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International audience; BACKGROUND: Use of a combination of targeted therapies (COMBIO) in patients with refractory/overlapping immune-mediated inflammatory diseases (IMIDs) has increased, but reported data remain scarce. We aimed to assess effectiveness and safety of COMBIO in patients with IMIDs. METHODS: We conducted a French ambispective multicenter cohort study from September 2020 to May 2021, including adults' patients with 1 or 2 IMIDs and treated at least 3-month with COMBIO. RESULTS: Overall, 143 patients were included. The most common IMIDs were Crohn's disease (63.6%), axial spondyloarthritis (37.7%), and ulcerative colitis (14%). Half of patients had only one IMID, of which 60% were Crohn's disease. Mean duration of COMBIO was 274.5±59.3 weeks, and COMBIO persistence at 104 weeks was estimated at 64.1%. The most frequent COMBIOs combined anti-TNF agents with vedolizumab (30%) or ustekinumab (28.7%). Overall, 50% of patients achieved significant and 27% mild-to-moderate improvement in patient-reported outcomes. Extended duration of COMBIO (aOR=1.09; 95% CI: 1.03-1.14; p=0.002) and diagnoses of two IMIDs (aOR=3.46; 95%CI: 1.29-9.26; p=0.013) were associated with significant improvement in patient-reported outcomes. Incidence of serious infection during COMBIO was 4.51 per 100 person-years (95% CI 2.20-8.27) and 5 COMBIOs were discontinued due to adverse events. CONCLUSIONS: COMBIO can be effective and safe in patients with refractory/overlapping IMIDs.

Inflammatory bowel diseases (IBDs) can be associated with various musculoskeletal (IBD-MSK) manifestations that could be difficult to classify for gastroenterologists. We aimed to evaluate the characteristics of patients with IBD-MSK and the prevalence of spondyloarthritis (SpA). In this observational cross-sectional study, we included patients with IBD-MSK complaints (peripheral or back pain). All patients underwent a standardized rheumatology evaluation including clinical, biological and imaging evaluations (MRI of spine and sacroiliac joints and ultrasonography of enthesis). We included 183 IBD patients (60.7% women; median [interquartile range] age 45 [36-56] years); 159 (87%) had joint pain. In 43 (23.5%) and 25/175 (14.3%) patients, enthesis abnormalities were found on ultrasonography and sacroiliitis on MRI, respectively. SpA was diagnosed in 54 (29.5%) patients. IBD-related arthralgia and degenerative spine disease were diagnosed in 105 (57.4%) and 72 (39.3%) patients. Sixteen (29.6%) SpA patients initiated a new conventional synthetic disease modifying anti-rheumatic drug (DMARD). A biologic DMARD was initiated in 10 patients or changed in 3. More than half of IBD-MSK patients had IBD-related arthralgia, and about one-third had definite SpA. Ultrasonography of enthesis and systematic MRI of sacroiliac joints seem useful for SpA classification and differential diagnosis in these patients who often have musculoskeletal pain complaints. Therapeutics were changed in most patients, which highlights the need for a multidisciplinary approach for managing IBD with extra-intestinal symptoms.

Objectives Very little is known on the efficacy and safety of drugs for the management of chronic calcium pyrophosphate (CPP) crystal inflammatory arthritis. To describe the drugs used in the management of chronic CPP crystal inflammatory arthritis in expert European centres, and to examine treatment retention. Methods This was a retrospective cohort study. Charts from patients with a diagnosis of persistent inflammatory and/or recurrent acute CPP crystal arthritis were reviewed in 7 European centres. Baseline characteristics were collected, and visits at months 3, 6, 12 and 24 included an assessment of treatment response and safety. Results 194 treatments were initiated in 129 patients. Colchicine (was used first-line in n = 73/86), methotrexate (used first-line in n = 14/36), anakinra (n = 27) and tocilizumab (n = 25) were the most prescribed treatments, while long-term corticosteroids, hydroxychloroquine, canakinumab and sarilumab were used occasionally. The 24-months on-drug retention was higher for tocilizumab (40%) than anakinra (18.5%)(p< 0.05), while the difference between colchicine (29.1%) and methotrexate (44.4%) was not statistically significant (p= 0.10). Adverse events lead to 14.1% of colchicine discontinuations (100% of diarrhoea), 4.3% for methotrexate, 31.8% for anakinra and 20% for tocilizumab, all other discontinuations were related to insufficient response or losses to follow-up. Efficacy outcomes did not differ significantly between treatments throughout follow-up. Conclusion Daily colchicine is the first-line therapy used in chronic CPP crystal inflammatory arthritis, which is considered efficient in a third to half of cases. Second-line treatments include methotrexate and tocilizumab, which have higher retention than anakinra.

