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Thomsen RS, Nilsen TIL, Haugeberg G, Sitter B, Kavanaugh A, Pedersen SJ, Hoff M. Changes of inflammation in patients with psoriatic arthritis after high intensity interval training assessed by ultrasound and MRI, a randomized controlled trial. BMC Musculoskelet Disord 2023; 24:743. [PMID: 37726677 PMCID: PMC10508016 DOI: 10.1186/s12891-023-06871-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND In psoriatic arthritis (PsA) there is a theoretical risk of increased disease activity related to strenuous physical activity, including exercise. We evaluated the effect of high intensity interval training (HIIT) on objective measures of inflammation in PsA assessed by ultrasound (US) of peripheral joints and entheses, and by bone marrow edema (BME) on MRI of the sacroiliac joints (SIJ) and spine. METHODS We randomly assigned 67 PsA patients to an intervention group that performed structured HIIT for 11 weeks, or to a control group instructed not to change their physical exercise habits. Outcome measures included US evaluation of the total cohort and MRI in a subgroup of 41; both assessed at 3 months. We calculated the proportions with an increased US B-mode and power-doppler (PD) signal of joints and entheses and Spondyloarthritis-Research-Consortium-of-Canada (SPARCC)-BME score of the SIJ and spine for both groups. RESULTS Proportions with an increased US B-mode score of the joints were 32% and 28% in HIIT and control groups, respectively. Corresponding proportions of PD scores of the joints were 7% and 10% and PD scores of entheses were 32% and 31%. The proportions with increased MRI BME of the SIJ were 6% in the HIIT group and 10% in the control group. Corresponding proportions were 6% and 5% for the MRI BME of the spine. CONCLUSION In PsA patients with a low to moderate disease activity, there was no clear evidence of objectively measured increased inflammation after HIIT, as evaluated by US and MRI. TRIAL REGISTRATION ClinicalTrials.gov NCT02995460 (16/12/2016).
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Affiliation(s)
- Ruth Stoklund Thomsen
- Department of Neuromedicine and Movement Science, NTNU, Faculty of Medicine, Norwegian University of Science and Technology, Post Box 8905, N-7491, Trondheim, Norway.
- Department of Circulation and Medical Imaging, NTNU, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
- Department of Rheumatology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Tom Ivar Lund Nilsen
- Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Anaesthesia and Intensive Care, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Glenn Haugeberg
- Department of Neuromedicine and Movement Science, NTNU, Faculty of Medicine, Norwegian University of Science and Technology, Post Box 8905, N-7491, Trondheim, Norway
- Division of Rheumatology, Department of Internal Medicine, Hospital of Southern Norway Trust, Kristiansand, Norway
| | - Beathe Sitter
- Department of Circulation and Medical Imaging, NTNU, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arthur Kavanaugh
- Division of Rheumatology, Allergy, and Immunology, School of Medicine, University of California, San Diego, USA
| | - Susanne Juhl Pedersen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Disease, Rigshospitalet, Denmark
| | - Mari Hoff
- Department of Neuromedicine and Movement Science, NTNU, Faculty of Medicine, Norwegian University of Science and Technology, Post Box 8905, N-7491, Trondheim, Norway
- Department of Rheumatology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Wortsman X. Key Points to Select a Device for Dermatologic Ultrasound. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:521-545. [PMID: 36394307 DOI: 10.1002/jum.16000] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 05/26/2023]
Abstract
What points to consider when selecting a device for practicing dermatologic ultrasound is an excellent question. After we met the requisites published in the guidelines for practicing dermatologic ultrasound, it is necessary to consider the main objective of the use because it is not the same to be focused mostly on the avoidance of the puncture of important facial vessels such as the case of injectors of cosmetic fillers in comparison to the use of operators that need to deal with the diagnosis and monitoring of a wide range of dermatologic pathologies. Currently, a broad variety of ultrasound devices meets the minimum requirements for practicing these examinations in the market. Thus, small, portable, and high-end devices may present advantages and limitations that must be balanced according to the primary purposes and the budget. Moreover, the shape and footprint of the probes can make difficult or facilitate a dermatologic procedure. Other points to consider are the type of storage and the need for technical service. In summary, there are key points that we need to consider when we select a dermatologic ultrasound device in dermatology or aesthetics.
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Affiliation(s)
- Ximena Wortsman
- Institute for Diagnostic Imaging and Research of the Skin and Soft Tissues, Santiago, Chile
- Department of Dermatology, Faculty of Medicine, Universidad de Chile, Santiago, Chile
- Department of Dermatology, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
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3
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Furer V, Wollman J, Levartovsky D, Aloush V, Elalouf O, Sarbagil-Maman H, Mendel L, Borok S, Paran D, Elkayam O, Polachek A. Sex-Based Differences in Sonographic and Clinical Findings Among Patients With Psoriatic Arthritis. J Rheumatol 2023; 50:197-203. [PMID: 36243411 DOI: 10.3899/jrheum.220547] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate sex-based sonographic differences in patients with psoriatic arthritis (PsA). METHODS The study population included consecutive prospectively recruited patients with PsA, as determined by the CASPAR (Classification for Psoriatic Arthritis) criteria, who underwent clinical and physical examinations, followed by a detailed ultrasound (US) evaluation (greyscale and Doppler). US evaluation included 52 joints, 40 tendons, and 14 points of entheses (Modified Madrid Sonographic Enthesis Index [MASEI] plus lateral epicondyles) performed by an experienced sonographer blinded to the clinical data. The US score was based on the summation of a semiquantitative score for synovitis, tenosynovitis, and enthesitis. The US enthesitis score was categorized into inflammatory lesions (ie, hypoechogenicity, thickening, bursitis, and Doppler) and structural lesions (ie, enthesophytes/calcifications and erosions). RESULTS The study population of 158 patients included 70 males and 88 females. The males had higher rates of employment (P = 0.01), Psoriasis Area and Severity Index scores (P = 0.04), and mean swollen joint counts (P = 0.04). The total US score and its subcategory scores-the synovitis and tenosynovitis scores-were similar for both sexes, whereas the total enthesitis score and its subcategory score-the inflammatory enthesitis score-were significantly higher for the males compared to the females (P = 0.01 and P = 0.005, respectively). Hypoechogenicity, thickening, and enthesophytes were more prevalent in males compared to females (P < 0.05). Multivariate ordinal logistic regression models showed that male sex was associated with a higher US inflammatory enthesitis score compared to female sex (odds ratio 1.96, P = 0.02). CONCLUSION Sonographic enthesitis was more prevalent in males compared to females with PsA. These differences were not reflected by enthesitis disease activity scores derived from clinical assessment.
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Affiliation(s)
- Victoria Furer
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Wollman
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Levartovsky
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Valerie Aloush
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Elalouf
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Sarbagil-Maman
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Mendel
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sara Borok
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daphna Paran
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Elkayam
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ari Polachek
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Macchioni P, Marchesoni A, Ciancio G, Sandri G, Zabotti A, Vukatana G, Montaguti L, Focherini M, Govoni M, Spinella A, Malavolta N, Zuliani F, Bruschi M, Mascella F, Salvarani C. Residual inflammation in psoriatic arthritis patients in stable minimal disease activity. Front Med (Lausanne) 2022; 9:1096547. [PMID: 36606060 PMCID: PMC9807803 DOI: 10.3389/fmed.2022.1096547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Background In psoriatic arthritis (PsA), low disease activity as defined by the Minimal Disease Activity (MDA) index is considered a good treatment target. However, as MDA is based only on clinical findings, it might not capture pauci-symptomatic inflammation. Sensitive imaging such as ultrasound (US) might disclose residual inflammatory signs in PsA patients in MDA. Methods In this cross-sectional multicentre study, adult PsA patients on biologic treatment in MDA for at least 6 months were consecutively enrolled for a thorough clinical and US examination. Data collection included demographics, personal history, main patient's reported outcomes, clinical and US findings of joints, tendon sheaths, tendons, bursae, and entheses involvement. All centers performed the US investigation in B-mode and Power Doppler (PD)-mode using a similar US machine equipped with a 18-6 and 13-5 MHz multifrequency linear probe. Statistical analysis included comparisons between groups and correlation tests. Results The 72 PsA patients enrolled in the study had a median duration of MDA of 12 (6-65) months. Overall, US examination revealed a low number of acute lesions. However, 54% of patients had at least one PD signal in the examined tissues. A joint or enthesis positive PD signal was found in about 19 and 24% of patients, respectively. Synovial hypertrophy, at least one acute entheseal lesions, and bursitis were the most common changes, detected in 41.7, 41.7 and 26% of patients, respectively. Conclusions PsA patients in a stable state of MDA may still have residual inflammation in peripheral articular structures detectable by US examination.
