Identification of patients with gout: elaboration of a questionnaire for epidemiological studies.

OBJECTIVES: In France, the prevalence of gout is currently unknown. We aimed to design a questionnaire to detect gout that would be suitable for use in a telephone survey by non-physicians and assessed its performance. METHODS: We designed a 62-item questionnaire covering comorbidities, clinical features and treatment of gout. In a case-control study, we enrolled patients with a history of arthritis who had undergone arthrocentesis for synovial fluid analysis and crystal detection. Cases were patients with crystal-proven gout and controls were patients who had arthritis and effusion with no monosodium urate crystals in synovial fluid. The questionnaire was administered by phone to cases and controls by non-physicians who were unaware of the patient diagnosis. Logistic regression analysis and classification and regression trees were used to select items discriminating cases and controls. RESULTS: We interviewed 246 patients (102 cases and 142 controls). Two logistic regression models (sensitivity 88.0% and 87.5%; specificity 93.0% and 89.8%, respectively) and one classification and regression tree model (sensitivity 81.4%, specificity 93.7%) revealed 11 informative items that allowed for classifying 90.0%, 88.8% and 88.5% of patients, respectively. CONCLUSIONS: We developed a questionnaire to detect gout containing 11 items that is fast and suitable for use in a telephone survey by non-physicians. The questionnaire demonstrated good properties for discriminating patients with and without gout. It will be administered in a large sample of the general population to estimate the prevalence of gout in France.

Iron excess limits HHIPL-2 gene expression and decreases osteoblastic activity in human MG-63 cells.

UNLABELLED: In order to understand mechanisms involved in osteoporosis observed during iron overload diseases, we analyzed the impact of iron on a human osteoblast-like cell line. Iron exposure decreases osteoblast phenotype. HHIPL-2 is an iron-modulated gene which could contribute to these alterations. Our results suggest osteoblast impairment in iron-related osteoporosis. INTRODUCTION: Iron overload may cause osteoporosis. An iron-related decrease in osteoblast activity has been suggested. METHODS: We investigated the effect of iron exposure on human osteoblast cells (MG-63) by analyzing the impact of ferric ammonium citrate (FAC) and iron citrate (FeCi) on the expression of genes involved in iron metabolism or associated with osteoblast phenotype. A transcriptomic analysis was performed to identify iron-modulated genes. RESULTS: FAC and FeCi exposure modulated cellular iron status with a decrease in TFRC mRNA level and an increase in intracellular ferritin level. FAC increased ROS level and caspase 3 activity. Ferroportin, HFE and TFR2 mRNAs were expressed in MG-63 cells under basal conditions. The level of ferroportin mRNA was increased by iron, whereas HFE mRNA level was decreased. The level of mRNA alpha 1 collagen type I chain, osteocalcin and the transcriptional factor RUNX2 were decreased by iron. Transcriptomic analysis revealed that the mRNA level of HedgeHog Interacting Protein Like-2 (HHIPL-2) gene, encoding an inhibitor of the hedgehog signaling pathway, was decreased in the presence of FAC. Specific inhibition of HHIPL-2 expression decreased osteoblast marker mRNA levels. Purmorphamine, hedgehog pathway activator, increased the mRNA level of GLI1, a target gene for the hedgehog pathway, and decreased osteoblast marker levels. GLI1 mRNA level was increased under iron exposure. CONCLUSION: We showed that in human MG-63 cells, iron exposure impacts iron metabolism and osteoblast gene expression. HHIPL-2 gene expression modulation may contribute to these alterations. Our results support a role of osteoblast impairment in iron-related osteoporosis.

Bone status in a mouse model of genetic hemochromatosis.

