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Nagit RE, Rezus E, Cianga P. Exploring the Pathogenesis of Spondylarthritis beyond HLA-B27: A Descriptive Review. Int J Mol Sci 2024; 25:6081. [PMID: 38892265 PMCID: PMC11172491 DOI: 10.3390/ijms25116081] [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: 03/21/2024] [Revised: 05/15/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024] Open
Abstract
Spondylarthritis (SpA) is a chronic inflammatory condition that encompasses damage to the axial or peripheral skeleton, accompanied by specific extra-articular symptoms. Within this group, Ankylosing Spondylitis stands out as the hallmark member. Although the heritability of Ankylosing Spondylitis is estimated to be over 95%, only a portion of the heritability has been explained, with HLA-B27 accounting for 20.1% of it; therefore, ongoing research endeavors are currently concentrated on investigating the potential participation of different entities in the development of the disease. Genome-wide association studies have led to significant advances in our understanding of the genetics of SpA. In this descriptive review, we delve into the pathogenesis of Spondylarthritis beyond HLA-B27. We summarize the latest research on the potential participation of various entities in the development of the disease, including other genetic loci, immune dysregulation, microbiota, and environmental factors. The multifactorial nature of SpA and the complex interplay of genetic, immunological, and environmental factors are being increasingly recognized; therefore, it is of paramount importance to consider a holistic approach to comprehend the pathogenesis of SpA in order to identify novel therapeutic targets.
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Affiliation(s)
- Ruxandra-Elena Nagit
- Immunology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
| | - Elena Rezus
- Rheumatology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
- Clinical Rehabilitation Hospital, 700661 Iași, Romania
| | - Petru Cianga
- Immunology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
- Immunology Laboratory, “St. Spiridon” Clinical Hospital, 700111 Iași, Romania
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Chao YJ, Hung JH, Lin CP, Kuo HK, Chen SN, Hwang YS, Li KJ, Lin CJ, Hwang DK, Sheu SJ. Diagnosis, Treatment, and Prevention of Noninfectious Acute Anterior Uveitis with or without Human Leukocyte Antigen B27 in Adults - Expert Consensus in Taiwan. Ocul Immunol Inflamm 2024; 32:226-233. [PMID: 36701640 DOI: 10.1080/09273948.2023.2165113] [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: 10/23/2022] [Accepted: 12/31/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Anterior uveitis is the most common anatomical type of uveitis. Patients with noninfectious anterior uveitis may develop various ocular complications and eventually visual impairment. Appropriately differentiating the etiologies can help clinicians to predict the outcome, arrange clinical follow-up, and decide the treatment or prevention strategy. Adequate treatment and effective prevention strategies can reduce the frequency of recurrence and the risk of developing complications. Human leukocyte antigen (HLA)-B27 is the most common positive finding in patients with noninfectious AAU in many countries including Taiwan. PURPOSE To report a consensus from experienced uveitis specialists and rheumatologists was made in Taiwan. METHODS A panel of nine ophthalmologists from nine different referral centers with expertise in the management of uveitis and an experienced rheumatologist was held on January 16, 2022. A comprehensive literature review was performed. Differential diagnoses for etiologies, general treatments, and prevention strategies were discussed. Each statement in the consensus was made only if more than 70% of the experts agreed. RESULTS A flow chart and seven statements regarding the differential diagnoses for etiologies, treatments and preventions, and co-management with rheumatologists were included in the consensus. CONCLUSIONS This article discusses the general diagnosis, treatment, and prevention of noninfectious acute anterior uveitis, with or without HLA-B27, in adults for general ophthalmologists to improve overall outcomes of these patients.
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Affiliation(s)
- Yu-Jang Chao
- Department of Ophthalmology, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Jia-Horung Hung
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Chang-Ping Lin
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Hsi-Kung Kuo
- Department of Ophthalmology, Kaohsiung Chang-Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan, ROC
| | - San-Ni Chen
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan, ROC
- Department of Medication, China Medical University, Taichung, Taiwan, ROC
| | - Yih-Shiou Hwang
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan, ROC
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan, ROC
- Department of Ophthalmology, Chang Gung Memorial Hospital, Xiamen Branch, Xiamen, China
- Department of Ophthalmology, Jen-Ai Hospital Dali Branch, Taichung, Taiwan
| | - Ko-Jen Li
- Division of Rheumatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chun-Ju Lin
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan, ROC
- Department of Optometry, Asia University, Taichung, Taiwan, ROC
| | - De-Kuang Hwang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shwu-Jiuan Sheu
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Ophthalmology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Michelena X, Zhao SS, Marco-Pascual C, Almirall M, Collantes-Estevez E, Font-Ugalde P, López-Medina C, Wei JCC, Morgan AW, Rodríguez J, Juanola X, Vázquez-Mellado J, Marzo-Ortega H. Diagnostic delay is associated with uveitis and inflammatory bowel disease in AS: a study of extra-musculoskeletal manifestations in SpA. Rheumatology (Oxford) 2024; 63:430-435. [PMID: 37184889 PMCID: PMC10836992 DOI: 10.1093/rheumatology/kead225] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/27/2023] [Accepted: 05/06/2023] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES To examine the prevalence of extra-musculoskeletal manifestations (EMM) and the association between diagnostic delay and their incidence in AS and PsA. METHODS This was a retrospective, cohort study comprising two single centre cohorts in Europe and one multicentre cohort in Latin America (RESPONDIA). Crude prevalence of EMMs (uveitis, IBD and psoriasis) was calculated across geographic area and adjusted by direct standardization. Cox proportional hazard analysis was performed to assess the association between diagnostic delay and EMM incidence. RESULTS Of 3553 patients, 2097 had AS and 1456 had PsA. The overall prevalence of uveitis was 22.9% (95% CI: 21.1, 24.8) in AS and 3.8% (95% CI: 2.9, 5.0) in PsA; 8.1% (95% CI: 7.0, 9.4) and 2.1% (1.3, 2.9), respectively, for IBD; and 11.0% (95% CI: 9.7, 12.4) and 94.6% (93.0, 95.9), respectively, for psoriasis. The EMM often presented before the arthritis (uveitis 45.1% and 33.3%, and IBD 37.4% and 70%, in AS and PsA, respectively). In the multivariable model, longer diagnostic delay (≥5 years) associated with more uveitis (hazard ratio [HR] 4.01; 95% CI: 3.23, 4.07) and IBD events (HR 1.85; 95% CI: 1.28, 2.67) in AS. Diagnostic delay was not significantly associated with uveitis (HR 1.57; 95% CI: 0.69, 3.59) or IBD events (HR 1.59; 95% CI: 0.39, 6.37) in PsA. CONCLUSION EMMs are more prevalent in AS than PsA and often present before the onset of the articular disease. A longer diagnostic delay is associated with the 'de novo' appearance of uveitis and IBD in AS, highlighting the need to enhance diagnostic strategies to shorten the time from first symptom to diagnosis in SpA.
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Affiliation(s)
- Xabier Michelena
- Rheumatology Unit, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- NIHR Leeds BRC, Leeds Teaching Hospitals NHS Trust and School of Medicine, University of Leeds, Leeds, UK
| | - Sizheng Steven Zhao
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
| | - Carla Marco-Pascual
- Rheumatology Unit, Hospital Dos de Maig—Consorci Sanitari Integral, Barcelona, Spain
- Rheumatology Unit, Bellvitge University Hospital, L’Hospitalet de Llobregat, Spain
| | - Miriam Almirall
- NIHR Leeds BRC, Leeds Teaching Hospitals NHS Trust and School of Medicine, University of Leeds, Leeds, UK
| | - Eduardo Collantes-Estevez
- Rheumatology Unit, Reina Sofia University Hospital and Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Pilar Font-Ugalde
- Rheumatology Unit, Reina Sofia University Hospital and Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Clementina López-Medina
- Rheumatology Unit, Reina Sofia University Hospital and Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ann W Morgan
- NIHR Leeds BRC, Leeds Teaching Hospitals NHS Trust and School of Medicine, University of Leeds, Leeds, UK
| | - Jesús Rodríguez
- Rheumatology Unit, Bellvitge University Hospital, L’Hospitalet de Llobregat, Spain
| | - Xavier Juanola
- Rheumatology Unit, Bellvitge University Hospital, L’Hospitalet de Llobregat, Spain
| | | | - Helena Marzo-Ortega
- NIHR Leeds BRC, Leeds Teaching Hospitals NHS Trust and School of Medicine, University of Leeds, Leeds, UK
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Li H, Xu Y, Guo Q, Zhang T, Zhou S, Wu M, Cheng Y, Guo C. Ankylosing spondylitis: acute/subacute vs. chronic iridocyclitis - a bidirectional two-sample Mendelian randomization study. Front Immunol 2024; 14:1295118. [PMID: 38274819 PMCID: PMC10808375 DOI: 10.3389/fimmu.2023.1295118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/13/2023] [Indexed: 01/27/2024] Open
Abstract
Background Observational studies found associations between ankylosing spondylitis (AS) and iridocyclitis (IC), but the causality remained unconfirmed. Methods We employed two-sample Mendelian randomization (MR) to investigate the bidirectional causal relationships between AS and IC. Single-nucleotide polymorphisms (SNPs) were chosen from the FinnGen database's genome-wide association studies (GWAS) following a rigorous evaluation of the studies' quality. Sensitivity analysis was performed to assess the potential influence of pleiotropy and heterogeneity on the MR findings. Results Elevated genetic risk for AS showed positive causal effects on IC and its subtypes (IC, OR = 1.094, 95% CI = 1.035-1.157, P = 0.00156; Acute/Subacute IC, OR = 1.327, 95% CI = 1.266-1.392, P = 8.73×10-32; Chronic IC, OR = 1.454, 95% CI = 1.308-1.618, P = 5.19×10-12). Significant causal association was specifically observed between Acute/Subacute IC and AS (OR = 1.944, 95% CI = 1.316-2.873, P = 8.38×10-4). Sensitivity analysis suggested that horizontal pleiotropy was unlikely to influence the causality, and the leave-one-out analysis confirmed that a single SNP did not drive the observed associations. Conclusion Our findings provide new proof of a positive causal relationship between AS and IC in the European population. Notably, it is Acute/Subacute IC, rather than IC as a whole or Chronic IC, that is associated with an elevated risk of AS. These results emphasize the significance of considering AS characteristics in the diagnosis of Acute/Subacute IC.
