[Total inverted shoulder prosthesis and rotator cuff insufficiency: evaluation and determination of anatomical parameters predictive of good functional outcome in 21 shoulders]. / Prothèse totale inversée de l'épaule et insuffisance de la coiffe des rotateurs: évaluation et approche de paramètres anatomiques prédictifs d'une bonne fonctionnalité à propos de 21 cas.

OBJECTIVE: Evaluation of the functional results of the Delta 3 inverted shoulder prosthesis and determination of a radio-anatomical index predictive of best functional outcome. PATIENTS AND METHODS: Retrospective analysis of 19 patients (21 shoulders). Clinical (pain, satisfaction, amplitudes, Constant index) and radiological (acromio-epiphyseal distance) evaluation at a mean follow up of 13.6 months. RESULTS: Outcomes concerning pain, quality of life and Constant index were good and similar to other series. Few complications were observed. An increase of the acromio-epiphyseal distance of 33 to 50% compared to the non operated side is associated with a good functional result. CONCLUSION: Our results confirm those of other series and show that Delta 3 inverted prosthesis is an efficient therapeutic alternative in arthropathy with rotator cuff tears. Rehabilitation is fairly short and easy. The increase of the acromio-epiphyseal distance determines the tension of the deltoid muscle and could predict a favorable outcome.

[Adverse effects of contrast media: results of a 6 months study]. / Effets indésirables des produits de contraste: bilan de 6 mois de suivi.

The use of iodinated contrast agents is associated with adverse drug reactions (ADRs) (mainly allergic). Data from the literature suggest a frequency of ADRs ranging from 5 to 8 per cent for the whole group of iodinated contrast agents. The present systematic prospective study performed over a period of six months investigated ADRs in a Radiology Department of the University Hospital in Toulouse. After 1480 injections of iodinated contrast agents, only five ADRs (i.e. 0.34 per cent) were observed. However, the frequency remained higher in patients with a history of allergy (1.5 per cent). The low frequency of ADRs can be explained both by the use of mainly low osmolality contrast agents (75 per cent) and by systematic preventive management of risk (detailed questionnaire, choice of the contrast agent according to risk).

Different patterns of extension and recurrence in algodystrophy.

A true recurrence at exactly the same site is quite unusual in algodystrophy. Local or regional extension is possible. The bone scan is an easy way to demonstrate that the areas successively affected are not the same. An apparent local recurrence could in fact be a microscopic compression fracture of trabecular bone or cortical fractures or part of a factitious disorder.

Further vascular, bone and autonomic investigations in algodystrophy.

Direct clinical observation is the most common means of diagnosing algodystrophy. Further investigations may be helpful to rule out other pathological conditions, such as occult or stress fractures or avascular osteonecrosis and to obtain a better understanding of algodystrophy. Transient vascular hyperpermeability in the affected part is well demonstrated by the clinical findings, the MRI signs, and the three-bone scan features. 99m Technectium EHDP bone scan provides an evaluation of the vascular abnormalities and of the osteoblastic activity. Dermal microcirculation and its reactions to sympathetic stimuli are investigated by laser doppler fluximetry and videophotometric capillaroscopy. Perhaps the sweat test does unveil what might be specific about algodystrophy. The amount of bone loss in algodystrophy in a few weeks or months is what might be expected over 10 years during the natural history of uncomplicated osteoporosis. An initial fracture is undoubtedly an initiating event in the appearance of algodystrophy, but patients suffering from algodystrophy may still have significant osteoporosis for a long period and hence be at risk for fracture. Densitometry could be an aid to the diagnosis and probably to monitoring treatment as well. The local colonization of fibroblasts following the transient stage of hyperpermeability must be kept in mind to explain the results of joint, bone, muscles or neurological investigations in late algodystrophy.

The AIMS2-SF: a short form of the Arthritis Impact Measurement Scales 2. French Quality of Life in Rheumatology Group.

