Classification criteria for spondyloarthropathies

The effectiveness of exercise and physical activity programs on fatigue and sleep in people with arthritis - A systematic review with meta-analysis

This systematic review aimed to systematically investigate the literature on the effectiveness of exercise and physical activity programs on fatigue and sleep in people with arthritis. For that, seven databases were searched for relevant randomized controlled trials. After the searches, 36 studies investigating 2281 participants were included. Risk of bias assessments were done by two independent reviewers using the Cochrane Risk of Bias tool 2. Random-effects meta-analyses were performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to judge the certainty of evidence. The evidence on benefits of exercise and physical activity programs on fatigue and sleep parameters in people with osteoarthritis and psoriatic arthritis was either lacking or inconclusive. There was very low to low certainty evidence for a slight benefit of exercise and physical activity programs on fatigue at short-term in people with ankylosing spondylitis and rheumatoid arthritis. However, the evidence was very uncertain for the medium- and long-term as well as for any sleep parameters. The results indicate that exercise and physical activity programs may offer some benefits on fatigue for people with arthritis in the short-term, although the best type of exercise remains uncertain. The available evidence on improvements in sleep was insufficient to draw strong conclusions.

Performance of Fully Automated Algorithm Detecting Bone Marrow Edema in Sacroiliac Joints

This study evaluates the performance of a fully automated algorithm to detect active inflammation in the form of bone marrow edema (BME) in iliac and sacral bones, depending on the quality of the coronal oblique plane in patients with axial spondyloarthritis (axSpA). The results were assessed based on the technical correctness of MRI examination of the sacroiliac joints (SIJs). A total of 173 patients with suspected axSpA were included in the study. In order to verify the correctness of the MRI, a deviation angle was measured on the slice acquired in the sagittal plane in the T2-weighted sequence. This angle was located between the line drawn between the posterior edges of S1 and S2 vertebrae and the line that marks the actual plane in which the slices were acquired in T1 and STIR sequences. All examinations were divided into quartiles according to the deviation angle measured in degrees as follows: 1st group [0; 2.2], 2nd group (2.2; 5.7], 3rd group (5.7; 10] and 4th group (10; 29.2]. Segmentations of the sacral and iliac bones were acquired manually and automatically using the fully automated algorithm on the T1 sequence. The Dice coefficient for automated bone segmentations with respect to reference manual segmentations was 0.9820 (95% CI [0.9804, 0.9835]). Examinations of BME lesions were assessed using the SPARCC scale (in 68 cases SPARCC > 0). Manual and automatic segmentations of the lesions were performed on STIR sequences and compared. The sensitivity of detection of BME ranged from 0.58 (group 1) to 0.83 (group 2) versus 0.76 (total), while the specificity was equal to 0.97 in each group. The study indicates that the performance of the algorithm is satisfactory regardless of the deviation angle.

MRI Findings in Axial Psoriatic Spondylarthritis

Psoriatic arthritis is a significant medical condition with a high prevalence, a wide variety of non-specific symptoms, and a high degree of overlap with other spondylarthritis disorders, particularly ankylosing spondylitis. Hence, knowledge of the magnetic resonance imaging (MRI) manifestations and a multidisciplinary strategy are required for the better management of these patients. We searched publications from the last 10 years and focused on the most relevant ones which discussed the classification criteria, the MRI characteristics of axial psoriatic arthritis, the importance of MRI for follow up, and the reliability of skin and synovial biopsy. Axial spondylarthritis can be diagnosed and followed up on using the well-established MRI technique and, additionally, a biopsy. The analysis and concordance between them can provide new directions for future studies.

Mucosal-associated invariant T cells in patients with axial spondyloarthritis

Background

Several studies implicate Th17-cells and its cytokine (IL-17) in disease pathogenesis of spondyloarthritis (SpA), with available evidence supporting a pathogenic role of CD8+ T-cells. However, data on the involvement of CD8+ mucosal-associated invariant T-cells (MAIT) and their phenotypic characterization and inflammatory function including IL-17 and Granzyme A production in a homogenous population of SpA-patients with primarily axial disease (axSpA) are lacking.

Objectives

Quantify and characterize the phenotype and function of circulating CD8+MAIT-cells in axSpA-patients with primarily axial disease.

