Long-term results of infliximab therapy in rheumatoid arthritis: experience acquired by the North-Pas-de-Calais hospital network.

OBJECTIVE: Infliximab is effective in patients with rheumatoid arthritis (RA). Add-on infliximab therapy in patients on methotrexate results in a rapid gain in effectiveness, which lasts at least 1 year. The objective of this study was to evaluate the effectiveness and continuation rate of infliximab in patients with RA after the first year of treatment. METHODS: The first 50 patients with RA who were given infliximab in the North-Pas-de-Calais region of France were included in a multicenter open-label study. The patients had severe RA or failed to respond to conventional medications. Infliximab was given in a dosage of 3 mg/kg every 8 weeks in combination with methotrexate. Effectiveness was evaluated using the DAS28-3 score and EULAR response criteria. The dates and reasons of infliximab discontinuations were recorded. RESULTS: The 2-year infliximab continuation rate was 70%. Serious adverse events requiring infliximab discontinuation occurred in 7 patients. Mean DAS28-3 scores in the 35 patients who took infliximab for at least 2 years were 6.42 at baseline, 4.33 after 30 weeks, 4.31 after 54 weeks, and 3.86 after 102 weeks. According to EULAR criteria after 102 weeks, there were 12 good responders, 18 moderate responders, and 5 nonresponders. CONCLUSION: Experience acquired in the North-Pas-de-Calais district of France suggests that infliximab is continued for more than 2 years in more than two-thirds of patients and remains effective over this period.

Bone metastases revealing primary tumors. Comparison of two series separated by 30 years.

OBJECTIVE: To compare two series of patients admitted to a rheumatology department for bone metastases 30 years apart and to obtain a pragmatic estimation of the percentage of bone metastases revealing cancer. METHODS: The recent series was composed of 132 patients seen between 1989 and 1996 and the earlier series of 50 patients admitted between 1958 and 1967. All patients were admitted to the same rheumatology department for bone metastases from a diagnosed or undiagnosed primary. Both series were studied retrospectively. The rate of occurrence of each cancer diagnosis was determined in the patients with and without known primaries. RESULTS: Among the patients with metastatic disease as the first manifestation of cancer, the percentage with lung cancer increased from the early to the recent series, particularly among women, whereas the percentages with prostate and breast cancer decreased. The primary remained unknown in 27% and 38% of patients in the early and recent series, respectively. CONCLUSION: Despite the introduction of new investigations, our ability to identify primaries responsible for bone metastases does not seem to have improved. However, our data should be interpreted with caution since recruitment probably differed between the two series.

Subchondral fractures of the femoral head: a review of seven cases.

OBJECTIVE: To describe the main characteristics of subchondral fractures of the femoral head. CASE-REPORTS: The seven patients, five women and two men, with a mean age of 50 years (37-76 years), presented with mechanical pain in the groin. Bone loss was the main risk factor. Two patients had postmenopausal osteoporosis (including one with a history of ovariectomy at 30 years of age), two had osteoporosis induced by glucocorticoid therapy given after transplantation (liver and allogeneic bone marrow, respectively), one had an ACTH-producing adenoma, and one had femoral osteopenia at a site of topical glucocorticoid therapy for atopic dermatitis. The remaining patient had osteopenia and a history of smoking. Phosphate and calcium levels were normal in five patients. One patient had isolated hypocalciuria and another had moderate proximal tubular disease with phosphate wasting and hypercalciuria. Magnetic resonance imaging (MRI) disclosed a subcapital line of low signal on T1- and T2-weighted sequences surrounded by an area of variable size generating low signal on T1 images and high signal on T2 images, with postgadolinium enhancement, denoting marrow edema. Complete elimination of weight bearing for 6 weeks, symptomatic agents, and treatment of the underlying causes of bone insufficiency were used in all seven patients. Mean follow-up was 2.4 years (range, 11-39 years). No cases of osteonecrosis were recorded. CONCLUSION: Several cases of subchondral fracture have been reported in the literature. Bone insufficiency was the main risk factor in all the patients.

Pain management in a rheumatology department: a satisfaction survey.