UNLABELLED: Genetic hemochromatosis is a cause of osteoporosis; mechanisms leading to iron-related bone loss are not fully characterized. We assessed the bone phenotype of HFE (-/-) male mice, a mouse model of hemochromatosis. They had a phenotype of osteoporosis with low bone mass and alteration of the bone microarchitecture. INTRODUCTION: Genetic hemochromatosis is a cause of osteoporosis. However, the mechanisms leading to iron-related bone loss are not fully characterized. Recent human data have not supported the hypothesis of hypogonadism involvement. The direct role of iron on bone metabolism has been suggested. METHODS: Our aim was to assess the bone phenotype of HFE (-/-) male mice, a mouse model of human hemochromatosis, by using microcomputed tomography and histomorphometry. HFE (-/-) animals were sacrificed at 6 and 12 months and compared to controls. RESULTS: There was a significant increase in hepatic iron concentration and bone iron content in HFE (-/-) mice. No detectable Perls' staining was found in the controls' trabeculae. Trabecular bone volume (BV/TV) was significantly lower in HFE (-/-) mice at 6 and 12 months compared to the corresponding wild-type mice: 9.88 ± 0.82% vs 12.82 ± 0.61% (p = 0.009) and 7.18 ± 0.68% vs 10.4 ± 0.86% (p = 0.015), respectively. In addition, there was an impairment of the bone microarchitecture in HFE (-/-) mice. Finally, we found a significant increase in the osteoclast number in HFE (-/-) mice: 382.5 ± 36.75 vs 273.4 ± 20.95 ¢/mm(2) (p = 0.004) at 6 months and 363.6 ± 22.35 vs 230.8 ± 18.7 ¢/mm(2) (p = 0.001) at 12 months in HFE (-/-) mice vs controls. CONCLUSION: Our data show that HFE (-/-) male mice develop a phenotype of osteoporosis with low bone mass and alteration of the microarchitecture. They suggest that there is a relationship between bone iron overload and the increase of the osteoclast number in these mice. These findings are in accordance with clinical observations in humans exhibiting genetic hemochromatosis and support a role of excess iron in relation to genetic hemochromatosis in the development of osteoporosis in humans.

[Sciatica with motor loss revealing meningoradiculitis due to varicella-zoster virus]. / Sciatique déficitaire révélant une méningoradiculite attachée au virus zona-varicelle.

Herpes zoster is a disease which occurs secondary to the reactivation of varicella-zoster virus. Motor involvement in acute herpes zoster is rare. We report a case of sciatica L5 due to herpes zoster infection with motor loss. Typical skin lesions occurred one week before the sciatica. Radiological finding did not explain the paresis. The diagnosis of zoster sciatica with motor involvement was suspected. Serological tests and cerebrospinal fluid examination established the diagnosis. The antiviral and physical treatment was conducted in order to improve functional outcome.

[Cutaneous lupus induced by etanercept in rheumatoid arthritis]. / Lupus érythémateux cutané induit par étanercept au cours de la polyarthrite rhumatoïde.

Therapy with anti-TNFalpha in rheumatoid arthritis may induce autoimmune disorders. Induction of autoantibodies is frequently observed, but lupus-like syndrome is rare and few cases only have been reported. We report a 41-year-old female, treated with etanercept for a rheumatoid arthritis, who developed a cutaneous lupus induced without any other organ involvement, associated with high ANA and DNA antibody titres. The skin biopsy and the histological analysis with immunofluorescence confirmed the diagnosis. The anti-TNFalpha treatment was stopped. Corticosteroids were increased and hydroxychloroquine administered because skin lesions persist after three months.

[Evaluation of CT guided cervical epidural injections in patients with mechanical cervicobrachial neuralgia]. / Evaluation des infiltrations épidurales cervicales sous contrôle tomodensitométrique dans le traitement des névralgies cervico-brachiales mécaniques.

PURPOSE: Prospective study evaluating the efficacy and tolerability of CT guided cervical epidural injections for mechanical cervicobrachial neuralgia. MATERIALS AND METHODS: Between July 2003 and August 2004, 34 patients (16 females, 18 males) with mean age of 44.5 years were enrolled. Enrollment criteria included mechanical cervicobrachial neuralgia of more than 1 month's duration, refractory to medical management, with good correlation between clinical and imaging findings. An evaluation using the Neck Pain Disability Score (NPDS) and associated Secondary criteria was performed by a single observer at day 0, day 30 and day 90. The injections were performed under CT guidance. RESULTS: The symptomatic efficacy of CT guided injections at 3 months was 45% using the NPDS, 47.1% using an analog pain scale, and 58.8% as graded by patients (effective/very effective). Tolerability was excellent (55.9%), moderate (41.2%) and poor (2.9%). CONCLUSION: CT guided cervical epidural injections appear effective and well-tolerated. A blinded randomized study could validate its value. However, a study comparing steroids and placebo raises ethical concerns.

