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Auyezkhankyzy D, Izekenova A, Kocyigit BF. Emergencies in inflammatory rheumatic diseases. Rheumatol Int 2024; 44:1637-1646. [PMID: 38981903 PMCID: PMC11343811 DOI: 10.1007/s00296-024-05660-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 07/05/2024] [Indexed: 07/11/2024]
Abstract
Inflammatory rheumatic diseases (IRDs), encompassing a broad spectrum of chronic disorders, typically necessitate prolonged therapeutic intervention. Nevertheless, these diseases can sometimes manifest as severe emergencies requiring prompt and extensive medical intervention. Urgent intervention is essential for effectively recognizing and managing these situations, as they have the potential to be life-threatening and can result in severe morbidity and mortality. Emergencies in IRDs can occur with different frequencies and manifestations, including nervous system issues, severe infections, thrombosis-emboli, renal crises, gastrointestinal issues, and cardiovascular events. The fact that these events can occur across different IRDs underscores the necessity for heightened awareness and readiness among healthcare professionals. The pathophysiologic mechanisms that cause rheumatic emergencies are complex and involve multiple factors. These emergencies frequently arise due to the interplay between the inflammatory characteristics of rheumatic diseases and different systemic triggers. Early detection and treatment can have a substantial impact on an individual's prognosis in cases of severe and life-threatening disorders that require prompt recognition. Rapid decision-making and urgent care are required to effectively address rheumatic emergencies, as well as the implementation of a diagnostic flowchart. This article provides an overview of the emergencies linked to IRDs, classifying and assessing them individually. This article aims to enhance healthcare professionals' knowledge and awareness of critical situations by examining current recommendations and pathophysiological information. Implementing standardized diagnostic and treatment methods, providing patient education, and conducting continuing research into the underlying mechanisms are essential for enhancing the management of these critical situations and improving patient outcomes.
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Affiliation(s)
- Dana Auyezkhankyzy
- Department of Emergency Medicine and Nursing, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Aigulsum Izekenova
- Department of Epidemiology with the Course of HIV Infection, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
| | - Burhan Fatih Kocyigit
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Adana City Research and Training Hospital, Adana, Türkiye.
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Ferjani HL, Boudriga O, Nessib DB, Kaffel D, Maatallah K, Hamdi W. Probability of the 10-year Risk of Hip and Major Osteoporotic Fracture in Non-radiographic Axial Spondyloarthritis. Curr Rheumatol Rev 2024; 20:82-87. [PMID: 37539931 DOI: 10.2174/1573397119666230804122659] [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: 12/30/2022] [Revised: 04/17/2023] [Accepted: 06/13/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Fracture risk in non-radiographic spondyloarthritis is underestimated. A reliable tool such as the Fracture Risk Assessment tool (FRAX) may assess this risk probability. This study aimed to assess the fracture risk by the FRAX score in patients with nr-axSpA and to determine factors associated with high fracture risk. METHODS We conducted a retrospective study of nr-axSpA patients meeting the Assessment of SpondyloArthritis International Society (ASAS) classification criteria for spondyloarthritis. All patients had Bone Mineral Density (BMD) by dual-energy X-ray absorptiometry (DEXA). The 10- year probability of major osteoporotic fracture (MOF) and hip fracture (HF) was calculated using the Fracture Risk Assessment Tool (FRAX). RESULTS Among 40 patients with nr-axSpA, 27 were women (67.5%). Their mean age was 43.7 ± 12.1 years. The mean disease duration was 3.15 ± 2.7 years. Eighteen patients (45%) had osteopenia, and 12 patients (30%) had osteoporosis. The median HF FRAX was 0% [0-1.2]. The median MOF FRAX was 0.5% [0.3-1.8]. MOF FRAX was positively correlated with age (p = 0.002), disease onset age (p = 0.006), disease duration (p = 0.024), and the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) (p < 0.0001), and negatively correlated with daily calcium intake (p < 0.0001). HF FRAX was positively correlated with mSASSS (p < 0.0001) and negatively correlated with daily calcium intake (p = 0.005). CONCLUSION Our study confirmed the frequency of bone loss during nr-axSpA and showed that osteoporotic risk fracture was related not only to traditional risk factors for osteoporosis but also to disease-related factors.
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Affiliation(s)
- Hanene Lassoued Ferjani
- Department of Rheumatology, Kassab Orthopedics Institute, Tunis El Manar University, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Ksar Saïd, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said 2010, Tunis, Tunisia
| | - Ons Boudriga
- Faculty of Medicine of Tunis, University Tunis el Manar, Ksar Saïd, Tunisia
| | - Dorra Ben Nessib
- Department of Rheumatology, Kassab Orthopedics Institute, Tunis El Manar University, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Ksar Saïd, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said 2010, Tunis, Tunisia
| | - Dhia Kaffel
- Department of Rheumatology, Kassab Orthopedics Institute, Tunis El Manar University, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Ksar Saïd, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said 2010, Tunis, Tunisia
| | - Kaouther Maatallah
- Department of Rheumatology, Kassab Orthopedics Institute, Tunis El Manar University, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Ksar Saïd, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said 2010, Tunis, Tunisia
| | - Wafa Hamdi
- Department of Rheumatology, Kassab Orthopedics Institute, Tunis El Manar University, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Ksar Saïd, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said 2010, Tunis, Tunisia
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Vanhoenacker FM, Vanhoenacker C, Lalam R. Complications of the Rigid Spine. Semin Musculoskelet Radiol 2023; 27:491-498. [PMID: 37816357 DOI: 10.1055/s-0043-1770136] [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: 10/12/2023]
Abstract
We present a short overview of the most common causes and imaging findings of a rigid spine including long-standing spondylarthritis, diffuse idiopathic skeletal hyperostosis, and the less common ossification of the posterior longitudinal ligament. The article also focuses on the pathogenesis and imaging findings of acute complications of the rigid spine due to fractures. These fractures may occur even after minor trauma and are difficult to detect on initial radiographs, resulting in a delayed diagnosis. They are often unstable with a high risk of severe neurologic complications, leading to high morbidity and mortality both in the initial phase and in the months following the fracture. Because the negative predictive value of conventional radiography is low, every patient with a rigid spine with newly appearing pain should be referred for subsequent cross-sectional imaging.
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Affiliation(s)
- Filip M Vanhoenacker
- Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium
- Department of Radiology, Antwerp University Hospital, Edegem, Belgium
- Faculty of Medicine and Health Sciences, Antwerp and Ghent, Belgium
- Faculty of Medicine, KU Leuven, Belgium
| | | | - Radhesh Lalam
- Department of Radiology, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, England, United Kingdom
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Valls-Pascual E, Orenes-Vera AV, Sendra-García A, Martínez-Ferrer À, Montolío-Chiva L, Vázquez-Gómez I, Flores-Fernández E, Ybáñez-García D, Vega-Martínez M, García-Ferrer L, Graells-Ferrer M, Alegre-Sancho JJ. Relationship between trabecular bone score, bone mineral density and vertebral fractures in patients with axial spondyloarthritis. BMC Musculoskelet Disord 2023; 24:316. [PMID: 37087414 PMCID: PMC10122358 DOI: 10.1186/s12891-023-06431-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/13/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND In patients with axial spondyloarthritis, vertebral fracture risk is elevated and not always correlated with bone mineral density (BMD). Trabecular bone score (TBS) may offer some advantages in the assessment of vertebral fracture risk in these patients. The primary objective of this study was to compare TBS and BMD between axial spondyloarthritis patients depending on their vertebral fracture status. Secondary objectives were to estimate the prevalence of morphometric vertebral fractures, and to explore factors associated with fracture, as well as the interference of syndesmophytes on BMD and TBS. METHODS A cross-sectional study was conducted. Data were collected on demographic and clinical characteristics, lab results, imaging findings and treatment. Statistical analysis was performed using SPSS v.13 statistical software. RESULTS Eighty-four patients (60 men and 24 women; mean age of 59 years) were included. Nearly half (47.6%) of them had lumbar syndesmophytes. The rate of morphometric fracture was 11.9%. TBS showed a higher area under the curve (0.89) than total hip, femoral neck and lumbar BMD (0.80, 0.78, and 0.70 respectively) for classifying patients regarding their fracture status. Nonetheless, the differences did not reach statistical significance. Syndesmophytes affected lumbar spine BMD (p < 0.001), but not hip BMD or TBS. Fractures were associated with TBS, total hip BMD, erythrocyte sedimentation rate and C-reactive protein levels. CONCLUSIONS We identified decreased TBS and total hip BMD, as well as increased erythrocyte sedimentation rate and C-reactive protein levels as factors associated with morphometric vertebral fractures. Unlike lumbar spine BMD, TBS is not affected by the presence of syndesmophytes.
