Assessment of rheumatoid arthritis patients' knowledge about foot problems related to their illness and foot care practice

INTRODUCTION

Foot problems are very common in rheumatoid arthritis (RA). Podiatric intervention through therapeutic education of RA patients on the different potential foot problems could improve patients' knowledge and management of their foot problems. This study aimed to evaluate the knowledge of RA patients on podiatric problems related to their illness and foot care practices.

METHODS

This was a cross-sectional study including patients diagnosed with RA and aged older than 18 years. Sociodemographic data, disease characteristics, and therapeutic data were collected. RA foot problems knowledge and foot care practice were assessed using a questionnaire combining questions developed from the literature search and a pretested validated questionnaire.

RESULTS

Overall, 103 patients were included of whom 94 were female. The mean age was 56 years (±10 years) and the mean disease duration was 15 years (±10 years). Over 77% of patients reported never having received foot-health-related education. With regard to their knowledge about RA foot involvement, patients were aware that RA can affect the feet similarly to the hands (83%), lead to deformation of the foot (86%), lead to walking difficulties and falling (68%), and produce skin lesions of the foot (31%). Regarding participant's knowledge of appropriate footwear, 65% agreed that it would be beneficial to wear quality standard sports shoes. However, less than one-third of patients know the podiatrist's skills.

CONCLUSION

Our study showed an awareness of the repercussions of RA on feet but a lack of knowledge on proper foot care, thus identifying a need for foot health therapeutic education.

Ultrasound Assessment of Psoriatic Arthritis Patients With Clinically Normal Nails and Evaluation of its Correlation with the Disease Activity: A Case-Control Study

OBJECTIVES

Nail unit is one of the targets of ultrasound (US) assessment. We aimed to compare ultrasound parameters of clinically normal nail unit in psoriatic arthritis (PsA) patients with healthy controls (HC) and evaluate their correlations with disease activity.

METHODS

This was a cross-sectional study including patients with PsA and matched HC. Tender (TJC) and swollen joint count (SJC), Psoriasis Area and Severity Index (PASI), and Disease Activity in Psoriatic Arthritis (DAPSA) were collected in PsA patients. Patients underwent US assessment of fingernails with a study of morphological changes and measurement of the thickness of nail bed (NBT), nail plate (NPT), and adjacent skin (ST). Correlation between nail unit parameters and disease activity was studied.

RESULTS

We evaluated 22 PsA patients (219 nails) and 21 HC (210 nails). Mean DAPSA was 21.56 ± 14.36 and mean PASI was 2.19 ± 3.8. PsA patients had more US morphological changes than HC (16.89 vs 3.33%, P = .03). NPT comparison between identical fingernails of PsA and HC did not reveal significant difference. However, NBT was significantly higher in HC (1.77 vs 2.07 mm, P = .027) as well as ST (2.26 vs 2.59 mm, P = .003). TJC and ST were positively correlated (r = .46, P = .03). No correlation was noted between disease activity scores and NPT, NBT, or ST in PsA patients. In biologic parameters, ESR was negatively correlated with ST (r = -.41, P = .05).

CONCLUSIONS

Nail bed and adjacent skin US morphological changes were contributive to distinguish psoriatic from healthy nails. Adjacent skin thickness measurement was positively correlated with TJC and ESR, suggesting that it could be used as an indicator of disease activity in PsA.

Burden of disease, pain catastrophizing, and central sensitization in relation to work-related issues in young spondyloarthritis patients

Introduction

Spondyloarthritis (SpA) is a common rheumatic inflammatory disease and can impact patients' work productivity. We aimed to evaluate the impact of pain catastrophizing and central sensitization on work outcomes in young SpA patients and determine the predictive factors of work productivity loss.

Material and methods

We performed a cross-sectional study over 6 months. We included patients aged between 18 and 50 years old, diagnosed with axial or peripheral SpA. Pain catastrophizing and central sensitization were assessed using the Pain Catastrophizing Scale (PCS) and Central Sensitization Inventory (CSI) questionnaire, respectively. Impact of SpA on work productivity and activity impairment during and outside of work was measured with the Work Productivity and Activity Impairment Questionnaire (WPAI: Spondyloarthritis).

Results

A total of 72 patients were enrolled, with a median age of 39 years (28.3-46), 65.3% men, and 54.4% working patients. Median scores of activity impairment outside of work, and work productivity loss were 50% (40-70), and 50% (40-60), respectively. Median absenteeism and presenteeism scores were 0% (IQR 0-7), and 100% (IQR 86.5-100), respectively. Regarding work-related outcomes: activity impairment was positively correlated with CSI and PCS; presenteeism was significantly associated with male sex (p = 0.009); and work productivity loss was positively associated with anxiety, depression, and poor quality of life. Multivariate regression analysis identified predictive factors of work productivity loss: male sex, poor quality of life, and prolonged morning stiffness.

Conclusions

Assessment of the impact of pain catastrophizing and central sensitization on work-related outcomes in patients with SpA is important to understand the burden of illness and to identify early those in need of interventions in clinical practice.

No Correlation between Anti-drug Antibodies and Therapeutic Response in Tunisian Patients with Chronic Inflammatory Diseases Treated by TNF Blockers

INTRODUCTION

Tumor necrosis factor alpha (TNF alpha) blockers such as infliximab (IFX) and adalimumab (ADA) had significantly changed the course of inflammatory diseases such as rheumatoid arthritis (RA), spondyloarthritis (SpA) and Crohn's disease (CD). However, about 30% of patients do not respond to these treatments. This lack of response may be due to the formation of antibodies against these drugs (anti-drug antibodies: ADAbs). The aim of this study was to determine the prevalence of ADAbs against IFX and ADA, and the trough serum concentration of IFX and ADA in RA, SpA or CD patients and to assess their impact on the therapeutic response.

METHODS

A cross sectional, multi-centric study was conducted, including patients with RA, SpA or CD treated with IFX or ADA as a first biotherapy for at least 6 months. ADAbs and trough levels were measured by an Enzyme Linked Immunosorbent assay (ELISA).

RESULTS

197 patients were included (57 RA, 73 SpA and 67 CD). ADAbs were positive in 40% of cases for IFX and 25% for ADA. They were positive in 40% of SpA, 35% of RA, and 21% of CD. The presence of ADAbs was inversely correlated to the trough levels of IFX and ADA during RA (p = 0.01 and p < 0.0001), SpA (p < 0.01 and p < 0.0001) and CD (p = 0.001 and p = 0.04). For all pathologies, the presence of ADAbs was not correlated with disease activity. Concomitant methotrexate significantly reduced immunogenicity.

CONCLUSION

In our study, the presence of ADAb and low trough levels seem to not affect the therapeutic response in patients on TNF alpha antagonists. Other tracks more than immunogenicity should be investigated to explain the loss of response to these biotherapies.

Screening of silent myocardial ischaemia using a stress test in rheumatoid arthritis patients: Association with traditional risk factors and disease activity

INTRODUCTION

We aimed to screen the presence of silent myocardial ischaemia, in established rheumatoid arthritis (RA) patients, using a stress test then to evaluate its association with the disease activity and the cardiovascular (CV) risk factors and Heartscore.

METHODS

It is a transversal study in a rheumatologic centre in Tunisia. One hundred three RA patients, asymptomatic for CV diseases, were submitted to a stress test. Demographic data, CV risk factors and disease characteristics were assessed and risk factors of silent myocardial ischaemia in RA patients were identified.

RESULTS

There were 103 patients (sex-ratio = 0.3) with a mean age of 53 ± 10 years. The evaluation of the disease activity showed that the mean Disease Activity Score in 28 joints C-reactive protein, Clinical Disease Activity Index and Simplified Disease Activity Index were 3.9 ± 1.38, 17.17 ± 11.4 and 33.39 ± 26, respectively. The ischaemic ratio (CT/HDL) revealed that 42% of patients had a moderate to high myocardial ischaemic risk. HeartSCORE was high in 35% of cases. A silent myocardial ischaemia in the stress test was found in 11 patients (10.6%) and was associated with male sex (p = 0.03), advanced age (p = 0.04), erosive character (p = 0.05), the advanced age of the RA diagnosis (p = 0.01) and the ischaemic ratio (p = 0.05). No relationship was found with the majority of traditional CV risk factors nor with disease activity variables.

CONCLUSION

Our results corroborated the hypothesis that the stress test could reveal subclinical CV dysfunction and supported the utility of the Heartscore as a screening tool.

Psoriatic Arthritis Quality of Life questionnaire: Translation, cultural adaptation and validation into Arabic language

BACKGROUND

Psoriatic arthritis (PsA) is a multifaceted inflammatory disease that has a strong negative impact on the quality of life (QoL) of patients. The Psoriatic Arthritis Quality of Life (PsAQoL) questionnaire was the first disease-specific patient-derived instrument developed to measure the QoL in patients with PsA. Our objective was to translate the PsAQol into Arabic language and evaluate its reliability and validity in patients with PsA.

