Changes in the incidence and management of spinal tuberculosis in a French university hospital rheumatology department from 1966 to 2010.

INTRODUCTION: Two previous single-center studies in a university hospital rheumatology department suggested an increase in the incidence of spinal tuberculosis in France in the 1990s. Our objective in this study was to obtain incidence data on spinal tuberculosis since 1995 in the same department and to describe changes over the entire study period from 1966 to 2010. We also compared patients seen between 1966 and 1995 to those seen between 1995 and 2010. METHODS: We conducted a retrospective review of all cases of spinal tuberculosis seen in our rheumatology department between 1966 and June 1995 and between July 1995 and 2010. We collected the annual incidence, clinical and radiological features, and diagnostic and therapeutic strategies. RESULTS: One hundred and thirty patients were managed between 1966 and 2010. The number of cases declined in the 1970s and 1980s then increased over the next two decades. None of the patients had HIV infection. Over 70% of patients were from continental France. Compared to patients seen during the earlier period, those seen after June 1995 were older (62.8±17.2 vs. 53±14.3 years, P=0.0006), had more comorbidities, and more often exhibited severe radiological findings (including multilevel involvement, epidural involvement, and abscesses). No changes occurred in time to diagnosis or management strategies. CONCLUSION: The incidence of spinal tuberculosis in a university hospital rheumatology department has increased over the last two decades, chiefly as a result of reactivation of past tuberculosis, as opposed to origin from endemic countries or HIV infection.

Efficacy in current practice of switching between anti-tumour necrosis factor- α agents in spondyloarthropathies.

OBJECTIVE: Anti-TNF-α agents are remarkably effective in the treatment of SpAs. However, 30% of patients withdraw from anti-TNF-α agents yearly because of inadequate efficacy or side effects. The objective of this study was to assess in current practice the response to a second and a third anti-TNF-α. METHODS: Retrospectively, all records of patients who had received at least two anti-TNF-α agents have been studied. For axial forms, treatment was considered effective if 3 months after switching the patient had a favourable expert opinion or showed an improvement in BASDAI of at least 2 on a scale of 0-10 or an improvement of 50% (BASDAI 50). For peripheral forms, the treatment was considered effective if the patient had a favourable expert opinion or if a clinical improvement of >30% of the swollen and tender joint counts was established. The reasons for switching were: (i) primary non-responder; (ii) loss of efficacy; and (iii) occurrence of side effects. To identify response predictor factors bivariate analysis was performed. RESULTS: Three hundred and seventy-seven patients under anti-TNF-α agents were treated and 99 patients had received at least two anti-TNF-α agents. Twenty-eight of these 99 patients had been treated with three anti-TNF-α agents. Following the failure of a first anti-TNF-α, the response to a second agent was satisfactory in 80.8%. Patients who had received a third anti-TNF-α following failure of the first two also showed a satisfactory response in 82.1%. The reason for switching from the first or second agent was not predictive of the response. CONCLUSION: In the event of failure or intolerance to anti-TNF-α in the treatment of SpAs, performing a first or second switch produces a satisfactory therapeutic response.

Study of the information delivery by general practitioners and rheumatologists to patients with acute low back pain.

