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Objective: To assess, using the OMERACT-OARSI criteria, the clinical response of patients presenting with symptomatic hip osteoarthritis (OA) to one intra-articular injection of hylan G-F 20., Methods: Open-label, multi-centre, prospective, pilot study. Fifty-six patients presenting with primary hip OA, Kellgren-Lawrence grade II-III, age > or =40, with walking pain measuring 50-90 mm on a 100 mm visual analogue scale (VAS). Intra-articular injection of a single 2 ml dose of hylan G-F 20 into the hip joint under fluoroscopic guidance. A second injection could be administered at day (D) 30, 60 or 90 if pain was unchanged or returned to baseline levels. EFFICACY CRITERIA: The outcome of the first injection in the intent-to-treat (ITT) population was analysed 90 days after the injection in those patients that received a single injection, and on the day of the second injection in those patients that required two injections, using OMERACT-OARSI responder criteria (obtained from WOMAC A and C indices and the patient's global evaluation) and variation in walking pain on VAS., Results: The percentage of responders according to the OMERACT-OARSI response criteria was 53.6%. An inverse correlation was observed between reduction in pain and joint space narrowing score (P=0.03)., Conclusion: In the absence of a control group, the efficacy of the treatment cannot be determined conclusively. Nevertheless these data suggest that hylan G-F 20 is a symptomatic treatment of hip OA, particularly in less severe radiological cases. A double-blind, controlled study is required to confirm these data.

Proinflammatory cytokines such as interleukin-1 beta and, to a lesser extent, tumor necrosis factor (TNF) alpha, play a key role in the destruction of the cartilage matrix in osteoarthritis. Intraarticular injection of specific IL-I inhibitors or antagonists has been shown to slow disease progression in animal models of osteoarthritis. A first randomized placebo-controlled trial of a IL-1 beta antagonist (a single intraarticular injection of 50 or 150 mg) had no analgesic effect during 3 months of follow-up. However, 150 mg of IL-1 ra had an early analgesic effect. Anti-TNF alpha therapy has also been tested in isolated cases of digital and knee osteoarthritis. Cytokine targeting in osteoarthritis is thus an appealing approach but one that needs to be validated in terms of the risk-benefit ratio.

Objective: To estimate the best Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) cutoff based on patients' perceptions of symptom relief collected in a large population of patients with spondyloarthropathies (SpA), in comparison to the BASDAI cutoff determined by experts., Methods: A survey of patient perceptions about current disease control was conducted among the members of Spondylis, one of the main not-for-profit SpA patient organizations in France. BASDAI was among data collected by the questionnaire. To estimate the best BASDAI cutoff for discriminating between poor and well perceived controlled groups, we plotted the receiver operating characteristic (ROC) curve. We also determined the cutoff separately in male and female patients., Results: Of the 1000 mailed questionnaires, 485 were returned without any missing data regarding perceived disease control and the BASDAI. Of these patients, 55.3% perceived inadequate control of their disease. The mean BASDAI in the overall population was 43.5 +/- 22.9, 30.4 +/- 19.9 in the well controlled group and 54 +/- 19.4 in the poorly controlled group (p < 0.001). The best BASDAI cutoff for discriminating between patients in the 2 groups was 39 (sensitivity 74.6% and specificity 72.4%). According to gender, the best cutoff was 44 for women and 36 for men., Conclusion: The best BASDAI cutoff of 39 based on patients' perceptions was very similar to that selected by international experts, i.e., 40. Gender affected the cutoff for perceived symptom relief in our study. These results need to be confirmed by further studies collecting the opinions of both patients and physicians.