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Affiliation(s)
- Elia Valls-Pascual
- Rheumatology Department, Doctor Peset University Hospital, Valencia, Spain.
| | | | - Ana Sendra-García
- Pharmacy Department, Doctor Peset University Hospital, Valencia, Spain
| | | | - Lydia Montolío-Chiva
- Rheumatology Department, University General Hospital of Castellón, Castellón de La Plana, Spain
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Nelson DA, Kaplan RM, Weisman MH, Kurina LM. Service discharges among US Army personnel with selected musculoskeletal and skin conditions: a retrospective cohort study. BMJ Open 2022; 12:e063371. [PMID: 36241350 PMCID: PMC9577895 DOI: 10.1136/bmjopen-2022-063371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To determine the probability of discharge from military service among soldiers following an incident diagnosis of ankylosing spondylitis (AS), rheumatoid arthritis (RA), psoriasis or systemic lupus erythematous. METHODS All soldiers on active duty in the US Army between January 2014 and June 2017 were included in a retrospective cohort analysis. Termination from service was ascertained using personnel records. Diagnostic codes were used to identify incident cases of the four musculoskeletal and skin diseases and, for comparison, diabetes mellitus (DM). Time to discharge was modelled using sex stratified multivariate survival analysis. RESULTS The analysis included 657 417 individuals with a total of 1.2 million person-years of observation. An elevated risk of discharge was observed in association with each of the five chronic conditions studied. The increase in adjusted risk of discharge was highest among soldiers with AS (men, HR=2.5, 95% CI 2.1 to 3.0; women, HR=2.1, 95% CI 1.4 to 3.2) and with DM (men, HR=2.4, 95% CI 2.2 to 2.7; women, HR=2.2, 95% CI 1.8 to 2.5), followed by those with RA (men, HR=1.8, 95% CI 1.5 to 2.2; women, HR=1.8, 95% CI 1.4 to 2.4). CONCLUSIONS Military discharges are consequential for the service and the service member. The doubling in risk of discharge for those with AS or RA was comparable to that for personnel with DM. Conditions that affect the spine and peripheral joints may often be incompatible with military readiness. Nevertheless, a substantial fraction of service members with these diagnoses continued in service.
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Affiliation(s)
- D Alan Nelson
- Department of Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Robert M Kaplan
- Department of Medicine, Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California, USA
| | - Michael H Weisman
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lianne M Kurina
- Department of Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
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Wu X, Zhang L, Bian T, Man S, Li H, Liu W, Zhou Y. The correlation between volumetric bone mineral density and morphological parameters of the proximal femur and clinical outcomes in ankylosing spondylitis patients with hip involvement. BMC Musculoskelet Disord 2022; 23:24. [PMID: 34980053 PMCID: PMC8725399 DOI: 10.1186/s12891-021-04912-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 11/24/2021] [Indexed: 11/23/2022] Open
Abstract
Background To measure volumetric bone mineral density (vBMD) with quantitative computed tomography (QCT) in the proximal femur of ankylosing spondylitis (AS) patients with hip involvement and analyze their correlations with radiographic and clinical parameters. Methods Sixty-five AS inpatients were enrolled in this study. The bone mineral density was measured by QCT and dual-energy x-ray absorptiometry (DXA), respectively. The morphological parameters of the proximal femur were measured on digital anteroposterior (AP) radiographs of the pelvis. The correlations between them were analyzed by SPSS software. Results The average trabecular vBMD measured at the femoral neck was 136.38 ± 25.58 mg/cm3. According to the BASRI-Hip score, group A consisted of 39 hips (0–2 score) and group B consisted of 26 hips (3–4 score). There were significant differences regarding trabecular CTXA equivalent T-score between group A and B at the femoral neck (p = 0.004); intertrochanteric region (p < 0.001) and greater trochanter (p = 0.001). The trabecular CTXA equivalent T-score at femoral neck had a negative correlation with disease duration (r = − 0.311, p = 0.012) and with CBR (r = − 0.319, p = 0.010). Conclusions The low trabecular bone density at the site of the hip was associated with the duration of disease progression and degree of hip involvement. Meanwhile, it had a correlation with hip function status although we failed to confirm a significant relationship between hip vBMD and disease activity.
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Affiliation(s)
- Xinfeng Wu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Liang Zhang
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Tao Bian
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Siliang Man
- Department of Rheumatology and Immunology, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Hongchao Li
- Department of Rheumatology and Immunology, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Wei Liu
- Department of Rheumatology and Immunology, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Yixin Zhou
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China.
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Shirado O, Arai Y, Iguchi T, Imagama S, Kawakami M, Nikaido T, Ogata T, Orita S, Sakai D, Sato K, Takahata M, Takeshita K, Tsuji T. Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition. J Orthop Sci 2022; 27:3-30. [PMID: 34836746 DOI: 10.1016/j.jos.2021.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/12/2021] [Accepted: 06/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine. METHODS The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members. RESULTS Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature. CONCLUSIONS The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.
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Affiliation(s)
- Osamu Shirado
- Department of Orthopaedic and Spinal Surgery, Aizu Medical Center (AMEC) at Fukushima Medical University, Japan.
| | - Yoshiyasu Arai
- Department of Orthopaedic Surgery, Saiseikai Kawaguchi General Hospital, Japan
| | - Tetsuhiro Iguchi
- Department of Orthopaedic Surgery, Saiseikai Hyogo Prefectural Hospital, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Japan
| | | | - Takuya Nikaido
- Department of Orthopaedic Surgery, Fukushima Medical University, Japan
| | | | - Sumihisa Orita
- Center for Frontier Medical Engineering (CFME), Department of Orthopaedic Surgery, Chiba University, Japan
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Japan
| | - Kimiaki Sato
- Department of Orthopaedic Surgery, Kurume University, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Japan
| | | | - Takashi Tsuji
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Japan
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Theodorou S, Theodorou D, Kakitsubata Y, Gelalis I, Tsifetaki N. Advanced ankylosing spondylitis: a multisite, multimodality densitometric analysis for investigation of bone loss in the axial and appendicular skeleton. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2021; 67:1627-1632. [PMID: 34909889 DOI: 10.1590/1806-9282.20210683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/18/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this study was to investigate if there is a bias in bone mineral density measurements among major densitometric techniques across multiple skeletal sites. METHODS In 25 advanced ankylosing spondylitis patients, bone mineral density measurements were acquired in the lumbar spine, the hip, and the forearm. RESULTS In total, 60% of patients had a bone mineral density Z-score of -2 or less at one or more skeletal sites. Dedicated loss of cortical bone was identified at the distal forearm (60% of patients). Differences in bone mineral density measurements across all densitometric techniques were highly significant (p≤0.001). Bone loss was more striking in spinal trabecular bone by three-dimensional quantitative computed tomography [Z-score -2.1] versus dual-energy X-ray absorptiometry [Z-score 0]. A trabecular bone loss quantified by quantitative computed tomography was about twice as much as a cortical bone loss by single-energy X-ray absorptiometry (p=0.001). CONCLUSIONS Low bone mineral density is prevalent in advanced ankylosing spondylitis patients, predominating in the spine. Bone mineral density measurements have systematic differences when compared to each other. Knowledge of these offsets is useful for improved diagnosis of regional bone loss that allows for targeted treatment of osteoporosis. Three-dimensional quantitative computed tomography is more suitable for evaluating spinal osteoporosis in advanced ankylosing spondylitis than dual-energy X-ray absorptiometry, which rather underestimates bone loss.
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Affiliation(s)
| | - Daphne Theodorou
- General Hospital of Ioannina G. Hatzikosta, Department of Radiology - Ioannina, Greece
| | - Yousuke Kakitsubata
- Miyazaki Konan Hospital, Department of Radiology and Bone Metabolism - Miyazaki, Japan
| | - Ioannis Gelalis
- University Hospital of Ioannina, Department of Orthopaedic Surgery - Ioannina, Greece
| | - Niki Tsifetaki
- General Hospital of Ioannina, Rheumatology Clinic, Department of Internal Medicine - Ioannina, Greece
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Nowakowska-Płaza A, Wroński J, Sudoł-Szopińska I, Głuszko P. Trabecular Bone Score (TBS) in Patients with Early Ankylosing Spondylitis-Limited Utility. J Clin Med 2021; 10:jcm10225373. [PMID: 34830653 PMCID: PMC8623295 DOI: 10.3390/jcm10225373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/04/2021] [Accepted: 11/16/2021] [Indexed: 01/01/2023] Open
Abstract
Purpose: Ankylosing spondylitis (AS) not only results in pathological ossification of the spine, but can also be associated with osteoporosis. Due to the presence of syndesmophytes and possible involvement of the hip joints, classical dual X-ray absorptiometry (DXA) is of limited use in patients with advanced stages of AS. Trabecular bone score (TBS) is a method complementary to DXA, providing additional information about bone microarchitecture. There is a growing body of evidence for the usefulness of TBS in AS patients. The aim of this study was to assess the clinical utility of TBS in patients with AS. Methods: Patients with AS underwent DXA with additional TBS assessment. A cross-sectional analysis of the frequency of osteoporosis and bone microarchitecture deterioration and their association with patients’ characteristics was done. Results: A total of 51 male patients, mean age 40.7 years, were enrolled. Osteoporosis was diagnosed in seven patients (13.7%). Lumbar bone mineral density (BMD) was higher (p < 0.001) than femoral BMD, indicating abnormal BMD readings in the spine caused by syndesmophytes. Patients with DXA-diagnosed osteoporosis had lower TBS (p = 0.03) and TBS T-score (p = 0.043) values compared to patients without osteoporosis. However, disturbed bone microarchitecture (TBS < 1.23) was present in only three patients (5.9%). None of the patients had a history of an osteoporotic fracture. A lower TBS T-score (p = 0.032) was demonstrated in patients with sacroiliitis grade 4 than in patients with sacroiliitis grade 2, with no significant differences in BMD and T-score values. Conclusion: Among patients with early AS, the clinical utility of TBS is limited—it does not add value to DXA.
