Neutrophile to lymphocyte and platelet to lymphocyte ratios predict clinical response to bDMARD in naïve spondylarthritis patients

Objective: We aim to study association between neutrophile to lymphocyte (NLR) and platelet to lymphocyte (PLR) ratios and disease activity, and their value to predict bDMARD response. Methods: A set of spondylarthritis (SpA) patients under bDMARD registered in the Reuma.pt registry was studied. Sociodemographic, clinical and laboratorial variables were assessed on bDMARD initiation, 6, 12, 18 and 24 months (M) thereafter. Univariable and multivariable generalized estimation equations models assessed associations with disease activity. The NLR and PLR predictive value was assessed using univariable and multivariable logistic regression models. Results: A total of 170 patients were included. Most were male (54.7%), with a predominantly axial phenotype (84.7%). Significant associations were observed between NLR [B=1.55, 95% confidence interval (CI) = (1.38; 1.74)] and PLR [(B=1.16, 95% CI = (1.09; 1.24)] with ASDAS-CRP (p < 0.001). Both baseline ratios predicted ∆ ASDAS-CRP ≥ 1.1 at 6 months [OR = 2.20, 95% CI = (1.21, 4.00) for NLR; OR = 1.02, 95% CI = (1.01, 1.04) for PLR, p < 0.01)]. PLR was a significant predictor of ∆ ASDAS-CRP ≥ 1.1 in all timepoints [OR (12 M) = 1.02, 95% CI = (1.00, 1.03), p < 0.05; OR (18M) = 1.02, 95% CI = (1.01, 1.03), p < 0.001; OR (24M) = 1.01, 95% CI = (1.01, 1.02), p < 0.01]. Conclusion: NLR and PLR were associated with disease activity during the follow up of these patients. They seem to be significant predictors of therapeutic response to bDMARD in naïve SpA patients.

Visual Scoring of Sacroiliac Joint/Sacrum Ratios of Single-Photon Emission Computed Tomography/Computed Tomography Images Affords High Sensitivity and Negative Predictive Value in Axial Spondyloarthritis

Spondyloarthritis (SpA) is characterized by inflammatory back pain. Magnetic resonance imaging (MRI) was the earlier gold standard technique for detecting early inflammatory change. We reassessed the diagnostic utility of sacroiliac joint/sacrum (SIS) ratios of single-photon emission computed tomography/computed tomography (SPECT/CT) for identifying sacroiliitis. We aimed to investigate of SPECT/CT in diagnosing SpA using a rheumatologist's visual scoring of SIS ratios assessment. We conducted a single-center, medical records review study of patients with lower back pain who underwent bone SPECT/CT from August 2016 to April 2020. We employed semiquantitative visual bone scoring methods of SIS ratio. The uptake of each sacroiliac joint was compared to that of the sacrum (0-2). A score of 2 for the sacroiliac joint of either side was considered diagnostic of sacroiliitis. Of the 443 patients assessed, 40 had axial SpA (axSpA), 24 being radiographic axSpA and 16 being nonradiographic axSpA. The sensitivity, specificity, and positive and negative predictive values of SIS ratio of SPECT/CT for axSpA were 87.5%, 56.5%, 16.6%, and 97.8%, respectively. In receiver operating curve analysis, MRI better diagnosed axSpA than did SIS ratio of SPECT/CT. Although the diagnostic utility of SIS ratio of SPECT/CT was inferior to MRI, visual scoring of SPECT/CT affords high sensitivity and negative predictive value in axSpA. When MRI is inappropriate for certain patients, SIS ratio of SPECT/CT is an alternative tool for identifying axSpA in real practice.

Qualitative concept elicitation and cognitive debriefing interviews of symptoms, impacts and selected customized PROMIS® Short Forms: a study in patients with axial spondyloarthritis

BACKGROUND

Sleep disturbance, pain, and fatigue are key symptoms/impacts of axial spondyloarthritis (axSpA). Three customized Patient-Reported Outcomes Measurement Information System (PROMIS^®) Short Forms (Sleep Disturbance, Pain Interference, and Fatigue) have been proposed for use in axSpA to assess these key disease concepts. This study was designed to further understand the patient experience of axSpA and evaluate the content validity of the three customized PROMIS^® Short Forms to support their use in axSpA clinical trials.

