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Rapp C, Boudif F, Bourgoin C, Lohse A, Conrozier T. A Cross-Sectional Study of Factors Predicting the Duration of the Efficacy of Viscosupplementation in Knee Osteoarthritis. J Clin Med 2024; 13:1949. [PMID: 38610715 PMCID: PMC11012299 DOI: 10.3390/jcm13071949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Background: An advanced radiological stage and obesity are predictive of poorer and shorter responses to viscosupplementation in patients with knee osteoarthritis (OA). Very little is known regarding the impact of other factors such as sport practice, comorbidities, or anatomical features of OA. Methods: This study aimed to investigate patients' and OA characteristics associated with the duration of the effectiveness (DE) of viscosupplementation in patients with knee OA. It was a cross-sectional, single-centre clinical trial in patients with knee OA treated with intra-articular (IA) hyaluronic acid (HA) injection(s) within the previous 3 years. The investigators collected data regarding demographic and radiographic features (Kellgren-Lawrence grade and involved knee compartments), dosing regimen (single or repeat injections), the presence and volume of joint effusion, previous or concomitant IA corticosteroid injection, the number of previous viscosupplementations, and comorbidities. Patients completed a questionnaire including the self-assessment of DE (the number of weeks during which viscosupplementation was effective on symptoms), the activity level (sedentary, active, or athletic), and the level of sport activity (light, moderate, or intensive). Predictors of the DE were studied in bivariate and multivariate analyses. Results: In total, 105 patients (149 knees) were analysed (62% women, mean age 66.1 ± 13.2 years, mean BMI 27.5 ± 7.5 kg/m2). The mean DE was 48.2 ± 24.8 weeks. In bivariate analysis, the predictors of a shorter DE were BMI > 27.5 kg/m2, more than three previous viscosupplementations, Kellgren-Lawrence grade 4, sedentary patients, and multicompartmental involvement. In the multivariate analysis, four independent factors remained associated with a shorter DE: BMI > 27.5 kg/m2, multicompartmental knee involvement, number of viscosupplementations >3, and sedentary lifestyle. A statistically significant association between a longer DE and arterial hypertension was found, suggesting a beneficial effect of certain antihypertensive medications. Conclusions: This study confirms that being overweight significantly reduces the duration of the effectiveness of viscosupplementation. It also shows that viscosupplementation is more lastingly effective in unicompartmental OA and among active or athletic patients. The duration of effectiveness decreases when the treatment is repeated more than three times.
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Affiliation(s)
- Charles Rapp
- Department of Rheumatology, Hôpital Nord Franche-Comté, 90400 Belfort, France; (C.R.); (F.B.); (A.L.)
| | - Feriel Boudif
- Department of Rheumatology, Hôpital Nord Franche-Comté, 90400 Belfort, France; (C.R.); (F.B.); (A.L.)
| | - Charlotte Bourgoin
- Clinical Research Unit, Hôpital Nord Franche-Comté, 90400 Belfort, France;
| | - Anne Lohse
- Department of Rheumatology, Hôpital Nord Franche-Comté, 90400 Belfort, France; (C.R.); (F.B.); (A.L.)
| | - Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, 90400 Belfort, France; (C.R.); (F.B.); (A.L.)
- Clinical Research Unit, Hôpital Nord Franche-Comté, 90400 Belfort, France;
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Darsy G, Patarin J, Conrozier T. Large Variations in Resistance to Degradation between Hyaluronic Acid Viscosupplements: A Comparative Rheological Study. Cartilage 2023:19476035231205696. [PMID: 37946382 DOI: 10.1177/19476035231205696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
AIM To compare the resistance to degradation of linear and cross-linked viscosupplements using a rheological model combining mechanical and oxidative stresses, mimicking what happens inside the joint following HA injection. METHODS The rheological properties of 8 HAs were measured using a stress-imposed Rheometer DHR3. Strain sweeps were carried out to evaluate the rheological properties at rest from 0.001 to 3000% at a frequency of 1 Hz. The complex modulus G*, in Pa, and the phase tangent tan δ, dimensionless, in the linear viscoelastic domain (LVED) were extracted. The oxidation tests were conducted by exposing the product to H2O2 for 30 minutes. The effect of oxidation was evaluated by measuring variations of G* and tan δ, using an oscillation time sweep. Those tests were carried out at a frequency of 1 Hz and at 1% strain in the LVED. RESULTS At rest, the different samples exhibited various viscous behaviors. During mixing process, G* decreased from -6.4% to -31.3%. G* of low-molecular-weight HAs decreased more than that of medium molecular weight (MW) and cross-linked products. After oxidative stress, G* variation ranged from -10.1% to -46.3%. Cross-linked HAs and those containing mannitol resisted the best to degradation. CONCLUSIONS We showed large variations in resistance to degradation between viscosupplements. The duration of effectiveness of these products deserves to be compared in randomized clinical studies.
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Affiliation(s)
- Guillaume Darsy
- Rheonova, Gières, France
- Domaine universitaire de Grenoble, Saint-Martin-d'Hères, France
| | - Jeremy Patarin
- Rheonova, Gières, France
- Domaine universitaire de Grenoble, Saint-Martin-d'Hères, France
| | - Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, Trevenans, France
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Conrozier T, Diraçoglù D, Monfort J, Chevalier X, Bard H, Baron D, Jerosch J, Migliore A, Richette P, Henrotin Y. EUROVISCO Good Practice Recommendations for a First Viscosupplementation in Patients with Knee Osteoarthritis. Cartilage 2023; 14:125-135. [PMID: 36443990 PMCID: PMC10416196 DOI: 10.1177/19476035221138958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Viscosupplementation (VS) with hyaluronic acid is widely used in the management of knee osteoarthritis. There is no clear recommendation on the decision-making to achieve VS. DESIGN Based on extensive research of the literature and expert opinion, the members of the EUROVISCO (European Viscosupplementation Consensus Group) task force were asked to give their degree of agreement with 60 issues, using a Delphi method. RESULTS The expert panel achieved unanimous agreement in favor of the following statements: It is recommended to assess pain on a visual or 10-point numeric scale before considering VS. VS can be considered for patients with pain scores between 3 and 8. A standard x-ray must be obtained before the decision of VS. If the x-ray is normal, osteoarthritis must be confirmed by MRI or computed tomography (CT) arthrogram before considering VS. The aims of VS are relieving pain, improving function, and reducing non-steroidal anti-inflammatory drug (NSAID) consumption. The use of VS must not be considered for treating an osteoarthritis flare. VS can be envisaged as a first-line pharmacological treatment in patients having a contra-indication to NSAIDs or analgesics. VS can be considered in patients with contra-indications to arthroplasty. In the case of severe comorbidities (diabetes, hypertension, gastrointestinal disorders, renal failure), VS can avoid the use of potentially dangerous treatments. VS can be considered in patients receiving antiplatelet agents, vitamin K antagonists, and direct factor Xa or thrombin inhibitors. Five other statements obtained a high level of consensus. CONCLUSION These recommendations, illustrated in a decision algorithm, have been established to help practitioners in the decision-making of knee VS.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Demirhan Diraçoglù
- Department of Physical Medicine and Rehabilitation, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Jordi Monfort
- Servei de Reumatología, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Xavier Chevalier
- Department of Rheumatology, Henri Mondor Hospital, Paris XII University, Creteil, France
| | - Hervé Bard
- Rheumatology, Cabinet Médical Vaudoyer, Paris, France
| | - Dominique Baron
- Centre de Réadaptation Fonctionnelle de Lannion-Trestel, Trévou-Tréguignec, France
| | - Jörg Jerosch
- Department of Orthopedic, Johanna Etienne Hospital, Neuss, Germany
| | - Alberto Migliore
- U.O.S. of Rheumatology, Ospedale San Pietro Fatebenefratelli, Rome, Italy
| | - Pascal Richette
- Université Paris Cité, UFR Médicale, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Service de Rhumatologie, Paris, France
| | - Yves Henrotin
- MusculoSKeletal Innovative Research Lab, Université de Liège, CHU Sart Tilman, Liège, Belgium
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Perruchet S, Balblanc JC, Rapp C, Bourgoin C, Guillochon C, Lohse A, Conrozier T. The Association between Radiographic Features and the Duration of Effectiveness of a Single Injection of Extended-Release Hyaluronic Acid (HANOX-M-XL) in Patients with Knee Osteoarthritis: Preliminary Results of a Prospective Trial. Cartilage 2023; 14:136-143. [PMID: 36527367 PMCID: PMC10416203 DOI: 10.1177/19476035221109230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/23/2022] [Accepted: 06/05/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Advanced radiological stage of knee osteoarthritis (OA) is predictive of poor response to viscosupplementation (VS). To date, the impact of x-ray features on the duration of effectiveness (DE) of VS has not been investigated. OBJECTIVES To investigate the radiological features associated with DE of VS in patients with knee OA. METHODS Cross-sectional study in patients with knee OA treated with 1 injection of cross-linked hyaluronic acid (HA). The primary outcome was DE, self-assessed by the patients in weeks of effectiveness. Radiological features (joint space narrowing-JSN topography and Kellgren-Lawrence [K-L] grade) associated with DE were studied. RESULTS Fifty-one patients-33 females (76 knees)-were analyzed. The average DE was 52.0 (24.7) weeks (range, 13-155 weeks). In the bivariate analysis, DE was 14 weeks longer in those with K-L grades 1 and 2 (62.6 ± 36.4 weeks) than in those with K-L 3 and 4 (48.9 ± 18.6) (P = 0.03). DE was not significantly different according to the involved compartment(s). It was significantly longer in men than in women (60 ± 31.4 vs. 47 ± 16 weeks; P = 0.035). In multivariate analysis, K-L grade (1-2 vs. 3-4) (P = 0.007), male gender (0.02), and older age (0.04) were independently associated with a longer DE. CONCLUSION DE of a single injection of extended-release HA is longer in K-L 1-2 than in K-L 3-4 OA knees, regardless of the JSN topography. However, even the patients with more advanced OA benefited from HANOX-M-XL injection for an average duration barely less than 1 year.
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Affiliation(s)
- Solène Perruchet
- Department of Physical Medicine and Rehabilitation, Hospital Jean-Minjoz, Centre Hospitalier Régional Universitaire de Besançon, Besançon, France
| | | | - Charles Rapp
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | | | - Cerise Guillochon
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Anne Lohse
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
- Clinical Research Unit, Hôpital Nord Franche-Comté, Belfort, France
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Migliore A, Alekseeva L, Avasthi SR, Bannuru RR, Chevalier X, Conrozier T, Crimaldi S, de Campos GC, Diracoglu D, Gigliucci G, Herrero-Beaumont G, Iolascon G, Ionescu R, Jerosch J, Lains J, Maheu E, Makri S, Martusevich N, Matucci-Cerinic M, Pavelka K, Petrella RJ, Raman R, Tarantino U. Early Osteoarthritis Questionnaire (EOAQ): a tool to assess knee osteoarthritis at initial stage. Ther Adv Musculoskelet Dis 2023; 15:1759720X221131604. [PMID: 36860967 PMCID: PMC9969428 DOI: 10.1177/1759720x221131604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 09/22/2022] [Indexed: 02/27/2023] Open
Abstract
Background Early stage of osteoarthritis (OA) is characterized by joint stiffness and pain as well as by subclinical structural changes that may affect cartilage, synovium, and bone. At the moment, the lack of a validated definition of early osteoarthritis (EOA) does not allow to make an early diagnosis and adopt a therapeutic strategy to slow disease progression. Also, no questionnaires are available to evaluate the early stage, and therefore this remains an unmet need. Objective Therefore, the purpose of the technical experts panel (TEP) of 'International Symposium of intra-articular treatment' (ISIAT) was to create a specific questionnaire to evaluate and monitor the follow-up and clinical progress of patients affected by early knee OA. Design The items for the Early Osteoarthritis Questionnaire (EOAQ) were identified according to the following steps: items generation, items reduction, and pre-test submission. Methods During the first step, literature has been reviewed and a comprehensive list of items about pain and function in knee EOA was drafted. Then, during the ISIAT (5th edition 2019), the draft has been discussed by the board, which reformulated, deleted, or subdivided some of the items. After the ISIAT symposium, the draft was submitted to 24 subjects affected by knee OA. A score based on the importance and the frequency was created and the items with a score ⩾0.75 were selected. After intermediate evaluation made by a sample of patients, the second and final version of the questionnaire EOAQ was submitted to the whole board for final analysis and acceptance in a second meeting (29 January 2021). Results After an exhaustive elaboration, the final version of the questionnaire contains two domains (Clinical Features and Patients Reported Outcome) with respectively 2 and 9 questions, for a total of 11 questions. Questions mainly explored the fields of early symptoms and patients reported outcomes. Marginally, the need of the symptoms treatment and the use of painkillers were investigated. Conclusions Adoption of diagnostic criteria of early OA is strongly encouraged and a specific questionnaire for the whole management of the clinical features and patients' outcome might really improve the evolution of OA in the early stages of the disease, when the treatment is expected to be more effective.
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Affiliation(s)
| | - Liudmila Alekseeva
- Department of Metabolic Diseases of Bone and
Joints, VA Nasonova Research Institute of Rheumatology, Moscow, Russian
Federation
| | - Sachin R. Avasthi
- Department of Emergency Medicine, Dr Ram
Manohar Lohia Hospital, Lucknow, India
| | - Raveendhara R. Bannuru
- Centre for Treatment Comparison and Integrative
Analysis Division of Rheumatology, Tufts Medical Centre, Boston, MA,
USA
| | | | | | - Sergio Crimaldi
- Chirurgia Ortopedica Mininvasiva e Nuove
Tecnologie, Humanitas Research Hospital, Castellanza, Italy
| | - Gustavo C. de Campos
- Department of Orthopaedics and Traumatology,
University of Campinas, São Paulo, Brazil
| | - Demirhan Diracoglu
- Department of Physical Medicine and
Rehabilitation Division of Pain Medicine, Istanbul University, Istanbul,
Turkey
| | | | | | - Giovanni Iolascon
- Department of Medical and Surgical Specialties
and Dentistry, University of Campania ‘L Vanvitelli’, Caserta, Italy
| | - Ruxandra Ionescu
- Department of Internal Medicine and
Rheumatology Sf. Maria Hospital, University of Medicine and Pharmacy ‘Carol
Davila’, Bucharest, Romania
| | - Jörg Jerosch
- Orthopaedic Department, Johanna Etienne
Hospital, Neuss, Germany
| | - Jorge Lains
- Physical Rehabilitation Medicine Department,
Rovisco Pais Medical and Rehabilitation Centre, Tocha, Portugal
| | - Emmanuel Maheu
- Rheumatology Department, AP-HP, Saint-Antoine
Hospital, Paris, France
| | - Souz Makri
- EUPATI Graduate and Patient Advocate,
Brussels, Belgium
| | - Natalia Martusevich
- Department of Rheumatology, Belorussian State
Medical University, Minsk, Belarus
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical
Medicine, University of Florence, Florence, Italy
| | | | - Robert J. Petrella
- Department of Family Medicine, School of
Kinesiology University Western Ontario, Ontario, ON, Canada
| | - Raghu Raman
- Academic Department of Orthopaedics, Hull and
East Yorkshire NHS Trust Castle Hill Hospital, Cottingham, UK
| | - Umberto Tarantino
- Department of Orthopaedics and Traumatology,
‘Policlinico Tor Vergata’ Foundation, Rome, Italy
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Baron D, Baron H, Baerer C, Bodere C, Conrozier T. Predictors for patient satisfaction of a single intra-articular injection of crosslinked hyaluronic acid combined with mannitol (HANOX-M-XL) in patients with temporomandibular joint osteoarthritis. Results of a prospective open-label pilot study (HAPPYMINI-ARTEMIS trial). BMC Musculoskelet Disord 2022; 23:392. [PMID: 35477406 PMCID: PMC9044650 DOI: 10.1186/s12891-022-05352-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background Chronic pain and functional impairment interfere with the quality of life of subjects suffering from temporomandibular joint (TMJ) disorders. Intra-articular (IA) hyaluronic acid (HA) injections have been shown to alleviate pain and improve mandibular mobility in patients with TMJ osteoarthritis (OA). Objectives The primary aim of the study was to identify the prognostic factors of patient satisfaction for a single IA injection of a mannitol-modified crosslinked HA (HANOX-M-XL) in patients with TMJ-OA. The second goal was to obtain clinical data on effectiveness, safety and mandibular mobility throughout a six-month follow-up period. Patients and methods This was an observational single-arm prospective trial with a six-month follow-up. Inclusion criteria: patients with TMJ-OA which is not relieved by analgesics and/or non-steroidal-anti-inflammatory drugs and/or orthotics, with radiological evidence of TMJ-OA. All patients received a single IA injection of 1 ml HANOX-M-XL in the target TMJ. The primary endpoint was patient satisfaction on day 180. The main secondary outcome measures were pain variation on a 11-point numeric scale (0–11) between the date of injection and month six, the variation over time of the Maximum Inter-Incisal Opening Distance (MIIOD) and the patient’s assessment of effectiveness. Predictive factors of success or failure were also studied. All adverse events were recorded. Results 36 subjects (mean age 55.3 years, mean disease duration 98 months), covering a total of 52 injected TMJs, were included. Between baseline and endpoint, the average pain while chewing decreased dramatically from 6.9 ± 1.2 to 2.9 ± 1.3 (p < 0.0001) and the MIIOD increased from 29 ± 7 to 35 ± 5 mm (p < 0.01). On day 180, all patients were satisfied with the treatment, with 34 patients (94%) rating it as highly effective or effective. Tolerability was good in all but one patient. In the multivariate analysis, patient satisfaction on day 180 was highly correlated with the pain while chewing score, pain on palpation score and the decrease of pain over time (all p < 0.0001) but not with MIIOD, gender, age, bruxism, articular noise and symptom duration. Previous viscosupplementation was also related to higher satisfaction (p = 0.01). Conclusion Despite a long history of pain, most of the patients with symptomatic TMJ-OA benefited from a single injection of HANOX-M-XL, as shown by the sustained (up to 6 months) decrease in pain and improvement in mandibular mobility, with no safety concerns. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05352-3.