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Affiliation(s)
- Hui Li
- The Third Affiliated Hospital, The Third School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Rheumatology and Immunology, The People’s Hospital of Baoan Shenzhen, The Second Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Yingying Xu
- Department of Intensive Care Medicine, Qingyuan People’s Hospital, Qingyuan, China
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Qin Guo
- Department of Rheumatology and Immunology, The People’s Hospital of Baoan Shenzhen, The Second Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Tiantian Zhang
- Department of Rheumatology and Immunology, The People’s Hospital of Baoan Shenzhen, The Second Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Shufen Zhou
- Department of Rheumatology and Immunology, The People’s Hospital of Baoan Shenzhen, The Second Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Meimei Wu
- Department of Rheumatology and Immunology, The People’s Hospital of Baoan Shenzhen, The Second Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Yuanxiong Cheng
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Chengshan Guo
- Department of Rheumatology and Immunology, The People’s Hospital of Baoan Shenzhen, The Second Affiliated Hospital of Shenzhen University, Shenzhen, China
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Barnett R, Gaffney K, Sengupta R. Diagnostic delay in axial spondylarthritis: A lost battle? Best Pract Res Clin Rheumatol 2023; 37:101870. [PMID: 37658016 DOI: 10.1016/j.berh.2023.101870] [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: 07/11/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 09/03/2023]
Abstract
Diagnostic delay in axial spondylarthritis (axSpA) remains an unacceptable worldwide problem; with evidence suggesting significant detrimental impact both clinically on the individual, and economically on society. There is therefore, a need for global action across various healthcare professions that come into contact with patients living, and suffering, with undiagnosed axSpA. Recent estimates of the median diagnostic delay suggest that globally, individuals with axSpA wait between 2 and 6 years for a diagnosis - revealing a clear benchmark for improvement. This timespan presents a window of opportunity for earlier diagnosis and intervention, which will likely improve patient outcomes. This review describes the current diagnostic delay as estimated across countries and over time, before presenting evidence from published strategies that may be implemented to improve this delay across primary and secondary care, including for specialties treating extra-musculoskeletal manifestations of axSpA (ophthalmology, gastroenterology, dermatology). Ongoing campaigns tackling delayed diagnosis in axSpA are also highlighted.
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Affiliation(s)
- Rosemarie Barnett
- Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, UK; Rheumatology Department, Royal National Hospital for Rheumatic Diseases & Brownsword Therapies Centre, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK.
| | - Karl Gaffney
- Rheumatology Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk & Norwich, University Hospital, Colney Lane, Norwich NR4 7UY, UK.
| | - Raj Sengupta
- Rheumatology Department, Royal National Hospital for Rheumatic Diseases & Brownsword Therapies Centre, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK.
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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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Corbitt K, Nowatzky J. Inflammatory eye disease for rheumatologists. Curr Opin Rheumatol 2023; 35:201-212. [PMID: 36943695 PMCID: PMC10461883 DOI: 10.1097/bor.0000000000000933] [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] [Indexed: 03/23/2023]
Abstract
PURPOSE OF REVIEW This review provides a framework for understanding inflammatory eye disease diagnosis, differential diagnosis, and management for rheumatologists. Uveitis, scleritis, episcleritis, peripheral ulcerative keratitis, and orbital inflammation are all discussed. The goal is to facilitate the development of approaches to inflammatory eye diseases that will help rheumatologists co-manage these patients with eye care providers specializing in ocular inflammation. RECENT FINDINGS In recent years, studies have aimed to advance biologic treatments and define standard-of-care therapy. Inflammatory eye diseases are highly heterogeneous and often rare, which poses significant challenges to their research and the interpretation of existing data. To date, glucocorticoids, mycophenolate, methotrexate, and TNF inhibitors remain the mainstay of treatment options for many of these diseases. SUMMARY Patients with inflammatory eye diseases require multidisciplinary care for best outcomes, frequently including rheumatologists. Understanding the differentials, diagnostics, and treatment are essential to preserving vision in these patients. The diverse nature of the disease processes within this field requires focusing on specific disease phenotypes and endotypes in research and clinical practice.
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Affiliation(s)
- Kelly Corbitt
- New York University Grossman School of Medicine, Department of Medicine, Division of Rheumatology
| | - Johannes Nowatzky
- New York University Grossman School of Medicine, Department of Medicine, Division of Rheumatology
- New York University Grossman School of Medicine, Department of Medicine, Division of Rheumatology, NYU Langone Behçet’s Disease Program, NYU Ocular Rheumatology Program
- New York University Grossman School of Medicine, Department of Pathology
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Rademacher J, Müllner H, Diekhoff T, Haibel H, Igel S, Pohlmann D, Proft F, Protopopov M, Rios Rodriguez V, Torgutalp M, Pleyer U, Poddubnyy D. Keep an Eye on the Back: Spondyloarthritis in Patients With Acute Anterior Uveitis. Arthritis Rheumatol 2023; 75:210-219. [PMID: 35905288 DOI: 10.1002/art.42315] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/02/2022] [Accepted: 07/20/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Judith Rademacher
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Epidemiology unit, German Rheumatism Research Centre, Berlin, Germany
| | - Hanna Müllner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Torsten Diekhoff
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Berlin, Germany
| | - Hildrun Haibel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Sabrina Igel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Dominika Pohlmann
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Ophthalmology, Berlin, Germany
| | - Fabian Proft
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Mikhail Protopopov
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Valeria Rios Rodriguez
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Murat Torgutalp
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Uwe Pleyer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Ophthalmology, Berlin, Germany
| | - Denis Poddubnyy
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Epidemiology unit, German Rheumatism Research Centre, Berlin, Germany
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Or C, Lajevardi S, Ghoraba H, Park JH, Onghanseng N, Halim MS, Hasanreisoglu M, Hassan M, Uludag G, Akhavanrezayat A, Nguyen QD. Posterior Segment Ocular Findings in HLA-B27 Positive Patients with Uveitis: A Retrospective Analysis. Clin Ophthalmol 2023; 17:1271-1276. [PMID: 37152636 PMCID: PMC10162386 DOI: 10.2147/opth.s408728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/17/2023] [Indexed: 05/09/2023] Open
Abstract
Purpose To describe the prevalence and characteristics of posterior segment manifestations in patients with HLA-B27-associated uveitis using wide field imaging. Methods Medical records of patients diagnosed with HLA-B27-associated uveitis from a tertiary uveitis clinic were reviewed. Posterior segment involvements including but not limited to peripheral vasculitis, optic disc inflammation, and macula edema documented based on medical records and various imaging modalities including wide field fluorescein angiography and optical coherence tomography, were noted. Demographic characteristics, accompanied with systemic diseases as well as duration and chronicity of uveitis, were also evaluated. Patients with significant systemic and ocular comorbidities were excluded. Statistical analyses including chi-squared tests and paired t-tests were employed. Results Of the 44 patients with HLA-B27 associated uveitis, 22 patients (50%) were noted to demonstrate posterior segment involvement. Disc leakage and peripheral vasculitis were the most common findings of posterior involvement. Those with anterior chamber inflammation were found to have a significantly increased risk of posterior involvement. Those with posterior involvement were also noted to have a statistically significant decreased visual acuity. No significant association was found between documented duration of disease and posterior segment involvement. Conclusion The prevalence of posterior segment involvement in HLA-B27 associated uveitis is higher compared to previous reports when evaluated with wide angle imaging modalities. Careful examination of the posterior segment is required in patients with HLA-B27 associated uveitis.
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Affiliation(s)
- Chris Or
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | - Sherin Lajevardi
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | - Hashem Ghoraba
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | - Jung Hyun Park
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | - Neil Onghanseng
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
- Department of Ophthalmology, Makati Medical Center, Manila, Philippines
| | | | - Murat Hasanreisoglu
- Department of Ophthalmology, Koç University, School of Medicine, Istanbul, Turkey
| | - Muhammad Hassan
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | - Gunay Uludag
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | | | - Quan Dong Nguyen
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
- Correspondence: Quan Dong Nguyen, Spencer Center for Vision Research, Byers Eye Institute at Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA, Tel +1 650 725 7245, Email
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Reveille JD, Ridley LK. Spondyloarthritis. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00058-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Lo TC, Chen YY, Chen HH. Risk of inflammatory bowel disease in uveitis patients: a population-based cohort study. Eye (Lond) 2022; 36:1288-1293. [PMID: 34155367 PMCID: PMC9151650 DOI: 10.1038/s41433-021-01645-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 06/01/2021] [Accepted: 06/14/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To investigate the potential association between uveitis and an increased risk of developing inflammatory bowel disease (IBD). METHODS We conducted a retrospective cohort study by interrogating data from the Taiwan National Health Insurance Research Database entered between January 1, 2001 and December 31, 2013 to identify uveitis patients and age- and gender-matched controls. The cumulative incidence rates of subsequent IBD in the two groups were compared. The adjusted hazard ratio (HR) of IBD related to uveitis was generated by a multivariate cox regression model after adjustment for hypertension, diabetes, hyperlipidaemia, obesity and smoking. Furthermore, the HRs of the Crohn's disease (CD) and ulcerative colitis (UC) IBD subtypes were calculated separately. RESULTS A total of 198,923 subjects with uveitis and 397,846 controls were enroled. The mean age of the cohort was 47.7 ± 18.9 years. A significantly higher cumulative incidence of IBD was found in the uveitis group than in controls (4.13% vs. 1.48%, p < 0.0001). Under univariate cox regression analysis, uveitis patients had a significantly higher risk of IBD (HR = 1.47; 95% confidence interval (CI): 1.43-1.52, p < 0.0001). The association remained significant in the multivariate regression model, with an adjusted HR of 1.44 (95% CI: 1.39-1.49, p < 0.0001). Moreover, in subgroup analysis, uveitis was significantly associated with an increased risk of Crohn's disease (adjusted HR = 1.49; 95% CI: 1.44-1.54), but not with ulcerative colitis (adjusted HR = 1.03; 95% CI: 0.92-1.15). CONCLUSIONS Patients with uveitis are at significantly greater risk of developing IBD than individuals without uveitis.
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Affiliation(s)
- Tzu-Chen Lo
- grid.410764.00000 0004 0573 0731Department of Medical Education, Taichung Veterans General Hospital, Taichung, 407 Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang Ming Chiao Tung University, Taipei, 112 Taiwan
| | - Yu-Yen Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan. .,Department of Ophthalmology, Taichung Veterans General Hospital, Taichung, 407, Taiwan. .,Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, 402, Taiwan.
| | - Hsin-Hua Chen
- grid.260539.b0000 0001 2059 7017School of Medicine, National Yang Ming Chiao Tung University, Taipei, 112 Taiwan ,grid.260539.b0000 0001 2059 7017Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, 112 Taiwan ,grid.411641.70000 0004 0532 2041School of Medicine, Chung Shan Medical University, Taichung, 402 Taiwan ,grid.265231.10000 0004 0532 1428Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, 407 Taiwan ,grid.410764.00000 0004 0573 0731Division of Allergy, Immunology, and Rheumatology & Division of General Internal Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, 407 Taiwan ,grid.260542.70000 0004 0532 3749Institute of Biomedical Science and Rong-Hsing Research Center for Translational Medicine, Chung-Hsing University, Taichung, 402 Taiwan
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12
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Eder L. Spondyloarthritis Among Patients With Uveitis: Can We Improve Referral Pathways? J Rheumatol 2022; 49:659-660. [PMID: 35569829 DOI: 10.3899/jrheum.220263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Delays in diagnosis remain a major gap in the care of patients with axial spondyloarthritis (axSpA). Despite efforts to improve awareness among family physicians and nonrheumatologist specialists, the average duration from onset of symptoms to diagnosis of axSpA is approximately 8 years,1 which is one of the longest in rheumatology. Such delays in diagnosis are associated with late initiation of therapy and worse disease outcomes.
