Acroparesthesias: An Overview

Acroparesthesia is a symptom characterized by a subjective sensation, such as numbness, tingling, prickling, and reduced sensation, affecting the extremities (fingers and toes). Despite its frequency, data regarding its diagnostic approach and management are scarce. The etiological diagnosis of acroparesthesia is sometimes challenging since it can be due to abnormality anywhere along the sensory pathway from the peripheral nervous system to the cerebral cortex. Acroparesthesia can reveal several diseases. It can be associated with rheumatic complaints such as arthritis or myalgia. Further cautions are required when paresthesia is acute (within days) in onset, rapidly progressive, severe, asymmetric, proximal, multifocal, or associated with predominant motor signs (limb weakness) or severe dysautonomia. Acroparesthesia may reveal Guillain-Barré syndrome or vasculitis, requiring rapid management. Acroparesthesia is a predominant symptom of polyneuropathy, typically distal and symmetric, often due to diabetes. However, it can occur in other diseases such as vitamin B12 deficiency, monoclonal gammopathy of undetermined significance, or Fabry's disease. Mononeuropathy, mainly carpal tunnel syndrome, remains the most common cause of acroparesthesia. Ultrasonography contributes to the diagnosis of nerve entrapment neuropathy by showing nerve enlargement, hypoechogenic nerve, and intraneural vascularity. Besides, it can reveal its cause, such as space-occupying lesions, anatomical nerve variations, or anomalous muscle. Ultrasonography is also helpful for entrapment neuropathy treatment, such as ultrasound-guided steroid injection or carpal tunnel release. The management of acroparesthesia depends on its causes. This article aimed to review and summarize current knowledge on acroparesthesia and its causes. We also propose an algorithm for the management of acroparesthesia.

Increased serum interleukin 22 levels in patients with axial spondyloarthritis

OBJECTIVES

The role of IL-22 in radiographic axial spondyloarthritis is not fully elucidated. Thus, there is a need for new insights into this cytokine in this disease. We aimed to compare interleukin (IL)-22 level between spondyloarthritis, nonspecific-low back pain patients, and pain-free controls, and to evaluate associations between this cytokine and spondyloarthritis characteristics.

METHODS

We conducted a case-control study including 62 patients with radiographic axial spondyloarthritis (G1), 46 with nonspecific low back pain (G2), and 42 healthy volunteers (G3). IL-22 was measured using Enzyme-linked immunosorbent assay. We evaluate disease activity and structural damage of spondyloarthritis.

RESULTS

IL-22 level was higher in G1 than in G2 and G3 (38±40 versus14.42±8.17 versus14.3±18.67 pg/mL, p<0.01). IL-22 discriminated patients in G1 from G2 with a cutoff of 22.28pg/mL (Sensitivity: 62.9%, Specificity: 97.8%, area under the curve (AUC): 0.808). IL-22 cutoff of 19.27pg/mL discriminated patients in G1 from G3 (Sensitivity: 67%, Specificity: 94.3%, AUC: 0.855). No associations were found between IL-22 levels and disease activity and structural damage.

CONCLUSIONS

Our study showed that IL-22 level was higher in radiographic axial spondyloarthritis patients compared to controls. It was also able to differentiate G1 patients from G2 and G3. This finding suggests that the IL-22 pathway showed to play a pathological role in spondyloarthritis.

Low Back Pain Among Students of Medical University of Tunis

OBJECTIVE

Low Back Pain (LBP) is the most common musculoskeletal disorder among working adults. It is one of the most prevalent complaints among students. Medical students are among those who are most exposed to this condition; due to stress, numerous hours of studying, and the sedentary lifestyle. Our study aimed to determine the prevalence and associated factors of LBP among the students of Tunis Faculty of Medicine and to assess its impact on student life.

METHODS

This cross-sectional study was carried out on the Tunis Faculty of Medicine students. Data were collected through an online self-administered questionnaire. Sociodemographic, personal, and lifestyle characteristics were collected. LBP was assessed using the Nordic Musculoskeletal Health Questionnaire and Its impact using the Oswestry Disability Index (ODI).

RESULTS

One hundred and forty-eight students were included. The mean age was 22.9 ± 2.3 years (19.64-38.21). The sex ratio was 0.29. According to the Nordic questionnaire, the point, annual and lifetime prevalence of LBP were 37.8%, 80.4%, and 90.5%, respectively. The mean ODI score was 10.32 ± 8.48 % (0-32). The ODI score was minimal in 87.3% and moderated in 12.7% of cases. The associated factors with LBP were: young age (p = 0.015), spending more than 4 hours in a sitting position (p = 0.059), second cycle of medical studies (p = 0.006), low screen projection in the amphitheater (p = 0.029) and poor layout of the amphitheatres (p = 0.000). The feeling of depression was significantly higher among LBP students (p = 0.018). In the multivariate analysis, the factors that remained statistically significant were the second cycle of medical studies (OR= 3.41), feeling of depression (OR = 3.7), and the belief in the responsibility for the poor layout of the amphitheaters in the genesis or maintenance of LBP (OR = 7.66).

CONCLUSION

LBP in medical students is multifactorial across both personal and college-life domains.

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

Introduction:

Overweight and obesity are common in patients with Rheumatoid Arthritis (RA), with a probable impact on bearing foot joints.

Aim:

Our study aimed to explore the impact of Body Mass Index (BMI) on foot health parameters in RA patients.

Methods:

It was a cross-sectional study. Domains of foot health explored were: foot pain (Numeric Rating Scale), foot-related activity limitations (Foot Function Index (FFI), and WOMAC scale), foot synovitis, foot deformity (Platto Score (PS)), radiological joint damage and footwear problems.

Results:

Fifty RA were included, 82% were female. The mean age was 45.68±10.3 years. The mean DAS28-CRP was 3.25±0.98. Sixty-six percent were overweight or obese, with a mean BMI of 29 Kg/m2±5.74. The average foot pain intensity while walking was 6±1.75. The mean swollen foot joint was 2.2±1.55. The average foot structural index was 7.8 ± 2.73. The mean FFI Disability score was 32±14.2 and WOMAC score was 33.8 ± 13.98. Half of our patients had footwear problems predominantly because of claw toe (40%). High BMI was significantly correlated with foot pain and foot-related activity limitations. It was also correlated with foot deformities assessed with PS (B=4.78; CI[3.87-5.68]; p=0.02), foot synovitis (OR=4.66, CI[2.61-8.32]; p<0.001) and problems with footwear (OR= 0.32; CI[0.18-0.56]; p=0.05). However, it was significantly associated with less radiological joint damage (CI[-0.7-1.1]; p=0.01) and lower foot sharp score (B= -13.9; CI[-0.34-0.01]; P = 0.06).

Conclusion:

Despite our findings of a possible protective effect of obesity on structural damage, obesity is still an important cause of increased pain, functional disability, and impaired QoL in RA patients.

Influencing factors in Tunisian Rheumatoid arthritis patients’ Quality of life: burden and Solutions

Background:

Rheumatoid Arthritis (RA) is a disease with a heavy functional, psychological, and socioeconomic impact. The management of Quality of Life (QoL) as a therapeutic objective is a fairly recent notion, especially in Tunisia. We aimed to evaluate QoL in RA patients and to identify its affecting factors.

Methods:

This was a cross-sectional study in a Tunisian rheumatology center. To assess QoL, we used the Short Form Health Survey (SF-36) and the Arthritis Impact Measurement Scales Short Form (AIMS2-SF). Health Assessment Questionnaire Disability Index (HAQ), the Hospital Anxiety and Depression Scale (HAD) for psychological disorders, Visual Analog Scale for Pain (VAS Pain), and for fatigue (VAS Fatigue) were also used. Disease activity was assessed by the Disease Activity Score (DAS28 CRP).

