New-onset inflammatory bowel diseases among IL-17 inhibitor-treated patients: results from the case-control MISSIL study.

OBJECTIVES: To describe new-onset IBD (new IBD) in patients treated with IL-17 inhibitors (IL-17i), to assess their incidence and to identify their risk factors in real life. METHODS: A French national registry (MISSIL) aimed to report all cases of new IBD in patients treated with IL-17i from January 2016 to December 2019. Using the estimated number of patients treated by IL-17 in France during the study period, the annual incidence rates of new IBD was reported in IL-17i-treated patients. A case-control study was performed with two controls per new IBD case matched by gender, age and underlying inflammatory disease. RESULTS: Thirty-one cases of new IBD under IL-17i were collected: 27 patients treated for spondyloarthritis and four patients for psoriasis. All were observed with secukinumab (SEK). The median time to onset of new IBD symptoms was 4.0 (1.5-7.5) months. SEK was discontinued in all patients. The evolution was favourable with complete resolution (17/31), improvement (7/31) or stabilization (5/31). Two patients died: one due to a massive myocardial infarction and one due to post-colectomy complications. The incidence of new IBD decreased from 0.69/100 patient-years [PY] (7/1010) in 2016 to 0.08/100 PY (6/7951) in 2019. No previous treatment with etanercept (odds ratio [OR] = 0.33, 95% CI: 0.14-0.80, P = 0.014) and low number of previous biologic therapies (OR = 0.67, 95% CI: 0.47, 0.94, P = 0.021) were significantly associated with new IBD. CONCLUSION: The incidence of new IBD was low and decreased from 2016 to 2019. The outcome was favourable in 24 out of 31 patients, but two patients died.

Factors Associated With Clinical Improvement and the Disappearance of Calcifications After Ultrasound-Guided Percutaneous Lavage of Rotator Cuff Calcific Tendinopathy: A Post Hoc Analysis of a Randomized Controlled Trial.

BACKGROUND: Calcific tendinitis of the rotator cuff is a frequent cause of shoulder pain. Ultrasound-guided percutaneous lavage (UGPL) is an effective treatment, but factors associated with good clinical and radiological outcomes still need to be identified. PURPOSE: To study the clinical, procedural, and radiological characteristics associated with improved shoulder function and the disappearance of calcification on radiograph after UGPL. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This is a post hoc analysis of the CALCECHO trial, a double-blinded randomized controlled trial conducted on 132 patients. The trial assessed the effect of corticosteroid injections after UGPL, and patients were randomly assigned to receive either corticosteroid or saline solution in the subacromial bursa. We analyzed all patients included in the randomized controlled trial as 1 cohort. We collected the patients' clinical, procedural, and radiological characteristics at baseline and during follow-up (3, 6, and 12 months). Univariable analysis, followed by multivariable stepwise regression through forward elimination, was performed to identify the factors associated with clinical success (Disabilities of the Arm, Shoulder and Hand [DASH] score <15) or the disappearance of calcification. RESULTS: Good clinical outcomes at 3 months were associated with steroid injections after the procedure (odd ratio [OR], 3.143; 95% CI, 1.105-8.94). At 6 months, good clinical evolution was associated with a lower DASH score at 3 months (OR, 0.92; 95% CI, 0.890-0.956) and calcium extraction (OR, 10.7; 95% CI, 1.791-63.927). A lower DASH at 6 months was also associated with a long-term favorable outcome at 12 months (OR, 0.939; 95% CI, 0.912-0.966). Disappearance of calcification at 3 and 12 months occurred more frequently in patients in whom communication was created between the calcification and the subacromial bursa during the procedure (OR, 2.728 [95% CI, 1.194-6.234] at 3 months; OR, 9.835 [95% CI, 1.977-48.931] at 12 months). Importantly, an association between calcification resorption and good clinical outcome was found at each time point. CONCLUSION: Assessing patients at 3 months seems to be an essential part of their management strategy. Calcium extraction and creating a communication between the calcific deposits and subacromial bursa are procedural characteristics associated with good clinical and radiological evolution.

