Association between hip morphology and prevalence, clinical severity and progression of hip osteoarthritis over 3 years: The knee and hip osteoarthritis long-term assessment cohort results.

OBJECTIVE: To assess the effects of variations in hip morphology on prevalence, clinical severity and progression of hip osteoarthritis. METHODS: From 2007 to 2009, we conducted a study of 242 patients aged between 40 and 75 years with symptomatic lower limb osteoarthritis, as part of a population-based osteoarthritis cohort study in France. Standard radiographs of both hips were obtained at baseline and at three years. The progression of hip osteoarthritis was evaluated according to the radiological Kellgren-Lawrence score (KL) and clinical severity from the scores on a Visual Analogic Scale (VAS) for pain recorded yearly. Five measures were used to describe hip morphology: centre edge angle, acetabular index (AI), vertical centre anterior angle, acetabular depth and neck-shaft angle. RESULTS: Of the 484 hips studied, 205 (42%) showed osteoarthritis at baseline and 16 (11 right and 5 left) underwent joint replacement during the follow-up. AI was the morphological measure most consistently and strongly associated with radiographic osteoarthritis at baseline (odds-ratio=1.05, 95% CI: 1.01-1.08 per degree of angle change), clinical severity (correlation coefficient with VAS during 3 years=0.15, P=0.004), radiological progression (odds-ratio=1.05, 95% CI: 1.00-1.10 per degree) and joint replacement (hazard ratio=1.18, 95% CI: 1.07-1.29 per degree). CONCLUSIONS: Acetabular obliquity and especially AI is strongly, and likely causally, associated with the existence, severity and progression of hip osteoarthritis.

Ultrasound assessment of the entheses in primary Sjögren syndrome.

Although tendon pain is commonly reported in primary Sjögren syndrome (pSS), the underlying mechanism is unknown. The objective of this study was to determine whether tendon pain in pSS is related to involvement of the tendons and entheses. We performed a physical examination of 288 entheseal insertion sites in 16 patients with active pSS and 162 entheseal insertion sites in 9 healthy controls without symptoms or medications. Then ultrasound was used to assess entheseal and tendon sites of these patients (n = 208) and controls (n = 117). Ultrasound was performed in B mode first to detect structural damages, and in power Doppler mode to detect blood flow abnormalities. By physical examination, 9 (56%) of the 16 pSS patients had pain to palpation of fibromyalgia tender points, two of whom had more than 11 tender points. The number of positive points ranged from 2 to 18, with a mean of 8 ± 6.0. None of the healthy controls had positive tender points. None had structural or blood-flow abnormalities by ultrasound. To conclude, this study provides the first data on ultrasound findings in patients with active pSS. Although 56% of patients had clinical tender points, none had structural or blood-flow abnormalities by ultrasound, suggesting the absence of inflammation of the tendons and entheses in this disease.

Relationship between hip dysplasia, pain, and osteoarthritis in a cohort of patients with hip symptoms.

OBJECTIVE: The relationship between acetabular dysplasia (HD) and hip osteoarthritis (OA) remains unclear, especially for mild forms of dysplasia. Our objectives were to estimate the prevalence of HD in a population-based sample with symptoms and to evaluate potential associations linking HD, hip OA, and hip pain. METHODS: Individuals 40 to 75 years of age with symptoms in 1 or both hips were recruited during a multiregional prevalence survey. All study participants underwent examination and radiographs. Radiographs were evaluated using Kellgren-Lawrence staging (with stages ≥ 2 indicating hip OA) and HD measures [center-edge (CE) angle, acetabular inclination angle (HTE), acetabular depth (AD), and vertical center-anterior margin angle]. RESULTS: We studied both hips of 842 individuals (1684 hips), among whom 203 had hip OA. Compared to left hips, right hips had significantly smaller CE angles and significantly greater AD and HTE values (p ≤ 0.001). Overall, the prevalence of HD ranged from 7.6% to 22.2% of the hips depending on the measure used. The prevalence of HD was higher in individuals with hip OA, with significant differences for abnormal HTE (19.1% vs 11.4%; p < 0.0001) and abnormal CE (11.3% vs 7.5%; p = 0.04). By logistic regression, only abnormal HTE remained associated with OA. Same-side hip pain was not statistically more common in individuals with HD after stratification on OA status (p = 0.12). CONCLUSION: Our study confirms the relationship between OA and HD, particularly as defined based on the HTE angle.

