The epidemiology of ankylosing spondylitis

"Long-term MRI findings in Ankylosing spondylitis patients treated with TNF inhibitors for a decade"

OBJECTIVE

This study aims to evaluate the active and chronic lesions in sacroiliac joints and lumbar spine over a decade of TNFi therapy in patients with AS.

METHODS

The study enrolled patients with AS under treatment with a TNFi for over a decade. The patients underwent a new MRI scan of their lumbar spine and sacroiliac joint (SIJ). Two readers evaluated all images. Inflammation of SIJ (SIS), SIJ structural damage (SSS) including Fat Metaplasia, Erosions, Backfill and Ankylosis, and Spondyloarthritis Research Consortium of Canada Bone marrow edema (SPARCC) spine score were recorded.

RESULTS

In the study, 15 patients were included, with 80% being male. The mean age during their first MRI was 38.1 (± 11.9) years old, and the majority (86.7%) tested positive for HLA-B27. While TNFi improved both BASDAI and BASFI scores, there was a noticeable increase in MRI acute lesions in the SIJ over time, where the median score increased from 0 (0-4) to 3 (0-10) after ten years (p = 0.028). After a decade of treatment, the median SPARCC spine score also increased from 0 (0-9) to 5 (0-16), p = 0.093. Finally, it was observed that there was a significant positive correlation between ESR and SIS erosions in cases of chronic lesions (r = 0.819, p < 0.001).

CONCLUSIONS

While TNFi have significantly improved the treatment of AS, this study shows that acute lesions can still develop despite treatment. A personalized approach that adapts MRI assessment to each patient's specific requirements may help detect changes early and enable doctors to intervene promptly to prevent further damage.

Utility of the ACR-1997, SLICC-2012 and EULAR/ACR-2019 classification criteria for systemic lupus erythematosus: a single-centre retrospective study

Background and aims

Several different versions of classification criteria, including the American College of Rheumatology (ACR)-1997, Systemic Lupus International Collaborating Clinics (SLICC)-2012 and European Alliance of Associations for Rheumatology (EULAR)/ACR-2019 classification criteria, have been launched in the past decades. The current study aimed to investigate the performance of these three classification criteria for diagnosing patients with SLE in a Chinese cohort.

Methods

352 patients with SLE and 385 controls with other diseases who had the detection results of ANA were enrolled into the study. Various clinical parameters were estimated, such as demographics variables, clinical characteristics and other variables related to three criteria.

Results

The current study demonstrated great diagnostic ability of the three criteria; and the receiver operating characteristic curve and the area under curve (AUC) were used to evaluate the diagnostic ability of three criteria: ACR-1997 (AUC=0.972), SLICC-2012 (AUC=0.986) and EULAR/ACR-2019 (AUC=0.983). Despite lower specificity of the SLICC-2012 and EULAR/ACR-2019 classification criteria, their sensitivity is significantly improved than ACR-1997. Of note, we also compared the median time interval between the appearance of the earliest item and fulfilment of the three sets of criteria, suggesting the SLICC-2012 and EULAR/ACR-2019 could achieve earlier diagnosis. Adjusting the thresholds of the EULAR/ACR-2019 criteria from 10 to 12, the specificity and accuracy significantly increased.

Conclusion

The SLICC-2012 and EULAR/ACR-2019 performed well in Chinese patients with SLE and showed better early diagnosis ability. In addition, by adjusting the classification threshold, the accuracy of the EULAR/ACR-2019 classification criteria was improved.

Age and Symptoms at Onset of Ankylosing Spondylitis in Japanese Patients

OBJECTIVE

To examine the age at onset and initial symptoms as clinical features of ankylosing spondylitis (AS) in Japanese patients.

METHODS

This retrospective study included 60 Japanese patients diagnosed with AS at our institute between January 2004 and June 2021. Initial symptoms were considered pain in axial joints and/or extra-axial joints. If a patient had initial symptoms at multiple sites, each site was counted. We assessed trends for the number of patients and sites of initial symptoms according to age at onset.

RESULTS

Mean age (± standard deviation) at onset was 28.9 (± 14.3) years. Approximately one-third of patients experienced onset before age 20. The back was the most common site of initial symptoms (36.7%), followed by the hip (26.7%), knee (15%), buttocks (15%), neck (10%), finger (6.7%), shoulder (3.3%), and others (including overlapping sites). Thirty-two (53.3%) and 25 (41.7%) patients had initial symptom only in axial joints and only in extra-axial joints, respectively. The proportion of patients with initial symptoms only in extra-axial joints significantly decreased with increasing age (p=0.024).

CONCLUSION

Sites of initial symptoms were frequently the back, hip, knee, and buttocks, and 41.7% had initial symptom only in extra-axial joints. Younger onset patients frequently had extra-axial involvement.

The applicability of trabecular bone score for osteoporosis diagnosis in ankylosing spondylitis

Ankylosing spondylitis (AS) patients have a high risk of osteoporotic fractures. The aim of this study was to evaluate the usefulness of trabecular bone score (TBS) in assessing fracture risk in patients with AS. 67 patients meeting the ASAS classification criteria were enrolled in the study. Fracture risk for each patient was assessed based on a lumbar spine exam encompassing bone mineral density (BMD), and TBS through a dual-energy X-ray absorptiometry (DXA) exam. In addition, each patient had an X-ray taken of their lumbar and thoracic spine to determine the presence of syndesmophytes and bony bridges, as well as spinous process and vertebral body fractures. Moreover, each patient's medical history was analyzed for other osteoporotic fractures. A major osteoporosis fracture (MOF) was found in 11 (16%) patients in total, of which 7 (10%) were vertebral body fractures. The mean TBS in patients with MOF and no MOF were, respectively, 1.12 and 1.29 (p < 0.001). No significant differences were found in BMD scores between the two groups. Syndesmophytes and bony bridges occurred more frequently in patients with MOF (p = 0.02). Age of 50 or more (RR = 9.86, p = 0.002), TBS score ≤ 1.31 (RR = 2.07, p < 0.0001), and presence of syndesmophytes and bony bridges (RR = 2.14, p = 0.04) were considered a relative risk (RR) increasing factors. TBS is a markedly more sensitive method of identifying patients with a high fracture risk compared to BMD measurement in a DXA exam in patients with AS.

Pregnancy outcomes in Korean women with ankylosing spondylitis

BACKGROUND/AIMS

Because ankylosing spondylitis (AS) mainly affects sacroiliac joints, special attention should be given to normal labour and pregnancy outcomes. Here, we investigate pregnancy outcomes in Korean women with AS.

METHODS

Based on data from the Korean Health Insurance Review and Assessment Service claims database since July 2007, maternal complications were compared between women with AS and 1:10 matched general population by maternal age and year of delivery. Additionally, the 27 deliveries from 21 patients with AS who were seen at a tertiary hospital were retrospectively evaluated using 1:4 matched control group by maternal and gestational age.

RESULTS

In the population-based cohort, there were 1,293 deliveries in 996 patients with AS. Higher maternal age and more comorbidities were reported than in the general population. However, compared to age and delivery-year matched population, only the rate of Caesarean section (CS) was higher in women with AS (odds ratio, 1.52; 95% confidence interval, 1.36 to 1.70). Incidence of other maternal complications was comparable between women with AS and control subjects. In the hospital-based cohort, the CS rate was higher in women with AS (44.4% vs. 20.4%, p = 0.002). Causes of CS was not different in both groups, including previous uterine surgery. There were no significant differences in foetal outcomes, including growth restriction, foetal malformations and Apgar score.

CONCLUSION

CS deliveries were performed more often in women with AS. However, other maternal complications and offspring complications were similar between women with AS and healthy control subjects.

Prevalence of axial spondyloarthritis in patients with inflammatory bowel disease using cross-sectional imaging: a systematic literature review

BACKGROUND

Patients with inflammatory bowel disease (IBD) have an excess burden of axial spondyloarthritis (axSpA), which, if left untreated, may significantly impact on clinical outcomes. We aimed to estimate the prevalence of axSpA, including previously undiagnosed cases, in IBD patients from studies involving cross-sectional imaging and identify the IBD features potentially associated with axSpA.

