POS0818 TREATMENT OF POLYMYALGIA RHEUMATICA WITH TOCILIZUMAB: RESULTS OF AN OBSERVATIONAL RETROSPECTIVE MULTICENTER STUDY

Background:

In 2017, TOCILIZUMAB (TCZ) obtained marketing authorization for treatment of giant cell arteritis (GCA); however, this doesn’t extend to polymyalgia rheumatica (PMR) therapy. Based on efficacy data for TCZ in GCA, TCZ is sometimes used as a glucocorticoid (GC) sparing agent when PMR is GC dependent or when a rapid steroid withdraw is needed. Currently, there are no available recommendations on the use of this therapeutic class in for this particular indication.

Objectives:

Here, we present the results of an observational French multicentric study of patients with PMR treated with TCZ.

Methods:

Thirteen medical centers were included in this study. The data was collected retrospectively between 2015 and 2020. The minimum duration of treatment was 3 months. Patients were included when receiving TCZ for isolated PMR or associated with a non-active GCA (asymptomatic, no vascular fixation on PET scanner).

Results:

Overall, 34 patients were included (24 women; mean age 70.1 years (+/-10.3)). At TCZ introduction, patients had been treated with GC for a mean duration of 27,9 months (+/-25.9) and the mean GC dose was 16,8mg/d (+/-10). Fifteen patients (44%) had one or more complications from GC therapy. Another immunosuppressant was added before TCZ treatment for 25 (74%); mostly METHOTREXATE (24/25).

TCZ was initiated intravenously at 8mg/kg every 4 weeks for 27 patients (79%) and subcutaneously at 162mg/week for 7 patients (21%).

The reasons for TCZ introduction included GC dependence (n=30, 88%), and necessity of quick GC sparing (n=4 patients,12%).

Of all patients, 76% (26 patients) had stopped GC treatment definitively, with a mean time of 9,4 (0-32) months.

The mean TCZ treatment period was 19,2 months (3-66). Fifteen patients (44%) permanently stopped TCZ at the end of the observation period (8 prolonged remissions;1 myocardial infarction; 1 cutaneous lymphoma; 1 primary failure, 3 lost to follow up).

Eighteen patients (60%) benefited from an attempted tapering of TCZ (infusion spacing or dose reduction), 6 attempts (1/3) led to a relapse. 1/2 patients had side effects mostly benign (cytopenia n=6, infections n=5).

Conclusion:

This is the largest cohort presenting results of the use of TCZ in PMR. Despite the small number of participants, our study suggests TCZ is effective as a GC sparing agent in PMR. As there are no official recommendations of use, indications for TCZ use within this population are no defined. Randomized Controlled Trial would be beneficial to validate these first results.

References:

[1]Toussirot, « Biothérapies, pseudo- polyarthrite rhizomélique et artérite à cellules géantes État des lieux en 2018 ».

[2]Devauchelle-Pensec et al., « Efficacy of First-Line Tocilizumab Therapy in Early Polymyalgia Rheumatica ».

[3]Genovese et al., « Longterm Safety and Efficacy of Tocilizumab in Patients with Rheumatoid Arthritis ».

[4]Stone et al., « Trial of Tocilizumab in Giant-Cell Arteritis ».

Disclosure of Interests:

None declared

AB0464 DRUG SURVIVAL OF TNFi AND SECUKINUMAB IN AXIAL SPONDYLARTHRITIS: A REAL-WORLD MULTICENTRIC COHORT OF 370 PATIENTS

Background:

IL17 inhibitors (IL17i) are an alternative for patients with axial spondyloarthritis (axSpA) who did not respond to TNF inhibitors (TNFi). Secukinumab (SEC) is the first human monoclonal antibody that binds to the protein interleukin-17A.

Objectives:

The objectives of this study were to describe the characteristics of axSpA patients treated with IL17i and TNFi and to assess the persistence with IL17i and TNFi in a real world cohort.

Methods:

A retrospective multicenter observational study was conducted. axSpA patients (pts) according to ASAS criteria initiating a IL17i or TNFi between June 2016 and December 2019 were included. Demographic features, current and previous use of biologic Disease-modifying antirheumatic drugs (bDMARDs) were collected. Date and reasons of discontinuation – i.e., lack of efficacy, safety issue, sustained remission or others – were collected. Kaplan-Meyer analysis were performed.

