Bernard Duquesnoy

Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients

OBJECTIVE To evaluate the diagnostic usefulness of provocative tests, Doppler ultrasonography, electrophysiological investigations, and helical computed tomography (CT) angiography in thoracic outlet syndrome (TOS). PATIENTS AND METHODS We prospectively evaluated 48 patients with a clinical suspicion of thoracic outlet syndrome. Standardized provocative tests, an electromyogram and somatosensory evoked responses, a Doppler ultrasonogram, and a helical CT arterial and/or venous angiogram with dynamic maneuvers were done on each patient. The final diagnosis was established by excluding all other causes based on all available data. The agreement between the results of each investigation and the final diagnosis was evaluated. RESULTS Provocative tests had mean sensitivity and specificity values of 72% and 53%, respectively, with better values for the Adson test (positive predictive value [PPV], 85%), the hyperabduction test (PPV, 92%), and the Wright test. Using several tests in combination improved specificity. Doppler ultrasonography visualized vascular parietal abnormalities and confirmed the diagnosis in patients with at least five positive provocative tests. Electrophysiological studies were useful mainly for the differential diagnosis or for detecting concomitant abnormalities. Although helical CT angiography provided accurate information on the location and mechanism of vascular compression, the usefulness of this investigation for establishing the diagnosis of TOS and for obtaining pretherapeutic information remains unclear.

Pulmonary function tests and high resolution computed tomography of the lungs in patients with rheumatoid arthritis

OBJECTIVE To compare the results of pulmonary function tests (PFTs) and high resolution computed tomography (HRCT) of the lungs in rheumatoid arthritis (RA) patients. METHODS Sixty eight patients (54 women, 14 men) fulfilling the revised criteria for RA were consecutively included in a transversal prospective study. Their mean age was 58.8 years (range: 35–82) and the mean duration of the disease was 12 years (range: 5–16). Rheumatoid factor was positive in 52 patients (76.5%). Fifty two patients (76.5%) were lifelong non-smokers. Detailed medical and drug histories were obtained. PFTs comprised spirometry and gas transfer measurements. Results for PFTs were expressed as percentage of predicted values for each individual adjusted for age, sex, and height. HRCT was undertaken with a Siemens Somatom Plus. RESULTS A significant decrease of FEV1/FVC, FEF25%, FEF50%, FEF75%, FEF25–75%, and TLCO was observed (p<0.05) and 13.2% of the patients had a small airways involvement defined by a decrease of FEF25–75% below 1.64 SD. The most frequent HRCT findings were: bronchiectasis (30.5%), pulmonary nodules (28%), and air trapping (25%). The patients with small airways involvement had a high frequency of recurrent bronchitis (75% v 34%, p=0.05) and bronchiectasis (71% v 23%, p=0.019). The patients with bronchiectasis were characterised by low values of FEV1, FVC, FEF25–75%, and TLCO (p<0.01), a high prevalence of small airways involvement (29% v 5%, p=0.019), and a low prevalence of HLA DQA1 *0501 allele (14% v 33%, p<0.05). CONCLUSION This study suggests a significant association between small airways involvement on PFTs and bronchiectasis on HRCT in unselected RA patients.

Use of high resolution computed tomography of the lungs in patients with rheumatoid arthritis.

OBJECTIVE--To assess the usefulness of high resolution computed tomography (HRCT) of the lungs in patients with rheumatoid arthritis (RA) with and without respiratory symptoms. PATIENTS AND METHODS--Eighty eight RA patients with a mean duration of disease 12 (SD 8) years were evaluated. Eleven patients were excluded because of previous exposure to silica. The 77 remaining patients formed two groups according to the absence (group I, n = 38) or the presence (group II, n = 39) of chronic respiratory symptoms. A control group consisted of 51 non-smoking, healthy patients. RESULTS--The most frequent abnormalities observed in the 77 RA patients were bronchiectasis or bronchiolectasis (n = 23, 30%), pulmonary nodules (n = 17, 22%), subpleural micronodules or pseudoplaques (n = 13, 17%), ground glass opacities (n = 11, 14%), and honeycombing (n = 8, 10%). Bronchiectasis or bronchiolectasis (p = 0.012), rounded opacities (p = 0.016), ground glass attenuation (p = 0.004), and honeycombing (p = 0.002) were found more often in RA group II (with respiratory symptoms) than in group I (no respiratory symptoms). Non-linear septal opacities were more frequent in group I than in the control group, but other HRCT findings did not differ statistically significantly between group I and the control group. CONCLUSION--Bronchiectasis may be a characteristic lung change in RA patients. Abnormalities on HRCT are less frequently observed in the absence of respiratory symptoms than in the presence of such symptoms (29% versus 69%).