METHODS

PubMed, Embase and Cochrane databases were searched systematically between 1990 and 2018. Article reference lists and key conference abstract lists from 2012 to 2018 were also reviewed. All abstracts were reviewed by two authors to determine eligibility for inclusion. The study inclusion criteria were (a) adults aged 18 years or above, (b) a clinical diagnosis of IBD and (c) reporting identification of sacroiliitis using cross-sectional imaging.

RESULTS

A total of 20 observational studies were identified: 12 used CT, 6 used MR and 2 utilised both computed tomography (CT) and magnetic resonance (MR) imaging. Sample sizes ranged from 25 to 1247 (a total of 4096 patients); 31 studies were considered to have low selection bias, 13 included two or more radiology readers, and 3 included rheumatological assessments. The prevalence of sacroiliitis, the most commonly reported axSpA feature, ranged from 2.2% to 68.0% with a pooled prevalence of 21.0% [95% confidence interval (CI) 17-26%]. Associated IBD features include increasing IBD duration, increasing age, male sex, IBD location, inflammatory back pain and peripheral arthritis. No significant difference in the prevalence of sacroiliitis between Crohn's disease and ulcerative colitis was identified. Study limitations include variability in the individual study sample sizes and patient demographics.

CONCLUSION

This review highlights the need for larger, well-designed studies using more sensitive imaging modalities and multivariable modelling to better estimate the prevalence of axSpA in IBD. An improved knowledge of the IBD phenotype(s) associated with axSpA and use of cross-sectional imaging intended for IBD assessment to screen for axSpA may help clinicians identify those patients most at risk.

Rates of spondyloarthropathies vary with age and ethnicity in HLAB27 uveitis

BACKGROUND/AIMS

To determine associations between HLAB27-positive uveitis, ethnicity and seronegative spondyloarthropathies (SpAs) in a New Zealand population.

METHODS

Retrospective observational cohort study. Medical records of all subjects with uveitis at Auckland District Health Board from 2008 to 2018 were reviewed for HLAB27 status, age of presentation, ethnicity and SpA.

RESULTS

In 10 years, 2567 subjects with uveitis were seen and 492 (19.2%) were HLAB27-positive. Of the HLAB27-positive subjects, 301 were male (60.3%) and median age was 37.8 years (IQR 29.7-50.0). Ethnicities were Caucasian (n=298, 60.6%), Asian (n=111, 22.6%), Maori (n=41, 8.2%) and Pacific Islander (n=38, 7.7%). Uveitis classification was anterior (n=478, 97.2%), intermediate (n=40, 8.1%), panuveitis (n=9, 1.8%) and scleritis (n=2, 0.4%). Maori or Pacific Islander ethnicity was associated with intermediate or panuveitis (p=0.003). Ankylosing spondylitis occurred in 163 subjects (33.1%); 29 (17.8%) were Maori or Pacific Islander. Subjects were younger (OR 0.982, p=0.009) and male (OR 1.980, p=0.001). There was no association with ethnicity or uveitis classification. Psoriatic arthritis (PsA) occurred in 11 subjects (2.2%). Chronic anterior uveitis was more common with PsA (27.3% vs 7.1%, p=0.023). There was no association with gender or ethnicity. Inflammatory bowel disease occurred in 19 subjects (3.8%) and reactive arthritis occurred in 14 subjects (2.8%). None developed chronic anterior uveitis (p=0.246 and p=0.227, respectively). There was no association with age at presentation, gender, ethnicity or uveitis classification.

CONCLUSION

This cohort of New Zealand-based subjects with HLAB27-positive uveitis showed a difference in age and ethnicity in uveitis subtypes and SpAs.

Three tesla and 3D multiparametric combined imaging evaluation of axial spondyloarthritis and pelvic enthesopathy

PURPOSE

Axial spondyloarthritis (SpA) is a group of diseases with temporally disseminated symptoms and clinical signs, which render the diagnosis challenging. Laboratory and MRI findings are used in addition for confirming the diagnosis and evaluation of disease activity. The purpose of this study was to evaluate clinically suspected axial SpA to determine the technical success of a multiparametric and 3D rheumatology lumbosacral MR imaging (MRLI) protocol and to assess the disease distribution, inter-reader reliability, and impact on patient management.

METHODS

A consecutive series of patients with clinical suspicion of axial SpA were included. Two rheumatologists recorded the clinical findings and disease activity on a confidence scale before and after MRLI. Two musculoskeletal (MSK) radiologists read the imaging data including enthesitis, arthritis, osseous lesions, ADC values, and enhancement. Prevalence-adjusted and bias-adjusted kappa (PABAK), ICC and Fisher exact test were calculated.

RESULTS

There were 41 patients including 31 females and 10 males with ages of 41 ± 10 and 41 ± 12 (mean ± SD), respectively. The spine T2W imaging received the highest quality scores followed by whole abdomen-pelvis 3D-T2W imaging, 3D-CEMR (contrast-enhanced MRI), and DWI. On spine imaging, acute and chronic lesions of lumbar spine and sacroiliac joints were seen in 4/41, 18/41 and 6/41, and 27/41 of the patients, respectively. Several additional enthesopathy lesions were seen on the whole abdomen-pelvis 3D sequence. ADC value of bone lesions was different 0.95 ± 0.23 (mean ± SD) than normal bone (0.20 ± 0.1). PABAK for acute and chronic findings ranged 0.70-1.0 and 0.41-0.51, respectively. Imaging changed the diagnosis in 17 of 41 patients. No association was noted with respect to treatment change (p = 1) or clinical response (p = 0.2).

CONCLUSION

Multiparametric lumbosacral MR imaging is a technically successful modality to identify multiple spinal and additional extraspinal sites of involvement in SpA, which are helpful in establishing the diagnosis of axial SpA. Larger patient population study is warranted to evaluate further impact on the treatment efficacy.

Antinuclear Antibodies and Lupus-like Manifestations in Rheumatoid Arthritis and Ankylosing Spondylitis Patients at 4 Months' Follow-up After Treatment with Infliximab and Etanercept

Background:

Up to 44% of patients treated with infliximab and 7% of patients treated with etanercept reported to have anti-drug antibodies within the first 6 months of treatment. Recently, anti-TNF-α therapies have been reported to be employed in the induction of the druginduced lupus erythematous.

Objective:

The aim of the present study was to investigate the relationship between anti-TNFα antibodies and various manifestations of lupus erythematous.

Methods:

We enrolled a total of 56 cases divided into 28 known cases of rheumatoid arthritis and 28 cases of ankylosing spondylitis patients and 56 controls. The case group was divided into 4 groups according to the underlying disease (RA or AS) and treatment regimen (infliximab or etanercept). ANA and anti-dsDNA levels and lupus criteria were assessed at the beginning of the study and 4 months after the initiation of anti-TNFα.

Results:

36% and 21% of RA patients treated with infliximab, were ANA and anti-dsDNA positive after 4 months (P=0.003, P=0.025). 28% and 7% of RA patients treated with etanercept, were ANA and anti-dsDNA positive after 4 months (P=0.009, P=0.15). 21% and 7% of AS patients treated with infliximab, were ANA and anti-dsDNA positive, respectively (P=0.025, P=0.15). 14% and 7% of AS patients treated with etanercept, were ANA and anti-dsDNA positive, respectively (P=0.63, P=0.15). Three patients who were positive for auto-antibodies developed three criteria for SLE.

Conclusions:

Infliximab potentially may increase both ANA and anti-dsDNA levels in rheumatoid arthritis, but only ANA in ankylosing spondylitis patients. In general, clinicians should consider different clinical symptoms of ATIL, which may be present as a lupus-like syndrome similar to idiopathic SLE or classical DIL.

