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International audience; To characterize Lyme arthritis, with a focus on management, and outcome. Observational retrospective multicentre study in Western France, of all consecutive cases of Lyme arthritis, documented by Borrelia burgdorferi IgG on ELISA serological testing, confirmed by Western blot, with or without positive Borrelia PCR in synovial fluid, with no alternative diagnosis. We enrolled 52 patients (29 males), with a mean age of 43 +/- 19.4 years. Most patients had monoarthritis (n = 43, 82.7%), involving the knee (n = 51, 98.1%), with a median delay between symptoms onset and Lyme arthritis diagnosis of 5 months (interquartile range, 1.5-8). Synovial fluid analysis yielded median white cell count of 16,000/mm(3) (9230-40,500), and positive PCR in 16 cases (39%), for B. burgdorferi sensu stricto (n = 5), B. garinii (n = 5), B. afzelii (n = 3), and undetermined (n = 3). All patients received antibiotics, for a median duration of 28 days (21-30), with doxycycline (n = 44, 84.6%), ceftriaxone (n = 6, 11.5%), or amoxicillin (n = 2). Twelve patients (23.1%) also received intra-articular injection of glucocorticoids as first-line treatment. Of 47 patients with follow-up, 35 (74.5%) had complete resolution of Lyme arthritis. Lyme arthritis in Western Europe may be due to B. burgdorferi ss, B. afzelii, or B. garinii. Clinical presentation is similar to Lyme arthritis in North America (i.e. chronic knee monoarthritis), with low sensitivity of synovial fluid PCR (39%).

International audience; OBJECTIVE: To evaluate the performance of the Gout-calculator in a cohort of consecutive acute arthritis affecting large and intermediate joints (without an attack on hallux or midfoot joints). METHODS: A retrospective study. Gout-calculator data were collected in medical records of patients included in the prospective consecutive cohort of acute arthritis called SYNOLACTATE. The diagnosis of gout was defined by the presence of sodium urate crystals in synovial fluid. The diagnostic performance of the Gout-calculator was studied by performing an ROC curve with the calculation of its AUC (95% CI) as well as the calculation of Sensitivity (Se), Specificity (Sp), and positive likelihood ratio (LR+). RESULTS: 170 patients with acute arthritis were included. Variables associated with the diagnosis of gout were as follows: serum uric acid > 350 μmol/L (OR 5.52 (2.52-12.1), p < 0.001), joint redness (OR 5.08 (1.85-14.0), p = 0.001), previous patient-reported arthritis attack (OR 4.04 (1.92-8.49), p < 0.001), male (OR 3.00 (1.17-7.69), p = 0.02), hypertension or cardiovascular disease (OR 2.33 (1.07-5.06), p = 0.03). The median (IQR) of Gout-calculator was significantly higher in gouty arthritis (7.0 [5.5-8.1]) than in associated-CPP acute arthritis (4.0 [2.0-5.8]), septic arthritis (3.0 [2.0-5.1]), or others arthritis (3.5 [2.0-5.5]). The AUC was 0.833 (0.768-0.897) with for the threshold ≥ 8, a Se at 27.5% (0.161-0.428), Sp 97.7% (0.934-0.992), and LR+ 11.9 (3.5-40). CONCLUSION: Despite diagnostic performances close to those published, the use of the Gout-calculator is not sufficient for the diagnosis of gout or to exclude the differential diagnosis of septic arthritis in the SYNOLACTATE cohort. KEY POINTS: • For a Gout-calculator threshold of ≤ 4, Sensitivity is 92.5%, Specificity 50.8% and LR- 0.15 to the gout diagnosis. • For a Gout-calculator threshold of > = 8, Sensitivity is 27.5%, Specificity 97.7% and LR+ 11.9 to the gout diagnosis. • In a population of acute arthritis affecting large joints, Gout-calculator is not sufficient to discriminate between gouty arthritis and septic arthritis.

Whipple disease (WD) is a rare infectious systemic disease. Rheumatologists are at the frontline of WD diagnosis due to the early rheumatological manifestations. An early diagnosis is crucial, as usual anti-rheumatic drugs, especially TNF inhibitors, may worsen the disease course. We conducted a retrospective multicentre national study from January 2010 to April 2020 to better characterize the rheumatological features of WD. Classic WD (CWD) was defined by positive periodic acid-Schiff (PAS) staining of a small-bowel biopsy sample, and non-CWD (NCWD) was defined by negative PAS staining of a small-bowel biopsy sample but at least one positive Tropheryma whipplei (TW) polymerase chain reaction (PCR) for a digestive or extradigestive specimen. Sixty-eight patients were enrolled, including 11 CWD patients. Twenty patients (30%) received TNF inhibitors during the WD course, with inefficacy or symptom worsening. More digestive symptoms and systemic biological features were observed in CWD patients than in NCWD patients, but both patient groups had similar outcomes, especially concerning the response to antibiotics and relapse rate. Stool and saliva TW PCR sensitivity were both 100% for CWD and 75% for NCWD and 89% and 60% for small-bowel biopsy sample PCR, respectively. WD encountered in rheumatology units has many presentations, which might result from different pathophysiologies that are dependent on host immunity. Given the heterogeneous presentations and the presence of chronic carriage, multiple TW PCR tests on samples from specific rheumatological sites when possible should be performed, but samples from nonspecific digestive and extradigestive sites also have great value.

International audience; Objective - To define a semiquantitative classification of finger pulp blood flow (FPBF) and to evaluate whether this classification could be used to assess FPBF in healthy controls and in systemic sclerosis (SSc) patients. Methods - Thirty controls and 86 SSc patients were consecutively included. A classification of FPBF including 5 grades (from grade 0 [no signal] to 4 [signal detected on the entire finger pulp, including the subepidermal vascular network]) was evaluated. This classification was explored in basal conditions and after hand baths in hot and cold water in controls. Its relevance was also assessed at room temperature in SSc patients. Results - In controls, power Doppler ultrasonography (PDUS) of FPBF was improved after hot challenge (P = 0.024), whereas cold challenge decreased FPBF (P = 0.001). FPBF correlated with the vasodilation status assessed by the resistivity index of radial arteries (Spearman's correlation coefficient = -0.50, P = 0.0049). Grade 0 was more frequent in SSc patients than in controls (22.1% versus 3.3%; P

Resume Objectifs Cette etude, menee dans une population de patients atteints de LES, avait pour objectifs (1) de decrire les atteintes articulaires echographiques (US), (2) d’estimer la correlation du nombre d’articulations cliniquement gonflees (NAG-C) et du SLEDAI clinique (SLEDAI-C) avec le NAG echographique (NAG-US) et le SLEDAI echographique (SLEDAI-US), (3) de mettre en evidence les caracteristiques specifiques des patients lupiques selon les observations en mode Doppler puissance (DP). Methode Nous avons inclus dans cette etude transversale multicentrique 151 patients adultes consecutifs atteints de LES. L’evaluation comprenait un examen clinique standardise des articulations, une echographie en mode B et en mode Doppler puissance (DP) sur 40 articulations et 26 tendons, en aveugle des resultats de l’examen clinique. La correlation entre l’examen clinique et l’echographie en mode B a ete calculee au moyen du coefficient de correlation intra-classe (ICC [Intervalle de confiance a 95 %]). Resultats Un taux tres eleve d’anomalies infracliniques echographiques a ete observe chez les patients asymptomatiques : l’existence d’au moins une manifestation echographique a ete retrouvee chez 85 % des patients qui ne presentaient aucun symptome articulaire. Parmi eux, 46 patients (87 %) avaient un antecedent d’atteinte articulaire. L’epanchement articulaire (108 patients), l’hypertrophie synoviale (HS, 109 patients) et la synovite (61 patients) etaient les anomalies les plus frequemment retrouvees. Un signal DP positif des articulations ou des tendons (grade > 1) a ete retrouve dans 44 % des cas (67/151). Des synovites ont ete detectees principalement aux articulations MCP et des poignets. Malgre la faible correlation de l’examen clinique au NAG-US en mode B, une bonne correlation du SLEDAI clinique au SLEDAI echographique a ete retrouvee. La comparaison des patients atteints de LES avec et sans signal DP n’a pas mis en evidence de caracteristiques specifiques du LES. Conclusion L’echographie est une methode d’imagerie qui a prouve son utilite pour l’evaluation des atteintes articulaires dans le LES mais qui ne modifiait pas de maniere significative le score SLEDAI.

