Three-dimensional volumetric ultrasonography. Does it improve reliabililty of musculoskeletal ultrasound?

OBJECTIVE: To compare the interobserver reliability of three-dimensional (3D) volumetric ultrasonography (US) and 2D real-time US in detecting inflammatory and destructive changes in rheumatoid arthritis (RA) wrist and hand. METHODS: Two RA patients were selected by a rheumatologist who performed independently a grey-scale and power Doppler (PD) volumetric acquisition at three anatomic sites in their more symptomatic wrist/hand using two identical scanners equipped with 3D volumetric probe. Twelve rheumatologists expert in MSUS were randomly assigned to a US scanner and a patient. In the first part of the study, each group of experts blindly, independently, and consecutively performed a 2D real-time grey-scale and PD US investigation of inflammatory changes and/or bone erosions at the three anatomic sites. In the second part of the study, each group of investigators blindly evaluated the same pathologic changes in the 6 volumes from the patient not scanned by them. RESULTS: The kappa values were higher for 3D volumetric US than for 2D US in the detection of synovitis/tenosyno-vitis (0.41 vs. 0.37) and PD signal (0.82 vs 0.45) and in the PD signal grading (0.81 vs. 0.55). CONCLUSION: 3D volumetric US may improve the interobserver reliability in RA multicentre studies.

Aceclofenac vs paracetamol in the management of symptomatic osteoarthritis of the knee: a double-blind 6-week randomized controlled trial.

OBJECTIVE: To evaluate the efficacy and tolerability of aceclofenac, 200 mg/day, and paracetamol, 3000 mg/day, in the treatment of osteoarthritis (OA) of the knee. METHODS: This was a double-blind, parallel-group, multicentre clinical trial involving patients with symptomatic OA of the knee, conducted in Spain. Patients were randomly allocated to aceclofenac 100 mg twice daily (n=82) or paracetamol 1000 mg three times daily (n=86). Patients were assessed at baseline and 6 weeks. Primary efficacy measures were severity of pain (visual analogue scale, VAS), Lequesne OA knee index, and patient's and physician's global assessment of disease activity. Severity of knee pain at rest or walking, stiffness, knee swelling and tenderness, and assessment of health-related quality of life (Health Assessment Questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index, and Short Form 36) were included as secondary endpoints. RESULTS: Both treatment groups showed significant improvement compared with their baseline values in the four primary endpoints. Mean between-treatment differences favoured aceclofenac over paracetamol on pain (VAS, 7.64 mm [95% confidence interval (CI), 0.44-14.85 mm]), Lequesne OA index (1.41 [95% CI, 0.45-2.36]), and patient's (0.33 [95% CI, 0.06-0.61]) and physician's (0.23 [95% CI, 0.01-0.47]) global assessments. Adverse events were similar for both drugs (paracetamol, 29% patients vs aceclofenac, 32%; P=0.71). Four patients withdrew in each group due to adverse events. Patients tended to prefer aceclofenac to paracetamol (P=0.001), and more treated with paracetamol withdrew from the study due to lack of efficacy (n=8 vs n=1, P=0.035, for paracetamol and aceclofenac, respectively). CONCLUSION: At 6 weeks, patients with symptomatic OA of the knee showed a greater improvement in pain and functional capacity with aceclofenac than paracetamol with no difference in tolerability.

III Actualización del Consenso de la Sociedad Española de Reumatología sobre terapia biológica en la artritis reumatoide / No disponible

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Artrosis e investigación: ¿una asignatura pendiente? / Osteoarthritis and research: an unsolved matter?

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Estudio ArtRoCad: evaluación de la utilización de los recursos sanitarios y la repercusión socioeconómica de la artrosis de rodilla y cadera. Presentación de resultados preliminares / The ArtRoCad study: evaluation of health resources’ utilization and the socioeconomic impact of osteoarthritis in osteoarthritis of the knee and hip. Preliminary results

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Segunda actualización del consenso de la Sociedad Española de Reumatología sobre la terapia biológica en la artritis reumatoide / II Update of the Consensus of the Spanish Society of Rheumatology on Biological Therapy in Rheumatoid Arthritis

