1
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Werkl P, Rademacher J, Pleyer U. HLA-B27-positive anterior uveitis : Clinical aspects, diagnostics, interdisciplinary management, and treatment. DIE OPHTHALMOLOGIE 2024; 121:12-22. [PMID: 38085287 DOI: 10.1007/s00347-023-01960-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 02/03/2024]
Abstract
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.
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Affiliation(s)
- Peter Werkl
- Universitätsaugenklinik Graz-LKH-Universitätsklinikum Graz, Medizinische Universität Graz, Auenbruggerplatz 4, 8036, Graz, Austria
| | - Judith Rademacher
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Division of Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203, Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Uwe Pleyer
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Universitäts-Augenklinik, Charité, Campus Virchow Klinikum-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, und Berlin Institute of Health, 13355, Berlin, Germany.
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2
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Sepriano A, van Dijk B, Ramiro S, van der Helm-van Mil A, Combe B, van Schaardenburg D, de Wit M, Kent A, Mateus E, Landewé R. Distinction and prognosis of early arthritis phenotypes: an analysis in three European cohorts. RMD Open 2023; 9:e003611. [PMID: 37914180 PMCID: PMC10626756 DOI: 10.1136/rmdopen-2023-003611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023] Open
Abstract
OBJECTIVES The objective of this study is to evaluate whether there are differences in the long-term prognosis across various phenotypes of early arthritis (EA). METHODS Three EA cohorts (Reade, Etude et Suivi des Polyarthrites Indifférenciées Récentes (ESPOIR) and Early Arthritis Clinic (EAC)) were analysed. Clinical data were collected up to 24 years. Hands and feet radiographs were scored according to the Sharp van der Heijde (SvdH) method. Latent class analysis was applied to determine the EA phenotypes at baseline. Each class received a label reflecting its most prominent features. Prognostic outcomes included Health Assessment Questionnaire (HAQ), Short Form 36 (SF36) and SvdH score. The association between class membership and outcomes over time was tested in multivariable models. RESULTS In total, 390 (Reade), 798 (ESPOIR) and 3991 (EAC) patients were analysed separately. Two classes with symmetrical polyarthritis emerged; one of these labelled as autoimmune inflammatory polyarthritis (AIPA), had high likelihood of acute phase reactants (APR) elevation and autoantibody positivity, while the other (mild-inflammatory polyarthritis; MIPA) had not. A third class had oligoarthritis of upper limbs (OAUL) and could be subdivided into autoimmune OAUL and mild-inflammatory OAUL. A fifth class had oligoarthritis of lower limbs. The SvdH scores were worse in patients with APR/autoantibodies (AIPA) than in those without (MIPA). No clinically meaningful differences across classes in HAQ or SF36 over time were found. CONCLUSION Radiographic progression over time primarily occurs in EA patients with APR/autoantibodies. The absence of these markers, however, does not necessarily translate into better long-term function and quality of life. Clinicians should not only aim at preventing joint damage, but look beyond structural progression in order to further improve the lives of people with EA.
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Affiliation(s)
- Alexandre Sepriano
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
- Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Sofia Ramiro
- Rheumatology, Leiden University Medical Center, Leiden, Netherlands
- Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, Netherlands
| | | | | | | | - Maarten de Wit
- EULAR Patient Research Partner Network, Zurich, Switzerland
| | - Alison Kent
- EULAR Patient Research Partner Network, Zurich, Switzerland
| | - Elsa Mateus
- EULAR Patient Research Partner Network, Zurich, Switzerland
| | - Robert Landewé
- Amsterdam Rheumatology Center, AMC, Amsterdam, Netherlands
- Rheumatology, Zuyderland Medical Centre, Heerlen, Netherlands
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3
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Puche-Larrubia MÁ, López-Medina C, Ziadé N. Peripheral spondyloarthritis: What have we learned? Best Pract Res Clin Rheumatol 2023; 37:101862. [PMID: 37599204 DOI: 10.1016/j.berh.2023.101862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 08/22/2023]
Abstract
The peripheral spondyloarthritis (pSpA) entity remains poorly defined in comparison with axial SpA and psoriatic arthritis, as the clinical symptoms have low specificity, the biological markers are virtually lacking, and dedicated randomized controlled trials in this specific indication remain scarce. In addition, clinical similarities between pSpA and psoriatic arthritis (PsA) have been described, partly explained by a resemblance in the pathophysiology of both entities. Thus, diagnosing pSpA can be challenging because of the overlap with other entities and the absence of a specific test or imaging study that can definitively diagnose the condition. The aim of this review is to summarize the current understanding of pSpA, its epidemiology, physiopathology, clinical diagnosis, and classification criteria. In addition, we present patient-reported outcomes used in pSpA clinical studies, available evidence on therapies, and future directions.
