Can rheumatologists unequivocally diagnose axial spondyloarthritis in patients with chronic back pain of less than 2 years duration? Primary outcome of the 2-year SPondyloArthritis Caught Early (SPACE) cohort

OBJECTIVES

To investigate the prevalence of axial spondyloarthritis (axSpA) in patients with chronic back pain (CBP) of less than 2 years (2y) duration referred to the rheumatologist, the development of diagnosis over time, and patient characteristics of those developing definite (d-)axSpA over 2y.

METHODS

We analysed the 2y data from SPondyloArthritis Caught Early, a European cohort of patients (<45 years) with CBP (≥3 months, ≤2y) of unknown origin. The diagnostic workup comprised evaluation of clinical SpA features, acute phase reactants, HLA-B27, radiographs and MRI (sacroiliac joints and spine), with repeated assessments. At each visit (baseline, 3 months, 1y and 2y), rheumatologists reported a diagnosis of axSpA or non-axSpA with level of confidence (LoC; 0-not confident at all to 10-very confident).

MAIN OUTCOME

axSpA diagnosis with LoC≥7 (d-axSpA) at 2y.

RESULTS

In 552 patients with CBP, d-axSpA was diagnosed in 175 (32%) at baseline and 165 (30%) at 2y. Baseline diagnosis remained rather stable: at 2y, baseline d-axSpA was revised in 5% of patients, while 8% 'gained' d-axSpA. Diagnostic uncertainty persisted in 30%. HLA-B27+ and baseline sacroiliitis imaging discriminated best 2y-d-axSpA versus 2y-d-non-axSpA patients. Good response to non-steroidal anti-inflammatory drugs and MRI-sacroiliitis most frequently developed over follow-up in patients with a new d-axSpA diagnosis. Of the patients who developed MRI-sacroiliitis, 7/8 were HLA-B27+ and 5/8 male.

CONCLUSION

A diagnosis of d-axSpA can be reliably made in nearly one-third of patients with CBP referred to the rheumatologist, but diagnostic uncertainty may persist in 5%-30% after 2y. Repeated assessments yield is modest, but repeating MRI may be worthwhile in male HLA-B27+ patients.

Follow-Up of Patients With Axial Spondyloarthritis in Specialist Health Care With Remote Monitoring and Self-Monitoring Compared With Regular Face-to-Face Follow-Up Visits (the ReMonit Study): Protocol for a Randomized, Controlled Open-Label Noninferiority Trial

BACKGROUND

Patients with chronic inflammatory joint diseases such as axial spondyloarthritis have traditionally received regular follow-up in specialist health care to maintain low disease activity. The follow-up has been organized as prescheduled face-to-face visits, which are time-consuming for both patients and health care professionals. Technology has enabled the remote monitoring of disease activity, allowing patients to self-monitor their disease and contact health care professionals when needed. Remote monitoring or self-monitoring may provide a more personalized follow-up, but there is limited research on how these follow-up strategies perform in maintaining low disease activity, patient satisfaction, safety, and cost-effectiveness.

OBJECTIVE

The Remote Monitoring in Axial Spondyloarthritis (ReMonit) study aimed to assess the effectiveness of digital remote monitoring and self-monitoring in maintaining low disease activity in patients with axial spondyloarthritis.

METHODS

The ReMonit study is a 3-armed, single-site, randomized, controlled, open-label noninferiority trial including patients with axial spondyloarthritis with low disease activity (Ankylosing Spondylitis Disease Activity Score <2.1) and on stable treatment with a tumor necrosis factor inhibitor. Participants were randomized 1:1:1 to arm A (usual care, face-to-face visits every sixth month), arm B (remote monitoring, monthly digital registration of patient-reported outcomes), or arm C (patient-initiated care, self-monitoring, no planned visits during the study period). The primary end point was disease activity measured with the Ankylosing Spondylitis Disease Activity Score, evaluated at 6, 12, and 18 months. We aimed to include 240 patients, 80 in each arm. Secondary end points included other measures of disease activity, patient satisfaction, safety, and cost-effectiveness.

RESULTS

The project is funded by the South-Eastern Norway Regional Health Authority and Centre for the treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Norway. Enrollment started in September 2021 and was completed with 242 patients by June 2022. The data collection will be completed in December 2023.

CONCLUSIONS

To our knowledge, this trial will be among the first to evaluate the effectiveness, safety, and cost-effectiveness of remote digital monitoring and self-monitoring of patients with axial spondyloarthritis compared with usual care. Hence, the ReMonit study will contribute important knowledge to personalized follow-up strategies for patients with axial spondyloarthritis. These results may also be relevant for other patient groups with inflammatory joint diseases.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05031767; hpps://www.clinicaltrials.gov/study/NCT05031767.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52872.

Cardiovascular organ damage in relation to hypertension status in patients with ankylosing spondylitis

PURPOSE

Hypertension is a major cardiovascular (CV) risk factor in ankylosing spondylitis (AS) patients. Less is known about the prevalence of CV organ damage in relation to hypertension status in AS patients.

MATERIALS AND METHODS

CV organ damage was assessed by echocardiography, carotid ultrasound and pulse wave velocity (PWV) by applanation tonometry in 126 AS patients (mean age 49 ± 12 years, 39% women) and 71 normotensive controls (mean age 47 ± 11 years, 52% women). CV organ damage was defined as presence of abnormal left ventricular (LV) geometry, LV diastolic dysfunction, left atrial (LA) dilatation, carotid plaque or high pulse wave velocity (PWV).

RESULTS

Thirty-four percent of AS patients had hypertension. AS patients with hypertension were older and had higher C-reactive protein (CRP) levels compared to AS patients without hypertension and controls (p < 0.05). The prevalence of CV organ damage was 84% in AS patients with hypertension, 29% in AS patients without hypertension and 30% in controls (p < 0.001). In multivariable logistic regression analyses, having hypertension was associated with a fourfold increased risk of CV organ damage independent of age, presence of AS, gender, body mass index, CRP, and cholesterol (odds ratio (OR) 4.57, 95% confidence interval (CI) 1.53 to 13.61, p = 0.006). In AS patients, presence of hypertension was the only covariable significantly associated with presence of CV organ damage (OR 4.40, 95% CI 1.40 to 13.84, p = 0.011).

