The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general

IgG-seq identifies immune-reactive enteric bacteria in Crohn's disease with spondyloarthritis

Joint inflammation is the most common extraintestinal manifestation of Crohn's disease (CD). Although alterations in the enteric microbiota are described in CD with spondyloarthritis (CD-SpA), it is not known whether distinct taxa serve as markers for clinical subtypes of axial (AxSpA) or peripheral SpA (pSpA) in CD. Moreover, it is not yet known whether these taxa generate a specific systemic IgG response. Here, we sequenced the fecal microbiome from 106 individuals (44 CD, 39 CD-SpA, 14 CD-AxSpA, and 9 healthy controls [HC]). This unique cohort revealed distinct taxonomic compositions of CD and CD-SpA compared to HC and demonstrates that the composition of the CD-AxSpA microbiome is distinct from that of CD-pSpA. Using autologous serum, we identified enteric bacteria recognized by serum IgG and demonstrate differences in the IgG coating index of specific bacterial genera associated with CD-SpA. The IgG coating index of Mediterraneibacter gnavus differentiated patients with CD-pSpA and is positively associated with joint disease activity. This work illustrates divergent microbiome compositions in CD-SpA subtypes, as well as the recognition of distinct enteric bacteria by serum IgG with the potential to serve as a marker of joint inflammation in CD.

Characteristics, risk factors, and disease course of musculoskeletal manifestations in patients with inflammatory bowel disease: a prospective longitudinal cohort study

BACKGROUND

Musculoskeletal manifestations occur in half of the patients with inflammatory bowel disease (IBD) and contribute to a reduced quality of life (QoL) and increased work disability. We aimed to evaluate the natural disease course, characteristics, and risk factors of musculoskeletal manifestations in patients with IBD.

METHODS

We performed a prospective longitudinal cohort study in patients with IBD with and without musculoskeletal manifestations with a 1-year follow-up. Primary outcome was the proportion of patients with resolution of musculoskeletal manifestations. Secondary outcomes included the proportion of patients with IBD that developed new musculoskeletal manifestations during follow-up; the correlation among IBD activity, baseline characteristics, and musculoskeletal disease course; and the difference in QoL between patients with and without musculoskeletal manifestations.

RESULTS

In total, 243 patients with IBD were included (124 with and 119 without musculoskeletal manifestations). In the majority of patients (62.2%), musculoskeletal manifestations were of noninflammatory nature. Overall, peripheral and axial manifestations were persistent in 85.7 and 44.6% at 1 year, respectively. The QoL at baseline and at 1 year was lower in the group with musculoskeletal manifestations compared with patients without these manifestations. Female sex and age above 40 were associated with the presence of musculoskeletal manifestations.

CONCLUSION

Musculoskeletal manifestations in patients with IBD are mostly noninflammatory disorders, persist at 1 year of follow-up, and occur more frequently in patients of age above 40 and female sex. Overall, patients with musculoskeletal manifestations have lower QoL compared with patients without musculoskeletal manifestations.

Minimally invasive ultrasound-guided biopsy of the common extensor tendon enthesis: a cadaveric study to standardise the technique

OBJECTIVE

To develop and validate a minimally invasive ultrasound (US)-guided biopsy technique to collect entheseal tissue from the common extensor tendon (CET) enthesis at the lateral humeral epicondyle.

METHODS

Seven sonographers performed a US examination of the CET on six human cadaveric upper limbs to locate the enthesis using an anatomical landmark-based approach. An adapted mini-arthroscopic system was introduced under US guidance to the target site for sample collection. At the end of the procedure, a dye was injected through the guide needle, followed by dissection, to confirm the sampling location. Histology and immunohistochemistry analyses were performed to assess the quality and representativeness of the samples. The reliability of the procedure among operators was evaluated by analysing the rate of successful sampling.

RESULTS

24 samples were collected. The target site to be biopsied was identified as the insertion of the extensor carpi radialis brevis component of the CET. On dissection, the stain used to verify sampling accuracy was confirmed within the defined target area, with no damage to adjacent structures. Histology and immunohistochemistry indicated that most of the samples exhibited characteristics consistent with entheseal tissue (21 out of 24). All participants identified the CET and successfully completed the procedure, demonstrating reliable sample quality across operators.

CONCLUSION

We developed a landmark-based approach to perform a minimally invasive full controlled US-guided biopsy of the CET enthesis that showed to be feasible and reproducible. We believe that this standardised, minimally invasive technique will widespread a reliable collection of entheseal tissue for future clinical and translational studies.

Musculoskeletal Symptoms and Clinical Findings in Bio-naïve Patients with Inflammatory Bowel Disease Prior to Biological Treatment Initiation: A Prospective Cohort Study

BACKGROUND

Musculoskeletal involvement in inflammatory bowel disease (IBD) patients contributes to poorer outcomes and reduced quality of life (QoL). We aimed to describe the prevalence and distribution of peripheral and axial musculoskeletal symptoms and clinical findings in patients with IBD prior to biological treatment.

METHODS

Bio-naïve patients with IBD were consecutively recruited. Musculoskeletal symptoms were assessed using questionnaires and a structured interview. A rheumatologist conducted a clinical evaluation of peripheral joints and entheses, spine mobility, and considered various differential diagnoses.

RESULTS

Of 82 patients (ulcerative colitis (UC): 33, Crohn's disease (CD): 49, mean age 46 years, 55% male), 51 (62.2%) had musculoskeletal symptoms and 51 (62.2%) had clinical findings. Peripheral joint pain was reported by 39 (47.6%) patients, entheseal pain by 15 (18.3%), and back pain by 33 (40.2%) patients. Clinical evaluation revealed arthritis in 24 (29%) patients and enthesitis in 50 (61%); enthesitis was asymptomatic in 72% of the cases. The Assessment of Spondyloarthritis international Society (ASAS) classification criteria for peripheral spondyloarthritis were met in 36 (44%) patients, and for fibromyalgia in 7 (8.5%) patients. Being female was associated with more frequent musculoskeletal symptoms and clinical findings. Significantly more patients with CD reported joint pain, but no differences in clinical findings were observed between UC and CD, nor between those with active and inactive IBD.

CONCLUSION

Two-thirds of patients with IBD scheduled for their first biological treatment exhibited musculoskeletal involvement, sometimes asymptomatically. Axial and peripheral symptoms were equally common. A multidisciplinary approach is crucial for early detection and integrated treatment aiming for remission in all disease domains to improve patients' QoL.

Neural networks for predicting etiological diagnosis of uveitis

BACKGROUND/OBJECTIVES

The large number and heterogeneity of causes of uveitis make the etiological diagnosis a complex task. The clinician must consider all the information concerning the ophthalmological and extra-ophthalmological features of the patient. Diagnostic machine learning algorithms have been developed and provide a correct diagnosis in one-half to three-quarters of cases. However, they are not integrated into daily clinical practice. The aim is to determine whether machine learning models can predict the etiological diagnosis of uveitis from clinical information.

METHODS

This cohort study was performed on uveitis patients with unknown etiology at first consultation. One hundred nine variables, including demographic, ophthalmic, and clinical information, associated with complementary exams were analyzed. Twenty-five causes of uveitis were included. A neural network was developed to predict the etiological diagnosis of uveitis. The performance of the model was evaluated and compared to a gold standard: etiological diagnosis established by a consensus of two uveitis experts.

RESULTS

A total of 375 patients were included in this analysis. Findings showed that the neural network type (Multilayer perceptron) (NN-MLP) presented the best prediction of the etiological diagnosis of uveitis. The NN-MLP's most probable diagnosis matched the senior clinician diagnosis in 292 of 375 patients (77.8%, 95% CI: 77.4-78.0). It achieved 93% accuracy (95% CI: 92.8-93.1%) when considering the two most probable diagnoses. The NN-MLP performed well in diagnosing idiopathic uveitis (sensitivity of 81% and specificity of 82%). For more than three-quarters of etiologies, our NN-MLP demonstrated good diagnostic performance (sensitivity > 70% and specificity > 80%).

CONCLUSION

Study results suggest that developing models for accurately predicting the etiological diagnosis of uveitis with undetermined etiology based on clinical information is feasible. Such NN-MLP could be used for the etiological assessments of uveitis with unknown etiology.

Ex vivo cell-based assay for assessment of response to TNF inhibitors in patients with rheumatic diseases

OBJECTIVE

There are five TNF inhibitors (TNFis), whose structure and signalling differ. An individual patient with a rheumatic disease may respond to one TNFi but not to another. In addition, 30-40% of patients with rheumatic diseases may respond inadequately to TNFis. The downstream signalling of the various TNFis may determine their clinical efficacy. Several reports have shown that the different TNFis exhibited differential effects on Th17 cells. We analysed the effects of the various TNFis on IL-17A expression in peripheral blood mononuclear cells (PBMCs) of patients with rheumatic diseases, in order to evaluate the possibility of predicting responses in an ex vivo setting.

METHODS

PBMCs were co-cultured with the various TNFis or medium (control), and IL-17A mRNA levels were analysed by quantitative PCR. IL-17A expression levels in response to four TNFis (not including certolizumab pegol) were compared with that of the control. The IL-17A expression level as determined by the assay was correlated with the clinical response. The assay sensitivity and specificity for distinguishing responders from non-responders was calculated by receiver-operating characteristic (ROC) analysis.