The role of HLA-DR-DR and HLA-DR-DP interactions in genetic susceptibility to rheumatoid arthritis.

In order to analyze the relationships between the DR and DP loci in the genetic susceptibility to RA, HLA-DRB1 and -DPB1 polymorphism was studied in 155 RA patients compared to 150 controls, using a reverse dot-blot analysis. Our data were consistent with the involvement of the amino acid in position 71 of the third hypervariable region of the DR beta 1 chain in susceptibility to the disease. The higher risk for RA was observed in patients who carried the association of a lysine (K), characterizing the DRB1* 0401 susceptibility allele, with an arginine (R), observed in all the other DRB1* susceptibility alleles (21.9% vs 0.6%, p(c) < 10(-6), OR = 42) In the absence of arginine, the presence of lysine was still associated with the disease (33% vs 19%, p(c) < 0.03, OR = 2). In contrast, in the absence of lysine, the frequency of arginine in position 71 was similar in patients and controls (30% vs 26%, p = NS). On another hand, the analysis of the HLA-DPB1 locus showed that the DPB1 *0401 allele frequency was significantly increased in the RA patient group (n = 47) who expressed only arginine at the position 71 of the beta 1 chain (82% vs 56% in controls, p < 0.008), with role of HLA-DR--DR and -DR-DP interactions in the genetic susceptibility to RA.

Sigma SR, a new method of measuring erythrocyte sedimentation rate. Its value in studying the action and interactions of non-steroidal anti-inflammatory agents.

Sigma SR is a new method of measuring erythrocyte sedimentation rate (ESR) and is characterized by an unvarying haematocrit, routinely corrected to 35%, and the sum of 4 sedimentation levels at 20, 30, 40, and 50 minutes. Two studies were carried out in patients with inflammatory arthritic disorders; the first in 25 patients treated with 1800 mg ibuprofen daily for 7 days, and the second in 31 patients treated either with indomethacin alone (150 mg/day) or combined with aspirin (1500 mg/day) for 5 days. In addition to the assessment of clinical parameters, the ESR was measured using the classical Westergren and the sigma SR methods. The results showed that there were little or no changes from baseline values in the ESR using the Westergren method. With the sigma SR method, however, statistically significant changes were recorded after treatment and these correlated with the clinical findings which demonstrated the anti-inflammatory action of ibuprofen and the reduction in activity of indomethacin by aspirin.

Confidence in the diagnosis of early spondylarthropathy: a prospective follow-up of 270 early arthritis patients.

OBJECTIVE: To study the confidence of office-based rheumatologists (OBR) and a college of 5 experts in their diagnosis of spondylarthropathy (SpA) for early arthritis after more than 2 years of follow-up; to determine whether at that time the degree of confidence was improved by the fulfilment of the ESSG criteria. METHODS: 270 patients with early-onset (< 1 year) arthritis were prospectively followed-up for 29+/-11 months. At the final examination, OBR and the college of 5 experts rated their confidence in the diagnosis of SpA on a 0-10 analogue scale and on a 1-4 Likert scale, respectively. RESULTS: After 29+/-11 months OBR had classified 56 patients (21%) as SpA, while a collegial diagnosis of probable (N = 32) or certain SpA (N = 14) was made for 46 patients (17%). At the final examination OBR confidence in their diagnosis (gold standard) was only 6.7+/-2.4 for all 56 cases of SpA. The cumulative fulfilment of ESSG criteria for SpA after 29+/-11 months correlated with the confidence of OBR and the experts in SpA, but improved only slightly the final confidence of OBR (7.1+/-2.3 versus 6.7+/-2.4 for all 56 SpA). Similarly, OBR confidence for the 18/56 SpA patients positive for HLA-B27 was only 7.1+/-2.0. Only 21 of these 56 patients were considered as SpA at baseline, although 37/56 (66%) had fulfilled ESSG criteria since thefirst examination. CONCLUSION: This study indicates a probable lack of consensus on the nosology of early SpA and the limited help provided by the ESSG criteria to differentiate early SpA from otherforms of arthritis at baseline.

