The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general

Disease-specific expansion of CD29+IL-17RA+ T effector cells possessing multiple signalling pathways in spondyloarthritis

OBJECTIVES

T cells adhere to enthesis fibrocartilage via integrins and intrinsically require IL-17RA-mediated signals to maintain their effector function. We analysed CD29+IL-17RA+ T cells in inflamed lesions and peripheral blood in patients with SpA and investigated their association with disease activity and therapeutic response.

METHODS

Transcriptome analysis of synovial fluid T cells from PsA was performed using publicly available bulk cell RNA sequencing data. Blood samples were obtained from healthy controls (n = 37), RA (n = 12), IgG4-related disease (IgG4-RD; n = 12), large vessel vasculitis (LVV; n = 12) and SpA (n = 28) and were analysed by flow cytometry.

RESULTS

T cells in the inflamed joints of PsA showed CD29 and IL-17RA expression. CD29+IL-17RA+ T cells showed enriched CXCR3+CD45RA+ effector cells and activation of spleen tyrosine kinase (Syk), nuclear factor κB (NF-κB) and Janus kinase-signal transducer and activator of transcription (JAK-STAT) pathways. The proportion of peripheral blood CD29+IL-17RA+ T cells was significantly increased in patients with SpA compared with patients with RA, IgG4-RD or LVV and in healthy controls. Based on the ASDAS-CRP scores, the proportion of CD29+IL-17RA+ T cells was positively correlated with disease activity in treatment-naïve patients with active SpA. Anti-IL-17 but not anti-TNF monoclonal antibodies reduced CD29+IL-17RA+ T cells.

CONCLUSIONS

CD29+IL-17RA+ T effector cells with enhanced Syk, NF-κB and JAK-STAT pathways were specifically increased in SpA and were correlated with disease activity, implicating a role of this newly identified T cell population in the pathogenesis. Anti-IL-17 monoclonal antibodies may be effective for patients by reducing this pathogenic T cell population.

The impact of diet on disease activity in spondyloarthritis: A systematic literature review

OBJECTIVES

Our study aimed to systematically review the evidence about the effect of diet or dietary supplements on spondyloarthritis (SpA) disease activity.

METHODS

a systematic literature review (SLR) was conducted in MEDLINE, EMBASE, Cochrane and SCOPUS according to the "PEO" format (Population, Exposure, Outcome). The population was SpA (axial or peripheral, axSpA/pSpA, including Psoriatic Arthritis-PsA); the intervention any kind of diet/dietary supplement; the outcome disease activity. Inclusion criteria were: adult patients, Randomized Controlled Trials (RCTs) and longitudinal studies (so that a pre-and post-intervention assessment were available), papers in English. Risk of bias (RoB) was conducted with different tools according to the design of the study.

RESULTS

Literature search yielded 1390 publications, of which 15 were finally inlcuded: 12 interventional and 3 observational studies. Among those with the lower RoB: a) 2 RCTs, one at unclear and one at low RoB, failed to show benefit of probiotics in SpA b) Two RCTs at unclear RoB provided evidence that weight loss, but not hypocaloric diet, was associated to MDA achievement in PsA. The remaining interventional studies were at high RoB. Among the observational studies, one study on Mediterranean diet demonstrated an association between diet adherence and a ≥ 20% decrease of ASDAS in axSpA. The other two observational studies were judged of poor quality.

CONCLUSIONS

weight loss seem to be able to impact disease activity in PsA, while probiotics do not seem useful in SpA; evidence for dietary behaviors is scarce and heterogeneous.

Imrecoxib and celecoxib affect sacroiliac joint inflammation in axSpA by regulating bone metabolism and angiogenesis

OBJECTIVE

To analyze the changes in the levels of bone metabolism markers related to sacroiliac joint (SIJ) inflammation in patients with axial spondyloarthritis (axSpA) after treatment with imrecoxib and celecoxib and evaluate their relationship with clinical efficacy.

METHODS

A total of 120 patients with axSpA with at least 2 magnetic resonance imaging (MRI) SIJ scans during a 12-week follow-up were enrolled. The levels of bone metabolism markers, including dickkopf-1(DKK-1), sclerostin, vascular endothelial growth factor (VEGF), bone morphogenetic protein-2 (BMP-2), osteoprotegerin (OPG), noggin, β-catenin, and RUNX2, were measured twice, and their association with disease activity and the Spondyloarthritis Research Consortium of Canada (SPARCC) score for SIJ were analyzed by univariate analysis of covariance.

RESULTS

A total of 116 patients completed the follow-up. The levels of sclerostin, OPG, noggin, DKK-1, and RUNX2 were increased, whereas those of VEGF and β-catenin were decreased. The levels of sclerostin and OPG were negatively correlated with disease duration. The levels of VEGF and β-catenin were significantly decreased (F = 7.866, P = 0.003; F = 4.106, P = 0.047) in patients with disease remission. A decrease in ESR was significantly correlated with decreased levels of Runx2 and SPARCC scores, with the levels of sclerostin being significantly elevated in the SPARCC-reduced group. There were no statistically significant differences between the imrecoxib and celecoxib groups (P> 0.05).

CONCLUSION

Imrecoxib and celecoxib affect SIJ inflammation, disease activity, and the course of disease by regulating bone metabolism and angiogenesis in axSpA. Key Points •After treatment with imrecoxib and celecoxib, the levels of sclerostin, OPG, noggin, DKK-1, and RUNX2 were increased, whereas those of VEGF and β-catenin were decreased, correlating with the course of disease, disease activity, and SIJ inflammation. • A decrease in ESR was significantly correlated with a decrease in the levels of RUNX2 and SIJ inflammation.. • The levels of sclerostin were more significantly elevated in SIJ inflammation remission group.. •Imrecoxib and celecoxib affect SIJ inflammation by regulating bone metabolism and angiogenesis in axSpA..

Cytokines in Spondyloarthritis and Inflammatory Bowel Diseases: From Pathogenesis to Therapeutic Implications

Spondyloarthritis and inflammatory bowel diseases are chronic immune disorders of the joints and the gut that often coexist in the same patient, increasing the burden of each disorder, worsening patients' quality of life, and influencing therapeutic strategies. Genetic predisposition, environmental triggers, microbiome features, immune cell trafficking, and soluble factors such as cytokines contribute to the pathogenesis of both articular and intestinal inflammation. Most of the molecular targeted biological therapies developed over the last two decades were based on evidence that specific cytokines may be involved in these immune diseases. Despite pro-inflammatory cytokine pathways sharing the pathogenesis of both articular and gut diseases (i.e., tumor necrosis factor and interleukin-23), several other cytokines (i.e., interleukin-17) may be differently involved in the tissue damage process, depending on the specific disease and the organ involved in inflammation, making difficult the identification of a therapeutic plan that is efficacious for both inflammatory manifestations. In this narrative review, we comprehensively summarize the current knowledge on cytokine involvement in spondyloarthritis and inflammatory bowel diseases, underlining similarities and differences among their pathogenetic pathways; finally, we provide an overview of current and potential future treatment strategies to simultaneously target both articular and gut immune disorders.

[18F] FDG uptake in patients with spondyloarthritis: correlation with serum inflammatory biomarker levels

BACKGROUND

We aimed to evaluate the correlation between 2-deoxy-2-[¹⁸F]fluoro-D-glucose (FDG) uptake and disease activity assessed by serum inflammatory biomarker levels in patients with spondyloarthritis (SpA).

METHODS

A total of 36 SpA patients (24 untreated and 12 treated) were examined using FDG positron emission tomography (PET)/computed tomography and classified into axial SpA (axSpA) and peripheral SpA (pSpA). FDG uptake was evaluated in 23 regions of the body and scored as follows: 0 = less than liver uptake; 1 = more than or equal to liver uptake; and 2 = more than or equal to twice liver uptake. A score of 1 or 2 was considered positive. The number of positive regions and the total score were counted in each patient. The maximum standardized uptake value (SUVmax) was calculated for each region, and maximum SUVmax (MaxSUVmax) was used as a representative value. Correlation of PET findings with serum inflammatory biomarker levels, including C-reactive protein (CRP), erythrocyte sedimentation rate, and matrix metalloproteinase 3 (MMP-3), was analyzed.

RESULTS

All but two patients had at least one positive lesion. PET indices correlated significantly with most of the serum inflammatory biomarker levels in untreated SpA, but not in treated SpA. Further, MaxSUVmax, number of positive regions, and total score correlated significantly with CRP (all P values < 0.001), and the number of positive regions (P = 0.012) and total score (P = 0.007) correlated significantly with MMP-3 in untreated pSpA. PET indices did not correlate with any serum inflammatory biomarker level in untreated axSpA.

CONCLUSION

FDG uptake in untreated pSpA correlated significantly with serum inflammatory biomarker levels.

Identification of circulating biomarkers of Crohn's disease and spondyloarthritis using Fourier transform infrared spectroscopy

Crohn's disease (CD) and spondyloarthritis (SpA) are two inflammatory diseases sharing many common features (genetic polymorphism, armamentarium). Both diseases lack diagnostic markers of certainty. While the diagnosis of CD is made by a combination of clinical, and biological criteria, the diagnosis of SpA may take several years to be confirmed. Based on the hypothesis that CD and SpA alter the biochemical profile of plasma, the objective of this study was to evaluate the analytical capability of Fourier transform infrared spectroscopy (FTIR) in identifying spectral biomarkers. Plasma from 104 patients was analyzed. After data processing of the spectra by Extended Multiplicative Signal Correction and linear discriminant analysis, we demonstrated that it was possible to distinguish CD and SpA from controls with an accuracy of 97% and 85% respectively. Spectral differences were mainly associated with proteins and lipids. This study showed that FTIR analysis is efficient to identify plasma biosignatures specific to CD or SpA.