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Affiliation(s)
| | - Clementina López-Medina
- Rheumatology Department, Reina Sofia University Hospital, IMIBIC, University of Cordoba, Cordoba, Spain.
| | - Nelly Ziadé
- Rheumatology Department, Saint-Joseph University, Beirut, Lebanon; Rheumatology Department, Hotel-Dieu de France Hospital, Beirut, Lebanon
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4
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Dos Reis Annunciato D, Oliveira TL, Magalhães VO, de Medeiros Pinheiro M. Extra-musculoskeletal manifestations driving the therapeutic decision-making in patients with Spondyloarthritis: a 12-month follow-up prospective cohort study. Adv Rheumatol 2023; 63:44. [PMID: 37626417 DOI: 10.1186/s42358-023-00324-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND The extra-musculoskeletal manifestations (EMMs) such as recurrent acute anterior uveitis (rAAU), psoriasis (Ps), and inflammatory bowel disease (IBD), are related to the Spondyloarthritis (SpA), as well as they are associated with disease activity and poor prognosis. However, there are no data addressing its relevance regarding therapeutic decision-making in clinical practice. OBJECTIVE To evaluate the impact of EMMs to drive the treatment decision-making in patients with SpA in a 12-month follow-up. PATIENTS AND METHODS SpA patients, according to the axial and peripheral ASAS classification criteria, as well as CASPAR criteria, with any active EMM, defined as main entry criteria, were included in this longitudinal cohort study. Individuals with a history of any disease or condition that could be associated with some of the studied endpoints, including neoplasms and infectious diseases, were excluded. Specific tools related to each EMM, including Psoriasis Area Severity Index (PASI), ophthalmologic evaluation, according to the Standardization of Uveitis Nomenclature (SUN) criteria, and gut complaints were used at baseline and during the 3-, 6- and 12-month of follow-up as outcomes measures over time. Descriptive and inferential analyses were used appropriately, including Pearson's correlation test, chi-squared test, and ANOVA. P value less than 0.05 was considered as significant. RESULTS A total of 560 patients were enrolled, of whom 472 meet the eligibility criteria. The majority (N = 274; 59.6%) had one or more EMM related to SpA umbrella concept. Among the EMM, the one that most influenced therapeutic decision-making was psoriasis (28.5%), followed by uveitis (17.5%) and IBD (5.5%), regardless of musculoskeletal manifestations. Clinical improvement of EMMs outcomes was observed in most patients over 12-month follow-up, especially in those with rAAU and IBD (P < 0.001). CONCLUSION Our results showed that EMMs guided the therapeutic decision-making in half of SpA patients, regardless of musculoskeletal condition, suggesting the inter-disciplinarity among the rheumatologist, ophthalmologist, dermatologist, and gastroenterologist plays a crucial role to manage them.
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Affiliation(s)
- Danielle Dos Reis Annunciato
- Spondyloarthritis Section, Rheumatology Division, Federal University of São Paulo (Unifesp/EPM), Borges Lagoa Street, 913/ 51-53, Vila Clementino, São Paulo, SP, 04038-034, Brazil
| | - Thauana Luiza Oliveira
- Spondyloarthritis Section, Rheumatology Division, Federal University of São Paulo (Unifesp/EPM), Borges Lagoa Street, 913/ 51-53, Vila Clementino, São Paulo, SP, 04038-034, Brazil
| | - Vanessa Oliveira Magalhães
- Spondyloarthritis Section, Rheumatology Division, Federal University of São Paulo (Unifesp/EPM), Borges Lagoa Street, 913/ 51-53, Vila Clementino, São Paulo, SP, 04038-034, Brazil
| | - Marcelo de Medeiros Pinheiro
- Spondyloarthritis Section, Rheumatology Division, Federal University of São Paulo (Unifesp/EPM), Borges Lagoa Street, 913/ 51-53, Vila Clementino, São Paulo, SP, 04038-034, Brazil.
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5
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Khokher W, Iftikhar S, Beran A, Malhas SE, Sayeh W, Kesireddy N, Rashid R, Ali H, Assaly R, Altorok N. The Use of Methotrexate to Treat Peripheral Edema Caused by Spondyloarthropathy. Am J Ther 2023; 30:e403-e405. [PMID: 37449934 DOI: 10.1097/mjt.0000000000001480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Waleed Khokher
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Saffa Iftikhar
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | | | - Wasef Sayeh
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Nithin Kesireddy
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Rakin Rashid
- Department of Internal Medicine, Trinity Health-Mercy Catholic Medical Center, Darby, PA
| | - Hyder Ali
- Department of Internal Medicine, Rosalind Franklin University-McHenry Hospital, McHenry, IL
| | - Ragheb Assaly
- Department of Pulmonary and Critical Care Medicine, University of, Toledo, OH
| | - Nezam Altorok
- Department of Rheumatology, University of Toledo, Toledo, OH
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Ohta R, Sano C. Differentiating Between Undifferentiated Peripheral Spondyloarthritis From Septic Arthritis: A Case Report. Cureus 2023; 15:e37742. [PMID: 37213946 PMCID: PMC10192946 DOI: 10.7759/cureus.37742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 05/23/2023] Open
Abstract
Undifferentiated peripheral spondyloarthritis (SpA) and septic arthritis are two distinct differential diagnoses for patients with acute-onset monoarthritis. Effective history-taking and thorough physical examination are essential to differentiate between these two diseases. Precise follow-up can be critical for diagnosing undifferentiated peripheral SpA. Herein, we report our experience with two cases that required differentiation between undifferentiated peripheral SpA and septic arthritis. This case series shows the importance of ruling out septic arthritis promptly and considering the possibility of undifferentiated peripheral PsA based on clinical findings and imaging tests.