Are corticosteroid injections needed after needling and lavage of calcific tendinitis? Randomised, double-blind, non-inferiority trial.

OBJECTIVE: Steroid injections are common after an ultrasound-guided puncture and lavage (UGPL) of calcific tendonitis of the rotator cuff. However, steroids may prevent calcification resorption and negatively affect tendon healing. Our study was designed to determine whether saline solution was non-inferior to steroids in the prevention of acute pain reactions in the week following UGPL. METHODS: This was a randomised, double-blinded, controlled non-inferiority trial with 12-month follow-up. We included 132 patients (66 in each group) with symptomatic calcification measuring more than 5 mm. Patients received 1 mL of saline or steroid (methylprednisolone 40 mg) in the subacromial bursa at the end of UGPL. Primary outcome was the maximal pain during the week following the procedure with a prespecified non-inferiority margin of 10 mm (0-100 visual analogue scale). Secondary outcomes included pain at rest and during activity, function (disabilities of the arm, shoulder and hand score) and radiological evolution of the calcification over the 12-month follow-up. RESULTS: The estimated mean difference in the first week's maximal pain between these two groups was 11.76 (95% CI 3.78 to 19.75). Steroids significantly improved VAS pain at rest and during activities, as well as function at 7 days and 6 weeks. They did not change the rate of calcification resorption, which occurred in 83% and 74% of patients at 12 months in the saline and steroid groups. CONCLUSION: Non-inferiority of saline when compared with steroids could not be established. However, steroid injection improved pain in the 6 weeks following the procedure, and function in the 3 months after, with no significant effect on calcification resorption. TRIAL REGISTRATION NUMBER: NTC02403856.

Corticosteroids injections versus corticosteroids with hyaluronic acid injections in rhizarthrosis: the randomised multicentre RHIZ'ART trial study protocol.

INTRODUCTION: Osteoarthritis of the trapeziometacarpal joint affects approximately 10%-25% of women, especially those who are postmenopausal. It may result in thumb dysfunction. Among the treatments, intra-articular injections of corticosteroid (CS) and hyaluronic acid (HA) are both effective and recommended. However, clinical trials have shown that HA improves functional capacity, whereas CS only produces a decrease in pain. The synergy of these two drugs has not been evaluated. The primary goal of this study was to determine whether the association between HA and CS produce an additional decrease of more pain during thumb movement at three months postinjection, compared to the level of pain relief from CS alone. METHODS AND ANALYSIS: RHIZ'ART is a prospective, multicentre, comparative, randomised, controlled, double-blind trial. Patients referred to the rheumatology department for thumb rhizarthrosis will receive an injection of betamethasone with HA or placebo (serum saline) based on central randomisation and stratification by centre. Injections will be given under ultrasound guidance. The primary outcome will compare the pain Visual Analogue Scale with motion at three months for both groups using a mixed model. The expected decrease in pain intensity in the CS group is 25% and 35% in the CS with HA group. In order to achieve a 80% power for detecting this difference with α set at 5%, 73 patients are needed in each group (146 total). The main secondary outcomes are the Cochin score (hand function) and grip strength. Follow-up visits are at 1, 3, 6 and 12 months. ETHICS AND DISSEMINATION: The study project has been approved by the appropriate ethics committee (CPP île de France III, 2017-002298-20). In agreement with current French regulations, a signed informed written consent will be obtained from each patient. Results of the main trial and of the secondary endpoints will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT03431584.

Sarcoidosis in Patients with Antisynthetase Syndrome: Presentation and Outcome.

