Vincent André

Information on glucocorticoid therapy in the main studies of biological agents.

OBJECTIVE To evaluate reported information on prednisone therapy in the main studies of biological agents used to treat rheumatoid arthritis (RA). METHODS We reviewed 66 publications (including four abstracts), including 11 studies of infliximab, 19 of etanercept, eight of adalimumab, five of golimumab, four of certolizumab, four of rituximab, eight of abatacept, and seven of tocilizumab. RESULTS Whether concomitant prednisone therapy was used, it was specified in only 56 (85%) of the 66 publications. Only 42 (64%) publications indicated that the prednisone dosage remained unchanged throughout the study. The maximum prednisone dosage allowed was specified in only 39 (59%) reports and was lower than 8 mg/day in only four (6%) studies. Data enabling determination of the mean daily prednisone dosage in prednisone-treated patients was available for only eight (12%) studies; the mean dosage ranged from 5.0 to 9 mg/day (mean, 7.1 ± 1.5). The percentage of patients receiving prednisone therapy was reported for only 41 (62%) studies. All the above-mentioned information was available in only two (3%) study reports. The percentage of patients on prednisone therapy ranged from 34% to 93% (mean, 58 ± 13%) overall and varied across biological agents as follows: abatacept, 74.4%; golimumab, 67.9%; infliximab, 60.6%; certolizumab, 57.5%; rituximab, 57.5%; etanercept, 54.4%; tocilizumab, 52.8%; and adalimumab, 50.4%. These percentages did not decline between 1997 and 2010. CONCLUSION Study reports provide inadequate information on prednisone therapy during biological treatment for RA.

Ultrasonography for diagnosing atypical gout. Two case reports

Gout is characterized by the deposition of monosodium urate crystals on the surface of the articular cartilage, within periarticular tissues, and within bone and skin. The diagnosis rests on identification of the crystals in joint fluid or a tophus. However, joint aspiration is not always feasible, and the presentation may be atypical. We describe two cases of chronic gouty arthritis misdiagnosed as psoriatic arthritis. Ultrasonography of the bone and joints disclosed two patterns recently described as highly suggestive of gout, namely, the double-contour appearance of the cartilage and the snowstorm appearance of the synovial membrane. In addition, ultrasonography was useful for guided aspiration of joint fluid or other material containing monosodium urate crystals. Thus, ultrasonography may contribute to improve the diagnosis and treatment of gout.

Improving agreement in assessment of synovitis in rheumatoid arthritis.

OBJECTIVE Synovitis assessment through evaluation of swollen joints is integral in steering treatment decisions in rheumatoid arthritis (RA). However, there is high inter-observer variation. The objective was to assess if a short collegiate consensus would improve swollen joint agreement between rheumatologists and whether this was affected by experience. METHODS Eighteen rheumatologists from French university rheumatology units participated in three 30 minutes rounds over a half day meeting evaluating joint counts of RA patients in small groups, followed by short consensus discussions. Agreement was evaluated at the end of each round as follows: (i) global agreement of swollen joints (ii) swollen joint agreement according to level of experience of the rheumatologist (iii) swollen joint count and (iv) agreement of disease activity state according to the Disease Activity Score (DAS28). Agreement was calculated using percentage agreement and kappa. RESULTS Global agreement of swollen joints failed to improve (kappa 0.50 to 0.52) at the joint level. Agreement between seniors did not improve but agreement between newly qualified rheumatologists and their senior peer, which was initially poor (kappa 0.28), improved significantly (to 0.54) at the end of the consensus exercises. Concordance of DAS28 activity states improved from 71% to 87%. CONCLUSION Consensus exercises for swollen joint assessment is worthwhile and may potentially improve agreement between clinicians in clinical synovitis and disease activity state, benefit was mostly observed in newly qualified rheumatologists.

