Is there subclinical enthesitis in early psoriatic arthritis? A clinical comparison with power doppler ultrasound

Power Doppler signal at the enthesis and bone erosions are the most discriminative OMERACT ultrasound lesions for SpA: results from the DEUS (Defining Enthesitis on Ultrasound in Spondyloarthritis) multicentre study

OBJECTIVES

To assess, in spondyloarthritis (SpA), the discriminative value of the Outcome Measures in Rheumatology (OMERACT) ultrasound lesions of enthesitis and their associations with clinical features in this population.

METHODS

In this multicentre study involving 20 rheumatology centres, clinical and ultrasound examinations of the lower limb large entheses were performed in 413 patients with SpA (axial SpA and psoriatic arthritis) and 282 disease controls (osteoarthritis and fibromyalgia). 'Active enthesitis' was defined as (1) power Doppler (PD) at the enthesis grade ≥1 plus entheseal thickening and/or hypoechoic areas, or (2) PD grade >1 (independent of the presence of entheseal thickening and/or hypoechoic areas).

RESULTS

In the univariate analysis, all OMERACT lesions except enthesophytes/calcifications showed a significant association with SpA. PD (OR=8.77, 95% CI 4.40 to 19.20, p<0.001) and bone erosions (OR=4.75, 95% CI 2.43 to 10.10, p<0.001) retained this association in the multivariate analysis. Among the lower limb entheses, only the Achilles tendon was significantly associated with SpA (OR=1.93, 95% CI 1.30 to 2.88, p<0.001) in the multivariate analyses. Active enthesitis showed a significant association with SpA (OR=9.20, 95% CI 4.21 to 23.20, p<0.001), and unlike the individual OMERACT ultrasound lesions it was consistently associated with most clinical measures of SpA disease activity and severity in the regression analyses.

CONCLUSIONS

This large multicentre study assessed the value of different ultrasound findings of enthesitis in SpA, identifying the most discriminative ultrasound lesions and entheseal sites for SpA. Ultrasound could differentiate between SpA-related enthesitis and other forms of entheseal pathology (ie, mechanical enthesitis), thus improving the assessment of entheseal involvement in SpA.

Significant functional impairment and disability in individuals with psoriatic arthritis and Achilles tendon pain: a cross-sectional observational study

The Achilles tendon (AT) insertion is the most common site of enthesitis in psoriatic arthritis (PsA). The structure and function of the AT in PsA, and the prevalence of mid-portion pathology, is unknown. To compare the structure and function of the AT in people with PsA with self-reported AT pain (PsA + AT), PsA without self-reported AT pain (PsA-AT) and healthy controls. A cross-sectional, observational study was conducted. The ATs were assessed by clinical and US examination (B-mode and Power Doppler), performance-based testing (bilateral heel raise test (HRT) and 10 m walk test), and patient-reported outcome measures (PROMs) (including the Victorian Institute of Sport Assessment-Achilles [VISA-A]). Between-group differences were described using descriptive statistics, Chi-squared testing, parametric (1-way ANOVA) and non-parametric (Mann-Whitney or Kruskal-Wallis) testing. 22 PsA (11 per group) and 11 healthy control participants who were comparable in terms of sex, age, and BMI (PsA-AT = longer PsA disease duration) were recruited. VISA-A scores were significantly worse in the PsA + AT group compared to the PsA-AT group and healthy controls (p < 0.001). Inflammatory US features were significantly more prevalent in the PsA + AT group (p < 0.001). Mid-portion AT pathology was observed in the PsA + AT group, irrespective of entheseal disease. Clinical examination alone missed 5/7 cases of 'active' US-confirmed AT enthesitis. AT functional deficits were significant in the PsA + AT group and both PsA groups had lower HRT repetition rates and walked slower compared to healthy controls. Less than 1/3 of the PsA + AT group had received podiatry or physiotherapy care. Significant differences in the structure and function of the AT in PsA were noted. Despite management in line with current guidance, AT pain appears to persist and can result in severe functional impairment.

Enthesitis in a European registry-based cohort of patients with psoriatic arthritis treated with tumour necrosis factor inhibitors: clinical burden, patient-reported outcomes, and treatment response

OBJECTIVE

To explore the registration of enthesitis among biologic-naïve patients with psoriatic arthritis (PsA) initiating tumour necrosis factor inhibitor (TNFi) treatment across 12 European registries, compare the disease burden and patient-reported outcomes (PROs) between patients with and without enthesitis, and assess the enthesitis treatment response.

METHOD

Demographics, clinical characteristics, and PROs at first TNFi (TNFi-1) initiation (baseline) were assessed in patients with PsA, diagnosed by a rheumatologist, with versus without assessment of entheses and between those with versus without enthesitis. Enthesitis scores and resolution frequency were identified at follow-up.

RESULTS

Of 10 547 patients in the European Spondyloarthritis (EuroSpA) Research Collaboration Network initiating TNFi, 1357 underwent evaluation for enthesitis. Eight registries included a validated scoring system for enthesitis. At baseline, 874 patients underwent entheses assessment [Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) 485 patients, Spondyloarthritis Research Consortium of Canada (SPARCC) 389 patients]. Enthesitis was detected by MASES in 170/485 (35%, mean score ± sd 3.1 ± 2.4) and by SPARCC in 236/389 (61%, 4 ± 3.4). Achilles enthesitis was most frequent, by both MASES (unilateral/bilateral 28%/9%) and SPARCC (48%/18%). MASES/SPARCC baseline and follow-up scores for TNFi-1 were available for 100/105 patients. Of these, 63 patients (63%) (MASES) and 46 (43.8%) (SPARCC) achieved resolution of enthesitis. The site-specific enthesitis resolution was overall lower at SPARCC sites (peripheral; 63-80%) than at MASES sites (mainly axial; 82-100%) following TNFi-1. Disease activity and PROs were worse in patients with versus without enthesitis.

CONCLUSION

Entheseal assessments are only registered in a minority of patients with PsA in routine care. When assessed, enthesitis was common, and a substantial proportion demonstrated resolution following treatment with TNFi-1.

Utility of Musculoskeletal Ultrasound in Psoriatic Arthritis

PURPOSE

Psoriatic arthritis (PsA) is a chronic autoimmune disease that causes a variety of musculoskeletal abnormalities. Musculoskeletal ultrasound in PsA is becoming increasingly popular, both in clinical practice and research. This narrative reviews recent literature on the utility of ultrasound in PsA.