RESULTS

The results of the assay for a retrospective cohort of patients with rheumatic diseases (n = 82) correlated with their therapeutic responses to the various TNFis with 89.5% accuracy. Our results indicated that the assay predicted the responses of a prospective cohort (n = 54) to specific TNFis with 79% accuracy.

CONCLUSION

This functional assay could assist in predicting the odds for response to TNFi therapy, indicating whether a given patient is likely to respond to a specific TNFi.

Peripheral Spondyloarthritis: Conceptualization and Diagnosis as a Distinct Rheumatologic Subset of Disease

Peripheral spondyloarthritis (pSpA) encompasses multiple entities affecting the musculoskeletal system with classic findings of synovitis, enthesitis, and tenosynovitis. It remains poorly defined when compared with the axial spondyloarthritides due to nonspecific symptoms, ill-defined imaging findings, and lack of specific testable biomarkers. Previous research has tried to distinguish between the two disease entities using clinical presentations, scoring systems, and radiographic findings; however, overlap remains. We summarize the current classification of pSpA, imaging findings, and the distinction between these entities and axial spondyloarthritis.

HLA-B5 prevalence in patients with spondyloarthritis and impact on disease phenotype: a multicentric case-control study

OBJECTIVE

The study aimed to estimate the prevalence of HLA-B51 and HLA-B52 in Lebanese patients with spondyloarthritis (SpA) compared with healthy controls (HC). We further aimed to evaluate the impact of HLA-B51 on phenotype and identify the distribution of the alleles in the HLA-B locus.

METHODS

A case-control study enrolled consecutive SpA patients from three rheumatology clinics in Lebanon, including axial (axSpA), peripheral SpA (pSpA), and psoriatic arthritis (PsA) and HCs from blood donors. Demographic and disease data were collected through interviews and file reviews, with testing of the entire HLA-B locus using molecular techniques. The prevalence of HLA-B51 and B52 was estimated in SpA patients vs controls. Prevalence comparisons were made, and logistic regression identified factors associated with HLA-B51 in patients.

RESULTS

Data from 120 HCs and 86 SpA patients (65 axSpA, 15 pSpA, 6 PsA), mean age 25.6 and 46.4 years, respectively, showed a higher HLA-B51 prevalence in SpA (25.6%), especially axSpA (29.2%) vs HC (12.5%) (P = 0.016), and a numerically higher HLA-B52 prevalence (8.1% vs 4.2%, P = 0.230). HLA-B51 correlated with recurrent oral ulcerations (OR 7.99; 95% CI: 2.14, 29.84) and radiographic juxta-articular erosions (OR 7.65; 95% CI: 1.14, 38.03). HLA-B35 was the most dominant allele in both groups (18.7%), followed by HLA-B27 (15.7%) and HLA-B51 (13.4%) in SpA.

CONCLUSION

HLA-B51 was identified more frequently in patients with SpA compared with HC and was associated with recurrent oral ulcerations and juxta-articular radiographic erosions. Longitudinal studies are needed to determine whether this association indicates a disease overlap or might correlate with a specific SpA phenotype.

The history of ankylosing spondylitis/axial spondyloarthritis - what is the driving force of new knowledge?

The history of (axial) spondyloarthritis has started several centuries ago. Since the end of the 19th century major achievements have been made. This historical review tries to show how closely the advances in clinical medicine in rheumatology have been related to advances made in basic sciences.

Axial Spondyloarthritis: Updates in Concepts and Reporting in Radiology

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease primarily affecting the axial skeleton, historically termed "human leukocyte antigen B27 positive spondyloarthropathy" or ankylosing spondylitis. Improved understanding of the underlying pathologic mechanisms has led to an ongoing redefinition of this disease state, a recognition of the substantial phenotypic and biological variation, and an emphasis on earlier detection. Magnetic resonance imaging has become central to identifying and confirming early axSpA, critical to fulfilling the promise of slowing disease progression and preventing irreversible structural abnormalities. We review the clinical background and current role of medical imaging in axSpA, with a focus on Assessment of SpondyloArthritis International Society consensus definitions, to improve radiology reporting and facilitate discussion between radiologists and other clinical experts in spondyloarthritis.

Prevalence, Clinical Features, and Extraintestinal Manifestations in Patients with Familial Inflammatory Bowel Diseases

BACKGROUND

A positive family history is considered the strongest recognizable risk factor for developing inflammatory bowel diseases (IBD) and is present in 8-12% of cases.

AIMS

To determine the prevalence of familial IBD and also to compare the clinical characteristics and extraintestinal manifestations between familial and sporadic cases.

METHODS

We conducted a cross-sectional study based on retrospectively-prospectively collected data from a cohort of IBD patients followed in daily clinical practice. Patients with biopsy-confirmed familial and sporadic IBD aged 16-90 years old were included in the study. A comprehensive questionnaire was used to collect data on each site visit. Logistic regression analysis and chi-squared test were used.

RESULTS

In total, 265 patients with IBD were included. 12.1% had a first-degree relative with IBD present (16.4% in Crohn's disease and 5.7% in the ulcerative colitis group, P < 0.05). Familial IBD patients were mainly females, were more frequently diagnosed with Crohn's disease and had a higher risk for hospitalization due to an IBD flare (P < 0.05), to undergo a surgical procedure (P < 0.001), to require treatment with biologic agents (P < 0.05), to develop perianal disease (P < 0.05), and extraintestinal manifestations (P < 0.05), mainly spine joint complications, erythema nodosum, and anterior uveitis.

CONCLUSION

In this study, a positive family history of IBD was present in 16.4% of Crohn's disease and 5.7% of ulcerative colitis patients and was associated with a greater risk for hospitalization, surgical procedures, occurrence of perianal disease, need for treatment with biologic agents, and development of extraintestinal manifestations.

[Russian Cross-disciplinary Consensus on the diagnosis and treatment of spondyloarthritis associated with inflammatory bowel diseases]

The Russian Cross-disciplinary Consensus on the diagnositic and treatment of spondyloarthritis (SpA) in inflammatory bowel diseases (IBD) was prepared on the initiative of the Loginov Moscow Clinical Scientific Center, using the Delphic system. Its purpose was to consolidate the opinions of experts on the most actual issues of diagnosis and treatment of concomitant immuno-inflammatory diseases (SpA and IBD). An interdisciplinary approach is provided by the participation of leading gastroenterologists and rheumatologists. The working group analyzed domestic and foreign publications on the problem of curation of patients with SpA and IBD. There have been 17 statements and 2 treatment algorithms formulated. Statements 1-3 reflect the fundamental principles of management of patients with SpA and IBD. The principles of early diagnosis of SpA and IBD, including the diagnosis of complications of therapy, are described below. Eleven statements are devoted to current methods of treatment, on the basis of which 2 treatment algorithms have been developed. The statements of the Consensus were submitted to the Expert Council for consideration, edits were made, after which an online vote took place. This paper presents current recommendations for the management, diagnosis and treatment of patients with SpA and IBD.

Evaluation of instruments assessing peripheral arthritis in spondyloarthritis: an analysis of the ASAS-PerSpA study

OBJECTIVES

To assess construct validity, including known-group discrimination, of the currently available disease activity instruments assessing peripheral arthritis in spondyloarthritis (SpA).

METHODS

In this analysis from the Assessment of SpondyloArthritis International Society (ASAS)-PerSpA study, patients with a diagnosis of axial SpA, peripheral SpA, or psoriatic arthritis (PsA) were included. The disease activity instruments evaluated were the Patient Global Assessment (PGA), Bath Ankylosing Spondylitis Disease Activity Index, Axial Spondyloarthritis Disease Activity Score, Disease Activity Index for PsA (DAPSA), Swollen Joint Count (SJC), Tender Joint Count, Disease Activity Score (DAS) 28, DAS44, and C-reactive protein (CRP). Construct validity was assessed through correlations with external constructs (Bath Ankylosing Spondylitis Functional Index, ASAS Health Index, and Euro Quality of Life 5 Dimensions) and known-group discrimination (active/inactive disease based on a combination of PGA [≥5/<5]), and SJC (≥1/0 and ≥2/<2) was analysed using standardised mean differences (SMDs).

RESULTS

In total, 4121 patients were included (mean age 45 [SD, 14] years, 61% males). When assessing the construct validity through correlations with external constructs, all instruments performed excellently (100% hypotheses confirmed). When assessing known-group discrimination, all disease activity measures, except CRP, presented SMDs ≥ 0.8 (good discrimination), with higher SMDs observed for DAS28 followed by DAPSA. Results were similar across disease phenotypes. Considering all combinations of PGA and SJC to discriminate between active/inactive disease, a better performance was observed for the composite scores, including joint counts.

CONCLUSIONS

In our construct validity analysis, all disease activity instruments assessing peripheral arthritis had a good performance as reflected in the correlations with external constructs and the known-group discrimination. The highest discriminatory capacity to distinguish between 'active/inactive disease' was observed for composite scores, including joint counts, like DAS28 and DAPSA.

