Mohamed Younes

Compared imaging of the rheumatoid cervical spine: Prevalence study and associated factors

INTRODUCTION Cervical spine involvement is common and potentially severe in patients with rheumatoid arthritis (RA). The objectives of this study were to compare the prevalences of cervical spine abnormalities detected by standard radiography, computed tomography (CT), and magnetic resonance imaging (MRI) in patients with RA; and to identify factors associated with cervical spine involvement. METHODS We studied 40 patients who met American College of Rheumatology criteria for RA and had disease durations of 2 years or more. Each patient underwent a physical examination, laboratory tests, standard radiographs (anteroposterior, lateral, open-mouth, flexion, and extension views), MRI with dynamic maneuvers in (if not contraindicated), and CT. RESULTS Cervical spine involvement was found by at least one imaging technique in 29 (72.5%) patients (standard radiography, 47.5%; CT, 28.2%; and MRI, 70%) and was asymptomatic in 5 (17.2%) patients. C1-C2 pannus was the most common lesion (62.5% of cases), followed by atlantoaxial subluxation (AAS, 45%). The most common AAS pattern was anterior subluxation (25%), followed by lateral subluxation (15%) then by vertical, rotatory, and subaxial subluxations (10% each). Erosions of the dens were seen in 67.5% of patients by MRI, 41% by CT, and 12.5% by standard radiography. Of the 10 cases of anterior AAS by any modality, 9 were detected by standard radiography and 7 by MRI. CT was the best technique for visualizing atypical rotatory or lateral AAS. MRI was best for assessing the C1-C2 pannus, dens erosions, and neurologic impact of the rheumatoid lesions. The comparison of patients with and without cervical spine lesions suggested that higher modified Sharp score and C-reactive protein values predicted cervical spine involvement (P=0.002 and P=0.004, respectively). CONCLUSION Cervical spine involvement is common and may be asymptomatic, indicating that routine cervical spine imaging is indicated in patients with RA. Standard radiography including dynamic views constitutes the first-line imaging method of choice. Sensitivity and comprehensiveness of the assessment are greatest with MRI. MRI and CT are often reserved for selected patients. Cervical spine involvement is associated with disease activity and with rapidly progressive joint destruction.

Socioeconomic impact of ankylosing spondylitis in Tunisia

OBJECTIVE Ankylosing spondylitis (AS) is the second most common chronic inflammatory joint disease after rheumatoid arthritis and causes substantial functional impairment, two features that generate a heavy socioeconomic burden. Here, our objective was to assess the socioeconomic impact of AS and to identify factors associated with higher costs. PATIENTS AND METHODS We retrospectively reviewed the medical charts of 50 patients with AS seen at the Monastir Public Health Service Hospital over the 6-month period from March to September 2006. The following were evaluated: direct costs of medical care; indirect costs related to work incapacity; and impact on marital life, offspring, social activities, and activities of daily living. RESULTS There were 42 men and eight women (male-to-female ratio, 5.25) with a mean age of 38.9+/-10.8 years (range, 19-60 years). The median mean direct cost of medical care for AS was 426.072 Tunisian Dinars (TND) (266.295 euro) per year, and the interquartile range (IQR) was 270.468 TND. Of the 34 patients who had paid employment, 12 (35%) were on sick leave. The mean indirect cost was 447.4+/-294.3 TND (279.625+/-183.937 euro) per patient per year. The median mean total cost was 873.472 TND (545,92 euro) per patient per year with an IQR of 292,324 TND. Factors associated with higher costs were the use of nonsteroidal anti-inflammatory drugs and higher values of the BASDAI and BASRI. Among married patients, 44.4% reported sexual problems, which correlated with the BASMI; and 37% reported a negative reaction on the part of the healthy spouse. Adverse effects on schooling and quality of life of the children were noted in 29.6% of cases. Among single patients, 30.4% felt their disease was responsible for their unmarried status. The disease adversely affected the ability to carry out many activities of daily living (grooming in 38% of cases, housework in 76%, shopping in 92%, sporting activities in 96%, socializing in 68%, and traveling in 80%). The patients usually reported receiving support from their family, which was physical in 74% of cases, financial in 52%, and psychological in 90%. CONCLUSION Our data indicate that AS generates a major socioeconomic burden. Most of the factors associated with higher costs were related to greater disease activity. Therefore, early appropriate treatment is crucial. Despite the many socioeconomic problems generated by AS, the patients remained connected to their social network thanks to support from their family and friends.