Results:

We enrolled 120 established RA, the mean age of our patients was 56.9±11.4 years, with a predominance of women (83.3%). The mean disease duration was 10.97±7.7 years. According to the HAD scale, 27% of our patients presented anxiety, and 26.7% had depressive disorders. There was significantly impaired QoL in patients with low educational level, dependent financial situation, long disease duration, high disease activity, high pain and fatigue levels, poor therapeutic education, functional disability, and psychological disorders (p<0.001). A strong negative correlation was detected between inflammatory markers, structural damage, and the scores of QoL. Patients under biologics scored significantly higher in the SF36 mental health domain (p<0.001).

Conclusion:

QoL is significantly poor in Tunisian RA. These patients should be managed using a multidisciplinary approach involving the patients themselves.

Factors associated with hip involvement in spondyloarthritis: a retrospective study

BACKGROUND

Hip involvement is a life-changing event during spondyloarthritis (SpA) since it's responsible for significant disability and functional impairment. This study aimed to determine the factors associated with hip involvement in patients with SpA.

METHODS

This was a retrospective study, including patients with axial and/or peripheral SpA divided into two groups: patients without and with hip involvement. Hip involvement was defined as pain or abnormality on clinical examination of the hip and/or on imaging. We collected clinical and laboratory data, activity and functional scores, and radiographic parameters. We conducted a multivariate analysis to identify the associated factors of hip involvement.

RESULTS

We included 165 patients with a mean age of 46.13 ± 13.07 years, 121 patients were male. The mean duration of disease was 10.91 ± 6.94 years. Hip involvement, defined as SpA-related hip pain, joint limitation, and dysfunction and/or imaging involvement (X-ray/MRI), was noted in 60 cases (36.4%). Multivariate analysis indicated that disease duration over 10 years (OR=3.847, 95% confidence interval (CI95%)[1.324-11.178], p=0.013), radiographic sacroiliitis (OR=8.949, CI95%[1.261-63.513], p=0.028), very high disease activity (Ankylosing Spondylitis Disease Activity Score: ASDASCRP≥3,5) (OR=9.364, CI95%[2.552-34.352], p=0.001), higher Bath Ankylosing Spondylitis Functional Index (BASFI) (OR=1.439, CI95%[1.120-1.850], p=0.004) and higher Bath Ankylosing Spondylitis Metrology Index (BASMI) (OR=1.311, CI95%[1.065-1.615], p=0.011) were independently associated with hip involvement in these patients. Regarding extra-articular features, we found that pulmonary involvement and osteoporosis were significantly more frequent in patients with hip involvement, but neither retained significance in multivariate analysis.

CONCLUSION

Disease duration over 10 years, radiographic sacroiliitis, very high disease activity, functional impairment, and limited spine mobility were potential associated factors with hip involvement. Patients with these factors should be closely monitored to detect hip involvement at an early stage.

The synovial fluid fibroblast-like synoviocyte: A long-neglected piece in the puzzle of rheumatoid arthritis pathogenesis

Rheumatoid arthritis (RA) is a systemic autoimmune disease during which fibroblast-like synoviocytes (FLS) contribute to both joint inflammation and destruction. FLS represent the core component of the synovial membrane. Following inflammation of this membrane, an effusion of cell-rich synovial fluid (SF) fills the joint cavity. Unlikely, SF has been shown to contain fibroblasts with some shared phenotypic traits with the synovial membrane FLS. These cells are called SF-FLS and their origin is still unclear. They are either brought into the synovium via migration through blood vessels, or they could originate within the synovium and exist in projections of the synovial membrane. SF-FLS function and phenotype are poorly documented compared to recently well-characterized synovial membrane FLS subsets. Furthermore, no study has yet reported a SF-FLS single-cell profiling analysis. This review will discuss the origin and cellular characteristics of SF-FLS in patients with RA. In addition, recent advances on the involvement of SF-FLS in the pathogenesis of RA will be summarized. Current knowledge on possible relationships between SF-FLS and other types of fibroblasts, including synovial membrane FLS, circulating fibrocytes, and pre- inflammatory mesenchymal (PRIME) cells will also be addressed. Finally, recent therapeutic strategies employed to specifically target SF-FLS in RA will be discussed.

Unknown Extra-Articular Manifestation of Spondyloarthritis: What About Retroperitoneal Fibrosis? A Case Based Literature Review

INTRODUCTION

Retroperitoneal fibrosis (RPF) is a rare disease characterized by fibro-inflammatory tissue proliferation in the retroperitoneum. It results in a chronic inflammatory and fibrosis condition, possibly leading to compression of the retroperitoneal structures, especially to encasement of the ureters and the inferior vena cava. It may have an idiopathic or a secondary origin. Spondyloarthritis (SpA) is one of the rare conditions described among the secondary forms.

CASE

Herein, we report a new case of RPF in a patient with AS. Who presented with acute abdominal pain radiating to the lumbar region and the left testicle. On clinical examination, we found a mild stiffness of the lumbar spine and a decrease in chest expansion. Sacroiliac joint pain was also found. The rest of the physical examination was normal. Laboratory tests showed inflammation with increased C-reactive protein (130 mg/l) and creatinine (112 micromol/l) levels. The computed tomography scan revealed a soft tissue density mass located around the sub-renal aorta. Diagnosis of idiopathic RPF associated with AS was retained. The patient was treated by a daily dosage of 1 mg/kg of oral glucocorticoid with good outcome.

CONCLUSION

RPF is a rare condition that can be either idiopathic or secondary. Its association with spondyloarthritis, mainly in its ankylosing spondylitis form, seems to be more than anectodal. Treatment may involve medical therapy and/or surgical management.

KEY MESSAGE

In the presence of back pain, fatigue, weight loss, and low grade fever in spondyloarthritis patients, physicians should screen for retroperitoneal fibrosis as it could be a possible cause.

Associated Factors with the Severity of Hip Involvement in Spondyloarthritis and Efficacy of TNF α Inhibitors in these Patients

INTRODUCTION

Hip involvement in patients with spondyloarthritis is responsible for disability and functional impairment. Its treatment is not codified. Our study aimed to determine the associated factors with moderate and severe hip involvement in spondyloarthritis patients. It also aimed to assess the efficacy of tumour necrosis factor inhibitors (TNFi) on hip disease.

METHODS

We conducted a cross-sectional study, including 44 spondyloarthritis patients with hip involvement. Hip involvement was diagnosed based on radiographic findings. We assessed the following parameters: Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Radiology Index (BASRI), patient global assessment (PGA), and Lequesne index. We compared these parameters and the mean radiographic joint space width between the time of the study to those right before the use of TNFi.

RESULTS

Hip involvement was bilateral in 31 patients. The mean age was 44.56±12.21 years. There were 29 men. Severe and moderate involvement (BASRI-hip>3) was reported in 21 hips from 75 affected. These patients were older and had longer diagnosis delays than patients with BASRI- hip<3. They had a higher body mass index and more limited spine mobility (BASMI). Functional hip impairment assessed by the Lequesne index was higher in these patients. TNFi prescribed in 23 patients with hip involvement, led to an improvement in the Lequesne index (12.75 vs 7.5, p: 0.001) and PGA (7 vs 2, p: 0.001). However, the mean joint space width remained unchanged (3.8 vs 3.7mm, p: 0.532).

CONCLUSION

Our study showed that higher body mass and Lequesne indexes are associated with moderate and severe hip involvement. TNFi may improve both the Lequesne index and PGA and stabilize the radiological findings.