OBJECTIVES: To evaluate the quality of pain management in a teaching hospital rheumatology department. METHODS: We conducted a satisfaction survey among all the patients admitted to the conventional rheumatology department of our teaching hospital over a 1-month period (88 patients with a mean length of stay of 5 d). The patients were asked to complete a questionnaire on the day of discharge. The professional staff was not informed of the survey. RESULTS: The mean pain severity score at admission (visual analog scale, VAS) was 7.76 +/- 1.76 and the mean score decrease with treatment was 7.27 +/- 2.81. Expected pain relief and actual pain relief were correlated (R = 0.39; P = 0.001). Nearly all the patients (96.1%) reported have been encouraged to communicate about their pain. Information on the treatment was given to 89.3% of the patients; no significant differences in pain severity or pain relief were found between the patients who did and did not receive this information. The patients were satisfied with their management by the physicians (VAS: 8.83 +/- 2.07) and nurses (VAS: 8.68 +/- 1.72). CONCLUSION: Satisfaction with pain management (a subjective criterion) was good in our patients. However, no validated tools for measuring satisfaction are available, and measurements should be repeated to look for improvements over time. Limitations to these results include the placebo effect, the influence of memory, and the effects of the behavior of hospitalized patients. A repeat survey is needed.

Use of disease-modifying antirheumatic drugs in patients with psoriatic arthritis.

UNLABELLED: Few prospective placebo-controlled studies have evaluated disease-modifying antirheumatic drugs (DMARDs) in the treatment of peripheral psoriatic arthritis. OBJECTIVE: To evaluate second-line treatments used in clinical practice in patients with psoriatic arthritis. METHOD: We studied a cross-section of 100 consecutive patients seen by hospital-based or office-based rheumatologists for psoriatic arthritis. PATIENTS: The 55 men and 45 women had a mean age of 48 years (range, 17-79 years) and a mean disease duration of 7 years (range, 1-24 years). RESULTS: The most commonly used DMARDs were sulfasalazine, gold, methotrexate, and hydroxychloroquine (64, 43, 41 et 17 patients, respectively). These drugs had been stopped because of inefficacy in 31%, 31%, 12%, and 53% of patients, respectively, and because of adverse events in 23%, 44%, 22%, and 41% of patients, respectively. At the time of the study, mean treatment durations were 15, 21, 34, and 12 months, respectively, and the drugs were still being used in 45%, 21%, 66%, and 6% of patients. CONCLUSION: Our data confirm the value of methotrexate and salazopyrine. Methotrexate had the best risk/benefit ratio. Gold was often responsible for side effects. Hydroxychloroquine was inadequately effective and poorly tolerated.

Evaluation of spinal curvatures after a recent osteoporotic vertebral fracture.

OBJECTIVES: To evaluate spinal curvature changes over a 3-year period in postmenopausal women who had had an osteoporotic vertebral fracture within the last 3 months. METHODS: Thoracic kyphosis and lumbar lordosis were measured using a curviscope at baseline and after 1, 3, 6, 12, and 36 months. Anteroposterior and lateral radiographs of the thoracolumbar spine were obtained after 1 and 3 years. RESULTS: Sixty-one patients were included. At baseline, a significant increase in thoracic curvature was found in the subgroup with thoracic fractures as compared to the subgroups with thoracolumbar or lumbar fractures (64 degrees +/- 9 degrees, 56 degrees +/- 10, and 56 degrees +/- 13, respectively; P < 0.05). No lumbar curvature differences were found. Thoracic curvature was significantly correlated with age (r = -0.48, P < 0.001) and with the vertebral deformity index (r = 0.6, P < 0.001). A significant increase in thoracic curvature was apparent 3 months into the study; after 3 years, the increase was 5.6 degrees +/- 0.7 (P < 0.01). A moderate increase in lumbar curvature was found after 3 years (P < 0.01). Five of 13 patients and five of 10 patients had at least one incident fracture after 1 and 3 years, respectively. Mean thoracic curvature was greater among the patients with than without incident fractures after 1 and 3 years, although the difference was not statistically significant. CONCLUSION: Thoracic compression fractures significantly increase thoracic kyphosis as compared to dorsolumbar and lumbar fractures. Thoracic kyphosis worsens overtime in patients with prevalent vertebral fractures. These data invite an evaluation of techniques capable of providing early correction of alignment disorders, such as widespread use of bracing or kyphoplasty.