Assessment of sarcopenia in young patients with inflammatory arthritis: a cross-sectional study

Sarcopenia is a disease characterized by decreasing muscle mass and strength or performance. The prevalence of sarcopenia in rheumatic diseases has been evaluated in single diseases using various diagnostic approaches, generating conflicting data. The study aims to investigate sarcopenia prevalence in young adults with inflammatory arthritis (IA) and to detect factors associated with low muscle mass and strength. The single-center, cross-sectional study included 138 young adults with IA. Dynamometry with a Jamar hand dynamometer was used to determine handgrip strength. Thresholds for reduced muscle strength were < 27 kg for males and < 16 kg for females. To determine skeletal mass index (SMI), dual photon X-ray absorptiometry (DXA) was done with such cut-off points < 5.67 kg/m2 in females and < 7.0 kg/m2 in males. Patients with both reduced muscle mass and strength were considered as sarcopenic. Logistic regression analyses estimated between sarcopenia and associated factors. Statistical significance was defined as a p-value < 0.05. The prevalence of sarcopenia was about 47% in all IA and was significantly different between juvenile idiopathic arthritis (JIA), spondyloarthritis (SpA), and rheumatoid arthritis (RA) groups (p = 0.006). At multivariable analysis, body mass index (BMI) (OR 0.84; CI 95% 0.72-0.86, p = 0.02), bone mineral density (BMD) at femur neck (OR 0.01; CI 95% 0.001-0.268, p = 0.01), 25-hydroxyvitamin D (25(OH)D) (OR 0.96; CI 95% 0.93-0.98, p = 0.001), and disability by Health Assessment Questionnaire (HAQ) (OR 14.54; CI 95% 4.92-51.77, p < 0.001) were associated with a significantly increased risk of sarcopenia. The results of our study demonstrate a high prevalence of sarcopenia among young patients with IA. In these participants, lower BMI, lower BMD, 25(OH)D concentration, and higher HAQ were linked to sarcopenia.

Clinical characterization of aortitis and periaortitis: study of 134 patients from a single university hospital

Aortitis and periaortitis refer to the inflammation of the aortic wall and the surrounding tissues. Both conditions are associated with various diseases and express nonspecific manifestations. Early diagnosis and treatment are crucial to improve the prognosis of the disease. This study aimed to assess the causes and main clinical features of aortitis and periaortitis in patients from a single centre in Spain. Observational, retrospective study of patients diagnosed with aortitis or periaortitis at a Spanish referral center over the last decade. 134 patients (87 female; mean age of 55.1 ± 9.1 years) were recruited, 132 of which had aortitis and two periaortitis. Aortitis was associated with giant cell arteritis (n = 102), Takayasu's arteritis (n = 6), IgG4-related disease (n = 6), infectious diseases (n = 3), malignancy (n = 1), drugs (n = 1), isolated aortitis (n = 1), and other immune-mediated inflammatory diseases (IMIDs) (n = 12). IMIDs included were Sjögren's syndrome (n = 2), sarcoidosis (n = 2), rheumatoid arthritis (n = 2), axial spondyloarthritis (n = 2), inflammatory bowel disease (n = 1), primary biliary cirrhosis (n = 1), idiopathic pulmonary fibrosis (n = 1), and polyarteritis nodosa (n = 1). Periaortitis was due to idiopathic retroperitoneal fibrosis in both cases. Imaging techniques used for diagnosis included 18F-FDG PET/CT scan (n = 133), CT-angiography (n = 44), and/or MRI-angiography (n = 33). Polymyalgia rheumatica (52.2%) and asthenia (53.7%) were the most common manifestations, followed by limb claudication (23.9%) and inflammatory back pain (26.9%). Acute-phase reactants were typically increased. Aortitis is a common condition and may be associated with multiple non-infectious diseases. Its clinical presentation is often unspecific, requiring a high level of suspicion to get an early diagnosis and treatment.

Diagnosis of Inflammatory Bowel Disease-Associated Peripheral Arthritis: A Systematic Review

BACKGROUND

Inflammatory bowel disease (IBD)-associated peripheral spondyloarthritis (pSpA) decreases quality of life and remains poorly understood. Given the prevalence of this condition and its negative impact, it is surprising that evidence-based disease definitions and diagnostic strategies are lacking. This systematic review summarizes available data to facilitate development and validation of diagnostics, patient-reported outcomes, and imaging indices specific to this condition.

METHODS

A literature search was conducted. Consensus or classification criteria, case series, cross-sectional studies, cohort studies, and randomized controlled trials related to diagnosis were included.

RESULTS

A total of 44 studies reporting data on approximately 1500 patients with pSpA were eligible for analysis. Data quality across studies was only graded as fair to good. Due to large heterogeneity, meta-analysis was not possible. The majority of studies incorporated patient-reported outcomes and a physical examination. A total of 13 studies proposed or validated screening tools, consensus, classification, or consensus criteria. A total of 28 studies assessed the role of laboratory tests, none of which were considered sufficiently accurate for use in diagnosis. A total of 17 studies assessed the role of imaging, with the available literature insufficient to fully endorse any imaging modality as a robust diagnostic tool.

CONCLUSIONS

This review highlights existing inconsistency and lack of a clear diagnostic approach for IBD-associated pSpA. Given the absence of an evidence-based approach, a combination of existing criteria and physician assessment should be utilized. To address this issue comprehensively, our future efforts will be directed toward pursuit of a multidisciplinary approach aimed at standardizing evaluation and diagnosis of IBD-associated pSpA.

Reducing diagnostic delays of extraintestinal manifestations in inflammatory bowel disease: a comparative study of a multidisciplinary outpatient clinic versus conventional referral specialists

Background

Managing extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD) patients remains challenging due to considerable heterogeneity in diagnostic criteria and the lack of a standardised definition and validated diagnostic pathways. Delays in recognising and treating EIMs can lead to significant disease progression. Therefore, early detection and treatment are crucial.

Objectives

We aimed to assess the effectiveness of a dedicated immune-mediated inflammatory diseases (IMIDs) clinic in reducing EIM diagnostic delays and improving patients' outcomes.

Design

A single-centre observational study was conducted, including IBD patients presenting with EIMs red flags.

Methods

We compared the EIMs diagnostic delay between patients who attended a multidisciplinary IMID outpatient clinic (IMID-G) and those who attended individual referral specialists representing the standard outpatient clinic group (SOC-G). We further evaluated the impact of diagnostic timing on 18-month clinical outcomes, including therapeutic changes, steroid and immunosuppressant use and biological therapy switch/swap.

Results

We enrolled 238 IBD patients, 127 in the IMID-G and 111 in the SOC-G. The average time to EIM diagnosis was 2.48 ± 1.8 and 5.36 ± 2.3 months for the IMID and SOC-Gs (Δ = 2.88 months, p = 0.005). The majority of patients received a diagnosis of peripheral arthritis (IMID-G = 37.5%; SOC-G = 33.7%) and spondyloarthropathy (IMID-G = 32.1%; SOC-G = 33.7%). No significant difference was observed in the rates of EIMs between the two groups (88.2% in IMID-G vs 92.8% in SOC-G, p = 0.27). Regarding therapeutic changes, the IMID-G reported a mean time to the first therapeutic change driven by the specialist referral of 2.96 ± 1.8 months, compared to 6.09 ± 2.5 months in the SOC-G, showing a significant difference (p = 0.007). The IMID-G had a higher frequency of biological therapy switching/swapping and adding immunosuppressive treatment than the SOC-G (p = 0.008 and p = 0.04, respectively). Survival curves revealed a significant reduction in diagnostic delay and time to treatment in the IMID-G compared to the SOC-G (log-rank test, p < 0.001).

Conclusion

Attending a dedicated IMID clinic can enhance the diagnostic process for EIMs in IBD patients, thereby reducing diagnostic delays and allowing early interventions to avoid disease progression.

1995-2025: thirty years of ASAS and its contribution to the understanding of spondyloarthritis

OBJECTIVE

To describe the role of the Assessment of SpondyloArthritis interntational Society (ASAS) over the past 30 years in the understanding of the field of spondyloarthritis.

METHODS

A narrative review of the achievements.

RESULTS

A summary of the role of ASAS in defining nomenclature, definition of and criteria for SpA, outcome assessments, recommendations, and education.

CONCLUSION

ASAS played an important role in shaping the field of SpA.

Metabolic musculoskeletal disorders in patients with inflammatory bowel disease

Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is a chronic inflammatory disorder that affects not only the gastrointestinal tract but also extraintestinal organs, leading to various extraintestinal manifestations and complications. Among these, musculoskeletal disorders such as osteoporosis, sarcopenia, and axial and peripheral spondyloarthritis are the most commonly observed. These conditions arise from complex mechanisms, including chronic inflammation, malnutrition, gut dysbiosis, and glucocorticoid use, all of which contribute to reduced bone density, muscle loss, and joint inflammation. Osteoporosis and sarcopenia may co-occur as osteosarcopenia, a condition that heightens the risk of fractures, impairs physical performance, and diminishes quality of life, particularly in elderly patients with IBD. Holistic management strategies, including lifestyle modifications, calcium, and vitamin D supplementation, resistance training, and pharmacological interventions, are essential for mitigating the impact of these conditions. Spondyloarthritis, which affects both axial and peripheral joints, further complicates disease management and significantly compromises joint health. Timely diagnosis and appropriate medical interventions, such as administration of nonsteroidal anti-inflammatory drugs and biologics, are critical for preventing chronic joint damage and disability. Moreover, a multidisciplinary approach that addresses both metabolic and inflammatory aspects is essential for optimizing physical function and improving treatment outcomes in patients who have IBD with musculoskeletal involvement.