Methods

Blood samples were obtained from 41 axSpA-patients and 30 age- and sex-matched healthy controls (HC). Numbers and percentages of MAIT-cells (defined as CD3+CD8+CD161highTCRVα7.2+) were determined, and production of IL-17 and Granzyme A (GrzA) by MAIT-cells were examined by flow cytometry upon in vitro stimulation. Serum IgG specific for CMV was measured by ELISA.

Results

No significant differences in numbers and percentages of circulating MAIT-cells were found between axSpA-patients and HCr zijn meer resultaten de centrale memory CD8 T cellen. cellen van patirculating MAIT cells.. Further phenotypic analysis revealed a significant decrease in numbers of central memory MAIT-cells of axSpA-patients compared to HC. The decrease in central memory MAIT-cells in axSpA patients was not attributed to an alteration in CD8 T-cell numbers, but correlated inversely with serum CMV-IgG titers. Production of IL-17 by MAIT-cells was comparable between axSpA-patients and HC, whereas a significant decrease in the production of GrzA by MAIT-cells from axSpA-patients was observed.

Conclusions

The decrease in cytotoxic capability of circulating MAIT-cells in axSpA-patients might implicate that these cell types migrate to the inflamed tissue and therefore associate with the axial disease pathogenesis.

Utility of selected sequence MRI imaging of the axial skeleton in the diagnosis of axial spondyloarthritis

BACKGROUND

Whole body MRI has been used to evaluate inflammatory lesions associated with axial spondyloarthritis (SpA). These sequences are extensive, time consuming and add to the cost of the investigation. We aimed to determine the utility of selected sequence MRI imaging of the axial skeleton including spine, pelvis and sacroiliac (SI) joints to identify features of (SpA).

METHODS

A retrospective study was conducted on 76 patients diagnosed with SpA that underwent a selective sequence MRI imaging of the axial skeleton. The MRI were reported by two musculoskeletal trained radiologists were reviewed. The MRI sequences included whole spine sequences of sagittal STIR (short tau inversion recovery), T1 weighted and T2 weighted sequences. Coronal STIR and T1 weighted images were studied for SI joints and pelvis. The MRI were assessed based on the guidelines outlined by the Assessment of SpondyloArthritis International Society (ASAS) for features of spondylitis, spondylodiscitis, enthesitis, synovitis, capsulitis, bone marrow edema, fatty marrow replacement, erosions and bony ankylosis. Inflammatory lesions were documented in the spine, sacroiliac, facet, hip and costovertebral joints.

RESULTS

The mean scan duration was 28 min. SI joint involvement was noted in 74 (97.3%) of patients. The other most prevalent findings were spondylitis in 44 (57.8%) patients, costovertebral joint involvement in 31 (40.7%), facet joint lesions in 32 (42.1%), spondylodiscitis in 21 (27.6%), enthesitis in 13 (17.1%), hip lesions in 16 (21%) and ankylosis in 10 (13.1%).

CONCLUSIONS

This selective sequence imaging of the pelvis and spine was able to identify typical lesions of SpA in a shorter time period. Fifty-five percent patients had lesions in the posterior elements including facet joints and costovertbral joints that would be missed on traditional SI joint imaging.

The value of magnetic resonance imaging and computed tomography in the study of spinal disorders

Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders.

Consensus statements for evaluation and nonpharmacological Management of Psoriatic Arthritis in UAE

OBJECTIVE

Psoriatic arthritis (PsA), a chronic inflammatory arthropathy, is often underdiagnosed in Middle Eastern countries, substantially impacting the treatment of affected individuals. This article aims to highlight current unmet clinical needs and provide consensus recommendations for region-specific evaluation methods and nonpharmacological therapies in the United Arab Emirates (UAE).

METHOD

An extensive literature review was conducted, focusing especially on global and regional guidelines for the evaluation and treatment of PsA. These form the basis of the consensus statements formulated. Additionally, an expert panel of key opinion leaders from the UAE reviewed these guidelines and available literature at an advisory board meeting to identify unmet needs, bridge clinical gaps in the UAE, and develop consensus statements for the evaluation and treatment of PsA.