Objective: To report early experience of switching anti-tumor necrosis factor-a (TNF-alpha) therapy from infliximab to etanercept in patients with spondyloarthropathy (SpA) and psoriatic arthritis (PsA)., Methods: Thirteen patients with various SpA (7 with ankylosing spondylitis and 6 with undifferentiated SpA) and 2 patients with PsA were receiving infliximab. Because they were experiencing inadequate response or adverse events, therapy was changed to etanercept. Patients were evaluated for response to the change in anti-TNF-alpha therapy at baseline, after 3 months, and then every 6 months., Results: During the mean 10-month followup after the change in therapy, 9 of 13 patients with SpA and both patients with PsA responded to etanercept and none experienced intolerance to this agent., Conclusion: These data suggest that switching between anti-TNF-alpha drugs may be useful for patients with SpA who are unresponsive or intolerant to a first anti-TNF-alpha agent.

Objective: Interleukin 1 (IL-1) plays a pivotal role in the pathogenesis of osteoarthritis (OA). In animal models of OA, IL-1 blockade by IL-1 receptor antagonist (IL-1Ra) can slow the progression of disease. We examined the safety of intraarticular (IA) injections of recombinant human IL-1Ra in patients with knee OA., Methods: A prospective multicenter trial was conducted using the continual reassessment method. Six doses were considered, 0.05 mg up to 150 mg IL-1Ra, and the trial was double-blind regarding the dose administered. Patients with symptomatic knee OA and without synovial fluid effusion were included. Acute inflammatory reaction (the primary endpoint defining intolerance) was recorded if pain increase over 30 mm on 100 mm visual analog scale and synovial fluid effusion occurred within 72 h after the IA injection. As a secondary aim, efficacy was estimated (by total pain and Western Ontario and McMaster University OA functional index) until Month 3., Results: One patient received 0.05 mg and 13 patients received 150 mg of IL-1Ra. No acute reaction occurred (one patient experienced postinjection joint swelling with no pain) and the 150 mg dose was considered the maximum tolerated dose (intolerance level 0%; confidence interval 0, 9.1%). A significant improvement was still observed until Month 3 in the 13 patients who received 150 mg IL-1Ra: pain improved by -20.4 +/- 23.3 mm (p = 0.008) and WOMAC global score by -19.5 +/- 20.1 (p = 0.005)., Conclusion: IA injection of IL-1Ra in patients with knee OA was well tolerated and did not induce any acute inflammatory reaction. The feasibility of such IA injections of IL-1Ra opens a promising therapeutic perspective for patients with OA.

Objective: To describe in a large population of patients with spondyloarthropathy (SpA) the proportion and characteristics of individuals whose disease was poorly controlled by their current treatment, compared to patients whose disease was well controlled., Methods: We conducted a survey among the members of Spondylis, one of the main not-for-profit SpA patient organizations in France. One thousand anonymous questionnaires were sent to patients throughout France. Among collected data were the opinions of patients about control of their symptoms as well as their past and current treatment., Results: Five hundred and seven respondents were included in the study of whom 75.9% were receiving nonsteroidal antiinflammatory drugs (NSAID), 55% reported inadequate control, and 45% good control of their nocturnal pain and morning stiffness. The Bath Ankylosing Spondylitis disease activity index (BASDAI) and functional index (BASFI) scores and the rates of occurrence of main symptoms were significantly higher in the group with poorly controlled disease. All drugs except NSAID were more often used currently and in the past by patients with poor disease control., Conclusion: Conventional treatments failed to provide adequate symptom relief in over half the patients with SpA, despite the use of various drugs in the vast majority of them. Although our results were obtained in a selected patient population, they suggest that a rather large proportion of SpA patients might be candidates for biotherapies.

Objectives: To assess knowledge of ankylosing spondylitis (AS) by patients and to identify factors associated with knowledge., Methods: Ninety patients receiving follow-up in France for AS completed a disease knowledge auto-questionnaire yielding a correct answer score [CAS] and a correct item score [CIS]. Correlations between these scores and other factors were examined., Results: Mean CAS was 16.4/25 (SD = 4.8) and mean CIS 7.3 +/- 3.1/14. Female gender, higher educational level, having read about AS, being aware of AS support groups, and having received longer tertiary-care hospital management were associated with better knowledge. In the multivariate analysis, only three factors were independently associated with the level of knowledge in this population: "reading about AS", "level of general education", and "awareness of an AS support group"., Conclusion: Knowledge of AS by French patients was lower than previously reported in a British population. Although education should be offered to all AS patients, the need may be greater in those with limited formal schooling. Booklets on the disease and contact with patient groups seem to be useful tools for improving knowledge of the disease.