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Affiliation(s)
- Dominique Baron
- Consultation pluridisciplinaire de la douleur, Centre de réadaptation fonctionnelle de Lannion-Trestel, Trévou-Tréguignec, France
| | - Hugo Baron
- Cabinet de chirurgie dentaire, Parc d'activités de Coataner, Douarnenez, France
| | - Catherine Baerer
- Consultation pluridisciplinaire de la douleur, Centre de réadaptation fonctionnelle de Lannion-Trestel, Trévou-Tréguignec, France
| | - Céline Bodere
- Faculté d'odontologie, Département des sciences anatomiques, Université de Bretagne Occidentale UBO, Brest, France
| | - Thierry Conrozier
- Service de rhumatologie, Hôpital Nord Franche-Comté, CS 10499 Trévenans, 90015, Belfort, France.
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Abstract
No disease-modifying treatments are currently available for osteoarthritis (OA). While many therapeutic approaches are now being investigated it is ethical to resort to alternative solutions as that we already possess. There are many reasons for thinking that, at sufficiently high doses, glucosamine (GlcN) sulphate possesses a clinically relevant effect on OA pain. Wide inter-individual variations in the symptomatic effects of GlcN are explained by the extreme variability of its bioavailability. In studies evaluating its structure-modifying effect, GlcN was more effective than placebo in reducing the rate of joint space narrowing in patients with knee OA. More recent data suggest that GlcN may be effective in the primary prevention of OA in sportsmen. There is no controversy concerning the safety of GlcN which does not differ to that of placebo. Several studies have recently revealed an unexpected effect of GlcN on cardiovascular mortality. After adjusting for confounding factors, the regular consumption of GlcN correlated with a 27% reduction in mortality and a 58% reduction in deaths from cardiovascular causes. These data confirm animal studies demonstrating a protective effect of GlcN against cancer and cardiovascular diseases due to modulation of the O-GlcNAcylation pathway. Disorders in O-GlcNAcylation are involved in diabetes, obesity and cancers, which all feature chronic low-grade inflammation (CLGI). By regulating CLGI, GlcN may be beneficial to the symptoms of OA, its outcome and to that of the concomitant chronic pathologies, making GlcN as a valuable candidate for the treatment of OA in patients with metabolic syndrome, diabetes or cardiovascular diseases.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Thomas Lohse
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
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Conrozier T, Lohse T. Commentary: New Viscoelastic Hydrogel Hymovis MORE Single Intra-Articular Injection for the Treatment of Knee Osteoarthritis in Sportsmen: Safety and Efficacy Study Results. Front Pharmacol 2022; 12:785074. [PMID: 35002717 PMCID: PMC8727518 DOI: 10.3389/fphar.2021.785074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
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Galois L, Coillard JY, Porterie J, Melac-Ducamp S, Conrozier T. Open-Label Pilot Study of a Single Intra-Articular Injection of Mannitol-Modified Cross-Linked Hyaluronic Acid (HANOX-M-XL) for the Treatment of the First Metatarsophalangeal Osteoarthritis (Hallux Rigidus): The REPAR Trial. Clin Med�Insights�Arthritis�Musculoskelet Disord 2022; 15:11795441211055882. [PMID: 35295206 PMCID: PMC8918964 DOI: 10.1177/11795441211055882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 10/07/2021] [Indexed: 11/15/2022]
Abstract
Purpose: The purpose of this study was to obtain information on safety and short-term efficiency of a single intra-articular injection of mannitol-modified cross-linked hyaluronic acid (HANOX-M-XL) in patients with painful first metatarsophalangeal joint osteoarthritis (1stMTPJ-OA). Methods: The study involved an observational, single-arm, prospective multicentre trial, with a 3-month follow-up. Inclusion criteria were patients with symptomatic 1st MTPJ-OA not relieved by analgesics and / or non-steroidal-anti-inflammatory drugs and / or foot orthotic. All patients received a single, imaging-guided intra-articular (IA) injection of 1 mL of HANOX-M-XL in the 1st MTPJ. The primary outcome was the change in pain between the date of injection and month 3. The secondary outcomes were the patient assessment of effectiveness, the decrease in painkiller use and the influence of the radiographic score on the clinical efficacy. Results: Sixty-five participants (72.3% women, mean age = 60) were included in the trial. Coughlin-Shurnas radiological grade was 1 in 28 patients, 2 in 29, and 3 in 6. At baseline and month 3, the average pain (0-10) was 6.5 ± 1.8 and 2.8 ± 2.3, respectively. The change in pain score was highly significant (−3.1 ± 2.9; P < .0001). At baseline there was no statistically difference in pain between the radiological stages (P = .69). At endpoint, the average pain score was 2.0 ± 1.9 in x-ray stage 1, 3.1 ± 2.3 in stage 2 and 3.3 ± 2.4 in stage 3 (P = .001). Mild to moderate adverse reactions were reported by 15 patients. All were a transient increase of the hallux pain that occurred immediately and up to 6 hours after injection and resolved in 1 to 7 days. Conclusion: This pilot study suggests that a single IA injection of HANOX-M-XL is safe and mainly benefits patients with mild moderate 1st MTPJ-OA. Further randomized controlled trials are necessary to confirm these preliminary encouraging results.
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Affiliation(s)
- Laurent Galois
- Service de chirurgie orthopédique, Centre hospitalier Universitaire de Nancy, Nancy, France
| | - Jean-Yves Coillard
- Service de chirurgie du pied et de la cheville, Clinique Orthopédique du Parc, Lyon, France
| | | | | | - Thierry Conrozier
- Service de rhumatologie, Hôpital Nord Franche-Comté, Belfort, France
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10
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Tiendrebeogo E, Choueiri M, Chevalier X, Conrozier T, Eymard F. Does the Presence of Neuropathic Pain Influence the Response to Hyaluronic Acid in Patients with Knee Osteoarthritis? Cartilage 2021; 13:1548S-1556S. [PMID: 32909439 PMCID: PMC8808856 DOI: 10.1177/1947603520954509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Up to 50% of patients with symptomatic knee osteoarthritis (OA) present with neuropathic pain (NP) features. We assessed the impact of NP according to DN4 (Douleurs Neuropathiques 4 questions) score on the response to intra-articular (IA) hyaluronic acid (HA) injections and the effects of HA injections on NP. MATERIALS AND METHODS We conducted a post hoc analysis from a multicenter, randomized, double-blind, noninferiority trial comparing the efficacy of 2 HA in symptomatic knee OA at 24 weeks. At baseline, demographic, anthropometric, radiologic data, and symptoms were recorded. The symptomatic effect of HA was assessed by VAS pain, patient global assessment (PGA), WOMAC, DN4, and OMERACT-OARSI response. RESULTS A total of 187 patients were included. NP according to DN4 score was present in 20 patients (10.7%) at baseline. Most common positive DN4 items were tingling (36.9%) and burning (36.4%). NP was associated with WOMAC pain score (P = 0.02). The presence of NP at baseline did not affect the symptomatic improvement after HA injections according to the VAS pain (P = 0.71), PGA (P = 050), WOMAC pain (P = 0.89), WOMAC function (P = 0.52), and rate of OMERACT-OARSI responders (P = 0.21). The prevalence of patients with NP decreased by 50% (n = 10) at 24 weeks after HA injections. Most improved DN4 items were itching (90%), hypoesthesia to pinprick (88%), and burning (50%). CONCLUSION In our study, NP was associated with pain severity, but did not influence the response to IA HA. On the other hand, HA injections reduced some NP features, especially itching, sting hypoesthesia, and burning.
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Affiliation(s)
| | - Magda Choueiri
- Department of Rheumatology, AP-HP Henri
Mondor Hospital, Creteil Cedex, France
| | - Xavier Chevalier
- Department of Rheumatology, AP-HP Henri
Mondor Hospital, Creteil Cedex, France
| | - Thierry Conrozier
- Department of Rheumatology, Nord
Franche-Comté Hospital, Belfort, France
| | - Florent Eymard
- Department of Rheumatology, AP-HP Henri
Mondor Hospital, Creteil Cedex, France,Florent Eymard, Department of Rheumatology,
AP-HP Henri Mondor Hospital, 51 avenue du Marechal de Lattre de Tassigny,
Creteil Cedex, F-94010, France.
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11
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Hick AC, Malaise M, Loeuille D, Conrozier T, Maugars Y, Pelousse F, Tits C, Henrotin Y. Cartilage Biomarkers Coll2-1 and Coll2-1NO2 Are Associated with Knee OA MRI Features and Are Helpful in Identifying Patients at Risk of Disease Worsening. Cartilage 2021; 13:1637S-1647S. [PMID: 34128409 PMCID: PMC8808823 DOI: 10.1177/19476035211021892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the cross-sectional association between serum levels of Coll2-1 and Coll2-1NO2, two cartilage degradation biomarkers; the burden of magnetic resonance imaging (MRI) features and clinical outcomes; and to evaluate the predictive value of these biomarkers on progression. DESIGN A total of 121 subjects with knee osteoarthritis (OA) were followed during 1 year with pain, function, and MRI assessment (PRODIGE study). Type II collagen-specific biomarker Coll2-1 and its nitrated form Coll2-1NO2 were directly measured in serum using immunoassays at baseline and after 3-, 6-, and 12-month follow-up. RESULTS Serum Coll2-1 and Coll2-1NO2 were correlated with several baseline knee features quantified with Whole-Organ Magnetic Resonance Imaging Score (WORMS). Coll2-1 was significantly correlated with periarticular cysts/bursitis (ρ = 0.29, P < 0.01), subarticular bone attrition (ρ = 0.25, P = 0.01), subarticular cysts (ρ = 0.24, P = 0.02), and articular cartilage integrity (ρ = 0.23, P = 0.03) WORMS subscores for the whole joint as well as with the medial femorotibial joint sum score (ρ = 0.26, P = 0.01) and medial femorotibial joint cartilage (ρ = 0.23, P = 0.02). Coll2-1NO2 correlated with WORMS total score (ρ = 0.23, P = 0.02), WORMS scores in the patellofemoral (ρ = 0.23, P = 0.02) and medial femorotibial compartments (ρ = 0.21, P = 0.03), with osteophytes scores (ρ = 0.27, P < 0.01), subarticular cysts (ρ = 0.24, P = 0.019), and intraarticular loose bodies (ρ = 0.27, P = 0.007). Baseline Coll2-1NO2 was higher in subjects with a pain worsening (426.4 pg/mL [278.04-566.95]) as compared to non-progressors (306.84 pg/mL [200.37-427.84]) over 1 year (AUC = 0.655, P = 0.015). CONCLUSION Serum cartilage biomarkers Coll2-1 and Coll2-1NO2 are associated with several knee OA features quantified with WORMS. Our study also shows that the baseline value of Coll2-1NO2 is positively associated with pain worsening.
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Affiliation(s)
| | - Michel Malaise
- Department of Rheumatology, CHU Sart
Tilman, University of Liège, Liège, Belgium
| | - Damien Loeuille
- Department of Rheumatology, University
Hospital of Nancy, Vandœuvre-lès-Nancy, France
- UMR 7365 CNRS-Université de Lorraine
IMoPA, Biopôle de l’Université de Lorraine, Campus Brabois-Santé,
Vandoeuvre-Lès-Nancy, France
| | - Thierry Conrozier
- Department of Rheumatology, Hôpital
Nord Franche-Comté, Belfort, France
| | - Yves Maugars
- Service de rhumatologie, Hôtel-Dieu,
CHU de Nantes, France
| | - Franz Pelousse
- SODIRAY, Solution Diagnostique
Radiologique, Liège, Belgium
| | | | - Yves Henrotin
- ARTIALIS SA, CHU Sart-Tilman, Liège,
Belgium
- Bone and Cartilage Research Unit,
Arthropole Liège, Center for Interdisciplinary Research on Medicines (CIRM),
University of Liège, CHU Sart-Tilman, Liège, Belgium
- Physical Therapy and Rehabilitation
Department, Princess Paola Hospital, Vivalia, Marche-en-Famenne, Belgium
- Yves Henrotin, ARTIALIS SA, 11 avenue de
l’hôpital, GIGA Tower, Level 3, CHU Sart-Tilman, 4000 Liège, Belgium.
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12
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Henrotin Y, Tits C, Paul J, Gramme P, Helleputte T, Migliore A, Richette P, Chevalier X, Monfort J, Diracoglu D, Bard H, Jerosch J, Baron D, Raghu R, Conrozier T. Retreatment with Hyaluronic Acid Viscosupplementation in Knee Osteoarthritis: Agreement between EUROVISCO Guidelines and Current Medical Practice. Cartilage 2021; 13:1696S-1701S. [PMID: 34696623 PMCID: PMC8808890 DOI: 10.1177/19476035211053827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES This work studied if and how current clinical practice agrees with European Viscosupplementation Consensus Group (EUROVISCO) recommendations and how this agreement might be different according to physician's specialization. In addition, this work aimed to identify key decision factors that practitioners consider in their decision to retreat or not a patient with hyaluronic acid viscosupplementation. METHODS Practitioners have been invited by e-mail to participate in an online exercise on viscosupplementation retreatment. They received a fictional patient case at random among a set of predefined fictional cases. The platform asked the practitioner if he/she would retreat the patient with viscosupplementation or not. To take a decision, the practitioner could select questions among a list of predefined questions. Among them, some were related to criteria used in the EUROVISCO decision tree and others served as confounding factors. RESULTS A total of 506 practitioners participated to the exercise, of which 399 gave their decision about the case assigned to them by the platform. The observed agreement between practitioner decisions and EUROVISCO recommendations was 58.89 ± 4.95% (95% confidence interval [CI]). Overall, the decision to retreat was taken in 47.87% of the cases, while the EUROVISCO guidelines follow-up would have led to 55.89% retreatment for the same cases (P = 0.03). CONCLUSIONS In current practice, physicians tended to reinject their patients less than recommended, although EUROVISCO guidelines for viscosupplementation retreatment consider decision criteria that clearly correspond to those of practitioners in real life. These include the patients' willingness to be treated or the patients' perception of the effectiveness of the treatment.