RESULT

The consensus statements were developed based on overarching principles for the management of PsA, evaluation of patients with PsA, and nonpharmacological approaches for the management of PsA. The overarching principles included adopting a targeted, multidisciplinary approach, along with collaboration between rheumatologists and dermatologists in cases of clinically significant skin involvement. The panel also highlighted the value of composite disease severity measures for characterizing clinical manifestations of PsA. In terms of nonpharmacological management approaches, lifestyle modification (comprising dietary change, exercise, and cessation of smoking) and psychotherapy were recommended.

CONCLUSION

The consensus statements will aid healthcare professionals in clinical decision-making in the context of PsA.

Association of Genetic Marker HLA-B27 with Spondyloarthritis In A Tertiary Care Centre In South India

Human leukocyte antigens (HLA) are gene products found in the major histocompatibility complex, aiding in differentiation of “self” from “non-self” antigens, and is crucial for the communication between immune cells of the human body. HLA-B27, in specific, has a strong interrelation with different types of Spondyloarthritis (SpA). The aim of this study is to study the frequency of HLA-B27 in suspected Spondyloarthritis patients presenting with axial and peripheral joint involvement, who attended our tertiary care centre from August-2017 to January-2021. Patients fulfilling Assessment of Spondyloarthritis International Society (ASAS) criteria for Spondyloarthritis were included in the study, and were further classified into Spondyloarthritis sub-groups. Blood samples were collected for CRP and ESR tests along with HLA-B27 detection by RT-PCR method. Magnetic resonance imaging was done for sacroiliac joints in patients with lower back pain. Analysis of 289 samples of SpA patients revealed 156 (54%) to be HLA-B27 positive and 133 (46%) to be HLA-B27 negative. There were 98 patients (63%) with Ankylosing spondylitis, 33 (21%) had Reactive arthritis, 19 (12%) had Psoriatic arthritis, 6 (4%) had Undifferentiated Spondyloarthritis, and inflammatory bowel disease was diagnosed in 0% in HLA-B27 positive Spondyloarthritis patients. The frequency of HLA-B27 among the Spondyloarthritis (SpA) patients in our study was found to be 54% (156), more common clinical manifestation in men belonging to the age group of 16-25 years positive patients. Ankylosing spondylitis (AS) was found to be the most common sub-groups observed among the SpA patients.

Multiparametric Large Field of View Rheumatology Imaging for Axial Spondyloarthropathy Detects Enthesitis in Setting of Inactive Sacroiliac Joint Disease and Impacts Clinical Diagnosis

AIM

To test the diagnostic efficacy of a multiparametric rheumatology lumbosacral magnetic resonance (MR) imaging protocol in detection and characterization of axial spondylarthritis (SpA) and compare it with serology and clinical findings.

METHODS

A consecutive series of multiparametric rheumatology lumbosacral MR imaging examinations performed on 3T MR scanner. Three-dimensional inversion recovery turbo spin echo, precontrast and postcontrast fat-suppressed T1-weighted images, as well as diffusion-weighted images were used to detect active erosions and enthesitis using established criteria. Pearson χ2 was used for categorical variables. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were measured for magnetic resonance imaging (MRI) and serology, based on the final diagnosis from rheumatologists. An alpha error below 0.05 was considered statistically significant.

RESULTS

The final study sample included 130 consecutive patients (80 women and 50 men; mean ± SD 44 ± 13 and 45 ± 14 years, respectively). Seventy-eight subjects were diagnosed with axial SpA and 52 with non-SpA arthropathy. In the non-SpA group, 27 patients were diagnosed with osteoarthritis, 6 had unremarkable imaging, whereas 19 were considered as clinically undetermined. There was positive correlation between positive MRI results and SpA diagnosis (P < 0.00001). No correlation existed between positive serology alone and SpA diagnosis (P = 0.0634). Although MRI and serology proved equally sensitive in detecting SpA, the specificity and overall accuracy of MRI were significantly higher. Inflammatory activity was detected in 45 (57.7%) cases, in the pelvic enthesis in 29 (37.2%) cases, in the lumbosacral spine in 16 (20.5%) cases, in the hip joints in 15 (19.2%) cases, and in the pubic symphysis in 5 (6.4%). Inactive sacral disease was seen in 7 of 35 enthesitis patients (20.0%), and in 2 SpA cases, there were no sacral lesions.

