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Maatallah K, Cherif I, Ferjani H, Ben Nessib D, Boumaiza R, Kaffel D, Hamdi W. Navigating the Factors Affecting Functional Impairment in Spondyloarthritis. Sultan Qaboos Univ Med J 2024; 24:235-242. [PMID: 38828242 PMCID: PMC11139368 DOI: 10.18295/squmj.3.2024.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/07/2024] [Accepted: 01/23/2024] [Indexed: 06/05/2024] Open
Abstract
Objectives This study aimed to assess the predictive factors of functional impairment in spondyloarthritis (SpA) patients assessed with bath ankylosing spondylitis functional index (BASFI) and Lequesne Index (LI). Methods This retrospective study was conducted at the Rheumatology Department of Mohamed Kassab Institute of Orthopedics, Manubah, Tunisia, and collected data from 2008 to 2019 over a period of 4 months (August to November 2019). Socio-demographic and disease-related data of SpA patients were collected. Disease activity was assessed using the bath ankylosing spondylitis-global score (BASG-s) and the bath ankylosing spondylitis disease activity index (BASDAI). The spinal mobility was evaluated by the bath ankylosing spondylitis metrology index (BASMI). Structural progression was evaluated with the bath ankylosing spondylitis radiologic index (BASRI) and modified stoke ankylosing spondylitis spine score (mSASSS). A multivariate analysis was done to search for predictive factors associated with BASFI and LI. Results A total of 263 patients were included. The mean age was 38.9 ± 12.7 years and the gender ratio was 2.7. The mean age of onset of SpA was 27.6 ± 10.8 years and disease duration was 11.3 ± 9.5 years. Occupation was significantly associated with BASFI and LI scores. A significant functional impact was notably correlated with a long duration of the disease. The two scores were correlated with a limitation of spinal mobility (BASMI), a greater disease activity (BASDAI and erythrocyte sedimentation rate) and a greater impact of the disease on health status (BASG-s). Significant functional impairment was also correlated with structural impairment (mSASSS, BASRI and sacroiliitis grade). The variables independently related to BASFI were the mSASSS score and the BASDAI. The variables independently related to LI were profession (unemployed subjects had higher scores), the mSASSS score and the BASMI. Conclusion Occupation, disease activity, mobility and structural progression predicted functional impairment in Tunisian SpA patients.
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Affiliation(s)
- Kaouther Maatallah
- University Tunis El Manar, Faculty of Medicine, Tunis, Tunisia; Kassab Institute of Orthopedics, Manubah, Tunisia
| | - Ines Cherif
- University Tunis El Manar, Faculty of Medicine, Tunis, Tunisia; Kassab Institute of Orthopedics, Manubah, Tunisia
| | - Hanen Ferjani
- University Tunis El Manar, Faculty of Medicine, Tunis, Tunisia; Kassab Institute of Orthopedics, Manubah, Tunisia
| | - Dorra Ben Nessib
- University Tunis El Manar, Faculty of Medicine, Tunis, Tunisia; Kassab Institute of Orthopedics, Manubah, Tunisia
| | - Rania Boumaiza
- University Tunis El Manar, Faculty of Medicine, Tunis, Tunisia; Kassab Institute of Orthopedics, Manubah, Tunisia
| | - Dhia Kaffel
- University Tunis El Manar, Faculty of Medicine, Tunis, Tunisia; Kassab Institute of Orthopedics, Manubah, Tunisia
| | - Wafa Hamdi
- University Tunis El Manar, Faculty of Medicine, Tunis, Tunisia; Kassab Institute of Orthopedics, Manubah, Tunisia
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García-Vicuña R, Juanola X, Navarro-Compán V, Moreno-Ramos MJ, Castillo-Gallego C, Moreno M, Galíndez E, Montoro M, Gómez I, Rebollo-Laserna FJ, Loza E. Management of Specific Clinical Profiles in Axial Spondyloarthritis: An Expert's Document Based on a Systematic Literature Review and Extended Delphi Process. Rheumatol Ther 2023; 10:1215-1240. [PMID: 37450194 PMCID: PMC10468481 DOI: 10.1007/s40744-023-00575-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION The management of specific clinical scenarios is not adequately addressed in national and international guidelines for axial spondyloarthritis (axSpA). Expert opinions could serve as a valuable complement to these documents. METHODS Seven expert rheumatologists identified controversial areas or gaps of current recommendations for the management of patients with axSpA. A systematic literature review (SLR) was performed to analyze the efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, conventional synthetic, biologic and targeted synthetic disease-modifying antirheumatic drugs (csDMARDs, b/tsDMARDs) in axSpA regarding controversial areas or gaps. In a nominal group meeting, the results of the SLR were discussed and a set of statements were proposed. A Delphi process inviting 150 rheumatologists was followed to define the final statements. Agreement was defined as if at least 70% of the participants voted ≥ 7 (from 1, totally disagree, to 10, totally agree). RESULTS Three overarching principles and 17 recommendations were generated. All reached agreement. According to them, axSpA care should be holistic and individualized, taking into account objective findings, comorbidities, and patients' opinions and preferences. Integrating imaging and clinical assessment with biomarker analysis could also help in decision-making. Connected to treatments, in refractory enthesitis, b/tsDMARDs are recommended. If active peripheral arthritis, csDMARD might be considered before b/tsDMARDs. The presence of significant structural damage, long disease duration, or HLA-B27-negative status do not contraindicate for the use of b/tsDMARDs. CONCLUSIONS These recommendations are intended to complement guidelines by helping health professionals address and manage specific groups of patients, particular clinical scenarios, and gaps in axSpA.