Providing information to patients regarding appropriate management of LBP is a crucial component of primary care and treatment of low back pain (LBP). Limited knowledge is available, however, about the information delivered by physicians to patients with low back pain. Hence, this study aimed at evaluating (1) the self-reported practices of French physicians concerning information about patients with acute LBP (2) the consistency of these practices with the COST B13 guidelines, and (3) the effects of the delivery of a leaflet summarizing the COST B13 recommendations on the management of patient information, using the following study design: 528 French physicians [319 general practitioners (GP) and 209 rheumatologists (RH)] were asked to provide demographic information, responses to a Fear Avoidance Beliefs questionnaire adapted for physicians and responses to a questionnaire investigating the consistency of their practice with the COST B13 guidelines. Half of the participants (163 GP and 105 RH) were randomized to receive a summary of the COST B13 guidelines concerning information delivery to patient with low back pain and half (156 GP and 104 RH) were not given this information. The mean age of physicians was 52.1±7.6 years, 25.2% were females, 75% work in private practice, 63.1% reported to treat 10-50 patients with LBP per month and 18.2%<10 per month. The majority of the physicians (71.0%) reported personal LBP episode (7.1% with a duration superior to 3 months). Among the 18.4% (97) of the physicians that knew the COST B13 guidelines, 85.6% (83/97) reported that they totally or partially applied these recommendations in their practice. The average work (0-24) and physical activity (0-24) FABQ scores were 21.2±8.4 and 10.1±6.0, respectively. The consistency scores (11 questions scored 0 to 6, total score was standardized from 0 to 100) were significantly higher in the RH group (75.6±11.6) than in GP group (67.2±12.6; p<0.001). The delivery of a summary of the COST B13 guidelines significantly improved the consistency score (p=0.018). However, a multivariate analysis indicated that only GP consistency was improved by recommendations' delivery.The results indicated that GP were less consistent with the European COST B13 guidelines on the information of patients with acute LBP than RH. Interestingly, delivery of a summary of these guidelines to GP improved their consistency score, but not that of the RH. This suggests that GP information campaign can modify the message that they deliver to LBP, and subsequently could change patient's beliefs on LBP.

Pregnancy during TNFalpha antagonist therapy: beware the rifampin-oral contraceptive interaction. Report of two cases.

We report two cases of pregnancy in patients taking TNFalpha antagonists for chronic inflammatory joint disease. A factor in both pregnancies was the use of rifampin concomitantly with a combined oral contraceptive. Both patients were taking rifampin and isoniazid for tuberculosis prophylaxis in compliance with French recommendations for patients with positive intradermal tuberculin tests who are scheduled to receive biotherapeutic agents.

Evaluation of bone loss and its mechanisms in anorexia nervosa.

The purpose of this cross-sectional study was to assess the extent of and mechanisms involved in bone loss in anorexia nervosa patients. We compared 113 anorexia nervosa patients (mean age 25 +/- 8 years, mean duration of disease 5.7 +/- 6.1 years) with 21 age-matched controls. Mean duration of amenorrhea was 3.2 +/- 4.7 years. We measured serum calcium and phosphate; bone remodeling markers (osteocalcin, bone-specific alkaline phosphatase [BSAP], serum crosslaps [CTX], and carboxyl-terminal telopeptide of type I collagen [ICTP]); follicle-stimulating hormone and luteinizing hormone levels; and estradiol (ultrasensitive assay), cortisol, urinary free cortisol, thyroid function, prolactin, and nutritional factors (insulin-like growth factor I [IGF-I], IGF binding protein 3 [IGFBP3]). In controls, only bone remodeling markers and nutritional factors were measured. Osteodensitometry was also performed on both patients and controls. Weight and body mass index (BMI) were significantly lower in anorexia nervosa patients than in controls (P < 0.0001). No significant differences were observed in biological indicators except for IGF-I, which was lower in anorexia nervosa patients (0.9 +/- 0.4 UI/mL) than in controls (1.5 +/- 0.4 UI/mL) (P < 0.0001). Densitometric measurements at three sites were significantly lower in anorexia nervosa patients and correlated with duration of disease and amenorrhea and with IGF-I at the hip only (P < 0.01). In the study population, osteoporosis was observed in 24 patients (21%) and osteopenia in 54 patients (48%). Patients with osteoporosis were significantly older and had longer disease and amenorrhea durations; lower weight and BMI; higher alkaline phosphatase, BSAP, and osteocalcin; and lower serum ICTP, IGF-I, and IGFBP3. All of these differences were significant and remained so even after multiple adjustments were made, except for IGF-I (P = 0.21). When multivariate analysis was performed, we found that age at onset of amenorrhea, weight, alkaline phosphatase, urinary free cortisol, and serum estradiol concentration accounted for 54% of the variance in spinal bone mineral density (BMD). Duration of amenorrhea, alkaline phosphatase, and weight explained 46.6% of the variance in femoral neck BMD. Duration of amenorrhea, IGF-I, and ICTP levels accounted for 38.6% of the variance observed in total hip BMD. The etiology of bone loss in patients with anorexia nervosa is multifactorial. Hypoestrogenia alone cannot account for this loss, and nutritional factors, IGF-I concentrations in particular, seem to play an important role.