CONCLUSIONS

The results suggest that in patients with suspected SpA, MRI should not be limited to the sacroiliac joints, but also include enthesitis sites and other joints of the axial skeleton. The multiparametric rheumatology protocol increases the efficacy of MRI in detecting enthesitis and joint inflammatory disease, thereby offering additional information to the clinician and assisting in the early diagnosis/detecting disease activity.

Autoimmune conditions in the World Trade Center general responder cohort: A nested case-control and standardized incidence ratio analysis

BACKGROUND

The World Trade Center (WTC) general responder cohort (GRC) was exposed to environmental toxins possibly associated with increased risk of developing autoimmune conditions.

OBJECTIVES

Two study designs were used to assess incidence and risks of autoimmune conditions in the GRC.

METHODS

Three clinically trained professionals established the status of possible GRC cases of autoimmune disorders adhering to diagnostic criteria, supplemented, as needed, by specialists' review of consenting responders' medical records. Nested case-control analyses using conditional logistic regression estimated the risk associated with high WTC exposure (being in the 9/11/2001 dust cloud or ≥median days' response worked) compared with low WTC exposure (all other GRC members'). Four controls were matched to each case on age at case diagnosis (±2 years), sex, race/ethnicity, and year of program enrollment. Sex-specific and sensitivity analyses were performed. GRC age- and sex-adjusted standardized incidence ratios (SIRs) were compared with the Rochester Epidemiology Project (REP). Complete REP inpatient and outpatient medical records were reviewed by specialists. Conditions meeting standardized criteria on ≥2 visits were classified as REP confirmed cases.

RESULTS

Six hundred and twenty-eight responders were diagnosed with autoimmune conditions between 2002 and 2017. In the nested case-control analyses, high WTC exposure was not associated with autoimmune domains and conditions (rheumatologic domain odds ratio [OR] = 1.03, 95% confidence interval [CI] = 0.77, 1.37; rheumatoid arthritis OR = 1.12, 95% CI = 0.70, 1.77). GRC members had lower SIR than REP. Women's risks were generally greater than men's.

CONCLUSIONS

The study found no statistically significant increased risk of autoimmune conditions with WTC exposures.

Integrative approach combining Ayurveda, counselling, Yoga and meditation with conventional management of Ankylosing Spondylitis - A case report

Lifelong medications are required for symptomatic relief in Ankylosing Spondylitis (AS). We report the potential of an integrative approach in reducing dependence on steroids and pain medications in chronic AS. A 59-year-old HLA-B27 positive male patient suffering from AS for 40 years sought Ayurvedic treatment for relapse of pain, stiffness, fatigue, intermittent constipation and disturbed sleep. Ayurvedic diagnosis was Amavata (a clinical condition characterised by joint inflammation) The patient was managed as outpatient for eleven days and hospitalised for thirty three days. Internal medicines and external therapies with diet modification, lifestyle adjustments, counselling, Yoga and IAM Technique (Integrated Amrita Meditation Technique ) were administered during the hospital stay. At yearly follow up, C-Reactive Protein was reduced to 15.7 mg/L from the baseline value of 37.5 mg/L, and ESR from 103 mm/h to 8 mm/h indicating reduction in inflammation. The dose of NSAID and DMARD (Disease Modifying Antirheumatic Drug) could be reduced from once in twenty-four hours to once in eighty-four hours and steroids from twice daily to once in a week. There was significant reduction in pain and stiffness. Integration of Ayurveda and Yoga with conventional treatment can reduce drug dependence and improve quality of life in AS.

A meta-analysis for association of TNF-α -308G>A polymorphism with susceptibility to Ankylosing Spondylitis

Objective

We performed a meta-analysis of all eligible studies on the association of TNF-α -308G>A polymorphism with risk of Ankylosing spondylitis (AS).

Methods

A comprehensive literature research was performed in online databases.

Results

A total of 28 studies with 4489 cases and 5919 controls were included. Pooled ORs showed a significant association between TNF-α -308G>A polymorphism and risk of AS. Moreover, stratified analysis by ethnicity showed a significant association between TNF-α -308G>A polymorphism and AS risk in Asians, Caucasians and Mixed populations, but not in Chinese population.

