[Algorithms to identify chronic inflammatory rheumatism and psoriasis in medico-administrative databases: A review of the literature]. / Algorithmes d'identification des rhumatismes inflammatoires chroniques et du psoriasis dans les bases médico-administratives : revue de la littérature.

BACKGROUND: We aimed to describe and discuss the algorithms used to identify chronic inflammatory rheumatisms and psoriasis in medico-administrative databases. METHODS: We performed a literature review on the Medline database of articles published up to 31 January 2018. Our inclusion criteria were: original articles using medico-administrative databases in accordance with the International Classification of Diseases, version 10 (ICD-10) and concerning rheumatoid arthritis (RA) or ankylosing spondylitis (AS) or psoriatic arthritis (PsoA) or Psoriasis (Pso). Our exclusion criteria were: letters to the editor, commentaries on published articles, studies using codes other than those of the ICD or a previous version. RESULTS: Out of the 590 articles identified, 37 studies were included. Concerning RA (n=10), all studies used the M05 code, associated with the M06 code in six studies. The remaining four studies specifically targeted codes M06.0, M06.2, M06.3, M06.8, M06.9, and two of them also used code M12.3. For AS (n=8), 7 studies used the M45 code, while only one study used M45.9, M46.1 or M46.8. For Pso (n=17), all studies used the L40 code and/or at least two dispensations of vitamin D. Concerning PsoA (n=13), all studies used the same codes: M07.0, M07.1, M07.2, M07.3. CONCLUSION: We recommend using codes M05 and M06 rather than M06.1 and M06.4 for RA, M45 for AS, the algorithm L40 and/or two dispensations of topical vitamin D for psoriasis, and codes M070 to M073 to identify PsoA patients in medico-administrative databases.

Disease-modifying drug retention rate according to patient age in patients with early rheumatoid arthritis: analysis of the ESPOIR cohort.

Physicians are sometimes hesitant to use disease-modifying antirheumatic drugs (DMARDs) in elderly patients with rheumatoid arthritis (RA), as they are deemed too fragile, although there are no sufficient scientific evidence. We aimed to compare DMARD treatment retention in early RA patients from the ESPOIR cohort, according to age upon inclusion. Overall, treatment retention was evaluated as the percentage of patients whose DMARDs were not stopped, with stratification by age group: < 50, 50-64, and > 65 years. Survival curves were measured using the Kaplan-Meier method. Of the entire ESPOIR cohort (n = 813), 7% were > 65 years old. Methotrexate (MTX) was used by 521 patients, and was the sole DMARD for 198 patients. MTX treatment retention appeared better in patients > 65 years old compared to < 50 years old [HR 0.45 (0.25; 0.81); p = 0.008, n = 195/198] with adjustment on sex, smoking, positive anti-cyclic citrullinated peptide antibodies, positive rheumatoid factor, body mass index, changes in DAS28 and corticosteroid treatment. The proportion of patients using etanercept (n = 111), and this drug's retention rate, did not differ according to patient age. The proportion of patients treated with adalimumab (n = 104) was significantly higher in patients < 50 years old (p = 0.003), and treatment retention was marginally better among younger patients [HR 1.68 (0.88; 3.22), p = 0.12]. Within the ESPOIR cohort, DMARD retention did not appear to differ according to age-except for better retention of MTX treatment in patients 50-64 years old, and of adalimumab in patients < 50 years old.

A six-week antibiotic treatment of endocarditis with spondylodiscitis is not associated with increased risk of relapse: A retrospective cohort study.

BACKGROUND: We compared the relapse rate at 1 year in patients with vertebral osteomyelitis with or without associated endocarditis. PATIENTS AND METHODS: We conducted a retrospective cohort study. Inclusion criteria were patients hospitalized in the infectious disease, rheumatology, cardiology, cardiovascular surgery and two internal medicine units for vertebral osteomyelitis (blood culture and/or disco-vertebral biopsy) and compatible imaging, between 2014 and 2017. We compared patients with associated endocarditis (VO-EI group) and without endocarditis (VO group) using logistic regression to determine the factors associated with relapse and EI. The main outcome was the relapse rate at 1 year. RESULTS: Out of the 207 eligible patients, 62 were included (35 in the VO group and 27 in the VO-EI group). Four patients presented with a new VO during follow-up, one (2.86%) patient in VO group and three (11.11%) in VO-EI group (P=0.68). There were more men in the VO-EI group than in the VO group (74.07% vs. 48.57%, P=0.04), valvulopathies (13/27 vs. 8/35, P=0.06), vertebral localization (1.22±0.50 vs. 1.03±0.17, P=0.04) and septic kidney embolism (5/27 vs. 0/35, P=0.01). Control blood cultures were more often positive in the VO-EI group (12/27 vs. 8/35, P=0.04). In 45% of patients, the germ was a staphylococcus, 29% streptococci, 10% enterococci, 10% gram-negative bacillus (GNB). There were more streptococci and enterococci in the VO-EI group than in the VO group (44.44% vs. 17.14% and 18.52% vs. 8.57%, respectively). Antibiotic safety was good and comparable between groups. CONCLUSION: In a relatively small population, we did not find significantly more relapse in the endocarditis group.