ObjectiveSteroid 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.MethodsThis 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.ResultsThe 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.ConclusionNon-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 numberNTC02403856.

Objective To establish a new predictive score for the diagnosis of septic arthritis (SA) according to different synovial fluid (SF) variables. Methods First, we analysed the different clinical, biological and SF variables associated with the diagnosis of SA (according to the Newman’s criteria) in a monocentric cohort of acute arthritis ( Results After multivariate analysis, four independent variables of the SF were included for RESAS: (i) purulent SF or white blood cells count ≥70 000/mm3; (ii) absence/presence of crystals; (iii) lactate; and (iv) glucose synovial level. RESAS ranged between −4 and +13 points. The performance of RESAS to predicted SA was excellent with area under the curve (AUC)=0.928 (0.877–0.980) in internal validation and AUC=0.986 (0.962–1.00) in external validation. For a RESAS threshold ≥+4, SA was diagnosed with Se=56.0% (0.371–0.733), Sp=98.1% (0.952–0.993), LR+=29.1 (10.4–81.6) in the first cohort and with Se=91.7% (0.646–0.985), Sp=98.3% (0.909–0.997), LR+=53.2 (7.56–373) in the second cohort. Conclusion RESAS is a new composite score of four SF variables with excellent performance to predicted SA in acute arthritis population.

Summary Background Various observations have suggested that the course of COVID-19 might be less favourable in patients with inflammatory rheumatic and musculoskeletal diseases receiving rituximab compared with those not receiving rituximab. We aimed to investigate whether treatment with rituximab is associated with severe COVID-19 outcomes in patients with inflammatory rheumatic and musculoskeletal diseases. Methods In this cohort study, we analysed data from the French RMD COVID-19 cohort, which included patients aged 18 years or older with inflammatory rheumatic and musculoskeletal diseases and highly suspected or confirmed COVID-19. The primary endpoint was the severity of COVID-19 in patients treated with rituximab (rituximab group) compared with patients who did not receive rituximab (no rituximab group). Severe disease was defined as that requiring admission to an intensive care unit or leading to death. Secondary objectives were to analyse deaths and duration of hospital stay. The inverse probability of treatment weighting propensity score method was used to adjust for potential confounding factors (age, sex, arterial hypertension, diabetes, smoking status, body-mass index, interstitial lung disease, cardiovascular diseases, cancer, corticosteroid use, chronic renal failure, and the underlying disease [rheumatoid arthritis vs others]). Odds ratios and hazard ratios and their 95% CIs were calculated as effect size, by dividing the two population mean differences by their SD. This study is registered with ClinicalTrials.gov, NCT04353609. Findings Between April 15, 2020, and Nov 20, 2020, data were collected for 1090 patients (mean age 55·2 years [SD 16·4]); 734 (67%) were female and 356 (33%) were male. Of the 1090 patients, 137 (13%) developed severe COVID-19 and 89 (8%) died. After adjusting for potential confounding factors, severe disease was observed more frequently (effect size 3·26, 95% CI 1·66–6·40, p=0·0006) and the duration of hospital stay was markedly longer (0·62, 0·46–0·85, p=0·0024) in the 63 patients in the rituximab group than in the 1027 patients in the no rituximab group. 13 (21%) of 63 patients in the rituximab group died compared with 76 (7%) of 1027 patients in the no rituximab group, but the adjusted risk of death was not significantly increased in the rituximab group (effect size 1·32, 95% CI 0·55–3·19, p=0·53). Interpretation Rituximab therapy is associated with more severe COVID-19. Rituximab will have to be prescribed with particular caution in patients with inflammatory rheumatic and musculoskeletal diseases. Funding None.

To evaluate the diagnostic performance of ultrasound examination of the salivary glands (US-SG) according to the 2019 Outcome Measures in Rheumatology (OMERACT) US scoring system for Sjögren's syndrome (SS).The present work was a retrospective study based on a multicentric cohort with SS/sicca syndrome. The American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) 2016 classification criteria for SS (a score of ≥4 without ocular staining score), the American-European Consensus Group (AECG) 2002 classification criteria, and clinician experts were considered as reference standards for diagnosis of SS. An OMERACT score of ≥2 according to 2 independent readers defined the diagnosis of SS based on US-SG assessment. Diagnostic performances and interobserver reproducibility of US-SG were assessed.Forty-two patients fulfilling the ACR/EULAR 2016 criteria for SS were compared to 30 control subjects with sicca syndrome. Twenty-five patients were diagnosed as having SS according to US-SG evaluation, and they were more frequently observed in the SS group (52.5%) than in the control group (10.0%) (P 0.001). US-SG showed an area under the curve (AUC) of 0.751 (95% confidence interval [95% CI] 0.621, 0.882) for the diagnosis of SS (ACR/EULAR 2016 classification). The inclusion of US-SG in the ACR/EULAR 2016 classification improved sensitivity (91.5% versus 89.4%) with limited decrease of specificity (96.0% versus 100%) and with an AUC of 0.975 (95% CI 0.945, 1.00). Similar results were observed when US-SG was included in the AECG 2002 classification criteria. Interobserver reproducibility of a score of ≥2 according to the 2019 OMERACT US scoring system for SS diagnosis was good (κ = 0.73 [95% CI 0.64, 0.81]). Histologic lymphocyte infiltration of the minor salivary glands was associated with the OMERACT grading of US-SG.The present study confirms the good specificity of the 2019 OMERACT US classification measures of US-SG for the diagnosis of SS and its feasibility in daily practice.

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 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.

Objectives The aim of this study was to show the usefulness of a mid-infrared fibre evanescent wave spectroscopy point of care device in the identification of septic arthritis patients in a multicentre cohort, and to apply this technology to clinical practice among physicians. Methods SF samples from 402 patients enrolled in a multicentre cohort were frozen for analysis by mid-infrared fibre evanescent wave spectroscopy. The calibration cohort was divided into two groups of patients (septic arthritis and non-septic arthritis) and relevant spectral variables were used for logistic regression model. Model performances were tested on an independent set of 86 freshly obtained SF samples from patients enrolled in a single-centre acute arthritis cohort and spectroscopic analyses performed at the patient’s bedside. Results The model set-up, using frozen–thawed SFs, provided good performances, with area under the curve 0.95, sensitivity 0.90, specificity 0.90, positive predictive value 0.41 and negative predictive value 0.99. Performances obtained in the validation cohort were area under the curve 0.90, sensitivity 0.92, specificity 0.81, positive predictive value 0.46 and negative predictive value 0.98. The septic arthritis probability has been translated into a risk score from 0 to 4 according to septic risk. For a risk score of 0, the probability of identifying a septic patient is very low (negative predictive value of 1), whereas a risk score of 4 indicates very high risk of septic arthritis (positive predictive value of 1). Conclusion Mid-infrared fibre evanescent wave spectroscopy could distinguish septic from non-septic synovial arthritis fluids with good performances, and showed particular usefulness in ruling out septic arthritis. Our data supports the possibility of technology transfer. Trial registration ClinicalTrials.gov, http://clinicaltrials.gov, NCT02860871.