Conclusion

This meta-analysis suggested that the TNF-α -308G>A polymorphism was associated with AS risk.

Disease Differentiation and Monitoring of Anti-TNF Treatment in Rheumatoid Arthritis and Spondyloarthropathies

Rheumatoid arthritis (RA), ankylosing spondylitis (AS), and psoriatic arthritis (PsA) are comprehensive immunological disorders. The treatment of these disorders is limited to ameliorating the symptoms and improving the quality of life of patients. In this study, serum samples from RA, AS, and PsA patients were analyzed with metabolomic tools employing the 1H NMR method in combination with univariate and multivariate analyses. The results obtained in this study showed that the changes in metabolites were the highest for AS > RA > PsA. The study demonstrated that the time until remission or until low disease activity is achieved is shortest (approximately three months) for AS, longer for RA and longest for PsA. The statistically common metabolite that was found to be negatively correlated with the healing processes of these disorders is ethanol, which may indicate the involvement of the gut microflora and/or the breakdown of malondialdehyde as a cell membrane lipid peroxide product.

The Role of Clinical and Ultrasound Enthesitis Scores in Ankylosing Spondylitis

Introduction: Ankylosing spondylitis (AS) is a chronic inflammatory disease, part of the spondyloarthritis (SpA) group, characterized by axial (spine and sacroiliac joints), entheseal, and peripheral joint involvement, which is frequently associated with extra-articular manifestations. Material and Methods: The study included a number of 30 patients diagnosed with AS according to the New York modified criteria, with history of entheseal pain, hospitalized between 2016–2018 in the Department of Rheumatology of the Emergency County Hospital of Craiova. Results: Regarding the Belgrade Ultrasound Enthesitis Score (BUSES) score and the disease activity calculated using the Ankylosing Spondylitis Disease Activity Score (ASDAS), they did not show a statistically significant association (p = 0.738). Additionally, BUSES did not have a statistically significant association with the disease activity quantified by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score (p = 0.094). The Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC) clinical score was not statistically associated with ASDAS (p = 0.434) nor with BASDAI (p = 0.130). The SPARCC clinical score and the BUSES ultrasound score were statistically significantly associated, registering a value of p = 0.018. Conclusions: Our study proved a significant correlation between SPARCC and BUSES, although in literature the evidence is contrasting.

Inflammatory Bowel Diseases and Coexisting Spondyloarthritis: A Neglected and too Often Under-Reported Association by Radiologists. A Multicenter Study by Italian Research Group of Imaging in Rheumatology

Purpose: The purpose of this study was to evaluate the prevalence and the underreporting rate of sacroiliitis (SI) in a large cohort of patients with biopsy-proved Crohn’s disease (CD) who underwent magnetic resonance enterography (MRE) or computed tomography enterography (CTE). Materials and Methods: Patients with CD were recruited from eight Italian health centers in the period from January 2013 to December 2017. Disease activity was recorded according to the CD activity index (CDAI). The scans were read by two blinded readers who defined the presence of SI according to Assessment of SpondyloArthritis International Society (ASAS) classifications and European League Against Rheumatism (EULAR) recommendations. Moreover, SI was scored using a simplified Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system. Results: Interobserver agreement in diagnosing SI on imaging was good (K = 0.72–0.83). SI was diagnosed in 129 (14.4%, 54 men, 75 women) out of 894 patients; however, sacroiliac joint (SIJ) abnormalities were not mentioned in the radiological reports of 112 patients (86%). Fifty (38.7%) out of 129 patients also underwent a subsequent SIJ evaluation through a dedicated MRI protocol to confirm SI. SI was found in a higher percentage of patients with “active” than “inactive” CD (18% vs. 4%). Conclusion: This study confirms the feasibility of CTE and MRE for the screening of SI in CD patients; however, it also underlines the remarkable problem concerning the underreporting of this entity in radiological practice.

Unmet needs in ankylosing spondylitis patients receiving tumour necrosis factor inhibitor therapy; results from a large multinational real-world study

Background

Symptoms and comorbidities of ankylosing spondylitis (AS) considerably reduce health-related quality of life (HRQoL) and ability to work. This real-world study assessed rates of tumour necrosis factor inhibitor (TNFi) use and switching, treatment failure, and associations between failing TNFi and HRQoL, work productivity and activity impairment (WPAI).