The effects of autoimmune rheumatic-related diseases on male reproductive health: A systematic review

Autoimmune rheumatic-related diseases (ARRDs) have physical and psychological impact on patients, including their sexual life. While many studies have investigated fertility problems in females, data on males-related fertility are scarce, which explains the lack of guidance. The main objective of this systematic review was to evaluate the reproductive health in males with ARRDs. This systematic review followed the preferred reporting items for systematic reviews guidelines. Original articles from Pubmed and Scopus, published until September 16, 2021, and tackling the effects of ARRDs and/or ARRDs treatments on male fertility and/or pregnancy outcomes, were included. A total of twenty-five studies met the inclusion criteria. They were published between 1981 and 2018. The studied ARRDs were spondyloarthritis (n = 9), systematic lupus erythematosus (SLE, n = 6), Behcet disease (BD, n = 5), rheumatoid arthritis (RA, n = 5), antiphospholipid syndrome (n = 1), and dermatomyositis (n = 1). The most reported effects of ARRDs on fertility are i) high levels of reproductive hormones, mainly in RA and SLE; ii) impaired semen quality in SLE, spondyloarthritis, and BD; and iii) higher rate of varicocele in BD and spondyloarthritis. Regarding the treatments effects, i) conventional synthetic disease-modifying anti-rheumatic drugs (e.g.; methotrexate and salazopyrine) increase testosterone level, ii) cyclophosphamide impairs fertility, iii) anti-tumor necrosis factor agents are associated with improvement in semen quality, and iv) no increased number of miscarriages or congenital abnormalities in children fathered by BD was reported. To conclude, both ARRDs and their treatments alter fertility in males with ARRDs. In practice, in addition to the conventional semen analysis, screening for infertility seems legitimate in males with ARRDs.

Expression of extracellular matrix components and cytokine receptors in human fibrocytes during rheumatoid arthritis

Purpose: Fibroblast-like synoviocytes (FLS) represent one of the principal effectors of joint damage in rheumatoid arthritis (RA). Recent discovery of the circulating fibrocyte, a potential precursor of FLS, has raised issues regarding the characterization of fibrocytes with respect to their morphology and their biological role. In this study, we evaluated the morphology of fibrocytes in vitro and their ability to produce different extracellular matrix (ECM) components in comparison with two populations of RA FLS: synovial fluid FLS (fd-FLS) and intimal lining FLS (td-FLS). We also studied the expression of ECM regulators and a set of cytokine receptors involved in the pathogenesis of RA. Materials and Methods: Fibrocytes were cultured from peripheral blood of patients with RA. FLS were cultured from synovial fluids and tissues. ECM proteins (collagen I (col I) and fibronectin), Matrix metalloproteinases (MMP) (MMP3, and MMP9), ECM regulators (β catenin, TCF4, and c-fos), and cytokine receptors (CXCR1, CXCR2, CXCR3, IL1RI, IL1RII, and IL6Rα) were analyzed using qRT-PCR and/or western blot. Results: Our results demonstrated that fibronectin and MMP3 levels were higher in FLS compared to fibrocytes. Although MMP9 was expressed in the three cell types, its level was greater in fibrocytes than in td/fd FLS. The three cell types expressed CXCR3, IL1RI, IL1RII, and IL6Rα, while the expression of CXCR1 and CXCR2 was restricted to fibrocytes. Conclusion: Our results demonstrated that fibrocytes express ECM molecules and cytokines receptors. The observed differences between fibrocytes and FLS may be due to their distinct functions or differentiation state during RA.Abbreviations: RA: Rheumatoid ArthritisFLS: fibroblast-like synoviocytestd: tissue derivedfd: fluid derivedSF: Synovial FluidWnt: WinglessMMP: Matrix MetalloproteinaseCIA: murine collagen induced arthritisECM: Extracellular matrixcol I: Collagen ITCF/LEF: T-cell factor/lymphoid enhancer-binding factorAP1: Activator Protein 1.

Poor work outcomes in patients with spondyloarthritis: causes, consequences, and solutions

BACKGROUND

Spondyloarthritis (SpA) affects patients in the prime of their economic productivity and can cause loss of work productivity and unemployment. We aim to identify factors associated with poor work outcomes in patients with SpA.

METHODS

A cross-sectional study was performed in 100 patients with SpA who were employed, retired, or off work because of SpA. Data on sociodemographic and professional characteristics were collected as well as specific indices: BASDAI, ASDAS-CRP, BASFI, and BASMI. Work productivity in employed patients was assessed by the Work Productivity and Activity Impairment scale (WPAI:SpA).

RESULTS

Patients were divided into 73 men and 27 women; the mean age was 43.68 ± 10.3 years. Fifty-nine percent of patients were employed and 26% were off work. The average disease duration was 12.24 ± 8.73 years. The mean BASDAI score was 4.4 ± 2.4, the average BASFI score was 4.6 ± 2.7, and the average ASDAS-CRP score was 2.77 ± 1.18. The mean BASMI was 4.4 ± 2.8. Among employed patients, the mean of absenteeism, presenteeism, and work productivity loss was 21.8 ± 33.13%, 42 ± 32%, and 46.5 ± 35.31%, respectively. In multivariable analysis, absenteeism was associated with ASDAS ≥ 2.1 (β = 20.14), peripheral joint involvement (β = 15.6), manual work (β = 14.31), low level of education (β = 7.92), and BASFI ≥ 4 (β = 6.39). Presenteeism and work productivity loss were associated with manual work, BASFI ≥ , body mass index ≥ 25 kg/m², smoking, the use of symptomatic treatment, and ASDAS-CRP ≥ 2.1.

CONCLUSION

Spondyloarthritis affects work productivity. Screening for predictive factors should be considered by the clinician in the overall management of the disease. Key Points • SpA occurs among young and active patients; it could affect their professional lives and thus lead to loss of work productivity and unemployment. • The management of patients with SpA must be multidisciplinary; this includes assessing contextual factors in order to act on modifiable factors such as smoking and BMI, optimal management of the disease to maintain at least a low disease activity, and to ensure workstation layout and elimination of professional constraints that can affect work outcomes in patients with SpA.

Acute transverse myelitis revealing ankylosing spondylitis: A case report and literature review

When faced with a patient with acute myelopathy, thorough investigations should be undertaken to determine the cause. Ankylosing spondylitis should be kept in mind as a possible cause.

SFRP5 Enhances Wnt5a Induced-Inflammation in Rheumatoid Arthritis Fibroblast-Like Synoviocytes

Background

Tissue derived fibroblast-like synoviocytes (td-FLS) are key actors in pannus formation and contribute to joint destruction and inflammation during rheumatoid arthritis (RA). Several members of the Wnt family, including Wnt5a, may contribute to RA td-FLS activation and can potentially serve as therapeutic targets.

Objective

The present work aimed to investigate the expression of Wnt5a signaling elements in RA td-FLS and their potential precursors (fluid derived (fd) FLS and fibrocytes). We also studied the role of Wnt5a in RA td-FLS pro-inflammatory activity and whether the inhibitor SFRP5 could restore Wnt5a-induced synovial dysfunction in vitro.

Materials and Methods

The levels of Wnt5a, SFRP5, Wnt5a receptors/coreceptors and Wnt5a pro-inflammatory targets were determined in cultured RA td-FLS, fd-FLS and fibrocytes using qPCR under basal conditions. The expression of pro-inflammatory molecules was assessed after RA td-FLS stimulation with Wnt5a and SFRP5 at different time points.

Results

Our data showed that td-FLS, fd-FLS and fibrocytes from patients with RA expressed similar levels of Wnt5a and a set of Wnt5a receptors/coreceptors. We also demonstrated that Wnt5a stimulated the expression of the pro-inflammatory targets, especially IL1β, IL8 and IL6 in RA td-FLS. Wnt5a-induced inflammation was enhanced in the presence of SFRP5. Furthermore, Wnt5a alone and in conjunction with SFRP5 inhibited the gene expression of TCF4 and the protein levels of the canonical coreceptor LRP5.

