The impact of psoriasis on professional life: PsoPRO, a French national survey.

BACKGROUND: The physical, social and mental burden of psoriasis is well known, but its occupational impact has been less investigated. OBJECTIVE: To assess the impact of psoriasis on the working life of patients compared with the general population. METHODS: A national survey compared people with and without psoriasis using online questionnaires. In addition to the demographic, medical and professional characteristics, data on recent absenteeism and presenteeism were captured using the validated WPAI-PSO questionnaire. RESULTS: The patient sample comprised 714 with psoriasis (PsO), including 81 treated with systemic therapies (PsoST), and 84 with associated psoriatic arthritis (PsO + PsA). The control sample comprised 604 active subjects representative of the French population. Compared to controls, the impact of the disease on working life was no greater in PsO patients. Conversely, unemployment within the past 5 years and mean number of sick leaves within the previous year were more frequent in PsO + PsA. In patients with active psoriasis skin lesions, all aspects of the WPAI questionnaire were negatively impacted in PsoST and PsO + PsA patients, but not in PsO patients: Levels of absenteeism were 3.3% in controls, 5.6% in PsO (NS), 8.3% in PsoST (P < 0.05) and 13.0% in Ps0 + PsA (P < 0.05); impairment in presenteeism reached 27.0%, 21.2% (NS), 43.5% (P < 0.05) and 53.2% (P < 0.05), respectively, while overall work impairment was 27.9%, 22.2% (NS), 46.3% (P < 0.05) and 57.6% (P < 0.05), respectively. Nevertheless, a higher proportion of PsoST and PsO + PsA patients reported that work was more important than any other activity in their life. CONCLUSION: The occupational impact of psoriasis is important and significant in patients who receive systemic therapy or have concurrent PsA but minimal or absent in other psoriasis patients. The findings show that psoriasis patients have a high level of motivation to work.

Psoriatic arthritis screening by the dermatologist: development and first validation of the 'PURE-4 scale'.

BACKGROUND: Dermatologists are recommended to ask psoriasis patients about musculoskeletal complaints to allow early detection and treatment of psoriatic arthritis (PsA). Screening tools have been developed to help identify patients warranting further rheumatologic assessment, but evidence suggests room for improvement in their diagnostic value and ease of use for outpatient practice. OBJECTIVE: To develop and internally validate a brief tool for dermatologists to screen patients to refer to a rheumatologist for PsA diagnosis. METHODS: After the literature review, 23 items were selected, covering pain at various locations and inflammatory signs of PsA. The validation study was conducted in medically diagnosed psoriasis patients consecutively recruited between 2012 and 2014 (Saint Joseph Hospital, Paris, France). Patients were enrolled by a dermatologist who helped to complete the questionnaire. Diagnosis of PsA was established by a rheumatologist based on CASPAR criteria. Multivariate logistic regression models were performed to build the scale, assessing discrimination through sensitivity, specificity and area under the ROC curve (AUC). Final model was internally validated using bootstrapping techniques. RESULTS: One hundred and sixty-eight patients were recruited, of whom nine were excluded for known PsA and 21 did not attend the rheumatologist consultation. Of 137 included patients (median age 43 years, 59.6% men), 21 (15.3%) had a PsA diagnosis. Final regression model retained four independent items, including evocative signs of dactylitis, inflammatory heel pain, bilateral buttock pain and peripheral joint pain with swelling in patients aged <50. A total score (the PURE-4) was computed (0-4 points) that demonstrated excellent discriminative power (AUC = 87.6%; Sensitivity = 85.7% and Specificity = 83.6% at the threshold of ≥1/4 points), with no evidence for over-optimism in bootstrapped internal validation. CONCLUSION: These findings demonstrate the good diagnostic properties of a new screening scale using only four easy-to-collect items. If confirmed in other populations, it may prove useful in outpatient dermatology clinics for triage of psoriasis patients requiring further assessment by the rheumatologist.

Impact of vedolizumab therapy on extra-intestinal manifestations in patients with inflammatory bowel disease: a multicentre cohort study nested in the OBSERV-IBD cohort.