OBJECTIVE: To develop a short form of the Arthritis Impact Measurement Scales 2 (AIMS2) questionnaire, preserving content validity as the priority criterion. METHODS: A 2-step reduction procedure was used: 1) Delphi technique, with 1 panel of patients and 1 panel of experts each selecting 1 set of items independently; and 2) nominal group technique, where members of both panels reached consensus on the final selection of items, using information derived from item analysis. Psychometric properties of the AIMS2-Short Form (AIMS2-SF) and AIMS2 were compared using data from a cohort of 127 rheumatoid arthritis patients who completed the AIMS2 twice prior to the initiation of methotrexate (MTX) treatment and 3 months post-initiation of MTX treatment. RESULTS: The 2 panels reached consensus on a 26-item AIMS2-SF (54.4% reduction from the AIMS2). Factor analysis showed preservation of the 5-component structure. Convergent validity (Physical and Symptom components with clinical variables: r = 0.24-0.59), test-retest reproducibility (intraclass correlation coefficient >0.7), and sensitivity to change at 3 months (standardized response mean 0.36-0.8, except Social Interaction component [0.08]) were very close to the values for the original AIMS2. CONCLUSION: The AIMS2-SF is a shorter version of the AIMS2 (i.e., available in 2-page format) and has psychometric properties similar to those of the AIMS2.

An epidemiological study of diagnostic and therapeutic strategies in office practice patients with subacute or chronic pain in the thoracic or low back. Comparison of practices in primary care and rheumatology settings.

UNLABELLED: There is a paucity of epidemiological data on diagnostic and therapeutic practices in office practice patients with subacute or chronic pain in the thoracic or low back. STUDY OBJECTIVE: to describe diagnostic and therapeutic strategies used in such patients. PATIENTS AND METHODS: descriptive, prospective, two-month epidemiological study in 50 general practitioners and 50 rheumatologists. Each physician was asked to provide data on the demographics, clinical features, history of spinal disease, investigations, prior treatments and treatments prescribed on D0 and D30 in two patients with low back pain and two with thoracic back pain, of one to 12 months' duration. RESULTS: A total of 352 patients were included. In the 217 patients with low back pain, including 107 women and 110 men, duration of the pain was 4.3 +/- 0.2 months and mean age was 49.6 +/- 1 years; 67% of these patients were economically active and 22% were retired; 59% were recruited by rheumatologists. In the thoracic back pain group, there were 135 patients, including 82 women (61%) and 53 men, with a mean duration of pain of 3.8 +/- 0.3 months and a mean age of 47.7 +/- 1.4 years; 60% were economically active and 22% were retired; 49% were recruited by rheumatologists. A history of conservatively-treated low or thoracic back pain was reported for 95.4% of patients in the low back pain group and 94% in the thoracic back pain group. Of the patients with low back pain, 6.3% had had spinal surgery. Investigations were as follows: roentgenograms in 85% of low back pain and 75% of thoracic back pain patients, computed tomography in 11% and 5.8%, magnetic resonance imaging in 2% and 1% and laboratory tests in 14% and 20%. Ninety-one per cent of low back pain and 84% of thoracic back pain patients were already under therapy on D0. Ninety-six per cent of patients overall were given a prescription at the end of the D0 visit, for a nonsteroidal antiinflammatory drug or an analgesic in 80% of low back pain and 63% of thoracic back pain patients, for muscle relaxants in 62% and 69%, for drugs aimed at preventing gastric side effects in 19% and 9.5%, for myotonic agents in 10% and 8% and for sedatives in 5% and 11%. A local steroid injection was given to 20% of low back pain patients. Twenty-four per cent of low back pain and 14% of thoracic back pain patients missed days of work (mean, 11 +/- 1.7 days and 13 +/- 4.6 days, respectively). Physical therapy was prescribed to 36% of low back pain and 27% of thoracic back pain patients and a lumbar support belt to 17% of low back pain patients. On D30, the pain had abated in 86% of low back pain and 89% of thoracic back pain patients and complete freedom from pain was reported by 28% and 32% of patients in these two groups, respectively. Treatments prescribed on D30 were physical therapy (43% and 31%), analgesics (40% and 36%) muscle relaxants (25% and 30%), and nonsteroidal antiinflammatory drugs (23% and 12%). Conclusion. This preliminary study provides data on common practices in subacute and chronic low back and back pain and may prove useful for health care cost estimations.

Epidural involvement in nontuberculous disk space infections. Incidence by magnetic resonance imaging, impact and prognosis.