METHODS

This was a cross-sectional study including patients with PsA. A clinical and biological assessment of the patients was performed at inclusion. The translation of the original PsAQoL into Arabic was performed by a professional bilingual and lay panel. Eight patients were interviewed to assess face and content validity. A separate sample of PsA patients (n = 30) were invited to participate in a test-retest postal study in order to investigate reproducibility and construct validity. One week separated the two administrations. The Arabic version of Health Assessment Questionnaire (HAQ) was used as a comparator instrument for convergent validity.

RESULTS

Face and content validity were satisfactory. The Arabic version of the PsAQoL was found to be relevant, understandable and easy to complete in only a few minutes. One item was excluded (item 16). It had no correlation with either the other 19 items or the total score of PsAQol. The Arabic PsAQol had excellent internal consistency (Cronbach's a = 0.926), and test-retest reliability (r = 0.982). There was a positive correlation between the total score of the PsAQoL and the Arabic version of HAQ (Spearman's r = 0.838, p < 10-3 ). Exploratory factor analysis had extracted two factors explaining 55% of the total variance.

CONCLUSION

Nineteen items were selected to compose the Arabic version of PsAQoL, which was found to be relevant and understandable and has excellent reliability and construct validity. The new measure will be a valuable new tool for use in routine care for patients' assessment.

Efficacy and safety of intravenous Zolidronic acid in the treatment of pediatric osteogenesis imperfecta: a systematic review

Osteogenesis imperfecta is an inherited clinically heterogeneous disorder of bone metabolism characterized by bone and skeletal fragility and an increased risk of fractures. Pamidronate infusion was the standard treatment, but zoledronic acid is increasingly used to treat children with osteogenesis imperfecta. We conducted a systematic literature review to evaluate the efficacy and safety of intravenous zoledronic acid in the treatment of osteogenesis imperfecta in pediatric patients. A systematic review of the published literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible articles were clinical trials and observational studies including pediatric patients (<16 years) with osteogenesis imperfecta treated with zoledronic acid. We selected articles published during the 20 past years. The selected languages were English and French. We included articles with a minimum sample size of five patients. Six articles fulfilled the selection criteria. The majority of patients were Chinese (58%). The predominant sex was male (65%), and the age of included patients ranged from 2.5 weeks to 16.8 years. For all patients, zoledronic infusions were administrated intravenously. The zoledronic treatment duration ranged from 1 to 3 years. Densitometry parameters before and after zoledronic treatment were evaluated and showed significant improvement both in lumbar spine-bone mineral density Z-score and femoral neck-bone mineral density Z-scores. A significant decrease in fracture rate has also been noted both in vertebral and nonvertebral fracture incidence. The two most common side effects were fever and flu-like reactions. None of the patients presented severe adverse events. Zoledronic acid appeared to be well-tolerated and effective in the treatment of pediatric osteogenesis imperfecta.

Foot function in rheumatoid arthritis: Correlation between the Rheumatoid and Arthritis Outcome Score and performance-based physical tests

BACKGROUND

Foot function is usually assessed using self-reported outcome measures which remain subjective in patients with rheumatoid arthritis (RA). Physical performance tests were recommended for functional assessment in lower limb osteoarthritis. However, foot function assessment's guidelines in RA are lacking. We aimed to investigate the correlation between a self-reported outcome measure and two performance-based physical tests for assessing foot function in RA patients.

METHODS

A cross-sectional study was performed over 7 months' period including RA patients. We used Rheumatoid and Arthritis Outcome score (RAOS) as a self-reported functional tool. Physical performance tests were 4-min walk test (4-MWT) and Timed up and go test (TUGT).

RESULTS

Fifty RA patients were included with 96% females and a mean age of 54.7 ± 10.4 years. Foot involvement occurred since the diagnosis of RA in 36% of patients. Foot pain was reported by 68% of patients (48% forefoot), and foot stiffness in 46% of patients. Skin lesions of the feet were found in 78% of patients, 90% had foot deformities and 56% had inflammatory disorders of feet. Radiographic lesions were found in 94% of patients. The most impaired RAOS subscales were Sports and Recreation and Quality of life. Poor physical-based performance was found in 34% of RA patients according to 4-MWT, in 42% of RA patients according TUGT, and in 46% of patients based on at least one performance test. RAOS was negatively correlated to the 4-MWT and positively correlated in the subscales pain, other symptoms, activities of daily living, and Sport/Rec of the RAOS. Poor performance-based physical tests were significantly associated with advanced age, sedentary lifestyle, higher disease activity score and impaired functional status. Foot-related parameters significantly associated with poor performance-based physical tests were: foot pain, foot deformity and inflammatory disorders. Multivariate analysis identified foot deformities and higher functional impairment as predictive factors for lower gait speed (4-MWT) and older age and higher functional impairment for higher duration of TUGT.

CONCLUSION

RAOS was significantly associated with performance-based physical function. In the era of connected technologies, these results encourage the regular assessment of rheumatoid foot function by the RAOS score through a connected programme using wearable trackers.

Assessment of the influence of Fc-γ receptor polymorphisms on biologics' pharmacokinetics in Tunisian rheumatoid arthritis patients

AIMS

This study aims to determine whether a modification in Fc-γ receptors' (FcgRs) affinity to Fc portion, caused by single nucleotide polymorphisms such as rs1801274-R131H FcgRIIa, rs396991-F158V FcgRIIIa and NA1/NA2-FcgRIIIb, might impact clearance of therapeutic monoclonal antibodies and thus serum drug levels and the development of anti-drug antibodies.

METHODS

A cross sectional, multicentral and noninterventional study was conducted in Tunisian RA patients treated with rituximab (RTX), etanercept (ETA), infliximab (IFX) and adalimumab (ADL). Serum drug level (SDL) of the different biologics and ADA against them were measured. All patients were genotyped for the 3 FcgR single nucleotide polymorphisms.

RESULTS

A total of 81 patients were included: 47 were under tumour necrosis factor inhibitors (18 ETA, 13 ADL and 16 IFX), and 34 were under RTX. Regardless of the type of biotherapy, SDL was in therapeutic range, in 35 patients (43.2%), of whom only 1 was treated with RTX. Fourteen patients (22.2%) developed ADA, but none of the patients treated with ETA had detectable ADA levels. There was no association between SDL positivity and FcgR polymorphisms. However, the high affinity FcgR2A 131 H/H receptor was statistically more prevalent in patients with detectable ADA treated with ADL, IFX and RTX (P = .018). The same result was obtained in the monoclonal antibody tumour necrosis factor inhibitor subgroup (n = 29, P = .022) as well as in patients treated only with IFX (n = 16, P = .029).

CONCLUSION

Our work supports the hypothesis of an impact of FcgR single nucleotide polymorphisms on biologics' immunogenicity, particularly FcgR R131H polymorphism, but further studies with larger cohorts need to be undertaken to confirm these results.

Risk factors for atlantoaxial dislocation in rheumatoid arthritis: A comparative study

BACKGROUND

The objective of the study was to assess clinical and imaging features of rheumatoid arthritis associated with atlantoaxial dislocation (RA-AAD) in comparison to RA without AAD (RA-C) and to identify the associated factors to AAD.

METHODS

This was a retrospective comparative study including RA patients over 18 years old. The control group of RA-C was matched according to age (±2 years), gender, and RA duration (±2 years). General data, RA characteristics, AAD features, and treatment modalities were recorded. Statistical analysis was performed to determine the predictive factors of AAD.

RESULTS

A total of 120 patients were included (78 RA-AAD and 42 RA-C); sex-ratio was 0.15. Mean age was 58.55 ± 9.14 years (RA-AAD) versus 60.43 ± 10.78 years (RA-C), (p = 0.31). Regarding RA features, RA-AAD patients have significantly a higher rheumatoid factor (RF) rate (p = 0.002), extra-articular manifestations (p = 0.009) especially osteoporosis (p < 10^-3 ), eye involvement (p = 0.02), coxitis (p < 0.0001), Disease Activity Score (DAS28) (p < 10^-3 ), and global health status scale (HAQ) (p = 0.003). X-ray analysis showed pathologic PADI (<14 mm) in 51.6% of cases. The AADI was pathological (>3 mm) in 100% of patients with the following distribution: 67.9% between (3-6 mm) and 23.3% between (6-9 mm). Atlantoaxial dislocation (AAD) was presumed anterior (85.4%), lateral (7.3%) and rotatory (7.3%). The abnormalities observed on magnetic resonance imaging (MRI) were: C1-C2 synovitis (61%), confirmed AAD (34.1%) and basilar impression (4.9%). AAD diagnosed by cervical MRI was anterior in 89.8% of cases, lateral (5.3%) and with a double ascending and anterior component in 4.9% of cases. An immobilisation with a type C4 cervical collar was indicated for all the patients and five of them had boluses of corticosteroid (methylprednisolone 1 g/day) for three consecutive days. C1-C2 arthrodesis by trans-articular screwing was performed in four patients with neurological signs or pathological measurements on cervical MRI. The outcome was favourable in 100% of cases after surgical treatment with improvement in neck pain and neurological condition within a mean decline of 4 ± 3 years [1-7]. Multivariate analysis identified coxitis, osteoporosis, high baseline DAS28, and a high rate of RF positivity as predictive factors of AAD.

CONCLUSION

Our results confirmed that predictive factors of AAD were related to higher disease activity and structural damage. These modifiable factors may be prevented by tight control, early treatment, and educating RA patients to improve treatment adherence.