CONCLUSIONS

CV organ damage in AS was strongly associated with hypertension, pointing to the importance of guideline-based hypertension management in AS patients.

Willingness, perceived facilitators and barriers to use remote care among healthcare professionals - a cross-sectional study

BACKGROUND

Remote care has the potential of improving access to timely care for people with inflammatory joint diseases (IJD), but there is limited knowledge on how this approach is regarded by healthcare professionals (HCP). This study aimed to examine willingness, perceived facilitators, and barriers to use remote care among HCP.

METHODS

Employees at 20 rheumatology departments in Norway received a digital survey containing 16 statements regarding willingness, perceived facilitators and barriers to use remote care. Statements were scored using numeric rating scales (NRS, 0-10, 10 = strongly agree), and analysed in linear regression models. Open-ended responses with participant-defined facilitators and barriers were analysed using qualitative manifest analysis.

RESULTS

A total of 130 participants from 17 departments completed the survey. The majority of participants were 45 years or older (n = 84, 54%), 54 (42%) were medical doctors, 48 (37%) nurses, and 27 (21%) were allied healthcare professionals, clinical leaders, or secretaries. A high willingness to use remote care was observed (median NRS: 9, IQR 8-10). The facilitator statement with the highest score was that patients save time and costs by using remote care, whereas the barrier statement with the highest score was the lack of physical examination. Willingness to use remote care was positively associated with the belief that patients wish to use it (β: 0.18, 95% CI: 0.00, 0.34), that patients in remission need less hospital visits (β: 0.30, 95% CI: 0.16, 0.43), and if remote care is widely adopted by co-workers (β: 0.27, 95% CI: 0.15, 0.39). Willingness was negatively associated with mistrust in the technical aspects of remote care (β: -0.26, 95% CI:-0.40, -0.11), and lack of physical examination (β: -0.24, 95% CI: -0.43, -0.06). The open-ended responses showed that technological equipment, eligible patients, user-friendly software, adequate training and work flow could be facilitators, but also that lack of these factors were considered barriers to use remote care.

CONCLUSION

This study showed that HCP have a high willingness to use remote care, and provides important new knowledge on perceived facilitators and barriers among HCP relevant for implementation of remote care for eligible patients with IJD.

High-Intensity Exercise Improves Fatigue, Sleep, and Mood in Patients With Axial Spondyloarthritis: Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

Although exercise is recommended in the treatment of axial spondyloarthritis (axSpa), the focus has been on flexibility, and the effect of high-intensity exercises is unknown. The purpose of this study was to investigate the effect of high-intensity exercises on fatigue, sleep, and mood in patients with axSpA.

METHODS

In this secondary analysis of a randomized controlled trial, participants were recruited from outpatient clinics at 4 hospitals in Scandinavia. A total of 100 patients with axSpA were randomized to either an exercise group (n = 50) or a control group (n = 50). High-intensity exercise was provided 3 times per week for 3 months and supervised by a physical therapist. The controls received no intervention. Measurements were self-reported at baseline, 3 months, and 12 months: fatigue, using the Fatigue Severity Scale (range = 0-7, 7 = worst, ≥5 = severe); vitality, using the RAND 36-item short-form health survey (SF-36, range = 0-100, 100 = best); sleep, using the Pittsburgh Sleep Quality Index (range = 0-21, 21 = worst, >5 = poor quality); mood, using the General Health Questionnaire 12 (range = 0-36, 36 = worst); and general health, using the EUROQoL (range = 0-100, 100 = best).

RESULTS

A total of 38 participants (76%) in the exercise group followed ≥80% of the exercise protocol. At 3 months, there was a significant beneficial effect on fatigue (mean group differences = -0.4, 95% CI = -0.7 to -0.1), vitality (5.0, 95% CI = 1.1 to 10.5), mood (-2, 95% CI = -3.7 to -0.04), and general health (9.0, 95% CI = 3.3 to 14.7) but no effect on sleep (-1.1, 95% CI = -2.1 to 0.2). Compared with the control group, the exercise group had a reduced rate of severe fatigue and poor sleep. No differences were seen between the groups at 12 months.

CONCLUSIONS

A 3-month exercise program had a beneficial effect on fatigue, sleep, mood, and general health in patients with axSpA at the end of the intervention; however, no long-term effects were seen.

IMPACT

High-intensity cardiorespiratory and strength exercises should be considered as important in exercise programs for patients with axSpA.

Biomarkers of cardiovascular risk across phenotypes of osteoarthritis

Background

The objective of this study was to explore the associations between ultrasonographic and radiographic joint scores and levels of arterial CVD risk markers in patients with osteoarthritis (OA). Secondly, to compare the levels of arterial CVD risk markers between OA phenotypes and controls.

Method

The "Musculoskeletal pain in Ullensaker" Study (MUST) invited residents of Ullensaker municipality with self-reported OA to a medical examination. OA was defined according to the American College of Rheumatology (ACR) criteria and phenotyped based on joint distribution. Joints of the hands, hips and knees were examined by ultrasonography and conventional radiography, and scored for osteosteophytes. Hands were also scored for inflammation by grey scale (GS) synovitis and power Doppler (PD) signal. Control populations were a cohort of inhabitants of Oslo (OCP), and for external validation, a UK community-based register (UKPC).Pulse pressure augmentation index (AIx) and pulse wave velocity (PWV) were measured using the Sphygmocor apparatus (Atcor®). Ankel-brachial index (ABI) was estimated in a subset of patients. In separate adjusted regression models we explored the associations between ultrasonography and radiograph joint scores and AIx, PWV and ABI. CVD risk markers were also compared between phenotypes of OA and controls in adjusted analyses.