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Evaluación de la progresión radiográfica en la artritis reumatoide según los métodos de Sharp/Van der Heijde (completo y simplificado) y de Larsen: resultados de un taller de lectura realizado por reumatólogos / Assessment of radiographic progression in rheumatoid arthritis according to the Sharp/Van der Heijde (full and simplified) and Larsen scoring methods: results of a reading session performed by rheumatologists

Objetivos: Familiarizarse con los métodos más extendidos de medida de la progresión radiográfica en la artritis reumatoide y discutir sus posibles ventajas en el contexto de la práctica clínica habitual. Material y métodos: Se organizó un taller interactivo con 20 reumatólogos con experiencia clínica e interés en la lectura radiográfica. En primer lugar, se revisaron los conceptos básicos y los procedimientos seguidos para la puntuación de tres métodos de uso extendido: el método de Larsen, el método de Sharp/Van der Heijde y el método simplificado propuesto por Van der Heijde. Posteriormente, cada reumatólogo procedió a la lectura individual de dos juegos de radiografías de manos y pies de una misma enferma realizadas en un intervalo de 12 meses. Todos leyeron de forma simultánea copias de las mismas radiografías. Para evaluar la variabilidad de los participantes se utilizó el coeficiente de variación y el recorrido ajustado por la escala (diferencia entre la puntuación máxima y mínima/valor máximo de la escala).Resultados: La variabilidad de las puntuaciones obtenidas en la evaluación del daño radiográfico de la paciente estudiada fue elevada con los tres métodos. Los métodos de Larsen, Sharp/Van der Heijde y Van der Heijde simplificado presentaron coeficientes de variación del 23,9-54,0 por ciento, 24,5-53,6 por ciento y 33,5-63,5 por ciento, respectivamente, y recorridos ajustados del 13,1-18,1 por ciento, 9,6-18,8 por ciento y 43,053,5 por ciento, respectivamente, al analizar las lecturas de las radiografías inicial y de seguimiento de forma independiente. Aunque la variabilidad del método Evaluación de la progresión radiográfica en la artritis reumatoide según los métodos de Sharp/Van der Heijde (completo y simplificado) y de Larsen: resultados de un taller de lectura realizado por reumatólogos simplificado fue mayor, cuando se evaluó la progresión radiográfica (cambio entre radiografías realizadas en momentos diferentes) el método simplificado presentó una variabilidad parecida a los otros dos métodos. Todos los participantes, sin entrenamiento previo, fueron capaces de detectar el cambio de forma cuantitativa. Conclusión: El método simplificado de Van der Heijde, aplicado a la evaluación de la progresión radiográfica, parece tener una variabilidad equiparable a los clásicos de Larsen y Sharp/Van der Heijde, por lo que ofrece claras ventajas para su utilización en la práctica clínica al ser más sencillo y precisar de menor tiempo, 3-5 min, para su realización (AU)

Evaluación objetiva del enfermo en la práctica clínica / Objective evaluation of the patient in the clinic

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Métodos de evaluación clínica en artritis reumatoide / Methods for the clinical evaluation of rheumatoid arthritis

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Synovial fluid analysis for diagnosis of intercritical gout.

BACKGROUND: The diagnosis of gout in the intercritical phase can be difficult. OBJECTIVE: To determine whether synovial fluid analysis allows the diagnosis of intercritical gout. DESIGN: Cross-sectional study. SETTING: Outpatient rheumatology clinics. PATIENTS: 101 patients with gout. INTERVENTION: Arthrocentesis of 80 knees and 21 first metatarsophalangeal joints (each joint from a different patient) that had been inflamed but were currently asymptomatic. MEASUREMENTS: Frequency with which arthrocentesis yielded synovial fluid; presence of monosodium urate crystals in the synovial fluid sample; and, for synovial fluid with crystals, the number of microscope fields that had to be scanned before crystals were found. RESULTS: Synovial fluid was obtained from 91 of 101 joints. The fluid from all 43 patients not receiving hypouricemic agents contained monosodium urate crystals. These crystals were found in the synovial fluid of only 34 of 48 patients receiving hypouricemic agents. In 90% of the synovial fluid samples that contained crystals, crystals were seen in the first five microscope fields examined. CONCLUSIONS: Arthrocentesis of asymptomatic knees and first metatarsophalangeal joints and synovial fluid analysis are simple procedures that facilitate the diagnosis of gout during intercritical periods.