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Affiliation(s)
- Yves Henrotin
- Musculoskeletal Innovative Research
Lab, Arthropole Liège, Center for Interdisciplinary Research on Medicines, Institute
of Pathology, University of Liège, Liège, Belgium,Yves Henrotin, Musculoskeletal Innovative
Research Lab, Arthropole Liège, Center for Interdisciplinary Research on
Medicines, Institute of Pathology, University of Liège, Level 5, CHU
Sart-Tilman, 4000 Liège, Belgium.
| | | | | | | | | | - Alberto Migliore
- U.O.S. of Rheumatology, Ospedale San
Pietro Fatebenefratelli, Rome, Italy
| | - Pascal Richette
- Université Paris Diderot, UFR médicale,
Hôpital Lariboisière, Paris, France
| | - Xavier Chevalier
- Department of Rheumatology, Hôpital
Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Jordi Monfort
- Servei de Reumatologia, Hospital del
Mar, Barcelona, Spain
| | - Demirhan Diracoglu
- Department of Physical Medicine and
Rehabilitation, Istanbul Faculty of Medicine, Istanbul University, Istanbul,
Turkey
| | | | - Jörg Jerosch
- Department of Orthopedic, Johanna
Etienne Hospital, Neuss, Germany
| | - Dominique Baron
- Centre de Réadaptation Fonctionnelle
de Lannion-Trestel, Trévou-Tréguignec, France
| | - Raman Raghu
- Academic Department of Orthopaedics,
Hull and East Yorkshire NHS Trust Castle Hill Hospital, Cottingham, UK
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13
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Brochard S, Pontin J, Bernay B, Boumediene K, Conrozier T, Baugé C. The benefit of combining curcumin, bromelain and harpagophytum to reduce inflammation in osteoarthritic synovial cells. BMC Complement Med Ther 2021; 21:261. [PMID: 34649531 PMCID: PMC8515758 DOI: 10.1186/s12906-021-03435-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Osteoarthritis (OA) is the most common form of arthritis, affecting millions of people worldwide and characterised by joint pain and inflammation. It is a complex disease involving inflammatory factors and affecting the whole joint, including the synovial membrane. Since drug combination is widely used to treat chronic inflammatory diseases, a similar strategy of designing plant-derived natural products to reduce inflammation in OA joints may be of interest. In this study, we characterised the response of OA synovial cells to lipopolysaccharide (LPS) and investigated the biological action of the combination of curcumin, bromelain and harpagophytum in this original in vitro model of osteoarthritis. METHODS Firstly, human synovial cells from OA patients were stimulated with LPS and proteomic analysis was performed. Bioinformatics analyses were performed using Cytoscape App and SkeletalVis databases. Additionally, cells were treated with curcumin, bromelain and harpagophytum alone or with the three vegetal compounds together. The gene expression involved in inflammation, pain or catabolism was determined by RT-PCR. The release of the encoded proteins by these genes and of prostaglandin E2 (PGE2) were also assayed by ELISA. RESULTS Proteomic analysis demonstrated that LPS induces the expression of numerous proteins involved in the OA process in human OA synovial cells. In particular, it stimulates inflammation through the production of pro-inflammatory cytokines (Interleukin-6, IL-6), catabolism through an increase of metalloproteases (MMP-1, MMP-3, MMP-13), and the production of pain-mediating neurotrophins (Nerve Growth Factor, NGF). These increases were observed in terms of mRNA levels and protein release. LPS also increases the amount of PGE2, another inflammation and pain mediator. At the doses tested, vegetal extracts had little effect: only curcumin slightly counteracted the effects of LPS on NGF and MMP-13 mRNA, and PGE2, IL-6 and MMP-13 release. In contrast, the combination of curcumin with bromelain and harpagophytum reversed lots of effects of LPS in human OA synovial cells. It significantly reduced the gene expression and/or the release of proteins involved in catabolism (MMP-3 and -13), inflammation (IL-6) and pain (PGE2 and NGF). CONCLUSION We have shown that the stimulation of human OA synovial cells with LPS can induce protein changes similar to inflamed OA synovial tissues. In addition, using this model, we demonstrated that the combination of three vegetal compounds, namely curcumin, bromelain and harpagophytum, have anti-inflammatory and anti-catabolic effects in synovial cells and may thus reduce OA progression and related pain.
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Affiliation(s)
- Sybille Brochard
- EA7451 BioConnect, Université de Caen Normandie, UNICAEN, 14032, Caen, France
| | - Julien Pontin
- Proteogen platform, Normandie Univ, UNICAEN, Caen, France
| | - Benoit Bernay
- Proteogen platform, Normandie Univ, UNICAEN, Caen, France
| | - Karim Boumediene
- EA7451 BioConnect, Université de Caen Normandie, UNICAEN, 14032, Caen, France
| | - Thierry Conrozier
- Rheumatology Department, Nord Franche-Comté Hospital, Trevenans, France
| | - Catherine Baugé
- EA7451 BioConnect, Université de Caen Normandie, UNICAEN, 14032, Caen, France.
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14
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Klopfenstein T, Gendrin V, Conrozier T, Gerazime A, Puyraveau M, Zayet S. Correspondence on 'Historically controlled comparison of glucocorticoids with or without tocilizumab versus supportive care only in patients with COVID-19-associated cytokine storm syndrome: results of the CHIC study'. Ann Rheum Dis 2021:annrheumdis-2021-220771. [PMID: 34162593 DOI: 10.1136/annrheumdis-2021-220771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 12/29/2022]
Affiliation(s)
| | - Vincent Gendrin
- Infectious Disease Department, North Franche-Comté Hospital, Montbeliard, France
| | - Thierry Conrozier
- Rheumatology Department, North Franche-Comté Hospital, Montbeliard, France
| | - Aurélie Gerazime
- Methodology unit, Clinical Investigation Center INSERM 1431, CHU Besancon, Besancon, France
| | - Marc Puyraveau
- Methodology unit, Clinical Investigation Center INSERM 1431, CHU Besancon, Besancon, France
| | - Souheil Zayet
- Infectious Disease Department, North Franche-Comté Hospital, Montbeliard, France
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15
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Conrozier T, Raman R, Chevalier X, Henrotin Y, Monfort J, Diraçoglù D, Bard H, Baron D, Jerosch J, Richette P, Migliore A. Viscosupplementation for the treatment of osteoarthritis. The contribution of EUROVISCO group. Ther Adv Musculoskelet Dis 2021; 13:1759720X211018605. [PMID: 34104232 PMCID: PMC8165874 DOI: 10.1177/1759720x211018605] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/28/2021] [Indexed: 01/08/2023] Open
Abstract
Viscosupplementation (VS) is a symptomatic treatment for knee and other joint osteoarthritis (OA). Despite a long history of use, conflicting opinions remain on the best clinical indications and the most appropriate patients to be treated with intra-articular hyaluronic acid (IA-HA), the optimal dosing regimen and the modalities of retreatment. A multidisciplinary committee of European experts on OA (EUROVISCO) was constituted to formulate recommendations, aimed at helping physicians in the decision-making and the optimal achievement of VS. Before each session members were tasked to collate an exhaustive literature review. Level of evidence and strength of recommendation were based on the level of agreement for each item according to the Delphi method. In 2015, a consensus position was proposed for 24 statements. Among those that obtained a consensual agreement, the working group stressed that VS is effective in mild/moderate knee OA but is not an alternative to surgery in advanced OA, and that dosing regimen must be supported by controlled trials. In 2018, two decision algorithms for the retreatment with IA-HA in knee OA were published. Among the key recommendations, the experts recommended to re-treat every year patients with high risk of OA progression, even if not symptomatic. In 2020, EUROVISCO published two sets of recommendations for the design of clinical trials on the disease-modifying effect of VS and for optimizing the results of VS. The working group underlined that an accurate analysis of radiological features and symptoms and a careful clinical examination may improve the chances of success of VS, as well as good technique of injection and the use of imaging guidance. Based on the exhaustive analysis of the literature and their own clinical experience, the EUROVISCO experts offer a wide range of recommendations intended to help practitioners, particularly in certain cases where the specific characteristics of the patients make the therapeutic decision difficult.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, 100 route de Moval, CS 10499 Trévenans, Belfort, 90015, France
| | - Raghu Raman
- Academic Department of Orthopaedics, Hull and East Yorkshire NHS Trust Castle Hill Hospital, Cottingham, UK
| | - Xavier Chevalier
- Paris XII University, UPEC, Department of Rheumatology, Henri Mondor Hospital, Creteil, France
| | - Yves Henrotin
- Bone and Cartilage Research Unit, Université de Liège, CHU Sart-Tilman, Liège, Belgium
| | - Jordi Monfort
- Servei de Reumatologia, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Demirhan Diraçoglù
- Department of Physical Medicine and Rehabilitation, Istanbul University and Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Hervé Bard
- Rheumatology Cabinet Medical Vaudoyer, Paris, France
| | - Dominique Baron
- Centre de réadaptation fonctionnelle de Lannion-Trestel, Trévou-Tréguignec, France
| | - Jörg Jerosch
- Orthopaedic Department, Johanna-Etienne-Hospital, Neuss, Germany
| | - Pascal Richette
- Université Paris Diderot, UFR médicale, Hôpital Lariboisière, Paris, France
| | - Alberto Migliore
- U.O.S. of Rheumatology, Ospedale San Pietro Fatebenefratelli, Rome, Italy
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16
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Klopfenstein T, Gendrin V, Kadiane-Oussou NJ, Conrozier T, Zayet S. Tocilizumab in COVID-19 pneumonia: Practical proposals based on a narrative review of randomised trials. Rev Med Virol 2021; 32:e2239. [PMID: 33882179 PMCID: PMC8250236 DOI: 10.1002/rmv.2239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 01/08/2023]
Abstract
In this article, we express our opinion about tocilizumab as an effective treatment in coronavirus disease 2019, based on a narrative review and a deep analysis of tocilizumab randomised trial results. Eight trials were included. No one was in favour for controlled arm about main endpoint of death or mechanical ventilation incidence at day 28–30. Five trials on heterogenous populations seem to not demonstrate tocilizumab efficacy, but showed encouraging results in subgroup analysis on severe/critical patients (in favour for tocilizumab). Trials on severe/critical COVID‐19 pneumonia as REMAP‐CAP and RECOVERY showed mortality benefit of tocilizumab administration; CORIMUNO, REMAP‐CAP and RECOVERY showed that tocilizumab decreased the incidence of mechanical ventilation. No safety signal about tocilizumab used was noticed in all trials. We concluded that tocilizumab reduces mortality and mechanical ventilation requirement if administered with the right timing in COVID‐19 pneumonia. The challenge now is to define the optimal group and timing for tocilizumab benefit and we suggest that: (i) tocilizumab has a place in treatment of severe/critical COVID‐19 pneumonia, with a high level of O2 flow or noninvasive ventilation or high flow nasal cannula; (ii) possibly early after intubation in patients on mechanical ventilation. Initiating tocilizumab in critically ill patients early before irreversible respiratory failure, especially in patients at an inflammatory stage could be the key to successful outcome.
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Affiliation(s)
- Timothée Klopfenstein
- Infectious Disease Department, Nord Franche-Comté Hospital, Montbéliard-Belfort, France
| | - Vincent Gendrin
- Infectious Disease Department, Nord Franche-Comté Hospital, Montbéliard-Belfort, France
| | | | - Thierry Conrozier
- Rheumatology Department, Nord Franche-Comté Hospital, Montbéliard-Belfort, France
| | - Souheil Zayet
- Infectious Disease Department, Nord Franche-Comté Hospital, Montbéliard-Belfort, France
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17
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Gueugnon M, Fournel I, Soilly AL, Diaz A, Baulot E, Bussière C, Casillas JM, Cherasse A, Conrozier T, Loeuille D, Maillefert JF, Mazalovic K, Timsit M, Wendling D, Ramon A, Binquet C, Morisset C, Ornetti P. Effectiveness, safety, and cost-utility of a knee brace in medial knee osteoarthritis: the ERGONOMIE randomized controlled trial. Osteoarthritis Cartilage 2021; 29:491-501. [PMID: 33524515 DOI: 10.1016/j.joca.2020.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 09/15/2020] [Accepted: 11/30/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This pragmatic, multicenter, open-label, randomized controlled trial (RCT) aimed to compare the effectiveness, safety, and cost-utility of a custom-made knee brace versus usual care over 1 year in medial knee osteoarthritis (OA). DESIGN 120 patients with medial knee OA (VAS pain at rest >40/100), classified as Kellgren-Lawrence grade II-IV, were randomized into two groups: ODRA plus usual care (ODRA group) and usual care alone (UCA group). The primary effectiveness outcome was the change in VAS pain between M0 and M12. Secondary outcomes included changes over 1 year in KOOS (function) and OAKHQOL (quality of life) scores. Drug consumption, compliance, safety of the knee brace, and cost-utility over 1 year were also assessed. RESULTS The ODRA group was associated with a higher improvement in: VAS pain (adjusted mean difference of -11.8; 95% CI: -21.1 to -2.5); all KOOS subscales (pain: +8.8; 95% CI: 1.4-16.2); other symptoms (+10.4; 95% CI: 2.7-18); function in activities of daily living (+9.2; 95% CI: 1.1-17.2); function in sports and leisure (+12.3; 95% CI: 4.3-20.3); quality of life (+9.9; 95% CI: 0.9-15.9), OAKHQOL subscales (pain: +14.8; 95% CI: 5.0-24.6); and physical activities (+8.2; 95% CI: 0.6-15.8), and with a significant decrease in analgesics consumption at M12 compared with the UCA group. Despite localized side-effects, observance was good at M12 (median: 5.3 h/day). The ODRA group had a more than 85% chance of being cost-effective for a willingness-to-pay threshold of €45 000 per QALY. CONCLUSIONS The ERGONOMIE RCT demonstrated significant clinical benefits of an unloader custom-made knee brace in terms of improvements in pain, function, and some aspects of quality of life over 1 year in medial knee OA, as well as its potential cost-utility from a societal perspective.
