The performance of psoriatic arthritis classification criteria in Turkish patients with psoriatic arthritis.

OBJECTIVES: To investigate performance of some of the published psoriatic arthritis (PsA) classification criteria as well as Assessment of Spondyloarthritis International Society (ASAS) criteria for peripheral spondyloarthritis (SpA) in Turkish patients with PsA (in early and late disease subgroups). METHODS: Patients were recruited using case report forms and physical examination methods proposed by the Anatolian Group for the Assessment in Rheumatic Diseases (ANGARD). The Moll and Wright (MW), modified Fournie (MF), modified McGonagle (mMG), Vasey and Espinoza (VE), classification of PsA (CASPAR) criteria and ASAS criteria were assessed in patients with PsA who were diagnosed based on expert opinion. RESULTS: One hundred and twenty-eight patients with PsA (58 male, 70 female, mean age 41.8 years) were included. Thirty patients were in the early PsA and 98 patients were in the late PsA groups. Diagnostic delay was 2.6 years. In the 15.6% of patients arthritis developed before the skin findings. The proportion of patients fulfilling the MW, MF, mMG, VE, CASPAR and ASAS criteria were at a ratio of 90.6%, 82.8%, 62.5%, 84.4%, 96.1% and 76.5%, respectively. In early PsA (< 12 months disease duration) the proportions were 93.4%, 83.3%, 76.7%, 76.7%, 96.7% and 66.6%, respectively. On the other hand, in late PsA the proportions were 89.8%, 82.6%, 57.1%, 86.7%, 95.9%, 79.5%, respectively. CONCLUSIONS: Even though the sensitivity of PsA classification criteria in Turkish patients changes, the CASPAR criteria seems to be more prominent among all criteria for both early and late cases with its high sensitivity.

Evidence-based algorithm for diagnosis and assessment in psoriatic arthritis: results by Italian DElphi in psoriatic Arthritis (IDEA).

Psoriatic arthritis (PsA) is a chronic inflammatory disease involving skin, peripheral joints, entheses, and axial skeleton. The disease is frequently associated with extrarticular manifestations (EAMs) and comorbidities. In order to create a protocol for PsA diagnosis and global assessment of patients with an algorithm based on anamnestic, clinical, laboratory and imaging procedures, we established a DElphi study on a national scale, named Italian DElphi in psoriatic Arthritis (IDEA). After a literature search, a Delphi poll, involving 52 rheumatologists, was performed. On the basis of the literature search, 202 potential items were identified. The steering committee planned at least two Delphi rounds. In the first Delphi round, the experts judged each of the 202 items using a score ranging from 1 to 9 based on its increasing clinical relevance. The questions posed to experts were How relevant is this procedure/observation/sign/symptom for assessment of a psoriatic arthritis patient? Proposals of additional items, not included in the questionnaire, were also encouraged. The results of the poll were discussed by the Steering Committee, which evaluated the necessity for removing selected procedures or adding additional ones, according to criteria of clinical appropriateness and sustainability. A total of 43 recommended diagnosis and assessment procedures, recognized as items, were derived by combination of the Delphi survey and two National Expert Meetings, and grouped in different areas. Favourable opinion was reached in 100% of cases for several aspects covering the following areas: medical (familial and personal) history, physical evaluation, imaging tool, second level laboratory tests, disease activity measurement and extrarticular manifestations. After performing PsA diagnosis, identification of specific disease activity scores and clinimetric approaches were suggested for assessing the different clinical subsets. Further, results showed the need for investigation on the presence of several EAMs and risk factors. In the context of any area, a rank was assigned for each item by Expert Committee members, in order to create the logical sequence of the algorithm. The final list of recommended diagnosis and assessment procedures, by the Delphi survey and the two National Expert Meetings, was also reported as an algorithm. This study shows results obtained by the combination of a DElphi survey of a group of Italian rheumatologists and two National Expert Meetings, created with the aim of establishing a clinical procedure and algorithm for the diagnosis and the assessment of PsA patients. In order to find accurate and practical diagnostic and assessment items in clinical practice, we have focused our attention on evaluating the different PsA domains. Hence, we conceived the IDEA algorithm in order to address PsA diagnosis and assessment in the context of daily clinical practice. The IDEA algorithm might eventually lead to a multidimensional approach and could represent a useful and practical tool for addressing diagnosis and for assessing the disease appropriately. However, the elaborated algorithm needs to be further investigated in daily practice, for evidencing and proving its eventual efficacy in detecting and staging PsA and its heterogeneous spectrum appropriately.

Patient's Global Assessment as an Outcome Measure for Psoriatic Arthritis in Clinical Practice: A Surrogate for Measuring Low Disease Activity?