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Affiliation(s)
- Pierluigi Macchioni
- Rheumatology Unit, Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy
| | - Antonio Marchesoni
- Rheumatology Unit, Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy,Rheumatology, Humanitas San Pio X, Milan, Italy,*Correspondence: Antonio Marchesoni ✉
| | - Giovanni Ciancio
- Division of Rheumatology, University Hospital of Ferrara, Ferrara, Italy
| | - Gilda Sandri
- Department of Rheumatology, Azienda Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Alen Zabotti
- Department of Medical and Biological Sciences, Rheumatology Clinic, University of Udine, Udine, Italy
| | | | | | | | - Marcello Govoni
- Division of Rheumatology, University Hospital of Ferrara, Ferrara, Italy
| | - Amelia Spinella
- Department of Rheumatology, Azienda Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Francesca Zuliani
- Department of Medical and Biological Sciences, Rheumatology Clinic, University of Udine, Udine, Italy
| | - Marco Bruschi
- Rheumatology Unit, Azienda USL di Cesena, Cesena, Italy
| | | | - Carlo Salvarani
- Rheumatology Unit, Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy,Department of Rheumatology, Azienda Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
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5
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Fodor D, Rodriguez-Garcia SC, Cantisani V, Hammer HB, Hartung W, Klauser A, Martinoli C, Terslev L, Alfageme F, Bong D, Bueno A, Collado P, D'Agostino MA, de la Fuente J, Iohom G, Kessler J, Lenghel M, Malattia C, Mandl P, Mendoza-Cembranos D, Micu M, Möller I, Najm A, Özçakar L, Picasso R, Plagou A, Sala-Blanch X, Sconfienza LM, Serban O, Simoni P, Sudoł-Szopińska I, Tesch C, Todorov P, Uson J, Vlad V, Zaottini F, Bilous D, Gutiu R, Pelea M, Marian A, Naredo E. The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:34-57. [PMID: 34479372 DOI: 10.1055/a-1562-1455] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Daniela Fodor
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | | | - Vito Cantisani
- Department of Radiological, Oncological and Anatomo-pathological Sciences, "Sapienza" University, Rome, Italy
| | - Hilde B Hammer
- Department of Rheumatology, Diakonhjemmet Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Wolfgang Hartung
- Clinic for Rheumatology and Clinical Immunology, Asklepios Clinic, Bad Abbach, Germany
| | - Andrea Klauser
- Department of Radiology, Medical University Innsbruck, Section Head Rheumatology and Sports Imaging, Innsbruck, Austria
| | - Carlo Martinoli
- Department of Health Science - DISSAL, University of Genova, Italy
- UO Radiologia, IRCCS Policlinico San Martino, Genova, Italy
| | - Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Fernando Alfageme
- Dermatology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - David Bong
- Instituto Poal de Reumatologia Barcelona, EULAR Working Group Anatomy for the Image, University of Barcelona, International University of Catalunya, Spain
| | - Angel Bueno
- Department of Musculoskeletal Radiology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Paz Collado
- Rheumatology Department, Transitional Care Clinic, Hospital Universitario Severo Ochoa, Madrid, Spain
| | - Maria Antonietta D'Agostino
- Istituto di Reumatologia Università Cattolica del Sacro Cuore, UOC Reumatologia, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | | | - Gabriella Iohom
- Department of Anaesthesiology and Intensive Care Medicine, Cork University Hospital and University College Cork, Cork, Ireland
| | - Jens Kessler
- Department of Anaesthesiology, Division of Pain Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Manuela Lenghel
- Radiology Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Clara Malattia
- UOC Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI) University of Genoa, Genoa, Italy
| | - Peter Mandl
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | | | - Mihaela Micu
- Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital Cluj-Napoca, Romania
| | - Ingrid Möller
- Instituto Poal de Reumatologia Barcelona, EULAR Working Group Anatomy for the Image, University of Barcelona, International University of Catalunya, Spain
| | - Aurelie Najm
- Institute of Infection, Immunity and Inflammation, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
| | - Riccardo Picasso
- Department of Health Science - DISSAL, University of Genova, Italy
- UO Radiologia, IRCCS Policlinico San Martino, Genova, Italy
| | - Athena Plagou
- Ultrasound Unit, Private Radiological Institution, Athens, Greece
| | - Xavier Sala-Blanch
- Department of Anaesthesiology, Hospital Clinic, Department of Human Anatomy, Faculty of Medicine, University of Barcelona, Spain
| | - Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Milano Italy
- Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | - Oana Serban
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Paolo Simoni
- Paediatric Imaging Department, "Reine Fabiola" Children's University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | | | - Plamen Todorov
- Department of Internal Disease Propaedeutic and Clinical Rheumatology, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Jacqueline Uson
- Department of Rheumatology Hospital Universitario Móstoles, Universidad Rey Juan Carlos, Madrid, Spain
| | - Violeta Vlad
- Sf. Maria Hospital, Rheumatology Department, Bucharest, Romania
| | - Federico Zaottini
- Department of Health Science - DISSAL, University of Genova, Italy
- UO Radiologia, IRCCS Policlinico San Martino, Genova, Italy
| | - Diana Bilous
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Roxana Gutiu
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Michael Pelea
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Anamaria Marian
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Esperanza Naredo
- Department of Rheumatology, Bone and Joint Research Unit, Hospital Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz, and Universidad Autónoma de Madrid, Madrid, Spain
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Song Y, Mascarenhas S. A Narrative Review of the Design of Ultrasound Indices for Detecting Enthesitis. Diagnostics (Basel) 2022; 12:diagnostics12020303. [PMID: 35204393 PMCID: PMC8870884 DOI: 10.3390/diagnostics12020303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/08/2022] [Accepted: 01/23/2022] [Indexed: 11/16/2022] Open
Abstract
With the increased utilization of musculoskeletal ultrasound in clinical practice, there has been rapid proliferation of publications on sonographic evaluation of enthesitis. This has led to the development of multiple new approaches to scoring sonographic findings in the detection of enthesitis, with variations including entheseal sites and sonographic features that limit cross-study comparisons. Furthermore, despite efforts to standardize the definition of enthesitis, there is still heterogeneity in the sonographic features included in existing ultrasound scores, and additional adjustments are required to distinguish active inflammatory changes from non-inflammatory conditions and to adjust for demographic features associated with increased prevalence of abnormal sonographic findings. This review provides an update on the current landscape of ultrasound scoring systems for enthesitis and emphasizes the importance of future data-based ultrasound scoring systems to improve the distinction between inflammatory and non-inflammatory or degenerative changes of the enthesis.
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7
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Polachek A, Furer V, Zureik M, Nevo S, Mendel L, Levartovsky D, Wollman J, Aloush V, Tzemach R, Elalouf O, Anouk M, Berman M, Kaufman I, Carmi O, Lahat Y, Eviatar T, Padova H, Sarbagil-Maman H, Borok S, Broyde A, Eder L, Paran D, Elkayam O. Role of ultrasound for assessment of psoriatic arthritis patients with fibromyalgia. Ann Rheum Dis 2021; 80:1553-1558. [PMID: 34215648 DOI: 10.1136/annrheumdis-2021-220562] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/23/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To investigate whether ultrasonography (US), as an objective imaging modality, can optimise the evaluation of disease activity in psoriatic arthritis (PsA) patients with concomitant fibromyalgia syndrome (FMS). METHODS The study population included 156 consecutive PsA patients who were recruited prospectively and fulfilled the ClASsification criteria for Psoriatic ARthritis criteria. The patients underwent complete clinical evaluation including assessment of fulfilment of the 2016 fibromyalgia classification criteria. All of the patients underwent US evaluation including 52 joints, 40 tendons and 14 entheses. The US score was based on the summation of a semiquantitative score (including synovitis, tenosynovitis and enthesitis). Scoring was performed by a sonographer blinded to the clinical data. Spearman's correlation coefficient and multivariate linear regression models were used to examine the association of FMS with clinical and the US scores. RESULTS Forty-two patients (26.9%) with coexisting PsA and FMS were compared with 114 (73.1%) PsA patients without FMS. Patients with PsA and FMS had significantly increased scores for clinical composite indices, including non-Minimal Disease Activity, Composite Psoriatic Disease Activity Index (CPDAI), Disease Activity for Psoriatic Arthritis (DAPSA) and Psoriatic Arthritis Disease Activity Score (PASDAS) (p<0.001). In contrast, the total US score and its subcategories were similar for those with and without FMS. The total US score significantly correlated with CPDAI, DAPSA and PASDAS (p<0.001) in the PsA without FMS but not in the PsA with FMS group. FMS was significantly associated with higher clinical scores (p<0.001) but not with the US score (multivariable linear regression models). CONCLUSIONS US has significantly greater value than composite clinical scores in the assessment of disease activity in PsA patients with FMS.
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Affiliation(s)
- Ari Polachek
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victoria Furer
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mirna Zureik
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Nevo
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Mendel
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Levartovsky
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Wollman
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Valerie Aloush
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Reut Tzemach
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Elalouf
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marina Anouk
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark Berman
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilana Kaufman
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Or Carmi
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Lahat
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Eviatar
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Padova
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Sarbagil-Maman
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sara Borok
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Broyde
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lihi Eder
- Women's College Hospital, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daphna Paran
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Elkayam
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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8
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Felbo SK, Wiell C, Østergaard M, Poggenborg RP, Bøyesen P, Hammer HB, Boonen A, Pedersen SJ, Sørensen IJ, Madsen OR, Slot O, Møller JM, Szkudlarek M, Terslev L. Do tender joints in active psoriatic arthritis reflect inflammation assessed by ultrasound and magnetic resonance imaging? Rheumatology (Oxford) 2021; 61:723-733. [PMID: 33895799 DOI: 10.1093/rheumatology/keab384] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/21/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To investigate the association between clinical joint tenderness and intra- and periarticular inflammation as assessed by ultrasound and magnetic resonance imaging (MRI) in patients with active psoriatic arthritis (PsA) and to explore if the associations differ according to patient-reported outcomes (PROs) and structural damage. METHODS Forty-one patients with active PsA and hand involvement had 76/78 joints examined for swelling/tenderness and ultrasound and MRI of 24 and 12 finger joints, respectively. Synovitis, tenosynovitis, periarticular inflammation and erosions were assessed using OMERACT definitions and scoring systems. Correlation between imaging inflammation sum-scores (intra-and periarticular) and tender/swollen joint counts were calculated using Spearman's rho, agreement at joint level was examined using prevalence and bias adjusted kappa (PABAK). Subgroup analyses explored the influence of PROs and radiographic erosive disease on these associations. RESULTS No significant correlations were found between tender or swollen joint counts and imaging inflammation sum-scores (rho=-0.31-0.38). In patients with higher level of overall pain, disability and lower self-reported mental health, a tendency towards negative correlations were found. At joint level, intra- and periarticular imaging inflammatory lesions had slight agreement with joint tenderness (PABAK=0.02-0.19) and slight to moderate with swelling (PABAK=0.16-0.54). For tender joints, agreement with imaging inflammation was even weaker in patients with either high overall pain scores, high disability scores, and/or non-erosive disease. CONCLUSION Joint tenderness had low association with imaging signs of inflammation in PsA patients, particularly in patients with high self-reported pain, disability and low mental health, indicating that tenderness is influenced by other parameters than local inflammation.
