CHRONIC MULTIMORBIDITY OF LOW BACK PAIN OR OTHER CHRONIC BACK DISORDERS IN THE REPUBLIC OF CROATIA.

The aim was to assess the prevalence of chronic multimorbidity in patients with chronic low back pain or other chronic back disorders (BD). We analyzed data from the population-based cross-sectional European Health Interview Survey (EHIS) performed in the Republic of Croatia 2014-2015 by the Croatian Institute of Public Health. Outcome was the point-prevalence of chronic multimorbidity defined as having ≥2 chronic illnesses out of 14 contained in the EHIS questionnaire, after adjustment for ten sociodemographic, anthropometric and lifestyle confounders. Amoung fourteen targeted illnesses were asthma, allergies, hypertension, urinary incontinence, kidney diseases, coronary heart disease or angina pectoris, neck disorder, arthrosis, chronic obstructive pulmonary disease, diabetes mellitus, myocardial infarction, stroke, depression, and the common category "other". We analyzed data on 268 participants with BD and 511 without it. Participants with BD had a significantly higher relative risk of any chronic multimorbidity (RRadj=2.12; 95% CI 1.55, 2.99; p<0.001), as well as of non-musculoskeletal chronic multimorbidity (RRadj=2.29; 95% CI 1.70, 3.08; p=0.001) than participants without BD. All chronic comorbidities except for asthma and liver cirrhosis were significantly more prevalent in participants with BD than in participants without BD. In the population with BD, the participants with multimorbidity had three to four times higher odds for unfavorable self-reported health outcomes than the participants with no comorbid conditions, whereas the existence of only one comorbidity was not significantly associated with a worse outcome compared to the population with no comorbidities. In conclusion, the population suffering from BD has a higher prevalence of chronic multimorbidity than the population without BD and this multimorbidity is associated with unfavorable health outcomes.

Lower concentration of vitamin D is associated with lower DAS28 and VAS-pain scores in patients with inflammatory rheumatic diseases treated with infliximab: a pilot study.

Vitamin D is beneficial in patients with immune-mediated rheumatic diseases as it has been shown that it lowers the incidence risk and the level of inflammation. To examine the association between clinical outcomes and initial 25-hydroxyvitamin D [25(OH)D] concentrations in patients with the immune-mediated rheumatic diseases treated with infliximab for 9 months. This study was performed in patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) treated with infliximab for at least 38 weeks. Disease activity was assessed using Disease Activity Score (DAS28) for RA and PsA and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for AS, while the global assessment was performed using the Visual Analogue Scale (VAS). Patients were divided into 2 groups according to 25(OH)D concentration which was classified as deficient or non-deficient (below and above 50 nmol/L, respectively). Concentrations of infliximab (IFX) and C-reactive protein (CRP) were measured according to the manufacturer's instructions.This study was performed in patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) treated with infliximab for at least 38 weeks. Disease activity was assessed using Disease Activity Score (DAS28) for RA and PsA and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for AS, while the global assessment was performed using the Visual Analogue Scale (VAS). Patients were divided into 2 groups according to 25(OH)D concentration which was classified as deficient or non-deficient (below and above 50 nmol/L, respectively). Concentrations of infliximab (IFX) and C-reactive protein (CRP) were measured according to the manufacturer's instructions. The study included 23 patients (14 with RA, 6 with AS and 3 with PsA), median age 54 years, 15 females. Vitamin D deficient and non-deficient groups had median initial concentrations of 38 and 61 nmol/L, respectively. DAS28 and pain on VAS calculated at the 2nd and 38th week showed a statistically significant decrease only in RA and PsA patients with vitamin D deficiency (P = 0.02 and 0.06, respectively). Lower initial concentration of 25(OH)D in patients treated with infliximab was associated with better improvement of clinical measures (DAS28 and VAS) of disease after 9 months of therapy.

[VAGAL NERVE STIMULATION IN THE TREATMENT OF PATIENTS WITH RHEUMATOID ARTHRITIS ­ RESULTS THROUGH DAY 84 OBTAINED AT THE CROATIAN CENTER OF AN INTERNATIONAL PILOT STUDY].