Modulation of IL-6 receptor/STAT3 downstream signaling in rheumatoid arthritis patients

Interleukin-6 (IL-6) is a relevant cytokine in rheumatoid arthritis (RA) pathogenesis, potentially activating Janus kinases (JAK)-1, -2, and tyrosine kinase 2 (TYK2), and thus, three signal transducer and activator of transcription (STAT)-1, -3 or - 5 pathways. This pilot study aims to explore differences in phosphorylated (p)STAT3 levels among patients with RA, those not classified as RA (nRA), and healthy donors (HD), providing some clues on the relative contribution of each JAK protein to the downstream of the IL-6-induced STAT3 pathway. Clinical data and blood samples from 80 subjects (41 RA, 14 nRA, and 25 HD) were collected. The activity of the JAK-STAT3 pathway was assessed by Western Blot and Real Time-PCR analysis for the quantification of STAT3 in peripheral blood mononuclear cells (PBMC). Furthermore, the impact of JAK-1, -2, and TYK2 inhibitors on pSTAT3 was assessed in vitro by FACS, with and without IL-6 stimulation in RA patients naïve to treatment with DMARD and steroids. The pSTAT3 (%) was significantly higher in PBMC from RA compared to nRA patients and HD. Furthermore, pSTAT3 (%) was significantly associated with inflammation and disease activity (ESR, CRP, and DAS28). The JAK-1 inhibitor was more effective in reducing pSTAT3 expression in CD14pos cells of RA patients, while the JAK-2 selective compound was more effective in CD4pos cells of RA patients. On the contrary, the TYK2 selective agent showed no significant effects. This study highlights the importance of the JAK/STAT3 pathway in RA. Some differences among various JAK proteins have been pointed out, with JAK1 and JAK2 standing as the most relevant mediators of the STAT3 pathway in this in-vitro model after IL-6R activation.

Inflammatory back pain as an unusual manifestation of Takayasu arteritis: a case report

Takayasu arteritis and spondyloarthritis are two rheumatological diseases whose co-existence is well-documented in the literature. Data on the presence of inflammatory back pain in Takayasu arteritis without a diagnosis of spondyloarthritis, however, is scarce. Here, we present a 33-year-old man who was admitted to the emergency department with acute-onset chest pain associated with left carotidynia, carotid bruit, and left arm claudication, normal electrocardiogram and computed tomography angiographic features suggesting Takayasu arteritis, including stenosis and occlusion of the aorta and its branches. Two years prior, he had undergone a clinical work-up for inflammatory back pain accompanied by alternating buttocks pain, morning stiffness lasting more than half an hour, and heel pain. HLA-B27 status and magnetic resonance imaging of the sacroiliac joints were both negative. He was prescribed non-steroidal anti-inflammatory drugs and was placed on adalimumab 40 mg subcutaneously every 2 weeks but had to switch to etanercept 2 months before his emergency admission due to supply issues. Oral prednisolone was initiated at a dose of 60 mg/day with symptomatic improvement in both his inflammatory back pain and his chest pain, but he had to be switched to methotrexate and infliximab due to steroid side effects. Inflammatory aortitis should be considered as a possibility during the assessment of inflammatory back pain to mitigate the risks of delayed diagnosis.

[James Joyce. Chronic recurrent iritis resulting from postvenereal reactive arthritis]

The Irish author James Joyce (1882-1941) suffered from chronic recurrent iritis with a variety of complications that led to almost complete blindness. Syphilis and a rheumatic disease, such as Reiter's syndrome were discussed as the main causes. The coincidence of a venereal infection, arthritis and the characteristic medically documented features of iritis, including typical complications, together with the chronic recurrent course of the eye disease, are convincing arguments for postvenereal reactive arthritis. A familial predisposition and smoking could have been responsible for the unfavorable course of the iritis. There is no reliable evidence of syphilis and, above all, the multiple recurrences of the iritis are not compatible with a syphilitic infection. Even after the medical publications in which the rheumatic genesis was convincingly discussed and in the knowledge of these, art historians have held on to the diagnosis of syphilis. It is therefore to be hoped that in the future the art historical literature will accurately reflect Joyce's illness in accordance with the medical knowledge.

Cytotoxic Response of CD4+ T Cells Orchestrated by SLAMF4 in Rheumatoid Arthritis

OBJECTIVE

This study aimed to assess whether signaling lymphocytic activation molecule family receptors (SLAMFs) are involved in the shaping of the pathologic response of CD4+ T cells in rheumatoid arthritis (RA).

METHODS

Peripheral blood (PB) and synovial fluid (SF) mononuclear cells from patients with RA were freshly isolated. In RA, we used a multimodal approach to determine the involvement of numerous subpopulations of CD4+ T cells expressing SLAMFs. Experimentally, multiple flow cytometry panels, RNA sequencing, and stimulations were used. Analyses involved high-dimensional unsupervised clustering of flow cytometry data and pathway enrichment analyses of transcriptomic data.

RESULTS

In PB of patients with RA with active disease, SLAMF4+ effector memory CD4+ T cells (Tem) represented the only overrepresented subpopulation of CD4+ T cells expressing SLAMFs. This positive correlation between RA activity and SLAMF4+ Tem was restricted to those coexpressing the intracellular molecule SLAM-associated protein (SAP) and the tissue-homing receptor CCR5. Gene Set Enrichment Analysis of RNA sequencing data reveals that SLAMF4+ CCR5+ Tem display a cytotoxicity-related gene signature. Moreover, based on the differential expression of cytotoxicity markers (GPR56, CX3CR1, granzyme-B, perforin, and granulysin), unsupervised clustering of flow cytometry data identified distinct subpopulations of PB cytotoxic Tem. Among them, only SLAMF4high SAP+ CCR5+ Tem (Cytotox-F4high Tem) were correlated with RA activity. Remarkably, Cytotox-F4high Tem emerged as the only cytotoxic population of CD4+ T cells (CD4+ CTLs) present in SF of patients with active disease.

CONCLUSION

This study emphasizes that Cytotox-F4high Tem represent a significant CD4+ CTL subpopulation involved in RA, suggesting that their inhibition represent a promising therapeutic interest.

Psoriatic arthritis phenotype clusters and their association with treatment response: a real-world longitudinal cohort study from the psoriatic arthritis research consortium

OBJECTIVES

To identify phenotype clusters and their trajectories in psoriatic arthritis (PsA) and examine the association of the clusters with treatment response in a real-world setting.

METHODS

In the multicentre PsA Research Consortium (PARC) study, we applied factor analysis of mixed data to reduce dimensionality and collinearity, followed by hierarchical clustering on principal components. We then evaluated the transition of PsA clusters and their response to new immunomodulatory therapy and tumour necrosis factor inhibitor (TNFi).

RESULTS

Among 627 patients with PsA, three clusters were identified: mild PsA and psoriasis only (PsO) (Cluster 1, 47.4%), severe PsA and mild PsO (Cluster 2, 34.3%) and severe PsA and severe PsO (Cluster 3, 18.3%). Among 339 patients starting or changing, significant differences in response were observed (mean follow-up of 0.7 years, SD 0.8), with Cluster 3 showing the largest improvements in cDAPSA and PsAID. No differences were found among those starting TNFi (n=218). cDAPSA remission and PsAID patient acceptable symptom state were achieved in 10% and 54%, respectively. Clusters remained stable over time despite treatment changes, though some transitions occurred, notably from Cluster 3 to milder clusters.

CONCLUSION

Data-driven clusters with distinct therapy responses identified in this real-world study highlight the extensive heterogeneity in PsA and the central role of psoriasis and musculoskeletal severity in treatment outcomes. Concurrently, these findings underscore the need for better outcome measures, particularly for individuals with lower disease activity.

16s RNA-based metagenomics reveal previously unreported gut microbiota associated with reactive arthritis and undifferentiated peripheral spondyloarthritis

OBJECTIVES

Reactive arthritis (ReA) provides a unique opportunity to comprehend how a mucosal infection leads to inflammatory arthritis at a distant site without the apparent invasion of the pathogen. Unfortunately, conventional stool cultures after ReA provide limited information, and there is a dearth of metagenomic studies in ReA. The objective of this study was to identify gut microbiota associated with the development of ReA.

METHODS

Patients with ReA or undifferentiated peripheral spondyloarthritis (UpSpA) were included if they presented within 4 weeks of the onset of the current episode of arthritis. Metagenomic DNA was extracted from the stools of these patients and of 36 age- and sex-similar controls. Sequencing and analysis were done using a standard 16S ribosomal pipeline.

RESULTS

Of 55 patients, there was no difference between the gut microbiota of postdiarrheal ReA (n = 20) and of upSpA (n = 35). Comparing the gut microbiota of patients vs healthy controls, the patients had significantly higher alpha and beta diversity measures. After stringency filters, Proteobacteria had high abundance while Firmicutes had lesser as compared with the controls. Six families were overexpressed in patients, while another five were overexpressed in controls. Sixteen genera and 18 species were significantly different between patients and controls. At the species level there was strong association of Staphylococcus aureus, Clostridium septicum Klebsiella pneumoniae, Escherichia coli, Empedobacter brevis, Roseburia hominis, Bacillus velezensis and Crassaminicella with ReA.