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Affiliation(s)
- Sara Kamp Felbo
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup
- Center for Rheumatology and Spine Diseases, Rigshospitalet
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup
- Center for Rheumatology and Spine Diseases, Rigshospitalet
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - René Panduro Poggenborg
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup
| | - Pernille Bøyesen
- Department of Rheumatology, Oslo University Hospital, Rikshospitalet
| | - Hilde Berner Hammer
- Department of Rheumatology, Diakonhjemmet Hospital
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Annelies Boonen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center
- Care and Public Health Research Institute (CAPHRI), Maastricht University, The Netherlands
| | | | | | - Ole Rintek Madsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Center for Rheumatology and Spine Diseases, Gentofte Hospital, Gentofte
| | - Ole Slot
- Center for Rheumatology and Spine Diseases, Rigshospitalet
| | | | - Marcin Szkudlarek
- Department of Rheumatology, Zealand's University Hospital Køge, Køge, Denmark
| | - Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup
- Center for Rheumatology and Spine Diseases, Rigshospitalet
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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9
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Sapsford M, Evans J, Clunie G, Jadon D. A comparison of clinical examination and ultrasound enthesitis indices in patients with psoriatic arthritis, adjusted for concomitant fibromyalgia. Ther Adv Musculoskelet Dis 2021; 13:1759720X211003812. [PMID: 33854573 PMCID: PMC8010809 DOI: 10.1177/1759720x211003812] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/22/2021] [Indexed: 01/20/2023] Open
Abstract
Objectives: To: (a) determine the extent of ultrasound (US)-detected peripheral enthesitis in a cohort of patients with psoriatic arthritis (PsA); (b) compare this with three clinical examination (CE) enthesitis indices; and (c) determine the effect of concurrent fibromyalgia on the evaluation of enthesitis. Methods: A prospective single-centre cross-sectional study of consecutive outpatients with established PsA undergoing clinical examination for enthesitis and US examination for inflammatory and structural lesions of enthesitis. Multivariable analyses tested for association between US scores, CE enthesitis indices and influence of concurrent fibromyalgia. Results: A total of 106 patients were assessed. Of these, 91/106 (85.8%) had CE enthesitis and 105/106 (99.1%) had ⩾1 US feature of enthesitis. There was a moderate correlation between US entheseal inflammation and both the Leeds Enthesitis Index (LEI) (Spearman rank, r = 0.36) and Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC) (r = 0.44). US entheseal damage did not correlate with CE enthesitis indices. Twenty-eight (26.4%) patients were classified as having concurrent fibromyalgia, in whom multivariable regression analyses demonstrated no correlation between US scores and CE enthesitis indices. PsA patients without fibromyalgia demonstrated a statistically significant association between both LEI (r = 0.48, p < 0.0001) and SPARCC (r = 0.62, p < 0.0001) and US entheseal inflammation. Conclusion: There is a moderate association between US entheseal inflammation, but not damage, and CE enthesitis indices in patients with PsA. The presence of concurrent fibromyalgia is linked with higher CE enthesitis scores, without an increase in US inflammation, suggesting that CE enthesitis indices should be used/interpreted with caution in these patients. Imaging, including US, should be the preferred modality to detect enthesitis in PsA patients with concurrent fibromyalgia.
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Affiliation(s)
- Mark Sapsford
- Department of Rheumatology, Cambridge University Hospitals NHSFT, Cambridge, UK
| | - Jobie Evans
- Department of Rheumatology, Cambridge University Hospitals NHSFT, Cambridge, UK
| | - Gavin Clunie
- Department of Rheumatology, Cambridge University Hospitals NHSFT, Cambridge, UK
| | - Deepak Jadon
- Rheumatology Research Unit, Addenbrooke's Hospital, Cambridge University Hospital Trust, Hills Road, Cambridge CB2 0QQ, UK
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10
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Hagège B, Tan E, Gayraud M, Fautrel B, Gossec L, Mitrovic S. Remission and low disease activity in psoriatic arthritis publications: a systematic literature review with meta-analysis. Rheumatology (Oxford) 2021; 59:1818-1825. [PMID: 32118267 DOI: 10.1093/rheumatology/keaa030] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/10/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Remission (REM) or low disease activity (LDA) is the treatment target in psoriatic arthritis (PsA). The objective of this study was to assess the reporting and prevalence of REM/LDA in published studies of PsA. METHODS This was a systematic literature review of all clinical papers published in PubMed, EMBASE or Cochrane database in English between 2012 and 2019 in the field of PsA. Data were collected regarding reporting of REM/LDA by very low disease activity/minimal disease activity (VLDA/MDA), Disease Activity index for Psoriatic Arthritis (DAPSA), or Disease Activity Score 28 joints (DAS28). The pooled rates of REM and LDA by each definition were calculated by random effect meta-analysis. RESULTS In all, 258 publications (corresponding to 114 651 patients), of which 81 (31%) were randomized controlled trials, were analysed: patients' mean age was 49.4 ( 4.4) years; with a mean disease duration of 8.5 ( 3.8) years. REM/LDA was reported in 91/258 (35.3%) publications. VLDA/MDA was used in 61/91 (67.0%) studies, DAPSA in 27/91 (29.6%) and DAS28 in 28/91 (30.7%), with 40/91 (43.9%) papers reporting several of these definitions. The pooled prevalence (lower-upper limits) of REM was 13.1% (10.9-15.4), 23.1% (16.8-30.1) and 42.1% (33.9-50.4) using VLDA, DAPSA-REM and DAS28, respectively. For LDA the pooled prevalence was 36.3% (32.3-40.5), 52.8% (41.8-63.6) and 60.4% (52.5-68.0) using MDA, DAPSA-LDA and DAS28, respectively. CONCLUSION REM/LDA status was reported in only1/3 of recent studies on PsA, with important variations in the frequency of these outcomes according to the definition used: 13.1-42.1% for REM, and 36.3-60.4% for LDA. This highlights the need for consensus.
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Affiliation(s)
- Benjamin Hagège
- Internal Medicine Department, Institut Mutualiste MontsourisParis, France
| | - Elina Tan
- Internal Medicine Department, Institut Mutualiste MontsourisParis, France
| | - Martine Gayraud
- Internal Medicine Department, Institut Mutualiste MontsourisParis, France
| | - Bruno Fautrel
- Rheumatology Department, Pitié Salpêtrière Hospital, Sorbonne Université-AP-HP, Paris, France.,INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, UMR S1136, Paris, France
| | - Laure Gossec
- Rheumatology Department, Pitié Salpêtrière Hospital, Sorbonne Université-AP-HP, Paris, France.,INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, UMR S1136, Paris, France
| | - Stéphane Mitrovic
- Internal Medicine Department, Institut Mutualiste MontsourisParis, France.,Rheumatology Department, Pitié Salpêtrière Hospital, Sorbonne Université-AP-HP, Paris, France.,INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, UMR S1136, Paris, France
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11
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Dubash SR, De Marco G, Wakefield RJ, Tan AL, McGonagle D, Marzo-Ortega H. Ultrasound Imaging in Psoriatic Arthritis: What Have We Learnt in the Last Five Years? Front Med (Lausanne) 2020; 7:487. [PMID: 32984374 PMCID: PMC7477070 DOI: 10.3389/fmed.2020.00487] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/17/2020] [Indexed: 12/13/2022] Open
Abstract
Psoriatic arthritis (PsA) is a complex heterogeneous disease with multiple inter-related pathologies such as synovitis, enthesitis, tendinopathy, and dactylitis. Clinical assessment is limited in its detail to assess pathology, thus in recent years, ultrasound (US) has become more popular, given its high sensitivity to detect inflammatory arthritis and ability to inform clinical decisions. Although a qualitative technique, US findings can be graded semi-quantitatively for grayscale (GS) and power Doppler (PD). Synovitis is frequently present in inflammatory arthritis pathologies, and in PsA, recent evidence shows a propensity for tendon and entheseal lesions. The presence of flexor tenosynovitis and flexor tendon insertional enthesopathy at accessory pulleys is supportive of the “Deep Koebner” concept. Peri-tendinous inflammation—mutual to PsA or rheumatoid arthritis (RA), is associated with soft tissue oedema with PD signal frequently at the flexor tendon compartments in PsA. Research on enthesitis in PsA/PsO has improved understanding in subclinical and clinical PsA, explored associations with progression to PsA, and investigated links to prognosis assessment. Dactylitis is a pathognomonic PsA lesion where US has enhanced knowledge of the disease course and pathology of lesions such as: flexor tenosynovitis; synovitis; and soft tissue oedema. Increased US sensitivity has also brought innovation including promising automated ultrasound scanning techniques. So, what have we learnt in recent years and what are the unmet needs to focus future research initiatives in this disabling disease? This narrative review article assesses the neoteric evidence, bringing into context the knowledge gained and highlighting potential areas of research.
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Affiliation(s)
- Sayam R Dubash
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Gabriele De Marco
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Richard J Wakefield
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Ai Lyn Tan
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Dennis McGonagle
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Helena Marzo-Ortega
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
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12
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Haugeberg G, Michelsen B, Østensen M, Kavanaugh A. Perceived influence of health status on sexual activity in patients with psoriatic arthritis. Scand J Rheumatol 2020; 49:468-475. [PMID: 32669024 DOI: 10.1080/03009742.2020.1774647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objective: To examine the prevalence of self-reported problems with sexual activity among psoriatic arthritis (PsA) patients, and to explore potential associations of such problems with various demographic, musculoskeletal, and dermatological disease variables. Method: Consecutive PsA patients were recruited from an outpatient clinic. Data collected included demographics, measures of musculoskeletal and skin disease activity, and treatments. Perceived effect of health status on sexual activity was assessed using question number 15 from the health-related quality of life instrument 15D; this was explored in univariate and multivariate logistic regression analyses. Results: The study assessed 135 patients (mean age 52.1 years, disease duration 8.7 years, 51.1% male). Mean scores included Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) 2.9, Disease Activity index for PSoriatic Arthritis (DAPSA) 18.2, patient global assessment (PGA) 36.0 mm, pain 33.7 mm, fatigue 45.1 mm, modified Health Assessment Questionnaire (mHAQ) 0.42, Psoriasis Area Severity Index (PASI) 2.5, and Dermatology Life Quality Index (DLQI) 3.4. Twenty-four patients (17.8%) reported that their health status had a large negative effect and 111 (82.2%) that it had no or little effect on their sexual activity. In univariate analyses, a statistically significant association with impaired sexual activity was found for longer disease duration and higher MASES, DAPSA, PGA, fatigue, and mHAQ scores, but not for demographic variables or variables reflecting skin psoriasis involvement (PASI, DLQI). In adjusted analyses, only PsA disease duration remained independently associated with impaired sexual activity. Conclusion: One in five PsA patients perceived that their health status had a negative impact on sexual activity. Disease duration and measures reflecting musculoskeletal involvement, but not measures reflecting skin psoriasis involvement, appeared to be associated with impaired sexual activity.
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Affiliation(s)
- G Haugeberg
- Division of Rheumatology, Department of Medicine, Sørlandet Hospital , Kristiansand, Norway.,Department of Neuroscience, Division of Rheumatology, Norwegian University of Science and Technology , Trondheim, Norway
| | - B Michelsen
- Division of Rheumatology, Department of Medicine, Sørlandet Hospital , Kristiansand, Norway
| | - M Østensen
- Division of Rheumatology, Department of Medicine, Sørlandet Hospital , Kristiansand, Norway
| | - A Kavanaugh
- Department of Medicine, School of Medicine, University of California , San Diego, CA, USA
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13
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Terslev L, Hammer HB. Ultrasound may improve patient care. Clin Rheumatol 2020; 39:1715-1717. [PMID: 32358662 DOI: 10.1007/s10067-020-05071-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Lene Terslev
- Copenhagen Center for Arthritis Research and Center for Rheumatology, Spine Diseases, Rigshospitalet-Glostrup, Copenhagen, Denmark. .,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark. .,Center for Rheumatology and Spinal Diseases, Copenhagen University Hospital, Rigshsopitalet, Nordre Ringvej 57, 2600, Glostrup, Copenhagen, Denmark.
