Serge Rozenberg

Proposal for a new set of classification criteria for adult-onset still disease.

IntroductionOver the last 20 years, classification criteria have been developed for rheumatic diseases (1,7). Many of these diseases do not have unequivocal or pathognomonic features corresponding to a true gold standard. Criteria sets thus constitute a way to identify homogenous groups of patients

Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial

Objective: To determine the efficacy of epidural corticosteroid injections for sciatica. Methods: Three epidural injections (two day intervals) of 2 ml prednisolone acetate (50 mg) or 2 ml isotonic saline were administered to patients with sciatica presumably due to a disk herniation lasting 15–180 days. Self evaluation was the main judgment criterion at day 20. Patients who recovered or showed marked improvement were considered as success. Pain measured by VAS, the SLR test, Schober’s test, Dallas pain questionnaire, and the Roland-Morris index were evaluated at days 0, 5, 20, and 35. Only analgesics were authorised, patients requiring non-steroidal anti-inflammatory drugs (NSAIDs) before day 20 were considered as failure. Results: 42 patients were included in the control group (CG), 43 in the steroid group (SG). On an intention to treat analysis 15/42 (36%) in the CG and 22/43 (51%) in the SG (p=0.15) were considered as success (difference 15.5%, 95% CI (−5.4 to 36.3)). Among the 48 failures, 14 patients (6 CG, 8 SG) required NSAIDs, 3 (2 CG, 1 SG) required surgery, and 7 (3 CG, 4 SG) other treatments. On analysis according to protocol, in 74 remaining patients 12/35 (34%) in the CG and 22/39 (56%) in the SG (p=0.057) were considered as success (difference 22.1%, 95% CI (0.0 to 44.2)). For all secondary end points intragroup improvement with time was significant, but intergroup differences were not. Conclusion: The efficacy of isotonic saline administered epidurally for sciatica cannot be excluded, but epidural steroid injections provide no additional improvement.

Fear-avoidance beliefs about back pain in patients with subacute low back pain

Abstract The fear‐avoidance beliefs of patients with subacute low back pain (LBP) considered at risk for chronic disabling LBP are not well known. The objectives of this cross‐sectional descriptive survey, conducted in secondary care practice, were to assess fear‐avoidance beliefs about back pain in patients with subacute LBP and to seek an association between physician or patient characteristics and level of fear‐avoidance beliefs. A total of 286 rheumatologists completed a self‐administered questionnaire assessing physicians’ demographic, professional data, personal history of back pain, and back pain fear‐avoidance beliefs (on the Fear‐Avoidance Belief Questionnaire [FABQ]) and 443 patients with sLBP completed one on pain, perceived handicap and disability (Quebec Back Pain Disability Scale), anxiety and depression (Hospital Anxiety Depression questionnaire), and back pain beliefs (FABQ). Mean FABQ scores for rheumatologists for physical activities (FABQ Phys) and occupational activities (FABQ Work) were 9.2 ± 4.4 (range 0–21) and 16.7 ± 6.9 (range 2–37), respectively, and patient scores were 16.7 ± 5.2 and 19.3 ± 12.4, respectively. A total of 68% of patients and 10% of physicians had a high rating on the FABQ Phys (>14). Patients’ fear‐avoidance beliefs about physical activity were associated with low level of education (odds ratio [OR] 4.19; 95% confidence interval [CI] 1.83–9.57), patients’ perceived disability (OR 1.05; CI 1.03–1.07), and physicians’ high FABQ Phys score (OR 5.92; CI 1.31–26.32). Here we show that fear‐avoidance beliefs about back pain were high in patients with subacute LBP and their rheumatologists.

CESAREAN SECTION SCAR EVALUATION BY SALINE CONTRAST SONOHYSTEROGRAPHY

To investigate the frequency of images suggesting the existence of a dehiscence at the site of the uterine scar after Cesarean section.