Methods

AS patients and their treating physicians completed questionnaires capturing patient demographics, clinical status, TNFi treatment history, reasons for switching TNFi, HRQoL and WPAI. Current TNFi was determined as “failing” if, after ≥3 months, physician-rated disease severity had worsened, remained severe, was “unstable/deteriorating”, physicians were dissatisfied with disease control and/or did not consider treatment a “success”.

Results

The analysis included 2866 AS patients from 18 countries. Of 2795 patients with complete treatment data, 916 (32.8%) patients had never received TNFi therapy, 1623 (58.1%) patients were receiving their 1st TNFi and 200 (7.2%) patients had ever received ≥2 TNFi (treatment switch). Primary or secondary lack of efficacy were the commonest reasons for switching, and the mean delay in switching after primary lack of efficacy was 11.1 months. 232 (15.4%) patients on TNFi were currently “failing” who, compared to those with treatment success, reported poorer HRQoL: 5-dimension EuroQoL (EQ-5D-3 L): 0.63 vs. 0.78; Medical Outcomes Study Short-Form Health Survey version 2 (SF-36v2) mental component summary (MCS): 41.8 vs. 46.3; physical component summary (PCS): 40.2 vs. 45.1; impaired work productivity: 46.4% vs. 25.0%; and activity: 44.5% vs. 29.6%; all P < 0.001.

Conclusions

Among AS patients, switching TNFi is uncommon and delayed by nearly 1 year despite primary lack of efficacy. Patients currently failing TNFi experience worse physical function, HRQoL and work productivity.

Simultaneous Adalimumab and Antitubercular Treatment for Latent Tubercular Infection: An Experience from Nepal

Introduction

In Nepal, adalimumab is the most common agent being used, but in a disease activity-based dose tapering to address the economic constraints. Another constraint is the high risk of reactivation of tuberculosis in countries with high burden, especially with the use of tumor necrosis factor blocking agents. Though there are recommendations for screening and treatment of latent tuberculosis infection (LTBI) before using adalimumab, data is not clear regarding the appropriate screening schedule and the timing of initiation of biologic therapy.

Methodology

This retrospective review of prospectively followed cohort of spondyloarthropathy patients aimed to evaluate the efficacy of simultaneous initiation of adalimumab with LTBI treatment. Patients fulfilling either the modified New York criteria for ankylosing spondylitis or Assessment in SpondyloArthritis international Society criteria and who were refractory to oral treatment were screened with Mantoux (≥10mm) and interferon gamma release assay (QuantiFERON) to detected LTBI. Those who tested positive were started on rifampicin/isoniazid combination for 3 months and adalimumab treatment on the same day. The patients were followed up at 2 weeks, 4 weeks, 12 weeks, and then every 3 months for 2 years.

Results

Out of 784 patients diagnosed, 92 were receiving adalimumab. LTBI was detected by positivity of either Mantoux or QuantiFERON in 29.3% patients. None of the patients with LTBI who were started on the 2 drug regime simultaneous with adalimumab developed activation of tuberculosis. However, two patients testing negative for both the tests developed tubercular pleural effusion during treatment.

Conclusions

Our findings indicate that screening for LTBI should be more frequent in patients from high tuberculosis burden countries; treatment of LTBI with rifampicin/isoniazid combination for 3 months is effective in preventing reactivation even when adalimumab is started simultaneously.

Magnetic resonance imaging of the sacroiliac joints in SpA: with or without intravenous contrast media? A preliminary report

OBJECT

Active sacroiliitis based on magnetic resonance imaging (MRI) without intravenous (I.V.) contrast material injection is considered sufficient for the diagnosis of spondyloarthritis (SpA), according to the Assessment of SpondyloArthritis International Society (ASAS) criteria. This work shows the added value of administering I.V. contrast material when evaluating the response to tumor necrosis factor (TNF) antagonists therapy, on the extension of bone marrow oedema (BMO) and pathological enhancement (osteitis/synovitis) in the sacroiliac joints (SIJs) on MRI.

