samples were analyzed for rheumatoid factor, human leukocyte antigen, and anti-cyclic citrullinated peptide antibody.

For the first iteration of the criteria, the researchers performed a classification and regression tree analysis of existing criteria. The presence of two findings—a history of psoriasis and current psoriasis—was 97% sensitive and 96% specific. “It's very hard to beat that,” Dr. Helliwell noted.

By multivariate logistical regression analysis, the top predictive features were negative rheumatoid arthritis factor, current dactylitis, a history of dactylitis, and a history of psoriasis. The results of those two analyses were combined to produce the CASPAR criteria.

Until now, the diagnosis of psoriatic arthritis has been widely based on the Moll-Wright criteria developed in 1973 (Semin. Arthritis Rheum. 1973;3:55–78). These criteria require an inflammatory arthritis (peripheral arthritis and/or sacroiliitis or spondylitis), the presence of psoriasis, and the absence of serologic tests for rheumatoid factor.

The Moll-Wright criteria are considered simple and sensitive; however, they are not very specific, suggesting that some seronegative rheumatoid arthritis patients with coincidental psoriasis are mistakenly classified with psoriatic arthritis, Dr. Helliwell said.

“Clearly we need criteria to help us to distinguish this group that may be confounding because of the seronegative rheumatoid factor and coincidental psoriasis,” he said. Another group that is hard to diagnose comprises those who meet all other criteria for psoriatic arthritis but who have not yet developed psoriasis.

STOCKHOLM — The search continues for sensitive and specific classification criteria for psoriatic arthritis.

At an international conference on psoriasis and psoriatic arthritis, the latest results were presented from the classification criteria for psoriatic arthritis (CASPAR) group, an international team of leading psoriatic arthritis researchers. The group has initiated a prospective study to evaluate existing diagnostic criteria as well as to derive new, more accurate criteria, said Philip S. Helliwell, Ph.D., of the rheumatology and rehabilitation research unit at the University of Leeds (England). The group's efforts are modeled on those of the OMERACT (Outcome Measures in Rheumatology) core set for rheumatoid arthritis.

Although clinical and radiologic evidence supports psoriatic arthritis as a separate disease, there's no consensus on diagnostic criteria. Such standardization would enhance research efforts by making patient comparisons easier. Although there are several sets of classification criteria for diagnosing psoriatic arthritis, only one was derived statistically from patient data, Dr. Helliwell said.

A diagnosis according to CASPAR criteria requires established inflammatory articular disease and a score of at least 3 points from the following features: current psoriasis (2 points), history of psoriasis but no evidence of psoriasis (1 point), family history of psoriasis but no evidence of psoriasis (1 point), dactylitis (1 point), juxtaarticular new bone formation (1 point), negative rheumatoid factor (1 point), and nail dystrophy (1 point). These criteria were specific (0.99) and fairly specific (0.91) for the diagnosis of psoriatic arthritis.

The criteria were derived using data collected prospectively from 588 patients with psoriatic arthritis and from 536 controls with other inflammatory arthritis diagnoses at 30 clinics in 13 countries. Of the controls, 71% had rheumatoid arthritis, 14% had ankylosing spondylitis, 7% had undifferentiated arthritis, 3% had connective tissue disorders, and 5% had other diseases.

The researchers collected data on more than 100 clinical and historical features. They also performed x-rays of the spine, hands, and feet. Samples were analyzed for rheumatoid factor, human leukocyte antigen, and anti-cyclic citrullinated peptide antibody.

For the first iteration of the criteria, the researchers performed a classification and regression tree analysis of existing criteria. The presence of two findings—a history of psoriasis and current psoriasis—was 97% sensitive and 96% specific. “It's very hard to beat that,” Dr. Helliwell noted.

By multivariate logistical regression analysis, the top predictive features were negative rheumatoid arthritis factor, current dactylitis, a history of dactylitis, and a history of psoriasis. The results of those two analyses were combined to produce the CASPAR criteria.

Until now, the diagnosis of psoriatic arthritis has been widely based on the Moll-Wright criteria developed in 1973 (Semin. Arthritis Rheum. 1973;3:55–78). These criteria require an inflammatory arthritis (peripheral arthritis and/or sacroiliitis or spondylitis), the presence of psoriasis, and the absence of serologic tests for rheumatoid factor.

The Moll-Wright criteria are considered simple and sensitive; however, they are not very specific, suggesting that some seronegative rheumatoid arthritis patients with coincidental psoriasis are mistakenly classified with psoriatic arthritis, Dr. Helliwell said.

“Clearly we need criteria to help us to distinguish this group that may be confounding because of the seronegative rheumatoid factor and coincidental psoriasis,” he said. Another group that is hard to diagnose comprises those who meet all other criteria for psoriatic arthritis but who have not yet developed psoriasis.

STOCKHOLM — The search continues for sensitive and specific classification criteria for psoriatic arthritis.

At an international conference on psoriasis and psoriatic arthritis, the latest results were presented from the classification criteria for psoriatic arthritis (CASPAR) group, an international team of leading psoriatic arthritis researchers. The group has initiated a prospective study to evaluate existing diagnostic criteria as well as to derive new, more accurate criteria, said Philip S. Helliwell, Ph.D., of the rheumatology and rehabilitation research unit at the University of Leeds (England). The group's efforts are modeled on those of the OMERACT (Outcome Measures in Rheumatology) core set for rheumatoid arthritis.

Although clinical and radiologic evidence supports psoriatic arthritis as a separate disease, there's no consensus on diagnostic criteria. Such standardization would enhance research efforts by making patient comparisons easier. Although there are several sets of classification criteria for diagnosing psoriatic arthritis, only one was derived statistically from patient data, Dr. Helliwell said.

A diagnosis according to CASPAR criteria requires established inflammatory articular disease and a score of at least 3 points from the following features: current psoriasis (2 points), history of psoriasis but no evidence of psoriasis (1 point), family history of psoriasis but no evidence of psoriasis (1 point), dactylitis (1 point), juxtaarticular new bone formation (1 point), negative rheumatoid factor (1 point), and nail dystrophy (1 point). These criteria were specific (0.99) and fairly specific (0.91) for the diagnosis of psoriatic arthritis.

The criteria were derived using data collected prospectively from 588 patients with psoriatic arthritis and from 536 controls with other inflammatory arthritis diagnoses at 30 clinics in 13 countries. Of the controls, 71% had rheumatoid arthritis, 14% had ankylosing spondylitis, 7% had undifferentiated arthritis, 3% had connective tissue disorders, and 5% had other diseases.

