Psoriatic arthritis screening by the dermatologist: development and first validation of the 'PURE-4 scale'.

BACKGROUND: Dermatologists are recommended to ask psoriasis patients about musculoskeletal complaints to allow early detection and treatment of psoriatic arthritis (PsA). Screening tools have been developed to help identify patients warranting further rheumatologic assessment, but evidence suggests room for improvement in their diagnostic value and ease of use for outpatient practice. OBJECTIVE: To develop and internally validate a brief tool for dermatologists to screen patients to refer to a rheumatologist for PsA diagnosis. METHODS: After the literature review, 23 items were selected, covering pain at various locations and inflammatory signs of PsA. The validation study was conducted in medically diagnosed psoriasis patients consecutively recruited between 2012 and 2014 (Saint Joseph Hospital, Paris, France). Patients were enrolled by a dermatologist who helped to complete the questionnaire. Diagnosis of PsA was established by a rheumatologist based on CASPAR criteria. Multivariate logistic regression models were performed to build the scale, assessing discrimination through sensitivity, specificity and area under the ROC curve (AUC). Final model was internally validated using bootstrapping techniques. RESULTS: One hundred and sixty-eight patients were recruited, of whom nine were excluded for known PsA and 21 did not attend the rheumatologist consultation. Of 137 included patients (median age 43 years, 59.6% men), 21 (15.3%) had a PsA diagnosis. Final regression model retained four independent items, including evocative signs of dactylitis, inflammatory heel pain, bilateral buttock pain and peripheral joint pain with swelling in patients aged <50. A total score (the PURE-4) was computed (0-4 points) that demonstrated excellent discriminative power (AUC = 87.6%; Sensitivity = 85.7% and Specificity = 83.6% at the threshold of ≥1/4 points), with no evidence for over-optimism in bootstrapped internal validation. CONCLUSION: These findings demonstrate the good diagnostic properties of a new screening scale using only four easy-to-collect items. If confirmed in other populations, it may prove useful in outpatient dermatology clinics for triage of psoriasis patients requiring further assessment by the rheumatologist.

[Streptococcus milleri: An unusual cause of skull extensive osteomyelitis in an immunocompetent patient]. / Streptococcus milleri : une cause inhabituelle d'ostéite extensive du crâne chez un patient immunocompétent.

INTRODUCTION: Streptococcus milleri (Streptococcus anginosus, intermedius and constellatus) are commensal organisms, which can become pathogenic and cause infection with frequent abscess formation, local or metastatic extension. Osteomyelitis of the skull has been rarely reported in this type of infection. CASE REPORT: Skull osteomyelitis due to Streptococcus milleri is reported in a 61-year-old immunocompetent man without any medical history, occurring 10 months after a head injury without any wound or complication at initial presentation. A progressive right parieto-occipital headache with worsening and increased acute phase reactants evoked a giant cell arteritis. After few days of corticosteroid therapy (0.5 mg/kg/day), diagnosis of subcutaneous abscess associated to an extensive osteomyelitis of the skull due to Streptococcus milleri was diagnosed. The outcome was favorable after drainage of one liter of pus, irrigation, debridement and antibiotherapy by amoxicillin for 8 weeks. CONCLUSION: It is necessary to discuss the differential diagnosis of giant cell arteritis particularly when symptoms are unusual. Even a short-term corticosteroid therapy may dramatically exacerbate an undetected infection.

Evaluation of collected outcome measures in axial spondyloarthritis in daily-care rheumatology settings: the experience of the RHEVER network.

OBJECTIVES: Nowadays, the recommended measures for optimal monitoring of axial Spondyloarthritis (ax-SpA) disease activity are either BASDAI and CRP, or ASDAS-CRP. However, there could be a gap between recommendations and daily practice. We aimed to determine the measures collected by rheumatologists in an ax-SpA follow-up visit, and to determine the impact of a meeting (where rheumatologists reached a consensus on the measures to be collected) on the collection of such measures. METHODS: A consensual meeting of a local network of 32 rheumatologists proposed, four months later, to report at least the BASDAI score in the medical file of every ax-SpA patient at every follow-up visit. An independent investigator reviewed the medical files of 10 consecutive patients per rheumatologist, seen twice during the year (e.g. before and after the meeting). The most frequently collected measures were assessed, and then, the frequency of collection before and after the meeting was compared. RESULTS: A total of 456 medical files from 228 patients were reviewed. Treatment (>60%), CRP (51.3%) and total BASDAI (28.5%) were the most reported measures in medical files. Before/After the meeting, the frequencies of collected measures in medical files were 28.5%/51.7%, 51.3%/52.2%, 16.7%/31.6% and 0.9%/6.1% for BASDAI, CRP, BASDAI + CRP and ASDAS, respectively reaching a statistically significance for BASDAI, ASDAS and BASDAI+CRP (p<0.05). CONCLUSIONS: This study revealed a low rate of systematic report of the recommended outcome measures in ax-SpA. However, it suggests that a consensual meeting involving practicing rheumatologists might be relevant to improve the implementation of such recommendations.

