Turkish Journal of Rheumatology - 2009; 24(3) - Current Issue

From the Editor

Deniz Evcik — 2009-09-01

The Ultrastructural Analyses of Meniscus Histology in Osteoarthritic Knees

Alper Kaya, Sibel Serin K�l��o�lu, Berk G��l�, Esra Erdemli, �smet Teoman Benli — 2009-09-01

Objective: Menisci are fibrocartilage tissue that have many functions in the knee joint. Studies showed the early progression of osteoarthrtic changes after meniscectomy. The osteoarthritic knee has some meniscal changes associated with articular cartilage degeneration. This study aimed to investigate the ultrastructural meniscal changes in degenerated knee joints. Materials and Methods: Samples were excised from patients who underwent total knee arthroplasty for primary varus osteoarthritis of the knee joint. Twenty medial menisci were examined histologically by light microscopy and transmission electron microscopy and compared with two normal menisci samples. Results: Ultrastructure of the tissue specimens taken from the pathologic meniscus group demonstrated a heterogeneous course in the collagen fibers. It was composed of concentric lamellae of fibrous bundles that were disorganized in some areas. Moreover, the amount of collagen fibers was decreased qualitatively in these groups. While metachromasia was remarkable around nearly all of the chondrocytes in the control group, it was detected especially in the matrix of the cell proliferation region in the degenerated meniscus group. Chondrocytes were oval and elongated cells in the degenerated menisci. The territorial matrix was mostly sparse or absent in the degenerated menisci; however, there were also instances where a typical chondrocyte was surrounded by territorial matrix containing proteoglycan particles and fibrils. Intracytoplasmic small lipid droplets in the chondrocytes of normal meniscus were also present but they were of more frequent occurrence and more prominent in size in the degenerated meniscus group. Electron dense gigantic calcified bodies in the intercellular matrix were also seen in the degenerated menisci specimens. One of the important findings of the study is the decreased synthesis of glycosaminoglycan in the degenerated menisci. Conclusion: This study shows the secondary structural changes of the meniscus in the osteoarthritic knee joint. (Turk J Rheumatol 2009; 24: 118-22)

Value of Ultrasonography on Diagnosis and Assessment of Pain and Grip Strength in Patients with Lateral Epicondylitis

Serdar Tarhan, Zeliha �nl�, G�lg�n Y�lmaz Oval�, Y�ksel Pabu��u — 2009-09-01

Objective: Lateral epicondylitis (LE) is generally diagnosed clinically. Ultrasonography (US) can provide useful information about the location, extent, and severity of LE. Our objective was to use US to confirm LE and to investigate the relationships between pain, grip strength, physical examination, and disability in these patients. Material and Methods: Fifty-two patients with unilateral LE were examined by US. Pain and functional status were assessed using a visual analog scale (VAS), physical functioning and bodily pain scales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and a patient-rated forearm evaluation questionnaire (PRFEQ). Grip strength and manual tests for LE were evaluated. Results: Clinical diagnosis of LE was confirmed by US in 28 (53.8%) patients. Our results showed close associations between clinical examination findings and SF-36 and PRFEQ assessments with pain in patients who had sonographic abnormalities. Grip strength was also correlated with clinical and functional evaluations in these cases. Conclusion: We concluded that evaluation of disability in LE requires methods different from those included in the traditional clinical examination. Pain and grip strength measurements provide numerical and quantitative data for evaluation of severity and disability in patients with sonographic findings of LE. (Turk J Rheumatol 2009; 24: 123-30)

Soluble CD30 Levels in Patients with Rheumatoid Arthritis

Birkan Sonel Tur, �ebnem Ataman, Nurben S�ld�r, Nur�en D�zg�n, Mesut Birol Atay — 2009-09-01

Objective: We aimed to determine serum soluble CD30 (sCD30) levels in patients with rheumatoid arthritis (RA) and to analyze their clinical significance in these patients. Materials and Methods: The study group consisted of 49 patients who fulfilled the 1987 American College of Rheumatology diagnostic criteria for RA, and 20 age- and gender-matched healthy controls. Morning stiffness (minutes), pain (visual analog scale, 0-100 mm VAS), fatigue (5-point scale), patient's and physician's general health assessment (0-100 mm VAS), number of tender and swollen joints (total 28 joints), disease activity (DAS28 score), and physical function capacity (disability) (Turkish version of the health assessment questionnaire, HAQ) were assessed. Presence of extraarticular manifestations was recorded. Radiographic assessment of hands and feet was evaluated according to the modified Sharp method. Routine laboratory tests, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor, immunoglobulins, and complements levels were determined by nephelometry. Serum sCD30 levels of the patients with RA and healthy controls were measured by ELISA. Results: The mean age was 51.1�13.1 years. The mean disease duration was 7.7�5.1 years. The median DAS28 score was 4.3 (2.3-6.8) and the median HAQ score 1.1 (0-3). The serum levels of sCD30 were significantly increased in RA patients (25.1�18.3 IU/ml) compared to healthy controls (17.2�8.1 IU/ml) (p=0.004). The mean serum level of sCD30 was not different between the low active and moderate/high active patient groups. There was a correlation between sCD30 level and extraarticular involvement (p=0.009, r=0.37) and physician's general health assessment (p=0.008, r=0.38). Conclusion: The present data suggest a possible involvement of CD30+ T cells in the immune processes of RA. Serum sCD30 levels might be a helpful tool for the evaluation of Th2 activity in RA. However, the relationship between sCD30 and clinical disease activity remains uncertain. Therefore, we suggest the need for further studies to investigate its clinical importance. (Turk J Rheumatol 2009; 24: 131-5)