Prompt regression of paravertebral and epidural abscesses in patients with pyogenic discitis. Sixteen cases evaluated using magnetic resonance imaging.

OBJECTIVE: To determine whether spinal magnetic resonance imaging performed one month into anti-microbial therapy for pyogenic discitis demonstrated changes of value for predicting outcomes and making therapeutic decisions. METHODS: Prospective study of 16 patients with discitis. A physical evaluation, laboratory tests for inflammation, plain radiographs centered on the affected vertebral level, and magnetic resonance imaging with gadolinium injection were performed at baseline and on day 30. All 16 patients were reevaluated after three months and 15 after six months. RESULTS: The 12 men and four women had a mean age of 59 years. Fourteen patients had a paravertebral abscess (n=12) and/or an epidural abscess (n=6). On day 30, 14 of the 16 patients were clinically improved and ten were radiologically improved. The C-reactive protein level was still elevated in five cases. All reevaluated patients were improved after three months (16/16) and six months (15/15). Only two magnetic resonance imaging features improved during the first month: the size of paravertebral abscesses decreased in 11 of 12 patients, and the size of epidural abscesses decreased in four of six patients. CONCLUSION: Paravertebral and epidural abscesses improve promptly under antimicrobial therapy. However, the presence of these lesions have no prognostic significance. Magnetic resonance imaging does not add significantly to the follow-up of patients who respond clinically to antimicrobial therapy. However, in patients with an unsatisfactory clinical response, follow-up magnetic resonance imaging can provide useful therapeutic orientation by showing whether the paravertebral and/or epidural abscesses have decreased in size.

Analysis of TNFalpha microsatellites in 35 patients with primary Sjögren's syndrome.

OBJECTIVES: Although the cause of Sjögren's syndrome remains unknown, many arguments suggest a role for both environmental and genetic factors. An association with HLA molecules has been established. Other genes on the short arm of chromosome 6 may be involved, most notably the TNF gene, which may be pivotal in the development of the epithelial lesions. METHODS: We investigated TNFalpha microsatellites in 35 patients with primary Sjogren's syndrome and in 146 healthy controls. RESULTS: The frequency of the TNFalpha10 allele showed a non-significant increase in the Sjögren's disease group (28.6% vs 15.8%; P = NS). We found significant increases when we considered only those Sjögren's disease patients with joint manifestations (N = 24; 37.5% vs 15.7%; P < 0.05) or only those with anti-Ro(SSA) antibodies (N = 10; 50% vs 15.7%; P < 0.05). CONCLUSION: Our data support a role for the TNFalpha10 allele in primary Sjögren's syndrome, particularly those forms with joint symptoms and anti-Ro(SS-A) antibodies.

Forceful sacrococcygeal injections in the treatment of postdiscectomy sciatica. A controlled study versus glucocorticoid injections.

UNLABELLED: The role of epidural fibrosis in postoperative sciatica is unclear. Few therapeutic trials have been published. We evaluated the mechanical effects of forceful saline injections through the sacrococcygeal hiatus comparatively with glucocorticoid injections. PATIENTS AND METHODS: Forty-seven patients with postdiscectomy sciatica but no evidence of compression by computed tomography or magnetic resonance imaging were included in a multicenter, randomized, controlled, parallel-group study comparing forceful injections of saline (20 ml) with or without prednisolone acetate (125 mg) to epidural prednisolone acetate (125 mg) alone. Each of the three treatments was given once a month for three consecutive months. Outcome measures were pain severity on a visual analog scale (VAS) and the scores on the Dallas algofunctional self-questionnaire on day 0, day 60, and day 120. Analysis of variance for repeated measures and Student's t test for paired series were used to evaluate the data. RESULTS: Forty-seven patients were evaluated. The VAS score improved significantly between day 0 and day 30 in the glucocorticoid group as compared to the forceful injection group (P = 0.01). No other significant differences were found across the groups. The VAS score improved steadily in the forceful injection group, producing a nearly significant difference on day 120 as compared to baseline (P = 0.08). CONCLUSION: Forceful epidural injections produced a non-significant improvement in postdiscectomy sciatica four months after surgery. Epidural glucocorticoids used alone induced short-lived pain relief.

