S.P. Stewart

A diagnostic algorithm for persistence of very early inflammatory arthritis: the utility of power doppler ultrasound when added to conventional assessment tools

Objectives: The aim of this study was to assess the value of power Doppler ultrasound (PDUS) in combination with routine management in a cohort of patients with very early inflammatory arthritis (IA). Methods: 50 patients with ⩽12 weeks of inflammatory symptoms with or without signs had clinical, laboratory and imaging assessments. Diagnosis was recorded at 12 months. Assuming a 15% pre-test probability of IA, post-test probabilities for various assessments were calculated and used to develop a diagnostic algorithm. Results: All patients positive for rheumatoid factor (RF) and/or cyclic citrullinated peptide (CCP) developed persistent IA, so the added value of PDUS was assessed in the seronegative (RF and CCP negative) group. The probability of IA in a seronegative patient was 6%. The addition of clinical and radiographic features raised the probability of IA to 30% and, with certain ultrasound features, this rose to 94%. Conclusions: In seronegative patients with early IA, combining PDUS with routine assessment can have a major impact on the certainty of diagnosis.

Hand bone loss in early undifferentiated arthritis: evaluating bone mineral density loss before the development of rheumatoid arthritis

Objectives: (1) To examine the change in regional bone mineral density (BMD), including the hands, and assess its role as a predictor of outcome in patients presenting with an early undifferentiated inflammatory arthritis; (2) to examine for associations with the changes in hand BMD. Methods: 74 patients with undifferentiated hand arthritis of less than 12 months’ duration were examined at baseline and then at three, six, and 12 months follow up, including BMD measurement of the femoral neck, spine (L2–4), and the whole hands using dual energy absorptiometry (DXA). Results: During the study, 13 patients were diagnosed as having rheumatoid arthritis, 19 as having inflammatory non-rheumatoid joint disorders, and 42 as having non-inflammatory joint disorders. At the femoral neck and lumbar spine no significant bone loss was seen in any of the three subgroups. At the 12 months follow up the mean (95% confidence interval) hand BMD loss in the patients with rheumatoid arthritis was −4.27% (−1.41 to −7.13); in the inflammatory non-rheumatoid group, −0.49% (−1.33 to +0.35); and in the non-inflammatory joint disorder group, −0.87% (−1.51 to −0.23). In a multivariate linear regression model (including age, rheumatoid factor, mean C reactive protein, mean HAQ score, and cumulative glucocorticoid dose), only mean C reactive protein (p<0.001) and rheumatoid factor (p = 0.04) were independently associated with change in hand BMD during follow up. Conclusions: Hand DXA provides a very sensitive tool for measuring bone loss in early rheumatoid arthritis and may be useful in identifying patients at high risk of developing progressive disease. Further studies are needed to evaluate the role of hand bone loss as a prognostic factor and outcome measure in rheumatoid arthritis.

Comparison of measures of body composition in a trial of low dose growth hormone replacement therapy

OBJECTIVE We assessed the effects of the administration of low dose growth hormone in growth hormone deficient adults on body composition and physical performance. We compared the validity of different measures of body composition in GH treated adults.

Hand bone densitometry: a more sensitive standard for the assessment of early bone damage in rheumatoid arthritis

Objective: To examine the role of hand dual-energy x ray absorptiometry (DEXA) compared with radiography in the assessment of bone involvement in patients with early rheumatoid arthritis (RA) who have active disease. Methods: The study population (n = 79) had RA of <12 months’ duration and were selected for poor prognostic features. Clinical data and bone mineral density (BMD) data were collected at baseline, 24 and 48 weeks. Hand radiographs were performed at baseline and 48 weeks. Bone damage analyses were performed for the group and individuals using the smallest detectable change (SDC) method. Results: At baseline, mean disease duration was 8.5 months, erythrocyte sedimentation rate was 34.3 mm/hour, C-reactive protein was 40.2 mg/l, Health Assessment Questionnaire score was 1.35 and 81% of patients were positive for rheumatoid factor. Mean (95% CI) hand BMD loss was 2.5% (−3.5 to −1.5) at 24 weeks and 2.6% (−3.8 to −1.5) at 48 weeks. Individual hand bone loss exceeding the SDC was seen in 46.8% at 24 weeks and in 58.2% at 48 weeks. In the subgroup of 58 patients who had undergone radiography, radiographic joint damage score evaluated by the Sharp–van der Heijde method increased from 4.8 to 10.6 (p = 0.001). Individual hand bone loss in this subgroup exceeding the SDC was seen in 50.0% at 24 weeks and in 56.9% at 48 weeks, whereas at 48 weeks only 22.4% had deteriorated in modified Sharp score. Conclusion: The study results indicate that hand DEXA is a more sensitive tool than radiology (radiographic joint-damage scores), for measuring disease-related bone damage in early RA.