Effectiveness of Iontophoresis Treatment on Knee Osteoarthritis

�zlem Alt�nda�, Neslihan Soran, Metin Er�in, Leman Ege — 2009-09-01

Objective: Osteoarthritis is the most common joint disease causing disability. The primary goals for osteoarthritis therapy are to relieve pain, maintain or improve functional status, and minimize deformity. Many treatment options, including non-pharmacological and pharmacological measures, have been recommended in the management of osteoarthritis. Among the non-pharmacological approaches is physiotherapy, which involves the use of physical modalities like heat therapy, exercise therapy, electrical stimulation, therapeutic ultrasound, iontophoresis, and phonophoresis. The aim of our study was to retrospectively evaluate the efficacy of iontophoresis in patients with knee osteoarthritis. Materials and Methods: The study group included 40 patients with knee osteoarthritis to whom ketoprofen gel iontophoresis was applied. Pre-treatment and post-treatment pain, functional status and physical limitation were evaluated by Visual Analogue Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Lequesne Index, respectively. Results: There was significant difference between the pre- and post-treatment evaluation in all parameters (p<0.05). Conclusion: Iontophoresis may be considered as an alternative therapy in knee osteoarthritis that is inexpensive, simple and non-invasive. (Turk J Rheumatol 2009; 24: 136-9)

Effect of Oral to Subcutaneous Switch of Methotrexate on Disease Activity in Rheumatoid Arthritis Patients

Lale Akbulut Aktekin, Filiz Eser, Hatice Bodur, Ahmet Tuto�lu — 2009-09-01

Objective: The aim of this study was to evaluate the effect of switching to subcutaneous (sc) methotrexate (MTX) from oral MTX treatment on disease activity in rheumatoid arthritis (RA) patients. Material and Methods: The efficacy of MTX usage and its administration route on disease activity in RA patients were evaluated retrospectively in patients who received oral MTX first and were afterwards switched to sc MTX. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values, DAS 28 disease activity score and side effects were recorded before initiation of oral MTX treatment (baseline), at the time of switch to sc MTX, and at 6th and 12th months of sc MTX usage. The reasons for switching the treatment route were recorded. Results: Sixteen (80%) female and 4 (20%) male subjects, with an average age of 50.25�12.35 years (29-70), were included in the study. Reductions in DAS 28 values were significant between baseline and at the time of switch to sc MTX and between initiation of sc MTX and at 6th months of sc MTX treatment. There were no significant side effects leading to discontinuation of the sc MTX treatment. Conclusion: MTX therapy may be switched from oral to sc form before the other disease-modifying drugs when the drug is inefficient in controlling disease activity or causes gastrointestinal side effects in RA patients. (Turk J Rheumatol 2009; 24: 140-3)

Short-Term Efficacy of Pulsed Electromagnetic Field Therapy on Pain and Functional Level in Knee Osteoarthritis: A Randomized Controlled Study

Duygu Geler K�lc�, G�l�in G�l�en, Elif �i�dem Altunok — 2009-09-01

Objective: We aimed to determine the efficacy of pulsed electromagnetic field therapy on pain and functional level in knee osteoarthritis when compared to therapeutic ultrasound (US) and controls. Material and Methods: Forty-five patients with knee osteoarthritis (mean age: 63.5�10.2 years) were randomly assigned to three groups. The first group received pulsed electromagnetic field therapy (frequency: 2 Hz, 100 Hz, 25 Hz consecutively, 35 minutes/ session), the second group received therapeutic US (frequency: 1 MHz, power: 1.5 watt/cm2 continuously, 10 minutes/session) and the third group served as the no- treatment control group. Evaluations were done at baseline and at the end of the treatment (third week). Assessment parameters were pain, stiffness and functional level scores of the Western Ontario and McMaster Universities (WOMAC) questionnaire and pain severity evaluated by Visual Analog Scale (VAS) (0-10). Results: VAS (p=0.005), WOMAC pain score (p=0.001), WOMAC joint stiffness score (p=0.027) and WOMAC functional level score (p=0.003) significantly improved in the first group. VAS (p=0.001), WOMAC pain scores (p=0.008), WOMAC stiffness scores (p=0.012) and WOMAC functional level (p=0.004) scores significantly improved in the second group as well. No change was observed in any assessment parameter in the third group (p>0.05). There were differences between groups regarding the percent change in VAS scores (p<0.001), WOMAC pain scores (p<0.001), WOMAC joint stiffness scores (p=0.013) and WOMAC functional level scores (p<0.001) after the treatments. Conclusion: Both the pulsed electromagnetic field and therapeutic US were significantly more effective than no treatment. The pulsed electromagnetic field may be applied as an effective and alternative therapy approach in knee osteoarthritis. (Turk J Rheumatol 2009; 24: 144-8)

