Ankylosing spondylitis: etiology, pathogenesis, and treatments

Effectiveness and safety of Chinese herbal formula combined with western medicine for ankylosing spondylitis: A protocol for systematic review and meta-analysis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic progressive inflammatory disease of the spine, which mainly invades the sacroiliac joint, spine, and large joints near the trunk, leading to fibrous and skeletal ankylosis and deformity, and can cause damage to the eyes, lung, cardiovascular, kidney and other organs. Chinese herbal formulas (CHF) is an important interventions of Traditional Chinese Medicine (TCM), and CHFs combined with western medicine are widely used in clinical practice to treat AS.

METHODS

Eight databases will be systematically retrieved from their inceptions to March 2021. Only randomized controlled trials (RCTs) of CHFs combined with western medicine for AS treatment will meet the inclusion criteria. The primary outcomes we focus on include clinical effectiveness rate, TCM syndrome score, TCM symptom score, Bath ankylosing spondylitis disease activity index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), chest expansion, nocturnal spinal pain, adverse reactions, erythrocyte sedimentation rate (ESR), and C protein response (CRP). The research screening, data extraction, and risk of bias assessment will be performed independently by 2 researchers, and divergence will be solved by a third researcher. Revman 5.3 software will be used for meta-analysis. The confidence of evidence will be graded using grading of recommendations assessment, development, and evaluation (GRADE) algorithm and methodological quality will be assessed adopting risk of bias in systematic reviews (ROBIS).

RESULTS

This systematic review (SR) will provide evidence-based medical evidence for AS therapy by CHF combined with western medicine and we will submit the findings of this SR for peer-review publication.

CONCLUSIONS

This SR will provide latest and updated summary proof for assessing the effectiveness and safety of CHF combined with western medicine for AS.

REGISTRATION NUMBER

INPLASY 202150089.

A case report of monoarthritis in a COVID-19 patient and literature review: Simple actions for complex times

RATIONALE

COVID-19 presentation is multifaceted and up to 44% of patients affected by COVID-19 experience musculoskeletal complaints, mostly in the form of diffuse aspecific arthromyalgias. Nevertheless, only a few cases of arthritis following SARS-CoV2 infection are reported.

PATIENT CONCERNS

A 27-year-old man affected by nail psoriasis presented with monoarthritis 2 weeks after being diagnosed with COVID-19.

DIAGNOSES

Diagnostic work-up and differential diagnosis were made difficult by patient isolation, absence of lab tests, and his visit via telemedicine, even though signs of first metacarpophalangeal joint involvement were clear.

INTERVENTIONS

Due to the inefficacy of acetaminophen and nonsteroidal anti-inflammatory drugs, the patient was prescribed oral steroids with a rapid benefit.

OUTCOMES

The patient's response to oral steroid was prompt and maintained even after therapy tapering. Even so, a formal diagnosis was not possible due to a difficult diagnostic work-up and lack of a long-term follow-up.

LESSONS

Like many other viral diseases, SARS-CoV2 can play as a causative agent or as a trigger for inflammatory arthritis development in predisposed individuals.

Ankylosing spondylitis: an autoimmune or autoinflammatory disease?

Ankylosing spondylitis (AS) is a chronic inflammatory disorder of unknown aetiology. Unlike other systemic autoimmune diseases, in AS, the innate immune system has a dominant role characterized by aberrant activity of innate and innate-like immune cells, including γδ T cells, group 3 innate lymphoid cells, neutrophils, mucosal-associated invariant T cells and mast cells, at sites predisposed to the disease. The intestine is involved in disease manifestations, as it is at the forefront of the interaction between the mucosal-associated immune cells and the intestinal microbiota. Similarly, biomechanical factors, such as entheseal micro-trauma, might also be involved in the pathogenesis of the articular manifestation of AS, and sentinel immune cells located in the entheses could provide links between local damage, genetic predisposition and the development of chronic inflammation. Although these elements might support the autoinflammatory nature of AS, studies demonstrating the presence of autoantibodies (such as anti-CD74, anti-sclerostin and anti-noggin antibodies) and evidence of activation and clonal expansion of T cell populations support an autoimmune component to the disease. This Review presents the evidence for autoinflammation and the evidence for autoimmunity in AS and, by discussing the pathophysiological factors associated with each, aims to reconcile the two hypotheses.

Vascular Endothelial Growth Factor Biology and Its Potential as a Therapeutic Target in Rheumatic Diseases

Rheumatic diseases constitute a diversified group of diseases distinguished by arthritis and often involve other organs. The affected individual has low quality of life, productivity even life-threatening in some severe conditions. Moreover, they impose significant economic and social burdens. In recent years, the patient outcome has been improved significantly due to clearer comprehension of the pathology of rheumatic diseases and the effectiveness of "treat to target" therapies. However, the high cost and the adverse effects are the concerns and full remissions are not often observed. One of the main processes that contributes to the pathogenesis of rheumatic diseases is angiogenesis. Vascular endothelial growth factor (VEGF), a central mediator that regulates angiogenesis, has different isoforms and functions in various physiological processes. Increasing evidence suggests an association between the VEGF system and rheumatic diseases. Anti-VEGF and VEGF receptor (VEGFR) therapies have been used to treat several cancers and eye diseases. This review summarizes the current understanding of VEGF biology and its role in the context of rheumatic diseases, the contribution of VEGF bioavailability in the pathogenesis of rheumatic diseases, and the potential implications of therapeutic approaches targeting VEGF for these diseases.

Differential gene expression analysis of ankylosing spondylitis shows deregulation of the HLA-DRB, HLA-DQB, ITM2A, and CTLA4 genes

Background

Ankylosing spondylitis (AS) is a rare inflammatory disorder affecting the spinal joints. Although we know some of the genetic factors that are associated with the disease, the molecular basis of this illness has not yet been fully elucidated, and the genes involved in AS pathogenesis have not been entirely identified. The current study aimed at constructing a gene network that may serve as an AS gene signature and biomarker, both of which will help in disease diagnosis and the identification of therapeutic targets. Previously published gene expression profiles of 16 AS patients and 16 gender- and age-matched controls that were profiled on the Illumina HumanHT-12 V3.0 Expression BeadChip platform were mined. Patients were Portuguese, 21 to 64 years old, were diagnosed based on the modified New York criteria, and had Bath Ankylosing Spondylitis Disease Activity Index scores > 4 and Bath Ankylosing Spondylitis Functional Index scores > 4. All patients were receiving only NSAIDs and/or sulphasalazine. Functional enrichment and pathway analysis were performed to create an interaction network of differentially expressed genes.

Results

ITM2A, ICOS, VSIG10L, CD59, TRAC, and CTLA-4 were among the significantly differentially expressed genes in AS, but the most significantly downregulated genes were the HLA-DRB6, HLA-DRB5, HLA-DRB4, HLA-DRB3, HLA-DRB1, HLA-DQB1, ITM2A, and CTLA-4 genes. The genes in this study were mostly associated with the regulation of the immune system processes, parts of cell membrane, and signaling related to T cell receptor and antigen receptor, in addition to some overlaps related to the IL2 STAT signaling, as well as the androgen response. The most significantly over-represented pathways in the data set were associated with the “RUNX1 and FOXP3 which control the development of regulatory T lymphocytes (Tregs)” and the “GABA receptor activation” pathways.

Conclusions

Comprehensive gene analysis of differentially expressed genes in AS reveals a significant gene network that is involved in a multitude of important immune and inflammatory pathways. These pathways and networks might serve as biomarkers for AS and can potentially help in diagnosing the disease and identifying future targets for treatment.