[Percutaneous spinal and sacroiliac biopsies for diagnostic purposes]. / Biopsies percutanées rachidiennes et sacro-iliaques à visée diagnostique.

The history of puncture biopsy of the spine is outlined, and a current method using a vertebral disc approach described, including principles (premedication, instrumentation, and puncture techniques), treatment of biopsy samples, and indications and contraindications of the procedure. Results are presented and compared with those reported in the literature.

[Value of magnetic resonance imaging in the diagnosis of recurrent postoperative lumbosciatica]. / Intérêt de l'imagerie par résonance magnétique dans le diagnostic des lombosciatiques récidivantes post-opératoires.

Twelve patients who had a subsequent lumbar sciatica after surgery were evaluated with computerized tomography (C.T.) and magnetic resonance imaging (M.R.I.). The M.R.I. was performed with a 0.35 T whole body superconducting unit using spin echo technique. Two pulse sequences were realized varying the repetition time (TR) from 500 to 2,000 ms and the echo time (TE) from 28 to 60 ms. For the longer pulse, the twice echo were interpreted. The slide obtained with a surface-coil were performed in sagittal plane for the twice pulse sequences and in transaxial plane for the shorter pulse sequence. In seven cases, the results obtained with C.T. and M.R.I. were correlated. In two cases, the C.T. showed a scar formation, the M.R.I. showed a recurrent disk herniation. In three times, C.T. was unable to differentiate clearly between recurrent disk herniation and scar formation, the M.R.I. showed unequivocally on one case a scar formation and on two cases a recurrent disk herniation.

[A new diagnostic method of spondylodiscitis. Magnetic resonance imaging]. / Une nouvelle méthode diagnostique de la spondylodiscite. L'imagerie par résonance magnétique.

Twenty four patients who were hospitalized for a suspicion of spondylodiscitis were prospectively evaluated with magnetic resonance imaging (MRI), radiology and radionuclide studies. Fifteen patients had an infectious spondylodiscitis, four had a vertebral degenerative disease, four had a rheumaticus spondylodiscitis, one had a chemical spondylodiscitis. The microbiological examinations and the clinical development bore the diagnosis out. Seven patients underwent Indium 111 scanning. The results of this scanning were correlated with MRI results. The MRI was performed with a 0.35 T whole body superconducting unit using spin echo technique. All patients were studied in the sagittal plane with two pulse sequences and more often with a surface-coil: TR 500 msec./TE 28 msec. and TR 2,000 msec./TE 60 msec. In all cases of true infectious spondylodiscitis the MRI results finding were characteristics. On the image obtained with the TR 500 msec./TE 28 msec., there was a confluent decreased signal intensity from the vertebral bodies and the intervertebral disk space. On the image obtained with TR 2,000 msec./TE 60 msec. there was an increased signal intensity from the vertebral bodies and the intervertebral disk space. The other spondylodiscitis have given a different MRI imaging, it was a confluent decreased signal intensity from the vertebral bodies and the intervertebral disk space on the twice pulse sequences. different images were obtained during the evolution of the infectious: first we observed a modification of the vertebral signal then the typical image that we described then a normal signal of the vertebral bodies with a pathological signal from the intervertebral disk space at last a degenerative intervertebral disk.(ABSTRACT TRUNCATED AT 250 WORDS)

[Contribution of indium-111 labelled polynuclear scintigraphy in the exploration of articular and bone infections]. / Apport de la scintigraphie aux polynucléaires marqués à l'indium 111 dans l'exploration des infections osseuses et articulaires.

