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Sepriano AR, Ramiro S, Araújo FC, Machado PM, Rodrigues AM, Gouveia N, Eusébio M, Canhão H, Branco J. Performance of referral strategies for spondyloarthritis: a population-based nationwide study. Rheumatology (Oxford) 2019; 58:1086-1094. [DOI: 10.1093/rheumatology/key436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/03/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Alexandre Rocha Sepriano
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sofia Ramiro
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Filipe C Araújo
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
- Rheumatology and Osteoporosis Unit, Hospital Ortopédico de Sant’Ana, Cascais, Portugal
| | - Pedro M Machado
- Centre for Rheumatology and MRC Centre for Neuromuscular Diseases, University College London, UK
- Rheumatology Department, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Ana M Rodrigues
- EpiDoC Unit, CEDOC, NOVA Medical School, Universidade Nova de Lisboa
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Nélia Gouveia
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Mónica Eusébio
- Sociedade Portuguesa de Reumatologia, Hospital Egas Moniz, Lisboa, Portugal
| | - Helena Canhão
- EpiDoC Unit, CEDOC, NOVA Medical School, Universidade Nova de Lisboa
- National School of Public Health, Hospital Egas Moniz, Lisboa, Portugal
- EpiReumaPt Investigation Team, Lisboa, Hospital Egas Moniz, Lisboa, Portugal
| | - Jaime Branco
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
- EpiReumaPt Investigation Team, Lisboa, Hospital Egas Moniz, Lisboa, Portugal
- Department of Rheumatology, CHLO, Hospital Egas Moniz, Lisboa, Portugal
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Association between inflammatory back pain features, acute and structural sacroiliitis on MRI, and the diagnosis of spondyloarthritis. Clin Rheumatol 2019; 38:1579-1585. [PMID: 30628016 DOI: 10.1007/s10067-019-04432-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 12/27/2018] [Accepted: 01/02/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To evaluate the association between inflammatory back pain (IBP) features, acute and structural MRI findings suggestive of sacroiliitis, and diagnosis of spondyloarthritis (SpA). METHODS Data from 224 patients who underwent MRI for suspected sacroiliitis (2005-2015) was retrospectively reviewed by an expert rheumatologist for the presence of IBP features and for clinical standard of reference diagnosis. A telephone questionnaire was performed in cases of missing data. Acute and structural MRI parameters were scored by an experienced radiologist for the presence of sacroiliitis using the Assessment of Spondyloarthritis International Society (ASAS) criteria, Berlin score, and observer's global impression (GI) scores. Association between IBP features and MRI scores, and odds ratio for SpA diagnosis, were calculated. RESULTS One hundred ninety-three subjects were included (119 F:74 M, mean age 39.7 ± 15.6, mean follow-up 49 ± 18 months). Fifty-two (26.9%) subjects were diagnosed with SpA. IBP scores were significantly higher in SpA patients (p < 0.001). IBP, ASAS, and GI MRI scores were significantly associated with the SpA diagnosis (p < 0.001 for all). The presence of night pain and morning stiffness was significantly associated with sacroiliac-joints' bone marrow edema (BME, p < 0.05). Sensitivity for diagnosis of SpA was high for IBP (96%) and low for the MRI parameters (26.9-57.4%), and specificity was low for IBP (32%) and high for the MRI parameters (88.3-94.3%). CONCLUSIONS The presence of IBP features is highly associated with diagnosis of SpA and correlates with MRI BME, all probably reflect inflammation. The combination of IBP and MRI should be the cornerstone in the clinician's final diagnosis of SpA.
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103
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Danve A, Deodhar A. Axial spondyloarthritis in the USA: diagnostic challenges and missed opportunities. Clin Rheumatol 2018; 38:625-634. [DOI: 10.1007/s10067-018-4397-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 12/15/2022]
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104
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Dillon CF, Weisman MH. US National Health and Nutrition Examination Survey Arthritis Initiatives, Methodologies and Data. Rheum Dis Clin North Am 2018; 44:215-265. [PMID: 29622293 DOI: 10.1016/j.rdc.2018.01.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The US National Health and Nutrition Examination Survey (NHANES) has collected population-based, nationally representative examination, laboratory, and radiographic data for arthritis and musculoskeletal diseases for more than 50 years. The resulting body of data and publications are substantial, yet much data remain unpublished. This review provides a basic understanding of the design and capabilities of the NHANES survey, reviewing the major accomplishments in the area of arthritis and musculoskeletal diseases. Currently available US National Health and Nutrition Examination Survey arthritis-related datasets are identified. Guidelines for using these data, and opportunities for data analysis and designing future studies are presented.
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Affiliation(s)
| | - Michael H Weisman
- Division of Rheumatology, Cedars Sinai Medical Center, 1545 Calmar Court, Los Angeles, CA 90024, USA
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105
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Poddubnyy D, Callhoff J, Spiller I, Listing J, Braun J, Sieper J, Rudwaleit M. Diagnostic accuracy of inflammatory back pain for axial spondyloarthritis in rheumatological care. RMD Open 2018; 4:e000825. [PMID: 30713715 PMCID: PMC6336095 DOI: 10.1136/rmdopen-2018-000825] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 10/28/2018] [Accepted: 10/29/2018] [Indexed: 11/17/2022] Open
Abstract
Objective Inflammatory back pain (IBP), the key symptom of axial spondyloarthritis (axSpA), including ankylosing spondylitis, has been proposed as a screening test for patients presenting with chronic back pain in primary care. The diagnostic accuracy of IBP in the rheumatology setting is unknown. Methods Six rheumatology centres, representing secondary and tertiary rheumatology care, included routinely referred patients with consecutive chronic back pain with suspicion of axSpA. IBP (diagnostic test) was assessed in each centre by an independent (blinded) rheumatologist; a second (unblinded) rheumatologist made the diagnosis (axSpA or no-axSpA), which served as reference standard. Results Of 461 routinely referred patients, 403 received a final diagnosis. IBP was present in 67.3%, and 44.6% (180/403) were diagnosed as axSpA. The sensitivity of IBP according to various definitions (global judgement, Calin, Berlin, Assessment of SpondyloArthritis international Society criteria for IBP) was 74.4%–81.1 % and comparable to published figures, whereas the specificity was unexpectedly low (25.1%–43.9%). The resulting positive likelihood ratios (LR+) were 1.1–1.4 and without major differences between sets of IBP criteria. The presence of IBP according to various definitions increased the probability of axSpA by 2.5%–8.4% only (from 44.6% to 47.1%–53.0%). Conclusions The diagnostic utility of IBP in the rheumatology setting was smaller than expected. However, this was counterbalanced by a high prevalence of IBP among referred patients, demonstrating the effective usage of IBP in primary care as selection parameter for referral to rheumatology. Notably, this study illustrates potential shifts in specificity and LR+ of diagnostic tests if these tests are used to select patients for referral.
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Affiliation(s)
- Denis Poddubnyy
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Johanna Callhoff
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Inge Spiller
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Listing
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Juergen Braun
- Department of Rheumatology, Rheumazentrum Ruhrgebiet, Herne, Germany
| | - Joachim Sieper
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Rudwaleit
- Department of Medicine and Rheumatology, Klinikum Bielefeld Rosenhöhe, Bielefeld, Germany, Charité Universitätsmedizin Berlin, Berlin, Germany, and Gent University, Gent, Belgium
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Lockwood MM, Gensler LS. Nonradiographic axial spondyloarthritis. Best Pract Res Clin Rheumatol 2018; 31:816-829. [PMID: 30509442 DOI: 10.1016/j.berh.2018.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 08/09/2018] [Indexed: 02/08/2023]
Abstract
Non-radiographic axial spondyloarthritis (nr-axSpA) is a complex disease process that is part of the spectrum of axial spondyloarthritis (axSpA). This article reviews the current state of the literature as the understanding of this disease spectrum expands. The conceptual history and terminology, genetics, and epidemiology are reviewed. The clinical manifestations, diagnostic approach, and measures of disease activity are examined. Finally the current treatment modalities and recommendations and the research agenda for nr-axSpA are reviewed. With the advent of new criteria, the disease spectrum can be studied in a systematic manner. These data have enriched our knowledge that reflects an earlier or milder form of disease on a spectrum same as that of ankylosing spondylitis (or radiographic axSpA). We learned how patients present in this stage and that despite an unacceptable delay in diagnosis (regardless of the stage), the burden of disease is high and unremitting. nr-axSpA clinical trials have been somewhat heterogeneous (with variable inclusion criteria) but have nevertheless shown considerable efficacy with tumor necrosis factor inhibitors and flare on withdrawal of therapy.
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Affiliation(s)
- Megan M Lockwood
- University of California, San Francisco, 533 Parnassus Avenue, Suite U127A, San Francisco, CA, 94143, USA.
| | - Lianne S Gensler
- University of California, San Francisco, 400 Parnassus Avenue, Box A094, San Francisco, CA, 94143, USA.
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107
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Alunno A, Carubbi F, Stones S, Gerli R, Giacomelli R, Baraliakos X. The Impact of Fibromyalgia in Spondyloarthritis: From Classification Criteria to Outcome Measures. Front Med (Lausanne) 2018; 5:290. [PMID: 30406105 PMCID: PMC6207601 DOI: 10.3389/fmed.2018.00290] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 09/24/2018] [Indexed: 01/13/2023] Open
Abstract
The term spondyloarthritis (SpA) encompasses a broad clinical spectrum characterized by chronic inflammatory conditions affecting the sacroiliac joints, the spine but also peripheral joints and tendons and being additionally associated with the involvement of organs, such as bowel, eye and skin (1). Musculoskeletal pain is a key symptom in SpA. However, although low back pain and/or joint pain are characteristic for SpA, undifferentiated pain at different enthesial sites may also be a concomitant or even the first clinical presentation in some patients (2). In addition, fatigue is another important symptom often reported by patients with SpA, which substantially affects the quality of life (QoL) (3). Fibromyalgia (FM) is the most common diagnosis in patients complaining of chronic diffuse pain with fatigue and may occur alone or in association with chronic inflammatory diseases (4). The prevalence of FM ranges from 2 to 8% in the general population and it can reach up to over 50% in patients with other rheumatic and musculoskeletal diseases (RMDs) (5-7). FM has been identified as the most disabling RMD, based on the patients' perception that their medical condition is not properly recognized (8). This is also due to the poor knowledge about its pathogenesis, and therefore the lack of reliable biomarkers reveals a major unmet need requiring to be addressed in further research studies. Over the last decade, an increasing body of evidence described the impact of FM in SpA highlighting the pitfalls for correct classification, appropriate differential diagnosis and assessment of outcome measures in both conditions. The purpose of this review is to provide an overview of currently available data with regard to the coexistence and reciprocal features of FM and SpA.