Objective US of salivary glands (SGUS) is a non-invasive tool that allows for diagnosing primary SS (pSS) or secondary SS (sSS). However, little is known about the prevalence of US findings of SS in other CTDs. The aim of this multi-centre observational study was to evaluate, in CTD patients with or without SS, the prevalence of abnormal SGUS findings and the possible association of the findings with clinical or biological phenotypes. Methods B-Mode SGUS was performed by one operator blinded to clinical data. Each SG was semi-quantitatively rated on a scale from 0 to 4 according to the Jousse-Joulin score; a score ≥2 was considered pathological. Results Data for 194 patients were analysed (pSS, n = 30; sSS, n = 39; other CTDs, n = 77; controls, n = 48). SGUS findings were abnormal in 80%, 67%, 25% and 2% of patients, respectively. Independent of the underlying disease, age and sex, abnormal SGUS findings were significantly associated with presence of anti-SSA antibodies (P Conclusion Abnormal SGUS findings were associated with anti-SSA antibody positivity independent of the underlying disease. In SS patients, abnormal findings were associated with immunologic features and mouth involvement. Among CTD patients, SGUS changes may be associated with a particular immune profile.

Objective: Interstitial lung disease (ILD) is a common feature of connective tissue disease (CTD). The diagnosis of CTD-ILD can be challenging and is important for therapeutic decisions. In this st...

Polymyalgia rheumatica (PMR) is an inflammatory disease with a diagnosis that is sometimes difficult to establish. Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) might be helpful. We analysed the usefulness of 18F-FDG PET/CT for the diagnosis of PMR.This was an observational retrospective study of individuals with PMR who underwent 18F-FDG PET/CT and a control group. We assessed clinical and 18F-FDG PET/CT characteristics. Sixteen sites were studied. The number of sites with significant FDG uptake, the mean maximum standardised uptake value (SUVmax) and the highest SUVmax value were assessed for each patient.Data for 123 patients with PMR (37 with corticosteroids [CSTs] use) were analysed; 85 had new-onset PMR. As compared with the 75 controls, patients with new-onset PMR had higher mean ± SD number of sites with significant FDG uptake (11.3 ± 3.3 vs. 0.9 ± 1.1, p0.001) and higher SUVmax scores (p0.001). A cut-off of 5 hypermetabolic sites provided sensitivity of 96.5% and specificity 100%. For the total SUVmax score, a cut-off of 3 had the best sensitivity (92.6%) and specificity (86.1%). As compared with PMR patients using CSTs, those who were CST-naive had significantly higher CRP level (p0.001), number of sites with significant FDG uptake (p0.001) and SUVmax scores (p0.01). In contrast, large-vessel vasculitis was more frequent in patients receiving CSTs than CST-naive patients (27% vs. 8%, p0.01).The number of hypermetabolic sites or SUVmax quantification might be useful for PMR diagnosis, and CSTs might affect the results of 18F-FDG PET/CT.

BackgroundRecent studies have shown a lack of implementation of gout recommendations in primary care. In this context of therapeutic inertia, the French Society of Rheumatology (SFR) published its first recommendations on gout in 2020, which were deliberately simple and concise. ObjectivesThe objectives were to determine the profile of patients referred to French gout expert centres, and to examine the results of their management and the factors leading to those results. MethodsThree hundred patients attending a first visit for gout management in three French referral centres were retrospectively and randomly included in this multicentre observational study.Visits were performed at baseline (M0) and scheduled for month 6 (M6), month 12 (M12), and month 24 (M24). Data collected included: patient profile; disease activity and treatments; serum urate (SU) level; estimated glomerular filtration rate (eGFR). ResultsPatients were 81% male and mean age 62.2 ± 15.2 years. Only 15,3% of them had difficult-to-treat gout at baseline. Management followed French recommendations after the baseline visit in 94.9% of cases. SU levels were below 6.0mg/dL in 59.4% of patients at M6, 67.9% at M12, and 78.6% at M24, with increasing clinical improvement (i.e. flare decrease) over 2 years of follow-up. At M24, 50% of patients were treated with allopurinol (313 ± 105 mg/d), which exceeded renal restrictions of doses in 61.5% of them, and 48.2% received febuxostat (84 ± 36mg/d). The need for a sufficient dosage of ULT was the only predictive factor found for successful reach SU levels ConclusionSimple application of gout management guidelines is feasible in clinical practice, and is efficient with a majority of patients achieving SU targets and clinical improvement.

OBJECTIVE The aim of this study was to assess the magnetic resonance imaging (MRI) features associated with microbial pathogen detection by computed tomography (CT)-guided biopsy in patients with suspected septic spondylodiscitis. METHODS For the last 10-year period, we analyzed the medical records of patients who underwent MRI and CT-guided biopsy for suspected septic spondylodiscitis. Clinical characteristics were recorded. The following MRI features were assessed: edema or contrast enhancement of the intervertebral disc, adjacent vertebrae, epidural and paravertebral space, presence of abscess, and paravertebral edema size. A positive biopsy was defined by pathogen identification on bacterial analysis or the presence of granuloma on histology. Predictors of a positive biopsy were assessed with a logistic regression model. RESULTS We analyzed data for 61 patients (34 [56%] male; mean age, 59.9 ± 18.0 years); for 35 patients (57%), CT-guided biopsy was positive for a pathogen. The 4 MRI findings significantly associated with a positive biopsy were epiduritis, greater than 50% vertebral endplate edema, loss of intradiscal cleft, and abscess. The size of paravertebral edema was greater with a positive than negative biopsy (median, 15.9 [interquartile range, 11.3-21.3] vs 7.3 [4.6-12.9] mm; p = 0.004). On multivariable analysis, epiduritis was the only independent predictor of a positive biopsy (adjusted odds ratio, 7.4 [95% confidence interval, 1.7-31.4]; p = 0.006). CONCLUSIONS Epiduritis and the size of paravertebral edema on MRI are associated with detection of a microbial pathogen in suspected septic spondylodiscitis. For patients without these MRI signs, the need for further investigations such as enriched or prolonged cultures, a second CT-guided biopsy, or even surgical biopsy need to be discussed.