Adiponectin Deregulation in Systemic Autoimmune Rheumatic Diseases

Deregulation of adiponectin is found in systemic autoimmune rheumatic diseases (SARDs). Its expression is downregulated by various inflammatory mediators, but paradoxically, elevated serum levels are present in SARDs with high inflammatory components, such as rheumatoid arthritis and systemic lupus erythematosus. Circulating adiponectin is positively associated with radiographic progression in rheumatoid arthritis as well as with cardiovascular risks and lupus nephritis in systemic lupus erythematosus. However, in SARDs with less prominent inflammation, such as systemic sclerosis, adiponectin levels are low and correlate negatively with disease activity. Regulators of adiponectin gene expression (PPAR-γ, Id3, ATF3, and SIRT1) and inflammatory cytokines (interleukin 6 and tumor necrosis factor α) are differentially expressed in SARDs and could therefore influence total adiponectin levels. In addition, anti-inflammatory therapy could also have an impact, as tocilizumab treatment is associated with increased serum adiponectin. However, anti-tumor necrosis factor α treatment does not seem to affect its levels. Our review provides an overview of studies on adiponectin levels in the bloodstream and other biological samples from SARD patients and presents some possible explanations why adiponectin is deregulated in the context of therapy and gene regulation.

Machine Learning in Chronic Pain Research: A Scoping Review

Given the high prevalence and associated cost of chronic pain, it has a significant impact on individuals and society. Improvements in the treatment and management of chronic pain may increase patients’ quality of life and reduce societal costs. In this paper, we evaluate state-of-the-art machine learning approaches in chronic pain research. A literature search was conducted using the PubMed, IEEE Xplore, and the Association of Computing Machinery (ACM) Digital Library databases. Relevant studies were identified by screening titles and abstracts for keywords related to chronic pain and machine learning, followed by analysing full texts. Two hundred and eighty-seven publications were identified in the literature search. In total, fifty-three papers on chronic pain research and machine learning were reviewed. The review showed that while many studies have emphasised machine learning-based classification for the diagnosis of chronic pain, far less attention has been paid to the treatment and management of chronic pain. More research is needed on machine learning approaches to the treatment, rehabilitation, and self-management of chronic pain. As with other chronic conditions, patient involvement and self-management are crucial. In order to achieve this, patients with chronic pain need digital tools that can help them make decisions about their own treatment and care.

Assessment of the effects of loneliness, perceived social support, and depression on medication adherence in patients with ankylosing spondylitis

PURPOSE

This study aims to investigate the effects of loneliness, perceived social support, and depression on medication adherence of patients with ankylosing spondylitis (AS).

DESIGN AND METHODS

This cross-sectional study was conducted with 119 AS patients. Data were collected using the Morisky-Green-Levine Medication Adherence Scale, the UCLA Loneliness Scale (ULS), the Multidimensional Scale of Perceived Social Support (MSPSS), and the Beck Depression Inventory (BDI).

FINDINGS

Nonadherent patients were younger (P = .033), scored higher on the ULS (P = .015), and BDI (P = .024) scales, and lower on the MSPSS scale (P = .039) and on family support (P = .002).

PRACTICAL IMPLICATIONS

The biopsychosocial aspects of patients with AS should be managed holistically to improve their medication adherence.

Ankylosing spondylitis risk factors: a systematic literature review

Radiographic axial spondyloarthritis (also known as ankylosing spondylitis [AS]) is a chronic immune-mediated arthritis characterized by inflammation of the axial skeleton, peripheral joints, and entheses. It is estimated that 1 in every 200 people are affected by AS, making it an important healthcare and socioeconomic issue. In this review, we aim to explore the current understanding of AS risk factors and provide a comprehensive update. Multiple search strings were used to identify articles of interest published in PubMed between January 1, 2013, and February 1, 2021. On the basis of the literature review and analysis, we present up-to-date information on the risk factors of developing AS and our viewpoints on disease onset and progression. Multiple genetic and nongenetic risk factors have been suggested in the onset of AS. HLA-B27 is known to have a strong association with the disease, but other genes have been implicated in disease development. Aside from genetics, other factors are thought to be involved; up to 70% of patients with AS have subclinical intestinal inflammation, suggesting that the origin of the disease may be in the gut. The exact mechanism by which AS onset begins is most likely complex and multifactorial. Key Points • It remains unclear how interactions between genes, microbes, mechanical stress, gender, and other environmental and lifestyle factors predispose patients to the development of ankylosing spondylitis (AS). • The exact mechanisms of AS are complex and multifactorial which will require much future research • Recognizing the risk factors, as well as understanding gene-environment interactions, may offer valuable insights into the etiology of AS and have important implications for diagnosis and treatment strategies.

Cardiovascular risk estimation in young patients with ankylosing spondylitis: A new model based on a prospective study in Constanta County, Romania

Cardiovascular (CV) risk assessment charts are useful in establishing a patient therapeutic plan, but the most commonly used charts have essential limitations when applied to special populations. Our aim was to determine whether the Systematic Coronary Risk Evaluation (SCORE) chart underestimates the CV risk in young patients with ankylosing spondylitis (AS) and to promote the necessity of new risk assessment models. We conducted a prospective study in Constanta County, Romania including 70 consecutive patients ≤50 years of age, previously diagnosed with AS, without a history of established CV disease, diabetes mellitus and chronic kidney disease. We estimated the CV risk using SCORE based on total cholesterol, applied for a high-risk population, such as the Romanian population. Estimation of CV risk was also conducted with the relative risk (RR) chart, considering the following variables: Smoking, systolic blood pressure and total cholesterol. The majority of patients (n=46, 65.71%) had low risk according to the SCORE chart and only 24 (34.28%) were found to have moderate CV risk; none of them with high or very high CV risk. Ten patients (21.74%) of the 46 who were considered to have a low risk based on the SCORE system presented with carotid plaques. Twelve patients (50%) of the remaining 24 with moderate CV risk were found to have carotid plaques. According to 2016 'European Society of Cardiology' (ESC) guidelines, 22 of all 70 patients were at high/very high CV risk due to the presence of carotid plaques. Comparing the RR chart with carotid plaque detection, only 4 out of 30 (13.3%) patients with RR=1 had carotid plaques; the frequency was higher in those with RR>1. Our results attested that the SCORE system underestimates the risk in patients with carotid plaques. Carotid ultrasound provided a more heightened sensitivity of the RR chart. C-reactive protein (CRP) >3 mg/dl is associated with RR>1, making this chart a better CV risk predictive system in this particular category of patients.

Chondrogenesis mediates progression of ankylosing spondylitis through heterotopic ossification

Ankylosing spondylitis (AS) is chronic inflammatory arthritis with a progressive fusion of axial joints. Anti-inflammatory treatments such as anti-TNF-α antibody therapy suppress inflammation but do not effectively halt the progression of spine fusion in AS patients. Here we report that the autoimmune inflammation of AS generates a microenvironment that promotes chondrogenesis in spine ligaments as the process of spine fusion. Chondrocyte differentiation was observed in the ligaments of patients with early-stage AS, and cartilage formation was followed by calcification. Moreover, a large number of giant osteoclasts were found in the inflammatory environment of ligaments and on bony surfaces of calcified cartilage. Resorption activity by these giant osteoclasts generated marrow with high levels of active TGF-β, which induced new bone formation in the ligaments. Notably, no Osterix+ osteoprogenitors were found in osteoclast resorption areas, indicating uncoupled bone resorption and formation. Even at the late and maturation stages, the uncoupled osteoclast resorption in bony interspinous ligament activates TGF-β to induce the progression of ossification in AS patients. Osteoclast resorption of calcified cartilage-initiated ossification in the progression of AS is a similar pathologic process of acquired heterotopic ossification (HO). Our finding of cartilage formation in the ligaments of AS patients revealed that the pathogenesis of spinal fusion is a process of HO and explained why anti-inflammatory treatments do not slow ankylosing once there is new bone formation in spinal soft tissues. Thus, inhibition of HO formation, such as osteoclast activity, cartilage formation, or TGF-β activity could be a potential therapy for AS.