Eleven of 25 patients admitted for nontuberculous disk space infections had magnetic resonance imaging evidence of epidural infection. No differences were found between the 11 patients with and the 14 patients without epidural infection regarding time to diagnosis, height of fever, presence of nerve root pain, presence of prespinal and/or paraspinal abscesses and proportion of cases due to Staphylococcus aureus. Antimicrobial therapy alone ensured a full recovery with no neurological sequelae in most cases, suggesting that presence of epidural sepsis does not affect the prognosis of nontuberculous disk space infections.

Minocycline related lupus.

The determination of a factor triggering lupus-like symptoms could yield new insights into the management of rheumatic disease. We describe a case of minocycline related lupus in a young patient positive for HLA-DR2 who was prescribed minocycline 4 times for mild acne and developed rheumatic symptoms each time. We review 8 other cases.

Sulphasalazine in psoriatic arthritis: a randomized, multicentre, placebo-controlled study.

A prospective double-blind, placebo-controlled, randomized study of 24 weeks duration was carried out comparing the efficacy and tolerability of sulphasalazine (SSZ) versus placebo in patients with psoriatic arthritis. A total of 120 patients were included in nine centres. All patients had active disease and fulfilled the criteria of definite psoriatic arthritis of at least 3 months duration. They received either SSZ (2.0 g/day) or placebo. Efficacy variables included pain, patient's overall assessment of joint and skin improvement, morning stiffness, Ritchie articular index, ESR and CRP. An intention-to-treat (ITT) analysis was performed for the 117 patients who qualified (three patients did not qualify due to missing data after baseline). A per-protocol analysis was performed for the 81 patients who completed the 6 months study period (SSZ = 38, placebo = 43). Major reasons for withdrawal were inadequate response (SSZ = 4, placebo = 7) and adverse events (SSZ = 8, placebo = 12). Pain was the only statistically significantly different primary outcome variable at end point in favour of SSZ in the ITT analysis. No significant differences were present in other clinical or biological variables, although there was a trend in favour of SSZ for some variables. SSZ, at a dose of 2.0 g/day, appeared to be a safe treatment in patients with psoriatic arthritis. At this dosage, its efficacy was only demonstrated for the pain variable.

Validation of the French version of the arthritis impact measurement scales 2 and comparison with the french version of the Nottingham Health Profile. "Quality of Life in Rheumatology" Task Force.

Appropriate attention can be directed to quality of life indices in the evaluation of therapeutic interventions only if reliable, valid measurement tools with good sensitivity to change are available. The goal of this study was to validate the French version of the Arthritis Impact Measurement Scales 2 (AIMS2), called EMIR (Echelle de Mesure de l'Impact de la polyarthrite Rhumatoïde) and to compare it with the validated French version of the Nottingham Health Profile, called ISPN (Indicateur de Santé Perceptuelle de Nottingham). The French version of the AIMS2 (37 items, 12 dimensions) was obtained via several independent translations and back-translations, followed by selection of the most relevant items by a panel of experts and a preliminary evaluation in rheumatoid arthritis patients. The measurement properties of EMIR (reliability, validity and sensitivity to change) were investigated in a cohort of rheumatoid arthritis patients who were put under methotrexate therapy and followed up for six months. Reliability was evaluated by test-retest at a ten-day interval (intraclass coefficients of correlation). Principal component factorial analysis was used to study construct validity and Cronbach's alpha coefficients to study internal consistency. Convergent validity was evaluated based on correlations between the quality of life scores obtained in selected dimensions of the EMIR and a number of other parameters (number of painful/swollen joints, pain severity score on a visual analog scale, erythrocyte sedimentation rate). Sensitivity to change after three and six months was determined by calculating mean standardized response means. The EMIR and ISPN were compared based on scores and sensitivity to change for the dimensions that investigated the same concepts. One hundred twenty-seven rheumatoid arthritis patients scheduled for methotrexate therapy were entered into the study. Principal component analysis established that all dimensions of the EMIR were independent from one another, except the "walking and bending" dimension. Internal consistency was satisfactory for each of the 12 dimensions, with Cronbach's alpha coefficients ranging from 0.70 to 0.90. Most correlations between quality of life scores and clinical or laboratory parameters were significant, indicating satisfactory convergent validity. The reliability study also yielded satisfactory results, with intraclass coefficients ranging from 0.65 to 0.90. Sensitivity to change after three and six months was significant for 11 of the 12 dimensions (mean standardized responses, 0.30 to 0.77). Sensitivity to change was slightly better for the EMIR than for the ISPN. Analysis of scores demonstrated that these two instruments did not measure quality of life in exactly the same way but complemented each other.

