Sarcopenia: a new issue in juvenile idiopathic arthritis. A study Protocol.

INTRODUCTION: The decrease in muscle function and mass is defined as sarcopenia. Known for a long time as an age-related disorder, sarcopenia is nowadays well recognized in childhood. Juvenile idiopathic arthritis (JIA), a chronic inflammatory joint disease may be associated with loss of skeletal mass. AIM: This protocol aims to evaluate the prevalence rate of sarcopenia and its associated factors in JIA. METHODS: To evaluate the prevalence rate and factors associated with sarcopenia in juvenile idiopathic arthritis, we are enrolling 30 children with JIA and 30 healthy children aged between 4-and 16 years. Clinical data will report: age, sex, body mass index, disease duration, and therapeutic management. All participants will undergo the Whole-body Dual-energy X-ray absorptiometry to assess the skeletal muscle mass. The muscle strength will be measured using the handgrip dynamometer and adjusted to the body mass index. Data will be analyzed and compared to age and sex reference curves. RESULTS: This study aims to detect sarcopenia in JIA children and identify subsequently the main associated factors. By collecting anthropometric data and extracting the main features of the disease, specific metrics will be extracted. Body composition will be obtained using the DXA scans, including appendicular lean mass and skeletal muscle mass. Muscle strength will also be assessed. CONCLUSION: This study aims to assess sarcopenia in JIA patients, using the sarcopenia update definition. If we will provide conclusive results, it will be possible to better identify the associated factors of sarcopenia and to prevent children from this complication. Clinical trials registration NCT05291416.

Osteonecrosis of the Tarsal Navicular: Not Always Spontaneous!

BACKGROUND: Mueller-Weiss disease, a rare and complex foot condition, is defined as spontaneous and progressive navicular fragmentation leading to midfoot pain and deformity. However, its exact etiopathogenesis remains unclear. We report a case series of tarsal navicular osteonecrosis to describe the clinical and imaging characteristics and etiologic profile of the disease. METHODS: This retrospective study included five women diagnosed as having tarsal navicular osteonecrosis. The following data were extracted from medical records: age, comorbidities, alcohol and tobacco consumption, history of trauma, clinical presentation, imaging modalities performed, treatment protocol, and outcomes. RESULTS: Five women with a mean age of 51.4 years (range, 39-68 years) were enrolled in the study. Mechanical pain and deformity over the dorsum of the midfoot was the main clinical presentation. Rheumatoid arthritis, granulomatosis with polyangiitis, and spondyloarthritis were reported by three patients. Radiographs revealed bilateral distribution in one patient. Three patients underwent computed tomography. It showed a fragmentation of the navicular bone in two cases.Magnetic resonance imaging was performed in one patient showing flattening of the lateral aspect of the navicular bone with signal abnormalities. Talonaviculocuneiform arthrodesis was performed in all of the patients. CONCLUSIONS: Mueller-Weiss disease-like changes may occur in patients with an underlying inflammatory disease such as rheumatoid arthritis and spondyloarthritis.

Non-pharmacological therapies in Fibromyalgia: New horizons for physicians, new hopes for patients.

INTRODUCTION: Fibromyalgia (FM) is a chronic musculoskeletal condition characterised by reduced quality of life and severe limitations in daily living activities. Considering the wide spectrum of symptoms and the ineffectiveness of a single pharmacological approach, the latest clinical guidelines recommend non-pharmacological therapies as both an alternative and a better-tolerated approach. Several studies have been conducted to determine the effectiveness of non-pharmacological therapies in the management of FM. AIMS: Through a literature review, this paper aims to describe the different complementary therapies and investigate their potential sustainability and effectiveness on FM symptoms in the short and/or long term. METHODS: We searched the PubMed and Google Scholar databases using broad search terms up to June 2022, to identify all types of study designs restricted to human subjects on non-pharmacological therapies in FM. RESULTS: Recent evidence demonstrated that physical activity is the mainstay of therapeutic management, highlighting the relevance of walking as the best method of exercise in FM patients. Nevertheless, adherence to physical activity remains fraught with obstacles that could be overcome with a multimodal and multidisciplinary approach involving a wide range of passive therapies. The effectiveness of passive non-pharmacological therapies remains however unproven in the long term. They can be therefore suggested as 'adjunct' or 'bridge' therapy to improve adherence to physical activity. CONCLUSION: To conclude, FM management requires a multimodal and symptom-based approach, guided by the predominant bothersome symptom on the one hand, and the preferences of each patient on the other hand.