Results:

370 pts were included. Among the 202 patients who received TNFi, 90 (44.6%) were female, mean age was 43.2 +/- 13.2 years, mean body mass index was 26.1 kg/m2 +/- 5.4, 49 pts (46.7%) were smokers. The most common SpA phenotype was axial radiographic (n = 89, 54,9%) and 114 (68.3%) pts were HLA B27 positive, mean BASDAI was 57.5 +/- 14.6, median disease duration was 8.6 years [3.0-10.5]. Among the 168 patients who received SEC, 78 (46.4%) were female, mean age was 47.7 +/- 11.8 years, mean body mass index was 27.2 kg/m2 +/- 5.8, 45 pts (44.1%) were smokers. The most common SpA phenotype was axial radiographic (n = 106, 76,3%) and 114 (78.1%) pts were HLA B27 positive, mean BASDAI was 62.8 +/- 14.8, median disease duration was 9 years [5.0-19.0]. TNFi was the first line bDMARD in 116/202 pts (57.4%) and SEC was the first line bDMARD in 15/168 pts (8.9%). SEC was prescribed at 150mg every month in 121/168 (73.3%) pts. The median persistence with TNFi and SEC were 18.0 months [11.0-27.0] and 12.0 months [6.0-22.0], respectively. During the 3-year follow-up, 130 pts (42 with TNFi and 88 with SEC) discontinued treatment: 80 (22 with TNFi and 58 with SEC) for lack of effectiveness, 41 (16 with TNFi and 25 with SEC) for adverse events. No patient treated with SEC presented a new-onset inflammatory bowel disease.

Figure 1.

Persistence with SEC after 3 years of follow-up

Conclusion:

In this real world cohort of AxSpA pts, SEC was mostly prescribed at second and third-line, contrary to axSpA pts treated with TNFi. Most reason of discontinuation were related to lack of effectiveness with both therapeutic classes.

Disclosure of Interests:

Thibaut DELEPINE: None declared., Peggy Philippe Speakers bureau: Abbvie, MSD, Fresenius, Pfizer, UCB Pharma, Novartis, Consultant of: Abbvie, MSD, Fresenius, Pfizer, UCB Pharma, Novartis, Emeline Cailliau: None declared., Eric Houvenagel: None declared., Xavier Deprez Speakers bureau: Pfizer, UCB, Abbvie, Novartis, MSD, Consultant of: Pfizer, UCB, René-Marc Flipo Speakers bureau: Novartis, Lilly, Abbvie, Pfizer, MSD, Consultant of: Novartis, Lilly, Abbvie, Pfizer, MSD, Jean-Guillaume Letarouilly Grant/research support from: Pfizer (research grant).

OP0175 IDENTIFYING PERIPHERAL VASCULAR MONOSODIUM URATE CRYSTAL DEPOSITION WITH DUAL-ENERGY CT: FACT OR FICTION? THE VASCURATE STUDY

Background:

The close relationship between gout and cardiovascular diseases is well established. A growing hypothesis explaining this association would be that monosodium urate (MSU) crystals are deposited within vessel walls. Dual-energy computed tomography (DECT) can identify and quantify MSU crystal deposition in soft tissues. It remains unclear whether vascular spots exhibiting DECT attenuation characteristics of MSU are artefacts or true MSU crystal deposits.

Objectives:

The objectives of this study were to determine whether the presence of peripheral vascular MSU crystal deposition identified with DECT is associated with the extent of MSU deposits in joint soft tissues, and if this association persists over time under urate-lowering therapy.

Methods:

Patients with a clinical suspicion or established gout diagnosis prospectively underwent DECT for identification and quantification of the MSU crystal burden in their knees and feet. Some of these patients were also enrolled in the GOUT-DECTUS longitudinal study, and thus underwent follow-up DECT scans of their knees and feet at 6, 12 and 24 months. DECT scans were examined for the presence of vascular spots ≥0.01 cm3 classified as MSU crystal deposits according to the default post-processing settings. Multiple linear regressions adjusting on serum urate levels and gout diagnosis were implemented to determine the association between DECT MSU crystal volume in joint soft tissues, and the presence of vascular MSU deposits. Mixed linear models were used to compare DECT volumes of MSU crystal deposition in soft tissues between vascular MSU positive and negative patients during follow-up.

Results:

A total of 169 patients were included, of which 140 had a final diagnosis of gout, including 15 also included in the longitudinal study. Patients were mostly male (78.8%) and were 65.5 ± 14.6 years old. Among gout patients, disease duration was 9.3 ± 9.9 years and 56.5% were urate lowering therapy-naive. A total of 11/29 (37.9%) controls and 40/140 (28.6%) gout patients presented with a least one vascular spot of DECT MSU deposition, with an average volume of 0.02 ± 0.02 cm3, and all subjects also presented at least one vascular calcification. In the feet, patients positive for vascular DECT MSU crystal deposition had an MSU volume of 3.81 ± 10.06 cm3 in joint soft tissues, compared with 1.85 ± 7.72 cm3 for those without vascular MSU deposition (p=0.018). In the knees, patients with vascular MSU deposition had an MSU crystal volume of 6.03 ± 24.13 cm3 in joint soft tissues, compared with 0.83 ± 2.88 cm3 for those without vascular evidence of MSU deposition. In the longitudinal subgroup analysis, coefficients of the fixed effects for the presence of vascular MSU deposits on the MSU crystal volume in joint soft tissues was 0.4 (p=0.35) in the feet and 1.21 (p=0.03) in the knees. The presence of vascular DECT MSU deposits was associated with a 3.4-fold increase in MSU crystal volume in knee joint soft tissues throughout follow-up.