Objective: Electrical stimulation of the vagus has proven effective in various inflammatory conditions in animal models. The aim of this study is to show the effect of vagal nerve neurostimulation on clinical and laboratory parameters in two patients with active rheumatoid arthritis (RA) and an inadequate response to methotrexate. Patients and methods: The research was conducted as part of an international pilot study. Patients were implanted with the Cyberonics system for electrical stimulation of the vagus. After an initial in-clinic stimulation, the patients performed the stimulations at home for 42 days, when the device was inactivated. On day 56 the stimulations were reinitiated. The following parameters were evaluated: tender and swollen joint count, physician's (PGA) and patient's (PtGA) global score, intensity of pain, disease activity (DAS28), functional ability (HAQ), serum CRP level, and EULAR response. Results: In the period from the screening visit to the day 42 visit, both patients experienced an improvement of DAS28 (7.00 and 6.22 vs. 4.03 and 2.13), PGA (70 and 53 vs. 27 and 16), PtGA (48 and 43 vs. 15 and 14), tender joint count (26 and 28 vs. 4 and 0), swollen joint count (24 and 14 vs. 8 and 2), intensity of pain (72 and 87 vs 21 and 7), HAQ score (2.25 and 2.25 vs. 1.5 and 1.375), and CRP levels (23.8 and 5.58 vs. 13 and 4.61). After the device deactivation, DAS28 and VAS pain worsened in both patients. Conclusion: Vagal neural stimulation in the treatment of patients with active RA and an inadequate response to methotrexate is effective in reducing clinical symptoms and parameters of inflammation. Our results are in accordance with the results obtained in other centers. Research on a larger number of subjects is necessary for a better evaluation of the effect of this new approach to the treatment of patients with rheumatoid arthritis.

[Controlled-release oxycodone in the treatment of chronic musculoskeletal pain: A preliminary experience of rheumatology center].

In the etiology of non-malignant pain, a significant proportion is constituted by patients with pain originating in the musculoskeletal system. The use of strong opioids in the treatment of non-malignant pain is still controversial. Therefore, the aim of this study was to establish the efficacy and safety of oxycodone with a controlled release of the active substance (CR) in the treatment of patients with chronic, not well-controlled musculoskeletal pain. Here we present our preliminary results. In this prospective, open, single-center study conducted at a rheumatology center we enrolled consecutive patients with musculoskeletal pain due to a variety of musculoskeletal diseases (osteoarthritis, pain in the lower back, spondyloarthritis), who suffered from moderate to severe pain despite previous analgesic therapy (with NSAIDs, weak opioids, or a fixed combination of paracetamol and weak opioids). Patients were switched to therapy with oxycodone CR and followed for 14 days. The starting dose of oxycodone CR was 10 mg, and later the dose was adapted as necessary. The primary endpoint was to assess the effectiveness of oxycodone CR on pain intensity, and the secondary goal was to assess the efficiency on the general health of the patient (both on a horizontal visual analogue scale, VAS 0 = best, 10 = worst). Fifteen patients (12 women, 3 men), with a mean age of 61 ± 12 years and a diagnosis of osteoarthritis, pain in the lower back, or inflammatory arthritis, were included in the study. The duration of pain was 41 ± 12 months. The average intensity of pain before oxycodone CR treatment was 7.87 ± 2.28 (range 7-10), and at the end of the study it was 5.92 ± 2.43 (range 4-9) (p=0.069). General health was rated 7.27 ± 2.14 (range 3-10) before the start and 6.00 ± 1.53 (range 3-9) at the end of the study (p=0.028). In one patient the treatment was discontinued due to dizziness and nausea, and one patient voluntarily left the study because of fear and the subjective impression of no adequate pain control after 2 days of treatment. The oxycodone side-effect profile was as expected. Results of our preliminary study show that in patients with chronic non-malignant pain which is not well controlled by simple analgesics, NSAIDs, and weak opioids, treatment with oxycodone CR contributed to a significant reduction in the level of pain and improved the general health of the subjects.

Advanced Clinical and Radiological Features of Ankylosing Spondylitis: Relation to Gender, Onset of First Symptoms and Disease Duration.