Pharmacodynamic Monitoring of Biological Therapies in Chronic Inflammatory Diseases

BACKGROUND

Psoriasis, psoriatic arthritis, spondyloarthritis, rheumatoid arthritis, ulcerative colitis, and Crohn disease share similar underlying pathophysiological processes, providing the opportunity to treat the patients using similar biological therapies. Failure of biological treatments due to underexposure can be managed by therapeutic drug monitoring. Adjusting the treatment based on pharmacokinetic monitoring can be further improved by taking pharmacodynamic parameters such as clinical and molecular markers into account.

METHODS

Here, we critically evaluate the existing evidence, the hurdles to be taken, and the opportunities for a widespread implementation of pharmacodynamic monitoring.

RESULTS

Pharmacodynamic monitoring typically is the monitoring of biochemical markers. A pharmacodynamic marker preferably is specific for the pharmacological action of a drug, but most of the time nonspecific pharmacodynamic markers are used, such as C-reactive protein and the erythrocyte sedimentation rate. Clinical pharmacodynamic markers typically evaluate physical variables or symptoms. Although physician-reported outcomes have been studied for a longer time and often have been shown to correlate well with molecular pharmacodynamic markers and treatment outcomes, the introduction of mobile health or mHealth technologies caused a shift toward patient-reported outcomes, with the associated challenge to consistently reflect the inflammatory state, thereby preventing undertreatment or unnecessary overdosing of patients.

CONCLUSIONS

The primary goal of pharmacodynamic monitoring is to optimize the response, but it can also have an impact on safety, costs, patient adherence, etc. Ideally, the constant remote monitoring of patient-reported disease activity is expected to become the standard, facilitated by mHealth technologies.

Sleep disturbances in ankylosing spondylitis: a systematic review and meta-analysis

The aim of this meta-analysis was to compare sleep outcomes of AS patients and controls. Six electronic databases were searched: PubMed, Embase, IndMed, Cochrane Library, CNKI and Web of Science. Statistical analyses were executed using Revman 5.3 software. Nine studies and a total of 3169 participants were included in the meta-analysis. When sleep was assessed using PSQI, significant differences were observed in subjective sleep quality, sleep latency, sleep efficiency, sleep disorders, sleep medication use and total PSQI between patients with AS and controls, and subjective sleep quality was most severely affected. In PSG, eight variables of sleep quality (stage I sleep, stage II sleep, slow wave sleep, rapid eye movement, arousal index, periodic leg movement index, sleep latency, sleep efficiency) were lower in AS patients than in controls. Three variables of sleep quality assessed by USI (estimated sleep time, sleep sufficiency index, number of awakenings per night) and two variables of sleep quality assessed by MOS sleep scale (sleep disturbance scale, sleep problem index II) were lower in AS patients than in controls. It indicated that AS patients experience more serious sleep disorders. Early recognition and appropriate interventions are essential to improve patients' sleep quality.

Pulmonary Function, Aerobic Capacity and Related Variables in Patients With Ankylosing Spondylitis

Objectives

This study aims to evaluate the cardiopulmonary functions and exercise performance of patients with ankylosing spondylitis (AS) and to investigate the relationship between these parameters and disease activity, spine mobility and quality of life (QoL).

Patients and methods

Forty-five patients with AS (group 1; 33 males, 12 females; mean age 43.1±12.1 years; range 22 to 70 years) and 30 control subjects (group 2; 23 males, 7 females; mean age 42.8±10.0; range 23 to 70 years) were included in the study. Disease activity was assessed with the Bath Ankylosing Spondylitis Disease Activity Index and spinal mobility measures with the Bath Ankylosing Spondylitis Metrology Index (BASMI). The Ankylosing Spondylitis Quality of Life (ASQoL) Questionnaire and the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) were used. The pulmonary function test (PFT) and cardiopulmonary exercise testing (CPET) were performed.

Results

There was no significant difference between groups 1 and 2 in terms of mean age. The peak expiratory flow value in PFT was significantly lower in group 1 (p<0.05). In group 1, the duration of CPET was significantly shorter, and maximum work load and metabolic equivalent were significantly lower than in group 2 (p<0.001). Maximum oxygen uptake (VO2max) in peak responses, work and heart rate were significantly lower in group 1. The duration of CPET and maximum work were negatively correlated with age and BASMI (p<0.001). VO2max was negatively correlated with age, MASES and ASQoL (p<0.05).

Conclusion

There was no significant difference in PFT parameters between the groups. On the other hand, CPET parameters were significantly lower in the AS group. While CPET parameters are affected by spinal mobility, declining aerobic capacity affects QoL.

Efficacy of etoricoxib for ankylosing spondylitis: A protocol for systematic review of randomized controlled trial

BACKGROUND

Previous clinical trials have reported that etoricoxib has been utilized to treat ankylosing spondylitis (AS) effectively. However, no study systematically investigated the efficacy and safety of etoricoxib for patients with AS. In this systematic review, we will assess the efficacy and safety of etoricoxib for AS.

METHODS

The following electronic databases will be searched from inception to the February 1, 2019: Cochrane Library, Embase, PubMed, Cumulative Index to Nursing and Allied Health Literature, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Chinese Scientific Journal Database. This study will include randomized controlled trials that explore the efficacy and safety of etoricoxib for AS. The primary outcome is pain intensity, as measured by any pain scales, such as Numerical Rating Scale. The secondary outcomes consist of AS function, as measured by Bath Ankylosing Spondylitis Functional Index, or other tools; quality of life, as assessed by Ankylosing Spondylitis Quality of Life questionnaire or any other relevant instruments; as well as adverse events. Two authors will independently carry out the study selection, data extraction, and risk of bias assessment. Statistical analysis will be performed by using RevMan 5.3 software.

RESULTS

This systematic review will provide a detailed summary of present evidence related to the efficacy and safety of etoricoxib for patients with AS.

CONCLUSION

The results of this study may provide management guidance for AS treated by etoricoxib.

DISSEMINATION AND ETHICS

This systematic review dose not needs ethical approval, because it will not analyze individual patient data. The findings of this study are expected to publish through a peer-reviewed journal.

SYSTEMATIC REVIEW REGISTRATION

CRD42019124768.

Non-inferiority of dose reduction versus standard dosing of TNF-inhibitors in axial spondyloarthritis

Objective

The objective was to determine if dose reduction is non-inferior to full-dose TNFi to maintain low disease activity (LDA) in patients already in remission with TNFi, in axial spondyloarthritis.

Methods

Randomized, parallel, non-inferiority, open-label multicentre clinical trial. Patients were eligible if they had axial spondyloarthritis and had been in clinical remission for ≥ 6 months with any available TNFi (adalimumab, etanercept, infliximab, golimumab) at the dose recommended by product labelling. Patients were randomized by automated central allocation to continue the same TNFi dose schedule, or to reduce the dose by roughly half according to the protocol. The main outcome was the proportion of subjects with LDA after 1 year. Serious adverse reactions or infections were recorded.

Results

The trial stopped due to end of the funding period, after 126 patients were randomized; 113 patients (84.1% male, mean age (SD) 45.6 (13.0) years) were included in the main per-protocol subset. Non-inferiority was concluded for LDA at 1 year (47/55 (83.8%) patients in the full-dose and 48/58 (81.3%) patients in the reduced-dose arm, adjusted difference (95% CI) − 2.5% (− 16.6% to 11.7%)). Serious adverse reactions or infections were reported in 7/62 patients (11.3%) assigned to full dose and 2/61 patients (3.3%) assigned to reduced dose (p value = 0.164).

Conclusion

In patients with ankylosing spondylitis in clinical remission for at least 6 months, dose reduction is non-inferior to full TNF inhibitor doses to maintain LDA after 1 year. Serious adverse events may be less frequent with reduced doses.

Trial registration

EU Clinical Trials Registry, EudraCT 2011–005871-18 and ClinicalTrials.gov, NCT01604629.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1772-z) contains supplementary material, which is available to authorized users.