BACKGROUND: The effectiveness of vedolizumab as a treatment for extraintestinal manifestations (EIM) is questionable due to its gut-specificity. AIM: To assess effectiveness of vedolizumab for EIM in patients with inflammatory bowel disease (IBD) in a large real-life experience cohort. METHODS: Between June and December 2014, 173 patients with Crohn's disease and 121 with ulcerative colitis were treated with vedolizumab. Patients were followed until week 54. EIM activity was assessed at weeks 0, 6, 14, 22, 30 and 54 by using a 3-step scale: complete remission, partial response and no response. RESULTS: At baseline, 49 (16.7%) patients had EIMs of which 47 had inflammatory arthralgia/arthritis, four had cutaneous lesions and two had both rheumatologic and skin EIM. At week 54, 21 (44.7%) patients had complete remission for inflammatory arthralgia/arthritis and three (75%) for cutaneous EIM. In multivariate analysis, complete remission of inflammatory arthralgia/arthritis was associated with clinical remission of IBD (OR = 1.89, IC95% [1.05-3.41], P = .03) and recent onset of inflammatory arthralgia/arthritis (OR = 1.99, IC95% [1.12-3.52], P = .02). During the follow-up period, 34 (13.8%) patients without any EIM at baseline, developed incident cases of inflammatory arthralgia/arthritis consisting mostly of peripheral arthralgia without evidence of arthritis and 14 (4.8%) incident cases of paradoxical skin manifestation. CONCLUSION: Vedolizumab therapy is commonly associated with improvement in EIM. This was associated with quiescent IBD and recent EIM. However, paradoxical skin manifestation and inflammatory arthralgia/arthritis may occur upon vedolizumab therapy.

Work-related discussions between French rheumatologists and their rheumatoid arthritis patients.

BACKGROUND: Rheumatoid arthritis (RA) causes significant impairment of physical function, and thus adversely affects patients' ability to work. AIMS: To document how often work limitations are discussed by rheumatologists and RA patients during consultations. METHODS: We conducted an observational study in a sample of French rheumatologists and in a parallel sample of patients recruited by pharmacists. We asked all rheumatologists in France practising in private practice or mixed practice (private practice and hospital) to participate in a telephone survey about their most recent consultation with an RA patient. Randomly selected pharmacists recruited RA patients to complete a questionnaire about their most recent consultation with their rheumatologist. We included patients aged 20-59, with a paid job or unemployed. We calculated the proportion of consultations including work-related discussions in both samples. RESULTS: Of the 1737 rheumatologists contacted, 153 (9%) described consultations with eligible patients. Of the 1200 pharmacists contacted, 39 (3%) recruited 81 RA patients. The proportion of consultations including work-related discussions was 50% [95% confidence interval (CI) 42-58%] in the rheumatologist sample and 52% (95% CI 41-63%) in the patient sample. The most frequent subject of discussion (88%) was physical problems related to work in both samples. CONCLUSIONS: This is the first study to document the proportion of consultations where rheumatologists and their RA patients discuss work. Both specialists and patients reported that work was discussed in one in every two consultations.

Non-radiographic axial spondyloarthritis: what is it?

The classification criteria recently developed by the Assessment of Spondyloarthritis International Society (ASAS) highlighted a specific entity: non radiographic axial spondyloarthritis (nr-axSpA). Although more and more widely used in the literature as well as clinical trials, limits and profile of this entity is still under known or debated. Some studies have already compared those forms to classical AS, even in recent forms. They showed that, apart from the difference in the ossification process, and the greater degree and frequency of systemic and MRI inflammation in AS, those 2 forms of SpA share the same genetic background, clinical patterns, and burden of disease. TNF antagonists seemed as effective in controlling symptoms in patients with nr-axSpA. Concerning the long-term outcome of nr-ax-SpA, only long-term ongoing cohorts of patients with recent nr-axSpA will be able to determine what proportion of patients have persistent non-radiographic disease and what proportion do progress to AS.

Performances of the Assessment of SpondyloArthritis International Society axial spondyloarthritis criteria for diagnostic and classification purposes in patients visiting a rheumatologist because of chronic back pain: results from a multicenter, cross-sectional study.