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Affiliation(s)
- Lihi Eder
- LE is supported by Canada Research Chair (Tier 2) in Inflammatory Rheumatic Diseases and Early Researcher Award from Ontario Ministry of Science, Research and Innovation. L. Eder, MD, PhD, Associate Professor of Medicine, University of Toronto and Women's College Hospital, Toronto, Ontario, Canada. LE received consultation fees and educational grants from Novartis, Pfizer, Eli Lilly, Janssen, AbbVie, and UCB. Address correspondence to Dr. L. Eder, 76 Grenville Street, Women's College Hospital, Toronto, ON M5S 1B2, Canada.
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Allegri P, Cimino L, Davis JL, Tugal-Tutkun I. Assessment of the Anti-inflammatory Effects of NORFLO® ORO in Acute Relapses of HLA-B27-associated Autoimmune Uveitis: A Multicenter, Randomized, Placebo-controlled, Double-blind Clinical Study. Ocul Immunol Inflamm 2022; 31:526-535. [PMID: 35353651 DOI: 10.1080/09273948.2022.2039210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND An effective therapy to reduce the number and severity of HLA-B27-related acute anterior uveitis (AAU) recurrences represents a clinical need. Curcumin is a promising therapeutic option in various inflammatory eye diseases. To enhance its absorption and eye tissue selectivity, a phospholipidic-curcumin complex (PHBC) has been formulated (Iphytoone®, Eye Pharma S.p.A.). AIMS This study investigates if PHBC is effective and safe to decrease the number and intensity of HLA-B27-related AAU relapses. METHODS HLA-B27-related AAU patients were randomly divided to receive PHBC or placebo for 12 months (NCT03584724). RESULTS Compared with the previous year, the number of relapses decreased in both groups. The proportion of responders was significantly higher in the PBHC group. The severity of attacks was comparable. The study drug was well tolerated. CONCLUSIONS A beneficial effect of PHBC treatment is suggested because the proportion of responders was significantly higher in this group of patients.
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Affiliation(s)
- Pia Allegri
- Uveitis and Inflammatory Eye Diseases Referral Center, Rapallo Hospital, Genova, Italy
| | - Luca Cimino
- Ocular Immunology Unit, Azienda USL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Janet L Davis
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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van der Linden SM, Khan MA, Li Z, Baumberger H, Zandwijk HV, Khan K, Villiger PM, Brown MA. Factors predicting axial spondyloarthritis among first-degree relatives of probands with ankylosing spondylitis: a family study spanning 35 years. Ann Rheum Dis 2022; 81:831-837. [DOI: 10.1136/annrheumdis-2021-222083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/22/2022] [Indexed: 12/27/2022]
Abstract
ObjectiveFactors predicting axial spondyloarthritis (axSpA) among first-degree relatives (FDRs) of ankylosing spondylitis (AS) patients need to be defined. We investigated the predictive value of the probands’ HLA-B27 and radiographic sacroiliitis status on disease occurrence among their FDR. We also assessed the predictive value of features of the clinical history, including chronic inflammatory back pain (CIBP) and acute anterior uveitis (AAU), among the FDR and how they can be used to improve classification and diagnosis of axSpA.MethodsIn 1985, we studied 363 AS probands and 806 FDR who underwent rheumatologic examination, completed questionnaires, provided blood samples for HLA-typing and underwent radiography of sacroiliac joints. At follow-up in 2018–2019, 125 patients and 360 FDR were available for study, and completed a postal questionnaire about axSpA features. FDRs were asked to report whether after 1985 they had been diagnosed by Swiss rheumatologists as having axSpA.ResultsAmong HLA-B27(+) FDR, axSpA occurred in 25.4%–26.3%, independent of the radiographic sacroiliitis status of the proband. AAU occurred in 13/34 (38.2%) FDR with axSpA vs 29/251 (11.6%) FDR without axSpA (p=0.00004, OR=4.74 95% CI 2.15 to 10.47). The presence of CIBP at baseline did not predict later occurrence of axSpA but combining CIBP and pain/discomfort at the thoracic spine and at anterior (ventral) chest wall ever, assessed at follow-up in 2018–2019, provided 83.1% sensitivity and 87.2% specificity for current axSpA.ConclusionOccurrence of AAU among FDR of axSpA probands should prompt screening for axSpA. Moreover, co-occurrence of CIBP and pain/discomfort in the thoracic spine and at anterior chest wall as a three-question tool may further enhance clinical suspicion of axSpA among these FDR.
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15
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van Bentum RE, Verbraak FD, Wolf S, Ongkosuwito J, Boers M, Tan HS, van der Horst-Bruinsma IE. High prevalence of previously undiagnosed axial spondyloarthritis in patients referred with anterior uveitis and chronic back pain - the SpEYE study. J Rheumatol 2022; 49:680-687. [DOI: 10.3899/jrheum.210345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 11/22/2022]
Abstract
Objective To reduce the diagnostic delay in axial spondyloarthritis (axSpA), guidelines recommend to refer patients with acute anterior uveitis (AAU) and chronic back pain (CBP) to a rheumatologist. This observational study evaluated the prevalence of previously unrecognized axSpA in AAU patients with CBP in daily practice, referred by ophthalmologists who had received instructions to increase awareness. Methods All AAU patients referred with CBP (≥3 months, started <45 years of age), from five Ophthalmology clinics underwent rheumatologic assessment, including pelvic X-rays. Patients with previously diagnosed rheumatic disease and established other cause of AAU were excluded. The primary endpoint was a clinical axSpA diagnosis by the rheumatologist. Results Eighty-one patients fulfilled the referral criteria (52% male, 56% HLA-B27 positive, median age 41 years, median CBP duration 10 years). In total, 58% (n=47) had recurring AAU, of whom 87% already had CBP during previous AAU attacks. After assessment, 23% (n=19) of patients were clinically diagnosed with definite-axSpA (10/19 radiographic), 40% (n=32) were suspicious of axSpA and 37% (n=30) did not have axSpA. AxSpA was diagnosed more often in men (33% of the men versus 13% of women). Conclusion A high prevalence of axSpA was found in AAU patients referred because of CBP. There was substantial diagnostic delay in the majority of patients with recurring AAU, as many already had back pain during previous AAU flares. In AAU, screening for CBP and prompt referral has a high diagnostic yield, and should consistently be promoted among ophthalmologists.
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Clinical Features and Prevalence of Spondyloarthritis in a Cohort of Italian Patients Presenting with Acute Nongranulomatous Anterior Uveitis. J Immunol Res 2022; 2022:6632081. [PMID: 35087912 PMCID: PMC8789471 DOI: 10.1155/2022/6632081] [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: 12/31/2020] [Revised: 11/02/2021] [Accepted: 12/24/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose To describe the clinical features of acute nongranulomatous anterior uveitis (NGAU) patients and to estimate the prevalence of concomitant spondyloarthritis (SpA). Methods Retrospective study of consecutive patients affected by NGAU referred to the Ocular Immunology Unit of the AUSL-IRCCS di Reggio Emilia, Italy, between January 2016 and January 2019. All patients underwent ophthalmic evaluation and blood test with HLA-B27 typing and were referred to a rheumatologist to identify any undiagnosed SpA. SpA was classified according to the Assessment of SpondyloArthritis international Society (ASAS) criteria in axial or peripheral SpA. Patients were divided into two groups: NGAU with associated SpA (SpA+) and NGAU without SpA (SpA-). Clinical and demographic features of the two groups, including sex, HLA-B27, family history of rheumatic disease, uveitis laterality, course, and severity of ocular inflammation, complications, and treatment, were compared. Results Ninety-nine patients with NGAU were enrolled, of whom 36 (36%) with a diagnosis of SpA: 14 with peripheral SpA and 22 with axial SpA. The prevalence of SpA was higher in HLA-B27-positive patients than in HLA-B27-negative patients (50% vs. 15%, p < 0.0001). The multivariate logistic regression (R2 = 0.28) for SpA diagnosis identified as significant predictive factors: age at diagnosis (odds ratio [OR] = 0.95, 95% confidence interval [CI]: 0.91-0.99) and HLA-B27+ (OR = 5.32, 95% CI: 1.80-15.70). Conclusions Our results confirmed the high prevalence of undiagnosed SpA in patients with NGAU, suggesting that, regardless of HLA-B27 status, in the presence of IBP and/or peripheral arthritis, patients with NGAU must be referred to the rheumatologist to allow earlier diagnosis.
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Bubova K, Hasikova L, Mintalova K, Gregova M, Kasalicky P, Klimova A, Brichova M, Svozilkova P, Heissigerova J, Vencovsky J, Pavelka K, Senolt L. The Prevalence of MRI-Defined Sacroiliitis and Classification of Spondyloarthritis in Patients with Acute Anterior Uveitis: A Longitudinal Single-Centre Cohort Study. Diagnostics (Basel) 2022; 12:diagnostics12010161. [PMID: 35054328 PMCID: PMC8774303 DOI: 10.3390/diagnostics12010161] [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: 11/29/2021] [Revised: 01/03/2022] [Accepted: 01/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Acute anterior uveitis (AAU) is a relatively common extra-musculoskeletal manifestation of axial spondyloarthritis (axSpA); however, data on the prevalence of active sacroiliitis in patients with AAU are limited. Methods: 102 patients with AAU and 39 healthy subjects (HS) underwent clinical assessment and sacroiliac joint MRI. Patients with absence of active sacroiliitis were reassessed after two years. International Spondyloarthritis Society (ASAS) classification criteria for axSpA (regardless of patient’s age) and expert opinion for definitive diagnosis of axSpA were applied. Results: Although chronic back pain was equally present in both groups, bone marrow edema (BME) in SIJ and BME highly suggestive of axSpA was found in 52 (51%) and in 33 (32%) patients with AAU compared with 11 (28%) and none in HS, respectively. Out of all AAU patients, 41 (40%) patients fulfilled the ASAS classification criteria for axSpA, and 29 (28%) patients were considered highly suggestive of axSpA based on clinical features. Two out of the 55 sacroiliitis-negative patients developed active sacroiliitis at the two-year follow-up. Conclusions: One-third of patients with AAU had active inflammation on SIJ MRI and clinical diagnosis of axSpA. Therefore, patients with AAU, especially those with chronic back pain, should be referred to a rheumatologist, and the examination should be repeated if a new feature of SpA appears.