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14
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Bosch P, Husic R, Ficjan A, Gretler J, Lackner A, Graninger WB, Duftner C, Hermann J, Dejaco C. Evaluating current definitions of low disease activity in psoriatic arthritis using ultrasound. Rheumatology (Oxford) 2020; 58:2212-2220. [PMID: 31199483 DOI: 10.1093/rheumatology/kez237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/08/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To evaluate low disease activity (LDA) cut-offs in psoriatic arthritis (PsA) using ultrasound. METHODS Eighty-three PsA patients underwent clinical and ultrasound examinations at two visits. LDA was assessed using the Disease Activity index for Psoriatic Arthritis (DAPSA ⩽ 14), the Psoriatic ArthritiS Disease Activity Score (PASDAS ⩽ 3.2), the Composite Psoriatic Disease Activity Index ⩽ 4, the DAS28-CRP ⩽ 2.8 and the minimal disease activity criteria. Ultrasound was performed at 68 joints and 14 entheses. Minimal ultrasound disease activity (MUDA-j/e) was defined as a Power Doppler score ⩽ 1, respectively at joints, paratendinous tissue, tendons and entheses. A global ultrasound score was calculated by summing Grey Scale and Power Doppler information (GUIS-j/e). RESULTS LDA was present in 33.7-65.0% at baseline and in 44.3-80.6% at follow-up, depending on the criteria used. MUDA-j/e was observed in 16.9% at baseline and in 30% at follow-up. GUIS-j/e was significantly higher in patients with moderate/high disease activity vs LDA according to DAPSA and PASDAS at baseline and DAPSA, PASDAS, Composite Psoriatic Disease Activity Index and minimal disease activity at follow-up. Patients in moderate/high disease activity had MUDA-j/e in 8.1-21.4% at baseline and in 8.3-20.0% at follow-up, depending on the applied clinical composite. MUDA-j/e patients with moderate/high disease activity had higher levels of pain and pain-related items than those with LDA. CONCLUSION The LDA cut-offs of DAPSA, PASDAS, Composite Psoriatic Disease Activity Index, minimal disease activity, but not DAS28-CRP are capable of distinguishing between high and low ultrasound activity. Pain and pain-related items are the main reason why PsA patients without signs of ultrasound inflammation are classified with higher disease activity.
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Affiliation(s)
- Philipp Bosch
- Department of Rheumatology and Immunology, Medical University Graz, Graz, Australia
| | - Rusmir Husic
- Department of Rheumatology and Immunology, Medical University Graz, Graz, Australia
| | - Anja Ficjan
- Department of Rheumatology and Immunology, Medical University Graz, Graz, Australia
| | - Judith Gretler
- Department of Rheumatology and Immunology, Medical University Graz, Graz, Australia
| | - Angelika Lackner
- Department of Rheumatology and Immunology, Medical University Graz, Graz, Australia
| | - Winfried B Graninger
- Department of Rheumatology and Immunology, Medical University Graz, Graz, Australia
| | - Christina Duftner
- Department of Internal Medicine II, Medical University Innsbruck, Innsbruck, Australia
| | - Josef Hermann
- Department of Rheumatology and Immunology, Medical University Graz, Graz, Australia
| | - Christian Dejaco
- Department of Rheumatology and Immunology, Medical University Graz, Graz, Australia
- Rheumatology Service, Hospital of Bruneck, Bruneck, Italy
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15
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Sapundzhieva T, Karalilova R, Batalov A. Hand ultrasound patterns in rheumatoid and psoriatic arthritis: the role of ultrasound in the differential diagnosis. Rheumatol Int 2020; 40:837-848. [PMID: 32211929 DOI: 10.1007/s00296-020-04559-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/14/2020] [Indexed: 01/08/2023]
Abstract
Many rheumatic diseases may present with an inflammatory joint syndrome, affecting the small joints of the hands, of which rheumatoid (RA) and psoriatic arthritis (PsA) being one of the most common. The aim of this systematic review was to focus on the literature evidence regarding the added value of ultrasound (US) of the hand in the differential diagnosis between RA and PsA. Pubmed and Scopus were searched to identify original manuscripts, published in the last 20 years utilising ultrasonography to reveal specific hand US patterns. Studies were eligible if they: (1) included adults (over 18 years) with a diagnosis of RA/PsA; (2) were published in the English language; (3) were published in peer-reviewed journals; (4) included description of the US machine; (5) used US for assessment of hand joints, periarticular tissues and nails. The search yielded 322 published studies, of which 16 were deemed relevant and were included in the present study. Overall, there was heterogeneity with regard to the pathology examined. Based on the included studies analysis, hand US patterns have several basic features to be considered-location of gray scale (GS) inflammatory findings, involvement of periarticular soft tissue, distribution and extent of Doppler signal (intra- and peri-articular), bone reaction, shape and location of erosions, involvement of tendons without synovial sheath, involvement of enthesis and nail abnormalities. Future research could focus on determining the sensitivity and specificity of the different US detected hand patterns in patients with early arthritis.
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Affiliation(s)
- Tanya Sapundzhieva
- Department of Internal Diseases, Medical University of Plovdiv, Plovdiv, Bulgaria. .,Rheumatology Clinic, University Hospital 'Kaspela', 64 Sofia Str, Block 2, Eight Floor, 4002, Plovdiv, Bulgaria.
| | - Rositsa Karalilova
- Department of Internal Diseases, Medical University of Plovdiv, Plovdiv, Bulgaria.,Rheumatology Clinic, University Hospital 'Kaspela', 64 Sofia Str, Block 2, Eight Floor, 4002, Plovdiv, Bulgaria
| | - Anastas Batalov
- Department of Internal Diseases, Medical University of Plovdiv, Plovdiv, Bulgaria.,Rheumatology Clinic, University Hospital 'Kaspela', 64 Sofia Str, Block 2, Eight Floor, 4002, Plovdiv, Bulgaria
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16
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Elsawy NA, Helal A, El Shafei M, Mikhael NL, Aboeladl NA. Serum Interleukin 23 in Psoriatic Arthritis Patients: Relation to
disease activity, physical function and health related quality of
life. AKTUEL RHEUMATOL 2019. [DOI: 10.1055/a-1059-9475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Objective To assess interleukin 23 (IL-23) levels in the sera of
psoriatic arthritis (PsA) patients and to determine the relationship of IL-23
with different disease activity indices, physical function and quality of life
(QoL).
Methods Fifty PsA patients and 46 matched healthy controls were included
in this study. Data including a detailed history, a thorough clinical
examination, skin severity based on the Psoriasis Area and Severity Index
(PASI), the Disease Activity index for Psoriatic Arthritis (DAPSA) and the
Composite Psoriatic Disease Activity Index (CPDAI) were obtained for all
patients. Physical function was assessed by the Health Assessment Questionnaire
Disability Index (HAQ-DI) and health-related QoL was assessed using the Short
Form Health Survey (SF-36), Psoriatic Arthritis Quality of Life (PsAQoL) and the
Dermatology Life Quality Index (DLQI) were also assessed. Serum IL-23 levels
were measured in the studied groups.
Results The study included 23(46%) females and 27 (54%)
males with a mean age of 42.78±12.33 years. The mean serum IL-23 level
was significantly higher in PsA patients
(50.89±13.86 pg/ml) than in controls
(43.88±6.34 pg/ml) (p=0.006). There were
significant correlations between serum IL-23 levels and different grades of
DAPSA activity (p=0.007) and PASI (p=0.015). No significant
correlations could be detected between serum IL-23 levels and (HAQ-DI, DLQI,
SF-36 or PsAQoL). CPDAI and DAPSA were significantly correlated with DLQI, SF-36
and PsAQoL.
Conclusion IL-23 is a useful biomarker for identifying joint activity or
skin severity but not QoL or physical function.
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Affiliation(s)
- Noha Abdelhalim Elsawy
- Physical medicine, Rheumatology and Rehabilitation Department, Faculty
of Medicine, Alexandria University, Alexandria, Egypt
| | - Abdelmoniem Helal
- Physical medicine, Rheumatology and Rehabilitation Department, Faculty
of Medicine, Alexandria University, Alexandria, Egypt
| | - Mohamed El Shafei
- Radiodiagnosis Department, Faculty of Medicine, Alexandria University,
Alexandria, Egypt
| | - Neveen Lewis Mikhael
- Clinical and Chemical Pathology Department, Faculty of Medicine,
Alexandria University, Alexandria, Egypt
| | - Nesrin Ahmed Aboeladl
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Helwan
University, Cairo, Egypt
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17
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Abstract
This article discusses treat-to-target strategies in axial spondyloarthritis and current status. Treatment ranging from nonsteroidal anti-inflammatory drugs to biologic and other disease-modifying drugs is discussed in the context of treat-to-target. The article explores evidence from landmark randomized, controlled trials and observational studies focusing on both radiographic and nonradiographic axial spondyloarthritis. The feasibility of treat-to-target, as well as predictors of remission are addressed in line with existing evidence. Finally, issues around management principles and challenges, as well as unmet need in the field, are highlighted.
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Affiliation(s)
- Elena Nikiphorou
- Department of Inflammation Biology, King's College London, Weston Education Centre, Cutcombe Road, Room 3.53, 3rd Floor, London SE5 9RJ, UK; Department of Rheumatology, King's College Hospital, London, UK
| | - Xenofon Baraliakos
- Rheumazentrum Ruhrgebiet Herne, Ruhr University Bochum, Claudiusstr. 45, Herne 44649, Germany.