National audience; Objectif: Évaluer les performances diagnostiques du dosage du lactate, du glucose et du ratio lactate/glucose synovial pour le diagnostic d'arthrite septique. Méthodes: Dans cette étude transversale monocentrique, les liquides synoviaux de patients souffrant d'un épanchement articulaire aigu (< 30 jours) sur articulations natives ont été recueillis de manière prospective. L'arthrite septique a été définie selon les critères de Newman. Pour évaluer les performances diagnostiques, ont été calculés la courbe ROC (Receiver Operating Characteristic) avec l'aire sous la courbe (AUC), la sensibilité (Se), la spécificité (Sp) et le rapport de vraisemblance positif (RV + ) avec leur intervalle de confiance à 95 %. La culture bactériologique des liquides synoviaux avec coloration de Gram, la recherche de microcristaux, la numération leucocytaire (GBsyn) et le dosage du glucose et du lactate ont été réalisés. Résultats: Au total, 233 liquides synoviaux ont été inclus comprenant 25 arthrites septiques et 208 arthrites non septiques (104 arthrites microcristallines, 15 PR, 8 SpA, 6 arthrites réactionnelles et 75 arthrites aiguës d'origine indéterminée). Le ratio lactate/glucose synovial était plus haut que le dosage séparé du lactate et du glucose synovial (AUC : 0,859 [0,772–0,945]). La valeur seuil idéale pour le ratio lactate/glucose synovial permettant de différencier l'arthrite septique de l'arthrite non septique était de 5 Se 52 % [0,34–0,7], Sp 98,1 % [0,95–0,99], RV+ 27,0 [9,50–76,00]). Conclusion: Les performances diagnostiques du ratio lactate/glucose synovial permettent de discriminer de manière efficace et très rapide les arthrites septiques des autres formes d'arthrite.

International audience; Introduction - Methotrexate (MTX)-related osteopathy is rare, defined by the triad of pain, osteoporosis, and "atypical fractures" when it was first described in the 1970s in children treated with high doses MTX for acute leukemia. Since then, several cases have been reported in patients treated with low-dose MTX for inflammatory diseases. Methods - A systematic research of cases of MTX-related osteopathy was performed in records of Rheumatology Department of Rennes University Hospital. Data collection focused on demographic data, corticosteroid doses, MTX doses and intake method, cumulative doses, year of diagnosis, fracture location, bone densitometry value, and osteoporosis treatment if necessary. A literature review was also conducted to identify other cases in literature and try to understand the pathophysiological mechanisms of this rare entity. Results - We report 5 cases identified between 2011 and 2019, which represents the largest cohort described excluding oncology cases. Fracture locations were atypical for osteoporotic fractures. All patients improved in the following months with MTX withdrawal. All patients except one were treated with antiresorptives (bisphosphonates, denosumab). Two patients, treated with bisphosphonates, had a recurrence of fracture, once again of atypical location. Twenty-five cases were collected in literature with similar clinical presentation. The cellular studies that investigated the bone toxicity of MTX mainly showed a decrease in the number of osteoblasts, osteocytes, and chondrocytes in the growth plate and an increase in the number and activity of osteoclasts. In vitro, consequences of mechanical stimulation on human trabecular bone cells in the presence of MTX showed an alteration in mechano-transduction, with membrane hyperpolarization, acting on the integrin pathway. In contrast with our report, the cases described in the literature were not consistently associated with a decrease in bone mineral density (BMD). Conclusion - MTX osteopathy while rare must be known by the rheumatologist, especially when using this treatment for inflammatory conditions. The mechanisms are still poorly understood, raising the question of a possible remnant effect of MTX on osteo-forming bone cells, potentially dose-dependent. Methotrexate (MTX) osteopathy, described as a clinical triad, pain, osteoporosis, and atypical stress fractures, while rare, must be known by the rheumatologist. Our cohort of 5 cases represent the largest series of the literature. Pathophysiological studies raised the question of a dose-dependent remnant effect of MTX on osteo-forming bone cells.

Supplemental material, sj-pdf-1-ajs-10.1177_0363546521992359 for 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 by Nicolas Dumoulin, Grégoire Cormier, Stéphane Varin, Guillaume Coiffier, Jean-David Albert, Benoit Le Goff and Christelle Darrieutort-Laffite in The American Journal of Sports Medicine

International audience; The performance of a pair of blood culture vials (BACTEC® Plus Aerobic/F, and Anaerobic Lytic/F) were analyzed in 496 osteoarticular specimens (246 synovial fluids and 250 crushed bone samples), obtained in patients during routine diagnostic procedure at the Teaching Hospital of Rennes (France). The positive detection times were recorded for a 14 day-incubation period, and compared between both vials and with agar cultures. For samples from infected patients, the positive detection time was significantly shortened when vials were used compared to agar plates (p

International audience; Avascular osteonecrosis of the femoral head (ONFH) is one of the causes of hip pain that clinicians need to know about. In many cases, it is a fortuitous discovery when pelvic X-rays is performed for another reason. In the other cases, pain reveals the disease. For the rheumatologist, a major part of the job is to look for a cause. An etiology can be found to ONFH in about 70% of the cases. Some of them are evident and the context give the diagnosis (corticosteroids, alcohol abuse…). However, in many cases, additional tests to imaging are required to make the causal diagnosis. In some cases, the treatment of the cause can prevent the recurrence of the disease.

International audience; Lower lumbar radicular pain is a benign and frequent condition, mostly induced by disk herniation or osteoarthritis. The management of lower lumbar radicular pain is a public health problem, with multimodal management. Lumbar epidural steroid injections are considered as a treatment but their effectiveness remains controversial, with conflicting results. Injection via the caudal hiatus route (CH) under ultrasound (US) guidance has gained popularity because of accessibility or US equipment, absence of irradiation, feasibility and very few complications reported.A pragmatic prospective observational two-center (Rennes and Nantes University Hospitals) study was performed to evaluate the effectiveness of a single steroid (cortivazol) epidural injection delivered under US guidance via the CH on lower lumbar radicular pain. The primary outcome for success was achieving a numerical pain rating scale score (NPRS ≤ 3/10 at day 30 (D30) after epidural injection. The secondary endpoints were achieving a NPRS ≤ 3/10 at D30 without opiates and NSAIDs, level of analgesic and NSAIDs consumption, absence from work and occurrence of adverse events. Factors related to efficacy were not well established.

National audience; Objectif: Évaluer les performances diagnostiques du dosage du lactate, du glucose et du ratio lactate/glucose synovial pour le diagnostic d'arthrite septique. Méthodes: Dans cette étude transversale monocentrique, les liquides synoviaux de patients souffrant d'un épanchement articulaire aigu (< 30 jours) sur articulations natives ont été recueillis de manière prospective. L'arthrite septique a été définie selon les critères de Newman. Pour évaluer les performances diagnostiques, ont été calculés la courbe ROC (Receiver Operating Characteristic) avec l'aire sous la courbe (AUC), la sensibilité (Se), la spécificité (Sp) et le rapport de vraisemblance positif (RV + ) avec leur intervalle de confiance à 95 %. La culture bactériologique des liquides synoviaux avec coloration de Gram, la recherche de microcristaux, la numération leucocytaire (GBsyn) et le dosage du glucose et du lactate ont été réalisés. Résultats: Au total, 233 liquides synoviaux ont été inclus comprenant 25 arthrites septiques et 208 arthrites non septiques (104 arthrites microcristallines, 15 PR, 8 SpA, 6 arthrites réactionnelles et 75 arthrites aiguës d'origine indéterminée). Le ratio lactate/glucose synovial était plus haut que le dosage séparé du lactate et du glucose synovial (AUC : 0,859 [0,772–0,945]). La valeur seuil idéale pour le ratio lactate/glucose synovial permettant de différencier l'arthrite septique de l'arthrite non septique était de 5 Se 52 % [0,34–0,7], Sp 98,1 % [0,95–0,99], RV+ 27,0 [9,50–76,00]). Conclusion: Les performances diagnostiques du ratio lactate/glucose synovial permettent de discriminer de manière efficace et très rapide les arthrites septiques des autres formes d'arthrite.