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Affiliation(s)
- Anna Nowakowska-Płaza
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland; (A.N.-P.); (P.G.)
| | - Jakub Wroński
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland; (A.N.-P.); (P.G.)
- Correspondence:
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| | - Piotr Głuszko
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland; (A.N.-P.); (P.G.)
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Carey JJ, Yang L, Erjiang E, Wang T, Gorham K, Egan R, Brennan A, Dempsey M, Armstrong C, Heaney F, McCabe E, Yu M. Vertebral Fractures in Ireland: A Sub-analysis of the DXA HIP Project. Calcif Tissue Int 2021; 109:534-543. [PMID: 34085087 PMCID: PMC8484104 DOI: 10.1007/s00223-021-00868-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/13/2021] [Indexed: 11/28/2022]
Abstract
Osteoporosis is an important global health problem resulting in fragility fractures. The vertebrae are the commonest site of fracture resulting in extreme illness burden, and having the highest associated mortality. International studies show that vertebral fractures (VF) increase in prevalence with age, similarly in men and women, but differ across different regions of the world. Ireland has one of the highest rates of hip fracture in the world but data on vertebral fractures are limited. In this study we examined the prevalence of VF and associated major risk factors, using a sample of subjects who underwent vertebral fracture assessment (VFA) performed on 2 dual-energy X-ray absorptiometry (DXA) machines. A total of 1296 subjects aged 40 years and older had a valid VFA report and DXA information available, including 254 men and 1042 women. Subjects had a mean age of 70 years, 805 (62%) had prior fractures, mean spine T-score was - 1.4 and mean total hip T-scores was - 1.2, while mean FRAX scores were 15.4% and 4.8% for major osteoporotic fracture and hip fracture, respectively. Although 95 (7%) had a known VF prior to scanning, 283 (22%) patients had at least 1 VF on their scan: 161 had 1, 61 had 2, and 61 had 3 or more. The prevalence of VF increased with age from 11.5% in those aged 40-49 years to > 33% among those aged ≥ 80 years. Both men and women with VF had significantly lower BMD at each measured site, and significantly higher FRAX scores, P < 0.01. These data suggest VF are common in high risk populations, particularly older men and women with low BMD, previous fractures, and at high risk of fracture. Urgent attention is needed to examine effective ways to identify those at risk and to reduce the burden of VF.
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Affiliation(s)
- John J Carey
- School of Medicine, National University of Ireland Galway, Galway, Ireland.
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland.
| | - Lan Yang
- School of Engineering, National University of Ireland Galway, Galway, Ireland
- Department of Industrial Engineering, Tsinghua University, Beijing, China
| | - E Erjiang
- Department of Industrial Engineering, Tsinghua University, Beijing, China
| | - Tingyan Wang
- Department of Industrial Engineering, Tsinghua University, Beijing, China
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Kelly Gorham
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
| | - Rebecca Egan
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
| | - Attracta Brennan
- School of Computer Science, National University of Ireland Galway, Galway, Ireland
| | - Mary Dempsey
- School of Engineering, National University of Ireland Galway, Galway, Ireland
| | | | - Fiona Heaney
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
| | - Eva McCabe
- School of Medicine, National University of Ireland Galway, Galway, Ireland
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
| | - Ming Yu
- Department of Industrial Engineering, Tsinghua University, Beijing, China
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Fauny M, Verhoeven F, Allado E, Albuisson E, Pinzano A, Morizot C, Chary-Valckenaere I, Loeuille D. Relationship between spinal structural damage on radiography and bone fragility on CT in ankylosing spondylitis patients. Sci Rep 2021; 11:9342. [PMID: 33927314 PMCID: PMC8085178 DOI: 10.1038/s41598-021-88838-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 04/19/2021] [Indexed: 11/25/2022] Open
Abstract
To evaluate whether the risk of bone fragility on computed tomography (CT) (scanographic bone attenuation coefficient of the first lumbar vertebra (SBAC-L1)) is associated with the severity of spine structural involvement (mSASSS) in patients with ankylosing spondylitis (AS). This retrospective study included AS patients, followed from 2009 to 2017, who fulfilled the New York criteria and who underwent thoraco-abdomino-pelvic CT and radiography (spine, pelvis). The structural involvement was retained for mSASSS ≥ 2. The SBAC-L1 was measured in Hounsfield units (HU). A SBAC-L1 ≤ 145 HU was used to define patients at risk of vertebral fracture (VF). A total of 73 AS patients were included (mean age: 60.3 (± 10.7) years, 8 women (11%), mean disease duration: 24.6 years (± 13.9)). Sixty patients (82.2%) had a mSASSS ≥ 2 (mean score 20.7 (± 21.2)). The mean SBAC-L1 was 141.1 HU (± 45), 138.1 HU (± 44.8) and 154.8 HU (± 44.9) in the total, mSASSS ≥ 2 and mSASSS < 2 populations, respectively. Patients with bone bridges had lower SBAC-L1 than mSASSS ≥ 2 patients without ankylosis (p = 0.02) and more often SBAC-L1 ≤ 145 HU (73% vs 41.9%, p = 0.006). A SBAC-L1 ≤ 145 HU was not associated with structural spine involvement, but patients with bone bridges had significantly decreased SBAC-L1 and an increased probability of being under the fracture threshold.
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Affiliation(s)
- Marine Fauny
- Department of Rheumatology, Hôpitaux de Brabois, Nancy University Hospital, 54511, Vandoeuvre les Nancy Cedex, France. .,Saint Charles Hospital, 54200, Toul, France.
| | - Frank Verhoeven
- Department of Rheumatology, Besançon University Hospital, Besançon, France
| | - Edem Allado
- Department of Rheumatology, Hôpitaux de Brabois, Nancy University Hospital, 54511, Vandoeuvre les Nancy Cedex, France.,Department of Pulmonary Function Testing and Exercise Physiology, University Hospital of Nancy, 54000, Nancy, France.,Development, Adaptation and Disadvantage, Cardiorespiratory Regulations and Motor Control (EA 3450 DevAH), University of Lorraine, 54505, Nancy, France
| | - Eliane Albuisson
- Faculté de Medecine, InSciDens, Université de Lorraine, 54000, Nancy, France.,Université de Lorraine, CNRS, IECL, 54000, Nancy, France.,CHRU-Nancy, DRCI, Département MPI, Unité de méthodologie, Data management et statistiques UMDS, 54000, Nancy, France
| | - Astrid Pinzano
- Ingénierie Moléculaire et Physiopathologie Articulaire (IMoPA), UMR 7365 CNRS - University of Lorraine, Nancy, France.,Contrat d'Interface, Department of Rheumatology, Nancy University Hospital, Nancy, France
| | - Caroline Morizot
- Department of Rheumatology, Hôpitaux de Brabois, Nancy University Hospital, 54511, Vandoeuvre les Nancy Cedex, France
| | - Isabelle Chary-Valckenaere
- Department of Rheumatology, Hôpitaux de Brabois, Nancy University Hospital, 54511, Vandoeuvre les Nancy Cedex, France.,Ingénierie Moléculaire et Physiopathologie Articulaire (IMoPA), UMR 7365 CNRS - University of Lorraine, Nancy, France
| | - Damien Loeuille
- Department of Rheumatology, Hôpitaux de Brabois, Nancy University Hospital, 54511, Vandoeuvre les Nancy Cedex, France.,Ingénierie Moléculaire et Physiopathologie Articulaire (IMoPA), UMR 7365 CNRS - University of Lorraine, Nancy, France
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12
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Lim MJ, Kang KY. A Contemporary View of the Diagnosis of Osteoporosis in Patients With Axial Spondyloarthritis. Front Med (Lausanne) 2020; 7:569449. [PMID: 33363182 PMCID: PMC7759657 DOI: 10.3389/fmed.2020.569449] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/13/2020] [Indexed: 01/31/2023] Open
Abstract
Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that primarily affects the axial joints. Altered bone metabolism associated with chronic inflammation leads to both new bone formation in the spine and increased bone loss. It is known that patients with axSpA have a high prevalence of osteoporosis and fractures. However, there is no consensus on which imaging modality is the most appropriate for diagnosing osteoporosis in axSpA. Bone mineral density measurement using dual-energy X-ray absorptiometry is the primary diagnostic method for osteoporosis, but it has notable limitations in patients with axSpA. This method may lead to the overestimation of bone density in patients with axSpA because they often exhibit abnormal calcification of spinal ligaments or syndesmophytes. Therefore, the method may not provide adequate information about bone microarchitecture. These limitations result in the underdiagnosis of osteoporosis. Recently, new imaging techniques, such as high-resolution peripheral quantitative computed tomography, and trabecular bone score have been introduced for the evaluation of osteoporosis risk in patients with axSpA. In this review, we summarize the current knowledge regarding imaging techniques for diagnosing osteoporosis in patients with axSpA.