Role of the IL-23/IL-17 Pathway in Rheumatic Diseases: An Overview

Interleukin-23 (IL-23) is a pro-inflammatory cytokine composed of two subunits, IL-23A (p19) and IL-12/23B (p40), the latter shared with Interleukin-12 (IL-12). IL-23 is mainly produced by macrophages and dendritic cells, in response to exogenous or endogenous signals, and drives the differentiation and activation of T helper 17 (Th17) cells with subsequent production of IL-17A, IL-17F, IL-6, IL-22, and tumor necrosis factor α (TNF-α). Although IL-23 plays a pivotal role in the protective immune response to bacterial and fungal infections, its dysregulation has been shown to exacerbate chronic immune-mediated inflammation. Well-established experimental data support the concept that IL-23/IL-17 axis activation contributes to the development of several inflammatory diseases, such as PsA, Psoriasis, Psoriatic Arthritis; AS, Ankylosing Spondylitis; IBD, Inflammatory Bowel Disease; RA, Rheumatoid Arthritis; SS, Sjogren Syndrome; MS, Multiple Sclerosis. As a result, emerging clinical studies have focused on the blockade of this pathogenic axis as a promising therapeutic target in several autoimmune disorders; nevertheless, a greater understanding of its contribution still requires further investigation. This review aims to elucidate the most recent studies and literature data on the pathogenetic role of IL-23 and Th17 cells in inflammatory rheumatic diseases.

Microbial-derived antigens and metabolites in spondyloarthritis

Spondyloarthritis (SpA) is a group of chronic, immune-mediated, inflammatory diseases affecting the bone, synovium, and enthesis. Microbiome, the community of microorganisms that has co-evolved with human hosts, plays a pivotal role in human health and disease. This invisible "essential organ" supplies the host with a myriad of chemicals and molecules. In turn, microbial metabolites can serve as messengers for microbes to communicate with each other and in the cross-talk with host cells. Gut dysbiosis in SpA is associated with altered microbial metabolites, and an accumulated body of research has contributed to the understanding that changes in intestinal microbiota can modulate disease pathogenesis. We review the novel findings from human and animal studies to provide an overview of the contribution of individual microbial metabolites and antigens to SpA.

Cytokine "fine tuning" of enthesis tissue homeostasis as a pointer to spondyloarthritis pathogenesis with a focus on relevant TNF and IL-17 targeted therapies

A curious feature of axial disease in ankylosing spondylitis (AS) and related non-radiographic axial spondyloarthropathy (nrAxSpA) is that spinal inflammation may ultimately be associated with excessive entheseal tissue repair with new bone formation. Other SpA associated target tissues including the gut and the skin have well established paradigms on how local tissue immune responses and proven disease relevant cytokines including TNF and the IL-23/17 axis contribute to tissue repair. Normal skeletal homeostasis including the highly mechanically stressed entheseal sites is subject to tissue microdamage, micro-inflammation and ultimately repair. Like the skin and gut, healthy enthesis has resident immune cells including ILCs, γδ T cells, conventional CD4+ and CD8+ T cells and myeloid lineage cells capable of cytokine induction involving prostaglandins, growth factors and cytokines including TNF and IL-17 that regulate these responses. We discuss how human genetic studies, animal models and translational human immunology around TNF and IL-17 suggest a largely redundant role for these pathways in physiological tissue repair and homeostasis. However, disease associated immune system overactivity of these cytokines with loss of tissue repair “fine tuning” is eventually associated with exuberant tissue repair responses in AS. Conversely, excessive biomechanical stress at spinal enthesis or peripheral enthesis with mechanically related or degenerative conditions is associated with a normal immune system attempts at cytokine fine tuning, but in this setting, it is commensurate to sustained abnormal biomechanical stressing. Unlike SpA, where restoration of aberrant and excessive cytokine “fine tuning” is efficacious, antagonism of these pathways in biomechanically related disease may be of limited or even no value.

Aberrant antigen processing and presentation: Key pathogenic factors leading to immune activation in Ankylosing spondylitis

The strong association of HLA-B*27 with ankylosing spondylitis (AS) was first reported nearly 50 years ago. However, the mechanistic link between HLA-B*27 and AS has remained an enigma. While 85-90% of AS patients possess HLA-B*27, majority of HLA-B*27 healthy individuals do not develop AS. This suggests that additional genes and genetic regions interplay with HLA-B*27 to cause AS. Previous genome-wide association studies (GWAS) identified key genes that are distinctively expressed in AS, including the Endoplasmic Reticulum Aminopeptidase (ERAP) 1 and ERAP2. As these gene-encoding molecules are primarily implicated in the process of peptide processing and presentation, potential pathological interaction of these molecules with HLA-B*27 may operate to cause AS by activating downstream immune responses. The aberrant peptide processing also gives rise to the accumulation of unstable protein complex in endoplasmic reticulum (ER), which drives endoplasmic reticulum-associated protein degradation (ERAD) and unfolded protein response (UPR) and activates autophagy. In this review, we describe the current hypotheses of AS pathogenesis, focusing on antigen processing and presentation operated by HLA-B*27 and associated molecules that may contribute to the disease initiation and progression of AS.

Cancer diagnosis and mortality in patients with ankylosing spondylitis: A Western Australian retrospective cohort study

AIM

Ankylosing spondylitis (AS) has been associated with a modest increase in the risk of cancer. However, little is known as to how AS influences risk of mortality following cancer diagnosis. This study compared the risk of cancer and subsequent mortality in patients with AS compared with a non-AS population group.

METHODS

Patients diagnosed with AS in Western Australia (WA) between 1980 and 2014 were identified from the WA Rheumatic Disease Epidemiological Register (N = 2152; 31 099 patient-years). A non-AS comparison group (N = 10 760; 165 609 patient-years) was selected from hospital records, matched 1:5 on age, Aboriginality, and gender. Data on cancer diagnosis, comorbidities and mortality were extracted from state cancer, hospital, and mortality registers. The relative risk of cancer (overall and by type) and mortality following cancer diagnosis between AS and non-AS comparators was compared using Cox proportional hazard models, adjusting for risk factors and comorbidities.

RESULTS

Ankylosing spondylitis patients had a 15% increase in the crude risk of cancer (hazard ratio [HR]: 1.15, 95% CI: 1.02-1.30). However, this association was attenuated following adjustment for smoking and common comorbidities (adjusted HR: 1.08, 95% CI: 0.95-1.22). Following a cancer diagnosis, patients with AS had an increased risk of 5-year mortality in the unadjusted (HR: 1.24, 95% CI: 1.03-1.49) and the adjusted models (adjusted HR: 1.37, 95% CI: 1.13-1.66).

CONCLUSION

Ankylosing spondylitis was not associated with an increased risk of cancer diagnosis. Following a cancer diagnosis, AS was associated with an increased risk of 5-year mortality.