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Affiliation(s)
- Kristyna Bubova
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
- Correspondence: ; Tel.: +420-234075-111; Fax: +420-224914-451
| | - Lenka Hasikova
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
| | - Katerina Mintalova
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
| | - Monika Gregova
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
| | | | - Aneta Klimova
- Department of Ophthalmology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12808 Prague, Czech Republic; (A.K.); (M.B.); (P.S.); (J.H.)
| | - Michaela Brichova
- Department of Ophthalmology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12808 Prague, Czech Republic; (A.K.); (M.B.); (P.S.); (J.H.)
| | - Petra Svozilkova
- Department of Ophthalmology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12808 Prague, Czech Republic; (A.K.); (M.B.); (P.S.); (J.H.)
| | - Jarmila Heissigerova
- Department of Ophthalmology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12808 Prague, Czech Republic; (A.K.); (M.B.); (P.S.); (J.H.)
| | - Jiri Vencovsky
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
| | - Karel Pavelka
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
| | - Ladislav Senolt
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
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How Shing Koy E, Labauge P, Baillet A, Prati C, Marotte H, Pers YM. Immunomodulation with IL-17 and TNF-α in spondyloarthritis: focus on the eye and the central nervous system. Ther Adv Musculoskelet Dis 2021; 13:1759720X211025894. [PMID: 34290832 PMCID: PMC8273400 DOI: 10.1177/1759720x211025894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/27/2021] [Indexed: 12/17/2022] Open
Abstract
Tumor necrosis factor alpha (TNF-α) and interleukin-17 (IL-17) are two pro-inflammatory cytokines involved in the pathophysiology of spondyloarthritis (SpA). Therapies targeting TNF-α or IL-17 are used as a second line among SpA patients failing non-steroidal anti-inflammatory drugs. The choice of such treatment has to take into account the patient’s comorbidities. Neurologic diseases are common and their association with SpA deserves to be studied. Therefore, the role of TNF-α and IL-17 cytokines is worth investigating in these neuropsychiatric diseases. This review aimed to explore the role of TNF-α and IL-17 in the pathogenesis of uveitis, multiple sclerosis, neuromyelitis optica, Alzheimer’s disease, Parkinson’s disease and depression. This update is critical to guide the therapeutic management of these co-morbidities in SpA patients.
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Affiliation(s)
- Elsa How Shing Koy
- Department of Rheumatology, Hôpital Nord, CHU Saint-Etienne, Saint-Etienne, France
| | - Pierre Labauge
- MS Unit, Department of Neurology, Montpellier University Hospital, Montpellier Cedex 5, France
| | - Athan Baillet
- Université Grenoble-Alpes, GREPI TIMC, UMR 5525, Grenoble France
| | - Clément Prati
- Department of Rheumatology, CHRU de BESANCON, University Teaching Hospital, Besançon, France
| | - Hubert Marotte
- Department of Rheumatology, Hôpital Nord, CHU Saint-Etienne, Saint-Etienne, France
| | - Yves-Marie Pers
- IRMB, University of Montpellier, INSERM, CHU Montpellier, Montpellier, France
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Coath FL, Gaffney K. Inflammatory back pain: a concept, not a diagnosis. Curr Opin Rheumatol 2021; 33:319-325. [PMID: 33973548 DOI: 10.1097/bor.0000000000000807] [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: 10/21/2022]
Abstract
PURPOSE OF REVIEW The concept of inflammatory back pain (IBP) describes a cohort of patients with chronic back pain (CBP) who have distinct clinical characteristics, rather than being a diagnosis in and of itself. IBP is a common and important feature of axial spondyloarthritis (axSpA) but this is not the only differential. This review examines the utility of IBP in both primary and secondary care settings. RECENT FINDINGS There are a number of suggested referral strategies for patients with suspected axSpA that include IBP. These strategies attempt to strike a balance between ensuring potential axSpA patients are not overlooked, whilst simultaneously not overwhelming secondary care services. Their success relies on the clinicians who first encounter these patients being familiar with IBP as a concept; however, it is still poorly recognized by many healthcare professionals. IBP may be helpful as part of a referral strategy; however, other clinical features, laboratory investigations and radiology must be incorporated for the final diagnostic outcome in axSpA. SUMMARY Delayed diagnosis is a major clinical problem in axSpA and is associated with worse clinical outcomes. When recognized and utilized correctly, IBP can be a useful tool to promote prompt referral to rheumatology services.
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Affiliation(s)
- Fiona Louise Coath
- Rheumatology Department, Norfolk and Norwich Hospital, Colney Lane, Norwich, UK
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Russell MD, Coath F, Yates M, Bechman K, Norton S, Galloway JB, Ledingham J, Sengupta R, Gaffney K. Diagnostic delay is common for patients with axial spondyloarthritis: results from the National Early Inflammatory Arthritis Audit. Rheumatology (Oxford) 2021; 61:734-742. [PMID: 33982063 PMCID: PMC8824413 DOI: 10.1093/rheumatology/keab428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/10/2021] [Indexed: 01/20/2023] Open
Abstract
Objectives Updated guidelines for patients with axial SpA (axSpA) have sought to reduce diagnostic
delay by raising awareness among clinicians. We used the National Early Inflammatory
Arthritis Audit (NEIAA) to describe baseline characteristics and time to diagnosis for
newly referred patients with axSpA in England and Wales. Methods Analyses were performed on sociodemographic and clinical metrics, including time to
referral and assessment, for axSpA patients (n = 784) recruited to the
NEIAA between May 2018 and March 2020. Comparators were patients recruited to the NEIAA
with RA (n = 9270) or mechanical back pain (MBP;
n = 370) in the same period. Results Symptom duration prior to initial rheumatology assessment was longer in axSpA than RA
patients (P < 0.001) and non-significantly longer in axSpA than MBP
patients (P = 0.062): 79.7% of axSpA patients had symptom durations of
>6 months, compared with 33.7% of RA patients and 76.0% of MBP patients. Following
referral, the median time to initial rheumatology assessment was longer for axSpA than
RA patients (36 vs 24 days; P < 0.001) and similar
to MBP patients (39 days; P = 0.30). Of the subset of patients deemed
eligible for early inflammatory arthritis pathway follow-up, fewer axSpA than RA
patients had disease education provided (77.5% vs 97.8%) and RA
patients reported a better understanding of their condition and treatment. Conclusion Diagnostic delay in axSpA remains a major challenge despite improved disease
understanding and updated referral guidelines. Disease education is provided to fewer
axSpA than RA patients, highlighting the need for specialist clinics and support
programmes for axSpA patients.
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Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Fiona Coath
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
| | - Mark Yates
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Joanna Ledingham
- Rheumatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Raj Sengupta
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | - Karl Gaffney
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
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21
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Liew DFL, Dau J, Robinson PC. Value-Based Healthcare in Rheumatology: Axial Spondyloarthritis and Beyond. Curr Rheumatol Rep 2021; 23:36. [PMID: 33909169 DOI: 10.1007/s11926-021-01003-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW This review examines axial spondyloarthritis (axSpA) and the wider field of rheumatology through a value-based healthcare (VBHC) lens. VBHC is focused on ensuring patients receive high quality care to improve outcomes and reduce unnecessary costs. RECENT FINDINGS There are many opportunities to apply the principles of VBHC in axSpA. These include the appropriate utilization of diagnostic investigations, such as HLA-B27 and magnetic resonance imaging, assessing outcomes meaningful to patients, and optimizing care pathways. Multidisciplinary care may improve value, and reduced specialist review and medication tapering may be appropriate. Increasing the value of the care we provide to patients can occur across domains and directly and indirectly improves patient outcomes. Taking the time to integrate principles of VBHC into our practice will allow us to justifiably gain and maintain access to diagnostic and therapeutic advances for the benefit of all our patients.
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Affiliation(s)
- David F L Liew
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.,Department of Rheumatology, Austin Health, Heidelberg, Victoria, Australia.,Department of Clinical Pharmacology and Therapeutics, Austin Health, Heidelberg, Victoria, Australia
| | - Jonathan Dau
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Philip C Robinson
- Faculty of Medicine, University of Queensland School of Clinical Medicine, Herston, Queensland, 4006, Australia. .,Department of Rheumatology, Royal Brisbane & Women's Hospital, Metro North Hospital & Health Service, Bowen Bridge Road, Herston, Queensland, 4006, Australia.
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22
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Huang JCC, Schleisman M, Choi D, Mitchell C, Watson L, Asquith M, Rosenbaum JT. Preliminary Report on Interleukin-22, GM-CSF, and IL-17F in the Pathogenesis of Acute Anterior Uveitis. Ocul Immunol Inflamm 2021; 29:558-565. [PMID: 31763950 PMCID: PMC7246145 DOI: 10.1080/09273948.2019.1686156] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/19/2019] [Accepted: 10/24/2019] [Indexed: 01/17/2023]
Abstract
Purpose:Anterior uveitis is the most common anatomic subset of uveitis. We developed a novel multi-parametric flow cytometry panel to identify immune dysregulation signatures in HLA B27-associated acute anterior uveitis (AAU) and axial spondyloarthritis (AxSpA).Methods: We used fluorescence activated cell sorting to characterize T cell cytokine expression in stimulated T cell subsets from patients with AAU (n = 4) compared to healthy controls (n = 14) or subjects with AxSpA (n = 6).Results: Positive findings among subjects with AAU included a statistically significant increase in stimulated granulocyte-macrophage colony stimulating factor (GM-CSF), IL-17, and IL-22 synthesized by CD8 cells, a trend for stimulated ILC (innate lymphoid cells)-3 cells to synthesize more IL-22 (p = .07), and stimulated MAIT (mucosa associated innate lymphoid cells)-like cells that express the T cell receptor V alpha 7.2 to express IL-17A, IL-17F, and IL-22 in a greater percentage of cells relative to controls. IL-17F, GM- CSF, and IL-22 represent potentially novel targets in AAU.Conclusion: Our report is arguably the first to implicate IL-17F or ILC-3 and MAIT cells in the pathogenesis of AAU.Abbreviations AAU: acute anterior uveitis; AxSpA: axial spondyloarthritis; BASDAI: Bath ankylosing spondylitis disease activity index; CCR: chemokine receptor; DMSO: dimethylsulfoxide; EULAR:European League Against Rheumatism; FACS: fluorescence activated cell sorter; FBS: fetal bovine serum; FSC: orward light scatter; GM-CSF: granulocyte-macrophage colony stimulating factor; HC: healthy control; ILC: innate lymphoid cell; KIR: killer immunoglobulin receptor; MAIT: mucosal associated immune T cell; ND: not detected; NK: natural killer cell; OHSU-Oregon Health & Science University; PBMC: peripheral blood mononuclear cell; SSC: side light scatter; TCR: T cell receptor.