Comparison of 90 degrees and 30 degrees laterally inclined positions in the prevention of pressure ulcers using transcutaneous oxygen and carbon dioxide pressures.

Although proper positioning is an important measure in pressure ulcer prevention, few objective measurements have been reported of the effects of different positions on oxygen supply to the skin area in direct contact with the mattress. This study compared the effects of 30 degree and 90 degree laterally inclined positions on the cutaneous oxygen supply to the skin through the measurement of transcutaneous oxygen pressure (TCPO2) and transcutaneous carbon dioxide pressure (TCPCO2) on the trochanteric (T) and the retro-trochanteric (R) areas in 20 healthy volunteers. Resting values were TCPO2 (T) 69.4 mm Hg (SD = 10.4), TCPCO2 (T) 36.3 mm Hg (SD = 5.1), and TCPO2 (R) 69.9 mm Hg (SD = 9.2). In the 90 degree laterally inclined position, the TCPO2 (R) value (68.2 mm Hg [SD = 9.9]) did not differ significantly from the resting value. These results show a dramatic impairment of oxygen supply to the skin in the 90 degree laterally inclined position but not in the 30 degree laterally inclined position. Additional studies of patients immobilized for long periods are needed to confirm the best positioning to prevent pressure ulcers.

Comparative study of 6 types of criteria in adult Still's disease.

OBJECTIVE: To compare the sensitivity of 6 sets of criteria proposed for adult Still's disease in published papers in a well defined patient population. METHODS: For inclusion we required a diagnosis of adult Still's disease established by a senior internist or senior rheumatologist. Sensitivity was evaluated in 65 new cases of adult Still's disease from a multicenter study based on signs and symptoms (1) in the first 6 months of illness, (2) in the same period in patients followed more than one year (52 patients), and (3) at any time in patients followed more than one year. RESULTS: The Yamaguchi criteria are most sensitive (93.5%), followed by those of Calabro and Londino. Medsger et al (80.6%), Kahn (69.3%), Reginato (55.2%), and Goldman (43.7%). Sensitivity was high even from the first 6 months, except for the 2 less sensitive criteria. CONCLUSION: Awareness of these discrepancies in adult Still's disease criteria are crucial to ensure comparability of different series of this condition.

Bacterial endocarditis revealed by infectious discitis.

A study of 30 patients admitted for infectious discitis identified four cases with concomitant bacterial endocarditis. All four patients were male and had concomitant streptococcal septicemia. Two patients had known aortic valve disease. The vertebral infection was located to the thoracic or lumbar spine. Ultrasonography disclosed aortic lesions in all four patients and mitral lesions in two. Management consisted of intravenous antimicrobial therapy for four weeks followed by a three-month course of oral antimicrobial therapy. The outcome of the discitis was favorable within the usual period of time. However, the endocardial lesions continued to progress, and three patients rapidly required valve replacement. Analysis of available data in the 30 patients with discitis showed that half the patients with streptococcal discitis also had bacterial endocarditis and that the latter condition developed in all the patients with streptococcal discitis and a history of valve disease. A number of risk factors were identified. An echocardiogram should be done routinely in patients with infectious discitis and risk factors for bacterial endocarditis.

Validity, reliability, and sensitivity to change of a French version of the arthritis impact measurement scales 2 (AIMS2) in patients with rheumatoid arthritis treated with methotrexate.