The Role of PTX3 in Mineralization Processes and Aging-Related Bone Diseases

The Long Pentraxin 3 (PTX3) is a multifunctional glycoprotein released by peripheral blood leukocytes and myeloid dendritic cells in response to primary pro-inflammatory stimuli, that acts as a non-redundant component of the humoral arm of innate immunity. In addition to the primary role in the acute inflammatory response, PTX3 seems to be involved in other physiological and pathological processes. Indeed, PTX3 seems to play a pivotal role in the deposition and remodeling of bone matrix during the mineralization process, promoting osteoblasts differentiation and activity. Recently, PTX3 was seen to be involved in the ectopic calcifications' formation in breast cancer disease. In this regard, it has been observed that breast cancer tumors characterized by high expression of PTX3 and high amount of Breast Osteoblast Like Cells (BOLCs) showed several Hydroxyapatite (HA) microcalcifications, suggesting a likely role for PTX3 in differentiation and osteoblastic activity in both bone and extra-bone sites. Furthermore, given its involvement in bone metabolism, several studies agree with the definition of PTX3 as a molecule significantly involved in the pathogenesis of age-related bone diseases, such as osteoporosis, both in mice and humans. Recent results suggest that genetic and epigenetic mechanisms acting on PTX3 gene are also involved in the progression of these diseases. Based on these evidences, the aim of our systemic review was to offer an overview of the variety of biological processes in which PTX3 is involved, focusing on bone mineralization, both in a physiological and pathological context.

Risk of cancer in patients with ankylosing spondylitis: a nationwide cohort study in Taiwan

Objective: To estimate the incidence of cancer among patients with ankylosing spondylitis (AS) and compare this risk with that of the general population.Method: We obtained data from Taiwan's National Health Insurance database on 19 289 patients with a first diagnosis of AS registered between 2000 and 2012 with no history of cancer before the diagnosis of AS. Standardized incidence ratios (SIRs) for all cancers and for site-specific cancers were used to assess whether AS was associated with an increased risk of cancer.Results: During the follow-up period, 485 patients developed cancer. The incidence rate was therefore 256.3 per 100 000 person-years. Compared with the general population, patients with AS had an increased risk of cancer [SIR 1.33, 95% confidence interval (CI) 1.20-1.47]. The SIR of cancer was higher in older patients; the risk increased from 8 years after initial diagnosis. Among solid tumours, the risk of melanoma was the highest (SIR 4.64, 95% CI 1.93-11.15), followed by prostate (SIR 2.53, 95% CI 2.01-3.19), thyroid (SIR 2.09, 95% CI 1.45-3.00), and bone cancer (SIR 2.00, 95% CI 1.01-3.99). Among haematological cancers, the risk of leukaemia was the highest (SIR 1.94, 95% CI 1.21-3.12). By contrast, the risks of oesophageal and oral cancers decreased in patients with AS.Conclusion: This nationwide population-based cohort study demonstrated that patients with AS in Taiwan are at an increased risk of cancer, particularly melanoma; prostate, thyroid, and bone cancers; and haematological malignancies.

Potential Role of Yoga in the Management of Ankylosing Spondylitis: A Retrospective Study

BACKGROUND

Ankylosing spondylitis (AS) is a chronic autoimmune inflammatory spondyloarthropathy with unclear pathogenesis. The inflammatory pain in AS leads to restricted spinal mobility and significant disability. Yoga is a nonpharmacological intervention that has positive effects on various musculoskeletal-related problems. However, its role in AS is unknown.

OBJECTIVE

The present retrospective study assessed the efficacy of a two-week residential yoga intervention on spinal flexibility among AS patients.

METHODS

The records for 24 male AS patients within the age range 30 to 50 years (average age 38.3 ± 10.5 years) who underwent a two-week residential yoga retreat between 2015 and 2020 were obtained from a yoga center located in South India. Yoga intervention consisted of yoga postures, breathing practices, meditation, a healthy diet, and devotional sessions. Pre and Post data of the sit-and-reach test, blood pressure, heart rate, and symptom score were analyzed using Statistical Package for Social Sciences (SPSS).

RESULTS

Compared to the baseline, the post scores of the sit-and-reach test, systolic blood pressure and heart rate were found to be significantly (P < .05) lower. The symptom score and analgesic medication score also showed significant improvement after two-weeks compared to the baseline.

CONCLUSION

This retrospective study indicates the positive impact of on and analgesic use among AS patients. However, additional studies using robust research designs are warranted.

Benefit of Biological Drugs for Quality of Life in Patients with Ankylosing Spondylitis: A Systematic Review and Meta-Analysis of Clinical Trials

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease involving the axial skeleton, peripheral joints, and extra-articular manifestations like psoriasis, inflammatory bowel disease, or uveitis. A deterioration of quality of life (QoL) affects the disease management and therapeutic decision-making. This meta-analysis focused on the influence of biological drugs on the QoL in SA compared to the effects of other therapeutic modalities. We searched the databases of MedLine, Academic Search Ultimate, CINAHL Complete, and Health Source - Nursing/Academic Edition for articles related to AS treatment using the terms "ankylosing spondylitis" OR "rheumatoid spondylitis" OR "spondylitis" AND "quality of life" OR "patient-reported outcomes" OR "well-being" OR "health-related quality of life" OR "biological treatment". The search came up with 10 English-language articles published between 2010 and 2020. Patients were evaluated with the following indexes and questionnaires: Assessment of Spondyloarthritis International Society (ASAS), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Quality of Life (ASQoL), 36-Item Short-Form Health Survey (SF-36), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), and the Bath Ankylosing Spondylitis Functional Index (BASFI), and Bath Ankylosing Spondylitis Functional (BASFI) Indexes. We found that the QoL, assessed with the ASQoL, improved significantly better in patients treated with biological drugs when compared to those treated with other standard therapies or placebo at a 4-month follow-up. However, improvements in other disease characteristics could not be differentiated based on the therapy modality. The finding that biological drugs are superior in improving the QoL should strengthen the recommendations for their use in patients with AS.

miRNA-451a and miRNA-125a Expression Levels in Ankylosing Spondylitis: Impact on Disease Diagnosis, Prognosis, and Outcomes

Background

Early diagnosis of ankylosing spondylitis (AS) is yet not elucidated, with a potential diagnostic glance of microRNAs (miRNAs).

Aim

Study the expression profile of miRNA-451a and miRNA-125a in AS patients and their impact on disease activity and prognosis.

Methods

A cross-sectional study included 55 AS patients diagnosed according to modified New York criteria in 1984 with 55 matched healthy controls. History, clinical examination, and disease activity assessment with Bath ankylosing spondylitis disease activity index (BASDAI) were done. Full laboratory and radiological assessment along with expression profile of m iRNA-451a and miRNA-125a were tabulated and analyzed.

Results

Higher expression levels of miRNA-125a and lower of miRNA-451a in AS patients compared to controls. Furthermore, miRNA-125a expression was high in active AS patients compared to inactive patients and controls (7.0 ± 3.4 vs. 4.1 ± 2.1 vs. 2.6 ± 0.6, p < 0.001, respectively). miRNA-451a was significantly lower in active AS patients compared to inactive patients and controls (2.2 ± 1.1 vs. 4.1 ± 2.3 vs. 7.1 ± 4.5, respectively). Both miRNAs (miRNA-125a and miRNA-451a) had evident accuracy for AS diagnosis with areas under the curve (AUC) of 0.788 and 0.802, respectively. miRNA-125a had potential impact on AS activity with AUC of 0.777. Plasma levels of both miRNAs were able to distinguish AS patients with structural damage with AUCs 0.775 and 0.692, respectively.

Conclusions

Both miRNA-451a and miRNA-125a were found to be of great value as sensitive noninvasive diagnostic, prognostic, and disease burden biomarker of AS patients in Egypt with suggested further studies for future therapeutic implications.

