Diagnostic delay is associated with uveitis and inflammatory bowel disease in AS: a study of extra-musculoskeletal manifestations in SpA

OBJECTIVES

To examine the prevalence of extra-musculoskeletal manifestations (EMM) and the association between diagnostic delay and their incidence in AS and PsA.

METHODS

This was a retrospective, cohort study comprising two single centre cohorts in Europe and one multicentre cohort in Latin America (RESPONDIA). Crude prevalence of EMMs (uveitis, IBD and psoriasis) was calculated across geographic area and adjusted by direct standardization. Cox proportional hazard analysis was performed to assess the association between diagnostic delay and EMM incidence.

RESULTS

Of 3553 patients, 2097 had AS and 1456 had PsA. The overall prevalence of uveitis was 22.9% (95% CI: 21.1, 24.8) in AS and 3.8% (95% CI: 2.9, 5.0) in PsA; 8.1% (95% CI: 7.0, 9.4) and 2.1% (1.3, 2.9), respectively, for IBD; and 11.0% (95% CI: 9.7, 12.4) and 94.6% (93.0, 95.9), respectively, for psoriasis. The EMM often presented before the arthritis (uveitis 45.1% and 33.3%, and IBD 37.4% and 70%, in AS and PsA, respectively). In the multivariable model, longer diagnostic delay (≥5 years) associated with more uveitis (hazard ratio [HR] 4.01; 95% CI: 3.23, 4.07) and IBD events (HR 1.85; 95% CI: 1.28, 2.67) in AS. Diagnostic delay was not significantly associated with uveitis (HR 1.57; 95% CI: 0.69, 3.59) or IBD events (HR 1.59; 95% CI: 0.39, 6.37) in PsA.

CONCLUSION

EMMs are more prevalent in AS than PsA and often present before the onset of the articular disease. A longer diagnostic delay is associated with the 'de novo' appearance of uveitis and IBD in AS, highlighting the need to enhance diagnostic strategies to shorten the time from first symptom to diagnosis in SpA.

Interval cancer in the Córdoba Breast Tomosynthesis Screening Trial (CBTST): comparison of digital breast tomosynthesis plus digital mammography to digital mammography alone

PURPOSE

This work aims to compare the interval cancer rate and interval cancer characteristics between women screened with digital breast tomosynthesis (DBT) + digital mammography (DM) and those screened with DM alone.

METHODS

The interval cancer rate and interval cancer characteristics of the study population included in the Córdoba Breast Tomosynthesis Screening Trial (CBTST) were compared to a contemporary control population screened with DM. The tumour characteristics of screen-detected and interval cancers were also compared. Contingency tables were used to compare interval cancer rates. The chi-square test and Fisher's exact test were used to compare the qualitative characteristics of the cancers whereas Student's t test and the Mann-Whitney U test were used to analyse quantitative features.

RESULTS

A total of 16,068 screening exams with DBT + DM were conducted within the CBTST (mean age 57.59 ± 5.9 [SD]) between January 2015 and December 2016 (study population). In parallel, 23,787 women (mean age 58.89 ± 5.9 standard deviation [SD]) were screened with DM (control population). The interval cancer rate was lower in the study population than in the control population (15 [0.93‰; 95% confidence interval (CI): 0.73, 1.14] vs 43 [1.8‰; 95% CI: 1.58, 2.04] respectively; p = 0.045). The difference in rate was more marked in women with dense breasts (0.95‰ in the study population vs 3.17‰ in the control population; p = 0.031). Interval cancers were smaller in the study population than in the control population (p = 0.031).

CONCLUSIONS

The interval cancer rate was lower in women screened with DBT + DM compared to those screened with DM alone. These differences were more pronounced in women with dense breasts.

CLINICAL RELEVANCE STATEMENT

Women screened using tomosynthesis and digital mammography had a lower rate of interval cancer than women screened with digital mammography, with the greatest difference in the interval cancer rate observed in women with dense breasts.

KEY POINTS

• The interval cancer rate was lower in the study population (digital breast tomosynthesis [DBT] + digital mammography [DM]) than in the control population (DM). • The difference in interval cancer rates was more pronounced in women with dense breasts. • Interval cancers were smaller in the study population (DBT + DM) than in the control population (DM).

Identification of the first signs or symptoms in different spondyloarthritis subtypes and their association with HLA-B27: data from REGISPONSER and RESPONDIA registries

OBJECTIVE

To describe and analyse the initial symptoms attributable to patients with spondyloarthritis (SpA) and their association with HLA-B27 status.

METHODS

This was an observational, cross-sectional and multicentre study with patients who fulfilled the European Spondyloarthropathy Study Group criteria for SpA from the Registry of Spondyloarthritis of Spanish Rheumatology (REGISPONSER) and Ibero-American Registry of Spondyloarthropathies (RESPONDIA) united registries. Differences in the first sign(s) or symptom(s) were compared across diagnoses and between HLA-B27 status. The diagnostic delay between patients who start the disease with musculoskeletal manifestations (MMs) and extra-MMs (EMMs) was compared.