METHODS

Non-interventional, cross-sectional, qualitative (concept elicitation [CE] and cognitive debriefing [CD]) study. Participants took part in 90-min telephone interviews. The CE section used open-ended questions to elicit information about axSpA symptoms and impacts. The CD section involved a 'think-aloud' exercise where participants read out each instruction, item, and response option for the customized PROMIS^® Short Forms and shared their feedback. Participants also discussed the relevance of the items, response options and recall period. Verbatim interview transcripts were subject to thematic and content analysis.

RESULTS

In total, there were 28 participants (non-radiographic axSpA, n = 12; ankylosing spondylitis, n = 16), from the US (n = 20) and Germany (n = 8). Mean age was 52.8 years, and 57% were male; mean time since diagnosis was 9.5 years. The CE section identified 12 distinct symptoms that characterized axSpA: pain, sleep problems, fatigue/tiredness, stiffness, swelling, vision/eye issues, restricted body movements, headache/migraine, spasms, change in posture/stature, balance/coordination problems, and numbness. Pain, sleep problems, and fatigue/tiredness were experienced by ≥ 90% of participants, occurring simultaneously and exacerbating one another. Participants reported axSpA impacted their lives across six domains of health-related quality of life (HRQoL): physical functioning (100%), emotional wellbeing (89%), work/volunteering (79%), social functioning (75%), activities of daily living (61%) and cognitive functioning (54%). Impacts were most frequently associated with pain, stiffness, and fatigue. CD showed the PROMIS^® instruments were conceptually comprehensive and well understood, with all items relevant to ≥ 50% of participants.

CONCLUSIONS

Pain, sleep problems and fatigue are pivotal symptoms of axSpA and associated with HRQoL impacts. These results were used to update a conceptual model of axSpA which was originally developed based on a targeted literature review. Interpretability and content validity of the customized PROMIS^® Short Forms were confirmed, with each deemed to adequately assess key impacts associated with axSpA, making them suitable for use in axSpA clinical trials.

Physical activity is associated with physical and global function in patients with axial spondyloarthritis, independent of disease activity

OBJECTIVES

To investigate whether physical activity is independently associated with physical and global function in patients with axial spondyloarthritis (axSpA), and to analyse the relationship between subtypes of physical activity (work, transport, and recreation) and functional impairment.

METHODS

One-hundred-and-eighty-five patients were included. Physical function was assessed using BASFI, and global function was assessed using the ASAS health index (HI). Physical activity was measured using the Global Physical Activity Questionnaire. Levels of physical activity were categorised as low, moderate or high. The associations between levels of physical activity and the BASFI and ASAS HI scores were analysed using multivariate regression analysis.

RESULTS

Of the 185 patients, 46, 63 and 76 reported low, moderate and high levels of physical activity, respectively. There was a negative correlation between the BASFI and total physical activity. Multivariate linear regression analysis revealed that a high level of physical activity was independently associated with BASFI after adjusting for age, ASDAS. sacroiliitis and syndesmophyte number (ß (95% CI) =-0.88 (-1.49--0.26); p=0.006). One-hundred-and-forty-six had good global functioning (ASAS HI≤5). Multivariate logistic regression analysis revealed that moderate physical activity was independently associated with good global functioning (OR (95% CI) = 2.82 (1.02-7.86); p = 0.047). Recreational activity, but not work- and transport-related activity, showed a significant relationship with ASAS HI scores (ß (95% CI) =-0.55 (-1.02-0.08); p = 0.023).

CONCLUSIONS

Physical activity in those with axSpA is associated independently with physical and global functioning. Among the subtypes of physical activity, recreational activity is related to global functioning.

Primary Biliary Cholangitis with Ankylosing Spondylitis

Primary biliary cholangitis is a chronic inflammatory autoimmune liver disease that is characterized by a positive antimitochondrial antibodies test and progressive destruction of the small intrahepatic bile duct. Ankylosing spondylitis is a chronic, systemic, inflammatory disease of the spine and the sacroiliac joints. The association between these two is very low. This paper reports a rare case who had ankylosing spondylitis and developed primary biliary cholangitis.

