Arthritis Mutilans

Perceived Usability of Tablet Crushers: Comparison of Devices by People with and without Limited Hand Functions

Tablet crushing is a common practice used by patients and their carers, mainly to facilitate swallowing. Various tablet-crushing devices with different designs are currently available on the market. This study aimed to compare the usability of different tablet-crushing devices in people with and without limited hand functions. The hand function of 100 adults recruited from the general community (40 of whom self-reported a limited hand function) was assessed using the hand and finger function subscale of the Arthritis Impact Measurement Scale version 2. The hand strength was measured using a dynamometer. Participants crushed tablets using 11 crushing devices and completed a Rapid Assessment of Product Usability and Universal Design questionnaire for each device. Hand-held twist-action crushers with an ergonomic grip received the highest usability scores among both groups, irrespective of the cost (p < 0.05). Crushers with bags were scored lower by those with limited hand functions, although the score improved if the device was automatic. Preferences regarding electronic crushers significantly changed once the cost was revealed. Economical twist-action crushers with ergonomic grips and without bags or cups were the most favoured crushers.

OA11 Treatment challenges and co-morbidity issues in a patient with Arthritis Mutilans

Introduction/Background

Psoriatic arthritis mutilans is known to be the most severe form of psoriatic arthritis¹ and reported to have a prevalence of 2-21%², depending on the classification used. Clinical features include shortening of the digits, telescoping and flail joints with radiographs showing severe osteolysis and bone resorption³. There is an increased prevalence of metabolic syndrome, cardiovascular disease and psychiatric illness among these patients⁴. Treatment of the disease is usually a stepwise approach starting with conventional synthetic disease modifying anti-rheumatic drug (csDMARD), combination csDMARD, biologic DMARD (bDMARD) or targeted synthetic DMARD (tsDMARD).

Description/Method

This 65-year-old gentleman has a diagnosis of psoriatic arthritis, mutilans type for more than 40 years. His other current co-morbidities include hypertension, hyperlipidaemia and depression. He was treated with methotrexate with good efficacy until this was stopped in 2012. Whilst on methotrexate, he had deranged liver function tests and the ultrasound scan of his abdomen showed fatty infiltration of the liver. Liver biopsy showed steato-hepatitis which was thought to be secondary to methotrexate and the drug was stopped. He was then started on Sulphasalazine, which was uptitrated to 1.5 g twice a day but with no benefit. He was having 12 swollen and 8 tender joints with a patient global score of 6/10 and physician global score of 7/10.

The patient was started on Golimumab in August 2013. He had four doses of 50 mg and two doses of 100 mg of the drug. Each dose had resulted in severe headaches which necessitated discontinuation of the treatment. He was then commenced on Adalimumab in August 2014, which also resulted in severe headaches and sweating with no efficacy otherwise. At that point, his Alanine Transaminase (ALT) levels continued to be fluctuating between 50 to 80 U/L and he was also noted to be hypertensive.

The patient was then started on Ustekinumab in October 2016 to which he tolerated well and had almost immediate noticeable improvement in his tender and swollen joints. The patient remained stable on this three monthly treatment till this day.

Interestingly, the erosive changes on the x-rays of his hands and feet has not progressed since 2010, despite tolerance and efficacy challenges of his treatment.

Despite stability of his disease and treatment, this gentleman sadly attempted suicide in March 2021 by consuming weed killer. He was informally admitted to a mental health ward.

Discussion/Results

We present a case of psoriatic arthritis mutilans which was complicated by side effects and lack of efficacy of several disease modifying treatment. He had methotrexate which had to be stopped due to steato-hepatitis. Both Golimumab and Adalimumab was stopped due to side effects characterised by headaches. Ustekinumab was started four years following the cessation of methotrexate which continues to be the most effective medication for this patient.

This patient also suffers with cardiovascular co-morbidities and depression. Tumour necrosis factor (TNF)-α associated endothelial dysfunction as well as interleukin (IL)-17A associated increased expression of adhesion and pro-inflammatory molecules may contribute to the association of psoriatic arthritis mutilans with cardiovascular disease^5,6. It is also known that there is a higher prevalence of mental health disease in patients with psoriasis. This is thought to be due to the involvement of the same inflammatory pathway as proinflammatory IL-1 and IL-6 are increased in both psoriatic arthropathy and depression⁷.

Key learning points/Conclusion

Based on our research, there is a lack of evidence for treatment specific to arthritis mutilans, due to the relatively rare nature of the disease. However, this case report has proved that treatment should be individualised to the patient, based on their response and tolerance to the medications.

It is also pertinent to be aware and manage co-morbidities associated with the disease which includes hypertension, hyperlipidaemia, diabetes mellitus and psychiatric illnesses. This requires close collaboration with the patient’s general practitioner.