RESULTS

A total of 4067 patients were included (2208 from REGISPONSER and 1859 from RESPONDIA) (ankylosing spondylitis (AS): 68.3%, psoriatic arthritis (PsA): 19.9%, undifferentiated SpA: 11.8%). Overall, 3624 (89.1%) patients initiated the disease with MMs and 443 (10.9%) with EMMs. Low back pain (61.7%) and lower-limb arthritis (38.5%) were the most frequent initial symptoms. In AS patients, the absence of HLA-B27 seems to be related to an increase in the probability of starting the disease with cervical pain and peripheral manifestations. In PsA, the onset of arthritis and psoriasis was more prevalent in HLA-B27-negative patients, while initiation with axial manifestations was more predominant in HLA-B27-positive patients. The diagnostic delay was longer in patients with initial MMs than in those with EMMs (7.2 (34.8) vs 4.5 (7.6) years, respectively).

CONCLUSION

In this SpA population, MMs were the most prevalent initial symptoms, with differences across diagnoses and depending on the presence of the HLA-B27 antigen.

Achilles enthesitis on physical examination leads to worse outcomes after 2 years of follow up in patients with ankylosing spondylitis from REGISPONSER-AS registry

BACKGROUND

Enthesitis represents one of the most important peripheral musculoskeletal manifestations in patients with axial spondyloarthritis (axSpA). However, studies specifically evaluating Achilles tendon enthesitis and its impact over time are scarce. The objectives of this study were to evaluate the impact of Achilles' tendon enthesitis found at baseline during physical examination on the outcome measures after 2 years of follow-up in patients with ankylosing spondylitis (AS).

METHODS

This was an observational and prospective study conducted during 2 years of follow-up in the REGISPONSER-AS registry. Linear regression models adjusted for age, body mass index (BMI), and anti-TNF intake were conducted to evaluate the association between the presence of Achilles enthesitis at baseline and the patient-reported outcome (PRO) scores at baseline. The impact of this feature on PROs over 2 years of follow-up was evaluated using mixed models for repeated measures adjusted for age, BMI, and anti-TNF intake.

RESULTS

Among the 749 patients included, 46 patients (6.1%) showed Achilles' tendon enthesitis during physical examination at the baseline study visit. Patients with Achilles enthesitis had an increase in the global VAS score, BASDAI, mBASDAI, ASDAS-CRP, and BASFI scores in comparison with patients without this feature. In addition, the mean global VAS, BASDAI, and ASDAS-CRP scores were significantly higher among patients with Achilles enthesitis over the 2 years of follow-up after adjusting for age, BMI, and current anti-TNF intake. The percentage of patients achieving ASDAS low disease activity (ASDAS < 2.1) after 2 years of follow-up was 15.9% and 31.5% for patients with and without Achilles enthesitis, respectively (p = 0.030).

CONCLUSIONS

In patients with AS, the presence of Achilles' tendon enthesitis was associated with worse scores on the outcome measures after 2 years of follow-up, leading to a lower probability of achieving low disease activity.

Brodalumab: Efficacy, safety, and survival in mid-term (52 weeks) on real clinical practice in Andalucia, Spain

INTRODUCTION

Brodalumab is a recombinant monoclonal antibody (IgG2) that binds with high affinity to the human interleukin-17 (IL-17) receptor A and blocks the biological activity of the proinflammatory cytokines IL-17A, IL-17F, IL-17A/F heterodimer, and IL- 25, resulting in inhibition of inflammation and clinical symptoms associated with psoriasis. Its introduction has managed to increase the levels of efficacy, safety (improving that previously presented by the anti-IL-17 class), and survival.

MATERIAL AND METHODS

Retrospective analysis of a multicenter, observational study of real clinical practice including patients with moderate to severe plaque psoriasis in treatment with brodalumab. This cross-sectional analysis includes information of patients between February 2019 and February 2022. A total of five tertiary hospitals in Andalusia (Spain) participated in this study. Analyses were performed "as observed" using GraphPad Prism version 8.3.0 for Windows.

RESULTS

Our study included 85 patients, 54 men (63.5%) and 31 women (36.5%), with moderate-severe psoriasis treated with brodalumab. In order to evaluate the efficacy of brodalumab, our patients started with mean Psoriasis Area and Severity Index (PASI) values of 12.8 and body surface area (BSA) of 16.9, as well as a Dermatology Life Quality Index (DLQI) of 15.6, highlighting that they reported that the mean baseline visual analog scale (VAS) pruritus was 6.15. On week 52, mean PASI reached 1.26 and mean BSA 2.3, showing a clear stabilization and even sustained improvement regarding results on week 12. Concerning the brodalumab survival, we obtained 85.8% persistence at week 52.

DISCUSSION

Brodalumab showed excellent results in the control of psoriasis in the mid-term with an elevated number of patients maintaining treatment after 52 weeks. There were no statistically significant differences in the efficiency, safety, or survival results of brodalumab between patients coming from previous therapies.

Characterising the axial phenotype of psoriatic arthritis: a study comparing axial psoriatic arthritis and ankylosing spondylitis with psoriasis from the REGISPONSER registry

AIMS

To explore the clinical and radiographical characteristics of axial psoriatic arthritis (PsA) and to compare it with ankylosing spondylitis (AS) with psoriasis.

METHODS

Cross-sectional study from the national multicentre registry REGISPONSER where participants fulfilled the European Spondyloarthropathy Study Group spondyloarthritis criteria at entry. Clinical, laboratory and radiographical characteristics between patients classified as axial PsA and AS with psoriasis by their rheumatologist are compared according to HLA-B27 status.

