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Objectives: There is no protocol of vitamin D supplementation used worldwide due to a great disparity of vitamin D supplements available in different countries. The aim of this study was to evaluate the efficiency of the protocol most often used in France to correct vitamin D deficiency defined by a serum 25-hydroxy vitamin D (25OHD) level of less than 30 ng/mL.Methods: This was a pragmatic multicentric study of vitamin D supplementation in 257 osteopenic/osteoporotic, vitamin D deficient patients who received 100,000 UI vitamin D3 vials every two weeks according to their initial serum 25OHD level (four vials when 25OHD less than 10 ng/mL, three when 25OHD was 10-19 ng/mL, two when 25OHD was 20-29 ng/mL). Blood samples were obtained at baseline, one (M1), two (M2), and three months (M3), after the end of the supplementation protocol.Results: At M1, 198/257 (77%) patients had a serum 25OHD level more than 30 ng/mL. Eighty-five percent of those with a BMI less than 25 kg/m2 had a 25OHD concentration more than 30 ng/mL, whereas only 66% of those with a BMI more than 25 had a level more than 30 ng/mL. At M2 and M3, 25OHD levels decreased significantly with 55% and 46% having still a level more than 30 ng/mL respectively, without any significant difference according to the initial 25OHD level.Conclusion: This protocol was effective in rising serum 25OHD of most vitamin D insufficient patients with a BMI less than 25 kg/m2, but not in overweight patients. As almost one half of our patients had a serum 25OHD level less than 30 ng/mL at M2, we suggest that regular doses should be started quite soon after this initial supplementation. [ABSTRACT FROM AUTHOR]

Objective: The identification of helpful or unhelpful behavioral strategies for coping with pain would assist in optimizing the management of patients with chronic low back pain (CLBP). The objective was to develop and validate a questionnaire for categorizing behavioral strategies in patients with nonspecific CLBP., Methods: (1) Development of a preliminary questionnaire based on a qualitative study in 25 patients with CLBP; (2) Item reduction and questionnaire validation by a multicenter international prospective study in patients with CLBP, with multiple correspondence analysis to identify behavioral profiles, whose characteristics and internal and external validities were assessed; 12-month study of treatments in 58 patients; (3) Evaluation of reproducibility in 30 patients., Results: (1) The preliminary questionnaire had 87 items in eight pain-coping domains. (2) Three behavioral profiles were identified: effective coping, emotional distress, and kinesiophobia. The questionnaire was reduced to 21 items in seven domains. Cronbach's α indicated moderate internal consistency (0.47-0.66). External validity versus anxiety, depression, and coping strategies was good. As expected, functional restoration program was used more often by patients with kinesiophobia than by those with effective coping (50% vs. 25%, P<0.05). (3) Reproducibility was good (κ=0.70)., Conclusion: This new, simple questionnaire allows the identification of three behavioral profiles, thus guiding the development of personalized management programs for NCLBP., (Copyright © 2017 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)

Unlabelled: Ultrasound (US) is widely used in rheumatology to study and guide injection of peripheral joints. It can also provide useful information about the anatomy of the lumbar spine. Studies have shown that US examination of the spine was a useful tool to help perform epidural anaesthesia. The purpose of the study was to determine if the selection of the optimum puncture level by US may facilitate epidural steroid injection in case of presumed difficult puncture (BMI>30 kg/m(2), age>60 years or lumbar scoliosis)., Methods: We performed a prospective randomized controlled study. Eighty patients were randomized in two groups: US group (n=40) which underwent a pre-procedure spinal US to determine the optimal lumbar level for injection or control group (n=40) for which the level of injection was determined by palpation. Primary endpoint was the pain during the procedure assessed using the Visual Analogue Scale (VAS)., Results: We found a positive correlation between depth of the epidural space and BMI (P<0.001) and a negative correlation between size of the interspinous spaces and age (P<0.01). Visibility of the epidural space was not altered by obesity or age. We observed a trend toward a reduction in pain intensity during the procedure in the US group compared to the control group with a mean difference at -0.94 [-1.90; 0.02] but the difference was not significant (P=0.054)., Conclusion: US of the lumbar spine was feasible in patients with lumbar conditions even in obese and old ones and allowed the visualization of the epidural space. However, pre-procedure US examination did not reduce pain during the procedure., (Copyright © 2015 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)