Results

Three hundred and sixty six persons with OA were included (mean age (range); 63.0 (42.0-75.0)), (females (%); 264 (72)). Of these, 155 (42.3%) had isolated hand OA, 111 (30.3%) had isolated lower limb OA and 100 (27.3%) had generalized OA. 108 persons were included in the OCP and 963 persons in the UKPC; (mean age (range); OCP: 57.2 (40.4-70.4), UKPC: 63.9 (40.0-75.0), females (%); OCP: 47 (43.5), UKPC: 543 (56.4%). Hand osteophytes were associated with AIx while GS and PD scores were not related to CVD risk markers. All OA phenotypes had higher levels of AIx compared to OCP in adjusted analyses. External validation against UKPC confirmed these findings.

Conclusions

Hand osteophytes might be related to higher risk of CVD. People with OA had higher augmented central pressure compared to controls.Words 330.

High intensity exercise for 3 months reduces disease activity in axial spondyloarthritis (axSpA): a multicentre randomised trial of 100 patients

Background

Exercise is considered important in the management of patients with rheumatic diseases, but the effect of high intensity exercises on disease activity is unknown.

Objective

To investigate the effectiveness of high intensity exercises on disease activity in patients with axial spondyloarthritis (axSpA).

Method

Assessor blinded multicentre randomised controlled trial. 100 patients (aged from their 20s to their 60s) with axSpA were randomly assigned to an exercise group or to a no-intervention control group. The exercise group performed cardiorespiratory and muscular strength exercises at high intensity over 3 months. The control group received standard care and was instructed to maintain their usual physical activity level. Primary outcome was disease activity measured with the Ankylosing Spondylitis (AS) Disease Activity Scale (ASDAS, higher score=worst) and the Bath AS Disease Activity Index (BASDAI, 0–10, 10=worst). Secondary outcomes were inflammatory markers, physical function and cardiovascular (CV)-health. There was patient involvement in the design and reporting of this study.

Results

97 of the 100 (97%) randomised patients completed the measurements after the intervention. There was a significant treatment effect of the intervention on the primary outcome (ASDAS: −0.6 [–0.8 to –0.3], p<0.001 and BASDAI: −1.2 [–1.8 to –0.7], p<0.001). Significant treatment effects were also seen for inflammation, physical function and CV-health.

Conclusion

High intensity exercises reduced disease symptoms (pain, fatigue, stiffness) and also inflammation in patients with axSpA. It improves patients’ function and CV health. This debunks concerns that high intensity exercise might exacerbate disease activity in patients with axSpA.

Trial registration number

NCT02356874.

Is it Useful to Repeat Magnetic Resonance Imaging of the Sacroiliac Joints After Three Months or One Year in the Diagnosis of Patients With Chronic Back Pain and Suspected Axial Spondyloarthritis?

Objective

To investigate the value of repeated magnetic resonance imaging (MRI) of the sacroiliac (SI) joints in diagnosing chronic back pain patients in whom axial spondyloarthritis (SpA) is suspected and to examine determinants of positive MRI findings in SI joints.

Methods

Patients with chronic back pain (duration 3 months–2 years, age ≥16 years, age at onset <45 years) with ≥1 SpA feature who were included in the Spondyloarthritis Caught Early cohort underwent visits at baseline, at 3 months, and at 1 year. Visits included an evaluation of all SpA features and repeated MRI of SI joints. MRI‐detected axial SpA positivity (according to the definition from the Assessment of SpondyloArthritis international Society) was evaluated by 2 or 3 well‐trained readers who were blinded with regard to clinical information. The likelihood of a positive MRI finding at follow‐up visits (taking into consideration contributing factors) was calculated by generalized estimating equation analysis.

Results

Of the 188 patients, 38.3% were male, the mean ± SD age was 31.0 ± 8.2 years, and the mean ± SD symptom duration was 13.2 ± 7.1 months. Thirty‐one patients (16.5%) had positive MRI findings in the SI joints at baseline. After 3 months and after 1 year, the MRI results had changed from positive to negative in 3 of 27 patients (11.1%) and 11 of 29 patients (37.9%), respectively, which was attributable in part to the initiation of anti–tumor necrosis factor therapy. Status changes from negative to positive were seen in 5 of 116 patients (4.3%) after 3 months and in 10 of 138 patients (7.2%) after 1 year. HLA–B27 positivity and male sex were independent determinants of the likelihood of a positive MRI scan at any time point (42% in HLA–B27+ men and 6% in HLA–B27− women). If the baseline results were negative, the likelihood of a positive scan at follow‐up was very low (≤7%).

Conclusion

MRI‐detected status changes in the SI joints were seen in a minority of the patients, and both male sex and HLA–B27 positivity were important predictors of MRI positivity. Our findings indicate that conducting MRI scans after 3 months or after 1 year in patients with suspected early axial SpA is not diagnostically useful.

Frequency of Impaired Spinal Mobility in Patients with Chronic Back Pain Compared to Patients with Early Axial Spondyloarthritis

OBJECTIVE

To examine the frequency of impaired spinal mobility in patients with chronic back pain of short duration and to compare it with the frequency of impaired spinal mobility in patients with axial spondyloarthritis (axSpA), possible SpA, and no SpA.

METHODS

The SpondyloArthritis Caught Early (SPACE) cohort includes patients with chronic back pain (≥ 3 mos, ≤ 2 yrs, onset < 45 yrs). Spinal mobility was assessed with lateral spinal flexion, chest expansion, cervical rotation, occiput-to-wall distance, and lumbar flexion. Hip mobility was assessed with intermalleolar distance. Mobility measures were defined as impaired if below the 5th percentile reference curve from general population, adjusted for age and height when appropriate. Proportions of patients categorized with impaired mobility were examined with chi square.

RESULTS

In total, 393 patients with chronic back pain were included: 142 axSpA, 140 possible SpA, and 111 no SpA. Impairment in ≥ 1 mobility measure was present in 66% of all patients. The most frequently impaired mobility measure was lateral spinal flexion (40%), followed by chest expansion (22%), cervical rotation (18%), intermalleolar distance (17%), lumbar flexion (15%), and occiput-to-wall distance (11%). No statistically significant differences in proportion of patients with impaired spinal mobility were found between patients with axSpA and the other subgroups in any of the tests.

CONCLUSION

Two out of 3 patients with chronic back pain of short duration had impaired spinal mobility compared to the general population. Impaired spinal mobility occurs as often in patients with early axSpA as in other forms of chronic back pain.