RESULTS

Of 2367 patients on REGISPONSER, n=405 had PsA, of whom 27% (n=109) had axial involvement as per the treating rheumatologist. 30% (n=26/86) of axial PsA were HLA-B27 positive. In the AS group, 9% (127/1422) had a history of psoriasis and were more frequently male, with longer diagnostic delay and more anterior uveitis than those with axial PsA who had more peripheral involvement and nail disease. Patients with HLA-B27-negative axial PsA reported less inflammatory pain and structural damage compared with AS with psoriasis. By contrast, HLA-B27-positive axial PsA shared clinical characteristics similar to AS and psoriasis although with a lower BASRI score. In the multivariable analysis, patients with AS and psoriasis were independently associated with HLA-B27 positivity (OR 3.34, 95% CI 1.42 to 7.85) and lumbar structural damage scored by BASRI (OR 2.14, 95% CI 1.4 to 3.19).

CONCLUSION

The more prevalent axial PsA phenotype is predominantly HLA-B27 negative and presents different clinical and radiological manifestations when compared with AS with psoriasis. There is great heterogeneity in what rheumatologists consider axial PsA from a clinical and imaging perspective, highlighting the need for research into possible genetic drivers and a consensus definition.

Relationship between onset of psoriasis and spondyloarthritis symptoms with clinical phenotype and diagnosis: data from REGISPONSER registry

Background

The relationship of psoriasis and spondyloarthritis (SpA) is well-known, and the age of appearance of different manifestations has been described as a determinant of SpA phenotype. However, differences between Spa with psoriasis and psoriatic arthritis (PsA) are still controversial.

Objectives

To evaluate whether the time of onset of psoriasis relative to the appearance of rheumatic symptoms in patients with SpA is associated with a clinical phenotype, a rheumatologist's diagnosis and the evolution of the disease.

Design

This was a cross-sectional study with data extracted from the REGISPONSER (Spondyloarthritis Registry of the Spanish Rheumatology Society) registry.

Methods

All patients had data available for both psoriasis and SpA dates of onset. Patients were classified into two groups depending on the time of appearance of psoriasis: psoriasis before or after rheumatic symptoms. The clinical characteristics, disease activity, radiographic damage, functional ability and received treatments were compared between the two groups. Moreover, the rheumatologists' diagnoses were compared between the two groups. Univariate and multivariate logistic regressions were conducted to evaluate the factors associated with each group.

Results

A total of 433/2367 (18.3%) patients included in the REGISPONSER database had psoriasis: 330 (76.2%) patients had psoriasis before rheumatic symptoms, and 103 (23.8%) had psoriasis after rheumatic symptoms. Patients with psoriasis before rheumatic symptoms had a shorter disease duration and a lower body mass index, a lower prevalence of both HLA-B27 antigens and anterior uveitis, a higher prevalence of dactylitis and an increase in levels of the erythrocyte sedimentation rate (ESR). Furthermore, a higher prevalence of PsA diagnoses (78.1% versus 56.4%) and a more frequent fulfilment of the CASPAR criteria (57.5% versus 42.2%) were found in these patients. The use of DMARDs was not significantly different between the two groups.

Conclusion

The time of appearance of psoriasis is associated with the clinical phenotype of SpA and could determine a diagnosis of PsA by rheumatologists.

Suicide Presentations to an Emergency Department Pre and During the COVID Lockdown, March-May 2020, in Spain

The impact of the COVID-19 pandemic and lockdown may affect suicide risk and behavior. We compared suicide-related presentations during the national quarantine with pre-COVID data. This observational incidence study compared all suicide-related presentations at the University Hospital Reina Sofia emergency department (ED) in Cordoba, Spain, for the lockdown period from 15 March to 15 May 2020, with the same period in 2019. Descriptive and inferential analyses of case characteristics between 2019 and 2020 periods were conducted, and a multivariable logistic regression model developed. Results: Despite a decrease in overall ED cases during the lockdown, the number of suicide-related presentations stayed the same and represented a significantly larger proportion of cases in comparison to the pre-COVID period (0.42 vs. 0.87%, in 2019 and 2020, respectively; p < .001). The number presenting alone more than doubled during the COVID lockdown, increasing to 42.9% compared with 19.4% in 2019 (p = .002). An increase in presentations with a family history of suicide was also found. Conclusions: Suicide cases represented an increased proportion of ED cases during the lockdown. Presenting to ED alone, having a family history of suicide, habitual drug consumption, and hospital admission to ICU differentiated cases between pre and during COVID periods. These findings should be considered in light of the second wave and further implementation of lockdown measures.

Impact of the number of comorbidities on the outcome measures and on the retention rate of the first anti-TNF in patients with Ankylosing Spondylitis. Two-year follow-up in REGISPONSER-AS

OBJECTIVES

To evaluate the impact of the number of comorbidities on the outcome measures after two years of follow-up in patients with Ankylosing Spondylitis (AS) and to determine whether the number of comorbidities influences the retention rate of the first anti-TNF.

METHODS

This was an observational and prospective study conducted during 2 years of follow-up in the REGISPONSER-AS registry. The patients were divided into three groups according to the number of comorbidities at baseline (0, 1 or ≥2). Linear regression models adjusted for disease duration, age, sex and smoking were constructed to evaluate the association between the number of comorbidities and the Patient Reported Outcomes (PRO) scores. The impact of the number of comorbidities on PROs over two years of follow-up was evaluated using mixed models for repeated measures adjusted for disease duration, age, sex and smoking. Finally, the retention rate of the first anti-TNF antibody across the three groups was evaluated using a log-rank test.