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Affiliation(s)
- Rosario García-Vicuña
- Servicio de Reumatología, Hospital Universitario La Princesa, IIS-Princesa, Madrid, Spain
| | - Xavier Juanola
- Servicio de Reumatología, Hospital Universitario de Bellvitge, Universidad de Barcelona, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | | | - Manuel José Moreno-Ramos
- Servicio de Reumatología, Hospital Clínico Universitario Virgen de La Arrixaca, El Palmar, Murcia, Spain
| | | | - Mireia Moreno
- Servicio de Reumatología, Universitari Parc Taulí Hospital, Institut d’Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain
| | - Eva Galíndez
- Servicio de Reumatología, Hospital Universitario de Basurto, Bilbao, Spain
| | - María Montoro
- Pfizer Medical Department, Alcobendas, Madrid, Spain
| | - Ismael Gómez
- Pfizer Medical Department, Alcobendas, Madrid, Spain
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Cretu I, Geoanta C, Bogheanu OI, Milicescu M, Bojinca M, Costache M, Cirstoiu C, Cretu B. Cerebral Tuberculosis in a Patient Following Treatment With Infliximab for Ankylosing Spondylitis: A Case Report. Cureus 2023; 15:e39117. [PMID: 37216132 PMCID: PMC10195647 DOI: 10.7759/cureus.39117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 05/24/2023] Open
Abstract
Ankylosing spondylitis (AS) mainly belongs to the group of axial spondylitis. It is a chronic inflammatory disease that primarily affects the spine, but can also affect peripheral joints. It is characterized by inflammatory lower back pain and morning stiffness. Tuberculosis is still a cause of morbidity and mortality in developing countries. Management of patients with AS consists of patient education, spinal mobility exercises, non-steroidal anti-inflammatory drugs (NSAIDs), corticotherapy, and anti-tumor necrosis factor alpha (TNF-α) biological agents. Anti-TNF-α biological agents have changed the prognosis of patients with AS. They contain anti-TNF-α monoclonal antibodies (golimumab, infliximab, adalimumab, certolizumab) and the soluble TNF-α receptor (etanercept). Hip and knee involvement is common in patients with AS, as evidenced in radiographs as bone erosion and joint space narrowing. The patient may have severe pain, stiffness, and loss of mobility, and the treatment involves surgery for joint arthroplasty. We present the case of a 63-year-old patient with axial spondyloarthritis who was treated with infliximab and developed cerebral tuberculosis after three years of biological therapy. The purpose of the study is to determine the possibility of resuming biological therapy at the time of AS reactivation, given the long-term treatment and adverse reactions of cortisone therapy (aseptic necrosis of the femoral head).