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Affiliation(s)
- Mie Jin Lim
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Inha University, Incheon, South Korea
| | - Kwi Young Kang
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Division of Rheumatology, Department of Internal Medicine, College of Medicine, Incheon Saint Mary's Hospital, The Catholic University of Korea, Incheon, South Korea
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13
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Fauny M, Morizot C, Allado E, Verhoeven F, Albuisson E, Semaan M, Pinzano A, Chary-Valckenaere I, Loeuille D. Consequences of spinal ankylosis on bone trabecular fragility assessed on CT scans in patients with ankylosing spondylitis. A retrospective study. Joint Bone Spine 2020; 87:625-631. [PMID: 32534203 DOI: 10.1016/j.jbspin.2020.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/14/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Ankylosing spondylitis (AS) patients seems to be at risk of osteoporosis but bone screening is not often performed. The objective was to evaluate the effect of vertebral ankylosis on scanographic bone attenuation coefficient (SBAC) on lumbar vertebrae in AS patients. METHODS This study included AS patients fulfilling New York criteria who underwent both thoraco-abdomino-pelvic computed tomography and X-rays during routine follow-up. The modified stoke ankylosing spondylitis spinal score (mSASSS) was scored on X-rays, and the presence of at least one syndesmophyte (mSASSS≥2) defined mSASSS+ patients. Ankylosis of a lumbar vertebra was defined by the presence of bone bridges to its two adjacent vertebrae. The SBAC was measured from L1 to L5, and the fracture threshold was set at SBAC≤145 HU. RESULTS A total of 73 AS patients were included (mean age: 60.3 [±10.7] years, 65 men [89%]). Sixty patients (82.2%) were mSASSS+; 13 patients (17.8%) presented ankylosis of at least one lumbar vertebra. The SBAC of each lumbar vertebra was not significantly different between mSASSS- and mSASSS+ patients. The SBAC was lower for patients with at least one bone bridge than for patients without (P<0.05). Patients with lumbar vertebral ankylosis had a higher risk of presenting an SBAC≤145 HU (OR: 4.95 (95% CI: 1.1-17.4)). CONCLUSION The presence of a bone bridge and complete ankylosis of lumbar vertebra were associated with a higher risk of SBAC under the fracture threshold, suggesting structural deterioration of trabecular bone in ankylosed vertebrae in AS patients.
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Affiliation(s)
- Marine Fauny
- Department of Rheumatology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France; Saint Charles Hospital, 54200 Toul, France.
| | - Caroline Morizot
- Department of Rheumatology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France
| | - Edem Allado
- Department of Rheumatology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France; Department of Pulmonary Function Testing and Exercise Physiology, Nancy University Hospital, 54000, Nancy, France; Development, Adaptation and Disadvantage, Cardiorespiratory regulations and motor control (EA 3450 DevAH), University of Lorraine, 54500 Nancy, France
| | - Frank Verhoeven
- Department of Rheumatology, Besançon University Hospital, Besançon, France
| | - Eliane Albuisson
- Université de Lorraine, Faculté de Medecine, InSciDens, 54000 Nancy, France; Université de Lorraine, CNRS, IECL, 54000 Nancy, France; CHRU-Nancy, DRCI, Département MPI, Unité de méthodologie, Data management et statistiques UMDS, 54000 Nancy, France
| | - Marie Semaan
- Ingénierie Moléculaire et Physiopathologie Articulaire (IMoPA). UMR 7365 CNRS-University of Lorraine, Nancy, France; Contrat d'Interface, Department of Rheumatology, Nancy University Hospital, Nancy, France
| | - Astrid Pinzano
- Ingénierie Moléculaire et Physiopathologie Articulaire (IMoPA). UMR 7365 CNRS-University of Lorraine, Nancy, France; Contrat d'Interface, Department of Rheumatology, Nancy University Hospital, Nancy, France
| | - Isabelle Chary-Valckenaere
- Department of Rheumatology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France; Ingénierie Moléculaire et Physiopathologie Articulaire (IMoPA). UMR 7365 CNRS-University of Lorraine, Nancy, France
| | - Damien Loeuille
- Department of Rheumatology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France; Ingénierie Moléculaire et Physiopathologie Articulaire (IMoPA). UMR 7365 CNRS-University of Lorraine, Nancy, France
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14
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Ognjenovic M, Raymond WD, Inderjeeth CA, Keen HI, Preen DB, Nossent JC. The Risk and Consequences of Vertebral Fracture in Patients with Ankylosing Spondylitis: A Population-based Data Linkage Study. J Rheumatol 2020; 47:1629-1636. [PMID: 32062601 DOI: 10.3899/jrheum.190675] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare the long-term prevalence, incidence, and outcomes of vertebral fracture (VF) between ankylosing spondylitis (AS) patients and matched controls, including the role of extraarticular manifestations (EAM) and osteoporosis. METHODS This was a statewide observational study using linked health data for 2321 patients with AS and 22,976 controls presenting to hospital from 1980 to 2015. Data were analyzed using incidence rates (per 1000 person-yrs) and ratios (IRR), multivariable Cox proportional hazards regression, and Kaplan-Meier survival curves. RESULTS Over a median 13.92 (interquartile range 7.58-21.67) years of follow-up, patients with AS had a greater VF prevalence and greater incidence of developing a new VF compared to controls (9.3% vs 2.5%, 6.8% vs 1.9%, respectively, all P < 0.001). Patients with AS had an increased risk of developing a VF after adjustments for age, sex, and osteoporosis (HR 2.55, 95% CI 2.11-3.09) compared to controls; this risk remained throughout the study period. Patients with AS were 5 years younger at time of first VF (P = 0.008) and had a greater likelihood of a recurrent VF (IRR 4.64; 95% CI 4.54-4.75) compared to respective controls. Mortality overall was comparable between patients with AS and controls after adjustment for age, sex, osteoporosis, and VF status (HR 0.90; 95% CI 0.80-1.01). CONCLUSION The significantly increased risk of VF in patients with AS has not altered following the introduction of tumor necrosis factor inhibitor treatment. Although patients with AS experience a first VF at a younger age than controls, this does not lead to an increased risk of death.
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Affiliation(s)
- Milica Ognjenovic
- M. Ognjenovic, MPH, W.D. Raymond, PhD student, School of Medicine, Faculty of Health Science, University of Western Australia;
| | - Warren D Raymond
- M. Ognjenovic, MPH, W.D. Raymond, PhD student, School of Medicine, Faculty of Health Science, University of Western Australia
| | - Charles A Inderjeeth
- C.A. Inderjeeth, FRACP (Rheumatologist), MPH, MBChB, J.C. Nossent, MD (Rheumatologist), PhD, Professor of Medicine, School of Medicine, Faculty of Health Science, University of Western Australia, and Department of Rheumatology, Sir Charles Gairdner Hospital, Perth
| | - Helen I Keen
- Helen I. Keen, MBBS, FRACP (Rheumatologist), School of Medicine, Faculty of Health Science, University of Western Australia, and Department of Rheumatology, Fiona Stanley Hospital, Perth
| | - David B Preen
- D.B. Preen, PhD, School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Johannes C Nossent
- C.A. Inderjeeth, FRACP (Rheumatologist), MPH, MBChB, J.C. Nossent, MD (Rheumatologist), PhD, Professor of Medicine, School of Medicine, Faculty of Health Science, University of Western Australia, and Department of Rheumatology, Sir Charles Gairdner Hospital, Perth
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15
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Fitzgerald G, Anachebe T, McCarroll K, O'Shea F. Measuring bone density in axial spondyloarthropathy: Time to turn things on their side? Int J Rheum Dis 2020; 23:358-366. [PMID: 31909570 DOI: 10.1111/1756-185x.13765] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/15/2019] [Accepted: 11/16/2019] [Indexed: 01/05/2023]
Abstract
AIM Osteoporosis in axial spondyloarthropathy (axSpA) is difficult to accurately diagnose due to osteoproliferation of the spine interfering with conventional (anteroposterior, AP) dual-energy X-ray absorptiometry (DXA). This study compares AP and lateral projections of DXA when assessing bone mineral density (BMD) of the spine and investigates the impact of osteoproliferation on AP DXA. METHOD In this cross-sectional study, structured standardized assessments collected demographic, clinical, laboratory and radiographic data. DXA assessed BMD of the spine using PA and lateral projections. Hip BMD was assessed in the usual manner. World Health Organization (WHO) criteria assessed prevalence of low BMD. Incorporating lateral DXA in the bone health assessment of axSpA was investigated. SPSS was used for statistical analysis. RESULTS A total of 100 patients had paired AP and lateral DXA studies: 78% were male, mean (SD) age 52 (12) years. BMD of the spine measured by AP projection was significantly higher than BMD measured by lateral projection (mean difference 0.34 g/cm2 , 95% CI 0.30-0.37). More patients had low BMD with lateral compared to AP projection (47% vs 16%, P = .01). At the hip, 34% of patients had low BMD. Disease duration, body mass index and radiographic severity independently predicted a difference between AP and lateral measurements of the spine. CONCLUSION Lateral DXA of the spine is unaffected by osteoproliferation of the spine in axSpA and detects significantly more cases of low BMD than conventional AP DXA. Lateral DXA should be included in BMD assessment of patients with axSpA.