Septic arthritis of the facet joint

OBJECTIVE Septic arthritis of the facet joint is a rare clinical entity. We report 11 cases of facet joint infections diagnosed in our institution. PATIENTS AND METHOD Patients were identified via the computerized patients record (PMSI). Their features were collected and compared with published data. RESULTS The clinical symptoms are similar to those of infectious spondylodiscitis: back pain with stiffness (11/11), fever (9/11), radicular pain (5/11), and asthenia. Ten patients presented with lumbar infection and 1 with dorsal infection. An inflammatory syndrome was observed in every case. A rapid access to spine MRI allowed making the diagnosis in every case, and assessing a potential extension of infection (epidural extension 5/11, paraspinal extension 5/11). Blood culture (8/11) or culture of spinal samples allowed identifying the causative bacterium in every case and adapting the antibiotic treatment. The bacteria identified in our series were different from previously reported ones, with less staphylococci. The origin of the infection was found in 4 cases. Another localization of infection was observed in 4 cases. The outcome was favorable with medical treatment in 10 cases. An abscess was surgically drained in 1 case. None of our patients presented with neurological complications, probably because of the rapid diagnosis. CONCLUSION Assessing the facet joint is essential in case of inflammatory back pain, and the radiologist must be asked to perform this examination.

Arthrites septiques à Staphylococcus caprae

Staphylococcus caprae est un staphylocoque coagulase négaive mis en évidence pour la première fois chez l’homme en 1991 1]. Il est associé à des infections ostéoarticulaires [2,3], des bacériémies [4,5], des infections urinaires [4], une endocardite [4] t une méningite [6]. Nous rapportons deux cas d’infection articulaire à S. caprae : ne sacro-iliite et une arthrite de genou sur prothèse totale.

Ultrasonography and detection of subclinical joints and tendons involvements in Systemic Lupus erythematosus (SLE) patients: A cross-sectional multicenter study

OBJECTIVES The aims of this study in SLE population were (1) to describe ultrasonography (US) joint abnormalities, (2) to estimate the reliability of clinical swollen joint count (C-SJC) and SLEDAI (C-SLEDAI) versus US-SJC and US-SLEDAI scores, (3) to highlight specific patterns of lupus patients with Power Doppler (PD) abnormalities. METHOD For this cross-sectional multicenter study, 151 consecutive adult SLE patients were recruited. Evaluation included a clinical standardized joint assessment, B-mode and PD US of 40 joints and 26 tendons blinded for clinical examination. Reliability and agreement between clinical and B-mode US were calculated using the intraclass correlation coefficients (ICC [95% Confidence Interval]). RESULTS We found a very high frequency of subclinical US abnormalities in asymptomatic patients: 85% of patients without joint symptoms had at least 1 US abnormality. Among them 46 patients (87%) had a history of joint involvement. The most frequent abnormalities were joint effusmaions (108 patients), synovial hypertrophy (SH, 109 patients) and synovitis (61 patients). Joint or tendon PD signal (grade>1) was found in 44% of patients (67/151). Synovitis were mainly located especially on MCPs and wrists. Even if reliability between clinical and grey-scale US SJC assessments was poor, reliability between clinical and US SLEDAI was good. Comparison between SLE patients with and without PD signal did not show any specific SLE pattern. CONCLUSION US may be useful to assess joint involvement in SLE patients but did not significantly change SLEDAI score.

Current role for radioisotope synovectomy

Radioisotope synovectomy has been extensively used to treat patients with chronic inflammatory joint disease but has moved to a less prominent position since the introduction of new and highly effective drugs. Remaining indications are refractory synovitis, pigmented villonodular synovitis as an adjunct to surgery, and hemophilic arthropathy. The three main radioisotopes used are yttrium-90, rhenium-186, and erbium-189. Radioisotope synovectomy should be performed only by highly experienced professionals, to minimize the risk of injection-related complications. The available safety data, in particular regarding the risk of malignancy, are reassuring. The efficacy of yttrium-90 in chronic inflammatory joint disease remains controversial.

Small patella syndrome.

Joint Bone Spine - In Press.Proof corrected by the author Available online since jeudi 23 juin 2016