Assessment of rheumatoid arthritis patients' knowledge about foot problems related to their illness and foot care practice.

INTRODUCTION: Foot problems are very common in rheumatoid arthritis (RA). Podiatric intervention through therapeutic education of RA patients on the different potential foot problems could improve patients' knowledge and management of their foot problems. This study aimed to evaluate the knowledge of RA patients on podiatric problems related to their illness and foot care practices. METHODS: This was a cross-sectional study including patients diagnosed with RA and aged older than 18 years. Sociodemographic data, disease characteristics, and therapeutic data were collected. RA foot problems knowledge and foot care practice were assessed using a questionnaire combining questions developed from the literature search and a pretested validated questionnaire. RESULTS: Overall, 103 patients were included of whom 94 were female. The mean age was 56 years (±10 years) and the mean disease duration was 15 years (±10 years). Over 77% of patients reported never having received foot-health-related education. With regard to their knowledge about RA foot involvement, patients were aware that RA can affect the feet similarly to the hands (83%), lead to deformation of the foot (86%), lead to walking difficulties and falling (68%), and produce skin lesions of the foot (31%). Regarding participant's knowledge of appropriate footwear, 65% agreed that it would be beneficial to wear quality standard sports shoes. However, less than one-third of patients know the podiatrist's skills. CONCLUSION: Our study showed an awareness of the repercussions of RA on feet but a lack of knowledge on proper foot care, thus identifying a need for foot health therapeutic education.

Hypoparathyroidism: Musculoskeletal Manifestations Related to Parathormone Deficiency.

BACKGROUND: Hypoparathyroidism is a rare metabolic disorder characterized by a deficiency in the parathyroid hormone. AIM: This manuscript aims to provide an updated review of musculoskeletal diseases and conditions associated with adult-onset nonsurgical nongenetic hypoparathyroidism. Musculoskeletal manifestations are frequent in patients with hypoparathyroidism and can reveal this disease. METHODS: They may include myopathy, shoulder disorder, immune-negative non-erosive peripheral arthritis, axial involvement simulating spondylarthritis, and diffuse ligamentous ossifications. An association between hypoparathyroidism and spondyloarthritis or autoimmune diseases is possible. T-cell activation can be seen in patients with hypoparathyroidism and may explain the co-occurrence of hypoparathyroidism with other autoimmune diseases. The treatment of these manifestations is based on conventional therapy with calcium and active vitamin D. Parathyroid hormone may have an anabolic effect on muscle atrophy and muscle weakness. Diffuse myalgia, muscle cramps, weakness, and myopathy can appear in patients with hypoparathyroidism. RESULT: Besides, parathyroid hormone can promote bone formation and bone resorption by stimulating osteoclast differentiation by increasing RANKL (receptor activator for nuclear factor kappa- B ligand) expression. Therefore, hypoparathyroidism can be responsible for an increase in bone mineral density. CONCLUSION: The risk of fractures does not appear to be reduced due to changes in bone microarchitecture and the high risk of falls. Treatment with parathyroid hormone has been shown to improve bone microarchitecture.

Influencing Factors in Tunisian Rheumatoid Arthritis Patients' Quality of Life: Burden and Solutions.

BACKGROUND: Rheumatoid Arthritis (RA) is a disease with a heavy functional, psychological, and socioeconomic impact. The management of Quality of Life (QoL) as a therapeutic objective is a fairly recent notion, especially in Tunisia. We aimed to evaluate QoL in RA patients and to identify its affecting factors. METHODS: This was a cross-sectional study in a Tunisian rheumatology center. To assess QoL, we used the Short Form Health Survey (SF-36) and the Arthritis Impact Measurement Scales Short Form (AIMS2-SF). Health Assessment Questionnaire Disability Index (HAQ), the Hospital Anxiety and Depression Scale (HAD) for psychological disorders, Visual Analog Scale for Pain (VAS Pain), and for fatigue (VAS Fatigue) were also used. Disease activity was assessed by the Disease Activity Score (DAS28 CRP). RESULTS: We enrolled 120 established RA, the mean age of our patients was 56.9 ± 11.4 years, with a predominance of women (83.3%). The mean disease duration was 10.97 ± 7.7 years. According to the HAD scale, 27% of our patients presented anxiety, and 26.7% had depressive disorders. There was significantly impaired QoL in patients with low educational level, dependent financial situation, long disease duration, high disease activity, high pain and fatigue levels, poor therapeutic education, functional disability, and psychological disorders (p < 0.001). A strong negative correlation was detected between inflammatory markers, structural damage, and the scores of QoL. Patients under biologics scored significantly higher in the SF36 mental health domain (p < 0.001). CONCLUSION: QoL is significantly poor in Tunisian RA. These patients should be managed using a multidisciplinary approach involving the patients themselves.