Conclusion

Wnt5a pro-inflammatory effect is not inhibited but enhanced by SFRP5 in RA td-FLS. This research highlights the importance of carefully evaluating changes in Wnt5a response in the presence of SFRP5.

POS1280 SPINAL LOCATION OF TUBERCULOSIS: WHAT HAS CHANGED OVER THE LAST YEARS?

Background:

Tuberculosis (TB) is no longer a disease limited to developing nations and is still a major cause of significant morbidity and mortality worldwide. It can affect the different parts of the spine.

Objectives:

The aim of this study was to determine the preferred spinal location of TB.

Methods:

We conduct a retrospective and descriptive study in a single rheumatology department. Data were collected from observations of patients hospitalized in the past 20 years (2000-2020) who have been diagnosed with tuberculous spondylodiscitis (TS).

Results:

Fifty-two patients were included (37F/15M). Their mean age was 55.21 years ± 17.79 [19-91]. TS was more frequently unifocal (75%) than multifocal (25%). Lumbar spine involvement was the most common (57.7%) and more frequent in women (63.3%) but with no statistically significant difference (p = 0.2). Other localizations were described such as: dorso-lumbar (21.2%), dorsal (15.4%), lumbosacral (3.8%) and cervical (1.9%). Lumbar pain was present in 34 patients (65.4%) and 29 patients (55.8%) suffered from segmental lumbar stiffness. Imaging was contributive by showing the vertebral location using standard X-rays, computed tomography and magnetic resonance imaging. Disc pinch, erosion of vertebral plateaus and vertebral collapse were the major signs (82.7%, 65.4% and 67.3%, respectively).

Conclusion:

TS is a rare but serious clinical condition which may lead to severe deformity and early or late neurological complications. Spinal involvement is often unifocal and mostly diagnosed with lumbar pain or stiffness. Multifocal forms, touching several parts of the spine, however remain rare. Our findings remain consistent with those of the literature.

Disclosure of Interests:

None declared

AB0793 CONTRIBUTION OF INVESTIGATIONS FOR THE QUEST OF PRIMITIVE CANCER IN FRONT OF BONE METASTASIS

Background:

Bone metastases (OM) or secondary cancers bones are bony locations of tumor cells, away from a primary malignant tumor. The Bone metastases are the most common metastases. They can be revealing in 20 to 30% cases or complicate the course of a known cancer. The bone metastases are a pejorative prognostic factor.

Objectives:

The aim of this study was to identify the Contribution of diagnostic methods for the quest of primitive cancer in presence of bone metastasis.

Methods:

We conduct a retrospective study of 35 files of patients who were hospitalized in the rheumatology department. All patients underwent a questionnaire and a clinical examination. Additional radiological assessment, bone biopsies, biopsies of other sites, bone scintigraphy and tumor markers were carried out on a case-by-case basis.

Results:

Thirty-five cases (25 men and 10 women) were analysed. The average age was 61 years [45-85]. Seven patients had a known history of neoplasia. One or more bone biopsies were performed in 8 cases. The vertebrae were the most biopsied bone site (6 cases). The bone biopsies were in favour of carcinoma (3 cases), adenocarcinoma (2 cases), squamous cell carcinoma (1 case) and inconclusive (2 cases). Non bony biopsies (2 pulmonary, 2 prostatic, 1 mammary) concluded to an adenocarcinoma (3 cases) and a carcinoma (2 cases). Bone scintigraphy was carried out in 7 cases and showed in all cases diffuse or localized hyperfixation. The localized value of tumor markers appeared relatively low except for Prostate Specific Antigen (PSA). Other metastatic localisations were identified: hepatic (6 cases) and pulmonary (1 case). The primary cancer identified was pulmonary for 11 patients, prostatic for 7, gynaecological for 4 and digestive for 3. One patient had Otorhinolaryngological cancer and another had bone cancer. Bone biopsy allowed the diagnosis in 6 cases (17%). The primary cancer was discovered by a biopsy of other non-bone sites in 5 cases (14%). Neoplastic antecedents and clinical context were considered sufficient in 16 cases (45%). Primary cancer remained undetermined in 8 cases (22%).

Conclusion:

Bone biopsy, as well as non-bone biopsy, remains an essential tool in the etiological diagnosis of bone metastases. They are very contributive in the same proportions. PSA is a major diagnostic asset in the search for primary cancer.

Disclosure of Interests:

None declared

POS1288 TUBERCULOUS SPONDYLODISCITIS IN ELDERLY: EPIDEMIOLOGY, CLINICAL, FEATURES, TREATMENT AND OUTCOMES

Background:

Tuberculosis is still endemic all over the world. The incidence of tuberculous spondylodiscitis (TS) is steadily increasing. Clinical features and outcomes of this affection are various and depending on various parameters, including age.

Objectives:

Our objective was to explore the differences in presentation and the results of further investigations and the prognosis of TS between young and elderly subjects.

Methods:

We conduct a retrospective and descriptive study in a single rheumatology department. Data were collected from files of patients hospitalized in the past 20 years (2000-2020) who have been diagnosed with TS. We carried out a comparative study concerning the clinical biological, imaging features and outcomes between young subjects and subjects aged over 65 years.

Results:

Fifty-two cases of TS were collected (37F/15M). The mean age of the population was 55.21 years ± 17.79 [19-91]. Thirty-three patients (69.2%) were classified as young versus 16 elderly patients (30.8%), with female predominance in both groups (69.4% and 75% respectively, p = 0.57). Young subjects was more frequently vaccinated (88.9%) by Bacillus Calmette–Guérin (BCG) (p < 0.001). A delayed diagnosis was noted in both groups (p = 0.24). Lumbar spine involvement was the most common (57.7%). In the two age ranges, the onset of the disease was progressive (p = 0.22), characterized by segmental spine stiffness (p = 0.57) and lumbar pain with general signs (p = 0.27), such as: impaired general condition, fever, night sweats and weight loss. Biological inflammatory syndrome and normochrome normocytic anemia were encountered in both cases (p = 0.08 and p = 0.2, respectively). Standard X-rays and Computed tomography were more performed in young subjects (94.4% and 69.4%, respectively; p < 0.001), unlike magnetic resonance imaging which was more common in elderly subjects but with no statistically significant difference (p = 0.22). Disc pinch, erosion of vertebral plateaus and vertebral collapse were the major signs (82.7%, 65.4% and 67.3%, respectively). Clinical, biological and imaging arguments contributed to positive diagnosis in both groups (p = 0.24). Common medical treatment was anti-tuberculosis: Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E) and physical treatment such as immobilization witch was more common in the eldery (56.3%, p = 0.16). The evolution of the disease was characterized by a clear improvement of young subjects during the second week of treatment (p < 0.001). A more frequent clinical improvement in older subjects was during the fourth week but with no statistically significant difference (p = 0.13). The occurrence of immediate complications was more frequent in the elderly (p = 0.23) with a predominance for drug complications (56.3%) such as: hepatic cytolysis (12.5%), hyperuricemia (18.8%) and major intolerance to anti-tuberculosis (18.8%).

Conclusion:

TS is a frequent condition that needs to be treated rapidly. the clinical presentation of TS in the elderly is less noisy which leads to more frequent complications and mortality.

Disclosure of Interests:

None declared

AB0139 RHEUMATOID ARTHRITIS AND SLEEP QUALITY

Background:

Consequences of rheumatoid arthritis (RA) are many and varied: physical, psycho-affective and financial.

Objectives:

The objective of our study is to evaluate the impact of RA on sleep quality.

Methods:

We conducted a cross-sectional study including 49 RA patients. An evaluation of sleep quality using the MOS-Sleep Scale was performed.