Magnetic resonance imaging of the hand for the diagnosis of rheumatoid arthritis in the absence of anti-cyclic citrullinated peptide antibodies: a prospective study.

OBJECTIVE: To assess the practical usefulness of magnetic resonance imaging (MRI) in establishing a positive diagnosis of rheumatoid arthritis (RA) in a cohort of patients with early inflammatory polyarthralgia, in the absence of anti-cyclic citrullinated peptide (anti-CCP) antibodies. METHODS: We prospectively followed 30 outpatients with inflammatory polyarthralgia and/or synovitis of at least one joint. Patients were disease modifying antirheumatic drug-naive and received no corticosteroids. At the initial visit a clinical examination, radiographs of hands, wrists and feet, and MRI of hands were performed. Rheumatoid factor and anti-CCP antibodies were assessed. The MRI procedure was T1 fat saturation with gadolinium injection [scores were established on the basis of the axial view of the carpal and metacarpal joints, using the RA MRI scoring system (RAMRIS) defined in the OMERACT study]. In all patients, radiographs at baseline were normal and anti-CCP antibodies were negative. RESULTS: At one-year followup, the final diagnosis was: 16 RA; the non-RA group was composed of 4 cases of spondyloarthropathy, 2 cases of fibromyalgia, 4 cases of undifferentiated arthritis (3 of which were self-limiting), 1 sicca syndrome, 1 hemochromatosis, 1 polymyositis, and 1 paraneoplastic syndrome. No statistical difference was found between patients with and without RA for carpal erosion, synovitis, and tenosynovitis. However, a statistical difference was observed between the RA and non-RA group where metacarpophalangeal (MCP) erosion scores were concerned (p = 0.024). This difference persisted when we compared erosions of the second and third MCP in the 2 groups (p = 0.044). ROC curve analysis revealed a positive MCP score at 15, with a specificity of 70% and a sensitivity of 64%. CONCLUSION: In our population of 30 anti-CPP negative patients with normal radiographs, MRI of hands, showing MCP erosions, can be helpful for the diagnosis of RA.

Information and low back pain management: a systematic review.

STUDY DESIGN: A systematic search of three electronic databases was done to identify randomized controlled trials on the effect of written or audiovisual information in low back pain. OBJECTIVES: To determine whether information is an effective preventive action and/or therapy for low back pain and which type of information is most effective. SUMMARY OF BACKGROUND DATA: Information is commonly used in the primary care of low back pain and mostly delivered by booklets. METHODS: A systematic computer-aided search of the Medline, PsyclInfo, and Embase database. A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results. RESULTS: Eleven randomized controlled trials were selected, including seven trials of high methodologic quality, as well as one parallel group controlled survey and one longitudinal study. Only three of the seven high-quality studies showed favorable results for information. There is strong evidence that a booklet increases knowledge and moderate evidence that physician-related cues increase the confidence in a booklet and adherence to exercises. There is limited evidence that a biopsychosocial booklet is more efficient than a biomedical booklet to shift patient's beliefs about physical activity, pain, and consequences of low back trouble. There is strong evidence that booklets are not efficient on absenteeism and conflicting evidence that they are efficient on healthcare use. There is no evidence that e-mail discussion or video programs alone are effective to reduce low back pain, disability, and healthcare costs. CONCLUSIONS: Information based on a biopsychosocial model is recommended in primary care to shift patient beliefs on low back pain. Nevertheless, information delivery alone is not sufficient to prevent absenteeism and reduce healthcare costs.

Streptococcal and enterococcal spondylodiscitis (vertebral osteomyelitis). High incidence of infective endocarditis in 50 cases.