Selective mortality in middle-aged American women with Diffuse Idiopathic Skeletal Hyperostosis (DISH)

OBJECTIVE

A mortality sample of white American male and female skeletons was examined to illustrate a simple means of identifying skeletal conditions associated with an increased risk of dying relatively early in adulthood and to determine if males and females with Diffuse Idiopathic Skeletal Hyperostosis (DISH) displayed the same general age-specific pattern of mortality.

METHODS

Age-specific probability distributions for DISH were generated from 416 white Americans who died from the 1980s to the present, and whose remains were donated to the University of Tennessee Forensic Anthropology Center. The age-specific frequency of DISH is analyzed using an empirical smoothing algorithm. Doing so allows for the identification of deviations (i.e., local maxima) from monotonically increasing age-specific probabilities.

RESULTS

In females (N = 199), there is a peak in the frequency of individuals with DISH around 60 years of age where 37.0% of the individuals have DISH. It is matched only by the frequency (38.7%) in the oldest females, those over 85 years old. In contrast, DISH frequencies for males (N = 217) increase monotonically with advancing age, reaching 62.5% in the ≥86 years age group. There was an association between DISH and high body weight in women, particularly those who died before they reached the age of 75.

CONCLUSIONS

Early-onset DISH in white American women is associated with an increased risk of dying indicated by a local maximum in the probability curve. Should this finding be replicated in additional mortality samples and the reason DISH is associated with early death is established, beyond being heavy, this radiologically visible ossification of the spine could be a potential component of health-monitoring programs for middle-aged women.

Concomitant fibromyalgia complicating chronic inflammatory arthritis: a systematic review and meta-analysis

Objectives

This systematic review and meta-analysis will describe the prevalence of concomitant FM in adults with inflammatory arthritis and quantify the impact of FM on DAS.

Methods

Cochrane library, MEDLINE, Psychinfo, PubMed, Scopus and Web of Science were searched using key terms and predefined exclusion criteria. As appropriate, proportional and pairwise meta-analysis methods were used to pool results.

Results

Forty articles were identified. In RA the prevalence of FM ranged from 4.9 to 52.4% (21% pooled). In axSpA the range was 4.11–25.2% (13% pooled in AS only). In PsA the range was 9.6–27.2% (18% pooled). The presence of concomitant FM was related to higher DAS in patients with RA and AS (DAS28 mean difference 1.24, 95% CI: 1.10, 1.37 in RA; BASDAI mean difference 2.22, 95% CI: 1.86, 2.58 in AS). Concomitant FM was also associated with higher DAS in existing PsA studies. Self-reported, rather than objective, components of DAS appear to be raised in the presence of FM (e.g. tender joint count and Visual Analogue Scale (VAS) pain scores).

Conclusion

FM is common in RA, AxSpA and PsA. Comorbid FM appears to amplify DAS and could therefore influence management of these rheumatic conditions.

Nephrolithiasis in ankylosing spondylitis and its relationship with disease assessment scales

OBJECTIVE:

The aim of this study was to investigate the frequency of renal calculi in patients with ankylosing spondylitis (AS) and to determine its relationship with disease assessment variables.

METHODS:

The study was designed retrospectively, and it included a cohort of 320 patients with AS diagnosed using the Modified New York Criteria. A total of 119 patients who underwent renal ultrasonography (USG), in who the erythrocyte sedimentation rate, C-reactive protein, blood calcium, phosphorus, Vitamin D, parathormone, and urinary calcium excretion were measured, and who also had lateral cervical and lumbar radiography in the same time period were extracted from the cohort. All patients’ demographic characteristics and the results of blood and urine tests were recorded. The Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Functional Index (BASFI), Ankylosing Spondylitis Mobility Index (BASMI), and Modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) were evaluated in all patients.

RESULTS:

Thirteen of the 119 patients had renal calculi confirmed by USG data. The frequency of nephrolithiasis detected by USG was 10.9% in patients with AS. The disease lasted significantly longer in patients with renal calculi ([nephrolithiasis (+): 18.39±8.72 years; nephrolithiasis (−): 12.02±8.43 years, p=0.01]). The BASMI total score was significantly higher in the group of patients with renal calculi. There was not any significant difference in terms of blood samples, HLA-B27, BASDAI, BASFI, and mSASSS between groups.

CONCLUSION:

The frequency of renal stones is increased in patients with AS compared to healthy population. Especially patients who had AS for a long time and higher BASMI values are more susceptible to renal calculi. It is important to point out that the results of this type of studies would be more reliable if the study is conducted on large patient groups and population-based prevalence.

A retrospective study of transcutaneous electrical nerve stimulation for chronic pain following ankylosing spondylitis

This study investigated the effect of transcutaneous electrical nerve stimulation (TENS) for the treatment of patients with chronic pain after ankylosing spondylitis (AS).A total of 72 eligible patients with chronic pain following AS were included. All included patients received exercise and were assigned to a treatment group and a control group equally. In addition, patients in the treatment group also underwent TENS therapy. All patients were treated for a total of 6 weeks. The primary outcome of pain intensity was measured by visual analog scale (VAS). The secondary outcomes included degree of functional limitation, as assessed by Bath Ankylosing Spondylitis Functional Index (BASFI); and quality of life, as evaluated by Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. All outcomes were assessed before and after 6 weeks treatment. Furthermore, adverse events were also recorded.After 6-week treatment, patients in the treatment group did not show more promising outcomes in pain reduction, as measured by VAS (P = .08); functional evaluation, as evaluated by BASFI (P = .19); as well as quality of life, as assessed by ASQoL (P = .18), compared with patients in the control group. No adverse events occurred in both groups.This study did not exert encouraging outcomes in patients with chronic pain following AS after 6-week treatment.

Fractures in Spinal Ankylosing Disorders: A Narrative Review of Disease and Injury Types, Treatment Techniques, and Outcomes

INTRODUCTION

Spinal ankylosing disorders encompass ankylosing spondylitis (AS), disseminated hyperostosis of the spine, and end-stage spondylosis. All these result in a stiffened and frequently deformed spinal column. This makes the spinal column highly susceptible to severe injuries that are commonly associated with unfavorable outcomes. Improved understanding of the underlying disease processes and clinical comorbidities may alter the poor injury related morbidity and mortality outcomes.

METHODS

A systematic review of the MEDLINE and PubMed databases was performed using the following key words to identify articles published between 2001 and 2016: "ankylosing spondylitis," "epidemiology," "DISH," "treatment," "outcome," and/or "fracture." Articles were read for data on methodology (retrospective vs. prospective), type of treatment, number of patients, mean patient age, and mean follow-up.

RESULTS

Twenty-one identified articles were analyzed. Average age was 63.4 years. Most patients were men. Ground level fall or low energy trauma caused most injuries. Diagnosis was delayed in 15%-41% cases. Hyperextension fracture patterns were most common. Cervical spine fractures were more common than thoracolumbar fractures, with the highest prevalence between C5 and C7. Neurologic deficits were encountered in 21%-100% of patients. Operative fixation and fusion were performed in 40%-100% of patients. Mortality was reported between 0% and 32% at 1 year postinjury. Complications were encountered in 84% of patients, mostly in the form of pneumonia, respiratory failure, and pseudoarthrosis. Neurologic deterioration has been reported in 16% of patients. Fusion was successful in 87%-100% of patients. Neurologic deficits improved in function in 6%-66% at the final follow-up.

CONCLUSIONS

Because of the stiffening of the spinal column, patients with spinal ankylosing disorders are preferably evaluated for spinal fractures and ligamentous injuries after even trivial trauma. Spinal injuries in patients with AS are difficult to diagnose on plain radiographs; computed tomography and magnetic resonance imaging are recommended instead. The entire spine should be scanned for multilevel involvement. Although osteoporosis makes fixation of spine implants a significant concern, the literature has reported that most patients with AS treated surgically had good outcomes. Numerous studies have reported risks associated with conservative management.

The health-related quality of life of ankylosing spondylitis patients assessed by SF-36: a systematic review and meta-analysis

PURPOSE

The main purpose of this meta-analysis was to evaluate the impact of ankylosing spondylitis on the health-related quality of life assessed by the Medical Outcomes Short-Form-36 questionnaire (SF-36).