The Influence of Vitamin D Receptor Gene Polymorphisms in Spondyloarthritis

Spondyloarthritis (SpA) is an inflammatory rheumatic disease related to low bone mineral density. Because vitamin D plays an important role in bone metabolism and immune system modulation, the aim of this study was to evaluate the influence of polymorphisms in vitamin D receptor genes (VDR) in the development of SpA. In this case-control study, a total of 244 patients with SpA and 197 individuals with no SpA were included. Among the patients, 174 had ankylosing spondylitis (AS) and 66 had psoriatic arthritis (PsA). Genotyping of FokI (rs2228570 C > T), BsmI (rs1544410 C > T), ApaI (rs7975232 A > C), and TaqI (rs731236 T > C) was performed using PCR-RFLP, while genotyping of HLA-B∗27 was performed using PCR-SSP. Serum levels for hydroxy (OH) vitamin D and the clinical activity index of the disease (BASDAI) were also evaluated. SNPStats and OpenEpi software were used for statistical analysis. The ApaI a allele and ApaI a/a genotype were less frequent in PsA compared with controls. The ApaI a/a genotype was associated with a protecting factor for PsA in females, and ApaI A/a was associated with a protecting factor for the disease in HLA-B∗27 positive patients. Notwithstanding, the ApaI a/a genotype was a risk factor for SpA and AS in males. The FokI f/f genotype was associated with a better clinical activity in PsA. When considering the covariates, vitamin D sufficiency, and gender, the FokI F/F genotype was associated with a risk factor in males with SpA and AS compared with females with this same genotype. In conclusion, the ApaI rs7975232 polymorphism was associated with PsA, and the FokI rs2228570 polymorphism was associated with better clinical PsA activity. ApaI and FokI were associated with SpA and AS when considering gender and vitamin D sufficiency.

Quality of internet videos related to exercise therapy of ankylosing spondylitis from mainland China : Content analysis

OBJECTIVE

The aim of this study is to assess the quality and reliability of online videos on ankylosing spondylitis (AS) exercises from the five most popular video websites in China.

DESIGN

Cross-sectional and descriptive study.

METHODS

We searched the video websites of Youku, Tencent, Tudou, IQiYi, and bilibili on February 15, 2020, using the keywords "Ankylosing spondylitis exercise" "Ankylosing spondylitis rehabilitation" and "Ankylosing spondylitis therapy" A total of 114 videos were included in the study and evaluated according to the Global Quality Scale (GQS) and modified DISCERN tool.

RESULTS

According to the GQS, the videos were classified as high quality (12.3%, n = 14), intermediate quality (63.2%, n = 72), and low quality (24.6%, n = 28). Using the modified DISCERN tool, the videos were divided into useless (53.5%, n = 61), useful (35.1%, n = 40), and misleading (11.4%, n = 13).

CONCLUSION

The analysis shows that the quality and reliability of online videos related to exercise therapy for Ankylosing spondylitis (AS) should be improved and supervised in China. Hospitals, universities, and medical doctors should make more useful and high-quality videos to provide effective exercise guidance for AS patients.

The association between Candida infection and ankylosing spondylitis: a population-based matched cohort study

AIMS

To explore whether newly diagnosed Candida infection increases the risk of developing ankylosing spondylitis (AS).

METHODS AND MATERIALS

We investigated 61,550 patients with newly diagnosed Candida infection between 1997 and 2013 from the Taiwan National Health Insurance Research Datasets to conduct a population-based matched-cohort study. Controls were 61,550 subjects without Candida infection and propensity score matched with the Candida exposure cohort. The follow-up period was defined as month from the initial diagnosis of Candida infection (or nested index date for controls) to the date of AS, or 31 December 2013. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the occurrence of AS.

RESULTS

The incidence rates of AS in the Candida group and comparison group were respectively 4.58 and 3.88 per 100,000 person-months. The adjusted HR (95% CI) of AS for the Candida group was 1.19 (0.99-1.44) compared to the control group after adjustment for age, gender and all covariates (95% CI = 1.77-2.27). However, an adjusted hazard ratio (aHR) of 1.77-fold (95% CI = 1.26-2.53) significant increase in the risk of developing AS was observed after 6 years of follow-up, when exposure to Candida was at baseline. The effect of Candida infection was significantly time varying (p value for interaction between follow-up period and Candida infection is .018).

CONCLUSIONS

A risk of AS was found after Candida infection, and a year of follow-up acts as an effect modifier between the Candida infection and risk of AS. Key messages What is already known on this subject? Links between spondyloarthritis and fungal infections have been found in animal studies before. What does this study add? Our study demonstrated that Candida infection is an independent risk factor for developing ankylosing spondylitis in terms of gender, age and relevant variables and comorbidities. A risk of ankylosing spondylitis was found after Candida infection, and year of follow-up acts as an effect modifier between the Candida infection and risk of AS. Clinicians should be aware of possible Candida infection in managing patients with ankylosing spondylitis. Implications: Clinicians must pay greater attention to patients with newly diagnosed Candida infection. Specifically, they should conduct tests for ankylosing spondylitis. Further research is needed to examine if and how treatment of Candida infection alleviates symptoms of AS.

Positive association of Parkinson's disease with ankylosing spondylitis: a nationwide population-based study

Background

Ankylosing spondylitis (AS) is characterized by excessive production of inflammatory cytokines. Recent evidence suggests that inflammation underlies the neurodegenerative process of Parkinson’s disease (PD). Whether AS has an influence on the development of PD is unclear. We aimed to examine a relationship, if any exists between AS and PD.

Methods

A population-based matched cohort study was performed using data from the 2000–2010 Taiwan National Health Insurance database. 6440 patients with AS and 25,760 randomly selected, age- and sex-matched controls were included in this study. The risk of PD in the AS cohort was evaluated by using a Cox model.

Results

This study revealed a positive association between AS and the risk of PD regardless of sex and age (aHR 1.75, p < .001). Particularly, AS cohort to non-AS cohort relative risk of PD significantly increased for the patients aged below 49 and above 65 years (aHR 4.70, p < .001; aHR 1.69, p < .001, respectively) and the patients with and without comorbidities (aHR 1.61, p < .001; aHR 2.71, p < .001, respectively). Furthermore, NSAID use was associated with lower risk of PD (aHR 0.69, p < .05). However, the risk of PD was higher (aHR 2.40, p < .01) in patients with AS receiving immunosuppressants than in those not receiving (aHR 1.70, p < .001).

Conclusions

Patients with AS had an increased risk of PD which might be related to underlying chronic inflammation. Further research is required to elucidate the underlying mechanism.

A Unique and Characteristic Cam FAI Morphology in Young Patients with Comorbid Inflammatory Conditions

BACKGROUND

The relationship between femoroacetabular impingement (FAI) and inflammatory medical comorbidities has not been established in the pediatric population. The purpose of this study was to investigate the prevalence of inflammatory conditions in pediatric patients with FAI and the morphology of the associated deformity.

METHODS

We performed a retrospective cohort study of 90 patients who were diagnosed with FAI in our institution's adolescent hip clinic from January 2016 to March 2018. Patients with an inflammatory comorbidity were identified. Standard quantitative radiographic FAI measurements as well as qualitative femoral head-neck junction morphology were analyzed.

RESULTS

Eight patients (8.9%) with 11 symptomatic hips were found to have an inflammatory condition. These 8 patients all had cam deformities. Nine of the symptomatic hips in this subset of patients had a negative femoral offset, where the cam deformity extended beyond the anterior margin of the femoral head. Qualitative assessment revealed a unique head-neck morphology with a prominent and "sharp-edged" bump at the head-neck junction, which resembled an inflammatory beak. In comparing patients with and without inflammatory comorbidities, a marked difference was found for alpha angles (difference, 26.6°; 95% confidence interval [CI], 18.2° to 35.0°) but not for age at diagnosis (difference, 0.5 years; 95% CI, -0.8 to 1.6 years) or the lateral center-edge angle (difference, 1.9°; 95% CI, -3.9° to 7.7°).