Health-related quality of life among spondyloarthritis and chronic low back pain patients: results from a nationwide population-based survey

PURPOSE

Both spondyloarthritis and chronic low back pain (CLBP) significantly impact health-related quality of life (HRQoL). It is important to clarify whether these disorders have different impacts on the several domains of HRQoL as different mechanisms may necessitate different treatment interventions. Moreover, the factors associated with HRQoL can inform more targeted group interventions to promote HRQoL.

METHODS

We used data from EpiReumaPt, a population-based survey conducted from September 2011 to December 2013. HRQoL was assessed with EuroQoL-5-Dimensions (EQ-5D). Spondyloarthritis was diagnosed by expert opinion (rheumatologist) and predefined criteria. CLBP was diagnosed if low back pain was present on the day of the interview and persisted for > 90 days. Univariable and multivariable linear regression analyses compared HRQoL among subjects with spondyloarthritis, CLBP, and no rheumatic diseases. Multivariable linear regression analyses evaluated HRQoL factors in spondyloarthritis and CLBP subjects.

RESULTS

We included 92 spondyloarthritis patients, 1376 CLBP patients, and 679 subjects without rheumatic diseases. HRQoL was similarly affected in spondyloarthritis and CLBP (ß =  - 0.03, 95% CI [- 0.08; 0.03]) in all EQ5D dimensions. A much lower HRQoL was found in spondyloarthritis and CLBP patients compared with subjects without rheumatic diseases (ß =  - 0.14, 95% CI [- 0.19; - 0.10]; ß =  - 0.12, 95% CI [- 0.14; - 0.09], respectively). In spondyloarthritis subjects, multimorbidity and active disease were associated with worse HRQoL (ß =  - 0.18; 95% CI [- 0.24; 0.03]; ß =  - 0.13; 95% CI [- 0.29; - 0.05], respectively), and regular physical exercise was associated with better HRQoL (ß = 0.18; 95% CI [0.10; 0.30]). In CLBP subjects, multimorbidity (β =  - 0.11; 95% CI [- 0.14; - 0.08]), obesity (β =  - 0.04; 95% CI [- 0.08; - 0.01]), and low back pain intensity (β =  - 0.02; 95% CI [- 0.03; - 0.02]) were associated with worse HRQoL, and regular physical exercise (β = 0.08; 95% CI [0.05; 0.11]) was significantly associated with better HRQoL.

CONCLUSION

Spondyloarthritis and CLBP subjects reported similar levels of impairment in the mental, physical, and social domains of HRQoL. Future health plans should address modifiable factors associated with HRQoL in these conditions to achieve better outcomes.

Keep an Eye on the Back: Spondyloarthritis in Patients With Acute Anterior Uveitis

OBJECTIVES

This study was undertaken to analyze the prevalence of spondyloarthritis (SpA) in patients with acute anterior uveitis (AAU), to identify parameters associated with the presence of SpA, and to evaluate the performance of referral algorithms for identifying patients with a high probability of having SpA.

METHODS

Prospectively recruited consecutive patients with noninfectious AAU underwent structured rheumatologic assessment including magnetic resonance imaging of the sacroiliac joints, allowing a definitive diagnosis/exclusion of concomitant SpA. Fisher's exact test and Mann-Whitney U test were used to compare AAU patients with SpA and AAU patients without SpA. Furthermore, logistic regression analyses were performed. The predictive performance of SpA referral strategies was analyzed by calculating the sensitivity, specificity, positive predictive value, and positive and negative likelihood ratios.

RESULTS

Among the 189 AAU patients evaluated, 106 (56%) were diagnosed as having SpA. The majority of SpA patients (93%) had predominantly axial SpA and 7 patients had peripheral SpA. In 74 patients (70%), the SpA diagnosis was established for the first time. In multivariable logistic regression analysis, psoriasis (odds ratio [OR] 12.5 [95% confidence interval (95% CI) 1.3-120.2]), HLA-B27 positivity (OR 6.3 [95% CI 2.4-16.4]), elevated C-reactive protein level (OR 4.8 [95% CI 1.9-12.4]), and male sex (OR 2.1 [95% CI 1.1-4.2]) were associated with the presence of SpA. None of the ophthalmologic parameters were found to be predictive of SpA. The Dublin Uveitis Evaluation Tool (DUET) showed higher specificity for SpA recognition than the Assessment of SpondyloArthritis international Society (ASAS) tool for the early referral of patients with a suspected diagnosis of axial SpA (specificity for SpA 42% versus 28%), whereas the sensitivity of the ASAS tool was slightly higher than the DUET tool (sensitivity for SpA 80% versus 78%). However, more than 20% of the AAU patients in this study who were diagnosed as having SpA would have been missed by both referral strategies.

CONCLUSION

Our study revealed a high prevalence of SpA in AAU patients overall, as well as a high prevalence of previously undiagnosed SpA in AAU patients. Therefore, we propose rheumatologic evaluation for all AAU patients with musculoskeletal symptoms.

Reactive arthritis occurring after COVID-19 infection: a narrative review

PURPOSE

Reactive arthritis is acute aseptic arthritis occurring 1 to 4 weeks after a distant infection in a genetically predisposed individual. It may occur after COVID-19 infection. We summarize, in this article, the current findings of reactive arthritis following COVID-19 infection.

METHODS

A literature search has been performed from December 2019 to December 2021. We included case reports of reactive arthritis occurring after COVID-19 infection. We collected demographic, clinical, and paraclinical data.

RESULTS

A total of 22 articles were reviewed. There were 14 men and 11 women with a mean age of 44.96 + 17.47 years. Oligoarticular involvement of the lower limbs was the most frequent clinical presentation. The time between arthritis and COVID infection ranged from 6 to 48 days. The diagnosis was based on clinical and laboratory findings. The pharmacological management was based on non-steroidal anti-inflammatory drugs in 20 cases. Systemic or local steroid therapy was indicated in 13 patients. Sulfasalazine was indicated in two cases. Alleviation of symptoms and recovery were noted in 22 cases. The mean duration of the clinical resolution was 16 + 57 days.

CONCLUSION

The diagnosis of reactive arthritis should be considered in patients with a new onset of arthritis following COVID-19 infection. Its mechanism is still unclear.

Axial Skeleton Bone Marrow Changes in Inflammatory Rheumatologic Disorders

Magnetic resonance imaging (MRI) of the axial skeleton, spine, and sacroiliac (SI) joints is critical for the early detection and follow-up of inflammatory rheumatologic disorders such as axial spondyloarthritis, rheumatoid arthritis, and SAPHO/CRMO (synovitis, acne, pustulosis, hyperostosis, and osteitis/chronic recurrent multifocal osteomyelitis). To offer a valuable report to the referring physician, disease-specific knowledge is essential. Certain MRI parameters can help the radiologist provide an early diagnosis and lead to effective treatment. Awareness of these hallmarks may help avoid misdiagnosis and unnecessary biopsies. A bone marrow edema-like signal plays an important role in reports but is not disease specific. Age, sex, and history should be considered in interpreting MRI to prevent overdiagnosis of rheumatologic disease. Differential diagnoses-degenerative disk disease, infection, and crystal arthropathy-are addressed here. Whole-body MRI may be helpful in diagnosing SAPHO/CRMO.

Apical fibrosis was the most common incidental pulmonary finding in a familial Mediterranean fever cohort

INTRODUCTION

Familial Mediterranean fever (FMF) is one of the common autoinflammatory diseases with multisystemic manifestation. Pleuritis is the only known pulmonary involvement of FMF; however, as far as we know, thoracic involvements in pleural, parenchymal, bronchial, and vascular structures have not been evaluated yet.

METHOD

We included 243 consecutive FMF patients who applied to our clinic within the last 5 years and were requested to have a thorax CT for any reason and 122 trauma patients without any comorbidity. An experienced radiologist evaluated the thorax CT images blindly according to the relevant guidelines. We then presented the common incidental pulmonary and mediastinal findings on the thorax CT. Additionally, we compared patients with and without lung involvement according to demographic and disease-related parameters.

RESULTS

In our study, 167 of 243 patients (68.7%) had at least one of the pulmonary findings on their thorax CT. The most common pulmonary findings were apical fibrosis in 96 (39.5%) patients, parenchymal fibrotic changes in 48 (19.8%) patients, and a solitary parenchymal nodule smaller than 4 mm in 33 (13.6%) patients. All demographic, genetic, and disease-related characteristics, including the frequency of spondyloarthropathy, were similar in patients with and without pulmonary findings.

CONCLUSIONS

We showed that the most common incidental pulmonary finding in our FMF cohort was apical fibrosis on thoracic CT. Our data did not show causality between FMF and apical fibrosis; therefore, more studies are needed to evaluate the frequency and clinical significance of apical fibrosis in FMF. Key Points • More than two-thirds of familial Mediterranean fever (FMF) patients in our study group who underwent a thoracic scan for any reason had pulmonary and mediastinal findings on thorax computed tomography (CT). • In our FMF cohort, the most common incidental pulmonary finding on their thorax CT was apical fibrosis. • All demographic and disease-related characteristics, including the frequency of spondyloarthritis, were similar between patients with and without pulmonary and mediastinal findings.

