Enthesitis and its relationship with disease activity, functional status, and quality of life in psoriatic arthritis: a multi-center study

Psoriatic arthritis (PsA) is an inflammatory arthritis with distinct phenotypic subtypes. Enthesitis is assigned as a hallmark of the disease, given its significant relations to disease activity and quality of life. Our objective is to evaluate the prevalence of enthesitis and its association with some clinical parameters, particularly quality of life, using data from a national registry. Patients with PsA meeting ClASsification criteria for Psoriatic Arthritis (CASPAR) were enrolled by means of a multi-centre Turkish League Against Rheumatism (TLAR) Network Project. The following information was recorded in web-based case report forms: demographic, clinical and radiographic data; physical examination findings, including tender and swollen joint counts (TJC and SJC); nail and skin involvement; Disease Activity Score-28 for Rheumatoid Arthritis with Erythrocyte Sedimentation Rate (DAS 28-ESR); Bath Ankylosing Spondylitis Disease Activity Index (BASDAI); Maastricht Ankylosing Spondylitis Enthesitis Score (MASES); Psoriasis Area Severity Index (PASI); Bath Ankylosing Spondylitis Radiology Index for the spine (BASRI-s); Health Assessment Questionnaire (HAQ); Bath Ankylosing Spondylitis Functional Index (BASFI); Health Assessment Questionnaire for the spondyloarthropathies (HAQ-s); Psoriatic arthritis quality of Life scale (PsAQoL); Short Form 36 (SF-36); Hospital Anxiety Depression Scale (HADS); Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F); and Fibromyalgia Rapid Screening Tool (FiRST) scores. The patients were divided into two groups, namely with and without enthesitis, based on the triple Likert-type physician-reported statement of 'active enthesitis', 'history of enthesitis' or 'none' in the case report forms. Patients with active enthesitis were compared to others in terms of these clinical parameters. A total of 1130 patients were enrolled in this observational study. Of these patients, 251 (22.2%) had active enthesitis according to the clinical assessment. TJC, HAQ-s, BASDAI, FiRST and PsAQoL were significantly higher whereas the SF-36 scores were lower in patients with enthesitis (p < 0.05). Chronic back pain, dactylitis, and tenosynovitis were more frequent in the enthesopathy group (59.4%/39%, 13.1%/6.5% and 24.7%/3.4%, respectively). Significant positive correlations between the MASES score and the TJC, HAQ, DAS 28-ESR, BASDAI, FiRST and PsAQoL scores, and a negative correlation with the SF-36 score were found. When linear regression analysis was performed, the SF-36 MCS and PCS scores decreased by - 9.740 and - 11.795 units, and the FiRST scores increased by 1.223 units in patients with enthesitis. Enthesitis is an important involvement of PsA with significant relations to quality of life determined with PsAQoL and SF-36 scores. Our study found higher frequency of dactylitis and chronic back pain, and worse quality of life determined with SF-36 and PsAQoL scores in patients with enthesitis.

The prevalence of fibromyalgia in patients with Behçet's disease and its relation with disease activity

Behçet's disease (BD) is a chronic disorder characterized by mucocutaneous and multisystem manifestations. Fibromyalgia (FM) is characterized by widespread musculoskeletal pain and may be present concomitantly with several rheumatic diseases. Our aims were to investigate the prevalence of FM in patients with BD and to evaluate the possible relation of FM presence with BD disease activity. A total of 104 Behcet patients were included in this study. Age, sex, disease durations and the BD Current Activity Form (BDCAF) scores as disease activity evaluation were recorded. Presence of FM and the Fibromyalgia Impact Questionnaire (FIQ) scores was investigated. Also, ESR and CRP concentrations were determined in all patients. Mann-Whitney U test and Pearson's correlation tests were used for the statistical analysis. There were 60 female and 40 male patients with an age range of 19-51 years. Eighteen of 100 BD patients were diagnosed as FM. Although ages, disease duration and laboratory parameters did not differ between BD patients with and without FM, BD patients with FM were more frequently female (p < 0.000). The presence of FM did not differ significantly between patients with and without systemic manifestations. Also, oral-genital ulcers, erythema nodosum, thrombophlebitis, pustular lesions and doctor's impression of disease activity scores were not found to be different in BD patients with or without FM. However, there were significant differences in fatigue, headache, arthralgia and patient impression of disease activity (today and last 28 days) between these groups (p < 0.000; p < 0.01; p < 0.01; p = 0.021 and p = 0.027, respectively). Also, there were significant correlations between BDCAF and FIQ items that refer pain and fatigue (p < 0.01). FM is a common and important clinical problem that may represent an additional factor that worsens pain and physical limitations in patients with BD. The higher prevalence of FM in patients with BD seems to be affected by BD itself, rather than its severity.