Conclusion:

This study suggests that some vascular spots identified with DECT as MSU crystal deposition may be real and not artefacts. This correlation remains throughout follow-up in the knees. However, the comparable prevalence of vascular DECT MSU deposits between gout patients and controls, the systematic co-existence of vascular calcifications and the uneven regression under urate-lowering therapy requires further analysis to determine which DECT spots are artefacts and which are not.

References:

[1]Dual-Energy Computed Tomography Detection of Cardiovascular Monosodium Urate Deposits in Patients With Gout. Klauser AS, Halpern EJ, Strobl S, Gruber J, Feuchtner G, Bellmann-Weiler R, Weiss G, Stofferin H, Jaschke W.

Disclosure of Interests:

Tristan Pascart Grant/research support from: Research Grant Horizon Pharma, Consultant of: Novartis, BMS, Sanofi, Pfizer,, Speakers bureau: Novartis, BMS, Paul Carpentier: None declared, Laurène Norberciak: None declared, Julie Legrand: None declared, Eric Houvenagel Speakers bureau: Janssen, Novartis, Fabio Becce: None declared, Jean-François Budzik: None declared

THU0386 PREDICTORS OF MAINTENANCE OF SECUKINUMAB TREATMENT IN A MULTICENTER COHORT OF 561 SPONDYLARTHRITIS

Objectives:

Secukinumab (SEC) is an interleukin-17 inhibitor used to treat patients with axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA). Drug maintenance is often used as a proxy for treatment effectiveness and safety in real life settings. We aim to assess SEC maintenance in routine clinical practice and to identify survival predictors associated.

Methods:

We conducted a retrospective, longitudinal, observational, multicenter study including all patients (pts) with axSpA or PsA who received at least 1 injection of SEC between July 2016 and October 2019. We collected patient’s demographics and clinic characteristics, SEC date of initiation and dosage and dosage modification of SEC, previous biologic Disease-modifying antirheumatic drugs (bDMARDs) and concomitant treatments. Date and reasons of discontinuation – i.e., lack of efficacy, safety issue, sustained remission or others – were collected. Several potential maintenance predictors were tested: age, gender, disease (axSpA or PsA), smoking status, bDMARDs history and concomitant treatment. Among patients with non-radiographic axSpA (nr-axSpA), evidence of MRI sacroiliitis or elevated CRP were also assessed as potential maintenance predictors. Drug maintenance was analyzed by the Kaplan-Meier method and adjusted for baseline factors were estimated by log rank analysis.

Results:

The main characteristics of the 561 pts included were the following: 363 (64.7%) axSpA, 198 (35.3%) PsA, 329 (58.6%) female, mean age 45,6 +/- 12 years, 221 (39.4%) smokers, 175 (31.2%) radiographic sacroiliitis, 259 (46.2%) MRI sacroiliitis, 198 (35.3%) elevated CRP, 247 (44.0%) HLA B27 positive, mean BASDAI 48,3 +/- 26.8%. SEC was associated to methotrexate (MTX) in 139 pts (24.8%) and was the first line bDMARD in 55 pts (9.8%). The median drug maintenance (MDM) of SEC was 79 weeks (wk) [73-84]. At 52 wk, 245 pts (60%) SpA were still treated with SEC. During the 3-year follow-up, 264 pts discontinued SEC: 180 (68.2%) pts for lack of effectiveness, 47 (17.8%) for adverse events, 14 (5.3%) for others and 23 (8.7%). SEC prescription as first line bDMARD was associated with longer survival versus second line or more: 111 wk [83-138] vs. 69 wk [57-80] (p=0. 017) (figure 1). MDM was not significantly different depending on gender, MTX combo, elevated CRP, axSpA vs PsA and smoking status. Among the nr-axSpA pts, MRI sacroiliitis or elevated CRP did not modify SEC maintenance (p=0.68) (figure 2).

Figure 1.

Secukinumab maintenance according to therapeutic line

Figure 2.

Secukinumab maintenance in nr-axSpA population

Conclusion:

In routine clinical practice, SEC median maintenance was 79 weeks. Fist line administration was the only independent factor associated with improved SEC retention. Lack of effectiveness was the most common reason of discontinuation.

Disclosure of Interests:

Benoît Flachaire: None declared, Jean-Guillaume Letarouilly Grant/research support from: Research grant from Pfizer, Céline Labadie: None declared, Nicolas Cohen Speakers bureau: Novartis, Janssen, Vincent Pradel: None declared, Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Guy Baudens: None declared, Pascal Claudepierre Speakers bureau: Janssen, Novartis, Lilly, Corinne Miceli Richard: None declared, Philippe Dieudé: None declared, Jean-Hugues Salmon Speakers bureau: Novartis, Janssen, Jérémie SELLAM: None declared, Eric Houvenagel Speakers bureau: Janssen, Novartis, Marie-Hélène Guyot: None declared, Chi Duc Nguyen: None declared, Xavier Deprez Speakers bureau: Novartis, Janssen, Isabelle CHARY VALCKENAERE: None declared, Pierre Lafforgue Speakers bureau: Novartis, Janssen, Damien LOEUILLE: None declared, Christophe Richez Consultant of: Abbvie, Amgen, Mylan, Pfizer, Sandoz and UCB., Rene-Marc Flipo Speakers bureau: Novartis, Janssen, Lilly, Thao Pham Speakers bureau: Novartis, Janssen, Lilly

