Najia Shakoor

Drug-induced systemic lupus erythematosus associated with etanercept therapy.

Specific antagonists of tumour necrosis factor (TNF)-alpha have rapidly gained popularity for the treatment of rheumatoid arthritis. The monoclonal antibody against TNF-alpha, infliximab, has been associated with induction of systemic lupus erythematosus (SLE); however, there have been no published reports of drug-induced SLE associated with the soluble TNF-alpha receptor etanercept. We describe four female patients who developed signs and symptoms of SLE during treatment with etanercept; in two SLE was unambiguous. On diagnosis of SLE, etanercept was discontinued and the SLE-related symptoms promptly resolved. Etanercept should be considered in the list of agents associated with drug-induced SLE.

Methotrexate pulmonary toxicity

Methotrexate is a commonly prescribed antineoplastic and immune modulating compound that has gained wide acceptance in the management of rheumatoid arthritis, psoriasis, sarcoidosis and a number of neoplastic disorders. Although generally considered safe and easy to use, methotrexate has been associated with a number of adverse reactions. Pulmonary toxicity has been well-described and may take a variety of forms. Pulmonary infiltrates are the most commonly encountered form of methotrexate pulmonary toxicity and these infiltrates resemble hypersensitivity lung disease. This discussion focuses primarily on low-dose methotrexate pulmonary toxicity and will discuss the diagnosis using clinical, pulmonary function, radiographical and pathological manifestations. Suggestions for clinical monitoring to detect adverse effects are given. In addition, management of pulmonary toxicity through discontinuation of the methotrexate, support and possibly the administration of corticosteroids is discussed.

Reduced lower extremity vibratory perception in osteoarthritis of the knee.

OBJECTIVE Vibratory perception threshold (VPT) assesses a distinct yet related sensory pathway that has been associated with neuropathic arthropathy but has not been assessed in knee osteoarthritis (OA). The purpose of this study was to evaluate VPT in subjects with knee OA to determine whether the lower extremity afferent deficits observed in knee OA involve more than just proprioception. METHODS Twenty-seven individuals with symptomatic and radiographic knee OA were compared with 14 age-matched normal subjects. VPT was assessed using a biothesiometer. Five sites of the lower extremity were evaluated. VPT of OA subjects was compared with VPT of normal subjects. RESULTS VPT of the OA subjects was significantly reduced at all 5 testing sites compared with normal subjects (P<0.05 at all sites). VPT scores (mean+/-SEM volts) for OA subjects and normal subjects were as follows: first metatarsophalangeal joint (15.0+/-1.9 versus 6.4+/-0.9), medial malleolus (22.0+/-2.2 versus 12.3+/-1.4), lateral malleolus (22.3+/-2.0 versus 10.4+/-0.8), medial femoral condyle (25.8+/-1.8 versus 15.9+/-1.9), and lateral femoral condyle (27+/-1.9 versus 18.9+/-2.4). CONCLUSION This was the first study to evaluate VPT in OA and demonstrate that VPT is reduced at the lower extremity of subjects with knee OA. The noted deficits in VPT may have significant implications in the neuromechanical pathophysiology of OA. VPT is a simple and reliable technique to measure sensory deficits in subjects with OA of the knee.

Aging or osteoarthritis: which is the problem?

OA is not an inevitable consequence of aging, but aging-related changes in the musculoskeletal system increase the risk of developing OA if other risk factors are also present. The joint is a functioning biomechanical unit of the neuromuscular system. Factors that contribute to the development of joint pain and loss of joint function include those associated with aging, those associated with underuse or misuse of the musculoskeletal system, and those associated directly with the development of OA. Complex interactions exist among many of these factors such as strength, balance, and proprioception, which are affected by aging, underuse, and OA. Many older adults who have joint pain and loss of function do not exhibit structural changes of OA that can be detected by standard radiography. When structural damage is present, its contribution to pain and disability is not always clear. In the absence of pharmacologic agents that can prevent the progression of structural damage in OA, management of older adults who have joint pain and loss of function should focus on improving neuromuscular function and preventing further declines.

Effects of specialized footwear on joint loads in osteoarthritis of the knee

OBJECTIVE Elevated dynamic joint loads have been associated with the severity and progression of osteoarthritis (OA) of the knee. This study compared the effects of a specialized shoe (the mobility shoe) designed to lower dynamic loads at the knee with self-chosen conventional walking shoes and with a commercially available walking shoe as a control. METHODS Subjects with knee OA were evaluated in 2 groups. Group A (n = 28) underwent gait analyses with both their self-chosen walking shoes and the mobility shoes. Group B (n = 20) underwent gait analyses with a control shoe and the mobility shoe. Frontal plane knee loads were compared between the different footwear conditions. RESULTS Group A demonstrated an 8% reduction in the peak external knee adduction moment with the mobility shoe compared with self-chosen walking shoes (mean +/- SD 49 +/- 0.80 versus 2.71 +/- 0.84 %BW x H; P < 0.05). Group B demonstrated a 12% reduction in the peak external knee adduction moment with the mobility shoe compared with the control shoe (mean +/- SD 2.66 +/- 0.69 versus 3.07 +/- 0.75 %BW x H; P < 0.05). CONCLUSION Specialized footwear can effectively reduce joint loads in subjects with knee OA, compared with self-chosen shoes and control walking shoes. Footwear may represent a therapeutic target for the treatment of knee OA. The types of shoes worn by subjects with knee OA should be evaluated more closely in terms of their effects on the disease.

Effects of common footwear on joint loading in osteoarthritis of the knee

Elevated joint loads during walking have been associated with the severity and progression of osteoarthritis (OA) of the knee. Footwear may have the potential to alter these loads. This study compares the effects of several common shoe types on knee loading in subjects with OA of the knee.