METHODS

A search of PubMed was used to identify publications written in English, with titles containing the term psoriatic arthritis and either ultrasound, ultrasonography, or sonographic. A total of 178 publications were identified; those that were not relevant (n = 59), were not original research (n = 45), or that had small (<30) sample sizes (n = 34) were excluded, leaving 40 studies for review of the use of ultrasound in various aspects of PsA. Publications with similar findings were grouped into seven domains: (1) the use of ultrasound findings compared to clinical assessment; (2) the use of ultrasound in the assessment of enthesitis; (3) the use of ultrasound in the assessment of nails; (4) the use of ultrasound as a screening tool in patients with psoriasis at risk for PsA; (5) the use of ultrasound in differentiating PsA from other similar conditions; (6) the use of ultrasound as a measure of disease activity; and (7) the use of ultrasound compared to MRI.

FINDINGS

In recent studies, ultrasound measures of inflammation tended to agree with objective clinical findings of disease, such as swollen joint counts, while being less influenced by subjective measures, such as pain. Ultrasound has utility in the assessment of enthesitis and psoriatic nail disease in PsA, and as an overall measure of disease activity. Ultrasound-based outcomes measures have been used in observational studies and in clinical trials involving PsA, and may have utility as a measure of treatment response. The findings from recent studies suggest that ultrasound may have utility in improving the accuracy and precision of screening programs designed to identify subclinical PsA in cohorts of patients with psoriasis; however, cost-efficacy remains to be determined. Beyond screening, ultrasound may have utility in the diagnosis of PsA in patients with suspected inflammatory arthritis, and ultrasound measures of inflammation agree with MRI measures of inflammation, meaning that incorporating ultrasound into clinical practice might help to overcome the barriers associated with MRI.

IMPLICATIONS

As ultrasound technology continues to advance, and associated costs decrease, it is likely that ultrasound will become more integrated into the clinical journeys of patients with PsA.

Reliability assessment of the definition of ultrasound enthesitis in SpA: results of a large, multicentre, international, web-based study

OBJECTIVES

To investigate the reliability of the OMERACT US Task Force definition of US enthesitis in SpA.

METHODS

In this web exercise, based on the evaluation of 101 images and 39 clips of the main entheses of the lower limbs, the elementary components included in the OMERACT definition of US enthesitis in SpA (hypoechoic areas, entheseal thickening, power Doppler signal at the enthesis, enthesophytes/calcifications, bone erosions) were assessed by 47 rheumatologists from 37 rheumatology centres in 15 countries. Inter- and intra-observer reliability of the US components of enthesitis was calculated using Light's kappa, Cohen's kappa, Prevalence And Bias Adjusted Kappa (PABAK) and their 95% CIs.

RESULTS

Bone erosions and power Doppler signal at the enthesis showed the highest overall inter-reliability [Light's kappa: 0.77 (0.76-0.78), 0.72 (0.71-0.73), respectively; PABAK: 0.86 (0.86-0.87), 0.73 (0.73-0.74), respectively], followed by enthesophytes/calcifications [Light's kappa: 0.65 (0.64-0.65), PABAK: 0.67 (0.67-0.68)]. This was moderate for entheseal thickening [Light's kappa: 0.41 (0.41-0.42), PABAK: 0.41 (0.40-0.42)], and fair for hypoechoic areas [Light's kappa: 0.37 (0.36-0.38); PABAK: 0.37 (0.37-0.38)]. A similar trend was observed in the intra-reliability exercise, although this was characterized by an overall higher degree of reliability for all US elementary components compared with the inter-observer evaluation.

CONCLUSIONS

The results of this multicentre, international, web-based study show a good reliability of the OMERACT US definition of bone erosions, power Doppler signal at the enthesis and enthesophytes/calcifications. The low reliability of entheseal thickening and hypoechoic areas raises questions about the opportunity to revise the definition of these two major components for the US diagnosis of enthesitis.

Musculoskeletal Ultrasound to Identify Subclinical Joint and Periarticular Involvement in Patients With Inflammatory Bowel Disease: A Systematic Literature Review

Background

Musculoskeletal ultrasonography identifies subclinical joint and entheseal inflammation, and it might be of value in patients with inflammatory bowel diseases (IBD), which are at higher risk of inflammatory arthropathy and disability. Our aim was to retrieve the evidence on the applications of ultrasound in patients with non-arthropathic IBD.

Methods

Studies enrolling patients with IBD without arthritis, undergoing ultrasound of joints, tendons or entheses were eligible. The outcomes of interest encompassed the frequency of ultrasound-detected lesions, their accuracy in diagnosing arthritis, their prognostic role and sensitivity to change. All study types, excluding case reports, case series and narrative reviews, were included. Search strategies were applied in PubMed and Embase. Abstract and full-texts were evaluated by pairs of reviewers. The risk of bias was evaluated through the Newcastle-Ottawa scale or the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) 2. The protocol was registered in PROSPERO (CRD42021264972).

Results

Out of 2,304 records, eight studies were included, all reporting the frequency of lesions, while only three evaluated also the diagnostic accuracy. All studies had a cross-sectional design, with no evidence on prediction or follow-up. All studies evaluated the entheses, while only three the joints. The most common chronic lesions were entheseal thickening (up to 81.5%) and enthesophytes (67.9%), while entheseal erosions were present in 16%−17% of patients. Among inflammatory lesions, power Doppler was reported in 14%−67% of patients. There were no differences among Crohn's disease or ulcerative colitis and depending on disease activity, while there were contrasting results on different disease durations. When evaluating the diagnostic performance, the best specificity for a diagnosis if IBD was 0.88 (95%CI, 0.8–0.94) for joint abnormalities. Also, the best sensitivity was 0.88 (95%CI, 0.76–0.95) for entheseal lesions. No studies assessed of the combination of lesions. Due to the limited number of studies, meta-analyses were not performed.

Conclusions

Despite the possible value of ultrasound in IBD, there is limited evidence deriving from cross-sectional studies. Longitudinal studies are needed to clarify the role of this technique, while its current placement might be that of complementing clinical assessment, in particular in early intestinal disease.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Musculoskeletal pain in psoriasis - relation to inflammation and additional value of ultrasound in psoriatic arthritis classification

OBJECTIVE

To investigate and compare clinical features and ultrasound signs of inflammation in joints and entheses in patients with psoriasis (PsO) with and without musculoskeletal pain, and the additional value of ultrasound in classification of psoriatic arthritis (PsA). Furthermore, to explore the association between such findings and patient-reported outcomes (PROs) and the performance of screening-questionnaires for identifying patients with PsA.