Associations Between Cardiorespiratory Fitness and Arterial Stiffness in Ankylosing Spondylitis: A Cross-sectional Study

Objective.

To assess associations between cardiorespiratory fitness (CRF), measured as peak oxygen uptake (VO2peak), and cardiovascular disease (CVD) risk, measured by arterial stiffness, in patients with ankylosing spondylitis (AS).

Methods.

VO2peak was assessed by a maximal walking test on a treadmill. Arterial stiffness was measured noninvasively (Sphygmocor apparatus). Cross-sectional associations between VO2peak and arterial stiffness were analyzed using backward multivariable linear regression.

Results.

Among 118 participating patients, there were significant inverse associations between VO2peak and arterial stiffness, independent of traditional CVD risk factors and measures of disease activity.

Conclusion.

Reduced CRF may be related to increased risk of CVD in AS.

Ankylosing Spondylitis Is Associated with Increased Prevalence of Left Ventricular Hypertrophy

OBJECTIVE

Ankylosing spondylitis (AS) is associated with increased risk for cardiovascular disease (CVD). Left ventricular (LV) hypertrophy is a strong precursor for clinical CVD. The aim of our study was to assess whether having AS was associated with increased prevalence of LV hypertrophy.

METHODS

Clinical and echocardiographic data from 139 AS patients and 126 age- and sex-matched controls was used. LV mass was calculated according to guidelines and indexed to height^2.7. LV hypertrophy was considered present if LV mass index was > 49.2 g/m^2.7 in men and > 46.7 g/m^2.7 in women.

RESULTS

Patients with AS were on average 49 ± 12 years old, and 60% were men. The prevalence of hypertension (HTN; 35% vs 41%) and diabetes (5% vs 2%) was similar among patients and controls, while patients with AS had higher serum C-reactive protein level (CRP; p < 0.001). The prevalence of LV hypertrophy was higher in patients with AS compared to controls (15% vs 6%, p = 0.01). In multivariable logistic regression analysis, having AS was associated with OR 6.3 (95% CI 2.1-19.3, p = 0.001) of having LV hypertrophy independent of the presence of HTN, diabetes, and obesity. In multivariable linear regression analyses, having AS was also associated with higher LV mass (β 0.15, p = 0.007) after adjusting for CVD risk factors including sex, body mass index, systolic blood pressure, diabetes, and serum CRP (multiple R² = 0.41, p < 0.001).

CONCLUSION

Having AS was associated with increased prevalence of LV hypertrophy independent of CVD risk factors. This finding strengthens the indication for thorough CVD risk assessment in patients with AS.

Magnetic Resonance Imaging of the Sacroiliac Joints Indicating Sacroiliitis According to the Assessment of SpondyloArthritis international Society Definition in Healthy Individuals, Runners, and Women With Postpartum Back Pain

Objective

To compare magnetic resonance images (MRIs) of the sacroiliac (SI) joints of healthy subjects and individuals with known mechanical strain acting upon the SI joints to those of patients with axial spondyloarthritis (SpA) and patients with chronic back pain.

Methods

Three readers who had received standardized training and were blinded with regard to study group randomly scored MRIs of the SI joints of 172 subjects, including 47 healthy individuals without current or past back pain, 47 axial SpA patients from the Spondyloarthritis Caught Early (SPACE) cohort (with a previous MRI confirmed positive for sacroiliitis), 47 controls with chronic back pain (irrespective of MRI results) from the SPACE cohort, 7 women with postpartum back pain, and 24 frequent runners. MRIs were scored according to the Assessment of SpondyloArthritis international Society (ASAS) definition and Spondyloarthritis Research Consortium of Canada (SPARCC) index.

Results

Of the 47 healthy volunteers, 11 (23.4%) had an MRI positive for sacroiliitis, compared to 43 (91.5%) of 47 axial SpA patients and 3 (6.4%) of 47 patients with chronic back pain. Three (12.5%) of the 24 runners and 4 (57.1%) of the 7 women with postpartum back pain had a positive MRI. Using a SPARCC cutoff of ≥2 for positivity, 12 (25.5%) of 47 healthy volunteers, 46 (97.9%) of 47 positive axial SpA patients, 5 (10.6%) of 47 controls with chronic back pain, 4 (16.7%) of 24 runners, and 4 (57.1%) of 7 women with postpartum back pain had positive MRIs. Deep bone marrow edema (BME) lesions were not found in healthy volunteers, patients with chronic back pain, or runners, but were found in 42 (89.4%) of 47 positive axial SpA patients and in 1 (14.3%) of 7 women with postpartum back pain.

Conclusion

A substantial proportion of healthy individuals without current or past back pain has an MRI positive for sacroiliitis according to the ASAS definition. Deep (extensive) BME lesions are almost exclusively found in axial SpA patients.

High-intensity cardiorespiratory and strength exercises reduced emotional distress and fatigue in patients with axial spondyloarthritis: a randomized controlled pilot study

OBJECTIVE

To investigate the effect of high-intensity exercise on emotional distress, fatigue, and ability to do a full day's activities in patients with axial spondyloarthritis (axSpA).

METHOD

A total of 28 physically inactive axSpA patients were randomized to either an exercise group (EG), which performed 12 weeks of cardiorespiratory and strength exercises, or a control group (CG), which received treatment as usual. The outcomes reported in this paper are secondary outcomes in the trial and included emotional distress (General Health Questionnaire-12, 0-36, 36 = worst), fatigue [numeric rating scale (NRS), 0-10, 10 = worst], and ability to do a full day's activities (NRS, 0-10, 10 = worst). Post-intervention differences were assessed by analysis of covariance with baseline values as covariates.

RESULTS

Twenty-four patients were included in the analyses. All patients in the EG followed the exercise protocol. The EG had a statistically significant beneficial effect [mean group differences (95% confidence interval)] on emotional distress [-5.8, (-9.7, -1.9), p < 0.01], fatigue [-2.4, (-4.3, -0.4), p = 0.02], and ability to do a full day's work [-2.2, (-3.9, -0.4), p = 0.02] compared to the CG.