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Affiliation(s)
- M Gueugnon
- INSERM, CIC 1432, Centre D'Investigation Clinique, Module Plurithématique, Plateforme D'Investigation Technologiques, Dijon, France CHU Dijon-Bourgogne, Dijon, France.
| | - I Fournel
- INSERM, CIC 1432, Centre D'Investigation Clinique, Module EC, CHU Dijon-Bourgogne, Dijon, France.
| | - A-L Soilly
- Department of Clinical Research, Clinical Research Unit-Methodological Support Network CHU Dijon-Bourgogne, F-21000, Dijon, France.
| | - A Diaz
- Department of Rheumatology, CHU Dijon Bourgogne, F-21000 Dijon, France.
| | - E Baulot
- Department of Orthopedic Surgery, CHU Dijon Bourgogne, F-21000 Dijon, France; INSERM UMR 1093-CAPS, Bourgogne Franche-Comté University, UFR des Sciences et Du Sport.
| | - C Bussière
- Department of Orthopedic Surgery, Centre Orthopédique Medico-chirugical, Dracy-Le-Fort, France.
| | - J M Casillas
- INSERM, CIC 1432, Centre D'Investigation Clinique, Module Plurithématique, Plateforme D'Investigation Technologiques, Dijon, France CHU Dijon-Bourgogne, Dijon, France; INSERM UMR 1093-CAPS, Bourgogne Franche-Comté University, UFR des Sciences et Du Sport; Department of Physical Medicine and Rehabilitation, CHU Dijon Bourgogne, F-2100 Dijon, France.
| | - A Cherasse
- Department of Rheumatology, Hospital Center Mâcon, Mâcon, France.
| | - T Conrozier
- Department of Rheumatology, Hospital Nord Franche-Comté, Belfort, France.
| | - D Loeuille
- Department of Rheumatology, CHU Nancy, F-54500 Vandoeuvre-lès-Nancy, France INSERM, CIC-EC CIE6, Nancy, France University Hospital of Nancy, Epidemiology and Clinical Evaluation, F-54500 Vandoeuvre-lès-Nancy, France.
| | - J-F Maillefert
- Department of Rheumatology, CHU Dijon Bourgogne, F-21000 Dijon, France; INSERM UMR 1093-CAPS, Bourgogne Franche-Comté University, UFR des Sciences et Du Sport.
| | - K Mazalovic
- INSERM, CIC 1432, Centre D'Investigation Clinique, Module EC, CHU Dijon-Bourgogne, Dijon, France; Department of General Medicine, Bourgogne Franche-Comté University, UFR des Sciences de Santé, Dijon, France.
| | - M Timsit
- Department of Physical Medicine and Rehabilitation, Clinique de Provence Bourbonne, F-13400 Aubagne, France.
| | - D Wendling
- Department of Rheumatology, CHU Besançon EA4266 Bourgogne Franche-Comté University, F-25030 Besançon, France.
| | - A Ramon
- Department of Rheumatology, CHU Dijon Bourgogne, F-21000 Dijon, France.
| | - C Binquet
- INSERM, CIC 1432, Centre D'Investigation Clinique, Module EC, CHU Dijon-Bourgogne, Dijon, France.
| | - C Morisset
- INSERM, CIC 1432, Centre D'Investigation Clinique, Module Plurithématique, Plateforme D'Investigation Technologiques, Dijon, France CHU Dijon-Bourgogne, Dijon, France.
| | - P Ornetti
- INSERM, CIC 1432, Centre D'Investigation Clinique, Module Plurithématique, Plateforme D'Investigation Technologiques, Dijon, France CHU Dijon-Bourgogne, Dijon, France; Department of Rheumatology, CHU Dijon Bourgogne, F-21000 Dijon, France; INSERM UMR 1093-CAPS, Bourgogne Franche-Comté University, UFR des Sciences et Du Sport.
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18
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Klopfenstein T, Conrozier T, Kadiane-Oussou NJ, Gendrin V, Zayet S. Is There Still a Place for Tocilizumab in Coronavirus Disease 2019? Open Forum Infect Dis 2021; 8:ofab013. [PMID: 33628858 PMCID: PMC7890594 DOI: 10.1093/ofid/ofab013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/11/2021] [Indexed: 12/15/2022] Open
Abstract
In this article, we sought to summarize the available evidence of tocilizumab as a treatment for coronavirus disease 2019. Recent tocilizumab randomized trials have not shown clear evidence of efficacy, especially on mortality, in contrast to observational studies. These clinical trials focus on a heterogeneous population of patients (clinical severity and inflammatory stage), and this is possibly one of the reasons that explain heterogeneity of results. However, these same trials have shown some evidence that tocilizumab may reduce intensive care unit admissions and/or mechanical ventilation incidence, which are huge challenges in the severe acute respiratory syndrome coronavirus 2 pandemic. Future clinical trials with primary endpoint built on this assumption are needed (1) to confirm whether tocilizumab reduces mechanical ventilation requirement and (2) to describe the right patient population and optimal timing for tocilizumab administration. Finding the optimal timing for tocilizumab administration and the group of patients who are susceptible to having the greatest benefit are probably the main challenge.
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Affiliation(s)
| | - Thierry Conrozier
- Rheumatology Department, Nord Franche-Comté Hospital, Trévenans, France
| | | | - Vincent Gendrin
- Infectious Disease Department, Nord Franche-Comté Hospital, Trévenans, France
| | - Souheil Zayet
- Infectious Disease Department, Nord Franche-Comté Hospital, Trévenans, France
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Lohse A, Bossert M, Bozgan AM, Charpentier A, Guillochon C, Bourgoin C, Balblanc JC, Conrozier T. Frequency and severity of COVID-19 in patients treated with biological disease-modifying anti-rheumatic drugs for inflammatory rheumatic disease: a cross-sectional study. Clin Exp Rheumatol 2020; 38:1273. [PMID: 33253100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/19/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Anne Lohse
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Marie Bossert
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Ana-Maria Bozgan
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Aline Charpentier
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Cerise Guillochon
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | | | | | - Thierry Conrozier
- Department of Rheumatology and Clinical Research Unit, Nord Franche-Comté Hospital, Belfort, France.
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Kadiane-Oussou N, Klopfenstein T, Toko L, Royer P, Lohse A, Conrozier T, Gendrin V, Zayet S. Pneumopathies graves liées au COVID-19 : facteurs prédictifs de mortalité après traitement par tocilizumab. Med Mal Infect 2020. [PMCID: PMC7442012 DOI: 10.1016/j.medmal.2020.06.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Introduction Matériels et méthodes Résultats Conclusion
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Klopfenstein T, Zayet S, Lohse A, Selles P, Zahra H, Kadiane-Oussou NJ, Toko L, Royer PY, Balblanc JC, Gendrin V, Conrozier T. Impact of tocilizumab on mortality and/or invasive mechanical ventilation requirement in a cohort of 206 COVID-19 patients. Int J Infect Dis 2020; 99:491-495. [PMID: 32798660 PMCID: PMC7423574 DOI: 10.1016/j.ijid.2020.08.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction No therapy has proven to be effective yet to reduce mortality and/or invasive mechanical ventilation (IMV) requirement in COVID-19. Tocilizumab (TCZ) in patients with severe COVID-19 could be an effective treatment. Methods We conducted a retrospective case-control study in the Nord Franche-Comté Hospital, France. We compared the outcome of patients treated with TCZ and patients without TCZ considering a combined primary endpoint: mortality and/or IMV requirement. Results Thirty patients were treated with TCZ and 176 patients were treated without TCZ. TCZ was used in patients in critical condition (oxygen therapy flow at TCZ onset was 10.5 L/min and 14/30 patients had ≥ 50% lung involvement on CT scan) as a rescue treatment (8/30 patients who died were not admitted in USC in regard to their comorbidities). However, mortality and/or IMV requirement were lower in patients with TCZ than in patients without TCZ (27% vs 52%, p = 0.009). Conclusion Despite the small sample size in the TCZ group, this result suggests that TCZ reduces mortality and/or IMV requirement in patients with severe SARS-CoV-2 pneumonia. This notion needs to be confirmed and spread in the medical community.
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Affiliation(s)
- Timothée Klopfenstein
- Infectious Disease Department, Nord Franche-Comté Hospital, 90400 Trévenans, France.
| | - Souheil Zayet
- Infectious Disease Department, Nord Franche-Comté Hospital, 90400 Trévenans, France.
| | - Anne Lohse
- Rheumatology Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - Phillippe Selles
- Medical Information Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - Hajer Zahra
- Diabetology and Endocrinology Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | | | - Lynda Toko
- Infectious Disease Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - Pierre-Yves Royer
- Infectious Disease Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | | | - Vincent Gendrin
- Infectious Disease Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - Thierry Conrozier
- Rheumatology Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
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Conrozier T, Lohse A, Balblanc JC, Dussert P, Royer PY, Bossert M, Bozgan AM, Gendrin V, Charpentier A, Toko L, Badie J, Mezher C, Roux MF, Kadiane-Oussou NJ, Contreras R, Kessler J, Mazurier I, Klopfenstein T, Zayet S. Biomarker variation in patients successfully treated with tocilizumab for severe coronavirus disease 2019 (COVID-19): results of a multidisciplinary collaboration. Clin Exp Rheumatol 2020; 38:742-747. [PMID: 32573419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Acute respiratory distress syndrome (ARDS) related to SARS-CoV-2 is likely due to a cytokine storm characterised by a major release of pro-inflammatory cytokines, including interleukin-6 (IL-6). Blocking excessive IL-6 production might be the key to the COVID-19-ARDS treatment. Beneficial effects of IL-6 blockade using a humanised anti-IL-6 receptor antibody, tocilizumab (TCZ) were previously reported in patients with COVID-19 related ARDS. The aim of the study was to study the variation over time of several biomarkers, demonstrated to be predictors of poor prognostic, in subjects successfully treated with TCZ for severe COVID-19. METHODS Retrospective analysis of a case series of patients with COVID-19-ARDS, evidenced by RT-PCR and lung CT-scan. Patients with increasing O2 requirements, within the window of opportunity for TCZ treatment (Day 7 to Day 17 after onset of symptoms) were treated with TCZ (2 infusions of 8 mg/kg). Demographic, biological and clinical data were collected from the patients' files. Serum levels of CRP, ferritin, fibrinogen, lymphocytes, platelets, creatinine, D-dimer and liver enzymes were assayed at the time of the first TCZ administration, then every two days for 8 days. RESULTS 40 patients were treated with TCZ. Most of them had several comorbidities, and all had multiple biological abnormalities (lymphopenia, increased CRP, ferritin, fibrinogen, D-dimer, liver enzymes). 30 patients (75%) benefited from TCZ and 10 patients died. In the survivors, following TCZ administration CRP decreased dramatically as early as day 4 (-86.7%, p<0.0001) and returned to normal at day 6. Fibrinogen and lymphocyte count returned to normal values at day 6. Ferritin also decreased significantly. No significant change was observed for D-dimer (p=0.68) and other studied biomarkers (haemoglobin, leucocyte count, AST). CONCLUSIONS In patients with COVID-19 acute respiratory distress syndrome, treatment with TCZ resulted in favourable evolution in 75% of the cases. Biomarkers of inflammation (CRP, ferritin, fibrinogen) decreased dramatically as early as the 4th day after TCZ injection. Lymphopenia, a predictor of poor prognostic, was reversed 6 days after TCZ injection.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France.
| | - Anne Lohse
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | | | - Pascale Dussert
- Department of Biology, Nord Franche-Comté Hospital, Belfort, France
| | - Pierre-Yves Royer
- Department of Infectious Diseases, Nord Franche-Comté Hospital, Belfort, France
| | - Marie Bossert
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Ana-Maria Bozgan
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Vincent Gendrin
- Department of Infectious Diseases, Nord Franche-Comté Hospital, Belfort, France
| | - Aline Charpentier
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Lynda Toko
- Department of Infectious Diseases, Nord Franche-Comté Hospital, Belfort, France
| | - Julio Badie
- Intensive Care Unit, Nord Franche-Comté Hospital, Belfort, France
| | - Chaouki Mezher
- Intensive Care Unit, Nord Franche-Comté Hospital, Belfort, France
| | | | | | | | - Julie Kessler
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | | | | | - Souheil Zayet
- Department of Infectious Diseases, Nord Franche-Comté Hospital, Belfort, France
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Lohse A, Klopfenstein T, Balblanc JC, Royer PY, Bossert M, Gendrin V, Charpentier A, Bozgan AM, Badie J, Bourgoin C, Contreras R, Mazurier I, Conrozier T, Zayet S. Predictive factors of mortality in patients treated with tocilizumab for acute respiratory distress syndrome related to coronavirus disease 2019 (COVID-19). Microbes Infect 2020; 22:500-503. [PMID: 32574789 PMCID: PMC7305501 DOI: 10.1016/j.micinf.2020.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 12/15/2022]
Abstract
COVID-19 patients (n = 34) suffering from ARDS were treated with tocilizumab (TCZ). Outcome was classified in two groups: “Death” and “Recovery”. Predictive factors of mortality were studied. Mean age was 75.3, mean oxygen (O2) requirements 10.4 l/min. At baseline, all patients had multiple biological abnormalities (lymphopenia, increased CRP, ferritin, fibrinogen, D-dimer and liver enzymes). 24 patients (70.5%) recovered after TCZ therapy and 10 died (29.5%). Deceased subjects differed from patients in whom treatment was effective with regard to more pronounced lymphopenia (0.6 vs 1.0 G/l; p = 0.037), lower platelet number (156 vs 314 G/l; p = 0.0001), lower fibrinogen serum level (0.6 vs 1.0 G/l; p = 0.03), higher aspartate-amino-transferase (108 vs 57 UI/l; p = 0.05) and greater O2 requirements (11 vs 8 l/min; p = 0.003).
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Affiliation(s)
- Anne Lohse
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | | | | | - Pierre-Yves Royer
- Department of Infectious Diseases, Nord Franche-Comté Hospital, Belfort, France
| | - Marie Bossert
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Vincent Gendrin
- Department of Infectious Diseases, Nord Franche-Comté Hospital, Belfort, France
| | - Aline Charpentier
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Ana-Maria Bozgan
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Julio Badie
- Intensive Care Unit, Nord Franche-Comté Hospital, Belfort, France; Clinical Research Unit, Nord Franche-Comté Hospital, Belfort, France
| | | | - Remy Contreras
- Department of Pharmacology, Nord Franche-Comté Hospital, Belfort, France
| | | | - Thierry Conrozier
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France; Clinical Research Unit, Nord Franche-Comté Hospital, Belfort, France
| | - Souheil Zayet
- Department of Infectious Diseases, Nord Franche-Comté Hospital, Belfort, France.
