Developing Ultrasound Measures for the Early Diagnosis of Psoriatic Arthritis

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) ultrasound (US) steering committee provided an update at GRAPPA's 2022 annual meeting on activities to enable earlier diagnosis of psoriatic arthritis. An update of the Diagnostic Ultrasound Enthesitis Tool (DUET) study included preliminary reliability results for US enthesitis elementary lesions. Common scanning pitfalls were reviewed. New projects included widening the scope of US beyond large entheses and validating small point-of-care US probes to evaluate enthesitis.

Sex differences in the efficacy, safety and persistence of patients with psoriatic arthritis treated with tofacitinib: a post-hoc analysis of phase 3 trials and long-term extension

BACKGROUND

Evaluate the impact of sex on tofacitinib efficacy, safety and persistence (time to discontinuation) in patients with psoriatic arthritis (PsA).

METHODS

Data were pooled from two phase 3 randomised controlled trials. Patients were randomised to tofacitinib 5 mg or 10 mg two times per day, adalimumab 40 mg every 2 weeks or placebo. Efficacy outcomes to month 12 included American College of Rheumatology (ACR)20/50/70, minimal disease activity (MDA), Psoriasis Area Severity Index (PASI)75, change from baseline (∆) in Health Assessment Questionnaire-Disability Index (HAQ-DI) and ∆Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). Safety was assessed to month 12 and persistence was assessed to month 42 of a long-term extension study.

RESULTS

Overall, 816 patients were included (54.3% females). At baseline, higher tender joint counts, enthesitis scores and worse HAQ-DI and FACIT-F were reported in females versus males; presence of dactylitis and PASI were greater in males versus females. At month 3, tofacitinib efficacy generally exceeded placebo in both sexes. Overall, similar ACR20/50/70, PASI75, ∆HAQ-DI and ∆FACIT-F were observed for tofacitinib between sexes; females were less likely to achieve MDA. Similar proportions of males/females receiving tofacitinib (both doses) experienced treatment-emergent adverse events (AEs). Serious AEs occurred in 3.4%/6.6% and 4.0%/5.9% males/females with tofacitinib 5 mg and 10 mg two times per day. Persistence was generally similar between sexes.

CONCLUSION

Tofacitinib efficacy exceeded placebo in both sexes and was comparable between sexes. Consistent with previous studies of PsA treatments, females were less likely to achieve MDA, likely due to baseline differences. Safety and time to discontinuation were generally similar between sexes.

TRIAL REGISTRATION NUMBER

NCT01877668; NCT01882439; NCT01976364.

Measurement properties of outcome instruments for large-vessel vasculitis: a systematic literature review

Objective

To systematically review the measurement properties of outcome instruments used in large-vessel vasculitis (LVV).

Methods

Medline, EMBASE, Cochrane and Scopus, were searched from inception to July 14, 2020 for studies addressing measurement properties of instruments used in giant cell arteritis (GCA) and Takayasu arteritis (TAK). The measurement properties of the instruments identified were collected following the OMERACT and COSMIN frameworks. Instruments were grouped according to the following domains measured: disease activity/damage, organ function, and health-related quality of life (HRQoL)/Health status.

Results

From 3534 articles identified, 13 met the predefined criteria. These studies addressed 12 instruments: 4 specific to TAK, 2 designed for all systemic vasculitis, and 6 non-diseasespecific instruments. No instruments specific to GCA were identified. In TAK, the Indian Takayasu Clinical Activity Score (ITAS) showed very good consistency, adequate reliability, but doubtful validity for disease activity. The Disease Extent Index-Takayasu (DEI-Tak) showed adequate construct but doubtful discriminating validity for disease activity/damage. Instruments, such as the Vasculitis Damage Index (VDI) and the Birmingham Vasculitis Activity Score (BVAS) were poorly assessed for disease activity/damage. Six non-vasculitisspecific patient-reported outcomes (PROs) instruments showed inadequate validity in GCA/TAK.

Conclusion

The measurement properties of 12 outcome instruments for LVV covering the OMERACT domains of disease activity/damage, organ function, and HRQoL were assessed. ITAS and DEI-Tak were the instruments with more adequate measurement properties for disease activity/damage in TAK. Disease activity/damage instruments specific for GCA, and validated PROs for both GCA and TAK are lacking.

Hidden in plain sight: Is there a crucial role for enthesitis assessment in the treatment and monitoring of axial spondyloarthritis?

OBJECTIVE

To review the evidence surrounding the pathophysiology of enthesitis in axial spondyloarthritis (axSpA), its prevalence and contribution to the overall disease burden, and response to treatment at axial and peripheral sites.

METHODS

Literature searches of the Cochrane Library, PubMed, and Embase / Medline using the terms "enthesitis", "enthesopathy", "spondyloarthritis", "axial spondyloarthritis", and "ankylosing spondylitis" were conducted. Publications mentioning enthesitis or enthesopathy in the context of pathophysiology, diagnosis, or treatment were included.

RESULTS

Enthesitis is a common symptom of axSpA, occurring with high prevalence at axial and several peripheral sites. Inflammation at the site of enthesis is an early key manifestation of axSpA. Clinically evaluable enthesitis contributes significantly to the burden of disease, correlating with worse symptomatology and downstream structural damage. Despite its importance in driving axSpA disease processes, enthesitis is somewhat neglected in current approaches to disease assessment and management. Enthesitis is excluded from some commonly used disease activity measures, is not routinely assessed in clinical practice, and many methods of clinical assessment omit key accessible axial sites, such as the spinous processes.

CONCLUSION

Enthesitis plays a central role in driving the pathophysiology of axSpA. There is a need for a renewed focus on the early detection, measurement and treatment of enthesitis.

The effects of an 8-week knitting program on osteoarthritis symptoms in elderly women: A pilot randomized controlled trial

BACKGROUND

Exercise therapy is effective in reducing symptoms and disability associated with hand osteoarthritis (HOA) but often has low adherence. An intervention consisting in a meaningful occupation, such as knitting, may improve adherence to treatment. This pilot randomized controlled trial (RCT) studied the adherence and clinical effectiveness of a knitting program in older females suffering from HOA to evaluate the acceptability of this intervention and assess the feasibility of a larger-scale RCT.

METHODS

Single-blind, two-arm pilot RCT with a parallel group design with 37 participants (18 control, 19 intervention). Control participants were given an educational pamphlet and assigned to a waiting list. The knitting program (8-week duration) had two components: bi-weekly 20-min group knitting sessions and daily 20-min home knitting session on the 5 remaining weekdays. Measures included knitting adherence (implementation outcomes) as well as stiffness, pain, functional status, hand physical activity level, patient's global impression of change, health-related quality of life, self-efficacy, and grip strength (clinical outcomes measured throughout the 8-week program and 4 weeks after the intervention).

RESULTS

Our protocol is feasible and the intervention was acceptable and enjoyable for participants, who showed high adherence. No difference was observed between the two groups for any of the clinical outcome measures (all p > .05).

