[Procedural pain assessment after spinal injections of corticosteroid]. / Douleur induite: complication méconnue des infiltrations péridurales aux corticoïdes chez l'adulte.

BACKGROUND: Spinal injections of corticosteroid are commonly performed by rheumatologists in their daily practice but little is known about the frequency, the intensity and the management of procedural pain observed in these osteoarticular injections in daily practice. AIM: To evaluate the prevalence and intensity of pain caused by spinal injections. METHODS: In this observational prospective study, data were collected over 6 months, for up to 44 procedures (corticosteroid spinal injection). Evaluation of the pain was evaluated immediately before and after the injection using Huskisson's visual analogue scale (VAS). Statistical analysis was carried out in order to compare patients who had suffered from pain whilst undergoing the procedure to those who had not. RESULTS: Data were analyzed for 17 patients (12 female, mean age 53.6 ± 10.5 years). Over 50% of patients experienced procedural pain. Significant predictive factors of genesis of the procedural pain were the young age (p=0.022) and the intensity of the initial pain (p < 0.001), while the existence of a co morbidity is rather a protective factor (p = 0.006). Others factors such us sex, origin, level of studies, socioeconomic conditions, didn't seem to have of effect on the procedural pain. CONCLUSION: Most patients undergoing spinal injections suffer from procedural pain. Specific research and guidelines for the management of procedural pain related to rheumatologic care should be established to improve the quality of care provided by physicians.

[Assessment of depression in rheumatoid arthritis: a cross sectional study on 60 patients]. / Prévalence et facteurs prédictifs de la dépression au cours de la polyarthrite rhumatoïde.

OBJECTIVE: To assess the prevalence of depression in a series of Tunisian patients with rheumatoid arthritis (RA) and to identify factors associated with its occurrence. METHODS: We performed a cross sectional study on 60 patients with RA. The evaluation of depression was performed using the Montgomery and Asberg depression rating scale. RESULTS: Our study revealed a high prevalence of depression in RA patients (45%). The main predictor factors of its occurrence were female gender, absence of professional activity, absence of social support, high activity of RA, impaired quality of life and existence of structural damage. PERSPECTIVES: Our results highlight the importance of a good management of RA in order to prevent the occurrence of depression. They also underline the interest of screening for depression in RA patients to avoid its adverse effects on the course of RA.

[Thoracic outlet syndrome]. / Le syndrome du défilé cervico-thoraco-brachial.

BACKGROUND: The thoracic outlet syndrome (TOS) is recognized as a cause of upper limb pain. It is often under-diagnosed and its frequency under-estimated by rheumatologists. AIM: To report the diagnostic problems related to TOC though a literature review. METHODS: A narrative review of literature RESULTS: The diagnosis of TOS is difficult because of intricacy of vascular and neurological symptoms. It requires provocative tests, electrophysiological investigations and Doppler ultrasonography. A good anatomical knowledge is mandatory in order to clarify the mechanisms and the location of the lesions which depend on sophisticated imaging exams. It is also recommended to exclude all other causes of upper limb pain, as well as peripheral nerve compression syndromes, which can coexist with TOS. CONCLUSION: Diagnosis and treatment of the TOS involves rheumatologists, neurologists, physiatrists, orthopedic surgeons,vascular surgeons, thoracic surgeons, neurosurgeons and sometimes psychiatrists who have to cooperate in order to prevent severe functional after-effects.

[Uncommon cervicobrachial neuralgia: about 17 cases]. / Les névralgies cervico-brachiales symptomatiques : Apropos de 17 cas.