OBJECTIVE: To evaluate the performances (sensitivity, specificity, and positive and negative predictive values) at diagnosis and study visit of the Assessment of SpondyloArthritis international Society (ASAS) criteria in axial spondyloarthritis in patients with chronic back pain (CBP). A secondary objective was to identify the most contributory item to diagnosis/classify spondyloarthritis. METHODS: We conducted a multicenter, cross-sectional study. Patients were ages <45 years with a history of CBP and seeing a rheumatologist in France. Data included items from the different sets of criteria, checking if present at diagnosis ("diagnosis")/after diagnosis, but at study visit ("classification"), and the rheumatologist's diagnosis at study visit. Statistical analysis included descriptive characteristics and performances for diagnosis and classification. The diagnosis of the rheumatologist was considered the "gold standard." RESULTS: A total of 1,210 patients were eligible for our analysis. Sensitivity and specificity for ASAS axial criteria were 0.76 and 0.94, respectively, and 0.87 and 0.92 for diagnostic and classification purposes, respectively. The positive likelihood ratio of the ASAS axial criteria was 13.6 and 10.30 for diagnostic and classification purposes, respectively. The most contributory items to diagnosis and classification were radiographic sacroiliitis, followed by magnetic resonance imaging sacroiliitis for diagnosis and history of uveitis for classification. CONCLUSION: We confirm the validity of the ASAS criteria for both diagnostic and classification purposes in a clinical setting of patients with CBP.

Differences between women and men with recent-onset axial spondyloarthritis: results from a prospective multicenter French cohort.

OBJECTIVE: To clarify sex differences in early axial spondyloarthritis (SpA). METHODS: In total, 475 patients included in the Devenir des Spondylarthropathies Indifférenciées Récentes (Outcome of Recent Undifferentiated Spondylarthropathies) cohort, a prospective multicenter French cohort of patients with early inflammatory back pain suggestive of SpA, and fulfilling the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial SpA were studied. The clinical and imaging features were compared between sexes and according to the clinical or imaging arm of the ASAS criteria using univariate and multivariate analysis. RESULTS: Comparisons between the 239 men and 236 women showed that women had higher disease activity when measured by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Patient Global Score and higher fatigue and functional scores despite having less radiographic sacroiliitis and magnetic resonance imaging (MRI) inflammation of sacroiliac joints and the spine than men. Disease activity measured by the C-reactive protein (CRP)-based Ankylosing Spondylitis Disease Activity Score was not different between men and women. In contrast to patients classified with the clinical arm, disease activity and functional scores did not differ between women and men with sacroiliitis on imaging scans, except for fatigue and the Ankylosing Spondylitis Quality of Life questionnaire. Women with sacroiliitis had more peripheral involvement and more family history, whereas HLA-B27 positivity, elevated CRP, and MRI inflammation of the spine were associated with male sex. CONCLUSION: Women with early axial SpA according to the ASAS criteria had greater disease activity when measured by the BASDAI and worse functioning despite fewer radiologic abnormalities than men. The differences in disease expression may be confounding factors to establish the diagnosis of SpA and to assess disease activity in women, suggesting that the imaging arm is a pivotal measure in the ASAS criteria.

Prevalence and factors associated with uveitis in spondylarthritis patients in France: results from an observational survey.

OBJECTIVE: To accurately estimate the prevalence of and the factors associated with uveitis in spondylarthritis (SpA) patients in France. METHODS: In an observational survey of SpA patients (diagnosis confirmed by the European Spondylarthropathy Study Group and/or Amor's criteria) consulting their rheumatologist for routine followup, we collected information regarding present/past history of uveitis, as well as detailed characteristics of the disease. Factors independently associated with uveitis were determined. RESULTS: From September 2008 to January 2009, 202 rheumatologists participated in the survey and recruited 902 patients (61% men) with a mean ± SD age of 45.3 ± 13.4 years and a mean ± SD disease duration of 10.4 ± 9.6 years. The SpA diagnoses were ankylosing spondylitis (71%), psoriatic arthritis (18%), or other SpA (11%). The HLA-B27 positivity rate was 76%. Uveitis prevalence was 32.2% (95% confidence interval [95% CI] 29.1-35.3%) since psoriasis and inflammatory bowel disease were 22.3% (95% CI 19.5-25.0%) and 8.6% (95% CI 6.7-10.5%), respectively. Recurrence of uveitis occurred in 52.3% and complications occurred in 11.7% of patients. Factors independently associated with uveitis were HLA-B27 positivity (adjusted odds ratio [OR(adj) ] 2.97 [95% CI 1.83-4.81], P < 0.0001) and disease duration (OR(adj) 1.28 [95% CI 1.16-1.41], P < 0.0001 for ≥10 years). CONCLUSION: Results indicate that uveitis is the most common extraarticular feature of SpA, occurring preferentially in HLA-B27-positive patients over the entire course of the disease.