FRI0348 PERSISTENCE OF SECUKINUMAB AND USTEKINUMAB IN PSORIATIC ARTHRITIS: A REAL-WORLD MULTICENTRIC COHORT OF 409 PATIENTS

Background:

Real-world data are missing for Ustekinumab (UST) and secukinumab (SEK) in psoriatic arthritis (PsA).

Objectives:

To evaluate the characteristics of the patients (pts) with PsA treated by UST or SEK and to assess real world persistence of UST and SEK in PsA.

Methods:

This is a retrospective, multicenter study of pts with PsA (CASPAR criteria or diagnosis confirmed by a rheumatologist) initiating UST or SEK with a follow-up ≥ 6 months from January 2011 to April 2019. The comparison of persistence between UST and SEK was analysed using a Cox model with an inverse probability of treatment weighting propensity score including 11 confounding factors. Subgroup analyses (age>65 years, gender, Body Mass Index (BMI), Charlson score>2, psoriasis, CRP>5mg/L, number (nb) of prior biotherapies, proportion of pts on maximum dose of UST or SEK, combination with methotrexate (MTX), enthesitic and axial forms of PsA) were also performed to test the heterogeneity of UST and SEK persistence. Finally, 2 sensitivity analyses were performed, first excluding the pts treated before the marketing authorization of SEK, and then excluding the pts that underwent a molecule switch. Causes of discontinuation were also collected.

Results:

406 pts were included: 245 with UST and 161 with SEK. At baseline before propensity score-matching, the UST group has a higher BMI (28.9 ± 6.4 kg/m2vs. 27.4 ± 6.0 kg/m2), more peripheral forms (98% vs. 90.8%), a higher nb of active smokers (27.1% vs. 19.9%), a higher frequency of psoriasis (96.3% vs. 83.2%), less MTX users (38.9% vs. 44.2%), a higher nb of pts with CRP >5mg/L (54.3% vs. 47%), a higher nb of pts naïve to biotherapies (22% vs. 13%) and a higher nb of pts with recommended dosing (97.3% vs 50.9%). The median persistence was 9.4 months and 14.7 months for UST and SEK, respectively. The persistence rate was lower in the UST group compared to the SEK group (40.9% vs. 59.1% % at 1 year; 26.4% vs. 38.0% at 2 years; weighted HR=1.42; 95% CI 1.07 to 1.92; p=0.015) (Fig 1). In subgroup analysis, combination with MTX was associated with a higher persistence rate in the patients with SEK compared to those receiving UST: 43.6% vs. 23.2% (HR=2.20; 95% CI 1.30 to 3.51; p=0.001), whereas no difference was observed in SEK and UST monotherapy: 33.8% vs 28.4%, respectively (HR=1.06; 95% CI 0.74 to 1.53; p=0.75) (Fig 2). A similar difference was found in the sensitivity analyses, with however a difference at the limit of significance for the analysis excluding pts with a molecule switch (adjusted HR=1.35; IC95% 0.96 to 1.92; p=0.085). The causes of discontinuation were due to inefficacy in 85% of cases and an adverse event in 12% of cases (19% in the SEK group and 9% in the UST group).

Conclusion:

In this first real-world study comparing UST and SEK persistence in PsA, the persistence of SEK was longer than that of UST. Subgroup analysis revealed this difference of persistence was restricted to patients treated in combination with MTX.

Disclosure of Interests:

Jean-Guillaume Letarouilly Grant/research support from: Research grant from Pfizer, Benoît Flachaire: None declared, Céline Labadie: None declared, Nicolas Cohen Speakers bureau: Novartis, Janssen, Maeva Kyheng: None declared, Jérémie SELLAM: None declared, Pascal Richette: None declared, Philippe Dieudé: None declared, Pascal Claudepierre Speakers bureau: Janssen, Novartis, Lilly, Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Eric Houvenagel Speakers bureau: Janssen, Novartis, Chi Duc Nguyen: None declared, Marie-Hélène Guyot: None declared, Nicolas Segaud: None declared, Frederic Maury: None declared, Laurent Marguerie: None declared, Xavier Deprez Speakers bureau: Novartis, Janssen, Jean-Hugues Salmon Speakers bureau: Novartis, Janssen, Guy Baudens: None declared, Corinne Miceli Richard: None declared, Elisabeth Gervais Speakers bureau: Novartis, Janssen, Roche, Pfizer, BMS, Abbvie, Isabelle CHARY VALCKENAERE: None declared, Pierre Lafforgue Speakers bureau: Novartis, Janssen, Damien LOEUILLE: None declared, Christophe Richez Consultant of: Abbvie, Amgen, Mylan, Pfizer, Sandoz and UCB., Thao Pham Speakers bureau: Novartis, Janssen, Lilly, Rene-Marc Flipo Speakers bureau: Novartis, Janssen, Lilly

Predictive risk factors of serious infections in patients with rheumatoid arthritis treated with abatacept in common practice: results from the Orencia and Rheumatoid Arthritis (ORA) registry

OBJECTIVES

Little data are available regarding the rate and predicting factors of serious infections in patients with rheumatoid arthritis (RA) treated with abatacept (ABA) in daily practice. We therefore addressed this issue using real-life data from the Orencia and Rheumatoid Arthritis (ORA) registry.

