Fabien Etchepare

Bio: Fabien Etchepare is an academic researcher from French Institute of Health and Medical Research. The author has contributed to research in topics: Synovitis & Arachnoiditis. The author has an hindex of 13, co-authored 28 publications receiving 573 citations.

Parkinson’s disease with camptocormia

Abstract: Background: Camptocormia is defined as an abnormal flexion of the trunk that appears when standing or walking and disappears in the supine position. The origin of the disorder is unknown, but it is usually attributed either to a primary or a secondary paravertebral muscle myopathy or a motor neurone disorder. Camptocormia is also observed in a minority of patients with parkinsonism. Objective: To characterise the clinical and electrophysiological features of camptocormia and parkinsonian symptoms in patients with Parkinson’s disease and camptocormia compared with patients with Parkinson’s disease without camptocormia. Methods: Patients with parkinsonism and camptocormia (excluding patients with multiple system atrophy) prospectively underwent a multidisciplinary clinical (neurological, neuropsychological, psychological, rheumatological) and neurophysiological (electromyogram, ocular movement recording) examination and were compared with age-matched patients with Parkinson’s disease without camptocormia. Results: The camptocormia developed after 8.5 (SD 5.3) years of parkinsonism, responded poorly to levodopa treatment (20%) and displayed features consistent with axial dystonia. Patients with camptocormia were characterised by prominent levodopa-unresponsive axial symptoms (ie, axial rigidity, gait disorder and postural instability), along with a tendency for greater error in the antisaccade paradigm. Conclusion: We suggest that (1) the salient features of parkinsonism observed in patients with camptocormia are likely to represent a specific form of Parkinson’s disease and camptocormia is an axial dystonia and (2) both camptocormia and parkinsonism in these patients might result from additional, non-dopaminergic neuronal dysfunction in the basal ganglia.

Sensitivity and Specificity of Ultrasonography in Early Diagnosis of Metatarsal Bone Stress Fractures: A Pilot Study of 37 Patients

Abstract: Objective. To date, early diagnosis of stress fractures depends on magnetic resonance imaging (MRI) or bone scan scintigraphy, as radiographs are usually normal at onset of symptoms. These examinations are expensive or invasive, time-consuming, and poorly accessible. A recent report has shown the ability of ultrasonography (US) to detect early stress fractures. Our objective was to evaluate sensitivity and specificity of US versus dedicated MRI (0.2 Tesla), taken as the gold standard, in early diagnosis of metatarsal bone stress fractures. Methods. A case-control study from November 2006 to December 2007 was performed. All consecutive patients with mechanical pain and swelling of the metatarsal region for less than 3 months and with normal radiographs were included. US and dedicated MRI examinations of the metatarsal bones were performed the same day by experienced rheumatologists with expertise in US and MRI. Reading was undertaken blind to the clinical assessment and MRI/US results. Results. Forty-one feet were analyzed on US and dedicated MRI from 37 patients (28 women, 9 men, mean age 52.7 ± 14.1 yrs). MRI detected 13 fractures in 12 patients. Sensitivity of US was 83%, specificity 76%, positive predictive value 59%, and negative predictive value 92%. Positive likehood ratio was 3.45, negative likehood ratio 0.22. Conclusion. In cases of normal radiographs, US is indicated in the diagnosis of metatarsal bone stress fractures, as it is a low cost, noninvasive, rapid, and easy technique with good sensitivity and specificity. From these data, we propose a new imaging algorithm including US.

Prediction of radiographic damage in early arthritis by sonographic erosions and power Doppler signal: a longitudinal observational study.