The researchers collected data on more than 100 clinical and historical features. They also performed x-rays of the spine, hands, and feet. Samples were analyzed for rheumatoid factor, human leukocyte antigen, and anti-cyclic citrullinated peptide antibody.

For the first iteration of the criteria, the researchers performed a classification and regression tree analysis of existing criteria. The presence of two findings—a history of psoriasis and current psoriasis—was 97% sensitive and 96% specific. “It's very hard to beat that,” Dr. Helliwell noted.

By multivariate logistical regression analysis, the top predictive features were negative rheumatoid arthritis factor, current dactylitis, a history of dactylitis, and a history of psoriasis. The results of those two analyses were combined to produce the CASPAR criteria.

Until now, the diagnosis of psoriatic arthritis has been widely based on the Moll-Wright criteria developed in 1973 (Semin. Arthritis Rheum. 1973;3:55–78). These criteria require an inflammatory arthritis (peripheral arthritis and/or sacroiliitis or spondylitis), the presence of psoriasis, and the absence of serologic tests for rheumatoid factor.

The Moll-Wright criteria are considered simple and sensitive; however, they are not very specific, suggesting that some seronegative rheumatoid arthritis patients with coincidental psoriasis are mistakenly classified with psoriatic arthritis, Dr. Helliwell said.

“Clearly we need criteria to help us to distinguish this group that may be confounding because of the seronegative rheumatoid factor and coincidental psoriasis,” he said. Another group that is hard to diagnose comprises those who meet all other criteria for psoriatic arthritis but who have not yet developed psoriasis.

GLASGOW, SCOTLAND — Involvement of the distal interphalangeal joint is a common feature of both psoriatic arthritis and osteoarthritis, but a new study using high-resolution magnetic resonance imaging has shown that the local microanatomical environment in psoriatic arthritis is quite distinct, according to Dr. Ai Lyn Tan.

The study included 10 patients with psoriatic arthritis (PsA), 10 with osteoarthritis (OA), and 10 normal controls. The distal interphalangeal joint structures, including ligaments, tendons, and entheses, were imaged using a 1.5-T MRI scanner with a 23-mm diameter microscopy coil and producing T-weighted spin-echo images, Dr. Tan wrote in a poster session at the annual meeting of the British Society for Rheumatology.

PsA was characterized by significant inflammation of ligaments and tendons, along with involvement of the corresponding entheseal insertions. Extracapsular enhancement and nail bed changes were striking, as was diffuse bone edema, particularly of the distal phalanx, she reported.

This condition was present in 80% of the PsA patients, often without cartilage damage.

“It appears that the ligament and extensor tendon entheses are the epicenter of the inflammatory response in PsA, with diffuse involvement of adjacent structures,” observed Dr. Tan of the Academic Unit of Musculoskeletal Disease, University of Leeds (England).

Findings among patients with OA also included more ligament and entheseal changes than among the normal controls, but there was significantly less contrast enhancement, compared with PsA. The OA joints were characterized by less soft-tissue swelling, and with degenerative changes such as loss of cartilage, usually at the volar aspect, she noted.

Osteophytes also were present in some OA joints, along with focal bone edema at the tendon entheses.

These observations suggest that, while in PsA inflammatory changes are prominent in ligaments, tendons, and adjacent bone, changes in the entheseal insertions appear to be primary, Dr. Tan suggested. Similar changes are present in OA, but they are much less marked.

“This study in patients with PsA adds further weight to the argument that enthesitis is the unifying concept in patients with true PsA,” Dr. Tan also wrote (Arthritis Rheum. 2006;54:1328–33).

GLASGOW, SCOTLAND — Involvement of the distal interphalangeal joint is a common feature of both psoriatic arthritis and osteoarthritis, but a new study using high-resolution magnetic resonance imaging has shown that the local microanatomical environment in psoriatic arthritis is quite distinct, according to Dr. Ai Lyn Tan.

The study included 10 patients with psoriatic arthritis (PsA), 10 with osteoarthritis (OA), and 10 normal controls. The distal interphalangeal joint structures, including ligaments, tendons, and entheses, were imaged using a 1.5-T MRI scanner with a 23-mm diameter microscopy coil and producing T-weighted spin-echo images, Dr. Tan wrote in a poster session at the annual meeting of the British Society for Rheumatology.

PsA was characterized by significant inflammation of ligaments and tendons, along with involvement of the corresponding entheseal insertions. Extracapsular enhancement and nail bed changes were striking, as was diffuse bone edema, particularly of the distal phalanx, she reported.

This condition was present in 80% of the PsA patients, often without cartilage damage.

“It appears that the ligament and extensor tendon entheses are the epicenter of the inflammatory response in PsA, with diffuse involvement of adjacent structures,” observed Dr. Tan of the Academic Unit of Musculoskeletal Disease, University of Leeds (England).

Findings among patients with OA also included more ligament and entheseal changes than among the normal controls, but there was significantly less contrast enhancement, compared with PsA. The OA joints were characterized by less soft-tissue swelling, and with degenerative changes such as loss of cartilage, usually at the volar aspect, she noted.

Osteophytes also were present in some OA joints, along with focal bone edema at the tendon entheses.

These observations suggest that, while in PsA inflammatory changes are prominent in ligaments, tendons, and adjacent bone, changes in the entheseal insertions appear to be primary, Dr. Tan suggested. Similar changes are present in OA, but they are much less marked.

“This study in patients with PsA adds further weight to the argument that enthesitis is the unifying concept in patients with true PsA,” Dr. Tan also wrote (Arthritis Rheum. 2006;54:1328–33).

GLASGOW, SCOTLAND — Involvement of the distal interphalangeal joint is a common feature of both psoriatic arthritis and osteoarthritis, but a new study using high-resolution magnetic resonance imaging has shown that the local microanatomical environment in psoriatic arthritis is quite distinct, according to Dr. Ai Lyn Tan.

The study included 10 patients with psoriatic arthritis (PsA), 10 with osteoarthritis (OA), and 10 normal controls. The distal interphalangeal joint structures, including ligaments, tendons, and entheses, were imaged using a 1.5-T MRI scanner with a 23-mm diameter microscopy coil and producing T-weighted spin-echo images, Dr. Tan wrote in a poster session at the annual meeting of the British Society for Rheumatology.