METHODS

Patients with PsO (n = 126) recruited from a nationwide survey were evaluated at one of four rheumatology departments. The evaluation included clinical examination, laboratory tests, radiography, greyscale (GS) and colour Doppler (CD) ultrasound of 48 joints and 12 entheses, PROs, and four screening-questionnaires for PsA. Patients were classified with Classification for PsA (CASPAR), ultrasound-modified CASPAR, and ultrasound-only criteria.

RESULTS

When subgroups of self-reported pain (63%), no pain (29%) and diagnosed PsA (9%) were compared, patients with pain had higher tenderness-related clinical scores (tender joints, entheses and fibromyalgia points) and ultrasound GS sum-scores, compared with 'no pain' patients. PROs were negligibly-moderately correlated with pain-related clinical scores (Spearman's rho = 0.11-0.59, all patients), and negligibly-weakly with ultrasound sum-scores (rho = 0.01-0.34). More patients could be classified as PsA when ultrasound synovitis/enthesitis was included as entry criterion (ultrasound-modified CASPAR, 66% of all patients) compared with conventional CASPAR (35%) or ultrasound-only criteria (52%). Sensitivities of screening-questionnaires were low for fulfilment of CASPAR (0.23-0.66), ultrasound-modified CASPAR (0.17-0.57), and ultrasound-only (0.20-0.57) criteria.

CONCLUSION

Self-reported pain in PsO is related to ultrasound inflammation. Ultrasound-modified CASPAR criteria identified almost twice as many patients as conventional CASPAR criteria. Screening-questionnaires showed limited value.

Ultrasound features of Achilles enthesitis in psoriatic arthritis: a systematic review

Objectives

The objectives were to evaluate the methodological and reporting quality of ultrasound (US) studies of Achilles enthesitis in people with psoriatic arthritis (PsA), to identify the definitions and scoring systems adopted and to estimate the prevalence of ultrasound features of Achilles enthesitis in this population.

Methods

A systematic literature review was conducted using the AMED, CINAHL, MEDLINE, ProQuest and Web of Science databases. Eligible studies had to measure US features of Achilles enthesitis in people with PsA. Methodological quality was assessed using a modified Downs and Black Quality Index tool. US protocol reporting was assessed using a checklist informed by the European League Against Rheumatism (EULAR) recommendations for the reporting of US studies in rheumatic and musculoskeletal diseases.

Results

Fifteen studies were included. One study was scored as high methodological quality, 9 as moderate and 5 as low. Significant heterogeneity was observed in the prevalence, descriptions, scoring of features and quality of US protocol reporting. Prevalence estimates (% of entheses) reported included hypoechogenicity [mean 5.9% (s.d. 0.9)], increased thickness [mean 22.1% (s.d. 12.2)], erosions [mean 3.3% (s.d. 2.5)], calcifications [mean 42.6% (s.d. 15.6)], enthesophytes [mean 41.3% (s.d. 15.6)] and Doppler signal [mean 11.8% (s.d. 10.1)].

Conclusions

The review highlighted significant variations in prevalence figures that could potentially be explained by the range of definitions and scoring criteria available, but also due to the inconsistent reporting of US protocols. Uptake of the EULAR recommendations and using the latest definitions and validated scoring criteria would allow for a better understanding of the frequency and severity of individual features of pathology.

The value of magnetic resonance imaging for assessing disease extent and prediction of relapse in early peripheral spondyloarthritis

OBJECTIVE

We aimed to assess the inflammatory burden in pSpA by lower-extremity MRI in an early remission-induction strategy study with TNF blockade. Furthermore, we sought to determine the value of MRI to predict disease relapse versus sustained remission after treatment discontinuation.

METHODS

Thirty-two early pSpA patients with lower limb involvement on clinical examination and confirmed by ultrasonography, participated in a remission-induction trial with a TNF-inhibitor (TNFi). Patients underwent MRI of joints and entheses of the lower extremities at baseline and at clinical remission, after which TNFi treatment was withdrawn. Images were evaluated for joint effusion, joint osteitis, entheseal soft tissue inflammation (STI), and entheseal osteitis.

RESULTS

Joint effusion and enthesitis on clinical examination and ultrasonography correlated well with MRI abnormalities. In addition, a substantial amount of subclinical involvement was seen on MRI, mainly in ankle joints and heel entheses. Inflammation scores were markedly lower in the subclinical joints and entheses versus those clinically involved. Inflammatory load on MRI decreased significantly upon TNFi treatment. Whereas 80% of the clinically involved joints at baseline showed no effusion on remission MRI, two out of three involved entheses at baseline showed residual inflammation. In addition, patients relapsing after treatment discontinuation displayed more entheseal STI on remission MRI compared to those maintaining drug-free remission.

CONCLUSION

Our findings delineate a differential response of synovitis and enthesitis, with enthesitis on MRI responding less upon TNFi treatment. Furthermore, residual entheseal inflammation might be indicative for the need for continuous therapy.

Explaining Variability in the Prevalence of Achilles Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals

OBJECTIVE

To estimate the prevalence of, and factors associated with, Achilles tendon abnormalities observed on imaging in asymptomatic individuals.

DESIGN

Systematic review with stratified meta-analysis and meta-regression.

LITERATURE SEARCH

Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science were searched from 1980 to August 2020.

STUDY SELECTION CRITERIA

We included studies that reported the prevalence of Achilles tendon abnormalities, observed with any imaging modality, in an asymptomatic population. We excluded studies if participant mean age was younger than 12 years or if participants had current/previous lower-limb tendon injuries/symptoms or other systemic conditions.

DATA SYNTHESIS

Random-effects proportion meta-analysis was used to estimate prevalence. We used meta-regression for continuous variables (mean age and body mass index [BMI], sample size, proportion of female participants) and stratified categorical variables (imaging modality and participation in physical activity) to explain between-study heterogeneity.

RESULTS

We included 91 studies (10 156 limbs, 5841 participants). The prevalence of Achilles tendon abnormalities on imaging ranged from 0% to 80% per participant. Between-study heterogeneity was high (I²>90%, P<.001), precluding data pooling. Between-study heterogeneity was partly explained by participant mean BMI (slope, 2.8% per 1-unit increase in BMI; 95% confidence interval: 0.57%, 5.03%; P = .015) and participation in physical activity per limb, and mean age of 40 years old or older (P = .022) per participant.