Effects of dynamic exercise on circulating IGF-1 and IGFBP-3 levels in patients with rheumatoid arthritis or ankylosing spondylitis

This study was performed to determine the effects of short-term dynamic exercise on serum insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3) levels in the patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Patients with RA or AS and healthy controls were recruited. Dynamic treadmill exercise therapy was accomplished for 20 min/session with all of the participants. There were five sessions per week for 2 weeks. Morning stiffness duration, body pain, Stanford health assessment questionnaire, Ritchie articular index, Bath ankylosing spondylitis disease activity index (BASDAI), and Bath ankylosing spondylitis functional index (BASFI) were evaluated in the RA and AS patients. Laboratory assessments included: erythrocyte sedimentation rate, serum C-reactive protein, IGF-1, and IGFBP-3. Clinical and laboratory assessments were recorded at baseline and during exercise treatment on days 7 and 15. Twenty patients with RA, 15 with AS, and 14 healthy controls were included in this study. The pain evaluation, Ritchie, BASDAI, and BASFI scores were significantly improved by the exercise treatment in both patient groups. The important increases were found in circulating IGF-1 in RA (p < 0.001) and AS (p = 0.001) at the end of 2 weeks. In control individuals, serum IGF-1 levels showed a significant decline in the first week (p < 0.05). No significant changes were observed on serum IGFBP-3 levels. Our data suggest that serum IGF-1 levels are increased by the dynamic exercise program in RA and AS patients. The increased IGF-1 may play an important role in the beneficial effects of dynamic exercise therapy in these patients.

The effect of individualized diet challenges consisting of allergenic foods on TNF- and IL-1 levels in patients with rheumatoid arthritis

OBJECTIVE

To investigate the effect of individualized diet challenges consisting of allergenic foods, defined by the skin prick test (SPT), on tumour necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) levels in patients with rheumatoid arthritis (RA).

METHODS

Twenty patients with a positive SPT response for food extracts and 20 with a negative SPT response were enrolled. None of the patients had active disease. All patients were fasted for the most common allergenic foods for 12 days and then allocated to two groups according to SPT results. Food challenges were performed with allergenic foods in the prick-positive group (PPG) and with corn and rice in the prick-negative group (PNG) for a period of 12 days. Then, allergenic foods were excluded from the PPG patients' diet and corn and rice were removed from the PNG patients' diet. Clinical examinations were performed after fasting (baseline), at the end of the challenge phase and at the end of the re-elimination phase. Stiffness, pain, tender and swollen joint counts, health assessment questionnaire (HAQ), Ritchie's articular index, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and serum TNF-alpha and IL-1beta levels were measured.

RESULTS

TNF-alpha (P < 0.01), IL-1beta (P < 0.05), ESR (P < 0.05) and CRP (P = 0.001) levels and all of the clinical variables, except HAQ, were increased with food challenges in the PPG. These increases were also recorded after the re-elimination phase. In the PNG, no significant change was seen in any of the variables, except pain (P < 0.05). During the study, important differences were observed for most of the variables between the two groups. Thirteen (72%) patients in the PPG and three (18%) in the PNG experienced disease exacerbation with challenges. This aggravation continued after elimination.

CONCLUSIONS

Our results suggest that individualized dietary revisions may regulate TNF-alpha and IL-1beta levels in selected patients with RA.

