Clinical aspects, outcome assessment, disease course, and extra-articular features of spondyloarthropathies

Predictors for pathologically confirmed aortitis after resection of the ascending aorta: a 12-year Danish nationwide population-based cross-sectional study

Introduction

Assessing the prevalence of, and predictors for, pathologically-confirmed inflammation of the aorta in Denmark, using a nationwide population-based study design.

Methods

We identified all adults with first-time surgery on the ascending aorta between January 1, 1997 and March 1, 2009 in Denmark. Presence of aortic inflammation was ascertained through linkage to a nationwide pathology registry. We used logistic regression to compute prevalence odds ratios (ORs) for sex, age at surgery, cardiovascular risk factors, cancer, connective tissue disease, and infectious diseases associated with the presence of aortitis.

Results

A total of 1,210 adults underwent resection of the ascending aorta, of who 610 (50.4%) had tissue submitted for pathological examination. Aortitis was found in 37 (6.1%) patients whose tissue was examined. Ten of the 37 patients were diagnosed with conditions known to be associated with aortitis or aortic aneurysm: five patients with temporal arteritis, one with Crohn's disease, one with rheumatoid arthritis, one with systemic lupus erythematosus, one with infectious aortitis, and one with Marfan's disease. Twenty-seven patients had idiopathic aortitis. Predictors of aortitis included history of connective tissue disease (adjusted OR 4.7, 95% confidence interval (CI) 1.6, 13.6), diabetes (OR 5.2, 95% CI 0.9, 29.7), advanced age (> 67 years OR 2.5, 95% CI 0.8, 7.6), and aortic valve pathology (OR 2.3, 95% CI 1.1, 4.9).

Conclusions

Aortitis was present in 6.1% of adults in Denmark who had pathological examination after resection of the ascending aorta. Predictors of inflammation included connective tissue disease, diabetes, advanced age, and aortic valve pathology.

Life strain-related tiredness and illness-related fatigue in individuals with ankylosing spondylitis

OBJECTIVE

To examine the nature of fatigue and how it is managed in daily life situations by individuals with ankylosing spondylitis (AS).

METHODS

Twelve informants, 8 women and 4 men ages 30-59 years, who had lived with the diagnosis of AS for 6 months to 36 years, participated in qualitative interviews. They were asked to describe their daily life during good and bad days of AS, and to give examples of everyday situations where they experienced fatigue and what they did to recover. The text analysis consisted of identifying and coding meaningful statements, sorting the codes into categories, and condensing themes.

RESULTS

Two separate conditions of fatigue were identified. One consisted of comprehensible, manageable tiredness related to a life strain that was exacerbated by having AS. Life strain-related tiredness indicated to the respondents that they should rest or temporarily slow down, and this protected them from overexertion. The other condition was an unfamiliar and unmanageable fatigue that was related to their illness. Illness-related fatigue was accompanied by unbearable pain, severe stiffness, and heaviness of the body that could not be alleviated by the individual. This condition was considered a sign of the onset or a flare up of inflammation.

CONCLUSION

Fatigue in the individuals with AS varied over time, and took the form of 2 different conditions. Life strain-related tiredness had a positive aspect in that it protected against overstrain and guided life strain regulation. In contrast, illness-related fatigue was nonpurposive for the individuals and seems to call for medical therapy.

Clinical significance of specific spinal mobilization for patients with ankylosing spondylitis evaluated by quantitative assessments and patient interviews

PURPOSE

To assess individual responses to specific spinal mobilization (SSM) in terms of spinal mobility, perceived stiffness, pain and activities of daily living (ADL) in patients with Ankylosis Spondylitis (AS), and whether and how interviews supported or supplemented the quantitative results.

METHODS

Spinal mobility was recorded by the fingertip-to-floor distance, the Modified Schober Test, myerinometer, and the chest expansion test. The measures corresponding to sites targeted by SSM was used as effect variables, and the other as control variables. Visual analogue scales assessed pain and stiffness. The Bath Ankylosing Spondylitis Functional Index assessed ADL. A single subject experimental design was applied. The patients' experiences were investigated by semistructured qualitative interviews.

RESULTS

Six patients completed 12 sessions of SSM. In five patients spinal mobility improved by 6-38%, and perceived stiffness reduced by 6-82%. Further improvements were found after three months. Improvements were not seen in the control variables. The interviews revealed that to become less stiff had various meanings for the patients, the SSM helped to get control of motion, and the conversations with the therapists enabled them to cope with the situation.

CONCLUSIONS

The findings suggest that SSM can diminish spinal stiffness, but this had different meanings for the patients. What were important were what they experienced and learnt during the therapy process.

Early spondyloarthropathy: scintigraphic, biological, and clinical findings in MRI-positive patients

There are no specific diagnostic tests or a gold standard method for measuring disease activity and outcome in spondyloarthropathies (SpA). Many different methods have been developed to assess the signs and symptoms in SpA. The aim of this study was to evaluate the value of scintigraphy, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and Bath Ankilosing Spondylitis Disease Activity Index (BASDAI) in the evaluation of disease activity in early axial SpA diagnosed with magnetic resonance imaging (MRI). Thirty early MRI-positive axial SpA patients (23 males, 7 females) with a median age of 35 (18-55) years and a median duration of inflammatory low back pain of 24 (8-60) months were included in the study. In the patients with sacroiliitis, the sensitivity, specificity, and positive and negative predictive values of disease activity parameters were determined regarding MRI as the gold standard method. The sensitivities of quantitative scintigraphy, visual scintigraphy, ESR, CRP, and BASDAI were 32, 82, 35, 71, and 60%, respectively. The specificities of quantitative scintigraphy, ESR, CRP, and BASDAI were 100, 100, 50, and 100%, respectively. The positive predictive values of quantitative scintigraphy, visual scintigraphy, ESR, CRP, and BASDAI were 100, 92, 100, 95, and 100%, respectively. The negative predictive values of quantitative scintigraphy, ESR, CRP, and BASDAI were 9, 10, 11, and 15%, respectively. Regarding MRI as the gold standard in the evaluation of disease activity, combined visual and quantitative bone scintigraphy can be valuable in patients with MRI-incompatible implants. Additionally, use of cheaper, simple, and readily reproducible tests such as CRP and BASDAI together could be valuable and practical in detecting disease activity in long-term follow-up of these patients.