PsA was characterized by significant inflammation of ligaments and tendons, along with involvement of the corresponding entheseal insertions. Extracapsular enhancement and nail bed changes were striking, as was diffuse bone edema, particularly of the distal phalanx, she reported.

This condition was present in 80% of the PsA patients, often without cartilage damage.

“It appears that the ligament and extensor tendon entheses are the epicenter of the inflammatory response in PsA, with diffuse involvement of adjacent structures,” observed Dr. Tan of the Academic Unit of Musculoskeletal Disease, University of Leeds (England).

Findings among patients with OA also included more ligament and entheseal changes than among the normal controls, but there was significantly less contrast enhancement, compared with PsA. The OA joints were characterized by less soft-tissue swelling, and with degenerative changes such as loss of cartilage, usually at the volar aspect, she noted.

Osteophytes also were present in some OA joints, along with focal bone edema at the tendon entheses.

These observations suggest that, while in PsA inflammatory changes are prominent in ligaments, tendons, and adjacent bone, changes in the entheseal insertions appear to be primary, Dr. Tan suggested. Similar changes are present in OA, but they are much less marked.

“This study in patients with PsA adds further weight to the argument that enthesitis is the unifying concept in patients with true PsA,” Dr. Tan also wrote (Arthritis Rheum. 2006;54:1328–33).

All rheumatologists should aim to incorporate ultrasonography into their daily practice, according to the European League Against Rheumatism's Working Party on Imaging in Rheumatology.

Ultrasound provides a convenient, quick method of confirming diagnostic suspicions. “If you have a patient with hip pain that you think may have arthritis, if you put the ultrasound machine on the patient, you will see the arthritis immediately,” said Dr. Nanno Swen, a rheumatologist at the Medical Center Alkmaar (the Netherlands) and a member of the ultrasonography working party.

Experts in ultrasonography discussed the practical applications of sonography and reviewed its advantages and challenges at the annual European Congress of Rheumatology in Amsterdam.

One challenge lies in standardizing the interpretation of ultrasonographic images. Interoperator variability exists even among experts, said Dr. Wolfgang A. Schmidt, also a member of the working party.

In his studies of ultrasonography experts, Dr. Schmidt of the Medical Center for Rheumatology in Berlin-Buch, Germany, found that interpretations were most variable at the feet and most consistent at the knee.

Dr. Swen noted, “I can assure you that if you do the same experiment on radiologists, you will have the same problem. … [A]ll of these imaging modalities have interobserver variability.”

Cardiologists and gynecologists do their own sonography, and rheumatologists need to learn the technique. The ultrasonography working party offers 3-day training courses once or twice each year for interested rheumatologists, said Dr. Swen.

Ultrasonography is less expensive than magnetic resonance imaging or bone scans, and it can be quite sensitive, according to Dr. Walter Grassi, chairman of the sonography working party and director of the department of rheumatology at the Università Politecnica delle Marche, Ancona, Italy.

All rheumatologists should aim to incorporate ultrasonography into their daily practice, according to the European League Against Rheumatism's Working Party on Imaging in Rheumatology.

Ultrasound provides a convenient, quick method of confirming diagnostic suspicions. “If you have a patient with hip pain that you think may have arthritis, if you put the ultrasound machine on the patient, you will see the arthritis immediately,” said Dr. Nanno Swen, a rheumatologist at the Medical Center Alkmaar (the Netherlands) and a member of the ultrasonography working party.

Experts in ultrasonography discussed the practical applications of sonography and reviewed its advantages and challenges at the annual European Congress of Rheumatology in Amsterdam.

One challenge lies in standardizing the interpretation of ultrasonographic images. Interoperator variability exists even among experts, said Dr. Wolfgang A. Schmidt, also a member of the working party.

In his studies of ultrasonography experts, Dr. Schmidt of the Medical Center for Rheumatology in Berlin-Buch, Germany, found that interpretations were most variable at the feet and most consistent at the knee.

Dr. Swen noted, “I can assure you that if you do the same experiment on radiologists, you will have the same problem. … [A]ll of these imaging modalities have interobserver variability.”

Cardiologists and gynecologists do their own sonography, and rheumatologists need to learn the technique. The ultrasonography working party offers 3-day training courses once or twice each year for interested rheumatologists, said Dr. Swen.

Ultrasonography is less expensive than magnetic resonance imaging or bone scans, and it can be quite sensitive, according to Dr. Walter Grassi, chairman of the sonography working party and director of the department of rheumatology at the Università Politecnica delle Marche, Ancona, Italy.

All rheumatologists should aim to incorporate ultrasonography into their daily practice, according to the European League Against Rheumatism's Working Party on Imaging in Rheumatology.

Ultrasound provides a convenient, quick method of confirming diagnostic suspicions. “If you have a patient with hip pain that you think may have arthritis, if you put the ultrasound machine on the patient, you will see the arthritis immediately,” said Dr. Nanno Swen, a rheumatologist at the Medical Center Alkmaar (the Netherlands) and a member of the ultrasonography working party.

Experts in ultrasonography discussed the practical applications of sonography and reviewed its advantages and challenges at the annual European Congress of Rheumatology in Amsterdam.

One challenge lies in standardizing the interpretation of ultrasonographic images. Interoperator variability exists even among experts, said Dr. Wolfgang A. Schmidt, also a member of the working party.

In his studies of ultrasonography experts, Dr. Schmidt of the Medical Center for Rheumatology in Berlin-Buch, Germany, found that interpretations were most variable at the feet and most consistent at the knee.

Dr. Swen noted, “I can assure you that if you do the same experiment on radiologists, you will have the same problem. … [A]ll of these imaging modalities have interobserver variability.”

Cardiologists and gynecologists do their own sonography, and rheumatologists need to learn the technique. The ultrasonography working party offers 3-day training courses once or twice each year for interested rheumatologists, said Dr. Swen.

Ultrasonography is less expensive than magnetic resonance imaging or bone scans, and it can be quite sensitive, according to Dr. Walter Grassi, chairman of the sonography working party and director of the department of rheumatology at the Università Politecnica delle Marche, Ancona, Italy.

GLASGOW, SCOTLAND — Data from a large cohort of patients with rheumatoid arthritis receiving anti-tumor necrosis factor-α therapy has determined that those with a history of malignancy are at heightened risk for additional cancers, and therefore such treatment should be used “with extreme caution” in these patients, according to Kath D. Watson, Ph.D.