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18
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Højgaard P, Ellegaard K, Nielsen SM, Christensen R, Guldberg-Møller J, Ballegaard C, Dreyer L, Mease P, de Wit M, Skov L, Glintborg B, Bliddal H, Bartels EM, Amris K, Kristensen LE. Pain Mechanisms and Ultrasonic Inflammatory Activity as Prognostic Factors in Patients With Psoriatic Arthritis: A Prospective Cohort Study. Arthritis Care Res (Hoboken) 2019; 71:798-810. [PMID: 29975012 DOI: 10.1002/acr.23693] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/03/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To study the prognostic value of widespread pain and of musculoskeletal ultrasound (US) examination for subsequent treatment outcomes in patients with psoriatic arthritis (PsA). METHODS An exploratory prospective cohort study enrolled patients with PsA initiating biologic or conventional synthetic disease-modifying antirheumatic drugs in routine care. Clinical, US, and patient-reported measures were collected at baseline and after 4 months. Widespread nonarthritic pain (WP) was defined as a Widespread Pain Index score of ≥4 with pain in ≥4 of 5 regions. PsA activity by US was defined as color Doppler (yes/no) in selected entheses, joints, or tendons. The main response criteria included the American College of Rheumatology 20% improvement, the Disease Activity in Psoriatic Arthritis 50% improvement, and minimal disease activity. The primary analyses were age- and sex-adjusted logistic regression. RESULTS WP was present in 24 of 69 included patients (35%) and was associated with worse patient-reported and composite baseline measures, while US and other objective findings were similar to those in patients without WP. The odds of reaching minimal disease activity after 4 months were significantly greater for patients enrolled without WP (odds ratio 18.43 [95% confidence interval 1.51, 224.41]; P = 0.022), while WP did not impair other response measures. Patients with baseline color Doppler activity (n = 42 [61%]) had a worse objective PsA burden, but their chance of treatment response was comparable to those without color Doppler. CONCLUSION More than one-third of patients with PsA presented with WP, which was associated with worse patient-reported scores and failure to achieve minimal disease activity following conventional synthetic or biologic disease-modifying antirheumatic drug therapy. PsA activity by color Doppler US had no influence on subsequent treatment response in this PsA cohort.
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Affiliation(s)
- Pil Højgaard
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, and Rigshospitalet Gentofte, Hellerup, Denmark
| | - Karen Ellegaard
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Sabrina Mai Nielsen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, and Odense University Hospital, Odense, Denmark, Aalborg, Denmark
| | - Robin Christensen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, and Odense University Hospital, Odense, Denmark, Aalborg, Denmark
| | - Jørgen Guldberg-Møller
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, and Rigshospitalet Gentofte, Hellerup, Denmark
| | - Christine Ballegaard
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, and Rigshospitalet Gentofte, Hellerup, Denmark
| | - Lene Dreyer
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Rigshospitalet Gentofte, Hellerup, and Aalborg University Hospital, Aalborg, Denmark
| | - Philip Mease
- Swedish Medical Center, University of Washington, Seattle
| | | | - Lone Skov
- Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Bente Glintborg
- Rigshospitalet Gentofte, Hellerup, and Rigshospitalet Glostrup, Glostrup, Denmark
| | - Henning Bliddal
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Else Marie Bartels
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Kirstine Amris
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Lars Erik Kristensen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
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19
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Baraliakos X, Conaghan PG, D'Agostino MA, Maksymowych W, Naredo E, Ostergaard M, Schett G, Emery P. Imaging in rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and osteoarthritis: An international viewpoint on the current knowledge and future research priorities. Eur J Rheumatol 2019; 6:38-47. [PMID: 30451654 PMCID: PMC6459329 DOI: 10.5152/eurjrheum.2018.18121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/03/2018] [Indexed: 12/26/2022] Open
Abstract
Imaging is increasingly used in the routine management of rheumatic diseases as well as in the clinical trials of these disorders. This viewpoint, authored by a group of international imaging experts following two meetings dedicated to imaging in rheumatology, reports a consensus about the current knowledge and addresses where further research should be focused based on the views of the international imaging experts and discussion of the evidence with attending imaging practitioners. The goal was to maximize the potential of imaging to improve the clinical management of four rheumatic diseases. These rheumatic diseases include rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and osteoarthritis.
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Affiliation(s)
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Maria-Antonietta D'Agostino
- Department of Rheumatology, APHP, Ambroise Paré Hospital, Boulogne-Billancourt, France.,INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, Saint-Quentin en Yvelines, France
| | - Walter Maksymowych
- Division of Rheumatology, University of Alberta School of Medicine and Dentistry, Alberta, Canada
| | - Esperanza Naredo
- Department of Rheumatology, Joint and Bone Research Unit, Hospital Universities Fundación Jiménez Díaz and Autonomy University, Madrid, Spain
| | - Mikkel Ostergaard
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nurnberg, Erlangen, Germany
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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20
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Pontifex EK, Dissanayake K, Bursill D, Gill T. Prevalence of minimal disease activity in Australian patients with Psoriatic Arthritis: Assessing the outcome of national funding criteria for biologic disease-modifying antirheumatic drug prescribing. Int J Rheum Dis 2018; 22:262-268. [PMID: 30450819 DOI: 10.1111/1756-185x.13441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 10/14/2018] [Accepted: 10/18/2018] [Indexed: 01/05/2023]
Abstract
AIM Discrepancies exist between international treatment guidelines and current Australian Pharmaceutical Benefits Scheme (PBS) criteria for funding biologic disease-modifying antirheumatic drug (bDMARD) prescribing in psoriatic arthritis (PsA). We aimed to determine the prevalence of minimal disease activity (MDA) achievement and differences in inflammatory marker levels between PsA patients who have and have not met the Australian PBS criteria for bDMARDs. METHOD Consecutive participants diagnosed with PsA were assessed for MDA components and serum inflammatory markers. For those on bDMARDs, joint counts and inflammatory markers at the time of bDMARD qualification were compared with matched rheumatoid arthritis (RA) controls. RESULTS Minimal disease activity was achieved by 56/105 participants overall. There were no differences in inflammatory marker levels or involved joint count patterns between the PsA and RA groups at the time of bDMARD qualification. Seventy-three percent of the 53 PsA patients on bDMARD achieved MDA, vs 33% in the non-bDMARD group (P < 0.001). More bDMARD than non-bDMARD patients achieved four out of seven MDA components. Of those with any enthesitis, its prevalence was higher in the non-bDMARD group (22 vs 10, P = 0.009). Regardless of treatment, there was no difference in inflammatory marker levels between those who did and did not achieve MDA. CONCLUSION The Australian PBS criteria, funding bDMARD prescribing for PsA, select well for MDA achievers. A high prevalence of MDA non-achievement remains in patients ineligible for bDMARD funding, and enthesitis in this population is more common. Inflammatory markers were not discriminators between treatment or MDA achievement groups.
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Affiliation(s)
- Eliza K Pontifex
- Department of Rheumatology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Kokum Dissanayake
- Department of Rheumatology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - David Bursill
- Department of Rheumatology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Tiffany Gill
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
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21
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Pukšić S, Bolton-King P, Sexton J, Michelsen B, Kvien TK, Berner Hammer H. DAPSA and ultrasound show different perspectives of psoriatic arthritis disease activity: results from a 12-month longitudinal observational study in patients starting treatment with biological disease-modifying antirheumatic drugs. RMD Open 2018; 4:e000765. [PMID: 30487999 PMCID: PMC6242028 DOI: 10.1136/rmdopen-2018-000765] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/17/2018] [Accepted: 09/22/2018] [Indexed: 12/19/2022] Open
Abstract
Objectives Disease Activity index for PSoriatic Arthritis (DAPSA) (sum score 68/66 tender/swollen joint counts (68TJC/66SJC), patient’s global assessment, pain and C-reactive protein (CRP)) is recommended for clinical assessment of disease activity in patients with psoriatic arthritis (PsA). Ultrasound (US) (grey scale (GS) and power Doppler (PD)) detects inflammation in joints and extra-articular structures. The present objectives were to explore the longitudinal relationships between DAPSA, clinical assessment as well as patient-reported outcome measures (PROMs) with US in patients with PsA initiating biological DMARDs and the associations between DAPSA and US remission. Methods 47 patients with PsA were examined at baseline and after 3, 6, 9 and 12 months. Assessments included 68TJC/66SJC, examiner’s global assessment (EGA), PROMs, CRP, erythrocyte sedimentation rate (ESR) and US GS and PD (48 joints, 10 flexor tendons, 14 entheses, 4 bursae). Clinical composite scores and PD sum scores (0=remission) were calculated. Longitudinal associations were explored by generalised estimating equations with linear and logistic regression. Results DAPSA was not longitudinally associated to PD. 66SJC, ESR, 28-joint Disease Activity Score, EGA and CRP were longitudinally associated with PD (p<0.001–0.03), whereas the pain-related components of DAPSA (68TJC and pain) as well as PROMs were not associated. At 6–12 months, remission was achieved in 29%–33 % of the patients for DAPSA and 59%–70 % for PD. The association between DAPSA and PD remission was not significant (p=0.33). Conclusions DAPSA was not associated with US inflammatory findings which indicates that DAPSA and US may assess different aspects of PsA activity.
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Affiliation(s)
- Silva Pukšić
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Department of Clinical Immunology, Rheumatology and Allergology, University Hospital Dubrava, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - Joseph Sexton
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | | | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
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22
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Coates LC, Conaghan PG, D'Agostino MA, De Wit M, FitzGerald O, Kvien TK, Lories R, Mease P, Nash P, Schett G, Soriano ER, Emery P. Remission in psoriatic arthritis-where are we now? Rheumatology (Oxford) 2018; 57:1321-1331. [PMID: 29045698 DOI: 10.1093/rheumatology/kex344] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Indexed: 01/13/2023] Open
Abstract
Advances in treatments and treatment strategies for PsA have led to many patients responding well to management of their disease, and targeting remission as a treatment goal is now a possibility. Treat to target is a strategy aimed at maximizing benefit, irrespective of the type of medication used, by monitoring disease activity and using it to guide therapy. The measurement of response to treatment has been the subject of wide discussions among experts for some time, and many instruments exist. Comparisons of the different measures and their different strengths and weaknesses is ongoing. The impact of modern imaging techniques on monitoring disease progression is also evolving, and advanced techniques using both MRI and US have the potential to improve management of PsA through identification of risk factors for poor prognosis as well as accurate assessment of inflammation and damage, including subclinical disease. Increased understanding of the pathways that drive the pathogenesis of PsA will be key to identifying specific biomarkers for the disease and developing effective treatment strategies. Targets for response, considerations for use of a treat to target strategy in PsA, different imaging techniques and serological aspects of remission are all discussed in this review, and areas for further research are identified.
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Affiliation(s)
- Laura C Coates
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and National Institute for Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and National Institute for Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Maria Antonietta D'Agostino
- APHP, Hôpital Ambroise Paré, Rheumatology Department, Boulogne-Billancourt, France.,INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, Saint-Quentin en Yvelines, France
| | - Maarten De Wit
- Department of Medical Humanities, VU University Medical Centre, Amsterdam, The Netherlands
| | - Oliver FitzGerald
- Department of Rheumatology, St Vincent's University Hospital, and Conway Institute for Biomolecular Research, University College Dublin, Ireland
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Rik Lories
- Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium; Division of Rheumatology, UZ Leuven, Leuven, Belgium
| | - Philip Mease
- University of Washington School of Medicine, Swedish Medical Center, Seattle, WA, USA.,Clinical Research Division, Swedish Medical Center, Seattle, WA, USA
| | - Peter Nash
- Department of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Georg Schett
- Department of Internal Medicine 3 and Institute for Clinical Immunology, Friedrich Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Enrique R Soriano
- Rheumatology Unit, Internal Medical Services, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and National Institute for Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
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23
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Elalouf O, Bakirci Ureyen S, Touma Z, Anderson M, Kaeley GS, Aydin SZ, Eder L. Psoriatic Arthritis Sonographic Enthesitis Instruments: A Systematic Review of the Literature. J Rheumatol 2018; 46:43-56. [DOI: 10.3899/jrheum.171466] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2018] [Indexed: 11/22/2022]
Abstract
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.