CONCLUSION

There was substantial variability in the prevalence of Achilles tendon abnormalities on imaging in asymptomatic individuals. Higher prevalence of abnormalities was associated with older age (40 years old or older), higher BMI, and participation in physical activity. A large proportion of heterogeneity remains unaccounted for, likely due to variations in abnormality definitions and study design. J Orthop Sports Phys Ther 2021;51(5):232-252. Epub 28 Mar 2021. doi:10.2519/jospt.2021.9970.

Physical Activity and Investigation With Magnetic Resonance Imaging Partly Explain Variability in the Prevalence of Patellar Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals

OBJECTIVE

To estimate the pooled prevalence of, and factors associated with, the presence of patellar tendon abnormalities observed on imaging in people without symptoms.

DESIGN

Systematic review with stratified meta-analysis and meta-regression.

LITERATURE SEARCH

We searched Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science from 1980 to August 2020.

STUDY SELECTION CRITERIA

We included studies that reported the prevalence of asymptomatic patellar tendon abnormalities on imaging. We excluded studies of participants with current tendon pain, a history of tendon pain, or other systemic conditions.

DATA SYNTHESIS

Stratification and meta-regression of studies based on study-level descriptive statistics (mean age, body mass index, proportion of female participants, physical activity participation, imaging modality) were performed using a random-effects model to account for between-study heterogeneity. Risk of bias was assessed using the modified Newcastle-Ottawa scale.

RESULTS

Meta-analysis of 64 studies (7125 limbs from 4616 participants) found significant between-study heterogeneity (I²≥90%, P<.01), which precluded a summary prevalence estimate. Heterogeneity was partially explained by studies that included participants who were physically active and studies that assessed tendon abnormalities using magnetic resonance imaging compared to ultrasound (P<.05). Mean age, body mass index, proportion of female participants, and sample size did not explain the remaining heterogeneity.

CONCLUSION

There was substantial variability in the reported prevalence of asymptomatic patellar tendon abnormalities. A clear and valid method is needed to assess and report the presence of patellar tendon abnormalities to increase research capacity and establish the clinical value of imaging the patellar tendon. J Orthop Sports Phys Ther 2021;51(5):216-231. Epub 28 Mar 2021. doi:10.2519/jospt.2021.10054.

[Depression and anxiety in patients with psoriatic arthritis: Prevalence and associated factors]

OBJECTIVE

To determine the prevalence of depression and anxiety in patients with psoriatic arthritis (PsA), to investigate whether there is a difference in the prevalence of depression and anxiety between PsA and rheumatoid arthritis (RA) patients and to identify associated risk factors for depression and anxiety in PsA patients.

METHODS

PsA and RA patients who visited Department of Rheumatology and Clinical Immunology in Peking University First Hospital from May 2018 to Sep 2019 were recruited. Self-rating anxiety scale and self-rating depression scale were surveyed and compared between PsA and RA patients. Demographics and clinical features including age, gender, disease duration, disease activity score, psoriasis area and severity index (PASI), and medical application were collected. Power Doppler and grey-scale ultrasound of joints, tenosynovitis and enthesis were performed. Multivariate Logistic regression was used to identify the factors associated with mood disorders and the odds ratio of depression and anxiety between the PsA and RA patients.

RESULTS

Among the 114 enrolled PsA patients, 37 (32.5%) had mood disorders, in which 36 (31.6%) with depression and 15 (13.2%) with anxiety. Compared with 201 RA patients, PsA patients showed greater odds for depression [adjusted OR (95%CI): 2.7 (1.1-6.4)]. Depression was more often observed in the PsA than in the RA patients (31.6% vs. 18.9%, P=0.011). The similar trend for anxiety was also observed, although the difference was insignificant (13.2% vs. 8.5%, P=0.185). Age (OR=0.95, P=0.008), psoriasis duration (OR=0.94, P=0.018), pain visual analogue scale (OR=1.47, P=0.011), PASI score (OR=1.07, P=0.007) and presence of ultrasound enthesitis (OR=4.13, P=0.009) were identified as factors associated with depression in the PsA patients. PASI score (OR=1.07, P=0.001) was identified as associated factor for anxiety in the PsA patients.

CONCLUSION

The prevalence of depression and anxiety is elevated in PsA patients. Depression is significantly more prevalent in PsA patients than in RA patients. Younger age, shorter psoriasis duration, worse pain and presence of ultrasound enthesitis are associated with depression, while severe psoriasis rash is associated with both depression and anxiety in PsA patients.

Differential Diagnosis of Inflammatory Arthropathies by Musculoskeletal Ultrasonography: A Systematic Literature Review

Background: Differential diagnosis in early arthritis is challenging, especially early after symptom onset. Several studies applied musculoskeletal ultrasound in this setting, however, its role in helping diagnosis has yet to be clearly defined. The purpose of this work is to systematically assess the diagnostic applications of ultrasonography in early arthritis in order to summarize the available evidence and highlight possible gaps in knowledge. Methods: In December 2017, existing systematic literature reviews (SLR) on rheumatoid arthritis (RA), osteoarthritis (OA), psoriatic arthritis (PsA), polymyalgia rheumatica (PMR), calcium pyrophosphate deposition disease (CPPD), and gout were retrieved. Studies on ultrasound to diagnose the target conditions and detecting elementary lesions (such as synovitis, tenosynovitis, enthesitis, bone erosions, osteophytes) were extracted from the SLRs. The searches of the previous reviews were updated and data from new studies fulfilling the inclusion criteria extracted. Groups of reviewers worked separately for each disease, when possible diagnostic accuracy (sensitivities, specificities) was calculated from primary studies. When available, the reliability of ultrasound to detect elementary lesions was extracted. Results: For all the examined disease, recent SLRs were available. The new searches identified 27 eligible articles, with 87 articles included from the previous SLRs. The diagnostic performance of ultrasound in identifying diseases was addressed by 75 studies; in most of them, a single elementary lesion was used to define diagnosis, except for PMR. Only studies on RA included consecutive patients with new onset of arthritis, while studies on gout and CPPD often focused on subjects with mono-arthritis. Most of the remaining studies enrolled patients with a defined diagnosis. Synovitis was the most frequently detected lesion; clinical diagnosis was the most common reference standard. The diagnostic performance of ultrasound across different conditions was extremely variable. Ultrasound to identify elementary lesions was assessed in 38 studies in OA, gout and CPPD. Its performance in OA was very variable, with better results in CPPD and gout. The reliability of ultrasound was moderate to good for most lesions. Conclusions: Although a consistent amount of literature investigated the diagnostic application of ultrasound, in only a minority of cases its additional value over clinical diagnosis was tested. This SLR underlines the need for studies with a pragmatic design to identify the placement of ultrasound in the diagnostic pathway of new-onset arthritis.