Association between dynamic exercise therapy and IGF-1 and IGFBP-3 concentrations in the patients with rheumatoid arthritis

We aimed to evaluate the relationship between short-term dynamic exercise therapy and insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3) levels in rheumatoid arthritis (RA) patients. Forty RA patients were assigned into dynamic or range of motion (ROM) exercise groups. Also control group carried out the same dynamic exercise protocol. Morning stiffness, pain (VAS), Health assessment questionnaire (HAQ) and Ritchie articular index (RAI) were evaluated and erythrocyte sedimentation rate, serum C-reactive protein, IGF-1 and IGFBP-3 levels of the participants were recorded. The assessments were determined before, at the 7th and 15th days of treatment. VAS and RAI scores were significantly improved by the dynamic exercises in RA patients. There were increases on IGF-1 in dynamic exercise group, although IGF-1 levels showed a decrease in ROM exercise and control groups. Also no significant changes were observed on IGFBP-3 in three groups. Our results suggest that short-term dynamic exercise therapy increases serum IGF-1 in RA patients. The manipulation of serum IGF-1 levels by dynamic exercise therapy may indicate the beneficial effects of dynamic exercise in RA patients.

Does Neuropathic Pain Affect the Quality of Sleep?

OBJECTIVE

We aimed to evaluate the quality of sleep (QoS) in patients with neuropathic pain (NP) and to investigate the association between possible QoS impairment and NP characteristics.

MATERIALS AND METHODS

Patients with NP and controls were examined. Age, sex, NP duration, NP cause (central, peripheral, or mixed), and pain intensity (with a Likert-type scale and visual analog scale) were recorded. NP was screened with Douleur Neuropathique 4 questions (DN4), and QoS was evaluated using the Pittsburg Sleep Quality Index (PSQI). Mann-Whitney U test and regression analysis were performed to evaluate the data.

RESULTS

Seventy patients with NP and 30 age- and sex-matched controls were included. The mean age of the patients and controls were 45.04±10.21 years and 39.00±19.23 years, respectively. Significantly higher scores of sleep latency (p=0.002), sleep duration (p=0.003), sleep efficiency (p=0.002), sleep disturbance (p<0.000), daytime dysfunction (p=0.04), and PSQI total were observed in patients with NP than in controls (p<0.000). In addition, 80% of patients with NP and 37 % of controls were classified as having poor QoS (p<0.000). Female sex, pain intensity, and NP duration were found to be factors related to having poor QoS in patients with NP (p=0.026, p=0.006, and p<0.000, respectively).

CONCLUSION

In our study, 80% of patients with NP had poor QoS regardless of the NP cause. Female sex, pain severity, and NP duration were found to be factors correlated with poor QoS. Treatment strategies that target not only NP itself but also better QoS may contribute to the overall success of management.

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

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

Protracted febrile myalgia syndrome in familial Mediterranean fever

Familial Mediterranean fever (FMF) is an autosomal, recessively inherited multisystem disease that affects various groups of people originating from the Mediterranean Sea region, most specifically those of Jewish, Turkish, Armenian, and Arabic ethnicity. Recurrent attacks of fever and sterile polyserositis of the peritoneum, synovial membranes, and pleura are the main clinical features, although the clinical features of FMF have been expanded in recent years to also include severe myalgia, scrotal swelling, cardiac involvement, and protracted febrile myalgia syndrome (PFMS). PFMS is seen in only a small percentage of FMF patients and is characterized by severe debilitating myalgia of the upper and lower extremities and high fever, occasionally accompanied by abdominal pain, diarrhea, arthritis/arthralgia, and transient vasculitic purpura mimicking Henoch-Schönlein purpura (HSP). Here, we report on a patient with FMF who also presents with PFMS, which is an uncommon and severe manifestation of the disease.