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Henrotin Y, Costes B, Malaise M, Loeuille D, Conrozier T, Maugars Y, Pelousse F, Lemaire JM, Helleputte T, Tits C, Cobraiville E, Pirson S, Garcia L, Labasse A, Hick AC. FRI0405 CARTILAGE BIOMARKERS S-COLL2-1 AND S-COLL2-1NO2 ARE HELPFUL IN IDENTIFYING KNEE OSTEOARTHRITIS PATIENTS AT RISK OF DISEASE WORSENING. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.3604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Coll2-1 is a peptide of 9 amino acid located in the triple helix of type II collagen molecule reflecting cartilage degradation (1). Coll2-1NO2 is the nitrated form of Coll2-1 and considered as a biomarker of the inflammatory-related cartilage degradation (2). This peptide is involved in osteoarthritis physiopathology since it was demonstrated that Coll2-1 induced synovitis in rat.Objectives:To identify if biochemical markers s-Coll2-1 and s-Coll2-1NO2 are associated to knee osteoarthritis (OA), focusing on pain, function as well as structural features assessed by MRI in various knee compartments and to assess their ability at predicting knee OA worsening.Methods:116 subjects with knee OA were followed during one year with pain, function and MRI evaluation (PRODIGE study,NCT02070224). Type II collagen-specific biomarker Coll2-1 and its nitrated form Coll2-1NO2 were directly measured in serum using immunoassays at baseline and after three, six and twelve months follow-up.Results:sColl2-1 and sColl2-1NO2 were associated to several baseline knee features quantified with Whole-Organ Magnetic Resonance Imaging Score (WORMS). S-Coll2-1 was significantly correlated with bursitis (r=0.29, P<0.01), bone attrition (r=0.25, P=0.01), cysts (r=0.24, P=0.02) and cartilage (r=0.23, P=0.03) WORMS sub-scores for the whole joint as well as with the medial femorotibial joint sum score (r=0.26, P=0.01) and medial femorotibial joint cartilage (r=0.23, P=0.02). s-Coll2-1NO2 was correlated with WORMS total score (r=0.23, P=0.02), WORMS scores in the patellofemoral (r=0.23, P=0.02) and medial femorotibial compartments (r=0.21, P=0.03) and with osteophytes scores (r=0.27, P<0.01). Baseline s-Coll2-1NO2 was higher in subjects with a pain worsening (426.4 pg/mL [278.04-566.95]) as compared to non-progressors (306.84 [200.37-427.84]) over one year (AUC=0.655, P=0.015).Conclusion:Cartilage biomarkers s-Coll2-1 and s-Coll2-1NO2 are associated to several knee OA features quantified with WORMS scoring system on MRI. Serum values of Coll2-1NO2 are also associated to a worsening of target knee pain over one year. Coll2-1 and Coll2-1NO2, in association with other structural features, pain and function, could help at identifying OA phenotypes and patients at risk of OA worsening.References:[1]Mobasheri A, Lambert C, Henrotin Y. Coll2-1 and Coll2-1NO2 as exemplars of collagen extracellular matrix turnover - biomarkers to facilitate the treatment of osteoarthritis? Expert Rev Mol Diagn. 2019 Sep;19(9):803-812. doi: 10.1080/14737159.2019.1646641. Epub 2019 Sep 4.[2]Lambert C, Borderie D, Dubuc JE, Rannou F, Henrotin Y. Type II collagen peptide Coll2-1 is an actor of synovitis. Osteoarthritis Cartilage. 2019 Nov;27(11):1680-1691. doi: 10.1016/j.joca.2019.07.009. Epub 2019 Jul 17.Acknowledgments:PRODIGE study (NCT02070224) was performed in the framework of a convention between the Walloon region and ARTIALIS SA. (convention n°6905).Disclosure of Interests:Yves Henrotin Grant/research support from: HEEL, TILMAN, Berenice Costes Employee of: Artialis SA, Michel Malaise: None declared, Damien Loeuille: None declared, Thierry Conrozier Consultant of: LABRHA, SANOFI, MEDAC, Yves Maugars: None declared, Franz Pelousse Shareholder of: Sodiray, Jean-Marc Lemaire Shareholder of: Sodiray, Thibault Helleputte Shareholder of: DNAlytics, Cedric Tits Employee of: DNAlytics, Elisabeth Cobraiville Employee of: Artialis SA, Sebastien Pirson Employee of: Artialis, Laetitia Garcia Employee of: Artialis, Alain Labasse Employee of: Artialis SA, Anne-Christine Hick Employee of: Artialis SA
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Klopfenstein T, Zayet S, Lohse A, Balblanc JC, Badie J, Royer PY, Toko L, Mezher C, Kadiane-Oussou NJ, Bossert M, Bozgan AM, Charpentier A, Roux MF, Contreras R, Mazurier I, Dussert P, Gendrin V, Conrozier T. Tocilizumab therapy reduced intensive care unit admissions and/or mortality in COVID-19 patients. Med Mal Infect 2020; 50:397-400. [PMID: 32387320 PMCID: PMC7202806 DOI: 10.1016/j.medmal.2020.05.001] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/04/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION No therapy has yet proven effective in COVID-19. Tocilizumab (TCZ) in patients with severe COVID-19 could be an effective treatment. METHOD We conducted a retrospective case-control study in the Nord Franche-Comté Hospital, France. We compared the outcome of patients treated with TCZ and patients without TCZ considering a combined primary endpoint: death and/or ICU admissions. RESULTS Patients with TCZ (n=20) had a higher Charlson comorbidity index (5.3 [±2.4] vs 3.4 [±2.6], P=0.014), presented with more severe forms (higher level of oxygen therapy at 13L/min vs 6L/min, P<0.001), and had poorer biological findings (severe lymphopenia: 676/mm3 vs 914/mm3, P=0.037 and higher CRP level: 158mg/L vs 105mg/L, P=0.017) than patients without TCZ (n=25). However, death and/or ICU admissions were higher in patients without TCZ than in the TCZ group (72% vs 25%, P=0.002). CONCLUSION Despite the small sample size and retrospective nature of the work, this result strongly suggests that TCZ may reduce the number of ICU admissions and/or mortality in patients with severe SARS-CoV-2 pneumonia.
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Affiliation(s)
- T Klopfenstein
- Infectious Disease Department, Nord Franche-Comté Hospital, 90400 Trévenans, France.
| | - S Zayet
- Infectious Disease Department, Nord Franche-Comté Hospital, 90400 Trévenans, France.
| | - A Lohse
- Rheumatology Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - J-C Balblanc
- Rheumatology Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - J Badie
- Intensive Care Unit Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - P-Y Royer
- Infectious Disease Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - L Toko
- Infectious Disease Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - C Mezher
- Intensive Care Unit Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - N J Kadiane-Oussou
- Infectious Disease Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - M Bossert
- Rheumatology Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - A-M Bozgan
- Rheumatology Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - A Charpentier
- Rheumatology Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - M-F Roux
- Pharmacology Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - R Contreras
- Pharmacology Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - I Mazurier
- Biological Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - P Dussert
- Biological Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - V Gendrin
- Infectious Disease Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
| | - T Conrozier
- Rheumatology Department, Nord Franche-Comté Hospital, 90400 Trévenans, France
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Conrozier T, Monfort J, Chevalier X, Raman R, Richette P, Diraçoglù D, Bard H, Baron D, Jerosch J, Migliore A, Henrotin Y. EUROVISCO Recommendations for Optimizing the Clinical Results of Viscosupplementation in Osteoarthritis. Cartilage 2020; 11:47-59. [PMID: 29926748 PMCID: PMC6921960 DOI: 10.1177/1947603518783455] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The 3 aims of the work were to identify population subgroups that can benefit the most from viscosupplementation (VS), to provide recommendations on injection techniques, and to discuss VS appropriateness in clinical situations that are commonplace in daily practice. METHODS The task force members voted on their degree of agreement on 27 statements, 36 recommendations, and 22 clinical scenarios using a 9-point scale. The strength of agreement/appropriateness/recommendation (SOA/SOR) was classified as strong if the median agreement score was ≥8. The level of consensus (LOC) was also obtained. RESULTS Among the assumed predictors for VS failure, obesity, radiographic severity, large synovial fluid effusion, severe patellofemoral involvement, major malalignment, and gross joint instability received a large majority of agreements. The lateral mid-patellar approach was recommended for knee injection. Imaging guidance was unanimously recommended for hip and ankle. Agreement was achieved to strictly respect the dosing regimen proven by controlled trials. There was agreement for treating with VS patients with mild to moderate knee and hip OA, with normal weight or moderate overweight, insufficiently improved by first-line therapies, or who do not wish get oral treatment or who have contraindications to pain killers. The group considered the patient's wishes as a key element in therapeutic decision making. CONCLUSION Based on literature data and clinical experience, the EUROVISCO group proposed a set of recommendations for optimizing the results of VS, aimed to help practitioners, especially in some cases in which the patients' specificities make the therapeutic decision difficult.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Hôpital Nord
Franche-Comté, Belfort, France,Thierry Conrozier, Department of
Rheumatology, Hôpital Nord Franche-Comté, 100 route de MOVAL, CS 10499
Trevenans, 90015 Belfort, France.
| | - Jordi Monfort
- Servei de Reumatologia, Hospital del
Mar, Barcelona, Spain
| | - Xavier Chevalier
- Paris XII University, UPEC, Department
of Rheumatology, Henri Mondor Hospital, Creteil, France
| | - Raghu Raman
- Academic Department of Orthopaedics,
Hull and East Yorkshire NHS Trust Castle Hill Hospital, Cottingham, UK
| | - Pascal Richette
- Université Paris Diderot, UFR Médicale,
Hôpital Lariboisière, Paris, France
| | - Demirhan Diraçoglù
- Department of Physical Medicine and
Rehabilitation, Istanbul University and Istanbul Faculty of Medicine, Istanbul,
Turkey
| | - Hervé Bard
- Department of Orthopaedics-Rheumatology,
American Hospital of Paris, Neuilly/Seine, France
| | - Dominique Baron
- Centre de réadaptation fonctionnelle de
Lannion-Trestel, Trévou-Tréguignec, France
| | - Jörg Jerosch
- Orthopedic Department,
Johanna-Etienne-Hospital, Neuss, Nordrhein-Westfalen, Germany
| | - Alberto Migliore
- U.O.S. of Rheumatology, Ospedale San
Pietro Fatebenefratelli, Rome, Italy
| | - Yves Henrotin
- Bone and Cartilage Research Unit,
Université de Liège, CHU Sart-Tilman, Liège, Belgium
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Henrotin Y, Chevalier X, Raman R, Richette P, Montfort J, Jerosch J, Baron D, Bard H, Carrillon Y, Migliore A, Conrozier T. EUROVISCO Guidelines for the Design and Conduct of Clinical Trials Assessing the Disease-Modifying Effect of Knee Viscosupplementation. Cartilage 2020; 11:60-70. [PMID: 29972025 PMCID: PMC6921954 DOI: 10.1177/1947603518783521] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Hyaluronic acid viscosupplementation is a commonly used intra-articular treatment for osteoarthritis (OA). Some recent preclinical and clinical trials have demonstrated a potential for its disease-modifying effects. The goal of this expert opinion, consensus-driven exercise is to provide guidelines for the design and conduct of clinical trials assessing the disease-modifying effect of viscosupplementation in the knee. METHODS The EUROVISCO group constitutes 10 members who had expertise in clinical research methodology in the field of OA and viscosupplementation. They initially drafted issues through an iterative process and had to vote on their degree of agreement on these recommendations. The scores were pooled to generate a median agreement score for each recommendation. RESULTS The document includes 31 recommendations regarding study population, imaging, clinical and biological assessment of disease-modifying effects of viscosupplementation. Agreements were reached on some recommendations. In particular, the experts reached unanimous agreement on double-blind study design, imaging primary outcomes, time interval between 2 radiographs, x-ray procedure standardization, and the combined use of imaging and biological markers. The group did not recommend the use of ultrasonography, computed tomography (CT) scan and CT arthrography as a tool for OA diagnosis or to assess progression over time. CONCLUSION In summary, the working group identified 31 recommendations that represent the current best practices regarding clinical trials that target the assessment of viscosupplementation disease-modifying effects in patients with knee OA. These recommendations integrate new imaging technologies and soluble biomarkers.
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Affiliation(s)
- Yves Henrotin
- Bone and Cartilage Research Unit,
Université de Liège, Liège, Belgium
| | - Xavier Chevalier
- Paris XII University, UPEC, Department
of Rheumatology, Henri Mondor Hospital, Creteil, France
| | - Raghu Raman
- Academic Department of Orthopaedics,
Hull and East Yorkshire NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Pascal Richette
- Université Paris Diderot, UFR Médicale,
Hôpital Lariboisière, Paris, France
| | - Jordi Montfort
- Servei de Reumatologia, Hospital del
Mar, Parc de Salut Mar, Barcelona, Catalonia, Spain
| | - Jörg Jerosch
- Orthopedic Department,
Johanna-Etienne-Hospital, Neuss, Nordrhein-Westfalen, Germany
| | - Dominique Baron
- Centre de réadaptation fonctionnelle de
Lannion-Trestel, Trévou-Tréguignec, France
| | - Hervé Bard
- Department of Rheumatology, Hôpital
Européen Georges-Pompidou, Paris, France
| | | | - Alberto Migliore
- U.O.S. of Rheumatology, Ospedale San
Pietro Fatebenefratelli, Rome, Italy
| | - Thierry Conrozier
- Department of Rheumatology, Hôpital
Nord Franche-Comté, Belfort, France
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Migliore A, Gigliucci G, Alekseeva L, Avasthi S, Bannuru RR, Chevalier X, Conrozier T, Crimaldi S, Damjanov N, de Campos GC, Diracoglu D, Herrero-Beaumont G, Iolascon G, Ionescu R, Isailovic N, Jerosch J, Lains J, Maheu E, Makri S, Martusevich N, Matucci Cerinc M, Micu M, Pavelka K, Petrella RJ, Tarantino U, Raman R. Treat-to-target strategy for knee osteoarthritis. International technical expert panel consensus and good clinical practice statements. Ther Adv Musculoskelet Dis 2019; 11:1759720X19893800. [PMID: 31903099 PMCID: PMC6923692 DOI: 10.1177/1759720x19893800] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/15/2019] [Indexed: 12/22/2022] Open
Abstract
Background: In this work, we aimed to establish a clinical target in the management of
knee osteoarthritis (KOA) and to propose good clinical practice (GCP)
statements for carrying out a treat-to-target strategy. Methods: A steering committee of seven experts had formulated a provisional set of
recommendations that were exposed for discussion and modification to a
technical expert panel (TEP) of 25 multidisciplinary experts from Europe,
North America, South America and Asia. The level of evidence and strength of
each recommendation was discussed. The TEP formulated overarching principles
and GCP statements based on the level of agreement for each item with a vote
using a 10-point numerical scale. Results: Two overarching principles and 10 GCP statements were formulated by the TEP.
These GCP statements suggest: treatment should achieve clinical improvement
bringing the patient to the Patient Acceptable Symptom State (PASS);
pharmacological and nonpharmacological treatment should begin as early as
possible, with an early diagnosis of symptomatic KOA; the patient should be
evaluated every 3–6 months; risk factors of KOA progression should be
identified and managed with patients at the beginning of the treatment and
monitored regularly; treatment should be adapted according to patient
phenotype and disease severity; healthy lifestyle must be promoted and
monitored. The level of agreement average ranged from 8.7 to 9.6 on
scale. Conclusions: The proposed overarching principles and GCP statements have the aim of
involving patients, general practitioners and multidisciplinary specialists
in sharing a therapeutic treat-to-target strategy for KOA management based
on the best evidence and expert opinions.
