Wafa Hamdi

Assessment of preclinical atherosclerosis in patients with ankylosing spondylitis.

Objective. Epidemiological studies recently confirmed the increased risk of vascular morbidity and mortality during ankylosing spondylitis (AS). Increase of intima-media thickness (IMT) of the common carotid artery is a useful and noninvasive marker of preclinical atherosclerosis. The aim of our study was to compare IMT in patients with AS with matched controls and to determine risk factors of atherosclerosis related to AS. Methods. We performed a prospective study of 60 consecutive patients meeting modified New York criteria for AS, compared to 60 controls matched for age and sex. Disease-specific measures were determined. Measurement of IMT was performed by the same radiologist using the same machine and probe in right and left common carotid arteries, and the average of the 2 measurements was considered. Results. In total 48 male and 12 female patients were recruited, and 60 corresponding controls; mean age was 36 ± 11 years. We found significantly increased IMT in the AS group (0.51 ± 0.12 mm) compared with controls (0.39 ± 0.09 mm; p = 0.001). After adjustment for confounding factors, increased IMT was still present (p = 0.003). Age at onset of AS (p = 0.001), Bath AS Disease Activity Index (p = 0.002), AS Disease Activity Score (ASDAS) erythrocyte sedimentation rate (ESR; p = 0.047), ASDAS C-reactive protein (CRP; p = 0.012), Bath AS Functional Index (p = 0.008), global spine visual analog scale for pain (p = 0.000), Schober index (p = 0.039), Bath AS Metrology Index (p = 0.028), modified Stoke Ankylosing Spondylitis Spine Score (p = 0.035), and high ESR (p = 0.001) and CRP (p = 0.000) were correlated with high IMT in patients with AS. Otherwise, status of arthritis (p = 0.442), enthesitis (p = 0.482), and HLA-B27 (p = 0.528) seemed to have no effect on IMT. Conclusion. AS is associated with an increased risk of atherosclerosis independent of traditional risk factors. Disease activity, functional and mobility limitations, structural damage, and inflammation are the most incriminated risk factors.

Impact of the ankylosing spondylitis on the professional activity

PURPOSE OF THE STUDY Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting axial skeleton, occurring in young and active patients and often condition their professional prospects. OBJECTIVES To describe the social and occupational characteristics of patients affected by AS, to estimate the impact of the disease on their professional activity and to determine factors exposing to elevated risk of premature withdrawal from the labor force. METHODS We had performed a cross-sectional study of 103 patients with AS recruited during 2 years (2005-2007) at the Department of Rheumatology, fulfilling the modified criteria of New York. Demographic, social and professional characteristics were determinated and some disease-specific instruments: BASDAI, BASFI, BASMI, BASG-s, BASRI, as well as an indicator of quality of life: the Short Form Survey-36 (SF-36). RESULTS It is about 88 man and 15 women, the average age is 37.6 years+/-11.7 (18-59 years). Seventy percent of patients live in urban zone and 17% have an educational level superior to 13 years. The disease duration is on average of 11.2+/-9.6 years. The mean score of BASFI is 45.5+/-27.5 (7-100), the mean score of BASDAI is 45.9+/-22.4 (9-100), the mean score of BASG-s is 53.8+/-21.2, the mean score of BASMI is of 4.4+/-2.2 (3-10), the mean score of BASRI is 8.4+/-3.5 (2-16). Among these patients 95 (92%) are eligible to a professional activity (aged between 18 and 65 years and having ended their studies or vocational training). The global unemployment rate is 25.3%, thats attributed to the disease is 20.6%. Some factors are associated with high risk of work withdrawal: female gender (p=0.0005), low educational level (p=0.02), living in rural zone (p=0.028), manual labor (p=0.038), cold exposing in work place (p=0.006), high work time a week (p=0.02) and the absence of colleague help (p=0.001). For the specific disease indexes, high risk of withdrawal is correlated with high scores of BASFI (p=0.00002), BASDAI (p=0.044), BAS-Gs (p=0.0005) and BASMI (0.0000). Concerning the SF-36, only the item of physical activity is more significantly altered in patients having stopped their work. CONCLUSION Several factors are identified to be associated to a high risk of premature working withdrawal in patients affected by AS. Prevention of this risk needs an early diagnosis and treatment of the disease, a vocational guidance, work preliminary training and eventually professional redeployment.

Correlations among clinical, radiographic, and sonographic scores for enthesitis in ankylosing spondylitis.