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Affiliation(s)
- Ioana Cretu
- Internal Medicine & Rheumatology, Doctor Ion Cantacuzino Clinical Hospital, Bucharest, ROU
| | - Corina Geoanta
- Internal Medicine & Rheumatology, Doctor Ion Cantacuzino Clinical Hospital, Bucharest, ROU
| | - Oana-Irina Bogheanu
- Internal Medicine & Rheumatology, Doctor Ion Cantacuzino Clinical Hospital, Bucharest, ROU
| | - Mihaela Milicescu
- Internal Medicine & Rheumatology, Doctor Ion Cantacuzino Clinical Hospital, Bucharest, ROU
| | - Mihai Bojinca
- Internal Medicine & Rheumatology, Doctor Ion Cantacuzino Clinical Hospital, Bucharest, ROU
| | - Mihai Costache
- Orthopedics & Traumatology, Bucharest University Emergency Hospital, Bucharest, ROU
| | - Catalin Cirstoiu
- Orthopedics & Traumatology, Bucharest University Emergency Hospital, Bucharest, ROU
| | - Bogdan Cretu
- Orthopedics & Traumatology, Bucharest University Emergency Hospital, Bucharest, ROU
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Davydova A, Kurochkina Y, Goncharova V, Vorobyeva M, Korolev M. The Interleukine-17 Cytokine Family: Role in Development and Progression of Spondyloarthritis, Current and Potential Therapeutic Inhibitors. Biomedicines 2023; 11:1328. [PMID: 37238999 PMCID: PMC10216275 DOI: 10.3390/biomedicines11051328] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
Spondyloarthritis (SpA) encompasses a group of chronic inflammatory rheumatic diseases with a predilection for the spinal and sacroiliac joints, which include axial spondyloarthritis, psoriatic arthritis, reactive arthritis, arthritis associated with chronic inflammatory bowel disease, and undifferentiated spondyloarthritis. The prevalence of SpA in the population varies from 0.5 to 2%, most commonly affecting young people. Spondyloarthritis pathogenesis is related to the hyperproduction of proinflammatory cytokines (TNFα, IL-17A, IL-23, etc.). IL-17A plays a key role in the pathogenesis of spondyloarthritis (inflammation maintenance, syndesmophites formation and radiographic progression, enthesites and anterior uveitis development, etc.). Targeted anti-IL17 therapies have established themselves as the most efficient therapies in SpA treatment. The present review summarizes literature data on the role of the IL-17 family in the pathogenesis of SpA and analyzes existing therapeutic strategies for IL-17 suppression with monoclonal antibodies and Janus kinase inhibitors. We also consider alternative targeted strategies, such as the use of other small-molecule inhibitors, therapeutic nucleic acids, or affibodies. We discuss advantages and pitfalls of these approaches and the future prospects of each method.
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Affiliation(s)
- Anna Davydova
- Research Institute of Clinical and Experimental Lymphology, Affiliated Branch of Federal Research Center of Cytology and Genetics, Siberian Division of the Russian Academy of Sciences, 630060 Novosibirsk, Russia; (Y.K.); (V.G.); (M.K.)
- Institute of Chemical Biology and Fundamental Medicine, Siberian Division of the Russian Academy of Sciences, 630090 Novosibirsk, Russia;
| | - Yuliya Kurochkina
- Research Institute of Clinical and Experimental Lymphology, Affiliated Branch of Federal Research Center of Cytology and Genetics, Siberian Division of the Russian Academy of Sciences, 630060 Novosibirsk, Russia; (Y.K.); (V.G.); (M.K.)
| | - Veronika Goncharova
- Research Institute of Clinical and Experimental Lymphology, Affiliated Branch of Federal Research Center of Cytology and Genetics, Siberian Division of the Russian Academy of Sciences, 630060 Novosibirsk, Russia; (Y.K.); (V.G.); (M.K.)
| | - Mariya Vorobyeva
- Institute of Chemical Biology and Fundamental Medicine, Siberian Division of the Russian Academy of Sciences, 630090 Novosibirsk, Russia;
| | - Maksim Korolev
- Research Institute of Clinical and Experimental Lymphology, Affiliated Branch of Federal Research Center of Cytology and Genetics, Siberian Division of the Russian Academy of Sciences, 630060 Novosibirsk, Russia; (Y.K.); (V.G.); (M.K.)