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24
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Gulati AM, Michelsen B, Diamantopoulos A, Grandaunet B, Salvesen Ø, Kavanaugh A, Hoff M, Haugeberg G. Osteoporosis in psoriatic arthritis: a cross-sectional study of an outpatient clinic population. RMD Open 2018; 4:e000631. [PMID: 30018797 PMCID: PMC6045713 DOI: 10.1136/rmdopen-2017-000631] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 05/22/2018] [Accepted: 05/29/2018] [Indexed: 01/21/2023] Open
Abstract
Background The risk of osteoporosis in patients with psoriatic arthritis (PsA) still remains unclear. The aim of this study was to investigate bone mineral density (BMD) at the hip and lumbar spine measured by dual-energy X-ray absorptiometry in patients with PsA. Methods From an outpatient clinic in southern Norway, 140 patients with PsA were consecutively recruited and assessed for osteoporosis as part of a prospective study from January 2013 to May 2014. An extensive data collection was performed including demographic data and measures reflecting disease activity and health status. Results Mean age was 52.4 years and 71 (50.7%) were women. Median disease duration was 7.8 years. The proportion of patients with low BMD (defined as Z score≤-1.0 SD) was comparable to the expected value of 16%, according to the normal distribution of the Z score in the population. Osteoporosis was only found in 6.4% (95% CI3% to 11%) of the patients. No significant associations were found between BMD and disease activity measures. Conclusion The prevalence of PsA patients with osteoporosis or low BMD was low and in the range seen in the reference population. This supports that patients with PsA are not at high risk for osteoporosis compared with the general population. Therefore, clinicians may follow the general population guidelines for monitoring of osteoporosis for patients with PsA.
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Affiliation(s)
- Agnete Malm Gulati
- Department of Rheumatology, St. Olavs Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Brigitte Michelsen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Rheumatology, Hospital of Southern Norway Trust, Kristiansand, Norway
| | | | - Berit Grandaunet
- Department of Rheumatology, St. Olavs Hospital, Trondheim, Norway
| | - Øyvind Salvesen
- Unit for Applied Clinical Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arthur Kavanaugh
- Department of Rheumatology, Allergy and Immunology, University of California San Diego, San Diego, California, USA
| | - Mari Hoff
- Department of Rheumatology, St. Olavs Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,Department of of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Glenn Haugeberg
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Rheumatology, Martina Hansens Hospital, Bærum, Norway
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25
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Gossec L, McGonagle D, Korotaeva T, Lubrano E, de Miguel E, Østergaard M, Behrens F. Minimal Disease Activity as a Treatment Target in Psoriatic Arthritis: A Review of the Literature. J Rheumatol 2017; 45:6-13. [PMID: 29142032 DOI: 10.3899/jrheum.170449] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2017] [Indexed: 02/08/2023]
Abstract
As in other inflammatory rheumatic diseases, the objective of psoriatic arthritis (PsA) treatment is the achievement of a defined target. Recent recommendations propose aiming for remission or low disease activity; however, a consensual definition of remission is lacking. A state of minimal disease activity (MDA) has been established and is defined by low activity assessed by tender/swollen joint counts, tender entheseal points, Psoriasis Area and Severity Index or body surface area, patient pain and global activity visual analog scale, and functional evaluation by Health Assessment Questionnaire. Since its development, MDA has been used increasingly in studies and clinical trials. In this article, the potential use of MDA as a treatment target in PsA is reviewed. The frequencies of MDA achievement with biologic disease-modifying antirheumatic drugs are summarized based on data from registries, observational studies, and clinical trials. Predictors and the prognostic effect of attaining MDA are also evaluated.
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Affiliation(s)
- Laure Gossec
- From Sorbonne Universités, UPMC Univ Paris 06; Department of Rheumatology, AP-HP, Pitié Salpêtrière Hospital, Paris, France; Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and UK National Institute for Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia; Dipartimento di Medicina e Scienze della Salute, Università degli Studi del Molise, Campobasso, Italy; Hospital Universitario La Paz, Rheumatology Department, Madrid, Spain; Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Rheumatology University Hospital Frankfurt and Project Group Translational Medicine and Pharmacology TMP, Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Goethe University Frankfurt am Main, Frankfurt, Germany. .,L. Gossec, Professor, MD, PhD, AP-HP, Pitié Salpêtrière Hospital; D. McGonagle, Professor, PhD, FRCPI, NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Institute of Rheumatic and Musculoskeletal Medicine; T. Korotaeva, Professor, MD, PhD, Department of Psoriatic Arthritis, V.A. Nasonova Research Institute of Rheumatology; E. Lubrano, Aggregate Professor, MD, Academic Rheumatology Unit, Department of Medicine and Health Sciences, University of Molise; E. de Miguel, Associate Professor, MD, PhD, Academic Rheumatology Unit, Hospital Universitario La Paz; M. Østergaard, Professor, MD, PhD, Copenhagen University Hospital, and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases; F. Behrens, MD, Head Clinical Research Rheumatology and Fraunhofer Institute IME.
| | - Dennis McGonagle
- From Sorbonne Universités, UPMC Univ Paris 06; Department of Rheumatology, AP-HP, Pitié Salpêtrière Hospital, Paris, France; Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and UK National Institute for Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia; Dipartimento di Medicina e Scienze della Salute, Università degli Studi del Molise, Campobasso, Italy; Hospital Universitario La Paz, Rheumatology Department, Madrid, Spain; Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Rheumatology University Hospital Frankfurt and Project Group Translational Medicine and Pharmacology TMP, Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Goethe University Frankfurt am Main, Frankfurt, Germany.,L. Gossec, Professor, MD, PhD, AP-HP, Pitié Salpêtrière Hospital; D. McGonagle, Professor, PhD, FRCPI, NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Institute of Rheumatic and Musculoskeletal Medicine; T. Korotaeva, Professor, MD, PhD, Department of Psoriatic Arthritis, V.A. Nasonova Research Institute of Rheumatology; E. Lubrano, Aggregate Professor, MD, Academic Rheumatology Unit, Department of Medicine and Health Sciences, University of Molise; E. de Miguel, Associate Professor, MD, PhD, Academic Rheumatology Unit, Hospital Universitario La Paz; M. Østergaard, Professor, MD, PhD, Copenhagen University Hospital, and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases; F. Behrens, MD, Head Clinical Research Rheumatology and Fraunhofer Institute IME
| | - Tatiana Korotaeva
- From Sorbonne Universités, UPMC Univ Paris 06; Department of Rheumatology, AP-HP, Pitié Salpêtrière Hospital, Paris, France; Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and UK National Institute for Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia; Dipartimento di Medicina e Scienze della Salute, Università degli Studi del Molise, Campobasso, Italy; Hospital Universitario La Paz, Rheumatology Department, Madrid, Spain; Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Rheumatology University Hospital Frankfurt and Project Group Translational Medicine and Pharmacology TMP, Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Goethe University Frankfurt am Main, Frankfurt, Germany.,L. Gossec, Professor, MD, PhD, AP-HP, Pitié Salpêtrière Hospital; D. McGonagle, Professor, PhD, FRCPI, NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Institute of Rheumatic and Musculoskeletal Medicine; T. Korotaeva, Professor, MD, PhD, Department of Psoriatic Arthritis, V.A. Nasonova Research Institute of Rheumatology; E. Lubrano, Aggregate Professor, MD, Academic Rheumatology Unit, Department of Medicine and Health Sciences, University of Molise; E. de Miguel, Associate Professor, MD, PhD, Academic Rheumatology Unit, Hospital Universitario La Paz; M. Østergaard, Professor, MD, PhD, Copenhagen University Hospital, and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases; F. Behrens, MD, Head Clinical Research Rheumatology and Fraunhofer Institute IME
| | - Ennio Lubrano
- From Sorbonne Universités, UPMC Univ Paris 06; Department of Rheumatology, AP-HP, Pitié Salpêtrière Hospital, Paris, France; Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and UK National Institute for Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia; Dipartimento di Medicina e Scienze della Salute, Università degli Studi del Molise, Campobasso, Italy; Hospital Universitario La Paz, Rheumatology Department, Madrid, Spain; Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Rheumatology University Hospital Frankfurt and Project Group Translational Medicine and Pharmacology TMP, Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Goethe University Frankfurt am Main, Frankfurt, Germany.,L. Gossec, Professor, MD, PhD, AP-HP, Pitié Salpêtrière Hospital; D. McGonagle, Professor, PhD, FRCPI, NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Institute of Rheumatic and Musculoskeletal Medicine; T. Korotaeva, Professor, MD, PhD, Department of Psoriatic Arthritis, V.A. Nasonova Research Institute of Rheumatology; E. Lubrano, Aggregate Professor, MD, Academic Rheumatology Unit, Department of Medicine and Health Sciences, University of Molise; E. de Miguel, Associate Professor, MD, PhD, Academic Rheumatology Unit, Hospital Universitario La Paz; M. Østergaard, Professor, MD, PhD, Copenhagen University Hospital, and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases; F. Behrens, MD, Head Clinical Research Rheumatology and Fraunhofer Institute IME
| | - Eugenio de Miguel
- From Sorbonne Universités, UPMC Univ Paris 06; Department of Rheumatology, AP-HP, Pitié Salpêtrière Hospital, Paris, France; Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and UK National Institute for Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia; Dipartimento di Medicina e Scienze della Salute, Università degli Studi del Molise, Campobasso, Italy; Hospital Universitario La Paz, Rheumatology Department, Madrid, Spain; Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Rheumatology University Hospital Frankfurt and Project Group Translational Medicine and Pharmacology TMP, Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Goethe University Frankfurt am Main, Frankfurt, Germany.,L. Gossec, Professor, MD, PhD, AP-HP, Pitié Salpêtrière Hospital; D. McGonagle, Professor, PhD, FRCPI, NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Institute of Rheumatic and Musculoskeletal Medicine; T. Korotaeva, Professor, MD, PhD, Department of Psoriatic Arthritis, V.A. Nasonova Research Institute of Rheumatology; E. Lubrano, Aggregate Professor, MD, Academic Rheumatology Unit, Department of Medicine and Health Sciences, University of Molise; E. de Miguel, Associate Professor, MD, PhD, Academic Rheumatology Unit, Hospital Universitario La Paz; M. Østergaard, Professor, MD, PhD, Copenhagen University Hospital, and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases; F. Behrens, MD, Head Clinical Research Rheumatology and Fraunhofer Institute IME
| | - Mikkel Østergaard