CONCLUSION

Knitting is a safe and accessible activity for older women with HOA. However, our 8-week knitting program did not result in improvements in any of our outcome measures. Knitting for a longer period and/or with higher frequency may yield better outcomes.

The Role of Ultrasound in Research and Clinical Practice in Psoriatic Arthritis: Highlights From the GRAPPA Ultrasound Workshop

Ultrasound (US) is a valuable imaging modality that can accurately identify relevant features of psoriatic arthritis (PsA), such as synovitis, tenosynovitis, and enthesitis. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) Ultrasound Committee ran a workshop during the annual GRAPPA meeting that was held in July 2020. The group presented the following 3 topics: (1) the transition from psoriasis to PsA and the role of US; (2) the effect of biomechanical forces on the entheses in health and disease, and insight for PsA pathogenesis; and (3) differentiation of enthesitis from pain sensitization: use and limitations of clinical and sonographic evaluation of enthesitis. This article summarizes the key messages from this workshop.

Identification of susceptibility loci for Takayasu arteritis through a large multi-ancestral genome-wide association study

Takayasu arteritis is a rare inflammatory disease of large arteries. We performed a genetic study in Takayasu arteritis comprising 6,670 individuals (1,226 affected individuals) from five different populations. We discovered HLA risk factors and four non-HLA susceptibility loci in VPS8, SVEP1, CFL2, and chr13q21 and reinforced IL12B, PTK2B, and chr21q22 as robust susceptibility loci shared across ancestries. Functional analysis proposed plausible underlying disease mechanisms and pinpointed ETS2 as a potential causal gene for chr21q22 association. We also identified >60 candidate loci with suggestive association (p < 5 × 10^-5) and devised a genetic risk score for Takayasu arteritis. Takayasu arteritis was compared to hundreds of other traits, revealing the closest genetic relatedness to inflammatory bowel disease. Epigenetic patterns within risk loci suggest roles for monocytes and B cells in Takayasu arteritis. This work enhances understanding of the genetic basis and pathophysiology of Takayasu arteritis and provides clues for potential new therapeutic targets.

The impact of smoking on prevalence of psoriasis and psoriatic arthritis

Objectives

In this systematic literature review and meta-analysis, we aimed to investigate the impact of cigarette smoking on the prevalence and incidence of psoriasis and psoriatic arthritis (PsA).

Method

We performed a systematic literature review using the MEDLINE, EMBASE and Cochrane Central Register databases. The literature included publications from January 1980 to July 2019. The studies that provided clear information on the number of patients with ever smoking data were included in the meta-analysis.

Results

The systematic literature review identified 52 and 24 articles for the prevalence of smoking in psoriasis and PsA, respectively. Of these, 16 articles on psoriasis and three and four (general population and psoriasis, respectively) articles on PsA met the criteria and were included in the meta-analysis. The prevalence of ever smoking was increased in psoriasis compared with the general population (OR: 1.84; 95% CI: 1.4, 2.3). For PsA the prevalence of ever smoking was reduced in psoriasis patients (OR: 0.70; 95% CI: 0.60, 0.81), but not changed compared with the general population (OR: 1.10; 95% CI: 0.92, 1.32).

Conclusion

This meta-analysis showed that ever smoking increases the risk of psoriasis in the general population, but may reduce the risk of PsA in psoriasis patients. The latter may be also due to the collider effect. Whether smoking cessation neutralizes the risk of developing psoriasis requires a well-defined smoking data collection for the past history and this is currently unavailable in the literature.

Update on Outcome Measure Development in Large-vessel Vasculitis: Report from OMERACT 2018

OBJECTIVE

The Outcome Measures in Rheumatology (OMERACT) Vasculitis Working Group seeks to develop validated outcome measures for use in trials for large-vessel vasculitis (LVV).

METHODS

An international Delphi exercise conducted among investigators identified items considered important to measure active disease. In parallel, qualitative research with patients was conducted, including interviews and focus groups.

RESULTS

Next steps prioritized by the group for LVV include (1) defining disease states (remission, flare, and patient-acceptable symptom state) and (2) selection of patient-reported outcome tools.

CONCLUSION

The ultimate goal is to develop an OMERACT-endorsed core set of outcome measures for use in clinical trials of LVV.

Options for Assessing Joints and Entheses in Psoriatic Arthritis by Ultrasonography and Magnetic Resonance Imaging: How to Move Forward

Psoriatic arthritis (PsA) is a heterogeneous disease with various manifestations of musculoskeletal inflammation. Recent advances in imaging, including ultrasound (US) and magnetic resonance imaging (MRI), allow for the accurate evaluation of the extent of inflammation and damage in the peripheral joints, spine, and entheses. The development and validation of outcome measures are critical steps in creating standardized evaluations of musculoskeletal inflammation and damage in psoriatic patients. At the 2017 meeting of the Group for Research and Assessment of Psoriasis and PsA (GRAPPA), recent work on outcome measures from the GRAPPA US and MRI working groups was summarized. The GRAPPA US group has been developing and validating a sonographic enthesitis scoring system in PsA. The GRAPPA MRI group focuses on the evaluation of whole-body MRI for the assessment of musculoskeletal inflammation in the joints and entheses in patients with PsA.

Psoriatic Arthritis Sonographic Enthesitis Instruments: A Systematic Review of the Literature

Objective.

As part of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) ultrasound working group, we performed a systematic review of the literature to assess the evidence and knowledge gaps in scoring instruments of enthesitis in psoriatic arthritis (PsA).

Methods.

A systematic search of PubMed, EMBase, and Cochrane databases was performed. The search strategy was constructed to find original publications containing terms related to ultrasound, enthesitis, spondyloarthritis (SpA) or PsA. Data extraction focused on the properties of the sonographic enthesitis instruments used in each study following components of the Outcome Measures in Rheumatology (OMERACT) filter: feasibility, test-retest reliability, construct validity as related to clinical assessment of enthesitis, biomarkers of inflammation and imaging of enthesitis by other modalities, discriminative validity, and responsiveness to treatment.

Results.

Fifty-one of 310 identified manuscripts were included. Only 1 scoring instrument of enthesitis was specifically developed and validated in patients with PsA. Only 18 (35%) of the studies involved patients with PsA, while the remaining studies focused on SpA. In PsA, construct validity was assessed using biomarkers and clinical examination in 1 (2%) and 11 (21.5%) of the studies, respectively, whereas no studies used imaging for the same purpose. Only 2 (4%) of the studies assessed discriminative validity in PsA. Responsiveness to treatment was assessed in 7 studies, none of which included patients with PsA.

Conclusion.

Although sonographic enthesitis scoring instruments have been developed for SpA, only a few have been validated in PsA. None of them passed the OMERACT filter in patients with PsA. Additional research is required before endorsing a specific instrument for the assessment of enthesitis in patients with PsA.

The Ottawa Panel guidelines on programmes involving therapeutic exercise for the management of hand osteoarthritis

OBJECTIVE:

To identify programmes involving therapeutic exercise that are effective for the management of hand osteoarthritis and to provide stakeholders with updated, moderate to high-quality recommendations supporting exercises for hand osteoarthritis.