BACKGROUND: Cervicobrachial neuralgia (CBN) is frequent in out patient clinic as well in general medicine as in rheumatology. Even though cervical disc degeneration and osteophytosis constitute the most frequent etiology of such a trouble, the practitioner must be aware of much more serious underlying cause. AIM: To investigate the epidemiology, clinical features, aetiologies and paraclinical characteristics of uncommon CBN. METHODS: Retrospective chart review about 17 cases of uncommon CBN among the 84 cases of CBN hospitalized at the rheumatology department of the Charles Nicolle Hospital during a 16-years-period [1990-2005]. RESULTS: There were 11 men and 6 women with a mean age of 63 years [33y-81y]. All patients presented a CBN since in average five months [2 months- 24 months]. Neck stiffness was noted in 60% of cases and a neurological impairment in 47% of cases. X-ray radiographs of cervical spine were normal in five cases. In the remaining cases, they showed lytic images (six cases), disk space narrowing with vertebral erosions (two cases) and vertebral fracture (three cases). Further investigations concluded that the CBN was due to a Pancoast'syndrome in five cases, an infectious spondylitis in three cases, cervical bone metastasis in two cases, a syringomyelia in two cases, a neuroma in one case, a thoracic outlet syndrome in one case and an erosive spondylarthropathy in a patient presenting chronic renal failure managed by hemodialysis. CONCLUSION: In comparison with common CBN, our patients presenting symptomatic CBN were characterised by an inflammatory and refractory pain. The more frequent recourse to modern imaging is justified.

[Bisphosphonates: indications in bone diseases other than osteoporosis]. / Indications des bisphosphonates dans les affections osseuses autres que l'ostéoporose

AIM: Report of bisphosphonates indications for osseous diseases other than osteoporosis. METHODS: Narrative review of the literature. RESULTS: Bisphosphonates represent a new medication which is increasingly used. Besides osteoporosis, it is indicated as first choice in different bone diseases such as Paget's disease and the prevention of bone complications in tumoral osteolysis. Bisphosphonates' efficiency has been proven in other pathologies: the fibrous dysplasia and the osteogenesis imperfecta. More over, many studies are driven having for goal to show the efficiency of bisphosphonates in the algoneurodystrophy, non corticosteroid-treated osteoporosis in chronic inflammatory rheumatism and aseptic osteonecrosis. CONCLUSION: Bisphosphonates are a powerful inhibition of osseous resoption frestable indicated for osteoporosis. Their indications were retended to paget's disease, malignant hypercalcemia, and osseous complications of malignant osterlysis.

[Obesity has a protective effect on radiographic joint damage in rheumatoid arthritis]. / L'obésité est un facteur protecteur contre l'atteinte structurale au cours de la polyarthrite rhumatoïde.

BACKGROUND: Obesity is a state of chronic low-grade inflammation that predisposes people to several diseases and that is increasingly prevalent. Rheumatoid arthritis (RA) is marked by the presence of proinflammatory cytokines and, in general, the presence of high levels of inflammatory markers is associated with a severe disease course and joint damage. AIM: To assess the impact of obesity on disease activity, quality of life and articular damage in patients with established RA. METHODS: Between July 2009 to December 2009, 119 RA patients were included and divided in two groups according to the body mass index (obeses and controls). RA activity was assessed by the Disease Activity Score (DAS) 28, quality of life by the Health Assessment Questionnaire (HAQ) and radiographic joint damage by the modified Sharp score. RESULTS: Obesity was not correlated with worsen RA activity (p=0.71) nor quality of life impairment (p=0.51). The obese group had a lower modified Sharp score than the control group (64.97versus113.64; p < 0.032) and this association remained significant after adjustment for age, sex, disease activity, extraarticular manifestations, comorbidities, presence of rheumatoid factor, and disease duration. CONCLUSION: Obesity does not have an impact on disease activity nor changes in quality of life, but it has a protective effect on the amount of joint destruction in established rheumatoid arthritis.

[Pott's disease of the upper cervical spine (three cases and literature review)]. / Mal de Pott du rachis cervical supérieur (à propos de 3 cas).

BACKGROUND: Sub-occipital Pott's disease is rare, but dangerous. AIM: To recall diagnostic aspects and spatially the neuroradiological ones of sub-occipital Pott's disease. METHODS: We describe three patients with sub-occipital Pott's disease followed in our department from 2002 to 2007. RESULTS: There were two women and one man (mean age at onset: 48 years). The early clinical picture was non specific. Exploration, in addition to standard radiographies included a computerized Tomography (CT) (n=2) and MRI (n=1 and n=3). The diagnosis was confirmed histologically on a biopsy of the abscess (n=1), a bacteriological evidence (n=2) and retained thanks to argument presumption (n=3). The treatment was based on quadruple antituberculous chemotherapy with external traction (n=2 and n=3) associated with urgent surgery (n=1) because of the worsening of the neurological complications. The evolution was fatal (n=1) and positive (n=2 and n=3). CONCLUSION: Tuberculosis should be suspected in patients with chronic torticollis and residing in an area when tuberculosis is endemic. Medical treatment is based on a quadruple antituberculosis chemotherapy with traction in the presence of atlanto-axial instability. Surgery is reserved in case of neurological worsening or persistent instability.