Clinical Significance of Different Profiles of anti-Ro Antibodies in Connective Tissue Diseases

Objective

Anti-Ro60 and anti-Ro52 antibodies are associated with different connective tissue diseases (CTDs). However, the clinical significance of anti-Ro antibodies is not always consistent among different global regions. The aim of this study was to investigate the clinical characteristics of patients with anti-Ro antibodies.

Methods

A total of 1596 inpatients with anti-Ro antibodies were included in the study. Demographic, clinical, and serological data were compared between individuals with different profiles of anti-Ro antibodies: patients with anti-Ro52 antibodies alone, patients with anti-Ro60 antibodies alone, and patients with combined anti-Ro52 and anti-Ro60 antibodies.

Results

Of the 1596 patients, 1362 (85.3%) were female, the mean age was 45.5 years, and systemic lupus erythematosus (SLE) (46.0%) and Sjogren's syndrome (SS) (19.0%) were the most common CTD diagnoses. Among the patients with anti-Ro52 antibodies alone, idiopathic inflammatory myopathy (18.8%) and SLE (17.6%) were the most common CTD diagnoses. The coexistent autoantibodies of this group were significantly lower compared with those of the other two groups, while the presence of anti-Jo1 antibodies were significantly higher compared with those of the other two groups (3.7% vs. 0.6% vs. 1.9%, p = 0.029). In addition, the patients with isolated anti-Ro52 antibodies were more likely to suffer from interstitial lung disease (35.5% vs. 11.3% vs. 13.7%, p < 10^-4) and pulmonary arterial hypertension (10.1% vs. 5.3% vs. 3.6%, p = 0.001) compared with the other two groups of patients. Compared with patients with isolated anti-Ro52 or anti-Ro60 antibodies, the patients with combined anti-Ro52 and anti-Ro60 antibodies were more likely to suffer from xerophthalmia and xerostomia. Furthermore, hypocomplementemia, hyperglobulinemia, and proteinuria were particularly prevalent in patients with anti-Ro60 antibodies.

Conclusion

Different profiles of anti-Ro antibodies were significantly associated with clinical phenotypic features in CTDs, indicating the potential diagnostic and prognostic value of these antibodies in clinical practice.

Vesicular traffic-mediated cell-to-cell signaling at the immune synapse in Ankylosing Spondylitis

The chronic inflammatory disease ankylosing spondylitis (AS) is marked by back discomfort, spinal ankylosis, and extra-articular symptoms. In AS, inflammation is responsible for both pain and spinal ankylosis. However, the processes that sustain chronic inflammation remain unknown. Despite the years of research conducted to decipher the intricacy of AS, little progress has been made in identifying the signaling events that lead to the development of this disease. T cells, an immune cell type that initiates and regulates the body's response to infection, have been established to substantially impact the development of AS. T lymphocytes are regarded as a crucial part of adaptive immunity for the control of the immune system. A highly coordinated interaction involving antigen-presenting cells (APCs) and T cells that regulate T cell activation constitutes an immunological synapse (IS). This first phase leads to the controlled trafficking of receptors and signaling mediators involved in folding endosomes to the cellular interface, which allows the transfer of information from T cells to APCs through IS formation. Discrimination of self and nonself antigen is somatically learned in adaptive immunity. In an autoimmune condition such as AS, there is a disturbance of self/nonself antigen discrimination; available findings imply that the IS plays a preeminent role in the adaptive immune response. In this paper, we provide insights into the genesis of AS by evaluating recent developments in the function of vesicular trafficking in IS formation and the targeted release of exosomes enriched microRNAs (miRNA) at the synaptic region in T cells.

S100A8 alarmin supports IL-6 and metalloproteinase-9 production by fibroblasts in the synovial microenvironment of peripheral spondyloarthritis

Introduction

Spondyloarthritis (SpA) is a common autoinflammatory disease. S100A8/ S100A9 alarmin is strongly expressed in the synovial sublining layers of psoriatic arthritis. S100A8/ S100A9 is the most abundant protein in rheumatoid arthritis synovial fluid (SF) and has a key role in promoting IL-6 expression in fibroblast-like synoviocytes (FLS). The molecular mechanisms and the role of S100-alarmins in the synovial microenvironment of SpA have never been demonstrated.

Methods and Results

Here, we confirm the effect of the synovial microenvironment of peripheral SpA on interleukin-6 (IL-6) and metalloproteinase (MMP)-9 production by FLS. MMP-9 expression and activity were detected, which were reduced in the presence of anti-IL-6R. Analyzing cell signaling mechanisms, we found that stimulation with IL-6 co-triggered MMP-9 and IL-10 secretion. MMP-9 secretion depended on JNK and p38 MAPKs, whereas IL-10 secretion was dependent on the JAK pathway as a potential feedback mechanism controlling IL-6-induced MMP-9 expression. Using a proteomic approach, we identified S100A8 in the peripheral SpA SF. This presence was confirmed by immunoblotting. S100A8 increased the IL-6 secretion via ERK and p38 MAPK pathways. Furthermore, anti-S100A8/A9 reduced both IL-6 and MMP-9 production induced by SpA SF in FLS.

Discussion

Our data reveal a marked relationship between S100A8 alarmin with IL-6 and MMP-9 secretion by FLS in the real synovial microenvironment of peripheral SpA. These results identify a mechanism linking S100A8 to the pathogenesis of peripheral SpA.

Deep learning methods in the diagnosis of sacroiliitis from plain pelvic radiographs

OBJECTIVES

The aim of this study is to develop a computer-aided diagnosis method to assist physicians in evaluating sacroiliac radiographs.

METHODS

Convolutional neural networks, a deep learning method, were used in this retrospective study. Transfer learning was implemented with pre-trained VGG-16, ResNet-101 and Inception-v3 networks. Normal pelvic radiographs (n = 290) and pelvic radiographs with sacroiliitis (n = 295) were used for the training of networks.

RESULTS

The training results were evaluated with the criteria of accuracy, sensitivity, specificity and precision calculated from the confusion matrix and AUC (area under the ROC curve) calculated from ROC (receiver operating characteristic) curve. Pre-trained VGG-16 model revealed accuracy, sensitivity, specificity, precision and AUC figures of 89.9%, 90.9%, 88.9%, 88.9% and 0.96 with test images, respectively. These results were 84.3%, 91.9%, 78.8%, 75.6 and 0.92 with pre-trained ResNet-101, and 82.0%, 79.6%, 85.0%, 86.7% and 0.90 with pre-trained inception-v3, respectively.

CONCLUSIONS

Successful results were obtained with all three models in this study where transfer learning was applied with pre-trained VGG-16, ResNet-101 and Inception-v3 networks. This method can assist clinicians in the diagnosis of sacroiliitis, provide them with a second objective interpretation and also reduce the need for advanced imaging methods such as magnetic resonance imaging.

Monocyte subpopulations display disease-specific miRNA signatures depending on the subform of Spondyloarthropathy

Spondyloarthropathies (SpA) are a family of rheumatic disorders that could be divided into axial (axSpA) and peripheral (perSpA) sub-forms depending on the disease clinical presentation. The chronic inflammation is believed to be driven by innate immune cells such as monocytes, rather than self-reactive cells of adaptive immune system. The aim of the study was to investigate the micro-RNA (miRNA) profiles in monocyte subpopulations (classical, intermediate and non-classical subpopulations) acquired from SpA patients or healthy individuals in search for prospective disease specific and/or disease subtype differentiating miRNA markers. Several SpA-specific and axSpA/perSpA differentiating miRNAs have been identified that appear to be characteristic for specific monocyte subpopulation. For classical monocytes, upregulation of miR-567 and miR-943 was found to be SpA-specific, whereas downregulation of miR-1262 could serve as axSpA-differentiating, and the expression pattern of miR-23a, miR-34c, mi-591 and miR-630 as perSpA-differentiating markers. For intermediate monocytes, expression levels of miR-103, miR-125b, miR-140, miR-374, miR-376c and miR-1249 could be used to distinguish SpA patients from healthy donors, whereas the expression pattern of miR-155 was identified as characteristic for perSpA. For non-classical monocytes, differential expression of miR-195 was recognized as general SpA indicator, while upregulation of miR-454 and miR-487b could serve as axSpA-differentiating, and miR-1291 as perSpA-differentiating markers. Our data indicate for the first time that in different SpA subtypes, monocyte subpopulations bear disease-specific miRNA signatures that could be relevant for SpA diagnosis/differentiation process and may help to understand SpA etiopathology in the context of already known functions of monocyte subpopulations.

Both Disease Activity and HLA-B27 Status Are Associated With Gut Microbiome Dysbiosis in Spondyloarthritis Patients

OBJECTIVE

Gut microbiome dysbiosis has previously been reported in spondyloarthritis (SpA) patients and could be critically involved in the pathogenesis of this disorder. The objectives of this study were to further characterize the microbiota structure in SpA patients and to investigate the relationship between dysbiosis and disease activity in light of the putative influence of the genetic background.

METHODS

Shotgun sequencing was performed on fecal DNA isolated from stool samples from 2 groups of adult volunteers: SpA patients (n = 102) and healthy controls (n = 63). A subset of the healthy controls comprised the age-matched siblings of patients whose HLA-B27 status was known. Changes in gut microbiota composition were assessed based on species diversity, enterotypes, and taxonomic and functional differences.