METHODS

ORA is an independent 5-year prospective registry promoted by the French Society of Rheumatology that includes patients with RA treated with ABA. At baseline, 3 months, 6 months and every 6 months or at disease relapse, during 5 years, standardised information is prospectively collected by trained clinical nurses. A serious infection was defined as an infection occurring during treatment with ABA or during the 3 months following withdrawal of ABA without any initiation of a new biologic and requiring hospitalisation and/or intravenous antibiotics and/or resulting in death.

RESULTS

Baseline characteristics and comorbidities: among the 976 patients included with a follow-up of at least 3 months (total follow-up of 1903 patient-years), 78 serious infections occurred in 69 patients (4.1/100 patient-years). Predicting factors of serious infections: on univariate analysis, an older age, history of previous serious or recurrent infections, diabetes and a lower number of previous anti-tumour necrosis factor were associated with a higher risk of serious infections. On multivariate analysis, only age (HR per 10-year increase 1.44, 95% CI 1.17 to 1.76, p=0.001) and history of previous serious or recurrent infections (HR 1.94, 95% CI 1.18 to 3.20, p=0.009) were significantly associated with a higher risk of serious infections.

CONCLUSIONS

In common practice, patients treated with ABA had more comorbidities than in clinical trials and serious infections were slightly more frequently observed. In the ORA registry, predictive risk factors of serious infections include age and history of serious infections.

Positivity for anti-cyclic citrullinated peptide is associated with a better response to abatacept: data from the 'Orencia and Rheumatoid Arthritis' registry

OBJECTIVES

Very limited data are available regarding the efficacy of abatacept (ABA) in real life. The aims of this study were to determine the efficacy of ABA in rheumatoid arthritis and predicting factors of efficacy in common practice.

METHODS

The Orencia and Rheumatoid Arthritis" (ORA) prospective registry, promoted by the French Society of Rheumatology, has included 1003 patients with RA.

RESULTS

773 patients had already fulfilled the 6-month follow-up visit. Only 21.3% of patients would have fulfilled inclusion criteria used in pivotal controlled trials. The European League Against Rheumatism (EULAR) response, was observed in 330 (59.1%) of the 558 assessed patients (good response: 20.4%, moderate response: 38.7%) and was similar in patients who did and in patients who did not fulfill inclusion criteria of controlled trials. Among EULAR responders, initial 28-joint disease activity score (5.4 (4.7-6.5) in responders vs 4.9 (4.0-6.0) in non responders, p< 0.0001), the proportion of rheumatoid factor (75.6% vs 66.7%, p= 0.03) and the proportion of anti-cyclic citrullinated peptide antibody (anti-CCP)-positivity (75.9% vs 62.2%, p= 0.001) were significantly higher. In multivariate analysis adjusted on initial 28-joint disease activity score and CRP, anti-CCP positivity was associated with EULAR response (OR=1.9;95% CI=1.2 to 2.9, p=0.007), but not rheumatoid factor (OR=1.0;95% CI=0.6 to 1.6, p=0.9). Anti-CCP positivity was also significantly associated with a higher ABA retention rate at 6 months.

CONCLUSIONS

Real life efficacy of ABA in the ORA registry was similar as that reported in clinical trials. Anti-CCP positivity was associated with a better response to ABA, independently from disease activity.

Spinal curvatures and quality of life in women with vertebral fractures secondary to osteoporosis

STUDY DESIGN

A prospective cross-sectional case-control study.

OBJECTIVES

To compare spinal curvatures in women with osteoporosis and control subjects with a new instrument, the curviscope.

SUMMARY OF BACKGROUND DATA

Few instruments are available for measuring spinal curvatures in the sagittal plane. Most of them have poor reproducibility, and they have been poorly investigated in osteoporosis.

METHODS

Ninety-eight postmenopausal women were evaluated. They were divided into two groups, according to their bone status: women with osteoporosis with at least one vertebral fracture (n = 51) and control subjects (n = 47). Women with osteoporosis were divided into two subgroups, according to the delay since the last vertebral fracture had occurred (i.e., more or less than 3 months). Quality of life was assessed by using a generic instrument, the Nottingham Health Profile, in patients with osteoporosis only.