CONCLUSIONS

At our institution, 8.9% of pediatric patients with FAI were found to have an inflammatory comorbidity. These patients presented with a characteristic prominent "sharp-edged" head-neck morphology that standard radiographic measurements captured as a negative femoral offset and a larger alpha angle than was seen in patients without systemic inflammatory disease. Awareness of the characteristic cam deformity that was found in these patients may help to identify patients with undiagnosed inflammatory conditions. This unique deformity also raises questions regarding the possible role of physeal inflammation in the development of cam deformities and indicates a need for additional studies to investigate the relationship between systemic inflammatory diseases and FAI.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Depression in patients with spondyloarthritis: prevalence, incidence, risk factors, mechanisms and management

Depression is a major neuropsychiatric disorder common in patients with rheumatological conditions including spondyloarthritis (SpA). It is associated with higher disease activity, functional impairment, poor treatment response and quality of life in patients with musculoskeletal disorders. Using ankylosing spondylitis (AS) and psoriatic arthritis (PsA) as examples, we have reviewed the evidence regarding the burden, risk factors, potential mechanisms and clinical management of depression in spondyloarthritis. The prevalence of depression is higher in patients with AS and PsA compared with the general population, with evidence of moderate/severe depression in about 15% of patients with AS or PsA. Mild depression is even more common and estimated to be present in about 40% of patients with AS. In addition to conventional risk factors such as stressful life events and socioeconomic deprivation, increased risk of depression in SpA may be associated with disease-related factors, such as disease activity, poor quality of life, fatigue, and sleep disturbances. Emerging evidence implicates inflammation in the aetiology of depression, which could also be a shared mechanism for depression and chronic inflammatory conditions such as AS and PsA. It is imperative for clinicians to actively assess and treat depression in SpA, as this could improve treatment adherence, quality of life, and overall long-term clinical and occupational outcomes. The use of validated tools can aid recognition and management of depression in rheumatology clinics. Management of depression in SpA, especially when to refer to specialist mental health services, are discussed.

Understanding the Pathogenesis of Spondyloarthritis

Spondyloarthritis comprises a group of inflammatory diseases of the joints and spine, with various clinical manifestations. The group includes ankylosing spondylitis, reactive arthritis, psoriatic arthritis, arthritis associated with inflammatory bowel disease, and undifferentiated spondyloarthritis. The exact etiology and pathogenesis of spondyloarthritis are still unknown, but five hypotheses explaining the pathogenesis exist. These hypotheses suggest that spondyloarthritis is caused by arthritogenic peptides, an unfolded protein response, HLA-B*27 homodimer formation, malfunctioning endoplasmic reticulum aminopeptidases, and, last but not least, gut inflammation and dysbiosis. Here we discuss the five hypotheses and the evidence supporting each. In all of these hypotheses, HLA-B*27 plays a central role. It is likely that a combination of these hypotheses, with HLA-B*27 taking center stage, will eventually explain the development of spondyloarthritis in predisposed individuals.

A Mechanism Underlying Sex-Associated Differences in Ankylosing Spondylitis: Troponin C2, Fast Skeletal Type (TNNC2) and Calcium Signaling Pathway

BACKGROUND Ankylosing spondylitis (AS) is a disease that causes pathological changes in the spine and sacroiliac joints. Numerous studies have shown that the characteristics of AS differ between males and females. The purpose of this study was to discover the key molecules that contribute to sex-associated differences in AS, which may provide a new molecular target for personalized treatment. MATERIAL AND METHODS The gene expression profile of GSE39340 was downloaded from the Gene Expression Comprehensive database, and 2 groups (AS vs. No-AS groups and male AS vs. female AS groups) of differentially expressed genes (EDGs) were obtained by GEO2R. The DAVID database was used for DEGs function and enrichment analysis. Based on data in the STRING online database, a protein-protein interaction (PPI) network was constructed in Cytoscape. Hub genes were selected from CytoHubba. With the intersection of the top 30 hub genes of 2 sets of EDGs, genes coexisting with the KEGG-related pathway were found. RESULTS We screened 560 genes between the AS and No-AS groups, and screened 710 genes that were differentially expressed between the male and female AS groups. GO analysis showed that DEGs were mainly co-enriched in molecular functions, including structural constituent of muscle. The KEGG pathway mainly included the structural constituent of muscle. Seven hub genes were obtained. Troponin C2 and fast skeletal type (TNNC2) were the key genes participating in the calcium signaling pathway. CONCLUSIONS This study contributes to understanding the molecular biological mechanism underlying sex-associated differences in AS. TNNC2 and calcium signaling pathway may be new targets for the individualized treatment of AS.

The effect of secukinumab treatment on hematological parameters in ankylosing spondylitis and psoriatic arthritis

OBJECTIVE

Secukinumab, a new treatment agent, selectively neutralizes interleukin (IL)-17A. It is used in the treatment of ankylosing spondylitis (AS), psoriatic arthritis (PsA), and psoriasis. It is known that the agents used in the treatment of rheumatic diseases have effects on hematological parameters. In this study, we aimed to determine whether hematological parameters are affected in secukinumab therapy in patients with AS and PsA.

METHODS

Thirty-six patients on secukinumab treatment were included in the study by scanning the database of our hospital. Data on patients' age, gender, complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), uric acid, aspartate aminotransferase (AST), alanine aminotransferase (ALT), urea, creatinine values, and additional drug treatments were recorded from our database. The 0- and 6-month values of patients were analyzed.

RESULTS

Sixteen males (44.4%) and 20 females (55.6%) were included in our study. The average age was calculated to be 39.8±8.9 years. Of these, 30 patients receiving secukinumab treatment were diagnosed with AS, and 6 patients were diagnosed with PsA. Twenty-three patients (63.9%) were continued with secukinumab treatment at the 6th month. When CBC, glucose, urea, creatine, AST, ALT, ESR, CRP, and uric acid values of the patients at 0 and 6 months were compared, there was no significant difference.

CONCLUSION

In our study, no significant difference was found between 0 and 6 months in terms of CBC, AST, ALT, urea, creatinine, uric acid, glucose, CRP, and ESR levels in patients receiving secukinumab. However, an increase in hemoglobin values was observed in patients who continued the treatment. These results may suggest that secukinumab treatment has no negative effects on hematological parameters.

The Role of the IL-23/IL-17 Pathway in the Pathogenesis of Spondyloarthritis

Spondyloarthritis (SpA) is a subset of seronegative rheumatic-related autoimmune diseases that consist of ankylosing spondylitis (AS), psoriatic spondylitis (PsA), reactive spondylitis (re-SpA), inflammatory bowel disease (IBD)-associated spondylitis, and unclassifiable spondylitis. These subsets share clinical phenotypes such as joint inflammation and extra-articular manifestations (uveitis, IBD, and psoriasis [Ps]). Inflammation at the enthesis, where ligaments and tendons attach to bones, characterizes and distinguishes SpA from other types of arthritis. Over the past several years, genetic, experimental, and clinical studies have accumulated evidence showing that the IL-23/IL-17 axis plays a critical role in the pathogenesis of SpA. These discoveries include genetic association and the identification of IL-23- and IL-17-producing cells in the tissue of mouse models and human patients. In this review, we summarize the current knowledge of the pathomechanism by focusing on the IL-23/IL-17 pathway and examine the recent clinical studies of biological agents targeting IL-23 and IL-17 in the treatment of SpA.