Evidence-based guidelines for the pharmacological treatment of postmenopausal osteoporosis: a consensus document by the Belgian Bone Club

Several drugs are available for the management of postmenopausal osteoporosis. This may, in daily practice, confuse the clinician. This manuscript offers an evidence-based update of previous treatment guidelines, with a critical assessment of the currently available efficacy data on all new chemical entities which were granted a marketing authorization. Osteoporosis is widely recognized as a major public health concern. The availability of new therapeutic agents makes clinical decision-making in osteoporosis more complex. Nation-specific guidelines are needed to take into consideration the specificities of each and every health care environment. The present manuscript is the result of a National Consensus, based on a systematic review and a critical appraisal of the currently available literature. It offers an evidence-based update of previous treatment guidelines, with the aim of providing clinicians with an unbiased assessment of osteoporosis treatment effect.

Primary osteoarthritis of hip, knee, and hand in relation to occupational exposure

Aim: To identify occupations with excess prevalence of osteoarthritis of the knee, hip, and hand in a nationwide survey and to compare occupations with and without excess prevalence with regard to biomechanical stresses and severity of osteoarthritis. Methods: Patients presenting with osteoarthritis of the knee, hip, or hand were recruited throughout France by their treating physician who collected information on history, including age at onset, occupation, and occupational stresses to joints. Severity was assessed using joint specific functional status questionnaires: Lequesne for the hip and knee and Dreiser for the hand. The distribution of osteoarthritis patients by occupation was compared with the distribution of occupations in all workers in France to obtain prevalence rate ratios. Results: Occupations with the greatest prevalence rate ratio were female cleaners (6.2; 95% CI 4.6 to 8.0), women in the clothing industry (5.0; 95% CI 3.9 to 6.3), male masons and other construction workers (2.9; 95% CI 2.6 to 3.3), and agriculture male and female workers (2.8; 95% CI 2.5 to 3.2). A twofold greater prevalence rate was observed within certain occupations between self-employed and salaried workers. Early onset of osteoarthritis was seen in the more heavy labour jobs with almost 40% of patients reporting their first symptoms before the age of 50. Conclusion: The early onset and severity of osteoarthritis in certain occupations warrants an urgent need for occupation specific studies for the development and evaluation of preventive strategies in this leading cause of disability in Western countries.

Evidence-based guidelines for the treatment of postmenopausal osteoporosis: a consensus document of the Belgian Bone Club

Osteoporosis is widely recognized as a major public health concern. The cumulative lifetime fracture risk for a 50-year woman with osteoporosis is as high as 60% [1]. In Belgium, the annual costs of osteoporotic fractures are currently estimated in the range of 150 million euros, on a societal perspective [2]. Effective fracture prevention would have a major impact on women’s morbidity and to a lesser extend mortality. The availability of new therapeutic agents has made clinical decision-making in osteoporosis more complex [3]. Because individual clinicians cannot systematically collect all the evidence bearing on the efficacy of osteoporosis therapies, they require summaries for consistent therapeutic patterns [3]. As recommended by the International Osteoporosis Foundation (IOF), nation-specific guidelines are requested to take into consideration the specificities of each and every health care environment. The present document is the result of a national consensus, based on a systematic review and a critical appraisal of the currently available literature. It offers an evidence-based update to previous Belgian Bone Club treatment guidelines [4], with the aim of providing clinicians with an unbiased assessment of osteoporosis treatment effect.

Non-pharmacological management of osteoporosis: a consensus of the Belgian Bone Club

This consensus article reviews the various aspects of the non-pharmacological management of osteoporosis, including the effects of nutriments, physical exercise, lifestyle, fall prevention, and hip protectors. Vertebroplasty is also briefly reviewed. Non-pharmacological management of osteoporosis is a broad concept. It must be viewed as an essential part of the prevention of fractures from childhood through adulthood and the old age. The topic also includes surgical procedures for the treatment of peripheral and vertebral fractures and the post-fracture rehabilitation. The present document is the result of a consensus, based on a systematic review and a critical appraisal of the literature. Diets deficient in calcium, proteins or vitamin D impair skeletal integrity. The effect of other nutriments is less clear, although an excessive consumption of sodium, caffeine, or fibres exerts negative effects on calcium balance. The deleterious effects of tobacco, excessive alcohol consumption and a low BMI are well accepted. Physical activity is of primary importance to reach optimal peak bone mass but, if numerous studies have shown the beneficial effects of various types of exercise on bone mass, fracture data as an endpoint are scanty. Fall prevention strategies are especially efficient in the community setting, but less evidence is available about their effectiveness in preventing fall-related injuries and fractures. The efficacy of hip protectors remains controversial. This is also true for vertebroplasty and kyphoplasty. Several randomized controlled studies had reported a short-term advantage of vertebroplasty over medical treatment for pain relief, but these findings have been questioned by recent sham-controlled randomized clinical studies.