RESULTS

Reproducibility of the curviscope was satisfactory. For kyphosis measurements, the coefficients of variation were 2.8% and 2.4% in control subjects and women with osteoporosis, respectively. Kyphosis values were significantly higher in women with osteoporosis than in age-matched control subjects (63 degrees +/- 13 degrees vs. 52 degrees +/- 11 degrees, respectively; P < 0.005). Nottingham Health Profile scores were significantly different (P < 0.05) in women with osteoporosis with a recently diagnosed vertebral fracture, compared with other women with osteoporosis in two aspects, physical mobility and energy. Kyphosis measurements were significantly correlated with age in the whole group (r = 0.26; P < 0.05). In the Nottingham Health Profile, physical mobility was significantly correlated with kyphosis (r = 0.35; P < 0.05).

CONCLUSIONS

The curviscope is a reliable tool, particularly useful in the assessment of osteoporosis. Moreover, kyphosis angles measured with the curviscope are markedly increased in women with osteoporosis, compared with control subjects. Finally, an increase of kyphosis angles is associated with decreased physical mobility.

Two new cancer locations accompanied with palmar fasciitis and polyarthritis

Only 35 cases of cancer with palmar fasciitis and polyarthritis have been published to date. We report two new cases, one with a transitional cell carcinoma of the renal pelvis and the other with an adenocarcinoma of the uterus. Neither of these locations has been reported in association with palmar fasciitis and polyarthritis. Palmar fasciitis with polyarthritis can occur in a wide range of cancers and warrants extensive investigations for a malignant tumor.

[Initial manifestations and late diagnosis in chronic atrophic polychondritis: apropos of a series of 15 patients]

An auricular or nasal chondritis or a saddle nose deformity are the initial manifestation in half of cases of relapsing polychondritis; the other initial manifestations are various and less evocative; polyarthritis, laryngo-tracheal symptoms, episcleritis which delay the diagnosis. From 15 cases of relapsing polychondritis, the diagnosis time from the first symptom are studied; this one is long, about 3 years and 6 months (from 3 months to 17 years) in 13/15 of the cases even if the first manifestation is typical (external chondritis). In two cases only, the diagnosis was established after the first attack. This late of diagnosis had socioeconomical impact and exposed to severe complications like tracheal chondritis.

[Osteoporotic vertebral crush fractures with severe neurologic manifestations. Apropos of 6 cases]

Osteoporotic vertebral crush fractures with neurologic complications are rarely reported in the literature. We report six new cases particularly severe in which death occurred in two cases. The study group included four women and two men with a mean age of 75 years (range: 72-79). Vertebral collapse causing neurological deficit was T5, T9, T11 in two cases, L1 and L3. The mean number of vertebral collapses was three per patient (range: 1-9). Back pain appeared without traumatism 6 weeks before admission (range: 1-24). Neurological complications appeared 2.5 weeks after back pain (range: 1-8). One patient suffered from a paraplegia, three from a paraparesia with bladder dysfunction (n = 1). In one case there was a severe weakness of the levator muscles of the foot and in another a L3 femoral neuralgia with severe bowel and bladder dysfunction. X-rays demonstrated backwards displacement of the posterior cortex in three cases, an intravertebral vacuum phenomenon in two cases and a heterogeneous appearance suggesting a malignancy in two cases. Computed tomography, performed in four patients and tomography in one patient, demonstrated fragmentation of the vertebral body in all the cases and vacuum phenomenon in four cases. Magnetic resonance imaging performed in four cases has confirmed the absence of epiduritis and a compression due to bony structures in two cases. A vertebral biopsy was performed in three cases. Osteoporosis was observed in all the cases and in two cases there was also an osteonecrosis. Surgical treatment was performed in three cases and conservative medical treatment in the other cases. After surgical treatment we have observed an absence of improvement of neurological complications in one case, an improvement in another and finally a full recovery in the last case. After conservative treatment we have noted in two cases an absence of improvement of neurological complications and in one case an improvement of neurological deficit. Two patients died (one after medical treatment and another after surgical treatment).

[HLA DRB1 polymorphism in rhizomelic pseudo-polyarthritis and Horton disease]

Some studies have suggested that distribution of HLA DRB1 alleles in polymyalgia rheumatica (PMR) resembles that found in giant cell arteritis (GCA). However these data are controversial. OBJECTIVE--To evaluate in French native patients whether PMR immunogenetically resembles GCA in determining HLA DRB1 alleles. PATIENTS AND METHODS--Fourty-five patients were included in the study. Twenty-one patients with PMR alone (Bird's criteria) and 24 with GCA (ACR criteria). In 11 patients, GCA was associated with PMR. HLA DRB1 genotype was determined by PCR-RFLP analysis. Statistical analysis was performed by the chi 2 test and determination of the odds ratio (OR). Two hundred and thirty-three unselected normal healthy subjects served as controls. RESULTS--A significant increased prevalence of HLA DR1 was observed in patient with PMR alone and an absence of DR7 (0% vs 10.3%, p = 0.02, OR = 0.1). An increased incidence of DR4 and particularly *0401 allele was only found in patients with GCA (OR = 2.4). No patient with isolated PMR had DR7 genotype compared with 25% in GCA (p < 0.001, OR = 0.03). A comparative study between isolated PMR versus GCA showed a significant increased in DR1 and DR3 alleles in isolated PMR and a significant increased prevalence of DR4 and DRB1 *0701 allele in GCA. CONCLUSION--The present study emphasizes the absence of similarity in HLA DRB1 allele distribution between PMR and GCA. The association of DR7 in patient with GCA seems characteristic in French native patients.