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Affiliation(s)
| | - Chiaki Sano
- Community Medicine Management, Shimane University Faculty of Medicine, Izumo, JPN
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Slouma M, Abbess M, Kharrat L, Bellagha C, Metoui L, Dhahri R, Gharsallah I, Louzir B. Ultrasonography of heel entheses in axial spondyloarthritis patients: frequency and assessment of associated factors. J Ultrasound 2023; 26:185-192. [PMID: 36068431 PMCID: PMC10063758 DOI: 10.1007/s40477-022-00715-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/27/2022] [Indexed: 10/14/2022] Open
Abstract
PURPOSE Foot entheses involvement is a common manifestation of spondyloarthritis. The superiority of ultrasonography examination in foot entheses damages detection has been reported. We aimed to compare the ultrasonography findings of foot entheses between spondyloarthritis patients. and healthy controls and to identify factors associated with enthesitic heel involvement. METHODS We conducted a cross-sectional study including 37 patients with axial spondyloarthritis (G1) and 37 healthy subjects matched by age and gender (G0). The following pro-inflammatory cytokines were measured: Interleukin (IL-)1, IL-6, IL-17, and IL-23. A blind ultrasonography of foot entheses was performed to examine calcaneal tendon (CT) and plantar fascia (PF). RESULTS The mean age was 44.62 ± 12.31 years. Non-steroidal anti-inflammatory drugs were taken in 92% of patients. Clinical heel enthesopathy was noted in 10 patients (27%) of G1. No participant has enthesitic pain in G0. Ultrasonography changes in CT and PF were more frequent in G1 than G0 (p = 0.001 and p = 10-3, respectively). In the PF, tendon thickening was significantly higher in G1 than G0 (p = 0.03). Power Doppler in both enthesitic sites was exclusively observed in G1 (p = 10-3). Regarding associated factors, CT enthesophytes were less frequent in patients taking non-steroidal anti-inflammatory drugs continuously or having regular physical activity. PF structural damages were associated with higher erythrocyte sedimentation rate (p = 0.02), higher IL-23 level (p = 0.01), and higher disease activity (p = 0.04). CONCLUSION Ultrasonography lesions of heel entheses were frequent in spondyloarthritis. Disease activity and inflammatory markers were higher in patients with heel enthesitis. Non-steroidal anti-inflammatory drugs intake and regular physical activity may prevent enthesophytes' occurrence.
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Affiliation(s)
- Maroua Slouma
- Department of Rheumatology, Military Hospital, 1007, Tunis, Tunisia
- University of Tunis El Manar, Tunis, Tunisia
| | - Maissa Abbess
- Department of Rheumatology, Military Hospital, 1007, Tunis, Tunisia
- University of Tunis El Manar, Tunis, Tunisia
| | - Lobna Kharrat
- Department of Rheumatology, Military Hospital, 1007, Tunis, Tunisia.
- University of Tunis El Manar, Tunis, Tunisia.
| | - Celia Bellagha
- Department of Internal Medicine, Military Hospital, Tunis, Tunisia
- University of Tunis El Manar, Tunis, Tunisia
| | - Leila Metoui
- Department of Rheumatology, Military Hospital, 1007, Tunis, Tunisia
- University of Tunis El Manar, Tunis, Tunisia
| | - Rim Dhahri
- Department of Rheumatology, Military Hospital, 1007, Tunis, Tunisia
- University of Tunis El Manar, Tunis, Tunisia
| | - Imen Gharsallah
- Department of Rheumatology, Military Hospital, 1007, Tunis, Tunisia
- University of Tunis El Manar, Tunis, Tunisia
| | - Bassem Louzir
- Department of Internal Medicine, Military Hospital, Tunis, Tunisia
- University of Tunis El Manar, Tunis, Tunisia
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8
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Werkl P, Rademacher J, Pleyer U. [HLA-B27 positive anterior uveitis : Clinical aspects, diagnostics, interdisciplinary management and treatment]. DIE OPHTHALMOLOGIE 2023; 120:108-122. [PMID: 36633629 DOI: 10.1007/s00347-022-01793-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Peter Werkl
- Universitätsaugenklinik Graz - LKH-Universitätsklinikum Graz, Medizinische Universität Graz, Auenbruggerplatz 4, 8036, Graz, Österreich
| | - Judith Rademacher
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Division of Gastroenterology, Infectious Diseases and Rheumatology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203, Berlin, Deutschland.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Uwe Pleyer
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland. .,Universitäts-Augenklinik, Charité, Campus Virchow Klinikum - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, und Berlin Institute of Health, Berlin, Deutschland.