OBJECTIVE: To assess the low disease activity (LDA) in a group of patients with psoriatic arthritis (PsA) receiving antitumor necrosis factor-α (TNF-α) by using the patient's global assessment (PtGA) in clinical practice, and to compare PtGA with minimal disease activity (MDA) and other outcome measures. METHODS: Patients with PsA classified by the ClASsification for Psoriatic ARthritis (CASPAR) criteria and consecutively admitted to an outpatient clinic dedicated to biologic therapy were assessed during their routine followup. The primary outcome measure was the proportion of patients achieving a PtGA ≤ 20 at 4-, 8-, and 12-month followups. Secondary outcome measures included the proportion of patients achieving MDA and other outcome measures. Correlation of PtGA with MDA and other process and outcome measures were also performed. RESULTS: During the period of observation, 124 patients were evaluated. PtGA ≤ 20 was achieved in 25.7% at 4 months, 48.9% at 8 months, and 65.3% at 12 months of followup. The percentage of PtGA ≤ 20 statistically improved throughout the 3 timepoint assessments and it was statistically correlated to MDA. A significant correlation with the Disease Activity index for PSoriatic Arthritis (DAPSA), Bath Ankylosing Spondylitis Disease Activity Index, and Health Assessment Questionnaire was also observed. MDA, DAPSA, and Disease Activity Score at 28 joints with C-reactive protein remission were achieved at 12 months in 64%, 36%, and 71% of patients, respectively. CONCLUSION: PtGA can estimate the LDA status and could be considered as a surrogate of outcome measures for the assessment of global disease activity in patients with PsA receiving anti-TNF therapy during routine clinical practice. These data suggest that PtGA might be used in outpatient settings, being a simple, reliable, and not time-consuming instrument.

Classification and clinical assessment.

There are at least nine classification criteria for psoriatic arthritis (PsA) that have been proposed and used in clinical studies. With the exception of the ESSG and Bennett rules, all of the other criteria sets have a good performance in identifying PsA patients. As the CASPAR criteria are based on a robust study methodology, they are considered the current reference standard. However, if there seems to be no doubt that they are very good to classify PsA patients (very high specificity), they might be not sensitive enough to diagnose patients with unknown early PsA. The vast clinical heterogeneity of PsA makes its assessment very challenging. Peripheral joint involvement is measured by 78/76 joint counts, spine involvement by the instruments used for ankylosing spondylitis (AS), dactylitis by involved digit count or by the Leeds dactylitis index, enthesitis by the number of affected entheses (several indices available) and psoriasis by the Psoriasis Area and Severity Index (PASI). Peripheral joint damage can be assessed by a modified van der Heijde-Sharp scoring system and axial damage by the methods used for AS or by the Psoriatic Arthritis Spondylitis Radiology Index (PASRI). As in other arthritides, global evaluation of disease activity and severity by patient and physician and assessment of disability and quality of life are widely used. Finally, composite indices that capture several clinical manifestations of PsA have been proposed and a new instrument, the Psoriatic ARthritis Disease Activity Score (PASDAS), is currently being developed.

Clinical assessment and outcome research in spondyloarthritis.

Spondyloarthritis (SpA; formerly called seronegative arthritis) generally follows a chronic course with an uncertain outcome and includes diseases, such as ankylosing spondylitis and psoriatic arthritis, that require regular medical care and monitoring to control for disease activity and maintain physical function. This article describes recent achievements in the field of clinical outcome assessment, imaging, and the classification of patients with SpA symptoms. Clinical instruments are addressed that measure function, disease activity, and pain through questionnaires, physical examination, and laboratory tests. Furthermore, the value of different imaging techniques for daily practice is described, and the new classification criteria for axial SpA are discussed.

Radiography in the assessment of musculoskeletal conditions.

Plain film radiography is the most widely used imaging technique for diagnosing and monitoring the progression of chronic inflammatory and degenerative joint diseases. Advanced imaging techniques that are better suited for detecting soft-tissue inflammation are available, but they are more costly and some of them may expose the patient to higher doses of radiation. Plain film radiographs are inexpensive, easy to generate, can be compared with baseline and prospective films, and provide a permanent, reproducible record. Radiographs can easily detect the features that are specific to various rheumatological disorders, and serial radiography can be used to assess response to therapy by measuring erosions, joint space narrowing, and other disease-specific features. This chapter discusses the use of radiography for diagnosing and differentiating various rheumatic joint diseases, specifically rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and osteoarthritis. The most frequently used scoring systems that are used to assess and monitor the severity and progression of these disorders are briefly described.

[Expert assessment of patients with seronegative spondyloarthropathies]. / Begutachtung von Patienten mit seronegativen Spondylarthropathien.

Besides rheumatoid arthritis, seronegative spondyloarthropathies are one of the most common inflammatory musculoskeletal diseases. The main clinical manifestations are spondylitis and sacroiliitis, but peripheral arthritis and involvement of other organ systems are known as well. The typical ankylosis of the spine is resulting in a marked loose of the functional capacity. During the course of disease, work disability is progressing and finally the patient may become permanent disabled. Patients with ankylosing spondylitis can be viewed by experts for several reasons. To guarantee an objective medical expert view, a detailed clinical examination and use of clinical indices are mandatory.