RESULTS

Patients with two or more comorbidities showed higher scores at baseline and during the two years of follow-up for the Global VAS, BASDAI, ASDAS, and BASFI and worse scores for the physical component of the SF12. A higher probability of discontinuation of the first anti-TNF was found in patients with 2 or more comorbidities compared with the patients in the other groups (38.2% vs. 26.6% vs. 25.4% for ≥2 comorbidities, 0 and 1 comorbidity, respectively), although these differences were not significant (log-rank test: p-value = 0.180).

CONCLUSION

In patients with AS, the presence of 2 or more comorbidities was associated with worse scores on the outcome measures test after two years of follow-up and a greater tendency of discontinuation for the first anti-TNF.

Distribution of comorbidities in spondyloarthritis with regard to the phenotype and psoriasis: data from the ASAS-COMOSPA study

INTRODUCTION

The aim of the study was to compare the prevalence of comorbidities between patients with axial and peripheral phenotypes and to evaluate the role of psoriasis in such comorbidities.

METHODS

Patients from the cross-sectional Assessment in SpondyloArthritis Inter-national Society (ASAS)-COMOSPA study were classified as having either the axial (presence of sacroiliitis on X-ray or MRI) or peripheral phenotype (absence of sacroiliitis AND presence of peripheral involvement). Patients with each phenotype were divided into two groups depending on the presence or history of psoriasis. Pair-wise comparisons among the four groups (axial/peripheral phenotype with/without psoriasis) were conducted through univariate logistic regressions and generalized linear mixed models using disease duration and sex as fixed effects and country as random effect.

RESULTS

A total of 3291 patients were included in this analysis. The peripheral involvement with psoriasis phenotype showed the highest prevalence of hypertension (44.9%), dyslipidaemia (34%) and diabetes (8.8%), while the axial involvement without psoriasis phenotype exhibited the lowest prevalence of dyslipidaemia (14.2%), diabetes (4.1%) and stroke (0.9%). Among patients with psoriasis, the axial phenotype showed a significantly lower prevalence of hypertension (OR: 0.51, 95% CI: 0.35-0.75) and lower prevalence of Framingham score ⩾15 (OR: 0.57, 95% CI: 0.38-0.85) than patients with peripheral involvement after adjusting for disease duration, sex and country. Among patients with the axial phenotype, patients with psoriasis showed a higher prevalence of hypertension (OR 1.76, 1.40-2.20), dyslipidaemia (OR: 1.99, 95% CI: 1.56-2.53), diabetes (OR: 2.05, 95% CI: 1.39-3.02) and Framingham score ⩾15 (OR: 2.00, 95% CI: 1.57-2.55) than non-psoriatic patients. No differences were found across groups concerning bone metabolism disorders.

CONCLUSION

Both the peripheral phenotype and psoriasis are independently associated with an increased prevalence of cardiovascular risk factors. No differences were found for bone metabolism disorders.

Genetic Polymorphisms of GGH and ABCC2 Are Associated with Methotrexate Intolerance in Patients with Rheumatoid Arthritis

OBJECTIVE

to identify new single-nucleotide polymorphisms (SNPs) in genes encoding proteins involved in methotrexate (MTX) metabolism and to evaluate the associations of these SNPs with MTX toxicity or intolerance in a southern Spanish cohort of patients with rheumatoid arthritis (RA).

METHODS

An observational, retrospective, and multicenter study was conducted at three participating hospitals in southern Spain. The main variable was intolerance to MTX (i.e., bDMARD monotherapy), defined as an interruption of treatment due to adverse events or toxicity. Patients being treated with MTX and bDMARDs (combined treatment) at the time of the study visit were considered "tolerant" of MTX. Ten polymorphisms were selected for sequencing in our patients according to a literature review. Each polymorphism was classified according to three possible genotypes (e.g., two homozygous (AA or GG) and one heterozygous (AG)), and the association of these combinations with MTX intolerance was evaluated.

RESULTS

A total of 227 patients were included in the final analysis (107 intolerant of MTX and 120 tolerant). A significant association was observed between MTX intolerance and the GGH-T401C AA/AG genotype (OR 2.13, 95% CI 1.06-4.29) in comparison with the GG genotype. On the other hand, an inverse association was observed between the ABCC2-C24T TT/TC genotype and intolerance to MTX (OR 0.59, 95% CI 0.35-1.00) in comparison with the CC genotype.

CONCLUSION

This study provides new data on the association between genetic polymorphisms and MTX intolerance, which may contribute to the development of new biomarkers and personalized medicine in patients with RA.

Which factors explain the patient global assessment in patients with ankylosing spondylitis? A hierarchical cluster analysis on REGISPONSER-AS

OBJECTIVES

To determine groups of factors (clusters) potentially associated with the patient global assessment (measured with the Bath Ankylosing Spondylitis Patient Global Score (BAS-G)), and to quantify the contribution of each cluster to the patient's well-being.

METHODS

This was a cross-sectional study in patients with a diagnosis of ankylosing spondylitis (AS) from the national, multicentre Spanish REGISPONSER-AS registry. A hierarchical cluster analysis was conducted to group the potential factors (sociodemographic, socioeconomic, patient-reported outcomes, physical exploration variables and depression) associated with the BAS-G. The contribution of each cluster to the variability of the BAS-G was evaluated using a multivariate linear regression model and the determination coefficient (R²) for each cluster.