The concept of telemedicine in pediatric rheumatology in Tunisia: Parents' perceptions.

INTRODUCTION: With the COVID-19 pandemic, health care systems are facing challenges in delivering proper patient care. Children and adolescents with juvenile idiopathic arthritis require specialized and comprehensive attention. In this context, telemedicine is an alternative that has the potential to improve access to healthcare in addition to cost savings. The objective of our study was to evaluate parents' willingness for telemedicine and factors helping to adopt this alternative in the era of COVID-19. METHODS: We undertook a cross-sectional study via structured phone interviews of parents' JIA patients as well as those with no established diagnoses. We evaluated their point of view and willingness to adhere to TM. RESULTS: The study included 40 parents. The main reasons for favoring TM were avoiding hospitals during the pandemic (32.5%), time saving (27.5%) as well as avoiding school absenteeism (27.5%). The main reasons for preferring a live consultation were the fear of a possible discrepancy between physical and distant evaluation (47.5%) and the fear of the trivialization of the disease (38.5%). There was no association between preference for TM and a family history of COVID-19 (p = 0.704) as well as electronic devices afforded (p = 0.263). However, patients who lived away from hospital, not familiar with the concept of TM and with higher income adhered less to TM. CONCLUSION: Unlike the literature data, our study showed the low prevalence of parents willing to accept TM as a model of care. This imply an urgent need for parent and patient education to promote TM especially in pediatric rheumatology.

Assessment of the functional impact of foot involvement in patients with rheumatoid arthritis.

AIM OF THE WORK: We aimed to evaluate the impact of foot involvement in patients with rheumatoid arthritis (RA) using the functional foot index (FFI) and to identify predictive factors of the functional impact of foot abnormalities in RA patients. PATIENTS AND METHODS: This was a cross-sectional study including patients with RA meeting the criteria of the American College of Rheumatology and the European League Against Rheumatism 2010. The main epidemiological data, results of podoscopic and clinical examination of the foot and ankle, biological tests and radiological findings were collected. The presence of foot pain was assessed by a visual analogic scale (0-10), and the functional impact of foot involvement was assessed based on the validated French version of the FFI. RESULTS: Fifty RA patients with an average age of 59.3 ± 9.9 years [39-79] were included, and 80% of them had foot involvement. Foot pain was present in 32 patients (64%), most frequently situated in the forefoot (56%). The average FFI score was 33.67 ± 30.53 [0-92.67]. The following factors had a significant association with the FFI score: an occupation soliciting the feet (p = 0.001), disease duration (p = 0.033, r = 0,302), the Health Assessment Questionnaire (p = 0.0001, r = 0,480), body mass index (p = 0.0001, r = 0,654), the presence of podiatric abnormalities (p = 0.0001) and Visual Analog Scale foot pain (p = 0.0001, r = 0,854). A significant association was also found between the FFI score and the presence of a hallux valgus (p = 0.004), a spread of the forefoot (p = 0.029), a claw of the toes (p = 0.002), a triangular forefoot (p = 0.0001), a quintus varus (p = 0.002), flat feet (p = 0.0001) and a valgus of the hindfoot (p = 0.001). CONCLUSION: Due to the high frequency of foot involvement and its significant functional impact, meticulous examination of the feet and assessment of their functional impact must be one of the parameters for monitoring the disease. Its impact on one's quality of life can be important. LEVEL OF CLINICAL EVIDENCE: 4 (cohort studies, non experimental, observational studies).

Factors associated with the inflammatory process in pain in ankylosing spondylitis.