Health-Related Quality of Life and Associated Factors Among Patients With Knee Osteoarthritis

BACKGROUND

Knee osteoarthritis, a chronic degenerative disease, is becoming a public health problem around the world due to increasing life expectancy.

OBJECTIVES

We aimed to assess the impact of knee osteoarthritis on the quality of life (QoL) of the patients and to identify factors associated with impaired QoL.

MATERIALS AND METHODS

We conducted a cross-sectional monocentric study including patients with knee osteoarthritis. The pain was evaluated by the Visual Analog Scale (VAS). The short form of the Knee injury and Osteoarthritis Outcome Score (KOOS-PS) was used to assess functional impact. QoL was assessed using the OsteoArthritis of Knee Hip Quality Of Life (OAKHQOL) questionnaire.

RESULTS

Fifty patients were included. The mean age of patients was 59±9 years. The sex ratio was 0.25. At least one comorbidity was noted in 77% of patients. The mean disease duration was 8.82 years. Mean VAS pain and KOOS-PS were 6.8±1.1 and 54.7±9.6/100; respectively. Assessment of the QoL by OAKHQOL showed impaired QoL in all domains; the worst scores concerned the areas of social functioning and pain. Factors associated with an altered QoL were age>65 years, longer disease duration, higher pain intensity, comorbidities, and functional impairment.

CONCLUSION

Our patients showed an impaired QoL in all domains, particularly in terms of physical activity and social functioning. Lower QoL scores were associated with age, comorbidities, pain, function, and disease duration. Factors associated with QoL should be considered in the management program of these patients. Screening and the treatment of comorbidities are also useful for the management of knee OA.

Fibromyalgia in Spondyloarthritis: Prevalence and Effect on Disease Activity and Treatment

BACKGROUND

Fibromyalgia may be associated to Spondyloarthritis with which it shares some common symptoms such as sleep disorders, fatigue and diffuse pain, leading to diagnostic and treatment dilemmas.

OBJECTIVES

We aimed to determine the prevalence of fibromyalgia in axial spondyloarthritis and to determine how fibromyalgia might influence the assessments of disease activity and how it might impact treatment.

METHODS

An observational cross-sectional study was conducted. The study included 100 patients with axial spondyloarthritis according to the Assessment of SpondyloArthritis international Society criteria. Fibromyalgia was diagnosed based on the 2010 American College of Rheumatology criteria. Demographics, disease characteristics, activity parameters and treatment were compared between patients with and without fibromyalgia. Patients were recruited from the hospitalization unit and the outpatient clinic of rheumatology.

RESULTS

The mean age of patients was 44.65 ± 13.13 years, with a sex ratio equal to 2. The prevalence of fibromyalgia was 20%. Fibromyalgia associated factors were advanced age and a late age at the onset of axial spondyloarthritis. Disease activity parameters such as global pain VAS, BASDAI, ASDAS-ESR, ASDAS-CRP, BASFI and BAS-G as well as MASES and BASMI were significantly higher in the presence of FM. Doses of paracetamol were significantly higher among FM+ patients. Also, treatment duration of the current anti-TNF alpha agent was significantly shorter among FM+ patients.

CONCLUSION

Our study showed that fibromyalgia was associated with axial spondyloarthritis in 20% of patients. Its presence was associated with higher disease activity parameters and negative impact on the treatment.

Variation of homocysteine levels in rheumatoid arthritis patients: relationship to inflammation, cardiovascular risk factors, and methotrexate

BACKGROUND

The aim of this study was to evaluate the variation of homocysteine (Hcy) levels in patients with rheumatoid arthritis (RA) and to analyze the relationship to inflammatory parameters, cardiovascular risk, and methotrexate (MTX).

METHODS

This cross-sectional study assessed disease activity and treatment in RA patients. The European League Against Rheumatism (EULAR) 2015 HeartSCORE was performed for cardiovascular (CV) risk estimation and levels of plasma Hcy, serum folate concentrations, vitamin B12, and erythrocyte sedimentation rate (ESR) were measured.

RESULTS

A total of 103 participants with mean age 53 ± 10 years and mean disease duration 10.55 ± 7.34 years were included. Patients were treated with MTX in 69.9% of cases and corticosteroid in 80.5% of cases. Of all patients, 13% had a cardiovascular inheritance, 25% were hypertensive, and 18% had diabetes. The EULAR 2015 HeartSCORE was high and very high (≥5%) in 35% of cases. Mean Hcy level was 12.54 ± 4.2 µmol/L [6.89-32.92] and hyperhomocysteinemia was noted in 20.4% of patients. Analytic study demonstrated that hyperhomocysteinemia was associated with male gender (p = 0.01), MTX use (p = 0.01), smoking (p = 0.008), renal failure (p = 0.04), and high disease activity (p = 0.05), but there was no association with the HeartSCORE (p = 0.23). Hcy level was negatively correlated with folate (p = 0.009) and vitamin B12 level (p = 0.02) and positively with age (p = 0.01), C‑reactive protein (CRP; p = 0.05), and Simplified Disease Activity Index (SDAI; p = 0.03). In multivariate logistic regression analysis, current MTX use, levels of vitamin B12 and creatine, and Clinical Disease Activity Index (CDAI) appeared to be independent factors associated with hyperhomocysteinemia.

CONCLUSION

MTX use, CDAI, and the levels of vitamin B12 and creatine are independent factors associated with hyperhomocysteinemia.

Association between Rheumatic Disease Comorbidity Index and factors of poor prognosis in a cohort of 280 patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is commonly associated with higher rates of comorbidities. Recent recommendations highlight screening comorbidities during the disease course because of their impact on patients' ability to function, on disease outcome, but also on treatment choices. Hence the interest of our study that aimed to quantify the impact of comorbidities among RA patients using a validated tool the Rheumatic Disease Comorbidity Index (RDCI) and to explore the association between comorbidities and disease characteristics.

METHODS

We conducted a cross-sectional study over 12 months period, including patients followed for an established RA according to the ACR/EULAR 2010 criteria and hospitalized in our rheumatology department. Patients' characteristics and disease features were collected for each patient. Comorbidities were quantified using the RDCI. We looked for the association between RDCI and patients characteristics and RA parameters. Univariable and multivariable analysis were made.

RESULTS

They were 280 patients: 233 female (83.2%) and 47 male (16.8%) with a mean age of 58.07 (SD 11.12) years. The mean follow-up period was 14.74 (SD 1.63) years. Comorbidities were noted in 133 patients (47.5%). The mean comorbidity score measured by the RDCI was 1.05 (SD 1.23). RDCI was positively correlated with age (p < 0.001, r = 0.359). RA patients whose age of disease onset exceeds 40 years have significantly higher RDCI (1.8 (SD 1.3) [CI 95%: 1.36-1.88] vs. 1.5 (SD 1.2), p = 0.007). Moreover, RDCI was significantly associated with the presence pulmonary involvement (p < 0.001) and ocular involvement (p = 0.002). RDCI was also associated with erosive RA (p = 0.006), the presence of atlanto-axial dislocation (p = 0.014), and coxitis (p = 0.029). Regarding therapy regimen, RDCI was statistically increased in patients receiving bDMARDs compared to patients under csDMARDs (2.8 (SD 1.6) vs. 1.0 (SD 1.0), p = 0.021).

CONCLUSION

In this study, comorbidity index was associated with signs of poor prognosis such as erosions, coxitis, and atlanto-axial dislocation. This confirmed the hypothesis that comorbidity can be a threat to the improvement in the long-term prognosis in RA patients.

Unexpected diagnosis of vertebral osteolysis

This is the case of a 50-year-old patient suffering from inflammatory low back pain. Radiological exploration showed posterior vertebral damage compatible with discovertebral pseudo-tumor tuberculosis. Pathological examination found no malignant cells, but caseous necrosis was present. The patient was put on antitubercular drugs. The evolution was favorable under treatement.

Synovial chondromatosis of the shoulder in rheumatoid arthritis: A case report and brief review of the literature

BACKGROUND

Synovial chondromatosis is an uncommon benign condition characterized by synovial membrane proliferation and metaplasia. Synovial chondromatosis cases in patients with rheumatoid arthritis have been reported. However, involvement of the glenohumeral joint is rare.

CASE PRESENTATION

We herein report a case of a rare association of synovial chondromatosis involving the shoulder in a rheumatoid arthritis patient. The symptoms have improved with anti-tumor necrosis factor drugs. Consequently, there was no need for invasive therapy for treating synovial chondromatosis.

CONCLUSIONS

Synovial chondromatosis can be aggressive and destructive. More trials are needed to establish a better clinical diagnostic strategy and pharmacological management.

Lumbar Spinal Involvement in Calcium Pyrophosphate Dihydrate Disease: A Systematic Literature Review

Background

Calcium-pyrophosphate-dihydrate-disease (CPPD) is a crystal-induced arthropathy. The lumbar-spinal involvement is rare and often under-diagnosed. This study aimed to report the case of a lumbar spine CPPD involvement and to perform a systematic review of clinical, imaging features of lumbar involvement in CPPD patients, and treatments that have been implemented.