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Affiliation(s)
- Jerry Chien-Chieh Huang
- Department of Ophthalmology, Oregon Health & Science University (OHSU)
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan 2. Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
| | | | - Dongseok Choi
- OHSU-PSU School of Public Health, Oregon Health & Science University and Graduate School of Dentistry, Kyung Hee University, Seoul, Korea
| | - Claire Mitchell
- Department of Ophthalmology, Oregon Health & Science University (OHSU)
| | - Lindsey Watson
- Department of Ophthalmology, Oregon Health & Science University (OHSU)
| | - Mark Asquith
- Department of Medicine, OHSU (Dr. Asquith is deceased)
| | - James T. Rosenbaum
- Departments of Ophthalmology, Medicine, and Cell Biology, OHSU
- Legacy Devers Eye Institute, Portland, Oregon
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23
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Abstract
The uveitides are a heterogeneous group of diseases characterized by inflammation inside the eye. The uveitides are classified as infectious or non-infectious. The non-infectious uveitides, which are presumed to be immune mediated, can be further divided into those that are associated with a known systemic disease and those that are eye limited,-ie, not associated with a systemic disease. The ophthalmologist identifies the specific uveitic entity by medical history, clinical examination, and ocular imaging, as well as supplemental laboratory testing, if indicated. Treatment of the infectious uveitides is tailored to the particular infectious organism and may include regional and/or systemic medication. First line treatment for non-infectious uveitides is corticosteroids that can be administered topically, as regional injections or surgical implants, or systemically. Systemic immunosuppressive therapy is used in patients with severe disease who cannot tolerate corticosteroids, require chronic corticosteroids at >7.5 mg/day prednisone, or in whom the disease is known to respond better to immunosuppression. Management of many of these diseases is optimized by coordination between the ophthalmologist and rheumatologist or internist.
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Affiliation(s)
- Bryn M Burkholder
- Wilmer Eye Institute, Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Douglas A Jabs
- Wilmer Eye Institute, Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Clinical Trials and Evidence Synthesis, the Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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24
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Gómez-García I, Ladehesa-Pineda ML, Puche-Larrubia MÁ, Ortega-Castro R, Font-Ugalde P, Pérez-Guijo V, Escudero-Contreras A, Diaz-Villalón G, López-Medina C, Collantes-Estévez E. Uveitis as the first symptom in spondyloarthritis and its association with the evolution of the disease. Results from the REGISPONSER registry. Joint Bone Spine 2021; 88:105136. [PMID: 33486107 DOI: 10.1016/j.jbspin.2021.105136] [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: 11/06/2020] [Accepted: 12/15/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To describe the time of onset of acute anterior uveitis (AAU) relative to the appearance of rheumatic symptoms and to determine its association with the evolution of the spondyloarthritis (SpA) in terms of activity, structural damage, functional ability and treatment. METHODS This was a cross-sectional study with data extracted from the REGISPONSER (SpA Registry of the Spanish Rheumatology Society). Thirty-one centres participated, and patients with SpA according to the ESSG criteria were included from 2004 to 2007. Patients were classified according to the time of uveitis appearance with regard to rheumatic symptom onset (before, concomitant with, or after rheumatic symptom onset). We compared the clinical characteristics, disease activity, radiographic damage and functional ability between "AAU before or concomitant with rheumatic symptoms" and "AAU after rheumatic symptoms onset". Finally, we compared whether the time of appearance of AAU had an impact on the use of conventional and biological disease-modifying antirheumatic drugs (csDMARDs and bDMARDs, respectively). RESULTS A total of 2367 patients were included in REGISPONSER, with an AAU prevalence of 16.2% (379 patients). Patients with AAU before/concomitant with rheumatic symptom onset (n=59) exhibited better functional ability (BASFI, OR 0.85 [0.73-0.99]) and less structural damage (spinal BASRI, OR 0.88 [0.79-0.99]). Additionally, this group of patients was older at SpA symptom onset (OR 1.05 [1.02-1.09]) and had a shorter diagnosis delay (OR 0.90 [0.84-0.96]) compared patients with AAU after rheumatic symptom onset (n=229). No statistically significant differences in the use of DMARDs were noted (27.9% vs 23.2% for csDMARD use and 15.3% vs 20.3% for bDMARD use in patients with AAU before or concomitant with rheumatic symptom onset vs after rheumatic symptom onset, respectively). CONCLUSION Patients presenting with a first episode of AAU before/concomitant with the onset of rheumatic symptoms had less severe disease (better functional ability and less structural damage) and a shorter diagnosis delay; however, the time of AAU onset did not impact the treatments received.
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Affiliation(s)
- Ignacio Gómez-García
- Reina Sofia University Hospital from Córdoba/Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), 14004 Córdoba, Spain.
| | - María Lourdes Ladehesa-Pineda
- Reina Sofia University Hospital from Córdoba/Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), 14004 Córdoba, Spain
| | - María Ángeles Puche-Larrubia
- Reina Sofia University Hospital from Córdoba/Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), 14004 Córdoba, Spain
| | - Rafaela Ortega-Castro
- Reina Sofia University Hospital from Córdoba/Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), 14004 Córdoba, Spain; University of Córdoba, Spain
| | - Pilar Font-Ugalde
- Reina Sofia University Hospital from Córdoba/Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), 14004 Córdoba, Spain; University of Córdoba, Spain
| | - Verónica Pérez-Guijo
- Reina Sofia University Hospital from Córdoba/Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), 14004 Córdoba, Spain; University of Córdoba, Spain
| | - Alejandro Escudero-Contreras
- Reina Sofia University Hospital from Córdoba/Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), 14004 Córdoba, Spain; University of Córdoba, Spain
| | | | - Clementina López-Medina
- Reina Sofia University Hospital from Córdoba/Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), 14004 Córdoba, Spain; Rheumatology Department, Cochin Hospital from Paris/Inserm U:1153, Clinical Epidemiology and Biostatistics, Paris, France
| | - Eduardo Collantes-Estévez
- Reina Sofia University Hospital from Córdoba/Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), 14004 Córdoba, Spain; University of Córdoba, Spain
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25
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Gudu T, Jadon DR. Multidisciplinary working in the management of axial and peripheral spondyloarthritis. Ther Adv Musculoskelet Dis 2020; 12:1759720X20975888. [PMID: 33354231 PMCID: PMC7734487 DOI: 10.1177/1759720x20975888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/14/2020] [Indexed: 12/24/2022] Open
Abstract
Multidisciplinary (MD) care is essential in the management of patients with spondyloarthritis (SpA) and is one of the main pillars of disease management and patient care. However, evidence supporting the effectiveness and benefits of this strategy in SpA is scarce. In this review we discuss the three types of MD care models: (i) combined clinics (MD units), including ‘face to face’, ‘parallel’ and ‘circuit approach’ clinics; (ii) MD team meetings; (iii) group consultations. The most frequently used model in SpA studies has been the ‘parallel’ combined clinic and usually encompasses a rheumatologist and another specialist, most commonly a dermatologist or a gastroenterologist, that work in tandem according to predefined referral criteria and treatment algorithms. MD working seems to improve the care of patients with SpA by a better identification and diagnosis of the disease, an earlier and more comprehensive treatment approach, and better outcomes for patients in terms of disease activity, physical function, quality of life and patient satisfaction. Nevertheless, challenges remain. Data on effectiveness and feasibility are scarce and are mostly derived from studies with design issues and often without a unidisciplinary care comparator arm. Although patient centricity is one of the core values of patient care and MD setting in SpA, the patient often does not play an active role in most of the MD settings studied or in common clinical practice. Further efforts should be made so that MD care reflects patients’ expectations and needs. Overcoming these limits will help to implement successfully SpA MD care in daily clinical practice and subsequently to achieve a higher quality of care for our patients.
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Affiliation(s)
- Tania Gudu
- Department of Rheumatology, Cambridge University Hospitals NHSFT, Cambridge, UK
| | - Deepak R Jadon
- Rheumatology Research Unit, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
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26
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Rademacher J, Poddubnyy D, Pleyer U. Uveitis in spondyloarthritis. Ther Adv Musculoskelet Dis 2020; 12:1759720X20951733. [PMID: 32963592 PMCID: PMC7488890 DOI: 10.1177/1759720x20951733] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
Uveitis is the most frequent extra-articular manifestation of axial spondyloarthritis (SpA), occurring in up to one-third of the patients. In the majority of patients, uveitis is acute, anterior and unilateral and presents with photosensitivity, sudden onset of pain and blurred vision. Topical steroids are an effective treatment; however, recurrent or refractory cases may need conventional disease-modifying antirheumatic drugs or biological treatment with monoclonal tumor necrosis factor (TNF) inhibitors, thus also influencing treatment strategy of the underlying SpA. Though the exact pathogenesis of SpA and uveitis remains unknown, both seem to result from the interaction of a specific, mostly shared genetical background (among other HLA-B27 positivity), external influences such as microbiome, bacterial infection or mechanical stress and activation of the immune system resulting in inflammation. Up to 40% of patients presenting with acute anterior uveitis (AAU) have an undiagnosed SpA. Therefore, an effective referral strategy for AAU patients is needed to shorten the diagnostic delay of SpA and enable an early effective treatment. Further, the risk for ophthalmological manifestations increases with the disease duration in SpA; and patients presenting with ocular symptoms should be referred to an ophthalmologist. Thus, a close collaboration between patient, rheumatologist and ophthalmologist is needed to optimally manage ocular inflammation in SpA.
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Affiliation(s)
- Judith Rademacher
- Department of Gastroenterology, Infectiology and Rheumatology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Hindenburgdamm 30, Berlin, 10117, Germany
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectiology and Rheumatology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Uwe Pleyer
- Department of Ophthalmology, Campus Virchow, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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27
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Abstract
Human leukocyte antigen (HLA) B27 is the key laboratory parameter for axial spondyloarthritis (axSpA). Its prevalence is variable across different geographic zones and ethnicities, and often mirrors the prevalence of axSpA. HLA-B27 plays a role in axSpA physiopathology. It is correlated with spondyloarthritis phenotype with a consistent positive association with family history, early disease onset, shorter diagnostic delay, hip involvement, and acute anterior uveitis. HLA-B27 has a pivotal role in many referral strategies. However, these strategies were developed in European populations and need to be evaluated in populations with lower HLA-B27 background prevalence, and where additional parameters might be needed.
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28
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van Bentum RE, van der Horst-Bruinsma IE. Axial Spondyloarthritis in the Era of Precision Medicine. Rheum Dis Clin North Am 2020; 46:367-378. [DOI: 10.1016/j.rdc.2020.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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29
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Deodhar AA, Miceli-Richard C, Baraliakos X, Marzo-Ortega H, Gladman DD, Blanco R, Das Gupta A, Martin R, Safi J, Porter B, Shete A, Rosenbaum JT. Incidence of Uveitis in Secukinumab-treated Patients With Ankylosing Spondylitis: Pooled Data Analysis From Three Phase 3 Studies. ACR Open Rheumatol 2020; 2:294-299. [PMID: 32352653 PMCID: PMC7231512 DOI: 10.1002/acr2.11139] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 03/23/2020] [Indexed: 01/17/2023] Open
Abstract
Objective The objective of this study was to report the incidence of uveitis in secukinumab‐treated patients with ankylosing spondylitis (AS) in a pooled analysis of three phase 3 trials (MEASURE 1‐3 [ClinicalTrials.gov identifiers NCT01358175, NCT01649375, NCT02008916]). Methods Analysis included pooled patient‐level data from all patients (N = 794) who received any dose (one or more) of secukinumab up to the last patient attending the week 156 study visit in MEASURE 1 and up to the week 156 visit in MEASURE 2 and the week 104 visit in MEASURE 3 for each patient. Postmarketing data were from the periodic safety update report. Incidence of uveitis is reported as the exposure‐adjusted incidence rate (EAIR) per 100 patient‐years of secukinumab exposure. Results Overall, 135 (17%) patients reported preexisting (but not active or ongoing) uveitis at baseline, and 589 (74.2%) patients were HLA antigen B27 positive. The EAIR for uveitis was 1.4 per 100 patient‐years over the entire treatment period. Among all cases of uveitis (n = 26), 14 (54%) were flares. The exposure‐adjusted reporting rate of uveitis in the postmarketing data (which included patients across the three approved indications of psoriasis, psoriatic arthritis, and AS) was 0.03 per 100 patient‐years based on cumulative secukinumab exposure of 96 054 patient‐years. Conclusion The incidence rate of uveitis in secukinumab‐treated patients with active AS does not suggest an increased risk with secukinumab treatment.