Introduction: sleep disorders, closely related to any chronic pain process, are frequent among patients with rheumatic diseases, mainly ankylosing spondylitis (AS). Our study aimed to determine the association between sleep disturbances and the inflammatory process in pain in AS patients compared with lower back pain (LBP) patients. We have additionally examined factors associated with sleep disorders among AS patients. Methods: we conducted a cross-sectional study among AS patients. Sociodemographic data, patient reported outcomes and disease characteristics were recorded. Sleep was assessed using the medical outcomes study sleep scale measure (MOS-SS). For psychological assessment, Beck anxiety (BAI) and depression index (BDI) was used. A multivariate logistic regression was performed to identify factors associated with sleep disorders. Results: the study included 50 patients with AS and 40 patients with low back pain. The most common affected domains among AS patients were inadequacy, sleep disturbance, and daily somnolence. The MOS-SS index was significantly higher in the AS group than in the control group (p<0.001). Sleep disorder was associated with age, female gender, analphabetism, patient-reported outcomes (all p<0.05), but was not associated with profession, comorbidities and smoking habits. In multivariate analysis, factors associated with sleep disruption were the duration of morning stiffness (MS), disease activity, bath ankylosing spondylitis metrology index (BASMI), ASQol, as well as anxiety and depression (odds ratio: 5.4(CI 95% 1.6-18.3), 9.9 (CI95%1.1-86); 6 (CI95%1.1-32); 13 (CI 95% 1.4-143.8); 15.7 (CI 95% 2.6-94.3); 14 (CI 95% 2-105.7) respectively, p<0.05 for each). Conclusion: our study highlighted the importance of sleep disorders among patients with AS with a predilection for inadequacy, sleep disturbance, and daily somnolence. Factors associated with sleep disruption were high disease activity, a longer duration of MS, an altered function and quality of life as well as anxiety and depression.

Enthesitis-related arthritis: monitoring and specific tools

Abstract Objective: In this article, the authors aimed to review the different tools used in the monitoring of enthesitis-related arthritis. Sources: The authors performed a literature review on PubMed, Google Scholar, and Scopus databases. The dataset included the original research and the reviews including patients with enthesitis-related arthritis or juvenile spondylarthritis up to October 2020. Summary of finding: Enthesitis-related arthritis is a category of juvenile idiopathic arthritis. It is characterized by the presence of enthesitis, peripheral arthritis, as well as axial involvement. The only validated tool for disease activity measurement in juvenile idiopathic arthritis is the Disease Activity Score: It has proven its reliability and sensitivity. Nevertheless, due to an absence of validated evaluation tools, the extent of functional impairment, as well as the children and parents' perception of the disease, could not be objectively perceived. Despite the great progress in the field of imaging modalities, the role they play in the evaluation of disease activity is still controversial. This is partially due to the lack of validated scoring systems. Conclusion: Further work is still required to standardize the monitoring strategy and validate the outcome measures in enthesitis-related arthritis.

Management of chronic recurrent multifocal osteomyelitis: review and update on the treatment protocol.

INTRODUCTION: Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder primarily affecting children. It is characterized by a peripheral involvement of the metaphysis of long bones rather than axial involvement. Due to the scarcity of the disease, there are no guidelines regarding its management. AREAS COVERED: This review aims to provide an overview of the different therapeutic alternatives and recent protocols. For this reason, first-line and second-line treatment, as well as the impact of new therapies, are discussed in depth. We conducted a search through PubMed on the different aspects of CRMO. Outcomes were categorized as first and second-line treatments. EXPERT OPINION: Non-steroidal anti-inflammatory drugs remain the keystone of CRMO management and are proposed as the first-line treatment. In the case of vertebral involvement, bisphosphonate should be considered, even as a first-line treatment. Several case series and retrospective studies highlight the efficacy of anti-TNF agents. Their use could be an optimal treatment choice for CRMO with comorbid immune-mediated diseases. The potentially favorable effect of interleukin-1 antagonists remains to be determined.

Which Metrological Index, the BASMI or EDASMI, is Best Correlated with Disease-Related Parameters in Spondylarthritis Patients?

OBJECTIVE: This study aimed at comparing the Edmonton Ankylosing Spondylitis Metrology Index (EDASMI) and Bath Ankylosing Spondylitis Metrology Index (BASMI) to determine which of the two is best correlated with disease-related parameters in axial spondyloarthritis (axSpA) patients. METHODS: A cross-sectional study was carried out involving 86 patients with radiographic axSpA. Sociodemographic data, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Ankylosing Spondylitis Disease Activity Score (ASDAS), the Bath Ankylosing Spondylitis Functional Index (BASFI), and the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire were applied. Spinal mobility was assessed by two indices: the BASMI and the EDASMI. Structural damage of the spine was also evaluated by two indices: the Bath Ankylosing Spondylitis Radiology Index (BASRI) and the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). RESULTS: Eighty-six patients with an average age of 43.21 ± 11.43 years (20-79) were included. Impaired spinal mobility, which corresponds to higher BASMI scores, was correlated with prolonged disease duration (p < 0.01, r = 0.310), higher ASDAS-CRP (p < 0.001, r = 0.386), severe functional disability on the BASFI (p < 0.01, r = 0.505) and poorer quality of life according to the ASQoL (p < 0.01, r = 0.369). However, the EDASMI score did not correlate with any disease parameter. The BASMI was correlated with the total BASRI (p < 0.01, r = 0.634) and mSASSS (p < 0.01, r = 0.388). Unlike the BASMI, the EDASMI was neither correlated with the BASRI (p = 0.520, r = 0.245) nor the mSASSS (p = 0.252, r = -0.120). CONCLUSION: Our results indicate that among the studied metrological indices, the BASMI is more contributory since it is correlated with clinical disease parameters and structural damage, unlike the EDASMI.

