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Journal: Joint, bone, spine : revue du rhumatisme

28

To compare the diagnostic accuracy of the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) and 1987 ACR criteria for rheumatoid arthritis (RA) in a cohort of patients with recent-onset arthritis followed-up for 10 years.

Concepts: Medical terms, Rheumatoid arthritis, Rheumatology, Vasculitis, Arthritis, Rheumatism, European League Against Rheumatism

28

The major strides accomplished in elucidating the pathophysiology of rheumatoid arthritis (RA) have translated into therapeutic breakthroughs in clinical practice. However, currently available treatments work only for as long as they are taken. The development of curative treatments will probably require a better understanding of the earliest phases of RA and perhaps the identification of the etiological factors, which are probably numerous. These objectives are being pursued in studies of preclinical RA. The literature review presented herein indicates that the immunological conflict probably originates outside the joints, at mucous membrane sites and, more specifically, in the upper aerodigestive tract. The preclinical phase of RA can last for many years, and some patients probably never progress to arthritis. An immunological conflict develops then spins out of control, causing increases in autoantibody titers and subsequently in levels of serum markers for inflammation, before the development of the first joint symptoms. Improved knowledge of the preclinical phase, together with information from genetic markers, will allow the identification of profiles associated with susceptibility to RA and perhaps, in the future, the development of preventive strategies.

Concepts: Medicine, Mucous membrane, Rheumatoid arthritis, Rheumatology, Osteoarthritis, Philosophy of science, Phase, Rheumatoid factor

28

OBJECTIVE: Systemic lupus erythematosus (SLE) is an autoimmune disease which may has joint impairment. Often, SLE patients complain of hand and wrist arthralgia (HA). Usually, these patients do not show any swelling in the physical exam. Our aim was to demonstrate Power Doppler Ultrasound (PDUS) abnormalities in SLE patients with HA. METHODS: We recruited 58 consecutive SLE patients and divided them into two groups: case group (n=28) were patients with HA, and control group (n=30) were patients without HA. We also collected socio-demographic and disease activity data, biological markers and SLEDAI index. We evaluated disability and quality of life by mHAQ and SF-12, respectively. We performed a bilateral hand and wrist PDUS on all patients. PDUS findings were based in OMERACT-7 group criteria. RESULTS: We found PDUS abnormalities in most of SLE patients who suffered HA, when compared to SLE controls (P<0.001). The main findings in Case Group were: tenosynovitis (39.2%), synovial effusion or hypertrophy (25%) and active synovitis (14.2%). SLEDAI score and dsDNA antibodies were related to the presence of PDUS abnormalities (P<0.05 and P<0.001, respectively). We also found worse physical SF-12 (P<0.05) and mHAQ (NS) scores in case group. CONCLUSIONS: SLE patients who present HA have more PDUS abnormalities. These findings are associated with a higher SLEDAI score and dsDNA antibodies. This articular affection may contribute to a worsened functional ability and a lower quality of life. PDUS seems to be a reliable tool in the assessment of SLE patients with HA.

Concepts: Rheumatoid arthritis, Rheumatology, Systemic lupus erythematosus, Lupus erythematosus

27

To evaluate the prevalence, types, and out-patient direct medical costs of comorbid conditions in patients with RA in Thailand.

Concepts: Rheumatoid arthritis, Rheumatology, Physician

27

OBJECTIVE: To evaluate the relationship among obesity, incidence of idiopathic median nerve lesion at the wrist (MNLW), idiopathic severe MNLW and diabetes mellitus type 2 (DMT2)-associated severe MNLW. METHODS: Clinical and electrodiagnostic data were prospectively collected from 676 patients (≥20years, 76% females) with carpal tunnel syndrome who were referred to our electrodiagnostic laboratories. In total, 229 patients had 314 cases of severe idiopathic MNLW, 447 had 777 cases of idiopathic non-severe MNLW, and 43 DMT2 patients had 62 cases of severe MNLW. We computed the standardized prevalence ratio (SPR) for obesity and compared the prevalence of obesity and body mass index (BMI) in patients with idiopathic MNLW and the 2009 OBesity EPIdemilogic (OBEPI) sample representing the prevalence of obesity in 24,455 French adults. We compared the prevalence of obesity in DMT2 patients and the Échantillon national témoin représentatif des personnes diabétiques (ENTRED) sample representing the prevalence of cardiovascular risk factors, including obesity, in 3894 French patients with DMT2. RESULTS: The SPR for obesity was 1.60 (95% confidence interval 1.23-2.07) for idiopathic severe MNLW as compared with the OBEPI sample, and 1.72 (1.17-2.46) for DMT2-associated severe MNLW as compared with the ENTRED sample. The risk of severe MNLW increased with BMI: the adjusted odds ratio was 1.09 (1.05-1.13) for each 1-point increase in BMI. This risk was not significant for patients 60years and older. DISCUSSION: The prevalence of obesity is increased for patients with severe MNLW and DMT2-associated severe MNLW as compared with their respective general populations.