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Affiliation(s)
- Alberto Migliore
- Rheumatology Unit, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | | | - Liudmila Alekseeva
- Department of Metabolic Diseases of Bone and Joints, VA Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
| | - Sachin Avasthi
- Department of Emergency Medicine, Dr Ram Manohar Lohia Hospital, Lucknow, India
| | - Raveendhara R Bannuru
- Centre for Treatment Comparison and Integrative Analysis Division of Rheumatology, Tufts Medical Centre, Boston, MA, USA
| | | | | | - Sergio Crimaldi
- Chirurgia Ortopedica Mininvasiva e Nuove Tecnologie, Humanitas Research Hospital, Castellanza, Italy
| | - Nemanja Damjanov
- Institute of Rheumatology, University of Belgrade Medical School, Belgrade, Serbia
| | | | - Demirhan Diracoglu
- Department of Physical Medicine and Rehabilitation Division of Pain Medicine, Istanbul University, Istanbul, Turkey
| | | | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania 'L Vanvitelli', Caserta, Italy
| | - Ruxandra Ionescu
- Department of Internal Medicine and Rheumatology Sf. Maria Hospital, University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania
| | - Natasa Isailovic
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Via A. Manzoni 56, Rozzano, Milan 20089, Italy
| | - Jörg Jerosch
- Orthopaedic Department, Johanna Etienne Hospital, Neuss, Germany
| | - Jorge Lains
- Physical Rehabilitation Medicine Department, Rovisco Pais Medical and Rehabilitation Centre, Tocha, Portugal
| | - Emmanuel Maheu
- Rheumatology Department, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Souzi Makri
- EUPATI Graduate and Patient Advocate, Brussels, Belgium
| | - Natalia Martusevich
- Department of Rheumatology, Belorussian State Medical University, Minsk, Belarus
| | - Marco Matucci Cerinc
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Mihaela Micu
- Second Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca, Romania
| | | | - Robert J Petrella
- Department of Family Medicine, School of Kinesiology University Western Ontario, Ontario, Canada
| | - Umberto Tarantino
- Department of Orthopaedics and Traumatology, 'Policlinico Tor Vergata' Foundation, Rome, Italy
| | - Raghu Raman
- Academic Department of Orthopaedics, Hull and East Yorkshire NHS Trust Castle Hill Hospital, Cottingham, UK
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Conrozier T, Eymard F, Chouk M, Chevalier X. Impact of obesity, structural severity and their combination on the efficacy of viscosupplementation in patients with knee osteoarthritis. BMC Musculoskelet Disord 2019; 20:376. [PMID: 31421686 PMCID: PMC6698328 DOI: 10.1186/s12891-019-2748-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 07/31/2019] [Indexed: 01/15/2023] Open
Abstract
Background Obesity and radiological severity have been identified to be independent predictors of a low rate of response to viscosupplementation (VS), in patients with knee osteoarthritis (OA). Is that enough to formally refute VS in such patients in whom surgery is sometimes contraindicated? Objectives To compare pain and function scores before and 6 months after knee VS, according to the weight status (obese versus non obese), the radiological severity (mild/moderate versus severe) and both combined. Methods Post-hoc analysis of a prospective, double blind, randomized, multicentre trial, comparing 2 viscosupplements, in patients with symptomatic knee OA. Patients were classified according to body mass index (BMI < or ≥ 30 kg.− 2), OARSI radiological grade (1–2 versus 3) and OMERACT-OARSI response criteria (Yes/No). WOMAC between-group comparisons (obese versus non-obese, OARSI 1–2 versus 3, and both combined) in all patients and in OMERACT-OARSI Responders, were achieved using Mannn-Whitney U test. Results One-hundred and sixty-six patients were analyzed: 28.3% were obese, 44% were OARSI grade 3, 42,2% were neither obese nor OARSI 3, whereas 14.5% were obese and OARSI 3. At baseline WOMAC pain score did not differ according to the patients sub-groups (p > 0.05). Six months after VS, WOMAC pain decreased significantly in all patient sub-groups (all p < 0.01). At month 6, WOMAC pain sub-score was significantly lower in non-obese than in obese patients (4.9 ± 4.1 versus 7.1 ± 4.9; p = 0.008) and in patients OARSI 1–2 versus 3 (4.8 ± 4.3 versus 6.4 ± 4.5; p = 0.009). However, in responder patients there was no difference in pain score and pain decrease related to the weight status and the radiological score. Conclusion These results do not confirm our previous conclusions that recommended not performing VS in obese patients with severe knee OA. Although the chances of being a responder were much reduced in these patients, the benefit of patients who respond to treatment was similar to that of subjects with normal weight and mild/moderate OA. Different pain phenotypes, more than overweight and advanced disease, might be the main reason for the success or failure of VS.
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Affiliation(s)
- Thierry Conrozier
- Department of rheumatology, Hôpital Nord Franche-Comté, 100 route de Moval, CS 10490, Trevenans, 90015, Belfort, France.
| | - Florent Eymard
- Department of Rheumatology, Hôpital Henri Mondor, Creteil, France
| | - Mickael Chouk
- Department of rheumatology, Hôpital Nord Franche-Comté, 100 route de Moval, CS 10490, Trevenans, 90015, Belfort, France
| | - Xavier Chevalier
- Department of Rheumatology, Hôpital Henri Mondor, Creteil, France
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Barmaki M, Maindet-Dominici C, Nizard J, Baron D, Russ I, Fardellone P, Ginies P, Marc JF, Conrozier T, Bertin P. Multicenter, Prospective, Controlled Double-Blind Study Comparing Fib-19-01, A Phytotherapy Treatment, To A Dietary Supplement And To Conventional Care In Patients Suffering From Fibromyalgia. Altern Ther Health Med 2019; 25:46-53. [PMID: 31202211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Current therapeutic modalities for fibromyalgia (FM) do not provide satisfactory results and new approaches have to be explored. OBJECTIVES To assess efficacy and safety of adding a phytotherapy treatment (Fib-19-01) to the current therapeutic regimen in patients with FM. METHODS Double-blind controlled trial: women with active FM (Fibromyalgia Index Questionnaire FIQ > 40) were randomised to receive Fib-19-01 or a food supplement (FS) undistinguishable from Fib-19-01 or no supplementary treatment (NoST). All continued the conventional therapy throughout the 6 month follow-up. Primary endpoint: change in FIQ between Day 0 and month 6 (M6). Secondary Criteria: variation over time FIQ ( repeated measurements), change in Pichot fatigue scale, Pittsburgh Sleep Quality Index (PSQI), SF-12 and Hospital Anxiety and Depression (HAD) scales. RESULTS 100 patients (Intent-To-Treat population) were analyzed. FIQ decreased significantly only in the Fib-19-01 group (P < .001) at both week 12 and 24. Improvement was higher for Fib-19-01 (-13.4 ± 18.9) than in the 2 other groups (-5.5 ± 15.6 and -5.6 ± 11.3) despite there was no statistical between-group difference at week 24 in FIQ score (P = .08 and P = .09 respectively). Analysis of variance in repeated measurements of FIQ showed a significant difference between Fib-19-01 and FS throughout the follow-up period (P = .03). Fib-19-01 was superior to both FS and NoST for Pichot scale decrease over time: -4.6 (range -6.9; -2.28), -0.29 (-2.7; 2.1) and -0.72 (-3.1; 1.66) (P = .013 and 0.023 respectively), mental and social SF12 [+8.1 (range 3.5; 12.6), -0.27(range -5.3; 4.8 ) and -0.02 (range -5.0; 4.9 ) P = .02 and 0.018)],HAD depression [-2.0 (range -3.3; -0.7), +0.5 (range -0.9; 1.9 ) and +0.71 (range -0.7; 2.1) P = .013 and 0.007]. No significant difference was found between FS and NoST groups for any outcome. All treatments were well and similarly tolerated. CONCLUSIONS In patients with FM taking conventional therapy, Fib-19-01 has a therapeutic effect on fatigue, emotion and social life, and depression associated with the disease.
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Abstract
The close association between osteoarthritis (OA) and obesity is well established. Mechanisms linking obesity and OA involve multifactorial phenomena such as systemic factors (i.e. adipokines and pro-inflammatory cytokines), hormonal disturbances (hyperinsulinemia) and muscule changes (i.e. sarcopenia and lower muscular tone). The concomitant increasing prevalence of the two diseases have major health, social and economic consequences. However, to date no specific recommendation for the medical management of obese patients with OA have been published. Current recommendations only specify that obese patients must lose weight and practice regular physical activity in addition to the usual care. Weight loss improves not only OA symptoms but also metabolic abnormalities and cardiovascular risk factors commonly altered in subjects with obesity. OA symptoms' improvement has been shown to become clinically relevant from a weight loss > 5% of the body weight. In case of morbid obesity, bariatric surgery may be the only alternative for pain relief. After bariatric surgery, an appropriate calcium and vitamin D intake is recommended, since it has been shown that bariatric surgery was associated with a reduction in the bone mineral density and increased risk of fractures. An exercise program is essential for preserving healthy muscles during weight loss. Non-steroidal anti-inflammatory drugs and corticosteroids must be avoided, especially in obese patients with metabolic syndrome. In such patients symptomatic slow acting drugs for OA (i.e. glucosamine, chondroitin) and some anti-oxidant drugs (i.e. curcumin, ginger extracts, copper) may be helpful thanks to their excellent benefit/risk ratio and their mode of action which may have a positive impact on both OA and obesity-related metabolic disorders. Recent research focuses on the development of molecules aimed for promoting the production of heme oxygenase (HO-1). HO-1 decreases the production of oxygen free radicals and protects tissues from oxidative stress in the insulin resistance syndrome. Intra-articular (IA) injections of hyaluronic acid and corticosteroid have few adverse events. However, physicians must inform patients that IA treatments have a lower success rate in obese patients than in those with normal body mass index. Spa therapy contributes to relief pain, favour weight-loss and reduces metabolic abnormalities with a favourable risk/benefit balance.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
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Henrotin Y, Bannuru R, Malaise M, Ea HK, Confavreux C, Bentin J, Urbin-Choffray D, Conrozier T, Brasseur JP, Thomas P, Hick AC, Marinello A, Giordan N, Richette P. Hyaluronan derivative HYMOVIS® increases cartilage volume and type ii collagen turnover in osteoarhritic knee: data from MOKHA study. BMC Musculoskelet Disord 2019; 20:293. [PMID: 31215422 PMCID: PMC6580647 DOI: 10.1186/s12891-019-2667-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 06/05/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The objective of this pilot study was to identify biological, clinical or structural biomarkers of an intra-articular hyaluronic acid injection efficacy (HYMOVIS®) for the design of a larger placebo-controlled clinical trial studying the disease-modifying activity of this treatment. METHODS Forty six patients with symptomatic knee Osteoarthritis (OA) were enrolled in this open-label, prospective, multicenter, pilot study. Patients received two treatment cycles of intra-articular injections (3 mL) of HYMOVIS® (8 mg/mL of hyaluronic acid hexadecylamide) at 6 months interval. Each treatment cycle involved two intra-articular injections 1 week apart. All patients had Magnetic Resonance Imaging (MRI) of the target knee at baseline and 1 year, and blood samples to assess joint biomarkers. The primary outcome was the change in type II collagen-specific biomarkers (Coll2-1, Coll2-1NO2 and CTX-II) after HYMOVIS® treatment versus baseline. Secondary endpoints included levels changes in aggrecan chondroitin sulfate 846 epitope (CS-846), Cartilage Oligomeric Matrix Protein (COMP), procollagen type II N-terminal propeptide (PIIANP), Matrix Metalloprotease (MMP)-3, Myeloperoxidase (MPO) and Interleukin (IL)-6 serum biomarkers, the ratio Coll2-1/PIIANP, CTX-II/PIIANP, variation of MRI cartilage volume, and Knee injury and Osteoarthritis Outcome Score (KOOS) index. RESULTS Coll2-1 serum levels significantly increased overtime while Coll2-1NO2 levels were only increased at D360. Serum PIIANP levels also progressively and significantly enhanced with time. In contrast, other serum biomarker levels including CTX-II, CS-846, COMP, MMP-3, MPO or IL-6 did not change significantly overtime. Interestingly, the ratios Coll2-1/PIIANP and CTX-II/PIIANP decreased, indicating a decrease of cartilage catabolism. Compared to baseline value, MRI cartilage volume and thickness increased in lateral femoral and lateral trochlea compartments and not in medial compartment. These results, in addition to an improvement of T2 mapping score suggest a positive structural effect of the product. Interestingly, WORMS effusion score, an indicator of synovitis, significantly decreased. Finally, global KOOS score and subscales significantly increased overtime while pain at rest, walking pain and patients or investigators global assessment of disease activity decreased. The safety profile was favorable with a low incidence of injection-site pain. CONCLUSION HYMOVIS®, a well-tolerated intra-articular treatment, significantly enhanced type II collagen turnover as suggested by the increase in Coll2-1 and PIIANP levels and cartilage volume observed by MRI in lateral knee compartment. Importantly, this study provides critical information for the design of a larger phase III clinical trial investigating Disease Modifying effect of HYMOVIS®. TRIAL REGISTRATION http://www.isrctn.com/ISRCTN12227846 11/02/2015.
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Affiliation(s)
- Yves Henrotin
- Bone and Cartilage Research Unit, Arthropole Liège, Université de Liège, Institute of Pathology, CHU Sart-Tilman, 4000 Liège, Belgium
- Artialis SA, GIGA Tower, CHU Sart-Tilman, Liège, Belgium
| | - Raveendhara Bannuru
- Center for Treatment Comparison and Integrative Analysis, Division of Rheumatology, Tufts Medical Center, Boston, MA USA
| | - Michel Malaise
- Service de Rhumatologie - CHU Sart-Tilman, Liège, Belgium
| | - Hang-korng Ea
- Service de Rhumatologie - Centre Viggo Petersen, Hôpital Lariboisière, Paris, France
| | | | - Jacques Bentin
- Service de Rhumatologie - CHU Brugmann, Bruxelles, Belgium
| | | | - Thierry Conrozier
- Service de Rhumatologie - Hôpital Nord Franche-Comté, Trévenans, France
| | | | - Philippe Thomas
- Service de Rhumatologie - CHR Metz-Thionville - Hôpital Bel Air, Thionville, France
| | | | | | | | - Pascal Richette
- Service de Rhumatologie - Centre Viggo Petersen, Hôpital Lariboisière, Paris, France
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Conrozier T, Renevier JL, Parisaux JM, Balblanc JC. Predictive factors of adherence to an association of glucosamine sulfate, copper, and ginger extracts in patients with symptomatic osteoarthritis: a prospective open-label French noninterventional study (the PREDOA study). Patient Prefer Adherence 2019; 13:915-921. [PMID: 31239649 PMCID: PMC6559715 DOI: 10.2147/ppa.s200892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/02/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Osteoarthritis (OA) management needs a combination of nonpharmacological and pharmacological modalities. However, as in many chronic conditions, the main concern with OA therapy is the difficulty in obtaining good medication compliance over a long period. The PREDOA study aimed to investigate the predictive factors of adherence to treatment in patients with OA treated with glucosamine sulfate (GS)-copper sulfate-ginger root (GCu), a symptomatic slow-acting drug for OA. Methods: Ambulatory patients with a clinical diagnosis of OA were included in a prospective (6 months) multicenter open-label observational study. All patients received two capsules of GS-GCu once daily for 6 months. Demographics, disease features (OA location, symptom duration, concomitant therapies, comorbidities), and patient self-assessment of pain (0-10) were obtained at baseline. At month 6, the investigator collected patient self-assessments of treatment observance, reasons for nonadherence, pain scores, patient perceptions of treatment efficacy, changes in analgesic intake, and occurrence of adverse events. Predictors of observance were studied in univariate and multivariate analyses. Results: A total of 2,030 patients were included in the study. At baseline, the average pain score was 6.4±1.7. Observance was good in 80% of patients. It was weaker in active than retired patients (P=0.005) in patients not taking concomitant treatment (P=0.008) or who had never been treated for OA (P=0.001). Observance was correlated with pain decrease (P<0.0001) and with lack of adverse effects (P<0.001). Age, sex, pain level at baseline, OA location, and number of painful joints were not related to treatment compliance. Conclusion: Medication compliance with GS-GCu depends both on the safety-efficacy balance and several patient related-factors. To improve adherence, detailed information about therapeutic objectives is necessary in active patients who do not get any other medications and for whom it is their first treatment for OA. Clinical trial identifier: CCTIRS 14-371 B.