Generalized vibratory deficits in osteoarthritis of the hip.

OBJECTIVE Lower extremity sensory deficits, including reduced proprioception, joint kinesthesia, and, recently, vibratory sense, have been described in subjects with osteoarthritis (OA) of the knee. However, comparable deficits in OA of the hip have not previously been evaluated. Vibratory perception threshold (VPT) is a reliable measure used to assess sensory deficits and is amenable to testing multiple body sites. This study examined VPT at the upper and lower extremities of subjects with hip OA compared with subjects without hip OA. METHODS Fourteen subjects with symptomatic and radiographic hip OA were compared with 13 age-matched controls without hip OA. VPT was assessed using a biothesiometer. Five sites in the lower extremity and 1 site in the upper extremity (radial head) were evaluated and compared between OA and control subjects. RESULTS VPT was significantly reduced at all 6 testing sites of the OA subjects compared with controls (P < 0.05 for all sites). VPT scores (mean +/- SEM volts) for OA subjects and controls were as follows: first metatarsophalangeal joint (13.5 +/- 1.4 versus 7.4 +/- 0.7), medial malleolus (18.1 +/- 2.6 versus 11.2 +/- 1.7), lateral malleolus (20.9 +/- 2.4 versus 10.6 +/- 1.5), medial femoral condyle (22.8 +/- 2.9 versus 12.6 +/- 1.3), lateral femoral condyle (26.7 +/- 2.6 versus 16.2 +/- 1.9), and radial styloid [corrected] (10.2 +/- 0.8 versus 7.5 +/- 0.6). CONCLUSION To our knowledge, this is the first study to evaluate sensory deficits in hip OA and to demonstrate that there is vibratory sense loss at both the upper and lower extremities in these subjects compared with controls. The noted generalized deficits may have significant implications in the neuromechanical pathophysiology of OA.

Lower limb osteoarthritis: biomechanical alterations and implications for therapy.

Purpose of reviewTo review the role of biomechanics in the pathogenesis of lower-extremity osteoarthritis and recent advances in biomechanically active intervention strategies for osteoarthritis. Recent findingsThe conventional approach to treating knee osteoarthritis with analgesics and physical therapy has not been shown to alter the natural history of the disease, suggesting that novel strategies are necessary. Progression of lower-extremity osteoarthritis is mediated by aberrant biomechanics, which can be assessed using gait analyses and validated markers of dynamic knee loading such as the peak adduction moment (AddM) and adduction angular impulse (AddImp). Recognition of the mechanical component of osteoarthritis progression has led to intervention strategies that seek to reduce functional loads at the knee, and thereby, potentially, to palliate pain and retard disease progression. SummaryBiomechanically active interventions have been demonstrated to reduce dynamic loading of the knees in patients with osteoarthritis, and are potentially promising strategies to treat symptoms as well as to alter disease progression in osteoarthritis.

Sagittal plane hip motion reversals during walking are associated with disease severity and poorer function in subjects with hip osteoarthritis

A midstance reversal of sagittal plane hip motion during walking, or motion discontinuity (MD), has previously been observed in subjects with endstage hip osteoarthritis (OA) and in patients with femoroacetabular impingement. The goal of the present study was to evaluate whether this gait pattern is a marker of OA presence or radiographic severity by analyzing a large IRB approved motion analysis data repository. We also hypothesized that subjects with the MD would show more substantial gait impairments than those with normal hip motion. We identified 150 subjects with symptomatic unilateral hip OA and Kellgren-Lawrence OA severity data on file, and a control group of 159 asymptomatic subjects whose ages fell within 2 standard deviations of the mean OA group age. From the gait data, the MD was defined as a reversal in the slope of the hip flexion angle curve during midstance. Logistic regressions and general linear models were used to test the association between the MD and OA presence, OA severity and, other gait variables. 53% of OA subjects compared to 7.5% of controls had the MD (p<0.001); occurrence of the MD was associated with OA severity (p=0.009). Within the OA subject group, subjects with the MD had reduced dynamic range of motion, peak, extension, and internal rotation moments compared to those who did not (MANCOVA p ≤ 0.042) after controlling for walking speed. We concluded that sagittal plane motion reversals are indeed associated with OA presence and severity, and with more severe gait abnormalities in subjects with hip OA.

Education, zip code based annualized household income and health outcomes in patients with systemic lupus erythematosus

Objective. To determine the association of socioeconomic status [SES; education and zip code-based annual household income (Z-AHI)] and ethnicity with health-related quality of life (HRQOL) among patients with systemic lupus erythematosus (SLE). Methods. Data on 211 subjects from a cross-sectional study (LupusPRO©) using the Medical Outcomes Study Short Form-36 questionnaire to evaluate physical health scores (PCS) and mental health scores were used to obtain education and zip code. The 2000 US Census was used to obtain each zip code’s median annual household income. Results. Education and Z-AHI correlated with PCS (education standardized β = 0.17, 95% CI 0.47, 3.65, p = 0.01, r2 = 0.03; Z-AHI standardized β = 0.15, 95% CI 0.57, 8.30, p = 0.02, r2 = 0.02) on regression analysis. Z-AHI was linked to PCS, independent of education. Ethnicity was associated with PCS through disease activity and SES. Conclusion. SES is associated with HRQOL in SLE. Z-AHI and education are equally predictive surrogates of SES; however, Z-AHI, independent of education, was predictive of HRQOL. Z-AHI has less subject bias and is easily obtainable, therefore its use for future HRQOL studies is suggested.