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9
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Llop M, Gratacós J, Moreno M, Arévalo M, Calvet J, Dougados M, López-Medina C. Uveitis in peripheral spondyloarthritis patients: an ancillary analysis of the ASAS-PerSpA study. Ther Adv Musculoskelet Dis 2022; 14:1759720X221119246. [PMID: 36081747 PMCID: PMC9445458 DOI: 10.1177/1759720x221119246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 07/26/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Acute anterior uveitis (AAU) is the most frequent extra-musculoskeletal manifestation in spondyloarhtritis (SpA). Previous data on AAU focused on axial disease; therefore, it is not well known whether the clinical characteristics of patients with AAU and recurrent AAU differ between patients with axial and peripheral SpA. Objective: Primary objective was to compare the clinical characteristics of patients with AAU from patients without AAU in axial and peripheral spondyloarthritis (SpA) patients. Secondary objectives were to describe the clinical features of patients with AAU in the subset of patients with peripheral SpA (pSpA) and the clinical characteristics of patients with recurrent AAU in SpA patients. Design: This is an ancillary analysis of the ASAS-PerSpA study which included 3152 patients, 2719 patients with axSpA and 433 with pSpA according to rheumatologist judgement. Methods: Recurrent AAU was defined as the presence of two or more episodes of AAU ever. Univariable and multivariable binary logistic regression analyses were conducted to identify factors associated with the presence of AAU ever and the presence of recurrent AAU. Results: Overall, 663 patients (21%) presented AAU. Of them, 444 (66.9%) presented recurrent episodes. In patients with SpA, HLA-B27 positivity is the most important factor linked to the presence of AAU, odds ratio (OR) = 2.70 (95% CI = 2.04–3.6). In patients with pSpA, HLA-B27 positivity was also the most relevant factor linked to the presence of AAU, OR = 6.08 (95% CI = 2.72–15.68). Moreover, disease duration, younger age and higher body mass index (BMI) were the only factors slightly linked to the presence of recurrent episodes, OR = 1.03 (95% CI = 1.01–1.04), OR = 1.01 (95% CI = 1.00–1.03) and OR = 1.04 (95% CI = 1.01–1.08), respectively. Conclusion: HLA-B27 positivity is the most relevant factor linked to AAU risk in SpA patients, and this association is even stronger in those patients with pSpA. Moreover, our study did not find an association between HLA-B27 positivity and recurrent AAU in SpA patients.
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Affiliation(s)
- Maria Llop
- Rheumatology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain
| | - Jordi Gratacós
- Rheumatology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), C/ Parc Taulí, 1, 08208 Sabadell, Barcelona, Spain.,Medicine Department, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Mireia Moreno
- Rheumatology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain
| | - Marta Arévalo
- Rheumatology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain
| | - Joan Calvet
- Rheumatology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain.,Medicine Department, Universitat Autònoma de Barcelona, Sabadell, Spain
| | | | - Clementina López-Medina
- Rheumatology Department, Hôpital Cochin, Paris, France.,Rheumatology Department, Hospital Universitario Reina Sofía/IMIBIC/Universidad de Córdoba, Córdoba, Spain
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10
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Ziade N, Rassi J, Elzorkany B, Lopez-Medina C, Gamal SM, Hlais S, Dougados M, Baraliakos X. What is peripheral spondyloarthritis? Identifying proportion, phenotype and burden in post hoc analysis of the ASAS-PerSpA study. Semin Arthritis Rheum 2022; 55:152012. [PMID: 35489171 DOI: 10.1016/j.semarthrit.2022.152012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Little is known about the prevalence, phenotype, and burden of peripheral spondyloarthritis (pSpA). The objective of the study is to compare the phenotype and burden of disease of pure pSpA to that of pure psoriatic arthritis (PsA), pure axial SpA (axSpA), and combined forms of SpA. METHODS This is a post hoc analysis of 4,185 patients from the cross-sectional ASAS-Peripheral involvement in SpA (PerSpA) study. Patients were approached in 2 ways: the first approach was based on the rheumatologist's diagnosis (diagnostic approach) and the second one was based on the fulfillment of ASAS or CASPAR classification criteria (classification criteria approach). Demographics, disease phenotype, and burden were compared among pure pSpA, PsA, axSpA, and the combined forms. FINDINGS The proportion of pSpA was 31.5% of SpA using the classification criteria approach and 10.3% using the diagnostic approach. pSpA was pure (i.e. without axSpA or PsA) in 16.8% of pSpA using the criteria, and in 62.3% using the diagnostic approach. Using classification criteria and diagnostic approach, respectively, pure pSpA patients had a high prevalence of peripheral joint disease (86 and 96%), synovitis (76 and 91%), and enthesitis (57 and 55%), a positive HLA-B27 in 65 and 59%, a high C-Reactive Protein level in 51% and inflammatory back pain in 52 and 42%. However, compared to pure PsA and pure axSpA, they had a significantly higher disease burden, but lower use of biologics using both approaches. INTERPRETATION The proportion of pSpA varies when using the classification criteria or the diagnostic approach. pSpA occurred in a pure form less frequently than PsA and axSpA and had intermediate features but a higher disease burden. FUNDING The PerSpA main study has been conducted under the umbrella of ASAS thanks to unrestricted grants from PFIZER, LILLY, ABBVIE, NOVARTIS, UCB, JANSSEN, MERCK.