To determine the frequency of advanced clinical and radiological features of AS with reference to gender, onset of symptoms and disease duration. Fifty-seven patients diagnosed with AS were included in this study. Functional evaluation of the musculoskeletal system detected advanced clinical features: rubber-ball phenomenon, flattening of the chest anterior wall, diastasis of rectus abdominis muscle, steel back phenomenon, umbilical extrusion, skiing posture. Conventional radiographs of sacroiliac joints, pelvis and axial skeleton were obtained in order to analyze signs of sacroiliitis, syndesmophytes, vertebral squaring and ligamentous ossification. Statistical significance is found in the distribution of particular advanced clinical and radiological features of AS between men and women: rubber-ball phenomenon (p = 0.002), flat chest (p = 0.002), diastasis of rectus abdominis muscle (p = 0.002), skiing position (p = 0.000), syndesmophytes (p = 0.009) and ligamentous ossification (p = 0.030) in thoracic and lumbar spine. Onset of first disease symptoms (> 20 years of age) is significantly associated with radiological changes in thoracic spine (ligamentous ossification, p = 0.015) and cervical spine (vertebral squaring, p = 0.032). Longer disease duration (> 10 years) is significantly associated with the appearance of particular clinical features: rubber-ball phenomenon, p < 0.01; rectus abdominis diastasis, p=0.042) and radiological changes of sacroiliac joints (grade IV sacroileitis, p = 0.012), thoracic and lumbar spine (syndesmophytes, p = 0.015; ligamentous ossification, p = 0.027). Our study shows that the occurrence of clinical and some radiological features of AS appears to be gender dependent. Furthermore, onset of first disease symptoms (> 20 years of age) and longer disease duration (> 10 years) are associated with the higher risk of developing particular clinical signs and radiological features in sacroiliac joints and axial skeleton.

Association of systemic and intra-articular osteoclastogenic potential, pro-inflammatory mediators and disease activity with the form of inflammatory arthritis.

PURPOSE: We aimed to assess osteoclastogenic potential of peripheral blood mononuclear cells (PBMC) and synovial fluid-derived mononuclear cells (SFMC) in different forms of arthritis and to correlate it with inflammatory mediators within intra-articular and circulatory compartments. METHODS: Paired PBMC and SFMC samples of patients with rheumatoid arthritis (RA; n = 10) and psoriatic arthritis (PsA; n = 10), and PBMC of healthy controls were cultured to assess osteoclastogenic potential by the number of tartrate-resistant acid phosphatase (TRAP)-positive osteoclasts (OCs) and expression of OC-related genes (receptor activator of nuclear factor-κΒ (RANK), cFMS, and TRAP). Osteoclastogenesis was correlated with the arthritis-related inflammatory indicators in serum and synovial fluid (SF). RESULTS: Number of OCs differentiated from PBMC was significantly higher in RA and PsA compared with control, with RA having more OCs compared with PsA. There was no difference in SFMC OC number between arthritic patients, but RANK expression in OCs differentiated from SFMC was higher in PsA compared with RA. SF of PsA patients more potently induced OC differentiation from control CD3(-)CD19(-)CD56(-)CD11b(+)CD115(+) PBMC compared with RA, paralleled with higher RANK-ligand expression in PsA SFMC. Positive correlations of OC number with erythrocyte sedimentation rate, serum level of CCL2, and PBMC gene expression of interleukin-18 and Fas-ligand were observed. CONCLUSION: Osteoclastogenic potential is systemically enhanced in patients with RA, paralleled by disordered systemic and local expression of proinflammatory mediators, whereas PsA involves specific deregulation in RANKL/RANK axis. Our study reveals arthritis-specific mediators associated with the form of arthritis, indicating clinical relevance for diagnosis and treatment.

Osteoporosis, spinal mobility and chest expansion index in patients with ankylosing spondylitis.