National audience; [No abstract available]

International audience

Introduction La vaccination contre la COVID19 est un enjeu crucial pour les patients, notamment ceux atteints de rhumatisme inflammatoire chronique. La pseudo-polyarthrite rhizomélique (PPR) et l’artérite à cellules géantes (ACG) sont deux maladies appartenant au même spectre. Leur physiopathologie est encore méconnue, mais un facteur déclenchant notamment infectieux ou vaccinal est supposé [1]. Nous rapportons le cas de 5 patients ayant développé une PPR ou une ACG dans les suites d’une vaccination contre la COVID19. Observation Trois PPR ont été diagnostiquées selon les critères ACR/EULAR 2012 avec facteur rhumatoïde (FR) et anti-CCP négatifs. Le premier patient était un homme de 71 ans qui a présenté 14 jours après une première dose de BNT162b2 (Pfizer) des douleurs inflammatoires des épaules avec raideur matinale de 2 heures. Après deux mois d’aggravation progressive et l’apparition de douleurs de la ceinture pelvienne, le diagnostic de PPR a été posé. La CRP était à 55 mg/l, l’échographie révélait une ténosynovite du long biceps et une bursite sous-acromio-deltoïdienne bilatérale. Un scanner thoraco-abdomino-pelvien ne montrait pas de vascularite. L’amélioration clinique fût rapide sous 15 puis 20 mg de prednisone (54 % d’amélioration du PMR-AS). Le deuxième, un homme de 63 ans, a développé, 7 jours après une dose de BNT162b2, des douleurs inflammatoires des épaules avec un dérouillage matinal de 2 h. La CRP était à 57 mg/l. L’échographie montrait une bursite sous-acromio-deltoïdienne gauche et une synovite de hanche droite. Les symptômes ont disparu en 48 h sous 15 mg/j de prednisone. La dernière patiente, 79 ans, avait reçu une dose de BNT162b2 14 jours avant l’apparition de douleurs inflammatoires des épaules avec dérouillage matinal d’une heure. La CRP était à 40 mg/l. Par ailleurs, deux cas d’ACG sont survenus de façon rapprochée après vaccination. La première patiente, âgée de 70 ans et atteinte d’une PPR en rémission sous prednisone 8 mg/j, a développé une altération de l’état général rapide 10 jours après sa vaccination par ChAdOx1 (AstraZeneca). La CRP était à 104 mg/l. Un Pet-scanner montrait un hypermétabolisme aortique et sous clavier en faveur d’une ACG extra-céphalique. Un mois après la majoration de la prednisone à 40 mg/j, la CRP était à 15 mg/l et les symptômes généraux avaient diminué. La dernière patiente, âgée de 74 ans, a présenté des céphalées et une hyperesthésie du cuir chevelu 7 jours après une dose de BNT162b2. L’apparition d’une claudication de la mâchoire et d’une altération de l’état général avec une CRP à 190 mg/l fît réaliser une biopsie d’artère temporale. L’histologie montrait un infiltrat granulomateux et une rupture de la limitante élastique interne. Sous prednisone 60 mg/j, ses symptômes et la CRP se sont améliorés. Discussion La succession rapide dans le temps de ces cas nous a interrogés sur la question de l’imputabilité du vaccin anti-COVID dans la survenu d’une PPR ou d’une ACG. Malgré tous ces deux affections sont fréquemment rencontrées en rhumatologie et en médecine interne avec une variation cyclique et saisonnière [2]. La vaccination contre la COVID19 a été réalisée de façon massive en France dans le même temps sur quelques mois. Il est donc difficile à partir de ces cas d’établir un lien de cause à effet. Conclusion La vaccination contre la COVID19 nécessite une attention particulière dans le cadre des rhumatismes inflammatoires chroniques. L’apparition de ces cas de PPR et ACG dans les suites de la vaccination soulèvent la question de la responsabilité du vaccin. Des études complémentaires collaboratives multicentriques sont nécessaires.

International audience; Objective: To evaluate the performance of combined cytology and microcrystal detection in joint fluid for diagnosing septic arthritis. Methods: Retrospective single-center study of joint fluid samples from patients with manifestations suggesting acute or chronic arthritis. The absolute leukocyte count (/mm(3)) was recorded; as well as the differential counts, particularly of neutrophils (%). Microcrystals were sought and bacteriological cultures performed. Septic arthritis was defined as positive cultures of joint fluid or blood samples. Diagnostic performance was assessed based on sensitivity, specificity, the receiver-operating characteristics (ROC) curve with the area under the curve (AUC), and the positive and negative likelihood ratios (LR+ and LR-). Results: Two hundred and eight joint fluid samples were included. The diagnoses were septic arthritis (n=28), chondrocalcinosis (n=41), gout (n=28), rheumatoid arthritis (n=33), spondyloarthritis (n=31), osteoarthritis (n=18), and undifferentiated arthritis (n=29). Among cytological parameters, those having the best diagnostic performance were the neutrophil count (cutoff, >50,000/mm(3)), the leukocyte count (cutoff, >50,000/mm(3)), and the percentage of neutrophils (cutoff, >95%); corresponding LR+ values were 8.93, 5.76, and 4.55, respectively. Neutrophil percentages lower than 80% had an LR-value of 0.07. Combining these cytological variables with the absence of crystals improved the diagnostic performance, yielding LR+ values of 11.36, 10.94, and 10.82 for neutrophils >95%, neutrophils >50,000/mm(3), and leukocytes >50,000/mm(3), respectively. Conclusion: Combining cytological characteristics of joint fluid with the absence of crystals benefits the diagnosis of septic arthritis. (C) 2016 Published by Elsevier Masson SAS on behalf of Societe francaise de rhumatologie.

Introduction Les lymphocytes T peripheral helper (Tph) constituent une sous-population decouverte recemment [1] , [2] , partageant avec les T follicular helper (Tfh) des fonctions d’aide a l’activation et a la maturation B, notamment via l’interleukine 21 (IL-21). Tph et Tfh expriment tous deux fortement PD-1 mais different par l’expression du recepteur de chimiokine CXCR5, ligand de CXCL13 permettant le homing au sein des structures lymphoides. L’objectif de ce travail etait d’analyser ces sous-populations lymphocytaires circulantes (Tph et Tfh) chez des patients atteints de polyarthrite rhumatoide (PR). Materiels et methodes Les patient inclus avaient une maladie active (DAS28 > 3,2), etaient naifs de biotherapie et debutaient un traitement par adalimumab. Les sous-populations lymphocytaires sanguines d’interet etaient identifiees par cytometrie de flux avant l’initiation de l’adalimumab (M0) et 3 mois apres (M3) en utilisant les marqueurs suivants : PD-1 + CXCR5-CD4+ pour les Tph, PD-1 + CXCR5 + CD4+ pour les Tfh. Leurs cytokines et chimiokines seriques associees (IL-21, CXCL13) etaient quantifiees par Luminex a M0 et M3. Les memes analyses etaient effectuees sur des temoins sains issus de dons de l’etablissement francais du sang. Les patients etaient suivis tous les 3 mois et la reponse clinique (DAS28 Resultats Trente et un patients ont ete inclus. Il s’agissait en majorite de femmes (20/31 ; 65 %), de 59 ans (28-77), dont la PR evoluait depuis 7 ans (0,75-43) et etait seropositive (Anti-CCP+ 27/31 ; 87 %). Dix-neuf temoins ont ete inclus, apparies en sexe, de 50 ans d’âge median (40-65). L’analyse des sous-populations lymphocytaires a M0 chez les PR comparee aux temoins a montre une surrepresentation des Tph, a la fois en nombre absolu et en pourcentage (p = 0,0325 ; p = 0,0002) ainsi que des Tfh (p = 0,0074 ; p = 0,0001). Les concentrations seriques d’IL-21 et de CXL13 etaient egalement significativement augmentees chez les patients comparativement aux temoins (p = 0,0024 et p = 0,0005). Parmi les patients, a M0, le nombre de Tph etait correle au titre d’anti-CCP (r = 0,47 ; p = 0,0125). Entre M0 et M3, seuls les Tfh ont significativement varie (diminution) sous adalimumab (p = 0,0022), independamment du statut repondeur ou non-repondeur. Aucune association n’a ete retrouvee entre la reponse clinique a M3, M6 ou M12 et le nombre ou le pourcentage des Tph et Tfh. Discussion Nous mettons en evidence une surrepresentation des Tph et Tfh circulantes dans la PR comparativement aux temoins, ainsi que de leurs cytokines et chimiokines associees et une correlation entre Tph et anti-CCP. Conclusion Ces donnees suggerent un potentiel role pathogene de ces cellules dans la PR, via l’activation lymphocytaire B et constituent d’interessantes futures cibles therapeutiques.