Foot function in rheumatoid arthritis: Correlation between the Rheumatoid and Arthritis Outcome Score and performance-based physical tests.

BACKGROUND: Foot function is usually assessed using self-reported outcome measures which remain subjective in patients with rheumatoid arthritis (RA). Physical performance tests were recommended for functional assessment in lower limb osteoarthritis. However, foot function assessment's guidelines in RA are lacking. We aimed to investigate the correlation between a self-reported outcome measure and two performance-based physical tests for assessing foot function in RA patients. METHODS: A cross-sectional study was performed over 7 months' period including RA patients. We used Rheumatoid and Arthritis Outcome score (RAOS) as a self-reported functional tool. Physical performance tests were 4-min walk test (4-MWT) and Timed up and go test (TUGT). RESULTS: Fifty RA patients were included with 96% females and a mean age of 54.7 ± 10.4 years. Foot involvement occurred since the diagnosis of RA in 36% of patients. Foot pain was reported by 68% of patients (48% forefoot), and foot stiffness in 46% of patients. Skin lesions of the feet were found in 78% of patients, 90% had foot deformities and 56% had inflammatory disorders of feet. Radiographic lesions were found in 94% of patients. The most impaired RAOS subscales were Sports and Recreation and Quality of life. Poor physical-based performance was found in 34% of RA patients according to 4-MWT, in 42% of RA patients according TUGT, and in 46% of patients based on at least one performance test. RAOS was negatively correlated to the 4-MWT and positively correlated in the subscales pain, other symptoms, activities of daily living, and Sport/Rec of the RAOS. Poor performance-based physical tests were significantly associated with advanced age, sedentary lifestyle, higher disease activity score and impaired functional status. Foot-related parameters significantly associated with poor performance-based physical tests were: foot pain, foot deformity and inflammatory disorders. Multivariate analysis identified foot deformities and higher functional impairment as predictive factors for lower gait speed (4-MWT) and older age and higher functional impairment for higher duration of TUGT. CONCLUSION: RAOS was significantly associated with performance-based physical function. In the era of connected technologies, these results encourage the regular assessment of rheumatoid foot function by the RAOS score through a connected programme using wearable trackers.

Osteoarticular manifestation of acute lymphoblastic leukemia in adults: a literature review.

Osteoarticular manifestations such as arthritis and bone pain are scarce among adults with acute lymphoblastic leukemia (ALL). We present a systematic review of osteoarticular first clinical manifestation related to ALL in adults, and we report a case of an adult patient with a B-cell ALL revealed by refractory pygalgia and arthritis. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the MEDLINE database, including case reports and case series describing osteoarticular manifestations revealing ALL in adults. There were 29 patients with osteoarticular manifestations, revealing ALL (including our case). The mean age was 34.00 ± 13.29 years. Osteoarticular manifestations were peripheral articular signs (7 cases), axial manifestations (17 cases), and osteolytic lesions (21 cases). Vertebral fractures were reported in 4 cases. MRI was performed in 15 cases, showing heterogeneous signal changes in the vertebra, skull, and sacroiliac bones. It showed avascular necrosis of the femoral head in one case. PET scan, performed in 7 cases, showed diffuse or localized FDG uptakes in the bone marrow. Hypercalcemia was noted in 9 cases. The treatment was based on chemotherapy (23 patients) and radiotherapy (4 cases). During the follow-up, remission was noted in 14 cases, death in 9 cases, and was not available in 6 patients. Our review showed that axial manifestations, joint swelling, bone pain, and hypercalcemia could be the first and only symptoms of ALL in adults, making the diagnosis of ALL difficult to recognize, leading to a diagnosis delay. Key Points • Acute lymphoblastic leukemia in adults revealed by osteoarticular manifestations can be misdiagnosed as rheumatic diseases. • Axial manifestations, joint swelling, bone pain, and hypercalcemia could be the first and only symptoms of acute lymphoblastic leukemia in adults. • Complete blood count and calcium blood test should be performed as first-line investigations in adults with axial or peripheral articular symptoms. • Physicians should be aware of this clinical presentation to avoid diagnosis delay and improve prognosis.