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Affiliation(s)
- Gillian Fitzgerald
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Department of Rheumatology, St. James's Hospital, Dublin, Ireland
| | | | - Kevin McCarroll
- Department of Medicine for the Elderly, St. James's Hospital, Dublin, Ireland
| | - Finbar O'Shea
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Department of Rheumatology, St. James's Hospital, Dublin, Ireland
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16
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Wei JCC, Chen HH, Hsieh TY, Lan HHC, Tseng JC, Liu CH, Chen YC, Tsai WC, Wu HTH, Chou CT. Clinical practice recommendations for the use of imaging in the diagnosis and management of axial spondyloarthritis in Taiwan. Int J Rheum Dis 2019; 23:24-36. [PMID: 31833212 DOI: 10.1111/1756-185x.13679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 07/02/2019] [Accepted: 07/20/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Axial spondyloarthritis (axSpA) is a chronic inflammatory disease bearing challenges in early diagnosis. To improve clinical diagnosis and management of axSpA, recommendations were developed with current axSpA classification criteria and recent advances in medical imaging applications. METHODS A systematic literature review was conducted by 10 rheumatologists and radiologists in Taiwan to retrieve research evidence on the utilization of imaging modalities, including conventional radiography (CR), magnetic resonance imaging (MRI), computed tomography (CT), ultrasound (US), quantitative sacroiliac scintigraphy (QSS), and dual-energy X-ray absorptiometry (DXA). The panel of experts proposed six key issues on the role of imaging in early diagnosis of axSpA, monitoring of disease activity and structural changes, predicting treatment effects, and assessing complications such as osteoporosis and spinal fracture. The consensus was established on the basis of research evidence, clinical experiences and expert opinions. For each recommendation statement, the level of evidence was evaluated, the strength of recommendation was graded and the final level of agreement was determined through voting. RESULTS In total, four overarching principles and 13 recommendations were formulated. These recommendations outlined different imaging approaches in the diagnosis and management of axSpA disease progression. Considering CT is easy to perform when MRI is less available in Taiwan, the expert panel proposed a concise and practical diagnostic scheme to strengthen the valuable role of MRI and CT in the diagnostic evaluation of axSpA without evident radiographic features. CONCLUSION These modified recommendations provide guidance for rheumatologists, radiologists and healthcare professionals on timely diagnosis of axSpA and disease management with appropriate imaging modalities.
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Affiliation(s)
- James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Medicine, Chun Shan Medical University, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Hsin-Hua Chen
- Division of Allergy Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Biomedical Science and Rong-Hsing Research Center for Translational Medicine, Chung-Hsing University, Taichung, Taiwan.,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
| | - Tsu-Yi Hsieh
- Division of Allergy Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Division of Clinical Training, Department of Medical Education, Taichung Veterans General Hospital, Taichung, Taiwan.,Evidence-Based Medicine Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Jui-Cheng Tseng
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chin-Hsiu Liu
- Division of Allergy, Immunology and Rheumatology, Buddhist Tzu Chi Medical Foundation, Taipei Tzu Chi Hospital, Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ying-Chou Chen
- Departments of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wen-Chan Tsai
- Department of Allergy, Immunology, and Rheumatology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Division of Rheumatology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Hung-Ta Hondar Wu
- Department of Radiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Musculoskeletal Section, Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Tei Chou
- Division of Allergy Immunology and Rheumatology, Taipei Veterans General Hospital, Taipei, Taiwan
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17
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Moltó A, Dougados M. Comorbidities in spondyloarthritis including psoriatic arthritis. Best Pract Res Clin Rheumatol 2018; 32:390-400. [PMID: 31171310 DOI: 10.1016/j.berh.2018.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/25/2018] [Accepted: 07/28/2018] [Indexed: 12/20/2022]
Abstract
Comorbidities in spondyloarthritis (SpA) including psoriatic arthritis have to be differentiated to the concept of clinical features of SpA (e.g., uveitis, psoriasis, and inflammatory bowel disease). In addition to atherosclerosis-related cardiovascular diseases, the most frequent comorbidities in SpA are osteoporosis, fibromyalgia, and depression. Moreover, the current available drug therapies (e.g., NSAIDs, corticosteroids, and biologics) might increase the risk of some comorbidities such as infections and gastrointestinal disorders. Awareness about these comorbidities is crucial to improve their screening and management. For this purpose, any systematic periodical review should integrate a program (ideally internationally standardized) focused on comorbidities.
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Affiliation(s)
- Anna Moltó
- Paris Descartes University, Department of Rheumatology, Hôpital Cochin, Assistance Publique, Hôpitaux de Paris, France; INSERM (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris, Cité. Paris, France.
| | - Maxime Dougados
- Paris Descartes University, Department of Rheumatology, Hôpital Cochin, Assistance Publique, Hôpitaux de Paris, France; INSERM (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris, Cité. Paris, France
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18
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Acupuncture and Neural Mechanism in the Management of Low Back Pain-An Update. MEDICINES 2018; 5:medicines5030063. [PMID: 29941854 PMCID: PMC6164863 DOI: 10.3390/medicines5030063] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 06/13/2018] [Accepted: 06/21/2018] [Indexed: 12/20/2022]
Abstract
Within the last 10 years, the percentage of low back pain (LBP) prevalence increased by 18%. The management and high cost of LBP put a tremendous burden on the healthcare system. Many risk factors have been identified, such as lifestyle, trauma, degeneration, postural impairment, and occupational related factors; however, as high as 95% of the cases of LBP are non-specific. Currently, LBP is treated pharmacologically. Approximately 25 to 30% of the patients develop serious side effects, such as drowsiness and drug addiction. Spinal surgery often does not result in a massive improvement of pain relief. Therefore, complementary approaches are being integrated into the rehabilitation programs. These include chiropractic therapy, physiotherapy, massage, exercise, herbal medicine and acupuncture. Acupuncture for LBP is one of the most commonly used non-pharmacological pain-relieving techniques. This is due to its low adverse effects and cost-effectiveness. Currently, many randomized controlled trials and clinical research studies have produced promising results. In this article, the causes and incidence of LBP on global health care are reviewed. The importance of treatment by acupuncture is considered. The efforts to reveal the link between acupuncture points and anatomical features and the neurological mechanisms that lead to acupuncture-induced analgesic effect are reviewed.
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19
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Abstract
The combination of physiological age-related changes (e. g. reduction in muscle mass and function, reduction in organ function and degenerative changes in joints) and disease-specific changes of ankylosing spondylitis (AS), make older AS patients vulnerable for additional diseases. In this patient population various processes lead to a reduction in physical function, changes in posture, osteoporosis and sarcopenia, which then can result in falls and fractures, especially vertebral fractures. Mortality is increased in patients with AS, particularly in men due to an increase in cardiovascular mortality. Although the standardized assessment of cardiovascular risk factors in patients with inflammatory rheumatic diseases (independent of age) has been recommended for years, it is rarely done in clinical practice. Overall, data on comorbidities and risk factors are only available for AS patients and are lacking for other forms of spondyloarthritides.
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20
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Moltó A, Nikiphorou E. Comorbidities in Spondyloarthritis. Front Med (Lausanne) 2018; 5:62. [PMID: 29594122 PMCID: PMC5857562 DOI: 10.3389/fmed.2018.00062] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/20/2018] [Indexed: 12/18/2022] Open
Abstract
Comorbidities in spondyloarthritis (SpA) add to the burden of disease by contributing to disease activity, functional and work disability, and mortality. Thus, awareness of comorbidities in SpA is crucial to improve their screening and management and to ultimately improve outcomes in those affected. Osteoporosis has been reported to be the most prevalent comorbidity in SpA, and its risk is increased in these patients, compared with the general population; the risk of vertebral fractures requires further evaluation. Cardiovascular risk is also increased in this population, both due to an increase of the traditional cardiovascular risk factors in these patients, but also due to the presence of inflammation. The role of non-steroidal anti-inflammatory drugs in this increased risk needs further elucidation, but there is consensus on the need to encourage smoking cessation and to perform periodic evaluation of cardiovascular risk in these patients, particularly in the case of change in treatment course. Concerning the risk of cancer, no increased risk inherent to SpA seems to exist. However, an increased neoplastic risk can occur due to SpA treatments, e.g., P-UVA. Data are sparse on the risk of infections compared with rheumatoid arthritis, but there appears to be no risk in the absence of TNF-inhibitor exposure. Regardless of which comorbidity, a gap exists between recommendations for their management and actual implementation in clinical practice, suggesting that there is still a need for improvement in this area. Systematic screening for these comorbidities should improve both short- and long-term outcomes in SpA patients.
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Affiliation(s)
- Anna Moltó
- Rheumatology B Department, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM (U1153) PRES Sorbonne Paris-Cité, Paris, France
| | - Elena Nikiphorou
- Academic Rheumatology Department, King's College London, London, United Kingdom.,Department of Rheumatology, Whittington Hospital, London, United Kingdom
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21
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Kang KY, Kim IJ, Park SH, Hong YS. Associations between trabecular bone score and vertebral fractures in patients with axial spondyloarthritis. Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Kwi Young Kang
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Division of Rheumatology, Department of Internal Medicine, Incheon St Mary’s Hospital, The Catholic University of Korea, Incheon, South Korea
| | - In Je Kim
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yeon Sik Hong
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Division of Rheumatology, Department of Internal Medicine, Incheon St Mary’s Hospital, The Catholic University of Korea, Incheon, South Korea
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22
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Kang KY, Chung MK, Kim HN, Hong YS, Ju JH, Park SH. Severity of Sacroiliitis and Erythrocyte Sedimentation Rate are Associated with a Low Trabecular Bone Score in Young Male Patients with Ankylosing Spondylitis. J Rheumatol 2018; 45:349-356. [DOI: 10.3899/jrheum.170079] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2017] [Indexed: 12/25/2022]
Abstract
Objective.To examine factors related to a low trabecular bone score (TBS) and the association between TBS and vertebral fractures in patients with ankylosing spondylitis (AS).Methods.One hundred patients (all male, aged < 50 yrs) who fulfilled the modified New York criteria for the classification of AS were enrolled. The TBS and bone mineral density (BMD) were assessed using dual-energy X-ray absorptiometry. Clinical variables, inflammatory markers, and the presence of vertebral fractures were also assessed. Sacroiliitis grade and spinal structural damage were measured using the modified New York criteria and the Stoke Ankylosing Spondylitis Spine Score (SASSS).Results.The mean TBS was 1.38 ± 0.13. The TBS showed a positive correlation with BMD at the lumbar spine, femoral neck, and total hip. TBS negatively correlated with SASSS, whereas BMD at the lumbar spine showed a positive correlation. A significant decrease in TBS values was observed in patients with spinal structural damage (p = 0.001). Univariate analysis identified disease duration, erythrocyte sedimentation rate (ESR), sacroiliitis grade, and SASSS as being associated with TBS. Multivariate analysis identified ESR and sacroiliitis grade as being independently associated with TBS (p = 0.006 and p < 0.001, respectively). Ten patients had morphometric vertebral fractures. The mean TBS was lower in patients with vertebral fractures than in age-matched patients without fractures (p = 0.028). Lower TBS predicted vertebral fractures (area under curve = 0.733, cutoff = 1.311).Conclusion.The TBS in young male patients with AS is associated with the ESR and severity of sacroiliitis. The TBS may be useful as a tool for assessing osteoporosis in AS.