Cannabis use assessment and its impact on pain in rheumatologic diseases: a systematic review and meta-analysis.

OBJECTIVES: Despite classic analgesic or effective treatments in rheumatic diseases, such as synthetic DMARDs in RA, patients remain in pain and often turn to non-prescribed pharmacological alternatives, such as cannabis self-therapeutic use. However, this medical use of cannabis has not been thoroughly studied. METHODS: We performed a systematic literature review up to June 2020. The incidence of cannabis consumption was calculated by metaproportion. Differences between cannabis users and non-users were expressed as standardized mean differences using the inverse-variance method. We also assessed the effects of cannabis on pain. RESULTS: A total of 2900 patients reported cannabis consumption in a sample of 10 873 patients [incidence 40.4% (95% confidence interval (CI): 0.28, 0.54)], and 15.3% (95% CI: 0.07, 0.27) specified that they were currently taking cannabis. Cannabis use was higher in the four fibromyalgia studies [68.2% (95% CI: 0.41, 0.90), n = 611] compared with seven articles concerning RA or lupus [26.0% (95% CI: 0.14, 0.41), n = 8168]. Cannabis consumption was associated with a decrease in pain intensity [VAS pain at baseline 8.2 (2.9) vs 5.6 (3.5) mm over time; pooled effect size -1.75 (95% CI: -2.75, -0.76)]. Cannabis users were younger [58.4 (11.4) vs 63.6 (12.1) years; P <0.001], more often smokers [OR 2.91 (95% CI: 1.84, 4.60)] or unemployed [OR 2.40 (95% CI: 1.31, 4.40)], and had higher pain intensity [5.0 (2.4) vs 4.1(2.6) mm; P <0.001] than non-users. CONCLUSION: Nearly 20% of patients suffering from rheumatologic diseases actively consume cannabis, with an improvement in pain. The issue of cannabis use in the management of these patients should be addressed during medical consultation, essentially with cannabis-based standardized pharmaceutical products.

Agranulocytosis under biotherapy in rheumatoid arthritis: three cases hypothesis of parvovirus B19 involvement in agranulocytosis observed under tocilizumab and rituximab for the treatment of rheumatoid arthritis.

Leukopenia is a considerably common complication of tocilizumab [TCZ] and rituximab [RTX] therapy. RTX-induced leukopenia typically exhibits delayed onset. While agranulocytosis has been reported linked to RTX treatment of lymphoma, this complication rarely occurs in rheumatoid arthritis (RA) treatment and, to our knowledge, has never been reported in association with TCZ therapy. We herein report four agranulocytosis cases in three patients, with the first two cases suspected to be secondary to human parvovirus B19 (PVB19) infection. Agranulocytosis manifested in the first patient 2 months following a third RTX course. Bone marrow (BM) polymerase chain reaction (PCR) was positive for PVB19. The patient relapsed after three TCZ courses, with her PCR again positive for PVB19. Both episodes resolved under granulocyte-macrophage colony-stimulating factor (GM-CSF). In the second patient, agranulocytosis manifested after the 74th TCZ course. Bone marrow PCR was positive for PVB19, and the evolution was favorable under intravenous immunoglobulin administration. The third case was a 53-year-old female patient with seropositive RA who presented agranulocytosis after the first infusion of her fourth RTX course. Unfortunately, no PCR PVB19 was made on myelogram. Evolution was favorable after 5 days of GM-CSF. PVB19 infection should be investigated in patients suffering from agranulocytosis manifesting during biotherapy. In cases manifesting from the 15th day of RTX treatment onwards, hemogram must be conducted before readministering the infusion.

French validation of the Foot Function Index (FFI).