Because anti-tumor necrosis factor (anti-TNF) plays an important role in the immune system's tumor surveillance, its blockade could potentially increase the risk of cancer, Dr. Watson said at the annual meeting of the British Society for Rheumatology. Although there have been reports of malignancies such as lymphoma associated with biologic response modifiers, the data thus far have been insufficient to precisely quantify the degree of risk—or to sort out risks deriving from treatment from those inherent in the disease process.

Analysis of data from the British Society for Rheumatology biologics registry is now beginning to clarify these concerns, as cancer incidence among 9,999 first-exposure anti-TNF-treated patients was compared with that of 1,877 biologic-naive rheumatoid arthritis patients taking traditional disease-modifying antirheumatic drugs (DMARDs), according to Dr. Watson of the Arthritis Research Campaign's epidemiology unit, University of Manchester, England.

Participants were followed from the date of their registration through September 2005, and reports on cancer cases were obtained from the Office for National Statistics or from 6-monthly physician questionnaires. Incidence rate ratios were adjusted for age, gender, disease severity, and smoking history.

The incidence of new malignancies among the anti-TNF-treated patients overall was not elevated, compared with that of the DMARD-treated group, with a relative risk of 0.7, Dr. Watson said.

But patients treated with biologics who had previous malignancies had an increased risk of developing a further malignancy after commencing therapy, with an incidence rate ratio of 2.5. This increased risk was higher than that for DMARD-treated patients who had had previous cancers. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

GLASGOW, SCOTLAND — Data from a large cohort of patients with rheumatoid arthritis receiving anti-tumor necrosis factor-α therapy has determined that those with a history of malignancy are at heightened risk for additional cancers, and therefore such treatment should be used “with extreme caution” in these patients, according to Kath D. Watson, Ph.D.

Because anti-tumor necrosis factor (anti-TNF) plays an important role in the immune system's tumor surveillance, its blockade could potentially increase the risk of cancer, Dr. Watson said at the annual meeting of the British Society for Rheumatology. Although there have been reports of malignancies such as lymphoma associated with biologic response modifiers, the data thus far have been insufficient to precisely quantify the degree of risk—or to sort out risks deriving from treatment from those inherent in the disease process.

Analysis of data from the British Society for Rheumatology biologics registry is now beginning to clarify these concerns, as cancer incidence among 9,999 first-exposure anti-TNF-treated patients was compared with that of 1,877 biologic-naive rheumatoid arthritis patients taking traditional disease-modifying antirheumatic drugs (DMARDs), according to Dr. Watson of the Arthritis Research Campaign's epidemiology unit, University of Manchester, England.

Participants were followed from the date of their registration through September 2005, and reports on cancer cases were obtained from the Office for National Statistics or from 6-monthly physician questionnaires. Incidence rate ratios were adjusted for age, gender, disease severity, and smoking history.

The incidence of new malignancies among the anti-TNF-treated patients overall was not elevated, compared with that of the DMARD-treated group, with a relative risk of 0.7, Dr. Watson said.

But patients treated with biologics who had previous malignancies had an increased risk of developing a further malignancy after commencing therapy, with an incidence rate ratio of 2.5. This increased risk was higher than that for DMARD-treated patients who had had previous cancers. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

GLASGOW, SCOTLAND — Data from a large cohort of patients with rheumatoid arthritis receiving anti-tumor necrosis factor-α therapy has determined that those with a history of malignancy are at heightened risk for additional cancers, and therefore such treatment should be used “with extreme caution” in these patients, according to Kath D. Watson, Ph.D.

Because anti-tumor necrosis factor (anti-TNF) plays an important role in the immune system's tumor surveillance, its blockade could potentially increase the risk of cancer, Dr. Watson said at the annual meeting of the British Society for Rheumatology. Although there have been reports of malignancies such as lymphoma associated with biologic response modifiers, the data thus far have been insufficient to precisely quantify the degree of risk—or to sort out risks deriving from treatment from those inherent in the disease process.

Analysis of data from the British Society for Rheumatology biologics registry is now beginning to clarify these concerns, as cancer incidence among 9,999 first-exposure anti-TNF-treated patients was compared with that of 1,877 biologic-naive rheumatoid arthritis patients taking traditional disease-modifying antirheumatic drugs (DMARDs), according to Dr. Watson of the Arthritis Research Campaign's epidemiology unit, University of Manchester, England.

Participants were followed from the date of their registration through September 2005, and reports on cancer cases were obtained from the Office for National Statistics or from 6-monthly physician questionnaires. Incidence rate ratios were adjusted for age, gender, disease severity, and smoking history.

The incidence of new malignancies among the anti-TNF-treated patients overall was not elevated, compared with that of the DMARD-treated group, with a relative risk of 0.7, Dr. Watson said.

But patients treated with biologics who had previous malignancies had an increased risk of developing a further malignancy after commencing therapy, with an incidence rate ratio of 2.5. This increased risk was higher than that for DMARD-treated patients who had had previous cancers. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

GLASGOW, SCOTLAND — Onychocryptosis poses a particular risk to patients with rheumatoid arthritis being treated with biologics, so vigilance should be practiced in the foot care of these patients, reported Heidi J. Davys.

Onychocryptosis can be accompanied by local sepsis, which is a serious concern in patients on anti-tumor necrosis factor-α therapy, Ms. Davys noted in a poster session at the annual meeting of the British Society for Rheumatology.

The full extent and impact of foot problems in these patients is not clear, but a retrospective 14-month audit in the rheumatology foot clinic at Leeds (England) General Infirmary, identified nine cases of onychocryptosis developing in rheumatoid arthritis (RA) patients on biologic therapy.

Five of the affected patients were female, mean age was 43 years, and mean disease duration was 10.9 years. Etanercept was the drug being used in seven cases, and infliximab and abatacept each were being used by one patient.

None of the patients had experienced previous episodes of onychocryptosis. The mean time between commencement of biologic therapy and symptom onset was 20 weeks, wrote Ms. Davys, who is a specialist in rheumatologic podiatry, Leeds Teaching Hospitals NHS Trust.

Therapy with the biologic was suspended in all patients prior to nail treatment for an average duration of 2 weeks, until healing was complete. Eight of the patients underwent partial or total nail avulsion, three with matrix phenolization to prevent regrowth. All patients also were treated with systemic antibiotics. The outcome was successful in all nine patients, allowing reinstitution of biologic therapy.