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Affiliation(s)
- Thierry Conrozier
- Service de Rhumatologie, Hôpital Nord Franche-Comté, Belfort, France
- Correspondence: Thierry Conrozier Department of Rheumatology, Hôpital Nord Franche-Comté, 100 route de MOVAL, CS 10499 Trevenans, Belfort, 90015, FranceTel +33 384 982 222Email
| | | | - Jean-Marc Parisaux
- Institut Monégasque de Médecine et Chirurgie Sportive, Monaco, Principauté de Monaco
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Conrozier T. Is the Addition of a Polyol to Hyaluronic Acid a Significant Advance in the Treatment of Osteoarthritis? Curr Rheumatol Rev 2018; 14:226-230. [DOI: 10.2174/1573397113666170710115558] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/30/2017] [Accepted: 07/01/2017] [Indexed: 11/22/2022]
Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Hopital Nord Franche-Comte, Belfort, France
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Conrozier T, Monet M, Lohse A, Raman R. Getting Better or Getting Well? The Patient Acceptable Symptom State (PASS) Better Predicts Patient's Satisfaction than the Decrease of Pain, in Knee Osteoarthritis Subjects Treated with Viscosupplementation. Cartilage 2018; 9:370-377. [PMID: 28800711 PMCID: PMC6139588 DOI: 10.1177/1947603517723072] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background In the management of knee osteoarthritis (OA), patient-reported-outcomes (PROs) are being developed for relevant assessment of pain. The patient acceptable symptom state (PASS) is a relevant cutoff, which allows classifying patients as being in "an acceptable state" or not. Viscosupplementation is a therapeutic modality widely used in patients with knee OA that many patients are satisfied with despite meta-analyses give conflicting results. Objectives To compare, 6 months after knee viscosupplementation, the percentage of patients who reached the PASS threshold (PASS +) with that obtained from other PROs. Methods Data of 53 consecutive patients treated with viscosupplementation (HANOX-M-XL) and followed using a standardized procedure, were analyzed at baseline and month 6. The PROs were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function, patient's global assessment of pain (PGAP), patient's self-assessment of satisfaction, PASS for WOMAC pain and PGAP. Results At baseline, WOMAC pain and PGAP (range 0-10) were 4.6 (1.1) and 6.0 (1.1). At month 6, they were 1.9 (1.2) and 3.1 (5) ( P < 0.0001). At 6 months, 83% of patients were "PASS + pain," 100% "PASS + function," 79% "PASS + PGAP," 79% were satisfied, and 73.6% experienced a ≥50% decrease in WOMAC pain. Among "PASS + pain" and "PASS + PGAP" subjects, 90% and 83.3% were satisfied with the treatment, respectively. Conclusion In daily practice, clinical response to viscosupplementation slightly varies according to PROs. "PASS + PGAP" was the most related to patient satisfaction.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France,Thierry Conrozier, Department of Rheumatology, Hôpital Nord Franche-Comté, 104 Route de Moval, 90400 Trevenans, Belfort, France.
| | - Matthieu Monet
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Anne Lohse
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Raghu Raman
- Academic Department of Orthopaedics, Hull and East Yorkshire NHS Trust Castle Hill Hospital, Cottingham, UK
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Raman R, Henrotin Y, Chevalier X, Migliore A, Jerosch J, Montfort J, Bard H, Baron D, Richette P, Conrozier T. Decision Algorithms for the Retreatment with Viscosupplementation in Patients Suffering from Knee Osteoarthritis: Recommendations from the EUROpean VIScosupplementation COnsensus Group (EUROVISCO). Cartilage 2018; 9:263-275. [PMID: 29110511 PMCID: PMC6042033 DOI: 10.1177/1947603517693043] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Viscosupplementation (VS) is a symptomatic treatment of knee osteoarthritis. Although systematic reviews of its repeat use showed favorable benefit/risk ratio, no study has focused on the indication of retreatment. Methods A task force was created to look at issues regarding retreatment with VS in knee osteoarthritis. An attempt was made to reach consensus on several issues: (1) to define treatment "success" and "failure," (2) to determine when to retreat patients successfully treated by a previous VS, (3) to determine how to retreat patients in whom VS failed, (4) to define what to do in case of adverse reaction following previous VS, and (5) to examine the interests of soluble biomarkers to manage retreatment. After debate and review of literature the working group voted on 88 issues. Two "decision trees" were built based on the results of the votes. Results In case of failure, the authors draw attention to the need of a rigorous clinical and radiological analysis, and consider evidence-based medicine. When VS was previously successful, retreatment can be considered after recurrence or increase in pain. However, in subjects with high risk of disease progression, in young patients, and in professional sportsmen, retreatment could be considered systematically, because of the probability of hyaluronic acid to slow osteoarthritis progression. Evidence on soluble biomarkers was not considered as enough strong to support their use as decision tools for patient retreatment. Conclusion The decision algorithms are intended to facilitate consideration of the therapeutic options, in patients with knee osteoarthritis previously treated with VS.
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Affiliation(s)
- Raghu Raman
- Academic Department of Orthopaedics, Hull and East Yorkshire NHS Trust Castle Hill Hospital, Cottingham, UK
| | - Yves Henrotin
- Bone and Cartilage Research Unit, Université de Liège, CHU Sart-Tilman, Liège, Belgium
| | - Xavier Chevalier
- Paris XII University, UPEC, Department of Rheumatology, Henri Mondor Hospital, Creteil, France
| | - Alberto Migliore
- U.O.S. of Rheumatology, Ospedale San Pietro Fatebenefratelli, Rome, Italy
| | - Jörg Jerosch
- Orthopedic Department, Johanna-Etienne-Hospital, Neuss, Germany
| | - Jordi Montfort
- Servei de Reumatologia, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Hervé Bard
- Department of Rheumatology. Hôpital Européen Georges-Pompidou, Paris, France
| | - Dominique Baron
- Centre de réadaptation fonctionnelle de Lannion-Trestel, Trévou-Tréguignec, France
| | - Pascal Richette
- Université Paris Diderot, UFR médicale, Hôpital Lariboisière, Paris, France
| | - Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
- Thierry Conrozier, Department of Rheumatology, Hôpital Nord Franche-Comté, F-90000, Belfort, France.
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Dauvissat J, Rizzo C, Lellouche H, Porterie J, Melac-Ducamp S, Locquet V, Travers V, Maillet B, Conrozier T. Safety and Predictive Factors of Short-Term Efficacy of a Single Injection of Mannitol-Modified Cross-Linked Hyaluronic Acid in Patients with Trapeziometacarpal Osteoarthritis. Results of a Multicentre Prospective Open-Label Pilot Study (INSTINCT Trial). Clin Med Insights Arthritis Musculoskelet Disord 2018; 11:1179544118782901. [PMID: 29977118 PMCID: PMC6024274 DOI: 10.1177/1179544118782901] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/20/2018] [Indexed: 12/18/2022]
Abstract
Purpose: To assess safety and search predictive factors of efficacy of a single intra-articular injection of a mannitol-modified hyaluronic acid (HA) viscosupplement, in patients having trapeziometacarpal (TMC) osteoarthritis (OA). Methods: Patients with symptomatic TMC OA, not adequately relieved by analgesic therapy and/or by the use of a thumb splint, were included in a 3-month prospective multicentre open-label trial. All underwent plain radiographs with the Kapandji incidences allowing the Dell radiological grade assessment (1-4). Primary end point was the variation between injection (D0) and day 90 (D90) of the thumb pain (11-point Likert scale). Treatment consisted in a single injection of 0.6 to 1 mL of a viscosupplement made of a cross-linked HA combined with mannitol. All injections were performed under imaging guidance. Predictive factors of pain decrease were studied in univariate and multivariate analysis. Results: A total of 122 patients (76% women, mean age 60, mean disease duration 36 months) were included and 120 (98%) were assessed at 3 months. The TMC OA was of Dell’s grade 1, 2, 3, and 4 in 23%, 36.8%, 36.8%, and 3.5% of cases, respectively. At D0, the average (SD) pain level was 6.5 ± 1.6 without significant difference between Dell groups (P = .21). At day 90, pain decreased from 6.5 ± 1.6 to 3.9 ± 2.5 (difference −2.7 ± 2.5; −42%; P < .0001) without significant difference between Dell grade (P = .055), despite a seemingly smaller number of responders in stage 2 patients. The average analgesic consumption decreased in more than 1 out of 2 patients. In multivariate analysis, no predictor of response was identified. There was no safety issue. All adverse events (11%) were transient increase in pain during or following HA administration and resolved without sequel within 1 to 7 days. Conclusions: This study suggests that a single course of HANOX-M-XL injection is effective in relieving pain in patients with TMC OA, without safety concern. Patients with advanced stage of OA benefit the treatment as much as those with mild or moderate OA.
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Affiliation(s)
- Jérémy Dauvissat
- Service de Rhumatologie, Hôpital Nord Franche-Comté, Belfort, France
| | | | | | - Jérôme Porterie
- Service d'Orthopédie du membre supérieur, Cabinet de Rhumatologie, Auch, France
| | | | - Vincent Locquet
- Institut Chirurgical de la Main et du Membre Supérieur, Villeurbanne, France
| | | | - Bernard Maillet
- Service de Rhumatologie, Polyclinique Saint-Odilon, Moulins, France
| | - Thierry Conrozier
- Service de Rhumatologie, Hôpital Nord Franche-Comté, Belfort, France
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Leighton R, Fitzpatrick J, Smith H, Crandall D, Flannery CR, Conrozier T. Systematic clinical evidence review of NASHA (Durolane hyaluronic acid) for the treatment of knee osteoarthritis. Open Access Rheumatol 2018; 10:43-54. [PMID: 29849470 PMCID: PMC5967379 DOI: 10.2147/oarrr.s162127] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Pain and limitations in joint mobility associated with knee osteoarthritis (OA) are clinically challenging to manage, and advanced progression of disease can often lead to total knee arthroplasty. Intra-articular injection of hyaluronic acid (HA), also referred to as viscosupplementation, is a non-surgical treatment approach for OA, the effectiveness of which may depend on the HA composition, and the length of time over which it resides in the joint. One of the available options for such therapies includes NASHA (Durolane HA), a non-animal, biofermentation-derived product, which is manufactured using a process that stabilizes the HA molecules to slow down their rate of degradation and produce a unique formulation with a terminal half-life of ~1 month. The objectives of the current review were to assess, in patients with OA of the knee, the efficacy and safety of intra-articular treatment with NASHA relative to control (saline) injections, other HA products, and other injectables (corticosteroids, platelet-rich plasma, mesenchymal stem cells). Methods This systematic evidence review examines patient outcomes following NASHA treatment as described in published data from studies conducted in subjects with knee OA. A Preferred Reporting Items for Systematic Reviews and Meta-analyses-compliant literature search strategy yielded 11 eligible clinical studies with a variety of comparator arms. Outcomes assessed at various time points following intra-articular treatment included measures of pain, function, quality of life, and incidence of treatment-related adverse events (AEs). Results The available evidence reported for the clinical studies assessed demonstrates sustained and effective relief of knee OA symptoms following a single injection of NASHA. In addition, an excellent biocompatibility profile is observed for NASHA as an intra-articular therapy for OA, as reflected by the low rate of AEs associated with treatment. Conclusion Treatment with NASHA is an effective and safe single-injection procedure, which can be beneficial in the clinical management of knee OA.
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Affiliation(s)
- Ross Leighton
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Jane Fitzpatrick
- Sports Medicine Professionals Pty Ltd, Richmond, VIC, Australia.,University of Western Australia, Perth, WA, Australia
| | | | | | | | - Thierry Conrozier
- Department of Rheumatology, Hospital Nord Franche-Comte, Belfort, France
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Eymard F, Chevalier X, Conrozier T. Obesity and radiological severity are associated with viscosupplementation failure in patients with knee osteoarthritis. J Orthop Res 2017; 35:2269-2274. [PMID: 28128473 DOI: 10.1002/jor.23529] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/23/2017] [Indexed: 02/04/2023]
Abstract
Viscosupplementation (VS) is still controversial. One of the key points is the lack of well-identified factors of response. We aimed to identify clinical and radiological factors associated with lack of relevant response after intra-articular (IA) hyaluronic acid (HA) injections in symptomatic knee osteoarthritis patients. A post hoc analysis of the HAV-2012 trial, a controlled, multicentre, double-blind, randomized, non-inferiority trial comparing 3 weekly IA injections of HA (HAnox-M or BioHA) for symptomatic tibiofemoral OA was performed. At inclusion, demographic, anthropometric, clinical data (WOMAC score, patient global assessment, presence of knee effusion), and radiological data (OARSI grade, patello-femoral involvement) were recorded. VS response was defined according to OMERACT-OARSI response criteria at month 6. Predictors of response were investigated in univariate then in multivariate analysis. One hundred and sixty-six patients with full available data were included. As baseline characteristics and treatment effectiveness were similar between the 2 HA groups, their data were pooled. The mean age was 65.2 [63.7-66.8] years; 101 (60.8%) were women; 73 (44.0%) had severe TF space narrowing. At 6 months, 113 patients (68.1%) were responders. Multivariate analysis showed that obesity (BMI ≥30 kg/m2) and radiological severity (OARSI grade 3) were significantly associated with VS failure (p = 0.001 and p = 0.008, respectively). Moreover, the association of obesity and severe TF space narrowing significantly increased the risk of VS failure. Baseline pain intensity and functional impairment were not associated with VS response. Consequently, IA injection of HA for knee OA should mainly be considered in subjects with low BMI and mild TF space narrowing. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2269-2274, 2017.
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Affiliation(s)
- Florent Eymard
- Department of Rheumatology, AP-HP Henri Mondor Hospital, F-94010, Créteil Cedex, France
| | - Xavier Chevalier
- Department of Rheumatology, AP-HP Henri Mondor Hospital, F-94010, Créteil Cedex, France
| | - Thierry Conrozier
- Department of Rheumatology, Nord Franche-Comté, Hospital, 90000, Belfort, France
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Deseyne N, Conrozier T, Lellouche H, Maillet B, Weber U, Jaremko JL, Paschke J, Epstein J, Maksymowych WP, Loeuille D. Hip Inflammation MRI Scoring System (HIMRISS) to predict response to hyaluronic acid injection in hip osteoarthritis. Joint Bone Spine 2017; 85:475-480. [PMID: 28893678 DOI: 10.1016/j.jbspin.2017.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 08/31/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess predictors of response, according to hip MRI inflammatory scoring system (HIMRISS), in a sample of patients with hip osteoarthritis (OA) treated by hyaluronic acid (HA) injection. METHOD Sixty patients with hip OA were included. Clinical outcomes were assessed at baseline and three months after HA injection by WOMAC. On hip MRI performed before HA injection, bone marrow lesion (BML) and synovitis were assessed by HIMRISS by four readers. The inter-reader reliability of HIMRISS was for HIMRISS total, acetabular BML, femoral BML and synovitis-effusion respectively 0.86, 0.64, 0.83 and 0.78. Associations between MRI features and clinical data were assessed. Logistic regression (univariate and multivariate) was used to explore associations between MRI features and response to HA injection, according to WOMAC50 response at three months. RESULTS In total, 45.5% of patients met WOMAC50 response. Five adverse events were reported. At baseline, WOMAC function correlated significantly to HIMRISS synovitis-effusion (r=0.27, P=0.03). In univariate analysis, BML femoral according to binary assessment (P=0.025), HIMRISS BML femoral (P=0.0038), HIMRISS BML acetabular (P=0.042), HIMRISS total (P=0.0092) were associated negatively with WOMAC50 response. In multivariate analysis, adjusted for age and BMI, HIMRISS femoral BML (P=0.02) and HIMRISS total (P=0.016) were negatively associated with response. At a HIMRISS threshold of<15, 82% of patients were responders, with specificity SP=0.97, sensitivity SN=0.39, and positive and negative predictive values of 0.91 and 0.64, respectively. CONCLUSION HIMRISS is reliable for total scores and sub-domains. It permits identification of responders to HA injection in hip OA patients.