Results:

The mean age of patients was 54.1 years, with a female predominance (89.8%). The mean duration of RA was 11.43 ± 7.32 years with a mean time to diagnosis of 2.35 years. Rheumatoid factor was positive in 77.6% of cases. A atlanto-axial dislocation was found in 4.1% of cases and coxitis in 8.2% of cases. All patients were on symptomatic treatment, 57.1% of whom were on corticosteroid therapy. 83.67% of patients were on cs-DMARDs and 14.2% were on biologics. At inclusion, sleep was optimal in 63.2% of cases and the mean Sleep Problem Index was 26.19 ± 22.77.

The index of sleep problems was higher in older subjects and in those with long diagnostic delays. The presence of co-morbidities and atlanto-axial dislocation and/or coxitis was associated with impaired sleep quality. Also, VAS pain and EGP were associated with an increase in the sleep problem index. In the multivariate study, EGP, the presence of co-morbidities and atlanto-axial dislocation and/or coxitis were the independent factors affecting sleep quality.

Conclusion:

The impact of RA on the patient’s quality of life and especially the quality of sleep is confirmed by several studies in the literature. A global management of the patient is necessary in order to adapt well to his disease.

Disclosure of Interests:

None declared

AB0123 ANXIETY AND DEPRESSION DURING RHEUMATOID ARTHRITIS

Background:

Although the management of rheumatoid arthritis (RA) has been booming since the advent of biological treatments, the consequences of this disease remain multiple, both physical and psychological.

Objectives:

The aim of our work was to investigate the factors influencing anxiety and depression in RA.

Methods:

This was a cross-sectional study of 49 RA patients. We used the Hospital Anxiety and Depression scale (HAD) to assess anxiety disorders.

Results:

We included 24 women and 5 men with an average age of 54.1 years. Sixty-nine percent of patients were unemployed and 81% had health insurance coverage. RA had been evolving for an average of 11.43 ± 7.32 years and the mean time to diagnosis was 2.35 years. It was erosive in 93.8% of cases. An atlanto-axial dislocation was found in 4.1% of cases and coxitis in 8.2% of cases. Eighty-three percent of patients were on cs-DMARDs and 14.2% were on biotherapy. Most patients had low active disease (53%) with a mean DAS28CRP score of 2.74 ± 0.81. Twelve percent of patients had a probable anxiety and 18% had a probable depression.

A long delay in diagnosis was associated with a higher risk of anxiety disorders. Working patients had a lower risk of depression while patients from rural areas had a higher risk. The risk of anxiety and depression disorders was associated with increased VAS pain, EGP, and DAS28. In the multivariate study, EGP was the independent risk factor for the development of anxiety and depression disorders.

Conclusion:

Anxiety and depression disorders are a frequent yet underestimated consequence in RA. Appropriate care in psychiatry is required as soon as the diagnosis is announced.

Disclosure of Interests:

None declared

AB0238 SECOND BIOLOGICAL DMARD THERAPY IN RHEUMATOID ARTHRITIS: A RETROSPECTIVE COHORT ANALYSIS

Background:

The development of biologic disease modifying antirheumatic drugs (bDMARD) has dramatically improved the management of rheumatoid arthritis (RA). However, some patients did not respond or partially respond to biologic agents. Management of first bDMARD failure may involve another biotherapy.

Objectives:

The aim of our study is to assess the efficacy of second line biologic as well as survival rates of 2nd line biotherapy in RA.

Methods:

This is a retrospective study based on Tunisian data including 374 RA patients treated with biologic agent from 2014 and followed until December 2018.

Results:

Tumor necrosis factor inhibitor (TNFi) was the most prescribed class as first-line therapy with 86.4% patients (Etanercept: ETA 54%; adalimumab: ADA 13.6%; certolizumab pegol: CZP 12.8% and infliximab: IFX 5.9%), IL-6 inhibitor (Tociluzimab: TCZ) and anti-CD 20 (Rituximab: RTX) were given respectively to 6.4% and 7.2% cases. The first biotherapy was discontinued for 146 patients (39%). Of these, 79 patients (21.1%) received a second bDMARD (mean age 52.6 ± 11.8; sex ratio = 0.12; ETA 17.7%, ADA 7.6%, CZP 41.8%, IFX 1.3%, TCZ 24.1% and RTX 7.6%). Average DAS28 at second line biotherapy initiation was 5.93 ± 0.96. Overall survival rates of 2nd line bDMARD at 12, 24 and 36 months was respectively 91%, 76.4% and 72.1%. Among the patients receiving second biologic agent, 30.4% patients (24 cases) achieved either low disease activity (LDA) or remission. On average 38 weeks [14 – 96] were needed to reach that therapeutic target. In fact, 27.8% of the TNFi vs. 40% of the non TNFi patients achieved LDA (p = 0.277). Second biotherapy was withdrawn in 16.7% of the cases of TNFi group vs. 20% of the non TNFi group (p = 0.718). Moreover, no significant difference has emerged between the TNFi and the non-TNFi patients when comparing time to biotherapy discontinuation (15.8 months vs. 20.9; p = 0.11).

Conclusion:

In our study, no significant difference was found between TNFi and non-TNFi switcher in RA. But, treatment strategy after first bDMARD failure is still controversial. Further studies have to be done to get the most beneficial strategy in RA.

Disclosure of Interests:

None declared

AB0240 PREDICTORS OF RESPONSE TO BIOLOGIC AGENTS IN RHEUMATOID ARTHRITIS

Background:

In rheumatoid arthritis (RA), the ‘treat-to-target’ therapeutic approach imposes rigorous control of disease activity. Although biological agents have been shown to be effective, these therapies fail sometimes to achieve therapeutic goals.

Objectives:

In this study we tried to determine predictive factors of good therapeutic response to biologic disease-modifying antirheumatic drugs (bDMARD).

Methods:

This is a retrospective study including 374 Tunisian patients who received their first biotherapy between 2014 and 2016. Categorical variables were reported in numbers and percentages, while quantitative variables were expressed by mean with standard deviations. The univariate analysis was performed using the student t-test or the Chi2 test. Multivariate analysis was performed by binary logistic regression.

Results:

Average age of our cohort was 55 ± 12.5 years with a female predominance of 87.2%. The average duration of RA was 11.7 ± 6.7 years. Rheumatoid factors were positive in 79% and ACPA were positive in 72% of cases. After the introduction of biotherapy, low disease activity (LDA) or remission was achieved in 55% of cases (206 patients).

No statistically significant difference between biotherapy responder and non-responder groups for age (55.7 vs. 54.7 years; p = 0.44), gender (Female: 86.5% vs. 88.7%; p = 0.08) and disease duration (12 years vs. 11.4 years; p = 0.41). A significant difference between the two groups was found for the positivity of rheumatoid factors (76.4% vs. 88.9%; p = 0.004), methotrexate’s association (65% vs. 53.4%; p = 0.02) and corticosteroids’ use (50% vs. 66.5%; p < 0.001).

Positive predictive factors of remission or LDA by biotherapy were female sex (Odds Ratio = 2.2; p = 0.026), presence of rheumatoid factors (Odds Ratio = 2.64; p = 0.001), association with methotrexate (Odds Ratio = 1.69; p = 0.028). Whereas, corticosteroid use (OR = 0.41; p < 10-3) was a negative predictor of disease control by bDMARDs.

Conclusion:

Achieving LDA low level or even remission is currently achievable with biological treatments. Certain factors need to be studied in order to optimize RA treatment and adapt the right bDMARD for each patient.