OBJECTIVE: To investigate the uncommon co-occurrence of antisynthetase syndrome (AS) and sarcoidosis. METHODS: From 2000 to 2015, patients with sarcoidosis were extracted from a retrospective multicentric cohort of 352 patients with AS. RESULTS: Ten patients (2.8%; 6 men, 8 whites, 5 smokers, median age 50 yrs) had both AS and sarcoidosis. Most of the time, sarcoidosis and AS occurred simultaneously (n = 7). Antibody testing revealed anti-Jo1 (n = 5), anti-PL12 (n = 4), or anti-PL7 (n = 1). Finally, no patient had a worsening of muscular condition, 5 patients presented respiratory deterioration, 3 remained stable, and 2 showed improvement. CONCLUSION: Sarcoidosis may be underdiagnosed in patients with AS.

Current role for radioisotope synovectomy.

Radioisotope synovectomy has been extensively used to treat patients with chronic inflammatory joint disease but has moved to a less prominent position since the introduction of new and highly effective drugs. Remaining indications are refractory synovitis, pigmented villonodular synovitis as an adjunct to surgery, and hemophilic arthropathy. The three main radioisotopes used are yttrium-90, rhenium-186, and erbium-189. Radioisotope synovectomy should be performed only by highly experienced professionals, to minimize the risk of injection-related complications. The available safety data, in particular regarding the risk of malignancy, are reassuring. The efficacy of yttrium-90 in chronic inflammatory joint disease remains controversial.

Efficacy of local glucocorticoid after local anesthetic in low back pain with lumbosacral transitional vertebra: A randomized placebo-controlled double-blind trial.

OBJECTIVE: The primary objective of this study was to compare the efficacy of local injection of a local anesthetic with a glucocorticoid versus a local anesthetic with saline to treat low back pain due to lumbosacral transitional vertebras (LSTV) with a pseudoarticulation. METHODS: A randomized placebo-controlled double-blind study was conducted in patients with unilateral low back pain ascribed clinically to LSTV. Patients were randomized to lidocaine plus saline (LS group) or lidocaine plus cortivazol (LC group) injected locally under computed tomography guidance. The primary outcome measure was the 24-hour mean visual analog scale (VAS) score for low back pain 4 weeks after the injection. RESULTS: Of 16 randomized patients, 15 were included in the analysis, 8 in the LS group and 7 in the LC group. The mean VAS pain score at week 4 was not significantly different between the two groups. In the two groups pooled, the mean VAS pain score decreased significantly from baseline to week 4, from 5.52±0.99 to 3.86±2.55 (P≤0.05). The difference remained significant at week 12. Significant improvements occurred in the EIFEL disability index and items of the Dallas Pain Questionnaire. No adverse events were recorded. CONCLUSION: In patients with chronic low back pain consistent with a symptomatic LSTV type II or IV in the Castellvi classification, a local injection of lidocaine with or without cortivazol may provide sustained improvements in pain and function. The underlying mechanism is unclear.

Ultrasound abnormalities in septic arthritis are associated with functional outcomes.

OBJECTIVES: To describe the ultrasound abnormalities seen in septic arthritis and to assess their associations with clinical, biological, and radiological outcomes. METHODS: We prospectively included 34 patients with septic arthritis of a native joint (knee, n=19; shoulder, n=6; hip, n=4; ankle, n=3; or wrist, n=2). Ultrasonography was performed to record synovial-membrane thickness and vascularity, joint effusion, and abnormalities of adjacent soft tissues, at baseline then 4days, 2weeks, and 3months later. Motion-range limitation of the affected joint was evaluated after 3months. Radiography was performed at inclusion and after 3months. RESULTS: Mean age was 63.7±17.6years. After 3months, 20 (58.8%) patients had motion-range limitation with worsening of the total radiological score (P<0.001). The proportion of patients with synovitis was very high initially (96.4% at baseline, 96.3% after 4days, and 100% after 2weeks) then diminished to 77.8% after 3months (P=0.051). Synovial-membrane thickness was significantly higher after 4days and 2weeks compared to baseline (median, +17.3% and +20%, respectively; P=0.015) and was significantly lower after 3months compared to the earlier time points (median, -31.5%, P=0.015). A positive Doppler signal was common at baseline (n=18, 64.3%) then significantly less so after 3months (n=7, 25.9%; P=0.04). An unchanged or higher Doppler grade after 2weeks compared to baseline was associated with motion-range limitation at last follow-up (P=0.033). CONCLUSION: We report the first study on ultrasound evidence of synovitis, joint effusion, and soft tissue alterations at baseline and over time in patients with septic arthritis. Persistent synovitis and joint effusion 3months after starting antibiotic therapy was not associated with treatment failure. However, Doppler signal changes over the first 2weeks were associated with the 3-month functional outcome.