RESULTS

Dysbiosis was confirmed in SpA patients as compared to healthy controls. The restriction of microbiota diversity was detected in patients with the most active disease, and the abundance of several bacterial species was correlated with Bath Ankylosing Spondylitis Disease Activity Index score. Among healthy controls, significant differences in microbiota composition were also detected between the HLA-B27-positive and the HLA-B27-negative siblings of SpA patients. We highlighted a decreased abundance of several species of bacteria in SpA patients, especially those bacteria belonging to the Clostridiales order. Among the few species of bacteria showing increased abundance, Ruminococcus gnavus was one of the top differentiating species.

CONCLUSION

These findings reveal that genetic background and level of disease activity are likely to influence the composition of the gut microbiota of patients with SpA. It may be appropriate for further research on chronic arthritis to focus on these key parameters.

Development and Validation of a Self-Administered Questionnaire Measuring Essential Knowledge in Patients With Axial Spondyloarthritis

OBJECTIVE

To develop and validate a patient knowledge questionnaire regarding axial spondyloarthritis (axSpA).

METHODS

Knowledge considered essential for patients with axSpA was identified through Delphi rounds among rheumatologists, healthcare professionals (HCPs), and patients, then reformulated to develop the knowledge questionnaire. Cross-sectional validation was performed in 14 rheumatology departments to assess internal validity (Kuder-Richardson coefficient), external validity, acceptability, reproducibility (Lin concordance correlation coefficient), and sensitivity to change (knowledge score before vs after patient education sessions and effect size).

RESULTS

The Spondyloarthritis Knowledge Questionnaire (SPAKE) is a self-administered 42-item questionnaire with a 32-item short form, both scored 0 to 100, assessing knowledge of disease, comorbidities, pharmacological treatments, nonpharmacological treatments, self-care, and adaptive skills. In the validation study (130 patients; 67 [51.5%] male, mean age 43.5 [SD 12.9] yrs), the mean (SD) score of the long-form questionnaire was 71.6 (15.4), with higher scores (better knowledge) in nonpharmacological treatments and adaptive skills and lower scores in cardiovascular comorbidity and pharmacological treatments. Acceptability was good, with no missing data; the internal validity coefficient was 0.85. Reproducibility was good (0.81, 95% CI 0.72-0.89). SPAKE showed good sensitivity to change; scores were 69.2 (15.3) then 82.7 (14.0) after patient education sessions (Hedges effect size = 0.92, 95% CI 0.52-1.31).

CONCLUSION

SPAKE is a knowledge questionnaire for patients with axSpA, developed with the involvement of HCPs and patients and reflecting current recommendations for the management of axSpA. SPAKE will be useful in assessing knowledge acquisition and self-management strategies in routine care and research.

[HLA-B27 positive anterior uveitis : Clinical aspects, diagnostics, interdisciplinary management and treatment]

Acute anterior uveitis (AAU) associated with human leukocyte antigen (HLA) B27 is the most common form of noninfectious intraocular inflammation and is considered to be a separate clinical entity. Young adults between the ages of 20 and 40 years are predominantly affected. The HLA-B27 positive AAU typically presents as a unilateral, fulminant disruption of the blood-aqueous humor barrier, which is accompanied by pronounced cellular infiltration and fibrinous exudation. Other characteristics are reduced intraocular pressure and a high tendency to relapse, which can also involve the partner eye. Patients with HLA-B27 positive AAU share a high risk for other genetically associated diseases, especially spondylarthritis, chronic inflammatory bowel diseases and psoriasis. As up to 40% of those affected have a systemic disease that has not yet been diagnosed, the ophthalmologist is of major importance for early detection.

Screening for spondyloarthritis in patients with inflammatory bowel diseases

Inflammatory bowel diseases (IBDs) can be associated with various musculoskeletal (IBD-MSK) manifestations that could be difficult to classify for gastroenterologists. We aimed to evaluate the characteristics of patients with IBD-MSK and the prevalence of spondyloarthritis (SpA). In this observational cross-sectional study, we included patients with IBD-MSK complaints (peripheral or back pain). All patients underwent a standardized rheumatology evaluation including clinical, biological and imaging evaluations (MRI of spine and sacroiliac joints and ultrasonography of enthesis). We included 183 IBD patients (60.7% women; median [interquartile range] age 45 [36-56] years); 159 (87%) had joint pain. In 43 (23.5%) and 25/175 (14.3%) patients, enthesis abnormalities were found on ultrasonography and sacroiliitis on MRI, respectively. SpA was diagnosed in 54 (29.5%) patients. IBD-related arthralgia and degenerative spine disease were diagnosed in 105 (57.4%) and 72 (39.3%) patients. Sixteen (29.6%) SpA patients initiated a new conventional synthetic disease modifying anti-rheumatic drug (DMARD). A biologic DMARD was initiated in 10 patients or changed in 3. More than half of IBD-MSK patients had IBD-related arthralgia, and about one-third had definite SpA. Ultrasonography of enthesis and systematic MRI of sacroiliac joints seem useful for SpA classification and differential diagnosis in these patients who often have musculoskeletal pain complaints. Therapeutics were changed in most patients, which highlights the need for a multidisciplinary approach for managing IBD with extra-intestinal symptoms.

Interactions between NSAIDs, opioids and the gut microbiota - Future perspectives in the management of inflammation and pain

The composition of intestinal microbiota is influenced by a number of factors, including medications, which may have a substantial impact on host physiology. Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics are among those widely used medications that have been shown to alter microbiota composition in both animals and humans. Although much effort has been devoted to identify microbiota signatures associated with these medications, much less is known about the underlying mechanisms. Mucosal inflammation, changes in intestinal motility, luminal pH and bile acid metabolism, or direct drug-induced inhibitory effect on bacterial growth are all potential contributors to NSAID- and opioid-induced dysbiosis, however, only a few studies have addressed directly these issues. In addition, there is a notable overlap between the microbiota signatures of these drugs and certain diseases in which they are used, such as spondyloarthritis (SpA), rheumatoid arthritis (RA) and neuropathic pain associated with type 2 diabetes (T2D). The aims of the present review are threefold. First, we aim to provide a comprehensive up-to-date summary on the bacterial alterations caused by NSAIDs and opioids. Second, we critically review the available data on the possible underlying mechanisms of dysbiosis. Third, we review the current knowledge on gut dysbiosis associated with SpA, RA and neuropathic pain in T2D, and highlight the similarities between them and those caused by NSAIDs and opioids. We posit that drug-induced dysbiosis may contribute to the persistence of these diseases, and may potentially limit the therapeutic effect of these medications by long-term use. In this context, we will review the available literature data on the effect of probiotic supplementation and fecal microbiota transplantation on the therapeutic efficacy of NSAIDs and opioids in these diseases.

Clinical Evaluation of High-Resolution MRI Combined With DWI in Identifying Vulnerable Carotid Plaque

BACKGROUND

High-resolution magnetic resonance imaging combined with diffusion weighted imaging is used to identify vulnerable plaques (VP) and their characteristic components, and apparent diffusion coefficient (ADC) correlation analysis with serum inflammatory markers to assess plaque vulnerability.

METHODS

In this study, 60 eligible patients were included, including 29 patients in VP group and 31 patients in non-VP group (N group). The average ADC value, serum inflammatory marker levels (high-sensitivity C-reactive protein, myeloperoxidase, and erythrocyte sedimentation rate) of the 2 groups were measured, and the characteristics of different plaque components and ADC levels of vascular wall in VP group were compared, to evaluate the correlation between serum inflammatory markers and the mean value of plaque ADC.

RESULTS

The results showed that the ADC mean value of the plaques in the VP group was significantly lower than that in the N group, and the levels of hypersensitive C-reactive protein and myeloperoxidase were correlated with the ADC mean value of the plaques.

CONCLUSION

The ADC value of plaque measured by high-resolution magnetic resonance imaging combined with diffusion weighted imaging sequence can quantify the identification of VP and its characteristic components, reflect the inflammation of plaque to a certain extent, and thus prevent and treat stroke and other adverse outcomes more effectively.

Levels of extracellular matrix metabolites are associated with changes in Ankylosing Spondylitis Disease Activity Score and MRI inflammation scores in patients with axial spondyloarthritis during TNF inhibitor therapy

BACKGROUND/PURPOSE

In axial spondyloarthritis (axSpA) inflammation of the sacroiliac joints and spine is associated with local extracellular matrix (ECM) remodeling of affected tissues. We aimed to investigate the association of ECM metabolites with treatment response in axSpA patients treated with TNF-α inhibitory therapy for 46 weeks.

METHODS

In a prospective clinical study of axSpA patients (n=55) initiating a TNF inhibitor (infliximab, etanercept, or adalimumab), serum concentrations of formation of type I (PRO-C1), type III (PRO-C3), and type VI (PRO-C6) collagen; turnover of type IV collagen (PRO-C4), and matrix-metalloproteinase (MMP)-degraded type III (C3M) collagen, MMP-degraded type IV (C4M), type VI (C6M), and type VII (C7M) collagen, and cathepsin-degraded type X collagen (C10C), MMP-mediated metabolite of C-reactive protein (CRPM), citrullinated vimentin (VICM), and neutrophil elastase-degraded elastin (EL-NE) were measured at baseline, week 2, week 22, and week 46.