Home-based rehabilitation in patients over 60 with stabilized ankylosing spondylitis during the COVID-19 pandemic

BACKGROUND

COVID-19 has become a significant healthcare issue, particularly challenging for patients with ankylosing spondylitis (AS), because immune-related diseases and their treatments could adversely affect the susceptibility to or severity of a viral infection.

OBJECTIVE

This study is conducted to present an exercise rehabilitation program that patients older than 60 years with AS can do at home during the COVID-19 pandemic.

METHODS

Three Delphi surveys were conducted to reach a consensus on home-based rehabilitation programs. This study recruited ten experts and performed three Delphi rounds for a month.

RESULTS

The expert panel suggested that home-based rehabilitation for the patients should be carried out with a clear rehabilitation goal. Their final recommendations are to institute a program aimed to ease symptoms, such as pain and stiffness; encourage patients to consult with experts regularly to ensure that they perform exercise rehabilitation properly at home; add fast walking and stretching to the rehabilitation program; and see if indoor cycling, Pilates, or yoga could be appropriate.

CONCLUSIONS

This study suggests that patients with AS over 60 should repeat low-intensity exercises, such as stretching, for an hour a day, four to six times a week during the COVID-19 pandemic.

WNT16 elevation induced cell senescence of osteoblasts in ankylosing spondylitis

BACKGROUND

WNT16 is critical for bone homeostasis, but the effect of WNT16 in ankylosing spondylitis (AS) is still unknown. Here, we investigated whether WNT16 influences bone formation and pathophysiological changes of AS in an in vitro model.

METHODS

The bone tissue from the facet joints was obtained from seven disease control and seven AS patients. Primary osteoprogenitor cells of the facet joints were isolated using an outgrowth method. Isolated osteoprogenitor cells from both control and AS tissues were analyzed by microarray, RT-qPCR, immunoblotting, and immunohistochemistry. The bone-forming activity of osteoprogenitor cells was assessed by various in vitro assays. β-galactosidase staining and senescence-associated secretory phenotype (SASP) using RT-qPCR were used to assess cell senescence.

RESULTS

In microarray analysis, WNT16 expression was significantly elevated in AS osteoprogenitor cells compared to the control. We also validated that WNT16 expression was elevated in AS-osteoprogenitor cells and human AS-bone tissues. WNT16 treatment inhibited bone formation in AS-osteoprogenitor cells but not in the control. Intriguingly, AS-osteoprogenitor cells were stained markedly with β-galactosidase for cell senescence in WNT16 treatment. Furthermore, in an H2O2 stress-induced premature senescence condition, WNT16 treatment increased cell senescence in AS-osteoprogenitor cells and WNT16 treatment under the H2O2 stress condition showed an increase in p21 protein and SASP mRNA expression. The WNT16-induced SASP expression in AS-osteoprogenitor cells was reduced in WNT16 knockdown cultures.

CONCLUSION

WNT16 is highly expressed in AS and WNT16 treatment facilitated cell senescence in AS-osteoprogenitor cells during osteoblast differentiation accompanied by suppression of bone formation. The identified role of WNT16 in AS could influence bone loss in AS patients.

The TNF-NF-kB-DKK1 Axis Promoted Bone Formation in the Enthesis of Ankylosing Spondylitis

Objective

This study aimed to determine the serum Dickkopf 1 (DKK1) levels in ankylosing spondylitis (AS) patients and decipher the mechanism of tumor necrosis factor (TNF)-mediated DKK1 regulation in human AS enthesis cells.

Methods

The sera were obtained from 103 patients with AS and 30 healthy controls (HCs) The enthesis of facet joints were obtained from 4 AS patients and 5 controls The serum levels of DKK1 were measured using ELISA and compared between AS and HCs The impact of TNF on DKK1 expression in human primary spinal enthesis cells was evaluated using various molecular biology techniques and bone formation indicators.