Ultrasonographic evaluation of subclinical enthesitis in patients with psoriasis

AIM

The primary objective of this study was to assess the ultrasonographic signs of subclinical enthesitis in patients with psoriasis. Secondary objective was to examine the associations between the clinical assessments of enthesitis, severity of psoriasis, and the ultrasonographic signs of enthesitis.

METHOD

This study included 30 patients with psoriasis who did not have clinically detectable arthritis or enthesitis and 30 healthy volunteers as a control group. In the patient group, PASI, NAPSI, MASES, and SPARCC scores were calculated, and in the control group, MASES and SPARCC scores were calculated. Acute, chronic, and total enthesitis scores were calculated by ultrasonographic examination of the enthesis points that are assessed during calculation of SPARCC score, performed by a researcher blinded to the clinical assessments.

RESULT

In the ultrasonographic assessment, total enthesitis score was significantly higher in the patient group compared with the control group (P = .04). There was no significant difference between the groups regarding acute or chronic enthesitis scores. NAPSI, PASI, MASES, or SPARCC scores did not show correlation with the ultrasonographically acute, chronic, or total enthesitis scores. There was a low-level correlation between MASES and SPARCC scores in the patient group, which was statistically significant (P = .03). No significant correlation was found between other clinical scores. There was no significant difference between patient and control groups in terms of MASES and SPARCC scores.

CONCLUSION

Entheseal changes may be frequently observed in patients with psoriasis who are asymptomatic. Musculoskeletal ultrasonography (MUS) may be utilized to detect such abnormalities at the early period.

Role of the IL-23 pathway in the pathogenesis and treatment of enthesitis in psoriatic arthritis

INTRODUCTION

Enthesitis is a key feature of spondyloarthritis (SpA). Several studies have underlined the role of interleukin (IL)-23 in SpA development as a crucial cytokine in the pathogenesis of enthesitis.

AREA COVERED

This review summarizes recent evidence of the role of IL-23 in the pathogenesis of and as a target of the treatment of enthesitis. We review the definition, diagnosis and clinical impact of enthesitis and its connection with microbial infections, gut dysbiosis, and mechanical stress. We also review clinical trials and real-life studies of drugs targeting the p19 or p40 subunits of IL-23.

EXPERT OPINION

Novel therapies targeting the p19 or p40 subunit of IL-23 appear to be promising treatment options for patients with enthesitis. Although we are currently unable to identify the best therapeutic window to target IL-23 in SpA disease evolution, the promising ability of this therapy to control the gut-entheseal axis is increasing our knowledge of SpA pathogenesis.

Psoriatic Arthritis: What is Happening at the Joint?

Psoriatic arthritis (PsA) is a heterogeneous and inflammatory disease with diverse clinical manifestations, including psoriasis, nail psoriasis, peripheral joint disease, axial joint disease, enthesitis, and dactylitis. Typically, this varied clinical presentation complicates the clinician's ability to distinguish PsA from other forms of arthritis. In the synovium of individuals with PsA, upregulation of the genes WNT3A, BMPR2, and TGFBR1 results in bone erosion and new bone formation, a pattern unique to the disease. Additionally, genes associated with angiogenesis and vascularization such as VEGF and TGFB1 facilitate inflammation and joint damage. Gross pathogenesis of PsA is driven by proinflammatory cytokines, and key cytokines affecting joint structures include tumor necrosis factor-α, interleukin (IL)-6, IL-17A, IL-21, IL-22, and IL-23. Early diagnosis is critical for providing treatment that prevents irreversible disease progression and function loss. This narrative review discusses differentiation of PsA from other forms of arthritis. Additionally, we detail the role of cytokines at the joint in mediating PsA pathogenesis.Funding: Novartis Pharmaceuticals Corporation.

Ultrasonographic and Clinical Assessment of Peripheral Enthesitis in Patients with Psoriatic Arthritis, Psoriasis, and Fibromyalgia Syndrome: The ULISSE Study

Objective.

The purpose of the ULISSE study was to evaluate the prevalence of clinical and ultrasonographic (US) entheseal involvement in patients with psoriatic arthritis (PsA), psoriasis, and fibromyalgia syndrome (FMS).

Methods.

In this cross-sectional multicenter study, patients with PsA and psoriasis (not taking systemic therapy) and FMS underwent a clinical evaluation of the entheses, and a B-mode and power Doppler examination of 6 pairs of entheses.

Results.

The study analyzed 140 patients with PsA, 51 with psoriasis, and 51 with FMS. Clinical and US examinations were performed in 1960 and 1680 entheses in the PsA group, and 714 and 612 entheses both in the psoriasis group and in the FMS group. In both per-patient and per-enthesis evaluation, the frequency of entheseal tenderness was higher in patients with FMS (92% of the patients and 46% of the entheses, compared with 66%/23% in the PsA group and 59%/18% in the psoriasis group). With US examination, signs of entheseal involvement were more frequent in both the per-patient and per-enthesis evaluation in PsA and psoriasis (about 90% of patients in both the PsA and psoriasis groups and 75% of patients in the FMS group had at least 1 site affected, and 54%, 41%, and 27% of the pairs of entheses in, respectively, PsA, psoriasis, and FMS patients showed at least 1 enthesis involved).

Conclusion.

The ULISSE study indicated that enthesitis is a common feature in patients with PsA, those with psoriasis, and in those with FMS if only clinical examination is used. US entheseal assessment showed findings more consistent with the 3 disorders.

Clinical assessment and ultrasonography in the follow-up of enthesitis in patients with spondyloarthritis: a multicenter ultrasound study in daily clinical practice

Objectives

The aim of this study was to compare the clinical Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and an established ultrasound enthesitis score following treatment change in patients with spondyloarthritis and enthesitis with respect to the sensitivity to change and health-related quality of life.

Materials and methods

About 145 patients with active ankylosing spondylitis (n=65), psoriatic arthritis without (n=66) or with (n=14) axial involvement undergoing intensification of their treatment were included in this multicenter study. At baseline, after 3 and 6 months, 13 entheses were scored by MASES, ultrasonography was performed for 14 entheses. Assessments of clinical, laboratory and patient-reported outcome measurements were performed.

Results

During 6 months of follow-up, MASES was reduced from 5.57 to 3.12 (P<0.001), which was similar to the reduction of the power Doppler sum score from 5.47 to 2.88 (P<0.001). Both MASES and power Doppler ultrasound were responsive at the 3-month follow-up visit, as indicated by a high sensitivity to change in patients initiating anti-tumor necrosis factor treatment (-0.96 for MASES and -0.74 for power Doppler ultrasound). Improvement of enthesitis did not correlate with patient-reported outcomes.

