Predicting the result of nerve conduction tests in carpal tunnel syndrome using a questionnaire.

We performed a study to determine whether the results of a questionnaire could be used to predict the results of nerve conduction tests in patients with suspected carpal tunnel syndrome. Two hundred and eleven consecutive patients underwent electrophysiological testing, and completed the questionnaire designed by Kamath and Stothard. Two questionnaire threshold scores were identified, which classified with high sensitivity and high specificity those patients who had normal, and abnormal nerve conduction tests respectively. Patients who scored greater than 6 on the questionnaire could be classified with 87% specificity as having abnormal tests, and patients scoring below 3 on the questionnaire could be classified with 87% sensitivity as having normal studies. We suggest therefore that patients who score above 6, or below 3 on this questionnaire may not need to be referred for nerve conduction tests, as the result can be predicted with adequate accuracy.

Acute and long-term management of patients with vertebral fractures.

Symptomatic vertebral fractures are associated with significant morbidity, excess mortality and health and social service expenditure. Up to 20% of patients with an incident vertebral fracture experience a further vertebral fracture within one year. It is therefore important that vertebral fractures are detected early, and treatment considered as soon as possible. Only a third of vertebral fractures come to medical attention, where they typically present with acute back pain, but other presentations include loss of height and increasing kyphosis. Spine X-rays should then be performed to confirm the diagnosis and exclude other pathology. Bone density measurements are not essential before starting treatment for osteoporosis in patients with low-trauma vertebral fractures, but may be useful to confirm osteoporosis when there is uncertainty about previous trauma. They may also aid in selecting the most appropriate therapy and monitoring response to treatment. Up to 30% of women and 55% of men with symptomatic vertebral crush fractures have underlying secondary osteoporosis, where treatment may lead to large increases in bone density. These conditions should therefore be sought by medical history, physical examination and appropriate investigations. The management of patients with acute vertebral fractures should include measures to reduce pain and improve mobility, as well as starting treatment for osteoporosis. Treatments have now been shown in randomized controlled trials to improve bone density and reduce the incidence of vertebral and non-vertebral fractures in patients with osteoporosis. Choice of treatment will depend on the underlying causes of bone loss, efficacy in any particular situation, cost, patient preference and the potential non-skeletal advantages and disadvantages.

[Rheumatoid arthritis and recurrent rheumatism associated with sclerosing cholangitis]. / Polyarthrite rhumatoïde et rhumatisme palindromique associés à une cholangite sclérosante.

The authors report two cases presenting to a rheumatologist, one with palindromic rheumatism and previously undiagnosed ulcerative colitis, and one with rheumatoid arthritis. Both were subsequently found to have early sclerosing cholangitis with some response treatment.

Diseases associated with calcium pyrophosphate deposition disease.

Although many metabolic and endocrine diseases have been reported to predispose to calcium pyrophosphate dihydrate crystal deposition, the validity of many of these associations remains unclear. A critical review of the literature relating to these associations, with illustrative cases and data derived from the authors' own experience, is presented. It is concluded that there is good evidence to associate hypophosphatasia, hypomagnesemia, and hyperparathyroidism with chondrocalcinosis and acute attacks of "pseudogout." Meta-analysis also suggests a small but significant association between hypothyroidism and chondrocalcinosis. Hemochromatosis stands alone in clearly associating not only with chondrocalcinosis but also with structural change and chronic arthropathy. The biochemical mechanisms that may produce these various associations are discussed. Recommendations are made concerning appropriate screening for metabolic and endocrine disease in patients with chondrocalcinosis.

Crystal deposition in hypophosphatasia: a reappraisal.

Six subjects (three female, three male; age range 38-85 years) with adult onset hypophosphatasia are described. Three presented atypically with calcific periarthritis (due to apatite) in the absence of osteopenia; two had classical presentation with osteopenic fracture; and one was the asymptomatic father of one of the patients with calcific periarthritis. All three subjects over age 70 had isolated polyarticular chondrocalcinosis due to calcium pyrophosphate dihydrate crystal deposition; four of the six had spinal hyperostosis, extensive in two (Forestier's disease). The apparent paradoxical association of hypophosphatasia with calcific periarthritis and spinal hyperostosis is discussed in relation to the known effects of inorganic pyrophosphate on apatite crystal nucleation and growth.

Urinary glycosaminoglycan excretion in systemic sclerosis subsets compared with normal controls.

Urinary glycosaminoglycan (GAG) excretion was studied in 30 patients with established systemic sclerosis and compared with 30 normal controls. There was no significant difference in excretion values in the patient group as a whole, but in the group defined as 'incomplete CREST' urinary GAG values were lower than the group with 'diffuse disease' and controls.

Comparison of urinary glycosaminoglycan excretion in rheumatoid arthritis, osteoarthritis, myocardial infarction, and controls.

Urinary glycosaminoglycan (GAG) excretion was measured in 24 patients with active rheumatoid arthritis (RA) before and after treatment with conventional second-line agents. Urinary GAG excretion was also measured in normal controls, patients with osteoarthritis (OA), and patients with acute myocardial infarction (MI). Total GAG excretion was increased in the RA group and fell after second-line therapy (p less than 0.01). More low than high molecular weight GAG was excreted in the active RA group, and this pattern was reversed after treatment. Excretion of total, high and low molecular weight GAG in the OA group did not differ significantly from controls. Total GAG excretion was increased in the MI group when compared with controls (p less than 0.02) and consisted mainly of high molecular weight GAG. The serial measurement of urinary GAG provides a further index of disease activity and may help to monitor response to treatment.