- From Sorbonne Universités, UPMC Univ Paris 06; Department of Rheumatology, AP-HP, Pitié Salpêtrière Hospital, Paris, France; Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and UK National Institute for Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia; Dipartimento di Medicina e Scienze della Salute, Università degli Studi del Molise, Campobasso, Italy; Hospital Universitario La Paz, Rheumatology Department, Madrid, Spain; Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Rheumatology University Hospital Frankfurt and Project Group Translational Medicine and Pharmacology TMP, Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Goethe University Frankfurt am Main, Frankfurt, Germany.,L. Gossec, Professor, MD, PhD, AP-HP, Pitié Salpêtrière Hospital; D. McGonagle, Professor, PhD, FRCPI, NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Institute of Rheumatic and Musculoskeletal Medicine; T. Korotaeva, Professor, MD, PhD, Department of Psoriatic Arthritis, V.A. Nasonova Research Institute of Rheumatology; E. Lubrano, Aggregate Professor, MD, Academic Rheumatology Unit, Department of Medicine and Health Sciences, University of Molise; E. de Miguel, Associate Professor, MD, PhD, Academic Rheumatology Unit, Hospital Universitario La Paz; M. Østergaard, Professor, MD, PhD, Copenhagen University Hospital, and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases; F. Behrens, MD, Head Clinical Research Rheumatology and Fraunhofer Institute IME
| | - Frank Behrens
- From Sorbonne Universités, UPMC Univ Paris 06; Department of Rheumatology, AP-HP, Pitié Salpêtrière Hospital, Paris, France; Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and UK National Institute for Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia; Dipartimento di Medicina e Scienze della Salute, Università degli Studi del Molise, Campobasso, Italy; Hospital Universitario La Paz, Rheumatology Department, Madrid, Spain; Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Rheumatology University Hospital Frankfurt and Project Group Translational Medicine and Pharmacology TMP, Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Goethe University Frankfurt am Main, Frankfurt, Germany.,L. Gossec, Professor, MD, PhD, AP-HP, Pitié Salpêtrière Hospital; D. McGonagle, Professor, PhD, FRCPI, NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Institute of Rheumatic and Musculoskeletal Medicine; T. Korotaeva, Professor, MD, PhD, Department of Psoriatic Arthritis, V.A. Nasonova Research Institute of Rheumatology; E. Lubrano, Aggregate Professor, MD, Academic Rheumatology Unit, Department of Medicine and Health Sciences, University of Molise; E. de Miguel, Associate Professor, MD, PhD, Academic Rheumatology Unit, Hospital Universitario La Paz; M. Østergaard, Professor, MD, PhD, Copenhagen University Hospital, and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases; F. Behrens, MD, Head Clinical Research Rheumatology and Fraunhofer Institute IME
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Michelsen B, Diamantopoulos AP, Soldal DM, Hammer HB, Kavanaugh A, Haugeberg G. Achilles enthesitis defined by ultrasound is not associated with clinical enthesitis in patients with psoriatic arthritis. RMD Open 2017; 3:e000486. [PMID: 28879054 PMCID: PMC5574441 DOI: 10.1136/rmdopen-2017-000486] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/31/2017] [Accepted: 06/25/2017] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Brigitte Michelsen
- Department of Rheumatology, Hospital of Southern Norway Trust, Kristiansand, Norway.,Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Dag Magnar Soldal
- Department of Rheumatology, Hospital of Southern Norway Trust, Kristiansand, Norway
| | | | - Arthur Kavanaugh
- Department of Rheumatology, Allergy and Immunology, University of California, San Diego, USA
| | - Glenn Haugeberg
- Department of Rheumatology, Hospital of Southern Norway Trust, Kristiansand, Norway.,Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Rheumatology, Martina Hansens Hospital, Oslo, Norway
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Smolen JS, Schöls M, Braun J, Dougados M, FitzGerald O, Gladman DD, Kavanaugh A, Landewé R, Mease P, Sieper J, Stamm T, Wit MD, Aletaha D, Baraliakos X, Betteridge N, Bosch FVD, Coates LC, Emery P, Gensler LS, Gossec L, Helliwell P, Jongkees M, Kvien TK, Inman RD, McInnes IB, Maccarone M, Machado PM, Molto A, Ogdie A, Poddubnyy D, Ritchlin C, Rudwaleit M, Tanew A, Thio B, Veale D, Vlam KD, van der Heijde D. Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force. Ann Rheum Dis 2017; 77:3-17. [PMID: 28684559 PMCID: PMC5754738 DOI: 10.1136/annrheumdis-2017-211734] [Citation(s) in RCA: 404] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/05/2017] [Accepted: 06/05/2017] [Indexed: 12/26/2022]
Abstract
Therapeutic targets have been defined for axial and peripheral spondyloarthritis (SpA) in 2012, but the evidence for these recommendations was only of indirect nature. These recommendations were re-evaluated in light of new insights. Based on the results of a systematic literature review and expert opinion, a task force of rheumatologists, dermatologists, patients and a health professional developed an update of the 2012 recommendations. These underwent intensive discussions, on site voting and subsequent anonymous electronic voting on levels of agreement with each item. A set of 5 overarching principles and 11 recommendations were developed and voted on. Some items were present in the previous recommendations, while others were significantly changed or newly formulated. The 2017 task force arrived at a single set of recommendations for axial and peripheral SpA, including psoriatic arthritis (PsA). The most exhaustive discussions related to whether PsA should be assessed using unidimensional composite scores for its different domains or multidimensional scores that comprise multiple domains. This question was not resolved and constitutes an important research agenda. There was broad agreement, now better supported by data than in 2012, that remission/inactive disease and, alternatively, low/minimal disease activity are the principal targets for the treatment of PsA. As instruments to assess the patients on the path to the target, the Ankylosing Spondylitis Disease Activity Score (ASDAS) for axial SpA and the Disease Activity index for PSoriatic Arthritis (DAPSA) and Minimal Disease Activity (MDA) for PsA were recommended, although not supported by all. Shared decision-making between the clinician and the patient was seen as pivotal to the process. The task force defined the treatment target for SpA as remission or low disease activity and developed a large research agenda to further advance the field.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.,2nd Department of Medicine, Hietzing Hospital, Vienna, Austria
| | | | - Jürgen Braun
- Rheumazentrum Ruhrgebiet, Ruhr-University Bochum, Herne, Germany
| | - Maxime Dougados
- Department of Rheumatology, Paris Descartes University, Paris, France
| | - Oliver FitzGerald
- Department of Rheumatology, St Vincent's University Hospital, Dublin, Ireland
| | - Dafna D Gladman
- Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada
| | - Arthur Kavanaugh
- Division of Rheumatology, University of California, San Diego, CA, USA
| | - Robert Landewé
- Amsterdam Rheumatology & Immunology Center, Amsterdam, The Netherlands
| | - Philip Mease
- Division of Rheumatology Research, Swedish-Providence St. Joseph Health System, University of Washington, Seattle, WA, USA
| | - Joachim Sieper
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Berlin, Germany
| | - Tanja Stamm
- Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Maarten de Wit
- Department of Medical Humanities, VU University Medical Centre, Amsterdam, The Netherlands
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | | | | | | | - Laura C Coates
- Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
| | - Lianne S Gensler
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Laure Gossec
- Department of Rheumatology, UPMC Univ Paris 06, GRC-UPMC 08 (EEMOIS); AP-HP, Pitié Salpêtrière Hospital, Paris, France
| | | | | | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Robert D Inman
- University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Iain B McInnes
- University of Glasgow, College of Medical Veterinary and Life Sciences, Glasgow, UK
| | - Mara Maccarone
- A.DI.PSO. (Associazione per la Difesa degli Psoriasici)-PE.Pso.POF (Pan European Psoriasis Patients' Organization Forum), Rome, Italy
| | - Pedro M Machado
- Centre for Rheumatology & MRC Centre for Neuromuscular Diseases, University College London, London, UK
| | - Anna Molto
- Department of Rheumatology, Paris Descartes University, Paris, France
| | - Alexis Ogdie
- Division of Rheumatology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, USA
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Berlin, Germany.,German Rheumatism Research Centrer, Berlin, Germany
| | - Christopher Ritchlin
- Allergy, Immunology and Rheumatology Division, University of Rochester Medical Center Rochester, New York, NY, USA
| | - Martin Rudwaleit
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Berlin, Germany.,Division of Internal Medicine and Rheumatology, Klinikum Bielefeld, Bielefeld, Germany
| | - Adrian Tanew
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Bing Thio
- Department of Dermatology, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
| | - Douglas Veale
- Department of Rheumatology, Klinikum Bielefeld, Bielefeld, Germany
| | - Kurt de Vlam
- Division of Rheumatology, University Hospitals Leuven, Leuven, Belgium
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28
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Michelsen B, Diamantopoulos AP, Høiberg HK, Soldal DM, Kavanaugh A, Haugeberg G. Need for Improvement in Current Treatment of Psoriatic Arthritis: Study of an Outpatient Clinic Population. J Rheumatol 2017; 44:431-436. [PMID: 28148701 DOI: 10.3899/jrheum.160973] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To explore the burden of skin, joint, and entheses manifestations in a representative psoriatic arthritis (PsA) outpatient cohort in the biologic treatment era. METHODS This was a cross-sectional study of 141 PsA outpatients fulfilling the ClASsification for Psoriatic ARthritis (CASPAR) criteria and examined between January 2013 and May 2014. Selected disease activity measures were explored including Disease Activity index for PSoriatic Arthritis (DAPSA), Composite Psoriatic Disease Activity Index (CPDAI), Psoriatic Arthritis Disease Activity Score (PASDAS), Disease Activity Score for 28 joints (DAS28), Simplified Disease Activity Index (SDAI), and Psoriasis Area Severity Index (PASI). Dermatology Life Quality Index (DLQI), minimal disease activity (MDA), and remission criteria were assessed. RESULTS Median (range) DAPSA was 14.5 (0.1-76.4), CPDAI 5 (1-11), PASDAS 3.1 (2.1-4.2), DAS28-erythrocyte sedimentation rate (ESR) 3.2 (0.6-6.4), SDAI 8.6 (0.1-39.5), PASI 1.2 (0.0-19.7), and DLQI 2.0 (0-17). The MDA criteria were fulfilled by 22.9% of the patients. DAPSA ≤ 4, CPDAI ≤ 2, PASDAS < 2.4, DAS28-ESR < 2.4, SDAI < 3.3, and Boolean's remission criteria were fulfilled by 12.1, 9.3, 7.8, 26.2, 21.3, and 5.7% of patients, respectively. The number of satisfied patients was similar regardless of whether the group was treated with tumor necrosis factor inhibitors. CONCLUSION Our real-life data indicate that there is still a need for improvement in today's treatment of PsA. Musculoskeletal inflammatory involvement was more prominent than psoriatic skin involvement. Only a few patients fulfilled the DAPSA, PASDAS, and CPDAI remission criteria, and about a quarter fulfilled the MDA criteria. Considerably fewer patients fulfilled PsA-specific remission criteria versus non-PsA specific remission criteria. Still, patient satisfaction was good and PASI and DLQI were low.