Abstract: Objective To assess the ability of ultrasonography (US) to predict radiographic damage in early arthritis. Methods ESPOIR is a multicentric cohort of early arthritis (i.e., ≥2 swollen joints between 6 weeks and 6 months). US synovitis in B mode, power Doppler (PD) mode, and erosions were searched on the second through the fifth metacarpophalangeal and fifth metatarsophalangeal joints according to Outcome Measures in Rheumatology definitions. Structural radiographic progression was assessed using the modified Sharp/van der Heijde erosion score (SHS) at baseline and 1 and 2 years. Predictive factors of erosive arthritis at 2 years and rapid radiographic progression (RRP) at 1 year (defined by change of SHS ≥5) were searched. Results A total of 127 patients were included, with a mean ± SD Disease Activity Score in 28 joints of 5.1 ± 1.3; 37.6% were anti–citrullinated protein antibody positive and 27.6% had typical rheumatoid arthritis (RA) erosions on radiographs. At 2 years, 42 patients (39.2%) had typical RA erosions. US erosions predicted radiographic evidence of erosive arthritis (odds ratio [OR] 1.44, 95% confidence interval [95% CI] 1.04–1.98). PD synovitis score was predictive of RRP at 1 year (OR 1.22, 95% CI 1.04–1.42). US erosions and PD synovitis scores were associated with change of SHS on linear regression. Of the 1,184 analyzed joints, 105 (8.9%) had radiographic erosion at 1 year. At the joint level, baseline US erosions were predictive of the presence of radiographic erosions at 1 year (P < 0.001). The same trend was observed in the joints without radiographic erosions at baseline (P = 0.052). Conclusion US is useful to evaluate the potential severity of early arthritis: US erosions and PD-positive synovitis have prognostic value to predict future radiographic damage.

Musculoskeletal ultrasonography in healthy subjects and ultrasound criteria for early arthritis (the ESPOIR cohort).

Abstract: Objective. To confirm the occurrence of bone erosions and synovitis in healthy subjects detectable by ultrasound (US) and to establish US criteria for early arthritis. Methods. Our study involved 127 healthy subjects matched with a cohort of patients with early arthritis (the ESPOIR cohort). The second and fifth metacarpophalangeal (MCP) joints and the fifth metatarsophalangeal (MTP) joint of both hands and feet were assessed with US to detect bone erosion; and the second, third, fourth, and fifth MCP and the fifth MTP were evaluated for synovial thickening in B-mode US and synovial vascularity in power Doppler. Bone erosion and synovitis were defined according to the Outcome Measures in Rheumatology Clinical Trials consensus. Results. Bone erosion and grade 2–3 synovial thickening in B-mode were detected in 11% and 9% of healthy subjects. To consider the diagnosis of early arthritis, a cutoff at 1 case of synovial thickening in B-mode enabled discrimination between patients with early arthritis and healthy subjects, with a good sensitivity of 74.8% (95% CI 67.2%–82.3%) and a high specificity of 90.5% (95% CI 85.4%–95.6%). If higher specificity is required to confirm the diagnosis of early arthritis, cutoff at 2 cases of synovial thickening in B-mode or at 2 cases of bone erosion gave optimal results, with specificity of 98.4% (95% CI 96.2%–100%) and 100%, respectively, and lower sensitivity of 59.8% (95% CI 51.2%–68.3%) and 17% (95% CI 10.5%–23.5%) (area under the curve = 0.85 for synovitis and 0.63 for bone erosion). Neither the combination of power Doppler signal plus bone erosion, nor bone erosions plus synovial thickening on the same joint, were seen in healthy subjects. Conclusion. A single case of bone erosion or synovial thickening in B-mode is common in healthy subjects. However, more than 1 case of synovial thickening in B-mode or bone erosion is a strong argument for the diagnosis of early inflammatory arthritis.

Parkinson’s disease: clinical features and diagnosis

Abstract: Objective: Parkinson’s disease (PD) is a progressive neurological disorder characterised by a large number of motor and non-motor features that can impact on function to a variable degree. This review describes the clinical characteristics of PD with emphasis on those features that differentiate the disease from other parkinsonian disorders. Methods: A MedLine search was performed to identify studies that assess the clinical characteristics of PD. Search terms included “Parkinson’s disease”, “diagnosis” and “signs and symptoms”. Results: Because there is no definitive test for the diagnosis of PD, the disease must be diagnosed based on clinical criteria. Rest tremor, bradykinesia, rigidity and loss of postural reflexes are generally considered the cardinal signs of PD. The presence and specific presentation of these features are used to differentiate PD from related parkinsonian disorders. Other clinical features include secondary motor symptoms (eg, hypomimia, dysarthria, dysphagia, sialorrhoea, micrographia, shuffling gait, festination, freezing, dystonia, glabellar reflexes), non-motor symptoms (eg, autonomic dysfunction, cognitive/neurobehavioral abnormalities, sleep disorders and sensory abnormalities such as anosmia, paresthesias and pain). Absence of rest tremor, early occurrence of gait difficulty, postural instability, dementia, hallucinations, and the presence of dysautonomia, ophthalmoparesis, ataxia and other atypical features, coupled with poor or no response to levodopa, suggest diagnoses other than PD. Conclusions: A thorough understanding of the broad spectrum of clinical manifestations of PD is essential to the proper diagnosis of the disease. Genetic mutations or variants, neuroimaging abnormalities and other tests are potential biomarkers that may improve diagnosis and allow the identification of persons at risk.