METHODS:

A systematic search and adapted selection criteria included comparable trials with exercise programmes for managing hand osteoarthritis. Based on the evaluated evidence, a panel of experts reached consensus through a Delphi approach endorsing the recommendations. A hierarchical alphabetical grading system (A, B, C+, C, C-, D-, D, D+, E, F) was based on clinical importance (≥15%) and statistical significance ( P < 0.05).

RESULTS:

Ten moderate- to high-quality studies were included. Eight studies with programmes involving therapeutic exercise (e.g. range of motion (ROM) + isotonic + isometric + functional exercise) seemed to be effective. Forty-six positive grade recommendations (i.e. A, B, C+) were obtained during short-term (<12 weeks) trials for pain, stiffness, physical function, grip strength, pinch strength, range of motion, global assessment, pressure pain threshold, fatigue and abductor pollicis longus moment and during long-term (>12 weeks) trials for physical function and pinch strength.

CONCLUSION:

Despite that many programmes involving exercise with positive recommendations for clinical outcomes are available to healthcare professionals and hand osteoarthritis patients that aid in the management of hand osteoarthritis, there is a need for further research to isolate the specific effect of exercise components.

The knitting community-based trial for older women with osteoarthritis of the hands: design and rationale of a randomized controlled trial

BACKGROUND

The prevalence of hand osteoarthritis (HOA) has been reported to be higher amongst women over 50 years old (66%) compared to men of the same age (34%). Although exercise therapy has been shown effective in reducing symptoms and disability associated with HOA, adherence to treatment programs remains low. The primary objective of this RCT is to examine the effectiveness of a 12-week knitting program for morning stiffness (primary outcome) and pain relief (secondary outcome) 2 h post-wakening in females (aged 50 to 85 years old) with mild to moderate hand osteoarthritis (HOA).

METHODS/DESIGN

A single-blind, two-arm randomized controlled trial (RCT) with a parallel group design will be used to reach this objective and compare results to a control group receiving an educational pamphlet on osteoarththritis (OA) designed by the Arthritis Society. The premise behind the knitting program is to use a meaningful occupation as the main component of an exercise program. The knitting program will include two components: 1) bi-weekly 20-min knitting sessions at a senior's club and 2) 20-min home daily knitting sessions for the five remaining weekdays. Participants assigned to the control group will be encouraged to read the educational pamphlet and continue with usual routine. Pain, morning stiffness, hand function, self-efficacy and quality of life will be measured at baseline, six weeks, 12 weeks (end of program) with standardized tools. We hypothesize that participants in the knitting program will have significant improvements in all clinical outcomes compared to the control group. A published case study as well as the preliminary results of a feasibility study as examined through a 6-week pre-post study (n = 5 women with HOA) involving 20-min daily knitting morning sessions led to this proposed randomized controlled trial research protocol. This article describes the intervention, the empirical evidence to support it.

DISCUSSION

This knitting RCT has the potential to enhance our understanding of the daily HOA symptoms control and exercise adherence, refine functional exercise recommendations in this prevalent disease, and reduce the burden of disability in older women.

TRIAL REGISTRATION

(ACTRN12617000843358) registered on 7/06/2017.

Enthesitis: A hallmark of psoriatic arthritis

OBJECTIVE

To describe the growing importance of enthesitis in patients with psoriatic arthritis (PsA) and discuss the advantages and disadvantages of clinical and imaging methods currently used to assess enthesitis.

METHODS

PubMed literature searches were conducted using the terms psoriatic arthritis, entheses, enthesitis, pathology, imaging, ultrasound, magnetic resonance imaging, clinical, and indices. Articles were deemed relevant if they provided insight into the pathology, monitoring, and/or diagnosis of enthesitis in PsA, or if they discussed clinical or imaging indices used to assess enthesitis.

RESULTS

Enthesitis is an early manifestation of PsA that is associated with increased disease activity and reduced quality of life. A variety of clinical indices exist to assess enthesitis in PsA; however, the Leeds Enthesitis Index and Maastricht Ankylosing Spondylitis Enthesitis Score index have been the most frequently used indices in recent clinical trials. Limitations of these indices include an inability to discern structural involvement, risk of missing subclinical enthesitis, and lack of sensitivity in detecting enthesitis, especially in patients with central sensitization and/or pain amplification. Such limitations have led to the emergent importance of imaging techniques in the assessment of enthesitis. Although there have been recent advances in magnetic resonance imaging, ultrasound (US) appears to be the preferred method for detecting enthesitis because it allows for accurate assessment of the soft-tissue components of entheses and also for new bone formation. Hypoechogenicity, increased thickness of tendon insertion, calcifications, enthesophytes, erosions, and Doppler activity have been identified as important US characteristics of enthesitis.

CONCLUSION

Enthesitis is thought to be integrally involved in the pathogenesis of PsA and is associated with worse prognostic outcomes in patients with PsA. A validated US index with entheses that are less confounded by mechanical factors and obesity would be the most effective measure of enthesitis in PsA. As imaging techniques continue to advance, our understanding of enthesitis and its involvement in PsA will also improve.

Development of a Core Set of Outcome Measures for Large-vessel Vasculitis: Report from OMERACT 2016

OBJECTIVE

Among the challenges in conducting clinical trials in large-vessel vasculitis (LVV), including both giant cell arteritis (GCA) and Takayasu arteritis (TA), is the lack of standardized and meaningful outcome measures. The Outcome Measures in Rheumatology (OMERACT) Vasculitis Working Group initiated an international effort to develop and validate data-driven outcome tools for clinical investigation in LVV.

METHODS

An international Delphi exercise was completed to gather opinions from clinical experts on LVV-related domains considered important to measure in trials. Patient interviews and focus groups were completed to identify outcomes of importance to patients. The results of these activities were presented and discussed in a "Virtual Special Interest Group" using telephone- and Internet-based conferences, discussions through electronic mail, and an in-person session at the 2016 OMERACT meeting. A preliminary core set of domains common for all forms of LVV with disease-specific elements was proposed.

RESULTS

The majority of experts agree with using common outcome measures for GCA and TA, with the option of supplementation with disease-specific items. Following interviews and focus groups, pain, fatigue, and emotional effect emerged as health-related quality of life domains important to patients. Current disease assessment tools, including the Birmingham Vasculitis Activity Score, were found to be inadequate to assess disease activity in GCA and standardized assessment of imaging tests were felt crucial to study LVV, especially TA.

CONCLUSION

Initial data from a clinician Delphi exercise and structured patient interviews have provided themes toward an OMERACT-endorsed core set of domains and outcome measures.

Assessment of Disease Activity in Large-vessel Vasculitis: Results of an International Delphi Exercise

OBJECTIVE

To arrive at consensus for candidate outcomes for disease activity assessment in large-vessel vasculitis (LVV) in clinical trials.

METHODS

A Delphi survey including 99 items was circulated among international experts for 3 rounds.