CONCLUSION

The microbiota of classical gut-associated ReA and upSpA is similar. Patients have higher diversities in their gut microbiota compared with healthy controls. Both known and previously unreported species associated with ReA/upSpA were identified.

Dysregulation of amino acid and lipid metabolism in patients with spondyloarthritis

OBJECTIVE

To conduct a metabolomics analysis in patients with spondyloarthritis (SpA) and compare results with those from healthy controls. The overall goal was to identify small-molecule substances that may have potential pathogenic and diagnostic significance in SpA.

METHODS

This was an observational, cross-sectional, single-centre study that included patients with axial (ankylosing spondylitis [AS]), peripheral (psoriatic arthritis [PsA]) and healthy controls.

RESULTS

The study included 50 patients with AS, 50 patients with PsA, and 164 controls. When compared with healthy controls, patients with SpA showed significant differences in 35 metabolites, primarily associated with amino acid and lipid metabolism. However, only two differences were found between the AS and PsA cohorts (glucose and glycerol).

CONCLUSIONS

Our data suggest that patients with SpA exhibit significant disruptions in amino acid and lipid metabolism. The large number of identified metabolites offers promising opportunities, both for discovering new SpA biomarkers and for gaining a deeper understanding of the pathophysiology of these chronic inflammatory diseases.

Arthralgia and Extraintestinal Manifestations in Crohn's Disease Elevate the Risk of IBD-Related Arthritis over Sacroiliitis

INTRODUCTION

Inflammatory bowel disease (IBD) related arthritis is the most prevalent extraintestinal manifestation (EIM) of IBD, ranging between 10 and 39%. Magnetic resonance enterography (MRE) is used to assess small bowel disease involvement in Crohn's disease (CD) and can detect signs of sacroiliitis in up to 23.5% of patients. The predicting role of sacroiliitis detected on MRE is still unknown. The aim of this study is to evaluate the predictive role of sacroiliitis at MRE and other clinical features for IBD-related arthritis development in a cohort of adult patients with CD.

METHODS

Between December 2012 and May 2020, consecutive patients with CD who performed MRE were enrolled in the study. Patients with a previous diagnosis of IBD-related arthritis were excluded. A baseline demographics and clinical characteristics of the patients were retrospectively collected. The identification of new-onset IBD-related arthritis events during the follow-up was based on rheumatological clinical diagnosis and fulfillment of the ASAS classification criteria.

RESULTS

Ninety-five patients, mean age 43.9 years (standard deviation [SD] ± 16.6), 52.6% female were enrolled in the study with a median follow-up of 83 months (Q25:75 25:143). Six out 95 (6.3%) developed IBD-related arthritis with a mean time of 11 months (SD ± 16.8). Sacroiliitis detected on MRE was not associated with an increased risk of IBD-related arthritis (odds ratio [OR] = 2.12 [95% confidence interval (CI) 0.36, 12.53, p = 0.408]). In contrast, the presence of arthralgia and EIMs were found to be a predictor for IBD-related arthritis development (OR = 84.0 [95% CI 8.18, 862.39, p < 0.0001] and OR = 7.37 [95% CI 1.25, 43.32, p = 0.027], respectively).

CONCLUSIONS

This study highlights that sacroiliitis, as assessed by MRE, was not associated with the development of IBD-related arthritis, whereas extraintestinal manifestations and arthralgia were significantly associated with later IBD-related arthritis development in patients with CD.

Fast, Present and Future of the Concept of Spondyloarthritis

PURPOSE OF REVIEW

Axial spondyloarthritis (axSpA) is a rather prevalent chronic inflammatory rheumatic disease that affects already relatively young patients. It has been known better since the end of the nineteenth century but quite a lot has been learned since the early 60ies when the first classification (diagnostic) criteria for ankylosing spondylitis (AS) were agreed on. I have been part of many developments in the last 30 years, and I'm happy to have been able to contribute to the scientific progress in terms of diagnosis, imaging, pathophysiology and therapy. When I was asked to write a manuscript about the SpA concept I felt honored. Thus, the purpose of this extensive review was, on the one hand, to describe the history of AS and axSpA, and on the other hand, to reason about the concept and the gestalt of axSpA, and finally to deliver some ideas what future researchers could possibly do to further study the disease.

RECENT FINDINGS

The last 3 decades were full of innovations for both, classification and treatment of axSpA which also helped us to learn about the pathophysiology. Thus, TNFa, IL-17, IL-23 and Janus kinase are established targets to reduce inflammation. IL-17 and IL-23 are very special in that regard because they both work for psoriasis but only anti-IL-17 agents which don't work in IBD are approved for axSpA, while IL 23 inhibitors are approved for both, psoriasis and IBD, but they don't work in axSpA. New imaging techniques such as low dose CT and synthetic MRI are likely to improve the detection of both active and structural lesions of axSpA. This manuscript tries to describe the most important findings about axSpA. The main aim of research remains to discover the pathophysiology and to further improve treatment options in order to reduce and abolish inflammation and prevent new bone formation to increase the quality of life of our patients. The differences between male and female disease and the role of the immune system in axSpA are now the main challenges, and the role of special T-cell receptors seem to deserve special interest.

Analysis of ASAS health index and its influencing factors in ankylosing spondylitis: a prospective study based on the population of Chaoshan region

Objective

This study aimed to evaluate the health-related quality of life (HRQoL) in ankylosing spondylitis (AS) patients in the Chaoshan region and identify factors influencing the ASAS Health Index (ASAS-HI) to enhance comprehensive AS treatment strategies.

Methods

A survey of ASAS-HI was conducted on 82 AS patients from the rheumatology outpatient department of the First Affiliated Hospital of Shantou University Medical College. The Bath Ankylosing Spondylitis Global Score (BAS-G) assessed overall health status, the Ankylosing Spondylitis Quality of Life Questionnaire (AS-QOL) evaluated quality of life, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) measured disease activity, and the Bath Ankylosing Spondylitis Functional Index (BASFI) assessed functional difficulties. Inflammatory markers and patient data were collected, and univariate/multivariate logistic regression analyses were used to explore influencing factors of ASAS-HI.

Results

The mean ASAS-HI score was 3.52 ± 3.12. ASAS-HI was positively correlated with BASDAI (r = 0.478, p < 0.001), ASDAS-CRP (r = 0.406, p < 0.001), BASFI (r = 0.338, p < 0.002), and BAS-G (r = 0.335, p < 0.002). Patients with ASDAS-ESR ≥ 2.1, ASDAS-CRP ≥ 2.1, and spinal tenderness had significantly higher ASAS-HI scores than others (p < 0.001). Spinal tenderness and radiographic grading were identified as key influencing factors.

Conclusion

ASAS-HI is significantly impacted by disease activity and functional limitations. Early assessment of ASAS-HI is crucial for optimizing disease management in AS patients.

A review on anterior uveitis and spondyloarthritis with a focus on the interdisciplinary approach between ophthalmologists and rheumatologists

Anterior uveitis (AU) is characterized by the inflammation of the iris and ciliary body and is the most frequent extra-articular manifestation of spondyloarthritis (SpA). In SpA patients, AU is typically described as unilateral alternating acute AU (AAU). Moreover, as AAU can be the initial clinical manifestation of SpA, ophthalmologists could play a key role in the early diagnosis of SpA. The diagnostic delay in SpA is associated with poorer outcomes, including functional impairment, reduced response to treatment, and lower quality of life. A well-structured screening of patients with AAU could facilitate the early diagnosis. Consequently, the interdisciplinary collaboration between ophthalmologists and rheumatologists is fundamental to reduce the diagnostic delays. A correct and early diagnosis of SpA, together with early treatment initiation is important prognostic factors. These measures are associated with better treatment responses and may help retard the development of structural damage, particularly in the era of biological therapies, which have significantly improved the care of patients with SpA. Although various algorithms have been proposed to guide the selection of appropriate candidates for rheumatology referral, to date, there are no formal guidelines or universally recognized criteria for referral. This review aimed to summarize the epidemiological, pathogenetic, clinical, and therapeutic aspects of AU associated with SpA as well as the ophthalmology-rheumatology interdisciplinary approach.

Factors associated with dietary practices and beliefs on food of patients with rheumatic and musculoskeletal diseases: A multicentre cross-sectional study

OBJECTIVES

To investigate dietary practices and beliefs of patients with rheumatic and musculoskeletal diseases (RMDs) and associated factors.

METHODS

In 2019-2020, a cross-sectional multicentre study enrolled patients with inflammatory arthritis (IA) (rheumatoid arthritis [RA], axial spondyloarthritis [axSpA]) or hand osteoarthritis (HOA) from secondary- and tertiary-care centres. A self-administered questionnaire explored dietary practices and patients' perceived effects of diet, foods and beverages on symptoms. Univariable and multivariable analyses investigated factors associated with diets and patients' views.

RESULTS

Of 448 included patients, data for 392 were analysed (123 with RA, 161 with axSpA, 108 with HOA), 26% were on or had been on at least one exclusion diet (mostly cow's milk- and gluten-free diets in IA, mostly cow's milk-free diet and detox/fasting in HOA). Only 5% of patients followed the Mediterranean diet. Among patients who had tried a diet, 51% reported a decrease in pain. Overall, 42% of patients identified at least one food or beverage that increased or decreased pain. On multivariable analyses, dieting or the perceived effect of food on pain was associated with health beliefs (positive or negative), the use of complementary and alternative medicines, and lack of support or information from healthcare professionals. Patients had received little dietary information from their physicians.