Novel hypotheses related to Temporomandibular joint derived from Ankylosing spondylitis

Ankylosing spondylitis (AS) is a seronegative arthropathy that affects fibrocartilaginous joints leading to arthritis and eventually ankylosis. Temporomandibular joint (TMJ), a fibrocartilaginous joint is affected to a lesser extent than the other joints, very rarely precipitating TMJ ankylosis. No explanation exists for the same in the present literature. Several hypothesis have been presented to explain this phenomenon of rarity of TMJ ankylosis in AS. The presence of an intraarticular disc acts as a physical barrier to the ankylotic process. However, in cases with AS, that present with TMJ ankylosis, this hypothesis needs several clarifications since the intraarticular disc is a constant phenomenon in TMJ. The cause of TMJ ankylosis in these cases might be explained by two hypotheses. Firstly, Pathological condylar loading in some cases; secondly, an application of the orthopaedic concept of functional enthesis to the TMJ disc and thirdly, an application of the concept of enthesis organ to TMJ. Using these hypotheses, important concepts on the anatomy and evolution of TMJ can be derived with evidence from literature. The intraarticular disc may be considered as an involuted tendon of the lateral pterygoid muscle which not only attaches to the mandibular condyle but also to the temporal bone via a elastic fiber mediated enthesis extending to the malleus through the discomalleolar ligament. The fibrocartilaginous changes that occur on the undersurface of the disc may support the concept of functional enthesis and provide a reverse evidence for the disc being a tendon. The evidence presented from extant monotremes may also throw light on the embryological development of the articular disc. These evidences are more of an anecdote than being focussed. Several scientific experiments, studies and data collection needs to be carried out to validate them. The proof of these hypotheses will be of use in establishing the development and role of the articular disc in TMJ function and TMJ disorders, including AS. The understanding of the role of the articular disc is important since many firstly, TMJ disorders are being treated by discectomy with good results, apparently rendering the disc vestigial and secondly, in the era of tissue engineering where efforts are being made to artificially produce articular disc and its analogues.

New developments in our understanding of ankylosing spondylitis pathogenesis

Ankylosing spondylitis (AS) is a common immune‐mediated inflammatory arthritis with a strong genetic predisposition. We review recent data from genetic and animal studies highlighting the importance of Type 17 immune responses. Furthermore, the efficacy (or lack thereof) of different anti‐cytokine monoclonal antibodies has highlighted the diversity of Type 17 immune cells and cytokines critical to AS and related spondyloarthritis pathogenesis. Recent studies have strongly implicated the gut microbiome in AS. Finally, we propose that the local metabolic environment of the joint may have a key role in driving AS, and present a novel model of AS pathogenesis.

Social isolation due to the COVID-19 pandemic has led to worse outcomes in females with inflammatory arthritis

Background

Prolonged social isolation as a result of the COVID-19 global pandemic has been a source of considerable psychological distress for many people. This can manifest in many ways and if left undetected can impact negatively on general health. It is essential to understand the impact of these conditions on inflammatory arthritis (IA) patients, especially axial spondyloarthropathy (axSpA).

Aim

To capture the level of psychological distress for patients with IA following prolonged social isolation.

Methods

A survey was sent out to patients with a confirmed diagnosis of IA. This captured changes in sleep, mood, disease activity, employment and general health since the beginning of the social isolation period. A PHQ-4 (Patient Health Questionnaire) was included to determine level of psychological distress.

Results

Females with IA reported significantly higher rates of decline in general health (40% vs 16%, p = 0.01), mood disturbance (43.4% vs 26%, p = 0.03) and increased disease activity (50% vs 16%, p = 0.01) compared to males. Evaluating the mean PHQ-4 scores, no significant difference was noted between genders (4.80 vs 3.44, p = 0.10). However, females demonstrated a non-significant trend toward increased rates of moderate to severe psychological distress (40% vs 30%, p = 0.13). Subanalysis of patients with axSpA found high rates of moderate to severe distress in both genders.

Conclusions

Females with IA reported significantly higher rates of decline in general health, mood disturbance and increased disease activity during the period of social isolation. This was reflected in a trend towards greater levels of psychological distress.

Cell death in chronic inflammation: breaking the cycle to treat rheumatic disease

Cell death is a vital process that occurs in billions of cells in the human body every day. This process helps maintain tissue homeostasis, supports recovery from acute injury, deals with infection and regulates immunity. Cell death can also provoke inflammatory responses, and lytic forms of cell death can incite inflammation. Loss of cell membrane integrity leads to the uncontrolled release of damage-associated molecular patterns (DAMPs), which are normally sequestered inside cells. Such DAMPs increase local inflammation and promote the production of cytokines and chemokines that modulate the innate immune response. Cell death can be both a consequence and a cause of inflammation, which can be difficult to distinguish in chronic diseases. Despite this caveat, excessive or poorly regulated cell death is increasingly recognized as a contributor to chronic inflammation in rheumatic disease and other inflammatory conditions. Drugs that inhibit cell death could, therefore, be used therapeutically for the treatment of these diseases, and programmes to develop such inhibitors are already underway. In this Review, we outline pathways for the major cell death programmes (apoptosis, necroptosis, pyroptosis and NETosis) and their potential roles in chronic inflammation. We also discuss current and developing therapies that target the cell death machinery.

Metabolomic Profiling in the Characterization of Degenerative Bone and Joint Diseases

Osteoarthritis and inflammatory arthropathies are a cause of significant morbidity globally. New research elucidating the metabolic derangements associated with a variety of bone and joint disorders implicates various local and systemic metabolites, which further elucidate the underlying molecular mechanisms associated with these destructive disease processes. In osteoarthritis, atty acid metabolism has been implicated in disease development, both locally and systemically. Several series of rheumatoid arthritis patients have demonstrated overlapping trends related to histidine and glyceric acid, while other series showed similar results of increased cholesterol and glutamic acid. Studies comparing osteoarthritis and rheumatoid arthritis reported elevated gluconic acid and glycolytic- and tricarboxylic acid-related substrates in patients with osteoarthritis, while lysosphingolipids and cardiolipins were elevated only in patients with rheumatoid arthritis. Other bone and joint disorders, including osteonecrosis, intervertebral disc degeneration, and osteoporosis, also showed significant alterations in metabolic processes. The identification of the molecular mechanisms of osteoarthritis and inflammatory arthropathies via metabolomics-based workflows may allow for the development of new therapeutic targets to improve the quality of life in these patient populations.

Down-regulated miR-495 can target programmed cell death 10 in ankylosing spondylitis

Background

MicroRNAs (miRNAs) play crucial roles in regulating eukaryotic gene expression. Recent studies indicated that aberrantly expressed miRNAs are involved in the pathogenesis of ankylosing spondylitis (AS). Indeed, hsa-miR-495-3p (miR-495) has been reported as an anti-oncogene in different cancers. However, the role of miR-495 in AS is still unknown.

Methods

In this study, quantitative real-time polymerase chain reaction (PCR) was used to detect the expression of miR-495 in the peripheral blood mononuclear cells (PBMCs), whole blood, and serum of patients with AS. Bisulfite-specific PCR sequencing and methylated DNA immunoprecipitation were used to detect the methylation in the promoter region of miR-495. To determine the influence of miR-495 expression on the target gene, programmed cell death 10 (PDCD10), dual luciferase reporter assays together with an adenoviral vector containing the miR-495 locus were used. Receiver operating characteristic (ROC) curves were used to evaluate the efficacy of miR-495 as a diagnostic biomarker of AS. Gene Ontology, Kyoto Encyclopedia of Genes and Genomes pathway analysis, and western blotting were used to explore the potential role of miR-495 in AS pathogenesis and the mechanism by which it facilitates AS pathogenesis.