CONCLUSION

This pilot study showed promising effects of cardiorespiratory and strength exercises on emotional distress, fatigue, and ability to do a full day's activities in patients with axSpA. The findings need to be confirmed in a larger trial.

Is the current ASAS expert definition of a positive family history useful in identifying axial spondyloarthritis? Results from the SPACE and DESIR cohorts

Background

The Assessment of SpondyloArthritis international Society (ASAS) definition of a positive family history (PFH) of spondyloarthritis (SpA) includes the following diseases in first- or second-degree relatives: ankylosing spondylitis (AS), acute anterior uveitis (AAU), reactive arthritis (ReA), inflammatory bowel disease (IBD), and psoriasis. However, it is not known if a PFH for each of these diseases contributes to making a diagnosis of axSpA, sacroiliitis on imaging, or fulfilling the ASAS criteria in patients presenting with chronic back pain (CBP). Therefore, the aim of this study was to assess which SpA diseases in family members are associated with human leukocyte antigen B27 (HLA-B27) and axial spondyloarthritis (axSpA) in CBP patients.

Methods

CBP patients suspected of axSpA from the SPACE (n = 438) and the DESIR (n = 647) cohort were asked about the presence of SpA diseases in first- or second-degree relatives (AS, AAU, ReA, IBD, and psoriasis). The associations between a PFH and HLA-B27, sacroiliitis on imaging (magnetic resonance imaging (MRI) or radiographs), axSpA diagnosis, and ASAS classification in CBP patients were assessed.

Results

In the SPACE and the DESIR cohort, a PFH of AS (odds ratio (OR) 5.9 (95% confidence interval (CI) 3.5–9.9), and OR 3.3 (95% CI 2.1–5.2)) and a PFH of AAU (OR 9.8 (95% CI 3.3–28.9) and OR 21.6 (95% CI 2.9–160.1)) were significantly associated with presence of HLA-B27. Furthermore, in both cohorts a PFH of AS and a PFH of AAU were positively associated with fulfilment of the ASAS criteria, but not with sacroiliitis on imaging. In SPACE but not in DESIR a PFH of AAU was positively associated with axSpA diagnosis. In both cohorts a PFH of ReA, IBD, or psoriasis was not positively associated with HLA-B27 positivity, sacroiliitis on imaging, axSpA diagnosis, or meeting the ASAS criteria for axSpA.

Conclusions

In our cohorts, a PFH of AS or AAU is useful for case-finding of axSpA as this is correlated with HLA-B27 carriership. However, as a PFH of ReA, IBD, or psoriasis does not contribute to identifying axSpA in CBP patients, these data suggest that the widely used ASAS definition of a PFH of SpA should be updated.

Trial registration

Trial registration number, NCT01648907. Registered on 20 July 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1335-8) contains supplementary material, which is available to authorized users.

Presence of multiple spondyloarthritis (SpA) features is important but not sufficient for a diagnosis of axial spondyloarthritis: data from the SPondyloArthritis Caught Early (SPACE) cohort

Objectives

Concerns have been raised about overdiagnosis of axial spondyloarthritis (axSpA). We investigated whether patients with chronic back pain (CBP) of short duration and multiple SpA features are always diagnosed with axSpA by the rheumatologist, and to what extent fulfilment of the Assessment of SpondyloArthritis International Society (ASAS) axSpA criteria is associated with an axSpA diagnosis.

Methods

Baseline data from 500 patients from the SPondyloArthritis Caught Early cohort which includes patients with CBP (≥3 months, ≤2 years, onset <45 years) were analysed. All patients underwent full diagnostic workup including MRI of the sacroiliac joints (MRI-SI) and radiograph of sacroiliac joints (X-SI). For each patient, the total number of SpA features excluding sacroiliac imaging and human leucocyte antigen B27 (HLA-B27) status was calculated.

Results

Before sacroiliac imaging and HLA-B27 testing, 32% of patients had ≤1 SpA feature, 29% had 2 SpA features, 16% had 3 SpA features and 24% had ≥4 SpA features. A diagnosis of axSpA was made in 250 (50%) of the patients: 24% with ≤1 SpA feature, 43% with 2 SpA features, 62% with 3 SpA features and 85% with ≥4 SpA features. Of the 230 patients with a positive ASAS classification 40 (17.4%) did not have a diagnosis of axSpA. HLA-B27 positivity (OR 5.6; 95% CI 3.7 to 8.3) and any (MRI-SI and/or X-SI) positive imaging (OR 34.3; 95% CI 17.3 to 67.7) were strong determinants of an axSpA diagnosis.

Conclusions

In this cohort of patients with CBP, neither the presence of numerous SpA features nor fulfilment of the ASAS classification criteria did automatically lead to a diagnosis axSpA. Positive imaging was considered particularly important in making a diagnosis of axSpA.

The Impact of Newer Biological Disease Modifying Anti-Rheumatic Drugs on Cardiovascular Risk Factors: A 12-Month Longitudinal Study in Rheumatoid Arthritis Patients Treated with Rituximab, Abatacept and Tociliziumab

OBJECTIVES

To assess whether treatment with one of three novel biological DMARDs; rituximab, abatacept or tocilizumab reduce cardiovascular disease (CVD) risk factors in patients with rheumatoid arthritis (RA).

METHODS

This is an open, observational and prospective study with visits at baseline, 3, 6, and 12 months. Patients were assigned to receive rituximab, abatacept or tocilizumab according to clinical indications assessed by an independent rheumatologist. Disease activity was quantified by the disease activity score (DAS28) and extensive ultrasonography. CVD risk was assessed by total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c), blood pressure and arterial stiffness measurements [pulse wave velocity (PWV) and augmentation index (AIx)]. Within group change in disease activity and CVD risk over 3 months was explored using paired samples bivariate tests. Predictors of change in CVD risk at 3 months were identified in linear regression models. Changes in CVD risk markers over the 12- month follow-up in patients receiving rituximab were assessed by mixed models repeated analyses.