OBJECTIVE: French validation of the Foot Function Index (FFI), self-questionnaire designed to evaluate rheumatoid foot according to 3 domains: pain, disability and activity restriction. METHODS: The first step consisted of translation/back translation and cultural adaptation according to the validated methodology. The second stage was a prospective validation on 53 patients with rheumatoid arthritis who filled out the FFI. The following data were collected: pain (Visual Analog Scale), disability (Health Assessment Questionnaire) and activity restrictions (McMaster Toronto Arthritis questionnaire). A test/retest procedure was performed 15 days later. The statistical analyses focused on acceptability, internal consistency (Cronbach's alpha and Principal Component Analysis), test-retest reproducibility (concordance coefficients), external validity (correlation coefficients) and responsiveness to change. RESULTS: The FFI-F is a culturally acceptable version for French patients with rheumatoid arthritis. The Cronbach's alpha ranged from 0.85 to 0.97. Reproducibility was correct (correlation coefficients>0.56). External validity and responsiveness to change were good. CONCLUSION: The use of a rigorous methodology allowed the validation of the FFI in the French language (FFI-F). This tool can be used in routine practice and clinical research for evaluating the rheumatoid foot. The FFI-F could be used in other pathologies with foot-related functional impairments.

Macro-creatine kinase: a neglected cause of elevated creatine kinase.

Macro-creatine kinase (macro-CK) is a neglected cause of raised CK. Over a 10-year period, we observed five cases. Three patients had macro-CK type 1. One patient with fibromyalgia underwent several explorations to find a muscular pathology; another, who had elevated CK-MB (muscle-brain fraction) activity, was referred to a cardiologist, and statin therapy was erroneously discontinued in two patients. Two patients had macro-CK type 2: a man with a neuroendocrine carcinoma and a woman with rheumatoid arthritis. Diagnosis of type 1 obviates the need to carry out pointless and expensive investigations seeking a neuromuscular or cardiac pathology, and also, the unwarranted discontinuation of statin therapy. Type 2 must prompt investigations for a neoplasm.

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.

[Palindromic rheumatism]. / Rhumatisme palindromique.

Palindromic rheumatism is characterized by episodes of arthritis or para-arthritis leaving no residual or radiographic changes. Several diseases should be ruled out in the differential diagnosis. Evolution to rheumatoid arthritis is common, especially in patient with positive rheumatoid factor and anticitrullinated peptides. In seronegative patients, palindromic rheumatism could be part of the spectrum of autoinflammatory diseases because of a high frequency of MEFV mutations. Treatment remains discussed. The use of antimalarials could delay the development of rheumatoid arthritis or another connective tissue disease.

Predictive factors of rituximab response in rheumatoid arthritis: results from a French university hospital.

OBJECTIVE: To study the influence of several factors (rheumatoid factor [RF], anti-cyclic citrullinated peptide [anti-CCP], serum Ig level, and Epstein-Barr virus [EBV] load) on clinical response to rituximab (RTX) after 6 months in rheumatoid arthritis (RA) patients. METHODS: Sixty-four patients receiving RTX (two 1-gm doses 2 weeks apart) for active RA were prospectively included. RF, anti-CCP, gamma globulin level, and EBV load were assessed prior to the first RTX cycle. Clinical responses were analyzed 6 months after RTX initiation using the European League Against Rheumatism criteria. Univariate and multivariate analyses were performed to identify factors associated with RTX response at 6 months. RESULTS: The mean disease duration was 16.4 years and 46 patients (71.9%) had already received at least 1 anti-tumor necrosis factor agent prior to RTX. At 6 months, 46 patients (71.9%) had a good to moderate response to RTX. Anti-CCP positivity was associated with a good to moderate response (odds ratio [OR] 4, 95% confidence interval [95% CI] 1.04-15.5; P = 0.04). RF positivity (P = 0.26) and positive initial EBV load (P = 0.16) were not associated with a good to moderate response. Hyperimmunoglobulin was correlated with a poorer response to RTX than normal Ig levels (OR 0.04, 95% CI 0.005-0.28; P = 0.002). CONCLUSION: Anti-CCP positivity was a predictor of good to moderate response to RTX in RA patients. On the other hand, high Ig levels were associated with a poorer outcome in contrast to previous findings. Further support from larger studies is necessary so as to optimize the management of the RA patients with high Ig levels.

Is IgG4-Related Disease a Cause of Xerostomia? A Cohort Study of 60 Patients.