OBJECTIVES To look for correlations among clinical, radiographic, and sonographic scores for enthesitis in patients with ankylosing spondylitis (AS). METHODS Prospective study of 60 patients meeting modified New York criteria for AS. The clinical evaluation relied on the BASDAI, BASFI, and ASQoL and on a visual analog scale (VAS) for entheseal pain, as well as on two specific enthesitis indices, the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and the Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC). Radiographs and ultrasound scans were taken of five entheses on both sides (patellar insertion of the quadriceps tendon, proximal and distal insertions of the patellar tendon, and calcaneal insertions of the Achilles tendon and superficial plantar fascia). Ultrasound scans were obtained using a Philips HD 11™ machine with a high-frequency linear probe. RESULTS We studied 48 men and 12 women with a mean age of 36±11 years. The radiographic score correlated with the VAS pain score, BASDAI, and BASFI. The sonographic score for acute enthesitis correlated only with the MASES, and the sonographic score for chronic enthesitis correlated with none of the clinical scores. The Doppler score correlated with the VAS pain score, BASDAI, BASFI, and ASQoL. The overall sonographic score correlated with the MASES and SPARCC. CONCLUSION Good correlations were found between the clinical and sonographic scores for enthesitis. The radiographic score seemed correlated with the general AS parameters rather than with the clinical scores. Larger studies are needed to better define the role for radiographs and sonography of the entheses in the diagnosis of AS and follow-up of treated AS patients.

Associated risk factors with worse functional prognosis and hip replacement surgery in ankylosing spondylitis

Joint Bone Spine - In Press.Proof corrected by the author Available online since mardi 5 juillet 2011

Piriformis muscle syndrome: an unusual adverse effect of atorvastatin.

Piriformis syndrome (PS) is an uncommon cause of sciatica-like pain with buttock pain referred to the leg and caused by extraspinal compression of the sciatic nerve by the piriformis muscle.1 Diagnosis is often difficult. Piriformis syndrome is frequently posttraumatic or in relation with anatomic a

Health-related Quality of Life Assessment on 100 Tunisian Patients with Ankylosing Spondylitis using the SF-36 Survey

OBJECTIVES The main objective of the study was to examine the self reported health status in patients with ankylosing spondylitis (AS) compared with the general population and the secondary objective (in the AS group) was to study the association between health status, demographic parameters, and specific disease instruments in AS. METHODS A cross sectional study of 100 AS patients recruited between 2006 and 2009 at the Department of Rheumatology. Health status was assessed by using the SF-36 health questionnaire in patients with AS. Demographic characteristics and disease-specific instruments were also examined by the questionnaire. A sample of 112 healthy individuals was also surveyed using the SF-36 health questionnaire. RESULTS This study showed a great impairment in the quality of life of patients with AS involving all scales. All male patients with AS reported significantly impaired health-related quality of life on all items of the SF-36 compared with the general population whereas female patients reported poorer health on three items only, namely physical functioning, general health and bodily pain. Mental health was mostly affected than physical role. The physical role was significantly higher in patients with high education level than in patients with low education level (p=0.01). Physical functioning was better in employed patients. All scales of SF-36 were correlated with BASFI, BASDAI and BAS-G. Only physical functioning and general health were correlated with BASMI. CONCLUSION Impairment in the quality of life can be significant when suffering from AS, affecting mental health more than physical health. Among disease parameters, functional impairment, disease activity, mobility limitation, and spinal pain were the most associated factors resulting to the deterioration of quality of life.

Sarcoidosis and spondyloarthritis: A coincidence or common etiopathogenesis?

Background: Sarcoidosis is a multisystem granulomatous disease. Co-existence with spondyloarthritis (SA) has been more described as an adverse effect of anti-TNF α therapy than an association. We report herein a case of a typical sarcoidosis confirmed by histological proofs and an advanced SA with a bamboo column. Case Presentation: A 48-years-old woman presented with inflammatory back pain for 5 years and ankle swelling for 1 year. On physical examination, she had an exaggerated dorsal kyphosis and disappearance of lumbar lordosis with limitation in motion of the cervical and lumbar spine. Laboratory tests did not show an inflammatory syndrome or hypercalcemia. Plain radiographies of the spine and pelvic revealed a triple ray appearance with sacroiliitis grade 4. Chest radiography and CT confirmed the presence of bilateral hilar lymph nodes and parenchymal nodes. Bronchoscopy and biopsies were performed showing non-calcified granulomatous reaction without cell necrosis. The diagnosis of SA was performed based on 9 points of Amor criteria associated with pulmonary sarcoidosis. She was treated with 15 mg per week of methotrexate and 1mg/kg/day of prednisone for pulmonary disease with good outcomes. Conclusions: Sarcoidosis may be associated to SA besides paradoxical drug effect. The same physio pathological pathways mediate by TNF α are arguments for association than hazardous coincidence.