Results

miR-495 is down-regulated and the promoter region of miR-495 is highly methylated in AS. The expression of miR-495 is negatively associated with PDCD10 expression in both patients with AS and healthy controls. Further experiments showed that PDCD10 can be targeted by miR-495. The ROC curves of miR-495 suggested that it is a very specific and sensitive biomarker for AS diagnosis. Bioinformatics analysis and signal pathway studies indicated that miR-495 can down-regulate β-catenin and transforming growth factor-β1.

Conclusions

Our studies indicated that down-regulation of miR-495 can be used as a potential molecular marker for the diagnosis and treatment of AS, thus providing new insights into the role of miRNAs in AS pathology.

Effects of dihydrotestosterone on osteoblast activity in curdlan-administered SKG mice and osteoprogenitor cells in patients with ankylosing spondylitis

Background

Ankylosing spondylitis (AS) is characteristically male-predominant, and progressive spinal ankylosis affects male patients more severely; however, the hormonal effects in males with AS are poorly understood.

Methods

In the present study, the regulatory effects of dutasteride, a 5-α reductase inhibitor that blocks the conversion of testosterone to dihydrotestosterone (DHT), were examined in curdlan-administered male SKG mice to determine spinal bone formation, bone metabolism-related markers, and interleukin (IL)-17A cytokine and T cell populations. In addition, the effects of DHT on primary osteoprogenitors from the facet joints of AS patients were assessed based on osteoblast-related parameters. DHT level was measured, and the correlation with modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) was analyzed in AS patients.

Results

In curdlan-administered SKG mice, dutasteride treatment resulted in an increased accumulation of hydroxyapatite in the spine which was positively correlated with serum IL-17A levels. In the analysis of bone metabolism-related molecules, a decrease in sclerostin levels was observed in the sera in the dutasteride group. Continuous exposure to DHT resulted in fewer calcium deposits in AS osteoprogenitors during osteoblast differentiation. DHT-treated AS osteoprogenitors showed decreased osteocalcin and increased DKK1 and SOST1 mRNA expression, supporting the results of the in vivo experiments. Treatment with dutasteride upregulated bone formation in the spine of curdlan-administered SKG mice and DHT treatment downregulated osteoblast differentiation in vitro.

Conclusions

Treatment with dutasteride affected the bone formation in the spine of curdlan-treated SKG mice, and DHT treatment attenuated osteoblast differentiation in vitro. Therefore, contrary to what could be expected if osteoblasts contributed to spinal ankylosis, DHT inhibition might increase rather than decrease the progression of spinal ankylosis despite the higher levels of DHT observed in many AS patients.

Safety Profile of Biologics Used in Rheumatology: An Italian Prospective Pharmacovigilance Study

Post-marketing surveillance activities are essential to detect the risk/benefit profile of biologic disease-modifying antirheumatic drugs (bDMARDs) in inflammatory arthritis. The aim of this study was to evaluate adverse events (AEs) in patients treated with bDMARDs in rheumatology during a prospective pharmacovigilance study from 2016 to 2018. Descriptive statistical analyses were performed to evaluate bDMARDs-related variables of patients without AEs/failures vs patients with AEs and failures. The risk profile among biologics was assessed by comparing patients treated with each bDMARD to patients treated with etanercept. A total of 1155 patients were enrolled, mostly affected by rheumatoid arthritis (46.0%). AEs and failures were experienced by 8.7% and 23.3%, respectively. The number of comorbidities significantly influenced the onset of AEs, while anxiety-depressive, gastrointestinal disease, and fibromyalgia influenced onset of failures. The probability of developing an AE was significantly lower in patients treated with secukinumab, while the probability of developing treatment failure was significantly lower in patients treated with golimumab, secukinumab and tocilizumab. A total of 216 AEs were reported (25.5% serious), mostly regarding infections (21.8%), musculoskeletal (17.6%) and skin (16.2%) disorders. Serious AEs included neutropenia (12.7%), lymphocytosis (9.1%) and uveitis (7.3%). The obtained results revealed known AEs but real-world data should be endorsed for undetected safety concerns.

MicroRNAs in ankylosing spondylitis: Function, potential and challenges

Epigenetic mechanisms such as DNA methylation, histone modifications and non-coding RNA, are considered the essential connection between a disorder's onset and the environment, on a permissive genetic background. Among autoimmune and inflammatory-mediated disorders, Ankylosing Spondylitis (AS), a chronic arthritis of the spine, is a very good example for the weight of epigenetics' contribution. MicroRNAs (miRNAs) are single-stranded nucleotides which regulate gene expression and are involved in pathological and physiological processes. In this manuscript we provide a clarification on the role of microRNAs in AS, with a focus on the mechanisms of pathogenesis. In specific, we have examined the contribution of miRNAs in the processes of inflammation, new bone formation and T-cell function, and the pathways (i.e. Wnt, BMP, TGFβ signalling etc.) they regulate. The utility of miRNAs in better understanding AS pathogenesis is undisputed and their utility as therapeutic opportunity is strongly increasing.

Systemic changes associated with quality of life after surgical treatment of kyphotic deformity in patients with ankylosing spondylitis: a systematic review

PURPOSE

In addition to changes in the skeletal system after spinal osteotomy for treatment of kyphotic deformity in advanced-stage AS patients, many other systemic changes associated with the patients' quality of life were reported. The purpose of this study was to conduct a systemic review of the literature to determine systemic changes associated with patients' quality of life following correction of kyphotic deformity secondary to ankylosing spondylitis.

METHODS

We searched the databases PubMed, EMBASE, Clinicalkey and Cochrane Library without time restriction. Selected papers were assessed by published guidelines. We investigated systemic changes associated with patients' quality of life after surgical treatment of advanced ankylosing spondylitis.

RESULTS

The initial search yielded 888 citations. Twelve of these studies met the inclusion and exclusion criteria. Two were level II evidence study, and ten were level III evidence studies. Changes were reported including aorta length, abdominal morphology, digestive function, cardiopulmonary function, psychological status, and sexual activity.

CONCLUSIONS

In addition to skeletal changes after spinal osteotomy for treatment of kyphotic deformity in advanced-stage AS patients, many other changes were reported. Spine surgeons should pay more attention to these life quality-related changes and be aware of potential risks when performing surgery for advanced-stage AS patients. These slides can be retrieved under Electronic Supplementary Material.

The efficacy and safety of Health Qigong for ankylosing spondylitis: Protocol for a systematic review and meta-analysis

BACKGROUND

Non-pharmacological treatments (education, exercise, and physical therapy) are remain basic approaches to long-term management of ankylosing spondylitis (AS) patients. As an important part of non-pharmacological treatments, Health Qigong is widely used for AS treatment. We will perform the systematic review to confirm the safety and efficacy of Health Qigong for AS.

METHODS

Systematical search of 6 electronic databases will be done, including English and Chinese, until December 2019. All randomized controlled trials (RCTs) involving Health Qigong in combination with conventional therapy for AS will be included. Study selection, data extraction, and validation were performed independently by 2 reviewers. RevMan (V.5.3) will be used for mata-analysis.

RESULTS

This systematic review will identify the safety and efficacy of Health Qigong in the treatment of AS and update evidence summaries of Health Qigong. At the end of the treatment, the primary outcome is Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) with a range of 0 to 10,and the secondary outcomes will include functional ability that measured by Bath Ankylosing Spondylitis Functional Index (BASFI), mobility measured by Bath Ankylosing Spondylitis Metrology Index (BASMI), chest expansion, night spinal pain, adverse reactions, laboratory measures such as erythrocyte sedimentation rate (ESR) and C protein response (CRP).

CONCLUSION

This study will provide evidence that whether Health Qigong can benefit patients with ankylosing spondylitis by reducing disease activity, alleviating pain to support the application of Health Qigong in the AS treatment.

REGISTRATION NUMBER

CRD42019159126.