OBJECTIVE: To characterize the clinical, biological, and imaging features and outcomes of patients with streptococcal and enterococcal spondylodiscitis (SESD). METHODS: This retrospective study of patients with SESD was carried out in 2 departments of rheumatology from 1990 through 2002. Comparison was made with cases of staphylococcal spondylodiscitis (SSD) seen during the same period, excluding postoperative cases. RESULTS: Fifty cases of SESD were reviewed and compared with 86 cases of SSD. The main finding was a higher frequency of concomitant infective endocarditis in patients with SESD (11/42 vs 1/37; p = 0.009). Evidence of inflammation, imaging features, and neurological impairment at admission appeared to be less severe in SESD, but the difference did not reach statistical significance. Duration of treatment was shorter in SESD than in SSD (105 +/- 26 days vs 130 +/- 49 days; p = 0.003). CONCLUSION: Our study confirms the high incidence of infective endocarditis (26%) during SESD. Clinicians must look for predisposing factors and clinical abnormalities in patients with spondylodiscitis whenever a streptococcal or enterococcal agent is identified. Echocardiography should be performed as routine in such situations.

Ultrasonographic assessment of arterial cross-sectional area in the thoracic outlet on postural maneuvers measured with power Doppler ultrasonography in both asymptomatic and symptomatic populations.

OBJECTIVE: The purpose of this study was to evaluate the feasibility and potential usefulness of power Doppler ultrasonography (PDU) in the assessment of changes in arterial cross-sectional area in the thoracic outlet during upper limb elevation. METHODS: Forty-four volunteers and 28 patients with a clinical diagnosis of arterial thoracic outlet syndrome were evaluated by B-mode imaging and PDU. Arterial cross-sectional area was assessed in the 3 compartments of the thoracic outlet with the arm alongside the body and at 90 degrees, 130 degrees, and 170 degrees of abduction. The percentage of arterial stenosis was calculated for each of these arm positions. Nineteen of the 28 patients were also assessed by magnetic resonance (MR) imaging. RESULTS: No significant arterial stenosis was shown in the interscalene triangle and in the retropectoralis minor space of the volunteers and patients. A significant difference (P < .01) in stenosis between volunteers and patients was seen for all degrees of abduction in the costoclavicular space. The 130 degrees hyperabduction maneuver appeared to be the most discriminating postural maneuver. Seven patients assessed with MR imaging did not have any arterial stenosis on MR images, whereas an appreciable degree of arterial stenosis was shown with ultrasonography. CONCLUSIONS: Arterial compression inside the thoracic outlet can be detected and quantified with B-mode imaging in association with PDU.

The rheumatoid shoulder: current consensus on diagnosis and treatment.

Shoulder involvement is usually inconspicuous in patients with rheumatoid arthritis, and the clinical manifestations are nonspecific. Nevertheless, shoulder involvement should be sought routinely and detected early. Range of motion at the shoulder should be evaluated. Although normal radiographic findings do not rule out shoulder involvement, radiographs are crucial for detecting micro- and macro-geodes during follow-up. The development of glenohumeral joint space narrowing is a turning point that indicates a risk of rapid joint destruction. Magnetic resonance imaging is useful for assessing the lesions and guiding the treatment strategy. Stepwise use of local interventions as indicated by imaging findings is recommended. Joint replacement should not be left too late, and surgical procedures on the shoulder should be built into the overall treatment plan.

Chronic neck pain and masticatory dysfunction.

Chronic nonspecific neck pain is a common problem in rheumatology and may resist conventional treatment. Pathophysiological links exist between the cervical spine and masticatory system. Occlusal disorders may cause neck pain and may respond to dental treatment. The estimated prevalence of occlusal disorders is about 45%, with half the cases being due to functional factors. Minor repeated masticatory dysfunction (MD) with craniocervical asymmetry is the most common clinical picture. The pain is usually located in the suboccipital region and refractory to conventional treatment. The time pattern may be suggestive, with nocturnal arousals or triggering by temporomandibular movements. MD should be strongly suspected in patients with at least two of the following: history of treated or untreated MD, unilateral temporomandibular joint pain and clicking, lateral deviation during mouth opening, and limitation of mouth opening (less than three fingerbreadths). Rheumatologists should consider MD among causes of neck pain, most notably in patients with abnormal craniocervical posture, signs linking the neck pain to mastication, and clinical manifestations of MD. Evidence suggesting that MD may cause neck pain has been published. However, studies are needed to determine whether treatment of MD can relieve neck pain.