Foot Functional Disability in Rheumatoid Arthritis: The Involvement of Body Mass Index.

INTRODUCTION: Overweight and obesity are common in patients with Rheumatoid Arthritis (RA), with a probable impact on bearing foot joints. AIM: Our study aimed to explore the impact of Body Mass Index (BMI) on foot health parameters in RA patients. METHODS: It was a cross-sectional study. Domains of foot health explored were: foot pain (Numeric Rating Scale), foot-related activity limitations (Foot Function Index (FFI), and WOMAC scale), foot synovitis, foot deformity (Platto Score (PS)), radiological joint damage and footwear problems. RESULTS: Fifty RA were included, 82% were female. The mean age was 45.68 ± 10.3 years. The mean DAS28-CRP was 3.25 ± 0.98. Sixty-six percent were overweight or obese, with a mean BMI of 29 Kg/m2 ± 5.74. The average foot pain intensity while walking was 6 ± 1.75. The mean swollen foot joint was 2.2 ± 1.55. The average foot structural index was 7.8 ± 2.73. The mean FFI Disability score was 32 ± 14.2 and WOMAC score was 33.8 ± 13.98. Half of our patients had footwear problems predominantly because of claw toe (40%). High BMI was significantly correlated with foot pain and foot-related activity limitations. It was also correlated with foot deformities assessed with PS (B=4.78; CI(3.87-5.68); p = 0.02), foot synovitis (OR=4.66, CI(2.61-8.32); p < 0.001) and problems with footwear (OR= 0.32; CI(0.18-0.56); p = 0.05). However, it was significantly associated with less radiological joint damage (CI(-0.7-1.1); p = 0.01) and lower foot sharp score (B = -13.9; CI(-0.34-0.01); P = 0.06). CONCLUSION: Despite our findings of a possible protective effect of obesity on structural damage, obesity is still an important cause of increased pain, functional disability, and impaired QoL in RA patients.

Tophaceous gout in a young man with Gitelman syndrome: a case report with an overview.

Gitelman syndrome represents the clinical manifestations of inactivation of the Slc12a3 genes encoding the thiazide-sensitive sodium chloride cotransporter and the Trpm6-Mg genes encoding the magnesium transporters in the distal convoluted tubule. In fact, the biochemical findings resemble those with thiazide diuretics such as hypokalemia, hypomagnesaemia, hypocalciuria, metabolic alkalosis, and low normal blood pressure. He is usually associated with calcium pyrophosphate deposition. Serum uricemia level is rarely affected in Gitelman syndrome. We aimed to report a rare association of chronic gout with Gitelman syndrome, hence the interest of our case. We describe a 29-year-old male patient with a history of Gitelman syndrome associated with articular gout including pelvic localization. We provided pictorial evidence of extensive and diffuse monosodium urate deposition in articular and periarticular structures to confirm the gout origin. A literature review illustrates 4 reported cases of Gitelman syndrome associated with gout. The gender distribution was equal with a mean age of 40 years.

Relevance of the video capsule as a tool for learning Schöber Index measurement in medical students.

INTRODUCTION: Medical education has progressed considerably. Information and communication technologies have been adopted as a learning tool. AIM: We aimed to evaluate the contribution of an educational video in the acquisition of knowledge on the measurement of the Schöber index in young medical students. METHODS: This is a prospective study, spread over 4 months (February 2022-May 2022) and conducted in the rheumatology and orthopedics departments of the Charles Nicolle Hospital in Tunis. We included medical students during their externship at the mentioned services. We compared the realization of the steps of the Schöber test (testing the flexibility of the lumbar spine) before and after the visualization of an educational video. RESULTS: A total of 32 students (6 men and 26 women) were enrolled. There were 18 students (56%) in DCEM1 and 14 students (44%) in PCEM2. Our study showed that the number of students who correctly performed the different steps of the Schöber test increased after viewing the instructional video compared to the beginning, but this increase was not significant. There were some differences between the PCEM2 and DCEM1 groups before viewing the video, but this difference decreased after viewing the video. CONCLUSION: Our study has demonstrated the value of an educational video in improving the knowledge of medical students. This work needs to be applied on a larger scale in different medical specialties.