To determine the correlation between the bone mineral density (BMD) and spinal mobility and chest expansion index in patients with ankylosing spondylitis. Eighty patients with confirmed diagnosis of ankylosing spondylitis were included in this study. In all of them physical examination was performed including assessment of spinal mobility and chest expansion index. Bone mineral density of the lumbar spine (L1-L4, anteroposterior view) and at the left hip was measured by dual X-ray absorptiometry (DXA) in standard manner According to the WHO classification of osteoporosis, patients were classified in three groups (normal, osteopenic or osteoporotic) depending on the osteoporotic status in lumbar spine, hip and femoral neck region. Eighty patients (46 men and 34 women; age 25-73 years) were included. Mean BMD for lumbar spine was 1.104 +/- 1.043 (T score: 0.67 +/- 2.15) and for total hip was 1.057 +/- 0.899 (T score: -0.28 +/- 2.34). Significant difference in the mobility of thoracic spine was observed in patients in regard to the WHO classification of osteoporosis in lumbar and femoral region (p = 0.031, Oneway Anova for osteoporosis of lumbar region; p = 0.022, Oneway Anova for osteoporosis of total hip region). Mean value for the chest expansion index was 3.07 +/- 1.66 cm. Chest expansion index was significantly reduced in patients having osteoporosis in lumbar and total hip region (p = 0.015, Oneway Anova for osteoporosis of lumbar region; p = 0.038, Oneway Anova for osteoporosis of total hip region). The observation that reduced mobility of thoracic and lumbar spine and chest expansion index occured in patients with low BMD in lumbar and total hip region suggest that osteoporosis should be monitored more frequently in patients with AS.

[Therapeutic exercise for patients with chronic low-back pain]. / Medicinske vjezbe za bolesnike s kronicnom krizoboljom.

Low Back Pain (LBP) is a major medical and socio-economical problem in the industrialized countries. Exercise therapy is the keystone of conservative treatment for chronic low back pain (CLBP). Numerous randomized trials and clinical practice guidelines have supported that exercise diminishes disability and pain severity while improving fitness and occupational status in patients with CLBP, as well as decrease its recurrence rate. However, there is no significant evidence that one particular type of exercise is clearly more effective than others. Here we present a descriptive review of different types of exercise for therapeutic or prevention purposes in patients with CLBP. Studies suggest that individually tailored, supervised exercise programs are associated with the best outcomes. High quality clinical trials are needed to determine the effectiveness of specific interventions (type, time, intensity and other characteristics) aimed at individuals and/or specific target groups.

Thoracic manifestations and respiratory function alterations in axial spondyloarthritis and newest possibilities of ultrasound to detect changes in diaphragm-a narrative review.

Background and Objective: Axial spondyloarthritis (axSpA) includes thoracic manifestations and changes in respiratory function that require a comprehensive understanding for effective treatment. This review aims to investigate these manifestations and evaluate the role of ultrasound in detecting diaphragmatic changes to provide insights for improved diagnosis and treatment strategies in axSpA patients. Methods: A systematic search was conducted in Index Medicus and Scopus from 2003 to 2023. Inclusion criteria included primary and secondary publications, with a focus on high-quality evidence such as randomised controlled trials and systematic reviews with or without meta-analysis. Keywords spondyloarthritis, respiratory, chest, thoracic, diaphragm and ultrasound were used in the search. A total of 22 articles were identified after duplicates, and inadequate papers were removed. Key Content and Findings: The review included the prevalence, classification and extra-articular manifestations of axSpA, highlighting the impact on respiratory function. Thoracic manifestations and the potential impact of pharmacological interventions were detailed, and various conditions affecting respiratory dynamics were discussed. In addition, the utility of ultrasonography in assessing diaphragmatic function was explained and the techniques, parameters and measurements used to assess diaphragmatic movement, muscle thickness and respiratory mobility were described. The results illustrate the changes in diaphragmatic function in axSpA patients and their correlation with disease activity. Conclusions: This narrative review highlights the intricate relationship between axSpA and respiratory manifestations and emphasises the significant impact on thoracic function and diaphragmatic dynamics. The utility of ultrasound in assessing diaphragmatic function offers a promising avenue for objective evaluation that provides insight into disease activity and potential therapeutic responses. This review emphasises the critical role of early diagnosis and vigilant monitoring, and advocates a multidisciplinary approach that integrates non-pharmacological interventions, particularly tailored physical activity, to maintain and improve respiratory function in axSpA patients. Increased research initiatives and awareness of pulmonary complications in axSpA are essential to optimise medical care and improve treatment outcomes in this patient group.