RESULTS

Fifty-seven items were accepted for both giant cell arteritis and Takayasu arteritis. Sixty-seven percent of experts voted to have a common approach for both diseases with additional disease-specific items such as weight loss, scalp tenderness/necrosis, morning stiffness, dizziness, visual symptoms, and imaging.

CONCLUSION

This study highlights similarities and differences in experts' perspectives for assessing clinical activity in LVV and may guide a consensus-driven core set of validated outcomes.

Current Status, Goals, and Research Agenda for Outcome Measures Development in Behçet Syndrome: Report from OMERACT 2014

OBJECTIVE

There is an unmet need for reliable, validated, and widely accepted outcomes and outcome measures for use in clinical trials in Behçet syndrome (BS). Our report summarizes initial steps taken by the Outcome Measures in Rheumatology (OMERACT) vasculitis working group toward developing a core set of outcome measures for BS according to the OMERACT methodology, including the OMERACT Filter 2.0, and discussions during the first meeting of the BS working group held during OMERACT 12 (2014).

METHODS

During OMERACT 12, some of the important challenges in developing outcomes for BS were outlined and discussed, and a research agenda was drafted.

RESULTS

Among topics discussed were the advantages and disadvantages of a composite measure for BS that evaluates several organs/organ systems; bringing patients and physicians together for discussions about how to assess disease activity; use of organ-specific measures developed for other diseases; and the inclusion of generic, disease-specific, or organ-specific measures. The importance of incorporating patients' perspectives, concerns, and ideas into outcome measure development was emphasized.

CONCLUSION

The planned research agenda includes conducting a Delphi exercise among physicians from different specialties that are involved in the care of patients with BS and among patients with BS, with the aim of identifying candidate domains and subdomains to be assessed in randomized clinical trials of BS, and candidate items for a composite measure. The ultimate goal of the group is to develop a validated and widely accepted core set of outcomes and outcome measures for use in clinical trials in BS.

Assessment of Patients with Takayasu Arteritis in Routine Practice with Indian Takayasu Clinical Activity Score

Objective.

To assess the Indian Takayasu Clinical Activity Score (ITAS2010) in followup of Takayasu arteritis (TA).

Methods.

ITAS2010 forms were filled in prospectively (n = 144). Clinical activity was assessed with physician’s global assessment (PGA) and criteria defined by Kerr,et al.

Results.

ITAS2010 was significantly higher in patients with active disease. Total agreement between ITAS2010 and PGA was 66.4%, and between ITAS2010 and Kerr,et alwas 82.8%. During followup, 14 of 15 patients showing vascular progression with imaging were categorized as having inactive disease according to ITAS2010.

Conclusion.

ITAS2010 was discriminatory for activity during the followup, but the agreement between PGA and ITAS2010 was moderate. Future work should include the incorporation of advanced vascular imaging and demonstration of ITAS2010 as a scalable measure and not simply a dichotomous measure of activity/flare versus remission.

Identification of Susceptibility Loci in IL6, RPS9/LILRB3, and an Intergenic Locus on Chromosome 21q22 in Takayasu Arteritis in a Genome-Wide Association Study

OBJECTIVE

Takayasu arteritis is a rare large vessel vasculitis with incompletely understood etiology. This study was undertaken to perform the first unbiased genome-wide association analysis of Takayasu arteritis.

METHODS

Two independent cohorts of patients with Takayasu arteritis from Turkey and North America were included in our study. The Turkish cohort consisted of 559 patients and 489 controls, and the North American cohort consisted of 134 patients and 1,047 controls of European ancestry. Genotyping was performed using the Omni1-Quad and Omni2.5 genotyping arrays. Genotyping data were subjected to rigorous quality control measures and subsequently analyzed to discover genetic susceptibility loci for Takayasu arteritis.

RESULTS

We identified genetic susceptibility loci for Takayasu arteritis with a genome-wide level of significance in IL6 (rs2069837) (odds ratio [OR] 2.07, P = 6.70 × 10(-9)), RPS9/LILRB3 (rs11666543) (OR 1.65, P = 2.34 × 10(-8)), and an intergenic locus on chromosome 21q22 (rs2836878) (OR 1.79, P = 3.62 × 10(-10)). The genetic susceptibility locus in RPS9/LILRB3 lies within the leukocyte receptor complex gene cluster on chromosome 19q13.4, and the disease risk variant in this locus correlates with reduced expression of multiple genes including the inhibitory leukocyte immunoglobulin-like receptor gene LILRB3 (P = 2.29 × 10(-8)). In addition, we identified candidate susceptibility genes with suggestive levels of association (P < 1 × 10(-5)) with Takayasu arteritis, including PCSK5, LILRA3, PPM1G/NRBP1, and PTK2B.

CONCLUSION

Our findings indicate novel genetic susceptibility loci for Takayasu arteritis and uncover potentially important aspects of the pathophysiology of this form of vasculitis.

Familial Mediterranean fever gene (MEFV) mutations and disease severity in systemic lupus erythematosus (SLE): implications for the role of the E148Q MEFV allele in inflammation

OBJECTIVE

Observed low prevalence of SLE among familial Mediterranean fever (FMF) patients in several large cohorts suggests a possible protective effect of the MEFV mutations from SLE. In contrast, SLE patient carriers for the common MEFV mutations had rather complex disease expression with an increased frequency of febrile episodes and pleurisy and a decreased renal complication rate. Our aim was to investigate the prevalence of MEFV gene mutations in patients with SLE and their effect on organ involvement in a well-defined group of biopsy-proven SLE nephritis patients.

MATERIAL AND METHOD

The prevalence of four MEFV gene mutations (M694V, M680I, V726A and E148Q) was investigated in 114 SLE patients and effect on disease severity was analyzed in patients with biopsy-proven SLE nephritis.

RESULTS

None of the SLE patients fulfilled the revised Tel-Hashomer criteria. Fourteen of 114 SLE patients (12.2%) were found to carry at least one MEFV mutation. A single patient in the SLE-Nephritis group was compound heterozygous for M694V/M680I mutations and only one patient in the SLE-Mild group was homozygous for E148Q mutation. Carrier frequency was similar to controls in SLE patients (12.2 vs 18.8%, p = 0.34). After the exclusion of the less penetrant E148Q mutation, re-analysis revealed an association between exon 10 mutations and SLE nephritis (p = 0.050, odds ratio (OR) = 4.16, 95% confidence interval (CI) = 1.04-16.6). Carrier rate for the E148Q mutation decreased in the SLE group (controls vs. SLE = 20/186 vs. 3/114, p = 0.08) and E148Q mutation was absent in SLE nephritis (controls vs. SLE nephritis = 20/186 vs. 0/47, p = 0.016, OR = 11.69, 95% CI = 0.69-197.13).

CONCLUSIONS

Carrier rate for the studied MEFV mutations was slightly lower in the SLE group, which is in agreement with previous observations that FMF may confer some protection from SLE. Exon 10 mutations were associated with SLE nephritis after the exclusion of the E148Q mutation. The significance of the E148Q as a disease-causing mutation is controversial, and whether E148Q substitution is a polymorphism generally affecting inflammatory pathways is not addressed in the current literature. In this regard, absence of the E148Q mutation in SLE nephritis may serve as a clue for further investigation into its role as a general modulatory polymorphism for inflammation. This clarification is necessary to conclude whether other more penetrant MEFV gene mutations confer susceptibility to nephritis in SLE.