METHODS

A systematic literature search was performed on PubMed and Web of Science until January 22, 2016 to obtain eligible studies. Random effect model was performed to summarize the scores of each domain. The radar chart was used to compare the scores of AS patients with other health conditions. Spearman's correlation analysis and meta-regression were used to explore the related factors. STATA (version 11.0) and SPSS (version 13.0) were adopted in this meta-analysis.

RESULTS

Thirty-eight studies were included in this study, which were all reliable to summarize the scores of the SF-36. Pooled mean scores of the physical health domains ranged from 45.93 to 58.17, with the RP and PF domains being the lowest and the highest, respectively. Pooled mean scores of the mental health domains ranged from 47.49 to 62.52, with the VT and SF domains being the lowest and the highest, respectively. Besides, the physical component summary was lower than the mental component summary. BASDAI and BASFI were negatively associated with some domains of the SF-36 significantly. Patients with AS had a substantial impaired HRQoL in comparison with the general population.

CONCLUSIONS

AS could adversely affect the HRQoL of patients. Measuring HRQoL should be considered as an essential part of the overall assessment of health status of AS patients, which would provide valuable clues for improving the management of disease and making decisions regarding treatment.

Review for Disease of the Year: Epidemiology of HLA-B27 Associated Ocular Disorders

Acute anterior uveitis is generally recognized as the most common form of uveitis. An association with HLA-B27 is seen in approximately half of cases of acute anterior uveitis. The prevalence of HLA-B27 varies widely between ethnic populations, with an approximate 8-10% prevalence in non-Hispanic whites and lower prevalence in Mexican- (4%) and African- (2-4%) Americans. A group of systemic inflammatory diseases, the spondyloarthropathies, similarly demonstrates a strong association with HLA-B27. The strength of association varies, depending on the specific spondyloarthropathy, with the strongest association found in patients with ankylosing spondylitis. The majority of patients with HLA-B27 associated uveitis will have an underlying spondyloarthropathy. Suspicion for HLA-B27 associated uveitis should prompt a careful clinical history to assess for features of a spondyloarthropathy as the characteristics of any associated uveitis may vary.

Long-term safety and efficacy of infliximab for the treatment of ankylosing spondylitis

The introduction of TNFα blockers has revolutionized the treatment of ankylosing spondylitis (AS). The objectives of this review are to summarize the most up-to-date data on long-term efficacy and safety of infliximab in AS, with special emphasis on axial and extra-articular disease, predictors of response, and radiological response. The general consensus of this literature search was that infliximab is highly efficacious in the treatment of AS. Most studies have demonstrated good clinical outcomes after 3 years of treatment, as measured by Spondyloarthritis International Society response in 75%-85% of treated AS patients. Reports on the long-term effects of infliximab as documented by radiological findings, however, are controversial. While some studies reported a similar progression rate as that of the historical OASIS cohort, others have suggested that infliximab may halt new bone formation. The long-term safety of infliximab is well known, mainly from data stored in national registries. While it has been suggested that side effects of infliximab may be fewer in AS compared to rheumatoid arthritis, data on this issue are sparse, with most of the information on long-term safety pertaining to rheumatoid arthritis. It can however be concluded that the long-term efficacy of infliximab is apparently maintained in AS and with an acceptable safety profile.

Evaluation of dose reduction versus standard dosing for maintenance of remission in patients with spondyloarthritis and clinical remission with anti-TNF (REDES-TNF): study protocol for a randomized controlled trial

BACKGROUND

Dose reduction schedules of tumor necrosis factor antagonists (anti-TNF) as maintenance therapy in patients with spondyloarthritis are used empirically in clinical practice, despite the lack of clinical trials providing evidence for this practice.

METHODS/DESIGN

To address this issue the Spanish Society of Rheumatology (SER) and Spanish Society of Clinical Pharmacology (SEFC) designed a 3-year multicenter, randomized, open-label, controlled clinical trial (2 years for inclusion and 1 year of follow-up). The study is expected to include 190 patients with axial spondyloarthritis on stable maintenance treatment (≥4 months) with any anti-TNF agent at doses recommended in the summary of product characteristics. Patients will be randomized to either a dose reduction arm or maintenance of the dosing regimen as per the official labelling recommendations. Randomization will be stratified according to the anti-TNF agent received before study inclusion. Patient follow-up, visit schedule, and examinations will be maintained as per normal clinical practice recommendations according to SER guidelines. The study aims to test the hypothesis of noninferiority of the dose reduction strategy compared with standard treatment. The first patients were recruited in July 2012, and study completion is scheduled for the end of April 2015.

DISCUSSION

The REDES-TNF study is a pragmatic clinical trial that aims to provide evidence to support a medical decision now made empirically. The study results may help inform clinical decisions relevant to both patients and healthcare decision makers.

TRIAL REGISTRATION

EudraCT 2011-005871-18 (21 December 2011).

The impact of ankylosing spondylitis/axial spondyloarthritis on work productivity

Ankylosing spondylitis (AS) is a chronic inflammatory condition that has a significant impact on the quality of life and work productivity. New classification criteria have enabled earlier diagnosis of this condition. However, work productivity is an important issue that is still often overlooked during clinical assessments and consultations. This article focusses on the relationship between axial spondyloarthritis (axial SpA) and work productivity. It summarises the impact of this condition on work productivity, and it highlights the tools available to assess this. It also highlights the increasing role and potential of employers, health professionals and new treatments for enhancing work productivity for people with this condition.

Maintenance of improvement in spinal mobility, physical function and quality of life in patients with ankylosing spondylitis after 5 years in a clinical trial of adalimumab

OBJECTIVE

Chronic pain and progressive loss of physical function with AS may adversely affect health-related quality of life (HRQoL). The objective of this study was to assess the 5-year data regarding spinal mobility, physical function and HRQoL in patients with AS who participated in the Adalimumab Trial Evaluating Long-term Efficacy and Safety for AS (ATLAS) study.

METHODS

Patients received blinded adalimumab 40 mg or placebo every other week for 24 weeks, then open-label adalimumab for up to 5 years. Spinal mobility was evaluated using linear BASMI (BASMIlin). BASDAI, total back pain, CRP, BASFI, Short Form-36 and AS quality of life (ASQoL) were also assessed. Correlations between BASMIlin and clinical, functional and ASQoL outcomes after 12 weeks and after 5years of adalimumab exposure were evaluated using Spearman's rank correlation. Associations were further analysed using multivariate regression.

RESULTS

Three hundred and eleven patients received ≥1 dose of adalimumab; 125 of the 208 patients originally randomized to adalimumab received treatment for 5 years. Improvements in BASMIlin were sustained through 5 years, with a mean change of -0.6 from baseline in the population who completed 5 years of treatment with adalimumab. Improvements in disease activity, physical function and ASQoL were also sustained through 5 years. BASMIlin was significantly correlated with all evaluated clinical outcomes (P < 0.001). The highest correlation was with BASFI at 12 weeks (r = 0.52) and at 5 years (r = 0.65). Multivariate regression analysis confirmed this association (P < 0.001).

CONCLUSION

Treatment with adalimumab for up to 5 years demonstrated sustained benefits in spinal mobility, disease activity, physical function and HRQoL in patients with active AS. Spinal mobility was significantly associated with short- and long-term physical function in these patients.

TRIAL REGISTRATION

Clinicaltrials.gov; https://clinicaltrials.gov/NCT00085644.

Retrospective analysis of spinal trauma in patients with ankylosing spondylitis: a descriptive study in Indian population

OBJECTIVE

This study aims to understand the demographics, mode of trauma, hospital stay, complications, neurological improvement, mortality and expenditure incurred by Indian patients with spinal trauma and ankylosing spondylitis (AS).