The impact of pregnancy on rheumatoid arthritis outcome: The role of maternofetal HLA class II disparity

OBJECTIVES To investigate the influence of pregnancy and postpartum on rheumatoid arthritis (RA) course and the impact of maternofetal HLA class II disparity. METHODS In 13 women with RA, disease activity was assessed prospectively, before and every three months throughout pregnancy and after delivery until one year in postpartum. The HLA class II disparity was evaluated by typing HLA-DRB1, DQB1 and DQA1 alleles by the PCR-SSOP for 12 couples mothers and babies. Furthermore, for three women, RA disease activity during a previous pregnancy was evaluated retrospectively and HLA typing was performed for the three children. RESULTS The mean age of patients was 30+/-5 years. All women had successful pregnancy. During pregnancy, a favourable RA outcome was noted in 62.5% of cases. Three patients were in remission after conception. Persistent disease activity was noted in 30% of cases. In postpartum, disease relapse occurred in 92% of cases at a mean delay of 80+/-63 days. Three women did not resume the initial modifying antirheumatic drugs (DMARDs) 12 months after delivery. For others, the mean delay was 6+/-3.5 months. There was no significant correlation between the clinicoradiological parameters and the RA outcome. We noted a tendency towards correlation between male newborns and an unfavourable RA outcome (p=0.059). A high degree of maternofetal disparity in HLA class II was seen in 73.5% of cases. We observed a more marked improvement in disease activity parameters in case of more than one disparity but without a significant statistical difference. CONCLUSION A favourable RA outcome during pregnancy in about two-thirds of the cases and a frequent relapse after delivery were observed. RA activity improvement is more obvious at the end of pregnancy. A high degree of maternofetal HLA class II disparity seems to modulate RA disease activity.

Validation of the Tunisian version of the Roland-Morris questionnaire

Our aim was to validate a culturally adapted, Tunisian-language version of the Roland-Morris Disability Questionnaire (RMDQ), which is a reliable evaluation instrument for low-back-pain disability. A total of 62 patients with low back pain were assessed by the questionnaire. Reliability for the 1-week test/re-test was assessed by a construction of a Bland Altman plot. Internal construct validity was assessed by Cronbach’s αtest. External construct validity was assessed by association with pain, the Schober test and the General Function Score. Sensitivity to change was determined using a t-test for paired data to compare RMDQ scores at inclusion and at completion of the therapeutic sequence of local corticosteroid injections. We also compared the questionnaire score with the General Function Score, both taken after completion of the therapeutic sequence. The constructed Bland Altman plot showed good reliability. Internal consistency of the RMDQ was found to be very good and the Cronbach’s α test was 0.94, indicating a good internal construct validity. The questionnaire is correlated with the pain visual analogue scale (r=33; p=0.0001), with the Schober test (r=0.27; p=0.0001) and the General Function Score (r=56; p=0.0001) indicating an adequate external construct validity. The RMDQ administered after the therapeutic sequence is sensitive to change (r=0.83; p=0.000). Comparison of the questionnaire score to the General Function Score, after completion of the therapeutic sequence, was satisfactory (r=0.75; p=0.000). We conclude that the Tunisian version of the Roland-Morris questionnaire has good reliability and internal consistency. Furthermore, it has a good internal- and external construct validity and high sensitivity to change. It is an adequate and useful tool for assessing low-back-pain disability.

Speed and Cardiac Recovery Variables Predict the Probability of Elimination in Equine Endurance Events