Systematic Review of Treatment Effectiveness and Outcome Measures for Enthesitis in Psoriatic Arthritis

Enthesitis is a characteristic feature of psoriatic arthritis (PsA) and is important in disease pathogenesis and classification. Use of clinical outcome measures for enthesitis is heterogeneous, and only 1 measure has been specifically developed and validated in PsA. Ultrasound and magnetic resonance imaging assessments of enthesitis may have advantages over clinical examination but are insufficiently studied. As part of an update of treatment recommendations by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), we performed a systematic literature review and identified randomized controlled trials with enthesitis outcomes in PsA. For each treatment agent we calculated treatment effect sizes (where applicable) and graded the level of evidence.

Defining enthesitis in spondyloarthritis by ultrasound: results of a Delphi process and of a reliability reading exercise

OBJECTIVE

To standardize ultrasound (US) in enthesitis.

METHODS

An initial Delphi exercise was undertaken to define US-detected enthesitis and its core components. These definitions were subsequently tested on static images taken from spondyloarthritis patients in order to evaluate their reliability.

RESULTS

Excellent agreement (>80%) was obtained for including hypoechogenicity, increased thickness of the tendon insertion, calcifications, enthesophytes, erosions, and Doppler activity as core elementary lesions of US-detected enthesitis. US definitions were subsequently obtained for each elementary component. On static images, the intraobserver reliability showed a high degree of variability for the detection of elementary lesions, with kappa coefficients ranging from 0.13-1. The interobserver kappa values were variable, with the lowest kappa coefficient for enthesophytes (0.24) and the highest coefficient for Doppler activity at the enthesis (0.63).

CONCLUSION

This is the first consensus-based US definition of enthesitis and its elementary components and the first step performed to ensure a higher degree of homogeneity and comparability of results between studies and in daily clinical work.

Ankylosing spondylitis and a diagnostic dilemma: coccydynia

OBJECTIVES

Coccydynia is defined as pain in or around the tail bone area. The most common cause of coccydynia is either a trauma such as a fall directly on to the coccyx or repetitive minor trauma. The etiology remains obscure in up to 30% of patients. The literature on the contribution of rheumatic diseases to coccydynia is scarce. Our objective was to investigate the prevalence of coccydynia in ankylosing spondylitis (AS) patients.

METHODS

One hundred and seven consecutive patients with AS were evaluated for coccydynia were enrolled between January and November 2012 for a cross-sectional analysis. Seventy-four consecutive patients were followed for mechanical back pain as controls and the AS patients were interviewed for the presence of coccydynia. The data collected was evaluated on SPSS® version 11.5 and Microsoft Excel® Programmes.

RESULTS

Prevalence of coccydynia in AS (38.3%) was significantly higher than the control group (p<0.0001) in both female and male AS patients (female AS vs. control=40.9% vs. 18.4%, p=0.015 and male AS vs. control=36.5% vs. 8.0%, p=0.005). Both genders were affected equally in the AS group whereas coccydynia was slightly more frequent in female patients in the control group.

CONCLUSIONS

Coccydynia is a previously neglected symptom of AS and it is almost three times more common in AS than in non-specific chronic low back pain. Our observation may implicate that inflammatory diseases have a role in the etiology of coccydynia, especially in those without a history of recent or past trauma and coccydynia may be a factor associated with the severity of AS as well.

Outcome measures used in clinical trials for Behçet syndrome: a systematic review

Behçet syndrome (BS) is a multisystem vasculitis that is most active during young adulthood, causing serious disability and significant impairment in quality of life. Differences in the disease course, severity, and organ involvement between patients, depending on the age at presentation and sex, makes it impossible to determine a single management strategy. The diversity and variability in the outcome measures used in clinical trials in BS makes it difficult to compare the results or inform physicians about the best management strategy for individual patients. There is a large unmet need to determine or develop validated outcome measures for use in clinical trials in BS that are acceptable to researchers and regulatory agencies. We conducted a systematic review to describe the outcomes and outcome measures that have been used in clinical trials in BS. This review revealed the diversity and variability in the outcomes and outcome measures and the lack of standard definitions for most outcomes and rarity of validated outcome tools for disease assessment in BS. This systematic literature review will identify domains and candidate instruments for use in a Delphi exercise, the next step in the development of a core set of outcome measures that are properly validated and widely accepted by the collaboration of researchers from many different regions of the world and from different specialties, including rheumatology, ophthalmology, dermatology, gastroenterology, and neurology.

Current status of outcome measure development in vasculitis

The conduct of randomized controlled trials for vasculitis, especially for the antineutrophil cytoplasmic antibody-associated vasculitides [AAV, granulomatosis with polyangiitis (Wegener's) and microscopic polyangiitis], has been greatly advanced by the development, use, and acceptance of validated outcome measures. Trials have subsequently provided the opportunity to validate and refine reliable, valid outcome measures for these multisystemic and relapsing rare diseases. The Outcome Measures in Rheumatology (OMERACT) Vasculitis Working Group was formed in 2004 to foster development of validated and widely accepted outcomes in vasculitis using data-driven analyses, a dedication to building consensus, and adherence to, and guidance by, the principles of the OMERACT approach. This work led to the endorsement by OMERACT of the core set of domains and associated outcome measures for AAV. Next steps for the study of existing outcome tools in AAV include better definition of response criteria through development of more data-driven weighting of the elements of activity and damage assessment. The Working Group is now also embarking on a series of linked projects to develop validated patient-reported outcomes for use in clinical research in vasculitis. Additionally, the Working Group is studying how current methods of disease assessment and plans for new outcomes can be informed by the conceptual framework of the International Classification of Function of the World Health Organization. The success of the Group's work in AAV has also led to a formal process for developing outcomes for the large vessel vasculitides (Takayasu arteritis and giant cell arteritis) and Behçet disease.

Magnetic resonance imaging assessment of axial psoriatic arthritis: extent of disease relates to HLA-B27

OBJECTIVE

To determine the prevalence, on magnetic resonance imaging (MRI), of bone marrow edema lesions in symptomatic axial psoriatic arthritis (PsA), and to compare this prevalence with that in nonradiographic axial spondyloarthritis (SpA) and ankylosing spondylitis (AS) and its relationship to HLA-B27 status.

METHODS

We performed a cross-sectional audit of MRI scans of lumbar spine (L-spine) and sacroiliac (SI) joints. Using the semiquantitative Leeds Scoring System in which bone marrow edema is graded from 0 to 3 according to severity of the lesions, MRI scans were scored independently by 2 expert readers who were blinded to the clinical characteristics of the patients. Concordant data from the 2 readers were used to report on definite lesions.