Prompt referral to a podiatry service is necessary if onychocryptosis develops in a patient. Podiatrists performing surgical procedures such as avulsion should be aware of current perioperative guidelines, and should work closely with the rheumatology team, wrote Ms. Davys.

Toenail surgery by a podiatrist is often required to repair onychocryptosis. Eight of the nine rheumatoid arthritis patients in the study had to undergo partial or total nail avulsion. All outcomes were successful, allowing reinstitution of biologic therapy. Photos courtesy Heidi J. Davys

Some Biologic Response Modifiers, Surgery Don't Mix

Perioperative management of patients taking immunosuppressive drugs has been a challenging issue.

Concerns are particularly significant with the biologic response modifiers, because of the risk of serious infection associated with their use.

Published treatment guidelines are based on the perioperative use of infliximab among patients with Crohn's disease and on animal model and tissue culture investigations. Until more evidence-based clinical data are available, the following are considered reasonable:

▸ Infliximab. This drug can be continued without interruption or discontinued 1 week before surgery and resumed 1–2 weeks after.

▸ Etanercept and anakinra. Experiments in animal models suggest that these drugs should be withdrawn the week of the procedure and resumed 1–2 weeks later.

▸ Adalimumab and rituximab. No data are available. These agents should be discontinued at least 1 week before surgery and resumed 1–2 weeks later.

Source: Curr. Opin. Rheumatol. 2004;16:192–8.

GLASGOW, SCOTLAND — Onychocryptosis poses a particular risk to patients with rheumatoid arthritis being treated with biologics, so vigilance should be practiced in the foot care of these patients, reported Heidi J. Davys.

Onychocryptosis can be accompanied by local sepsis, which is a serious concern in patients on anti-tumor necrosis factor-α therapy, Ms. Davys noted in a poster session at the annual meeting of the British Society for Rheumatology.

The full extent and impact of foot problems in these patients is not clear, but a retrospective 14-month audit in the rheumatology foot clinic at Leeds (England) General Infirmary, identified nine cases of onychocryptosis developing in rheumatoid arthritis (RA) patients on biologic therapy.

Five of the affected patients were female, mean age was 43 years, and mean disease duration was 10.9 years. Etanercept was the drug being used in seven cases, and infliximab and abatacept each were being used by one patient.

None of the patients had experienced previous episodes of onychocryptosis. The mean time between commencement of biologic therapy and symptom onset was 20 weeks, wrote Ms. Davys, who is a specialist in rheumatologic podiatry, Leeds Teaching Hospitals NHS Trust.

Therapy with the biologic was suspended in all patients prior to nail treatment for an average duration of 2 weeks, until healing was complete. Eight of the patients underwent partial or total nail avulsion, three with matrix phenolization to prevent regrowth. All patients also were treated with systemic antibiotics. The outcome was successful in all nine patients, allowing reinstitution of biologic therapy.

Prompt referral to a podiatry service is necessary if onychocryptosis develops in a patient. Podiatrists performing surgical procedures such as avulsion should be aware of current perioperative guidelines, and should work closely with the rheumatology team, wrote Ms. Davys.

Toenail surgery by a podiatrist is often required to repair onychocryptosis. Eight of the nine rheumatoid arthritis patients in the study had to undergo partial or total nail avulsion. All outcomes were successful, allowing reinstitution of biologic therapy. Photos courtesy Heidi J. Davys

Some Biologic Response Modifiers, Surgery Don't Mix

Perioperative management of patients taking immunosuppressive drugs has been a challenging issue.

Concerns are particularly significant with the biologic response modifiers, because of the risk of serious infection associated with their use.

Published treatment guidelines are based on the perioperative use of infliximab among patients with Crohn's disease and on animal model and tissue culture investigations. Until more evidence-based clinical data are available, the following are considered reasonable:

▸ Infliximab. This drug can be continued without interruption or discontinued 1 week before surgery and resumed 1–2 weeks after.

▸ Etanercept and anakinra. Experiments in animal models suggest that these drugs should be withdrawn the week of the procedure and resumed 1–2 weeks later.

▸ Adalimumab and rituximab. No data are available. These agents should be discontinued at least 1 week before surgery and resumed 1–2 weeks later.

Source: Curr. Opin. Rheumatol. 2004;16:192–8.

GLASGOW, SCOTLAND — Onychocryptosis poses a particular risk to patients with rheumatoid arthritis being treated with biologics, so vigilance should be practiced in the foot care of these patients, reported Heidi J. Davys.

Onychocryptosis can be accompanied by local sepsis, which is a serious concern in patients on anti-tumor necrosis factor-α therapy, Ms. Davys noted in a poster session at the annual meeting of the British Society for Rheumatology.

The full extent and impact of foot problems in these patients is not clear, but a retrospective 14-month audit in the rheumatology foot clinic at Leeds (England) General Infirmary, identified nine cases of onychocryptosis developing in rheumatoid arthritis (RA) patients on biologic therapy.

Five of the affected patients were female, mean age was 43 years, and mean disease duration was 10.9 years. Etanercept was the drug being used in seven cases, and infliximab and abatacept each were being used by one patient.

None of the patients had experienced previous episodes of onychocryptosis. The mean time between commencement of biologic therapy and symptom onset was 20 weeks, wrote Ms. Davys, who is a specialist in rheumatologic podiatry, Leeds Teaching Hospitals NHS Trust.

Therapy with the biologic was suspended in all patients prior to nail treatment for an average duration of 2 weeks, until healing was complete. Eight of the patients underwent partial or total nail avulsion, three with matrix phenolization to prevent regrowth. All patients also were treated with systemic antibiotics. The outcome was successful in all nine patients, allowing reinstitution of biologic therapy.

Prompt referral to a podiatry service is necessary if onychocryptosis develops in a patient. Podiatrists performing surgical procedures such as avulsion should be aware of current perioperative guidelines, and should work closely with the rheumatology team, wrote Ms. Davys.

Toenail surgery by a podiatrist is often required to repair onychocryptosis. Eight of the nine rheumatoid arthritis patients in the study had to undergo partial or total nail avulsion. All outcomes were successful, allowing reinstitution of biologic therapy. Photos courtesy Heidi J. Davys

Some Biologic Response Modifiers, Surgery Don't Mix

Perioperative management of patients taking immunosuppressive drugs has been a challenging issue.