RESULTS

Patients were mostly males (82%), HLA-B27 positive (84%), with a median age of 40 years (IQR: 32-48), disease duration of 5.5 years (IQR: 2-10), and a baseline Ankylosing Spondylitis Disease Activity Score (ASDAS) of 3.9 (IQR: 3.0-4.5). Compared to baseline, PRO-C1 levels were significantly increased after two weeks of treatment, C6M levels were significantly decreased after two and 22 weeks (repeated measures ANOVA, p=0.0014 and p=0.0015, respectively), EL-NE levels were significantly decreased after 2 weeks (p=0.0008), VICM levels were significantly decreased after two and 22 weeks (p=0.0163 and p=0.0374, respectively), and CRP were significantly decreased after two and 22 weeks (both p=0.0001). Baseline levels of PRO-C1, PRO-C3, C6M, VICM, and CRP were all associated with ASDAS clinically important and major improvement after 22 weeks (ΔASDAS ≥1.1) (Mann-Whitney test, p=0.006, p=0.008, p<0.001, <0.001, <0.001, respectively), while C6M, VICM and CRP levels were associated with ASDAS clinically important and major improvement after 46 weeks (ΔASDAS ≥2.0) (p=0.002, p=0.044, and p<0.001, respectively). PRO-C1 and C6M levels were associated with a Bath AS Disease Activity Score (BASDAI) response to TNF-inhibitory therapy after 22 weeks (Mann-Whitney test, p=0.020 and p=0.049, respectively). Baseline levels of PRO-C4 and C6M were correlated with the total SPARCC MRI Spine and Sacroiliac Joint Inflammation score (Spearman's Rho ρ=0.279, p=0.043 and ρ=0.496, p=0.0002, respectively).

CONCLUSIONS

Extracellular matrix metabolites were associated with ASDAS response, MRI inflammation, and clinical treatment response during TNF-inhibitory treatment in patients with axSpA.

The impact of psoriasis on the clinical characteristics, disease burden and treatment patterns of peripheral spondyloarthritis

OBJECTIVES

To evaluate the clinical characteristics, disease burden, and treatment patterns of peripheral spondyloarthritis (pSpA) patients with and without psoriasis using data from the ASAS-perSpA study.

METHODS

We included 433 patients who had a diagnosis of pSpA according to the rheumatologist's diagnosis from the ASAS-PerSpA study. The presence of a personal history of psoriasis was defined as the presence of signs of psoriasis at physical examination or the presence of psoriatic nail dystrophy, including onycholysis, pitting and hyperkeratosis, or a history of psoriasis diagnosed by a physician. Clinical characteristics, patient-reported outcomes and treatment pattern were compared between subgroups with and without psoriasis.

RESULTS

A total of 83 patients (19.2%) had a personal history of psoriasis. Patients with psoriasis were older (48.4 vs 43.2 years) and had a longer diagnostic delay (7.4 vs 3.5 years), a higher frequency of dactylitis (36.1 vs 20.0%) and enthesitis (65.1 vs 55.4%) than patients without psoriasis. A longer diagnostic delay (odds ratio [OR] = 1.06 [95% CI 1.01, 1.11]), lower odds for HLA-B27 positivity (OR = 0.31 [95% CI 0.15, 0.65]) and higher odds for enthesitis (OR = 2.39 [95% CI 1.16, 4.93]) were associated with the presence of psoriasis in a multivariable regression analysis. While patient-reported outcomes were comparable between groups, a higher use of biologic DMARDs was observed in patients with vs without psoriasis.

CONCLUSION

The presence of psoriasis has an impact on clinical characteristics of pSpA. pSpA patients without psoriasis were less frequently treated with biologic DMARDs despite similar disease burden as compared with patients with psoriasis.

Spinal radiographic progression is correlated with preclinical atherosclerosis in spondyloarthritis

BACKGROUND

A higher prevalence of cardiovascular risk was observed in spondyloarthritis (SpA). The relationship between disease-related factors structural damage and subclinical atherosclerosis is still unknown.

OBJECTIVE

The aim of our study was to evaluate the association of subclinical atherosclerosis with radiographic structural damage in patients with SpA.

METHODS

Forty-seven SpA patients who fulfilled the ASAS criteria were enrolled in a case-control study conducted over 12 months and compared with 47 age and sex-matched healthy controls. None of the subjects had a previous history of cardiovascular diseases or cardiovascular risk factors. Demographic and disease characteristics were recorded. Structural lesions were evaluated using plain radiography, and two scoring tools were used to spine (BASRI and mSASSS). Subclinical atherosclerosis was assessed using ultrasound measurements of flow-mediated dilation (FMD) and carotid intima-media thickness (cIMT).

RESULTS

The median age of patients was 36 years. The sex ratio was 2.35. The median BASRI total score was 3 (IQR 2-4), median mSASSS score was 10 (IQR 415). cIMT was significantly increased in SpA patients compared to controls (p< 0.0001), and FMD was significantly lower in patients than in healthy subjects (p= 0.008). cIMT was significantly associated with ankylosis of the facet joints (p= 0.035) and Romanus spondylitis (p= 005). FMD was negatively associated with vertebral squaring (p= 0049), bridging syndesmophytes (p= 0031) and mSASSS score (p= 0.047).

CONCLUSION

Our result supports the association of radiographic structural damage and subclinical atherosclerosis assessed using cIMT and FMD. This finding highlights the importance of earlier treatment in order to prevent radiographic damage progression and atherosclerotic events.

Association between HLA-B27 and peripheral spondyloarthritis phenotype: results from the ASAS perSpA study

OBJECTIVE

To analyse the influence of HLA-B27 in the phenotypical expression of peripheral spondyloarthritis (pSpA).

METHOD

This is an observational cross-sectional study using data from the Assessment of SpondyloArthritis international Society perSpA registry, including all patients with an available HLA-B27 test result and with a diagnosis of pSpA or psoriatic arthritis (PsA) as per rheumatologist's judgement. Demographic and clinical data, presence of extra musculoskeletal manifestations (EMM) and fibromyalgia were the variables included in a simple and multiple logistic regression model to assess their association to HLA-B27 positivity.

RESULTS

From the 4465 patients included in the registry, 790 were classified as having either pSpA or PsA and had the HLA-B27 typing available. HLA-B27-positive patients presented a male predominance, had an earlier disease onset and a shorter diagnostic delay compared with the negatives. HLA-B27-positive patients presented a higher frequency of axial involvement, radiographic sacroiliitis, enthesitis and uveitis. Also, root joint involvement, poliarticular joint patern and tarsitis were significantly higher within HLA-B27-positive patients. Furthermore, we did not observe any association between the presence of HLA-B27 and peripheral joint damage, dactylitis, other EMM (psoriasis, inflammatory bowel disease) or fibromyalgia.The multivariable analysis confirmed the independent association of HLA-B27 positivity with male sex, an earlier onset of the disease, the presence of axial involvement, tarsitis and uveitis.

SUMMARY

In summary, the presence of HLA-B27 in pSpA patients was associated with earlier disease onset and higher axial involvement, tarsitis and uveitis, but not with other EMM, fibromyalgia or peripheral structural damage.

Prolonged peripheral seronegative spondyloarthritis following BioNTech coronavirus disease 2019 vaccination: A case report

A female 17-year-old diagnosed with seronegative spondyloarthritis (SpA) following the first jab of the BioNTech162b2 (BNT162b2) vaccine presented with recurrent swelling and painful knee accompanied by posterior heel tenderness over the past 1.5 months. Laboratory investigations revealed elevated serum erythrocyte sedimentation rate and C-reactive protein. Synovial aspiration yielded level 3 crystal-free, aseptic and inflammatory effusion. She tested positive for the human leukocyte antigen-B27 and was diagnosed with peripheral SpA. She received daily celecoxib (400 mg), methylprednisolone (8 mg), and sulfasalazine (2 g), but the effect was limited. Nonetheless, her symptoms improved significantly with weekly subcutaneous etanercept administration (50 mg). Four weeks later, her arthritis was completely resolved. To our knowledge, this is the first case report of newly diagnosed seronegative peripheral SpA in an autoimmunity-disease-free individual following messenger RNA BNT coronavirus disease 2019 vaccination.

Primary antibody deficiency-associated arthritis shares features with spondyloarthritis and enteropathic arthritis

OBJECTIVE

The clinical spectrum of primary antibody deficiencies (PADs) and especially common variable immunodeficiency (CVID) includes various autoimmune disorders. We studied the prevalence and the features of articular rheumatic disease in a cohort of patient with PADs.

METHODS

In this retrospective cohort study, complete clinical data of 268 patients with PADs, mainly consisting of patients with CVID, visiting the immunology outpatient clinic of a German tertiary hospital between 2018 and 2021 were collected. Those included case history, physical examination, laboratory as well as radiological findings.

RESULTS

Inflammatory arthritis was diagnosed in 16.4% of studied patients and was significantly more common among patients with PAD-associated enteropathy (OR 13.39, p=0.0001), splenomegaly (OR 6.09, p=0.0001) or atopic diseases (OR 3.31, p=0.021). Given HLA-B27 status, the involvement of the axial skeleton and the presence of features, such as anterior uveitis, inflammatory bowel disease, psoriasis and/or dactylitis, 75% of studied patients fulfilled the Assessment of Spondyloarthritis International Society classification criteria.