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Affiliation(s)
- Alessia Alunno
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - Francesco Carubbi
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- ASL1 Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | - Simon Stones
- School of Healthcare, University of Leeds, Leeds, United Kingdom
- Fibromyalgia Action UK, Paisley, United Kingdom
| | - Roberto Gerli
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - Roberto Giacomelli
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Xenofon Baraliakos
- Rheumazentrum Ruhrgebiet Herne, Ruhr University of Bochum, Bochum, Germany
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108
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Yap KS, Ye JY, Li S, Gladman DD, Chandran V. Back pain in psoriatic arthritis: defining prevalence, characteristics and performance of inflammatory back pain criteria in psoriatic arthritis. Ann Rheum Dis 2018; 77:1573-1577. [PMID: 30077991 DOI: 10.1136/annrheumdis-2018-213334] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE We aimed to determine the agreement between rheumatologist-judged inflammatory back pain (IBP) and criteria defining IBP in patients with psoriatic arthritis (PsA) and predictive value of IBP in identifying axial involvement in PsA. METHODS Using prospectively collected data, we investigated the agreement between rheumatologist judgement of IBP and IBP criteria (Calin, Rudwaleit and Assessment of Spondyloarthritis International Society) using the kappa coefficient. We also determined the sensitivity, specificity and likelihood ratios of the presence of back pain, rheumatologist-judged IBP and the three IBP criteria for detecting axial PsA (AxPsA). Finally, we compared the clinical and genetic markers in patients with PsA with axial radiological changes with and without back pain. RESULTS 171 patients (52% male, mean age 46.6 years) were identified. Ninety-six (56.13%) patients reported chronic back pain. Sixty-five (38.01%) had IBP. 54 (32%) patients had evidence of radiological change in the spine. The agreement between rheumatologist judgement of IBP and IBP criteria was highest for the Calin criteria (0.70). Positive likelihood ratio for the presence of radiological axial involvement was highest for Rudwaleit criteria (2.17). No differences between patients with AxPsA with or without back pain were found, except for higher Bath Ankylosing Spondylitis Disease Activity Index and lower prevalence of human leucocyte antigen-B*38 in those with back pain. CONCLUSION Rheumatologist-judged IBP or the criteria for IBP developed for ankylosing spondylitis may not perform well when ascertaining axial involvement in PsA.
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Affiliation(s)
- Kristy S Yap
- University of Toronto Psoriatic Arthritis Clinic, Centre for Prognostic Studies in the Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada.,Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Justine Y Ye
- University of Toronto Psoriatic Arthritis Clinic, Centre for Prognostic Studies in the Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Suzanne Li
- University of Toronto Psoriatic Arthritis Clinic, Centre for Prognostic Studies in the Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Dafna D Gladman
- University of Toronto Psoriatic Arthritis Clinic, Centre for Prognostic Studies in the Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada.,Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Vinod Chandran
- University of Toronto Psoriatic Arthritis Clinic, Centre for Prognostic Studies in the Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada.,Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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109
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Swinnen TW, Westhovens R, Dankaerts W, de Vlam K. Widespread pain in axial spondyloarthritis: clinical importance and gender differences. Arthritis Res Ther 2018; 20:156. [PMID: 30053895 PMCID: PMC6062924 DOI: 10.1186/s13075-018-1626-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/14/2018] [Indexed: 11/10/2022] Open
Abstract
Background There is a remarkable lack of detailed knowledge on pain areas in axial spondyloarthritis (axSpA), and their clinical relevance is largely unknown. Pain area may reflect local disease processes, but amplification of nervous system signalling may alter this relationship. Also, gender differences in pain area may exist in axSpA, possibly confounding disease activity outcomes. Therefore, we firstly detailed pain locations in axSpA and evaluated gender differences. Secondly, we explored the relationship of regional pain definitions with clinical outcomes. Finally, we explored the role of pain area in the assessment of disease activity. Methods Body charts informed on the presence of axial, peripheral articular and non-articular pain in 170 patients (108 men, 62 women) with axSpA. Multivariate Odds Ratios (ORs) were used to compare genders. General linear models were used to explore clinical differences in disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]), activity limitations (Bath Ankylosing Spondylitis Functional Index [BASFI]), fear of movement (Tampa Scale for Kinesiophobia 11-item version [TSK-11]), anxiety (Hospital Anxiety and Depression Scale subscale anxiety [HADS-A]) and depression (HADS subscale depression [HADS-D]) between four subgroups classified by widespread non-articular pain (WNAP+/−) and physician global assessment of disease activity (PGDA+/−) (p < .05). Principal Component Analysis (PCA) was performed to explore gender differences in the structure of disease activity. Results Axial thoracic pain was least prevalent (lumbar, 74.4%; cervical, 47.6%; cervicothoracic, 47.6%; thoracic, 32.4%), but it was about three times more likely in women (OR, 2.92; p = .009). Axial cervicothoracic junction pain spread more diffusely in women (OR, 2.48; p = .018). Women exhibited a two- to threefold increased likelihood of widespread axial (OR, 3.33; p = .007) and peripheral articular (OR, 2.34; p = .023) pain. A subgroup of WNAP+/PGDA− combined with low PGDA (27% of all patients) was associated with worse BASFI, BASDAI, HADS-A and HADS-D in men and worse TSK-11 and HADS-A in women (p < .05). Disease activity outcomes showed a two-factor structure in women but not in men. Conclusions In patients with axSpA, the location and spread of pain was different between genders and was related to worse clinical status. On the basis of pain area and PGDA, clinical subgroups exhibiting a remarkably distinct health status were identified. Outcome instruments such as BASDAI should acknowledge gender differences to ensure structural validity. Electronic supplementary material The online version of this article (10.1186/s13075-018-1626-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thijs Willem Swinnen
- Division of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Herestraat 49 box 7003/13, 3000, Leuven, Belgium. .,Musculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, KU Leuven, Tervuursevest 101 box 1501, 3001, Leuven, Belgium.
| | - René Westhovens
- Division of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Herestraat 49 box 7003/13, 3000, Leuven, Belgium
| | - Wim Dankaerts
- Musculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, KU Leuven, Tervuursevest 101 box 1501, 3001, Leuven, Belgium
| | - Kurt de Vlam
- Division of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Herestraat 49 box 7003/13, 3000, Leuven, Belgium
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110
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Ji Y, He Y, Nian X, Sun E, Li L. Inflammatory or Neuropathic Pain: Characteristics and Their Relationships with Disease Activity and Functional Status in Axial Spondyloarthritis Patients. PAIN MEDICINE 2018; 20:882-888. [PMID: 30020521 DOI: 10.1093/pm/pny138] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Yaru Ji
- Department of Nursing, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yi He
- Department of Rheumatology and Immunology, The Third Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Xinying Nian
- Department of Nursing, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Erwei Sun
- Department of Rheumatology and Immunology, The Third Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Li Li
- Department of Nursing, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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111
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An epidemiological study of the prevalence rate of inflammatory back pain and axial spondyloarthritis in a university in the south of China. Clin Rheumatol 2018; 37:3087-3091. [PMID: 29974281 DOI: 10.1007/s10067-018-4175-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 05/10/2018] [Accepted: 06/05/2018] [Indexed: 12/19/2022]
Abstract
Inflammatory back pain (IBP) is an important clinical feature for axial spondyloarthritis (SpA). Yet, little is known about their prevalences in China. We conducted an epidemiological study in a university to detect the prevalences of IBP and axial SpA according to the Assessment of SpondyloArthritis International Society (ASAS) criteria. We investigated 3770 participants from South China Agricultural University by face-to-face questionnaires and evaluated the prevalences of chronic low back pain (CLBP) and IBP. In addition, 333 students including all IBP patients volunteered to do HLA-B27 test, and we performed X-ray examination on students with suspect axial SpA. Axial SpA was confirmed by rheumatologists according to ASAS criteria. The mean (± SD) age of screened population was 19.48 (± 2.80) years, while female to male ratio was 1.45:1 (2229/1541). Seven hundred thirty-one (19.39%) of all participants had CLBP and 111 (2.94%) had IBP. Among the 333 students receiving HLA-B27 test, 13 (0.34%, 13/3770) fulfilled ASAS criteria for axial SpA. Nine students had sacroiliitis on imaging plus at least one SpA feature (IBP and positive HLA-B27 results). Four students had positive HLA-B27 plus at least two other SpA features (arthritis/enthesitis and good response to NSAIDs). For CLBP, female/male was 485/246. For axial SpA, female/male was 4/9(P = 0.014). In southern China, the prevalences of CLBP and IBP were respectively 19.39 and 2.94% in university, and the prevalence of axial SpA was 0.34%. Although more female students had CLBP, males were more likely to suffer from axial SpA.
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112
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Dubreuil M, Sieper J. Editorial: Inflammatory Back Pain and Axial Spondyloarthritis: Lessons for Clinical Practice and Epidemiologic Research. Arthritis Rheumatol 2018; 70:981-983. [PMID: 29471586 PMCID: PMC6019605 DOI: 10.1002/art.40462] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 02/15/2018] [Indexed: 02/04/2023]
Affiliation(s)
- Maureen Dubreuil
- Boston University School of Medicine and VA Boston Healthcare System, Boston, Massachusetts
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113
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Wang R, Crowson CS, Wright K, Ward MM. Clinical Evolution in Patients With New-Onset Inflammatory Back Pain: A Population-Based Cohort Study. Arthritis Rheumatol 2018; 70:1049-1055. [PMID: 29471593 PMCID: PMC6019558 DOI: 10.1002/art.40460] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 02/15/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Inflammatory back pain (IBP) is often an early manifestation of spondyloarthritis (SpA), but the prognosis of patients with incident IBP is unknown. This study was undertaken to investigate long-term outcomes in patients with IBP, and predictors of progression to SpA, in a population-based cohort. METHODS We conducted a retrospective, longitudinal study using the Rochester Epidemiology Project, a longstanding population-based cohort of residents of Olmsted County, MN. Patients ages 16-35 years with clinical visits for back pain from 1999 to 2003 were identified, and we screened these patients for the presence of new-onset IBP and performed medical record reviews to collect data on clinical, laboratory, and imaging features of SpA. Outcomes in these patients were followed up until July 2016. We used survival analysis for competing risks to examine progression to either SpA, a non-SpA diagnosis, or resolution of back pain. Recursive partitioning was used to identify predictors of progression to SpA. RESULTS Among 5,304 patients with back pain, we identified 124 patients with new-onset IBP. After a median follow-up of 13.2 years, IBP had progressed to SpA in 39 patients, 15 patients developed a non-SpA diagnosis, and 58 patients had resolution of IBP. At 10 years, the probability of having SpA was 30%, while the probability of resolution of IBP was 43%. The most important predictors for progression to SpA were uveitis, male sex, and family history of SpA. CONCLUSION In a minority of patients, new-onset IBP progresses to SpA, while IBP resolves in many. That IBP often resolves may explain the difference between the prevalence of IBP (3-6%) and the prevalence of SpA (0.4-1.3%).