Concerns are particularly significant with the biologic response modifiers, because of the risk of serious infection associated with their use.

Published treatment guidelines are based on the perioperative use of infliximab among patients with Crohn's disease and on animal model and tissue culture investigations. Until more evidence-based clinical data are available, the following are considered reasonable:

▸ Infliximab. This drug can be continued without interruption or discontinued 1 week before surgery and resumed 1–2 weeks after.

▸ Etanercept and anakinra. Experiments in animal models suggest that these drugs should be withdrawn the week of the procedure and resumed 1–2 weeks later.

▸ Adalimumab and rituximab. No data are available. These agents should be discontinued at least 1 week before surgery and resumed 1–2 weeks later.

Source: Curr. Opin. Rheumatol. 2004;16:192–8.

Hand bone loss as noted on a dual-energy absorptiometry scan may make earlier diagnosis of rheumatoid arthritis possible in patients with joint pain, reported Dr. Paul Emery and his colleagues at the University of Leeds, (England).

Dual-energy absorptiometry (DXA) scans in 74 patients with undifferentiated arthritis lasting less than 12 months showed significant changes in hand bone mineral density (BMD) in patients who were eventually diagnosed with rheumatoid arthritis (RA), Dr. Emery and his colleagues reported.

“This longitudinal study supports the view that hand BMD loss, even at the earliest stages of the disease process, is related to measures of disease activity and severity in rheumatoid arthritis,” the investigators wrote (Ann. Rheum. Dis. 2006;65:736–40).

The study participants were mostly women (88%), with an average age of 44 years. They underwent serial BMD measurements of the hands, femoral neck, and spine (L2–L4) using serial DXA scans at baseline, and at 3, 6, and 12 months, the investigators reported.

None of the patients had received disease-modifying drugs or prednisone prior to the start of the study.

Patients had ongoing diagnostic tests for RA during the study period. Thirteen patients were eventually diagnosed as having RA, 19 patients were determined to have inflammatory nonrheumatoid joint disorders, and the remaining 42 patients were diagnosed with noninflammatory joint disorders, Dr. Emery and his fellow investigators reported.

The results revealed that at 12-month follow-up, none of the patient groups sustained significant bone loss at the femoral neck and spine.

However, patients who were eventually diagnosed with RA had significant hand BMD loss at 12 months, compared with the other patient groups.

In patients diagnosed with RA, hand BMD loss was 4.27%; the inflammatory non-RA group had a 0.49% loss; and the noninflammatory joint disorder group had a BMD loss of 0.87%, the investigators reported.

Hand bone loss as noted on a dual-energy absorptiometry scan may make earlier diagnosis of rheumatoid arthritis possible in patients with joint pain, reported Dr. Paul Emery and his colleagues at the University of Leeds, (England).

Dual-energy absorptiometry (DXA) scans in 74 patients with undifferentiated arthritis lasting less than 12 months showed significant changes in hand bone mineral density (BMD) in patients who were eventually diagnosed with rheumatoid arthritis (RA), Dr. Emery and his colleagues reported.

“This longitudinal study supports the view that hand BMD loss, even at the earliest stages of the disease process, is related to measures of disease activity and severity in rheumatoid arthritis,” the investigators wrote (Ann. Rheum. Dis. 2006;65:736–40).

The study participants were mostly women (88%), with an average age of 44 years. They underwent serial BMD measurements of the hands, femoral neck, and spine (L2–L4) using serial DXA scans at baseline, and at 3, 6, and 12 months, the investigators reported.

None of the patients had received disease-modifying drugs or prednisone prior to the start of the study.

Patients had ongoing diagnostic tests for RA during the study period. Thirteen patients were eventually diagnosed as having RA, 19 patients were determined to have inflammatory nonrheumatoid joint disorders, and the remaining 42 patients were diagnosed with noninflammatory joint disorders, Dr. Emery and his fellow investigators reported.

The results revealed that at 12-month follow-up, none of the patient groups sustained significant bone loss at the femoral neck and spine.

However, patients who were eventually diagnosed with RA had significant hand BMD loss at 12 months, compared with the other patient groups.

In patients diagnosed with RA, hand BMD loss was 4.27%; the inflammatory non-RA group had a 0.49% loss; and the noninflammatory joint disorder group had a BMD loss of 0.87%, the investigators reported.

Hand bone loss as noted on a dual-energy absorptiometry scan may make earlier diagnosis of rheumatoid arthritis possible in patients with joint pain, reported Dr. Paul Emery and his colleagues at the University of Leeds, (England).

Dual-energy absorptiometry (DXA) scans in 74 patients with undifferentiated arthritis lasting less than 12 months showed significant changes in hand bone mineral density (BMD) in patients who were eventually diagnosed with rheumatoid arthritis (RA), Dr. Emery and his colleagues reported.

“This longitudinal study supports the view that hand BMD loss, even at the earliest stages of the disease process, is related to measures of disease activity and severity in rheumatoid arthritis,” the investigators wrote (Ann. Rheum. Dis. 2006;65:736–40).

The study participants were mostly women (88%), with an average age of 44 years. They underwent serial BMD measurements of the hands, femoral neck, and spine (L2–L4) using serial DXA scans at baseline, and at 3, 6, and 12 months, the investigators reported.

None of the patients had received disease-modifying drugs or prednisone prior to the start of the study.

Patients had ongoing diagnostic tests for RA during the study period. Thirteen patients were eventually diagnosed as having RA, 19 patients were determined to have inflammatory nonrheumatoid joint disorders, and the remaining 42 patients were diagnosed with noninflammatory joint disorders, Dr. Emery and his fellow investigators reported.

The results revealed that at 12-month follow-up, none of the patient groups sustained significant bone loss at the femoral neck and spine.

However, patients who were eventually diagnosed with RA had significant hand BMD loss at 12 months, compared with the other patient groups.

In patients diagnosed with RA, hand BMD loss was 4.27%; the inflammatory non-RA group had a 0.49% loss; and the noninflammatory joint disorder group had a BMD loss of 0.87%, the investigators reported.

GLASGOW, SCOTLAND — Treatment with a biologic agent may be life- and sight-saving in cases of refractory necrotizing scleritis, as was the case for a 60-year-old man with a 10-year history of rheumatoid arthritis and a 2-week history of red, painful eyes and blurred vision.