[Rheumatology research. Analysis of Spanish papers published in 1990-1996 in 9 foreign journals in the field]. / Investigación en Reumatología. Análisis de los documentos españoles publicados durante 1990-1996 en nueve revistas extranjeras de la especialidad.

BACKGROUND: A relevant increase in the spanish biomedical production has occurred in the last few years. The magnitude, evolution and characteristics of the Spanish scientific production in Rheumatology is here analyzed through the published papers in foreign specialty journals. METHODS: Location in spanish documents published from 1990 to 1996 in nine foreign rheumatology journals of great visibility in MEDLINE. Classification of documents according to type of publication, specialty of authors and type of design. Estimation of bibliometric and collaboration indicators. Analysis of their evolution and comparison with data published for 1987. RESULTS: The number of Spanish documents from 1990 to 1996 doubled and from 1987 to 1996 tripled, with a 54% increase for the four journals with more visibility. In 1996, the spanish documents reached 5% of the total of published documents in several journals. From 1990 to 1996 original papers increased almost four times more than letters, the analytical studies increased almost eight times more than descriptive studies, and the mean expected impact factor of the originals multiplied by 1.6. The published documents by spanish rheumatologists had a more favorable profile--higher ratios for originals: letters, analytical studies: descriptive studies--than publications performed by other specialists in this area. The number of authors by document (median) increased from 5 to 6 during the analyzed period. Seventy-two percent of documents was signed by more than one department and 75% by only one institution. CONCLUSIONS: A relevant increase has occurred in the number and quality spanish documents published in the rheumatology area during the last ten years. To note a lack of collaboration between different institutions and few analytical studies of great complexity: cohort studies and controlled clinical trials.

SAPHO Presenting with a Lesion in the Symphysis Pubis.

SAPHO is an acronym for synovitis, acne, pustulosis, hyperostosis, and osteitis. It is used to define characteristic bone or joint lesions associated with either pustulosis palmoplantaris or acne. The bone lesions are characterized by sclerosis and hyperostosis, and there may be an associated synovitis. These bone lesions occur most frequently in the anterior thoracic wall, but may be found elsewhere. The lesions tend to have a benign course, and usually are treated with nonsteroidal anti-inflammatory drugs (NSAIDs). The etiology of the SAPHO syndrome is unknown at present. We report the following case because the patient presented with involvernent of the pubis, with a symptomatic osteitis pubis. The presence of palmoplantar pustulosis allowed proper identification of the disease.Characteristic sclerotic bone lesions, found usually in the anterior thoracic wall and associated with palmoplantar pustulosis, were initially de-scribed in Japan in 1967 (1); several similar descriptions followed (2-6). Similar skeletal lesions have also been found associated with other dermatology disorders, mainly acne conglobata (7-13). These bony lesions may occur in various sites in the axial skeleton and occasionally in peripheral bones, where they may be associated with an inflammatory synovitis. In 1987, the acronym SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) was coined to refer to this cluster of cutaneous and osteoarticular manifestations (14).Although involvement of the symphysis pubis has occasionally been mentioned in patients with SAPHO (14, 15), the features of the disease in this particular joint have not been described. In this report, we describe the case of a woman with palmoplantar pustulosis who was seen for pubic pain and sclerotic bone lesions akin to those of SAPHO.

Urinary albumin excretion in patients with systemic lupus erythematosus without renal disease.