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Affiliation(s)
- Runsheng Wang
- Columbia University College of Physicians and Surgeons, New York, New York, and National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
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de Bruin F, Treyvaud MO, Feydy A, de Hooge M, Pialat JB, Dougados M, Gossec L, Bloem JL, van der Heijde D, Reijnierse M. Prevalence of degenerative changes and overlap with spondyloarthritis-associated lesions in the spine of patients from the DESIR cohort. RMD Open 2018; 4:e000657. [PMID: 29955382 PMCID: PMC6018874 DOI: 10.1136/rmdopen-2018-000657] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/11/2018] [Accepted: 05/01/2018] [Indexed: 12/14/2022] Open
Abstract
Objectives To describe the prevalence of degenerative changes on MRI and conventional radiographs of the spine in a young population with suspicion of axial spondyloarthritis (axSpA) and assess whether it is possible to discriminate between degenerative changes and lesions associated with axSpA. Methods Whole spine MRI and cervical and lumbar radiographs of patients ≥18 years with chronic back pain (≥3 months, ≤3 years, onset <50 years) were assessed for degeneration by two readers, and for SpA lesions by two other readers, all blinded for clinical information and results of the other readers. Degenerative scores were adjudicated in case of disagreement (by a third reader). Patients fulfilling and not fulfilling the Assessment of SpondyloArthritis international Society axSpA criteria were compared for prevalence of degenerative lesions. Scores for degenerative and SpA lesions were compared, and overlap was defined as the presence of both types of lesions in a single vertebral unit (VU). Results In 456/648 (70.4%) patients (46.8% men, mean age 33.6), degenerative lesions were found with similar percentages in patients with no axSpA and with axSpA (72.4% and 69.2%, p=0.45). Modic changes were found more often in patients with no axSpA (29/239, 12.1%) versus patients with axSpA (19/409, 4.6%, p=0.01). Other lesions were evenly distributed. Overlap was minimal in 19 patients (3.0%) and 32/14 674 (0.2%) VUs for SpA reader 1 and in 23 patients (3.6%) and 34/14 674 VUs (0.2%) for SpA reader 2. Conclusion The prevalence of degeneration is high in an early inflammatory back pain cohort. Discrimination between degeneration and axSpA lesions is very well possible with little overlap between degenerative and axSpA readings.
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Affiliation(s)
- Freek de Bruin
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marco O Treyvaud
- Service de radiologie, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Antoine Feydy
- Service de radiologie, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Manouk de Hooge
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jean-Baptiste Pialat
- Department of Radiology, Edouard Herriot Hospital, Hospices Civils de Lyon, Université Lyon, Lyon, France
| | - Maxime Dougados
- Service de Rhumatologie B, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Descartes, Paris, France
| | - Laure Gossec
- Department of Rheumatology, Sorbonne Universités, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Pitié Salpêtrière Hospital, Paris, France
| | - Johan L Bloem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Monique Reijnierse
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Eren R, Can M, Alibaz-Öner F, Yilmaz-Oner S, Yilmazer B, Cefle A, Direskeneli H, Atagündüz P. Prevalence of inflammatory back pain and radiologic sacroiliitis is increased in patients with primary Sjögren's syndrome. Pan Afr Med J 2018; 30:98. [PMID: 30344882 PMCID: PMC6191247 DOI: 10.11604/pamj.2018.30.98.15588] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/23/2018] [Indexed: 01/21/2023] Open
Abstract
Introduction The prevalence of Sjögren's syndrome (SS) in patients with the diagnosis of SpA has been reported to be higher than normal population. Yet, the vice-versa is unclear. In this study, we aimed to investigate the prevalence of IBP, radiologic sacroiliitis and SpA in patients with primary SS. Methods 85 patients followed at the rheumatology clinics of the Marmara and Kocaeli Universities with the diagnosis of primary SS between November 2011 and August 2012 were included in this study. The control group consisted of 100 age-and gender-matched patients. Inflammatory back pain and axial SpA were diagnosed according to the assessment of spondylo arthritis International Society (ASAS) criteria. Results 83 patients were (97%) female and 2 (3%) were male. Mean age of the patients was 49.1 (±11) years. Mean disease duration was 7.3 (±4) years. The patient and control groups were comparable in terms of age and gender (p > 0.05). Inflammatory back pain was observed in 21 (24.7%) of 85 primary SS patients and in 4 (4%) of 100 control subjects (p < 0.001), radiographic sacroiliitis was demonstrated in 9 (10.5%) of primary SS patients and 2 (2%) of the control subjects (p = 0.025). Remaining SpA findings were not encountered in either group. Conclusion inflammatory back pain and radiologic sacroiliitis is increased in patients with primary SS. Whether IBP, SI joint inflammation and radiologic sacroiliitis is due to the co-existence of SpA and primary SS or IBP is an underdiagnosed clinical feature of SS deserves further studies of large patient numbers.
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Affiliation(s)
- Rafet Eren
- Department of Hematology, University of Health Sciences, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Meryem Can
- Department of Rheumatology, Medipol University, Faculty of Medicine, Istanbul, Turkey
| | - Fatma Alibaz-Öner
- Department of Rheumatology, Marmara University, Faculty of Medicine, Istanbul, Turkey
| | - Sibel Yilmaz-Oner
- Department of Rheumatology, Bakirköy Sadi Konuk Training and Research Hospital, Istanbul,Turkey
| | - Baris Yilmazer
- Department of Rheumatology, Kocaeli University, Faculty of Medicine, Kocaeli, Turkey
| | - Ayse Cefle
- Department of Rheumatology, Kocaeli University, Faculty of Medicine, Kocaeli, Turkey
| | - Haner Direskeneli
- Department of Rheumatology, Marmara University, Faculty of Medicine, Istanbul, Turkey
| | - Pamir Atagündüz
- Department of Rheumatology, Marmara University, Faculty of Medicine, Istanbul, Turkey
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Ford JJ, Richards MC, Surkitt LD, Chan AYP, Slater SL, Taylor NF, Hahne AJ. Development of a Multivariate Prognostic Model for Pain and Activity Limitation in People With Low Back Disorders Receiving Physiotherapy. Arch Phys Med Rehabil 2018; 99:2504-2512.e12. [PMID: 29852152 DOI: 10.1016/j.apmr.2018.04.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 03/19/2018] [Accepted: 04/21/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To identify predictors for back pain, leg pain, and activity limitation in patients with early persistent low back disorders (LBDs). DESIGN Prospective inception cohort study. SETTING Primary care private physiotherapy clinics in Melbourne, Australia. PARTICIPANTS Individuals (N=300) aged 18-65 years with low back and/or referred leg pain of ≥6 weeks and ≤6 months duration. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Numeric rating scales for back pain and leg pain as well as the Oswestry Disability Scale. RESULTS Prognostic factors included sociodemographics, treatment related factors, subjective/physical examination, subgrouping factors, and standardized questionnaires. Univariate analysis followed by generalized estimating equations were used to develop a multivariate prognostic model for back pain, leg pain, and activity limitation. Fifty-eight prognostic factors progressed to the multivariate stage where 15 showed significant (P<.05) associations with at least 1 of the 3 outcomes. There were 5 indicators of positive outcome (2 types of LBD subgroups, paresthesia below waist, walking as an easing factor, and low transversus abdominis tone) and 10 indicators of negative outcome (both parents born overseas, deep leg symptoms, longer sick leave duration, high multifidus tone, clinically determined inflammation, higher back and leg pain severity, lower lifting capacity, lower work capacity, and higher pain drawing percentage coverage). The preliminary model identifying predictors of LBDs explained up to 37% of the variance in outcome. CONCLUSIONS This study evaluated a comprehensive range of prognostic factors reflective of both the biomedical and psychosocial domains of LBDs. The preliminary multivariate model requires further validation before being considered for clinical use.
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Affiliation(s)
- Jon J Ford
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia.
| | - Matt C Richards
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
| | - Luke D Surkitt
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
| | - Alexander Y P Chan
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
| | - Sarah L Slater
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
| | - Nicholas F Taylor
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
| | - Andrew J Hahne
- Low Back Research Team, College of Science, Health & Engineering, La Trobe University, Bundoora, Victoria, Australia
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Increase In Il-31 Serum Levels Is Associated With Reduced Structural Damage In Early Axial Spondyloarthritis. Sci Rep 2018; 8:7731. [PMID: 29769586 PMCID: PMC5956108 DOI: 10.1038/s41598-018-25722-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 03/29/2018] [Indexed: 11/22/2022] Open
Abstract
In spondyloarthritis, little is known about the relation between circulating cytokines and patient phenotype. We have quantified serum levels of T helper type 1 cell (Th1), Th2 and Th17 cytokines in patients with recent-onset axial spondyloarthritis (AxSpA) from the DESIR cohort, a prospective, multicenter French cohort consisting of 708 patients with recent-onset inflammatory back pain (duration >3 months but <3 years) suggestive of AxSpA. Serum levels of Th1, Th2, and Th17 cytokines were assessed at baseline in patients from the DESIR cohort fulfilling the ASAS criteria (ASAS+) and were compared with age- and sex-matched healthy controls. At baseline, ASAS+ patients (n = 443) and healthy controls (n = 79) did not differ in levels of most of the Th1, Th2 and Th17 cytokines except for IL-31, and sCD40L, which were significantly higher for ASAS+ patients than controls (p < 0.001 and p = 0.012, respectively). On multivariable analysis of ASAS+ patients, IL-31 level was associated with sCD40L level (p < 0.0001), modified Stoke AS Spine Score (mSASSS) < 1 (p = 0.035). The multivariable analyses showed that IL-31 was an independent factor associated with mSASSS < 1 (p = 0.001) and low bone mineral density (p = 0.01). Increased level of IL-31 might protect against structural damage but is also related to low BMD.
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Ritchlin C. Editorial: Magnetic Resonance Imaging Signals in the Sacroiliac Joints of Healthy Athletes: Refining Disease Thresholds and Treatment Strategies in Axial Spondyloarthritis. Arthritis Rheumatol 2018; 70:629-632. [DOI: 10.1002/art.40426] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 01/23/2018] [Indexed: 12/17/2022]
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Rademacher J, Poddubnyy D. Emerging drugs for the treatment of axial spondyloarthritis. Expert Opin Emerg Drugs 2018; 23:83-96. [DOI: 10.1080/14728214.2018.1445719] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Judith Rademacher
- Department of Gastroenterology, Infectiology and Rheumatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectiology and Rheumatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Rheumatism Research Centre, Berlin, Germany
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Arnbak B, Jurik AG, Jensen TS, Manniche C. Association Between Inflammatory Back Pain Characteristics and Magnetic Resonance Imaging Findings in the Spine and Sacroiliac Joints. Arthritis Care Res (Hoboken) 2018; 70:244-251. [DOI: 10.1002/acr.23259] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 04/11/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Bodil Arnbak
- Spine Centre of Southern Denmark and Hospital Lillebaelt, Middelfart and University of Southern Denmark Odense Denmark
| | - Anne G. Jurik
- Spine Centre of Southern Denmark and Hospital Lillebaelt, Middelfart and University of Southern Denmark Odense Denmark
- Aarhus University Hospital Aarhus Denmark
| | - Tue S. Jensen
- Spine Centre of Southern Denmark and Hospital Lillebaelt, Middelfart and University of Southern Denmark Odense Denmark
- Nordic Institute of Chiropractic and Clinical Biomechanics Odense Denmark
| | - Claus Manniche
- Spine Centre of Southern Denmark and Hospital Lillebaelt, Middelfart and University of Southern Denmark Odense Denmark
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Gazeau P, Cornec D, Timsit MA, Dougados M, Saraux A. Classification criteria versus physician's opinion for considering a patient with inflammatory back pain as suffering from spondyloarthritis. Joint Bone Spine 2018; 85:85-91. [DOI: 10.1016/j.jbspin.2017.01.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 01/19/2017] [Indexed: 12/25/2022]
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Swinnen TW, Vlaeyen JW, Dankaerts W, Westhovens R, de Vlam K. Activity Limitations in Patients with Axial Spondyloarthritis: A Role for Fear of Movement and (Re)injury Beliefs. J Rheumatol 2017; 45:357-366. [DOI: 10.3899/jrheum.170318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
Abstract
Objective.To determine whether fear of movement and (re)injury [FOM/(R)I] beliefs, measured with the Tampa Scale for Kinesiophobia 11-item version (TSK-11), influence activity limitations and mediate the relationship between pain severity and activity limitations in axial spondyloarthritis (axSpA).Methods.In 173 patients with axSpA, these data were collected: sex, body mass index, disease duration, medication, activity limitations (BASFI; Bath Ankylosing Spondylitis Functional Index), disease activity [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI); BASDAIinf, items 5 and 6; BASDAIpain, items 2 and 3; C-reactive protein and physician’s global assessment], spinal mobility (BASMI; Bath Ankylosing Spondylitis Metrology Index), and FOM/(R)I (TSK-11). Scaling assumptions and reliability of TSK-11 were tested with item-to-total correlations, item variances, and Cronbach’s alpha coefficient. Hypothesis testing determined TSK-11’s construct validity. Multiple linear regression showed the contribution of TSK-11 to BASFI (enter and backward modeling). Mediation by TSK-11 was analyzed (bias-corrected bootstrapping and Sobel test).Results.Adequate scale (Cronbach’s alpha = 0.80) and item internal consistency (range item-scale correlations 0.41–0.58, except for item 5, r = 0.23), equal item-scale correlations, and item variances were found for TSK-11. Construct validity was confirmed, except for the hypothesized positive relationship between TSK-11 and BASMI. Regression models (enter method, adjusted R2 range 53–74%) consistently identified TSK-11 as a determinant of BASFI (β range 0.155 to 0.321, p < 0.05), although BASMI (β range 0.441 to 0.537) and disease activity (β range 0.243 to 0.571, p < 0.05) were the largest determinants. TSK-11 partially mediated the BASDAIpain/BASFI relationship (B = 0.107; Sobel test, p = 0.004; bias-corrected CI 0.046–0.197).Conclusion.TSK-11 is a promising and valid tool to assess fearful beliefs in relation to activity limitations in axSpA. Future research applying TSK-11 may reveal FOM/(R)I as a novel treatment target in axSpA.