Methods

This systematic review was conducted in accordance with the Preferred-Reporting-Items-for-Systematic-Reviews and Meta-Analyses (PRISMA) guidelines.

Results

One hundred and sixty-seven articles met the search criteria using electronic databases searches. We retained 28 articles (20 case reports, 2 case series, 1 family survey, 4 retrospective studies, and 1 prospective study) involving a total of 62 patients. The age ranged between 39 and 89 years old. Among patients with lumbar spine CPPD, 32 were women. The duration of symptoms varied between one day and 8 years. The affection has been discovered during back pain in most cases. In 5 studies, the diagnosis was made on histological specimens of patients operated on for another pathology. X-ray showed calcifications in 2 cases. CT-scan detected calcium deposit in 7 cases. MRI showed lesions going from the increased signal of the disk, to calcified or not-cystic lesion of the facet joints, an intramedullary mass mimicking a schwannoma. Histological examination established the diagnosis of CPPD in 21 patients in all studies. Medical treatment included NSAIDs, Colchicine, Interleukin-1-receptor-antagonist, and antibiotics. Surgery was performed on 13 patients and allowed to establish the histological diagnosis.

Conclusion

In the case of inflammatory back pain in elderly subjects, without an infectious gateway, diagnosis of CPPD should be considered, especially for patients with a history of spinal surgery or degenerative radiography changes. CT scan is more sensitive than conventional radiographs. The discovertebral biopsy is the Gold-Standard and should be performed whenever the diagnosis was uncertain. Treatment includes the medical and surgical components.

Neuropathic arthropathy of the shoulder as a presenting feature of Chiari malformation with syringomyelia: a case report with a systematic literature review

BACKGROUND

Neuropathic arthropathy (NA) of the shoulder is a chronic progressive process characterized by joint destruction in the presence of a neurosensory deficit. Syringomyelia, a spinal cord disease, is the leading cause of NA in the upper extremity.

OBJECTIVE

We present a systematic review of NA with syringomyelia cases alongside a case report of an adult with NA of the shoulder that occurs a few 4 years after a revelation and surgical management of a Chiari malformation with syringomyelia.

METHODS

A systematic review was conducted following PRISMA guidelines. A PubMed, Scopus, Isiknowledge, and manual search through references of relevant publications were used to identify all published case reports of NA. Data were collected from each case report on patient characteristics.

RESULTS

The systematic review identified 56 publications and 85 patients (including ours): nearly the same number of males (n = 41) and females (n = 44). The mean age was 50,69. Presentations included reduction of mobility (n = 66), swelling (n = 61) and sensory disorder (n = 63). The pain was absent in 41 cases. In the majority of reported cases 56 (65.1%), syringomyelia was revealed by neuropathic arthropathy, and eleven patients (12.9%) had a history of syringomyelia. Treatment was categorized into non-operative management (37[43.5%]), operative management (27[31.7%]). Following-up was non-reported in 31 (36%) cases. Improvement was reported more with patients who underwent a surgical approach than medical one 28.5% versus 8.1%.

CONCLUSION

Physicians need to be more aware of this destructive joint disease, rare, and often misdiagnosed. Also, it is imperative to integrate clinical, pathological, and imaging findings for accurate diagnosis and for delivering appropriate therapy.

Eumycotic mycetoma involving the right foot: A new Tunisian case

A Tunisian patient with painless swelling and discharging sinuses of the right foot was diagnosed with Eumycetoma after 1 year of evolution. Mycetoma is a neglected disease relatively rare in our country. An early and accurate diagnosis, based on histopathological and microbiological examinations, limits functional and esthetical damage.

Endothelial dysfunction and increased carotid intima-media thickness in patients with spondyloarthritis without traditional cardiovascular risk factors

Background

The aim of our study was to assess subclinical atherosclerosis in spondyloarthritis (SpA) by combining three ultrasound methods (flow-mediated dilation (FMD), carotid intima–media thickness (cIMT) and Ankle Brachial Index (ABI)) and to determine the predictive factors of theses parameters.

Methods

This was a case control study conducted over 12 months including 47 patients with SpA-free-cardiovascular (CV) disease in comparison with age and sex matched 47 healthy controls. Sociodemographic, clinical and biological features as well as therapeutic modalities were recorded in our patients. All subjects had Doppler ultrasound with measurement of cIMT, FMD and ABI. Ultrasound measurements were compared between patients and controls. Linear regression was performed and assessed by machine learning to determine the predictive models of markers of subclinical atherosclerosis.

Results

We found higher cIMT (p<0.0001), lower FMD (p=0.008) and higher left ABI (0.048) in patients with SpA compared with controls. cIMT was positively correlated to patient-related parameters (age, systolic blood pressure) and disease parameters (age at onset of SpA, disease duration and renal involvement). Biologically, cIMT was positively correlated with creatinine, blood-glocose, total cholesterol (CT) and CT/cholesterol-high density lipoprotein ratio. FMD was negatively correlated with male gender, age, systolic blood pressure, creatinine, blood glucose and Left Lequesne Index. ABI was significantly associated with diastolic blood pressure. Multiple regression analysis identified age, CT and creatinine as independents predictive factors for increased cIMT. Regarding endothelial dysfunction, blood glucose and Left Lequesne Index were the independents predictive factors of decreased FMD.

Conclusion

Our study supported the accelerated subclinical atherosclerosis in patients with SpA. This subclinical atherosclerosis was mainly mediated by traditional CV risk factors.

Increased epicardial adipose tissue thickness correlates with endothelial dysfunction in spondyloarthritis

INTRODUCTION

We aimed to investigate the relationship between epicardial adipose tissue (EAT) thickness, flow-mediated dilation (FMD), and carotid intima-media thickness (cIMT) in spondyloarthritis (SpA) patients compared to healthy controls.

METHODS

We performed a cross-sectional study including SpA patients aged ≤ 50 years without traditional cardiovascular risk factors and healthy controls matched for age and gender. Baseline characteristics, laboratory data, and SpA-related parameters were recorded. All participants underwent ultrasound examination with measurement of EAT thickness, FMD, and cIMT by both an experienced cardiologist and radiologist blinded to clinical data. The relationships between the ultrasound measurements were analyzed using Spearman's correlation coefficient and Person correlation.

RESULTS

The study included 94 subjects (47 SpA and 47 healthy controls). The sex-ratio was 2.35; the median age of patients was 36 years (IQR: 28-46), and the median disease duration was 11 years (IQR: 5-16). Compared to the control group, SpA patients had significantly higher values of EAT thickness (p = 0.001) and cIMT (p < 0.0001). FMD values were significantly lower in SpA patients compared to controls (p = 0.008). The univariate analysis detected a significant negative association between EAT thickness and FMD (p = 0.026; r =  - 0.325), and between left cIMT and FMD (p = 0.027; r =  - 0.322). No association was found between EAT thickness and cIMT.

CONCLUSION

EAT thickness, FMD, and cIMT were significantly impaired in SpA patients compared with healthy controls supporting evidence of accelerated atherosclerosis in SpA. EAT thickness was correlated to endothelial dysfunction suggesting the role of EAT in predicting the early reversible stages of atherosclerosis. Key Points • Spondyloarthritis is associated with impaired subclinical atherosclerosis markers accurately increased epicardial fat and carotid intima-media thickness and endothelial dysfunction. • Increased epicardial fat thickness is correlated with impaired endothelial function in spondyloarthritis patients.

Influence of Vitamin D Status on Fatigue in Ankylosing Spondylitis

Fatigue is a common symptom in ankylosing spondylitis. Hypovitaminosis D is one of the factors influencing fatigue during inflammatory rheumatisms. This study aimed to determine the influence of vitamin D deficiency on fatigue in ankylosing spondylitis. In this cross-sectional study, 40 patients with ankylosing spondylitis and 40 patients suffering from low back pain were recruited. Clinical and laboratory data, including vitamin D dosage, disease activity, functional impairment, and quality of life, were evaluated using specific and validated scores. Fatigue was assessed by the FACIT-F score. Both groups of patients were compound of 27 men and 13 women with a mean of 43.55±12.26 years in the study group and 47.77±13.63 years in the case group, respectively. Ankylosing spondylitis was active according to the ASDASCRP score in 67.5% of cases. All patients were suffering from fatigue with a mean FACIT-F score of 21.13. Severe levels of fatigue were noted in 50% of cases. 92.5% of patients were vitamin D deficient with a mean vitamin D of 16.57±7.15 ng/mL. Factors associated with fatigue were: female gender (P=0.05), spinal pain (P<0.001), enthesitis (P<0.001), disease activity (P<0.001), functional impairment (P<0.001), and quality of life (P<0.001). However, smoking was the only factor related to vitamin D deficiency (P=0.05). Vitamin D level was not correlated with fatigue (r= -0.02, P=0.91). In our study, vitamin D status did not seem to have an impact on fatigue in patients with ankylosing spondylitis.

AB0351 IMPACT OF FCGR2A, FCGR3A AND FCGR3B POLYMORPHISM ON RITUXIMAB EFFICACY IN RHEUMATOID ARTHRITIS

Background

Identifying reliable biomarkers of response to biologics in rheumatoid arthritis (RA) is necessary to improve responsiveness, preserve functions and structure of joints, as well as to reduce treatment’s cost. Single nucleotide polymorphisms (SNP’s) of Fc-gamma receptors genes (FCGRs), by inducing a variation of receptors’ affinity to Fc fragment of Gamma immunoglobulin, might influence the efficacy of therapeutic monoclonal antibodies by modifying their clearance.

