The spondylarthropathies: classification and diagnosis. Do we need new terminologies?

A historical perspective of the spondyloarthritis

PURPOSE OF REVIEW

The history of ankylosing spondylitis, the main representative of the spondyloarthritides, is dating back to several thousand years BC and recently proven for medieval skeleton by HLA-B27 typing with modern molecular techniques. In modern time, the history of spondyloarthritis (SpA) is characterized by fluctuation between lumping and splitting. Actually, the recent advent of new classification criteria demands to discuss the consequences and clinical implications in the historical context of the development of the concept of SpA including the controversy of lumping and splitting.

RECENT FINDINGS

The new Assessment of SpondyloArthritis International Society classification criteria for axial and peripheral SpA are primarily developed to provide support for clinical trials with biologicals and other treatment modalities, which intend to cover the whole spectrum, especially early clinical manifestations of spondyloarthritides. New insights into genetics and the evolving etiological role of Chlamydia in SpA including the most recent finding of the effective combination antibiotic therapy are major advances in the evolving history of SpA.

SUMMARY

The concept of SpA is well accepted for the classification, diagnosis, and therapeutic management of a high proportion of individuals with inflammatory rheumatic conditions. For further advances research technologies are now available to enlarge the current body of clinical, immunologic, and genetic studies using pivotal microbiologic research and new antimicrobial therapeutic strategies.

Evaluation of classification criteria for juvenile-onset spondyloarthropathies

OBJECTIVE

The aim of this study was to investigate the adequacy of the following criteria for the classification of juvenile-onset spondyloarthropathies (JSpA): European Spondyloarthropathy Study Group criteria (ESSGCr) and Amor criteria (ACr) (proposed for adult SpA), Garmisch-Partenkirchen (G-PCr), seronegative enthesopathy and arthropathy syndrome (SEACr), and atypical spondyloarthropathies classification criteria (ASpCr) (proposed for JSpA).

METHODS

Sixty-two patients with JSpA (48 male and 14 female) and 64 with juvenile idiopathic arthritis (27 male and 37 female) (excluding enthesitis-related and psoriatic arthritis) were enrolled in the study group. Twenty-nine of the patients with JSpA were diagnosed with definite JSpA and the remaining 35 with undifferentiated JSpA. One hundred six patients in the study group were evaluated by one investigator, who was unaware of the diagnosis, according to the following: ESSGCr, ACr, G-PCr, ASpCr, and SEACr.

RESULTS

Analysis of the patients diagnosed with JSpA showed 83.9%, 82.3%, 95.2%, 61.3%, and 62.9% sensitivity and 87.5%, 95.3%, 78.1%, 98.4%, and 92.2% specificity for the ESSGCr, ACr, G-PCr, ASpCr, and SEACr sets, respectively.

CONCLUSION

None of the criteria evaluated above is sufficient for the classification of JSpA. There is a definite need for a new set of criteria with high specificity and sensitivity for early recognition and classification.

The tainted legacy of Hans Reiter

There is more than ample evidence that Hans Reiter, whose name has been eponymously linked to a rheumatologic syndrome, was a Nazi war criminal. He was responsible for heinous atrocities that violated the precepts of humanity, ethics, and professionalism. The authors suggest that Reiter's legacy is sufficiently tainted that the professional and ethical position of the medical community should be to no longer afford him this recognition. He should be remembered symbolically to remind us of our moral and professional responsibilities to prevent the kind of "experiments" he perpetrated as Director of the Nazi office for such matters. Medicine is a moral enterprise. Physicians serve to promote the welfare of their patients. Hans Reiter and others like him who have behaved in such a manner have acted beyond the pale of acceptable human behavior. These crimes by Reiter and others like him were transcendently aberrant and evil. We regard Reiter and others like him as tainted. We see no acceptable rationale to preserve any professional memory of Reiter and others like him within our medical culture except as a symbol of what our societal values obligate us to reject. We suggest reverting to or substituting other terms for the syndrome (such as spondyloarthropathy, spondyloarthritis, oligoarthritis, inflammatory oligoarthritis, reactive arthritis, [oligo-] arthritis with conjunctivitis/urethritis/diarrhea, etc) until pathophysiologic or other insights lead to better ones. (It should be noted that the description of this syndrome was not original to Reiter and that current nomenclature is probably in need of revision in any case because the terminology and classification is outdated and clinically imprecise.) We offer these recommendations because we cannot forget. We cannot forget that Reiter and others like him represented an abhorrent evil. We cannot forget that Reiter and others like him desecrated the traditions of our civilization. We cannot forget that Reiter and others like him violated the precepts of the Hippocratic oath. The legacy of Hans Reiter should be that we remember only this and resolve that such transgressions never again occur.

Building consensus on nomenclature and disease classification for ankylosing spondylitis: results and discussion of a questionnaire prepared for the International Workshop on New Treatment Strategies in Ankylosing Spondylitis, Berlin, Germany, 18-19 January 2002

BACKGROUND

There is currently no universal consensus on nomenclature for spondyloarthropathy (SpA), or on activity and severity criteria for ankylosing spondylitis (AS).

METHOD

Points of agreement and majority opinions among 28 international experts in the field were identified by questionnaire. Agreement was defined as >80% concurrence, clear majority as >60% concurrence, and a majority or trend as >50% concurrence.

RESULTS

Respondents agreed on the need for one term that reflects the inflammatory nature of the disease, but no agreement was reached on a specific term. Agreement included subdivision of patients with SpA into AS, psoriatic arthritis, inflammatory bowel disease associated arthritis, and undifferentiated spondyloarthritis/spondyloarthropathy. A majority of experts defined active disease as fulfilling classification criteria for AS and/or a SpA, and disease activity measured by a Bath AS Disease Activity Index (BASDAI) score >4 determined by two patient visits during a two month period, but no maximum radiographic score. The majority of participants considered failure of treatment response to non-steroidal anti-inflammatory drugs (NSAIDs) alone to be a prerequisite for active/severe AS, and 15/28 (54%) thought that NSAID treatment failure should be defined as lack of response to two or more NSAIDs.

CONCLUSIONS

Respondents agreed that a two to five year study is the ethical method to demonstrate effects of anti-tumour necrosis factor alpha (TNFalpha) therapy on radiographic progression of AS, and that inclusion criteria should include a certain level of disease activity (measured by BASDAI) and failure of certain treatments. After the efficacy of anti-TNFalpha therapy in AS and psoriatic arthritis is proved, respondents agreed that more studies will be needed to show efficacy for other SpA subsets.