Reproducibility of radiographic hip measurements in adults.

INTRODUCTION: Hip dysplasia may cause pain and premature hip osteoarthritis. Here, our objective was to assess the inter- and intraobserver reproducibility of radiographic hip parameter measurement in adults. METHODS: We used anteroposterior pelvic radiographs and false-profile lateral hip radiographs from 30 individuals (60 hips) enrolled in a prevalence study of hip osteoarthritis. For each hip, two independent observers recorded five parameters twice, at an interval of 1 month. The five parameters were the vertical-center-edge angle (VCE), the anterior center-edge angle (vertical-center-anterior angle, VCA), the acetabular roof angle (HTE), the neck-shaft angle (CC'D), and acetabulum depth (AD). Reproducibility was assessed using Bland-Altman plots, intraclass correlation coefficients (ICCs), and kappa coefficients for the radiographic diagnosis of hip dysplasia using widely accepted cutoffs. RESULTS: Of the 60 hips, 51 were assessable. Intraobserver ICC values ranged from 0.72 to 0.94 and interobserver ICC values from 0.68 to 0.84. Kappa coefficients were between 0.60 and 1.00, except for the VCA angle (κ=0.41). CONCLUSION: In this study, reproducibility of the main radiographic hip parameters was good according to all evaluation methods used. However, CC'D and, to an even greater extent, the VCA angle seemed challenging to measure.

The KHOALA cohort of knee and hip osteoarthritis in France.

OBJECTIVES: This study aimed to describe the prevalence of symptomatic knee and hip osteoarthritis (OA) and its course over time, as well as identify prognostic factors of OA course and determinants of costs and access to care in France in a patient cohort. METHODS: Subjects aged 40 to 75 years, with uni- or bilateral symptomatic hip and/or knee OA (ACR criteria), Kellgren and Lawrence (KL) stage 2 or greater, were recruited from a French national prevalence survey for the multicenter KHOALA cohort study. Data collected at baseline included sociodemographic and clinical data; WOMAC, IKS and Harris scores for pain and function; MAQ score for physical activity; functional comorbidity index; GHQ28 score for psychological status; and SF-36 (generic) and OAKHQOL (specific) scores for quality of life. Blood and urine samples were collected. RESULTS: Eight hundred and seventy-eight subjects were included, 222 with OA of the hip (mean age 61.2±8.8 years), 607 knee (mean age 62.0±8.5 years) and 49 both hip and knee (mean age 64.9±7.9 years). Mean body mass index was 26.9±4.5 for hip OA and 30.3±6.3 for knee OA. Hip and knee OA patients had 1.99 and 2.06 comorbidities, on average, respectively. Disease severity on X-rays for KL stages 2, 3 and 4 for hip OA was 69.8, 26.1 and 4.1%, respectively, and for knee OA, 44.5, 30.3, and 25.2%. As compared with population norms, age- and sex-standardized SF-36 scores were greatly decreased for both knee and hip OA in all dimensions, particularly physical and emotional dimensions. PERSPECTIVES: Patients will be followed up annually, alternately by mail and clinical visit. This cohort of representative patients with knee and hip OA will be an opportunity for future collaborative research.

Comparison of ACR 1987 and ACR/EULAR 2010 criteria for predicting a 10-year diagnosis of rheumatoid arthritis.