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Affiliation(s)
- Nelly Ziade
- Rheumatology Department, Saint-Joseph University, Beirut, Lebanon; Rheumatology Department, Hotel-Dieu de France Hospital, Beirut, Lebanon.
| | - Joe Rassi
- Surgery Department, Saint-Joseph University, Beirut, Lebanon; Orthopedic Surgery Department, Hotel-Dieu de France Hospital, Beirut, Lebanon.
| | - Bassel Elzorkany
- Rheumatology Department, Kasr Alaini Hospitals, Cairo University, Egypt.
| | - Clementina Lopez-Medina
- Rheumatology Department, Cochin Hospital, Paris, France; Rheumatology Department, Reina Sofia University Hospital / IMIBIC/ University of Cordoba, Cordoba, Spain.
| | - Sherif M Gamal
- Rheumatology Department, Kasr Alaini Hospitals, Cairo University, Egypt.
| | - Sani Hlais
- Family Medicine Department, Saint-Joseph University, Beirut, Lebanon; Family Medicine Department, American University of Beirut, Lebanon.
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11
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Sarbu MI, Sarbu N, Cristea Ene D, Corche D, Baz R, Negru D, Nechita A, Fotea S, Anghel L, Tatu AL. New Perspectives on Diagnosing Psoriatic Arthritis by Imaging Techniques. Open Access Rheumatol 2021; 13:343-352. [PMID: 35221735 PMCID: PMC8866993 DOI: 10.2147/oarrr.s331859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/22/2021] [Indexed: 11/23/2022] Open
Abstract
Psoriatic arthritis is a chronic inflammatory condition that can lead to severe functional impairment and irreversible damage. The diagnosis can be difficult in early cases where the clinical exam is often scarce. The lack of a serological biomarker can lead to a considerable delay in diagnosis. In this review, we discuss the existent imaging methods that have improved the diagnosis of psoriatic arthritis (PsA). The degree and type of musculoskeletal involvement cannot be assessed by only one imaging method. We think that a combination of methods is the best approach to evaluate both structural damage and inflammatory lesions and that ultrasound (US) could be the best tool to screen a patient when considering the diagnosis of PsA. US is an accessible, non-ionizing technique that offers information regarding active inflammation in joints, entheses, and soft tissues.
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Affiliation(s)
| | - Nicolae Sarbu
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, Al. I. Cuza No 35, Galati, Romania
- Correspondence: Nicolae Sarbu Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, Al. I. Cuza No 35, Galati, RomaniaTel +40728301044 Email
| | | | - Daniela Corche
- Sf Apostol Andrei Clinical County Emergency Hospital, Galati, Romania
| | - Radu Baz
- Department of Radiology and Medical Imaging, Clinical County Emergency Hospital Constanta, “Ovidius” University, Constanta, Romania
| | - Dragos Negru
- Department of Radiology – Imaging, University Hospital “Sf. Spiridon”, University of Medicine and Pharmacy “Grigore T. Popa”, Iasi, Romania
| | - Aurel Nechita
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, Galati, Romania
- Department of Pediatrics, “Sf. Ioan” Clinical Hospital for Children, Galati, Romania
| | - Silvia Fotea
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, Galati, Romania
- Department of Pediatrics, “Sf. Ioan” Clinical Hospital for Children, Galati, Romania
| | - Lucretia Anghel
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, Galati, Romania
- Sf Apostol Andrei Clinical County Emergency Hospital, Galati, Romania
| | - Alin Laurentiu Tatu
- Faculty of Medicine and Pharmacy, Clinical Department, Medical and Pharmaceutical Research Unit/Competitive, Interdisciplinary Research Integrated Platform’, ReForm-UDJG, “Dunarea de Jos” University, Galati, Romania
- Clinical Hospital St Parascheva of Infectious Diseases, Dermatology Department, Galati, Romania
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12
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López-Medina C, Chevret S, Molto A, Sieper J, Duruöz T, Kiltz U, Elzorkany B, Hajjaj-Hassouni N, Burgos-Vargas R, Maldonado-Cocco J, Ziade N, Gavali M, Navarro-Compan V, Luo SF, Biglia A, Tae-Jong K, Kishimoto M, Pimentel-Santos FM, Gu J, Muntean L, van Gaalen FA, Geher P, Magrey M, Ibáñez-Vodnizza SE, Bautista-Molano W, Maksymowych W, Machado PM, Landewé R, van der Heijde D, Dougados M. Identification of clinical phenotypes of peripheral involvement in patients with spondyloarthritis, including psoriatic arthritis: a cluster analysis in the worldwide ASAS-PerSpA study. RMD Open 2021; 7:rmdopen-2021-001728. [PMID: 34750246 PMCID: PMC8576480 DOI: 10.1136/rmdopen-2021-001728] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/05/2021] [Indexed: 11/06/2022] Open
Abstract
Objective To identify clusters of peripheral involvement according to the specific location of peripheral manifestations (ie, arthritis, enthesitis and dactylitis) in patients with spondyloarthritis (SpA) including psoriatic arthritis (PsA), and to evaluate whether these clusters correspond with the clinical diagnosis of a rheumatologist. Methods Cross-sectional study with 24 participating countries. Consecutive patients diagnosed by their rheumatologist as PsA, axial SpA or peripheral SpA were enrolled. Four different cluster analyses were conducted: one using information on the specific location from all the peripheral manifestations, and a cluster analysis for each peripheral manifestation, separately. Multiple correspondence analyses and k-means clustering methods were used. Distribution of peripheral manifestations and clinical characteristics were compared across the different clusters. Results The different cluster analyses performed in the 4465 patients clearly distinguished a