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Who Benefits Most From Individualized Physiotherapy or Advice for Low Back Disorders? A Preplanned Effect Modifier Analysis of a Randomized Controlled Trial. Spine (Phila Pa 1976) 2017; 42:E1215-E1224. [PMID: 28263227 DOI: 10.1097/brs.0000000000002148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A preplanned effect modifier analysis of the Specific Treatment of Problems of the Spine randomized controlled trial. OBJECTIVE To identify characteristics associated with larger or smaller treatment effects in people with low back disorders undergoing either individualized physical therapy or guideline-based advice. SUMMARY OF BACKGROUND DATA Identifying subgroups of people who attain a larger or smaller benefit from particular treatments has been identified as a high research priority for low back disorders. METHODS The trial involved 300 participants with low back pain and/or referred leg pain (≥6 wk, ≤6 mo duration), who satisfied criteria to be classified into five subgroups (with 228 participants classified into three subgroups relating to disc-related disorders, and 64 classified into the zygapophyseal joint dysfunction subgroup). Participants were randomly allocated to receive either two sessions of guideline based advice (n = 144), or 10 sessions of individualized physical therapy targeting pathoanatomical, psychosocial, and neurophysiological factors (n = 156). Univariate and multivariate linear mixed models determined the interaction between treatment group and potential effect modifiers (defined a priori) for the primary outcomes of back pain, leg pain (0-10 Numeric Rating Scale) and activity limitation (Oswestry Disability Index) over a 52-week follow-up. RESULTS Participants with higher levels of back pain, higher Örebro scores (indicative of higher risk of persistent pain) or longer duration of symptoms derived the largest benefits from individualized physical therapy relative to advice. Poorer coping also predicted larger benefits from individualized physical therapy in the univariate analysis. CONCLUSION These findings suggest that people with low back disorders could be preferentially targeted for individualized physical therapy rather than advice if they have higher back pain levels, longer duration of symptoms, or higher Örebro scores. LEVEL OF EVIDENCE 2.
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Harvard S, Guh D, Bansback N, Richette P, Saraux A, Fautrel B, Anis AH. Adherence to Antitumor Necrosis Factor Use Recommendations in Spondyloarthritis: Measurement and Effect in the DESIR Cohort. J Rheumatol 2017; 44:1436-1444. [PMID: 28668809 DOI: 10.3899/jrheum.161399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate a classification system to define adherence to axial spondyloarthritis (axSpA) anti-tumor necrosis factor (anti-TNF) use recommendations and examine the effect of adherence on outcomes in the DESIR cohort (Devenir des Spondylarthropathies Indifférenciées Récentes). METHODS Using alternate definitions of adherence, patients were classified as adherent "timely" anti-TNF users, nonadherent "late" anti-TNF users, adherent nonusers ("no anti-TNF need"), non-adherent nonusers ("unmet anti-TNF need"). Multivariate models were fitted to examine the effect of adherence on quality-adjusted life-years (QALY), total costs, and nonbiologic costs 1 year following an index date. Generalized linear regression models assuming a γ-distribution with log link were used for costs outcomes and linear regression models for QALY outcomes. RESULTS Using the main definition of adherence, there were no significant differences between late anti-TNF users and timely anti-TNF users in total costs (RR 0.86, 95% CI 0.54-1.36, p = 0.516) or nonbiologic costs (RR 0.72, 95% CI 0.44-1.18, p = 0.187). However, in the sensitivity analysis, late anti-TNF users had significantly increased nonbiologic costs compared with timely users (RR 1.58, 95% CI 1.06-2.36, p = 0.026). In the main analysis, there were no significant differences in QALY between timely anti-TNF users and late anti-TNF users, or between timely users and patients with unmet anti-TNF need. In the sensitivity analysis, patients with unmet anti-TNF need had significantly lower QALY than timely anti-TNF users (-0.04, 95% CI -0.07 to -0.01, p = 0.016). CONCLUSION The effect of adherence to anti-TNF recommendations on outcomes was sensitive to the definition of adherence used, highlighting the need to validate methods to measure adherence.
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Affiliation(s)
- Stephanie Harvard
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Daphne Guh
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Nick Bansback
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Pascal Richette
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Alain Saraux
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Bruno Fautrel
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Aslam H Anis
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France.
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences.
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Harvard S, Guh D, Bansback N, Richette P, Saraux A, Fautrel B, Anis A. Access criteria for anti-TNF agents in spondyloarthritis: influence on comparative 1-year cost-effectiveness estimates. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2017; 15:20. [PMID: 28904528 PMCID: PMC5590198 DOI: 10.1186/s12962-017-0081-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 08/23/2017] [Indexed: 12/17/2022] Open
Abstract
Background Anti-tumor necrosis factor (anti-TNF) agents are an effective, but costly, treatment for spondyloarthritis (SpA). Worldwide, multiple sets of access criteria aim to restrict anti-TNF therapy to patients with specific clinical characteristics, yet the influence of access criteria on anti-TNF cost-effectiveness is unknown. Our objective was to use data from the DESIR cohort, a prospective study of early SpA patients in France, to determine whether the French anti-TNF access criteria are the most cost-effective in that setting relative to other potential restrictions. Methods We used data from the DESIR cohort to create five study populations of patients meeting anti-TNF access criteria from Canada, France, Germany, United Kingdom, and Hong Kong, respectively. For each study population, we calculated the costs and quality-adjusted life years (QALYs) over 1 year of patients treated and not treated with anti-TNF therapy. To control for differences between anti-TNF users and non-users, we used linear regression models to derive adjusted mean costs and QALYs. We calculated incremental cost-effectiveness ratios (ICERs) representing the incremental cost per additional QALY gained by treating with an anti-TNF within each of the five study populations, using bootstrapping to explore the range of uncertainty in costs and QALYs. A series of sensitivity analyses was conducted, including one to simulate the effect of a 24-week stopping rule for anti-TNF non-responders. Results Anti-TNF access criteria from France were satisfied by the largest proportion of DESIR patients (27.8%), followed by Germany (25.1%), Canada (23.8%), the UK (12.1%) and Hong Kong (8.6%). Confidence intervals around incremental costs and QALYs in the basecase analysis were overlapping, indicating that anti-TNF cost-effectiveness estimates derived from each subset were similar. In the sensitivity analysis that examined the effect of excluding costs accumulated past 24 weeks by anti-TNF non-responders, the incremental cost per QALY was reduced by approximately 25% relative to the basecase analysis (France: €857,992 vs. €1,105,859; Canada: € 626,459 vs. €818,186; Germany: € 422,568 vs. €545,808); UK €578,899 vs. €766,217; Hong Kong €335,418 vs. €456,850). Conclusions Anti-TNF cost-effectiveness is strongly affected by treatment continuation among non-responders. Access criteria could improve anti-TNF cost-effectiveness by defining patients likely to respond. Electronic supplementary material The online version of this article (doi:10.1186/s12962-017-0081-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stephanie Harvard
- University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcome Sciences, 588-1081, Burrard Street, Vancouver, BC V6Z 1Y6 Canada.,Sorbonne Universités, UPMC-GRC08, Pierre Louis Institute for Epidemiology and Public Health, Paris, France
| | - Daphne Guh
- Centre for Health Evaluation and Outcome Sciences, 588-1081, Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Nick Bansback
- University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcome Sciences, 588-1081, Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Pascal Richette
- University Paris Diderot, Faculty of Medicine, Paris 07, Paris, France.,AP-HP, Rheumatology Department, Lariboisiere University Hospital, Paris, France
| | - Alain Saraux
- Rheumatology Unit, Hôpital de la Cavale Blanche, 29609 Brest, France.,EA2216, INSERM ESPRI ERI29 Université de Brest LabEx IGO, Brest, France
| | - Bruno Fautrel
- Sorbonne Universités, UPMC-GRC08, Pierre Louis Institute for Epidemiology and Public Health, Paris, France.,AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris, France
| | - Aslam Anis
- University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcome Sciences, 588-1081, Burrard Street, Vancouver, BC V6Z 1Y6 Canada
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128
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Fractures in Spinal Ankylosing Disorders: A Narrative Review of Disease and Injury Types, Treatment Techniques, and Outcomes. J Orthop Trauma 2017; 31 Suppl 4:S57-S74. [PMID: 28816877 DOI: 10.1097/bot.0000000000000953] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Spinal ankylosing disorders encompass ankylosing spondylitis (AS), disseminated hyperostosis of the spine, and end-stage spondylosis. All these result in a stiffened and frequently deformed spinal column. This makes the spinal column highly susceptible to severe injuries that are commonly associated with unfavorable outcomes. Improved understanding of the underlying disease processes and clinical comorbidities may alter the poor injury related morbidity and mortality outcomes. METHODS A systematic review of the MEDLINE and PubMed databases was performed using the following key words to identify articles published between 2001 and 2016: "ankylosing spondylitis," "epidemiology," "DISH," "treatment," "outcome," and/or "fracture." Articles were read for data on methodology (retrospective vs. prospective), type of treatment, number of patients, mean patient age, and mean follow-up. RESULTS Twenty-one identified articles were analyzed. Average age was 63.4 years. Most patients were men. Ground level fall or low energy trauma caused most injuries. Diagnosis was delayed in 15%-41% cases. Hyperextension fracture patterns were most common. Cervical spine fractures were more common than thoracolumbar fractures, with the highest prevalence between C5 and C7. Neurologic deficits were encountered in 21%-100% of patients. Operative fixation and fusion were performed in 40%-100% of patients. Mortality was reported between 0% and 32% at 1 year postinjury. Complications were encountered in 84% of patients, mostly in the form of pneumonia, respiratory failure, and pseudoarthrosis. Neurologic deterioration has been reported in 16% of patients. Fusion was successful in 87%-100% of patients. Neurologic deficits improved in function in 6%-66% at the final follow-up. CONCLUSIONS Because of the stiffening of the spinal column, patients with spinal ankylosing disorders are preferably evaluated for spinal fractures and ligamentous injuries after even trivial trauma. Spinal injuries in patients with AS are difficult to diagnose on plain radiographs; computed tomography and magnetic resonance imaging are recommended instead. The entire spine should be scanned for multilevel involvement. Although osteoporosis makes fixation of spine implants a significant concern, the literature has reported that most patients with AS treated surgically had good outcomes. Numerous studies have reported risks associated with conservative management.