Nearly 50% of the horses participating in endurance events are eliminated at a veterinary examination (a vet gate). Detecting unfit horses before a health problem occurs and treatment is required is a challenge for veterinarians but is essential for improving equine welfare. We hypothesized that it would be possible to detect unfit horses earlier in the event by measuring heart rate recovery variables. Hence, the objective of the present study was to compute logistic regressions of heart rate, cardiac recovery time and average speed data recorded at the previous vet gate (n-1) and thus predict the probability of elimination during successive phases (n and following) in endurance events. Speed and heart rate data were extracted from an electronic database of endurance events (80–160 km in length) organized in four countries. Overall, 39% of the horses that started an event were eliminated—mostly due to lameness (64%) or metabolic disorders (15%). For each vet gate, logistic regressions of explanatory variables (average speed, cardiac recovery time and heart rate measured at the previous vet gate) and categorical variables (age and/or event distance) were computed to estimate the probability of elimination. The predictive logistic regressions for vet gates 2 to 5 correctly classified between 62% and 86% of the eliminated horses. The robustness of these results was confirmed by high areas under the receiving operating characteristic curves (0.68–0.84). Overall, a horse has a 70% chance of being eliminated at the next gate if its cardiac recovery time is longer than 11 min at vet gate 1 or 2, or longer than 13 min at vet gates 3 or 4. Heart rate recovery and average speed variables measured at the previous vet gate(s) enabled us to predict elimination at the following vet gate. These variables should be checked at each veterinary examination, in order to detect unfit horses as early as possible. Our predictive method may help to improve equine welfare and ethical considerations in endurance events.

Hyperhomocystéinémie et schizophrénie : étude cas–témoin

OBJECTIVES Homocysteine (Hcys) is a sulphur-containing amino acid that has been widely investigated for its putative role in neuropsychiatric disorders. Elevated plasma homocysteine levels have been associated with schizophrenia. Among other factors, low folate and vitamin B12 levels have been implicated in the increase in homocysteine. The aim of the study was to determine plasma Hcys, folate and vitamin B12, and the frequency and severity of hyperhomocysteinemia in patients with schizophrenia, and to investigate the association between Hcys and clinical features and its relationship with folate and vitamin B12 levels. METHODS This was a case-control study carried out on 61 (54 males and seven females, mean age=33.3 ± 9.2) inpatients with chronic schizophrenia according to DSM-IV criteria and 46 (25 males and 21 females, mean age=45.9 ± 14.2) healthy controls. Most of patients (90.2%) were treated by first generation antipsychotics with a mean daily dosage of 401.6 mg chlorpromazine equivalents. Total homocysteine serum levels were determined quantitatively by fluorescence-polarization immunoassay (FPIA) with an AxSYM analyzer™ (Abbott). Quantitative vitamin B12 and folate serum levels were measured with an Elecsys 2010 analyzer™ (Roche Diagnostics). Differences between patients and controls were examined using a two-way Ancova with gender and diagnosis as independent variables, adjusting for age. RESULTS Patients with schizophrenia showed higher plasma Hycs and lower plasma folate than controls (mean=16.1 μmol/L in patients versus 10.9 μmol/L in controls; P=0.028 for Hycs and 4.2 μg/L in patients versus 8.2 μg/L in controls; P<0.001 for folate). Patients and controls did not differ in vitamin B12 levels. Both male and female patients had increased plasma Hcys compared to controls. Hyperhomocysteinemia (Hcys levels>15 μmol/L) was present in 34.4% of the patients versus 15.2% in controls. The prevalence of moderate hyperhomocysteinemia (Hcys levels: 15-29 μmo/L) was 26.2% and that of intermediate hyperhomocysteinemia (Hcys levels: 30-100 μmol/L) was 8.2%. In patients with schizophrenia, plasma Hcys was not correlated with age (r=0.07; P=0.56), duration of illness (r=-0.04; P=0.78) and did not differ with gender and clinical sub-types. Moreover, plasma Hcys was higher in patients without family history of psychiatric disorders (19.2 μmol/L) versus 12.7 μmol/L in patients with family history of psychiatric disorders (P=0.032). Concerning therapeutic features, plasma Hcys did not differ with type of antipsychotic and was not related to daily dosage of antipsychotics. A negative correlation was found between plasma Hcys and vitamin B12 levels (r=-0.26; P=0.04). CONCLUSION These results confirm an increase of Hcys levels in schizophrenic patients and suggest that it is associated with absence of family history of psychiatric disorders and with low vitamin B12 levels. Hyperhomocyteinemia could be related to the pathophysiology of aspects of this illness. Homocysteine should be considered as a factor to consider in monitoring and management of patients with schizophrenia.