Objectives

The aim of this study was to investigate whether FCGR2A, FCGR3A and FCGR3B SNP’s were predictive factors of response to rituximab (RTX) in Tunisian RA patients.

Methods

A cross-sectional, observational and analytic multicentric cohort study was conducted in a group of patients suffering from RA treated with RTX. Treatment outcome was evaluated after 6 months, using DAS28 variation from baseline and EULAR response criteria. R131H-FCGR2A, F158V-FCGR3A and NA1/NA2-FCGR3B SNPs were studied using PCR-SSP and direct sequencing process.

Results

Thirty-four patients were enrolled with a sexe ratio M/F=5/29. The mean age at inclusion was 54,24±11,78 years [29-77]. All patients received at least one cs-DMARDS priorly to the prescription of RTX. Concomitant treatment with methotrexate was pursued in 77,3% of patients. As shown in Table 1, an association, that tend to signification, was found between R/R FCGR2A receptors and a greater variation in DAS28 score (p=0,053). This association was also found using EULAR criteria, since all patients with R/R genotypes had a good or moderate response to RTX but was not significative (p=0,131).

Table 1.

Correlation of FCGR SNPs with response to rituximab at 6 months of treatment

Genetic studyΔDAS28CRPpΔDAS28ESRpEULAR (R-) (n=7)EULAR (R+) (n=27)PFCGR2A R131H*0,1380,7610,301GenotypesRR2,53±1,560,0531,83±0,750,4800(0)7 (100)0,131HH2,05±2,510,8682,29±1,640,6831 (33,3)2 (66,7)0,576RH1,09±1,360,062,00±1,730,8556 (25)18(75)0,324AllelesR1,45±1,520,8681,96±1,490,6836 (0,194)25(0,806)0,576H1,17±1,430,0532,1±1,600,4807 (0,259)20(0,741)0,131FCGR3A F158V*0,4280,8730,370GenotypesFF1,35±1,570,8601,91±1,860,7052 (16,7)10(83,3)0,676VV0,95±0,980,2882,85±0,320,6371 (10)9(90)0,324FV2,06±1,830,2371,84±1,5114 (33,3)8(66,7)0,175AllelesF1,72±1,700,2881,87±1,560,6376 (0,25)18(0,75)0,324V1,56±1,570,8602,13±1,330,7055(0,227)17(0,773)0,676FCGR3B NA1/NA2*0,2170,4850,645GenotypesNA1NA12,29±1,810,092,13±1,080,7152(22,2)7 (78,8)0,888NA2NA20,79±1,300,3290,60,3432 (33,3)4 (66,7)0,395NA1NA21,23±1,360,3912,28±2,070,3453 (15,8)16(84,2)0,436AllelesNA21,15±1,330,091,95±1,950,7155 (0,20)20(0,80)0,888NA11,60±1,580,3292,19±1,450,3435 (0,179)23(0,821)0,395

DAS: disease activity score,ΔDAS: mean variation of DAS at 6 months, *:Comparison of the global distribution of the 3 genotypes,**: p while comparing the prevalence of R/R genotype to R/H and H/H genotypes,R+: good or moderate EULAR response,R-: bad EULAR response

Conclusion

The low affinity receptor R/R FcgRIIa might be predictive of good response in RA patients treated with RTX. More studies need to be conducted in larger cohorts to confirm this association, with the aim of identifying reliable biomarkers of response to biologics to improve responsiveness, preserve joints functions and structure, as well as reduce treatment’s cost.

Disclosure of Interests

None declared

AB0958 The relationship between the extensor tendon enthesis and the nail in distal interphalangeal joint disease in psoriatic arthritis: ultrasound study

Background

It has been shown that there is an anatomical link between the distal interphalangeal joint (DIP) extensor tendon enthesitis and the nail changes in psoriatic arthritis (PsA) [1].

Objectives

To evaluate the relationship between nail involvement and enthesopathy at DIP level in PsA patients using ultrasonography (US).

Methods

We included patients with PsA. According to OMERACT, the following elemental lesions were dichotomously (presence/absence) evaluated on greyscale US assessment at extensor tendon insertion at distal phalanx of DIP joints: abnormally hypoechoic, enthesophytes, and erosions. We also measured the tendon thickness. Increased abnormal vascularization at entheseal level was also assessed using PD technique. We also performed an US assessment of the finger nails that included the study of morphological changes and measurement of the thickness of nail bed (NBT), nail plate (NPT) and adjacent skin (ST).

Results

We included 33 PsA patients (323 DIP). Eleven patients (34 %) presented psoriatic onychopathy (45 fingernails) with a mean NAPSI 7 (IQR (25,75)) [2 -18]. US study of the nails revealed dystrophy in 75 nails (23%).

At patient level, the mean NPT, NBT and SK were 1.90±0.22, 0.38±0.09, and 2.33±0.62, respectively.

None of the patients had clinical involvement of DIP.

Using US, we examined 325 extensor tendon. The mean thickness of the tendon was 0.63mm ±0.1 mm. The tendon was abnormally hypoechoic in two fingers (0.61%).

Erosions were present in 16 DIP (4.9%).

We found enthesophytes in 82 DIP joints at insertion of extensor digitorum tendon (25.23%).

We did not observe increased abnormal vascularization at entheseal level.

At finger level, the extensor tendon thickness was higher in the presence of US nail dystrophy (0.70 mm vs 0.60, p=0.01). Erosions were more common in fingers with US nail involvement (14.6 % vs 1.9%, p=0.00).

Osteophytes were present in 20% of fingers with US nail involvement and 26.3% of fingers without US nail involvement (p=0.166).

The thickness of DIP digital extensor tendons was correlated with the NBT(r = 0.412, p = 0.00), the NPT (r = 0.310, p = 0.00), and the thickness of the adjacent skin (r = 0.509, p = 0.00).

Conclusion

The presence of US nail dystrophy was associated with thicker extensor tendon and more erosions. The thickness of the tendon was correlated with the thickness of the nail parts.

This might be explained by the close relationship between nail and enthesis and supports the theory of the enthesis as an extended organ beyond the tendon bony attachment.

References

[1]Tan, A. L .et al (2006). Rheumatology, 46(2), 253–256.

Disclosure of Interests

None declared

AB0956 To what extend is nail ultrasound discriminative between psoriatic arthritis and healthy subjects?

Background

Clinical physical examination can detect superficial nail changes in psoriatic patients. However, the nail matrix and bed are not accessible for clinical assessment. Recently, ultrasonography (US) has emerged as a useful tool to assess nail involvement in psoriatic arthritis (PsA) patients.

Objectives

To assess the discriminative utility of nail features detected by B-mode (BM) and color Doppler (CD) ultrasound (US) between patients with psoriatic arthritis (PsA) and healthy controls (HC).

Methods

This was a cross-sectional study including PsA patients and HC.

All patients and controls underwent an US assessment of the fingernails that included the study of morphological changes based on Wortsman’s description [1]: focal hyperechoic involvement of the ventral plate without involvement of the dorsal plate (type I), loosening of the borders of the ventral plate (type II), appearance of wavy plates (type III) and loss of definition on both plates (type IV), blood flow disturbances and measurement of the thickness of nail bed (NBT), nail plate (TNP) and adjacent skin.

Results

A total of 536 nails were examined (PsA:326 nails, HC:210). Patients with PsA had significantly more morphological changes of the nails than healthy controls (23% vs 3.33%, p = 0.006).

In PsA patients, the most frequently observed aspect was type III (47 nails, 14.4%), followed by type II (40 nails,12.3%) and type IV (38 nails, 11.6%). In HC, the only observed type was type (type II). US detected subclinical nail involvement in 37 healthy nails among PsA patients (11.34%). On the other hand, seven nails with clinical involvement did not demonstrate US changes: perionyxis (n=1), pitting (n=2), onycholyses (n=3), hemorrhage (n=1).

The power Doppler signal of the nail bed and matrix was comparable between the groups (54% vs 61%, p= 0.603 and 41% vs 37.1%, p=0.432, respectively).

NBT and skin thickness were higher in the HC group than the PsA group (1.90±0.22 mm vs 2.07±0.34 mm, p=0.047 and 2.25±0.69 vs 2.59±0.31 mm, p=0.002, respectively). While NPT was similar between the groups (0.38±0.09 vs 0.36±0.07mm, p=0.239).

Conclusion

Us detected morphological changes in clinically healthy fingernails in both PsA patients and healthy controls. However subclinical involvement was more common in PsA patients.

Loosening of the borders of the ventral plate (type II) was the only aspect observed in HC. This would suggest that this type is not a specific feature of psoriatic nail.

With regards to nail plate thickness, the measurements were similar between PsA patients and HC as previously reported by Mondal et al [2].

However, unlike previous studies, we showed that the nail bed and skin thickness were significantly higher in healthy controls than PsA patients [3].

References

[1]Wortsman X, Jemec GB. Ultrasound imaging of nails. Dermatol Clin. 2006;24(3):323‑8.