Contribution of percutaneous biopsy to the definite diagnosis in patients with suspected bone tumor.

OBJECTIVES: Percutaneous biopsy is widely used for the diagnosis of primary and secondary bone malignancies. The primary objective of this study was to evaluate the contribution of percutaneous biopsy to the definite diagnosis in patients with suspected bone tumor. The secondary objective was to assess the potential diagnostic benefits of a second percutaneous biopsy when the first failed to provide the diagnosis. METHODS: We retrospectively reviewed 108 percutaneous biopsies of bone lesions in 89 patients admitted to our rheumatology department from January 1994 to December 2001. There were 61 men and 28 women with a mean age of 59 years. The biopsies were done under computed tomography guidance in 68 patients and fluoroscopy in 21 patients. RESULTS: The diagnostic yield of percutaneous biopsies was 68.5% overall and was significantly higher in patients with metastatic bone disease (100%) than in patients with primary tumors (83%) or hematological malignancies (58%) (P = 0.0004 and P < 0.0001, respectively). Yields were higher for peripheral lesions (85%) than for vertebral (65%) and pelvic (60%) lesions. Yields were 87% for lytic lesions, 66% for sclerotic lesions, and 50% for mixed lesions. When soft tissues were sampled, the yield was 100%, as compared to 86% for biopsies composed only of bone. CONCLUSION: Percutaneous biopsy of suspected bone tumors is a safe and inexpensive procedure that consistently ensures the diagnosis of bone metastases. The diagnostic yield is lowest in patients with bone lesions caused by hematological malignancies. When two biopsies fail to provide the diagnosis, further biopsies are unlikely to be helpful.

Long-term follow-up of vertebral osteoporotic fractures treated by percutaneous vertebroplasty.

The aim of this study was: to assess the long-term efficacy and safety of percutaneous vertebroplasty (PVP) for treating painful vertebral osteoporotic fractures, and to estimate the risk of vertebral fracture in the vicinity of a cemented vertebra. A prospective open study was conducted. PVP were carried out between July 1995 and September 2000 for 16 patients with symptomatic osteoporotic vertebral fracture that had not responded to extensive conservative medical therapy. All the patients were followed-up for more than 1 year. The efficacy of the PVP was assessed by the changes over time in pain on Huskisson's visual analog scale (VAS) and on the McGill-Melzack scoring system (MGM). The efficacy of the procedure was also assessed by measuring the changes over time in quality of life assessed by the Nottingham Health Profile (NHP instrument): twenty-one vertebrae treated by PVP in 16 patients were evaluated. The mean duration of follow-up was 35 months. Pain assessed by the VAS significantly decreased from a mean of 71.4 mm+/-13 before PVP to 36 mm+/-30 after 6 months, and to 39 mm+/-33 at the time of maximal follow-up ( p<0.05 for both comparisons). The results were also significant for the MGM: 3.00+/-0.57 before PVP to 1.6+/-1.4 at the long-term follow-up ( p<0.05). The solely statistically significant decrease for quality of life was noted for pain. A slight but not significant improvement was noted for 3/6 dimensions of the NHP scores. A slight but significant increase in social isolation was also found. No severe complication occurred immediately after PVP. At the long term follow-up (35 months) there was a slight but not significantly increased risk of vertebral fracture in the vicinity of a cemented vertebra: odds ratio 3.18 (95% confidence interval (CI) 0.51-19.64). The odds ratio of a vertebral fracture in the vicinity of an uncemented fractured vertebra was 2.14 (95% CI: 0.17-26.31). In conclusion, PVP appears to be safe and effective for treating persistent painful osteoporotic fractures. Controlled studies with long-term follow-up are needed to evaluate the risk of vertebral fractures in the vicinity of a cemented vertebra.

Bone metastases revealing primary tumors. Comparison of two series separated by 30 years.