RESULTS

MRIs from 76 patients with comparable age ranges were categorized into 3 groups: those from PsA patients, those from patients with nonradiographic axial SpA, and those from AS patients. HLA-B27 positivity was similar in PsA patients (10 of 33) and patients with nonradiographic axial SpA (10 of 24) and higher in AS patients (18 of 19). Total MRI scores (L-spine plus SI joints) were higher in AS patients than in PsA patients (P = 0.025) or in patients with nonradiographic axial SpA (P = 0.007). A relationship was seen between the severity and extent of disease and HLA-B27 positivity in PsA patients, which was comparable to that in AS patients. HLA-B27-negative PsA patients had lower MRI scores than HLA-B27-positive PsA patients (P = 0.03) and AS patients (P = 0.006), whereas scores were similar in HLA-B27-positive PsA patients and AS patients. Similarly, MRI scores of HLA-B27-negative patients with nonradiographic axial SpA were lower than those of AS patients (P = 0.01).

CONCLUSION

HLA-B27 positivity defines a group of patients with more severe axial bone marrow edema that is likely related to the classic AS phenotype. Clinically, HLA-B27-negative PsA is more likely to be reported as a "negative" MRI examination result.

Ultrasound and magnetic resonance imaging in the evaluation of psoriatic dactylitis: status and perspectives

OBJECTIVE

Dactylitis, a characteristic feature of the spondyloarthropathies, occurs in up to 48% of patients with psoriatic arthritis (PsA). No clear consensus on the underlying components and pathogenesis of dactylitis exists in the literature. We undertook a systematic review of ultrasound (US) and magnetic resonance imaging (MRI) literature to better define imaging elements that contribute to the dactylitic digit seen in PsA. Our objectives were to determine first the level of homogeneity of each imaging modality's definition of the components of dactylitis, and second, to evaluate the metric properties of each imaging modality according to the Outcome Measures in Rheumatology Clinical Trials (OMERACT) filter.

METHODS

Searches were performed in PUBMED and EMBASE for articles pertaining to MRI, US, and dactylitis. Data regarding the reported features of dactylitis were collected and categorized, and the metrological qualities of the studies were assessed.

RESULTS

The most commonly described features of dactylitis were flexor tendon tenosynovitis and joint synovitis (90%). Extratendinous soft tissue thickening and extensor tendonitis were described nearly equally as being present and absent. Discrepancy exists as to whether entheses proper contribute to the etiology of dactylitis. An increasing number of studies categorize abnormalities in several tissue compartments including the soft tissue, tendon sheaths, and joints, as well as ligaments.

CONCLUSION

The understanding of which tissues contribute to dactylitic inflammation has evolved. However, there is a lack of literature regarding the natural history of these abnormalities. This systematic review provides guidance in defining elementary lesions that may discriminate dactylitic digits from normal digits, leading to development of a composite measure of activity and severity of dactylitis.

Activity and damage in granulomatosis with polyangiitis

AIM

To retrospectively analyze disease activity and damage-associated factors in granulomatosis with polyangiitis (GPA) in Turkey.

METHOD

A retrospective analysis was carried out in 21 GPA patients. Assessments for activity were performed with the Birmingham Vasculitis Activity Score for GPA (BVAS/GPA) and for permanent organ damage by the Vasculitis Damage Index (VDI).

RESULTS

Lower BVAS/GPA (P = 0.002), absence of renal involvement (P = 0.003) and higher creatinine clearence (P = 0.000) at diagnosis increased the likelihood of achieving remission at 6 weeks. Relapses were associated with high creatinine clearence (P = 0.021), low BVAS/GPA (P = 0.014), absence of renal involvement (P = 0.036) and proteinuria (< 0.5/24 h) (P = 0.013) at diagnosis, whereas achieving remission at 6 weeks (P = 0.012) was associated with absence of co-trimoxazole usage (P = 0.038) and less severe clinical subgroup (P = 0.034). Lower cumulative first 6 months of cyclophosphamide and methylprednisolone were associated with earlier (≤ 12 months) relapses (P = 0.048 and P = 0.083, respectively). Baseline damage (VDI ≥ 1) was associated with a delay in diagnosis (P = 0.032), presentation with milder clinical subgroups (P = 0.052) and low serum creatinine (P = 0.013). The increase in VDI in the first 12 months (early damage) constituted most (91%) of the total damage measured at the end of follow-up.

CONCLUSIONS

Despite high early remission rates, relapse represents a major problem in localized GPA in our study. Baseline damage was associated with longer diagnostic delay and lower baseline serum creatinine. The initial phase of the disease seems to be the most crucial period for mortality and accumulated damage.

Takayasu's arteritis is associated with HLA-B*52, but not with HLA-B*51, in Turkey

Introduction

HLA-B*51 and HLA-B*52 are two close human leukocyte antigen (HLA) allele groups with minor amino acid differences. However, they are associated with two different vasculitides (HLA-B*51 in Behçet's disease and HLA-B*52 in Takayasu's arteritis (TAK)) and with major clinical and immunological differences. In this study, we aimed to screen a large cohort of TAK patients from Turkey for the presence of HLA-B*51 and HLA-B*52 as susceptibility and severity factors.

Methods

TAK patients (n = 330) followed at a total of 15 centers were included in the study. The mean age of the patients was 37.8 years, and 86% were women. DNA samples from the patients and healthy controls (HC; n = 210) were isolated, and the presence of HLA-B*51 or HLA-B*52 was screened for by using PCR with sequence-specific primers.

Results

We found a significant association of HLA-B*52 with TAK (20.9% vs HC = 6.7%, P = 0.000, OR = 3.7, 95% CI = 2.02 to 6.77). The distribution of HLA-B*51 did not differ between TAK patients and HCs (22.7% vs 24.8%, OR = 0.9, 95% CI = 0.60 to 1.34). The presence of HLA-B*52 decreased in late-onset patients (> 40 years of age; 12.0%, P = 0.024, OR = 0.43, 95% CI = 0.20 to 0.91). Patients with angiographic type I disease with limited aortic involvement also had a lower presence of HLA-B*52 compared to those with all other disease subtypes (13.1% vs 26%, P = 0.005, OR = 0.43, 95% CI = 0.23 to 0.78).

Conclusions

In this study, the previously reported association of TAK with HLA-B*52 in other populations was confirmed in patients from Turkey. The functional relevance of HLA-B*52 in TAK pathogenesis needs to be explored further.

The OMERACT core set of outcome measures for use in clinical trials of ANCA-associated vasculitis

There has been a marked increase in the past 15 years in the number and quality of clinical trials in the idiopathic inflammatory vasculitides, especially the small-vessel vasculitides known as antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis [AAV; granulomatosis, with polyangiitis (Wegener's)]. These trials have been conducted by multicenter, international groups in Europe and the United States with financial support provided by government agencies and biopharmaceutical companies. This increased clinical trial activity in vasculitis has been accompanied by the development and validation of new outcome measures--a challenging process for these complex, multiorgan system diseases. The international OMERACT Vasculitis Working Group has developed and implemented an iterative research agenda that has utilized accumulated experience and datasets from several multicenter clinical trials and large cohort studies. This work has led to the development, evaluation, validation, and endorsement, through the OMERACT consensus and validation processes, of a "core set" of outcome measurements for use in clinical trials of AAV. The core set includes domains of disease activity, damage assessment, patient-reported outcomes, and mortality; there is at least one validated outcome measurement instrument available for each domain. This report reviews the domains of illness in AAV included in the OMERACT core set, describes the instruments validated to measure these domains, and presents the approved core set.