[Monoarthritis of the elbow revealing an intraarticular osteoid osteoma]. / Monoarthrite du coude révélatrice d'un ostéome ostéoïde intra-articulaire.

BACKGROUND: Osteoid osteoma is one of the unusual causes of musculoskeletal pain. Its diagnosis is usually not difficult in classic diaphyseal localization. However, the diagnosis of juxta or intraarticular osteoid osteoma is challenging because of atypical clinical presentation responsible for long diagnosis delay. AIM: Report a new case. CASE REPORT: We report herein the case of a 22-year-old woman presenting an intraarticular osteoid osteoma of the elbow. Diagnosis has been established on imaging findings (MRI and CT-scan) after 10 months because of atypical clinical presentation as a chronic monoarthritis of the elbow. The picture of an osteoid osteoma of the lower extremity of the humerus associated to a synovitis and a joint effusion was suspected on MRI. It had been confirmed on CT-scan wich showed the nidus. Surgical removal of the tumor allowed pain relief and functional restoration in postoperatively. CONCLUSION: Regarding an unexplained chronic monoarthritis, the diagnosis of intraarticular osteoid osteoma should be evoked. CT-can remains the investigation of choice for identifying the nidus. Surgical exicision permits the relief of symptoms.

[Morbidity of the elderly in inpatient rheumatology clinic]. / Morbidité hospitalière du sujet âgé en milieu rhumatologique.

BACKGROUND: The improvement of life expectation in our country explains at least in part the increase of the proportion of the elderly in hospitalized patients. AIM: The aim of this study was to identify the main diseases leading to hospitalization of the aged in a rheumatology department, to establish their clinical profiles and to evaluate the quality of their management. METHODS: Retrospective chart review about the elderly (age > or =65 years) admitted in the rheumatology department of the Charles Nicolle Hospital during a 2-year-period [January 2003-December 2004]. RESULTS: Among the 831 patients admitted to our inpatient clinic during that period, 86 were 65-year-old or more representing 10% of the total. Mean age was 71.2 years [65-88]. The sex ratio was 1/3. A history of a mean of two associated diseases [0-5] was noted. They were dominated by hypertension (50%) and diabetes (26.7%). Almost 1/3 of the elders had a surgical history. Gastro-intestinal troubles have been noted in only 19% of cases. The main cause of hospitalization was a diagnosis exploration (77.6%). The remainings were admitted for therapeutic adjustment. The disease was evolving since in mean 16 months (15 days-15 years). The mean duration of hospitalization was 21.2 days (4-60). The pathologies involved were varied dominated by degenerative rheumatisms (26.7%) with a predilection to lumbar spine, systemic diseases: 18 cases (20.9%) with 13 cases of rheumatoid arthritis, and malignant bone diseases (18.7%). At least two rheumatic diseases were found together in 49 patients (57%). The clinical findings were atypical in almost half cases (42.4%) in such aged patients. Besides drugs prescribed for non rheumatic diseases, our patients took a mean of 3.4 drugs (1-8) as symptomatic, adjuvant or etiologic treatment. The treatment observance was good in 74.4% of cases. Iatrogenic incidents occurred in 14 cases (16.2%). The outcome was favorable in 68.9% of cases. Twelve of our patients necessitated a third help. Half of our patients (54%) were controlled in our outpatient clinic 1-2 months after their issue, 12 have been hospitalized for the same disease, 8 deceased, and 19 have been lost. CONCLUSIONS: The management of the elderly patients in hospitalization must be multidisciplinary. It should take into account the clinical and therapeutic particularities of such a population. Prevention remains the best guarantee for a good quality of life and to decrease social and economic costs.

[Update in treatment of psoriatic arthritis]. / Actualités thérapeutiques du rhumatisme psoriasique.