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Affiliation(s)
| | - Corine Miceli-Richard
- Paris Descartes University, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, and European League Against Rheumatism Center of Excellence, Paris, France
| | | | | | | | - Ricardo Blanco
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - Ruvie Martin
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Jorge Safi
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Brian Porter
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - James T Rosenbaum
- Oregon Health & Science University and Legacy Devers Eye Institute, Portland
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30
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Coto P, Riestra S, Rozas P, Señaris A, Queiro R. Improving the standard of care for patients with spondyloarthritis-related immune inflammatory conditions: results of a Delphi study and proposal for early detection. Ther Adv Chronic Dis 2020; 11:2040622320904295. [PMID: 32110287 PMCID: PMC7016300 DOI: 10.1177/2040622320904295] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/07/2020] [Indexed: 12/29/2022] Open
Abstract
Background Our objective was to provide consensus recommendations on the optimal management of the immune-mediated inflammatory diseases (IMIDs) seen in patients with spondyloarthritis (SpA) using a multidisciplinary approach, and to develop a simple tool to help earlier recognition and referral of coexisting IMIDs in patients who already have one type of IMID. Methods A total of 28 experts in the multidisciplinary management of the SpA-associated IMIDs assessed two questionnaires: one with statements focused on the multidisciplinary management of IMIDs, and a second questionnaire focused on questions useful for early recognition and referral. Panelists assessed the statements with a 9-point ordinal scale (1 = strongly disagree, 9 = strongly agree) using a modified Delphi methodology. Results Consensus was reached on 72 out of the 82 statements (87.8%). Panelists agreed that the multidisciplinary approach to IMIDs is not sufficiently developed. The creation of multidisciplinary IMID units might be necessary. These units might focus primarily on patients with two or more coexisting IMIDs, or on IMIDs that are especially complex from a diagnostic or therapeutic point of view. Specialists who attend to patients with IMIDs should perform a screening for other coexisting IMIDs. A simple tool to help earlier recognition and referral of coexisting IMIDs is proposed. Conclusions There is a need to improve care for patients with SpA-associated IMIDs. We provide expert recommendations to guide the adoption of a multidisciplinary approach for these cases, and a simple tool that may be useful for earlier recognition of coexisting IMIDs.
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Affiliation(s)
- Pablo Coto
- Dermatology Division, Hospital Vital Alvarez Buylla, Mieres-Asturias, Spain
| | - Sabino Riestra
- Gastroenterology Service, IBD Unit, Hospital Universitario Central de Asturias, Oviedo-Asturias, Spain
| | - Paloma Rozas
- Ophthalmology Service, Hospital Universitario Central de Asturias, Oviedo-Asturias, Spain
| | - Ana Señaris
- Ophthalmology Service, Hospital Universitario Central de Asturias, Oviedo-Asturias, Spain
| | - Rubén Queiro
- Rheumatology Division, Department of Internal Medicine, Hospital Universitario Central de Asturias (HUCA), Av. Roma, s/n, Oviedo-Asturias, 33011, Spain
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31
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Zagora SL, Cornish EE, Symes RJ, Younan C, Sammel A, Wakefield D, McCluskey P. Inflammatory eye and rheumatic disease. Int J Rheum Dis 2019; 22:2091-2095. [PMID: 31797538 DOI: 10.1111/1756-185x.13714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 01/27/2023]
Affiliation(s)
- Sophia L Zagora
- Uveitis Unit, Sydney Eye Hospital, Sydney, NSW, Australia.,Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia
| | - Elisa E Cornish
- Uveitis Unit, Sydney Eye Hospital, Sydney, NSW, Australia.,Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia
| | - Richard J Symes
- Uveitis Unit, Sydney Eye Hospital, Sydney, NSW, Australia.,Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia
| | - Christine Younan
- Uveitis Unit, Sydney Eye Hospital, Sydney, NSW, Australia.,Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia
| | - Anthony Sammel
- Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia.,Rheumatology Department, Prince of Wales Hospital and Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Denis Wakefield
- Immunology Department, University of New South Wales, Sydney, NSW, Australia
| | - Peter McCluskey
- Uveitis Unit, Sydney Eye Hospital, Sydney, NSW, Australia.,Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia
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32
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Rosenbaum JT, Bodaghi B, Couto C, Zierhut M, Acharya N, Pavesio C, Tay-Kearney ML, Neri P, Douglas K, Pathai S, Song AP, Kron M, Foster CS. New observations and emerging ideas in diagnosis and management of non-infectious uveitis: A review. Semin Arthritis Rheum 2019; 49:438-445. [DOI: 10.1016/j.semarthrit.2019.06.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 04/18/2019] [Accepted: 06/05/2019] [Indexed: 02/07/2023]
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33
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Rosenbaum JT. The eye in spondyloarthritis ✰. Semin Arthritis Rheum 2019; 49:S29-S31. [PMID: 31779847 DOI: 10.1016/j.semarthrit.2019.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
Acute anterior uveitis is the most common extra-articular clinical manifestation of spondyloarthropathy. Rheumatologists should be aware of uveitis, know how it presents, understand the differential diagnosis of uveitis and arthritis, and be familiar with the role of systemic medications in the treatment or prevention of uveitis.
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Affiliation(s)
- James T Rosenbaum
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, United States; Legacy Devers Eye Institute, Suite 200, Portland, OR 97210, United States.
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34
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Rosenbaum JT, Asquith M. The microbiome and HLA-B27-associated acute anterior uveitis. Nat Rev Rheumatol 2019; 14:704-713. [PMID: 30301938 DOI: 10.1038/s41584-018-0097-2] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute anterior uveitis (AAU) and the spondyloarthritis (SpA) subtypes ankylosing spondylitis, reactive arthritis and psoriatic arthritis are among the inflammatory diseases affected by the biology of the intestinal microbiome. In this Review, the relationship between AAU, SpA and the microbiome is discussed, with a focus on the major SpA risk gene HLA-B*27 and how it is associated with both intestinal tolerance and the loss of ocular immune privilege that can accompany AAU. We provide four potential mechanisms to account for how dysbiosis, barrier function and immune response contribute to the development of ocular inflammation and the pathogenesis of AAU. Finally, potential therapeutic avenues to target the microbiota for the clinical management of AAU and SpA are outlined.
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Affiliation(s)
- James T Rosenbaum
- Departments of Ophthalmology, Medicine and Cell Biology, Oregon Health and Science University, Portland, OR, USA.,Legacy Devers Eye Institute, Portland, OR, USA
| | - Mark Asquith
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA.
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35
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Anterior uveitis in patients with spondyloarthropathies in a single US academic center: a retrospective study. Rheumatol Int 2019; 39:1607-1614. [PMID: 31342080 DOI: 10.1007/s00296-019-04386-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
Uveitis may represent an opportunity to diagnose spondyloarthropathies (SpA) earlier and influence treatment decisions. We describe the percentage of acute anterior uveitis (AAU) in a diverse group of SpA patients seen at one academic setting and compare demographic and clinical characteristics according to the presence of uveitis. We conducted a retrospective study of patients with SpA and AAU (January 2016-June 2017). Patients were identified using ICD-10 and administrative claim codes, diagnoses were confirmed through chart review. Extracted data included demographics, laboratory, clinical data, treatment and Routine Assessment of Patient Index Data 3 (RAPID3) scores based on Multidimensional Health Assessment Questionnaire (MDHAQ). Baseline description and comparison between the two groups were performed. We included 190 patients, mostly men (59.5%), with a mean age of 45.9 years: 48% with ankylosing spondylitis (AS), 26% with psoriatic arthritis (PsA), 22% with undifferentiated SpA, and 4% with SpA associated with inflammatory bowel disease (IBD). Uveitis was identified in 17% of patients, ranging from 25% in AS to 4% in PsA. Time from symptom onset to SpA diagnosis was longer in patients with uveitis (10.9 versus 5.9 years, p < 0.001). A higher percentage of patients with uveitis were HLA-B27 positive (85% versus 67%, p = 0.02). The prevalence of uveitis in our population was 17%, slightly lower than previously reported in the literature. There was a diagnostic delay of about 7 years, significantly longer in patients with uveitis. New screening strategies in collaboration with ophthalmology may lead to earlier diagnosis and better outcomes.
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Varkas G, Vastesaeger N, Cypers H, Colman R, Renson T, Praet LV, Carron P, Raeman F, Devinck M, Gyselbrecht L, Corluy L, Piette Y, Lenaerts J, Thevissen K, Vanneuville B, Bosch FVD, Elewaut D. Association of Inflammatory Bowel Disease and Acute Anterior Uveitis, but Not Psoriasis, With Disease Duration in Patients With Axial Spondyloarthritis: Results From Two Belgian Nationwide Axial Spondyloarthritis Cohorts. Arthritis Rheumatol 2019; 70:1588-1596. [PMID: 29740978 DOI: 10.1002/art.40551] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 05/01/2018] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To determine the link between extraarticular manifestations (EAMs) and baseline characteristics in patients with axial spondyloarthritis (SpA), and to define their potentially differential prognostic value in 2 large, independent Belgian axial SpA cohorts with distinct recruitment periods. METHODS Information on demographic and clinical characteristics and extraarticular manifestations (EAMs) was obtained from patients with axial SpA originating from the (Be)Giant (Belgian Inflammatory Arthritis and Spondylitis) cohort, which includes consecutive axial SpA patients whose data have been collected since 2010, and from the ASPECT (Ankylosing Spondylitis Patients Epidemiological Cross-sectional Trial) cohort, a Belgian registry of cross-sectional data collected between February 2004 and February 2005 from consecutive patients with ankylosing spondylitis (AS) or probable AS. RESULTS Among the 1,250 Belgian patients studied, disease duration was associated with risk of developing inflammatory bowel disease (IBD), with an increase in risk by 20% per 10 years of disease duration (relative risk [RR] 1.2, P = 0.026), and associated with risk of developing acute anterior uveitis, with an increase in risk by 30% per 10 years of disease duration (RR 1.3, P < 0.001). In the subgroup of 171 newly diagnosed patients with prospective follow-up data, higher mean C-reactive protein levels over time were demonstrated in those with acute anterior uveitis or IBD compared to those without EAMs or those with psoriasis alone (each P = 0.01). CONCLUSION The risk of developing acute anterior uveitis or IBD, but not psoriasis, in patients with axial SpA seems to increase with disease duration and appears to be linked to a higher cumulative exposure to inflammation, thus providing a possible explanation for the differential structural progression observed in those with axial SpA.