Skeletal tuberculosis (TB) is rare. We aimed to report on diagnostic strategy and treatment of skeletal TB.In this multidisciplinary single-center medical records review study, all adult patients admitted between January 2009 and December 2019 with microbiologically proven skeletal TB were included. Demographic, medical history, laboratory, imaging, pathologic findings, treatment, and follow-up data were extracted from medical records.Among 184 patients identified with TB, 21 (16 women, 42 years [27, 48 years]) had skeletal involvement. Skeletal TB included spondylitis (n = 11), lytic bone lesions (n = 7), sacroiliitis (n = 5), arthritis (n = 3), osteitis (n = 2), and diffuse muscle abscesses without bone lesion (n = 1). Lytic lesions involved both axial and peripheral skeleton at multiple sites in most cases. 18F-fluorodeoxyglucose positron emission tomography was performed in 13 patients and helped to detect multifocal asymptomatic lesions and to target biopsy. All patients were treated with anti-TB therapy for 7 to 18 months. Fifteen patients (71.4%) received steroids as an adjunct therapy. Eleven patients needed an orthopedic immobilization corset, and 3 patients underwent surgery. All patients clinically improved under treatment, but 2 relapsed over a median follow-up of 24 months (12-30 months). No patient died or suffered long-term disabilities.Our study emphasizes the diversity of skeletal involvement in TB. 18F-fluorodeoxyglucose positron emission tomography scanner at diagnosis is key to assess the extension of skeletal involvement and guide extraskeletal biopsy. Neurological complications might be prevented by adding corticosteroids to anti-TB therapy.

Resume Objectif Developper des recommandations de la Societe Francaise de Rhumatologie pour la prise en charge du traitement hypouricemiant de la goutte. Methodes A partir d’une revue systematique de la litterature, un groupe de travail compose de neuf rhumatologues (hospitaliers ou liberaux), trois generalistes, un cardiologue, un nephrologue et un patient a elabore des recommandations fondees sur les preuves. Le groupe de travail a redige une premiere ebauche des recommandations au cours d’une reunion et les a finalisees en utilisant la technique Delphi. Resultats Une serie de trois principes generaux et cinq recommandations a ete elaboree. Les principes generaux soulignent l’importance de l’education du patient, particulierement la necessite d’expliquer l’importance de l’abaissement chronique de l’uricemie afin de permettre la dissolution des cristaux, la resolution des symptomes cliniques et la prevention des complications. Un traitement hypouricemiant est indique des la confirmation du diagnostic de la goutte. Il faut reduire l’uricemie a un taux inferieur a 300 μmol/L (50 mg/L) chez tous les patients, ou au moins inferieur a 360 μmol/L (60 mg/L) lorsque la cible de 300 μmol/L ne peut pas etre atteinte, et la maintenir a ce niveau a vie avec une surveillance reguliere. Le choix du medicament hypouricemiant depend de la fonction renale : si le debit de filtration glomerulaire estime (DFGe) est superieur a 60 mL/min/1,73m2, l’allopurinol est indique en premiere intention ; en cas de DFGe de 30 a 60 mL/min/1,73m2, l’utilisation de l’allopurinol doit etre prudente et le febuxostat est une alternative ; en cas de DFGe inferieur a 30 mL/min/1,73m2, il faut eviter l’allopurinol et preferer le febuxostat. La prevention des crises de goutte induites par le traitement hypouricemiant se fait par l’augmentation progressive de la posologie de l’hypouricemiant et l’adjonction de colchicine a faible dose pendant au moins 6 mois. Les facteurs de risque et maladies cardiovasculaires, le syndrome metabolique et l’insuffisance renale chronique sont a depister et a prendre en charge. Conclusion Ces recommandations se veulent etre un guide clair et simple pour la conduite du traitement hypouricemiant en France.

Bone sarcoidosis is usually rare. Imaging procedures such as fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) can reveal bone sarcoidosis with better sensitivity than conventional radiography. We aimed to describe bone sarcoidosis involvement detected with 18F-FDG PET/CT. This was an observational retrospective study of individuals with pulmonary sarcoidosis who underwent 18F-FDG PET/CT. According to the ATS/ERS/WASOG criteria, sarcoidosis was diagnosed by the presence of clinical and/or imaging features of sarcoidosis and evidence of non-caseating epithelioid granulomas on a biopsy. We assessed clinical and 18F-FDG PET/CT characteristics. Data for 85 patients with sarcoidosis (56.5% female, median age 47 [range 21–80] years) were analyzed. The median follow-up was 4 years. Among 56 patients, sarcoidosis occurred in more than three organs. According to ATS/ERS/WASOG criteria, bone sarcoidosis was diagnosed in 12 (14%) patients. The spine was the most commonly affected location (92%, n = 11), followed by the pelvis (67%, n = 8), sternum (33%, n = 4), humerus (25%, n = 3), and fingers (17%, n = 2). Only peripheral adenopathy was associated with bone sarcoidosis (p = 0.04). Seven patients had a 18F-FDG PET/CT follow-up, all showing a decrease of bone lesions. Bone sarcoidosis occurred in 14% of patients with sarcoidosis, affecting multiple bones and mostly the axial skeleton. 18F-FDG PET/CT seems a sensitive tool for diagnosis and follow-up of bone sarcoidosis.