Effects of Age, Exercise Duration, and Test Conditions on Heart Rate Variability in Young Endurance Horses

Although cardiac recovery is an important criterion for ranking horses in endurance competitions, heart rate variability (HRV) has hardly ever been studied in the context of this equestrian discipline. In the present study, we sought to determine whether HRV is affected by parameters such as age, exercise duration and test site. Accordingly, HRV might be used to select endurance horses with the fastest cardiac recovery. The main objective of the present study was to determine the effects of age, exercise duration, and test site on HRV variables at rest and during exercise and recovery in young Arabian endurance horses. Over a 3-year period, 77 young Arabian horses aged 4–6 years performed one or more exercise tests (consisting of a warm-up, cantering at 22 km.h−1and a final 500 m gallop at full speed) at four different sites. Beat-to-beat RR intervals were continuously recorded and then analyzed (using a time-frequency approach) to determine the instantaneous HRV components before, during and after the test. At rest, the root-mean-square of successive differences in RR intervals (RMSSD) was higher in the 4-year-olds (54.4 ± 14.5 ms) than in the 5-or 6-year-olds (44.9 ± 15.5 and 49.1 ± 11.7 ms, respectively). During the first 15 min of exercise (period T), the heart rate (HR) and RMSSD decreased with age. In 6-year-olds, RMSSD decreased as the exercise duration increased (T: 3.0 ± 1.4 vs. 2T: 3.6 ± 2.2 vs. 3T: 2.8 ± 1.0). During recovery, RMSSD was negatively correlated with the cardiac recovery time (CRT) and the recovery heart rate (RHR; R = −0.56 and −0.53, respectively; p < 0.05). At rest and during exercise and recovery, RMSSD and several HRV variables differed significantly as a function of the test conditions. HRV in endurance horses appears to be strongly influenced by age and environmental factors (such as ambient temperature, ambient humidity, and track quality). Nevertheless, RMSSD can be used to select endurance horses with the fastest cardiac recovery.

Prevalence of subclinical amyloidosis in Tunisian patients with rheumatoid arthritis

INTRODUCTION Secondary amyloidosis is a serious complication of rheumatoid arthritis (RA). Symptoms are late to occur, so that screening is in order, most notably in patients with long-standing RA. The objectives of our study were to determine the prevalence of subclinical amyloidosis in RA patients by abdominal fat aspiration biopsy (AFAB) and minor salivary gland biopsy (MSGB) and to identify factors associated with subclinical amyloidosis. METHODS We prospectively studied 107 consecutive patients with RA (94 women and 13 men) recruited between March 2005 and January 2006. Clinical and laboratory findings, imaging study results, and treatment were recorded for each patient. AFAB and MSGB were performed routinely. Amyloid deposits were identified by polarized light microscopy after Congo red staining. RESULTS The prevalence of subclinical amyloidosis was 21.5% by AFAB and 3.7% by MSGB. Factors associated with subclinical amyloidosis were a longer time to diagnosis (P=0.03), extraarticular manifestations (P=0.019), proteinuria >0.3 g/24 h (P=0.024), and absence of methotrexate therapy (P=0.046). Subclinical amyloidosis was not associated with age, sex, RA duration, joint deformities, DAS28 score, Health Assessment Questionnaire score, Steinbrocker radiological stage, rheumatoid factor, erythrocyte sedimentation rate, C-reactive protein, creatinine, or hemoglobin. CONCLUSION The prevalence of subclinical amyloidosis by AFAB is high (21.5%). AFAB is more sensitive than MSGB for detecting subclinical amyloidosis. A simple screening tool such as AFAB should be used, particularly in patients with risk factors. Subclinical amyloidosis requires close monitoring to ensure the early detection and treatment of symptomatic amyloidosis.

Orbital myositis in Behçet's disease.

Joint Bone Spine - In Press.Proof corrected by the author Available online since dimanche 8 decembre 2013

Sécurité des médicaments à usage rhumatologique en âge de procréation

The aim of this study is to determine the safety of commonly prescribed antirheumatic drugs at childbearing age, in pregnancy and lactation, through systematic literature review. Patients who take cytotoxic drugs should be informed of the risks of impared fertility. During pregnancy, non steroidal anti-inflammatory drugs (NSAIDs) can be safely administered until gestational week 32. Acetaminophen and low to moderate doses of corticosteroids are safe. Among, the disease-modifying agents, antimalarial agents, sulfasalazine, azathioprine and ciclosporin are compatible with pregnancy, and can be administered until birth. Paracetamol, prednison, antimalarial agents, sulfasalazine and most NSAIDs can safely be used by lactating mothers. To ensure a favourable outcome for both the mother and the child, the pregnancy should be planned, started during a period of disease stability, monitored closely and treated as needed.