Kidney disease in RA patients: prevalence and implication on RA-related drugs management: the MATRIX study

OBJECTIVES The prevalence of kidney disease (KD) indicators together with the profile of RA drugs prescribed in RA patients was investigated in the MATRIX study (MeThotreXate And Renal Insufficiency). METHODS Renal function (RF) was assessed using Cockcroft-Gault (CG) and abbreviated Modification of Diet in Renal Disease (aMDRD) study formulae. RESULTS Serum creatinine (SCr) was normal in 81.4% of the 129 patients included. According to the National Kidney Foundation (NKF) classification, the distribution by stage of KD was, using the aMDRD and CG formulae, as follows: stage 1: 11.3% and 11.4%; stage 2: 20.0% and 20.3%; stage 3: 15.0% and 24.1%; stage 4: 0% and 1.3%; stage 5: 0%. Proteinuria, haematuria and leucocyturia were observed in 16%, 17% and 20% of the patients, respectively. Using the aMDRD and CG formulae, 36% and 38% of the prescriptions made in patients with glomerular filtration rate (GFR) <60 ml/min required a dosage adjustment. Among the patients with GFR <60 ml/min, 83-90% received at least one drug that required a dosage adjustment and 67-70% received at least one drug that was potentially nephrotoxic, according to aMDRD or CG formulae, respectively. Five (50%) and 8 (47%) patients did not have appropriate MTX dosage adjustment according to their stage of KD with aMDRD or CG formulae, respectively. CONCLUSION Systematic estimation of RF with CG or aMDRD formulae and urine dipstick are necessary in RA patients. In patients with KD at high risk for drug toxicity, dosage should be adapted to RF.

Cyclical pamidronate infusions in postmenopausal osteoporosis

OBJECTIVES Until recently, two bisphosphonates, pamidronate (APD) and etidronate were available for clinical purposes. Contrary to etidronate, pamidronate was not extensively studied in osteoporosis. Therefore, we investigated the effect of cyclic intravenous APD treatment in postmenopausal osteoporosis. METHODS Parameters of bone remodelling and lumbar spine bone mineral density (BMDL) were assessed in 36 postmenopausal women with osteoporosis (BMDL t-score < -2.5). They received five courses of APD. Intervals between courses were defined according to the fasting urinary calcium excretion (UCa/Cr, mg/mg creatinine) which was measured before each APD course and every 2 weeks after the first treatment. The patients were retreated when UCa/Cr had reached baseline levels. Serum biochemical parameters and urinary hydroxyproline (UOHPro/Cr, mg/mg) were measured before each APD. RESULTS UCa/Cr decreased during 21-28 days after each course but UCa/Cr measured before APD infusion remained unchanged. UOHPro/Cr significantly fell after the third APD (P = 0.02). Serum calcium was however not modified. Parameters of bone remodelling decreased with time: bone-GLA protein (BGP) started to fall after the first APD (P = 0.0001) and continued to decrease until the fourth APD course, alkaline phosphatase (ALP) significantly decreased after the first APD (P = 0.005); intact PTH significantly increased at the fifth APD (P = 0.02). BMDL significantly increased after 1 year treatment: +2.9% of baseline value. CONCLUSIONS Cyclical pamidronate treatment of postmenopausal osteoprosis appeared to be effective in reducing bone turnover assessed by BGP, ALP and OHPro/Cr. This effect is followed by an increase in vertebral BMD.