RESULTS

A total of 681 patients with complete data were included. Three clusters of variables potentially associated with the BAS-G were found: cluster 1 contained the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), depression, sex (female) and university studies; cluster 2 included the Graffar scale, age and body mass index; and cluster 3 contained the Bath Ankylosing Spondylitis Functional Index (BASFI), the individual items of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), pain during the last week, nocturnal pain and the number of swollen joints. A total of 6.8% of the variability of the BAS-G was explained by cluster 1, 0.5% was explained by cluster 2, and 60.8% was explained by cluster 3.

CONCLUSION

The BAS-G is mostly explained by pain and function, while demographic and socioeconomic factors are weakly associated with the BAS-G. Depression also has a weak effect on this score.

Prevalence and Associated Factors of Low Bone Mineral Density in the Femoral Neck and Total Hip in Axial Spondyloarthritis: Data from the CASTRO Cohort

Studies on osteoporosis in axial spondyloarthritis (axSpA) have focused on the lumbar segment, and few studies have assessed bone mineral density (BMD) in the hip and femoral neck in these patients. The aim of this study was to evaluate the prevalence of low BMD and osteopenia in the total hip or femoral neck and the factors associated with these conditions in axSpA patients. This was a single-centre, observational, cross-sectional study among consecutive patients with axSpA according to the ASAS criteria from the CASTRO registry. All patients underwent total hip and femoral neck DXA BMD measurements. Low BMD was defined as a Z-score less than −1, and osteopenia was defined as a T-score less than −1. Multivariate logistic and generalised linear regressions were used to evaluate factors independently associated with low BMD and osteopenia in the hip or femoral neck and those associated with variability in BMD, respectively. A total of 117 patients were included, among which 30.8% were female and the mean age was 45 years. A total of 36.0% of patients had low BMD (28.1% in the total hip and 27.4% in the femoral neck), and 56.0% of patients had osteopenia (44.7% in the total hip and 53.8% in the femoral neck). A multivariate logistic regression showed that age, radiographic sacroiliitis and ASAS-HI were independently associated with low BMD in the total hip or femoral neck. Factors that were independently associated with osteopenia were Body Mass Index, disease duration, radiographic sacroiliitis and ASAS-HI. In conclusion, 36% of the patients with axSpA had low BMD in the total hip or femoral neck. A younger age and radiographic sacroiliitis were the most important factors associated with decreased BMD.

Uveitis as the first symptom in spondyloarthritis and its association with the evolution of the disease. Results from the REGISPONSER registry

OBJECTIVES

To describe the time of onset of acute anterior uveitis (AAU) relative to the appearance of rheumatic symptoms and to determine its association with the evolution of the spondyloarthritis (SpA) in terms of activity, structural damage, functional ability and treatment.

METHODS

This was a cross-sectional study with data extracted from the REGISPONSER (SpA Registry of the Spanish Rheumatology Society). Thirty-one centres participated, and patients with SpA according to the ESSG criteria were included from 2004 to 2007. Patients were classified according to the time of uveitis appearance with regard to rheumatic symptom onset (before, concomitant with, or after rheumatic symptom onset). We compared the clinical characteristics, disease activity, radiographic damage and functional ability between "AAU before or concomitant with rheumatic symptoms" and "AAU after rheumatic symptoms onset". Finally, we compared whether the time of appearance of AAU had an impact on the use of conventional and biological disease-modifying antirheumatic drugs (csDMARDs and bDMARDs, respectively).

RESULTS

A total of 2367 patients were included in REGISPONSER, with an AAU prevalence of 16.2% (379 patients). Patients with AAU before/concomitant with rheumatic symptom onset (n=59) exhibited better functional ability (BASFI, OR 0.85 [0.73-0.99]) and less structural damage (spinal BASRI, OR 0.88 [0.79-0.99]). Additionally, this group of patients was older at SpA symptom onset (OR 1.05 [1.02-1.09]) and had a shorter diagnosis delay (OR 0.90 [0.84-0.96]) compared patients with AAU after rheumatic symptom onset (n=229). No statistically significant differences in the use of DMARDs were noted (27.9% vs 23.2% for csDMARD use and 15.3% vs 20.3% for bDMARD use in patients with AAU before or concomitant with rheumatic symptom onset vs after rheumatic symptom onset, respectively).

CONCLUSION

Patients presenting with a first episode of AAU before/concomitant with the onset of rheumatic symptoms had less severe disease (better functional ability and less structural damage) and a shorter diagnosis delay; however, the time of AAU onset did not impact the treatments received.

How to calculate the ASDAS based on C-reactive protein without individual questions from the BASDAI: the BASDAI-based ASDAS formula

OBJECTIVES

To develop a new equation to calculate the Ankylosing Spondylitis Disease Activity Score based on CRP (ASDAS-CRP) using only the BASDAI total score and CRP.

METHODS

Axial SpA (axSpA) patients from the Cordoba Spondyloarthritis Registry cohort were recruited as a derivation cohort, while a retrospective sample from the Spanish Rheumatology Society National Registry of Spondyloarthropathies and Ibero American Spondyloarhtritis Registry registers was used as a validation cohort. We built a new equation based only on the BASDAI and CRP, defining a new formula: the BASDAI-based ASDAS (BASDAS). Linear regression analysis was used to determine the coefficients of the equation in the derivation cohort and it was subsequently validated in the validation cohort.