International audience

International audience; Objective - To evaluate the diagnostic performance of bacterial identification by broad-range polymerase chain reaction (PCR) of ribosomal DNA (rDNA) 16 s (16S rDNA PCR) for the diagnosis of septic arthritis on native joints. Methods - Patients with acute mono or oligoarthritis who underwent synovial fluid puncture and prospective follow-up allowing definitive diagnosis (septic arthritis, crystal related disease, chronic inflammatory arthritis, undifferentiated arthritis) were recruited in this single-center study. Systematic analysis of synovial fluid included leukocytes count, search for urate and pyrophosphate crystals with polarized light microscopy, direct bacteriological examination (gram staining), bacteriological culture, and 16S rDNA PCR. Results - Ninety-five patients were included, 34 of which (35.8%) had septic arthritis. Nineteen (20.0%) patients had received probabilistic antibiotic therapy prior to joint puncture. Gram + cocci infection accounted for 79.4% of septic arthritis, of which nearly half (47.1%) was caused by Staphylococcus aureus. Eight (23.5%) septic arthritis patients had a 16S rDNA PCR positive in the synovial fluid with an AUC of 0.618 (95% CI, 0.493-0.742), a sensitivity of 0.24 (95% CI, 0.12-0.40), and a specificity of 1.00 (95% CI 0.94-1.00). The diagnostic performance of 16S rDNA PCR was lower than that of direct examination (AUC at 0.691, CI 95%, 0.570-0.812), blood cultures (AUC at 0.727, CI 95%, 0.610-0.844), and culture (0.925, CI 95%, 0.856-0.994) for the diagnosis of septic arthritis. There was no difference in the positivity of 16S rDNA PCR according to previous exposure to antibiotics. Conclusions - 16 s rDNA PCR in the synovial fluid does not improve the diagnostic performance of septic arthritis on native adult joints, particularly for Gram-positive cocci infections.

Resume Objectif Evaluer les performances diagnostiques de la combinaison des donnees cytologiques et de la recherche des microcristaux dans le liquide synovial pour le diagnostic d’arthrite septique. Methodes Etude retrospective monocentrique a partir de liquides synoviaux de patients presentant un tableau d’arthrites aigues ou chroniques. Etaient analyses sur les liquides synoviaux : numeration leucocytaire (/mm3), formule leucocytaire avec taux de polynucleaires neutrophiles (PNN) (%), la recherche de microcristaux et les cultures bacteriologiques. Le diagnostic d’arthrite septique etait retenu lorsque les cultures etaient positives sur le liquide synovial ou dans les hemocultures. Pour evaluer la performance diagnostique, ont ete calcules, sensibilite, specificite, courbe ROC avec l’aire sous la courbe et le rapport de vraisemblance positif (LR+) ou negatif (LR−). Resultats Deux cent huit liquides synoviaux ont ete analyses : 28 arthrites septiques, 41 chondrocalcinoses, 28 gouttes, 33 polyarthrites rhumatoides, 31 spondyloarthrites, 18 arthroses, 29 arthrites indifferenciees. Les donnees cytologiques avec les meilleures performances diagnostiques etaient la numeration en PNN (seuil > 50 000/mm3), la numeration en leucocyte (seuil > 50 000/mm3) et le pourcentage de PNN (seuil > 95 %), avec des LR+ correspondant de 8,93, 5,76 et 4,55. Pour un seuil de PNN 95 %, PNN > 50 000/mm3 et leucocytes > 50 000/mm3. Conclusion La combinaison des donnees cytologiques des liquides synoviaux avec l’absence de microcristaux permet d’ameliorer les performances diagnostiques dans le diagnostic d’arthrite septique.

Background:Circulating anti-drug antibodies (ADAs) are detectable approximatively in 33% of adalimumab treated rheumatoid arthritis (RA) patients, often within the first 6 months of therapy1-2. Classically, circulating ADAs associate with their specific drugs to form immune complexes, increasing drug clearance, and by this mechanism reducing therapeutic effect3. B cell involvement leading to ADAs production is not yet well established.Objectives:To study early ADAs formation according to clinical response to an adalimumab therapy in RA patients and the relationship between ADAs and circulating B cell subsets.Methods:28 RA patients and 13 healthy controls were included. Patients all presented inadequately controlled RA under conventional treatment, were naive of biotherapies, and started an adalimumab treatment at baseline (M0). Responder status was determined according to the DAS28CRP score (3.2) at 3 (M3) and 6 months (M6). ADAs plasma concentration >10pg/mL at M3 defined the immunized patient group. Circulating B cell subsets were quantified by flow cytometry at M0 and M3.Results:11 (42.3%) patients were immunized at M3. Among them, 4 (36.4%) were responders at M6 and 7 (63.6%) were non-responders. Presence and concentration of ADAs at M3 was associated to non-responder status at M6 (p=0.043; p=0.042). Immunized patients had lower transitional B cells count at M0 compared to non-immunized patients (p=0.031).Conclusion:A high but classical proportion of RA patients developed ADAs after only 3 months of adalimumab treatment. This immunization was associated to non-responder status at M6 and to a low blood transitional B cells count at baseline. Our results suggest transitional B cells implication inRA activity and biotherapy resistance due to immunization. Low concentrations of transitional B cells could be an early biomarker of immunization process against adalimumab.References:[1]Bartelds GM et al. JAMA. 2011[2]Moots RJ et al. PLoS ONE. 2017[3]Van Schouwenburg PA et al. Ann Rheum Dis. 2013Table.Patients characteristics at baselineCharacteristicsAll RA patients (n=28)M6 responders(n=16)M6 non-responders(n=10)Age (years)60.5 [47-78]65.5 [47-76]54 [47-78]Sex ratio M/F (% of F)0.4 (71,4%)0.5 (68.8%)0.3 (80.0%)Disease duration, (years)5.6 [0.7-43.0]6.8 [1.0-43.0]2.9 [0.7-31.0]Oral steroid use, (%)18 (64,3%)9 (56.2%)8 (80.0%)Oral steroids, dose (mg/day)5.0 [2.0-15]5.0 [4.0-12.5]8.5 [2.5-15.0]Methotrexate use, (%)24 (50.9%)14 (87.5%)8 (80.0%)Methotrexate, dose (mg/week)20 [10-25]20 [10-25]15 [10-20]*Leflunomide use, (%)3 (10.7)1 (6.3%)2 (20.0%)Leflunomide, dose (mg/day)20 [20-20]20 [20-20]20 [20-20]CRP, (mg/dL)5.5 [1.0-57.0]6.6 [1.0-46.8]3.6 [1.0-57.0]DAS28CRP score4.3 [3.3-5.7]4.1 [3.3-5.2]4.5 [3.4-5.7]RF positive, (%)20 (71.4%)12 (75.0%)6 (60.0%)RF, (U/mL)116 [19-640]88 [21-640]181 [19-336]ACPA positive, (%)25 (89.3%)15 (93.8%)8 (80.0%)ACPA, (U/mL)340 [11-340]340 [14-340]340 [11-340]Values are medians with ranges and frequencies with percentages. *p=0.050.Figure 1.Graph 1Immunization against treatment at 3 months and clinical response at 6 months in RA patients (n=26). Presence of ADAs at 3 months is associated to non-responder status at 6 months. Fisher exact test. R, responders at 6 months; NR, non-responders at 6 months; ADA+, immunized patients at 3 months; ADA-, non-immunized patients at 3 months.Figure 2.Graph 2Absolute number of transitional B cells at baseline in RA patients (n=28) according to immunized status at 3 months. Immunized patients at 3 months had lower transitional B cells at baseline than non-immunized patients. ADA+, immunized patients at 3 months; ADA-, non-immunized patients at 3 months. Data represent the mean; *pDisclosure of Interests:None declared

