Radiologic features of DISH may mimic ankylosing spondylitis.

Intervertebral bony bridging and enthesopathy can occur in both diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) and we have seen difficulties in the radiological differentiation between them. We describe 6 patients selected because the bridges resembled syndesmophytes and this initially suggested a diagnosis of AS, although other considerations showed them to be part of the radiologic picture of DISH. The previously reported suggestions of the coexistence of DISH and AS are reviewed.

Research in rheumatology: a six-month review of selected medical journals.

Research in rheumatology has dramatically increased in the past decades, and researchers can choose among over 20,000 journals to publish their findings. The purpose of this study was to examine the current extent and impact of rheumatological research on the medical literature. The tables of contents of 1,158 biomedical journals were analyzed during a 6-month period and those with a rheumatology-related title were selected. In total, 2,549 articles from 406 journals were related to rheumatology. The 10 rheumatology journals selected for the analysis contained 769 articles (30% of the total); thus, over two-thirds of the information on rheumatology topics was provided by non-rheumatology journals. Over 65 different journals included information about rheumatoid and systemic lupus erythematosus. It is concluded that research in rheumatology is extensive and widespread. Since articles in rheumatology are scattered over a variety of journals, it is suggested that the periodic publication of a rheumatology reference index may assist rheumatologists in updating information from various sources.

[The "Hospital Real de San Josef de los Naturales" and the rheumatic conditions found in New Spain during the 16th century]. / L'"Hospital Real de San Josef de los Naturales" e le malattie reumatiche nella Nueva España (Messico) durante il XVI secolo.

The rheumatic conditions found in New Spain during the sixteenth century were not different from those seen in Mexico in present times. We present the humoral conceptions on which medical theory was based in those times, and the contributions made by Alonso López de Hinojosos during his practice in the Hospital Real de San Josef de los Naturales, in Mexico City. Among them were the clinical distinction between gout and rheumatoid arthritis more than one hundred years before Sydenham, and the identification of arthritis and ocular involvement associated with a contagious disease more than three hundred years before Reiter. We conclude that the analysis of ancient medical traditions is an interesting and fruitful enterprise.

Performance of online biomedical databases in rheumatology.

OBJECTIVE: To compare the performance of MEDLINE, EMBASE, and BIOSIS in selected rheumatology topics. METHODS: Online literature searches were conducted with regard to the epidemiology of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and ankylosing spondylitis (AS), as well as for 3 specific questions representing clinical, clinical/laboratory, and therapeutic topics in rheumatology. Total number of citations retrieved, type and language of publication, percentage of contribution from rheumatology journals, and degree of overlap among the databases were recorded. Publications retrieved for the 3 specific questions were also graded for relevance. RESULTS: For 1991, each online biomedical database (OBD) retrieved more than 1,100 citations for RA, over 600 for SLE, and over 110 for AS. For the epidemiology subtopic, fewer than 25% of the citations were retrieved by more than one of the databases. About 3/4 of the citations obtained for the specific search questions were retrieved by a single database. No major differences were observed among databases in relation to number of relevance of citations retrieved. Over 60% of the papers assessed had low relevance in relation to the topic of the search. Efficiency was estimated as the percentage of all relevant citations retrieved by each OBD. Results varied according to the topic, but in most cases each database retrieved at least 50% of the relevant citations. About 45% of the citations retrieved for the 3 search questions were published in nonrheumatology journals. CONCLUSION: No database was superior in all respects. The majority of the citations were retrieved by a single database. A high percentage of the articles retrieved were not relevant, implying low specificity. If a comprehensive online search in rheumatology is required, 2 or more databases should be utilized.

The first descriptions of therapeutic arthrocentesis: a historical note.

The existence of synovial fluid has been known since Hippocratic times. The abnormal accumulation of liquid inside the joints has been recognized as the proximal cause of rheumatic diseases since humoral theory was the dominant paradigm in Occidental medical culture. Although evacuating the excess of the abnormal humour was the target of all therapeutic measures taken during this era, no mention of arthrocentesis is found in Occidental medical texts until 1652. We present two earlier indications of arthrocentesis to treat abnormal accumulation of liquid inside the joints. One in the Codex Badianus, an Aztec manuscript written in the 16th century, and the other in the Tractado breve de medicina, published in Mexico in 1592.

Two year followup of anterior and vertical atlantoaxial subluxation in ankylosing spondylitis.