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Deminger A, Klingberg E, Lorentzon M, Geijer M, Göthlin J, Hedberg M, Rehnberg E, Carlsten H, Jacobsson LT, Forsblad-d'Elia H. Which measuring site in ankylosing spondylitis is best to detect bone loss and what predicts the decline: results from a 5-year prospective study. Arthritis Res Ther 2017; 19:273. [PMID: 29216909 PMCID: PMC5721362 DOI: 10.1186/s13075-017-1480-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 11/20/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Studies have shown increased prevalence of osteoporosis and increased risk for vertebral fractures in patients with ankylosing spondylitis (AS). Measurements of bone mineral density (BMD) in the lumbar spine anterior-posterior (AP) projection may be difficult to interpret due to the ligamentous calcifications, and the lateral projection might be a better measuring site. Our objectives were to investigate BMD changes after 5 years at different measuring sites in patients with AS and to evaluate disease-related variables and medications as predictors for BMD changes. METHODS In a longitudinal study, BMD in Swedish AS patients, 50 ± 13 years old, was measured with dual-energy x-ray absorptiometry (DXA) at the hip, the lumbar spine AP and lateral projections, and the total radius at baseline and after 5 years. Patients were assessed with questionnaires, blood samples, and spinal radiographs for grading of AS-related alterations in the spine with the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) and assessment of vertebral fractures by the Genant score. Multiple linear regression analyses were used to investigate predictors for BMD changes. RESULTS Of 204 patients included at baseline, 168 (82%) were re-examined after 5 years (92 men and 76 women). BMD decreased significantly at the femoral neck and radius and increased significantly at the lumbar spine, both for AP and lateral projections. Mean C-reactive protein during follow-up predicted a decrease in the femoral neck BMD (change in %, β = -0.15, p = 0.046). Use of bisphosphonates predicted an increase in BMD at all measuring sites (p < 0.001 to 0.013), except for the total radius. Use of tumor necrosis factor inhibitors (TNFi) predicted an increase in AP spinal BMD (β = 3.15, p = 0.012). CONCLUSION The current study (which has a long follow-up, many measuring sites, and is the first to longitudinally assess the lateral projection of the spine in AS patients) surprisingly showed that lateral projection spinal BMD increased. This study suggests that the best site to assess bone loss in AS patients is the femoral neck and that inflammation has an adverse effect, and the use of bisphosphonates and TNFi has a positive effect, on BMD in AS patients.
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Affiliation(s)
- Anna Deminger
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Box 480, 405 30, Gothenburg, Sweden.
| | - Eva Klingberg
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Box 480, 405 30, Gothenburg, Sweden
| | - Mattias Lorentzon
- Geriatric Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg and Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Mats Geijer
- Department of Radiology, Faculty of Medicine and Health, Örebro University, 701 82, Örebro, Sweden.,Department of Clinical Sciences, Lund University, Box 117, 221 00, Lund, Sweden
| | - Jan Göthlin
- Department of Radiology, Sahlgrenska University Hospital/Mölndal, 431 80, Mölndal, Sweden
| | - Martin Hedberg
- Section of Rheumatology, Södra Älvsborg Hospital, 501 82, Borås, Sweden
| | - Eva Rehnberg
- Section of Rheumatology, Alingsås Hospital, 441 33, Alingsås, Sweden
| | - Hans Carlsten
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Box 480, 405 30, Gothenburg, Sweden
| | - Lennart T Jacobsson
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Box 480, 405 30, Gothenburg, Sweden
| | - Helena Forsblad-d'Elia
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Box 480, 405 30, Gothenburg, Sweden.,Department of Public Health and Clinical Medicine, Rheumatology, Umeå University, 901 87, Umeå, Sweden
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24
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Pritchard NS, Smoliga JM, Nguyen AD, Branscomb MC, Sinacore DR, Taylor JB, Ford KR. Reliability of analysis of the bone mineral density of the second and fifth metatarsals using dual-energy x-ray absorptiometry (DXA). J Foot Ankle Res 2017; 10:52. [PMID: 29209416 PMCID: PMC5704601 DOI: 10.1186/s13047-017-0234-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/15/2017] [Indexed: 01/13/2023] Open
Abstract
Background Metatarsal fractures, especially of the fifth metatarsal, are common injuries of the foot in a young athletic population, but the risk factors for this injury are not well understood. Dual-energy x-ray absorptiometry (DXA) provides reliable measures of regional bone mineral density to predict fracture risk in the hip and lumbar spine. Recently, sub-regional metatarsal reliability was established in fresh cadaveric specimens and associated with ultimate fracture force. The purpose of this study was to assess the reliability of DXA bone mineral density measurements of sub-regions of the second and fifth metatarsals in a young, active population. Methods Thirty two recreationally active individuals participated in the study, and the bone density of the second (2MT) and fifth (5MT) metatarsals of each subject was measured using a Hologic QDR x-ray bone densitometer. Scans were analyzed separately by two raters, and regional bone mineral density, bone mineral content, and area measurements were calculated for the proximal, shaft, and distal regions of the bone. Intra-rater, inter-rater, and scan-rescan reliability were then determined for each region. Results Proximal and shaft bone mineral density measurements of the second and fifth metatarsal were reliable. ICC's were variable across regions and metatarsals, with the distal region being the poorest. Conclusions Bone mineral density measurements of the metatarsals may be a better indicator of fracture risk of the metatarsals than whole body measurements. A reliable method for measuring the regional bone mineral densities of the metatarsals was found. However, inter-rater reliability and scan-rescan reliability for the distal regions were poor. Future research should examine the relationship between DXA bone mineral density measurements and fracture risk at the metatarsals.
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Affiliation(s)
| | - James M Smoliga
- Department of Physical Therapy, High Point University, High Point, NC USA
| | - Anh-Dung Nguyen
- Department of Athletic Training, High Point University, High Point, NC USA
| | - Micah C Branscomb
- Department of Physical Therapy, High Point University, High Point, NC USA
| | | | - Jeffrey B Taylor
- Department of Physical Therapy, High Point University, High Point, NC USA
| | - Kevin R Ford
- Department of Physical Therapy, High Point University, High Point, NC USA
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25
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Ramírez J, Nieto-González JC, Curbelo Rodríguez R, Castañeda S, Carmona L. Prevalence and risk factors for osteoporosis and fractures in axial spondyloarthritis: A systematic review and meta-analysis. Semin Arthritis Rheum 2017; 48:44-52. [PMID: 29290311 DOI: 10.1016/j.semarthrit.2017.12.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/24/2017] [Accepted: 12/05/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To describe the prevalence of osteoporosis, the prevalence and incidence of fractures, and the frequency of risk factors for low bone mineral density (BMD) in axial spondyloarthritis (Ax-SpA). METHODS A systematic review and meta-analysis of observational studies was conducted. Medline, Embase, and Cochrane Library databases were searched with a sensitive strategy. Large cross-sectional and longitudinal studies published in the last 10 years (January 2006-2016) with representative samples of patients with Ax-SpA estimating the frequency of osteoporosis, risk factors or fractures were selected. RESULTS After screening 3597 titles and abstracts, 46 studies were reviewed in detail, of which 35 studies had a cross-sectional design, 5 were prospective and 6 retrospective; 21 studies compared Ax-SpA patients with a control group-either healthy individuals (18 studies) or subjects with other diseases (6 studies). The prevalence of osteoporosis varied from 11.7% to 34.4% and that of fractures from 11% to 24.6%. Alcohol intake (58-61%), use of corticosteroids (11.7-66.9%), and 25-OH vitamin D deficiency (26-76%) were unexpectedly high in Ax-SpA patients. CONCLUSION The prevalence of osteoporosis and fractures in Ax-SpA varies between 11.7% and 34.4% and 11-24.6%, respectively. Alcohol intake, steroid use, and low levels of 25-OH-vitamin D should be taken into account in osteoporosis assessment in patients with Ax-SpA. Inconsistent results, lack of bone quality assessment, and high likelihood of bias of the published studies confirm the need for performing well-designed studies.