The usual treatment involves systemic corticosteroids and immunosuppressants. Cyclophosphamide is the immunosuppressive drug of choice, Dr. Ismael Atchia explained in a poster session at the annual meeting of the British Society for Rheumatology.

The patient in question had joint stiffness and swelling, vasculitic lesions on the fingers, and the articular deformities typical of chronic RA, according to Dr. Atchia of the rheumatology department, Sunderland (England) Royal Hospital. He appeared cachectic and had several decubitus ulcers. He had been treated with nonsteroidal anti-inflammatory drugs, but had never received any disease-modifying antirheumatic drugs.

Ocular examination revealed intense bilateral inflammation manifesting as fulminating, necrotizing scleritis with severe bilateral peripheral ulcerative keratitis that threatened corneal perforation. Laboratory investigations revealed elevated inflammatory markers, with an erythrocyte sedimentation rate of 139 mm/hr, a C-reactive protein measurement of 149 mg/L, and a positive rheumatoid factor titer of 1:640.

Treatment of the ocular symptoms consisted of intensive topical lubrication with carmellose as well as prophylactic chloramphenicol and autologous serum eyedrops. He also received temporary punctual plugs and underwent bilateral temporary lateral tarsorrhaphies.

Systemic therapy included pulses of intravenous methylprednisolone plus oral prednisone (60 mg/day) along with cyclophosphamide (15 mg/kg) with mesna coverage on three occasions during the ensuing 6 weeks, Dr. Atchia noted. The vasculitic skin lesions cleared with the immunosuppressive treatment, but ocular deterioration continued until the right eye perforated at the temporal limbus.

The patient then received intravenous infliximab (3 mg/kg), plus oral methotrexate (10 mg weekly) and continued treatment with oral prednisone. Additional doses of infliximab were given at weeks 2 and 6.

Within 2 weeks of the first infliximab dose, the patient's eyes improved dramatically, according to Dr. Atchia.

“This case suggests that biologic agents may be considered in refractory cases of sight- and life-threatening scleritis. However, these agents are expensive and have potentially serious side effects, so their long-term efficacy and safety for use in inflammatory eye disease remain to be determined,” he concluded.

GLASGOW, SCOTLAND — Treatment with a biologic agent may be life- and sight-saving in cases of refractory necrotizing scleritis, as was the case for a 60-year-old man with a 10-year history of rheumatoid arthritis and a 2-week history of red, painful eyes and blurred vision.

The usual treatment involves systemic corticosteroids and immunosuppressants. Cyclophosphamide is the immunosuppressive drug of choice, Dr. Ismael Atchia explained in a poster session at the annual meeting of the British Society for Rheumatology.

The patient in question had joint stiffness and swelling, vasculitic lesions on the fingers, and the articular deformities typical of chronic RA, according to Dr. Atchia of the rheumatology department, Sunderland (England) Royal Hospital. He appeared cachectic and had several decubitus ulcers. He had been treated with nonsteroidal anti-inflammatory drugs, but had never received any disease-modifying antirheumatic drugs.

Ocular examination revealed intense bilateral inflammation manifesting as fulminating, necrotizing scleritis with severe bilateral peripheral ulcerative keratitis that threatened corneal perforation. Laboratory investigations revealed elevated inflammatory markers, with an erythrocyte sedimentation rate of 139 mm/hr, a C-reactive protein measurement of 149 mg/L, and a positive rheumatoid factor titer of 1:640.

Treatment of the ocular symptoms consisted of intensive topical lubrication with carmellose as well as prophylactic chloramphenicol and autologous serum eyedrops. He also received temporary punctual plugs and underwent bilateral temporary lateral tarsorrhaphies.

Systemic therapy included pulses of intravenous methylprednisolone plus oral prednisone (60 mg/day) along with cyclophosphamide (15 mg/kg) with mesna coverage on three occasions during the ensuing 6 weeks, Dr. Atchia noted. The vasculitic skin lesions cleared with the immunosuppressive treatment, but ocular deterioration continued until the right eye perforated at the temporal limbus.

The patient then received intravenous infliximab (3 mg/kg), plus oral methotrexate (10 mg weekly) and continued treatment with oral prednisone. Additional doses of infliximab were given at weeks 2 and 6.

Within 2 weeks of the first infliximab dose, the patient's eyes improved dramatically, according to Dr. Atchia.

“This case suggests that biologic agents may be considered in refractory cases of sight- and life-threatening scleritis. However, these agents are expensive and have potentially serious side effects, so their long-term efficacy and safety for use in inflammatory eye disease remain to be determined,” he concluded.

GLASGOW, SCOTLAND — Treatment with a biologic agent may be life- and sight-saving in cases of refractory necrotizing scleritis, as was the case for a 60-year-old man with a 10-year history of rheumatoid arthritis and a 2-week history of red, painful eyes and blurred vision.

The usual treatment involves systemic corticosteroids and immunosuppressants. Cyclophosphamide is the immunosuppressive drug of choice, Dr. Ismael Atchia explained in a poster session at the annual meeting of the British Society for Rheumatology.

The patient in question had joint stiffness and swelling, vasculitic lesions on the fingers, and the articular deformities typical of chronic RA, according to Dr. Atchia of the rheumatology department, Sunderland (England) Royal Hospital. He appeared cachectic and had several decubitus ulcers. He had been treated with nonsteroidal anti-inflammatory drugs, but had never received any disease-modifying antirheumatic drugs.

Ocular examination revealed intense bilateral inflammation manifesting as fulminating, necrotizing scleritis with severe bilateral peripheral ulcerative keratitis that threatened corneal perforation. Laboratory investigations revealed elevated inflammatory markers, with an erythrocyte sedimentation rate of 139 mm/hr, a C-reactive protein measurement of 149 mg/L, and a positive rheumatoid factor titer of 1:640.

Treatment of the ocular symptoms consisted of intensive topical lubrication with carmellose as well as prophylactic chloramphenicol and autologous serum eyedrops. He also received temporary punctual plugs and underwent bilateral temporary lateral tarsorrhaphies.

Systemic therapy included pulses of intravenous methylprednisolone plus oral prednisone (60 mg/day) along with cyclophosphamide (15 mg/kg) with mesna coverage on three occasions during the ensuing 6 weeks, Dr. Atchia noted. The vasculitic skin lesions cleared with the immunosuppressive treatment, but ocular deterioration continued until the right eye perforated at the temporal limbus.