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Zheng Y, Bai C, Zhang K, Han Q, Guan Q, Liu Y, Zheng Z, Xia Y, Zhu P. Deep-learning based quantification model for hip bone marrow edema and synovitis in patients with spondyloarthritis based on magnetic resonance images. Front Physiol 2023; 14:1132214. [PMID: 36935744 PMCID: PMC10020192 DOI: 10.3389/fphys.2023.1132214] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Objectives: Hip inflammation is one of the most common complications in patients with spondyloarthritis (SpA). Herein, we employed use of a deep learning-based magnetic resonance imaging (MRI) evaluation model to identify irregular and multiple inflammatory lesions of the hip. Methods: All of the SpA patients were enrolled at the Xijing Hospital. The erythrocyte sediment rate (ESR), C-reactive protein (CRP), hip function Harris score, and disease activity were evaluated by clinicians. Manual MRI annotations including bone marrow edema (BME) and effusion/synovitis, and a hip MRI scoring system (HIMRISS) assessment was performed by experienced musculoskeletal radiologists. The segmentation accuracies of four deep learning models, including U-Net, UNet++, Attention-Unet, and HRNet, were compared using five-fold cross-validation. The clinical agreement of U-Net was evaluated with clinical symptoms and HIMRISS results. Results: A total of 1945 MRI slices of STIR/T2WI sequences were obtained from 195 SpA patients with hip involvement. After the five-fold cross-validation, U-Net achieved an average segmentation accuracy of 88.48% for the femoral head and 69.36% for inflammatory lesions, which are higher than those obtained by the other three models. The UNet-score, which was calculated based on the same MRI slices as HIMRISS, was significantly correlated with the HIMRISS scores and disease activity indexes (p values <0.05). Conclusion: This deep-learning based automatic MRI evaluation model could achieve similar quantification performance as an expert radiologist, and it has the potential to improve the accuracy and efficiency of clinical diagnosis for SpA patients with hip involvement.
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Affiliation(s)
- Yan Zheng
- Department of Clinical Immunology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- National Translational Science Center for Molecular Medicine, Xi’an, China
| | - Chao Bai
- National Engineering Laboratory for Integrated Aero-Space-Ground-Ocean Big Data Application Technology, School of Computer Science and Engineering, Northwestern Polytechnical University, Xi’an, China
| | - Kui Zhang
- Department of Clinical Immunology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- National Translational Science Center for Molecular Medicine, Xi’an, China
| | - Qing Han
- Department of Clinical Immunology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- National Translational Science Center for Molecular Medicine, Xi’an, China
| | - Qingbiao Guan
- National Engineering Laboratory for Integrated Aero-Space-Ground-Ocean Big Data Application Technology, School of Computer Science and Engineering, Northwestern Polytechnical University, Xi’an, China
| | - Ying Liu
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Zhaohui Zheng
- Department of Clinical Immunology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- National Translational Science Center for Molecular Medicine, Xi’an, China
| | - Yong Xia
- National Engineering Laboratory for Integrated Aero-Space-Ground-Ocean Big Data Application Technology, School of Computer Science and Engineering, Northwestern Polytechnical University, Xi’an, China
| | - Ping Zhu
- Department of Clinical Immunology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- National Translational Science Center for Molecular Medicine, Xi’an, China
- *Correspondence: Ping Zhu,
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Zhang K, Zheng Y, Han Q, Liu Y, Wang W, Ding J, Wang Y, Zhang B, Jia J, Zheng M, Zheng Z, Zhu P. The Clinical and MRI Effect of TNF-α Inhibitors in Spondyloarthritis Patients With Hip Involvement: A Real-World Observational Clinical Study. Front Immunol 2021; 12:740980. [PMID: 34659233 PMCID: PMC8511713 DOI: 10.3389/fimmu.2021.740980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives Hip involvement is an important cause of disability and poor prognosis in patients with spondyloarthritis (SpA). Tumor necrosis factor (TNF)-α inhibitor treatment has been demonstrated to be effective in SpA patients with hip arthritis; however, quantitative assessment using MRI in long-term follow-up needs further application and observation. Methods A total of 239 patients were involved in this study. Methotrexate and sulfasalazine were given as basic treatment. In total, 165 patients received TNF-α inhibitors plus basic treatment, and 74 received basic treatment only, as controls. Clinical symptoms were assessed at baseline and at weeks 12, 24, and 52. MRI performances of hip arthritis, including bone marrow edema (BME) and synovitis, were quantitatively assessed using the Hip Inflammation MRI Scoring System (HIMRISS). Results The clinical values of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Harris hip score, and Ankylosing Spondylitis Disease Activity Score (ASDAS)-ESR in both groups showed significant clinical remission at week 52 (p < 0.001). However, the change in disease activity levels at week 52 in the control group was significantly worse than in the TNF-α inhibitor group. At week 52, MRI showed a significant remission trend in the TNF-α inhibitor group versus baseline, and total HIMRISS scores were significantly decreased (26.49 ± 10.37 vs. 20.59 ± 9.41, p < 0.001); the control group only had slight improvement (p < 0.05). Conclusions TNF-α inhibitors could significantly improve clinical and MRI manifestations of hip involvement in patients with SpA. Quantitative MRI assessment combined with clinical assessment can be used to accurately evaluate the treatment effect of TNF-α in SpA patients with hip involvement to help guide targeted treatment.