OBJECTIVE: To compare the diagnostic accuracy of the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) and 1987 ACR criteria for rheumatoid arthritis (RA) in a cohort of patients with recent-onset arthritis followed-up for 10 years. METHODS: One hundred and sixty-four patients with recent-onset arthritis of less than 1 year's duration were included prospectively between 1995 and 1997. The diagnosis of RA was defined as having a diagnosis of RA made by the office-based rheumatologist 10 years after enrolment. We compared the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the criteria sets at baseline. RESULTS: At baseline, 60 of the 164 patients had alternative diagnoses better explaining the arthritis and 13 had erosions typical for RA; of the 91 remaining patients, 33 had at least 6 ACR/EULAR points (indicating definite RA), and 58 had fewer than 6 points. The ACR/EULAR criteria had a quite similar sensitivity than the 1987 ACR criteria (33/57 [57.9%] for ACR/EULAR criteria vs 34/57 [59.6%] for the 1987 ACR criteria), but higher specificity, PPV, and NPV (95/107 [88.8%], 34/46 [73.9%], and 95/118 [80.5%], respectively) than the 1987 ACR criteria (80/107 [74.8%], 33/63 [52.4%], and 80/104 [76.9%], respectively). CONCLUSION: ACR/EULAR criteria performed substantially better than ACR 1987 criteria for predicting a diagnosis of RA after 10 years. Much of the improvement was ascribable to the use of exclusion criteria. BULLET POINTS: (1) The ACR/EULAR criteria had the same sensitivity, but higher specificity, PPV, and NPV than the 1987 ACR criteria; (2) Much of the improvement was ascribable to the use of exclusion criteria.

Diagnostic accuracy of ACR/EULAR 2010 criteria for rheumatoid arthritis in a 2-year cohort.

OBJECTIVE: To evaluate the diagnostic accuracy of the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) and 1987 ACR criteria for rheumatoid arthritis (RA), and the respective role of the algorithm and scoring of the ACR/EULAR. METHODS: In total, 270 patients with recent-onset arthritis of < 1 year duration were included prospectively between 1995 and 1997 and followed for 2 years. RA was defined as the combination, at completion of followup, of RA diagnosed by an office-based rheumatologist and treatment with a disease-modifying antirheumatic drug or glucocorticoid. We compared the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the criteria sets in the overall population, in the subgroup meeting the tree condition for ACR/EULAR scoring, and in the overall population classified according the full tree. RESULTS: At baseline, 111 of the 270 patients had better alternative diagnoses and 16 had erosions typical for RA; of the 143 remaining patients, 52 had more than 6 ACR/EULAR 2010 points (indicating definite RA) and 91 had fewer than 6 points. After 2 years, 11/16 patients with erosions and 40/52 with more than 6 points had RA. 100 of the 270 patients met the reference standard for RA. Sensitivity, specificity, PPV, and NPV of the ACR/EULAR (full tree) were 51/100 (51%), 153/170 (90%), 51/68 (75.4%), and 153/202 (75.7%), respectively. Diagnostic accuracies of the ACR/EULAR score and ACR 1987 criteria were not statistically different. CONCLUSION: Much of the improvement of the ACR/EULAR criteria was ascribable to the use of exclusion criteria in the algorithm.

Effects of rituximab therapy on quality of life in patients with primary Sjögren's syndrome.

OBJECTIVES: To assess the efficacy of the anti-CD20 antibody rituximab in improving physical function and health-related quality of life (HRQoL) in patients with active primary Sjögren's syndrome (pSS), as well as the duration and sources of HRQoL improvements. METHODS: Sixteen patients with pSS received rituximab infusions (375 mg/m2) at weeks 0 and 1 and were followed up for 36 weeks. All patients fulfilled 2002 American-European Consensus Group criteria for pSS and had active disease defined as scores >50 mm on two of four 100-mm visual analogue scales (VAS) evaluating global disease activity, fatigue, pain, and dryness. Standardised evaluations including the Short Form 36 Health Survey (SF-36) were conducted. SF-36 score changes from baseline to weeks 12, 24, and 36 were assessed. RESULTS: Baseline mean SF-36 scores were considerably decreased, compared to the general same-age population. Role-physical (14.1 ± 27.4), role-emotional (12.5 ± 29.9), vitality (26.2 ± 14.3), and general health (32.6 ± 11.2) were the dimensions with the worst scores. Twelve weeks after rituximab, the mental component summary score was improved in 15 patients (mean improvement, 31.2 ± 36.4, p=0.001) and the physical component summary score in 14 patients (mean improvement, 16.9 ± 26.2, p=0.049). Further improvements occurred from week 12 to week 24, and most of the gains were sustained at week 36. Improvements in the physical and mental component summary scores failed to correlate with improvements in the VAS scores. CONCLUSIONS: Substantial alterations in HRQoL were noted in patients with pSS. Rituximab infusions without corticosteroid therapy produced meaningful improvements in HRQoL. Controlled studies of rituximab are needed.