OBJECTIVES: To investigate the prevalence of microalbuminuria, urinary albumin excretion (UAE) between 20-200 micrograms/min, in systemic lupus erythematosus (SLE) patients without clinical renal disease, and to discover if this could predict the development of renal disease. METHODS: This study made six monthly measurements of UAE, creatinine clearance, serological and clinical data in 22 ambulatory women patients with SLE, without clinical renal disease, hypertension, diabetes or heart failure. The patients were followed up for a period of 18 months (four measurements). Age and sex matched healthy controls were used as a comparative group. UAE was measured by nephelometry in three timed overnight urine samples at each visit. RESULTS: There were no significant differences in the creatinine clearance between the control group and the SLE patients. Creatinine clearance did not show significant changes throughout the study period. SLE patients had wide variations in the UAE rate compared with healthy controls. In five patients (5 of 22; 23%), on occasions, there was mild, transient increase in UAE reaching the level of microalbuminuria. During follow up, one patient with basal (4.67 micrograms/min) and six month (4.73 micrograms/min) normal UAE rate, was admitted with a nephrotic syndrome confirmed on biopsy examination to be proliferative lupus nephritis. Six months after beginning treatment with prednisone and cyclophosphamide her UAE rate returned to normal values (4.65 micrograms/min). CONCLUSION: SLE patients without clinical renal disease may have microalbuminuria, although this does not seem to warrant any specific action.

The efficacy and tolerability of aceclofenac in the treatment of patients with ankylosing spondylitis: a multicenter controlled clinical trial. Aceclofenac Indomethacin Study Group.

OBJECTIVE: To evaluate the efficacy and tolerability of aceclofenac, a new nonsteroidal antiinflammatory drug, in patients with active ankylosing spondylitis (AS). METHODS: 310 outpatients with active AS were enrolled in a 3 month, multicenter, parallel, double blind trial and were randomly assigned to receive aceclofenac (200 mg daily) or indomethacin (100 mg daily). They were evaluated after a washout period of 7 days, at baseline, 15, 30, 60, and 90 days. RESULTS: No significant differences were found between aceclofenac and indomethacin in the number of withdrawals due to lack of efficacy or adverse events. A repeated measures analysis (ANOVA) of patients who completed the trial showed no significant differences between either treatment. Within-group comparisons in an intention-to-treat analysis showed improvement (p < 0.05) in all the primary efficacy variables: pain visual analog scale (VAS) (37 vs 41%), morning stiffness (51 vs 46%), modified Schober's test (21 vs 16%), C7-iliac crest line distraction (11 vs 14%), lateral spinal flexion (6 vs 10%), in aceclofenac and indomethacin treated patients, respectively. Other variables including chest expansion, occiput-to-wall, Likert pain score, use of analgesic rescue, and patient and physician global assessment, also showed significant improvement from baseline values. No significant differences between treatments were noted for any efficacy variable. Good to excellent improvement in pain (52 vs 64%) and morning stiffness (70 vs 68%) was observed in aceclofenac and indomethacin treated patients, respectively. Patients taking aceclofenac had significantly fewer central nervous system related adverse events than patients treated with indomethacin (p < 0.001). CONCLUSION: Aceclofenac and indomethacin did not differ with respect to efficacy in the treatment of active AS, although aceclofenac was slightly better tolerated.

Spanish version of the Health Assessment Questionnaire: reliability, validity and transcultural equivalency. Grupo para la Adaptación del HAQ a la Población Española.

OBJECTIVE: To study the feasibility, reliability, and validity, of a Spanish European version of the Health Assessment Questionnaire (SHAQ). METHODS: A total of 170 patients with rheumatoid arthritis (RA) from 11 public general hospitals in Spain were included. We studied (a) the feasibility of the SHAQ by finding the proportion of patients able to self-administer it and the time they take to do so; (b) the test-retest reliability of the SHAQ when completed twice, with an interval of one week, calculating the Pearson correlation coefficient (r) between the first and second SHAQ scores; (c) the criterion validity of the SHAQ by comparing the clinician's assessment of the patient's activities (observed disability) with the scores noted by the patient in the questionnaire (referred disability); (d) cross sectional construct validity comparing the scores of the SHAQ with the other tests used in the assessment of RA; and (e) the longitudinal construct validity of the SHAQ comparing the difference between the initial and final SHAQ scores with the patient rating of improvement or worsening after a 3-month followup. RESULTS: The SHAQ was self-administered by 63% of patients, the rest needed the presence of an interviewer. The time taken to complete the questionnaire was 6.4 min. Test-retest reliability (r = 0.89), criterion validity (r = 0.87), cross sectional construct validity, and longitudinal construct validity were satisfactory and similar to other HAQ versions used in different countries. CONCLUSION: The SHAQ is a reliable, valid tool, but for use in Spain an interviewer may be necessary.