Case report of Osteopoikilosis in patient with psoriatic arthritis.

Osteopoikilosis (OPK) is one of the rare genetic musculoskeletal, non-inflammatory disorders that we should increase awareness toward. We report a case of a patient diagnosed with psoriatic arthritis with incidental imaging findings of lesions suggestive of osteopoikilosis.

Vertebral sarcoidosis: diagnosis to management.

Sarcoidosis is a systemic inflammatory granulomatous disease that can develop in almost any organ system. Rheumatologists may encounter sarcoidosis in different situations varying from arthralgia to bone involvement. While the peripheral skeleton was a frequent location, data regarding axial involvement is scarce. Most patients with vertebral involvement have a known diagnosis of intrathoracic sarcoidosis. They tend to report mechanical pain or tenderness over the involved area. Imaging modalities, particularly Magnetic Resonance Imaging (MRI), are a mainstay of axial screening. It helps exclude differential diagnoses and delineate the extent of bone involvement. Histological confirmation combined with the ap- propriate clinical and radiological presentation is the key of diagnosis. Corticosteroids remain the cornerstone of treatment. In refractory cases, methotrexate is the steroid- sparing agent of choice. Biologic therapies may be used, although the evidence base for their efficacy is bone sarcoidosis controversial.

Rheumatoid arthritis occurring after coronavirus disease 2019 (COVID-19) infection: Case based review.

Introduction: Rheumatoid arthritis (RA) is a multifactorial disease. Genetic predisposition and environmental triggers including infections are the major players of autoimmunity. We present a case of rheumatoid arthritis occurring after the coronavirus disease 2019(COVID-19) infection. Case presentation: A 72-year-old woman with a medical history of hypertension and atrial fibrillation presented for a 2-month history of bilateral symmetric polyarthritis starting 2 weeks after asymptomatic COVID-19 infection. Physical examination showed swelling and tenderness of the metacarpophalangeal and proximal interphalangeal joints, wrists, and knees. She had increased inflammatory biomarkers (C-reactive protein:108 mg/L, erythrocyte sedimentation rate: 95 mm, alpha-2 and gamma-globulins, interleukin 6: 16.5 pg/mL). Immunological tests revealed positive rheumatoid factor (128 UI/mL), anti-cyclic citrullinated peptide antibodies (200UI/mL), anti-nuclear antibodies (1:320), and anti-SARS-CoV-2 IgG (12.24U/mL). She had the genotype: HLA-DRB1*04:11, HLA-DQB1*03:01, and HLA-DQB1* 03:02. Hands and feet radiographs did not show any erosion. Ultrasonography showed active synovitis and erosion of the 5th right metatarsal head. The diagnosis of RA was made. The patient received intravenous pulses of methylprednisolone (250 mg/day for 3 consecutive days) then oral corticosteroids (15 mg daily) and methotrexate (10 mg/week) were associated, leading to clinical and biological improvement. Conclusion: Despite its rarity, physicians should be aware of the possibility of the occurrence of RA after COVID-19 infection. This finding highlights the autoimmune property of this emerging virus and raises further questions about the pathogenesis of immunological alterations.

Sustainable positive effects of Ramadan intermittent fasting in rheumatoid arthritis.