METHODS

Retrospective analysis of the patient data admitted to a tertiary referral hospital from 2008 to 2013 with the diagnosis of AS and spinal trauma was carried out. The variables studied were demographics, mode of trauma, neurological status, neurological improvement, involved vertebral level, duration of hospital stay, comorbid factors, expenditure and complications during the stay.

RESULTS

Forty-six patients with diagnosis of AS with spine trauma were admitted over the last 5 years with a total of 52 fractures. All were male patients; 58.6% had injury because of trivial trauma and 78.2% patients presented with neurological injury. C5 C6, C6 C7, C7 D1 and D12 were the most common injured level. Fractures through intervertebral disc were most common in cervical spine. Of the patients, 52.7% had shown neurological improvement of at least grade 1(AIS). Mean expenditure of patient admitted with spinal cord injury (SCI) with AS is 7957 USD (United States dollar), which is around five times the per capita income in India (as per year 2013).

CONCLUSION

Males with AS are much more prone to spinal fractures than females and its incidence may be higher than previously reported. Domestic falls are the most common mechanism of spinal trauma in this population. High velocity injuries are associated with complete SCI. The study reinforces the need for development of subsidized spinal care services for SCI management.

Recent mitochondrial DNA mutations increase the risk of developing common late-onset human diseases

Mitochondrial DNA (mtDNA) is highly polymorphic at the population level, and specific mtDNA variants affect mitochondrial function. With emerging evidence that mitochondrial mechanisms are central to common human diseases, it is plausible that mtDNA variants contribute to the “missing heritability” of several complex traits. Given the central role of mtDNA genes in oxidative phosphorylation, the same genetic variants would be expected to alter the risk of developing several different disorders, but this has not been shown to date. Here we studied 38,638 individuals with 11 major diseases, and 17,483 healthy controls. Imputing missing variants from 7,729 complete mitochondrial genomes, we captured 40.41% of European mtDNA variation. We show that mtDNA variants modifying the risk of developing one disease also modify the risk of developing other diseases, thus providing independent replication of a disease association in different case and control cohorts. High-risk alleles were more common than protective alleles, indicating that mtDNA is not at equilibrium in the human population, and that recent mutations interact with nuclear loci to modify the risk of developing multiple common diseases.

There is a growing body of evidence indicating that mitochondrial dysfunction, a result of genetic variation in the mitochondrial genome, is a critical component in the aetiology of a number of complex traits. Here, we take advantage of recent technical and methodological advances to examine the role of common mitochondrial DNA variants in several complex diseases. By examining over 50,000 individuals, from 11 different diseases we show that mitochondrial DNA variants can both increase or decrease an individual's risk of disease, replicating and expanding upon several previously reported studies. Moreover, by analysing several large disease groups in tandem, we are able to show a commonality of association, with the same mitochondrial DNA variants associated with several distinct disease phenotypes. These shared genetic associations implicate a shared underlying functional effect, likely changing cellular energy, which manifests as distinct phenotypes. Our study confirms the important role that mitochondrial DNA variation plays on complex traits and additionally supports the utility of a GWAS-based approach for analysing mitochondrial genetics.

Aerobic capacity and its correlates in patients with ankylosing spondylitis

AIM

To evaluate aerobic capacity in patients with ankylosing spondylitis (AS) and determine possible relationships between aerobic capacity, pulmonary function, and disease-related variables.

METHOD

Forty-two patients with AS and 42 healthy controls were recruited in the study. Descriptive data, disease-related variables (grip strength, lumbosacral mobility, occiput-to-wall distance, chest expansion, finger-to-floor distance, Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Global Score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and hemoglobin), and chest and thoracic spine x-rays were collected in each patient with AS. All subjects took standard pulmonary function and exercise tolerance tests, and forced vital capacity (FVC) and aerobic capacity were recorded.

RESULTS

Both aerobic capacity and FVC in patients with AS were significantly lower than those in normal subjects (P < 0.05). AS patients with BASFI scores of < 3 or BASDI scores of < 4 had a higher aerobic capacity. There was significant correlation between aerobic capacity, vital capacity, chest expansion, Schober's test, cervical range of motion, and BASFI in patients with AS. Neither aerobic capacity nor vital capacity correlated with disease duration, ESR, CRP, and hemoglobin.

CONCLUSIONS

Significantly reduced aerobic capacity and FVC were observed in patients with AS, and there was significant correlation between aerobic capacity, vital capacity, chest expansion, and BASFI.

Prevalence and clinical manifestations of ankylosing spondylitis in young Greek males

Increased awareness and sensitivity of general physicians have increased the early diagnoses of seronegative arthritis in young patients, while new agents such as anti-TNF blockers have significantly changed the treatment of the disease. To investigate the prevalence, the clinical manifestations, and the ability for military service of young Greek males (18-30 years old) with ankylosing spondylitis (AS) in the pre-anti-TNF era. We retrospectively studied the AS cases recorded from 1989 to 1995 of the rheumatology department of the largest General Military Hospital in Greece; the diagnosis was based on the modified New York criteria for AS. A total of 285 AS cases were diagnosed among 357,184 young men. The overall prevalence of AS on December 1995 was estimated at 8.2 cases per 10,000 young men (95 % C.I. 7.2-9.2). All the patients had chronic back pain. Two hundred forty (84 %, 95 % C.I. 79-88 %) patients presented sacroiliitis of whom 163 (68 %, 95 % C.I. 62-73 %) were bilateral. Two hundred five patients (72 %, 95 % C.I. 66-77 %) had peripheral joint involvement. Thirty-one patients presented with anterior uveitis (11 %, 95 % C.I. 8-15 %). One patient had IgA nephropathy. None had gut involvement. HLA-B27 antigen was found in 257 patients (90 %, 95 % C.I. 86-93 %). Ninety-one patients (32 %, 95 % C.I. 27-38 %) had permanent discharge from the military service, while 128 (45 %, 95 % C.I. 39-51 %) were able for auxiliaries attendances. The prevalence of AS for the age group 18-30 years old in this young Greek men cohort was significantly lower than in other Caucasian European populations, and the clinical manifestations were considered as mild.

Spondyloarthropathies

Spondyloarthropathies (SpA) are a group of common inflammatory rheumatic disorders characterised by axial and or peripheral arthritis, associated with enthesitis, dactylitis and potential extra-articular manifestations such as uveitis and skin rash. The diseases, which comprise the group, share a common genetic predisposition, the HLA-B27 gene; however, this association varies markedly among the various SpAs and among different ethnic groups. Environmental factors seem to be triggering the diseases in the genetically predisposed individuals. The radiographic hallmark of the group is sacroiliitis, which when present is of help in the diagnosis. Various sets of diagnostic and classification criteria were developed over the years including the European Spondyloarthropathy Study Group (ESSG) criteria which were until recently the most widely used. The new Assessment in SpondyloArthritis international Society (ASAS) international working group has recently proposed a new set of diagnostic criteria that would enable identification of SpA before structural changes develop in the spine. Magnetic resonance imaging (MRI) changes have now been included in the new classification criteria of early axial SpA and are now considered as a major tool in the diagnosis. Until recently, there were no real disease-modifying anti-rheumatic drugs which were able to halt the disease progression. Over the past decade, tumour necrosis factor (TNF)-alfa-blocking agents have been extensively investigated and became the mainstream of therapy providing the patients an effective treatment option.

Association between ED in ankylosing spondylitis: a population-based study

Even though a growing number of studies have found that patients with ankylosing spondylitis (AS) suffer from sexual problems, only very few studies have specifically addressed the relationship between AS and ED. Using a population-based data set, this case-control study aimed to examine the association of ED with a prior diagnosis of AS in Taiwan. We selected 2213 ED patients ≥40 years old and 17,704 matched controls. We considered the date of the first diagnosis of ED as the index date for cases. Multivariate logistic regression was performed to calculate the odds ratio (OR) and corresponding 95% confidence interval (CI) for the association between previously diagnosed AS and ED. A total of 224 out of the 19,917 sampled subjects (1.1%) had been diagnosed with AS before the index date. Prior AS was found in 42 (1.9%) cases and 182 (1.0%) controls. After adjusting for geographic location, urbanization level, hypertension, diabetes, coronary heart disease, hyperlipidemia, obesity, depressive disorder and alcohol abuse/alcohol-dependence syndrome, multivariate logistic regression revealed that cases were more likely to have been previously diagnosed with AS than controls (OR=1.58, 95% CI=1.09-2.19, P=0.019). There was an association between ED and AS. We suggest that physicians should be attentive to sexual complaints from AS patients in order to refer them to other specialists for multidisciplinary management.