RESULTS

24 patients on rituximab, 5 on abatacept and 7 on tocilizumab were included. At 3 months PWV was significantly reduced in the tocilizumab group only, but at 12 months rituximab patients showed a significant reduction in PWV. Reduced inflammation at 3 months was associated with increased TC and HDL-c in the entire cohort.

CONCLUSION

Treatment with tocilizumab and rituximab reduces PWV, a marker of CVD risk, in patients with RA.

Circulating levels of inflammatory cytokines and cytokine receptors in patients with ankylosing spondylitis: a cross-sectional comparative study

OBJECTIVES

Insight into the most important inflammatory pathways in ankylosing spondylitis (AS) could be of importance in risk stratification and the development of treatment strategies. Therefore, we aimed to compare circulating levels of inflammatory biomarkers between AS patients and controls, and explore associations between these biomarkers and clinical measures of disease activity.

METHOD

In a cross-sectional study, 143 AS patients were compared with 124 population controls. Blood samples were analysed by immunoassays for interleukin (IL)-6, IL-17a, IL-23, soluble tumour necrosis factor receptor 1 (sTNF-R1) and 2 (sTNF-R2), and osteoprotegerin (OPG). Disease activity was measured by the AS Disease Activity Score (ASDAS) and the Bath AS Disease Activity Index (BASDAI).

RESULTS

Analysis of covariance (ANCOVA) demonstrated elevated plasma levels of sTNF-R1 [geometrical mean 0.94 (95% CI 0.88-1.00) vs. 0.83 (95% CI 0.78-0.89) ng/mL, p < 0.01] and OPG (2.3, 95% CI 2.1-2.4 vs. 2.0, 95% CI 1.9-2.2 ng/mL, p = 0.02) and, although not significant, of IL-23 (122, 95% CI 108-139 vs. 106, 95% CI 93-120 pg/mL, p = 0.07) in AS patients vs.

CONTROLS

More AS patients had a high level of sTNF-R2 than controls (22 vs. 1, p < 0.01). No differences between the groups were seen for IL-6 and IL-17a. In patients, no significant associations were seen between inflammatory markers and disease activity measures after adjusting for personal characteristics.

CONCLUSION

Significantly higher plasma levels of sTNF-R1, sTNF-R2, and OPG and numerically but non-significantly higher levels of IL-23 were found in AS patients compared to controls, indicating that these cytokines and cytokine receptors are important inflammatory pathways. Clinical measures of disease activity were not significantly correlated with circulating inflammatory markers.

CRP and ASDAS are associated with future elevated arterial stiffness, a risk marker of cardiovascular disease, in patients with ankylosing spondylitis: results after 5-year follow-up

OBJECTIVE

To identify factors associated with elevated arterial stiffness in a 5-year follow-up of patients with ankylosing spondylitis (AS).

METHODS

C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), Bath AS disease activity index (BASDAI) and AS disease activity score (ASDAS) were recorded in 2003, and arterial stiffness (Augmentation Index (AIx) and pulse wave velocity (PWV)) in 2008/2009. Patients were grouped into quartiles according to baseline CRP, ESR and BASDAI and four ASDAS groups. Trend analyses were performed using ANCOVA (AIx/PWV as dependent variable) with separate models for CRP, ESR, BASDAI and ASDAS (age and gender adjusted). Independent predictors of future AIx and PWV levels were identified in multivariate linear regression models.

RESULTS

In total, 85 patients participated. Increasing baseline values of CRP, ESR and ASDAS were associated with elevated AIx on follow-up (p(trend) 0.01, 0.05 and 0.04, respectively). Similar non-significant patterns were seen for PWV. In the multivariate analyses, baseline CRP and ASDAS were independently associated with future elevated AIx (p=0.03 and0.02, respectively). In the multivariate PWV model, results for CRP and ASDAS were non-significant.

CONCLUSIONS

Baseline CRP and ASDAS were associated with future elevated arterial stiffness measured as AIx, supporting that disease activity is related to future risk of cardiovascular disease in patients with AS.

Disease activity in ankylosing spondylitis and associations to markers of vascular pathology and traditional cardiovascular disease risk factors: a cross-sectional study

OBJECTIVE

To compare the risk of cardiovascular disease (CVD) in ankylosing spondylitis (AS) and population controls, and to examine the associations between disease activity and CVD risk.

METHODS

A cross-sectional study was done of patients with AS grouped according to Ankylosing Spondylitis Disease Activity Score (ASDAS) into ASDAS-high and ASDAS-low. Markers of vascular pathology, impaired endothelial function [asymmetric dimethylarginine (ADMA)], and arterial stiffness [augmentation index (AIx) and pulse wave velocity (PWV)], and traditional CVD risk factors [blood pressure, lipids, body mass index (BMI), CVD risk scores] were compared between AS and controls as well as across ASDAS-high versus ASDAS-low versus controls using ANCOVA analyses.

RESULTS

Altogether, 151 patients with AS and 134 controls participated. Patients had elevated ADMA (µmol/l) and AIx (%) compared to controls: mean difference (95% CI): 0.05 (0.03, 0.07), p < 0.001 and 2.6 (0.8, 4.3), p = 0.01, respectively. AIx increased with higher ASDAS level, p(trend) < 0.04. There were no significant group differences of PWV. BMI was higher in ASDAS-high compared to ASDAS-low (p = 0.02). Total cholesterol was lower in AS compared to controls, and lower with higher ASDAS, p(trend) = 0.02. CVD risk scores were similar across groups except for Reynolds Risk Score, where the ASDAS-high group had a significantly higher score, compared to both ASDAS-low and controls.

CONCLUSION

Elevated ADMA and AIx in AS support a higher CVD risk in AS. Elevated AIx and BMI in AS with high ASDAS indicate an association between disease activity and CVD risk. Lower total cholesterol in AS may contribute to underestimation of CVD risk.

Efficacy of high intensity exercise on disease activity and cardiovascular risk in active axial spondyloarthritis: a randomized controlled pilot study

BACKGROUND

Physical therapy is recommended for the management of axial spondyloarthritis (axSpA) and flexibility exercises have traditionally been the main focus. Cardiovascular (CV) diseases are considered as a major health concern in axSpA and there is strong evidence that endurance and strength exercise protects against CV diseases. Therefore, the aim of this study was to investigate the efficacy of high intensity endurance and strength exercise on disease activity and CV health in patients with active axSpA.