MATERIALS AND METHODS

Forty-three patients (25 females and 18 males, mean age of 54 ± 16.60 years, range 22-75 years) with a clinical diagnosis of SpA and active sacroiliitis at MRI with I.V. contrast material, were considered for a follow-up MRI after 6 months of TNF antagonists therapy. Disease activity was monitored by a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) questionnaire. Descriptive statistics, Student's t test and Cohen's kappa were used. P < 0.05 was considered statistically significant.

RESULTS

Thirty-eight patients were finally included in the study; 36 of them showed an improvement on clinical assessment after therapy. Score's difference (improvement) after treatment was calculated in the MRI sequences both with and without contrast agent (respectively, mean value and range 3.18, 0-12 with contrast and 1.63, 0-7 without contrast). This improvement was statistically significant in each group (P value of 7.097e-08 with contrast and 6.741e-06 without contrast), and there was a significant difference between the two group too (P-value of 8.598e-07). Cohen's kappa for dichotomous variables showed a better agreement between the post-contrast MRI findings and BASDAI (K = 0.53, agreement = 92.11%, P = 0.0001) than MRI without contrast and BASDAI (K = 0.11, agreement = 57.89%, P = 0.06).

CONCLUSIONS

The evaluation of enhancement is a reliable tool for the assessment of the response to therapy in SIJs involvement in SpA, better than BMO; hence, it should be advised in the MRI of these patients.

Telerheumatology: The VA Experience

OBJECTIVES

We sought to characterize the correlation between diagnoses made during telerheumatology and face-to-face visits and to document patients' satisfaction with telerheumatology visits.

METHODS

This quality assurance study of the use of telerheumatology evaluated new patients referred to a Veterans Affairs rheumatology clinic. Patients were seen at a community clinic by a nurse practitioner with a rheumatologist participating in the encounter via telelink. All of the patients had a second face-to-face visit with the same rheumatologist. Diagnoses made during telerheumatology and face-to-face visits were compared. Patients' satisfaction with telerheumatology was ascertained.

RESULTS

Thirty-eight patients were included in the study. Initially, 23 were diagnosed as having an inflammatory or rheumatic condition; 15 were subsequently confirmed at the face-to-face visits. All of the patients with inflammatory, rheumatic conditions were identified at the telerheumatology visits. The overall correlation was 79% between the telerheumatology and face-to-face visits. Among patients with inflammatory, rheumatic conditions, 66% preferred a face-to-face visit compared with 41% among those without such conditions (not significant). Immediately after the telerheumatology visit, all of the patients gave a 10 out of 10 rating for satisfaction. During the subsequent telephone survey, 30 remained highly satisfied with the telemedicine encounter (10 out of 10 rating).

CONCLUSIONS

Telerheumatology at the Palo Alto Veterans Affairs was well received by patients; provided an accurate diagnosis of noninflammatory, nonrheumatic conditions; and may be appropriate for screening and prioritizing patients for in-person rheumatology clinics.

The Impact of Fibromyalgia in Spondyloarthritis: From Classification Criteria to Outcome Measures

The term spondyloarthritis (SpA) encompasses a broad clinical spectrum characterized by chronic inflammatory conditions affecting the sacroiliac joints, the spine but also peripheral joints and tendons and being additionally associated with the involvement of organs, such as bowel, eye and skin (1). Musculoskeletal pain is a key symptom in SpA. However, although low back pain and/or joint pain are characteristic for SpA, undifferentiated pain at different enthesial sites may also be a concomitant or even the first clinical presentation in some patients (2). In addition, fatigue is another important symptom often reported by patients with SpA, which substantially affects the quality of life (QoL) (3). Fibromyalgia (FM) is the most common diagnosis in patients complaining of chronic diffuse pain with fatigue and may occur alone or in association with chronic inflammatory diseases (4). The prevalence of FM ranges from 2 to 8% in the general population and it can reach up to over 50% in patients with other rheumatic and musculoskeletal diseases (RMDs) (5-7). FM has been identified as the most disabling RMD, based on the patients' perception that their medical condition is not properly recognized (8). This is also due to the poor knowledge about its pathogenesis, and therefore the lack of reliable biomarkers reveals a major unmet need requiring to be addressed in further research studies. Over the last decade, an increasing body of evidence described the impact of FM in SpA highlighting the pitfalls for correct classification, appropriate differential diagnosis and assessment of outcome measures in both conditions. The purpose of this review is to provide an overview of currently available data with regard to the coexistence and reciprocal features of FM and SpA.