CONCLUSION

PAD-associated arthritis frequently shares features with spondyloarthritis (SpA) and enteropathic arthritis. The latter may suggest the interconnected pathomechanisms of inflammatory arthritis in SpA and PADs.

Antigen-specific immune reactions by expanded CD8+ T cell clones from HLA-B*27-positive patients with spondyloarthritis

Spondyloarthritis (SpA) is a chronic inflammatory disease that is tightly linked to HLA-B*27 but the pathophysiological basis of this link is still unknown. It is discussed whether either the instability of HLA-B*27 molecules triggers predominantly innate immune reactions or yet unknown antigenic peptides presented by HLA-B*27 induce adaptive autoimmune reactions by CD8⁺ T cells. To analyze the pathogenesis of SpA, we here investigated the T cell receptor (TCR) usage and whole transcriptomes of CD8⁺ single cells from synovial fluid of HLA-B*27-positive SpA patients and HLA-B*27-negative controls. In HLA-B*27-positive patients, we confirmed preferential expression of several TCR β-chain families, found even more restricted usage of particular TCR α-chains, assigned matching TCR αβ-chain pairs with homologous CDR3-sequences, and detected identical TCR-chains in different patients. Gene expression analyses by single cell mRNAseq revealed that genes specific for the tissue resident memory phenotype, exhaustion, and apoptosis were particularly highly expressed in expanded clonotypes from HLA-B*27-positive SpA patients. Together, several independent lines of evidence argue in favor of an (auto)antigenic peptide related pathogenesis.

18F-FDG PET molecular imaging: A relevant tool to investigate chronic inflammatory rheumatisms in clinical practice?

18F-Labeled Fluorodeoxyglucose-Positron Emission Tomography (18F-FDG PET) is a molecular imaging tool commonly used in practice for the assessment of many cancers. Thanks to its properties, its use has been progressively extended to numerous inflammatory conditions, including chronic inflammatory rheumatism (CIR) such as rheumatoid arthritis (RA), spondylarthritis (SpAs) and polymyalgia rheumatica (PMR). 18F-FDG PET is currently not recommended for the diagnostic of CIRs. However, this whole-body imaging tool has emerged in clinical practice, providing a general overview of systemic involvement occurring in CIRs. Numerous studies have highlighted the capacity of 18F-FDG PET to detect articular and extra articular involvements in RA and PMR. However, the lack of specificity of 18F-FDG limits its use for diagnosis purpose. Finally, the key question is the definition of the best way to integrate this whole-body imaging tool in the patient's management workflow.

Drug Retention and Safety of Secukinumab in a Real-World Cohort of Ankylosing Spondylitis and Psoriatic Arthritis Patients

Real-life data that support effectiveness of secukinumab (SEC), an interleukin 17A inhibitor, in Poland are few. We aimed to evaluate SEC effectiveness based on drug retention and safety measures reported in electronic medical records (EMRs) of patients with psoriatic arthritis (PsA) and ankylosing spondylitis (AS) from two tertiary-care centers in the region of Lesser Poland. A total one-hundred eighty seven (127 PsA and 60 AS) first (n = 112), second (n = 59) and third-line SEC users were enrolled. The mean (SD) age of the sample was 45.7 (12.9), and 48% were male. All patients were classified with active and severe disease prior to initiation. Administrative delays for SEC users last a median 2 weeks. Median delay from symptom onset to diagnosis was 4 years (IQR 8), and differed by predominant disease subtype. The inefficacy rate was 10.7% and 18.6% for first and second-line users with median (IQR) drug maintenance estimated at 1.22 years (1.46) and 1.51 (1.38), respectively. First-year drug loss defined as drug switch due to inefficacy or adverse event was rare, with median estimates of 0.91 (95% CI; 0.85, 0.97) and 0.86 (95% CI; 0.77, 0.95) for first and second-line, respectively.

Reliability assessment of the definition of ultrasound enthesitis in SpA: results of a large, multicentre, international, web-based study

OBJECTIVES

To investigate the reliability of the OMERACT US Task Force definition of US enthesitis in SpA.

METHODS

In this web exercise, based on the evaluation of 101 images and 39 clips of the main entheses of the lower limbs, the elementary components included in the OMERACT definition of US enthesitis in SpA (hypoechoic areas, entheseal thickening, power Doppler signal at the enthesis, enthesophytes/calcifications, bone erosions) were assessed by 47 rheumatologists from 37 rheumatology centres in 15 countries. Inter- and intra-observer reliability of the US components of enthesitis was calculated using Light's kappa, Cohen's kappa, Prevalence And Bias Adjusted Kappa (PABAK) and their 95% CIs.

RESULTS

Bone erosions and power Doppler signal at the enthesis showed the highest overall inter-reliability [Light's kappa: 0.77 (0.76-0.78), 0.72 (0.71-0.73), respectively; PABAK: 0.86 (0.86-0.87), 0.73 (0.73-0.74), respectively], followed by enthesophytes/calcifications [Light's kappa: 0.65 (0.64-0.65), PABAK: 0.67 (0.67-0.68)]. This was moderate for entheseal thickening [Light's kappa: 0.41 (0.41-0.42), PABAK: 0.41 (0.40-0.42)], and fair for hypoechoic areas [Light's kappa: 0.37 (0.36-0.38); PABAK: 0.37 (0.37-0.38)]. A similar trend was observed in the intra-reliability exercise, although this was characterized by an overall higher degree of reliability for all US elementary components compared with the inter-observer evaluation.

CONCLUSIONS

The results of this multicentre, international, web-based study show a good reliability of the OMERACT US definition of bone erosions, power Doppler signal at the enthesis and enthesophytes/calcifications. The low reliability of entheseal thickening and hypoechoic areas raises questions about the opportunity to revise the definition of these two major components for the US diagnosis of enthesitis.

Diet and Disease Activity in Patients with Axial Spondyloarthritis: SpondyloArthritis and NUTrition Study (SANUT)

Axial Spondyloarthritis (axSpA) patients with inflamed intestines have higher SpA activity. Diets that modulate microbiota may influence inflammation and SpA activity. Today, data concerning the impact of diet on SpA activity are scarce. SANUT was a single-center, noninterventional, cohort study that assessed dietetic profiles associated with SpA activity in axSpA. Demographic, clinical, SpA-related, quality of life (QoL), fatigue, physical activity, and dietary data were collected. SpA activity was assessed by Ankylosing Spondylitis Disease Activity Score (ASDAS) and by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). We assessed whether high SpA activity was associated with nutriment consumption. Between 12 February 2018 and 12 February 2020, 278 patients participated. High SpA activity, as measured by ASDAS and BASDAI, was significantly associated with higher body mass index and waist circumference, negative HLA-B27, lower QoL, higher fatigue, and higher digestive-symptom scores. Furthermore, high SpA activity, as measured by BASDAI, was associated with female sex, smoking status, patients who were not actively employed, reduced physical activity, and high intake of ultra-transformed foods, while high SpA activity, as measured by ASDAS, was associated with low intake of omega-3 PUFAs and fiber. Therefore, low intakes of omega-3 PUFAs and fiber, and high intake of ultra-transformed foods, are associated with high SpA activity.

Oral manifestations associated with inflammatory bowel disease and early endoscopic findings in patients with spondyloarthritis

BACKGROUND AND AIMS

Spondyloarthritis (SpA) is a group of autoinflammatory disorders, of which the primary extra-articular manifestation is inflammatory bowel disease (IBD). The oral cavity being a part of gastrointestinal tract, is significantly compromised in IBD, and in many cases, it is the first site of clinical manifestations of IBD. This study aimed to identify changes in the oral mucosa associated with the onset of IBD and their association with endoscopic/histological findings.

MATERIALS AND METHODS

The study assessed 80 patients with SpA and 52 healthy controls. Oral, rheumatological, and gastroenterological assessments were performed. The ileocolonoscopy was performed via digital magnification chromoendoscopy. The statistical analysis consisted of Chi-square, Fisher's exact, and multiple correspondence discriminant analysis tests.

RESULTS

From the disease cohort, 63.0% patients showed oral lesions (p = 0.050). These manifestations ranged from gingivitis (55.0%, p = 0.001), aphthous stomatitis (3.8%, p = 0.091), angular cheilitis (2.6%, p = 0.200), and perioral erythema with scaling (1.3%, p = 0.300). All patients who presented with alterations in colonic mucosa also had oral lesions associated with IBD (p = 0.039), specifically gingivitis/aphthous stomatitis (p = 0.029).

CONCLUSION

The patients with SpA without IBD present significant oral signs and symptoms. Gingivitis seems to be the most relevant because of its associations with early endoscopic and histological findings.

CLINICAL RELEVANCE

An integral approach to the diagnostic tests that includes evaluations of oral, rheumatological and gastroenterological tissues may favor timely attention and improve patients' quality of life.

Morphologic, dynamic and high-resolution microscopy MRI in early-onset spondyloarthritis finger dactylitis

OBJECTIVE

Up to now, the pathophysiology of SpA dactylitis has not been entirely clarified. It is not clear which are the involved tissues and which is the primary lesion of the "sausage-like" digit. The aim of our study was to examine the finger structures in early-onset finger dactylitis using high-resolution microscopy MRI together with morphologic and dynamic MRI.