[2]Mondal S et al. Rheumatol Int. 2018;38(11):2087‑93

[3]Idolazzi L, et al. Clin Rheumatol .2019;38(3):913‑20

Disclosure of Interests

None declared

AB0960 Ultrasonographic assessment of distal interphalangeal joints in psoriatic arthritis

Background

Distal interphalangeal (DIP) joint involvement is frequent in Psoriatic arthritis (PsA). Ultraousnd (US) may help identify subclinal DIP arthritis.

Objectives

We aimed to assess by US the DIP joint involvement in PsA in comparison with healthy controls (HC).

Methods

This was a cross-sectional study including 33 PsA patients and 21 matched-healthy controls (HC).

An US scan of all DIP joints was performed in order to look for erosions, synovitis (B-mode and doppler) and extensor tendon enthesopathy.

Results

We included 33 patients with PsA and 21 HC.

There was no difference between the two groups regarding the age (51.2 ±12.5 vs 53±11.8 years, p=0.5), sex-ratio (0.65 vs 0.61, p=1), manual activity (p=1) and smoking status (23.8% vs 18%, p=0.433).On clinical examination,we did not find any tender nor swollen DIP joints in both groups. Eleven PsA patients (34 %) had psoriatic onychopathy (45 fingernails) with a mean NAPSI 7 (IQR (25,75)) [2 -18].

In the PsA group, a total of 323 DIP joints were examined by US, synovitis of the DIP joints was detected in ten DIP joints (3.1%)(right hand: seven, left hand:three), six of them had PD (right hand:four, left hand:two). Eosions were found in 16 DIP joints (4.95%) (right hand:seven, left hand: nine). Enthesophytes were seen in 82 DIP joints (25,2%).

At patient level, six PsA patients had at least one US synovitis (18.1%), seven had at least one erosion (21.2%) and 22 had at least one DIP joint with enthesophytes (66.6%)

Compared to HC, PsA patients had more synovitis (3.1% vs 0, p=0.001),more erosions (4.95% vs 0.4%, p=0,03), and more enthesophytes (25.2% vs, 17%, p=0,002)

The was no difference between the two groups regarding the thickness of the extensor tendon (0.63 mm vs 0.61 mm, p=0.594).

In the PsA group, the patients with nail dystrophy had more osteophytes (24% vs 10%, p<0,001), more erosions (14.6% vs 1.96%, p=0.000), and more synovitis (6%, vs 1.9%, p=0.037).

Conclusion

Subclinical involvement of DIP joints is common in PsA patients, notably in the presence of nail dystrophy.

Disclosure of Interests

None declared

AB1544-HPR CLINICAL COMORBIDITY PHENOTYPE IN KNEE OSTEOARTHRITIS IS ASSOCIATED WITH HIGHER INTENSITY SCORES

Background

Knee osteoarthritis (OA) is a common osteoarticular disease. Its prevalence increases with age as well as the coexistence of other chronic diseases. Recent researches have revealed an association between OA and cardiovascular diseases. However, association between knee OA and comorbidities has not been fully studied.

Objectives

The purpose of this study was to investigate the association between knee OA and comorbidities.

Methods

In this cross-sectional study, patients with knee OA were enrolled. Sociodemographic data as well as comorbidities were collected. Grading of knee OA was performed using the Kellgren-Lawrence (KL) grading system. Functional impact of knee OA was assessed by KOOS-Physical Function Shortform (KOOS-PS).

Results

This study assessed 104 patients with knee OA (10 men and 94 women). Mean age was 65.83 ±11.08 years. Mean VAS pain was 6.56 ± 1.72. Mean KOOS-PS was 15.58 ± 6.73. Up to 81 patients (77.9%) had severe knee OA according to the KL grading system. Comorbidity was noted in 92 cases (88%). The most frequent comorbidities were obesity (62.5%), hypertension (61.5%) and dyslipidemia (43.3%). Comorbidities in knee OA were associated with age (p=0.04), neuropathic pain component (p=0.02) and VAS pain (p=0.04). Our study also showed a significant correlation between comorbidities and structural grading of knee OA (p=0.04). However, comorbidities were not correlated with KOOS-PS score (p=0.06).

Conclusion

The accumulation of comorbidities is significantly associated with higher intensity scores in knee OA. Physicians should additionally pay close attention to the prevention and the treatment of comorbidities in the management of OA.

Disclosure of Interests

None declared

WITHDRAWN: Neuropathic Pain in Patients with Knee Osteoarthritis: Relation with Comorbidities and Functional Status

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Isolated Sacral Sarcoidosis a Hidden Cause of Sciatica: Case Report and Brief Review of the Literature

Bone involvement in sarcoidosis is rare; its estimated prevalence ranges between 3 and 13%. Osseous lesions usually occur in the phalanges of the hands and feet. Involvement of the axial skeleton is more uncommon. Osseous involvement may be asymptomatic. It is often incidentally discovered on imaging modalities. Radiological techniques can reveal sclerotic and/or destructive lesions. We present a case of a 61-year-old woman in whom osseous sarcoidosis of the sacrum was revealed by back pain and sciatica. To our knowledge, only one isolated case of sacral sarcoidosis has been reported in the literature. Sarcoid bone lesions can be present at disease onset without pulmonary involvement. A biopsy is often required in order to eliminate other conditions, especially malignancy. Treatment is not specific and also not needed in a significant number of cases.

Clinical Comorbidity Phenotype in Knee Osteoarthritis is Associated With Higher Intensity Scores

Knee osteoarthritis (OA) is a common osteoarticular disease. Its prevalence increases with age, as well as the coexistence of other chronic diseases. Recent research has revealed an association between OA and cardiovascular diseases. However, the association between knee OA and comorbidities has not been fully studied. Therefore, the purpose of this study was to investigate the association between knee OA and comorbidities. In this cross-sectional study, patients with knee OA were enrolled. Sociodemographic data, as well as comorbidities, were collected. Grading of knee OA was performed using the Kellgren-Lawrence (KL) grading system. The functional impact of knee OA was assessed by KOOS-Physical Function Shortform (KOOS-PS). This study assessed 104 patients with knee OA (10 men and 94 women). The mean age was 65.83±11.08 years. Mean VAS pain was 6.56±1.72. Mean KOOS-PS was 15.58±6.73. Up to 81 patients (77.9%) had severe knee OA, according to the KL grading system. Comorbidity was noted in 92 cases (88%). The most frequent comorbidities were obesity (62.5%), hypertension (61.5%), and dyslipidemia (43.3%). Comorbidities in knee OA were associated with age (P=0.04), axial deviation in the sagittal plane (P=0.01), neuropathic pain component (P=0.02), and VAS pain (P=0.04). Our study also showed a significant correlation between comorbidities and structural grading of knee OA (P=0.04). However, comorbidities were not correlated with the KOOS-PS score (P=0.06). The accumulation of comorbidities is significantly associated with higher intensity scores in knee OA. Physicians should additionally pay close attention to the prevention and treatment of comorbidities in the routine management of OA.

Complications of Paget Bone Disease: A Study of 69 Patients

INTRODUCTION

Paget bone disease (PBD) is characterized by a disorder in the bone remodeling activity at sites of involvement. This can produce dramatic alterations of local bone architecture and causes most of the complications. We aimed to focus on the characteristics of complications of PDB among hospitalized patients.

MATERIAL AND METHODS

A retrospective study was conducted, on PBD patients hospitalized in two rheumatology centers from 1994 to 2019. Characteristics of the PBD complications were studied.

RESULTS

Sixty-nine patients were collected with a sex ratio of 0.76 and a mean age of 75.4±6.4 years [43-101]. The diagnosis of PBD was established in the average age of 64.2±11.5 years. The primary reason for consultation was pain (78.3%). The PBD was localized in the pelvis (58%), lower limb (42%), spine (36.2%), skull (23.2%) and upper limb (5.8%). It was polyostotic in 44.9% of cases. Dosage of ALP was 324 [68-8390]. The PDB complication rate was 52.2% and it decreased over time. The main complication was osteoarthritis (23.2%), followed by deafness (17.4%), fracture (15.9%), hydrocephalus (7.2%), neurological disease (7.2%) and osteosarcoma (1.4%). The presence of complications was significantly associated with the polyostotic form (p=0.01), the skull localization (p=0.04), an increased ALP (p=0.02).

CONCLUSION

According to our study, the incidence rate of PBD among hospitalized cases is higher among elderly women and decreases over time. Complications related to PDB are frequent (52%). It concerns patients with a polyostotic form, skull localization and high ALP.