Results

AS patients showed higher serum DKK1 levels than HCs after adjusting for age (9174 [6153∼1,3100] pg/mL vs 8262 [6703∼9278] pg/mL, p=0043) TNF treatment promoted bone formation and DKK1 expression in both control enthesis cells and those of AS This enhanced bone formation by TNF was pronounced in AS-enthesis than those of controls Mechanically, TNF induced NF-kB activation upregulates the DKK1 transcript level While, NF-kB inhibitor led to downregulate DKK1 expression in the enthesis Besides, DKK1 overexpression promoted bone formation in enthesis.

Conclusion

TNF induced DKK1 expression in the enthesis through NF-kB activation TNF-induced DKK1 expression may play a bone formation in the radiologic progression of ankylosing spondylitis.

STAT3 phosphorylation inhibition for treating inflammation and new bone formation in ankylosing spondylitis

OBJECTIVE

AS is a rheumatic disease characterized by chronic inflammation and bony ankylosis. This study was to evaluate whether a signal transducer and activator of transcription 3 phosphorylation inhibitor (stat3-p Inh) could treat both chronic inflammation and bone formation in AS.

METHODS

Primary AS osteoprogenitor cells and spinal entheseal cells were examined for osteogenic differentiation. SF mononuclear cells (SFMCs) and lamina propria mononuclear cells (LPMCs) were obtained from AS patients. Inflammatory cytokine-producing cells were analysed using flow cytometry and ELISA. Female SKG mice were treated with stat3-p Inh, IL-17A blocker or vehicle. Inflammation and new bone formation were evaluated using immunohistochemistry, PET and micro-CT.

RESULTS

In the SKG mouse model, stat3-p Inh significantly suppressed arthritis, enthesitis, spondylitis and ileitis. In experiments culturing SFMCs and LPMCs, the frequencies of IFN-γ-, IL-17A- and TNF-α-producing cells were significantly decreased after stat3-p Inh treatment. When comparing current treatments for AS, stat3-p Inh showed a comparable suppression effect on osteogenesis to Janus kinase inhibitor or IL-17A blocker in AS-osteoprogenitor cells. Stat3-p Inh suppressed differentiation and mineralization of AS-osteoprogenitor cells and entheseal cells toward osteoblasts. Micro-CT analysis of hind paws revealed less new bone formation in stat3-p Inh-treated mice than vehicle-treated mice (P = 0.005). Hind paw and spinal new bone formation were similar between stat3-p Inh- and anti-IL-17A-treated SKG mice (P = 0.874 and P = 0.117, respectively).

CONCLUSION

Stat-3p inhibition is a promising treatment for both inflammation and new bone formation in AS.

Anterior Chest Wall Involvement in Spondyloarthritis Patients as Detected by Magnetic Resonance Imaging: A Case Series and Literature Review

Magnetic resonance imaging (MRI) plays an important role in diagnosing and classifying axial spondyloarthritis (SpA) and is also useful for appropriate evaluation of disease status owing to its ability to detect inflammation early and reveal structural changes. However, dedicated MRI for the anterior chest wall (ACW) is not routinely considered despite relatively frequent presence of ACW lesions. To date, no study has investigated the imaging findings and clinical features of ACW involvement in Korean SpA patients. Thus, we aimed to show ACW involvement in SpA patients using ACW lesions found by MRI. We describe 20 cases of ACW involvement in which MRI-detected manubriosternal joint lesions. The lesion types included subchondral bone marrow edema, marginal or central bone erosions, subchondral fat infiltration or deposition, and ankylosis, with erosions being the most prevalent finding. We also provide the literature review results describing MRI findings of ACW lesions in SpA patients.