SUBJECTS AND METHODS

In a 6-month period, 13 SpA patients (7 females and 6 males), mean age 54.07 years (range 37-73 years) and mean disease duration 7.07 years (range 1-44 years) with early-onset finger dactylitis (less than 3 months) were recruited. Nine patients had PsA, 3 HLA-B27-positive uSpA and 1 HLA-B27-negative uSpA. One patient had 2 dactylitis fingers. Ten healthy volunteers matched for age and sex with no personal and family history of SpA were enrolled. All dactylitis fingers and randomly selected fingers of the normal control subjects were imaged by morphologic, dynamic and high-resolution microscopy MRI.

RESULTS

We have found flexor tenosynovitis in all the 14 dactylitis fingers, joint synovitis in 5 and oedema in the finger soft tissue in 10. In 2 dactylitis fingers, there was oedema at the insertion of the joint capsule suggesting enthesitis. In 5 dactylitis fingers, there was only mild enhancement at the enthesis organ (collateral ligament, flexor and extensor tendons).

CONCLUSIONS

Our MRI study on early-onset dactylitis demonstrates that flexor tenosynovitis, joint synovitis and oedema of the digit soft tissue are the predominant alterations visible in the early phase of evolution of dactylitis and that, therefore, enthesitis may not be considered the primary lesion of dactylitis.

Targeted resequencing of the 13q13 spondyloarthritis-linked locus identifies a rare variant in FREM2 possibly associated with familial spondyloarthritis

OBJECTIVES

The strong heritability of spondyloarthritis remains poorly explained, despite several large-scale association studies. A recent linkage analysis identified a new region linked to SpA on 13q13. Here we searched for variants potentially explaining this linkage signal by deep-sequencing of the region.

METHODS

Re-sequencing of the 1.4 Mb target interval was performed in 92 subjects from the 43 best-linked multicases families (71 spondyloarthritis and 21 unaffected relatives), using hybridization capture-based protocol (Illumina Nextera®). Variants of interest were then genotyped by TaqMan and high resolution melting to check their co-segregation with disease in the same families and to test their association with spondyloarthritis in an independent cohort of 1,091 unrelated cases and 399 controls. Expression of FREM2 was assessed by immunostaining.

RESULTS

Of the 7,563 variants identified, 24 were non-synonymous coding single-nucleotide variants. Two of them were located in the FREM2 gene on a haplotype co-segregating with the disease, including one common variant (R1840W, minor allele frequency=0.11) and one rare variant (R727H, minor allele frequency=0.0001). In the case-control analysis, there was no significant association between R1840W and spondyloarthritis (P-value=0.21), whereas R727H was not detected in any of the genotyped individuals. Immunostaining experiments revealed that FREM2 is expressed in synovial membrane, cartilage and colon.

CONCLUSIONS

Targeted re-sequencing of a spondyloarthritis-linked region allowed us to identify a rare non-synonymous coding variant in FREM2, co-segregating with spondyloarthritis in a large family. This gene is expressed in several tissues relevant to spondyloarthritis pathogenesis, supporting its putative implication in spondyloarthritis.

Novel peripheral blood diagnostic biomarkers screened by machine learning algorithms in ankylosing spondylitis

Background: Ankylosing spondylitis (AS) is a chronic inflammatory disorder of unknown etiology that is hard to diagnose early. Therefore, it is imperative to explore novel biomarkers that may contribute to the easy and early diagnosis of AS. Methods: Common differentially expressed genes between normal people and AS patients in GSE73754 and GSE25101 were screened by machine learning algorithms. A diagnostic model was established by the hub genes that were screened. Then, the model was validated in several data sets. Results: IL2RB and ZDHHC18 were screened using machine learning algorithms and established as a diagnostic model. Nomograms suggested that the higher the expression of ZDHHC18, the higher was the risk of AS, while the reverse was true for IL2RB in vivo. C-indexes of the model were no less than 0.84 in the validation sets. Calibration analyses suggested high prediction accuracy of the model in training and validation cohorts. The area under the curve (AUC) values of the model in GSE73754, GSE25101, GSE18781, and GSE11886 were 0.86, 0.84, 0.85, and 0.89, respectively. The decision curve analyses suggested a high net benefit offered by the model. Functional analyses of the differentially expressed genes indicated that they were mainly clustered in immune response-related processes. Immune microenvironment analyses revealed that the neutrophils were expanded and activated in AS while some T cells were decreased. Conclusion: IL2RB and ZDHHC18 are potential blood biomarkers of AS, which might be used for the early diagnosis of AS and serve as a supplement to the existing diagnostic methods. Our study deepens the insight into the pathogenesis of AS.

Environmental Risks for Spondyloarthropathies

Spondyloarthropathies, also known as spondyloarthritis, encompasses a spectrum of diseases classified by it's axial and peripheral musculoskeletal manifestations. Extra-articular features are common in SpA making these systemic rheumatologic diseases involve the skin, eye, gut, and other organ systems.Research has identified risk factors for the development of spondyloarthritis, particularly regarding genetic susceptibility and the strong association with HLA-B27. Multiple studies have elucidated clinical risk factors associated with SpA disease activity and severity. In this review, we aim to explore the environmental risk factors for spondyloarthritis.

Peripheral spondyloarthritis and psoriatic arthritissine psoriase: are we dealing with semantics or clinically meaningful differences?

Diagnosing peripheral spondyloarthritis (pSpA) remains a significant challenge due to the lack of specific disease biomarkers and the overlap with other SpA subtypes, mainly psoriatic arthritis (PsA), which represents a diagnostic challenge particularly in the absence of skin psoriasis (PsAsine psoriase). This narrative review aimed to compare the epidemiology, genetic susceptibility, pathophysiology, classification criteria, disease phenotype and burden, and therapeutic guidelines between patients diagnosed with pSpA and those with PsAsine psoriase,to determine if the two entities should be considered jointly or distinctly. Globally, pSpA appears to be more inclusive compared with PsAsine psoriase. Areas of similarities include age of onset, number of joints involved and prevalence of axial involvement. However, patients with pSpA have a male gender predominance, a higher prevalence of HLA-B27, enthesitis and involvement of large joints of the lower limbs, whereas patients with PsAsine psoriasehave a higher prevalence HLA-Cw6, dactylitis and involvement of hand distal interphalangeal joints. Therefore, the difference between pSpA and PsAsine psoriasegoes beyond semantics. The few dissimilarities should drive scientific efforts to reach a better characterisation of pSpA as an individual disease. Accordingly, randomised clinical trials should target patients with well-defined pSpA to identify effective therapies in this population.

Association Between Inflammatory Bowel Disease and Spondyloarthritis: Findings from a Nationwide Study in Sweden

BACKGROUND AND AIMS

Inflammatory bowel disease [IBD] has been associated with spondyloarthritis [SpA], but population-based estimates are scarce. Here we compare the occurrence of SpA before and after a diagnosis of IBD with the general population, overall and by IBD subtype and age.

METHODS

We used a nationwide register-based cohort study of 39 203 patients diagnosed with IBD during 2006-2016, identified from Swedish registers and gastrointestinal biopsy data, and 390 490 matched reference individuals from the general population. Conditional logistic regression models were used to estimate odds ratios [ORs] for a prior [prevalent] SpA diagnosis and conditional Cox regression to calculate hazard ratios [HRs] for a subsequent [incident] SpA diagnosis in IBD patients.

RESULTS

IBD patients were more likely to have prevalent SpA at IBD diagnosis [2.5%] compared with reference individuals [0.7%] with an OR of 3.48 [95% CI: 3.23, 3.75]. They also more often received an incident diagnosis of SpA; during 23 341 934 person-years of follow-up in IBD patients, there were 1030 SpA events [5.0/1000 person-years] compared with 1524 SpA events in the reference group [0.72/1000 person-years], corresponding to an HR of 7.15 [95% CI: 6.60, 7.75]. In subgroup analyses, associations were most pronounced among patients with Crohn's disease ([OR = 5.20; 95% CI: 4.59, 5.89], and [HR = 10.55; 95% CI: 9.16, 12.15]) and paediatric onset IBD ([OR = 3.63; 95% CI: 2.35, 5.59] and [HR = 15.03; 95% CI: 11.01, 20.53]).

CONCLUSIONS

IBD patients more frequently experience SpA both before and after the diagnosis of IBD compared with the general population, supporting evidence of a shared pathophysiology. The variation in SpA comorbidity, across IBD subtypes and age groups, calls for targeted approaches to facilitate timely diagnosis and intervention.

Cutaneous and rheumatological manifestations of reactive arthritis: A case report

Reactive arthritis is a rare form of spondyloarthropathies occurring after genital or enteric infection. It is most often self-limited but can progress to chronic spondylarthritis. We report the case of a 30-year-old man who presented with acute arthritis occurring 2 months after an episode of urethral discharge. Physical examination revealed polyarthritis, dactylitis, sacroiliac joint involvement, and plantar papulosquamous plaques. The human leukocyte antigen B27 was positive. Detection of Chlamydia trachomatis and Gonococcus in the first catch urine specimen was negative. Hepatitis B and C, Chlamydia trachomatis, human immunodeficiency virus, and syphilis serologic test results were negative. Pelvic magnetic resonance imaging revealed left sacroiliitis. The patient was treated with antibiotics, diclofenac, and sulfasalazine. After 6 months of follow-up, a significant clinical improvement was obtained without remission, suggesting an evolution to chronic spondylarthritis. Diagnosis of Reactive arthritis is difficult since microbiologic examinations are commonly negative. This disease should be considered in patients with rheumatologic manifestations occurring after a urogenital or enteric infection, mainly when associated with skin manifestations and human leukocyte antigen B27.