RESULTS

A total of 52 axSpA patients in the derivation cohort and 3359 patients in the validation cohort were included. In the derivation cohort, the mean BASDAS [2.24 (s.d. 0.90)] was very similar to the ASDAS-CRP [2.23 (s.d. 0.95)], with a very strong correlation (r = 0.96, P < 0.001). In the validation cohort, the mean BASDAS was 3.31 (s.d. 1.37) and the ASDAS-CRP was 3.19 (s.d. 1.27), which also had a very strong correlation (r = 0.95, P < 0.001). Intraclass correlation coefficients were excellent in both cohorts (0.963 and 0.947, respectively).

CONCLUSION

The BASDAS performs similarly to the ASDAS-CRP and can be calculated with only the BASDAI total score and CRP, allowing evaluation of disease activity in retrospective studies where the individual items of the BASDAI are not available.

Axial and peripheral spondyloarthritis: does psoriasis influence the clinical expression and disease burden? Data from REGISPONSER registry

Objective

To evaluate whether the presence of psoriasis influences the clinical expression, disease activity and disease burden in both axial and peripheral phenotypes of spondyloarthritis (SpA).

Methods

Patients from the Spanish REGISPONSER registry classified as having SpA according to the ESSG criteria were included. Patients were classified as psoriatic or non-psoriatic depending on the presence of cutaneous or nail psoriasis; thereafter, they were classified as having either axial [presence of radiographic sacroiliitis OR inflammatory back pain (IBP)] or peripheral phenotype (absence of radiographic sacroiliitis AND absence of IBP AND presence of peripheral involvement). Pair-wise univariate and multivariate analyses among the four groups (psoriatic/non-psoriatic axial phenotypes and psoriatic/non-psoriatic peripheral phenotypes) were performed with adjustment for treatment intake.

Results

A total of 2296 patients were included in the analysis. Among patients with axial phenotype, psoriasis was independently associated (P &lt; 0.05) with HLA-B27+ [odds ratio (OR) 0.27], uveitis (OR 0.46), synovitis (ever) (OR 2.59), dactylitis (OR 2.78) and the use of conventional synthetic DMARDs (csDMARDs) (OR 1.47) in comparison with non-psoriatic patients. Among patients with peripheral phenotype and adjusting for csDMARD intake, psoriasis was independently associated with higher age at disease onset (OR 1.05), HLA-B27+ (OR 0.14) and heel enthesitis (OR 0.22). Higher scores for patient-reported outcomes and greater use of treatment at the time of the study visit were observed in psoriatic patients with either axial or peripheral phenotype.

Conclusion

These findings suggest that, among all patients with SpA, psoriasis is associated with differences in clinical expression of SpA, a greater disease burden and increased use of drugs.

Enhanced NETosis generation in radiographic axial spondyloarthritis: utility as biomarker for disease activity and anti-TNF-α therapy effectiveness

Background

Radiographic axial spondyloarthritis (r-axSpA) is a chronic inflammatory form of arthritis in which tumor necrosis factor (TNF)-α, a potent inducer of inflammatory response and a key regulator of innate immunity and of Th1 immune responses, plays a central role. NETosis is a mechanism of innate immune defense that is involved in diverse rheumatology diseases. Nevertheless, spontaneous NETosis generation in r-axSpA, its association to disease pathogenesis, and the NETosis involvement on anti-TNF-α therapy’s effects has never been explored.

Methods

Thirty r-axSpA patients and 32 healthy donors (HDs) were evaluated. Neutrophil extracellular trap (NET) formation, mediators of signal-transduction cascade required for NETosis induction and cell-free NETosis-derived products were quantified. An additional cohort of 15 r-axSpA patients treated with infliximab (IFX) for six months were further analyzed. In vitro studies were designed to assess the effects of IFX in NETosis generation and the inflammatory profile triggered.

Results

Compared to HDs, neutrophils from r-axSpA patients displayed augmented spontaneous NET formation, elevated expression of NET-associated signaling components, nuclear peptidylarginine deiminase 4 translocation and increased citrullinated histone H3. Furthermore, patients exhibited altered circulating levels of cell-free NETosis-derived products (DNA, nucleosomes and elastase). Additional studies revealed that cell-free NETosis-derived products could be suitable biomarkers for distinguish r-axSpA patients from HDs. Correlation studies showed association between cell-free NETosis-derived products and clinical inflammatory parameters. Besides, nucleosomes displayed potential as a biomarker for discriminate patients according to disease activity.

IFX therapy promoted a reduction in both NETosis generation and disease activity in r-axSpA patients. Mechanistic in vitro studies further unveiled the relevance of IFX in reducing NET release and normalizing the augmented inflammatory activities promoted by NETs in mononuclear cells.

Conclusions

This study reveals that NETosis is enhanced in r-axSpA patients and identifies the NETosis-derived products as potential disease activity biomarkers. In addition, the data suggests the potential role of NET generation analysis for assessment of therapeutic effectiveness in r-axSpA.