About an aggressive bone lesion

We report here a case of hyperparathyroidism with disseminated brown tumors mimicking malignancy. The important clinical teaching of our case is that hyperparathyroidism can take various aspects. Plasma parathyroid hormone concentration should be measured in all patients with multiple bone lesions.

Syringomyelia associated to rheumatoid-atlantoaxial subluxation: about a new case

We report a case of 64-year-old Tunisian woman with a 12-year history of rheumatoid arthritis, who presented with a 3-month history of increasing inflammatory neck pain. Neurological examination noted a quadripyramidal syndrome without any neurological deficit. Radiographs of her neck showed ananterior atlantoaxial subluxation (A). MRI revealed a pannus around the atlanto axial joint. It also showed a co-existing syringomyelia (B). The cervical spine is frequently involved in patients with rheumatoid arthritis. However, rheumatoid atlantoaxial subluxation with syringomyelia is very rare. Many hypothesised mechanisms were suggested for thesyrinx formation. The most commonly admitted, suggested that atlanto axial sub luxation may reduce the rate of ascending cerebrospinal fluid, so it would travel through the spinal cord producing syringomyelia.

THU0373 Use of corticosteroid hip joint injections in spondyloarthritis patients under tnf alpha inhibitors

Background The hip disease is a serious complication of spondyloarthritis (SpA), engaging the functional prognosis of patients. TNF alpha inhibitors are a breakthrough for the treatment of SpA and the management of this complication. Objectives To assess the efficacy of TNF alpha inhibitors on hip involvement in SpA by evaluating the use of intra-articular corticosteroid infiltrations. Methods Observational cohort study that included 94 SpA patients with hip disease (ASAS2009). Two groups were studied. Group 1 (G1): patients under anti-TNF alpha therapy and Group 2 (G2): TNF alpha inhibitors naive patients. Clinical (BASDAI, BASFI, hip (pain/mobility), index of severity for osteoarthritis for the hip (ISH)), biological (CRP) data were assessed and the use of corticosteroid hip joint infiltration was compared. Evaluations were performed and compared between the 2 groups at baseline (T0), two years (T2) and Tn (greater than or equal to 3 years). The correlation study was made by Pearson test. A correlation was considered statistically significant if p<0.05. Results Group 1 and 2 included 48 and 46 patients respectively. The socio demographic and clinical characteristics of the disease were comparable between the two groups. Biological and radiological assessments of the two groups were comparable at T0. Group 1 had however a more active disease and a greater functional impairment. NSAIDs were prescribed in 40% of patients in G1 and 86% in G2 (p<0.0001). DMARDS were prescribed in 20 patients in G1 and in 22 patients in G2 (p=0.6). In G1 patients received infliximab, adalimumab and etanercept in 48%, 15% and 37% of cases respectively. Four patients of G1 and three of G2 patients received intra-articular corticosteroid infiltration in the year prior to the initial assessment (p=0.7). Assessment at T2 showed a greater improvement in clinical and biological parameters of the disease in group 1 than in group 2 with Δ (T2-T0) significantly lower in group 1 for the BASDAI (p<0.0001), the BASFI (p<0.0001) and the ISH (p=0.017). The number of painful hip was significantly lower in group 1 (p<0.0001). The evaluation at Tn showed a sustained clinical and biological efficacy of TNF alpha inhibitors in Group 1. The use of corticosteroid injections was significantly higher in group 2. Table 1 summarizes the assessment of different parameters at T2 and Tn.Table 1. Comparison of Clinical and biological variations between the 2groups at T2 and Tn T2/T0 Tn/T0 G1 G2 p G1 G2 p ΔISH -7,7 [-19, 2] -1,6 [-19, 8] 0,01 -9,3 [-20, 2] 0,1 [-4, 4] 0,005 ΔBASFI -2,7 [-9, 7] 1,1 [-1, 4] <0,0001 -3,2 [-9, 1] 0,2 [-3, 6] <0,0001 ΔBASDAI -3 [-8, 3] 0,4 [-3, 5] <0,0001 -3,4 [-9, 2] -0,9 [-6, 4] 0,001 Hip pain (%) 35 75 <0,0001 20 67 <0,0001 Limitation of hip mobility (%) 71 83 0,2 50 86 <0,0001 ΔCRP (mg/l) -33,6 [-132,69] -6,1 [-72,18] 0,3 -25,5 [-89, 6] -1 [-99,58] 0,04 Corticosteroids hip joint injections (n) 1 3 0,2 0 4 0,04 Conclusions Hip involvement is a marker of severity of spondyloarthritis. Anti-TNF alpha treatment is effective on hip disease. It reduces the use of intra articular injections of corticosteroids. Disclosure of Interest None declared