Association between Rheumatic Disease Comorbidity Index and factors of poor prognosis in a cohort of 280 patients with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) is commonly associated with higher rates of comorbidities. Recent recommendations highlight screening comorbidities during the disease course because of their impact on patients' ability to function, on disease outcome, but also on treatment choices. Hence the interest of our study that aimed to quantify the impact of comorbidities among RA patients using a validated tool the Rheumatic Disease Comorbidity Index (RDCI) and to explore the association between comorbidities and disease characteristics. METHODS: We conducted a cross-sectional study over 12 months period, including patients followed for an established RA according to the ACR/EULAR 2010 criteria and hospitalized in our rheumatology department. Patients' characteristics and disease features were collected for each patient. Comorbidities were quantified using the RDCI. We looked for the association between RDCI and patients characteristics and RA parameters. Univariable and multivariable analysis were made. RESULTS: They were 280 patients: 233 female (83.2%) and 47 male (16.8%) with a mean age of 58.07 (SD 11.12) years. The mean follow-up period was 14.74 (SD 1.63) years. Comorbidities were noted in 133 patients (47.5%). The mean comorbidity score measured by the RDCI was 1.05 (SD 1.23). RDCI was positively correlated with age (p < 0.001, r = 0.359). RA patients whose age of disease onset exceeds 40 years have significantly higher RDCI (1.8 (SD 1.3) [CI 95%: 1.36-1.88] vs. 1.5 (SD 1.2), p = 0.007). Moreover, RDCI was significantly associated with the presence pulmonary involvement (p < 0.001) and ocular involvement (p = 0.002). RDCI was also associated with erosive RA (p = 0.006), the presence of atlanto-axial dislocation (p = 0.014), and coxitis (p = 0.029). Regarding therapy regimen, RDCI was statistically increased in patients receiving bDMARDs compared to patients under csDMARDs (2.8 (SD 1.6) vs. 1.0 (SD 1.0), p = 0.021). CONCLUSION: In this study, comorbidity index was associated with signs of poor prognosis such as erosions, coxitis, and atlanto-axial dislocation. This confirmed the hypothesis that comorbidity can be a threat to the improvement in the long-term prognosis in RA patients.

Synovial hemangioma: A rare cause of chronic knee pain.

Synovial hemangioma is a rare benign vascular tumor responsible for chronic knee pain and swelling. Given its non-specific symptoms, synovial hemangioma is often misdiagnosed. We report a case of synovial hemangioma of bilateral knee joints occurring in a young military man.

Multifocal tuberculosis on certolizumab pegol in a patient followed for rheumatoid arthritis.

Tuberculosis must be considered in front of deterioration in general condition in patient with rheumatic disease under biological therapy. Rheumatologists may pay attention and screen infections before and after prescribing biological therapy.

Psoriatic arthritis associated with peliosis hepatis: characteristics and therapeutic management.

Peliosis hepatis is characterized by hepatic sinusoidal dilatation and multiple blood-filled cystic cavities within the liver parenchyma. It can be due to infectious diseases, immunological disorders, neoplasia, and the use of various kinds of drugs. We presented the case of a nonsmoker 55-year-old man who complained about a 5-month history of arthritis. Medical history was consistent with psoriasis and hypertension. He denied any drug use or alcohol consumption. Physical examination showed extended psoriatic lesions. He had arthritis of the knees, ankles, wrists, and elbows. His body mass index was 22 kg/m2. Laboratory findings revealed an increased serum gamma-glutamyl transferase level (1014 UI/L, normal value (N) 11-55) and total alkaline phosphatase (278 U/L, N 30-171). Hepatitis A, B, and C serologic test results were negative. Anti-nuclear antibodies, anti-Ro/SSA, anti-GP210, anti-SP100, anti-SLA, anti-LKM1, anti-M2, anti-LC1, and anti-PML were also negative. Histopathological examination of a liver biopsy specimen revealed peliosis hepatis.The pelvic radiograph showed bilateral ankylosis of sacroiliac joints. Hand and foot radiographs showed periosteal bone apposition. The diagnosis of psoriatic arthritis associated with peliosis hepatis was made. The patient received infliximab (5 mg/kg) with a significant improvement after 3 months of follow-up. Peliosis hepatis should be considered as a possible etiology of liver enzyme abnormalities in patients with psoriatic arthritis. We highlighted the effectiveness and safety of the TNF inhibitors in the treatment of peliosis hepatis associated with psoriatic arthritis. Key Points • Peliosis hepatis should be considered as a possible etiology of liver enzyme disturbance in patients with psoriatic arthritis. • Special caution should be advised in the management of psoriatic arthritis associated with peliosis hepatis to avoid the worsening of liver function. • Infliximab is suggested as a possible treatment of peliosis hepatis associated with psoriatic arthritis.