Immunogenicity of antitumor necrosis factor therapy in patients with spondyloarthritis

Objectives To evaluate the serum dosage of the biomedicine (DBM) and the incidence of antidrug antibody (ADA) against antitumor necrosis factor (TNF) in spondyloarthritis, and to demonstrate the influence of these parameters on the clinical efficiency. Methods We conducted a cross-sectional multicentric study including patients with spondylarthritis (SpA) under antiTNF (infliximab [INF], etanercept [ETA] and adalimumab [ADL]) for at least 6 months. A dosage of the ADA and DBM were practiced by the immuno-enzymatic essay. Result Seventy one patients were recruited. Disease modifying antirheumatic drugs (DMARDs) were associated with anti-TNF in 30%. ADA was positive in 54% for INF, 33% for ADL and 0% for ETA with a significant difference(p<0.0001). Immunogenicity was correlated to a bad therapeutic response (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]≥4)(p=0.04). The DBM was inversely correlated with the rate of ADA for patients treated with INF(p<0.0001) and ADL(p<0.0001). The DBM was also inversely correlated with BASDAI of INF(p=0.03) and ADL (p=0.01). ADA was significantly associated with an anterior switch of anti TNF(p=0.04), the use of INF(p=0.002), presence of coxitis(p=0.01) and higher body mass index (BMI)(p=0.007). DMARDs associated with anti TNF were not a protective factor for positive ADA. In a multivariate study, only INF and BMI were independent factors of positive ADA. Conclusion The ADA formation lowered the DBM and favored the therapeutic failure.

Sexual dysfunction and its determinants in women with rheumatoid arthritis

OBJECTIVES

To evaluate sexual function in Tunisian women with rheumatoid arthritis (RA) and to examine factors that are predictors of female sexual dysfunction including sociocultural factors, disease activity, and psychological status.

METHODS

We conducted a cross-sectional study including 71 women with a confirmed diagnosis of RA according to the 2010 American College of Rheumatology/European League against Rheumatism (ACR/EULAR) criteria. Clinical and sociodemographic characteristics were collected. The participants were asked to complete the Female Sexual Function Index (FSFI), which contains 19 questions, assessing six areas of female sexual function in the previous 4 weeks. Sexual dysfunction was defined as an FSFI score less than or equal to 26.55. The psychosocial status was evaluated by the Hospital Anxiety and Depression (HAD) scale. Prevalence of sexual dysfunction and predictors of sexual difficulties were assessed.

RESULTS

The prevalence of female sexual dysfunction in women with RA was 49.3%. All areas were altered especially desire (2.92 ± 1.3), arousal (3.27 ± 1.5), and orgasm (3.77 ± 1.5). In univariate analysis, sexual dysfunction was correlated with the age of patients (p = 0.049), the age of partners (p = 0.013), pain (p = 0.001), number of night awakenings (p = 0.02), morning stiffness (p = 0.010), tender joints (p = 0.05), disease activity score (DAS28 ESR) (p = 0.043), fatigue (p = 0.028), and Health assessment questionnaire (HAQ) (p = 0.02). In multivariate analysis, the age of patients and pain were predictive factors of sexual dysfunction. By analyzing each area of the FSFI score, the age of patients was the independent variable associated with desire. Tender joints were associated with lubrication and the age of partners with arousal, orgasm, and satisfaction.

CONCLUSION

Our study suggests that rheumatoid arthritis has a negative impact on patients' sexuality. Age of patients and partners, pain, and tender joints appear to be the main factors influencing sexual function.

Efficacy of local injection therapy for heel pain in rheumatic inflammatory diseases: A systematic review

Heel pain or achillodynia is one of the most common manifestations in patients with rheumatic inflammatory diseases (RID) and particularly spondyloarthritis (SpA). It can be associated with inflammation at the bone insertion of tendon, ligament, bursa or fascia. However, treatment is still a challenge for rheumatologists. Several findings highlighted the proven benefit of nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and recently, tumor necrosis factor (TNF)-α inhibitors. However, only limited data about the efficacy of local therapy such as glucocorticoid and anti-TNF injections are available. The aim of this systematic review was to assess the efficacy and safety of local therapies in heel pain and to make recommendations for further studies. Five studies discussing the effectiveness of local treatments of heel pain in RID were included. All studies recognized that the ultrasonography (US)-guided local corticosteroid or etanercept injections were effective and safe modalities for the treatment of inflammatory heel enthesitis, tendinitis, and retrocalcaneal bursitis (RCB) in patients with RID. Pain relief at the local site was associated with a reversion of the acute inflammatory changes in the heel. Furthermore, US-guided injection in RCB with a lateral approach was beneficial in terms of preventing side effects.

Paget's Disease of Bone in Tunisia: A Study of 69 Patients

CONTEXT

Paget's disease of bone is a common bone disease with a striking variation in its incidence and characteristics in different parts of the world. It is uncommonly reported in African patients.

AIMS

Given the lack of studies describing the characteristics of patients with Paget's disease of bone in North Africa, we aimed to describe demographic, clinical, biochemical, and imaging characteristics, as well as treatment outcomes of Tunisian patients with Paget's disease of bone.

SUBJECTS AND METHODS

This bicentric and retrospective study included patients with Paget's disease of bone. Clinical, laboratory, radiological profile, and response to treatment were analyzed.

RESULTS

Sixty-nine patients were identified. The mean age was 64.9 ± 11.6 years and 52.2% were women. One patient reported a positive family history. Seven patients were asymptomatic. Bone pain was the most common presenting symptom. Eight patients had a history of malignancy. In three patients, Paget's disease of bone was diagnosed as part of a metastatic workup. Monostotic disease was found in half of the cases. The most commonly involved sites were pelvis (43.5%), femur (21.7%), and spine (21.7%). The mean serum alkaline phosphatase level at presentation was 591 U/L (68-8380). Two patients received salmon calcitonin (2.8%) and 47 patients (68.1%) received bisphosphonates. After a mean follow-up of 55 months (2-240 months), bone pain improved in 43.1% of patients and the serum alkaline phosphate levels had normalized in 22 of them (43.1%). During follow-up, there was no malignant transformation.

CONCLUSIONS

In this series of Tunisian patients, Paget's disease of bone had a female predominance and was usually monostotic. The clinical and radiological presentations were similar to the European series.

AB0261 IMPACT OF COMORBIDITIES IN THE DISEASE ACTIVITY OF PATIENTS WITH SPONDYLOARTHRITIS AND RHEUMATOID ARTHRITIS: TUNISIAN REGISTRY (BINAR)

Background:

Comorbidities can be associated with rheumatoid arthritis (RA) and spondyloarthritis (SpA). This association can be fortuitous but can also be secondary to rheumatism itself or to the effects of the treatments used. These comorbidities can worsen the disease and even increase patient mortality.

Objectives:

To assess the prevalence of comorbidities in RA or SpA patients from the Tunisian BIologics National Registry (BINAR) and to focus on their influence on the disease activity.

Methods:

BINAR is a multicenter non-interventional and prospective study, conducted in Tunisia with 80 rheumatologists over a period of three years. It included patients with RA (ACR / EULAR 2010 criteria) or SpA (ASAS 2009 criteria). Data were collected and analyzed through an electronic platform managed by DACIMA. They included demographic data, smoking status and types of comorbidities (cardiovascular disease, diabetes, dyslipidemia, osteoporosis, high blood pressure (HBP), neoplasia, gastrointestinal ulcer, depression and fibromyalgia). RA activity was evaluated by the DAS28-VS score and SpA activity by the BASDAI and ASDAS-CRP scores.

Results:

We included 298 patients (175 PR and 123 SpA) making the mean sex ratio 0.6 and mean age 49.18 years ± 14.1 [18-79]. Mean BMI was 27.0 ± 5.5 kg / m2[15 -45] and 17.7% of the patients were current smokers. Concerning disease activity, mean DAS28-VS in RA was at 4.9 ± 1.5 [1.1 - 8.1 and mean BASDAI and ASDAS-CRP, in SpA, were respectively 4.1 ± 1.8 and 2.8 ± 1.1. Comorbidities were noted in 54% of patients (62.1% in SpA and 37.9% in RA), with an average of 1.7 comorbidities per patient.

The most common comorbidities were osteoporosis (38.8%), cardiovascular disease (20.1%), diabetes (16.8%), HBP (18.1%), dyslipidemia (6.7%) and GIU (6.0%). Depression, fibromyalgia and neoplasia were mentioned in 1.7%, 1% and 1%, respectively.

No correlation was found between the number of comorbidities and the activity level of RA: DAS28-VS (p=0.12), nor the activity level of SpA: BASDAI(p=0.07), ASDAS-CRP(p=0.15). Correlations were studied between each comorbidity and activity disease parameters of RA and SpA, they are specified in Table 1. We found that only the presence of osteoporosis was associated with SpA activity, (ASDAS-CRP; p = 0.02).

Tableau n°1:

Relation between comorbidities and the disease activity parameters of rheumatoid arthritis and Spondyloarthritis

DAS 28 ESRBASDAIASDAS CRPDiabetesp = 0.737p = 0.633p = 0.652High Blood pressurep = 0.252p = 0.998p = 0.323Obesityp = 0.565p = 0.585p = 0.904Dyslipidemiap = 0.332p = 0.349p = 0.997Osteoporosisp = 0.372p = 0.989p = 0.020Gastrointestinal ulcerp = 0.829p = 0.286p = 0.910

DAS: disease activity score; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; ASDAS: Ankylosing Spondylitis Disease Activity Score

Conclusion:

According to this study, in patients with RA and SpA associated comorbidities may occur more frequently than expected (54%). However, they had no relation to the activity of the disease according to their frequencies or their types, except osteoporosis which was significantly associated with the SpA activity. Identifying these comorbidities may affect the management and treatment decisions for these patients to ensure an optimal clinical outcome.