Differential expression of proteins with heparin affinity in patients with rheumatoid and psoriatic arthritis: a preliminary study.

OBJECTIVES: Using proteomic approach in this study, we sought to identify proteins with heparin affinity associated with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and non-inflammatory arthritis (NIA). METHODS: Plasma samples from adult RA, PsA and NIA patients, 20 of each, were collected. After enrichment of proteins with heparin affinity, SDS-PAGE and in-gel digestion with trypsin were performed. Peptides were concentrated, micro-purified, separated and measured by nano-scale HPLC system coupled to a mass spectrometer. Peak lists were generated from raw spectra and searched against human complete proteome set by MaxQuant software. Statistical analysis of protein relative expression levels was done in IPython interactive Python shell using NumPy and Matplotlib libraries. Individual protein impact on the whole dataset correlation was done by excluding one protein at a time and calculating the correlation coefficient of remaining data points. RESULTS: Three hundred and eighty-four different proteins were identified keeping false discovery rate to 1%, from which 163 were identified in all three conditions. The plasma proteome showed a good correlation between rheumatoid (RA) and psoriatic arthritis (PsA). Out of 10 proteins whose impact on the correlation coefficient fell outside of two standard deviations from the mean, four were up-regulated (complement factor I, complement component C8 beta, glyceraldehyde-3-phosphate dehydrogenase and inter-alpha-trypsin inhibitor heavy chain H1), and two were down-regulated (immunoglobulin heavy chain V-III region BRO, and immunoglobulin J chain), both in PsA and RA by a similar ratio when compared to NIA. The remaining four proteins (Serpin A11, complement factor H-related protein 5, cartilage acidic protein 1 and coagulation factor IX) were down-regulated in PsA and up-regulated in RA when compared to NIA. CONCLUSIONS: We found differently expressed proteins in patients with inflammatory and non-inflammatory rheumatic conditions. Out of 384 proteins with heparin affinity four proteins should be further validated as potential diagnostic biomarkers in patients with RA and PsA.

Relationship of bone mineral density with disease activity and functional ability in patients with ankylosing spondylitis: a cross-sectional study.

In ankylosing spondylitis, inflammatory activity probably plays a key role in the pathophysiology of bone loss. The aim of the study was to investigate the relationship of bone mineral density (BMD) at the lumbar spine and hip region with some measures of disease activity and functional ability in patients with ankylosing spondylitis. In 80 patients with established ankylosing spondylitis, disease activity and functional ability were determined by C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI). Spinal pain and patient global health were assessed using horizontal visual analog scale. BMD was measured by dual-energy X-ray absorptiometry. There was a significant negative correlation of bone density T scores with acute-phase reactants (i.e., patients with lower T scores had higher level of CRP and ESR). That relationship was reflected more reliably at proximal femur sites than at the lumbar spine. There were also significant differences in ESR, BASDAI, BASFI, spinal pain and global health between three groups of patients according to WHO classification of osteoporosis (normal, osteopenic and osteoporotic). Significantly, more patients with osteopenia at the lumbar spine had lower BASDAI index than those with normal BMD (P = 0.030). Our results indicate an association of low BMD with high disease activity in patients with AS. Femoral BMD seems to be more associated with disease activity and functional ability than lumbar spine BMD.

Which clinical variables have the most significant correlation with quality of life evaluated by SF-36 survey in Croatian cohort of patient with ankylosing spondylitis and psoriatic arthritis?