Ultrasonographic Assessment of Arterial Cross-sectional Area in the Thoracic Outlet on Postural Maneuvers Measured With Power Doppler Ultrasonography in Both Asymptomatic and Symptomatic Populations

Objective. The purpose of this study was to evaluate the feasibility and potential usefulness of power Doppler ultrasonography (PDU) in the assessment of changes in arterial cross‐sectional area in the thoracic outlet during upper limb elevation. Methods. Forty‐four volunteers and 28 patients with a clinical diagnosis of arterial thoracic outlet syndrome were evaluated by B‐mode imaging and PDU. Arterial cross‐sectional area was assessed in the 3 compartments of the thoracic outlet with the arm alongside the body and at 90°, 130°, and 170° of abduction. The percentage of arterial stenosis was calculated for each of these arm positions. Nineteen of the 28 patients were also assessed by magnetic resonance (MR) imaging. Results. No significant arterial stenosis was shown in the interscalene triangle and in the retropectoralis minor space of the volunteers and patients. A significant difference (P < .01) in stenosis between volunteers and patients was seen for all degrees of abduction in the costoclavicular space. The 130° hyperabduction maneuver appeared to be the most discriminating postural maneuver. Seven patients assessed with MR imaging did not have any arterial stenosis on MR images, whereas an appreciable degree of arterial stenosis was shown with ultrasonography. Conclusions. Arterial compression inside the thoracic outlet can be detected and quantified with B‐mode imaging in association with PDU.

Total knee arthroplasty in hemophilic arthropathy

UNLABELLED Chronic arthropathy causes major functional disability in patients with severe hemophilia. OBJECTIVE To evaluate the results of total knee arthroplasty (TKA) and its impact on both quality of life and clotting factor use in patients with severe hemophilia. PATIENTS AND METHODS We evaluated 17 TKAs in 12 patients. The TKAs were performed between 1986 and 1996, and follow-up was 8-132 months (mean, 54 months). Mean age at arthroplasty was 39 years (22-51 years). Quality of life was evaluated using the Short Form 36 (SF-36). RESULTS Results were good or excellent in 94% of patients. The improvement was greatest for pain. Recurrent hemarthrosis in six patients and development of an anticoagulant in two patients were the only postoperative complications. Clotting factor use did not decrease significantly after surgery. SF-36 scores showed an increase in physical activity responsible for an improvement in quality-of-life indicators. However, this improvement in functional capabilities seemed to wane over time as a result of arthropathy in other joints and of intercurrent diseases. CONCLUSION TKA for hemophilic arthropathy provides good results that translate into quality-of-life gains.

Efficacy in current practice of switching between anti-tumour necrosis factor-α agents in spondyloarthropathies

OBJECTIVE Anti-TNF-α agents are remarkably effective in the treatment of SpAs. However, 30% of patients withdraw from anti-TNF-α agents yearly because of inadequate efficacy or side effects. The objective of this study was to assess in current practice the response to a second and a third anti-TNF-α. METHODS Retrospectively, all records of patients who had received at least two anti-TNF-α agents have been studied. For axial forms, treatment was considered effective if 3 months after switching the patient had a favourable expert opinion or showed an improvement in BASDAI of at least 2 on a scale of 0-10 or an improvement of 50% (BASDAI 50). For peripheral forms, the treatment was considered effective if the patient had a favourable expert opinion or if a clinical improvement of >30% of the swollen and tender joint counts was established. The reasons for switching were: (i) primary non-responder; (ii) loss of efficacy; and (iii) occurrence of side effects. To identify response predictor factors bivariate analysis was performed. RESULTS Three hundred and seventy-seven patients under anti-TNF-α agents were treated and 99 patients had received at least two anti-TNF-α agents. Twenty-eight of these 99 patients had been treated with three anti-TNF-α agents. Following the failure of a first anti-TNF-α, the response to a second agent was satisfactory in 80.8%. Patients who had received a third anti-TNF-α following failure of the first two also showed a satisfactory response in 82.1%. The reason for switching from the first or second agent was not predictive of the response. CONCLUSION In the event of failure or intolerance to anti-TNF-α in the treatment of SpAs, performing a first or second switch produces a satisfactory therapeutic response.

ICAM-1, E-selectin, and TNF α expression in labial salivary glands of patients with rheumatoid vasculitis

OBJECTIVE To assess the expression of ICAM1, VCAM1, E-selectin, CD44, and TNF α in labial salivary glands of patients with rheumatoid vasculitis. METHODS Labial salivary glands from six patients with rheumatoid vasculitis before and after treatment, six aged matched rheumatoid arthritis patients without clinical evidence of rheumatoid vasculitis, 10 patients with primary Sjögren syndrome, 10 patients with rheumatoid arthritis and proven secondary Sjögren syndrome, and six controls were tested with specific antibodies. RESULTS ICAM1, E-selectin, and TNF α were significantly expressed in endothelial cells and perivascular cellular infiltrate only in rheumatoid vasculitis before treatment. CONCLUSIONS The expression of ICAM1, E-selectin, and TNF α allows an assessment of the activity of the vasculitic process in rheumatoid vasculitis. Labial salivary gland biopsy findings in patients with rheumatoid arthritis and visceral vasculitis without purpura or neuropathy (that is, mesenteric, coronary, or cerebral vasculitis) would be of interest and are examples where labial salivary gland tissue is more accessible than the affected tissue.