Acknowledgments:

none

Disclosure of Interests:

None declared

AB0879 DOES BODY WEIGHT INFLUENCE THE KNEE INJURY AND OSTEOARTHRITIS OUTCOME SCORE IN PERSONS WITH SYMPTOMATIC KNEE OSTEOARTHRITIS?

Background:

Overweight is a major risk factor for the development and progression of knee osteoarthritis (OA). Weight loss for patients with knee OA has been associated with improvement in self-reported pain and function and is recommended by EULAR as part of the therapeutic management.

Objectives:

The aim of the study was to evaluate the relation between overweight and functional impairment in adults with knee OA.

Methods:

It was a prospective study conducted in a rheumatologic department over a 4 months period. Patients with symptomatic knee OA based on the ACR criteria, were included. A screening of body mass index (BMI) was carried out for all patients. It was categorized following the WHO classification into: normal (<25 kg/m2), overweight (25 to <30), obese (up to 30).

Pain level was evaluated using the Visual Analogue Scale (VAS). Function was assessed by the short form of the Knee injury and Osteoarthritis Outcome Score (KOOS-PS) (KOOS-PS scores to 0 representing no difficulty and 100 representing extreme difficulty). The patients’ knee radiographies were graded according to Kellgren Lawrence criteria (KL). The patients were allocated in two groups; as grade I-II KL (Group 1) and grade III-IV KL (Group 2).

Results:

We included 143 patients with a mean age of 65.17± 10.7 years and 88.1% of women. Patients were from low socio-economic class in 30.8% of cases. Mean disease duration of the KOA was 5.4 years [3months-20 years] and mean BMI was 31.8±5.6kg/m2. Patients were with normal weight in 16.1%, overweight in 19.6% and obese in 64.3%.

Knee OA was bilateral in 85.3% and other OA sites were associated in 37.8% of patients. Mean VAS pain of knee OA was 6.6±1.5 and KOOS-PS was 48.8±16.5/100. Concerning the radiographic damage; we found grade I-II (KL) in 22.6% and grade III-IV (KL) in 77.4%.

High BMI (BMI≥25 kg/m2was not significantly associated with worse KOOS score (p=0.9), more pain (p=0.5) or an increasing severity of radiological knee osteoarthritis (p=0.14). Moreover, the level BMI was not associated with the presence of other OA sites (p=0.9) or a bilateral KOA (p=0.07).

Conclusion:

These data, from a subset of participants with symptomatic radiographic knee OA, demonstrate no correlation between obesity and pain, functional impairment and radiographic severity.

Acknowledgments:

none

Disclosure of Interests:

None declared

AB0880 NEUROPATHIC PAIN IN PATIENTS WITH KNEE OSTEOARTHRITIS: PREVALENCE AND RELATED FACTORS

Background:

Discordance between radiographic and pain severity in osteoarthritis (OA) has led researchers to investigate other pain mechanisms, including neuropathic pain (NP). Recent meta-analysis concluded that NP prevalence in people with knee or hip OA was 23% [1].

Objectives:

The primary objective of this study was to determine the prevalence of NP in patients with painful knee OA. Secondarily, we evaluated the relationship between NP and pain intensity, function and radiographic severity of knee OA.

Methods:

This cross-sectional study enrolled patients with knee OA (ACR criteria) from a rheumatology outpatient Hospital over a four-month period. Exclusion criteria were: knee surgery, chronic conditions of the nervous system, cognitive or psychiatric disorders. The patient’s characteristics and pain severity using the Visual Analogue Scale (VAS) were evaluated. The NP was assessed according to the Douleur Neuropathique 4 questionnaire (DN4) (arabic valid version). Functional impairment was estimated using the short form of the Knee injury and Osteoarthritis Outcome Score (KOOS-PS) (KOOS-PS scores to 0 representing no difficulty and 100 representing extreme difficulty). Radiographs were rated using the Kellgren Lawrence (KL) grade classification (I-IV). Statistical analysis was performed to find the factors closely related with NP.

Results:

Ninety three patients with knee OA were included in the study. The mean age was 65.03±18.5 years with a sex ratio of 0.08. Mean duration of symptoms was 3.5 years [3months-20 years]. Concerning the marital status: 53.8% were married, 34.4% were widow and 10.8% were divorced. The majority of patients were illiterate (65.6%) and only 2.2% went to university. Patients were from low socio-economic class in 37.6% of cases. At least one comorbidity was revealed for 90.3% of patients and their mean BMI was 31.6±6.3 [19.9-52.3]. Concerning the clinical features of the KOA, mean VAS pain was 6.6±1.6 and KOOS-PS was 45.6±18.5. Of the subjects, 22.6% have radiographic at grade II, 57% at grade III and 20.4% at grade IV based on KL grading.

The mean (SD) score by the study participants on the DN4 was 4.9± 2.4. The prevalence of NP (DN4≥4) was 71%.

A DN4 score≥4 was significantly associated with the VAS pain (p=0.00) and the KOOS-PS (p=0.00) and the presence of comorbidity (p=0.04). However, there was no significant relation between DN4 score and, age, sex, marital status, socio economic class, level of education, BMI and KL grade (p=0.7, p=0.08, p=0.7,p=0.3, p=0.7, p=0.7, p=0.6).

Conclusion:

Our results highlight the high frequency of NP in patients with knee OA according to the DN4. Knee OA patients with NP encounter clinically relevant functional limitation. Thus, it is important to be aware of this neuropathic component to ensure appropriate management in the treatment of knee OA pain.

References:

[1]French HP, Smart KM, Doyle F. Prevalence of neuropathic pain in knee or hip osteoarthritis: A systematic review and meta-analysis. Semin Arthritis Rheum. 2017;47(1):1-8.

Acknowledgments:

none

Disclosure of Interests:

None declared

AB0319 DRUG SURVIVAL OF BIOLOGICS IN RHEUMATOID ARTHRITIS: PRELIMINARY DATA FROM THE TUNISIAN BINAR REGISTRY

Background:

The arrival of Biotherapy has changed the management and prognosis of rheumatoid arthritis (RA). However, drug survival of the first biotherapy is changing according to the studies.

Objectives:

We aimed to report the data on the drug survival of biotherapies in RA, collected from the Tunisian BIologics National Registry (BINAR)

Methods:

BINAR is a multicenter non-interventional and prospective study, conducted in Tunisia with 80 rheumatologists over a period of three years. It included patients with RA (ACR / EULAR 2010 criteria) and refractory to conventional background treatments (csDMARDs), who required the use of biological treatment of anti TNF, anti IL6 or Rituximab type. Data were collected and analyzed through an electronic platform managed by DACIMA. Sociodemographic data (age, gender, body mass index (BMI), smoking) and characteristics of RA (duration of evolution, erosive character) were collected. RA activity was studied by the DAS28-VS score and drug survival was evaluated by the duration of the biologics.

Results:

We included 175 patients with a sex ratio of 5.7 and a mean age of 54.1 ± 12.6 years [19-79]. Patients were smoking in 6.7% of cases and mean BMI was 27.9 ± 5.2 kg/m2[15.1-45.2]. RA was erosive in 73.1% of cases and the mean disease duration was 6.7±3.5 years. Disease activity was moderate (mean DAS28vs: 4.9±1.5). Concerning the treatments, 139 (79.4%) of the patients received TNFα inhibitor, 31 (17.7%) of the patients were on IL6 inhibitor and 15 (8.6%) were on Rituximab.

The mean duration of drug survival for TNFα inhibitor agents was 15.2 months, 18 months for anti IL6 and 16.3 months for Rituximab. The drug was discontinued by 19 patients (10.8%). The causes of discontinuation were primary failure in 31.8% (7 subjects), secondary escape in 9.1% (4 subjects), the occurrence of adverse effects in 31.8% (7 subjects), intolerance to drug in 9.1% (2 subjects), non-compliance for one patient and for other reasons in one case.

The drug survival of TNF inhibitor was not associated with socio-demographic data (gender (p=0.9), age (p=0.4), smoking (p=0.9), BMI (p=0.9)), nor with the characteristics of the disease duration (p = 0.5), DAS28 vs (p = 0.9), association with a csDMARDs (p = 0.2)) except the presence of erosion (p = 0.013).

Also, drug survival of IL6 inhibitor drugs was not associated with socio-demographic parameters (gender (p = 0.1), age (p= 0.6), smoking (p= 0.6), BMI (p = 0.4)) and the characteristics of the disease (duration (p = 0.9), erosive character (p = 0.6), DASvs (p = 0.1), association with a csDMARDs (p = 0.2)).

Similarly, drug survival of Rituximab was not associated with socio-demographic data (gender (p = 0.6), age (p = 0.7), BMI (p = 0.7)) or with the characteristics of RA (duration of evolution (p= 0.5), erosive character (p = 0.6), DASvs (p = 0.08), association with a csDMARDs (p = 0.5))

Conclusion:

Our study demonstrated that IL6 inhibitor had the longest duration of drug survival (18 months). The major causes of cessation were dominated by primary failure and the occurrence of an adverse event. Finally, the drug survival of TNF inhibitor agents was associated with the erosive character.

Acknowledgments:

none

Disclosure of Interests:

None declared