Sex differences in effects and use of anti-inflammatory drugs

Gender accounts for important differences in the incidence, prevalence, and course of many immunoinflammatory diseases. However, similar treatment strategies, such as the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and tumor necrosis factor-α (TNF-α) inhibitors, have been advocated for both genders. Experimental studies found that molecular mechanisms of inflammation differ in males and females. In our chapter we summarize the data concerning gender-specific aspects about prevalence of use, drug survival, responsiveness, and adverse drug effects of NSAIDs and TNF-α inhibitors. Gender-related differences in the prevalence and course of many autoimmune diseases as well as differences in effects of anti-inflammatory drugs should be considered for the tailored treatment options for these patients.

Validity and reliability of the metric measurements in the assessment of lumbar spine motion in patients with ankylosing spondylitis

STUDY DESIGN

A prospective, controlled clinical study performed in a tertiary care center.

OBJECTIVE

To determine reliability and validity of low-tech measurements in assessment of range of motion (ROM) of lumbar flexion in ankylosing spondylitis (AS).

SUMMARY OF BACKGROUND DATA

ROM measurements of lumbar flexion in patients with AS and healthy subjects are evaluated using original Schober test (OST), modified Schober index (MSI), and modified-modified Schober test (MMST) and compared with radiography.

METHODS

Fifty patients with AS and 17 healthy subjects were included. A tape measure was used for measuring OST, MSI, and MMST, and goniometer was used for measuring angle of lumbar ROM on lateral radiographical views in erect position and maximal forward bending position.

RESULTS

Angle between L1 and S1 vertebrae displayed a change upon flexion by 18.2° ± 18.7° in AS group and 30.4° ± 11.1° in controls (P = 0.002). Angle between L3 and S1 vertebrae was detected to change upon flexion by 25.3° ± 25.4° in AS group and 46.7° ± 14.2° in controls (P = 0.0001). A weak correlation was observed between MSI, OST, and L1-S1 radiographical mobility measurements as (P = 0.018 and P = 0.063) and MSI, OST, and L3-S1 radiographical mobility measurements as (P = 0.009 and P = 0.024), respectively for AS. There were correlations between MSI, OST, and radiographical mobility measurements in patients with AS (r = 0.333, P = 0.018, and r = 0.363, P = 0.009, respectively). There was a correlation between OST and radiographical mobility measurements in controls (r = -0.504, P = 0.039). Intrarater reliability was determined to be excellent for OST, MSI, and MMST.

CONCLUSION

Despite excellent intrarater reliabilities for OST, MSI, and MMST, only a weak correlation could be established between OST, MSI, and MMST and radiographical analysis. MMST was found not to reflect lumbar spine angular motions. Although MSI reflected spinal mobility better than OST, both seemed to reflect lumbar spine angular motion poorly.

Back mobility and interincisor distance ranges in racially diverse North American healthy children and relationship to generalized hypermobility

BACKGROUND

Given the dearth of normal values, we conducted a cross-sectional study of North American racially diverse children to determine normal values of interincisor distance and lower spine flexion.

METHODS

Demographs of 307 children aged 5-17 seeking treatment emergency care were obtained along with interincisor distance measured by incisor tooth-to-tooth gap, lower spine flexion measured by the Schober and modified Schober measurements, popliteal extension, hypermobility (Beighton) score, weight and height.

RESULTS

Normal range of motion values for the Schober was a mean of 14.3 cm (95% confidence interval (CI) was 11.2 to 17. cm) and the mean modified Schober's was 21.6 cm (95% CI 18.4 cm to 24.8 cm). Retained lumbar lordosis on forward flexion was observed in 33%. Back mobility was associated with body mass index (BMI), popliteal angle, and Beighton score but not sex, race or retained lordosis. The mean interincisor distance measurement was 47 mm (95% CI 35 mm to 60 mm) and was associated with height and BMI but not sex, race, or Beighton score.

CONCLUSION

Normal values for lower back range of motion and interincisor distance were obtained which are needed in pediatric rheumatologic clinics and do not significantly vary as to race or sex. Retained lordosis on forward flexion is a normal variant. Hamstring tightness, hypermobility and BMI need to be considered when ascertaining back mobility.

Treatment efficacy of etanercept and MTX combination therapy for ankylosing spondylitis hip joint lesion in Chinese population

To investigate the efficacy of etanercept and MTX (methotrexate) combination therapy in Chinese patients with ankylosing spondylitis hip joint lesion, the possible courses and maintenance protocol, altogether 97 ankylosing spondylitis patients fulfilling the modified New York criteria with hip joint lesion were enrolled in a 12-month trial treated with combined etanercept and MTX. All these patients were required to be poor responders to SSZ (Sulfasalazine) or MTX therapy for 6 consecutive months or the longer. Etanercept was administered subcutaneously twice a week at a fixed dosage of 25 mg for the first six months, followed by 25 mg once a week in patients with good control of both symptoms and radiological progression, or twice a week for another six months in patients with BASDAI > or = 4. Combined MTX was administered intravenously once a week at the dosage of 15 mg. Demographics, clinical and laboratory features, physical function and quality of life using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI), Harris hip score, and radiological assessment using the BASRI-hip index were recorded. Most patients achieved pain release at the end point of assessment. Significant improvement in Bath AS Disease Activity Index (BASDAI) (P < 0.05), Bath AS Functional Activity Index (BASFI) (P < 0.05), and Harris hip score (P < 0.05) was demonstrated. Radiographic progression was recorded as no exacerbation or alleviated. Larger interval between two etanercept administrations would provide similar advantages to standard method and possibly less adverse events if MTX was combined. Etanercept and MTX combination therapy was beneficial to ankylosing spondylitis patients with hip joint lesion, and staged dosage deduction in the long term proved to be effective as well as adverse event preventing.

Fifteen-year trends of long-term disability and sick leaves in ankylosing spondylitis

The aim of this study is to assess the trends in work disability and sick leave in ankylosing spondylitis (AS). In 1993 and 2007, patients diagnosed with AS that attended to a secondary- or a tertiary-care outpatient rheumatology clinics were evaluated for demographics, disease characteristics, axial mobility, working status, and work days missed due to sick leave or permanent disability. Factors that impacted labor status were identified by multiple regression analysis. In 1993, 91 study individuals (mean age 35 years, mean disease duration 10 ± 8 years) included 28 (31%) on permanent disability and 63 currently working; of these 63, 42 (67%) had missed at least 1 work day in the previous 12 months (mean 69 ± 63 days). In the next 5 years, the annual permanent disability was 3%. In 2007, 185 study individuals (mean age 42, mean disease duration 12 ± 10 years) included 53 (39%) on permanent disability and 132 active workers; 35 (66%) out of the 53 began permanent disability between 1999 and 2007 (2.1% annual disability rate), and 53 (40%) out of 132 active workers missed at least 1 work day in the previous 12 months (mean 52 ± 63 days). Only age predicted disability, with 10% and 11% increases in risk per year in 1993 and 2007, respectively (hazard ratios 1.09 and 1.11, respectively; p = 0.03 for both). Although the impact of AS on work seems to decrease slightly during the last 15 years, the actual impact is still substantial. An important proportion of patients went on permanent disability in the three decades before retirement. Extrapolating these results to official data for the year 2005, we may infer that between 1.3 million and nearly 15 million working days were missed that year due to AS.

