Recent clinical experience with etodolac in the treatment of osteoarthritis of the knee.

Interim results are reported for three double-blind clinical trials comparing etodolac, a new nonsteroidal anti-inflammatory drug (NSAID), with piroxicam, diclofenac, or naproxen in patients with osteoarthritis (OA) of the knee. Patients assigned to receive etodolac were given 200 mg three times a day in the diclofenac comparison and 300 mg twice a day in the other two studies. The comparator groups in the three studies received piroxicam 20 mg once a day, diclofenac 50 mg three times a day, or naproxen 500 mg twice a day. The length of the studies ranged from 6 to 12 weeks, and patients were seen at baseline and every 2 weeks thereafter. Etodolac, piroxicam, and diclofenac treatment consistently resulted in similar and statistically significant changes from baseline, indicative of improvement, in all primary efficacy variables (physicians' and patients' global assessments of improvement, pain intensity, and night pain) at every evaluation. In the comparison with naproxen, patients who received etodolac showed statistically significant improvement at most evaluations, whereas significant changes were less frequent in the naproxen group. Response rates in the three studies (response was defined as a decrease of 1 or more units in the patient's overall global evaluation, which is based on a 5-point scale ranging from 1 = very good to 5 = very poor) were as follows: etodolac 72%, piroxicam 75%; etodolac 66%, diclofenac 56%; and etodolac 40%, naproxen 16%. These interim results suggest that the efficacy of etodolac compares favorably with that of other NSAIDs in the treatment of OA of the knee.

Pyogenic osteomyelitis presenting as an acute sterile arthropathy.

We report two cases of osteomyelitis secondary to staphylococcal septicaemia, presenting with large sterile effusions in adjacent joints. In both cases the clinical features were suggestive of septic arthritis. Multiple joints were involved in each patient. Initial radiographs showed no abnormalities.

Stress fractures in rheumatoid arthritis: a case series and case-control study.

OBJECTIVE: To review cases of stress fracture in patients with rheumatoid arthritis (RA) presenting to our service over a 10 year period; to identify possible risk factors and test these in a case-control study. METHODS: A retrospective case note review of all patients with a final diagnosis of stress fracture, presenting between 1990 and 1999 was performed. A case-control study of consecutive patients with RA, matched for age, sex and duration of disease, attending the same clinics. CASE SERIES: 24 stress fractures were identified in 18 patients, representing 0.8% of the RA clinic population; all were women, median age 69.5 years (range 47-79). Bone mineral densitometry showed median T scores of -3.06 and -2.27 SD at the hip and lumbar spine, respectively. Case-control study: In the stress fractures group, past steroid doses were higher (p = 0.003). No significant differences in the bone mineral density (BMD) T score at the hip or lumbar spine were found (p = 0.59, p = 0.77). CONCLUSIONS: Stress fractures are a significant cause of morbidity in RA. Diagnosis is often delayed and presentation can be misleading. Past steroid use, particularly at higher doses, confers an increased risk of stress fracture, but the increased risk is not attributable to osteoporosis as assessed by BMD.

Costs of providing a rheumatological service.

As a result of a management budgeting exercise, the costs of rheumatology services in two hospitals in the Northern Region have been calculated. These comprehensive and itemized charges were derived by an external group of accountants. The data for a 1-year period from April 1985 are presented. Differences in both mean out-patient-visit and in-patient bed-day charges between hospitals were found. Factors contributing to these differences are discussed. The major costs, particularly of in-patient care, are not directly controllable by the clinician. Mean costs per out-patient visit were 26.00 pounds and 36.90 pounds at the two hospitals. Costs for in-patient care per bed-day were 49.00 pounds and 70.71 pounds, respectively. The calculated total cost of the rheumatology service in Newcastle was approximately 1.00 pound per capita catchment population per annum.

Cervical myelopathy and rheumatoid arthritis: a retrospective analysis of management.

BACKGROUND: Although a number of recent studies have described the outcome of surgical treatment of patients with rheumatoid cervical myelopathy, few have reported outcome in those unable to have surgery. We sought to examine the outcome in this group of patients regardless of surgical intervention. DESIGN: Retrospective and descriptive. SETTING: Department of Rheumatology, Freeman Hospital, Newcastle upon Tyne, UK. METHODS: Retrospective review of case notes of 40 patients (31 females, 9 males) with rheumatoid cervical myelopathy diagnosed 1988-1997. RESULTS: The mean age was 64 years (range 36-80 years). The mean duration of rheumatoid arthritis (RA) before the development of myelopathy was 21 years (range 5-44 years). The common impairments were paraesthesia in the arms, neck pain and weakness. Twenty-five patients (60%) were deemed fit for surgery (group I). Twenty-two patients successfully had operative treatment and the others refused. Twelve of the 15 patients who reported pain preoperatively obtained pain relief. Six of the 11 patients who were nonambulant (Ranawat class IIIB) were able to walk postoperatively. There were two deaths within six months (9% mortality) after primary surgery due to pneumonia and sepsis. Seven of the 15 patients managed conservatively (group II) because of coexisting medical complications died within six months of presentation (47% mortality). CONCLUSIONS: The study confirms the overall benefit of surgical intervention in those who are medically stable. Following surgery some functional improvement may occur even in patients with severe myelopathy.

The acute hot joint in medical practice.

We have studied patients with acute hot joints presenting to general practice, casualty and inpatient rheumatology services. Their investigation, management and outcome were measured against guidelines. Different spectra of disease were seen in the different health care settings. The guidelines were not adhered to for crystal arthritis, particularly when it affected the first metatarso-phalangeal joints. The guidelines were broadly adhered to and useful for other joints, especially where septic arthritis was considered to be the likely diagnosis. We found no benefit on outcome from adhering to the guidelines. There was a tendency for the outcome to be worse where the guidelines were followed in full, suggesting that more investigations are performed in the more difficult cases. We conclude that drawing up guidelines for patient management is difficult even in an area where there is broad medical agreement.