Bath Ankylosing Spondylitis Disease Activity Index is Associated With the Quality of Sleep in Ankylosing Spondylitis Patients

Objective

High disease activity of ankylosing spondylitis (AS) is associated with poor sleep quality The purpose of this study was to identify which of the representative tools for evaluating the disease activity of AS best reflect the quality of sleep

Methods

A total of 107 AS patients were enrolled in the study and the sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) Age, sex, concomitant medication, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) level, Beck Depression Inventory second edition (BDI-II), Bath ankylosing spondylitis disease activity index (BASDAI), ankylosing spondylitis disease activity score (ASDAS)-ESR, ASDAS-CRP, pain visual analog scale, Insomnia Severity Index (ISI), and Epworth Sleepiness Scale (ESS) were analyzed as covariates

Results

Overall, 65% (70/107) of subjects reported poor sleep quality (PSQI>5) There was a positive correlation between the sleep quality and disease activity as measured by the BASDAI, ASDAS-ESR, and ASDAS-CRP In addition, the BASDAI demonstrated good correlations with ISI, ESS, and BDI-II, respectively However, only BASDAI showed reliable correlation with PSQI among the disease activity parameters of AS (adjusted odd ratio 5.36, p=0.023)

Conclusion

BASDAI is the most reliable parameter of disease activity associated with the sleep quality in patients with AS

Clonorchis sinensis-Derived Protein Attenuates Inflammation and New Bone Formation in Ankylosing Spondylitis

Helminth infections and their components have been shown to have the potential to modulate and attenuate immune responses. The objective of this study was to evaluate the potential protective effects of Clonorchis sinensis-derived protein (CSp) on ankylosing spondylitis (AS). Cytotoxicity of CSp at different doses was assessed by MTS and flow cytometry before performing experiments. Peripheral blood mononuclear cells (PBMCs) and synovial fluid mononuclear cells (SFMCs) were obtained from AS patients. Inflammatory cytokine-producing cells were analyzed using flow cytometry. The levels of INF- γ , IL-17A, TNF-α, and IL-6 were measured by enzyme-linked immunosorbent assay (ELISA). SKG mice were treated with CSp or vehicles. Inflammation and new bone formation were evaluated using immunohistochemistry, positron emission tomography (PET), and micro-computed tomography (CT). Treatment with CSp resulted in no reduced cell viability of PBMCs or SFMCs until 24 h. In experiments culturing PBMCs and SFMCs, the frequencies of IFN- γ and IL-17A producing cells were significantly reduced after CSp treatment. In the SKG mouse model, CSp treatment significantly suppressed arthritis, enthesitis, and enteritis. Micro-CT analysis of hind paw revealed reduced new bone formation in CSp-treated mice than in vehicle-treated mice. We provide the first evidence demonstrating that CSp can ameliorate clinical signs and cytokine derangements in AS. In addition, such CSp treatment could reduce the new bone formation of AS.

Clinical performance of ASAS Health Index in patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis: real-world evidence from Multicenter Nationwide Registry

The Assessment of SpondyloArthritis international Society Health Index (ASAS HI) is used as a new instrument in measuring the function, disability and health of patients with spondyloarthritis (SpA). However, the real-world evidence of ASAS HI is very limited. In the present study, our objective is to evaluate the psychometric properties and performance of ASAS HI in the real-world setting as well as comparing ASAS HI with the current instruments to assess the construct validity and determine the cut-off points in patients with both ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA). A total of 991 patients with axSpA who fulfilled either the ASAS classification criteria for axial SpA (axSpA) or the Modified New York Criteria (mNY) for AS were recruited from the Biologic and targeted Synthetic antirheumatic drugs Registry (BioStaR) SpA. The construct validity of ASAS HI against the Bath Ankylosing Spondylitis Disease Activities Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score-C-Reactive Protein (ASDAS-CRP) the Bath Ankylosing Spondylitis Functional index (BASFI) was performed. Using the receiver operating characteristic (ROC) curves analysis, the cut-off points were calculated. Of all the recruited patients, 851 (85.9%) were AS and 140 (14.1%) were nr-axSpA. The difference in the mean ASAS HI scores of the patients with AS and the ones with nr-axSpA were not statistically significant (6.12 ± 4.29 and 6.42 ± 4.86, respectively). The mean ASAS HI score was significantly higher in females and small city residents. The ASAS HI had a strong construct validity against ASDAS-CRP, BASDAI and BASFI. A cut-off point of ≤ 4 was determined to discriminate good and moderate, as well as ≥ 12 to discriminate moderate and poor health status. In conclusion, ASAS HI is a reliable instrument to evaluate health and functioning for both patients with AS and nr-axSpA in clinical practice.