Background:Clinical assessment of swollen joint count (SJC) in rheumatoid arthritis (RA) might be affected by obesity in terms of obesity-related excess adipose tissue.Objectives:To compare the level of agreement between synovitis evaluated by Power Doppler ultrasound (PDUS) and clinical examination (SJC as component of SDAI) in obese (O) (i.e. Body Mass Index (BMI) >30) versus non-obese (NO) (BMI≤30) RA patients.Methods:RA patients ≥18 years fulfilling 2010 ACR-EULAR criteria were included in the cross-sectional multicentre (13 centres) French observational RABODI study (ClinicalTrials.gov Identifier:NCT03004651). Clinical synovitis was evaluated on 44 joints. ESR and CRP were collected and SDAI, DAS28, DAS were calculated. A standard US examination on 44 joints was performed by an independent investigator blinded to clinical data. US synovitis was defined by a synovial hypertrophy ≥1 and PD signal≥1 on a semi-quantitative scale according to the EULAR-OMERACT scoring system. Levels of agreement between number of synovitis defined by PDUS and clinical examination were compared in O versus NO patients using Chi2 test, and Kappas (k) and ORs were calculated. A patient was considered “discordant” if ≥1 joint was discordantly classified by PDUS and clinical examination. SDAI was calculated and compared, with SJC defined either by clinical examination or PDUS.Results:121 patients were included: mean (SD) age of 58.5 (12.7) years, mean disease duration of 11.1 (9.7) years. 81% were female, 84.3% anti-CCP positive, 63.6% had erosive disease. Mean SDAI was 12.6 (±10.2). 53 (43.8%) had a BMI >30 and 68 (56.2%) ≤30. 59 (48.7%) and 62 (51.2%) had a SDAI≤11 and >11, respectively. The 2 groups were comparable, except for weight (mean (SD) 65.4 (13.5) vs 96.7 (14.7) kg, p< 0.001), some comorbidities (diabetes, asthma and fibromyalgia more frequent in O patients), tender joint count (mean 4.04 (±5.23) in NO vs 7.38 (±8.64) in O, p=0.021). Mean number of SJC was 2.4 (3.3), and PDUS 6.7 (±6.3). Levels of agreement between clinical and PDUS findings were comparable in O vs. NO patients regarding SDAI and other scores (Table). Patients with ≥3 discordant joints were numerically higher in O patients compared to NO (26/53 (49.1%) vs 22/68 (32.4%), p=0.062). At the joint level, discordance was higher in O patients in MCP4 (p=0.057), wrist (p=0.089).Table.Level of agreement between PDUS synovitis and SJC in obese versus normally weighted RA patientsScore with PDUS vs. SJCBMI ≤ 30N=68BMI > 30N=53OR(95%CI)P*SDAINon-Discordant (ND)63461.92(0.57-6.42)0.28Discordant (D)57Kappa0.850.73DAS28ND62471.32(0.4-4.35)0.64D66Kappa0.810.77DAS44ND63520.24(0.03-2.14)0.23D51Kappa0.830.96≥1 synovitisND51351.54(0.7-3.4)0.28D1718Kappa0.500.32Conclusion:In RA patients, despite a perceived higher difficulty to clinically detect SJ in O patients, the discrepancy between clinically- and PDUS defined synovitis was not significantly higher than in NO patients, and did not impact the extend of the definition of disease activity level.Disclosure of Interests:Gael Mouterde: None declared, Federico Manna: None declared, Benoit Le Goff: None declared, Jean-David Albert: None declared, Sandrine Jousse-Joulin: None declared, Frederique Gandjbakhch: None declared, Damien LOEUILLE: None declared, Philippe Gaudin Speakers bureau: Lilly, Muriel PIPERNO: None declared, BANAL Frédéric: None declared, Bénédicte Jamard: None declared, Carine Salliot: None declared, Nicolas Molinari: None declared, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Maria-Antonietta D’Agostino: None declared, Cédric Lukas: None declared

Background: Septic arthritis diagnostic is an emergency which implies a treatment with antibiotics and hospitalization. The diagnosis is based on the cytobacteriological examination of the synovial fluid (SF), but direct bacteriological examination is insensitive and the result of the culture is obtained only after several days. Therefore, there is still a need for a rapid, simple and reliable method for the positive diagnosis of septic arthritis. Such method must allow avoiding both unrecognized septic arthritis leading to major functional consequences, and overdiagnosis that will induce unnecessary expensive hospitalization and unjustified treatment with consequences in term of health and social costs. Mid-infrared (MIR) spectroscopy, that gives a metabolic profiling of biological samples, has been proposed for early and fast diagnosis. Objectives: The objective of this study was to confirm (1) the interest of mid-infrared (MIR) spectroscopy to discriminate synovial fluid samples from patients with septic arthritis from other causes of joint effusion. Methods: Synovial fluids from patients referred for suspected arthropathies were prospectively collected in six hospitals in western France and stored at -80°C. The infrared absorption spectrum was acquired for each of the frozen samples using a chalcogenide fibre sensor. The most informative spectral variables (allowing to discriminate between septic arthritis and non-septic arthritis with reference to cytobiological examination) were selected and then used to develop an algorithm. Non-frozen synovial fluids were also analysed at Rennes University Hospital, the pilot centre, to validate the algorithm. Results: The cohort consists of synovial fluid samples from patients exhibiting various etiologies. These samples (n=402), by using SF bacteriological analysis and culture and 16S PCR analysis were classified as septic arthritis (n=30) or non septic arthritis (n=372). On the frozen samples the performances of the algorithm show a sensitivity of 97%, a specificity of 71%, a VPN of 99% and a VPP of 21%, the area under the ROC curve (AUROC) was 0.91. Conclusions: This study confirms the interest of optical fibre infrared spectroscopy for the discrimination between septic and non septic synovial fluids. The high negative predictive value and the very short time (about ten minutes) required to obtain the result makes it possible to quickly rule out an infection diagnosis, which could make it possible to avoid unnecessary hospitalization and antibiotic therapy. Reference 1. Albert J-D, et al. Joint Bone Spine2016;83:318–323. Disclosure of Interest: J.-D. ALBERT: None declared, M. Le Corvec Employee of: DIAFIR, A. MARTIN: None declared, X. GUENNOC: None declared, C. DAVID: None declared, S. HOANG: None declared, C. GUEDES: None declared, M. FERREYRA: None declared, E. HOPPE: None declared, B. LEGOFF: None declared, S. JOUSSE-JOULIN: None declared, H. TARIEL Shareholder of: DIAFIR, O. SIRE Consultant for: DIAFIR, A. JOLIVET-GOUGEON: None declared, P. GUGGENBUHL: None declared, O. LOREAL Shareholder of: DIAFIR

Background Interstitial Lung Disease (ILD) related to Rheumatoid Arthritis (RA) is frequent. ILD is associated with an increased mortality in RA patients. Predictive factors for ILD progression are not well studied. Objectives In RA patients with an ILD according to CT scan criteria, identify clinical and biological predictive factors for ILD progression. Methods It is a retrospective multicentric study. RA patients with ILD confirmed by a first thoracic CT scan (tCT at T0) were included if ILD progression could be studied with a second CT scan (Tx) done at least 6 months after T0. RA patients were classified in two groups after double tCT evaluation on a blind review of data: those with ILD progression (pILD) and those with a stable ILD (sILD). Predictive factors for tCT ILD progression were studied by comparing these two groups. Studied data were ILD pattern, classified into typical UIP (Usual Interstitial Pneumonia) or not typical UIP, RA disease characteristics, biological parameters, and RA treatments, collected for each patient at T0 and Tx. Results Thirty-six RA patients with ILD confirmed by tCT were included. During an average follow-up of 3 years, 21 RA patients (58.1%) had ILD progression. Predictive factors for ILD progression a T0 are shown in table 1. In pILD group, we observed a significant higher value of the C Reactive Protein (CRP). A CRP rate superior to 20 mg/L was highly associated to ILD progression (Odds ratio=14.4; IC95%(1.36–15.2); p=0.02). Eight patients were treated at T0 by a DMARD different from Methotrexate (MTX). They all were in pILD group (p=0.01). Thirteen patients were treated with MTX at T0. Eight of them were in sILD group (61.5%) and only 5 patients in pILD group (38.5%). Eight patients continued MTX treatment after ILD diagnosis and for one patient, MTX was introduced between T0 and TX. For these 9 patients exposed to MTX after ILD diagnosis, during 27 months on average, no significant ILD progression was observed. Conclusions Factors associated with ILD progression were biological inflammation and exposure to a DMARD different from MTX. Exposure to MTX before or after ILD diagnosis was not associated with ILD worsening during the follow up. Disclosure of Interest None declared