Objective. Immunoglobulin-G4-(IgG4-) related disease (IgG4 RD) is a fibrosing process characterized by a significant infiltration of IgG4-secreting plasma cells. IgG4 RD can affect almost all organs including salivary glands. Whether IgG4 RD plays a role in the development of sicca syndrome and particularly dry mouth syndrome remains to be investigated. Methods. We conducted a monocentric cohort study for two years to search for IgG4 RD features in patients with dry mouth syndrome using immunostainings of labial salivary gland specimens with anti-IgG4 antibody. Results. Among 60 patients presenting with dry mouth syndrome who underwent labial salivary gland biopsy, 18 showed positive immunostaining with the anti-IgG4 antibody including 4 patients with typical systemic IgG4 RD. Five also fulfilled criteria for Sjögren's syndrome. Conclusion. These findings suggest that clinical forms of IgG4 RD salivary involvement without salivary swelling may occur. This salivary involvement is probably overlooked in everyday practice and could represent a mild form of IgG4 RD.

Screening of tuberculosis before biologics.

Using anti-TNF has significantly improved the management of chronic inflammatory rheumatism. However, there is clear evidence that this treatment increases the risk of reactivating tuberculosis. The intradermal tuberculin skin test (ITT) and interferon-γ-release assays (IGRAs) are currently used to detect latent tuberculosis infection. The results of ITT are difficult to analyze in patients vaccinated with Bacille Calmette-Guérin (BCG) and because of variation in test administration and reading. Numerous authors have compared the sensitivity and specificity of IGRA and ITT, including in two recent meta-analyses and one literature review. These authors, however, compared different populations with different ITT positive thresholds (5, 10, and 15mm). We performed a meta-analysis of studies in which the threshold was 15mm, the recommended level in France. The sensitivity of QuantiFERON, T-spot, and ITT was 79% (IC 76%-83%), 84% (IC 75%-95%), and 69% (IC 65%-73%), respectively. In France, it is recommended to detect latent tuberculosis infection on the basis of history taking, physical examination, 5-unit ITT, and lung X-ray. This screening leads to treating 20%-30% of patients, with considerable adverse-effects. Because of the sensitivity and specificity of IGRAs, it is no longer justified to systematically perform TST for detection of tuberculosis before initiating anti-TNF treatment.

[Treatment of gout]. / Traitement de la goutte.

In France, colchicine remains the standard treatment for the acute flare of gout. The lowest dose currently used decreases digestive toxicity. Doses of colchicine should be adapted to renal function and age, and possible drug interactions should be considered. Non steroidal anti-inflammatory drugs are an alternative to colchicine, but their use is frequently limited by comorbidity. When these treatments are contraindicated, corticosteroid injections can be performed after excluding septic arthritis. Systemic corticosteroids could be used in severe polyarticular flares. Anti-IL1 should provide a therapeutic alternative for severe cortico dependant gout with tophus. To prevent acute flares and reduce tophus volume, uric acid serum level should be reduced and maintained below 60mg/L (360µmol/L). To achieve this objective, it is often necessary to increase the daily dose of allopurinol above 300mgs, but the need to adapt the dose to renal function is a frequent cause of therapeutic failure. In the absence of renal stone or renal colic and hyperuraturia, uricosuric drugs are the second-line treatment. Probenecid is effective when creatinine clearance is superior to 50mL/min Benzbromarone, which was withdrawn due to hepatotoxicity, can be obtained on an individualized patient basis in the case of failure of allopurinol and probenecid. Febuxostat, which was recently approved, is a therapeutic alternative. Diuretics should be discontinued if possible. Use of fenofibrate should be discussed in the presence of dyslipidemia and losartan in patient with high blood pressure. Uricolytic drugs (pegloticase), which are currently being investigated, may be useful for the treatment of serious gout with tophus, especially in the presence of renal failure. Education of patient, identification and correction of cardiovascular risk factors should not be forgotten.

Disease activity score-driven therapy versus routine care in patients with recent-onset active rheumatoid arthritis: data from the GUEPARD trial and ESPOIR cohort.