Objectives: To assess the feasibility and safety of caudal epidural glucocorticoid injections performed with ultrasound guidance., Methods: We studied 30 patients with low back pain and nerve root pain related to disk herniation or associated with lumbar spinal stenosis. A caudal epidural injection was performed under ultrasound guidance. Prednisolone acetate, 5 ml, was administered with 10 ml of saline and 5 ml of iodinated contrast agent, providing an epidurogram. Acceptability of the procedure by the patient was assessed. Adverse events occurring immediately after the procedure and within the first month were collected., Results: The sacral hiatus was identified in 29 (96.6%) patients. Mean distance between the two sacral cornua was 1.42 cm (range, 0.83-2.13) and mean diameter of the sacral hiatus was 0.60 cm (0,2-1.28). The injection proved feasible in 28 of the 29 patients. The epidurogram indicated that the injection was successful in 27 patients. Mean procedure duration was 15 minutes (30-10). No cerebrospinal fluid reflux occurred. Blood reflux was noted in 9/29 patients and resolved in eight upon needle repositioning. All patients deemed the procedure acceptable. No complications were recorded during the first month., Conclusion: Ultrasound-guided caudal glucocorticoid injection is a fast, easy-to-perform, well accepted procedure. In our study, an epidurogram confirming that the needle was in the epidural space was obtained in 27 of 28 patients., (Copyright © 2010 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)

Objective: To assess the clinical results at 6 months of etanercept 25 mg once weekly (half-dose), and etanercept 25 mg twice weekly (full-dose), in patients with rheumatoid arthritis or spondylarthropathy., Methods: Case records of all patients treated by etanercept for at least 6 months in the same rheumatology unit were retrospectively studied, to assess the mean values of DAS-28 and BASDAI, just before (J0), and after 6 months (M6) of treatment, in patients with rheumatoid arthritis or spondylarthropathy treated with etanercept 25 mg given either once or twice weekly., Results: 112 patients had been treated for at least 6 months (44 at half-dose, and 68 at full-dose). Values of DAS-28 or BASDAI both at J0 and M6 were available in 92 patients. DAS-28 dramatically improved both in the half-dose group (from 5.2+/-0.8 to 3.5+/-0.8) and in the full-dose group (from 5.5+/-1.0 to 4.1+/-1.0). BASDAI also strikingly improved both in the half-dose group (from 60+/-13 to 25+/-18), and in the full-dose group (from 58+/-15 to 37+/-23)., Conclusion: Although this was not a double-blind, prospective, randomised study, the strong improvement noticed in the half-dose group suggests that etanercept 25 mg once a week can induce major clinical and biological relief in some patients with RA or spondylarthropathy.

Objectives: To assess the frequency, features, and outcome of excruciating lumbar, dorsal, and/or thoracic pain following injections of local corticosteroids in rare instances., Methods: A questionnaire mailed to 500 French rheumatologists., Results: Three hundred and eighteen cases were reported by 92 rheumatologists (one event per 8000 injections or 6.5 years of practice), following injections into lumbar epidural space (39%), an upper limb (30%), a lower limb (mostly the heel) (24%), or other locations (7%), of cortivazol (67%), hydrocortisone (25%), betamethasone (7%), or paramethasone (1%). Symptoms occurred 1-5 min (78%) or less than 1 min (22%) after injection, and highly acute axial pain usually lasted for less than 5 min (34%) or 5-15 min (51%). In addition to pain in lumbar (84%) and/or dorsal regions (25%) [often preceded or associated with thoracic pain (36%)], other signs were: anxiety (87%), shortness of breath (64%), facial flushing (64%), diffuse sweating (41%), agitation (29%), transient cough (23%), abdominal pain (20%), transient hypertension (15%), paleness (10%), hypotension (8%), diarrhoea (3%) and headache (3%). None of these patients was known to be allergic, and urticaria developed in only 2%. Outcome was favourable in all cases (even though 4/318 patients were transiently hospitalised) with an overall duration of 25 +/- 71 min. Another injection was performed later in 146/318 cases (46%), but Tachon's syndrome recurred in only 20 of these 146 patients (14%)., Conclusion: The outcome of this impressive syndrome seems excellent. Tachon's syndrome might be the venous counterpart of Nicolau's syndrome (injection of corticosteroids in an artery).