Disclosure of Interests:

None declared

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

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

New Markers of Bone Fragility in Hemodialysis Patients: A Monocentric Study

INTRODUCTION

Mechanisms underlying bone fragility in patients under dialysis are various. The assessment of bone disorder is not yet codified in these patients. Our study aimed to determine the relationship between the serum fibroblast growth factor 23 (FGF23) level and bone fragility. We also aimed to assess the bone alkaline phosphatase (bAP) to the C-terminal telopeptide of type I (CTX) ratio and the FGF23*bAP product to CTX ratio in patients under hemodialysis.

METHODOLOGY

We conducted a cross-sectional study, including 76 patients under hemodialysis. To assess bone fragility, we measured bAP, CTX, and FGF 23. We calculated the bAP to the CTX ratio (bAP/CTX) and the FGF23*bAP product to the CTX ratio (FGF23*bAP/CTX). We defined bone fragility as the existence of osteoporosis or fragility fractures. Receiver operating characteristic (ROC) curves were evaluated for each biological using the existence of osteoporosis or fragility fracture as the gold standard for bone fragility.

RESULTS

There were 51 men. The mean age was 53.36 ± 14.27 years. Bone fragility was noted in 25 cases. Patients with osteoporosis had higher FGF*bAP/CTX and bAP/CTX ratios. The ability of the ratio (bAP/CTX) to distinguish patients with osteoporosis from those without osteoporosis was good, with a ROC AUC of 0.707. The optimal ratio cut-off value with the highest accuracy was 9.72. The ability of the ratio (FGF23*bAP/CTX) to distinguish patients with bone fragility was good, with a ROC AUC of 0.701. The optimal ratio cut-off value with the highest accuracy was 1621.89 (sensitivity 60%, specificity 78.4%).

CONCLUSION

Our study showed FGF23, FGF23*bAP product to CTX ratio, and the bAP to CTX ratio can be used as markers of bone fragility in hemodialysis patients. Therefore, these noninvasive and relatively inexpensive methods may serve to diagnose bone fragility in patients under hemodialysis.

THU0602 EXTENDED BONE HYDATIDOSIS IN THE HIP AND FEMUR WITH EXTENSION TO THE SOFT PARTS: A CASE REPORT

Background:

Osseous hydatid cyst is an uncommon disease with weak response to treatment.hydatid disease should be included in the differential diagnosis of cystic lesions of bone in endemic regions. Bone cysts account for only 0.5 to 2.5% of all hydatid cysts in humans.

Objectives:

To report a case of osseous hydatid disease extended on hip and femur

Methods:

We report a case of osseous hydatid disease

Results:

A 49 YEAR OLD BRICKLAYER, with no past-medical history and no animal contact, was admitted to our department for a left hip pain. the patient was apyretic and in a good general health condition. He had a very painful walk. the mobilility of the left hip joint was very painful and restricted.

The pelvis X-rays showed osteolytic lesions in the ischiopubic branch and in the left femur and proximal extremity of the tibia.

The C-Reactive protein value, the protein electrophoresis were normal. tumor markers test was negative.

An ultrasound of the hip showed a low abondance intra-articular effusion. The Pelvic MRI showed multilocular appearance extending over the bone and muscle with breach of the bone cortex of the femur very suggesting of the diagnosis of a bony and muscular echinococcosis.

NO other localization of hydatidosis were detected, body ct scan was normal

Conclusion:

Hydatid disease occurs worldwide and mainly associated with sheep farming. The liver and lungs are the most common locations. Bone cysts are uncommon but severe. Although immunofluorescent assays are useful, the final diagnosis depends on histology. The treatment is almost surgery. Recurrence is common

Disclosure of Interests:

None declared

AB0962 LOW BACK PAIN AMONG MEDICAL STUDENTS: PREVALENCE AND RISK FACTORS

Background:

Low back pain (LBP) is a common health problem among all age groups. Medical students do not seem to be spared. In fact LBP is one of the most common musculoskeletal disorder and its prevalence is variable ranging from 41% to 72%.

Objectives:

The aim of our study was to determine the prevalence of LBP among Tunisian medical students and to assess its associated factors.

Methods:

We conducted a cross-sectional study over 2 months carried out on medical students in a Tunisian medical college. A digital questionnaire entered by Google forms was sent by e-mail and was completed by the students. Our study included students from the first year of the first cycle of medical studies up to the third year of the second cycle. Socio-demographic, personal characteristics and life habits were collected. LBP was assessed using the Nordic musculoskeletal health questionnaire. The impact of low back pain was assessed using the Oswestry disability index (ODI).

Results:

One hundred and seventy-nine students were included. The mean age was 22.9 ± 2.3 years [19.64-38.21]. The sex ratio was 0.29. The average body mass index was 23.55 ± 4.22 kg / m2 [17.67-43.07]. 82% of the students were in the second cycle of medical studies. 26.4% of the students had a regular sports activity. 91.2% spent more than 4 hours a day in a sitting position. The point, annual, and lifetime prevalence of LBP among medical students was 41.2%, 80.4% and 90.6%, respectively. Low back pain was acute in more than 58.8%, subacute in 14.9% and chronic in 26.3%. The mean ODI score was 10.32% ± 8.48% [0-32%]. Students with LBP were significantly younger than students without LBP (p = 0.015). LBP was more common in students who spent more than 4 hours in a sitting position with a difference at the limit of significance (p = 0.059). Being in the 2nd cycle was significantly associated with the occurrence of LBP (p = 0.006). Poor screen projection in the amphitheater was significantly associated with the occurrence of LBP (p = 0.029).We found a statistically very significant relationship between the occurrence of LBP and the poor layout of the amphitheaters (p = 0.000). The feeling of depression was significantly higher among LBP students (p = 0.018). Feelings of fatigue, being overwhelmed, irritability and worry were more frequently found in LBP students, but this difference was not statistically significant. In a multivariate analysis, the only factors that remained statistically significant were feeling of depression (p = 0.046, OR = 3.88; CI = [1,3-11,55]) and the poor layout of the amphitheaters (p = 0.006, OR = 8.99; CI = [2.55-31.69]).

Conclusion:

The annual prevalence of LBP was 80.4%. These results testify to the magnitude of this health problem. The factors associated to LBP seemed to be essentially modifiable factors. This encourages special attention from medical schools to increase students’ awareness of low back pain and to provide appropriate measures at reduce this musculoskeletal disorder.

Disclosure of Interests:

None declared

AB0320 BDMARDS SURVIVAL: THE TUNISIAN DATA

Background:

The advent of biotherapies in the late 90s radically changed the face of inflammatory diseases including rheumatoid arthritis. The survival of these innovative therapies is an indicator, in clinical practice, of their long-term efficacy and safety.

Objectives:

The objective of this study was to assess their use in Tunisia through their survival during rheumatoid arthritis as well as to determine the factors that may influence their therapeutic maintenance in real life.

Methods:

This is a retrospective study including RA patients (ACR/EULAR 2010 criteria) and putted on biotherapy between 01-01-2014 and 12-31-2016. They were followed until 12-31-2018. The therapeutic maintenance rate at 12, 24, 36 and 48 months as well as the survival curves of biotherapies were analyzed using the Kaplan-Meier survival curves and compared by the Log-rank test. Reasons for interruption and patterns of biological change have been reported. Finally, an analysis of factors influencing survival was performed using Cox regression.

A p<0.05 was considered statistically significant.