Usefulness of the cytology in the diagnosis of bone lesions.

OBJECTIVE: This study aims to evaluate the interest to systematically combine cytology and histology for all bone specimens. METHODS: We reviewed all the bone biopsies performed in the University Hospital of Brest, France, between January 2000 and March 2008 and for which cytology and histology, obtained at the same time, were available. The interest of cytology and histology, alone and in combination was studied in comparison with the diagnostic made by the practitioner who treated the patient, which was considered the reference. RESULTS: Seventy patients were included. Among them, 55 had a final diagnosis of cancer. Thirty-nine of them were identified either by cytology or histology: twenty-five were identified by the two techniques, eight only by histology, and six only by cytology. There was no false-positive result, but false-negative results occurred with cytology (n=3) and histology (n=4). The agreement malignancy/benignancy was high (κ=0.84) between cytology and histology when taking into account the only contributive results. It dropped to 0.52 when taking into account all the samples. CONCLUSION: Cytology and histology are complementary to each other in diagnosing bone lesion. Combining cytomorphology and tissue architecture increases the accuracy of bone sample and would systematically be performed for each bone biopsy.

Changes over time in the diagnosis of rheumatoid arthritis in a 10-year cohort.

OBJECTIVE: We assessed levels of agreement between a diagnosis of rheumatoid arthritis (RA) at inclusion in a recent-onset arthritis cohort, then 2 and 10 years later. Performance of American College of Rheumatology (ACR) criteria alone or combined with rheumatologist diagnosis, and of recent new criteria adding antibodies to cyclic citrullinated peptides ("anti-CCP-revised criteria") to existing ACR criteria, was evaluated. METHODS: In total, 270 patients with recent-onset arthritis of less than 1 year duration were included between 1995 and 1997 and followed for 2 years. A diagnosis was recorded by an office-based rheumatologist (OBR) at inclusion, then 2 years later. In 2007, a questionnaire was sent to each rheumatologist to collect the final diagnosis, which was considered the reference. RESULTS: Final diagnosis was available for 164 patients: 57 had RA. Agreement was low (kappa = 0.27) between the baseline and final diagnoses, and substantial (kappa = 0.69) between the 2-year and final diagnoses. Anti-CCP-revised criteria had sensitivity of 65% to 81% and specificity of 55% to 75%. Sensitivity and specificity of ACR criteria were 57.9% (44.1%-70.9%) and 74.8% (65.5%-82.7%) at inclusion, 80.7% (70.5%-90.0%) and 63.6% (54.5%-72.7%) at 2 years. The combination OBR diagnosis/ACR criteria after 2 years showed considerably increased specificity (87% vs 64%) and slightly decreased sensitivity (77% vs 81%). CONCLUSION: ACR criteria for RA showed poor performance even at 2 years. The absence of exclusion criteria may explain the lack of specificity, which improved when combined with the OBR diagnosis. Adding anti-CCP criteria to the existing criteria could help in diagnosing RA.

Prevalence in two-phase surveys: accuracy of screening procedure and corrected estimates.