Cartilage diseases

Hyaline cartilages, fibrocartilages and elastic cartilages play multiple roles in the human body including bearing loads in articular joints and intervertebral discs, providing joint lubrication, forming the external ears and nose, supporting the trachea, and forming the long bones during development and growth. The structure and organization of cartilage's extracellular matrix (ECM) are the primary determinants of normal function. Most diseases involving cartilage lead to dramatic changes in the ECM which can govern disease progression (e.g., in osteoarthritis), cause the main symptoms of the disease (e.g., dwarfism caused by genetically inherited mutations) or occur as collateral damage in pathological processes occurring in other nearby tissues (e.g., osteochondritis dissecans and inflammatory arthropathies). Challenges associated with cartilage diseases include poor understanding of the etiology and pathogenesis, delayed diagnoses due to the aneural nature of the tissue and drug delivery challenges due to the avascular nature of adult cartilages. This narrative review provides an overview of the clinical and pathological features as well as current treatment options available for various cartilage diseases. Late breaking advances are also described in the quest for development and delivery of effective disease modifying drugs for cartilage diseases including osteoarthritis, the most common form of arthritis that affects hundreds of millions of people worldwide.

Harmonization, data management, and statistical issues related to prospective multicenter studies in Ankylosing spondylitis (AS): Experience from the Prospective Study Of Ankylosing Spondylitis (PSOAS) cohort

Ankylosing spondylitis (AS) is characterized by inflammation of the spine and sacroiliac joints causing pain and stiffness and, in some patients, ultimately new bone formation, and progressive joint ankyloses. The classical definition of AS is based on the modified New York (mNY) criteria. Limited data have been reported regarding data quality assurance procedure for multicenter or multisite prospective cohort of patients with AS. Since 2002, 1272 qualified AS patients have been enrolled from five sites (4 US sites and 1 Australian site) in the Prospective Study Of Ankylosing Spondylitis (PSOAS). In 2012, a Data Management and Statistical Core (DMSC) was added to the PSOAS team to assist in study design, establish a systematic approach to data management and data quality, and develop and apply appropriate statistical analysis of data. With assistance from the PSOAS investigators, DMSC modified Case Report Forms and developed database in Research Electronic Data Capture (REDCap). DMSC also developed additional data quality assurance procedure to assure data quality. The error rate for various forms in PSOAS databases ranged from 0.07% for medications data to 1.1% for arthritis activity questionnaire-Global pain. Furthermore, based on data from a sub study of 48 patients with AS, we showed a strong level (90.0%) of agreement between the two readers of X-rays with respect to modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). This paper not only could serve as reference for future publications from PSOAS cohort but also could serve as a basic guide to ensuring data quality for multicenter clinical studies.

Large enthesophytes in teenage skulls: Mechanical, inflammatory and genetic considerations

BACKGROUND

The literature implies that large enthesophytes are exclusive to genetically predisposed individuals and to Spondyloarthropathies sufferers. Accordingly, the aim of this investigation and report was to assess the involvement of genetic predisposition, inflammatory and/or mechanical influences in the development of large enthesophytes in a sample population of teenagers presenting with large enthesophytes emanating from the external occipital protuberance.

METHODS

Analysis was based on four teenage males (13-16 year-old) possessing 14.5-30.5 mm enthesophytes projecting from the external occipital protuberance. This study included assessment of radiographs, MRI scans, blood-work, history, the SF-36 health survey, and the comparison of these data with the relevant literature to describe the interrelationships between the presence of enlarged external occipital protuberance, forward head protraction, active inflammation and/or genetic factors.

FINDINGS

Known genetic markers (e.g. HLA-B27) were not detected by allele-specific primers and both ESR and CRP tests were negative. Additionally, MRI analyses failed to detect active localised inflammation at the external occipital protuberance and surrounding structures. The health survey yielded normal parameters for all participants. All participants displayed significantly large Forward Head Protraction values (>40 mm), and interviews with participants and their parents indicated that concerns related to posture were prevalent since early childhood.

INTERPRETATION

This report suggests that mechanical load has an important role in enthesophyte development, irrespective the involvement of inflammatory or genetic factors.