OBJECTIVE: To compare two series of patients admitted to a rheumatology department for bone metastases 30 years apart and to obtain a pragmatic estimation of the percentage of bone metastases revealing cancer. METHODS: The recent series was composed of 132 patients seen between 1989 and 1996 and the earlier series of 50 patients admitted between 1958 and 1967. All patients were admitted to the same rheumatology department for bone metastases from a diagnosed or undiagnosed primary. Both series were studied retrospectively. The rate of occurrence of each cancer diagnosis was determined in the patients with and without known primaries. RESULTS: Among the patients with metastatic disease as the first manifestation of cancer, the percentage with lung cancer increased from the early to the recent series, particularly among women, whereas the percentages with prostate and breast cancer decreased. The primary remained unknown in 27% and 38% of patients in the early and recent series, respectively. CONCLUSION: Despite the introduction of new investigations, our ability to identify primaries responsible for bone metastases does not seem to have improved. However, our data should be interpreted with caution since recruitment probably differed between the two series.

Primary amyloidoma of the axis and acute spinal cord compression: a case report.

BACKGROUND: Localized primary amyloidosis is a disease characterized by a single tumor and localized amyloid deposit (amyloidoma) with no evidence of generalized amyloidosis. The occurrence of an amyloidoma in the spine is rare and only three cases affecting the axis have been previously reported. We describe the case of a 79-year-old woman presenting with a mass involving the odontoid process, responsible for an acute tetraparesia. Diagnosis of local primary amyloidosis was made after surgical excision. RESULTS: Despite the critical presentation, outcome was excellent after total excision of the mass. This case can be classified as a primary localized amyloidoma. The patient did not exhibit any infection, tumor or inflammatory disease, and continued investigations failed to demonstrate other amyloid deposit after one-year follow-up. CONCLUSIONS: Amyloidoma must be discussed in presence of a tumor-like mass of the odontoid process and may be responsible, as in our case, for spinal cord compression.

Bone mineral density changes in hypercalciuretic osteoporotic men treated with thiazide diuretics.

UNLABELLED: A few studies suggest that thiazide diuretic agents may have modest beneficial effects on bone. Few data are available on the effects of these medications in patients with osteoporosis and hypercalciuria. OBJECTIVE: To evaluate the effects of thiazide diuretic therapy on bone mass and urinary calcium excretion in hypercalciuretic osteoporotic male patients. PATIENTS AND METHODS: Osteoporosis was defined as a greater than 2.5 standard deviation (S.D.) decrease in bone mineral density (BMD) at the lumbar spine or hip (T-score). We used an open-label prospective design to compare 14 patients with hypercalciuretic osteoporosis treated with a thiazide diuretic for 18 months and 13 patients with primary osteoporosis treated with calcium and vitamin D supplementation. Mean age was 53.5 +/- 9.6 years in the thiazide group and 48.7 +/- 8.4 years in the calcium-vitamin D supplementation group. The following serum parameters were assayed at baseline: 25OH-D3, 1,25OH-D3, parathyroid hormone (PTH), and bone turnover markers. Urinary calcium excretion and BMD by dual-energy X-ray absorptiometry at the spine and hip were determined at baseline and after 18 months of treatment. RESULTS: Annual BMD increases were similar in the two groups during the 18-month treatment period: lumbar spine, 0.6 +/- 2.5% (P = 0.47) in the thiazide group and 0.004 +/- 3% (P = 0.78) in the supplementation group; femoral neck, 0.47 +/- 2.6% (P = 0.89) and 1.1 +/- 3.2% (P = 0.22); total hip, 0.65 +/- 2.5% (P = 0.37) and 0.12 +/- 2.1% (P = 0.51). Urinary calcium excretion fell by 45.9% in the thiazide group from baseline to study completion (P = 0.0015). CONCLUSION: We found no evidence that thiazide therapy increased bone mass in patients with hypercalciuria and osteoporosis as compared to calcium-vitamin D supplementation in patients with osteoporosis but no hypercalciuria. In contrast, our results establish the efficacy of thiazide diuretics in reducing urinary calcium excretion, an effect that may decrease the risk of urinary lithiasis. Studies in larger patient cohorts treated for longer periods are needed to confirm or refute our findings.

Multiple myeloma presenting with widespread osteosclerotic lesions.