The short-term positive effects of intermittent fasting during the month of Ramadan on rheumatic inflammatory diseases have been previously evaluated. The objective of this study was to assess the sustainability of these effects on rheumatoid arthritis (RA) activity. This prospective study included 35 patients with RA, who observed fasting during Ramadan 2019. The disease activity was assessed and compared between three time points: T1 (6 months before the beginning of Ramadan), T2 (during the month between the 7th day of fasting and the 7th day after Ramadan), and T3 (averagely 3.4 months after fasting). The disease activity score 28 (DAS28) was used to evaluate the disease activity. After a significant decrease of all disease activity parameters between T1 and T2, a gradual increase of clinical and biological outcomes was seen between T2 and T3. Except for CRP, which was significantly higher at T3 (p = 0.02), the changes of the other disease activity parameters were not statistically significant. By reference to baseline data (T1), the decrease of ESR, DAS28 CRP, and DAS28 ESR induced after Ramadan fast was maintained until T3, with statistically significant differences. We can therefore conclude that this study has been conducted at the beginning of the fading-out of the effects of Ramadan fast, and that the duration of 3 months may be the recommended interval between fasting periods to maintain the positive effects of intermittent fasting on RA activity. Key Points • Intermittent fasting can induce a rapid improvement of rheumatoid arthritis activity. • The positive effects of this model of fasting can last up to 3 months. • The recommended interval between fasting periods may be estimated at 3 months.

Enthesitis-related arthritis: monitoring and specific tools.

OBJECTIVES: In this article, the authors aimed to review the different tools used in the monitoring of enthesitis-related arthritis. SOURCES: The authors performed a literature review on PubMed, Google Scholar, and Scopus databases. The dataset included the original research and the reviews including patients with enthesitis-related arthritis or juvenile spondylarthritis up to October 2020. SUMMARY OF FINDING: Enthesitis-related arthritis is a category of juvenile idiopathic arthritis. It is characterized by the presence of enthesitis, peripheral arthritis, as well as axial involvement. The only validated tool for disease activity measurement in juvenile idiopathic arthritis is the Disease Activity Score: It has proven its reliability and sensitivity. Nevertheless, due to an absence of validated evaluation tools, the extent of functional impairment, as well as the children and parents' perception of the disease, could not be objectively perceived. Despite the great progress in the field of imaging modalities, the role they play in the evaluation of disease activity is still controversial. This is partially due to the lack of validated scoring systems. CONCLUSIONS: Further work is still required to standardize the monitoring strategy and validate the outcome measures in enthesitis-related arthritis.

Enthesitis-related arthritis and spondylarthritis: the same disease or disparate entities?

OBJECTIVES: The aim of this study is to compare the clinical features, disease activity and physical impairment, between enthesitis-related arthritis, adult and late-onset spondylarthritis in Tunisian patients. METHODS: This study included 190 patients divided into three groups according to their age at the onset of symptoms: ERA (onset of symptoms ≤ 16 years of age), AOSpA (16 < onset of symptoms < 50 years of age) and LOSpA (onset of symptoms ≥ 50 years of age). AOSpA and LOSpA patients fulfilled the ASAS criteria for SpA. Whereas, ERA patients were classified according to the ILAR criteria. RESULTS: Among 190 patients, 21% had ERA, 70.5% had AOSpA, and 8.5% had LOSpA. There were no differences in gender ratio between ERA and AOSpA groups. Regarding the clinical presentation, ERA and LOSpA groups had more peripheral symptoms than AOSpA in whom the axial manifestation pattern continued throughout the course of the disease. HLA-B27 was more associated with ERA (p = 0,007). Extra-articular manifestations were more observed in the ERA group (p = 0.004). Disease activity, functional status and anthropometric parameters were similar between groups. Nevertheless, health-related quality-of-life assessed by ASQoL and SF-36 scores were better in the AOSpA group but with no significant differences. Regarding the treatment option, methotrexate was widely used in the ERA group (p < 0.001). CONCLUSION: ERA is characterized mainly by marked peripheral arthritis, more extra-articular manifestations, and a higher frequency of hip involvement.

Radiculopathies caused by spontaneous pneumorrachis: Two case reports and review of literature.

Pneumorarchis is a rare condition of low back pain. It is usually asymptomatic and secondary to trauma. Spontaneous pneumorrachis is scarce.

Tuberculosis arthritis of the ankle mimicking a talar osteochondritis.

Tuberculosis arthritis of the ankle accounts for 10% of all cases of osteoarticular tuberculosis (OT). Because of its rarity and insidious symptoms, diagnosing it may be challenging. Furthermore, its imaging findings mimic those of other diseases. The case of ankle tuberculosis arthritis misdiagnosed as talus necrosis is reported. The difficulties faced by clinicians when confronting such situations are also illustrated.

Intra-articular hip neurofibromas in von Recklinghausen's disease.

Neurofibromatosis is a genetic disorder with osteo-articular manifestations. The intra-articular location of neurofibroma is scarce.