Objectives Polymyalgia rheumatica (PMR) is the commonest inflammatory disorder of the elderly; an association with environmental triggers and a deregulated immune response have been described. The aim of this study was to investigate the association of environmental triggers before the onset of PMR. Material and methods The database of 58 consecutive PMR patients recruited from a single rheumatology secondary care setting was retrospectively analyzed to investigate the frequency of environmental triggers and correlations with clinical characteristics, ultrasound and laboratory data. Results Fifteen PMR patients (26%) described a connection with environmental agents: six PMR patients reported a vaccination, 4 reported a respiratory tract infection, 5 reported seasonal influenza before the onset of the disease. The model of multivariate linear regression which better predicted a shorter time to normalize inflammatory reactants (R2 = 27.46%, p = 0.0042) comprised the presence of an environmental trigger and a higher PCR. A linear regression analysis confirmed an inverse correlation between PCR at onset and time to normalize inflammatory reactant (r = –0.3031, p = 0.0208). A significant correlation was demonstrated between presence of environmental trigger and shorter time to normalize inflammation (r = –0.5215, p< 0.0001), and lesser frequency of gleno-humeral synovitis on US (r = –0.3774, p = 0.0038). Conclusions Our work describes a correlation between environmental triggers in PMR and higher CRP at diagnosis, faster response to therapy, and milder shoulder synovitis. We may suppose that these patients belong to a more specific subtype of PMR, in whom external stimuli, such as vaccination or infection, may lead to a deregulated response within the context of an impaired senescent immuno-endocrine system.

Background: In a context of therapeutic inertia, the French Society of Rheumatology (SFR) published its first recommendations on gout in 2020, which were deliberately simple and concise. The objectives of the study were to determine the profile of patients referred to French gout-expert centres, and to examine the results of their management and the factors leading to those results. Methods: Three hundred patients attending a first visit for gout management in three French referral centres were retrospectively and randomly included in this multicentre observational study. Visits were performed at baseline (M0) and scheduled for month 6 (M6), month 12 (M12), and month 24 (M24). Results: Patients were 81% male and had a mean age 62.2 ± 15.2 years. Management followed French recommendations after the baseline visit in 94.9% of cases. SU levels were below 6.0 mg/dL in 59.4% of patients at M6, 67.9% at M12, and 78.6% at M24, with increasing clinical improvement (i.e., flare decrease) over 2 years of follow-up. At M24, 50% of patients were treated with allopurinol (313 ± 105 mg/d), which exceeded renal restrictions of doses in 61.5% of them, and 48.2% received febuxostat (84 ± 36 mg/d). The need for a sufficient dosage of ULT was the only predictive factor found for successful achievement of SU levels < 6.0 mg/dL at a given visit. Conclusions: Simple application of gout-management guidelines is feasible in clinical practice and is efficient, with a majority of patients achieving SU targets and clinical improvement.

To evaluate the relevance ofIn 2 rheumatology departments, we identified PMR and atypical SpA patients who underwentBetween September 2012 and August 2018, we enrolled 35 PMR and 27 SpA patients (median [interquartile range] age 71 years [63.5-74.5] and 54 years [41.5-63], P0.001).

Resume Objectif La calcification de cristaux d’hydroxyapatite (HA) intra- ou peri-articulaires peut provoquer des poussees aigues hyperalgiques. Une etude pilote a suggere que l’inhibiteur de l’interleukine-1β (IL-1β) anakinra etait un traitement efficace. L’objectif de cette etude observationnelle etait de confirmer ce resultat dans un plus grand groupe de patients et de decrire le suivi a long terme. Methodes Une poussee a ete definie comme des douleurs aigues pendant moins de 10 jours. Une calcification intra- ou peri-articulaire (coiffe des rotateurs : 15/23 patients) a ete confirmee par radiographie classique et/ou echographie. Une dose quotidienne de 100 mg d’anakinra a ete administree par voie sous-cutanee pendant un a trois jours consecutifs. Les donnees cliniques collectees avant l’injection et aux jours 3 et 21 comprenaient le score de douleur sur une echelle visuelle analogique (EVA, 0-10 cm) et le taux de proteine reactive C (CRP). Lorsqu’ils etaient disponibles, les resultats de l’echographie a l’inclusion et pendant le suivi ont ete compares. Les donnees de suivi a long terme ont ete collectees dans les dossiers des patients et/ou par telephone. Resultats Vingt trois patients (15 hommes, âge moyen [ET] 58 [11] ans) ont ete inclus. Le score de douleur EVA moyen (ET) a l’inclusion etait de 7,7 (1) cm et la moitie des patients avaient un taux de CRP eleve. Apres traitement, le score de douleur EVA moyen (ET) a diminue rapidement pendant les trois premiers jours pour atteindre 1,6 (1,4) cm (p Conclusion Cette etude suggere que l’inhibition de l’IL-1β peut constituer une approche therapeutique efficace et d’un bon profil de securite pour les poussees d’HA aigues.