Decreased patient exposure to ionizing radiation during interventional rheumatology procedures after optimization of protection.

OBJECTIVES: To decrease radiation exposure of patients undergoing interventional rheumatology procedures, without adversely affecting quality of care. METHODS: The radiation dose received, assessed by the dose-area product (DAP), was measured during 283 intraarticular injections performed under fluoroscopic guidance between May and July 2013. Then, three steps were taken to decrease patients' radiation exposure: a copper filter was added, the anti-scatter grid was removed, and exposure cell sensitivity was set at the highest value. DAP was measured during 158 intraarticular injections performed in 2014 with these measures in place. RESULTS: Mean DAP before optimization was 175µGray·m2 during facet joint injections (n=4) and 43µGray·m2 during hip injections but was less than 20µGray·m2 for injections into the shoulders (15.7µGray·m2), ankles (7.7µGray·m2), wrists (3.7µGray·m2), and fingers (3.3µGray·m2). After optimization, DAP decreased markedly for all injection sites, by 52% (shoulders) to 87% (facet joints, 22.7µGray·m2). Decreases occurred at all three steps of the procedure, i.e., patient installation, injection, and last image hold. Exposure during facet joint injections varied from 84 (54.5-108.5) µGray·m2 when body mass index (BMI) was <25kg/m2 to 228.9 (161.3-340.4)µGray·m2 when BMI was>30kg/m2. CONCLUSION: Simple technical changes translate into large decreases in patient radiation exposure during fluoroscopically-guided injections, particularly at the facet joints and in obese patients.

Treatment of shoulder calcifications of the cuff: a controlled study.

OBJECTIVES: About 1 in 10 patients with shoulder calcifications complains of chronic pain. Removal techniques have been developed. We carried out the first randomized study to validate bursoscopy (BS) and (needling fragmentation irrigation) (NFI) versus a control group (CT). METHODS: 102 shoulders (96 patients) with calcifications >5 mm whose medical treatment had failed (>4 months) were first injected using a corticosteroid; 49 shoulders improved by more than 70%. The other 53 shoulders were randomized in 3 groups: NFI (n=16), BS (n=20), and CT (n=17). All patients were reviewed at T 1-4-12-24 months. RESULTS: After 4 months, we observed respectively in groups NFI-BS-CT: 62%, 65% and 29% patients showing global improvements >70% (NFI vs CT: p=0.03; BS vs CT: p=0.02); -37%, -29% and -11% pain VAS variation (ns), +16%, +12% and -15% Constant score variation (NFI vs CT: p=0.03; BS vs CT: p=0.02), and -58%, -77% and +4% area calcification variation (NFI vs CT: p=0.005; BS vs CT: p=0.0002; BS vs NFI: p=0.01). After 24 months, results were maintained in NFI and BS groups, and in the CT group only 6/17 patients were still improved. There were no significant differences between NFI and BS groups. Three partial tears of the cuff were found using MRI in failures, (1 in each group). CONCLUSION: NFI and BS are now validated removal techniques of shoulder calcifications when there is chronic pain and other medical treatments have failed. Results were maintained after 24 months, and were similar between NFI and BS. However NFI could be preferred because of its simplicity and low cost.

Chronic, eventually fatal, Kawasaki-like disease in an adult with spondylarthropathy responding to IVIG therapy.