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Affiliation(s)
- Gaëlle Varkas
- Ghent University Hospital and VIB Center for Inflammation Research, Ghent University, Ghent, Belgium
| | | | - Heleen Cypers
- Ghent University Hospital and VIB Center for Inflammation Research, Ghent University, Ghent, Belgium
| | - Roos Colman
- Biostatistics Unit of the Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Thomas Renson
- Ghent University Hospital and VIB Center for Inflammation Research, Ghent University, Ghent, Belgium
| | | | - Philippe Carron
- Ghent University Hospital and VIB Center for Inflammation Research, Ghent University, Ghent, Belgium
| | | | | | | | | | | | | | | | | | - Filip Van den Bosch
- Ghent University Hospital and VIB Center for Inflammation Research, Ghent University, Ghent, Belgium
| | - Dirk Elewaut
- Ghent University Hospital and VIB Center for Inflammation Research, Ghent University, Ghent, Belgium
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Aletaha D, Epstein AJ, Skup M, Zueger P, Garg V, Panaccione R. Risk of Developing Additional Immune-Mediated Manifestations: A Retrospective Matched Cohort Study. Adv Ther 2019; 36:1672-1683. [PMID: 31102202 PMCID: PMC6824390 DOI: 10.1007/s12325-019-00964-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Immune-mediated inflammatory diseases (IMIDs) cause significant impairment in quality of life. Although they share similar genetic factors, environmental precipitants, and pathophysiological mechanisms, there is little evidence on the risk of developing subsequent IMIDs after an initial IMID diagnosis. We sought to assess the risk of developing subsequent IMIDs among patients diagnosed with an initial IMID. METHODS This retrospective matched cohort study used a large US commercial health insurance claims database (01/01/2006-09/30/2015). The risks of developing secondary IMIDs among patients aged 18-64 years with a diagnosis of one of nine IMIDs of interest (ankylosing spondylitis, celiac disease, hidradenitis suppurativa [HS], inflammatory bowel disease, lupus, psoriatic arthritis [PsA], psoriasis, rheumatoid arthritis, and uveitis) as identified from diagnosis codes on medical claims were compared with up to 1000 matched controls without the primary IMID using Cox proportional hazards models. RESULTS Across the nine IMIDs of interest, there were 398,935 unique case patients matched to 256,795,796 non-unique control patients. Case patients with an initial IMID had higher risks of developing each, any one, and any two of the other eight secondary IMIDs compared to their matched controls. Hazard ratios [95% confidence intervals] for the risk of developing any one secondary IMID ranged from 5.4 [5.0, 5.8] (initial IMID: HS) to 62.2 [59.9, 64.6] (initial IMID: PsA), and hazard ratios for developing any two secondary IMIDs ranged from 3.0 [2.3, 3.8] (HS) to 75.2 [69.3, 81.7] (PsA). CONCLUSIONS This study demonstrates that the risk of developing a second IMID is significantly higher for individuals who have already experienced a first IMID in a large and contemporary US claims database. Certain pairs of IMIDs co-occur more frequently than others. The risk of developing subsequent IMIDs may be an important consideration for clinicians when selecting treatment strategies. FUNDING Abbvie.
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Abstract
Acute anterior uveitis (AAU) is the most frequent uveitis subtype. It is often associated with HLA-B27 and with inflammatory rheumatic diseases, in particular with spondyloarthritis (SpA), which itself is strongly associated with HLA-B27. About 40-60% of patients with AAU have an associated spondyloarthritis, and 20-40% of patients with spondyloarthritis also have uveitis. The incidence of AAU in patients with SpA clearly correlates with disease duration. The AAU has an acute onset, usually affects only one eye at a time, and shows a tendency for recurrence. Early therapy of AAU with topical steroids is relevant for good visual outcomes. Minimum duration of therapy of flares of AAU is 6-8 weeks in order to prevent early recurrency. The rate of local complications correlates with the rate of AAU flares and the visual outcome is often good. Refractory uveitis and frequent recurrencies of AAU may be treated with conventional disease-modifying antirheumatic drugs (DMARDs, such as sulfasalazine and methotrexate) and biologicals (e.g. TNF-alpha inhibitors). Any first episode of AAU diagnosed by an ophthalmologist should prompt referral to rheumatology for suspected SpA, particularly if rheumatic symptoms are present.
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Choi RY, Rivera-Grana E, Rosenbaum JT. Reclassifying Idiopathic Uveitis: Lessons From a Tertiary Uveitis Center. Am J Ophthalmol 2019; 198:193-199. [PMID: 30352197 DOI: 10.1016/j.ajo.2018.10.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 10/08/2018] [Accepted: 10/10/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Idiopathic uveitis is frequently the most common diagnosis in series from uveitis clinics. This study sought to determine the percentage of patients initially diagnosed as idiopathic, noninfectious uveitis referred to a tertiary uveitis center who were subsequently found to have an identifiable cause of uveitis. DESIGN Retrospective case series. METHODS We performed a computerized database analysis of 179 consecutive patients who were referred to our practice with the diagnosis of idiopathic, noninfectious uveitis between 2008 and 2016. Patients were evaluated by a thorough history and ophthalmic examination with selected laboratory testing targeted by clues from the history and examination. Standardization of Uveitis Nomenclature (SUN) criteria were used to better assess different types of uveitis. RESULTS Fifty-two out of 179 (29.0%) patients initially diagnosed with idiopathic uveitis were subsequently diagnosed with an underlying condition. Among patients referred with a diagnosis of idiopathic disease, female patients were most commonly affected (121/179; 67.6%). Among subsequent diagnoses, sarcoidosis was the most common (19/52 or 36.5%), followed by HLA-B27-associated uveitis (11/52, 21.1%), infectious uveitis (6/52, 11.5%), tubulointerstitial nephritis with uveitis (6/52, 11.5%), and juvenile idiopathic uveitis (4/52, 7.7%). Other diagnosable conditions included Behçet disease, multifocal choroiditis, panuveitis, Crohn disease, multiple sclerosis, and relapsing polychondritis. An underlying condition was not found in 127 of 179 (70.9%) patients. CONCLUSIONS We report that 29% of patients referred to our tertiary uveitis center diagnosed as "idiopathic" had an associated identifiable cause. Identifying an underlying condition associated with uveitis could be potentially lifesaving for some illnesses (eg, sarcoidosis with cardiac involvement) and is critical to management (eg, infection). Although we were able to use limited testing to classify many patients who had been previously incorrectly labeled with idiopathic uveitis, idiopathic uveitis remains the most common diagnosis in our uveitis clinic.
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Immunological Ocular Disease. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00074-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Rosenbaum JT, Dick AD. The Eyes Have it: A Rheumatologist's View of Uveitis. Arthritis Rheumatol 2018; 70:1533-1543. [PMID: 29790291 DOI: 10.1002/art.40568] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 05/17/2018] [Indexed: 12/18/2022]
Abstract
Uveitis is defined as intraocular inflammation. It is an extraarticular manifestation of many forms of joint disease, which include spondyloarthritis, juvenile idiopathic arthritis, and Behçet's disease. Rheumatologists may be asked to consult on the ophthalmologic care of patients with uveitis in order to identify an associated systemic illness. Diagnoses such as spondyloarthritis, sarcoidosis, and interstitial nephritis with uveitis are frequently overlooked by referring ophthalmologists. Alternatively, rheumatologists may be asked to help manage the patient's immunosuppression, including biologic therapy, which can be required to treat a subset of patients with uveitis. This review is intended to provide rheumatologists with the necessary information to facilitate collaboration in the comanagement of patients with uveitis.
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Affiliation(s)
- James T Rosenbaum
- Oregon Health & Science University and Legacy Devers Eye Institute, Portland, Oregon
| | - Andrew D Dick
- University College London, National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital, London, UK, and University of Bristol, Bristol Eye Hospital, Bristol, UK
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Lim CSE, Sengupta R, Gaffney K. The clinical utility of human leucocyte antigen B27 in axial spondyloarthritis. Rheumatology (Oxford) 2018; 57:959-968. [PMID: 29029331 DOI: 10.1093/rheumatology/kex345] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Indexed: 12/17/2022] Open
Abstract
The association between HLA-B27 and AS was first established in the early 1970s. Since then, our understanding of this disease has changed, such that we now recognize AS to be the extreme of the clinical phenotype within a disease spectrum known as axial SpA (axSpA). Recent advances in therapeutic options have driven the need for earlier diagnosis and many screening strategies have been proposed to facilitate this. In parallel, our understanding of axSpA genetics, and especially the contribution of HLA-B27, has expanded. In this article we will present and discuss the evidence supporting the use of HLA-B27 in clinical practice. We will briefly summarize the evolution of the concept of axSpA, the prevalence of HLA-B27 and axSpA and the potential role of HLA-B27 in the aetiopathogenesis of axSpA and focus on the utility of HLA-B27 in everyday clinical practice.
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Affiliation(s)
| | - Raj Sengupta
- Rheumatology Department, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | - Karl Gaffney
- Rheumatology Department, Norfolk & Norwich University Hospital, Norwich, UK
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Standardization of red flags for referral to rheumatologists and ophthalmologists in patients with rheumatic diseases and ocular involvement: a consensus statement. Rheumatol Int 2018; 38:1727-1734. [DOI: 10.1007/s00296-018-4094-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/21/2018] [Indexed: 12/19/2022]
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Sykes MP, Hamilton L, Jones C, Gaffney K. Prevalence of axial spondyloarthritis in patients with acute anterior uveitis: a cross-sectional study utilising MRI. RMD Open 2018. [PMID: 29531779 PMCID: PMC5845401 DOI: 10.1136/rmdopen-2017-000553] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objective Acute anterior uveitis (AAU) is the most common extra-articular manifestation of axial spondyloarthritis (axSpA). In this study, patients presenting with AAU were evaluated clinically and with MRI in order to estimate the prevalence of axSpA. Methods Consecutive patients presenting to a university teaching hospital between February 2014 and March 2015 with AAU were invited to participate. Those with a history of chronic back pain (CBP) beginning <45 years were evaluated clinically and with MRI of thoracolumbar spine and sacroiliac joints. Results Of 366 patients with AAU, 57 had a pre-existing diagnosis of axSpA; 77 others fulfilled the study eligibility criteria and 73 (95%) completed the study. Seventeen patients (23.3%) were diagnosed with axSpA by an experienced rheumatologist; of these, eight were human leucocyte antigen-B27 negative. Including those with a previous diagnosis, this equates to a minimum axSpA prevalence of 20.2%; one-quarter of patients were previously undiagnosed. Conclusion This is the first study to actively search for the presence of axSpA in unselected patients presenting with AAU utilising MRI as an essential part of the assessment. There is a significant burden of undiagnosed axSpA in patients with AAU, but there does not appear to be a simple mechanism for screening. We recommend that ophthalmologists refer all patients with AAU with CBP, onset <45 years, to rheumatology for further evaluation.