Cancer incidence among patients with ankylosing spondylitis in Sweden 1965-95: a population based cohort study

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory joint disease which may lead to extra-articular complications. The disease associated cancer risk has been poorly explored. Recently, tumour necrosis factor alpha blockers have been found to be efficacious in AS, but their long term risk is unknown.

OBJECTIVE

To analyse a large national cohort of patients with AS to determine the overall cancer risk in AS as a background to the future introduction of new treatments.

METHODS

All patients with AS admitted to Swedish hospitals 1965-95 were linked through individual national registration numbers to the Swedish Cancer Register and National Death Register. Standardised incidence ratio (SIR) of cancer risk was calculated in 6621 people, monitored during 67 885 person-years.

RESULTS

No overall increase in cancer risk was found (SIR 1.05, 95% CI 0.94 to 1.17). Rectal cancer was less common (SIR 0.41, 95% CI 0.15 to 0.89) while unspecified kidney cancer was more common (SIR 5.90, 95% CI 1.61 to 15.1). Risks for colon, renal parenchymal, and renal pelvic cancer were not significantly increased. Laryngeal cancer was more common than expected, while lung cancer was not. Risks of haematopoietic malignancies were not increased.

CONCLUSIONS

No overall increase in cancer risk was found. The decreased risk of rectal cancer might be due to local application of NSAIDs, and the increased risk of unspecified kidney cancer to frequent radiological pelvic examinations. If information on disease characteristics, including HLA-B27, was available for individual patients with cancer, risk-benefit analysis of long term effects of new immunomodulation treatment might be improved.

The effect of chiropractic care for a 30-year-old male with advanced ankylosing spondylitis: a time series case report

BACKGROUND

Manipulative treatment for ankylosing spondylitis is a controversial subject, and no literature on using this therapy for advanced cases with fusion of the spine could be found.

OBJECTIVE

To discuss the case presentation of a patient with advanced ankylosing spondylitis who was treated with chiropractic manipulation and mobilization. Clinical features The patient was a 30-year-old Asian male who was first diagnosed with ankylosing spondylitis at age 12. Despite medical intervention, a series of exacerbations had fused his sacroiliac joints and the facet joints in his lumbar and cervical spine. He presented with local moderate-to-severe pain in his low back and neck and lack of mobility. Intervention and outcome The patient was treated with grade 5 manipulation of his thoracic spine and grade 3 mobilization of his lumbar and cervical spine, along with physical therapy and stretches for a period of 12 weeks. He reported some improvement of his condition as measured by the SF-36 Health Survey and several measures of spinal flexibility.

CONCLUSIONS

This case shows that even advanced cases of ankylosing spondylitis may show a favorable response to chiropractic manipulative therapy.

Clinical features and predictive factors in psoriatic arthritis-related uveitis

OBJECTIVES

To analyze the clinical features of uveitis in psoriatic arthritis (PsA) and to investigate the factors predicting its appearance.

PATIENTS AND METHODS

Retrospective cohort study (1991-2000) of 71 patients diagnosed with PsA according to the criteria of Moll and Wright. All patients were studied according to a standard protocol. The group was divided into 3 articular categories: axial, oligoarticular, and polyarticular. Human leukocyte antigen (HLA)-Cw typing was performed by the polymerase chain reaction-sequence specific oligonucleotide probes (PCR-SSOP) method in 65 patients and in 177 healthy donors. HLA-DR typing was done by serologic methods in the 71 patients and in 82 healthy donors from the same racial and geographic origin. The HLA-B27 allele also was tested among the study population. All subjects with possible inflammatory ocular disease received a complete ophthalmologic examination at the Ophthalmology Department of our hospital. Only patients with uveitis were analyzed. Univariate and multivariate analyses were applied.

RESULTS

Thirteen patients had uveitis (18% of this series), 4 (31%) had an insidious onset, and the remaining had acute-onset uveitis. Five cases (39%) had bilateral-simultaneous uveitis. Ten (77%) presented with anterior uveitis only, 2 with anterior and posterior pole involvement, and only 1 case with isolated posterior pole involvement. Four patients needed oral corticosteroids; 2 of them also used immunosuppresive drugs. None of our patients developed sequelae or complications. In univariate analysis, uveitis was associated with inflammatory back pain (P =.02), sacroiliac pain (P =.001), syndesmophytes (P =.001), bilateral sacroileitis (P =.0001), HLA-DR13 (P =.002), and HLA-B27 (P =.026). In multivariate analysis, the predictive factors for uveitis were bilateral sacroileitis (OR 17, 95% CI: 3.7-76, P =.0002), HLA-DR13 (OR 24, 95% CI: 3.78-150, P =.0056), and syndesmophytes (OR 9.7, 95% CI: 0.97-97, P =.05).

CONCLUSIONS

Insidious onset, bilaterality, posterior pole involvement, and chronicity are common in PsA patients with uveitis. In this study, extensive axial involvement (bilateral sacroileitis and syndesmophytes), and the HLA-DR13 antigen were the best predictors for the appearance of uveitis.