CONCLUSIONS

This study provides insights into patients' dietary practices and factors associated with these practices, including patients' health beliefs and insufficient support by health professionals, in RMDs.

The 'Tree trunk and root' model: key imaging findings may anatomically differentiate axial psoriatic arthritis and DISH from axial spondyloarthropathy

Variable axial skeleton inflammation and axial skeleton tissue remodelling with aberrant ligamentous soft-tissue ossification occurs across the axial spondyloarthritis (ax-SpA) axial psoriatic arthritis (ax-PsA) and the diffuse idiopathic skeletal hyperostosis (DISH) spectrum. In this article, we show how imaging has resulted in an enthesis-centric model for different disease pathology compartmentalisation or a 'root and trunk' model for pathological process development. Whilst ankylosing spondylitis is predominantly characterised by early entheseal bony anchorage-related osteitis (root inflammation) and DISH is characterised by ligamentous soft-tissue ossification, ax-PsA is more heterogenous. Whilst ax-PsA may share an identical osteitis pattern to ax-SpA, a substantial proportion of ax-PsA cases have a soft tissue or tree trunk pathology that manifests as back pain with lack of osteitis but prominent ligamentous trunk ossification at later stages. We illustrate this using different imaging modalities to create a base for imaging research to elucidate this pattern of pathology.

Spine and Sacroiliac Joint Involvement in Newly Diagnosed Patients With Inflammatory Bowel Disease: Clinical and MRI Findings From a Population-Based Cohort

INTRODUCTION

In patients with inflammatory bowel disease (IBD), co-occurring spondyloarthritis (SpA) leads to poorer outcomes and impaired quality of life, highlighting the importance of early detection and effective treatment. This is the first study to assess the prevalence and distribution of axial symptoms and magnetic resonance imaging (MRI)-detected involvement of the spine and sacroiliac joints (SIJs) in early IBD.

METHODS

Newly diagnosed patients with IBD from a prospective, population-based cohort were consecutively recruited. Rheumatological interview, clinical, ultrasound, and MRI assessment for SIJ and spine inflammatory and structural lesions were made using validated scoring methods and consensus definitions of axial SpA (axSpA).

RESULTS

Of 110 patients (ulcerative colitis: 70, Crohn's disease: 40, mean age of 42 years, and 40% male), 48 (44.9%) reported back and/or buttock pain, and 10 (9.1%) had inflammatory back pain. Seventeen (16.7%) patients had MRI findings indicative of axSpA; only 10 of these patients had axial symptoms. Inflammatory MRI lesions were present in SIJs and the spine of 27 (26.5%) and 30 (30.3%) patients, respectively. The Assessment of SpondyloArthritis International Society classification criteria for axSpA were met in 11 (10%) cases. MRI findings typical of axSpA were associated with peripheral joint and entheseal inflammation detected by ultrasound ( P = 0.04). No differences in clinical or imaging findings were found between patients with ulcerative colitis and Crohn's disease.

DISCUSSION

One-in-6 newly diagnosed patients with IBD had MRI findings indicative of axSpA. As 40% of these patients were asymptomatic, this suggests that axSpA is underdiagnosed in early IBD. Multidisciplinary collaboration is essential to ensure early detection of axial inflammation and to enable optimal therapy preventing future structural damage and disability.

Diagnosis and Management of Inflammatory Bowel Disease-Associated Spondyloarthritis

Inflammatory bowel disease (IBD)-associated spondyloarthritis (SpA) is common but remains poorly understood. In this review article, we aimed to provide guidance regarding the diagnosis and management of this condition. For diagnosis of IBD-associated peripheral SpA (IBD-pSpA), we recommend collaboration with rheumatology for incorporation of clinical symptoms, physical examination findings, joint imaging if applicable, and available diagnostic criteria. For the management of IBD-pSpA, we first recommend assessment and treatment of underlying luminal IBD disease activity. We provide guidance regarding positioning of advanced therapies for IBD in patients with IBD-pSpA based on the limited available literature. For diagnosis of IBD-associated axial SpA, we recommend rheumatology referral to make the diagnosis based on incorporation of symptoms, laboratory data, imaging findings (sacroiliitis), and available diagnostic criteria. For the management of axial SpA, we recommend comanagement with rheumatology and use of either antitumor necrosis factor agents or Janus kinase inhibitors, when applicable.

Different disease activity trajectories in early axial spondyloarthritis lead to significantly different long-term outcomes: a trajectory-based analysis of the DESIR cohort over 10 years

INTRODUCTION

The study aimed to identify and describe disease activity trajectories over 10 years in patients with recent-onset axial spondyloarthritis (axSpA) and determine their impact on long-term outcomes.

METHODS

This prospective, multicentre study (Devenir des Spondylarthropathies Indifférenciées Récentes cohort, ClinicalTrials.gov NCT) followed patients with early axSpA for 10 years. Only patients with at least three Axial Spondylitis Disease Activity Score (ASDAS) values were included. Long-term outcomes assessed were TNF inhibitors (TNFi) exposure, structural progression, function (Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Metrology Index), quality of life (36-items Short Form Survey), sick leave days and cardiovascular (CV) events. ASDAS trajectories were identified using k-means clustering. Multinomial multivariable regression estimated associations between baseline characteristics and trajectories. Long-term outcomes for each trajectory were described.

RESULTS

Among 601 patients, five ASDAS trajectories were identified: persistent low disease activity/remission (tA), clinically important improvement (tD) and persistent moderate (tB), high (tC) or very high (tE) disease activity. Patients in tA were more likely to be male, have a university degree, have white-collar jobs, have positive HLA B27 status and have less fibromyalgia. Trajectory tE was linked to poorer function (BASFI 50/100 vs 7/100 for lower ASDAS trajectory), higher TNFi exposure (74% vs 29%) and more CV events (5.7% vs 0). Structural progression was low but comparable across trajectories, except for higher sacroiliac joint progression in tB.

CONCLUSION

The k-means method revealed distinct disease activity trajectories in axSpA. Higher disease activity trajectories were associated with a higher prevalence of fibromyalgia and poorer outcomes, except for structural progression, which was comparable across trajectories.

Treatment of Reactive Arthritis with Biological Agents

PURPOSE OF THE REVIEW

Reactive arthritis (ReA) is an inflammatory joint condition triggered by an infection elsewhere in the body, and this review aims to provide a comprehensive synthesis of recent studies including case reports and case series to determine whether biologics are a treatment option.

RECENT FINDINGS

Recent studies indicate that biological agents, including anti-TNF agents (infliximab, adalimumab, etanercept), anti-IL17 (secukinumab), and anti-IL6 (tocilizumab), are effective in treating refractory cases of ReA. Evidence suggests these agents are associated with significant clinical improvement. Notably, the data reveal that these biologics are generally well-tolerated, with a low incidence of major adverse events, which supports their safety profile for use in ReA. Biological agents, including anti-TNF, anti-IL17, and anti-IL6 therapies, can be safely and effectively used in the treatment of ReA when conventional therapies fail. It further emphasizes the need for a well-designed controlled trial to provide scientific basis for better informed clinical decisions in cases not responding to conventional treatment.

Current Concepts and Medical Management for Patients with Radiographic Axial Spondyloarthritis

Radiographic axial spondyloarthritis (r-axSpA), a chronic inflammatory disease, can cause significant radiographic damage to the axial skeleton. Regarding the pathogenic mechanism, association of r-axSpA with tumor necrosis factor (TNF) and the interleukin-23/17 (IL23/ IL17) pathway has been reported. Development of extraarticular manifestations, including uveitis, inflammatory bowel disease, and psoriasis, has been reported in some patients. The pivotal role of human leukocyte antigen-B27 in the pathogenesis of r-axSpA remains to be clarified. Symptoms usually start in late adolescence or early adulthood, and disease progression can vary in each patient, with clinical manifestations ranging from mild joint stiffness without radiographic changes to advanced manifestations including complete fusion of the spine, and severe arthritis of the hip, and could include peripheral arthritis and extraarticular manifestations. The modified New York criteria was used previously in diagnosis of r-axSpA. However, early diagnosis of the disease prior to development of bone deformity was required due to development of biological agents. As a result of Assessment of SpondyloArthritis international Society (ASAS), the classification was improved in part for diagnosis of spondyloarthritis prior to development of bone deformity. The diagnosis is based on comprehensive laboratory findings, physical examinations, and radiologic findings. Medical treatment for r-axSpA involves the use of a stepwise strategy, starting with administration of nonsteroidal anti-inflammatory drugs and physiotherapy, and progressing to sulfasalazine or methotrexate and biologics including TNF-α inhibitors or IL-17 inhibitors as needed. Use of Janus kinase inhibitors has been recently reported.