Results:

Three hundred seventy-four patients were included in the study; sex ratio was 0,147. The baseline age was 55 ± 12.5 years [20 – 90] and the average disease duration was 11.7 ± 6.7 years [2 – 41]. Rheumatoid factor and ACPA were positive respectively in 79% and 71% cases. After failure of cDMARD, the first biotherapy prescribed was etanercept in 54% of cases, adalimumab in 14% of cases, certolizumab pegol 13%, infliximab 6%, tocilizumab 6% and rituximab in 7% of cases, with an average DAS28 at baseline 6.01 ± 0.89 [5,37 – 6,50]. Association with methotrexate was observed in 59,6% case and with corticosteroid in 57.2% case. Drug persistency rate at 12 months was 85.8%; at 24 months, 69.9%; at 36 months, 60.6% and at 48 months, 55.9%. Survival was on average 41.7 months with 95% CI (39.47 - 43.91). The presence of rheumatoid factors, the co-prescription of methotrexate as well as good initial therapeutic response were predictor of a better survival of biologicals at a statistically significant level p<0.01 (Hazard Ratios for pursuit of biotherapy were respectively 1.79, 1.91 and 2,3). The use of glucocorticoids was a negative predictor of retention (Hazard Ratio for therapy pursuit was 0.47 p < 0.001). This first biotherapy was stopped in 39% of cases and ineffectiveness was the major reason of interruption (52.7%). The anti-TNFα cycling was the most adopted therapeutic strategy with 64.6% of cases. The survival rates of the second biotherapy at 12, 24 and 36 months were 91%, 76.4% and 72.1%, respectively.

Conclusion:

Our study provides information about biotherapy prescription practices in Tunisia and their effectiveness in “real life”. It informs us about the use of these new therapies in our country and has shown an efficacy and a tolerance profile close to those reported in international registers.

Disclosure of Interests:

None declared

AB0287 HEMATOLOGICAL SIDE EFFECTS OF BIOLOGICAL THERAPY IN RHEUMATOLOGY: DATA FROM THE TUNISIAN REGISTER

Background:

During the last decade, the treatment of chronic inflammatory rheumatism (CIR) has been greatly improved with the advent of biotherapy.However, the use of biological treatment can lead to a number of side effects including abnormalities in the blood count.

Objectives:

The aim of this study was to assess the different hematological side effects of biological treatment in patients with rheumatoid arthritis (RA) and spondyloarthitis (SA).

Methods:

This study included patients with RA (ACR/EULAR 2010) and SA (ASAS 2009) registred with the Tunisian Biologic National Registry (BINAR).Patients were followed and treated with biologics for 2 years of less. Clinical data relative to biological treatment, including haematological side effects, have been collected.

Results:

Two hundred and ninety-eight patients (178 women and 111 men) were included in the study.

The mean age was 49.2 ± 14.1 years. The male/female ratio was 0.6. The mean diseases durations for RA and SA were respectively 6.7 ± 3.5 years and 6.5 ±3.6 years.

Anti-TNFα agents were prescribed in 87.9% of patients (n = 263) with respectively: Infliximab (20.4%) Etanercept (23.1%), Adalimumab (24.6%) and Certolizumab (26.5%).

Tocilizumab and Rituximab were prescribed in 10.4% and 5% of the patients, respectively.

Blood count abnormalities were noted in 15.4 % of patients (n=46).

Neutropenia was the most frequently anomaly met on the hemogram (9.1%) followed by anemia (3.4%) and thrombocytopenia (3%). Pancytopenia was found in 11.4% of patients (n=34).

The median time between biological therapy initiation and the onset of hematologic manifestations was 4.8 months [1-12]. Biological treatment was interrupted in two patients.

In the other cases, the biological treatment was maintained with close monitoring of blood cell count. No case of death related to these hematological disturbances has been reported.

Conclusion:

In our registry, hematological side effects of biological treatment were found in 15.4% of cases and were noted with a median delay of 4.8 [1-12] months after the treatment initiation. Further studies are needed to confirm our preliminary results.

Disclosure of Interests:

None declared

Mineral bone disorder and osteoporosis in hemodialysis patients

BACKGROUND

Bone disease is common in patients undergoing hemodialysis. It is the result of bone turnover abnormalities and the decrease of bone mineral density (BMD). We aimed to determine the usefulness of serum bone turnover markers and BMD measurement by dual-energy x-ray absorptiometry (DXA) in hemodialysis patients.

METHODS

We conducted a cross-sectional study including 90 hemodialysis for more than 12 months. Bone mineral density was assessed by DXA. Peripheral blood samples were obtained from each patient before dialysis in a fasting state within a week of the DXA. Biochemical variables of calcium and phosphate were measured. One bone formation marker (bone-specific alkaline phosphatase (bAP), one bone resorption marker (carboxy-terminal telopeptides of type 1 collagen (CTX)) were measured. Total alkaline phosphatase (TAP), intact parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23) which is a bone-derived hormone were also measured.

RESULTS

CTX values were 6.25 times higher than the normal limit of the assay. Bone alkaline phosphatase levels were less than 10 ng/mL in 28.8% of cases. 23% of patients have osteoporosis and 45% have osteopenia. Femoral BMD had negative correlations with age and PTH levels. FGF23 levels were significantly increased in patients with osteoporosis affecting the lumbar. The levels of bAP and CTX showed a positive correlation. Both circulating bAP and CTX levels showed also positive correlations with PTH levels. Fractures, observed in 12.2% of cases, were associated with low PTH values and the existence of osteoporosis.

CONCLUSIONS

Our study showed that osteoporosis and fracture are common in dialysis patients. The reduced BMD was associated with advanced age and elevated levels of PTH. Markers of bone turnover and FGF23 may play a role in the diagnosis of bone disease in hemodialysis patients. DXA measurement is necessary for the monitoring for bone loss.

Molecular basis of complement factor I deficiency in Tunisian atypical haemolytic and uraemic syndrome patients

AIM

The aim of the present study was to characterize the molecular basis of complement factor I deficiency in Tunisian atypical haemolytic and uremic syndrome patients with low factor I levels.

METHODS

Six adults and seven children were enrolled in this study. Complement factor I levels were assessed by a homemade sandwich ELISA and ranged between 12.5% and 60%. Genomic DNA was amplified by way of a polymerase chain reaction using intronic primers flanking the 13 coding exons. Sequencing of amplified products was carried out by the dye terminator sequencing method. Molecular study was performed on parental samples for three dead paediatric patients. The control group consisted of 100 healthy Tunisian donors.

RESULTS

We identified a total of 13 substitutions and one insertion: seven in introns, four in exons and three in UTR. The new mutations were c.-132G > C, c.71 + 181 T > A in 5'UTR and intron 1, respectively. Three intronic polymorphisms were predicted to have impact on splicing events: c.482 + 6C > T, c.884-42_884-41insTTAAA (rs34422850) and c.1429 + 33 A > G (rs9998151). They were three missense mutations leading to a p.Ile 357Met, p.Ile416Leu and p.GLu548Gln. p.Ile 357Met was found in two patients and one relative. Half of the patients had associated mutation and/or polymorphisms.

CONCLUSION

This is the first genetic study in Tunisian and Maghrebin atypical haemolytic and uraemic syndrome patients. The high occurrence of Ile357Met mutation may reflect a founding effect. Functional impact of the two new mutations c.-132G > C and c.71 + 181A > T have to be studied. Association of simultaneous genetic abnormalities may explain the variability of atypical haemolytic and uraemic syndrome, penetrance and disease phenotype.

A cross sectional study of bone and cartilage biomarkers: correlation with structural damage in rheumatoid arthritis

The aim of our study was to assess the relationship between bone and cartilage remodeling biomarkers and joint damage in Rheumatoid Arthritis (RA), and to detect whether they have the capacity to predict the progression of joint disease assessment by computed tomography (CT) erosion score. We analyzed 65 female patients with established RA in our Rheumatology Department. Serum levels of bone and cartilage markers were measured: osteocalcin (OC), N-propeptide of type I collagen (PINP), collagen type I and II, C-telopeptide (CTX I, CTX-II) and cartilage oligomeric matrix protein (COMP). Radiography of both wrist and MCP joints were available. Two expert-readers independently scored articular damage and progression using the High-resolution low dose CT scan in a blinded fashion. 65 female patients with established RA with a median age of 44 years were included. The median disease-duration was two years and the median (Disease activity score) DAS 28 score at 4.46 [2.65-7.36]. The percentage of patient with low disease activity was 13.8%, while 55.4 and 30.8% for those with moderate and high disease activity respectively. The resorption bone markers were high in active versus non-active RA. Wrist and MCP erosion scores were also associated with RA activity. Our study shows that biomarkers of bone and cartilage collagen breakdown were related to specific joint erosion in RA and could predict subsequent radiographic damage in RA. Further larger scale longitudinal studies maybe needed to confirm our data.