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129
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Aydin SZ, Kilic L, Kucuksahin O, Ureyen SB, Kalyoncu U. Performances of inflammatory back pain criteria in axial psoriatic arthritis. Rheumatology (Oxford) 2017; 56:2031-2032. [DOI: 10.1093/rheumatology/kex307] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
The term spondyloarthritis (SpA) is now increasingly used to classify and diagnose patients who are characterized by inflammation in the axial skeleton and peripheral manifestations (arthritis and enthesitis). The management of SpA should be tailored according to the current manifestations of the disease, the disease activity and functional impairment. The current article focuses on diagnosis and therapy in patients with axial SpA. Diagnostic procedures are discussed in light of diagnostic utility and feasibility in daily routine care. Cornerstones of treatment in patients with axial SpA are a combination of regular exercise and pharmacological treatment options aiming at anti-inflammatory strategies.
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131
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Eder L, Polachek A, Rosen CF, Chandran V, Cook R, Gladman DD. The Development of Psoriatic Arthritis in Patients With Psoriasis Is Preceded by a Period of Nonspecific Musculoskeletal Symptoms: A Prospective Cohort Study. Arthritis Rheumatol 2017; 69:622-629. [PMID: 27792862 DOI: 10.1002/art.39973] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/27/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To assess whether the presence of nonspecific musculoskeletal symptoms, their degree, and change over time predict the development of psoriatic arthritis (PsA) in a prospective cohort of psoriasis patients without arthritis at baseline. METHODS This prospective cohort study involved patients with psoriasis who were assessed at baseline to exclude the presence of clinical PsA. The study participants were reassessed annually to determine if they had developed PsA. The presence of musculoskeletal symptoms and the patients' assessments of pain, fatigue, stiffness, physical function, and psychological distress were recorded at each visit. Cox proportional hazards models were used to assess what symptoms predicted the development of PsA. RESULTS A total of 57 of 410 psoriasis patients developed PsA. At baseline, the presence of arthralgia in women (hazard ratio [HR] 2.59, P = 0.02), heel pain (HR 4.18, P = 0.02), high fatigue score (HR 2.36, P = 0.007), and high stiffness score (HR 2.03, P = 0.045) predicted subsequent development of PsA. In addition, an increase from baseline in fatigue score (HR 1.27, P = 0.001), pain score (HR 1.34, P < 0.001), and stiffness score (HR 1.21, P = 0.03), and a worsening in physical function score (HR 0.96, P = 0.04) predicted the development of PsA. CONCLUSION A preclinical phase exists in patients with PsA prior to the diagnosis of the disease. This phase is characterized by nonspecific musculoskeletal symptoms, including joint pain, fatigue, and stiffness.
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Affiliation(s)
- Lihi Eder
- Women's College Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Ari Polachek
- University Health Network, Toronto, Ontario, Canada
| | - Cheryl F Rosen
- University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Vinod Chandran
- University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Richard Cook
- University of Waterloo, Waterloo, Ontario, Canada
| | - Dafna D Gladman
- University of Toronto and University Health Network, Toronto, Ontario, Canada
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132
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Dougados M, Demattei C, van den Berg R, Vo Hoang V, Thevenin F, Reijnierse M, Loeuille D, Feydy A, Claudepierre P, van der Heijde D. Rate and Predisposing Factors for Sacroiliac Joint Radiographic Progression After a Two-Year Follow-up Period in Recent-Onset Spondyloarthritis. Arthritis Rheumatol 2017; 68:1904-13. [PMID: 26990518 PMCID: PMC5129505 DOI: 10.1002/art.39666] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 02/25/2016] [Indexed: 01/15/2023]
Abstract
Objective To evaluate the rate of radiographic structural progression in the sacroiliac (SI) joints in patients with radiographic or nonradiographic axial spondyloarthritis (SpA), and to determine factors predisposing to such progression, over 2 years. Methods Patients with recent‐onset axial SpA (from the Devenir des Spondyloarthropathies Indifferérenciées Récentes cohort) were assigned a radiographic SI joint score according to the modified New York criteria. Demographic characteristics, smoking status, HLA–B27 positivity, inflammation on magnetic resonance imaging (MRI) of the SI joints, disease activity, and treatment were investigated as potential predisposing factors. The main analysis consisted of the evaluation of the switch from nonradiographic to radiographic axial SpA, but other definitions of radiographic progression were also evaluated. Results Of the 708 patients enrolled, 449 had baseline and 2‐year pelvic radiographs. Of these patients, 47% were men. Their mean ± SD age was 34 ± 9 years, 61% were B27 positive, and 37% had inflammation of the SI joints on MRI. The percentages of patients who switched from nonradiographic to radiographic axial SpA (4.9% [16 of 326]) and from radiographic to nonradiographic axial SpA (5.7% [7 of 123]) were low. The mean ± SD change in the total SI joint score (range 0–8) was small (0.1 ± 0.8) but highly significant (P < 0.001). The potential baseline predisposing factors for meeting the modified New York criteria in the multivariate analysis were current smoking, HLA–B27 positivity, and inflammation of the SI joints on MRI, with odds ratios of 3.3 (95% confidence interval [95% CI] 1.0–11.5], 12.6 (95% CI 2.3–274), and 48.8 (95% CI 9.3–904), respectively. Conclusion Our findings suggest that structural progression does exist in early SpA, but it is quite small and observed in a small number of patients, and that environmental (smoking status), genetic (HLA–B27 positivity), and inflammation (inflammation of the SI joints on MRI) markers might be independent predisposing factors for progression.
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Affiliation(s)
- Maxime Dougados
- Université Paris Descartes, Hôpital Cochin, AP-HP, and INSERM U1153, PRES Sorbonne Paris-Cité, Paris, France
| | | | | | | | | | | | - Damien Loeuille
- Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Antoine Feydy
- Université Paris Descartes and Hôpital Cochin, AP-HP, Paris, France
| | - Pascal Claudepierre
- Université Paris Est Créteil and Hôpital Henri Mondor, AP-HP, Créteil, France
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Dougados M, Sepriano A, Molto A, van Lunteren M, Ramiro S, de Hooge M, van den Berg R, Navarro Compan V, Demattei C, Landewé R, van der Heijde D. Sacroiliac radiographic progression in recent onset axial spondyloarthritis: the 5-year data of the DESIR cohort. Ann Rheum Dis 2017; 76:1823-1828. [PMID: 28684556 PMCID: PMC5705846 DOI: 10.1136/annrheumdis-2017-211596] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/05/2017] [Accepted: 06/05/2017] [Indexed: 01/08/2023]
Abstract
Objective To estimate sacroiliac joint radiographic (X-SIJ) progression in patients with axial spondyloarthritis (axSpA) and to evaluate the effects of inflammation on MRI (MRI-SIJ) on X-SIJ progression. Methods X-SIJ and MRI-SIJ at baseline and after 2 and 5 years in patients with recent onset axSpA from the DESIR cohort were scored by three central readers. Progression was defined as (1) the shift from non-radiographic (nr) to radiographic (r) sacroiliitis (by modified New York (mNY) criteria) or alternative criteria, (2) a change of at least one grade or (3) a change of at least one grade but ignoring a change from grade 0 to 1. The effects of baseline inflammation on MRI-SIJ on 5-year X-SIJ damage (mNY) were tested by generalised estimating equations. Results In 416 patients with pairs of baseline and 5-year X-SIJ present, net progression occurred in 5.1% (1), 13.0% (2) and 10.3% (3) respectively, regarding a shift from nr-axSpA to r-axSpA (1), a change of at least one grade (2) or a change of at least one grade but ignoring a change from grade 0 to 1 (3). Baseline MRI-SIJ predicted structural damage after 5 years in human leukocyte antigen-B27 (HLA-B27) positive (OR 5.39 (95% CI 3.25 to 8.94)) and in HLA-B27 negative (OR 2.16 (95% CI 1.04 to 4.51)) patients. Conclusions Five-year progression of X-SIJ damage in patients with recent onset axSpA is limited but present beyond measurement error. Baseline MRI-SIJ inflammation drives 5-year radiographic changes.
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Affiliation(s)
- Maxime Dougados
- Department of Rheumatology, Paris Descartes University, Hôpital Cochin, Hôpitaux de Paris, Paris, France.,INSERM (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-City, Paris, France
| | - Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Anna Molto
- INSERM (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-City, Paris, France.,Department of Rheumatology, Hôpital Cochin, Paris, France
| | - Miranda van Lunteren
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Manouk de Hooge
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rosaline van den Berg
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Christophe Demattei
- Department of Biostatistics, Epidemiology, Public Health and Medical Information (BESPIM), Nimes University Hospital, Nimes, France
| | - Robert Landewé
- Amsterdam Rheumatology & Clinical Immunology Center (ARC), Amsterdam and Zuyderland Medical Center, Heerlen, The Netherlands
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Abstract
The term axial spondyloarthritis covers both patients with non-radiographic and radiographic axial spondyloarthritis, which is also termed ankylosing spondylitis. The disease usually starts in the third decade of life with a male to female ratio of two to one for radiographic axial spondyloarthritis and of one to one for non-radiographic axial spondyloarthritis. More than 90% heritabilty has been estimated, the highest genetic association being with HLA-B27. The pathogenic role of HLA-B27 is still not clear although various hypotheses are available. On the basis of evidence from trials the cytokines tumour necrosis factor (TNF)-α and interleukin-17 appear to have a relevant role in pathogenesis. The mechanisms of interaction between inflammation and new bone formation is still not completely understood but clarification will be important for the prevention of long-term structural damage of the bone. The development of new criteria for classification and for screening of patients with axial spondyloarthritis have been crucial for the early indentification and treatment of such patients, with MRI being the most important existing imaging method. Non-steroidal anti-inflammatory drugs and TNF blockers are effective therapies. Blockade of interleukin-17 is a new and relevant treatment option.