Conclusion

Clinical assessment by MASES and power Doppler sonography as well reflects anti-tumor necrosis factor treatment response in patients with spondyloarthritis. Improvement of enthesitis did not correlate with changes in quality of life measures.

Entheseal involvement in patients with systemic lupus erythematosus: an ultrasound study

Objectives

The main objective of this study is to explore the prevalence and distribution of entheseal US changes in a cohort of SLE patients, taking as controls a group including both PsA patients and healthy subjects. The secondary objective is to investigate the correlation between the US findings and the clinical and serological data in SLE patients.

Methods

Clinical and US assessment of quadriceps, patellar and Achilles tendons, and plantar fascia entheses were performed by independent rheumatologists on 65 patients with SLE, 50 patients with PsA and 50 healthy subjects. US findings were identified according to the OMERACT definitions. In SLE patients, the correlation between the US changes and the clinical and laboratory findings was evaluated.

Results

US revealed one or more abnormalities in at least one enthesis in 44 out of 65 SLE patients (67.7%), 47 out of 50 PsA patients (94.0%) and 22 out of 50 healthy subjects (44.0%). In SLE patients, US findings indicating active inflammation were significantly more frequently detected than in healthy subjects (P < 0.001). The distal enthesis of the patellar tendon was the most commonly involved. The presence of power Doppler signal at the enthesis was an independent predictor of SLE disease activity (SLEDAI-2k P < 0.001, β = 0.52; musculoskeletal-BILAG P < 0.001, β = 0.56).

Conclusion

The burden of entheseal sonographic changes was significantly higher in SLE patients than in healthy subjects, especially as regards active inflammation. The presence of power Doppler signal at the enthesis may represent a potential biomarker of SLE disease activity.

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.

Enthesitis: Much More Than Focal Insertion Point Inflammation

Purpose of Review

Recognition of the importance of enthesitis as the pivotal pathological process underpinning spondyloarthropathies (SpA) has increased in recent years. Thus, we summarized the current knowledge on the pathogenic role of enthesitis on SpA shown by both animal models and human studies in vivo.

Recent Findings

Experimental models have shown several SpA-like diseases that commence at entheses and are linked to nail disease as well as dactylitis, two important entheseal-associated conditions in humans. Frequently, enthesitis is not the primary outcome measure in studies of peripheral PsA and SpA although arguably it is the key parameter being indirectly assessed in spinal disease in ankylosing spondylitis. The use of different agents including JAK, IL-17, and IL-23 inhibitors contributes significantly to our understanding of enthesitis in terms of involved immune pathways.

Summary

Enthesitis and enthesis organ inflammation may be the primary pathological process underlying SpA associated skeletal inflammation. Emergent studies are beginning to elucidate the molecular basis for this type of joint inflammatory response.

ENTHESITIS AND PSORIATIC ONYCHOPATHY AS A FACTOR FOR PREDICTION OF PSORIATIC ARTHRITIS IN PSORIASIS

Psoriatic arthritis is a psoriasis-related spondyloarthropathy that occurs in 20–30 % of patients with psoriasis. Psoriatic arthritis affects the patient’s quality of life indicators and are more often associated with disabilities of working age than psoriasis skin form. Nail psoriasis has been proposed as a predictor for the development of psoriatic arthritis. The inflammation involving the entheses, called enthesitis, is an early inflammatory change seen in psoriatic arthritis, and nail changes appear to result from the close relationship between the nail and the enthesis of the distal interphalangeal extensor tendon, one of the main entheseal compartments affected in psoriatic arthritis. Various imaging studies have demonstrated that there is a considerable proportion of undiagnosed psoriatic arthritis among patients with psoriasis. Since early detection and treatment of psoriatic arthritis could, ultimately, allow the prevention of clinical and radiologic progression of the disease, there is the need to establish clinical indicators to detect this risk.

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.

Musculoskeletal ultrasonography for psoriatic arthritis and psoriasis patients: a systematic literature review

Objective

To systematically review the role of musculoskeletal US in patients suffering from PsA or psoriasis (Pso) in terms of prevalence, diagnosis, prognosis, monitoring and treatment.

Methods

A systematic literature review was conducted through medical databases (MEDLINE via PubMed, Embase) and the grey literature up to September 2015 to inform a new study of the Musculoskeletal Ultrasound Study Group of the Italian Society for Rheumatology. All articles reporting data on musculoskeletal US in PsA or Pso were included and extracted according to the underlying clinical question.

Results

A total of 86 publications were included. The prevalence of US abnormalities showed a wide range for each examined feature (e.g. 37-95% for entheses thickness of the lower limbs). The performance of US for diagnosis of disease or elementary lesions was variable across studies, but no study evaluated the overall performance of US in addition to clinical findings for diagnosing PsA. Considering US in defining PsA and Pso prognosis, several works focused on US of entheses of lower limbs in Pso, while for the monitoring of PsA activity five different scoring systems were identified. Last, the results of the role of US in guiding intra-articular interventions were controversial for the clinical outcomes, but in favour of US for accuracy.

Conclusion

despite the recognized importance of US in the management of PsA and Pso, this review clearly demonstrated the need of pivotal research in order to optimize the use of US in the diagnosis and monitoring of psoriatic disease.

Achilles enthesitis defined by ultrasound is not associated with clinical enthesitis in patients with psoriatic arthritis

Objective

To compare clinical and ultrasonographic (US) evaluation of Achilles enthesitis in patients with psoriatic arthritis (PsA).

Methods

The Achilles insertion of outpatients with PsA was examined by clinical assessment of tenderness and US evaluation of (1) inflammatory activity (defined as the presence of power Doppler signal, tendon thickening and/or hypoechogenicity) and (2) structural damage (defined as the presence of erosions, calcifications and/or enthesophytes). Univariate and multivariate logistic regression analyses were performed0.4 to explore the associations between clinical characteristics and US scores.

Results

282 Achilles tendons in 141 patients with PsA were assessed. Mean (SD) age was 52.4 (10.2) years, disease duration 9.5 (6.6) years and 50.4% were females. Palpatory tenderness was found in 88 (31.2%), US-verified inflammatory activity in 46 (16.3%) and structural damage in 148 (52.5%) of the Achilles. Total US scores, as well as their components, were similar for patients with and without palpatory tenderness. None of the clinical characteristics were associated with inflammatory activity. Age, body mass index (BMI), regular physical exercise and current use of biological disease-modifying antirheumatic drugs (bDMARDs) were associated with structural damage.