Clinical utility of the new ASAS criteria for spondyloarthritis and the disease activity score

The advent of new therapeutic agents that are efficacious in the treatment of ankylosing spondylitis and related spondyloarthropathies has highlighted important unmet needs in our understanding of these conditions. Chief among these is the possibility of making a diagnosis at the early, nonradiographic phase, when the burden of disease is substantial and comparable to that of more advanced stages. The new Assessments in Spondyloarthritis International Society (ASAS) classification criteria provide a unique tool to allow research standardization in this area and may also be of clinical utility. The development of the disease activity index ASDAS (Ankylosing Spondylitis Disease Activity Score) aims to provide a composite measure that can discriminate and show sensitivity to change while incorporating measurable biomarkers. Both instruments represent a major step forward in the research field of spondyloarthritis, although further validation is now required.

PDCD1 polymorphisms are not associated with Takayasu's arteritis in Turkey

OBJECTIVES

Takayasu's arteritis (TA) is a chronic arterial inflammation of unknown etiology involving mainly the aorta and its major branches. Based on the associations of programmed death-1 (PD-1) protein encoding gene (PDCD1) with connective tissue diseases and vasculitides, PDCD1 polymorphisms are studied for susceptibility to TA in this study.

METHODS

The study group is made up of TA patients (n=229) fulfilling the 1990 ACR classification criteria and compared to 193 healthy controls (HC). PD-1.3, PD-1.5 and PD-1.6 single nucleotide polymorphisms of PDCD1 gene are genotyped by polymerase chain reaction and restriction analysis (PCR-RFLP).

RESULTS

The distribution of PD-1.5 polymorphism in TA patients and HC revealed a similar presence of TT genotype in patients and controls (13.3% vs. 11.4%). PD-1.3 and PD-1.6 were less polymorphic and did not differ between the groups. Rare AA genotype of PD-1.3 (1.4% vs. 1.0%) and AG genotype of PD-1.6 was again similarly (22.4% vs. 19.2%) present in TA and HC.

CONCLUSIONS

PD-1.3, 1.5 and 1.6 polymorphisms of PDCD1 gene, which were shown to be associated with various autoimmune disorders and vasculitides, are not associated with a susceptibility to TA in Turkish population.

Validation of the ASAS criteria and definition of a positive MRI of the sacroiliac joint in an inception cohort of axial spondyloarthritis followed up for 8 years

Background

The new Assessment of SpondyloArthritis international Society (ASAS) criteria classify axial spondyloarthritis (SpA) into human leucocyte antigen-B27 and/or imaging-based arms. To aid implementation, ASAS has proposed a definition of a positive MRI for active sacroiliitis.

Objective

The authors aimed to test the diagnostic and predictive value of the ASAS criteria and definition of a ‘positive’ MRI.

Methods

Baseline MRI scans on 29 patients with early inflammatory back pain and 18 controls were read independently by four experienced rheumatologists. Both arms of the criteria were tested against a ‘gold standard’ of physician diagnosis of SpA. MRI abnormalities were assessed according to a global assessment of MRI and the ASAS definition. Sensitivity, specificity and likelihood ratios for individual and concordant reader data were calculated for axial SpA diagnosis at baseline and the development of radiographic sacroiliitis, fulfilling the modified New York criteria at 8 years.

Results

All patients were classified as having axial SpA, with more patients fulfilling the imaging arm (83%, n=24/29) than the human leucocyte antigen B27 arm (62%, n=18/29). Concordant reader data showed that the baseline MRI had high diagnostic utility for SpA according to global assessment (sensitivity/specificity: 66%/94%, LR+ (positive likelihood ratio) 11.8, LR− (negative likelihood ratio) 0.4) and ASAS definition (sensitivity/specificity: 79%/89%, LR+ 7.1, LR− 0.2). Likewise, a positive baseline MRI had 100% sensitivity for subsequent radiographic sacroiliitis by either assessment, although specificity was lower (56% for global assessment and 33% for ASAS definition).

Conclusion

Both arms of the ASAS criteria have good diagnostic utility in early SpA, although they are of limited value for the prediction of radiographic progression. This may be due to the definition of a positive MRI for sacroiliitis that lacks specificity at baseline.

Development of outcome measures for large-vessel vasculitis for use in clinical trials: opportunities, challenges, and research agenda

Giant cell (GCA) and Takayasu's arteritis (TAK) are 2 forms of large-vessel vasculitis (LVV) that involve the aorta and its major branches. GCA has a predilection for the cranial branches, while TAK tends to affect the extracranial branches. Both disorders may also cause nonspecific constitutional symptoms. Although some clinical features are more common in one or the other disorder and the ages of initial presentation differ substantially, there is enough clinical and histopathologic overlap between these disorders that some investigators suggest GCA and TAK may be 2 processes within the spectrum of a single disease. There have been few randomized therapeutic trials completed in GCA, and none in TAK. The lack of therapeutic trials in LVV is only partially explained by the rarity of these diseases. It is likely that the lack of well validated outcome measures for LVV and uncertainties regarding trial design contribute to the paucity of trials for these diseases. An initiative to develop a core set of outcome measures for use in clinical trials of LVV was launched by the international OMERACT Vasculitis Working Group in 2009 and subsequently endorsed by the OMERACT community at the OMERACT 10 meeting. Aims of this initiative include: (1) to review the literature and existing data related to outcome assessments in LVV; (2) to obtain the opinion of experts and patients on disease content; and (3) to formulate a research agenda to facilitate a more data-based approach to outcomes development.

Assessment of disease activity and progression in Takayasu's arteritis

Takayasu's arteritis (TA) is a rare, chronic panarteritis of the aorta and its major branches presenting commonly in young ages. Physical examination findings, presence of constitutional features, elevated acute-phase reactants, and new vessel involvement in imaging are major features of an active disease. However, assessment of disease activity and damage in TA is problematic given the chronic, indolent disease course and lack of specific laboratory and imaging findings. Although CT, MRI, and FDG-PET are commonly used imaging modalities, their lack of specificity to discriminate active disease from damage, limit their usefulness in routine practice. Two recently introduced multi-systemic clinical assessment tools, the DEI.Tak and the ITAS (both derived from BVAS), seem to be helpful in assessing disease activity and damage in TA. However, physician's global assessments of disease activity and decisions regarding treatments are still strongly influenced by changes in the acute-phase response and imaging. A comprehensive approach to both systemic and vascular features of TA to define a validated set of outcome measures for use in clinical trials and clinical practice is clearly needed. The OMERACT Vasculitis Working Group has taken on this task and has embarked on a research agenda to advance outcome measure development in TA.