Psoriatic arthritis is a chronic rheumatic disease making part of spondylarthropathies. It is the most frequent chronic inflammatory rheumatism after rheumatoid arthritis. Eventhough, it is usually a benign affection, it may be destructive leading to handicap. Several new medications have been introduced, including anti-tumor necrosis factor (TNF alpha blockers) and leflunomide for treatment of psoriatic arthritis. Many studies show the efficacy of these medications in this disease.

[Adult onset Still's disease: about 11 cases]. / La maladie de still de l'adulte: à propos de 11 cas.

BACKGROUND: Adult onset Still's disease (AOS) is an inflammatory disorder which associates variable articular and systemic manifestations. Despite a better knowledge of its biological and clinical particularities; the pathogeny of this disease remains unknown. The aim of this study is to analyze the epidemiological, clinical, biological and, outcome characteristics of AOS. METHODS: It is a retrospective study about 11 cases of AOS hospitalized over a 24-year-period (1982-2005) at The Rheumatology Department of Charles Nicolle's Hospital of Tunis. All patients responded to the Yamaguchi criteria. RESULTS: Mean age was 35.4 years [20y-70y] with a sex-ratio of 0.57. Fever and articular involvement were the most frequent signs. Cutaneous symptoms were present in 6 patients. Three of our patients developed destructive arthritis. Renal amyloidosis, a rare complication of AOS, has been noted in one case. CONCLUSION: AOS is an unfrequent disorder characterized by its diagnosis and treatment difficulties. Recent advances in immunotherapy may better the management of AOS.

Usefulness of video-capillaroscopy in clinical practice: systematic review of indications and results in rheumatology and in non-rheumatic disorders.

BACKGROUND: Nailfold video-capillaroscopy (VCP) is nowadays worldwide considered as one of the best diagnostic noninvasive imaging technique able to study microcirculation in vivo. AIM: To review the applications of VCP in the clinical practice and its results in rheumatic and non-rheumatic diseases. METHODS: Review of literature RESULTS: The possibility of managing the imaging, by means of dedicated software able to characterize quantitative and qualitative data, represents another relevant property of VCP. This technique is very useful at the identification of microvascular involvement in many rheumatic diseases, particularly in systemic sclerosis and related disorders. At the same time, VCP has been showed valuable in many other extra-rheumatic diseases. The authors review the applications of VCP in the clinical practice and its results in rheumatic and non-rheumatic diseases.

[Septic arthritis in the elderly: about 21 cases]. / Les arthrites septiques du sujet âgé: à propos de 21 cas.

BACKGROUND: Septic arthritis (SA) is a serious disease especially if occurring in elderly debilitated by frequent comorbidities and diminished immunity. AIM: The authors discuss diagnosis difficulties, prognosis and, therapeutic consequences of the occurrence of septic arthritis in elders. METHODS: It is a retrospective study about 21 cases of septic arthritis (SA) occurring in the elderly aged 65-year-old or more, hospitalized over a ten year period [1994-2005] at the department of Rheumatology of Charles Nicolle's Hospital of Tunis. RESULTS: Mean age was 70.8 years [65y-83y] with a sex-ratio of 1.1. A history of rheumatologic and/or systemic diseases was present in 62% of cases. Clinic presentation was atypical explaining the long mean diagnosis delay; 23 days for pyogenic SA, 9.3 months for tuberculous arthritis. The germ involved, isolated in 11 cases, was a Staphylococcus Aureus in most ones. Tuberculous arthritis represented 28.6% of cases. The outcome was favourable in 19 cases (90%) after antibiotherapy. CONCLUSION: Because of its seriousness, SA should be evocated in front of any articular inflammation occurring in elderly. Adequate management must be started as soon as possible.

Tuberculosis of the greater trochanter: a report of three cases.

Trochanteric tuberculosis represents less than 2% of all musculo-skeletal tuberculosis. The diagnosis is difficult especially if abscess and fistula are missing. The authors report 3 cases of trochanteric tuberculosis. The diagnosis was established, respectively, 4, 9 months and 1 year after the beginning of the symptoms. The tuberculosis was plurifocal in all cases. Diagnosis was based on the presence of caseum granuloma in the first case, positive Lowenstein culture in the second case and on clinical and paraclinical arguments in the third one. Healing was obtained after medical treatment alone. The authors discuss the potential role of the newer imaging modalities in diagnosis of trochanteric tuberculosis and the indications of medical and surgical treatment.