Clinical and body composition predictors of bone turnover and mineral content in obese postmenopausal women

The purpose of this study was to determine the predictors of bone mineral density (BMD), bone mineral content (BMC), and bone turnover markers in obese postmenopausal women. In this cross-sectional study, 81 postmenopausal women aged 58.40 ± 6.08 years were analyzed. Anthropometric parameters were recorded. Serum glucose parameters, serum lipid profiles, adipokines, renal, hepatic parameters, and bone markers concentrations were determined by well-validated laboratory routine methods. BMD, BMC, and body composition were measured by Dual X-ray Absorptiometry. We found a significant correlation of BMD with age, years since menopause, anthropometric parameters, glycemia, alkaline phosphatase, fat mass, and lean mass. Multiple regression analysis demonstrated that years since menopause, waist circumference, alkaline phosphatase, trunk fat, and lean mass were independently associated to BMD. Also, age, years since menopause, anthropometric parameters, total cholesterol, alkaline phosphatase, fat mass, and lean mass were correlated to BMC. However, only waist circumference and trunk fat were independently related to BMC. Bone turnover markers were significantly correlated to the age, glycemia, HbA1c, adipokines, hepatic parameters, and lean mass. Nevertheless, only adipokines, gamma glutamyl transferase (GGT), and alkaline phosphatase were independently associated to bone turnover markers. These observations suggest that number of years since menopause, waist circumference, alkaline phosphatase, trunk fat, and lean mass were the only significant predictors of BMD. However, waist circumference seems to be a stronger predictor than trunk fat for BMC. Moreover, adiponectin, resistin, GGT, and alkaline phosphatase were significant predictors of the bone resorption (CTX-I) and the bone formation (P1NP) markers.

Positive Association of Obesity and Insulin Resistance With Bone Mineral Density in Tunisian Postmenopausal Women

The association of bone mineral density (BMD) with obesity and insulin resistance remains unclear. This study aimed to explore these associations in Tunisian menopausal women. Eighty-one postmenopausal women were recruited. Data were analyzed for obese (N = 57) and non-obese women (N = 24) and for insulin-resistant (N = 43) and non insulin-resistant women (N = 36). Anthropometric and biochemical parameters were recorded. BMD in different sites and body composition were measured using dual-energy X-ray absorptiometry. Higher BMD was observed in obese women than those non-obese in the left femur (p = 0.0067), right femur (p = 0.0108), total hip (p = 0.0077), and the whole body (p = 0.0276). Also BMD was significantly greater in insulin-resistant women than in non-insulin-resistant women when measured in the left femur and total hip. Positive correlations were recorded between BMD and anthropometric parameters, body composition parameters, and glycemia (r = 0.249, p < 0.05). Multiple linear regression analysis shows that only trunk fat (p < 0.05) and lean mass (p < 0.05) were independently and positively related to BMD, and the waist circumference was the only anthropometric parameter independently and negatively associated to BMD. BMD is improved in obese and insulin-resistant women. Also, trunk fat and lean mass are likely to be key positive independent factors for BMD.

-643C > T RANKL gene polymorphism is associated with osteoporosis in Tunisian postmenopausal women

OBJECTIVES

The dynamic nature of the skeleton is achieved by a remodeling process. Receptor activator of nuclear factor kappa B (RANK) ligand (RANKL) stimulates bone resorption by activating RANK signaling. Therefore it is considered as a candidate gene regulating susceptibility to osteoporosis. In the current study, we have investigated the association between the RANKL gene -693G > C and -643 C > T polymorphisms and bone mineral density (BMD) in a population of postmenopausal Tunisian women.

METHODS

Polymorphic sites in RANKL gene (rs9533155 -693G > C and rs9533156 -643 C > T polymorphisms) were determined using PCR-RFLP analysis in 566 postmenopausal Tunisian women. All statistical analysis were examined by SPSS software.

RESULTS

We have detected a significant difference in lumbar spine and hip BMD for -643C > T genotypes. For -693G > C genotypes, a significant difference was detected only in hip BMD. The distribution of -643C > T genotypes and alleles between three groups (osteoporotic, osteopenic and normal women) revealed a significant association of the TT genotype with development of osteoporosis (p = 0.01; odds ratio 2.15), although for the -693G > C polymorphism, no significant results were found.

CONCLUSION

We have demonstrated the association of the -643C > T polymorphism with BMD variation and osteoporosis risk in postmenopausal Tunisian women.

sFRP3 and DKK1 Regulate Fibroblast-Like Synoviocytes Markers and Wnt Elements Expression Depending on Cellular Context

CONTEXT

Fibroblast-like synoviocytes (FLS) from rheumatoid arthritis (RA) display pathogenic behavior. Various members of the Wnt pathway, especially the canonical Wnt/β-catenin cascade, may contribute to autonomous RA FLS activation. It has been shown that the two Wnt inhibitors: sFRP3 and DKK1 contribute to several critical aspects of joint biology. However, their effects on RA FLS are poorly characterized. The aim of our study was to investigate the effects of sFRP3 and DKK1 on FLS markers, Wnt components, and target oncogenes expression by RA FLS and compare the findings to osteoarthritic (OA) FLS.

MATERIALS AND METHODS

RA and OA FLS were treated with sFRP3 and DKK1 for 6 days. Wnt signaling components (Wnt5a, LRP5 and β-catenin), Wnt target oncogenes (cyclin E1 and WISP1), and FLS markers (fibronectin and MMP3) were analyzed using western blotting and/or qRT-PCR.

RESULTS

Our data indicated that sFRP3 down-regulated the key gene β-catenin in RA FLS. sFRP3 decreased fibronectin, a well-known downstream effectors gene of Wnt/β-catenin pathway, and LRP5 expression in both RA and OA FLS. In OA FLS, sFRP3 induced increased expression of Wnt5a and MMP3 but did not affect their levels in RA FLS. On the other hand, DKK1 increased fibronectin expression in RA FLS and decreased its expression in OA FLS.

CONCLUSION

Our results confirm the involvement of Wnt signaling in FLS transformation and show that two inhibitors of the same cascade can regulate differently the same elements and that a single inhibitor can initiate signaling depending on cellular context.

ABBREVIATIONS

FLS: fibroblast-like synoviocytes; RA: rheumatoid arthritis; Wnt: Wingless; Fz: frizzled; LRP: Fz/low-density lipoprotein receptor protein; WISP1: Wnt1 inducible signaling pathway protein 1; sFRP: secreted Fz-related proteins; DKK: Dickkopf; OA: osteoarthritis; DMEM: Dulbecco's modified Eagle's medium; FBS: fetal bovine serum; PBS: phosphate buffered saline; SDS-PAGE: sodium dodecyl sulfate-polyacrylamide gel electrophoresis; ECL: enhanced chemiluminescence detection solution; MMP3: metaloproteinase 3; qRT-PCR: quantitative real-time polymerase chain reaction; S.D: standard deviation; CRD: cysteine-rich domain; MeCP2: methyl-CpG-binding protein; RANKL: nuclear factor-kappa B ligand.

Congenital Butterfly Vertebra

Keywords: Lumbar Vertebrae/abnormalities; Lumbar Vertebrae/radiography.