Challenges of cardiovascular risk assessment in the routine rheumatology outpatient setting: an observational study of 110 rheumatoid arthritis patients.

OBJECTIVE: An annual assessment of cardiovascular (CV) risk factors in rheumatoid arthritis (RA) is recommended, but its practical modalities have not been determined. The objective was to assess the feasibility and usefulness of a standardized CV risk assessment in RA, performed by rheumatologists during outpatient clinics. METHODS: We used a cross-sectional design within a network of rheumatologists. Each rheumatologist included 5 consecutive unselected patients with definite RA. Data collection included standardized assessment of CV risk factors: blood pressure, interpretation of glycemia and of lipid levels, and calculation of the Framingham CV risk score. Outcome criteria included feasibility (missing data and time taken to assess the patients) and usefulness (the CV risk assessment was considered useful if at least 1 modifiable and previously unknown CV risk factor was evidenced). RESULTS: Twenty-two rheumatologists (77% in office-based practice) assessed 110 RA patients. The mean ± SD age was 57 ± 10 years, and the mean ± SD RA duration was 11 ± 9 years; 50 patients (45%) were treated with biologic agents, and 76% were women. Regarding feasibility, missing data were most frequent for glycemia (27% of patients) and cholesterolemia (14% of patients). The mean ± SD duration of the CV risk assessment was 15 ± 5 minutes. The CV risk assessment was considered useful in 33 patients (30%), evidencing dyslipidemia (15% of patients) or high blood pressure (9% of patients) as the most frequently previously unknown CV risk factor. CONCLUSION: The assessment of CV risk factors is feasible, but labor intensive, during an outpatient rheumatology clinic. This assessment identified modifiable CV risk factors in 30% of the patients. These results suggest that RA patients are not sufficiently assessed and treated for CV risk factors.

[Thoraco-abdominal aortitis in ankylosing spondylitis: a case report and review of literature]. / Aortite thoraco-abdominale au cours d'une spondylarthrite ankylosante: un nouveau cas et revue de la littérature.

UNLABELLED: We report a case of aortitis in a patient with ankylosing spondylitis revealed by an unexplained persistent inflammation. CASE STUDY: The diagnosis of ankylosing spondylitis was retained in a 64-year-old woman suffering from inflammatory back and neck pain combined with buttock pain relieved by anti-inflammatory drugs (NSAIDs) since 2004 and more recent bilateral heel pain in the morning since 2006; sacroiliitis was grade 3 on the right and grade 2 on the left (modified New-York criteria). The patient had remained asymptomatic from April 2006 to 2007 with NSAID as needed. Nevertheless, biological inflammation persisted: erythrocyte sedimentation rate 44 to 55 mm/h, activated protein C 34 to 90 mg/L. Complementary examinations are negative: bilateral temporal artery biopsy, endoscopy with duodenal biopsy looking for Tropheryma whipplei. The thoraco-abdominal and pelvic CT scan revealed aortitis extending from the abdominal aorta to the iliac axis. Treatment with prednisone 0.5 mg/kg was started to decrease the inflammatory aortitis. DISCUSSION: The most "classical" cardiovascular damage observed in spondylitis is aortic insufficiency and conduction disturbances. The first cases of aortitis were reported in 1958. CONCLUSION: Inflammatory vascular disease should be evoked as a possible diagnosis in patients with ankylosing spondylitis the presenting an unexplained biological inflammation (ESR and CRP).

Recurrence of spondylarthropathy among first-degree relatives of patients: a systematic cross-sectional study.