[Typical arthritis of the hands : Psoriatic arthritis]

BACKGROUND

Psoriatic arthritis (PsA) is considered the prototype of peripheral spondyloarthritides (SpA) and is associated as skin-bone disease (SkiBo) with typical skin changes and with typical arthritides of the joints, especially of the hands and feet.

OBJECTIVE

Systematic review of imaging manual findings patterns in PsA with its typical enthesitic arthritides in context with clinical findings.

MATERIALS AND METHODS

A review based on the current literature on the subject from a radiological and rheumatological point of view is provided.

RESULTS

In PsA, inflammatory manifestations in the hands and feet are the most frequently affected regions of the body. Image morphological variability between early and late stages is evident. The projection radiographic characteristic of PsA is the simultaneous coexistence of osteodestructive-rarefactive changes with typical osteoproliferative-proliferative changes, which are part of the Classification of Psoriatic Arthritis (CASPAR) criteria. With the help of magnetic resonance imaging (MRI), the image-morphological spondyloarthritis inflammatory patterns of enthesitis, dactylitis and osteitis can be detected in the hands even in the early stages.

CONCLUSIONS

The basic knowledge of the image morphological changes of this complex autoimmunological skin-bone disease will be imparted in order to gain the necessary confidence in the systematic diagnostic evaluation of hand arthritis patterns typical for PsA in images both at the initial diagnosis and over the course of the disease and in the classification of early and late stages, which serve as a guide for rheumatologists regarding "step-up" treatments.

Disease activity in and quality of life of patients with psoriatic arthritis mutilans: the Nordic PAM Study

OBJECTIVE

To describe the social status and health-related quality of life of patients with psoriatic arthritis mutilans (PAM) in the Nordic countries.

METHOD

Patients with at least one mutilated joint confirmed by radiology were studied. Disease activity involving joints and skin, physician-assessed disease activity, and patient's education and work status were recorded. Data from the 36-item Short Form Health Survey, Health Assessment Questionnaire and Dermatology Life Quality Index questionnaire were gathered and correlated with disease duration, pain, and general well-being (visual analogue scale). The controls were 58 Swedish patients with long-standing psoriatic arthritis sine PAM.

RESULTS

Sixty-seven patients were included. Patients with PAM had a protracted disease history (33 ± 14 years) and disease onset at a relatively early age (30 ± 12 years). Overall inflammatory activity at inclusion was mild to moderate. The mean number of mutilated joints was 8.2 and gross deformity was found in 16% of patients. Forty per cent were treated with biological and 32% with conventional synthetic disease-modifying anti-rheumatic drugs. Forty-two per cent had retired early or were on sick leave. Impaired functional capacity with little or no ability to perform self-care or everyday tasks was reported by 21% of the patients. Patients between 45 and 60 years of age reported the most impaired quality of life in comparison to the control group.

CONCLUSION

PAM seriously affects social functioning. Whether early recognition of PAM and new forms of therapy can improve disease outcome and quality of life remains to be studied.

The Epidemiology of Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic systemic inflammatory disorder characterized by joint and entheseal inflammation with a prevalence of 0.05% to 0.25% of the population and 6% to 41% of patients with psoriasis. PsA is a highly heterogeneous inflammatory arthritis. In this review, current knowledge is discussed regarding the epidemiology of PsA, including disease manifestations, classification criteria for adult and juvenile PsA, methods for recognizing early PsA, including use of screening tools and knowledge of risk factors for PsA, and medical comorbidities associated with PsA.

Radiographic development during three decades in a patient with psoriatic arthritis mutilans

Psoriatic arthritis mutilans (PAM) is the most severe and rare form of psoriatic arthritis (PsA). We describe radiological development in a typical case of PAM covering three decades in order to elucidate the need for early diagnosis of PAM. Radiographs of hands and feet, taken from 1981 to 2010, were evaluated using the Psoriatic Arthritis Ratingen Score (PARS). When PsA was diagnosed, in 1981, gross deformity was observed in the second PIP joint of the left foot. Several pencil-in-cup deformities and gross osteolysis were present in the feet in the first decade of the disease. Over 10 years, many joints had reached maximum scores. During the follow-up, other joints became involved and the disease developed clinically. Reporting early signs suggestive of PAM, e.g. pencil-in cup deformities and gross osteolysis in any joint, should be mandatory and crucial. This would heighten our awareness of PAM, accelerate the diagnosis, and lead to improved effective treatment in order to minimize joint damages resulting in PAM.

Psoriatic Arthritis Mutilans: Clinical and Radiographic Criteria. A Systematic Review

Objective.