Conclusion

There appears to be a lack of association between clinical and US signs of Achilles enthesitis in PsA. Age, BMI, regular physical exercise and current use of bDMARDs were associated with structural damage on US.

Case-control Study on Dactylitis, Enthesitis, and Anterior Uveitis in Spondyloarthritis Associated with Inflammatory Bowel Diseases: Role of Coexistent Psoriasis

OBJECTIVE

To evaluate the frequency of dactylitis, enthesitis, and anterior uveitis (AU) in spondyloarthritis (SpA) associated with inflammatory bowel disease (IBD-SpA) compared with other SpA, and to assess the role of associated psoriasis in the occurrence of dactylitis and enthesitis.

METHODS

In a 12-month case-control study, the frequency of dactylitis and enthesitis in 29 patients with ulcerative colitis (UC) and 59 with Crohn disease (CD) who satisfied the Spondyloarthritis international Society criteria for axial or peripheral SpA was compared with 176 controls, including 97 (55.1%) with psoriatic arthritis (PsA), 47 (26.7%) with ankylosing spondylitis (AS), and 32 (18.2%) with nonradiographic axial SpA (nr-axSpA). The occurrence of these features in IBD-SpA with and without psoriasis was also evaluated.

RESULTS

Axial, peripheral, or mixed involvement was observed in 46 (52%), 29 (33%), and 13 (15%) patients, respectively; and 14/88 (16%) had psoriasis. Dactylitis was recorded in 4/88 patients (4.5%) with IBD-SpA and in 30 controls (17.4%; p = 0.008), enthesitis in 16 cases (18.1%) and in 78/176 controls (44.3%; p < 0.001), and AU in 3 patients (3.4%) with IBD-SpA and in 26 controls (14.7%; p = 0.01). No significant differences were found between patients with UC-SpA and those with CD-SpA. Dactylitis and enthesitis were significantly more common in patients with IBD-SpA who also had psoriasis compared to those without skin disease (p = 0.009 and 0.003, respectively).

CONCLUSION

Dactylitis, enthesitis, and AU are significantly less frequent in IBD-SpA compared with other types of SpA. Given the frequent association of psoriasis and IBD, overlooking coexistent skin disease may lead to overestimating the frequency of these features.

Assessment of enthesitis in patients with psoriatic arthritis using clinical examination and ultrasound

BACKGROUND

Enthesitis is a major feature of psoriatic arthritis. However, clinical assessment of enthesitis is known to lack accuracy and have poor interobserver reliability.

OBJECTIVE

To determine effect of training on clinical assessment of enthesitis and to compare ultrasonography with clinical examination for the detection of entheseal abnormalities.

METHODS

20 rheumatologists performed repeated assessment of enthesitis in patients with established psoriatic arthritis before and after a 2-hour training session in standardised enthesitis count according to Leeds Enthesitis Index (LEI) and Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC). Moreover, 20 patients underwent clinical and ultrasonographic examination of entheses to evaluate consensus-based elementary lesions of enthesitis.

RESULTS

Training significantly increased Intra-class Correlation Coefficient for LEI from 0.18 to 0.82 and for SPARCC from 0.38 to 0.67. Ultrasound examination showed high associations between hypoechogenicity and increased thickness of the entheses and clinical examination. There was no correlation between erosions and enthesophytes found by ultrasound and clinical assessments.

CONCLUSION

Training in standardised enthesitis scoring systems significantly improved clinical assessments of enthesitis and should be performed before use in daily clinical practice. Ultrasound revealed more advanced stages of enthesitis, such as enthesophytes and erosions, which were not detected with clinical examination.

An ultrasonographic study of enthesis in early psoriatic arthritis patients naive to traditional and biologic DMARDs treatment

The aim of this study was to evaluate the rate of power Doppler ultrasound (PDUS) abnormalities at entheseal sites in patients with early psoriatic arthritis (PsA) naïve to traditional and biologic DMARDs and to compare the PDUS findings with clinical examination. PsA patients with early disease and naïve to traditional and biologic DMARDs were consecutively enrolled in this study. Patients underwent PDUS examination of the following bilateral entheseal sites: common extensor tendon at its insertion at the lateral humeral epicondyle; quadriceps tendon at its insertion at the superior pole of the patella; patellar tendon at its insertion at the tibial tuberosity; medial collateral ligament at its proximal insertion and Achilles tendon at its insertion at the calcaneus. The Leeds enthesitis index (LEI) was used to assess clinical entheseal involvement. Twenty-one early PsA patients completed the clinical and PDUS examinations. Clinical entheseal involvement was found in 9 (42.9 %) and PDUS abnormalities in 20 (95.5 %) of the 21 early PsA patients. Achilles tendon insertion was the site with the major entheseal abnormalities. Active (power Doppler positive) entheseal lesions were found in 4.7, 9.5, 14.3 and 14.3 % of patients at the lateral humeral epicondyle; quadriceps tendon, patellar tendon insertions, and Achilles tendon insertions, respectively. Concordance between clinical (LEI) and PDUS was poor. The present study confirms that PDUS allows detecting structural and inflammatory abnormalities of enthesis in early PsA patients. Our study shows that, in early disease, active abnormalities seem to have a low prevalence.

Assessing disease activity in psoriasis and psoriatic arthritis: impact on management and therapy

The management of psoriatic arthritis (PsA) and psoriasis has undergone major advancements over the last decade. This has been made possible, in part, due to the introduction of new therapies for their management, as well as global collaboration in the development of outcome measures and "treat- to- target" paradigms. In this review article, we discuss how disease activity is measured and the outcome measures that have been recently developed for the management of PsA. The importance of assessing the individual domains as well as global assessments both from the physician and patient perspective, and the development of composite measures are discussed. The newer PsA specific measures are expected to be more commonly used in clinical trials as well as clinical practice.

Comparison of Clinical Examination versus Whole-body Magnetic Resonance Imaging of Enthesitis in Patients with Early Axial Spondyloarthritis during 3 Years of Continuous Etanercept Treatment

Objective.

To compare clinical examination versus whole-body magnetic resonance imaging (WB-MRI) of enthesitis in patients with early axial spondyloarthritis during 3 years of continuous etanercept (ETN) treatment.

Methods.

Forty-one patients underwent clinical and WB-MRI examinations for enthesitis at baseline and after 2 and 3 years of treatment. Twenty-one sites were assessed in 4 anatomic regions — anterior chest wall, pelvis, knee, and foot.