Concepts: Epidemiology, Diabetes mellitus, Medical statistics, Obesity, Body mass index, Wrist, Carpal tunnel, Carpal tunnel syndrome

25

Few studies have assessed Health-Related Quality of Life (HR-QoL) in adults following juvenile idiopathic arthritis, and none since the advent of biotherapies. The aim of our study is to assess the impact of juvenile idiopathic arthritis on quality of life in a large transitional cohort, evaluate which factors influence quality of life in juvenile idiopathic arthritis, and determine which questionnaire should be used in practice.

22

Cryoglobulinemia is defined as the persistent presence in serum of abnormal immunoglobulins (Igs) that precipitate at low temperatures and dissolve again upon warming. Cryoglobulins may be composed only of a monoclonal Ig (simple type I cryoglobulinemia), of a monoclonal Ig bound to the constant domain of polyclonal Ig heavy chains (mixed type II cryoglobulinemia), or only of polyclonal Igs (mixed type III cryoglobulinemia). The manifestations of type I cryoglobulinemia are often related to intravascular obstruction, whereas those seen in the mixed cryoglobulinemias often originate in true immune complex-mediated vasculitis. The main clinical manifestations affect the skin (purpura, necrotic ulcers), joints, peripheral nervous system, and kidneys (membranoproliferative glomerulonephritis). Patients with type I cryoglobulinemia should be investigated for hematological malignancies (myeloma and B-cell lymphoma). Hepatitis C is the main diagnosis to consider in patients with mixed cryoglobulinemia, followed by connective tissue disease and B-cell non-Hodgkin’s lymphoma. The treatment depends mainly on the cause of the cryoglobulinemia. For instance, hepatitis C virus (HCV) eradication is in order in patients with HCV-associated cryoglobulinemia vasculitis, and the underlying hematological malignancy must be treated in patients with type I cryoglobulinemia.

5

To examine beliefs about cracking sounds heard during high-velocity low-amplitude (HVLA) thrust spinal manipulation in individuals with and without personal experience of this technique.

Concepts: Joint manipulation, Spinal manipulation, Spinal adjustment, Chiropractic treatment techniques, Cracking joints

3

Calcific tendonitis of the rotator cuff is due to apatite deposits in the shoulder tendons. Patients affected by calcific tendonitis have chronic shoulder pain and disability. Although the disease is frequent, about 10 to 42% of painful shoulders, mechanisms leading to this pathological mineralization are still largely unknown. Research reported in the 90s suggested that the formation of calcific deposits is linked to cells looking like chondrocytes identified around calcium deposits within a fibrocartilage area. They were considered to be derived from tenocytes but more recently, tendon stem cells, able to differentiate into chondrocytes, were isolated. The pro-mineralizing properties of these chondrocytes-like cells, especially the role of alkaline phosphatase, are not currently clarified. The calcium deposits contain poorly crystalline carbonated apatite associated with protein. Among these proteins, only osteopontin has been consistently identified as a potential regulating factor. During the disease, spontaneous resorption can occur with migration of apatite crystals into the subacromial bursa causing severe pain and restriction of movement. In in vivo and in vitro experiments, apatite crystals were able to induce an influx of leucocytes and a release of IL-1β and IL-18 through the activation of the NLRP3 inflammasome. However, mechanisms leading to spontaneous resolution of this inflammation and disappearance of the calcification still need to be elucidated.

Concepts: Enzyme, In vivo, Pain, In vitro, Shoulder, Tendon, Rotator cuff, Tendinitis

3

The classification of morphine as a step III analgesic, based on pharmacological data, creates a strong bias toward a belief in the efficacy of this drug. However, double-blind emergency-room trials showed similar levels of pain relief with intravenous acetaminophen as with intravenous morphine in patients with renal colic, low back pain or acute limb pain. In patients with chronic noncancer low back pain, morphine and other strong opioids in dosages of up to 100mg/day were only slightly more effective than their placebos, no more effective than acetaminophen, and somewhat less effective than nonsteroidal anti-inflammatory drugs (NSAIDs). In patients with osteoarthritis, strong opioids were not more effective than NSAIDs and, in some studies, than placebos. The only randomized controlled trial in patients with sciatica found no difference with the placebo. Chronic use of strong opioids can induce hyperalgesia in some patients. Hyperpathia with increased sensitivity to cold leading the patient to request higher dosages should suggest opioid-induced hyperalgesia. Pain specialists in the US have issued a petition asking that strong opioids be used in dosages no higher than 100mg/day of morphine-equivalent, in an effort to decrease the high rate of mortality due to the misuse and abuse of strong opioids (10,000 deaths/year in the US). Healthcare providers often overestimate the efficacy of step III analgesics, despite pain score decreases of only 0.8 to 1.2 points.

Concepts: Opioid, Non-steroidal anti-inflammatory drug, Paracetamol, Ibuprofen, Diclofenac, Analgesic, Celecoxib, Analgesics