Impact of obesity on quality of life, psychological status, and disease activity in psoriatic arthritis: a multi‑center study

This article aims to evaluate the possible effect of obesity on quality of life, psychological status, and other clinical variables in Psoriatic arthritis (PsA). PsA patients have been recruited by the Turkish League Against Rheumatism-Network from various centers in Turkey in this cross-sectional study. Patients with a body mass index (BMI) ≥ of 30 kg/m² were considered obese. Differences among patients with regard to obesity status were assessed with health-related quality of life measures (PsA Quality of Life Questionnaire [PsAQoL]), psychological status (Hospital Anxiety and Depression Scale [HADS]), and disease activity parameters (the Disease Activity index for PSoriatic Arthritis [DAPSA], Disease Activity Score 28-C-reactive protein [DAS28-CRP], Bath Ankylosing Spondylitis Disease Activity Index [BASDAI], Psoriasis Area and Severity Index [PASI]), physical functions (Ankylosing Spondylitis Functional Index [BASFI], Health Assessment Questionnaire [HAQ], and Health Assessment Questionnaire for the spondyloarthropathies [HAQ-S]). Pain was assessed using visual analog scale of pain (VAS-P), and fatigue was evaluated using visual analog scale of fatigue (VAS-F) and Functional Assessment of Chronic Illness Therapy (FACIT). A total of 1033 patients with PsA, 650 (62.9%) non-obese and 383 (37.1%) obese were included in the study. The PsAQoL, HADS-Anxiety, HADS-Depression, DAPSA, DAS28-CRP, BASDAI, BASFI, HAQ and HAQ-S scores of the obese group were higher than the non-obese group (p < 0.05). VAS-P and PASI scores were similar between group of patients with and without obesity. Obese patients had higher median scores of VAS-F and FACIT than non-obese patients (p < 0.05). Linear regression analysis showed that BMI affects the quality of life, depression, and disease activity. Consequently, obesity has significant associations with higher disease activity, lower QoL, risk of anxiety, depression, and fatigue. Therefore, obesity should also be taken into account in the management of PsA patients.

General or personal diet: the individualized model for diet challenges in patients with rheumatoid arthritis

This study was performed to evaluate the effect of individualized diet challenges consisting of allergen foods on disease activity in rheumatoid arthritis (RA) patients. Twenty patients with positive skin prick test (SPT) response for food extracts and 20 with negative SPT response were included. All patients were instructed to restrict the most common allergen foods during 12 days and then assigned into two groups according to SPT results. Food challenges were performed with all of the allergen foods in prick test positive group (PTPG) and with corn and rice in prick test negative group (PTNG) during 12 days. Allergen foods were then eliminated from PTPG patients' diet, while corn and rice were removed in PTNG. Clinical evaluations were performed after fasting (baseline), at the end of the challenge phase and reelimination phase. Stiffness, pain, physician's and patient's global assessment of disease activity, health assessment questionnaire (HAQ), Ritchie's index, serum amyloid A protein, erythrocyte sedimentation rate and C-reactive protein were determined. All of the disease variables, except HAQ, were increased with food challenges in PTPG. In PTNG, no significant change was observed in any of the variables except pain (P<0.05) and patient's global assessment (P<0.05). Our results showed that the individualized dietary manipulations may effect the disease activity for selected RA patients.

Legg-Perthes disease-like joint involvement and diagnosis delay in Scheie syndrome: a case report

Mucopolysaccharidosis (MPS) type I is an inherited disease caused by the absence or malfunctioning of lysosomal enzymes. Three subtypes, based on severity of symptoms, were described, and Scheie syndrome (also called MPS I S) is the mildest form. Although there may be some typical extra-articular manifestations, musculoskeletal involvement may be the only presenting sign in the absence of other symptoms in the patients with less severe forms. The patients with MPS I S, especially in attenuated phenotypes, may be sometimes difficult to recognize for physicians not familiar with the disease. With this case presentation, it is aimed to draw attention to this disease, which could be delayed for the correct diagnosis. An increased awareness of the disease may contribute to more accurate diagnosis, and patients may benefit from early intervention.

Hyperostosis frontalis interna in a patient with giant cell arteritis

Hyperostosis frontalis interna (HFI) is a disorder characterized by progressive symmetric thickening of the inner table of the frontal bone of the human skull. HFI may be accompanied by headache and some neuropsychiatric diseases such as epilepsy and dementia. Giant cell arteritis (GCA), also called temporal arteritis, is a systemic inflammatory vasculitis of unknown etiology that affects medium- and large-sized arteries. It affects elderly people and may result in a wide variety of systemic, neurologic and ophthalmologic complications. As no association of HFI and GCA was encountered in the literature, we found it interesting to report a case with both of these clinical entities.