Results.

Clinical examination at baseline detected enthesitis in 57% of the patients (85 lesions, mean 2.1 lesions, SD 2.9), most of them in the pelvis (42 lesions in 17 patients) and anterior chest wall (19 lesions in 10 patients). The proportion of patients with clinically detected enthesitis decreased to 19% at Year 2 (mean 0.5, SD 1.5) and 14% at Year 3 (mean 0.7, SD 1.8). WB-MRI detected enthesitis at baseline in 21% of patients (22 lesions, mean 0.5 lesions, SD 1.1), also most frequently in the pelvis (12 lesions) and anterior chest wall (7 lesions). MRI-positive enthesitis decreased to 13% at Year 2 (mean 0.2 lesions, SD 0.5) and 14% at Year 3 (mean 0.2 lesions, SD 0.5). There was positive correlation of clinical and MRI findings at baseline at the anterior chest wall (p = 0.001) and the pelvis (p = 0.0001). No correlation was found at the knee and foot at baseline and for all regions at followup.

Conclusion.

Both clinical examination and WB-MRI show a decrease in enthesitis after 2 and 3 years of ETN treatment, but correlation was limited to the pelvis and anterior chest wall at baseline.

Entheseal involvement in systemic disorders

The objective of this study is to review the data on entheseal involvement in systemic disorders. A Pubmed search utilizing the indexing terms "enthesis" and "enthesitis" was conducted and the data pertinent to the aim of the review was extracted and organized in accordance with the preplanned structure of the manuscript. A number of cadaver-based studies, as well as studies using ultrasonography and magnetic resonance imaging, have detailed new distinct aspects of enthesis physiology and pathology in a variety of rheumatic and non-rheumatic systemic disorders. Major progress has been done in characterization of separate components of the enthesis organ, imaging of entheses, elaboration of the role and features of entheseal disease in spondyloarthropathies, juvenile idiopathic arthritis, osteoarthritis, familial Mediterranean fever, hyperuricemia, and other systemic conditions. The knowledge acquired and summarized herein shows that entheses can be affected in various ways in variety of medical disorders with different pathogenesis. Better understanding of the risk factors, mechanisms and natural history of enthesopathies is warranted. The current progress in the understanding of entheseal involvement in systemic disorders represents just the first step in resolving the entheses-related enigmas.

The assessment of lesions of the Achilles tendon by ultrasound imaging in inflammatory arthritis: A systematic review and meta-analysis

OBJECTIVE

Ultrasound (US) is a highly sensitive, reliable and non-invasive tool, which allows for the assessment of lesions of tendons and entheseal sites. The aim of this systematic review and meta-analysis is to identify differences in US lesions of the Achilles tendon (AT) between people with inflammatory arthritis (IA) and healthy controls.

METHODS

An electronic literature search was performed on Medline, CINAHL, SportDiscus and The Cochrane Library. Methodological quality was assessed using a modified Quality Index. Odds ratios with 95% confidence intervals (CI) were determined. Meta-analysis was conducted on those studies that were considered to be homogenous.

RESULTS

A total of 13 high-to-medium quality studies met the inclusion criteria. The majority of studies reported US lesions in spondyloarthropathy (SpA), with limited evidence for other forms of IA. US lesions were not consistently defined with regard to Outcome Measures in Rheumatology Clinical Trials (OMERACT) definitions, and numerous scoring systems were used across the majority of studies. The mean AT thickness at the enthesis in people with SpA was 0.54mm thicker (95% CI: 0.10-0.97mm) with more frequent erosions in people with SpA (odds ratio = 7.43, 95% CI: 1.99-27.77, P = 0.003) and rheumatoid arthritis (RA) (odds ratio = 9.60, 95% CI: 1.23-74.94, P = 0.03), compared to controls. There was no significant difference in the frequency of enthesophyte formation in people with SpA compared to the controls (odds ratio = 2.48, 95% CI: 0.64-9.70, P = 0.19).

CONCLUSIONS

The systematic review identified that a majority of studies reporting US lesions were in SpA, but limited evidence relating to other forms of IA. Consistent application of the OMERACT US definitions and scoring of US lesions is required in future studies of AT disease in IA. Further work is also required to distinguish between US lesions reflective of inflammation and structural damage.

Is the Madrid Sonographic Enthesitis Index Useful for Differentiating Psoriatic Arthritis from Psoriasis Alone and Healthy Controls?

Objective.

To assess the usefulness of the MAdrid Sonographic Enthesitis Index (MASEI) in classifying patients as having psoriatic arthritis (PsA) and comparing entheseal abnormalities between patients with PsA, psoriasis alone (PsC), and healthy controls (HC).

Methods.

Patients with PsC were assessed to exclude inflammatory arthritis. The MASEI scoring system was used to quantify the extent of ultrasonographic (US) entheseal abnormalities. The total MASEI score was categorized into items that reflected inflammatory abnormalities (MASEI-inflammatory) and chronic damage (MASEI-damage). Nonparametric tests were used to compare MASEI scores across the groups. A cutoff point of MASEI ≥ 20 was used to calculate the sensitivity and specificity of the MASEI to classify patients as having PsA.

Results.

Patients with PsA (n = 50), PsC (n = 66), and HC (n = 60) were assessed. Total MASEI scores were higher in patients with PsA than in those with PsC, and both those groups were higher than HC (p < 0.0001). MASEI-inflammatory showed a similar trend (p < 0.0001). MASEI-damage was higher in patients with PsA compared to both patients with PsC and HC (p < 0.0001); however, no difference was observed between patients with PsC and HC. No significant difference in MASEI scores was found across the 3 groups in patients with a body mass index > 30. The sensitivity of the MASEI score to correctly classify patients as having PsA was 30% and the specificity was 95% when compared to HC and 89% when compared to PsC.

Conclusion.

The severity of US entheseal abnormalities is highest in patients with PsA followed by PsC and is lowest in healthy controls. MASEI can specifically classify patients as having PsA.

[Screening and early diagnosis of psoriasis arthritis]

Psoriasis arthritis (PsA) encompasses many diverse clinical symptoms. Epidemiological data about the prevalence in general, predisposed age groups, prevalence of joint, spine, enthesis, and extra-articular manifestations are very heterogeneous. Even for the PsA specialist the clinical picture is not always easy to differentiate from other overlapping or clinically similar disease entities. This paper tries to give some guidance on how to screen for and how to detect PsA early in the population of psoriasis patients on the basis of the Mainz PsA screening and early diagnosis algorithm.