METHODS

In a single blinded randomized controlled pilot study the exercise group (EG) performed 12 weeks of endurance and strength exercise while the control group (CG) received treatment as usual. The primary outcome was the Ankylosing Spondylitis (AS) Disease Activity Score (ASDAS). Secondary outcomes included patient reported disease activity (Bath AS Disease Activity Index [BASDAI]), physical function (Bath AS Functional Index [BASFI]), and CV risk factors measured by arterial stiffness (Augmentation Index [Alx]) and Pulse Wave Velocity [PWV]), cardiorespiratory fitness (VO2 peak) and body composition. ANCOVA on the post intervention values with baseline values as covariates was used to assess group differences, and Mann Whitney U-test was used for outcomes with skewed residuals.

RESULTS

Twenty-eight patients were included and 24 (EG, n = 10, CG, n = 14) completed the study. A mean treatment effect of -0.7 (95%CI: -1.4, 0.1) was seen in ASDAS score. Treatment effects were also observed in secondary outcomes (mean group difference [95%CI]): BASDAI: -2.0 (-3.6, -0.4), BASFI: -1.4 (-2.6, -0.3), arterial stiffness (estimated median group differences [95% CI]): AIx (%): -5.3 (-11.0, -0.5), and for PVW (m/s): -0.3 (-0.7, 0.0), VO2 peak (ml/kg/min) (mean group difference [95%CI]: 3.7 (2.1, 5.2) and trunk fat (%): -1.8 (-3.0, -0.6). No adverse events occurred.

CONCLUSION

High intensity exercise improved disease activity and reduced CV risk factors in patients with active axSpA. These effects will be further explored in a larger trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01436942.

Uveitis is associated with hypertension and atherosclerosis in patients with ankylosing spondylitis: a cross-sectional study

OBJECTIVES

Uveitis is the most common extra-articular manifestation in patients with ankylosing spondylitis (AS), but the literature describing AS patients with a history of uveitis is limited. The objective was to examine if a history of uveitis in patients with AS is associated with increased disease activity and functional impairment and to investigate whether uveitis is associated with an increased frequency of cardiovascular comorbidities, defined here as hypertension and atherosclerosis.

METHODS

Data were recorded cross-sectionally through patient interviews, blood samples, clinical examination, and questionnaires. Carotid plaques were identified by ultrasonography. AS disease activity and function were compared across categories of uveitis using ANCOVA analyses. Associations between uveitis and hypertension and atherosclerosis [atherosclerotic cardiovascular disease (CVD) and/or carotid plaque] were analyzed in multivariate logistic regression models.

RESULTS

Of 159 patients with AS (61.6% male, mean age 50.5 years), 84 (52.8%) had experienced one or more episodes of uveitis. AS disease activity was higher in patients with a history of uveitis, statistically significant for functional impairment [Bath AS Functional Index (BASFI)] [mean difference (95% CI)] lnBASFI = 0.2 (0.0-0.3), p = 0.05. Patients with uveitis had an increased odds ratio [OR (95% CI)] for hypertension [3.29 (1.29-8.41), p = 0.01] and atherosclerosis [2.57 (1.15-5.72), p = 0.02].

CONCLUSIONS

AS patients with a history of uveitis had non-significantly higher disease activity and significantly higher functional impairment. A history of uveitis was associated with hypertension as well as atherosclerosis. These results may be important in identifying AS patients with elevated risk of CVD but should be confirmed in longitudinal cohorts.

Relations between subjective evaluations of memory and objective memory performance

Several explanations for the weak relations between subjective memory judgements and objective memory performance were investigated in two groups of normal older adults. Group 1 sampled a general population (mean age 61.6 yr., range 46-89), while Group 2 sampled subjects who were on a waiting list for memory training (mean age 63.0 yr., range 45-85 years). In both groups, subjective memory judgments were assessed with global ratings of memory capacity and with ratings of frequency of forgetting in specific memory situations. Memory performance was assessed with several well-known tests and with recently developed tests for domain-specific aspects of memory. Most tests concerned episodic memory. Study 1 also included measures of semantic, incidental and working memory. Study 2 further examined the influence of the domain-specificity of objective and subjective measures for remembering names, intentions, and texts. Relations between memory self-reports and performance were weak in both groups and for all kinds of tests. Against expectations, the low correlations could not be explained by differences between ecological and laboratory tests or incidentally and intentionally remembered information, or by differences between specific failures compared to global, stereotyped judgments. Surprisingly, correlations did not increase when subjective and objective measures assessed the same ability, like remembering names. Also noncognitive variables (mood and lifestyle) did not influence the relations. The (weak) relations between subjective and objective memory measures were comparable for subjects over and under 65 years of age. Furthermore, relations were comparable for the general population sample and the memory compliant group.

[Memory strategies of elderly: training efficacy]

Does memory strategy training improve the quantity and quality of reported strategy use of normal older adults (N = 111, mean age 63 years, range 46-85 years) in daily life? Three strategy training conditions, remembering names (N = 26), intentions (N = 20) and verbal information (N = 20) and an educational training (N = 23) were compared to a test-retest control group (N = 22). Strategy use was assessed with a Strategy Frequency Questionnaire (investigating the reported frequency of strategy use on five scales: encoding, retrieval, general, external and no strategies) and a Memory Situations Questionnaire (investigating the preference of strategies in specific situations). Three months after training, the frequency of strategy use as assessed by the scale scores had not increased more in the strategy training conditions than in the control condition. No demographic or psychological characteristics were identified that could predict which individuals were most likely to change their strategy use. When strategies were analyzed separately, only after names training a specific effect was demonstrated, indicating that subjects more frequently used the strategy for remembering names (association) at follow-up. With regard to changes in the strategies used in specific situations, subjects in the names and intention training conditions reported an increase in the use of the trained strategies on names and prospective situations respectively. Moreover, there was some evidence of a generalization of training to strategies that were not directly dealt with during training. The control group showed that repeated practice with memory tests may result in changes in strategy use in specific situations, which are not always for the better, how-ever.