Assessment of Doctors' Knowledge and Attitudes Towards Confidentiality in Hospital Care

The physician's duty of confidentiality is based on the observance of the patient's privacy and intimacy and on the importance of respecting both of these rights, thus creating a relationship of confidence and collaboration between doctor and patient. The main objective of this work consists of analyzing the aspects that are related to the confidentiality of patients' data with respect to the training, conduct and opinions of doctors from different Clinical Management Units of a third-level hospital via a questionnaire. The present study aimed to define the problem and determine whether the opinions of these professionals correspond to those observed in a previous work conducted at the same center. Of the 200 questionnaires that were collected, 62.5% were from consultants and the rest were from residents (37.5%) with an average of 14.4 ± 12.5 years in professional practice. The respondents noted habitual situations in which confidentiality was breached in the reference hospital (74%). The section on their attitudes and behaviors towards situations related to confidentiality showed a slightly lower average score than that of their medical knowledge; significant differences in these scores were observed between the consultants and residents as well as between the extreme age groups (≤ 30 vs. ≥ 51 years) and years of professional practice, thus more inadequate attitudes were consistently noted in younger doctors who had fewer years of experience. Finally, the respondents answered that the training of doctors in the aspects of healthcare law and ethics was the most important measure that the hospital could adopt regarding confidentiality practices.

Circulating microRNAs as potential biomarkers of disease activity and structural damage in ankylosing spondylitis patients

Ankylosing spondylitis (AS) remains difficult to diagnose before irreversible damage to sacroiliac joint is noticeable. Circulating microRNAs have demonstrated to serve as diagnostic tools for several human diseases. Here, we analysed plasma microRNAs to identify potential AS biomarkers. Higher expression levels of microRNA (miR)-146a-5p, miR-125a-5p, miR-151a-3p and miR-22-3p, and lower expression of miR-150-5p, and miR-451a were found in AS versus healthy donors. Interestingly, higher miR-146a-5p, miR-125a-5p, miR-151a-3p, miR-22-3p and miR-451a expression was also observed in AS than psoriatic arthritis patients. The areas under the curve, generated to assess the accuracy of microRNAs as diagnostic biomarkers for AS, ranged from 0.614 to 0.781; the six-microRNA signature reached 0.957. Bioinformatics analysis revealed that microRNAs targeted inflammatory and bone remodeling genes, underlying their potential role in this pathology. Indeed, additional studies revealed an association between these six microRNAs and potential target proteins related to AS pathophysiology. Furthermore, miR-146a-5p, miR-125a-5p and miR-22-3p expression was increased in active versus non-active patients. Moreover, miR-125a-5p, miR-151a-3p, miR-150-5p and miR-451a expression was related to the presence of syndesmophytes in AS patients. Overall, this study identified a six-plasma microRNA signature that could be attractive candidates as non-invasive biomarkers for the AS diagnosis, and may help to elucidate the disease pathogenesis.

High Reproducibility of an Automated Measurement of Mobility for Patients with Axial Spondyloarthritis

OBJECTIVE

Conventional measures of spinal mobility used in the assessment of patients with axial spondyloarthritis (axSpA), such as the Bath Ankylosing Spondylitis Metrology Index and its components, are subject to interobserver variability. The University of Córdoba Ankylosing Spondylitis Metrology Index (UCOASMI) is a validated composite index based on a motion video-capture system, UCOTrack. Our objective was to assess its reproducibility in clinical practice settings.

METHODS

We carried out an observational study of repeated measures in 3 centers. Video-capture systems were installed and adapted to clinical rooms. Patients with axSpA and stable disease were selected by consecutive stratified sampling [disease duration, sex, and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)]. Intraobserver reliability of the UCOASMI and of conventional measures was tested 3-5 days apart. For interobserver reliability, 3 patients from each center were evaluated in the other centers, within 3-7 days. The intraclass correlation coefficients (ICC) were calculated.

RESULTS

Thirty patients were included (73% men, mean age 53 yrs, mean BASDAI 3.0). Interobserver and intraobserver ICC of the UCOASMI was 0.98. Conventional measurements showed lower but adequate reproducibility as well, except for interobserver reliability of lateral flexion (0.41), cervical rotation (0.61), and Schöber test (0.07), and intraobserver reliability of tragus-to-wall distance (0.30).

CONCLUSION

Reproducibility of the UCOASMI seems very high, and apparently more reliable than conventional measures of mobility.

Enhanced depth OCT imaging of the lamina cribrosa for 24 hours

The lamina cribrosa thickness (LCT) could be affected by dynamic changes in its structure. Using Spectral-domain-optical coherence tomography (SD-OCT), we have studied the behaviour of the laminar region in 14 young subjects over 24h. Significant changes in LCT were observed, depending on the time at which the measurement was taken, with the maximum thickness being observed at 7.30 p.m., and the minimum at 7.30 a.m. This finding could suggests a circadian pattern in the LCT thickness in healthy subjects, which could have implications for the classification, diagnosis and prognosis of both normal and glaucomatous subjects.

Inter-rater reliability of clinical mobility measures in ankylosing spondylitis

BACKGROUND

Several measurements are often used in daily clinical practice in the assessment of Ankylosing Spondylitis (AS) patients. The Assessment in SpondyloArthiritis International Society (ASAS) recommend in its core set: chest expansion modified Schöber test, Occiput to wall distance, lateral lumbar flexion, cervical rotation and The Bath Ankylosing Spondylitis Metrology Index (BASMI). BASMI also includes five measurements, some of them recommended by ASAS. Three versions of BASMI have been published with different scales and intervals for each component of the index. Though studies about reliability of these measurements are needed. The aim of this study was to analyze inter-rater reliability of recommended spinal mobility measures in AS.