Use of disease-modifying antirheumatic drugs in patients with psoriatic arthritis

UNLABELLED Few prospective placebo-controlled studies have evaluated disease-modifying antirheumatic drugs (DMARDs) in the treatment of peripheral psoriatic arthritis. OBJECTIVE To evaluate second-line treatments used in clinical practice in patients with psoriatic arthritis. METHOD We studied a cross-section of 100 consecutive patients seen by hospital-based or office-based rheumatologists for psoriatic arthritis. PATIENTS The 55 men and 45 women had a mean age of 48 years (range, 17-79 years) and a mean disease duration of 7 years (range, 1-24 years). RESULTS The most commonly used DMARDs were sulfasalazine, gold, methotrexate, and hydroxychloroquine (64, 43, 41 et 17 patients, respectively). These drugs had been stopped because of inefficacy in 31%, 31%, 12%, and 53% of patients, respectively, and because of adverse events in 23%, 44%, 22%, and 41% of patients, respectively. At the time of the study, mean treatment durations were 15, 21, 34, and 12 months, respectively, and the drugs were still being used in 45%, 21%, 66%, and 6% of patients. CONCLUSION Our data confirm the value of methotrexate and salazopyrine. Methotrexate had the best risk/benefit ratio. Gold was often responsible for side effects. Hydroxychloroquine was inadequately effective and poorly tolerated.

Ultrasound Velocity Through the Phalanges in Normal and Osteoporotic Patients

Abstract. Quantitative ultrasound (US) measurements have been shown to be a new technique assessing bone status. This study aimed to assess a new US instrument, the DBM Sonic 1200® (IGEA) which permits the measurement of the speed of sound in the proximal phalanges (SOSp) of the hand. The results obtained were compared with DXA (SOPHOS) and US measurements at the calcaneus (Achilles® LUNAR). The in vivo precision expressed by coefficient of variation was 0.91%. Ultrasound measurements of phalanges were significantly correlated with BMD in the entire group of 90 subjects: osteoporotic patients (n = 47) and controls (n = 43) (r = 0.44, femoral neck and 0.45, lumbar spine, P < 0.01). A significant correlation was also found in the control group (r = 0.33, lumbar spine and 0.38, femoral neck, P < 0.05) but not in the osteoporotic group (r = 0.3, lumbar spine and 0.17, femoral neck, P > 0.05). Mean values for 31 postmenopausal, osteoporotic women and age-matched controls showed a significant decrease in US measurements at the phalanges (P < 0.05) and the calcaneus (P < 0.01) as well as bone mineral density (BMD) at the spine and femoral neck (P < 0.01) in the osteoporotic group. A decision threshold for a sensitivity of 80% for osteoporotic fractures resulted in a specificity value of only 37% for SOSp, between 53 to 65% for calcaneus US measurements and 45 to 56% for BMD. The Z score, the odds ratio, the ROC curves, and areas under the curves plotted for the subgroup of 31 fractures and their healthy controls showed poorer values for SOSp than BMD and calcaneus US measurements. In conclusion, US measurements of phalanges seem to be less efficient than calcaneus US and BMD measurements to distinguish osteoporotic from healthy women. Other studies and also prospective studies are required to assess the interest in fracture risk assessment.

Multiple myeloma presenting with widespread osteosclerotic lesions

Sclerotic lesions are rare in malignant monoclonal gammopathies, although they are occasionally associated with POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes). In most cases, osseous lesions in POEMS syndrome present as an isolated sclerotic deposit or a combination of both lytic and sclerotic lesions. Diffuse osteosclerosis is extremely rare and may lead to the diagnosis of multiple myeloma, classically known to present as lytic lesions in the skeleton, with or without diffuse osteoporosis. We report a 74-year-old woman with widespread and substantial osteosclerotic lesions, associated with IgA-lambda myeloma, and with no other criteria for POEMS syndrome, and who was rapidly diagnosed with compression of the spinal cord. Detailed knowledge of imaging features in myeloma emphasises the need to consider plasma cell neoplasm in the differential diagnosis of any pattern of bone sclerosis. Although exceptional, multiple myeloma must be borne in mind in the presence of diffuse bone sclerosis.