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Affiliation(s)
- Joachim Sieper
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany
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Ez-Zaitouni Z, Bakker PAC, van Lunteren M, de Hooge M, van den Berg R, Reijnierse M, Fagerli KM, Landewé RBM, Ramonda R, Jacobsson LTH, Saraux A, Lenczner G, Feydy A, Pialat JB, Thévenin F, van Gaalen FA, van der Heijde D. The yield of a positive MRI of the spine as imaging criterion in the ASAS classification criteria for axial spondyloarthritis: results from the SPACE and DESIR cohorts. Ann Rheum Dis 2017; 76:1731-1736. [DOI: 10.1136/annrheumdis-2017-211486] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/08/2017] [Accepted: 06/01/2017] [Indexed: 11/03/2022]
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Abstract
Spondyloarthritides (SpA) are inflammatory rheumatic diseases affecting the axial skeleton, peripheral joints and entheses, and also manifest at extraskeletal sites. According to the more recently introduced nomenclature, predominant axial SpA is distinguished from predominant peripheral SpA. Axial SpA is further divided into radiographic and nonradiographic axial SpA. Genetic factors are relevant, with HLA-B27 being most important. The interleukin 23/17 pathway seems to be relevant and points towards new therapeutic targets. Inflammatory back pain is the leading symptom in axial SpA and has certain characteristics. In addition, HLA-B27 and sacroiliitis on imaging are important for diagnosis. Therapy consists of physiotherapy, nonsteroidal anti-inflammatory drugs (first line) and biologicals (second line). Conventional disease-modifying antirheumatic drugs are effective only in peripheral arthritis.
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137
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Sleep Quality Is Related to Disease Activity in Patients With Ankylosing Spondylitis: A Polysomnographic Study. J Clin Rheumatol 2017; 22:248-52. [PMID: 27464768 DOI: 10.1097/rhu.0000000000000355] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Ankylosing spondylitis (AS) is a chronic inflammatory disease that is associated with poor sleep quality. OBJECTIVES The present study aimed to investigate the relationship between disease activity and sleep quality in patients with AS and to evaluate the potential effect of anti-tumor necrosis factor (TNF) treatment on sleep quality and pattern. METHODS Fifty-nine patients with AS were consecutively included in the study. Twenty-eight patients (47.5%) were receiving anti-TNF, and 31 (52.5%) patients were receiving only nonsteroidal anti-inflammatory drugs (NSAIDs). Demographic and treatment characteristics, spinal mobility measurements, disease activity measurements, and sleep questionnaire results of each patient were recorded. Each patient underwent a polysomnography examination for the evaluation of sleep patterns. RESULTS When compared with the patients on NSAID treatment, patients receiving anti-TNF treatment had significantly greater total sleep time and sleep efficiency (P = 0.003 and P < 0.001, respectively). They had a significantly lower (better) Pittsburgh Sleep Quality Index, sleep onset latency, number of awakenings, and arousal index (P < 0.001, for all). Moreover, they had a significantly shorter superficial sleep period (stage 1) and a significantly longer rapid eye movement sleep period (P < 0.001 and P = 0.02, respectively). Higher indexes of disease activity (Bath AS Disease Activity Index, Bath AS Functional Index, and visual analog scale) were reflecting poorer sleep quality. CONCLUSIONS Sleep quality and pattern was markedly better in patients with AS on anti-TNF compared with the patients on NSAID treatments. Increased disease activity can impair the quality of sleep in AS. Improved sleep quality and pattern in patients on anti-TNF treatment may be related to improved disease activity.
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Bendahan LT, Machado NP, Mendes JG, Oliveira TL, Pinheiro MM. Performance of the classification criteria in patients with late-onset axial spondyloarthritis. Mod Rheumatol 2017; 28:174-181. [PMID: 28569568 DOI: 10.1080/14397595.2017.1320819] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM To evaluate the performance of four different classification criteria for spondyloarthritis (SpA) in patients with late-onset symptoms and to compare the clinical, laboratory and radiographic outcomes among the patients with symptoms before and after 45 years of age. PATIENTS AND METHODS A total of 329 patients with SpA were enrolled in this prospective cohort. Patients with psoriatic arthritis, reactive arthritis, colitis associated arthritis and peripheral or undifferentiated SpA were excluded. The remaining individuals were divided into two groups based on their ages at the time of onset of symptoms: from 16 to 45 years of age (adult-onset, A-O) and after 45 years of age (late-onset, L-O). The clinical data were collected, including BASDAI, BASFI, BASMI, mSASSS, ASDAS, as were concomitant diseases and medications, efficacy and safety data. The performance of four SpA classification criteria, including modified New York, ESSG, Amor and ASAS, was evaluated in both groups. p value <.05 was considered as significant. RESULTS Thirty-two patients (9.72%) had L-O axial SpA. Mean age of diagnosis and symptoms were 57.6 (8.0) years and 7.6 (5.1) years, respectively. L-O patients had statistically worse functional impairment and higher disease activity. However, they had lower radiographic sacroiliac and spine damage (p < .001). CONCLUSION Our data showed that almost 10% of the patients with SpA had late-onset of symptoms. Moreover, they had higher disease activity, worse physical function and lower spine radiographic damage than A-O SpA patients. Additionally, the ASAS classification criteria had the best performance and might be used in clinical practice.
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Affiliation(s)
- Louise T Bendahan
- a Rheumatology Division , Universidade Federal de São Paulo (UNIFESP) , Brazil
| | - Natália P Machado
- a Rheumatology Division , Universidade Federal de São Paulo (UNIFESP) , Brazil
| | - Jamille G Mendes
- a Rheumatology Division , Universidade Federal de São Paulo (UNIFESP) , Brazil
| | - Thauana L Oliveira
- a Rheumatology Division , Universidade Federal de São Paulo (UNIFESP) , Brazil
| | - Marcelo M Pinheiro
- a Rheumatology Division , Universidade Federal de São Paulo (UNIFESP) , Brazil
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Ez-Zaitouni Z, Hilkens A, Gossec L, Berg IJ, Landewé R, Ramonda R, Dougados M, van der Heijde D, van Gaalen F. Is the current ASAS expert definition of a positive family history useful in identifying axial spondyloarthritis? Results from the SPACE and DESIR cohorts. Arthritis Res Ther 2017; 19:118. [PMID: 28569222 PMCID: PMC5452625 DOI: 10.1186/s13075-017-1335-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 05/15/2017] [Indexed: 01/31/2023] Open
Abstract
Background The Assessment of SpondyloArthritis international Society (ASAS) definition of a positive family history (PFH) of spondyloarthritis (SpA) includes the following diseases in first- or second-degree relatives: ankylosing spondylitis (AS), acute anterior uveitis (AAU), reactive arthritis (ReA), inflammatory bowel disease (IBD), and psoriasis. However, it is not known if a PFH for each of these diseases contributes to making a diagnosis of axSpA, sacroiliitis on imaging, or fulfilling the ASAS criteria in patients presenting with chronic back pain (CBP). Therefore, the aim of this study was to assess which SpA diseases in family members are associated with human leukocyte antigen B27 (HLA-B27) and axial spondyloarthritis (axSpA) in CBP patients. Methods CBP patients suspected of axSpA from the SPACE (n = 438) and the DESIR (n = 647) cohort were asked about the presence of SpA diseases in first- or second-degree relatives (AS, AAU, ReA, IBD, and psoriasis). The associations between a PFH and HLA-B27, sacroiliitis on imaging (magnetic resonance imaging (MRI) or radiographs), axSpA diagnosis, and ASAS classification in CBP patients were assessed. Results In the SPACE and the DESIR cohort, a PFH of AS (odds ratio (OR) 5.9 (95% confidence interval (CI) 3.5–9.9), and OR 3.3 (95% CI 2.1–5.2)) and a PFH of AAU (OR 9.8 (95% CI 3.3–28.9) and OR 21.6 (95% CI 2.9–160.1)) were significantly associated with presence of HLA-B27. Furthermore, in both cohorts a PFH of AS and a PFH of AAU were positively associated with fulfilment of the ASAS criteria, but not with sacroiliitis on imaging. In SPACE but not in DESIR a PFH of AAU was positively associated with axSpA diagnosis. In both cohorts a PFH of ReA, IBD, or psoriasis was not positively associated with HLA-B27 positivity, sacroiliitis on imaging, axSpA diagnosis, or meeting the ASAS criteria for axSpA. Conclusions In our cohorts, a PFH of AS or AAU is useful for case-finding of axSpA as this is correlated with HLA-B27 carriership. However, as a PFH of ReA, IBD, or psoriasis does not contribute to identifying axSpA in CBP patients, these data suggest that the widely used ASAS definition of a PFH of SpA should be updated. Trial registration Trial registration number, NCT01648907. Registered on 20 July 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1335-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zineb Ez-Zaitouni
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Andrea Hilkens
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Laure Gossec
- Sorbonne Universités, UPMC Univ Paris 06, GRC-08, Paris, France.,Rheumatology Department, Pitie-Salpétrière Hospital, AP-HP, Paris, France
| | - Inger Jorid Berg
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Robert Landewé
- Department of Clinical Immunology and Rheumatology, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Maxime Dougados
- Paris Descartes University, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, INSERM (U1153): Epidémiologie Clinique et Biostatistiques, PRES Sorbonne Paris-Cité, Paris, France
| | - Désirée van der Heijde
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Floris van Gaalen
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
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140
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de Hooge M, Pialat JB, Reijnierse M, van der Heijde D, Claudepierre P, Saraux A, Dougados M, Feydy A. Assessment of typical SpA lesions on MRI of the spine: do local readers and central readers agree in the DESIR-cohort at baseline? Clin Rheumatol 2017; 36:1551-1559. [PMID: 28536822 DOI: 10.1007/s10067-017-3643-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/27/2017] [Accepted: 03/27/2017] [Indexed: 10/19/2022]
Abstract
Comparing local reading (LocR) with central reading (CentR) of typical spondyloarhritis lesions including bone marrow edema (BME) and structural lesions on magnetic resonance imaging of the spine (MRI-spine), in patients with inflammatory back pain (IBP; ≥3 months, <3 years). Baseline data of 667 patients, age 18-50 years, from the Devenir des Spondylarthopathies Indifferenciees Recentes (DESIR)-cohort were used. Two trained central readers scored anterior and posterior corner BME, fatty lesions, erosions and syndesmophytes on MRI-spine. Presences of lesions, based on average scores, were used for CentR. A local radiologist and/or rheumatologist scored MRI-spine on presence/doubt/absence of 'inflammation' and 'structural lesions'. Agreement between central readers and readings was calculated (Cohen's kappa: κ). Agreement between central readers was moderate (BME κ = 0.55, fatty lesions κ = 0.50) to slight (erosions κ = 0.12, syndesmophytes κ = 0.19). Agreement between LocR and CentR was κ = 0.32 (BME) and κ = 0.13 (structural lesions). In 78/160 patients (48.8%) LocR were in doubt while CentR scored BME lesions, for structural lesions this was 17.8% (28/157 patients). Agreement between 2 central readers for scoring spondyloarhritis-like lesions on MRI-spine was moderate but better compared to LocR and CentR agreement. LocR often doubt about the presence of MRI-spine lesions while central trained readers score lesions.
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Affiliation(s)
- Manouk de Hooge
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jean-Baptiste Pialat
- Department of Radiology, Edouard Herriot Hospital, Hospices Civils de Lyon, INSERM (U1033), Université Lyon 1, Lyon, France
| | - Monique Reijnierse
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Pascal Claudepierre
- Department of Rheumatology, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France.,Laboratoire d'Investigation Clinique (LIC), Université Paris Est Créteil, Créteil, France
| | - Alain Saraux
- Rheumatology Unit, Hôpital de la Cavale Blanche, Brest University Medical School, 29609, Brest, France
| | - Maxime Dougados
- Rheumatology B Department, Cochin Hôpital, Paris Descartes University, Paris, France.,Department of Rheumatology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris Descartes University, Paris, France
| | - Antoine Feydy
- Radiology B Department, Cochin Hôpital, Paris Descartes University, Paris, France. .,Service de Radiologie B - Hôpital Cochin, Université Paris Descartes, 27 rue du Fbg St Jacques, 75679, Paris Cedex 14, France.