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Affiliation(s)
- Kui Zhang
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,National Translational Science Center for Molecular Medicine, Xi'an, China
| | - Yan Zheng
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,National Translational Science Center for Molecular Medicine, Xi'an, China
| | - Qing Han
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,National Translational Science Center for Molecular Medicine, Xi'an, China
| | - Ying Liu
- Department of Radiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Weitao Wang
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,National Translational Science Center for Molecular Medicine, Xi'an, China
| | - Jin Ding
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,National Translational Science Center for Molecular Medicine, Xi'an, China
| | - Yan Wang
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,National Translational Science Center for Molecular Medicine, Xi'an, China
| | - Bei Zhang
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,National Translational Science Center for Molecular Medicine, Xi'an, China
| | - Junfeng Jia
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,National Translational Science Center for Molecular Medicine, Xi'an, China
| | - Minwen Zheng
- Department of Radiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Zhaohui Zheng
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,National Translational Science Center for Molecular Medicine, Xi'an, China
| | - Ping Zhu
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,National Translational Science Center for Molecular Medicine, Xi'an, China
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Ziadé N, El Hajj J, Rassi J, Hlais S, Lopez-Medina C, Gamal SM, Elzorkany B, Dougados M, Baraliakos X. Root Joint Involvement in Spondyloarthritis: A Post-hoc Analysis from the International ASAS-PerSpA Study. Rheumatology (Oxford) 2021; 61:667-678. [PMID: 33905488 DOI: 10.1093/rheumatology/keab380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/20/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Primary objective was to compare the clinical characteristics of spondyloarthritis (SpA) patients with and without root joint disease (RJD+ and RJD-). Secondary objectives were to compare the prevalence of RJD across various SpA subtypes and in different world regions, to compare the SpA axial severity and SpA burden between RJD+ and RJD-. METHODS This is a post-hoc analysis of the ASAS-PerSpA study (PERipheral involvement in SpondyloArthritis), which included 4,465 patients with SpA (axial (axSpA), peripheral (pSpA), psoriatic (PsA), inflammatory bowel disease, reactive and juvenile) according to the rheumatologist's diagnosis. RJD was defined as the "ever" presence of hip or shoulder involvement related to SpA, according to the rheumatologist. The patient's characteristics were compared between RJD+ and RJD-. Multivariable stepwise binary logistic regression analyses were conducted to identify factors associated with "RJD", "hip" and "shoulder" involvement. RESULTS RJD was significantly associated with the SpA main diagnosis (highest in pSpA), a higher prevalence of HLA-B27 positivity, enthesitis, tender and swollen joints, CRP, cs-DMARDs, loss of lumbar lordosis and occiput-wall distance > 0. RJD was more prevalent in Asia, and occurred in 1,503 patients (33.7%), with more hip (24.2%) than shoulder (13.2%) involvement. Hip involvement had a distinct phenotype, similar to axSpA (including younger age at onset, HLA-B27 positivity), whereas shoulder involvement was associated with features of pSpA (including older age at onset). CONCLUSION RJD+ SpA patients had a distinctive clinical phenotype compared with RJD-. Hip involvement, based on the rheumatologist's diagnosis, was more prevalent than shoulder involvement and was clinically distinct.
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Affiliation(s)
- Nelly Ziadé
- Rheumatology, Saint-Joseph University, Beirut, Lebanon.,Rheumatology, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Jean El Hajj
- Rheumatology, Saint-Joseph University, Beirut, Lebanon.,Rheumatology, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Joe Rassi
- Rheumatology, Saint-Joseph University, Beirut, Lebanon.,Rheumatology, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Sani Hlais
- Rheumatology, Saint-Joseph University, Beirut, Lebanon.,Rheumatology, American university of Beirut, Lebanon
| | - Clementina Lopez-Medina
- Rheumatology Department, Cochin Hospital, Paris, France.,Rheumatology Department, Reina Sofia University Hospital/IMIBIC/University of Cordoba, Cordoba, Spain
| | | | | | - Maxime Dougados
- Université de Paris, Department of Rheumatology, Hôpital Cochin. Assistance Publique-Hôpitaux de Paris-INSERM (U1153): Clinical epidemiology and biostatistics, PRES Sorbonne Paris-Cité
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