predominantly axial phenotype (cluster 1) and a predominantly peripheral phenotype (cluster 2). In the predominantly axial phenotype, hip involvement and lower limb large joint arthritis, heel enthesitis and lack of dactylitis were more prevalent. In the predominantly peripheral phenotype, different subgroups were distinguished based on the type and location of peripheral involvement: a predominantly involvement of upper versus lower limbs joints, a predominantly axial enthesitis versus peripheral enthesitis, and predominantly finger versus toe involvement in dactylitis. A poor agreement between the clusters and the rheumatologist‘s diagnosis as well as with the classification criteria was found. Conclusion These results suggest the presence of two main phenotypes (predominantly axial and predominantly peripheral) based on the presence and location of the peripheral manifestations.
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Affiliation(s)
- Clementina López-Medina
- Rheumatology, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France .,Rheumatology, Reina Sofia University Hospital, Maimónides Institute for Biomedical Research of Córdoba (IMIBIC), University of Cordoba, Cordoba, Spain
| | - Sylvie Chevret
- CRESS, Université de Paris, INSERM U-1153, Paris, France
| | - Anna Molto
- Rheumatology, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,CRESS, Université de Paris, INSERM U-1153, Paris, France
| | - Joachim Sieper
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Tuncay Duruöz
- PMR Department, Rheumatology Division, Marmara University School of Medicine, Istanbul, Turkey
| | - Uta Kiltz
- Rheumatology, Rheumazentrum Ruhrgebiet, Herne, Germany.,Rheumatology, Ruhr University Bochum, Bochum, Germany
| | | | | | - Ruben Burgos-Vargas
- Rheumatology, Hospital General de México Eduardo Liceaga, Mexico City, Mexico
| | - José Maldonado-Cocco
- Rheumatology, Buenos Aires University School of Medicine, Buenos Aires, Argentina
| | - Nelly Ziade
- Rheumatology, Saint Joseph University, Beirut, Lebanon.,Rheumatology, Mount Lebanon Hospital, Beirut, Lebanon
| | - Meghna Gavali
- Department of Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | | | - Shue-Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan
| | - Alessandro Biglia
- Rheumatology, Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy
| | - Kim Tae-Jong
- Department of Rheumatology, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | | | | | - Jieruo Gu
- Rheumatology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Laura Muntean
- Rheumatology, University of Medicine and Pharmacy Iuliu Hatieganu, Cluj-Napoca, Romania.,Rheumatology, County Emergency Clinical Hospital, Cluj-Napoca, Romania
| | - Floris A van Gaalen
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pál Geher
- Rheumatology, Semmelweis University, Budapest, Hungary
| | - Marina Magrey
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | | | - Wilson Bautista-Molano
- Rheumatology, University Hospital Fundación Santa Fé de Bogotá and Universidad El Bosque, Bogotá, Colombia
| | | | - Pedro M Machado
- Centre for Rheumatology and Department of Neuromuscular Diseases, University College London, London, UK.,Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK.,Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Robert Landewé
- Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| | | | - Maxime Dougados
- Rheumatology, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,CRESS, Université de Paris, INSERM U-1153, Paris, France
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13
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Martire MV, Collado P. Upper-Limb Entheses in Healthy Children: A Comprehensive Ultrasound Study. J Clin Rheumatol 2021; 27:S322-S326. [PMID: 33264248 DOI: 10.1097/rhu.0000000000001622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Interest in ultrasound (US) as a diagnostic tool in spondyloarthritis is growing. Although the literature has provided detailed description of normal lower-limb entheses for adults and children, validated normal US findings of the pediatric upper-limb (UL) entheses are lacking. OBJECTIVES The aim of this study was to describe the sonographic characteristics of the UL entheses in healthy children to provide a basis for assessing pathologic findings in children with rheumatic diseases. METHODS This is an observational, cross-sectional study. The recruited healthy children were grouped according to age: group 1, 3-9 years (n = 22); group 2, 10 to 13 years (n = 12); and group 3, 14 to 18 years (n = 9). The following UL entheses were examined: (1) supraspinatus, (2) common flexor, (3) common extensor, and (4) triceps. Ultrasound examination was performed in B mode for morphology and structural abnormalities, and power Doppler was applied to detect vascularization within the enthesis and cartilage sites. RESULTS Forty-three children with a median age of 9 years (6-13 years) were included; 55% were boys. A total of 344 entheses were evaluated; all of them presented a homogeneous hyperechoic fibrillar pattern. Tendon insertion thickness at the bone attachment site increased with age and was greater in males. No signs of chronic enthesopathy were detected. Doppler signal was observed in children from groups 1 and 2, but not in any of the patients in group 3. In group 1, intraentheses signal was detected in the common extensor tendon insertion as an isolated signal (n = 2 patients), whereas intracartilage signal was detected in the supraspinatus (n = 1 patient) and the triceps (n = 1 patient). In group 2, intracartilage signal was detected in the common extensor (n = 2 patients) and the common flexor (n = 2 patients). Interobserver agreement for the