Objectives: In May 2001, we surveyed French rheumatologists to determine how they inform their patients about serious side effects of drugs., Results: Of the 600 rheumatologists invited to participate in the study, 341 completed and returned the questionnaire. Most respondents believed that full information on patients would become the rule (mean, 62.1 +/- 28.3, the items being scored on a 100-point scale where 0 was "not at all" and 100 "absolutely"). The answer to this item varied little across age groups. Respondents felt that patient information fell primarily on the physician, (78 +/- 23), followed by pharmaceutical companies (64 +/- 32) and pharmacists (46 +/- 33). The respondents believed that full information of patients about side effects would primarily benefit physicians (51 +/- 32), followed by pharmaceutical companies (43 +/- 30) and patients (38 +/- 28). The reaction of patients to information on drug-related risks was described as "always favorable" by 2% of the respondents and as "fairly often favorable" by 55%. Among respondents, 9% always gave information on serious side effects, 66% fairly often, and 4% never; 2% always communicated information on the approximate frequency of serious adverse events, 21% fairly often, and 33% never. Similarly, 3% of the respondents always warned their patients of lethal risks, 11% fairly often, and 44% never. When evaluated on a 100-point scale (0, not at all knowledgeable; 100, very knowledgeable), knowledge of serious side effects of drugs for musculoskeletal conditions was 73 +/- 23, whereas knowledge of the frequency of these effects was only 52 +/- 22. Eight percent of the respondents always recommended that patients read the package insert, 27% fairly often, and 32% never. Conversely, the possible adverse effects of not taking the treatment were always specified by 21% of the respondents and fairly often by 88%.

Pathogenic hypotheses for spondyloarthropathies are evolving. Several candidates have been added to the list of inciting microorganisms, and genes other than HLA-B27 are under scrutiny. Above all, the chiefly 'immunological' theory of spondyloarthropathies incriminating a cross-reaction between self-proteins and bacterial peptides is giving way to a more 'microbiological' concept in which latent bacteria residing within macrophagic or dendritic cells undergo reactivation through a process facilitated by HLA-B27. This molecule is prone to misfolding, which decreases the presentation of bacterial peptides to the immune system and stimulates the Nf-KB inflammation pathway within infected macrophages and/or dendritic cells. Migration of these infected cells from the mucous membranes to the tissues targeted by spondyloarthropathies, particularly the bone marrow located near entheses, may facilitate transient reactivation of dormant intracellular bacteria by creating a favorable cytokine environment. This environment may include high levels of TGFbeta and IL-10, noted also at other sites that enjoy immune privilege, such as the eye. The reactivation may be stopped by a local response of CD4+ and/or CD8+ T cells at the expense of local inflammation responsible for clinical manifestations. This scenario seems consistent with results from studies of murine models transgenic for the HLA-B27 antigen: exposure to bacteria is necessary to the development of spondyloarthropathy, but the disease occurs even when only the heavy chain of HLA-B27 is present (i.e., beta2-microgloblin is not indispensable). Improved understanding of the mechanisms that confer to some bacterial strains a strong potential for persisting within cells, including macrophagic cells, may open the way toward new treatment approaches capable of complementing antagonists of TNF-alpha and other monokines, which merely suspend the disease process, and antibiotic therapy, which fails to kill dormant bacteria located within cells. Pathogenic hypotheses for spondyloarthropathies are evolving. This review presents the most recent concepts. These concepts have not all received confirmation from experimental data. However, the high degree of consistency among them prompted us to consolidate them into a single picture. Although this approach may yield a motley composite of fact and speculation, it may open up new avenues of thought for rheumatologists interested in the links between chronic intracellular infections and inflammatory joint disease.