Resume Objectifs Les inhibiteurs de l’interleukine (IL)-1β, efficaces dans les crises de goutte, sont recommandes en cas de contre-indications a la prise en charge standard, notamment insuffisance renale chronique (IRC) de stade 4 ou 5. Or, il existe peu de donnees disponibles sur l’efficacite et la securite de ces agents dans cette population de patients. Nous avons souhaite explorer l’efficacite et la securite de l’anakinra utilise pour traiter les crises de goutte chez des patients presentant une IRC de stade 4 ou 5 ou ayant subi une transplantation renale. Methodes Cette etude retrospective menee dans trois centres universitaires a inclus des patients consecutifs presentant une IRC de stade 4 ou 5 ou ayant subi une transplantation renale qui prenaient de l’anakinra en traitement d’une arthrite goutteuse aigue et avaient effectue au moins une visite de suivi. L’efficacite, la survenue d’infections et les variations de la fonction renale ont ete consignees. Resultats Sur les 31 patients inclus (24 hommes, âge moyen 72 ± 11 ans), 25 n’avaient pas subi de transplantation et presentaient une IRC de stade 4 ou 5 (estimation du debit de filtration glomerulaire moyen [eDFG] selon la formule MDRD 22,7 ± 6,5 mL/min/1,73 m2) et 6 avaient subi une transplantation renale (eDFG moyen 41,5 ± 22,8 mL/min/1,73 m2). La duree mediane de la goutte etait de 3,5 ans et le taux moyen d’uricemie de 8,7 mg/dL. Vingt-et-un patients (68 %) presentaient des tophi et 21, une arthropathie goutteuse. L’anakinra a ete efficace chez tous les patients (EVA final 10 et CRP finale 10 mg/L). Dix patients (32 %) etaient dependants de l’anakinra (c.-a-d. qu’un traitement prolonge d’anakinra etait necessaire). Une infection grave a ete enregistree chez une seule patiente, trois mois apres l’instauration de l’anakinra. Aucune variation significative de la fonction renale n’a ete observee. Conclusion L’anakinra peut constituer une option therapeutique sure chez les patients goutteux presentant une IRC a un stade avance. Des etudes comparatives randomisees supplementaires sont necessaires pour confirmer nos resultats.

Bowel-associated dermatosis-arthritis syndrome (BADAS) is a rare syndrome that was described for the first time in 19711 in patients who received bypass obesity surgery,2 taking the name of bowel bypass syndrome. Similar cases were reported with patients who had inflammatory bowel disease3 leading to the name of BADAS. It causes both arthralgia and skin eruptions, which, in context of bowel disease, has to put us in mind of the possibility of the diagnosis. Here we report a case of a positron emission tomography (PET) scanner description.

Hydroxyapatite (HA) crystal calcifications in or around the joint can induce acute flares with severe pain. A previous pilot study suggested that the interleukin-1β (IL-1β) inhibitor anakinra was effective. The goal of this observational study was to confirm these results in a larger set of patients and to report on the long-term follow-up.Flare was defined as acute pain for10 days. Calcification in or around a joint (rotator cuff: 15/23 patients) was confirmed by conventional radiography and/or ultrasonography (US). Anakinra 100mg daily was administered subcutaneously for 1 to 3 consecutive days. Clinical data collected before the injection and on days 3 and 21 included pain score on a visual analog scale (VAS, 0-10cm) and C-reactive protein (CRP) level. When available, US baseline and follow-up findings were compared. Long-term follow-up data were collected from patient charts and/or after a phone call.23 patients (15 males, mean [SD] age 58 [11] years) were included. Baseline mean (SD) VAS pain was 7.7 (1) cm and CRP level was elevated in half of the patients. After therapy, mean (SD) VAS pain score decreased rapidly in the first 3 days to 1.6 (1.4) cm (P0.001) and remained stable for 3 weeks at 1.8 (2.1) cm. US assessment revealed decreased Doppler intensity but no significant change in size of calcifications. No significant side effects were noted. After long-term follow-up (median duration 24 months), half of the patients still had some chronic pain, but only 4 experienced acute relapse.This study suggests that IL-1β inhibition may be an efficient therapeutic approach for acute HA flare, with a good safety profile.

Objectives Interleukin (IL)-1β blocking is effective for the treatment of gout flares and is recommended in patients with contraindications to the standard of care, such as stage 4–5 chronic kidney disease (CKD) patients. However, efficacy and safety data regarding these agents are lacking in this population. We aimed to investigate the efficacy and safety of anakinra for the treatment of gout flares in patients with stage 4–5 CKD or renal transplantation. Methods This retrospective study encompassing 3 academic centres included consecutive patients with stage 4–5 CKD or kidney transplantation who received anakinra for the treatment of acute gouty arthritis and completed at least one follow-up visit. Efficacy, occurrence of infection, and renal function variations were recorded. Results Of the 31 included patients (24 men, mean age 72 ± 11 years), 25 were non-transplant subjects with stage 4–5 CKD (mean estimated glomerular filtration rate, MDRD formula (eGFR) 22.7 ± 6.5 mL/min/1.73 m 2 ), and six had undergone kidney transplantation (mean eGFR 41.5 ± 22.8 mL/min/1.73 m 2 ). Median gout duration was 3.5 years, and the mean serum urate (SUA) level was 8.7 mg/dL. Twenty-one (68%) patients had tophi, and 21 had gout arthropathy. Anakinra was efficacious in all patients (final VAS 10 and CRP level 10 mg/L). Ten patients (32%) were anakinra dependent (i.e., required prolonged treatment with anakinra). A serious infection was recorded in only one patient, occurring 3 months after starting anakinra. No significant variation in renal function was observed. Conclusion Anakinra may be a safe therapeutic option for gout patients with advanced CKD. Further randomized controlled studies are required to confirm our results.