OBJECTIVE: To describe the clinical and radiological 2-yr followup of 22 patients with anterior atlantoaxial subluxation (AAS) from a prospective cohort of patients with ankylosing spondylitis. METHODS: The 2-yr assessment included a structured questionnaire for rheumatologic and neurologic complaints and lateral cervical radiographs in maximal flexion view. Initial and 2-yr radiographs were assessed blind to patient data. The course of anterior AAS was classified as unchanged (< 1 mm), progression (> or = 1 mm) or regression (> or = 1 mm) at 2 yrs compared with baseline. Vertical AAS was classified using the Sakaguchi-Kauppi method. Magnification factor was corrected using the ratio of C3 width. RESULTS: Anterior AAS was detected in 22 patients at baseline examination. Two patients also had vertical AAS; 86% were male. Mean age was 33 +/- 9 yrs and mean disease duration was 12 +/- 7 yrs. At followup, one patient had died of acquired immunodeficiency syndrome, 3 could not be reached, and 2 had undergone surgical fusion due to severe myelopathy and now showed complete neurological recovery. Of the remaining 16 patients, 7 (32%) showed progression and 9 (41%) showed no change in the C1-odontoid distance. Vertical AAS developed in one patient. After the 2-yr assessment, 3 additional patients had surgical fusion because of notable progression of AAS, despite absence of neurological signs. CONCLUSION: Anterior AAS progressed in a number of these patients in the 2 yrs following its detection, and with or without neurological signs, surgical management was thought appropriate in a considerable number of them.

Temporomandibular joint osseous morphology in a consecutive sample of ankylosing spondylitis patients.

OBJECTIVE: To evaluate temporomandibular joint (TMJ) osseous morphology in a consecutive sample of Mexican patients with ankylosing spondylitis. METHODS: Consecutive patients with a diagnosis of ankylosing spondylitis who attended two secondary care outpatient rheumatology clinics were included in the study. Patients had a rheumatological assessment using a structured questionnaire and examination. Recorded variables included demographic data, disease characteristics, TMJ symptoms, and axial mobility measurements. Hypocycloidal tomography of the TMJ was obtained on all subjects. Radiographic variables included condyle position, superior joint space, range of movement, condylar osseous changes, and temporal osseous changes. Patients also underwent standard cervical spine radiography. A control group of normal people without either TMJ symptoms or systemic rheumatic disease was obtained. RESULTS: 65 subjects were studied (65 right sided and 63 left sided tomograms). The control group consisted of 22 individuals. Both groups were similar in age [33 (SD 11) v 34 (9) years, P = 0.8]. Patients with ankylosing spondylitis had more variability in TMJ mobility than controls (P < 0.05) and showed increased frequency of condylar erosions (P < 0.01), flattening (P < 0.01), sclerosis (P < 0.01), and temporal flattening (P < 0.01). Condylar erosions were associated with longer duration of ankylosing spondylitis (P < 0.05), neck complaints (P < 0.05), and atlantoaxial subluxation (P < 0.05). CONCLUSIONS: TMJ involvement is frequent in this population of patients with ankylosing spondylitis and is associated with variables that suggest more severe disease.

Magnetic resonance changes in the temporomandibular joint in ankylosing spondylitis.

OBJECTIVE: To evaluate temporomandibular joint (TMJ) involvement of patients with severe ankylosing spondylitis (AS) using magnetic resonance imaging (MRI). METHODS: All patients with severe cervical involvement, defined as occiput-wall distance > or = 3 cm and/or < 10 degrees of cervical flexion, from a consecutive cohort of 103 patients with AS were included in the study. Patients completed a questionnaire designed to evaluate symptoms of temporomandibular disorder (TMD). Open and closed mouth sagittal T1 weighted MRI sequences of the right TMJ was performed in all patients. MR images were specifically reviewed for condylar position and morphology, as well as articular disc position and morphology. RESULTS: Eleven patients were identified and included in the study. Temporomandibular symptoms were absent in 4 (37%), a single symptom was present in one (9%), 2 symptoms in one (9%), 3 symptoms in 3 (27%), and 4 symptoms in 2 (18%). Ten of the 11 patients had abnormalities on MR, including condylar alterations such as abnormal shape, erosions, and reduction in translation. Disc alterations were present in 8 patients and osteophytes in 7. Two patients were graded as having mild abnormalities, another 2 as moderate, and the remaining 6 were considered grossly abnormal. In 2 patients there were changes compatible with ankylosis of the right TMJ. CONCLUSION: Although it is uncommon for patients to complain spontaneously about TMD symptoms, involvement of the TMJ in patients with severe AS appears to be frequent and, in some, severe. The effect of TMJ involvement on the overall well being and nutritional status in patients with AS remains to be determined.