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Affiliation(s)
- Nicolas Deseyne
- Department of Rheumatology, CHRU de Nancy, 5, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.
| | - Thierry Conrozier
- Department of Rheumatology, North Hospital Franche-Comté, 25200 Montbéliard, France
| | - Henri Lellouche
- Department of Rheumatology, Lariboisière Hospital, 75475 Paris cedex 10, France
| | - Bernard Maillet
- Department of Rheumatology, Clinique Saint-Odilon, 03000 Moulins, France
| | - Ulrich Weber
- King Christian 10th Hospital for Rheumatic Diseases, Gråsten, Denmark; Institute of Regional Health Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Alberta AB T6G 2R3, Edmonton, Canada
| | - Joel Paschke
- CaRE Arthritis, Alberta T6W 2Z8, Edmonton, Canada
| | - Jonathan Epstein
- CEC-Inserm CIE6, epidemiology and clinical evaluations department, CHRU de Nancy, 54500 Vandœuvre-lès-Nancy, France
| | - Walter P Maksymowych
- Department of Medicine, University of Alberta, Alberta AB T6G 2R3, Edmonton, Canada
| | - Damien Loeuille
- Department of Rheumatology, CHRU de Nancy, 5, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
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Abstract
In order to extensively investigate on the synovial membrane – related diseases, we outlined a specific medical branch named “Synoviology”, targeted to the physiopathology and therapy of synovial membrane dysfunction. We searched Pubmed/Medline using the terms “synovial disease”, “therapy”, “synovial membrane”, “joints” and “drugs”, alone and combined. Selected papers from 1960 to 2015 were chosen based on their content (evidence-based quality and reliability). Clinical and experimental articles were included. Viscosupplementation with structurally different hyaluronic acid compounds, for restoration of the synovial membrane, and cartilage. The impact of other old and new medical treatments either locally or systemically administered was also included. Synoviology integrates biological, clinical and biochemical info for the progress of new therapeutic options in osteo-articular pathology.Asian Journal of Medical Sciences Vol.8(3) 2017 1-10
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Eymard F, Maillet B, Lellouche H, Mellac-Ducamp S, Brocq O, Loeuille D, Chevalier X, Conrozier T. Predictors of response to viscosupplementation in patients with hip osteoarthritis: results of a prospective, observational, multicentre, open-label, pilot study. BMC Musculoskelet Disord 2017; 18:3. [PMID: 28056915 PMCID: PMC5217257 DOI: 10.1186/s12891-016-1359-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 12/06/2016] [Indexed: 01/22/2023] Open
Abstract
Background To identify predictive factors of response to viscosupplementation (VS) in patients with hip osteoarthritis (HOA). Methods Prospective, multicentre, open-label trial, achieved in daily practice conditions. Patients with HOA were treated with a single intra-articular injection of a cross-linked hyaluronic acid combined with mannitol (HAnox-M-XL), using imaging guidance. WOMAC pain and function scores and patient global assessment (PGA) were assessed at baseline and day 90. Improvement, satisfaction and efficacy were self-assessed at day 90. Hip radiographs at baseline were scored using Kellgren-Lawrence grade and Osteoarthritis Research Society International (OARSI) score. Associations between clinical and radiological features and response to VS (pain improvement > 50% at day 90) were assessed in univariate analysis, and then using logistic regression, adjusted for confounding factors. Results The intent-to-treat (ITT) population included 97 patients (57 females, mean age 63). Ninety completed the follow-up and 80 had full clinical and radiological data. Response to VS was achieved in 47.8% of patients. In univariate analysis, the only clinical outcome statistically and negatively related to response was PGA at baseline (p = 0.047). Radiologically, response to VS was negatively correlated with joint space narrowing (JSN) score (JSN < 2 vs. JSN ≥ 2, p = 0.01) and was related to the patterns of femoral head migration (p = 0.008). In multivariate analysis, only JSN grade (p = 0.03) remained significantly related to a poor response. Conclusion This pilot study, which needs further confirmation by larger scale trials, suggests that radiological features might be of importance for the decision of VS in patients with HOA. Trial registration number ID RCB N°2013-A00165-40. Registered 31 January 2013.
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Affiliation(s)
- Florent Eymard
- Department of rheumatology, AP-HP Henri Mondor Hospital, 51 avenue du Maréchal de Lattre de Tassigny, Créteil, 94000, France.
| | | | - Henri Lellouche
- Department of rheumatology, AP-HP Lariboisière Hospital, Paris, 75010, France
| | | | - Olivier Brocq
- Department of rheumatology, Princesse Grace Hospital, Monaco, 98000, Monaco
| | - Damien Loeuille
- Department of rheumatology and IMoPA (Ingénierie Moléculaire et Physiopathologie Articulaires), Brabois University Hospital, Vandoeuvre-les-Nancy, 54511, France
| | - Xavier Chevalier
- Department of rheumatology, AP-HP Henri Mondor Hospital, 51 avenue du Maréchal de Lattre de Tassigny, Créteil, 94000, France
| | - Thierry Conrozier
- Department of rheumatology, Nord Franche Comté Hospital, Belfort, 90000, France
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Bossert M, Boublil D, Parisaux JM, Bozgan AM, Richelme E, Conrozier T. Imaging Guidance Improves the Results of Viscosupplementation with HANOX-M-XL in Patients with Ankle Osteoarthritis: Results of a Clinical Survey in 50 Patients Treated in Daily Practice. Clin Med Insights Arthritis Musculoskelet Disord 2016; 9:195-199. [PMID: 27891055 PMCID: PMC5120624 DOI: 10.4137/cmamd.s40401] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/29/2016] [Accepted: 10/01/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND The objective of this survey was to assess retrospectively the interest of performing viscosupplementation using imaging guidance in patients suffering from ankle osteoarthritis (OA). PATIENTS AND METHODS This is a multicenter retrospective survey using a standardized questionnaire. Fifty patients suffering from ankle OA and treated, in daily clinical practice, with a single intra-articular injection of a novel viscosupplement made of a combination of a non-animal cross-linked hyaluronan and mannitol, HANOX M-XL, were included in the survey. The injection procedure (imaging or landmark guidance), demographic data, patient’s self-evaluation of pain, satisfaction, treatment efficacy, and tolerability were collected. Predictive factors of both efficacy and patient’s satisfaction were investigated. RESULTS The percentages of patients very satisfied/satisfied and not really satisfied/dissatisfied with the treatment were 68% and 32%, respectively. Efficacy was rated as very good, good, moderate, and poor by 38%, 30%, 12%, and 20% of the cases, respectively. Efficacy was unrelated to gender and age and was highly correlated with pain score (P < 0.0001). In satisfied patients, the decrease in consumption of analgesics/non-steroidal anti-inflammatory drugs was >75% in 64% of the cases. Efficacy was significantly different with regard to imaging guidance. There was a statistically significant difference in efficacy and satisfaction between landmark-guided and imaging-guided injections (P = 0.02). The success rate was 2.3 times higher in the imaging-guided group than in the landmark-guided group. No significant difference was found between patients injected under fluoroscopy or ultrasound guidance, despite a trend favoring ultrasound (P = 0.09). Tolerability was rated as very good/good in 47 patients, moderate in two, and poor in one and was unrelated to the type of guidance. CONCLUSION This preliminary study suggests that the use of imaging guidance significantly optimizes the success rate of ankle viscosupplementation. No safety concern was observed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Marie Bossert
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Daniel Boublil
- Department of Orthopaedic Surgery, Clinique du Parc, Lyon, France
| | - Jean-Marc Parisaux
- Department of Sports Medicine, Institut Monégasque de Médecine du Sport, Principauté de Monaco, Monaco
| | - Ana-Maria Bozgan
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Emmanuel Richelme
- Department of Orthopaedic Surgery, Institut de Chirurgie Orthopédique et Sportive, Marseille, France
| | - Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
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Conrozier T, Eymard F, Afif N, Balblanc JC, Legré-Boyer V, Chevalier X. Safety and efficacy of intra-articular injections of a combination of hyaluronic acid and mannitol (HAnOX-M) in patients with symptomatic knee osteoarthritis: Results of a double-blind, controlled, multicenter, randomized trial. Knee 2016; 23:842-8. [PMID: 27353769 DOI: 10.1016/j.knee.2016.05.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 05/20/2016] [Accepted: 05/31/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND To compare both safety and efficacy of a novel intra-articular viscosupplement made of intermediate molecular weight (MW) hyaluronic acid (HA) mixed with high concentration of mannitol with a marketed high MW HA, in patients with knee osteoarthritis (OA). METHODS Patients with symptomatic knee OA, with radiological OARSI grades 1 to 3, were enrolled in a controlled, double-blind, parallel-group, non-inferiority trial. They were randomized to receive three intra-articular injections, at weekly intervals, of either HAnOX-M made of a combination of HA (MW one to 1.5MDa, 31mg/2ml) and mannitol (70mg/2ml) or Bio-HA (MW 2.3 to 3.6MDa, 20mg/2ml). The primary outcome was six-month change in the WOMAC pain subscale (0 to 20). Sample size was calculated according to a non-inferiority margin of 1.35. Secondary endpoints included six-month change in function and walking pain, analgesic consumption and safety. RESULTS The intention-to-treat (ITT) and per-protocol (PP) populations consisted of 205 and 171 patients. HAnOX-M and Bio-Ha groups did not differ statistically at baseline. The primary analysis was conducted in the PP population, then in the ITT population. The average WOMAC pain score at baseline was 9.5 in both groups. Mean (SD) variations in WOMAC pain score were -4.4 (3.8) and -4.5 (4.3) mm, for HAnOX and Bio-HA respectively, satisfying the claim for non-inferiority. Similar results were obtained for all other secondary endpoints. CONCLUSION Treatment with of HAnOX-M is effective to alleviate knee OA symptoms and to improve joint function over six months, with similar safety than conventional HA viscosupplement.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France.
| | - Florent Eymard
- Department of Rheumatology, Hôpital Henri Mondor, Creteil, France
| | - Naji Afif
- Department of Rheumatology, Hôpital Emile Muller, Mulhouse, France
| | | | - Virginie Legré-Boyer
- Institut de l'Appareil Locomoteur Nollet, Paris, France; Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Xavier Chevalier
- Department of Rheumatology, Hôpital Henri Mondor, Creteil, France; Paris XII University, UPEC, France
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Conrozier T, Bozgan AM, Bossert M, Sondag M, Lohse-Walliser A, Balblanc JC. Standardized Follow-up of Patients with Symptomatic Knee Osteoarthritis Treated with a Single Intra-articular Injection of a Combination of Cross-Linked Hyaluronic Acid and Mannitol. Clin Med Insights Arthritis Musculoskelet Disord 2016; 9:175-9. [PMID: 27688712 PMCID: PMC5036533 DOI: 10.4137/cmamd.s39432] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/29/2016] [Accepted: 05/31/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The objective of this study is to obtain pilot data from daily practice conditions of a viscosupplement made of a cross-linked high-molecular-weight hyaluronic acid (HA) combined with mannitol in patients with knee osteoarthritis (KOA). METHODS The data of 40 consecutive patients, 29 women and 11 men, who were prospectively followed up for 6 months, using a standardized procedure, were retrospectively analyzed. All patients have received a single intra-articular injection of HAnox-M-XL (4.4 mL), viscosupplement made of a cross-linked HA (16 mg/mL) + mannitol (35 mg/mL), in the target knee. The primary outcome was safety. The secondary end points included 3- and 6-month change in the WOMAC pain (0–50) and WOMAC total (0–240) and patient’s global assessment (PGA). Patient’s self-assessment of treatment efficacy (0–3) and analgesic consumption were obtained at months 3 and 6. An intent-to-treat analysis was performed. RESULTS Mean (SD) age was 60.7 (13.9) years, and mean BMI was 28.6 (5.0). Kellgren–Lawrence radiological grade was I/II and III/IV in 13 and 27 of the subjects, respectively. The average WOMAC pain and WOMAC total scores at baseline were 21.5 (9.8) and 89.9 (42.8), respectively. Thirty-nine patients completed the follow-up. HAnox-M-XL was well tolerated; two patients experienced knee pain after injection, which resolved within three days. No treatment-related severe adverse event was reported. Mean (SD) variations in WOMAC pain and WOMAC total scores were −8.2 (8.9) and −38.4 (35.6), respectively, at month 6 (P = 0.001). PGA decreased from 5.5 (2.0) to 3.0 (2.2) (P = 0.006). Efficacy was rated as good or very good in 76.9% of the cases. Most of the regular analgesics users decreased their consumption. CONCLUSION Treatment with one injection of 4.4 mL HAnox-M-XL is effective to alleviate KOA symptoms over six months, without safety concern. Controlled trials are needed to confirm these pilot data.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Ana-Maria Bozgan
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Marie Bossert
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Maxime Sondag
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
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Eymard F, Maillet B, Lellouche H, Conrozier T. AB0764 Radiographic Characteristics of The Hip May Predict Response To Viscosupplementation in Patients with Hip Osteoarthritis. Results of A Prospective Observational, Multicenter, Open-Label, Pilot Study. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.3200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Eymard F, Conrozier T, Chevalier X. OP0135 Predictive Factors of Failure of Viscosupplementation in Patients with Knee Osteoarthritis. Results of A Post-Hoc Analysis of A Double Blind, Controlled Non Inferiority Trial. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.3415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Conrozier T, Patarin J, Mathieu P, Rinaudo M. Steroids, lidocain and ioxaglic acid modify the viscosity of hyaluronic acid: in vitro study and clinical implications. Springerplus 2016; 5:170. [PMID: 27026867 PMCID: PMC4766165 DOI: 10.1186/s40064-016-1762-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 02/12/2016] [Indexed: 01/18/2023]
Abstract
Background Viscosupplementaion by intra-articular injection of hyaluronic acid (HA) is a therapeutic modality for treating osteoarthritis of the knee, of the hip and less frequently of other joints. During viscosupplementation, it is usual to inject other drugs, without knowing whether this association may have a deleterious effect thereon. The rheological properties of a viscosupplement are highly dependent on the product [molecular weight × concentration] of HA. Therefore, any reduction of its viscoelastic properties is related either to a decrease of its concentration or/and of its molecular weight. The presence of other molecules can create favorable or unfavorable molecular interactions with HA. The objective of the study was to investigate the effect of products, that are commonly associated with HA (corticosteroids, lidocain, iodinated contrast media), on the rheological behavior of HA, then to try drawing practical conclusions. Methods The rheological behavior of both a linear and a cross-linked HA, was studied before and after mixing with different volumes (ratio 1:0.5–1:4) of the following compounds: phosphate buffered saline (PBS, as a control), cortivazol, triamcinolone hexacetonide, lidocain chlorhydrate and meglumine ioxaglate. The flow curve of the different samples was obtained using a measuring method based on a constant shear rate. Results Whatever the dilution and the added molecule were, viscosity of the cross-linked viscosupplement remained much higher than that of the linear one. Addition of PBS at a ratio 1:1 caused a dramatic decrease (up to 97.5 %) of HA viscosity. Cortivazol and lidocain had a similar effect than PBS on linear HA. Both were much deleterious on cross-linked HA viscosity. Among corticosteroids, triamcinolone decreased much less HA viscosity than cortivazol. The effect of meglumine ioxaglate was dose-dependent. Up to a ratio 1:1 viscosity of the linear HA remained above the dilution effect. On the cross-linked HA, the deleterious effect of the contrast agent was evident as soon as a ratio 1:1 and became very marked at 1:2. Conclusion HA viscosity varies widely in presence of other molecules. These changes are due to both dilution and molecular interactions. This study suggests that addition of other molecules with HA can lead to a major decrease of its viscosity. However, provided to respect a maximum ratio of 1:1, the contrast medium and triamcinolone seem to have no major deleterious effect on the viscosity level, especially on crosslinked HA. The study also suggests a deleterious effect of lidocain on the cross-linked HA. These in vitro data suggest that drugs associations must be avoided when they are not essential. However, clinical trials are needed to determine whether these rheological changes may have a significant impact on the clinical outcome.
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Affiliation(s)
- Thierry Conrozier
- Service de rhumatologie, Hôpital Nord Franche-Comté, 14 rue de Mulhouse, 90000 Belfort, France
| | - Jeremy Patarin
- Rhéonova, Domaine Universitaire, 363, rue de la chimie, 38400 Saint Martin d'Hères, France
| | - Pierre Mathieu
- Laboratoire de Rhumatologie Appliquée, 19 place Tolozan, 69001 Lyon, France
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Eymard F, Bossert M, Lecurieux R, Maillet B, Chevalier X, Conrozier T. Addition of Mannitol to Hyaluronic Acid may Shorten Viscosupplementation Onset of Action in Patients with Knee Osteoarthritis: Post-Hoc Analysis of A Double-blind, Controlled Trial. ACTA ACUST UNITED AC 2016. [DOI: 10.4172/2471-8416.100021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Affiliation(s)
- Thierry Conrozier
- Service de rhumatologie, hôpital Nord Franche-Comté, 14, rue de Mulhouse, 90000 Belfort, France.
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