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Affiliation(s)
- Julio Ramírez
- Rheumatology Department, Arthritis Unit, Hospital Clinic and IDIBAPS, Barcelona, Spain.
| | | | | | - Santos Castañeda
- Rheumatology Department, Hospital Universitario La Princesa, IIS-Princesa, Madrid, Spain
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26
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Tan S, Yao L, Ward MM. Thoracic Syndesmophytes Commonly Occur in the Absence of Lumbar Syndesmophytes in Ankylosing Spondylitis: A Computed Tomography Study. J Rheumatol 2017; 44:1828-1832. [PMID: 28966206 PMCID: PMC11210185 DOI: 10.3899/jrheum.170340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine the extent of thoracic involvement with syndesmophytes in ankylosing spondylitis (AS) relative to lumbar involvement. METHODS We performed thoracolumbar spine computed tomography (CT) and lumbar radiography on 18 patients. We quantitated syndesmophytes in 11 intervertebral disc spaces and related these to the presence of syndesmophytes on lumbar radiographs. RESULTS Syndesmophytes were slightly more common in the thoracic than in the lumbar spine and bridging was significantly more common. Thoracic syndesmophytes were universally present in patients without visible lumbar syndesmophytes on either radiographs or CT. CONCLUSION Syndesmophytes predominate in the thoracic spine. Lumbar radiographs underestimate the degree of thoracic involvement.
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Affiliation(s)
- Sovira Tan
- From the Intramural Research Program, US National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH); Radiology and Imaging Sciences, Clinical Center, NIH, Bethesda, Maryland, USA.
- S. Tan, PhD, Intramural Research Program, NIAMS, NIH; L. Yao, MD, Radiology and Imaging Sciences, Clinical Center, NIH; M.M. Ward, MD, MPH, Intramural Research Program, NIAMS, NIH.
| | - Lawrence Yao
- From the Intramural Research Program, US National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH); Radiology and Imaging Sciences, Clinical Center, NIH, Bethesda, Maryland, USA
- S. Tan, PhD, Intramural Research Program, NIAMS, NIH; L. Yao, MD, Radiology and Imaging Sciences, Clinical Center, NIH; M.M. Ward, MD, MPH, Intramural Research Program, NIAMS, NIH
| | - Michael M Ward
- From the Intramural Research Program, US National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH); Radiology and Imaging Sciences, Clinical Center, NIH, Bethesda, Maryland, USA
- S. Tan, PhD, Intramural Research Program, NIAMS, NIH; L. Yao, MD, Radiology and Imaging Sciences, Clinical Center, NIH; M.M. Ward, MD, MPH, Intramural Research Program, NIAMS, NIH
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27
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Briot K, Geusens P, Em Bultink I, Lems WF, Roux C. Inflammatory diseases and bone fragility. Osteoporos Int 2017; 28:3301-3314. [PMID: 28916915 DOI: 10.1007/s00198-017-4189-7] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 08/01/2017] [Indexed: 12/19/2022]
Abstract
Systemic osteoporosis and increased fracture rates have been described in chronic inflammatory diseases such as rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus, inflammatory bowel diseases, and chronic obstructive pulmonary disease. Most of these patients receive glucocorticoids, which have their own deleterious effects on bone. However, the other main determinant of bone fragility is the inflammation itself, as shown by the interactions between the inflammatory mediators, the actors of the immune system, and the bone remodelling. The inflammatory disease activity is thus on top of the other well-known osteoporotic risk factors in these patients. Optimal control of inflammation is part of the prevention of osteoporosis, and potent anti-inflammatory drugs have positive effects on surrogate markers of bone fragility. More data are needed to assess the anti-fracture efficacy of a tight control of inflammation in patients with a chronic inflammatory disorder. This review aimed at presenting different clinical aspects of inflammatory diseases which illustrate the relationships between inflammation and bone fragility.
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Affiliation(s)
- K Briot
- Department of Rheumatology, Cochin Hospital, Assistance-Publique-Hôpitaux de Paris, Paris, France.
- Hôpital Cochin, Service de Rhumatologie, 27, Rue du Faubourg, St. Jacques, 75014, Paris, France.
- INSERM UMR 1153, Paris, France.
| | - P Geusens
- Department of Internal Medicine, Subdivision of Rheumatology, Maastricht University Medical Center, Maastricht, The Netherlands
- Hasselt University, Hasselt, Belgium
| | - I Em Bultink
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, The Netherlands
| | - W F Lems
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, The Netherlands
| | - C Roux
- Department of Rheumatology, Cochin Hospital, Assistance-Publique-Hôpitaux de Paris, Paris, France
- Hôpital Cochin, Service de Rhumatologie, 27, Rue du Faubourg, St. Jacques, 75014, Paris, France
- INSERM UMR 1153, Paris, France
- Paris Descartes University, Paris, France
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28
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Fitzgerald GE, O'Shea FD. The Fascinating Paradox of Osteoporosis in Axial Spondyloarthropathy. J Rheumatol 2017; 44:1767-1776. [PMID: 28966207 DOI: 10.3899/jrheum.170051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2017] [Indexed: 12/21/2022]
Abstract
Low bone mineral density (BMD) is a recognized feature of axial spondyloarthropathy (axSpA). However, the osteoproliferation inherent in axSpA can make traditional dual-energy x-ray absorptiometry assessment inaccurate, particularly in structurally advanced disease. As a result, much about osteoporosis in axSpA is unknown. There is a wide variation in prevalence figures for low BMD in the literature. There is also no consensus regarding risk factors for developing low BMD in axSpA. It is accepted that there is an excess of vertebral fractures in patients with axSpA, but the role of low BMD in contributing to this risk is virtually unknown. This article provides a comprehensive review of the current knowledge regarding low BMD in axSpA. It highlights our current BMD measurement techniques along with their potential pitfalls, and discusses the significance of BMD in vertebral fractures. It also identifies gaps in our knowledge and makes recommendations for future research.
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Affiliation(s)
- Gillian E Fitzgerald
- From the Department of Rheumatology, St. James's Hospital, Dublin, Ireland. .,G.E. Fitzgerald, MB, BCh, BAO, MRCPI, Rheumatology Specialist, Registrar, Department of Rheumatology, St. James's Hospital; F.D. O'Shea, MB, BCh, BAO, MRCPI, Consultant Rheumatologist and General Physician, Department of Rheumatology, St. James's Hospital.
| | - Finbar D O'Shea
- From the Department of Rheumatology, St. James's Hospital, Dublin, Ireland.,G.E. Fitzgerald, MB, BCh, BAO, MRCPI, Rheumatology Specialist, Registrar, Department of Rheumatology, St. James's Hospital; F.D. O'Shea, MB, BCh, BAO, MRCPI, Consultant Rheumatologist and General Physician, Department of Rheumatology, St. James's Hospital
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29
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Malochet-Guinamand S, Pereira B, Tatar Z, Tournadre A, Moltó A, Dougados M, Soubrier M. Prevalence and risk factors of low bone mineral density in spondyloarthritis and prevalence of vertebral fractures. BMC Musculoskelet Disord 2017; 18:357. [PMID: 28830392 PMCID: PMC5567922 DOI: 10.1186/s12891-017-1718-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 08/11/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Investigate the prevalence and risk factors of low bone mineral density (BMD) in patients with axial spondyloarthritis as well as investigating the prevalence of vertebral fractures. METHODS Patients underwent BMD measurements with dual-energy X-ray absorptiometry (DXA) in the anterior-posterior lumbar spine, lateral spine and hip. We screened for vertebral fractures using vertebral fracture assessment, and then checked for syndesmophytes on the VFA images. Sociodemographic and clinical variables were collected. RESULTS A total of 89 patients (41,6% female) took part in the study with a mean age of 44 ± 14 years and disease duration 10.2 ± 10.6 years. According to World Health Organization (WHO) criteria, 48,3% of patients displayed osteopenia and 6,7% osteoporosis. In the subgroup of women who underwent measurement at all sites including the lateral spine, the prevalence of osteopenia was 39.3% in the anterior-posterior spine, 32.1% in the lateral spine, and 64.3% with all sites together. VFA led to the diagnosis of at least one vertebral fracture in 6.2% of patients. On VFA, syndesmophytes were found in 24.3% of patients. The variables associated in multivariate analyses with low BMD in different measurement sites were low body mass index (BMI), a high physician's global assessment score, a high Bath Ankylosing Spondylitis Functional Index (BASFI) score and female gender. CONCLUSION Our study found a high prevalence (around 50%) of low BMD in SpA. Conversely, the prevalence of osteoporosis (6.7% according to WHO criteria) and vertebral fractures (6.2%) was lower than generally reported in the literature. While lateral spine BMD measurement did little to improve the detection of osteopenia in women, the sample size was not large enough to enable us to draw definite conclusions.