[Quality indicators for managing patients with low back pain]

INTRODUCTION

Low back pain (LBP) is an epidemiologically and economically relevant health care problem appropriate for quality assurance approaches. Therefore an expert panel (AQUIK) of the National Association of Statutory Health Insurance Physicians has proposed three quality indicators (QI) for monitoring the quality of ambulatory care for LBP. The aim of this article is to present and evaluate the proposed QIs.

MATERIAL AND METHODS

The three proposed QIs relating to red flags, imaging and sick leave certificates were evaluated with regard to the underpinning evidence, epidemiology and feasibility. Guidelines and original research as well results from surveys and observational studies evaluating adherence to LBP guidelines were used for assessment.

RESULTS

The expert panel concluded that only the recording of red flags is a relevant and feasible QI. Despite a two-stage expert method the epidemiology of LBP, feasibility and existing routine health care data were not sufficiently taken into account. The author's conclusion differs in two instances. The red flag concept is not sufficiently clinically validated and recordable to be used as a QI. Otherwise imaging is considered a suitable QI given the observed overuse and the availability of billing data.

CONCLUSION

Deriving valid and pragmatic QI from LBP guidelines for evaluating care for LBP is difficult. The core messages of guidelines are only recommendations with limited precision and transferability to individual patients. For pragmatic reasons definition of an upper or lower proportion of patients receiving a given health care service is recommended instead of tedious individual evaluation. Reasonable estimates can be based on data from research on health care services. Because of this uncertainty QIs should be evaluated before they are used as a steering instrument.

ERAP1 Is Associated with Ankylosing Spondylitis in Han Chinese

Objective.

Genetic components play important roles in the incidence and development of ankylosing spondylitis (AS). Aminopeptidase regulator of tumor necrosis factor receptor shedding 1 (ERAP1) was recently found to be associated with AS in North American and British cohorts. We evaluated whether ERAP1 is associated with AS in a Chinese Han population.

Methods.

A sample of 50 patients and 50 healthy controls was recruited for preliminary screening for informative single-nucleotide polymorphisms (SNP). Then 6 SNP of suggestive significance in the initial screening were followed up in a large sample of 471 patients with AS and 456 ethnically matched controls. Diagnosis of AS followed the 1984 modified New York criteria. Linkage disequilibrium coefficient (D’ and r2) and haplotypes were estimated by Haploview.

Result.

Two SNP (rs27434, p = 0.00039, and rs27529, p = 0.0083) in ERAP1 other than that reported previously were found to be significantly associated with AS. Haplotype analysis using 5 SNP within 1 linkage disequilibrium block identified 2 risk haplotypes (GATGT and GACGT) and 1 protective haplotype (GGTGT) for AS.

Conclusion.

Our study demonstrated that 2 novel SNP in ERAP1 were associated with AS in the Han Chinese population, suggesting that ERAP1 might confer genetic risk for AS in Han Chinese through the common mechanism shared by different populations, although the AS-associated SNP in ERAP1 might be population-specific.

Maintained clinical response of infliximab treatment in ankylosing spondylitis: a 6-year long-term study

OBJECTIVES

To investigate the efficacy, safety and drug discontinuation in patients with ankylosing spondylitis treated with infliximab, as well as the drug survival over a period of 6 years.

METHODS

Forty patients with ankylosing spondylitis treated with infliximab were included in this open label study. All patients fulfilled the New York revised criteria for ankylosing spondylitis. Infliximab was given intravenously (5 mg/kg/body weight) at weeks 0, 2, 6 and every 8 weeks thereafter for a period of 6 years. Data concerning infliximab efficacy, tolerability, adverse events and drug discontinuation, were recorded. Clinical improvement according to the Bath Ankylosing Spondylitis Disease Activity Index 50% and the Ankylosing Spondylitis Assessment Study Group 20% and 40% were also recorded.

RESULTS

A significant improvement in the Bath Ankylosing Spondylitis Disease Activity Index and Ankylosing Spondylitis Assessment Study Group scores was noted in the first year which sustained through the sixth year of treatment. More specifically, after the sixth year of treatment, Bath Ankylosing Spondylitis Disease Activity Index 50% was achieved by 65% of patients (26/40), Ankylosing Spondylitis Assessment Study Group 20% by 72.5% (29/40) and Ankylosing Spondylitis Assessment Study Group 40% was reached by 70% (28/40) of patients. Clinical improvement was associated with the reduction of acute phase reactants, such as C-reactive protein levels. After the first and the second year of treatment, the survival rate of infliximab reached 95%, after the third year it was 80%, while after the fourth year it was 72.5%, which was maintained throughout the fifth and sixth year of therapy. Five patients were increased the dose of infliximab and three of them had shortened the interval infusion. Overall, 11 patients were withdrawn during the observational period, three because of adverse events, two because of lack of efficacy, while six were lost from follow-up.

CONCLUSION

Infliximab was effective, safe and well-tolerated in patients with ankylosing spondylitis. The clinical response was maintained for a period of 6 years, with high infliximab survival rate, reaching the percentage of 72.5%.

Clinical and radiographic features of adult-onset ankylosing spondylitis in Korean patients: comparisons between males and females

The objective of this study was to investigate clinical and radiographic features and gender differences in Korean patients with adult-onset ankylosing spondylitis. Multicenter cross-sectional studies were conducted in the rheumatology clinics of 13 Korean tertiary referral hospitals. All patients had a confirmed diagnosis of ankylosing spondylitis according to the modified New York criteria. Clinical, laboratory, and radiographic features were evaluated and disease activities were assessed using the Bath ankylosing spondylitis disease activity index. Five hundred and five patients were recruited. The male to female ratio was 6.1:1. Average age at symptom onset was 25.4+/-8.9 yr and average disease duration was 9.6+/-6.8 yr. Males manifested symptoms at a significantly earlier age. HLA-B27 was more frequently positive in males. Hips were more commonly affected in males, and knees in females. When spinal mobility was measured using tragus-to-wall distance and the modified Schober's test, females had significantly better results. Radiographic spinal changes, including bamboo spine and syndesmophytes, were more common in males after adjustment of confounding factors. In conclusion, we observed significant gender differences in radiographic spinal involvement as well as other clinical manifestations among Korea patients with adult-onset ankylosing spondylitis. These findings may influence the timing of the diagnosis and the choice of treatment.

Combination Treatment with Etanercept and an Intensive SPA Rehabilitation Program in Active Ankylosing Spondylitis

The aim of this study is to determine the effects of a combination treatment with etanercept and spa rehabilitation versus etanercept alone on function, disability and quality of life in a group of patients with active ankylosing spondylitis (AS). Sixty patients with AS underwent etanercept as suggested by ASAS/EULAR recommendations. As the clinical and laboratory conditions improved, 30 patients accepted the proposal of coupling the medical therapy with a 7-day rehabilitation program in a thermal baths centre; the remaining 30 subjects continued to take the biologic agent alone. The comparisons between the 2 groups were made after 3 and 6 months. The primary outcome was an improvement in BASFI. The secondary outcome was an improvement in the visual analogic scale of EuroQol (EQ-5Dvas). After 6 months a statistically significant improvement in BASFI (p < 0.05) and EQ-5DVAS (p < 0.05) scores was observed in both groups. The mean change in EQ-5DVAS value showed a statistically significant difference in favour of the combination therapy group versus the monotherapy group (22 vs 32, p < 0.05). A therapeutic regimen combining etanercept with an intensive rehabilitation program contributes to disability reduction and ameliorates quality of life for AS patients.

Living with Ankylosing Spondylitis

Ankylosing Spondylitis (AS) is a potentially debilitating chronic condition that necessitates a biopsychosocial approach for successful long-term management. However, the psychosocial consequences of AS are not well understood. In this study patients ( N = 68) reported impacts of AS across a wide range of life domains; negative impacts included physical effects of AS, changes in mood or personality, effects on social life and relationships with friends and family, low self-esteem, stigma and worry about the future; positive impacts included increased exercise, feelings of achievement and empathy, stronger relationships, slower pace of life and a more positive perspective. Implications for treatment are discussed.