Objectives: To identify medical and nonmedical reasons for admission of disk-related sciatica patients., Patients and Methods: 125 patients were evaluated prospectively using a 25-items questionnaire, including seven items on medical reasons, four on psychological reasons, four on work-related reasons, six on social and family reasons, and four on miscellaneous reasons., Results: Severe nerve root pain (34%), motor loss (17%), atypical clinical manifestations (13%), severe low back pain (8%), and/or sphincter dysfunction (4%) were recorded in only 55% of patients, and only 16% had at least two of these reasons. A minority of patients were admitted to avoid premature surgery (13%) or to try one more conservative approach prior to surgery (15%). Seventy-five per cent of patients reported at least one of the psychological reasons listed in the questionnaire (irritability/fatigue, 66%; anxiety, 42%; depression, 26%; panic disorder, 21%), 50% reported at least one work-related reason (workaholism, 21%; job offer, 16%; self-employed, 14%; fear of losing their job, 11%), 66% reported at least one social or family reason (living alone, 34%; one or more dependents younger than seven years of age, 32%; too many demands from household members, 22%; one or more dependents older than seven years of age, 8%; need to care for another person, 9%; important upcoming family or personal event, 6%), and 26% reported at least one miscellaneous reason (firm belief that sciatica can be cured only by inhospital treatment, 10%; desire to put pressure on the employer or on an expert, 7% and 6%, respectively; admission via the emergency room without prior medical advice, 6%)., Conclusion: In France, the reason for admission of patients with disk-related sciatica is frequently a mixture of physical, psychological, and social problems, with only 55% of patients having a symptom requiring inhospital management.

Concepts regarding the nosology, pathophysiology and pathogenesis of reflex sympathetic dystrophy syndrome are currently in a state of flux. Causalgia and reflex sympathetic dystrophy syndrome are now generally felt to be on the same continuum and as a result interest for defining criteria for the latter condition has waned. The pathogenic role of adrenergic sympathetic activity has been so successfully challenged that the last international consensus conference judged inappropriate any reference to the sympathetic system in the terms used to designate these conditions, thus confirming the position long defended by most French authors. The vasomotor abnormalities may be due to antidromic release of neuromediators by the endings of polymodal C fibers. These fibers do not belong to the sympathetic system but often travel with sympathetic nerves, a characteristic that may explain the efficacy of sympathetic nerve blocks, although other possibilities exist including a placebo effect. Also, efferent sympathetic fibers may undergo activation by nonadrenergic mediators. The mechanisms capable of initiating and perseverating activation of polymodal C afferents are being actively investigated and have been found to exhibit similarities with the mechanisms underlying peripheral and central sensitization of pain-producing afferents. Growth factors, such as nerve growth factor, may play an important role in causalgia. In "reflex sympathetic dystrophy syndrome", microcirculatory stasis may contribute to the initiation or perpetuatation of the disorders. Further work on the nerve supply to the venular network and on the venoarterial reflex is needed.

Treatment with low dose methotrexate in rheumatoid arthritis is associated with serious side effects in about 5 per cent of cases (respiratory, haematological or infectious). The goal of a null risk seems unrealistic because of the idiosyncrasy of some of the risks and our poor understanding of others (enzymatic polymorphisms might be operational, and infectious agents could act as co-factors). However, risk can be greatly reduced by a careful selection of patients. Some contraindications are strict: poor compliance and the possibility of mistake in the timing of the administration; pregnancy or desire for pregnancy; treatment with trimetoprim; haemodialysis; renal insufficiency (clearance < or = 50 ml/min) (and therefore old age), alcoholism. Others remain relative although well established; hypoalbuminaemia, diabetes mellitus, obesity, past infection with hepatitis virus. Others are dubious: starvation, macrocytosis, surgical stress, NSAIDs. An extensive large study of side effects is warranted.