BACKGROUND: Two-phase surveys often are used to estimate prevalence, in particular when the disease is rare or the case ascertainment procedure difficult and/or costly. However, few authors of such surveys take into account the sensitivity error associated with the use of a screening procedure in the first phase and its imprecision in correcting the prevalence estimate and confidence interval. METHODS: Two examples of two-phase surveys of rheumatic diseases (hip and knee osteoarthritis, rheumatoid arthritis and spondyloarthropathies) are used to present methodological approaches to obtain corrected prevalence estimates. Two methods for assessing the accuracy of the screening procedure are described--two-phase pilot and case-control designs--that are best suited for frequent and rare diseases, respectively, and naive and corrected estimates of prevalence compared. RESULTS: When the sensitivity error is not taken into account, prevalence is underestimated, as is, especially, the width of its confidence interval. In our examples, the corrected confidence interval width increased up to 50% as compared with naïve one. CONCLUSIONS: The screening procedure accuracy should be thoroughly assessed in two-phase prevalence surveys and prevalence estimates and their confidence intervals corrected accordingly.

Improvement of Sjögren's syndrome after two infusions of rituximab (anti-CD20).

OBJECTIVE: There is evidence to support a dominant role for B cells in the pathophysiology of primary Sjögren's syndrome (SS). Therefore, we evaluated the safety and efficacy of anti-CD20 monoclonal antibody. METHODS: Sixteen patients who met the new American-European Consensus Group criteria for primary SS and scored >50 on at least 2 of 4 visual analog scales (VAS; 100 mm) evaluating global disease, pain, fatigue, and global dryness received infusions of low-dose rituximab (375 mg/m(2)) at weeks 0 and 1 without steroid premedication. RESULTS: Slow rituximab infusions (100 mg/hour) were well tolerated, with only 1 patient experiencing serum sickness-like disease. There was a dramatic reduction in B cells of the blood and salivary gland (SG). At week 12, VAS scores with respect to fatigue and dryness (P < 0.05), tender point count (P < 0.035), and quality of life as evaluated by the Short Form 36 questionnaire (SF-36; P < 0.001) were significantly improved. At week 36, significant improvements were noted in the 4 VAS scores (P < 0.05), tender joint count (P = 0.017), tender point count (P = 0.027), and SF-36 (P < 0.03). Pulmonary manifestations were ameliorated in 1 patient. Patients with improvements on at least 3 of the 4 VAS scores at any visit (n = 11) had a shorter disease duration than the other patients (n = 5; mean +/- SD duration 3.8 +/- 5.4 versus 30.1 +/- 29.5 years; P = 0.02). CONCLUSION: Low-dose rituximab infusions were well tolerated without the benefit of steroids. Infusions induced a rapid depletion of B cells in the blood and SG and could improve primary SS. Controlled studies are needed.

Ultrasound assessment of salivary glands in patients with primary Sjögren's syndrome treated with rituximab: Quantitative and Doppler waveform analysis.

OBJECTIVES: Noninvasive objective tests are needed to diagnose primary Sjogren's syndrome (pSS) and to evaluate treatment responses. Ultrasound imaging of the salivary glands is rapid and noninvasive. Recent open-label studies suggested that anti-CD20 (rituximab) may be effective in pSS. The purpose of this study was to look for ultrasound evidence of the effects of rituximab in pSS. METHODS: We compared 16 patients fulfilling the new American-European consensus group criteria for pSS to 9 controls, using B-mode ultrasound features (parenchymal homogeneity and gland size) and Doppler waveform analysis of the transverse facial artery of parotid glands. We compared the same parameters in the patients before and after 12 weeks of intravenous rituximab therapy. RESULTS: Compared to controls, untreated patients had significant abnormalities in salivary gland structure (p < 0.0001) and parotid size (2.05 +/- 0.33 cm versus 1.70 +/- 0.28 cm; p = 0.001). Doppler waveform analysis showed significant differences before, but not after, lemon stimulation between untreated patients and controls. After rituximab treatment, significant size reductions were noted in the parotids (2.05 +/- 0.3 cm at baseline and 1.86 +/- 0.27 cm at week 12; p = 0.002) and submandibular glands (2.02 +/- 0.54 cm at baseline and 1.66 +/- 0.34 cm at week 12; p = 0.001). Doppler resistive indices after lemon stimulation were significantly increased after rituximab treatment. CONCLUSION: Salivary gland measurements and blood inflow responses to salivary stimulation as assessed by ultrasound hold promise as objective noninvasive tools for evaluating rituximab effects in patients with pSS.