To determine whether leukocyte esterase reagent strip test (LERST) analysis could help distinguish inflammatory arthritis from mechanical joint effusion. We analyzed synovial fluid (SF) from consecutive patients with a non-traumatic joint effusion during a 6-month period. Inflammatory SF was defined by white blood cell (WBC) count ≥ 2000/mm3. The LERST was performed with both semi-quantitative visual analysis (VA) and automated colorimetric reader (ACR) analysis. Leukocytes ≥ 1+ was considered a positive LERST result and WBC count was the reference. We obtained 100 SF samples (87 knees, 7 ankles, 5 hips, and 1 elbow) from 100 patients (mean ± SD age 61 ± 17 years, 59% men). The laboratory analyzed 88 SF samples (37 mechanical and 51 inflammatory). The remaining 12 SF samples were 10 hemarthrosis not allowing LERST analysis and 2 samples with coagulum not allowing WBC count. As compared with the laboratory analysis, the LERST had sensitivity and specificity 55% and 89% with VA and 47% and 92% with ACR analysis. The positive and negative predictive values were 87.5% and 59% with VA and 89% and 55% with ACR analysis. We found almost perfect agreement between VA and ACR results (kappa 0.70 [95% CI 0.50–0.90]). The WBC count increased with number of + observed after VA. Our results confirm that the LERST is able to detect inflammation in SF of native joints, thereby representing a useful and cheap tool in primary care. Its low sensitivity limits its use for ruling out inflammatory disorders.

International audience; Objectives: To determine whether changes in ultrasonography (US) features of monosodium urate crystal deposition is associated with the number of gouty flares after stopping gout flare prophylaxis.Methods: We performed a 1-year multicentre prospective study including patients with proven gout and US features of gout. The first phase of the study was a 6-month US follow-up after starting urate-lowering therapy (ULT) with gout flare prophylaxis. After 6 months of ULT, gout flare prophylaxis was stopped, followed by a clinical follow-up (M6 to 12) and ULT was maintained. Outcomes were the proportion of relapsing patients between M6 and M12 according to changes of US features of gout and determining a threshold decrease in tophus size according to the probability of relapse.Results: We included 79 gouty patients [mean (±SD) age 61.8±14 years, 91% males, median disease duration 4 (IQR 1.5;10) years]. Among the 49 completers at M12, 23 (47%) experienced relapse. Decrease in tophus size ≥50% at M6 was more frequent without than with relapse (54% vs. 26%, P=0.049). On ROC curve analysis, a threshold decrease of 50.8% in tophus size had the best sensitivity/specificity ratio to predict relapse [AUC 0.649 (95% confidence interval 0.488; 0.809)]. Probability of relapse was increased for patients with a decrease in tophus size

Background Rheumatoid arthritis (RA) is associated with increased risk of infections. Screening for oral (dental and/or sinus) infection could be proposed before biologic disease-modifying antirheumatic drugs (bDMARDs) initiation but is not systematically recommended. The aim of our study was to assess the prevalence of oral infection in RA patients requiring bDMARDs. Materials and methods This was a monocentric retrospective study. We included patients with RA and active disease requiring bDMARDs. Dental infection and sinusitis were assessed by a stomatologist and otorhinolaryngologist after clinical, panoramic dental X-ray and sinus CT evaluation. Factors associated with oral infections were analysed in uni- and multivariate models, estimating odds ratios (ORs) and 95% confidence intervals (CIs). Results We included 223 RA patients (79.4% women, mean disease duration 8.9 ± 8.6 years). The mean age was 54.4 ± 10.9 years and mean Disease Activity Score in 28 joints 5.5 ± 2.6. Systematic dental screening revealed infection requiring treatment before bDMARDs initiation in 46 (20.9%) patients. Sinusitis was diagnosed by the otorhinolaryngologist in 33 (14.8%) patients. Among the 223 patients, 69 (30.9%) had dental and/or sinus infection. On univariate analysis, active smoking was associated with increased probability of oral infection (OR = 2.16 [95% CI 1.02-4.57], P = .038) and methotrexate with reduced probability (OR = 0.43 [95% CI 0.23-0.81], P = .006). On multivariate analysis, no RA variables were associated with oral infection. Conclusion In our study, asymptomatic oral infection was confirmed in one third of RA patients.