[Optimized use of cross-sectional imaging for the early diagnosis and management of ankylosing spondyloarthropathy]. / Comment intégrer l'imagerie moderne dans le diagnostic précoce et le suivi de la spondylarthrite ankylosante?

It is becoming increasingly desirable to diagnose ankylosing spondyloarthropathy (AS) at its pre-radiographic stage (prior to the presence of sacro-iliitis on radiographs). MRI plays a key role for early diagnosis of AS, as illustrated by recently proposed international diagnostic criteria (ASAS). MRI of the SI joints is most helpful for early diagnosis; sequences using fat suppression and/or Gadolinium administration are necessary for the detection of inflammatory changes. However, the rate of false positive and false negative results of MR imaging of the SI joints, especially early in the course of the disease, is unknown and requires prudent interpretation of imaging findings. In patients with normal MRI examination of the SI joints and/or if symptoms are limited to the spine, MRI of the lumbar spine with STIR and/or Gadolinium administration may be helpful; again the positive and negative predictive values are unknown, especially early in the course of the disease. The demonstration of inflammatory changes on MRI, at the axial level, could be an indication for anti-TNF treatment, outside of WMA (national and international recommendations). The role of Doppler US, especially for peripheral entheses, remains hypothetical for early diagnosis. The role of MRI for structural evaluation is also being assessed even though radiographs remain the standard of reference. To date, no treatment, conventional or other, has been shown to have a structural effect (aside from limitations related to the methodology of available studies).

Acute myeloid leukemia after infliximab: a case report.

Concern has arisen regarding a possible increase in the risk of malignant diseases such as lymphoproliferative disorders in a patient taking TNF-alpha antagonists for the treatment of chronic inflammatory diseases. The evidence of a causal link remains unclear. We report a case of 60-year-old male patient who developed acute myeloid leukemia during infliximab therapy for ankylo-sing spondylitis.

[Psoriatic arthritis]. / Rhumatisme psoriasique.

Psoriatic arthritis is a comorbidity frequently associated to psoriasis. A major problem is the absence of diagnostic criteria and the lack of consensus on the classification criteria of this arthritis. The clinical presentation is extremely variable, since axial, peripheric, and enthesopathic lesions can exist alone, successively or in association in a same patient. Peripheric lesions can be mono- or more often oligo- or polyarthritis. Onychopathies and dactylitis are frequently associated to arthritis. The dermatologist must recognize psoriatic arthritis at an early stage, in order to avoid the development of destructive lesions. The treatment includes symptomatic treatments (antalgics, non steroidal anti-inflammatory agents, corticosteroids), long-term treatments (sulfasalazine, methotrexate, azathioprine, ciclosporine, leflunomide), and TNF-alpha-inhibitors. Therapeutic strategies must be adapted to the clinical presentation.

Continuation of treatment with infliximab in ankylosing spondylitis: 2-yr open follow-up.