Sclerotic lesions are rare in malignant monoclonal gammopathies, although they are occasionally associated with POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes). In most cases, osseous lesions in POEMS syndrome present as an isolated sclerotic deposit or a combination of both lytic and sclerotic lesions. Diffuse osteosclerosis is extremely rare and may lead to the diagnosis of multiple myeloma, classically known to present as lytic lesions in the skeleton, with or without diffuse osteoporosis. We report a 74-year-old woman with widespread and substantial osteosclerotic lesions, associated with IgA-lambda myeloma, and with no other criteria for POEMS syndrome, and who was rapidly diagnosed with compression of the spinal cord. Detailed knowledge of imaging features in myeloma emphasises the need to consider plasma cell neoplasm in the differential diagnosis of any pattern of bone sclerosis. Although exceptional, multiple myeloma must be borne in mind in the presence of diffuse bone sclerosis.

Pain management in a rheumatology department: a satisfaction survey.

OBJECTIVES: To evaluate the quality of pain management in a teaching hospital rheumatology department. METHODS: We conducted a satisfaction survey among all the patients admitted to the conventional rheumatology department of our teaching hospital over a 1-month period (88 patients with a mean length of stay of 5 d). The patients were asked to complete a questionnaire on the day of discharge. The professional staff was not informed of the survey. RESULTS: The mean pain severity score at admission (visual analog scale, VAS) was 7.76 +/- 1.76 and the mean score decrease with treatment was 7.27 +/- 2.81. Expected pain relief and actual pain relief were correlated (R = 0.39; P = 0.001). Nearly all the patients (96.1%) reported have been encouraged to communicate about their pain. Information on the treatment was given to 89.3% of the patients; no significant differences in pain severity or pain relief were found between the patients who did and did not receive this information. The patients were satisfied with their management by the physicians (VAS: 8.83 +/- 2.07) and nurses (VAS: 8.68 +/- 1.72). CONCLUSION: Satisfaction with pain management (a subjective criterion) was good in our patients. However, no validated tools for measuring satisfaction are available, and measurements should be repeated to look for improvements over time. Limitations to these results include the placebo effect, the influence of memory, and the effects of the behavior of hospitalized patients. A repeat survey is needed.

Thoracic outlet: assessment with MR imaging in asymptomatic and symptomatic populations.

PURPOSE: To compare the dynamic modifications of the thoracic outlet in asymptomatic volunteers and symptomatic patients and assess the presence and location of vasculonervous compressions in these two populations. MATERIALS AND METHODS: Thirty-five healthy volunteers and 54 patients with clinical symptoms of thoracic outlet syndrome (TOS) underwent magnetic resonance (MR) imaging of the thoracic outlets with their arms alongside their bodies and after a postural maneuver. Measurements were obtained at the interscalene triangle (thickness of anterior scalene muscle, interscalene angle), at the costoclavicular space (minimum costoclavicular distance, distance between inferior border of subclavius muscle and the anterior chest wall, maximum thickness of subclavius muscle, angle between first rib shaft and horizontal), and at the retropectoralis minor space (distance between posterior border of pectoralis minor muscle and posterior lining of axilla at the passage of the axillary vessels, thickness of pectoralis minor muscle). The presence and location of vasculonervous compressions were also assessed. Group data were analyzed with the Student t test. RESULTS: Patients with TOS had a smaller costoclavicular distance after the postural maneuver (P <.001), a thicker subclavius muscle in both arm positions (P <.001), and a wider retropectoralis minor space after the postural maneuver (P <.001) than did volunteers. Venous compressions after the postural maneuver were observed in 47% of volunteers and 63% of patients at the prescalene space, in 54% of volunteers and 61% of patients at the costoclavicular space, and in 27% of volunteers and 30% of patients at the retropectoralis minor space. Arterial and nervous compressions, respectively, were seen in 72% and 7% of patients. No arterial or nervous compression was seen in volunteers. Except for venous thrombosis, vasculonervous compressions were demonstrated only with arm elevation. Only three thoracic outlet measurements differed significantly in both populations. CONCLUSION: MR imaging appeared helpful in demonstrating the location and cause of arterial or nervous compressions.