Forearm can forewarn

Findings on magnetic resonance imaging (MRI) of the dominant wrist in patients with early rheumatoid arthritis can foretell future functional outcome, say New Zealand researchers. If a poor prognosis is likely, aggressive management with a disease-modifying antirheumatic agent could begin sooner rather than later. The study involved 42 patients, and found that the total baseline MRI score, and particularly the bone oedema score, was predictive of physical function assessed six years later. Bone marrow oedema reflects both bone inflammation and the potential for erosion and structural joint damage.

Ann Rheum Dis 2004; 63: 555-561

Homocysteine and bone

High plasma homocysteine levels are associated with an increased risk of osteoporotic fracture in older persons; the risk is similar in magnitude to the increased risk of cardiovascular disease. The evidence comes from population-based studies in the Netherlands, and data from the Framingham study. Although we don’t know whether homocysteine is the culprit or marker for other causal factors, we do know its levels can be reduced by increasing dietary intake of folic acid, B6 and B12.

1. N Engl J Med 2004; 350: 2089-2090
2. N Engl J Med 2004; 350: 2033-2041
3. N Engl J Med 2004; 350: 2042-2049

Cutting it fine

Reports of promising results after carotid surgery in more than 3000 patients with asymptomatic stenoses have been tempered with caution.1,2 The international Asymptomatic Carotid Surgery Trial (ACST) found that "immediate" carotid endarterectomy halved the five-year stroke risk from about 12% to about 6% in asymptomatic patients younger than 75 years of age with carotid stenosis on ultrasonography of 70% or more (10-year results will be reported when available). However, both the triallists and a Canadian commentator warned that unsuccessful surgery can do much harm and that, in non-trial settings, poor surgery, inadequate audits and inappropriate selection of patients could result in misuse of carotid endarterectomy.

1. Lancet 2004; 363: 1491-1502
2. Lancet 2004; 363: 1486-1487

e-patients

We should welcome the first generation of e-patients — those who seek online guidance for their ailments — as our new medical colleagues, say US editorialists. e-patients can not only manage their own care, but also help provide care for others, improve the quality of health professionals' services and participate in collaborations between patients and professionals.1 The editorial is one of many thought-provoking articles in a BMJ theme issue on electronic communication and healthcare. In his column "Editor’s choice" (15 May), BMJ editor Richard Smith imagines a brave new world in which sensors placed in patients' homes and clothing will feed information to all-inclusive electronic biographies.

1. BMJ 2004; 328: 1148-1149

Statins in multiple sclerosis?

Dutch commentators want physicians, scientists, drug companies and regulatory agencies to come together and conduct randomised studies that further examine a possible beneficial effect of statins in mutiple sclerosis (MS). Moreover, "all involved" should ensure that such studies are not jeopardised by the premature, widespread, "off-label" use of statins.1 Their cautious hope accompanies the first reported clinical trial of a statin in MS — a US multicentre, open-label, single-arm study in 30 patients with relapsing-remitting MS — in which daily treatment with 80 mg oral simvastatin for six months led to a reduced number and volume of gadolinium-enhanced lesions on brain MRI scans.2 Simvastatin may inhibit the inflammatory components of MS that lead to neurological disability.

1. Lancet 2004; 363: 1570
2. Lancet 2004; 363: 1607-1608

— Dr Ann Gregory, MJA