Objective: There is evidence that autoimmunity plays a significant role in the pathogenesis of relapsing polychondritis (RP). This study was designed to investigate circulating levels of various cytokines in relation to the etiology of this rare disorder, and to compare the pattern of cytokine elevations in RP with that in another autoimmune disease, rheumatoid arthritis (RA)., Methods: Serum from 22 patients with active RP and an equal number of age- and sex-matched healthy controls and RA patients were available for analysis. The following cytokines were measured: interleukin-1beta (IL-1beta), IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17, interferon-gamma (IFNgamma), tumor necrosis factor alpha, granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), monocyte chemoattractant protein 1 (MCP-1), and macrophage inflammatory protein 1beta (MIP-1beta). Results were analyzed by nonparametric Mann-Whitney test with Holm stepdown adjustment for multiple testing., Results: The levels of 3 of these cytokines showed significant differences between RP patients and controls. Compared with controls, mean serum levels of MCP-1, MIP-1beta, and IL-8 were all much higher in patients with active RP. In contrast, RA patients showed a more general increase in all cytokines measured, with much higher levels of IL-2, IL-4, IL-5, IL-6, IL-7, IL-10, IL-13, IFNgamma, G-CSF, GM-CSF, MCP-1, and MIP-1beta compared with controls., Conclusion: Levels of 3 serum cytokines were significantly higher in RP patients than in age- and sex-matched controls. One of these 3 cytokines, IL-8, was not significantly elevated in RA samples. Overall, in RP, a more discrete group of cytokines exhibited significantly increased levels than was found in RA. Each of the 3 cytokines that were elevated in RP is a proinflammatory chemokine, characteristic of activation of the monocyte and macrophage lineage, and in the case of IL-8, also of neutrophils. These data suggest a major role for a cell-mediated immune response in the pathophysiology of RP.

Study Design: A case of atypical osseous tuberculosis (TB) mimicking multiple secondary metastases on radiologic and nuclear imaging is presented., Objectives: To emphasize the contribution of nuclear bone scanning for the assessment of osseous tuberculosis in typical and atypical presentations., Summary and Background Data: Skeletal locations of TB mostly involve the dorsolumbar spine and diagnosis is often delayed. The presence of multiple TB sites can mimic secondary metastases and biopsy remains the mainstay for final diagnosis., Methods: Clinical symptoms, lab tests, and imaging data are presented. Possible diagnoses are discussed. A review of imaging characteristics in cases of typical and atypical presentations of osseous TB is proposed., Results: A dorsal spine spondylitis was first diagnosed on a 56-year-old patient presenting neurologic deficit of the left arm. Fine needle aspiration identified bacterial infection but was negative for Mycobacterium tuberculosis. Whole-body bone scan allowed the identification of an asymptomatic sacroiliac lesion, which was accessible to biopsy and gave a final diagnosis., Conclusion: Nuclear bone scanning should be kept in mind when assessing spinal pain in patients at high risk of TB infection or reactivation.

Objective: To describe the safety of tumor necrosis factor-a blockade in 2 patients with inflammatory rheumatic disease with chronic hepatitis B and C., Methods: We used infliximab therapy in 2 patients with chronic inflammatory joint disease and chronic hepatitis B or C. We describe the clinical and laboratory test data obtained in these patients during the first year of treatment. Disease activity, liver function tests, and HCV and HBV status were evaluated before infliximab therapy was started and were reevaluated before each infusion. Liver biopsy was performed in both patients before infliximab therapy., Result: After more than one year of treatment, no worsening in liver function or virological status was observed, while a dramatic clinical improvement of joint disease was observed in both patients., Conclusion: These cases suggest that infliximab therapy may be safe in some quiescent or controlled chronic HBV or HCV infection.