Strontium Ranelate for the Treatment of Post-Menopausal Osteoporosis

Ismahan Bozbey, Ay�e Peyman Yal��n — 2009-09-01

Strontium ranelate is a new agent developed for the management of post-menopausal osteoporosis. It has dual action on bone metabolism in that it stimulates the formation of new bone tissue and decreases bone resorption. There are evidences that CaSR-dependent and -independent pathways mediate the beneficial effects of strontium ranelate. It was found that strontium ranelate reduces vertebral, nonvertebral and major nonvertebral fractures and it is well tolerated over 1, 3, 4, and 5 years in post-menopausal osteoporosis. A reduction in vertebral and nonvertebral fracture risk was also shown in senile osteoporosis, and it was well tolerated. It has been suggested that strontium ranelate is able to reduce the progression of spine osteoarthritis. Here, we review strontium ranelate's mechanism of action, results of efficacy and tolerability studies and its place in the management of post-menopausal osteoporosis. (Turk J Rheumatol 2009; 24: 149-55)

Acute Myocardial Infarction in a Child with Systemic Lupus Erythematosus and Antiphospholipid Syndrome

2009-09-01

Systemic lupus erythematosus (SLE) is a chronic, autoimmune, complex, multi-organic and episodic disease. Approximately 15% of all cases experience onset in childhood and adolescence. The coronary pathology has been recognized as the primary cause of morbidity and mortality in patients with SLE, with an incidence 9 times higher and an attributed mortality of up to 36%. Different mechanisms, alone or combined, have been implicated in the pathogenesis of coronary disease in patients with SLE. The procoagulant state in SLE patients promotes the development of acute coronary events, determined not only by the antiphospholipid antibodies, but also by the high levels of fibrinogen and plasminogen inhibitor-1. The antiphospholipid syndrome (APS) is characterized by vascular thrombosis, pregnancy loss, and thrombocytopenia with antiphospholipid antibodies. The cardiac system is one of the primary targets in APS. Patients with SLE and APS have an increase risk of acute myocardial infarction (10 times greater). Prospective studies have demonstrated the association between antiphospholipid antibodies and the first episode of venous thrombosis, acute myocardial infarction and cerebral vascular accidents. We present the clinical case of a 13-year-old male with a diagnosis of SLE and secondary APS with an extensive acute myocardial infarction. In our patient, coronary alterations were not found, which correlates more to APS. It is important to remember that patients with SLE and secondary APS may develop thrombotic complications at any level, and even though thrombotic or ischemic cardiac events are unusual, they must always be considered. (Turk J Rheumatol 2009; 24: 156-8)

Coexistence of Psoriatic Spondyloarthropathy and Gout: A Case Report

Yasemin Turan, Zehra Kocaa�a, Hikmet Ko�yi�it, Alev G�rgan, Bayram Korhan — 2009-09-01

We present a 60-year-old male patient who had concurrent psoriatic spondyloarthropathy and gout, which has not been reported in the literature previously. In this paper, the clinical and radiological features of both rheumatic diseases are discussed in light of the recent literature. (Turk J Rheumatol 2009; 24: 159-62)

Klippel-Feil Syndrome and Dextrocardia: A Case Report

Erkan Kaya, Ali Hikmet Kayar, Selahattin �zy�rek, Memduh Dursun — 2009-09-01

Klippel-Feil syndrome is a congenital malformation that exists because of a failure of the normal segmentation of cervical somites during the third and eighth weeks of gestation. The classical triad includes short neck, low hair line, restriction in neck motion, and fusion of at least two cervical segments. Patients with Klippel-Feil syndrome usually present with the disease during childhood but may present later in life. In this case report, we present a 17-year-old female patient with cervical vertebra anomalies, scoliosis, Sprengel's deformity, dextrocardia, and costa anomalies (13 costa on the right side and 11 costa on the left side). (Turk J Rheumatol 2009; 24: 163-5)

A Case of Axial Spondyloarthritis without Sacroiliitis

�mit Se�kin, Hatice Bodur, Filiz Eser — 2009-09-01

Our case is an HLA B27-positive 60-year-old female patient who had been suffering from inflammatory back and heel pain for 10 years. While sacroiliitis was not observed on either magnetic resonance imaging or pelvic X-ray, all possible radiographic findings of axial spondylitis and enthesopathy were observed on the radiographs, including bamboo spine and trolley track sign. We thus stress the diagnostic difficulties. (Turk J Rheumatol 2009; 24: 166-9)