Pain in Parkinson's disease: Prevalence and characteristics.

Abstract: Parkinson’s disease is a chronic, progressive, incurable neurodegenerative disease. As the disease progresses, motor disturbances and non-motor symptoms represent considerable illness burdens. Symptom relief is the goal for the treatment. Pain is frequently observed in patients with Parkinson’s disease, but its prevalence, characteristics and associations with Parkinson’s disease are poorly documented. These were investigated in 176 home-living PD patients. They underwent a neurological examination and a structured interview for registration of pain characteristics in addition to responding to standardised questionnaires. Pain was reported by 146 (83%) patients. Compared to the general population, the Parkinson’s disease patients experienced significantly more pain as measured by SF-36 Bodily Pain Scale. The average pain during the last 24 h measured by the Brief Pain Inventory was 2.85. Fifty-three percent of the patients reported one, 24% reported two and 5% reported three pain types. Musculoskeletal pain was reported by 70%, dystonic pain by 40%, radicular-neuropathic pain by 20% and central neuropathic pain by 10%. Thirty-four percent were on analgesic medication. Pain was not associated with age, disease duration or severity of the disease; female gender was the only significant predictor of pain. Pain is frequent and disabling, independent of demographic and clinical variables except for female gender, and is significantly more common in Parkinson’s patients compared to the general population. A minority of the Parkinson’s disease patients with pain received analgesic medication. The findings call for improved attention to assessment and treatment of pain in the follow-up of Parkinson’s disease patients.

Postural deformities in Parkinson's disease

Abstract: Postural deformities are frequent and disabling complications of Parkinson's disease (PD) and atypical parkinsonism. These deformities include camptocormia, antecollis, Pisa syndrome, and scoliosis. Recognition of specific postural syndromes might have differential diagnostic value in patients presenting with parkinsonism. The evidence to date suggests that postural deformities have a multifactorial pathophysiology. Contributing factors include muscular rigidity; axial dystonia; weakness caused by myopathy; body scheme defects due to centrally impaired proprioception; and structural changes in the spine. The relative contribution of these different factors varies between patients and across specific syndromes. Improved understanding of the mechanisms underlying postural deformities in PD might ultimately lead us to more effective management strategies for these disabling and drug-refractory complications.

Bone loss before the clinical onset of rheumatoid arthritis in subjects with anticitrullinated protein antibodies

Abstract: Objective Anticitrullinated protein antibodies (ACPA) are a major risk factor for bone loss in rheumatoid arthritis (RA). We have recently shown that ACPA directly induce bone loss by stimulating osteoclast differentiation. As ACPA precede the clinical onset of RA by years, we hypothesised that ACPA positive healthy individuals may already show skeletal changes. Methods We performed a comparative micro-CT analysis of the bone microstructure in the metacarpophalangeal joints of ACPA positive and ACPA negative healthy individuals without clinical signs of arthritis. Results ACPA positive (n=15) and negative (n=15) healthy individuals were not different in age (48.2±4.1 vs 51.4±3.8 years, p=0.57) or gender (eight women and two men in both groups). Bone mineral density was significantly reduced in ACPA positive individuals (mean±SEM 280±11 mg/cm 3 ) compared with controls (327±6). Bone loss was based on cortical bone changes, with significant (p=0.044) reduction in cortical thickness in the ACPA positive group (mean±SEM 0.22±0.03 mm) compared with controls (0.32±0.03 mm). Areas of cortical porosity were significantly (p=0.0005) more widespread in ACPA positive (mean±SEM 7.4±1.4%) than in ACPA negative individuals (1.0±0.3%). Discussion Structural bone damage starts before the clinical onset of arthritis in subjects with ACPA. These findings revise the concept that bone damage is an exclusive consequence of synovitis in patients with RA.