Blog

Does DAS28 remission equal healthy joints?

2012-03-05T03:52:47Z

Sadly, no. Patient’s in DAS28 remission continue to have ongoing joint damage if they still have swollen joints.

Other interesting side points:

15% of patients on methotrexate monotherapy achieve DAS28 remission
Joint damage is related to acute-phase response and swollen joint counts
Joint damage is not related to tender joint counts

Aletaha D, Smolen JS. Joint damage in rheumatoid arthritis progresses in remission according to the Disease Activity Score in 28 joints and is driven by residual swollen joints. Arthritis Rheum. 2011;63(12):3702–3711.

Modified Phalen's test

2012-02-07T01:50:06Z

This article^[1] examined a modification of the Phalen's test vs. the traditional Phalen's test for carpal tunnel syndrome using NCS as the gold standard. NCS has been shown to give sensitivities of 50-85% and specificities in the high 90s.^[2] In this study of 37 patients (66 hands) both the traditional and the modified Phalen's had specificities of 100% but the modified Phalen's was much more sensitive at 85% compared to 50% for the traditional Phalen's.

The modified Phalen's is almost as easy to perform, needing only a monofilament in addition to the standard wrist flexion maneuver.

Clinically, I'm not sure I'm going to use this in my clinic. I don't have monofilaments, but I bet I could get some from my primary care colleagues. The problem is, if I'm only gaining a bit of sensitivity, if the symptoms are concerning, I'll just treat them. If they don't respond to conservative treatment, I'm probably going to get an NCS anyway. I don't see that adding the monofilament is going to change my practice.

Still. I could be wrong. Certainly is something to think about.

[1]: Bilkis S, Loveman DM, Eldridge JA, Ali SA, Kadir A, McConathy W. Modified Phalen's test as an aid in diagnosing carpal tunnel syndrome. Arthritis Care Res. 2012;64(2):287–289.

[2]: Practice parameter: Electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. 2002;58(11):1589–1592.

ANCA vasculitis video from the Cleveland Clinic

2012-01-06T04:56:49Z

This is a pretty good video covering some recent studies in ANCA vasculitis from the Cleveland Clinic.

I was enjoying it up until minute 25 when Drs. Calabrese and Hoffman made some inappropriate comments about how patients with ANCA vasculitis need to be treated at large centers like theirs.

Maybe Dr. Hoffman was "ill equipped to take care of these patients" when he was a "general rheumatologist" but treatment of ANCA vasculitis really isn't that difficult, most patients do not have the means or desire to travel to some place like the CC for chronic care, and I think most rheumatology fellows these days are training soley in the treatment of autoimmune diseases and not chronic pain syndromes like when they were in training. This ivory tower arrogance is disappointing.

Erosive osteoarthritis, PAPA, MTP synovitis and cryoglobulinemic vasculitis

2011-12-19T04:54:58Z

The first paper describes a rare disease that as an adult rheumatologist who does not see pediatric patients I will probably never be the first to make this diagnosis (hopefully), which is all the more important that I have "exposure" to these patients via several nice case reports laid out in this well-written article. Certainly, this topic is fair game on the boards and is a disease that I would likely be the "expert" for in my community. As these patients age, I could be taking over their care from their pediatric rheumatologists so it's good to have a paper like this in my Papers library for future reference.

Genotype, phenotype, and clinical course in five patients with pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA) syndrome.

Andrew P Demidowich, Alexandra F Freeman, Douglas B Kuhns, Ivona Aksentijevich, John I Gallin, Maria L Turner, Daniel L Kastner, and Steven M Holland. Arthritis Rheum, 2011.

This next paper examined symptoms and pain medication use in patients with erosive osteoarthritis presenting to a rheumatology outpatient clinic, comparing them to patients with regular osteoarthritis and well-controlled rheumatoid arthritis and psoriatic arthritis with prior structural damage. As I would have assumed from my own experience, the pain and disability in erosive osteoarthritis is worse than in osteoarthritis and well-controlled inflammatory arthritis. My own frustration with erosive osteoarthritis is how damaging it is to the joints similar to severe cases of rheumatoid arthritis but without any of the good DMARD therapy that we have for the inflammatory arthropathies.

Interestingly, 60% of the consecutively presenting patients with osteoarthritis in this study had the erosive type. This likely was due to a selection bias with the more difficult to treat cases of erosive osteoarthritis being referred to rheumatologists.

This paper highlights the need to have far better treatment modalities in erosive osteoarthritis. It also should be a caution to some of the online rheumatology patient communities who have a habit of degrading those with osteoarthritis as if in some way it's not as bad as their own disease.

Predictors of functional impairment and pain in erosive osteoarthritis of the interphalangeal joints: Comparison with controlled inflammatory arthritis.

Ruth Wittoek, Bert Vander Cruyssen, and Gust Verbruggen. Arthritis Rheum, 2011

Rheumatoid arthritis likes to attack the MTPs. Joint counts and disease activities scores that don't include the feet end up missing active disease there and underestimating disease activity. Not surprising, but good to have data proving this.

Active foot synovitis: Criteria for remission and disease activity underestimate foot involvement in rheumatoid arthritis.

Mihir D Wechalekar, Susan Lester, Susanna M Proudman, Leslie G Cleland, Samuel L Whittle, Maureen Rischmueller, and Catherine L Hill. Arthritis Rheum, 2011

Finally, two papers accepted this month for publication studied the use of rituximab for the treatment of Cryoglobulinemic Vasculitis. Both demonstrated impressive results. The first paper was an open label trial of weekly rituximab vs standard care with 10 of 12 achieving the primary end point of remission compared to only 1 of 12 in the control group. The second paper was also unblinded with rituximab 1 gram given two weeks apart vs. steroids or cyclophosphamide or plasmapheresis. The rituximab group showed attainment of the primary end-point of survival in 63% vs. 4%, necessitating the trial be stopped on ethical grounds given the clear superiority of the treatment. Again, both trials show impressive results and I think it's clear that rituximab will become the standard therapy for cyroglobulinemic vasculitis as well as future therapy in similar diseases.

A randomized controlled trial of rituximab following failure of antiviral therapy for hepatitis C-associated cryoglobulinemic vasculitis.

Michael C Sneller, Zonghui Hu, and Carol A Langford. Arthritis Rheum, 2011

A randomized, controlled, trial of rituximab for treatment of severe cryoglobulinemic vasculitis.

S De Vita, L Quartuccio, M Isola, C Mazzaro, P Scaini, M Lenzi, M Campanini, C Naclerio, Tavoni A, M Pietrogrande, C Ferri, Mt Mascia, P Masolini, A Zabotti, M Maset, D Roccatello, AL Zignego, P Pioltelli, A Gabrielli, D Filippini, O Perrella, S Migliaresi, M Galli, S Bombardieri, and G Monti. Arthritis Rheum, 2011

Facet injections have large failure rate

2011-12-02T17:32:36Z

failure rates for facet interventions for the treatment of axial spine pain have ranged from 39% to 47%, and persistent pain is common.

via Rheumatology News