We report on an unusual case of a 40-year-old Caucasian male displaying severe Kawasaki-like symptoms. The disease lasted for seven years before diffuse coronary aneurysms occurred, leading to the patient's death, despite ongoing treatment by intravenous immunoglobulins (IVIGs). The patient had also been suffering from a disabling inflammation of the spine, which was reported to have started at the onset of the disorder. Whereas neither NSAIDS, nor high doses corticosteroids, or anti-TNF drugs had a clear effect, the clinical features of spinal inflammation were highly sensitive to IVIGs, and were attributed definitively to HLA-B27-negative axial spondylarthropathy after bone scan and magnetic resonance imaging disclosed typical enthesitis of both heels and bilateral sacroiliitis.

25 mg etanercept once weekly in rheumatoid arthritis and spondylarthropathy.

OBJECTIVE: To assess the clinical results at 6 months of etanercept 25 mg once weekly (half-dose), and etanercept 25 mg twice weekly (full-dose), in patients with rheumatoid arthritis or spondylarthropathy. METHODS: Case records of all patients treated by etanercept for at least 6 months in the same rheumatology unit were retrospectively studied, to assess the mean values of DAS-28 and BASDAI, just before (J0), and after 6 months (M6) of treatment, in patients with rheumatoid arthritis or spondylarthropathy treated with etanercept 25 mg given either once or twice weekly. RESULTS: 112 patients had been treated for at least 6 months (44 at half-dose, and 68 at full-dose). Values of DAS-28 or BASDAI both at J0 and M6 were available in 92 patients. DAS-28 dramatically improved both in the half-dose group (from 5.2+/-0.8 to 3.5+/-0.8) and in the full-dose group (from 5.5+/-1.0 to 4.1+/-1.0). BASDAI also strikingly improved both in the half-dose group (from 60+/-13 to 25+/-18), and in the full-dose group (from 58+/-15 to 37+/-23). CONCLUSION: Although this was not a double-blind, prospective, randomised study, the strong improvement noticed in the half-dose group suggests that etanercept 25 mg once a week can induce major clinical and biological relief in some patients with RA or spondylarthropathy.

Endoneural metastasis of the sciatic nerve disclosing the relapse of a renal carcinoma, four years after its surgical treatment.

METHODS: To report on an exceptional case of renal metastasis. Indeed, endoneural metastases of peripheral nerves are thought to be exceptional, and such an event has not yet been ascribed to a renal carcinoma. RESULTS: We report on a sciatica leading to the discovery of a tumour of the right thigh which proved to be an endoneural metastasis of the sciatic nerve from a renal carcinoma surgically removed 4 years before. CONCLUSION: A thorough palpation of peripheral nerve can help recognise such metastases in patients previously diagnosed with renal carcinoma.

Suspected disk space infection with negative microbiological tests-report of eight cases and comparison with documented pyogenic discitis.

UNLABELLED: Few data are available on patients with suspected noniatrogenic pyogenic discitis but negative microbiological tests. OBJECTIVES: To compare the features, treatment, and outcomes in patients with suspected versus microbiologically documented noniatrogenic pyogenic discitis. PATIENTS: A retrospective chart review identified eight patients with suspected noniatrogenic pyogenic discitis managed at our institution over a 15-year period. Eighteen age- and sex-matched patients with microbiologically documented noniatrogenic pyogenic discitis managed at our institution during the same period served as controls. RESULTS: The eight cases had a longer time to diagnosis, a greater risk of abscess formation or epidural infection, and a smaller number of cutaneous portals of entry, as compared to the controls. None of the cases had evidence of endocarditis or diabetes mellitus. Infection at another site preceded the discitis in half the cases. Empirical treatment with two antimicrobials (usually a fluoroquinolone with a beta-lactam or fosfomycin) ensured a full recovery in all eight cases, with no relapses or long-term recurrences, whereas relapses occurred in three of the 18 controls treated with antibiotics selected by antibiotic susceptibility testing. CONCLUSION: Noniatrogenic pyogenic discitis with negative microbiological studies is associated with distinctive clinical features consistent with smoldering infection. The outcome is favorable under empirical two-drug antimicrobial therapy, usually including a fluoroquinolone given by the intravenous route.