Background Rotator cuff calcific tendinopathy is a common condition causing up to 20% of the painful shoulder. Ultrasound guided percutaneous lavage (UGPL) is indicated after failure of conservative treatments. Steroids injections in the subacromial bursa (SAB) are usually performed after the lavage to prevent the pain induced by the procedure. However, some suggested that this injection could prevent the inflammatory reaction leading to the disappearance of the calcific deposit. Moreover, its efficacy to prevent post-procedure pain has never been demonstrated. Objectives The goal of this study was to evaluate the effect of a steroid injection in the SAB after UGPL on the pain and the radiographic evolution of the calcification. Methods This was a multicentric prospective double blinded randomised controlled study. We included patients with shoulder pain for more than 3 months and a type A or B calcification >5 mm on X-Ray. Patients were treated with UGPL using a single needle technic. At the end of the procedure, they received a blind injection of either 2 mL of methylprednisolone acetate or 2 mL of serum saline. The primary outcome was the maximal VAS pain (0–100) the first week following UGPL. Secondary outcomes were the evolution of VAS pain at 7 days, 6 weeks and 3 months and the radiographic changes of the calcification at 3 months. Results We included 134 patients, mean age 49.8 (±9.7) years, 89 females (67.4%). Calcifications involved the supraspinatus, infraspinatus and subscapularis in 114 (85%), 14 (10%) and 6 patients (5%) respectively. Calcifications were type A and type B in 42,5% and 57,5% of the cases respectively and mean size of the calcification was 1,5 cm (±0,5). Backflow of calcific material was obtained in 107 patients (81.1%). Maximum pain during the first week following UGPL was 71.5 [CI95%:63.9–79.20] in the serum saline group versus 59.8 [CI95%:52.2–67.41] in the steroid group with a mean difference of 11.7 [CI95%:3.7–19.7]. More patients in the placebo group needed to take NSAID (12.1% versus 6.1%) and paracetamol (16.7% versus 9.1%) during the first week. VAS pain at rest and during activities decreased significantly more in the steroid group compared to the placebo: VAS pain during activity was 72.02 [62.98–81.06], 26.63 [17.60–35.67], 32.30 [23.11–41.49] and 43.27 [34.18–52.37] in the steroid group versus 72.46 [63.41–81.51], 48.22 [39.14–57.31], 51.44 [42.26–60.62] and 51.09 [41.95–60.24] in the placebo group at day 0, 7, 6 weeks and 3 months respectively (figure 1). At 3 months no difference was found in the radiographic evolution: 62.1% of the patients treated with steroid and 64.8% treated with serum saline had more than 50% of resorption of their calcification. Conclusions Our study shows that steroid injection in the SAB leads to a significant decrease of maximal pain the following week. This treatment also decreases significantly the pain during the 3 first months after UGPL. Importantly, we found no difference between the 2 groups in the radiographic evolution of the calcification at 3 months. Overall, steroids injections in the SAB can be recommended after UGPL. Disclosure of Interest None declared

To assess the diagnostic value of ultrasound-guided (US-guided) synovial biopsy in routine clinical practice in cases of acute and chronic arthritis. A retrospective, single-center study of US-guided synovial biopsies between 2003 and 2013. The clinical, laboratory, radiographic, synovial fluid, and histological and bacteriological results of synovial biopsies were analyzed. Arthritis was classified according to disease duration

International audience; Background - Bilateral ankle arthritis is a classic diagnostic criterion for Löfgren syndrome. The objective of this study was to use ultrasonography to characterize the articular and periarticular involvement of the ankles in patients with Löfgren syndrome. Methods - Multicenter descriptive cohort study of patients with Löfgren syndrome who underwent ultrasonography of the ankles. We collected clinical data, imaging study findings, blood test results, and joint fluid properties in patients who underwent joint aspiration. Results - Findings from ultrasonography of the ankles in 40 patients were analyzed. The most common B-mode abnormality was subcutaneous edema (26/40), followed by tenosynovitis (22/40), with no differences in frequency across compartments. Joint involvement manifested as synovitis in 7 patients and effusion in 10 patients. Synovitis with increased vascularity by power Doppler was found in 3 patients. No statistically significant associations were found linking synovitis or tenosynovitis to clinical features (age and gender), laboratory tests, or imaging study findings. Conclusion - Contrary to the classical view, our results indicate that ankle involvement in Löfgren syndrome is more often abarticular than articular. The inclusion of bilateral ankle arthritis among the diagnostic criteria for Löfgren syndrome deserves reappraisal.

International audience; Refers to: Bruce Rothschild, Maltese cross interpretation. Comment on: “Acute phospholipid microspherule associated arthritis: Is it rare?” by Coiffier et al., Joint Bone Spine 2017;84;537-40. Joint Bone Spine, Volume 85, Issue 3, May 2018, Pages 391

International audience

Resume Dans cette revue iconographique, les auteurs decrivent les aspects ultrasonographiques des calcifications periarticulaires et discutent de l’apport diagnostique et therapeutique de l’echographie a la prise en charge du rhumatisme a depots d’apatite.

Resume Objectifs Determiner la sensibilite, specificite, valeur predictive positive et negative et la concordance inter-observateur de l’analyse du liquide synovial a l’etat frais par le rhumatologue par rapport a celle du laboratoire. Methodes Etude prospective monocentrique menee au CHU de Rennes sur 1 an. Analyse du liquide synovial par le rhumatologue : appreciation du caractere mecanique ou inflammatoire et presence de cristaux d’urate de sodium (UMS) ou de pyrophosphate de calcium (PPC). Les resultats ont ete compares a l’analyse par le laboratoire pour la concordance. Ils ont ensuite ete analyses en fonction du diagnostic final etabli par le clinicien sur les donnees cliniques, biologique et d’imagerie pour la sensibilite, specificite, valeur predictive positive et negative. Resultats Cent quatre-vingts liquides synoviaux ont ete collectes. Le coefficient de concordance Kappa est de 0,80 pour le caractere mecanique ou inflammatoire, 0,97 pour la recherche de cristaux d’UMS et 0,69 pour les cristaux de PPC. La sensibilite et la specificite de la lecture par le rhumatologue etaient respectivement de 94,2 % et 84,6 % pour le caractere inflammatoire, 80,7 % et 100 % pour les cristaux d’UMS, 66,7 % et 93,2 % pour les cristaux de PPC. Conclusion L’analyse du liquide synovial par le rhumatologue presente donc une concordance bonne a excellente avec l’analyse au laboratoire concernant la recherche de cristaux d’UMS et de PPC ainsi que le caractere mecanique ou inflammatoire.