The aim of our study was to assess clinical variables with the best correlation to quality of life (QOL) assessed by medical outcome survey Short-Form 36 (SF-36) in patients with spondyloarthritides, including ankylosing spondylitis (AS) and psoriatic arthritis (PsA). We analyzed the cohort of 54 patients (22 patients with PsA and 32 patients with AS), who filled the Croatian version of SF-36. For each type of arthritis, patients were clinically evaluated using the extensive list of clinical variables categorized into subjective and objective group. For AS patients, subjective and objective variables (spinal mobility measurements, clinical assessment of spinal pain, patient assessments of disease activity and pain) correlated mainly with the physical functioning concept of SF-36. Patients assessments of fatigue correlated with the energy/fatigue subscale, whereas patient assessment of enthesial pain correlated with the pain subscale. Correlations between clinical variables and SF-36 concepts of PsA patients showed more diverse distribution than for AS. Objective variables (spinal mobility measurements, a 76-joint score, clinical assessment of spinal pain) correlated with concepts concerning physical health and pain. Several subjective patient assessments correlated with energy/fatigue, emotional well-being, pain and general health subscales. Both patient and physician assessment of PsA activity correlated with the role limitations due to emotional problems. Bath ankylosing spondylitis functional index (BASFI) had the strongest correlation with the physical functioning concept of SF-36 in both diseases. Our findings provide important information to help selecting the variables with strongest impact on QOL, for better planning the management strategies and achieving better rehabilitation results.

[Diagnosis and conservative treatment of low back pain: review and guidelines of the Croatian Vertebrologic Society]. / Dijagnostika i konzervativno lijecenje krizobolje: pregled i smjernice Hrvatskog Vertebroloskog Drustva.

Low back pain (LBP) is a very common condition with high costs of patient care. Medical doctors of various specialties from Croatia have brought an up-to-date review and guidelines for diagnosis and conservative treatment of low back pain, which should result in the application of evidence-based care and eventually better outcomes. As LBP is a multifactorial disease, it is often not possible to identify which factors may be responsible for the onset of LBP and to what extent they aggravate the patient's symptoms. In the diagnostic algorithm, patient's history and clinical examination have the key role. Furthermore, most important is to classify patients into those with nonspecific back pain, LBP associated with radiculopathy (radicular syndrome) and LBP potentially associated with suspected or confirmed severe pathology. Not solely a physical problem, LBP should be considered through psychosocial factors too. In that case, early identification of patients who will develop chronic back pain will be helpful because it determines the choice of treatment. In order to make proper assessment of a patient with LBP (i.e. pain, function), we should use validated questionnaires. Useful approach to a patient with LBP is to apply the principles of content management. Generally, acute and chronic LBP cases are treated differently. Besides providing education, in patients with acute back pain, advice seems to be crucial (especially to remain active), along with the use of drugs (primarily in terms of pain control), while in some patients spinal manipulation (performed by educated professional) or/and short-term use of lumbosacral orthotic devices can also be considered. The main goal of treating patients with chronic LBP is renewal of function, even in case of persistent pain. For chronic LBP, along with education and medical treatment, therapeutic exercise, physical therapy and massage are recommended, while in patients with a high level of disability intensive multidisciplinary biopsychosocial approach has proved to be effective.

Is Exercise Beneficial in Patients with Low Back Pain? - A Cochrane Review Summary with Commentary.

The aim of this commentary is to discuss from a rehabilitation perspective the Cochrane Review "Exercise therapy for chronic low back pain" (1) by Hayden JA, Ellis J, Ogilvie R, Malmivaara A and van Tulder MW [1] published by Cochrane Musculoskeletal Group. This Cochrane Corner is produced in agreement with Journal of Rehabilitation Medicine by Cochrane Rehabilitation with views* of the review summary authors in the "implications for practice" section. This summary is based on a Cochrane Review previously published in the Cochrane Database of Systematic Reviews 2021, Issue 9, Art. No.:CD009790, DOI: 10.1002/14651858.CD009790.pub2 (see www.cochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and Cochrane Database of Systematic Reviews should be consulted for the most recent version of the review. * The views expressed in the summary with commentary are those of the Cochrane Corner author (different than the original Cochrane Review authors) and do not represent the Cochrane Library or Journal of Rehabilitation Medicine.

Clinical efficacy and safety of adalimumab versus etanercept in patients with ankylosing spondylitis and total spinal ankylosis in Croatia: a multicentre 12-month follow-up study.