[Memory tests in healthy elderly: age factors and norms]

The study aimed to assess the strength of age effects on both standard laboratory and ecological memory tests and the psychometric qualities of these tests. Furthermore, norm data are constructed. Memory performance was assessed in a random group of older adults (mean age 62 years, range 46-89) and a group of older adults having memory complaints who applied for memory training (mean age 63 years, range 45-85). Age effects were found on almost all memory tests, whether artificial laboratory or more ecological tests were used. Age effects remained generally present after correction for educational level. Retest reliabilities of the ecological memory tests did not differ systematically from those of standard laboratory tests. However, not all tests showed satisfactory retest reliabilities, this was even true for tests often used in clinical settings. For tests with retest reliabilities above r = .65 norms corrected for age and educational level were provided. The group of older adults having memory complaints performed on average better than the random group of older adults from the population. In the first group, higher performance thresholds should be employed in assessing whether memory performance is deviant.

[Suboptimal health and memory performance of elderly]

The influence of health-related incidents on memory test performance and subjective memory ratings was assessed in a) a group of healthy older adults recruited via the register of population (group 1: N = 117, mean age 62 years, range 46-89) and b) a group of healthy older subjects having memory complaints and applying for memory training (group 2: N = 111, mean age 63 years, range 45-85). The study tries to cross-validate a previous study, where the presence and frequency of health-related incidents were related to cognitive performance. The presence of 9 categories of health-related incidents (consultation of a neurologist, systemic diseases, repeated mild concussions, repeated anaesthesia, use of psychotropic medication, alcohol use, other neurotoxic factors, such as exposure to organic solvents, psychiatric disorders, birth complications or developmental problems) was assessed in a semi-structured interview. Memory performance was assessed with a battery covering different aspects of memory. Memory self-ratings were assessed with questionnaires asking for frequencies of memory failures and a general judgement of memory capacity. Health-related incidents occurred in about half of both subject groups and were not related to age or other demographic characteristics. In both subject groups, the presence, nor the number of health-related incidents was related to memory performance or memory complaints and there was no interaction with age. The results are not in agreement with the notion that health-related indices explain age differences in cognitive performance.

[Memory strategies in the elderly]

The frequency and preference of memory strategies were investigated in a group of independently living older adults (N = 111, 45-85 year) who were interested in memory training because of subjective and objective memory problems. Mokken scale analysis identified, besides the use of 'no strategy', four strategy scales, viz. encoding, retrieval, general, and external strategies. These five scales allowed for a differentiated analysis of strategy use. Frequency judgments showed that external strategies were used most frequently, followed by retrieval strategies. Encoding strategies were used least often. Reports on the preference of strategies in specific situations showed that subjects reported to use specific strategies in the majority of situations, although here too external strategies were used most generally. Strategy reports were more related to psychological variables (mental speed, primary memory ability, need for cognition and memory complaints) than to demographic characteristics (age, educational level and sex). The explained variances, however, were low which suggests substantial individual differences in use and preference of memory strategies.

[Memory and learning abilities in everyday life of the elderly]

Self-evaluations by adults (varying in age from 45-92 years) of their memory and learning abilities were investigated and related to performance on laboratory and ecological memory tasks. Hardly any association was found between subjective and objective measures. Self-evaluations were strongly influenced by (systematically varied) frames of reference: optimistic in comparisons with other people, pessimistic in comparisons with their own previous level of functioning. The most frequent problems were 'learning something new' and 'remembering names'. In contrast to external memory aids, cognitive strategies were rarely used spontaneously. Strategy training led to significant improvement of performance, that remained stable at follow-up. A further opportunity for improving performance was realized by ergonomic adaptations of computerized systems (teleshopping). Problems in learning to use such systems were strongly reduced by decreasing the load on working memory and by adapting the system to existing knowledge and skills of the users. A general observation in the different projects was that age-differences could explain only a small percentage of the variance in subjective and objective memory measures.

[Memory training for remembering names: initial results in the healthy elderly]

In this study, a memory training program for remembering names was developed. It was assumed that names are remembered better if they have meaning. The effect of training is compared with two control conditions a) a placebo training, aimed at reducing worries about forgetfulness by giving information about memory and aging and b) a retest control group. Participants were healthy persons over 43 years old (M = 70 years) having subjective memory complaints and objective memory problems. The effect of training is evaluated with tasks for remembering names. Because the learned memory strategy can be applied to these tasks, these are called target memory tests. Other evaluation measures concerned remembering verbal information and intentions. These are called control memory tests, because the memory strategy learned cannot be applied directly. In accordance with the expectations, performance in the placebo training group (n = 10) did not improve more than in the retest control group (n = 11). The names training group (n = 13) improved more than both control groups on tests for remembering names. This improvement was maintained for at least three months after training. As expected, the improvement in performance on the target memory tests did not generalize to the control tasks, because of the specificity of the learned strategies.

Spared recognition capacity in elderly and closed-head-injury subjects with clinical memory deficits

This study describes the performance of three groups of subjects on a pictorial forced-recognition task, the Hundred Pictures Test. The aim was to determine whether subjects with memory deficits (elderly and closed-head-injured subjects) would perform as well as healthy young subjects, both on immediate and very long-term recognition. The results indicate that memory for complex meaningful pictures is spared in subjects with an otherwise impaired memory, and that despite increasing forgetting rates with increasing retention intervals (up to 27 weeks), still no differences are found between performance of these subjects and healthy young controls. It will be discussed how this result might be interpreted.

[Are memory courses effective?]

After a general overview of the many forms, aims and methods of memory courses, especially in the Netherlands, a strategy-oriented memory course for healthy elderly in a residential home is evaluated. The participants (N = 18) were compared with control subjects from the same home of comparable age, level of education and memory performance. Significant effects of the course could be demonstrated on subjective measures of memory but not on objective and 'ecologically valid' memory tests. Although one could consider subjectively experienced memory improvement as a very satisfactory result of memory courses, the authors state that adjustments to achieve objectively demonstrable progress are both necessary and possible.