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141
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The Nonradiographic Axial Spondyloarthritis, the Radiographic Axial Spondyloarthritis, and Ankylosing Spondylitis: The Tangled Skein of Rheumatology. Int J Rheumatol 2017; 2017:1824794. [PMID: 28555158 PMCID: PMC5438843 DOI: 10.1155/2017/1824794] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/04/2017] [Accepted: 04/10/2017] [Indexed: 01/21/2023] Open
Abstract
Since 1984 the diagnosis of ankylosing spondylitis (AS) has been based upon the modified New York (mNY) criteria with mandatory presence of radiographic sacroiliitis, without which the diagnosis is not tenable. However, it may take years or decades for radiographic sacroiliitis to develop delaying the diagnosis for long periods. It did not matter in the past because no effective treatment was available. However, with the availability of a highly effective treatment, namely, tumour necrosis factor-α inhibitors (TNFi), the issue of early diagnosis of AS acquired an urgency. The Assessment of SpondyloArthritis International Society (ASAS) classification criteria published in 2009 was a significant step towards this goal. These criteria described an early stage of the disease where sacroiliitis was demonstrable only on MRI but not on standard radiograph. Therefore, this stage of the disease was labelled “nonradiographic axial SpA” (nr-axSpA). But questions have been raised if, in search of early diagnosis, specificity was compromised. The Federal Drug Administration (FDA, USA) withheld approval for the use of TNFi in patients with nr-axSpA because of issues related to the specificity of these criteria. This review attempts to clarify some of these aspects of the nr-axSpA-AS relationship and also tries to answer the question whether ASAS classifiable radiographic axial spondyloarthritis (r-axSpA) term can be interchangeably used with the term AS.
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142
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Pisetsky DS. EULAR recommendations for disease management: guidance not guidelines. Ann Rheum Dis 2017; 76:935-938. [DOI: 10.1136/annrheumdis-2016-211005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/15/2017] [Accepted: 03/15/2017] [Indexed: 11/04/2022]
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143
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Roussou E, Bouraoui A. Real-life experience of using conventional disease-modifying anti-rheumatic drugs (DMARDs) in psoriatic arthritis (PsA). Retrospective analysis of the efficacy of methotrexate, sulfasalazine, and leflunomide in PsA in comparison to spondyloarthritides other than PsA and literature review of the use of conventional DMARDs in PsA. Eur J Rheumatol 2017; 4:1-10. [PMID: 28293446 PMCID: PMC5335880 DOI: 10.5152/eurjrheum.2017.1608] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 01/15/2017] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE With the aim of assessing the response to treatment with conventional disease-modifying anti-rheumatic drugs (DMARDs) used in patients with psoriatic arthritis (PsA), data on methotrexate, sulfasalazine (SSZ), and leflunomide were analyzed from baseline and subsequent follow-up (FU) questionnaires completed by patients with either PsA or other spondyloarthritides (SpAs). MATERIAL AND METHODS A single-center real-life retrospective analysis was performed by obtaining clinical data via questionnaires administered before and after treatment. The indices used were erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Function Index (BASFI), wellbeing (WB), and treatment effect (TxE). The indices measured at baseline were compared with those measured on one occasion in a FU visit at least 1 year later. RESULTS A total of 73 patients, 51 with PsA (mean age 49.8±12.8 years; male-to-female ratio [M:F]=18:33) and 22 with other SpAs (mean age 50.6±16 years; M:F=2:20), were studied. BASDAI, BASFI, and WB displayed consistent improvements during FU assessments in both PsA patients and controls in comparison to baseline values. SSZ exhibited better efficacy as confirmed by TxE in both PsA patients and controls. ESR and CRP displayed no differences in either the PsA or the SpA group between the cases before and after treatment. CONCLUSION Real-life retrospective analysis of three DMARDs used in PsA (and SpAs other than PsA) demonstrated that all three DMARDs that were used brought about improvements in BASDAI, BASFI, TxE, and WB. However, the greatest improvements at FU were seen with SSZ use in both PsA and control cohorts.
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Affiliation(s)
- Euthalia Roussou
- Department of Rheumatology and Rehabilitation, Barking Havering and Redbridge University Hospitals NHS Trust, King George Hospital, Barley Lanes, London, UK
| | - Aicha Bouraoui
- Department of Rheumatology and Rehabilitation, Barking Havering and Redbridge University Hospitals NHS Trust, King George Hospital, Barley Lanes, London, UK
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144
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Baraliakos X, Fruth M, Kiltz U, Braun J. [Inflammatory spinal diseases: axial spondyloarthritis : Central importance of imaging]. Z Rheumatol 2017; 76:149-162. [PMID: 28124744 DOI: 10.1007/s00393-016-0252-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The diagnosis of axial spondyloarthritis (axSpA) includes classical ankylosing spondylitis (AS) as well as earlier stages and abortive courses of the disease, in which structural alterations have not yet occurred. These are classified as non-radiographic axSpA (nr-axSpa). Inflammatory changes in the entire axial skeleton are characteristic for axSpA and can be visualized by magnetic resonance imaging (MRI), while in most patients structural alterations, such as new bone formation with syndesmophytes and ankylosis develop in the later course of the disease. These bony alterations can best be visualized by conventional radiography and by computed tomography. Certain MRI sequences are nowadays considered as the standard method for depiction of inflammatory changes in axSpA. The introduction of MRI has led to a paradigm shift for this disease because the inflammatory lesions characteristic for the disease can be visualized at an early stage using appropriate MRI sequences.
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Affiliation(s)
- X Baraliakos
- Rheumazentrum Ruhrgebiet Herne, Claudiusstr. 45, 44649, Herne, Deutschland.
| | - M Fruth
- Rheumazentrum Ruhrgebiet Herne, Claudiusstr. 45, 44649, Herne, Deutschland
| | - U Kiltz
- Rheumazentrum Ruhrgebiet Herne, Claudiusstr. 45, 44649, Herne, Deutschland
| | - J Braun
- Rheumazentrum Ruhrgebiet Herne, Claudiusstr. 45, 44649, Herne, Deutschland
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145
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Li X, Chai W, Zhang G, Ni M, Chen J, Dong J, Zhou Y, Hao L, Bai Y, Wang Y. Down-Regulation of lncRNA-AK001085 and its Influences on the Diagnosis of Ankylosing Spondylitis. Med Sci Monit 2017; 23:11-16. [PMID: 28042142 PMCID: PMC5226297 DOI: 10.12659/msm.898915] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Long non-coding RNAs (lncRNAs) have been confirmed to play an important role in the development and progression of diseases. Ankylosing spondylitis (AS) is a chronic inflammatory systemic disease and it is hard to be found in early time. The purpose of this study was to investigate the role of lncRNA-AK001085 in the diagnosis of AS. Material/Methods The expression of lncRNA-AK001085 was detected by quantitative real-time polymerase chain reaction (qRT-PCR) analysis. The relationship between its expression and clinicopathologic characteristics was also analyzed. Meanwhile the correlation between lncRNA-AK001085 expression and diseases activity indexes was estimated. In addition, the value of it in the diagnosis of AS was explored through establishing receiver operating characteristic (ROC) curve. Results Serum lncRNA-AK001085 expression was decreased in patients with AS compared with healthy individuals. And its expression was proved to be influenced by ever cigarette smoker, exercise level and occupational activity level. Besides, the correlation of the expression of lncRNA-AK001085 and disease activity indexes (BASDI, ASDAS, ESR, CRP) were all negative, which suggested that the lncRNA-AK001085 was significantly lower in patients with a high disease activity score. It might showed that the expression of lncRNA-AK001085 affected the activity of AS. Conclusions LncRNA-AK001085 was down-regulated in AS patients and it could be an independent diagnostic indicator.
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Affiliation(s)
- Xiang Li
- Department of Orthopaedics, PLA General Hospital, Beijing, China (mainland)
| | - Wei Chai
- Department of Orthopaedics, PLA General Hospital, Beijing, China (mainland)
| | - Guoqiang Zhang
- Department of Orthopaedics, PLA General Hospital, Beijing, China (mainland)
| | - Ming Ni
- Department of Orthopaedics, PLA General Hospital, Beijing, China (mainland)
| | - Jiying Chen
- Department of Orthopaedics, PLA General Hospital, Beijing, China (mainland)
| | - Jiyuan Dong
- Department of Orthopaedics, PLA General Hospital, Beijing, China (mainland)
| | - Yonggang Zhou
- Department of Orthopaedics, PLA General Hospital, Beijing, China (mainland)
| | - Libo Hao
- Department of Orthopaedics, PLA General Hospital, Beijing, China (mainland)
| | - Yang Bai
- Department of Stomatology, PLA General Hospital, Beijing, China (mainland)
| | - Yan Wang
- Department of Orthopaedics, PLA General Hospital, Beijing, China (mainland)
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Singh N, Yadav H, Marotta F, Singh V. PROBIOTICS - A PROBABLE THERAPEUTIC AGENT FOR SPONDYLOARTHROPATHY. INTERNATIONAL JOURNAL OF PROBIOTICS & PREBIOTICS 2017; 12:57-68. [PMID: 31007634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Spondyloarthropathy (SpA) or spondyloarthrosis refers to any joint disease of the vertebral column. Among the entities of SpA, ankylosing spondylitis has drawn the attention of some researchers, because of its specific mechanism of disease progression. It has been studied earlier that its progression is due to the presence of HLA (human leukocyte antigen) - B27. It shows molecular similarity and immunological cross-reactivity with some of the gut microbiome. Since SpA could be treated or its symptoms could be lessen by medications, but medications itself show many side effects and other complications. Probiotic- being the natural product has been found to be effective against many SpA entities, including Ankylosing Spondylitis. It alters gut microflora somehow in such a way that it helps in reducing the predisposition of any factor to SpA. Here we consider the complex relationship between SpA pathogenesis and gut microbes; with discussion that how use of probiotics as an alternative drug therapy may treat or reduce the progression of SpA, which could be a better future target to treat SpA entities.