OBJECTIVE: To evaluate the 12-month efficacy and safety profile of adalimumab and etanercept in patients with ankylosing spondylitis (AS) and total spinal ankylosis (TSA). TYPE OF STUDY DESIGN: Case-series follow-up study. DESIGN: Twenty-eight patients (26 men and 2 women) with active AS (BASDAI > 4) and TSA were treated as follows: 19 patients receiving adalimumab and 9 patients receiving etanercept. Twelve-month data related to the efficacy and safety of these two TNF-alpha inhibitors were evaluated. The primary endpoint was ASAS 20 (the ASsessment in AS International Working Group criteria for 20% improvement) at weeks 12 and 52. Other measures that were evaluated were function (BASFI), disease activity (BASDAI), patient's and physician's global disease assessment on visual analogue scale (VAS) and C-reactive protein. RESULTS: In both adalimumab and etanercept groups, there was a significant improvement in all observed variables (baseline compared to weeks 12 and 52). This improvement was sustained for the whole follow-up period. In the adalimumab group, at week 12, ASAS 20 was achieved in 18/19 patients and at week 52 in 17/19 patients. In the etanercept group, at week 12 ASAS 20 was achieved in all patients and at week 52 in 6/9 patients. CONCLUSION: In patients with active AS and TSA, adalimumab and etanercept treatment showed significant improvement in function and disease activity. No serious side effects or adverse effects were observed in our cohort. Key Points • TNF-alpha inhibitors can be effective treatment options for patients with AS and having total spinal ankylosis. • Patients with advanced AS should not be disregarded as good candidates for treatment with biologic disease-modifying antirheumatic drugs.

[Novelties in pathophysiology, radiology diagnostics and conservative treatment of painful spine conditions and deformities]. / Novosti u patofiziologiji, radioloskoj dijagnostici i konzervativnom lijecenju bolnih stanja i deformacija kraljeznice.

Spinal pain, especially chronic low-back pain is one of the most prominent health and healthcare problems. Better understanding of pain pathophysiology and more precise visualization using modern imaging techniques help us to focus our intervention and obtain better outcome. In most patients with spine conditions symptoms and function resolve with conservative treatment. In this article we report on novelties in pathophysiology of spinal pain, magnetic resonance imaging and conservative treatment options (medications, therapeutic exercise, physical therapy and orthoses) of painful spine conditions and scoliosis. Apart from being informative, together with the corresponding article about novelties in invasive/surgical treatment, this special focus article on recent developments in this area can be used as an aid in decision making when approaching these patients.

Cochrane Rehabilitation: 2020 annual report.

During its fourth year of existence, Cochrane Rehabilitation went on to promote evidence-informed health decision-making in rehabilitation. In 2020, the outbreak of the COVID-19 pandemic has made it necessary to alter priorities. In these challenging times, Cochrane Rehabilitation has firstly changed its internal organisation and established a new relevant project in line with pandemic needs: the REH-COVER (Rehabilitation - COVID-19 evidence-based response) action. The aim was to focus on the timely collection, review and dissemination of summarised and synthesised evidence relating to COVID-19 and rehabilitation. Cochrane Rehabilitation REH-COVER action has included in 2020 five main initiatives: 1) rapid living systematic reviews on rehabilitation and COVID-19; 2) interactive living evidence map on rehabilitation and COVID-19; 3) definition of the research topics on "rehabilitation and COVID-19" in collaboration with the World Health Organization (WHO) rehabilitation programme; 4) Cochrane Library special collection on Coronavirus (COVID-19) rehabilitation; and 5) collaboration with COVID-END for the topics "rehabilitation" and "disability." Furthermore, we are still carrying on five different special projects: Be4rehab; RCTRACK; definition of rehabilitation for research purposes; ebook project; and a prioritization exercise for Cochrane Reviews production. The Review Working Area continued to identify and "tag" the rehabilitation-relevant reviews published in the Cochrane library; the Publication Working Area went on to publish Cochrane Corners, working more closely with the Cochrane Review Groups (CRGs) and Cochrane Networks, particularly with Cochrane Musculoskeletal, Oral, Skin and Sensory Network; the Education Working Area, the most damaged in 2020, tried to continue performing educational activities such as workshops in different online meetings; the Methodology Working Area organized the third and fourth Cochrane Rehabilitation Methodological (CRM) meetings respectively in Milan and Orlando; the Communication Working Area spread rehabilitation evidences through different channels and translated the contents in different languages.