Successful treatment of Crohn's disease-related peripheral spondyloarthritis with upadacitinib: two case reports and case-based review

Inflammatory bowel disease (IBD), including ulcerative colitis and Crohn's disease (CD), not only causes significant intestinal inflammation but also leads to extra-intestinal manifestations such as spondyloarthritis (SpA). Although the efficacy of tumor necrosis factor (TNF) inhibitors has been reported for IBD-related SpA, some cases still encounter treatment failure, highlighting the need for novel therapeutic alternatives. Recently, Janus kinase inhibitors have demonstrated their efficacy in IBD and SpA, yet their impact on CD-related SpA remains unexplored. Here we present the first two cases of CD-related peripheral SpA successfully treated with upadacitinib. Additionally, our literature review identified a reported case of CD-related peripheral SpA treated with tofacitinib. All cases achieved clinical remission of both CD and peripheral SpA with Janus kinase inhibitors, and no adverse events or disease relapses were reported during the observation period. Our cases and literature review highlight the promising potential of Janus kinase inhibitors as a novel treatment not only for intestinal inflammation of CD, but also for CD-related peripheral SpA.

Ultrasound of the Foot and Ankle in Peripheral Spondyloarthritis

Seronegative spondyloarthritis (SpA) is an umbrella term that includes ankylosing spondylitis (AS), psoriatic arthritis, reactive arthritis, and arthritis related to inflammatory bowel disease. Apart from AS, these other conditions predominantly affect the appendicular skeleton. Both the foot and ankle are frequently involved peripheral joints. According to the latest Assessment of Spondyloarthritis International Society criteria, imaging is a key way to diagnose peripheral seronegative SpA. Common imaging features are enthesitis, synovitis, tenosynovitis, erosive and bone-proliferative changes in the affected joints, and effusion.Although magnetic resonance imaging is the gold standard technique, ultrasound (US) is a cost-effective imaging method that can readily detect the features just described. Additionally, it can semi-quantify inflammatory changes, helping in treatment and dose modifications. Imaging-guided procedures, such as biopsies and steroid injections, are routinely performed using US. Furthermore, US can easily be deployed at outpatient rheumatology clinics, making it an ideal point-of-care investigation.

Utility of polygenic risk scores to aid in the diagnosis of rheumatic diseases

Rheumatic diseases (RDs) are characterized by autoimmunity and autoinflammation and are recognized as complex due to the interplay of multiple genetic, environmental, and lifestyle factors in their pathogenesis. The rapid advancement of genome-wide association studies (GWASs) has enabled the identification of numerous single nucleotide polymorphisms (SNPs) associated with RD susceptibility. Based on these SNPs, polygenic risk scores (PRSs) have emerged as promising tools for quantifying genetic risk in this disease group. This chapter reviews the current status of PRSs in assessing the risk of RDs and discusses their potential to improve the accuracy of the diagnosis of these complex diseases through their ability to discriminate among different RDs. PRSs demonstrate a high discriminatory capacity for various RDs and show potential clinical utility. As GWASs continue to evolve, PRSs are expected to enable more precise risk stratification by integrating genetic, environmental, and lifestyle factors, thereby refining individual risk predictions and advancing disease management strategies.

Neuropathic pain in spondyloarthritis: Decoding its prevalence, risk factors, and impact on disease activity

OBJECTIVES

This study aimed to evaluate the prevalence and characteristics of neuropathic pain in patients with various subtypes of spondyloarthritis (SpA), including axial SpA (axSpA), psoriatic arthritis (PsA), and undifferentiated peripheral SpA (p-SpA). Additionally, the study sought to identify potential risk factors associated with the presence or severity of neuropathic pain and to investigate its impact on clinical disease activity assessment.

METHODS

We conducted a cross-sectional study at two tertiary rheumatology centers, enrolling patients diagnosed with SpA. Data on demographic and clinical characteristics, comorbidities, and current therapies were collected. Neuropathic pain was assessed using the PainDETECT Questionnaire (PD-Q) and the Neuropathic Pain Symptom Inventory (NPSI). Statistical analyses included descriptive statistics, t-tests, and Pearson's correlations to evaluate the relationships between neuropathic pain scores and clinical disease activity indices.

RESULTS

The study included 177 patients. Of these, 22.2% had a PD-Q score ≥19, showing a high likelihood of neuropathic pain, while 64.9% scored ≤12, suggesting the absence of significant neuropathic components. The mean PD-Q score was 11.5 ± 10.1. Subgroup analyses showed that females had significantly higher scores for paroxysmal and evoked pain (p < 0.05), and obese patients had significantly higher scores across all NPSI subscores (p < 0.05). Moderate positive correlations were found between neuropathic pain scores and clinical disease activity indices, such as DAPSA (r = 0.46, p < 0.0001) and ASDAS-CRP (r = 0.42, p < 0.01).

CONCLUSIONS

Neuropathic pain is prevalent among patients with SpA and is significantly associated with disease activity assessments and management. This study highlights the importance of integrating neuropathic pain evaluation into the clinical assessment of SpA to tailor treatment approaches effectively and improve patient outcomes.

The management of adult and paediatric uveitis for rheumatologists

Uveitis encompasses multiple different conditions that are all characterized by intra-ocular inflammation. Uveitis occurs in the context of many different rheumatological conditions and carries a substantial risk to vision. Uveitis can develop both at the early stages of rheumatic diseases, sometimes even preceding other clinical features, and at later stages of disease. Uveitis can also occur as either a direct or an indirect complication of therapies used to treat patients with rheumatic disease. Conversely, patients with uveitis of non-rheumatic aetiology sometimes require immunosuppression, a treatment option that is not readily accessible to ophthalmologists. Thus, collaborative working between rheumatologists and ophthalmologists is critical for optimal management of patients with uveitis. This Review is written with rheumatologists in mind, to assist in the care of patients with uveitis. We collate and summarize the latest evidence and best practice in the diagnosis, management and prognostication of uveitis, including future trends and research priorities.

Effectiveness of N-3 fatty acids supplementation on spondyloarthritis: A systematic review and meta-analysis

BACKGROUND & AIMS

The study aims to systematically review and meta-analyze randomized controlled trials (RCTs) assessing the effects of n-3 fatty acids (FA) supplementation on spondyloarthritis (SpA) disease activity, inflammatory markers, and imaging.

METHODS

The study protocol was developed and registered online in advance. The PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases were systematically searched for RCTs up to April 2024. Two independent reviewers screened, assessed for eligibility, and extracted data from the eligible RCTs. The revised Cochrane Risk of Bias tool was used to assess the quality of trials. The random-effects model was used to calculate the pooled estimates.

RESULTS

We included four RCTs, involving 245 patients with SpA. Supplementation with n-3 FA did not improve physician-reported outcomes [number of tender joints (four trials, standardized mean difference (SMD): -0.22; 95 % confidence interval (CI): -0.74 to 0.29; I2 = 61 %), number of swollen joints (two trials, SMD: -0.13; 95 % CI: -0.42 to 0.15; I2 = 0 %)], and patient-reported outcomes [pain (three trials, SMD: -0.16; 95 % CI: -1.03 to 0.70; I2 = 74 %), Health Assessment Questionnaire (three trials, SMD: -0.04; 95 % CI: -0.78 to 0.70; I2 = 71 %). The other nine pre-specified outcomes were not analyzed due to lack of information from the original RCTs which were evaluated as «some concerns» or «high risk» of bias.

CONCLUSIONS

In the present systematic review and meta-analysis including placebo-controlled RCTs, n-3 FA supplementation did not show improvement in the reported outcomes. Future RCTs should be conducted with homogenous intervention, placebo, and outcomes to re-examine possible beneficial effects.

Classification Criteria for Axial Disease in Youth With Juvenile Spondyloarthritis

OBJECTIVE

The goal was to develop and validate classification criteria for axial juvenile spondyloarthritis (SpA; AxJSpA).

METHODS

This international initiative consisted of four phases: (1) item generation, (2) item reduction, (3) criteria development, and (4) validation of the AxJSpA criteria by an independent team of experts in an internationally representative validation cohort.

RESULTS

These criteria are intended to be used on youth with a physician diagnosis of juvenile SpA and for whom axial disease is suspected. Item generation consisted of a systematic literature review and a free-listing exercise using input from international physicians, which collectively resulted in 108 items. After the item reduction exercise and expert panel input, 37 items remained for further consideration. The final AxJSpA criteria domains included the following: imaging of active inflammation, imaging of structural lesions, pain chronicity, pain pattern, pain location, stiffness, and genetics. The most heavily weighted domains were active inflammation and structural lesions on imaging. Imaging typical of sacroiliitis was deemed necessary, but not sufficient, to classify a youth with AxJSpA. The threshold for classification of AxJSpA was a score of ≥55 (out of 100). When tested in the validation data set, the final criteria had a specificity of 97.5% (95% confidence interval [CI] 91.4%-99.7%), sensitivity of 64.3% (95% CI 54.9%-73.1%), and area under the receiver operating characteristic curve of 0.81 (95% CI 0.76%-0.86%).

CONCLUSION

The new AxJSpA classification criteria require an entry criterion and a physician diagnosis of juvenile SpA and include seven weighted domains. The AxJSpA classification criteria are validated and designed to identify participants for research studies.