OBJECTIVE: To evaluate the continuation and safety of treatment with infliximab in ankylosing spondylitis (AS) over a 2-yr period. METHODS: This study was an open, observational, 2-yr extension study of an open-label study of three induction infusions of infliximab in refractory AS. The fourth infusion was performed only in case of relapse. Thereafter, infliximab was to be administered as needed according to the rheumatologist's opinion; however, for some patients, infusions were performed systematically. RESULTS: None of the 50 recruited patients was lost to follow-up. Thirteen patients (26%) interrupted their treatment by infliximab: four for inefficacy, seven for adverse events, of which four were for allergic reactions to the infusion, and two for other reasons. For all of the 46 patients who had had three infusions judged efficacious and well tolerated, a fourth infusion was performed because of a flare of the disease, after a mean interval of 20.3+/-9.9 weeks (range 7.3-57.9). Over the 24 months, the mean interval between infusions was 11.6+/-9.0 weeks. This interval was longer when patients were treated only as needed (mean 14.3+/-12.1 weeks) than systematically (mean 9.8+/-5.7 weeks). Side-effects were similar to those noted in shorter-term studies; seven patients suffered serious adverse events. There were no deaths, no malignancies and no tuberculosis. CONCLUSION: This study confirms the long-term treatment continuation of infliximab in AS, and shows an acceptable safety profile. It appears that for some patients the disease can be controlled with long intervals between infusions; these findings warrant further studies.

Efficacy of infliximab in refractory ankylosing spondylitis: results of a six-month open-label study.

OBJECTIVE: To evaluate the efficacy and safety of a loading regimen of the anti-tumour necrosis factor alpha (TNF-alpha) antibody infliximab in predominantly axial severe ankylosing spondylitis (AS). METHODS: We enrolled in this study 50 patients (76% males, 87% HLA-B27(+), median age 35 yr, median disease duration 13 yr) with active AS [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) >or=30/100 and serum C-reactive protein concentration >or=15 mg/l) despite treatment with a non-steroidal anti-inflammatory drug, and without peripheral arthritis, uveitis or active inflammatory bowel disease. Other disease-modifying anti-rheumatic drugs were discontinued >or=3 months before inclusion and were not allowed during the study. Patients received three infusions of infliximab (5 mg/kg) at weeks 0, 2 and 6 and were monitored clinically and biologically until week 24. RESULTS: Forty-eight patients completed the treatment. In intention-to-treat analysis, all parameters were significantly improved at week 2 and generally reached maximal improvement at week 8. The proportion of responders, defined by a reduction of >or=20% in the global assessment of pain (GAP) or by the AS Assessment Study Group (ASAS 20%) criteria, and the proportion of patients reaching partial remission were 98, 94 and 70% respectively. Relapse, defined as >or=50% loss of maximal GAP improvement, occurred in 73% of completers, with a median delay of 14 weeks after the third infusion. No serious adverse event related to the treatment was observed. CONCLUSIONS: This study confirms, in a large group of severely affected AS patients, the remarkable efficacy of infliximab. Relapse usually occurred after discontinuation of the drug, but almost one-third of completers were still free of relapse 4 months after the last infusion.

Hemarthrosis: an unusual complication of type 1 neurofibromatosis.

Type 1 neurofibromatosis is one of the most common autosomal-dominant disorders and often includes orthopedic manifestations. We report the case of a 48-year-old woman with hemarthrosis caused by a popliteal cyst infiltrated by a diffuse neurofibroma associated with angiodysplasia. Surgical resection of this tumor was followed by postoperative hemorrhagic complications.

Tissue inhibitor of metalloprotease-1 (TIMP-1) serum level may predict progression of hip osteoarthritis.

OBJECTIVE: To determine the predictive value of serum levels of TIMP-1 and hyaluronic acid in a 1 year prospective study in hip osteoarthritis (OA). METHODS: Twenty-nine patients with OA of the hip were enrolled in a 1-year prospective study (median follow-up, 13 months). Biochemical analysis was used to assess TIMP-1 and hyaluronic acid at entry and at the end of the study. Radiographic evaluation with an assisted computed program was performed to calculate progression of joint space narrowing. Statistical tests served to determine correlations between observed serum levels and radiograph joint space narrowing. RESULTS: Among the 29 patients, 10 showed joint space narrowing greater than 0.6 mm per year. The initial concentration of TIMP-1 as well as delta value of variation in serum levels of TIMP-1 (difference between TIMP-1 concentration at entry and at the end) correlated with the progression of joint space narrowing. A cut-off value of 600 ng/ml of TIMP-1 allowed the patients who progressed slowly from those who progressed more rapidly. Hyaluronic acid serum level was not predictive of evolution. CONCLUSION: TIMP-1 serum level may serve to predict the evolution of patients with hip OA.