OBJECTIVES: To compare the efficacy of disease activity score in 28 joints (DAS28ESR)-driven therapy with anti-tumour necrosis factor (patients from the GUEPARD trial) and routine care in patients with recent-onset rheumatoid arthritis (patients of the ESPOIR cohort). RESULTS: After matching GUEPARD and ESPOIR patients on the basis of a propensity score and a 1:2 ratio, at baseline all patients had comparable demographic characteristics, rheumatoid factor, anticyclic citrullinated peptide antibody positivity and clinical disease activity parameters: erythrocyte sedimentation rate, C-reactive protein, mean DAS (6.26±0.87), Sharp/van der Heijde radiographic score (SHS), health assessment questionnaire (HAQ). Disease duration was longer in GUEPARD patients (5.6±4.6 vs 3.5±2.0 months, p<0.001). After 1 year, the percentage of patients in remission with an HAQ (<0.5) and an absence of radiological progression was higher in the tight control group (32.3% vs 10.2%, p=0.011) as well as the percentage of patients in low DAS with an HAQ (<0.5) and an absence of radiological progression (36.1% vs 18.9%, p=0.045). However, there was no difference in the decrease in DAS, nor in the percentage of EULAR (good and moderate), ACR20, ACR50 and ACR70 responses. More patients in the tight control group had an HAQ below 0.5 (70.2% vs 45.2%, p=0.005). Overall, pain, patient and physician assessment and fatigue decreased more in the tight control group. The mean SHS progression was similar in the two groups as was the percentage of patients without progression. CONCLUSIONS: In patients with recent onset active rheumatoid arthritis, a tight control of disease activity allows more patients to achieve remission without disability and radiographic progression.

[Transversal fractures in spinal ankylosis: a case series of 17 patients]. / Fractures transversales du rachis ankylosé : une série de 17 cas.

PURPOSE: Transverse fractures of the spine are rare. They occur in ankylosed spine and may lead to neurological complications. We report a series of 18 cases observed in 17 patients with ankylosing spondylitis (AS). The objective of this study were to describe the clinical, diagnostic and therapeutic features of our series and to compare our results with those of the literature. METHODS: We conducted a retrospective study from 1975 to 2008 in the neurosurgery and rheumatology departments of the university hospital (CHU) of Clermont-Ferrand. RESULTS: Eighteen transverse spine fractures were documented in 17 patients (one female patient had two fractures of the lumbar vertebrae). The 13 male and four female patients included in this series had a mean age of 57.4 ± 17.2 years and AS for a mean time of 21.3 ± 12 years (5-40). All patients had spinal ankylosis with a "bamboo" spine appearance. The reasons for hospital admission were suspicion of AS flare (n=10) and suspected traumatic fracture (n=8). Trauma, in most cases minor, was noted in 15 patients. Fourteen patients presented with mechanical spinal pain and three had both mechanical and inflammatory pain. Three patients experienced severe pain on mobilization. Two patients had pyramidal syndrome. The mean time to diagnosis of the fracture was 6.8 ± 8.4 weeks (0-22). The fracture was located in cervical spine (n=2), dorsal spine (n=8) and lumbar spine (n=8). It was transdiscal and transcorporeal in nine cases each. Standard radiographs (n=18) identified the fracture in nine cases. The fracture was demonstrated in all CT-scan (n=13). Magnetic resonance imaging (MRI) (n=6) showed the fracture in five cases and epidural hematoma in one. Eleven patients had orthopedic treatment and six underwent surgery. Outcome was favorable in 16 patients. One paraplegic patient died of pulmonary embolism. CONCLUSION: Transverse fractures of the spine are rare and diagnosis should be considered in a patient with AS and ankylosed spine who presented mechanical spine pain following even minor trauma. If standard radiographs are normal, further investigations should be performed using MRI, CT-scan, or both.

Two more cases of evaluation of POEMS syndrome using 18-FDG PET/CT.

Following the article of Alberti et al., we would like to provide our own experience with two more cases in evaluation of POEMS syndrome using morphological and functional imaging modalities, including plain X-rays, computed tomography (CT), magnetic resonance imaging (MRI), bone scintigraphy and positrons emission tomography with computed tomography (PET/CT). Among them, 18-FDG PET/CT proved its usefulness allowing extensive screening of the bony lesions involved.

[Efficacy of infliximab in the treatment of follicular occlusion triad]. / Efficacité de l'infliximab dans le traitement d'une triade d'occlusion folliculaire.

BACKGROUND: Dermatological treatments for the follicular occlusion triad have only partial and transient efficacy. PATIENTS AND METHODS: A 20-year-old patient presented folliculitis of the scalp, acne and hidradenitis suppurativa, associated with spondyloarthritis. Treatment with infliximab for rheumatologic symptoms induced complete and lasting dermatological and rheumatological remission. COMMENTS: The efficacy of anti-TNF-alpha in follicular occlusion triad provided confirmation that infection is not at the heart of the aetiological process. However, efficacy data is still sparse and additional studies are required.