Objectives The aims of this study in SLE population were (1) to describe ultrasonography (US) joint abnormalities, (2) to estimate the reliability of clinical swollen joint count (C-SJC) and SLEDAI (C-SLEDAI) versus US-SJC and US-SLEDAI scores, (3) to highlight specific patterns of lupus patients with Power Doppler (PD) abnormalities. Method For this cross-sectional multicenter study, 151 consecutive adult SLE patients were recruited. Evaluation included a clinical standardized joint assessment, B-mode and PD US of 40 joints and 26 tendons blinded for clinical examination. Reliability and agreement between clinical and B-mode US were calculated using the intraclass correlation coefficients (ICC [95% Confidence Interval]). Results We found a very high frequency of subclinical US abnormalities in asymptomatic patients: 85% of patients without joint symptoms had at least 1 US abnormality. Among them 46 patients (87%) had a history of joint involvement. The most frequent abnormalities were joint effusmaions (108 patients), synovial hypertrophy (SH, 109 patients) and synovitis (61 patients). Joint or tendon PD signal (grade > 1) was found in 44% of patients (67/151). Synovitis were mainly located especially on MCPs and wrists. Even if reliability between clinical and grey-scale US SJC assessments was poor, reliability between clinical and US SLEDAI was good. Comparison between SLE patients with and without PD signal did not show any specific SLE pattern. Conclusion US may be useful to assess joint involvement in SLE patients but did not significantly change SLEDAI score.

International audience; Advantages of MALDI-TOF MS (MS) were evaluated for diagnosis of bone and joint infections after enrichment of synovial fluid (SF) or crushed osteoarticular samples (CSs). MS was performed after enrichment of SF or crushed osteoarticular samples CS (n = 108) in both aerobic and anaerobic vials. Extraction was performed on 113 vials (SF: n = 47; CS: n = 66), using the Sepsityper(®) kit prior identification by MS. The performances of MS, score and reproducibility results on bacterial colonies from blood agar and on pellets after enrichment in vials, were compared. MS analysis of the vial resulted in correct identification of bacteria at a species and genus level (80.5% and 92% of cases, respectively). The reproducibility was superior for aerobic Gram-positive bacteria (Staphylococci and Gram-positive bacilli: 100% colonies), as compared to aerobic Gram-negative bacilli (89.7%), anaerobes (83.3%) and Streptococcus/Enterococcus (58.8%). MS performance was significantly better for staphylococci than for streptococci on all identification parameters. For polymicrobial cultures, identification (score>1.5) of two species by MS was acceptable in 92.8% of cases. Use of MS on enrichment pellets of bone samples is an accurate, rapid and robust method for bacterial identification of clinical isolates from osteoarticular infections, except for streptococci, whose identification to species level remains difficult.

International audience; Joint fluid analysis must be performed as part of the diagnostic workup for acute arthritis, most notably to rule out septic arthritis and to allow the identification of crystal-induced arthritis (gout or calcium pyrophosphate deposition disease), which is one of the most common causes. However, the detection of monosodium urate or calcium pyrophosphate microcrystals is not the only goal of the polarized light microscopy examination of joint fluid. Other, less common microcrystals may be found. Among them are phospholipid microspherules, which are easily recognized microscopically based on their Maltese cross-like appearance. Phospholipid microspherules are a cause of acute arthritis that is often missed by rheumatologists and may therefore be more common than generally believed. © 2016 Société française de rhumatologie

Introduction Structural damage progression is a major outcome in rheumatoid arthritis (RA). Its evaluation and follow-up in trials should involve radiographic scoring by 1 or 2 readers (reference assessment), which is challenging in large longitudinal cohorts with multiple assessments. Objectives To compare the reproducibility of multireader and reference assessment to improve the feasibility of detecting radiographic progression in a large cohort of patients with early arthritis (ESPOIR). Methods We used 3 sessions to train 12 rheumatologists in radiographic scoring by the van der Heijde-modified Sharp score (SHS). Multireader scoring was based on 10 trained-reader assessments, each reader scoring a random sample of 1/5 of all available radiographs (for double scoring for each X-ray set) for patients included in the ESPOIR cohort with complete radiographic data at M0 and M60. Reference scoring was performed by 2 experienced readers. Scoring was performed blindly to clinical data, with radiographs in chronological order. We compared multireader and reference assessments by intraclass correlation coefficients (ICCs) for SHS and significant radiographic progression (SRP). Results The intrareader and inter-reader reproducibility for trained assessors increased during the training sessions (ICC 0.79 to 0.94 and 0.76 to 0.92), respectively. For the 524 patients included, agreement between multireader and reference assessment of SHS progression between M0 and M60 and SRP assessment were almost perfect, ICC (0.88 (95% CI 0.82 to 0.93)) and (0.99 (95% CI 0.99 to 0.99)), respectively. Conclusions Multireader assessment of radiographic structural damage progression is comparable to reference assessment and could be used to improve the feasibility of radiographic scoring in large longitudinal cohort with numerous X-ray evaluations.

International audience; The majority of patients do not receive anti-osteoporotic treatment following a major osteoporotic fracture, despite the guidelines and the availability of effective anti-osteoporotic treatments. The fight against factors limiting the diagnosis and treatment of osteoporosis should become a priority to improve secondary prevention after an initial osteoporotic fracture. PURPOSE: Despite the availability of effective anti-osteoporotic treatments, osteoporosis management is currently insufficient. The main objective of this study was to assess the prevalence of anti-osteoporotic treatments introduced after an initial prior major osteoporotic fracture during hospitalization for recurring fractures. METHODS: We conducted an observational, cross-sectional, bicentric study that included all patients aged over 50 years who were hospitalized or seen in consultation for major osteoporotic fracture. RESULTS: One hundred twenty-eight out of two hundred four (62.7%) patients had a past history of major osteoporotic fracture and therefore had an indication of treatment based on guidelines. Among these patients, only 43/128 (33.5%) had received anti-osteoporotic treatment as secondary prevention after the initial fracture. The main causes of non-prescription identified were the attending physicians' ignorance of the indication of treatment (n = 30; 35.3%), ignorance of the fracture (n = 17; 20%), and comorbidities (n = 12; 14.1%). The failure to introduce treatment was associated with the presence of comorbidities with a Charlson Comorbidity Index ≥6 (OR = 0.34 [0.16-0.73], p

OBJECTIVE. In some cases, sciatica-like symptoms radiating through the buttock, anterior thigh, or leg result from spinal root compression in an extraspinal location or from injury to the pelvic girdle. It has been suggested that adding a coronal STIR sequence dedicated to the lumbosacral plexus and pelvis to the routine MRI protocol can provide a good depiction of disorders of this type. MATERIALS AND METHODS. Two hundred nine patients with sciatica-like symptoms of suspected lumbar origin were included in the study. Disorders responsible for symptoms involving extraspinal compression of the lumbosacral plexus or pelvic girdle were retrospectively noted and correlated with age, sex, location of pain, referring physician, presence of discoradicular impingement liable to explain symptoms, and history of neoplasia. RESULTS. An extraspinal cause of symptoms was depicted in 12 cases (5.7%), including three cases of extraspinal compression and nine differential diagnoses in the pelvic region. Prevalence of an extraspinal cause of pain was significantly correlated with the absence of discoradicular impingement in the spine (p = 0.046). A higher prevalence of extraspinal compression of the lumbosacral plexus (p = 0.029) was seen in patients 60 years old or older, whereas no other feature was statistically associated with an extraspinal cause of pain. CONCLUSION. Because of its short acquisition time and subsequent low cost, the additional coronal STIR sequence should be performed in the routine MRI investigation of sciatica-like symptoms when no discoradicular impingement is seen in the spine to depict an extraspinal cause of symptoms.

We read with great interest the new ultrasound scoring system of salivary glands for primary Sjogren’s syndrome (pSS) developed by Outcome Measures in Rheumatology (OMERACT) and recently reported by Jousse-Joulin et al .1 The salivary gland ultrasound (SGUS) is a simple, non-irradiating, non-expensive and accessible assessment tool. Several previous SGUS scoring systems have been proposed so far, but not all of them take into account every pathological features, especially in the parotid gland (such as hyperechoic bands) for the diagnosis of pSS. The lack of consensus between each of these SGUS scoring systems also had a negative impact on the reproducibility of the examination so far. By offering an updated consensual classification, the OMERACT initiative therefore constitutes an undeniable progress for the diagnosis of pSS. Recently, in a multicentre prospective study of 97 patients referred for clinical sicca syndrome (39 pSS and 22 secondary Sjogren’s syndrome (sSS) according to American-European Consensus Group (AECG) criteria in comparison with 36 controls), we …