METHODS

We examined reproducibility of spinal mobility measurements on 33 AS patients performed by two experienced rheumatologists in the same day. Descriptive statistics, Intraclass Correlation Coefficients (ICC), and Smallest Detectable Difference (SDD) using the Bland-Altman criteria were obtained for all the measurements.

RESULTS

Chest expansion showed the lowest value of ICC (0.66) and occiput-wall the highest (0.97). SDD was 2.43 units for BASMI2 and 1.27 units for BASMI10.

CONCLUSIONS

Reliability according to ICC was moderate to high in all measurements. BASMI10, instead BASMI2, must be used: measurements used to calculate are the same but there is better reliability. Inter-rater variation, expressed as SDD, must be taken in account: smaller improvements do not demonstrate the efficacy of treatment because they can be due to experimental error and not to the treatment itself.

Assessment of Fatigue in Spondyloarthritis and Its Association with Disease Activity

Objective.

To evaluate fatigue in patients with spondyloarthritis (SpA) and to define its association with disease-related factors and patients’ features.

Methods.

A cross-sectional multicenter study which includes 2251 patients with SpA selected from the national Spondyloarthropathies Registry (the Spanish Society of Rheumatology; REGISPONSER) Spanish cohort. The primary outcome was the assessment of fatigue performed with the first item of the Bath Ankylosing Spondyloarthritis Disease Activity Index followed by the study of its relation with different factors organized into 4 groups: sociodemographics, emotional, disease-related, and disease activity. Univariate logistic regressions, multivariate logistic regression, and multiple linear regressions were performed to relate fatigue with the studied covariates.

Results.

Mean fatigue score in all patients with SpA was 4.3 ± 2.9, with statistically significant differences between different SpA types. In univariate logistic regressions, significant differences were seen for many variables included in the 4 groups. Multivariate logistic regression showed that high fatigue score was related with sex (female), emotional component, the Ankylosing Spondylitis Quality of Life score, stiffness, and high levels of 2 visual analog scale items (vertebral pain in the last week and patient’s global assessment of disease activity). The multivariate linear regression showed that fatigue was mainly explained by disease-related factors and disease activity (54.1%), but sex and emotional status may also be involved in 13.5% of the variance.

Conclusion.

Fatigue is associated with disease-related factors and mostly with SpA activity. However, the emotional component and sex may contribute to the onset of fatigue.

Impact of 3D vision on mental workload and laparoscopic performance in inexperienced subjects

OBJECTIVE

To assess the effect of vision in three dimensions (3D) versus two dimensions (2D) on mental workload and laparoscopic performance during simulation-based training.

MATERIALS AND METHODS

A prospective, randomized crossover study on inexperienced students in operative laparoscopy was conducted. Forty-six candidates executed five standardized exercises on a pelvitrainer with both vision systems (3D and 2D). Laparoscopy performance was assessed using the total time (in seconds) and the number of failed attempts. For workload assessment, the validated NASA-TLX questionnaire was administered.

RESULTS

3D vision improves the performance reducing the time (3D = 1006.08 ± 315.94 vs. 2D = 1309.17 ± 300.28; P < .001) and the total number of failed attempts (3D = .84 ± 1.26 vs. 2D = 1.86 ± 1.60; P < .001). For each exercise, 3D vision also shows better performance times: "transfer objects" (P = .001), "single knot" (P < .001), "clip and cut" (P < .05), and "needle guidance" (P < .001). Besides, according to the NASA-TLX results, less mental workload is experienced with the use of 3D (P < .001). However, 3D vision was associated with greater visual impairment (P < .01) and headaches (P < .05).

CONCLUSION

The incorporation of 3D systems in laparoscopic training programs would facilitate the acquisition of laparoscopic skills, because they reduce mental workload and improve the performance on inexperienced surgeons. However, some undesirable effects such as visual discomfort or headache are identified initially.

Prognostic value of microvascular invasion in predicting survival in renal cell carcinoma

OBJECTIVE

To assess microvascular tumor invasion and other clinical and histological parameters as potential prognostic factors in surgically treated renal cell carcinoma.

MATERIALS AND METHODS

Surgical specimens from 238 consecutive patients who underwent radical or partial surgery between 1990 and 2006 were retrospectively evaluated. The series included clinically localized or metastatic renal cell carcinoma (pT1-4; N0-1; M0-1). Disease-free and cancer-specific survival assessments were the end points with median follow-up of 75 months (range 1-189 months). Variables studied included: age, sex, tumor size, TNM 2010 classification, Fuhrman grade, histological subtype and microvascular tumor invasion.

RESULTS

Microvascular tumor invasion was observed in 79 patients (33,2%) and was significantly associated with age (P=.010), tumor size (P=.000), Fuhrman grade (P=.000), pT stage 2010 (P=.000),N stage 2010 (P=.000) and M stage 2010 (P=.000). Multivariate analyses determined that sex, Fuhrman grade, pT stage 2010 and histological subtipe were independent prognostic factors of disease-free survival, while sex, Fuhrman grade, pT stage 2010, M stage 2010, histological subtype and microvascular invasion were prognostic factors for cancer-specific survival.

CONCLUSIONS

Our study shows that microvascular tumor invasion is an independent prognostic factor for cancer-specific survival in surgically treated patients with renal cell carcinoma.