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Affiliation(s)
- Nandini Singh
- Department of Microbiology, Barkatullah University, Bhopal, Madhya Pradesh, INDIA
| | - Hariom Yadav
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Francesco Marotta
- ReGenera Research Group for Aging Intervention & San Babila Clinic, Milano, ITALY
| | - Vinod Singh
- Department of Microbiology, Barkatullah University, Bhopal, Madhya Pradesh, INDIA
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147
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Disease activity trajectories in early axial spondyloarthritis: results from the DESIR cohort. Ann Rheum Dis 2016; 76:1036-1041. [DOI: 10.1136/annrheumdis-2016-209785] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 10/23/2016] [Accepted: 11/05/2016] [Indexed: 01/20/2023]
Abstract
BackgroundDisease activity may change over time in axial spondyloarthritis (axSpA). The objectives were to identify patterns of disease activity evolution in patients with early axSpA.MethodsPatients from the prospective early axSpA cohort (DEvenir des Spondyloarthrites Indifférenciées Récentes (DESIR)) who fulfilled the Assessment in SpondyloArthritis Society (ASAS) criteria for axSpA at baseline and with at least three Ankylosing Spondylitis Disease Activity Score (ASDAS) values available over the 3 years of follow-up were analysed. Statistical analyses: trajectories were estimated by group-based trajectory modelling; predisposing baseline factors for such trajectories were identified by univariate and multivariable multinomial (logit) regression; work disability over time was compared between the trajectories by Cox hazard model.ResultsIn all, 370 patients were analysed: mean disease duration was 1.6 (±0.9) years. The five distinct trajectories of disease activity over the 3 years were (t1) ‘persistent moderate disease activity’ (n=134 (36.2%)); (t2) ‘persistent inactive disease’ (n=66 (17.8%); (t3) ‘changing from very high disease activity to inactive disease’ ((n=29 (7.8%)); (t4) ‘persistent high disease activity’ (n=126 (34.1%)) and (t5) ‘persistent very high disease activity’ (n=15 (4.1%)). After adjustment for other characteristics, t2 was associated with a white-collar job (OR=2.6 (95% CI 1.0 to 6.7)) and t3 with male gender (OR=7.1 (1.6 to 32.2)), higher education level (OR=9.4 (1.4 to 63.4)) and peripheral joint involvement (OR=6.2 (1.23 to 31.32)). Patients from (t4) and (t5) were more often declared work disabled over follow-up (HR=5.2 (1.5 to 18.0) and HR=8.0 (1.3 to 47.9), respectively).ConclusionsTrajectory modelling of disease activity was feasible in early axSpA: more than 30% patients (141/370) were in a trajectory with a persistent high disease activity. Persistent high disease activity trajectories were significantly associated with consequences on work.Trial registration numberNCT01648907.
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148
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Jacquemin C, Rubio Vargas R, van den Berg R, Thévenin F, Lenczner G, Reijnierse M, Ferkal S, Le Corvoisier P, Rahmouni A, Loeuille D, Feydy A, Dougados M, van der Heijde D, Claudepierre P. What is the reliability of non-trained investigators in recognising structural MRI lesions of sacroiliac joints in patients with recent inflammatory back pain? Results of the DESIR cohort. RMD Open 2016; 2:e000303. [PMID: 27933207 PMCID: PMC5133415 DOI: 10.1136/rmdopen-2016-000303] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 09/08/2016] [Accepted: 09/12/2016] [Indexed: 12/20/2022] Open
Abstract
Objective The objective of this study was to evaluate the reliability of recognising structural lesions on MRI (erosions, fatty lesions, ankylosis) of the sacroiliac joints (MRI-SIJ) in clinical practice compared to a central reading in patients with a possible recent axial spondyloarthritis (axSpA). Methods Patients aged 18–50 years, with recent (<3 years) and chronic (≥3 months) inflammatory back pain, suggestive of axSpA were included in the DEvenir des Spondyloarthrites Indifférenciées Récentes (DESIR) cohort. MRI-SIJ structural lesions were scored by non-trained local readers, and by two trained central readers. Local readers scored each SIJ as normal, doubtful or definite lesions. Central readers scored separately each type of lesion. The central reading (mean of the two central readers’ scores) was the external standard. Agreement (κ) was calculated first between local (3 definitions of a positive MRI-SIJ) and central readings (9 definitions), and then between the two central readers. Results 664/708 patients with complete available images were included. Agreements between local and central readings were overall ‘fair’, except when considering at least 2 or 3 fatty lesions and at least 3 erosions and/or fatty lesions where agreement was ‘moderate’. Agreement between central readers was similar. MRI-SIJ was positive for 52.6% of patients according to central reading (at least 1 structural lesion) and for 35.4% of patients according to local reading (at least unilateral ‘doubtful‘ or ‘definite’ structural lesions). Conclusions Agreement on a positive structural MRI-SIJ was fair to moderate between local and central readings, as well as between central readers. The reliability improved when fatty lesions were considered. Trial registration number NCTO 164 8907.
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Affiliation(s)
| | - Roxana Rubio Vargas
- Department of Rheumatology , Leiden University Medical Center , Leiden , The Netherlands
| | - Rosaline van den Berg
- Department of Rheumatology , Leiden University Medical Center , Leiden , The Netherlands
| | | | - Gregory Lenczner
- Department of Radiology , Clinique Hartmann , Neuilly-sur-Seine , France
| | - Monique Reijnierse
- Department of Radiology , Leiden University Medical Center , Leiden , The Netherlands
| | - Salah Ferkal
- Clinical Investigation Center 1430, AP-HP and Inserm, Hôpital Henri Mondor , Créteil , France
| | - Philippe Le Corvoisier
- Clinical Investigation Center 1430, AP-HP and Inserm, Hôpital Henri Mondor , Créteil , France
| | - Alain Rahmouni
- Department of Radiology , Hôpital Henri Mondor , Créteil , France
| | - Damien Loeuille
- Department of Rheumatology , Hôpital Brabois , Nancy , France
| | - Antoine Feydy
- Department of Radiology , Hôpital Cochin , Paris , France
| | - Maxime Dougados
- Department of Rheumatology , Hôpital Cochin , Paris , France
| | - Désirée van der Heijde
- Department of Rheumatology , Leiden University Medical Center , Leiden , The Netherlands
| | - Pascal Claudepierre
- Department of Rheumatology, Hôpital Henri Mondor, Créteil, France; Université Paris Est Créteil, EA 7379-EpidermE, F-94010, Créteil, France
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Kalyoncu U, Bayindir Ö, Ferhat Öksüz M, Doğru A, Kimyon G, Tarhan EF, Erden A, Yavuz Ş, Can M, Çetin GY, Kılıç L, Küçükşahin O, Omma A, Ozisler C, Solmaz D, Bozkirli EDE, Akyol L, Pehlevan SM, Gunal EK, Arslan F, Yılmazer B, Atakan N, Aydın SZ. The Psoriatic Arthritis Registry of Turkey: results of a multicentre registry on 1081 patients. Rheumatology (Oxford) 2016; 56:279-286. [PMID: 27794533 DOI: 10.1093/rheumatology/kew375] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 09/09/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aim was to assess the characteristics of PsA, find out how well the disease is controlled in real life, demonstrate the treatments and identify the unmet needs. METHODS The PsA registry of Turkey is a multicentre Web-based registry established in 2014 and including 32 rheumatology centres. Detailed data regarding demographics for skin and joint disease, disease activity assessments and treatment choices were collected. RESULTS One thousand and eighty-one patients (64.7% women) with a mean (sd) PsA duration of 5.8 (6.7) years were enrolled. The most frequent type of PsA was polyarticular [437 (40.5%)], followed by oligoarticular [407 (37.7%)] and axial disease [372 (34.4%)]. The mean (sd) swollen and tender joint counts were 1.7 (3) and 3.6 (4.8), respectively. Of these patients, 38.6% were on conventional synthetic DMARD monotherapy, 7.1% were on anti-TNF monotherapy, and 22.5% were using anti-TNF plus conventional synthetic DMARD combinations. According to DAS28, 86 (12.4%) patients had high and 105 (15.2%) had moderate disease activity. Low disease activity was achieved in 317 (45.7%) patients, and 185 (26.7%) were in remission. Minimal disease activity data could be calculated in 247 patients, 105 of whom (42.5%) had minimal disease activity. The major differences among sexes were that women were older and had less frequent axial disease, more fatigue, higher HAQ scores and less remission. CONCLUSION The PsA registry of Turkey had similarities with previously published registries, supporting its external validity. The finding that women had more fatigue and worse functioning as well as the high percentage of active disease state highlight the unmet need in treatment of PsA.
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Affiliation(s)
- Umut Kalyoncu
- Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, Hacettepe University, Ankara
| | - Özün Bayindir
- Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, Ege University, Izmir
| | - Mustafa Ferhat Öksüz
- Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, Uludag University, Bursa
| | - Atalay Doğru
- Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, Suleyman Demirel University, Isparta
| | - Gezmiş Kimyon
- Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, Gaziantep University, Ankara
| | - Emine Figen Tarhan
- Department of Internal Medicine, Division of Rheumatology, Izmir Katip Celebi University School of Medicine, Izmir
| | - Abdulsamet Erden
- Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, Hacettepe University, Ankara
| | - Şule Yavuz
- Istanbul Florence Nightingale Hospital, Department of Rheumatology, Istanbul Bilim University
| | - Meryem Can
- Department of Rheumatology, Fatih Sultan Mehmet Education and Research Hospital, İstanbul
| | - Gözde Yıldırım Çetin
- Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, Sutcu Imam University, Kahramanmaras
| | - Levent Kılıç
- Department of Rheumatology, Yildirim Beyazit University, Yenimahalle Education and Research Hospital, Ankara
| | - Orhan Küçükşahin
- Faculty of Medicine, Atatürk Education and Research Hospital Department of Rheumatology, Yıldırım Beyazit University
| | - Ahmet Omma
- Department of Rheumatology, Ankara Numune Training and Research Hospital
| | - Cem Ozisler
- Department of Rheumatology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara
| | - Dilek Solmaz
- Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, Namik Kemal University, Tekirdag
| | | | - Lütfi Akyol
- Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, Ondokuz Mayıs University, Samsun
| | | | | | - Fatos Arslan
- Istanbul Medeniyet University, Goztepe Training and Research Hospital
| | - Barış Yılmazer
- Department of Rheumatology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, İstanbul
| | - Nilgun Atakan
- Faculty of Medicine, Department of Dermatology, Hacettepe University, Ankara, Turkey
| | - Sibel Zehra Aydın
- Division of Rheumatology, University of Ottawa, Ottawa, Ontario, Canada
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150
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Leverment S, Clarke E, Wadeley A, Sengupta R. Prevalence and factors associated with disturbed sleep in patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis: a systematic review. Rheumatol Int 2016; 37:257-271. [PMID: 27796520 DOI: 10.1007/s00296-016-3589-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 10/22/2016] [Indexed: 12/12/2022]
Abstract
This review explores the prevalence and factors associated with disturbed sleep for patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis in order to clarify consistent findings in this otherwise disparate research field. The association of physical, demographic and psychological factors correlating with poor sleep was explored, and the effectiveness of interventions assessed. Ten electronic databases were searched: AMED, CINAHL, Embase, Medline, PsycINFO, PubMed, Scopus, Web of Science, OpenGrey and BASE. Following application of inclusion and exclusion criteria, 29 articles were critically assessed on the basis of methodology, experimental design, ethics and quality of sleep data, leading to the selection of 15 studies for final review. Poor sleep was reported in 35-90% of patients with axial spondyloarthritis and is more prevalent within this clinical population compared to healthy control subjects. Disturbed sleep is an important aspect of disease for patients and reflects the severity of disease activity, pain, fatigue and functional disability. However, the direction of this relationship is undetermined. Associations with age, gender, years spent in education, quality of life and depression have also been demonstrated. Anti-TNF medication is effective in reducing poor sleep, and exercise has also produced beneficial results. Future research into poor sleep should take account of its multifactorial nature. There is also a current lack of research investigating non-pharmacological interventions or combination therapies. A standardised, validated measurement of poor sleep, appropriate for regular patient screening, would be a useful first step for future research.
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Affiliation(s)
| | - Emily Clarke
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK
| | | | - Raj Sengupta
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK.
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