entheses' thickness was as follows: intracorrelation coefficient class (ICC) of 0.86 (95% confidence interval [CI], 0.84-0.92) for the supraspinatus enthesis, ICC of 0.83 (95% CI, 0.83-0.90) for the common extensor enthesis, ICC of 0.96 (95% CI, 0.91-0.97) for the common flexor enthesis, and ICC of 0.94 (95% CI, 0.89-0.95) for the triceps enthesis. The κ index was 0.93 for the detection of the power Doppler signal. Intraobserver agreement was good for all evaluated entheses: ICC of 0.85 (95% CI, 0.83-0.91) for supraspinatus, ICC of 0.86 (95% CI, 0.84-0.91) for common extensor entheses, ICC of 0.89 (95% CI, 0.86-0.93) for common flexor entheses, and ICC of 0.96 (95% CI, 0.90-0.97) for evaluation of triceps entheses. The κ index was 0.91 for the detection of Doppler signal. CONCLUSIONS The current study provides a comprehensive description of the structural appearance and vascularization of UL entheses on healthy children. This information can be useful as reference for interpretation of pathological findings in children with musculoskeletal diseases in clinical practice.
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Affiliation(s)
| | - Paz Collado
- Hospital Severo Ochoa, Leganés, Madrid, España
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14
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Santos-Moreno P, Baraliakos X, García-Salinas R. Engagement process for patients with spondyloarthritis: PANLAR early SpA clinics project - centers of excellence. Clin Rheumatol 2021; 40:4759-4766. [PMID: 34273002 DOI: 10.1007/s10067-021-05806-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/22/2021] [Accepted: 05/31/2021] [Indexed: 11/30/2022]
Abstract
Spondyloarthritis (SpA) is one of the most complex rheumatological diseases to diagnose and treat because, in the early stages of the disease, the inflammatory low back pain is often difficult to identify, and patients are diagnosed when they already have advanced structural processes. There is an urgent need to establish healthcare models that allow optimization of the management of these patients. The objective of this work is to propose a care model that is adaptable to the factual realities of Latin America. A systematic search of the literature terms (MeSH) was performed to search associated terms. Taking the model of the REAL-PANLAR project as an example and incorporating some related literature, a model of centers of excellence for SpA in Latin America is proposed that can be reasonably established and implemented. This model proposes 3 types of centers of excellence for SpA according to the level of complexity of each institution, and its criteria are defined based on indicators of structure, processes, and results. This is the first effort in Latin America to try to standardize the care of patients with spondyloarthritis. Key Points • The unmet needs in Latin America in the care of SpondyloArthritis (SpA), demand solutions that facilitate the rapid and assertive access of patients to specialized centers such as Center of Excellence in SpA. • This project facilitates the standardization of high-quality care for patients with SpA, starting from its diagnosis and up to clinical follow-up. • Due to standardization of care, better clinical and safety outcomes are achieved for patients, as well as patient-reported outcomes. • By standardized models of care, will be achieved a reduction in the progress of this pathology and optimization in the use of high-complexity services and high-cost therapies, improving cost-efficiency for public health systems in each country.
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15
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Weiss PF, Fuhlbrigge RC, von Scheven E, Lovell DJ, Colbert RA, Brunner HI. Children with enthesitis-related arthritis could benefit from treatments targeted for adults with spondyloarthritis. Arthritis Care Res (Hoboken) 2020; 74:1058-1064. [PMID: 33278336 DOI: 10.1002/acr.24529] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/13/2020] [Accepted: 12/01/2020] [Indexed: 12/22/2022]
Abstract
This review will summarize clinical, genetic and pathophysiologic characteristics that are shared between children with enthesitis related arthritis (ERA) with axial involvement and adults with non-radiographic, and in some cases radiographic, axial spondyloarthritis (SpA); and between children with ERA and primarily peripheral disease manifestations and adults with peripheral SpA. Due to the differences in classification criteria for children with ERA and adults with axial and peripheral SpA, the FDA granted automatic full waivers of studies in children for new medications for "axial spondyloarthropathies including ankylosing spondylitis" up until July 2020. Thus, although current juvenile idiopathic arthritis (JIA) treatment guidelines recommend the use of biologic disease modifying anti-rheumatic drugs (DMARDs) as part of the early treatment for patients with ERA, none of the FDA-approved therapies for peripheral SpA or non-radiographic axial SpA (certolizumab pegol, ixekizumab, and secukinumab) have been studied or are labelled for use in children with ERA. Considering the similarities between adult spondyloarthritis and ERA in terms of etiology, genetics, pathogenesis and clinical manifestations summarized in this review, medications approved for axial SpA or peripheral SpA should also be studied in children with active ERA involving axial or peripheral joints, respectively, with the intent to achieve labeling for use in children. Considering the current lack of effective FDA-approved therapies for ERA, the FDA should also consider requiring pediatric studies for medications that have already been approved for the treatment of adults with SpA.