Rare but characteristic MRI Shoulder findings of chlamydia trachomatis-associated reactive arthritis

Spondyloarthritis is an inflammatory disease characterised by tendon adhesions and sacroiliitis. Herein, we present a case of reactive arthritis (ReA) after Chlamydia infection. The condition was characterised by rotator cuff enthesitis accompanied by inflammation of the rotator cuff muscles and presence of contrast-enhanced lesions at several tendon attachments without pelvic sacroiliitis. Some studies have reported about shoulder joint involvement observed on magnetic resonance imaging (MRI) in ankylosing spondylitis and psoriatic arthritis. However, there are no reports on shoulder lesions detected on MRI in C. trachomatis infection-associated ReA. The patient presented with hip, lower back and right shoulder pain. MRI of the pelvis revealed inflammation of the tendon attachments such as the spinous process, sciatic tuberosity and greater and lesser trochanter. However, sacroiliitis was not observed. These imaging findings indicated enthesitis. The patient tested positive for C. trachomatis immunoglobulin but negative for HLA-B27 antigen. Hence, he was diagnosed with Chlamydia-related ReA. Antibiotic treatment combined with sulfasalazine was initiated. This resulted in an evident clinical improvement without remission. To the best of our knowledge, this is the first case report showing the presence of shoulder lesions on MRI in C. trachomatis infection-associated ReA. Further, this study showed that shoulder lesions in spondyloarthritis, including ReA, are characterised by not only adhesive inflammation but also bone marrow oedema in the tendon attachments and rotator cuff inflammation.

Efficacy and Safety of CT-P13 as First- and Second-Line Treatment in Patients with Ankylosing Spondylitis

Background/Objectives: CT-P13 is a biosimilar version of infliximab, a monoclonal antibody. In individuals with ankylosing spondylitis (AS), CT-P13 has been shown to be effective and to have a well-tolerated safety profile. The aim of this study was to evaluate the long-term drug persistence, safety, and efficacy of infliximab biosimilar CT-P13 in patients with AS undergoing first-line (1st-line) and later (≥2nd-line) treatment in clinical practice. Methods: We performed an observational cohort study that included AS patients based on the biological drug database in the TURKBIO Registry between 2014 and 2021. The patients were divided into two groups: those receiving CT-P13 as first-line treatment or as a switch (≥2nd-line) from another TNF inhibitor (TNFi). Standard disease activity metrics were used to assess the effectiveness of CT-P13, and drug retention rates were investigated. Results: There were 179 AS patients using CT-P13 (47.4% male, mean age: 42.9 ± 11.3 years). Of these patients, 123 (68.7%) were receiving CT-P13 as a first-line treatment. The mean length of treatment was 3.5 years. CT-P13 drug retention rates in the general patient population were 58.6% and 48.2% in the first-line and ≥second-line treatment, respectively, after 3 years of follow-up. The most common reason for CT-P13 treatment discontinuation was lack of efficacy. The first-line CT-P13 group had statistically substantially higher ASAS20/40 response rates at three and six months. Nonetheless, both groups' response rates at one year were comparable. Conclusions: In this real-world data analysis, AS patients who were TNFi naïve (1st-line) and subsequently treated (≥2nd-line) with CT-P13 showed encouraging drug retention rates with acceptable long-term effectiveness and safety.

Comprehensive analysis of rheumatic diseases, comorbidities, and mortality in geriatric population: Real-world data of 515 patients in a single rheumatology clinic

Rheumatic diseases present unique challenges in the elderly, with changes in the immune system contributing to varied clinical presentations. More individuals are now living with chronic diseases due to greater life expectancy, but there is a lack of real-world data about rheumatic diseases and comorbidities in older people. This study aimed to investigate disease types, comorbidities, treatments, and mortality in geriatric patients in comparison to non-geriatric patients at a rheumatology clinic. This retrospective observational cohort study reviewed the medical records of 2610 patients from January 2021 to January 2024 at 2 branches of a private hospital's rheumatology clinics. Demographic information and data on rheumatic diseases, noninflammatory conditions, treatments, comorbidities, and mortality were collected, and geriatric patients were compared to non-geriatric patients. Geriatric patients (n = 515) had a significantly higher prevalence of rheumatoid arthritis (50.6% vs 28.8%, P < .001), polymyalgia rheumatica (11.1% vs 0.2%, P < .001), and crystal arthritis (19.6% vs 8.8%, P < .001), with more frequent geriatric-onset cases. Osteoarthritis was also more prevalent in geriatric patients (51.2% vs 11.3%, P < .001), while fibromyalgia was more common in the non-geriatric group (15.9% vs 4.1%, P < .001). Geriatric patients experienced higher rates of comorbidities, including hypertension (72.4% vs 17.8%, P < .001), diabetes (33.6% vs 12.1%, P < .001), and osteoporosis (64.9% vs 35.4%, P < .001). These patients used more corticosteroids (74.5% vs 44%, P < .001), and conventional synthetic disease-modifying antirheumatic drugs (62.4% vs 49.4%, P < .001) but fewer biological disease-modifying antirheumatic drugs (9.2% vs 23.1%, P < .001). Mortality rates were significantly higher in geriatric patients (6% vs 0.3%), with cancer (P = .001), ischemic heart disease (P = .04), heart failure (P = .01), chronic kidney disease (P = .02), and interstitial lung disease (P = .01) being associated with increased mortality. Geriatric rheumatology should receive greater focus in future research to help address the anticipated increases in demand and to develop tailored management strategies for elderly patients with rheumatic diseases and comorbidities.

The Effects of Smoking, Alcohol, and Dietary Habits on the Progression and Management of Spondyloarthritis

Spondyloarthritis (SpA) is a group of chronic inflammatory diseases affecting the spine and peripheral joints, causing pain, stiffness, and reduced mobility. This narrative review examines how lifestyle factors-specifically smoking, alcohol consumption, and unhealthy diet-contribute to the onset and progression of SpA. It highlights their impact on disease activity, comorbidities, radiographic damage, and treatment response. Therefore, healthcare providers are encouraged to support patients in making personalized lifestyle changes. These findings underscore the importance of a comprehensive approach to SpA management, integrating lifestyle modifications with conventional therapies for optimal disease control and improved outcomes.

Elevated Calprotectin Levels Reveal Loss of Vascular Pattern and Atrophy of Villi in Ileum by Digital Chromoendoscopy and Magnification Colonoscopy in Patients with Spondyloarthritis Without Having Inflammatory Bowel Disease

OBJECTIVE

This study aimed to establish a correlation between fecal calprotectin levels (FC) and intestinal inflammation in patients with spondyloarthritis without inflammatory bowel disease.

METHODS

A total of 180 SpA patients were included in the study of them 20.6% required Digital chromoendoscopy (DCE). FC, C-reactive protein (CRP), HLA-B*27 and clinical indices were assessed.

RESULTS

Positive fecal calprotectin (PFC) and high fecal calprotectin (HFC) levels were observed in 27.0% and 16.0% of patients, respectively. HFC correlated with a Bath Ankylosing Spondylitis Functional Index (BASFI) score > 4.0 (p = 0.036) and a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score > 4.0 (p = 0.047). Loss of vascular pattern in the ileum (LVPI) was observed in approximately 70.0% of patients (p = 0.005), which was associated with PFC and abdominal bloating (p = 0.020). LVPI was also linked to microscopic inflammation (p = 0.012) and PFC with abdominal pain (p = 0.007). HFC was significantly associated with alterations in the ileal mucosa (p = 0.009) and LVPI (p = 0.001). Additionally, HFC and diarrhea were associated with LVPI in 27.3% of patients (p = 0.037) and with erosions in the ileum (p = 0.031). Chronic ileal inflammation correlated with HFC (p = 0.015), ASDAS-CRP > 2.1 (p = 0.09), LVPI (p = 0.001), and villous atrophy (p = 0.014). Factorial analysis of mixed data (FAMD) identified significant associations between micro/macroscopic changes in chronic inflammation and HFC (CC = 0.837); increased levels of CRP and microscopic acute inflammation (CC = 0.792); and clinical activity scores of ASDAS-CRP and BASDAI (CC = 0.914).

CONLUSIONS

FC levels were significantly elevated in patients with SpA, particularly those with LVPI, suggesting their potential as a valuable biomarker for managing SpA when joint manifestations coincide with ileal villous atrophy. This indicates a shared immune pathway linked to chronic gut damage.

Recording of non-musculoskeletal manifestations, comorbidities and safety outcomes in European spondyloarthritis registries: a survey

Objectives

Real-world evidence is needed to inform treatment strategies for patients with PsA and axial SpA (axSpA) who have non-musculoskeletal manifestations (NMMs), various risk factors and comorbidities. International collaboration is required to ensure statistical power and to enhance generalizability. The first step forward is identifying which data are currently being collected. Across 17 registries participating in the European Spondyloarthritis Research Collaboration (EuroSpA), we aimed to map recording practices for NMMs, comorbidities and safety outcomes in patients with PsA and axSpA.

Methods

Through a survey with 4,420 questionnaire items, we explored the recording practices of 58 pre-defined conditions (i.e. NMMs, comorbidities and safety outcomes) covering 10 disease areas. In all registries we mapped for each condition whether it was recorded, the recording procedure and the potential to identify it through linkage to other national registries.

Results

Conditions were generally recorded at entry into the registry and clinical follow-up visits using a pre-specified list or a coding system. Most registries recorded conditions within the following disease areas: NMMs (number of registries, n = 15-16), cardiovascular diseases (n = 10-14), gastrointestinal diseases (n = 12-13), infections (n = 10-13) and death (n = 14). Nordic countries had the potential for data linkage and generally had limited recording of conditions in their registry, while other countries had comprehensive recording practices.

Conclusion

A wide range of conditions were consistently recorded across the registries. The recording practices of many conditions and disease areas were comparable across the registries. Our findings support the potential for future collaborative research.