Bone mineral density improvement in spondyloarthropathy after treatment with etanercept

New bone formation with spinal fusion is the hallmark of ankylosing spondylitis (AS) and the related spondyloarthropathies (SpA), although concomitant osteoporosis is also a major problem both in early and established disease and correlates with disease activity.1 We have previously reported the efficacy of etanercept in patients with active and resistant spinal and peripheral SpA.2 Our aim in this study was to investigate whether suppression of inflammation with etanercept prevents bone loss in patients with AS and SpA. Ten patients with active, resistant spinal and peripheral SpA were treated with a six month course of etanercept 25 mg subcutaneously twice weekly, as previously reported.2 Diagnoses in this group were: AS (n=7), Crohn’s spondylitis (n=2), and undifferentiated SpA (n=1). Results were compared with those for a second group of patients with equivalent disease activity, but shorter disease duration treated conventionally (table 1). The diagnoses of the second group were: undifferentiated SpA …

Does extremity-MRI improve erosion detection in severely damaged joints? A study of long-standing rheumatoid arthritis using three imaging modalities

Background: Long-standing rheumatoid arthritis produces unique challenges when assessing damage due to joint deformity. The use of extremity magnetic resonance imaging (eMRI) offers the possibility of improved disease assessment because of greater patient tolerability. Objectives: The aim of this cross-sectional study was to compare the identification of wrist erosions in a severe rheumatoid arthritis cohort by eMRI with a restricted field of view (eMRI-RV) to radiography and high field MRI, using the latter as the reference. Methods: Fifteen patients (87% female, median age 56 years) with active rheumatoid arthritis (median DAS28 7.01 and disease duration 11 years) on leflunomide were enrolled. Radiography of hands, eMRI-RV (0.2 T MagneVu MV 1000) and high field MRI of unilateral wrist joints were performed. Results: Of 86 comparable wrist joint areas, high field MRI identified 70 erosions, eMRI-RV 32 and radiography 4. With high field MRI considered the reference, the sensitivity, specificity and accuracy of eMRI-RV for erosions were 46%, 94% and 55%, and the corresponding values for x ray were 6%, 100% and 23%, respectively. Conclusions: In severely damaged rheumatoid arthritis joints, sensitivity of erosion detection was markedly higher for eMRI-RV than radiography, using high field MRI as the reference. eMRI-RV was, however, less sensitive than high field MRI.

Comparison of changes in bone mineral in idiopathic and secondary osteoporosis following therapy with cyclical disodium etidronate and high dose calcium supplementation

OBJECTIVE Our clinical practice has been to offer treatment with cyclical disodlum etidronate and high dose calcium supplements (1500–1600 mg/day) to ail female patients with osteoporosis who are unable or unwilling to take hormone replacement therapy (HRT), and male osteoporotics. In a retrospective study we compared the effect of this treatment on measures of bone mineral over a 12‐month period in women wlth post‐menopausal and secondary osteoporosis. We also assessed its effects in 10 male osteoporotics.

Risk factors for loss of lean body mass after liver transplantation

BACKGROUND After liver transplantation there is a fall in lean body mass. AIMS To determine the risk factors for this fall in lean body mass using univariate and subgroup analyses. PATIENTS AND METHODS Dual energy X-ray absorptiometry was performed in 36 patients (12 with Child-Pugh Class A, 20 with Class B and 4 with Class C disease) before and up to 24 months after liver transplantation. Univariate and sub-group comparative analyses were performed to assess possible risk factors for the fall in lean body mass post-transplantation. RESULTS The pre-transplantation serum albumin inversely correlated with the fall lean body mass at 1 month (r = 0.55; p < 0.009) and at 6-9 months (r = 0.51; p < 0.05) post-transplantation. A positive correlation between the fall in lean body mass and: (i) cumulative dose of steroids administered at 2-5 months (r = 0.57; p < 0.05) and (ii) length of hospital stay after transplantation (r = 0.52; p < 0.05) were also observed. Neither the severity or presence of cholestatic liver disease pre-transplant, nor acute cellular rejection post-transplant were risk factors for a fall in lean mass. DISCUSSION A hypercatabolic state post-transplant (represented by low albumin pre-transplantation), immobility, lack of exercise and steroid induced catabolism of muscle may cause the observed fall in lean mass after liver transplantation. Earlier transplantation of patients with better nutritional status and the use of low dose steroid immunosuppressive regimens may prevent the observed fall in lean body mass after transplantation.

Body Composition Analysis in Liver Cirrhosis. The Measurement of Body Fat by Dual Energy X-ray Absorptiometry in Comparison to Skinfold Anthropometry, Bioelectrical Impedance and Total Body Potassium

In this cross-sectional study of methods to determine total body fat in patients with abnormal body composition secondary to chronic liver disease, we have demonstrated that TBFDXA by four-site skinfold anthropometry was highly correlated to TBFDXA, with small SEE and no bias in patients with ascites, but a small and significant bias in patients without ascites. TBFBIA showed no bias but a weaker correlation with a large SEE. In the presence of fluid retention the correlation coefficient decreased. TBFTBK showed a highly significant bias, and the correlation was not as good as SFA, and decreased in the presence of fluid retention.

A Four-Compartment Model to Determine Body Composition in Liver Cirrhosis

It is known that patients who have significant deterioration in liver function develop abnormalities of body composition; tissue wasting, ascites and edema are clinical symptoms. These abnormalities may render some established methods of assessing body composition invalid. In order to assess the efficacy of treatment regimes aimed at correcting or modifying the effects of the disease it is important to develop new techniques to monitor body composition in patients with these abnormalities.