Labial salivary gland biopsy assessment in rheumatoid vasculitis

OBJECTIVES

To assess the vascular involvement in labial salivary gland (LSG) from patients with rheumatoid vasculitis (RV).

METHODS

Forty seven patients with rheumatoid arthritis (RA) took part in a prospective study. Among them, 12 had proven RV. LSG biopsy was performed after local anaesthesia.

RESULTS

Histological appearance of inflammatory vascular damage was observed in all but one patient with proven RV (92%). Inflammatory vascular involvement was also identified in LSG biopsy of seven patients with RA (20%) and only one patient in the control group (8%). A second specimen of LSG was studied after a mean treatment period of six months and failed to show any feature of inflammatory vascular involvement in three of the five cases that were analysed.

CONCLUSIONS

The study emphasises the high incidence of immunopathological features of microvascular damage in patients with RV. LSG biopsy is minimally invasive and may be a potential useful tool for the diagnosis of RV especially when skin lesions are absent or impossible to biopsy. The assessment of the predictive value of positive LSG biopsy in RA requires a long term prospective study.

Increased capillary permeability in systemic rheumatoid vasculitis: detection by dynamic fluorescence nailfold videomicroscopy

OBJECTIVE

Several histological studies suggest a vascular involvement in rheumatoid arthritis (RA). We evaluated morphological and functional changes of skin capillaries in patients with RA.

METHODS

We studied capillary permeability by nailfold fluorescence videomicroscopy in patients with RA with and without systemic vasculitis to establish the sensitivity, specificity, and the prognostic value of the technique for the diagnosis of systemic rheumatoid vasculitis (SRV). Nine patients with SRV, 22 patients with active RA without signs of vasculitis, and 16 controls were evaluated.

RESULTS

No difference in conventional capillaroscopy was observed when we compared patients with SRV and RA. Using fluorescence videomicroscopy after intravenous injection of fluorescein sodium, we observed an increase of transcapillary dye diffusion in 9/9 patients with SRV, in 13/22 patients with RA without vasculitis and in 4/16 control patients. Our results give a sensitivity of 100% in SRV, a specificity of 44%, a positive predictive value of 34% and a negative predictive value of 100%.

CONCLUSION

Our present study points out the functional alteration of the capillary wall in patients with RA with or without vasculitis and suggests the usefulness of dynamic fluorescence nailfold capillaroscopy in patients with RA when systemic vasculitis is suspected, not as a diagnostic tool, but because of the high negative predictive value of the technique.

[Cardiac complications in adult onset Still disease: from pericarditis to tamponade as manifestations]

Pericarditis is a common manifestation of adult still's diseases (ASD), observed in 20% to 3% cases. Pericardial tamponade is more seldom, less than ten cases have been reported in the literature. We reported two observations of patients with ASD and pericardial tamponade above a series of 18 patients with ASD, in one case revealed the disease. The first patient was a 32-year-old women and had fever, arthritis, high white blood cell count and developed pericardial tamponade. The evolution was favourable with bolus of methylprednisolone. In the second case, cardiac tamponade occurred several years after the onset of the disease. Surgical drainage was first required (800 ml) because of inefficacity of oral prednisone. A dramatic improvement was observed after bolus of methylprednisolone. In conclusion pericardial tamponade is a seldom but sometimes the first manifestation of ASD and may required in first intention bolus of methylprednisolone.

[Rheumatoid polyarthritis in the elderly--rhizomelic pseudopolyarthritis: what differences?]

The authors have conducted a comparative retrospective study between polymyalgia rheumatic (N = 26) and rheumatoid arthritis in the elderly (N = 44), including HLA DRB1 genotype determination by PCR-RFLP analysis. No clinical nor biological differences were significant between the 2 groups of patients. However 70% of RA patients had one ore more susceptibility alleles (shared epitope hypothesis) and 50% in polymyalgia rheumatica.

[Cardiac complication of adult-onset Still's disease: from pericarditis to tamponade, sometimes a manifestation of the disease]

Cardiac tamponade is very seldom complication of adult onset-Still's disease. We reported 2 cases; it was the first manifestation of the disease in one case.