Radionuclide imaging with Indium 111-labelled polymorphonuclears was performed on 90 occasions in 84 patients with suspected osteo-articular infection. The sensitivity of this technique was 70% and its specificity 87%. The Indium 111 technique is less sensitive than those using Technetium 99m and/or Gallium 67, but it is much more specific of infection. There are several causes of error when using this method: false-negative results due to the peculiarities of bone infection may occur, but false-positive results are rare, except in inflammatory diseases of peripheral joints. Among the best indications are infected articular prosthesis, spondylodiscitis, osteitis and osteomyelitis.

[Bronchial dilatation and rheumatoid arthritis: a little known association]. / Dilatation des bronches et polyarthrite rhumatoïde: une association méconnue.

Since Ellmann's description in 1948 numerous authors have studied the respiratory manifestations associated with rheumatoid arthritis. Amongst the numerous disorders described, dilatation of the bronchi, although one of the most frequent, remains largely under-estimated. The authors report a series of 21 patients presenting jointly with both rheumatoid arthritis and bronchiectasis which was documented using thoracic computed scanning. All the subjects were female. For 20 of these patients, the appearance of bronchial suppuration preceded that of the articular manifestations by several years. Bronchial dilatation in these cases can, only with difficulty, be considered as a complication of arthritis as has been previously suggested. Rather it appears as a possible pre-disposing factor in the occurrence of the rheumatoid disease. These hypotheses explain the pathophysiological mechanisms implicated in this association are discussed.

[Value of scintigraphy using labelled polynuclears in the diagnosis of infection of a joint prosthesis]. / Intérêt de la scintigraphie aux polynucléaires marqués dans le diagnostic des infections de prothèse articulaire.

Fifty-three patients with suspected infection of prosthetic joints had Indium-111 granulocyte scintigraphy. Twenty-nine of them had associated technetium-99m phosphate scans. Labelled granulocyte sensitivity was 82% and specificity 100% for the group of 47 patients with suspected late infection. Technetium phosphate sensitivity was 92% and specificity 25%. The main quality of labelled granulocyte scintigraphy is its high specificity: there were no false positives in our series. Its main limitation seems to be that sensitivity is sometimes only moderate: we had 4 false negatives. The probable explanation is the histological characteristics of bone infection: vascular thromboses occur frequently and at an early stage, the inflammatory infiltrate is not very abundant and often has a low granulocyte content. The method is therefore reliable and can be used in situations where diagnosis of periprosthetic infection is difficult with conventional techniques.

[Chronic urticarial eruption with arthritis, papillary edema, and meningoencephalitis of childhood onset]. / Eruption urticarienne chronique avec arthrites, cedème papillaire, méningo-encéphalite à début infantile.

The authors report on a case of chronic urticarial eruption since infancy in a man who is now 27-year-old; the association of numerous chronic symptoms, principally meningo-encephalitis, polyarthritis, hepato-spleno-adenomegaly allows the authors to compare this case to those described by Prieur and Griscelli in 1981 and 16 others cases found in literature. It appears as a "systemic disease" without biological or immunological markers; it might belong to the group of chronic normocomplementemic vasculitis.

[Idiopathic pulmonary hemosiderosis and rheumatoid arthritis. Apropos of a case]. / Hémosidérose pulmonaire idiopathique et polyarthrite rhumatoïde. A propos d'une observation.

A 38-year-old woman was known to have had a histologically proven "idiopathic" pulmonary hemosiderosis for 7 years; the authors report the onset in this patient of polyarthralgias with articular swelling and positivity of rheumatoid factor, all features consistent with the diagnosis of rheumatoid arthritis, whose beginning was certainly hidden by steroid therapy. This case, as some others previously published, outlines the possibility of the association of pulmonary hemosiderosis and rheumatoid arthritis: is this a casual association, or may pulmonary hemosiderosis be a rare manifestation of rheumatoid arthritis?