Active disease requiring TNF-alpha-antagonist therapy can be well discriminated with different ASDAS sets: a prospective, follow-up of disease activity assessment in ankylosing spondylitis

OBJECTIVES

To evaluate the validity of different ASDAS sets to assess disease activity in ankylosing spondylitis (AS) in comparison to standard activity assessment tools in routine clinical setting and to determine the best cut-off values for deciding active disease requiring TNF-α antagonist therapy.

METHODS

Two hundred consecutive AS patients (M/F:104/96) were enrolled. Mean (SD) age was 40.3 (11.7) and disease duration was 11 (8.5) years. Disease activity was assessed by four different ASDAS sets, BASDAI, patient and physicians' global assessments, ESR and CRP. The correlation between different parameters and ASDAS scores of patients requiring TNF-α antagonist therapy were determined.

RESULTS

At the time of the assessment 18.5% of the patients were only having NSAIDs, 43% were receiving sulphasalazine and/or methotrexate and 38.5% were under TNF-α antagonists. After the evaluation, 36 (18%) patients were decided to require TNF-α antagonist therapy, 33 (16.5%) patients were started sulphasalazine or methotrexate or their dose increased and 131 (65.5%) patients were decided to be stable without any requirement for a change in therapy. The patients requiring new-TNFα antagonist therapy had significantly higher ASDAS values. The ROC curve analysis revealed best-cut off values for ASDAS sets (ASDAS A: 3.28, ASDAS B: 3.07, ASDAS C: 2.38 and ASDAS D: 3.1) When standardised mean differences were compared, ASDAS B was the best set within the others, but not significantly different from other ASDAS sets and standard assessment tools except acute-phase reactants.

CONCLUSIONS

ASDAS sets perform well to discriminate TNF-α antagonist requirement in advanced AS patients. However BASDAI and patient's or physician's global assessments also had acceptable performances in our clinical setting.

Association of salivary S. mutans colonisation and mannose-binding lectin deficiency with gender in Behçet's disease

OBJECTIVE

The present study aimed to investigate the interactions among salivary S. mutans colonisation, serum mannose binding lectin level (MBL), oral ulcer activity and disease course in patients with Behçet's disease (BD).

METHODS

One hundred and six BD patients, 25 patients with rheumatoid arthritis (RA) and 42 healthy controls (HC) were included in the study. BD patients were grouped as active (n=52) or inactive (n=54) according to oral ulcer status of the previous 3 months. Salivary colonisation of S. mutans levels were investigated by standard Caries Risk Test (CRT) Bacteria kits (Ivoclar, Vivadent). S. mutans colonies were categorized as high (> or =10(5) colony forming unit (CFU)/ml of saliva) or low (10(5)CFU/ml). Serum mannose binding lectin (MBL) levels were measured by ELISA.

RESULTS

High levels of salivary S. mutans colonisation was significantly more present in BD (50%) than HC (28.6%)(p=0.039), whereas no significant difference was observed between RA and other groups (p>0.05). S. mutans presence in saliva was associated with oral ulcers (61.5% in patients with active oral ulcers vs 38.9% in inactives) (p=0.020). S. mutans colonisation in saliva was significantly higher among male BD patients with a severe disease course than a milder disease (p=0.04). Increased salivary S. mutans colonisation was also related to very low serum MBL (<100 ng/ml) in BD compared to controls (p=0.04).

CONCLUSION

The relationship between increased presence of S. mutans and MBL deficiency with active disease pattern may indicate an impaired innate immune response in BD patients which may predispose to oral infections and a severe disease course.

Takayasu's arteritis in Turkey - clinical and angiographic features of 248 patients

OBJECTIVE

Takayasu's arteritis (TA) is a chronic, inflammatory vasculitis affecting the aorta and its major branches. Although it is more prevalent in Far-East Asia, the distribution of the disease is worldwide with different vascular involvement patterns and clinical manifestations. The objective of this study was to evaluate the demographic, clinical, angiographic and prognostic features of TA patients in Turkey.

METHODS

Clinical and angiographic findings of 248 TA patients (228 female, 27 male) followed at 15 Rheumatology Centers were prospectively evaluated according to a predefined protocol.

RESULTS

The mean age was 40.1 years (30.2 years at the clinical onset). Clinical manifestations included constitutional symptoms in 66%, absent or diminished pulses in 88%, bruits in 77%, extremity pain in 69%, claudication in 48%, hypertension in 43% and cerebrovascular accidents (CVA) in 18% of the patients. Renal artery stenosis, aortic regurgitation and pulmonary hypertension were present in 26%, 33% and 12%, respectively. According to the new angiographic classification, type V (50.8%) and Type I (32%) were the most frequent types of involvement. Corticosteroids were the main treatment in 93% of the patients alone (9%) or in combination with immunosuppressive agents (84%). Most frequently preferred immunosuppressive agents were methotrexate (63%), azathioprine (22%) and cyclophosphamide (13%). Remission was observed at least once in 94% of the patients and sustained remission in 71% during follow-up.

CONCLUSION

The demographical, clinical and angiographic findings of TA patients in our series were similar to those reported from Japan, Brazil and Colombia. Combination therapies with immunosuppressive agents were the preferred choice of treatment in Turkey.

Anti-Saccharomyces cerevisiae antibodies (ASCA) in spondyloarthropathies: a reassessment

OBJECTIVES

Seronegative spondyloarthropathies, especially ankylosing spondylitis (AS), is shown to be associated with inflammatory bowel disease. Anti-Saccharomyces cerevisiae antibodies (ASCA) is a valid serological marker for Crohn's disease. Presence of ASCA is controversial in AS. In this study, we aimed to investigate the prevalence of ASCA in spondyloarthropathies and its relationship with disease activity and severity.

METHODS

One hundred and seventy-five patients with AS, 47 patients with undifferentiated spondyloarthropathy (uSpA) and 103 healthy controls (HCs) were studied. All patients were questioned for demographic features and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores. Radiological damage is assessed by Bath Ankylosing Spondylitis Radiology Index (BASRI) and modified Stroke Ankylosing Spondylitis Spinal Score (mSASSS). ASCA levels were measured with standard ELISA kits.

RESULTS

There was an overall increased prevalence of ASCA IgA in AS and uSpA compared with HCs (20.6 and 19.1% vs 5.8%, P = 0.0008 and P = 0.02, respectively). No association was observed between ASCA positivity and erythrocyte sedimentation rate, C-reactive protein levels and BASDAI scores. However, ASCA-positive patients had higher BASRI scores [median BASRI: 7 (2-12) vs 6 (2-12); P = 0.037]. Although not reaching significance, they also had reduced chest expansion and higher Bath Ankylosing Spondylitis Functional Index (BASFI) scores. ASCA-positive AS patients also required anti-tumour necrosis factor therapy more frequently (P = 0.006).

CONCLUSIONS

ASCA IgA seems to be more prevalent in AS and uSpA. ASCA can also be a marker of radiological damage and a more severe course in AS.