Research on psoriatic arthritis mutilans (PAM), the most severe form of psoriatic arthritis, is impeded by the lack of an accepted classification criteria. We performed a systematic review of the literature to identify and synthesize clinical and radiographic features associated with the definition of PAM.

Methods.

A systematic literature search limited to human studies was conducted without language restriction. Abstracts were independently screened by 2 investigators and studies that reported information on patients with PAM were included. A standardized form was used to independently collect clinical and radiographic items defining PAM, patient’s demographics, disease characteristics, and outcomes.

Results.

There were 8570 citations searched to identify 112 articles for full review and 58 articles for data abstraction. We identified 8 definitions of PAM that were used in 283 subjects with a mean age ± SD at diagnosis of PsA of 33.9 ± 8.2 years. Disease manifestations (prevalence) included dactylitis (29–64%), enthesitis (29–32%), axial disease (14–27%), and nail lesions (47%). PAM definitions include 1 (n = 2 studies) or more (n = 14 studies) joints involving interphalangeal, metacarpophalangeal, or metatarsophalangeal joints. The most prevalent PAM clinical features were digital telescoping (34%), digital shortening (33%), and flail joints (22%). The most prevalent PAM radiographic items were bone resorption (41%), pencil-in-cup change (16%), total joint erosions (14%), ankylosis (21%), and subluxation (7%).

Conclusion.

We have identified 8 definitions of PAM, and synthesized the clinical and radiographic items that are important for the classification of PAM. We have established the groundwork for future development classification criteria for PAM.

GRAPPA Trainees Symposium 2014: A Report from the GRAPPA 2014 Annual Meeting

The seventh trainees symposium was held at the 2014 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) in New York, New York, USA. A total of 26 rheumatology and dermatology trainees engaged in psoriasis or psoriatic arthritis research presented their work to meeting attendees. This article briefly reviews the 4 oral presentations and 22 posters presented at the meeting.

Psoriatic Arthritis Mutilans: Characteristics and Natural Radiographic History

Objective.

(1) To compare clinical characteristics of patients with psoriatic arthritis (PsA) with PsA mutilans (PAM) and without PAM, and (2) to determine the rate of PAM radiographic progression.

Methods.

A retrospective cohort study was conducted of all patients with PsA attending a teaching hospital. The most recent hand and feet radiographs were screened for PAM. Serial radiographs (earliest to most recent) were quantitatively scored for osteolysis, erosion, joint space narrowing, and osteoproliferation.

Results.

Out of the 610 cases, 36 PsA cases had PAM (5.9%). PAM cases were younger at diagnosis of PsA than non-PAM cases (p = 0.04), had more prevalent psoriatic nail dystrophy (OR 5.43, p < 0.001), and worse health assessment questionnaire score (1.25 vs 0.63, p < 0.04). Radiographic axial disease (OR 2.31, adjusted p = 0.03) and especially radiographic sacroiliitis (OR 2.99, adjusted p = 0.01) were more prevalent in PAM. PAM were more likely than non-PAM cases to have used a disease-modifying antirheumatic drug (DMARD; OR 16.36, p < 0.001). Out of 33 cases, 29 PAM cases had initiated a synthetic DMARD and 4/13 had initiated anti-tumor necrosis factor (anti-TNF) prior to first demonstration of PAM. A median 5 radiographs were scored for each PAM case (interquartile range 3–7). PAM progressed from monoarticular (60%) to polyarticular (80%) involvement. Osteolysis was initially rapid and progressive in the hands and feet, tapering later during disease course. Nail dystrophy predicted more severe osteolysis (p = 0.03).

Conclusion.

Compared with non-PAM cases, PAM cases have earlier age at PsA diagnosis, poorer function, more prevalent nail dystrophy, and more radiographic axial disease/sacroiliitis. The rate of osteolysis is higher in earlier disease, and more severe in those with nail dystrophy. DMARD and anti-TNF therapy appear not to prevent PAM occurrence.

Proteomics focusing on immune markers in psoriatic arthritis

The immune-pathogenesis of psoriatic arthritis represents a subject of intense research, as a still unknown factor can trigger the chronic inflammation that, upon a defective immune terrain, generates this auto-immune/auto-inflammatory condition. The pathogenesis complexity of psoriatic arthritis resides in the psoriatic synovitis milieu, where intricate immune relations are emerging during disease development. Innate immune response generates inflammatory cytokines driving effectors functions for immune and non-immune cells that sustain the chronical character of the synovitis. Herein, we review the updated information regarding biomarkers/immune markers that sustain the heterogeneity and complexity of psoriatic arthritis pathogenesis, this complexity leading to multifaceted methodological approaches for disease investigation. New immune proteomic or genomic biomarkers can enlarge and identify new therapeutic targets.