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Affiliation(s)
- Brigitte Michelsen
- From the Department of Rheumatology, Hospital of Southern Norway Trust, Kristiansand; Department of Rheumatology, Haugesund Rheumatism Hospital, Haugesund, Norway; Division of Rheumatology, Allergy, Immunology, University of California at San Diego, San Diego, California, USA; Department of Rheumatology, Martina Hansens Hospital, Bærum; Norwegian University of Science and Technology, Trondheim, Norway. .,B. Michelsen, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A.P. Diamantopoulos, PhD, Department of Rheumatology, Haugesund Rheumatism Hospital; H.K. Høiberg, MD, Department of Rheumatology, Hospital of Southern Norway Trust; D.M. Soldal, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A. Kavanaugh, PhD, Division of Rheumatology, Allergy, Immunology, University of California at San Diego; G. Haugeberg, PhD, Department of Rheumatology, Hospital of Southern Norway Trust, and Department of Rheumatology, Martina Hansens Hospital, and Norwegian University of Science and Technology.
| | - Andreas P Diamantopoulos
- From the Department of Rheumatology, Hospital of Southern Norway Trust, Kristiansand; Department of Rheumatology, Haugesund Rheumatism Hospital, Haugesund, Norway; Division of Rheumatology, Allergy, Immunology, University of California at San Diego, San Diego, California, USA; Department of Rheumatology, Martina Hansens Hospital, Bærum; Norwegian University of Science and Technology, Trondheim, Norway.,B. Michelsen, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A.P. Diamantopoulos, PhD, Department of Rheumatology, Haugesund Rheumatism Hospital; H.K. Høiberg, MD, Department of Rheumatology, Hospital of Southern Norway Trust; D.M. Soldal, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A. Kavanaugh, PhD, Division of Rheumatology, Allergy, Immunology, University of California at San Diego; G. Haugeberg, PhD, Department of Rheumatology, Hospital of Southern Norway Trust, and Department of Rheumatology, Martina Hansens Hospital, and Norwegian University of Science and Technology
| | - Hege Kilander Høiberg
- From the Department of Rheumatology, Hospital of Southern Norway Trust, Kristiansand; Department of Rheumatology, Haugesund Rheumatism Hospital, Haugesund, Norway; Division of Rheumatology, Allergy, Immunology, University of California at San Diego, San Diego, California, USA; Department of Rheumatology, Martina Hansens Hospital, Bærum; Norwegian University of Science and Technology, Trondheim, Norway.,B. Michelsen, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A.P. Diamantopoulos, PhD, Department of Rheumatology, Haugesund Rheumatism Hospital; H.K. Høiberg, MD, Department of Rheumatology, Hospital of Southern Norway Trust; D.M. Soldal, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A. Kavanaugh, PhD, Division of Rheumatology, Allergy, Immunology, University of California at San Diego; G. Haugeberg, PhD, Department of Rheumatology, Hospital of Southern Norway Trust, and Department of Rheumatology, Martina Hansens Hospital, and Norwegian University of Science and Technology
| | - Dag Magnar Soldal
- From the Department of Rheumatology, Hospital of Southern Norway Trust, Kristiansand; Department of Rheumatology, Haugesund Rheumatism Hospital, Haugesund, Norway; Division of Rheumatology, Allergy, Immunology, University of California at San Diego, San Diego, California, USA; Department of Rheumatology, Martina Hansens Hospital, Bærum; Norwegian University of Science and Technology, Trondheim, Norway.,B. Michelsen, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A.P. Diamantopoulos, PhD, Department of Rheumatology, Haugesund Rheumatism Hospital; H.K. Høiberg, MD, Department of Rheumatology, Hospital of Southern Norway Trust; D.M. Soldal, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A. Kavanaugh, PhD, Division of Rheumatology, Allergy, Immunology, University of California at San Diego; G. Haugeberg, PhD, Department of Rheumatology, Hospital of Southern Norway Trust, and Department of Rheumatology, Martina Hansens Hospital, and Norwegian University of Science and Technology
| | - Arthur Kavanaugh
- From the Department of Rheumatology, Hospital of Southern Norway Trust, Kristiansand; Department of Rheumatology, Haugesund Rheumatism Hospital, Haugesund, Norway; Division of Rheumatology, Allergy, Immunology, University of California at San Diego, San Diego, California, USA; Department of Rheumatology, Martina Hansens Hospital, Bærum; Norwegian University of Science and Technology, Trondheim, Norway.,B. Michelsen, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A.P. Diamantopoulos, PhD, Department of Rheumatology, Haugesund Rheumatism Hospital; H.K. Høiberg, MD, Department of Rheumatology, Hospital of Southern Norway Trust; D.M. Soldal, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A. Kavanaugh, PhD, Division of Rheumatology, Allergy, Immunology, University of California at San Diego; G. Haugeberg, PhD, Department of Rheumatology, Hospital of Southern Norway Trust, and Department of Rheumatology, Martina Hansens Hospital, and Norwegian University of Science and Technology
| | - Glenn Haugeberg
- From the Department of Rheumatology, Hospital of Southern Norway Trust, Kristiansand; Department of Rheumatology, Haugesund Rheumatism Hospital, Haugesund, Norway; Division of Rheumatology, Allergy, Immunology, University of California at San Diego, San Diego, California, USA; Department of Rheumatology, Martina Hansens Hospital, Bærum; Norwegian University of Science and Technology, Trondheim, Norway.,B. Michelsen, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A.P. Diamantopoulos, PhD, Department of Rheumatology, Haugesund Rheumatism Hospital; H.K. Høiberg, MD, Department of Rheumatology, Hospital of Southern Norway Trust; D.M. Soldal, MD, Department of Rheumatology, Hospital of Southern Norway Trust; A. Kavanaugh, PhD, Division of Rheumatology, Allergy, Immunology, University of California at San Diego; G. Haugeberg, PhD, Department of Rheumatology, Hospital of Southern Norway Trust, and Department of Rheumatology, Martina Hansens Hospital, and Norwegian University of Science and Technology
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29
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Mathew AJ, Coates LC, Danda D, Conaghan PG. Psoriatic arthritis: lessons from imaging studies and implications for therapy. Expert Rev Clin Immunol 2016; 13:133-142. [DOI: 10.1080/1744666x.2016.1215245] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Ashish J. Mathew
- Clinical Immunology & Rheumatology, Christian Medical College, Vellore, India
| | - Laura C. Coates
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Debashish Danda
- Clinical Immunology & Rheumatology, Christian Medical College, Vellore, India
| | - Philip G. Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
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30
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Imaging in the diagnosis and management of peripheral psoriatic arthritis—The clinical utility of magnetic resonance imaging and ultrasonography. Best Pract Res Clin Rheumatol 2016; 30:624-637. [DOI: 10.1016/j.berh.2016.08.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 08/04/2016] [Accepted: 08/06/2016] [Indexed: 12/19/2022]
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Lackner A, Duftner C, Ficjan A, Gretler J, Hermann J, Husic R, Graninger WB, Dejaco C. The association of clinical parameters and ultrasound verified inflammation with patients' and physicians' global assessments in psoriatic arthritis. Semin Arthritis Rheum 2016; 46:183-189. [PMID: 27373500 DOI: 10.1016/j.semarthrit.2016.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/18/2016] [Accepted: 05/27/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To study the association of clinical and/or ultrasound variables with patients' (PGA) and physicians' (EGA) global assessment of disease activity in psoriatic arthritis (PsA). The correlation of these parameters with the discordance between PGA and EGA, as well as with PGA/EGA changes over 6 months was also investigated. METHODS Prospective study of 83 consecutive PsA patients with 2 visits scheduled 6 months apart. All patients underwent the following assessments: tender (TJC) and swollen joint count (SJC), PASI, dactylitis and Leeds enthesitis index. PGA, patients' level of pain (pain VAS), EGA, and HAQ were also recorded. Grey scale (GS) and power Doppler (PD) ultrasound were performed at 68 joints (evaluating synovia and tendons) and 14 entheses. Regression analyses were performed to assess the association of these variables with PGA and EGA. Two new variables "PGAminusEGA" and "PGAchange - EGAchange" were developed to explore the discrepancy between PGA and EGA and the consistency of PGA/EGA changes over time, respectively. RESULTS The parameters explaining most of PGA and EGA variability were pain VAS (30.5%) and SJC (48.5%), respectively. The correlation between EGA and joint counts was stronger in patients with high vs. low levels of ultrasound verified inflammation. PGAminusEGA was mainly explained by pain and SJC. Pain was the most important predictor of PGA change whereas TJC and HAQ were more closely associated with EGA changes. "PGAchange-EGAchange" was linked to pain and SJC. Ultrasound scores were not linked with either of these variables. CONCLUSIONS Pain VAS and joint counts are the most important clinical parameters explaining patients' and physicians' perception of disease activity, whereas the correlation of active inflammation as verified by sonography with these factors is limited.
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Affiliation(s)
- Angelika Lackner
- Department of Rheumatology and Immunology of the Medical University Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Christina Duftner
- Department of Internal Medicine VI, Medical University Innsbruck, Innsbruck, Austria
| | - Anja Ficjan
- Department of Rheumatology and Immunology of the Medical University Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Judith Gretler
- Department of Rheumatology and Immunology of the Medical University Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Josef Hermann
- Department of Rheumatology and Immunology of the Medical University Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Rusmir Husic
- Department of Rheumatology and Immunology of the Medical University Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Winfried B Graninger
- Department of Rheumatology and Immunology of the Medical University Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Christian Dejaco
- Department of Rheumatology and Immunology of the Medical University Graz, Auenbruggerplatz 15, 8036 Graz, Austria.
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