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Affiliation(s)
- Mark P Sykes
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Louise Hamilton
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Colin Jones
- Department of Ophthalmology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Karl Gaffney
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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Abstract
PURPOSE OF REVIEW Uveitis is the most common, clinically apparent, extra-articular manifestation of axial spondyloarthritis. This review summarizes recent publications related to this form of uveitis. RECENT FINDINGS Studies published since the start of 2015 address the worldwide prevalence of human leukocyte antigen (HLA) B27-associated uveitis, the prevalence of axial spondyloarthritis among patients with B27-associated acute anterior uveitis (AAU), the genetics of AAU and some of the clinical implications of AAU. Progress has been made in the treatment of uveitis in general and in the treatment of uveitis in association with spondyloarthropathy in particular. The pathogenesis of AAU might derive clues from the above as well as from an understanding of the microbiome and possibly from knowledge derived from uveitis in association with Ebola. SUMMARY Although HLA B27-associated uveitis has been recognized since 1973, a variety of recent observations shed new light on this common clinical association with spondyloarthritis.
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Abstract
Anterior uveitis is the most common form of uveitis. There are several known and many possible etiologies for anterior uveitis. After examining the posterior segment and ruling out masquerade syndromes, the main step of etiologic diagnosis is clinical characterization. It is essential to establish unilateral versus bilateral involvement and presence or absence of granulomatous features. Subsequently, a work-up may be obtained which then helps to confirm diagnostic hypotheses based on the detailed history and clinical examination. The priority is to rule out an infection, although less frequent, before starting steroid therapy, adapted to the severity of the clinical picture. Finally, biologics have greatly changed the management and prevention of some forms of anterior uveitis, in particular uveitis associated with HLA-B27 and juvenile idiopathic arthritis-associated anterior uveitis.
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Affiliation(s)
- J Gueudry
- Service d'ophtalmologie, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76031 Rouen Cedex, France.
| | - M Muraine
- Service d'ophtalmologie, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76031 Rouen Cedex, France
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Gueudry J, Muraine M. Anterior uveitis. J Fr Ophtalmol 2017; 41:e11-e21. [PMID: 29290458 DOI: 10.1016/j.jfo.2017.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 09/07/2017] [Accepted: 11/14/2017] [Indexed: 12/17/2022]
Abstract
Anterior Uveitis is the most common form of uveitis. There are several known and many possible etiologies for anterior uveitis. After examining the posterior segment and ruling out masquerade syndromes, the main step of etiologic diagnosis is clinical characterization. It is essential to establish the presence or absence of unilateral versus bilateral and granulomatous features. Subsequently, a directed work-up may be obtained which then helps to confirm diagnostic hypotheses based on the detailed history and clinical examination. The priority is to rule out an infection. Treatments are adapted according to etiology and disease severity. Finally, biologics have greatly changed the management and prevention of some forms of anterior uveitis, in particular uveitis associated with HLA-B27 and juvenile idiopathic arthritis-associated anterior uveitis.
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Affiliation(s)
- J Gueudry
- Service d'ophtalmologie, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France.
| | - M Muraine
- Service d'ophtalmologie, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France
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Oliveira TL, Maksymowych WP, Lambert RGW, Muccioli C, Fernandes ARC, Pinheiro MM. Sacroiliac Joint Magnetic Resonance Imaging in Asymptomatic Patients with Recurrent Acute Anterior Uveitis: A Proof-of-concept Study. J Rheumatol 2017; 44:1833-1840. [PMID: 29093157 DOI: 10.3899/jrheum.170036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Our aim was to quantify bone marrow edema (BME) and/or structural lesions in the sacroiliac joints (SIJ) of patients with recurrent acute anterior uveitis (rAAU) with or without back pain, to evaluate the frequency of axial (axSpA) and peripheral spondyloarthritis (pSpA) and to establish which criterion for magnetic resonance imaging (MRI) positivity best reflected the global assessment of SIJ MRI. METHODS A total of 50 patients with rAAU without prior rheumatologic diagnosis were included in our cross-sectional study, and these patients were compared to 21 healthy volunteers. SIJ MRI scans were read by 2 rheumatologists according to the Spondyloarthritis Research Consortium of Canada (SPARCC/MORPHO) protocol. Discrepant cases were adjudicated by a radiologist. RESULTS Patients with rAAU were diagnosed with axSpA (Group 1, n = 20, 40%) and nonspecific back pain (Group 2, n = 6, 12%), or as being asymptomatic (Group 3, n = 24, 48%). Group 3 results showed 9 patients (37.5%) had SIJ MRI and/or were radiography-positive for axSpA (5 MRI and radiograph, 1 MRI, 3 radiograph). SIJ MRI scans that were compatible with SpA in groups 1 (n = 12) and 3 (n = 6) were similar in acute and structural lesions that were analyzed according to SPARCC/MORPHO. The best sensitivity/specificity criterion for defining a positive global MRI assessment was a BME score ≥ 3 (88%/94%). CONCLUSION This is the first study evaluating SIJ MRI in patients with rAAU without back symptoms, showing positive findings for sacroiliitis. Moreover, a BME score ≥ 3 had better performance to define an SIJ MRI as positive for axSpA.
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Affiliation(s)
- Thauana L Oliveira
- From Division of Rheumatology, Department of Ophthalmology, and Department of Radiology and Diagnostic Imaging, Federal University of São Paulo (UNIFESP/EPM), São Paulo, Brazil; Department of Medicine, and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada. .,T.L. Oliveira, MD, MSc, Division of Rheumatology, UNIFESP/EPM; W.P. Maksymowych, MD, PhD, Department of Medicine, University of Alberta; R.G. Lambert, MD, PhD, Department of Radiology and Diagnostic Imaging, University of Alberta; C. Muccioli, MD, PhD, Department of Ophthalmology, UNIFESP/EPM; A.R. Fernandes, MD, PhD, Department of Radiology and Diagnostic Imaging, UNIFESP/EPM; M.M. Pinheiro, MD, PhD, Division of Rheumatology, UNIFESP/EPM.
| | - Walter P Maksymowych
- From Division of Rheumatology, Department of Ophthalmology, and Department of Radiology and Diagnostic Imaging, Federal University of São Paulo (UNIFESP/EPM), São Paulo, Brazil; Department of Medicine, and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada.,T.L. Oliveira, MD, MSc, Division of Rheumatology, UNIFESP/EPM; W.P. Maksymowych, MD, PhD, Department of Medicine, University of Alberta; R.G. Lambert, MD, PhD, Department of Radiology and Diagnostic Imaging, University of Alberta; C. Muccioli, MD, PhD, Department of Ophthalmology, UNIFESP/EPM; A.R. Fernandes, MD, PhD, Department of Radiology and Diagnostic Imaging, UNIFESP/EPM; M.M. Pinheiro, MD, PhD, Division of Rheumatology, UNIFESP/EPM
| | - Robert G W Lambert
- From Division of Rheumatology, Department of Ophthalmology, and Department of Radiology and Diagnostic Imaging, Federal University of São Paulo (UNIFESP/EPM), São Paulo, Brazil; Department of Medicine, and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada.,T.L. Oliveira, MD, MSc, Division of Rheumatology, UNIFESP/EPM; W.P. Maksymowych, MD, PhD, Department of Medicine, University of Alberta; R.G. Lambert, MD, PhD, Department of Radiology and Diagnostic Imaging, University of Alberta; C. Muccioli, MD, PhD, Department of Ophthalmology, UNIFESP/EPM; A.R. Fernandes, MD, PhD, Department of Radiology and Diagnostic Imaging, UNIFESP/EPM; M.M. Pinheiro, MD, PhD, Division of Rheumatology, UNIFESP/EPM
| | - Cristina Muccioli
- From Division of Rheumatology, Department of Ophthalmology, and Department of Radiology and Diagnostic Imaging, Federal University of São Paulo (UNIFESP/EPM), São Paulo, Brazil; Department of Medicine, and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada.,T.L. Oliveira, MD, MSc, Division of Rheumatology, UNIFESP/EPM; W.P. Maksymowych, MD, PhD, Department of Medicine, University of Alberta; R.G. Lambert, MD, PhD, Department of Radiology and Diagnostic Imaging, University of Alberta; C. Muccioli, MD, PhD, Department of Ophthalmology, UNIFESP/EPM; A.R. Fernandes, MD, PhD, Department of Radiology and Diagnostic Imaging, UNIFESP/EPM; M.M. Pinheiro, MD, PhD, Division of Rheumatology, UNIFESP/EPM
| | - Artur R C Fernandes
- From Division of Rheumatology, Department of Ophthalmology, and Department of Radiology and Diagnostic Imaging, Federal University of São Paulo (UNIFESP/EPM), São Paulo, Brazil; Department of Medicine, and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada.,T.L. Oliveira, MD, MSc, Division of Rheumatology, UNIFESP/EPM; W.P. Maksymowych, MD, PhD, Department of Medicine, University of Alberta; R.G. Lambert, MD, PhD, Department of Radiology and Diagnostic Imaging, University of Alberta; C. Muccioli, MD, PhD, Department of Ophthalmology, UNIFESP/EPM; A.R. Fernandes, MD, PhD, Department of Radiology and Diagnostic Imaging, UNIFESP/EPM; M.M. Pinheiro, MD, PhD, Division of Rheumatology, UNIFESP/EPM
| | - Marcelo M Pinheiro
- From Division of Rheumatology, Department of Ophthalmology, and Department of Radiology and Diagnostic Imaging, Federal University of São Paulo (UNIFESP/EPM), São Paulo, Brazil; Department of Medicine, and Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada.,T.L. Oliveira, MD, MSc, Division of Rheumatology, UNIFESP/EPM; W.P. Maksymowych, MD, PhD, Department of Medicine, University of Alberta; R.G. Lambert, MD, PhD, Department of Radiology and Diagnostic Imaging, University of Alberta; C. Muccioli, MD, PhD, Department of Ophthalmology, UNIFESP/EPM; A.R. Fernandes, MD, PhD, Department of Radiology and Diagnostic Imaging, UNIFESP/EPM; M.M. Pinheiro, MD, PhD, Division of Rheumatology, UNIFESP/EPM
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Mindfulness and Diagnostic Acumen. Ophthalmology 2016; 123:1630-1631. [PMID: 27450813 DOI: 10.1016/j.ophtha.2016.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 11/22/2022] Open
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