[Unsatisfactory results of intradiscal injection of triamcinolone hexacetonide in the treatment of sciatica caused by intervertebral disk herniation]

Sciatica caused by intervertebral disc herniation can be treated with intradiscal injection of chymopapain. A search for a cheaper and less allergizing product led to triamcinolone hexacetonide, this procedure being known as "nucleorthesis". The first results at 6 months were encouraging. In 3 centres where triamcinolone hexacetonide was tested with a more than 2 years' follow-up 92 patients could be evaluated. The results obtained were considered satisfactory in 34 patients (36.9 percent), but they were poor in 19 patients (20.6 percent), and 39 patients (42 percent) had to be operated upon within 2 years. Return to surgery took place within the 6 months following nucleorthesis in 18 patients (19.56 percent) and beyond this period in 17 patients (22.8 percent) with degradation of the results. Moreover, calcifications were found in 19 out of 38 patients; they were of varying size, sometimes detected only at computerized tomography, and some of them appeared to produce symptoms. All considered, the failure rates, the number of patients who required surgery and the occurrence of large and sometimes symptomatic calcifications make triamcinolone nucleorthesis unacceptable compared with the recognized percentages of success with papain nucleolysis and surgical operations. For these reasons, we consider that this treatment should be abandoned.

[A case of Weismann-Netter and Stuhl toxopachyosteosis with new bone sites]

A case of Weismann-Netter-Stuhl toxopachyosteosis in a 63-year-old man is reported. Bone deformities had been present since the age of 18 months. Tibio-fibular dysmorphism was severe. Radiological evaluation revealed other lesions encountered more rarely: bilateral femoral incurvature and exostoses, bilateral coxa vara, radio-ulnar incurvature and flattening of the last ribs. Two other previously undescribed lesions were seen in this patient; bradymetacarpism of the last four rays of the left hand and dysmorphic lengthening of the left patella. This case illustrates the widespread nature and unusual extent of bone lesions in the context of toxopachyosteosis.

[Weismann-Netter and Stuhl toxopachyosteosis. Apropos of 30 cases]

Toxopachyosteosis, a rare bone disease, was described in 1954 by Weissmann-Netter and Stuhl. This congenital osteopathy, which may be familial, is defined by an anteroposterior curvature (toxon = arc) and thickening (pachus = thick) of the shafts of both leg bones. Other bones may be affected. Short stature and delayed walking are other important special features of the disease. It is most often diagnosed late and by chance because of the minimal functional consequences of the deformities. Sequelae of vitamin D-deficient rickets are the main differential diagnosis. The aim of this study undertaken by the Bone and Calcium/Phosphorus Metabolism Section of the Société Française de Rhumatologie (French Society of Rheumatology) was an overall assessment of the disease. The authors report 30 cases of toxopachyosteosis and evaluate their main characteristics on the basis of data from the literature.

[Effects on the bone metabolism of long-term treatment with antivitamins K1]

Oral anticoagulants (OC) prevent the activation by carboxylation of coagulation proteins. However this action also affects osteocalcin, or bone Gla-protein, a parameter of bone remodelling. Phosphorus and calcium metabolism, osteocalcin levels and bone mineral content were studied in twelve men aged under 60, and who had been taking OC for more than a year, in comparison with a paired group of nine controls with the same cardiovascular pathology but not taking anticoagulants. Osteocalcin levels were lower in the OC group (3.44 ng/ml) than in the control group (5.88 ng/ml) (p = 0.01). There was no significant difference in other phosphorus/calcium balance parameters nor in bone density between the two groups. No evidence was found of any osteopathy in the OC group, but the decrease in serum osteocalcin could result either from inhibition of its secretion or of its carboxylation, or from an action on the osteoblast.

[Spondylodiscitis disclosing bacterial endocarditis. Apropos of a case. Review of the literature]

The authors report a case of infectious spondylodiscitis revealing a staphylococcal endocarditis in a patient with a Carpentier aortic heterograft. This case, along with 60 descriptions from the literature, has enabled them to specify the characteristics of occurrence of endocarditis during a spondylodiscitis. The clinical factors in favor of this association are: a pre-existing cardiopathy, an oral port of entry, occurrence of other rheumatoid manifestations, even more the presence of complications of endocarditis. The laboratory factors in favor of an association are: discovery of an inflammatory anemia, of circulating immune complexes, of a cryoglobulinemia, of a rheumatoid factor, of hematuria. But it is mostly the demonstration of streptococcus in blood cultures and other samples that should be an indication to search for an endocarditis, the course of which dominates the prognosis.

[Chromosome anomalies in rheumatoid polyarthritis. Breakage level and study of the breaking factor]

This current study confirms the significant elevation of the rate of chromosomal abnormalities (18.32 p. cent in 90.62 p. cent of cases) and the presence of a breaking capacity of the serum in a series of 78 rheumatoid polyarthritis compared with a control group. Chromosomal gaps and breaks represent the most frequently encountered lesions. These lesions are observed from the onset of the disease but are not specific of this disease. Chromosomal abnormalities do not seem to be randomly distributed on the chromosomes. They are not correlated with clinical or biological parameters in a statistically significant fashion. The cytogenetic study only represents a non specific biological test of rheumatoid disease. The advantage could apply, in practice, to beginning or atypical forms of rheumatoid polyarthritis in order to identify them within the group of auto-immune diseases.