OBJECTIVE: To develop and validate a cross cultural version of the Arthritis Impact Measurement Scales 2 (AIMS2) to be used by French speaking populations. METHODS: A French version of the AIMS2 was obtained using back translation, committee review, and pretesting. The French AIMS2 was studied in 127 patients with rheumatoid arthritis (RA) about to receive therapy with methotrexate (MTX). Construct validity of the questionnaire was assessed by factor analysis. Convergent validity was evaluated by correlation coefficients with joint counts, pain assessment, and sedimentation rate. Reliability was assessed by test-retest procedure at a 10-day interval, Cronbach's coefficients of internal consistency, and within scale factor analyses. Sensitivity to change after 12 and 24 weeks of therapy with MTX was assessed with computation of standardized response means (SRM) and paired t test comparisons. RESULTS: Factor analyses of the French version clearly identified the same scales of the AIMS2, except for the walking and bending scale which loaded on several factors. Convergent validity of the physical and symptom components of the instrument was demonstrated by significant correlations with clinical and laboratory features. All the scales were reliable (intraclass correlation coefficients: 0.65 to 0.90; percentage of explained variance larger than 50% in all but one scale; Cronbach's alpha: 0.70 to 0.90). Sensitivity to change was demonstrated in 11 of the 12 scales (SRM: 0.30 to 0.77). Most of the improvement was noted by Week 12. CONCLUSIONS: This cross cultural adaptation of AIMS2 in French is valid, reliable, and responsive in patients with RA in whom MTX therapy is instituted. It would permit international comparison studies. This study provides evidence for construct validity and responsiveness of the original version of the AIMS2, not demonstrated previously.

Adult Still's disease: part I. Manifestations and complications in sixty-five cases in France.

DESIGN: a retrospective multicenter study conducted in France identified 65 cases of adult Still's disease. Data were recorded on a standardized questionnaire validated by the Inflammatory Joint Disease and Immunorheumatology Committee of the Société Française de Rhumatologie. OBJECTIVES: (1) To compare clinical and laboratory findings in our patients with those reported in earlier studies, particularly two large series from Canada and Japan, respectively; (2) to describe the systemic and visceral complications associated with adult Still's disease. RESULTS: as compared with the two above-mentioned series, our study group included more patients who had experienced onset of their disease after the age of 35 years and fewer patients with involvement of the liver, spleen, or lymph nodes. Rates of occurrence of arthritis, myalgia, sore throat, pleuritis, pericarditis, and abdominal pain were significantly higher in the Canadian series than in the other two series. Arthritis was absent in one fourth of our patients. Life-threatening complications included "Still's hepatopathy", disseminated intravascular coagulation (with hemophagocytosis in some cases), and "Still's myocarditis". CONCLUSION: differences in the expression of adult Still's disease were found between patients from Canada, France, and Japan. Adult Still's disease can be responsible for life-threatening complications.

Adult Still's disease. Part II. Management, outcome, and prognostic factors.

DESIGN: a multicenter study conducted in France identified 65 cases of adult Still's disease. Follow-up exceeded one year in 52 cases. OBJECTIVES: were as follows: 1) to describe treatments used; 2) to analyze disease course patterns; 3) to study joint alterations; 4) to determine whether any characteristics present within the first six months of onset were of prognostic significance. RESULTS: aspirin was ineffective. Indomethacin ensured satisfactory control in eight patients. Corticosteroid therapy was required in 88% of cases. Among patients followed up for more than one year, half developed radiologic joint alterations; 23% had monocyclic systemic disease, 38.5% had polycyclic systemic disease and 38.5% had chronic articular disease. More than half of the patients (58%) had more than one systemic flare. Polyarthritis at onset and involvement of the proximal limb joints were significantly predictive of chronic articular disease, whereas isolated arthralgia was predictive of monocyclic or polycyclic systemic disease. Oligoarthritis was not predictive of the outcome. CONCLUSION: the knowledge that polyarthritis or proximal limb joint involvement within six months of onset is predictive of chronic joint disease may have important therapeutic implications.

Direct effect of calcitriol on the regulation of parathyroid hormone secretion in a case of pseudo-hypoparathyroidism (a 24-month follow-up study).

The diagnosis of pseudohypoparathyroidism with osteitis fibrosa was made in a 51-year-old woman on the basis of hypocalcaemia, elevated plasma PTH (1-84) and blunted cAMP response to hPTH infusion. Radiologically, widespread signs of hyperparathyroidism were observed and quantitative histomorphometry confirmed the increased bone cellular turnover. Treatment with calcitriol (1,25 dihydroxyvitamin D3) induced a dramatic improvement of bone lesions. During treatment PTH (1-84) normalized with high dosage of calcitriol in spite of low or subnormal levels of serum calcium, and subsequently increased for each reduction of calcitriol dosage despite normal calcium levels. Our observations support a major and direct effect of 1,25 dihydroxyvitamin D3 on the regulation of parathyroid secretion of parathyroids glands.