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Affiliation(s)
- Pamela F Weiss
- Children's Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia, USA
| | - Robert C Fuhlbrigge
- Children's Hospital Colorado, University of Colorado School of Medicine, Colorado, USA, Cincinnati
| | - Emily von Scheven
- University of California, San Francisco. California, USA, Cincinnati
| | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, USA
| | - Robert A Colbert
- National Institute of Arthritis, Musculoskeletal, and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Hermine I Brunner
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, USA
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16
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Polivka L, Frenzel L, Jouzeau JY, Hermine O, Moulin D. Mast cells in spondyloarthritis, more than simple inflammatory bystanders? Ther Adv Musculoskelet Dis 2020; 12:1759720X20971907. [PMID: 33240405 PMCID: PMC7675857 DOI: 10.1177/1759720x20971907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Laura Polivka
- Department of Dermatology, Reference Center for
Genodermatoses (MAGEC), Necker-Enfants Malades Hospital (AP-HP5), Paris-Centre
University; Imagine Institute, INSERM U1163, Laboratory of Molecular Mechanisms of
Hematologic Disorders and Therapeutic Implications, Paris, France; French National
Reference Center for Mastocytosis (CEREMAST)
| | - Laurent Frenzel
- Department of Hematology, Necker-Enfants Malades Hospital
(AP-HP5), Paris-Centre University; Imagine Institute, INSERM U1163, Laboratory of
Molecular Mechanisms of Hematologic Disorders and Therapeutic Implications, Paris,
France; French National Reference Center for Mastocytosis (CEREMAST)
| | - Jean-Yves Jouzeau
- IMoPA, UMR7365 CNRS-Université de Lorraine, Vandœuvre-lès
Nancy, France
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17
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Fujikawa K, Kawashiri SY, Endo Y, Mizokami A, Tsukada T, Mine M, Uetani M, Kawakami A. Diagnostic efficacy of ultrasound detection of enthesitis in peripheral spondyloarthritis. Mod Rheumatol 2019; 30:1060-1066. [PMID: 31663417 DOI: 10.1080/14397595.2019.1687113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective: We investigated the diagnostic efficacy of power Doppler ultrasound (PDUS) to detect enthesitis in Japanese patients with peripheral spondyloarthritis (SpA).Methods: This was a single-center cohort study of patients with peripheral symptoms suggestive of SpA. Articular synovia, tendons, and entheses were assessed by PDUS at baseline. Clinical, laboratory, and radiologic findings and classification criteria for SpA were also evaluated.Results: 136 patients were consecutively evaluated. A definite diagnosis was obtained in 111 patients, including 72 with SpA and 39 non-SpA. Among the patients with SpA, PDUS demonstrated articular synovitis in 40 of the 72 patients (56%), tenosynovitis or peritendinitis in 48 (67%), and enthesitis in 63 (88%). Considering PDUS alone, enthesitis in at least one site was the most useful means of differentiating SpA from non-SpA (sensitivity 87.5%; specificity 82.1%; accuracy 85.6%; positive likelihood ratio 4.88). Combining that finding along with fulfillment of Amor, European Spondyloarthropathy Study Group, or Assessment of SpondyloArthritis international Society criteria for peripheral SpA increased the specificity of the diagnosis (92.5%, 92.3%, and 97.4%, respectively).Conclusion: PDUS enthesitis is useful for the diagnosis of SpA with peripheral symptoms. Combining PDUS enthesitis with established SpA classification criteria is beneficial in diagnosing peripheral SpA.
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Affiliation(s)
- Keita Fujikawa
- Department of Rheumatology, Japan Community Healthcare Organization, Isahaya General Hospital, Isahaya, Japan
| | - Shin-Ya Kawashiri
- Department of Immunology and Rheumatology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Yushiro Endo
- Department of Rheumatology, Japan Community Healthcare Organization, Isahaya General Hospital, Isahaya, Japan.,Department of Immunology and Rheumatology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Akinari Mizokami
- Department of Rheumatology, Japan Community Healthcare Organization, Isahaya General Hospital, Isahaya, Japan
| | - Toshiaki Tsukada
- Department of Rheumatology, Aino Memorial Hospital, Unzen, Japan
| | - Masanobu Mine
- Department of Rheumatology, Suga Orthopedic Hospital, Isahaya, Japan
| | - Masataka Uetani
- Department of Radiological Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
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