Use of Imaging in Axial Spondyloarthritis for Diagnosis and Assessment of Disease Remission in the Year 2022

Medical imaging remains the cornerstone of diagnostics and follow-up of axial spondyloarthritis (axSpA) patients. With the lack of specific biomarkers allowing monitoring of disease activity and progression, clinicians refer to imaging modalities for accurate evaluation of the axSpA burden. Technological advances and increasing availability of modern imaging techniques such as MRI have enabled faster diagnosis of the disease, hence dramatically changed the diagnostic delay and improved the prognosis and functional outcomes for axSpA patients.Active sacroiliitis as visualized by MRI has been widely accepted as a diagnostic tool, and definitions of inflammatory and structural lesions within the axial skeleton have been developed. Recently, it has been acknowledged that bone marrow edema, suggestive of sacroiliitis, is a common finding among non-SpA patients, and could be attributed to mechanical loading or accumulate with age in healthy individuals. Therefore, it is crucial to distinguish between true pathological and concealing imaging findings, not only for diagnostic but also for disease remission purposes. New imaging modalities, aimed for in vivo visualization of specific molecular processes, could be employed to cross-validate findings from techniques used in daily clinical practice. This review critically evaluates the use of different imaging modalities for diagnosis and assessment of disease remission in axSpA in the year 2022.

Role of the microbiome and its metabolites in ankylosing spondylitis

Ankylosing spondylitis (AS), a chronic condition that commonly influences the spine and sacroiliac joints, usually progresses to stiffness and progressive functional limitation. Its fundamental etiology and pathogenesis are likely multifactorial and remain elusive. As environmental factors, gut microbiota performs critical functions in the pathogenesis of AS through various mechanisms, including interacting with genes, enhancing intestinal permeability, activating the gut mucosa immune system, and affecting the intestinal microbiota metabolites. This review provides an overview of recent advances in investigating gut microbiota in AS pathogenesis and discusses potential methods for future therapeutic intervention.

The Role of Core Stability and Core Muscles in Ankylosing Spondylitis: A Review of Functional and Clinical Importance

Purpose: Physiotherapy and exercise training are one of the cornerstones in the treatment of patients with ankylosing spondylitis (AS). However, although the effects of exercise programs and their superiority over each other have still not been determined, research on this subject is continuing in the literature day by day. Due to the pathophysiology of AS, the spine is one of the most affected areas of the musculoskeletal system. Therefore, stabilization of the lumbopelvic region and the spine, which is the reference point for the core muscles, is important for the treatment and management of this disease. In this review, the involvement of core muscles and core stability in patients with AS and the literature on core training programs will be discussed.

Long-Term Adherence to Etanercept in Treatment Effectiveness of Patients with Spondyloarthritis: 7-Year Data from the Iraq National Registry

INTRODUCTION

The diagnosis and treatment of spondyloarthritis (SpA) is a global challenge, with no cure available. Adherence to treatment with biologic disease-modifying antirheumatic drugs, such as the tumor necrosis factor-α inhibitor etanercept, varies among patients with SpA. Inadequate or poor adherence to treatment may have a negative effect on clinical outcome and quality of life and may lead to greater health-related expense.

METHODS

This observational, retrospective study used real-world patient data from the Iraq National Center of Rheumatology database to retrospectively assess long-term adherence to etanercept, specifically evaluating 1- and 7-year adherence to etanercept among Iraqi patients with SpA.

RESULTS

In total, data from 763 patients were included in the analysis. The majority of patients were men (82.2%). Mean disease duration at baseline was 5.85 years; 84.0% of patients received concomitant steroids, and 14.2% were treated with concomitant methotrexate. Measures of disease activity and functional status (mean ± SD) at baseline based on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI) were 8.06 ± 0.83 (range 6.0-9.5) and 7.75 ± 1.12 (range 4.1-9.7), respectively. Around 30% of patients initiated etanercept treatment within 1 year of diagnosis. After 1 and 7 years, 91.7% (700/763) and 60.6% (80/132) of patients were adherent to etanercept treatment. Mean (± SD) changes from baseline in BASDAI and BASFI scores for adherent versus non-adherent patients at 1 year were 6.73 (± 1.90) versus 4.20 (± 1.85) (p = 0.0001) and 6.43 (± 2.04) versus 4.18 (± 1.88) (p = 0.0001), respectively.

CONCLUSIONS

These results suggest that Iraqi patients with SpA benefit from long-term adherence to etanercept treatment; however, additional analyses are needed to further assess the reasons for treatment discontinuation, which may include disease remission.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04507776.

MAPK activated kinase 2 inhibition shifts the chemokine signature in arthritis synovial fluid mononuclear cells from CXCR3 to CXCR2

BACKGROUND

The development of novel treatment strategies of immune-mediated inflammatory arthritis (IMIA) is still a clinical unmet need. The mitogen-activated protein kinase (MAPK) pathway is activated by environmental stressors, growth factors and inflammatory cytokines. However, the inhibition of central MAPK proteins has so far had undesirable side effects. The MAPK-activated protein kinase 2 (MK2) is a downstream mediator in the MAPK signaling pathway.

OBJECTIVES

The objective of this study was to explore the effects of a small molecule inhibiting MK2 on synovial fluid mononuclear cells from patients with IMIA.

METHODS

Synovial fluid mononuclear cells (SFMCs) were obtained from a study population consisting of patients with active rheumatoid arthritis (RA), peripheral spondyloarthritis (SpA) or psoriatic arthritis (PsA) with at least one swollen joint (for obtaining synovial fluid) (n = 11). SFMCs were cultured for 48 h with and without the MK2 inhibitor CC0786512 at 1000 nM, 333 nM and 111 nMand cell free supernatants were harvested and frozen before they were analyzed by the Olink proseek multiplex interferon panel.

RESULTS

In SFMCs cultured for 48 h, the MK2 inhibitor decreased the production of chemokine (C-X-C motif) ligand 9 (CXCL9) (P < 0.001), CXCL10 (P < 0.01), hepatocyte growth factor (HGF) (P < 0.01), CXCL11 (P < 0.01), tumor necrosisfactor-like weak inducer of apoptosis (TWEAK) (P < 0.05), and interleukin 12B (IL-12B) (P < 0.05) and increased the production of CXCL5 (P < 0.0001), CXCL1 (P < 0.0001), CXCL6 (P < 0.001), transforming growthfactoralpha (TGFα) (P = 0.01), monocyte-chemotactic protein 3 (MCP-3) (P < 0.01), latency-associated peptide (LAP) TGFβ (P < 0.05) dose-dependently.

CONCLUSIONS

This study reveals the downstream effects of MK2 inhibition on the secretory profile of SFMCs. Specifically, C-X-C motif chemokine receptors 3 (CXCR3) chemokines were decreased and CXCR2 chemokines were increased. This shift in the chemokine milieu may be one of the mechanisms behind the anti-inflammatory effects of MK2 inhibitors.

The standardisation of uveitis nomenclature (SUN) project

The uveitides are a collection of over 30 diseases characterised by intraocular inflammation. Previous work demonstrated that the agreement among uveitis experts on diagnosis was modest at best with some pairs of experts having chance alone agreement on selected diseases. The Standardisation of Uveitis Nomenclature (SUN) is a17-year collaboration among experts in uveitis, ocular image grading, informatics, and machine learning to improve clinical and translational uveitis research. The SUN "Developing Classification Criteria for the Uveitides" project used a rigorous, multi-phase approach to develop classification criteria for 25 of the most common uveitic diseases. The project's phases were: (1) informatics; (2) case collection; (3) case selection; (4) machine learning; and (5) consensus review and publication. The results were classification criteria with a high degree of accuracy (93.3%-99.3% depending on anatomic class of the uveitis), the goal of which is to form the basis for future uveitis research.

Tapering biologics in axial spondyloarthritis: A systematic literature review

INTRODUCTION

The emergence of biologics has improved the management of patients with rheumatic disease, mainly with spondyloarthritis (SpA). Sustained remission has become a reachable goal thanks to the treat to target strategy. Contrary to rheumatoid arthritis, data on biologic optimization among SpA patients in remission is scarce and still a subject of debate. The main objective of this systematic review was to provide the most up-to-date published literature regarding biologic tapering in axial spondyloarthritis.

METHODS

This systematic review followed the preferred reporting items for systematic reviews guidelines. Original articles from Pubmed and Scopus, published until December 20th 2021, and tackling tapering strategies of the biologics in patients with axial SpA were included RESULTS: Fourteen studies met the inclusion criteria. They were published between 2008 and 2020. The most studied molecules were Etanercept (ETN) (n = 13), Infliximab (IFX) (n = 6), Adalimumab (ADA) (n = 5), certolizumab pegol (CZP) (n = 2), Golimumab (n = 1) and ETN biosimilar. There are no studies published regarding anti-IL 17 tapering strategy. Patient-tailored dose reduction of anti TNF-α agents was successful in preserving stable low disease activity in most of the studies with remission rates ranging between 20.2 % and 93.7 %. Complete treatment discontinuation is associated with a high risk of flares.

CONCLUSION

To conclude, published data indicate that a progressive tapering strategy for anti TNF-α therapy is successful among axial SpA in sustained remission. However, further studies with more homogenized tapering strategies are needed in order to ascertain the specific implication of each subset for a better holistic approach.