Demographic and Clinical Characteristics of Patients with Sustained and Switching Treatments Using Biological and Targeted Synthetic Disease-Modifying Antirheumatic Drugs: A Multicenter, Observational Cross-Sectional Study for Rheumatoid Arthritis

Introduction

Rheumatoid arthritis is a chronic inflammatory disease with different disease activity grades. Several registries have been designed to determine the appropriate regimens of disease-modifying antirheumatic drugs to obtain sustained clinical remission. We examined epidemiological and clinical characteristics of rheumatoid arthritis patients using a clinical registry database (BioSTaR) and analyzed the differences in patients with sustained and switched therapies.

Methods

A multicenter, observational cross-sectional study for rheumatoid arthritis was performed between February 2019 and September 2020 using the BioStaR-RA registry.

Demographic and clinical characteristics were prospectively recorded into a specifically designed electronic database. The patients were divided into three groups due to the heterogeneity of the study cohort. Patients were grouped as Group I (Initial; within the first 6 months of treatment with biological/targeted synthetic drugs), Group ST (Sustained Treatment; any first drug lasting for at least 6 months without any change), and Group S (Switch; any switching to another drug). Comparative analysis was performed between sustained treatment (Group ST) and drug switching (Group S) groups.

Results

The study included a total of 565 patients. The mean age was 53.7 ± 12.8 years, and the majority were female (80.4%). There were 104, 267, and 194 patients in Groups I, ST, and S, respectively. Erosive arthritis and hematological extra-articular involvement were more frequently detected in Group S than Group ST (p = 0.009 and p = 0.001). The patients in Group S had significantly higher disease activity scores (DAS28-CRP, CDAI, and SDAI) (p = 0.025, p = 0.010, and p = 0.003). There were significantly more patients with moderate disease activity in Group S (p < 0.05).

Conclusions

The groups with sustained treatment and switching included patients with different disease activity status, although higher disease activity was determined in switchers. Overall, moderate disease activity and remission were the most common disease activity levels. Lower disease activity scores, lower hematologic manifestations, better functional status, and lesser radiographic damage are associated with sustained treatment.

Clinical performance of rheumatoid arthritis impact of disease score: a real-life evidence from the multicenter nationwide registry BioStaR

The rheumatoid arthritis impact of disease (RAID) score was developed as a patient-derived composite response index for the evaluation of the disease impact on cases with rheumatoid arthritis (RA). The aim of this study was to evaluate the psychometric properties and performance of RAID score in the real-life settings. Cases with RA from our multi-center, nationwide registry called Biologic and targeted Synthetic antirheumatic drugs Registry RA (BioStaR RA) were included in this cross-sectional observational study. Demographic data, disease duration, pain, patient's global assessment (PGA) and physician's global assessment (PhyGA) were recorded. DAS28-ESR, DAS28-CRP, the simplified disease activity index (SDAI) and the clinical disease activity index (CDAI) were assessed as disease activity evaluations. The health assessment questionnaire-disability index (HAQ-DI) and RAID were completed by all the participants. The construct validity was tested by the analysis of correlations between RAID score and scores of PGA, disease activity indexes and HAQ-DI. We also evaluated the discriminatory ability of RAID to distinguish patients with different levels of disease activity and disability and the cut-off values were calculated by ROC analysis. 585 cases with RA were included in this investigation. The RAID score was significantly positively correlated with PGA, all disease activity indexes and HAQ-DI (p < 0.001). The discriminatory ability of RAID score in different disease activity and disability groups was also demonstrated (p < 0.001). To estimate DAS28-ESR (remission/low + moderate + high), RAID score cut-off points were 2.88 (sensitivity 73%, specificity 62%), 3.23 (sensitivity 75%, specificity 60%) and 3.79 (sensitivity 74%, specificity 58%), respectively. Our study indicated that RAID was a reliable tool in daily clinical practice by presenting its correlations with disease activity and disability assessments and by showing its discriminatory ability in these parameters in the real-life experiences.