The patient then received intravenous infliximab (3 mg/kg), plus oral methotrexate (10 mg weekly) and continued treatment with oral prednisone. Additional doses of infliximab were given at weeks 2 and 6.

Within 2 weeks of the first infliximab dose, the patient's eyes improved dramatically, according to Dr. Atchia.

“This case suggests that biologic agents may be considered in refractory cases of sight- and life-threatening scleritis. However, these agents are expensive and have potentially serious side effects, so their long-term efficacy and safety for use in inflammatory eye disease remain to be determined,” he concluded.

Researchers in joint and tissue repair have mastered the art and science of harvesting skeletal tissue in vitro.

The next challenges to be faced are developing the best repair strategies and making the technologies cost effective, according to Dr. Francesco Dell'Accio and colleagues, who spoke at a translational science session on joint and tissue repair at the annual European Congress of Rheumatology in Amsterdam.

“Cell-based tissue repair is progressively exiting the experimental, 'proof of principle' phase,” said Dr. Dell'Accio of King's College London in an interview.

“Obtaining skeletal tissues in vitro from a variety of mature or stem cell populations is not a big challenge anymore. However, for cell-based repair strategies to reach the routine clinical applicability, we should develop cell preparations that consistently and reproducibly differentiate into the desired tissues in the diseased microenvironment.” Another important issue is to make such technologies cost effective. Allogeneic stem cell technologies or in situ recruitment of resident cells are important opportunities.

“Finally, biodegradable matrices and scaffolds that allow at the same time delivery (ideally arthroscopically) and containment of the cell preparation and control on tissue formation, patterning and maturation may prove of crucial importance,” Dr. Dell'Accio said.

New technologies may soon allow rheumatologists to perform procedures that traditionally have been the exclusive realm of orthopedists, he noted. “For many years, skeletal tissue repair has been predominantly of orthopedic interest because the inflammatory environment of rheumatic joints has been an obstacle for effective tissue regeneration and for the difficulty of the surgery required. Recently, however, the development of potent tools to control inflammation and the potential of these technologies to be delivered arthroscopically may allow the clinical rheumatologist not only to control inflammation but also to achieve tissue repair and reduce the disability of many rheumatic patients.”

It was noted that major new trial data are coming soon, as well as important changes in the regulatory path in Europe to allow development of these treatments into products—notably, a central route through the European Medicines Agency's Committee for Advanced Therapies.

Cell-based tissue repair could relieve the pain of superficial osteochondral defects. Courtesy Dr. Frank P. Luyten

Researchers in joint and tissue repair have mastered the art and science of harvesting skeletal tissue in vitro.

The next challenges to be faced are developing the best repair strategies and making the technologies cost effective, according to Dr. Francesco Dell'Accio and colleagues, who spoke at a translational science session on joint and tissue repair at the annual European Congress of Rheumatology in Amsterdam.

“Cell-based tissue repair is progressively exiting the experimental, 'proof of principle' phase,” said Dr. Dell'Accio of King's College London in an interview.

“Obtaining skeletal tissues in vitro from a variety of mature or stem cell populations is not a big challenge anymore. However, for cell-based repair strategies to reach the routine clinical applicability, we should develop cell preparations that consistently and reproducibly differentiate into the desired tissues in the diseased microenvironment.” Another important issue is to make such technologies cost effective. Allogeneic stem cell technologies or in situ recruitment of resident cells are important opportunities.

“Finally, biodegradable matrices and scaffolds that allow at the same time delivery (ideally arthroscopically) and containment of the cell preparation and control on tissue formation, patterning and maturation may prove of crucial importance,” Dr. Dell'Accio said.

New technologies may soon allow rheumatologists to perform procedures that traditionally have been the exclusive realm of orthopedists, he noted. “For many years, skeletal tissue repair has been predominantly of orthopedic interest because the inflammatory environment of rheumatic joints has been an obstacle for effective tissue regeneration and for the difficulty of the surgery required. Recently, however, the development of potent tools to control inflammation and the potential of these technologies to be delivered arthroscopically may allow the clinical rheumatologist not only to control inflammation but also to achieve tissue repair and reduce the disability of many rheumatic patients.”

It was noted that major new trial data are coming soon, as well as important changes in the regulatory path in Europe to allow development of these treatments into products—notably, a central route through the European Medicines Agency's Committee for Advanced Therapies.

Cell-based tissue repair could relieve the pain of superficial osteochondral defects. Courtesy Dr. Frank P. Luyten

Researchers in joint and tissue repair have mastered the art and science of harvesting skeletal tissue in vitro.

The next challenges to be faced are developing the best repair strategies and making the technologies cost effective, according to Dr. Francesco Dell'Accio and colleagues, who spoke at a translational science session on joint and tissue repair at the annual European Congress of Rheumatology in Amsterdam.

“Cell-based tissue repair is progressively exiting the experimental, 'proof of principle' phase,” said Dr. Dell'Accio of King's College London in an interview.

“Obtaining skeletal tissues in vitro from a variety of mature or stem cell populations is not a big challenge anymore. However, for cell-based repair strategies to reach the routine clinical applicability, we should develop cell preparations that consistently and reproducibly differentiate into the desired tissues in the diseased microenvironment.” Another important issue is to make such technologies cost effective. Allogeneic stem cell technologies or in situ recruitment of resident cells are important opportunities.

“Finally, biodegradable matrices and scaffolds that allow at the same time delivery (ideally arthroscopically) and containment of the cell preparation and control on tissue formation, patterning and maturation may prove of crucial importance,” Dr. Dell'Accio said.

New technologies may soon allow rheumatologists to perform procedures that traditionally have been the exclusive realm of orthopedists, he noted. “For many years, skeletal tissue repair has been predominantly of orthopedic interest because the inflammatory environment of rheumatic joints has been an obstacle for effective tissue regeneration and for the difficulty of the surgery required. Recently, however, the development of potent tools to control inflammation and the potential of these technologies to be delivered arthroscopically may allow the clinical rheumatologist not only to control inflammation but also to achieve tissue repair and reduce the disability of many rheumatic patients.”

It was noted that major new trial data are coming soon, as well as important changes in the regulatory path in Europe to allow development of these treatments into products—notably, a central route through the European Medicines Agency's Committee for Advanced Therapies.

Cell-based tissue repair could relieve the pain of superficial osteochondral defects. Courtesy Dr. Frank P. Luyten