OBJECTIVE: To examine the recurrence of manifestations belonging to the spectrum of spondylarthropathy (SpA) in first-degree relatives of patients with SpA, and to estimate the recurrence risk ratio. METHODS: Parents and siblings of consecutive SpA probands have been thoroughly investigated, including clinical data collection, pelvic x ray and human leukocyte antigen (HLA)-B27 status determination. The diagnosis of SpA was made according to European Spondylarthropathy Study Group and/or the Amor criteria. The recurrence risk ratio lambda(1), which gives an estimate of the weight of genetic factors, was calculated as the ratio of the recurrence risk of SpA in first-degree relatives compared with the population prevalence of SpA. The lambda(non-HLA) was obtained by similar calculations restricted to HLA-B27+ individuals. RESULTS: Most manifestations of SpA were more frequent among the 157 HLA-B27+ relatives of 83 probands than among their 111 HLA-B27- relatives. A diagnosis of SpA was made in 50 relatives of 31 (37%) probands. Recurrence was very similar between parents and siblings, without gender difference, resulting in overall recurrence risk of 12% in first-degree relatives and of 22.7% in HLA-B27+ relatives. The lambda(1) value was 40 and the lambda(non-HLA) value was 6.5, very close to the lambda(HLA) value of 6.25 estimated from linkage study in SpA. CONCLUSIONS: A similar recurrence risk of SpA was observed between parents and siblings, consistent with a model of inheritance with no dominance variance and without sex influence. The weight of the non-HLA genetic component was equivalent to that estimated for the HLA locus, and fitted a model of multiplicative interaction between HLA and non-HLA genetic components.

Interleukin-1 receptor antagonist (anakinra) treatment in patients with systemic-onset juvenile idiopathic arthritis or adult onset Still disease: preliminary experience in France.

BACKGROUND: Anakinra treatment has been reported to be effective in some patients with systemic-onset juvenile idiopathic arthritis (SoJIA) or adult-onset Still disease (AoSD). OBJECTIVES: To assess the efficacy and the safety of anakinra treatment in SoJIA and AoSD. METHODS: SoJIA and AoSD patients were treated with anakinra (1-2 mg/kg/day in children, 100 mg/day in adults); we analysed its effect on fever, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, numbers of swollen and tender joints, the assessment of disease activity (by physician and parent/patient) and pain (by parent/patient), and American College of Rheumatology (ACR) pediatric core set criteria for JIA activity. RESULTS: A total of 35 patients were included, 20 with SoJIA and 15 with AoSD. Their mean age (range) at the onset of treatment was 12.4 (3-23) and 38.1 (22-62) years, respectively; disease duration was 7.0 (1-16) and 7.8 (2-27) years, respectively. Active arthritis was present in all cases but one. Of the 20 SoJIA patients, 5 achieved ACR 50% improvement in symptoms (ACR50) response criteria at 6 months. Steroid dose had been decreased by 15% to 78% in 10 cases. A total of 11 of the 15 AoSD patients achieved at least a 50% improvement for all disease markers (mean follow-up: 17.5 (11-27) months). Steroids had been stopped in two cases and the dose was decreased by 45% to 95% in 12 patients. Two patients stopped anakinra due to severe skin reaction, and two patients due to infection: one visceral leishmaniasis and one varicella. CONCLUSION: Anakinra was effective in most AoSD patients, but less than half SoJIA patients achieved a marked and sustained improvement.

Lyme meningoradiculitis: prospective evaluation of biological diagnosis methods.

The symptoms of Lyme meningoradiculitis and the value of biological examinations in an endemic area were determined in a prospective study in which data were collected on all patients consecutively hospitalised for Lyme meningoradiculitis at our institution during an 18-month period. Specific antibody titres in the serum and cerebrospinal fluid (CSF) were determined by Vidas enzyme-linked-immunosorbent-assay (IgG + IgM), Dade-Behring enzyme immunoassay (EIA) (IgM; IgG) and Western blot analysis (IgG). We also searched for Borrelia burgdorferi in the CSF by PCR analysis and following culture on a specific medium. A control group was recruited, consisting of 16 consecutive patients who had been referred during the same period with suspected but not confirmed Lyme meningoradiculitis. Eleven patients were included. Borrelia EIA of the serum revealed that 40% of the patients had both elevated specific IgM titres and intrathecal synthesis of specific IgG; 40% of the patients was negative for IgM but had isolated intrathecal synthesis of IgG; 20% of the patients had elevated specific IgM titres without intrathecal synthesis of IgG. PCR analysis and the CSF culture were positive in one case only (B. garinii). The results of this study highlight the importance of systematic serological testing for B. burgdorferi in the CSF in the case of early neuroborreliosis suspicion, even in the absence of IgM serum antibodies, which was the case in 40% of the patients in the present study. Nevertheless, intrathecal anti-B. burgdorferi IgG synthesis, which remains the "gold standard" for the diagnosis of neuroborreliosis, was not detectable in 20% of the patients for whom diagnosis was subsequently confirmed by demonstration of specific serum IgM.