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Affiliation(s)
- Sandrine Malochet-Guinamand
- Rheumatology Department, Clermont-Ferrand University Hospital, 58 Rue Montalembert, FR 63003, Clermont-Ferrand, France.
| | - Bruno Pereira
- Biostatistics unit (Clinical Research Direction), University Hospital of Clermont-Ferrand (CHU), Clermont-Ferrand, France
| | - Zuzana Tatar
- Rheumatology Department, Clermont-Ferrand University Hospital, 58 Rue Montalembert, FR 63003, Clermont-Ferrand, France
| | - Anne Tournadre
- Rheumatology Department, Clermont-Ferrand University Hospital, 58 Rue Montalembert, FR 63003, Clermont-Ferrand, France
| | - Anna Moltó
- Rheumatology Department, Paris Descartes University, Cochin Hospital, AP-HP, Paris, France
| | - Maxime Dougados
- Rheumatology Department, Paris Descartes University, Cochin Hospital, AP-HP, Paris, France
| | - Martin Soubrier
- Rheumatology Department, Clermont-Ferrand University Hospital, 58 Rue Montalembert, FR 63003, Clermont-Ferrand, France
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30
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Pray C, Feroz NI, Nigil Haroon N. Bone Mineral Density and Fracture Risk in Ankylosing Spondylitis: A Meta-Analysis. Calcif Tissue Int 2017; 101:182-192. [PMID: 28421263 DOI: 10.1007/s00223-017-0274-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/28/2017] [Indexed: 12/14/2022]
Abstract
We conducted a meta-analysis of studies to examine the risk of vertebral and non-vertebral fractures in patients with ankylosing spondylitis (AS). Additionally, we evaluated the risk factors of vertebral fractures in AS. Two authors independently searched Embase and Medline for studies that had assessed the risk of fractures in patients with AS. Twenty-two studies were eligible for the meta-analysis. Patients with AS had high frequency of vertebral fractures [OR (95% CI): 1.96 (1.52-2.51)]. Major risk factors for vertebral fractures in patients with AS include low BMD at the femoral neck and total hip, male gender, longer disease duration, higher BASDAI, higher BASRI, and possibly inflammatory bowel disease. The risk of non-vertebral fractures [OR (95% CI) 1.10 (1.04-1.15)] was 10% higher in AS patients than in controls. The risk of hip fractures in AS patients was not statistically significant [OR (95% CI) 1.17 (0.71-1.92)] in our pooled analysis. We found that patients with AS are at high risk of vertebral fractures. Male sex, duration of AS, mSASSS, BASRI, and low BMD at the hip and distal forearm were associated with the risk of vertebral fractures. Current evidence on the risk of hip fractures in patients with AS is inconsistent. Data about the effect of NSAIDs and TNF inhibitors on fracture risk in AS are limited.
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Affiliation(s)
- Cara Pray
- University College Cork, Cork, Ireland
| | | | - Nisha Nigil Haroon
- Northern Ontario School of Medicine, Sudbury, ON, Canada.
- , Suite M277, 865 Regent St. South, Sudbury, ON, P3E 3Y9, Canada.
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31
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Lespessailles E, Cortet B, Legrand E, Guggenbuhl P, Roux C. Low-trauma fractures without osteoporosis. Osteoporos Int 2017; 28:1771-1778. [PMID: 28161747 DOI: 10.1007/s00198-017-3921-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 01/10/2017] [Indexed: 01/03/2023]
Abstract
In clinical practice, areal bone mineral density (aBMD) is usually measured using dual-energy X-ray absorptiometry (DXA) to assess bone status in patients with or without osteoporotic fracture. As BMD has a Gaussian distribution, it is difficult to define a cutoff for osteoporosis diagnosis. Based on epidemiological considerations, WHO defined a DXA-based osteoporosis diagnosis with a T-score <-2.5. However, the majority of individuals who have low-trauma fractures do not have osteoporosis with DXA (i.e., T-score <-2.5), and some of them have no decreased BMD at all. Some medical conditions (spondyloarthropathies, chronic kidney disease and mineral bone disorder, diabetes, obesity) or drugs (glucocorticoids, aromatase inhibitors) are more prone to cause fractures with subnormal BMD. In the situation of fragility fractures with subnormal or normal BMD, clinicians face a difficulty as almost all the pharmacologic treatments have proved their efficacy in patients with low BMD. However, some data are available in post hoc analyses in patients with T score >-2. Overall, in patients with a previous fragility fracture (especially vertebra or hip), treatments appear to be effective. Thus, the authors recommend treating some patients with a major fragility fracture even if areal BMD T score is above -2.5.
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Affiliation(s)
- E Lespessailles
- Laboratoire I3MTO, Université d'Orléans, 4708, 45067, Orléans, EA, France.
- Regional Hospital of Orleans, 14 avenue de l'hopital, 45067, Orleans, Cedex 2, France.
| | - B Cortet
- EA 4490 PMOI-Physiopathologie des Maladies Osseuses Inflammatoires, Université de Lille, 59000, Lille, France
- Service de Rhumatologie, CHU Lille, 59000, Lille, France
| | - E Legrand
- Service de Rhumatologie, CHU d'Angers, 49933, Angers, France
| | - P Guggenbuhl
- Service de Rhumatologie, CHU Rennes, 35203, Rennes, France
- , INSERM UMR 991, 35000, Rennes, France
- Faculté de Médecine, Université Rennes 1, 35043, Rennes, France
| | - C Roux
- INSERM U 1153, hôpital Cochin, Université Paris Descartes, Paris, France
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32
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Maas F, Spoorenberg A, van der Slik BPG, van der Veer E, Brouwer E, Bootsma H, Bos R, Wink FR, Arends S. Clinical Risk Factors for the Presence and Development of Vertebral Fractures in Patients With Ankylosing Spondylitis. Arthritis Care Res (Hoboken) 2017; 69:694-702. [DOI: 10.1002/acr.22980] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 05/10/2016] [Accepted: 06/28/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Fiona Maas
- University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Anneke Spoorenberg
- University of Groningen, University Medical Center Groningen, Groningen, and Medical Center Leeuwarden; Leeuwarden The Netherlands
| | | | - Eveline van der Veer
- University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Elisabeth Brouwer
- University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Hendrika Bootsma
- University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Reinhard Bos
- Medical Center Leeuwarden; Leeuwarden The Netherlands
| | - Freke R. Wink
- Medical Center Leeuwarden; Leeuwarden The Netherlands
| | - Suzanne Arends
- University of Groningen, University Medical Center Groningen, Groningen, and Medical Center Leeuwarden; Leeuwarden The Netherlands
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33
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Leone A, Marino M, Dell'Atti C, Zecchi V, Magarelli N, Colosimo C. Spinal fractures in patients with ankylosing spondylitis. Rheumatol Int 2016; 36:1335-46. [PMID: 27379763 DOI: 10.1007/s00296-016-3524-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 06/28/2016] [Indexed: 12/13/2022]
Abstract
The ankylosed spine is prone to fracture even after minor trauma due to its changed biomechanical properties. The two central features of ankylosing spondylitis (AS) that promote the pathological remodeling of the spine are inflammation and new bone formation. AS is also associated with osteoporosis that is attributed to an uncoupling of the bone formation and bone resorption processes. Therefore, bone resorption occurs and promotes weakening of the spine as well as increased risk of vertebral fractures which can be hugely different in terms of clinical relevance. Even in the presence of symptomatic clinical vertebral fractures, the diagnosis can be overruled by attributing the pain to disease activity. Furthermore, given the highly abnormal structure of the spine, vertebral fracture diagnosis can be difficult on the basis of radiography alone. CT can show the fractures in detail. Magnetic resonance imaging is considered the method of choice for the imaging of spinal cord injuries, and a reasonable option for exclusion of occult fractures undetected by CT. Since it is equally important for radiologists and clinicians to have a common knowledge base rather than a compartmentalized view, the aim of this review article was to provide the required clinical knowledge that radiologists need to know and the relevant radiological semiotics that clinicians require in diagnosing clinically significant injury to the ankylosed spine.
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Affiliation(s)
- Antonio Leone
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy.
| | - Marzia Marino
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Claudia Dell'Atti
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Viola Zecchi
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Nicola Magarelli
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Cesare Colosimo
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
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Quaden DHF, De Winter LM, Somers V. Detection of novel diagnostic antibodies in ankylosing spondylitis: An overview. Autoimmun Rev 2016; 15:820-32. [PMID: 27288842 DOI: 10.1016/j.autrev.2016.06.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 06/05/2016] [Indexed: 12/17/2022]
Abstract
Ankylosing spondylitis (AS) is a debilitating, chronic, rheumatic disease characterized by inflammation and new bone formation resulting in fusion of the spine and sacroiliac joints. Since early treatment is impeded by a delayed diagnosis, it is highly important to find new biomarkers that improve early diagnosis and may also contribute to a better assessment of disease activity, prognosis and therapy response in AS. Because of the absence of rheumatoid factor, AS was long assumed to have a seronegative character and antibodies are thus not considered a hallmark of the disease. However, emerging evidence suggests plasma cells and autoantibodies to be involved in the disease course. In this review, the role of B cells and antibodies in AS is discussed. Furthermore, an overview is provided of antibodies identified in AS up till now, and their diagnostic potential. Many of these antibody responses were based on small study populations and further validation is lacking. Moreover, most were identified by a hypothesis-driven approach and thus limited to antibodies against targets that are already known to be involved in AS pathogenesis. Hence, we propose an unbiased approach to identify novel diagnostic antibodies. The already successfully applied techniques cDNA phage display and serological antigen selection will be used to identify antibodies against both known and new antigen targets in AS plasma. These newly identified antibodies will enhance early diagnosis of AS and provide more insight into the underlying disease pathology, resulting in a more effective treatment strategy and eventually an improved disease outcome.
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Affiliation(s)
- Dana H F Quaden
- Biomedical Research Institute and Transnationale Universiteit Limburg, School of Life Sciences, Hasselt University, Hasselt, Belgium
| | - Liesbeth M De Winter
- Biomedical Research Institute and Transnationale Universiteit Limburg, School of Life Sciences, Hasselt University, Hasselt, Belgium
| | - Veerle Somers
- Biomedical Research Institute and Transnationale Universiteit Limburg, School of Life Sciences, Hasselt University, Hasselt, Belgium.
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