Frequency of atlantoaxial subluxation and neurologic involvement in patients with ankylosing spondylitis.

OBJECTIVE: To determine the prevalence of anterior and vertical atlantoaxial subluxation (AAS) and its neurological effect in a consecutive sample of Mexican patients with ankylosing spondylitis (AS). METHODS: Consecutive patients with a diagnosis of AS who attended 2 secondary care outpatient rheumatology clinic in the city of Guadalajara within a period of 6 mo were included in the study. Patients had prospective rheumatologic and neurologic assessments using structured questionnaires and examinations. Recorded variables included demographic data, disease characteristics, neurologic symptoms and signs, and axial mobility measurements. Somatosensory evoked potentials (SSEP) were performed in all patients. Patients also underwent standard cervical spine radiography with anteroposterior open mouth, and neutral, full flexion and extension lateral views. RESULTS: We studied 103 patients. Mean age was 35 yrs, 74% were male, and mean disease duration was 10 yrs (S/- SD 7.9). Anterior AAS was observed in 22 patients (21%, 95% CI 13-29%) and vertical AAS in 2 cases (2%, 95% CI 0-7%). Ossification of the posterior longitudinal ligament (OPLL) was present in 16 patients. Statistically significant associations were observed between anterior AAS and SSEP (p < 0.0001) and OPLL (p = 0.04). The degree of radiologic sacroiliitis was also associated with anterior AAS. After completion of the study, 2 patients required surgical fusion due to severe cervical cord compression. CONCLUSION: The prevalence of AAS and OPLL in this population was higher than previously reported in other settings. The association of anterior AAS with OPLL and radiological sacroiliitis could identify a subgroup of patients with more severe axial enthesopathy. Although clinically significant neurologic complications are not frequent in these patients, AAS may cause severe spinal cord compression requiring surgical fusion.

Ossification of the posterior longitudinal ligament in three geographically and genetically different populations of ankylosing spondylitis and other spondyloarthropathies.

STUDY DESIGN: Cross sectional. RESEARCH QUESTIONS: (a) Is any clinical variable of ankylosing spondylitis (AS) associated with the presence of ossification of the posterior longitudinal ligament (OPLL)? and (b) Is OPLL present in patients with AS from different geographical or genetic backgrounds? METHODS: Three groups were assembled: (1) a prospective group of 103 consecutive AS patients from two community based rheumatology clinics from Guadalajara, who were evaluated using: a questionnaire with disease characteristics variables; clinical assessment by a neurologist; lateral radiographic views of the cervical spine and somatosensory evoked potentials (SSEP). (2) Fifty one spondyloarthropathies (SpA) patients from Mexico city whose cervical spine films were retrospectively reviewed. (3) Thirty nine AS patients from Edmonton, Canada whose cervical spine films were retrospectively reviewed and compared with 72 controls. RESULTS: Group 1: 74% of the 103 patients were men and 86% were HLA-B27 positive. The mean age was 35 years, and mean (SD) disease duration 10 (8) years. OPLL was reported in 16 patients (15.5%; 95% CI 9, 22). OPLL was statistically associated with older age (p = 0.001), longer disease duration (p = 0.001), clinical myelopathy (p = 0.03), worst functional index (p = 0.042), restricted axial movement measurements (all p < 0.001), radiological sacroilitis (p < 0.001 for linear association), osteitis pubis (p = 0.009), hip involvement (p = 0.006 for linear association), and abnormal SSEP (p = 0.008). Group 2: 92% of 51 patients were men; the mean age was 30 years and the mean (SD) disease duration 11 (7) years. OPLL was reported in 15 (29%, 95% CI 17, 41) patients (nine AS, two psoriatic arthritis, three juvenile AS, and one Reiter's syndrome). Group 3: 95% of the 39 patients were men; the mean of age was 46 years and disease duration of 18 (10) years. OPLL was reported in nine (23%; 95% CI 10, 36) patients, including one with psoriatic arthritis, and two with Crohn's disease. OPLL was observed in two of the control group. CONCLUSIONS: The prevalence of OPLL in AS and SpA is higher than previously recognised and seems to be associated with variables identifying more severe axial disease.