AIM To determine whether findings from lung ultrasound and chest high-resolution computed tomography (HRCT) correlate when evaluating COVID-19 pulmonary involvement. MATERIALS AND METHODS The present prospective single-centre study included consecutive symptomatic patients with reverse transcription polymerase chain reaction (RT-PCR)-proven COVID-19 who were not in the intensive care unit. All patients were assessed using HRCT and ultrasound of the lungs by distinct operators blinded to each other's findings. The number of areas (0–12) with B-lines and/or consolidations was evaluated using ultrasound and compared to the percentage and classification (absent or limited, 75%) of lung involvement on chest HRCT. RESULTS Data were analysed for 21 patients with COVID-19 (median [range] age 65 [37–90] years, 76% male) and excellent correlation was found between the ultrasound score for B-lines and the classification (p, Highlights • Ultrasonography is correlated with chest CT in COVID-19 patients. • Lung ultrasonography could be a relevant alternative to chest CT. • Lung ultrasonography is correlated with oxygen parameters.

Resume Objectif Elaborer les recommandations de la Societe francaise de rhumatologie pour la prise en charge des crises de goutte. Methodes Ces recommandations ont ete elaborees par 9 rhumatologues (hospitaliers ou liberaux), 3 generalistes, 1 cardiologue, 1 nephrologue et 1 patient, sur la base d’une revue systematique de la litterature. Resultats Quatre principes generaux et 4 recommandations ont ete etablis. Les principes generaux soulignent l’importance de l’education du patient, et du traitement precoce des crises de goutte, si possible dans les 12 premieres heures, selon un traitement pre-defini. Les patients doivent savoir que la goutte est une maladie chronique qui necessite un traitement hypo-uricemiant en sus du traitement de la crise. Les comorbidites et les possibles interactions medicamenteuses, qui peuvent contre-indiquer certains traitements anti-inflammatoires, doivent etre recherchees avec soin chez tous les patients. La colchicine doit etre prescrite a la dose suivante : 1 mg puis 0,5 mg une heure plus tard, puis 0,5 mg deux a trois fois par jour les jours suivants. La diarrhee est le premier symptome d’intoxication a la colchicine, et doit faire diminuer les posologies. La posologie de la colchicine doit egalement etre diminuee chez les patients presentant une insuffisance renale chronique ou prenant des medicaments qui interagissent avec son metabolisme. Les autres options de premiere ligne sont les corticoides (oraux ou intra-articulaires), les anti-inflammatoires non steroidiens (AINS). Les anti-IL-1 sont un traitement de seconde ligne, en cas d’echec, intolerance ou contre-indication a la colchicine, aux corticoides ou aux AINS. Ils sont contre-indiques en cas d’infection et doivent faire surveiller les polynucleaires neutrophiles. Conclusion Ces recommandations proposent des strategies d’utilisation des anti-inflammatoires pour une meilleure prise en charge des crises de goutte.

Objective To develop French Society of Rheumatology-endorsed recommendations for the management of gout flares. Methods These evidence-based recommendations were developed by 9 rheumatologists (academic or community-based), 3 general practitioners, 1 cardiologist, 1 nephrologist and 1 patient, using a systematic literature search, one physical meeting to draft recommendations and 2 Delphi rounds to finalize them. Results A set of 4 overarching principles and 4 recommendations was elaborated. The overarching principles emphasize the importance of patient education, including the need to auto-medicate for gout flares as early as possible, if possible within the first 12 h after the onset, according to a pre-defined treatment. Patients must know that gout is a chronic disease, often requiring urate-lowering therapy in addition to flare treatment. Comorbidities and the risk of drug interaction should be screened carefully in every patient as they may contraindicate some anti-inflammatory treatments. Colchicine must be early prescribed at the following dosage: 1 mg then 0.5 mg one hour later, followed by 0.5 mg , 2 to 3 times/day over the next days. In case of diarrhea, which is the first symptom of colchicine poisoning, dosage must be reduced. Colchicine dosage must also be reduced in patients with chronic kidney disease or taking drugs, which interfere with its metabolism. Other first-line treatment options are systemic/intra-articular corticosteroids, or non-steroidal anti-inflammatory agents (NSAIDs). IL-1 inhibitors can be considered as a second-line option in case of failure, intolerance or contraindication to colchicine, corticosteroids and NSAIDs. They are contraindicated in cases of infection and neutrophil blood count should be monitored. Conclusion These recommendations aim to provide strategies for the safe use of anti-inflammatory agents, in order to improve the management of gout flares.

Objective To develop French Society of Rheumatology-endorsed recommendations for the management of urate-lowering therapy (ULT). Methods Evidence-based recommendations were developed by 9 rheumatologists (academic or community-based), 3 general practitioners, 1 cardiologist, 1 nephrologist and 1 patient, using a systematic literature search, one physical meeting to draft recommendations and two Delphi rounds to finalize them. Results A set of 3 overarching principles and 5 recommendations was elaborated. The overarching principles emphasize the importance of patient education, especially the need for explaining the objective of lowering serum urate (SU) level to obtain crystal dissolution, clinical symptoms disappearance and avoidance of complications. ULT is indicated as soon as the diagnosis of gout is established. SU level must be decreased below 300 μmol/l (50 mg/l) in all gout patients or at least below 360 μmol/l (60 ml/l) when the 300 μmol/l target cannot be reached, and must be maintained at these targets and monitored life-long. The choice of the ULT primarily relies on renal function: in patients whose estimated glomerular filtration rate (eGFR) is above 60 ml/min/1.73 m2, first-line ULT is allopurinol; in those with eGFR between 30 and 60 ml/min/1.73 m2, allopurinol use must be cautious and febuxostat can be considered as an alternative; and in those whose eGFR is below 30 ml/min/1.73 m2, allopurinol must be avoided and febuxostat should be preferred. Prophylaxis of ULT-induced gout flares involves progressive increase of ULT dosage and low-dose colchicine for at least 6 months. Cardiovascular risk factors and diseases, the metabolic syndrome and chronic kidney disease must be screened and managed. Conclusion These recommendations aim to provide simple and clear guidance for the management of ULT in France.

ObjectiveTo evaluate the efficacy of tocilizumab, an antibody against IL-6 receptor, in patients with hand osteoarthritis.MethodsThis was a multicentre, 12-week, randomised, double-blind, placebo-controlled study from November 2015 to October 2018. Patients with symptomatic hand osteoarthritis (pain ≥40 on a 0–100 mm visual analogue scale (VAS) despite analgesics and non-steroidal anti-inflammatory drugs; at least three painful joints, Kellgren-Lawrence grade ≥2) were randomised to receive two infusions 4 weeks apart (weeks 0 and 4) of tocilizumab (8 mg/kg intravenous) or placebo. The primary endpoint was changed in VAS pain at week 6. Secondary outcomes included the number of painful and swollen joints, duration of morning stiffness, patients’ and physicians’ global assessment and function scores.ResultsOf 104 patients screened, 91 (45 to tocilizumab and 46 to placebo; 82% women; mean age 64.4 (SD 8.7) years) were randomly assigned and 79 completed the 12-week study visit. The mean change between baseline and week 6 on the VAS for pain (primary outcome) was −7.9 (SD 19.4) and −9.9 (SD 20.1) in the tocilizumab and placebo groups (p=0.7). The groups did not differ for any secondary outcomes at weeks 4, 6, 8 or 12. Overall, adverse events were slightly more frequent in the tocilizumab than placebo group.ConclusionTocilizumab was no more effective than placebo for pain relief in patients with hand osteoarthritis.

(1) Background: To determine which factors are associated with the volume of monosodium urate (MSU) crystal deposition quantified by dual-energy computed tomography (DECT) in urate-lowering therapy (ULT)-naive gout patients. (2) Methods: In this multicenter cross-sectional study, DECT scans of knees and feet/ankles were prospectively obtained from ULT-naive gout patients. Demographic, clinical (including gout history and comorbidities), and biological data were collected, and their association with DECT MSU crystal volume was analyzed using bivariate and multivariate analyses. A second bivariate analysis was performed by splitting the dataset depending on an arbitrary threshold of DECT MSU volume (1 cm3). (3) Results: A total of 91 patients were included. In the bivariate analysis, age (p = 0.03), gout duration (p = 0.003), subcutaneous tophi (p = 0.004), hypertension (p = 0.02), diabetes mellitus (p = 0.05), and chronic heart failure (p = 0.03) were associated with the total DECT volume of MSU crystal deposition. In the multivariate analysis, factors associated with DECT MSU volumes &ge, 1 cm3 were gout duration (odds ratio (OR) for each 10-year increase 3.15 (1.60, 7.63)), diabetes mellitus (OR 4.75 (1.58, 15.63)), and chronic heart failure (OR 7.82 (2.29, 31.38)). (4) Conclusion: Specific comorbidities, particularly chronic heart failure and diabetes mellitus, are more strongly associated with increased MSU crystal deposition in knees and feet/ankles than gout duration, regardless of serum urate level.

Background The microbiological diagnosis of bone and joint infections (BJI) currently relies on cultures, and the relevance of molecular methods is still debated. The aim of this study was to determine whether polymerase chain reaction (PCR) could improve the etiological diagnosis of BJI. Methods A prospective study was conducted during a 4-year period at Lariboisiere University Hospital (Paris, France), including patients with suspicion of infectious spondylodiscitis, septic arthritis, prosthetic joint infections, and respective noninfected groups. Clinical and radiological data were collected at inclusion and during follow-up. All samples were analyzed by conventional cultures and 16S ribosomal deoxyribonucleic acid (rDNA) gene (16S-PCR). Specific cultures and PCR targeting Mycobacterium tuberculosis were also performed for spondylodiscitis samples. Case records were subsequently analyzed by an independent expert committee to confirm or invalidate the suspicion of infection and definitively classify the patients in a case or control group. The sensitivity of the combination of culture and PCR was compared with culture alone. Results After expert committee analysis, 105 cases of BJI cases and 111 control patients were analyzed. The most common pathogens of BJI were staphylococci (30%), M tuberculosis (19%), and streptococci (14%). Adding PCR enhanced the sensitivity compared with culture alone (1) for the diagnosis of M tuberculosis spondylodiscitis (64.4% vs 42.2%; P < .01) and (2) for nonstaphylococci BJI (81.6% vs 71.3%; P < .01). It is interesting to note that 16S-PCR could detect BJI due to uncommon bacteria such as Mycoplasma and fastidious bacteria. Conclusions Our study showed the benefit of 16S-PCR and PCR targeting M tuberculosis as add-on tests in cases of suspected BJI., For high suspicion of bone and joint infection, 16S-PCR must be considered, particularly when cultures remain negative, with performance depending on the pathogens involved. Specific PCR for Mycobacterium tuberculosis detection is beneficial in case of high suspicion of tuberculous spondylodiscitis.

International audience